Effect of maternal diabetes and ethanol interactions on embryo development in the mouse.

The aim of this study was to determine the possible fetal effects of interaction between maternal diabetes and acute doses of alcohol. Pregnant TO mice were made diabetic by a single injection of streptozotocin (STZ) on gestation day (GD) 2. Single dose of 0.003 or 0.03 ml/g body weight of fresh ethanol (25% v/v of absolute alcohol in normal saline) was injected into groups of diabetic and nondiabetic animals on GD 7 or 8. One group of diabetic animals had a daily dose of 6-8 IU of insulin subcutaneously. Fetuses were collected on GD 18. There was a significant increase in the incidence of implantation failure in the diabetes plus ethanol groups and insulin control group. Ethanol injection on GD 7 accentuated diabetes-related embryonic resorption and intrauterine growth retardation (IUGR). This effect was less marked in the diabetic group treated with ethanol on GD 8. Diabetes alone produced a greater incidence of IUGR than ethanol alone. Midfacial hypoplasia and minor anomalies were found more frequently in the combination treatment groups. Holoprosencephaly and thymus hypoplasia observed in diabetic groups were found to be reduced in frequency in the diabetes plus ethanol groups, suggesting an antagonistic type of ethanol-diabetes interaction, stage-dependently. Since severely malformed embryos are known to be resorbed/killed in utero in mice, this reduction might reflect the magnitude of early death of severely malformed embryos. These data suggest that the interaction effects are possibly related to alterations in fundamental developmental processes of early embryos.

Effects of alpha-lipoic acid supplementation on maternal diabetes-induced growth retardation and congenital anomalies in rat fetuses.

The mechanism of diabetic embryopathy is not known. Excessive reactive oxygen species (ROS) produced in diabetes may be causally related to foetal anomalies. The objective of this study was to determine whether supplementation with the antioxidant lipoic acid (LA) could prevent maternal diabetes-related foetal malformations and intrauterine growth retardation (IUGR) in rats. Pregnant rats were non-treated (Group I) or made diabetic on gestation day (GD) 2 by injecting streptozotocin (Group II). Group III was injected with 20 mg kg(-1) of LA daily starting on GD 6 and continued through GD 19. Group IV was administered only Tris buffer on the corresponding days. Group V was a set of STZ-treated animals, which were supplemented with a daily dose of 20 mg kg(-1) of LA from GD 6 through GD 19. All fetuses were collected on GD 20. Lipoic acid did not affect the blood sugar levels of diabetic animals significantly but improved their body weight gain and reduced food and water consumption. Diabetic group had a high incidence of embryonic resorption, IUGR, craniofacial malformations, supernumerary ribs and skeletal hypoplasia. Lipoic acid significantly reduced these abnormalities. These data support the hypothesis that ROS are causally related to fetal maldevelopment and IUGR associated with maternal diabetes in the rat. They also highlight the possible role of antioxidants in the normal processes of embryo survival, growth and development.

Effect of different doses of vitamin E on the incidence of malformations in pregnant diabetic rats.

BACKGROUND/AIMS: Previously we have shown that administration of 150 mg of vitamin E (alpha-tocopherol) per day to rats having diabetes decreases the rate of embryo malformations and increases their maturation and size. The present study was addressed to determine the effects of different doses of vitamin E upon these parameters. METHODS: Female rats were made diabetic (D) with streptozotocin, and from day 0 of gestation they were treated daily with 25 (D+25), 50 (D+50), 100 (D+100), 150 (D+150), and 500 (D+500) mg of vitamin E administered orally and were compared with control (C) animals. RESULTS: On day 11.5 of gestation, crown-rump length, somite number, and protein and DNA levels were lower in D than in C embryos. Crown-rump length and somite number increased with 100 mg or higher doses of vitamin E, although the values observed in C embryos were not reached. The proportions of reabsorption and malformations were 24.7 and 50%, respectively, in D rats, and in the rats supplemented with vitamin E they decreased to 22.7 and 19% in D+25, 16.4 and 21.3% in D+50, 16.2 and 12% in D+100, 12.9 and 13.9% in D+150, and to 43.9 and 10.8% in D+500 rats, whereas the values were 6.8 and 4.9% in C animals. CONCLUSIONS: Administration of vitamin E to D rats decreases the rate of embryo malformations, dependent on the dose administered. However, high doses have a negative effect in the conceptus, as shown by the increased rate of reabsorptions in the D+500 group.

Effects of ergothioneine on diabetic embryopathy in pregnant rats.

The natural antioxidant ergothioneine (2-mercaptohistidine trimethylbetaine) is a fungal metabolite and found in most plant and animal tissues. The effect of ergothioneine on diabetic embryopathy in rats was assessed. Supplementation of diabetic pregnant rats with L-ergothioneine (1.147 mg/kg body weight) daily for the first 11.5 days of pregnancy reduced the rate of embryo malformations, to values similar to the non-diabetic animals. The ergothioneine had no effect on the plasma glucose levels, both in diabetic and control animals. We conclude that the inhibition of the glucose-mediated free radical dependent embryo malformation by ergothioneine is an important antioxidant prophylactic mechanism, which when combined with vitamin E could benefit the management of diabetic embryopathy.

Diacylglycerol production and protein kinase C activity are increased in a mouse model of diabetic embryopathy.

Activation of the diacylglycerol-protein kinase C (DAG-PKC) cascade by excess glucose has been implicated in vascular complications of diabetes. Its involvement in diabetic embryopathy has not been established. We examined DAG production and PKC activities in embryos and decidua of streptozotocin (STZ)-diabetic or transiently hyperglycemic mice during neural tube formation. STZ diabetes significantly increased DAG and total PKC activity in decidua (1.5- and 1.4-fold, respectively) and embryos (1.7- and 1.3-fold, respectively) on day 9.5. Membrane-associated PKC alpha, betaII, delta, and zeta were increased in decidua by 1.25- to 2.8-fold. Maternal hyperglycemia induced by glucose injection on day 7.5, the day before the onset of neural tube formation, also increased DAG, PKC activity, and PKC isoforms (1.1-, 1.6-, and 1.5-fold, respectively) in the embryo on day 9.5. Notably, membrane-associated PKC activity was increased 24-fold in embryos of diabetic mice with structural defects. These data indicate that hyperglycemia just before organogenesis activates the DAG-PKC cascade and is correlated with congenital defects.

Maternal diabetes increases the risk of caudal regression caused by retinoic acid.

Maternal diabetes increases the risk of congenital malformations in the offspring of affected pregnancies. This increase arises from the teratogenic effect of the maternal diabetic milieu on the developing embryo, although the mechanism of this action is poorly understood. In the present study, we examined whether the vitamin A metabolite retinoic acid (RA), a common drug with well-known teratogenic properties, may interact with maternal diabetes to alter the incidence of congenital malformations in mice. Our results show that when treated with RA, embryos of diabetic mice are significantly more prone than embryos of nondiabetic mice to develop caudal regression, a defect that is highly associated with diabetic pregnancy in humans. By studying the vestigial tail (Wnt-3a(vt)) mutant, we provide evidence that Wnt-3a, a gene that controls the development of the caudal region, is directly involved in the pathogenic pathway of RA-induced caudal regression. We further show that the molecular basis of the increased susceptibility of embryos of diabetic mice to RA involves enhanced downregulation of Wnt-3a expression. This positive interaction between RA and maternal diabetes may have implications for humans in suggesting increased susceptibility to environmental teratogens during diabetic pregnancy.

Polymorphic susceptibility to the molecular causes of neural tube defects during diabetic embryopathy.

Previously, we demonstrated that neural tube defects (NTDs) are significantly increased in a mouse model of diabetic pregnancy. In addition, expression of Pax-3, a gene encoding a transcription factor required for neural tube development, is significantly decreased. This suggests that diabetic embryopathy results from impaired expression of genes regulating essential morphogenetic processes. Here, we report that in one mouse strain, C57Bl/6J, embryos are resistant to the effects of maternal diabetes on NTDs and Pax-3 expression, in contrast to a susceptible strain, FVB, in which maternal diabetes significantly increases NTDs (P = 0.02) and inhibits Pax-3 expression (P = 0.01). Resistance to NTDs caused by diabetic pregnancy is a dominant trait, as demonstrated by heterozygous embryos of diabetic or nondiabetic mothers of either strain. There was no significant difference between strains in expression of genes that regulate free radical scavenging pathways, suggesting that susceptibility to oxidative stress does not account for the genetic differences. Understanding the genetic bases for differential susceptibility to altered gene expression and NTDs in diabetic mice may be important in delineating the mechanisms by which maternal hyperglycemia interferes with embryo gene expression. Moreover, if susceptibility to diabetic embryopathy is variable in humans as well as in mice, it may be possible to screen individuals at increased risk for this complication of diabetes.

Hypoglycemia and embryonic heart development.

Abnormal embryonic development is a complication of the diabetic pregnancy, and heart defects are among the most common and detrimental congenital malformations of the diabetic embryopathy. Hypoglycemia is a common side effect of diabetes therapy and is a potential teratogen. An association between hypoglycemia and congenital defects has been difficult to demonstrate in humans, but in vivo and in vitro animal studies have illustrated the importance of glucose as a substrate for normal development. Hypoglycemia alters embryonic heart morphology, producing abnormal looping and chamber expansion, decreased myocardial thickness, disorganized layers, and decreased overall size. Hypoglycemia decreases embryonic heart rate and vascularity, and it alters embryonic heart metabolism by increasing glucose uptake and glycolysis. Hypoglycemia also affects protein expression in the embryonic heart, increasing the expression of glucose regulated proteins, hexokinase, and glucose transport protein. Thus, hypoglycemia interferes with normal cardiogenesis and alters morphology, function, metabolism, and expression of certain proteins in the developing heart. It is likely that these factors contribute to heart defects observed in the diabetic embryopathy, but the definitive link has yet to be made. Future studies are expected to further elucidate mechanisms mediating hypoglycemia-induced cardiac dysmorphogenesis.

Glycemic control throughout pregnancy and fetal growth in insulin-dependent diabetes.

OBJECTIVE: To determine the time of growth acceleration in fetuses of insulin-dependent diabetic women who are large for gestational age (LGA) at birth and the relationship between growth acceleration and diabetic control throughout pregnancy. METHODS: We studied a consecutive sample of 76 women with insulin-dependent diabetes divided by those who delivered LGA or normally grown infants. Fetal abdominal circumference (AC) was measured ultrasonically at regular intervals between 20 and 34 weeks' gestation. Diabetic control was assessed by regular measurement of glycosylated hemoglobin and capillary blood glucose levels. RESULTS: A significant difference in fetal AC between groups developed between 20 and 24 weeks' gestation, and the LGA group continued to have accelerated fetal growth. Between 18 and 24 weeks glycosylated hemoglobin and capillary blood glucose concentrations were significantly higher in women who delivered LGA infants. After 28 weeks, blood glucose concentrations and glycosylated hemoglobin did not differ significantly between groups. There was a nonsignificant trend toward more vaginal deliveries in the normal group (45% versus 32%). CONCLUSION: In insulin-dependent diabetic pregnancy, although actual growth acceleration occurred from about 20 weeks' gestation, growth potential of fetuses appeared to be determined by prevailing maternal glucose concentrations before then. Excessive growth continued despite subsequent satisfactory glucose control. If strict blood glucose control is maintained during first and second trimesters, it might reduce the incidence of LGA infants.

Fetal pancreatic function in infants of diabetic and rhesus-isoimmunized women.

OBJECTIVE: To measure insulin and glucagon concentrations in amniotic fluid (AF) collected near term in basal conditions and after an arginine test in diabetic, rhesus-isoimmunized, and control pregnant women. METHODS: At baseline, AF was collected from 44 diabetic, 32 rhesus-isoimmunized, and 27 control pregnant women in late pregnancy. Fifty-two diabetic, six rhesus-isoimmunized, and nine control pregnant women had amniocentesis 2 hours after arginine infusion (30 g intravenous/30 minutes) at 33-36 weeks. RESULTS: Baseline AF glucose concentrations were significantly greater in diabetic women than the other conditions, and they related to the gestational age in the women with hemolytic disease of the newborn. Insulin and glucagon AF content of isoimmunized pregnancies overlapped controls, whereas insulin and insulin/glucagon molar ratios were significantly higher, and glucagon values lower, in diabetic pregnancies compared with isoimmunized and control pregnancies. In isoimmunized pregnancies, the AF concentrations of glucose, insulin, and glucagon were correlated with gestational age (less than 34, 34 weeks or more). The samples collected after arginine infusion, compared with those collected at baseline, showed significantly greater insulin and insulin/glucagon molar ratio values in diabetic (28 +/- 5 versus 11 +/- 1 microU/mL, P = .001; 29.4 +/- 1.7 versus 12.0 +/- 2.8, P = .001) and in Rh pregnant women (18 +/- 6 versus 7.7 +/- 0.7 microU/mL, P = .001; 30 +/- 9 versus 3.4 +/- 0.4 I/G, P = .001), whereas no significant difference was observed in the controls. CONCLUSION: Basal islet hormone concentrations in AF are modified by maternal diabetes and further influenced by arginine administration. Arginine produces an AF response that is similar in pregnancies complicated by diabetes mellitus and rhesus-isoimmunization, despite different (hyperglycemia and euglycemia) maternal blood glucose levels.

Patterns of congenital anomalies and relationship to initial maternal fasting glucose levels in pregnancies complicated by type 2 and gestational diabetes.

OBJECTIVES: We sought to determine the types of congenital anomalies affecting infants of women with gestational diabetes mellitus or type 2 diabetes and to examine the relationship between those malformation types and measures of initial glycemia of women at entry into prenatal care with type 2 diabetes or at time of diagnosis in women with gestational diabetes mellitus. STUDY DESIGN: A total of 4,180 pregnancies complicated by gestational diabetes mellitus (n = 3764) or type 2 diabetes (n = 416) that were delivered after 20 weeks of gestation were reviewed for the presence of congenital malformations diagnosed before hospital discharge. Anomalies were categorized as being absent, minor, major, genetic syndromes, or aneuploidies. Major anomalies were further categorized by the number and type of affected organ systems. In addition to maternal clinical and historical parameters, the initial fasting serum glucose either from the diagnostic glucose tolerance test (gestational diabetes mellitus) or at entry to prenatal care (type 2 diabetes) and the initial glycosylated hemoglobin before insulin therapy were examined for a relationship to anomalies. RESULTS: The initial fasting serum glucose and glycosylated hemoglobin levels were significantly higher in pregnancies with major (n = 143) and minor (n = 112) anomalies and genetic syndromes (n = 9) compared with pregnancies with no anomalies (n = 3895). Of those pregnancies with major anomalies, the most commonly affected organ systems were the cardiac (37.6%), musculoskeletal (14.7%), and central nervous systems (9.8%) and anomalies involving multiple organ systems (16%). There was no increased predominance of any specific organ system involvement seen with increasing fasting serum glucose levels in pregnancies with major congenital anomalies. Pregnancies with major anomalies affecting multiple organ systems had significantly higher initial fasting serum glucose levels (166 +/- 64 mg/dL) compared with pregnancies in which one organ system was affected (141 +/- 55 mg/dL, P <.04) or no organ systems were affected (115 +/- 38 mg/dL, P <.0001). CONCLUSION: Congenital anomalies in offspring of women with gestational and type 2 diabetes affect the same organ systems that have been previously described in pregnancies complicated by type 1 diabetes. Increasing hyperglycemia at diagnosis or presentation for care was associated with an increasing risk of anomalies in general and with anomalies involving multiple organ systems without a preferential increase in involvement of specific organ system.

Aphallia as part of urorectal septum malformation sequence in an infant of a diabetic mother.

A male patient with aphallia, anal stenosis, tetralogy of Fallot, multiple vertebral anomalies including sacral agenesis and central nervous system (CNS) malformations was born after a pregnancy complicated by poorly controlled maternal diabetes. Aphallia is an extremely rare abnormality and can be part of the urorectal septum malformation sequence (URSMS). While aphallia has not been reported in infants of diabetic mothers, urogenital malformations are known to occur with increased frequency. Two female products of pregnancies complicated by diabetes presented with multiple malformations including anal atresia and recto-vaginal fistula consistent with the diagnosis of URSMS. The three patients share CNS, cardiac, and vertebral anomalies, abnormalities secondary to abnormal blastogenesis and characteristic of diabetic embryopathy. URSMS is also caused by abnormal blastogenesis. Therefore, this particular malformation should be viewed in the context of the multiple blastogenetic abnormalities in the cases reported here. The overlap of findings of URSMS in our cases with other abnormalities of blastogenesis, such as VATER association or sacral agenesis is not surprising, as these associations are known to lack clear diagnostic boundaries.

Apoptosis in embryos of diabetic rats.

The aim of the present study was to determine whether maternal diabetes affects rat embryo and yolk sac apoptosis during the postimplantation period. Severely malformed and growth-retarded embryos of gestational day 12 from diabetic rats exhibited pronounced DNA laddering on agarose gels. On the other hand, no DNA laddering could be observed in any of the non-malformed embryos from control and diabetic rats, or in their corresponding yolk sacs. Analysis of embryos of gestational day 10 revealed only a few scattered TUNEL positive cells mainly located in the allantois, the foregut epithelium, the cranial neuroepithelium and in the cranial mesenchyme. Embryonic tissue of gestational day 12 showed numerous aggregates of TUNEL-positive cells, indicating developmental remodelling of multiple organs. Analysis of non-malformed embryos of day 10 and 12 revealed a distribution and frequency of TUNEL positive cells unaffected by the diabetic state of the mother on both days. In vitro incubation (2-8 hr) of normal day-12 yolk sacs resulted in strong DNA laddering, but not in the corresponding embryos. Dispersed yolk sac cells generated higher levels of reactive oxygen species than dispersed embryonic cells. Reactive oxygen species levels in both embryonic and yolk sac cells were unaffected by the diabetic state of the mother. Moreover, immunoblot analysis showed high Bcl-2 and undetectable caspase-1 levels in embryos from both normal and diabetic rats and low Bcl-2 and high caspase-1 levels in the corresponding yolk sacs. Immunohistochemical analysis of embryos demonstrated caspase-1-reactivity in a small subpopulation of cells located in proximity to TUNEL-positive cells. We conclude that the inherent capacity of embryonic cells to enter apoptosis in vitro is low as compared to yolk sac cells, and that wide-spread apoptosis is not likely to play a major role in diabetes-induced dysmorphogenesis but rather in early phases of resorption of severely malformed and developmentally retarded embryos.

Fetal cardiac function and septal thickness in diabetic pregnancy: a controlled observational and reproducibility study.

OBJECTIVE: To determine the reproducibility of duplex Doppler waveform analysis and fetal cardiac interventricular septal thickness measurement and to compare these parameters in matched pregnancies with and without well-controlled maternal Type 1 diabetes at 18-20 weeks of gestation. DESIGN: A prospective blind twin cohort study and a blinded inter-observer and intra-observer agreement study. SETTING: A tertiary referral prenatal diagnostic unit within a university hospital. RESULTS: Good inter- and intra-observer agreement was found for the measurement of transvalvular peak flow velocities and the duration of ventricular ejection in the fetal heart. Inter-observer agreement for aortic flow acceleration rate was poor. M-mode measurement of interventricular septal thickness showed moderate reproducibility. The mean (SD) width of the interventricular septum in the fetuses of well controlled diabetic women was 2 1 mm (0.2 mm), and was significantly greater (P=0.01) when compared with the corresponding value in matched controls [1.9 mm (0.2 mm)]. No cardiac functional differences were evident. CONCLUSIONS: On-screen video analysis of Doppler cardiac flow waveforms and M-mode measurement of intraventricular septal thickness demonstrated good reproducibility. The fetuses of well controlled diabetic pregnancies demonstrated signs of altered cardiac morphology early in pregnancy, before any evident alterations in cardiac function.

Plasma leptin concentrations in newborns of diabetic and nondiabetic mothers.

Leptin plays an important role in regulating body composition through modulation of appetite and energy expenditure. We hypothesized that leptin levels in umbilical cord blood correlate with newborn body weight and habitus. We also hypothesized that infants of diabetic mothers would demonstrate altered leptin metabolism. Venous blood was sampled at birth from the umbilical cords of 105 infants (74 infants of nondiabetic mothers, and 31 infants of diabetic mothers). Thirty-nine mothers had plasma leptin concentrations measured. Analysis was done using Student's t-test, Pearson's correlation, and Spearman's correlation. Univariate/multivariate regression was used for analysis of factors associated with leptin concentration in umbilical cord plasma. Maternal and newborn characteristics were correlated with log leptin levels in umbilical venous plasma. Leptin concentration in umbilical cord plasma correlated best with birth weight for newborns of both nondiabetic and diabetic mothers (p < 0.01 for either). Umbilical cord plasma concentration of leptin was higher in infants of diabetic mothers than in infants of nondiabetic mothers (2.53 +/- 1.09 vs. 1.76 +/- 0.82; p < 0.001). Multiple regression analysis revealed a significant (p < 0.01) relationship between umbilical cord leptin level and newborn birth weight, as well as maternal DM, but not with gestational age. Similarly, there was no significant correlation with maternal plasma leptin concentration. The strong correlation of leptin concentration in umbilical cord plasma with newborn birth weight, and the lack of significant correlation with maternal leptin plasma levels, suggest that normal fetal leptin metabolism reflects fetal size and/or body habitus independent of maternal leptin metabolism. On the other hand, the higher umbilical plasma levels in infants of diabetic mothers may reflect an influence of altered fetal insulin homeostasis on fetal leptin metabolism, and suggests that maternal diabetes may influence fetal leptin metabolism.