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Rainford M, Barbour LA, Birch D, Catalano P, Daniels E, Gremont C, Marshall NE, Wharton K, Thornburg K. Barriers to implementing good nutrition in pregnancy and early childhood: Creating equitable national solutions. Ann N Y Acad Sci 2024; 1534:94-105. [PMID: 38520393 DOI: 10.1111/nyas.15122] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
Exposure to deleterious stressors in early life, such as poor nutrition, underlies most adult-onset chronic diseases. As rates of chronic disease continue to climb in the United States, a focus on good nutrition before and during pregnancy, lactation, and early childhood provides a potential opportunity to reverse this trend. This report provides an overview of nutrition investigations in pregnancy and early childhood and addresses racial disparities and health outcomes, current national guidelines, and barriers to achieving adequate nutrition in pregnant individuals and children. Current national policies and community interventions to improve nutrition, as well as the current state of nutrition education among healthcare professionals and students, are discussed. Major gaps in knowledge and implementation of nutrition practices during pregnancy and early childhood were identified and action goals were constructed. The action goals are intended to guide the development and implementation of critical nutritional strategies that bridge these gaps. Such goals create a national blueprint for improving the health of mothers and children by promoting long-term developmental outcomes that improve the overall health of the US population.
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Affiliation(s)
- Monique Rainford
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Linda A Barbour
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Darlena Birch
- Public Health Nutrition, National WIC Association, Washington, District of Columbia, USA
| | - Patrick Catalano
- Department of Obstetrics and Gynecology, Tufts University, Boston, Massachusetts, USA
| | - Ella Daniels
- Veggies Early & Often, Partnership for a Healthier America, Washington, District of Columbia, USA
| | - Caron Gremont
- Share Our Strength, Washington, District of Columbia, USA
| | - Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Kurt Wharton
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Kent Thornburg
- Knight Cardiovascular Institute, Center for Developmental Health, and Moore Institute for Nutrition & Wellness, Oregon Health & Science University, Portland, Oregon, USA
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Doratt BM, Sureshchandra S, True H, Rincon M, Marshall NE, Messaoudi I. Mild/asymptomatic COVID-19 in unvaccinated pregnant mothers impairs neonatal immune responses. JCI Insight 2023; 8:e172658. [PMID: 37698937 PMCID: PMC10629812 DOI: 10.1172/jci.insight.172658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023] Open
Abstract
Maternal SARS-CoV-2 infection triggers placental inflammation and alters cord blood immune cell composition. However, most studies focus on outcomes of severe maternal infection. Therefore, we analyzed cord blood and chorionic villi from newborns of unvaccinated mothers who experienced mild/asymptomatic SARS-CoV-2 infection during pregnancy. We investigated immune cell rewiring using flow cytometry, single-cell RNA sequencing, and functional readouts using ex vivo stimulation with TLR agonists and pathogens. Maternal infection was associated with increased frequency of memory T and B cells and nonclassical monocytes in cord blood. Ex vivo T and B cell responses to stimulation were attenuated, suggesting a tolerogenic state. Maladaptive responses were also observed in cord blood monocytes, where antiviral responses were dampened but responses to bacterial TLRs were increased. Maternal infection was also associated with expansion and activation of placental Hofbauer cells, secreting elevated levels of myeloid cell-recruiting chemokines. Moreover, we reported increased activation of maternally derived monocytes/macrophages in the fetal placenta that were transcriptionally primed for antiviral responses. Our data indicate that even in the absence of vertical transmission or symptoms in the neonate, mild/asymptomatic maternal COVID-19 altered the transcriptional and functional state in fetal immune cells in circulation and in the placenta.
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Affiliation(s)
- Brianna M. Doratt
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, Kentucky, USA
| | - Suhas Sureshchandra
- Department of Physiology and Biophysics, School of Medicine, and
- Institute for Immunology, University of California, Irvine, California, USA
| | - Heather True
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Monica Rincon
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Nicole E. Marshall
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ilhem Messaoudi
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, Kentucky, USA
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Marshall NE, Blanton MB, Doratt BM, Malherbe DC, Rincon M, Messaoudi I. Monoclonal Antibody Therapy of Breastfeeding Patient Infected with SARS-CoV-2: A Case Report. Breastfeed Med 2023; 18:626-630. [PMID: 37615569 PMCID: PMC10460680 DOI: 10.1089/bfm.2023.0102] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Introduction: Although safety data demonstrated the efficacy and effectiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination for all individuals over 6 months of age, including pregnant and breastfeeding individuals, optimal treatment courses for symptomatic pregnant and lactating individuals infected with SARS-CoV-2 remain to be defined. Case Description: A coronavirus disease 2019 (COVID-19)-vaccinated breastfeeding woman received anti-SARS-CoV-2 monoclonal antibody treatment casirivimab-imdevimab 5 days after diagnosis of a symptomatic breakthrough SARS-CoV-2 infection. Results and Conclusions: The patient did not present with obvious defects in innate or adaptive cellular subsets, but compared with controls had minimal maternal antibody response to recommended pregnancy vaccinations including SARS-CoV-2 and tetanus, diphtheria, pertussis (TDaP). The outcome of the monoclonal antibody infusion treatment was favorable as it transiently increased SARS-CoV-2 antibody titers in plasma and human milk compartments.
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Affiliation(s)
- Nicole E. Marshall
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Madison B. Blanton
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Brianna M. Doratt
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Delphine C. Malherbe
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Ilhem Messaoudi
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
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Sureshchandra S, Doratt BM, True H, Mendoza N, Rincon M, Marshall NE, Messaoudi I. Multimodal profiling of term human decidua demonstrates immune adaptations with pregravid obesity. Cell Rep 2023; 42:112769. [PMID: 37432849 PMCID: PMC10528932 DOI: 10.1016/j.celrep.2023.112769] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/24/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023] Open
Abstract
Leukocyte diversity of the first-trimester maternal-fetal interface has been extensively described; however, the immunological landscape of the term decidua remains poorly understood. We therefore profiled human leukocytes from term decidua collected via scheduled cesarean delivery. Relative to the first trimester, our analyses show a shift from NK cells and macrophages to T cells and enhanced immune activation. Although circulating and decidual T cells are phenotypically distinct, they demonstrate significant clonotype sharing. We also report significant diversity within decidual macrophages, the frequency of which positively correlates with pregravid maternal body mass index. Interestingly, the ability of decidual macrophages to respond to bacterial ligands is reduced with pregravid obesity, suggestive of skewing toward immunoregulation as a possible mechanism to safeguard the fetus against excessive maternal inflammation. These findings are a resource for future studies investigating pathological conditions that compromise fetal health and reproductive success.
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Affiliation(s)
- Suhas Sureshchandra
- Department of Physiology and Biophysics, School of Medicine, University of California, Irvine, Irvine, CA 92697, USA; Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA
| | - Brianna M Doratt
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, KY 40536, USA
| | - Heather True
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, KY 40536, USA; Department of Pharmaceutical Sciences, University of Kentucky, Lexington, KY 40536, USA
| | - Norma Mendoza
- Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA
| | - Monica Rincon
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Ilhem Messaoudi
- Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA; Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, KY 40536, USA.
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Marshall NE, Blanton MB, Doratt BM, Malherbe DC, Rincon M, True H, McDonald T, Beauregard C, Adatorwovor R, Messaoudi I. SARS-CoV-2 vaccine booster elicits robust prolonged maternal antibody responses and passive transfer to the offspring via the placenta and breastmilk. Am J Obstet Gynecol MFM 2023; 5:100830. [PMID: 36462615 PMCID: PMC9710099 DOI: 10.1016/j.ajogmf.2022.100830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Madison B Blanton
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY; Department of Pharmaceutical Sciences, University of Kentucky, Lexington, KY
| | - Brianna M Doratt
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY
| | - Delphine C Malherbe
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Heather True
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY; Department of Pharmaceutical Sciences, University of Kentucky, Lexington, KY
| | - Taylor McDonald
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY
| | - Caroline Beauregard
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY
| | | | - Ilhem Messaoudi
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, 760 Press Ave., Lexington, KY 40536.
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Sureshchandra S, Doratt BM, Mendza N, Varlamov O, Rincon M, Marshall NE, Messaoudi I. Maternal obesity blunts antimicrobial responses in fetal monocytes. eLife 2023; 12:81320. [PMID: 36645353 PMCID: PMC9894585 DOI: 10.7554/elife.81320] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 01/15/2023] [Indexed: 01/17/2023] Open
Abstract
Maternal pre-pregnancy (pregravid) obesity is associated with adverse outcomes for both mother and offspring. Amongst the complications for the offspring is increased susceptibility and severity of neonatal infections necessitating admission to the intensive care unit, notably bacterial sepsis and enterocolitis. Previous studies have reported aberrant responses to LPS and polyclonal stimulation by umbilical cord blood monocytes that were mediated by alterations in the epigenome. In this study, we show that pregravid obesity dysregulates umbilical cord blood monocyte responses to bacterial and viral pathogens. Specifically, interferon-stimulated gene expression and inflammatory responses to respiratory syncytial virus (RSV) and E. coli were significantly dampened, respectively . Although upstream signaling events were comparable, translocation of the key transcription factor NF-κB and chromatin accessibility at pro-inflammatory gene promoters following TLR stimulation was significantly attenuated. Using a rhesus macaque model of western style diet-induced obesity, we further demonstrate that this defect is detected in fetal peripheral monocytes and tissue-resident macrophages during gestation. Collectively, these data indicate that maternal obesity alters metabolic, signaling, and epigenetic profiles of fetal monocytes leading to a state of immune paralysis during late gestation and at birth.
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Affiliation(s)
- Suhas Sureshchandra
- Institute for Immunology, University of California, IrvineIrvineUnited States
- Department of Molecular Biology and Biochemistry, University of California, IrvineIrvineUnited States
| | - Brianna M Doratt
- Department of Molecular Biology and Biochemistry, University of California, IrvineIrvineUnited States
- Department of Microbiology, Immunology, and Molecular Genetics, University of KentuckyLexingtonUnited States
| | - Norma Mendza
- Department of Molecular Biology and Biochemistry, University of California, IrvineIrvineUnited States
| | - Oleg Varlamov
- Division of Cardiometabolic Health, Oregon National Primate Research Center, Oregon Health & Science UniversityBeavertonUnited States
| | - Monica Rincon
- Maternal-Fetal Medicine, Oregon Health & Science UniversityPortlandUnited States
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health & Science UniversityPortlandUnited States
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, University of California, IrvineIrvineUnited States
- Maternal-Fetal Medicine, Oregon Health & Science UniversityPortlandUnited States
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Sureshchandra S, Zulu MZ, Doratt BM, Jankeel A, Tifrea D, Edwards R, Rincon M, Marshall NE, Messaoudi I. Single cell RNA sequencing reveals immunological rewiring at the maternal-fetal interface following asymptomatic/mild SARS-CoV-2 infection. Cell Rep 2022; 39:110938. [PMID: 35662411 PMCID: PMC9130636 DOI: 10.1016/j.celrep.2022.110938] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/21/2022] [Accepted: 05/18/2022] [Indexed: 11/06/2022] Open
Abstract
While severe coronavirus 2019 (COVID-19) is associated with immune activation at the maternal-fetal interface, responses to asymptomatic/mild severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy remain unknown. Here, we assess immunological adaptations in blood and term decidua in response to asymptomatic/mild disease in pregnant women. We report attenuated antigen presentation and type I interferon (IFN) signaling pathways, loss of tissue-resident decidual macrophages, and upregulated cytokine/chemokine signaling in monocyte-derived decidual macrophages. Furthermore, we describe increased frequencies of activated tissue-resident T cells and decreased abundance of regulatory T cells with infection while frequencies of cytotoxic CD4/CD8 T cells are increased in the blood. In contrast to decidual macrophages, type I IFN signaling is higher in decidual T cells. Finally, infection leads to a narrowing of T cell receptor diversity in both blood and decidua. Collectively, these observations indicate that asymptomatic/mild COVID-19 during pregnancy results in remodeling of the immunological landscape of the maternal-fetal interface, with a potential for long-term adverse outcomes for the offspring.
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Vesco KK, Marshall NE, Baetscher E, Leo MC, Rooney W, Francisco M, Baker E, King JC, Catalano P, Frias AE, Purnell JQ. Changes in Visceral and Ectopic Adipose Tissue Stores Across Pregnancy and Their Relationship to Gestational Weight Gain. J Nutr 2022; 152:1130-1137. [PMID: 35022776 PMCID: PMC8970982 DOI: 10.1093/jn/nxac010] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/25/2021] [Accepted: 01/06/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Excessive gestational weight gain has been associated with increased total body fat (TBF), metabolic syndrome, and abdominal obesity. However, little is known about the relationship of gestational weight gain with changes in metabolically active visceral or ectopic (hepatic and skeletal muscle) lipid stores. OBJECTIVES In a prospective study of 50 healthy, pregnant women, we assessed whether changes in weight were associated with changes in total, visceral, and ectopic lipid stores. METHODS Participants (ages 19-39) were primarily White (84%). The mean preconception BMI was 25.8 kg/m2 (SD, 4.5 kg/m2; min-max, 17.1-35.9 kg/m2). Measurements were completed at visits 1 and 2 at means of 16 and 34 weeks gestation, respectively, and included TBF using BOD POD; abdominal subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) using MRI; and intrahepatic lipids (IHL), intramyocellular lipids (IMCL), and extramyocellular lipids (EMCL) using magnetic resonance spectroscopy. We used paired t-tests to examine changes in adipose tissue and Pearson's correlation to examine associations of adipose tissue changes and weight changes. We also examined whether changes in adipose tissue stores differed by preconception BMI (normal, overweight, and obese), using 1-way ANOVA. RESULTS The TBF (mean change, +3.5 kg; 95% CI: 2.4-4.6 kg), SAT (mean change, +701 cm3; 95% CI: 421-981 cm3), VAT (mean change, +275 cm3; 95% CI: 170-379 cm3), and IHL (percentage water peak; median, +0.15; IQR = -0.01 to 0.32) values increased significantly; the IMCL and EMCL values did not change. Changes varied by BMI strata, with the least increase (or, for SAT, net loss) among women with obesity. Weight change was positively correlated with changes in TBF (r = 0.83; P < 0.001), SAT (r = 0.74; P < 0.001), and VAT (r = 0.63; P < 0.001) but not significantly correlated with changes in ectopic lipids (IHL, IMCL, and EMCL; -0.14 < r < 0.26). CONCLUSIONS Preferential deposition of adipose tissue to the viscera in pregnancy, as seen in our sample, could serve an important metabolic function; however, excessive deposition in this region could negatively affect maternal health.
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Affiliation(s)
- Kimberly K Vesco
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Nicole E Marshall
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Eric Baetscher
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR, USA
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - William Rooney
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR, USA
| | - Melanie Francisco
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Eric Baker
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR, USA
| | - Janet C King
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, CA, USA
| | - Patrick Catalano
- Mother Infant Research Institute, Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA, USA
| | - Antonio E Frias
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jonathan Q Purnell
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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Mester NS, Packer CH, Doshi U, Caughey AB, Marshall NE, Gibbins KJ. Optimal Timing of Delivery in Women with History of Stillbirth: A Decision Analysis. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.811] [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: 11/01/2022]
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Sureshchandra S, Zulu MZ, Doratt B, Jankeel A, Tifrea D, Edwards R, Rincon M, Marshall NE, Messaoudi I. Deep immune profiling of the maternal-fetal interface with mild SARS-CoV-2 infection. bioRxiv 2021:2021.08.23.457408. [PMID: 34462741 PMCID: PMC8404883 DOI: 10.1101/2021.08.23.457408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/24/2022]
Abstract
Pregnant women are an at-risk group for severe COVID-19, though the majority experience mild/asymptomatic disease. Although severe COVID-19 has been shown to be associated with immune activation at the maternal-fetal interface even in the absence of active viral replication, the immune response to asymptomatic/mild COVID-19 remains unknown. Here, we assessed immunological adaptations in both blood and term decidua from 9 SARS-exposed pregnant women with asymptomatic/mild disease and 15 pregnant SARS-naive women. In addition to selective loss of tissue-resident decidual macrophages, we report attenuation of antigen presentation and type I IFN signaling but upregulation of inflammatory cytokines and chemokines in blood monocyte derived decidual macrophages. On the other hand, infection was associated with remodeling of the T cell compartment with increased frequencies of activated CD69+ tissue-resident T cells and decreased abundance of Tregs. Interestingly, frequencies of cytotoxic CD4 and CD8 T cells increased only in the blood, while CD8 effector memory T cells were expanded in the decidua. In contrast to decidual macrophages, signatures of type I IFN signaling were increased in decidual T cells. Finally, T cell receptor diversity was significantly reduced with infection in both compartments, albeit to a much greater extent in the blood. The resulting aberrant immune activation in the placenta, even with asymptomatic disease may alter the exquisitely sensitive developing fetal immune system, leading to long-term adverse outcomes for offspring.
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Affiliation(s)
- Suhas Sureshchandra
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine CA 92697
- Institute for Immunology, University of California, Irvine CA 92697
| | - Michael Z Zulu
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine CA 92697
- Institute for Immunology, University of California, Irvine CA 92697
| | - Brianna Doratt
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine CA 92697
- Institute for Immunology, University of California, Irvine CA 92697
| | - Allen Jankeel
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine CA 92697
| | - Delia Tifrea
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California, Irvine CA 92697
| | - Robert Edwards
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California, Irvine CA 92697
| | - Monica Rincon
- Maternal-Fetal Medicine, Oregon Health and Sciences University, Portland OR 97239
| | - Nicole E. Marshall
- Maternal-Fetal Medicine, Oregon Health and Sciences University, Portland OR 97239
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine CA 92697
- Institute for Immunology, University of California, Irvine CA 92697
- Center for Virus Research, University of California, Irvine CA 92697
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11
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Sureshchandra S, Marshall NE, Mendoza N, Jankeel A, Zulu MZ, Messaoudi I. Functional and genomic adaptations of blood monocytes to pregravid obesity during pregnancy. iScience 2021; 24:102690. [PMID: 34195568 PMCID: PMC8233196 DOI: 10.1016/j.isci.2021.102690] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 04/27/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022] Open
Abstract
Pregravid obesity is associated with several adverse maternal health outcomes, such as increased risk of infection, suggesting an altered immunological state. However, the mechanisms by which obesity disrupts the pregnancy “immune clock” are still unknown. Here, we profiled circulating immune mediators, immune cell subset frequencies, and peripheral immune responses during the first and third trimesters of pregnancy in lean and obese mothers. While both Th1 and Th2 cytokines were elevated with pregnancy regardless of BMI, obese subjects had dysregulated myeloid factors in circulation at term. Pregnancy in lean subjects was associated with enhanced monocyte activation, augmented chromatin accessibility at inflammatory loci, and heightened responses to LPS. Pregravid obesity disrupted this trajectory, resulting in a lack of transcriptional, epigenetic, and metabolic changes strongly suggesting a skewing toward innate immune tolerance. These findings provide novel insight into the increased susceptibility to infections in women with obesity during pregnancy and following cesarean delivery. Pregnancy is associated with activation and enhanced responses of monocytes Heightened monocyte response is associated with epigenetic adaptions Pregravid obesity leads to a state akin to LPS tolerance in monocytes Pregravid obesity is associated with a lack of epigenetic and metabolic plasticity
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Affiliation(s)
- Suhas Sureshchandra
- Department of Molecular Biology and Biochemistry, University of California, 2400 Biological Sciences III, Irvine, CA 92697, USA.,Institute for Immunology, University of California, Irvine, CA 92697, USA
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Norma Mendoza
- Department of Molecular Biology and Biochemistry, University of California, 2400 Biological Sciences III, Irvine, CA 92697, USA
| | - Allen Jankeel
- Department of Molecular Biology and Biochemistry, University of California, 2400 Biological Sciences III, Irvine, CA 92697, USA
| | - Michael Z Zulu
- Department of Molecular Biology and Biochemistry, University of California, 2400 Biological Sciences III, Irvine, CA 92697, USA.,Institute for Immunology, University of California, Irvine, CA 92697, USA
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, University of California, 2400 Biological Sciences III, Irvine, CA 92697, USA.,Institute for Immunology, University of California, Irvine, CA 92697, USA.,Center for Virus Research, University of California, Irvine, CA 92697, USA
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Cantor AG, Jungbauer RM, McDonagh M, Blazina I, Marshall NE, Weeks C, Fu R, LeBlanc ES, Chou R. Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:2094-2109. [PMID: 34032824 DOI: 10.1001/jama.2021.4230] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category. OBJECTIVE To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation. DATA SOURCES Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021. STUDY SELECTION Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG. DATA EXTRACTION AND SYNTHESIS Independent data abstraction and study quality rating with dual review. MAIN OUTCOMES AND MEASURES Gestational weight-related outcomes; maternal and infant morbidity and mortality; harms. RESULTS Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], -1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, -2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, -1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, -1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, -1.02 kg [95% CI, -1.30 to -0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, -7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, -0.63 kg [95% CI, -1.44 to -0.01]). Data on harms were limited. CONCLUSIONS AND RELEVANCE Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.
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Affiliation(s)
- Amy G Cantor
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Rebecca M Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Marian McDonagh
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Ian Blazina
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Chandler Weeks
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University-Portland State University
| | - Erin S LeBlanc
- Kaiser Permanente, Center for Health Research, Portland, Oregon
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Sureshchandra S, Mendoza N, Jankeel A, Wilson RM, Marshall NE, Messaoudi I. Phenotypic and Epigenetic Adaptations of Cord Blood CD4+ T Cells to Maternal Obesity. Front Immunol 2021; 12:617592. [PMID: 33912153 PMCID: PMC8071865 DOI: 10.3389/fimmu.2021.617592] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/22/2021] [Indexed: 01/02/2023] Open
Abstract
Pregravid obesity has been shown to disrupt the development of the offspring’s immune system and increase susceptibility to infection. While the mechanisms underlying the impact of maternal obesity on fetal myeloid cells are emerging, the consequences for T cells remain poorly defined. In this study, we collected umbilical cord blood samples from infants born to lean mothers and mothers with obesity and profiled CD4 T cells using flow cytometry and single cell RNA sequencing at resting and following ex vivo polyclonal stimulation. We report that maternal obesity is associated with higher frequencies of memory CD4 T cells suggestive of in vivo activation. Moreover, single cell RNA sequencing revealed expansion of an activated subset of memory T cells with maternal obesity. However, ex vivo stimulation of purified CD4 T cells resulted in poor cytokine responses, suggesting functional defects. These phenotypic and functional aberrations correlated with methylation and chromatin accessibility changes in loci associated with lymphocyte activation and T cell receptor signaling, suggesting a possible link between maternal obesogenic environment and fetal immune reprogramming. These observations offer a potential explanation for the increased susceptibility to microbial infection in babies born to mothers with obesity.
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Affiliation(s)
- Suhas Sureshchandra
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, Irvine, CA, United States.,Institute for Immunology, University of California Irvine, Irvine, CA, United States
| | - Norma Mendoza
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, Irvine, CA, United States
| | - Allen Jankeel
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, Irvine, CA, United States
| | - Randall M Wilson
- Division of Biomedical Sciences, University of California Riverside, Riverside, CA, United States
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, Irvine, CA, United States.,Institute for Immunology, University of California Irvine, Irvine, CA, United States.,Center for Virus Research, University of California Irvine, Irvine, CA, United States
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14
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Abstract
Lactation insufficiency is variously defined and includes the inability to produce milk, not producing enough milk to exclusively meet infant growth requirements, and pathological interruption of lactation (e.g., mastitis). Of women with intent-to-breastfeed, lactation insufficiency has been estimated to affect 38%-44% of newly postpartum women, likely contributing to the nearly 60% of infants that are not breastfed according to the World Health Organization's guidelines. To date, research and clinical practice aimed at improving feeding outcomes have focused on hospital lactation support and education, with laudable results. However, researchers' reports of recent rodent studies concerning fundamental lactation biology have suggested that the underlying pathologies of lactation insufficiency may be more nuanced than is currently appreciated. In this article, we identify mucosal biology of the breast and lactation-specific liver biology as two under-researched aspects of lactation physiology. Specifically, we argue that further scientific inquiry into reproductive state-dependent regulation of immunity in the human breast will reveal insights into novel immune based requirements for healthy lactation. Additionally, our synthesis of the literature supports the hypothesis that the liver is an essential player in lactation-highlighting the potential that pathologies of the liver may also be associated with lactation insufficiency. More research into these biologic underpinnings of lactation is anticipated to provide new avenues to understand and treat lactation insufficiency.
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Affiliation(s)
- Courtney B Betts
- 89020 Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA
| | - Alexandra Quackenbush
- 89020 Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA
| | - Weston Anderson
- 89020 Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA
| | - Nicole E Marshall
- Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Pepper J Schedin
- 89020 Department of Cell, Developmental and Cancer Biology, Oregon Health and Science University, Portland, OR, USA.,University of Colorado Cancer Center, Aurora, CO, USA.,Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
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15
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Marshall NE, Lallande LF, Schedin PJ, Thornburg KL, Purnell JQ. Exclusive Breastfeeding Rates at 6 Weeks Postpartum as a Function of Preconception Body Mass Index Are Not Impacted by Postpartum Obstetrical Practices or Routines. Breastfeed Med 2020; 15:458-464. [PMID: 32412795 PMCID: PMC7374594 DOI: 10.1089/bfm.2020.0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 12/16/2022]
Abstract
Objective: Women with overweight/obesity have significantly lower rates of exclusive breastfeeding (EBF) at 6 weeks postpartum compared with women of normal weight. We sought to determine whether differences in Baby-Friendly Hospital Initiative (BFHI) adherence, obstetric practices, or social support explain these weight-related EBF disparities. Methods: One hundred forty-two healthy women who intended EBF (61 normal weight, 50 overweight, and 31 obese by preconception body mass index [BMI]) were enrolled in a cross-sectional study. Obstetric data were collected and participants completed modified Infant Feeding Practices Study II surveys at 6 weeks postpartum. Results: Women with obesity were significantly less likely to undergo spontaneous labor and more likely to receive synthetic oxytocin and epidural anesthesia compared with women with overweight or normal weight. Women who were overweight were less likely to report extended family support for breastfeeding compared with women with obesity or normal weight; however, BFHI components and composite BFHI score did not differ by maternal BMI. Furthermore, regardless of BMI, women with greater adherence to BFHI practices were more likely to be EBF at 6 weeks postpartum (p-value <0.001). Nonetheless, at 6 weeks postpartum, women with obesity were expressing milk more frequently and less likely to have met their own breastfeeding goals compared with women with overweight and normal weight. Conclusions: Differences in EBF rates by BMI were not explained by BFHI adherence or obstetric practices. These data suggest physiological differences, rather than intrapartum practices and support services, may explain differences in EBF rates by maternal overweight/obesity.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Developmental and Cancer Biology, Oregon Health & Science University, Portland, Oregon, USA
| | - Laura F Lallande
- Providence St. Vincent Medical Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Pepper J Schedin
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Kent L Thornburg
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan Q Purnell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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16
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Boone-Heinonen J, Biel FM, Marshall NE, Snowden JM. Maternal prepregnancy BMI and size at birth: race/ethnicity-stratified, within-family associations in over 500,000 siblings. Ann Epidemiol 2020; 46:49-56.e5. [DOI: 10.1016/j.annepidem.2020.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/19/2019] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
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17
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Cabral K, Thornburg K, Purnell J, Marshall NE. 624: Changes in fasting maternal triglyceride levels predict neonatal weight but not fat mass. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.640] [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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18
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Sureshchandra S, Marshall NE, Messaoudi I. Impact of pregravid obesity on maternal and fetal immunity: Fertile grounds for reprogramming. J Leukoc Biol 2019; 106:1035-1050. [PMID: 31483523 DOI: 10.1002/jlb.3ri0619-181r] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 06/05/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 12/12/2022] Open
Abstract
Maternal pregravid obesity results in several adverse health outcomes during pregnancy, including increased risk of gestational diabetes, preeclampsia, placental abruption, and complications at delivery. Additionally, pregravid obesity and in utero exposure to high fat diet have been shown to have detrimental effects on fetal programming, predisposing the offspring to adverse cardiometabolic, endocrine, and neurodevelopmental outcomes. More recently, a deeper appreciation for the modulation of offspring immunity and infectious disease-related outcomes by maternal pregravid obesity has emerged. This review will describe currently available animal models for studying the impact of maternal pregravid obesity on fetal immunity and review the data from clinical and animal model studies. We also examine the burden of pregravid obesity on the maternal-fetal interface and the link between placental and systemic inflammation. Finally, we discuss future studies needed to identify key mechanistic underpinnings that link maternal inflammatory changes and fetal cellular reprogramming events.
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Affiliation(s)
- Suhas Sureshchandra
- Department of Molecular Biology and Biochemistry, University of California Irvine, Irvine, CA, USA
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, University of California Irvine, Irvine, CA, USA
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19
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Marshall NE, Biel FM, Boone-Heinonen J, Dukhovny D, Caughey AB, Snowden JM. The Association between Maternal Height, Body Mass Index, and Perinatal Outcomes. Am J Perinatol 2019; 36:632-640. [PMID: 30292175 PMCID: PMC6453733 DOI: 10.1055/s-0038-1673395] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 10/28/2022]
Abstract
OBJECTIVE To test the hypothesis that maternal height is associated with adverse perinatal outcomes, controlling for and stratified by maternal body mass index (BMI). STUDY DESIGN This was a retrospective cohort study of all births in California between 2007 and 2010 (n = 1,775,984). Maternal height was categorized into quintiles, with lowest quintile (≤20%) representing shorter stature and the uppermost quintile (≥80%) representing taller stature. Outcomes included gestational diabetes mellitus (GDM), preeclampsia, cesarean, preterm birth (PTB), macrosomia, and low birth weight (LBW). We calculated height/outcome associations among BMI categories, and BMI/outcome associations among height categories, using various multivariable logistic regression models. RESULTS Taller women were less likely to have GDM, nulliparous cesarean, PTB, and LBW; these associations were similar across maternal BMI categories and persisted after multivariable adjustment. In contrast, when stratified by maternal height, the associations between maternal BMI and birth outcomes varied by specific outcomes, for example, the association between morbid obesity (compared with normal or overweight) and the risk of GDM was weaker among shorter women (adjusted odds ratio [aOR], 95% confidence interval [CI]: 3.48, 3.28-3.69) than taller women (aOR, 95% CI: 4.42, 4.19-4.66). CONCLUSION Maternal height is strongly associated with altered perinatal risk even after accounting for variations in complications by BMI.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Frances M Biel
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | | | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Jonathan M Snowden
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University, Portland, Oregon
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20
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Marshall NE, Thornburg KL, Purnell JQ. 1014: Maternal diet across gestation: Impact on gestational weight gain and fat mass. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.1038] [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: 11/24/2022]
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21
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Skeith AE, Marshall NE, Chandrasekaran S, Cheng YW, Caughey AB. 689: Pregnancy outcomes in the setting of super obesity and super-super obesity. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.712] [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: 11/29/2022]
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22
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Marshall NE, Lau B, Purnell JQ, Thornburg KL. Impact of maternal obesity and breastfeeding intention on lactation intensity and duration. Matern Child Nutr 2018; 15:e12732. [PMID: 30345729 DOI: 10.1111/mcn.12732] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/01/2018] [Accepted: 09/19/2018] [Indexed: 12/30/2022]
Abstract
Exclusive breastfeeding (EBF) has numerous maternal health benefits. However, EBF rates are lower in mothers with obesity. We sought to better understand whether maternal body composition measurements in early pregnancy are also predictive of lower rates of EBF. Healthy pregnant women with prepregnancy body mass index (BMI) of 17.5-51 kg/m2 underwent determination of percent body fat (% body fat) in early (12-16 weeks) and late (37 weeks) gestation. Intent and duration of EBF were determined by surveys completed at 6 weeks and 6 months postpartum (PP). Unadjusted and adjusted analyses were performed to compare EBF rates and weaning by maternal BMI and % body fat. Increasing BMI and % body fat in early pregnancy were significantly associated with lower rates of EBF among women intending EBF. Women with BMI ≥ 25 were less likely to be EBF at 6 weeks and 6 months PP compared with women of normal BMI (67 and 37% vs. 91 and 79%, P value 0.005 and 0.001, respectively). Among primiparous women intending EBF, 100% of women in the lowest two body fat quartiles in early pregnancy were EBF at 6 weeks PP compared with 66.7 and 63.6% of women in the higher quartiles (P = 0.03). Lactation cessation by 6 months PP was higher with increasing maternal BMI (P = 0.001). Maternal obesity in early gestation is associated with lower EBF rates among women intending EBF and earlier weaning. Excess adiposity in early pregnancy may impede EBF.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Bernard Lau
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan Q Purnell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Kent L Thornburg
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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23
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Marshall NE, Keller RA, Dines J, Bush-Joseph C, Limpisvasti O. Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons. Musculoskelet Surg 2018; 103:55-61. [PMID: 30361837 DOI: 10.1007/s12306-018-0574-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 12/27/2017] [Accepted: 10/19/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction. LEVEL OF EVIDENCE Cross sectional study, Level IV. METHODS Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport. RESULTS A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1 years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9 months in 67% and overall 94% from 6 to 12 months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery. CONCLUSION Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6 months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.
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Affiliation(s)
- N E Marshall
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Terrace Dr., Los Angeles, CA, 90045, USA.
| | - R A Keller
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Terrace Dr., Los Angeles, CA, 90045, USA
| | - J Dines
- The Hospital for Special Surgery, 541 E 71st St., New York, NY, 10021, USA
| | - C Bush-Joseph
- Midwest Orthopedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - O Limpisvasti
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Terrace Dr., Los Angeles, CA, 90045, USA
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Sureshchandra S, Marshall NE, Wilson RM, Barr T, Rais M, Purnell JQ, Thornburg KL, Messaoudi I. Inflammatory Determinants of Pregravid Obesity in Placenta and Peripheral Blood. Front Physiol 2018; 9:1089. [PMID: 30131724 PMCID: PMC6090296 DOI: 10.3389/fphys.2018.01089] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/23/2018] [Indexed: 01/02/2023] Open
Abstract
Pre-pregnancy (pregravid) obesity has been linked to several adverse health outcomes for both mother and offspring. Complications during pregnancy include increased risk for gestational diabetes, hypertension, preeclampsia, placental abruption, and difficulties during delivery. Several studies suggest that these negative outcomes are mediated by heightened systemic inflammation as well as changes in placental development and function. However, the molecular mechanisms by which pregravid obesity affects these processes are poorly understood. In this study, we aimed to address this question by carrying out a comprehensive analysis of the systemic maternal immune system coupled with placental gene expression and microbial profiling at term delivery (11 lean and 14 obese). Specifically, we examined the impact of pregravid obesity on circulating cytokines, chemokine, adipokines, and growth factors using multiplex Luminex assay. Innate and adaptive immune cell frequencies and their cytokine production in response to stimuli were measured using flow cytometry. Finally, changes in placental transcriptome and microbiome were profiled using RNA- and 16S-sequencing, respectively. Pregravid obesity is characterized by insulin and leptin resistance, high levels of circulating inflammatory markers IL-6 and CRP, in addition to chemokine IL-8 (p < 0.01). Moreover, pregravid obesity was associated with lower frequency of naïve CD4+ T-cells (p < 0.05), increased frequency of memory CD4+ T-cells (p < 0.01), and a shift towards Th2 cytokine production (p = 0.05). Myeloid cells from the obese cohort produced higher levels of pro-inflammatory cytokines but lower levels of chemokines following TLR stimulation (p < 0.05). Lastly, pregravid obesity is associated with increased abundance of Bacteroides and changes in the expression of genes important for nutrient transport and immunity (FDR < 0.05). Collectively, these data indicate that pregravid obesity is associated with heightened systemic inflammation and of dysregulated nutrient transport in the placenta and provide insight into the basis of fetal reprogramming.
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Affiliation(s)
- Suhas Sureshchandra
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, CA, United States
| | - Nicole E. Marshall
- Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Randall M. Wilson
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA, United States
| | - Tasha Barr
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA, United States
| | - Maham Rais
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA, United States
| | - Jonathan Q. Purnell
- Department of Medicine, The Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States
| | - Kent L. Thornburg
- Department of Medicine, The Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, CA, United States
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Grandy M, Snowden JM, Boone-Heinonen J, Purnell JQ, Thornburg KL, Marshall NE. Poorer maternal diet quality and increased birth weight . J Matern Fetal Neonatal Med 2018; 31:1613-1619. [PMID: 28514885 PMCID: PMC5694379 DOI: 10.1080/14767058.2017.1322949] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/14/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Maternal diet and gestational weight gain (GWG) influence birth weight and infant adiposity, which are important predictors of lifetime health. To better understand these relationships, we studied associations between maternal diet and GWG, adiposity, and birth weight in a well characterized cohort of pregnant women. STUDY DESIGN Data were obtained from 41 term (>37 weeks), uncomplicated, singleton pregnancies according to pre-pregnancy BMI categories of normal (n = 11), overweight (n = 15), or obese (n = 15). Daily consumption of protein, fat, and carbohydrates and a Healthy Eating Index (HEI-2010) score were determined from 24 h food recall collections. Associations were modeled using multinomial logistic and linear regression. RESULTS Neither the third trimester maternal diet quality nor the macronutrient consumption was associated with GWG after adjusting for pre-pregnancy BMI, maternal age, and parity. A ten-point lower HEI-2010 score was associated with 200 g higher infant birth weight and a 1.0 cm longer length. However, maternal HEI-2010 and macronutrient composition were unrelated to infant percent body fat, ponderal index, or abdominal circumference. CONCLUSIONS Poorer third trimester maternal diet quality was associated with higher birth weight and longer length, but was unrelated to markers of infant adiposity. GWG was independent of third trimester maternal diet composition and quality.
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Affiliation(s)
- Madeline Grandy
- School of Medicine, Oregon Health & Science University, Portland, OR
| | - Jonathan M. Snowden
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Janne Boone-Heinonen
- School of Public Health, Oregon Health & Science University/Portland State University, Portland, OR
| | - Jonathan Q. Purnell
- Department of Medicine, Oregon Health & Science University, Portland, OR
- Knight Cardiovascular Institute, Center for Developmental Health, Oregon Health & Science University, Portland, OR
| | - Kent L. Thornburg
- Knight Cardiovascular Institute, Center for Developmental Health, Oregon Health & Science University, Portland, OR
| | - Nicole E. Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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Skeith AE, Marshall NE, Pereira LM, Caughey AB. 567: Indications for cesarean delivery after a shift in provider culture: A retrospective cohort study. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.094] [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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Skeith AE, Marshall NE, Pereira LM, Caughey AB. 923: Change in provider culture and cesarean delivery rates: a retrospective cohort study. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.510] [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: 11/16/2022]
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Abstract
BACKGROUND There is an evidence gap regarding the use of regional anaesthesia (epidural, spinal, or combined epidural/spinal anaesthesia) and associated complications by maternal body mass index (BMI). We examine associations between regional anaesthesia, mode of delivery, and regional anaesthesia complications by pre-pregnancy BMI categories among term deliveries. METHODS Retrospective cohort study of births in California, 2007-2010, utilizing linked birth certificate data and patient discharge data. Outcomes were mode of delivery (among laboured deliveries) and select regional anaesthesia complications. Multivariable Poisson regression was used to adjust for maternal characteristics. RESULTS In women undergoing labour (i.e. laboured delivery), women with higher BMI categories were more likely to receive regional analgesia in a dose-response fashion (adjusted risk ratio [RR] 1.10, 95% confidence interval [CI] 1.10, 1.11 for primiparous women with category I obesity), and in those receiving regional anaesthesia, were less likely to deliver vaginally (e.g. RR 0.85, 95% CI 0.84, 0.85 for the same category of women). Regional anaesthesia complications displayed a complex relationship with maternal BMI, with women in intermediate obesity categories having decreased odds as compared to normal-weight women, and women in the highest BMI category having a twofold increased risk of complications (RR 2.34, 95% CI 1.37, 4.02 for primiparous women). CONCLUSION Labouring women in higher BMI categories were more likely to receive regional anaesthesia and more likely to deliver via caesarean compared to normal weight women and women without regional anaesthesia. Rates of anaesthesia complications were highest among women in the highest BMI category.
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Affiliation(s)
- Frances M. Biel
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Nicole E. Marshall
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Jonathan M. Snowden
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR,Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
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Sureshchandra S, Wilson RM, Rais M, Marshall NE, Purnell JQ, Thornburg KL, Messaoudi I. Maternal Pregravid Obesity Remodels the DNA Methylation Landscape of Cord Blood Monocytes Disrupting Their Inflammatory Program. J Immunol 2017; 199:2729-2744. [PMID: 28887432 PMCID: PMC7384891 DOI: 10.4049/jimmunol.1700434] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 03/24/2017] [Accepted: 08/07/2017] [Indexed: 01/03/2023]
Abstract
Prepregnancy maternal obesity is associated with adverse outcomes for the offspring, including increased incidence of neonatal bacterial sepsis and necrotizing enterocolitis. We recently reported that umbilical cord blood (UCB) monocytes from babies born to obese mothers generate a reduced IL-6/TNF-α response to TLR 1/2 and 4 ligands compared to those collected from lean mothers. These observations suggest altered development of the offspring's immune system, which in turn results in dysregulated function. We therefore investigated transcriptional and epigenetic differences within UCB monocytes stratified by prepregnancy maternal body mass index. We show that UCB monocytes from babies born to obese mothers generate a dampened response to LPS stimulation compared with those born to lean mothers, at the level of secreted immune mediators and transcription. Because gene expression profiles of resting UCB monocytes from both groups were comparable, we next investigated the role of epigenetic differences. Indeed, we detected stark differences in methylation levels within promoters and regulatory regions of genes involved in TLR signaling in resting UCB monocytes. Interestingly, the DNA methylation status of resting cells was highly predictive of transcriptional changes post-LPS stimulation, suggesting that cytosine methylation is one of the dominant mechanisms driving functional inadequacy in UCB monocytes obtained from babies born to obese mothers. These data highlight a potentially critical role of maternal pregravid obesity-associated epigenetic changes in influencing the function of an offspring's monocytes at birth. These findings further our understanding of mechanisms that explain the increased risk of infection in neonates born to mothers with high prepregnancy body mass index.
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Affiliation(s)
- Suhas Sureshchandra
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, Irvine, CA 92697
| | - Randall M Wilson
- Division of Biomedical Sciences, University of California Riverside, Riverside, CA 92521
| | - Maham Rais
- Division of Biomedical Sciences, University of California Riverside, Riverside, CA 92521
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health and Science University, Portland, OR 97239; and
| | - Jonathan Q Purnell
- Department of Medicine, The Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR 97239
| | - Kent L Thornburg
- Department of Medicine, The Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR 97239
| | - Ilhem Messaoudi
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, Irvine, CA 92697;
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Khalil LS, Keller RA, Mehran N, Marshall NE, Okoroha K, Frisch NB, DeSilva SP. The utility of botulinum toxin A in the repair of distal biceps tendon ruptures. Musculoskelet Surg 2017; 102:159-163. [PMID: 29027640 DOI: 10.1007/s12306-017-0515-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 04/24/2017] [Accepted: 10/08/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of our study is to report the outcomes and complications in patients who underwent distal biceps tendon repair with the use of Botulinum toxin A (BoNT-A) as an adjunct to surgery. METHODS A retrospective review of 14 patients who underwent 15 distal biceps tendon repairs was performed. All repaired tendons had their correlating muscle bellies injected intraoperatively with a mixture of 100U of BoNT-A and 10 ml of normal saline. Each patient was evaluated for surgical and post-operative complications and followed with Disabilities of the Arm, Shoulder and Hand (DASH) Disability Scores. RESULTS The cohort was exclusively male, 14/14 (100%). The mean age at procedure was 52.1 years (range: 29-65 years). Types of injuries repaired included: 12 acute biceps tendon ruptures, one chronic partial (> 50% of tendon) biceps tear, and two chronic biceps ruptures. Average final follow-up was 32.9 months (SD: 19.6; range: 7.07-61.72). Average time to repair of chronic injury was 5.75 months (range: 2-12 months). There were no intraoperative complications, and all patients were discharged home on the day of surgery. Average DASH score at latest follow-up was 4.9 (range: 0.0-12.5). All patients had return of function of paralyzed muscle prior to final follow-up. One patient required an incision and drainage for a deep infection 1 week post-operatively, without any further complications. Another patient required operative removal of heterotopic ossification located around the tendon fixation site, which was the result of a superficial infection treated with antibiotics 2 weeks post-operatively. This patient later healed with improvement in supination/pronation range-of-motion and no further complications. CONCLUSIONS Injection of BoNT-A is safe and effective to protect distal biceps tendon repair during the early phases of bone-tendon healing. CLINICAL RELEVANCE BoNT-A may is safe and effective to protect distal biceps tendon repair. The utility of BoNT-A as an adjunct to surgical repair may be applicable to acute or chronic tears as well as repairs in the non-compliant patient without decreases in functional scores after return of function of the biceps muscle. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- L S Khalil
- Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA.
| | - R A Keller
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Ter #400, Los Angeles, CA, 90045, USA
| | - N Mehran
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Ter #400, Los Angeles, CA, 90045, USA
| | - N E Marshall
- Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - K Okoroha
- Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - N B Frisch
- Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - S P DeSilva
- Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
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Marshall NE, Purnell JQ, Thornburg KL. 539: Higher maternal essential amino acid levels are associated with higher placental amino acid transporter gene expression. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.274] [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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Snowden JM, Robinson WR, Marshall NE, Boone-Heinonen J. Race, obesity, and birth outcomes: Unraveling a complex association to improve maternal-child health. Obesity (Silver Spring) 2016; 24:2447. [PMID: 27891831 PMCID: PMC5557633 DOI: 10.1002/oby.21642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan M Snowden
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
- School of Public Health, Oregon Health & Science University/Portland State University, Portland, Oregon, USA
| | - Whitney R Robinson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nicole E Marshall
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Janne Boone-Heinonen
- School of Public Health, Oregon Health & Science University/Portland State University, Portland, Oregon, USA
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O'Tierney-Ginn PF, Gillingham M, Fowler J, Brass E, Marshall NE, Thornburg KL. Maternal Weight Gain Regulates Omega-3 Fatty Acids in Male, Not Female, Neonates. Reprod Sci 2016; 24:560-567. [PMID: 27470150 DOI: 10.1177/1933719116660843] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 11/15/2022]
Abstract
The fetus largely depends on maternal supply and placental transport for its source of long-chain polyunsaturated fatty acids (LCPUFAs), which are essential for proper neurological and cardiovascular development. Pregnancy complications such as diabetes reduces neonatal LCPUFA supply, but little is known of how fatty acid delivery is affected by maternal body type or weight gain in uncomplicated pregnancies. In a cross-sectional study of maternal-neonatal pairs at term, we sought to determine the effect of gestational weight gain on neonatal LCPUFA supply. Forty maternal-neonatal pairs of uncomplicated (no gestational hypertension or diabetes) term pregnancies were recruited upon admission to Oregon Health & Science University Labor & Delivery for scheduled cesarean section. Maternal and umbilical cord plasma fatty acid profiles were measured using gas chromatography-mass spectrophotometry. First trimester weight gain was negatively correlated with maternal n-3 LCPUFA ( r = -0.80, P = .0002), and this was not affected by fetal sex. High maternal weight gain in the first trimester was negatively associated with cord n-3 polyunsaturated fatty acid levels ( r = -0.70, P = .03) and placental thickness ( r = -0.69, P = .03) in male, but not female, offspring. High maternal weight gain in the first trimester is associated with a thinner placenta and low levels of n-3 LCPUFA in male offspring. Further study is required to confirm that male offspring are at a higher risk of poor outcomes associated with high maternal weight gain early in pregnancy.
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Affiliation(s)
- Perrie F O'Tierney-Ginn
- 1 Department of Reproductive Biology, Center for Reproductive Health, Case Western Reserve University, Cleveland, OH, USA
| | - Melanie Gillingham
- 2 Department of Molecular & Medical Genetics, Oregon Health and Science University (OHSU), Portland, OR, USA
| | - Jessica Fowler
- 3 Department of Obstetrics & Gynecology, UCLA, Los Angeles, CA, USA
| | - Elizabeth Brass
- 4 Department of Obstetrics & Gynecology, Kaiser Permanente, Hillsboro, OR, USA
| | - Nicole E Marshall
- 5 Department of Obstetrics & Gynecology, OHSU, Portland, OR, USA.,6 Center for Developmental Health, OHSU, Portland, OR, USA
| | - Kent L Thornburg
- 6 Center for Developmental Health, OHSU, Portland, OR, USA.,7 Department of Medicine (Cardiovascular Medicine), OHSU, Portland, OR, USA
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Snowden JM, Mission JF, Marshall NE, Quigley B, Main E, Gilbert WM, Chung JH, Caughey AB. The Impact of maternal obesity and race/ethnicity on perinatal outcomes: Independent and joint effects. Obesity (Silver Spring) 2016; 24:1590-8. [PMID: 27222008 PMCID: PMC4925263 DOI: 10.1002/oby.21532] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/27/2016] [Accepted: 03/25/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Independent and joint impacts of maternal race/ethnicity and obesity on adverse birth outcomes, including pre-eclampsia, low birth weight, and macrosomia, were characterized. METHODS Retrospective cohort study of all 2007 California births was conducted using vital records and claims data. Maternal race/ethnicity and maternal body mass index (BMI) were the key exposures; their independent and joint impact on outcomes using regression models was analyzed. RESULTS Racial/ethnic minority women of normal weight generally had higher risk as compared with white women of normal weight (e.g., African-American women, pre-eclampsia adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI]: 1.48-1.74 vs. white women). However, elevated BMI did not usually confer additional risk (e.g., pre-eclampsia aOR comparing African-American women with excess weight with white women with excess weight, 1.17, 95% CI: 0.89-1.54). Obesity was a risk factor for low birth weight only among white women (excess weight aOR, 1.24, 95% CI: 1.04-1.49 vs. white women of normal weight) and not among racial/ethnic minority women (e.g., African-American women, 0.95, 95% CI: 0.83-1.08). CONCLUSIONS These findings add nuance to our understanding of the interplay between maternal race/ethnicity, BMI, and perinatal outcomes. While the BMI/adverse outcome gradient appears weaker in racial/ethnic minority women, this reflects the overall risk increase in racial/ethnic minority women of all body sizes.
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Affiliation(s)
- Jonathan M Snowden
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
- School of Public Health, Oregon Health & Science University/Portland State University, Portland, Oregon, USA
| | - John F Mission
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nicole E Marshall
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Brian Quigley
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Elliott Main
- California Maternal Quality Care Collaborative (CMQCC), Stanford, California, USA
| | | | - Judith H Chung
- University of California, Irvine Medical Center, Orange, California, USA
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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Marshall NE, Murphy EJ, King JC, Haas EK, Lim JY, Wiedrick J, Thornburg KL, Purnell JQ. Comparison of multiple methods to measure maternal fat mass in late gestation. Am J Clin Nutr 2016; 103:1055-63. [PMID: 26888714 PMCID: PMC4807697 DOI: 10.3945/ajcn.115.113464] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 04/20/2015] [Accepted: 01/06/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Measurements of maternal fat mass (FM) are important for studies of maternal and fetal health. Common methods of estimating FM have not been previously compared in pregnancy with measurements using more complete body composition models. OBJECTIVES The goal of this pilot study was to compare multiple methods that estimate FM, including 2-, 3- and 4-compartment models in pregnant women at term, and to determine how these measures compare with FM by dual-energy X-ray absorptiometry (DXA) 2 wk postpartum. DESIGN Forty-one healthy pregnant women with prepregnancy body mass index (in kg/m(2)) 19 to 46 underwent skinfold thickness (SFT), bioelectrical impedance analysis (BIA), body density (Db) via air displacement plethysmography (ADP), and deuterium dilution of total body water (TBW) with and without adjustments for gestational age using van Raaij (VRJ) equations at 37-38 wk of gestation and 2 wk postpartum to derive 8 estimates of maternal FM. Deming regression analysis and Bland-Altman plots were used to compare methods of FM assessment. RESULTS Systematic differences in FM estimates were found. Methods for FM estimates from lowest to highest were 4-compartment, DXA, TBW(VRJ), 3-compartment, Db(VRJ), BIA, air displacement plethysmography body density, and SFT ranging from a mean ± SD of 29.5 ± 13.2 kg via 4-compartment to 39.1 ± 11.7 kg via SFT. Compared with postpartum DXA values, Deming regressions revealed no substantial departures from trend lines in maternal FM in late pregnancy for any of the methods. The 4-compartment method showed substantial negative (underestimating) constant bias, and the air displacement plethysmography body density and SFT methods showed positive (overestimating) constant bias. ADP via Db(VRJ)and 3-compartment methods had the highest precision; BIA had the lowest. CONCLUSIONS ADP that uses gestational age-specific equations may provide a reasonable and practical measurement of maternal FM across a spectrum of body weights in late pregnancy. SFT would be acceptable for use in larger studies. This trial was registered at clinicaltrials.gov as NCT02586714.
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Affiliation(s)
| | | | - Janet C King
- Children's Hospital Oakland Research Institute, Oakland, CA
| | - E Kate Haas
- Oregon Health & Science University, Portland, OR
| | - Jeong Y Lim
- Oregon Health & Science University, Portland, OR
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Abstract
Obesity has increased dramatically in the United States over the last several decades, with approximately 40% of pregnant women now considered overweight or obese. Obesity has been shown to be associated with numerous poor pregnancy outcomes, including increased rates of preeclampsia, gestational diabetes, fetal macrosomia, stillbirth, postterm pregnancy, and increased rates of cesarean delivery. Many of these complications have been found to increase even further with increasing body mass index in a dose-response fashion. In this review, the association of obesity with maternal, fetal, and pregnancy outcomes is discussed as are the recommendations for caring for the obese gravida.
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Affiliation(s)
- John F Mission
- Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Hospital of UPMC, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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Wilson RM, Marshall NE, Jeske DR, Purnell JQ, Thornburg K, Messaoudi I. Maternal obesity alters immune cell frequencies and responses in umbilical cord blood samples. Pediatr Allergy Immunol 2015; 26:344-51. [PMID: 25858482 PMCID: PMC9271931 DOI: 10.1111/pai.12387] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [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] [Accepted: 03/31/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Maternal obesity is one of the several key factors thought to modulate neonatal immune system development. Data from murine studies demonstrate worse outcomes in models of infection, autoimmunity, and allergic sensitization in offspring of obese dams. In humans, children born to obese mothers are at increased risk for asthma. These findings suggest a dysregulation of immune function in the children of obese mothers; however, the underlying mechanisms remain poorly understood. The aim of this study was to examine the relationship between maternal body weight and the human neonatal immune system. METHODS Umbilical cord blood samples were collected from infants born to lean, overweight, and obese mothers. Frequency and function of major innate and adaptive immune cell populations were quantified using flow cytometry and multiplex analysis of circulating factors. RESULTS Compared to babies born to lean mothers, babies of obese mothers had fewer eosinophils and CD4 T helper cells, reduced monocyte and dendritic cell responses to Toll-like receptor ligands, and increased plasma levels of IFN-α2 and IL-6 in cord blood. CONCLUSION These results support the hypothesis that maternal obesity influences programming of the neonatal immune system, providing a potential link to increased incidence of chronic inflammatory diseases such as asthma and cardiovascular disease in the offspring.
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Affiliation(s)
- Randall M Wilson
- Graduate program in Cel, Molecular and Developmental Biology, University of California, Riverside, CA, USA
| | - Nicole E Marshall
- Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Daniel R Jeske
- Department of Statistics, University of California, Riverside, CA, USA
| | - Jonathan Q Purnell
- Department of Medicine, The Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Kent Thornburg
- Department of Medicine, The Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Ilhem Messaoudi
- Graduate program in Cel, Molecular and Developmental Biology, University of California, Riverside, CA, USA.,Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, USA
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Marshall NE, Vanderhoeven J, Eden KB, Segel SY, Guise JM. Impact of simulation and team training on postpartum hemorrhage management in non-academic centers. J Matern Fetal Neonatal Med 2014; 28:495-9. [PMID: 24824110 DOI: 10.3109/14767058.2014.923393] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [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: 11/13/2022]
Abstract
OBJECTIVE Prompt recognition and response to postpartum hemorrhage (PPH) are vital in preventing maternal morbidity and mortality. We conducted a multi-center study to evaluate in situ simulation and team training for PPH among experienced clinical teams in non-academic hospitals in urban and rural communities. METHODS A longitudinal intervention study was performed in six Oregon community hospitals. All teams responded to an in situ simulated delivery and postpartum hemorrhage using trained actors and an obstetric birthing simulator, followed by a debriefing and training session. The simulation scenario was then repeated in 9-12 months. All sessions were digitally video recorded and independently reviewed by two obstetricians using a structured evaluation form. PPH management including clinical response times were compared before and after team training using Student's paired t-test and McNemar's test. RESULTS Twenty-two teams completed paired case simulations. Team training significantly improved response times in the management of PPH, including the recognition of PPH, time to administer first medication, performance of uterine massage and time to administer second medication. Medical management (use of three indicated medications) improved after training from 27.3% to 63.6%, p = 0.01. CONCLUSIONS Simulation and team training significantly improved postpartum hemorrhage response times among clinically experienced community labor and delivery teams.
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Abstract
OBJECTIVE To determine the effect of increasing maternal obesity, including superobesity (body mass index [BMI] ≥ 50 kg/m2), on perinatal outcomes in women with diabetes. STUDY DESIGN Retrospective cohort study of birth records for all live-born nonanomalous singleton infants ≥ 37 weeks' gestation born to Missouri residents with diabetes from 2000 to 2006. Women with either pregestational or gestational diabetes were included. RESULTS There were 14,595 births to women with diabetes meeting study criteria, including 7,082 women with a BMI > 30 kg/m2 (48.5%). Compared with normal-weight women with diabetes, increasing BMI category, especially superobesity, was associated with a significantly increased risk for preeclampsia (adjusted relative risk [aRR] 3.6, 95% confidence interval [CI] 2.5, 5.2) and macrosomia (aRR 3.0, 95% CI 1.8, 5.40). The majority of nulliparous obese women with diabetes delivered via cesarean including 50.5% of obese, 61.4% of morbidly obese, and 69.8% of superobese women. The incidence of primary elective cesarean among nulliparous women with diabetes increased significantly with increasing maternal BMI with over 33% of morbidly obese and 39% of superobese women with diabetes delivering electively by cesarean. CONCLUSION Increasing maternal obesity in women with diabetes is significantly associated with higher risks of perinatal complications, especially cesarean delivery.
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Affiliation(s)
- Nicole E. Marshall
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Camelia Guild
- Department of Pediatrics, Saint Louis University, St. Louis, Missouri
| | - Yvonne W. Cheng
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Donna R. Halloran
- Department of Pediatrics, Saint Louis University, St. Louis, Missouri
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Abstract
OBJECTIVE To estimate the effect of race on perinatal outcomes in obese women. METHODS Retrospective cohort study of birth records linked to hospital discharge data for all live born singleton infants ≥37 weeks gestation born to African-American or Caucasian Missouri residents from 2000 to 2006. We excluded major congenital anomalies and women with diabetes or chronic hypertension. Obesity was defined as pre-pregnancy body mass index ≥30 kg/m(2). RESULTS There were 312 412 births meeting study criteria. 27.1% (11 776) of African-American mothers and 19.1% (49 415) of Caucasian mothers were obese. There were no differences in cesarean delivery or preeclampsia between obese African-American and obese Caucasian women. Infants of obese African-American women were significantly less likely to be macrosomic (0.9% vs. 2.2%, adjusted odds ratio [aOR] 0.5, 95% confidence interval [CI] 0.4 0.6) and more likely to be low birth weight (3.4% vs. 1.8%, aOR 1.9, 95% CI 1.7, 2.2) compared to infants of obese Caucasian women. Compared to their normal weight peers, obese Caucasian women had a greater relative risk of developing preeclampsia (aOR 3.1, 95% CI 2.9, 3.2) than obese African-American women (aOR 2.1, 95% CI 1.9, 2.4). CONCLUSION Racial disparities impact obesity-related maternal and neonatal complications of pregnancy.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics & Gynecology, Oregon Health & Science University , Portland, OR
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Halloran DR, Marshall NE, Kunovich RM, Caughey AB. Obesity trends and perinatal outcomes in black and white teenagers. Am J Obstet Gynecol 2012; 207:492.e1-7. [PMID: 23174388 PMCID: PMC3569854 DOI: 10.1016/j.ajog.2012.09.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/23/2012] [Accepted: 09/21/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Our objective was to explore the trends in prepregnancy body mass index (BMI) for black and white teenagers over time and the association between elevated BMI and outcomes based on race. STUDY DESIGN This was a retrospective cohort study of singleton infants (n = 38,158) born to black (34%) and white (66%) teenagers (<18 years of age). We determined the prevalence of elevated prepregnancy BMI between 1993 and 2006 and the association between elevated prepregnancy BMI (primary exposure) and maternal and perinatal outcomes based on race (2000-2006). RESULTS The percentage of white teenagers with elevated prepregnancy BMI increased significantly from 17-26%. White and black overweight and obese teenagers were more likely to have pregnancy-related hypertension than normal-weight teenagers; postpartum hemorrhage was increased only in obese black teenagers, and infant complications were increased only in overweight and obese white teenagers. CONCLUSION Because the percentage of elevated prepregnancy BMI has increased in white teenagers, specific risks for poor maternal and perinatal outcomes in the overweight and obese teenagers varies by race.
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Affiliation(s)
- Donna R Halloran
- Department of Pediatrics, Saint Louis University, St. Louis, MO, USA.
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Abstract
Obesity is an increasingly common complication of pregnancy with over half of all women in the United States starting pregnancy overweight or obese. Obese women face unique physiological changes during pregnancy, and these women and their neonates are at increased risk for perinatal morbidity and mortality. In this review, we discuss physiological alterations in obese pregnant women and examine obesity-related antepartum, intrapartum, and postpartum complications along with management options.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Marshall NE, Guild C, Cheng YW, Caughey AB, Halloran DR. Maternal superobesity and perinatal outcomes. Am J Obstet Gynecol 2012; 206:417.e1-6. [PMID: 22542116 DOI: 10.1016/j.ajog.2012.02.037] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [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: 10/31/2011] [Revised: 01/17/2012] [Accepted: 02/29/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effect of maternal superobesity (body mass index [BMI], ≥ 50 kg/m(2)) compared with morbid obesity (BMI, 40-49.9 kg/m(2)) or obesity (BMI, 30-39.9 kg/m(2)) on perinatal outcomes. STUDY DESIGN We conducted a retrospective cohort study of birth records that were linked to hospital discharge data for all liveborn singleton term infants who were born to obese Missouri residents from 2000-2006. We excluded major congenital anomalies and women with diabetes mellitus or chronic hypertension. RESULTS There were 64,272 births that met the study criteria, which included 1185 superobese mothers (1.8%). Superobese women were significantly more likely than obese women to have preeclampsia (adjusted relative risk [aRR], 1.7; 95% confidence interval [CI], 1.4-2.1), macrosomia (aRR, 1.8; 95% CI, 1.3-2.5), and cesarean delivery (aRR, 1.8; 95% CI, 1.5-2.1). Almost one-half of all superobese women (49.1%) delivered by cesarean section, and 33.8% of superobese nulliparous women underwent scheduled primary cesarean delivery. CONCLUSION Women with a BMI of ≥ 50 kg/m(2) are at significantly increased risk for perinatal complications compared with obese women with a lower BMI.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA.
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Marshall NE, Guild C, Cheng YW, Caughey AB, Halloran DR. 308: Impact of maternal BMI on induction of labor. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.326] [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: 10/14/2022]
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Hallaron DR, Marshall NE, Cheng YW, Caughey AB. 551: Induction trends for late preterm infants across maternal pre-pregnancy BMI. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.569] [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: 10/14/2022]
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Marshall NE, Fraley G, Feist C, Burns MJ, Pereira L. Chorionic villus sampling for abnormal screening compared to historical indications: prevalence of abnormal karyotypes. J Matern Fetal Neonatal Med 2011; 25:1463-6. [PMID: 22098166 DOI: 10.3109/14767058.2011.640727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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 prevalence of abnormal karyotype results in women undergoing chorionic villus sampling (CVS) for abnormal first trimester screening compared to CVS for historical indications (advanced maternal age (AMA) or prior aneuploidy). METHODS Retrospective cohort of all patients undergoing CVS at Oregon Health & Science University from January 2006 to June 2010. Patients were separated based on CVS indication: (1) positive ultrasound (U/S) or serum screening; or (2) AMA or prior aneuploidy with normal or no screening. Prevalence of abnormal karyotype results were compared between groups. RESULTS Fetal karyotyping was successful in 500 of 506 CVS procedures performed. 203 CVS were performed for positive screening with 69 abnormal karyotypes (34.0%). 264 CVS were performed for historical indications with 11 abnormal karyotypes (4.2%). This difference was statistically significant (χ(2) 71.9, p < 0.001; OR 11.8 [95% CI 5.8, 24.6]). There were two age-related aneuplodies in AMA women without positive screening. 42 out of 44 AMA women diagnosed with aneuploidy (95.5%) had abnormal U/S and/or serum screening (35 U/S, 4 serum, 3 U/S and serum). CONCLUSIONS Combined ultrasound and serum screening should be recommended to all women, including AMA women, prior to undergoing invasive testing to improve risk-based counseling and minimize morbidity.
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Affiliation(s)
- Nicole E Marshall
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011; 205:262.e1-8. [PMID: 22071057 DOI: 10.1016/j.ajog.2011.06.035] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 05/02/2011] [Accepted: 06/08/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the impact of increasing numbers of cesarean deliveries on maternal morbidity. This study was performed for the 2010 National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean: New Insights. STUDY DESIGN We conducted a systematic review and metaanalysis of observational studies. RESULTS Twenty-one studies (2,282,922 deliveries) were included. The rate of hysterectomy, blood transfusions, adhesions, and surgical injury all increased with increasing number of cesarean deliveries. The incidence of placenta previa increased from 10/1000 deliveries with 1 previous cesarean delivery to 28/1000 with ≥3 cesarean deliveries. Compared with women with previa and no previous cesarean delivery, women with previa and ≥3 cesarean deliveries had a statistically significant increased risk of accreta (3.3-4% vs 50-67%), hysterectomy (0.7-4% vs 50-67%), and composite maternal morbidity (15% vs 83%; odds ratio, 33.6; 95% confidence interval, 14.6-77.4). CONCLUSION Serious maternal morbidity progressively increased as the number of previous cesarean deliveries increased.
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Marshall NE, Ballman KV, Michalak JC, Schomberg PJ, Burton GV, Sandler HM, Cascino TL, Jaeckle KA, Buckner JC. Ototoxicity of cisplatin plus standard radiation therapy vs. accelerated radiation therapy in glioblastoma patients. J Neurooncol 2005; 77:315-20. [PMID: 16273313 DOI: 10.1007/s11060-005-9049-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [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] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess the effect of cisplatin (CDDP) plus concurrent radiation therapy on hearing loss. METHODS 451 patients with glioblastoma multiforme (GBM) were randomly assigned after surgery to: Arm A: Carmustine (BCNU) + standard radiation therapy (SRT); Arm B: BCNU + accelerated radiation therapy (ART: 160 cGy twice daily for 15 days); Arm C: CDDP + BCNU + SRT; or Arm D: CDDP + BCNU + ART. Patients on arms C and D received audiograms at baseline, and prior to the start of RT, and prior to cycles 3 and 6. Otologic toxicities were recorded at each visit. RESULTS 56% of patients had hearing loss at baseline. 13% and 50% of patients experienced worsening ototoxicity after 1 year of treatment in arms A and B vs. C and D, respectively, with 13% of those on arms C and D experiencing significant ototoxicity (>or= grade 3) at 6 months. Increasing age was associated with an increased risk of ototoxicity. CONCLUSIONS Increased exposure to CDDP increases the risk of ototoxicity over time. Older patients are more susceptible to hearing loss with CDDP. The low proportion of patients with clinically significant ototoxicity suggests that baseline screening is unnecessary in GBM patients.
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Maye J, Marshall NE. Penetrating mine injury to the heart with a pericardial tamponade. CRNA 1996; 7:25-8. [PMID: 8680352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Cardiac tamponade is a life-threatening emergency. Immediate recognition and surgical intervention is essential to preserve myocardial function and maintain cardiac output. The following is a case report of a penetrating mine injury to the heart with a resulting pericardial tamponade. The positive outcome and the facilities in which the resuscitation and surgical repair occurred make this a unique case report.
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