Research ajog.

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1 OBSTETRICS 56
2 57
3 Increased glucose and placental GLUT-1 in 58
4 59
5 large infants of obese nondiabetic mothers 60
6 Q4 Ometeotl Acosta, MD; Vanessa I. Ramirez, MS; Susanne Lager, PhD; Francesca Gaccioli, PhD; 61
7 Donald J. Dudley, MD; Theresa L. Powell, PhD; Thomas Jansson, MD, PhD 62
8 63
9 64
10 OBJECTIVE: Obese women are at increased risk to deliver a large RESULTS: Birthweight was positively correlated with umbilical vein 65
11 infant, however, the underlying mechanisms are poorly understood. glucose and insulin and maternal body mass index. Umbilical 66
12 Fetal glucose availability is critically dependent on placental transfer vein glucose levels were positively correlated with placental weight 67
13 and is linked to fetal growth by regulating the release of fetal growth and maternal body mass index, but not with maternal fasting 68
14 hormones such as insulin. We hypothesized that (1) umbilical vein glucose. Basal plasma membranes GLUT-1 expression was posi- 69
15 glucose and insulin levels and (2) placental glucose transporter (GLUT) tively correlated with birthweight. In contrast, syncytiotrophoblast 70
16 expression and activity are positively correlated with early pregnancy microvillous GLUT-1 and -9, basal plasma membranes GLUT-9 71
17 maternal body mass index and infant birthweight. expression and syncytiotrophoblast microvillous and basal plasma 72
18 membranes glucose transport activity were not correlated with 73
19 STUDY DESIGN: Subjects in this prospective observational cohort 74
birthweight.
20 study were nondiabetic predominantly Hispanic women delivered 75
21 at term. Fasting maternal and umbilical vein glucose and insulin 76
CONCLUSION: Because maternal fasting glucose levels and placental
22 concentrations were determined in 29 women with varying early 77
glucose transport capacity were not increased in obese women
23 pregnancy body mass index (range, 18.0e54.3) who delivered infants 78
delivering larger infants, we speculate that increased placental size
24 with birthweights ranging from 2800e4402 g. We isolated syncy- 79
promotes glucose delivery to these fetuses.
25 tiotrophoblast microvillous and basal plasma membranes from 80
33 placentas and determined the expression of GLUT-1 and -9 Key words: fetal growth, maternal-fetal exchange, maternal obesity, 81
26
(Western blot) and glucose uptake (radiolabeled glucose). trophoblast 82
27
28 83
Cite this article as: Acosta O, Ramirez VI, Lager S, et al. Increased glucose and placental GLUT-1 in large infants of obese nondiabetic mothers. Am J Obstet Gynecol 84
29
2014;211:x-ex-x-ex.
30 85
31 86
32 87
33
34
35
O besity in pregnancy is linked to
a multitude of short- and long-
term adverse fetal outcomes.1 For
morbidity and risk of developing obesity
and metabolic syndrome later in life.1,2
Fetal growth is highly dependent on
increased glucose availability could in-
crease fetal adiposity.
Placental glucose transport occurs via
88
89
90
36 example, obese women are more likely to the availability of nutrients such as facilitated diffusion, mediated by glucose 91
37 give birth to a macrosomic infant, which glucose; however, the mechanisms un- transporters (GLUT). GLUT-1 is highly 92
38 is associated with increased perinatal derlying fetal overgrowth in nondiabetic expressed in the 2 plasma membranes 93
39 pregnancies of obese women remain to of the syncytiotrophoblast (microvillous 94
40 be fully established. membrane, [MVM] and basal mem- 95
From the Department of Obstetrics and
41 Gynecology, Center for Pregnancy and
Glucose is the primary energy sub- brane, [BM]), the transporting epithe- 96
42 Newborn Research, University of Texas Health strate for the placenta and the fetus and lium of the human placenta.6,7 Because 97
43 Science Center at San Antonio, San Antonio, TX. fetoplacental glucose needs are met BM has been shown to have a much 98
44 Received March 28, 2014; revised June 14, entirely by uptake from the maternal lower expression of GLUT-1 than 99
45 2014; accepted Aug. 12, 2014. circulation.3 Approximately 55% of the MVM, the transfer across BM has been 100
46 The authors report no conflict of interest. glucose taken up from the utero- suggested to be the rate limiting step 101
47 Supported by National Institutes of Health (grant placental circulation is metabolized by in maternofetal glucose transport.7,8 102
48 Q3 no. DK089989; T.L.P.). the placenta and the remaining 45% is This model is supported by recent 103
49 Presented at the 60th annual meeting of the transferred to the fetus.4 Glucose stim- mathematical modeling of placental 104
50 Society for Gynecologic Investigation, Orlando, ulates fetal secretion of insulin and glucose transport9 and studies in 105
51
FL, March 20-23, 2013. insulin-like growth factor-I (IGF-I), the in vitro perfused placenta.10 BM GLUT-1 106
Corresponding author: Ometeotl Acosta, MD. 2 primary fetal growth hormones, expression and glucose transporter ac-
52 107
acostao@uthscsa.edu
53 providing a direct link between fetal tivity are increased in pregnancies 108
54
0002-9378/$36.00 glucose availability and fetal growth.5 complicated by diabetes, in particular in 109
ª 2014 Elsevier Inc. All rights reserved.
55 http://dx.doi.org/10.1016/j.ajog.2014.08.009 In addition, glucose can be converted to association to increased fetal growth.11 110
fat consistent with the possibility that In addition, GLUT-9 is also expressed in

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111 167
112 term placentas12 and MVM and BM hypothesized that (1) umbilical vein Antonio institutional review board 168
113 GLUT-9 expression has been reported to glucose and insulin levels and (2) (HSC20100262H), to which pregnant 169
114 be increased in pregnancies complicated placental glucose transporter expression women were recruited following written 170
115 by diabetes.13 and activity are positively correlated informed consent. We used samples 171
116 Increased fetal glucose availability with early pregnancy maternal BMI and from healthy women with normal term 172
117 could contribute to fetal overgrowth in infant birthweight. To address this hy- pregnancies. Samples were selected 173
118 obese women without diabetes. Because pothesis we collected maternal and um- randomly with the exception that we 174
119 of the facilitated nature of maternal-fetal bilical vein plasma samples and placentas included all overweight/obese women 175
120 glucose transfer even a modest increase from pregnancies of women with vary- giving birth to large infants from whom 176
121 in maternal glucose levels may enhance ing BMI giving birth to infants across samples were available. Samples from a 177
122 glucose supply to the fetus, which is the growth spectrum, from appropriate total of 52 women who were lean (BMI 178
123 consistent with the continuous associa- for their gestational age to large infants 18.0-24.9, n ¼ 20) or overweight/obese 179
124 tion between maternal glucose levels with birthweights greater than 4000 g. (BMI 25-54.3, n ¼ 32) during early 180
125 (below those diagnostic of diabetes) and We determined maternal and fetal pregnancy (<20 weeks’ gestational age) 181
126 increased birthweight reported by the plasma glucose levels and studied GLUT- and had uncomplicated term pregnancy 182
127 HAPO Study.14 Obese women are at 1 and GLUT-9 protein expression and (>37 weeks of gestation) were used. In 183
128 greater risk for glucose intolerance in glucose transport activity in isolated 10/52 study subjects both blood and 184
129 pregnancy because of their markedly MVM and BM. placental samples were available. Thus, 185
130 lower insulin sensitivity as compared of the 29 women in whom we had 186
with lean controls15 and intermittent M ATERIALS AND M ETHODS blood samples and the 33 where we had
131 187
132 minor elevations of maternal blood Study subjects placental samples (29 þ 33 ¼ 62) 10 188
133 glucose could contribute to stimulate We obtained coded placental tissue and overlap, corresponding to the 52 unique 189
134 fetal growth in these women. Alterna- plasma samples and deidentified rele- study subjects. Study subjects were 190
135 tively, an enhanced placental glucose vant medical information from a tissue delivered by cesarean section (n ¼ 47) or 191
136 transport capacity could increase fetal repository approved by the University vaginally (n ¼ 5). Seventy-five percent 192
137 glucose availability in obese women. We of Texas Health Science Center, San of the study subjects were Hispanic 193
138 (Mexican-American), 21% were non- 194
139 Hispanic whites, 2% were Asian, and 195
140 2% were African-American. 196
TABLE
141 Maternal and pregnancy characteristics 197
Collection of blood and determination
142 198
Descriptions BMI <25 BMI ‡25 Total/P value of glucose concentrations
143 199
144 n 20 32 52 After at least an 8-hour self-reported fast, 200
maternal blood samples were obtained
145 Age, y 29.1  1.5 27.6  1.0 .39 201
146 from the antecubital vein before cesarean 202
Gestational age, wks 39.1  0.2 39.5  0.1 .16 delivery. Immediately after delivery,
147 203
148 Nulliparous 1 1 2 blood was collected from the umbilical 204
149 Labor 3 4 7 vein. All blood samples were collected in 205
150 a purple top vacutainer blood collection 206
Early pregnancy BMI 21.3  0.4 34.3  1.0 < .0001
151 tube containing ethylenediaminetetra- 207
Birthweight, g 3191  50 3768  66 < .0001 acetic acid and within 30 minutes of
152 (2800-3699) (3167-4402) 208
153 collection, were centrifuged at 2500 rpm. 209
154
BMI at delivery 27.4  1.0 36.8  1.3 < .0001 Plasma was flash frozen in liquid nitro- 210
155 Gestational weight gain, lbs 24.2  2.4 18.2  3.5 .21 gen and subsequently stored at 80 C. 211
156 Maternal and fetal plasma glucose levels 212
Male/Female 13/7 17/15 30/22
157 were measured in triplicate using an 213
Placental weight, g 661  18 782  32 .006 Analox Glucose Analyzer GM9. Q1
158 214
Maternal fasting glucose, mg/dL 73.4  3.2 74.6  1.5 .71
159 215
Maternal insulin, pg/mL 342.0  59 532  60 .05 Placenta collection and
160 216
immunohistochemistry
161 Maternal HOMA-IR 1.65  0.33 2.5  0.29 .09 217
162 Placentas were placed on ice immedi- 218
Fetal insulin, pg/mL 160  30.8 238  51.0 .23 ately after delivery and several small
163 219
164 Fetal HOMA-IR 0.50  0.10 0.82  0.20 .21 villous tissue pieces were rinsed in cold 220
165 BMI, body mass index; HOMA-IR, homeostasis model assessment of insulin resistance. physiologic saline before being fixed 221
166 Acosta. Maternal obesity, fetal glucose, and placental glucose transport. Am J Obstet Gynecol 2014. in formalin and embedded in paraf- 222
fin. Immunohistochemical analysis was

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224 performed on 5 mm sections. The slides transporter ferroportin-1 (SLC40A1), described previously,7 with the modifi- 280
225 were heated to 60-70 C for 20 minutes which is almost exclusively expressed on cation that amido black was used to 281
226 and thereafter cooled to room tempera- the BM to facilitate unidirectional iron quantify the total protein for normali- 282
227 ture. The paraffin was removed by transport from mother to fetus.17-19 zation.20 GLUT-1 was used at 1:20,000 283
228 xylene, and the tissue rehydrated with The mean enrichment of ferroportin and GLUT-9 at 1:1000 dilution. Relative 284
229 ethanol and then placed in phosphate expression in BM was 15.7  2.5. GLUT-1 and GLUT-9 densities were 285
230 buffered saline. The slides were boiled analyzed by densitometry by means of 286
231 for 10 minutes in citrate buffer (H-3300 ImageJ software (National Institutes of 287
Antigen Unmasking Solution; Vector Western blot Health). To facilitate comparisons be-
232 Protein expression of GLUT-1 and 288
233 Laboratories, Burlingame, CA). The tween groups, the expression of the 289
slides were cooled for 30 minutes in GLUT-9 in MVM and BM was deter- target protein in each individual sample
234 mined using commercial antibodies 290
235 room temperature and thereafter (target/total protein density) was then 291
washed 3 times in phosphate buffered (Millipore and Abcam) and Western calculated as percentage of the mean of
236 blotting, which was performed as 292
237 saline for 5 minutes. The immuno- all samples. 293
238 chemical staining was done with the 294
Vectastain Elite ABC kit (Vector Labo- Glucose transport activity
239 FIGURE 1
295
ratories) with some minor modifica- measurements
240 The relationship between 296
241 tions. Briefly, endogenous peroxidase Uptake of radiolabeled D- and L-glucose 297
was quenched in 3% H2O2 for 20 mi- umbilical vein glucose, insulin, into plasma membranes vesicles was
242 maternal BMI and birthweight 298
243 nutes. The sections were incubated with measured at 23 C as described previ- 299
244 primary antibodies overnight at 4 C in ously7 with some modifications. With 300
245 a humidified chamber. Primary anti- 2 investigators performing the experi- 301
246 bodies targeting GLUT-1 and GLUT-9 ment, one investigator promptly mixed 302
247 were purchased from Millipore, Teme- vesicles at 23 C (40 mL) with 20 mL D- 303
248 cula, CA and Abcam, Cambridge, glucose (12 mmol/L), mannitol (288 304
249 MA, respectively. Subsequently, sections mmol/L), and HEPES-Tris (10 mmol/L; 305
250 were incubated in secondary antibodies pH 7.4) containing [14C] D-glucose 306
251 for 60 minutes at room temperature. (0.015 mCi/mL) and tritiated L-glucose 307
252 Staining was visualized with a peroxidase (0.048 mCi/mL). Using a metronome, 308
253 substrate kit (DAB SK-4100; Vector after 0.6 seconds, uptake of radiolabeled 309
254 Laboratories). Sections were then coun- glucose was terminated by the addition 310
255 terstained with hematoxylin, cleared, of 2 mL of ice cold stop solution (250 311
256 dehydrated, and mounted. mmol phloretin per liter in buffer A, 312
257 plus 2% ethanol) by a second investi- 313
Isolation of syncytiotrophoblast gator using a precalibrated bottle top
258 314
plasma membranes
259 315
260 Syncytiotrophoblast MVM and BM 316
261 were isolated according to a well- FIGURE 2 317
262 characterized protocol.16 The isolated The relationship between 318
263 MVM and BM vesicles were stored placental weight and umbilical 319
264 at 80 C in buffer D containing prote- vein glucose 320
265 ase and phosphatase inhibitors (Sigma- 321
266 Aldrich). Protein content of the vesicles 322
267 was determined using Pierce BCA Pro- 323
268 tein Assay Kit (Pierce Biotechnology, 324
269 Rockford, IL). Purity of isolated MVM 325
270 was measured by enrichment of alkaline 326
271 phosphatase activity. At least a 10-fold 327
Birthweight positively correlates with A, umbili-
272 enrichment of enzyme activity in iso- 328
cal vein glucose (P ¼ .008, n ¼ 29), and with B,
273 lated vesicles compared with placental 329
umbilical vein insulin (P ¼ .04, n ¼ 26) and with
274 homogenate was used as a marker for 330
C, maternal BMI (P ¼ .03, n ¼ 29). All analyses Placental weight positively correlates with um-
successful enrichment. The mean en-
275 are based on Pearson’s correlation. bilical vein glucose (P ¼ .001, n ¼ 28) based 331
276 richments of alkaline phosphatase in 332
BMI, body mass index. on Pearson’s correlation.
277 MVM was 13.86  0.89. The enrich- 333
Acosta. Maternal obesity, fetal glucose, and placental glucose Acosta. Maternal obesity, fetal glucose, and placental glucose
278 ment of BM was determined using transport. Am J Obstet Gynecol 2014. transport. Am J Obstet Gynecol 2014. 334
the protein expression of the iron

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335 391
336 automatic dispenser. Vesicles were Data presentation and statistics Ninety-six percent of the study subjects 392
337 separated from the substrate medium by Our sample sizes represent a conve- were multiparous and 87% of the 393
338 filtration on mixed ester filters (0.45 mm nience sample as we did not have suffi- women had not experienced labor. Per 394
339 pore size, Millipore) and washed with cient data for a power calculation or study design, there was a difference in 395
340 6 mL of rinse solution (100 mmol sample size determination. There were a early pregnancy maternal BMI and in- 396
341 phloretin per liter in buffer A, plus total of 52 unique study subjects across fant birthweight between the 2 groups 397
342 2% ethanol). Measurements were car- the range of maternal BMIs; 29 plasma (P < .0001, P < .0001; Table). Maternal 398
343 ried out in triplicate for each sample. and 33 placental samples with 10 study BMI remained significantly higher in the 399
344 Filters were placed in 2 mL liquid scin- subjects’ samples overlapping between Ow/Ob group at delivery as compared 400
345 tillation fluid and counted. Uptake at the 2 groups. Summary data are pre- with the normal BMI group (P < .0001, 401
346 0.6 seconds was taken to approximate sented as means  SEM. Because our Table). Gestational weight gain was not 402
347 the initial rate. Net (carrier-mediated) data did not significantly deviate from significantly different between the 2 403
348 D-glucose uptake was calculated by normality for most variables (as tested groups (Table). Fifty-eight percent of 404
349 subtracting the L-glucose rate from the using Shapiro-Wilk test) and the well- the newborns were male and 42% were 405
350 total D-glucose uptake rate. To slow the established robustness of t tests even female. The placental weight of Ow/Ob 406
351 rate of glucose uptake and confirm the with relatively small sample sizes and women was significantly greater than 407
352 initial findings, the experiment was with significant deviations from normal normal BMI women (P ¼ .006; Table). 408
353 duplicated at þ4 C. Uptake at 1.5 sec- distribution,21 statistical significant dif- No difference was observed between 409
354 onds was taken to approximate the initial ferences between groups were deter- maternal fasting glucose, maternal/ fetal 410
355 rate after establishing a time course mined using Student t test. In addition, insulin and homeostasis model assess- 411
356 for þ4 C. because the approximate normal distri- ment of insulin resistance values be- 412
357 bution of data, variables were analyzed tween the 2 groups (Table). Birthweight 413
358 using Pearson’s correlation coefficients was positively correlated with umbilical 414
FIGURE 3 vein glucose (P ¼ .008; Figure 1, A), in- ½F1 415
359 as continuous across the range of birth-
The relationship between weights, placental weights, maternal sulin (P ¼.04; Figure 1, B), and maternal
360 maternal BMI, maternal fasting 416
361 BMI, and maternal fasting glucose. A BMI (P ¼ .03; Figure 1, C). Placental 417
glucose and umbilical vein P < .05 value was considered significant. weight positively correlated with umbil-
362 glucose 418
363 ical vein glucose (P ¼ .001; Figure 2). ½F2 419
R ESULTS Maternal BMI (P ¼ .04; Figure 3, A), ½F3 420
364
Demographic data and glucose but not gestational weight gain (not
365 421
concentrations shown), was positively correlated with
366 422
367 Maternal age and gestational age at de- umbilical vein glucose. However, there 423
368 livery did not differ between the normal was no relationship between maternal 424
369 BMI (BMI <25) and overweight/obese fasting glucose and umbilical vein 425
370 (Ow/Ob) (BMI 25) groups (Table). glucose (P ¼ .94; Figure 3, B). ½T1
426
371 427
372 428
373 FIGURE 4 429
374 Immunohistochemistry of term human placenta 430
375 431
376 web 4C=FPO 432
377 433
378 434
379 435
380 436
381 437
382 438
383 Umbilical vein glucose positively correlates with 439
384 A, maternal BMI (P ¼ .04, n ¼ 29), but does not 440
385 correlate with B, maternal fasting glucose (P ¼ 441
386 .94, n ¼ 29). All analyses are based on Pear- A, GLUT-1 and B, GLUT-9 staining predominantly in the syncytiotrophoblast and its plasma 442
387 son’s correlation. membrane, in particular in the microvillous plasma membrane. Large arrow is microvillous plasma 443
388 BMI, body mass index.
membrane and small arrow is basal plasma membrane. C, Negative control. Scale bar is 20 mm. 444
GLUT, glucose transporter.
389 Acosta. Maternal obesity, fetal glucose, and placental glucose 445
transport. Am J Obstet Gynecol 2014. Acosta. Maternal obesity, fetal glucose, and placental glucose transport. Am J Obstet Gynecol 2014.
390 446

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447 503
448 GLUT-1 and GLUT-9 in the human 504
FIGURE 5
449 placenta 505
GLUT-1 and GLUT-9 protein expression Q2
450 Cellular localization of glucose trans- 506
451 porters was investigated by immuno- 507
452 histochemistry in sections of term 508
453 placenta to demonstrate that the glucose 509
454 transporters under study are expressed 510
455 in this tissue. GLUT-1 and GLUT-9 511
456 were predominantly expressed in the 512
457 syncytiotrophoblast plasma membranes 513
458 ½F4 (Figure 4), in particular in the MVM. 514
459 ½F5 MVM GLUT-1 (P ¼ .99; Figure 5, B), 515
460 MVM GLUT-9 (P ¼.82; Figure 5, D) and 516
461 BM GLUT-9 (P ¼ .90; Figure 5, E) pro- 517
462 tein expression did not correlate with 518
463 birthweight. In contrast, BM GLUT-1 519
464 transporter expression positively corre- 520
465 lated with birthweight (P ¼.03; Figure 5, 521
466 C). We measured glucose transport 522
467 activity at 23 C in the same vesicle 523
468 preparations used to determine glucose 524
469 transporter expression and found that 525
470 ½F6 neither MVM (P ¼ .70; Figure 6, A) nor 526
471 BM glucose transport activity correlated 527
472 to birthweight (P ¼ .63; Figure 6, B). 528
473 Similarly, glucose transport activity in 529
474 BM measured at þ4 C did not correlate 530
475 to birthweight (not shown). 531
476 The inclusion of 7/52 of study subjects 532
477 who experienced labor in the study of 533
478 placental transport raises the question 534
479 that labor affected our results. However, 535
480 this is unlikely because we have previ- 536
481 ously reported that there is no difference 537
482 in MVM/BM GLUT-1 density or glucose A, Representative Western blots of GLUT-1 and GLUT-9 in the MVM and BM of lean and overweight/ 538
483 transport activity between cesarean and obese womeAcostn. Birthweight does not correlate with the protein expression of B, MVM GLUT-1 539
7,22
484 vaginal deliveries. Furthermore, to (P ¼ .89, n ¼ 33), D, MVM GLUT-9 (P ¼ .82, n ¼ 33) or E, BM GLUT-9 (P ¼ .98, n ¼ 32). However, 540
485 adjust birthweights for gestational age, birthweight positively correlates with the protein expression of C, BM GLUT-1 (P ¼ .03, n ¼ 33). All 541
486 fetal sex, and parity, we used published analyses are based on Pearson’s correlation. 542
487 references for birthweights of Mexican- BM, basal membrane; GLUT, glucose transporter; MVM, microvillous membrane. 543
488 American infants born in the United Acosta. Maternal obesity, fetal glucose, and placental glucose transport. Am J Obstet Gynecol 2014. 544
489 States23 to calculate birthweight z-scores. 545
490 Using birthweight z-scores instead of 546
491 absolute birthweights did not affect levels, which may contribute to fetal The positive correlation between 547
492 any of the relationships with umbilical overgrowth in these pregnancies. Fetal maternal BMI and infant birthweight 548
493 vein glucose or insulin, maternal BMI, hyperglycemia could not be explained is well established in the literature.24,25 549
494 MVM/BM glucose transporter expres- by increased maternal fasting glucose In addition, our data agrees with 550
495 sion or activity. levels or enhanced activity of placental Walsh et al,26 duplicating the positive 551
496 glucose transporters. In contrast, pla- correlation between birthweight and 552
497 cental weight was strongly associated fetal hyperglycemia. Glucose availability 553
498
C OMMENT with umbilical vein glucose, suggesting constitutes an important regulator of 554
499 Our study is the first to investigate that increased placental size may con- fetal growth because glucose is an im- 555
500 placental glucose transport in pregnan- tribute to fetal hyperglycemia, and portant secretagogue of fetal insulin, a 556
501 cies of nondiabetic Ow/Ob mothers. indirectly to fetal overgrowth in some critical growth hormone in intrauterine 557
502 Birthweight was positively correlated infants born to mothers with high life. Fetal hyperglycemia in overweight/ 558
with umbilical vein glucose and insulin BMI. obese mothers may therefore constitute

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559 615
560 placental membrane surface area, it is 616
FIGURE 6 plausible that women with BMI 25
561 The relationship between birth and glucose uptake 617
562 with heavier placentas also had larger 618
563 surface areas compared with placentas 619
564 of normal BMI women, allowing for 620
565 increased transport of glucose. This 621
566 increased transport of glucose over the 622
567 length of gestation would thus produce a 623
568 heavier infant and would not be detect- 624
569 able by measuring glucose transporter 625
570 activity in isolated plasma membrane 626
571 vesicles. Other possible explanations 627
572 for fetal hyperglycemia of obese mothers 628
573 in the absence of changes in placental 629
574 Birthweight does not correlate with A, MVM glucose uptake (P ¼ .70, n ¼ 23) or B, BM glucose glucose transport activity include a 630
575 uptake (P ¼ .63, n ¼ 32). decreased metabolism of glucose in 631
576 BM, basal membrane; MVM, microvillous membrane. their placentas thus allowing for more 632
577 Acosta. Maternal obesity, fetal glucose, and placental glucose transport. Am J Obstet Gynecol 2014. glucose to be available to be transported 633
578 to the fetus. Yet another possible expla- 634
579 nation is that fetuses born to women 635
580 a mechanism underlying fetal over- This possibility is consistent with recent with BMI 25 may already exhibit a 636
581 growth in these pregnancies and could reports in the literature. For example, certain degree of insulin resistance at 637
582 also contribute to increased fetal adi- Myatt and colleagues29 speculated that birth explaining their elevated fetal 638
583 posity, a well-established consequence of higher nitration of placental taurine glucose and increasing umbilical vein 639
584 maternal obesity.25 The lack of associa- transporter reduces its activity and insulin with birthweight. This hypothe- 640
585 tion between maternal fasting glucose amino acid transfer across the placenta sis is supported by a recent study of in- 641
586 levels and umbilical vein glucose con- in pregnancies with preeclampsia and sulin sensitivity in newborns of obese 642
587 centrations in our study demonstrate IUGR. Moreover, Desforges et al30 mothers.32 643
588 that increased fetal glucose availability suggested that inhibition of placental The impact on maternal obesity on 644
589 in Ow/Ob mothers has other causes in taurine transporter by phosphorylation the placenta may show ethnic differ- 645
590 addition to maternal hyperglycemia. decreases its activity and deregulates ences. For example, in a cohort of pre- 646
591 GLUT-1 is likely to be the predomi- syncytiotrophoblast cellular renewal in dominantly African-American women, 647
592 nant glucose transporter isoform medi- preeclampsia and maternal obesity. maternal obesity was reported to be as- 648
593 ating transplacental glucose transfer The impact of maternal BMI 25 on sociated with placental macrophage 649
594 in the human7 and the BM has been placental glucose transporter activity accumulation and inflammation33; 650
595 suggested to be the rate limiting step appears to be distinct from the effect of whereas, a similar study in white women 651
596 in transplacental glucose transfer.7,27,28 diabetes on placental glucose transport failed to find infiltration of immune 652
597 Our finding that BM GLUT-1 protein capacity. Specifically, BM glucose trans- cells in the placentas of obese women.34 653
598 expression positively correlated to bi- port activity and GLUT-1 expression Thus, it is possible that our findings 654
599 rthweight is consistent with this model. have been reported to be increased in in a predominantly Hispanic group of 655
600 However, BM glucose transport activity large infants born to mothers with type- women may differ from other ethnic 656
601 was not increased in nondiabetic Ow/Ob 1 diabetes.11,12 Furthermore, the protein groups. Limitations of the study include 657
602 mothers giving birth to large infants in expression of GLUT-9 is increased in using umbilical vein glucose and insulin 658
603 the current study. There may be several MVM and BM isolated from placentas as a surrogate for fetal glucose and in- 659
604 possible explanations for this apparent of women with diabetes.13 The reason sulin because this does not take into 660
discrepancy. First, it cannot be excluded for these differences remains to be account fetal metabolism. -
605 661
606 that GLUT isoforms not studied in the established but may be related to the 662
607 current report may contribute to BM more abnormal glucose metabolism in U NCITED R EFERENCE 663
608 glucose transport. We focused on GLUT- pregnant women with diabetes as 35. 664
609 1 and GLUT-9 in the present study compared with Ow/Ob women without 665
610 because these isoforms have previously diabetes. 666
ACKNOWLEDGMENTS
611 been shown to be altered in diabetic Our study confirms previous reports 667
pregnancies. Second, BM GLUT-1 that placental weight is increased in We are grateful to the patients and staff at Uni-
612 versity Hospital in San Antonio, TX, for making 668
613 transporters may be subjected to post- women with BMI 25 and that fetal collection of blood and placental tissue possible. 669
614 translational modifications in Ow/Ob glucose positively correlates to placental We are also indebted to E. Miller who was 670
women giving birth to large infants. weight.31 Although we did not measure responsible for tissue collection.

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REFERENCES transporter-like protein-9 (GLUT9): alternative born in the United States. Obstet Gynecol
672 splicing alters trafficking. J Biol Chem 2004;279: 1999;93:943-7. 728
673 1. Catalano PM. Management of obesity in 729
16229-36. 25. Dennedy MC, Avalos G, O’Reilly MW,
pregnancy. Obstet Gynecol 2007;109:419-62.
674 14. Bibee KP, Illsley NP, Moley KH. Asymmetric O’Sullivan EP, Gaffney G, Dunne F. ATLANTIC- 730
2. Boney CM, Verma A, Tucker R, Vohr BR.
675 syncytial expression of GLUT9 splice variants DIP: raised maternal body index (BMI) adversely 731
Metabolic syndrome in childhood: association
in human term placenta and alterations in dia- affects maternal and fetal outcomes in glucose-
676 with birth weight, maternal obesity, and gesta- 732
betic pregnancies. Reprod Sci 2011;18:20-7. tolerant women according to International
677 tional diabetes mellitus. Pediatrics 2005;115: 733
15. Metzger BE, Lowe LP, Dyer AR, et al. Hy- Association of Diabetes and Pregnancy Study
678 e290-6. 734
perglycemia and adverse pregnancy outcomes. Groups (IADPSG) criteria. J Clin Endocrinol
3. Prendergast CH, Parker KH, Gray R, et al.
679 Glucose production by the human placenta
N Engl J Med 2008;358:1991-2002. Metab 2012;97:E608-12. 735
680 16. Catalano PM, Ehrenberg HM. The short and 26. Stuebe AM, Landon MB, Lai Y, et al. 736
in vivo. Placenta 1999;20:591-8.
long term implications of maternal obesity on Maternal BMI, glucose tolerance, and adverse
681 4. Hauguel S, Challier JC, Cedard L, Olive G. 737
the mother and her offspring. BJOG 2006;113: pregnancy outcomes. Am J Obstet Gynecol
682 Metabolism of the human placenta perfused 738
1126-33. 2012;207:62.e1-7.
683 in vitro: glucose transfer and utilization, O2 739
17. Illsley NP, Wang ZQ, Gray A, Sellers MC, 27. Walsh JM, Mahony R, Byrne J, Foley M,
consumption, lactate and ammonia production.
684 Pediatr Res 1983;17:729-32.
Jacobs MM. Simultaneous preparation of McAuliffe FM. The association of maternal and 740
685 paired, syncytial, microvillous and basal mem- fetal glucose homeostasis with fetal adiposity 741
5. Pedersen J. Weight and length at birth of
branes from human placenta. Biochem Biophys and birthweight. Eur J Obstet Gynecol Reprod
686 infants of diabetic mothers. Acta Endocrinol 742
Acta 1990;1029:218-26. Biol 2011;159:338-41.
687 1954;16:330-42. 743
18. Bastin J, Drakesmith H, Rees M, Sargent I, 28. Vardhana PA, Illsey NP. Transepithelial
688 6. Takata K, Kasahara T, Kasahara M, Ezaki O, 744
Townsend A. Localisation of proteins of iron glucose transport and metabolism in BeWo
Hirano H. Localization of erythrocyte/HepG2-
689 type glucose transporter (GLUT1) in human
metabolism in the human placenta and liver. Br J choriocarcinoma cells. Placenta 2002;23: 745
690 Haematol 2006;134:532-43. 653-60. 746
placental villi. Cell Tissue Res 1992;267:407-12.
19. Donovan A, Brownlie A, Zhou Y, et al. Po- 29. Barta E, Drugan A. Glucose transport from
691 7. Jansson T, Wennergren M, Illsley NP. 747
sitional cloning of zebrafish ferroportin 1 iden- mother to fetus- a theoretical study. J Theor Biol
692 Glucose transporter protein expression in hu- 748
tifies a conserved vertebrate iron exporter. 2010;263:295-302.
693 man placenta throughout gestation and in in- 749
Nature 2000;403:776-81. 30. Webster RP, Roberts VH, Myatt L. Protein
trauterine growth restriction. J Clin Endocrinol
694 20. Bradley J, Leibold EA, Harris ZL, et al. In- nitration in placenta-functional significance. 750
Metab 1993;77:1554-62.
695 fluence of gestational age and fetal iron status on Placenta 2008;29:985-94. 751
8. Johnson LW, Smith CH. Glucose transport
IRP activity and iron transporter protein expres- 31. Desforges M, Ditchfield A, Hirst CR, et al.
696 across the basal plasma membrane of human 752
sion in third-trimester human placenta. Am J Reduced placental taurine transporter (TauT)
697 placental syncytiotrophoblast. Biochem Bio- 753
Physiol Regul Integr Comp Physiol 2004;287: activity in pregnancies complicated by pre-
698 phys Acta 1985;815:44-50. 754
R894-901. eclampsia and maternal obesity. Adv Exp Med
9. Day PE, Cleal JK, Lofthouse EM, Hanson MA,
699 21. Lanoix D, St-Pierre J, Lacasse AA, Viau M, Biol 2013;776:81-91. 755
Lewis RM. What factors determine placental
700 Lafond J, Vaillancourt C. Stability of reference 32. Swanson LD, Bewtra C. Increase in normal 756
glucose transfer. Placenta 2013;40:391-6.
proteins in human placenta: general protein placental weights related to increase in maternal
701 10. Schneider H, Reiber W, Sager R, Malek A. 757
stains are the benchmark. Placenta 2012;33: body mass index. J Matern Fetal Neonatal Med
702 Asymmetrical transport of glucose across the 758
151-6. 2008;21:111-3.
703 in vitro perfused human placenta. Placenta 759
22. Skovlund E, Fenstad GU. Should we always 33. Catalano PM, Presley L, Minium J, Hauguel-
2003;24:27-33.
704 11. Jansson T, Wennergren M, Powell TL.
choose a nonparametric test when comparing de Mouzon S. Fetuses of obese mothers 760
705 two apparently nonnormal distributions? J Clin develop insulin resistance in utero. Diabetes 761
Placental glucose transport and GLUT1
Epidemiol 2001;54:86-92. Care 2009;32:1076-80.
706 expression in insulin-dependent diabetes. Am 762
23. Jansson T, Ylven K, Wennergren M, 34. Challier JC, Basu S, Bintein T. Obesity in
707 J Obstet Gynecol 1999;180:163-8. 763
Powell TL. Glucose transport and system A ac- pregnancy stimulates macrophage accumula-
708 12. Gaither K, Quraishi AN, Illsley NP. Diabetes 764
tivity in syncytiotrophoblast microvillous and tion and inflammation in the placenta. Placenta
alters the expression and activity of the human
709 placental GLUT1 glucose transporter. J Clin
basal plasma membrane in intrauterine growth 2008;29:274-8. 765
710 restriction. Placenta 2002;23:392-9. 35. Roberts KA, Riley SC, Reynolds RM, et al. 766
Endocrinol Metab 1999;84:695-701.
24. Overpeck MD, Hediger ML, Zhang J, Placental structure and inflammation in preg-
711 13. Augustin R, Carayannopoulos MO, 767
Trumble AC, Klebanoff MA. Birth weight for nancies associated with obesity. Placenta
712 Dowd LO, Phay JE, Moley JF, Moley KH. Iden- 768
gestational age of Mexican American infants 2011;32:247-54.
713 tification and characterization of human glucose 769
714 770
715 771
716 772
717 773
718 774
719 775
720 776
721 777
722 778
723 779
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