The role of Gestational Diabetes Mellitus and pelvic floor 3D-ultrasound assessment during pregnancy predicting urinary incontinence: a prospective cohort study.

Postpartum urinary incontinence may have a severe impact on women's health. Despite pregnancy and parturition being the most recognized risk factors, methods to identify new pregnant predictor risk factors are needed. Our study investigated the Gestational Diabetes Mellitus, clinical and pelvic floor 3D-ultrasound markers in pregnant women as predictors for 6-18 months of urinary incontinence. This prospective cohort study included nulliparous pregnant women submitted to Gestational Diabetes Mellitus screening in the second trimester. Pelvic floor 3D Ultrasound was performed at the second and third trimesters of gestation to evaluate the pelvic floor muscles and functions. Clinical data, the ICIQ-SF, and ISI questionnaires for urinary incontinence were applied in the third trimester and 6-18 months postpartum. Univariate analysis (P < .20) to extract risk factors variables and multivariate logistic regression analysis (P < .05) to obtain the adjusted relative ratio for urinary incontinence were performed. A total of 93 participants concluded the follow-up. Using the variables obtained by univariate analysis and after adjustments for potential confounders, multivariate analysis revealed that Gestational Diabetes Mellitus exposure was a solid and independent risk factor for 6-18 months of urinary incontinence (Adjusted RR 8.08; 95%CI 1.17-55.87; P:0.034). In addition, a higher Hiatal area observed in distension maneuver from the second to third trimester was negatively associated (Adjusted RR 0.96; 95%CI 0.93-0.99; P:0.023). In conclusion, Gestational Diabetes Mellitus was positively associated with 6-18 months of urinary incontinence, and higher Hiatal area distension was negatively associated.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus.

BACKGROUND: Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated. METHODS: The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy. DISCUSSION: To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

Hyperglycemia induces inflammatory mediators in the human chorionic villous.

This study was based on the hypothesis that IL-1ß and its central regulator, the inflammasome, may play a role in the inflammatory condition exhibited by placental tissues from mothers with different gestational hyperglycemia levels. Pregnant women were classified according to the glycemic reference as non-diabetic (n = 15), mild gestational hyperglycemia (n = 15), gestational diabetes mellitus (n = 15) and type 2 diabetes mellitus (n = 15). We investigated levels of pro-inflammatory factors in maternal plasma and placental tissues (by ELISA or immunohistochemistry) and, NFKB activity (by electrophoretic mobility shift assay) and inflammasome protein expression (by Western blot) in chorionic villous. Maternal plasma and placental levels of inflammatory factors (IL-1ß, IL-6, and MCP-1) were increased during all hyperglycemic conditions. Villous stroma cells showed strong immunoreactivity to CD68. In addition, with syncytiotrophoblast, the villous stroma cells were also stained to detect iNOS, MCP-1, TLR2, and TLR4. Although the levels of protein had fluctuated in the groups, NLRP1, NLRP3, ASC, and Caspase 1 were up-regulated in all hyperglycemic groups suggesting the inflammasome may be assembled in these pregnant women. The NFKB activity also exhibited higher levels in hyperglycemic groups, which might imply in pro-inflammatory cytokines production. In summary, increased maternal glucose levels during pregnancy changed systemic and placental inflammatory patterns, which occurred in parallel with the expression of inflammasome factors and processing and secretion of the pro-inflammatory cytokine IL-1ß. These results suggest an inflammatory condition in all gestational hyperglycemic conditions, even in hyperglycemia that is less severe than gestational or overt diabetes, likely associated with inflammasome activation and inflammatory cytokine secretion. Inflammasome activation as a possible source of inflammatory factors may be an important target to be considered while managing hyperglycemia and preventing adverse pregnancy outcomes.

Risk factors for postpartum urinary incontinence: The impact of early-onset and late-onset Gestational Diabetes Mellitus in a nested case-control study.

BACKGROUND: Gestational Diabetes Mellitus (GDM) and many other clinical variables have been associated with postpartum urinary incontinence (UI). However, the data are still restricted, and no study explored early- or late-onset GDM as a risk factor for this condition. We aimed to identify independent risk factors for postpartum UI, focusing on GDM and its early or late onset. METHODS: A nested case control derived from the Diamater cohort study included 517 pregnant women who submitted to a planned C-section and followed by 6-18 months after delivery according to the timing of GDM diagnosis: early-onset GDM (before 20 weeks) and late-onset GDM(24-28 weeks) and the occurrence of UI. RESULTS: Univariate analysis showed that the risk for 6-18 months postpartum UI was 49% higher in non-Caucasian ethnicity (1.49,1.02-2.18), 3,3 times higher in previous bariatric surgery [3.37,1.36-8.21], 39% higher in GDM women (1.39,1.01-1.93), and 5% higher for each BMI score in prepregnancy (1.05, 1.03-1.08) and at the end of pregnancy (1.05,1.02-1.08). Multivariate logistic regression analysis indicates that prepregnancy BMI was the only independent factor associated with the 6-18 months postpartum UI (adj 1.05, 95 %CI 1.02-1.08, P <.001). After stratifying, a second univariate and multivariate analysis were done according to the prepregnancy BMI cutoff score of 25. Thus, a significant association between GDM and postpartum UI in prepregnancy overweight women (RR: 1.91; 95 %CI 1.25-2.90, P =.003) and no association between GDM and 6-18 months postpartum UI in normal prepregnancy BMI (RR: 0.78, 95 %CI 0.39-1.54, P =.482) were found. After multivariate regression, the early-onset-GDM remained the unique independent adjusted risk factor for 6-18 months postpartum UI analysis (adjRR 2.15, 95 %CI 1.33-3.46, P =.002). CONCLUSION: After a planned C-section, we observed a 6-18 months postpartum UI higher occurrence after GDM, either in early-onset GDM or late-onset GDM. In addition, being overweight (BMI > 25) among women with early-onset GDM was associated with postpartum UI.

Reversal of diabetic-induced myopathy by swimming exercise in pregnant rats: a translational intervention study.

Gestational diabetes mellitus (GDM) plus rectus abdominis muscle (RAM) myopathy predicts long-term urinary incontinence (UI). Atrophic and stiff RAM are characteristics of diabetes-induced myopathy (DiM) in pregnant rats. This study aimed to determine whether swimming exercise (SE) has a therapeutic effect in mild hyperglycemic pregnant rats model. We hypothesized that SE training might help to reverse RAM DiM. Mild hyperglycemic pregnant rats model was obtained by a unique subcutaneous injection of 100 mg/kg streptozotocin (diabetic group) or citrate buffer (non-diabetic group) on the first day of life in Wistar female newborns. At 90 days of life, the rats are mated and randomly allocated to remain sedentary or subjected to a SE protocol. The SE protocol started at gestational day 0 and consisted of 60 min/day for 6 days/week in a period of 20 days in a swim tunnel. On day 21, rats were sacrificed, and RAM was collected and studied by picrosirius red, immunohistochemistry, and transmission electron microscopy. The SE protocol increased the fiber area and diameter, and the slow-twitch and fast-twitch fiber area and diameter in the diabetic exercised group, a finding was also seen in control sedentary animals. There was a decreased type I collagen but not type III collagen area and showed a similar type I/type III ratio compared with the control sedentary group. In conclusion, SE during pregnancy reversed the RAM DiM in pregnant rats. These findings may be a potential protocol to consider in patients with RAM damage caused by GDM.

The safe motherhood referral system to reduce cesarean sections and perinatal mortality - a cross-sectional study [1995-2006].

BACKGROUND: In 2000, the eight Millennium Development Goals (MDGs) set targets for reducing child mortality and improving maternal health by 2015. OBJECTIVE: To evaluate the results of a new education and referral system for antenatal/intrapartum care as a strategy to reduce the rates of Cesarean sections (C-sections) and maternal/perinatal mortality. DESIGN: Cross-sectional study. SETTING: Department of Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University/UNESP, Brazil. POPULATION: 27,387 delivering women and 27,827 offspring. DATA COLLECTION: maternal and perinatal data between 1995 and 2006 at the major level III and level II hospitals in Botucatu, Brazil following initiation of a safe motherhood education and referral system. MAIN OUTCOME MEASURES: Yearly rates of C-sections, maternal (/100,000 LB) and perinatal (/1000 births) mortality rates at both hospitals. DATA ANALYSIS: Simple linear regression models were adjusted to estimate the referral system's annual effects on the total number of deliveries, C-section and perinatal mortality ratios in the two hospitals. The linear regression were assessed by residual analysis (Shapiro-Wilk test) and the influence of possible conflicting observations was evaluated by a diagnostic test (Leverage), with p < 0.05. RESULTS: Over the time period evaluated, the overall C-section rate was 37.3%, there were 30 maternal deaths (maternal mortality ratio = 109.5/100,000 LB) and 660 perinatal deaths (perinatal mortality rate = 23.7/1000 births). The C-section rate decreased from 46.5% to 23.4% at the level II hospital while remaining unchanged at the level III hospital. The perinatal mortality rate decreased from 9.71 to 1.66/1000 births and from 60.8 to 39.6/1000 births at the level II and level III hospital, respectively. Maternal mortality ratios were 16.3/100,000 LB and 185.1/100,000 LB at the level II and level III hospitals. There was a shift from direct to indirect causes of maternal mortality. CONCLUSIONS: This safe motherhood referral system was a good strategy in reducing perinatal mortality and direct causes of maternal mortality and decreasing the overall rate of C-sections.

Toxic and essential elements in blood from delivering women in selected areas of São Paulo State, Brazil.

This study was designed to evaluate the degree of environmental contamination and possible exposure of pregnant women to toxic elements in seven selected areas of São Paulo State, Brazil. The overall median concentration of Mo in maternal blood was 0.53 µg L⁻¹, highly significant differences found between sites (p < 0.0001). Cd was found to be low overall - 0.09 µg L⁻¹ (0.01-0.58 µg L⁻¹) - with mothers from the Coastal and Rural 1 sites having the highest levels (p < 0.016).Median Hg concentration was 0.60 µg L⁻¹ (0.06 µg L⁻¹-4.35 µg L⁻¹); median Pb level was 16.2 µg L⁻¹ (3.5-57.7 µg L⁻¹) and no differences between sites were observed for both metals. Median Mn level was 16.7 µg L⁻¹ (7.0-39.7 µg L⁻¹), being highest in Urban 2 site (p < 0.016). Concentrations of maternal Co were found to range between 0.06 µg L⁻¹ and 1.1 µg L⁻¹ (median 0.25 µg L⁻¹) and As level was 0.60 µg L⁻¹ (0.10-3.8 µg L⁻¹) overall, with no statistical significance between sites for Co and As. Median Se concentrations were found to be 64 µg L⁻¹ (36-233 µg L⁻¹), with the highest median levels found in Urban 3 site; site differences were statistically significant (p < 0.0001). Correlation for each element (between paired maternal and cord blood) was measured only in Rural site 1; significant correlation was shown for Hg, Pb, Mn and Co (p < 0.05). These findings may be interpreted as indicating low environmental contamination in São Paulo State, Brazil. These findings could also indicate that pregnant women have little or no contact with pollutants, possibly due to awareness campaigns carried out by public health practitioners.

Symphysis-Fundal Height Curve in Pregnancies Complicated by Maternal Hyperglycemia: Comparison with Curves of Nondiabetic Pregnant Women.

BACKGROUND: Reference symphysis-fundal height (SFH) curves for pregnancies complicated by maternal hyperglycemia are not available. OBJECTIVE: To build an SFH curve according to gestational age for pregnant women with hyperglycemia-type 2 diabetes (T2DM), gestational diabetes mellitus (GDM), or mild gestational hyperglycemia (MGH) and compare it with three other curves in use in Brazil. METHODS: Prospective cohort study of 422 pregnant women with hyperglycemia attending the Perinatal Diabetes Research Center (PDRC) of Botucatu Medical School, São Paulo State University/UNESP. Between 13 and 41 weeks of pregnancy, 2470 SFH measurements were obtained (mean 5.85 per woman). For the assessment of glycemic control, 2074 glucose level measurements were taken and the glycemic mean (GM) at each gestational week was estimated. RESULTS: GM was adequate (<120 mg/dL) in 94.9% and inadequate (≥120 mg/dL) in 5.1% of the cases. The equation applied for SFH prediction was expressed as SFH = 1.082 + 0.966∗week (r 2 = 84.6%). At visual analysis, P10 and P90 SFH measurements were higher in the study curve than in the three other curves. Statistical analysis confirmed that SFH median values in this study were higher than those in the reference curve of habitual risk pregnancies, especially after 19 weeks of pregnancy. CONCLUSION: Taking into account that the maternal hyperglycemia was at strict control, our unedited results suggest that the current SFH curve can be a useful tool in prenatal care of T2DM, GDM, and MGH pregnant women.

Maternal factors associated with hyperglycemia in pregnancy and perinatal outcomes: a Brazilian reference center cohort study.

BACKGROUND: While sufficient evidence supporting universal screening is not available, it is justifiable to look for specific risk factors for gestational diabetes mellitus (GDM) or hyperglycemia in pregnancy (HIP). The objective of this study is to identify independent risk factors for HIP and its adverse perinatal outcomes in a Brazilian public referral center. METHODS: We included 569 singleton pregnant women who were split into three groups by glucose status: GDM (n = 207), mild gestational hyperglycemia (MGH; n = 133), and control (n = 229). Women who used corticosteroids or had a history of DM were excluded. HIP comprised both GDM and MGH, diagnosed by a 100 g- or 75 g-oral glucose tolerance test (OGTT) and a glucose profile at 24-28 weeks. Maternal characteristics were tested for their ability to predict HIP and its outcomes. Bivariate analysis (RR; 95% CI) was used to identify potential associations. Logistic regression (RRadj; 95% CI) was used to confirm the independent risk factors for HIP and its perinatal outcomes (p < 0.05). RESULTS: Age ≥ 25 years [1.83, 1.12-2.99], prepregnancy BMI ≥ 25 kg/m2 [2.88, 1.89-4.39], family history of DM [2.12, 1.42-3.17] and multiparity [2.07, 1.27-3.37] were independent risk factors for HIP. Family history of DM [169, 1.16-2.16] and hypertension [2.00, 1.36-2.98] were independent risk factors for C-section. HbA1c ≥ 6.0% at birth was an independent risk factor for LGA [1.99, 1.05-3.80], macrosomia [2.43, 1.27-4.63], and birthweight Z-score > 2.0 [4.17, 1.57-11.10]. CONCLUSIONS: MGH presents adverse pregnancy outcomes similar to those observed in the GDM group but distinct from those observed in the control (no diabetes) group. In our cohort, age ≥ 25 years, prepregnancy BMI ≥ 25 kg/m2, family history of DM, and multiparity were independent risk factors for HIP, supporting the use of selective screening for this condition. These results should be validated in populations with similar characteristics in Brazil or other low- and middle-income countries.

Impact of Gestational Diabetes Mellitus on Sexual Function: A Case-Control Study.

Background: The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide, and this condition may be compromising female sexual function. However, there are controversial findings regarding the impact of GDM diagnosis and proposed treatments on sexual function during pregnancy. Therefore, this study seeks to elucidate the impact of GDM on sexual function in pregnant women by making a comparison between GDM and non-GDM groups using pregnancy sexual response inventory (PSRI). Materials and Methods: A case-control study involved 303 [168 women without GDM (control group) and 108 women diagnosed with GDM (case group)] Brazilian pregnant women at the Perinatal Diabetes Research Centre-Universidade Estadual Paulista, Brazil. PSRI was used to collect the data. The sexual function was scored in 10 domains as composite and specific scores by domains, categorized into quartiles (0 < 25 "very low," 25 < 50 "low," 50 < 75 "high," and 75-100 "very high"), for "before pregnancy" and "during pregnancy." The obtained data were subjected to statistical analysis using Student's t-, F-, and chi-square tests. Results: GDM women (PSRI composite score <50) are at risk of decreased sexual function during pregnancy, while non-GDM women are not at risk (PSRI composite score >50). There were no significant differences in the sexual functions between the two groups before pregnancy (p > 0.0001). After GDM diagnosis and proposed treatment, the differences were significant (p < 0.0001), notably in the frequency, arousal, orgasm, satisfaction, and dyspareunia score. Conclusions: This study showed that GDM diagnosis and proposed treatment resulted in decreased sexual functions during pregnancy.

Alterations in the structural characteristics of rectus abdominis muscles caused by diabetes and pregnancy: A comparative study of the rat model and women.

BACKGROUND AND OBJECTIVE: In the present study, we compared the effect of diabetic pregnancy on the rectus abdominis muscle (RAM) in humans and rats. We hypothesized that our animal model could provide valuable information about alterations in the RAM of women with Gestational Diabetes (GDM). METHOD: Newborns female rats (n = 10/group) were administered streptozotocin (100 mg/kg body weight) subcutaneously and were mated on reaching adulthood, to develop the mild hyperglycemic pregnant (MHP) rat model. At the end of pregnancy, the mothers were sacrificed, and the RAM tissue was collected. Pregnant women without GDM (non-GDM group; n = 10) and those diagnosed with GDM (GDM group; n = 8) and undergoing treatment were recruited, and RAM samples were obtained at C-section. The RAM architecture and the distribution of the fast and slow fibers and collagen were studied by immunohistochemistry. RESULTS: No statistically significant differences in the maternal and fetal characters were observed between the groups in both rats and women. However, significant changes in RAM architecture were observed. Diabetes in pregnancy increased the abundance of slow fibers and decreased fast fiber number and area in both rats and women. A decrease in collagen distribution was observed in GDM women; however, a similar change was not observed in the MHP rats. CONCLUSION: Our results indicated that pregnancy- associated diabetes- induced similar structural adaptations in the RAM of women and rats with slight alterations in fiber type number and area. These findings suggest that the MHP rat model can be used for studying the effects of pregnancy-associated diabetes on the fiber structure of RAM.

Deleterious effects of gestational diabetes mellitus on the characteristics of the rectus abdominis muscle associated with pregnancy-specific urinary incontinence.

AIMS: To evaluate the effects of gestational diabetes mellitus (GDM) on the structural characteristics of the rectus abdominis muscle (RAM) and its indirect effects on pregnancy-specific urinary incontinence (PSUI). METHODS: A total of 92 pregnant women were divided into four groups, according to their clinical conditions: non-GDM continent, non-GDM associated PSUI, GDM continent and GDM associated PSUI. The muscle morphometry (histochemistry and immunohistochemistry) for the fiber types and collagen fiber distribution, the ultrastructural analysis (transmission electron microscopy), the protein expression of fiber types and calcium signaling (Western blotting), and the content of types I and III collagen fiber (ELISA) in RAM collected at delivery were assessed. RESULTS: The GDM groups presented a significantly increased number of slow fibers and slow-twitch oxidative fiber expression; decreased fiber area, number of fast fibers, and area of collagen; an increase in central nuclei; ultrastructural alterations with focal lesion areas such as myeloid structures, sarcomere disorganization, and mitochondrial alteration. The PSUI groups presented a considerable decrease in types I and III collagen contents and the localization of collagen fiber. CONCLUSIONS: Our data reveal that GDM causes morphological, biochemical and physiological changes in the RAM, and this might predispose women to PSUI.

Design and validity of a questionnaire to assess sexuality in pregnant women.

BACKGROUND: A review of validated methods for assessing female sexual dysfunction and a review of male and female sexual dysfunction did not refer to any specific questionnaire for evaluating sexuality during pregnancy. A study was performed at the Obstetrics and Gynecology Department of Botucatu Medical School, São Paulo State University, Brazil to design and validate a pregnancy sexuality questionnaire, the Pregnancy Sexual Response Inventory (PSRI). METHODS: Women with a singleton pregnancy between 10 and 35 weeks of gestation were randomly recruited. There were five phases in the development of the PSRI: (1) item selection; (2) item development; (3) determination of internal consistency, reliability and convergence; (4) content validity; and (5) determination of inter-interviewer reliability. Internal consistency and reliability were evaluated using Cronbach's alpha. Inter-interviewer reliability was assessed by evaluating the responses of 18 academics at various institutions, using Kappa Index and Student t test. RESULTS: Good internal consistency and reliability were obtained (Cronbach's alpha coefficient = 0.79). Among the 18 academics, 13 totally agreed (K = 1.0), three partially agreed (K = 0.67) and two disagreed (K = 0.33) with the proposed questions. Comparisons of the mean PSRI domain scores made between the primary investigators and the other interviewers showed no significant differences in all domains (p > 0.05). CONCLUSION: PSRI is a new validated instrument for evaluating sexuality and sexual activity and related health concerns during pregnancy.

Brazilian network for the surveillance of maternal potentially life threatening morbidity and maternal near-miss and a multidimensional evaluation of their long term consequences.

BACKGROUND: It has been suggested that the study of women who survive life-threatening complications related to pregnancy (maternal near-miss cases) may represent a practical alternative to surveillance of maternal morbidity/mortality since the number of cases is higher and the woman herself is able to provide information on the difficulties she faced and the long-term repercussions of the event. These repercussions, which may include sexual dysfunction, postpartum depression and posttraumatic stress disorder, may persist for prolonged periods of time, affecting women's quality of life and resulting in adverse effects to them and their babies. OBJECTIVE: The aims of the present study are to create a nationwide network of scientific cooperation to carry out surveillance and estimate the frequency of maternal near-miss cases, to perform a multicenter investigation into the quality of care for women with severe complications of pregnancy, and to carry out a multidimensional evaluation of these women up to six months. METHODS/DESIGN: This project has two components: a multicenter, cross-sectional study to be implemented in 27 referral obstetric units in different geographical regions of Brazil, and a concurrent cohort study of multidimensional analysis. Over 12 months, investigators will perform prospective surveillance to identify all maternal complications. The population of the cross-sectional component will consist of all women surviving potentially life-threatening conditions (severe maternal complications) or life-threatening conditions (the maternal near miss criteria) and maternal deaths according to the new WHO definition and criteria. Data analysis will be performed in case subgroups according to the moment of occurrence and determining cause. Frequencies of near-miss and other severe maternal morbidity and the association between organ dysfunction and maternal death will be estimated. A proportion of cases identified in the cross-sectional study will comprise the cohort of women for the multidimensional analysis. Various aspects of the lives of women surviving severe maternal complications will be evaluated 3 and 6 months after the event and compared to a group of women who suffered no severe complications in pregnancy. Previously validated questionnaires will be used in the interviews to assess reproductive function, posttraumatic stress, functional capacity, quality of life, sexual function, postpartum depression and infant development.

Phenotypic characterization of regulatory T cells populations in maternal blood, cord blood and placenta from diabetic mothers.

Purpose: Changes in regulatory T cells (Treg) in peripheral blood are associated with a number of pathologies, including diabetes. However, the immunological responses of pregnant diabetic women remain scarcely known, and the effects of Treg cells in these patients have yet to be investigated. The present study characterized the expression of regulatory T cells in the maternal blood, cord blood and placenta of diabetic pregnant women. Materials and methods: The women were divided according to glycemic status into a non-diabetic (ND; N = 20) or type 2 diabetic (T2DM; N = 20) group. Cell subsets were determined by flow cytometry. Results: Compared to ND, T2DM blood cells exhibited a higher expression of CD25+, Foxp3+, CD4+CD25+, CD4+Foxp3+ and CD25+Foxp3+; and cord blood cells showed a lower expression of CD25+, CD4+Foxp3+ and CD25+Foxp3+. In the placenta of T2DM, the villous layer of the proportion, CD3+ and CD25 was lower than that of CD4+Foxp3+ and CD25+Foxp3+, and the extravillous placenta layer contained the lowest levels of CD4+ and CD25+ and highest proportions of CD4+Foxp3+. In maternal blood from T2DM, the frequency of CD3+CD95+ and CD3CD4+ T cells expressing CD95+ was lower. In cord blood from T2DM, the rate of CD3+CD95+ was lower. The placenta villous layer of T2DM showed a lower count of CD3+CD95+ and of CD3CD4+ T cells expressing CD95+, whereas the number of cells expressing CD3+CD45RO+ decreased in both placental layers. Conclusion: The data obtained suggest that hyperglycemia changes the phenotypes of regulatory T cells and Fas expression in memory T cells.

Mitochondrial-related gene associated to obesity can be modulated by in utero hyperglycemic environment.

We investigated whether mitochondrial-related genes and proteins are modulated by hyperglycemia promoted by gestational diabetes (GDM), thereby increasing neonate obesity predisposition. 19 healthy pregnant women, 16 pregnant women with GDM and their respective neonates were enrolled. Additionally, 19 obese and 19 eutrophic adults were recruited as a reference population. Umbilical cord, peripheral blood and placental (villous and decidua) tissues were collected to evaluate SOD2, PPAR-α and PPARGC-1ß and their respective protein expressions. Data from the reference population confirmed that the three genes and proteins were overexpressed in blood cells of obese compared to eutrophic subjects. Only SOD2 was found upregulated in placental villous (fetal side) tissue of GDM women. Therefore, our findings showed an interaction between the hyperglycemic environment and SOD2 modulation, but also indicated that none of the three genes is useful as potential biomarkers for obesity development.

Prenatal exposure to gestational diabetes mellitus increases developmental defects in the enamel of offspring.

BACKGROUND AND OBJECTIVE: Gestational diabetes mellitus (GDM) is associated with short- and long-term maternal and perinatal repercussions. Our objective was to evaluate the long-term consequences of intrauterine exposure to hyperglycemia on Developmental Defects of Enamel (DDE) in offspring. RESULTS: Overall, 50 children of women with GDM and 250 children of normoglycemic women participated, the latter serving as controls. Children were examined at the age between 3 and 12 years. In addition to physical examination, two independent observers examined and rated photographs to identify specific types of DDE in a blinded fashion. Among offspring of mothers with GDM, rates of DDE (all types combined) and hypoplasia (specific type) were significantly higher (p<0.001, p = 0.04), in comparison to offspring of normoglycemic mothers. Considering only the affected teeth (1060 in GDM category; 5499 in controls), rates of DDE (all types combined) were significantly higher for total teeth (p <0.001) and deciduous teeth (p<0.001), but not permanent teeth. In specific types of DDE involving deciduous teeth, rates of demarcate opacity were significantly higher (p<0.001; canine and 2nd mandibular molars) and hypoplasia (p <0.001; 2nd maxillary molars and 2nd mandibular molars). In permanent teeth, the rate of diffuse opacity in association with GDM was significantly higher (p<0.001; maxillary central incisors and 1st maxillary molars). CONCLUSION: GDM was associated with the adverse effects of DDE on offspring. This study lays the foundation for future studies to determine the impact of GDM on long-term risk of DDE.

The influence of hyperglycemia on the remodeling of urethral connective tissue in pregnant rats.

OBJECTIVE: To analyze the distribution and quantification of the key structural extracellular matrix components of the urethral tissue in a rat model of hyperglycemia and pregnancy. STUDY DESIGN: A total of 120 female Wistar rats were distributed into the following four experimental groups: virgin, pregnant, hyperglycemic and hyperglycemic + pregnant groups. The urethra was harvested for histochemical, morphometric, immunohistochemical, Western blot and glycosaminoglycan analyses. All protocols were approved by the Institutional Animal Care and Use Committee of Botucatu Medical School (process number 828-2010). RESULTS: The hyperglycemic + pregnant group showed significantly increased stiffness in urethral tissue. The total striated muscle was decreased, with increased deposition of collagen fibers around the muscle fibers and a change in the organization of the collagen fibrils. An increase in the relative collagen type I/III ratio and a decrease in total glycosaminoglycans were also observed. CONCLUSIONS: This study provides the first line of experimental evidence supporting a metabolic relationship between hyperglycemia and urethral remodeling of connective tissue in pregnant rats. The different organization of the collagen fibrils and the profile of glycosaminoglycans found in urethral samples suggest that the pathology of the urethral fibromuscular system could be related to hyperglycemia-induced pelvic floor dysfunction in women, which has direct clinical implications with the possibility to develop new multidisciplinary treatments for improving the health care of these women.

The modulatory role of cytokines IL-4 and IL-17 in the functional activity of phagocytes in diabetic pregnant women.

The study investigated the role of cytokines IL-4 and IL-17 in the modulation of the functional activity of mononuclear phagocytes in diabetic pregnant women with hyperglycemia. Sixty pregnant women were assigned to the following groups: nondiabetic (ND), mild gestational hyperglycemia (MGH), gestational diabetes mellitus (GDM), or type 2 diabetes mellitus (DM2). The functional activity of phagocytes from maternal blood, cord blood, and colostrum was assessed by determining their superoxide release, phagocytosis, microbicidal activity, and intracellular Ca2+ release. Irrespective of glycemic status, colostrum and blood cells treated with IL-4 and IL-17 increased superoxide release in the presence of enteropathogenic Escherichia coli (EPEC). The highest phagocytosis rate was observed in cells from the DM2 group treated with IL-4. In all the groups, phagocytes from colostrum, maternal blood, and cord blood exhibited higher microbicidal activity against EPEC when treated with cytokines. IL-17 increased intracellular Ca2+ release by colostrum phagocytes in diabetic groups. The results indicate that the IL-4 and IL-17 modulate the functional activity of phagocytes in the maternal blood, cord blood, and colostrum of diabetic mother. The natural immunity resulting from the interaction between the cells and cytokines tested may be an alternative procedure to improve the prognosis of maternal and newborn infections.

Morphometric study of placental villi and vessels in women with mild hyperglycemia or gestational or overt diabetes.

In this study, morphometric measures of placental terminal villi and villous vessels were compared in overt, as well as gestational diabetes mellitus, and mild hyperglycemia diagnosed by oral 100 g glucose tolerance test (100 g-OGTT) and glucose profile (GP). At delivery (gestational age> or =34 weeks) a total of 207 placentas were assigned to a control group (n=56) or to one of three groups complicated by mild hyperglycemia (n=51), gestational diabetes (n=59) and overt diabetes (n=41). Placenta samples were randomly selected for blind morphometric assessment with an image analyser. Morphometric measures obtained included area and number of terminal villi and their respective villous vessels. Statistical analyses were performed using the chi-square test, ANOVA and stepwise regression (p< or =0.05). Glycemic means were 86.2 mg/dL in controls, 98.9 mg/dL in mild hyperglycemia, 114.1 mg/dL in gestational diabetes and 122.1 mg/dL in overt diabetes. Our results show that abnormal maternal glycemic levels may change the placental morphometric characteristics related to materno-fetal exchanges.