Elucidating the optimal macronutrient composition for dietary management of gestational diabetes mellitus(GDM) 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(RCTs) 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 GDM remains an area in grave need for high-quality RCTs.
Lactating women exhibit more favorable blood glucose and insulin profiles, as well as increased insulin sensitivity than nonlactating women. Yet, much less is known about whether these favorable effects on metabolic risk factors persist long-term among women with gestational diabetes mellitus (GDM). The evidence that lactation reduces incident type 2 diabetes after GDM pregnancy is limited and inconsistent. Well-controlled, prospective studies that measure lactation intensity and duration, and comprehensively screen for postpartum glucose tolerance are needed to conclusively determine whether lactation can lead to reduced risk of type 2 diabetes after GDM pregnancy.
lactation; diabetes; gestational diabetes; breastfeeding; pregnancy; postpartum
Women who have significant bone loss or a new fracture on monotherapy are considered for combination therapy. Combination therapies increases bone density more than mono-therapy by targeting different parts of the osteoclast pathway.
In early post-menopausal women who are symptomatic the use of combination anti resorptives should include hormone therapy with a bisphosphonate or with bazodoxifene. In women who initially receive a weaker anti-resorptive such as the SERM raloxifene, then a combination with bisphosphonates and calcium supplementation is necessary to prevent bone loss. In older women over 65 years who often have impaired calcium absorption, the combination of calcitriol with bisphosphonates has been shown to be increase bone density more than monotherapy.
A newly recognized primary cause of the obesity epidemic is the developmental programming effects of infants born to mothers with obesity or gestational diabetes, intrauterine growth restricted newborns, and offspring exposed to environmental toxins including Bisphenol A. The mechanisms which result in offspring obesity include the programming of the hypothalamic appetite pathway and adipogenic signals regulating lipogenesis. Processes include nutrient sensors, epigenetic modifications, and alterations in stem cell precursors of both appetite/satiety neurons and adipocytes which are modulated to potentiate offspring obesity. Future strategies for the prevention and therapy of obesity must address programming effects of the early life environment.
The incidence of pediatric non-alcoholic fatty liver disease has increased dramatically, and growing evidence indicates that the pathophysiology may be unique from the adult form, suggesting a role for early-life events. Recent radiologic techniques have now demonstrated that maternal obesity contributes to hepatic fat storage in newborn infants. In this review, we will explore how maternal obesity and a hyperlipidemic environment can initiate liver histopathogenesis in utero, including steatosis, mitochondrial dysfunction, oxidative stress, and inflammatory priming. Thus, early exposure to excess lipids may represent the 'first hit' for the fetal liver, placing it on a trajectory towards future metabolic disease.
NAFLD; Nonalcoholic steatohepatitis; Pediatric NASH; Maternal Obesity; Fetal Programming; Mitochondrial Dysfunction; Lipotoxicity; Sirtuins
Rapid postnatal growth and differentiation of fetal arterial smooth muscle is coordinated by a cacophony of growth factors, one of the most important of which is vascular endothelial growth factor (VEGF). In fetal arterial smooth muscle, VEGF influences both the expression and intracellular organization of contractile proteins and helps mediate hypoxic vascular remodeling. Numerous factors influence the expression of VEGF and its receptors, including chronic hypoxia, maternal food restriction, glucocorticoids, and miRNA. Continued study of the coupling between VEGF and transcription factors such as myocardin that govern smooth muscle differentiation, offers great promise for better clinical management of neonates at risk for cardiovascular dysregulation.
contractile proteins; fetal arteries; hypoxia; smooth muscle phenotype; vascular endothelial growth factor
Altered maternal nutrition and metabolism, restricted utero-placental blood flow and other perturbations in the maternal compartment may disturb critical periods of fetal development resulting in increased susceptibility to develop disease in childhood and adult life. In response to these perturbations, placental structure and function changes, which influence the supply of nutrients, oxygen and methyl donors and alter the secretion of hormones and other signaling molecules into the fetal circulation. Thus, the placenta plays a critical role in modulating maternal-fetal resource allocation, thereby affecting fetal growth and the long-term health of the offspring.
Maternal-fetal exchange; nutrient transport; trophoblast; pregnancy; fetal programming
Early life environment predicts future health. The initial precedents and research focus for this concept arose out of historical events. However, this concept continues to be relevant as evidenced by the recent Chinese Famine and the evidence of racial disparities in the United States. The latter allows us to introduce the “life course model” and “weathering” as relevant epigenetic phenomena. We then review the molecular components of environmental epigenetics. We subsequently present glucocorticoid receptor biology as a paradigm that involves all of the components. Finally, we suggest that environmental epigenetics are a key component of the future of personalized medicine.
The growing field of epigenetics and human behavior affords an unprecedented opportunity to discover molecular underpinnings of mental health disorders and pave the way for the development of preventive intervention programs. Maternal depression during pregnancy is a serious public health issue and leads to a fourfold increase in the likelihood that the child will develop depression. We describe how mood disorders, particularly depression, may be shaped by early life stress, programming, and epigenetic processes and pathways showing how these processes could lead to depression in childhood. Implications of this approach to the study of mental health disorders for preventive interventions are discussed.
maternal depression; childhood depression; programming; epigenetics; stress; developmental origins
This article will discuss the diagnosis of osteoporosis in premenopausal women and the evaluation and management of those with low-trauma fractures and/or low bone mineral density. As secondary causes (glucocorticoid excess, anorexia nervosa, premenopausal estrogen deficiency, and celiac disease) are commonly the underlying cause of osteoporosis in this population, treatment of the underlying condition should be the focus of management. Additional management options, generally reserved for those with major or multiple fractures and/or ongoing bone loss, will also be described.
premenopausal women; osteoporosis; bone mineral density; pregnancy-associated osteoporosis; lactation- associated osteoporosis; idiopathic osteoporosis
Intrauterine growth restriction (IUGR) impairs insulin secretion in humans and in animal models of IUGR. Several underlying mechanisms have been implicated, including decreased expression of molecular regulators of β-cell mass and function, in some cases shown to be due to epigenetic changes initiated by an adverse fetal environment. Alterations in cell cycle progression contribute to loss of β-cell mass, whereas decreased islet vascularity and mitochondrial dysfunction impair β-cell function in IUGR rodents. Animal models of IUGR sharing similar insulin secretion outcomes as the IUGR human are allowing underlying mechanisms to be identified. This review will focus on models of uteroplacental in sufficiency.
intrauterine growth restriction; β-cells; diabetes; insulin secretion
Women are seeking care for pelvic organ prolapse (POP) in increasing numbers and a significant proportion of them will undergo a second repair for recurrence. This has initiated interest by both surgeons and industry to utilize and design prosthetic mesh materials to help augment longevity of prolapse repairs. Unfortunately, the introduction of transvaginal synthetic mesh kits for use in women was done without the benefit of Level 1 data to determine its utility compared to native tissue repair. This report summarizes the potential benefit/risks of transvaginal synthetic mesh use for POP and recommendations regarding its continued use.
The significance for maternal and fetal health of gestational Obstructive Sleep Apnea, Primary Insomnia, Restless Legs Syndrome, & Narcolepsy are summarized. The pathophysiology, signs, symptoms, and basic Sleep Medicine concepts that assist the obstetrician in suspecting these four conditions are described. Where appropriate, initial management options are also outlined. Referral guidelines to a Sleep Medicine specialist are included when further diagnostic, severity assessment, and management suggestions are needed.
Stroke is a neurological emergency that carries a risk of morbidity and mortality. Recent studies have shown that the incidence of stroke, while rare, is increasing in pregnant females. In this review, stroke and other vasculopathies in the pregnant and post-partum female are examined. A discussion of the symptoms and clinical presentation of stroke is provided, as well as the current guideline for treatment of stroke in pregnancy. Finally, the data illustrating the recent increases in stroke incidence is outlined.
stroke; pregnancy; puerperium; vasculopathy; cerebral sinus venous thrombosis; intracerebral hemorrhage
Recent rise in rates of opiate replacement therapy among pregnant women have resulted in increasing number of infants requiring treatment for neonatal abstinence syndrome. Short- and long-term developmental outcomes associated with prenatal opiate exposure are discussed, including symptoms and severity of neonatal abstinence syndrome (NAS), and early cognitive and motor delays. Maternal and infant risk factors are discussed, and include patterns of maternal substance use during pregnancy, genetic risk, polysubstance exposure pharmacologic treatment for NAS and breastfeeding. The importance of characterizing corollary environmental risk factors is also considered.
Neonatal Abstinence Syndrome; maternal opiate dependence; pharmacological treatment for opiate addiction; neonatal and long-term developmental outcomes
Osteoporosis is a skeletal disorder characterised by reduced bone quantity and quality and an increased susceptibility to fracture, and appears to be one of many chronic conditions that might be influenced by events early in life. Specifically, there is growing evidence of an interaction between the genome and the environment in the expression of the disease.
osteoporosis; programming; bone; fracture; nutrition; cohort
Untreated infection may cause stillbirth by several mechanisms, including direct fetal infection, placental damage, and severe maternal illness. Many bacteria, viruses, and protozoa have been associated with stillbirth. In developed countries, up to 24% of stillbirths have been attributed to infection, although with increased availability of sophisticated diagnostics and rigorous screening, it appears likely that higher numbers may actually be associated with infection. In developed countries, ascending bacterial infection is usually the most common infectious cause of stillbirth, with a number of viral infections also an important factor. Screening, prevention and treatment of maternal infections are important to reduce stillbirth risk.
Stillbirth; infection; chorioamnionitis
Health professionals have begun using social media to benefit patients, enhance professional networks, and advance understanding of individual and contextual factors influencing public health. However, discussion of the dangers of these technologies in medicine has overwhelmed consideration of positive applications. This article summarizes the hazards of social media in medicine and explores how changes in functionality on sites like Facebook may make these technologies less perilous for health professionals. Finally, it describes the most promising avenues through which professionals can use social media in medicine – improving patient communication, enhancing professional development, and contributing to public health research and service.
social media; technology; professionalism; patient-physician relationships; communication; public health
Neonatal herpes, seen roughly in 1 of 3,000 live births in the United States, is the most serious manifestation of herpes simplex virus (HSV) infection in the perinatal period. Although acyclovir therapy decreases infant mortality associated with perinatal HSV transmission, development of permanent neurologic disabilities is not uncommon. Mother-to-neonate HSV transmission is most efficient when maternal genital tract HSV infection is acquired proximate to the time of delivery, signifying that neonatal herpes prevention strategies need to focus on decreasing the incidence of maternal infection during pregnancy and more precisely identifying infants most likely to benefit from prophylactic antiviral therapy.
herpes simplex virus infection; humoral immunity; neonatal transmission; pregnancy
While postnatal psychological distress has been widely studied for many years, particularly with a focus on postpartum depression, symptoms of maternal depression, stress, and anxiety are not more common or severe after childbirth than during pregnancy. This paper reviews the newer body of research aimed at identifying the effects of women’s antenatal psychological distress on fetal behavior and child development, and the biological pathways for this influence. These studies are in line with the growing body of literature supporting the “fetal origins hypothesis” that prenatal environmental exposures — including maternal psychological state–based alterations in in utero physiology — can have sustained effects across the lifespan.
fetal heart rate; fetal movement; HPA axis; neurobehavioral development; developmental psychopathology
Despite widespread use of many methods of antenatal testing, limited evidence exists to demonstrate effectiveness at improving perinatal outcomes. An exception is the use of Doppler ultrasound in monitoring high-risk pregnancies thought to be at risk of placental insufficiency. Otherwise, obstetricians should proceed with caution and approach the initiation of a testing protocol by obtaining an informed consent. When confronted with an abnormal test, clinicians should evaluate with a second antenatal test and consider administering betamethasone, performing amniocentesis to assess lung maturity, and/or repeating testing to minimize the chance of iatrogenic prematurity in case of a healthy fetus.
antenatal testing; fetal well-being; fetal movement counting; nonstress test; fetal lung maturity; Doppler ultrasound
Unless an ectopic pregnancy is visible by ultrasound, diagnosis can be a challenge. Differentiating ectopic pregnancies from intrauterine pregnancies can be impossible without intervention or follow-up. This poses a clinical dilemma to the practitioner given the inherent danger to the mother of tubal rupture of an ectopic pregnancy versus the fear of intervening in the case of a desired pregnancy without certainty of diagnosis. Early diagnostic modalities are clearly lacking, and serum biomarkers are currently being investigated as a solution to need for a rapid and accurate test for ectopic pregnancy.
ectopic pregnancy; serum test; biomarkers; proteomics; multiple markers
Medical management has become increasingly popular in the treatment of ectopic pregnancy. Given its convenience, for many it is used as a first line treatment, but this is not always the optimal choice for the patient. It is important to understand the options for medical treatment and when it is appropriate to treat a particular patient with medical management, or when one should opt for surgical management. This review outlines the different regimens for methotrexate administration and the associated risks and benefits to medical management.
Ectopic pregnancy; methotrexate; treatment; hCG; medical treatment
Measles, mumps, and rubella are viral diseases that may adversely affect non-immune pregnant women and their fetuses/neonates. Prevention of these diseases and their complications can be achieved through measles-mumps-rubella (MMR) vaccination prior to pregnancy. The vaccine is contraindicated during pregnancy because it contains live, attenuated viruses that pose a theoretical risk to the fetus. However, accidental receipt of MMR vaccination is not known to cause maternal/fetal complications. MMR immunization is recommended to non-immune obstetric patients upon completion or termination of pregnancy.
Measles-Mumps-Rubella Vaccine; Measles; Mumps; Rubella; Congenital Rubella Syndrome; Obstetrics
Congenital cytomegalovirus (CMV) infection is an important cause of hearing impairment, mental retardation and cerebral palsy. Principal sources of infection during pregnancy are young children and intimate contacts. Prevention of maternal and congenital CMV infection depends on counseling women regarding the sources of infection and hygienic measures that might prevent infection. There is currently insufficient evidence to support use of antiviral treatment or passive immunization for post-exposure prophylaxis of pregnant women or as a maternal treatment aimed at preventing fetal infection. Vaccines for CMV are under development but it will be a number of years before one is licensed.
Cytomegalovirus; congenital infection; CMV prevention; prenatal counseling