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Query: UMLS:C0011849 (diabetes)
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A total of 20 infants who had levels of erythropoietin (Ep), the major hormone regulating erythropoiesis, measured in their cord blood also had determinations of the pulmonary excretion rate of CO (VECO) performed, as an index of total bilirubin production. They were either infants of normal mothers or those of mothers with diabetes, gestational diabetes, and missed abnormalities of gestational glucose metabolism. The mean VECO (13.0 +/- 3.5 mu 1/kg/hr) and the mean Ep (20.0 +/- 9.7 SD mU/ml) of the infants with normal mothers (n = 9) were not different from the means previously established by our laboratories (13.9 +/- 3.5 SD mu 1/kg/hr, n = 20; and 23.7 +/- 12.8 SD mU/ml, n = 30, respectively); they were significantly lower than those of the infants of the abnormal mothers in this study. The 5 infants who had a cord blood Ep level greater than 50 mU/ml had a higher mean VECO, 27.8 +/- 7.1 mu 1/kg/hr, compared with 17.2 +/- 4.9 SD mu 1/kg/hr, of the six infants with cord blood Ep levels that were within 2 SD of the previously established normal mean cord blood Ep level (p less than .025). These data suggest that increased cord blood Ep levels and postnatal bilirubin production in infants whose mothers had abnormalities of gestational glucose metabolism are associated phenomena. Since polycythemia did not occur in these infants, ineffective erythropoiesis or mild, compensated hemolysis remains a likely cause of the increased total bilirubin production. In some cases, perinatal hypoxic stress may have affected the Ep response.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Pulmonary excretion of carbon monoxide in the human infant as an index of bilirubin production. IIc. Evidence for the possible association of cord blood erythropoietin levels and postnatal bilirubin production in infants of mothers with abnormalities of gestational glucose metabolism. 651 65

Thrombus formation depends on adherence of blood-formed elements to the intimal surface through platelet-vessel surface interaction, platelet release phenomena and aggregation, formation of fibrin, and the enmeshing of blood cells. Arterial thrombi involve platelet aggregation, whereas venous thrombi found in low flow or during stasis have greater proportions of erythrocytes and fibrin. It is not known if or how abnormalities of flow resistance, platelet thrombus formation, or endothelial and dynamic parameters affect the microcirculation, largely due to the difficulty of obtaining comprehensive data from these systems. Increases of fibrinogen observed in many disorders may result in minor changes in blood viscosity without known physiologic consequence, but in most disorders in which thrombosis is observed, the pathophysiologic mechanisms are multifactorial and abnormal blood viscosity is presumed to be a significant but not limiting component. Therapeutic approaches in thrombotic disorders should recognize which elements of the thrombotic triad predominate. In arterial disorders focus should be on platelet activity, and the objectives of venous thrombosis treatment include prevention of morbidity and death from pulmonary embolism, reduction of morbidity resulting from the acute thrombotic episode, and prevention of the postphlebitic syndrome. Pathology, mechanism, and treatment for specific thrombogenic disorders are described. Treatments suggested for hyperviscosity involve giving antibiotics during crises. Also discussed are thalassemia, paroxysomal nocturnal hemoglobinuria, polycythemia, cryoglobulinemia, paraproteinemia, diabetes mellitus, and disseminated intravascular coagulation. Studies have established a relationship between thromboembolic disease and oral contraceptives (OCs). The risk is only increased while the patient is taking OCs but is compounded in women undergoing surgery or who have a disorder which predisposes to venous disease. The risk for myocardial infarction or stroke is significantly increased when OCs are taken over age 35 and when there is hypertension, smoking, type-II hyperlipoproteinemia, and diabetes mellitus. The risk appears to be a function of estrogen dosage, causing a 25% mean increase in calf venous volume and 30% decrease in vein velocity of venous blood compared to controls. Low flow rates may contribute to venous thromboembolism. OCs may alter precisely regulated systems of coagulation and fibrinolysis and recent studies confirm abnormalities in the hemostatic system attributed to OCs. 16% of women taking OCs have a 60% or greater reduction in antithrombin III activity. The multiple effects of OCs often result in low-grade activation of the hemostatic system, potentially lowering the threshold to precipitate thrombus formation and possibly explaining the increased incidence of thromboembolic disease. Heparin appears to reverse many of these problems.
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PMID:Blood viscosity and thrombosis: clinical considerations. 676 12

All contributory factors to the unusual occurrence of stroke in young people were evaluated in patients under age 40 admitted to the Stroke Unit of the Austin Hospital in Melbourne, Australia. Over the August 1977 to December 1980 period there were 700 admissions. Of these 14 patients were under the age of 40. There were 7 males and 7 females whose ages ranged from 17-38 years. Each patient was screened for factors which might contribute to premature vascular disease including hypertension, diabetes, smoking, obesity, and hyperlipidemia. In addition, the following tests were performed to exclude an arteritic process: full blood examination; ESR; protein electrophoresis; syphilis serology; and the presence of antinuclear factor. Each of the 14 patients suffered cerebral infarction. A summary of each case is presented in a table. In 9 patients, infarction occurred in the carotid territory of supply. Large cortical infarcts with or without subcortical involvement occurred in cases 1-8, of whom 5 had major vessel occlusion demonstrated angiographically and another had stenosing and ulcerative atheromatous disease at the extracranial carotid bifurcation. In a further 4 patients, infarction occurred within the vertebrobasilar territory and was either confined to the brain stem, the occiptal cortex, or involved both. Angiograms were performed in 2 of these patients and showed irregular narrowing of the vertebral artery which was interpreted as spasm and segmentally narrowing of the basilar artery. The final patient had several ischemic events which included right sided amaurosis fugax, and left frontal, right parieto-occipital and left occipital infarctions. Angiography was normal. All patients survived the stroke and were able to go home. There may be an interrelationship between the pathological findings of Irey et al. (1978) and the effect oral contraceptives (OCs) has on migraine. This is relevant to Case 13. Sustained exposure to OCs may produce the pathological changes described (visible as segmental narrowing angiographically). In 2 patients cerebral infarction was caused by atheromatous or hypertensive occlusive vascular disease. In Case 3 an embolus occluded the middle cerebral artery. Infarction complicating migraine was diagnosed confidently in 4 patients on the basis of typical migrainous symptomatology in the past and accompanying the stroke. Of the 12 patients fully evaluated, there were no cases of polycythemia or thrombocytosis. There were no abnormalities of the clotting factors. Almost every patient had some form of emotional upset, and there were 7 who had significant psychiatric illness and emotional problems of extreme magnitide.
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PMID:Stroke syndromes in young people. 692 82

Two patients with end-stage renal disease from diabetes mellitus on peritoneal dialysis for 2 or more years developed sterile peritonitis secondary to splenic infarcts with associated peripheral embolic phenomena. The dialysate had WBC counts > 200/microL, of which 70% or more were polymorphonuclear cells, and RBC counts of 60/microL or less, although transient hemoperitoneum occurred in both patients. Extensive atherosclerotic vascular disease as well as hematologic abnormalities were also present in both patients. One patient had polycythemia due to decreased plasma volume. The other patient had evidence of dysfibrinogenemia. The patients responded well to anticoagulation with warfarin. When the warfarin was discontinued, recurrent emboli occurred in both patients. Splenic infarct should be included in the differential diagnosis of diabetic patients with atherosclerotic disease who present with sterile peritonitis that does not respond to antibiotic therapy, especially if hemoperitoneum occurs even transiently. The diagnosis can be confirmed with CT scan of the abdomen. Warfarin therapy is effective in preventing recurrent embolic phenomena, but may need to be continued indefinitely.
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PMID:Splenic infarct presenting as sterile peritonitis with peripheral embolic phenomena. 810 24

Infants born to women with poorly controlled diabetes mellitus have an increased incidence of perinatal asphyxia, cardiovascular abnormalities, elevated catecholamines, and sudden fetal death. Although hyperinsulinemic fetuses of diabetic women often exhibit polycythemia, they may also develop anemia because of pregnancy- and/or delivery-related complications. Experimental fetal hyperinsulinemia results in cardiovascular changes and a surge in catecholamines. We hypothesized that reductions in fetal O2 availability via anemic hypoxia limits O2 transport and compromises the hemodynamically and metabolically stressed but compensated hyperinsulinemic fetus. Chronically catheterized fetuses receiving insulin (n = 9) or placebo (n = 5) for 48 h were rendered anemic by an isovolemic exchange transfusion. In the hyperinsulinemic state, anemic-hypoxia augmented the insulin-mediated surge in norepinephrine concentration and increases in blood flow to brain, heart, and adrenal glands. Insulin-related increase in the combined ventricular output was sustained during anemia. O2 delivery to the fetus decreased, extraction increased, and O2 uptake did not change. Regional O2 delivery to the brain, kidney, gastrointestinal tract, muscle, fat, pancreas, spleen, and carcass decreased. Hyperinsulinemic ovine fetus exposed to anemic hypoxia demonstrated an accentuated surge in norepinephrine, a sustained increase in the combined ventricular output, preservation of systemic O2 uptake, and compromised regional O2 delivery to certain vascular regions. We conclude that the hyperinsulinemic fetus was able to compensate for anemic hypoxia by increased or sustained regional vascular perfusion.
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PMID:Circulatory and metabolic effects of anemia in hyperinsulinemic ovine fetuses. 830 6

Sixty patients with diabetes mellitus (DM) antedated pregnancy were enrolled; seven had proliferative retinopathy, 13 had simple retinopathy, and 40 were intact. Diet and/or insulin was prescribed to adjust their glucose control at fasting to < 100 mg/dl, as well as at 2 hours postprandial to < 120 mg/dl. Glycohemoglobin (Hemoglobin A1c) levels ranged between 5.4% and 6.4% in the third trimester in three groups. Incidences of pregnancy complications (toxemia, hydramnios, urinary tract infection and cesarean section) and neonatal complications (low Apgar score, hypoglycemia, jaundice, polycythemia, respiratory distress syndrome and anomaly) did not differ significantly with the grade of retinopathy. Compared with the intact group, the duration of DM was significantly longer in the retinopathy groups and the incidence of fetal distress was significantly higher in the proliferative retinopathy group. In ten of 60 patients (16.7%) the grade of retinopathy progressed during pregnancy. In four patients photocoagulation was performed for neovascularization, and proved to be effective. There was a tendency for those whose retinopathy progressed to the proliferative stage during pregnancy to have larger decreases in glycohemoglobin and for their retinopathy to worsen after delivery. With tight maternal glucose control and intensive fetal surveillance, we obtained good perinatal outcome in pregnancies with diabetic retinopathy, as compared to diabetic pregnancy without diabetic microangiopathy. Careful and frequent monitoring of retinal changes should be required during pregnancy and the postpartum period.
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PMID:[Retinopathy and perinatal outcome in diabetic pregnancy]. 852 82

The perinatal mortality rate of infants of diabetic mothers (IDMs) has declined dramatically from 250 per 1000 live births in the 1960s to a near-normal 20 per 1000 live births in the 1980s. Five to 8% of all IDMs suffer from major congenital malformations, and it is the latter that are responsible for 50% of these perinatal deaths. It has been shown that tight glycemic control prior to conception and during pregnancy can prevent an excess rate of congenital malformations, fetal macrosomia, birth trauma, and neonatal respiratory distress syndrome. We briefly review the short- and long-range complications that occur in offspring of diabetic mothers (ODMs) from gestation through young adulthood. Short-term neonatal complications, such as hypoglycemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia, and polycythemia, are related mainly to fetal hyperinsulinemia, hypoxemia, and prematurity. They are readily controllable within the setup of modern neonatal intensive care units. Long-range complications include an increased rate of childhood and adolescent obesity, impaired glucose tolerance or diabetes mellitus, and subtle neuropsychological dysfunctions. These may be related to the severity of the maternal hyperglycemia during pregnancy, the consequent fetal hyperinsulinemia, and third trimester maternal lipid metabolism disturbances. Today we have at hand the knowledge and tools to properly treat both pregestational and gestational diabetes. Increased education of the general practitioner and the target population regarding early referral of pregestational diabetic mothers and the implementation of screening programs for gestational diabetes will further reduce diabetic pregnancy-related morbidity.
J Diabetes Complications
PMID:Short- and long-range complications in offspring of diabetic mothers. 888 19

Current increase in the incidence of diabetes mellitus complicating pregnancy is of concern since it is associated with an increase in mortality and morbidity of the fetus and neonate. Pregnancy itself is diabetogenic caused by increased insulin resistance due to the production of hormones like estrogen, progesterone, cortisol, human chorionic somatomammotropin (hCS) and human placental lactogen (hPL). The latter increases lypolysis which provides free fatty acids and ketones as fuels for energy for the pregnant mother. This spares maternal blood glucose, amino acids and ketones which cross the placenta to the fetus. The influx of nutrients increases fetal insulin production which together with hPL induce somatogenesis. Maternal hyperglycemia and fetal hypoxemia are shown to be responsible for structural congenital anomalies of the rapidly developing organs of the fetus during the early weeks of gestation while continuing hyperglycemia and hypoxemia in the second and third trimester are factors related to the production of macrosomia, including cardiomyopathy, delay in lung maturation, and polycythemia. Metabolic problems such as hypoglycemia, hypocalcemia, hypomagnesemia and hyperbilirubinemia are common neonatal morbidities. Follow-up of the infants of diabetic mothers indicates that these infants have a 20 fold increase in acquiring diabetes. Early identification of maternal diabetes with strict metabolic control prior to conception as well as throughout pregnancy together with careful fetal monitoring can reduce the incidence of congenital anomalies and morbidities in the fetus and neonate.
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PMID:Infant of diabetic mother: a continuing challenge for perinatal-neonatal medicine. 894 23

A retrospective case-control study of necrotizing enterocolitis (NEC) affecting infants weighing > 2,000 g at birth was performed to determine those factors which could contribute to the development of NEC. Twenty-four infants met the criteria of definite NEC. For each case the next 2 healthy newborns were matched as controls. When compared with the control group, NEC infants had a significantly higher frequency of prolonged rupture of membranes, chorioamnionitis, Apgar score < 7 at 1 and 5 min, respiratory problems, congenital heart disease, hypoglycemia, and exchange transfusions. Only 3 infants with NEC were healthy newborns with an unremarkable perinatal course before NEC. There were no differences in the frequency of preeclampsia, maternal diabetes, maternal drug abuse, meconium-stained amniotic fluid and polycythemia. These results indicate that most of these more mature infants have a predisposing factor before developing NEC.
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PMID:Necrotizing enterocolitis in full-term or near-term infants: risk factors. 916 50

Intrauterine growth retardation (IUGR) is an important determinant of neonatal mortality, morbidity and poor neurologic outcome. The study was aimed to evaluate the magnitude of perinatal risk factors in causation and the neonatal outcome of small for gestational age (SGA) babies. One hundred and three SGA babies born over a period of one year were retrospectively analysed during their hospital stay. 3.53 per cent of the babies were SGA with mean birth weight of 1657 +/- SD 354 gm (range 600-2200 gm). 68.9 per cent were term babies and 51.5 per cent were females. Toxemia of pregnancy (30.09%), hypertensive diseases of pregnancy (HDP) excluding toxemia (5.8%), diabetes mellitus (1.94%), medical disorders including renal and cardiac (3.88%), anemia (Hb < 8 gm%) and IU infection (0.97%) were the main conditions responsible for SGA. In 56.3% pregnancies, no cause could be ascertained. The common perinatal problems were infections in 27 (26.2%), birth asphyxia in 22 (21.36%), polycythemia in 25 (24.3%), jaundice in 22 (21.36%) and hypoglycemia in 7 (6.8%). Congenital malformations in 2 (1.94%) and Hyaline membrane disease in 1 (0.97%) were uncommon problems. 5.8 per cent babies died due to various perinatal problems. Based on these findings it was concluded that idiopathic (? Constitutional) intrauterine growth retardation was the commonest cause of SGA in Indian babies. 58.3 per cent babies had neonatal problems and they had a better survival compared to their western counterparts.
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PMID:Small for gestational age babies: Indian scene. 1077 39


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