Maternal ketosis and its effects on the fetus

Cardiac mitochondrial metabolism during pregnancy and the postpartum period

The goal of the present study was to characterize changes in mitochondrial respiration in the maternal heart during pregnancy and after birth. Timed pregnancy studies were performed in 12-wk-old female FVB/NJ mice, and cardiac mitochondria were isolated from the following groups of mice: nonpregnant (NP), midpregnancy (MP), late pregnancy (LP), and 1-wk postbirth (PB). Similar to our previous studies, we observed increased heart size during all stages of pregnancy (e.g., MP and LP) and postbirth (e.g., PB) compared with NP mice. Differential cardiac gene and protein expression analyses revealed changes in several mitochondrial transcripts at LP and PB, including several mitochondrial complex subunits and members of the Slc family, important for mitochondrial substrate transport. Respirometry revealed that pyruvate- and glutamate-supported state 3 respiration was significantly higher in PB vs. LP mitochondria, with respiratory control ratio (RCR) values higher in PB mitochondria. In addition, we found that PB mitochondria respired more avidly when given 3-hydroxybutyrate (3-OHB) than mitochondria from NP, MP, and LP hearts, with no differences in RCR. These increases in respiration in PB hearts occurred independent of changes in mitochondrial yield but were associated with higher abundance of 3-hydroxybutyrate dehydrogenase 1. Collectively, these findings suggest that, after birth, maternal cardiac mitochondria have an increased capacity to use 3-OHB, pyruvate, and glutamate as energy sources; however, increases in mitochondrial efficiency in the postpartum heart appear limited to carbohydrate and amino acid metabolism.NEW & NOTEWORTHY Few studies have detailed the physiological adaptations that occur in the maternal heart. We and others have shown that pregnancy-induced cardiac growth is associated with significant changes in cardiac metabolism. Here, we examined mitochondrial respiration and substrate preference in isolated mitochondria from the maternal heart. We show that following birth, cardiac mitochondria are "primed" to respire on carbohydrate, amino acid, and ketone bodies. However, heightened respiratory efficiency is observed only with carbohydrate and amino acid sources. These results suggest that significant changes in mitochondrial respiration occur in the maternal heart in the postpartum period.

Starvation Ketoacidosis in a Young Healthy Female After Prolonged Religious Fasting

Ketone bodies are important energy sources for the body and are produced by the liver when the body is in a deficiency state of glucose, which is used in the peripheral tissues to provide energy. There are several ketone bodies that are produced by the liver, of which two are important: acetoacetate and beta-hydroxybutyrate. Even though ketone bodies are always present in the body, they are minimal when a person is not fasting. Ketone bodies are produced by the oxidation of fatty acids to fulfill the metabolic needs of tissues, especially the brain. The biochemical reactions of forming ketone bodies are triggered by a lack of insulin and an elevated glucagon level in the blood. Both cause unopposed lipolysis and free fatty acid oxidation resulting in the production of ketone bodies and eventually high anion gap metabolic acidosis. We present a case of young healthy female who presented with euglycemic ketoacidosis after involving prolonged fasting for her religious ceremony. She also physically exerted quite more during her fasting. With a detailed history and excluding other possibilities, we made the diagnosis of starvation ketoacidosis. She improved well with the treatment and established her pre-morbid condition in our review.

Using a Very Low Energy Diet to Achieve Substantial Preconception Weight Loss in Women with Obesity: A Review of the Safety and Efficacy

Obesity in women of reproductive age is common. Emerging evidence suggests that maternal obesity not only increases the risk of adverse pregnancy outcomes but also has an enduring impact on the metabolic health of the offspring. Given this, management of obesity prior to pregnancy is critically important. Almost all international guidelines suggest that women with obesity should aim to achieve weight loss prior to pregnancy. However, current pre-conception weight loss therapies are sub-optimal. Lifestyle modification typically results in modest weight loss. This may assist fertility but does not alter pregnancy outcomes. Bariatric surgery results in substantial weight loss, which improves pregnancy outcomes for the mother but may be harmful to the offspring. Alternative approaches to the management of obesity in women planning pregnancy are needed. Very low energy diets (VLEDs) have been proposed as a possible tool to assist women with obesity achieve weight loss prior to conception. While VLEDs can induce substantial and rapid weight loss, there are concerns about the impact of rapid weight loss on maternal nutrition prior to pregnancy and about inadvertent exposure of the early fetus to ketosis. The purpose of this review is to examine the existing literature regarding the safety and efficacy of a preconception VLED program as a tool to achieve substantial weight loss in women with obesity.

Dermatologic and cosmetic procedures in pregnancy

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The Role of Lifestyle Intervention in the Prevention and Treatment of Gestational Diabetes

Obesity during pregnancy is associated with the development of adverse outcomes, including gestational diabetes mellitus (GDM). GDM is highly associated with obesity and independently increases the risk of both complications during pregnancy and future impaired glycemic control and risk factors for cardiovascular disease for both the mother and child. Despite extensive research evaluating the effectiveness of lifestyle interventions incorporating diet and/or exercise, there remains a lack of definitive consensus on their overall efficacy alone or in combination for both the prevention and treatment of GDM. Combination of diet and physical activity/exercise interventions for GDM prevention demonstrates limited success, whereas exercise-only interventions report of risk reductions ranging from 3 to 49%. Similarly, combination therapy of diet and exercise is the first-line treatment of GDM, with positive effects on maternal weight gain and the prevalence of infants born large-for-gestational age. Yet, there is inconclusive evidence on the effects of diet or exercise as standalone therapies for GDM treatment. In clinical care, women with GDM should be treated with a multidisciplinary approach, starting with lifestyle modification and escalating to pharmacotherapy if needed. Several key knowledge gaps remain, including how lifestyle interventions can be optimized during pregnancy, and whether intervention during preconception is effective for preventing the rising prevalence of GDM.

Ketones in Pregnancy: Why Is It Considered Necessary to Avoid Them and What Is the Evidence Behind Their Perceived Risk?

Current dietary advice for women with gestational diabetes mellitus is to avoid diets that result in elevated ketone levels. This guidance stems from a concern that maternal ketones are associated with poor fetal and childhood outcomes, including reduced childhood intelligence quota. The evidence behind these guidelines is conflicting and inconsistent. Given that dietary counseling is the initial treatment strategy for women with diabetes in pregnancy, it is important that clinicians understand the concern regarding maternal ketones. This review examines the physiology of ketogenesis in pregnancy, the prevalence of elevated maternal ketone levels, and the relationship between maternal ketones and fetal and childhood outcomes.

Lactation Ketoacidosis: A Systematic Review of Case Reports

Background and Objective: Lactation ketoacidosis is a rare cause of high anion gap metabolic acidosis affecting breastfeeding mothers. We aim to review and analyze all cases of lactation ketoacidosis reported. Materials and Methods: A systematic search of PubMed/MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL), identifying relevant case reports published from 1 January 1970 to 31 December 2019. We extracted the following data: the first author, country, year of publication, age of the mother, age of the child, weight/body mass index (BMI) of the mother, precipitating factors, presenting symptoms, biochemical results, treatment, breastfeeding, and time from presentation to the resolution of ketoacidosis. Results: Sixteen case reports and 1 case series reporting 18 cases of lactation ketoacidosis were found. Presenting symptoms were nausea (72%, 13/18), vomiting (67%, 12/18), malaise (56%, 10/18), abdominal pain (44%, 8/18), dyspnea (33%, 6/18), headache (22%, 4/18), and palpitation (11%, 2/18). Dieting and physical exercise to lose weight were reported in 76% (14/18). The treatments included IV dextrose, sodium bicarbonate, insulin, rehydration, monitoring and replacement of electrolytes, and resumption of a balanced diet. The prognoses were good, with no mortalities. Conclusions: lactation ketoacidosis should be suspected in unwell breastfeeding women with high anion gap metabolic acidosis, after excluding other causes.

Gestational diabetes mellitus: Multi-disciplinary treatment approaches

Gestational diabetes mellitus (GDM) is the most common metabolic disease of pregnancy, associated with several perinatal complications. Adequate glycemic control has been proved to decrease risk of GDM-related complications. Several studies have shown the beneficial effect of exercise and medical nutrition treatment on glycemic and weight control in GDM-affected women. Moreover, pharmacological agents, such as insulin and specific oral anti-diabetic agents can be prescribed safely during pregnancy, decreasing maternal blood glucose and, thus, perinatal adverse outcomes. Multi-disciplinary treatment approaches that include both lifestyle modifications (medical nutritional therapy and daily physical exercise) and pharmacological treatment, in cases of failure of the former, constitute the most effective approach. Insulin is the gold standard pharmacological agent for GDM treatment. Metformin and glyburide are two oral anti-diabetic agents that could serve as alternative, although not equal in terms of effectiveness and safety, treatment for GDM. As studies on short-term safety of metformin are reassuring, in some countries it is considered as first-line treatment for GDM management. More studies are needed to investigate the long-term effects on offspring. As safety issues have been raised on the use of glyburide during pregnancy, it must be used only when benefits surpass possible risks.

Health consequences for mother and baby of substantial pre-conception weight loss in obese women: study protocol for a randomized controlled trial

BACKGROUND

Current guidelines for the management of obesity in women planning pregnancy suggest lifestyle modification before conception. However, there is little evidence that lifestyle modification alters pregnancy outcomes. Bariatric surgery results in significant weight loss. This appears to reduce the risk of adverse pregnancy outcomes for the mother but may increase the risk of adverse outcomes for the infant. In order to reduce the risks of obesity-related adverse pregnancy outcomes for both mother and offspring, alternative approaches to the management of obesity in women planning pregnancy are needed.

METHODS/DESIGN

This study, a two-arm, parallel group, randomized control trial, will be conducted at the Metabolic Disorders Centre, University of Melbourne. This trial will recruit 164 women aged 18-38 years with a body mass index of 30-55 kg/m² who plan to conceive in the next 6-12 months. Women will be randomized to one of two 12-week interventions (Group A and Group B). Group A will aim for modest weight loss (MWL; ≤ 3% body weight) using a hypocaloric diet. Group B will aim for substantial weight loss (SWL; 10-15% body weight) using a modified very low energy diet (VLED) program. All participants will be asked to comply with National Health and Medical Research Council (NHMRC) guidelines for exercise and will be provided with standard pre-pregnancy advice according to Royal Australian and New Zealand College of Obstetrics and Gynaecology guidelines. All participants will then be observed for the subsequent 12 months. If pregnancy occurs within the 12-month follow-up period, data on weight and metabolic status of the mother, and pregnancy outcomes of mother and offspring will be recorded. The primary outcome is maternal fasting plasma glucose at 26-28 weeks' gestation, given that this is known to correlate with pregnancy outcomes. Time to conception, live birth rate, gestational weight gain, and a composite of adverse pregnancy outcomes for mother and baby will comprise the secondary outcomes.

DISCUSSION

There is increasing emphasis on obese women losing weight before conception. To date, no randomized controlled trial has demonstrated an effective means of weight loss that results in improved pregnancy outcomes for both mother and baby. This study intends to determine if substantial pre-conception weight loss, achieved using a VLED, improves pregnancy outcomes for mother and baby when compared with standard care. This research will potentially change clinical care of an obese woman planning pregnancy.

TRIAL REGISTRATION

ANZCTR, 12,614,001,160,628 . Registered on 5 November 2014.

The Ketogenic Diet

The ketogenic diet (KD), a well-established treatment for childhood epilepsy, is gradually gaining acceptance as a therapeutic modality for obesity and type 2 diabetes. The perception of ketone bodies as an unhealthy or “sinful” entity has led to concerns and doubts regarding the efficacy and safety of KD in physicians. This article describes the mechanism of action of KD and shares a pragmatic approach to its usage. It highlights the importance of predietary counseling, screening for indications/contraindications, and clinico-nutritional monitoring during therapy. Robust indications for KD are mentioned, to help place KD’s utility in the management of obesity and type 2 diabetes.

Prevalence of maternal urinary ketones in pregnancy in overweight and obese women

Background

Ketonuria may be associated with adverse fetal outcomes. This study aimed to determine the prevalence of ketonuria at three time points in pregnancy and to assess whether ketonuria correlates with a clinical indication for performing a urine test.

Methods

Women had fasting urinary ketone levels measured at 16 and 28 weeks gestation and random ketone levels measured close to 36 weeks gestation. All ketone levels in the third trimester were recorded along with the clinical indication for the test.

Results

One hundred and eighty-seven women were included in the study. Twenty-two per cent of women had ketonuria at either 16 or 28 weeks gestation and 8% at 36 weeks gestation. Ketonuria was significantly more likely if a test was performed for a clinical indication (p = 0.0002).

Conclusion

Ketonuria in pregnancy is common affecting at least one in five women. Ketonuria is more common in women who have a clinical indication for performing a urine test.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

A gestational ketogenic diet alters maternal metabolic status as well as offspring physiological growth and brain structure in the neonatal mouse

BACKGROUND

The use of the ketogenic diet (KD) among women of child-bearing age has been increasing, leading to increased interest in identifying the diet's suitability during gestation. To date, no studies have thoroughly investigated the effect of a gestational KD on offspring growth. Since ketones have been reported to play a role in cerebral lipid and myelin synthesis, it is particularly important to investigate the diet's impact on brain anatomy of the offspring.

METHODS

To fill this knowledge gap we imaged CD-1 mouse neonates whose mothers were fed either a standard diet (SD) or a KD prior to and during gestation. Images were collected at postnatal (P) 11.5 and 21.5 using Magnetic Resonance Imaging (MRI). Maternal metabolic status was also tracked during lactation, by following their body weight, blood glucose, ketone, cholesterol, and triglyceride concentrations.

RESULTS

The KD dams exhibit a significant reduction in maternal fertility and litter size, as well as a high risk of developing fatal ketoacidosis by mid-lactation. To increase survival of the KD dams and offspring, fostering of P2.5 pups (from both KD and SD litters) by SD-foster dams was carried out. This resulted in stabilization of blood ketones of the KD dams, and aversion of the fatal ketoacidosis. We also note a slower and smaller weight loss for the KD compared with the SD dams. The average fostered KD pup exhibits retarded growth by P21.5 compared with the average fostered SD pup. An anatomical comparison of their brains further revealed significant structural differences at P11.5, and particularly at P21.5. The KD brain shows a relative bilateral decrease in the cortex, fimbria, hippocampus, corpus callosum and lateral ventricle, but a relative volumetric enlargement of the hypothalamus and medulla.

CONCLUSION

A gestational ketogenic diet deleteriously affects maternal fertility and increases susceptibility to fatal ketoacidosis during lactation. Prenatal and early postnatal exposure to a ketogenic diet also results in significant alterations to neonatal brain structure, and results in retarded physiological growth. These alterations could be accompanied by functional and behavioural changes in later postnatal life.

Effects of a ketogenic diet during pregnancy on embryonic growth in the mouse

BACKGROUND

The increasing use of the ketogenic diet (KD), particularly by women of child-bearing age, raises a question about its suitability during gestation. To date, no studies have thoroughly investigated the direct implications of a gestational ketogenic diet on embryonic development.

METHODS

To fill this knowledge gap we imaged CD-1 mouse embryos whose mothers were fed either a Standard Diet (SD) or a KD 30 days prior to, as well as during gestation. Images were collected at embryonic days (E) 13.5 using Optical Projection Tomography (OPT) and at E17.5 using Magnetic Resonance Imaging (MRI).

RESULTS

An anatomical comparison of the SD and KD embryos revealed that at E13.5 the average KD embryo was volumetrically larger, possessed a relatively larger heart but smaller brain, and had a smaller pharynx, cervical spinal cord, hypothalamus, midbrain, and pons, compared with the average SD embryo. At E17.5 the KD embryo was found to be volumetrically smaller with a relatively smaller heart and thymus, but with enlarged cervical spine, thalamus, midbrain and pons.

CONCLUSION

A ketogenic diet during gestation results in alterations in embryonic organ growth. Such alterations may be associated with organ dysfunction and potentially behavioral changes in postnatal life.

A case of nondiabetic ketoacidosis in third term twin pregnancy

CONTEXT

We report on a case of nondiabetic ketoacidosis due to mild starvation in a third term twin pregnancy.

OBJECTIVE

The aim was to present a case report and review of the literature in nondiabetic ketoacidosis in pregnancy, including precipitating factors and underlying pathophysiology.

DESIGN

The case report includes collation of earlier data and literature review.

SETTING

The patient was admitted to the obstetrics ward of a large general hospital and, after cesarean section, was transferred to the intensive care unit.

PATIENT

We present the case of a 26-yr-old obese patient with a 35-wk twin pregnancy.

INTERVENTION

We provided appropriate management with fluid infusion after cesarean delivery.

RESULTS

The patient and her two daughters survived, and no disabilities were foreseen. Alcohol, methanol, and lactic acid levels were normal. No signs of renal disease or diabetes were present. Pathological examination revealed no abnormalities of the placentae. Toxicological tests revealed a salicylate level of less than 5 mg/liter, an acetaminophen level of less than 1 mg/liter, and an acetone level of 300 mg/liter (reference, 5-20 mg/liter).

CONCLUSIONS

We present a case of third term twin pregnancy with high anion gap metabolic acidosis due to (mild) starvation. Starvation, obesity, third term twin pregnancy, and perhaps a gastroenteritis were the ultimate provoking factors. In the light of the erroneous suspicion of sepsis and initial fluid therapy lacking glucose, one wonders whether, under a different fluid regime, cesarean section could have been avoided. Severe ketoacidosis in the pregnant woman is associated with impaired neurodevelopment. It therefore demands early recognition and immediate intervention.

Is salt, vitamin, or endocrinopathy causing this encephalopathy? A review of endocrine and metabolic causes of altered level of consciousness

Altered level of consciousness describes the reason for 3% of critical emergency department (ED) visits. Approximately 85% will be found to have a metabolic or systemic cause. Early laboratory studies such as a bedside glucose test, serum electrolytes, or a urine dipstick test often direct the ED provider toward endocrine or metabolic causes. This article examines common endocrine and metabolic causes of altered mentation in the ED via sections dedicated to endocrine-, electrolyte-, metabolic acidosis-, and metabolism-related causes.

Differential Diagnosis of Metabolic Acidosis

Metabolic acidosis is defined as an acidemia created by one of three mechanisms: increased production of acids, decreased excretion of acids, or loss of alkali. This article addresses the identification and correct diagnosis of metabolic acidosis by reviewing important historical factors, pathophysiological principles, clinical presentation,and laboratory findings accompanying common high and normal anion gap metabolic acidoses in emergency department patients.

Midwifery dilemma: to fast or feed the labouring woman Part 2: the case supporting oral intake in labour

This article has, so far, explored the phenomenon of aspiration associated with obstetric general anaesthesia (see Part 1). Part 2 examines the literature pertaining to the history of dietary regimes for labour and the physiological and psychological effect of restricting or allowing food and fluids during labour. The increasing trend among some health professionals to allow food and fluids during labour and research conducted to investigate the effect of the labouring woman's oral intake on the labour and birth outcomes is also discussed.

Dermatologic surgery and the pregnant patient

BACKGROUND

Because of concerns about potential harm to the mother or fetus, dermatologic surgeons are frequently hesitant to perform cutaneous surgery on pregnant patients.

OBJECTIVE

To review the relevant physiologic changes during pregnancy, appropriate preparation for and timing of procedures, and drug safety.

METHODS

A literature review was performed of dermatologic and nondermatologic journals discussing physiology, surgery, and drug safety in the pregnant patient.

RESULTS

Special positioning is required for the pregnant patient during surgery. Low doses of most local anesthetics with epinephrine as well as nitrous oxide less than 50% are safe to use during pregnancy. Sedatives and opioids are potential teratogens and should be avoided. Safe antibiotics to use during skin surgery in pregnancy include penicillins, cephalosporins, and nonestolate erythromycin. If necessary, lymph node dissections under general anesthesia in the pregnant melanoma patient should occur during the second trimester.

CONCLUSION

With appropriate preparation, safe and successful cutaneous surgery can be performed on the pregnant patient.

Ketone-body metabolism in tumour-bearing rats

During starvation for 72 h, tumour-bearing rats showed accelerated ketonaemia and marked ketonuria. Total blood [ketone bodies] were 8.53 mM and 3.34 mM in tumour-bearing and control (non-tumour-bearing) rats respectively (P less than 0.001). The [3-hydroxybutyrate]/[acetoacetate] ratio was 1.3 in the tumour-bearing rats, compared with 3.2 in the controls at 72 h (P less than 0.001). Blood [glucose] and hepatic [glycogen] were lower at the start of starvation in tumour-bearing rats, whereas plasma [non-esterified fatty acids] were not increased above those in the control rats during starvation. After functional hepatectomy, blood [acetoacetate], but not [3-hydroxybutyrate], decreased rapidly in tumour-bearing rats, whereas both ketone bodies decreased, and at a slower rate, in the control rats. Blood [glucose] decreased more rapidly in the hepatectomized control rats. Hepatocytes prepared from 72 h-starved tumour-bearing and control rats showed similar rates of ketogenesis from palmitate, and the distribution of [1-14C] palmitate between oxidation (ketone bodies and CO2) and esterification was also unaffected by tumour-bearing, as was the rate of gluconeogenesis from lactate. The carcinoma itself showed rapid rates of glycolysis and a poor ability to metabolize ketone bodies in vitro. The results are consistent with the peripheral, normal, tissues in tumour-bearing rats having increased ketone-body and decreased glucose metabolic turnover rates.

A comparison of the effects of four intravenous solutions for the treatment of ketonuria during labour

Forty women in whom ketonuria was detected during the first stage of labour were allocated randomly to intravenous treatment with one litre of either normal saline, Hartmann's solution, 5% dextrose or 10% dextrose. The solutions were administered over 1 h and blood was taken immediately beforehand and thereafter at 30-min intervals for 90 min to assess their effect on intermediary metabolism, plasma osmolality and acid-base status. Although both the 5 and 10% dextrose infusions caused a rapid decline in whole blood D-3-hydroxybutyrate concentrations, they also produced pathological degrees of maternal hyperglycaemia and hyperinsulinaemia and a marked elevation in the mean blood lactate and pyruvate concentrations. Administration of 10% dextrose was also associated with a significant increase in serum osmolality. Hartmann's solution produced significantly higher mean whole blood lactate and pyruvate concentrations than did normal saline. There was a significant increase in the venous base deficit in the group infused with 10% dextrose, indicating that the buffering capacity of the blood had been exceeded. It is concluded that rapid infusions of dextrose or Hartmann's solution should not be administered during labour. Normal saline should be used for rehydration and if dextrose therapy is deemed necessary the dose administered should not exceed physiological requirements.