The role of free radicals and membrane lipids in diabetes-induced congenital malformations.
OBJECTIVE
The incidence of major congenital malformations is approximately 6-9% in pregnancies complicated by diabetes mellitus. This incidence is 3-4-fold higher than that in the general population. Congenital malformations are now ranked as the leading cause of death in the offspring of women with diabetes. The precise mechanism(s) by which these anomalies are induced is unknown. It is also not clear what predisposes women to deliver malformed infants, which infants are at risk, and why some are spared even when exposed to presumably high risk conditions. The purpose of this report is to determine, from the literature, the primary etiologic factors associated with diabetes-induced embryopathy and its prevention.


METHODS
A review of the current literature regarding malformations in diabetic pregnancies was conducted to elucidate dominant concepts in the pathogenic mechanism(s) of these anomalies and to discuss current and future strategies for their prevention.


RESULTS
Numerous investigators have demonstrated that hyperglycemia has a teratogenic effect during organogenesis. However, the exact mechanisms involved have not been completely elucidated. Dietary supplementation of deficient substrates (arachidonic acid or myo-inositol), either in vitro or in vivo, has been shown to reduce the incidence of diabetes-related malformations in offspring of diabetic pregnant animals. In addition, free oxygen radical-scavenging enzymes and antioxidants aimed at reducing the excess load of radicals also result in a reduced malformation rate. Clinical evidence has demonstrated that the teratogenic effects of hyperglycemia may be obviated by maintaining euglycemia throughout organogenesis. Numerous studies have demonstrated that participation in a preconception care program can reduce the incidence of malformations in women with diabetes to the background rate. Unfortunately, less than 10% of women with diabetes currently enter these programs.


CONCLUSIONS
Diabetic embryopathy remains the single most common lethal problem affecting diabetic pregnancies today. Although preconception planning and glycemic control can reduce the incidence of malformations, it is often difficult to get women to attend such programs and to achieve and maintain euglycemia. The use of dietary supplements, which presumably would override the teratogenic effects of aberrant metabolic fuels, holds great promise for the future as a prophylaxis against diabetic embryopathy.
Reece
E A
EA
Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
Homko
C J
CJ
Wu
Y K
YK
Wiznitzer
A
A
D000818:Animals; D000013:Congenital Abnormalities / Q000209:etiology*; D005260:Female; D005609:Free Radicals; D006801:Humans; D006943:Hyperglycemia / Q000150:complications; D007003:Hypoglycemia / Q000150:complications; D007294:Inositol / Q000378:metabolism; D008563:Membrane Lipids; D011247:Pregnancy; D011254:Pregnancy in Diabetics / Q000150:complications*; D015017:Yolk Sac
D005609:Free Radicals; D008563:Membrane Lipids; D007294:Inositol