Effects of epidural analgesia on pelvic floor function after spontaneous delivery : a longitudinal retrospective study

Abstract: The aim of the study was to assess the effects of epidural analgesia on pelvic floor function. Eighty- two primiparous women (group 1, consisting of 41 given an epidural, and group 2 of 41 not given an epidural) were investigated during pregnancy and at 2 and 10 months after delivery by a questionnaire, clinical examination, and assessment of bladder neck behavior, urethral sphincter function and intravaginal/intra-anal pressures. The prevalence of stress urinary incontinence was similar in both groups at 2 months (24% vs. 17%, P = 0.6) and 10 months (22% vs. 7%, P = 0.1), as was the prevalence of decreased sexual vaginal response at 10 months (27% vs. 10%, P= 0.08). Bladder neck behavior, urethral sphincter function and intravaginal and intra-anal pressures showed no significant differences between the two groups. Ten months after spontaneous delivery, there were no significant differences in the prevalence of stress urinary incontinence and decreased sexual vaginal response, or in bladder neck behavior, urethral sphincter function and pelvic floor muscle strength between women who had or had not had epidural analgesia.

Autocrine secretion of IGF2 regulates adult ß cell functional plasticity

In the pathogenesis of type 2 diabetes, hyperglycemia appears when ß cell mass and insulin secretory capacity are no longer sufficient to compensate for insulin resistance. The reduction in ß cell mass results from increased apoptosis. Therefore, finding strategies to preserve ß cell mass and function may be useful for the treatment or prevention of diabetes. Glucagon-like peptide-1 (GLP-1) protects ß cells against apoptosis, increases their glucose competence, and induces their proliferation. Previous studies in the lab of Prof. Bernard Thorens showed that the GLP-1 anti- apoptotic effect was mediated by robust up-regulation of IGF-1R expression, and this was paralleled with an increase in Akt phosphorylation. This effect was dependent not only on increased IGF-1R expression but also on the autocrine secretion of insulin-like growth factor 2 (IGF2). They also demonstrated that GLP-1 up-regulated IGF-1R expression by a protein a kinase A-dependent translational control mechanism. The main aim of this PhD work has been to further investigate the role of the IGF2/IGF-1 Receptor autocrine loop in ß cell function and to determine the physiological role of IGF2 in ß cell plasticity and its regulation by nutrients. This PhD thesis is divided in 3 chapters. The first chapter describes the role of IGF2/IGF-1R autocrine loop in ß cell glucose competence and proliferation. Here using MIN6 cells and primary mouse islets as an experimental model we demonstrated that the glucose competence of these cells was dependent on the level of IGF-1R expression and on IGF2 secretion. Furthermore, we showed that GLP-1-induced primary ß cell proliferation was significantly reduced by Igf-lr gene inactivation and by IGF2 immunoneutralization or knockdown. In the second chapter we examined the role of this IGF2/IGF-1R autocrine loop on the ß cell functional plasticity during ageing, pregnancy, and in response to acute induction of insulin resistance using mice with ß cell-specific inactivation of ig/2. Here we showed a gender-dependent role of ß cell IGF2 in ageing and high fat diet-induced metabolic stress; we demonstrated that the autocrine secretion of IGF2 is essential for ß cell mass adaptation during pregnancy. Further we also showed that this autocrine loop plays an important role in ß cell expansion in response to acute induction of insulin resistance. The aim of the third chapter was to investigate whether we can modulate the expression and secretion of IGF2 by nutrients in order to increase the activity of autocrine loop. Here we showed that glutamine induces IGF2 biosynthesis and its fast secretion through the regulated pathway, a mechanism enhanced in the presence of glucose. Furthermore, we demonstrated that glutamine-mediated Akt phosphorylation is dependent on IGF2 secretion, indicating that glutamine controls the activity of the IGF2/IGF1R autocrine loop through IGF2 up-regulation. In summary, this PhD work highlights that autocrine secretion of IGF2 is required for compensatory ß cell adaptation to ageing, pregnancy, and insulin resistance. Moreover IGF2/IGF1R autocrine loop is regulated by two feeding-related cues, GLP-1 to increase IGF-1R expression and glutamine to control IGF2 biosynthesis and secretion. -- Dans le diabète de type 2, lorsque la sécrétion d'insuline des cellules Beta du pancréas n'est plus suffisante pour compenser la résistance à l'insuline, une hyperglycémie est observée. Cette baisse de sécrétion d'insuline est Causée par la diminution de la masse de cellules Beta suite à l'augmentation du phénomène de mort cellulaire ou « apoptose ». En diabétologie, une des stratégies médicales concerne la préservation des cellules Beta du pancréas. Une des protéines intervenant dans cette fonction est GLP-1 (Glucagon-like peptide-1). GLP-1 est capable de protéger les cellules Beta contre la mort cellulaire et d'induire leur prolifération. Des études précédemment menées dans le laboratoire du Professeur Bernard Thorens ont montrées que l'activité « anti-apoptotique » de GLP-1 est le résultat l'une augmentation de l'expression du gène IGF-1R sous la dépendance de la sécrétion autocrine d'IGF2 (Insulin-Like Growth Factor). Le but de mon travail de thèse aura été d'étudier le mécanisme de la régulation de GLP-1 par IGF2 et plus précisément de déterminer le rôle physiologique d'IGF2 dans la plasticité des cellules ß ainsi que sa régulation par les nutriments. Ce manuscrit est ainsi divisé en trois chapitres : Le premier chapitre décrit la fonction d'IGF2/IGF- R1 dans la réponse des cellules Beta au glucose ainsi que dans leur capacité à proliférer. Dans ce chapitre nous avons montré l'importance du niveau d'expression d'IGFR-1 et de la sécrétion d'IGF2 dans la régulation du métabolisme du glucose. Dans un deuxième chapitre, nous étudions la boucle de régulation IGF2/IGF-R1 sur la plasticité des cellules Beta lors du vieillissement, de la grossesse ainsi que dans un modèle de souris résistantes à l'insuline. Cette étude met en évidence un dimorphisme sexuel dans le rôle d'IGF2 lors du vieillissement et lors d'un stress métabolique. Nous montrons également l'importance d'IGF2 pour l'adaptation des cellules Beta tout au long de la grossesse ou lors du phénomène de résistance à l'insuline. Dans un troisième chapitre, nous mettons en évidence la possibilité de moduler l'expression et la sécrétion d'IGF2 par les nutriments. En conclusion, ce travail de thèse aura permis de mettre en évidence l'importance d'IGF2 dans la plasticité des cellules ß, une plasticité indispensable lors du vieillissement, de la grossesse ou encore dans le cas d'une résistance à l'insuline.

Thrombosis in paroxysmal nocturnal hemoglobinuria at a glance: a clinical review.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired stem cell disorder, with its primary clinical manifestations being hemolytic anemia, marrow failure and thrombophilia. Chronic hemolysis, failures of the fibrinolytic system, increased leukocyte-derived tissue factor levels in plasma, procoagulant microparticles generated through complement-mediated damage of platelets and venous endothelium are related to the acquired hypercoagulable state. Visceral thrombosis (including hepatic veins and mesenteric veins), cerebrovascular events and pulmonary embolism predict a poor outcome. Thrombosis is also associated with significant morbidity during pregnancy. Depending on the sites of thrombosis, a score-based probability to predict outcome can be assigned. Abdominal vein thromboses account for the majority of morbidity and mortality related to thrombosis, and time-dependent trends suggest that mortality rates tend to decline, with the advent of evolution of therapeutic and diagnostic strategies. In contrast, mortality rates from cerebrovascular events display no significant decline. Prompt diagnosis requires both clinical suspicion and sophisticated imaging techniques, along with multidisciplinary therapeutic intervention. In the eculizumab era, a significant reduction of thrombotic events was observed during therapy, and long-term follow up is needed to establish any benefit in rates and pattern of this complication. However, up to now, only bone marrow transplantation permanently abolishes the coagulation defect.

Exposition aux immunosuppresseurs in utero [Exposure in utero to immunosuppressives]

The number of pregnant women receiving immunosuppressive therapy is increasing. Use of immunosuppressants during pregnancy is indicated for anti-rejection therapy in transplantation patients and treatment of autoimmune diseases. Despite the maternal and fetal risks of these pregnancies, the proportion of surviving infants is improving and the possibility that a pregnancy could occur in these women during their childbearing years should be considered. All immunosuppressant drugs and their metabolites cross the placenta, raising questions about the long-term outcome of the children exposed to these agents in utera. There is no increased risk of congenital anomalies. However, there is an elevated incidence of prematurity, intrauterine growth retardation (IUGR) and therefore low birthweight, as well as maternal hypertension and preeclampsia. The most frequent neonatal complications are those associated with prematurity and IUGR, as well as adrenal insufficiency with corticosteroids, immunological disturbances with azathioprine and cyclosporin, and hyperkalemia with tacrolimus. The long-term follow-up of infants exposed to immunosuppressants in utero is still limited and experimental studies raise the question whether there could be an increased incidence at adult age of some pathologies including renal insufficiency, hypertension and diabetes. The follow-up of these infants should be carefully organized and multidisciplinary, taking the perinatal context into account.

Gestational diabetes mellitus and the risk of metabolic syndrome: a population-based study in Lausanne, Switzerland.

AIMS: To investigate the relationships between gestational diabetes mellitus (GDM) and the metabolic syndrome (MS), as it was suggested that insulin resistance was the hallmark of both conditions. To analyse post-partum screening in order to identify risk factors for the subsequent development of type 2 diabetes mellitus (DM). METHODS: A retrospective analysis of all singleton pregnancies diagnosed with GDM at the Lausanne University Hospital for 3 consecutive years. Pre-pregnancy obesity, hypertension and dyslipidaemia were recorded as constituents of the MS. RESULTS: For 5788 deliveries, 159 women (2.7%) with GDM were identified. Constituents of the MS were present before GDM pregnancy in 26% (n = 37/144): 84% (n = 31/37) were obese, 38% (n = 14/37) had hypertension and 22% (n = 8/37) had dyslipidaemia. Gestational hypertension was associated with obesity (OR = 3.2, P = 0.02) and dyslipidaemia (OR = 5.4, P=0.002). Seventy-four women (47%) returned for post-partum OGTT, which was abnormal in 20 women (27%): 11% (n = 8) had type 2 diabetes and 16% (n = 12) had impaired glucose tolerance. Independent predictors of abnormal glucose tolerance in the post-partum were: having > 2 abnormal values on the diagnostic OGTT during pregnancy and presenting MS constituents (OR = 5.2, CI 1.8-23.2 and OR = 5.3, CI 1.3-22.2). CONCLUSIONS: In one fourth of GDM pregnancies, metabolic abnormalities precede the appearance of glucose intolerance. These women have a high risk of developing the MS and type 2 diabetes in later years. Where GDM screening is not universal, practitioners should be aware of those metabolic risks in every pregnant woman presenting with obesity, hypertension or dyslipidaemia, in order to achieve better diagnosis and especially better post-partum follow-up and treatment.

Genetic variants of the FADS gene cluster and ELOVL gene family, colostrums LC-PUFA levels, breastfeeding, and child cognition

Introduction: Breastfeeding effects on cognition are attributed to long-chain polyunsaturated fatty acids (LC-PUFAs), but controversy persists. Genetic variation in fatty acid desaturase (FADS) and elongase (ELOVL) enzymes has been overlooked when studying the effects of LC-PUFAs supply on cognition. We aimed to: 1) to determine whether maternal genetic variants in the FADS cluster and ELOVL genes contribute to differences in LC-PUFA levels in colostrum; 2) to analyze whether these maternal variants are related to child cognition; and 3) to assess whether children's variants modify breastfeeding effects on cognition. Methods: Data come from two population-based birth cohorts (n = 400 mother-child pairs from INMA-Sabadell; and n = 340 children from INMA-Menorca). LC-PUFAs were measured in 270 colostrum samples from INMA-Sabadell. Tag SNPs were genotyped both in mothers and children (13 in the FADS cluster, 6 in ELOVL2, and 7 in ELOVL5). Child cognition was assessed at 14 mo and 4 y using the Bayley Scales of Infant Development and the McCarthy Scales of Children"s Abilities, respectively. Results: Children of mothers carrying genetic variants associated with lower FADS1 activity (regulating AA and EPA synthesis), higher FADS2 activity (regulating DHA synthesis), and with higher EPA/AA and DHA/AA ratios in colostrum showed a significant advantage in cognition at 14 mo (3.5 to 5.3 points). Not being breastfed conferred an 8- to 9-point disadvantage in cognition among children GG homozygote for rs174468 (low FADS1 activity) but not among those with the A allele. Moreover, not being breastfed resulted in a disadvantage in cognition (5 to 8 points) among children CC homozygote for rs2397142 (low ELOVL5 activity), but not among those carrying the G allele. Conclusion: Genetically determined maternal supplies of LC-PUFAs during pregnancy and lactation appear to be crucial for child cognition. Breastfeeding effects on cognition are modified by child genetic variation in fatty acid desaturase and elongase enzymes.

Free-living energy expenditure measured by two independent techniques in pregnant and nonpregnant Gambian women.

Free-living energy expenditure (EE) was assessed in 37 young pregnant Gambian women at the 12th (n = 11, 53.5 +/- 1.7 kg), 24th (n = 14, 54.7 +/- 2.1 kg), and 36th (n = 12, 65.0 +/- 2.6 kg) wk of pregnancy and was compared with nonpregnant nonlactating (NPNL) control women (n = 12, 50.3 +/- 1.6 kg). The following two methods were used to assess EE: 1) the heart rate (HR) method using individual regression lines (HR vs EE) established at different activity levels in a respiration chamber and 2) the doubly labeled water (2H2(18)O) method in a subgroup of 25 pregnant and 7 control women. With the HR method the EE during the agricultural rainy season was found to be 2,408 +/- 87, 2,293 +/- 122, and 2,782 +/- 130 kcal/day at 12, 24, and 36 wk of gestation and were not significantly different from the control group (2,502 +/- 133 kcal/day). These findings were confirmed by the 2H2(18)O measurements, which failed to show any effect of pregnancy on EE. Expressed per unit body weight, the free-living EE was found to be lower (P less than 0.01 with 2H2(18)O method) at 36 wk of gestation than in the NPNL group. It is concluded that, in these Gambian women, energy-sparing mechanisms that contribute to meet the additional energy stress of gestation are operating during pregnancy (e.g., diminished spontaneous physical activity).

Defining the genomic signature of the parous breast.

ABSTRACT: BACKGROUND: It is accepted that a woman's lifetime risk of developing breast cancer after menopause is reduced by early full term pregnancy and multiparity. This phenomenon is thought to be associated with the development and differentiation of the breast during pregnancy. METHODS: In order to understand the underlying molecular mechanisms of pregnancy induced breast cancer protection, we profiled and compared the transcriptomes of normal breast tissue biopsies from 71 parous (P) and 42 nulliparous (NP) healthy postmenopausal women using Affymetrix Human Genome U133 Plus 2.0 arrays. To validate the results, we performed real time PCR and immunohistochemistry. RESULTS: We identified 305 differentially expressed probesets (208 distinct genes). Of these, 267 probesets were up- and 38 down-regulated in parous breast samples; bioinformatics analysis using gene ontology enrichment revealed that up-regulated genes in the parous breast represented biological processes involving differentiation and development, anchoring of epithelial cells to the basement membrane, hemidesmosome and cell-substrate junction assembly, mRNA and RNA metabolic processes and RNA splicing machinery. The down-regulated genes represented biological processes that comprised cell proliferation, regulation of IGF-like growth factor receptor signaling, somatic stem cell maintenance, muscle cell differentiation and apoptosis. CONCLUSIONS: This study suggests that the differentiation of the breast imprints a genomic signature that is centered in the mRNA processing reactome. These findings indicate that pregnancy may induce a safeguard mechanism at post-transcriptional level that maintains the fidelity of the transcriptional process.

"A renewed sense of purpose": Mothers' and fathers' experience of having a child following a recent stillbirth.

Background Most research has focused on mothers¿ experiences of perinatal loss itself or on the subsequent pregnancy, whereas little attention has been paid to both parents¿ experiences of having a child following late perinatal loss and the experience of parenting this child. The current study therefore explored mothers¿ and fathers' experiences of becoming a parent to a child born after a recent stillbirth, covering the period of the second pregnancy and up to two years after the birth of the next baby.MethodIn depth interviews were conducted with 7 couples (14 participants). Couples were eligible if they previously had a stillbirth (after 24 weeks of gestation) and subsequently had another child (their first live baby) who was now under the age of 2 years. Couples who had more than one child after experiencing a stillbirth and those who were not fluent in English were excluded. Qualitative analysis of the interview data was conducted using Interpretive Phenomenological Analysis.ResultsFive superordinate themes emerged from the data: Living with uncertainty; Coping with uncertainty; Relationship with the next child; The continuing grief process; Identity as a parent. Overall, fathers' experiences were similar to those of mothers', including high levels of anxiety and guilt during the subsequent pregnancy and after the child was born. Coping strategies to address these were identified. Differences between mothers and fathers regarding the grief process during the subsequent pregnancy and after their second child was born were identified. Despite difficulties with bonding during pregnancy and at the time when the baby was born, parents' perceptions of their relationship with their subsequent child were positive.ConclusionsFindings highlight the importance of tailoring support systems not only according to mothers' but also to fathers' needs. Parents¿, and particularly fathers', reported lack of opportunities for grieving as well as the high level of anxiety of both parents about their baby's wellbeing during pregnancy and after birth implies a need for structured support. Difficulties experienced in bonding with the subsequent child during pregnancy and once the child is born need to be normalised.

Treatment of adult-onset Still's disease: a review

Adult-onset Still's disease (AOSD) is a rare inflammatory disorder that has been recently classified as a polygenic autoinflammatory disorder. The former classification, based on the disease course, seems to be quite dated. Indeed, there is accumulating evidence that AOSD can be divided into two distinct phenotypes based on cytokine profile, clinical presentation, and outcome, ie, a "systemic" pattern and an "articular" pattern. The first part of this review deals with the treatments that are currently available for AOSD. We then present the different strategies based on the characteristics of the disease according to clinical presentation. To do so, we focus on the two subsets of the disease. Finally, we discuss the management of life-threatening complications of AOSD, along with the therapeutic options during pregnancy.

Nasal immunization of mice with virus-like particles protects offspring against rotavirus diarrhea.

Rotavirus is the major cause of diarrhea among young infants in both humans and animals. Immune protection of newborns by vaccination is difficult to achieve since there is not enough time to mount an immune response before exposure to the virus. We have designed a vaccination strategy mediating transfer of neutralizing antibodies from the mother to the offspring during pregnancy and/or lactation. Adult female mice were nasally immunized with virus-like particles (VLPs) made of viral proteins VP2 and 6 (VLP2/6) or VP 2, 6, and 7 (VLP2/6/7) derived from the RF rotavirus strain in the presence or absence of cholera toxin. Both vaccines elicited serum and milk antibodies against the respective VPs. Four days after parturition, suckling pups were challenged orally with RF rotavirus. Pups from mothers immunized with VLP2/6/7 but not VLP2/6 were protected against rotavirus diarrhea, indicating that VP7 plays a key role in protection. Protection was mediated by milk rather than serum antibodies, and mucosal adjuvants were not required. In conclusion, VLPs containing VP7 administered nasally to mothers represent a promising vaccine candidate for the protection of suckling newborns against rotavirus-induced diarrhea, even in the absence of a mucosal adjuvant.

Arthrogryposis multiplexa congenita: an epidemiologic study of nearly 9 million births in 24 EUROCAT registers.

OBJECTIVE: To examine the occurrence of arthrogryposis multiplex congenita (AMC) in Europe and to identify possible risk factors. STUDY DESIGN: Retrospective population-based epidemiological study using EUROCAT congenital anomaly registries. The study population included all cases of AMC (based on WHO ICD-9 or ICD-10 codes) that were livebirths (LB), fetal deaths (FD) from 20 weeks gestation and underwent termination of pregnancy for fetal anomaly (TOPFA), 1980-2006. RESULTS: Among 8.9 million births covered by 24 EUROCAT congenital anomaly registries, 757 AMC cases were reported. This gives a prevalence of 8.5 per 100,000. Five hundred and four (67%) AMC cases were LB, 199 (26%) cases were TOPFA, and FD occurred in 54 (7%) cases. First week survival status was known for 381 of the 504 LB (76%), of whom 87 (23%) died within the first week of life. Perinatal mortality associated with AMC was 32%. Two hundred and eighty-two (37%) cases had isolated AMC, 90 (12%) had additional syndrome or chromosomal anomalies and 385 (51%) had other major malformations. The same or similar anomaly was reported in 13% of siblings and in 12% of the mother's own family background. Information on prenatal testing was available for 521 cases of which 360 tested positive for a congenital anomaly, representing a sensitivity of 69%. Information on maternal illness before and during pregnancy and medication use in the first trimester was available for approximately a third of the mothers, of whom the vast majority reported no maternal illness or medication use. CONCLUSION: AMC is a rare occurrence, with a reported prevalence of 1:12,000. In this study, while information on potential risk factors such as maternal disease or maternal use of drugs was limited, they did not appear to be associated with the occurrence of AMC. AMC was lethal in a third of cases, either in utero or during the first week of life, although this may not be solely attributed to AMC as most cases had additional malformations.

Longer term clinical and virological outcome of sub-Saharan African participants on antiretroviral treatment in the Swiss HIV Cohort Study.

OBJECTIVES: Persons from sub-Saharan Africa (SSA) are increasingly enrolled in the Swiss HIV Cohort Study (SHCS). Cohorts from other European countries showed higher rates of viral failure among their SSA participants. We analyzed long-term outcomes of SSA versus North Western European participants. DESIGN: We analyzed data of the SHCS, a nation-wide prospective cohort study of HIV-infected adults at 7 sites in Switzerland. METHODS: SSA and North Western European participants were included if their first treatment combination consisted of at least 3 antiretroviral drugs (cART), if they had at least 1 follow-up visit, did not report active injecting drug use, and did not start cART with CD4 counts >200 cells per microliter during pregnancy. Early viral response, CD4 cell recovery, viral failure, adherence, discontinuation from SHCS, new AIDS-defining events, and survival were analyzed using linear regression and Cox proportional hazard models. RESULTS: The proportion of participants from SSA within the SHCS increased from 2.6% (<1995) to 20.8% (2005-2009). Of 4656 included participants, 808 (17.4%) were from SSA. Early viral response (6 months) and rate of viral failure in an intent-to-stay-on-cART approach were similar. However, SSA participants had a higher risk of viral failure on cART (adjusted hazard ratio: 2.03, 95% confidence interval: 1.50 to 2.75). Self-reported adherence was inferior for SSA. There was no increase of AIDS-defining events or mortality in SSA participants. CONCLUSIONS: Increased attention must be given to factors negatively influencing adherence to cART in participants from SSA to guarantee equal longer-term results on cART.

Infant's triangular communication in "two for one" versus "two against one" family triangles: Case illustrations

Infants use their social competence very early to communicate not only in dyads but also in triads, in particular in the triangle they form with their mother and father. The development of this triangular communication is largely shaped by the ways the parents support or undermine each other in relation to their child. Whereas triangular communication is facilitated in "two for one" alliances, it is recruited in the service of regulating the parents' conflicts in "two against one" coalitions. These processes are manifest in toddlerhood and may be traced back to the coparenting alliance in formation during pregnancy.

Family interactions in IVF families: change over the transition to parenthood

Objective: This article presents a study of the change over time in the family interactions of couples who conceived through in-vitro fertilisation (IVF). Background: Observational methods are rarely used to study family interactions in families who used assisted reproductive techniques, but these methods are crucial for taking account of the communication that occurs in interactions with infants. Methods: Thirty-one couples expecting their first child were seen during the fifth month of pregnancy and when the child was nine months old. Family interactions were recorded in pre- and postnatal versions of the Lausanne Trilogue Play situation. Measures of marital satisfaction and parent-to-foetus/baby attachment or 'bonding' were also used to assess family relational dynamics. Results: Results showed that family alliance, marital satisfaction and parental attachment scores in the IVF sample were all similar to or higher than those in the reference sample during pregnancy. However, at nine months postnatally, the family alliance scores were lower. While marital satisfaction decreased over the period and parent-baby attachment increased, the family alliance scores were unstable, as no association was observed between the pre- and postnatal scores. In addition, neither prenatal marital satisfaction nor parent-foetus attachment predicted the postnatal family alliance. Conclusion: The change in the family alliance over the transition to parenthood appears to be specific to our IVF sample. Given that postnatal family functioning could not be predicted by prenatal family functioning, our observational data underline the importance of offering postnatal support to these families.