Association of high cortisol levels in pregnancy and altered fetal growth. Results from the MAASTHI, a prospective cohort study, Bengaluru

The Impact of Emotional Responses on Female Reproduction: Fibrinolysis in the Spotlight

Fibrinolytic enzymes modify various substrates required for tissue remodeling, playing a crucial role in mechanisms underlying resilience, reward processing, ovulation, embryo implantation, and placentation. Individuals with low resilience and reduced reward responsiveness, when exposed to chronic stress, are at increased risk of experiencing a range of negative emotions. Chronic anxiety and melancholia are examples of negative emotions associated with hypercortisolism, while fear and atypical depression are characterized by systemic inflammation. Both cortisol and inflammatory cytokines stimulate the production of plasminogen activator inhibitor-1 (PAI-1), a potent fibrinolysis inhibitor. Chronic anxiety, fear, and depression are among the many hypofibrinolytic conditions increasing the risk of oligo-anovulation, miscarriage, fetal growth restriction, and preeclampsia. Although significant, the impact of negative emotions on implantation is not as obvious as on ovulation or placentation. Other hypofibrinolytic conditions that may affect female reproduction through mechanisms dependent or independent of PAI-1 include metabolic disturbances (e.g., due to consumption of highly palatable foods, often used to alleviate negative affect), inflammation, hyperhomocysteinemia, hypothyroidism, hypercortisolism, antiphospholipid antibodies, and the 4G allele of the PAI-1 gene. Benzodiazepines and antidepressants should be used with caution in the first trimester as this combination may cause malformations. Also, selective serotonin reuptake inhibitors have fibrinolytic properties that increase the risk of bleeding after surgical procedures. Psychological interventions, especially group therapy, are effective in the prevention of reproductive disorders. Controlled trials are needed to test the hypothesis that female reproductive health depends on psychological well-being, a balanced diet and physical activity, suppression of inflammation and autoantibodies, and homocysteine and hormonal homeostasis.

Placental nanoparticle-mediated IGF1 gene therapy corrects fetal growth restriction in a guinea pig model

Fetal growth restriction (FGR) caused by placental insufficiency is a major contributor to neonatal morbidity and mortality. There is currently no in utero treatment for placental insufficiency or FGR. The placenta serves as the vital communication, supply, exchange, and defense organ for the developing fetus and offers an excellent opportunity for therapeutic interventions. Here we show efficacy of repeated treatments of trophoblast-specific human insulin-like 1 growth factor (IGF1) gene therapy delivered in a non-viral, polymer nanoparticle to the placenta for the treatment of FGR. Using a guinea pig maternal nutrient restriction model (70% food intake) of FGR, nanoparticle-mediated IGF1 treatment was delivered to the placenta via ultrasound guidance across the second half of pregnancy, after establishment of FGR. This treatment resulted in correction of fetal weight in MNR + IGF1 animals compared to sham treated controls on an ad libitum diet, increased fetal blood glucose and decreased fetal blood cortisol levels compared to sham treated MNR, and showed no negative maternal side-effects. Overall, we show a therapy capable of positively impacting the entire pregnancy environment: maternal, placental, and fetal. This combined with our previous studies using this therapy at mid pregnancy in the guinea pig and in two different mouse model and three different human in vitro/ex vivo models, demonstrate the plausibility of this therapy for future human translation. Our overall goal is to improve health outcomes of neonates and decrease numerous morbidities associated with the developmental origins of disease.

Incidence of adverse perinatal outcomes in highly vulnerable pregnant women - the Mothers of Rotterdam study

BACKGROUND

Socioeconomic disadvantaged circumstances are known to affect health outcomes, but during pregnancy it also affects the growth and development of the fetus. This often results in adverse perinatal outcomes and other long lasting effects. Here we refer to pregnant women living in such circumstances as a highly vulnerable population.

OBJECTIVES

To study adverse perinatal outcomes in highly vulnerable pregnant women within the Mothers of Rotterdam (MoR) study and to compare findings to the outcomes of women in the Netherlands as a whole and the city of Rotterdam.

METHODS

Pregnancy and childbirth data from women participating in the MoR study (2015-2019) was requested from their obstetric professional. For comparison, data from the Dutch national birth registry (Perined) were used representing women in the Netherlands and Rotterdam. Main outcome measures were preterm birth (PTB) and small for gestational age (SGA). Secondary outcome measures were perinatal mortality and a low Apgar score. Only singleton viable pregnancies (i.e. birthweight above 500 g or born after 22 + 0 weeks of gestation) were included in this study. Prevalence rates and corresponding 95% confidence intervals (95%CI) were calculated for all outcomes in each group. Direct standardization was used to account for possible differences in case-mix composition between the studied groups.

RESULTS

Data on 346 childbirths within the MoR study were retrieved and compared to 813,755 and 34,009 childbirths in the Netherlands and Rotterdam, respectively. The prevalence of PTB (4.34% (95%CI 2.19-6.48) was lower in the MoR population compared to both the Netherlands (6.21% (95%CI 6.16-6.27)) and Rotterdam (6.39% (95%CI 6.13-6.65)). The prevalence of SGA (21.09% (95% CI 16.80-25.40)) was higher in the MoR population compared to both the Netherlands (10.11% (95%CI 10.04-10.17)) and Rotterdam (13.28% (95%CI 12.92-13.65)). There were no cases of perinatal mortality registered in the MoR population. The prevalence of a low Apgar score (0.87% (95%CI 0.00-1.84)) was lower in the MoR population.

CONCLUSIONS

Our study found unexpected low PTB and high SGA prevalence rates in the MoR population compared to the Netherlands and Rotterdam. Mechanisms through which socioeconomic disadvantaged circumstances affect perinatal health seem to work differently in various strata of vulnerable populations.

Exploring stress and depressive symptoms in pregnancy and the IL-1β, IL-6, and C-reactive protein pathway: Looking for possible biomarker targets

Background

Individuals undergo significant stress throughout pregnancy and are at high risk for depressive symptoms. Elevated stress and depressive symptoms are associated with inflammatory processes and adverse maternal-infant outcomes. However, the biological processes associated with psychosocial outcomes and the maternal immune system remain unclear. As such, we aimed to examine associations among perceived stress, depressive symptoms, salivary IL-1β, IL-6, and CRP levels, and hair and salivary cortisol levels during the second and third trimesters of pregnancy.

Methods

We conducted an ancillary study consisting of 37 pregnant individuals. Participants collected salivary samples and measures of perceived stress and depression at 17-19 weeks, 25-27 weeks, and 32-34 weeks gestation. We collected a one-time hair sample between 36 and 40 weeks. Provided salivary samples were used to detect changes in cortisol, IL-1β, IL-6, and CRP levels. Hair was used to detect changes in cortisol levels throughout pregnancy.

Results

Elevated levels of perceived stress and depressive symptoms are associated with increased salivary CRP levels, respectively (p = 0.0142, p = 0.0008). Salivary and hair cortisol increased significantly throughout the second and third trimesters of pregnancy (p = 0.0004 and p < 0.0001). We also observed variations in IL-6 during pregnancy (p = 0.029) and significant increases between 25 and 27 weeks (p = 0.016).

Conclusion

Salivary samples may provide a non-invasive measurement of alterations in cytokine and cortisol levels in pregnant individuals reporting elevated stress and depressive symptoms. These may be candidate biomarkers for mechanistic study possibly aiding providers in early detection of deleterious immunological processes which could result in adverse maternal-infant outcomes.

Association between pre-pregnancy maternal stress and small for gestational age: a population-based retrospective cohort study

BACKGROUND

Maternal stress is a potential factor affecting fetal growth, but it is unknown whether it directly affects fetal growth restriction. This study aims to investigate the association between pre-pregnancy maternal stress with small for gestational age (SGA).

METHODS

This study used a population-based retrospective cohort analysis to examine the association between pre-pregnancy maternal stress and SGA in offspring. Data were extracted from the National Preconception Health Care Project (NPHCP), conducted between 2010 and 2012, which encompassed preconception health-related information from 572,989 individuals across various regions in China. Logistic regression models were used to assess the associations between pre-pregnancy maternal stress variables and the risk of SGA. In addition, Synthetic Minority Over-sampling Technique (SMOTE) and Propensity Scores (PS) methods were used to enhance the model's ability to the associations between pre-pregnancy maternal stress and SGA.

RESULTS

Pre-pregnancy maternal stress was significantly associated with an increased the risk of SGA in offspring (OR 1.35, 95% CI 1.20 to 1.51, P < 0.001). Stress related to life and economic factors notably increased the risk of SGA across different socio-economic conditions, whereas stress related to friends did not show a statistically significant association (P > 0.05). Specially, individuals with lower socio-economic status that characterized by below high school education levels (OR = 1.45, 95% CI: 1.23 to 1.70), farmer occupation (OR = 1.33, 95% CI: 1.15 to 1.55, P = 0.002), rural residence (OR = 1.38, 95% CI: 1.22 to 1.56, P < 0.001), and younger age (under 35 years: OR = 1.35, 95% CI: 1.20 to 1.52, P < 0.001) were more susceptible to pre-pregnancy maternal stress, increasing their risk of SGA.

CONCLUSIONS

Pre-pregnancy maternal stress was positively associated with an increased risk of SGA in offspring. Individuals with lower socio-economic status were more likely to experience pre-pregnancy maternal stress related to life and economic factors, which in turn contributed to a higher risk of SGA.

Effects of hypoxia on uteroplacental and fetoplacental vascular function during pregnancy

During pregnancy, marked changes in vasculature occur. The placenta is developed, and uteroplacental and fetoplacental circulations are established. These processes may be negatively affected by genetic anomalies, maternal environment (i.e., obesity or diabetes), and environmental conditions such as pollutants and hypoxia. Chronic hypoxia has detrimental effects on the vascular adaptations to pregnancy and fetal growth. The typical pregnancy-dependent rise in uterine blood flow by vascular remodeling and vasodilation of maternal uterine arteries is reduced, leading to increases in vascular tone. These maladaptations may lead to complications such as fetal growth restriction (FGR) and preeclampsia. In this review, the effect of hypoxia on uteroplacental and fetoplacental circulation and its impact on pregnancy outcomes in humans and animal models are discussed. Evidence is provided for several mechanisms that affect pregnancy through hypoxia-induced alterations. Future directions to fill gaps in knowledge and develop therapeutic strategies to prevent or alleviate hypoxia-related pregnancy complications, such as FGR and preeclampsia, are suggested.

Maternal dietary and environmental factors associated with infant circadian rhythm, growth, and temperament: Research protocol for a prospective cohort study

Introduction: Emerging evidence has been explored to determine the factors affecting the development of infant circadian rhythm. While fetal programming happens during the pregnancy period, external environmental cues and infant nutritional programming can have substantial effects on the infant circadian rhythm. Understanding prenatal and postnatal factors determining infant circadian rhythm can improve future interventions in optimizing maternal and infant health. Methods: This is a prospective observational cohort study, targeting 216 pregnant women from government maternity clinics in Kuala Lumpur, Malaysia. Pregnant women will be recruited at third trimester (baseline), and follow up at 3 months, and 6 months. A subsample will be collected for salivary cortisol analysis to determine circadian rhythm of the mother and infant at third trimester and 3 months. Data of eating misalignment, light exposure, chronotype, infant temperament, sleep quality, and mood will be collected via validated questionnaires. Anthropometric data and birth outcomes will be collected from antenatal and postnatal health records. Summary: Studies on infant circadian rhythm development have yet to be explored and established, hence this study presents a novel approach to identify the factors from prenatal to postnatal periods on infant circadian rhythm and its influence on growth and temperament. Findings from this study will provide insights in the critical timing which has larger effects on infant circadian rhythm development for future interventions to be conducted.

D, Mandal S, Menon JS, Roy A, Dixit S, Gupta R, Swaminathan S, Thankachan P, Bhavnani S, Divan G, Prabhakaran P, van Schayck OCP, Babu GR, Srinivas PN, Mukherjee D, COINCIDE consortium. Protocol of the Nutritional, Psychosocial, and Environmental Determinants of Neurodevelopment and Child Mental Health (COINCIDE) study

Background

Over 250 million children are developing sub-optimally due to their exposure to early life adversities. While previous studies have examined the independent effects of nutritional status, psychosocial adversities, and environmental pollutants on children's outcomes, little is known about their interaction and cumulative effects.

Objectives

This study aims to investigate the independent, interaction, and cumulative effects of nutritional, psychosocial, and environmental factors on children's cognitive development and mental health in urban and rural India. It also seeks to explain pathways leading to inequities in child outcomes at the individual, household, and neighbourhood levels.

Methods

A mixed-methods prospective cohort study will be conducted on 1600 caregiver-child dyads (child age 3-10 years) in urban and rural India. Nutritional status, psychosocial adversities, environmental pollutants, and child mental health outcomes will be assessed using parent-report questionnaires. Performance-based measures will be used to assess cognitive outcomes. Venous blood and urine samples will be used to measure nutritional and pesticide biomarkers in 500 children. Indoor air pollution will be monitored in 200 households twice, during two seasons. Multilevel regression, weighted quantile sum regression, and Bayesian kernel machine regression will assess the individual and combined effects of exposures on child outcomes. Thematic analysis of in-depth interviews and focus group discussions will explore pathways to middle-and late childhood development inequities.

Discussion

The data will be used to formulate a Theory of Change (ToC) to explain the biological, psychosocial, and environmental origins of children's cognitive and mental health outcomes across the first decade of life in diverse Indian settings, which can inform interventions targets for promoting children's outcomes beyond the first 1000 days, potentially generalizable to similar under-resourced global settings. The COINCIDE research infrastructure will comprise a valuable global health resource, including prospective cohort data, validated study tools, and stored biological and environmental samples for future studies.

Relationship Between the Serum Cortisol, Insulin, Adrenocorticotropic Hormone (ACTH), and Blood Glucose Levels of Pregnant Women With Gestational Diabetes Mellitus in the Kingdom of Bahrain

Background Gestational diabetes mellitus (GDM) can be defined as hyperglycemia that develops during pregnancy. GDM poses both maternal and fetal potential risks. Elevated maternal cortisol levels have been linked to maternal hyperglycemia and insulin resistance. The present study aimed to investigate the relationship between GDM and serum cortisol levels in Bahraini and non-Bahraini pregnant women in the Kingdom of Bahrain. We also investigated the relationship between age and ethnicity in the development of GDM. Methods Data were collected from a total of 75 pregnant women; 41 of which were diagnosed with GDM and 34 had normal blood glucose levels. Serum cortisol, insulin, adrenocorticotropic hormone (ACTH), fasting (FBG), and random (RBG) blood glucose levels were measured. Results FBG, RBG, and insulin blood levels were significantly higher in the GDM group when compared to the control group. Serum cortisol and ACTH levels tended to be higher in the GDM group; however, they were statistically insignificant. Within the GDM group, there were no statistically significant differences in serum insulin, cortisol, and ACTH levels between Bahraini and non-Bahraini patients or between patients less than or more than 30 years old. Conclusion Our results suggest that cortisol may not have a major role in the development of GDM in our patients. Further research is needed to confirm these results. This study highlights the necessity to better understand the underlying mechanisms of the development of GDM in pregnant women.

Placental Nanoparticle-mediated IGF1 Gene Therapy Corrects Fetal Growth Restriction in a Guinea Pig Model

Fetal growth restriction (FGR) caused by placental insufficiency is a major contributor to neonatal morbidity and mortality. There is currently no in utero treatment for placental insufficiency or FGR. The placenta serves as the vital communication, supply, exchange, and defense organ for the developing fetus and offers an excellent opportunity for therapeutic interventions. Here we show efficacy of repeated treatments of trophoblast-specific human insulin-like 1 growth factor (IGF1) gene therapy delivered in a non-viral, polymer nanoparticle to the placenta for the treatment of FGR. Using a guinea pig maternal nutrient restriction model (70% food intake) of FGR, nanoparticle-mediated IGF1 treatment was delivered to the placenta via ultrasound guidance across the second half of pregnancy, after establishment of FGR. This treatment resulted in correction of fetal weight in MNR + IGF1 animals compared to sham treated controls on an ad libitum diet, increased fetal blood glucose and decreased fetal blood cortisol levels compared to sham treated MNR, and showed no negative maternal side-effects. Overall, we show a therapy capable of positively impacting the entire pregnancy environment: maternal, placental, and fetal. This combined with our previous studies using this therapy at mid pregnancy in the guinea pig and in two different mouse model and three different human in vitro/ex vivo models, demonstrate the plausibility of this therapy for future human translation. Our overall goal is to improve health outcomes of neonates and decrease numerous morbidities associated with the developmental origins of disease.