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Abstract
Diabetes mellitus is one of the most commonly encountered pregnancy complications and is associated with multiple adverse perinatal outcomes. Technology has progressed to address the unique challenges patients face in managing diabetes mellitus in pregnancy. Technology has bolstered diabetes mellitus education with smartphone applications focused on nutrition counseling and carbohydrate intake advice. Continuous glucose monitors and insulin infusion systems have shown benefit by simplifying glycemic monitoring and insulin administration. Improvements in glycemic control and perinatal outcomes have been seen with continuous glucose monitor use when compared with intermittent blood glucose monitoring, and more pregnant people are using insulin pumps instead of multiple daily insulin injections. Hybrid closed-loop systems are emerging and are able to integrate continuous glucose monitoring and insulin pump technologies while maximizing automated features in the nonpregnant population, but these have not been endorsed for use in pregnancy yet. Applying telehealth practices has been associated with high patient satisfaction among those with diabetes mellitus in pregnancy, and leveraging remote patient monitoring through telehealth platforms and short-range wireless technologies can reduce the burden of patient visits. As technology becomes more integrated into routine management of diabetes mellitus in pregnancy, practitioners should emphasize individualized counseling and device selection to ensure patient autonomy and safety.
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Affiliation(s)
- Sydney M. Thayer
- Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO (Drs Thayer and Lawlor)
| | - Kelley J. Williams
- Division of Endocrinology, Washington University in St Louis, St Louis, MO (Dr Williams)
| | - Megan L. Lawlor
- Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO (Drs Thayer and Lawlor)
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Buchanan CQ, Lawlor ML, Okafor C, Kurian SR, Philip AE, Finkle AE, McQuillan JJ, Haridas S, Koenig JM. Linked Th17 and Calgranulin Responses in Maternal-cord Blood Dyads of Preterm Gestations with Histologic Chorioamnionitis. Newborn (Clarksville) 2023; 2:133-141. [PMID: 37790838 PMCID: PMC10547109 DOI: 10.5005/jp-journals-11002-0064] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Maternal-fetal immune crosstalk mechanisms are increasingly identified in the pathogenesis of gestational disorders, including histologic chorioamnionitis (HCA). Although an inflammatory Th17 immune phenotype has been described in preterm neonates with HCA, the associated maternal Th17 response is relatively unknown. To refine our understanding of Th17 biology in this context, we examined Th17 responses in maternal-cord blood dyads of preterm gestations. Materials and methods Paired maternal and cord blood (CB) samples were prospectively collected from preterm gestations (23-34 weeks) with HCA or controls. Th17-linked cell frequencies and plasma calgranulin (S100A8, S100A12) levels were determined by flow cytometry and enzyme-linked immunoassay, respectively. Results Analyses of 47 maternal-cord blood pairs showed striking parallel increases in Th17 cell frequencies as well as plasma calgranulin levels in the presence of fetal inflammation. Cord blood S100A12 levels were directly correlated with Th17 cell frequencies. In CB cultures, rh-S100A12 promoted in vitro propagation of Th17-type CD4+ cells. Conclusions Maternal and CB Th17-linked responses are dually amplified in gestations with HCA, supporting a biological role for maternal-fetal interactions in this disorder. In addition to advancing current knowledge of neonatal Th17 mechanisms, these data shed new light on their association with maternal inflammation.
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Affiliation(s)
- Christopher Q Buchanan
- Department of Obstetrics, Gynecology and Women’s Health, Division of Maternal–Fetal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Megan L Lawlor
- Department of Obstetrics, Gynecology and Women’s Health, Division of Maternal–Fetal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Chukwuebuka Okafor
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Shannon R Kurian
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Andrea E Philip
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Abigael E Finkle
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Jay J McQuillan
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Seema Haridas
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Joyce M Koenig
- Department of Pediatrics, Division of Neonatal–Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
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Powel JE, Zantow EW, Bialko MF, Farley LG, Lawlor ML, Mullan SJ, Vricella LK, Tomlinson TM. Predictive index for adverse perinatal outcome in pregnancies complicated by fetal growth restriction. Ultrasound Obstet Gynecol 2023; 61:367-376. [PMID: 36856169 DOI: 10.1002/uog.26044] [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] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/01/2022] [Accepted: 07/25/2022] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To develop and validate an index predictive of adverse perinatal outcome (APO) in pregnancies meeting the consensus-based criteria for fetal growth restriction (FGR) endorsed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). METHODS This was a retrospective analysis of consecutive singleton non-anomalous gestations meeting the ISUOG-endorsed criteria for FGR at a single tertiary care center from November 2010 to August 2020. The dataset was divided randomly into a development set (two-thirds) and a validation set (one-third). The primary composite APO comprised one or more of: perinatal demise, Grade III-IV intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), seizures, hypoxic ischemic encephalopathy (HIE), necrotizing enterocolitis (NEC), sepsis, bronchopulmonary dysplasia (BPD) and length of stay in the neonatal intensive care unit (NICU) > 7 days. Regression analysis incorporated clinical factors readily available at the time of FGR diagnosis. The sum of β coefficient-based weights yielded an index score, the performance of which was assessed in the validation set. Score cut-offs were selected to identify 'high-risk' and 'low-risk' ranges for which positive (PPV) and negative (NPV) predictive values and positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS Of the 875 consecutive pregnancies that met the criteria for FGR and were included in the study cohort, 405 (46%) were complicated by one or more components of the composite APO, including 54 (6%) perinatal deaths, 22 (3%) neonates with Grade III-IV IVH and/or PVL, nine (1%) with seizures and/or HIE, 91 (10%) with BPD, 57 (7%) with sepsis, 21 (2%) with NEC, and 361 (41%) who remained in the NICU > 7 days. In addition, 270 (31%) pregnancies were delivered by Cesarean section for non-reassuring fetal status, 43 (5%) were admitted to the NICU for < 7 days, 79 (9%) had 5-min Apgar score < 7, 125/631 (20%) had a cord gas pH ≤ 7.1 and 35/631 (6%) had a base excess ≥ 12 mmol/L. The predictive index we developed included seven factors available at the time of FGR diagnosis: hypertensive disorder of pregnancy (HDP) (+8 points), chronic hypertension without HDP (+4 points), gestational age ≤ 32 weeks (+5 points), absent or reversed end-diastolic flow in the umbilical artery (+8 points), prepregnancy body mass index ≥ 35 kg/m2 (+3 points), isolated abdominal circumference < 3rd percentile (-4 points) and non-Hispanic black race (-2 points). The bias-corrected bootstrapped (1000 replicates) area under the receiver-operating-characteristics curve (AUC) of the predictive index for composite APO in the validation group was 0.88 (95% CI, 0.84-0.92), which was similar to that in the development group (AUC, 0.86 (95% CI, 0.82-0.89); P = 0.34). In the total cohort, 40% of pregnancies had a low-risk index score (≤ 2), associated with a NPV of 85% (95% CI, 81-88%) and a LR- of 0.21 (95% CI, 0.16-0.27), and 23% had a high-risk index score (≥ 10), associated with a PPV of 96% (95% CI, 93-98%) and a LR+ of 27.36 (95% CI, 14.33-52.23). Of the remaining pregnancies that had an intermediate-risk score, 50% were complicated by composite APO. CONCLUSION An easy-to-use index incorporating seven clinical factors readily available at the time of FGR diagnosis is predictive of APO and may prove useful in counseling and management of pregnancies meeting the ISUOG-endorsed criteria for FGR. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J E Powel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - E W Zantow
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - M F Bialko
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - L G Farley
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - M L Lawlor
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - S J Mullan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - L K Vricella
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
| | - T M Tomlinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Women's Health, Saint Louis University School of Medicine, St Louis, MO, USA
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O'Nan S, Huang R, peinan Zhao, Barry VG, Lawlor ML, Carter EB, Kelly JC, Frolova AI, England SK, Raghuraman N. Dietary risk factors for hypertensive disorders of pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.696] [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: 01/08/2023]
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Trammel C, Lawlor ML, Jacobsen H, Mills M, Krauss M, Galati B, Raghuraman N, Carter EB, Odibo AO, Kelly JC. Patient satisfaction with buprenorphine or methadone for treatment of opioid use disorder during obstetric care. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.506] [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: 01/09/2023]
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Zantow EW, Powel JE, Mullan SJ, Lawlor ML, Lannaman K, Tomlinson TM. 998 Fetal growth restriction and the association between abnormal placental changes and significant adverse neonatal outcomes. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.1023] [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: 12/01/2022]
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Powel JE, Zantow EW, Bialko MF, Lawlor ML, Mullan SJ, Vricella LK, Tomlinson TM. 305 A predictive index for severe adverse perinatal outcomes in pregnancies complicated by fetal growth restriction. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.327] [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: 10/22/2022]
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Lawlor ML, Boerrigter A, Jakes C, Pyon R, Goldkamp J, Gross G, Vricella LK, Aurora R. 819 Cervicovaginal microbiome and cytokine expression in twin versus singleton gestations. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.842] [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: 11/28/2022]
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Powel JE, Bialko MF, Zantow EW, Mullan SJ, Lawlor ML, Desai D, Vricella LK, Tomlinson TM. 304 Predicting severe adverse perinatal outcomes in pregnancies complicated by fetal growth restriction: a validation study. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.326] [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: 10/22/2022]
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Lawlor ML, Buchanan CQ, Vricella LK, McQuillan J, Kurian S, Lewis A, Koenig JM. 820: Elevated plasma S100 protein levels in preterm gestations with histologic chorioamnionitis. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.835] [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: 10/25/2022]
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Mullan SJ, Powel JE, Edwards AM, Lawlor ML, Ong SK, Li X, Vricella LK, Babbar S. 171: Pulse pressure and acute response to labetalol in women with severe hypertension in pregnancy. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.187] [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: 10/25/2022]
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Lawlor ML, Shook LA, McQuerry K, Srinivasan A, Johnson QB, Chavan NR, Critchfield AS. Care-by-parent model as a tool for reduction of neonatal opioid withdrawal syndrome in neonates exposed to buprenorphine maintenance therapy in-utero. J Matern Fetal Neonatal Med 2019; 33:2718-2722. [PMID: 30563376 DOI: 10.1080/14767058.2018.1558201] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To determine if a structured care-by-parent (CBP) protocol is associated with a reduction in diagnosis of treatment-requiring Neonatal Opioid Withdrawal Syndrome (NOWS).Study design: We performed a pilot retrospective, case control study of pregnant women enrolled in a comprehensive prenatal care program for opioid-dependent patients during which they received buprenorphine for Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD). Patients who participated in the CBP program actively roomed-in with their infants even after maternal hospital discharge while infants continued to be monitored for development of treatment-requiring NOWS. The primary outcome was the rate of treatment-requiring NOWS in the CBP grouping.Results: Thirty-two (32) cases that were enrolled in the CBP model were compared with 32 matched controls that were not enrolled in this model. There was a significant reduction in the rate of treatment-requiring NOWS among cases compared to the controls (OR = 0.10; p = .001). Neonates undergoing CBP had a decreased length of stay and lower Finnegan scores compared to those who did not undergo CBPConclusion: Among infants born to mothers with OUD in pregnancy, CBP significantly reduces the rate of treatment-requiring NOWS.
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Affiliation(s)
- Megan L Lawlor
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Lori A Shook
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kristen McQuerry
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Aarthi Srinivasan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Quinetta B Johnson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Niraj R Chavan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Agatha S Critchfield
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
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Abstract
Background and Objectives: After being encouraged to change the technique for opening the vaginal cuff during robotic surgery, this study was performed to determine the correlation between vaginal cuff complications and electrosurgical techniques. Methods: The study group consisted of patients who had their vaginal cuffs opened with a cutting current compared to the group of patients having their vaginal cuff opened with a coagulation current. Data were collected on 150 women who underwent robotic surgery for endometrial cancer. All patients received preoperative antibiotics. Data, including operative time, type of electrosurgery used, estimated blood loss, transfusion rate, and complications, were collected from the patients' records. Results: Surgeries in 150 women and the associated complications were studied. The mean age of the patients was not significantly different between the groups (P = .63). The mean body mass index was 38 kg/m2 in the coagulation arm and 36 kg/m2 in the cutting arm (P = .03). Transfusion was not required. Estimated blood loss and operative time were not significantly different in the coagulation versus the cutting arms (P = .29 and .5; respectively). No patients in the cutting arm and 4 patients (with 5 complications) in the coagulation arm had cuff complications (P = .02). Conclusions: Complications involving the vaginal cuff appear to occur more frequently when the vagina is entered by using electrosurgery with coagulation versus cutting in this cohort of patients undergoing robot-assisted surgery for endometrial cancer..
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Affiliation(s)
- Megan L Lawlor
- Division of Gynecologic Oncology, Cancer Treatment Centers of America, Newnan, Georgia
| | - Rama Rao
- Division of Gynecologic Oncology, Cancer Treatment Centers of America, Newnan, Georgia
| | - Kelly J Manahan
- Division of Gynecologic Oncology, Cancer Treatment Centers of America, Newnan, Georgia
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