Optimizing Evaluation and Treatment of Patients with Nausea and Vomiting of Pregnancy in the Emergency Department

Problem Definition Nausea and vomiting of pregnancy (NVP). Approximately 50% prevalence rate Pregnant patients with NVP require special considerations for treatment Long ER wait times Possibly avoidable hospital admission

Insulin and Leptin Signaling Interact in the Mouse Kiss1 Neuron during the Peripubertal Period.

Reproduction requires adequate energy stores for parents and offspring to survive. Kiss1 neurons, which are essential for fertility, have the potential to serve as the central sensors of metabolic factors that signal to the reproductive axis the presence of stored calories. Paradoxically, obesity is often accompanied by infertility. Despite excess circulating levels of insulin and leptin, obese individuals exhibit resistance to both metabolic factors in many neuron types. Thus, resistance to insulin or leptin in Kiss1 neurons could lead to infertility. Single deletion of the receptors for either insulin or the adipokine leptin from Kiss1 neurons does not impair adult reproductive dysfunction. However, insulin and leptin signaling pathways may interact in such a way as to obscure their individual functions. We hypothesized that in the presence of genetic or obesity-induced concurrent insulin and leptin resistance, Kiss1 neurons would be unable to maintain reproductive function. We therefore induced a chronic hyperinsulinemic and hyperleptinemic state in mice lacking insulin receptors in Kiss1 neurons through high fat feeding and examined the impact on fertility. In an additional, genetic model, we ablated both leptin and insulin signaling in Kiss1 neurons (IR/LepRKiss mice). Counter to our hypothesis, we found that the addition of leptin insensitivity did not alter the reproductive phenotype of IRKiss mice. We also found that weight gain, body composition, glucose and insulin tolerance were normal in mice of both genders. Nonetheless, leptin and insulin receptor deletion altered pubertal timing as well as LH and FSH levels in mid-puberty in a reciprocal manner. Our results confirm that Kiss1 neurons do not directly mediate the critical role that insulin and leptin play in reproduction. However, during puberty kisspeptin neurons may experience a critical window of susceptibility to the influence of metabolic factors that can modify the onset of fertility

Reproductive axis function in IR^Kiss mice after HFD treatment.

<p>(A) Serum estradiol in females (n = 3, 6) after 3 months on HFD in adulthood. (B) Serum testosterone levels in males (n = 4, 5) and females (n = 4, 7) after 3 months on HFD in adulthood. (C) GnRH gene expression after 4 months on HFD in adulthood in males (n = 6, 4) and females (n = 5, 4). (D) Serum LH levels in females (n = 13, 6) after 3 months on HFD in adulthood. (E) Serum testosterone levels in females (n = 13, 6) after 3 months on HFD in adulthood. (F) Body weight growth curve in females placed on HFD at weaning (n = 4, 4). + indicates control low and high fat diet groups differ significantly, # indicates IR^Kiss low and high fat diet groups differ significantly. (G) Age of vaginal opening and first estrus in females placed on HFD at weaning (n = 11, 10). (H) Age of vaginal opening and first estrus in females placed on HFD at weaning (n = 11, 10).</p

Metabolic parameters in IR^Kiss mice after HFD treatment.

<p>(A) Female body weight growth curve after HFD (n = 8, 8). Body weights of a low-fat diet cohort included for comparison, + indicates control low and high fat diet groups differ significantly, # indicates IR^Kiss low and high fat diet groups differ significantly, * indicates two HFD groups differ significantly. (B) Male body weight growth curve after HFD (Control, n = 7; IR^Kiss, n = 5). Body weights of a low-fat diet cohort included for comparison. + indicates control low and high fat diet groups differ significantly, # indicates IR^Kiss low and high fat diet groups differ significantly. (C) Female body composition measured by NMR 3 months after HFD (n = 8, 8). (D) Male body composition measured by NMR 3 months after HFD (n = 7, 5). (E) Serum leptin levels in lean males (n = 16, 8) and males after 3 months of exposure to HFD (n = 7, 4) (F) Serum leptin levels in lean females (n = 7, 7) and females after 3 months of exposure to HFD (n = 4, 9) (G) Serum insulin levels in lean males (n = 11, 10) and males after 3 months of exposure to HFD (n = 6, 5) (H) Serum insulin levels in lean females (n = 9, 10) and females after 3 months of exposure to HFD (n = 3, 9).</p

Glucose regulation in IR/LepR^Kiss mice (A) 4–5 months old female GTT and area under curve (AUC) (inset) in control (n = 11) and IR/LepR^Kiss (n = 5) mice.

<p>(B) 4–5 months old male GTT and AUC (inset) in control (n = 10) and IR/LepR^Kiss (n = 8) mice. (C) 5–6 months old female ITT and AUC (inset) in control and IR/LepR^Kiss mice (n = 7). (D) 5–6 months old male ITT and AUC (inset) in control (n = 11) and IR/LepR^Kiss (n = 7) mice.</p

Genotyping primer sequences.

<p>Genotyping primer sequences.</p

Generation of IR/LepR^ΔKiss mice.

<p>(A) Construct in making IR/LepR^ΔKiss mice. Adapted from previous publications [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0121974#pone.0121974.ref048" target="_blank">48</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0121974#pone.0121974.ref050" target="_blank">50</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0121974#pone.0121974.ref081" target="_blank">81</a>]. (B) PCR of DNA from different tissues. The exercised LepR and IR both appear as a 500bp band, whereas unexercised LepR shown as 1kb band and unexercised IR as a 2.2kb band. (C) Representative IRβ expression in different tissues and densitometry.</p

Electrophysiological response of <i>Kiss1</i> neurons to insulin.

<p>A: Averaged membrane potential (Vm) recordings from an insulin-responsive <i>Kiss1</i> neuron elicited with (solid line) and without (dashed line) a 4 x 20 ms pressure application of 200 nM insulin in ACSF. Gray shading represents the mean ± SEM from traces averaged across 11 repetitions obtained every 10 sec. B: same as A with recordings averaged across 11 repetitions from a <i>Kiss1</i> neuron that did not respond to pressure pulses of 200 nM insulin. Time course of pressure pulses is shown below Vm traces in A—B. C: recordings from same neuron in A in which APs were elicited by 0.2 ms depolarizing current pulses during (solid line) and without (dashed line) 4 x 20 ms pressure application of 200 nM insulin in ACSF. D: APs from C displayed on magnified time scale and aligned at peak to identify whether any changes occurred in AP time course. E: Locations of recordings from EGFP positive <i>Kiss1</i> neurons. Red Xs represent insulin-responsive neurons, and the blue Xs represent insulin nonresponsive neurons. Modified from <i>Mouse Brain in Stereotaxic Coordinates</i>, <i>3</i>^<i>rd</i><i>Edition</i> by Franklin and Paxinos (used with permission).</p

Overnight fast serum insulin and leptin.

<p>Overnight fast serum insulin and leptin.</p

Metabolic phenotype in IR/LepR^Kiss mice.

<p>(A) Weekly body weight of female mice (Control n = 15 and IR/LepR^Kiss n = 8) mice (B) Weekly body weight of male mice (n = 16 each group). (C) Female average daily food intake calculated from weekly measurement. (D) Male average daily food intake calculated from weekly measurement. (E) Female body composition at the age of 4 months in control (n = 13) and IR/LepR^Kiss (n = 7) mice. (F) Male body composition at the age of 4 months in control (n = 15) and IR/LepR^Kiss (n = 12) mice.</p