Inverse relationship between gestational weight gain and glucose uptake in human placenta from female foetuses

BACKGROUND

Maternal obesity and gestational weight gain (GWG) have a significant impact on the in utero environment, and thus on foetal development and the health of the offspring later in life.

OBJECTIVE

The aim of this study was to determine the effect of maternal pre-existing obesity and maternal GWG on glucose uptake from placentas from male and female offspring.

METHODS

Total glucose uptake was measured in placental explants using radio-labelled glucose.

RESULTS

In the female placentas (n = 36), GWG and glucose uptake were significantly negatively correlated (r = -0.7, P < 0.0001; n = 36), and customized birthweight centile correlated with placental glucose uptake (r = 0.36, P = 0.03) but not GWG. In the male placentas (n = 45), GWG and glucose uptake were not related, and customized birthweight centile correlated with GWG (r = 0.34, P = 0.02; n = 45), but not placental glucose uptake.

CONCLUSIONS

The female placenta can adapt glucose uptake in the face of excessive GWG. The male placenta showed no evidence of changing glucose uptake in response to maternal GWG.

Mindfulness and burnout among competitive adolescent tennis players

Background. Burnout among adolescent athletes is a cause for concern. However, little is known about the intrapersonal factors that may be related to burnout in this population.Objectives. To explore the relationship between burnout and mindfulness among competitive adolescent tennis players.Methods. Competitive adolescent tennis players (N=104; mean age 16 years) completed measures of mindfulness and athlete burnout. Correlations were calculated with regard to mindfulness and burnout. A one-way multivariate analysis of variance (MANOVA) was conducted to determine whether athletes assigned to three levels of mindfulness (high, moderate and low) differed significantly with regard to burnout.Results. Mindfulness exhibited significant negative correlations with global burnout, emotional/physical exhaustion, reduced sense of accomplishment and sport devaluation. The results of the MANOVA indicated that individuals in the three mindfulness groups (high, moderate and low) reported significantly different levels of burnout. Post hoc analyses revealed that participants in the high mindfulness group reported a significantly lower sense of reduced accomplishment and global burnout than participants in the low mindfulness group. In addition, participants in the low mindfulness group reported significantly higher levels of global burnout than individuals in the high and moderate mindfulness groups.Conclusion. Mindfulness appears to be negatively related to athlete burnout among competitive adolescent tennis players. Furthermore, athletes reporting different levels of mindfulness exhibit differing levels of burnout. The potential protective effect of mindfulness with regard to burnout among adolescent athletes warrants further investigation.

Mindfulness and burnout among competitive adolescent tennis players

Background. Burnout among adolescent athletes is a cause for concern. However, little is known about the intrapersonal factors that may be related to burnout in this population.Objectives. To explore the relationship between burnout and mindfulness among competitive adolescent tennis players.Methods. Competitive adolescent tennis players (N=104; mean age 16 years) completed measures of mindfulness and athlete burnout. Correlations were calculated with regard to mindfulness and burnout. A one-way multivariate analysis of variance (MANOVA) was conducted to determine whether athletes assigned to three levels of mindfulness (high, moderate and low) differed significantly with regard to burnout.Results. Mindfulness exhibited significant negative correlations with global burnout, emotional/physical exhaustion, reduced sense of accomplishment and sport devaluation. The results of the MANOVA indicated that individuals in the three mindfulness groups (high, moderate and low) reported significantly different levels of burnout. Post hoc analyses revealed that participants in the high mindfulness group reported a significantly lower sense of reduced accomplishment and global burnout than participants in the low mindfulness group. In addition, participants in the low mindfulness group reported significantly higher levels of global burnout than individuals in the high and moderate mindfulness groups.Conclusion. Mindfulness appears to be negatively related to athlete burnout among competitive adolescent tennis players. Furthermore, athletes reporting different levels of mindfulness exhibit differing levels of burnout. The potential protective effect of mindfulness with regard to burnout among adolescent athletes warrants further investigation.

Peak plasma anti-Xa levels after first and third doses of enoxaparin in women receiving weight-based thromboprophylaxis following caesarean section: a prospective cohort study

BACKGROUND

Women undergoing caesarean section are at higher risk for thromboembolic complications following delivery than other parturients. The aim of this study was to determine whether higher doses of enoxaparin based on body weight are safe and more likely to achieve plasma anti-Xa levels within the accepted thromboprophylactic range.

METHODS

We undertook a prospective cohort study of 80 women undergoing caesarean section in a tertiary obstetric hospital with >6000 deliveries per year. Enoxaparin was administered after caesarean section using the Royal College of Obstetricians and Gynaecologists weight-adjusted dosing guidelines. Plasma anti-Xa levels were measured at baseline and 3-4 h after enoxaparin administration on days one and three postoperatively. The main outcomes of interest were plasma anti-Xa levels and the proportion of patients with plasma anti-Xa levels in the range of 0.2-0.4 IU/mL.

RESULTS

The proportion of women with anti-Xa levels between 0.2 and 0.4 IU/mL was 72% (95% CI 60-81%). Unadjusted mean anti-Xa levels were 0.26 ± 0.09 IU/mL and 0.28 ± 0.08 IU/mL on day one and day three respectively. No woman had levels >0.48 IU/mL.

CONCLUSION

The majority of women receiving weight-based enoxaparin thromboprophylaxis following caesarean section achieved plasma anti-Xa levels within the putative thromboprophylactic range. No woman achieved levels associated with an increased risk of bleeding (>0.8 IU/mL). These findings provide a safety basis for a large prospective study using this regimen.

Circulating RNA coding genes regulating apoptosis in maternal blood in severe early onset fetal growth restriction and pre-eclampsia

OBJECTIVE

To determine whether the intrinsic apoptosis pathway is differentially expressed in placenta and maternal blood in severe preterm fetal growth restriction (FGR) and pre-eclampsia (PE), and to examine whether circulating RNA in maternal blood may be potential biomarkers.

STUDY DESIGN

Maternal blood samples and placental biopsies were collected from women with preterm: FGR (n=20), PE without FGR (n=8) and controls (n=20). Real-time PCR examined the expression of genes in the intrinsic apoptosis pathway in FGR and PE, stratified according to the severity of placental insufficiency.

RESULT

Severe preterm FGR, with or without PE, was associated with increased expression of BCL2, BCL-XL, BIM, BAD and Survivin in both the placenta and maternal blood (1.6 to 3.3-fold, P<0.05). In preterm PE, but not FGR, there was increased placental expression of BCL-XL and BCL2 (1.6 to 2.5-fold, P<0.05), but only BCL2 was significantly increased in the maternal blood (1.8-fold, P<0.05). Increased expression of genes of the intrinsic apoptosis pathway reflected the severity of FGR as determined by deteriorations in umbilical artery Doppler velocimetry.

CONCLUSION

In severe early onset FGR there was increased expression of genes regulating intrinsic apoptosis in both the placenta and maternal blood. Circulating RNA regulating placenta apoptosis may be used to develop noninvasive novel biomarkers for FGR.

Obstructive sleep apnea and pregnancy: the effect on perinatal outcomes

Obstructive sleep apnea (OSA) is characterized by repeated episodes of upper airway obstruction, resulting in hypoxemia, hypercapnia and sleep fragmentation. Pathophysiological sequelae include sympathetic activation, increased oxidative stress and a generalized inflammatory response, culminating in endothelial dysfunction. These are the proposed mechanisms that mediate the increased risk of hypertension and cardiovascular disease among patients with OSA outside of pregnancy. It is intriguing to consider the consequences of these events on pregnancy outcomes. There is a growing literature on the impact of maternal OSA on hypertensive disorders of pregnancy, gestational diabetes and impaired fetal growth. The data, while promising, require confirmation with larger numbers to verify the findings. OSA may be an important mediator of the poor perinatal outcomes associated with maternal obesity; moreover, one which may be amenable to treatment. This review discusses OSA and summarizes the current literature linking OSA with adverse perinatal outcomes.

The PAI-1 4G/5G polymorphism is not associated with an increased risk of adverse pregnancy outcome in asymptomatic nulliparous women

BACKGROUND

Plasminogen activator inhibitor type 1 (PAI-1) is an important regulator of fibrinolysis. A common deletion polymorphism that results in a sequence of 4G instead of 5G in the promoter region of the gene is associated with a small increase in the risk of venous thromboembolism. Its potential association with adverse pregnancy events remains controversial.

OBJECTIVE

We aimed to assess the impact of the 4G PAI-1 polymorphism on pregnancy outcomes in women who had no prior history of adverse pregnancy outcomes or personal or family history of venous thromboembolism.

PATIENTS/METHODS

This study represents a secondary investigation of a prior prospective cohort study investigating the association between inherited thrombophilias and adverse pregnancy events in Australian women. Healthy nulliparous women were recruited to this study prior to 22 weeks gestation. Genotyping for the 4G/5G PAI-1 gene was performed using Taqman assays in an ABI prism 7700 Sequencer several years after the pregnancy was completed. Pregnancy outcome data were extracted from the medical record. The primary outcome was a composite comprising development of severe pre-eclampsia, fetal growth restriction, major placental abruption, stillbirth or neonatal death.

RESULTS

Pregnancy outcome data were available in 1733 women who were successfully genotyped for this polymorphism. The primary composite outcome was experienced by 139 women (8% of the cohort). Four hundred and fifty-nine women (26.5%) were homozygous for the 4G deletion polymorphism, while 890 (51.4%) were heterozygous. Neither homozygosity nor heterozygosity for the PAI-1 4G polymorphism was associated with the primary composite outcome (homozygous OR = 1.30, 95% CI = 0.81-2.09, P = 0.28, heterozygous OR = 0.84, 95% CI = 0.53-1.31, P = 0.44) or with the individual pregnancy complications.

CONCLUSION

The PAI-1 4G polymorphism is not associated with an increase in the risk of serious adverse pregnancy events in asymptomatic nulliparous women.

Pregnancy in a woman with proportionate (primordial) dwarfism: a case report and literature review

Primordial dwarfism is a rare form of severe proportionate dwarfism which poses significant challenges in pregnancy. A 27-year-old with primordial dwarfism (height 97 cm, weight 22 kg) and coexisting morbidities of familial hypercholesterolaemia and hypertension presented to our unit. Early pregnancy was complicated by difficult blood pressure control, sinus tachycardia, biochemical hyperthyroidism and insulin-requiring gestational diabetes. Delivery was indicated at 24 weeks with uncontrollable hypertension, progressive renal impairment and intrauterine growth restriction. A caesarean section was performed under general anaesthesia, resulting in the delivery of a 486 g male infant. This case highlights the difficulties of managing pregnancy in a woman with primordial dwarfism. Her limited capacity to respond to the physiological demands of pregnancy created a life-threatening situation, culminating in profound preterm birth.

Early development of New Zealand hapuku Polyprion oxygeneios eggs and larvae

This study describes for the first time the normal development of New Zealand hapuku Polyprion oxygeneios embryos and larvae reared from fertilization to 11 days post-hatch (dph) at a constant temperature. Fertilized eggs were obtained from natural spawnings from communally reared captive wild broodstock. Eggs averaged 2 mm in diameter and had single or multiple oil globules. Embryos developed following the main fish embryological stages and required an average of 1859·50 degree hours post-fertilization (dhpf) to hatch. The newly hatched larvae (4·86 mm mean total length, L(T) ) were undifferentiated, with unpigmented eyes, a single and simple alimentary tube and a finfold that covered the entire body. Larvae relied on the energy from the yolk-sac reserves until 11 dph (7·33 mm mean L(T) ), when yolk-sac reabsorption was almost completed. Some of the major developmental stages from hatching to yolk-sac reabsorption were eye pigmentation (5 dph), upper jaw formation (7 dph), lower jaw formation (8 dph) and mouth opening (8-9 dph). By 9 dph, the digestive system consisted of pancreas, liver, primordial stomach, anterior and posterior gut; therefore, P. oxygeneios larvae would be capable of feeding on live prey. The developmental, morphological and histological data described constitutes essential baseline information on P. oxygeneios biology and normal development.

Preventing behaviour problems through a universal intervention in Jamaican basic schools: a pilot study

OBJECTIVE

To evaluate the effect of a preventative intervention in Jamaican basic schools on child behaviour and parent-teacher contacts.

DESIGN AND METHODS

Five basic schools in Kingston, Jamaica, were randomly assigned to an intervention (n = 3) or control (n = 2) condition. Intervention involved seven whole-day teacher workshops using the Incredible Years Teacher Training Programme supplemented by fourteen lessons on social and emotional skills in each class. Within each classroom (n = 27), children were screened for behaviour difficulties through teacher report and children with the greatest difficulties were selected for evaluation of outcomes (135 children). Teachers'reports of child behaviour using the Strengths and Difficulties Questionnaire and of the quality of teacher-parent contacts were collected at the beginning and end of the school year Multilevel regression analyses controlling for school and classroom were used to evaluate the effects of intervention on child behaviour.

RESULTS

Significant benefits of intervention were found for children's conduct problems (regression coefficient (b) = -0.62, 95% confidence interval (CI): -0.01, -1.23), hyperactivity (b = -0.84, 95% CI: -1.57, -0.11) and peer problems (b = -1.24, 95% CI: -1.89, -0.59). The effect sizes were 0.26 for conduct problems, 0.36 for hyperactivity and 0.71 for peer problems. No significant benefits were found for the prosocial and emotional problems subscales. The intervention also resulted in increases in the number of positive teacher-parent contacts (p < 0.0001). No benefits were found for the number of negative teacher-parent contacts.

CONCLUSION

This is a promising approach for reducing children's externalizing behaviour and peer problems and for improving the quality of teachers' contacts with parents of children with behaviour problems.

The management of epilepsy in pregnancy

While most women with epilepsy can expect a normal pregnancy outcome, epilepsy remains a significant contributor to both maternal and perinatal morbidity. Pre-pregnancy planning must address reliable contraception and optimisation of antiepileptic drug (AED) regimens to minimise teratogenic risk while maintaining seizure control. The most recent data from the AED registries regarding malformations is presented in this review, as is the limited data on the newer AEDs and studies linking neurocognitive outcomes to AED exposure. During pregnancy, important considerations include; therapeutic drug monitoring, surveillance for obstetric complications and vigilance for seizures during the intrapartum and postpartum period.

Quality of life in Caribbean youth with diabetes

BACKGROUND

As the prevalence of youth onset diabetes in Jamaica increases, the impact of this disease on Health Related Quality of life (QOL) needs to be evaluated.

METHODS

Patients from two major referral hospitals had QOL assessed using a modified diabetes-39 questionnaire administered by a trained interviewer. Subscale scores were transformed to standard scale scores ranging from 0 (lowest impact) to 100 (highest impact) and the impact of socio-demographic factors, treatment and medical history on QOL examined.

RESULTS

Fifty-seven participants (21M, 36F, mean age 19.0 +/- 5.1 years, diabetes duration 2.7 +/- 2.2 years, 96% black) had QOL assessed. Anxiety and worry had the greatest impact (median score = 41) and sexual functioning, the lowest impact (median Score = 0) on QOL. Older age, later age of onset, longer diabetes duration, better glucose control and not using insulin were associated with a higher anxiety and worry score. Multiple regression analysis was conducted to determine which of these were associated with the anxiety and worry score after controlling for age. Anxiety and worry increased with age (regression coefficient (SE); 2.05[0.68]) and was higher in those on oral agents compared to those using insulin (-27.9 [10.9]).

CONCLUSION

Measures to address anxiety and worry in Jamaican youth with diabetes need to be implemented to minimize the impact the disease may have on their QOL.

The association between early childhood stunting and weight status in late adolescence

BACKGROUND

Cross-sectional studies have shown associations between stunting and overweight; however, there are few prospective studies of stunted children.

OBJECTIVES

To determine whether stunting before age 2 years is associated with overweight and central adiposity at 17-18 years and whether growth in height among stunted children predicts body mass index (BMI) in late adolescence.

DESIGN

Prospective cohort study.

PARTICIPANTS

One-hundred and three participants stunted by age 2 years and 64 non-stunted participants (78% of participants enrolled in childhood). Participants were measured in early childhood and at ages 7, 11 and 17 years.

RESULTS

Stunted subjects remained shorter and had lower BMIs, smaller skinfolds and circumferences than non-stunted subjects. Overweight (BMI >/=25 m(2)) was not significantly different among stunted and non-stunted male subjects (5.2 and 12.5%) but non-stunted female subjects were more likely to be overweight than those who experienced early childhood stunting (11.1 and 34.4%, P=0.013). Centralization of fat (waist to hip ratio (WHR), subscapular/triceps skinfold ratio (SSF/TSF)) did not differ between stunted and non-stunted groups (mean WHR 0.77 and mean SSF/TSF 1.18 in both groups). Stunted subjects with greater increases in height-for-age for the intervals 3-7 and 7-11 years had higher BMI at age 17 years (P=0.04 and P=0.001, respectively).

CONCLUSION

Participants stunted by age 2 years were less likely to be overweight than those who were never stunted. This suggests that cross-sectional studies of the association between stunting and overweight may be misleading. Among stunted children, greater linear growth during mid- to late childhood was associated with greater BMI at age 17 years.

Factors affecting umbilical venous perfusion during experimental cord knotting

The aim was to determine experimentally the factors that increase the risk of venous occlusion by applying a standardised tightening force to isolated perfused umbilical cords tied in a true knot in vitro. Umbilical cords were collected from patients undergoing Caesarean section. Cords were clamped, isolated and studied within 15 min. The umbilical vein was cannulated, the cord tied in a true knot and traction was applied using standard weights. The umbilical vein was perfused with modified Krebs solution at a constant pressure of 40 mmHg and the attached weight increased until perfusion ceased. The cord mass index (weight/length), hydration index/100-[(dry weight/wet weight)x100], and coiling index (coils/length) were determined. Cord morphometric analysis was performed on 193 cords. Intra uterine growth restriction was associated with decreased cord mass index (p=0.002) and increased coiling index (p=0.002). Venous perfusion experiments were performed on 75 cords. Using multivariate regression analysis, cord morphometric factors that increased the risk of cord occlusion were decreased cord mass index (p=0.008), decreased cord hydration index (p=0.004), and low venous flow capacity (p=0.001). During experimental cord knotting with applied traction, the susceptibility to venous occlusion was increased with low cord mass index, low cord hydration index and low venous flow capacity. These cord characteristics were associated with low fetal body weight and intrauterine growth restriction. An increased susceptibility to cord occlusion may contribute to the higher perinatal morbidity and mortality in growth restricted pregnancies.

Factors associated with size and proportionality at birth in term Jamaican infants

The objective of this study was to identify the factors associated with size and proportionality at birth in a cohort of term infants established to investigate their growth and development. One hundred and forty term low-birth-weight (birth-weight < 2,500 g) infants and 94 normal birth-weight infants (2,500- < 4,000 g) were recruited within 48 hours of birth at the main maternity hospital, Kingston, Jamaica. Birth anthropometry and gestational age were measured, and maternal information was obtained by interview and from hospital records. Controlling for gestational age, variables independently associated with birth-weight were rate of weight gain in the second half of pregnancy, maternal height, haemoglobin level < 9.5 microg/dL, time of first attendance in antenatal clinic, birth order, pre-eclampsia, and consumption of alcohol, with 33% of the variance in birth-weight explained. Birth length was associated only with maternal height and age, while measures of proportionality (ponderal index and head/length ratio) were associated with characteristics of the environment in late pregnancy, including rate of weight gain, weight in late pregnancy, and pre-eclampsia. The variation in maternal characteristics associated with size or proportionality at birth may reflect the times during gestation when different aspects of growth are most affected.

Obesity in a cohort of black Jamaican children as estimated by BMI and other indices of adiposity

OBJECTIVE

To examine the relationships of body mass index (BMI) to obesity indices derived from anthropometry and to determine tracking of overweight between late childhood and early adolescence, in a cohort of children with mixed nutritional history. We also compared identification of overweight children using The International Obesity Task Force (IOTF) BMI cut-off points with skinfolds.

DESIGN

Prospective study.

SETTING

Kingston, Jamaica.

SUBJECTS

A total of 306 children examined at 7-8 y and at 11-12 y.

MEASUREMENTS

Triceps (TSF) and subscapular skinfolds (SSF), height and weight were measured. The sum of the skinfolds (sum SF), BMI, percentage body fat (%fat) and fat mass (FM) were calculated. Pubertal stage was assessed at 11-12 y.

RESULTS

Overweight increased from 3.5 to 9.5% over the follow-up period. BMI was better correlated with the other indices of adiposity in girls and in the older age group. BMI tracking over follow up was high. In regression analysis BMI explained 52 and 61% of the variance in FM in boys and girls at 7-8 y. This increased to 69% in both sexes at 11-12 y. Using the IOTF cut-off points BMI had low sensitivity to identify children >85th percentile of the NHANES references for SSF. The sensitivity for those assessed by TSF and sum SF was higher, but between 14 and 30% of the children were misclassified. The specificity of BMI was high.

CONCLUSIONS

Adiposity increased over follow-up. Although the cohort remained relatively lean BMI rank among the fattest children was maintained. Girls were fatter than boys, reflecting adult obesity patterns. Children identified as overweight by the IOTF BMI cut-off points are likely to have high body fatness. However the BMI cut-off points may not identify many children with high body fatness.

Fasting levels of serum glucose, cholesterol and triglyceride at age eleven to twelve years in stunted and non-stunted Jamaican children

AIM

To determine whether fasting serum concentrations of glucose, cholesterol and triglyceride at age 11-12 y (a) differed between children stunted in early childhood and those who were never stunted, (b) were related to birthweight or current anthropometry and (c) were related to stunting after controlling for current size.

METHODS

Anthropometry, serum glucose and lipid concentrations were measured in 112 children stunted in early childhood and 181 non-stunted children.

RESULTS

Children who were stunted in infancy remained shorter, weighed less and were significantly less fat than non-stunted children but had a more central distribution of fat. They were also less likely to have entered puberty. Non-stunted children had higher fasting serum triglyceride concentrations than stunted children (p < 0.05). There were no significant correlations between birthweight and fasting glucose or any measure of serum lipids. The percentage of variance in biochemical measures explained by anthropometry was low: between 2.1 for HDL cholesterol and 14.6 for triglyceride. Nutritional status in early childhood (stunted or non-stunted) made no additional contribution to the variance.

CONCLUSIONS

Linear growth retardation in early childhood was not independently related to fasting serum concentrations of glucose, cholesterol and triglyceride at age 11-12 y. However, despite being thinner, stunted children had a more central distribution of fat.

Early childhood stunting and later behaviour and school achievement

BACKGROUND

Stunting in early childhood is common in developing countries and is associated with poorer cognition and school achievement in later childhood. The effect of stunting on children's behaviours is not as well established and is examined here.

METHOD

Children who were stunted at age 9 to 24 months and had taken part in a 2-year intervention programme of psychosocial stimulation with or without nutritional supplementation were reexamined at age 11-12 years and compared with non-stunted children from the same neighbourhoods. Their school and home behaviours were assessed using the Rutter Teacher and Parent Scales and school achievement was measured using the Wide Range Achievement Test (WRAT) and the Suffolk Reading Scales.

RESULTS

No significant intervention effects were found among the stunted groups. Thus data from the four intervention groups were aggregated for subsequent analyses, comparing all 116 stunted children with 80 non-stunted children. Controlling for social background variables, the stunted group had more conduct difficulties (p < .05) as rated by their parents. They also had significantly lower scores in arithmetic, spelling, word reading and reading comprehension than the non-stunted children (all p < .001). Conduct difficulties and hyperactivity were related to poorer school achievement. Controlling for the children's IQ, the stunted children's arithmetic scores remained significantly lower than those of the non-stunted children, but reading and spelling scores were not different.

CONCLUSIONS

Previously stunted children had more conduct difficulties at home, regardless of their social background, than non-stunted children. Their educational attainment was also poorer than non-stunted children and these results are suggestive of a specific arithmetic difficulty. Children with behaviour problems performed less well at school.

Mid-trimester fetal subdural hemorrhage: prenatal diagnosis

A routine antenatal ultrasound examination at 20 weeks' gestation revealed a space-occupying lesion in the fetal right cerebral hemisphere. The borders of the mass were indistinct and there was no midline shift. A small collection of echogenic bowel was identified at the right iliac fossa. In an attempt to explain both findings a provisional diagnosis of a fetal blood dyscrasia was made. Fetal cranial magnetic resonance imaging 24 h later confirmed the diagnosis of a subdural hemorrhage. Subsequent fetal blood sampling confirmed severe fetal thrombocytopenia. To our knowledge this is the first report of the antenatal diagnosis of spontaneous mid-trimester fetal subdural hemorrhage.