Hyperglycemia in pregnancy - prevalence and perinatal outcomes. A retrospective multicenter cohort study in Poland.

OBJECTIVES: Hyperglycemia in pregnancy (HIP) is one of the most common complications of pregnancy. Recently adopted new criteria for the diagnosis of HIP as well as the greater prevalence of risk factors could have a significant impact on HIP prevalence. The objective of the study was to assess the rates of HIP and the associated complications. MATERIAL AND METHODS: This was a retrospective analysis of clinical records from pregnant women who delivered in eight tertiary hospitals in Poland in 2016. RESULTS: The number of pregnant women with hyperglycemia totaled 1280 (7.25%), including gestational diabetes mellitus (GDM) in 1169 (6.62%) women and pregestational diabetes mellitus (PGDM) in 111 (0.63%). In addition to dietary modifications, 477 (41% of the GDM group) women received medical treatment (GDMG2). In women with PGDM multiple daily insulin injections (MDI) were used in 53 (47.7%) cases, continuous subcutaneous insulin infusions (CSII) in 57 (51.3%) cases and one woman was treated with metformin. The rate of cesarean sections was 69.4% and 62.9% for PGDM and GDM, respectively. Large-for-gestational-age (LGA) infants accounted for 38% and 21% of births in the PGDM and GDM groups, respectively. Of note are high rates of hyperbilirubinemia in infants born to mothers treated with insulin (13.5% for PGDM and 14.4% for GDMG2) vs infants born to mothers with diet (GDMG1) (3.4%). CONCLUSIONS: In Poland, the prevalence of HIP has nearly doubled in the past twenty years. Even with appropriate management, HIP is a significant risk factor for a cesarean section delivery, bearing an LGA infant and adverse neonatal outcomes.

Maternal and neonatal serum expression of the vascular growth factors in hyperglycemia in pregnancy.

INTRODUCTION: Hyperglycemia in pregnancy (HIP) occurs in up to 8-17% of pregnancies. Unfavorable impact of the pregnancy induced hyperglycemia on both maternal and fetal tissues is associated with adverse pregnancy outcomes. Vascular growth factors, especially in the early phase of gestation, are considered as one of the most significant molecules that regulate pregnancy course and their serum expression may be altered in patients affected with HIP. MATERIAL AND METHODS: Fifty-five consecutive pregnant patients who underwent elective cesarean section were incorporated into this study. During the surgery, maternal and cord blood samples were collected. Serum expression levels of vascular growth factors: PlGF, VEGF, THBS-2 and Ang-2 were compared among non-HIP and pregnancies affected by gestational diabetes. Subsequently, laboratory results were correlated with obstetric outcomes. RESULTS: There were no statistical differences in maternal characteristics, neonatal outcomes and maternal or neonatal serum levels between study and control groups. However, our results revealed significant differences between fetal and maternal levels of VEGF (p = .028 and .0001), THBS-2 (p = .013 and .0014) and Ang-2 (p = .035 and .048) for HIP and non-HIP group, respectively. CONCLUSIONS: Similar serum expressions of vascular growth factors in and non-HIP and HIP pregnancies point that normal glycemia due to thorough prenatal surveillance may result in normal angio- and vasculogenesis associated with good pregnancy outcomes.

First trimester erythropoietin (EPO) serum concentration as a potential marker for abnormal placentation disorders. Reference values for erythropoietin (EPO) concentration at 11-13⁺6 weeks of gestation.

OBJECTIVES: To investigate the possible effect of abnormal placentation disorders such as preeclampsia (PE), pregnancy induced hypertension (PIH) and intrauterine growth restriction (IUGR) on erythropoietin (EPO) serum concentration in women in the first trimester of pregnancy. MATERIAL AND METHODS: A prospective study was performed in a group of pregnant women between 11 and 13⁺6 weeks' gestation. Serum concentration of EPO, beta HCG, PAPP-A and PlGF was measured. Mean arterial pressure (MAP) and uterine artery pulsatility index was calculated. RESULTS: A group of 198 analyzed patients was divided into three groups depending on pregnancy outcome: abnormal placentation group (n=30), macrosomia (n=13) and control group (n=155). EPO concentrations between the three groups of patients revealed that they differ significantly (F=15.172, P<0.001). EPO concentration is significantly higher in abnormal placentation patients compared to the control group (P<0.001) and macrosomia group (P=0.004). The most significant increase in EPO concentration was detected within patients with PIH. Also the uterine artery pulsatility index was positively correlated with EPO concentration (P<0.01). CONCLUSIONS: First-trimester maternal EPO concentration might be considered as a possible marker of abnormal placentation disorders and should be given more attention in future prospective studies.

Reference values for placental growth factor (PlGF) concentration and uterine artery doppler pulsatility index (PI) at 11-13(+6) weeks of gestation in the Polish population.

OBJECTIVES: The aim of the study was to determine placental growth factor (PIGF) concentration and uterine artery (UtA) Doppler pulsatility index (PI) at 11-13(+6) weeks of gestation in the Polish population. MATERIAL AND METHODS: A prospective study was performed in pregnant women who underwent routine ultrasound scan at 11-13(+6) weeks of gestation. All participants completed a questionnaire about their medical history demographics and current pregnancy. Mean arterial pressure (MAP) was calculated. Gestational age was confirmed by CRL and mean UtA PI was calculated. Blood samples were taken to measure beta HCG, PAPP-A and P/GF concentrations. RESULTS: Out of the 577 analyzed participants, 60 (10.4%) were found to have abnormal placentation disorders (20 -hypertensive disorders and 40-IUGR). The patients were subdivided into two groups, depending on pregnancy outcome: unaffected (n = 517) and affected (n = 60). The study did not confirm the anticipated correlation between maternal BMI and PIGF, but the concentration of PIGF was significantly increased in smokers. UtA PI values were not statistically significantly different depending on maternal age, BMI, method of conception, smoking or parity The study confirms that both, UtA PI and PIGF concentrations are CRL-dependent. Median MoM values for PIGF and UtA PI were obtained for each set of CRL measurements. Median PIGF MoM was decreased in pregnancies complicated by hypertensive disorders and IUGR as compared to the unaffected group. CONCLUSIONS: The established reference ranges for UtA PI and PIGF at 11-13(+6) weeks of gestation may be of clinical value in predicting placenta-associated diseases in early stages of pregnancy in the Polish population.

[Tocolysis in preterm labour--current recommendations]. / Tokoliza w porodzie przedwczesnym--aktualne wytyczne.

Common use of tocolytic drugs in preterm labor has not been shown to reduce the rate of neonatal mortality and morbidity Currently tocolytics should be administered in the course of a 48-h administration of antepartum glucocorticoids and/or transfer of the gravida to a center with neonatal intensive care unit. Only oxytocin receptor antagonist--atosiban and short-acting beta-agonists--fenoterol are licensed to reduce preterm uterine activity Owing to its safety and efficacy atosiban should be the first-choice tocolytic, especially in women with other diseases or multiple gestations.

Doppler flow parameters in orbital arteries in gestational diabetes mellitus patients.

OBJECTIVE: To evaluate the blood flow in orbital arteries in patients with gestational diabetes mellitus (GDM). MATERIAL: We have examined 65 GDM patients and 38 healthy pregnant women at 28-32 weeks. Doppler parameters were assessed in ophthalmic, central retinal and short posterior ciliary arteries. RESULTS: In ophthalmic arteries V2 was significantly higher and RI lower in GDM. In the subgroup treated with insulin V1 and V2 in ciliary artery and V2 in central retinal artery were significantly lower and PI in ciliary artery was higher when compared to subgroup on diet. CONCLUSION: Doppler examination can be useful in detection of pre-clinical ophthalmological changes in GDM patients.

First trimester maternal serum vitamin D and markers of preeclampsia.

OBJECTIVE: There is evidence that vitamin D deficiency is associated with preeclampsia. The aim of the study was to determine if maternal levels of vitamin D at 1st trimester were related to markers of preeclampsia. MATERIAL: Serum levels of 25-hydroxy-vitamin D (25OHD), PAPP-A, PlGF, uterine artery pulsatility index and mean arterial pressure were measured in 280 pregnant women. RESULTS: Preeclampsia markers were not related to 25OHD concentration. CONCLUSION: First trimester maternal serum concentration of vitamin D does not seem to be connected with markers of preeclampsia.

Maternal weight gain in women with gestational diabetes mellitus.

OBJECTIVE: The aim of the study was to examine the perinatal outcomes in gestational diabetes in women with body mass index (BMI)-adjusted gestational weight gain (GWG) according to the Institute of Medicine (IOM) 2009 recommendations. MATERIAL AND METHODS: The clinic's database was used to analyze 675 singleton GDM pregnancy outcomes. GWG for the entire pregnancy was compared to IOM recommendations and adjusted for prepregnancy BMI categories: underweight <18.5; normal 18.5-24.9; overweight 25-29.9; and obese >30. The study group was divided into three categories: below IOM limits, within IOM limits and above IOM limits. RESULTS: Only 37% of women achieved the proper weight gain (n=256). Almost 30% of women with GDM (n=196) had an excessive weight gain. GWG above limits was associated with a significantly higher neonatal measurements and a higher rate of large-for-gestational-age neonates. In underweight and normal-prepregnancy-weight women, no relation between GWG and birth-weight percentile was noted. For the overweight and obese women, a positive significant correlation between GWG until GDM diagnosis and birth-weight percentile was noted (P=0.002), which was not present when GWG until delivery was considered. CONCLUSIONS: Limited weight gain in overweight and obese women with gestational diabetes mellitus results in favourable pregnancy outcomes.

[Evaluation of changes in the mode of twin deliveries over the years]. / Ocena zmian w sposobie prowadzenia porodu ciaz blizniaczych na przelomie lat.

AIM: The aim of the study was to evaluate changes in the course of twin deliveries over the years, with particular emphasis on the history of infertility duration of pregnancy mode of delivery indications for caesarean section (CS) and infant condition. MATERIAL AND METHODS: The study consisted of three groups of patients who delivered twins at the First Department of Obstetrics & Gynecology Medical University of Warsaw: 92 women in years 1987-1991 (G1), 62 in years 1997-2001 (G2) and 126 in years 2007-2010 (G3). The history of infertility treatment (especially in vitro fertilization), mode of delivery indications for cesarean section and newborn condition were taken into account. The results were afterwards compared among the groups and the differences were analyzed with the use of Statistica 10.0 software, with p value <0.05 considered as significant. RESULTS: The rate of twin deliveries in G1 was 1.03% of all deliveries, 1.09% in G2 and 1.77% in G3 (p=0.049 G3 vs. G1). An increase of twin deliveries among primiparas (from 44.5% in G1 through 48.3% in G2 to 66.7% in G3; p=0.0016) and primiparas after in vitro fertilization (from 9.76% in G1 through 26.67% in G2 to 58% in G3; p<0.001) was noted. The average age of patients and mean duration of pregnancies were similar in G1, G2 and G3. However there was a significant increase in preterm delivery rate in G2 and G3 in comparison to G1 (G1 - 38.4%; G2 - 63.3%; G3 - 64.3%; G1 vs G2 and G3 p<0.001). CS was performed in 47.8% vs. 58% vs. 90.5% of all cases (p<0.0001). In G1 CS was most often performed when the presentation of the 1st fetus was non-cephalic (53.3%). In G2 and G3 the non-cephalic presentation of the 1st or 2nd fetus was equally important as an indication for CS (30.5%, 30.5% and 19.3%, 21.9%, respectively). Manual maneuvers on the 2nd twins were applied in 25% vs. 6.5% vs. 0.79% of deliveries (p<0.01). Cesarean section on the second twin, after the first twin was delivered vaginally was performed in 1.07% of the cases in G1, 1.61% in G2 and in 0.79% in G3 (p=ns). There were no differences in the Apgar scores of the first twins in the 1st and 5th minute of life among the studied groups. However, second twins were delivered in significantly better condition in G2 and G3 than in G1 (5-minute Apgar of 8-10 points: 79.7% vs. 93.3% vs. 92.6%; p<0.05). CONCLUSIONS: Twin pregnancy rate almost doubled over the years, mostly due to a growing popularity of the infertility treatment. Cesarean section is increasingly being chosen to deliver twins. The non-cephalic position of the 2nd fetus has become an important indication for cesarean section. Change in the mode of twin deliveries can be beneficial for the condition of the 2nd twin.

Pregnancy in patients with cancer.

We analyzed 12 cases of pregnant women divided into two separate groups: tumor diagnosed and treated before pregnancy and tumor diagnosed during pregnancy. Increasing number of simultaneous incidence of cancer and pregnancy is probably related to higher childbearing age. Our results suggest that cancer diagnosed both during and before pregnancy does not necessarily result in poor maternal and neonatal outcome.

Third trimester plasma adiponectin and leptin in gestational diabetes and normal pregnancies.

The aim of this study was to compare pregnant women with and without gestational diabetes (GDM) with regard to third trimester adiponectin, leptin and insulin resistance, as well as to investigate their relation to fetal growth and macrosomia. 134 pregnant women were enrolled in the study: 86 with GDM and 48 controls. Maternal plasma adiponectin, leptin, fasting insulin, glucose and fetal biometry were measured between 27 and 32 weeks of gestation. Birthweight and delivery data were also assessed. Adiponectin in GDM patients was lower when compared to non-diabetic women while mean leptin concentration was not different. In GDM group only mothers' weight gain until third trimester was significantly different between the groups of patients with normal and accelerated fetal growth. No correlation of adiponectin and leptin with fetal growth was shown. Mothers' weight gain until third trimester and mean fasting glucose between 33 and 34 weeks of gestation were associated with neonatal macrosomia. There were no differences in adiponectin and leptin between mothers of macrosomic and non-macrosomic neonates. Fetal growth seems not to be related to third trimester adiponectin and leptin concentrations, while increased third trimester fasting glucose may be an independent risk factor of macrosomia.

Placental first trimester's measurements in relation to maternal plasma adiponectin, leptin and insulin concentrations.

OBJECTIVE: The dysregulation of adiponectin and leptin is found in insulin resistance. There is evidence that both cytokines and insulin might contribute to the placental development and the fetal growth. The objective of this study was to evaluate the relationship of maternal plasma cytokine and insulin concentrations with the placental dimension in the first trimester of pregnancy. METHODS: 34 women with singleton pregnancy, between 11th and 14th weeks, were included to the study. Plasma levels of adiponectin, leptin, insulin and glucose were quantified with ultrasound measurements of the placenta. HOMA-IR were calculated to assess the insulin sensitivity. RESULTS: Mean concentrations of adiponectin, leptin and insulin were 18,39±13.99 µg/ml; 6.99±5.67 ng/ml and 43.98±23.89 pmol/l respectively. The placenta thickness was positively associated with the maternal adiponectin plasma concentration (r=0.36; p=0.037). There were no associations between placental measurements and leptin, fasting insulin, fasting glucose and HOMA-IR. There was not significant correlation between placental measurements and the fetal Crown Rump Length (CRL). CONCLUSIONS: The results of this study imply that maternal adiponectin plasma concentration may have a role in placental growth.

Maternal plasma adipokines and insulin concentrations in relation to fetal biometry in the gestational diabetes.

OBJECTIVE: Maternal insulin sensitivity have strong correlation with fetal growth. The dysregulation of adiponectin and leptin is found in insulin resistance. The aim of this study was to determine whether there is an association between ultrasound fetal biometry and the maternal plasma cytokines and insulin concentrations at the beginning of gestational diabetes treatment. METHODS: 121 women with gestational diabetes diagnosed between 26th and 30th weeks, were included to the study. Plasma levels of adiponectin, leptin, insulin and glucose were quantified with the measurements and percentiles of the biparietal diameter, head circumference and abdominal circumference , estimated fetal weight and the actual birthweight. RESULTS: Associations between both of the adipokines and fetal biometry measurements were not evident. There were also no differences in their serum concentrations between groups of women with and without accelerated fetal growth . Adiponectin negatively correlated with pre-pregnancy BMI (r=-0.366, p=0.01). Leptin positively correlated with pre - pregnancy BMI (r=0.42, p=0.002), fasting insulin (r=0.51, p=0.0006) and HOMA-IR (r=0.43, p=0.005). No association was found between adiponectin, leptin, fasting insulin, HOMA-IR and neonatal birth weight or birth weight percentile. CONCLUSION: The results of this study imply that adiponectin, leptin and insulin maternal plasma concentrations in the third trimester do not have influence on fetal growth in gestational diabetes.

Maternal plasma cytokines concentrations and insulin resistance in first trimester in relation to fetal growth.

OBJECTIVE: Fetal growth is determined by genetic factors and placental supply. There is evidence that insulin might contribute to the up-regulation of placental transporter activity. The dysregulation of adiponectin and leptin is found in insulin resistance. The objective of this study was to evaluate the relation of maternal plasma cytokine and insulin concentrations in the first trimester of pregnancy to fetal growth. METHODS: 55 women with singleton pregnancy, between 12th and 14th weeks of gestation, were included to the study. Plasma concentrations of adiponectin, leptin, insulin and glucose were analyzed together with fetal ultrasound measurements and neonatal birth weight. The HOMA-IR were calculated (fasting insulin (microU/ml) x fasting glucose (mmol/l/22.5) to assess the insulin sensitivity. RESULTS: Mean concentrations of adiponectin, leptin and insulin were 15.29 +/- 13.83 microg/ml, 6.93+/-5.39 ng/ml and 43.59+/-26.28, respectively. The average insulin resistance defined by HOMA-IR was 1.35+/-0.8. The ratios of adiponectin to leptin, adiponectin to insulin and HOMA-IR were calculated. The percentiles of fetal crown-rump length (CRL) were negatively correlated with adiponectin plasma concentration (r=-0.32; p<0.05), with no relation to leptin and insulin plasma concentration. Correlations between fetus CRL percentile and the ratio of adiponectin to leptin concentration (r=-0.37; p<0.02) and adiponectin to HOMA-IR (r=0.35; p<0.05) were also observed. No association between adiponectin, leptin, fasting insulin, HOMA-IR and neonatal birth weight or birth weight percentile was found. The percentile of fetal CRL in the 1st trimester was positively correlated with neonatal birth weight percentile (r=0.3; p<0.05). CONCLUSIONS: The results of this study imply that maternal adiponectin concentration may play a role in early determination of fetal growth.

[Diagnostic of gestational diabetes mellitus and the prevalence of LGA (Large for Gestational Age)]. / Diagnostyka cukrzycy ciazowej a wystepowanie hipertrofii plodu (LGA).

OBJECTIVES: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance, first time detected in pregnancy. Early diagnosis of the disease may reduce fetal exposure to maternal hyperglycemia and decrease the risk of LGA. The aim of the study was to examine the influence of time and diagnostic method of GDM on the prevalence of LGA and pregnancy outcome among patients with gestational diabetes. MATERIAL AND METHODS: The study was conducted among 211 women with gestational diabetes mellitus, the patients of 1st Clinic of Obstetrics and Gynecology at the Medical University in Warsaw. We have reviewed the results of fasting plasma glucose, 50-g glucose screening test (GCT) and 2 hour 75-g glucose tolerance test in GDM patients with LGA and eutrophic newborns. The t-student or the Mann-Whitney test was used in order to compare both groups. P<0.05 was deemed statistically significant. RESULTS: LGA was diagnosed in 10.4% of patients. We did not find any significant differences in gestational age when GDM was diagnosed, results of fasting glucose GCT and OGTT among LGA (M) and control (K) group. However, when we compared the percentage of LGA in groups of women with different time of GDM diagnosis, the highest prevalence was noted in the group of first trimester diagnosis and between 28 and 32 weeks of pregnancy, which we found interesting. We compared the women and the results of the diagnostic tests with the group of standard time of GDM diagnosis (24-28 week of pregnancy) and the only difference was the late diagnosis. If 75-g glucose tolerance test had not included 1-hour after load glucose assignment, GDM would not have been diagnosed at all in 18.2% of female patients with LGA. We have not found any correlations between the results of the diagnostic tests, the time of the diagnosis or the mode of treatment GDM (diet alone or with insulin) and the birth weight. CONCLUSIONS: 1. Results of fasting glucose and glucose tolerance tests are not useful in the prediction of LGA in GDM pregnancies. 2. Diagnosis of GDM during the recommended period (between 24 and 28 weeks of pregnancy) may decrease the prevalence of LGA (comparing to later diagnostics). 3. 75-g glucose tolerance test should provide fasting, 1 and 2-hour after load glucose assignment.

Blood pressure and lipid changes in gestational diabetes mellitus.

OBJECTIVE: It is suggested that gestational diabetes mellitus (GDM) is the earliest phase of DM. Nowadays DM is treated as a part of insulin resistance syndrome--patients with DM tend to be obese, dyslipidemic and hypertensive. It is postulated that similar abnormalities are found in GDM patients. METHODS: The study was conducted among 81 women with GDM and 41 healthy controls. After diagnosis or negative screening for GDM the women underwent 24-hour blood pressure monitoring and measurements of plasma lipids, insulin concentrations and insulin resistance (expressed by HOMA score). The incidence of gestational hypertension and blood pressure until delivery was also analyzed. RESULTS: 17 (21%) of GDM women and only 1 glucose tolerant control developed pregnancy induced hypertension. GDM women had significantly higher arterial pressure during the daytime and nighttime (accordingly 112.1/69.4 mmHg vs. 105.4/64.8 mmHg and 101.5/62.4 mmHg vs. 93.0/58.8 mmHg), although the average BP was within normal range. Heart rate was also faster in GDM group. Compared with healthy pregnant women, GDM patients had higher serum TG concentrations (247,9 vs 205 mg%; p<0,01), fasting insulin (66 vs 42,5 pmol/l; p<0,001) and insulin resistance (HOMA 2,15 vs 1,13; p<0,001). No correlation was found between blood pressure and insulin concentrations and insulin resistance among healthy and GDM women. CONCLUSIONS: The results suggest that symptoms of insulin resistance are present in GDM women. They are characterized by higher arterial blood pressure, heart rate, serum triglycerides, insulin and increased insulin resistance.