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Kimberly K Ma,
Lisa Mele,
Mark B Landon,
Catherine Y Spong,
Susan M Ramin,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
John M Thorp,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Steve N Caritis,
Yoram Sorokin,
Alan M Peaceman
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ABSTRACT: Objective To assess the relationship between a low 50-g 1-hour glucose loading test (GLT) and maternal and neonatal outcomes in women without diabetes.Study Design This was a secondary analysis of a multicenter observational cohort from a randomized trial of treatment for mild gestational diabetes. Maternal and neonatal outcomes were compared between women with GLT values < 90 mg/dL and those with results 90 to 119 mg/dL.Results Of 436 enrolled women, 297 (68.1%) had a GLT result of 90 to 119 mg/dL and 139 (31.9%) had a result of < 90 mg/dL. There was a lower incidence of neonatal hypoglycemia in those with a GLT < 90 mg/dL (5.7% versus 16.5%, p = 0.006). Other outcomes were not associated with test results.Conclusion A GLT result < 90 mg/dL compared with 90 to 119 mg/dL is associated with a lower risk of neonatal hypoglycemia, but no other significant findings.
American Journal of Perinatology 12/2012; · 1.32 Impact Factor
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Maged M Costantine,
Lisa Mele,
Mark B Landon,
Catherine Y Spong,
Susan M Ramin,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
John M Thorp,
Anthony Sciscione, Patrick Catalano,
Steve N Caritis,
Yoram Sorokin,
Alan M Peaceman,
Jorge E Tolosa,
Garland D Anderson
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ABSTRACT: Objective To compare the ability of customized versus normalized population fetal growth norms in identifying neonates at risk for adverse perinatal outcomes (APOs) associated with fetal overgrowth and gestational diabetes (GDM).Study Design Secondary analysis of a multicenter treatment trial of mild GDM. The primary outcome was a composite of neonatal outcomes associated with fetal overgrowth and GDM. Birth weight percentiles were calculated using ethnicity- and gender-specific population and customized norms (Gardosi).Results Two hundred three (9.8%) and 288 (13.8%) neonates were large for gestational age by population (LGApop) and customized (LGAcust) norms, respectively. Both LGApop and LGAcust were associated with the primary outcome and neonatal hyperinsulinemia, but neither was associated with hypoglycemia or hyperbilirubinemia. The ability of customized and population birth weight percentiles for predicting APOs were poor (area under the receiver operating characteristic curve < 0.6 for six of eight APOs).Conclusion Neither customized nor normalized population norms better identify neonates at risk of APOs related to fetal overgrowth and GDM.
American Journal of Perinatology 11/2012; · 1.32 Impact Factor
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Erica K Berggren,
Lisa Mele,
Mark B Landon,
Catherine Y Spong,
Susan M Ramin,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Steve N Caritis,
Yoram Sorokin,
Alan M Peaceman,
Jorge E Tolosa
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ABSTRACT: OBJECTIVE:: To compare perinatal outcomes between self-identified Hispanic and non-Hispanic white women with mild gestational diabetes mellitus (GDM) or glucose intolerance. METHODS:: In a secondary analysis of a mild GDM treatment trial, we compared perinatal outcomes by race and ethnicity for 767 women with glucose intolerance (abnormal 50-g 1-hour screen, normal 100-g 3-hour oral glucose tolerance test), 371 women with mild GDM assigned to usual prenatal care, and 397 women with mild GDM assigned to treatment. Outcomes included: composite adverse perinatal outcome (neonatal death, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, stillbirth, birth trauma), gestational age at delivery, birth weight, and hypertensive disorders of pregnancy. Adjusted regression models included: 100-g 3-hour oral glucose tolerance test results, parity, gestational age, body mass index, maternal age at enrollment, and current tobacco use. RESULTS:: The sample of 1,535 women was 68.3% Hispanic and 31.7% non-Hispanic white. Among women with glucose intolerance, Hispanic women had more frequent composite outcome (37% compared with 27%, adjusted odds ratio [OR] 1.62, 95% confidence interval [CI] 1.10-2.37) with more neonatal elevated C-cord peptide (19% compared with 13%, adjusted OR 1.79, 95% CI 1.04-3.08) and neonatal hypoglycemia (21% compared with 13%, adjusted OR 2.04, 95% CI 1.18-3.53). Among women with untreated mild GDM, outcomes were similar by race and ethnicity. Among Hispanic women with treated mild GDM, composite outcome was similar to non-Hispanic white women (35% compared with 25%, adjusted OR 1.62, 95% CI 0.92-2.86), but Hispanic neonates had more frequent hyperinsulinemia (21% compared with 10%, adjusted OR 2.96, 95% CI 1.33-6.60). CONCLUSION:: Individual components of some neonatal outcomes were more frequent in Hispanic neonates, but most perinatal outcomes were similar between Hispanic and non-Hispanic ethnic groups. LEVEL OF EVIDENCE:: II.
Obstetrics and Gynecology 11/2012; 120(5):1099-1104. · 4.73 Impact Factor
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Alison M Stuebe,
Mark B Landon,
Yinglei Lai,
Catherine Y Spong,
Marshall W Carpenter,
Susan M Ramin,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Yoram Sorokin,
Alan M Peaceman,
Jorge E Tolosa
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ABSTRACT: The purpose of this study was to estimate the association of pregravid body mass index (BMI), independent of 3-hour oral glucose tolerance test (OGTT) results, with pregnancy outcome.
In this secondary analysis of a cohort of women with untreated mild gestational glucose intolerance, which was defined as a 50-g glucose loading test between 135 and 199 mg/dL and fasting glucose level of <95 mg/dL, we modeled the association between pregravid BMI, OGTT results, and both pregnancy complications and neonatal adiposity.
Among 1250 participants, both pregravid BMI and glucose at hour 3 of the OGTT were associated with increased risk of gestational hypertension. Maternal pregravid BMI also was associated positively with large-for-gestational-age infants; both maternal BMI and fasting glucose were associated with birthweight z-score and neonatal fat mass.
Among women with untreated mild gestational glucose intolerance, pregravid BMI is associated with increased gestational hypertension, birthweight, and neonatal fat mass, independent of OGTT values.
American journal of obstetrics and gynecology 05/2012; 207(1):62.e1-7. · 3.28 Impact Factor
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Ray O Bahado-Singh,
Lisa Mele,
Mark B Landon,
Susan M Ramin,
Marshall W Carpenter,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
John M Thorp,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Steve N Caritis,
Alan M Peaceman,
Jorge E Tolosa
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ABSTRACT: We evaluated whether improvements in pregnancy outcomes after treatment of mild gestational diabetes mellitus differed in magnitude on the basis of fetal gender.
This is a secondary analysis of a masked randomized controlled trial of treatment for mild gestational diabetes mellitus. The results included preeclampsia or gestational hypertension, birthweight, neonatal fat mass, and composite adverse outcomes for both neonate (preterm birth, small for gestational age, or neonatal intensive care unit admission) and mother (labor induction, cesarean delivery, preeclampsia, or gestational hypertension). After stratification according to fetal gender, the interaction of gender with treatment status was estimated for these outcomes.
Of the 469 pregnancies with male fetuses, 244 pregnancies were assigned randomly to treatment, and 225 pregnancies were assigned randomly to routine care. Of the 463 pregnancies with female fetuses, 233 pregnancies were assigned randomly to treatment, and 230 pregnancies were assigned randomly to routine care. The interaction of gender with treatment status was significant for fat mass (P = .04) and birthweight percentile (P = .02). Among women who were assigned to the treatment group, male offspring were significantly more likely to have both a lower birthweight percentile (50.7 ± 29.2 vs 62.5 ± 30.2 percentile; P < .0001) and less neonatal fat mass (487 ± 229.6 g vs 416.6 ± 172.8 g; P = .0005,) whereas these differences were not significant among female offspring. There was no interaction between fetal gender and treatment group with regard to other outcomes.
The magnitude of the reduction of a newborn's birthweight percentile and neonatal fat mass that were related to the treatment of mild gestational diabetes mellitus appears greater for male neonates.
American journal of obstetrics and gynecology 05/2012; 206(5):422.e1-5. · 3.28 Impact Factor
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ABSTRACT: The purpose of this study was to gain insight into the pathways that are associated with inflammation at the maternal-fetal interface. This study examined the molecular characteristics of monocytes that were derived from the maternal circulation and the placenta of obese women.
Mononuclear cells were isolated from placenta, venous maternal, and umbilical cord blood at term delivery; activated monocytes were separated with CD14 immunoselection. The genotype and expression pattern of the monocytes were analyzed by microarray and real-time reverse transcriptase-polymerase chain reaction.
The transcriptome of the maternal blood and placental CD14 monocytes exhibited 73% homology, with 10% (1800 common genes) differentially expressed. Genes for immune sensing and regulation, matrix remodeling, and lipid metabolism were enhanced 2-2006 fold in placenta, compared with maternal monocytes. The CD14 placental monocytes exhibited a maternal genotype (9% DYS14 expression) as opposed to the fetal genotype (90% DYS14 expression) of the trophoblast cells.
CD14 monocytes from the maternal blood and the placenta share strong phenotypic and genotypic similarities with an enhanced inflammatory pattern in the placenta. The functional traits of the CD14 blood and placental monocytes suggest that they both contribute to propagation of inflammation at the maternal-fetal interface.
American journal of obstetrics and gynecology 09/2011; 205(3):265.e1-8. · 3.28 Impact Factor
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Celeste P Durnwald,
Lisa Mele,
Catherine Y Spong,
Susan M Ramin,
Michael W Varner,
Dwight J Rouse,
Anthony Sciscione, Patrick Catalano,
George Saade,
Yoram Sorokin,
Jorge E Tolosa,
Brian Casey,
Garland D Anderson
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[hide abstract]
ABSTRACT: To estimate the association between fasting and 2-hour postprandial blood glucose levels and neonatal outcomes in women treated for mild gestational diabetes.
In this secondary analysis of a multicenter randomized treatment trial of mild gestational diabetes, the median fasting and 2-hour postprandial glucose levels were analyzed in 2-week intervals and change over time (slope) was calculated for women with gestational diabetes (abnormal oral glucose tolerance test) and a fasting glucose less than 95 mg/dL who received nutritional management with self blood glucose monitoring and insulin as needed. Regression analyses were performed to estimate the relationship between median fasting and postprandial glucose and neonatal fat mass, cord blood C-peptide, birth weight, large-for-gestational-age neonates, macrosomia (greater than 4,000 g), and neonatal hypoglycemia.
Among 460 women with gestational diabetes, median fasting (P<.001), postprandial breakfast (P<.001), and postprandial lunch (P<.001) glucose values declined over the treatment period, whereas postprandial dinner values remained stable (P=.83). Higher median fasting glucose during the first 2 weeks of treatment was significantly associated with increased odds ratios for neonatal fat mass (1.35; 95% CI 1.09-1.66; P=.006) and elevated C-peptide (1.29; CI 1.09-1.52; P=.003). Higher median fasting glucose during the last 2 weeks before delivery was associated with higher rates of large-for-gestational-age neonates (1.27; CI 1.05-1.53; P=.01), macrosomia (1.32; CI 1.04-1.65; P = .02), and elevated C-peptide (1.19; CI 1.03-1.38; P=.02).
In women treated for mild gestational diabetes, higher fasting glucose during initiation of diet therapy was associated with increased neonatal fat mass and elevated C-peptide and during the last 2 weeks before delivery with macrosomia, large-for-gestational age, and elevated C-peptide.
II.
Obstetrics and Gynecology 04/2011; 117(4):819-27. · 4.73 Impact Factor
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Mark B Landon,
Lisa Mele,
Catherine Y Spong,
Marshall W Carpenter,
Susan M Ramin,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
John M Thorp,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Steve N Caritis,
Yoram Sorokin,
Alan M Peaceman,
Jorge E Tolosa,
Garland D Anderson
[show abstract]
[hide abstract]
ABSTRACT: To examine the relationship between varying degrees of maternal hyperglycemia and pregnancy outcomes.
This was a secondary analysis of a treatment trial for mild gestational diabetes including four cohorts: 1) 473 women with untreated mild gestational diabetes; 2) 256 women with a positive 50-g screen and one abnormal oral glucose tolerance test (OGTT) value; 3) 675 women with a positive screen and no abnormal OGTT values; and 4) 437 women with a normal 50-g screen. Groups were compared by test of trend for a composite perinatal outcome (neonatal hypoglycemia, hyperbilirubinemia, elevated cord C-peptide level, and perinatal trauma or death), frequency of large for gestational age neonates, shoulder dystocia, and pregnancy-related hypertension. Three-hour OGTT levels (fasting, 1-, 2-, and 3-hour) levels were divided into categories and analyzed for their relationship to perinatal and maternal outcomes.
There were significant trends by glycemic status among the four cohorts for the composite and all other outcomes (P<.001). Analysis for trend according to OGTT categories showed an increasing relationship between fasting and all postload levels and the various outcomes (P<.05). Fasting glucose 90 mg/dL or greater and 1 hour 165 mg/dL or greater were associated with an increased risk for the composite outcome (odds ratios and 95% confidence intervals of 2.0 [1.03–4.15] and 1.46 [1.02–2.11] to 1.52 [1.08–2.15] for the fasting and 1 hour, respectively). A 1 hour glucose 150 mg/dL or greater was associated with an increased risk for large for gestational age (odds ratios, 1.8 [1.02–3.18] to 2.35 [1.35–4.14]); however, 2- and 3-hour glucose levels did not increase the risk for the composite or large for gestational age until well beyond current gestational diabetes diagnostic thresholds.
A monotonic relationship exists between increasing maternal glycemia and perinatal morbidity. Current OGTT criteria require reevaluation in determining thresholds for the diagnosis and treatment of gestational diabetes.
II
Obstetrics and Gynecology 02/2011; 117(2 Pt 1):218-24. · 4.73 Impact Factor
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Mark B. Landon,
Lisa Mele,
Catherine Y. Spong,
Marshall W. Carpenter,
Susan M. Ramin,
Brian Casey,
Ronald J. Wapner,
Michael W. Varner,
Dwight J. Rouse,
John M. Jr Thorp,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Steve N. Caritis,
Yoram Sorokin,
Alan M. Peaceman,
Jorge E. Tolosa,
Garland D. Anderson
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: To examine the relationship between varying degrees of maternal hyperglycemia and pregnancy outcomes.
METHODS: This was a secondary analysis of a treatment trial for mild gestational diabetes including four cohorts: 1) 473 women with untreated mild gestational diabetes; 2) 256 women with a positive 50-g screen and one abnormal oral glucose tolerance test (OGTT) value; 3) 675 women with a positive screen and no abnormal OGTT values; and 4) 437 women with a normal 50-g screen. Groups were compared by test of trend for a composite perinatal outcome (neonatal hypoglycemia, hyperbilirubinemia, elevated cord C-peptide level, and perinatal trauma or death), frequency of large for gestational age neonates, shoulder dystocia, and pregnancy-related hypertension. Three-hour OGTT levels (fasting, 1-, 2-, and 3-hour) levels were divided into categories and analyzed for their relationship to perinatal and maternal outcomes.
RESULTS: There were significant trends by glycemic status among the four cohorts for the composite and all other outcomes (P<.001). Analysis for trend according to OGTT categories showed an increasing relationship between fasting and all postload levels and the various outcomes (P<.05). Fasting glucose 90 mg/dL or greater and 1 hour 165 mg/dL or greater were associated with an increased risk for the composite outcome (odds ratios and 95% confidence intervals of 2.0 [1.03–4.15] and 1.46 [1.02–2.11] to 1.52 [1.08–2.15] for the fasting and 1 hour, respectively). A 1 hour glucose 150 mg/dL or greater was associated with an increased risk for large for gestational age (odds ratios, 1.8 [1.02–3.18] to 2.35 [1.35–4.14]); however, 2- and 3-hour glucose levels did not increase the risk for the composite or large for gestational age until well beyond current gestational diabetes diagnostic thresholds.
CONCLUSION: A monotonic relationship exists between increasing maternal glycemia and perinatal morbidity. Current OGTT criteria require reevaluation in determining thresholds for the diagnosis and treatment of gestational diabetes.
LEVEL OF EVIDENCE: II
Obstetrics and Gynecology 01/2011; 117(2, Part 1):218-224. · 4.73 Impact Factor
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Mark B Landon,
Catherine Y Spong,
Elizabeth Thom,
Marshall W Carpenter,
Susan M Ramin,
Brian Casey,
Ronald J Wapner,
Michael W Varner,
Dwight J Rouse,
John M Thorp,
Anthony Sciscione, Patrick Catalano,
Margaret Harper,
George Saade,
Kristine Y Lain,
Yoram Sorokin,
Alan M Peaceman,
Jorge E Tolosa,
Garland B Anderson
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ABSTRACT: It is uncertain whether treatment of mild gestational diabetes mellitus improves pregnancy outcomes.
Women who were in the 24th to 31st week of gestation and who met the criteria for mild gestational diabetes mellitus (i.e., an abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg per deciliter [5.3 mmol per liter]) were randomly assigned to usual prenatal care (control group) or dietary intervention, self-monitoring of blood glucose, and insulin therapy, if necessary (treatment group). The primary outcome was a composite of stillbirth or perinatal death and neonatal complications, including hyperbilirubinemia, hypoglycemia, hyperinsulinemia, and birth trauma.
A total of 958 women were randomly assigned to a study group--485 to the treatment group and 473 to the control group. We observed no significant difference between groups in the frequency of the composite outcome (32.4% and 37.0% in the treatment and control groups, respectively; P=0.14). There were no perinatal deaths. However, there were significant reductions with treatment as compared with usual care in several prespecified secondary outcomes, including mean birth weight (3302 vs. 3408 g), neonatal fat mass (427 vs. 464 g), the frequency of large-for-gestational-age infants (7.1% vs. 14.5%), birth weight greater than 4000 g (5.9% vs. 14.3%), shoulder dystocia (1.5% vs. 4.0%), and cesarean delivery (26.9% vs. 33.8%). Treatment of gestational diabetes mellitus, as compared with usual care, was also associated with reduced rates of preeclampsia and gestational hypertension (combined rates for the two conditions, 8.6% vs. 13.6%; P=0.01).
Although treatment of mild gestational diabetes mellitus did not significantly reduce the frequency of a composite outcome that included stillbirth or perinatal death and several neonatal complications, it did reduce the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders. (ClinicalTrials.gov number, NCT00069576.)
New England Journal of Medicine 10/2009; 361(14):1339-48. · 53.30 Impact Factor
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ABSTRACT: The purpose of this study was to compare body composition measures in neonates of women who were overweight/obese (body mass index, > or = 25 kg/m2) versus women who were lean/average (body mass index, < 25 kg/m2), all of whom had normal glucose tolerance levels.
Seventy-six neonates (34 female and 42 male) of singleton pregnancies of pregravid overweight/obese women and 144 neonates (67 female and 77 male) of lean/average women were assessed with anthropometric measures and total body electrical conductivity evaluation of body composition at birth.
There was a borderline increase in birthweight (3436 +/- 567 g vs 3284 +/- 534 g; P = .051) but not lean body mass (3020 +/- 410 g vs 2950 +/- 400 g; P = .23) in the overweight/obese versus lean/average weight groups. However, there were significant increases in percent body fat (11.6% +/- 4.7% vs 9.7 +/- 4.3%; P = .003) and fat mass (420 +/- 220 g vs 380 +/- 170 g; P = .01) in neonates of overweight/obese women versus lean/average weight women.
Overweight/obese women with normal glucose tolerance levels have neonates who are heavier than lean/average weight women because of increased adiposity. We speculate that this increased obesity in offspring of obese women with normal glucose tolerance levels is a significant risk for adolescent obesity and components of the metabolic syndrome.
American journal of obstetrics and gynecology 10/2006; 195(4):1100-3. · 3.28 Impact Factor
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ABSTRACT: Leptin, which was identified originally as an adipocyte-derived protein, was regarded for years as an exclusive regulator of satiety and energy homeostasis. A role for leptin in pregnancy was later suggested by the findings that plasma levels during gestation are greater than in nongravid individuals and that leptin is synthesized within the fetoplacental unit. Observational studies have established that leptin production is dysregulated in several pathologic stages of pregnancy in association with alterations of fetal growth. For example, an overproduction of leptin by the placenta in pregnancy with diabetes mellitus or hypertension is associated with maternal hyperleptinemia. Evidence is also accumulating that umbilical leptin levels can be viewed as a biomarker of fetal adiposity. Ten years after its discovery as a hormone, we review the known and unknowns of leptin in pregnancy with particular emphasis on its functions in health and disease. We aim to demonstrate that studies of leptin in pregnancy largely have contributed to insight into the mechanisms of leptin action, both as a hormone and as a cytokine.
American journal of obstetrics and gynecology 07/2006; 194(6):1537-45. · 3.28 Impact Factor
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ABSTRACT: Obesity and diabetes during pregnancy are associated with increased insulin resistance and higher neonatal adiposity. In turn, insulin resistance triggers inflammatory pathways with accumulation of placental cytokines.
To determine placental signals that translate into development of excess adipose tissue, we investigated the role of phospholipases A2 (PLA2) as targets of inflammatory mediators.
The study was conducted at Case Western Reserve University, Department of Reproductive Biology.
Volunteers gave informed written consent in accordance with the Institutional Review Board guidelines. Placenta and cord blood samples were obtained at the time of elective cesarean section in 15 term pregnancies.
Neonatal anthropometric measurements were performed within 48 h of delivery. Placentas were grouped based on neonatal percentage body fat as obese (body fat > or = 16%) and lean control (body fat < or = 8%).
The primary outcomes were placenta PLA2 expression and fatty acid concentration.
Expression of PLA2G2A and PLA2G5, the main placenta phospholipases, was greater (P < 0.05) in placenta of obese compared with control neonates and was associated with increased 20:3 and 20:5 omega-3 polyunsaturated fatty acids. TNF-alpha and leptin content was increased 3-fold in placenta of obese neonates. TNF-alpha and leptin both induced a time-dependent activation of PLA2G2 and PLA2G5 in placental cells.
Accumulation of omega-3 fatty acids through secretory PLA2 activation is associated with high neonatal adiposity. We propose that the generation of placental lipid mediators through TNF-alpha and leptin stimulation represents a key mechanism to favor excess fetal fat accretion.
Journal of Clinical Endocrinology & Metabolism 02/2006; 91(1):248-55. · 6.50 Impact Factor
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ABSTRACT: Fetal overgrowth and higher adiposity are hallmarks of pregnancy with maternal obesity and poor glucose tolerance, two conditions associated with decreased maternal insulin sensitivity. In non-pregnant individuals, adipokines, vasoactive peptides, and components of the immune system crosstalk with metabolic factors to generate signals triggering obesity and impaired insulin action. We have investigated circulating maternal and fetal cytokines and growth-factors as potential biochemical markers of fetal adiposity. Mothers and neonates were classified into three tertiles (T1-T3) using total neonatal fat mass as the outcome with 309 +/- 25 g in T1, 478 +/- 40 g in T2, and 529 +/- 39 g in T3. Umbilical cord endothelin-1 (ET-1), C-peptide, and leptin were higher in T3 and T2 versus T1. Only cord leptin was strongly associated with fetal fat mass (P < .01), whereas neonatal lean body mass was negatively correlated with maternal insulin-like growth factor binding protein-I (IGFBP-I) (r = -0.53, P < .04). This study shows an association between increased fetal adiposity and maternal systemic interleukin-6 (IL-6). No such correlation was found with factors circulating in cord blood, suggesting that the stimuli favoring fetal fat accretion derive from maternal or placental sources rather than from the fetus.
Journal of the Society for Gynecologic Investigation 02/2006; 13(1):53-7. · 2.26 Impact Factor
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ABSTRACT: To determine the influence of pregravid obesity and diabetes on cesarean delivery (CD) risk.
Women with singleton pregnancies of 23 weeks or more estimated gestational age who were undergoing a trial of labor January 1997 through June 2001 were categorized by pregravid body mass index (underweight [<19.8 kg/m 2 ], normal [19.8-25 kg/m 2 ], overweight [25.1-30 kg/m2], obese [>30 kg/m2]). Diabetes (DM) was divided into categories of gestational, treated with diet modification (A1GDM) or insulin (A2GDM), and pregestational (PDM). Prior CDs were excluded. CD rates for each group were compared in univariate analyses stratified by estimated gestational age (term, preterm, total). Other variables examined included DM, macrosomia (birth weight 4500 g or more), induction, and parity. Multiple regression included significant variables to predict the influence of diabetes and obesity on CD risk.
Records for 12,303 deliveries were evaluated (obese: 2828 [22.9%]; overweight: 2605 [21.2%]; A1GDM: 270 [2.2%]; A2GDM: 93 [0.8%]; PDM: 126 [1%]). Obese and overweight subjects had a higher risk for CD, compared with normal subjects (13.8% and 10.4% versus 7.7%, P < .0001 for each). Other CD risk factors were macrosomia (25% versus 9.4%), nulliparity (16.5% versus 4.7%), induction (17.4% versus 8.3%), diabetes (A1GDM: 16.7% versus 9.4%; A2GDM: 24.7% versus 9.5%; PDM: 34.9% versus 9.3%) and black race (10.7% versus 8.8%) ( P < .0001 for each). In multiple regression models including term deliveries, obesity and PDM were independent CD risk factors ([adjusted OR overweight: 1.5, P < .0001; adjusted OR PDM: 2.9, P = .01]; [adjusted OR obese: 2.4, P < .0001, PDM: 2.9, P = .0002]).
Pregravid obesity and diabetes independently increase the risk for CD. Given the disparate prevalence of obesity and diabetes in the United States, body habitus has a significantly larger impact on CD risk.
American Journal of Obstetrics and Gynecology 09/2004; 191(3):969-74. · 3.47 Impact Factor
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ABSTRACT: The purpose of this study was to determine whether there is a difference in body composition and the factors that are associated with fat mass in the large-for-gestational-age infants of women with gestational diabetes mellitus compared with the large-for-gestational-age infants of women with normal glucose tolerance levels.
Large for gestational age was defined as weight >90th percentile for gestational age, race, and sex on the basis of our population's normative data. Anthropometric measurements and/or total body electrical conductivity estimated body composition that included fat mass, percent body fat, and lean body mass were obtained. Multiple stepwise regression was used to determine factors correlating with fat mass.
Fifty cases of women with gestational diabetes mellitus and 52 cases of women with normal glucose tolerance levels were evaluated. Infants of mothers with gestational diabetes mellitus had increased fat mass (662 vs 563 g; P = .02) and percent body fat (16.2% vs 13.5%; P = .002) but decreased lean body mass (3400 vs 3557 g; P = .0009), as compared with infants of mothers with normal glucose tolerance levels, despite similar birth weights. Stepwise regression on all 102 women showed gestational age and a diagnosis of gestational diabetes mellitus correlated with fat mass (r2 = 0.11; P = .001). For gestational diabetes mellitus alone, both gestational age and fasting value of the oral glucose tolerance test correlated with fat mass and percent body fat (r2 = 0.33 [P = .0009] and r2 = 0.26 [P = .005], respectively).
Large-for-gestational-age infants of mothers with gestational diabetes mellitus have increased fat mass and decreased lean body mass compared with infants of mothers with normal glucose tolerance levels. In gestational diabetes mellitus, gestational age and fasting value of the oral glucose tolerance test correlated best with fat mass.
American Journal of Obstetrics and Gynecology 09/2004; 191(3):804-8. · 3.47 Impact Factor
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ABSTRACT: A physiological state of insulin resistance is required to preferentially direct maternal nutrients toward the feto-placental unit, allowing adequate growth of the fetus. When women develop gestational diabetes mellitus (GDM), insulin resistance is more severe and disrupts the intrauterine milieu, resulting in accelerated fetal development with increased risk of macrosomia. As a natural interface between mother and fetus, the placenta is the obligatory target of such environmental changes. However, the molecular basis for the imbalance that leads to fetal, neonatal, and adult metabolic compromises is not well understood. We report that GDM elicits major changes in the expression profile of placental genes with a prominent increase in markers and mediators of inflammation. Within the 435 transcripts reproducibly modified, genes for stress-activated and inflammatory responses represented the largest functional cluster (18.5% of regulated genes). Upregulation of interleukins, leptin, and tumor necrosis factor-alpha receptors and their downstream molecular adaptors indicated an activation of pathways recruiting stress-activated protein/c-Jun NH(2)-terminal kinases. Transcriptional activation of extracellular matrix components and angiogenic activators pointed to a major structural reorganization of the placenta. Thus, placental transcriptome emerges as a primary target of the altered environment of diabetic pregnancy. The genes identified provide the basis to elucidate links between inflammatory pathways and GDM-associated insulin resistance.
Diabetes 01/2004; 52(12):2951-8. · 8.29 Impact Factor
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ABSTRACT: A 35-year-old woman, gravida 2, para 0, was seen at 20 weeks' gestation with complete T10 spinal cord transection at age 15 years, subsequent bilateral total leg amputation, urinary diversion, colostomy, and lumbar spine resection. Pregnancy complications included recurrent urinary tract infections, preterm contractions without cervical change, lumbosacral abscesses, and fetal malpresentation. Delivery was through cesarean section near term.
American Journal of Obstetrics and Gynecology 05/2003; 188(4):1096-9. · 3.47 Impact Factor
