Fetomaternal adrenomedullin levels in diabetic pregnancy.

We investigated whether maternal and fetoplacental adrenomedullin, a newly discovered hypotensive peptide involved in the insulin regulatory system, is modified in diabetic pregnancy. We studied its correlation with pregnancy complications associated with this disease. Thirty-six pregnant women with diabetes (13 with type I and 23 with gestational diabetes mellitus) and in 40 uncomplicated pregnancies were included. 10 out of 36 diabetic pregnancies were complicated by gestational hypertension. In each woman, adrenomedullin concentration in maternal and fetal plasma and in amniotic fluid was assessed by specific radioimmunoassay. We found that overall mean amniotic fluid adrenomedullin concentration was higher (p < 0.05) in diabetic (14.7 +/- 1.6 fmol/ml) than in uncomplicated pregnancies (10.8 +/- 0.9 fmol/ml), whereas no differences were present in maternal and fetal plasma adrenomedullin levels between diabetic and uncomplicated pregnant women. High levels of amniotic fluid adrenomedullin were found in both type I and gestational diabetes mellitus pregnancies (13.7 +/- 1.4 and 15.6 +/- 2.2 fmol/ml, respectively). Diabetic pregnancies complicated by gestational hypertension showed lower (p < 0.05) amniotic fluid adrenomedullin concentrations than normotensive diabetic patients. These findings suggest that placental adrenomedullin production is upregulated in diabetic pregnancy, and it may be important to prevent excessive vasoconstriction of placental vessels.     

Blood glucose and insulin relationships in the human mother and fetus before onset of labour

The effects of a maternal intravenous glucose load on the fetal plasma levels of glucose and insulin have been studied in 11 patients before the onset of labour. Within five minutes the fetal plasma glucose concentration rose significantly, indicating a rapid transfer of glucose across the placenta. Following this, the rate of fall in fetal plasma glucose closely reflected that in the mother.Serial fetal insulin estimations carried out in 8 of the 11 subjects following maternal glucose showed an early rise in fetal insulin in four and a delayed rise in one; in the remaining three there was no definite change.It is concluded that the blood glucose level of the fetus is controlled by that of the mother, but that the fetal pancreas at term may respond to hyperglycaemia by the secretion of insulin.     

Carbohydrate metabolism in pregnancy. Part II. Relation between maternal glucose tolerance and glucose metabolism in the newborn.

The objective of clinical management of the pregnant diabetic woman is to prevent the serious adverse effects of an abnormal glucose environment on the fetus. Neonatal glucose assimilation and insulin release over the first two hours of life were correlated with various indices of maternal carbohydrate metabolism in the third trimester. Of the 31 mothers studied 21 were defined as normal and 10 as having chemical diabetes. Neontal glucose assimilation during the first two hours of life correlated strongly with functions of both maternal glucose tolerance and mean diurnal glucose level, the strongest correlation being with the area under the three-hour oral glucose tolerance curve (P less than 0.001), Two-hour neonatal plasma glucose values of under 1.7 mmol/1 (30 mg/100 ml) were found only in the newborn of women whose glucose tolerance area measured over 41.6 area units (750 traditional units); thus, even in the borderline diabetic range glucose tolerance testing during the last trimester of pregnancy may be valuable in predicting likelihood of neonatal hypoglycaemia. The findings also shed light on the possible sensitizing role of mild maternal hyperglycaemia on fetal insulin production and secretion.     

Human placental GLUT1 glucose transporter expression and the fetal insulin-like growth factor axis in pregnancies complicated by diabetes

We have previously described regulation of syncytial GLUT1 glucose transporters by IGF-I. Despite this, it is not clear what signal regulates transplacental glucose transport. In this report we asked whether changes in GLUT1 expression and glucose transport activity in diabetic pregnancies were associated with alterations in the fetal IGF axis. Cord blood samples and paired syncytial microvillous and basal membranes were isolated from normal term pregnancies and pregnancies characterized by gestational diabetes type A2 (GDM A2) and pre-existing insulin-dependent diabetes mellitus (IDDM). Circulating IGF-I, basal membrane GLUT1 expression and glucose transporter activity were correlated with birth weight, but only in control, not diabetic groups. Basal membrane GLUT1 and transporter activity were correlated with IGF-I concentrations in control, but not diabetic groups. IGF binding protein (IGFBP) binding capacity showed a ≥50% reduction in the diabetic groups compared to control; both showed a higher level of free IGF-I. The absence of a correlation between birth weight and factors such as fetal IGF-I or GLUT1 expression in the diabetic groups suggests that IGF-I-stimulated effects may have reached a limiting threshold, such that further increases in IGF-I (or GLUT1) are without effect. These data support that fetal IGF-I acts as a fetal nutritional signal, modulating placental GLUT1 expression and birth weight via altered levels of fetal circulating IGFBPs. Diabetes appears to exert its effects on fetal and placental factors prior to the third trimester and, despite good glycemic control immediately prior to, and in the third trimester, these effects persist to term.     

The effects of hypoxia on glucose turnover in the fetal sheep

The origin of the hypoxia-induced rise in fetal blood glucose concentration in fetal sheep of 124-135 days was investigated. Hypoxia was induced in pregnant sheep and fetuses with chronically implanted vascular catheters by causing the ewes to breathe 9% O2 and 3% CO2 in N2 for 60 min. The rise in fetal plasma glucose caused by a 60% reduction in maternal PaO2 was associated with a 50% fall in plasma insulin concentration. The fall in insulin and rise in glucose was prevented by the alpha-adrenergic blocking agent phentolamine but not by the beta-antagonist propranolol. Turnover of glucose in the fetus under these conditions was measured with [6-3H] and [U-14C] glucose. Hypoxia reduced fetal glucose consumption despite the hyperglycaemia. After 30 min of hypoxia there was no evidence of fetal production of glucose but by 60 min substantial production was evident. The reduced fetal consumption and increased production of glucose was inhibited by phentolamine but not by propranolol. It is concluded that in the fetal sheep hypoxia induced hyperglycaemia is first caused by reduced consumption of glucose and thus fetal glycogen stores are not depleted. If the hypoxia persists fetal blood glucose is elevated further by fetal production of glucose.     

Risk of minor and major fetal malformations in diabetics with high haemoglobin A1c values in early pregnancy.

Maternal haemoglobin A1c (HbA1c) values were measured before the end of the 15th week of gestation in 142 pregnancies in women with insulin dependent diabetes. In pregnancies complicated by fetal malformations (n = 17) the mean initial HbA1c value was 9.5 (SD 1.8)% of the total haemoglobin concentration, which was significantly (p less than 0.001) higher than in pregnancies without malformations (8.0 (SD 1.4)%; n = 125). HbA1c values did not differ between pregnancies complicated by minor and major fetal malformations, but the rate of malformations showed a positive relation to the HbA1c value in early pregnancy (chi 2 = 11.9; p = 0.001). Fetal malformations occurred in six out of 17 pregnancies (35.3%) in mothers whose initial HbA1c value was 10% or more, in eight out of 62 pregnancies (12.9%) in mothers with initial values between 8.0% and 9.9%, and in only three out of 63 pregnancies (4.8%) in mothers with an initial value below 8.0%. These data support the hypothesis that the increased incidence of fetal malformations in mothers with insulin dependent diabetes is associated with maternal hyperglycaemia during organogenesis. Hence diabetic women who are planning to have a child--especially those with a high HbA1c value--should receive intensified metabolic control.     

Fetal insulin and placental 3-O-methyl glucose clearance in near-term sheep

It is difficult, if not impossible, to measure the placental transfer of glucose directly because of placental glucose consumption and the low A-V glucose difference across the sheep placenta. We have approached the problem of quantifying placental hexose transfer by using a nonmetabolized glucose analogue (3-O-methyl glucose) which shares the glucose transport system. We have measured the clearance by using a multisample technique permitting least squares linear computing to avoid the errors implicit in the Fick principle. The placental clearance of 3-O-methyl glucose was measured in the control condition and after the administration of insulin to the fetal circulation. A glucose clamp technique was used to maintain constant transplacental glucose concentrations throughout the duration of the experiment. A control series was performed in which the only intervention was the infusion of normal saline. In these experiments the maternal and fetal glucose concentrations remained constant as did the volume of distribution of 3-O-methyl glucose in the fetus. The maternal insulin concentration remained constant and fetal insulin concentration changed from 11 +/- 2 microU/ml to 355 +/- 51 microU/ml (P less than 0.01). In the face of this large increase in fetal plasma insulin, there was no change in the placental clearance of 3-O-methyl glucose. In the control condition the clearance was 14.1 +/- 1.0 ml/min per kg and this was 13.8 +/- 1.0 ml/min per kg in the high insulin condition. Fetal insulin may change placental glucose flux by decreasing fetal plasma glucose concentrations but does not do so by changing the activity of the glucose transport system.     

Alanine turnover in normal and diabetic dogs

The rate of turnover of alanine was determined in normal and insulin-deprived pancreatectomized dogs using a primed constant infusion of U-14 C-alanine. In the diabetic group, alanine levels and turnover rates were closely correlated suggesting that alanine production is a major determinant of its concentration. Alanine metabolism varied according to the degree of hyperglycaemia: when glucose levels were less than 22 mmol/l, alanine fluxes and concentrations remained normal as observed in previously published studies. In contrast, when glucose levels exceeded 25 mmol/l, alanine concentrations and fluxes tended to be markedly elevated (up to 4-5 times the normal values). This finding suggests that in severely hyperglycaemic animals in which hepatic glucose production is likely to be strikingly elevated, an excessive rate of transport of alanine from muscle to the liver might contribute to the accelerated rate of gluconeogenesis.     

Diabetes and the Gynecologist

The concept of a metabolic disorder of carbohydrate tolerance that progresses with age is examined. It is considered that acute exacerbations may occur at the time of puberty or during pregnancy or the menopause, leading to the development of manifest clinical diabetes.Pregnancy offers a unique opportunity for early diagnosis of potential diabetes in the mother. Existing screening tests are not satisfactory or reliable in uncovering this inborn error of metabolism that may lead to stillbirth or a grossly overweight baby, the onset of clinical diabetes in the mother occurring only many years later.Evidence is presented concerning four conditions that may cause maternal and fetal hyperinsulinism (the primary cause of fetal macrosomia). Also reported is the finding that approximately 50% of apparently normal women over the age of 50 show impaired glucose tolerance.     

Fetal rat islet insulin deficiency following maternal administration of streptozotocin

Pancreatic islets were isolated from the fetuses of normal rats and rats made diabetic by the iv administration of streptozotocin (STZ) on either Day 3 or 5 of pregnancy. Of the rats made diabetic on Day 3, one group also received insulin injections at the appearance of glucosuria. Maternal blood glucose on Day 20 of gestation was significantly different in the diabetic rats (405 +/- 27 mg/dl) from the normal (97 +/- 1 mg/dl) and insulin-treated diabetic rats (69 +/- 9 mg/dl). While fetal weight was significantly decreased in the STZ-treated rats (2.64 +/- 0.13 g vs 3.52 +/- 0.05 g for the control group, P less than 0.005), fetal glucose was significantly higher in the STZ-treated than in normal pups (342 +/- 11 vs 35 +/- 1 mg/dl, P less than 0.005). Both fetal weight and glucose were normalized by insulin treatment: 3.16 +/- 0.18 g and 31 +/- 7 mg/dl, respectively. Insulin release from fetal islets of diabetic dams was blunted after a week in culture both in basal and stimulated conditions. After 2 weeks in culture, there was partial recovery in the insulin response to glucose but it did not equal to that measured in fetal islets from the normal and insulin-treated diabetic rats. These data suggest maternal hyperglycemia severely impairs fetal weight and insulin release from fetal rat islets in vitro, and correction of the hyperglycemia by insulin treatment not only improves fetal weight and glucose concentrations, but it also normalizes insulin release from fetal rat islets in vitro.     

The extended Pedersen hypothesis

The Pedersen hypothesis of fetal macrosomia in neonates born to diabetic mothers has been extended. In neonates born to gestational diabetic mothers, it is suggested that an intrinsic fetal pancreatic beta-cell hyperplasia 'pulls' glucose across the placenta, i.e. assists in glycemic control of the mother. The initial increase in fetal size due to fetal hyperinsulinism gives rise to developing hypoxemia, and the limitation in fetal oxygen availability alters differential tissue utilization of glucose, increases alpha-glycerophosphate synthesis in fetal adipocytes, and gives rise to a further increase in fetal adiposity.     

Effects of maternal diabetes on the development of carbohydrate metabolizing enzymes in fetal rat liver

Effects of streptozotocin-induced maternal diabetes on fetal hepatic carbohydrate-metabolizing enzyme development and hormonal status has been explored in the rat. Hepatic glycogen synthase a activity of the normal fetus rose to a maximum at 20 days of gestation, then fell prior to parturition. In fetuses of diabetic mothers, this prepartum decline was curtailed, resulting in enhanced synthase a activity and increased glycogen content in fetal livers at term. Elevation in hepatic synthase a in fetuses of diabetic mothers was due, not to altered interconversion between existing synthase a and b, but to equivalent increases in both forms of the enzyme. Both hepatic and free plasma corticosterone levels were elevated in fetuses of diabetic mothers and may be responsible for the enhanced development of total glycogen synthase observed in these fetuses. In normal fetuses hepatic phosphofructokinase and pyruvate kinase activities also rose to maxima at 20 days, then declined prior to term. In fetuses of diabetic mothers pyruvate kinase activity attained higher than normal maximal levels and phosphofructokinase activity fell more gradually, thus resulting in elevations in both enzyme activities at term. Augmentations in these glycolytic enzymes are compatible with hyperinsulinemia observed in fetuses of diabetic mothers. The following conclusions may be drawn from these findings. During late fetal life developmental patterns of rate-limiting hepatic glycogen-synthesizing and glycolytic enzymes are adapted to glucose utilization. In the normal fetus these patterns reverse at term, thereby promoting glucose mobilization, which prepares the fetus for abrupt deprivation of maternal glucose at birth. Maternal diabetes results in retardation of these reversal processes, presumably due to elevations in fetal glucocorticoid and insulin levels. Glycogenolytic and glucogenic capacities are thereby impaired in these fetuses.     

Expression of glucocorticoid receptor and glucose transporter-1 during placental development in the diabetic rat

In various tissues, glucocorticoids (GCs) are known to downregulate glucose transport systems; however, their effects on glucose transporters (GLUTs) in the placenta of a diabetic rat are unknown. Glucocorticoid hormone action within the cell is regulated by the glucocorticoid receptor (GR). Thus, this study was designed to investigate the relationship between GR and glucose transporter expression in the placenta of the diabetic rat. Our immunohistochemical results indicated that GR and glucose transporter protein 1 (GLUT 1) are expressed ubiquitously in the trophoblast and endothelial cells of the labyrinthine zone, where maternal fetal transport takes place in the rat placenta. Expression of GR in the junctional zone of the rat placenta was detected in giant cells, and in some spongiotrophoblast cells, but not in the glycogen cells. GLUT 1 was present, especially in glycogen cells during early pregnancy, and in the spongiotrophoblast cells of the junctional zone during late pregnancy. Amounts of GR and GLUT 1 protein were increased towards the end of gestation both in the control and the diabetic placenta. However, at days 17 and 19 of gestation, only the placental GR protein was significantly increased in the streptozotocin-induced diabetic rats compared to control rats. Diabetes led to a significant decrease in placental weight at gestation day 15. In contrast, at gestational days 17 and 21, the weights of the diabetic placenta were significantly increased as compared with the controls. Moreover, diabetes induced fetus intrauterine growth retardation at gestational days 13, 17 and 21. In conclusion, the localization pattern of GR and GLUT 1 proteins in the same cell types led us to believe that there might be a relationship between GR and GLUT 1 expressions at the cellular level. GLUT 1 does not play a pivotal role in diabetic pregnancies. However, placental growth abnormalities during diabetic pregnancy may be related to the amount of GR.     

Placental Glucose Transfer: A Human In Vivo Study

ObjectivesThe placental transfer of nutrients is influenced by maternal metabolic state, placenta function and fetal demands. Human in vivo studies of this interplay are scarce and challenging. We aimed to establish a method to study placental nutrient transfer in humans. Focusing on glucose, we tested a hypothesis that maternal glucose concentrations and uteroplacental arterio-venous difference (reflecting maternal supply) determines the fetal venous-arterial glucose difference (reflecting fetal consumption).MethodsCross-sectional in vivo study of 40 healthy women with uncomplicated term pregnancies undergoing planned caesarean section. Glucose and insulin were measured in plasma from maternal and fetal sides of the placenta, at the incoming (radial artery and umbilical vein) and outgoing vessels (uterine vein and umbilical artery).ResultsThere were significant mean (SD) uteroplacental arterio-venous 0.29 (0.23) mmol/L and fetal venous-arterial 0.38 (0.31) mmol/L glucose differences. The transplacental maternal-fetal glucose gradient was 1.22 (0.42) mmol/L. The maternal arterial glucose concentration was correlated to the fetal venous glucose concentration (r = 0.86, p<0.001), but not to the fetal venous-arterial glucose difference. The uteroplacental arterio-venous glucose difference was neither correlated to the level of glucose in the umbilical vein, nor fetal venous-arterial glucose difference. The maternal-fetal gradient was correlated to fetal venous-arterial glucose difference (r = 0.8, p<0.001) and the glucose concentration in the umbilical artery (r = −0.45, p = 0.004). Glucose and insulin concentrations were correlated in the mother (r = 0.52, p = 0.001), but not significantly in the fetus. We found no significant correlation between maternal and fetal insulin values.ConclusionsWe did not find a relation between indicators of maternal glucose supply and the fetal venous-arterial glucose difference. Our findings indicate that the maternal-fetal glucose gradient is significantly influenced by the fetal venous-arterial difference and not merely dependent on maternal glucose concentration or the arterio-venous difference on the maternal side of the placenta.     

Placental Transfer of Lactate,Glucose and 2-deoxyglucose in Control and Diabetic Wistar Rats

Placental transfer of lactate, glucose and 2-deoxyglucose was examined employing the in situ perfused placenta. Control and streptozotocin induced diabetic Wistar rats were infused with [U¹⁴C]-glucose and [³H]-2-deoxyglucose (2DG). The fetal side of the placenta was perfuseci with a cell free medium and glucose uptake was calculated in the adjacent fetuses. Despite the 5-fold higher maternal plasma glucose concentration in the diabetic dams the calculated fetal glucose metabolic index was not significantly different between the 2 groups. Placental blood flow was reduced in the diabetic animals compared with controls but reduction of transfer of [U¹⁴C]-glucose and [³H]-2-deoxyglucose and endogenously derived [¹⁴C]-Lactate to the fetal compartment, could not be accounted for by reduced placental blood flow alone. There was no significant net production or uptake of lactate into the perfusion medium that had perfused the fetal side of the placenta in either group. The plasma lactate levels in the fetuses adjacent to the perfused placenta were found to be higher than in the maternal plasma and significantly higher in the fetuses of the diabetic group compared with control group. In this model the in situ perfused placenta does not secrete significant quantities of lactate into the fetal compartment in either the control or diabetic group.     

Do glucose transporters have other roles in addition to placental glucose transport during early pregnancy?

Human placenta regulates the transport of maternal molecules to the fetus. It is known that glucose transport occurs via glucose transporters (GLUTs) in the feto–placental unit. Data on the expression of GLUTs during implantation are very scarce. Moreover, the question of how the decidual leukocytes obtain the energy for their activation during implantation mechanism is still under investigation. We studied the distributions of GLUT1, GLUT3, and GLUT4 in tissue sections of first trimester pregnancies the human maternal–fetal interface. GLUT1 was present in apical microvilli of the syncytiotrophoblast, in cytotrophoblast, and in vascular patterns of the villous core, whereas GLUT3 was localized in cytotrophoblasts of placental villi and in some fetal endothelial cells. Moreover, the proliferating cells of the proximal cell columns were also immunopositive for GLUT1 and GLUT3. We did not observe any positive immunoreactivity for GLUT4 in placental and decidual tissues. Essentially, GLUT3 and also to some extent GLUT1 was present in maternal leukocytes and platelets. In conclusion, our results suggest that the glucose taken up via GLUT1 and GLUT3 from the maternal circulation might not only be needed for placental functions but also for successful implantation by trophoblast invasion, proliferation and also by having a role to support energy for maternal leukocytes.     

FiSBoG (fetal steroid binding glycoprotein) as a fetal function test

FiSBoG is a recently described fetal protein. It can be detected in the cord blood. It can be identified in maternal serum in late pregnancy. In this study the values in maternal serum in late pregnancy in 31 normal pregnancies were compared with 23 abnormal pregnancies: 4 twin pregnancies, 4 stillbirth, 4 cases of pre-eclampsia, 4 who had a significant antepartum haemorrhage and 7 who were small-for-dates, to assess its potential as a test of fetal well-being. FiSBoG appeared to have no significant role as a test of fetal well-being.     

Genetic and environmental influence on diabetic rat embryopathy

We assessed genetic and environmental influence on fetal outcome in diabetic rat pregnancy. Crossing normal (N) and manifestly diabetic (MD) Wistar Furth (W) and Sprague-Dawley (L) females with W or L males yielded four different fetal genotypes (WW, LL, WL, and LW) in N or MD rat pregnancies for studies. We also evaluated fetal outcome in litters with enhanced or diminished severity of maternal MD state, denoted MD(+)WL and MD(-)LW. The MDWW litters had less malformations and resorptions (0 and 19%) than the MDLL litters (17 and 30%). The MDWL litters (0 and 8%) were less maldeveloped than the MDLW litters (9 and 22%), whereas the MD(+)WL (3 and 23%) and MD(-)LW (1 and 17%) litters showed increased and decreased dysmorphogenesis (compared with MDWL and MDLW litters). The pregnant MDW rats had lower serum levels of glucose, fructosamine, and branched-chain amino acids than the pregnant MDL rats, whereas the pregnant MD(+)W and MD(-)L rats had levels comparable with those of the MDL and MDW rats, respectively. The 8-iso-PGF2α levels of the malformed MDLW offspring were increased compared with the nonmalformed MDLW offspring. Diabetes decreased fetal heart Ret and increased Bmp-4 gene expression in the MDLW offspring and caused decreased GDNF and Shh expression in the malformed fetal mandible of the MDLW offspring. We conclude that the fetal genome controls the embryonic dysmorphogenesis in diabetic pregnancy by instigating a threshold level for the teratological insult and that the maternal genome controls the teratogenic insult by (dys)regulating the maternal metabolism.     

Birth defects in infants of diabetic mothers: A historical review

Background: Over the past 80+ years, outcomes in diabetic pregnancies have improved remarkably. In the preinsulin era, both fetal and maternal deaths were common. After insulin was discovered, the likelihood of a successful pregnancy increased, but fetal losses were still common. By the end of the 20th century, a number of medical advances allowed women with diabetes to reasonably expect to deliver a healthy infant, although the perinatal mortality rate was twice that reported for women without diabetes. The excess losses were attributable to birth defects.Objective: The purpose of this article was to use the recognition of, and approach to, birth defects in infants of mothers with diabetes as an example of the gradual evolution of clinical care and research from the dawn of the insulin era to the age of molecular biology.Methods: Archival material from the Joslin Diabetes Center (Boston, Massachusetts) was used to document the early history of the problem. Particular emphasis was given to the writings of Priscilla White, MD. Illustrative articles, especially those cited in textbooks, were chosen to highlight developments over the mid to late 20th century.Results: Before the discovery of insulin, maternal death was the primary issue in diabetic pregnancies. With the availability of insulin, the maternal death rate decreased sharply and fetal deaths became the preeminent problem. Many of these losses were due to iatrogenic prematurity complicated by respiratory distress syndrome; early deliveries avoided stillbirth in late gestation. In the last quarter of the 20th century, methods of assessing fetal well-being and lung maturity allowed pregnancies to proceed nearer to term. Birth defects then emerged as the leading cause of perinatal mortality. The risk for birth defects was linked to diabetes control early in the first trimester, and the mechanism was related to free oxygen radicals from excess glucose. Preconception programs have been shown to reduce the risk.Conclusions: Clinical advances often are not dramatic. This article illustrates how resolution of a problem may evolve incrementally over decades. Birth defects, once unnoticed in infants of diabetic mothers, became a leading concern. It is now possible to reduce the incidence of these defects to levels seen in nondiabetic pregnancies. Epigenetic mechanisms responsible for malformations have been elucidated.