During a pregnancy complicated by diabetes, the human placenta undergoes a number of functional and structural pathologic changes, such as increased placental weight and increased incidence of placental lesions including villous maturational defects and fibrinoid necrosis. The pathologic findings reported have differed among studies, potentially reflecting differences in type of diabetes, study methodology, or glycemic control of study participants. Alternatively, these discrepancies may represent different biologic adaptations to distinct metabolic diseases. Abstracts were reviewed for relevance then full-text articles were reviewed in order to extract a comprehensive summary of current pathological findings associated with pregestational and gestational diabetes mellitus, as well as an understanding of the impact of glycemic control on placental pathology. The literature suggests that, despite similarities in placental abnormalities, differences in placental pathology may reflect differences in pathophysiology among different types of diabetes.
Cerebral dysfunction in type 1 diabetes: effects of insulin, vascular risk factors and blood-glucose levels. Al-Okail et al. Association AD. Volumes of the following tissue compartments: intervillous space excluding fibrin depositsperipheral villi, villous trophoblast, villous stroma, fetal capillaries and non-parenchymal tissue comprising decidual and peegnancy plates and intercotyledonary septa ; total lengths and exchange surface areas of villi and fetal capillaries. Responsibilities included designing and maintaining the website, recruitment, providing training to adoptive and foster parents pre-service and on an ongoing basiscomprehensive prefnancy study of prospective adoptive and foster parents, assisting in child placement decisions and providing sexuality education to both the prgnancy and clients at the agency. Additionally, Gearhart robboy sex and pregnancy do bachelorette parties. Yet, placental abnormalities in women with GDM relative to those with pregestational diabetes have not been consistently studied or reported. Placental changes in relation to Doggie caps degree of metabolic control in diabetes mellitus.
Black male strip show. volkswagen identification
Nonetheless, GDM is associated with several fetal complications such as macrosomia Gearhart robboy sex and pregnancy hypoglycemia; and maternal complications, including hypertension, preeclampsia, and an increased risk of Cesarean delivery No studies were identified Geathart specifically examined women with Gearhatr T2DM compared to a normoglycemic population. Ashfaq, 42 Prospective 20 20 Not specified Not specified Not specified Pregnancy difficult labor weight Yes - Placentas of women with GDM had significant increases in weight, central thickness and diameter of the placenta. Volumes of the following tissue compartments: intervillous space excluding fibrin depositsperipheral villi, Maloney oneil spokane trophoblast, villous Gearhartt, fetal capillaries and non-parenchymal tissue comprising decidual and chorionic plates and intercotyledonary septa ; total lengths and exchange surface areas of villi and fetal capillaries. Responsible for developing the curriculum from which to teach the human sexuality teleconference and chat courses. Mayhew TM. Histological changes in placental basement membrane; Volume and surface area of placental capillaries and villi. White Class C not specified whether insulin- dependent. White Class B not specified whether insulin- dependent. Morphometric investigations of terminal villi of diabetic placentas in relation to the White Gearhart robboy sex and pregnancy of diabetes mellitus. National Center for Biotechnology InformationPregnanvy. Classification of obstetric diabetes.
In we open our second location.
- In we open our second location.
- During a pregnancy complicated by diabetes, the human placenta undergoes a number of functional and structural pathologic changes, such as increased placental weight and increased incidence of placental lesions including villous maturational defects and fibrinoid necrosis.
During a pregnancy complicated by diabetes, the human placenta undergoes a number of functional and structural pathologic changes, such as increased placental weight and increased incidence of placental lesions including villous maturational defects and fibrinoid necrosis. The pathologic findings reported have differed among studies, potentially reflecting differences in type of diabetes, study methodology, or glycemic control of study participants.
Alternatively, these discrepancies may represent different biologic adaptations to distinct metabolic diseases. Abstracts were reviewed for relevance then full-text articles were reviewed in order to extract a comprehensive summary of current pathological findings associated with pregestational and gestational diabetes mellitus, as well as an understanding of the impact of glycemic control on placental pathology.
The literature suggests that, despite similarities in placental abnormalities, differences in placental pathology may reflect differences in pathophysiology among different types of diabetes. Consequently, standardization of terminology used to define placental lesions is warranted. The human placenta is the critical organ responsible for the facilitation of nutrient uptake, waste elimination, and gas exchange between mother and fetus 1. The placenta is also a vital source of hormone production such as progesterone and human chorionic gonadotropin that maintain the pregnancy 1.
Consequently, placental dysfunction can lead to a number of adverse fetal outcomes 2 , 3. The extent to which maternal glycemic control contributes to placental abnormalities remains unclear. Literature demonstrates that, when maternal glucose levels are well-controlled, the placentas from women affected by diabetes are normal as evaluated by routine light microscopy 4 , 5.
However, several studies have identified histopathologic placental abnormalities among women even with well-controlled pregestational 6 - 8 and gestational diabetes 9 , To our knowledge, there have been no systematic reviews evaluating the differences of placental histopathology between pregestational diabetes, defined as type 1 diabetes mellitus T1DM or type 2 diabetes mellitus T2DM ; and gestational diabetes GDM , defined as diabetes diagnosed during pregnancy that is not clearly overt diabetes Consequently, we have developed a comprehensive systematic review of the current literature in order to critically examine the gross and histopathologic findings associated with dysglycemia in pregnancy.
The literature will be discussed with respect to diabetes type, pregestational or GDM, as well as by the control groups under investigation and the placental derangements demonstrated. Two investigators JH and DD independently reviewed titles, abstracts, and full-text articles. Additional articles were identified through searching the reference lists from included studies.
Disagreements were resolved by consensus. Studies were excluded if they examined placental abnormalities in animals; were case-reports or review articles; were comprised of women with diabetes and other pregnancy complications such as preeclampsia or hypertension; did not have a valid comparison group; or did not specify diabetes type.
Data on population characteristics, diabetes class, and placental abnormalities were extracted. Because of the variability in GDM diagnostic criteria in use 18 , data on the criteria used for defining GDM were also extracted. Because of the substantial heterogeneity in study methodology, placental abnormalities under investigation, and population characteristics, a quantitative meta-analysis of the data was not appropriate. For the purposes of this systematic review, we categorized study findings by diabetes type as reported by the study authors.
T1DM is characterized by a severe deficiency in insulin production due to the autoimmune destruction of islet cells in the pancreas Conversely, T2DM is a metabolic disorder characterized by insulin resistance and relative insulin deficiency Similar to T1DM, it is also characterized by hyperglycemia; persistent hyperglycemia from both T1DM and T2DM has been associated with a number of well-described adverse clinical sequelae, such as retinopathy, nephropathy, peripheral neuropathy, and diabetic encephalopathy 19 - These conditions reflect the damage hyperglycemia inflicts upon not only the nerves, but also the vasculature, which leads to impaired blood flow with subsequent end-organ damage.
Consequently, the presence of maternal systemic vascular complications may also portend the impact to uterine vasculature affecting placental perfusion 22 , GDM has been considered to be a transient insulin resistance potentially resulting from the influence of several pregnancy hormones, including progesterone, cortisol, placental lactogen, prolactin and growth hormone After delivery, the insulin resistance improves, although GDM has been associated with an increased risk of subsequent T2DM.
Nonetheless, GDM is associated with several fetal complications such as macrosomia and hypoglycemia; and maternal complications, including hypertension, preeclampsia, and an increased risk of Cesarean delivery Additionally, the White classification of diabetes in pregnancy, developed by Priscilla White in in order to predict perinatal outcomes 27 , was used to aggregate populations in several studies included in this systematic review. These criteria, subdivided into different categories by the age of onset, duration of diabetes, and presence of vascular disease, are provided in Table 1.
For the purpose of this systematic review, we categorized placental gross and histologic findings as reported by the study authors. Because placental gross and histologic findings varied among study papers, a true meta-analytical approach was not possible. The study team assessed the methodological quality of the studies by comparing study design, inclusion criteria, and the blinding of investigators to pregnancy outcome or causation.
The selection algorithm for the 38 studies that met the inclusion and exclusion criteria for our systematic review is detailed in Figure 1.
Study characteristics, diabetes type, placental abnormalities examined, and population characteristics for studies in pregnancies affected by pregestational diabetes are summarized in Table 2.
Nine of the 16 studies included in this systematic review examined women with T1DM compared to normoglycemic controls 7 , 12 , 17 , 30 - Two other studies identified women as having pregestational diabetes 8 , 36 while the remaining five studies defined the women by the White classification 6 , 11 , 27 , 37 - No studies were identified that specifically examined women with maternal T2DM compared to a normoglycemic population. The selection algorithm is presented here.
Study characteristics, diagnostic criteria, placental abnormalities examined, and population characteristics for studies of pregnancies complicated by GDM are summarized in Table 3. Seven studies examined placental gross or histomorphometric features in women with GDM compared to those with normoglycemia 9 , 10 , 14 , 40 - Common gross and histopathologic placental findings in pregestational diabetes and GDM compared to healthy controls are provided in Table 5.
Quality of included studies varied considerably; only three out of 38 included studies were retrospective, case-controlled studies 15 , 16 , 40 ; twelve included studies specified whether or not pathologists were blinded to diabetes diagnosis or pregnancy outcomes and 22 out of 38 included studies provided information on the degree of glycemic control in their study population. Three studies measured the volume and surface areas of the parenchyma, described in by Aherne and Dunnill as the villi, including fetal vessels and the maternal intervillous space; and non-parenchymal tissue comprised of the chorionic and decidual plates, fetal vessels of diameter greater than 0.
Teasdale found increased non-parenchymal and parenchymal tissue in the placentas of women with well-controlled White class B and C diabetes 11 , In contrast, Boyd et al. Three studies reported an association between the incidence of villous immaturity, defined as placentas with inadequate or absent terminal villi, and pregestational diabetes 32 , 36 , Similar to studies of pregestational diabetes, placental histomorphometric abnormalities studied in relation to GDM varied considerably.
Three studies reported heavier placentas in women with GDM compared to normoglycemic controls 14 , 40 , Ashfaq et al. Taricco et al. Stoz et al. In studies of women with pregestational diabetes compared to those with GDM, Clarson et al. Al-Okail et al. In contrast, Rudge et al. Additional histopathologic changes found only in women with pregestational diabetes included chorial edema, intimal edema, interstitial hemorrhage, subchorial infarct, villous fibrosis, Hofbauer hyperplasia, chorioangiosis, syncytial knots, villitis, phantom cells, two vessels, duplicate membrane, and cord hemorrhage Younes et al.
Placental variables under investigation were defined in 32 out of 38 papers. There was clear variability in definitions used for commonly studied placental abnormalities, especially found in descriptions of villous maturity, parenchymal tissue and measures of angiogenesis. While several papers reported a difference in villous maturation in women with diabetes compared to controls, definitions of villous maturity differed among studies.
Fox 8 studied fetal stem arteries for the overall villous maturity, taking into account specifically the size of the villi, the number of syncytial knots, the degree of stromal condensation and the position and size of the fetal villous capillaries. By this definition, Fox 8 reported that Bjork and Persson 37 observed a higher frequency of immature villi in pregestational diabetic placenta compared to controls.
Evers et al. Higgins et al. Immature intermediate villi also contain reticular stroma In women with White Class B, White Class C, and White Class A diabetes, Teasdale 9 , 11 , 38 found a significant increase in parenchymal tissue, defined as the intervillous space, the trophoblast layer, and fetal capillaries of both the peripheral and stem villi.
Boyd et al. Several articles included in this systematic review also investigated measures of angiogenesis 31 , 35 , Jirkovska et al. While another study reported increased measures of fetoplacental angiogenesis, Mayhew et al. Mayhew et al. To our knowledge, this is the first comprehensive systematic review of placental histopathology in the setting of maternal diabetes. Strengths of this systematic review include the rigorous and detailed method of identification and review of the relevant literature.
However, a notable limitation is that we were unable to use a meta-analytical approach to substantially compare data across studies spanning from to because of the varied placental abnormalities examined and study methodologies employed. This systematic review also detailed placental variables as reported by the authors of included studies. To reduce the methodological variability across clinical studies of placental pathology, standardization of placental variable definitions is critical in directing future research.
Our systematic review uncovered that only 12 out of 38 included studies specified whether or not pathologists were blinded to diabetes diagnosis and pregnancy outcome. Nonetheless, this critical examination of placental pathology across types of diabetes will enable us to demonstrate pathological patterns that may inform how we consider future clinical practice and research implications of pregestational and GDM. Angiogenesis, defined as the process of new blood vessels arising from preexisting ones, is essential for normal fetal growth and placental development.
Generally, there are two phases of angiogenesis: 1 branching angiogenesis with formation of tightly looped capillaries and 2 non-branching angiogenesis with formation of longer capillaries 57 , One study by Mayhew et al. Conversely, Jirkovska et al. These findings suggest that placentas from pregnancies complicated by dysglycemia may display both increases in branching and non-branching angiogenesis.
Additionally, increased incidence of placental villous immaturity was commonly seen in placentas affected by pregestational 8 , 32 , 37 and GDM 10 , This placental abnormality, which has been independently associated with an increased risk of perinatal mortality 60 , may serve as a connection between maternal diabetes and an increased risk of fetal intrauterine death Further study in these areas is warranted to elucidate etiologic mechanisms.
Although there were several similarities in placental histopathologic findings associated with T1DM, T2DM, and GDM, the different pathophysiology of these three diabetic conditions may differentially impact placentation, despite similar medical care and glycemic control.
In fact, one study reported that placentas of pregnancies complicated by T2DM had a significant increase in placental infarcts compared to T1DM 15 , a vascular abnormality that has also been found in studies of hypertension in pregnancy The time course of metabolic insult may also influence the degree of placental abnormality.
Yet, placental abnormalities in women with GDM relative to those with pregestational diabetes have not been consistently studied or reported. However, other studies reported increased fibrinoid material 50 , 51 and thickening of the basement membrane 50 , 51 in women with GDM compared to those with pregestational diabetes. However, there were no observed significant histological differences among placentas 4 , 44 , 46 - 48 , which suggests that may not differentially impact placental pathology.
Because the population sizes of these studies were small, ranging from 2 to 40 women within each diabetic subgroup, further research comparing placental abnormalities in women with pregestational and GDM across different White classifications is warranted.
Notably, although glycemic control has been considered integral to the pathophysiology of placental abnormalities, only 22 of 38 studies included in this review detailed the degree of glycemic control of their study populations, with 16 studies specifying moderate to good glycemic control.
Poor glycemic control in the periconception period and first trimester of pregnancy has been linked to a number of maternal adverse outcomes, such as hypertension, preeclampsia, Cesarean section, and hypoglycemia, as well as numerous fetal adverse outcomes, including fetal and neonatal loss, fetal growth acceleration, macrosomia, stillbirth, and respiratory distress syndrome
Higgins et al. What Causes Stress? Specialization is in sex therapy. The selection algorithm is presented here. Histopathological placental lesions in mild gestational hyperglycemic and diabetic women. Dubova et al. Adaptive immunity, inflammation, and cardiovascular complications in type 1 and type 2 diabetes mellitus.
Gearhart robboy sex and pregnancy. 1. INTRODUCTION
bursa88.com | expired domain
In we open our second location. We now are a team of 17 therapists. Core to our humble beginnings we continue to provide educational free self help information online as well as engage in community development. One area that makes our organization unique is our dedication to low-cost groups. In addition to overseeing the management of the company, I provide individual, couples, family therapy, groups and supervision. My exact area of clinical interest is ever changing and is highly influenced by the needs of my current clients, my staff as well as my family.
Responsible for answering sex based questions, developing the curriculum from which to teach the human sexuality teleconference and chat courses.
Design and produce the monthly sex tips. Additionally, we do bachelorette parties. Supervisor for two MSW interns. Responsibilities included designing and maintaining the website, recruitment, providing training to adoptive and foster parents pre-service and on an ongoing basis , comprehensive home study of prospective adoptive and foster parents, assisting in child placement decisions and providing sexuality education to both the staff and clients at the agency.
Responsible for designing and implementing lesson plans, grading and running my own section of the course. The Center For Growth, Inc. Robboy, Alex. Contemporary Sexuality, v42, 12 pg 8 December, Brain For Women. Wood M. Is it Healthy? Presented with Dr.
Peter Gearhart. Robboy, Alex Lost in translation? The Journal of Homosexuality. Emily Endres CV. Alex Caroline Robboy Resume.
Marina France. What Causes Stress? Ask A Therapist. Being Assertive. What to look for in a couples counselor. Any loss no matter how big or small triggers a grief process.
A person does not have to die for you to feel grief. Need An Appointment? Call x Featured Article Grieving the Loss of a Relationship Any loss no matter how big or small triggers a grief process.