Melissa S. Mancuso

Maternal Glucose Concentration During Pregnancy Predicts Fat and Lean Mass of Prepubertal Offspring

OBJECTIVE Intrauterine exposure to high maternal glucose is associated with excess weight gain during childhood, but it is not clear whether the excess weight represents increased fat or lean mass. The purpose of this study was to examine the relationship between maternal glucose concentrations during pregnancy and offspring body composition. A secondary goal was to examine whether the association between maternal glucose and children’s body fat was independent of energy intake, energy expenditure, or physical activity. RESEARCH DESIGN AND METHODS Children aged 5–10 years and their biological mothers (n = 27) were recruited. Maternal glucose concentration 1 h after a 50-g oral glucose load, used to screen for gestational diabetes mellitus at 24–28 weeks gestation, was retrieved from medical records. Children underwent dual-energy X-ray absorptiometry to measure body composition, indirect calorimetry to measure resting energy expenditure (REE), accelerometry to measure physical activity, and three 24-h diet recalls to measure energy intake. RESULTS Maternal glucose concentration during pregnancy was positively associated with children’s lean mass (P < 0.05) and adiposity (fat mass adjusted for lean mass; P < 0.05). The association between maternal glucose and children’s adiposity was independent of children’s REE, percent of time spent physically active, and energy intake (P < 0.001). CONCLUSIONS Intrauterine exposure to relatively high maternal glucose is associated with greater lean mass and adiposity among prepubertal offspring. Further research is needed to examine the mechanisms by which maternal glucose concentrations during pregnancy influence children’s body composition.

Overweight status and intrauterine exposure to gestational diabetes are associated with children's metabolic health.

Offspring of women with gestational diabetes (OGD) have greater risk for obesity and impaired metabolic health. Whether impaired metabolic health occurs in the absence of obesity is not clear.

Cervical Cerclage for the Prevention of Preterm Birth

Contemporary evidence supports the concept that cervical insufficiency is anything but a well-defined and distinct clinical entity. Instead, it is only 1 component of the larger and more complex preterm birth syndrome. Premature cervical ripening, as evidenced by shortening and effacement beginning at the internal os, provides strong evidence that parturition has begun and is the result of multiple interrelated pathways and inciting factors. Ultrasonographic screening of the cervix and treatment with cerclage for cervical shortening in the mid-trimester is reserved for women with prior spontaneous preterm birth (Fig. 1). Although cerclage benefit increases as the cervix shortens to less than 25 mm, it is appropriate to offer cerclage to women with shortened cervical length of less than 25 mm, and particularly those with a coexistent U-shaped funnel.

Prevention of Preterm Birth Based on a Short Cervix: Cerclage

In an attempt to prevent preterm birth, clinicians have recommended cerclage for women with shortened cervical length and other worrisome sonographic cervical features in the mid-trimester, although randomized trials have not supported this practice. Emerging data suggest that preterm birth is a complex and poorly understood syndrome comprising several anatomic and functional components. As a result, preventive efforts have been mostly empiric and generally ineffective. Plausibly, effective preterm birth therapies exist, but matching the effective treatment with the correct patient has been problematic. Mid-trimester cervical changes visualized with vaginal sonography likely represent a pathologic process of premature cervical ripening and not real mechanical disability which has been traditionally treated with suture support. Cerclage may effectively reduce preterm birth in carefully selected women who have experienced a prior early preterm birth and who have shortened mid-trimester cervical length.

Cesarean Delivery for Abnormal Labor

Cesarean delivery is indicated at any stage in the labor process in the presence of nonreassuring fetal status or when conservative measures fail in the setting of abnormal labor. In the absence of maternal or fetal indications for expedited delivery, cesarean delivery is not indicated for latent phase disorders. When to intervene for protracted labor is arguable, but slow rates of labor progress are consistent with safe vaginal delivery. Cesarean delivery in the second stage should be avoided for at least 4 hours if there is progressive fetal descent.

Gut hormone activity of children born to women with and without gestational diabetes.

What is already known about this subject Children born to women with gestational diabetes have greater risk for obesity. Obesity in adults and children is associated with blunted postprandial gut hormone responses.

Does midtrimester Nugent score or high vaginal pH predict gestational age at delivery in women at risk for recurrent preterm birth

OBJECTIVE To estimate whether bacterial vaginosis, as defined by either Nugent score or vaginal pH, predicts gestational age at delivery in women at risk for recurrent preterm birth. STUDY DESIGN Planned secondary analysis of a randomized cerclage trial in women with prior spontaneous preterm birth 17⁰(/)⁷-33⁶(/)⁷ weeks. Vaginal Gram stain and pH were collected at the initial study visit. Women not assigned to cerclage, either because they did not experience cervical shortening <25 mm or because they were randomly assigned to no cerclage, were studied. RESULTS Seven hundred eighty-six women had complete delivery gestational age, Gram stain, and pH results. The diagnosis of bacterial vaginosis by either Nugent score ≥ 7 or by pH ≥ 5 was not associated with earlier birth. CONCLUSION The presence of bacterial vaginosis at 16-21⁶(/)⁷ weeks does not predict gestational age at birth in women at risk for recurrent preterm birth.

Association of late-night carbohydrate intake with glucose tolerance among pregnant African American women.

Obesity and late-night food consumption are associated with impaired glucose tolerance. Late-night carbohydrate consumption may be particularly detrimental during late pregnancy because insulin sensitivity declines as pregnancy progresses. Further, women who were obese (Ob) prior to pregnancy have lower insulin sensitivity than do women of normal weight (NW). The aim of this study is to test the hypothesis that night-time carbohydrate consumption is associated with poorer glucose tolerance in late pregnancy and that this association would be exacerbated among Ob women. Forty non-diabetic African American women were recruited based upon early pregnancy body mass index (NW, <25 kg m(-2) ; Ob, ≥30 kg m(-2) ). Third trimester free-living dietary intake was assessed by food diary, and indices of glucose tolerance and insulin action were assessed during a 75-g oral glucose tolerance test. Women in the Ob group reported greater average 24-h energy intake (3055 kcal vs. 2415 kcal, P < 0.05). Across the whole cohort, night-time, but not day-time, carbohydrate intake was positively associated with glucose concentrations after the glucose load and inversely associated with early phase insulin secretion (P < 0.05). Multiple linear regression modelling within each weight group showed that the associations among late-night carbohydrate intake, glucose concentrations and insulin secretion were present only in the Ob group. This is the first study to report an association of night-time carbohydrate intake specifically on glucose tolerance and insulin action during pregnancy. If replicated, these results suggest that late-night carbohydrate intake may be a potential target for intervention to improve metabolic health of Ob women in late pregnancy.

Relatively Low β-Cell Responsiveness Contributes to the Association of BMI with Circulating Glucose Concentrations Measured under Free-Living Conditions among Pregnant African American Women

BACKGROUND Body mass index (BMI, in kg/m(2)) is positively associated with plasma glucose in late pregnancy and with risk of adverse obstetric outcomes. Much of the existing research uses single-clinic measures of plasma glucose, which may not accurately reflect circulating glucose under free-living conditions. Furthermore, little is known about circulating glucose concentrations of African American women, who tend to have poorer diet quality and a greater risk of obstetric complications. OBJECTIVE The objective of the study was to test the hypothesis that the positive association of BMI in early pregnancy with third-trimester circulating glucose concentrations measured under free-living conditions among African American women would be at least partially attributable to lower β-cell insulin secretion relative to insulin sensitivity [i.e., lower disposition index (DI)]. METHODS Using a prospective, observational design, 40 pregnant African American women (mean ± SD age: 23.1 ± 4.0 y; mean ± SD BMI: 28.4 ± 7.5) wore continuous glucose monitors and accelerometers for 3 d at 32-35 wk of gestation and concurrently maintained a food diary to report their self-selected meals. The DI was derived from a 75-g oral glucose tolerance test. Linear regression modeling was used to calculate the association of BMI with the 24-h glucose (GLUC24h) and 2-h (GLUC2hPP) postprandial glucose areas under the curve and with the percentage of time the glucose concentrations were >120 mg/dL. RESULTS The positive associations between BMI and GLUC24h (standardized β = 0.36, P = 0.03) and the percentage of time glucose concentrations were >120 mg/dL (standardized β = 0.40, P = 0.02) were independent of total carbohydrate intake and physical activity and were attenuated when DI was added to the model. The positive association of BMI with GLUC2hPP was attenuated when DI was added to the model, and DI itself was independently associated with GLUC2hPP after self-selected breakfast and dinner (standardized β = -0.33 and -0.42, respectively; P = 0.01). CONCLUSIONS The association of BMI with high circulating glucose in free-living pregnant African American women is at least partially attributable to lower β-cell responsiveness.