Physiologic Adaptations to Pregnancy

The potential presence of infection may be indicated through non-invasive prediction of procalcitonin and C-reactive protein levels within the initial three days after cervical cerclage: a retrospective case-control study

PURPOSE

To identify which non-invasive infection indicators could better predict post-cervical cerclage (CC) infections, and on which days after CC infection indicators should be closely monitored.

METHODS

The retrospective, single-center study included 619 single-pregnancy patients from January 2021 to December 2022. Patients were categorized into infected and uninfected groups based on physicians' judgments of post-CC infections. Registered information included patient characteristics, cervical insufficiency history, gestational age at CC, surgical method (McDonald/Shirodkar), purpose of CC, mid-pregnancy miscarriage/preterm birth, infection history or risk factors, and infection indices on days 1, 3, 5, and 7 after CC. Propensity score matching (PSM) was applied to reduce patient characteristic bias. Statistical analysis of C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), percentage of neutrophil count (NEU_P), interleukin-6 (IL-6), and procalcitonin (PCT) in the infected group compared with the uninfected group was performed using chi-square tests and t-tests. Receiver operating characteristic (ROC) curves were used to further assess the diagnostic value of CRP, PCT, and CRP-PCT in combination.

RESULTS

Among the 619 included patients, 206 patients were matched using PSM and subsequently assessed. PCT values on day 1 and day 3 after CC exhibited significant differences between the two groups in two statistical ways (P < 0.01, P < 0.05). The CRP levels on day 1 were significantly higher in the infected group compared to the uninfected group in two statistical ways (P < 0.05). On day 3, the mean CRP value was significantly elevated in the infected group compared to the uninfected group (P < 0.05). Analyses of IL-6, WBC, NEU, and NEU_P did not yield clinically significant results. The area under the ROC curves for CRP, PCT, and CRP-PCT on day 1 and day 3 were all below 0.7. In the preventive CC group, the AUC values of CRP and CRP-PCT obtained on d1 were found to be higher than 0.7, indicating moderate diagnostic accuracy.

CONCLUSION

For women after CC surgery, especially of preventive aim, increased serum CRP and PCT levels from post-CC day 1 to day 3 may signal a potential postoperative infection, warranting close monitoring.

Association Analysis Between Maternal Neutrophil Ratio and the Risk of Histological Chorioamnionitis in Pregnant Women with Premature Rupture of Membranes in Late Pregnancy

Background

We aimed to investigate the association between maternal neutrophil ratio and histological chorioamnionitis (HCA) risk in pregnant women with premature rupture of membranes (PROM) in late pregnancy.

Methods

A retrospective analysis was conducted on 95 cases of women with PROM in their late pregnancy between March 2018 and August 2021. These women were divided into two groups based on the presence of HCA. General clinical data and laboratory indicators were compared between the two groups. A generalized additive model was used for curve fitting, and a segmented regression model was used to explain further the non-linear relationship between neutrophil ratio and HCA risk.

Results

After adjusting for confounding factors, the curve fitting showed a "U"-shaped curve relationship between the neutrophil ratio and the risk of HCA. When the neutrophil ratio was <76.3%, the risk of HCA exhibited a decreasing trend, but the difference was not statistically significant (adjusted OR = 0.884, 95% CI: 0.781-1.001, P = 0.053). However, when the neutrophil ratio was >76.3%, the HCA risk was significantly increased (adjusted OR = 1.339, 95% CI: 1.067-1.680, P = 0.012). Furthermore, we equally divided the neutrophil ratio into three groups. The risk of HCA was significantly increased in the low-ratio group (OR = 4.292, 95% CI: 1.247-14.706, P = 0.021) compared with the middle-ratio group, which was used as the reference group. Similarly, the HCA risk of the high-ratio group (OR = 13.145, 95% CI: 1.796-96.233, P = 0.011) was also significantly enhanced. However, there was no significant difference in HCA risk between the high-ratio and low-ratio groups (OR = 1.182, 95% CI: 0.357-3.909, P = 0.784).

Conclusion

There was a significant "U"-shaped relationship between maternal neutrophil ratio and HCA risk in women with PROM in late pregnancy.

Adverse pregnancy outcomes as a risk factor for new-onset metabolic dysfunction-associated steatotic liver disease in postpartum women: A nationwide study

Background & Aims

Adverse pregnancy outcomes (APOs) can worsen cardiometabolic risk factors in women, raising their likelihood of developing cardiometabolic diseases at a young age after their initial pregnancy. Nevertheless, there are limited data on the risk of newly developing metabolic dysfunction-associated steatotic liver disease (MASLD) in women who have had APOs. This study aimed to evaluate the risk of new-onset MASLD after experiencing APOs.

Methods

Singleton pregnant women who underwent national health screenings 1 year before pregnancy and 1 year after delivery were included in this study. APOs were defined as the presence of at least one of the followings: hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), preterm birth, low birth weight, and placental abruption. The primary outcome was new-onset MASLD based on the presence of APOs.

Results

Among 80,037 study participants, 9,320 (11.6%) experienced APOs during pregnancy. Women who experienced APOs had an increased risk of developing new-onset MASLD after delivery even after adjustments for various covariates (adjusted odds ratio [OR] 1.58, 95% CI 1.45-1.72). In particular, women who experienced either HDP or GDM showed a significantly increased risk of developing new-onset MASLD (adjusted OR 2.20, 95% CI 1.81-2.67, for HDP and adjusted OR 1.83, 95% CI 1.65-2.03, for GDM). Moreover, there was a tendency toward an increased risk of new-onset MASLD according to the number of APOs (p <0.001 for trend of odds).

Conclusions

APOs were associated with the risk of new-onset MASLD after delivery. Specifically, only HDP or GDM were identified as risk factors for new-onset MASLD.

Impact and implications

This nationwide cohort study confirms that postpartum women with a history of adverse pregnancy outcomes (APOs) are at an increased risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD). These findings may bring us one step closer to understanding the exact mechanisms underlying such an important association between prior APOs and cardiovascular disease (CVD) risk among postpartum women. This bidirectional association between APOs and MASLD highlights the importance of considering pregnancy history in assessing CVD risk in women. It suggests a need for closer monitoring and lifestyle interventions for women with a history of APOs to reduce the risk of MASLD and subsequent CVD complications.

Association of residential greenness, air pollution with adverse birth outcomes: Results from 61,762 mother‑neonatal pairs in project ELEFANT (2011-2021)

BACKGROUND

Emerging evidence has demonstrated the benefits of greenness exposure on human health, while conflicts remain unsolved in issue of adverse birth outcomes.

METHODS

Utilizing data from project ELEFANT spanning the years 2011 to 2021, we assessed residential greenness using the NDVI from MODIS data and residential PM2.5 exposure level from CHAP data. Our primary concerns were PTD, LBW, LGA, and SGA. Cox proportional hazard regression model was used to examine the association of residential greenness and air pollution exposure with risk of adverse birth outcomes. We performed mediation and modification effect analyses between greenness and air pollutant.

RESULTS

We identified 61,762 mother‑neonatal pairs in final analysis. For per 10 μg/m3 increase in PM2.5 concentration during entire pregnancy was associated with 19.8 % and 20.7 % increased risk of PTD and LGA. In contrast, we identified that an 0.1 unit increment in NDVI were associated with 24 %, 43 %, 26.5 %, and 39.5 % lower risk for PTD, LBW, LGA, and SGA, respectively. According to mediation analysis, NDVI mediated 7.70 % and 7.89 % of the associations between PM2.5 and PTD and LGA. Residential greenness could reduce the risk of PTD among mothers under 35 years old, living in rural areas, primigravidae and primiparity..

CONCLUSIONS

In summary, our results highlighted the potential of residential greenness to mitigate the risk of adverse birth outcomes, while also pointing to the adverse impact of PM2.5 on increased risk of multiple adverse birth outcomes (PTD and LGA). The significant mediation effect of NDVI emphasizes its potential as an important protective factor of PM2.5 exposure. Additionally, the identification of susceptible subgroups can inform targeted interventions to reduce adverse birth outcomes related to air pollution and lack of green spaces. Further research and understanding of these associations can contribute to better public health strategies aimed at promoting healthier pregnancies and birth outcomes.

Impact of indoor Air Pollution on the Linear growth of children in Jimma, Ethiopia

BACKGROUND

Stunting in children is the term for reduced linear growth and development, which is frequently brought on by a persistently inadequate diet, recurrent infections and chronic diseases or poor health conditions. Apart from the classic covariates of stunting, which include diet and illness, the relative contribution of household air pollution to chronic nutrition conditions is least studied. Hence, this study is conducted to investigate the impact of household air pollution on the linear growth of under-five children in Jimma town, Ethiopia.

METHODS

A prospective cohort study was employed to collect data from 280 under-five children who lived in households using solid fuel (exposed group, n = 140) and clean fuel (unexposed group, n = 140). Height-for-age Z scores were compared in both groups over a 12-month follow-up period. The difference in differences estimators were used for comparison of changes in the height-for-age Z scores from baseline to end line in exposed and non-exposed groups. The independent effect of the use of solid fuels on height-for-age Z scores was analyzed through a multivariable linear regression model. Statistical Significances were declared at P < 0.05 and 95% CI level.

RESULTS

In an unadjusted model (Model 1), compared with the clean fuel type, the mean difference in the height-for-age Z score of children in households using solid fuel was lower by 0.54 (-0.54, 95% CI -0.97, -0.12, P = 0.011). The beta coefficient remained negative after adjusting for age and sex (Model 2 -0.543, 95% CI -1.373, -0.563) and sociodemographic variables (Model 3: -0.543, 95% CI -1.362, -0.575). In the final model (Model 4), which adjusted for wealth quantile, dietary practice, water, sanitation and hygiene status and household food insecurity access scale, the beta coefficient held the same and significant (beta: -0.543, 95% CI -1.357, -0.579, P < 0.001). Higher HAZ scores were observed among female child (β: = 0.48, 95%CI: 0.28, 0.69), Child with father attended higher education (β: = 0.304 95%CI: 0.304, 95% CI 0.19, 0.41) as compared to male gender and those who did not attend a formal education, respectively. In contrast, child living in households with poor hygiene practices had lower HAZ score (β: -0.226, 95% CI: -0.449, -0.003), P < 0.001.

CONCLUSIONS

Exposure to indoor air pollution was inversely related to linear growth. Furthermore, sex, educational status and hygiene were found relevant predictors of linear growth. In such a setting, there is a need to step up efforts to design and implement public education campaigns regarding the health risks associated with exposure to household air pollution. Promoting improvements to kitchen ventilation and the use of improved cooking stoves, which will help to mitigate the detrimental effects of indoor air pollution on child growth impairment and its long-term effects.

Convergent genomic signatures associated with vertebrate viviparity

BACKGROUND

Viviparity-live birth-is a complex and innovative mode of reproduction that has evolved repeatedly across the vertebrate Tree of Life. Viviparous species exhibit remarkable levels of reproductive diversity, both in the amount of care provided by the parent during gestation, and the ways in which that care is delivered. The genetic basis of viviparity has garnered increasing interest over recent years; however, such studies are often undertaken on small evolutionary timelines, and thus are not able to address changes occurring on a broader scale. Using whole genome data, we investigated the molecular basis of this innovation across the diversity of vertebrates to answer a long held question in evolutionary biology: is the evolution of convergent traits driven by convergent genomic changes?

RESULTS

We reveal convergent changes in protein family sizes, protein-coding regions, introns, and untranslated regions (UTRs) in a number of distantly related viviparous lineages. Specifically, we identify 15 protein families showing evidence of contraction or expansion associated with viviparity. We additionally identify elevated substitution rates in both coding and noncoding sequences in several viviparous lineages. However, we did not find any convergent changes-be it at the nucleotide or protein level-common to all viviparous lineages.

CONCLUSIONS

Our results highlight the value of macroevolutionary comparative genomics in determining the genomic basis of complex evolutionary transitions. While we identify a number of convergent genomic changes that may be associated with the evolution of viviparity in vertebrates, there does not appear to be a convergent molecular signature shared by all viviparous vertebrates. Ultimately, our findings indicate that a complex trait such as viviparity likely evolves with changes occurring in multiple different pathways.

Preconception Counseling for a Patient With a Mechanical Tricuspid Valve

A 37-year-old woman with mechanical tricuspid valve thrombosis presented for preconception consultation. Multimodality imaging confirmed a malfunctioning bileaflet mechanical tricuspid valve with both leaflets fixed and open. This case highlights the key discussions held by the multidisciplinary pregnancy heart team.

Different neurocognitive controls modulate obstacle avoidance through pregnancy

Understanding why falls during pregnancy occur at over 25% rate over gestation has clinical impacts on the health of pregnant individuals. Attention, proprioception, and perception of the environment are required to prevent trips and falls. This research aimed to understand how the changes to these neurocognitive processes control obstacle avoidance through gestation. Seventeen pregnant participants were tested five times in 6-week intervals. Participants walked an obstacle course (OC), and we analyzed the crossings over obstacles that were set to 10% of participants' body height. Participants also performed an attentional network test (ANT: performance of specific components of attention), an obstacle perception task (OP: ability to visually define an obstacle and translate that to a body posture), and a joint position sense task (JPS: ability to recognize and recreate a joint position from somatosensation). In the OC task, average leading and trailing foot crossing heights significantly reduced by 13% and 23% respectively, with no change in variation, between weeks 13 and 31 of pregnancy, indicating an increased risk of obstacle contact during this time. The variability in minimum leading foot distances from the obstacle was correlated with all three neurocognition tasks (ANT, OP, and JPS). Increased fall rates in the second and third trimesters of pregnancy may be driven by changes in attention, with additional contributions of joint position sense and environmental perception at various stages of gestation. The results imply that a holistic examination on an individual basis may be required to determine individual trip risk and appropriate safety modifications.

Environmental Justice Index and adverse pregnancy outcomes

BACKGROUND

The Environmental Justice Index is a tool released by the Centers for Disease Control and Prevention that quantifies and ranks the environmental burden and social vulnerability of each census tract. Racial and ethnic disparities in adverse pregnancy outcomes are well established. The relative contributions of individual (person-level) and environmental (neighborhood-level) risk factors to disease prevalence remain poorly understood.

OBJECTIVE

This study aimed to determine whether the Environmental Justice Index is associated with adverse pregnancy outcomes after adjustment for individual clinical and sociodemographic risk factors.

STUDY DESIGN

This was a retrospective cross-sectional study of all patients who delivered a singleton newborn at ≥23 weeks of gestation between January 2019 and February 2022 at 7 hospitals within a large academic health system in New York. Patients were excluded if their home address was not available, if the address could not be geocoded to a census tract, or if the census tract did not have corresponding Environmental Justice Index data. Patients were also excluded if they had preexisting diabetes or hypertension. For patients who had multiple pregnancies during the study period, only the first pregnancy was included for analysis. Clinical and demographic data were obtained from the electronic medical record. Environmental Justice Index score, the primary independent variable, ranges from 0 to 1. Higher Environmental Justice Index scores indicate communities with increased cumulative environmental burden and increased social vulnerability. The primary outcome was adverse pregnancy outcome, defined as the presence of ≥1 of any of the following conditions: hypertensive disorders of pregnancy, gestational diabetes, preterm birth, fetal growth restriction, low birthweight, small for gestational age newborn, placental abruption, and stillbirth. Multivariable logistic regression was performed to investigate the relationship between Environmental Justice Index score and adverse pregnancy outcome, adjusting for potential confounding variables, including body mass index group, race and ethnicity group, advanced maternal age, nulliparity, public health insurance, and English as the preferred language.

RESULTS

A total of 65,273 pregnancies were included for analysis. Overall, adverse pregnancy outcomes occurred in 37.6% of pregnancies (n=24,545); hypertensive disorders of pregnancy (13.4%) and gestational diabetes (12.2%) were the most common adverse pregnancy outcome conditions. On unadjusted analysis, the strongest associations between Environmental Justice Index score and individual adverse pregnancy outcome conditions were observed for stillbirth (odds ratio, 1.079; 95% confidence interval, 1.025-1.135) and hypertensive disorders of pregnancy (odds ratio, 1.052; 95% confidence interval, 1.042-1.061). On multivariable logistic regression, every 0.1 increase in Environmental Justice Index score was associated with 1.4% higher odds of adverse pregnancy outcome (adjusted odds ratio, 1.014; 95% confidence interval, 1.007-1.021). The strongest associations with adverse pregnancy outcomes were observed with well-established clinical and social risk factors, including class 3 obesity (adjusted odds ratio, 1.710; 95% confidence interval, 1.580-1.849; reference: body mass index <25 kg/m2) and certain race and ethnicity groups (reference: non-Hispanic White), particularly Asian and Pacific Islander (adjusted odds ratio, 1.817; 95% confidence interval, 1.729-1.910), and non-Hispanic Black (adjusted odds ratio, 1.668; 95% confidence interval, 1.581-1.760) people.

CONCLUSION

Environmental Justice Index score is positively associated with adverse pregnancy outcomes, and most strongly associated with stillbirth and hypertensive disorders of pregnancy. Geospatial analysis with Environmental Justice Index may help to improve our understanding of health inequities by identifying neighborhood characteristics that increase the risk of pregnancy complications.

Development and Validation of a Multivariable Predictive Model for the Risk of Histologic Chorioamnionitis in Patients with Premature Rupture of Membranes in the Late Preterm and Term

Background

This study aimed to develop and validate a model to predict histologic chorioamnionitis (HCA) risk in late preterm and term premature rupture of membranes (PROM) patients using clinical and laboratory parameters.

Methods

We conducted a retrospective study on 116 late preterm and term PROM cases, divided into a training (n=81) and a validation set (n=35). A multivariable logistic regression model was developed using the training set. Performance was assessed via the area under the receiver operating characteristic curve (AUC) and net reclassification index (NRI). Decision curve analysis (DCA) evaluated the model's clinical utility. Additionally, nomograms and a web version of the model were developed.

Results

In the training set, the combined model constructed using maternal BMI, gravidity, amniotic fluid characteristics, and prenatal white blood cell (WBC) count showed significantly higher AUC than WBC alone (0.859 vs 0.710, P=0.010), with improved accuracy and sensitivity. In the validation set, the AUC of the combined model remained higher than that of WBC, but the difference was not statistically significant (0.728 vs 0.584, P=0.173). NRI analysis indicated that the combined model improved the correct classification of HCA by 25.0% (P=0.012) compared to that of WBC alone. DCA demonstrated that the combined model had a higher net benefit than WBC in most cases. The nomograms and web version of the model provided convenient tools for clinicians to predict the risk of HCA.

Conclusion

This study successfully developed and validated a clinically feasible multivariable model to predict the risk of HCA in women with late preterm and term PROM.

Predictive Efficacy of the Perfusion Index for Hypotension following Spinal Anesthesia in Parturient Undergoing Elective Cesarean Section: A Systematic Review and Meta-Analysis

This meta-analysis assessed the predictive efficacy of perfusion index for hypotension following spinal anesthesia (SA) in parturients undergoing elective cesarean section (CS). Electronic databases, including Google Scholar, EMBASE, Cochrane Library, and MEDLINE, were searched from inception to June 2023. The primary outcome was the diagnostic accuracy of the perfusion index in predicting the probability of perioperative hypotension following SA. The review included 12 studies involving 2009 patients, published between 2017 and 2023. The pooled sensitivity and specificity were 0.81 (95% confidence interval (CI) = 0.72-0.87) and 0.75 (95% CI = 0.67-0.82), respectively. Additionally, the pooled area under the curve (AUC) was calculated as 0.84 (95% CI = 0.81-0.87), suggesting a moderate to good accuracy of the diagnostic test. Using Fagan's nomogram plot, the positive likelihood ratio (LR) and negative LR were found to be 3 and 0.26, respectively. The results demonstrated that the perfusion index exhibited an acceptable level of accuracy in predicting perioperative hypotension after spinal anesthesia in parturients undergoing elective CS. These findings highlight the potential value of incorporating a perfusion index as a useful tool for clinicians to integrate into routine clinical practice, which necessitates further large-scale studies for verification.

Wildfire smoke exposure and early childhood respiratory health: a study of prescription claims data

Wildfire smoke is associated with short-term respiratory outcomes including asthma exacerbation in children. As investigations into developmental wildfire smoke exposure on children's longer-term respiratory health are sparse, we investigated associations between developmental wildfire smoke exposure and first use of respiratory medications. Prescription claims from IBM MarketScan Commercial Claims and Encounters database were linked with wildfire smoke plume data from NASA satellites based on Metropolitan Statistical Area (MSA). A retrospective cohort of live infants (2010-2016) born into MSAs in six western states (U.S.A.), having prescription insurance, and whose birthdate was estimable from claims data was constructed (N = 184,703); of these, gestational age was estimated for 113,154 infants. The residential MSA, gestational age, and birthdate were used to estimate average weekly smoke exposure days (smoke-day) for each developmental period: three trimesters, and two sequential 12-week periods post-birth. Medications treating respiratory tract inflammation were classified using active ingredient and mode of administration into three categories:: 'upper respiratory', 'lower respiratory', 'systemic anti-inflammatory'. To evaluate associations between wildfire smoke exposure and medication usage, Cox models associating smoke-days with first observed prescription of each medication category were adjusted for infant sex, birth-season, and birthyear with a random intercept for MSA. Smoke exposure during postnatal periods was associated with earlier first use of upper respiratory medications (1-12 weeks: hazard ratio (HR) = 1.094 per 1-day increase in average weekly smoke-day, 95%CI: (1.005,1.191); 13-24 weeks: HR = 1.108, 95%CI: (1.016,1.209)). Protective associations were observed during gestational windows for both lower respiratory and systemic anti-inflammatory medications; it is possible that these associations may be a consequence of live-birth bias. These findings suggest wildfire smoke exposure during early postnatal developmental periods impact subsequent early life respiratory health.

Pregnancy-specific beta-1-glycoprotein 1-enriched exosomes are involved in the regulation of vascular endothelial cell function during pregnancy

INTRODUCTION

Pregnancy is a dynamic time period associated with significant physiological changes in the cardiovascular system. It is well known that during pregnancy, the placenta secretes a variety of molecular signals, including exosomes, into the maternal circulation to adapt to increased blood volume and maintain blood pressure at normotensive levels.

METHODS

In the present study, we compared the effects of exosomes derived from the peripheral blood serum of nonpregnant women (NP-Exo) and pregnant women with uncomplicated pregnancy (P-Exo) on endothelial cell function. We also analyzed the proteomic profiles of these two groups of exosomes and the molecular mechanisms underlying the effect of exosome cargoes on vascular endothelial cell function.

RESULTS

We found that P-Exo were positively involved in regulating the function of human umbilical vein endothelial cell (HUVEC) and promoting the release of nitric oxide (NO). Furthermore, we revealed that trophoblast-derived pregnancy-specific beta-1-glycoprotein 1 (PSG1)-enriched exosomes treatment induced the promotion of HUVEC proliferation and migration as well as the release of NO. In addition, we found that P-Exo maintained blood pressure at normal levels in mice.

DISCUSSION

These results suggested that PSG1-enriched exosomes derived from maternal peripheral blood regulate the function of vascular endothelial cells and play an important role in maintaining maternal blood pressure during pregnancy.

Evidence of Nitric Oxide Impairment During Hypertensive Pregnancies

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, and they can be classified into (1) gestational hypertension, (2) preeclampsia, (3) chronic hypertension and (4) chronic hypertension with preeclampsia. Nitric oxide (NO) plays an essential role in the haemodynamic adaptations observed during pregnancy. It has been shown that the nitric oxide pathway's dysfunction during pregnancy is associated with placental- and vascular-related diseases such as hypertensive disorders of pregnancy. This review aims to present a brief definition of hypertensive disorders of pregnancy and physiological maternal cardiovascular adaptations during pregnancy. We also detail how NO signalling is altered in the (a) systemic vasculature, (b) uterine artery/spiral arteries, (c) implantation and (d) placenta of hypertensive disorders during pregnancy. We conclude by summarizing the anti-hypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy.

Cellular mechanisms linking to outdoor and indoor air pollution damage during pregnancy

Pregnancies are a critical window period for environmental influences over the mother and the offspring. There is a growing body of evidence associating indoor and outdoor air pollution exposure to adverse pregnancy outcomes such as preterm birth and hypertensive disorders of pregnancy. Particulate matter (PM) could trigger oxi-inflammation and could also reach the placenta leading to placental damage with fetal consequences. The combination of strategies such as risk assessment, advise about risks of environmental exposures to pregnant women, together with nutritional strategies and digital solutions to monitor air quality can be effective in mitigating the effects of air pollution during pregnancy.

Knowledge, Attitude, and Beliefs of Medication Use in Pregnancy in an Urban Tertiary Care Center

Medication use in pregnancy is common. However, there is a gap in the literature assessing the knowledge of pregnant individuals about medication use in pregnancy. The aim of our study is to assess the knowledge, attitudes, and beliefs of pregnant people on medication use in pregnancy. We conducted a cross-sectional survey questionnaire that was completed by pregnant patients from December 2021 to January 2022. The survey included questions regarding knowledge, attitude, and sources for obtaining information about medication use in pregnancy and general statements from the Beliefs about Medicines Questionnaire (BMQ). A total of 150 participants completed the survey. Most patients reported that a person should know that medication use for chronic diseases must be modified during pregnancy and that medications can be used in any trimester of pregnancy. Most reported that medication use can lead to fetal growth restriction and maternal bleeding. The mean scores (SDs) on the BMQ-General for the overuse, harm, and benefit statements were 8.7 (2.4), 8.2 (3.1), and 15.7 (2.8). Even though medication use in pregnancy is common, it is an area of concern to pregnant patients. More research on identifying the risks of different medicines used in pregnancy is thus needed.

Association of traffic-related air pollution with Newborn's anthropometric indexes at birth

An emerging body of evidence has associated exposure to traffic-related air pollution (TRAP) during pregnancy with birth outcomes. However, the evidence on the association of TRAP exposure and neonatal anthropometric measurements (NAPM) in low and middle-income countries is very scarce yet. Therefore, we investigate the association of prenatal exposure to indicators of traffic and ambient particulate matter (PM) with NAPM. This cross-sectional study was based on hospital medical records of 4053 mother-neonate pairs between May 16, 2016, and December 5, 2018. PMs were estimated at residential addresses based on validated spatiotemporal models. Moreover, total street length in 100, 300 and 500m buffers around the home, residential distance to the ring road, major roads, heavy-traffic lights, gas station, motorway junction, bank, square, bus terminal, public parking and industrial land-use were calculated as indicators of traffic. The head circumference (HC), birth weight (BW) and birth length (BL) of neonates were collected as NAPM. Multivariate regression models were applied to evaluate the relationship between PMs and indicators of traffic with NAPM, controlled for relevant covariates. The median (IQR) of BW, BL, and HC of newborns were 3250 (592) gr, 51.0 (3.5) cm, 35 (2) cm, respectively. The adjusted models revealed that higher exposure to PM_2.5 and PM₁₀ was significantly related with lower BW and BL. Similar results were observed for total street length in a 100 m buffer around maternal home with BW and BL. Moreover, higher distance to heavy traffic lights was significantly associated with higher BW and BL. An IQR increase in PM₁₀ was significantly related to lower HC (95% CI: 0.11, -0.01, P-value = 0.03). An increase in distance from residential address to heavy traffic lights, ring roads, bus terminal, and transportation land-use was associated with higher HC. Overall, our findings suggested that higher prenatal exposure to TRAP was related with lower BW, BL and HC.

Endoscopic management of idiopathic subglottic stenosis in pregnancy

Aims

To describe the use of laser, endoscopic balloon dilatation with jet ventilation anaesthesia in the treatment of pregnant women with idiopathic subglottic stenosis.

Materials and methods

This is a case review of pregnant women with idiopathic subglottic stenosis, presenting to a tertiary referral centre with worsening breathlessness. Data were extracted from patient case notes.

Results

Four women underwent surgical management of subglottic stenosis in pregnancy. One patient required two procedures during the course of their pregnancy due to restenosis. All women had improvement in symptoms post-operatively and went on to deliver healthy babies at term.

Conclusion

Endoscopic balloon dilatation of idiopathic subglottic stenosis is a safe and viable treatment option in pregnancy and should be offered as first-line treatment in symptomatic women.

Fetoplacental vasculature as a model to study human cardiovascular endocrine disruption

Increasing evidence has associated the exposure of endocrine-disrupting chemicals (EDCs) with the cardiovascular (CV) system. This exposure is particularly problematic in a sensitive window of development, pregnancy. Pregnancy exposome can affect the overall health of the pregnancy by dramatic changes in vascular physiology and endocrine activity, increasing maternal susceptibility. Moreover, fetoplacental vascular function is generally altered, increasing the risk of developing pregnancy complications (including cardiovascular diseases, CVD) and predisposing the foetus to adverse health risks later in life. Thus, our review summarizes the existing literature on exposures to EDCs during pregnancy and adverse maternal health outcomes, focusing on the human placenta, vein, and umbilical artery associated with pregnancy complications. The purpose of this review is to highlight the role of fetoplacental vasculature as a model for the study of human cardiovascular endocrine disruption. Therefore, we emphasize that the placenta, together with the umbilical arteries and veins, allows a better characterization of the pregnant woman's exposome. Consequently, it contributes to the protection of the mother and foetus against CV disorders in life.

Prenatal Air Pollution Exposure and Placental DNA Methylation Changes: Implications on Fetal Development and Future Disease Susceptibility

The Developmental Origins of Health and Disease (DOHaD) concept postulates that in utero exposures influence fetal programming and health in later life. Throughout pregnancy, the placenta plays a central role in fetal programming; it regulates the in utero environment and acts as a gatekeeper for nutrient and waste exchange between the mother and the fetus. Maternal exposure to air pollution, including heavy metals, can reach the placenta, where they alter DNA methylation patterns, leading to changes in placental function and fetal reprogramming. This review explores the current knowledge on placental DNA methylation changes associated with prenatal air pollution (including heavy metals) exposure and highlights its effects on fetal development and disease susceptibility. Prenatal exposure to air pollution and heavy metals was associated with altered placental DNA methylation at the global and promoter regions of genes involved in biological processes such as energy metabolism, circadian rhythm, DNA repair, inflammation, cell differentiation, and organ development. The altered placental methylation of these genes was, in some studies, associated with adverse birth outcomes such as low birth weight, small for gestational age, and decreased head circumference. Moreover, few studies indicate that DNA methylation changes in the placenta were sex-specific, and infants born with altered placental DNA methylation patterns were predisposed to developing neurobehavioral abnormalities, cancer, and atopic dermatitis. These findings highlight the importance of more effective and stricter environmental and public health policies to reduce air pollution and protect human health.

Enhanced elimination of betamethasone in dichorionic twin pregnancies

AIM

No study has evaluated the betamethasone pharmacokinetics in twin pregnancies according to chorionicity. This study aimed to describe and compare the betamethasone pharmacokinetic parameters in singleton and dichorionic (DC) and monochorionic twin pregnancies in the third trimester of pregnancy.

METHODS

Twenty-six pregnant women received 2 intramuscular doses of 6 mg of betamethasone sodium phosphate plus 6 mg betamethasone acetate due to preterm labour. Serial blood samples were collected for 24 hours after the first intramuscular dose of betamethasone esters. Betamethasone plasma concentrations were quantified using a validated liquid chromatography-tandem mass spectrometry analytical method, and the pharmacokinetic parameters were obtained employing a noncompartmental model. Preliminary data on the betamethasone placental transfer are also presented.

RESULTS

The geometric mean (95% confidence interval) of AUC^0-∞ 645.1 (504.3-825.2) vs. 409.8 (311.2-539.6) ng.h/mL and CL/F 17.70 (13.84-22.65) vs. 27.87 (21.17-36.69) were significantly different, respectively, in singleton pregnancies when compared to DC twins.

CONCLUSION

Data from this study suggest that the presence of 2 foetoplacental units may increase the betamethasone metabolism by hepatic CYP3A4 and/or placental 11β-HSD2 enzymes. Pharmacokinetic-pharmacodynamic clinical studies are needed to investigate whether these betamethasone pharmacokinetic changes have clinical repercussions for the newborns and require dose adjustment in DC twin pregnancies.

Cardiovascular risk factors before and during pregnancy: Does pregnancy unmask or initiate risk?

OBJECTIVES

To understand if pregnancy unmasks previously silent cardiovascular (CV) adverse factors, or initiates lasting injury.

METHODS

Pre-pregnancy and during pregnancy CV risk factors (blood pressure, fasting lipids, and glucose) from 296 women belonging to studies in the International Childhood Cardiovascular Cohort (i3C) Consortium, a group of studies assessing the relationship between child and adolescent CV risk factors and adult outcomes, were used. Correlation coefficients between the pre- and during pregnancy measures were calculated, and the mean difference between the measures was modeled with adjustment for age, body mass index, race, smoking, and study.

RESULTS

Measures were strongly correlated at pre- and during-pregnancy visits (p < 0.01), with r of between 0.30 and 0.55. In most cases, the difference between pre-pregnancy and during-pregnancy did not differ significantly from 0 after adjustment for confounders. Stratification by gestational age indicated stronger correlations with measurements obtained during the first and second trimesters than the third. The correlation did not differ by the time elapsed between the pre-pregnancy and pregnancy visits.

CONCLUSIONS

Pre- and during-pregnancy CV risk factors are moderately well correlated. This may indicate that susceptible women enter pregnancy with higher risk rather than pregnancy inducing new vascular or metabolic effects.

The effects of Helicobacter pylori infection on pregnancy-related diseases and fetal development in diabetes in pregnancy

Background

This study aimed to determine the association of Helicobacter pylori (H. pylori) infection with pregnancy-related diseases and fetal development in women with diabetes in pregnancy (DIP).

Methods

All the participants were recruited before 16 weeks of gestation. According to their medical history and the results of a 75-g oral glucose tolerance test at the 24^th week of pregnancy, the participants were divided into a normal control group (NC group), a gestational diabetes mellitus group (GDM group), and a pre-pregnancy diabetes mellitus group (PGDM group). According to the results of an H. pylori serum antibody detection test, each group was further divided into two subgroups: an H. pylori positive subgroup (HP+ subgroup) and an H. pylori negative group (HP- subgroup). The incidences of pregnancy-related diseases, the fetal developmental status, and the newborn status were compared among the groups.

Results

This study recruited 356 pregnant women. The infection rates of type I H. pylori were significantly higher in the GDM group and the PGDM group than in the NC group (χ²=6.949, P=0.031). With the exception of the NC-HP+ subgroup, there were higher incidences of pregnancy-related diseases in the HP+ subgroups than in the HP− subgroups (P<0.05). Furthermore, the incidences of pregnancy-induced hypertension (PIH), preeclampsia, and premature delivery were significantly higher in the GDM-HP+ subgroup and the PGDM-HP+ subgroup than in the NC-HP+ subgroup (P<0.05). At the end of pregnancy, all 3 HP− subgroups showed better fetal development than the HP+ subgroups (P<0.05), and the NC-HP+ subgroup showed better fetal development than the GDM-HP+ and PGDM-HP+ subgroups (P<0.05). Meanwhile, the PGDM-HP+ subgroup showed poor fetal development, even in the 2^nd trimester of pregnancy.

Conclusions

H. pylori infection is extremely common in DIP. For women with DIP, infection with H. pylori can increase the risks of pregnancy-related diseases and poor fetal development. H. pylori screening and eradication therapy before pregnancy may aid in preventing pregnancy-related diseases and improve fetal development.

Diagnostic Cardiovascular Imaging and Therapeutic Strategies in Pregnancy: JACC Focus Seminar 4/5

The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.

Application of a Prediction Model Based on the Laboratory Index Score in Prelabor Rupture of Membranes with Histologic Chorioamnionitis During Late Pregnancy

Background

This study aimed to establish a prediction model based on the maternal laboratory index score (Lab-score) for histologic chorioamnionitis (HCA) in patients with prelabor rupture of membranes (PROM) during late pregnancy.

Material/Methods

Sixty-nine cases of pregnant women with PROM were retrospectively analyzed. The general information and laboratory indicators were compared between the HCA (n=22) and non-HCA (n=47) groups. A multivariate logistic regression method was used to establish the prediction model. We plotted the receiver operating characteristic curve and calculated the area under the curve (AUC). The clinical effectiveness of each model was compared by decision curve analysis.

Results

Only C-reactive protein (CRP) in the laboratory index predicted HCA, but its diagnostic efficacy was not ideal (AUC=0.651). Then, we added CRP to the platelet/white blood cell count ratio and triglyceride level to construct the Lab-score. Based on the Lab-score, important clinical parameters, including body mass index, diastolic blood pressure, and preterm birth, were introduced to construct a complex joint prediction model. The AUC of this model was significantly larger than that of CRP (0.828 vs. 0.651, P=0.035), but not significantly different from that of Lab-score (0.828 vs. 0.724, P=0.120). Considering the purpose of HCA screening, the net benefit of the complex model was better than that of Lab-score and CRP.

Conclusions

The complex model based on Lab-score is useful in the clinical screening of high-risk populations with PROM and HCA during late pregnancy.

Ledipasvir plus sofosbuvir in pregnant women with hepatitis C virus infection: a phase 1 pharmacokinetic study

Background

Hepatitis C virus (HCV) infection is increasing among pregnant women because of the opioid epidemic, yet there are no interventions to reduce perinatal HCV transmission or to treat HCV during pregnancy. Physiological changes in pregnancy alter the pharmacokinetics of some medications; thus, our aim was to compare the pharmacokinetic parameters of ledipasvir 90 mg plus sofosbuvir 400 mg during pregnancy with non-pregnant women.

Methods

This was an open-label, phase 1 study of pregnant women with genotype 1 HCV infection and their infants. A reference group of women who had participated in pharmacokinetic studies of ledipasvir–sofosbuvir during phase 2 and 3 trials was used. Participants were enrolled at Magee-Womens Hospital (Pittsburgh, PA, USA) between 23 and 24 weeks’ gestation and had a 12-week course of oral ledipasvir–sofosbuvir (daily 90 mg ledipasvir plus 400 mg sofosbuvir). Three 12-h intensive pharmacokinetic visits were done at 25–26, 29–30, and 33–34 weeks’ gestation and individual pharmacokinetics were summarised by geometric mean across the three visits. The primary outcome, analysed in all participants without suspected dosing errors, was the ledipasvir–sofosbuvir area under the concentration–time curve of the dosing interval (AUC_tau) during pregnancy compared with the reference group by geometric mean ratio. This study is registered with ClinicalTrials.gov, NCT02683005.

Findings

From Oct 1, 2016, to Sept 30, 2018, 29 pregnant women were screened and nine (31%) were enrolled. Eight (89%) women were included in the primary analysis. Ledipasvir and sofosbuvir exposures were similar in the pregnant women versus the non-pregnant reference group (geometric mean ratio of AUC_tau ledipasvir 89·3% [90% CI 68·7–116·1]; sofosbuvir 91·1% [78·0–106·3]).

Interpretation

Ledipasvir–sofosbuvir was safe and effective without clinically meaningful differences in drug exposure among pregnant versus non-pregnant women.

Funding

National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health/Office of Research on Women’s Health, and Gilead Sciences.

Pregnancy-induced Cardiovascular Pathologies: Importance of Structural Components and Lipids

Pregnancy leads to adaptations for maternal and fetal energy needs. The cardiovascular system bears the brunt of the adaptations as the heart and vessels enable nutrient supply to maternal organs facilitated by the placenta to the fetus. The components of the cardiovascular system are critical in the balance between maternal homeostatic and fetus driven homeorhetic regulation. Since lipids intersect maternal cardiovascular function and fetal needs with growth and in stress, factors affecting lipid deposition and mobilization impact risk outcomes. Here, the cardiovascular components and functional derangements associated with cardiovascular pathology in pregnancy, vis-à-vis lipid deposition, mobilization and maternal and/or cardiac and fetal energy needs are detailed. Most reports on the components and associated pathology in pregnancy, are on derangements affecting the extracellular matrix and epicardial fat, followed by the endothelium, vascular smooth muscle, pericytes and myocytes. Targeted studies on all cardiovascular components and pathological outcomes in pregnancy will enhance targeted interventions.

Plasticity of the Maternal Vasculature During Pregnancy

Maternal cardiovascular changes during pregnancy include an expansion of plasma volume, increased cardiac output, decreased peripheral resistance, and increased uteroplacental blood flow. These adaptations facilitate the progressive increase in uteroplacental perfusion that is required for normal fetal growth and development, prevent the development of hypertension, and provide a reserve of blood in anticipation of the significant blood loss associated with parturition. Each woman's genotype and phenotype determine her ability to adapt in response to molecular signals that emanate from the fetoplacental unit. Here, we provide an overview of the major hemodynamic and cardiac changes and then consider regional changes in the splanchnic, renal, cerebral, and uterine circulations in terms of endothelial and vascular smooth muscle cell plasticity. Although consideration of gestational disease is beyond the scope of this review, aberrant signaling and/or maternal responsiveness contribute to the etiology of several common gestational diseases such as preeclampsia, intrauterine growth restriction, and gestational diabetes.

Maternal and Fetal Outcomes in Iranian Patients with Systemic Lupus Erythematosus: A Five-Year Retrospective Study of 60 Pregnancies

BACKGROUND

As a multisystem autoimmune disease, Systemic Lupus Erythematosus (SLE) mainly affects women during reproductive age. This retrospective study was designed to investigate the fetal and maternal outcomes of Iranian women with SLE.

METHODS

Clinical and laboratory records of 60 pregnancies in 55 SLE patients who attended Hafez hospital, a tertiary referral center for high risk pregnancies and SLE patients affiliated with Shiraz University of Medical Science, were reviewed during April 2012 and March 2016.

RESULTS

The mean age of the patients was 29.28±4.6 years and mean disease duration was 5.09±4.2 years. Live birth rate was 83.3% after exclusion of elective abortions. There were 50 live births, 3 neonatal deaths, 3 spontaneous abortions and 7 stillbirths. 9 (15%) women developed preeclampsia and there was 1 (1.6%) case of HELLP syndrome. Lupus flares occurred in 27 (45%) patients during pregnancy. Preterm delivery occurred in 11.6% of pregnancies. Skin and joints were the most frequently affected organs. Patients with previous lupus nephritis (n=18) were associated with a higher risk of maternal complication, but fetal outcomes were similar in both groups. Cesarean rate was about 66%, mostly related to fetal indications (50%).

CONCLUSION

Pregnancies in most women with pre-existing SLE can now be managed with successful results although presence of previous lupus nephritis is still a major risk factor for adverse maternal outcomes. In our study, fetal outcome was not different between patients with lupus nephritis compared with the patients without nephritis who were under treatments. Hence, to achieve favorable long-term results, we recommend regular multispecialty treatment approaches and progestational counseling for women with SLE.

Influence of Estrogens on Uterine Vascular Adaptation in Normal and Preeclamptic Pregnancies

During pregnancy, the maternal cardiovascular system undergoes significant changes, including increased heart rate, cardiac output, plasma volume, and uteroplacental blood flow (UPBF) that are required for a successful pregnancy outcome. The increased UPBF is secondary to profound circumferential growth that extends from the downstream small spiral arteries to the upstream conduit main uterine artery. Although some of the mechanisms underlying uterine vascular remodeling are, in part, known, the factors that drive the remodeling are less clear. That higher circulating levels of estrogens are positively correlated with gestational uterine vascular remodeling suggests their involvement in this process. Estrogens binding to the estrogen receptors expressed in cytotrophoblast cells and in the uterine artery wall stimulate an outward hypertrophic remodeling of uterine vasculature. In preeclampsia, generally lower concentrations of estrogens limit the proper uterine remodeling, thereby reducing UPBF increases and restricting the growth of the fetus. This review aims to report estrogenic regulation of the maternal uterine circulatory adaptation in physiological and pathological pregnancy that favors vasodilation, and to consider the underlying molecular mechanisms by which estrogens regulate uteroplacental hemodynamics.

Maternal cooking during pregnancy may increase hyperactive behaviors among children aged at around 3 years old

Cooking is one of the main sources of indoor air pollution in China. Given emerging evidence of a link between air pollutants and neurodevelopmental delays, we examined whether maternal experiences with cooking during gestation might increase their child's hyperactivity at 3 years of age. The participants involved 45 518 mothers of children who were newly enrolled at kindergarten in the Longhua District of Shenzhen from 2015 to 2017. The results show that maternal exposure to cooking fumes during pregnancy was related to an increased risk of their offspring having hyperactivity behaviors at the age of 3 years. Compared with pregnant mothers who never cooked, pregnant mothers who cooked sometimes, often, or always had children who showed a significantly higher hyperactivity risk. Households using cooking fuels such as coal, gas during the mothers' pregnancy, exhibited more hyperactivity behaviors in the young child when compared to those using electricity for cooking. In addition, poor ventilation during cooking, while mothers were pregnant, was found to be a significant risk factor for clinical levels of the offspring's hyperactive behaviors. Furthermore, the positive association with maternal cooking during pregnancy and their offsprings' hyperactivity was relatively consistent across strata defined by social class, education, and other covariates.

Establishment of reference intervals for maternal blood and umbilical cord blood procalcitonin in healthy Chinese women in late pregnancy

AIM

To establish reference intervals (RIs) for maternal blood and umbilical cord blood procalcitonin (PCT) in healthy Chinese women in late pregnancy.

METHODS

One hundred and twenty-seven healthy Chinese women in late pregnancy, including 70 vaginal deliveries and 57 cesarean section deliveries, were retrospectively analyzed. These pregnant women gave birth to 58 male infants and 69 female infants. Another 127 age-matched healthy women who were not pregnant were enrolled as the control group. PCT levels in maternal blood, umbilical cord blood and control blood were determined using electrochemiluminescence immunoassay. The RIs of PCT were defined using an intermediate 95% interval.

RESULTS

The RIs for maternal blood and umbilical cord blood PCT were 0.020-0.075 ng/mL and 0.020-0.159 ng/mL, respectively. The cord blood PCT level was not significantly different between different delivery methods (P > 0.05). In contrast, the umbilical cord blood PCT in female newborns was higher than that in male newborns (0.088 ± 0.046 ng/mL vs 0.072 ± 0.030 ng/mL, P < 0.05).

CONCLUSION

Maternal blood and umbilical cord blood PCT of Chinese women in late pregnancy have different RIs, and umbilical cord blood PCT level is affected by the gender of newborns.

Uncovering changes in proteomic signature of rat pelvic floor muscles in pregnancy

BACKGROUND

Structural and functional changes of the rat pelvic floor muscles during pregnancy, specifically, sarcomerogenesis, increase in extracellular matrix content, and higher passive tension at larger strains protect the integral muscle components against birth injury. The mechanisms underlying these antepartum alterations are unknown. Quantitative proteomics is an unbiased method of identifying protein expression changes in differentially conditioned samples. Therefore, proteomics analysis provides an opportunity to identify molecular mechanisms underlying antepartum muscle plasticity.

OBJECTIVE

To elucidate putative mechanisms accountable for pregnancy-induced adaptations of the pelvic floor muscles, and to identify other novel antepartum alterations of the pelvic floor muscles.

MATERIALS AND METHODS

Pelvic floor muscles, comprised of coccygeus, iliocaudalis, and pubocaudalis, and nonpelvic limb muscle, tibialis anterior, were harvested from 3-month-old nonpregnant and late-pregnant Sprague-Dawley rats. After tissue homogenization, trypsin-digested peptides were analyzed by ultra-high-performance liquid chromatography coupled with tandem mass spectroscopy using nano-spray ionization. Peptide identification and label free relative quantification analysis were carried out using Peaks Studio 8.5 software (Bioinformatics Solutions Inc., Waterloo, ON, Canada). Proteomics data were visualized using the Qlucore Omics Explorer (New York, NY). Differentially expressed peptides were identified using the multi-group differential expression function, with q-value cutoff set at <0.05. Proteomic signatures of the pelvic floor muscles were compared to nonpelvic limb muscle and between nonpregnant and pregnant states.

RESULTS

Unsupervised clustering of the data showed clear separation between samples from nonpregnant and pregnant animals along principal component 1 and between pelvic and nonpelvic muscles along principal component 2. Four major gene clusters were identified segregating proteomic signatures of muscles examined in nonpregnant vs pregnant states: (1) proteins increased in the pelvic floor muscles only; (2) proteins increased in the pelvic floor muscles and tibialis anterior; (3) proteins decreased in the pelvic floor muscles and tibialis anterior; and (4) proteins decreased in the pelvic floor muscles alone. Cluster 1 included proteins involved in cell cycle progression and differentiation. Cluster 2 contained proteins that participate in mitochondrial metabolism. Cluster 3 included proteins involved in transcription, signal transduction, and phosphorylation. Cluster 4 comprised proteins involved in calcium-mediated regulation of muscle contraction via the troponin tropomyosin complex.

CONCLUSION

Pelvic floor muscles gain a distinct proteomic signature in pregnancy, which provides a mechanistic foundation for the antepartum physiological alterations acquired by these muscles. Variability in genes encoding these proteins may alter plasticity of the pelvic floor muscles and therefore the extent of the protective pregnancy-induced adaptations. Furthermore, pelvic floor muscles' proteome is divergent from that of the nonpelvic skeletal muscles.

Inflammation in gastrointestinal disorders: prevalent socioeconomic factors

Western populations harbor a chronic inflammation pattern that lacks organ cardinal signs (edema, increased temperature, pain, and impaired function), releases increased levels of C-reactive protein, and often runs a creeping clinical course with generalized debilitating disease superimposed on system-specific involvement, mostly including nervous tissue (multiple sclerosis, Parkinson’s syndromes), joints (arthritis), and skin (psoriasis). A finalistic interpretation may apply to the consideration of the gut as the source of inflammation. In fact, these kind of local events as well as the remote manifestations named above, could be conditioned by the microbiome, the huge cell population indwelling the gut which is under growing scrutiny. The role of the gut as a barrier organ justifies lingering submucosal inflammation as a patrolling activity to maintain bodily integrity; the microbiome, launching inflammogenic signals in response to abrupt diet changes, confers to gut inflammation a socioeconomic vector calling for hitherto unrecognized multi-disciplinary interventions.

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Prepregnancy Dietary Patterns and Their Association with Perinatal Outcomes: A Prospective Cohort Study

BACKGROUND

Dietary intake may be associated with neonatal outcomes, yet little is known about the influence of prepregnancy dietary pattern (DP).

OBJECTIVES

To evaluate the association between prepregnancy DPs and perinatal outcomes.

DESIGN

Prospective cohort study during pregnancy (baseline between 5 and 13 gestational week and three follow-up visits: 20 to 26 gestational weeks, 30 to 36 gestational weeks, and 30 to 40 days postpartum, respectively). Diet was assessed in the first trimester using a food frequency questionnaire and having prepregnancy as the time frame.

PARTICIPANTS/SETTING

Two hundred fifty-three pregnant women met the following eligibility criteria (20 to 40 years of age, 5 to 13 weeks of gestation at baseline, free of chronic [except obesity] or infectious diseases, and with a singleton pregnancy). The final sample was composed of 193 pregnant women attending a public health care center in Rio de Janeiro, Brazil, from 2009 to 2012.

MAIN OUTCOME MEASURES

Type of delivery, large for gestational age (LGA), birth length (BL)>90th percentile, Apgar score<7 at 1 minute, and preterm birth.

STATISTICAL ANALYSES

Reduced rank regression was used to identify prepregnancy DPs that explain the following response variables: fiber density (daily dietary fiber intake in grams, divided by total daily energy intake in kilocalories), dietary energy density, and percent energy from saturated fat. Statistical analyses included multiple logistic regression models. The following covariates were defined as confounders based on a unique Direct Acyclic Graph for each outcome: maternal age, current smoker, alcohol consumption, years of education, and first-trimester leisure physical activity.

RESULTS

The prevalence of normal delivery was 56.7%. LGA occurred in 16%, BL>90th percentile in 24.3%, Apgar score<7 at 1 minute in 14.2%, and preterm birth in 9.5% of the study population. Three DPs were identified: "fast food and candies" was associated with higher odds of LGA (odds ratio [OR]=4.38, 95% CI: 1.32 to 14.48) and BL>90th percentile (OR=4.81, 95% CI: 1.77 to 13.07); "beans, bread, and fat" was inversely associated with Apgar score<7 at 1 minute (OR=0.14, 95% CI: 0.03 to 0.70); and "vegetables and dairy" was inversely associated with preterm birth (OR=0.24, 95% CI: 0.06 to 0.97). There was no association between adherence to DPs and type of delivery.

CONCLUSIONS

Higher adherence to fast food and candies prepregnancy DP increased the odds of LGA birth, while a higher adherence to vegetables and dairy DP decreased the odds of preterm birth.

Estimation of Gastric Volume Before Anesthesia in Term-Pregnant Women Undergoing Elective Cesarean Section, Compared With Non-pregnant or First-Trimester Women Undergoing Minor Gynecological Surgical Procedures

BACKGROUND

Traditionally, intubation of pregnant women has been performed using a rapid sequence induction. This is due to the classical concept that women with more than 18 weeks of pregnancy (mid-second trimester) are always considered to have an increased risk of aspiration due to a number of factors, regardless of the fasting duration. Rapid sequence induction is associated with a higher rate of adverse events.

AIMS

Our study aimed to illuminate the hypothesis that there is no difference in gastric volume between term-pregnant women and non-pregnant or first-trimester pregnant women who were undergoing minor gynecological surgical procedures. Accordingly, we measured gastric volume and content before anesthesia in term-pregnant women undergoing elective cesarean section, and to compare it with non-pregnant or first-trimester pregnant women who were undergoing minor gynecological surgical procedures.

METHODS

In this single-center prospective study, the gastric volume and content were assessed by abdominal ultrasound (AUS) just prior to the scheduled procedure. AUS was performed in the sagittal or para-sagittal plain in the upright position and the stomach content was estimated according to the antral circumferential area. Group 1 consisted of 50 term-pregnant women scheduled for cesarean section. Group 2 consisted of 45 non-pregnant or first-trimester pregnant women who were scheduled for minor gynecologic procedure.

RESULTS

Despite significant longer fasting time prior to the interventional procedure in the non-pregnant or first-trimester women group, there was no significant difference in gastric volume between term-pregnant and first-trimester pregnant women (3.2 ± 0.97 cm2 vs 3.2 ± 0.79 cm2; P = .97). Gastric volume was small in the two groups.

CONCLUSION

Fasting gastric volume before cesarean section in term-pregnant women is small and is not different than in non-pregnant or first-trimester women undergoing minor gynecologic procedures. Ultrasound estimation of gastric volume is a reliable and easy-to-perform technique which might help in decision-making regarding the airway management prior to induction of anesthesia in pregnant women.

Iodine Nutrition During Pregnancy: Past, Present, and Future

Iodine is a trace element that is important for the synthesis of thyroid hormones. During pregnancy, iodine requirements are increased by approximately 50% because of physiological changes. Adequate iodine status in pregnancy is crucial for maternal health and fetal growth. The World Health Organization (WHO) recommends a daily intake of 250 μg iodine for pregnant women to maintain adequate iodine status. Severe iodine deficiency during pregnancy can result in a series of detrimental effects on maternal and fetal health including hypothyroidism, goiter, stillbirth, abortion, increased neonatal mortality, neurological damage, and intellectual impairment. Correction of severe iodine deficiency can reduce the risk of adverse impacts. However, the influences of mild-to-moderate maternal iodine deficiency on fetal neural development and cognitive function are less clear. The safety and efficacy of iodine supplementation in mildly-to-moderately iodine-deficient women also remain uncertain. In addition, excess iodine during pregnancy carries a risk of adverse effects, and the recommended safe upper limits of iodine intake are controversial. Effective iodine supplementation should be implemented, and routine monitoring is necessary to guarantee adequate iodine status.

Ambient air pollution and pregnancy outcomes: A comprehensive review and identification of environmental public health challenges

There is a growing number of studies on the association between ambient air pollution and adverse pregnancy outcomes, but their results have been inconsistent. Consequently, a comprehensive review of this research area is needed. There was a wide variability in studied pregnancy outcomes, observed gestational windows of exposure, observed ambient air pollutants, applied exposure assessment methods and statistical analysis methods Gestational duration, preterm birth, (low) birth weight, and small for gestational age/intrauterine growth restriction were most commonly investigated pregnancy outcomes. Gestational windows of exposure typically included were whole pregnancy period, 1st, 2nd, 3rd trimester, first and last gestational months. Preterm birth was the outcome most extensively studied across various gestational windows, especially at the beginning and at the end of pregnancy. Particulate matter, nitrogen dioxide, ozone, and carbon monoxide were the most commonly used markers of ambient air pollution. Continuous monitoring data were frequently combined with spatially more precisely modelled estimates of exposure. Exposure to particulate matter and ozone over the entire pregnancy was significantly associated with higher risk for preterm birth: the pooled effect estimates were 1.09 (1.03-1.16) per 10 μg/m³ increase in particulate matter with an aerodynamic diameter of 10 µm or less (PM₁₀)_,1.24 (1.08-1.41) per 10 μg/m³ increase in particulate matter with an aerodynamic diameter of 2.5 µm or less (PM_2.5), and 1.03 (1.01-1.04) per 10 ppb increase in ozone. For pregnancy outcomes other than PTB, ranges of observed effect estimates were reported due to smaller number of studies included in each gestational window of exposure. Further research is needed to link the routine pregnancy outcome data with spatially and temporally resolved ambient air pollution data, while adjusting for commonly defined confounders. Methods for assessing exposure to mixtures of pollutants, indoor air pollution exposure, and various other environmental exposures, need to be developed.

The Role of Placental Hormones in Mediating Maternal Adaptations to Support Pregnancy and Lactation

During pregnancy, the mother must adapt her body systems to support nutrient and oxygen supply for growth of the baby in utero and during the subsequent lactation. These include changes in the cardiovascular, pulmonary, immune and metabolic systems of the mother. Failure to appropriately adjust maternal physiology to the pregnant state may result in pregnancy complications, including gestational diabetes and abnormal birth weight, which can further lead to a range of medically significant complications for the mother and baby. The placenta, which forms the functional interface separating the maternal and fetal circulations, is important for mediating adaptations in maternal physiology. It secretes a plethora of hormones into the maternal circulation which modulate her physiology and transfers the oxygen and nutrients available to the fetus for growth. Among these placental hormones, the prolactin-growth hormone family, steroids and neuropeptides play critical roles in driving maternal physiological adaptations during pregnancy. This review examines the changes that occur in maternal physiology in response to pregnancy and the significance of placental hormone production in mediating such changes.

Exercise as a therapeutic intervention to optimize fetal weight

The Developmental Origins of Health and Disease suggest the in utero environment programs offspring obesity and cardiovascular disease. Therefore, there is a need to implement safe therapeutic interventions that do not involve the intake of medications or biological products during pregnancy that can improve maternal and fetal health. Prenatal exercise is established to promote maternal and fetal health. It is generally recommended that women accumulate at least 150 min per week of moderate-intensity exercise. It has been demonstrated that prenatal exercise maintains healthy weight gain and improves maternal glucose control, maternal cardiac autonomic control, placental efficiency (increases angiogenesis, downregulates genes involved in fatty acid transport and insulin transport across the placenta, and upregulates genes involved in amino acid transport across the placenta), and oxidative stress. These adaptations following exercise improve maternal metabolism and provide adequate uteroplacental perfusion. In this review, we will focus on exercise as a therapeutic intervention to optimize fetal weight. It has been established that prenatal exercise does not increase the risk of having a small for gestational age baby. To the contrary, prenatal exercise has been associated with the prevention of excessive fat accumulation in the newborn and the maintenance of fetal muscle mass.

Higher Transplacental Pathogen-Specific Antibody Transfer Among Pregnant Women Randomized to Triple Antiretroviral Treatment Versus Short Course Zidovudine

BACKGROUND

HIV-1 infection may impair transplacental antibody transfer to infants. The impact of highly active antiretroviral treatment (ART) given during pregnancy on transplacental antibody transport is unknown.

METHODS

HIV-1 infected pregnant women with CD4 counts between 200 - 500 were randomized to short-course zidovudine (ZDV) or triple ART at 32 weeks gestation for prevention of mother-to-child HIV-1 transmission. Levels of maternal antibody against measles, pneumococcus and rotavirus at delivery, and antibody transfer to the baby through cord blood, were compared between trial arms.

RESULTS

Overall, 141 and 148 women were randomized to triple ART and ZDV, respectively; cord blood was available for a subset (n = 20 in triple ART and n = 22 in ZDV). Maternal antibody levels to all pathogens during pregnancy and at delivery were not significantly different between arms. Within each arm, antibody levels at delivery were lower than at enrolment. For all antibodies, a woman's levels before delivery were an important predictor of amount transferred to her infant. Women on triple ART transferred higher levels of pathogen-specific antibodies when compared with women on short course ZDV.

CONCLUSIONS

Women on triple ART transferred higher levels of pathogen-specific antibodies compared with women on ZDV alone.

Sympathetic neurovascular regulation during pregnancy: A longitudinal case series study

NEW FINDINGS

What is the main observation in this case? The main observation of this case report is that during pregnancy there is a progressive sympatho-excitation in basal conditions and under stress, which is offset by a concurrent reduction in neurovascular transduction. Strong correlations between autonomic nervous system activity and sex hormones (oestrogen and progesterone), vasopressin and aldosterone were found. What insights does it reveal? Our findings suggest that hormonal surges might be associated with central sympathetic activation.

ABSTRACT

The adaptations of sympathetic nerve activity (SNA) during pregnancy remain poorly understood. An increase in blood volume, cardiac output and SNA, with a concomitant drop in total peripheral resistance (TPR), suggest that during pregnancy there is a reduced transduction of SNA into TPR. Most of these findings have originated from cross-sectional studies; thus, we conducted a longitudinal assessment of SNA and TPR in two participants. Measurements were made before pregnancy (early follicular phase), on four occasions during pregnancy and at 2 months postpartum. Mean arterial pressure and cardiac output were used to calculate TPR. The SNA was measured using microneurography (peroneal nerve). There was a gestation-dependent increase in SNA burst frequency (r²  = 0.96, P = 0.009). Neurovascular transduction, however, decreased by 53% in both women. Sympathetic hyperactivity was reversed postpartum, whereas neurovascular transduction remained lower. These longitudinal data highlight the progressive sympatho-excitation of pregnancy, which is offset by a concurrent reduction in neurovascular transduction.

A meta-analysis of the association between Helicobacter pylori (H. pylori) infection and hyperemesis gravidarum

BACKGROUND

Hyperemesis gravidarum remains a common, distressing, and significant yet poorly understood disorder during pregnancy. The association between maternal Helicobacter pylori (H. pylori) infection and hyperemesis gravidarum has been increasingly recognized and investigated. This study thus aimed to provide an updated review and meta-analysis of the topic.

METHODS

Using the search terms (H. pyloriOR Helicobacter ORHelicobacter pyloriOR infection) AND (pregnancy OR emesis OR hyperemesis gravidarum OR nausea OR vomiting), a preliminary search on the PubMed, Ovid, Web of Science, Google Scholar, and WanFang database yielded 372 papers published in English between January 1st, 1960 and June 1st, 2017.

RESULTS

A total of 38 cross-sectional and case-control studies, with a total of 10 289 patients were eligible for review. Meta-analysis revealed a significant association between H. pylori infection and hyperemesis gravidarum during pregnancy, with a pooled odds ratio of 1.348 (95% CI: 1.156-1.539, P < .001). Subgroup analysis found that serologic and stool antigen tests were comparable methods of detecting H. pylori as they yielded similar odds ratios.

LIMITATIONS

Although the studies did not have high heterogeneity (I²  = 28%), publication bias was observed, and interstudy discrepancies in the diagnostic criteria adopted for hyperemesis gravidarum limit the reliability of findings. Also, 15 of the included studies were from the same country (Turkey), which could limit the generalizability of current findings. The prevalence of H. pylori infection varies throughout the world, and there may also be pathogenic differences as most strains of H. pylori in East Asia carry the cytotoxin-associated gene A gene.

CONCLUSION

H. pylori infection was associated with an increased likelihood of hyperemesis gravidarum during pregnancy. Given the high prevalence of H. pylori infections worldwide, detecting H. pylori infection and the eradication of maternal H. pylori infection could be part of maternal hyperemesis gravidarum management. Further confirmation with robust longitudinal studies and mechanistic investigations are needed.

Effect of maternal Helicobacter Pylori infection on gestational weight gain in an urban community of Uganda

Introduction

Maternal Helicobacter pylori (H. pylori) infection has been associated with undesirable effects during pregnancy such as; hyperemesis gravidarum, anemia, intrauterine fetal growth restriction and miscarriage. Our aim was to document the effect of H. pylori infection on gestational weight gain (GWG) in a low-income urban setting in Uganda.

Methods

This was a prospective cohort study conducted in Kampala between May 2012 and May 2013. The participants were HIV negative, H. pylori positive and H. pylori negative primigravidae and secundigravidae. Recruitment was at gestation age of eighteen or less weeks and follow up assessments were carried out at 26 and 36 weeks gestation age. H. pylori infection was determined using H. pylori stool antigen test. Maternal weight and height were measured, and body mass index (BMI) and rates of GWG were calculated.

Results

The participants’ mean±standard deviation (sd) age was 20.9±2.7 years. Primigravidae were 68.8% (n = 132) and 57.3% (n = 110) of the participants were positive for H. pylori infection. Low pre-women pregnancy BMI (< 18.5 kg/m²) was recorded in 14.6% (n = 28). The mean±sd rate of GWG during second and third trimesters was 300.5±79.7 grams/week. The mean±sd weight gained by 36 weeks of gestation was 9.6±2.2 kg while gestation age at delivery was 39.4±1.0 weeks. Factors independently associated with the rates of GWG during the second and third trimesters were parity (P=0.023), H. pylori infection (P = 0.006), pre-pregnancy BMI (P = 0.037), height (P = 0.022) and household income (P = 0.003).

Conclusion

H. pylori infection is associated with low rates of GWG among primigravidae and secundigravidae.

Relationship Between Gestational Weight Gain and Pregnancy Complications or Delivery Outcome

The purpose of this study is to analyse the association between gestational weight gain and delivery outcome or the morbidity of pregnancy complications. A total of 1,102 pregnant women who delivered at Peking University People’s Hospital in China between January 2011 and December 2012 were included in this study. We divided them into 4 groups according to the baseline BMI quartiles and weight gain quartiles in different trimesters of pregnancy to analyse the status of delivery outcome and morbidity of pregnancy complications. Baseline BMI was significantly positive correlated with the morbidity of gestational hypertension and gestational diabetes. Weight gain in the second trimester of pregnancy was significantly positively correlated with the morbidity of macrosomia. Weight gain in the third trimester of pregnancy showed significantly positive correlation with the morbidity of macrosomia, and significantly negative correlation with the morbidity of neonatal death, preterm birth, gestational diabetes, and low birth-weight infant. Gestational weight gain showed significantly positive correlation with the morbidity of macrosomia and significantly negative correlation with neonatal death, stillbirth, gestational diabetes, preterm birth and low birth-weight infant. There is a correlation between baseline BMI, pregnancy weight gain and gestational complications, adverse pregnancy outcomes, and status of neonate in varying degrees.

Fundamentals of Clinical Pharmacology With Application for Pregnant Women

Medication use is common in pregnancy, yet for most medications the optimal formulation and dosage have not been described specifically for pregnant women. Often, adverse effects are only discovered anecdotally or after extensive off-label use occurs. Since pharmacologic research that includes pregnant women is sparse and animal studies are often not applicable to the human fetus, providers must use knowledge of drug behavior and normal physiologic changes of pregnancy to personalize treatment for pregnant women. In this review, we present an overview of the basic concepts of clinical pharmacology: pharmacokinetics, pharmacodynamics, and pharmacogenomics. The normal physiologic changes of pregnancy are presented as a framework to understand alterations in drug behavior. A clinical vignette that addresses 4 pregnancy scenarios involving medications-preterm birth, vaccination, herpes simplex virus infection, and codeine toxicity-is provided to illustrate application of core clinical pharmacologic concepts. Discussion of relevant literature illustrates the challenges of offering individualized pharmacologic therapy in pregnancy.

Neurological Disorders Complicating Pregnancy - Focus on Obstetric Outcome

INTRODUCTION

Neurological disorders in pregnancy can be pregnancy related or can be caused by exacerbation of a pre-existing neurological condition or sometimes may even be detected for the first time during pregnancy in which it might be an incidental finding. The diagnosis and management of the neurological disorders in pregnancy is always a challenging task due to varied symptomatology and risks to the fetus. The evaluation and management should be performed in a stepwise fashion and requires multidisciplinary approach.

AIM

The present study was conducted with the aim to study the influence of neurological disorders on outcome of pregnancy.

MATERIAL AND METHODS

This was a prospective observational study conduted over a period of 1 year (2013-2014) including 54 pregnant women with neurological manifestations. The spectrum of neurological manifestations was divided into-pregnancy specific, incidental and pre-existing neurological disorders for analysis. Five unusual cases with varied manifestations were studied in detail. Any pregnant woman presenting with neurological manifestation, irrespective of gestational age were included in the present study. The neurological manifestation and the obstetric outcome were analysed in the present study.

RESULTS

There were 54 women with varied neurological manifestations, majority (74%) of them being primigravida. Seizure was the most common (63%) manifestation. The incidence of pregnancy specific disorder (eclampsia), pre-existing disease (epilepsy) and incidental causes were 40.8%, 37% and 22.2% respectively. Of the 22 women with eclampsia, 15(68%) had seizure during antepartum period and 7(32%) in the postpartum period. Three patients out of 22 who had eclampsia had intrauterine fetal demise on arrival itself, whereas the perinatal outcome was good in the other 19 patients who had live born babies. The most common incidental cause in the present study was tubercular meningitis (44%). There was however a maternal and perinatal mortality in woman with structural malformation who had massive intra-ventricular haemorrhage, secondary to ruptured cerebral cavernoma. Here we have described in detail 5 patients with varied clinical manifestation causing diagnostic dilemma. They are spinal arterio-venous malformation, disseminated toxoplasmosis, massive intra-ventricular haemorrhage (ruptured cerebral cavernoma), tubercular meningitis with cortical venous thrombosis, suspected Bartter syndrome presenting as coma.

CONCLUSION

Neurological manifestation during pregnancy may not always be a primary neurological disorder, instead may be manifestation secondary to any systemic illness. Hence, a wide index of suspicion and neuroimaging aids in arriving at the diagnosis certainly improves the pregnancy outcome.