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Cardio Diabetes Medicine 2017 589

as they are at increased risk of developing diabetes velopment of fat mass and leptin production. Leptin
predominantly Type 2 DM as are their children. Ges- reduces energy intake and suppresses the insulin
tational Diabetes Mellitus is defined as carbohydrate secretion via leptin receptors on pancreatic β-cells.
intolerance of variable severity with onset or first rec- Abnormal functioning of this adipoinsular axis may
ognition during the present pregnancy. Women with lead to hyperphagia, dysregulation of the energy bal-
GDM have an increased lifetime risk of developing ance and excessive adiposity 8
diabetes, at over 3 times compared to controls at
16 years after index pregnancy . By 17 years of age Maternal Obesity and It’s Influence on Off-
2
one-third of children born to GDM mothers have had Spring and CVD
evidence of IGT or T 2 DM .
3
Exposure to maternal hyperglycemia in intrauterine
life confers an additional risk of developing cardio-
Impact of maternal hyperglycemia
vascular disease in later part of life. This risk is in-
it has been now recognized that GDM may be playing dependent of any genetic predisposition or adiposity.
an important role in increasing prevalence of diabe- Studies are required to explain the mechanisms of
tes. Also, causing insulin resistance, obesity, dyslip- maternal hyperglycemia conferring the cardiovascu-
idemia, increased inflammatory markers , endothelial lar risk . There is an increasing interest in another
dysfunction , hypertension and ultimately leading to hypothesis on maternal obesity that leads to meta-
increased risk of cardiovascular diseases. Maternal bolic consequences in offspring’s. This can add up
hyperglycemia in pregnancy is an independent risk to accelerate the obesity epidemic too which is in-
factor for putting the offspring at increased risk of dependent to genetic or environmental factors. The
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IGT, obesity , hypertension at 7 years of age, while glycemic index of diets also has an influence on
CV risk continues to increase from adolescent to birth weight of offspring’s. Exposure to high-glycemic
adulthood. There is also effect on childhood adipos- index diets led to higher birth weight and skinfold
4
ity which is only evident in girls and not boys .There thickness compared to exposure to a low glycemic
has been an association of maternal hyperglycemia diet.
with offspring’s adiposity and insulin resistance. In-
trauterine exposure to hyperglycemia has deleterious It can be safely concluded that exposure to a hyper-
effects that are in addition to those related to genetic glycemic environment in the intrauterine life is asso-
predisposition Also, in utero exposure to hyperin- ciated with increased occurrence of impaired glucose
5
sulinemia is an independent predictor of abnormal tolerance and a defective insulin secretary respons-
glucose tolerance in later childhood. Maternal hy- es. Gestational Diabetes Mellitus: gives an opportuni-
perglycaemia in pregnancy predisposes both mother ty where in development of T2DM and cardiovascular
and child at future risk of developing diabetes and Disease in young Women can be prevented. Women
6
cardiovascular diseases . with previous gestational diabetes (pGDM),are at in-
creased risk of developing Type 2 diabetes. Some-
Glucose that normally acts as fuel for developing fe- times GDM may represent an early stage in the nat-
tus, in hyperglycemic state becomes deleterious for ural history of Type 2 diabetes. Also in subsequent
growing fetus. That gave rise to hypothesis called, years after the index pregnancy, these women with
“The fuel-mediated teratogenesis”, that first pro- pGDMshow deranged cardiovascular profile with an
posed the explanation for the association of exces- increased incidence of cardiovascular disease.
sive growth of fetus with maternal hyperglycemia.
Maternal insulin does not cross placenta freely while Steps to ameliorate
maternal glucose does and in response to that fetal
pancreas tries to balance by producing more insu- UNIVERSAL TESTING
lin. This in turn acts as fetal growth hormone and Women of Asian origin and more so ethnic Indians,
becomes responsible for promoting growth and ad- are at a higher risk of developing GDM and subse-
iposity.
quent type 2 diabetes. Universal screening for GDM is
essential and early screening should be done in pop-
Role of adipoinsular axis ulation where there is a higher prevalence of T2DM.
An endocrine feedback loop called as adipoinsu- As per new recommendations all women should be
laraxis connects the endocrine pancreas with adi- screened for GDM even if there are no symptoms.
pose tissue and the brain. This axis regulates hunger Compared to selective screening universal screening
and fat storage through the hormones named insulin of GDM detects more cases and ultimately improves
and leptin. Insulin is responsible for promoting de- maternal and neonatal outcomes.

Cardio Diabetes Medicine