Preventing Adverse Cardiovascular Outcomes in Pregnancy Complicated by Obesity.

Purpose of review: Obesity is a chronic disease that is becoming increasingly prevalent, and more individuals of reproductive age have obesity prior to becoming pregnant. Obesity in pregnancy is associated with short- and long-term adverse consequences for both the birthing person and their offspring which have been associated with increased long-term cardiovascular morbidity and mortality. The goal of this review is to discuss what is currently understood about the relationship between maternal obesity and adverse pregnancy outcomes (APOs), the association between APOs and future cardiovascular disease (CVD) risk, and what evidence-based interventions can be implemented to prevent adverse outcomes in this population. Recent findings: Maternal obesity has been associated with an increased risk of APOs such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth as well as an increased risk of future CVD, such as metabolic syndrome, chronic hypertension, coronary heart disease, and stroke. The impact of maternal obesity also extends beyond the pregnant individual to the offspring, increasing the risk of fetal, neonatal, and infant mortality, as well as of congenital malformations, prematurity, and long-term health problems such as insulin resistance and childhood obesity. Prevention guidelines are incorporating the increased risk of adverse outcomes from maternal obesity into formalized risk assessments to guide both prenatal and postpartum care. It is becoming evident that a multidisciplinary cardio-obstetrics team is an important part of providing comprehensive care for pregnant individuals with obesity and other cardiovascular risk factors, including preexisting CVD and a history of prior APOs. There remains a need for further studies to better understand the mechanisms underlying the relationship between maternal obesity and APOs, as well as the racial and ethnic disparities that have been noted in the prevalence of APOs and associated CVD risk and mortality. Summary: There is increasing awareness that obesity in pregnancy is associated with various short- and long-term adverse maternal and offspring outcomes. There are multiple screening and prevention strategies that may be implemented before, during, and after pregnancy to prevent these adverse outcomes.

Maternal Immunomodulation Therapy for Prevention of Preterm Birth and Prematurity-Related Morbidity: The New Era of Immuno-Perinatology.

Preterm birth and associated prematurity-related morbidity can significantly affect neonatal health and outcomes. While the mechanisms of preterm labor are yet to be fully understood, there is a need for prenatal therapeutic interventions to treat these conditions. As it is recognized from literature, the immune mechanisms responsible for preterm labor may be different from those responsible for prematurity-related conditions in the neonate. Differentiating the mechanisms for these two processes is yet to be addressed, and steps need to be taken to move forward the new field of immune-perinatology. One class of treatment is immunotherapy to target the immune modulators involved in preterm labor and its sequelae. This paper focuses on reviewing existing literature on studying the efficacy of maternal immunomodulatory therapy on preventing preterm birth and prematurity- related adverse outcomes in the newborn.

Pathogenesis and Molecular Mechanisms of Zika Virus.

Zika virus (ZIKV) is one of the most important emerging viruses of 2016. A developing outbreak in the Americas has demonstrated an association between the virus and serious clinical manifestations, such as Guillain-Barré syndrome in adults and congenital malformations in infants born to infected mothers. Pathogenesis and mechanisms of neurologic or immune disease by ZIKV have not been clearly delineated. However, several pathways have been described to explain viral involvement in brain and immune system as well as other organ systems such as eye, skin, and male and female reproductive tracts. ZIKV activates toll-like receptor 3 and several pathways have been described to explain the mechanisms at a molecular level. The mechanism of microcephaly has been more difficult to demonstrate experimentally, likely due to the multifactorial and complex nature of the phenotype. This article provides an overview of existing literature on ZIKV pathogenicity and possible molecular mechanisms of disease as outlined to date.

Comparison of insulin infusion protocols targeting 110-140 mg/dL in patients after cardiac surgery.

BACKGROUND: Continuous intravenous insulin infusion (CII) following coronary artery bypass graft (CABG) surgery reduces postoperative complications and hospitalization duration. Because of limited data evaluating outcomes of CII with revised glycemic targets (110-140 mg/dL) in cardiac surgery, this study compared efficacy and safety of two different CII protocols having revised targets. SUBJECTS AND METHODS: This is a retrospective study comparing two different protocols between August 2009 and March 2010. Protocol 1 consists of four algorithms, and Protocol 2 is a table to adjust CII. Blood glucose (BG) and CII rates were recorded for 48 h postoperatively or CII discontinuation. Efficacy was defined by the percentage of BG values in the target range, and safety was defined by the percentage of BG values<40 and 40-69 mg/dL. RESULTS: Protocol 1 (n=117) patients were older (65 vs. 61 years; P=0.006) and had more CABG and fewer valve procedures compared with Protocol 2 (n=130). There were no differences in baseline BG level (149±40.6 vs. 151±38.1 mg/dL), body mass index (30±6.3 vs. 30±6.4 kg/m(2)), hematocrit (28% vs. 28%), percentage of diabetes patients (32% vs. 31%), percentage of patients with glomerular filtration rate of <30 mL/min (5% vs. 6%), CII duration (42 [9-48] vs. 40 [14-48] h), total insulin units received (99 [15-376] vs. 114 [12-457]), hourly insulin rate (median of average rate [range], 2.59 [0-21) vs. 2.96 [0-25] units/h), percentage of BG values 110-140 mg/dL, <40 mg/dL, 40-69 mg/dL, and >180 mg/dL, and BG coefficient of variation (21±6.5 vs. 21±6.1). Shorter time to goal (3.32 [0.22-19.35] vs. 5.03 [0.92-19.80] h; P=0.018) and lower mean BG level (127±12.2 vs. 133±12.1 mg/dL; P<0.001) were noted with Protocol 1. DISCUSSION: CII protocols targeting 110-140 mg/dL were effective in achieving revised targets with low hypoglycemia. Despite differences in mean BG level and time to target, each hospital continued using its existing protocols and identified areas for improvement.

Peptide YY in adolescent athletes with amenorrhea, eumenorrheic athletes and non-athletic controls.

BACKGROUND: Bone mineral density (BMD) is lower in amenorrheic athletes (AA) compared with eumenorrheic athletes (EA). Decreased energy availability and altered levels of appetite regulating hormones (ghrelin and leptin) in AA contribute to hypogonadism, an important cause of low BMD. The role of other nutritionally regulated hormones such as peptide YY (PYY) and adiponectin in mediating gonadal status and bone metabolism remains to be determined. OBJECTIVES: Our objective was to determine whether PYY and adiponectin are higher in AA compared with EA and contribute to hypogonadism and impaired bone metabolism in AA. METHODS: We determined PYY and adiponectin in 16 AA, 15 EA and 16 non-athletic controls 12-18 years old, and other nutritionally dependent hormones including ghrelin, leptin and IGF-1. We also measured testosterone, estradiol, PINP and NTX (markers of bone formation and resorption) and BMD. RESULTS: PYY was higher in AA than EA (111+/-52 vs. 61+/-29 pg/ml, p<0.05), whereas adiponectin did not differ between groups. Although activity scores did not differ, BMI was lower in AA than EA and a larger proportion (62.5% vs. 6.7%) reported disordered eating, indicating lower energy availability. PYY and adiponectin were independent predictors of testosterone in a regression model (p=0.01 and 0.04), but did not predict estradiol. PYY, but not adiponectin, was an independent and negative predictor of PINP (p=0.002) and lumbar bone mineral apparent density Z-scores (p=0.045) in this model. CONCLUSION: High PYY levels (but not adiponectin) differentiate AA from EA, and may be an important factor contributing to low bone density in athletes.