Human milk imparts higher insulin concentration in infants born to women with type 2 diabetes mellitus.

OBJECTIVE: Human milk (HM) insulin plays many roles for the infant, especially for the newborn. We hypothesized HM insulin in women with type 2 diabetes (T2DM) would be higher than BMI-matched women with either gestational diabetes (GDM) or normal glucose tolerance (NGT). In T2DM, we also assessed macronutrient composition and relationships between maternal glycemic control and HM insulin. STUDY DESIGN: HM was characterized at 2-weeks postpartum among three BMI-matched groups: T2DM (n= 12), diet-controlled GDM (n= 12), and NGT (n= 12). In T2DM, additional fasting and postprandial HM samples were collected while wearing a continuous glucose monitor (CGM), as well as fasting and 90-minute postprandial samples after a standardized meal at 1-2 weeks postpartum. RESULTS: Fasting HM insulin was two times higher in T2DM compared to GDM and NGT (p < .001), which were not different from each other. Among T2DM, fasting (p < .001) and postprandial (p = .01) HM insulin levels were between 2 and 5× higher than plasma. Postprandial HM insulin (p = .03) and glucose (p < .001) were increased compared to fasting. Mean nocturnal glucose (p < .01) and maternal hemoglobin A1c (p < .01) positively associated with fasting HM insulin. CONCLUSIONS: These data are the first to show HM insulin concentrations are doubled in T2DM compared to BMI-matched GDM and NGT. In HM of T2DM, insulin increases postprandially, may be concentrated relative to plasma, and is influenced by maternal glycemic control, with potential clinical implications that merit further study.

Diamond-Blackfan Anemia: A Case Report and Review of the Literature.

We report a case of a male neonate delivered urgently via cesarean at thirty-five 5/7 weeks gestation for non-reassuring fetal monitoring who was found to have severe anemia at birth that could not be explained by acute blood loss. He was born to a 24-year-old mother, whose pregnancy was complicated by abnormal ultrasound findings, including a radial ray defect and fetal growth restriction. Trio rapid whole-exome sequencing (rWES) confirmed Diamond-Blackfan anemia in both the neonate and mother. This case highlights the importance of fetal surveillance and the clinical utility of rWES in the neonatal intensive care setting.

Effect of type 2 diabetes mellitus on placental expression and activity of nutrient transporters and their association with birth weight and neonatal adiposity.

AIMS: Infants born to women with Type 2 Diabetes Mellitus (T2DM) are at risk of being born large for gestational age due to excess fetal fat accretion. Placental nutrient transport determines fetal nutrient availability, impacting fetal growth. The aims of the study were to evaluate the effect of T2DM on placental insulin signaling, placental nutrient transporters and neonatal adiposity. METHODS: Placentas were collected from BMI-matched normoglycemic controls (NGT, n = 9) and T2DM (n = 9) women. Syncytiotrophoblast microvillous (MVM) and basal (BM) plasma membranes were isolated. Expression of glucose (GLUT1, -4), fatty acid (FATP2, -4, -6, FAT/CD36), amino acid (SNAT1, -2, -4, LAT1, -2) transporters, insulin signaling, and System A transporter activity was determined. Neonatal fat mass (%) was measured in a subset of neonates born to T2DM women. RESULTS: GLUT1 protein expression was increased (p = 0.001) and GLUT4 decreased (p = 0.006) in BM from T2DM. MVM FATP6 expression was increased (p = 0.02) and correlated with birth weight in both T2DM and NGT groups (r = 0.65, p = 0.02). BM FATP6 expression was increased (p = 0.01) in T2DM. In MVM of T2DM placentas, SNAT1 expression was increased (p = 0.05) and correlated with birth weight (r = 0.84, p = 0.004); SNAT2 was increased (p = 0.01), however System A transporter activity was not different between groups. MVM LAT1 expression was increased (p = 0.01) in T2DM and correlated with birth weight (r = 0.59, p = 0.04) and neonatal fat mass (r = 0.76, p = 0.06). CONCLUSION: In pregnancies complicated by T2DM placental protein expression of transporters for glucose, amino acids and fatty acids is increased, which may contribute to increased fetal growth and neonatal adiposity.

Cesarean wound closure in body mass index 40 or greater comparing suture to staples: a randomized clinical trial.

BACKGROUND: Cesarean delivery is the most common major surgical procedure performed in the United States. Women with class III obesity have an increased risk of cesarean delivery and have wound complication rates higher than healthy body mass index counterparts. Available evidence regarding optimal wound closure is lacking specific to the population of women with class III obesity despite a known increased rate of wound complications. OBJECTIVE: This study aimed to compare rates of postoperative wound complications among women with class III obesity (body mass index of ≥40 kg/m2) undergoing cesarean delivery with skin closure by either subcuticular suture or surgical staples. STUDY DESIGN: Patients were randomly assigned to skin closure by nonabsorbable stainless steel surgical staples or subcuticular suture of the surgeon's choice at the time of cesarean delivery at 2 university hospitals. Randomization was stratified for scheduled vs unscheduled cesarean delivery and for the 2 study sites. The primary outcome was the rate of any documented wound complication during the first 6 weeks after delivery. Any predictors of the composite outcome that in univariate analysis had a P<.20 were entered into a forward logistic regression. Sample size was calculated based on published literature and estimating the rate of wound complications within 6 weeks of follow-up at 20% with staples and 10% with sutures. For a power of 0.80 with a 2-tailed of 0.05, a total of 199 participants per group were required. RESULTS: From September 2015 to May 2019, 232 women were randomized to staples (n=117) or sutures (n=115). Nearing the planned interim analysis, enrollment in the study was concluded administratively owing to low enrollment. With loss to follow-up and exclusions, a total of 90 women were analyzed in each group. In the suture group, one-third was closed with braided suture and two-thirds were closed with monofilament suture. Median staple removal was 5 days postoperatively. Fewer composite wound complications were noted in the surgical staples group than the subcuticular suture group (20.0% vs 27.6%), although this difference was not statistically significant (P≥.5). The rate of surgical site infection was significantly lower in the staples group (10.5% vs 22.7%; P=.041). In the multiple logistic regression, the 3 significant independent predictors of the outcome were body mass index (odds ratio, 1.08; P=.004), scheduled vs unscheduled cesarean delivery (odds ratio, 0.40; P=.018), and study site (odds ratio, 0.36; P=.028). CONCLUSION: Surgical staples or subcuticular suture for skin closure at the time of cesarean delivery in women with a body mass index of ≥40 kg/m2 resulted in similar composite wound complication rates; however, lower cesarean wound infection rates were noted among wounds closed with staples.