Multi-ancestry genome-wide association study of gestational diabetes mellitus highlights genetic links with type 2 diabetes

Gestational diabetes mellitus (GDM) is associated with increased risk of pregnancy complications and adverse perinatal outcomes. GDM often reoccurs and is associated with increased risk of subsequent diagnosis of type 2 diabetes (T2D). To improve our understanding of the aetiological factors and molecular processes driving the occurrence of GDM, including the extent to which these overlap with T2D pathophysiology, the GENetics of Diabetes In Pregnancy Consortium assembled genome-wide association studies of diverse ancestry in a total of 5485 women with GDM and 347 856 without GDM. Through multi-ancestry meta-analysis, we identified five loci with genome-wide significant association (P < 5 × 10-8) with GDM, mapping to/near MTNR1B (P = 4.3 × 10-54), TCF7L2 (P = 4.0 × 10-16), CDKAL1 (P = 1.6 × 10-14), CDKN2A-CDKN2B (P = 4.1 × 10-9) and HKDC1 (P = 2.9 × 10-8). Multiple lines of evidence pointed to the shared pathophysiology of GDM and T2D: (i) four of the five GDM loci (not HKDC1) have been previously reported at genome-wide significance for T2D; (ii) significant enrichment for associations with GDM at previously reported T2D loci; (iii) strong genetic correlation between GDM and T2D and (iv) enrichment of GDM associations mapping to genomic annotations in diabetes-relevant tissues and transcription factor binding sites. Mendelian randomization analyses demonstrated significant causal association (5% false discovery rate) of higher body mass index on increased GDM risk. Our results provide support for the hypothesis that GDM and T2D are part of the same underlying pathology but that, as exemplified by the HKDC1 locus, there are genetic determinants of GDM that are specific to glucose regulation in pregnancy.

Early pregnancy plasma fatty acid profiles of women later diagnosed with gestational diabetes

INTRODUCTION

Fatty acid (FA) concentrations have previously been associated with gestational diabetes mellitus (GDM). However, few studies on GDM have examined FA profiles in early pregnancy or before diagnosis. This study aimed to compare early pregnancy plasma FA profiles of women with and without GDM diagnoses as well as their reported dietary consumption.

RESEARCH DESIGN AND METHODS

The subjects comprised 853 women from the prospective study: Pregnant Women in Iceland II (PREWICE II), attending their 11-14 weeks ultrasound appointment in 2017-2018. During the visit, blood samples were collected for plasma FA analysis, and dietary habits were assessed using a short food frequency questionnaire. Information on GDM diagnoses was then later extracted from medical records. Differences in FA profile between GDM cases and non-cases were evaluated using the Mann-Whitney U test.

RESULTS

GDM was diagnosed in 127 women (14.9%). Concentrations of saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids (PUFA) n-6, PUFA n-3 and total FA were higher in the women who later developed GDM compared with those who did not (p≤0.05). The medians for total FA were 2898 μg/mL for the women with GDM and 2681 μg/mL for those without GDM. Mean adjusted difference for total FA between the groups was 133 μg/mL (95% CI 33 to 233). Similar results were observed in prepregnancy normal-weight women and overweight women/women with obesity. Overall diet quality in early pregnancy appeared to be lower among the women later diagnosed with GDM.

CONCLUSION

We found that plasma FA profiles in early pregnancy were different for women later diagnosed with GDM compared with those who were not, independent of the women's body mass index.

Higher Alkylresorcinol Concentrations, a Consequence of Whole-Grain Intake, are Inversely Associated with Gestational Diabetes Mellitus in Iceland

BACKGROUND

A diet rich in whole grains may provide benefits for pregnant women due to whole grains' high nutritional value and dietary fiber content.

OBJECTIVES

To study the associations of whole-grain consumption, as well as the plasma alkylresorcinol concentration, a whole-grain consumption biomarker, in early pregnancy with gestational diabetes mellitus (GDM) diagnoses.

METHODS

Subjects were women from the prospective study Pregnant Women in Iceland II (PREWICE II; n = 853) who attended their ultrasound appointment in gestational weeks 11-14 during the period from October 2017 to March 2018. During that visit, whole-grain consumption was estimated using a diet screening questionnaire, and blood samples were collected for analysis of plasma alkylresorcinols (ARs). Information on GDM diagnoses was later extracted from medical records. Multivariate log-binomial regression was used to evaluate the association of dietary whole-grain and AR concentrations with GDM.

RESULTS

In total, 14.9% of the women adhered to the national food-based dietary guidelines (n = 127), which recommend 2 portions of whole grains daily. GDM was diagnosed in 127 women (14.9%). The frequency of whole-grain consumption was lower in women who were later diagnosed with GDM compared to the women without GDM (median, 5 times/week vs. 6 times/week, respectively; P = 0.02). This difference was reflected in the lower median concentration of total AR in women diagnosed with GDM (163 nmol/L vs. 209 nmol/L, respectively; P < 0.01). The quartile with the highest concentrations of AR had a RR of 0.50 (95% CI: 0.27-0.90) of being diagnosed with GDM, in comparison to the lowest quartile. There was a significant dose response in the GDM risk with higher AR levels.

CONCLUSIONS

We found that a higher consumption of whole grains, reflected both by reported consumption according to the FFQ and AR biomarkers, was associated with a decreased risk of receiving a GDM diagnosis.

Vitamin D status and association with gestational diabetes mellitus in a pregnant cohort in Iceland

Background

Vitamin D deficiency has been associated with an increased risk of gestational diabetes mellitus (GDM), one of the most common pregnancy complications. The vitamin D status has never previously been studied in pregnant women in Iceland.

Objective

The aim of this research study was to evaluate the vitamin D status of an Icelandic cohort of pregnant women and the association between the vitamin D status and the GDM incidence.

Design

Subjects included pregnant women (n = 938) who attended their first ultrasound appointment, during gestational weeks 11-14, between October 2017 and March 2018. The use of supplements containing vitamin D over the previous 3 months, height, pre-pregnancy weight, and social status were assessed using a questionnaire, and blood samples were drawn for analyzing the serum 25‑hydroxyvitamin D (25OHD) concentration. Information regarding the incidence of GDM later in pregnancy was collected from medical records.

Results

The mean ± standard deviation of the serum 25OHD (S-25OHD) concentration in this cohort was 63±24 nmol/L. The proportion of women with an S-25OHD concentration of ≥ 50 nmol/L (which is considered adequate) was 70%, whereas 25% had concentrations between 30 and 49.9 nmol/L (insufficient) and 5% had concentrations < 30 nmol/L (deficient). The majority of women (n = 766, 82%) used supplements containing vitamin D on a daily basis. A gradual decrease in the proportion of women diagnosed with GDM was reported with increasing S-25OHD concentrations, going from 17.8% in the group with S-25OHD concentrations < 30 nmol/L to 12.8% in the group with S-25OHD concentrations ≥75 nmol/L; however, the association was not significant (P for trend = 0.11).

Conclusion

Approximately one-third of this cohort had S-25OHD concentrations below adequate levels (< 50 nmol/L) during the first trimester of pregnancy, which may suggest that necessary action must be taken to increase their vitamin D levels. No clear association was observed between the vitamin D status and GDM in this study.

Insufficient iodine status in pregnant women as a consequence of dietary changes

Background

Historically, Iceland has been an iodine-sufficient nation due to notably high fish and milk consumption. Recent data suggest that the intake of these important dietary sources of iodine has decreased considerably.

Objective

To evaluate the iodine status of pregnant women in Iceland and to determine dietary factors associated with risk for deficiency.

Methods

Subjects were women (n = 983; 73% of the eligible sample) attending their first ultrasound appointment in gestational weeks 11–14 in the period October 2017–March 2018. Spot urine samples were collected for assessment of urinary iodine concentration (UIC) and creatinine. The ratio of iodine to creatinine (I/Cr) was calculated. Median UIC was compared with the optimal range of 150–249 μg/L defined by the World Health Organization (WHO). Diet was assessed using a semiquantitative food frequency questionnaire (FFQ), which provided information on main dietary sources of iodine in the population studied (dairy and fish).

Results

The median UIC (95% confidence interval (CI)) and I/Cr of the study population was 89 μg/L (42, 141) and 100 (94, 108) μg/g, respectively. UIC increased with higher frequency of dairy intake, ranging from median UIC of 55 (35, 79) μg/L for women consuming dairy products <1 time per week to 124 (98, 151) μg/L in the group consuming dairy >2 times per day (P for trend <0.001). A small group of women reporting complete avoidance of fish (n = 18) had UIC of 50 (21, 123) μg/L and significantly lower I/Cr compared with those who did not report avoidance of fish (58 (34, 134) μg/g vs. 100 (94, 108) μg/g, P = 0.041). Women taking supplements containing iodine (n = 34, 3.5%) had significantly higher UIC compared with those who did not take supplements (141 (77, 263) μg/L vs. 87 (82, 94), P = 0.037).

Conclusion

For the first time, insufficient iodine status is being observed in an Icelandic population. There is an urgent need for a public health action aiming at improving iodine status of women of childbearing age in Iceland.

The majority of early term elective cesarean sections can be postponed

INTRODUCTION

To minimize the risk of neonatal respiratory morbidity it is recommended that elective cesarean sections should not be done before 39-week gestation unless medically indicated. However, elective cesarean sections are still being performed at early term (at 37⁰-38⁶ weeks gestation) without sound medical indications. In this study, we evaluated the indications for elective cesarean sections performed at early term to assess the proportion of procedures that could possibly have been postponed until ≥39 weeks to avoid neonatal respiratory morbidity.

MATERIAL AND METHODS

Maternal and neonatal information was collected from medical records on all elective cesarean sections performed in singleton pregnancies at ≥37⁰ weeks gestation over a 20-year period in a population with secure ultrasound gestational age assignment. Indications were grouped and uterine scar, breech, or transverse presentation and maternal request classified as nonurgent.

RESULTS

There were 3411 elective cesarean sections performed at ≥37-week gestation, of which 790 (23.2%) were at 37⁰-38⁶ weeks. Medical indications were present for 34% (272/790), but 65.6% (518/790) could possibly have been postponed until ≥39⁰ weeks. Of the neonates 5.7% developed respiratory morbidity if delivery was at 37⁰-38⁶ weeks gestation compared to 2.4% at 39⁰-42¹ weeks gestation (p < .001).

CONCLUSION

Of elective cesarean sections before 39-week gestation two-thirds were done without a clear medical indication, thereby exposing the newborn to an increased risk of respiratory morbidity. Scheduling elective cesarean sections at ≥39-week gestation is important to minimize the risk of neonatal respiratory morbidity, unless a clear medical indication dictates earlier delivery.

Development of a dietary screening questionnaire to predict excessive weight gain in pregnancy

Excessive gestational weight gain (GWG) is a risk factor for several adverse pregnancy outcomes, including macrosomia. Diet is one of the few modifiable risk factors identified. However, most dietary assessment methods are impractical for use in maternal care. This study evaluated whether a short dietary screening questionnaire could be used as a predictor of excessive GWG in a cohort of Icelandic women. The dietary data were collected in gestational weeks 11–14, using a 40‐item food frequency screening questionnaire. The dietary data were transformed into 13 predefined dietary risk factors for an inadequate diet. Stepwise backward elimination was used to identify a reduced set of factors that best predicted excessive GWG. This set of variables was then used to calculate a combined dietary risk score (range 0–5). Information regarding outcomes, GWG (n = 1,326) and birth weight (n = 1,651), was extracted from maternal hospital records. In total, 36% had excessive GWG (Icelandic criteria), and 5% of infants were macrosomic (≥4,500 g). A high dietary risk score (characterized by a nonvaried diet, nonadequate frequency of consumption of fruits/vegetables, dairy, and whole grain intake, and excessive intake of sugar/artificially sweetened beverages and dairy) was associated with a higher risk of excessive GWG. Women with a high (≥4) versus low (≤2) risk score had higher risk of excessive GWG (relative risk = 1.23, 95% confidence interval, CI [1.002, 1.50]) and higher odds of delivering a macrosomic offspring (odds ratio = 2.20, 95% CI [1.14, 4.25]). The results indicate that asking simple questions about women's dietary intake early in pregnancy could identify women who should be prioritized for further dietary counselling and support.

A rare missense mutation in CHRNA4 associates with smoking behavior and its consequences

Using Icelandic whole-genome sequence data and an imputation approach we searched for rare sequence variants in CHRNA4 and tested them for association with nicotine dependence. We show that carriers of a rare missense variant (allele frequency=0.24%) within CHRNA4, encoding an R336C substitution, have greater risk of nicotine addiction than non-carriers as assessed by the Fagerstrom Test for Nicotine Dependence (P=1.2 × 10(-4)). The variant also confers risk of several serious smoking-related diseases previously shown to be associated with the D398N substitution in CHRNA5. We observed odds ratios (ORs) of 1.7-2.3 for lung cancer (LC; P=4.0 × 10(-4)), chronic obstructive pulmonary disease (COPD; P=9.3 × 10(-4)), peripheral artery disease (PAD; P=0.090) and abdominal aortic aneurysms (AAAs; P=0.12), and the variant associates strongly with the early-onset forms of LC (OR=4.49, P=2.2 × 10(-4)), COPD (OR=3.22, P=2.9 × 10(-4)), PAD (OR=3.47, P=9.2 × 10(-3)) and AAA (OR=6.44, P=6.3 × 10(-3)). Joint analysis of the four smoking-related diseases reveals significant association (P=6.8 × 10(-5)), particularly for early-onset cases (P=2.1 × 10(-7)). Our results are in agreement with functional studies showing that the human α4β2 isoform of the channel containing R336C has less sensitivity for its agonists than the wild-type form following nicotine incubation.

Survival and neurodevelopmental outcome of ELBW children at 5 years of age: comparison of two cohorts born 10 years apart

AIM

To examine survival and outcome of extremely low-birth-weight (ELBW) children (birth weight < 1000 g) in two 5-year periods, 10 years apart.

METHODS

In a retrospective population-based study, information on all ELBW children born in Iceland in 1991-1995 and in 2001-2005 was obtained from the National Birth Registry, hospital charts and medical records. The two periods were compared.

RESULTS

In 1991-1995, 102 of 22.261 newborn children (0.5%) were extremely low birth weight compared with 70 of 20.923 newborns (0.33%) in 2001-2005 (p = 0.04). At 5 years of age, 52% (35/67) of live-born children born in 1991-1995 were alive compared with 63% (31/49) of children born in 2001 - 2005 (p = 0.2). Six ELBW children (17%) born 1991-1995 were diagnosed with disabilities at 5 years of age, three with major neurodevelopmental disabilities compared with six (19%) born 2001-2005, thereof one with severe neurodevelopmental disabilities (p = 0.57).

CONCLUSION

The incidence of childhood disabilities in ELBW children in Iceland remains stable despite an increase in survival rate. The severity of neurodevelopmental disabilities has decreased.

Obstetric and neonatal risks among extremely macrosomic babies and their mothers

OBJECTIVE

We estimated the risk of complications at birth of extremely large babies (≥5000 g).

STUDY DESIGN

This was a cohort study including all births of extremely large babies in 1996 through 2005 and comparison cohort with normal birthweight (1:2) identified in the national birth registration.

RESULTS

There were 343 extremely large babies or 0.9% of all singletons. Compared to the normal birthweight cohort (n = 679), there were increased odds of shoulder dystocia (odds ratio [OR], 26.9; 95% confidence interval [CI], 11.1-65.1), emergency cesarean section (OR, 5.2; 95% CI, 3.4-8.0), and failed labor induction (OR, 4.3; 95% CI, 1.7-11.0). The risk of elective section was not increased (OR, 1.1; 95% CI, 0.6-2.0). Minor congenital malformations were more frequent (OR, 2.1; 95% CI, 1.2-3.7), as were birth injuries (OR, 3.7; 95% CI, 2.1-6.8) and minor metabolic disturbance (OR, 2.5; 95% CI, 1.1-6.2), but not asphyxial births.

CONCLUSION

The risk of shoulder dystocia for very large babies is markedly raised, as are minor complications, while for mothers the main risk is emergency section.

Effects of knowledge, education, and experience on acceptance of first trimester screening for chromosomal anomalies

OBJECTIVES

To assess pregnant women's knowledge and understanding of first trimester prenatal screening (nuchal translucency, maternal serum free beta-human chorionic gonadotrophin and pregnancy-associated plasma-protein-A), to evaluate the impact of a new information booklet and investigate the effects of education and experiential knowledge of congenital disabilities on the perceived likelihood of accepting prenatal screening.

DESIGN

A quasi-experimental quantitative study with a self-completion questionnaire.

SETTING

Five different maternity care clinics in Iceland.

POPULATION

Expectant mothers in first trimester of pregnancy (n = 379).

MATERIAL AND METHODS

Expectant mothers were divided into two groups, an intervention and a control group, both receiving traditional care and information. The intervention group additionally received an information booklet about prenatal screening and diagnosis.

MAIN OUTCOME MEASURES

Women's knowledge score of prenatal screening. The correlation between education, knowledge score, experiential knowledge of congenital disabilities, and the likelihood of accepting prenatal screening.

RESULTS

More than half of the women (57%) believed they received sufficient information to make an informed decision about screening. Knowledge scores were significantly higher for the intervention group (with mean 4.8 compared with 3.7 on a 0-8 scale, p < 0.0001). Those with higher scores were more likely to accept screening (p < 0.0001). Women with experiential knowledge of congenital anomalies in their own families were more likely to accept prenatal screening (p = 0.017).

CONCLUSIONS

Various factors, e.g. experiential knowledge, education and information about prenatal screening affect the likelihood of participation in prenatal screening programs. More information results in better knowledge and higher uptake rate.

An international outbreak of Shiga toxin-producing Escherichia coli O157 infection due to lettuce, September-October 2007

Between 14 September and 20 October 2007, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157 simultaneously occurred in the Netherlands and Iceland. A total of 50 laboratory-confirmed cases were reported with a STEC O157 infection caused by the same clone. The strain was of type O157:H-, PT8, positive for stx1, stx2, eae and e-hly, and sorbitol negative. The most probable cause of this international outbreak was contaminated lettuce, shredded and pre-packed in a Dutch food processing plant. Samples of the environment, raw produce and end products, taken at several vegetable growers and processing plants all tested negative for STEC O157. However, the only epidemiological link between the cases in the Netherlands and in Iceland was the implicated Dutch processing plant. In Europe, food products are often widely distributed posing the risk of potential spread of food borne pathogens simultaneously to several countries. This international outbreak emphasises the importance of common alert and surveillance systems in earlier detection of international outbreaks and better assessment of their spread.

[Vaginal birth after one previous cesarean section]

OBJECTIVE

To evaluate the frequency of different modes of delivery after one previous cesarean section and those factors which may influence mode of delivery.

MATERIAL AND METHODS

During the study period (1.1.2001-31.12.2005) 925 women with a previous cesarean section and a following singleton pregnancy were identified and included. Information regarding mode of delivery, induction of labor, instrumental delivery, the urgency and indications for first and second cesarean section, birth weight and Apgar scores were collected retrospectively.

RESULTS

Trial of labor (TOL) was initiated for 564 women of which 61% were successful while 39% delivered by an emergent cesarean section. In total, 346 women delivered vaginally (37%), 341 women (37%) delivered with an elective cesarean section and 238 (26%) underwent an emergency cesarean section. The VBAC rate increased during the study period, from 35% to 46%. Women who underwent an elective cesarean section due to fetal malpresentation (most often breech) in their first pregnancy were significantly more likely to have a successful VBAC in their second pregnancy (53%) compared with women who had an elective cesarean section for any other indication (21%) (p<0.0001). Uterine rupture occurred in six women (1%) during TOL, five underwent an emergency cesarean section and had healthy infants while there was one intrapartum fetal death. No correlation was found between birth mode and Apgar scores at five minutes. Perinatal mortality rate was 5,4 per thousand. Trial of labor was less likely to succeed if the infant's birth weight was >4000 grams compared with <4000 grams (p<0.01).

CONCLUSION

The results of this study indicate that VBAC is a safe option for women with a history of one previous cesarean section while in the hospital setting where there are resources for an immediate cesarean section.

KEYWORDS

Vaginal birth after cesarean section (VBAC), uterine rupture, perinatal mortality rate. Correspondence: Hildur Hardardóttir, hhard@landspitali.is.

[The effects of normal vaginal delivery on oxygen transport to the fetus]

OBJECTIVE

To evaluate the effects of normal vaginal delivery (NVD) on oxygen transport to the fetus. Study group and methods: Fifty newborn infants born by NVD and as a control group 50 infants born by elective Cesarean section (ECS) were studied. Factors reflecting oxygen transport to the fetus were measured in venous and arterial cord blood: pH, partial pressure of oxygen (pO2) and carbon dioxide (pCO2), oxygen saturation (SO2), blood oxygen content, base deficit, and lactic acid concentrations, erythropoietin concentrations, number of nucleated red blood cells and haemoglobin concentrations.

RESULTS

There was no significant difference in venous blood oxygen content between the two groups of infants. However, arterial blood oxygen content was significanlty lower in the infants born by ECS than in those born by NVD (p<0.001). Infants born by NVD had significantly lower pH (p<0.001), greater base deficit (p<0.001), higher lactic acid (p<0.001) and erythropoietin concentrations (p=0.01), more nucleated red blood cells (p=0.004), and higher hemoglobin concentrations (p=0.002) in venous blood than in the infants born by ECS. pH was lower (p<0.001) and lactic aicid concentrations were higher (p<0.001) in arterial blood than venous blood in both groups of infants.

CONCLUSIONS

(1) NVD causes reduction in oxygen transport to the fetus, resulting in acidosis and stimulation of blood forming tissues. (2) ECS is associated with more reduction in umbilical arterial cord blood oxygen content than NVD. (3) When evaluating acidosis in newborns after delivery it is more reliable to measure pH and lactic acid concentrations in arterial rather than venous cord blood.

STEC O157 outbreak in Iceland, September-October 2007

From 28 September to 22 October, nine domestically acquired cases of Shiga toxin (Stx)-producing Escherichia coli (STEC) O157 were diagnosed in Iceland, one of which is probably a secondary case.

[Birth asphyxia and hypoxic ischemic encephalopathy, incidence and obstetric risk factors]

OBJECTIVE

Modern medical practice has changed dramatically during the past decades because of improved technology. Still, fetal surveillance during labor is relatively unchanged since 1960 s when fetal heart rate monitoring (FHR) became standard practice. Newborn infants are still suffering from birth asphyxia and in severe cases leading to hypoxic ischemic encephalopathy (HIE) which sometimes results in permanent neurological damage. The incidence of birth asphyxia and HIE in Iceland is unknown and so are the risk factors for severe asphyxia. The objective of this study was to assess the incidence, obstetric risk factors and the sequela of severe asphyxia at Landspitali university hospital (LSH).

MATERIAL AND METHODS

All term infants born at LSH from 1.1.1997- 31.12.2001 with birth asphyxia, defined as five minute Apgar score %lt;6, were included in the study (n=127). Clinical information were collected retrospectively from maternal records on maternal diseases during pregnancy, cardiotocogram (CTG), type of birth, the presence of meconium and operative delivery rates. Information was also collected regarding birth asphyxia and HIE in the neonatal period.

RESULTS

The incidence of birth asphyxia was 9.4/1000 live term births during the study period, with increasing incidence during the three last years. The incidence of HIE was 1.4/ 1,000 live term births. Severe maternal diseases during pregnancy were not a significant risk factor for asphyxia. The amniotic fluid was meconium stained in fifty percent of cases and the umbilical cord was wrapped around the fetal neck in 41% of cases. Abnormal CTG tracing was observed in 66% of cases in the study group and in 79% of the HIE cases. Operative deliveries were significantly more common in the study cohort compared with other deliveries at LSH at the same time: ventouse delivery 22% vs 6.8% (p<0,001), forceps delivery 6.3% vs 1,03% (p<0,001), emergency cesarean section 19.7% vs 11.4% ( p=0,008).

CONCLUSION

The incidence of birth asphyxia is higher in LSH compared with the incidence found in other studies. Signs of fetal distress on CTG and delivery with operative interventions are common. With current available methods to detect intrapartum asphyxia there is a poor correlation with CTG and the development of HIE after severe asphyxia. The presence of severe maternal diseases does not correlate with increased incidence of asphyxia, presumably due to increased surveillance of these pregnancies and a lower treshold for intervention during delivery. In low risk pregnancies there is a lack of appropriate methods with high sensitivity and specificity to detect intrapartum asphyxia.

The effects of smoking in pregnancy on factors influencing fetal growth

AIM

To evaluate the influence of maternal smoking during pregnancy on factors influencing fetal growth.

METHODS

Thirty newborns of smoking mothers were prospectively compared with 60 newborns of non-smoking mothers. Pre-albumin, albumin, triglycerides, glucose, insulin, insulin-like growth factor I, IGF binding protein 3, pH, lactic acid, erythropoietin and hemoglobin concentrations were measured in umbilical cord blood.

RESULTS

Infants of smoking mothers had a significantly lower birth weight (3418 +/- 533 vs. 3863 +/- 503 g; p < 0.001), length (50.5 +/- 2,6 vs. 52.3 +/- 1.9 cm; p < 0.001) and head circumference (34.6 +/- 1.8 vs. 35.8 +/- 1.1 cm; p < 0.001) than controls. They also had significantly lower insulin (3.2 (2.0-4.9) vs. 5.8 (4.6-7.1) mU/L; p = 0.008), insulin-like growth factor I (54.4 +/- 32.5 vs. 93.8 +/- 54.5 microg/L; p = 0.001) and IGF binding protein 3 (1664 +/- 432 vs. 1943 +/- 421 microg/L; p = 0.01) concentrations, than controls. Infants of smoking mothers also had significantly higher hemoglobin (167 +/- 14 vs. 157 +/- 13 g/L; p = 0.002) and erythropoietin (42.3 (25.1-72.4) vs. 26.3 (21.9-30.9) U/L; p = 0.03) than controls, but not pH or lactate concentrations. There was no significant difference in pre-albumin, albumin, triglycerides and glucose concentrations.

CONCLUSIONS

Smoking during pregnancy causes symmetrical fetal growth impairment, possibly due to decreased oxygen transport to the fetus and decreased concentrations of fetal insulin, insulin-like growth factor I and IGF binding protein 3.

Campylobacter spp. in Icelandic poultry operations and human disease

We describe the observed relationship of campylobacter in poultry operations to human cases in a closed environment. During 1999 in Iceland, domestic cases of campylobacteriosis reached peak levels at 116/100,000 and in 2000 dropped to 33/100,000. Approximately 62% of broiler carcass rinses were contaminated with Campylobacter spp. in 1999. During 2000, only 15% of the broiler flocks tested Campylobacter spp. positive. In 2000, carcasses from flocks which tested positive on the farms at 4 weeks of age were subsequently frozen prior to distribution. We suggest that public education, enhanced on-farm biological security measures, carcass freezing and other unidentified factors, such as variations in weather, contributed to the large reduction in poultry-borne campylobacteriosis. There is no immediate basis for assigning credit to any specific intervention. We continue to seek additional information to understand the decline in campylobacteriosis and to create a risk assessment model for Campylobacter spp. transmission through this well defined system.

[Misoprostol and dinoprostone for induction of labor: a prospective randomized study.]

OBJECTIVE

The ideal agent for induction of labor when the cervix is unripe is unknown, but several prostaglandin derivatives are currently available. Recently, the synthetic prostaglandin El derivative misoprostol has been used with good success for induction of labor. The cost of misoprostol is only a fraction of the cost of the traditionally used dinoprostone. We conducted a prospective, randomized trial comparing the efficacy and safety of misoprostol and dinoprostone for induction of labor.

MATERIAL AND METHODS

One hundred and twenty-three women with an indication for induction of labor and an unfavorable cervical score and intact membranes were randomized to receive either one dose of misoprostol 100 meg or two doses of dinoprostone 3 mg at eight hour intervals, in the posterior vaginal fornix.

RESULTS

Fifty-one women received misoprostol and 60 dinoprostone. Twelve women dropped out of the study after randomization, thereof 11 from the miso notprostol group due to a too favorable cervical score (n=9) and ruptured membranes (n=2). The mean time from induction of labor to delivery was 548 and 1,087 minutes in the misoprostol and dinoprostone groups, respectively (p<0.05). The need for oxytocin was 40% in the misoprostol and 71% in the dinopro notstone group (p<0.05). There was no difference in mode of delivery between the groups; 21.6% and 25% were delivered by cesarean section in the miso notprostol and dinoprostone groups, respectively. The incidence of fetal distress as evaluated by brady notcardia, tachycardia or late decelerations was similar in both groups. The occurrence of meconium was 41% and 20.5% in the misoprostol and dinoprostone groups, respectively (p=0.056). The incidence of uterine hyperstimulation was 59.6% in the misopro notstol group and 18.6% in the dinoprostone group (p<0.05). The Apgar score at one minute was 6.6 and 7.6 and at five minutes 8.5 and 9.0 in the misoprostol and dinoprostone groups, respectively (p=0.048 and 0.037). When only vaginal births are examined there was no difference in Apgar score at one and five minutes (p=0.11; p=0.21).

CONCLUSIONS

Intravaginal misoprostol and dinopro notstone are both effective in inducing labor when the cervix is unripe. Delivery is faster with this dose of misoprostol compared to dinoprostone and there is less requirement for further augmentation of labor with oxytocin, but the incidence of uterine hyperstimulation is higher. This was, however, not reflected in an increased incidence of fetal distress, cesarean section or adverse neonatal outcome. The ideal dose of misoprostol for induction of labor remains to be determined.

Effects of transdermal nicotine or smoking on nicotine concentrations and maternal-fetal hemodynamics

OBJECTIVE

To compare nicotine concentrations and fetal middle cerebral artery resistance indices (RIs) during 21-mg transdermal nicotine use with these values during maternal smoking.

METHODS

In this randomized, crossover study, participants smoked approximately 20 cigarettes daily and were between 24 and 36 weeks' gestation. Subjects were randomized to transdermal nicotine or to smoking ad libitum for 8 hours. One week later, they crossed over to the other condition. Maternal plasma nicotine concentrations and hemodynamic measurements were obtained before and after the onset of smoking or patch placement.

RESULTS

Area under the plasma nicotine concentration-time curve during patch use was similar to continued smoking (93 versus 89 ng-hour/mL, respectively) (P = .77). The mean (standard error [SE] change in the middle cerebral artery RI from baseline to 4 hours later was similar during patch use and smoking: -.002 (0.008) versus -.02 (0.015), respectively (P = .3). The study had greater than 80% power to detect a 25% difference in nicotine concentrations and a change of 2 standard deviations in the middle cerebral artery RI between conditions. An unexpected finding was that of a loss of fetal heart rate (FHR) reactivity in 5/8 tracings after patch placement versus 1/6 tracings after smoking (P = .12). The baseline FHR increased by a mean (SE) of 8 (4) beats per minute with loss of reactivity in the patch condition, compared with a decrease of 3 (3) beats per minute without loss of reactivity (P = .05).

CONCLUSION

Eight-hour use of 21-mg transdermal nicotine yields nicotine concentrations and middle cerebral artery RIs similar to those produced by hourly smoking in pregnant smokers.

Renal tubular acidosis in pregnancy: case report and literature review

Renal tubular acidosis is a rare form of chronic metabolic acidosis, which is either inherited as an autosomal dominant condition (Types 1, 2, and 3) or acquired. Its effects on pregnancy and vice versa are not known, but chronic acidosis may affect fetal bone growth and development. Chronic maternal acidosis may also lead to fetal distress, which should respond to correction of the maternal acidosis. The patient is a 20-year-old gravida 2, para 1-0-0-1, Hispanic female with distal renal tubular acidosis, diagnosed 1 year prior to this pregnancy after suffering from hypokalemic paralysis. During the pregnancy she required steadily increasing doses of potassium and bicarbonate, to maintain electrolyte balance. She delivered a healthy full-term female infant, weighing 2,892 g, with Apgars of 5 and 9 at 1 and 5 min, respectively, following an induction of labor for oligohydramnios. There was no evidence of intrapartum or neonatal distress, and the infant was discharged home with her mother on the first postpartum day in good health. Established renal tubular acidosis, which was adequately treated with bicarbonate and potassium supplementation during pregnancy, had no apparent ill effects on fetal or neonatal well-being in this case.

Atypical presentation of preeclampsia in high-order multifetal gestations

OBJECTIVE

To describe our experience with preeclampsia in high-order multifetal gestations.

METHODS

Records for all triplet and quadruplet pregnancies delivered after 24 weeks' gestation from January 1988 through June 1994 were reviewed. All patients were treated with bed rest from 20 weeks' gestation onward and received corticosteroids weekly beginning at 24 weeks. Tocolytics were used as needed.

RESULTS

Twenty-one triplet and eight quadruplet pregnancies were studied. The mean gestational age at delivery was 32.3 and 27.9 weeks, and mean birth weights were 1547 and 1028 g, respectively. Seventeen of 29 patients developed preeclampsia, 14 of the 21 triplet mothers and three of the eight quadruplet mothers. Among 16 patients who were delivered for preeclampsia, only eight had blood pressure (BP) elevation before delivery, whereas ten had epigastric pain, visual disturbances and/or headache; nine had elevated liver enzyme levels; and seven had low platelet counts. Only three patients had proteinuria, and only six had edema. Five women developed the syndrome of hemolysis, elevated liver enzymes, and low platelets postpartum, all of whom had normal BP before delivery. Two patients developed preeclampsia after delivery. A total of 95 infants were delivered, all by cesarean, of whom 93 (98%) survived.

CONCLUSION

Preeclampsia is common in high-order multifetal gestations and often presents in an atypical manner. Hypertension is not always the presenting sign, and symptoms consistent with severe preeclampsia and abnormal laboratory values predominate.

Mixed bacteremia with Vibrio metschnikovii in an 83-year-old female patient

An 83-year-old woman suddenly fell ill and was admitted to the hospital on suspicion of a heart attack. After admission she developed high fever, chills and malaise. Vibrio metshnikovii and Staphylococcus hominis were isolated from 2 separately obtained blood cultures. One of the cultures also yielded Escherichia coli. The patient's condition improved rapidly after treatment with ampicillin intravenously. To our knowledge, this is the fourth reported case of V. metschnikovii bacteremia in humans.

[Diagnosis of Helicobacter pylori infection. Rapid urease test, microscopy of smears and culture from ventricular biopsy compared with the 14C-urea breath test]

By employing the 14C-urea breath test as the reference method we determined the specificity and sensitivity of three bioptic methods for diagnosis of Helicobacter pylori infection in 103 subjects. All biopsy specimens were obtained from the gastric antrum. For culture the specificity was 100%. Its applicability was reduced, however, by a low sensitivity (73.8%) and a delay of several days before the final result was available. Microscopy of Loeffler-stained biopsy smears yielded a specificity of 100% and a sensitivity of 92.9%, but the method was regarded time-consuming. The rapid urease test yielded a specificity of 98.4% and a sensitivity of 85.7%. Being quick, simple and inexpensive the rapid urease test is well suited for routine use in gastroscopy.

New monoclonal antibodies identify the glycoprotein carrying the CA 125 epitope

CA 125 is an antigenic determinant located on the surface of ovarian carcinoma cells and elevated in the serum of greater than 90% of patients with carcinoma. The antigen, derived from the ovarian epithelium, has been described as a mucinlike glycoprotein greater than 200 kd. To date little is known of the metabolic regulation or expression of this antigen in either normal or neoplastic tissues. New monoclonal antibodies that we describe here recognize both unique and similar epitopes to OC 125. These reagents may allow for a more complete definition of the structure and expression of the CA 125 complex. These antibodies recognize high-molecular weight (greater than 200 kd) subspecies and a lower-molecular-weight (68 kd) subspecies of the antigen and identify it in the cytoplasm and the extracellular matrix of CA 125-producing cells.

Temafloxacin: in vitro comparison with five other antibacterial agents

The in vitro activity of the new fluorinated quinolone temafloxacin was compared with the activities of ciprofloxacin, fleroxacin, ofloxacin, ceftazidime and tobramycin. A total of 662 recent clinical isolates were included in the study, representing a variety of gram-negative and gram-positive bacteria. An agar dilution method was employed for the determination of minimal inhibitory concentrations (MICs). Ciprofloxacin showed the highest potency against the Enterobacteriaceae, 90% of the isolates being inhibited by 0.06 mg/l or less. The other quinolones were also highly active (MIC90 = 0.25-0.5 mg/l). Ciprofloxacin and tobramycin were the most active agents against the Pseudomonas isolates (MIC90 = 0.25 and 0.5 mg/l, respectively), whereas the activities of temafloxacin, fleroxacin and ofloxacin were more variable. All the quinolones had relatively high and similar activity against Staphylococcus aureus and S. epidermidis, but S. saprophyticus was markedly less susceptible to fleroxacin than to the other quinolones. The activity of temafloxacin against Streptococcus pneumoniae was somewhat higher than those of the other quinolones tested. Temafloxacin showed variable activity against Bacteroides fragilis isolates but was generally more potent against these isolates than were the other quinolones. The MICs of temafloxacin were slightly lower at pH 7.3 compared with those obtained at pHs 5.8 or 8.8.

Distribution of CA 125 in embryonic tissues and adult derivatives of the fetal periderm

New murine monoclonal antibodies to a partially purified CA 125 antigen were developed and identified as M 2 and M 11. With immunohistochemical techniques, these new antibodies and OC 125 antibody were used to search for CA 125 in embryonic tissues and adult apocrine sweat glands and mammary glands. The embryonic skin, the periderm, expressed CA 125 antigen and its adult derivatives, the mammary glands and apocrine sweat glands, expressed CA 125 while in the active state of secretion. In a 6-week-old formalin-fixed and paraffin-embedded ectopic embryo specimen, antibodies M 2 and M 11 recognized CA 125 in the periderm, the notochord, the myocardium, the pericardium, the gastroenteric tract, enteric duct remnants in the umbilical cord (vitelline and allantoic ducts), the mesonephric duct, and the amnion. OC 125 staining of these formalin-fixed specimens was either very faint or absent. In a formalin-fixed and paraffin-embedded specimen of apocrine sweat glands from the axilla, antibodies M 2 and M 11 detected CA 125 antigen intracellularly in the secretory cells. Again no staining was observed with OC 125 antibody. In a frozen and acetone-fixed specimen of lactating mammary glands, antibodies M 2 and OC 125 detected CA 125 antigen intraductally. Colostrum and milk collected from 25 mothers at various stages post partum had mean CA 125 levels of 34,213 U/ml in colostrum, 1469 U/ml at 3 to 7 days, and 105 U/ml at 5 to 26 weeks.