Optimal Glycemic Control, Pre-eclampsia, and Gestational Hypertension in Women With Type 1 Diabetes in the Diabetes and Pre-eclampsia Intervention Trial

Holmes, Valerie; Young, Ian S.; Patterson, Christopher; Pearson, Donald; Walker, James; Maresh, Michael; McCance, David R.

doi:10.2337/dc11-0244

Cited by 180 publications

(140 citation statements)

References 22 publications

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“…Previous studies have reported similar increasing rates of pre-eclampsia with increasing severity of diabetes according to White's classification [12,13,30,31]. Our results suggest that the association of White's class with pre-eclampsia is possibly even more pronounced than that of suboptimal glycaemic control and chronic hypertension, which are established risk factors of pre-eclampsia in diabetic pregnancies [21,31,32]. However, in logistic regression analysis, White's classes from B to F were not strong predictors of adverse outcomes other than pre-eclampsia.…”

Section: Discussionsupporting

confidence: 77%

White’s classification and pregnancy outcome in women with type 1 diabetes: a population-based cohort study

et al. 2015

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Aims/hypothesis Our aim was to examine the association of White's classification with obstetric and perinatal risk factors and outcomes in type 1 diabetic patients. Methods Obstetric records of a population-based cohort of 1,094 consecutive type 1 diabetic patients with a singleton childbirth during 1988-2011 were studied. The most recent childbirth of each woman was included. Results The prepregnancy and the first trimester HbA 1c increased from White's class B to F (p for trend <0.001). Systolic and diastolic blood pressure and pre-eclampsia frequencies increased stepwise from class B to F (p for trends <0.001).Vaginal deliveries decreased and Caesarean sections and deliveries before 37 weeks increased from class B to F (p for trends <0.001). Fetal macrosomia (p for trend=0.003) decreased and small-for-gestational age infants (p for trend=0.002) and neonatal intensive care unit admissions (p for trend=0.001) increased from class B to F. In logistic regression analysis, White's classes were associated with pre-eclampsia but, with the exception of class R (proliferative retinopathy) and F (nephropathy), not with other adverse outcomes when adjusted for first trimester HbA 1c ≥7% (≥53 mmol/mol) and blood pressure ≥140/90 mmHg. First trimester HbA 1c ≥7% was associated with pre-eclampsia, preterm delivery, fetal macrosomia and neonatal intensive care unit admission. Conclusions/interpretation White's classification is useful in estimating the risk of pre-eclampsia in early pregnancy independently of suboptimal glycaemic control and hypertension. However, its utility in predicting adverse perinatal outcomes seems limited when information on first trimester HbA 1c , blood pressure and diabetic microvascular complications is available.

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Section: Discussionsupporting

confidence: 77%

White’s classification and pregnancy outcome in women with type 1 diabetes: a population-based cohort study

et al. 2015

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“…So, in the context of disease, vacuolation is observed as a response to stress and oxygen restriction. [2,21,22] Regarding the villous core, the present study showed that edematous spaces were obviously seen in women with GDM. Gauster et al [23] and Slukvin et al [13] mentioned that the placental villi showed spaces consistent with villous edema in GDM women.…”

Section: Discussionmentioning

confidence: 50%

Ultrastructure of the placenta in gestational diabetes mellitus

Hassan¹,

Essa²

2016

Anatomy

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Objectives: The placenta plays critical roles during pregnancy and is essential for fetal growth and development. Its functions are determined by the ultrastructure of the placental barrier that is an important feature to maintain the exchange surface area between the fetus and the mother. Gestational diabetes mellitus (GDM) comprises unfit conditions for embryonic and feto-placental development, and may result in placental abnormalities. The aim of this study was to detect the ultrastructural changes of the placenta in women with GDM. Methods:The placentas of 10 women with GDM without pregestational diabetics, hypertension and chronic diseases and 10 controls were studied. Six control women were delivered vaginally and the remaining cases by caesarian section at a gestational age of 36 to 39 weeks. Placental samples were measured for their thickness and prepared for light and transmission electron microscopy study.Results: Light microscopic study of the control placentas showed numerous densely packed microvilli with syncytial knots and thin-walled blood vessels and wide intervillous spaces. The placentas of GDM cases showed reduced number of microvilli with syncytial knots, thick-walled vessels, edematous spaces, areas of fibrosis and perivillous fibrinoid degeneration. Electron microscopic study of the placentas of the control women showed terminal villi with a thick layer of syncytiotrophoblasts (Sy) with a lot of regular cylindrical microvilli and a thin layer of cytotrophoblasts (Cy). There were some endoplasmic reticulum cisternae besides few mitochondria. The underlying villus core was harboring fetal capillaries lined with flat endothelial cells and thin basement membrane. There was no fibrosis or edema. In the placenta of GDM women, there was hypertrophy of Cy with atrophy of Sy with multiple vacuoles and areas for glycogen storage. The subtrophoblastic membrane was thick and the microvilli were scarce. The villous core showed congested capillaries, stromal macrophages, edematous spaces, glycogen storage areas and fibrosis. Conclusion:All the changes in placentas of gestational diabetes were attributed to associated hypoxia and oxidative stress due to decreased uteroplacental flow that was aggravated by the thick placental barrier and the presence of edema, fibrosis and glycogen storage areas that increased the distance of transfer between the fetus and mother.

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“…Poor glycemic control before pregnancy is associated with pregnancy complications such as congenital malformations (43,44), pre-eclampsia (45)(46)(47), and preterm delivery (1,43). Strict glycemic control is therefore the goal and HbA1c as close to normal as possible at least ,7% is recommended.…”

Section: Glycemic Controlmentioning

confidence: 99%

“…Development of pre-eclampsia is more frequent in women with higher levels of HbA1c in early pregnancy (45)(46)(47). In addition, improvement of glycemic control during pregnancy is associated with less pre-eclampsia (56).…”

Section: Treatment Of Women With Diabetic Nephropathy During Pregnancmentioning

confidence: 99%

Obstetric Nephrology

Mathiesen

Ringholm

Feldt‐Rasmussen

et al. 2012

Clinical Journal of the American Society of Nephrology

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SummaryThis review highlights factors of importance for the clinical care of pregnant women with pregestational diabetes and microalbuminuria or diabetic nephropathy with particular focus on the role of intensive antihypertensive treatment during pregnancy. Most information in the literature comes from women with type 1 diabetes and diabetic nephropathy, but this is probably also valid for women with type 2 diabetes. Careful counseling of women with diabetic nephropathy before pregnancy with estimation of the risk for the mother and fetus is important. Pregnancy does not result in worsening of kidney function in women with diabetic nephropathy and normal serum creatinine, but pregnancy complications such as pre-eclampsia and preterm delivery are common. Intensive metabolic control before and during pregnancy, low-dose aspirin from 12 gestational weeks onward, and intensive antihypertensive treatment are important. Methyldopa, labetalol, and nifedipine are regarded safe in pregnancy, whereas angiotensin converting enzyme inhibitors, AngII antagonists, or statins should be paused before pregnancy. Case series and pathophysiological studies support the use of a stringent goal for BP and albumin excretion in pregnant women with diabetic nephropathy. Screening for diabetic retinopathy before and during pregnancy is mandatory and laser treatment should be performed if indicated. Pregnancy outcome in women with diabetic nephropathy has improved considerably with a take-home-baby rate of approximately 95%. Further research on the benefits and risks of intensive antihypertensive treatment in this population is needed.

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Optimal Glycemic Control, Pre-eclampsia, and Gestational Hypertension in Women With Type 1 Diabetes in the Diabetes and Pre-eclampsia Intervention Trial

Cited by 180 publications

References 22 publications

White’s classification and pregnancy outcome in women with type 1 diabetes: a population-based cohort study

White’s classification and pregnancy outcome in women with type 1 diabetes: a population-based cohort study

Ultrastructure of the placenta in gestational diabetes mellitus

Obstetric Nephrology

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