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Gestational diabetes remains the most common medical disorder in pregnancy, with short-term and long-term consequences for mothers and offspring. New insights into pathophysiology and management suggest that the current gestational diabetes treatment approach should expand from a focus on late gestational diabetes to a personalised, integrated life course approach from preconception to postpartum and beyond. Early pregnancy lifestyle intervention could prevent late gestational diabetes. Early gestational diabetes diagnosis and treatment has been shown to be beneficial, especially when identified before 14 weeks of gestation. Early gestational diabetes screening now requires strategies for integration into routine antenatal care, alongside efforts to reduce variation in gestational diabetes care, across settings that differ between, and within, countries. Following gestational diabetes, an oral glucose tolerance test should be performed 6-12 weeks postpartum to assess the glycaemic state. Subsequent regular screening for both dysglycaemia and cardiometabolic disease is recommended, which can be incorporated alongside other family health activities. Diabetes prevention programmes for women with previous gestational diabetes might be enhanced using shared decision making and precision medicine. At all stages in this life course approach, across both high-resource and low-resource settings, a more systematic process for identifying and overcoming barriers to preventative care and treatment is needed to reduce the current global burden of gestational diabetes.
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Diabetes Gestacional , Humanos , Diabetes Gestacional/diagnóstico , Diabetes Gestacional/terapia , Diabetes Gestacional/prevención & control , Femenino , Embarazo , Atención Prenatal/métodos , Prueba de Tolerancia a la Glucosa , Tamizaje MasivoRESUMEN
The aim of this meta-analysis was to examine the associations among infant feeding types, sleeping habits, and maternal sleep postpartum. Databases including Cumulative Index of Nursing and Allied-Health Literature (CINAHL), PubMed, and Google Scholar were searched in addition to reference lists from selected articles and other key references. A critical review of relevant articles from the data sources was conducted with attention to the infant feeding types and maternal night-time sleep. The methodological quality was assessed systematically. The pooled mean difference was calculated. Narrative summaries were also used. A total of 6,472 participants from seven studies were included in the meta-analysis. A random-effects model demonstrated a significantly higher maternal night-time sleep in breastfeeding mothers than non-breastfeeding mothers with a pooled standardized mean difference of 0.24 h (95% confidence interval 0.03-0.46, p = 0.026). Co-sleeping with infants during the night also increased the sleeping hours in breastfeeding mothers. Homogeneity was observed with a Tau2 of 0.0308 and I2 of 44.3%. Funnel plots, Egger's and Begg's tests revealed no evidence of publication bias. This systematic review and meta-analysis demonstrated that breastfeeding may be associated with a longer night-time sleep postpartum and the synthesis of the literature suggested that co-sleeping with the infant was associated with longer sleep duration in breastfeeding women. Further research into factors involving maternal decisions on infant feeding types and their effects on maternal sleep is needed to better understand the mothers' attitude toward infant feeding and their own sleep.
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Lactancia Materna , Periodo Posparto , Lactante , Femenino , Humanos , Sueño , Madres , Factores de TiempoRESUMEN
BACKGROUND: Scientific discovery progresses by exploring new and uncharted territory. More specifically, it advances by a process of transforming unknown unknowns first into known unknowns, and then into knowns. Over the last few decades, researchers have developed many knowledge bases to capture and connect the knowns, which has enabled topic exploration and contextualization of experimental results. But recognizing the unknowns is also critical for finding the most pertinent questions and their answers. Prior work on known unknowns has sought to understand them, annotate them, and automate their identification. However, no knowledge-bases yet exist to capture these unknowns, and little work has focused on how scientists might use them to trace a given topic or experimental result in search of open questions and new avenues for exploration. We show here that a knowledge base of unknowns can be connected to ontologically grounded biomedical knowledge to accelerate research in the field of prenatal nutrition. RESULTS: We present the first ignorance-base, a knowledge-base created by combining classifiers to recognize ignorance statements (statements of missing or incomplete knowledge that imply a goal for knowledge) and biomedical concepts over the prenatal nutrition literature. This knowledge-base places biomedical concepts mentioned in the literature in context with the ignorance statements authors have made about them. Using our system, researchers interested in the topic of vitamin D and prenatal health were able to uncover three new avenues for exploration (immune system, respiratory system, and brain development) by searching for concepts enriched in ignorance statements. These were buried among the many standard enriched concepts. Additionally, we used the ignorance-base to enrich concepts connected to a gene list associated with vitamin D and spontaneous preterm birth and found an emerging topic of study (brain development) in an implied field (neuroscience). The researchers could look to the field of neuroscience for potential answers to the ignorance statements. CONCLUSION: Our goal is to help students, researchers, funders, and publishers better understand the state of our collective scientific ignorance (known unknowns) in order to help accelerate research through the continued illumination of and focus on the known unknowns and their respective goals for scientific knowledge.
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Bases del Conocimiento , Conocimiento , Procesamiento de Lenguaje Natural , Femenino , Humanos , Recién Nacido , Nacimiento Prematuro , Publicaciones , Vitamina DRESUMEN
BACKGROUND: Optimizing care during labor protraction is a key strategy for reducing cesareans, especially among people with obesity. The pathophysiology of labor dystocia remains poorly understood, limiting precise interventions targeting the cause of protraction. METHODS: In this secondary analysis of nulliparas (n = 92) with obesity (BMI ≥ 30 kg/m2 ) and spontaneous labor onset, we classified labor into four phenotypes based on duration of protraction and birth route: (1) no protraction, (2) short protraction and vaginal birth, (3) extended protraction meeting criteria for labor arrest, but with eventual progression and vaginal birth, and (4) extended protraction meeting criteria for labor arrest and cesarean birth. Across these phenotypes, we compared MVU, oxytocin dose, and novel measures of uterine responsiveness to oxytocin augmentation (MVU to oxytocin dose ratios). RESULTS: In our sample, phenotype group 1 comprised 14.1% (n = 13); group 2 comprised 30.4% (n = 28); group 3 comprised 34.8% (n = 32); and group 4 comprised 20.7% (n = 19). Uterine responsiveness to oxytocin, but not MVU, decreased with each labor phenotype. Participants with cesarean birth had the lowest uterine responsiveness to oxytocin. CONCLUSION: Labor and birth outcomes were associated with measures of uterine responsiveness to oxytocin rather than MVU alone, and thus these may be more clinically appropriate measures for guiding clinical decision-making. Current criteria for labor arrest are likely too stringent for nulliparas with obesity, many of whom appear to progress to safe vaginal birth after longer labor durations. Differences in uterine responsiveness to oxytocin augmentation across the groups suggests underlying physiologic differences in the labor phenotypes, which should drive future research targeting pathophysiology.
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PURPOSE: To describe existing guidance for qualifications of principal investigator s (PI s) of human subjects research and explore how they are operationalized for pediatric nurse scientists and clinical nurses in children's hospitals. DESIGN AND METHODS: After reviewing federal regulations, accreditation guidelines, and the literature, a convenience sample of members of the National Pediatric Nurse Scientist Collaborative (NPNSC). Participants completed a 33-item survey that included questions about Institutional Review Board (IRB), guidelines, and policies for PI status at their affiliated children's hospitals. RESULTS: The survey was electronically disseminated to 179 members of NPNSC through the Collaborative's listserv. Of the 39 members who responded, 90% hold a PhD and 80% practice in a free-standing children's hospital, nearly all of which (93%) are recognized as Magnet® hospitals. While the majority of respondents indicated that nurse scientists and other nurses were allowed to be PIs of research studies, educational requirements for PI status varied, with 3% requiring a PhD, 15% a baccalaureate degree, and 10% a graduate degree. 54% of respondents reported there was no degree requirement for PI status; however15% reported that even doctorally prepared nurse scientists cannot serve as PIs of research studies at their affiliated children''s hospitals. CONCLUSIONS: The survey identified substantial variability in requirements for PI status and potential barriers to pediatric nurses conducting independent research as PIs at children's hospitals. PRACTICE IMPLICATIONS: Operationalizing existing guidance will expand inclusion of nurse scientist expertise in human subjects research.
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Enfermeras Pediátricas , Investigadores , Niño , Humanos , Encuestas y Cuestionarios , Escolaridad , Enfermería PediátricaRESUMEN
AIMS: To understand morning biopsychosocial factors that predict glycemia, adherence, and goal attainment in adolescents and young adults (AYA) with type 1 diabetes (T1D) on a daily basis. METHODS: Eight-eight AYA (mean 17.6 ± 2.6 years, 54% female, HbA1c 7.9 ± 1.4%, diabetes duration 8.5 ± 4.5 years) with T1D who use Continuous Glucose Monitoring (CGM) completed a 2-week prospective study. Participants chose a self-management goal to focus on during participation. For six days, participants prospectively completed a 25-item Engagement Prediction Survey to assess biopsychosocial factors to predict daily diabetes outcomes and an end-of-day Goal Survey. Lasso and mixed-model regression were used to determine items in the Engagement Prediction Survey most predictive of perceived goal attainment, CGM Time-in-Range (TIR, 70-180 mg/dl), sensor mean glucose, number of insulin boluses and hyperglycemia response (bolus within 30 min of high alert or glucose <200 mg/dl within 2 hours). RESULTS: A 7-item model (including current glucose, planning/wanting to manage diabetes, wanting to skip self-management, feeling good about self, health perception and support needs) explained 16.7% of the daily variance in TIR, 18.6% of mean sensor glucose, 2.1% of the number of boluses, 14% of hyperglycemia response, and 28.7% of goal attainment perceptions. The mean absolute change in day-to-day TIR was 16%, sensor glucose was 30 mg/dl, and the number of boluses was 2. AYA reported more positive Engagement Prediction Survey responses on mornings when they awoke with lower glucose levels. CONCLUSIONS: Morning biopsychosocial state factors predict glycemic and adherence outcomes in AYA with diabetes and could be a novel intervention target for future behavioural interventions.
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Diabetes Mellitus Tipo 1 , Hiperglucemia , Automanejo , Adolescente , Glucemia , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/psicología , Femenino , Hemoglobina Glucada/análisis , Humanos , Hiperglucemia/prevención & control , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Estudios Prospectivos , Adulto JovenRESUMEN
Most women in the United States do not meet the recommendations for healthful nutrition and weight before and during pregnancy. Women and providers often ask what a healthy diet for a pregnant woman should look like. The message should be "eat better, not more." This can be achieved by basing diet on a variety of nutrient-dense, whole foods, including fruits, vegetables, legumes, whole grains, healthy fats with omega-3 fatty acids that include nuts and seeds, and fish, in place of poorer quality highly processed foods. Such a diet embodies nutritional density and is less likely to be accompanied by excessive energy intake than the standard American diet consisting of increased intakes of processed foods, fatty red meat, and sweetened foods and beverages. Women who report "prudent" or "health-conscious" eating patterns before and/or during pregnancy may have fewer pregnancy complications and adverse child health outcomes. Comprehensive nutritional supplementation (multiple micronutrients plus balanced protein energy) among women with inadequate nutrition has been associated with improved birth outcomes, including decreased rates of low birthweight. A diet that severely restricts any macronutrient class should be avoided, specifically the ketogenic diet that lacks carbohydrates, the Paleo diet because of dairy restriction, and any diet characterized by excess saturated fats. User-friendly tools to facilitate a quick evaluation of dietary patterns with clear guidance on how to address dietary inadequacies and embedded support from trained healthcare providers are urgently needed. Recent evidence has shown that although excessive gestational weight gain predicts adverse perinatal outcomes among women with normal weight, the degree of prepregnancy obesity predicts adverse perinatal outcomes to a greater degree than gestational weight gain among women with obesity. Furthermore, low body mass index and insufficient gestational weight gain are associated with poor perinatal outcomes. Observational data have shown that first-trimester gain is the strongest predictor of adverse outcomes. Interventions beginning in early pregnancy or preconception are needed to prevent downstream complications for mothers and their children. For neonates, human milk provides personalized nutrition and is associated with short- and long-term health benefits for infants and mothers. Eating a healthy diet is a way for lactating mothers to support optimal health for themselves and their infants.
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Ganancia de Peso Gestacional , Dieta , Femenino , Humanos , Lactancia , Masculino , Estado Nutricional , Obesidad , Embarazo , Verduras , Aumento de PesoRESUMEN
PURPOSE: Youth with type 1 diabetes (T1D) often use Continuous Glucose Monitoring (CGM) devices; however, many do not wear them consistently enough to obtain optimal glycemic benefit. This study aimed to identify demographic and psychosocial predictors of optimal CGM use in adolescents with T1D to inform nurse-led interventions to improve adherence. DESIGN AND METHODS: Cross-sectional survey data from youth (12-19 years) using CGM were analyzed to determine whether perceived benefits/burdens of CGM, self-efficacy, and coping predicted being a "CGM Optimizer" (wearing CGM 6-7 days/week) or "CGM Sub-user." RESULTS: Of 282 adolescents (54% female), 161 were CGM Optimizers and 121 were CGM Sub-Users. Optimizers were younger (15.91 ± 2.17 years vs. 16.79 ± 2.17, p = 0.001), more likely non-Hispanic White (91.9% vs 83.5%, p = 0.029), and more likely to have private insurance (82.0% vs. 69.4%, p = 0.009). Every 1-point increase on Benefits of CGM scale was associated with 2.8 times greater odds of being an Optimizer (OR = 2.82, 95% CI 1.548-5.132, p = 0.001), and every 1-point increase on the Burdens of CGM scale was associated with a 52% decrease in odds (OR = 0.48, 95% CI = 0.283-0.800, p = 0.005), with final logistic regression model (including only these two predictors) explaining 22.3% of variance. CONCLUSION: CGM Optimizing adolescents were more likely to perceive higher benefit and lower burden of CGM. PRACTICAL IMPLICATIONS: Nurse-led interventions to promote benefits of CGM and mitigate burden may help youth increase adherence with CGM to achieve glycemic benefit.
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Diabetes Mellitus Tipo 1 , Adolescente , Glucemia , Automonitorización de la Glucosa Sanguínea , Estudios Transversales , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Femenino , Humanos , Masculino , AutoeficaciaRESUMEN
Cells in human milk are an untapped source, as potential "liquid breast biopsies", of material for investigating lactation physiology in a non-invasive manner. We used single cell RNA sequencing (scRNA-seq) to identify milk-derived mammary epithelial cells (MECs) and their transcriptional signatures in women with diet-controlled gestational diabetes (GDM) with normal lactation. Methodology is described for coordinating milk collections with single cell capture and library preparation via cryopreservation, in addition to scRNA-seq data processing and analyses of MEC transcriptional signatures. We comprehensively characterized 3740 cells from milk samples from two mothers at two weeks postpartum. Most cells (>90%) were luminal MECs (luMECs) expressing lactalbumin alpha and casein beta and positive for keratin 8 and keratin 18. Few cells were keratin 14+ basal MECs and a small immune cell population was present (<10%). Analysis of differential gene expression among clusters identified six potentially distinct luMEC subpopulation signatures, suggesting the potential for subtle functional differences among luMECs, and included one cluster that was positive for both progenitor markers and mature milk transcripts. No expression of pluripotency markers POU class 5 homeobox 1 (POU5F1, encoding OCT4) SRY-box transcription factor 2 (SOX2) or nanog homeobox (NANOG), was observed. These observations were supported by flow cytometric analysis of MECs from mature milk samples from three women with diet-controlled GDM (2-8 mo postpartum), indicating a negligible basal/stem cell population (epithelial cell adhesion molecule (EPCAM)-/integrin subunit alpha 6 (CD49f)+, 0.07%) and a small progenitor population (EPCAM+/CD49f+, 1.1%). We provide a computational framework for others and future studies, as well as report the first milk-derived cells to be analyzed by scRNA-seq. We discuss the clinical potential and current limitations of using milk-derived cells as material for characterizing human mammary physiology.
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Biología Computacional/métodos , Diabetes Gestacional/metabolismo , Lactancia/fisiología , Glándulas Mamarias Humanas/metabolismo , Leche Humana/citología , Adulto , Diabetes Gestacional/dietoterapia , Células Epiteliales/metabolismo , Femenino , Citometría de Flujo , Humanos , Glándulas Mamarias Humanas/citología , Periodo Posparto/metabolismo , Embarazo , RNA-Seq/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Análisis de la Célula Individual , Células Madre/metabolismoRESUMEN
The postpartum period represents a critical window to initiate targeted interventions to improve cardiometabolic health following pregnancies complicated by gestational diabetes mellitus and/or a hypertensive disorder of pregnancy. The purpose of this systematic review was to examine studies published since 2011 that report rates of postpartum follow-up and risk screening for women who had gestational diabetes and/or a hypertensive disorder of pregnancy and to identify disparities in care. Nine observational studies in which postpartum follow-up visits and/or screening rates were measured among US women following pregnancies complicated by gestational diabetes and/or a hypertensive disorder of pregnancy were reviewed. Rates of postpartum follow-up ranged from 5.7% to 95.4% with disparities linked to black race and Hispanic ethnicity, low level of education, and coexisting morbidities such as mental health disorders. Follow-up rates were increased if the provider was an obstetrician/endocrinologist versus primary care. Payer source was not associated with follow-up rates. The screening rate for diabetes in women who had gestational diabetes did not exceed 58% by 4 months across the studies analyzed, suggesting little improvement in the last 10 years. While women who had a hypertensive disorder appear to have had a postpartum blood pressure measured, it is unclear whether follow-up intervention occurred. Overall, postpartum screening rates for at-risk women remain suboptimal and vary substantially. Further research is warranted including reliable population-level data to inform equitable progress to meeting the evidence-informed guidelines.
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Diabetes Gestacional/diagnóstico , Disparidades en Atención de Salud/economía , Hipertensión Inducida en el Embarazo/diagnóstico , Tamizaje Masivo/normas , Muerte Materna/prevención & control , Atención Posnatal/métodos , Diabetes Gestacional/mortalidad , Diabetes Gestacional/terapia , Femenino , Estudios de Seguimiento , Disparidades en Atención de Salud/etnología , Humanos , Hipertensión Inducida en el Embarazo/mortalidad , Hipertensión Inducida en el Embarazo/terapia , Tamizaje Masivo/tendencias , Periodo Posparto , Embarazo , Resultado del Embarazo , Embarazo de Alto Riesgo , Medición de RiesgoRESUMEN
PURPOSE OF REVIEW: Excess fetal growth is increasingly recognized as a risk factor for childhood obesity, and mounting evidence supports that maternal glucose is not the only driver. This review focuses on the role of clinically applicable maternal non-glycemic contributors to excess fetal growth, particularly lipids, in addition to amino acids (AA), insulin resistance, inflammation, maternal nutrition, and gestational weight gain (GWG) in obesity and gestational diabetes mellitus (GDM). RECENT FINDINGS: Lipids, specifically triglycerides and free fatty acids, appear to be strong contributors to excess fetal fat accretion and adiposity at birth, particularly in obese pregnancies, which account for the largest number of large-for-gestational-age infants. Maternal pre-pregnancy body mass index (BMI), GWG, insulin resistance, inflammation, and glucose, lipid, and AA concentrations have both independent and interacting effects on fetal growth, operating both early and late in pregnancy. All are sensitive to maternal nutrition. Early vs. later gestational exposure to excess maternal fuels in fasting and postprandial conditions may differentially impact fetoplacental outcomes. Compelling evidence suggests that targeting interventions early in pregnancy beyond glucose may be critical to improve fetal growth patterns.
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Diabetes Gestacional/fisiopatología , Desarrollo Fetal/fisiología , Lípidos/sangre , Obesidad/fisiopatología , Femenino , Humanos , Resistencia a la Insulina , Fenómenos Fisiologicos Nutricionales Maternos , EmbarazoRESUMEN
BACKGROUND: Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women. METHODS: Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type. RESULTS: A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births. DISCUSSION: In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.
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Cesárea/estadística & datos numéricos , Trabajo de Parto , Enfermeras Obstetrices/estadística & datos numéricos , Paridad , Médicos/estadística & datos numéricos , Adulto , Colorado , Bases de Datos Factuales , Extracción Obstétrica/estadística & datos numéricos , Femenino , Humanos , Modelos Logísticos , Oxitocina/administración & dosificación , Embarazo , Estudios Retrospectivos , Salud de la Mujer , Adulto JovenRESUMEN
OBJECTIVES: Neonatal adiposity is associated with chronic metabolic sequelae such as diabetes and obesity. Identifying fetuses at risk for excess neonatal body fat may lead to research aimed at limiting nutritional excess in the prenatal period. We sought to determine whether fetal arm and leg soft tissue measurements at 28 weeks' gestation were predictive of neonatal percent body fat METHODS : In this prospective observational cohort study of singleton term pregnancies, we performed sonography at 28 and 36 weeks' gestation, including soft tissue measurements of the fetal arm and thigh (fractional limb volume and cross-sectional area). We estimated the neonatal body composition (percent body fat) using anthropometric measurements and air displacement plethysmography. We estimated Spearman correlations between sonographic findings and percent body fat and performed modeling to predict neonatal percent body fat using maternal characteristics and sonographic findings. RESULTS: Our analysis of 44 women yielded a mean maternal age of 30 years, body mass index of 26 kg/m(2), and birth weight of 3382 g. Mean neonatal percent body fat was 8.1% by skin folds at birth and 12.2% by air displacement plethysmography 2 weeks after birth. Fractional thigh volume measurements at 28 weeks yielded the most accurate model for predicting neonatal percent body fat (R(2) = 0.697; P = .001), outperforming models that used abdominal circumference (R(2)= 0.516) and estimated fetal weight (R(2)= 0.489). CONCLUSIONS: Soft tissue measurements of the fetal thigh at 28 weeks correlated better with neonatal percent body fat than currently used sonographic measurements. After validation in a larger cohort, our models may be useful for prenatal intervention strategies aimed at the prevention of excess fetal fat accretion and, potentially, optimization of long-term metabolic health.
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Tejido Adiposo/diagnóstico por imagen , Peso Fetal/fisiología , Ultrasonografía Prenatal , Tejido Adiposo/embriología , Adulto , Brazo/diagnóstico por imagen , Brazo/embriología , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Pierna/diagnóstico por imagen , Pierna/embriología , Embarazo , Tercer Trimestre del Embarazo , Estudios ProspectivosRESUMEN
IN BRIEF Restriction of dietary carbohydrate has been the cornerstone for treatment of gestational diabetes mellitus (GDM). However, there is evidence that a balanced liberalization of complex carbohydrate as part of an overall eating plan in GDM meets treatment goals and may mitigate maternal adipose tissue insulin resistance, both of which may promote optimal metabolic outcomes for mother and offspring.
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Femoral subcutaneous adipose tissue (SAT) appears to be cardioprotective compared with abdominal SAT, possibly through better triglyceride (TG) sequestration. We hypothesized that removal of femoral SAT would increase postprandial TG through a reduction in dietary fatty acid (FA) storage. Normal-weight (means ± SD; BMI 23.9 ± 2.6 kg/m(2)) women (n = 29; age 45 ± 6 yr) were randomized to femoral lipectomy (LIPO) or control (CON) and followed for 1 yr. Regional adiposity was measured by DEXA and CT. A liquid meal labeled with [(14)C]oleic acid was used to trace the appearance of dietary FA in plasma (6-h postprandial TG), breath (24-h oxidation), and SAT (24-h [(14)C]TG storage). Fasting LPL activity was measured in abdominal and femoral SAT. DEXA leg fat mass was reduced after LIPO vs. CON (Δ-1.4 ± 0.7 vs. 0.1 ± 0.5 kg, P < 0.001) and remained reduced at 1 yr (-1.1 ± 1.4 vs. -0.2 ± 0.5 kg, P < 0.05), as did CT thigh subcutaneous fat area (-39.6 ± 36.6 vs. 4.7 ± 14.6 cm(2), P < 0.05); DEXA trunk fat mass and CT visceral fat area were unchanged. Postprandial TG increased (5.9 ± 7.7 vs. -0.6 ± 5.3 × 10(3) mg/dl, P < 0.05) and femoral SAT LPL activity decreased (-21.9 ± 22.3 vs. 10.5 ± 26.5 nmol·min(-1)·g(-1), P < 0.05) 1 yr following LIPO vs. CON. There were no group differences in (14)C-labeled TG appearing in abdominal and femoral SAT or elsewhere. In conclusion, femoral fat remained reduced 1 yr following lipectomy and was accompanied by increased postprandial TG and reduced femoral SAT LPL activity. There were no changes in storage of meal-derived FA or visceral fat. Our data support a protective role for femoral adiposity on circulating TG independent of dietary FA storage and visceral adiposity.
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Hiperlipidemias/etiología , Lipectomía , Grasa Subcutánea/cirugía , Muslo/cirugía , Adiposidad/fisiología , Adulto , Femenino , Humanos , Hiperlipidemias/sangre , Lipectomía/métodos , Persona de Mediana Edad , Complicaciones Posoperatorias/sangre , Periodo Posprandial , Grasa Subcutánea Abdominal/cirugía , Triglicéridos/sangreRESUMEN
Over a third of women of childbearing age in the United States are obese, and during pregnancy they are at increased risk for delayed labor onset and slow labor progress that often results in unplanned cesarean delivery. The biology behind this dysfunctional parturition is not well understood. Studies of obesity-induced changes in parturition physiology may facilitate approaches to optimize labor in obese women. In this review, we summarize known and proposed biologic effects of obesity on labor preparation, contraction/synchronization, and endurance, drawing on both clinical observation and experimental data. We present evidence from human and animal studies of interactions between obesity and parturition signaling in all elements of the birth process, including: delayed cervical ripening, prostaglandin insensitivity, amniotic membrane strengthening, decreased myometrial oxytocin receptor expression, decreased myocyte action potential initiation and contractility, decreased myocyte gap junction formation, and impaired myocyte neutralization of reactive oxygen species. We found convincing clinical data on the effect of obesity on labor initiation and successful delivery, but few studies on the underlying pathobiology. We suggest research opportunities and therapeutic interventions based on plausible biologic mechanisms.
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Obesidad/complicaciones , Complicaciones del Trabajo de Parto/etiología , Complicaciones del Trabajo de Parto/fisiopatología , Parto/fisiología , Complicaciones del Embarazo/fisiopatología , Adipoquinas/fisiología , Índice de Masa Corporal , Cesárea/estadística & datos numéricos , Colesterol/fisiología , Distocia/epidemiología , Femenino , Humanos , Inflamación/complicaciones , Inflamación/epidemiología , Leptina/sangre , Miometrio/fisiopatología , Obesidad/fisiopatología , Complicaciones del Trabajo de Parto/epidemiología , Fenotipo , Embarazo , Prostaglandinas/fisiología , Receptores de Oxitocina/fisiología , Transducción de Señal , Contracción Uterina/fisiología , Útero/fisiopatologíaRESUMEN
The definition of optimal glycemic control in pregnancies affected by diabetes remains enigmatic. Diabetes phenotypes are heterogeneous. Moreover, fetal macrosomia insidiously occurs even with excellent glycemic control. Current blood glucose (BG) targets (FBG ≤95, 1-h post-prandial <140, 2 h <120 mg/dL) have improved perinatal outcomes, but arguably they have not normalized. The conventional management approach has been to replicate a pattern of glycemia in normal pregnancy. Although these patterns are lower than previously appreciated, a randomized controlled trial (RCT) has never compared current vs. lower glucose targets powered on maternal/fetal outcomes. This paper provides historical context to the current targets by reviewing evidence supporting their evolution. Using lower targets (FBG <90, 1 h <122, 2 h <110, mean BG ≤95 mg/dL) may help normalize outcomes, but phenotypic differences (type 1 vs. type 2 vs. gestational diabetes) might require different glycemic goals. There remains a critical need for well-designed RCTs to confirm optimal glycemic control that minimizes both small for and large for gestational age across pregnancies affected by diabetes.
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Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 2/sangre , Diabetes Gestacional , Macrosomía Fetal/prevención & control , Hemoglobina Glucada/metabolismo , Índice Glucémico , Embarazo en Diabéticas , Adulto , Peso al Nacer , Índice de Masa Corporal , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/historia , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/historia , Diabetes Gestacional/sangre , Diabetes Gestacional/historia , Femenino , Macrosomía Fetal/historia , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Recién Nacido , Metaanálisis como Asunto , Periodo Posprandial , Embarazo , Embarazo en Diabéticas/sangre , Embarazo en Diabéticas/historia , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service. METHODS: We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors. RESULTS: When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression. DISCUSSION: No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.
Asunto(s)
COVID-19 , Partería , Atención Prenatal , Telemedicina , Humanos , Femenino , Telemedicina/estadística & datos numéricos , COVID-19/epidemiología , Atención Prenatal/estadística & datos numéricos , Estudios Retrospectivos , Embarazo , Adulto , Partería/estadística & datos numéricos , Disparidades en Atención de Salud , SARS-CoV-2 , Enfermeras Obstetrices/estadística & datos numéricos , Estudios de Cohortes , Adulto JovenRESUMEN
Gestational diabetes mellitus (GDM) triggers alterations in the maternal microbiome. Alongside metabolic shifts, microbial products may impact clinical factors and influence pregnancy outcomes. We investigated maternal microbiome-metabolomic changes, including over 600 metabolites from a subset of the "Choosing Healthy Options in Carbohydrate Energy" (CHOICE) study. Women diagnosed with GDM were randomized to a diet higher in complex carbohydrates (CHOICE, n = 18, 60% complex carbohydrate/25% fat/15% protein) or a conventional GDM diet (CONV, n = 16, 40% carbohydrate/45% fat/15% protein). All meals were provided. Diets were eucaloric, and fiber content was similar. CHOICE was associated with increases in trimethylamine N-oxide, indoxyl sulfate, and several triglycerides, while CONV was associated with hippuric acid, betaine, and indole propionic acid, suggestive of a healthier metabolome. Conversely, the microbiome of CHOICE participants was enriched with carbohydrate metabolizing genes and beneficial taxa such as Bifidobacterium adolescentis, while CONV was associated with inflammatory pathways including antimicrobial resistance and lipopolysaccharide biosynthesis. We also identified latent metabolic groups not associated with diet: a metabolome associated with less of a decrease in fasting glucose, and another associated with relatively higher fasting triglycerides. Our results suggest that GDM diets produce specific microbial and metabolic responses during pregnancy, while host factors also play a role in triglycerides and glucose metabolism.
RESUMEN
Elucidating the optimal macronutrient composition for dietary management of gestational diabetes mellitus has enormous potential to improve perinatal outcomes. Diet therapy may result in significant cost savings if effective in deterring the need for expensive medical management within this growing population. In only 6 randomized controlled trials in 250 women, data suggest that a diet higher in complex carbohydrate and fiber, low in simple sugar, and lower in saturated fat may be effective in blunting postprandial hyperglycemia, preventing worsened insulin resistance and excess fetal growth. The use of diet in gestational diabetes mellitus remains an area in grave need for high-quality randomized controlled trials.