Serena Ottanelli

Glucose Variability in Diabetic Pregnancy

BACKGROUND Fetal overgrowth is the most important complication of gestational (GDM) and pregestational diabetes mellitus. METHODS We correlated maternal glucose profiles, as detected by continuous glucose monitoring (CGM), with fetal growth parameters for 80 pregnant women (32 with type 1 diabetes, 31 with GDM, and 17 healthy controls). Glucose profiles were monitored in the first, second, and third trimesters of pregnancy for type 1 diabetes women and in the second and third trimesters for GDM women and controls. To analyze glycemic variability, we considered the mean amplitude of glycemic excursion, mean glycemia, the continuous overlapping net glycemic action (CONGA), the SD, the High Blood Glucose Index (HBGI), the Low Blood Glucose Index, and the interquartile range (IQR). RESULTS Mean age was the same for the three groups. Prepregnancy body mass index was higher for the women with diabetes (GDM and type 1) than for controls. The newborns mean birth weight and ponderal index were higher, although not significantly so, for the women with diabetes than for controls. For the type 1 diabetes patients, ponderal index correlated with the HBGI in the first trimester, CONGA1 and IQR in the second, and mean glycemia and SD in the third. For GDM patients, ponderal index correlated with mean glycemia and the HBGI in the second trimester. CONCLUSIONS Fetal exposure to glycemic variability and hyperglycemia seems to be important in determining fetal overgrowth in pregnant women with diabetes. Optimal glucose control and less glucose variability are needed as early as possible in both type 1 diabetes and GDM patients to ensure normal fetal growth.

Metabolomic profile of term infants of gestational diabetic mothers.

Abstract Objective: Maternal diabetes increases the risk of perinatal mortality and morbidity, but the maintenance of antenatal normal glucose serum prevents the majority of neonatal complications. The aim of our study is to compare the metabolomic profile of infants of gestational diabetic mothers (IGDMs) to that of infants of healthy mothers to evaluate if differences remain despite a strict control of gestational diabetes. Methods: We performed the metabolomics study in cord serum sampled from 30 term IGDMs and 40 controls recording the occurrence of the most frequent complications in IGDMs. Results: We demonstrated that IGDMs have lower level of glucose and higher level of pyruvate, histidine, alanine, valine, methionine, arginine, lysine, hypoxanthine, lipoprotein and lipid than controls, but we did not find any clinical differences. Conclusions: Our results suggest that prolonged fetal exposure to hyperglycemia during pregnancy can change neonatal metabolomic profile at birth without affecting the clinical course.

Stillbirth and fetal growth restriction

Objective: To confirm the role of fetal growth restriction (FGR) as a cause of stillbirth, and to compare diagnostic accuracy of customized fetal growth and population-based standards in identifying FGR within a pathological population of early and late stillbirths. Methods: Retrospective study on a cohort of 189 stillbirths occurred in single pregnancy between January 2006 and September 2011. Unexplained stillbirths, defined by Aberdeen-Wigglesworth and ReCoDe classifications, were evaluated on the basis of fetal birthweight with both Tuscany population and Gardosi customized standards. Unexplained stillbirths have been classified as early or late depending on the gestational age of occurrence. Results: Aberdeen-Wigglesworth classification, applied to the 189 cases of stillbirth, left 94 unexplained cases (49.7%), whereas the ReCoDe classification left only 40 (21%). By applying population standards to the 94 unexplained stillbirths we have identified 31 FGRs (33% of sample), while customized standards identified 54 FGRs (57%). Customised standards identified a larger number of FGRs with respect to population standards during the third trimester (i.e. 51% vs. 25% respectively) than in the second trimester (73% vs. 54% respectively) (p = 0.05). Conclusions: Customized standards have a higher diagnostic accuracy in identifying FGRs especially during the third trimester.

Continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) of rapid-acting insulin analogues and detemir in type 1 diabetic (T1D) pregnant women

Abstract Objective: To compare glycemic control, maternal-neonatal outcomes and fetal fat body mass growth of type 1 diabetic pregnant women treated with continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) with the long-acting insulin analogue detemir as basal insulin. Methods: Retrospective study of 53 women, attending the Unit of Prenatal Medicine of Careggi University Hospital, Florence, from 2009 to 2012: 35 treated with CSII, 18 with MDI-detemir. Each woman performed daily blood glucose self-monitoring, had an individualized nutritional therapy, weekly prenatal visits and ultrasound scans (US) according to the Tuscan guidelines. US were also performed every two weeks from 28 to 38 weeks of gestation to assess fetal fat body mass growth. Student’s t-test and Chi-square test were performed to compare the groups’ results. Results: No significant differences were observed in metabolic control, in any maternal and neonatal outcome nor fetal fat body mass growth for either group. The MDI group needed higher daily doses of insulin (MDI: 1.00 ± 0.32 UI/kg versus CSII: 0.75 ± 0.29 UI/kg, p = 0.007) to reach results comparable to the CSII group. Conclusions: MDI therapy with detemir is a safe and effective alternative, with a good benefit–cost ratio compared to insulin pumps.

Ethical issue and consent form in the management of high-risk pregnancy

Through the description of two high risk unplanned pregnancy cases and the subsequent interview of the patients, a few years after delivery, this article focuses on the following issues: The importance of a planned pregnancy in a woman with diabetes or other chronic disease; The ethical role of counselling and how it should not be influenced by the ethical belief of the obstetrician; The legal aspect related to the knowledge and qualifications of the obstetrician in the management of a high-risk pregnancy to improve both maternal and fetal outcomes. Here, two cases of complicated type 1 diabetes in women with unplanned pregnancies and the importance of counselling in high-risk pregnancy are presented.

Prescribing exercise for prevention and treatment of gestational diabetes: review of suggested recommendations

Abstract Exercise has been proved to be safe during pregnancy and to offer benefits for both mother and fetus; moreover, physical activity may represent a useful tool for gestational diabetes prevention and treatment. Therefore, all women in uncomplicated pregnancy should be encouraged to engage in physical activity as part of a healthy lifestyle. However, exercise in pregnancy needs a careful medical evaluation to exclude medical or obstetric contraindications to exercise, and an appropriate prescription considering frequency, intensity, type and duration of exercise, to carefully balance between potential benefits and potential harmful effects. Moreover, some precautions related to anatomical and functional adaptations observed during pregnancy should be taken into consideration. This review summarized the suggested recommendations for physical activity among pregnant women with focus on gestational diabetes.

Nutrition in pregnancy and lactation: how a healthy infant is born

Maternal nutrition during pregnancy and lactation influences the growth and potential development of the fetus and contributes to the maturity of a healthy baby. The lack of sufficient calories, of macro- and micronutrients, can lead to deficiencies in building materials for the development and growth of the fetus: moreover there is growing evidence that the maternal nutritional status can alter the epigenetic state of the fetal genome, therefore alterations in nutrition during crucial periods of fetal development may result in developmental adaptations that permanently change the physiology, the metabolism of the offspring, and, as a consequence, predispose these individuals to diseases as adults. In this review we collected indications for the recommended intake of calories and nutrients for a healthy diet during pregnancy and lactation, also analyzing some nutritional choices that may increase the risk of nutritional deficiencies and the way to prevent them. Pregnancy-related dietary changes should begin prior to conception, with appropriate modifications throughout pregnancy and lactation, and appropriate supplementation of vitamins and minerals. Proceedings of the 11 th International Workshop on Neonatology and Satellite Meetings · Cagliari (Italy) · October 26 th -31 st , 2015 · From the womb to the adult Guest Editors: Vassilios Fanos (Cagliari, Italy), Michele Mussap (Genoa, Italy), Antonio Del Vecchio (Bari, Italy), Bo Sun (Shanghai, China), Dorret I. Boomsma (Amsterdam, the Netherlands), Gavino Faa (Cagliari, Italy), Antonio Giordano (Philadelphia, USA)

Mothers with HIP – the short term and long-term impact, what is new?

Hyperglycemia is one of the most common medical conditions that women encounter during pregnancy and it is due to gestational diabetes (GDM) in the majority of cases (International Diabetes Federation, 2015) [1]. GDM is associated with a higher incidence of maternal morbidity in pregnancy in term of hypertensive disorders/preclampsia and higher rate of cesarean delivery but also with long-term risk of type 2 diabetes and cardiovascular disease. Pregnancy can therefore be considered a stress test; diagnosis of HIP can unmask a preexisting susceptibility and consequently a future risk for type 2 diabetes and can be a useful marker of future cardiovascular risk. Postpartum follow up provides an excellent opportunity to implement healthy lifestyle behaviors to prevent or delay the development of diabetes or cardiovascular disease. The aim of the current review is to focus on short and long term maternal morbidity of HIP.

Human leukocyte antigen DQ2/DQ8 positivity in women with history of stillbirth

The aim of this study was to investigate the prevalence of human leukocyte antigens (HLA) DQ2 and DQ8 haplotypes, two common polymorphisms associate with celiac disease (CD), in women with previous stillbirth, but not affected by CD.

D4. MCA/UtA ratio at first observation is associated with birthweight in late onset IUGR.

Abstract Introduction: MCA and uterine artery Doppler PI are commonly used in the evaluation of IUGR. Targets: This retrospective pilot study aims to investigate whether MCA/UtA ratio may identify adverse outcome in late onset IUGRs. A cohort of 69 pregnancies affected with late IUGR which underwent labor induction according to local protocols was retrospectively revised on the relationship between MCA/UtA ratio at first observation and the following adverse outcomes: cesarean section for nonreassuring fetal status, birthweight (expressed as percentile and continuous values, umbilical artery pH, NICU admission and Apgar score < 7 after 1 and 5 min. Results: The study population included 75.4% nulliparous women. Mean gestational age was 36.7 and 38.7 weeks’ gestation for diagnosis and induction, respectively. MCA/UtA ratio resulted significantly associated with a lower trend in birthweight, with a variation of 109.72 g for each unit considered (p = 0.040). The other outcomes considered showed no association. Conclusions: MCA/UtA ratio at first observation may be associated with lower birthweight in late onset IUGRs. Further prospective studies are expected.