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Khalilipalandi S, Lemieux A, Lauzon-Schnitka J, Perreault L, Dubois M, Tousignant A, Watelle L, Pratte G, Dallaire F. Systematic Review and Meta-analysis of Prenatal Risk Factors for Congenital Heart Disease: Maternal Chronic Diseases and Parental Exposures. Can J Cardiol 2024:S0828-282X(24)00524-5. [PMID: 38996968 DOI: 10.1016/j.cjca.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/14/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND There is considerable heterogeneity in studies on prenatal risk factors for congenital heart diseases (CHDs). We performed a meta-analysis of all nongenetic factors of CHDs. This report presents results of factors related to maternal chronic diseases and parental exposures. METHODS A systematic search encompassing concepts of CHD and risk factors was used, using the following inclusion criteria: (1) original peer-reviewed articles, (2) quantifying the effects of risk factors for CHDs, (3) between 1989 and 2022. Pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated using a random-effect model. RESULTS Inclusion criteria were met for 170 studies. There was an association between being overweight or obese and CHDs (OR, 1.26; 95% CI, 1.15-1.37), with a dose-effect relationship. Pregestational diabetes (PGDM) was associated with CHDs (OR, 3.51; 95% CI, 2.86-4.3), without difference between type 1 and type 2 PGDM. The effect size of gestational diabetes was less than that of PGDM (OR, 1.38; 95% CI, 1.18-1.61). There was an association between CHDs and pre-eclampsia (OR, 2.01; 95% CI, 1.32-3.05), paternal smoking (OR, 1.32; 95% CI, 1.03-1.70), and alcohol use (OR, 1.50; 95% CI, 1.08-2.08). A smaller association was found with maternal smoking and advanced maternal age. CONCLUSIONS There exists robust evidence for increased risk of CHD in the presence of obesity, maternal diabetes, maternal smoking, and increased maternal age. The effect sizes were relatively modest, except for PGDM. The robustness of the evidence decreased when CHDs were divided into subgroups or when the analyses were restricted to severe CHDs.
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Affiliation(s)
- Sara Khalilipalandi
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Alyssia Lemieux
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Jonathan Lauzon-Schnitka
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Laurence Perreault
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Mélodie Dubois
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Angélique Tousignant
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Laurence Watelle
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Gabriel Pratte
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada
| | - Frédéric Dallaire
- Faculty of Medicine and Health Sciences, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebéc, Canada.
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Viswanathan S, Sandeep Oza P, Bellad A, Uttarilli A. Conotruncal Heart Defects: A Narrative Review of Molecular Genetics, Genomics Research and Innovation. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2024; 28:324-346. [PMID: 38986083 DOI: 10.1089/omi.2024.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Congenital heart defects (CHDs) are most prevalent cardiac defects that occur at birth, leading to significant neonatal mortality and morbidity, especially in the developing nations. Among the CHDs, conotruncal heart defects (CTDs) are particularly noteworthy, comprising a significant portion of congenital cardiac anomalies. While advances in imaging and surgical techniques have improved the diagnosis, prognosis, and management of CTDs, their molecular genetics and genomic substrates remain incompletely understood. This expert review covers the recent advances from January 2016 onward and examines the complexities surrounding the genetic etiologies, prevalence, embryology, diagnosis, and clinical management of CTDs. We also emphasize the known copy number variants and single nucleotide variants associated with CTDs, along with the current planetary health research efforts aimed at CTDs in large cohort studies. In all, this comprehensive narrative review of molecular genetics and genomics research and innovation on CTDs draws from and highlights selected works from around the world and offers new ideas for advances in CTD diagnosis, precision medicine interventions, and accurate assessment of prognosis and recurrence risks.
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Affiliation(s)
- Sruthi Viswanathan
- Institute of Bioinformatics, Bengaluru, Bangalore, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Prachi Sandeep Oza
- Institute of Bioinformatics, Bengaluru, Bangalore, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Anikha Bellad
- Institute of Bioinformatics, Bengaluru, Bangalore, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Anusha Uttarilli
- Institute of Bioinformatics, Bengaluru, Bangalore, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
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Weir TL, Majumder M, Glastras SJ. A systematic review of the effects of maternal obesity on neonatal outcomes in women with gestational diabetes. Obes Rev 2024; 25:e13747. [PMID: 38679418 DOI: 10.1111/obr.13747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 10/03/2023] [Accepted: 03/19/2024] [Indexed: 05/01/2024]
Abstract
Maternal obesity and gestational diabetes mellitus (GDM) prevalence are increasing, with both conditions associated with adverse neonatal outcomes. This review aimed to determine the risk of adverse outcomes in women with obesity and GDM, compared with women with obesity alone. A systematic search identified 28 eligible articles. Meta-analysis was conducted using a random effects model, to generate pooled estimates (odds ratios, OR, or mean difference, MD). Compared with normal-weight controls, women with obesity had increased risks of large for gestational age (LGA, OR 1.98, 95% CI: 1.56, 2.52) and macrosomia (OR 2.93, 95% CI: 1.71, 5.03); the latter's risk almost double in women with obesity than GDM. Birth weight (MD 113 g, 95% CI: 69, 156) and shoulder dystocia (OR 1.23, 95% CI: 0.85, 1.78) risk was also higher. GDM significantly amplified neonatal risk in women with obesity, with a three- to four-fold risk of LGA (OR 3.22, 95% CI: 2.17, 4.79) and macrosomia (OR 3.71, 95% CI: 2.76, 4.98), as well as higher birth weights (MD 176 g, 95% CI: 89, 263), preterm delivery (OR 1.49, 95% CI: 1.25, 1.77), and shoulder dystocia (OR 1.99, 95% CI: 1.31, 3.03), when compared with normal-weight controls. Our findings demonstrate that maternal obesity increases serious neonatal adverse risk, magnified by the presence of GDM. Effective strategies are needed to safeguard against neonatal complications associated with maternal obesity, regardless of GDM status.
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Affiliation(s)
- Tessa L Weir
- Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Endocrinology, Nepean-Blue Mountains Hospital, Kingswood, New South Wales, Australia
| | - Monica Majumder
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Sarah J Glastras
- Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Mamasoula C, Bigirumurame T, Chadwick T, Addor MC, Cavero-Carbonell C, Dias CM, Echevarría-González-de-Garibay LJ, Gatt M, Khoshnood B, Klungsoyr K, Randall K, Stoianova S, Haeusler M, Nelen V, Neville AJ, Perthus I, Pierini A, Bertaut-Nativel B, Rissmann A, Rouget F, Schaub B, Tucker D, Wellesley D, Zymak-Zakutnia N, Barisic I, de Walle HEK, Lanzoni M, Sayers G, Mullaney C, Pennington L, Rankin J. Maternal age and the prevalence of congenital heart defects in Europe, 1995-2015: A register-based study. Birth Defects Res 2023; 115:583-594. [PMID: 36734416 DOI: 10.1002/bdr2.2152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/18/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Evidence on the direction and strength of association between maternal age and the prevalence of congenital heart defects (CHD) in different age group categories is conflicting. Some studies have illustrated different trends with an increase in prevalence in younger and older age groups while other studies have reported a linear relationship. Given the increase in maternal age over recent years, it is important to study the CHD prevalence by maternal age. OBJECTIVES To examine the association between maternal age and the prevalence of CHD in Europe between 1995 and 2015 using population-based data from 24 registries belonging to the European Surveillance of Congenital Anomalies (EUROCAT) network. METHODS Associations over time of all nonsyndromic CHD according to maternal age category and for three CHD severity groupings (severity group I: very severe; severity group II: severe; severity group III: less severe) were examined using Bayesian multilevel Poisson regression modeling. Further subgroup analyses were undertaken within four maternal age-bands: ≤24, 25-29, 30-34 and 35-44 years. Descriptive summaries are also presented. RESULTS There were 51,608 nonsyndromic CHD cases in Europe over the 20-year study period. Total prevalence for all CHD combined was increased for younger mothers (≤24 years) and for mothers 35-44 years of age when compared with mothers aged 25-29 years (reference group) (IRR: 1.05, 95% CI: 1.02, 1.07). The total prevalence was increased for severity group I (very severe) only for younger mothers compared to those aged 25-29 years (IRR: 1.14, 95% CI: 1.04, 1.23). We found an increased prevalence of the following CHD subtypes: double outlet right ventricle (IRR:1.33, 95% CI: 1.09, 1.60), hypoplastic left heart syndrome (IRR: 1.18, 95% CI: 1.05, 1.32), hypoplastic right heart syndrome (IRR: 1.41, 95% CI: 1.05, 1.84), atrioventricular septal defect (IRR: 1.15, 95% CI: 1.01, 1.32), coarctation of aorta (IRR: 1.15, 95% CI: 1.03, 1.28) and atrial septal defect (IRR: 1.08, 95% CI: 1.02, 1.13). For older mothers (35-44 years) compared to the reference category, we observed an increased risk in the prevalence for severity group II (IRR: 1.09, 95% CI: 1.03, 1.14), severity group III (IRR: 1.05, 95% CI: 1.01, 1.08) and an increased prevalence of the CHD subtypes: Pulmonary valve stenosis (IRR: 1.22, 95% CI: 1.09, 1.34), ASD (IRR: 1.07, 95% CI: 1.02, 1.13), CoA (IRR: 1.18, 95% CI: 1.06, 1.32) and Tetralogy of Fallot (IRR: 1.14, 95% CI: 1.01, 1.28). Finally, for all age categories compared to the reference category, different associations of ASD and an increased prevalence of CoA was also observed. CONCLUSIONS Based on data for cases of CHD from 24 European population-based registries, evidence of a positive association between maternal age and the total prevalence of CHD for younger (≤24 years old) and older (35-44 years old) mothers was observed. The results suggest that young maternal age (≤24 years old) is a factor associated with severe CHD phenotypes while a positive association between advanced maternal age (35-44 years old) and mild CHD phenotypes was observed.
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Affiliation(s)
| | | | - Thomas Chadwick
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Marie-Claude Addor
- Department of Woman-Mother-Child, University Medical Center CHUV, Lausanne, Switzerland
| | - Clara Cavero-Carbonell
- Rare Diseases Research Unit, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, Valencia, Spain
| | - Carlos M Dias
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
- Epidemiology Department, National Institute of Health Doutor Ricardo Jorge, Lisbon, Portugal
| | - Luis-Javier Echevarría-González-de-Garibay
- Ministry of Health of the Basque Government. Directorate for Healthcare Planning, Organisation and Evaluation, Registries and Health Information Unit, Vitoria-Gasteiz, Spain
| | - Miriam Gatt
- Malta Congenital Anomalies Register, Directorate for Health Information and Research, Pietà, Malta
| | - Babak Khoshnood
- Université de Paris, INSERM U1153, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Kari Klungsoyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Division for Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Kay Randall
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sylvia Stoianova
- South West Congenital Anomaly Register, Bristol Medical School, University of Bristol, Bristol, UK
| | - Martin Haeusler
- Styrian Malformation Registry, Med. University of Graz, Graz, Austria
| | - Vera Nelen
- Provinciaal Instituut voor Hygiene (PIH), Antwerp, Belgium
| | - Amanda J Neville
- Registro IMER - IMER Registry (Emilia Romagna Registry of Birth Defects), Center for Clinical and Epidemiological Research, University of Ferrara, Ferrara, Italy
| | - Isabelle Perthus
- Auvergne registry of congenital anomalies (CEMC-Auvergne), Department of clinical genetics, Centre de Référence des Maladies Rares, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Anna Pierini
- Tuscany Registry of Congenital Defects (RTDC), Institute of Clinical Physiology - National Research Council/ Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Anke Rissmann
- Malformation Monitoring Centre Saxony-Anhalt, Medical Faculty Otto-von-Guericke University, Magdeburg, Germany
| | - Florence Rouget
- Brittany Registry of Congenital Anomalies, CHU Rennes, University Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), Rennes, France
| | - Bruno Schaub
- French West Indies Registry, Registre des Malformations des Antilles (REMALAN), Maison de la Femme de la Mère et de l'Enfant, University Hospital of Martinique, Fort-de-France, France
| | - David Tucker
- CARIS, Public Health Wales, Singleton Hospital, Swansea, UK
| | - Diana Wellesley
- Wessex Clinical Genetics Department, Princess Anne Hospital, Southampton, UK
| | - Natalya Zymak-Zakutnia
- OMNI-Net Ukraine Birth Defects Program and Khmelnytsky City Children's Hospital, Khmelnytsky, Ukraine
| | - Ingeborg Barisic
- Centre of Excellence for Reproductive and Regenerative Medicine, Children's Hospital Zagreb, Medical School University of Zagreb, Zagreb, Croatia
| | - Hermien E K de Walle
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, Netherlands
| | - Monica Lanzoni
- European Commission, Joint Research Centre (JRC), Ispra, Italy
| | - Gerardine Sayers
- Health Service Executive, Dr Steeven's Hospital, Dublin, Ireland
| | - Carmel Mullaney
- Department of Public Health, Service Executive (HSE) South East Area, Limerick, Ireland
| | - Lindsay Pennington
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
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Wu L, Li N, Liu Y. Association Between Maternal Factors and Risk of Congenital Heart Disease in Offspring: A Systematic Review and Meta-Analysis. Matern Child Health J 2023; 27:29-48. [PMID: 36344649 PMCID: PMC9867685 DOI: 10.1007/s10995-022-03538-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION This study aimed to summarize the evidence describing the relationship between maternal factors during gestation and risk of congenital heart disease (CHD) in offspring. METHODS PubMed, EMBASE, and the Cochrane Library were searched for potentially relevant reports from inception to May 2021. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) calculated by the random-effects model were used to evaluate the association between maternal factors and CHD risk. RESULTS There was a significant association between CHD risk and obesity in pregnancy (OR 1.29, 95% CI 1.22-1.37; P < 0.001), smoking in pregnancy (OR 1.16, 95% CI 1.07-1.25; P < 0.001), maternal diabetes (OR 2.65, 95% CI 2.20-3.19; P < 0.001), and exposure of pregnant women to organic solvents (OR 1.82, 95% CI 1.23-2.70; P = 0.003). No correlations were revealed between CHD susceptibility and advanced maternal age (OR 1.04, 95% CI 0.96-1.12; P = 0.328), underweight (OR 1.02, 95% CI 0.96-1.08; P = 0.519), alcohol intake in pregnancy (OR 1.08, 95% CI 0.95-1.22; P = 0.251), coffee intake (OR 1.18, 95% CI 0.97-1.44; P = 0.105), and exposure to irradiation (OR 1.80, 95% CI 0.85-3.80; P = 0.125). DISCUSSION Maternal factors including maternal obesity, smoking in pregnancy, maternal diabetes and exposure to organic solvents might predispose the offspring to CHD risk.
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Affiliation(s)
- Lina Wu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Na Li
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yong Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China.
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Rashkin SR, Cleves M, Shaw GM, Nembhard WN, Nestoridi E, Jenkins MM, Romitti PA, Lou XY, Browne ML, Mitchell LE, Olshan AF, Lomangino K, Bhattacharyya S, Witte JS, Hobbs CA. A genome-wide association study of obstructive heart defects among participants in the National Birth Defects Prevention Study. Am J Med Genet A 2022; 188:2303-2314. [PMID: 35451555 PMCID: PMC9283270 DOI: 10.1002/ajmg.a.62759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 01/19/2023]
Abstract
Obstructive heart defects (OHDs) share common structural lesions in arteries and cardiac valves, accounting for ~25% of all congenital heart defects. OHDs are highly heritable, resulting from interplay among maternal exposures, genetic susceptibilities, and epigenetic phenomena. A genome-wide association study was conducted in National Birth Defects Prevention Study participants (Ndiscovery = 3978; Nreplication = 2507), investigating the genetic architecture of OHDs using transmission/disequilibrium tests (TDT) in complete case-parental trios (Ndiscovery_TDT = 440; Nreplication_TDT = 275) and case-control analyses separately in infants (Ndiscovery_CCI = 1635; Nreplication_CCI = 990) and mothers (case status defined by infant; Ndiscovery_CCM = 1703; Nreplication_CCM = 1078). In the TDT analysis, the SLC44A2 single nucleotide polymorphism (SNP) rs2360743 was significantly associated with OHD (pdiscovery = 4.08 × 10-9 ; preplication = 2.44 × 10-4 ). A CAPN11 SNP (rs55877192) was suggestively associated with OHD (pdiscovery = 1.61 × 10-7 ; preplication = 0.0016). Two other SNPs were suggestively associated (p < 1 × 10-6 ) with OHD in only the discovery sample. In the case-control analyses, no SNPs were genome-wide significant, and, even with relaxed thresholds ( × discovery < 1 × 10-5 and preplication < 0.05), only one SNP (rs188255766) in the infant analysis was associated with OHDs (pdiscovery = 1.42 × 10-6 ; preplication = 0.04). Additional SNPs with pdiscovery < 1 × 10-5 were in loci supporting previous findings but did not replicate. Overall, there was modest evidence of an association between rs2360743 and rs55877192 and OHD and some evidence validating previously published findings.
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Affiliation(s)
- Sara R Rashkin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Mario Cleves
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Health Informatics Institute, Tampa, Florida, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Wendy N Nembhard
- Department of Epidemiology and Arkansas Center for Birth Defects and Prevention, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Eirini Nestoridi
- Massachusetts Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Mary M Jenkins
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Paul A Romitti
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Xiang-Yang Lou
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Marilyn L Browne
- Birth Defects Research Section, New York State Department of Health, Albany, New York, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York, USA
| | - Laura E Mitchell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Andrew F Olshan
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Sudeepa Bhattacharyya
- Bioinformatics and Data Science at University of Arkansas, Little Rock, Arkansas, USA
| | - John S Witte
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Charlotte A Hobbs
- Rady Children's Institute for Genomic Medicine, San Diego, California, USA
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Morton SU, Pereira AC, Quiat D, Richter F, Kitaygorodsky A, Hagen J, Bernstein D, Brueckner M, Goldmuntz E, Kim RW, Lifton RP, Porter GA, Tristani-Firouzi M, Chung WK, Roberts A, Gelb BD, Shen Y, Newburger JW, Seidman JG, Seidman CE. Genome-Wide De Novo Variants in Congenital Heart Disease Are Not Associated With Maternal Diabetes or Obesity. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2022; 15:e003500. [PMID: 35130025 PMCID: PMC9295870 DOI: 10.1161/circgen.121.003500] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) is the most common anomaly at birth, with a prevalence of ≈1%. While infants born to mothers with diabetes or obesity have a 2- to 3-fold increased incidence of CHD, the cause of the increase is unknown. Damaging de novo variants (DNV) in coding regions are more common among patients with CHD, but genome-wide rates of coding and noncoding DNVs associated with these prenatal exposures have not been studied in patients with CHD. METHODS DNV frequencies were determined for 1812 patients with CHD who had whole-genome sequencing and prenatal history data available from the Pediatric Cardiac Genomics Consortium's CHD GENES study (Genetic Network). The frequency of DNVs was compared between subgroups using t test or linear model. RESULTS Among 1812 patients with CHD, the number of DNVs per patient was higher with maternal diabetes (76.5 versus 72.1, t test P=3.03×10-11), but the difference was no longer significant after including parental ages in a linear model (paternal and maternal correction P=0.42). No interaction was observed between diabetes risk and parental age (paternal and maternal interaction P=0.80 and 0.68, respectively). No difference was seen in DNV count per patient based on maternal obesity (72.0 versus 72.2 for maternal body mass index <25 versus maternal body mass index >30, t test P=0.86). CONCLUSIONS After accounting for parental age, the offspring of diabetic or obese mothers have no increase in DNVs compared with other children with CHD. These results emphasize the role for other mechanisms in the cause of CHD associated with these prenatal exposures. REGISTRATION URL: https://clinicaltrials.gov; NCT01196182.
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Affiliation(s)
- Sarah U. Morton
- Division of Newborn Medicine, Department of Medicine, Boston Children’s Hospital, Boston, MA USA,Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | | | - Daniel Quiat
- Department of Pediatrics, Harvard Medical School, Boston, MA USA,Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Felix Richter
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Alexander Kitaygorodsky
- Departments of Systems Biology and Biomedical Informatics, Columbia University Medical Center, New York, NY USA
| | - Jacob Hagen
- Departments of Systems Biology and Biomedical Informatics, Columbia University Medical Center, New York, NY USA
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA USA
| | - Martina Brueckner
- Departments of Genetics and Pediatrics; Yale University School of Medicine, New Haven, CT USA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | | | - Richard P. Lifton
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY USA
| | - George A. Porter
- Department of Pediatrics, University of Rochester Medical Center, The School of Medicine and Dentistry, Rochester, NY USA
| | | | - Wendy K. Chung
- Departments of Pediatrics and Medicine, Columbia University Medical Center, New York, NY USA
| | - Amy Roberts
- Department of Pediatrics, Harvard Medical School, Boston, MA USA,Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Bruce D. Gelb
- Mindich Child Health and Development Institute and Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Yufeng Shen
- Departments of Systems Biology and Biomedical Informatics, Columbia University Medical Center, New York, NY USA
| | - Jane W. Newburger
- Department of Pediatrics, Harvard Medical School, Boston, MA USA,Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - J. G. Seidman
- Department of Genetics, Harvard Medical School, Boston, MA USA
| | - Christine E. Seidman
- Department of Genetics, Harvard Medical School, Boston, MA USA,Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA USA,Howard Hughes Medical Institute, Chevy Chase, MD USA
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Wu XX, Ge RX, Huang L, Tian FY, Chen YX, Wu LL, Niu JM. Pregestational diabetes mediates the association between maternal obesity and the risk of congenital heart defects. J Diabetes Investig 2021; 13:367-374. [PMID: 34510805 PMCID: PMC8847144 DOI: 10.1111/jdi.13666] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS/INTRODUCTION We aimed to explore whether the association between obesity and congenital heart defects (CHDs) can be mediated by maternal pregestational diabetes (PGDM). MATERIALS AND METHODS We included 53,708 mother-infant pairs with deliveries between 2017 and 2019 from the Birth Cohort in Shenzhen. Mothers were categorized into four groups: the underweight group (body mass index [BMI] <18.5), normal weight group (18.5 ≤ BMI < 24), overweight group (24 ≤ BMI < 28) and obesity group (BMI ≥28). Multivariable logistic regression models were used to evaluate the association between BMI and CHDs. Mediation analysis was used to confirm the effect of PGDM on the association between maternal obesity and CHDs. RESULTS The proportion of obese individuals in the Birth Cohort in Shenzhen was 2.11%. Overall, 372 (0.69%) infants were diagnosed with CHDs. Maternal obesity was associated with an increased risk of CHDs (odds ratio 1.97, 95% confidence interval 1.14-3.41). The mediation effect of PGDM on the association between maternal obesity and CHDs was significant (odds ratio 1.18, 95% confidence interval 1.06-1.32). The estimated mediation proportion was 24.83%. CONCLUSIONS Maternal obesity was associated with increased risk for CHDs, and PGDM partially mediated the association between maternal obesity and CHDs.
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Affiliation(s)
- Xiao-Xia Wu
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
| | - Ru-Xiu Ge
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
| | - Le Huang
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
| | - Fu-Ying Tian
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
| | - Yi-Xuan Chen
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
| | - Lin-Lin Wu
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
| | - Jian-Min Niu
- Department of Obstetrics, Cheeloo College of Medicine, Shenzhen Maternity and Child Healthcare Hospital, Shandong University, Shenzhen, Guangdong, China
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Tinker SC, Gilboa SM, Moore CA, Waller DK, Simeone RM, Kim SY, Jamieson DJ, Botto LD, Fisher SC, Reefhuis J. Modification of the association between diabetes and birth defects by obesity, National Birth Defects Prevention Study, 1997-2011. Birth Defects Res 2021; 113:1084-1097. [PMID: 33876578 PMCID: PMC10926945 DOI: 10.1002/bdr2.1900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/05/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Maternal pregestational diabetes and obesity are risk factors for birth defects. Diabetes and obesity often occur together; it is unclear whether their co-occurrence compounds birth defect risk. METHODS We analyzed 1997-2011 data on 29,671 cases and 10,963 controls from the National Birth Defects Prevention Study, a multisite case-control study. Mothers self-reported height, pregestational weight, and diabetes (pregestational and gestational; analyzed separately). We created four exposure groups: no obesity or diabetes (referent), obesity only, diabetes only, and both obesity and diabetes. We estimated odds ratios (ORs) using logistic regression and the relative excess risk due to interaction (RERI). RESULTS Among mothers with pregestational obesity without diabetes, modest associations (OR range: 1.1-1.5) were observed for neural tube defects, small intestinal atresia, anorectal atresia, renal agenesis/hypoplasia, omphalocele, and several congenital heart defects. Pregestational diabetes, regardless of obesity, was strongly associated with most birth defects (OR range: 2.0-75.9). Gestational diabetes and obesity had a stronger association than for obesity alone and the RERI (in parentheses) suggested additive interaction for hydrocephaly (1.2; 95% confidence interval [CI]: -0.1, 2.5), tetralogy of Fallot (0.9; 95% CI: -0.01, 1.8), atrioventricular septal defect (1.1; 95% CI: -0.1, 2.3), hypoplastic left heart syndrome (1.1; 95% CI: -0.2, 2.4), and atrial septal defect secundum or not otherwise specified (1.0; 95% CI: 0.3, 1.6; only statistically significant RERI). CONCLUSIONS Our results do not support a synergistic relationship between obesity and diabetes for most birth defects examined. However, there are opportunities for prevention by reducing obesity and improving glycemic control among women with pregestational diabetes before conception.
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Affiliation(s)
- Sarah C. Tinker
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M. Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cynthia A. Moore
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - D. Kim Waller
- School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Regina M. Simeone
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shin Y. Kim
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Denise J. Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Lorenzo D. Botto
- Division of Medical Genetics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sarah C. Fisher
- Birth Defects Research Section, New York State Department of Health, Albany, New York
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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10
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Hedermann G, Hedley PL, Thagaard IN, Krebs L, Ekelund CK, Sørensen TIA, Christiansen M. Maternal obesity and metabolic disorders associate with congenital heart defects in the offspring: A systematic review. PLoS One 2021; 16:e0252343. [PMID: 34043700 PMCID: PMC8158948 DOI: 10.1371/journal.pone.0252343] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/12/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Congenital heart defects (CHDs) are the most common congenital malformations. The aetiology of CHDs is complex. Large cohort studies and systematic reviews and meta-analyses based on these have reported an association between higher risk of CHDs in the offspring and individual maternal metabolic disorders such as obesity, diabetes, hypertension, and preeclampsia, all conditions that can be related to insulin resistance or hyperglycaemia. However, the clinical reality is that these conditions often occur simultaneously. The aim of this review is, in consequence, both to evaluate the existing evidence on the association between maternal metabolic disorders, defined as obesity, diabetes, hypertension, preeclampsia, dyslipidaemia and CHDs in the offspring, as well as the significance of combinations, such as metabolic syndrome, as risk factors. METHODS A systematic literature search of papers published between January 1, 1990 and January 14, 2021 was conducted using PubMed and Embase. Studies were eligible if they were published in English and were case-control or cohort studies. The exposures of interest were maternal overweight or obesity, hypertension, preeclampsia, diabetes, dyslipidaemia, and/or metabolic syndrome, and the outcome of interest was CHDs in the offspring. Furthermore, the studies were included according to a quality assessment score. RESULTS Of the 2,250 identified studies, 32 qualified for inclusion. All but one study investigated only the individual metabolic disorders. Some disorders (obesity, gestational diabetes, and hypertension) increased risk of CHDs marginally whereas pre-gestational diabetes and early-onset preeclampsia were strongly associated with CHDs, without consistent differences between CHD subtypes. A single study suggested a possible additive effect of maternal obesity and gestational diabetes. CONCLUSIONS Future studies of the role of aberrations of the glucose-insulin homeostasis in the common aetiology and mechanisms of metabolic disorders, present during pregnancy, and their association, both as single conditions and-particularly-in combination, with CHDs are needed.
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Affiliation(s)
- Gitte Hedermann
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- * E-mail:
| | - Paula L. Hedley
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
| | - Ida N. Thagaard
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital, Slagelse Hospital, Slagelse, Denmark
| | - Lone Krebs
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Kvist Ekelund
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thorkild I. A. Sørensen
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael Christiansen
- Department for Congenital Disorders, Danish National Biobank and Biomarkers, Statens Serum Institut, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
The prevalence of diabetes in reproductive age women has been reported to be as high as 6.8%, with pregestational diabetes affecting 2% of all pregnancies. As cases of diabetes in children and adolescents rise, more patients will be entering reproductive age and pregnancy with diagnoses of obesity, prediabetes, type 2 diabetes. Early interventions of diet modification and exercise to maintain healthy weights can delay or even prevent these complications. It is critical for health care providers to emphasize the importance of preconception counseling in this high-risk patient population to reduce the morbidities associated with obesity and diabetes in pregnancy.
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Abstract
PURPOSE OF REVIEW Fetuses of diabetic mothers are at increased risk for congenital malformations. Research in recent decades using animal and embryonic stem cell models has revealed many embryonic developmental processes that are disturbed by maternal diabetes. The aim of this review is to give clinicians a better understanding of the reasons for rigorous glycemic control in early pregnancy, and to provide background to guide future research. RECENT FINDINGS Mouse models of diabetic pregnancy have revealed mechanisms for altered expression of tissue-specific genes that lead to malformations that are more common in diabetic pregnancies, such as neural tube defects (NTDs) and congenital heart defects (CHDs), and how altered gene expression causes apoptosis that leads to malformations. Embryos express the glucose transporter, GLUT2, which confers susceptibility to malformation, due to high rates of glucose uptake during maternal hyperglycemia and subsequent oxidative stress; however, the teleological function of GLUT2 for mammalian embryos may be to transport the amino sugar glucosamine (GlcN) from maternal circulation to be used as substrate for glycosylation reactions and to promote embryo cell growth. Malformations in diabetic pregnancy may be not only due to excess glucose uptake but also due to insufficient GlcN uptake. Avoiding maternal hyperglycemia during early pregnancy should prevent excess glucose uptake via GLUT2 into embryo cells, and also permit sufficient GLUT2-mediated GlcN uptake.
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Affiliation(s)
- Mary R Loeken
- Section on Islet Cell and Regenerative Biology, Department of Medicine, Joslin Diabetes Center and Harvard Medical School, One Joslin Place, Boston, MA, 02215, USA.
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Hautala J, Gissler M, Ritvanen A, Helle E, Pihkala J, Mattila IP, Pätilä T, Salminen J, Puntila J, Jokinen E, Räsänen J, Vahlberg T, Ojala T. Perinatal and perioperative factors associated with mortality and an increased need for hospital care in infants with transposition of the great arteries: A nationwide 11-year population-based cohort. Acta Obstet Gynecol Scand 2020; 99:1728-1735. [PMID: 32640036 DOI: 10.1111/aogs.13953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/25/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Newborn infants with transposition of the great arteries (d-TGA) need immediate care for an optimal outcome. This study comprised a nationwide 11-year population-based cohort of d-TGA infants, and assessed whether the implementation of a nationwide systematic fetal screening program, or other perinatal, or perioperative factors, are associated with mortality or an increased need for hospital care. MATERIAL AND METHODS The national cohort consisted of all live-born infants with simple d-TGA (TGA ± small ventricular septal defect, n = 127) born in Finland during 2004-2014. Data were collected from six national registries. Prenatal diagnosis and perinatal and perioperative factors associated with mortality and length of hospitalization were evaluated. RESULTS Preoperative mortality was 7.9%, and the total mortality was 8.7%. The prenatal detection rate increased after introducing systematic fetal anomaly screening from 5.0% to 37.7% during the study period (P < .0001), but the total mortality rate remained unchanged. All prenatally diagnosed infants (n = 27) survived. Lower gestational age (odds ratio 0.68, P = .012) and higher maternal age at birth (odds ratio 1.16, P = .036) were associated with increased mortality in multivariable analysis. Older infant age at time of operation (P = .002), longer aortic clamp time (P < .001), and higher maternal body mass index (P = .027) were associated with longer initial hospital stay. An extended need for hospital care during the first year of life was multi-factorial. CONCLUSIONS In our cohort, none of the prenatally diagnosed d-TGA infants died. As a result of the limited prenatal detection rates, however, the sample size was insufficient to reach statistical significance. The d-TGA infants born with lower gestational age and to older mothers had increased mortality.
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Affiliation(s)
- Johanna Hautala
- Department of Obstetrics and Gynecology, Women's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Gissler
- Information Services Department, Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Annukka Ritvanen
- Retired from the Register of Congenital Malformations, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Emmi Helle
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jaana Pihkala
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka P Mattila
- Division of Pediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tommi Pätilä
- Division of Pediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka Salminen
- Division of Pediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Puntila
- Division of Pediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eero Jokinen
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Räsänen
- Department of Obstetrics and Gynecology, Women's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tero Vahlberg
- Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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14
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Patel J, Nembhard WN, Politis MD, Rocheleau CM, Langlois PH, Shaw GM, Romitti PA, Gilboa SM, Desrosiers TA, Insaf T, Lupo PJ. Maternal occupational exposure to polycyclic aromatic hydrocarbons and the risk of isolated congenital heart defects among offspring. ENVIRONMENTAL RESEARCH 2020; 186:109550. [PMID: 32335433 PMCID: PMC8756335 DOI: 10.1016/j.envres.2020.109550] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/07/2020] [Accepted: 04/15/2020] [Indexed: 05/19/2023]
Abstract
BACKGROUND Although there is evidence in experimental model systems that exposure to polycyclic aromatic hydrocarbons (PAHs) is linked with congenital heart defects (CHDs), few studies have examined the association in humans. We conducted a case-control study to examine the association between maternal exposure to PAHs and CHDs in offspring using data from the National Birth Defects Prevention Study (NBDPS) (1997-2011). METHODS We obtained detailed information on maternal occupation during the month before to three months after conception. Expert raters, masked to case-control status, assessed job descriptions to assign categorical levels of exposure. Categories were quantitatively mapped to estimate cumulative exposure to PAHs, incorporating exposure intensity, frequency, work duration, and work hours. Quartiles were generated for cumulative maternal exposure to PAHs. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using unconditional logistic regression for quartiles of PAH exposure and six CHD groupings (e.g. conotruncal) and specific subtypes (e.g. tetralogy of Fallot [ToF]). Final models were adjusted for maternal age, race/ethnicity, education, smoking, anticonvulsant use, folic acid supplementation, and study center. RESULTS There were 4,775 case and 7,734 control infants eligible for the study. The prevalence of occupational exposure to PAHs was 10.2% among both case and control mothers. In adjusted analysis, compared to mothers with no occupational PAH exposure, those in the highest quartile of exposure were more likely to have offspring in the conotruncal heart defects group (OR 1.41; 95% CI 1.00-2.00), and with ToF (OR 1.83; 95% CI 1.21-2.78). CONCLUSIONS Women in the highest quartile of estimated cumulative occupational PAH exposure during early pregnancy were more likely to have offspring with conotruncal heart defects, specifically ToF, compared to women with no occupational PAH exposure. Other comparisons between PAHs and other CHDs subgroups did not show any statistically precise associations.
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Affiliation(s)
- Jenil Patel
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Arkansas Center for Birth Defects Research and Prevention, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Wendy N Nembhard
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Arkansas Center for Birth Defects Research and Prevention, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Maria D Politis
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Arkansas Center for Birth Defects Research and Prevention, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Carissa M Rocheleau
- National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, OH, USA
| | - Peter H Langlois
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, TX, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Suzanne M Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tania A Desrosiers
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Tabassum Insaf
- Bureau of Environmental and Occupational Epidemiology, Center for Environmental Health, New York State Department of Health, Albany, NY, USA; Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, NY, USA
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX, USA
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15
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Congenital heart diseases: genetics, non-inherited risk factors, and signaling pathways. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2020. [DOI: 10.1186/s43042-020-0050-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Abstract
Background
Congenital heart diseases (CHDs) are the most common congenital anomalies with an estimated prevalence of 8 in 1000 live births. CHDs occur as a result of abnormal embryogenesis of the heart. Congenital heart diseases are associated with significant mortality and morbidity. The damage of the heart is irreversible due to a lack of regeneration potential, and usually, the patients may require surgical intervention. Studying the developmental biology of the heart is essential not only in understanding the mechanisms and pathogenesis of congenital heart diseases but also in providing us with insight towards developing new preventive and treatment methods.
Main body
The etiology of congenital heart diseases is still elusive. Both genetic and environmental factors have been implicated to play a role in the pathogenesis of the diseases. Recently, cardiac transcription factors, cardiac-specific genes, and signaling pathways, which are responsible for early cardiac morphogenesis have been extensively studied in both human and animal experiments but leave much to be desired. The discovery of novel genetic methods such as next generation sequencing and chromosomal microarrays have led to further study the genes, non-coding RNAs and subtle chromosomal changes, elucidating their implications to the etiology of congenital heart diseases. Studies have also implicated non-hereditary risk factors such as rubella infection, teratogens, maternal age, diabetes mellitus, and abnormal hemodynamics in causing CHDs.
These etiological factors raise questions on multifactorial etiology of CHDs. It is therefore important to endeavor in research based on finding the causes of CHDs. Finding causative factors will enable us to plan intervention strategies and mitigate the consequences associated with CHDs. This review, therefore, puts forward the genetic and non-genetic causes of congenital heart diseases. Besides, it discusses crucial signaling pathways which are involved in early cardiac morphogenesis. Consequently, we aim to consolidate our knowledge on multifactorial causes of CHDs so as to pave a way for further research regarding CHDs.
Conclusion
The multifactorial etiology of congenital heart diseases gives us a challenge to explicitly establishing specific causative factors and therefore plan intervention strategies. More well-designed studies and the use of novel genetic technologies could be the way through the discovery of etiological factors implicated in the pathogenesis of congenital heart diseases.
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Lyu C, Webber DM, MacLeod SL, Hobbs CA, Li M. Gene-by-gene interactions associated with the risk of conotruncal heart defects. Mol Genet Genomic Med 2020; 8:e1010. [PMID: 31851787 PMCID: PMC6978401 DOI: 10.1002/mgg3.1010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/11/2019] [Accepted: 09/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The development of conotruncal heart defects (CTDs) involves a complex relationship among genetic variants and maternal lifestyle factors. In this article, we focused on the interactions between 13 candidate genes within folate, homocysteine, and transsulfuration pathways for potential association with CTD risk. METHODS Targeted sequencing was used for 328 case-parental triads enrolled in the National Birth Defects Prevention Study (NBDPS). To evaluate the interaction of two genes, we applied a conditional logistic regression model for all possible SNP pairs within two respective genes by contrasting the affected infants with their pseudo-controls. The findings were replicated in an independent sample of 86 NBDPS case-parental triads genotyped by DNA microarrays. The results of two studies were further integrated by a fixed-effect meta-analysis. RESULTS One SNP pair (i.e., rs4764267 and rs6556883) located in gene MGST1 and GLRX, respectively, was found to be associated with CTD risk after multiple testing adjustment using simpleM, a modified Bonferroni correction approach (nominal p-value of 4.62e-06; adjusted p-value of .04). Another SNP pair (i.e., rs11892646 and rs56219526) located in gene DNMT3A and MTRR, respectively, achieved marginal significance after multiple testing adjustment (adjusted p-value of .06). CONCLUSION Further studies with larger sample sizes are needed to confirm and elucidate these potential interactions.
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Affiliation(s)
- Chen Lyu
- Department of Epidemiology and BiostatisticsIndiana UniversityBloomingtonINUSA
| | - Daniel M. Webber
- Department of Pathology & ImmunologyWashington University at St LouisSaint LouisMOUSA
| | | | | | - Ming Li
- Department of Epidemiology and BiostatisticsIndiana UniversityBloomingtonINUSA
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AIUM Practice Parameter for the Performance of Fetal Echocardiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:E5-E16. [PMID: 31846540 DOI: 10.1002/jum.15188] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Hennig CL, Childs J, Aziz A, Quinton A. The effect of increased maternal body habitus on image quality and ability to identify fetal anomalies at a routine 18‐20‐week morphology ultrasound scan: a narrative review. SONOGRAPHY 2019. [DOI: 10.1002/sono.12202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christina L. Hennig
- Medical ImagingRoyal Brisbane and Women's Hospital Herston Queensland Australia
| | - Jessie Childs
- School of Health SciencesUniversity of South Australia Adelaide Australia
| | - Aamer Aziz
- School of Health, Medical and Applied SciencesCentral Queensland University Mackay Australia
| | - Ann Quinton
- Medical SonographyCentral Queensland University Australia
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Persson M, Razaz N, Edstedt Bonamy AK, Villamor E, Cnattingius S. Maternal Overweight and Obesity and Risk of Congenital Heart Defects. J Am Coll Cardiol 2019; 73:44-53. [PMID: 30621950 DOI: 10.1016/j.jacc.2018.10.050] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Congenital heart defects are more frequent in offspring of mothers with overweight or obesity. However, associations between maternal overweight and obesity, and risks of complex and specific heart defects are not clear. OBJECTIVES This study sought to analyze associations between maternal overweight and obesity severity and rates of complex and specific heart defects. METHODS This was a population-based cohort study in Sweden, including 2,050,491 live singleton infants born between 1992 and 2012. Data on maternal and infant characteristics, and diagnoses of congenital heart defects were retrieved from nationwide registries. Maternal body mass index (BMI) was categorized as underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5 to <25 kg/m2), overweight (BMI 25 to <30 kg/m2), obesity class I (BMI 30 to <35 kg/m2), class II (BMI 35 to <40 kg/m2), and class III (BMI ≥40 kg/m2). Outcomes included complex heart defects (tetralogy of Fallot, transposition of the great arteries, atrial septal defects [ASD], aortic arch defects, and single-ventricle heart) and subgroups of specific heart defects diagnosed up to 5 years of age. The authors calculated adjusted prevalence rate ratios (PRRs) with 95% confidence intervals. RESULTS A total of 28,628 (1.40%, N = 2,050,491) children had at least 1 congenital heart defect. PRRs of aortic arch defects increased with maternal obesity severity. Compared with offspring of normal weight mothers, PRRs of aortic arch defects and transposition of the great arteries were doubled in offspring of mothers with severe obesity. PRRs of ASD and persistent ductus arteriosus in term infants increased with maternal BMI. CONCLUSIONS PRRs of aortic branch defects, ASD, and persistent ductus arteriosus increase with maternal obesity severity.
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Affiliation(s)
- Martina Persson
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Diabetes and Endocrinology, Sachsska Children's Hospital, Södersjukhuset, Stockholm, Sweden.
| | - Neda Razaz
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | | | - Eduardo Villamor
- Department of Epidemiology, School of Public Health and Center for Human Growth and Development, University of Michigan, Ann Arbor, Michigan
| | - Sven Cnattingius
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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20
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Maternal Body Mass Index and Risk of Congenital Heart Defects in Infants: A Dose-Response Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1315796. [PMID: 31360700 PMCID: PMC6642764 DOI: 10.1155/2019/1315796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 05/15/2019] [Accepted: 05/22/2019] [Indexed: 01/19/2023]
Abstract
Objective The exact shape of the dose-response relationship between maternal body mass index (BMI) and the risk of congenital heart defects (CHDs) in infants has not been clearly defined yet. This study aims to further clarify the relationship between maternal obesity and the risk of CHDs in infants by an overall and dose-response meta-analysis. Methods PubMed, Embase, and Web of Science databases were searched to identify all related studies. The studies were limited to human cohort or case-control studies in English language. Random-effect models and dose-response meta-analysis were used to synthesize the results. Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were also assessed. Results Nineteen studies with 2,416,546 participants were included in our meta-analysis. Compared with the mothers with normal weight, the pooled relative risks (RRs) of infants with CHDs were 1.08 (95% CI=1.03-1.13) in overweight and 1.23 (95% CI=1.17-1.29) in obese mothers. According to the findings from the linear meta-analysis, we observed an increased risk of infants with CHDs (RR=1.07, 95% CI=1.06-1.08) for each 5 kg/m2 increase in maternal BMI. A nonlinear relationship between maternal BMI and risk of infants with CHDs was also found (p=0.012). Conclusion The results from our meta-analysis indicate that increased maternal BMI is related to increased risk of CHDs in infants.
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21
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Bakker MK, Bergman JEH, Krikov S, Amar E, Cocchi G, Cragan J, de Walle HEK, Gatt M, Groisman B, Liu S, Nembhard WN, Pierini A, Rissmann A, Chidambarathanu S, Sipek A, Szabova E, Tagliabue G, Tucker D, Mastroiacovo P, Botto LD. Prenatal diagnosis and prevalence of critical congenital heart defects: an international retrospective cohort study. BMJ Open 2019; 9:e028139. [PMID: 31270117 PMCID: PMC6609145 DOI: 10.1136/bmjopen-2018-028139] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess international trends and patterns of prenatal diagnosis of critical congenital heart defects (CCHDs) and their relation to total and live birth CCHD prevalence and mortality. SETTING Fifteen birth defect surveillance programmes that participate in the International Clearinghouse for Birth Defects Surveillance and Research from 12 countries in Europe, North and South America and Asia. PARTICIPANTS Live births, stillbirths and elective terminations of pregnancy for fetal anomaly diagnosed with 1 of 12 selected CCHD, ascertained by the 15 programmes for delivery years 2000 to 2014. RESULTS 18 243 CCHD cases were reported among 8 847 081 births. The median total prevalence was 19.1 per 10 000 births but varied threefold between programmes from 10.1 to 31.0 per 10 000. CCHD were prenatally detected for at least 50% of the cases in one-third of the programmes. However, prenatal detection varied from 13% in Slovak Republic to 87% in some areas in France. Prenatal detection was consistently high for hypoplastic left heart syndrome (64% overall) and was lowest for total anomalous pulmonary venous return (28% overall). Surveillance programmes in countries that do not legally permit terminations of pregnancy tended to have higher live birth prevalence of CCHD. Most programmes showed an increasing trend in prenatally diagnosed CCHD cases. DISCUSSION AND CONCLUSIONS Prenatal detection already accounts for 50% or more of CCHD detected in many programmes and is increasing. Local policies and access likely account for the wide variability of reported occurrence and prenatal diagnosis. Detection rates are high especially for CCHD that are more easily diagnosed on a standard obstetric four-chamber ultrasound or for fetuses that have extracardiac anomalies. These ongoing trends in prenatal diagnosis, potentially in combination with newborn pulse oximetry, are likely to modify the epidemiology and clinical outcomes of CCHD in the near future.
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Affiliation(s)
- Marian K Bakker
- Department of Genetics, Eurocat registration Northern Netherlands, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorieke E H Bergman
- Department of Genetics, Eurocat registration Northern Netherlands, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sergey Krikov
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Emmanuelle Amar
- Registre Des Malformations en Rhone Alpes, REMERA, Lyon, France
| | - Guido Cocchi
- Neonatology Unit, S.Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Janet Cragan
- Metropolitan Atlanta Congenital Defects Program, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hermien E K de Walle
- Department of Genetics, Eurocat registration Northern Netherlands, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Miriam Gatt
- Malta Congenital Anomalies Registry, Directorate for Health Information and Research, Malta, Malta
| | - Boris Groisman
- National Network of Congenital Anomalies of Argentina (RENAC), National Center of Medical Genetics, National Ministry of Health, Buenos Aires, Argentina
| | - Shiliang Liu
- Maternal, Child and Youth Health Division, Public Health Agency of Canada, Ottawa, Canada
| | - Wendy N Nembhard
- Arkansas Reproductive Health Monitoring System, University of Arkansas for Medical Sciences, Fay W Boozman College of Public Health and the Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Anna Pierini
- Institute of Clinical Physiology, National Research Council and Fondazione Toscana Gabriele Monasterio, Tuscany Registry of Congenital Defects, Pisa, Italy
| | - Anke Rissmann
- Malformation Monitoring Centre, Medical Faculty, Otto von Guericke University, Magdeburg, Germany
| | | | - Antonin Sipek
- Institute of Medical Biology and Genetics First Faculty of Medicine Charles University and General University Hospital, Prague, Czech Republic
| | - Elena Szabova
- Slovak Teratologic Information Centre (FPH), Slovak Medical University, Bratislava, Slovakia
| | - Giovanna Tagliabue
- Lombardy Birth Defects Registry, Fondazione IRCCS Instituto Nazionale Tumori, Milan, Italy
| | - David Tucker
- Congenital Anomaly Register and Information Service for Wales, Public Health Wales, Swansea, Wales, UK
| | | | - Lorenzo D Botto
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- International Center on Birth Defects, University of Utah, Salt Lake City, Utah, USA
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22
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Abstract
BACKGROUND Ebstein anomaly is a rare congenital heart defect (CHD) that, when severe, requires corrective surgery or other catheter-based intervention in the first year of life. Due to its rarity, risk factors for Ebstein anomaly remain largely unknown. Using national data, we examined 18 potential risk factors for Ebstein anomaly. METHODS Using 1997-2011 data from the National Birth Defects Prevention Study, a population-based case-control study, we calculated crude and adjusted odds ratios and 95% confidence intervals for paternal age, maternal socio-demographics, reproductive history, and modifiable risk factors, and infant characteristics reported by mothers of 135 Ebstein anomaly cases and 11,829 controls. RESULTS Mothers of Ebstein anomaly cases had 4.1 (95% confidence interval: 1.8, 9.5) times the odds of reporting a family history of CHD compared with mothers of controls. Ebstein anomaly was associated with maternal second-hand cigarette smoke exposure at home (odds ratio = 2.2 [95% confidence interval: 1.1, 4.4]), but not maternal cigarette smoking (odds ratio = 1.3 [95% confidence interval: 0.8, 2.1]). Odds were elevated, but the 95% confidence interval included 1.0, for maternal marijuana use (odds ratio = 1.8 [95% confidence interval: 0.9, 3.8]) and paternal age ≥40 years at delivery (odds ratio = 1.9 [95% confidence interval: 1.0, 3.5]). CONCLUSIONS Maternal exposure to second-hand cigarette smoke at home and a family history of CHD were associated with elevated odds of Ebstein anomaly. Genetic analyses could clarify the potential heritability of Ebstein anomaly.
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23
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Hautala J, Gissler M, Ritvanen A, Tekay A, Pitkänen-Argillander O, Stefanovic V, Sarkola T, Helle E, Pihkala J, Pätilä T, Mattila IP, Jokinen E, Räsänen J, Ojala T. The implementation of a nationwide anomaly screening programme improves prenatal detection of major cardiac defects: an 11-year national population-based cohort study. BJOG 2019; 126:864-873. [PMID: 30576052 DOI: 10.1111/1471-0528.15589] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate whether a nationwide prenatal anomaly screening programme improves detection rates of univentricular heart (UVH) and transposition of great arteries (TGA), and whether maternal risk factors for severe fetal heart disease affect prenatal detection. DESIGN Population-based cohort study. SETTING Nationwide data from Finnish registries 2004-14. POPULATION A total of 642 456 parturients and 3449 terminated pregnancies due to severe fetal anomaly. METHODS Prenatal detection rates were calculated in three time periods (prescreening, transition and screening phase). The effect of maternal risk factors (obesity, in vitro fertilisation, pregestational diabetes and smoking) was evaluated. MAIN OUTCOME MEASURES Change in detection rates and impact of maternal risk factors on screening programme efficacy. RESULTS In total, 483 cases of UVH and 184 of TGA were detected. The prenatal detection rate of UVH increased from 50.4% to 82.8% and of TGA from 12.3% to 41.0% (P < 0.0001). Maternal risk factors did not affect prenatal detection rate, but detection rate differed substantially by region. CONCLUSIONS A nationwide screening programme improved overall UVH and TGA detection rates, but regional differences were observed. Obesity or other maternal risk factors did not affect the screening programme efficacy. The establishment of structured guidelines and recommendations is essential when implementing the screening programme. In addition, a prospective screening register is highly recommended to ensure high quality of screening. TWEETABLE ABSTRACT Implementation of a nationwide prenatal anomaly screening improved detection rates of UVH and TGA.
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Affiliation(s)
- J Hautala
- Department of Obstetrics and Gynaecology, Women's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M Gissler
- Information Services Department, National Institute for Health and Welfare, Helsinki, Finland.,Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - A Ritvanen
- Register of Congenital Malformations, National Institute for Health and Welfare, Helsinki, Finland
| | - A Tekay
- Department of Obstetrics and Gynaecology, Women's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - O Pitkänen-Argillander
- Department of Paediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - V Stefanovic
- Department of Obstetrics and Gynaecology, Women's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Sarkola
- Department of Paediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E Helle
- Department of Paediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J Pihkala
- Department of Paediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Pätilä
- Division of Paediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - I P Mattila
- Division of Paediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E Jokinen
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J Räsänen
- Department of Obstetrics and Gynaecology, Women's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Ojala
- Department of Paediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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24
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Correa A. Maternal Body Mass Index and Congenital Heart Defects. J Am Coll Cardiol 2019; 73:54-57. [DOI: 10.1016/j.jacc.2018.10.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 11/16/2022]
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25
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McDonald SD, Woolcott C, Chapinal N, Guo Y, Murphy P, Dzakpasu S. Interprovincial variation in pre-pregnancy body mass index and gestational weight gain and their impact on neonatal birth weight with respect to small and large for gestational age. Canadian Journal of Public Health 2018; 109:527-538. [PMID: 30191462 DOI: 10.17269/s41997-018-0086-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/22/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To explore provincial variation in both excess and inadequate pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) and their impact on small- and large-for-gestational-age (SGA, LGA) infants. METHODS Four provinces with a perinatal database capturing the required exposures participated: British Columbia (BC), Ontario (ON), Nova Scotia (NS), and Newfoundland and Labrador (NL). In multiple, concurrent retrospective studies, we included women ≥ 19 years, who gave birth from 22+0 to 42+6 weeks' gestation, to a live singleton from April 2013-March 2014. From adjusted odds ratios, we calculated population attributable fractions (PAF) of SGA and LGA for BMI and GWG. RESULTS The proportion of overweight and obese women increased from western to eastern Canada. In BC, ON, NS, and NL, the proportions of women who were overweight were 21.1%, 24.0%, 23.7%, and 25.4%, while obesity proportions were 14.2%, 18.1%, 24.2%, and 29.8%, respectively. Excess GWG affected 53.9%, 49.9%, 57.6%, and 65.6% of women, respectively. Excess GWG contributed to 29.5-42.5% of LGA, compared with the PAFs for overweight (6.8-12.0%) and obesity (13.2-20.6%). Inadequate GWG's contribution to SGA (4.8-12.3%) was higher than underweight BMI's (2.9-6.2%). CONCLUSION In this interprovincial study, high and increasing proportions of women from west to east had excess pre-pregnancy BMI, and between half to two thirds had excess GWG. The contributions of GWG outside of recommendations to SGA and LGA were greater than that of low or high BMI. GWG is a potentially modifiable determinant of SGA and LGA across Canada.
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Affiliation(s)
- Sarah D McDonald
- Department of Obstetrics & Gynecology, Department of Health Research Methods, Evidence, and Impact, Department of Radiology, McMaster University, 1280 Main Street West, Room 3N52B, Hamilton, ON, L8S 4K1, Canada.
| | - Christy Woolcott
- Departments of Obstetrics & Gynaecology and Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | - Yanfang Guo
- Better Outcomes Registry & Network, Ottawa, ON, Canada
| | - Phil Murphy
- Perinatal Program Newfoundland and Labrador, and Disciplines of Obstetrics and Gynecology and Pediatrics, Faculty of Medicine, Memorial University, Newfoundland, St. John's, NL, Canada
| | - Susie Dzakpasu
- Maternal, Child and Youth Health Unit, Public Health Agency of Canada, Ottawa, ON, Canada
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26
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Maternal Obesity as a Risk Factor for the Development of Total Anomalous Pulmonary Venous Connection in Their Offspring. Arch Med Res 2018; 49:109-113. [PMID: 29907426 DOI: 10.1016/j.arcmed.2018.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 06/01/2018] [Indexed: 11/24/2022]
Abstract
The incidence of total anomalous pulmonary venous connection (TAPVC) in the Caucasian population is 2.5/100,000 live births (LB), and the incidence in the Hispanic population is 19.8/100,000 LB. Without knowing the exact etiology for the development of congenital heart disease, our objective was to determine the maternal factors associated with the development of TAPVC. METHODS 55 mother-child binomials with isolated TAPVC (group I) and 152 healthy mother-child binomials (group II) were included. Both groups had no maternal history of addiction, pre-eclampsia, or type 1, 2 or gestational diabetes mellitus. Complete clinical histories were obtained for the women in both groups and perinatal and birth data were recorded. In addition, genealogies across three generations were constructed to determine affected first- or second-degree relatives with complex congenital heart disease. RESULTS Among the maternal characteristics analyzed, women in group I had a higher number of pregnancies before gestation of the index case (p = <0.05), and the Body Mass Index (BMI) before pregnancy was higher compared to Group II (p < 0.05), with an adjusted risk of OR = 3.6 (p = 0.011). The family history showed a higher prevalence in the group of patients with TAPVC compared to healthy children (p < 0.05). CONCLUSION Maternal obesity before pregnancy is a risk factor for the development of CATVP in children in the Mexican population.
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27
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Maslen CL. Recent Advances in Placenta-Heart Interactions. Front Physiol 2018; 9:735. [PMID: 29962966 PMCID: PMC6010578 DOI: 10.3389/fphys.2018.00735] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/28/2018] [Indexed: 12/12/2022] Open
Abstract
Congenital heart defects (CHD) occur in ∼1 in every 100 live births. In addition, an estimated 10% of fetal loss is due to severe forms of CHD. This makes heart defects the most frequently occurring birth defect and single cause of in utero fatality in humans. There is considerable evidence that CHD is heritable, indicating a strong contribution from genetic risk factors. There are also known external environmental exposures that are significantly associated with risk for CHD. Hence, the majority of CHD cases have long been considered to be multifactorial, or generally caused by the confluence of several risk factors potentially from genetic, epigenetic, and environmental sources. Consequently, a specific cause can be very difficult to ascertain, although patterns of associations are very important to prevention. While highly protective of the fetus, the in utero environment is not immune to insult. As the conduit between the mother and fetus, the placenta plays an essential role in maintaining fetal health. Since it is not a fully-formed organ at the onset of pregnancy, the development of the placenta must keep pace with the growth of the fetus in order to fulfill its critical role during pregnancy. In fact, the placenta and the fetal heart actually develop in parallel, a phenomenon known as the placenta–heart axis. This leaves the developing heart particularly vulnerable to early placental insufficiency. Both organs share several developmental pathways, so they also share a common vulnerability to genetic defects. In this article we explore the coordinated development of the placenta and fetal heart and the implications for placental involvement in the etiology and pathogenesis of CHD.
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Affiliation(s)
- Cheryl L Maslen
- Knight Cardiovascular Institute, Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, United States
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28
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McDonald SD, Viaje KA, Rooney RA, Jarde A, Giglia L, Maxwell CV, Small D, Pearce Kelly T, Sabatino L, Thabane L. A clinical carepath for obese pregnant women: a pragmatic pilot cluster randomized controlled trial. J Matern Fetal Neonatal Med 2018; 32:3915-3922. [PMID: 29772928 DOI: 10.1080/14767058.2018.1478957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Objectives: Obese women are at increased risks for complications during pregnancy, birth, and in their infants. Although guidelines have been established for the clinical care of obese pregnant women, management is sometimes suboptimal. Our goal was to determine the feasibility of implementing and testing a clinical carepath for obese pregnant women compared to standard care, in a pilot cluster randomized controlled trial (RCT). Methods: A pragmatic pilot cluster RCT was conducted, randomly allocating eight clinics to the carepath or standard care for obese pregnant women. Women were eligible if they had a pre-pregnancy body mass index (BMI) of ≥30 kg/m2 and a viable singleton <21 weeks. The primary outcomes were the feasibility of conducting a full-scale cluster RCT (defined as >80%: randomization of clinics, use in eligible women, and completeness of follow-up) and of the intervention (defined as >80%: compliance with each step in the carepath and recommendation of the carepath by clinicians to a colleague). Results: All eight approached clinics agreed to participate and were randomized. Half of the intervention clinics used the carepath, resulting in <80% uptake of eligible women. High follow-up (99.5%) was achieved, in 188 of 189 women. The carepath was feasible for numerous guideline-directed recommendations for screening, but less so for counseling topics. When the carepath was used in the majority of women, all clinicians, most of whom were midwives, reported they would recommend it to a colleague. The intervention group had significantly higher overall adherence to the guideline recommendations compared to control (relative risk: 1.71, 95% confidence interval: 1.57-1.87). Conclusions: In this pragmatic pilot cluster RCT, a guideline-directed clinical carepath improved some aspects of care of obese pregnant women and was recommended by clinicians, particularly midwives. A cluster RCT may not be feasible in a mix of obstetric and midwifery clinics, but may be feasible in midwifery clinics.
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Affiliation(s)
- Sarah D McDonald
- Department of Obstetrics and Gynaecology, McMaster University , Hamilton , Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University , Hamilton , Canada
| | - Kristen A Viaje
- Department of Obstetrics and Gynaecology, McMaster University , Hamilton , Canada
| | | | - Alexander Jarde
- Department of Obstetrics and Gynaecology, McMaster University , Hamilton , Canada
| | - Lucia Giglia
- Department of Pediatrics, McMaster University , Hamilton , Canada
| | - Cynthia V Maxwell
- Maternal Fetal Medicine Division, Mount Sinai Hospital , Toronto , Canada
| | - David Small
- Department of Obstetrics and Gynaecology, McMaster University , Hamilton , Canada.,Department of Obstetrics and Gynaecology, St. Joseph's Healthcare , Hamilton , Canada
| | - Tracy Pearce Kelly
- Department of Family Medicine, McMaster University , Hamilton , Canada.,Burlington & Area Midwives , Burlington , Canada
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University , Hamilton , Canada.,Biostatistics Unit/FSORC, St. Joseph's Healthcare , Hamilton , Canada
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29
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Vavolizza RD, Dar P, Suskin B, Moore RM, Stern KWD. Clinical yield of fetal echocardiography for suboptimal cardiac visualization on obstetric ultrasound. CONGENIT HEART DIS 2018; 13:407-412. [PMID: 29372591 DOI: 10.1111/chd.12584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 11/17/2017] [Accepted: 12/29/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Suboptimal cardiac imaging on obstetric ultrasound is a frequent referral indication for fetal echocardiography, even in the absence of typical risk factors for fetal cardiac disease. The clinical profile of patients and findings of examinations performed for such an indication are not well defined. Given the increased cost, time and resource utilization of fetal echocardiography, we sought to determine the clinical findings of such referrals. STUDY DESIGN We performed a single-center review of such referrals from January 2010 to June 2016. Patients with commonly accepted indications for fetal echocardiography were excluded. Demographic variables and echocardiogram findings were collected. Findings were classified as (1) "normal," (2) "probably normal," if minor pathology could not confidently be excluded, or if minor findings were noted that were expected to resolve, or (3) "abnormal." Rates of pathology were determined with comparison of nonobese and obese populations. RESULTS A total of 583 gestations in 562 women were included (median gestational age 23.3 weeks, range 19.0-38.4). The median body mass index (BMI) was 34.6 kg/m2 (range 17.2-66.3 kg/m2 ). The majority of women were obese (BMI ≥ 30 kg/m2 in 74.6%). Overall, 574 of 583 examinations (98.5%) were normal or "probably normal." Pathology was noted in 9 fetuses (1.5%), 3 of whom required intervention (0.5%). No ductal dependent lesions were diagnosed. There was no significant difference in pathology rates between nonobese and obese mothers. CONCLUSIONS We found a low fetal cardiac anomaly rate in studies performed for suboptimal views on obstetric ultrasound. The majority of women referred for this indication were obese. The practice of routine referral for this indication deserves further evaluation.
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Affiliation(s)
- Rick D Vavolizza
- Department of Pediatrics, Division of Cardiology, Children's Hospital at Montefiore, New York, New York, USA.,University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Pe'er Dar
- Department of Obstetrics and Gynecology, Division of Fetal Medicine and Ultrasound, Montefiore Medical Center, New York, New York, USA.,Albert Einstein College of Medicine, New York, New York, USA
| | - Barrie Suskin
- Department of Obstetrics and Gynecology, Division of Fetal Medicine and Ultrasound, Montefiore Medical Center, New York, New York, USA.,Albert Einstein College of Medicine, New York, New York, USA
| | - Robert M Moore
- Albert Einstein College of Medicine, New York, New York, USA.,Department of Obstetrics and Gynecology; Division of Maternal Fetal Medicine, Jacobi Medical Center, New York, New York, USA
| | - Kenan W D Stern
- Department of Pediatrics, Division of Cardiology, Children's Hospital at Montefiore, New York, New York, USA.,Albert Einstein College of Medicine, New York, New York, USA
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30
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Zhu Y, Chen Y, Feng Y, Yu D, Mo X. Association between maternal body mass index and congenital heart defects in infants: A meta-analysis. CONGENIT HEART DIS 2018; 13:271-281. [PMID: 29363266 DOI: 10.1111/chd.12567] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/05/2017] [Accepted: 12/10/2017] [Indexed: 11/28/2022]
Abstract
We conducted this meta-analysis to address the open question of a possible association between maternal body mass index (BMI) and congenital heart defects (CHDs) in infants. We conducted a comprehensive computerized search of PubMed, Web of Science, Medline, and Embase databased (January 1980 through August 2017). We assessed the association between maternal BMI and the risk for congenital heart defects in their offspring. Study-specific relative risk estimates were polled according to random-effect or fixed-effect models. From 2567 citations, a total of 13 case-control studies and 4 cohort studies were selected for a meta-analysis, including more than 1 150 000 cases. The pooled odds radio (OR) of 1.065 (95% confidence interval [CI], 1.021-1.100; P = .001; I2 = 60.1%) indicated a positive effect of maternal overweight status (BMI 25.0-29.9 kg/m2 ) on the risk for congenital heart defects in infants. Moreover, we observed a significant association between maternal obesity (BMI ≥ 30 kg/m2 ) and congenital heart defects in their offspring (OR: 1.174; 95% CI, 1.146-1.203, P = 0.161; I2 =25.5%). However, there was little significant evidence of an association between maternal underweight status (BMI < 18.5 kg/m2 ) and offspring with congenital heart defects, and the pooled OR was 1.015 (95% CI, 0.980-1.052; P = 0.085; I2 =34.0%). Our meta-analysis provides robust evidence of the positive association between maternal BMI and the risk for fetal congenital heart defects.
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Affiliation(s)
- Yu Zhu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Chen
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Feng
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Soochow, China
| | - Di Yu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
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31
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Chaemsaithong P, Leung TY, Sahota D, Cheng YKY, Leung WC, Lo TK, Poon LCY. Body mass index at 11–13 weeks’ gestation and pregnancy complications in a Southern Chinese population: a retrospective cohort study. J Matern Fetal Neonatal Med 2018; 32:2056-2068. [PMID: 29301455 DOI: 10.1080/14767058.2018.1424824] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Piya Chaemsaithong
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - Daljit Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - Yvonne Kwun Yue Cheng
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing Cheong Leung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong, China
| | - Tsz Kin Lo
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Liona Chiu Yee Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
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Hoang TT, Goldmuntz E, Roberts AE, Chung WK, Kline JK, Deanfield JE, Giardini A, Aleman A, Gelb BD, Mac Neal M, Porter GA, Kim R, Brueckner M, Lifton RP, Edman S, Woyciechowski S, Mitchell LE, Agopian AJ. The Congenital Heart Disease Genetic Network Study: Cohort description. PLoS One 2018; 13:e0191319. [PMID: 29351346 PMCID: PMC5774789 DOI: 10.1371/journal.pone.0191319] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/03/2018] [Indexed: 01/05/2023] Open
Abstract
The Pediatric Cardiac Genomics Consortium (PCGC) designed the Congenital Heart Disease Genetic Network Study to provide phenotype and genotype data for a large congenital heart defects (CHDs) cohort. This article describes the PCGC cohort, overall and by major types of CHDs (e.g., conotruncal defects) and subtypes of conotrucal heart defects (e.g., tetralogy of Fallot) and left ventricular outflow tract obstructions (e.g., hypoplastic left heart syndrome). Cases with CHDs were recruited through ten sites, 2010–2014. Information on cases (N = 9,727) and their parents was collected through interviews and medical record abstraction. Four case characteristics, eleven parental characteristics, and thirteen parent-reported neurodevelopment outcomes were summarized using counts and frequencies and compared across CHD types and subtypes. Eleven percent of cases had a genetic diagnosis. Among cases without a genetic diagnosis, the majority had conotruncal heart defects (40%) or left ventricular outflow tract obstruction (21%). Across CHD types, there were significant differences (p<0.05) in the distribution of all four case characteristics (e.g., sex), four parental characteristics (e.g., maternal pregestational diabetes), and five neurodevelopmental outcomes (e.g., learning disabilities). Several characteristics (e.g., sex) were also significantly different across CHD subtypes. The PCGC cohort is one of the largest CHD cohorts available for the study of genetic determinants of risk and outcomes. The majority of cases do not have a genetic diagnosis. This description of the PCGC cohort, including differences across CHD types and subtypes, provides a reference work for investigators who are interested in collaborating with or using publically available resources from the PCGC.
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Affiliation(s)
- Thanh T. Hoang
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, United States of America
| | - Elizabeth Goldmuntz
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Amy E. Roberts
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts, United States of America
| | - Wendy K. Chung
- Department of Pediatrics, Columbia University Medical Center, New York, New York, United States of America
- Department of Medicine, Columbia University Medical Center, New York, New York, United States of America
| | - Jennie K. Kline
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - John E. Deanfield
- Cardiothoracic Unit, Great Ormond Street Hospital, London, England
- University College London Institute of Cardiovascular Science, University College London, London, England
| | | | - Adolfo Aleman
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Bruce D. Gelb
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Meghan Mac Neal
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - George A. Porter
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Richard Kim
- Section of Cardiothoracic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, United States of America
| | - Martina Brueckner
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Richard P. Lifton
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Yale Center for Mendelian Genomics, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Sharon Edman
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Stacy Woyciechowski
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Laura E. Mitchell
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, United States of America
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, United States of America
- * E-mail:
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Lin N, Cai Y, Zhang L, Chen Y. Identification of key genes associated with congenital heart defects in embryos of diabetic mice. Mol Med Rep 2017; 17:3697-3707. [PMID: 29286097 PMCID: PMC5802176 DOI: 10.3892/mmr.2017.8330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 09/05/2017] [Indexed: 12/13/2022] Open
Abstract
Maternal diabetes has been reported to be a critical factor for congenital heart defects (CHD) in offspring. The present study aimed to screen the key genes that may be involved in CHD in offspring of diabetic mothers. The present study obtained the gene expression profile of GSE32078, including three embryonic heart tissue samples at embryonic day 13.5 (E13.5), three embryonic heart tissue samples at embryonic day 15.5 (E15.5) from diabetic mice and their respective controls from normal mice. The cut-off criterion of P<0.08 was set to screen differentially expressed genes (DEGs). Their enrichment functions were predicted by Gene Ontology. The enriched pathways were forecasted by Kyoto Encyclopedia of Genes and Genomes and Reactome analysis. Protein-protein interaction (PPI) networks for DEGs were constructed using Cytoscape. The present study identified 869 and 802 DEGs in E13.5 group and E15.5 group, respectively and 182 DEGs were shared by the two developmental stages. The pathway enrichment analysis results revealed that DEGs including intercellular adhesion molecule 1 (Icam1) and H2-M9 were enriched in cell adhesion molecules; DEGs including bone morphogenetic protein receptor type 1A, transforming growth factor β receptor 1 and SMAD specific E3 ubiquitin protein ligase 1 were enriched in the tumor growth factor-β signaling pathway. In addition, DEGs including Icam1, C1s and Fc fragment of IgG receptor IIb were enriched in Staphylococcus aureus infection. Furthermore, the shared DEGs including Icam1, nuclear receptor corepressor 1 (Ncor1) and AKT serine/threonine kinase 3 (Akt3) had high connectivity degrees in the PPI network. The shared DEGs including Icam1, Ncor1 and Akt3 may be important in the cardiogenesis of embryos. These genes may be involved in the development of CHD in the offspring of diabetic mothers.
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Affiliation(s)
- Nan Lin
- Department of Obstetrics and Gynecology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yan Cai
- Department of Obstetrics and Gynecology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Linlin Zhang
- Gastroenterology Department, Harbin The First Hospital, Harbin, Heilongjiang 150001, P.R. China
| | - Yahang Chen
- Department of Obstetrics and Gynecology, The Hospital of Heilongjiang, Harbin, Heilongjiang 150001, P.R. China
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Maffoni S, De Giuseppe R, Stanford FC, Cena H. Folate status in women of childbearing age with obesity: a review. Nutr Res Rev 2017; 30:265-271. [PMID: 28587698 PMCID: PMC6232191 DOI: 10.1017/s0954422417000142] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Several studies have described a positive association between elevated BMI and birth defects risk. Data on plasma concentration of folate in pregnant women with obesity have shown values far below those recommended, regardless of diet, while folate levels should increase before pregnancy to reduce neural tube defects. We report a descriptive review of the most recent studies (from 2005 to 2015) to evaluate folate status through a population of women of childbearing age affected by obesity. The literature contains few studies, which present conflicting results regarding folate status in non-pregnant women of childbearing age affected by obesity, and it appears that there is a modification in folate metabolism, with a reduction in plasma folate levels and an increase in erythrocyte folate uptake. In conclusion, the folate status in women of childbearing age should be assessed by both plasma and erythrocyte levels to start a personalised and more adequate supplementation before conception. Further studies need to be conducted in a larger population, which take into account variables that can affect folate metabolism, such as dietary intake, lifestyle and genetic factors, oral contraceptives or other drug use, previous weight-loss programmes, or a history of bariatric surgery.
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Affiliation(s)
- Silvia Maffoni
- University of Pavia, Department of Public Health, Experimental and Forensic Medicine, Unit of Human Nutrition, Pavia, Italy
| | - Rachele De Giuseppe
- University of Pavia, Department of Public Health, Experimental and Forensic Medicine, Unit of Human Nutrition, Pavia, Italy
| | - Fatima Cody Stanford
- Department of Medicine and Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hellas Cena
- University of Pavia, Department of Public Health, Experimental and Forensic Medicine, Unit of Human Nutrition, Pavia, Italy
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Trevathan E. Editorial brain malformation surveillance in the Zika era. ACTA ACUST UNITED AC 2017; 106:869-874. [PMID: 27891785 PMCID: PMC5132043 DOI: 10.1002/bdra.23582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022]
Abstract
The current surveillance systems for congenital microcephaly are necessary to monitor the impact of Zika virus (ZIKV) on the developing human brain, as well as the ZIKV prevention efforts. However, these congenital microcephaly surveillance systems are insufficient. Abnormalities of neuronal differentiation, development and migration may occur among infants with normal head circumference who have intrauterine exposure to ZIKV. Therefore, surveillance for congenital microcephaly does not ascertain many of the infants seriously impacted by congenital ZIKV infection. Furthermore, many infants with normal head circumference and with malformations of the brain cortex do not have clinical manifestations of their congenital malformations until several months to many years after birth, when they present with clinical manifestations such as seizures/epilepsy, developmental delays with or without developmental regression, and/or motor impairment. In response to the ZIKV threat, public health surveillance systems must be enhanced to ascertain a wide variety of congenital brain malformations, as well as their clinical manifestations that lead to diagnostic brain imaging. Birth Defects Research (Part A) 106:869–874, 2016. © 2016 The Authors Birth Defects Research Part A: Clinical and Molecular Teratology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Edwin Trevathan
- The Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,The Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Parnell AS, Correa A, Reece EA. Pre-pregnancy Obesity as a Modifier of Gestational Diabetes and Birth Defects Associations: A Systematic Review. Matern Child Health J 2017; 21:1105-1120. [PMID: 28120287 DOI: 10.1007/s10995-016-2209-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Inconsistent findings of associations between gestational diabetes mellitus (GDM) and birth defects suggest unaccounted confounders may underlie the actual basis for such associations. We conducted a systematic review to assess observed associations between GDM and birth defects and the extent to which these could be explained by pre-pregnancy obesity. Methods Using a combination of search terms for GDM and birth defects, we searched PubMed, Scopus, CINAHL, and ClinicalTrials.gov for human-based studies published through September 2013. Studies were eligible for inclusion if they included information on maternal diabetes status, method of diagnosis of GDM, and assessment of birth defects. Twenty-four of 768 potential articles were included. We collected information on study design, location and period, method of determination of diabetes status, types of birth defects, and measures of association reported. Results There was no evidence for consistent association of GDM with birth defects, with the exception of a weak association between GDM and congenital heart defects. When stratified by maternal pre-pregnancy BMI, an association between GDM and congenital heart defects and between GDM and neural tube defects was evident only in women with both GDM and pre-pregnancy obesity. Conclusions for Practice Our findings suggest reported associations between GDM and birth defects may be due, in part, to undiagnosed metabolic disorders associated with obesity, such as pregestational diabetes mellitus, rather than GDM. These findings highlight the need for increased efforts for pre-pregnancy screening for undiagnosed diabetes and awareness of the importance of weight management among women of childbearing age with obesity.
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Affiliation(s)
- Aimee S Parnell
- Department of Pediatrics, University of Mississippi School of Medicine, 2500 North State Street, Jackson, MS, 39216, USA.
- Children's of Mississippi, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Adolfo Correa
- Department of Pediatrics, University of Mississippi School of Medicine, 2500 North State Street, Jackson, MS, 39216, USA
- Department of Medicine, University of Mississippi School of Medicine, 2500 North State Street, Jackson, MS, 39216, USA
| | - E Albert Reece
- University of Maryland School of Medicine, 655 W. Baltimore Street, Room 14-029, Baltimore, MD, 21201-1559, USA
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Benítez S, Barreto Paternina A, Duro E. Relación entre sobrepeso y obesidad materna con cardiopatías congénitas. Estudio retrospectivo caso-control en el área norte de Buenos Aires. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2017. [DOI: 10.1016/j.rprh.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Nembhard WN, Tang X, Hu Z, MacLeod S, Stowe Z, Webber D. Maternal and infant genetic variants, maternal periconceptional use of selective serotonin reuptake inhibitors, and risk of congenital heart defects in offspring: population based study. BMJ 2017; 356:j832. [PMID: 28264803 PMCID: PMC6283388 DOI: 10.1136/bmj.j832] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To evaluate whether the association between maternal periconceptional use of selective serotonin reuptake inhibitors (SSRIs) and increased risk of congenital heart defects in offspring is modified by maternal or infant genetic variants in folate, homocysteine, or transsulfuration pathways.Design Population based study. DNA from mothers, fathers, and infants was genotyped with an Illumina GoldenGate custom single nucleotide polymorphism panel. A hybrid design based on a log linear model was used to calculate relative risks and Bayesian false discovery probabilities (BFDP) to identify polymorphisms associated with congenital heart defects modified by SSRI use.Data sources Data from the US National Birth Defects Prevention Study on 1180 liveborn infants with congenital heart defects and 1644 controls, born 1997-2008.Main outcome measures Cases included infants with selected congenital heart defects and control infants had no major defects. SSRI use was obtained from telephone interviews with mothers.Results For women who reported taking SSRIs periconceptionally, maternal SHMT1 (rs9909104) GG and AGgenotypes were associated with a 5.9 and 2.4 increased risk of select congenital heart defects in offspring, respectively, versus the AA genotype (BFDP=0.69). Compared with the AA genotype, BHMT (rs492842 and rs542852) GG and AG genotypes were associated with twice the riskof congenital heart defects (BFDP=0.74 and 0.79, respectively). MGST1 (rs2075237) CC and ACgenotypes were associated with an increased risk compared with the GG genotype (8.0 and 2.8, respectively; BFDP=0.79). Single nucleotide polymorphism in infant genes in the folate (MTHFS rs12438477), homocysteine (TRDMT1 rs6602178 and GNMT rs11752813) and transsulfuration (GSTP1 rs7941395 and MGST1 rs7294985) pathways were also associated with an increased risk of congenital heart defects.Conclusions Common maternal or infant genetic variants in folate, homocysteine, or transsulfuration pathways are associated with an increased risk of certain congenital heart defects among children of women taking SSRIs during cardiogenesis.
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Affiliation(s)
- Wendy N Nembhard
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, 72202, USA
| | - Xinyu Tang
- Division of Biostatistics, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, AR, 72202 USA
| | - Zhuopei Hu
- Division of Biostatistics, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, AR, 72202 USA
| | - Stewart MacLeod
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, 72202, USA
| | - Zachary Stowe
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, 72205, USA
| | - Daniel Webber
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, 72202, USA
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Pei L, Kang Y, Zhao Y, Yan H. Prevalence and risk factors of congenital heart defects among live births: a population-based cross-sectional survey in Shaanxi province, Northwestern China. BMC Pediatr 2017; 17:18. [PMID: 28086762 PMCID: PMC5237335 DOI: 10.1186/s12887-017-0784-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/07/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Nearly half of the population of Northwest China live in Shaanxi province, but population-based data on the epidemiologic characteristics of congenital heart defects (CHD) in this population is limited. The study aimed to investigate the prevalence and epidemiologic characteristics of the CHD among infants born between 2010 and 2013 in Shaanxi province. METHODS Infants born between 2010 and 2013 in Shaanxi province were surveyed using a stratified multi-stage sampling method. Participant characteristics were recorded by questionnaire, medical records were reviewed and CHD was diagnosed using a specialized neonatal echocardiography. A Poisson regression model was applied to assess the association between any CHD and possible risk factors. RESULTS A total of 29098 live infants were surveyed with an overall prevalence of 76.0 (95% CI: 66.3, 86.7) per 10000 live infants. The prevalence of major and minor CHD were 26.1 and 49.8 per 10000 live infants, respectively, in surveyed areas. Poisson regression analysis indicated that, compared with singleton infants, the prevalence rate ratio of CHD was higher in twin and multi-fetal infants (PRR:3.1, 95% CI:1.6, 6.1). Using southern Shaanxi as a reference, the PRR of CHD were lower in northern (PRR:0.4, 95% CI:0.3, 0.6) and central Shaanxi province (PRR:0.5, 95% CI:0.4, 0.7). PRR was higher in mothers over 30 years of age than in those under 25 years (PRR:1.6, 95% CI:1.0, 2.5), and in mothers with ≥3 parity than that in mothers with only one parity (PRR:2.2, 95% CI:1.2, 4.2). The risk for CHD among live infants was positively associated with family history of CHD (PRR: 9.8, 95% CI: 5.3, 18.1). Additionally, CHD was less common in the floating population than the permanent population (PRR: 0.6, 95% CI: 0.4, 0.9). CONCLUSION The CHD among live infants seemed to be a serious health problem in Shaanxi province as well as in Northwestern China. Our research have important policy implications for recommendations on CHD intervention in Northwest China.
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Affiliation(s)
- Leilei Pei
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Yijun Kang
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Yaling Zhao
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Hong Yan
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, People's Republic of China.
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Jay PY, Akhirome E, Magnan RA, Zhang MR, Kang L, Qin Y, Ugwu N, Regmi SD, Nogee JM, Cheverud JM. Transgenerational cardiology: One way to a baby's heart is through the mother. Mol Cell Endocrinol 2016; 435:94-102. [PMID: 27555292 PMCID: PMC5014674 DOI: 10.1016/j.mce.2016.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 08/18/2016] [Accepted: 08/18/2016] [Indexed: 12/17/2022]
Abstract
Despite decades of progress, congenital heart disease remains a major cause of mortality and suffering in children and young adults. Prevention would be ideal, but formidable biological and technical hurdles face any intervention that seeks to target the main causes, genetic mutations in the embryo. Other factors, however, significantly modify the total risk in individuals who carry mutations. Investigation of these factors could lead to an alternative approach to prevention. To define the risk modifiers, our group has taken an "experimental epidemiologic" approach via inbred mouse strain crosses. The original intent was to map genes that modify an individual's risk of heart defects caused by an Nkx2-5 mutation. During the analysis of >2000 Nkx2-5(+/-) offspring from one cross we serendipitously discovered a maternal-age associated risk, which also exists in humans. Reciprocal ovarian transplants between young and old mothers indicate that the incidence of heart defects correlates with the age of the mother and not the oocyte, which implicates a maternal pathway as the basis of the risk. The quantitative risk varies between strain backgrounds, so maternal genetic polymorphisms determine the activity of a factor or factors in the pathway. Most strikingly, voluntary exercise by the mother mitigates the risk. Therefore, congenital heart disease can in principle be prevented by targeting a maternal pathway even if the embryo carries a causative mutation. Further mechanistic insight is necessary to develop an intervention that could be implemented on a broad scale, but the physiology of maternal-fetal interactions, aging, and exercise are notoriously complex and undefined. This suggests that an unbiased genetic approach would most efficiently lead to the relevant pathway. A genetic foundation would lay the groundwork for human studies and clinical trials.
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Affiliation(s)
- Patrick Y Jay
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA; Departments of Genetics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
| | - Ehiole Akhirome
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Rachel A Magnan
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - M Rebecca Zhang
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Lillian Kang
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Yidan Qin
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Nelson Ugwu
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Suk Dev Regmi
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Julie M Nogee
- Departments of Pediatrics, Washington University School of Medicine, Box 8208, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - James M Cheverud
- Department of Biology, Loyola University Chicago, Chicago, IL, USA
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Riehle-Colarusso TJ, Bergersen L, Broberg CS, Cassell CH, Gray DT, Grosse SD, Jacobs JP, Jacobs ML, Kirby RS, Kochilas L, Krishnaswamy A, Marelli A, Pasquali SK, Wood T, Oster ME. Databases for Congenital Heart Defect Public Health Studies Across the Lifespan. J Am Heart Assoc 2016; 5:JAHA.116.004148. [PMID: 27912209 PMCID: PMC5210337 DOI: 10.1161/jaha.116.004148] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tiffany J Riehle-Colarusso
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lisa Bergersen
- Department of Cardiology, Harvard Medical School, Children's Hospital of Boston, MA
| | - Craig S Broberg
- Adult Congenital Heart Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | - Cynthia H Cassell
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Darryl T Gray
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, MD
| | - Scott D Grosse
- Office of the Director, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, FL.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Marshall L Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, FL.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Russell S Kirby
- Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, FL
| | - Lazaros Kochilas
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Asha Krishnaswamy
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Arianne Marelli
- McGill Adult Unit for Congenital Heart Disease, Montreal, Québec, Canada
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Thalia Wood
- Association of Public Health Laboratories, Silver Spring, MD
| | - Matthew E Oster
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.,Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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Simeone RM, Tinker SC, Gilboa SM, Agopian AJ, Oster ME, Devine OJ, Honein MA. Proportion of selected congenital heart defects attributable to recognized risk factors. Ann Epidemiol 2016; 26:838-845. [PMID: 27894567 DOI: 10.1016/j.annepidem.2016.10.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 09/30/2016] [Accepted: 10/08/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess the contribution of multiple risk factors for two congenital heart defects-hypoplastic left heart syndrome (HLHS) and tetralogy of Fallot (TOF). METHODS We used data from the National Birth Defects Prevention Study (1997-2011) to estimate average adjusted population attributable fractions for several recognized risk factors, including maternal prepregnancy overweight-obesity, pregestational diabetes, age, and infant sex. RESULTS There were 594 cases of isolated simple HLHS, 971 cases of isolated simple TOF, and 11,829 controls in the analysis. Overall, 57.0% of HLHS cases and 37.0% of TOF cases were estimated to be attributable to risk factors included in our model. Among modifiable HLHS risk factors, maternal prepregnancy overweight-obesity accounted for the largest proportion of cases (6.5%). Among modifiable TOF risk factors, maternal prepregnancy overweight-obesity and maternal age of 35 years or older accounted for the largest proportions of cases (8.3% and 4.3%, respectively). CONCLUSIONS Approximately half of HLHS cases and one-third of TOF cases were estimated to be attributable to risk factors included in our models. Interventions targeting factors that can be modified may help reduce the risk of HLHS and TOF development. Additional research into the etiology of HLHS and TOF may reveal other modifiable risk factors that might contribute to primary prevention efforts.
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Affiliation(s)
- Regina M Simeone
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Sarah C Tinker
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Suzanne M Gilboa
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - A J Agopian
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Houston, TX
| | - Matthew E Oster
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA; Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Owen J Devine
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA; Carter Consulting, Atlanta, GA
| | - Margaret A Honein
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
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The impact of environmental factors on the occurrence of congenital heart disease in the form of hypoplastic left heart syndrome. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:204-7. [PMID: 26702275 PMCID: PMC4631911 DOI: 10.5114/kitp.2015.54455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 08/18/2015] [Accepted: 08/25/2015] [Indexed: 11/30/2022]
Abstract
Introduction Congenital heart defects are the most common abnormalities in neonatal age. Congenital heart defects occur with a frequency of 3-12/1000 births. A special group is constituted by children with hypoplastic left heart syndrome because their treatment is extremely complex, requiring three-stage surgery and the involvement of various specialists. Material and methods We analysed 100 infants with congenital heart defects in the form of hypoplastic left heart syndrome (HLHS). They were compared with a control group of 100 newborns without structural heart defects. The children's parents were asked to fill out a questionnaire consisting of 10 simple questions. It had been constructed in consultation with a psychologist in order not to offend the feelings of the parents affected by the illness of their offspring. Results Congenital heart defects were present in the family medical histories of 16 HLHS children and 11 healthy children (p = 0.4). Genetic disorders were present in the family medical histories of 13 HLHS children and 15 healthy children (p = 0.73). In the HLHS group, the mothers smoked cigarettes or were exposed to tobacco smoke in 32% of cases; in the control group, this proportion amounted to 23% (p = 0.76). Conclusions The study found no relationship between the occurrence of hypoplastic left heart syndrome in children and the parents’ age, the presence of genetic disorders, or heart defects in the family medical histories.
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Carmichael SL, Yang W, Gilboa S, Ailes E, Correa A, Botto LD, Feldkamp ML, Shaw GM. Elevated body mass index and decreased diet quality among women and risk of birth defects in their offspring. ACTA ACUST UNITED AC 2015; 106:164-71. [PMID: 26663631 DOI: 10.1002/bdra.23471] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND We examined whether risks of 32 birth defects were higher than expected in the presence of overweight or obese body mass index (BMI) and low diet quality, based on estimating individual and joint effects of these factors and calculating relative excess risk due to interaction. METHODS Analyses included mothers of 20,250 cases with birth defects and 8617 population-based controls without birth defects born from 1997 to 2009 and interviewed for the National Birth Defects Prevention Study. We used logistic regression to generate adjusted odds ratios (AORs) reflecting the combined effects of BMI and diet quality. We focused analyses on 16 birth defects (n = 11,868 cases, 8617 controls) for which initial results suggested an association with BMI or diet quality. RESULTS Relative to the reference group (normal weight women with not low diet quality, i.e., >lowest quartile), AORs for low diet quality among normal weight women tended to be >1, and AORs for overweight and obese women tended to be stronger among women who had low diet quality than not low diet quality. For 9/16 birth defects, AORs for obese women who had low diet quality-the group we hypothesized to have highest risk-were higher than other stratum-specific AORs. Most relative excess risk due to interactions were positive but small (<0.5), with confidence intervals that included zero. CONCLUSION These findings provide evidence for the hypothesis of highest birth defect risks among offspring to women who are obese and have low diet quality but insufficient evidence for an interaction of these factors in their contribution to risk.
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Affiliation(s)
| | - Wei Yang
- Department of Pediatrics, Stanford University, Stanford, California
| | - Suzanne Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth Ailes
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adolfo Correa
- Departments of Medicine and Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lorenzo D Botto
- Division of Medical Genetics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Marcia L Feldkamp
- Division of Medical Genetics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gary M Shaw
- Department of Pediatrics, Stanford University, Stanford, California
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Adekola H, Soto E, Dai J, Lam-Rachlin J, Gill N, Leon-Peters J, Puder K, Abramowicz JS. Optimal visualization of the fetal four-chamber and outflow tract views with transabdominal ultrasound in the morbidly obese: Are we there yet? JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:548-555. [PMID: 26419498 DOI: 10.1002/jcu.22307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/27/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND To compare optimal visualization of the four-chamber and outflow-tract views of the fetal heart on sonographic examination between morbidly obese (body mass index [BMI] ≥ 40 kg/m(2) ) and nonobese (BMI < 25 kg/m(2) ) pregnant women. METHODS In this retrospective cohort study, we included records and images from 509 pregnant women who had first undergone sonographic examination between 18 and 36 weeks' fetal gestational age. RESULTS Compared with the nonobese women, morbidly obese women had lower optimal visualization of the four-chamber and outflow-tract heart views: four-chamber view, morbidly obese, 83/186 (44.6%), versus nonobese, 283/323 (87.6%), and outflow-tract view, morbidly obese, 80/186 (43%) versus nonobese, 258/290 (89%); p < 0.0001 for each comparison. Similar outcomes were observed when the results from each subcategory of morbidly obese women (ie, BMI 40-49.9, 50-59.9, and ≥60 kg/m(2) ) were compared with that from nonobese women; p < 0.0001 for each comparison. These outcomes remained the same regardless of whether this comparison was made among those who had their examination before or at 19 weeks' or more gestational age. Among the morbidly obese women, there was no difference in optimal visualization of the four-chamber or outflow-tract views regardless of whether the examination was performed at <23 weeks' or at ≥23 weeks' gestational age: four-chamber view <23 weeks, 44.8% (78/174), versus four-chamber view ≥23 weeks, 41.7% (5/12); p = 0.8, and outflow-tract view <23 weeks, 43.1% (75/174), versus outflow-tract view ≥23 weeks, 41.7% (5/12); p = 0.9. After controlling for maternal age and race, the odds of visualizing the four-chamber and outflow-tract views in the morbidly obese were reduced compared with those in their nonobese counterparts: odds ratio (OR) for four-chamber, 0.13; 95% confidence interval (CI), 0.08-0.21, and OR for outflow-tract, 0.11; 95% CI, 0.07-0.17. CONCLUSIONS Optimal visualization of the fetal four-chamber and outflow-tract views was achieved in less than 50% of morbidly obese women, compared with almost 90% in nonobese women.
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Affiliation(s)
- Henry Adekola
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wayne State University/Detroit Medical Center, Detroit, MI, 48201
| | - Eleazar Soto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Health Science Center at Houston, Houston, TX, 77030
| | - Jing Dai
- C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, 48201
| | - Jennifer Lam-Rachlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wayne State University/Detroit Medical Center, Detroit, MI, 48201
| | - Navleen Gill
- Department of Obstetrics and Gynecology, Wayne State University/Detroit Medical Center, Detroit, MI, 48201
| | - Jocelyn Leon-Peters
- Department of Obstetrics and Gynecology, Wayne State University/Detroit Medical Center, Detroit, MI, 48201
| | - Karoline Puder
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wayne State University/Detroit Medical Center, Detroit, MI, 48201
| | - Jacques S Abramowicz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wayne State University/Detroit Medical Center, Detroit, MI, 48201
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Dawson AL, Razzaghi H, Arth A, Canfield MA, Parker SE, Reefhuis J. Maternal exposures in the National Birth Defects Prevention Study: Time trends of selected exposures. BIRTH DEFECTS RESEARCH. PART A, CLINICAL AND MOLECULAR TERATOLOGY 2015; 103:703-12. [PMID: 25884728 PMCID: PMC4617636 DOI: 10.1002/bdra.23377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Our objective was to describe time trends in selected pregnancy exposures in the National Birth Defects Prevention Study (NBDPS). METHODS We analyzed data from the NBDPS, a multi-site case-control study of major birth defects, for mothers of live-born infants without birth defects (controls), with an expected date of delivery (EDD) from 1998 to 2011. Mothers from the 10 participating centers across the United States were interviewed by phone between 6 weeks and 2 years after the EDD. We focused on maternal race/ethnicity and five maternal risk factors: obesity, use of folic acid-containing multivitamins, opioid analgesics, selective serotonin reuptake inhibitors, and loratadine because of their prevalence of use and some reports of associations with major birth defects. Prevalence time trends were examined using the Kendall's τβ test statistic. RESULTS The exposure trend analysis included 11,724 control mothers with EDDs from 1998 to 2011. We observed a significant increase in obesity prevalence among control mothers, as well as use of selective serotonin reuptake inhibitors and loratadine. We also observed an increase in periconceptional use of folic acid-containing multivitamins. Some of the time trends varied by race/ethnicity. No remarkable trend in the overall use of opioid analgesics was observed. The racial/ethnic distribution of mothers changed slightly during the study period. CONCLUSION Long-term, population-based case-control studies continue to be an effective way to assess exposure-birth defects associations and provide guidance to health care providers. However, investigators examining rare outcomes covering many years of data collection need to be cognizant of time trends in exposures.
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Affiliation(s)
- April L Dawson
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Hilda Razzaghi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Annelise Arth
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Samantha E Parker
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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Alwan S, Chambers CD. Findings from the National Birth Defects Prevention Study: Interpretation and translation for the clinician. ACTA ACUST UNITED AC 2015; 103:721-8. [PMID: 26109026 DOI: 10.1002/bdra.23394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The National Birth Defects Prevention Study (NBDPS) is a large U.S. multi-site case-control study first established in 1996 to identify potentially preventable environmental causes and genetic risk factors for more than 30 selected categories of major birth defects. METHODS Numerous reports with both positive and negative findings have been produced by the NBDPS, and many have influenced clinical practice. Many NBDPS reports have included novel findings, and in some cases these findings could only be considered hypothesis-generating. Other reports have met criteria for causality such as replication of findings in other studies, biological plausibility, and coherence. RESULTS However, translation of even strongly supported associations, in some cases, has required clinicians to learn to communicate information to patients about small and uncertain absolute risks in the context of the potential effects of under- or poorly treated maternal conditions. CONCLUSION The NBDPS has continued to play an important role as a rich U.S. data source that can advance the understanding of maternal conditions and their treatments in relation to birth defects.
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Affiliation(s)
- Sura Alwan
- Department of Medical Genetics, University of British Columbia, Vancouver BC, Canada
| | - Christina D Chambers
- Department of Pediatrics, University of California, San Diego, La Jolla, California.,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California
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Iessa N, Bérard A. Update on Prepregnancy Maternal Obesity: Birth Defects and Childhood Outcomes. J Pediatr Genet 2015; 4:71-83. [PMID: 27617118 PMCID: PMC4918711 DOI: 10.1055/s-0035-1556739] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 01/25/2015] [Indexed: 12/16/2022]
Abstract
Obesity is a growing global health epidemic. It is estimated that more than 20% of pregnancies are complicated by obesity. Prepregnancy obesity has been associated with birth defects such as neural tube defects, macrosomia, fetal death, and long-term effects such as asthma on the offspring. We provide a summary of the most recent studies and meta-analyses on obesity and birth outcome. Possible mechanisms of actions are explored and recommendations for further research are highlighted.
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Affiliation(s)
- Noha Iessa
- Faculty of Pharmacy, University of Montreal, Montreal, Québec, Canada
- Research Center, CHU Sainte-Justine, Montreal, Québec, Canada
| | - Anick Bérard
- Faculty of Pharmacy, University of Montreal, Montreal, Québec, Canada
- Research Center, CHU Sainte-Justine, Montreal, Québec, Canada
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Tang X, Cleves MA, Nick TG, Li M, MacLeod SL, Erickson SW, Li J, Shaw GM, Mosley BS, Hobbs CA. Obstructive heart defects associated with candidate genes, maternal obesity, and folic acid supplementation. Am J Med Genet A 2015; 167:1231-42. [PMID: 25846410 PMCID: PMC4675451 DOI: 10.1002/ajmg.a.36867] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 10/17/2014] [Indexed: 01/13/2023]
Abstract
Right-sided and left-sided obstructive heart defects (OHDs) are subtypes of congenital heart defects, in which the heart valves, arteries, or veins are abnormally narrow or blocked. Previous studies have suggested that the development of OHDs involved a complex interplay between genetic variants and maternal factors. Using the data from 569 OHD case families and 1,644 control families enrolled in the National Birth Defects Prevention Study (NBDPS) between 1997 and 2008, we conducted an analysis to investigate the genetic effects of 877 single nucleotide polymorphisms (SNPs) in 60 candidate genes for association with the risk of OHDs, and their interactions with maternal use of folic acid supplements, and pre-pregnancy obesity. Applying log-linear models based on the hybrid design, we identified a SNP in methylenetetrahydrofolate reductase (MTHFR) gene (C677T polymorphism) with a main genetic effect on the occurrence of OHDs. In addition, multiple SNPs in betaine-homocysteine methyltransferase (BHMT and BHMT2) were also identified to be associated with the occurrence of OHDs through significant main infant genetic effects and interaction effects with maternal use of folic acid supplements. We also identified multiple SNPs in glutamate-cysteine ligase, catalytic subunit (GCLC) and DNA (cytosine-5-)-methyltransferase 3 beta (DNMT3B) that were associated with elevated risk of OHDs among obese women. Our findings suggested that the risk of OHDs was closely related to a combined effect of variations in genes in the folate, homocysteine, or glutathione/transsulfuration pathways, maternal use of folic acid supplements and pre-pregnancy obesity.
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Affiliation(s)
- Xinyu Tang
- Biostatistics Program, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mario A Cleves
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Todd G Nick
- Biostatistics Program, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ming Li
- Biostatistics Program, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Stewart L MacLeod
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Stephen W Erickson
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jingyun Li
- Biostatistics Program, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gary M Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Bridget S Mosley
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Charlotte A Hobbs
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Wang F, Reece EA, Yang P. Oxidative stress is responsible for maternal diabetes-impaired transforming growth factor beta signaling in the developing mouse heart. Am J Obstet Gynecol 2015; 212:650.e1-11. [PMID: 25595579 DOI: 10.1016/j.ajog.2015.01.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 12/20/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Oxidative stress plays a causal role in diabetic embryopathy. Maternal diabetes induces heart defects and impaired transforming growth factor beta (TGFβ) signaling, which is essential for cardiogenesis. We hypothesize that mitigating oxidative stress through superoxide dismutase 1 (SOD1) overexpression in transgenic (Tg) mice reverses maternal hyperglycemia-impaired TGFβ signaling and its downstream effectors. STUDY DESIGN Day 12.5 embryonic hearts from wild-type (WT) and SOD1 overexpressing embryos of nondiabetic (ND) and diabetic mellitus (DM) dams were used for the detection of oxidative stress markers: 4-hydroxynonenal (4-HNE) and malondlaldehyde (MDA), and TGFβ1, 2, and 3, phosphor (p)-TGFβ receptor II (TβRII), p-phosphorylated mothers against decapentaplegic (Smad)2, and p-Smad3. The expression of 3 TGFβ-responsive genes was also assessed. Day 11.5 embryonic hearts were explanted and cultured ex vivo, with or without treatments of a SOD1 mimetic (Tempol; Enzo Life Science, Farmingdale, NY) or a TGFβ recombinant protein for the detection of TGFβ signaling intermediates. RESULTS Levels of 4-HNE and MDA were significantly increased by maternal diabetes, and SOD1 overexpression blocked the increase of these 2 oxidative stress markers. Maternal diabetes suppresses the TGFβ signaling pathway by down-regulating TGFβ1 and TGFβ3 expression. Consequently, phosphorylation of TβRII, Smad2, and Smad3, downstream effectors of TGFβ, and expression of 3 TGFβ-responsive genes were reduced by maternal diabetes, and these reductions were prevented by SOD1 overexpression. Treatment with Tempol or TGFβ recombinant protein restored high-glucose-suppressed TGFβ signaling intermediates and responsive gene expression. CONCLUSION Oxidative stress mediates the inhibitory effect of hyperglycemia in the developing heart. Antioxidants, TGFβ recombinant proteins, or TGFβ agonists may have potential therapeutic values in the prevention of heart defects in diabetic pregnancies.
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Affiliation(s)
- Fang Wang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - E Albert Reece
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD; Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD
| | - Peixin Yang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD; Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD.
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