Prevention of Congenital Malformations in Infants of Insulin-dependent Diabetic Mothers

Fuhrmann, K; Reiher, H; Semmler, K; Fischer, Friedericke; Fischer, Michael; Glöckner, E

doi:10.2337/diacare.6.3.219

Cited by 421 publications

(135 citation statements)

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“…Much more important is the constant awareness of the possibility of pregnancy and the ability to discuss this at routine diabetic clinic attendance. The logic of pre-pregnancy counselling was first pointed out by Steel et al [18], and the need for this to take place more or less continuously in those who are actively trying to achieve pregnancy is now established [19][20][21]. A suitable pamphlet explaining the idea and the reasons behind it is a useful adjunct, especially in a large diabetic clinic where the patient may not always be seen by the same physician.…”

Section: Internal Medical Aspectsmentioning

confidence: 99%

“…Several groups have shown that increased glycosylated haemoglobin, when measured during the first trimester, is associated with an increased risk of fetal abnormality [72,73]. The converse, that a normal level of plasma glucose and of glycosylated haemoglobin throughout early pregnancy will abolish the risk of congenital abnormality, is more difficult to prove [21]. Other factors such as better nutrition, improved social circumstances, and recognition of the risks of smoking and of alcohol must play a part.…”

Section: Fetal Abnormalitiesmentioning

confidence: 99%

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Diabetes in pregnancy 1985

Hadden

1986

Diabetologia

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The art of obstetrics is not a subject which is often discussed in the pages of Diabetologia. However, as the care of the diabetic mother and her offspring is rightly an interdisciplinary responsibility between obstetrician, diabetologist and neonatologist, it is important that each has a close understanding of the various problems. Dr. M. I. Drury (Dublin), speaking as an internist, raises a question on the optimum time and method of delivery of the baby; this has more than purely obstetrical implications. Drs. L. Molsted-Pedersen (Copenhagen) and C. K~ihl (Copenhagen and Klampenborg), obstetrician and internist from the longest-established joint obstetric/diabetic service in the world, present a Scandinavian view on the management of pregnancy. Both centres have distinguished records in the management of diabetic pregnancy. The different viewpoints in Denmark and in Ireland are clear -in Copenhagen, therapeutic abortion is practiced in a pregnancy at risk of severe congenital malformation; in Dublin it is not. Dr. Drury quotes a perinatal loss of 13 of 285 pregnancies (4.5%) in the past 5 years, but does not include the recognised spontaneous abortions which, on his overall figures, are about 10% of conceptions. Dr. Molsted-Pedersen reports a perinatal loss of 3 of 201 infants (1.5%), excluding 17 spontaneous and 9 induced abortions. If these 9 aborted pregnancies, which were performed due to a risk of severe congenital malformation, were included as fatalities, the Copenhagen figure would be 12 of 210 (5.5%). Of course, we do not know if all those 9 fetuses were affected. The spontaneous abortion rate was 17 of 223 (8.0%). Thus, if total fetal loss is taken as the index, there appears to be little difference between the two centres. The clinical controversy on the timing and method of birth in the different centres will continue --pundits can be conservative as well as radical, and, as Dr. Drury remarks, the truth probably lies somewhere in between.The bottom line in reports on the management of diabetes in pregnancy used to be the perinatal mortality (from 28 weeks gestation to the end of the first week of life). With the continuing improvement in neonatal care, more babies who would have died during the perinatal period are surviving beyond the seventh day of life. As a result, their subsequent deaths are not recorded in many publications. Even greater emphasis will fall on the quality of life for those infants surviving with a major congenital abnormality (heart and neural tube defect) which produces profound childhood morbidity. Prevention of these congenital abnormalities is the most important aim of pre-and early conceptional care of the diabetic mother. Both centres which report their recent results in this issue would agree that there has been an improvement even in the past 5 years -the problem is to define exactly which developments account for the change for the better, and which previously-trusted techniques can safely be allowed to fall by the wayside.

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Section: Internal Medical Aspectsmentioning

confidence: 99%

Section: Fetal Abnormalitiesmentioning

confidence: 99%

Diabetes in pregnancy 1985

Hadden

1986

Diabetologia

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“…These studies demonstrate that preconception care for diabetic mothers can reduce the incidence of malformations from approximately 9% to 2%, a rate similar to that observed in infants of mothers without diabetes. [120][121][122][123][124][125][126][127] Because of the increased risks associated with suboptimal preconception care, type II diabetic women who are of childbearing potential should receive preconception counseling. Preconception counseling and optimization of glycemic control in women with diabetes mellitus results in optimal maternal and fetal outcomes.…”

Section: Pregnancy and Preconception Counselingmentioning

confidence: 99%

Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus

et al. 1997

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PURPOSE:To summarize current knowledge of interventions that should improve the care of patients with type II diabetes mellitus. Interventions lie within the realms of prevention, screening, and treatment, all of which are focused on office practice. METHODS:Review of the literature by a multidisciplinary team involved in the care of patients with diabetes, followed by synthesis of the literature into a clinical care guideline. Literature was identified through consultation with experts and a focused MEDLINE search. MAIN RESULTS:An algorithm-based guideline for screening and treatment of the complications of diabetes was developed. The emphasis is on prevention of atherosclerotic disease, and prevention, screening, and early treatment of microvascular disease. Implementation of these practices has the potential to significantly improve quality of life and increase life expectancy in patients with type II diabetes mellitus. ype II diabetes is a common condition, affecting 2% to 3% of the adult population, and up to 20% to 25% of the elderly population. 1 Type II diabetes typically occurs in patients who are over 30 years old and weigh more than 120% of ideal body weight, and accounts for 90% of all cases of diabetes mellitus diagnosed in the United States. 1 Minorities have a prevalence of type II diabetes mellitus that is 2 to 6 times greater than that of white persons. The morbidity and mortality are higher for minorities than for white persons, and the rate is increasing. 2 The reasons for this disparity remain unclear, but could include differences in disease severity, comorbidities, or access to care.Diabetes has significant associated morbidity. Prevention and treatment of the complications of diabetes mellitus have the potential to improve quality of life and increase life expectancy. 3 The rate of cardiovascular disease is markedly elevated among patients with type II diabetes, leading to an increased mortality rate compared with the general population. 4,5 In addition, microvascular complications, which include retinopathy, nephropathy, and neuropathy, can progress to end-stage outcomes such as blindness, end-stage renal disease (ESRD), and amputation. Screening and early treatment for diabetic complications have been shown to be effective in reducing the incidence of end-stage disease 6,7 ; despite this evidence, implementation rates of recommended interventions are low. 8 This frequently leads to ineffective or delayed treatment of complications. 9-11 Because optimal diabetes care is a complex process, we developed a clinical care guideline to help busy clinicians incorporate prevention, screening, and treatment recommendations into practice. METHODSA multidisciplinary team was assembled to develop an evidence-based guideline for the prevention and treatment of complications of type II diabetes. The multidisciplinary team included members from endocrinology, family practice, general internal medicine, obstetrics-gyncecology, nursing, and postgraduate medicine departments. Team members have an interest ...

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“…[4][5][6][7][8][9][10][11][12] Diabetes is associated with a high incidence of congenital malformations including urogenital abnormalities. 13,14 These congenital malformations result from developmental defects occurring in early organogenesis. They include genitourinary abnormalities that can be so severe as to cause renal agenesis.…”

mentioning

confidence: 99%

Expression of matrix metalloproteinases MMP-2 and MMP-9 is altered during nephrogenesis in fetuses from diabetic rats

Huyen

Viltard

Nehiri

et al. 2007

Laboratory Investigation

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Remodeling of extracellular matrix (ECM) is an important physiological feature of normal growth and development. Recent studies have emphasized the role of matrix metalloproteinases (MMP-2 and MMP-9) in normal mouse nephrogenesis. We have demonstrated previously in the rat that in utero exposure to maternal diabetes impairs renal development leading to a 30% reduction in the nephron number. Transforming growth factor-b1 (TGF-b1) and connective tissue growth factor (CTGF) are known to mediate high glucose effects on matrix degradation. The aim of the present study was to address the expression of type IV collagenase and TGF-b1/CTGF systems in rat kidney during normal development and after in utero exposure to maternal diabetes. Both MMP-2 and MMP-9 mRNA metanephric expressions and activities were dramatically downregulated in kidneys issued from diabetic fetuses and in metanephros cultured in the presence of high glucose concentration. TGF-b1 and CTGF expressions were significantly enhanced in diabetic fetal kidneys and in high glucose cultured metanephroi. Conditioned media obtained from metanephroi grown with high glucose concentration upregulated functional TGF-b activity in transfected ATDC5 cells. In conclusion, in impaired nephrogenesis resulting from in utero exposure to maternal diabetes, alteration of both type IV collagenase and TGF-b1/ CTGF systems may lead to abnormal remodeling of ECM, which may, in turn, induce defects in ureteral bud branching leading to the observed reduction in the nephron number with consequences later in life: progression of chronic renal disease and hypertension. The development of the kidney is based on reciprocal induction between two mesodermally derivated tissues. Morphogenesis starts when the ureteric bud (UB) invades the metanephric mesenchyme and initiates reciprocal induction. The mesenchyme induces the UB to grow and branch to form the collecting ducts. The UB, in turn, induces the mesenchyme to undergo a mesenchymal to epithelial conversion to form nephrons via a series of morphogenetic events (aggregation of mesenchyme to form renal vesicles then S-shaped bodies and finally mature glomeruli). 1,2 Regulation of this process involves the participation of various DNAbinding proteins, that is, transcription factors, growth factors and their receptors, and proto-oncogenes acting as growth factor receptors. A constant remodeling of the extracellular matrix (ECM) is needed at the growing tips of the invading uretric bud to allow further branchings in the metanephric mesenchyme. 3,4 Production of ECM-degrading enzymes is expectedly linked to metanephric development to regulate the expression of ECM protein and ECM-related proteins by proteolytic processing. This creates a gradient of all these molecules in strategic locations with spatiotemporal distribution. 4 The ECM-degrading enzymes are collectively known as matrix metalloproteinases (MMPs) because their activity is dependent on the presence of metal ion, for example, Zn 2 þ . The activity of MMPs is inhibited by tissue...

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Prevention of Congenital Malformations in Infants of Insulin-dependent Diabetic Mothers

Cited by 421 publications

References 0 publications

Diabetes in pregnancy 1985

Diabetes in pregnancy 1985

Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus

Expression of matrix metalloproteinases MMP-2 and MMP-9 is altered during nephrogenesis in fetuses from diabetic rats

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