Threshold values of maternal blood glucose in early diabetic pregnancy--prediction of fetal malformations.

BACKGROUND: The prevention of congenital malformations in the newborns of diabetic mothers still constitutes one of the main problems in this group of patients. AIM: The aim of this study was to analyze the prevalence of fetal malformations in diabetic pregnancies, as well as detection of the cut-off points for the first-trimester glycemia levels, relating to diabetes-induced fetal malformations. METHODS: The data for analysis were collected retrospectively from the case histories of diabetic pregnant women and their newborns, treated in our departments. For the evaluation of maternal diabetes control, the whole-day glycemia profiles as well as glycated hemoglobin (HbA1C) levels were registered. To establish the glucose cut-off values for malformations, we have used receiver operating characteristic (ROC) curves for fasting, 1-hr, and 2-hr postprandial glucose levels. To determine how metabolic control influences the risk of giving birth to a malformed infant, we followed 198 newborns of diabetic mothers and 4700 infants born of healthy mothers (control group). RESULTS: We detected malformations in the infants of 8.6% (n = 17) of diabetic mothers and 3.8% of the control (odds ratio: 2.35, 95% CI = 1.40-3.96). We compared this group of diabetic patients to another diabetic pregnancy group, analyzed over a period of 1988-93 (n = 209), in which 13 newborns (6.2%) manifested congenital malformations (odds ratio: 1.41, 95% CI = 0.67-2.99) (the difference was statistically insignificant). HbA1C level during organogenesis was not significantly higher in women whose infants were malformed. We proved, however, that the risk of malformations was higher, when HbA1C value exceeded 9.3%. The malformation rate in diabetes classes D-H (according to White) was higher than in classes B and C, but the difference was not significant. A wide spectrum of anomalies has been observed in the newborns of diabetic mothers. CONCLUSIONS: Our results confirm the view that diabetic pregnancy, despite the improved metabolic control, is still a strong risk factor for alterations in fetal development, particularly in patients with a tendency to brittle glycemia during first trimester of pregnancy. It seems that keeping fasting glucose levels in first trimester below 5.8 mmol/l and postprandial glucose levels below 9.1 mmol/l can contribute to decreasing number of fetal malformations in pregestational diabetes mellitus (PGDM) pregnancy. The ROC curves appear to be useful and adequate tool for the analysis of factors influencing fetal development in diabetic pregnancy.

Changes of oxidative stress parameters in diabetic pregnancy.

BACKGROUND: The molecular aetiology of disturbed embryogenesis and other unfavourable outcomes in offspring of diabetic mothers is not fully understood. Experimental studies have suggested an involvement of radical oxygen species (ROS) in the teratological process. THE AIM OF OUR STUDY: To investigate if maternal diabetes in humans is capable of inducing alterations in vascular oxidative stress parameters and whether such changes are associated with disturbances in foetal development. METHODS: Seventy patients with pre-gestational diabetes (PGDM) were chosen for the study: 29 (41.4%) belonged to class B according to White, 15 (21.4%) to class C, 8 (11.4%) to class D, 3 (4.3%) to class F, 3 to class R and 12 (17.1%) to class F/R. In 20 (28.6%) patients from this group an unfavourable outcome was noted. All patients were subjected to intensive insulin therapy. Glycaemia was estimated by daily self-monitoring, and diurnal glucose profiles and glycated haemoglobin (HbA1c) concentrations were measured monthly. Oxidative stress was evaluated as changed superoxide dismutase, catalase and glutathione peroxidase activities as well as of malondialdehyde (MDA) and peroxides concentrations in maternal erythrocytes and blood serum. RESULTS: Prior to conception, the mean glycaemia in the group that had a planned pregnancy was 6.6mmol/l and HBA1c was 9.35%. Throughout the course of pregnancy, these parameters were maintained at a level of 6.7 mmol/l and 7.85%, respectively. The activity of all antioxidative enzymes was lower before than during pregnancy, and so was the concentration of MDA. The MDA concentrations were higher in patients with elevated glycaemia and with an unfavourable outcome. The investigated ROS, the glycaemia level, as well as the concentration of HBA1c did not show any significant differences between pregnancies with and without vascular complications. Patients with a favourable perinatal outcome presented a higher activity of antioxidant enzymes, than those with unfavourable outcome, throughout the whole course of pregnancy. The appearance of unfavourable perinatal outcomes in relation to parameters of oxidative stress was assessed by logistic regression. Both SOD and GPX activities, as well as peroxides' concentration, showed significant correlations (p < 0.005) with foetal complications. However, after mean glucose levels in the studied group were included into these analyses, this relationship was only evident with SOD and GPX activity (p < 0.0016). CONCLUSION: Oxidative stress is one of several important factors contributing to unfavourable outcome of human diabetic pregnancy.

[Diagnostic value of transvaginal ultrasound in the detection of ovarian endometriosis]. / Wartosc diagnostyczna ultrasonografii dopochwowej w rozpoznawaniu endometriozy jajnika.

The aim of the study was to estimate of efficiency of endovaginal ultrasonography in diagnosis of ovarian endometriosis. The study was performed in 59 women with ovarian tumors. Ultrasound examinations were performed with Aloka 2000 using 5.0 MHz transducers. The endovaginal ultrasonography is very useful in diagnosis of ovarian endometriosis, showing sensitivity--90%, specificity--68%, positive predictive value--75%, negative predictive value--86%. Ultrasound examination is an important tool in noninvasive diagnostic procedure of adnexal pathology.

[Qualitative blood flow parameters in the spiral artery and progesterone concentration in pregnancy complicated by threatened abortion]. / Jakosciowe parametry przeplywu krwi w tetnicach spiralnych a stezenie progesteronu w surowicy krwi u ciezarnych zagrozonych poronieniem.

OBJECTIVES: The aim of the study was to determine the values of i.e. resistance index (RI) and pulsatility index (PI) in the spiral arteries and to evaluate the maternal serum concentration of progesterone trying to find correlation between these parameters in the group of patients in early pregnancy complicated by threatened abortion. STUDY METHODS: We have analysed 30 pregnant women between 5th and 12th weeks of pregnancy with the symptoms of vaginal bleeding & lower abdominal pains diagnosed as threatened abortion. In all patients transvaginal ultrasound examination with pulse color Doppler was performed. The RI and PI values were calculated for blood flow velocity waveforms obtained from the spiral arteries. The concentration of progesterone in maternal serum was evaluated by Microparticle Enzyme Immunoassay. The correlation between analysed parameters and pregnancy duration was examined with use of linear correlation by Pearson. The correlation between Doppler and biochemical parameters were analysed with use of rang correlation method by Spearman. RESULTS: Thirty flow velocity waveforms from spiral arteries were analysed and blood flow indices were calculated. We have found statistically significant negative correlation between the values of both blood flow parameters (RI & PI) and successive weeks of pregnancy (p < 0.001) and statistically significant positive correlation between maternal serum concentration of progesterone and pregnancy duration (p < 0.05). In the tested group in 40% of patients the level of progesterone was abnormal. We have not find any correlation between serum progesterone concentration and doppler parameters in our study. CONCLUSIONS: There is observed the characteristic drop of resistance to the blood flow in the vessels of the uteroplacental circulation in the successive weeks of early pregnancy in patients with threatened abortion similar to normal early pregnancies. Lack of correlation between maternal serum concentration of progesterone and blood flow parameters indicates that other hormonal factors play major role in the regulation of the blood flow in these vessels in early pregnancy. Only the combination of Doppler blood flow analysis in spiral arteries and progesterone evaluation in the maternal serum performed in first trimester may be useful for the intensive fetal monitoring of high risk pregnancies.

[Influence of the degree of carbohydrate metabolism imbalance in gestational diabetes on pregnancy and newborns condition]. / Wplyw stopnia nasilenia zaburzen metabolizmu weglowodanów w momencie rozpoznania cukrzycy ciazowej na przebieg ciazy i stan noworodków.

UNLABELLED: The aim of our study was the evaluation of the correlation between carbohydrate metabolism imbalance at the moment of gestational diabetes mellitus (GDM) diagnosis and regulation of glycemia during pregnancy, pregnancy complications, time and mode of delivery and conditions of the newborns. MATERIAL: 231 women with GDM delivered in our hospital between 1993-1996 were investigated. This population was divided into 6 groups, according to glycemia levels. METHOD: The term of diagnosis of the GDM, medical treatment (diet or diet and insulin), the degree of metabolic regulation archived, mode and time of delivery, as well as state of newborns were analysed. RESULTS: In groups I and VI we noticed the greatest percentage of patients treated with insulin (68%, 67%), versus 26% in group II and 17% in group III. In group VI in all cases treated with insulin we begun this therapy shortly after marking GDM. Glycemia in 24 hrs period after GDM diagnosis in group I were 122.7 +/- 28.6 mg/dl, in group VI 112.0 +/- 23.6 mg/dl, while we noticed 90.3 +/- 15.6 mg/dl in group II and 87.7 +/- 15.9 mg/dl in group III. Blood glucose level < 100 mg/dl in first determination of 24 hrs profiles we noticed in 5% in group I, 2% in group VI while 20% in group II and 51% in group III. Average levels of glycemia in last 24 hrs profiles before delivery in group I were 93.0 +/- 15.8 mg/dl, in group VI 96.2 +/- 21.1 mg/dl while 87.8 +/- 13.5 mg/dl in group II and 86.8 +/- 14.1 mg/dl in group III. Blood glucose level < 100 mg/dl of daily profile before the end of pregnancy was discovered in 8% in group I, 47% in group III. The greatest amount of complications (pregnancy induced hypertension and imminent premature delivery) was diagnosed in group VI-75% and in group III-55%. Surgical delivery took place in group I in 50%, in group V in 46%, in group VI in 67% while 17% in group II, 35% in group III and 30% in group IV. Macrosomy of newborns (> 4000 g) was diagnosed in group I in 36% in group V in 23% and in group VI in 42% while 9%, 6% and 15% in groups, II, III and IV respectively. The condition of newborns in the 1st minute of life was determined as good (8-10 points in Apgar scale) in significant percentage, in 87%, 75%, 70% in groups II, III, IV while only 59%, 62%, 58% in groups I, V, VI respectively. CONCLUSION: Serious intensification of carbohydrates metabolism disorders at the moment of diagnosing GDM, such as fasting glycemia > 140 mg/dl and the result after 2 hours > 200 mg/dl in 75 g OGTT more often requires insulin treating connect with numerous difficulties both in pregnancy monitoring and also has inadventageous influence on obstetrics outcomes-increasing percentage of surgery deliveries and macrosomies, that change the condition of newborns for worse.

[Transvaginal color Doppler study of the uteroplacental circulation in early pregnancy]. / Analiza przeplywu krwi w krazeniu maciczno-lozyskowym metoda "kolorowego Dopplera" we wczesnej ciazy.

OBJECTIVE: To compare resistance index (RI) and pulsatility index (PI) values of blood flow in arteries of uteroplacental circulation in normal and threatened abortion first trimester pregnancies. STUDY DESIGN: We have analysed 36 pregnant woman between 5th and 12th weeks of pregnancy--17 patients with threatened abortion as a test group and 19 patients with normal intrauterine pregnancy taken as controls. In all patients transvaginal ultrasonography with pulse color Doppler was performed. The RI and PI values were calculated for blood flow velocity waveforms obtained from uterine artery and its branches--arcuate, radial and spiral arteries. RESULTS: In the test group we have analysed 17 flow velocity waveforms from uterine artery (mean RI 0.852; SD 0.080, mean PI 2.324; SD 0.693), 16 from arcuate artery (mean RI 0.638; SD 0.049, mean PI 1.315; SD 0.064,), 17 from radial artery (mean RI 0.638; SD 0.049, mean PI 1.009; SD 0.177) and 15 from spiral artery (mean RI 0.548; SD 0.068, mean PI 0.804; SD 0.160); in controls we have analysed 16 flow velocity waveforms from uterine artery (mean RI 0.866; SD 0.066, mean PI 2.469; SD 0.618), 17 from arcuate artery (mean RI 0.728; SD 0.123, mean PI 1.352; SD 0.362), 19 from radial artery (mean RI 0.630; SD 0.092, mean PI 1.017; SD 0.261) and 16 from spiral artery (mean RI 0.511; SD 0.100, mean PI 0.760; SD 0.202). CONCLUSION: There was no significant difference in mean RI and PI values between normal and abnormal pregnancies. A gradual statistically significant decrease of RI and PI values during time of pregnancy we have observed only in radial arteries in both groups. For other vessels in the control group the RI and PI values tended to decrease during the time of pregnancy while in the test group some even rose up.

[The evaluation of the efficiency of treatment in ectopic pregnancy with the application of various surgical procedures]. / Ocena skutecznosci leczenia ciazy ektopowej z zastosowaniem róznych metod operacyjnych.

In our study we analyzed 54 women with confirmed diagnosis of ectopic pregnancy, in whom two different surgical approaches were performed. There were 40 salpingotomies and 14 salpingectomies. The dynamics of the decrease of beta hCG serum level were assessed. The beta hCG levels not greater than 5 mIU/ml (2nd IS) were the markers of the recovery. Similar therapeutic effect was obtained in both testing group. The normalisation of the beta hCG serum level was observed after 19th and 21st days after salpingectomy and salpingotomy, respectively.

[Glycemia control in diabetic pregnancies under intensive insulin treatment with and without the aid of the Camit-Diacomp system]. / Kontrola wyrównania glikemii u ciezarnych z cukrzyca leczonych intesywna insulinoterapia przy pomocy oraz bez systemu Camit-Diacomp.

The efficiency of glycemia control was compared in two groups of insulin dependent diabetic pregnancies treated with insulin, with and without the aid of the Camit-Diacomp system. The efficiency of glycemia control was analysed in all three trimesters of pregnancy. Mean diurnal fluctuations of glycemia levels in both study groups were compared. The clinical state of newborns, their glycemia and insulin levels in cord blood were analysed as well. No statistically significant differences of glycemia levels between the two compared groups of patients were found, however the observed significant differences of the HbA1C levels between these groups can speak in favour of the efficiency of treatment under the Camit-Diacomp system, which enables a more precise self control of the treatment and dosage of insulin.

[Analysis of unsuccessful outcomes in a group of pregnancies with diabetes from the intensive care clinic of the Institute of Obstetrics and Gynecology in Poznan during the years 1988-1993]. / Analiza niepowodzen polozniczych w grupie ciezarnych z cukrzyca w KIN IGIP AM w Poznaniu w latach 1988-1993.

In the present paper we analysed 416 diabetic pregnant women, treated in the Intensive Care Clinic--Poznan, between 1988-93. We found in this period 8 (1.93%) stillbirth, 6 (1.44%) perinatal deaths and 4 (0.96%) deaths in neonatal period. It was together 18 fetal and neonatal deaths, which gives 4.33 per cent of perinatal and neonatal mortality rate. Four newborns died because of RDS, 2 with congenital anomalies (pulmonary hypoplasia), 3 with heart defects and 1 with oesophagus anomaly. Only 3 diabetic pregnant women of the total 18, were under special care from the I trimester, and almost all been difficult to normalize the glycemia. Only in 6 cases this group glycemia profile was below 100 mg/dl, in other 8 cases this value was above 120 mg/dl. Unsuccessful outcomes mostly occurred in women with long--lasting diabetes and with vascular complications. This study prove, that despite substantial reduction of perinatal mortality rate in children of diabetic mothers, diabetes still is a cause of congenital anomalies, as well as fetal anoxia. Special adverse impact of diabetes on the development of the fetus is observed in long--lasting diabetes and uncontrolled metabolism.

[Doppler evaluation of blood flow in the umbilical artery when confronted with morphologic changes in human placenta of pregnancy complicated by diabetes]. / Dopplerowska ocena przeplywu krwi w tetnicy pepowinowej w konfrontacji ze zmianami morfologicznymi w lozysku ludzkim w ciazy powiklanej cukrzyca.

Doppler ultrasound velocimetry in umbilical artery was performed in 23 pregnant women in different classes of the diabetes. Results obtained were compared with the afterbirths' morphology. Strict correlation was found between arteries obliteration in the placenta and vascular resistance in higher classes of the diabetes. Normal structure of the villi with signs of their morphological maturity has basic influence on proper umbilical artery flow maintenance.