Type 1 Diabetes Mellitus and the First Trimester Placenta: Hyperglycemia-Induced Effects on Trophoblast Proliferation, Cell Cycle Regulators, and Invasion.

Type 1 diabetes mellitus (T1DM) is associated with reduced fetal growth in early pregnancy, but a contributing role of the placenta has remained elusive. Thus, we investigated whether T1DM alters placental development in the first trimester. Using a protein array, the level of 60 cell-cycle-related proteins was determined in human first trimester placental tissue (gestational week 5-11) from control (n = 11) and T1DM pregnancies (n = 12). Primary trophoblasts (gestational week 7-12, n = 32) were incubated in the absence (control) or presence of hyperglycemia (25 mM D-glucose) and hyperosmolarity (5.5 mM D-glucose + 19.5 mM D-mannitol). We quantified the number of viable and dead trophoblasts (CASY Counter) and assessed cell cycle distribution (FACS) and trophoblast invasion using a transwell assay. T1DM was associated with a significant (p < 0.05) downregulation of Ki67 (-26%), chk1 (-25%), and p73 (-26%). The number of viable trophoblasts was reduced under hyperglycemia (-23%) and hyperosmolarity (-18%), whereas trophoblast invasion was increased only under hyperglycemia (+6%). Trophoblast cell death and cell cycle distribution remained unaffected. Collectively, our data demonstrate that hyperglycemia decreases trophoblast proliferation as a potential contributing factor to the reduced placental growth in T1DM in vivo.

Concentrations of fatty acids among macrosomic neonates delivered by healthy women and women with type 1 diabetes mellitus.

OBJECTIVE: To evaluate the concentration and profile of fatty acids (FAs) among macrosomic neonates delivered by healthy pregnant women and pregnant women with type 1 diabetes mellitus (T1DM). METHODS: A prospective study of women who delivered macrosomic neonates at a University Hospital Center, Zagreb, Croatia, 2016-2018. Maternal, umbilical vein, and arterial blood samples were collected immediately on delivery. After lipid extraction, total FAs in maternal, umbilical vein, and arterial serum samples were assessed by gas chromatography. Data were compared between women with T1DM and healthy control women. RESULTS: In total, 50 women were enrolled: 22 with T1DM and 28 control women. Neonates in the T1DM group had a higher ponderal index as compared with the control group (P=0.006). Umbilical vein insulin, insulin resistance, and leptin concentration were higher in the T1DM group than in the control group (all P<0.001). Umbilical vein serum concentrations of total saturated, monounsaturated, n-3 polyunsaturated, and n-6 polyunsaturated FAs were higher in the T1DM group (P=0.004, P<0.001, P=0.015, and P=0.014, respectively). CONCLUSION: Macrosomic neonates delivered by women with T1DM had a higher Ponderal index, and higher concentrations of insulin, leptin, and FAs in the umbilical vein and artery as compared with control group newborns.

Higher Cord Blood Levels of Fatty Acids in Pregnant Women With Type 1 Diabetes Mellitus.

Context: Type 1 diabetes mellitus (T1DM) is associated with a disturbance of carbohydrate and lipid metabolism. Objective: To determine whether T1DM alters maternal and neonatal fatty acid (FA) levels. Design: Observational study. Setting: Academic hospital. Patients: Sixty pregnant women (30 women with T1DM with good glycemic control and 30 healthy women) were included in the study. Maternal blood, umbilical vein, and artery blood samples were collected immediately upon delivery. Following lipid extraction, the FA profiles of the total FA pool of maternal serum and umbilical vein and artery serum were determined by gas chromatography. Results: Total FA concentration in maternal serum did not differ between the study groups; it was significantly higher in umbilical vein serum of the T1DM group compared with that in the control group [median (interquartile range)]: T1DM 2126.2 (1446.4 to 3181.3) and control 1073.8 (657.5 to 2226.0; P < 0.001), and in umbilical artery vein serum: T1DM 1805.7 (1393.1 to 2125.0) and control 990.0 (643.3 to 1668.0; P < 0.001). Composition of FAs in umbilical vein serum showed significantly higher concentrations of saturated, monounsaturated, and polyunsaturated FAs (SFAs, MUFAs, and PUFAs, respectively) in the T1DM group than compared with those in the control group (P = 0.001). Furthermore, cord blood levels of leptin (P < 0.001), C-peptide (P < 0.001), and insulin resistance (P = 0.015) were higher in the T1DM group compared with controls. Conclusion: The neonates born to mothers with T1DM had higher concentrations of total FAs, SFAs and MUFAs, as well as PUFAs, compared with control newborns.

Maternal Type 1 diabetes activates stress response in early placenta.

INTRODUCTION: Human pregnancy and in particular the first trimester, is a period highly susceptible towards adverse insults such as oxidative stress, which may lead to inadequate embryonic and feto-placental development. Diabetes mellitus is associated with increased oxidative stress caused by hyperglycemia, reactive oxygen species (ROS) production and inflammatory signals. In pregnancy, diabetes elevates the risk for early pregnancy loss, preeclampsia and fetal growth restriction, pathologies that origin from early placental maldevelopment. We hypothesized that maternal Type 1 diabetes mellitus (T1DM) induces oxidative stress in the first trimester human placenta. METHODS: We quantified stress induced, cytoprotective proteins, i.e. heat shock protein (HSP)70 and heme oxygenase (HO)-1 and determined protein modifications as markers for oxidation and glycation, i.e. levels of 4-hydroxynonenal (HNE) or Nε-(carboxymethyl)lysine (CML) modified proteins. Moreover, we measured expression levels of enzymes involved in antioxidant defense in the first trimester (week 7-9) placenta of normal and T1DM women by immunoblot and real-time qPCR. Primary human trophoblasts were isolated from first trimester placenta and the effects of oxygen, hyperglycemia and the pro-inflammatory cytokine tumor necrosis factor (TNF)-α on levels of HSP70 and HO-1 were analyzed. RESULTS: HSP70 (+19.9± 10.1%) and HO-1 (+63.5± 14.5%) were elevated (p < 0.05) in first trimester placenta of T1DM women when compared to normal women. However, levels of HNE or CML modified proteins were unchanged. Also, expression of most antioxidant enzymes was unchanged, with only superoxide dismutase 3 (SOD3) being upregulated by 3.0-fold (p < 0.05). In isolated primary trophoblasts, HSP70 and HO-1 were upregulated by increasing oxygen tension, but not by hyperglycemia or TNF-α. CONCLUSION: Although protein oxidation and glycation was not elevated, we infer that T1DM increases placental cellular stress in the first trimester. Elevated stress in early placenta of T1DM women may contribute to disturbances in placental development.

[Pregnancy outcomes in a patient-heterozygous carrier of R506Q mutation of factor V (Leiden)]. / Ishodi trudnoca u bolesnice-heterozigotne nositeljice R506Q mutacije faktora V (Leiden).

The aim was to review currently available evidence on the association between thrombophilia and adverse pregnancy outcomes. Maternal thrombophilia has recently been identified as a major cause of thromboembolism, placental thrombosis and adverse pregnancy outcome including severe preeclampsia, placental abruption, intrauterine growth retardation, recurrent pregnancy loss, and stillbirth. The relatively high prevalence of thrombophilia defects in the general population and the association with adverse maternal and fetal outcomes have prompted obstetricians to focus their interest on this area. We focused on genetic thrombophilias (factor V Leiden mutation) and its possible impact on severe preeclampsia, placental abruption and intrauterine fetal death. A 39-year-old patient was regularly treated at our Department. Her mother had placental abruption and deep venous thrombosis of lower extremities in medical history. Our patient was suffering from multiple sclerosis from 1990. Until this pregnancy she had been pregnant for six times and had delivered one healthy child. She had four cesarean sections, one for preeclampsia (live-born infant died three days after birth), two for placental abruption (both stillbirths), one spontaneous abortion and one artificial abortion. Having in mind her family and medical history, we focused on genetic thrombophilia. Using the PCR-method we identified activated protein C resistance due to factor V Leiden mutation. The patient was treated by low-molecular weight heparin. A healthy infant was born by cesarean section after 37 weeks of gestation. Therapy with low-molecular weight heparin continued for ten days postpartum.

Prevalence of gestational diabetes mellitus according to IADPSG and NICE criteria.

OBJECTIVE: To investigate the impact of the International Association of Diabetic Pregnancy Study Group (IADPSG) diagnostic criteria on the prevalence of gestational diabetes mellitus (GDM) and overt diabetes as compared with the UK National Institute for Health and Care Excellence (NICE) criteria, and to evaluate the prevalence of maternal and perinatal outcomes among pregnant women with fasting plasma glucose (FPG) levels of 5.1-5.5 mmol/L. METHODS: A retrospective study was undertaken of data for women who underwent a 2-hour 75-g oral glucose tolerance test at 24-32 weeks of a singleton pregnancy at a center in Croatia between January 2012 and December 2014. RESULTS: Among 4646 included women, 1074 (23.1%) had GDM according to IADPSG criteria, 826 (17.8%) would be diagnosed according to NICE criteria, and 50 (1.1%) had overt diabetes. FPG levels were 5.1-5.5 mmol/L for 409 (8.8%) women. Compared with a control group (n=3391), these women had higher odds of large-for-gestational-age newborns (odds ratio 3.7, 95% CI 2.0-4.6) and cesarean delivery (odds ratio 1.8, 95% CI 1.3-2.3). CONCLUSION: Women with FPG levels of 5.1-5.5 mmol/L have an increased risk of adverse maternal and perinatal outcome, although they would not be diagnosed with GDM according to NICE criteria.

Myasthenia gravis in pregnancy: report on 69 cases.

OBJECTIVE: To review our experience with pregnancies in women with myasthenia gravis (MG). STUDY DESIGN: Sixty nine pregnancies among 65 women with MG patients managed by our department over 28 years were included. The course of the disease in pregnancy, mode of delivery and postpartal period were evaluated. RESULTS: One pregnancy miscarried. In 15% of patients the MG deteriorated in pregnancy a further 16% in the puerperium. 17% of pregnancies were delivered by cesarean section, one due to myasthenia exacerbation. All women with puerperal infections developed exacerbations. One neonatal death, not attributable to myasthenia, was recorded. Transitory neonatal myasthenia gravis (TNMG) was diagnosed in 30% infants. Its incidence was inversely associated with maternal disease duration (P < 0.05). Newborns of thymectomized mothers showed lower rate of neonatal myasthenia compared to those of non-thymectomized women (P < 0.05). CONCLUSIONS: MG patients can have normal pregnancy and delivery but the course is unpredictable. Shorter disease history and infection predispose to puerperal exacerbation. Maternal thymectomy lessens the likelihood of neonatal myasthenia. An interdisciplinary approach is required for managing the pregnant women with MG.

Splenic rupture in pregnancy--traumatic or spontaneous event?

Splenic rupture in pregnancy or postpartum is a rare and frequently misdiagnosed occurrence. Failure to recognise it is common, and can be fatal for both mother and child. With all our highly developed diagnostic methods and equipment, aetiology of splenic ruptures in pregnancy remains a dilemma in many cases.

[Glycemic control and the risk of preeclampsia in women with gestational diabetes mellitus]. / Utjecaj regulacije glikemije na ucestalost preeklampsije u trudnica s gestacijskim dijabetesom.

INTRODUCTION: Gestational diabetes mellitus (GDM) is associated with an increased risk of preeclampsia and other complications throughout pregnancy. AIM: The aim of the study was to analyze the incidence of preeclampsia and other risk factors in GDM pregnant women. STUDY DESIGN AND METHODS: During 1992-2001 period, 472 consecutive unselected pregnancies were followed up in women with GDM. Glycemic control was assessed by HbA1c at the time of diagnosis. Preeclampsia was defined as blood pressure 140/90 mm Hg combined with albuminuria of >0.3 g/L. The occurrence of preeclampsia was also assessed in a control group comprising 324 unselected pregnant women. RESULTS: Preeclampsia developed in 14.4% of GDM women and 4.3% of controls. After adjustment by logistic regression, both fasting blood glucose (FBG) and profile blood glucose (PBG) and their changes during pregnancy remained significant predictors for preeclampsia. The odds for preeclampsia increased by a factor 1.2 for each 1 mmol/L increment in initial FBG level and PBG level, and decreased by factor 0.8 for each 1 mmol/L decrease of FBG or PBG level achieved during pregnancy. CONCLUSION: Improvement of the glycemic control during pregnancy reduces the risk of preeclampsia.

[Cardiovascular neuropathy in pregnant women with type 1 diabetes]. / Kardiovaskularna neuropatija u trudnica s dijabetesom tipa 1.

OBJECTIVE: Autonomic neuropathy has recently been recognized as a potential risk factor in pregnancy of type 1 diabetics. The aim of the study was to highlight this poorly recognized problem in the obstetric management of diabetic mothers. STUDY DESIGN: 94 pregnant type 1 diabetics aged 20-35 with a minimum five--year duration of diabetes. A normal population, i.e. 46 age-matched pregnant women without diabetes were evaluated, because there are no normal values for this population. Cardiovascular tests and structured clinical examination were performed on 3 occasions 3 times during pregnancy (once in each trimester). Cardiovascular tests were performed using the ProSciCard system. A full test battery were performed and six basic tests were evaluated. HbA1c was used to assess diabetes control. Diabetic polyneuropathy was clinically assessed by Dyck's staging system. RESULTS: The incidence of moderate and severe autonomic neuropathy in type-1 diabetic pregnant women was 8.5%. There was no increase in the perinatal morbidity and mortality associated with moderate and severe autonomic neuropathy. CONCLUSION: The presence of moderate to severe symptomatic autonomic neuropathy in patients with type-1 diabetes is not a contraindication for pregnancy. If pregnancy is achieved, the patients should be monitored for the occurrence of pernicious vomiting.

Arachidonic and docosahexaenoic acid in the blood of a mother and umbilical vein in diabetic pregnant women.

OBJECTIVE: The aim of the study was to determine the total concentration of fatty acids (FAs) in the maternal vein serum and in the umbilical vein serum in pregnant women suffering from Type 1 diabetes compared to healthy women. Additional goal was to determine the percentages of arachidonic (AA) and docosahexaenoic acid (DHA) in comparison to the total concentration of FAs. METHODS: The study included 63 pregnant women, 32 suffering from Type 1 diabetes and 31 healthy pregnant women. Extraction of total lipids was performed using gas chromatography. RESULTS: There was statistically significant difference in the total FAs concentration in the maternal vein serum and the umbilical vein serum between the two groups. There was a statistically significant higher concentration of total FAs in the maternal and umbilical vein serum of the diabetic group. Higher AA and DHA concentrations were found in the maternal vein serum compared to an umbilical vein serum of the diabetic group. CONCLUSION: No difference was found in AA and DHA percentages in the maternal or in the umbilical vein serum of diabetic pregnant women. Despite of T1DM, a good metabolic control leads to insignificant changes in the AA and DHA levels in diabetic pregnancy.

Successful pregnancy and delivery of two sets of monozygotic twins after intracytoplasmic sperm injection and embryo transfer: case report and literature review.

OBJECTIVE: To report a unique case of successful pregnancy and delivery of two pair of monozygotic twins (quadruplets) after intracytoplasmic sperm injection (ISCI) and transfer of two blastocysts. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 30-year-old nulligravida, who had first ISCI, assisted hatching, and fresh embryo transfer because of a male factor of infertility (severe olygoasthenozoospermia). INTERVENTION(S): Prophylactic cervical cerclage sec. McDonald in the 21st week of pregnancy, hospitalization, and intensive care of pregnancy, ending with delivery by planned Cesarean section (CS) in the 34th week of pregnancy. MAIN OUTCOME MEASURE(S): Successful pregnancy and delivery of two male and two female twins in the 34th week of pregnancy. RESULT(S): Two blastocysts were divided and four embryos developed. After extensive counseling the couple decided to keep all embryos. In the 21st week prophylactic cerclage was preformed. During hospitalization the ultrasound examination was performed every 2 weeks, and from the 30th week on a cardiotocogram was recorded. At the 33rd week her blood pressure increased and she received antihypertensive therapy. At the 34th week planned CS was performed and four newborns (two male monochorionic monoamniotic twins, and two female monochorionic biamniotic twins) weighted between 1,300 and 2,170 g were born. CONCLUSION(S): Even without embryoreduction, intensive care throughout pregnancy including prophylactic cerclage, bed rest, prophylactic anticoagulant, and antihypertensive therapy results in delivery of four healthy newborns.

MT1-MMP expression in first-trimester placental tissue is upregulated in type 1 diabetes as a result of elevated insulin and tumor necrosis factor-alpha levels.

OBJECTIVE: In pregestational diabetes, the placenta at term of gestation is characterized by various structural and functional changes. Whether similar alterations occur in the first trimester has remained elusive. Placental development requires proper trophoblast invasion and tissue remodeling, processes involving matrix metalloproteinases (MMPs) of which the membrane-anchored members (MT-MMPs) such as MT1-MMPs are key players. Here, we hypothesize a dysregulation of placental MT1-MMP in the first trimester of type 1 diabetic pregnancies induced by the diabetic environment. RESEARCH DESIGN AND METHODS: MT1-MMP protein was measured in first-trimester placentas of healthy (n = 13) and type 1 diabetic (n = 13) women. To identify potential regulators, first-trimester trophoblasts were cultured under hyperglycemia and various insulin, IGF-I, IGF-II, and tumor necrosis factor-alpha (TNF-alpha) concentrations in presence or absence of signaling pathway inhibitors. RESULTS: MT1-MMP was strongly expressed in first-trimester trophoblasts. In type 1 diabetes, placental pro-MT1-MMP was upregulated, whereas active MT1-MMP expression was only increased in late first trimester. In isolated primary trophoblasts, insulin, IGF-I, IGF-II, and TNF-alpha upregulated MT1-MMP expression, whereas glucose had no effect. The insulin effect was dependent on phosphatidylinositol 3-kinase, the IGF-I effect on mitogen-activated protein kinase, and the IGF-II effect on both. CONCLUSIONS: This is the first study reporting alterations in the first-trimester placenta in type 1 diabetes. The upregulated MT1-MMP expression in type 1 diabetes may be the result of higher maternal insulin and TNF-alpha levels. We speculate that the elevated MT1-MMP will affect placental development and may thus contribute to long-term structural alterations in the placenta in pregestational diabetes.

Ultrasonic morphological characteristics of yolk sac in pregnancy complicated with type-1 diabetes mellitus.

BACKGROUND/AIMS: In pregnancy complicated with type-1 diabetes mellitus (DM), information on the predictive value of yolk sac (YS) measurement and YS morphology on outcome has been scant. The aim of this study was to compare the size and shape of the YS using transvaginal sonography (TVS) in normal pregnancies and those complicated with well-regulated type-1 DM. METHODS: Sixty healthy pregnant women and 60 pregnant women with type-1 DM underwent TVS. The correlation coefficients between YS and gestational age (GA), YS and crown-rump length (CRL), and YS and human chorionic gonadotropin (HCG) were calculated. Statistical analysis showed that the difference between the YS diameters for each gestational week among the groups studied was highly statistically significant. Statistical analysis of the results was performed with SPSS 10 software. RESULTS: A highly statistically positive correlation was found between YS diameter and GA, CRL and HCG levels for both groups studied. The YS diameter in type-1 DM pregnancies was statistically significantly larger for GA than that of healthy pregnant women. The YS diameter in type-1 DM women was statistically significantly larger after 6 weeks of gestation and the HbA1c levels were >6% when compared to the YS dimensions in the group with HbA1c concentrations of <6%. CONCLUSION: A gross change in YS size may indicate or reflect significant dysfunction of the maternofetal transport system in early pregnancy which is complicated with type-1 DM.

Obstetric risk factors associated with placenta previa development: case-control study.

AIM: To evaluate potential risk factors and perinatal outcome of pregnancies complicated with placenta previa in Croatian population of pregnant women recruited from the largest tertiary care perinatal center in Croatia. METHODS: This retrospective case-control study included a total of 202 singleton pregnancies with placenta previa during a 10-year study period and 1,004 randomly selected simple singleton controls. Data on potential risk factors for placenta previa development were carefully extracted from medical records, reviewed, and compared with a control group of women. Data were statistically analyzed with chi-square test and Mann-Whitney U test, and crude odds ratio (OR) with 95% confidence interval (95% CI) were provided. RESULTS: The incidence of placenta previa was 0.4%. Factors significantly associated with a placenta previa development were advanced maternal age (especially >34 years, even after adjustment for high parity), gravidity of 3 and more (OR, 4; 95% CI, 2.5-6.6), more than one previous delivery (OR, 2.76; 95% CI, 1.7-4.3), history of previous cesarean sections (OR, 2.0; 95% CI, 1.17-3.44), abortions (OR, 2.8; 95% CI, 2.04-3.83), and presence of various uterine abnormalities (OR, 8.5; 95% CI, 1.75-44.5). The risk was significantly increased after two previous cesarean sections (OR, 7.32; 95% CI, 2.1-25) and after one previous abortion (OR, 4.8; 95% CI, 2.7-8.3). No difference between the groups was found regarding the history of previous placenta previa, drug abuse, and male sex at birth. Smoking history was significantly less frequent in women with placenta previa than controls (16.3% vs 25.6%, chi-square=7.9, p=0.007). The main perinatal complication was preterm birth, with 14-fold higher risk in women with placenta previa. Preterm infants of mothers with placenta previa were more likely to have lower first- (6 vs 10, p<0.001) and fifth-minute median Apgar scores (8 vs 10, p<0.045). Term infants of mothers with placenta previa had significantly lower birth weight then their controls (3,300 vs 3,500 g, p<0.001). CONCLUSION: The most important obstetric factors for placenta previa development were advanced maternal age especially >34 years, 3 or more previous pregnancies, parity of 2 and more, rising number of previous abortions, and history of previous cesarean section, but not child sex at birth, history of drug abuse and previous placenta previa. Smoking cigarettes was significantly less frequent in women with placenta previa. Preterm delivery still remains the greatest problem in pregnancies complicated with placenta previa.

Fetal tobacco syndrome and perinatal outcome.

OBJECTIVE: The aim of this study was to evaluate perinatal outcome in newborns of mothers who are smokers. METHODS: The study included 87 pregnant women with a single pregnancy in the cephalic position, 64 of them nonsmokers (group 1), 13 who smoked 5-20 cigarettes per day (group 2) and 10 who smoked more than 20 cigarettes per day (group 3). Maternal demographic variables and laboratory hemoglobin concentration, hematocrit and erythrocyte count in the last trimester were recorded. Perinatal outcome included type of delivery (vaginal or cesarean section), birth weight, occurrence of meconium in the amniotic fluid, 5-min Apgar score, umbilical arterial blood pH postpartum, sex of the newborn, need for treatment at a neonatal intensive care unit (NICU) and clinically and neurosonographically verified postpartum neurologic complications in the newborn. RESULTS: A statistically significant correlation (p < 0.01) was found with the mean gestational age at delivery in all three groups of women, especially in those smoking >20 cigarettes per day, who had a higher incidence of premature deliveries. Maternal laboratory findings also differed significantly among the three groups of women, i.e. erythrocyte count (p < 0.01), hemoglobin concentration (p < 0.01) and hematocrit (p < 0.001). The rate of delivery by cesarean section was significantly higher in the groups of smokers, irrespective of the number of cigarettes per day (groups 2 and 3). Birth weight was lower by about 250 and 350 g (p < 0.001) in groups 2 and 3, respectively. Five-minute Apgar score and umbilical arterial blood pH were lower in group 3 as compared with groups 1 and 2 (p < 0.01). NICU treatment was required in more than 50% of infants born to group 3 mothers, in whom 70% of perinatal neurologic complications such as subependymal hemorrhage, periventricular hemorrhage, porencephalic cysts, intracranial hemorrhage and swallowing disturbance of the newborn were recorded (p < 0.001). The infants born to group 3 mothers had a longer and more difficult period of adaptation, thus often requiring an NICU stay. CONCLUSION: Our study confirmed that pregnancy burdened with smoking, especially in the case of >20 cigarettes a day, is associated with a high risk due to the development of maternal anemia and fetal hypoxia and polyglobulia, which in turn result in a significantly poorer perinatal outcome in infants born to smoking mothers and compromised subsequent development of the child, as evidenced by the morphological substrates on the brain resulting from the fetal mechanism of defense against hypoxia. Clinically, there was no other (etiologic) reason for (chronic) fetal hypoxia; thus, the clinical substrate of fetal tobacco syndrome could be presumed to have developed consequentially to chronic smoking during pregnancy, as a preuterine factor of fetal hypoxia. Other gestational or gestation-related diseases (e.g., gestosis, diabetes) that may potentially cause nutritional and respiratory insufficiency of the placenta were ruled out.