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Huang TS, Rosales O, Durnwald CP, Dolin CD. Feasibility and Acceptability of Home-Delivered Medically Tailored Meals for Treatment of Diabetes in Pregnancy. J Nutr 2024; 154:777-784. [PMID: 38141775 DOI: 10.1016/j.tjnut.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Diabetes complicates ≤7% of pregnancies in the United States. Although medical nutrition therapy is the mainstay of diabetes treatment, many barriers exist to the successful implementation of dietary modifications. Home-delivered medically tailored meals (MTMs) are promising to overcome such barriers. OBJECTIVE The objective of this study was to evaluate the feasibility and acceptability of home-delivered MTM in pregnant patients with diabetes. METHODS We performed a prospective cohort study of home-delivered MTM for pregnant patients with diabetes using a mixed-methods approach. Participants <35 wk of gestation at the time of enrollment received weekly home delivery of diabetes-specific meals. Qualitative semistructured interviews were conducted to gain insight into participants' experience. Diabetes self-efficacy was assessed pre- and postintervention using the Diabetes Self-Efficacy Scale and 2-Item Diabetes Distress Screening Scale. The difference in mean scores was compared using t-tests with P value of <0.05 considered significant. Feasibility and acceptability were evaluated through participants' attitude toward MTM in qualitative interviews and indirectly evaluated through diabetes self-efficacy surveys. RESULTS Twenty pregnant people with diabetes who received home-delivered MTM during pregnancy were interviewed postpartum. Participants found this program convenient for various reasons, including reduced time for grocery shopping and preparing meals. Participants were satisfied with meals, citing a positive impact on diabetes management, accessibility of healthy foods, reduced stress with meal planning, and greater perceived control of blood glucose. Most participants shared meals with their families or received specific meals for their dependents, which was positively received. Reduced financial and mental stress was also widely reported. Diabetes self-efficacy was significantly improved postintervention with MTM. CONCLUSION Home-delivered MTM is feasible and acceptable in pregnant patients with diabetes and may improve diabetes self-efficacy. Individual experiences offered insight into various barriers overcome by using this service. Home-delivered MTM may help ensure an accessible, healthy diet for pregnant patients with diabetes.
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Affiliation(s)
- Tiffany S Huang
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States.
| | - Odette Rosales
- Department of Obstetrics and Gynecology, Drexel University, Philadelphia, PA, United States
| | - Celeste P Durnwald
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, United States
| | - Cara D Dolin
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, United States
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Dolin CD, Mullin AM, Ledyard RF, Bender WR, South EC, Durnwald CP, Burris HH. Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance. Int J Environ Res Public Health 2023; 20:6175. [PMID: 37372761 PMCID: PMC10298257 DOI: 10.3390/ijerph20126175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.
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Affiliation(s)
- Cara D. Dolin
- Department of Obstetrics and Gynecology, Women’s Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
| | - Anne M. Mullin
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Rachel F. Ledyard
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Whitney R. Bender
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA
| | - Eugenia C. South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Celeste P. Durnwald
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Heather H. Burris
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Hamm RF, Teefey CP, Dolin CD, Durnwald CP, Srinivas SK, Levine LD. Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol. Am J Perinatol 2021; 38:1453-1458. [PMID: 34282575 PMCID: PMC9108751 DOI: 10.1055/s-0041-1732459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. STUDY DESIGN This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m2) and nonobese (<30 kg/m2) women. Indication for cesarean was also evaluated. RESULTS A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol. CONCLUSION Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. KEY POINTS · Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction..
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Affiliation(s)
- Rebecca F. Hamm
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina P. Teefey
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cara D. Dolin
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Celeste P. Durnwald
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lisa D. Levine
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Dolin CD, Compher CC, Oh JK, Durnwald CP. Pregnant and hungry: addressing food insecurity in pregnant women during the COVID-19 pandemic in the United States. Am J Obstet Gynecol MFM 2021; 3:100378. [PMID: 33932628 DOI: 10.1016/j.ajogmf.2021.100378] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Food insecurity is a major social determinant of health affecting more than 10% of Americans. Social determinants of health are increasingly recognized as a driving force of health inequities. It is well established that food insecurity leads to adverse health outcomes outside of pregnancy, such as obesity, hypertension, diabetes mellitus, and mental health problems. However, limited data exist about the impact of food insecurity during pregnancy on maternal and neonatal outcomes. Food insecurity and other social determinants of health are rarely addressed as part of routine obstetrical care. The COVID-19 pandemic has only exacerbated the crisis of food insecurity across the country, disproportionally affecting women and racial and ethnic minorities. Women's health providers should implement universal screening for maternal food insecurity and offer resources to women struggling to feed themselves and their families. Reducing maternal health inequities in the United States involves recognizing and addressing food insecurity, along with other social determinants of health, and advocating for public policies that support and protect all women's right to healthy food during pregnancy.
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Affiliation(s)
- Cara D Dolin
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Drs Dolin, Oh, and Durnwald).
| | - Charlene C Compher
- Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA (Dr Compher)
| | - Jinhee K Oh
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Drs Dolin, Oh, and Durnwald)
| | - Celeste P Durnwald
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Drs Dolin, Oh, and Durnwald)
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Abstract
OBJECTIVE This article evaluates the differences in adverse maternal outcomes related to severe preeclampsia in obese versus nonobese women. STUDY DESIGN Retrospective cohort study and planned secondary analysis of women with severe preeclampsia comparing a composite adverse maternal outcome related to preeclampsia among obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese (BMI < 30 kg/m2) women. The composite outcome was defined as ≥ 1 of the following prior to discharge: renal failure, liver abnormality, thrombocytopenia, blood transfusion, pulmonary edema, disseminated intravascular coagulation, stroke, or eclampsia. Multivariable logistic regression was used to control for confounders. RESULTS Of the 152 women included, 37.5% were obese and 62.5% were nonobese. The prevalence of the primary outcome was 15.8% with obese women less likely to have the composite outcome compared with nonobese women (7% vs. 21.1%, p = 0.02). This remained after adjusting for confounders including maternal age, race, and chronic hypertension (adjusted odds ratio, 0.33 [0.12-0.89], p = 0.03). Obese women were, however, more likely to require intravenous antihypertensive medication peripartum compared with nonobese women (49.1% vs. 28.4%, p = 0.01). CONCLUSION Obese women with severe preeclampsia may have a different phenotype of severe preeclampsia that is more associated with severe hypertension rather than end-organ damage.
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Affiliation(s)
- Christina Paidas Teefey
- The Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine - University of Pennsylvania, Philadelphia, Pennsylvania
| | - Celeste P. Durnwald
- The Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine - University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sindhu K. Srinivas
- The Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine - University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa D. Levine
- The Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine - University of Pennsylvania, Philadelphia, Pennsylvania
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Durnwald CP, Downes K, Leite R, Elovitz M, Parry S. Predicting persistent impaired glucose tolerance in patients with gestational diabetes: The role of high sensitivity CRP and adiponectin. Diabetes Metab Res Rev 2018; 34. [PMID: 29078256 DOI: 10.1002/dmrr.2958] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/02/2017] [Accepted: 10/08/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND To evaluate whether maternal serum adiponectin and high-sensitivity C-reactive protein (hsCRP) levels at the time of gestational diabetes mellitus (GDM) diagnosis are associated with persistent glucose intolerance in GDM women at 6 to 12 weeks postpartum. METHODS This is a secondary analysis of prospective randomized trial of GDM women enrolled in a behaviour education programme. Women with a GDM diagnosis ≥20 weeks were included. At the time of randomization, serum adiponectin and hsCRP levels were drawn. After delivery, women underwent a 2-hour 75-g oral glucose tolerance test at 6 to 12 weeks postpartum. Persistent impaired glucose tolerance (P-IGT) was defined as impaired fasting glucose, impaired glucose tolerance, or a diagnosis of type 2 diabetes mellitus. Regression models and receiver operator curves were used to evaluate the association between midpregnancy adiponectin and hsCRP and persistent impaired glucose tolerance. RESULTS Of 100 women in the trial, 63 completed postpartum glucose testing. Twenty (31.7%) of the women had P-IGT. Median hsCRP levels were higher at randomization (22-34 wk) in women with persistent impaired glucose tolerance compared with women with normal glucose tolerance (5.1 vs 3.8, P = .01). After adjustment for the original study intervention, the association between hsCRP and P-IGT persisted (odds ratio, 3.45; 95% confidence interval, 1.34-8.92; P = .01) and had good diagnostic performance with an area under the curve of 0.73. There was no difference in median adiponectin levels between groups (44.8 vs 52.0, P = .57) or in odds of P-IGT (odds ratio, 0.81; 95% confidence interval, 0.33-1.99; P = .65), and area under the curve = 0.54. CONCLUSIONS Midpregnancy high sensitivity CRP is a potential predictor of persistent impaired glucose tolerance diagnosed on the postpartum 2-hour 75-g oral glucose tolerance test in GDM women in the immediate postpartum period. Further investigation is needed in a larger population of women prior to using specific cut-offs for diagnostic purposes. High-sensitivity C-reactive protein levels in the immediate postpartum period should be seen as an adjunct, not a replacement, for the standard long-term screening of women with a history of a GDM pregnancy.
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Affiliation(s)
- Celeste P Durnwald
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katheryne Downes
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rita Leite
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michal Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samuel Parry
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Durnwald CP. 1000: Fibroblast growth factor 21 and metabolic dysfunction in women with a prior glucose intolerant pregnancy. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Maternal obesity, excessive gestational weight gain, and preexisting diabetes are known risk factors for increased maternal and neonatal morbidity. These conditions are more prevalent in certain racial and ethnic minorities. Identification and acknowledgement of racial and ethnic inequalities related to maternal metabolic disease is crucial for clinicians to provide the most comprehensive care in pregnancy. Research and clinical efforts should focus on implementation of healthy lifestyle interventions preconceptually and risk reduction efforts in disease complications during pregnancy. In addition, obstetrical providers can provide the framework and ongoing support for sustainable lifestyle modifications, thereby, improving a woman's long-term metabolic health.
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Affiliation(s)
- Christina Paidas Teefey
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 2 Silverstein Building, 3400 Spruce St, Philadelphia, PA 19104.
| | - Celeste P Durnwald
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 2 Silverstein Building, 3400 Spruce St, Philadelphia, PA 19104
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Ghartey J, Ghaffari N, Levine LD, Schwartz N, Durnwald CP. Implementation of a universal cervical length screening program: identifying factors associated with decline rates. J Matern Fetal Neonatal Med 2017; 31:1124-1127. [PMID: 28320241 DOI: 10.1080/14767058.2017.1309386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Cervical length (CL) measurement is now accepted as a screening strategy for identifying women at risk for preterm birth (PTB). However, patient acceptability may limit its implementation. Our objective was to identify characteristics associated with women who decline this screening. MATERIALS AND METHODS This is a secondary analysis of a prospective cohort study of women offered UCL screening from January 2012 to June 2012. Women with a singleton gestation 18 0/7-23 6/7 weeks at the time of anatomy scan were included. Trained sonographers were instructed to perform UCL screening on all eligible patients using an "opt-out" approach. Chi square statistics and Wilcoxon rank sum tests were used to compare categorical and continuous data, where appropriate. Logistic regression was used to calculate odds ratio for factors associated with declining UCL screening Results: 1348 women were offered CL screening; 131 (9.7%) declined. Overall, multiparous women were more than twice as likely to decline UCL screening compared to primiparous women [OR 2.4 (1.6-3.8)]. Patient acceptance of screening was significantly dependent on the sonographer (p < .05). CONCLUSION Multiparous women are less likely to accept this strategy of PTB prevention. A standardized counseling approach may improve patient acceptance and mitigate variability in acceptance rates observed amongst sonographers.
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Affiliation(s)
- Jeny Ghartey
- a Maternal-Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | - Neda Ghaffari
- a Maternal-Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | - Lisa D Levine
- a Maternal-Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | - Nadav Schwartz
- a Maternal-Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| | - Celeste P Durnwald
- a Maternal-Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
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Ruhstaller KE, Elovitz MA, Stringer M, Epperson CN, Durnwald CP. Obesity and the association with maternal mental health symptoms. J Matern Fetal Neonatal Med 2017; 30:1897-1901. [PMID: 27623338 DOI: 10.1080/14767058.2016.1229766] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the association between maternal obesity and mood disorders including depression, anxiety, stress, and pregnancy-specific stress during pregnancy. STUDY DESIGN This was a planned secondary analysis of a prospective cohort study investigating factors associated with preterm delivery. The cohort included women who initiated prenatal care before 20 weeks with a singleton pregnancy. Maternal mental health was assessed using four standard psychosocial behavioral measures to screen for depression, pregnancy-specific stress, anxiety, and stress. Screen positive scores for each tool were established based on previously published "high" scores. RESULTS Of the 1010 women included in the cohort, 355 (35.1%) were obese. There was no significant difference in the number of obese women with stress (64.2% versus 68.4%, p = 0.18), pregnancy-specific stress (26.2% versus 22.1%, p = 0.15), or anxiety (38.6% versus 41.2%, p = 0.42); however, a greater number of obese women did report symptoms consistent with major depression when compared to women with BMIs <30 (30.4% versus 21.2%, p < 0.01). CONCLUSION Obese women had higher rates of depression in early pregnancy compared to nonobese women. As many of the health behavior interventions for obese women during pregnancy have proven ineffective, incorporating depression screening and treatment into prenatal care may improve perinatal outcomes.
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Affiliation(s)
- Kelly E Ruhstaller
- a Department of Obstetrics and Gynecology, Maternal-Child Health Research Program, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Michal A Elovitz
- a Department of Obstetrics and Gynecology, Maternal-Child Health Research Program, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Marilyn Stringer
- b Women's Health Nursing, School of Nursing, University of Pennsylvania , Philadelphia, PA , USA
| | - C Neill Epperson
- c Departments of Psychiatry and Obstetrics and Gynecology, Penn Center for Women's Behavioral Wellness, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA , USA.,d Penn Center for Research on Sex and Gender in Health, University of Pennsylvania , Philadelphia, PA , USA
| | - Celeste P Durnwald
- a Department of Obstetrics and Gynecology, Maternal-Child Health Research Program, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
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Abstract
Objective The epigenetic mechanisms underlying fetal metabolic programming are poorly understood. We studied whether obesity is associated with alterations in placental miRNA expression. Study Design A cross-sectional study was performed, including (1) normal-weight women (BMI 20-24.9 kg/m2) and normal-birth-weight (BW) infants (2,700-3,500 g) (n = 20), (2) normal-weight and macrosomic infants (BW ≥ 4,000 g) (n = 10), (3) obese (BMI ≥ 35 kg/m2) and normal BW infants (n = 16), and (4) obese and macrosomic infants (n = 10). All had term deliveries (37-41 weeks) and normal glucose tolerance (1 hour GCT < 7.2 mmol/L [130 mg/dL]). The expression of 5,639 placental miRNAs was assessed using miRNA microarray. Differential miRNA expression was determined using two-way ANOVA and pairwise contrasts, with the Benjamini-Hochberg (BH) correction. MiRNAs with Z-scores ≥ 2 and false discovery rate (FDR) < 20% were considered significant. Results Principal components analysis demonstrated similar global miRNA expression profiles among groups. Of 5,639 miRNAs, only 5 were significantly different between obese and controls, which were not validated by quantitative polymerase reaction. Conclusion There was no difference in placental miRNA expression associated with obesity or overgrowth. Aberrant placental miRNA expression is an unlikely mechanism underlying fetal metabolic programming related to maternal obesity.
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Affiliation(s)
- Neda Ghaffari
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Maternal and Child Health Research Program, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Samuel Parry
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Maternal and Child Health Research Program, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michal A Elovitz
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Maternal and Child Health Research Program, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Celeste P Durnwald
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Maternal and Child Health Research Program, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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Durnwald CP, Kallan MJ, Allison KC, Sammel MD, Wisch S, Elovitz M, Parry S. A Randomized Clinical Trial of an Intensive Behavior Education Program in Gestational Diabetes Mellitus Women Designed to Improve Glucose Levels on the 2-Hour Oral Glucose Tolerance Test. Am J Perinatol 2016; 33:1145-51. [PMID: 27398697 DOI: 10.1055/s-0036-1585085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective To evaluate whether women with gestational diabetes mellitus (GDM) enrolled in an intensive behavior education program (IBEP) demonstrate lower mean fasting glucose levels on the 2-hour 75 g oral glucose tolerance test (2-hour OGTT) at 6 to 12 weeks postpartum compared with women who undergo routine GDM management. Study Design A prospective randomized controlled trial of women diagnosed with GDM was conducted. Exclusion criteria were GDM diagnosis ≥ 33 weeks or < 20 weeks. Women were randomly assigned to one of two treatment arms: (1) routine GDM management or (2) an IBEP. Women underwent a 2-hour OGTT at 6 to 12 weeks postpartum. Fisher exact test, t-test, and Wilcoxon rank sum test were used as appropriate. Results Of the 101 women randomized, 49 were assigned to IBEP and 52 received routine GDM management. There was no difference in mean fasting and 2-hour glucose levels on the postpartum 2-hour OGTT between the IBEP and routine management group (88.5 ± 22.9 mg/dL vs. 85.2 ± 13.3 mg/dL, p = 0.49 and 109.8 ± 38.5 mg/dL vs. 109.4 ± 40.8 mg/dL, p = 0.97, respectively). Conclusion GDM women enrolled in a healthy lifestyle intervention program did not demonstrate lower glucose values on the postpartum 2-hour OGTT.
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Affiliation(s)
- Celeste P Durnwald
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kelly C Allison
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary D Sammel
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Wisch
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michal Elovitz
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel Parry
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Ruhstaller KE, Bastek JA, Thomas A, Mcelrath TF, Parry SI, Durnwald CP. The Effect of Early Excessive Weight Gain on the Development of Hypertension in Pregnancy. Am J Perinatol 2016; 33:1205-10. [PMID: 27490769 DOI: 10.1055/s-0036-1585581] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background Previous studies have shown an association between total excessive gestational weight gain and hypertension in pregnancy. However, this may be a reflection of excessive water retention associated with the pathophysiology of hypertensive disorders of pregnancy. Early excessive weight gain, prior to the third trimester, results in greater maternal fat deposition and inflammation, which has also been associated with the development of hypertension. By focusing on early excessive weight gain, the association between maternal weight gain and the future development of hypertension can be examined. Objective To evaluate the association between early excessive maternal weight gain and the development of hypertension during pregnancy. Study Design This was a secondary analysis of a longitudinal cohort study of 1,441 women without chronic hypertension who were enrolled in a prospective study evaluating maternal angiogenic factors and the prediction of preeclampsia. Initial body mass index (BMI) was calculated by weight and height at the first study visit. Early excessive maternal weight gain was defined as weight gain by 28 weeks that exceeded the Institute of Medicine (IOM) guidelines and was calculated utilizing the maximum amount of weight gain per week recommended by the IOM based on the patient's starting BMI (normal: 0.45 kg; overweight: 0.32 kg; obese: 0.27 kg). Hypertension was defined as a sustained systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg. Logistic regression was used to determine the association between early excessive weight gain, initial BMI, and the development of hypertension, including gestational hypertension and preeclampsia, during pregnancy. Results Of 1,441 women, 767 (53.2%) had weight gain that exceeded the IOM guidelines in the first 28 weeks and 154 (10.8%) developed hypertension during pregnancy. Women whose weight gain exceeded the IOM guidelines were more likely to develop hypertension even after adjusting for relevant confounders (12.5 vs. 8.6%; p = 0.02; adjusted odds ratio [OR] = 1.70; 95% confidence interval [CI]: 1.18-2.44; p < 0.01). Obese women had a 2.4-fold increased risk of developing hypertension, even after controlling for excessive weight gain (adjusted OR = 2.44; 95% CI: 1.66-3.59; p < 0.01) Conclusions Early excessive maternal weight gain and initial BMI are independently associated with the diagnosis of a hypertensive disorder of pregnancy. Women should be counseled regarding the benefits of achieving a normal BMI prior to pregnancy and appropriate weight gain during pregnancy, as well as the potential harms of excessive weight gain related to perinatal outcomes.
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Affiliation(s)
- Kelly E Ruhstaller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jamie A Bastek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann Thomas
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas F Mcelrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel I Parry
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Celeste P Durnwald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Durnwald CP, Huynh T, Ghaffari N, Bastek J. 675: Prenatal care in a specialized diabetes in pregnancy program improves compliance with postpartum testing. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Traylor J, Chandrasekaran S, Limaye M, Srinivas S, Durnwald CP. Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy. J Matern Fetal Neonatal Med 2015; 29:2067-72. [PMID: 26371379 DOI: 10.3109/14767058.2015.1081591] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study is to evaluate a woman's risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy. METHODS A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed. RESULTS Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (p = 0.004 and 0.005, respectively) and hypertension later in life (p = 0.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (p = 0.006 and 0.002, respectively). CONCLUSIONS Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.
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Affiliation(s)
- Jessica Traylor
- a Department of Obstetrics and Gynecology , University of Pennsylvania , Philadelphia , PA , USA
| | - Suchitra Chandrasekaran
- a Department of Obstetrics and Gynecology , University of Pennsylvania , Philadelphia , PA , USA
| | - Meghana Limaye
- a Department of Obstetrics and Gynecology , University of Pennsylvania , Philadelphia , PA , USA
| | - Sindhu Srinivas
- a Department of Obstetrics and Gynecology , University of Pennsylvania , Philadelphia , PA , USA
| | - Celeste P Durnwald
- a Department of Obstetrics and Gynecology , University of Pennsylvania , Philadelphia , PA , USA
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Ghaffari N, Srinivas SK, Durnwald CP. The multidisciplinary approach to the care of the obese parturient. Am J Obstet Gynecol 2015; 213:318-25. [PMID: 25747546 DOI: 10.1016/j.ajog.2015.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/20/2015] [Accepted: 03/01/2015] [Indexed: 12/19/2022]
Abstract
Maternal obesity in pregnancy is associated with increased maternal and fetal risks. Pregnancy management should include counseling, screening, and optimization of maternal health, increased fetal surveillance, and preparation for parturition. A multidisciplinary approach should be implemented including collaboration from obstetricians, nutritionists, anesthesiologists, social workers, and neonatologists to optimize perinatal outcomes. Pregnancy is an ideal window of opportunity to influence both the patient's long-term health and the health of the offspring.
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Abstract
OBJECTIVE Exposure to maternal obesity in utero predisposes offspring to obesity and metabolic disease. This study investigated whether maternal obesity is associated with alterations in expression of fetal microRNA (miRNA). STUDY DESIGN A cohort study of women with body mass index (BMI) ≥35 kg/m(2) (n = 16) versus those with normal BMI 20 to 24.9 (n = 20) was performed. All participants had normal glucose tolerance (1-hour glucose challenge test <130) and normally grown neonates (2700-3500 g). Umbilical cord samples were collected immediately after delivery. Expression of miRNA was assessed using Affymetrix GeneChip miRNA 3.0 Arrays. Differential miRNA expression was determined using Student t tests with Benjamini-Hocherg correction. RESULTS For 1733 human mature miRNAs, the expression levels were not statistically different in umbilical cord blood samples from pregnancies of obese women compared to controls. CONCLUSION Expression of fetal miRNA is not altered in umbilical cord blood in response to in utero exposure to obesity. Alternate mechanisms underlying the fetal effects of maternal obesity should be explored.
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Affiliation(s)
- Neda Ghaffari
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, Center for Research on Reproduction and Women's Health, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Samuel Parry
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, Center for Research on Reproduction and Women's Health, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Michal A Elovitz
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, Center for Research on Reproduction and Women's Health, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Celeste P Durnwald
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Program, Center for Research on Reproduction and Women's Health, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
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Chandrasekaran S, Bastek JA, Turitz AL, Durnwald CP. A prediction score to assess the risk of delivering a large for gestational age infant among obese women. J Matern Fetal Neonatal Med 2014; 29:22-6. [DOI: 10.3109/14767058.2014.991709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chandrasekaran S, Levine LD, Durnwald CP, Elovitz MA, Srinivas SK. Excessive weight gain and hypertensive disorders of pregnancy in the obese patient. J Matern Fetal Neonatal Med 2014; 28:964-8. [PMID: 24983666 DOI: 10.3109/14767058.2014.939624] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the association between excessive weight gain and pregnancy-related hypertension (PRH) among obese women (body mass index (BMI) ≥30 kg/m(2)). METHODS We performed a case control study among women with (n = 440) and without (n = 600) PRH from 2005 to 2007. Height and weight were recorded at initial and final prenatal visits. 695 women had BMI recorded at ≤18 weeks of gestation, of which 257 (36.9%) were obese. Obese women were divided into three categories based on 2009 Institute of Medicine (IOM) guidelines: (1) below recommended amount (under weight gain - UWG); (2) more than recommended (excessive weight gain - EWG) or (3) within recommended amount (normal weight gain - NWG). PRH was defined as gestational hypertension, mild or severe preeclampsia. Patients with and without PRH were prospectively identified. The association between weight gain category and development of PRH was analyzed. RESULTS We noticed a 1.5-fold higher odds of having PRH with an initial BMI ≥30 kg/m(2) compared to BMI <30 kg/m(2) (OR 1.64, 95% CI 1.2-2.2, p = 0.002). Among obese women, we noted a 2-fold higher odds of having PRH with EWG compared to NWG (OR 2.52, 95% CI 1.2-3.9, p = 0.012). The increased odds persisted after adjusting for race, chronic hypertension and diabetes, and length of gestation (AOR 2.61, 95% CI 1.4-4.9, p = 0.003). Among obese women with PRH, those with EWG had a 76% decreased odds of having severe disease compared to NWG (OR = 0.242 [0.07-0.79], p = 0.019). CONCLUSION We have demonstrated that EWG among obese patients increases overall risk of PRH.
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Affiliation(s)
- Suchitra Chandrasekaran
- Department of Maternal & Child Health Research Program, Obstetrics and Gynecology, The Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
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Durnwald CP. 17 OHPC for prevention of preterm birth in twins: back to the drawing board? Am J Obstet Gynecol 2013; 208:167-8. [PMID: 23433323 DOI: 10.1016/j.ajog.2013.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/15/2013] [Indexed: 11/30/2022]
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Behrendt N, Foy P, Center J, Durnwald CP. Influence of maternal body mass index and gestational age on accuracy of first trimester gender assignment. J Matern Fetal Neonatal Med 2011; 25:253-6. [PMID: 21500978 DOI: 10.3109/14767058.2011.569616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the influence of maternal body mass index (BMI) and gestational age on the accuracy of image acquisition, first trimester fetal gender determination, and correct assignment. METHODS Women presenting for first trimester aneuploidy risk assessment at 11(0) to 13(6) weeks were prospectively enrolled. A mid-sagittal view of the fetus including the genital tubercle was obtained. The angle of the genital tubercle was measured with male assigned for angle >30°, female <10°, and indeterminate if 10-30°. This was compared with gender at birth. The influence of maternal and pregnancy characteristics on both image acquisition and correct gender assignment were evaluated. RESULTS A total of 256 women with 260 fetuses undergoing first trimester risk assessment were enrolled. The genital tubercle was identified in 247/260 (95%) of cases. Image acquisition was negatively influenced by increasing maternal BMI and early gestational age (34.8 ± 7.7 vs. 27.0 ± 6.1 kg/m(2), p < 0.0001 and 12.3 ± 0.5 vs. 12.6 ± 0.5 weeks, p = 0.02). Gender was assigned in 93.1% and correctly matched in 85.8% of fetuses. Positive predictive value (PPV) for male and female fetuses were 88.9% and 79.8%, respectively. Correct gender assignment was more likely in male compared with female fetuses (91.4 vs. 80.5%, p = 0.02). CONCLUSION Increasing maternal BMI negatively influences image acquisition during the first trimester for gender determination, but does not decrease the accuracy of correct gender assignment if the image is obtained.
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Affiliation(s)
- Nicholas Behrendt
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
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Abstract
Since their introduction, insulin analogues are the preferred choice for short-acting insulin due to their superior pharmacologic profiles, leading to greater flexibility and convenience of dosing and, thus, greater patient satisfaction and improved quality of life. Over the past few years, clinical experience with insulin analogues in pregnancy has increased. The most studied, insulin lispro, has been shown to be a safe and clinically effective option in the treatment of the diabetic gravida. Studies of the other insulin analogues are limited, but promising. Further research is warranted to evaluate safety and efficacy of these analogues.
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Affiliation(s)
- Celeste P Durnwald
- Department of Obstetrics and Gynecology, The Ohio State University, 395 West 12th Avenue, Columbus, OH 43210, USA.
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Durnwald CP, Momirova V, Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, Varner MW, Malone FD, Mercer BM, Thorp JM, Sorokin Y, Carpenter MW, Lo J, Ramin SM, Harper M, Spong CY. Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-α hydroxyprogesterone caproate. J Matern Fetal Neonatal Med 2010; 23:1360-4. [PMID: 20441408 DOI: 10.3109/14767051003702786] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare rates of preterm birth before 35 weeks based on cervical length measurement at 16-20 weeks in women with twin gestations who received 17-α hydroxyprogesterone caproate (17OHPC) or placebo. METHODS This is a secondary analysis of a randomised, double-blind, placebo-controlled trial of twin gestations exposed to 17OHPC or placebo. Baseline transvaginal ultrasound evaluation of cervical length was performed prior to treatment assignment at 16-20 weeks. Cervical length measurements were categorised according to the 10th, 25th, 50th and 75th percentiles in the women studied. The effect of 17OHPC administration in women with a short (25th percentile) and long (75th percentile) cervix was evaluated. RESULTS Of 661 twin gestations studied, 221 (33.4%) women enrolled at 11 centers underwent cervical length measurement. The 10th, 25th, 50th, 75th percentiles for cervical length at 16-20 weeks were 32, 36, 40 and 44 mm, respectively. The risk of preterm birth <35 weeks was increased in women with a cervical length <25th percentile (55.8 vs. 36.9%, p=0.02). However, a cervical length >75th percentile at this gestational age interval was not protective for preterm birth (36.5 vs. 42.9%, p=0.42). Administration of 17OHPC did not reduce preterm birth before 35 weeks among those with either a short or a long cervix (64.3 vs. 45.8%, p=0.18 and 38.1 vs. 35.5%, p=0.85, respectively). CONCLUSION Women with twin gestations and a cervical length below the 25th percentile at 16-20 weeks had higher rates of preterm birth. In this subgroup of women, 17 OHPC did not prevent preterm birth before 35 weeks gestation. A cervical length above the 75th percentile at 16-20 weeks did not significantly reduce the risk of preterm birth in this high risk population.
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Affiliation(s)
- Celeste P Durnwald
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH 43210, USA.
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Abstract
OBJECTIVE To evaluate the myometrial thickness (MT) of multiple uterine sites during all three trimesters of pregnancy in an attempt to identify anticipated myometrial thickness in each trimester for these sites. METHODS In this prospective cross sectional study, MT was evaluated by ultrasound in women with viable singleton pregnancies. Women with suspected abruption, accreta, previa, fibroids, uterine and fetal anomalies, abnormal fluid volume, labor were excluded. MT was measured at the fundus, anterior wall (AW), posterior wall (PW), right and left side walls, lower uterine segment (LUS) and under the placenta. The cohort was divided to determine differences in MT at each site in each trimester (TRI). Differences in MT between sites were assessed. RESULTS One hundred and seventy five women underwent ultrasound by a single observer. There were 25 1st, 100 2nd and 50 3rd TRI scans at mean (SD) gestations of 11.0 (1.9), 21.5 (3.6) and 34.1 (3.0) weeks, respectively. Women were 37% African American, 72% government insured, 39.4% nulliparous. A total of 13% of women had a prior cesarean. MT of the fundus was less than AW, PW, right and left side walls (p < 0.05 each). For all sites, MT was less in 2nd compared with 1st TRI (p < 0.0001 each). This was most evident with fundal and LUS MT (35% less each). There was no difference in MT between 2nd and 3rd TRI. Fundal, AW, left side wall, subplacental and LUS MT were greater in parous women (p < 0.05 each). With anterior placentation, AW MT was less than when the placenta was implanted elsewhere (6.6 vs 7.4 mm, p = 0.008). This was not found with fundal or posterior placentas. The LUS MT was not less with prior cesarean (6.1 vs 6.0 mm, p = 0.84). CONCLUSION Myometrial thickness of all uterine sites is less in 2nd and 3rd trimesters compared with the 1st trimester. Fundal MT is less than other upper segment MT in the 2nd and 3rd trimesters. LUS MT is not less with prior cesarean.
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Durnwald CP, Landon MB. A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy. J Matern Fetal Neonatal Med 2008; 21:309-13. [PMID: 18446657 DOI: 10.1080/14767050802022797] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe perinatal outcomes of women with pregestational diabetes treated with short-acting, regular insulin and the short-acting insulin analogue, lispro. STUDY DESIGN This was a prospective observational study of women with pregestational diabetes maintained on short-acting insulin regimens over a 3-year period. Clinical characteristics, aspects of diabetic therapy, and perinatal/neonatal outcomes were collected. RESULTS Of 107 women, 49 were maintained on regular insulin and 58 utilized the insulin analogue, lispro. Frequency of type 1 diabetes, maternal age, overweight/obese pregravid body mass index (> or =25 kg/m2), preexisting hypertension, and presence of vascular disease were similar between groups. Women treated with lispro had a longer duration of diabetes (11.4 vs. 8.3 years, p = 0.04). Glycemic control was improved in women managed with lispro compared to regular insulin (HgbA1c 5.9 vs. 6.7, p = 0.009). Total insulin requirements were lower in the lispro group in the first (0.58 vs. 0.79 units/kg, p = 0.02), second (0.75 vs. 1.10 units/kg, p = 0.002), and third (0.98 vs. 1.25 units/kg, p = 0.03) trimesters of pregnancy. Mean infant birth weight was greater in the lispro group, whereas the rate of large for gestational age infants and ponderal indices were similar between groups. Malformation rate, gestational age at delivery, neonatal intensive care unit admission, neonatal length of stay, rates of respiratory distress syndrome, and hypoglycemia were similar. CONCLUSIONS Women treated with lispro demonstrated improved glycemic control and lower total insulin requirements during pregnancy compared to those receiving regular insulin. Perinatal outcomes were similar between women treated with both types of insulin.
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Affiliation(s)
- Celeste P Durnwald
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University, Columbus, Ohio 43210, USA
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Durnwald CP, Rouse DJ, Leveno KJ, Spong CY, MacPherson C, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM, Gabbe SG. The Maternal-Fetal Medicine Units Cesarean Registry: safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery. Am J Obstet Gynecol 2006; 195:1119-26. [PMID: 17000244 DOI: 10.1016/j.ajog.2006.06.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 05/22/2006] [Accepted: 06/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study was undertaken to compare success rates of vaginal birth after cesarean (VBAC) delivery, and uterine rupture as well as maternal/perinatal outcomes between women with preterm and term pregnancies undergoing trial of labor (TOL), and to compare maternal and neonatal morbidities in those women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD). STUDY DESIGN Prospective 4-year observational study of women with a singleton gestation and a prior cesarean delivery at 19 academic centers. Clinical characteristics, maternal complications and VBAC delivery success for those with a preterm (24(0)-36(6) weeks) TOL, preterm RCD and term TOL (> or = 37 weeks) were analyzed. RESULTS Among 3119 preterm pregnancies with prior cesarean delivery, 2338 (75%) underwent a TOL. 15,331 women undergoing TOL at term were also analyzed as a control group. TOL success rates for preterm and term pregnancies were similar (72.8% vs 73.3%, P = .64). Rates of uterine rupture (0.34% vs 0.74%, P = .03) and dehiscence (0.26% vs 0.67%, P = .02) were lower in preterm compared with term TOL. Thromboembolic disease, coagulopathy and transfusion were more common in women undergoing a preterm TOL than those at term. Among women undergoing a preterm TOL, rates of uterine dehiscence, coagulopathy, transfusion, and endometritis were similar to those having a preterm RCD. After controlling for gestational age at delivery and race, neonatal outcomes such as Neonatal Intensive Care Unit (NICU) admission, intraventricular hemorrhage, sepsis, and ventilatory support were similar in both groups except for a higher rate of respiratory distress syndrome in those delivered after a TOL. CONCLUSION The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture. Perinatal outcomes are similar with preterm TOL and RCD. TOL should be considered as an option for women undergoing preterm delivery with a history of prior cesarean delivery.
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Affiliation(s)
- Celeste P Durnwald
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH, USA
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Durnwald CP, Walker H, Lundy JC, Iams JD. Rates of recurrent preterm birth by obstetrical history and cervical length. Am J Obstet Gynecol 2005; 193:1170-4. [PMID: 16157132 DOI: 10.1016/j.ajog.2005.06.085] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Revised: 06/14/2005] [Accepted: 06/29/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study was undertaken to determine rates of recurrent preterm birth according to number of prior preterm births, 1 versus 2 or more and cervical length by endovaginal ultrasound at 22(0) to 24(6) weeks, less than 25 mm versus more than 25 mm. STUDY DESIGN We retrospectively analyzed data from charts of women with prior spontaneous preterm birth seen in a Prematurity Prevention Clinic from 1998 through 2004. Women with a history of 1 or more spontaneous preterm births (18(0)-36(6) weeks) were included. Women with multiple gestations, uterine anomalies, and prior cervical surgery were excluded. Transvaginal sonography was used to evaluate each woman's cervical length at 22(0) to 24(6) weeks. Cerclage, bed rest, tocolysis, and steroids were used when clinically appropriate. Primary outcome was gestational age at delivery less than 32 and less than 35 weeks. Data were analyzed according to number of prior preterm births (1 vs > or = 2) and sonographic cervical length at 22(0) to 24(6) weeks (<25 mm vs > or = 25 mm). RESULTS A total of 188 eligible women were evaluated. Median gestational age of earliest preterm birth was 26.3 weeks. Of the total 188, 118 (62.8%) women had 1 prior and 70 (37.2%) had 2 or more preterm births. Thirty-eight (20.2%) of the women had a cervical length less than 25 mm and 150 (79.8%) had a cervical length 25 mm or greater. A higher percentage of women with a cervical length less than 25 mm and 2 or more preterm births delivered less than 32 weeks compared with women with 1 prior preterm birth, although this did not reach statistical significance (21.5% vs 12.5%, P = .47). Rates of delivery less than 35 weeks in women with a cervical length less than 25 mm were similar in those with a history of 1 and 2 or more preterm births. Women who had 2 or more prior preterm births were analyzed separately to identify if a cervical length greater than 30 mm or greater than 35 mm could be reassuring for decreasing the risk of recurrent preterm birth. CONCLUSION Rates of preterm birth less than 32 and less than 35 weeks were similar in women whose cervical length was less than 25 mm at 22(0) to 24(6) weeks, regardless of number of prior preterm births. Women with 2 prior preterm births and a cervix greater than 35 mm were at low risk for subsequent preterm birth less than 35 weeks.
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Affiliation(s)
- Celeste P Durnwald
- Division of Maternal Fetal Medicine, The Ohio State University, Columbus, OH, USA
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Abstract
OBJECTIVE To determine the influence of pregravid obesity and diabetes on cesarean delivery (CD) risk. STUDY DESIGN Women with singleton pregnancies of 23 weeks or more estimated gestational age who were undergoing a trial of labor January 1997 through June 2001 were categorized by pregravid body mass index (underweight [<19.8 kg/m 2 ], normal [19.8-25 kg/m 2 ], overweight [25.1-30 kg/m2], obese [>30 kg/m2]). Diabetes (DM) was divided into categories of gestational, treated with diet modification (A1GDM) or insulin (A2GDM), and pregestational (PDM). Prior CDs were excluded. CD rates for each group were compared in univariate analyses stratified by estimated gestational age (term, preterm, total). Other variables examined included DM, macrosomia (birth weight 4500 g or more), induction, and parity. Multiple regression included significant variables to predict the influence of diabetes and obesity on CD risk. RESULTS Records for 12,303 deliveries were evaluated (obese: 2828 [22.9%]; overweight: 2605 [21.2%]; A1GDM: 270 [2.2%]; A2GDM: 93 [0.8%]; PDM: 126 [1%]). Obese and overweight subjects had a higher risk for CD, compared with normal subjects (13.8% and 10.4% versus 7.7%, P < .0001 for each). Other CD risk factors were macrosomia (25% versus 9.4%), nulliparity (16.5% versus 4.7%), induction (17.4% versus 8.3%), diabetes (A1GDM: 16.7% versus 9.4%; A2GDM: 24.7% versus 9.5%; PDM: 34.9% versus 9.3%) and black race (10.7% versus 8.8%) ( P < .0001 for each). In multiple regression models including term deliveries, obesity and PDM were independent CD risk factors ([adjusted OR overweight: 1.5, P < .0001; adjusted OR PDM: 2.9, P = .01]; [adjusted OR obese: 2.4, P < .0001, PDM: 2.9, P = .0002]). CONCLUSION Pregravid obesity and diabetes independently increase the risk for CD. Given the disparate prevalence of obesity and diabetes in the United States, body habitus has a significantly larger impact on CD risk.
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Affiliation(s)
- Hugh M Ehrenberg
- Case Western Reserve University School of Medicine, Department of Reproductive Biology, MetroHealth Medical Center, Cleveland, Ohio, USA
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30
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Abstract
OBJECTIVE This study was undertaken to determine the impact of maternal obesity on success of a trial of labor (vaginal birth after cesarean section [VBAC]) after a single low transverse cesarean delivery. STUDY DESIGN Individual charts of women with low transverse cesarean delivery in their first viable pregnancy who underwent a VBAC in their second viable pregnancy at our urban tertiary care institution were reviewed. Maternal body mass index (BMI) was classified as underweight (<19.8 kg/m2), normal (19.8-24.9 kg/m2), overweight (25-29.9 kg/m2), or obese (> or =30 kg/m2). Clinical characteristics and labor outcomes were assessed. Factors potentially affecting VBAC success were analyzed by univariate analysis. Logistic regressions were performed to determine the impact of maternal pregravid BMI on VBAC success after controlling for confounding factors. RESULTS Of 510 women attempting a trial of labor, 337 (66%) were successful and 173 (34%) failed VBAC. Decreased VBAC success was seen in obese (54.6%) but not overweight (65.5%) women compared with women of normal BMI (70.5%), P = .003 and .36, respectively. Underweight women had more VBAC success than women of normal BMI (84.7% vs 70.5%, P = .04). Controlling for other factors, the association between increasing pregravid BMI and BMI > or =30 kg/m 2 with decreased VBAC success persisted, P = .03 and .006, respectively. Normal BMI women who became overweight before the second pregnancy had decreased VBAC success compared with those whose BMI remained normal (56.6% vs 74.2%, P = .006). However, overweight women who decreased their BMI to normal before the second pregnancy did not significantly improve VBAC success (64.0% vs 58.4%, P = .67). CONCLUSION Increasing pregravid BMI and weight gain between pregnancies reduce VBAC success after a single low transverse cesarean delivery.
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Affiliation(s)
- Celeste P Durnwald
- Department of Obstetrics and Gynaecology, Metro Health Medical Center at Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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31
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Abstract
BACKGROUND The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment. METHODS Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis. RESULTS There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance. CONCLUSIONS We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.
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Affiliation(s)
- D D Muehrcke
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio, USA
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