Florence M. Brown

Managing preexisting diabetes for pregnancy: Summary of evidence and consensus recommendations for care

This document presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The intent is to help clinicians deal with the broad spectrum of problems that arise in management of diabetes before and during pregnancy, and to prepare diabetic women for treatment that may reduce complications in the years after pregnancy. A thorough discussion of the evidence supporting the recommendations is presented in the book, Management of Preexisting Diabetes and Pregnancy , authored by the consensus panel and published by the American Diabetes Association (ADA) in 2008 (1). A consensus statement on obstetrical and postpartum management will appear separately. The recommendations are diagnostic and therapeutic actions that are known or believed to favorably affect maternal and perinatal outcomes in pregnancies complicated by diabetes. The grading system adapted by the ADA was used to clarify and codify the evidence that forms the basis for the recommendations (2). Unfortunately there is a paucity of randomized controlled trials (RCTs) of the different aspects of management of diabetes and pregnancy. Therefore our recommendations are often based on trials conducted in nonpregnant diabetic women or nondiabetic pregnant women, as well as on peer-reviewed experience before and during pregnancy in women with preexisting diabetes (3–4). We also reviewed and adapted existing diabetes and pregnancy guidelines (5–10) and guidelines on diabetes complications and comorbidities (2,3,11–14). ### A. Organization of preconception and pregnancy care #### Recommendations

Risk for developing gestational diabetes in women with twin pregnancies

Objective. To examine the risk of developing gestational diabetes mellitus (GDM) in women with twin compared with singleton pregnancies. Research design and methods. We examined a cohort of 23,056 pregnant women who gave birth to a live infant between 1 September 1998 and 31 December 2006, 553 of whom had twin pregnancy. The primary exposure was twin versus singleton pregnancy, and the primary outcome was the development of GDM. Standard univariate analyses were performed, as were multivariable analysis with logistic regression to control for potential confounding variables. GDM was diagnosed using criteria of the National Diabetes Data Group. Results. Patients with twin pregnancies had a higher rate of GDM when compared with singleton pregnancies (3.98%vs. 2.32%; p = 0.01). In a multiple regression analysis after adjusting for age, race/ethnicity, body mass index, maximal systolic and diastolic blood pressure, smoking and parity, twin pregnancy was associated with an approximately two-fold increase in risk for developing GDM (OR 2.2, 95% CI 1.4–3.6). In a stratified analysis, women between the ages of 25 and 30 years and African-American women had the highest risk of developing GDM in twin pregnancies. When compared with twins of non-diabetic mothers, twins of gestational diabetics had a higher rate of admission to the neonatal intensive care unit (37%vs. 52%; p = 0.05), had longer hospitalisation (8 ± 0.5 vs. 16 ± 4 days; p = 0.01) and higher rate for respiratory distress syndrome (7%vs. 27%; p = 0.001). Conclusion. There is a significant increase in the incidence of GDM in twin pregnancies versus singleton pregnancies. The risk is highest in African-American and young women.

Anti-Sympathetic Ganglia Antibodies and Postural Blood Pressure in IDDM Subjects of Varying Duration and Patients at High Risk of Developing IDDM

We examined the sera of 94 subjects with insulindependent diabetes mellitus (IDDM) for the presence of complement-fixing sympathetic ganglia (CF-SG) antibodies. In a cross-sectional analysis (duration 0–43 yr), 22% had detectable CF-SG antibodies. Subjects at high risk for IDDM were also studied. Four groups were studied: group 1 (aged 4–64 yr) islet cell antibodypositive (ICA+) prediabetic subjects, 10 of 19 (53%) were CF-SG+ ; group 2 (aged 6–14 yr) ICA− prediabetic subjects (first-degree relatives of IDDM subjects with either transient hyperglycemia, impaired oral glucose tolerance, and/or first-phase insulin release after intravenous glucose tolerance testing), 4 of 9 (44%) were CF-SG+ (2 of the 4 ICA− CF-SG+ subjects have progressed to IDDM); group 3 (aged 1.5-43 yr) ICA+ IDDM subjects (≤1 yr duration) 6 of 10 (60%) were CF-SG+; and group 4 (aged 8–59 yr) ICA IDDM subjects (≤1 yr duration), 2 of 11 (18%) were CF-SG+. All groups had increased CF-SG compared with controls. Postural blood pressure and simultaneous CF-SG antibody measurements were performed in 28 IDDM subjects. The drop in systolic blood pressure was greater in the CF-SG+ subjects (P < .05), and the frequency of CF-SG was greater in the mean to – 2SD group (P < .03) when data were analyzed within mean ± 2SD of the normal blood pressure response.

Complement-Fixing Antibodies to Sympathetic and Parasympathetic Tissuesin IDDM: Autonomic Brake Index and Heart-Rate Variation

We describe herein complement-fixing anti-adrenal medullary (CF-ADM) andanti-sympathetic ganglia (CFSG) antibodies in insulin-dependent diabetes mellitus (IDDM). This study describes complement-fixing antivagus (CF-V) nerve antibodies and their relationship to the cardiovascular autonomic brake index (a measure of transient decrease in heart rate during the 1st min after a tilt), and R-R interval variation with deep breathing. CF-V was detectable in 7 of 83 (8.4%) subjects with IDDM aged 1.5–65.5 yr (mean ± SE 28.7± 1.8 yr) and duration of diabetes 0–47 yr (11.8 ± 1.4 yr). Seventy-six nondiabetic subjects (aged 10–65 yr) all had negative CF-V scores. CF-V scores correlated with CF-ADM (0–16 yr of IDDM, r = 0.61, P < 0.0001) and CF-SG (r = 0.39, P < 0.05). Seventy IDDM subjects (aged 28 ± 5 yr, duration of diabetes 17 ± 3 yr) without proteinuria or proliferative retinopathy were screened for CF-ADM, CF-SG, and CF-V antibodies. Five of 70 (7.1%) had CF-SG only (negative for CF-ADM and CF-V). Brake indices ranged from 14.7 to 51.3 (37.3 ± 6.9). Three of 70 (4.2%) had CF-ADM only, with brake indices from 26.9 to 45.1 (32.9 ± 6.1). Four of 70 (5.7%) had CF-V antibodies only, with brake indices of 12.7–17.3 (15.1 ± 1.1). Subjects with CF-SG or CF-ADM (antisympathetic) had higher brake indices than subjects with CF-V (anti-parasympathetic) antibodies (P < 0.03). Subjects with CF-SG had higher brake indices than those with CF-V (P < 0.04). The heart-rate variation with deep breathing was 23.3 ± 10.0 in subjects with CF-V and 45.66 ± 5.1 in the CF-SG+ and/or CF-ADM+ group (P < 0.03). This study demonstrates CF-V antibodies in IDDM and their association with a lower brake index and R-R interval variation compared with patients with sympathetic nervous system autoimmunity.

Anti-Sympathetic Nervous System Autoantibodies: Diminished Catecholamines With Orthostasis

The etiology of autonomic neuropathy in insulin-dependent diabetes mellitus (IDDM) is unknown. Previous studies have noted the presence of anti-adrenal medullary antibodies in IDDM. Recently, we have also demonstrated the presence of anti-sympathetic ganglia antibodies in IDDM. We initiated a study to evaluate whether subjects with complement-fixing anti-adrenal medullary (CF-ADM) and anti-sympathetic ganglia (CF-SG) antibodies have a decreased catecholamine response to change in posture. Seven IDDM subjects aged 19–41 yr with duration of disease 5–21 yr at the time of the posture study were evaluated. Serums collected longitudinally were evaluated for the presence of CF-ADM and CF-SG antibodies. Three IDDM subjects were CF-ADM− and CF-SG− at all testing intervals (Ab− group). Four IDDM subjects were CF-ADM+ and/or CF-SG+ on at least one testing date (Ab+ group). Baseline mean norepinephrine and epinephrine levels were not significantly different in Ab+ and Ab− subjects. Norepinephrine levels 5 min after standing were mean ± SD 227 ±16 and 419 ± 48 pg/ml for Ab+ and Ab− subjects, respectively (P < .03). The means of the 5-min minus basal norepinephrine levels were 88 ± 42 (Ab+) and 207 ± 26 (Ab−) pg/ml (P < .03). Mean epinephrine levels after 5 min of standing were 35 ±16 (Ab+) and 101 ± 44 (Ab−) pg/ml (P < .03). The means of the 5-min minus basal epinephrine levels were 1 ± 5 (Ab+) and 43 ± 38 (Ab) pg/ml (P < .03). Mean change in systolic blood pressure on standing was not different in the two groups. This suggests that CF-ADM and CF-SG are associated with a decreased catecholamine response to change in posture.

Anti-adrenal medullary antibodies in IDDM subjects and subjects at high risk of developing IDDM.

Previous reports have noted the presence of antiadrenomedullary antibodies in subjects with insulindependent diabetes mellitus (IDDM). We initiated a study to evaluate the presence of complement-fixing anti-adrenomedullary antibodies (CF-ADM) in the following subjects: group 1 (age 4–60 yr), anti-islet cell antibody-positive (ICA+) subjects at high risk of developing diabetes, in which 9 (32%) of 28 were positive for CF-ADM; group 2 (age 6–41 yr), anti-ICA negative (ICA−) subjects at high risk of developing diabetes, in which 0 (0%) of 15 were positive for CFADM; group 3 (age 1–58 yr), ICA+ diabetic subjects, in which 7 (30%) of 23 were positive for CF-ADM; group 4 (age 5–68 yr), ICA− diabetic subjects, in which 1 (4%) of 24 was positive for CF-ADM; group 5 (age 20–56 yr), volunteer blood bank donor controls, in which 2 (6%) of 32 were positive for CF-ADM; and group 6, known healthy controls, in which 0 (0%) of 14 were positive for CF-ADM. CF-ADM were increased in group 1 compared with group 2 (P < .02) and both control groups (P < .02). CF-ADM were increased in group 3 compared with group 4 (P < .03) and both control groups (P < .03 vs. group 5, P < .05 vs. group 6). Presence of CF-ADM was associated with presence of ICA in group 1 (P < .02) and group 3 (P < .03). In view of these results, adrenomedullary autoimmunity is emerging as a new member of the human organ-specific autoimmune disorders. It occurs before the development of clinically overt diabetes and is associated with the presence of ICAs. The functional significance of adrenomedullary autoimmunity needs to be evaluated.

The association of circulating angiogenic factors and HbA1c with the risk of preeclampsia in women with preexisting diabetes

Objective: To assess whether glycemic control, soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) were associated with the development of preeclampsia (PE) or gestational hypertension (GHTN) in women with preexisting diabetes. Methods: Maternal circulating angiogenic factors (sFlt1 and PlGF) measured on automated platform were studied at four time points during pregnancy in women with diabetes (N = 159) and reported as multiples of the median (MOM) of sFlt1/PlGF ratio (median, 25th–75th percentile) noted in non-diabetic non-hypertensive control pregnant population (N = 139). Diagnosis of PE or GHTN was determined by review of de-identified clinical data. Results: PE developed in 12% (N = 19) and GHTN developed in 23% (N = 37) of the women with diabetes. Among diabetic women without PE or GHTN, median sFlt1/PlGF levels at 35–40 weeks was threefold higher than in non-diabetic controls [MOM 3.21(1.19–7.24), p = 0.0001]. Diabetic women who subsequently developed PE had even greater alterations in sFlt1/PlGF ratio during the third trimester [MOM for PE at 27–34 weeks 15.18 (2.37–26.86), at 35–40 weeks 8.61(1.20–18.27), p ≤ 0.01 for both windows compared to non-diabetic controls]. Women with diabetes who subsequently developed GHTN also had significant alterations in angiogenic factors during third trimester; however, these findings were less striking. Among women with diabetes, glycosylated hemoglobin (HbA1c) during the first trimester was higher in subjects who subsequently developed PE (7.7 vs 6.7%, p = 0.0001 for diabetic PE vs diabetic non-PE). Conclusions: Women with diabetes had a markedly altered anti-angiogenic state late in pregnancy that was further exacerbated in subjects who developed PE. Altered angiogenic factors may be one mechanism for the increased risk of PE in this population. Increased HbA1c in the first trimester of pregnancies in women with diabetes was strongly associated with subsequent PE.

Circulating levels of the antiangiogenic marker soluble FMS-like tyrosine kinase 1 are elevated in women with pregestational diabetes and preeclampsia: angiogenic markers in preeclampsia and preexisting diabetes.

Preeclampsia is characterized by the development of proteinuria and hypertension after 20 weeks gestation, and it is associated with maternal and fetal morbidity. Preeclampsia affects ∼5% of pregnancies, though women with preexisting diabetes are three to four times more likely to develop preeclampsia (1). Preeclampsia is associated with altered angiogenic factors, including increased levels of circulating soluble FMS-like tyrosine kinase 1 (sFlt1) and reduced levels of vascular endothelial growth factor and placental growth factor (PlGF). Hypertension and proteinuria of preeclampsia may be caused by an imbalance of these angiogenic factors (2–10). Circulating sFlt1, an antiangiogenic protein, binds to proangiogenic proteins, vascular endothelial growth factor, and PlGF, preventing their interaction with endothelial cell receptors and inducing endothelial dysfunction. Rats given sFlt1 develop proteinuria, hypertension, and glomerular endotheliosis, which are hallmarks of preeclampsia (3). Alterations in sFlt1 and PlGF are observed several weeks before symptoms (2). It is unknown whether alterations in sFlt1 and PlGF are present in women with diabetes who then develop preeclampsia or whether a different pathway is responsible. Ultimately, it would be helpful to have a way to diagnose and predict preeclampsia in women with pregestational diabetes, as they frequently have preexisting hypertension and/or proteinuria, which make it difficult to differentiate superimposed preeclampsia. We evaluated a small group of women with diabetes and compared levels of sFlt1 and PlGF at delivery in both those who developed preeclampsia and those …

Permanent teratocarcinoma-derived cell lines stabilized by transformation with SV40 and SV40tsA mutant viruses.

Publisher Summary This chapter discusses the permanent teratocarcinoma-derived cell lines stabilized by transformation with SV40 and SV40tsA mutant viruses. Mouse teratocarcinoma cells derived from embryoid bodies of 129SvS1 mice were cultured in vitro to permit their differentiation. These cells were then infected with three different SV40tsA mutants at 32°C, and six cloned cell lines (SVtsA-teratocarcinoma derived cells) were derived from these cultures. All six cell lines expressed the SV40 tumor antigen (94,000 MW) in a temperature-sensitive fashion, with lower levels of this antigen detected at the nonpermissive temperature. Mock infected teratocarcinoma-derived cells did not give rise to permanent cell lines demonstrating the necessity of the virus or its products in the formation of the teratocarcinoma-derived cell lines. Temperature shift experiments demonstrated that the viral A gene product plays an essential role in the ability of the SVtsA cell lines to form colonies on plastic surfaces in 2% serum-containing medium, on top of monolayer cell cultures in 10% serum-containing medium, or in agar suspension cultures.

Adrenal Medullary Fibrosis in IDDM of Long Duration

We conducted a retrospective pathology study to determine whether subjects with long-standing insulindependent diabetes mellitus (IDDM) have abnormalities of the adrenal medulla compared with subjects with non-insulin-dependent diabetes mellitus (NIDDM) and nondiabetic individuals. Slides were scored from 0 (no fibrosis) to 3+ (complete fibrosis). Nineteen IDDM subjects aged 30–60 yr (mean ± SE 44.9 ± 2.5 yr) at autopsy and with duration of diabetes 13–45 yr (26.8 ± 1.8 yr) were studied. Twelve NIDDM subjects aged 61–84 yr (73.3 ± 2.5 yr) with duration of diabetes 17–33 yr (22.8 ± 1. 9 yr) were studied. Twenty-two nondiabetic subjects aged 32–77 yr (53.7 ± 2.9 yr) were studied. Four of 19 (27%) IDDM subjects had moderate to severe fibrosis compared to 1 of 12 (8.3%) NIDDM subjects and 1 of 22 (4.5%) control subjects. Thirteen of 19 (68%) IDDM subjects had a score of 1, 2, or 3 compared to 3 of 22 (13.6%) control subjects (P < .0005). There was an association between duration of IDDM and fibrosis score (r = .46, P < .05) and between age and fibrosis score among IDDM subjects (r = .57, P = .01). No association between age or duration of diabetes and /ibrosis score was observed for NIDDM or control subjects. Adrenal medullary fibrosis may be an anatomical correlate of the diminished epinephrine secretion that occurs in response to insulin-induced hypoglycemia in some IDDM subjects.