Prevention of congenital malformations in infants of insulin-dependent diabetic mothers.

From April 1977 to April 1981, 420 deliveries of infants of insulin-dependent diabetic women were performed in our department. Of the infants delivered, 23 had congenital malformations (5.5%). The malformation rate was 1.4% for infants of 420 nondiabetic women. Strict metabolic control was begun after 8 wk gestation in 292 of the diabetic women who delivered 22 infants with congenital malformations (7.5%). Intensive treatment was begun before conception in 128 diabetic women planning pregnancy. There was only one malformation in infants of this group (0.8%), a significant reduction from the anomaly rate in the late registrants (X2 = 7.84; P less than 0.01). These observations indicate that reasonable metabolic control started before conception and continued during the first weeks of pregnancy can prevent malformations in infants of diabetic mothers.

Age-dependent insulin secretion of the endocrine pancreas in vitro from fetuses of diabetic and nondiabetic patients.

Fetal hyperinsulinemia is assumed to play a key role in the pathogenesis of diabetic fetopathy. To investigate the role of enhanced fetal B-cell mass as one cause of fetal hyperinsulinemia during diabetic pregnancy, we studied human fetal pancreatic slices from diabetic women (FDW) with poor metabolic control and nondiabetic women (FNDW) between 11 and 26 wk of pregnancy, morphometrically and by in vitro incubation experiments. Abortions had been performed due to different medical indications. We found a good correlation between the calculated B-cell mass and the gestational age in both FDW and FNDW, but the increase in FDW was much more pronounced. Such a correlation was also found in vitro regarding the insulin response to glucose and IBMX. The FDW had significantly higher values than FNDW of the same age range. In contrast to this, we found in two diabetic patients with tight metabolic control during the whole pregnancy results similar to those in FNDW. Therefore, we assume that it could be possible to prevent fetal hyperinsulinemia and perhaps even diabetic fetopathy in diabetic women by tight metabolic control during the whole pregnancy, but further investigations are necessary.

Neuron-specific enolase (NSE) as a neuroendocrine cell marker in the human fetal pancreas.

Using the PAP technique, we investigated the presence of neuron-specific enolase in the human fetal pancreas of 10, 12, and 14 weeks of gestational age. Neuron-specific enolase is present in the islet cells in the 10th week. Positive cells are situated mainly in duct epithelium. The number of cells with a positive reaction increases from the 12th to the 14th week. In the 14th week, they are clustered either near the ducts or between the acini. The numbers and localizations of the cells correspond to those obtained in previous studies with 4 basic islet cell types in the same material. The present results are a further proof that islet cells are biologically active during early fetal development.

Detection of proinsulin, C-peptide, insulin-A-chain, and glicentin in pancreatic islet cells of early human fetogenesis.

The presence of C-peptide, proinsulin, insulin-A-chain, and glicentin in human fetal pancreatic cells by using the PAP-technique was investigated and the results obtained compared with the occurrence of insulin or glucagon immunoreactive cells. In pancreatic sections obtained from 10 weeks old human fetuses we could identify cells reacting with antibodies directed against C-peptide, proinsulin, and insulin-A-chain. The majority of the cells were found in the duct epithelium and their number increased from the 10th to 14th week forming clusters near the ducts. The number and localization of the cells correspond exactly to the insulin positive cells. The presence of proinsulin and insulin-A-chains is a further proof of biological activity already in an early step of fetal development. The presence of glicentin-positive cells in the 10th week of gestational age as well as cells reacting with glucagon antibodies provide evidence for active glucagon biosynthesis. The number of these cells increased markedly in the 14th week of gestational age.

[Inversio uteri post partum (author's transl)]. / Inversio uteri post partum.

Reported in this paper are four cases of puerperal inversio uteri which occurred within six months. Manual reposition was vaginally applied in two cases, whereas abdominal hysterectomy had to be performed on the other two.

[Behaviour of human placental lactogen (HPL) following continuous glucose infusion in late pregnancy (author's transl)]. / Das Verhalten des HPL (Humanes plazentares Laktogen) unter Glukoseinfusionsbelastung in der Spätschwangerschaft.

Continuous intravenous glucose infusion was applied to 15 pregnant women of normal body weight, in the 37th week of pregnancy. The glucose levels in the blood, serum immunoreactive insulin, and placental lactogenic hormone (HPL) were monitored for three hours. Glucose tolerances were found to be normal in five probands, borderline in another five, and pathological in five, as well. No relationships were found to exist between insulin requirement und plasma HPL levels. While all HPL levels were somewhat increased in those patients with pathological glucose tolerances, the differences were not significant.

[A case of septic ovarian vein thrombosis]. / Ein Fall von septischer Ovarialvenenthrombose.

Puerperal ovarian vein thrombosis commonly originates from purulent necrotic endomyometritis. The incidence is published to be 1 to 600 deliveries. According to the puerperal uterine drainage, the predominant location is the right ovarian vein in 90% of all cases. The leading symptoms are lower abdominal pain, fever and leucocytosis. Discrepancy between the given clinical picture and the insignificant findings on gynaecologic examinations is common.

[Rare coincidence of Ehlers-Danlos syndrome, diabetes mellitus and pregnancy]. / Seltenes Zusammentreffen von Ehlers-Danlos-Syndrom, Diabetes mellitus und Schwangerschaft.

A report is given about a seldom coincidence of Ehlers-Danlos-Syndrome, diabetes mellitus and pregnancy in a 31 year old patient.--The course of pregnancy was uncomplicated except a cervical insufficiency and a secondary wound healing of the episiotomy. The exact diagnosis of the Ehlers-Danlos-syndrome should be done already before pregnancy.

Phases in the early development of the human islet organ.

The study included morphometric examination and biochemical investigation of 41 human pancreata taken from 14th to 26th weeks of fetal development. 3 phases of development were observed. Phase I (weeks 14 to 16) is characterized by the presence of mainly islet buds. They were originated from the ducts and are vascularized during week 16. During phase II (17th to 20th weeks) the islet buds were detached from the ducts and they formed new mantled islets with the B cells in the centre. Non-B cells are situated on the periphery around the insulin producing cells. Phase III lasts from week 21 to week 26. During this phase B cells and non-B cells become more irregularly positioned within the islet, a cytology, which is similar approximating that of as also found in adult human islets. The changes of islet structure during pancreatic development are accompanied by other typical phenomena: Islet size increases during phases I and II, but decreases again during phase III. The proportion of isolated B cells outside of the islets varies during this stage of fetal development, but they generally account for about 15% of the total islet organ. This should be taken into account when assessing the islet function De Pablo et al. (1985) on a morphological basis.

Human amniotic fluid stimulates DNA synthesis of rat pancreatic islets.

Collagenase isolated pancreatic islets from newborn Lewis rats were used to study the effect of human amniotic fluid (HAF) on DNA synthesis measured as incorporation of 3H-thymidine into islet DNA and as estimation of labeling index. We investigated individual samples of HAF obtained from pregnant women between the 28th and 39th week of gestation. Since there were no significant differences of HAF obtained from different gestational weeks on islet DNA synthesis, the following experiments were carried out with pooled HAF. When islets were cultured for 2 days in TCM 199 containing 10 mmol/l glucose the addition of 50% HAF resulted in a significantly increased DNA synthesis in comparison to islets cultured in TCM 199 supplemented to 50% with Hank's balanced salt solution (HANK). When extending the culture period from 2 to 4 days the stimulatory effect of 50% HAF was well preserved. Islets cultured in HANK are characterized by a declined DNA-content, which was prevented in the presence of HAF. There was a good correlation between incorporation of 3H-thymidine and the percentage of labeled nuclei, estimated on hematoxylin/eosin-stained autoradiograms of islets cultured for 4 days either in TCM 199 alone, in the presence of 50% HANK or 50% HAF, indicating that the measured incorporation of labeled thymidine into islet DNA was representative for islet replication.

The effect of human amniotic fluid on DNA synthesis of rat pancreatic islets in tissue culture.

In this study we investigated the effect of human amniotic fluid (HAF) on the incorporation of 3H-thymidine into cultured rat islets. The addition of 1% HAF (1% HAF, 99% TCM) did not alter the incorporation of labeled thymidine, in comparison to TCM 199 alone (100%). The culture in the presence of 50% HAF (1:1 diluted with TCM, v/v) resulted in a significantly increased DNA synthesis. To exclude any effect of ionic composition or substrate dilution by the HAF, the TCM 199 was also either diluted (1:1) with saline or Hank's balanced salt solution (HBSS). Islets cultured under these conditions did not show any stimulated thymidine incorporation into islet DNA. From these results we conclude that HAF contains an activity which stimulates islet replication. In order to concentrate this stimulatory activity, HAF was tested after it had been lyophilized or evaporated. Independent of the method used, in no case a stimulatory effect of concentrated HAF was found. In contrast, the concentrated form of HAF inhibited the incorporation of labeled thymidine into islet DNA.

[Fetal hyperinsulinism in early pregnancy--a cause of diabetic fetopathy?]. / Der fetale Hyperinsulinismus in der Frühsehwangerschaft--eine Ursache der diabetischen Fetopathie?

The influence of fetal hyperinsulinemia on the development of diabetic fetopathy was investigated. Human fetal pancreatic slices of fetus between the 12th and 26th weeks of pregnancy from non diabetic (n = 32) and diabetic (n = 18) women were incubated in vitro for one hour. The insulin secretion results clearly demonstrate an age dependent increase in both groups investigated, but the increase is much more pronounced in fetuses from diabetic women. The differences between the groups are present already during the 12th week of pregnancy. The results support the concept to normalize the metabolic control in pregnancy as early as possible in order to prevent the diabetic fetopathy.

Effect of glucose on human fetal pancreatic tissue in vitro.

For investigating insulin secretion in vitro human fetal pancreatic slices prepared from women with a normal carbohydrate tolerance at a mean gestational age of 12 +/- 1 weeks were incubated in the presence of various secretagogues. Glucose concentration up to 20 mmol/l failed to enhance insulin secretion, whereas an increase of glucose up to 40 mmol/l, the addition of the phosphodiesterase inhibitor IBMX or a priming period of 30 min in the presence of 20 mmol/l glucose resulted in an enhancement of hormone release, calculated per microgram dry weight. For the first time the results demonstrates an intact secretory machinery of the B-cells under controlled conditions in an early stage of gestational development.

The effect of intensified conventional insulin therapy before and during pregnancy on the malformation rate in offspring of diabetic mothers.

56 out of the 200 pregnant diabetic women admitted to our clinic between July 1981 and June 1983 had followed a pre-pregnancy metabolic intensive treatment programme. Most of these patients achieved near-normoglycemia: 87% or more of all their blood glucose readings before conception and in the early weeks of gestation were normoglycemic. The 56 patients were delivered of 57 babies, one of them suffering from fatal heart malformation. The 144 pregnant diabetics who were admitted to hospital only after eight weeks of pregnancy and had not had any special preconceptional metabolic control gave birth to 145 children, 9 of which presented congenital malformations: 3 of these were fatal another 3 were severe, and 3 were minor. These data are in line with our previously reported results on the years 1977-81. They stress the importance of a reasonably strict metabolic control, started well before conception, to prevent excess rates of congenital malformation.

[Quantitative-histologic studies of human fetal pancreas from metabolically healthy and insulin-dependent diabetic women]. / Quantitativ-histologische Untersuchungen des fetalen menschlichen Pankreas von stoffwechselgesunden Frauen und insulinabhängigen Diabetikerinnen.

Human fetal pancreases from nondiabetic (n = 26) and insulin-dependent diabetic women (n = 14) between the 13th and 26th week of pregnancy were investigated morphologically. There was in enhanced islet cell volume in fetuses from diabetic patients compared to those from nondiabetics, mainly caused by nesidioblastosis. This phenomenon could be caused by the metabolic state of the insulin-dependent diabetic patients. There were also single beta cells or groups of beta cells, which could be found between the exocrine pancreatic tissue, already at an early stage in pregnancy. It is assumed, that the nesidioblastosis in fetuses from diabetic women is caused by a continuous stimulation of the fetal endocrine pancreas during pregnancy. These results are in a good correlation to the in vitro results of the insulin secretion of human fetal pancreatic slices after incubation.

[Immunocytochemical studies of the development of basal cell types of human islet organs]. / Immunzytochemische Untersuchungen zur Entwicklung der Grundzelltypen des menschlichen Inselorgans.

The investigations are carried out in 19 human fetal pancreases. The detection of the 4 islet hormones insulin, glucagon, somatostatin and PP ist carried out in PAP-technique. The parts of these 4 types of islet cells are estimated quantitatively. In the 10th to 15th week of development insulin-producing B-cells are present. Moreover glucagon-, somatostatin- and PP-cells in the islet organ are present. In the group of 16th to 20th week of gestation insulin-, glucagon- and somatostatin-cells are increased compared to the first group. PP-cells are not altered. The increase of 3 types of islet cells is a result of fetal development.

Tissue cultivation as a method for preservation of human foetal islet parenchyma--a correlated biochemical, immunohistochemical and morphometric investigation.

Tissue culture of human foetal pancreas slices, obtained at a gestational age between 10 and 19 weeks, as a method of preservation and to pool the material before transplantation was investigated. Before and after 2 weeks of culture the pancreatic insulin content, the insulin secretion in response to glucose and isobutylmethylxanthin (IBMX) as well as the protein biosynthesis were measured. In addition, the distribution of the insulin immunoreactive cells was examined, as well as their relative volume density. After 2 weeks' culture an increase of the basal insulin secretion was observed; this was probably due to the glucose content (10 mmol/l) in the culture medium. Neither the stimulated insulin secretion, nor the protein biosynthesis, the insulin content, and the B-cell volume were altered by the used culture conditions. It was concluded that tissue culture is a suitable method to preserve human foetal pancreas slices before transplantation.

[Experiences with centralized care for pregnant diabetic women--results of the 1976 treatment period]. / Erfahrungen mit der zentralisierten Betreuung schwangerer Diabetikerinnen--Ergebnisse des Behandlungszeitraumes 1976.

73 diabetic pregnant were controled and treated in our clinic 1976, there was a perinatale mortality of 2,7%. The great part of EPH--gestosis and infections of the urinary system and more operative deliveries show of a higher risk already in the stage of latent diabetes. By screening methodes for diabetics during pregnancy and by intensive control in the first trimester it will be possible to obtain better results in the future.

[Studies into human foetal pancreas--critical appraisal of methods for tissue preparation (author's transl)]. / Untersuchungen am humanen fetalen Prankreas--Methodenkritik zur Gewebegewinnung.

Three different methods of legal abortion were applied to 23 patients, who had asked for termination of pregnancy, between the eleventh and 14th weeks of pregnancy. In vitro studies into human foetal pancreas were taken into consideration, when the choice was made. Carbohydrate tolerance was normal in all cases (50 g oGTT). Timing of intra-uterine foetal death, in the context of the three above methods (B-scan ultrasonic diagnosis and HPL level measurement) as well as studies into in vitro stimulation of foetopancreatic insulin secretion have shown purely mechanical, surgical abortion, sometimes following prostaglandin cervical gel priming, to be indispensable a condition for successful in vitro elucidation of the aetiopathogenesis of foetal diabetes. Extra-amniotic prostaglandin induction of abortion has failed to yield any relevant information, in that context.

PIP: 3 different methods of legal abortion were administered to 23 patients who had requested termination of pregnancy between weeks 11-14 of pregnancy. In vitro studies into human fetal pancreas were taken into consideration when the choice was made. Carbohydrate tolerance was normal in all cases (50 g oGTT). Timing of intrauterine fetal death, in the context of the 3 above methods (B-scan ultrasonic diagnosis and HPL level measurement), as well as studies into in vitro stimulation of fetopancreatic insulin secretion, have shown purely mechanical, surgical abortion, sometimes following prostaglandin (PG) cervical gel priming, to be indispensable as a condition for successful in vitro elucidation of the etiopathogenesis of fetal diabetes. Extraamniotic PG induction of abortion has failed to yield any relevant information in that context. (author's)

Secretion and biosynthesis of (pro)insulin by pancreatic islets isolated from fetuses of normal and diabetic women.

Insulin secretion, biosynthesis and content of isolated pancreatic islets prepared for fetuses of nondiabetic or insulin-dependent diabetic women were investigated in vitro. Glucose failed to stimulate the hormone release during an incubation period of 60 min in islets of fetuses from non-diabetic women. Prolongation of the glucose exposure or the addition of theophylline resulted in a significantly enhanced insulin release. The islets isolated from fetuses of insulin-dependent mothers are glucose-sensitive with respect to hormone release and biosynthesis. The results demonstrated that the human fetal B-cell is glucose-sensitive after glucose exposure. The differences between the islets of fetuses of nondiabetic and diabetic women are discussed as a response to the fetal plasma glucose levels.