Éva Baranyi

Tumor necrosis factor system in insulin resistance in gestational diabetes

OBJECTIVE The aim of the study was to investigate the pathophysiological role of the tumor necrosis factor (TNF) system in insulin resistance in patients with gestational diabetes (GDM) and during the course of normal pregnancy. PATIENTS AND METHODS Thirty women with GDM (16-39 gestational weeks), 35 healthy pregnant women (15 first, nine second and 11 third trimester) and 25 healthy age-matched non-pregnant women were studied. Serum TNF-alpha, and its soluble receptors 1 and 2 (sTNFR-1 and -2) were measured. RESULTS In non-diabetic pregnant women in the third trimester all measures were significantly higher (P<0.05 or less) than in the first trimester and in non-pregnant women (BMI 27.6 +/- 4.1 (+/- S.D.), 24.1 +/- 2.6, 22.4 +/- 2.4 kg/m(2)), serum TNF-alpha (4.6 +/- 0.6, 4.1 +/- 0.4, 4.1 +/- 0.4 ng/l), sTNFR-1 (2.7 +/- 0.9, 2.0 +/- 0.5, 2.0 +/- 0.1 microg/l), sTNFR-2 (5.6 +/- 2.6, 4.6 +/- 2.1, 3.3 +/- 0.2 microg/l), C-peptide (3.1 +/- 1.7, 1.1 +/- 0.7, 1.1 +/- 0.8 microg/l), and C-peptide:blood glucose ratio (0.6 +/- 0.2, 0.2 +/- 0.1, 0.2 +/- 0.1 microg/mmol). In GDM these measures were even higher than in any subgroup of healthy pregnant women (BMI) (33.4 +/- 6.4 kg/m(2), TNF-alpha) (6.3 +/- 0.6 microg/l), sTNFR-1 (3.0 +/- 0.5 microg/l), sTNFR-2 (10.0 +/- 6.9 microg/l, C-peptide 6.0 +/- 2.7 microg/l, C-peptide:blood glucose ratio: 1.2 +/- 0.5 microg/mmol, P<0.01). Significant (P<0.01) positive linear correlations were found in gestational diabetic and non-diabetic women between serum TNF-alpha, C-peptide levels, and BMI. In gestational diabetic women, in multivariate analysis studying the dependency of C-peptide only BMI remained significant (r(2)=0.67, P=0.01). CONCLUSIONS Our observation emphasizes the obesity-related component of insulin resistance driven by adipocytokines, such as TNF-alpha and its receptors during the course of normal pregnancy and GDM.

Studies of dental and oral changes of pregnant diabetic women

SummaryThe longitudinal examination of 132 pregnant diabetic women under care showed a 96.2% prevalence of gingivitis. The intensity of gingivitis was most marked in weeks 11 to 15, and 24 to 26 of pregnancy, and the correlation with changes in oral hygiene was statistically significant (p<0.001). On the other hand, the severity of diabetes had no effect on the degree of gingival inflammation. As for caries, the mean DMF values increased during diabetic pregnancy, the number of carious (D) and filled (F) teeth to a higher, that of extracted (M) teeth to a lesser degree, than in diabetic non-pregnant women.

Early prediction of fetal macrosomia in diabetes mellitus

We studied 374 pregnant diabetic women to determine the value of various ultrasound parameters in the prediction of fetal macrosomia. The correlation between ultrasonographic signs and maternal glycaemia in the development of fetal macrosomia was also studied. Significant correlation was observed between the accurence of hydramnios and future macrosomia during the second-trimester (p less than 0.001). Serum fructosamine levels as an index of maternal glycaemia in patients of macrosomic fetuses were significantly higher throughout the pregnancy as compared with mothers of infants with normal birth weight (p less than 0.001). These data suggest: 1. The presence of hydramnios in the second trimester is a useful predictor of macrosomia in diabetic patients (specificity: 86%, negative predictive value: 88%). 2. Maternal diabetic control during pregnancy has a significant influence on fetal growth and contributes to the development of fetal macrosomia. 3. The lack of correlation between the frequency of hydramnios and fructosamine levels suggests that a mechanism other than carbohydrate metabolism also plays an important role in the development of fetal macrosomia.

Diabetes és terhesség

Metabolic characteristics of physiological and diabetic pregnancies are discussed. The basic factor of these changes is the increasing insulin resistance throughout pregnancy, which in case of diabetes may result in hyperglycemia with undesirable clinical consequences and complications for both the mother and the fetus. Prevention of these complications by maintaining physiological metabolic state of diabetic pregnant women is possible, which is similar to that of healthy women. The aim of treatment of pregnant diabetics is to achieve normoglycemic state during the whole gestation that is possible by early diagnosis in case of gestational diabetes and by adequate preconception care in case of pregestational diabetes. To obtain desirable glycemic conditions insulin treatment is necessary in most of the cases together with adequate, quantitative nutrition therapy, while oral antidiabetic drugs during pregnancy and lactation are to be avoided. For adequate care of the cases with diabetes and pregnancy interdisciplinary diabetes centers with well-trained experts are required.

Care of pregnant diabetics: Medical aspects

SummaryA method has been worked out for the intensive care of pregnant diabetics with the object of preventing damage both to the mother and the fetus. The method requires close cooperation between a team of doctors including obstetrician, internist and pediatrician. The present paper reports the experience of the first two years of application of the method and refers to a total of 75 women. The main point consists in an attempt to maintain a normal blood glucose level by administering increasing doses of insulin. Periods of inpatient management alternated with close outpatient control. Of the 75 insulin-dependent diabetics 45% had severe diabetes (White classes D-F); nevertheless, perinatal mortality was only 5.78 per cent. It is worth stressing that the 25 diabetics who came under intensive care before conception or in the early stages of pregnancy all gave birth to live healthy babies.

Comparison of the effectiveness of two internationally recommended screening methods for the diagnosis of gestational diabetes

INTRODUCTION Early diagnosis and adequate care of gestational diabetes is of great importance for both the mother and her fetus. Although several national and international guidelines are known on the methodology for screening gestational diabetes, a not negligible part of the cases remain unrecognized when applying even the most widely used criteria recommended by the World Health Organization (1st recommendation). A connection has been found between the maternal blood glucose values and the prevalence of still-birth, preeclampsia and large for gestational age neonates in several studies, from which the Hyperglycaemia and Adverse Pregnancy Outcomes study has come into prominence. According to conclusions of this study the International Association of Diabetic Pregnancy Study Groups suggested new numeric criteria for the evaluation of the 75-gram oral glucose tolerance test (2nd recommendation), which differs from the evaluation used in the aforementioned screening system. AIMS The aim of the study was to compare the effectiveness of the two screening systems by evaluation of the pregnancy outcomes. METHODS By following non-twin pregnancies of 1107 pregnant mothers (831 with normal glucose tolerance, 276 with gestational diabetes based on any of the applied screening methods) the maternal (pre- and post-term birth, caesarean section, toxaemia) and newborns pregnancy outcomes (infants small and large for gestational age, hypoglycaemia) were analysed. RESULTS With the exception of the prevalence of large for gestational age infants - which was higher among women screened by the new evaluation - no substantial difference in the efficacy of the two investigated methods was found. CONCLUSION The decision whether the screening of gestational diabetes using the new criteria results in safer recognition of the disturbances of glucose metabolism during pregnancy requires further investigations including a large number of cases.

A gestatiós diabetes szurésére ajánlott két nemzetközi eljárás hatékonysá gának összehasonlítása

INTRODUCTION Early diagnosis and adequate care of gestational diabetes is of great importance for both the mother and her fetus. Although several national and international guidelines are known on the methodology for screening gestational diabetes, a not negligible part of the cases remain unrecognized when applying even the most widely used criteria recommended by the World Health Organization (1st recommendation). A connection has been found between the maternal blood glucose values and the prevalence of still-birth, preeclampsia and large for gestational age neonates in several studies, from which the Hyperglycaemia and Adverse Pregnancy Outcomes study has come into prominence. According to conclusions of this study the International Association of Diabetic Pregnancy Study Groups suggested new numeric criteria for the evaluation of the 75-gram oral glucose tolerance test (2nd recommendation), which differs from the evaluation used in the aforementioned screening system. AIMS The aim of the study was to compare the effectiveness of the two screening systems by evaluation of the pregnancy outcomes. METHODS By following non-twin pregnancies of 1107 pregnant mothers (831 with normal glucose tolerance, 276 with gestational diabetes based on any of the applied screening methods) the maternal (pre- and post-term birth, caesarean section, toxaemia) and newborns pregnancy outcomes (infants small and large for gestational age, hypoglycaemia) were analysed. RESULTS With the exception of the prevalence of large for gestational age infants - which was higher among women screened by the new evaluation - no substantial difference in the efficacy of the two investigated methods was found. CONCLUSION The decision whether the screening of gestational diabetes using the new criteria results in safer recognition of the disturbances of glucose metabolism during pregnancy requires further investigations including a large number of cases.