Outside Of Pregnancy Research Articles

Intrapartum Management of Sickle Cell Anemia With Rare Antibody and Minimal Blood Availability

Sickle cell disease (SCD) can pose serious maternal and fetal risk in pregnancy. Transfusion, both during and outside of pregnancy, can improve patient morbidity and mortality but carries risk of alloimmunization, complicating future management. This case describes a 29-year-old gravida 1, para 0 woman with sickle cell anemia and rare red blood cell alloantibody (anti-Rh46) who presented with severe vaso-occlusive crisis at 29 weeks with hemoglobin of 7.6 g/dL. Only one unit of compatible blood existed in the country. Planning for transfusion with least-incompatible blood was made. She ultimately underwent cesarean section at 31 weeks and 2 days for abnormal fetal testing. This case highlights that blood products should be utilized judiciously because their adverse effects, like alloimmunization, can increase patient morbidity and mortality. J Med Cases. 2020;11(6):157-159 doi: https://doi.org/10.14740/jmc3479

OR08-03 Association of Hemoglobin A1c with Early Postpartum Metabolic Syndrome in Women with Gestational Diabetes

Background: Women with gestational diabetes (GDM) are at increased risk of metabolic syndrome (MetS), an important risk factor for development of type 2 diabetes (T2DM) and cardiovascular disease. Elevated hemoglobin A1c (HbA1c) is associated with MetS outside of pregnancy and may enhance detection of MetS. It is not known whether HbA1c is associated with MetS in the early postpartum period in women with recent GDM.Objective: We aimed to characterize the prevalence of MetS 4-12 weeks postpartum in women with recent GDM and to determine whether there was an association between HbA1c and MetS.Methods: Women with GDM as defined by Carpenter-Coustan criteria or clinician diagnosis were enrolled into the Balance After Baby Intervention trial of a web-based intervention to prevent T2DM. They underwent a baseline study visit at 4-12 weeks postpartum. Waist circumference and blood pressure were obtained and a fasting lipid panel, HbA1c and a 75-g, 2 hr OGTT was performed. We defined MetS by NCEP ATP III criteria. We fit a logistic regression model adjusted for age, race/ethnicity, and number of weeks postpartum.Results: 181 women with GDM were enrolled in the study. Three women were excluded because they did not have fasting lipid measurements. Women were a mean of 8.0 ± 1.8 weeks postpartum at their baseline study visit. 24.2% (n=43) of women had MetS (at least 3 of 5 NCEP ATP III criteria). Of these, 77% met the waist circumference criterion, 37.6% met the HDL criterion, 23.6% met the triglycerides criterion, 16.9% met the fasting glucose criterion and 14.6% met the blood pressure criterion. HbA1c as a continuous variable was not significantly associated with MS (OR for each 0.5% increase: 1.60, 95% CI 0.88-2.91). Elevated HbA1c (prediabetes range ≥5.7 to <6.5%) was also not associated with MetS (OR 0.98, 95% CI 0.46-2.12). A 2 hr blood glucose value of ≥140 mg/dL on OGTT testing was significantly associated with MetS (OR 5.28, 95% CI 2.11-13.22).Conclusion: Nearly 1 in 4 women with recent GDM had MetS in the early postpartum period. There was no significant association between HbA1c and presence of MetS. However, an elevated 2 hr value on OGTT was significantly associated with MetS, suggesting that women with elevated 2 hr values may require additional monitoring for MetS and may have elevated cardiometabolic risk beyond the risk of development of T2DM.

SUN-629 Text for Success in Gestational Diabetes: Development and User Experience Testing of a Text Messaging Program

Background: Gestational diabetes mellitus (GDM) affects 5–10% of pregnancies in the United States. Poorly controlled GDM can lead to serious fetal and maternal complications. Women diagnosed with GDM are asked to form many new self-management habits. Studies have shown that text messaging is an effective, easily accessible way to improve management of diabetes outside of pregnancy, but this method has not been studied in GDM.Objective: Obtain user feedback and iteratively incorporate it into a personalized text messaging program for women with GDM.Methods: We performed user experience testing of a text messaging program (Txt4GDM), which was created by a multidisciplinary team based on the Health Belief Model. The program includes: 1) reminders to check blood glucoses sent 4 times per day based on self-reported mealtimes, 2) positive feedback for each blood glucose reported by a user (with an algorithm instructing users to contact their care team if too high/low), 3) one educational message and 4) one motivational message per week.Women with GDM received simulated messages on a study smartphone. Subjects participated in semi-structured interviews about the content and phrasing of text messages. Interview replies were categorized into themes and used to iteratively optimize the program.Results: 10 women completed user experience testing. All participants thought the program would be useful for women with newly diagnosed GDM and would use it during their first pregnancy with GDM. There were several features of the program that participants particularly liked, which were categorized into two themes: 1) customization of timing of messages and 2) messages including information not adequately covered in routine care (such as healthy snack ideas and exercise).Several themes emerged from the semi-structured interviews that were used to optimize the program. 1) Further customization of message timing: We added the ability to enter different mealtimes for weekends and weekdays, which was well-received in subsequent iterations. 2) Minimization of jargon: Multiple women did not know what the “M” in GDM stood for, so we removed “GDM” from the messages. 3) Women wanted the messages to be more specifically related to GDM. For example, an educational message said: “Drinking water, instead of soda or juice, is healthy for you.” The phrase “and can help regulate your blood sugar” was added based on participant feedback.Conclusions: Overall, women with GDM would use the Txt4GDM text messaging program and think it would be helpful for GDM self-management. Based on user feedback, enhanced customization of timing of text message delivery, minimization of jargon, and language specific to GDM in educational messages were added. We are testing the optimized text messaging program in an ongoing usability study.

SUN-270 The Exploding Pituitary - A Case of Atypical Meningitis

Introduction: Pituitary apoplexy is a rare presenting pathology of a pituitary mass. Apoplexy means “sudden attack”, which is a fitting description of the patient’s presentation. Apoplexy is breakdown of the pituitary gland due to insufficient blood flow, leading to ischemia, necrosis, and hemorrhage. Two proposed mechanisms exist: 1. Supra-sellar masses can outgrow their blood supply, 2. Growth inside the suprasellar fossa can constrict blood flow. Patients with pituitary apoplexy typically present with abrupt onset of severe headache, nausea, vomiting, altered level of consciousness, visual impairment and endocrine deficiency. Sheehan took credit for obstetric associated pituitary necrosis however, apoplexy can also be life threatening outside of pregnancy. Case Presentation: This case features 68-year-old females w history of migraines, bradycardia requiring a pace maker, CAD s/p stents, Rheumatoid Arthritis, and urothelial carcinoma of the left kidney which resulted in unilateral nephrectomy. Following surgery: Patient developed generalized weakness, weight loss, Headache. Presented later to ED with severe headache, photophobia, and hypotension. CT Head showed growth of suprasellar mass, edema of hypothalamus and thalamus. Laboratory tests showed Free T4 0.39 (08-1.7), LH < 0.3, FSH 3.7, Ptolactin diluted 85.7, Low Utine Osm 105, cortisol baseline 6.9, cortisol 60 min value post high dose Cosytropin stimulation was 15.5.Spinal fluid analysis was suggestive of aseptic meningitis. Our patient was treated for 10 days in ICU for Sepsis syndrome and viral meningitis before Endocrine consult was obtained, then he got started on hormonal treatment and referred to pituitary Neurosurgeon. Patient underwent Transphenoidal surgery. Pathology revealed Metastasis of Urothelial cancer to pituitary. DISCUSSION & CONCLUSION: Apoplexy causing an atypical meningitis is a rare presentation. We theorize apoplexy can lead to aseptic meningitis by leakage of blood or necrotic tissue into the subarachnoid space. Either agent can induce a cytokine mediated response and the presentation of meningitis. Based on CTs, our patient’s pituitary tumor grew significantly in 30 days. Medical management of pituitary apoplexy includes fluid electrolyte balance, glucocorticoids, hemodynamic monitoring, replacement of missing hormones, and the use of Decadron to decreases cerebral edema. Diabetes insipidus was an alarming symptom for possible metastatic cancer to pitutaryCONCLUSIONThis case highlights the difficulty in diagnosing pituitary pathologies and the rare presentation of apoplexy. Aseptic meningitis and a decrease in centrally controlled hormones should alert Physicians to include pituitary apoplexy in the differential diagnosis. Metastatic urothelial cancer to pituitary is extraordinarily uncommon.

Plasma Prolactin and Progesterone Levels and the Risk of Gestational Diabetes: A Prospective and Longitudinal Study in a Multiracial Cohort.

Objective: Prolactin and progesterone are implicated in glucose homeostasis in and outside of pregnancy. However, their associations with gestational diabetes (GDM) risk were not well-understood. This study investigates this question in a prospective and longitudinal cohort.Methods: This is a nested case-control study of 107 incident GDM cases and 214 matched non-GDM controls within the NICHD Fetal Growth Studies-Singleton Cohort. Blood samples were collected at gestational weeks 10–14, 15–26, 23–31, and 33–39. The odds ratios (OR) of GDM were estimated using conditional logistic regression. The longitudinal changes in prolactin and progesterone were estimated using linear mixed-effects models.Results: Compared to controls, cases have significantly higher prolactin levels at weeks 10–14 (median: 50.4 vs. 42.1 ng/mL), and significantly lower progesterone levels at weeks 10–14 (median: 109.4 vs. 126.5 nmol/L). Prolactin levels at weeks 10–14 were significantly and positively associated with GDM risk; the adjusted ORs across increasing quartiles were 1.00, 1.13, 1.80, 2.33 (p-trend = 0.02). A similar but slightly attenuated association was observed at weeks 15–26 (p-trend = 0.05). Progesterone was not associated with GDM risk at either time points. Longitudinal changes in prolactin and progesterone between the first two visits were not associated with GDM risk. In addition, prolactin was significantly and positively associated with insulin and C-peptide levels at weeks 10–14, and significantly and inversely associated with C-peptide levels at weeks 15–26; progesterone was significantly and inversely associated with glucose and insulin levels.Conclusions: This study provided the first prospective evidence of a positive association between prolactin levels in early pregnancy and GDM risk.

Respect women, promote health and reduce stigma: ethical arguments for universal hepatitis C screening in pregnancy

In the USA, there are missed opportunities to diagnose hepatitis C virus (HCV) in pregnancy because screening is currently risk-stratified and thus primarily limited to individuals who disclose history of...

Changes in sexual experiences and sexual satisfaction during pregnancy: data from a Greek secondary hospital

Changes in sexual experiences and sexual satisfaction during pregnancy: data from a Greek secondary hospital

Intrapartum Management of Sickle Cell Anemia With Rare Antibody and Minimal Blood Availability

Sickle cell disease (SCD) can pose serious maternal and fetal risk in pregnancy. Transfusion, both during and outside of pregnancy, can improve patient morbidity and mortality but carries risk of alloimmunization, complicating future management. This case describes a 29-year-old gravida 1, para 0 woman with sickle cell anemia and rare red blood cell alloantibody (anti-Rh46) who presented with severe vaso-occlusive crisis at 29 weeks with hemoglobin of 7.6 g/dL. Only one unit of compatible blood existed in the country. Planning for transfusion with least-incompatible blood was made. She ultimately underwent cesarean section at 31 weeks and 2 days for abnormal fetal testing. This case highlights that blood products should be utilized judiciously because their adverse effects, like alloimmunization, can increase patient morbidity and mortality.

421: Perinatal outcomes in a contemporary cohort of pregestational diabetic women with hemoglobin A1c values >10%

Because hemoglobin A1c (HbgA1c) values greater than 10% in the first trimester have been associated with increased rates of fetal anomalies in women with pregestational diabetes mellitus (DM), our aim was to examine perinatal outcomes according to HbgA1c values greater than 10% in the first trimester. This was a retrospective cohort study of pregnant women with pregestational DM at a single academic center. All women included in this analysis had a HbgA1c value obtained at presentation to prenatal care at less than 14 weeks gestation and delivered at our hospital. Maternal characteristics and perinatal outcomes were compared between women with HbgA1c values of ≤10% and those with HbgA1c values of >10%, and for specific perinatal outcomes an analysis across rising HbgA1c values was performed. Between May 2009 and December 2018, a total of 1,052 women met inclusion criteria. Of these, 273 (26%) had a first trimester HbgA1c of greater than 10%. When compared to women with HbgA1c < 10%, women with HbgA1c >10% were older (30+6 vs 32+6 years, P< 0.001) and had a longer duration of DM—6[3,10] vs 4 [2,7] years (P< 0.001). Selected perinatal outcomes are shown in the Table. Women with HbgA1c values >10% had significantly higher rates of preeclampsia (P=0.002), shoulder dystocia (P=0.045), neonatal death (P=0.042), and fetal anomalies (P< 0.001). As shown in the Figure, HbgA1c values above 10% were significantly associated with increased rates of preeclampsia—OR 1.16 (1.08, 1.23). Reflecting limited access to care outside of pregnancy, more than one-quarter of women with DM entered prenatal care with a HbgA1c of >10%. Such HbgA1c values >10% in early pregnancy were associated with increased rates of adverse perinatal outcomes to include preeclampsia, fetal anomalies, and neonatal death when compared to those with HbgA1c < 10%. Indeed, there appears to be a significant relationship between elevated HbgA1c values above 10% and increased rates of preeclampsia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Interleukin-1 Receptor-1 Deficiency Impairs Metabolic Function in Pregnant and Non-Pregnant Female Mice.

Glucose intolerance during pregnancy is associated with short- and long-term maternal and offspring health consequences. In young male mice, knockout of the major pro-inflammatory mediator interleukin-1-receptor-1 (IL1R1) protects against high-fat diet (HFD)-induced glucose intolerance and metabolic dysfunction. This phenotype has not been examined during pregnancy. The hypothesis that IL1R1 depletion will protect females against HFD-induced glucose intolerance and metabolic dysfunction before, during, and post pregnancy is tested. C57BL/6J control and IL1R1 knockout (IL1R1-/- ) mice are randomized to either a control diet (10%kcal from fat) or HFD (45%kcal from fat), and three distinct cohorts are established: nulliparous, pregnant, and postpartum females. Contrary to the authors' hypothesis, it is found that IL1R1-/- does not protect against glucose intolerance in nulliparous or pregnant females, and while control HFD animals see a resolution of glucose tolerance postpartum, IL-1R1-/- mice remain impaired. These effects are accompanied by adipocyte hypertrophy, hyperleptinemia, and increased adipose tissue inflammatory gene expression. Maternal genotype differentially affects fetal growth in male and female fetuses, demonstrating sexual dimorphism in this genotype prior to birth. These findings suggest that IL1R1 signaling is important for normal metabolic functioning in females, during and outside of pregnancy.

KEHAMILAN DENGAN GANGGUAN JIWA

Pregnancy is a dramatic episode of the biological and psychological changes and adaptations of a woman who never experienced it. The incidence of mental disorders in pregnancy was lower than postpartum and outside of pregnancy with 10 - 15% on post partum 10-15% and 2-7% beyond pregnancy. However Ohara reported that 10% of pregnant women was eligible if diagnosed with major and minor depression. There are two phases of pharma- cological management is described in the guidelines panel: the acute phase, symptoms are treated, drug dosage adjusted to prevent the adverse effects and patient given counseling, severe phase, patients were monitored at an effective dose to prevent relapse . In the maintenance phase, patients at risk for relapse is often still treated with medicines. Reported here the case of a female patient aged 31 years diagnosed with G2P1A0H1 term gravid 37- 38 weeks + bipolar affective disorder, current episode manic with psychotic symptoms. Patients have been known to suffer from a mental disorder since 2000 and has been submitted to psychiatry ward for as much as 9 times. Trigger disorder is unknown at this time, the patient suddenly angry for no apparent reason. Patients treated with pharmacotherapy of haloperidol 2x2 mg, roboransia and psychotherapy. Treatments including consideration of the patient to provide pharmacological therapy in a minimun dosage and psychotherapy to effectively reduce teratogenic risk to the fetus. Patients have been known to suffer from a mental disorder since 2000 and has been submitted to psychiatry ward for as much as 9 times. Trigger disorder is unknown at this time, the patient suddenly angry for no apparent reason. Patients treated with pharmacotherapy of haloperidol 2x2 mg, roboransia and psychotherapy. Treatments including consideration of the patient to provide pharmacological therapy in a minimun dosage and psychotherapy to effectively reduce teratogenic risk to the fetus. Patients have been known to suffer from a mental disorder since 2000 and has been submitted to psychiatry ward for as much as 9 times. Trigger disorder is unknown at this time, the patient suddenly angry for no apparent reason. Patients treated with pharmacotherapy of haloperidol 2x2 mg, roboransia and psychotherapy. Treatments including consideration of the patient to provide pharmacological therapy in a minimun dosage and psychotherapy to effectively reduce teratogenic risk to the fetus.Keywords: Mental disorders, bipolar affective disorder, pregnancy, psychotherapy

Using the Novel Approach of an Artificial Pancreas to Manage Type 1 Diabetes Mellitus in Pregnancy

Recent National Institute for Health and Care Excellence (NICE) guidelines suggest that insulin pump therapy should be used in pregnant women with Type 1 diabetes mellitus (T1DM) who do not achieve optimal glycaemic control with multiple daily injection (MDI) therapy. Furthermore, a landmark trial has confirmed that prospective continuous glucose monitoring (CGM) may be beneficial for women using both MDI and insulin pumps during pregnancy, with positive effects on neonatal outcomes. More recently, overnight use of an artificial pancreas (AP) with a model-predictive control algorithm has been shown to improve the amount of time women spend within the overnight glucose target range (3.5–7.8 mmol/L) during pregnancy. However, preliminary studies where the AP is used day and night have shown a high degree of interindividual variability in response to the intervention, and further randomised trials are needed to understand which women are suitable candidates for CGM, insulin pump, and AP technology. It is understood that improvements in maternal glycaemic control can minimise the risk of adverse neonatal outcomes. Given the substantial improvements in glycaemic control with AP use outside of pregnancy, the recent advances in AP technology provide hope that AP systems will improve the effectiveness of continuous subcutaneous insulin infusion and CGM during pregnancy. Further research is needed to evaluate whether AP can optimise glucose control and neonatal outcomes in T1DM pregnancy. This paper will discuss emerging technologies available for the management of T1DM in pregnancy.

Augmented insulin secretory response in early pregnancy.

This study aimed to examine changes in the insulin secretory response in early pregnancy, while accounting for changes in insulin sensitivity. This is a secondary analysis of a previously conducted longitudinal physiological study. In 34 women, insulin secretory response (by IVGTT) and insulin sensitivity (by euglycaemic clamp) were assessed prior to pregnancy, in early pregnancy (12-14weeks gestation) and in late pregnancy (34-36weeks gestation). Using mixed-effects models, we compared insulin secretory response and sensitivity in early pregnancy to the same variables prior to pregnancy and in late pregnancy, with adjustment for age, obesity status and gestational diabetes mellitus (GDM). We examined changes in insulin secretory response after adjustment for insulin sensitivity using both multivariate modelling and the disposition index (DI). We explored the relationship between insulin secretory response and circulating hormones. The insulin secretory response increased from prior to pregnancy to early pregnancy (unadjusted mean [SD] first-phase insulin response 465.1 [268.5] to 720 [358.2], p < 0.0001) and from early pregnancy to late pregnancy (to 924 [494.6], p = 0.01). Insulin sensitivity increased from prior to pregnancy to early pregnancy (insulin sensitivity index 0.10 [0.04] to 0.12 [0.05], p = 0.001) and decreased in late pregnancy (to 0.06 [0.03], p < 0.0001). Accounting for changes in insulin sensitivity, using either multivariate modelling or the DI, did not attenuate the early-pregnancy augmentation of insulin secretory response. Leptin was positively associated with insulin secretory response, independent of insulin sensitivity and adiposity (p = 0.004). Adjustment for leptin attenuated the observed augmentation of insulin secretory response in early pregnancy (adjusted mean change 121.5, p = 0.13). The insulin secretory response increases markedly in early pregnancy, prior to and independent of changes in insulin sensitivity. Circulating hormones may mediate this metabolic adaptation. Identifying mediators of this physiological effect could have therapeutic implications for treating hyperglycaemia during and outside of pregnancy.

1642-P: Glucose Control among Diabetes Cases Selected from a Representative National Survey in Brazil

Background: A target of an HbA1c &amp;lt;7% is frequently the cornerstone of clinical guidelines for the care of diabetes globally. Yet, nationally representative NHANES surveys indicate that only 50 to 60% of those with diabetes meet this target. Our aim was to evaluate glucose control when assessed by HbA1c in a national sample of Brazilian adults with diabetes. Methods: A sub-sample of adults (18 years or older) of the representative Brazilian National Health Survey (2014-2015) was randomly selected for the collection of biological samples. Of these, 8952 (52%) individuals provided samples, and 8541 (50%) have HbA1c results. HbA1c was measured at a NDPG-certified central laboratory. Diabetes was defined by self-report of a physician diagnosis. Given the complex sampling used to select participants and the response rate obtained, we used the rake method of post-stratification survey weights, calculated according to sex, age, and education, to estimate national rates. Results: Among the 8541 adults, 573 (5.87%; 95% CI: 5.41%-6.33%) reported having received a previous diagnosis of diabetes outside of pregnancy. Of these, only 55.2% (51.1%-59.4%) had HbA1c less than 7%, and 69.5% (65.7%-73.4%) less than the more flexible HbA1c target of 8%. On the other hand, 19.8% (16.5%-23.1%) had HbA1c ≥9.0%, indicating very poor glucose control. Though small sample size limited statistical testing, we found no differences across socio-demographic characteristics except for educational achievement, those of lesser education more frequently presenting worse glucose control (p=0.004). Conclusion: Our results, showing a glucose control similar to that observed in representative U.S. surveys, highlight the large fraction of cases with very poor control. New strategies are needed to improve glucose control in the entire population of persons living with diabetes. Disclosure R.C.P. dos Reis: None. B.B. Duncan: Research Support; Self; Eli Lilly and Company. Research Support; Spouse/Partner; Eli Lilly and Company. M.I. Schmidt: Research Support; Self; Eli Lilly and Company. Research Support; Spouse/Partner; Eli Lilly and Company.

Marijuana Use in Pregnancy: An Updated Look at Marijuana Use and Its Impact on Pregnancy.

This article aims to provide an updated look at the use of marijuana in the United States and its impact on pregnancy. First, the prevalence of marijuana use is examined, including use both in and outside of pregnancy. The literature surrounding attitudes and beliefs with regard to use in pregnancy is reviewed. The impact on pregnancy outcomes is reviewed along with the evidence of marijuana's impact on neural development of the fetus. Finally, clinical considerations for providers are discussed.

Lois Jovanovič, MD, MACE: Pioneer in the Field of Diabetes and Pregnancy and Beyond.

Lois Jovanovic is a name that has become synonymous with good pregnancy outcomes for women with type 1 diabetes. Having type 1 diabetes herself and experiencing the challenges it poses for the pregnant woman, Dr. Jovanovic devoted her career to helping women with diabetes prepare for pregnancy and experience successful outcomes. She always emphasized the importance of being in excellent metabolic balance before becoming pregnant and always told her patients that they were “not allowed to get pregnant until she gave them permission.” As newer insulin analogs became available, they were only approved for use outside of pregnancy. Dr. Jovanovic pioneered testing these analogs in pregnancy, proving that not only were they safe for pregnant women and their babies but resulted in improved diabetes control throughout the pregnancy. Dr. Jovanovic developed an algorithm for insulin use that she taught her patients so they could more easily manage their diabetes during the stress of pregnancy (1). She was very proud of how successful the outcome could be when a pregnancy was meticulously managed and for years kept a picture of each newborn whose mother she had worked with through the pregnancy. Dr. Jovanovic was passionate about her patients—more than one was overheard saying “Dr. Lois is the first diabetes doctor who really understood what I’m going through.” Others swore they are only mothers because of Dr. Lois; she was their devoted “cheerleader” (her term) as she kept in close touch with her moms throughout their pregnancies, including through daily faxed glucose diaries and phone calls. Dr. Jovanovic authored or coauthored numerous texts and monographs to help women and their physicians better understand the diabetic pregnancy. These included Diabetes & Pregnancy: What to Expect (2) and Gestational Diabetes: What to Expect (3), which the American Diabetes Association relied on for years along …

Attitudes to E-Cigarettes and Cessation Support for Pregnant Women from English Stop Smoking Services: A Mixed Methods Study.

Smoking in pregnancy remains a public health problem. In the UK e-cigarettes are the most popular aid to quitting smoking outside of pregnancy, but we don’t know the extent of e-cigarette use in pregnancy or how English Stop Smoking Services (SSS) respond to pregnant women who vape. In 2015 we surveyed SSS managers about cessation support for pregnant women and responses to clients who vaped. Subsequently we interviewed a sub-sample of managers to seek explanations for the SSS’ position on e-cigarettes; interviews were thematically analysed. Survey response rate was 67.8% (72/106); overall managers reported 2.2% (range 1.4–4.3%) of pregnant clients were using e-cigarettes. Most SSS reported supporting pregnant women who already vaped, but would not recommend e-cigarette use; for women that were still smoking and not using e-cigarettes, 8.3% of SSS were likely/very likely to advise using e-cigarettes, with 56.9% of SSS unlikely/very unlikely to advise using them. Fifteen respondents were interviewed; interviewees were generally positive about the potential of e-cigarettes for cessation in pregnancy although concerns about perceived lack of evidence for safety were expressed and most wanted research on this. Clear guidance on e-cigarette use informed by pregnancy specific research will assist SSS to provide consistent evidence-based support.

APC-resistance as a possible predictor of recurrent thrombosis in women with Factor V Leiden

Hypothesis/aims of study. The current analysis was undertaken to elucidate the role of Factor Va resistance to proteolytic cleavage by activated protein C in FVL(1691)GA female carriers in the development of acute and recurrent thromboses.&#x0D; Study design, materials and methods. A prospective clinical cohort study of 1100 women of reproductive age was conducted, with the course and outcomes of 2,707 pregnancies analyzed. Two cohorts were specified: the main group consisted of 500 patients with FV(1691)GA genotype, and the control group consisted of 600 patients with FVL(1691)GG genotype.&#x0D; Results. FVL(1691)GA genotype was significantly associated with the development of venous thromboembolic complications (VTEC) compared to FVL(1691)GG genotype (OR 9.3; p &lt; 0.0001). Episodes of recurrent thrombosis during and outside of pregnancy were registered only in FVL(1691)GA patients (OR 5.7, p = 0.2). In all cases, at the time of the thrombotic event and during the period before the episode of acute or recurrent thrombosis, an APC resistance normalized ratio (NR) value was ≤ 0.49, with no episodes of VTEC registered with an APC resistance NR value ≥ 0.5.&#x0D; Conclusion. Venous thromboses occur under the condition of expressed APC resistance with underlying FVL(1691)GA carriage. The APC resistance index can serve as an objective biochemical marker to determine the feasibility of thromboprophylaxis within the framework of personalized medicine.

Genetic determinants of glucose levels in pregnancy: genetic risk scores analysis and GWAS in the Norwegian STORK cohort.

Objective Hyperglycaemia during pregnancy increases the risk of adverse health outcomes in mother and child, but the genetic aetiology is scarcely studied. Our aims were to (1) assess the overlapping genetic aetiology between the pregnant and non-pregnant population and (2) assess the importance of genome-wide polygenic contributions to glucose traits during pregnancy, by exploring whether genetic risk scores (GRSs) for fasting glucose (FG), 2-h glucose (2hG), type 2 diabetes (T2D) and BMI in non-pregnant individuals were associated with glucose measures in pregnant women. Methods We genotyped 529 Norwegian pregnant women and constructed GRS from known genome-wide significant variants and SNPs weakly associated (p > 5 × 10-8) with FG, 2hG, BMI and T2D from external genome-wide association studies (GWAS) and examined the association between these scores and glucose measures at gestational weeks 14-16 and 30-32. We also performed GWAS of FG, 2hG and shape information from the glucose curve during an oral glucose tolerance test (OGTT). Results GRSFG explained similar variance during pregnancy as in the non-pregnant population (~5%). GRSBMI and GRST2D explained up to 1.3% of the variation in the glucose traits in pregnancy. If we included variants more weakly associated with these traits, GRS2hG and GRST2D explained up to 2.4% of the variation in the glucose traits in pregnancy, highlighting the importance of polygenic contributions. Conclusions Our results suggest overlap in the genetic aetiology of FG in pregnant and non-pregnant individuals. This was less apparent with 2hG, suggesting potential differences in postprandial glucose metabolism inside and outside of pregnancy.

Rationale, design, and methods for the Medical Optimization and Management of Pregnancies with Overt Type 2 Diabetes (MOMPOD) study

BackgroundAnnually in the US, over 100,000 pregnant women with overt type 2 diabetes give birth. Strict maternal glycemic control is the key to optimizing infant outcomes. Medical treatment of type 2 diabetes in pregnancy is generally restricted to insulin, as data on the safety and efficacy of oral hypoglycemic agents in pregnancy are limited. However, over one-third of infants born to women with type 2 diabetes experience an adverse outcome, such as premature delivery, large-for-gestational age, hypoglycemia, hyperbilirubinemia, or birth trauma, suggesting that current treatment regimens fall short of optimizing outcomes. Metformin is the pharmacologic treatment of choice for type 2 diabetes outside of pregnancy. Metformin is favored over insulin because it results in less weight gain, fewer hypoglycemic episodes, and is administered orally rather than injected. However, metformin is not typically used for treatment of type 2 diabetes complicating pregnancy, mainly because no large clinical studies have been conducted to examine its use in this context.Methods/designThis is a randomized double-blind multi-center clinical trial of insulin plus metformin versus insulin plus placebo for the treatment of type 2 diabetes complicating pregnancy. A total of 1200 women with type 2 diabetes will be randomized between 10 weeks 0 days’ and 20 weeks 6 days’ gestation and followed until 30 days after delivery. Neonate outcomes will be followed until 30 days of age. The primary aim is to compare the effect of insulin and metformin versus insulin and placebo on composite adverse neonatal outcomes, comprising perinatal mortality, preterm delivery, neonatal hypoglycemia, hyperbilirubinemia, large-for-gestational age small for gestational age, low birth weight, and/or birth trauma. Key secondary aims are to compare treatment groups for neonatal fat mass and rate of maternal hypoglycemia. Additional aims are to assess the side effects and safety of insulin and metformin among pregnant women with overt type 2 diabetes and to compare gestational weight gain among women treated with metformin plus insulin versus insulin alone.DiscussionSuccessful completion of this study will result in high-quality, contemporary evidence for management of overt type 2 diabetes complicating pregnancy to improve neonatal outcomes.Trial registrationNCT02932475 (05/17/2016).