Effect of Adiponectin and TNFa on Uterine Contractility in GDM and Obese Pregnant Patients
Conditions: Myometrium; Contractility, GDM, Obesity
Sponsor: University of Minnesota

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
Page 1 of 20
Revised: 1/19/2018
Protocol Title 
Effect of Adiponectin and TNFa on uterine 
contractility in GDM and obese pregnant patients 
Principal 
Investigator/Faculty 
Advisor 
Name: Katherine Jacobs 
Department: Assistant Professor, Maternal-Fetal 
Medicine  
Telephone Number: 612-301-3410 
Institutional Email Address: gran0254@umn.edu 
Co-Investigator 
Name: Hiba Mustafa 
Department: Fellow, Maternal-Fetal Medicine 
Telephone Number: (832)475-4061 
Institutional Email Address: musta062@umn.edu 
Co-Investigator 
Name: Lisa Gill 
Department: Fellow, Maternal-Fetal Medicine 
Telephone Number: 612-301-3408 
Institutional Email Address: lgill@umn.edu 
Co-Investigator 
Name: Paul Iaizzo 
Department:  Professor, Surgery; Integrative 
Biology and Physiology 
Institutional Email Address:iaizz001@umn.edu 
Scientific 
Assessment 
HRPP facilitated scientific assessment 
IND/IDE # (if 
applicable) 
N/A. 
IND/IDE Holder 
N/A. 
Investigational 
Drug Services # (if 
applicable) 
N/A. 
Version 
Number/Date: 
1/02-14-2018 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 2 of 20 
Revised: 1/19/2018 
 
REVISION HISTORY 
 
Revision 
# 
Version 
Date 
Summary of Changes 
Consent 
Change? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 3 of 20 
Revised: 1/19/2018 
 
 
 
 
 
 
 
 
 
 
Table of Contents 
 
1.0 
Objectives .............................................................................................. 5 
2.0 
Background............................................................................................ 5 
3.0 
Study Endpoints/Events/Outcomes ....................................................... 7 
4.0 
Study Intervention(s)/Investigational Agent(s) ..................................... 7 
5.0 
Procedures Involved .............................................................................. 7 
6.0 
Data and Specimen Banking ............................................................... 11 
7.0 
Sharing of Results with Participants: results will not be shared with 
participants. ................................................................................................... 12 
8.0 
Vulnerable Populations ....................................................................... 12 
9.0 
Local Number of Participants: ............................................................ 13 
10.0 Withdrawal of Participants .................................................................. 13 
11.0 Risks to Participants ............................................................................ 13 
12.0 Potential Benefits to Participants ........................................................ 13 
13.0 Statistical Considerations .................................................................... 13 
14.0 Confidentiality: .................................................................................... 14 
15.0 Provisions to Protect the Privacy Interests of Participants ................. 14 
16.0 Compensation for Research-Related Injury ........................................ 14 
17.0 Consent Process ................................................................................... 14 
18.0 Setting .................................................................................................. 15 
19.0 Multi-Site Research: N/A .................................................................... 16 
20.0 References ........................................................................................... 16 
 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 4 of 20 
Revised: 1/19/2018 
ABBREVIATIONS/DEFINITIONS 
 
GDM Gestational Diabetes Mellitus  
DM Diabetes Mellitus  
OGTT Oral glucose tolerance test 
CS Cesarean section 
OR Odds Ratio 
P4 Progesterone   
HPC 17a-Hydroxyprogesterone  
 
 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 5 of 20 
Revised: 1/19/2018 
1.0 
Objectives 
Primary objective: Determine the effect of  adipokines adiponectin and 
TNFa on the force of myometrial contractility in diabetic, non-obese 
pregnant women and obese, non-diabetic term pregnant womenat the time of 
scheduled cesarean delivery 
Secondary objectives: 
1. Compare the force of myometrial contractility in study groups compared 
to control group (non-DM, non-obese term pregnant patients) 
2. Investigate the anti-inflammatory properties of Progesterone (P4) and 
17a-Hydroxyprogesterone (HPC) on Adiponectin induced myometrial 
contractility in control group. 
 
2.0 
Background 
 
Gestational diabetes mellitus (GDM) and obesity are two of the most 
important global health issues that are associated with significant fetal and 
maternal morbidity and mortality [1-4].  
There is a consensus among researchers that the Caesarean section (CS) rate 
is higher in women with diabetes and obese women [5-7], with with reported 
rates of up to 67.4% in these populations [8]. 
Some authors suggest that the increased CS rate is due to the confounding 
factor of obesity [9,10]; however, other analyses have found diabetes 
mellitus to be an independent risk for CS [11-13]. 
The literature reports that at least half of indicated cesarean deliveries in a 
diabetic population are due to labor dystocia or failed induction of labor. 
This is true even when controlling for infant size. Post-partum hemorrhage is 
also six times more common in diabetic women, raising suspicion that 
myometrial contractility may be impaired in this population [14,15]. 
Therefore, poor myometrial contractility may be an important factor 
contributing to the increased CS rates. Further evidence to implicate poor 
myometrial contractility is that post-partum hemorrhage is six times more 
common in diabetic women [15]. 
Obesity may alter the pregnant uterine contractility as well, and hence make 
the gestation period shorter or longer [16,17] 
Obesity was found to be an independent risk factor for emergency cesarean 
section (CS) delivery [18-23].  

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 6 of 20 
Revised: 1/19/2018 
When stratified by BMI,the indication for cesarean section was significantly 
more likely to be arrest of labor in the first stage at higher BMI 
categories[24].  
A subsequent analysis of more than 230,000 Swedish births  concluded that 
labor dystocia is a key factor leading to the increased rate of CS among 
obese women, and found no evidence that obstruction was a cause after 
control for birth weight. As progress in labor is critically dependent on 
myometrial contractions, these data suggest that myometrial contractility is 
adverselyinfluenced by obesity. As in diabetic women, obese women 
delivering vaginally have excessive blood loss which is also consistent with 
poor myometrial contractility [25].  This has subsequently been validated 
using in vitro evaluation of myometrium from obese women obtained at the 
time of scheduled cesarean delivery (Zhang et. al). 
  The mechanism of this change in myometrial contractility is not completely 
elucidated, however the increased adiposity in obese women has yielded a 
hypothesis.  Adipokines are defined as cell signaling mediators secreted by 
the adipose tissue [26]. The adipose tissue is a multifunctional organ which 
secretes a large spectrum of adipokines.  These substances may act in a pro- 
or anti-inflammatory manner.  In the inflammatory of states of diabetes and 
obesity, pro-inflammatory adipokines such as leptin, TNF-α, visfatin, and 
resistin are elevated, while the anti-inflammatory adipokine adiponectin is 
decreased in these populations.  This is true both in and outside of 
pregnancy.  The same adipokine profile is found in gestational diabetics [28-
30]. 
  
Smooth muscle in the vasculature is known to contain receptors for 
adipokines, and these substances have been shown to modulate smooth 
muscle contraction in vascular smooth muscle.  Likewise, adipokine 
receptors are found in human myometrium, yielding an interesting potential 
mechanism for differences in myometrial contractility in an obese or 
diabetic population. Myometrial contractility in vitro has been shown to be 
modulated by adipokines.  Pro-inflammatory adipokines, such as leptin and 
visfatin, have been shown to decrease myometrial contractility in 
vitro.Unpublished data from our group shows that adiponectin may act to 
stimulate myometrial contraction in vitro in an otherwise healthy population 
(manuscript submitted for publication currently)  If adiponectin increases 
myometrial contractility in a normal population, we hypothesize that this 
effect may be enhanced in a population known to be deficient in this 
substance. 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 7 of 20 
Revised: 1/19/2018 
 
 
 
3.0 
Study Endpoints/Events/Outcomes 
Eligible individuals will be recruited during their pre-natal clinic visits after 
they had been scheduled for a CS delivery.  They will be presented with the 
consent form, and HIPPA form for their review.  Eligible subjects will be 
recruited by one of the co-investigators.Those who agree to participate will 
be consented for the study upon their presentation for their scheduled CS 
delivery. 
Uterine muscle biopsies will be obtained from the upper aspect of a low 
transverse hysterotomy during the CS procedure after delivery of the fetus 
and placenta and prior to uterine incision closure.  The sample will be placed 
in physiologic buffer by the study staff.  The sample will be given a number 
by Bionet staff for tracking purposes and the sample will be transported to 
the Visible Heart Lab (PI:  Dr. Paul Iaizzo) in the Mayo Building, University 
of Minnesota. 
 
 
4.0 
Study Intervention(s)/Investigational Agent(s) 
No intervention will be used directly on participants, however 
obtained myometrial biopsy will be tested for contractility in the 
presence of human adiponectin or TNF-α.  Chemicals will be 
purchased through the University 
 
5.0 
Procedures Involved 
5.1 Study Design: Prospective observational cohort study 
 
5.2 Study groups: 
Control group: healthy, term, non-obese (BMI < 30) pregnant women 
with a singleton gestation scheduled for CS delivery at 37-41 weeks 
of gestation. 
Study group 1: term pregnant, non-obese (BMI <30), diagnosed with 
gestational diabetes, scheduled for CS delivery between 37-41 weeks 
of gestation. 
Study group 2: term pregnant, obese (BMI >30), non-diabetic and 
scheduled for CS delivery between 37-41 weeks of gestation. 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 8 of 20 
Revised: 1/19/2018 
 
5.3 Study Procedures:  
Inclusion criteria: the inclusion criteria for all groups: 
1) Pregnant patients scheduled for a CS at  37-41 weeks of 
gestation at M Health Birth Place 
2) Participants age ≥18. 
3) Full informed consent able to be provided by the participant. 
 
Exclusion criteria  
1) Patients undergoing general anesthesia for their CS. 
2) Pre-gestational DM, and DM diagnosed <24 weeks gestation. 
3) Patients unable to consent for themselves 
4) Multiple gestation 
Screening and recruitment  
• Subjects undergoing cesarean section will identified through the C-
section schedule in EPIC and the schedule book in Labor and 
delivery. 
• Epic will be reviewed to identify subjects who opted out of research. 
• For subjects who did not opt out of research, obstetric clinic progress 
noted, and vitals including BMI will be reviewed for the subjects 
undergoing C-section to determine eligibility.  
• Eligible participants (please see inclusion and exclusion criteria 
above) will be approached and recruited for the study by the either Dr. 
Mustafa or Dr. Gill during the subject clinic visits in Riverside 
Professional Building clinics. 
• Subjects will not be approached in clinic only after notifying their 
clinic provider who will ask for their permission to meet with the 
study team consenting them. 
•  During that clinic visit subjects will be given a copy of the consent 
form and HIPPA form. 
• The consent will be obtained subsequently upon presentation to labor 
and delivery for cesarean delivery. 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 9 of 20 
Revised: 1/19/2018 
• No local recruitment methods/materials( e.g. advertisement) will be 
used  
• No payment will be given to participants  
 
Methods 
• Upon participants presentation for their scheduled CS delivery at the 
birth center, informed consent will be obtained . 
• At the time of scheduled cesarean delivery, a strip of myometrium 
approximately 5 mm in diameter length will be collected from the 
upper border of the low transverse hysterotomy along its length.  
• The biopsy will be obtained by the surgical team performing the 
procedure. 
• The removal of this length of myometrial tissue will not significantly 
change the surgical procedure for the cesarean section. It is 
anticipated that the acquisition of this tissue will add approximately 
0.5-1 minute to the surgical procedure, with a clinically insignificant 
increase in blood loss. Therefore, less than minimal increase in patient 
risk or outcome due to the acquisition of this tissue is anticipated, and 
the technique has been described in numerous publications previously 
for similar testing.  
 
• Myometrial tissue will be immediately immersed in in physiologic 
Krebs buffer provided by the Visible Heart Lab, labelled with a 
unique code assigned for each participant. Bionet registration is 
anticipated in a pass-through fashion.  The sample will then be 
transported to the Visible Heart Lab immediately for testing. 
 
• Myometrial tissue biopsies will then be dissected free of serosa and 
connective tissue under light microscopy into multiple bundles 
approximately 2 cm in length and 2 mm in diameter. The longitudinal 
strips will be suspended in oxygenated physiologic Krebs solution 
isometrically at 37 degrees Celsius. Dilute oxytocin will be added to 
the tissue baths to induce contractions.  The muscle bundles will be 
allowed to equilibrate for approximately 1 hour. Recordings of the 
force of contraction will be obtained over a one hour period, as 
previously described in similar studies [34, 35].  Data will be 
continuously recorded with a custom-built LabView interface. 
 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 10 of 20 
Revised: 1/19/2018 
• For gestational diabetic and obese groups, after one hour of baseline 
data is recorded, bundles will be assigned to adiponectin infusion, 
TNF-alpha infusion or saline infusion.  Force of contraction will again 
be continuously recorded for one hour. 
 
 
• Myometrial biopsies from the control group will be treated in 
duplicate with Progesterone(P4) or 17a-hydroxyprogesterone (HPC). 
Those samples will be subsequently exposed to Adiponectin.  UtSMC 
with +/- Adiponectin will serve as positive and negative controls. IL-6 
will be measured in the culture media by ELISA to assess the 
inflammatory response.  
 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 11 of 20 
Revised: 1/19/2018 
• Following completion of data recordings, samples will be disposed by 
using standard biohazard disposal technique. Data regarding baseline 
characteristics of women enrolled in the trial will be collected by chart 
review by the principle investigator. These data will be maintained on 
a password protected departmental server utilizing REDCap. Data 
collected will include: name, medical record number, age, BMI at 
start of pregnancy, BMI at delivery, A1c level in pregnancy for GDM 
patients, weight gain (kg) in pregnancy, ethnicity, gravidity, parity, 
gestational age at delivery, and infant birth weight. Upon time for data 
analysis, each participant will be assigned a unique code so data will 
be de-identified. 
 
5.4 Study Duration: Enrollment and statistical analysis is expected to 
finish by 07/2019 
5.5 Individually Identifiable Health Information:  
Name and MR numbers will be collected initially in REDCap; 
study data later will be coded (unique code will be assigned for 
every participant) for the statistical analysis. 
5.6 Use of radiation: N/A  
5.7 Use of Center for Magnetic Resonance Research: N/A 
 
6.0 
Data and Specimen Banking 
6.1 Storage and Access: Data will be stored in REDCap and will be 
banked for future use. Myometrial specimens will be disposed by 
using standard biohazard disposal technique. All study team 
members will have access to the data. Bionet will be utilized on a 
“Pass-through” basis. 
6.2 Data: The data that will be banked for future use include the de-
identified data: BMI at start of pregnancy, BMI at delivery, A1c 
level for GDM patients, weight gain (kg) in pregnancy, ethnicity, 
gravidity, parity, gestational age at delivery, and infant birth 
weight. 
6.3 Release/Sharing: Stored data will be de-identified for analysis 
using the unique code assigned for every participant.  

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 12 of 20 
Revised: 1/19/2018 
 
7.0 
Sharing of Results with Participants: results will not be shared with 
participants.  
 
 
8.0 
Vulnerable Populations 
8.1 Vulnerable Populations:  
☐ Fetuses/Neonates/Children 
☒ Pregnant women 
☐ Prisoners 
☐ Adults lacking capacity to consent and/or adults with 
diminished capacity to consent, including, but not limited to, 
those with acute medical conditions, psychiatric disorders, 
neurologic disorders, developmental disorders, and behavioral 
disorders 
☐ Approached for participation in research during a stressful 
situation such as emergency room setting, childbirth (labor), 
etc. 
☐ Disadvantaged in the distribution of social goods and services 
such as income, housing, or healthcare 
☐ Serious health condition for which there are no satisfactory 
standard treatments 
☐ Fear of negative consequences for not participating in the 
research (e.g. institutionalization, deportation, disclosure of 
stigmatizing behavior) 
☐ Any other circumstance/dynamic that could increase 
vulnerability to coercion or exploitation that might influence 
consent to research or decision to continue in research 
☐ Undervalued or disenfranchised social group 
☐ Members of the military 
☐ Non-English speakers 
☐ Those unable to read (illiterate) 
☐ Employees of the researcher 
☐ Students of the researcher 
☐ None of the above 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 13 of 20 
Revised: 1/19/2018 
 
 
9.0 
Local Number of Participants: 
20 controls, 20 gestational diabetics, and 20 obese women will be recruited. 
 
10.0 Withdrawal of Participants 
Participants will be withdrawn from the study if any clinically significant 
event or condition is uncovered during the surgery (e.g., excessive bleeding, 
acute sepsis) that might render the subject medically unstable or complicate 
the subject’s postsurgical course. Data will not be collected or used if 
participants were withdrawn from the study. Likewise, participants are free 
to withdraw their consent from the study at any time. 
 
 
11.0 Risks to Participants 
 
Myometrial biopsies will be obtained after delivery of the fetus. So no risks 
are anticipated to the fetus. 
The removal of this length of myometrial tissue will not significantly change 
the surgical procedure for the cesarean section. It is anticipated that the 
acquisition of this tissue will add approximately 0.5-1 minute to the surgical 
procedure, with a clinically insignificant increase in blood loss. Therefore, a 
minimal increase in patient risk or outcome due to the acquisition of this 
tissue is anticipated, and the technique has been described in numerous 
publications previously for similar testing [36-38] 
 
12.0 Potential Benefits to Participants 
There is no direct benefit to individual participants.  
 
13.0 Statistical Considerations 
Anticipated numbers for each group were estimated from those 
compared in prior studies. No a priori data for this particular subset of 
patients are available, and as such a power calculation was not 
feasible. Sample size was determined using sample sizes from 
previous similar studies, and in accordance to resources available as 
well as number of patients available for recruitment. Using custom-
built MatLab software mean and median values for maximum 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 14 of 20 
Revised: 1/19/2018 
contractile force will be evaluated, as well as area under the curve. 
These values will be compared using univariate analysis of either a 
Mann Whitney U test for medians or t-test for means. A p value <0.05 
will be considered significant. 
 
14.0 Confidentiality: 
All data will be stored in a secure data shelter available through REDCap. 
The data will be accessible only to study staff that has completed HIPAA 
compliance training through the University of Minnesota.  REDCap 
database is password protected.  All paper forms will be destroyed after 
finishing the study.   
 
15.0 Provisions to Protect the Privacy Interests of Participants 
• The consent process will be done in a secluded private setting. 
• HIPAA authorization will be obtained from each participant to 
accesspersonal health information (PHI) to obtain only the required 
related information to the study. 
• Refusing to participate in the study will not affect their care in any 
way. 
• A unique code will be assigned to every participant to de-identify 
PHI. 
• If interpreter is needed during the process, subject’s permission will 
be obtained first to discuss study details using the interpreter.  
• Data will be accessed and stored using a password protected REDCap 
database. 
 
16.0 Compensation for Research-Related Injury 
No research related injury is anticipated in this research study, but in the 
event that this research activity results in an injury, treatment will be 
available , including first aid, emergency treatment and follow up care as 
needed. Care for such injuries will be billed in the ordinary manner. No 
personal compensation will be provided. 
 
17.0 Consent Process 
 
17.1 Consent process:  

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 15 of 20 
Revised: 1/19/2018 
• Eligible participants (please see inclusion and exclusion criteria 
above) will be approached and recruited for the study by the PI 
during their clinic visits after they had being scheduled for their 
CS delivery by their provider, and they will be given a copy of 
the consent form and HIPPA form during that clinic visit.  
• The consent will be obtained subsequently upon presentation to 
labor and delivery in Riverside Hospital for their scheduled 
cesarean delivery. 
17.2 Waiver or alteration of consent process: N/A 
17.3 Non-English Speaking Participants:  
• After obtaining subject’s permission to discuss study details 
using an interpreter. Oral instructions will be explained via the 
interpreter; written instructions will be given in her language. 
• Written instructions will be translated to the desired language 
using certified interpreter. 
• The language of the investigator obtaining consent is English. 
• Patients will be screened for eligibility through reviewing their 
medical chart by the PI who has legitimate access to these 
patient’s records as she routinely take part in cesarean 
deliveries in the birth place. 
17.4 Participants Who Are Not Yet Adults (infants, children, 
teenagers under 18 years of age): Will be excluded from the study 
17.5 Cognitively Impaired Adults, or adults with fluctuating or 
diminished capacity to consent: Will be excluded from the study 
17.6 Adults Unable to Consent: Will be excluded from the study 
 
18.0 Setting 
18.1 Research Sites:  
• 
Research team will identify and recruit potential participants 
during their clinic visits at Fairview Riverside Women’s 
Clinic, Women’s Health Specialists Clinic, and Maternal 
Fetal Medical Center in the Riverside Professional Building. 
• 
Biopsies will be obtained at the M Health Birth Place and 
muscle contraction studies will take place in the Visible 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
Page 16 of 20 
Revised: 1/19/2018 
Heart Lab in the Mayo Building on the East Bank of the 
University of Minnesota. 
18.2 International Research: N/A 
 
19.0 Multi-Site Research: N/A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
20.0 References 
 
1. Soheilykhah, S., Mojibian, M., Rahimi-Saghand, S., Rashidi, M. and 
Hadinedoushan, H. (2011) Maternal serum leptin concentration in 
gestational diabetes. Taiwan J Obstet Gynecol 50: 149–153 
 
2. Buchanan, T. and Xiang, A. (2005) Gestational diabetes mellitus. J Clin 
Invest 115: 485–491. 
3. Hehir MP, Morrison JJ. The adipokine apelin and human uterine 
contractility. Am J Obstet Gynecol. 2012;206:359.e1-5. 
doi:10.1016/j.ajog.2012.01.032. Medline:22360921 
 

PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
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7.Dunne F, Brydon P, Smith K, Gee H (2003) Pregnancy in women with 
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8.Department of Health (2010) NHS Maternity Statistics, England. 2002–
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9.Evers IM, de Valk HW, Visser GH (2004) Risk of complications of 
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PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
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14. Evers IM, de Valk HW, Visser GH (2004) Risk of complications of 
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PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
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BJOG 114 (3) (2007) 343–348. 
 
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PROTOCOL TITLE: Effect of Adiponectin and TNFa on uterine contractility in GDM 
and obese pregnant patients 
PROTOCOL DATE: 02/26/2018 
 
 
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Revised: 1/19/2018 
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