Intergenerational Associations of Chronic Disease and Polycystic Ovary Syndrome

Extent: 4p.Background: Polycystic ovary syndrome (PCOS) is a common female endocrine disorder of heterogeneous clinical presentation, high disease burden, and unknown aetiology. The disease and associated conditions cluster in families, suggesting that PCOS may be the reproductive consequence of underlying chronic disease susceptibility. Objective: To determine whether parents of young women with PCOS were more likely to have a history of diabetes or cardiovascular disease in later adult life. Design, Setting and Participants: Structured interviews with 715 members of a cohort constructed by tracing female infants born at a single general hospital in Adelaide between 1973 and 1975. Participants were asked whether they had a pre-existing medical diagnosis of PCOS, and whether each parent had ever had high blood pressure, high cholesterol, diabetes, stroke, or heart disease. Maternal high blood pressure during pregnancy was taken from the medical record of the pregnancy with the study participant. Results and Conclusions: Mothers of women with PCOS were more likely than mothers of other women to have any cardiovascular disease (RR 1.78, 95% CI 1.29, 2.47), and nearly twice as likely to have high blood pressure (RR 1.95, 95% CI 1.38, 2.76). Fathers of women with PCOS were more than twice as likely to have heart disease (RR 2.36, 95% CI 1.44, 3.88) and over four times as likely to have had a stroke (RR 4.37, 95% CI 1.97, 9.70). Occurrence of cardiovascular disease in both mother and father are associated with the risk of PCOS in daughters. Further detailed study is required to elucidate the precise pathways that may be causally related to the observations.Michael J. Davies, Jennifer L. Marino, Kristyn J. Willson, Wendy A. March and Vivienne M. Moor

Changes in nutrient intake during the menstrual cycle of overweight women with premenstrual syndrome

This study presents the nutrient data collected from women who were being screened for premenstrual syndrome (PMS) for entry into an intervention study. Screening was by the Steiner self-rated questionnaire. One hundred and forty-four overweight women completed the screening process and eighty-eight met the criteria for PMS. All women kept 4 d diet diaries pre- and postmenstrually over two menstrual cycles. The mean energy and macronutrient intakes were compared between the pre- and postmenstrual phases. Energy and macronutrient intake was also calculated according to food categories. Goldberg's cut-off limit for the ratio of energy intake to estimated basal metabolic rate was used to exclude data that was incompatible with predicted energy requirements. The diet diaries were also used to determine the mean number of meals or snacks eaten pre- and postmenstrually. Nutrient analysis of the diet diaries of the women with PMS showed a significant increase (P<0.001) in total energy and all macronutrients premenstrually when compared to nutrient intake postmenstrually. Women who did not meet the criteria for PMS showed a significant increase in energy and fat intake (P<0.05) but not in the other macronutrients. When adjusted for energy, data collected from women with PMS showed a premenstrual significant increase in fat, carbohydrate (P<0.05) and simple sugars (P<0.001). There was a significant decrease (P<0.001) in protein premenstrually. Women not meeting the PMS criteria showed no significant difference between pre- and postmenstrual intakes when adjusted for energy. Analysis according to food categories in women with PMS showed a significantly greater intake premenstrually of energy and all macronutrients for cereals, cakes and desserts and high-sugar foods (P<0.001). In women with PMS there was a significantly greater number of ‘episodes of eating’ premenstrually (P<0.001). This study provides further evidence, to support the very limited number of earlier studies, that there is a group of women with PMS who increase their nutrient intake during the premenstrual phase. This could potentially be a contributing factor for some women experiencing difficulties adhering to suggested dietary modification and should be considered when counselling premenopausal women.Giordana B. Cross, John Marley, Helen Miles and Kristyn Willso

A pragmatic cluster randomised controlled trial to evaluate the safety, clinical effectiveness, cost effectiveness and satisfaction with point of care testing in a general practice setting – rationale, design and baseline characteristics

Background: Point of care testing (PoCT) may be a useful adjunct in the management of chronic conditions in general practice (GP). The provision of pathology test results at the time of the consultation could lead to enhanced clinical management, better health outcomes, greater convenience and satisfaction for patients and general practitioners (GPs), and savings in costs and time. It could also result in inappropriate testing, increased consultations and poor health outcomes resulting from inaccurate results. Currently there are very few randomised controlled trials (RCTs) in GP that have investigated these aspects of PoCT. Design/Methods: The Point of Care Testing in General Practice Trial (PoCT Trial) was an Australian Government funded multi-centre, cluster randomised controlled trial to determine the safety, clinical effectiveness, cost effectiveness and satisfaction of PoCT in a GP setting. The PoCT Trial covered an 18 month period with the intervention consisting of the use of PoCT for seven tests used in the management of patients with diabetes, hyperlipidaemia and patients on anticoagulant therapy. The primary outcome measure was the proportion of patients within target range, a measure of therapeutic control. In addition, the PoCT Trial investigated the safety of PoCT, impact of PoCT on patient compliance to medication, stakeholder satisfaction, cost effectiveness of PoCT versus laboratory testing, and influence of geographic location. Discussion: The paper provides an overview of the Trial Design, the rationale for the research methodology chosen and how the Trial was implemented in a GP environment. The evaluation protocol and data collection processes took into account the large number of patients, the broad range of practice types distributed over a large geographic area, and the inclusion of pathology test results from multiple pathology laboratories. The evaluation protocol developed reflects the complexity of the Trial setting, the Trial Design and the approach taken within the funding provided. The PoCT Trial is regarded as a pragmatic RCT, evaluating the effectiveness of implementing PoCT in GP and every effort was made to ensure that, in these circumstances, internal and external validity was maintained.Caroline Laurence, Angela Gialamas, Lisa Yelland, Tanya Bubner, Philip Ryan, Kristyn Willson, Briony Glastonbury, Janice Gill, Mark Shephard, Justin Beilby for members of the PoCT Trial Management Committe

Borderline gestational diabetes mellitus and pregnancy outcomes

Background: The impact of borderline gestational diabetes mellitus (BGDM), defined as a positive oral glucose challenge test (OGCT) and normal oral glucose tolerance test (OGTT), on maternal and infant health is unclear. We assessed maternal and infant health outcomes in women with BGDM and compared these to women who had a normal OGCT screen for gestational diabetes. Methods: We compared demographic, obstetric and neonatal outcomes between women participating in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS) who had BGDM and who screened negative on OGCT. Results: Women who had BGDM were older (mean difference 1.3 years, [95% confidence interval (CI) 0.3, 2.2], p = 0.01) and more likely to be obese (27.1% vs 14.1%, relative risk (RR) 1.92, [95% CI 1.41, 2.62], p &lt; 0.0001) than women who screened negative on OGCT. The risk of adverse maternal outcome overall was higher (12.9% vs 8.1%, RR 1.59, [95% CI 1.00, 2.52], p = 0.05) in women with BGDM compared with women with a normal OGCT. Women with BGDM were more likely to develop pregnancy induced hypertension (17.9% vs 11.8%, RR 1.51, [95% CI 1.03, 2.20], p = 0.03), have a caesarean for fetal distress (17.1% vs 10.5%, RR 1.63, [95% CI 1.10, 2.41], p = 0.01), and require a longer postnatal hospital stay (mean difference 0.4 day, [95% CI 0.1, 0.7], p = 0.01) than those with a normal glucose tolerance. Infants born to BGDM mothers were more likely to be born preterm (10.7% vs 6.4%, RR 1.68, [95% CI 1.00, 2.80], p = 0.05), have macrosomia (birthweight ≥4.5 kg) (4.3% vs 1.7%, RR 2.53, [95% CI 1.06, 6.03], p = 0.04), be admitted to the neonatal intensive care unit (NICU) (6.5% vs 3.0%, RR 2.18, [95% CI 1.09, 4.36], p = 0.03) or the neonatal nursery (40.3% vs 28.4%, RR 1.42, [95% CI 1.14, 1.76], p = 0.002), and have a longer hospital stay (p = 0.001). More infants in the BGDM group had Sarnat stage 2 or 3 neonatal encephalopathy (12.9% vs 7.8%, RR 1.65, [95% CI 1.04, 2.63], p = 0.03). Conclusion: Women with BGDM and their infants had an increased risk of adverse health outcomes compared with women with a negative OGCT. Intervention strategies to reduce the risks for these women and their infants need evaluation. Trial registration: Current Controlled Trials ISRCTN00416244Hong Ju, Alice R. Rumbold, Kristyn J. Willson and Caroline A. Crowthe

The risk of adverse pregnancy outcomes in women who are overweight or obese

Extent: 8p.Background: The prevalence of obesity amongst women bearing children in Australia is rising and has important implications for obstetric care. The aim of this study was to assess the prevalence and impact of mothers being overweight and obese in early to mid-pregnancy on maternal, peripartum and neonatal outcomes. Methods: A secondary analysis was performed on data collected from nulliparous women with a singleton pregnancy enrolled in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS). Women were categorized into three groups according to their body mass index (BMI): normal (BMI 18.5-24.9 kg/m2); overweight (BMI 25-29.9 kg/m2) and; obese (BMI 30-34.9 kg/m2). Obstetric and perinatal outcomes were compared by univariate and multivariate analyses. Results: Of the 1661 women included, 43% were overweight or obese. Obese women were at increased risk of pre-eclampsia (relative risk (RR) 2.99 [95% confidence intervals (CI) 1.88, 4.73], p < 0.0001) and gestational diabetes (RR 2.10 [95%CI 1.17, 3.79], p = 0.01) compared with women with a normal BMI. Obese and overweight women were more likely to be induced and require a caesarean section compared with women of normal BMI (induction - RR 1.33 [95%CI 1.13, 1.57], p = 0.001 and 1.78 [95%CI 1.51, 2.09], p < 0.0001, caesarean section - RR 1.42 [95%CI 1.18, 1.70], p = 0.0002 and 1.63 [95%CI 1.34, 1.99], p < 0.0001). Babies of women who were obese were more likely to be large for gestational age (LFGA) (RR 2.08 [95%CI 1.47, 2.93], p < 0.0001) and macrosomic (RR 4.54 [95%CI 2.01, 10.24], p = 0.0003) compared with those of women with a normal BMI. Conclusion: The rate of overweight and obesity is increasing amongst the Australian obstetric population. Women who are overweight and obese have an increased risk of adverse pregnancy outcomes. In particular, obese women are at increased risk of gestational diabetes, pregnancy induced hypertension and pre-eclampsia. Effective preventative strategies are urgently needed.Chaturica Athukorala, Alice R Rumbold, Kristyn J Willson and Caroline A Crowthe

Mild gestational diabetes in pregnancy and the adipoinsular axis in babies born to mothers in the ACHOIS randomised controlled trial

BACKGROUND: Mild gestational diabetes is a common complication of pregnancy, affecting up to 9% of pregnant women. Treatment of mild GDM is known to reduce adverse perinatal outcomes such as macrosomia and associated birth injuries, such as shoulder dystocia, bone fractures and nerve palsies. This study aimed to compare the plasma glucose concentrations and serum insulin, leptin and adiponectin in cord blood of babies of women (a) without gestational diabetes mellitus (GDM), (b) with mild GDM under routine care, or (c) mild GDM with treatment. METHODS: 95 women with mild GDM on oral glucose tolerance testing (OGTT) at one tertiary level maternity hospital who had been recruited to the ACHOIS trial at one of the collaborating hospitals and randomised to either Treatment (n = 46) or Routine Care (n = 49) and Control women with a normal OGTT (n = 133) were included in the study. Women with mild GDM (treatment or routine care group) and OGTT normal women received routine pregnancy care. In addition, women with treated mild GDM received dietary advice, blood glucose monitoring and insulin if necessary. The primary outcome measures were cord blood concentrations of glucose, insulin, adiponectin and leptin. RESULTS: Cord plasma glucose was higher in women receiving routine care compared with control, but was normalized by treatment for mild GDM (p = 0.01). Cord serum insulin and insulin to glucose ratio were similar between the three groups. Leptin concentration in cord serum was lower in GDM treated women compared with routine care (p = 0.02) and not different to control (p = 0.11). Adiponectin was lower in both mild GDM groups compared with control (Treatment p = 0.02 and Routine Care p = 0.07), while the adiponectin to leptin ratio was lower for women receiving routine care compared with treatment (p = 0.08) and control (p = 0.05). CONCLUSION: Treatment of women with mild GDM using diet, blood glucose monitoring and insulin if necessary, influences the altered fetal adipoinsular axis characteristic of mild GDM in pregnancy

Calcium supplementation in pregnancy and its impact on blood pressure in children and women: Follow up of a randomised controlled trial

The definitive version is available at www.blackwell-synergy.comBackground: Follow up of participants in trials of antenatal calcium supplementation has reported an impact on blood pressure among mothers and children. Aims: To determine whether blood pressure at 4–7 years follow up would be lower for calcium-supplemented mothers in the Australian Calcium Trial (ACT) and for their children. Methods: This follow up targeted 414 of the original ACT participants with liveborn infants who lived in South Australia. Mothers and their children attended the Women's and Children's Hospital for anthropomorphic examination. Information on lifestyle factors was collected by questionnaire. Descriptive statistics examined differences between respondents and non-respondents and multiple regression models examined associations with blood pressure. Results: Blood pressure and body measurements were available on 45 and 43% of eligible women and children, respectively; questionnaire data were available on 50% of this cohort. At follow up, there were no differences between treatment groups in blood pressure in the women or their children. Both children of women who had high blood in pregnancy (pre-eclampsia or pregnancy-induced hypertension) and the women themselves had higher systolic and diastolic blood pressure at follow up. Among children, there was a trend towards an interaction with the treatment group with both systolic and diastolic blood pressure at follow up. Conclusion: There is no evidence that the impact of calcium supplementation in reducing the risk of high blood pressure in pregnancy is sustained 4–7 years after the index pregnancy either in woman or in their children; however, calcium supplementation may lower blood pressure in children of pregnant women with hypertension.Janet E. Hiller, Caroline A. Crowther, Vivienne A. Moore, Kristyn Willson, Jeffrey S. Robinso