Associations of neonatal adiponectin and leptin with growth and body composition in African American infants.

BACKGROUND: Cord blood adiponectin and leptin concentrations are associated with birth weight and adiposity. Birth size and rate of infant weight gain are associated with future obesity risk. However, it is unclear whether biomarkers reflecting the intrauterine environment are predictive of infant prospective body composition change. OBJECTIVES: To examine whether cord blood adiponectin and leptin are predictive of neonatal adiposity and fat mass (FM) accrual to 3 months of age. METHODS: Participants (n = 36) were healthy African American infants. Leptin and adiponectin concentrations were measured in umbilical cord blood. At 2 weeks and 3 months, infant body composition was assessed via air displacement plethysmography. Weight-for-length z-scores (WLZ) were calculated using World Health Organization standards. Multiple linear regression was used to examine associations of cord blood adiponectin and leptin with birth WLZ; WLZ, FM and fat-free mass at 2 weeks, and the conditional change in these variables from 2 weeks to 3 months (body composition at 3 months adjusted for body composition at 2 weeks). RESULTS: Adiponectin was positively associated with FM at 2 weeks (r = 0.45, P < 0.01), but inversely associated with conditional FM change from 2 weeks to 3 months of age (r = -0.38, P < 0.05). Leptin was not significantly associated with infant body composition. CONCLUSIONS: Adiponectin may be a marker for FM accrual in African American infants, a relatively understudied population with a high long-term obesity risk. Mechanistic studies are needed to determine whether adiponectin directly influences infant growth or is simply a maker reflective of other ongoing biological changes after birth.

Association of early pregnancy body mass index with post-partum weight change among African-American women.

Post-partum weight retention is relatively common and increases the risk for future obesity. Women who are overweight or obese prior to pregnancy, or who gain excessively during pregnancy, are more likely to retain weight post-partum. Much of the existing research is limited by a single post-partum body-weight measure and therefore cannot distinguish post-partum weight retention from post-partum weight accrual. This study tested the hypothesis that early pregnancy body mass index (BMI) is positively associated with post-partum weight change, independent of gestational weight gain (GWG) and breastfeeding (BF) among African-American women, a demographic group with greater risk for obesity. Healthy African-American women (n = 32) were weighed at 2 weeks and 3 months post-partum to derive post-partum weight change. Data from prenatal care records were retrieved to calculate BMI at the first prenatal care visit and GWG. BF status at 2 weeks post-partum was self-reported. Early pregnancy BMI was positively associated with post-partum weight change (partial r = 0.53, P < 0.005), independent of GWG and BF status at 2 weeks post-partum. These results extend the literature by suggesting that the association between early pregnancy BMI and post-partum weight retention may be at least partially attributable to the accrual of new weight during the post-partum period. Future research in a larger and more diverse cohort is warranted and should explore potential mechanisms contributing to post-partum weight change.

Is use of multiple antihypertensive agents to achieve blood pressure control associated with adverse pregnancy outcomes?

OBJECTIVE: We assessed whether requiring >1 medication for blood pressure control is associated with adverse pregnancy outcomes. STUDY DESIGN: Retrospective cohort of 974 singletons with chronic hypertension at a tertiary care center. Subjects on >1 antihypertensive agent were compared with those on one agent <20 weeks gestational age with results stratified by average blood pressure (<140/90 and ⩾140/90 mm Hg) from prenatal visits. The primary maternal outcome was preeclampsia; the primary neonatal outcome was small for gestational age (<10th percentile). RESULT: Among women with blood pressure ⩾140/90 mm Hg, women on multiple agents had the greatest risk of preeclampsia, severe preeclampsia, antenatal admissions to rule out preeclampsia, preterm birth <35 weeks and composite neonatal adverse outcomes. CONCLUSION: Compared with use of a single agent when blood pressure is ⩾140/90 mm Hg, use of multiple agents increases adverse risks, while no such finding exists when blood pressure is controlled below 140/90 mm Hg.

Predicting failure of glyburide therapy in gestational diabetes.

OBJECTIVE: We sought to develop a prediction model to identify women with gestational diabetes (GDM) who require insulin to achieve glycemic control. STUDY DESIGN: Retrospective cohort of all singletons with GDM treated with glyburide from 2007 to 2013. Glyburide failure was defined as reaching glyburide 20 mg day(-1) and receiving insulin. Glyburide success was defined as any glyburide dose without insulin and >70% of visits with glycemic control. Multivariable logistic regression analysis was performed to create a prediction model. RESULT: Of the 360 women, 63 (17.5%) qualified as glyburide failure and 157 (43.6%) as glyburide success. The final prediction model for glyburide failure included prior GDM, GDM diagnosis ⩽26 weeks, 1-h glucose challenge test ⩾228 mg dl(-1), 3-h glucose tolerance test 1-h value ⩾221 mg dl(-1), ⩾7 postprandial blood sugars >120 mg dl(-1) in the week glyburide started and ⩾1 blood sugar >200 mg dl(-1). The model accurately classified 81% of subjects. CONCLUSION: Women with GDM who will require insulin can be identified at the initiation of pharmacological therapy.

Foley catheter for induction of labor: potential barriers to adopting the technique.

OBJECTIVE: To evaluate if a learning curve exists for cervical Foley placement for labor induction in women with unfavorable cervices and whether labor curves differ compared with the dinoprostone insert (PGE2). STUDY DESIGN: We conducted a secondary analysis of a multicenter randomized controlled trial. RESULT: For Foley and PGE2, successful placement occurred in 157/185 (85%) and 188/191 (98%) women (P<0.001). Unsuccessful Foley placements decreased over time (P=0.005); all occurred at the site previously using PGE2 preferentially. In women with allocated agent placed successfully who achieved complete cervical dilation, median progress with Foley (n=112), compared with PGE2 (n=123), was: 1-3 cm (6.2 vs 14.1 h; P<0.001), 3-6 cm (11.1 vs 6.7 h; P<0.001) and 6-10 cm (1.9 vs 1.5 h; P=0.14). CONCLUSION: There is a learning curve for placing cervical Foley catheters. Despite faster times to delivery, Foley is associated with slower dilation from 3 to 6 cm compared with PGE2.

Timing of elective delivery in gastroschisis: a decision and cost-effectiveness analysis.

OBJECTIVE: To determine the most cost-effective timing of delivery in pregnancies complicated by gastroschisis, using a decision-analytic model. METHODS: We created a decision-analytic model to compare planned delivery at 35, 36, 37, 38 and 39 weeks' gestation. Outcomes considered were stillbirth, death within 1 year of birth and respiratory distress syndrome (RDS). Probability estimates of events (stillbirth, complex gastroschisis and RDS for each gestational age at delivery and risk of death with simple and complex gastroschisis), utilities and costs assigned to the outcomes were obtained from the published literature. Cost analysis was assessed from a societal perspective, using a willingness-to-pay threshold of $100,000 per surviving infant. Outcomes and costs were considered throughout 1 year of postnatal life. Multiway sensitivity analysis was performed to address uncertainties in baseline assumptions. RESULTS: In the base-case analysis, delivery at 38 weeks' gestation was the most cost-effective strategy. Planned delivery at 35 weeks was associated with the fewest stillbirths and deaths within 1 year of delivery, owing largely to a lower ongoing risk of stillbirth. In Monte Carlo simulation when every variable was varied over its entire range, delivery at 38 weeks was cost-effective compared to delivery at 39 weeks in 76% of trials and delivery at 37 weeks was cost-effective in 69% of trials. Delivery at 38 weeks resulted in three additional cases of RDS for every 100 stillbirths or deaths within 1 year that were prevented. CONCLUSIONS: For pregnancies complicated by gastroschisis, the most cost-effective timing of delivery is at 38 weeks. Few additional cases of RDS are caused for every one stillbirth or death within 1 year that was prevented with delivery at 37-38 weeks compared with at 39 weeks.

Pregnancy and active Huntington disease: a rare combination.

We describe the complicated course of a rare pregnant woman with symptomatic Huntington disease (HD) and discuss multidisciplinary care issues that may be encountered. A 31-year-old gravida 2, para 1 with advanced HD was admitted at 30 weeks gestation for preterm labor. Her course was complicated by progressive cognitive and physical impairment, dysphagia, malnutrition, diabetes insipidus, aspiration pneumonia, chorioamnionitis, preterm delivery and pyelonephritis. Pregnant women with symptomatic HD may present multiple challenges requiring extensive multidisciplinary input.

Can prenatal ultrasound findings predict ambulatory status in fetuses with open spina bifida?

OBJECTIVE: To determine whether prenatal sonographic findings in fetuses with open spina bifida can predict ambulatory potential and the need for postnatal shunt placement. STUDY DESIGN: Ongoing pregnancies complicated by isolated open spina bifida from January 1996 to March 2000 were studied retrospectively. Static images and reports generated every 3-4 weeks from diagnosis until delivery were reviewed for lesion level and type, ventricular width, and lower extremity appearance. Operative summaries as well as neonatal and pediatric charts were reviewed. Ambulatory was defined in infants > or =2 years old as walking with or without appliances. In those <2 years of age, ambulatory was defined as at least 4/5 lower extremity muscle strength. RESULTS: Thirty-three cases of isolated open spina bifida were identified. Lower (more caudal) lesion levels and smaller ventricular size were associated with ambulatory status in univariate analyses (P <.001, P =.003, respectively). No infant with a thoracic lesion was ambulatory (n = 11); all had ventriculomegaly diagnosed prenatally and all required shunt placement. In contrast, all infants with L4-sacral lesions (n = 10) were ambulatory, and 60% had ventriculomegaly diagnosed prenatally. Of patients with L1-L3 lesions (n = 12), 50% were ambulatory. In this group, ambulatory potential could not be determined by the presence of ventriculomegaly, ventricular size, or the presence of club foot. In the entire cohort, no infant with a myeloschisis was ambulatory, and all infants except one with a sacral lesion required postnatal shunt placement. CONCLUSIONS: Sonographic determination of lesion level and type is useful in predicting the ambulatory potential of fetuses with open spina bifida.

Hydramnios prediction of adverse perinatal outcome.

OBJECTIVE: To determine whether hydramnios is associated with an increased risk of adverse perinatal outcomes. METHODS: Computerized records of all ultrasound examinations done at the University of Alabama at Birmingham from 1986 to 1996 (n = 40,065) were reviewed to identify 370 women with singleton pregnancies beyond 20 weeks' gestation and hydramnios diagnosed sonographically by amniotic fluid index of 25 cm or more, largest vertical pocket of 8 cm or more, or subjective impression. Controls were all women with singleton gestations with normal amniotic fluid volumes (n = 36,426). Obstetric outcomes were determined by cross-reference to our database. Cases with hydramnios were compared with controls for perinatal death, anomaly rate, fetal growth restriction (FGR), cesarean delivery, fetal aneuploidy, and maternal diabetes. Cases were sorted according to diabetes status, after which perinatal death, anomaly rate, FGR, cesarean delivery, and fetal aneuploidy were compared again. RESULTS: The incidence of hydramnios was 1%. The perinatal mortality rate in all women with hydramnios was 49 per 1000 births, compared with 14 per 1000 births in the control group (P < .001). Women with hydramnios had 25 times more anomalies than controls (8.4% versus 0.3%; P < .001), although the prevalence of fetal aneuploidy was not significantly different (one in 370 versus one in 3643; P = .10). The cesarean rate was three times higher in women with hydramnios compared with controls (47.0% versus 16.4%; P < .001). When hydramnios cases were divided according to diabetes status, all of the increased risk was in nondiabetic women: Perinatal mortality was 60 per 1000 in nondiabetic women versus 0 per 1000 in diabetic women (P = .03); the anomaly rate was 10.4% versus 0%, respectively (P = .005). CONCLUSION: Hydramnios indicated an increased risk of adverse perinatal outcomes, especially if not associated with diabetes. A comprehensive fetal evaluation, a workup to rule out maternal factors, and fetal surveillance are warranted; amniocentesis for fetal karyotype analysis might not be necessary.