Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy.

Background and Objective: The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy. Methods: The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared. Results: DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) (P < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 +/- 4.6 vs 27.5 +/- 4.8, P < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L. Conclusions: DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.     

Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: Case–control study and a case report of euglycemic diabetic ketoacidosis in pregnancy

Background and Objective:  The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy.
Methods:  The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared.
Results:  DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) ( P  < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 ± 4.6 vs 27.5 ± 4.8, P  < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L.
Conclusions:  DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.     

Fall in the heat-labile alkaline phosphatase isoenzyme levels during pregnancy in healthy Nigerians

Summary. Estimation of heat-labile alkaline phosphatase isoenzyme in the serum of 45 healthy non-pregnant women and 98 women in the second and third trimesters of pregnancy revealed a statistically significant reduction of this isoenzyme during pregnancy. Variations in normal activity were also more marked in the pregnant women compared with the non-pregnant control subjects. Now that normal serum levels of the heat-labile alkaline phosphatase isoenzyme in pregnancy have been established it is possible to use estimations of the enzyme as part of the assessment of maternal liver function in pregnancy.     

Fall in the heat-labile alkaline phosphatase isoenzyme levels during pregnancy in healthy Nigerians

Estimation of heat-labile alkaline phosphatase isoenzyme in the serum of 45 healthy non-pregnant women and 98 women in the second and third trimesters of pregnancy revealed a statistically significant reduction of this isoenzyme during pregnancy. Variations in normal activity were also more marked in the pregnant women compared with the non-pregnant control subjects. Now that normal serum levels of the heat-labile alkaline phosphatase isoenzyme in pregnancy have been established it is possible to use estimations of the enzyme as part of the assessment of maternal liver function in pregnancy.     

Spondylolysis and pregnancy--a risk analysis

A possible interference of various musculo-skeletal anomalies with pregnancy is often discussed by obstetricians. Pregnancy as a risk factor for progression of spondylolisthesis, olisthesis as a risk factor for pregnancy complications, and pregnancy in women with spondylolysis as the cause of increased low-back symptoms, are questions hitherto not analysed. In the present study, a comparison between men, non-pregnant women, and women who had been pregnant, was made with respect to the degree of spondylolisthesis and its subsequent progression over an observation period of at least 20 years. Occurrence and intensity of low-back symptoms, and functional impairment due to low-back symptoms (such as change of work, sick-leave, sick-pension, limitation in non-occupational activities, and treatment) during this long observation time were also analysed. The mean values for the group of women who had been pregnant did not differ from those of the other groups as regards any of these variables. On the basis of these results, it is concluded that pregnancy does not constitute a risk for progression of spondylolisthesis, or for increased low-back symptoms in a woman with spondylolysis. Nor is spondylolysis, with or without olisthesis, a risk factor for pregnancy complications.     

Homeostatic model assessment of beta cell function predicting abnormal oral glucose tolerance testing in pregnancy: a systematic review and meta-analysis

Background: Gestational diabetes mellitus (GDM) complicates 1–14% of pregnancies and relates to increased risk of adverse obstetric outcomes. Currently GDM is diagnosed using an oral glucose tolerance test (OGTT), which is burdensome and time intensive.

Objective: To compare current literature on whether the homeostatic model assessment beta cell function (HOMA-β) is an accurate predictor of an abnormal OGTT in pregnant women.

Methods: Pubmed, Cochrane and Embase were searched. Included studies evaluated pregnant women at risk for GDM using the homeostatic model assessment of beta cell function (HOMA-β) for the assessment of beta cell function and the OGTT. Studies with animals, non-pregnant women, women with type 2 diabetes and post-partum diabetes were excluded. The QUADAS-2 criteria were used to assess the methodological quality of studies.

Results: A total of 12 studies were included, reporting on 7292 women. Seven studies showed a difference in beta cell function between women with impaired glucose tolerance compared to healthy pregnant women. HOMA-β is significantly lower in impaired glucose tolerance (p?Conclusions: Although HOMA-β is lower in women with abnormal OGTT in pregnancy, given the high degree of heterogeneity of studies, we do not propagate HOMA-β as a sole diagnostic tool replacing OGTT to diagnose GDM.     

Peripheral blood neutrophils reactive oxygen intermediates (ROI) production in early pregnancy complicated by diabetes mellitus type I

The components of maternal innate immune system are activated in pregnancy. Increased number of circulating neutrophils and monocytes, reactive oxygen intermediate production (ROI), increased expression of the adhesion molecules can be observed. The activation status and neutrophils response to stimulators in pregnant diabetic women's comprise, to some extend, both situations pregnancy and diabetes, combined effect of both seems to be very intriguing. AIM OF STUDY: Evaluation production of ROI on peripheral blood neutrophils in early pregnancy of diabetic mothers. MATERIAL: 12 pregnant diabetic women demonstrating good glycemic control and without major complications before pregnancy were studied at 8-12 weeks of first gestation, 11 healthy pregnant women match for weeks of gestation, age and parity; 11 healthy non-diabetic women; 13 diabetic, non-pregnant women, were also studied. METHODS: ROI production was evaluated with chemiluminescence method using standard stimuli fMLP, PMA, OZ and also after 15 min. priming with TNF-alpha. We used MLX Microtiter Plate Luminometr DYNEX, USA. with computer program Revelation 97. For statistic analysis Fisher, Kolmogorow-Smirnow and Wilcoxon tests were used (p < 0.05). RESULTS: 1. Peripheral blood neutrophils of healthy pregnant, diabetic and pregnant diabetic women independently from the stimuli used showed an increase in ROI production 2. Peripheral blood neutrophils change their activity, evaluate by ROI production during pregnancy, diabetes and pregnancy complicated by diabetes. 3. Peripheral blood neutrophils of pregnant diabetes women do not show expected impairment of their function. CONCLUSIONS: Diabetes type 1 with good glycemic control and pregnancy, change the production of ROI by peripheral blood neutrophils but these events do not sum up in diabetic pregnancies.     

Pregnant Women’s Knowledge of Influenza and the Use and Safety of the Influenza Vaccine During Pregnancy

IntroductionWe wished to assess pregnant women’s knowledge of influenza, vaccine safety during pregnancy and breast feeding, and the recommendations for use of the influenza vaccine in pregnancy.MethodsWe performed a cross-sectional survey of postpartum women during influenza season in 2006.ResultsPregnant women’s overall knowledge of these subjects was poor. Most women (95%) knew that influenza is highly contagious, but almost 90% incorrectly believed that pregnant women have the same risk of complications as non-pregnant women. Only one half of the women were aware of national recommendations for vaccination during pregnancy and that the vaccine is safe during pregnancy and breast feeding, and 80% incorrectly believed that the vaccine can cause birth defects. Only 20% of women had been offered the vaccine during the current pregnancy or a prior pregnancy.ConclusionsPregnant women’s knowledge about influenza vaccine recommendations and safety during pregnancy is poor. There is substantial room for improvement among prenatal care providers in both patient education and offering the vaccine.     

Serum levels of 1,5-anhydro-D-glucitol during the normal and diabetic pregnancy and puerperium

In 25 normally non-pregnant women, 543 normally pregnant women and 75 pregnant women with diabetes mellitus or gestational diabetes mellitus, the relationship between the serum concentration of 1,5-anhydro-D-glucitol (1-deoxy-glucose) and carbohydrate metabolism was studied. The concentration of 1,5-anhydro-D-glucitol was estimated by means of gas-liquid chromatography. In normally non-pregnant women the concentration was found to be 18.6 +/- 5.2 mg/l (mean +/- SD). During the normal pregnancy, from 9 weeks of gestation, a steadily decreasing concentration was observed as the pregnancy progressed and the lowest value (10.2 +/- 4.6 mg/l) was found in the third trimester. After 5 days of puerperium the concentrations were found to be 10.8 +/- 3.7 mg/l. On the 30th day postpartum, the level was within the range for non-pregnant subjects. The values in pregnant women with diabetes mellitus and gestational diabetes mellitus were mostly below 10 mg/l throughout the entire pregnant period. The 1,5-anhydro-D-glucitol concentration was not affected by meals or oral glucose loading. A concentration below 10 mg/l was found in 36% of the normally pregnant women, where oral glucose tolerance tests and measurement of glycohemoglobin were shown to be within the normal range. The present study suggests that a change of 1,5-anhydro-D-glucitol level during pregnancy may reflect a mild alteration of carbohydrate metabolism that goes undetected by all the other diabetic indicators.     

Lipid and lipoprotein cardiovascular risk factor changes during normal pregnancy in Africans

OBJECTIVES: The study was designed to determine how pregnancy affects lipid and lipoprotein profiles among women living in a typical suburban commercial community in Africa, and to highlight the consequences of such changes. STUDY DESIGN: Lipid and lipoprotein levels and coronary heart disease (CHD) risk predictor index [High density lipoprotein-cholesterol (HDLC)/Total cholesterol (TC)] were evaluated in 27 African pregnant and 17 non-pregnant women of the same age and demographic profiles. RESULTS: Total cholesterol and low density lipoprotein-cholesterol (LDLC) levels increased, while HDLC level and HDLC/TC ratio decreased in the pregnant women. CONCLUSIONS: These findings suggest that African women are more prone to hyperlipidemia during normal pregnancy. The consequences of the adverse lipid and lipoprotein changes as seen in the pregnant women, on the fetal development and welfare should be explored in further studies. In general, these results have added to our understanding and knowledge of the numerous factors that could cause abnormal lipid and lipoprotein levels in African women.     

Diabetes in pregnancy

Diabetes is probably the most frequent pathological condition that influences the outcome of pregnancy. 0.2–0.3% of women of reproductive age are known to have diabetes prior to conception and a further significant proportion of pregnancies in otherwise normal women may be complicated by gestational diabetes. Diabetic pregnancy is a high risk state for both the woman and fetus. The usual complications of pregnancy such as infection, hydramnios, pre-eclampsia and placental insufficiency may occur more frequently and the diabetic state predisposes additional complications. These include: the development of progression of specific diabetic complications; particularly retinopathy; miscarriage; stillbirth; intrauterine death; congenital malformation and macrosomia in the fetus; increased perinatal mortality rate and neonatal morbidity. Without appropriate care of established diabetes during pregnancy, perinatal mortality may exceed 10% and the rate of major congenital malformations is at least 2–3 times higher than in non-diabetic pregnancies. Increased fetal growth in the last trimester of pregnancy is the main risk in gestational diabetes and early recognition through screening is important. Most of these complications can be reduced to the level of the non-diabetic pregnant population by expert medical care and the achievement of nearly normal glucose levels in the pregnant woman.     

Endothelial function is preserved in pregnant women with well-controlled type 1 diabetes

Objective Pregnant women with diabetes mellitus have a higher incidence of adverse pregnancy outcomes. Vascular, and in particular, endothelial function may be significantly modified in diabetes resulting in impaired endothelium-dependent relaxation. This study aims to investigate endothelium-dependent relaxation in pregnant women with pre-existing type 1 diabetes mellitus.
Methods Small arteries (mean luminal diameter ∼295 μm) were isolated from biopsies of subcutaneous fat from pregnant women with pre-existing type 1 diabetes mellitus, non-diabetic pregnant women, and non-diabetic non-pregnant women. Endothelial and smooth muscle function were determined using wire myography, and the contributions of nitric oxide, vasodilator prostanoid and endothelial hyperpolarisation were studied using specific inhibitors.
Results Arteries obtained from the diabetic pregnant women did not demonstrate any difference in either endothelial or smooth muscle function when compared with non-diabetic pregnant women. The contribution of nitric oxide to endothelium-dependent relaxation was ∼20% in the pregnant women regardless of whether they were diabetic, and ∼11% in the non-pregnant women. Endothelial hyperpolarisation appeared to contribute largely to vasorelaxation in human subcutaneous arteries, and was at least twice that of nitric oxide in pregnant women and fivefold greater in non-pregnant women.
Conclusions This study provides evidence that pregnant women with well-controlled pre-existing type 1 diabetes mellitus have both normal endothelial and smooth muscle function. Endothelium-dependent hyperpolarisation appears to play a large role in vascular relaxation in human subcutaneous resistance arteries. This study suggests that the problems associated with diabetic pregnancies are unlikely to be due to vascular dysfunction.     

Soluble P-selectin levels during normal pregnancy: a longitudinal study

Objective To investigate soluble P-selectin (sP-selectin) levels and platelet parameters in normal pregnant women compared with non-pregnant control subjects.
Design A longitudinal case–control study.
Setting Obstetric outpatient clinic in the Jubilee Maternity Hospital, Belfast.
Population One hundred and twenty normal pregnant women and 41 non-pregnant age-matched control subjects.
Methods The plasma concentration of sP-selectin in pregnant women sampled at 12, 20 and 35 weeks of gestation, and, in a subgroup at three days postpartum, and non-pregnant controls sampled in parallel, was determined using a commercial quantitative sandwich immunoassay kit. Platelet parameters on each blood sample were also recorded using a SYSMEX SE 9500 analyser.
Main outcome measures Plasma sP-selectin as a measure of platelet activation in normal pregnancy.
Results Soluble P-selectin was significantly higher in pregnant women than in non-pregnant control subjects at 20 and 35 weeks of gestation, (   P < 0.01, and P < 0.001, respectively  ). Correlation analyses showed positive correlation between sP-selectin and platelet count in pregnant women at 20 and 35 weeks of gestation (   r = 0.247, P < 0.05 and r = 0.360, P < 0.001, respectively  ). Soluble P-selectin concentration per platelet was also significantly higher in pregnant women than in non-pregnant control subjects at 20 and 35 weeks of gestation (   P < 0.001  ).
Conclusions Our results show that sP-selectin concentration is significantly higher in the second and third trimester of pregnancy when compared with non-pregnant control subjects sampled in parallel. This finding clarifies previous conflicting results on platelet activation in normal pregnancy, and is in agreement with those earlier studies which reported, using other methods, increased platelet activation in normal pregnancy.     

Effect of exercise on catecholamines and plasma renin activity in pregnant women

Strenuous muscular exercise is known to induce increases in plasma values of adrenalin (A) and noradrenaline (NA) and a twofold increase in plasma renin activity (PRA) in healthy men and women. The effect in pregnant women is not known. In 36 pregnant women, systolic blood pressure and plasma levels of PRA, A and NA were determined at rest, during an orthostatic test and during submaximal leg exercise on a bicycle ergometer. Eight of these women were re-examined after delivery and served as a non-pregnant control group. The pregnant women had a significantly greater increase in systolic blood pressure than the non-pregnant subjects. PRA showed a sevenfold increase during pregnancy, but exercise caused no further change in plasma values. As expected, the non-pregnant PRA values doubled during exercise. Resting values of A and NA were not altered by pregnancy. Near-maximal exercise caused a significant rise in A and NA, both in pregnant and in non-pregnant women. The results indicate that there is no activation of the sympathetic nervous system either at rest or during strenuous exercise in pregnancy and that the sensitivity of the circulatory system seems to be well adjusted to the increased activity of the renin angiotensin system during pregnancy.     

Transient postpartum diabetes insipidus associated with HELLP syndrome

Diabetes insipidus in pregnancy has different causes. The association of diabetes insipidus with disturbances of liver function has been reported, however, diabetes insipidus has rarely been reported in HELLP syndrome. We present a 23-year-old primigravida with a singleton gestation complicated by HELLP syndrome who developed postpartum diabetes insipidus. Labor was induced promptly to terminate pregnancy because of intrauterine fetal death and liver dysfunction. 1-deamino-8-D-arginine-vasopressin was administered. Diabetes insipidus and liver dysfunction resolved within 2 weeks. Development of diabetes insipidus may result from increased vasopressinase activity mainly caused by deterioration of liver functions caused by HELLP syndrome. In pregnant women with liver disease as a result of any cause, the development of diabetes insipidus should be assessed with particular attention.     

Oxidative stress in diabetic pregnancy: SOD, CAT and GSH-Px activity and lipid peroxidation products.

Diabetic pregnancy is often complicated by a number of pathological conditions among which is increased oxidative stress. This study was conducted to investigate the parameters of oxidative stress in 90 patients divided into the three groups: pregnant women with Type 1 diabetes mellitus, healthy pregnant women and non-pregnant women. In pregnancy groups all parameters were followed in 1st, 2nd and 3rd trimester. Diabetic control was monitored by fasting blood glucose and glycosylated hemoglobin (HbA(1c)) and these values, as well as measured biochemical parameters (urea, creatinine, total cholesterol and uric acid), were appropriate throughout the study. The concentration of TBARS, as a measure of lipid peroxidation, and activity of antioxidant enzymes superoxide dismutase (Cu, Zn-SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) were investigated in hemolysate of erythrocytes. TBARS concentration increased significantly in pregnant women when compared with control group (non-pregnant women), as well as in pregnant diabetics compared with healthy pregnant women. The SOD activity was gradually increased in the group of normal pregnant women vs. non-pregnant group, but decreased significantly in the group of diabetic pregnant women. Catalase activity was significantly increased only in 3rd trimester diabetic pregnant women. Increased lipid peroxidation and reduced antioxidant status, despite good diabetic control, show that pregnant women are exposed to oxidative stress to a greater degree than controls.     

Respiratory disease in pregnancy

The pregnant patient is at risk of several pregnancy-specific pulmonary complications, including amniotic fluid embolism, tocolytic-associated pulmonary oedema and pulmonary oedema complicating pre-eclampsia. In addition, the pregnant state increases the risk of other respiratory complications, particularly pulmonary embolism and gastric acid aspiration. Community-acquired pneumonia occurs in pregnant women at a similar incidence to the non-pregnant population, but the risk of varicella pneumonitis is increased. AIDS-related pulmonary infections should always be considered in this sexually active population.Management of the pregnant patient with pulmonary disease must take into account the anatomic and physiological changes affecting the respiratory system in pregnancy. Although management is similar to that in the non-pregnant patient, the welfare of the fetus must be considered in radiological investigations and pharmacological therapy.     

Immunological markers in HIV-infected pregnant and non-pregnant women

OBJECTIVE: To assess the influence of pregnancy on the course of HIV infection by comparing the behaviour of total lymphocyte counts and lymphocyte subsets (CD4(+) and CD8(+) and their ratio) in a cohort of infected pregnant women. Setting: Tertiary referral centre for high risk obstetrics and infectious diseases in pregnancy. PATIENTS AND METHODS: A prospective study was designed, HIV infected women being enrolled at the beginning of pregnancy and sampled each trimester and in the puerperium. As controls, a group of non-pregnant HIV-infected women, cross-matched for age, risk factors and stage of disease were included and similarly evaluated in the same period. RESULTS: All the parameters, when longitudinally evaluated, were stable during gestation. Compared with non-pregnant subjects, patients had higher CD4(+) counts at the beginning and increased values of total lymphocytes count and subsets during the puerperium. Antepartum and postpartum risk factors such as drug abuse, smoking, antiretroviral therapy, length of gestation, maternal complications and HIV status of the neonate were not influential on the total lymphocytes counts and subsets. DISCUSSION: According to this data, pregnancy per se seems to have a negligible influence over the course of HIV infection, at least as far as immune parameters are concerned.     

Criteria for the oral glucose tolerance test in pregnant and non-pregnant Nigerian women

In order to establish diagnostic criteria for detection of abnormal oral glucose tolerance test (OGTT) in pregnant and non-pregnant Nigerian women, the test was performed in 25 non-pregnant and 60 pregnant non-diabetic women at various trimesters of pregnancy. The upper limit of normal plasma glucose was the same as that from caucasian populations with respect to the fasting values but much less at 60 and 120 min. When compared to the non-pregnant controls, fasting plasma glucose was significantly lower during pregnancy, however, there was no change in glucose tolerance during pregnancy. The possible reasons for these observations are discussed and it would appear that our criteria would be the ideal ones to use for clinical purposes in Nigerian women.     

Assessment of thyroid function during pregnancy.

Serum levels of thyroid stimulating hormone and of the two thyroid hormones were compared in pregnant women and in non-pregnant control subjects. Circulating levels of thyroid stimulating hormone did not alter significantly throughout pregnancy. Total thyroxine and triiodothyronine concentrations increased markedly during the first and second trimesters, associated with a progressive increase in the thyroid binding capacity of serum proteins. Urinary triiodothyronine and thyroxine excretion during the third trimester of pregnancy was comparable to that found in non-pregnant euthyroid females and, it is concluded, provides the simplest method of assessing thyroid function during pregnancy.