1. Prof. Sahar A Hammouda, Prof. Ahmed A Mohamedin Taibah University
Serum levels of some micronutrients among first trimester pregnant Saudi women at the pre-diabetes stage.
Prof. Sahar A Hammouda, Prof. Ahmed A Mohamedin
Taibah University

2. Association between identified hyperglycemias and poor pregnancy outcome is well known; however there is less information about the role of glycated hemoglobin (A1c) at the prediabetic levels in determining associated risks.

3. Objective
To compare the serum levels of some micronutrients between women with normal glycemic control, pre-diabetes and diabetics as classified by A1c.

4. Methods
This was part of a large prospective cohort study aimed at identifying some preventable risk factors that cause congenital malformations among Saudi women.

5. In a previous published data from the same study, A1c was found to be a valuable predictor of the risk of birth defects among Saudi women living at Al-Madinah Al-Monawarah city.

6. Subjects
Eleven hundred and eighty (1180), healthy, first-trimester pregnant Saudi females without known diabetes, were selected from various antenatal care clinics at Al-Madinah Al-Monawarah city. Demographic, clinical and biochemical data were collected for this study at the first visit and examination of the new born was done after delivery.

7. Exclusion criteria:
Presence of systemic diseases that are known to cause birth defects as epilepsy, heart diseases, any chronic disease including diabetes (type 1 & 2)
Clinical history, examination & lab analysis were done (serum levels of folic acid, vitamins B12, vitamin A & E, magnesium, zinc, selenium, homocystine, TSH & A1c).

8. Results
Seventy-seven cases dropped out for different reasons and a total of 1103 were followed till the end of pregnancy. Mean age of the participants was 27.9 ± 6.25 years.

9. Results: 78.9% (870 subjects) had normal A1c (<5.7%),
19.1% ( 211 subjects) had A1c in the range of prediabetes (5.7-<6.5%), and
1.99% (22 subjects) had A1c>6.5% denoting undiagnosed type 2 diabetes

10. Serum levels of the studied nutrients were significantly lower among the prediabetics compared to normal subjects, while serum levels of TSH & homocystein were significantly higher. same results were obtained when comparing diabetics and pre-diabetics and diabetics and normal subjects.

11. There was a significant negative correlation between the levels of A1c and all the studied nutrients and significant positive correlations between A1c, TSH and homocystein levels.

12. Homocysteine (µmol/L)
Statistical comparison in the mean serum levels of the studied nutrients between women with normal A1c and those with pre-diabetic level
P value
Prediabetes
(A1c 5.7-<6.5)
N=211
Normal
(A1c<5.7%) n=870
<.0001
20.01±2.7
30.82±3.8
Vitamin E (mg/L)
420.89±61.68
703.52±99.6
Vitamin A (µg/L)
33.58±6.60
54.77±7.22
Folic acid (nmol/L)
378.47±49.7
552.6±59.6
Vitamin B12 (pmol/L)
7.17±.55
12.10±2.5
Selenium (µg/dl)
76.30±6.16
104.3±14.39
Zinc( µg/dl)
2.42±.59
4.35±.65
Magnesium (mg/dl)
12.36±1.36
7.210± .932
Homocysteine (µmol/L)
5.93±.18
4.96±.32
A1c%

13. Undiagnosed type 2 diabetes
Statistical comparison in the mean serum levels of the studied nutrients between women with undiagnosed type 2 and those with pre-diabetic level
P value
Prediabetes
(A1c 5.7-<6.5)
N=211
Undiagnosed type 2 diabetes
(A1c≥6.5%) n=22
<.0001
20.01±2.7
12.86±4.6
Vitamin E (mg/L)
420.89±61.68
258.8±99.07
Vitamin A (µg/L)
33.58±6.60
21.59±7.021
Folic acid (nmol/L)
378.47±49.7
252.7±78.99
Vitamin B12 (pmol/L)
7.17±.55
5.538±.973
Selenium (µg/dl)
76.30±6.16
61.68±9.44
Zinc( µg/dl)
2.42±.59
1.77± .48
Magnesium (mg/dl)
12.36±1.36
16.16± 1.58
Homocysteine (µmol/L)
5.93±.18
7.05± .62
A1c%

14. Undiagnosed type 2 diabetes n=22
Statistical comparison in the mean serum levels of the studied nutrients between women with undiagnosed type 2 pre-diabetic level and normal women
P value = <.0001
Undiagnosed type 2 diabetes n=22
Prediabetes
N=211
Normal
n=870
levels of
7.05
5.93
4.96
A1C%
12.86
20.01
30.82
Vitamin E (mg/L)
258.8
420.89
703.52
Vitamin A (µg/L)
21.59
33.58
54.77
Folic acid (nmol/L)
252.7
378.47
552.6
Vitamin B12 (pmol/L)
5.538
7.17
12.10
Selenium (µg/dl)
61.68
76.30
104.3
Zinc( µg/dl)
1.77
2.42
4.35
Magnesium (mg/dl)
5.4
3.69
1.8
TSH (normal 4-7 µIU/ml)
16.16
12.36
7.21
Homocysteine (µmol/L)
22.7% (n=5)
9. 0% (n=19)
2.8% (n=24)
Rate of birth defects
18.2% (n=4)
8.1%
8.6%
Rate of abortion & IUFD

15. Undiagnosed type 2 diabetes
Prevalence of minor & major congenital malformations among mothers with different A1C%
Undiagnosed type 2 diabetes
(A1c≥6.5%) n=22
Prediabetes
(A1c 5.7-<6.5%)
N=211
Normal
(A1c<5.7%) n=870
7.05
5.93
4.96
A1C%
22.7% (n=5)
9. 0% (n=19)
2.8% (n=24)
Rate of birth defects
18.2%
(n=4)
4.3%
(n=9)
1.7%
(n=15)
Major malformations
4.5%
4.7%
1.1%
Minor malformations
Major malformations
resulted in death, severe disability or needed major surgical intervention
P value = <.0001

16. Undiagnosed type 2 diabetes
Type of CM
P value = <.0001
Undiagnosed type 2 diabetes
(A1c≥6.5%) n=22
Prediabetes
(A1c 5.7-<6.5)
N=211
Normal
(A1c<5.7%) n=870
7.05
5.93
4.96
A1C%
9.1% (n=2)
2.4% (n=5)
.1% (n=1)
CNS malformations
4.5% (n=1)
.5% (n=1)
.6% (n=5)
Congenital heart disease
.9%(n=2)
.2% (n=2)
Kidney and urinary tract
.5% (n=4)
GIT
1.9% (n=4)
1% (n=9)
eye, ear, face and neck
skin malformations
Respiratory
Skeletal

17. Predictors of congenital malformations by multiple regression (Stepwise Model) using congenital anomalies as the dependable variable
Variables R2
R change
Beta
t-value p
Laboratory study:
A1c levels
.046
.034
.105
2.256
.024
TSH levels
.087
2.558
.011
Folic acid levels
-.099
-3.024
.003
F= (P=000).

18. In this study all data and laboratory parameters were collected during the periods of embryogenesis and organogenesis. The sub-optimum levels of those nutrients or another factors related to glycation products may have contributed to the increased malformations that occurred with pre-diabetes and diabetes.

19. Decreased levels of all the studied nutrients were reported to be associated with birth defects in humans.
Reduced levels of B vitamins, vitamin A, E, selenium were reported among people with diabetes.
Serum magnesium levels in individuals with prediabetes are significantly lower than in those with normal glucose tolerance

20. Plasma homocysteine were reported to be significantly elevated in the prediabetes stage, indicating endothelial dysfunction. The small elevation of blood glucose levels in the prediabetic state may have a detectable influence on endothelial function, causing increased DNA-damage and homocysteine release from endothelial cells.
L. Maschirow, K. Khalaf, H.A. Al-Aubaidy, H.F. Jelinek : Inflammation, coagulation, endothelial dysfunction and oxidative stress in prediabetes — Biomarkers as a possible tool for early disease detection for rural screening. Clinical Biochemistry. 48, (9), 2015, 581–585

21. Elevation of homocysteine levels is associated with developmental abnormalities and birth defects in humans.
It is not clear if this the abnormal levels of nutrients and homocysteine are the cause or the result of the prediabetes state.

22. Oxidative stress plays an important role in the pathogenesis and the complications of diabetes.
On the other hand, hyperglycemia results in overproduction of oxygen free radicals, which contributes to the progression of diabetes.

23. Homocysteinemia may play an etiologic role in the pathogenesis of type 2 diabetes by promoting oxidative stress, systemic inflammation, and endothelial dysfunction.
Song, Yiqing; Cook, Nancy R; Albert, Christine M; Van Denburgh, Martin; Manson, JoAnn E. Effect of Homocysteine-Lowering Treatment With Folic Acid and B Vitamins on Risk of Type 2 Diabetes in Women: A Randomized, Controlled Trial, . Diabetes 2009:

24. There is increasing evidence suggesting that oxidative stress may contribute to birth defects. It was found that depletion of antioxidant systems as well as increased free radical generation are likely to be involved in the pathophysiology of some congenital malformations in humans

25. The high TSH level in pre-diabetic and diabetic mothers significantly predicts congenital malformations
A high thyroid stimulating hormone level was reported in type 2 diabetes patients and is associated with diabetic peripheral neuropathy.
Weijing Zhao, Hui Zeng, Xiaoyan Zhang, Fengjing Liu, Jiemin Pan, Jungong Zhao, Jun Zhao, Lianxi Li, Yuqian Bao, Fang Liu, , , Weiping Jia , A high thyroid stimulating hormone level is associated with diabetic peripheral neuropathy in type 2 diabetes patients. Diabetes Research and Clinical Practice. Available online 19 January 2016

26. Conclusion
Pre-diabetic state is not without complications and women with A1c between (5.7 -<6.5%), suffer from low levels of many nutrients compared to women with lower A1C, which may reflect the impact of high blood glucose on several metabolic processes

27. Recommendations
Studies should be done for re-establishment of safe target levels of A1c for prevention of birth defects and other poor outcome of pregnancy.

28. Recommendations
Inclusion of A1c in routine maternal care can be cost effective by identifying high risk group and reducing congenital malformations.
A1c could be a useful addition to fasting glucose in the screening for undiagnosed diabetes affecting early pregnancy.

29. Recommendations
Establishment of policies for care of pregnant mothers having higher than normal A1c at first visit.
Programs should be established to target subjects at the pre-diabetic stage with the aim of delaying the onset of diabetes and avoiding its complications.