Relationships between misreported energy intake and pregnancy in the pregnancy, infection and nutrition study: new insights from a dynamic energy balance model

OBJECTIVE

Providing effective dietary counselling so that pregnancy weight gain remains within the 2009 Institute of Medicine (IOM) guidelines requires accurate maternal energy intake measures. Current practice is based on self-reported intake that has been demonstrated unreliable. This study applies an objective calculation of energy intake from a validated mathematical model to identify characteristics of individuals more likely to misreport during pregnancy.

METHODS

A validated maternal energy balance equation was used to calculate energy intake from gestational weight gain in 1,368 subjects. The difference between self-reported and model-predicted energy intake was tested for demographics, economic status, education level and maternal health status.

RESULTS

A weight gain of 15.2 kg resulted in model-predicted intake during pregnancy of 2,882.97 ±  135.71 kcal day-1, which differed from self-reported intake of 2,180.5 ± 856.0 kcal day-1. The achieved weight gain exceeded the IOM guidelines; however, the model predicted weight gain from self-reported energy intake was below IOM guidelines. Higher income (p = 0.004), education (p = 0.003), birth weight (p = 0.017), gestational diabetes (p = 0.008) and pre-existing diabetes (p < 0.001) were associated with under-reported energy intake. More children living at home (p = 0.001) were associated with more accurate self-reported intake.

CONCLUSIONS

When assessing self-reported energy intake in pregnancy studies, birth weight, gestational diabetes status, pre-existing diabetes, higher income and education predict higher under-reporting. Clinicians providing dietary treatment recommendations during pregnancy should be aware that individuals with pre-existing diabetes and gestational diabetes mellitus are more likely to misreport their intake. Additionally, the systems model approach can be applied early in intervention to objectively monitor dietary compliance to treatment recommendations.

The role of morphology in mathematical models of placental gas exchange

The performance of the placenta as a gas exchanger has a direct impact on the future health of the newborn. To provide accurate estimates of respiratory gas exchange rates, placenta models need to account for both the physiology of exchange and the organ morphology. While the former has been extensively studied, accounting for the latter is still a challenge. The geometrical complexity of placental structure requires use of carefully crafted approximations. We present here the state of the art of respiratory gas exchange placenta modeling and demonstrate the influence of the morphology description on model predictions. Advantages and shortcomings of various classes of models are discussed, and experimental techniques that may be used for model validation are summarized. Several directions for future development are suggested.

IFPA Meeting 2010 Workshops Report II: Placental pathology; trophoblast invasion; fetal sex; parasites and the placenta; decidua and embryonic or fetal loss; trophoblast differentiation and syncytialisation

Workshops are an important part of the IFPA annual meeting. At IFPA Meeting 2010 diverse topics were discussed in twelve themed workshops, six of which are summarized in this report. 1. The placental pathology workshop focused on clinical correlates of placenta accreta/percreta. 2. Mechanisms of regulation of trophoblast invasion and spiral artery remodeling were discussed in the trophoblast invasion workshop. 3. The fetal sex and intrauterine stress workshop explored recent work on placental sex differences and discussed them in the context of whether boys live dangerously in the womb.4. The workshop on parasites addressed inflammatory responses as a sign of interaction between placental tissue and parasites. 5. The decidua and embryonic/fetal loss workshop focused on key regulatory mediators in the decidua, embryo and fetus and how alterations in expression may contribute to different diseases and adverse conditions of pregnancy. 6. The trophoblast differentiation and syncytialisation workshop addressed the regulation of villous cytotrophoblast differentiation and how variations may lead to placental dysfunction and pregnancy complications.

Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study

AIM

We report a multicentric prospective study which aimed to evaluate Doppler-assisted ligation of the terminal haemorrhoidal arteries (THD) for II and III degree haemorrhoids.

METHOD

A total of 112 patients from five colorectal units, including 81 men, mean age 48 +/- 13 years, with II degree (39) and III degree (73) haemorrhoids were treated by Doppler-guided transanal de-arterialization and anopexy using a new device (THD).

RESULTS

The mean operative time was 33.9 +/- 8.8 minutes, and the mean number of ligatures applied was 7.2 +/- 1.5. Postoperatively, 72% of patients did not need analgesics and the other 28% used nonsteroidal antiinflammatory drugs 1-3 times/day for less than 2 days. All the patients were operated as a day case. Early postoperative complications included haemorrhoidal thrombosis (2 patients), bleeding (1) treated by haemostatic suture, dysuria (6) and acute urinary retention (1). After a mean follow-up of 15.6 +/- 6.5 months (range 6-32), 2/105 (20.9%) patients complained of minor bleeding, while mild pain was still present in 4/51 patients (7.8%). There were no statistically significant differences in the sample population regarding the gender or stage of the disease. Tenesmus was cured in 15/17 patients, dyschaezia in 20/22 patients and mucous soiling in 10/10 patients. No new cases of altered defaecation or faecal incontinence were recorded. Overall, 85.7% of patients were cured and 7.1% improved. Residual haemorrhoids were treated by elastic band ligation in nine (8%) patients and by surgical excision in further five patients (4.5%).

CONCLUSION

Doppler-assisted ligation of the terminal branches of the haemorrhoidal arteries for II and III degree haemorrhoids is highly effective and painless. Complications are few and the technique can be performed as a day case.

Ligasure Precise vs. conventional diathermy for Milligan-Morgan hemorrhoidectomy: a prospective, randomized, multicenter trial

PURPOSE

Milligan-Morgan hemorrhoidectomy using radiofrequency dissection (Ligasure) has been proposed instead of conventional diathermy in view of its potential benefits in terms of postoperative anal pain and better hemostatic control, but the medical literature is still controversial. This multicenter, randomized, controlled trial was designed to compare the outcomes between Ligasure and conventional diathermy hemorrhoidectomy in the Milligan-Morgan procedures in a sufficient number of patients.

METHODS

Patients with Grades III and IV hemorrhoids were randomized to two groups: Ligasure hemorrhoidectomy and conventional diathermy. Postoperative anal pain was measured by the Visual Analog Scale (VAS) and the analgesia required. Postoperative complications, wound healing, and return to working activities also were evaluated as secondary outcomes.

RESULTS

A total of 273 patients, well matched for age, gender, working activity and grade of hemorrhoids, were randomized to two groups: Ligasure 146, and diathermy 127. The severity of postoperative anal pain was significantly less in the Ligasure group when measured at least 12 hours after defecation (P < 0.01), whereas it was similar at the time of defecation. The Ligasure group had significantly lower requirements for painkiller pills. There were no significant differences in early and late complications. Return to work and normal activities was significantly faster in the Ligasure group.

CONCLUSION

Ligasure hemorrhoidectomy is an effective procedure for Grades III and IV hemorrhoids and facilitates a faster return to work and normal activities by reducing postoperative pain.

Cigarette smoking and pregnancy II: vascular effects

The act of smoking introduces a complex set of chemicals that have a broad range of effects, both complementary and antagonistic, at various levels within the vascular tree. A general review of these systemic effects is followed by a summary of documented effects of smoking on the uterine vasculature and of relationships of smoking to pregnancy outcomes known to be associated with vascular pathology. Last, we offer a potential resolution for the apparent paradox of the seemingly 'protective' effect of smoking to reduce the incidence of pre-eclampsia, one of the most serious vascular complications of pregnancy.

Cigarette smoking and pregnancy I: ovarian, uterine and placental effects

This review examines the major observations and principal controversies relating to the effects of smoking and the constituents of tobacco on ovarian, uterine and placental tissues. Maternal exposure is assessed relative to specific tobacco-related chemicals and the feto-placental impact of mutagenic products, in addition to nicotine replacement as a pharmacological intervention for smoking cessation. Important new information is being learned from clinical in vitro fertilization and assisted reproduction technologies regarding the effects of smoking on fertility. Present evidence supports an adverse effect of smoking on ovarian function which is prolonged and dose-dependent, whereas there appear to be more reversible effects on implantation and ongoing pregnancy. The anti-oestrogenic effect of smoking is reviewed in terms of direct effects of nicotine, cadmium and polyaromatic hydrocarbons on oestrogen synthesis and metabolism, oocytes and granulosa-luteal function. Innovative new models provide evidence that smoking may alter fertility through effects on uterine-fallopian tube functions which mediate gamete and conceptus transport. It is of interest that smoking is associated with a decreased incidence of uterine fibroids, endometriosis and uterine cancer, which may reflect inhibitory effects of smoke constituents on uterine cell proliferation and extracellular matrix interactions. The increased miscarriage rate among mothers who smoke may be related to direct adverse effects of nicotine, cadmium and polyaromatic hydrocarbons on trophoblast invasion and proliferation. In this respect, alterations in trophoblast differentiation along invasive or proliferative pathways may explain the changes in endocrine function and vascular morphology that are observed in smokers. In summary, significant advances are being made in the understanding of cellular and molecular mechanisms which underlie the differential effects of cigarette smoking on reproductive tissues.

Insulin-like growth factors (IGFs) and IGF binding proteins-1, -2, and -3 in newborn serum: relationships to fetoplacental growth at term

Cord sera were obtained from term, Chilean newborns exhibiting various patterns of intrauterine growth and assayed for IGF-1, IGF-2, IGFBP-1, IGFBP-2, and IGFBP-3 by specific radioimmunoassays (RIA). Serum levels of each peptide were correlated with birth weight (BW), ponderal index (PI), and placental weight (PW). Total IGF-1 levels correlated with BW (r = 0.665, P = 0.0001). PI (r = 0.527, P = 0.004), and PW (r = 0.596, P = 0.0017). In contrast, IGF-2 failed to correlate with any growth parameter. Of the three binding proteins, IGFBP-3 exhibited the strongest relationship to each growth parameter. IGFBP-3 correlated significantly with BW (r = 0.71, P < 0.0001), PI (r = 0.782, P < 0.0001), and PW (r = 0.57, P = 0.0029). In addition IGFBP-3 levels positively correlated to IGF-1 levels (r = 0.614, P = 0.0005). By contrast, circulating IGFBP-1 and IGFBP-2 were inversely related to IGF-1 levels. All five peptides were subjected to multiple regression analysis and related to BW. Significant relationships between the predicted BW and the actual BW were observed in these infants (r = 0.802, P = 0.0006). The BWs of a cohort of unrelated North American infants were also predicted using the Chilean-derived equation and found to be significantly related to their actual BWs (r = 0.453, P = 0.0033). These relationships were strengthened by the inclusion of estimated gestational age (EGA) as an independent variable. These data point to particularly important roles for IGF-1 and IGFBP-3 in regulating fetal growth at term, and suggest that they are regulated in a coordinated manner during the latter stage of gestation. Furthermore, they suggest that IGFBPs play multiple, and potentially opposing, regulatory roles in modulating IGF action. Lastly, an integrated expression of IGF activity derived from one population significantly correlated with newborn BW in a geographically and culturally distinct population.

Is oligohydramnios a risk factor for infection in term premature rupture of membranes?

Our objective was to determine if a reduced volume of amniotic fluid is a risk factor for microbial invasion of the amniotic cavity in women with rupture of membranes at term. Transabdominal amniocentesis under ultrasound guidance was used to evaluate the microbiological state of the amniotic cavity in 53 patients with term premature rupture of membranes before vaginal examination. Amniotic fluid index was measured prior to the procedure in all cases. The prevalence of microbial invasion of the amniotic cavity was 32.1% (17/53). Women with microbial invasion of the amniotic cavity had a significantly lower median amniotic fluid index than did women without evidence of infection (median 4.4 cm, range 1.0-8.1 vs. median 7.8 cm, range 1.3-14.4, respectively; p < 0.001). An amniotic fluid index of < 5 cm had a sensitivity of 71% (12/17) a specificity of 89% (32/36), a positive predictive value of 75% (12/16) and a negative predictive value of 87% (32/37) in the prediction of microbial invasion of the amniotic cavity. Among women who delivered vaginally, those with an amniotic fluid index of < 5 cm had a higher rate of endometritis than those with an amniotic fluid index of >or= 5 cm (19% (3/16) vs. 0% (0/26), respectively; p < 0.05). We conclude that women with term premature rupture of membranes and an amniotic fluid index of < 5 cm are at an increased risk for microbial invasion of the amniotic cavity and puerperal infection after a vaginal delivery.

Circulating levels of IGFs and IGF binding proteins in human cord serum: relationships to intrauterine growth

Cord sera were obtained from 44 term, human infants exhibiting various patterns of intrauterine growth and were assayed for IGF-1, IGF-2, and IGFBP-1, 2, and 3 by specific RIAs. Serum levels were correlated with birth weight (BW), ponderal index (PI), and placental weight (PW). Total IGF-1 levels correlated significantly with BW (r = 0.392), PW (r = 0.351), and PI (r = 0.481). By contrast, the correlation of IGF-2 with birth weight was not statistically significant (r = 0.264, P = 0.091). The association of IGF-2 with PI, however, was significant (r = 3.348, P = 0.024). IGFBP-3 exhibited significant correlations with BW, PI, and PW, similar to those seen with IGF-1. IGFBP-1 and IGFBP-2, however, were not significantly related to growth parameters. IGF-1 levels correlated strongly with IGFBP-3 levels (r = 0.646, P = 0.001). By contrast, IGF-1 correlated with the reciprocal of both IGFBP-1 and IGFBP-2. Based upon in vitro affinity constants, theoretical concentrations for each [IGF/IGFBP] complex, free IGFs, and free IGFBPs were calculated for each infant. Multiple regression analysis was performed including all 11 calculated variables and correlated with each growth parameter. This analysis revealed that an integrated expression of IGF activity exhibited stronger correlations with growth than each individual peptide species (BW, r = 0.681; PI, r = 0.660; PW, r = 0.658). These data further support roles for IGF related peptides (IGFRPs) in human fetal and placental growth and suggest regulatory/counterregulatory roles for the IGFBPs. It also supports the hypothesis that individual IGFRPs interact in a complex manner to define 'net IGF activity' in relation to fetal growth and/or metabolic status.

Placental and decidual histology in spontaneous abortion: detailed description and correlations with chromosome number

OBJECTIVES

To determine the histopathology of failed pregnancy in clinically symptomatic women with no more than one prior pregnancy loss in order to provide baseline data, and to determine whether the histology of the conceptus in spontaneous abortions could predict a normal or abnormal chromosome number.

METHODS

A review of all spontaneous abortions from which karyotypes were obtained between 1984-1991 yielded 224 cases in which maternal history indicated no more than one prior spontaneous abortion, a reliable date of last menstrual period (LMP), and available villous (221) and/or decidual/implantation site (175) pathology. Molar pregnancies were excluded.

RESULTS

Multivariate logistic regression analysis showed a significant relationship between chromosome number and gestational age at loss as calculated from the LMP. Considering this confounder, a villous circulation indicating fetal life to 11 or more weeks, chronic intervillositis and villous infarcts (each P < .01), and decidual vasculitis (P < .05) were more frequent in chromosomally normal conceptions. Substituting possible variables into the logistic regression equation yielded predictions ranging from 88% likelihood of chromosomal abnormality to 97% likelihood of normal chromosome number.

CONCLUSIONS

Histology can assist in assessing whether a spontaneous abortion is chromosomally normal or abnormal. There are many pathologic findings seen in spontaneous abortions regardless of karyotype; however, certain findings are more common in chromosomally normal abortions. These data provide a baseline for study of the histopathology of habitual abortion.

The relationship between spontaneous rupture of membranes, labor, and microbial invasion of the amniotic cavity and amniotic fluid concentrations of prostaglandins and thromboxane B2 in term pregnancy

OBJECTIVE

The purpose of this study was to examine the relationship between rupture of membranes, labor, and microbial invasion of the amniotic cavity and amniotic fluid concentrations of eicosanoids in patients with spontaneous rupture of membranes at term.

STUDY DESIGN

Amniotic fluid was retrieved by transabdominal amniocentesis from patients with rupture of membranes and patients with intact membranes at term. Studies to determine the microbial state of the amniotic cavity included culture for bacteria and mycoplasmas, Gram stain, amniotic fluid white blood cell count, and Limulus amebocyte lysate. Eicosanoids (prostaglandin E2, prostaglandin F2 alpha and its stable metabolite, 6-keto-prostaglandin F1 alpha, and thromboxane B2) were determined with sensitive and specific radioimmunoassays validated for human amniotic fluid. Statistical inference was conducted with analysis of variance and linear contrast.

RESULTS

(1) Spontaneous rupture of membranes at term was associated with a significant increase in amniotic fluid concentrations of all eicosanoids measured in this study except 6-keto-prostaglandin F1 alpha. (2) Early labor in patients with rupture of membranes was associated with a significant increase in the amniotic fluid concentration of all eicosanoids. (3) A significant increase in amniotic fluid eicosanoids in women with microbial invasion of the amniotic cavity could not be documented.

CONCLUSIONS

Whereas preterm labor in the absence of microbial invasion of the amniotic cavity is not associated with a significant increase in amniotic fluid concentrations of prostaglandins, a clear increase was documented in women with early labor after spontaneous rupture of membranes. These observations suggest that there are fundamental differences in the biochemistry of term and preterm parturition.

Diagnosis and significance of cystic hygroma in the first trimester

Thirty cases of cervical cystic hygroma were diagnosed in the first trimester of pregnancy. Karyotype analysis was available in 29 (97 per cent). Fifteen (52 per cent) had a chromosomal abnormality. The ultrasound appearance was described as posterior cervical, lateral cervical, or cervical hygroma with hydrops. Of the 14 euploid embryos, six were electively aborted, two are undelivered, and six have been delivered as phenotypically normal infants. In cases in which the chromosomes were normal and the pregnancy continued, all lesions resolved by 18 weeks.

Transvaginal ultrasonographic detection of congenital anomalies in the first trimester

Transvaginal ultrasonography enables detailed visualization of the first-trimester pregnancy. Thirty-three structural anomalies have been diagnosed in the first trimester of pregnancy during a 2-year study period. An understanding of normal embryonic development is essential before attempting diagnosis in this gestational period.

Ultrasonographic criteria for the prenatal diagnosis of placental chorionicity in twin gestations

Thirty-two patients with uncomplicated twin pregnancies had ultrasonographic examinations for genetic amniocentesis, confirmation of twinning, or assessment of fetal growth. The dividing membranes between the fetuses were visualized, and the thickness of the membranes was measured. With a thickness of 2 mm used as a cutoff point, the accuracy in predicting monochorionic or dichorionic twinning was 82% and 95%, respectively. Prenatal assessment of these dividing membranes may be helpful in the management of twin gestations.

The phenotype of human placental macrophages and its variation with gestational age

The antigenic phenotype of human villous stromal macrophages (M phi s) from first and third trimester placentas was analyzed using a large number of monoclonal antibodies (MAbs) to monocyte (Mo)/M phi-associated cell membrane determinants. The purpose of this study was to investigate M phi phenotypic heterogeneity to create a database for the correlation of M phi phenotype with specific immunologic functions. The results showed that villous stromal mononuclear cells express many cell surface antigens found on Mo and M phi s and that they are morphologically diverse, ranging in appearance from classic Hofbauer cells to spindle-shaped cells with long cytoplasmic processes. Villous stromal M phi s were the numerically dominant cell type in this structure and exhibited some major phenotypic differences from M phi s in other tissues. Comparison of first- and third-trimester placentas revealed variation in antigen expression with increasing gestational age, in particular of class II major histocompatibility complex (MHC) determinants: HLA-DR and HLA-DP antigen density was low on first-trimester villous M phi s and much higher on third-trimester M phi s while HLA-DQ was undetectable in the first trimester but present on cells in third trimester placentas. The CD1 (T6) antigen, found on Langerhans (LH) cells and cortical thymocytes, was detected on villous M phi s by two thirds of the MAbs directed against different epitopes on this determinant. Furthermore, comparison with similar studies of lymphoid tissues showed that villous M phi s and dendritic cells share the expression of a number of other cell surface antigens. Finally, it was shown that M phi s in first- and third-trimester villi exhibit strong reactivity with MAbs (Leu 3a,b) to the CD4 antigen that serves as the receptor for the human immunodeficiency virus (HIV), suggesting that these cells may be a portal of entry or reservoir for this virus in the fetuses of pregnant, HIV+ women.

Sonographic diagnosis of a pregnancy with a diffuse hydatidiform mole and coexistent 46,XX fetus: a case report

Placental molar change with a coexistent live fetus is an unusual entity, particularly when diagnosed in the second trimester of pregnancy. In this case report, the sonographic findings of an abnormally enlarged, diffuse molar placenta with a normal living fetus in the second trimester prompted karyotype analysis. Although triploidy was anticipated, a normal 46,XX chromosomal complement was identified. Histopathology of the placenta after delivery confirmed the rare syndrome of diploid partial mole. Antenatal management of this unusual pregnancy complication is addressed.