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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 233-238

Serum insulin and C-peptide levels as markers of pre-eclampsia in pregnant women


Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission16-Jun-2014
Date of Acceptance20-Aug-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Youmna M Murad
Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.156000

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  Abstract 

Objectives
This study aimed to detect the relation between fasting C-peptide level and serum insulin level in pre-eclamptic pregnant women.
Background
Pre-eclampsia is a systemic disease that is characterized by increased vascular resistance, endothelial dysfunction, proteinuria, coagulopathy, and hypertension. Similarities in certain biochemical variables between pre-eclampsia and the insulin resistance syndrome imply a possible link between insulin resistance and pre-eclampsia.
Patients and methods
A total of 60 pregnant women were included in this study after the approval of the ethical committee of the Alexandria University (where the study was conducted in); then, they were divided into two groups: 30 normal pregnant women as controls and another 30 pregnant women with the complication of pre-eclampsia served the study group. This group was subdivided into 10 patients with severe pre-eclampsia and another 20 with mild pre-eclampsia. All the patients were subjected to the oral glucose tolerance test (OGTT), assessment of fasting serum insulin and fasting C-peptide, and urine for dipstick.
Results
A statistically significant difference was found between the two groups in the mean arterial blood pressure, systolic blood pressure, and diastolic blood pressure. There was a statistically significant difference between the two groups in BMI as increased BMI was associated with pre-eclampsia. There were statistically significant differences between the two groups in serum C-peptide, serum insulin, and protein in urine.
Conclusion
Serum C-peptide and serum insulin levels were significantly lower in women with severe pre-eclampsia than in women with mild pre-eclampsia and normotensive pregnant women, with weak associations to pre-eclampsia. BMI was significantly higher in women with severe and mild pre-eclampsia than in normotensive pregnant women, with strong associations to pre-eclampsia.

Keywords: BMI, C-peptide, insulin resistance, pre-eclampsia


How to cite this article:
El Sayed MA, Abdel Gayed AM, El Shalakany AH, Murad YM. Serum insulin and C-peptide levels as markers of pre-eclampsia in pregnant women. Menoufia Med J 2015;28:233-8

How to cite this URL:
El Sayed MA, Abdel Gayed AM, El Shalakany AH, Murad YM. Serum insulin and C-peptide levels as markers of pre-eclampsia in pregnant women. Menoufia Med J [serial online] 2015 [cited 2019 Sep 21];28:233-8. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/233/156000


  Introduction Top


Pre-eclampsia is a complication that develops in 2-8% of pregnancies worldwide and is associated with an increased risk of adverse outcomes for the mother and the baby [1]. Although gross pathologic changes are not always seen in the placentas of women with pre-eclampsia, placental profiles including abnormal uterine artery Doppler and placental morphology have been used to identify high-risk women who go on to develop the syndrome [2]. It is a potentially dangerous complication in the second half of pregnancy, labor, or early period after delivery. Currently, there is no effective therapy for pre-eclampsia, although it largely resolves after placenta and fetus delivery [3]. Pre-eclampsia is one of the most common reasons for induced preterm delivery [4]. Insulin resistance plays a major role in type II diabetes mellitus and in the pathogenesis of hypertension, dyslipidemias, and coronary artery disease. Almost all obese women with hypertension have an elevated insulin level [5]; the highest levels occur in obese women with excessive abdominal adipose tissue [6]. Insulin resistance is a hallmark of obesity, and in pregnant women, obesity is a consistent risk factor for pre-eclampsia.

It has been proposed that insulin resistance may be the common denominator for such metabolic changes [7]. Other similarities between insulin resistance syndrome and pre-eclampsia are endothelial dysfunction, thrombogenicity with abnormalities in platelet function and clotting factors, and reduced fibrinolytic activity [8]. Because of changes in lipids, lipoprotein, and other metabolic processes, such as hyperinsulinemia and hyperuricemia, found in pre-eclampsia resemble the main features of the insulin resistance syndrome.

Obesity is a major epidemic in developed countries that is now also prevalent in developing countries [9]. Obesity increases the risk of all 'forms' of pre-eclampsia. Thus, the risk of severe and mild pre-eclampsia [10] and pre-eclampsia occurring in early and late gestation [11] are greater in obese and overweight women.


  Patients and methods Top


This study was carried out on 60 pregnant women attending the El-Gomhoria Hospital Alexandria after the approval of the ethical committee was obtained.

This study was carried out between 2010 and 2013. The patients selected were subdivided into two groups:

Group I (control group): It included 30 women with normal pregnancies.

Group II (pre-eclamptic patients): It included 30 pre-eclamptic pregnant women who were classified into two subgroups:

Group A (mild pre-eclampsia): It included 20 women fulfilling the following criteria:

  1. Blood pressure 140/90 mmHg<160/110 mmHg.
  2. Proteinuria 1+ dipstick.


Group B (severe pre-eclampsia): It included 10 women fulfilling the following criteria:

  1. Blood pressure 160/110 mmHg.
  2. Proteinuria 3+ by dipstick.


Exclusion criteria

  1. Patients with a history of hypertension, diabetes mellitus, liver disease, or renal disease.
  2. Patients with a history of vascular or blood disease.
  3. Patients receiving any anticoagulants or other drugs affecting vessel epithelium.
  4. Patients receiving corticosteroids and aspirin.


A 5 ml fasting venous blood sample was obtained from all patients before performing the oral glucose tolerance test (OGTT). Venous blood samples were collected in a clean dry plastic test tube and allowed to clot for 1 h and then centrifuged at 3500 rpm for 10 min to separate serum. Hemolyzed serum samples were discarded. Serum glucose and uric acid were estimated using the colorimetric methods [12,13]. Meanwhile, two samples of 0.5 ml each of serum were stored in two Eppendorf tubes at −20°C for the estimation of insulin and C-peptide.

Oral glucose tolerance test

OGTT were performed by administration of 75 g sugar after l0 h of fasting; the load of anhydrous glucose in 300 ml of water was ingested within 5 min. The glucose concentration in venous whole blood was measured at 0, 0.5, 1, 1.5, and 2 h. The glucose concentration was measured using the colorimetric method (BioMerieux vitek Inc.) [13].

Measurement of serum insulin

Serum insulin was measured at 0, 0.5, 1, 1.5, and 2 h during the OGTT and stored at −20°C until analyzed. This was done using radioimmunoassay (RIA) on the basis of a double-antibody solid-phase technique [1NS1-CTK IRMA (P001739); DiaSorin].

Measurement of scrum C-peptide

Fasting serum samples for C-peptide were stored at −20°C until analyzed. This was done using the enzyme-linked immunosorbent assay technique (DSL code 10-7000).

Statistical analysis

The following statistical measures were used:

  1. Descriptive measures included arithmetic mean, SD, minimum, and maximum.
  2. Statistical tests include: one-way analysis of variance (F) was used for quantitative variables.
  3. Statistical tests to measure the insulin sensitivity (SI) were used.


SI = MCR/logMSI = M/MBG/logMSImg.mmol.1 -1 .mU -1 .min,

where SI is the insulin sensitivity, MCR the metabolic clearance rate, MSI the mean serum insulin, M the metabolized glucose (mg/min), MBG the mean blood glucose.

The level of significance selected for this study was P value less than 0.05.


  Results Top


Our results indicated that the BMI among the different groups studied was 28.934 ± 1.807, 36.026 ± 6.198, and 33.378 ± 7.174 kg/m 2 in normotensive pregnant women, women with mild pre-eclampsia, and women with severe pre-eclampsia, respectively, as shown in [Table 1]. There were no significant differences in the demographic characteristics between the study group and the control group. Fasting blood sugar was 99.20 ± 9.886 mg/dl in women with severe pre-eclampsia, 96.70 ± 9.809 mg/dl in women with mild pre-eclampsia, and 99.73 ± 7.652 mg/dl in normotensive pregnant women; then, 1 h after the administration of 75 g glucose, blood sugar values were 132.4 ± 13.15 mg/dl in women with severe pre-eclampsia, 125.1 ± 18.73 mg/dl in women with mild pre-eclampsia, and 119.67 ± 13.36 mg/dl in the control group. Finally, 2 h after the administration of 75 g glucose, the blood sugar values were 95 ± 3.52 mg/dl in women with severe pre-eclampsia, 98.2 ± 9.5 mg/dl in women with mild pre-eclampsia, and 98.67 ± 14.37 mg/dl in the controls as shown in [Table 2]. The serum insulin levels among the different groups studied were 10.84 ± 1.86, 9.3 ± 0.07, and 8.76 ± 0.038 mIU/ml in normotensive pregnant women versus the groups with mild and severe pre-eclampsia, with a statistically significant difference between the mild pre-eclampsia and the severe pre-eclampsia groups as shown in [Table 3]. The serum C-peptide levels in our study among the different groups studied were 2.35 ± 0.34, 2.68 ± 0.36, and 2.39 ± 0.13 ng/ml; a low statistically significant difference was found in normotensive pregnant women, women with mild pre-eclampsia, and women with severe pre-eclampsia women, respectively, as shown in [Table 3].
Table 1: Comparison of BMI between the two groups studied and the control group

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Table 2: Oral glucose tolerance test comparison between the two groups studied and the control group

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Table 3: Comparison of fasting serum insulin and C-peptide between the two groups studied and the control group

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  Discussion Top


Pre-eclampsia complicates 2-8% of pregnancies worldwide and is associated with an increased risk of adverse outcomes for the mother and the baby [1]. The simultaneous evidence of immunological alterations [14,15], increased inflammatory activation [4], metabolic alterations with insulin resistance [16], and circulating angiogenic factors [17] may play a pathogenic role in this disorder, although none of these can explain this disorder completely.

Pre-eclampsia is a potentially dangerous complication in the second half of pregnancy, labor, or early period after delivery. Currently, there is no effective therapy for pre-eclampsia, although it largely resolves after placenta and fetus delivery [3]. Pre-eclampsia is one of the most common reasons for induced preterm delivery [4].

Almost all obese women with hypertension have an elevated insulin level [5]. The highest levels occur in obese women with excessive abdominal adipose tissue [6]. Insulin resistance is a hallmark of obesity, and in pregnant women, obesity is a consistent risk factor for pre-eclampsia. Obesity increases the risk of all forms of pre-eclampsia. Thus, the risks of severe and mild pre-eclampsia [10] are higher in obese and overweight women. Many studies have shown the relation between insulin resistance and pre-eclampsia [16,18], whereas other studies have shown the relation between insulin resistance and pre-eclampsia, but with no statistical significance [19]. In contrast, several other studies have not shown an association between insulin resistance and pre-eclampsia [20,21]. Several authors, therefore, have reached the conclusion that the relation between insulin resistance and pre-eclampsia is unclear and ambiguous, and more studies on a wide scale are needed [22]. Our primary objective was to determine associations of glucose, BMI, serum insulin, and C-peptide with the risk of pre-eclampsia. The current research focused on the associations of maternal BMI, C-peptide, and serum insulin with pre-eclampsia, in addition to the associations of maternal glucose level with pre-eclampsia.

The BMI among the different groups studied (in our study) was 28.934 ± 1.807, 36.026 ± 6.198, and 33.378 ± 7.174 kg/m 2 in normotensive pregnant women, women with mild pre-eclampsia, and women with severe pre-eclampsia, respectively, with a statistically significant difference between them. Also, there was a highly statistically significant difference between the group of women with mild pre-eclampsia and the control group; again, a statistically significant difference was found between the group of women with mild pre-eclampsia and the group of women with severe pre-eclampsia.

Our results are in agreement with the results of a study published by HAPO Study Cooperative Research Group [23]. This study was carried out as an international multicenter study and included 1116 pre-eclamptic women and 20 248 normotensive pregnant women as controls between 34 and 37 weeks' gestational age; the frequency of pre-eclampsia increases from 2.1% in the lowest BMI category (≤23.2 kg/m 2 ) to 30.4% in the highest category (>44.0 kg/m 2 ) and was significantly low in the control group: 27.4 ± 4.9 kg/m 2 .

Several other authors such as Ros et al. [24] found a strong relation between BMI and the occurrence of pre-eclampsia. Also, Goldman et al. [19] reported the relation between maternal overweight and pre-eclampsia, but they suggested that it is not only related to obesity alone, and additional studies in large groups are needed. Catov et al. [11] found that women with high BMI are over-represented in cases of both mild and severe pre-eclampsia or early onset of pre-eclampsia. Finally, Bodnar et al. [10] similarly, support a clear relationship between prepregnancy BMI and the risk of mild and severe pre-eclampsia, which increases in both white and black women.

However, our results are not in agreement with the study of Sinha et al. [25] that was carried out in India between 2011 and 2012 and included 14 pre-eclamptic women and 14 controls in the third trimester. An insignificant difference was found between the pre-eclamptic patients (24.3 ± 2.6 kg/m 2 ) and the control group (25.4 ± 3.2 kg/m 2 ). Valensise et al. [26], in their work, reported no significant difference between the pre-eclamptic women (23.4 ± 6.1 kg/m 2 ) and the control group (22.1 ± 5.9 kg/m 2 ). Also, Emery et al. [27] found no relation between BMI and pre-eclampsia. Kun [20], in their published data in 2011, suggested no relation between the degree of obesity and its contribution toward the risk of development of pre-eclampsia.

A serum sample for fasting C-peptide was collected at the OGTT visit. Hemolysis is known to increase insulin degradation, but not to affect C-peptide, and also because C-peptide and insulin are secreted in equimolar amounts, we measured C-peptide and serum insulin levels in parallel. Fasting indices of C-peptide provide an acceptable measure of insulin sensitivity in pregnancy. Levels of fasting serum insulin or C-peptide or derived variables that also include fasting glucose concentration are commonly used as an index of insulin sensitivity. We used fasting serum C-peptide as an index so that we could examine the association between fasting C-peptide and glucose separately.

In the present study, it was found that the OGTT levels among the different groups studied in a fasting state, 1 h after ingestion of 75 g glucose, and after 2 h in normotensive pregnant women, women with mild pre-eclampsia, and women with severe pre-eclampsia showed a statistically insignificant difference. These results are in agreement with the study of Valensise et al. [26], which was carried out in Tor-Vergata University, Rome, Italy, between January 2000 and January 2001 and included 35 pre-eclamptic patients and 146 normotensive pregnant women as controls in the third trimester. OGTT was determined in all patients using the glucose oxidase method with an immune assay kit after 10-12 h of fasting; there were no significant differences in the demographic characteristics between the study group and the control group. Fasting blood sugar was 67.7 ± 6.3 mg/dl in women with pre-eclampsia and 68.3 ± 5.2 mg/dl in normotensive pregnant women; then, 1 h after ingestion of 75 g glucose, the blood sugar was 117.4 ± 6.2 mg/dl in pre-eclamptic women and 116.3 ± 5.3 mg/dl in the controls. Finally, 2 h after ingestion of 75 g glucose, the blood sugar was 100.2 ± 7.2 mg/dl in the pre-eclamptic women and 99.4 ± 6.2 mg/dl in the controls.

Also, our results were in agreement with those of the study of Montoro et al. [18], which was carried out in the University of Southern California on 29 pre-eclamptic patients and 150 normotensive pregnant women as a control group in the early third trimester (28-34 gestational weeks). All women were ethically Latin; there were no significant differences in the demographic characteristics between the study and the control group. OGTT was carried out using a glucose oxidase analyzer. Fasting blood sugar was 103.9 ± 10.6 mg/dl in women with pre-eclampsia and 101.8 ± 18.5 mg/dl in the controls; 1 h after the ingestion of 50 g glucose, blood sugar was 165.4 ± 37.7 mg/dl for pre-eclamptic patients and 170.1 ± 35.3 mg/dl for the controls they did not proceed for 2 h postprandial.

In other studies, Malek-Khosravi and colleagues [28,29] found that the fasting and postloading OGTT glucose values were similar in normotensive and pre-eclamptic women.

Again, review of the important international multicenter study carried out by HAPO Study Cooperative Research Group [23] indicated disagreement with our current findings; OGTT was performed and because of the large number of patient included, the results were reported as percentage. In fasting blood sugar, the frequency of pre-eclampsia was 3.1% in the lowest fasting blood sugar category (<75 mg/dl) and increased to 17.6% in the highest category (≥100 mg/dl); the value was 80.7 ± 6.8 mg/dl in the controls. Then, 1 h after ingestion of 75 g glucose, the frequency of pre-eclampsia was 3.3% in the lowest 1 h category (≤105 mg/dl) and increased to 7.7% in the highest 1 h category (≥212 mg/dl); the value in the controls was 133.4 ± 30.8 mg/dl. At 2 h after ingestion of 75 g glucose, the frequency of pre-eclampsia was 3.6% in the lowest 1 h category (ͳ90 mg/dl) and increased to 8.8% in the highest 2 h category (≥178 mg/dl), and it was 110.5 ± 23.4 mg/dl in the control group. This disagreement may be because of the large number of patients compared with our limited numbers, differences in ethnicity, more advanced laboratories, and the large number of researchers in multi-international centers.

In the current study, the serum insulin levels among the different groups studied were 10.84 ± 1.86, 9.3 ± 0.07, and 8.76 ± 0.038 mIU/ml in normotensive pregnant women versus women with mild and severe pre-eclampsia, with a statistically significant difference between mild pre-eclampsia and severe pre-eclampsia groups. These findings are in agreement with the study of Sinha et al. [25] which was carried out in India between 2011 and 2012 and included 14 pre-eclamptic women and 14 controls in the third trimester; there was no significant difference in the demographic characteristics between the study and the control groups. Fasting serum insulin was 9.5 ± 4.1 mIU/ml in pre-eclamptic patients and 15.2 ± 5.9 mIU/ml in the controls. Also, Valensise et al. [26] found no statistically significant difference between pre-eclamptic patients (12.5 ± 5.6 mIU/ml) and the control group (10.3 ± 3.2 mIU/ml).

However, our results are not in agreement with the result of Kaaja et al. [7] This study included 22 pre-eclamptic women and 16 normotensive pregnant women without complications at 29-39 weeks' gestational age; all were nulliparous after 8 h of fasting. The serum insulin level was 7.4 ± 0.6 mIU/ml in pre-eclamptic patients and 6.1 ± 0.06 mIU/ml in the controls. The results showed a slight significant difference between the pre-eclamptic and the control groups; this disagreement may have been because of different ethnicities and because all patients were nulliparous.

Also, our results not in agreement with the study of Montoro et al. [18], which was carried out on 150 normotensive pregnant women and 29 pre-eclamptic patients. The serum insulin was measured by RIA and showed a statistically insignificant difference between the pre-eclamptic patients (29.6 ± 26.1 mIU/ml) and the controls (23.4 ± 9.06 mIU/ml). A study of Teimoori et al. [21] was carried out in Iran in 2007 on 26 normotensive pregnant women and 26 patients with a complication of severe pre-eclampsia in younger age women (15-25 years); all were primigravida at gestational age 37 weeks. The serum insulin was measured by enzyme-linked immunosorbent assay and showed a statistically insignificant difference between the pre-eclamptic patients (3.13 ± 6.63 mIU/ml) and the control group (3.42 ± 3.27 mIU/ml); this disagreement may have also resulted from different ethnicities, the fact that all patients included in their study were nulliparous, and the much younger age group.

Review of the work of other published reports by authors such as Malek-Khosravi et al. [28] found the insulin level in the pre-eclamptic group to be higher than that in the control group (10 ± 1.5 vs. 5.8 ± 1.4 mIU/ml). Moran et al. [29] also found a higher level of fasting serum insulin in women with pre-eclampsia compared with the control group.

Finally and, in contrast, a report by Roberts et al. [30] found a lower level of fasting serum insulin in women with pre-eclampsia compared with healthy pregnant women; no explanations were provided for these results.

The serum C-peptide levels in our study among the different groups studied were 2.35 ± 0.34, 2.68 ± 0.36, and 2.39 ± 0.13 ng/ml, and showed a slight statistically significant difference in normotensive pregnant women, women with mild pre-eclampsia, and women with severe pre-eclampsia, respectively.

Our results were in agreement with those of the study of HAPO Study Cooperative Research Group [23] (a multicenter study) in which the C-peptide was determined at the OGTT visit; the measurements were performed on an Autodelfia instrument. The level of serum C-peptide in normotensive women was 1.9 ± 0.8 mg/l; in the pre-eclamptic group, the frequency of increase of pre-eclampsia ranged from 1.7% in the lowest category (≤1.2 mg/l) of C-peptide level to 16.9% in the highest category (≤4.8 mg/l).

However, our results were not in agreement with the study of Valensise et al. [26]. This study was carried out in Tor-Vergata University, Rome, Italy, between January 2000 and January 2001 and included 35 pre-eclamptic patients and 146 normotensive pregnant women as a control group at the beginning of the third trimester of gestation; after 10-12 h of fasting, serum C-peptide was measured by RIA. The level of C-peptide in the pre-eclamptic group (2.3 ± 0.8 ng/dl) was similar to the level in the controls (2.2 ± 1.1 ng/dl); this disagreement with our results may be because the patients fasted for 10-12 h, were of different ethnicities, and all patients were in the early third trimester. In the study of Montoro et al. [18], the level of C-peptide in the pre-eclamptic group (2.37 ± 0.65 ng/ml) was similar to that of the control group (2.26 ± 0.50 ng/ml); this disagreement could be because of the use a different ethnic group (Latin patients).


  Conclusion Top


(1) Serum C-peptide and serum insulin levels were significantly lower in pregnant women with severe pre-eclampsia than those in pregnant women with mild pre-eclampsia and normotensive pregnant women with weak associations to pre-eclampsia.

(2) BMI was significantly higher in women with severe and mild pre-eclampsia than in normotensive pregnant women with strong associations to pre-eclampsia.


  Acknowledgements Top


Conflicts of interest

None declared.

 
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