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Biomedical subjects

Mathew Sermer

Publications and source records attributed to Mathew Sermer.

16 recordsLinked to original sources
PubMed2006

Aortic dissection complicating pregnancy following prophylactic aortic root replacement in a woman with Marfan syndrome.

Prophylactic aortic root replacement is the main factor explaining the increase in median probability of survival in Marfan syndrome (MFS) patients. In women with MFS, earlier root replacement has been suggested as a strategy to facilitate safe pregnancy. However, in this case report a pregnant patient with MFS who sustained a Type B aortic dissection in her second trimester, with fatal outcome, despite having had a prophylactic aortic root replacement five months prior to conception is described.

Adult↗
PubMed2006

Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes.

In women with heart disease, sustained arrhythmias can result in an increased risk to the mother and fetus. The purpose of this study was to determine the recurrence rates of arrhythmias during pregnancy in women with cardiac rhythm disorders and examine the impact on fetal and neonatal outcomes. Women with tachyarrhythmias before pregnancy who underwent obstetric care at the Toronto General and Mount Sinai Hospitals from 1990 to 2002 were included. The recurrence rates of arrhythmias were calculated. A multivariate logistic model was used to identify predictors of fetal complications. Seventy-three women had 87 pregnancies; 36 pregnancies were in women with a history of paroxysmal supraventricular tachycardia, 23 with paroxysmal atrial fibrillation or atrial flutter (AF/Afl), 6 with persistent AF/Afl, and 22 with ventricular tachycardia. In the women in sinus rhythm at baseline, 44% (36 of 81 pregnancies) developed recurrences of tachyarrhythmias during pregnancy or in the early postpartum period. The specific recurrence rates during pregnancy in women with a history of supraventricular tachycardia, paroxysmal AF/Afl, and ventricular tachycardia were 50%, 52%, and 27%, respectively. The 6 women in AF/Afl at baseline remained in this rhythm throughout their pregnancy. Adverse fetal events occurred in 17 of the 87 pregnancies (20%). Adverse fetal events occurred more commonly in women who developed antepartum arrhythmias (RR 3.4, 95% confidence interval 1.0 to 11.0, p = 0.045) compared with those who did not. In conclusion, in women with preexisting cardiac rhythm disorders, exacerbation of arrhythmia during pregnancy is common. Recurrence of arrhythmia during the antepartum period increases the risk of adverse fetal complications, independent of other maternal and fetal risk factors.

Adult↗
PubMed2006

Impaired glucose tolerance of pregnancy is a heterogeneous metabolic disorder as defined by the glycemic response to the oral glucose tolerance test.

OBJECTIVE: Gestational diabetes mellitus (GDM), defined by two abnormal glucose values on a 3-h oral glucose tolerance test (OGTT), is associated with insulin resistance and a low serum concentration of adiponectin. The metabolic implications of impaired glucose tolerance (IGT) of pregnancy (i.e., a single abnormal value on an OGTT), however, are not well established. We sought to evaluate the metabolic phenotype of pregnant women with IGT in relation to the timing of their isolated hyperglycemia. RESEARCH DESIGN AND METHODS: A cross-sectional study was performed in pregnant women undergoing a 3-h, 100-g OGTT. The OGTT stratified participants into four groups: 1) GDM (n = 48), 2) 1-h IGT (single elevated value at 1 h) (n = 15), 3) 2-h/3-h IGT (single elevated value at either 2 or 3 h) (n = 23), and 4) normal glucose tolerance (NGT) (n = 93). Insulin sensitivity was measured by the validated insulin sensitivity index (IS(OGTT)) of Matsuda and DeFronzo. RESULTS: Measures of severity of glycemia (fasting glucose, area under the glucose curve from the OGTT, and glucose challenge test result) were highest in the GDM group, followed by the 1-h IGT, 2-h/3-h IGT, and NGT groups, respectively (each trend P < 0.0001). Consistent with this finding, IS(OGTT) was highest in the NGT group (5.1), followed by the 2-h/3-h IGT (4.6), 1-h IGT (3.8), and GDM (3.2) groups (trend P < 0.0001). Furthermore, on multiple linear regression analysis of IS(OGTT), both GDM and 1-h IGT were independently associated with reduced insulin sensitivity (whereas 2-h/3-h IGT was not). Mean adjusted adiponectin was highest in the NGT group (15.7 microg/ml), followed by the 2-h/3-h IGT (15.6 microg/ml), 1-h IGT (13.7 microg/ml), and GDM (12.0 microg/ml) groups (trend P = 0.0024). CONCLUSIONS: The metabolic implications of IGT in pregnancy vary in relation to the timing of the abnormal glucose value from the diagnostic OGTT. The metabolic phenotype associated with 1-h IGT resembles that of GDM, whereas the phenotype associated with 2-h/3-h IGT exhibits similarity to that of NGT.

Administration, Oral↗
PubMed2005

Ethnicity modifies the effect of obesity on insulin resistance in pregnancy: a comparison of Asian, South Asian, and Caucasian women.

CONTEXT: Women of Asian and South Asian descent are at increased risk of developing gestational diabetes mellitus compared with Caucasians, despite lower body mass index (BMI). Nevertheless, there has been limited study of insulin action during pregnancy in these ethnic groups. OBJECTIVE: The objective of the study was to compare insulin sensitivity in pregnancy in Asian, South Asian, and Caucasian subjects and to determine whether the impact of obesity on insulin action is modified by ethnicity. DESIGN AND PARTICIPANTS: A cross-sectional study was performed in outpatients undergoing oral glucose tolerance testing in late pregnancy. Participants were stratified into three groups: 1) Caucasian (n = 116); 2) South Asian (n = 31); and 3) Asian (n = 28). MAIN OUTCOME MEASURE: Insulin sensitivity was measured using the oral glucose tolerance test (IS(OGTT)) index of M. Matsuda and R. DeFronzo, previously validated in pregnancy. RESULTS: There were no significant ethnic differences in insulin sensitivity despite variation in prepregnancy BMI (Caucasians, 25.2 kg/m(2); South Asians, 23.3 kg/m(2); Asians, 21.4 kg/m(2); overall P = 0.0001). On multiple linear regression analysis, the strongest independent determinants of IS(OGTT) were gestational diabetes mellitus (t = -5.71; P < 0.0001) and BMI (t = -5.43; P < 0.0001). Importantly, both Asian (t = -2.87; P = 0.0047) and South Asian (t = -2.46; P = 0.015) ethnicity also emerged as negative, independent determinants of IS(OGTT). Furthermore, Asian ethnicity significantly modified the association of prepregnancy BMI with IS(OGTT) (interaction term, t = -2.29; P = 0.0231). CONCLUSIONS: Asian and South Asian ethnicity are both independently associated with increased insulin resistance in late pregnancy. Prepregnancy BMI has a much greater effect on insulin resistance in pregnancy in Asian women than in Caucasians. Ethnicity thus emerges as a factor that modulates the effect of obesity on insulin resistance in pregnancy.

Adult↗
PubMed2005

Obstetric outcome of extreme macrosomia.

OBJECTIVE: To determine the effect of extreme macrosomia on perinatal outcome. METHODS: We conducted a retrospective review of all deliveries with birth weight > or = 5000 g in a tertiary centre from 1986 to 2000 and analyzed the method of delivery and perinatal outcome. RESULTS: Extreme macrosomia (birth weight > or = 5000 g) was coded in 111 deliveries. There were 62 deliveries by Caesarean section (CS) (25 in labour and 37 elective). The 49 vaginal deliveries were complicated by 10 (20%) cases of shoulder dystocia and 3 (6%) of Erb's palsy. Permanent Erb's palsy was noted in only 1 of these 3 cases. Shoulder dystocia was associated with use of oxytocin and instrumental deliveries. CONCLUSION: Implementing the 2002 guidelines from the American College of Obstetricians and Gynecologists (that is, recommending Caesarean delivery of fetuses with an estimated weight of at least 5000 g) would have a negligible effect on the CS rate while eliminating 10 cases of shoulder dystocia in 49 births. A policy eliminating the use of oxytocin and instrumental deliveries would have prevented most birth traumas in this group. Unfortunately, this high-risk group is difficult to identify in the antepartum period, complicating the implementation of these guidelines and probably leading to higher rates of CS. In addition, the effect of endorsing such a policy on overall neonatal and maternal morbidity is minimal, because most morbidity occurs in newborns weighing less than 4000 g.

Birth Injuries↗
PubMed2005

Goodpasture syndrome in a pregnant woman.

BACKGROUND: Goodpasture syndrome, an immunologic disorder characterized by glomerulonephritis and pulmonary hemorrhage, rarely presents in pregnancy. CASE: We describe a patient who was diagnosed with Goodpasture syndrome in her second trimester. She required daily hemodialysis, intermittent plasmapheresis, and immunosuppressive therapy. Her pregnancy was complicated by hypertension, and she delivered a low birth weight neonate prematurely at 26 4/7 weeks of gestation by cesarean due to nonreassuring fetal status. Deterioration in the fetal status may have been secondary to complications of hypertension, in addition to prematurity. CONCLUSION: Goodpasture syndrome in pregnancy may be associated with significant maternal and fetal morbidity.

Adult↗
PubMed2005

A randomised controlled trial of biopsy forceps and cannula aspiration for transcervical chorionic villus sampling.

OBJECTIVE: This trial compared two instruments for transcervical chorionic villus sampling (CVS). DESIGN: Randomised controlled trial. SETTING: Regional university prenatal diagnosis and treatment centre. POPULATION: Two hundred women were randomised at 10(+0)-12(+6) weeks of gestation to transcervical CVS using cannula aspiration (CA) or biopsy forceps (BF). METHODS: Women undergoing indicated CVS signed informed consent. Randomisation after decision to perform transcervical CVS. MAIN OUTCOME MEASURES PRIMARY OUTCOME: the rise in maternal serum alpha-fetoprotein (alpha-FP). SECONDARY OUTCOMES: (i) placental trauma (fetomaternal haemorrhage [FMH]); (ii) laboratory, procedure, and cytogenetic results and pregnancy outcomes; (iii) patient and operator satisfaction; and (iv) economic analyses. Analyses were performed by intention to treat. RESULTS: The -FP rise did not differ between groups; there was no other evidence of placental trauma. BF were better tolerated by women, provided culturable tissue, after fewer instrument passes, with greater ease and in less time. BF were associated with cost savings. CONCLUSIONS: Unlike -FP, other markers of FMH were unaltered, questioning the reliability of alpha-FP as an indicator of FMH. Compared with CA, transcervical BF caused comparable placental trauma, appeared to be similarly effective and safe and were preferred by operators and patients.

Biopsy, Needle↗
PubMed2005

The impact of insulin resistance on proinsulin secretion in pregnancy: hyperproinsulinemia is not a feature of gestational diabetes.

OBJECTIVE: Excessive secretion of the insulin precursor proinsulin, as manifested by an increased serum proinsulin-to-insulin ratio, has been associated with beta-cell dysfunction. In women with gestational diabetes mellitus (GDM), previous studies of the proinsulin-to-insulin ratio have yielded conflicting results, despite the presence of beta-cell dysfunction. The interpretation of the proinsulin-to-insulin ratio, however, may be confounded by the variable effects of hepatic insulin extraction. Thus, we sought to determine whether GDM is characterized by relative hyperproinsulinemia as measured by the proinsulin-to-C-peptide ratio, an alternate measure of proinsulin secretion that is not affected by hepatic insulin extraction. RESEARCH DESIGN AND METHODS: Serum proinsulin, C-peptide, and insulin were measured in a cross-sectional study of 180 women undergoing oral glucose tolerance tests (OGTTs) in the late second or early third trimester. Based on the OGTT, participants were stratified into three groups: 1) normal glucose tolerance (NGT; n = 93), 2) impaired glucose tolerance (IGT; n = 39), and 3) GDM (n = 48). Insulin sensitivity (IS) was measured using the IS(OGTT) index of Matsuda and DeFronzo, which has been previously validated in pregnant women. RESULTS: There were no significant differences in mean fasting proinsulin-to-C-peptide ratio between the three glucose tolerance groups (NGT, 0.024; IGT, 0.022; GDM, 0.019; P = 0.4). Furthermore, adjustment for age, weeks' gestation, prepregnancy BMI, ethnicity, previous GDM, and family history of diabetes did not reveal any association between the proinsulin-to-C-peptide ratio and glucose tolerance status. Using Spearman univariate correlation analysis, fasting proinsulin-to-C-peptide ratio was significantly correlated with IS(OGTT) (r = 0.29, P < 0.0001) and inversely related to the homeostasis model assessment of insulin resistance (r = -0.36, P < 0.0001) and prepregnancy BMI (r = -0.23, P < 0.005). On multiple linear regression analysis, IS(OGTT) emerged as the strongest independent correlate of the dependent variable proinsulin-to-C-peptide ratio. Furthermore, after adjustment for potential covariates, a stepwise decrease in proinsulin-to-C-peptide ratio was observed per decreasing tertile of IS(OGTT) (trend P = 0.0019), consistent with enhanced efficiency of proinsulin processing (i.e., reduced proinsulin-to-C-peptide ratio) as insulin resistance increases. CONCLUSIONS: GDM is not independently associated with hyperproinsulinemia as measured by the proinsulin-to-C-peptide ratio. Instead, in pregnant women, increased insulin resistance is associated with decreased proinsulin-to-C-peptide ratio, independently of glucose tolerance status. These data suggest that relative proinsulin secretion in late pregnancy is primarily related to insulin resistance and does not necessarily reflect beta-cell function.

Adult↗
PubMed2004

Spontaneous dissection of the left main coronary artery.

Spontaneous coronary artery dissection remains a rare but important cause of acute coronary syndromes. Presentation depends on the extent of the dissection, the vessels involved and the rate of its development, and can encompass the entire spectrum of coronary syndromes, with some patients being asymptomatic and others presenting with angina, non-ST segment elevation myocardial infarction, ST-elevation myocardial infarction and sudden cardiac death. The authors describe a 33-year-old pregnant woman who presented with a non-ST segment elevation myocardial infarction secondary to a spontaneous dissection of the left main coronary artery.

Adult↗
PubMed2003

C-reactive protein and gestational diabetes: the central role of maternal obesity.

Acute-phase biomarkers such as C-reactive protein (CRP) and IL-6 have emerged as predictors of incident type 2 diabetes mellitus, implicating chronic subclinical inflammation as a factor in the pathophysiology of diabetes. Gestational diabetes (GDM) identifies a population of women at high risk of subsequent type 2 diabetes mellitus, representing an early stage in the natural history of the disease. In this context, we performed a cross-sectional study to determine whether markers of subclinical inflammation are elevated in patients with GDM. We studied 180 healthy pregnant women undergoing oral glucose tolerance testing in the late second or early third trimester. Based on oral glucose tolerance testing and prepregnancy body mass index (BMI), participants were stratified into four groups: 1) normal glucose tolerance (NGT) lean (BMI, <25 kg/m(2)) (n = 65); 2) NGT overweight (n = 28); 3) impaired glucose tolerance (n = 39); and 4) GDM (n = 48). Median CRP level was highest in overweight NGT subjects (8.8 mg/liter), followed by GDM (5.5 mg/liter), impaired glucose tolerance (4.4 mg/liter), and lean NGT (4.4 mg/liter) (overall P = 0.0297). CRP was significantly correlated with prepregnancy BMI (r = 0.38, P < 0.0001), followed by fasting insulin (r = 0.27, P = 0.0002) and fasting blood glucose (r = 0.18, P = 0.016). In multivariate linear regression analysis, prepregnancy BMI emerged as the most important determinant of CRP concentration, whereas glycemic tolerance status was not a significant factor. Furthermore, the observed stepwise increase in CRP per tertile of prepregnancy BMI was not significantly attenuated by glycemic tolerance status or factors known to be associated with GDM. In summary, we demonstrate that maternal serum levels of CRP are not related to GDM but rather correlate significantly with prepregnancy obesity. An independent contribution of CRP to risk of GDM could not be confirmed. These data suggest a model in which obesity mediates a systemic inflammatory response, with possible downstream metabolic sequelae, including insulin resistance and glucose dysregulation.

Adult↗
PubMed2002

Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease.

BACKGROUND: Pregnant women with heart disease (HD) are at increased risk for cardiac (CV) complications. However, the frequency of neonatal (NE) complications in pregnant women with HD relative to pregnant women without HD has not been examined. METHODS AND RESULTS: Pregnant women with HD were prospectively monitored during 302 pregnancies. The frequency of NE and CV complications was compared with those in a control group without HD during 572 pregnancies. The frequency of NE complications was higher in the HD group (18% versus 7%; HD versus controls). The NE complication rate was lowest in pregnancies of women age 20 to 35 years who did not smoke during pregnancy, did not receive anticoagulants, and had no obstetric risk factors: 4% in control patients, 5% in HD patients with no cardiac risk factors for NE complications (left heart obstruction, poor functional class, or cyanosis), and 7% in HD patients with > or =1 such risk factor. In contrast, the event rate in pregnancies of controls age <20 or >35 years who had obstetric risk factors or multiple gestation or who smoked was 11%. In the HD group, women age <20 or >35 years who had obstetric risk factors or multiple gestation, who smoked, or who received anticoagulants experienced an even higher NE complication rate (27% with no cardiac risks for NE events and 33% in the presence of >or =1 cardiac risk factors). The frequency of CV complications was higher in the HD group (17% versus 0%; HD versus controls). CONCLUSION: Pregnant women with HD are at increased risk for both NE and CV complications. The risk for NE adverse events in pregnant women with HD is highest in those with both obstetric and cardiac risk factors for NE complications.

Abortion, Spontaneous↗