Aberrant DNA Methylation Mediates the Transgenerational Risk of Metabolic and Chronic Disease Due to Maternal Obesity and Overnutrition

Maternal obesity is a rapidly evolving universal epidemic leading to acute and long-term medical and obstetric health issues, including increased maternal risks of gestational diabetes, hypertension and pre-eclampsia, and the future risks for offspring’s predisposition to metabolic diseases. Epigenetic modification, in particular DNA methylation, represents a mechanism whereby environmental effects impact on the phenotypic expression of human disease. Maternal obesity or overnutrition contributes to the alterations in DNA methylation during early life which, through fetal programming, can predispose the offspring to many metabolic and chronic diseases, such as non-alcoholic fatty liver disease, obesity, diabetes, and chronic kidney disease. This review aims to summarize findings from human and animal studies, which support the role of maternal obesity in fetal programing and the potential benefit of altering DNA methylation to limit maternal obesity related disease in the offspring.

ASHA Kirana: when digital technology empowered front-line health workers

This practice paper describes our experience of implementing accredited social health activists (ASHA) Kirana, a digital technology-enabled Maternal Clinical Assessment Tool (M-CAT) and how the ASHAs felt empowered in the process. M-CAT aimed to train ASHAs to collect data that assists doctors in identifying maternal risks, in Karnataka, India. Systematic clinical assessment is not common in rural public health institutions. High caseloads, a tendency to ‘normalise’ maternal risks, varied competence of doctors and task shifting to insufficiently trained cadres may be some contributing factors. M-CAT was a response to this challenge. ASHAs asked a set symptom-cluster-based questions during home visits that were analysed by software algorithms to generate reports for doctors. M-CAT was implemented in one primary health centre with a group of 14 ASHAs, 2 auxiliary nurse midwives and 349 pregnant and postpartum women over 4 months. Our team worked with the ASHAs to refine the tool and supported them with training, hands-on assistance and regular debrief meetings. By learning how to collect individual-level data that they could interpret and act on, the ASHAs felt empowered with new knowledge on maternal risks. Their perfunctory data collection at home visits changed to substantive interactions with women and families, during which they captured pertinent qualitative information. The information asymmetry between doctors and ASHAs reduced. ASHAs started taking proactive steps on early indications of maternal risks. They changed from being mere transmitters of information to active users of it. Thus, technology-driven initiatives that include empowerment as an objective can strengthen the role of front-line workers in health systems.

State-of-the-Art Review of Pregnancy-Related Psoriasis

Psoriasis is a chronic immunologic disease involving inflammation that can target internal organs, the skin, and joints. The peak incidence occurs between the age of 30 and 40 years, which overlaps with the typical reproductive period of women. Because of comorbidities that can accompany psoriasis, including metabolic syndrome, cardiovascular involvement, and major depressive disorders, the condition is a complex one. The role of hormones during pregnancy in the lesion dynamics of psoriasis is unclear, and it is important to resolve the implications of this pathology during pregnancy are. Furthermore, treating pregnant women who have psoriasis represents a challenge as most drugs generally prescribed for this pathology are contraindicated in pregnancy because of teratogenic effects. This review covers the state of the art in psoriasis associated with pregnancy. Careful pregnancy monitoring in moderate-to-severe psoriasis vulgaris is required given the high risk of related complications in pregnancy, including pregnancy-induced hypertensive disorders, low birth weight for gestational age, and gestational diabetes. Topical corticosteroids are safe during pregnancy but effective only for localised forms of psoriasis. Monoclonal antibodies targeting cytokines specifically upregulated in psoriasis, such as ustekinumab (IL-12/23 inhibitor), secukinumab (IL-17 inhibitor) can be effective for the severe form of psoriasis during pregnancy. A multidisciplinary team must choose optimal treatment, taking into account fetal and maternal risks and benefits.

Fetal surgery in the context of myelomeningocele: repercussions and prognosis

Background: Myelomeningocele (MMC) is a congenital malformation of neural tube closure. The clinical picture comprises sensory and motor deficits at the point of spinal cord injury and below, in addition to ventriculomegaly, which requires ventriculo-peritoneal drains (DVP). Exposure of nervous tissue to amniotic fluid and trauma to the uterine wall, generates secondary damage. Intrauterine correction is the gold standard for MMC and aims to reduce organic and functional sequelae, improving the patient’s neurological prognosis. Objectives: The objective of this work is to identify the impact of fetal surgery against MMC. Methods: An integrative literature review was carried out based on articles selected from the Google Scholar and Scientific Eletronic Library Online databases. Results: The benefits of intrauterine neurosurgery outweigh the harm, based on maternal complications. Such maternal risks are: oligohydramnios, spontaneous rupture of the membrane, uterine dehiscence, premature birth, infections, blood transfusion, acute lung edema and contraindication for vaginal delivery due to uterine scarring. For the child, all the studies analyzed showed the same gains, extremely significant when compared to postnatal surgery: better cognitive development, greater probability of walking without using orthoses, less need for DVP. The gains from the fetal surgery technique go beyond the postnatal intervention. Conclusions: Therefore, the importance of early intrauterine treatment, in a properly equipped place and by qualified professionals, is reiterated, offering comprehensive care to pregnant women, preventing potential impasses and aiming at a better prognosis and quality of life for the child.

The impact of chorionicity on maternal and fetal outcomes

Background: Women carrying twin pregnancies receive extensive antenatal counselling on fetal risks, but less is known about whether the presence of two placentas confers dissimilar maternal risks. We pretend to determine the impact of chorionicity on the maternal and fetal outcome, evaluating the possibility of finding the association between complications and the presence of two placental masses.Methods: We conducted a retrospective observational cohort study of 550 twin pregnancies monitored at a level-3 hospital, between January 2004 and December 2018.Results: Of the 550 pregnancies, 419 (76.2%) were bichorionic and 131 (23.8%) were monochorionic. Caesarean delivery was more frequent in monochorionic group (70.2% vs. 61.8%, p=0.05). There were no statistically significant differences in the proportion of adverse maternal outcomes between bichorionic and monochorionic pregnancies, despite a trend towards higher proportions in bichorionic group. Regarding fetal outcomes, monochorionic twins were delivered earlier (mean gestational age of 34+4 weeks vs. 35+1 weeks, p=0.04) and the proportion of preterm delivery cases between 32+0 and 36+6 weeks was higher in monochorionic pregnancies (72.5% vs. 54.9%, p=0.002). Stillbirth of one or both twins was more frequent in monochorionic group (3.1% vs. 0.5%, p=0.03).Conclusions: The presence of two placental masses does not seems to confer an increase in maternal risks, despite a trend towards higher proportions of adverse outcomes in bichorionic pregnancies. However, monochorionicity is associated with an increase in fetal risks, particularly prematurity. Counselling and monitoring of bichorionic or monochorionic pregnancies may be identical with respect to maternal risks, but chorionicity should be considered when evaluating fetal risks.

Neurosurgery guidelines for the care of people with spina bifida

Myelomeningocele (MMC) arises from an early neural developmental anomaly and results in a variety of structural abnormalities and associated functional neurologic deficits. As such, neurologic issues are central to virtually all clinical problems. Neurosurgical intervention strives to correct or improve these defects and prevent secondary complications. These interventions include closure of the open myelomeningocele and management (across the life span) of hydrocephalus, the Chiari II malformation (C2M) and tethered spinal cord (TSC). The development of pre-natal closure techniques and reports of improved outcome with in-utero closure (IUMC) have revolutionized the neurosurgical approach to myelomeningocele. Controversies remain surrounding patient selection, maternal risks, technique of IUMC (endoscopic vs. open) and long-term outcomes. However, real gains include reduced rates of hydrocephalus, modestly improved motor capabilities and reduction in C2M morbidity. For many decades, the cornerstone of treatment of hydrocephalus for many decades has been the placement and support of ventricular shunts. Endoscopic third ventriculostomy (ETV) with or without choroid plexus coagulation (ETV/CPC) is an appealing alternate strategy that avoids the morbidity and complications associated with shunts. The exact criteria for ETV-CPC candidacy and best metrics for outcome analysis remain active areas of debate and controversy. Similarly, neurosurgical management C2M, has centered upon the indications and clinical thresholds for performing posterior fossa surgical decompression. Tethered spinal cord management incorporates the diagnosis and surgical management of adhesions formed at the initial closure site, the consequent longitudinal traction related stress on the cord and the resulting neurologic signs and symptoms.

Self-Medication and Safety Profile of Medicines Used among Pregnant Women in a Tertiary Teaching Hospital in Jimma, Ethiopia: A Cross-Sectional Study

Background: Despite the potential foetal and maternal risks of self-medication, studies on self-medication and safety profile of medicines used during pregnancy are scarce. This study determined the prevalence, predictors and safety profile of medicines used for self-medication during pregnancy at Jimma University Medical Centre (JUMC) in Ethiopia. Methods: A hospital-based cross sectional study was conducted on 1117 hospitalized pregnant women or postpartum women in the maternity and gynaecology wards at JUMC between February and June 2017. Data were collected using an interviewer-administered structured questionnaire and by reviewing patient medical records. Data were analysed using descriptive statistics and logistic regression. Result: Nearly 3 out of 10 women reported taking at least one type of conventional medicine for self-medication, mainly analgesics 92.3%. Almost 75.0% of the self-medicated women used medicines classified as probably safe and 13.6% as potentially risky to use during pregnancy. Medicinal plant use, religion and access to a health facility near their residency were significantly associated with self-medication during pregnancy. Conclusions: Self-medication is common among pregnant women at JUMC. Most women used medicines classified as safe to use during pregnancy. There is need for enlightenment of pregnant women on the potential dangers of self-medication during pregnancy to prevent foetal and maternal risks.

Corticosteroid Guidance for Pregnancy during COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) pandemic is causing a necessary, rapid adjustment within the field of obstetrics. Corticosteroid use is a mainstay of therapy for those women delivering prematurely. Unfortunately, corticosteroid use has been associated with worse outcomes in COVID-19 positive patients. Given this information, it is necessary that obstetricians adjust practice to carefully weigh the fetal benefits with maternal risks. Therefore, our institution has examined the risks and benefits and altered our corticosteroid recommendations. Key Points