Matthew Garabedian

Neonatal adiposity following maternal treatment of gestational diabetes with glyburide compared with insulin

OBJECTIVE We hypothesized that body composition would be similar among neonates of women with gestational diabetes (GDM) treated with glyburide or insulin. STUDY DESIGN Women with GDM requiring medical therapy were randomized to insulin or glyburide. The primary outcome was percent neonatal fat mass measured by total body electrical conductivity. Secondary outcomes included anthropometrics, glycemic control, and biomarkers. Statistical analysis included Student t test, chi(2), and regression modeling. RESULTS Eighty-two neonates underwent postnatal measurements. Baseline factors were not different by group. Neonatal percent fat mass did not differ between treatment groups (11.2 +/- 4.2 vs 12.8 +/- 5.7). Fat mass, body mass index, ponderal index, skinfold sum, and arm fat area were not different when analyzed by intent to treat or actual treatment group. Cord concentrations of biomarkers were also similar. CONCLUSION There was no difference in neonatal adiposity in infants of women treated for GDM with glyburide or insulin.

Violence Against Women and Postpartum Depression

BACKGROUND Violence against women (VAW), including intimate partner violence (IPV) in its various forms (sexual, physical, or stalking), and childhood violence (sexual or physical) are common and are associated with depressive symptoms. We examined the association between these violence exposures and self-reported history of postpartum depression (PPD). METHODS Women from the Kentucky Womens Health Registry (KWHR) who reported at least one live birth were included in this study. Individual IPV and child abuse histories were examined for association with self-reported history of PPD. Multivariate regression analysis estimated adjusted risk ratios (aRR) and 95% confidence intervals (95% CI), controlling for age, obstetrical history, and substance abuse history. RESULTS The 5380 women in the KWHR reporting at least one live birth were included in this study. Of these women, 2508 (46.6%) reported a history of any VAW. A history of adult VAW was associated with a history of PPD (aRR 1.48, 95% CI 1.12-1.95). Physical IPV (aRR 1.48, 95% CI 1.12-1.95) and stalking IPV (aRR 1.39, 95% CI1.03-1.87) were individually associated with PPD. Other types of violence were not individually associated with a history of PPD. The strength of association increased with each additional type of violence experienced (aRR1.17, 95% CI 1.06-1.30). CONCLUSIONS Adult VAW is associated with self-reported history of PPD. With an increase in the number of types of abuse experienced, this association became stronger. Our findings highlight the need for thorough VAW screening in obstetrical populations.

Extreme morbid obesity and labor outcome in nulliparous women at term.

We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m2) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥ 50) from morbid obesity (BMI ≥ 40 to < 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed. CD was most common among women with a prepregnancy BMI ≥ 50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22). Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.

Up-regulation of oxytocin receptor expression at term is related to maternal body mass index.

BACKGROUND The likelihood of cesarean is in part related to maternal body mass index (BMI). Myometrial changes may be responsible. METHODS Myometrial biopsies were collected from the upper edge of the hysterotomy from women undergoing scheduled cesarean with term, singleton gestations. Oxytocin receptor and connexin-43 mRNA protein expression was quantified with real-time polymerase chain reaction and Western blot. RESULTS Twenty subjects were recruited: 13 repeat and 7 primary cesareans. Oxytocin receptor mRNA was associated with BMI among women undergoing primary (r = 0.75; p = 0.05) but not repeat cesarean (p > 0.05). Controlling for gestational age, this association strengthened (p = 0.004). Receptor protein expression showed a linear correlation with BMI in the primary cesarean group (p = 0.002). Connexin-43 mRNA expression was not related to BMI in women undergoing primary (r = -0.14, p = 0.76) or repeat (r = -0.01, p = 0.86) cesarean. CONCLUSIONS Oxytocin receptor, but not connexin-43, expression is related to BMI, suggesting an alteration in oxytocin receptor expression or function related to obesity.

Prenatal diagnosis of partial trisomy 16p and its association with congenital diaphragmatic hernia.

A 30y/oG2P1001 presented at 6 6/7weeks gestation for a routine ultrasound. The gestational sac, the fetus, and the cardiac activity were normal, but the yolk sac appeared enlarged. It was round and regular, measuring 7.4mm in diameter. She denied any signs or symptoms of early pregnancy loss. Her medical history was significant for mitral valve stenosis and tobacco use (15 cigarettes per day) in the first week of pregnancy. Medications included cetirizine for seasonal allergies and prenatal vitamins. Her obstetric history revealed a full term, normal infant delivered by cesarean secondary to failure to descend. Maternal family history was significant for a sister with monosomy X. Paternal family history was significant for several male relatives with cardiac deaths prior to 40 years of age. Given the association of an enlarged yolk sac with both spontaneous abortion and aneuploidy, she returned 2weeks later for a second ultrasound. At 9weeks gestation, the gestational sac again appeared normal; interval fetal growth was normal as well as cardiac activity. The yolk sac had maintained a normal shape but continued to be very enlarged. She again denied any signs or symptoms of early pregnancy loss. Genetic counseling was completed out of concern for an increased risk for aneuploidy. The patient declined chorionic villous sampling (CVS) and opted to wait for first trimester screening or possible amniocentesis. At 12 5/7weeks gestation, she presented for first trimester screening. Fetal growth, as measured by crown rump length, and cardiac activity were normal. Nuchal translucency (NT) was thickened, measuring 3.3mm (Figure 1). She again declined CVS and elected to return for an early anatomic survey and possible amniocentesis. First trimester screening was not completed. Ultrasound at 16 6/7weeks gestation revealed a left-sided congenital diaphragmatic hernia (CDH) along with left renal pelviectasis. Fetal biometry and amniotic fluid volume were normal. She elected to have amniocentesis. Chromosome analysis identified an unbalanced translocation between one chromosome 16 and one chromosome 17 resulting in trisomy for most of the short (p) arm of chromosome 16 (p11.2!pter): (46,XX,der(17)t(16;17)(p11.2;q25.3) (Figure 2). Fluorescence in situ hybridization with the 17q subtelomere probe D17S928 identified a signal on the derivative 17 suggesting no or very minimal loss of chromosome 17 material from the derivative. There were three 16p subtelomere signals with probe 16pTEL05 confirming that the additional chromatin on 17q was derived from 16p. The cytogenetic findings were consistent with pure partial trisomy 16p. The patient elected to terminate the pregnancy given the poor prognosis of a diaphragmatic hernia due to a chromosome imbalance. Maternal and paternal chromosome analyses were normal indicating the translocation was de novo. Trisomy 16 is one of the most common chromosomal causes of spontaneous abortion in the first trimester, but its occurrence among live births is exceedingly rare. In fact, nonmosaic trisomy 16 is considered a lethal genetic imbalance. There are reports, however, of infants born with partial or complete trisomy of the short arm (p) of chromosome 16. These cases have been summarized in an effort to define the phenotype of trisomy 16p. Recurring anomalies for trisomy 16p include craniofacial abnormalities (prominent glabella, hypertelorism, anteverted nares, short philtrum, cleft palate, and micrognathia), congenital heart defects, renal anomalies, single umbilical artery, and skeletal abnormalities. The mortality rate in infancy is approximately 50%. There are rare long-term survivors. In these individuals, growth delays, severe intellectual disability, and seizures are very common. Our finding of a CDH has not been considered as part of the phenotype for trisomy 16p. However, there is a recent report of a 15 year old with a repaired CDH, dysmorphism and autism, and a microduplication of 16p11.2 detected by chromosomal microarray analysis (CMA). The molecular breakpoints were