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PLACENTA AND DIABETES
Kitova Tanya
Assoc. Prof. MD, Ph.D. Department of Anatomy, Histology and Embryology, Medical University of Plovdiv, "Vasil
Aprilov", Bulgaria
ABSTRACT
Diabetes mellitus (DM) is a disease that remains a constant object of numerous studies.
Pregnancy may be complicated by any of the different forms of diabetes - existing pre-pregnancy type 1 and type 2 diabetes or gestational diabetes. Questions about its effect on the placenta and the development of the fetus and therefore on the course and outcome of the pregnancy, remain relevant. The purpose of this work is to examine the pathological changes of the placenta under the influence of type 1 diabetes, type 2 and gestational diabetes. Post-mortem examination of placentas of pregnant women with diabetes and their comparison with those from normal pregnancies indicates the presence of several major abnormalities in histological structure - hyperplasia and hypervascularisation of placental villi, swelling of the villi, syncytial knots and thickening of the syncytial membrane, deposition of lipids etc.
Diabetes mellitus is a disease that affects the normal development of pregnancy, and the pathological changes in the placenta that are caused by it are of great significance.
Keywords: Diabetes mellitus, placenta, glycemic control, pathological changes, pregnancy
Introduction
Diabetes mellitus (DM) continues to be a constant object of medical research. Type 1 diabetes is insulin dependent diabetes mellitus, which is caused by autoimmune destruction of the pancreatic beta cells, resulting in an absolute insulin deficit. Type 2 diabetes mellitus is non-insulin dependent. It is caused by peripheral insulin resistance and consequently the development of beta-cell dysfunction.
Gestational diabetes is a degree of glucose intolerance with either onset or diagnosis during pregnancy. Some authors assume that gestational diabetes is actually type 2 DM (has the same pathogenesis), which is caused by the physiological metabolic changes during pregnancy [1]
Frequency of diabetes in Bulgaria is 2,5-3,0 %, as the total incidence of diabetes mellitus in Bulgaria varies between 70 and 100 cases per 100 000 per year. Only 9.6% of patients with diabetes have type 1 diabetes, and the remaining 90.4% are diabetes mellitus type 2 [2]. The frequency of gestational diabetes is approximately 7% (1-14%) of pregnancies [1].
Because of diabetes' significant frequency, the questions about its effect on the placenta and the development of the fetus and therefore on the course and outcome of the pregnancy, remain relevant.
Objective The purpose of this work is to examine the pathological changes of the placenta under the influence of type 1 diabetes, type 2 and gestational diabetes.
Method
The materials were three placentas. One was received after birth after 34 weeks gestation and two were received after 40 weeks gestation from mothers with diabetes. We obtained a control placenta from a mother without diabetes in the Specialized Hospital of Obstetrics and Gynecology for active treatment «Prof. Dr. D. Stamatov» - Varna, Bulgaria. All of them were obtained in the period May-September 2014. Data was collected from obstetric diagnoses and method of delivery. Epidemiologic and clinical data regarding fasting blood glucose levels during pregnancy and data from the obstetric history were collected. Macroscopic examination of placentas and umbilical cordons as well as biometrics were made. Microscopic examination of the placentas was conducted by applying the classical paraffin methods and subsequent staining with hematoxylin-eosin. Photographs of the findings were collected. Placental examination was performed only after autopsy authorization was given by the mother.
Results Epidemiologic and biochemical results as well as the data from the obstetric examination are shown in table 1.
Table1.
Epidemiologic, biochemical results and the data from the obstetric examination
Type diabetes Age of mothers/ years Glucose levels in blood/mmol/l Child weight/g Placental weight/ gestation week (g.w.) Previous births
Diabetes Type 1 30 12 mmol/l 3180 g 380 g / 34 g.w. One child with weight 3046 g, 57 cm
Diabetes Type 2 24 6 mmol/l 2700 g 538 g/ 40 g.w. First pregnancy and first birth
Gestational diabetes 40 8 mmol/l 4000 g 643 g/ 40 g.w. Four live born children with weight around 4000 g
The highest glucose levels were registered in the mother with Biometric examination proved an increase in weight and size DM type 1 - 12 mmol/l. of the placentas.
Macroscopic examination revealed thrombotic, and whitish- cellular hyperplasia and chorial edema. Thickening of the basal
yellow alterations on the amniotic surface of the placenta as well membrane of the syncytiotrophoblast was also found (figure 1) .
as dilated blood vessels, necrotic regions and retro placental Syncitial nodes and lipid accumulation were frequently observed
hematomas. (figure 2).
Microscopic examination found hyperplasia of chorionic villi, increased angio- and vasculogenesis, villitis associated with
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Figurel. Microscopy of the placenta.A: Thickening of the basal membrane of the syncytiotrophoblast. H& E stain. (400 X).
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Figure2. Microscopy of the placenta.A: Syncytial nodes and lipid accumulation. H&E stain.(400X)
Conclusions
Diabetes mellitus is an extragenital disease that fairly often complicates pregnancy. It may develop on the background of previously diagnosed diabetes or it may occur in connection with pregnancy and be diagnosed for the first time during pregnancy (Gestational Diabetes). Combined with diabetes every pregnancy is at risk of developing a wide variety of severe complications - preeclampsia, eclampsia, premature birth, miscarriage, fetal macrosomia, congenital malformations, etc. Despite the variety of post-mortem changes resulting from gestational diabetes, one of the most striking morphological substrates of diabetic pregnancy are the changes affecting the placenta. The presence of placenta is a condition sine qua non for the normal development of any pregnancy. Therefore all structural and functional alterations of this key maternal-fetal organ directly affect the course of gestation, and in particular the condition of the fetal development and growth.
We observed many histological changes in placental structures as a reflection of the influence that the hyperglycemic state has on a normal pregnancy. Similar histological alterations were observed by other authors. For example Mayhew and Jairam [3], comparing these findings with the microscopic appearance of placentas of women with good glycemic control, concluded that blood glucose levels play a central role in the pathophysiological cascade leading to the observed changes. Sala et al. [4] consider hyperplasia and hypervascularization of placental villi, and the thromboses as a manifestation of a compensatory response to tissue hypoxia and blood stasis. According to Hidan et al. [5] these changes are mediated by dysregulation of growth factors and their receptors. This phenomenon may be the reason for the increased incidence of syncytial knots observed in the placentas
of pregnant women with poor glycemic control. Lipid deposits are probably a consequence of hyperinsulinemia [6]. Syncytial membrane thickening is probably a result of deposition of glycogen in the vessel walls [7]. Along with these observations, it must be taken into account that some authors have reported that the control of hyperglycemia prevents the development of placental abnormalities only to a limited extent. Therefore, it can be considered that hyperglycemia is only one of many factors that causes histopathological alterations in the placentas of a diabetic women [8].
Established correlation between clinical manifestations and histopathological findings demonstrate the importance of complex analysis during prenatal ultrasound. It is important to examine not only the fetus, but also the placenta, and in particular its size, morphology as well as the mode of fixation of the umbilical cord. The outcome of pregnancy depends mainly on the adequacy of glycemic control.
References
[1] Decherney A., Nathan L., Laufer N., Roman AS. "Current Diagnosis & Treatment: Obstetrics & Gynecology", 11E, Mc Graw Hill, 2013; 515-518.
[2] Димитраков Д., Клиника и терапия на вътрешни-те болести. Първо издание, «Медицински Университет»-Пловдив. 2006. [Dimitrakov D. Clinic and therapy of internal diseases. First edition. «Medical University « - Plovdiv 2006.
[3] Mayhew T.M., Jairam I.C. "Stereological comparision of 3D spatial relationship involving villi and intervillous pores in human placenta from control and diabetic pregnancies." J Anat, 2000; 197(2):263-274.
[4] Sala M.A., Matheus M., Valeri V." Regional variation in the frequency of fibrinoid degeneration in human term placenta." Z Geburtshilfe Perinatal. 1982; 186(2): 80-81.
[5] Hiden U., Glitzner E., Hartmann M., Desoye G. "Insulin and IGF system in human placenta of normal and diabetic pregnancies." J Anat. 2009; 215(1): 60-68.
[6] Elchalal U., Smith S.D., Schaiff W.T."Insulin and fatty acid regulate the expression of fat droplet associated protein
adipophilin in primary human trophoblasts." Am J Obstet Gynecol. 2005;193:1716-1723.
[7] Jone C.J., Desoye G. "Glycogen distribution in the capillaries of placental villus in normal, overt and gestational diabetic pregnancies." Placenta. 1993; 14: 505-517.
[8] Verma R. "Cellular changes in the placenta in pregnancies complicated with diabetes." Inter J Morphol. 2010; 28(1): 259264.
CARRYING OUT THE COMMON PREVENTIVE EXAMINATIONS OF PEOPLE OVER 18 IN BULGARIA - STATUS AND TRENDS
Kostadinova Penka Stefanova
doctorant. M U - Pleven, Faculty of Public Health, Department of « Public Health Sciences»
Kostadinov Sergey Deyanov
assistant professor. M U - Pleven, Faculty of Public Health, Department «General Medicine, Forensic Medicine and Deontology»
Simeonova Joana Ivanova
assistant professor. M U - Pleven, Faculty of Public Health, Department of « Public Health Sciences»
Stoilova Irena Jordanova
assistant professor. MU- Pleven, Faculty of Public Health, Department» Hygiene and Occupational Disease
ABSTRACT
One of the main activities of general practitioners (GPs) in Bulgaria is the annual holding of a general checkup of people over '18 prophylactic examination includes a basic package of activities and research based on who identify as persons with diseases and patients who are at increased risk for developing certain major diseases. The aim of this study was to determine the scope of the population and the views of patients and GPs for conducting check-ups. They are used official data from the National Health Insurance Fund and has held direct individual survey with 229 GPs from three areas of Bulgaria and 515 insured persons over 18 years. It was found that despite the mandatory nature of these reviews had a relatively low range of the underlying population -approximately 50% of adults annually performs check-up. Record the underfunding of this activity. Main drawbacks are indicated in surveys of doctors, insufficient awareness and motivation, and lack of time. The majority of patients consider that these examinations are carried out formally. No resistance, monitoring and reporting on the effect of these examinations.
Keywords: GPs, check-up.
Introduction: In Bulgaria after reforms in the health sector was perceived health insurance model and enhance the role of general practitioners (GPs) as a key figure for providing primary outpatient care (PIMP). One of the main responsibilities of GPs in execution of contracts with the Health Insurance Fund is carrying out preventive examinations compulsory insured persons over 18 and the formation of risk groups.
Since 2006, the total check-in GP is mandatory [1.2] for all insured persons, regardless of their health status. It is financed from the budget of the National Health Insurance Fund (NHIF)
Activities and studies included in the review in a prophylactic health insurance fund (NHIF)
and includes a basic package of activities and research (see Table. 1) [3]. Within these checks, GPs identified as individuals with diseases and patients who are at increased risk of developing certain socially important diseases, such as cardiovascular, malignant diseases (colon cancer, breast cancer and cervical cancer in women, prostate cancer in men) and diabetes. Patients with established high risk for these socially significant diseases subject to further consultation with a specialist and further research. [13]
Table. 1
of persons over 18 years, financed by the budget of the National
Age Activities and studies included in the prophylactic examination Frequency
over 18 years the calculation of body mass index, an assessment of mental status examination, vision acuity, measurement of blood pressure, electrocardiogram; study of urine for protein, glucose, bilirubin, urobilinogen/ketone bodies and pH (with test strip in Office); determination of blood sugar in the lab in the presence of risk factors. annually
