High First Trimester Levels of TSH as an Independent Risk Factor for Gestational Diabetes Mellitus: A Retrospective Cohort Study.

Although numerous articles have found an association between alterations in thyroid function and the risk of gestational diabetes mellitus (GDM), other studies have failed to demonstrate this association. This may be due to the different cut-off points used to define subclinical hypothyroidism. We aim to clarify the role of thyroid stimulating hormone (TSH) level in GDM within pregnant women with normal free thyroxine (fT4) levels. This retrospective cohort study was performed in 6775 pregnant women. The association between TSH and GDM was assessed by bivariate and multivariate logistic regression. Pregnant women with subclinical hypothyroidism are at significantly greater risk for GDM when compared with euthyroid pregnant women (OR = 1.85; 95% CI = 1.36-2.52). We have also observed that TSH levels increase the risk of GDM within euthyroid pregnant women, since the TSH levels between 2.5 and 4.71 showed a higher risk of GDM than those whose TSH levels are between 0.31 and 2.49 (OR = 1.54; 95% CI = 1.28-1.84). In addition, pregnant women with positive thyroid antibodies have almost 2.5 times the risk of developing GDM (OR = 2.47; 95% CI = 1.57-3.89). Our results support that in pregnant women with normal fT4 levels, higher first trimester TSH level implies a higher risk of GDM.

INTERGROWTH-21st versus a customized method for the prediction of neonatal nutritional status in hypertensive disorders of pregnancy.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) generate complications and are one of the principal causes of maternal, foetal, and neonatal mortality worldwide. It has been observed that in pregnancies with HDP, the incidence of foetuses small for their gestational age (SGA) is twice as high as that in noncomplicated pregnancies. In women with HDP, the identification of foetuses (SGA) is substantially important, as management and follow-up are determined by this information. OBJECTIVE: The objective of this study was to evaluate whether the INTERGROWTH-21st method or customized birthweight references better identify newborns with an abnormal nutritional status resulting from HDP. METHOD: A comparative analysis study was designed with two diagnostic methods for the prediction of neonatal nutritional status in pregnancies with HDP. The performance of both methods in identifying neonatal malnutrition (defined by a neonatal body mass index < 10th centile or a ponderal index < 10th centile) was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, diagnostic odds ratio, Youden's index and probability ratios. RESULTS: The study included 226 pregnant women diagnosed with HDP. The customized method identified 45 foetuses as small for gestational age (19.9%), while the INTERGROWTH-21st method identified 27 newborns with SGA (11.9%). The difference between proportions was statistically significant (p < 0.01). Using body mass index (< 10th centile) as a measure of nutritional status, newborns identified as SGA by the customized method showed a higher risk of malnutrition than those identified as SGA by INTERGROWTH-21st (RR: 4.87 (95% CI: 1.86-12.77) vs. 3.75 (95% CI: 1.49-9.43)) (DOR: 5.56 (95% CI: 1.82-16.98) vs. 4.84 (95% CI: 1.51-15.54)) Even when using Ponderal index (< 10th centile), newborns identified as SGA by the customized method showed a higher risk of malnutrition than those identified as SGA by INTERGROWTH-21st (RR 2.37 (95% CI: 1.11-5.05) vs. 1.68 (95% CI: 0.70-4.03))(DOR 2.62 (95% CI: 1.00-6.87) vs. 1.90 (95% CI: 0.61-5.92)). CONCLUSION: In pregnant women with HDP, the predictive ability of the customized foetal growth curves to identify neonatal malnutrition appears to surpass that of INTERGROWTH-21st.

"INTERGROWTH21st vs customized fetal growth curves in the assessment of the neonatal nutritional status: a retrospective cohort study of gestational diabetes".

BACKGROUND: Gestational diabetes mellitus is associated with increased incidence of adverse perinatal outcomes including newborns large for gestational age, macrosomia, preeclampsia, polyhydramnios, stillbirth, and neonatal morbidity. Thus, fetal growth should be monitored by ultrasound to assess for fetal overnutrition, and thereby, its clinical consequence, macrosomia. However, it is not clear which reference curve to use to define the limits of normality. Our aim is to determine which method, INTERGROWTH21st or customized curves, better identifies the nutritional status of newborns of diabetic mothers. METHODS: This retrospective cohort study compared the risk of malnutrition in SGA newborns and the risk of overnutrition in LGA newborns using INTERGROWTH21st and customized birth weight references in gestational diabetes. The nutritional status of newborns was assessed using the ponderal index. Additionally, to determine the ability of both methods in the identification of neonatal malnutrition and overnutrition, we calculate sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios. RESULTS: Two hundred thirty-one pregnant women with GDM were included in the study. The rate of SGA indentified by INTERGROWTH21st was 4.7% vs 10.7% identified by the customized curves. The rate of LGA identified by INTERGROWTH21st was 25.6% vs 13.2% identified by the customized method. Newborns identified as SGA by the customized method showed a higher risk of malnutrition than those identified as SGA by INTERGROWTH21st. (RR 4.24 vs 2.5). LGA newborns according to the customized method also showed a higher risk of overnutrition than those classified as LGA according to INTERGROWTH21st. (RR 5.26 vs 3.57). In addition, the positive predictive value of the customized method was superior to that of INTERGROWTH21st in the identification of malnutrition (32% vs 27.27%), severe malnutrition (22.73% vs 20%), overnutrition (51.61% vs 32.20%) and severe overnutrition (28.57% vs 14.89%). CONCLUSIONS: In pregnant women with DMG, the ability of customized fetal growth curves to identify newborns with alterations in nutritional status appears to exceed that of INTERGROWTH21st.

Neuroapoptosis in newborns with respiratory acidosis at birth.

BACKGROUND: S100B protein is one of the most accurate biomarkers for diagnosis of neuroapoptosis and brain damage. The aim was to evaluate the lactate concentration and acid-base balance (pH, pCO2, pO2, HCO3c and BEb) in umbilical cord blood to predict high risk of neuroapoptosis and analyze the relationship between the levels of these biomarkers and umbilical cord blood S100B protein concentration at birth. METHODS: Apparently healthy newborns were included. S100B protein and blood gas test (lactate and acid-base balance) were determined in umbilical cord blood at birth. Newborns were classified into two groups: with and without high risk of neuroapoptosis. Newborns with high umbilical cord blood S100B protein concentration were considered newborns at high risk of neuroapoptosis. RESULTS: Sixty-one newborns were included, 12 had high risk of neuroapoptosis and 49 did not. S100B protein concentration correlate directly with pCO2 levels (Rho: 0.286, p = .0321) and lactate concentration (Rho: 0.278, p = .0315); and indirectly with pH (Rho: -0.332, p = .01). The analysis of the ROC curves yielded significant curves for pH and pCO2 to predict high risk of neuroapoptosis, pH optimal cutoff value was 7.19 (sensitivity: 50%, specificity: 83.7%, AUC: 0.708); and pCO2 optimal cutoff value was 60 mmHg (sensitivity: 30%, specificity: 85.4%, AUC: 0.705). CONCLUSIONS: Respiratory acidosis is associated to high concentrations of S100B protein in umbilical cord blood at birth. Umbilical cord blood pH and pCO2 may be useful in differentiating newborns at high risk of neuroapoptosis. Umbilical cord blood gas test may be valuable as risk indicator for neuroapoptosis at birth.

Indications of caesarean section in overweight and obese versus normal-weight pregnant women: a retrospective cohort study.

PURPOSE: The aim of this study was to test the hypothesis that indications of c-section in overweight or obese pregnant women are different from those with normal-weight. METHODS: Retrospective cohort study at University Hospital of Puerto Real (Cádiz-Spain). We compared frequency distribution of c-section indications in overweight and obese versus normal-weight. The risk of c-section by different indications was calculated as relative risk. RESULTS: A total of 4685 births were included in the study. There are significant differences in the frequency distribution of caesarean indications among normal weight and overweight or obese women. In overweight, we found an increased risk of c-section due to previous c-section (RR: 1.73; confidence interval [CI] 95% 1.24-2.42), obstructed/non-progressive labour (RR: 1.34; CI 95% 1.03-1.75), failed induction of labour (RR: 2.38; CI 95% 1.30-4.34) and foetal distress (RR: 1.73; CI 95% 1.21-2.49). This risk was even higher in obese women: previous c-section (RR: 3.25; CI 95% 2.24-4.71), obstructed/non-progressive labour (RR: 2; CI 95% 1.45-2.77), failed induction (RR: 2.52; CI 95% 1.15-5.51) and foetal distress (RR: 2.35; CI 95% 1.51-3.65). CONCLUSIONS: The risk of caesarean section due to previous caesarean section, obstructed/non-progressive labour, failed induction of labour or foetal distress is greater in overweight and obese than in normal-weight. This increase in risk also increases progressively as maternal BMI increases.

"Hypothyroidism screening during first trimester of pregnancy".

BACKGROUND: Subclinical hypothyroidism is defined as an elevated thyroid-stimulating hormone level with a normal thyroxin level without signs or symptoms of hypothyroidism. Although it is well accepted that overt hypothyroidism has a deleterious impact on pregnancy, recent studies indicate that subclinical hypothyroidism may affect maternal and fetal health. Studies suggest an association between miscarriage and preterm delivery in euthyroid women positive for anti-peroxidase antibodies and/or anti-thyroglobulin antibodies. A proposal of a new set-point to diagnose SCH was recently published. The aim of this research was to determine the optimal thyroid-stimulating hormone cut-off point to screen for subclinical hypothyroidism in the first trimester of gestation in a population of our clinical area and to determine the diagnostic value of this screening test for detecting anti-thyroid peroxidase antibodies. METHODS: This cross-sectional study determines the cutoff point for SCH screening and evaluates its usefulness to detect TPO Ab using the Receiver Operating Characteristics (ROC) curve. Prevalence of SCH was calculated using as cut-off 2.5 mIU/L, 4 mIU/L, and our TSH 97.5th percentile. The ability to detect positive anti-thyroglobulin antibodies (TG Ab) and anti-thyroid peroxidase antibodies (TPO Ab) in patients with levels of TSH >97.5th percentile was determined by ROC curves. RESULTS: The mean, range and standard deviation of TSH was 2.15 ± 1.34 mIU/L (range 0.03-8.82); FT4 was 1.18 ± 0.13 ng/dL (range 0.94-1.3); TG Ab was 89.87 ± 413.56 IU/mL (range 0.10-4000); and TPO Ab was 21.61 ± 46.27 IU/mL(range 0.10-412.4). The ROC. analysis of the ability of the TSH level to predict the presence of positive TPO Ab found an AUC of 0.563. CONCLUSION: In our population, the TSH cutoff value for gestational SCH screening is 4.7 mIU/L. Using the SEGO recommended 2.5 mIU/L TSH cut-off point, the prevalence of SCH is 37%. Applying the ATA 2017 recommended cutoff point of 4 mIU/L, the prevalence of SCH is 9.6%. Finally, when the cut-off of 4.7 mIU/L (our 97.5th centile) was used, the SCH prevalence is 5%. TSH levels in the first trimester of pregnancy are not useful to detect TPO Ab.

Assessment of environmentally friendly fuel emissions from in-use vehicle exhaust: low-blend iso-stoichiometric GEM mixture as example.

Gasoline-ethanol-methanol fuel blends were formulated with the same stoichiometric air-to-fuel ratio and volumetric energy concentration as any binary ethanol-gasoline blend. When the stoichiometric blends operated in a vehicle, the time period, injector voltage, and pressure for each fuel injection event in the engine corresponded to a given stoichiometric air-to-fuel ratio, and the load was essentially constant. Three low oxygen content iso-stoichiometric ternary gasoline-ethanol-methanol fuel blends were prepared, and the properties were compared with regular-type fuel without added oxygen. One of the ternary fuels was tested using a fleet of in-use vehicles for15 weeks and compared to neat gasoline without oxygenated compounds as a reference. Only a small number of publications have compared these ternary fuels in the same engine, and little data exist on the performance and emissions of in-use spark-ignition engines. The total hydrocarbon emissions observed was similar in both fuels, in addition to the calculated ozone forming potential of the tailpipe and evaporative emissions. In ozone non-attainment areas, the original purpose for oxygenate gasolines was to decrease carbon monoxide emissions. The results suggest that the strategy is less effective than expected because there still exist a great number of vehicles that have suffered the progressive deterioration of emissions and do not react to oxygenation, while new vehicles are equipped with sophisticated air/fuel control systems, and oxygenation does not improve combustion because the systems adjust the stoichiometric point, making it insensitive to the origin of the added excess oxygen (fuel or excess air). Graphical abstract Low level ternary blend of gasoline-ethanol-methanol were prepared with the same stoichiometric air-fuel ratio and volumetric energy concentration, based on the volumetric energy density of the pre-blended components. Exhaust and evaporative emissions was compared with a blend having no oxygen in a fleet of 12 in-use vehicles. Vehicles that had suffer a normal deterioration of emissions and do not react to oxygenation, and new vehicles with more sophisticated air/fuel control systems do not improve combustion.

Birthweight in pregnant women with protein S deficiency treated with low-molecular-weight heparin: a retrospective cohort study.

OBJECTIVE: To determine the risk of small-for-gestational-age (SGA) and intrauterine growth retardation (IUGR) in pregnant women with protein S (PS) deficiency who received low-molecular-weight heparin (LMWH). METHODS: Retrospective cohort study of pregnant women seen from January 2002 to December 2011. The study cohort comprised a total of 328 patients with PS deficiency, who received prophylactic enoxaparin during pregnancy. The control cohort included 11 884 pregnant women without significant past medical history. The risk of SGA and IUGR was calculated as odds ratio. Multivariate regression analysis over the entire reference population was performed determining the risk of both SGA and IUGR by adjusting for maternal age, first delivery, maternal underweight status, pre-eclampsia, other treated thrombophilias or history of recurrent abortion. RESULTS: The SGA rates in the PS deficiency and control cohorts were 10.7% and 8.5%, respectively (p > 0.05). There was no increased risk of SGA (unadjusted OR = 1.28, 95% confidence interval [CI] 0.9-1.83; adjusted OR = 1.35, 95% CI 0.91-2.01). The IUGR rate was 2.7% in pregnant women with PS deficiency versus 4.1% in the control group (p > 0.05). Also, we did not find a significant risk of IUGR (OR = 0.66; 95% CI 0.34-1.28; adjusted OR = 0.843; 95% CI 0.42-1.70). CONCLUSIONS: In women with PS deficiency treated with LMWH, the risk of SGA and IUGR is similar to the one found in healthy pregnant women.

Customized versus Population-Based Birth Weight References for Predicting Fetal and Neonatal Undernutrition.

OBJECTIVES: The aim of our study was to construct a model of customized birth weight curves based on a Spanish population and to compare the ability of this customized model to our population-based chart to predict a neonatal ponderal index (PI) <10th percentile. METHODS: We developed a model that can predict the 10th percentile for a fetus according to gestational age and gender as well as maternal weight, height, and age. We compared the ability of this customized model to that of our own population-based model to predict a neonatal PI <10th percentile. Data from a large database were used (32,854 live newborns, from 1993 through 2012). Only singleton pregnancies with a gestational age at delivery of 32-42 weeks were included. RESULTS: In the entire pregnant population, the customized method was superior to the population-based method for detecting newborns with a PI <10th percentile (sensitivity: 55 vs. 40.96%; specificity: 99.6 vs. 91.23%; positive predictive value: 11.49 vs. 9.55%, and negative predictive value: 98.84 vs. 98.55%, respectively). In pregnant women with a BMI >90th percentile, the sensitivity was 75%, compared to 50% in the population-based method. In pregnant women with a height >90th percentile, the sensitivity was almost as high as in the population-based method (61.53 vs. 33.33%). CONCLUSION: The customized birth weight curve is superior to the population-based method for the detection of newborns with a PI <10th percentile. This is especially the case in women in the higher scales of height and weight as well as in preterm babies.

Treatment of D alloimmunization in pregnancy with plasmapheresis and intravenous immune globulin: case report.

The prevalence of D alloimmunization occurs between 0.15% and 0.4%. The anti-D can cross the placenta and cause hemolysis and fetal anemia. At present, a Doppler study of the middle cerebral artery allows the monitoring of the degree of fetal anemia. The treatment in cases of moderate to severe anemia in fetuses of less than 34-35 weeks of gestation is intrauterine transfusion via cordocentesis. However, with high titers of anti-D, in the absence of fetal anemia it is possible to modulate the maternal immune response by plasmapheresis and intravenous immunoglobulin administration. We present a case report of an Rh(D) alloimmunized pregnancy treated with plasmapheresis followed by intravenous immunoglobulin administration. We performed a caesarean section at 31 weeks, 5 days of gestation. The hemoglobin at birth was 13.8 g/dl and hematocrit 40.8%. Intrauterine transfusion was not necessary.

Propuesta de un índice numérico para evaluar la calidad del sedimento influenciado por la industria petrolera / Proposal of a numerical index to evaluate the quality of sediments influenced by the oil industry

El presente estudio tiene por objeto la integración, en un índice numérico, de los parámetros de sedimento derivados de la caracterización granulométrica, mineralógica, química, biológica y toxicológica, además del contenido de Ni y V, a fin de evaluar la calidad del sedimento del río Pánuco, México. Para ello se llevó a cabo una serie de análisis durante dos épocas de estudio (secas ó estiaje y nortes) y tres zonas del río (margen derecho, centro y margen izquierdo), con el fin de detectar la variación espacial y temporal. A fin de integrar todos estos parámetros y evaluar la calidad del sedimento con base a esos dos metales, se creó el Indice de la Calidad del Sedimento (ICS). Los resultados del ICS mostraron una mejor calidad ambiental en la época de secas, fenómeno atribuible a la menor resuspensión del sedimento que en la época de nortes y al dragado. El ICS mostró un comportamiento similar al del Indice Trófico de la Infauna, explicando el 65 por ciento de la variabilidad espacial y temporal en el sistema acuático. Considerando que no hay índices similares al planteado en el presente estudio, el ICS se considera como una herramienta útil para la evaluación de la calidad sedimentaria de la zona de estudio.