Antonietta Colatrella

Hypertension in diabetic pregnancy: impact and long-term outlook

Hypertensive disorders in pregnancy can be chronic, pregestational or just diagnosed before the 20th week, or newly diagnosed in the second half of pregnancy. Any type of hypertension is more frequent in diabetic pregnancies with a different distribution among different types of diabetes. Most of the evidence is for pre-eclampsia associated with a marked increase in primary caesarean section, preterm birth and more need for neonatal intensive care. Different risk factors and pregnancy outcomes would support the hypothesis that pre-eclampsia and gestational hypertension might be largely separate entities, but this position is not unanimously accepted. Chronic hypertension increases with age and duration of diabetes, predicting increased rates of prematurity and neonatal morbidity, especially when associated with superimposed pre-eclampsia. Long-term consequences are observed in women whose pregnancy was complicated by hypertension such as chronic hypertension and cardiovascular diseases.

Twenty-four-hour blood pressure monitoring in normoalbuminuric normotensive type 1 diabetic women during pregnancy

UNLABELLED We monitored blood pressure (BP) for a 24-h period in type 1 diabetic women at each trimester of pregnancy (10-13, 20-22, and 30-33 weeks of gestation) to identify early alterations of BP profile in pregnancies complicated by hypertension. PATIENTS AND METHODS We prospectively studied 71 type 1 diabetic pregnant women and 48 nondiabetic pregnant women (homogeneous by age and pre-pregnancy BMI) consecutively recruited at 10+/-2 weeks of pregnancy in the space of 2 years (1999-2000). They were all normotensive (<130/80 mm Hg) and normoalbuminuric (AER<20 microg/min) at entry to the study. STATISTICS Analysis of variance (ANOVA) and simple regression and chi(2) were applied as appropriate by an Apple software program (Stat View). RESULTS In diabetic women, we recorded higher levels of diastolic BP (even if within a normal range) at each time point; diabetic vs. nondiabetic women: first trim daytime diastolic BP: 71.35+/-8.75 vs. 67.7+/-9.7, P=.01; second trim nighttime diastolic BP: 62.15+/-6.45 vs. 58.05+/-6.7, P=.05; third trim nighttime diastolic BP: 66.03+/-8.72 vs. 60.7+/-6.5, P=.01. Among diabetics, those who later developed pregnancy-induced hypertension (36.6%) showed significantly higher values of BP at the first and third trimester compared to those who remained normotensive. In the two groups, there were no differences in age and pre-pregnancy BMI by contrast of diabetes duration (hypertensive vs. normotensive, 19.18+/-7.3 vs. 14.35+/-9.1 years, P=.03) and age of diagnosis (hypertensive vs. normotensive, 9.6+/-5.5 vs. 14.7+/-8.6 years, P=.01). Positive correlation was found between fasting blood glucose and diastolic BP at each trimester of pregnancy.

Visual evoked potentials in infants of diabetic mothers: Relations to clinical and metabolic status during pregnancy and delivery

OBJECTIVE To evaluate Visual Evoked Potentials (VEPs) and psychomotor development of infants of diabetic mothers (IDMs) in relation to clinical and metabolic data during pregnancy and delivery. METHODS VEPs and psychomotor development (Brunet-Lézine) were analysed in 40 two-month-old IDMs (21 males, 19 females), 24 from mothers with type-1 diabetes, 13 gestational diabetes, and 3 type-2 diabetes. Normative VEP data were obtained from 63 age matched controls. RESULTS VEP latencies were significantly longer in IDMs than in controls (O1 wave IV=197.9+/-35.5 vs 155.3+/-30.3; P<0.001; O2 wave IV=200.2+/-33.8 vs 155.6+/-29.0; P<0.001). The mean developmental quotient was normal. In IDMs with type-1 diabetes delayed VEPs were related to increased weight during pregnancy (r 0.516; P 0.009), 1st trimester fasting blood glucose (r 0.458; P 0.037), insulin requirement during the 2nd (r 0.441; P 0.035) and 3rd trimester (r 0.422; P 0.039); in IDMs with gestational diabetes, VEP latency showed negative relation to Apgar scores (r -0.748; P 0.008). CONCLUSIONS IDMs have delayed VEPs, which may possibly be related to poor metabolic control in pre-gestational diabetes, and to delivery complications in gestational diabetes. SIGNIFICANCE IDMs show subtle neurophysiologic changes detectable by VEPs.

Use of Repaglinide During the First Weeks of Pregnancy in Two Type 2 Diabetic Women

Repaglinide, the only glinide available in Italy, is a secretagogue developed for type 2 diabetes (1). There is no evidence about its use during human pregnancy. Studies on rats that showed its effects on long bone growth excluded any teratogenity (2). More data exist regarding the safety of metformin in pregnancy, even though it is not recommended as an oral hypoglycemic agent in diabetic pregnancy (3,4). We report two case subjects of type 2 diabetic women who used repaglinide at conception and during the first 6–7 weeks …

Comparison of Insulin Lispro Protamine Suspension with NPH Insulin in Pregnant Women with Type 2 and Gestational Diabetes Mellitus: Maternal and Perinatal Outcomes.

Insulin therapy is still the gold standard in diabetic pregnancy. Insulin lispro protamine suspension is an available basal insulin analogue. Aim. To study pregnancy outcomes of women with type 2 and gestational diabetes mellitus when insulin lispro protamine suspension or human NPH insulin was added to medical nutrition therapy and/or short-acting insulin. Methods. In this retrospective study, for maternal outcome we recorded time and mode of delivery, hypertension, glycaemic control (fasting blood glucose and HbA1c), hypoglycemias, weight increase, and insulin need. For neonatal outcome birth weight and weight class, congenital malformations was recorded and main neonatal complications. Two-tail Students t-test and chi-square test were performed when applicable; significant P < 0.05. Results. Eighty-nine pregnant women (25 with type 2 diabetes and 64 with gestational diabetes mellitus; 53 under insulin lispro protamine suspension and 36 under human NPH insulin) were recruited. Maternal and neonatal outcomes were quite similar between the two therapeutic approaches; however, insulin need was higher in NPH. At the end of pregnancy, eight women with gestational diabetes continued to use only basal insulin analogue. Conclusions. Pregnancy outcome in type 2 and gestational diabetes mellitus with insulin lispro protamine suspension was similar to that with NPH insulin, except for a lower insulin requirement.

Effects of Maternal Diabetes on Visual Evoked Potentials and Early Psychomotor Development of the Offspring

Planning and intensive treatment of diabetes in pregnancy has resulted in dramatic improvements in outcomes in terms of congenital malformations or perinatal morbidity (1), but it is still not clear to what extent maternal diabetes affects cognitive development of newborns. In infants of diabetic mothers (IDMs), significant relations have been reported between poor maternal metabolic regulation during pregnancy and poor child intellectual performance, despite an achievement of overall healthy neuropsychological functioning …

Continuous Subcutaneous Insulin Infusion (CSII) in Diabetic Pregnancy: A Review

In 2008, ADA provided new standards of care and recommendations including therapeutic actions favourably affecting health outcomes of patients with diabetes. In this context, Continuous Subcutaneous Insulin Infusion (CSII) becomes a great flexible therapeutic alternative, because of glucose sensors availability, theoretical support and improved therapeutic decisions. However, there are no conclusive studies on the benefits of CSII in pregnancy. In particular, ‘80’ randomized and controlled trials describe the pregnancy outcomes of few type 1 and type 2 diabetic patients. A recent Cochrane review, including 61 pregnancies concluded that there is no sufficient evidence to support any sort of insulin administration in diabetic pregnancy. Similar conclusions were reported by another review and a meta-analysis of 6 randomized and controlled trials on 213 subjects. No better results were obtained by recent retrospective studies. Doubts exist about CSII timing (before/and or after conception). Poor results are due to the inadequate patients selection, education, and abilities. Multi -centre studies are needed to verify the real utility of insulin pump during pregnancy, considering risks, costs and benefits including quality of life, in order to outline recommendations for an appropriate use. This review article also discussed some recent patents related to the field.

A Lower Level of Entropy in Circadian Rhythm of the Sinus R‐R Intervals Suggests a Prevalence of the Cardiac Sympathetic Regulation in Early Physiological Pregnancy

The study estimates the unpredictable disorder (chaos) within the 24 h pattern of sinus R‐R intervals (SRRI) in clinically healthy pregnant women (CHPW) and clinically healthy non‐pregnant women (CHNPW), in order to evaluate the early gestational changes in neurovegetative cardiac pacing. SRRI were provided by the 24‐h Holter ECG of 10 CHPW and 10 CHNPW. SRRI were investigated by descriptive conventional statistics by means of the Time and Frequency Domain Analysis, and subsequently, in their chaotic component by means of entropy analysis. Both the SRRI and entropy were tested via the Cosinor method to better decipher whether or not the periodic disorder in heart rate variability is modified in pregnancy as a result of a gestational tonic resetting of the cardiac sympatho‐vagal regulation. Cosinor analysis documented that the circadian rhythm of both the SRRI and entropy were preserved in CHNPW and CHPW. However, the circadian rhythm of SRRI and entropy in CHPW exhibited a significantly decreased 24 h mean. Via the analysis of the rhythmicity of entropy, this study has documented that the chaos in the 24 h pattern of SRRI is less prominent in CHPW than in CHNPW. Such a reduction of level in the deterministic periodic chaos of heart rate variability provides evidence that, in early pregnancy, a tonic elevation of the sympathetic activity regulates cardiac pacing.

The loss of entropy circadian rhythm in sinusal R-R intervals of type 1 diabetic pregnant women suggests an indeterministic chaos in cardiac pacing (minimum delirium cordis syndrome). A newly identifiable type of silent cardiac dysautonomia?

Objective — The scope of this study is to detect whether or not the entropy (E) circadian rhythm (CR) is maintained preserved in sinusal R-R intervals (SRRI), its loss being the expression of a transition to an indeterministic chaos in heart rate variability (HRV). Methods — The E of SRRI was estimated in 14 type 1 diabetic pregnant women (DPW) in the first trimester of an apparently uncomplicated gestation (7 patients - mean age = 30.3 ± 4.1 y - without clinical and laboratory evidence of cardiac autonomic neuropathy, and 7 patients - mean age = 30.7 ± 3.6 y - with positive tests for a cardiac dysautonomia).The E CR was studied via the single cosi-nor method, and summarized via the population-mean cosinor method. Results — The E CR was found not to be preserved in both the investigated type 1 DPW, despite the occurrence of the SRRI CR. Conclusions — The loss of the E CR confirms that in type 1 DPW there is a transition to an indeterministic disorder in HRV due to the lack of an autocorrelated periodic chaos in cardiac pacing. Such an unphysiological neurovegetative regulation suggests a new silent cardiac dysautonomic syndrome, that we intend to call “minimum delirium cordis syndrome” (MDCS). Can the MDCS be regarded as a condition of cardiovascular risk? To answer this question, it seems justified to suggest that the study of the E CR should be added to the routine tests that are presently applied to clinical analysis of the Holter ECG, being the classic tests of linear analysis not methodologically suitable for detecting the indeterministic chaos of the MDCS.