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Abstract
Breastfeeding is associated with positive maternal and infant outcomes. It is recommended that women exclusively breastfeed for the first 6 months postpartum; however, these recommendations are not met in the majority of women. Psychological distress in pregnancy is associated with lower rates of breastfeeding initiation and duration in the postpartum period. The mechanisms linking maternal distress to breastfeeding are not understood. In this study we examined maternal circadian cortisol as a mechanism linking distress in pregnancy to breastfeeding. This study is a secondary data analysis of 197 pregnant women with singleton pregnancies who were part of a larger study of the effects of maternal mood on fetal and infant development. About 34% of women reported exclusively breastfeeding, 18% reported exclusively formula feeding, and 48% reported mixed feeding. Participants reported on perceived stress, perinatal anxiety and depression, and socioeconomic status during pregnancy. They provided salivary cortisol samples at three times a day for 3 days at 24, 30, and 36 weeks' gestation. Participants who reported lower socioeconomic status in pregnancy were less likely to breastfeed, and lower maternal cortisol awakening responses mediated this association. This area of research may identify foci in the prenatal period that could serve as targets for interventions to increase rates of breastfeeding. Lay summary Pregnant women who reported lower socioeconomic status in pregnancy were less likely to breastfeed. This association was mediated by lower cortisol awakening responses, but not evening cortisol levels, over pregnancy.
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Affiliation(s)
- M H Bublitz
- a The Miriam Hospital , Providence , RI , USA
- b Department of Medicine , Alpert Medical School of Brown University , Providence , RI , USA
- c Department of Psychiatry and Human Behavior , Alpert Medical School of Brown University , Providence , RI , USA
| | - G Bourjeily
- a The Miriam Hospital , Providence , RI , USA
- b Department of Medicine , Alpert Medical School of Brown University , Providence , RI , USA
| | - C Bilodeau
- a The Miriam Hospital , Providence , RI , USA
- b Department of Medicine , Alpert Medical School of Brown University , Providence , RI , USA
| | - L R Stroud
- a The Miriam Hospital , Providence , RI , USA
- c Department of Psychiatry and Human Behavior , Alpert Medical School of Brown University , Providence , RI , USA
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Bublitz MH, Carpenter M, Amin S, Okun ML, Millman R, De La Monte SM, Bourjeily G. The role of inflammation in the association between gestational diabetes and obstructive sleep apnea: A pilot study. Obstet Med 2018; 11:186-191. [PMID: 30574181 DOI: 10.1177/1753495x18780095] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/06/2018] [Indexed: 12/18/2022] Open
Abstract
Background Obstructive sleep apnea is associated with pregnancy complications including gestational diabetes. Mechanisms underlying the association between obstructive sleep apnea and gestational diabetes remain to be elucidated. Methods Twenty-three participants with gestational diabetes underwent home sleep apnea testing. Obstructive sleep apnea was defined as an apnea hypopnea index > 5. Fasting morning blood samples were measured using multianalyte profiling (xMAP) multiplexed bead array immunoassay for Interleukin 6, tumor necrosis factor-alpha, and Interleukin 8. Results Age, body mass index, and gestational age at enrollment were 31 + 4.4 years, 35.7 + 7.4 kg/m2, and 28 ± 4 weeks, respectively. Participants were 52% Caucasian and 16% had obstructive sleep apnea. We observed positive correlations between apnea hypopnea index and Interleukin 6 (r = 0.62, p = 0.005), Interleukin 8 (r = 0.56, p = .56), and tumor necrosis factor-alpha (r = .58, p = .009). Women with obstructive sleep apnea had higher levels of Interleukin 6 (F = 5.01, p = .037) and Interleukin 8 (F = 6.33, p = .021) vs. women without obstructive sleep apnea. Conclusion These preliminary results indicate that in women with gestational diabetes, apnea hypopnea index is associated with an elevated inflammatory profile.
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Affiliation(s)
- M H Bublitz
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Medicine, The Miriam Hospital, Providence, USA.,Women's Medicine Collaborative of Lifespan, Providence, USA
| | - M Carpenter
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Medicine, The Miriam Hospital, Providence, USA.,Women's Medicine Collaborative of Lifespan, Providence, USA
| | - S Amin
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Medicine, The Miriam Hospital, Providence, USA.,Department of Medicine, Rhode Island Hospital, Rhode Island Hospital, Providence, USA
| | - M L Okun
- Lane Center for Academic Health Sciences, Clinical and Biobehavioral Research, University of Colorado, Colorado Springs, USA
| | - R Millman
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Medicine, Rhode Island Hospital, Rhode Island Hospital, Providence, USA.,Sleep Disorders Center of Lifespan Hospitals, Providence, USA
| | - S M De La Monte
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Medicine, Rhode Island Hospital, Rhode Island Hospital, Providence, USA.,Department of Pathology (Neuropathology), Rhode Island Hospital, Providence, USA
| | - G Bourjeily
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, USA.,Department of Medicine, The Miriam Hospital, Providence, USA.,Women's Medicine Collaborative of Lifespan, Providence, USA
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Sequeira T, Bublitz M, Adodoadji E, Livingston Z, Bourjeily G. 0500 STOPBANG QUESTIONNAIRE CORRECTLY DETECTS THE ABSENCE OF OBSTRUCTIVE SLEEP APNEA IN THE FIRST TRIMESTER OF PREGNANCY. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bourjeily G, Danilack V, Bublitz M, Lipkind H, Caldwell D, Muri J. 0474 A NATIONAL COHORT STUDY OF OBSTRUCTIVE SLEEP APNEA IN PREGNANCY AND ADVERSE NEONATAL OUTCOMES. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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He M, Curran P, Raker C, Martin S, Larson L, Bourjeily G. Placental findings associated with maternal obesity at early pregnancy. Pathol Res Pract 2016; 212:282-7. [DOI: 10.1016/j.prp.2016.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 12/18/2015] [Accepted: 01/22/2016] [Indexed: 12/17/2022]
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Abstract
Introduction The current approach to, cardiopulmonary resuscitation of pregnant women in the third trimester has been to adhere to the “four-minute rule”: If pulses have not returned within 4 min of the start of resuscitation, perform a cesarean birth so that birth occurs in the next minute. This investigation sought to re-examine the evidence for the four-minute rule. Methods A literature review focused on perimortem cesarean birth was performed using the same key words that were used in formulating the “four-minute rule.” Maternal and neonatal injury free survival rates as a function of arrest to birth intervals were determined, as well as actual incision to birth intervals. Results Both maternal and neonatal injury free survival rates diminished steadily as the time interval from maternal arrest to birth increased. There was no evidence for any specific survival threshold at 4 min. Skin incision to birth intervals of 1 min occurred in only 10% of women. Conclusion Once a decision to deliver is made, care providers should proceed directly to Cesarean birth during maternal cardiac arrest in the third trimester rather than waiting for 4 min for restoration of the maternal pulse. Birth within 1 min from the start of the incision is uncommon in these circumstances. Half of maternal/fetal pairs who are delivered by Cesarean birth within 25 min survive without injury. The injury free survival rate for both has a roughly linear decrease as the time interval from arrest to birth increases. Very few babies could be delivered within 1 min of the Cesarean section incision.
This information suggests that the current cardio-pulmonary resuscitation guideline in pregnancy, known as the four-minute rule, needs to be changed. Injury free survival for both mother and baby decreases steadily from the moment of cardiac arrest until cesarean birth. Furthermore, in actual practice, the baby usually cannot be delivered within 1 min of the start of surgery. Once a decision for delivery has been made, Cesarean birth should be initiated promptly without waiting for 4 min. In practice, the recommendation to proceed to cesarean birth without delay is also likely to result in less confusion than the current “Four-Minute rule.”
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Affiliation(s)
- M D Benson
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, NorthShore University Health System and Advocate Condell Medical Center, United States.
| | - A Padovano
- Washington University School of Medicine, United States
| | - G Bourjeily
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, United States
| | - Y Zhou
- Center for Biomedical Research Informatics, NorthShore Research Institute, United States
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Lapinsky SE, Rojas-Suarez JA, Crozier TM, Vasquez DN, Barrett N, Bourjeily G. Obstetric delivery in mechanically ventilated critically ill pregnant women. Intensive Care Med Exp 2015. [PMCID: PMC4796420 DOI: 10.1186/2197-425x-3-s1-a275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lapinsky SE, Rojas-Suarez JA, Crozier TM, Vasquez DN, Barrett N, Austin K, Plotnikow GA, Orellano K, Bourjeily G. Mechanical ventilation in critically-ill pregnant women: a case series. Int J Obstet Anesth 2015; 24:323-8. [PMID: 26355021 DOI: 10.1016/j.ijoa.2015.06.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/01/2015] [Accepted: 06/27/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Approximately 0.1-0.2% of pregnancies are complicated by respiratory failure requiring mechanical ventilatory support, but few data exist to inform clinical management. This study aimed to characterize current practice and the effect of delivery on respiratory function. METHODS A retrospective review was performed of pregnant women who received mechanical ventilation for more than 24h, from four intensive care units in institutions with large-volume obstetric units. RESULTS Data were collected from 29 patients with a mean gestation at intensive care unit admission of 25.3 ± 6 weeks. Tidal volumes were 7.7 ± 1.7 mL/kg predicted body weight. Estimated respiratory system compliance was reduced, but was higher in four patients ventilated for neurological conditions without lung disease. Three maternal and three neonatal deaths occurred. Ten patients delivered while on ventilatory support: one spontaneous delivery, four for obstetric indications and five for worsening maternal condition. Following delivery of these 10 patients, three demonstrated a greater than 50% decrease in oxygenation index and five a greater than 50% increase in compliance. No characteristics identified which patients may benefit from delivery. CONCLUSIONS Review of current practice in four centers suggests that mechanical ventilation in pregnant patients follows usual guidelines applicable to non-pregnant patients. Delivery was associated with modest improvement in maternal respiratory function in some patients. Any potential benefit of delivery in improving maternal physiology must be weighed against the stress of delivery. The risks of premature birth for the fetus must be weighed against continued exposure to maternal hypoxemia and hypotension.
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Affiliation(s)
- S E Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - J A Rojas-Suarez
- Intensive Care Unit, Gestión Salud Clinic, Cartagena, Colombia; Grupo de Investigación en Cuidados intensivos y Obstetricia, GRICIO, Universidad de Cartagena, Gestión Salud Clinic, Cartagena, Colombia
| | - T M Crozier
- Intensive Care Unit, Monash Medical Centre, Clayton, Victoria, Australia; The Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Australia
| | - D N Vasquez
- Sanatorio Anchorena, Ciudad de Buenos Aires, Argentina
| | - N Barrett
- The Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Australia
| | - K Austin
- Intensive Care Unit, Mount Sinai Hospital, Toronto, Canada
| | - G A Plotnikow
- Sanatorio Anchorena, Ciudad de Buenos Aires, Argentina
| | - K Orellano
- Grupo de Investigación en Cuidados intensivos y Obstetricia, GRICIO, Universidad de Cartagena, Gestión Salud Clinic, Cartagena, Colombia; Universidad del Sinu, Cartagena, Colombia
| | - G Bourjeily
- Pulmonary and Critical Care Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA; The Miriam Hospital, Providence, RI, USA
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Affiliation(s)
- G Bourjeily
- Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI, USA
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Bourjeily G, Barbara N, Larson L, He M. Clinical manifestations of obstructive sleep apnoea in pregnancy: more than snoring and witnessed apnoeas. J OBSTET GYNAECOL 2012; 32:434-8. [PMID: 22663313 DOI: 10.3109/01443615.2012.658892] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sleep disordered breathing and its symptoms have been associated with a multitude of fetal and maternal complications including gestational hypertensive disorders, gestational diabetes and possibly pre-term labour and other markers of alterations in fetal wellbeing. The disease remains underdiagnosed in the general population but likely also in pregnancy, mostly because providers do not appropriately screen for the disorder. Sleep disordered breathing may manifest differently in women, since women report more fatigue and less snoring than men do. This paper discusses typical presentations of sleep disordered breathing but also reports some less obvious presentations to help providers recognise those manifestations and screen for the disorder when warranted. Our case series describes patients with diagnoses such as chronic hypertension, pre-eclampsia, pulmonary hypertension, nocturnal asthma and panic attacks, who were diagnosed with sleep disordered breathing and offered treatment with CPAP during pregnancy.
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Affiliation(s)
- G Bourjeily
- Department of Medicine, The Miriam Hospital, Women's Medicine Collaborative of Lifespan, 146 West River Street, Providence, RI 02904, USA.
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Bourjeily G, Khalil H, Miller MA, O'Connor K, Rosene-Montella K. Pregnancy and delivery in a patient with hypoplastic lung and dyspnoea. J OBSTET GYNAECOL 2008; 28:228-9. [PMID: 18393028 DOI: 10.1080/01443610801916205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- G Bourjeily
- Warren Alpert Medical School of Brown University, Providence, RI, USA
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Abstract
Exercise limitation is a common and disturbing manifestation of COPD. The exercise intolerance is often caused by multiple interrelated anatomic and physiologic disturbances. Importantly, exercise tolerance can be improved despite the presence of fixed structural abnormalities in the lung. Exercise training, undertaken alone or in the context of comprehensive PR, improves exercise endurance and, to a lesser degree, the maximal tolerated workload of patients with COPD. Pulmonary rehabilitation also improves dyspnea and QOL. Exercise training and PR should be considered for all patients lacking contraindications who experience exercise intolerance despite optimal medical therapy. Lower-extremity training should be included routinely in the exercise prescription. The choice of type and intensity of training should be based primarily on the patient's individual baseline functional status, symptoms, needs, and long-term goals. When tolerated, high-intensity (continuous or interval) training may lead to greater improvements in aerobic fitness than low-intensity training but is not absolutely necessary to achieve gains in exercise endurance. Upper-extremity training should be undertaken when possible. Ventilatory muscle training should be considered for patients who continue to experience exercise limitation and breathlessness despite medical therapy and general exercise reconditioning. Exercise tolerance may improve following exercise training because of gains in aerobic fitness or peripheral muscle strength; enhanced mechanical skill and efficiency of exercise; improvements in respiratory muscle function, breathing pattern, or lung hyperinflation; as well as reduction in anxiety, fear, and dyspnea associated with exercise. Gains made in exercise tolerance can last up to 2 years following a limited duration (6-12 week) rehabilitation program.
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Affiliation(s)
- G Bourjeily
- Section of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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