Controversies in Diabetes and Pregnancy PDF
Preview Controversies in Diabetes and Pregnancy
IE:~ Endocrinology and Metabolism Progress in Research and Clinical Practice Margo Panush Cohen Piero P. Foa Series Editors Endocrinology and Metabolism Progress in Research and Clinical Practice Margo Panush Cohen Piero P. Foa Series Editors Cohen and Foa (eds): Hormone Resistance and Other Endocrint! Paradoxes (Vol. 1) Jovanovic (ed.): Controversies in Diabetes and Pregnancy (Vol. 2) Forthcoming volumes: Cohen and Foa (eds.): The Brain as an Endocrine Organ (Vol. 3) Ginsberg-Fellner and McEvoy (eds): Autoimmunity and the Pathogenesis of Diabetes (Vol. 4) Lois Jovanovic Editor Controversies in Diabetes and Pregnancy With a Foreword by Steven G. Gabbe With 36 Illustrations, 4 in Full Color Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Lois Jovanovic, M.D. Senior Scientist Sansum Medical Research Foundation Santa Barbara, CA 93105 USA Series Editors Margo Panush Cohen, M.D., Ph.D. Piero P. Foa, M.D., Sc.D. Professor of Medicine Professor Emeritus of Physiology University of Medicine and Wayne State University Dentistry of New Jersey Chairman Emeritus Newark, NJ 07103 Department of Research Director, Institute for Metabolic Sinai Hospital Research Detroit, MI University City Science Center Mailing address: Philadelphia, PA 19104 2104 Rhine Road USA West Bloomfield, MI 48033 USA Library of Congress Cataloging-in-Publication Data Controversies in diabetes and pregnancy. (Endrocrinology and metabolism ; v. 2) I. Diabetes in pregnancy. I. Jovanovic, Lois. II. Series. [DNLM: 1. Pregnancy in Diabetes. WQ 248 C764] RG580.D5C66 1988 618.3'26 87-28485 © 1988 by Springer-Verlag New York Inc. Softcover reprint of the hardcover I st edition 1988 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag, 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information is this book are believed to be true and accurate at the date of going to press, neither the auti10rs nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by David E. Seham Associates Inc., Metuchen, New Jersey. 9 8 7 654 3 2 I ISBN-13:978-1-4612-8353-9 e-ISBN-13:978-1-4612-3792-1 DOl: 10.1007/978-1-4612-3792-1 Foreword As I read this unique volume on diabetes and pregnancy edited by Lois Jovanovic, I was struck by two themes that run throughout these collected chapters. First, this volume provides an excellent assessment of past problems, present management, and future challenges presented by dia betes in pregnancy. Orury's unique, longitudinal experience with diabetes iIi pregnancy provides the reader with an important overview, as does Coetzee's discussion of gestational diabetes. Current problems-deter mining the etiology and prevention of congenital malformations in infants of diabetic mothers (10M), assessment of antepartum fetal condition, management of pregnant patients with diabetic retinopathy, recognition of thyroid dysfunction in the pregnant diabetic woman, and understanding the multitude of metabolic sequelae observed in the 10M-are thoroughly reviewed. Finally, important considerations for future treatment and ther apy such as the adaptation of the fetal pancreas to the disordered intra uterine environment often seen in maternal diabetes, the use of fetal pan creatic tissue for transplantation, the application of exercise in the management of the pregnant woman with diabetes, and the long-term con sequences for the 10M provide an exciting glimpse into the future. The second important theme that emerges is the critical role the problem of diabetes in pregnancy has played in our understanding of maternal and fetal physiology. Clinical observations supported by basic research have emphasized the role of fetal fuels in teratogenesis. Studies of both the macrosomic infant and the hyperinsulinemic animal model have demon strated the importance of insulin as a fetal growth hormone. Our under standing of normal surfactant synthesis and of the effects of hyperglycemia and hyperinsulinemia has been enhanced by studies of the 10M. The im pact pregnancy may have on diabetic retinopathy may prove important in our understanding of this complication in nonpregnant patients. I am certain that further investigations into the effects of diabetes on pregnancy and pregnancy on diabetes will yield significant findings. With these thoughts in mind, I hope that as the reader enjoys each of VI Foreword these excellent contributions, he or she will find that the whole can be greater than the sum of its parts. Columbus, Ohio Steven G. Gabbe, M.D. Professor and Chairman Department of Obstetrics and Gynecology The Ohio State University College of Medicine Preface It is a great honor to be the editor of this volume, Controversies in Diabetes and Pregnancy, for these collected works not only represent "state of the art" information, but also serve as a forum for the expression of opin ion; in many cases it may even be the minority opinion. To fully enjoy this book, the reader should have a basic understanding of the field of diabetes and pregnancy. In this sense, the book is for the serious student of the topic of pregnancy and glucose metabolism. A basic theme that unites all the works in this volume is the philosophy that normalization of maternal blood glucose throughout pregnancy will normalize the outcome of such pregnancies. Even this basic tenet is con troversial in some circles. But the book also discusses minor themes that have become contested issues, such as the utility of exercise as a treatment modality for glucose intolerance in pregnancy, and the management and timing of delivery. Because each author assumed that the reader would be familiar with basic approaches and definitions, many chapters begin with the debate. Although in one chapter the author redefines the ter minology of gestational diabetes, he does not do this for the naive reader, but he does it to have definitions conform with his views about treatment modalities. Several of the approaches incorporate agents that currently are not approved for use during pregnancy in the United States. The sec tion on the use of oral hypoglycemic agents for the treatment of the ges tational diabetic woman is particularly interesting for the American reader, who may learn from this large series that there might be a better way. In addition, a closely observed group of women in good glucose control were given the "ticket to go to term" without the "benefit" of fetal surveillance protocols. Here, too, there is a take-home message. The section on fetal islet ontogeny contains an essay on the impact of maternal fuels on the development of the fetal pancreas. Then comes a chapter that deals with the delicate subject of the use of fetal tissue for transplantation in persons with diabetes. Both chapters suggest the pos sibility that there may someday be a cure for a disease that afflicts more than 17 million persons. Preface VIII In addition to presenting pathophysiology and alternative treatment protocols, this work also provides a glimpse at the fetus in diabetic preg nancy. There is a chapter on the immediate neonatal metabolic picture and a chapter on the long-term follow-up of infants of diabetic mothers. These two chapters allow readers to form their own opinion on whether normalization of maternal blood glucose is worth all the time, effort, and expense if the infant outcome is the variable of interest. Although this work does not pretend to be a comprehensive review of the entire field of diabetes and pregnancy, each chapter is well-annotated to allow for more reading. I hope you will enjoy and profit from these collected works written with fervor, assertion, and sometimes pure faith, about a very exciting and controversial field. Santa Barbara, California Lois Jovanovic, M.D. Contents Foreword ................ ... ........ ........ ..... ............... ... ..... v Preface ................................................................. vii Part I Animal Models for the Study of Diabetes and Pregnancy 1. Experimental Studies of Congenital Malformations in Diabetic Pregnancy .............................................. 3 ULF J. ERIKSSON Introduction ....................................................... 3 Maternal Diabetes ................................................. 4 Increased Levels of Different Sugars In vivo....................... 16 In vitro Studies .................................................... 17 Etiologic Reflections ............................................... 19 Conclusions ........................................................ 23 Part II Islet Ontogeny: Fetal Pancreatic Ontogeny and Maternal Substrates 2. Adaptation of the Fetal Pancreas to Maternal Diabetes 33 PIERO P. FoA 3. The Use of Human Fetal Pancreatic Tissue for Transplantation .................................................. 43 CHARLES M. PETERSON, LOIS JOVANOVIC, and BENT FORMBY History............................................................ 43 Studies of Isolation, Storage, Shipment, and Function In vitro..... 43 Studies of Function In vivo ........................................ 47 Conclusions and Implications for the Infant of the Woman With Diabetes Mellitus .................................................. 49
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