1. The role of HPL in gestational diabetes
Dr. Agron N. Hoxha
Ob/Gyn. Specialist

2. Diabetes is the most common medical complication of pregnancy.
Gestational diabetes mellitus is defined as glucose intolerance or diabetes diagnosed for the first time during pregnancy.
Diabetes occurs in about 1-3% of all pregnancies.
Ninety percent of these cases represent gestational diabetes mellitus (GDM).
Pregestational diabetes is present prior to pregnancy, and it is classified as either type 1  or type 2.
Gestational diabetes is glucose intolerance first recognized during pregnancy.

3. OBJECTIVES : The role of HPL GESTATIONAL DIABETES
How does gestational diabetes to differ from other types of diabetes ?
DIABETES AND PREGNANCY
The role of HPL
GESTATIONAL DIABETES
IMPAIRED GLUCOSE TOLERANCE (IGT)

4. Insulin is made and secreted by the beta cells of the pancreatic islets , small islands of the endocrine cells in the pancreas. Insulin is a protein hormone that contains 51 aminoacides.
Glucagon is the another hormone, that is made and secreted by the alfa cells of the pancreatic islets. Glucagon has the opposite effects to insulin, mobilizes glucose
Insulin:
-stimulates liver and muscle cells to store glucose in glycogen
-stimulates fat cells to form fats from fatty acids and glycerol
-stimulates liver and muscle cells to make proteins from amino-acids
Inhibits the liver and kidney cells from making glucose from intermediate compounds of metabolic pathways (gluconeogenesis).
AND STIMULATES GLUCOSE UPTAKE FROM BLOOD.

5. How does gestational diabetes to differ from other types of diabetes ?
Women with gestational diabetes make a plenty of insulin. In fact , they usually make more insulin than women who are not pregnant. However , the effect of their insulin is partially blocked by a variety of hormones made in placenta. This is called insulin resistance.
The placenta supplies the growing baby with nutrients and water from the mother blood’s stream. It also produces a variety of vital hormones . Several of this hormones estrogen, cortisol and human placental lactogen (HPL) block the effects of insulin. This is called insulin resistance and usually starts about midway (20-40 weeks) through pregnancy.
As the placenta grows larger, more of these hormones are made. This causes more insulin resistance. For most women , the pancreas is able to make extra insulin. When the pancreas makes all the insulin it can and there still isn’t enough to overcome the resistance caused by the hormones, gestational diabetes occurs.

6. X 2.Maternal hyperglycemia 3. Glucose 4. Facilitated diffusion
5. Fetal hyperglycemia Pancreas hyperplasion

7. X 3.Maternal hyperglycemia 4.Glucose 6.Fetal pancreas hyperplasion
5.Fetal hyperglycemia

8. HPL
Human placental lactogen (HPL) is a polypeptide produced during pregnancy. The concentration of HPL exhibits relatively little diurnal and day-to-day variation compared to that of steroid hormones such as estriol. It has a very short half-life in circulation of approximately minutes.
Physiological Action: HPL concentration is a direct reflection of placental function and an indirect marker of fetal well-being.
Regulation &Secretion: Produced by the placenta from aminoacides of maternal origin.
Detectable from about sixth week of pregnancy with levels increasing steadily and reaching a plateau by approximately the 34th week (when the placenta stops growing)
Concentration correlate with placental weight.

9. Reference value range for the HPL concentration in serum
Weeks of pregnancy HPL concentration (mg/l)
Up to
Up to
Up to
Up to
Up to
Up to
Up to

10. Gestational diabetes is pathophysiologically similar to type II diabetes, HPL blocks insulin receptors and increases in direct linear relation to the length of pregnancy. However , Human placental lactogen (HPL) block the effects of insulin. This is called insulin resistance and usually starts about midway (20-40 weeks) through pregnancy.
Normal
Insulin resistance- caused hyperglycemia from the HPL

11. X What is impaired glucose tolerance (IGT) and how is it diagnosed?
People with IGT have blood glucose levels that are higher than normal but not high enough to say that they have diabetes. This condition is diagnosed using the oral glucose tolerance test (OGTT). After a fast of 8 to 12 hours , a person’s blood glucose is measured before and 2 hours after drinking a glucose containing solution.
After 2 hour
glucose X
1.In the normal glucose tolerance, blood glucose rises no higher than 140mg/dl (7.8 mmol/l) hours after the drink.
2. In impaired glucose tolerance (IGT) the 2-hour blood glucose is between mg/dl ( mmol/l).
3. If the 2 hour blood glucose rises to 200 mg /dl (11 mmol/l) ore above , a person has diabetes.

12. The role of high maternal glucose in fetal macrosomia
One of the major problems a woman with gestational diabetes faces is a condition the baby may develop called “Macrosomia”.
Macrosomia means “large body” and refers to a baby that is considerably larger than normal. All of nutrients the fetus receives come directly from the mothers blood. If the maternal blood has too much glucose, the pancreas of the fetus senses the high glucose levels and produces more insulin in an attempt to use the glucose. The fetus converts the extra glucose to fat. Even when the mother has gestational diabetes , the fetus is able to produce all the insulin it needs. The combination of high blood glucose levels from the mother and high insulin levels in the fetus results in large deposits of fat which causes the fetus to grow excessively large, a condition known as macrosomia.
In addition to macrosomia, gestational diabetes increases the risk hypoglycemia in the baby immediately after delivery. This problems occurs if the mother’s blood sugar levels have been consistently high causing the fetus to have a high level of insulin in its circulation. After delivery the baby continues to have a high insulin level , but it no longer has the high level of sugar from its mother , resulting in the newborn’ s blood sugar level becoming very low.

13. 1. Mother’s blood brings extra glucose to fetus
2.Fetus makes more insulin to handle the extra glucose
3. Extra glucose gets stored as fat and fetus becomes larger than normal

15. Alterations of maturity Metabolic alterations
GESTATIONAL DIABETES REPERCUSIONS ON:
Embryo
Fetus
Newborn
Abortions
Malformations
Growth alterations MACROSOMIA IUGR
Alterations of maturity
Respiratory distress syndrome
Metabolic alterations
Hypoglicemia
Hyocalemia
Hyperbilirubinemia
Policitemia
Distocia
Perinatal asphyxia

16. Family history of diabetes in a first- degree relative
Screening procedures for GDM ( risk factors in 50% women identified ) :
Age (>35)
Pre pregnancy weight
Family history of diabetes in a first- degree relative
Previous large baby an previous perinatal loss
GLUCOSURIA is a common finding in pregnancy

17. The end
With many regards
from Kosovo.
Dr.Agron N. Hoxha