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Finkelstein JL, Fothergill A, Venkatramanan S, Layden AJ, Williams JL, Crider KS, Qi YP. Vitamin B12 supplementation during pregnancy for maternal and child health outcomes. Cochrane Database Syst Rev 2024; 1:CD013823. [PMID: 38189492 PMCID: PMC10772977 DOI: 10.1002/14651858.cd013823.pub2] [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: 01/09/2024]
Abstract
BACKGROUND Vitamin B12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B12 supplementation during pregnancy may confer longer-term benefits to maternal and child health outcomes. OBJECTIVES To evaluate the benefits and harms of oral vitamin B12 supplementation during pregnancy on maternal and child health outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) on 2 June 2023, and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs, or cluster-RCTs evaluating the effects of oral vitamin B12 supplementation compared to placebo or no vitamin B12 supplementation during pregnancy. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes. MAIN RESULTS The review included five trials with 984 pregnant women. All trials were conducted in low- and middle-income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta-analyses of the effects of vitamin B12 supplementation compared to placebo or no vitamin B12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low-certainty evidence). Maternal vitamin B12 status: vitamin B12 supplementation during pregnancy may reduce the risk of maternal vitamin B12 deficiency compared to placebo or no vitamin B12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low-certainty evidence). Women who received vitamin B12 supplements during pregnancy may have higher total vitamin B12 concentrations compared to placebo or no vitamin B12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low-certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low-certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta-analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B12 supplementation during pregnancy on neural tube defects. Infant vitamin B12 status: children born to women who received vitamin B12 supplementation had higher total vitamin B12 concentrations compared to placebo or no vitamin B12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes: three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta-analyses. In one study, maternal vitamin B12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social-emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID-III); 1 trial; low-certainty evidence) or neurophysiological outcomes (72 months, event-related potential measures; 1 trial; low-certainty evidence), though children born to women who received vitamin B12 supplementation had improved expressive language domain compared to placebo (30 months, BSID-III; 1 trial; low-certainty evidence). AUTHORS' CONCLUSIONS Oral vitamin B12 supplementation during pregnancy may reduce the risk of maternal vitamin B12 deficiency and may improve maternal vitamin B12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B12 supplementation, but the evidence is very uncertain. The effects of vitamin B12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B12 supplementation during pregnancy may improve maternal and infant vitamin B12 status, but the potential impact on longer-term clinical and functional maternal and child health outcomes has not yet been established.
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Affiliation(s)
| | - Amy Fothergill
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Alexander J Layden
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer L Williams
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Krista S Crider
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yan Ping Qi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Layden AJ, Bertolet M, Parks WT, Adibi JJ, Roberts JM, Catov JM. Prepregnancy obesity and risk of placental inflammation at term: a selection bias analysis. Ann Epidemiol 2023; 86:25-33.e7. [PMID: 37302673 PMCID: PMC10546767 DOI: 10.1016/j.annepidem.2023.06.003] [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: 12/30/2022] [Revised: 05/20/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE Placental histopathology is a resource for investigating obesity-associated pregnancy conditions. However, studies oversample adverse pregnancies, biasing findings. We examine the association between prepregnancy obesity (risk factor for inflammation) and histologic placental inflammation (correlated with impaired infant neurodevelopment) and how selection bias may influence the association. METHODS Singleton term deliveries between 2008 and 2012 from the Magee Obstetric Maternal and Infant database were analyzed. Prepregnancy body mass index (BMI) was categorized as underweight, lean (referent), overweight, and obese. Outcomes were diagnoses of acute (acute chorioamnionitis and fetal inflammation) and chronic placental inflammation (chronic villitis). Risk ratios for associations between BMI and placental inflammation were estimated using selection bias approaches: complete case, exclusion of pregnancy complications, multiple imputation, and inverse probability weighting. E-values approximated how susceptible estimates were to residual selection bias. RESULTS Across methods, obesity was associated with an 8-15% lower risk of acute chorioamnionitis, a 7%-14% lower risk of acute fetal inflammation, and a 12%-30% higher risk of chronic villitis relative to lean women. E-values indicated modest residual selection bias could explain away associations, though few measured indications of placental evaluations met this threshold. CONCLUSIONS Obesity may contribute to placental inflammation, and we highlight robust methods to analyze clinical data susceptible to selection bias.
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Affiliation(s)
| | - Marnie Bertolet
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA; Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, PA
| | - W Tony Parks
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, CA
| | - Jennifer J Adibi
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - James M Roberts
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA; Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA
| | - Janet M Catov
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA
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Williams IM, Albertolle ME, Layden AJ, Tao SY, Fisher SJ, Gandley RE, Roberts JM. Lipidomics Reveals Elevated Plasmalogens in Women with Obesity Who Develop Preeclampsia. J Clin Med 2023; 12:jcm12082970. [PMID: 37109308 PMCID: PMC10147017 DOI: 10.3390/jcm12082970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Objective: Preeclampsia (PE) is a prevalent pregnancy disorder worldwide with limited preventative treatments available. Obesity triples the risk for PE, yet only 10% of women with obesity develop PE. The factors that distinguish PE from uncomplicated pregnancies in the context of obesity have not been fully established. Methods: We studied a cohort of women with obesity throughout pregnancy to identify lipid mediators and/or biomarkers of PE. Blood samples were collected at each trimester and analyzed by both targeted lipidomics and standard lipid panels. Individual lipid species were compared by PE status at each trimester, as well as by self-identified race (Black vs. White) and fetal sex. Results: Standard lipid panels and clinical measurements revealed few differences between PE and uncomplicated pregnancies. Targeted lipidomics, however, identified plasmalogen, phosphatidylethanolamine, and free fatty acid species that were elevated in the third trimester of women with PE. Furthermore, race and trimester of pregnancy were considerable sources of plasma lipidomic variation in women with obesity. Conclusions: First and second trimester individual plasma lipid species do not predict the development of PE in obese women. In the third trimester, PE patients have elevated levels of plasmalogens-a class of lipoprotein-associated phospholipids that have been implicated in the response to oxidative stress.
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Affiliation(s)
- Ian M Williams
- Lipid Nanoparticle Platform Department, Takeda Development Center Americas, San Diego, CA 92121, USA
| | - Matthew E Albertolle
- Drug Metabolism and Pharmacokinetics Department, Takeda Development Center Americas, San Diego, CA 92121, USA
| | - Alexander J Layden
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261, USA
| | - Sunny Y Tao
- University of Pittsburgh Medical Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Susan J Fisher
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| | | | - James M Roberts
- Magee-Womens Research Institute, Pittsburgh, PA 15213, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Weill SR, Layden AJ, Nabozny MJ, Leahy J, Claxton R, Zelenski AB, Zimmermann C, Childers J, Arnold R, Hall DE. Applying VitalTalk TM Techniques to Best Case/Worst Case Training to Increase Scalability and Improve Surgeon Confidence in Shared Decision-making. J Surg Educ 2022; 79:983-992. [PMID: 35246401 DOI: 10.1016/j.jsurg.2022.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Best Case/Worst Case (BC/WC) is a communication tool designed to promote shared decision-making for high-risk procedures near the end of life. This study aimed to increase scalability of a BC/WC training program and measure its impact on surgeon confidence in and perceived importance of the methodology. DESIGN A prospective cohort pre-post study; December 2018 to January 2019. SETTING Multi-center tertiary care teaching hospital. PARTICIPANTS Forty-eight resident surgeons from general surgery and otolaryngology. RESULTS Learners were 24 to 37 years old with 52% in post graduate year 1 to 2. Although learners encountered high-stakes communication (HSC) frequently (3.6 [0.7] on 5-point Likert scale), most reported no HSC training in medical school (74.5%) or residency (87.5%). BC/WC training was accomplished with an instructor to learner ratio of 1-to-5.3. After training, learner confidence improved on all measured communication skills on a 5-point scale (e.g., exploring patient's values increased from 3.6 [0.8] to 4.1 [0.6], p = <0.0001); average within-person improvement was 0.72 (0.6) points across all skills. Perceived importance improved across all skills (e.g., basing a recommendation on patient's values increased from 4.4 [0.8] to 4.8 [0.5], p = 0.0009); average within-person improvement was 0.46 (0.5) points across all skills. Learners reported this training would likely help them in future interactions (4.4 [0.73] on 5-point scale) and 95.2% recommended it be offered to resident physicians in other residency programs and to attending surgeons. CONCLUSIONS Formal training in BC/WC increases learners' perception of both the importance of HSC skills and their confidence in exercising those skills in clinical practice. VitalTalkTM methodology permitted scaling training to 5.3 learners per instructor and was highly recommended for other surgeons. Ongoing training, such as this, may support more patient-centered decision-making and care.
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Affiliation(s)
- Sydney R Weill
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Alexander J Layden
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Janet Leahy
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Rene Claxton
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Amy B Zelenski
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Julie Childers
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania; The Wolff Center at UPMC, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Layden AJ, Bertolet M, Parks WT, Roberts JM, Adibi JJ, Catov JM. Latent class analysis of placental histopathology: a novel approach to classifying early and late preterm births. Am J Obstet Gynecol 2022; 227:290.e1-290.e21. [PMID: 35288092 PMCID: PMC9308632 DOI: 10.1016/j.ajog.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/25/2022] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Neonatal morbidity attributable to prematurity predominantly occurs among early preterm births (<32 weeks) rather than late preterm births (32 to <37 weeks). Methods to distinguish early and late preterm births are lacking given the heterogeneity in pathophysiology and risk factors, including maternal obesity. Although preterm births are often characterized by clinical presentation (spontaneous or clinically indicated), classifying deliveries by placental features detected on histopathology reports may help identify subgroups of preterm births with similar etiology and risk factors. Latent class analysis is an empirical approach to characterize preterm births on the basis of observed combinations of placental features. OBJECTIVE To identify histopathologic markers that can distinguish early (<32 weeks) and late preterm births (32 to <37 weeks) that are also associated with maternal obesity and neonatal outcomes. STUDY DESIGN Women with a singleton preterm birth at University of Pittsburgh Medical Center Magee-Womens Hospital (Pittsburgh, PA) from 2008 to 2012 and a placental evaluation (89% of preterm births) were stratified into early (n=900, 61% spontaneous) and late preterm births (n=3362, 57% spontaneous). Prepregnancy body mass index was self-reported at first prenatal visit and 16 abstracted placental features were analyzed. Placental subgroups (ie, latent classes) of early and late preterm births were determined separately by latent class analysis of placental features. The optimal number of latent classes was selected by comparing fit statistics. The probability of latent class membership across prepregnancy body mass indexes was estimated in early preterm births and in late preterm births by an extension of multinomial regression called pseudo-class regression, adjusting for race, smoking, education, and parity. The frequencies of severe neonatal morbidity (composite outcome: respiratory distress, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia, patent ductus arteriosus, and retinopathy of prematurity), small-for-gestational-age, and length of neonatal intensive care unit stay were compared across latent classes by chi-square and Kruskal-Wallis tests. RESULTS Early preterm births were grouped into 4 latent classes based on placental histopathologic features: acute inflammation (38% of cases), maternal vascular malperfusion with inflammation (29%), maternal vascular malperfusion (25%), and fetal vascular thrombosis with hemorrhage (8%). As body mass index increased from 20 to 50kg/m2, the probability of maternal vascular malperfusion and fetal vascular thrombosis with hemorrhage increased, whereas the probability of maternal vascular malperfusion with inflammation decreased. There was minimal change in the probability of acute inflammation with increasing body mass index. Late preterm births also had 4 latent classes: maternal vascular malperfusion (22%), acute inflammation (12%), fetal vascular thrombosis with hemorrhage (9%), and low-risk pathology (58%). Body mass index was not associated with major changes in likelihood of the latent classes in late preterm births. Associations between body mass index and likelihood of the latent classes were not modified by type of delivery (spontaneous or indicated) in early or late preterm births. Maternal malperfusion and fetal vascular thrombosis with hemorrhage were associated with greater neonatal morbidity than the other latent classes in early and late preterm births. CONCLUSION Obesity may predispose women to early but not late preterm birth through placental vascular impairment. Latent class analysis of placental histopathologic data provides an evidence-based approach to group preterm births with shared underlying etiology and risk factors.
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Xun X, Qin X, Layden AJ, Yin Q, Swan SH, Barrett ES, Bush NR, Sathyanarayana S, Adibi JJ. Application of 4-way decomposition to the analysis of placental-fetal biomarkers as intermediary variables between maternal body mass index and birthweight. Front Reprod Health 2022; 4:994436. [PMID: 36545491 PMCID: PMC9760955 DOI: 10.3389/frph.2022.994436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
Human chorionic gonadotropin (hCG) is a placental hormone measured in pregnancy to predict individual level risk of fetal aneuploidy and other complications; yet may be useful in understanding placental origins of child development more generally. hCG was associated with maternal body mass index (BMI) and with birthweight. The primary aim here was to evaluate hCG as a mediator of maternal BMI effects on birthweight by causal mediation analysis. Subjects were 356 women from 3 U.S. sites (2010-2013). The 4-way decomposition method using med4way (STATA) was applied to screen for 5 types of effects of first trimester maternal BMI on birthweight: the total effect, the direct effect, mediation by hCG, additive interaction of BMI and hCG, and mediation in the presence of an additive interaction. Effect modification by fetal sex was evaluated, and a sensitivity analysis was performed to evaluate the assumption of unmeasured confounding. Additional placental-fetal biomarkers [pregnancy associated plasma protein A (PAPPA), second trimester hCG, inhibin-A, estriol, alpha fetoprotein] were analyzed for comparison. For first trimester hCG, there was a 0.20 standard deviation increase in birthweight at the 75th vs. 25th percentile of maternal BMI (95% CI 0.04, 0.36). Once stratified, the direct effect association was null in women carrying females. In women carrying males, hCG did not mediate the relationship. In women carrying females, there was a mediated effect of maternal BMI on birthweight by hCG in the reverse direction (-0.06, 95% CI: -0.12, 0.01), and a mediated interaction in the positive direction (0.06, 95% CI 0.00, 0.13). In women carrying males, the maternal BMI effect on birthweight was reverse mediated by PAPPA (-0.09, 95% CI: -0.17, 0.00). Sex-specific mediation was mostly present in the first trimester. Second trimester AFP was a positive mediator of maternal BMI effects in male infants only (0.06, 95% CI: -0.01, 0.13). Effect estimates were robust to potential bias due to unmeasured confounders. These findings motivate research to consider first trimester placental biomarkers and sex-specific mechanisms when quantifying the effects of maternal adiposity on fetal growth.
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Affiliation(s)
- Xiaoshuang Xun
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Xu Qin
- Department of Health and Human Development, School of Education, University of Pittsburgh, Pittsburgh, PA, United States
| | - Alexander J Layden
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Qing Yin
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shanna H Swan
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Emily S Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ, United States
| | - Nicole R Bush
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, United States
| | | | - Jennifer J Adibi
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
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Adibi JJ, Layden AJ, Birru RL, Miragaia A, Xun X, Smith MC, Yin Q, Millenson ME, O’Connor TG, Barrett ES, Snyder NW, Peddada S, Mitchell RT. First trimester mechanisms of gestational sac placental and foetal teratogenicity: a framework for birth cohort studies. Hum Reprod Update 2021; 27:747-770. [PMID: 33675653 PMCID: PMC8222765 DOI: 10.1093/humupd/dmaa063] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 09/18/2020] [Revised: 12/18/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The function of the gestational sac (GS) and the placenta in the closely related processes of embryogenesis and teratogenicity in the first trimester has been minimally described. The prevailing assumption is that direct teratogenic effects are mediated by the critical extraembryonic organ, the placenta, which either blocks or transfers exposures to the foetus. Placental transfer is a dominant mechanism, but there are other paradigms by which the placenta can mediate teratogenic effects. Knowledge of these paradigms and first trimester human developmental biology can be useful to the epidemiologist in the conduct of biomarker-based studies of both maternal and child health. OBJECTIVE AND RATIONALE Our aim is to provide a causal framework for modelling the teratogenic effects of first trimester exposures on child health outcomes mediated by the GS and placenta using biomarker data collected in the first trimester. We initially present first trimester human developmental biology for the sake of informing and strengthening epidemiologic approaches. We then propose analytic approaches of modelling placental mechanisms by way of causal diagrams using classical non-embryolethal teratogens (diethylstilboestrol [DES], folic acid deficiency and cytomegalovirus [CMV]) as illustrative examples. We extend this framework to two chronic exposures of particular current interest, phthalates and maternal adiposity. SEARCH METHODS Information on teratogens was identified by a non-systematic, narrative review. For each teratogen, we included papers that answered the five following questions: (i) why were these exposures declared teratogens? (ii) is there a consensus on biologic mechanism? (iii) is there reported evidence of a placental mechanism? (iv) can we construct a theoretical model of a placental mechanism? and (v) can this knowledge inform future work on measurement and modelling of placental-foetal teratogenesis? We prioritized literature specific to human development, the organogenesis window in the first trimester and non-embryolethal mechanisms. OUTCOMES As a result of our review of the literature on five exposures considered harmful in the first trimester, we developed four analytic strategies to address first trimester placental mechanisms in birth cohort studies: placental transfer and direct effects on the foetus (DES and maternal adiposity), indirect effects through targeted placental molecular pathways (DES and phthalates), pre-placental effects through disruptions in embryonic and extraembryonic tissue layer differentiation (folic acid deficiency), and multi-step mechanisms that involve maternal, placental and foetal immune function and inflammation (DES and CMV). WIDER IMPLICATIONS The significance of this review is to offer a causal approach to classify the large number of potentially harmful exposures in pregnancy when the exposure occurs in the first trimester. Our review will facilitate future research by advancing knowledge of the first trimester mechanisms necessary for researchers to effectively associate environmental exposures with child health outcomes.
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Affiliation(s)
- Jennifer J Adibi
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexander J Layden
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahel L Birru
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandra Miragaia
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xiaoshuang Xun
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Megan C Smith
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Qing Yin
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Thomas G O’Connor
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, USA
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, USA
| | - Emily S Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Nathaniel W Snyder
- Department of Microbiology and Immunology, Center for Metabolic Disease Research, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Shyamal Peddada
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rod T Mitchell
- MRC Centre for Reproductive Health, The University of Edinburgh, Queens Medical Research Institute, Edinburgh, UK
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Medina‐Rivera M, Centeno‐Tablante E, Finkelstein JL, Rayco‐Solon P, Peña‐Rosas JP, Garcia‐Casal MN, Rogers L, Ridwan P, Martinez SS, Andrade J, Layden AJ, Chang J, Zambrano MP, Ghezzi‐Kopel K, Mehta S. Presence of Ebola virus in breast milk and risk of mother-to-child transmission: synthesis of evidence. Ann N Y Acad Sci 2021; 1488:33-43. [PMID: 33113592 PMCID: PMC8048832 DOI: 10.1111/nyas.14519] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/16/2020] [Accepted: 10/08/2020] [Indexed: 12/28/2022]
Abstract
To help inform global guidelines on infant feeding, this systematic review synthesizes evidence related to the presence of the Ebola virus (EBOV) in breast milk and its potential risk of viral transmission to the infant when breastfeeding. We relied on a comprehensive search strategy to identify studies including women with suspected, probable, or confirmed EBOV infection, intending to breastfeed or give breast milk to an infant. Our search identified 10,454 records, and after deduplication and screening, we assessed 148 full texts. We included eight studies reporting on 10 breastfeeding mothers and their children (one mother with twins), who provided breast milk samples for assessment. EBOV was detected via RT-PCR or viral culture in seven out of ten breast milk samples. Four out of the five-breastfed infants with EBOV-positive breast milk were found positive for EBOV infection, and all of these EBOV-positive infants died. Since previous reports have detected EBOV in tears, saliva, sweat, and contaminated surfaces, with the current evidence, it is not possible to conclude with certainty that breast milk was the main route of EBOV transmission.
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Affiliation(s)
| | | | | | - Pura Rayco‐Solon
- Department of Maternal, Newborn, Child and Adolescent Health and AgeingWorld Health OrganizationGenevaSwitzerland
| | | | | | - Lisa Rogers
- Department of Nutrition and Food SafetyWorld Health OrganizationGenevaSwitzerland
| | - Pratiwi Ridwan
- Division of Nutritional SciencesCornell UniversityIthacaNew York
| | - Sabrina Sales Martinez
- Department of Dietetics and Nutrition, Robert Stempel College of Public Health and Social WorkFlorida International UniversityMiamiFlorida
| | - Joyce Andrade
- Hospital de Niños Roberto Gilbert ElizaldeGuayaquilEcuador
| | | | - Juan Chang
- Hospital de Niños Roberto Gilbert ElizaldeGuayaquilEcuador
| | | | | | - Saurabh Mehta
- Division of Nutritional SciencesCornell UniversityIthacaNew York
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9
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Adibi JJ, Layden AJ, Yin Q, Xun X, Peddada S, Birru RL. A toolkit for the application of placental-fetal molecular biomarkers in epidemiologic studies of the fetal origins of chronic disease. CURR EPIDEMIOL REP 2020; 8:20-31. [PMID: 33777648 DOI: 10.1007/s40471-020-00258-x] [Citation(s) in RCA: 5] [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: 12/19/2022]
Abstract
Purpose of review In this review, we provide essential background knowledge and an analytical framework for the application of placental-fetal molecular biomarkers in fetal origins chronic disease epidemiology. The widely available and highly quantitative placental hormone human chorionic gonadotropin (hCG) is used as an example. hCG is currently used for diagnosing fetal genetic disorders; yet it can and should be expanded to understanding the fetal origins of chronic diseases. We provide justification and methods to do this. Recent findings Ten papers published in the last 5 years were identified with supportive findings relevant to the application of biomarkers of hCG in epidemiologic studies on the developmental origins of health and disease (DOHaD). Summary There is increasing and consistent evidence that placental-fetal biomarkers may be highly informative in observational studies, as exemplified by hCG, with the correct approaches for measurement and data analysis.
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Affiliation(s)
- Jennifer J Adibi
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health
| | - Alexander J Layden
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health
| | - Qing Yin
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health
| | - Xiaoshuang Xun
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health
| | - Shyamal Peddada
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health
| | - Rahel L Birru
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health
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10
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Finkelstein JL, Colt S, Layden AJ, Krisher JT, Stewart-Ibarra AM, Polhemus M, Beltrán-Ayala E, Tedesco JM, Cárdenas WB, Endy T, Mehta S. Micronutrients, Immunological Parameters, and Dengue Virus Infection in Coastal Ecuador: A Nested Case-Control Study in an Infectious Disease Surveillance Program. J Infect Dis 2020; 221:91-101. [PMID: 31428794 DOI: 10.1093/infdis/jiz427] [Citation(s) in RCA: 5] [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] [Received: 05/10/2019] [Accepted: 08/16/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Micronutrients are known to modulate host immunity, and there is limited literature on this association in the context of dengue virus infection (DENV). METHODS Using a nested case-control design in a surveillance program, we measured the following: anthropometry; nutritional biomarkers including serum ferritin, soluble transferrin receptor, retinol-binding protein (RBP), 25-hydroxy vitamin D, folate, and vitamin B12; and a panel of immune response markers. We then compared these measures across 4 illness categories: healthy control, nonfebrile DENV, other febrile illness (OFI), and apparent DENV using multivariate polytomous logistic regression models. RESULTS Among 142 participants, serum ferritin (ng/mL) was associated with apparent DENV compared to healthy controls (odds ratio [OR], 2.66; confidence interval [CI], 1.53-4.62; P = .001), and RBP concentrations (µmol/L) were associated with apparent DENV (OR, 0.03; CI, 0.00-0.30; P = .003) and OFI (OR, 0.02; CI, 0.00-0.24; P = .003). In a subset of 71 participants, interleukin-15 levels (median fluorescent intensity) were positively associated with apparent DENV (OR, 1.09; CI, 1.03-1.14; P = .001) and negatively associated with nonfebrile DENV (OR, 0.89; CI, 0.80-0.99; P = .03) compared to healthy controls. CONCLUSIONS After adjusting for the acute-phase response, serum ferritin and RBP concentrations were associated with apparent DENV and may represent biomarkers of clinical importance in the context of dengue illness.
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Affiliation(s)
| | - Susannah Colt
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Alexander J Layden
- Division of Nutritional Sciences, Cornell University, Ithaca, New York.,University of Pittsburgh School of Medicine, Pennyslvania
| | - Jesse T Krisher
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Anna M Stewart-Ibarra
- Department of Medicine and Center for Global Health and Translational Science, SUNY Upstate Medical University, Syracuse, New York
| | - Mark Polhemus
- Department of Medicine and Center for Global Health and Translational Science, SUNY Upstate Medical University, Syracuse, New York
| | - Efraín Beltrán-Ayala
- Ministry of Health, Machala, El Oro, Ecuador.,Department of Medicine, Technical University of Machala, El Oro, Ecuador
| | - Julia M Tedesco
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Washington B Cárdenas
- Escuela Superior Politécnica del Litoral, Laboratorio para Investigaciones Biomédicas, Guayaquil, Ecuador
| | - Timothy Endy
- Department of Medicine and Center for Global Health and Translational Science, SUNY Upstate Medical University, Syracuse, New York
| | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
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11
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Medina-Rivera M, Centeno-Tablante E, Finkelstein J, Peña-Rosas JP, Garcia-Casal MN, Rogers L, Ridwan P, Martinez SS, Andrade J, Layden AJ, Chang J, Zambrano MP, Ghezzi-Kopel K, Mehta S. Presence of Ebola Virus in Breast Milk and Its Risk of Transmission to Breastfeeding Infants: Synthesis of Evidence. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa054_108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
This study aimed to synthesize evidence related to the presence in and transmission of the Ebola virus (EBOV) through breast milk to help inform global guidelines on infant feeding.
Methods
We conducted a comprehensive systematic search in international and regional databases to identify original studies describing women with suspected or confirmed EBOV infection intending to breastfeed or give breast milk to an infant. Studies documenting any breastfeeding woman who has been vaccinated or is suspected or confirmed of viral infection at any time during or after pregnancy were identified. Records were independently screened by two authors and after duplicate records were removed, studies that met the inclusion criteria were selected for data extraction.
Results
From a total of 24,473 non-duplicate studies, we found six case reports that included seven breastfeeding mothers with suspected or confirmed EBOV infection and their eight children (one mother with twins). EBOV was detected via RT-PCR and/or by culture in five out of six breast milk samples that were collected from the mothers. Five out of the seven breastfed infants were found positive for EBOV infection and all of the identified cases led to death.
Conclusions
Ebola virus was detected in 5 out of 6 breast milk samples analyzed. Since the virus has also been detected in tears, saliva, and sweat, it is not possible to conclude with certainty that the transmission was through breast milk. Prospective studies are needed in order to define the safety of feeding infants with breast milk from mothers infected with EBOV.
Funding Sources
Department of Nutrition and Food Safety, WHO.
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Affiliation(s)
| | | | | | | | | | - Lisa Rogers
- Department of Nutrition and Food Safety, World Health Organization
| | | | | | | | | | - Juan Chang
- Hospital de Niños Roberto Gilbert Elizalde
| | | | | | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University
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12
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Layden AJ, Täse K, Finkelstein JL. Neglected tropical diseases and vitamin B12: a review of the current evidence. Trans R Soc Trop Med Hyg 2018; 112:423-435. [PMID: 30165408 DOI: 10.1093/trstmh/try078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/30/2018] [Indexed: 12/15/2022] Open
Abstract
Vitamin B12 deficiency is an urgent public health problem that disproportionately affects individuals in low- and middle-income settings, where the burden of neglected tropical diseases (NTDs) is also unacceptably high. Emerging evidence supports a potential role of micronutrients in modulating the risk and severity of NTDs. However, the role of vitamin B12 in NTD pathogenesis is unknown. This systematic review was conducted to evaluate the evidence on the role of vitamin B12 in the etiology of NTDs. Ten studies were included in this review: one study using an in vitro/animal model, eight observational human studies and one ancillary analysis conducted within an intervention trial. Most research to date has focused on vitamin B12 status and helminthic infections. One study examined the effects of vitamin B12 interventions in NTDs in animal and in vitro models. Few prospective studies have been conducted to date to examine the role of vitamin B12 in NTDs. The limited literature in this area constrains our ability to make specific recommendations. Larger prospective human studies are needed to elucidate the role of vitamin B12 in NTD risk and severity in order to inform interventions in at-risk populations.
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Affiliation(s)
| | - Kristos Täse
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY.,St. John's Research Institute, Bangalore, India
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13
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Layden AJ, O'Brien KO, Pressman EK, Kent TR, Finkelstein JL. Vitamin B
12
and Placental Expression of Transcobalamin in Pregnant Adolescents. FASEB J 2016. [DOI: 10.1096/fasebj.30.1_supplement.272.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Tera R. Kent
- Division of Nutritional SciencesCornell UniversityIthacaMA
| | - Julia L. Finkelstein
- Division of Nutritional SciencesCornell UniversityIthacaMA
- St. John's Research InstituteBangaloreIndia
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14
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Abstract
Vitamin B-12 deficiency (<148 pmol/L) is associated with adverse maternal and neonatal outcomes, including developmental anomalies, spontaneous abortions, preeclampsia, and low birth weight (<2500 g). The importance of adequate vitamin B-12 status periconceptionally and during pregnancy cannot be overemphasized, given its fundamental role in neural myelination, brain development, and growth. Infants born to vitamin B-12-deficient women may be at increased risk of neural tube closure defects, and maternal vitamin B-12 insufficiency (<200 pmol/L) can impair infant growth, psychomotor function, and brain development, which may be irreversible. However, the underlying causal mechanisms are unknown. This review was conducted to examine the evidence that links maternal vitamin B-12 status and perinatal outcomes. Despite the high prevalence of vitamin B-12 deficiency and associated risk of pregnancy complications, few prospective studies and, to our knowledge, only 1 randomized trial have examined the effects of vitamin B-12 supplementation during pregnancy. The role of vitamin B-12 in the etiology of adverse perinatal outcomes needs to be elucidated to inform public health interventions.
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Affiliation(s)
- Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore, India
| | | | - Patrick J Stover
- Division of Nutritional Sciences, Cornell University, Ithaca, NY; and
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