Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36,821 women over a 15-year period

Fetal Growth and Adiposity of Infants Born Large for Gestational Age in Three Harmonized Randomized Trials

OBJECTIVE

 Infants born large for gestational age (LGA) are at an increased risk of short- and longer-term adverse outcomes. Understanding fetal growth and adiposity and their trajectories may help inform interventions to prevent birth of LGA infants. We aimed to compare fetal growth and adiposity measures of infants born LGA with those born not LGA, to determine whether the discrepancy at birth was primarily due to larger size throughout gestation, or instead to different trajectories of fetal growth.

STUDY DESIGN

 This was a secondary analysis of secondary outcomes of fetal growth and adiposity from three harmonized randomized trials-the LIMIT, GRoW, and Optimise randomized trials. These trials recruited women in early pregnancy, and a singleton gestation, from three major public metropolitan Adelaide maternity hospitals. Maternal body mass index (BMI) ranged from 18.5 to ≥40.0 kg/m2. Data were obtained from enrolled women who underwent research ultrasounds at 28 and 36 weeks' gestation. Outcome measures were ultrasound measures of fetal biometry and adiposity.

RESULTS

 Infants born LGA had larger fetal biometry measures, and higher growth trajectories, from 20 weeks' gestation. Fetal adiposity measures were consistently larger among infants born LGA and these differences increased over time. We did not find evidence that the differences in biometry and adiposity measurements varied according to maternal BMI.

CONCLUSION

 Infants born LGA had larger fetal biometry measures at all time points from 20 weeks' gestation, compared with infants born not LGA suggesting any interventions to prevent LGA likely need to commence earlier in pregnancy or prior to conception.

KEY POINTS

· Infants born LGA had larger fetal biometry measures from 20 weeks' gestation.. · Infants born LGA had larger fetal adiposity measures.. · Interventions to prevent LGA need to start earlier in pregnancy or prior to conception..

Expectant management of preeclampsia with severe features diagnosed at less than 24 weeks

BACKGROUND

The recent American College of Obstetricians and Gynecologists Practice Bulletin offers no guidance on the management of preeclampsia with severe features at <24 weeks of gestation. Historically, immediate delivery was recommended because of poor perinatal outcomes and high maternal morbidity. Recently, advances in neonatal resuscitation have led to increased survival at periviable gestational ages.

OBJECTIVE

This study aimed to report perinatal and maternal outcomes after expectant management of preeclampsia with severe features at <24 weeks of gestation.

STUDY DESIGN

This was a retrospective case series of preeclampsia with severe features at <24 weeks of gestation at a level 4 center between 2017 and 2023. Individuals requiring delivery within 24 hours of diagnosis were excluded. Perinatal and maternal outcomes were analyzed. Categorical variables from our database were compared with previously published data using chi-square tests.

RESULTS

A total of 41 individuals were diagnosed with preeclampsia with severe features at <24 weeks of gestation. After the exclusion of delivery within 24 hours, 30 individuals (73%) were evaluated. The median gestational age at diagnosis was 22 weeks (interquartile range, 22-23). Moreover, 16% of individuals had assisted reproductive technology, 27% of individuals had chronic hypertension, 13% of individuals had pregestational diabetes mellitus, 30% of individuals had previous preeclampsia, and 73% of individuals had a body mass index of >30 kg/m2. The median latency periods at 22 and 23 weeks of gestation were 7 days (interquartile range, 4-23) and 8 days (interquartile range, 4-13). In preeclampsia with severe features, neonatal survival rates were 44% (95% confidence interval, 3%-85%) at 22 weeks of gestation and 29% (95% confidence interval, 1%-56%) at 23 weeks of gestation. There were 2 cases of acute kidney injury (7%) and 2 cases of pericardial or pleural effusions (7%). Overall perinatal survival at <24 weeks of gestation was 30% in our current study vs 7% in previous reports (P=.02).

CONCLUSION

For cases of expectant management of preeclampsia with severe features at <24 weeks of gestation, our findings showed an increased perinatal survival rate with decreased maternal morbidity compared with previously published data. This information may be used when counseling on expectant management of preeclampsia with severe features at <24 weeks of gestation.

Risk factors for placenta accreta spectrum disorders in women with any prior cesarean and a placenta previa or low lying: a prospective population-based study

This study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or low-lying. The PACCRETA prospective population-based study took place in 12 regional perinatal networks from 2013 through 2015. All women with one or more prior cesareans and a placenta previa or low lying were included. Placenta accreta spectrum (PAS) was diagnosed at delivery according to standardized clinical and histological criteria. Of the 520,114 deliveries, 396 fulfilled inclusion criteria; 108 were classified with PAS at delivery. Combining the number of prior cesareans and the placental location yielded a rate ranging from 5% for one prior cesarean combined with a posterior low-lying placenta to 63% for three or more prior cesareans combined with placenta previa. The factors independently associated with PAS disorders were BMI ≥ 30, previous uterine surgery, previous postpartum hemorrhage, a higher number of prior cesareans, and a placenta previa. Finally, in this high-risk population, the rate of PAS disorders varies greatly, not only with the number of prior cesareans but also with the exact placental location and some of the women's individual characteristics. Risk stratification is thus possible in this population.

Clinical characteristics and outcomes of obstetric patients transferred directly to intensive care units

BACKGROUND

Medical complications in peripartum patients are uncommon. Often, these patients are transferred to tertiary care centers, but their conditions and outcomes are not well understood. Our study examined peripartum patients transferred to an intensive care unit (ICU) at an academic quaternary center.

METHODS

We reviewed charts of adult, non-trauma, interhospital transfer (IHT) peripartum patients sent to an academic quaternary ICU between January 2017 and December 2021. We conducted a descriptive analysis and used multivariable ordinal regression to examine associations of demographic and clinical factors with ICU length of stay (LOS) and hospital length of stay (HLOS).

RESULTS

Of 1,794 IHT peripartum patients, 60 (3.2%) were directly transferred to an ICU. The average was 32 years, with a median Sequential Organ Failure Assessment (SOFA) score of 3 (1-4.25) and Acute Physiology and Chronic Health Evaluation (APACHE) II score of 8 (7-12). Respiratory failure was most common (32%), followed by postpartum hemorrhage (15%) and sepsis (14%). Intubation was required for 24 (41%), and 4 (7%) needed extracorporeal membrane oxygenation. Only 1 (1.7%) died, while 45 (76.3%) were discharged. Median ICU LOS and HLOS were 5 days (212) and 8 days (5-17). High SOFA score was linked to longer HLOS, as was APACHE II.

CONCLUSIONS

Transfers of critically ill peripartum patients between hospitals were rare but involved severe medical conditions. Despite this, their outcomes were generally positive. Larger studies are needed to confirm our findings.

Time trends in preeclampsia and gestational diabetes in Denmark and Alberta, Canada, 2005-2018-A population-based cohort study

INTRODUCTION

Preeclampsia and gestational diabetes mellitus share risk factors such as obesity and increased maternal age, which have become more prevalent in recent decades. We examined changes in the prevalence of preeclampsia and gestational diabetes between 2005 and 2018 in Denmark and Alberta, Canada, and investigated whether the observed trends can be explained by changes in maternal age, parity, multiple pregnancy, comorbidity, and body mass index (BMI) over time.

MATERIAL AND METHODS

This study was a register-based cohort study conducted using data from the Danish National Health Registers and the provincial health registers of Alberta, Canada. We included in the study cohort all pregnancies in 2005-2018 resulting in live-born infants and used binomial regression to estimate mean annual increases in the prevalence of preeclampsia and gestational diabetes in the two populations across the study period, adjusted for maternal characteristics.

RESULTS

The study cohorts included 846 127 (Denmark) and 706 728 (Alberta) pregnancies. The prevalence of preeclampsia increased over the study period in Denmark (2.5% to 2.9%) and Alberta (1.7% to 2.5%), with mean annual increases of 0.03 (95% confidence interval [CI] 0.02-0.04) and 0.06 (95% CI 0.05-0.07) percentage points, respectively. The prevalence of gestational diabetes also increased in Denmark (1.9% to 4.6%) and Alberta (3.9% to 9.2%), with average annual increases of 0.20 (95% CI 0.19-0.21) and 0.44 (95% CI 0.42-0.45) percentage points. Changes in the distributions of maternal age and BMI contributed to increases in the prevalence of both conditions but could not explain them entirely.

CONCLUSIONS

The prevalence of both preeclampsia and gestational diabetes increased significantly from 2005 to 2018, which portends future increases in chronic disease rates among affected women. Increasing demand for long-term follow up and care will amplify the existing pressure on healthcare systems.

Impact of bariatric surgery on maternal gestational weight gain and pregnancy outcomes in women with obesity: A population-based cohort study from Qatar

BACKGROUND

Bariatric surgery is performed in obese women of reproductive age to help achieve a healthy prepregnancy weight to reduce the complications associated with obesity in pregnancy. However, these procedures can impact maternal nutrition and gestational weight gain (GWG). This study evaluates the maternal and neonatal outcomes in women with prepregnancy bariatric surgery and determines the impact on GWG.

METHODS

This study included 24 weeks gestation or more pregnancies, with a maternal BMI at delivery of 30 kg/m2 or more. It was categorized into two groups based on whether they had prepregnancy bariatric surgery (exposed) or not (unexposed). The outcomes included gestational diabetes (GDM), gestational hypertension (GHT), mode of delivery, preterm birth (PTB), GWG, birthweight (BW) and customized BW centiles, low birthweight (LBW), congenital anomalies, and admission to the neonatal intensive unit (NICU). Categorization was also done based on the adequacy of GWG (low, adequate, and excess).

RESULTS

A total of 8,323 women were included in the study, 194 of whom had prepregnancy bariatric surgery. After adjusting for confounders, the exposed group had a mean GWG 1.33 kg higher than the unexposed group (95% CI 0.55-2.13, p = 0.001). The exposed group had higher odds of PTB (aOR 1.78, 95% CI 1.16-2.74, p = 0.008), CD (aOR 6.52, 95% CI 4.28-9.93, p < 0.001), LBW in term babies (aOR 2.60, 95% CI 1.34-5.03, p = 0.005), congenital anomalies (aOR 2.64, 95% CI 1.21-5.77, p = 0.015), low APGAR score (aOR 3.75, 95% CI 1.12-12.5, p = 0.032) and 80.4g lesser birthweight (95% CI -153.0, -5.8; p = 0.034). More women in the low GWG category had LBW babies (28.6% versus 6.7% in the high GWG group, p = 0.033), lowest mean BW and median BW centiles (2775 grams versus 3289 grams in the high GWG group, p = 0.004 and 57.5% versus 74.5% in the high GWG group, p = 0.040, respectively).

CONCLUSION

The findings of this study highlight differences in perinatal outcomes such as preterm birth, low birth weight, congenital anomalies, cesarean deliveries, and gestational weight gain between post-bariatric women and controls. These insights can help inform the planning and provision of appropriate maternity care to enhance patient safety and outcomes. The results of this study can also guide the counseling of reproductive age-group women who are planning to undergo bariatric surgery.

How the structural determinants of health inequities impact access to prescription medication for pregnant women in Australia: a narrative review

Structural factors that contribute to health disparities (e.g., population-level policies, cultural norms) impact the distribution of resources in society and can affect medication accessibility; even in high-income countries like Australia. Industry practices and regulatory approaches (e.g., a conservative approach to testing medicines in pregnant women) influence the availability of safety and efficacy data necessary for the licencing and funding of prescription medications used during pregnancy. Consequently, pregnant women may be prescribed medications outside of regulatory or funder-approved indications, posing risks for both prescribers and pregnant women and potentially compromising equitable access to medications. This review examines the regulatory and legislative structural factors that contribute to health disparities and perpetuate the deeply ingrained social norm that we should be protecting pregnant women from clinical research rather than safeguarding them through such research. Addressing these challenges requires a renewed commitment to integrated, woman-centred maternal healthcare and strengthened collaboration across all sectors.

Funding

Australian Government Research Training Program Stipend from the University of Technology Sydney, National Health and Medical Research Council (NHMRC) Fellowship, Channel 7 Children's Research Foundation Fellowship (CRF-210323).

Interpregnancy weight change as a potential risk factor for large-for-gestational-age infants: the Japan Environment and Children's Study

OBJECTIVE

This study aimed to estimate the impact of interpregnancy weight change from the first to the second pregnancy on the risk of infants being large for gestational age (LGA).

METHODS

This nationwide prospective birth cohort analysis included 3245 women who delivered their first two live singletons between 2011 and 2014. Interpregnancy weight change was calculated as the difference between the prepregnancy body mass index (BMI) of the first and second pregnancies. LGA infants were compared among three interpregnancy weight change groups: weight loss (a BMI loss >1 unit), weight gain (a BMI gain >1 unit), and stable weight (BMI maintained within - 1 to <1 unit). Interpregnancy weight change was assessed in mothers with a BMI <25 and ≥25 kg/m², and adjusted odds ratios (ORs) were calculated for LGA infants by multiple logistic regression.

RESULTS

The incidence of LGA infants was 8.6% (279 out of 3245). Compared with the stable weight group, interpregnancy weight gain was associated with an increased risk of infants being LGA (adjusted OR: 1.69, 95% confidence interval: 1.21-2.36) in the normal BMI (<25 kg/m²) group. In contrast, in the overweight/obese BMI (≥25 kg/m²) group, interpregnancy BMI was not a significant risk factor for LGA infants.

CONCLUSIONS

Accurate risk stratification using interpregnancy BMI could assist the clinical management of women with a normal BMI who are at risk of delivering LGA infants.

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum

Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.

Effect of a Diet-Induced Obesity on the Progeny Response in a Murine Model

Diet-induced obesity could have detrimental effects on adults and their progeny. The aim of this study was to determine the effect of a high-energy diet on both F1 mice body weight and tissue/organ weight and F2 offspring growth. A simple murine model for obesity was developed using a high-energy diet and mice reared in litters of five or ten, from 30 dams receiving a cafeteria diet of either commercial chow (low energy), or a mixture of commercial chow, chocolate (50% cacao), and salty peanuts (high energy). This diet continued from mating until weaning, when the pups were allocated according to sex into eight groups based on maternal diet, litter size, and post-weaning diet. On day 74, the males were slaughtered, and the females were bred then slaughtered after lactation. As a result, the high-energy maternal diet increased the F1 offspring growth during lactation, while the high-energy post-weaning diet increased the F1 adult body weight and tissue/organ weight. The high-energy maternal diet could negatively affect the onset of the F1 but not the maintenance of breastfeeding of F1 and F2 offspring. For F2 offspring growth, the high energy overlapped the low-energy post-weaning diet, due to problems of gaining weight during lactation.

The EVA (Early Vascular Aging) Study: Association of Central Obesity With Worse Arterial Health After Preeclampsia

Background Women with preeclampsia have a higher risk of cardiovascular disease. This is partly explained by the worse arterial health after preeclampsia. Central obesity (CO) is a risk factor for both preeclampsia and cardiovascular disease. Whether CO contributes to further worsening of arterial health after preeclampsia remains unclear. Our objective was to evaluate the effect of CO and previous preeclampsia on arterial hemodynamics. Methods and Results We studied 40 women with previous preeclampsia (<6 years) and 40 age-matched controls with previous normotensive pregnancy in the same timeframe. We estimated arterial hemodynamics with validated techniques combining applanation tonometry and echocardiography. CO was defined as a waist-to-hip ratio ≥0.85. Differences in arterial hemodynamics across the 3 groups (preeclampsia with CO, preeclampsia without CO, and controls) were assessed with multivariable linear regression models adjusted for potential confounders. Twenty-six (65%) of the participants with preeclampsia had CO compared with 18 (45%) controls. Mean waist-to-hip ratio in patients with preeclampsia with CO, those with preeclampsia and no CO, and controls was 0.94±0.05, 0.80±0.04, and 0.83±0.07, respectively. In multivariable analyses, women with preeclampsia and CO had higher central blood pressure, arterial stiffness (carotid-femoral pulse wave velocity), steady arterial load (systemic vascular resistance), and wave reflections (reflected pressure wave amplitude, augmentation index) compared with controls (P<0.05 for each). Fewer hemodynamic domains were altered in the preeclampsia with no CO group, with higher central diastolic blood pressure, systemic vascular resistance, and wave reflections than controls (P<0.05). Conclusions Women with previous preeclampsia who also experience CO have the greatest alterations in arterial health and hemodynamics. Patients with preeclampsia with CO may represent a higher-risk subgroup who could be targeted for risk stratification and primary prevention of cardiovascular disease.

Pharmacoepidemiology and costs of medications dispensed during pregnancy: A retrospective population-based study

OBJECTIVE

To describe the pharmacoepidemiology and costs associated with medications dispensed during pregnancy.

DESIGN

Pharmacoepidemiological study and cost analysis.

SETTING

Queensland, Australia.

POPULATION

All women who gave birth in Queensland between January 2013 and June 2018.

METHODS

We used a whole-of-population linked administrative dataset, Maternity1000, to describe medications approved for public subsidy that were dispensed to 255 408 pregnant women. We describe the volume of medications dispensed and their associated costs from a Government and patient perspective.

MAIN OUTCOME MEASURES

Prevalence of medication use; proportion of total dispensings; total medication costs in AUD 2020/21 ($1AUD = $0.67USD/£0.55GBP in December 2022).

RESULTS

During pregnancy, 61% (95% CI 60.96-61.29%) of women were dispensed at least one medication approved for public subsidy. The mean number of items dispensed per pregnancy increased from 2.14 (95% CI 2.11-2.17) in 2013 to 2.47 (95% CI 2.44-2.51) in 2017; an increase of 15%. Furthermore, mean Government cost per dispensing increased by 41% from $21.60 (95% CI $20.99-$22.20) in 2013 to $30.44 (95% CI $29.38-$31.49) in 2017. These factors influenced the 53% increase in total Government expenditure observed for medication use during pregnancy between 2013 and 2017 ($2,834,227 versus $4,324,377); a disproportionate rise compared with the 17% rise in women's total out-of-pocket expenses observed over the same timeframe ($1,880,961 versus $2,204,415).

CONCLUSIONS

Prevalence of medication use in pregnancy is rising and is associated with disproportionate and rapidly escalating cost implications for the Government.

Impact of Obesity and Hyperglycemia on Pregnancy-specific Urinary Incontinence

OBJECTIVE

 The lack of data on the impact of hyperglycemia and obesity on the prevalence of pregnancy-specific urinary incontinence (PSUI) led us to conduct a cross-sectional study on the prevalence and characteristics of PSUI using validated questionnaires and clinical data.

METHODS

 This cross-sectional study included 539 women with a gestational age of 34 weeks who visited a tertiary university hospital between 2015 and 2018. The main outcome measures were the prevalence of PSUI, the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and the Incontinence Severity Index (ISI) questionnaires. The women were classified into four groups: normoglycemic lean, normoglycemic obese, hyperglycemic lean, and hyperglycemic obese. The differences between groups were tested using descriptive statistics. Associations were estimated using logistic regression analysis and presented as unadjusted and adjusted odds ratios.

RESULTS

 Prevalence rates of PSUI were no different between groups. However, significant difference in hyperglycemic groups worse scores for severe and very severe PSUI. When adjusted data for confound factors was compared with normoglycemic lean group, the hyperglycemic obese group had significantly higher odds for severe and very severe forms of UI using ICIQ-SF (aOR 3.157; 95% CI 1.308 to 7.263) and ISI (aOR 20.324; 95% CI 2.265 to 182.329) questionnaires and highest perceived impact of PSUI (aOR 4.449; 95% CI 1.591 to 12.442).

CONCLUSION

 Our data indicate that obesity and hyperglycemia during pregnancy significantly increase the odds of severe forms and perceived impact of PSUI. Therefore, further effective preventive and curative treatments are greatly needed.

The association between food desert severity, socioeconomic status, and metabolic state during pregnancy in a prospective longitudinal cohort

Poor metabolic health during pregnancy is associated with health concerns for pregnant individuals and their offspring. Lower socioeconomic status (SES) is one risk factor for poor metabolic health, and may be related to limited access to healthful and affordable foods (e.g., living in a food desert). This study evaluates the respective contributions of SES and food desert severity on metabolic health during pregnancy. The food desert severity of 302 pregnant individuals was determined using the United States Department of Agriculture Food Access Research Atlas. SES was measured using total household income adjusted for household size, years of education, and amount of reserve savings. Information about participants' glucose concentrations one hour following an oral glucose tolerance test during the second trimester was extracted from medical records and percent adiposity during the second trimester was assessed using air displacement plethysmography. Information about participants' nutritional intake during the second trimester was obtained by trained nutritionists via three unannounced 24-h dietary recalls. Structural equation models showed that lower SES predicted higher food desert severity (β = - 0.20, p = 0.008) and higher adiposity (β = - 0.27, p = 0.016) and consumption of a more pro-inflammatory diet (β = - 0.25, p = 0.003) during the second trimester of pregnancy. Higher food desert severity also predicted higher percent adiposity during the second trimester (β = 0.17, p = 0.013). Food desert severity significantly mediated the relationship between lower SES and higher percent adiposity during the second trimester (βindirect = - 0.03, 95% CI [- 0.079, - 0.004]). These findings indicate that access to healthful and affordable foods is a mechanism by which SES contributes to adiposity during pregnancy and may inform interventions intended to improve metabolic health during pregnancy.

Monitoring gestational weight gain: setting up a regional surveillance system in Italy

BACKGROUND

In many countries, including Italy, there are few national data on pre-pregnancy Body Mass Index (BMI) and gestational weight gain (GWG), despite these being important predictors of maternal and neonatal health outcomes. This dearth of information makes it difficult to develop and monitor intervention policies to reduce the burden of disease linked to inadequate BMI status and/or GWG in pregnant women. This study describes the setting up and initial implementation of a regional surveillance system on pre-pregnancy BMI and GWG.

METHODS

Between 1 January 2017 and 31 December 2018, anthropometric data were collected from all pregnant women accessing public health services in the Friuli Venezia Giulia region (Italy) for first ultrasound check (T1) and at delivery (T2). Anthropometric data collected at T1 (self-reported pre-pregnancy weight and measured weight and height) and T2 (measured weight and self-reported pre-pregnancy weight and height) were compared.

RESULTS

The system was able to reach 43.8% of all the women who gave birth in the region, and provided complete data for 6400 women of the 7188 who accessed the services at T1. At the beginning of pregnancy 447 (7.0%) women were underweight, 4297 (67.1%) had normal weight, 1131 (17.7%) were overweight and 525 (8.2%) had obesity. At delivery, 2306 (36.0%) women were within the appropriate weight gain range, while for 2021 (31.6%) weight gain was insufficient and for 2073 (32.4%) excessive. Only minor differences were observed between measured and self-reported anthropometric data.

CONCLUSIONS

The surveillance system offers an overview of the weight status of women during pregnancy. About 1/3 of women entered pregnancy with unsatisfactory BMI and 2/3 did not achieve the recommended weight gain. This surveillance system can be an effective tool to guide public health interventions.

Carbohydrate quantity is more closely associated with glycaemic control than weight in pregnant women with type 1 diabetes: Insights from the Diabetes and Pre-eclampsia Intervention Trial (DAPIT)

BACKGROUND

The present study aimed to explore the relationships between carbohydrate intake, body mass index (BMI) and glycaemic control (HbA1c) in pregnant women with type 1 diabetes mellitus (T1DM) METHODS: Secondary analysis of data was undertaken to assess dietary intake in a cohort of women who participated in a randomised controlled trial (RCT) of antioxidant supplementation to prevent preeclampsia (DAPIT¹⁰ ). Study-specific peripheral venous blood samples were obtained for HbA1c at 26 and 34 weeks. Diet was collected using a validated semiquantitative food frequency questionnaire at 26-28 weeks of gestation which assessed dietary intake over 2 weeks. Mean daily average nutrient intakes were analysed using Q Builder nutritional software and SPSS, version 25.

RESULTS

Dietary data were available for 547 pregnant women (72% of cohort) aged 29 years (95% confidence interval [CI] = 28.9-29.9) with average diabetes duration 11.8 years (95% confidence interval = 11.1-12.6). Average body mass index (BMI) (<16 weeks of gestation) was 26.7 kg/m² (95% CI = 26.3 -27, range 18.8-45.6 kg/m² ); 43% (n = 234) were overweight (BMI = 25.0-29.9 kg/m² ) and 20% (n = 112) were obese (BMI ≥ 30 kg/m² ). Differences in HbA1c and carbohydrate quantity and quality were found when adjusted for age and insulin dose. No differences between BMI group were observed for total carbohydrate and glycaemic control; however, differences were noted in fibre and glycaemic index.

CONCLUSIONS

Average quantity of dietary carbohydrate influenced HbA1c when adjusted for insulin dose however, BMI had less impact. More research is required on the relationship between carbohydrate consumption and glycaemic control in pregnancy.

An evaluation of adherence to folic acid supplementation in pregnant women during early gestation for the prevention of neural tube defects

OBJECTIVE

Neural tube defects (NTD) are potentially preventable by periconceptual folic acid supplementation. Women with obesity are at higher risk of NTD, therefore, are recommended a higher dose of 5 mg folic acid to mitigate this risk. The aim of this study was to evaluate maternal practice of folic acid supplementation amongst the antenatal population in relation to maternal obesity status.

DESIGN

Prospective observational study.

SETTING

Women ≤18 weeks' gestation at their first antenatal appointment attending University Maternity Hospital Limerick (Ireland) were recruited. Maternal height and weight were measured. Obesity was defined at a threshold of ≥30·0 kg/m² and ≥27·5 kg/m² when adjusting for ethnicity. A two-part questionnaire captured maternal characteristics and assessed supplementation compliance, commencement and dosage. Fisher's exact test for independence analysed differences in variables. A P value of <0·05 was considered significant.

PARTICIPANTS

A total of 328 women participated over a duration of 6 weeks.

RESULTS

Mean gestational age was 12·4 ± 1·4 weeks and mean BMI 26·7 kg/m² ± 5·2 kg/m². 23·8 % (n 78) were classified as obese. 96·5 % (n 315) were taking folic acid and 95·7 % (n 314) supplemented daily. 30·2 % (n 99) commenced supplementation 12 weeks prior to conception. Overall, 57·9 % (n 190) of women met folic acid supplementation dose requirements. 89·1 % (n 55) of women with obesity did not. Women with obesity were less likely to meet the higher folic acid supplementation dose requirements (P =< 0·001).

CONCLUSION

Folic acid supplementation practices within this cohort were suboptimal to prevent their risk of NTD. This study showed inadequate compliance of folic acid supplementation, and inadequate dosage for women with obesity. Increased patient education and awareness are needed within the antenatal period of pregnancy to bring folic acid supplementation practices in line with best practice guidelines.

Incidence, prevalence, and global burden of autism spectrum disorder from 1990 to 2019 across 204 countries

Autism spectrum disorder (ASD) substantially contributes to the burden of mental disorders. Improved awareness and changes in diagnostic criteria of ASD may have influenced the diagnostic rates of ASD. However, while data on trends in diagnostic rates in some individual countries have been published, updated estimates of diagnostic rate trends and ASD-related disability at the global level are lacking. Here, we used the Global Burden of Diseases, Injuries, and Risk Factors Study data to address this gap, focusing on changes in prevalence, incidence, and disability-adjusted life years (DALYs) of ASD across the world. From 1990 to 2019, overall age-standardized estimates remained stable globally. Both prevalence and DALYs increased in countries with high socio-demographic index (SDI). However, the age-standardized incidence decreased in some low SDI countries, indicating a need to improve awareness. The male/female ratio decreased between 1990 and 2019, possibly accounted for by increasing clinical attention to ASD in females. Our results suggest that ASD detection in low SDI countries is suboptimal, and that ASD prevention/treatment in countries with high SDI should be improved, considering the increasing prevalence of the disorder. Additionally, growing attention is being paid to ASD diagnosis in females, who might have been left behind by ASD epidemiologic and clinical research previously. ASD burden estimates are underestimated as GBD does not account for mortality in ASD.

Epidemiology of pre-pregnancy body mass index (BMI) among mothers in Abu Dhabi, the United Arab Emirates

Pre-pregnancy obesity is a risk factor for several health problems such as gestational diabetes, preeclampsia, labor induction, postpartum hemorrhage, and neonatal hypoglycemia. Being underweight is a risk factor for fetal growth restriction. Despite the negative impact of abnormal pre-pregnancy body mass index (BMI) (over and underweight) on pregnancy outcomes, a limited amount of studies has been conducted on the prevalence of pre-pregnancy over and underweight and associated factors in the United Arab Emirates (UAE). Thus, the aim of this study was to investigate the prevalence and factors associated with underweight, overweight, and obesity among mothers with children under the age of 2 years in Abu Dhabi, the UAE. A cross-sectional multicenter study was conducted in 2017 and included data from seven government health care centers in Abu Dhabi. Maternal pre-pregnancy BMI was calculated as the weight in kilograms (kg) divided by the square of the height in meters (m), (kg/m2). A total of 1,622 mother–child pairs were included in this study. Out of the 1,622 mothers, 43 (2.7%) were underweight, 1,068 (65.8%) were normal weight, 412 (25.4%) were overweight, and 99 (6.1%) were obese. Mothers with advanced maternal age (AMA) (≥35 years) were more likely to be overweight, odds ratio [OR] = 1.93, (95% confidence interval [CI] 1.52–2.3), p ≤ 0.001, and obese OR = 2.15 (95% CI 1.32–3.39), p = 0.001. Mothers with lower family income were more likely to be obese OR = 2.72 (95% CI 1.44–5.93), p = 0.002. Mothers with high parity (≥2) were more likely to be overweight OR = 1.91 (95% CI 1.49–2.50), p ≤ 0.001; obese OR = 1.76 (95% CI 1.06–2.92), p = 0.024; and less likely to be underweight OR = 0.52 (95% CI 0.27–0.94), p = 0.037. Obese mothers were more likely to deliver via cesarean section (CS) OR = 1.95 (95% CI 1.27–2.96), p = 0.002. This study provides valuable baseline information on the epidemiology of pre-pregnancy BMI in the UAE. The sociodemographic factors identified in the study can be used to target at-risk women. The study findings can also be used to develop contextualized strategies to prevent and manage complications associated with abnormal pre-pregnancy BMI in Emirati women.

Changing Trends of Adverse Pregnancy Outcomes With Maternal Pre-pregnancy Body Mass Index: A Join-Point Analysis

Objective

Adverse pregnancy outcomes have been related to obesity and thinness; however, the changing trends of the specific outcome with pre-pregnancy BMI remain unknown. The aim of this study was to investigate the change in risk trends of specific adverse outcomes for different pre-pregnancy BMI and analyze the recommended BMI range for pre-pregnancy counseling.

Methods

Data were extracted from the medical records of 39 public hospitals across 14 provinces in China from 2011 to 2012. The eligibility criteria were singleton birth with delivery week ≥28 weeks. Join-point analysis was adopted to explore changing trends with pre-pregnancy BMI and calculate slopes and join points of different pregnancy complications.

Results

A total of 65,188 women were eligible for analysis. There were three categories of trend style. Continuously increasing trends were linear for intrahepatic cholestasis of pregnancy, postpartum hemorrhage, and low 1-min Apgar score, and non-linear for cesarean delivery with one join point of BMI 23, hypertension disorder in pregnancy with two join points of BMI 20 and 28, gestational diabetes mellitus with one join point of BMI 22, and macrosomia with one join point of BMI 19. The trend was continuously and linearly decreasing for anemia. The bidirectional trends were downward and upward for premature rupture of the membrane with join BMI 22, preterm premature rupture of the membrane with join BMI 22, placenta abruption with join BMI 23, preterm birth with join BMI 19, and low birth weight with join BMI 19.

Conclusions

The changes in the trends of specific outcomes differed with pre-pregnancy BMI. Our results suggested that a pre-pregnancy BMI ranging between 19 and 23 may help reduce the risk of poor maternal and neonatal outcomes.

Effects of breastfeeding on postpartum weight change in Japanese women: The Japan Environment and Children’s Study (JECS)

Aim

The aim of this study was to examine the relationship between breastfeeding and postpartum maternal weight change.

Method

This study used data from the Japan Environment and Children’s Study (JECS), an ongoing nationwide birth cohort study. Participants were categorized into two groups: full breastfeeding (FB) and non-full breastfeeding (NFB) groups. Postpartum weight changes between the FB (n = 26,340) and NFB (n = 38,129) groups were compared.

Results

At 6 months postpartum, mean weight retention was significantly lower in the FB group than in the NFB group (0.2 vs 0.8 kg, respectively, p<0.001). Weight retention differed by pre-pregnancy body mass index (BMI), with postpartum weights of overweight (pre-pregnancy BMI 25.0–29.9) and obese (pre-pregnancy BMI ≥30.0) participants being lower than pre-pregnancy weight; this trend was more pronounced in the FB group than in the NFB group (overweight: −2.2 vs −0.7 kg, respectively; obese: −4.8 vs −3.4 kg, respectively). Factors affecting weight retention at 6 months postpartum were weight gain during pregnancy (β = 0.43; p<0.001), pre-pregnancy BMI (β = −0.147; p<0.001) and feeding method. FB resulted in lower weight retention than NFB (β = −0.107; p<0.001).

Conclusion

Breastfeeding reduced maternal weight retention, which was greater in mothers who were obese before pregnancy. For obese women, active breastfeeding may improve their health.

Association of Maternal Obesity and Neonatal Hypoxic-Ischemic Encephalopathy

OBJECTIVE

More women are obese at their first prenatal visit and then subsequently gain further weight throughout pregnancy than ever before. The impact on the infant's development of neonatal hypoxic ischemic encephalopathy (HIE) has not been well studied. Using defined physiologic and neurologic criteria, our primary aim was to determine if maternal obesity conferred an additional risk of HIE.

STUDY DESIGN

Data from the New York State Perinatal Data System of all singleton, term births in the Northeastern New York region were reviewed using the NIH obesity definition (Body Mass Index (BMI) ≥ 30 kg/m2). Neurologic and physiologic parameters were used to make the diagnosis of HIE. Physiologic criteria included the presence of an acute perinatal event, 10-min Apgar score ≤ 5, and metabolic acidosis. Neurologic factors included hypotonia, abnormal reflexes, absent or weak suck, hyperalert, or irritable state or evidence of clinical seizures. Therapeutic hypothermia was initiated if the infant met HIE criteria when assessed by the medical team. Logistic regression analysis was used to assess the effect of maternal body mass index on the diagnosis of HIE.

RESULTS

In this large retrospective cohort study we evaluated outcomes of 97,488 pregnancies. Infants born to obese mothers were more likely to require ventilatory assistance and have a lower 5-min Apgar score. After adjusting for type of delivery and maternal risk factors, infants of obese mothers were diagnosed with HIE more frequently than infants of non-obese mothers, OR 1.96 (1.33-2.89) (p = 0.001).

CONCLUSION

Infants of obese mothers were significantly more likely to have the diagnosis of HIE.

Pregnancy outcomes in twin pregnancies over 10 years

OBJECTIVE

The aim of this study was to evaluate the changes in twin pregnancy outcomes between 2007 and 2016 in a Korean population.

METHODS

The data for this nationwide population-based study was obtained from the national birth registry of the Korean National Statistical Office and the Health Insurance Review & Assessment Service of Korea. Women with twin pregnancies who gave birth between 2007 and 2016 were included.

RESULTS

From 2007 to 2016, the rate of twin pregnancies increased (1.37% vs. 1.91%, respectively, P<0.0001). The risk of preterm birth (adjusted odds ratio [aOR], 1.77; 95% confidence interval [CI], 1.66-1.89) also increased; however, the risk of twin growth discordance (aOR, 0.90; 95% CI, 0.82-0.99) decreased. The risks of cesarean section (aOR, 1.16; 95% CI, 1.03-1.29), gestational diabetes mellitus (aOR, 2.10; 95% CI, 1.83-2.39), and postpartum hemorrhage (aOR, 1.27; 95% CI, 1.14-1.41) all increased from 2007 to 2016.

CONCLUSION

Twin pregnancy outcomes have changed significantly in Korea over a recent 10-year period.

Maternal Obesity and Its Associated Factors and Outcomes in Klang Valley, Malaysia: Findings from National Obstetric Registry

INTRODUCTION

Maternal obesity presents significant health risks to mothers and their fetuses. This study aimed to determine the proportion, associated factors and outcomes of maternal obesity among pregnant women in Klang Valley, Malaysia.

METHODS

A retrospective cross-sectional study was conducted between January 2018 and March 2018 using secondary data from the Malaysian National Obstetric Registry (NOR) for the year 2015. All pregnant women with first-trimester booking at 12 weeks and below that were registered with the NOR and met the inclusion and exclusion criteria were included in the study. Descriptive statistics and multiple logistic regression analysis were used. Data were analysed using SPSS version 22.0. A total of 2113 respondents were included in this study to determine the proportion, associated factors and outcomes of maternal obesity. Regarding the univariate and multivariate analyses, respondents were classified into two groups: normal and obese. The obese group comprised overweight and obese mothers. The underweight group was excluded in the subsequent analysis.

RESULTS

Out of the 2113 respondents, 7.1% were underweight, 41.7% were of normal weight, 28.6% were overweight, 15.9% were in obese class I, 4.6% were in obese class II, and 2.1% were in obese class III according to the WHO (1995) reference. However, when the MOH (2003) cutoff point was used, there was a marked increase in the proportion of respondents in the overweight categories by 2.7% and obesity class I by 12.8%. The Indian (AdjOR 2.06, 95% CI: 1.11, 3.83, p=0.021) and Malay (AdjOR 1.75, 95% CI: 1.02, 3.00, p=0.040) ethnicities, as well as both multiparity (AdjOR 1.46, 95% CI: 1.23, 1.73, p <0.001) and grand multiparity (AdjOR 2.41, 95% CI: 1.78, 3.26, p <0.001), were significantly associated with maternal obesity. There were significant association between maternal obesity with hypertensive disorder in pregnancy (p=0.025), caesarean section delivery (p=0.002) and macrosomic infant (p <0.001).

CONCLUSION

The identification of risk factors for maternal obesity is important to facilitate intervention programmes focused on improving the pregnancy outcomes for a high-risk group of women.

Practice nurse-supported weight self-management delivered within the national child immunisation programme for postnatal women: a feasibility cluster RCT

BACKGROUND

Pregnancy is a high-risk time for excessive weight gain. The rising prevalence of obesity in women, combined with excess weight gain during pregnancy, means that there are more women with obesity in the postnatal period. This can have adverse health consequences for women in later life and increases the health risks during subsequent pregnancies.

OBJECTIVE

The primary aim was to produce evidence of whether or not a Phase III trial of a brief weight management intervention, in which postnatal women are encouraged by practice nurses as part of the national child immunisation programme to self-monitor their weight and use an online weight management programme, is feasible and acceptable.

DESIGN

The research involved a cluster randomised controlled feasibility trial and two semistructured interview studies with intervention participants and practice nurses who delivered the intervention. Trial data were collected at baseline and 3 months later. The interview studies took place after trial follow-up.

SETTING

The trial took place in Birmingham, UK.

PARTICIPANTS

Twenty-eight postnatal women who were overweight/obese were recruited via Birmingham Women's Hospital or general practices. Nine intervention participants and seven nurses were interviewed.

INTERVENTIONS

The intervention was delivered in the context of the national child immunisation programme. The intervention group were offered brief support that encouraged self-management of weight when they attended their practice to have their child immunised at 2, 3 and 4 months of age. The intervention involved the provision of motivation and support by nurses to encourage participants to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. The role of the nurse was to provide regular external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a record card in their child's health record ('red book') or using the online programme. The behavioural goal was for women to lose 0.5-1 kg per week. The usual-care group received a healthy lifestyle leaflet.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of a Phase III trial to test the effectiveness of the intervention, as assessed against three traffic-light stop-go criteria (recruitment, adherence to regular self-weighing and registration with an online weight management programme).

RESULTS

The traffic-light criteria results were red for recruitment (28/80, 35% of target), amber for registration with the online weight loss programme (9/16, 56%) and green for adherence to weekly self-weighing (10/16, 63%). Nurses delivered the intervention with high fidelity. In the qualitative studies, participants indicated that the intervention was acceptable to them and they welcomed receiving support to lose weight at their child immunisation appointments. Although nurses raised some caveats to implementation, they felt that the intervention was easy to deliver and that it would motivate postnatal women to lose weight.

LIMITATIONS

Fewer participants were recruited than planned.

CONCLUSIONS

Although women and practice nurses responded well to the intervention and adherence to self-weighing was high, recruitment was challenging and there is scope to improve engagement with the intervention.

FUTURE WORK

Future research should focus on investigating other methods of recruitment and, thereafter, testing the effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12209332.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 49. See the NIHR Journals Library website for further project information.

"Moving for My Baby!" Motivators and Perceived Barriers to Facilitate Readiness for Physical Activity during Pregnancy among Obese and Overweight Women of Urban Areas in Northern Taiwan

Low levels of physical activity (PA) are of a health concern among high body mass index (BMI) women living a sedentary lifestyle and being overweight or obese during pregnancy is associated with increased risks of maternal and fetal health complications. Obstetricians often provide advice regarding recommended PA levels, yet this has not been easily achieved in this group to prevent adverse birth-related outcomes. The purpose of this study is to explore motivators/enablers and perceived barriers through in-depth qualitative inquiry, guided by a behavioral change model, for understanding of pregnant women's decisions to engage, or refrain from PA practice. Thirteen overweight and obese pregnant women aged 28 to 45 years with an inactive, sedentary lifestyle in urban areas of northern Taiwan were recruited to participate in six focus group sessions for their intent and readiness for PA engagement in pregnancy. A thematic content analysis was performed with a constant comparison method to categorize interview data and generate themes. The findings illustrate the extent to which obese and overweight pregnant women's readiness for PA is affected by multiple factors, including personal beliefs, perceived societal norms, peer support, and the competing priorities in the environment. PA interventions are to be effective by focusing on overcoming barriers, increasing motivations, and enhancing self-management. Strategies shared by participants shed lights for program developers to design preferable behavioral interventions for this group of women who are low self-esteem with low self-efficacy to increase PA and meet recommended levels. There is considerable potential for health care providers to provide accessible information, facilitate PA, and promote an active lifestyle during and after pregnancy.

Maternal pre-pregnancy underweight as a risk factor for the offspring: Survey of Neonates in Pomerania

AIM

The aim was to investigate socio-economic risk factors for maternal underweight before pregnancy and then associations of underweight with neonatal outcomes.

METHODS

Data of 3401 mother-child dyads from the population-based birth cohort Survey of Neonates in Pomerania (SNiP) were analysed.

RESULTS

Bivariate analysis showed that underweighted mothers were younger, smoked more often, had a lower equivalent income and lower socio-economic status (employment status and/or educational level) compared to women with normal weight. The final prediction model revealed that only younger maternal age (OR = 0.93; 95%-CI = 0.90-0.97) and maternal smoking during pregnancy (OR = 2.52; 95%-CI = 1.74-3.66) were associated with underweight. Compared to women with normal pre-pregnancy BMI, underweight women had an increased chance of premature labour (OR = 1.73; 95% CI: 1.29-2.31) and a reduced placental weight. The offspring of underweight women had an increased risk of late preterm birth (OR = 1.82; 95% CI: 1.21-2.74) and birthweight < 2500 g (OR = 1.91; 95% CI: 1.23-2.95).

CONCLUSION

Smoking during pregnancy and a younger age were identified as risk factors for maternal pre-pregnancy underweight which then was associated with late preterm birth and low birthweight.

Higher maternal BMI early in pregnancy is associated with overweight and obesity in young adult offspring in Thailand

Background

Rates of overweight and obesity among women of reproductive age have been steadily increasing worldwide and in Thailand. There is mounting evidence that maternal obesity during pregnancy is associated with an increased risk of obesity and other adverse health outcomes in the offspring, but such data are lacking for Thailand. We examined the associations between maternal body mass index (BMI) and anthropometry (particularly the likelihood of obesity) and cardiometabolic parameters in young adult offspring.

Methods

This was a prospective follow-up study of a birth cohort in Chiang Mai (Thailand). Pregnant women carrying singletons were recruited at their first antenatal visit (< 24 weeks of gestation) and followed until delivery in 1989–1990. Participants were their young adult offspring followed up in 2010. Maternal BMI was recorded at the first antenatal visit. The offspring underwent clinical assessments, including anthropometry, lipid profile, insulin sensitivity (HOMA-IR), blood pressure, and carotid intima-media thickness. The primary outcome of interest was the likelihood of obesity in the offspring.

Results

We assessed 628 young adults (54% were females) at 20.6 ± 0.5 years of age (range 19.1–22.1 years). The young adult offspring of mothers with overweight/obesity was 14.1 kg (95%CI 9.7, 18.5; p < 0.0001) and 9.4 kg (95% CI 6.1, 12.8; p < 0.0001) heavier than those born to mothers with underweight or normal weight, respectively, and had BMI 3.46 kg/m² (95%CI 2.26, 4.67; p < 0.0001) and 5.27 kg/m² (95%CI 3.67, 8.68; p < 0.0001) greater, respectively. For every 1-kg/m² increase in maternal BMI, the adjusted odds ratio (aOR) of offspring obesity was 25% greater (95%CI 1.10, 1.42; p < 0.001). Thus, the aOR of obesity in offspring of mothers with overweight/obesity was 4.6 times greater (95%CI 1.86, 11.26; p < 0.001) and nearly 17-fold greater (95%CI 1.96, 146.4; p = 0.010) compared to young adults born to mothers with normal weight or underweight, respectively. There were no observed associations between maternal BMI status and offspring metabolism or blood pressure.

Discussion

Maternal overweight/obesity early in pregnancy was associated with increased BMI and greater odds of obesity in their young adult offspring in Thailand. These findings highlight the public health importance of fostering healthier lifestyle choices among women of reproductive age.

Prophylactic perioperative cefuroxime levels in plasma and adipose tissue at the time of caesarean section (C-LACE): a protocol for a pilot experimental, prospective study with non-probability sampling to determine interpatient variability

Background

The aim of the C-LACE study is to measure cefuroxime concentration in plasma and adipose tissue of non-obese and obese pregnant women undergoing caesarean section.

Methods

This study plans to compare maternal cefuroxime concentrations (plasma and adipose tissue), at the time of skin incision and time of skin closure during a caesarean section from non-obese (body mass index BMI < 30 kg/m²) and obese (BMI ≥ 30 kg/m²) pregnant women. The incidence of post-surgical site infection will also be measured. At least 15 participants are required for each arm (non-obese vs obese) with a total of 30 participants. The study participants will be followed up between 30 and 40 days post-caesarean section to record details of any post-caesarean surgical infection to explore correlations between BMI, measured cefuroxime concentrations and post-caesarean infection rates.

Discussion

This pilot study will allow the development of a model testing the inter-patient variability in plasma and adipose tissue concentrations of cefuroxime. The results will facilitate the development of a larger study to determine whether differences in cefuroxime plasma and tissue concentration in obese and non-obese women can support the development of a physiologically based pharmacokinetic model. This model can then be used to propose dosing adjustments that can be used in a further trial to optimise cefuroxime dosing for women undergoing caesarean section.

Trial registration

ISRCTN Registry, ISRCTN17527512. Registered on 26 October 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00794-3.

[Gestational weight gain and postpartum weight retention: data from the 2015 birth cohort in Pelotas, Rio Grande do Sul State, Brazil]

The study's objectives were to describe the prevalence of gestational weight gain and weight retention at 3 and 12 months postpartum and to identify possible socioeconomic inequalities in adequate gestational weight gain. A longitudinal study was performed with data from the 2015 Pelotas, Rio Grande do Sul State, Brazil, birth cohort. Gestational weight gain was classified according to the US Institute of Medicine guidelines. Weight retention at 3 and 12 months was calculated according to the mother's weight at each period, subtracting pregestational weight. To identify possible inequalities, the study used Slope Index (SII) and Concentration Index (CIX). The sample included mothers with information on the study's outcome (n = 4,102). Prevalence of adequate gestational weight gain was 33.5% (95% confidence interval - 95%CI: 32.1; 35.0). Slight inequalities were observed in the prevalence of adequate weight gain in mothers with less schooling [CIX = 1.88 (95%CI: -0.76; 4.52); SII = 4.27 (95%CI: -0.87; 9.41)] and in mothers belonging to the poorest income quintile- 1st quintile- [CIX = 1.04 (95%CI: -1.60; 3.67); SII = 2.93 (95%CI: -2.06; 7.92)], but these differences were not statistically significant. Mean postpartum weight gain was 2.3kg (standard deviation - SD = 6.4) and 1.4kg (SD = 8.8) at 3 and 12 months, respectively. One-third of the women showed adequate weight gain. The observed inequalities in prevalence of adequate gestational weight gain in women with less schooling and in the poorest income quintile were not statistically significant.

Impact of prepregnancy body mass index on pregnancy outcomes, incidence of urinary incontinence and quality of life during pregnancy - An observational cohort study

Background

To evaluate the effects of prepregnancy body mass index (BMI) on pregnancy outcomes, prevalence of urinary incontinence, and quality of life.

Methods

The observational cohort included 2210 pregnant women who were divided into 4 groups according to their prepregnancy BMI: underweight (<18.5), normal weight (18.5–24.9), overweight (25–29.9), and obese (≥30). Data were analyzed for pregnancy outcomes, prevalence of urinary incontinence during pregnancy, scores of the Short Form 12 health survey (SF-12) and changes in sexual function.

Results

Compared with normal weight, overweight and obesity were associated with advanced maternal age, low education level, multiparity, preterm delivery, cesarean section, gestational weight gain above the Institute of Medicine (IOM) guidelines, preeclampsia, gestational diabetes, macrosomia and large fetal head circumference. After adjusting for confounding factors, women with overweight and obesity were more likely to have adverse maternal outcomes (gestational weight gain above the IOM guidelines, preeclampsia and gestational diabetes) and fetal outcomes (large fetal head circumference and macrosomia) compared to normal weight women. Overweight and obese women (BMI ≥ 25) were more likely to have urinary incontinence than normal weight and underweight women. There were no significant differences in SF-12 scores among the 4 BMI groups, but more than 90% of pregnant women had reduced or no sexual activities regardless of BMI.

Conclusions

Maternal prepregnancy overweight and obesity are associated with greater risks of preeclampsia, gestational diabetes, macrosomia and urinary incontinence. Health care providers should inform women to start their pregnancy at a BMI in the normal weight category.

Oxytocin at elective caesarean delivery: a dose-finding study in women with obesity

Prophylactic oxytocin administration at the third stage of labour reduces blood loss and the need for additional uterotonic drugs. Obesity is known to be associated with an increased risk of uterine atony and postpartum haemorrhage. It is unknown whether women with obesity require higher doses of oxytocin in order to achieve adequate uterine tone after delivery. The purpose of this study was to establish the bolus dose of oxytocin required to initiate effective uterine contraction in 90% of women with obesity (the ED₉₀ ) at elective caesarean delivery. We conducted a double-blind dose-finding study using the biased coin up-down design method. Term pregnant women with a BMI ≥ 40 kg.m^-2 undergoing elective caesarean delivery under regional anaesthesia were included. Those with conditions predisposing to postpartum haemorrhage were not included. Oxytocin was administered as an intravenous bolus over 1 minute upon delivery of the fetus. With the first woman receiving 0.5 IU, oxytocin doses were administered according to a sequential allocation scheme. The primary outcome measure was satisfactory uterine tone, as assessed by the operating obstetrician 2 minutes after administration of the oxytocin bolus. Secondary outcomes included the need for rescue uterotonic drugs, adverse effects and estimated blood loss. We studied 30 women with a mean (SD) BMI of 52.3 (7.6) kg.m^-2 . The ED₉₀ for oxytocin was 0.75 IU (95%CI 0.5-0.93 IU) by isotonic regression and 0.78 IU (95%CI 0.68-0.88 IU) by the Dixon and Mood method. Our results suggest that women with a BMI ≥ 40 kg.m^-2 require approximately twice as much oxytocin as those with a BMI < 40 kg.m^-2 , in whom an ED₉₀ of 0.35 IU (95%CI 0.15-0.52 IU) has previously been demonstrated.

Evaluation of carcinoembryonic antigen-related cell adhesion molecule 1 blood serum levels in women at high risk for preeclampsia

PROBLEM

The aim of this study was to evaluate the sCEACAM1 concentrations in serum from patients in the first trimester who have a high risk for developing PE during pregnancy.

METHOD OF THE STUDY

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) levels were determined with ELISA. The patients (n = 109) were divided into two groups: patients who have a high risk of developing PE early-onset and a control group. Patients who have a high risk of developing PE were then divided into two subgroups depending on PE development in third trimester of pregnancy: PE in third trimester versus no PE in third trimester.

RESULTS

sCEACAM1 concentrations in patients who were screened as having a high risk for developing PE were significantly higher than in healthy pregnant women in the first trimester (p = .03). The highest sCEACAM1 concentration was found in the high-risk group with PE development compared to the control group (p = .004).

CONCLUSION

Elevated sCEACAM1 blood serum levels in women with PE suggest that there is immune dysregulation in early pregnancy, which may be helpful in PE prediction and therapy.

Naegele's rule and the length of pregnancy - A review

BACKGROUND

The proposition that a pregnancy is 40 weeks or 280 days in duration is attributed to the German obstetrician Franz Naegele (1778-1851). His rule adds nine months and seven days to the first day of the last menstrual period. The expected date of confinement from this formula is approximately right in the majority of cases. However, the idea that this rule can apply to every pregnant female - young or old, nulliparous or multigravida, Caucasian, Asian, African, or Indigenous - stretches credulity. In addition, many women regard the 40-week date as a deadline, which if crossed, may then place the baby under stress. Forty weeks is such a simple, round, convenient figure that it has proved difficult to challenge, despite criticism. Nonetheless, what might have been an appropriate formula in Germany in the 19th century deserves to be revisited in the 21st.

AIMS

To review the length of pregnancy, in the light of current technology, in particular ultrasound scanning, and assisted reproductive techniques.

MATERIAL AND METHODS

A Medline search was performed for variables on the length of pregnancy, the expected date of confinement, and prolonged pregnancy.

RESULTS

A number of factors were found to significantly influence the length of a pregnancy, including ethnicity, height, variations in the menstrual cycle, the timing of ovulation, parity and maternal weight.

CONCLUSIONS

Naegele's rule should be considered as a guideline for the expected date of confinement, and not a definite date.

Skin and subcutaneous fascia closure at caesarean section to reduce wound complications: the closure randomised trial

BACKGROUND

Wound infection is a common complication following caesarean section. Factors influencing the risk of infection may include the suture material for skin closure, and closure of the subcutaneous fascia. We assessed the effect of skin closure with absorbable versus non-absorbable suture, and closure versus non-closure of the subcutaneous fascia on risk of wound infection following Caesarean section.

METHODS

Women undergoing caesarean birth at an Adelaide maternity hospital were eligible for recruitment to a randomised trial using a 2 × 2 factorial design. Women were randomised to either closure or non-closure of the subcutaneous fascia and to subcuticular skin closure with an absorbable or non-absorbable suture. Participants were randomised to each of the two interventions into one of 4 possible groups: Group 1 - non-absorbable skin suture and non-closure of the subcutaneous fascia; Group 2 - absorbable skin suture and non-closure of the subcutaneous fascia; Group 3 - non-absorbable skin suture and closure of the subcutaneous fascia; and Group 4 - absorbable skin suture and closure of the subcutaneous fascia. The primary outcomes were reported wound infection and wound haematoma or seroma within the first 30 days after birth.

RESULTS

A total of 851 women were recruited and randomised, with 849 women included in the analyses (Group 1: 216 women; Group 2: 212 women; Group 3: 212 women; Group 4: 211 women). In women who underwent fascia closure, there was a statistically significant increase in risk of wound infection within 30 days post-operatively for those who had skin closure with an absorbable suture (Group 4), compared with women who had skin closure with a non-absorbable suture (Group 3) (adjusted RR 2.17; 95% CI 1.05, 4.45; p = 0.035). There was no significant difference in risk of wound infection for absorbable vs non-absorbable sutures in women who did not undergo fascia closure.

CONCLUSION

The combination of subcutaneous fascia closure and skin closure with an absorbable suture may be associated with an increased risk of reported wound infection after caesarean section.

TRIAL REGISTRATION

Prospectively registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12608000143325 , on the 20th March, 2008.

Developmental programming of peripheral diseases in offspring exposed to maternal obesity during pregnancy

Obesity is an increasing global health epidemic that affects all ages, including women of reproductive age. During pregnancy, maternal obesity is associated with adverse pregnancy outcomes that lead to complications for the mother. In addition, maternal obesity can increase the risk of poor perinatal outcomes for the infant due to altered development. Recent research has investigated the effects of maternal obesity on peripheral organ development and health in later life in offspring. In this review, we have summarized studies that investigated the programming effects of maternal obesity before and during pregnancy on metabolic, cardiovascular, immune, and microbiome perturbations in offspring. Epidemiological studies investigating the effects of maternal obesity on offspring development can be complex due to other copathologies and genetic diversity. Animal studies have provided some insights into the specific mechanisms and pathways involved in programming peripheral disease risk. The effects of maternal obesity during pregnancy on offspring development are often sex specific, with sex-specific changes in placental transport and function suggestive that this organ is likely to play a central role. We believe that this review will assist in facilitating future investigations regarding the underlying mechanisms that link maternal obesity and offspring disease risk in peripheral organs.

Reappraisal of Gestational Weight Gain Recommendations in Obese Pregnant Women: A Population-Based Study of 337,590 Births

BACKGROUND AND OBJECTIVE

Maternal obesity is an epidemic health problem that is aggravated by excessive gestational weight gain (GWG) and postpartum weight retention. Current US Institute of Medicine (now US National Academy of Medicine) guidelines (2009) for GWG need to be evaluated against the current rise in obesity in the general and pregnant population. We wanted to study the relation between GWG and pregnancy and birth outcomes and to relate this to the current recommendations for GWG.

METHODS

Population-based study. We performed an epidemiological analysis in a cohort of Belgian pregnant women with singleton live births at term (≥37 weeks) between 2009 and 2014 (n = 337,590). Logistic regression was used to determine the optimal GWG in relation to relevant pregnancy and birth outcomes.

RESULTS

The prevalence of maternal obesity significantly increased from 10.3% in 2009 to 11.4% in 2014. The mean (SD) body mass index at the start of the pregnancy significantly increased from 23.9 (4.5) in 2009 to 24.2 (4.6) in 2014. Excessive GWG was frequent, especially in overweight (56.8%) and obese (52.9%) pregnant women. In the logistic regression model, the amount of GWG associated with the lowest incidence of both large-for-gestational-age and small-for-gestational-age infants was 21 kg in underweight women, 14 kg in normal weight, 8 kg in overweight, 0 kg in obese class I, -4 kg in obese class II and -5 kg in obese class III.

CONCLUSION

The prevalence of maternal obesity has risen in Belgium between 2009 and 2014. Current GWG guidelines, based on historic observational data, are probably too liberal for class II and III obese women in which better outcomes are being predicted for lower weight gain than recommended.

Maternal prepregnancy body mass index and physical activity during pregnancy assessed by accelerometer

BACKGROUND

Maternal prepregnancy overweight and obesity increase the risk of adverse pregnancy outcomes, whereas physical activity during pregnancy has a beneficial effect on both the mother and the fetus. Limited data are available on how maternal prepregnancy overweight and obesity affect physical activity during pregnancy.

OBJECTIVE

The purpose of this study was to describe the association between prepregnancy body mass index and physical activity during pregnancy.

STUDY DESIGN

An observational prospective cohort study of 400 singleton pregnant women who were attending routine antenatal care at Aarhus University Hospital, Denmark (2010-2015), was conducted. Physical activity was assessed by an accelerometer (SenseWear Armband) for 7 days for each trimester. Participants were stratified in 3 different groups of prepregnancy body mass index: normal weight (body mass index <25 kg/m²), overweight (body mass index 25-29.9 kg/m²), and obese (body mass index ≥30 kg/m²). Physical activity was measured as the number of steps per day, metabolic equivalent of task per day, time in moderate- to vigorous-intensity physical activity (>3 metabolic equivalent of task), and time in vigorous-intensity physical activity (>6 metabolic equivalent of task). Linear regression and multilevel mixed-effects models were used to explore the association between prepregnancy body mass index and physical activity variables during pregnancy.

RESULTS

We found an inverse linear relationship between prepregnancy body mass index and both mean number of steps per day and mean metabolic equivalent of task per day (P<.001). At baseline, women with normal weight walked a median of 1214 steps per day (95% confidence interval, 576-1852) more than women who were obese (P<.05), and women who were overweight walked a median of 948 steps per day (95% confidence interval, 218-1677) more than women who were obese (P<.05). Independent of prepregnancy body mass index, all variables of physical activity decreased over the course of pregnancy (P<.05), with the greatest decrease in the third trimester.

CONCLUSION

Maternal physical activity measured by an accelerometer decreased across pregnancy independent of maternal body mass index status and was inversely associated with prepregnancy body mass index. Thus, being overweight or obese before pregnancy increased the risk of sedentary behavior during pregnancy.

Maternal obesity and its determinants: A neglected issue?

Maternal obesity is a global public health concern that affects every aspect of maternity care. It affects the short-term and long-term health of the mother and her offspring. Obese pregnant mothers are at an increased risk of developing complications during antenatal, intrapartum, and postnatal periods. Maternal complications include gestational diabetes mellitus, hypertensive disorder in pregnancy, pre-eclampsia and eclampsia, increased rate of cesarean delivery, pulmonary embolism, and maternal mortality; fetal complications include congenital malformation, stillbirth, and macrosomia. Moreover, both mother and infant are at an increased risk of developing subsequent non-communicable diseases and cardiovascular problems later in life. Several factors are associated with the likelihood of maternal obesity, including sociodemographic characteristics, obstetric characteristics, knowledge, and perception of health-promoting behavior. Gaining a sound understanding of these factors is vital to reaching the targets of Sustainable Developmental Goal 3-to reduce global maternal mortality and end preventable deaths of children under 5 years of age-by 2030. It is essential to identify pregnant women who are at risk of maternal obesity in order to plan and implement effective and timely interventions for optimal pregnancy outcomes. Importantly, maternal obesity as a significant pregnancy risk factor is largely modifiable.

Lifestyle information and access to a commercial weight management group to promote maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility RCT

Background

Increasing numbers of UK women have overweight or obese body mass index scores when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.

Objectives

The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal-setting and motivation to achieve dietary change commencing 8–16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour.

Design

The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation.

Setting

The setting was a single centre in an inner city setting in the south of England.

Participants

Participants were women with body mass index scores of > 25 kg/m2 at antenatal ‘booking’ and women with normal body mass index scores (18.0–24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks’ gestation.

Main outcome measures

Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs.

Results

Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (> 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended ≥ 10 sessions. Barriers to attending sessions included capability, opportunity and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.

Limitations

The trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain.

Conclusions

It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores who gain excessive gestational weight need to be considered. Commercial weight management groups could support women’s weight management as assessed at 12 months postnatally, with probable greater benefit from attending ≥ 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN39186148.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Healthy weight services in England before, during and after pregnancy: a mixed methods approach

Background

Maternal overweight and obesity are associated with numerous adverse outcomes including higher rates of maternal and infant mortality and morbidity. Overweight and obesity before, during and after pregnancy are therefore a significant public health priority in England. This project explored and mapped healthy weight service availability at different stages of the childbearing cycle.

Methods

A mixed methods approach included a questionnaire-based survey disseminated through Local Maternity Systems and semi-structured interviews or focus groups with providers and commissioners. Current maternal weight service provision was explored along with some of the barriers and facilitators for providing, delivering and accessing healthy weight services. Descriptive statistics were reported for quantitative data and content analysis was used for thematic reporting of qualitative data.

Results

A total of 88 participants responded to the survey. All services were offered most frequently during pregnancy; with healthy eating and/or weight management services offered more often than physical activity services. Few services were targeted specifically at women with a raised body mass index. There was a high degree of inconsistency of service provision in different geographical areas.

Several themes were identified from qualitative data including “equity and variation in service provision”, “need for rigorous evaluation”, “facilitators” to encourage better access or more effective service provision, including prioritisation, a change in focus and co-design of services, “barriers” encountered including financial and time obstacles, poor communication and insufficiently clear strategic national guidance and “the need for additional support”.

Conclusions

There is a need to reduce geographical variation in services and the potential health inequalities that this may cause. Improving services for women with a raised body mass index as well as services which encourage physical activity require additional emphasis. There is a need for more robust evaluation of services to ensure they are fit for purpose. An urgent need for clear national guidance so that healthcare providers can more effectively assist mothers achieve a healthy weight gain was identified. Commissioners should consider implementing strategies to reduce the barriers of access identified such as childcare, transport, location and making services free at the point of use.

Multiple deprivation and other risk factors for maternal obesity in Portsmouth, UK

BACKGROUND

Maternal obesity is known to be associated with a range of adverse outcomes, both for the mothers and their children. It may be more prevalent in areas with higher deprivation as measured by the Index of Multiple Deprivation (IMD), but this has not been demonstrated consistently. This study focused primarily on the relationship between maternal obesity and deprivation in a setting where areas of significant deprivation are surrounded by the overall affluent South East England.

METHODS

The study used the records of 3830 women who delivered under the care of a Portsmouth hospital from 1 April 2013 to 31 March 2014. Logistic regression was used to analyse the association between national IMD quintiles and maternal obesity, accounting for the potential confounders of age, ethnic origin, smoking status and parity.

RESULTS

Following adjustment, women in the most deprived IMD quintile were 1.60 (95% CI: 1.13, 2.26) times more likely to be obese compared to those in the least deprived quintile. Maternal obesity was also found to be associated with ethnicity and parity, but not with age or smoking status.

CONCLUSIONS

Maternal obesity increased with increasing deprivation. IMD may be a useful group-level indicator when planning interventions aimed at tackling maternal obesity.

Sleep disordered breathing in pregnancy: A review of the pathophysiology of adverse pregnancy outcomes

Sleep disordered breathing (SDB) is a common obesity-related co-morbidity with strong associations to cardiometabolic disease. The risk of SDB is increased during pregnancy, particularly among obese pregnant women. Accumulating evidence suggests that an association exists between maternal SDB and the development of adverse pregnancy outcomes, particularly gestational diabetes and hypertensive disorders of pregnancy. Intermittent hypoxia, a central characteristic of SDB, has been shown in animal and clinical studies to dysregulate several biological pathways. This includes the promotion of oxidative stress, increased inflammation, activation of the hypothalamic-pituitary-adrenal axis, increased sympathetic activity and impaired glucose and insulin metabolism. This review considers how, during pregnancy, these pathophysiological processes are plausible mechanisms through which SDB may contribute to an increased risk of adverse outcomes, for the mother and perhaps also the offspring. However, a lack of robust evidence specific to the pregnant population, including limited evaluation of the placental function in affected pregnancies, limits our ability to draw definite conclusions on mechanisms contributing to adverse pregnancy outcomes and, indeed, the strength of association between SDB and certain pregnancy complications.

Obstetric admissions to intensive care units in Australia and New Zealand: a registry-based cohort study

OBJECTIVE

Describe the epidemiology of obstetric patients admitted to an Intensive Care Unit (ICU).

DESIGN

Registry-based cohort study.

SETTING

One hundred and eighty-three ICUs in Australia and New Zealand.

POPULATION

Women aged 15-49 years, admitted to ICU between 2008 and 2017, classified as pregnant, postpartum or with an obstetric-related diagnosis.

METHODS

Data were extracted from the Australia and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and national agencies.

MAIN OUTCOME MEASURES

Incidence of ICU admission, cohort characteristics, maternal outcomes and changes over time.

RESULTS

The cohort comprised 16 063 patients. The annual number of obstetric ICU admissions increased, whereas their proportion of total ICU admissions (1.3%) did not change (odds ratio 1.02, 95% CI 0.99-1.04, P = 0.14). There were 10 518 (65%) with an obstetric-related ICU diagnosis, and 5545 (35%) with a non-obstetric ICU diagnosis. Mean (SD) age was 31 (6.4) years, 1463 (9.1%) were Indigenous, 2305 (14%) were transferred from another hospital, and 3008 (19%) received mechanical ventilation. Median [IQR] length of stay in hospital was 5.2 [3.1-7.9] days, which included 1.1 [0.7-1.8] days in ICU. There were 108 (0.7%) maternal deaths, most (n = 97, 90%) having a non-obstetric diagnosis. There was no change in risk-adjusted length of stay or mortality over time.

CONCLUSIONS

Obstetric patients account for a stable proportion of ICU admissions in Australia and New Zealand. These patients typically have a short length of ICU stay and low hospital mortality.

TWEETABLE ABSTRACT

Obstetric patients in Australia/New Zealand ICUs have a short length of ICU stay and low mortality.

Who Is at Risk for Preeclampsia? Risk Factors for Developing Initial Preeclampsia in a Subsequent Pregnancy

BACKGROUND

The incidence of preeclampsia, which may cause significant maternal and perinatal morbidity, has risen in recent years, therefore it is critical to identify women at risk for preeclampsia. We aimed to identify risk factors in the first pregnancy (not complicated by preeclampsia) for preeclampsia in the subsequent pregnancy.

METHODS

A retrospective population-based nested case-control study was conducted, including all women with first (P1) and second (P2) singleton consecutive deliveries. Women who had experienced preeclampsia in their first pregnancy were excluded. Cases were defined as women with preeclampsia in their second pregnancy, and were compared to the controls, defined as women without this diagnosis in second pregnancy. Characteristics and complications of the first pregnancy were compared between cases and controls, and multivariable regression models were used to study the association between pregnancy complications (in the first pregnancy) and preeclampsia (in the subsequent pregnancy), while adjusting for confounders.

RESULTS

A total of 40,673 women were included in the study, 1.5% of second pregnancies were diagnosed with preeclampsia (n = 627, i.e., Cases). Cases, as compared to controls were older in their 1st pregnancy, with longer inter-pregnancy interval, and were more likely to have the following complications in their first pregnancy: preterm delivery (15.0% vs. 7.7%), low birthweight (17.9% vs. 10.3%), perinatal mortality (3.2% vs. 1.1%), and gestational diabetes (7.0% vs. 2.7%). In the multivariable model, adjusted for maternal age, obesity and inter-pregnancy interval, either one of these first pregnancy complications were independently associated with an increased risk for preeclampsia (adjusted OR for either of first pregnancy complication =1.73; 95% CI 1.37-2.14, <0.001), and the risk was greater for each additional complication (adjusted OR for ≥2 risk factors =3.54; 95% CI 2.28-5.52, p < 0.001).

CONCLUSIONS

Complications in first pregnancy, including preterm delivery, perinatal mortality and gestational diabetes, are risk factors for primary preeclampsia in second pregnancy. First pregnancy may serve as a window of opportunity to identify women at risk for future preeclampsia and other morbidities later in life.