Maternal obesity and pregnancy complications: a review

A Systematic Review and Meta-analysis of Prenatal, Birth, and Postnatal Factors Associated with Attention-Deficit/Hyperactivity Disorder in Children

Previous studies have shown mixed results on the relationship between prenatal, birth, and postnatal ("pregnancy-related") risk factors and attention-deficit/hyperactivity disorder (ADHD). We conducted meta-analyses to identify potentially modifiable pregnancy-related factors associated with ADHD. A comprehensive search of PubMed, Web of Science, and EMBASE in 2014, followed by an updated search in January 2021, identified 69 articles published in English on pregnancy-related risk factors and ADHD for inclusion. Risk factors were included in the meta-analysis if at least three effect sizes with clear pregnancy-related risk factor exposure were identified. Pooled effect sizes were calculated for ADHD overall, ADHD diagnosis, inattention, and hyperactivity/impulsivity. Odds ratios (OR) were calculated for dichotomous measures and correlation coefficients (CC) for continuous measures. Prenatal factors (pre-pregnancy weight, preeclampsia, pregnancy complications, elevated testosterone exposure), and postnatal factors (Apgar score, neonatal illness, no breastfeeding) were positively associated with ADHD overall; the findings for ADHD diagnosis were similar with the exception that there were too few effect sizes available to examine pre-pregnancy weight and lack of breastfeeding. Prenatal testosterone was significantly associated with inattention and hyperactivity/impulsivity. Effect sizes were generally small (range 1.1-1.6 ORs, -0.16-0.11 CCs). Risk factors occurring at the time of birth (perinatal asphyxia, labor complications, mode of delivery) were not significantly associated with ADHD. A better understanding of factors that are consistently associated with ADHD may inform future prevention strategies. The findings reported here suggest that prenatal and postnatal factors may serve as potential targets for preventing or mitigating the symptoms of ADHD.

Mediating processes underlying the associations between maternal obesity and the likelihood of cesarean birth

BACKGROUND

Pregnant women with obesity are more likely to experience cesarean birth compared to women without obesity. Yet, little is known about the underlying mechanisms. The objective of this study was therefore to evaluate how mediators contribute to the association between obesity and prelabor/intrapartum cesarean birth.

METHODS

We retrospectively analyzed Swiss cohort data from 394,812 singleton, cephalic deliveries between 2005 and 2020. Obesity (BMI ≥ 30 kg/m2 ) was defined as the exposure and prelabor or intrapartum cesarean birth as the outcomes. Hypothesized mediators included gestational comorbidities, large-for-gestational-age infant, pregnancy duration >410/7 weeks, slower labor progress, labor induction, and history of cesarean birth. We performed path analyses using generalized structural equation modeling and assessed mediation by a counterfactual approach.

RESULTS

Women with obesity had a cesarean birth rate of 39.36% vs. 24.12% in women without obesity. The path models mainly showed positive direct and indirect associations between obesity and cesarean birth. In the total sample, the mediation models explained up to 39.47% (95% CI 36.92-42.02) of the association between obesity and cesarean birth, and up to 57.13% (95% CI 54.10-60.16) when including history of cesarean birth as mediator in multiparous women. Slower labor progress and history of cesarean birth were found to be the most clinically significant mediators.

CONCLUSIONS

This study provides empirical insights into how obesity may increase cesarean birth rates through mediating processes. Particularly allowing for a slower labor progress in women with obesity might reduce cesarean birth rates and prevent subsequent repeat cesarean births in multiparous women.

Examining the Relationship Between Extreme Temperature, Microclimate Indicators, and Gestational Diabetes Mellitus in Pregnant Women Living in Southern California

Few studies have assessed extreme temperatures' impact on gestational diabetes mellitus (GDM). We examined the relation between GDM risk with weekly exposure to extreme high and low temperatures during the first 24 weeks of gestation and assessed potential effect modification by microclimate indicators.

Methods

We utilized 2008-2018 data for pregnant women from Kaiser Permanente Southern California electronic health records. GDM screening occurred between 24 and 28 gestational weeks for most women using the Carpenter-Coustan criteria or the International Association of Diabetes and Pregnancy Study Groups criteria. Daily maximum, minimum, and mean temperature data were linked to participants' residential address. We utilized distributed lag models, which assessed the lag from the first to the corresponding week, with logistic regression models to examine the exposure-lag-response associations between the 12 weekly extreme temperature exposures and GDM risk. We used the relative risk due to interaction (RERI) to estimate the additive modification of microclimate indicators on the relation between extreme temperature and GDM risk.

Results

GDM risks increased with extreme low temperature during gestational weeks 20--24 and with extreme high temperature at weeks 11-16. Microclimate indicators modified the influence of extreme temperatures on GDM risk. For example, there were positive RERIs for high-temperature extremes and less greenness, and a negative RERI for low-temperature extremes and increased impervious surface percentage.

Discussion

Susceptibility windows to extreme temperatures during pregnancy were observed. Modifiable microclimate indicators were identified that may attenuate temperature exposures during these windows, which could in turn reduce the health burden from GDM.

Metformin Impacts Human Syncytiotrophoblast Mitochondrial Function from Pregnancies Complicated by Obesity and Gestational Diabetes Mellitus in a Sexually Dimorphic Manner

Maternal obesity and gestational diabetes mellitus (GDM) are associated with placental dysfunction, small for gestational age (SGA) offspring, and programming of adult-onset disease. We examine how metformin, commonly used to treat type A2 GDM, affects placental metabolism as well as mitochondrial content and function. Syncytiotrophoblasts (STBs) were prepared from placentas of male and female fetuses collected at term cesarean section from lean (pre-pregnancy BMI < 25), obese (BMI > 30), and obese A2GDM women. Metformin treatment (0.001–10 mM) of STB caused no change in non-mitochondrial respiration but significant concentration-dependent (1 and 10 mM) decreases in basal, maximal, and ATP-linked respiration and spare capacity. Respiration linked to proton leak was significantly increased in STB of male A2GDM placentas at low metformin concentrations. Metformin concentrations ≥1 mM increased glycolysis in STB from placentas from lean women, but only improved glycolytic capacity in female STB. Whereas metformin had little effect on superoxide generation from male STB of any group, it gave a concentration-dependent decrease in superoxide generation from female STB of lean and obese women. Fewer mitochondria were observed in STB from obese women and male STB from lean women with increasing metformin concentration. Metformin affects STB mitochondrial function in a sexually dimorphic manner but at concentrations above those reported in maternal circulation (approximately 0.01 mM) in women treated with metformin for GDM.

Modelling the impact of diet and physical activity on body mass index in pre-pregnant and postpartum women

OBJECTIVES

This study aimed to assess, using simulation modeling, the theoretical effect of key diet and physical activity (PA) modification scenarios could have on body mass index (BMI) in prepregnant and postpartum women.

METHODS

Simulation modeling using data from the 2011 to 2012 National Nutrition and Physical Activity Survey was performed for a subsample of prepregnant and postpartum women. The regression coefficients for each diet and PA component from multivariable linear regression equations for BMI were used to calculate a predicted BMI. Scenario modeling using a moderation approach was applied to targeted diet and PA components for the entire sample and subgroups of populations of women who failed to meet dietary and PA recommendations and among the lowest socioeconomic groups.

RESULTS

In prepregnancy and postpartum scenarios, respectively, increasing whole grains by 2 to 3 servings/d reduced BMI by 1.16 and 0.85 kg/m². For postpartum women, BMI was reduced by 0.28 kg/m² for every 5-g/d increase in fiber intake. A 480- and 540-min/wk increase in PA resulted in average BMI reductions of 0.95 and 1.19 kg/m² in prepregnant and postpartum women, respectively. A similar pattern of theoretical reductions in BMI was observed with increased whole grains, fiber, and PA among the most disadvantaged socioeconomic groups of women.

CONCLUSIONS

Increasing intake of whole grains by 2 to 3 servings/d could result in reductions in BMI of 1.16 and 0.85 kg/m², and a 480- and 540-min/wk increase in PA could result in BMI reduction of 0.95 and 1.19 kg/m² in prepregnant and postpartum women, respectively. This provides an evidence base to guide tailored nutrition messaging for obesity prevention efforts in reproductive age women.

Evidence of lifestyle interventions in a pregnant population with chronic hypertension and/or pre-existing diabetes: A systematic review and narrative synthesis

BACKGROUND

Pregnant people with chronic hypertension, pre-existing diabetes or both are at high risk of developing cardiovascular disease. Lifestyle interventions play an important role in disease management in non-pregnant populations.

AIM

To review the existing evidence of randomised controlled trials (RCTs) that examine lifestyle interventions in pregnant people with chronic hypertension and/or pre-existing diabetes.

METHODS

A systematic review and narrative synthesis was conducted. Five electronic databases were searched from inception to April 2021 for RCTs evaluating antenatal lifestyle interventions in people with chronic hypertension and/or pre-existing diabetes with outcomes to include weight or blood pressure change.

RESULTS

Nine randomised controlled trials including 7438 pregnant women were eligible. Eight studies were mixed pregnant populations that included women with chronic hypertension and/or pre-existing diabetes. One study included only pregnant women with pre-existing diabetes. Intervention characteristics and procedures varied and targeted diet, physical activity and/or gestational weight. All studies reported weight and one study reported blood pressure change. Outcome data were frequently unavailable for the subset of women of interest, including subgroup data on important pregnancy and birth complications. Eligibility criteria were often ambiguous and baseline data on chronic hypertension was often omitted.

CONCLUSION

A lack of primary interventional trials examining the effect of lifestyle interventions on weight and blood pressure outcomes in pregnant populations with chronic hypertension and/or pre-existing diabetes was evident. Lifestyle modification has the potential to alter disease progression. Future trials should address the ambiguity and frequent exclusion of these important populations.

Potential mechanisms and modulators of food intake during pregnancy

Dietary choice during pregnancy is crucial not only for fetal development, but also for long-term health outcomes of both mother and child. During pregnancy, dramatic changes in endocrine, cognitive, and reward systems have been shown to take place. Interestingly, in different contexts, many of these mechanisms play a key role in guiding food intake. Here, we review how food intake may be impacted as a function of pregnancy-induced changes across species. We first summarize changes in endocrine and metabolic signaling in the course of pregnancy. Then, we show how these may be related to cognitive function and reward processing in humans. Finally, we link these to potential drivers of change in eating behavior throughout the course of 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.

A pragmatic lifestyle intervention for overweight and obese women with gestational diabetes mellitus (PAIGE2): A parallel arm, multicenter randomized controlled trial study protocol

Background

The global epidemic of type 2 diabetes (T2D) and obesity has been translated into pregnancy, with approximately 18% of women being diagnosed worldwide with Gestational Diabetes Mellitus (GDM). Whilst preventive strategies have proven effective in the non-pregnant context, attrition rates are high and there is an urgent need to develop a customized, pragmatic lifestyle intervention for women both during and after pregnancy. Diet and exercise modification, behavioral support, and Commercial Weight Management Organizations have been strongly recommended to aid postpartum weight reduction for mothers with previous GDM, subsequently reducing their risk of developing obesity and T2D. This study, informed by a previous pilot study, aims to determine the effectiveness of a pragmatic pregnancy and postpartum lifestyle modification program for overweight women with previous GDM (PAIGE2) to reduce body weight at 12 months postpartum.

Methods/design

This paper summarizes the protocol for the PAIGE2 study, which has been developed based on results from a pilot study (PAIGE). A six center, two parallel arm, 12-month, randomized controlled trial will be conducted across Northern Ireland and the Republic of Ireland (3 centers each), involving 340 women with GDM and body mass index ≥25 kg/m² recruited during pregnancy. The lifestyle intervention involves a one-hour virtual educational program (to take place at 32-36 weeks gestation). Postpartum, the intervention will include monthly phone calls, weekly motivational text messages, weekly step counts, and referral for three months to a Commercial Weight Management Organization (Slimming World). The control arm will receive usual care as offered by the local maternity hospital. The primary outcome is weight loss at 12 months postpartum. Study visits for anthropometric and clinical measurements, fasting blood samples, questionnaires pertaining to health, wellbeing and physical activity will take place at 6 weeks, 6- and 12-months postpartum. Focus groups will be conducted with intervention mothers' post-intervention to determine the acceptability of the study design including utility of a Commercial Weight Management Organization, feasibility of remote patient contact, family involvement and patient satisfaction.

Discussion

The PAIGE2 study will address the gaps in previously conducted research and, if positive, has the potential to have major public health implications for the prevention of future GDM and subsequent T2D.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04579016?term=NCT04579016&draw=2&rank=1, identifier NCT04579016.

Gestational weight gain in women with pre-pregnancy overweight or obesity and anthropometry of infants at birth

Objective

To examine the association of gestational weight gain (GWG) among women with pre-pregnancy overweight or obesity with infant weight and BMI z-score at birth.

Methods

This study is a secondary analysis of a randomized controlled trial including data from 208 infants at birth born by mothers with pre-pregnancy BMI between 28 and 45 kg/m² who completed the APPROACH study (randomized to a high-protein low-glycemic index diet or a moderate-protein moderate-glycemic index diet). This analysis pooled the two diet treatment groups together and data were analyzed using a linear mixed model.

Results

Limiting GWG by 1 kg was associated with lower birthweight (-16 g, P = 0.003), BMI z-score (-0.03SD, P = 0.019), weight z-score (-0.03SD, P = 0.004), and infant abdominal circumference (-0.06 cm, P = 0.039). Infants born by mothers whose GWG was ≤9 kg weighed less (122 g, 95% CI: 6-249, P = 0.040), had similar BMI z-score (0.2SD, 95% CI: -0.06 to 0.55, P = 0.120), and lower incidence of emergency cesarean deliveries (11.5% vs. 23.1%, P = 0.044) compared to infants born by mothers whose GWG was >9 kg. When women were classified into GWG quartiles, women in Q1 (GWG range: -7.0 to 3.2 kg) gave birth to smaller infants (3,420 g, P = 0.015) with lower BMI z-score (-0.5SD, P = 0.041) than women in Q2 (3.3-7.1 kg), Q3 (7.2-10.9 kg) and Q4 (11.1-30.2 kg).

Conclusions

Limiting GWG among women with pre-pregnancy overweight or obesity was associated with lower infant weight, BMI z-score, weight z-score, and abdominal circumference at birth. Moreover, GWG below the Institute of Medicine guideline of a maximum of 9 kg was associated with lower birthweight and fewer emergency cesarean deliveries.

Maternal diabetes negatively impacts fetal health

Diabetes is a chronic metabolic disease affecting an increasing number of people. Although diabetes has negative health outcomes for diagnosed individuals, a population at particular risk are pregnant women, as diabetes impacts not only a pregnant woman's health but that of her child. In this review, we cover the current knowledge and unanswered questions on diabetes affecting an expectant mother, focusing on maternal and fetal outcomes.

A high-protein low-glycemic index diet attenuates gestational weight gain in pregnant women with obesity: the "An optimized programming of healthy children" (APPROACH) randomized controlled trial

BACKGROUND

Prepregnancy overweight and excessive gestational weight gain (GWG) increase the risk of complications and offspring obesity.

OBJECTIVES

We aimed to investigate the effect of a high-protein low-glycemic index (HPLGI) diet on GWG, birth weight, and risk of gestational complications in pregnant women with obesity.

METHODS

A total of 279 women with prepregnancy overweight or obesity (BMI: 28-45 kg/m2), between 18 and 45 y old, and in their late first trimester with singleton pregnancies, were randomly assigned to 1 of 2 ad libitum diets: a high-protein low-glycemic index diet (HPLGI: 25%-28% of energy from protein and glycemic index ≤ 55) and a moderate-protein moderate-glycemic index diet (MPMGI: 15%-18% of energy from protein and glycemic index ∼60). Diets were consumed from gestational week 15 and throughout pregnancy. Participants received dietary guidance by a clinical dietician 9 times to facilitate adherence.

RESULTS

Out of 141 and 138 women randomly assigned to the HPLGI and MPMGI diets, 105 and 104 completed the intervention, respectively (75%). In the available case analyses, GWG was 6.8 ± 1.3 kg among women assigned the HPLGI diet and this was significantly lower, by -1.7 kg (95% CI: -2.8, -0.5 kg; P = 0.004), than the GWG of 8.5 ± 1.3 kg among women assigned the MPMGI diet. There were no significant differences between diets on major neonatal outcomes (birth weight and other anthropometric measures). The incidence of composite pregnancy complications was lower for the HPLGI than for the MPMGI diet (35.4% compared with 53.7%, respectively; P = 0.009), including cesarean delivery (15.4% compared with 28.8%, respectively; P = 0.03). There were no reported maternal, fetal, or neonatal deaths. Incidence of miscarriages (1%-2%) did not differ between groups.

CONCLUSIONS

A moderate increase in dietary protein in conjunction with a reduction in glycemic index during the last 2 trimesters of pregnancy reduced GWG and limited complications and cesarean deliveries among women with overweight or obesity.

Differences in Rates of Low Birth Weight among Prefectures in Japan: An Ecological Study Using Government Statistics Data

The differences in the rates and trends of the overall low birth weight and term low birth weight in recent years are unknown for the Japanese prefectures. In this ecological study, we revealed the rates for each prefecture and investigated the factors affecting the regional differences in these outcomes. Aggregated vital statistics data from 2007 to 2019 were obtained from the Ministry of Health, Labour, and Welfare in Japan. The association between the outcomes and the variables, including the infants’ birth characteristics, medical characteristics, and socioeconomic characteristics of the prefectures, were analyzed. An analysis of repeated-measures data was conducted using the data from 2013 and 2018 for each prefecture. The trend for the rates of overall low birth weight and term low birth weight over the years differed among the prefectures. Moreover, the proportions of multiple births and lean (body mass index <18.5 kg/m2) and obese (body mass index ≥25.0 kg/m2) women had a statistically significant positive association with both the overall low birth weight rate and the term low birth weight rate among the prefectures. It was suggested that to resolve the difference in these outcomes among the prefectures, being obese or underweight needs to be addressed in mothers.

Knowledge, Perception and Practice towards the Risks of Excessive Weight Gain during Pregnancy among Pregnant Mothers at Myung Sung Christian Medical General Hospital, Addis Ababa, Ethiopia

Background

Being overweight and obese represents a severe public health deterioration affecting all population in general and vulnerable groups, such as pregnant women in particular. This study aimed to assess the knowledge, perception and practice towards the risks of excessive weight gain during pregnancy among pregnant mothers at Myung Sung Christian Medical General Hospital.

Methods

An institution based cross-sectional study was conducted from July to August, 2019. A systematic random sampling technique was employed to select participants. A total of 176 respondents were included in the study. Data was collected using interviewer administered questionnaire, observation checklist, and measurements of weight and height. Statistical product and service solution version 20.0 was employed for analysis. Descriptive statistics, using tables and charts, was used to present results.

Results

Gestational diabetes mellitus (83.5%) and high blood pressure (80.7%) were the major known risks associated with excessive weight gain during pregnancy. Based on the mean score, 96(54.5%) had poor knowledge while 80(45.5%) had good knowledge about the risks of excessive weight gain. The majority (92.0%) overweight and all obese pregnant mothers did not know their actual weight status. Similarly, 134(76.1%) of the study participants were not engaged in regular physical exercise during the current pregnancy.

Conclusion

This study revealed that pregnant mothers attending in Korean General Hospital were generally poorly knowledgeable on the risks of excessive weight gain during pregnancy, had poor perception on current weight status and poor practices on their weight gain management. Facility based education and community awareness creation should accompany antenatal care services.

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.

Social support, nutrition and health among women in rural Bangladesh: complex tradeoffs in allocare, kin proximity and support network size

Malnutrition among women of reproductive age is a significant public health concern in low- and middle-income countries. Of particular concern are undernutrition from underweight and iron deficiency, along with overweight and obesity, all of which have negative health consequences for mothers and children. Accumulating evidence suggests that risk for poor nutritional outcomes may be mitigated by social support, yet how social support is measured varies tremendously and its effects likely vary by age, kinship and reproductive status. We examine the effects of different measures of social support on weight and iron nutrition among 677 randomly sampled women from rural Bangladesh. While we find that total support network size mitigates risk for underweight, other results point to a potential tradeoff in the effects of kin proximity, with nearby adult children associated with both lower risk for underweight and obesity and higher risk for iron deficiency and anaemia. Social support from kin may then enhance energy balance but not diet quality. Results also suggest that a woman's network of caregivers might reflect their greater need for help, as those who received more help with childcare and housework had worse iron nutrition. Overall, although some findings support the hypothesis that social support can be protective, others emphasize that social relationships often have neutral or negative effects, illustrating the kinds of tradeoffs expected from an evolutionary perspective. The complexities of these effects deserve attention in future work, particularly within public health, where what is defined as 'social support' is often assumed to be positive. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

The Relationship of Diet and Physical Activity with Weight Gain and Weight Gain Prevention in Women of Reproductive Age

Reproductive-age women often see increased weight gain, which carries an increased risk of long-term overweight and obesity and adverse maternal and child health outcomes. Supporting women to achieve optimal weight through lifestyle modification (diet and physical activity) is of critical importance to reduce weight gain across key reproductive life-stages (preconception, pregnancy and postpartum). This review comprehensively summarizes the current state of knowledge on the contribution of diet and physical activity to weight gain and weight gain prevention in reproductive-aged women. Suboptimal diets including a higher proportion of discretionary choices or energy intake from fats, added sugars, sweets or processed foods are associated with higher weight gain, whereas increased consumption of core foods including fruits, vegetables and whole grains and engaging in regular physical activity are associated with reduced weight gain in reproductive age women. Diet and physical activity contributing to excessive gestational weight gain are well documented. However, there is limited research assessing diet and physical activity components associated with weight gain during the preconception and postpartum period. This review highlights the need for further research to identify key dietary and physical activity components targeting the critical windows of reproductive life-stages in women to best guide interventions to prevent weight gain.

Benefit of insufficient gestational weight gain in obese women with gestational diabetes mellitus: A multicenter study in Portugal

BACKGROUND

Both obesity and gestational diabetes mellitus (GDM) are independent risk factors for adverse maternal and fetal outcomes. The Institute of Medicine (IOM) recommends different targets for an adequate gestational weight gain (GWG), depending on the prepregnancy body mass index, but they have been questioned. We aim to compare obese pregnant women with GDM according to GWG stratification (insufficient, adequate and excessive) with regard to maternal and neonatal outcomes and to clarify whether insufficient GWG can be associated with better outcomes.

METHODS

A multicenter observational study with prospectively collected data of obese singleton pregnant women with GDM was conducted. GWG was expressed according to the 2009 IOM's recommendations.

RESULTS

Of 4563 obese women with GDM, 34.5%, 30.4% and 35.2% registered insufficient, adequate and excessive GWG, respectively. Multiple logistic regression analysis revealed that women with insufficient GWG had lower odds of gestational hypertension, preeclampsia, caesarean section, large for gestational age (LGA) neonates and prediabetes in postpartum. Despite the higher incidence of small for gestational age (SGA) neonates, they were not associated with adverse outcomes. Women with excessive GWG had higher odds of caesarean section, macrosomic and LGA neonates.

CONCLUSIONS

Insufficient GWG in obese women with GDM was beneficial due to better maternal and neonatal outcomes. In clinical practice, we should be strict with regard to weight gain in obese pregnant women with GDM and encourage a reduced GWG, provided an adequate fetal growth is guaranteed.

Placental mitochondrial dysfunction with metabolic diseases: Therapeutic approaches

Both obesity and gestational diabetes mellitus (GDM) lead to poor maternal and fetal outcomes, including pregnancy complications, fetal growth issues, stillbirth, and developmental programming of adult-onset disease in the offspring. Increased placental oxidative/nitrative stress and reduced placental (trophoblast) mitochondrial respiration occur in association with the altered maternal metabolic milieu of obesity and GDM. The effect is particularly evident when the fetus is male, suggesting a sexually dimorphic influence on the placenta. In addition, obesity and GDM are associated with inflexibility in trophoblast, limiting the ability to switch between usage of glucose, fatty acids, and glutamine as substrates for oxidative phosphorylation, again in a sexually dimorphic manner. Here we review mechanisms underlying placental mitochondrial dysfunction: its relationship to maternal and fetal outcomes and the influence of fetal sex. Prevention of placental oxidative stress and mitochondrial dysfunction may improve pregnancy outcomes. We outline pathways to ameliorate deficient mitochondrial respiration, particularly the benefits and pitfalls of mitochondria-targeted antioxidants.

Body Mass Index and Gestational Weight Gain Are Associated with Maternal and Neonatal Outcomes Based on Chinese Women

The objective of the study is to analyze the association between early pregnancy body mass index (BMI), gestational weight gain (GWG), and maternal and neonatal outcomes. The retrospective cohort study was conducted at Quanzhou First Hospital Affiliated to Fujian Medical University from January 2018 to May 2021, with 552 women enrolled. Women were divided into the underweight group, normal weight group, overweight group, and obese group according to early pregnancy BMI. Univariate and multivariate logistic regression analyses were performed. The absolute risk of adverse maternal and neonatal outcomes in the early pregnancy BMI group was calculated to further analyze the association between GWG and adverse maternal and neonatal outcomes. Of the 552 women, 390 (70.65%) women had adverse maternal and neonatal outcomes. The result revealed that overweight was associated with increased risk of adverse maternal and neonatal outcomes (odds ratio (OR): 1.643, 95% confidence interval (CI): 1.006-2.684), maternal complications (OR: 1.937, 95% CI: 1.188-3.159), and large for gestational age (LGA) (OR: 1.905, 95% CI: 1.061-3.422). In the obese group, the risk of adverse maternal and neonatal outcomes (OR: 5.760, 95% CI: 1.997-16.786), maternal complications (OR: 3.112, 95% CI: 1.645-5.887), gestational diabetes mellitus (GDM) (OR: 2.943, 95% CI: 1.509-5.741), cesarean section (OR: 1.899, 95% CI: 1.002-3.599), and preterm delivery (OR: 4.752, 95% CI: 1.395-16.185) increased. Besides, there was an association between insufficient GWG and decreased risk of LGA (OR: 0.392, 95% CI: 0.187-0.826) and higher risk of preterm delivery (OR: 2.818, 95% CI: 1.171-6.784). This study demonstrates that BMI and GWG are related to maternal and neonatal outcomes. It is necessary to regularly monitor the weight of pregnant women during pregnancy. And regional guidelines for GWG also need to be explored.

Associations of maternal metabolic profile with placental and fetal cerebral and cardiac hemodynamics

OBJECTIVE

Maternal obesity and metabolic health affect pregnancy outcomes. We examined whether maternal metabolic profiles are associated with placental and fetal hemodynamics.

STUDY DESIGN

In a population-based prospective cohort study among 1175 women we examined the associations of an adverse maternal metabolic profile in early pregnancy with placental, fetal cerebral and cardiac hemodynamic development. We obtained maternal pre-pregnancy BMI by questionnaire and measured blood pressure, cholesterol, triglycerides and glucose concentrations at a median gestational age of 12.6 (95 % range 9.6-17.1) weeks. An adverse maternal metabolic profile was defined as ≥4 risk factors. Placental and fetal hemodynamics were measured by pulsed-wave-Doppler at a median gestational age of 30.3 (95 % range 28.8-32.3) weeks.

RESULTS

An adverse maternal metabolic profile was associated with a 0.29 Z-score higher (95 %CI 0.08-0.50) fetal cerebral middle artery pulsatility index (PI), but not with placental or fetal cardiac hemodynamic patterns. When the individual components of an adverse maternal metabolic profile were assessed, we observed that higher maternal total cholesterol and triglyceride concentrations were associated with a higher cerebral middle artery PI (Z-score, 0.09 (95 %CI 0.02-0.15), 0.09 (95 %CI 0.03-0.15) per Z-score increase). Higher total and HDL maternal cholesterol concentrations were also associated with a higher aorta ascendens peak systolic velocity (PSV) Z-score, 0.08 (95 %CI 0.01-0.14)), and a larger left cardiac output (Z-score, 0.08 (95 %CI 0.00-0.15), respectively).

CONCLUSION

An adverse maternal metabolic profile, especially higher cholesterol and triglycerides concentrations, are associated with increased fetal cerebral vascular resistance and larger fetal aorta ascendens diameter, PSV and left cardiac output, but not with placental vascular resistance indices. Further studies are needed to identify long-term consequences of the observed associations.

Innovations in Infant Feeding: Future Challenges and Opportunities in Obesity and Cardiometabolic Disease

The field of nutrition in early life, as an effective tool to prevent and treat chronic diseases, has attracted a large amount of interest over recent years. The vital roles of food products and nutrients on the body’s molecular mechanisms have been demonstrated. The knowledge of the mechanisms and the possibility of controlling them via what we eat has opened up the field of precision nutrition, which aims to set dietary strategies in order to improve health with the greatest effectiveness. However, this objective is achieved only if the genetic profile of individuals and their living conditions are also considered. The relevance of this topic is strengthened considering the importance of nutrition during childhood and the impact on the development of obesity. In fact, the prevalence of global childhood obesity has increased substantially from 1990 and has now reached epidemic proportions. The current narrative review presents recent research on precision nutrition and its role on the prevention and treatment of obesity during pediatric years, a novel and promising area of research.

Using a citizens' jury approach to determine a good nutrition resource for pregnant women

OBJECTIVE

The development of user-friendly nutrition resources for pregnant women seldom involves end-users. This qualitative study used a citizens' jury approach to determine if our modification of a longstanding, frequently used dietitian-informed diet and diabetes booklet was deemed to be a good healthy eating resource for pregnant women.

DESIGN

Midwives recruited thirteen first-time pregnant women not requiring specialist obstetric care or specialist dietetic advice for any reason. Participants were sent a copy of the modified healthy eating in pregnancy booklet prior to 'jury day'. Five women were unable to attend the citizens' jury citing reasons such as early labour. At the jury, five experts presented evidence. Participants adjourned, with an independent facilitator, to 'deliberate' as to whether the resource was suitable or not. The verdict was presented, and subsequent discussion was audio-recorded, transcribed and inductively content analysed.

SETTING

Southland, New Zealand.

PARTICIPANTS

Pregnant women aged 19-35 years (n 8), of whom half had a household income <$NZ30 000.

RESULTS

The verdict was 'Yes'; the resource was good. Three themes were derived: communication of health information, resource content and harm reduction in pregnancy. Based on these data, ways to enhance the quality and usability of the booklet were evident.

CONCLUSIONS

Citizens' juries can be used to obtain an independent assessment by end-users of health resources. Our modified diet and diabetes booklet was considered suitable for providing healthy eating advice to pregnant women. Inclusion of end-users' perspectives is critical for end-user relevant content, comprehension and resource credibility.

Metabolomic alternations of follicular fluid of obese women undergoing in-vitro fertilization treatment

Obesity exerts negative effects on the metabolic homeostasis of cells in various tissues, but how it influences ovum metabolism is not fully understood. Previous studies demonstrate that oocyte genes that regulate oxidative stress, lipid metabolism, and inflammation are highly expressed in obese women. However, the metabolic effects of these genetic variations are not clear. To address this gap, we conducted an exploratory evaluation of follicular fluid (FF) metabolites in underweight, normal-weight, overweight, and obese women undergoing in vitro fertilization (IVF) treatment. The FF samples from the underweight (Group A, n = 40), normal-weight (Group B, n = 40), overweight (Group C, n = 40), and obese women (Group D, n = 40) were analyzed using ultra-performance liquid chromatography high-resolution mass spectrometry. A novel, high-coverage, semi-targeted metabolomics method (SWATH to MRM) and a targeted metabolomics method were employed to identify and verify the differential metabolites between the four groups. Sixteen differentially expressed FF metabolites were identified. Increase of BMI was associated with upregulation of 5 metabolites, ganoderiol H, LPI (18:3), sedoheptulose 1,7-bisphosphate, austalide L and 2 - {[hydroxyl (3-hydroxy-4-methoxyphenylmethylidene] amino} acetic acid, and downregulation of 5 metabolites, 1-phenyl-1,3-elcosanedione, retinol acetate, p-Cresol sulfate, setariol and arachidonyl carnitine. These metabolites were enriched in different metabolic pathways of retinol metabolism and fatty acid metabolism. These obesity-related differential metabolites provide a pathogenesis mechanism that explains the decline of oocyte development during obesity. These results suggest that obesity affects follicular environment prior to pregnancy, a time-window that may be important for lifestyle interventions to decrease obesity levels.

Socio-ecological determinants of lifestyle behavior of women with overweight or obesity before, during and after pregnancy: qualitative interview analysis in the Netherlands

Background

Maternal overweight and obesity are related to several health risks in the periods before, during and after pregnancy including a higher risk of gestational diabetes mellitus, preeclampsia and preterm birth. At the same time, women’s daily life quickly changes in these periods. Therefore, we hypothesize that the value of determinants of lifestyle behavior within different levels of the socio-ecological model differ accordingly and influence lifestyle behavior. These dynamics of determinants of lifestyle behavior in the periods before, during and after pregnancy are unexplored and therefore evaluated in this study. These insights are needed to offer appropriate guidance to improve lifestyle in women of childbearing age.

Methods

Individual semi-structured interviews were conducted before, during or after pregnancy in 26 women with overweight or obesity living in the Netherlands. Questions covered all levels of the socio-ecological model, i.e. intrapersonal, interpersonal, institutional and environmental/societal. All interviews were transcribed and coded.

Results

Determinants at all levels of the socio-ecological model were perceived as relevant by women of childbearing age. Various determinants were mentioned including knowledge of a healthy lifestyle, social support, access to customized lifestyle guidance, and distance to healthy lifestyle supporting activities. The importance women attributed to determinants differed between the periods before, during and after pregnancy. Before pregnancy, child’s wellbeing as motivator for adopting a healthy lifestyle was mentioned less frequently than during and after pregnancy. Women described that the interplay and balance between determinants varied on a daily basis, and not merely per period. This was often expressed as fluctuation in energy level per day which influences their willingness to put effort in making healthy choices.

Conclusions

Findings of this study confirm the importance of determinants at multiple socio-ecological levels for shaping lifestyle behavior in women of childbearing age. The findings add to current insights that the perceived importance of determinants and their interplay differ before, during and after pregnancy. They influence lifestyle behavior decisions, not only per period but even on a daily basis, in particular in this phase of life. This perspective can be helpful in optimizing lifestyle guidance for women of childbearing age in order to prevent perinatal complications.

Association between insulin and post-caesarean resuscitation rates in infants of women with GDM: A retrospective study

BACKGROUND

Gestational diabetes mellitus (GDM) and caesarean deliveries independently increase the risk of postoperative complications. There are limited data on the influence of insulin use on the outcomes of neonates who were delivered via caesarean section. We sought to investigate the impact of insulin use in women with GDM on resuscitation rates of infants post caesarean delivery.

METHODS

A retrospective database review of women with singleton term (≥ 37 weeks) pregnancies who were on insulin for GDM delivering between January 2005 and December 2014 at a major metropolitan hospital in Sydney.

RESULTS

One thousand eight hundred and fifty-seven women with GDM were identified. The mean age was 31.01 ± 5.63 years and mean gestational period of 39.07 ± 1.00 weeks. 31.0% received insulin treatment for GDM. Women who were on insulin were older (31.9 ± 5.7 vs 30.6 ± 5.6 years, P < 0.001), had a higher body mass index (BMI) (31.2 ± 7.7 vs 29.0 ± 7.4 kg/m2, P < 0.001), higher rates of preeclampsia (7.3% vs 4.1%, P = 0.004), lower rates of alcohol consumption (0.4% vs 1.7%, P = 0.014), and had infants with lower resuscitation rates (21.2% vs 28.6%, P = 0.001). Infants who required resuscitation had a lower gestational age, lower five-minute APGAR score, and lower birth weight, length, and head circumferences. On multivariate analysis, women with GDM treated with insulin (odds ratio [OR] = 0.69, CI = 0.54-0.89, P = 0.004), higher gestational age (OR = 0.88, CI = 0.78-0.99, P = 0.032), higher maternal BMI (OR = 1.02, CI = 1.01-1.04, P = 0.005), and emergency caesarean (OR = 2.33, CI = 1.74-3.12, P < 0.001) independently predicted incidence of resuscitation.

CONCLUSIONS

The findings suggest a relationship between insulin use and reduced resuscitation rates of infants born from mothers with GDM. Further studies investigating the role, dosage, and criteria for insulin use in women with GDM are required.

Observations on Glucose Excursions With the Use of a Simple Protocol for Insulin, Following Antenatal Betamethasone Administration

AIMS

Pregnant women with diabetes often require preterm delivery. Antenatal betamethasone reduces perinatal morbidity and mortality, but induces hyperglycemia. The primary objective was to observe glucose excursions and determine the preliminary safety of a protocol for subcutaneous insulin following betamethasone administration in an antenatal ward.

MATERIAL AND METHODS

This retrospective study included all women with diabetes who received betamethasone due to anticipated preterm delivery. Glucose excursions were evaluated in the fasting state and 2-h postprandial. Blood glucose values ≥14mmol/L or ≤3.5mmol/L were regarded as unacceptable hyper- and hypoglycemia respectively. Events over the first 96 h were documented.

RESULTS

This study spanned 52 months and included fifty-nine women. Eleven episodes of defined hypoglycemia occurred in six women, all receiving insulin therapy, but none after a corrective dose of insulin. No serious hypoglycemic incident was reported. Seventeen women experienced hyperglycemic incidents almost entirely (47/56) within 48 h of betamethasone administration, most often postprandially (34/56) and in 85% of episodes, preceded by pre-prandial values >9 mmol/L (29/34). 14 (82.4%) of these women were receiving background insulin therapy. No case with gestational diabetes encountered defined hyperglycemia.

CONCLUSIONS

This small study demonstrated preliminary safety of the protocol. Enhanced surveillance is necessary for 72 h after initiation of betamethasone.

Towards Prepared mums (TOP-mums) for a healthy start, a lifestyle intervention for women with overweight and a child wish: study protocol for a randomised controlled trial in the Netherlands

INTRODUCTION

Periconception obesity is associated with a higher risk for adverse perinatal outcomes such as gestational diabetes mellitus, preeclampsia, large for gestational age, operative delivery and preterm birth. Lifestyle interventions during pregnancy have resulted in insufficient effects on reducing these perinatal complications. A few reasons for this disappointing effect can be suggested: (1) the time period during pregnancy for improvement of developmental circumstances is too short; (2) the periconception period in which complications originate is not included; and (3) lifestyle interventions may not have been sufficiently multidisciplinary and customised. A preconception lifestyle intervention might be more effective to reduce perinatal complications. Therefore, the aim of the Towards Prepared mums study is to evaluate the effect of a lifestyle intervention starting prior to conception on lifestyle behaviour change.

METHODS AND ANALYSIS

This protocol outlines a non-blinded, randomised controlled trial. One hundred and twelve women (18-40 years of age) with overweight or obesity (body mass index≥25.0 kg/m²) who plan to conceive within 1 year will be randomised to either the intervention or care as usual group. The intervention group will receive a multidisciplinary, customised lifestyle intervention stimulating physical activity, a healthy diet and smoking cessation, if applicable. The lifestyle intervention and monitoring will take place until 12 months postpartum. The primary outcome is difference in weight in kg from baseline to 6 weeks postpartum. Secondary outcomes are gestational weight gain, postpartum weight retention, smoking cessation, dietary and physical activity habits. Furthermore, exploratory outcomes include body composition, cardiometabolic alterations, time to pregnancy, need for assisted reproductive technologies, perinatal complications of mother and child, and lung function of the child. Vaginal and oral swabs, samples of faeces, breast milk, placenta and cord blood will be stored for evaluation of microbial flora, epigenetic markers and breast milk composition. Furthermore, a cost-effectiveness analysis will take place.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Medical Ethical Committee of Maastricht University Medical Centre+ (NL52452.068.15/METC152026). Knowledge derived from this study will be made available by publications in international peer-reviewed scientific journals and will be presented at (inter)national scientific conferences. A dissemination plan for regional and national implementation of the intervention is developed.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02703753.

Confounding effect of ethnic diversity on booking-in body mass index and prevalence of gestational diabetes and hypertensive disorders in pregnant women in western Sydney 1997-2016

BACKGROUND

Maternal obesity is a key risk factor for morbidity in pregnancy. Accurate data on trends in obesity are required in high-risk populations such as in western Sydney to implement effective policy.

AIMS

This study examines multi-site public hospital data on maternal ethnicity, body mass index (BMI), gestational diabetes mellitus (GDM) and hypertension across 20 years in Western Sydney Local Health District (WSLHD).

MATERIALS AND METHODS

This is a retrospective cohort study of all women who delivered a live birth beyond 20 weeks at Westmead, Blacktown and Auburn Hospitals (WSLHD) between 1 January 1997 and 31 December 2016.

RESULTS

There were 112 308 pregnant women included. Between 1997 and 2006, mean booking-in BMI climbed from 24.9 (median 23.9) to peak at 26.2 (24.9). It then fell to 25.3 (24.1) in 2012 before rising to 25.6 (24.4) in 2016. Rates of hypertensive disorders changed little over the period, with a small fall in pre-eclampsia. In contrast, there was a progressive upward trend in the prevalence of GDM, accelerating considerably after 2010. These trends were associated with a shifting ethnic profile with proportions of Australia/New Zealand-born women falling from 56.9% to 36.8%, while those from South Asia increased from 4.5% to 26.3%.

CONCLUSIONS

Western Sydney booking-in BMI fluctuated between 1997 and 2016, reaching its peak in 2006. Despite this, rates of GDM progressively rose, with one in six mothers in western Sydney now diagnosed with some form of the condition. Both patterns are associated with a notable shift in the ethnic profile of patients booking-in to antenatal care in the region.

Gestational weight gain outside the Institute of Medicine recommendations and adverse pregnancy outcomes: analysis using individual participant data from randomised trials

BACKGROUND

High Body Mass Index (BMI) and gestational weight gain (GWG) affect an increasing number of pregnancies. The Institute of Medicine (IOM) has issued recommendations on the optimal GWG for women according to their pre-pregnancy BMI (healthy, overweight or obese). It has been shown that pregnant women rarely met the recommendations; however, it is unclear by how much. Previous studies also adjusted the analyses for various women's characteristics making their comparison challenging.

METHODS

We analysed individual participant data (IPD) of healthy women with a singleton pregnancy and a BMI of 18.5 kg/m2 or more from the control arms of 36 randomised trials (16 countries). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used to describe the association between GWG outside (above or below) the IOM recommendations (2009) and risks of caesarean section, preterm birth, and large or small for gestational age (LGA or SGA) infants. The association was examined overall, within the BMI categories and by quartile of GWG departure from the IOM recommendations. We obtained aOR using mixed-effects logistic regression, accounting for the within-study clustering and a priori identified characteristics.

RESULTS

Out of 4429 women (from 33 trials) meeting the inclusion criteria, two thirds gained weight outside the IOM recommendations (1646 above; 1291 below). The median GWG outside the IOM recommendations was 3.1 kg above and 2.7 kg below. In comparison to GWG within the IOM recommendations, GWG above was associated with increased odds of caesarean section (aOR 1.50; 95%CI 1.25, 1.80), LGA (2.00; 1.58, 2.54), and reduced odds of SGA (0.66; 0.50, 0.87); no significant effect on preterm birth was detected. The relationship between GWG below the IOM recommendation and caesarean section or LGA was inconclusive; however, the odds of preterm birth (1.94; 1.31, 2.28) and SGA (1.52; 1.18, 1.96) were increased.

CONCLUSIONS

Consistently with previous findings, adherence to the IOM recommendations seem to help achieve better pregnancy outcomes. Nevertheless, even in the context of clinical trials, women find it difficult to adhere to them. Further research should focus on identifying ways of achieving a healthier GWG as defined by the IOM recommendations.

Pregestational body mass index, trimester-specific weight gain and total gestational weight gain: how do they influence perinatal outcomes?

OBJECTIVE

To investigate the association between pre-gestational body mass index (BMI), total gestational weight gain (GWG), and/or trimester-specific weight gain (GWGT) with adverse maternal or perinatal outcomes (AMPOs).

MATERIALS AND METHODS

Maternal clinical characteristics and pregnancy and perinatal outcomes were used to predict AMPOs. The predictive ability of BMI, GWG, or GWGT for AMPOs was analyzed using the area under the curve (AUC). Logistic regression models in a univariate and multivariate analysis were performed to estimate the odds ratios (OR) and 95% confidence intervals (CI) to predict maternal outcomes (pregnancy-induced hypertension, preeclampsia or gestational diabetes mellitus) and perinatal outcomes (small for gestational age, large for gestational age, 5-min Apgar score, admission to neonatal intensive care unit or umbilical cord pH <7.15).

RESULTS

Women with AMPOs (n = 293) were younger with higher rate of nulliparity (p < .001) and with lower height (p = .018) as compared to controls (n = 134). In the univariate study, GWGT in third trimester was associated with double risk of pregnancy-induced hypertension (OR 2.00; 95% CI, 1.01-3.97). Nonetheless, third-trimester GWG and total GWG have a negative relationship with gestational diabetes mellitus OR 0.32 (95% CI, 0.18-0.58) and OR 0.35 (95% CI, 0.21-0.59), respectively. Women with greater overall and in second trimester, GWG have a lower risk of having SGA neonates, OR 0.62 (95% CI, 0.39-0.98) and OR 0.60 (95% CI, 0.37-0.98), respectively. In the multivariate study, pre-gestational BMI is strongly related to the development of preeclampsia and the area under the curve (AUC) of the combination of pre-gestational BMI and total weight gain was 0.832 (95% CI, 0.63-0.81) for preeclampsia and 0.719 (95% CI, 0.71-0.94) for gestational diabetes mellitus.

CONCLUSION

Our results suggest than timing of gestational weight gain influence in maternal and perinatal outcomes. Pre-gestational BMI is a determinant of preeclampsia, maternal weight gain in the third trimester is a determinant of pregnancy-induced hypertension and the increase in total GWG reduces the risk of gestational diabetes mellitus and small for gestational age.

Nutritional adversity, sex and reproduction: 30 years of DOHaD and what have we learned?

It is well established that early life environmental signals, including nutrition, set the stage for long-term health and disease risk - effects that span multiple generations. This relationship begins early, in the periconceptional period and extends into embryonic, fetal and early infant phases of life. Now known as the Developmental Origins of Health and Disease (DOHaD), this concept describes the adaptations that a developing organism makes in response to early life cues, resulting in adjustments in homeostatic systems that may prove maladaptive in postnatal life, leading to an increased risk of chronic disease and/or the inheritance of risk factors across generations. Reproductive maturation and function is similarly influenced by early life events. This should not be surprising, since primordial germ cells are established early in life and thus vulnerable to early life adversity. A multitude of 'modifying' cues inducing developmental adaptations have been identified that result in changes in reproductive development and impairments in reproductive function. Many types of nutritional challenges including caloric restriction, macronutrient excess and micronutrient insufficiencies have been shown to induce early life adaptations that produce long-term reproductive dysfunction. Many pathways have been suggested to underpin these associations, including epigenetic reprogramming of germ cells. While the mechanisms still remain to be fully investigated, it is clear that a lifecourse approach to understanding lifetime reproductive function is necessary. Furthermore, investigations of the impacts of early life adversity must be extended to include the paternal environment, especially in epidemiological and clinical studies of offspring reproductive function.

Preconception management of women with obesity: A systematic review

The prevalence of women of child-bearing age with obesity continues to rise at an alarming rate. This has significant implications for both the short-term and long-term health of mother and offspring. Given the paucity of evidence-based literature in this field, the preconception management of women with obesity is highly variable both between institutions and around the world. This systematic review aims to evaluate studies that inform us about the role of preconception weight loss in the fertility and pregnancy outcomes of women with obesity. Current therapeutic interventions are discussed, with a specific focus on the suitability of weight loss interventions for women with obesity planning pregnancy. There are significant knowledge gaps in the current literature; these are discussed and areas for future research are explored.

Contribution of maternal overweight and obesity to the occurrence of adverse pregnancy outcomes

AIMS

Maternal overweight and obesity in pregnancy are known to increase the risk of a range of complications and adverse pregnancy outcomes. This study estimates the population-level contribution of maternal overweight and obesity to adverse pregnancy outcomes.

METHODS

Data derived from the Australian Capital Territory (ACT) Maternal and Perinatal Data Collection were analysed. A total of 24 161 women who had a singleton birth in 2009-2015, with maternal weight and height information available, were included. In this study, the association between risk factors and outcomes was investigated using multilevel regression modelling. Based on model predictions under various hypothetical maternal weight scenarios, the number and proportion of adverse perinatal outcomes that could be potentially prevented were estimated.

RESULTS

Maternal overweight and obesity were associated with increased risks of gestational diabetes mellitus (GDM), pre-eclampsia, caesarean delivery, preterm birth (PTB), large for gestational age (LGA) and admission to the special care nursery or neonatal intensive care unit (SCN/NICU). The estimated proportions of adverse pregnancy outcomes attributable to overweight and obesity in pregnancy are 29.3% for GDM, 36.2% for pre-eclampsia, 15.5% for caesarean delivery, 21.6% for longer antenatal stay in hospital (≥2 days), 16.3% for extreme PTB, 25.2% for LGA and 6.5% for SCN/NICU admission.

CONCLUSIONS

Maternal overweight and obesity contribute to a large proportion of obstetric complications and adverse outcomes in the ACT. Effective intervention strategies to reduce the prevalence of overweight and obesity in pregnant women could have significant beneficial effects on pregnancy outcomes.

Enablers and barriers to physical activity in overweight and obese pregnant women: an analysis informed by the theoretical domains framework and COM-B model

Background

Obesity during pregnancy is associated with increased risk of gestational diabetes mellitus (GDM) and other complications. Physical activity is a modifiable lifestyle factor that may help to prevent these complications but many women reduce their physical activity levels during pregnancy. Interventions targeting physical activity in pregnancy are on-going but few identify the underlying behaviour change mechanisms by which the intervention is expected to work. To enhance intervention effectiveness, recent tools in behavioural science such as the Theoretical Domains Framework (TDF) and COM-B model (capability, opportunity, motivation and behaviour) have been employed to understand behaviours for intervention development. Using these behaviour change methods, this study aimed to identify the enablers and barriers to physical activity in overweight and obese pregnant women.

Methods

Semi-structured interviews were conducted with a purposive sample of overweight and obese women at different stages of pregnancy attending a public antenatal clinic in a large academic maternity hospital in Cork, Ireland. Interviews were recorded and transcribed into NVivo V.10 software. Data analysis followed the framework approach, drawing on the TDF and the COM-B model.

Results

Twenty one themes were identified and these mapped directly on to the COM-B model of behaviour change and ten of the TDF domains. Having the social opportunity to engage in physical activity was identified as an enabler; pregnant women suggested being active was easier when supported by their partners. Knowledge was a commonly reported barrier with women lacking information on safe activities during pregnancy and describing the information received from their midwife as ‘limited’. Having the physical capability and physical opportunity to carry out physical activity were also identified as barriers; experiencing pain, a lack of time, having other children, and working prevented women from being active.

Conclusion

A wide range of barriers and enablers were identified which influenced women’s capability, motivation and opportunity to engage in physical activity with “knowledge” as the most commonly reported barrier. This study is a theoretical starting point in making a ‘behavioural diagnoses’ and the results will be used to inform the development of an intervention to increase physical activity levels among overweight and obese pregnant women.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1816-z) contains supplementary material, which is available to authorized users.

Health consequences for mother and baby of substantial pre-conception weight loss in obese women: study protocol for a randomized controlled trial

BACKGROUND

Current guidelines for the management of obesity in women planning pregnancy suggest lifestyle modification before conception. However, there is little evidence that lifestyle modification alters pregnancy outcomes. Bariatric surgery results in significant weight loss. This appears to reduce the risk of adverse pregnancy outcomes for the mother but may increase the risk of adverse outcomes for the infant. In order to reduce the risks of obesity-related adverse pregnancy outcomes for both mother and offspring, alternative approaches to the management of obesity in women planning pregnancy are needed.

METHODS/DESIGN

This study, a two-arm, parallel group, randomized control trial, will be conducted at the Metabolic Disorders Centre, University of Melbourne. This trial will recruit 164 women aged 18-38 years with a body mass index of 30-55 kg/m² who plan to conceive in the next 6-12 months. Women will be randomized to one of two 12-week interventions (Group A and Group B). Group A will aim for modest weight loss (MWL; ≤ 3% body weight) using a hypocaloric diet. Group B will aim for substantial weight loss (SWL; 10-15% body weight) using a modified very low energy diet (VLED) program. All participants will be asked to comply with National Health and Medical Research Council (NHMRC) guidelines for exercise and will be provided with standard pre-pregnancy advice according to Royal Australian and New Zealand College of Obstetrics and Gynaecology guidelines. All participants will then be observed for the subsequent 12 months. If pregnancy occurs within the 12-month follow-up period, data on weight and metabolic status of the mother, and pregnancy outcomes of mother and offspring will be recorded. The primary outcome is maternal fasting plasma glucose at 26-28 weeks' gestation, given that this is known to correlate with pregnancy outcomes. Time to conception, live birth rate, gestational weight gain, and a composite of adverse pregnancy outcomes for mother and baby will comprise the secondary outcomes.

DISCUSSION

There is increasing emphasis on obese women losing weight before conception. To date, no randomized controlled trial has demonstrated an effective means of weight loss that results in improved pregnancy outcomes for both mother and baby. This study intends to determine if substantial pre-conception weight loss, achieved using a VLED, improves pregnancy outcomes for mother and baby when compared with standard care. This research will potentially change clinical care of an obese woman planning pregnancy.

TRIAL REGISTRATION

ANZCTR, 12,614,001,160,628 . Registered on 5 November 2014.

Maternal obesity and its association with the mode of delivery and the neonatal outcome in induced labour: Implications for midwifery practice

INTRODUCTION

Maternal obesity carries an increased risk of complications during pregnancy and childbirth. This study investigated whether the body mass index (BMI) of women with induced labour was associated with the mode of delivery and neonatal outcome.

METHODS

This was a retrospective study of primigravidae women under the age of 40 years who were induced at term for various indications. Data were collected from the electronic database of the Maternity Unit where these women gave birth.

RESULTS

We sampled 1274 women with a mean age of 26.3±5.9 years. The mean BMI at booking was 26.5 kg/m², with 28.8% being overweight and 24.3% obese. In the sample, 70.4% had a normal vaginal delivery, 15.4% a caesarean section (CS) and 14.2% an instrumental delivery. An increasing BMI was independently associated with the odds for a CS, with women who were overweight and obese having a 1.58 and 2.75 times greater likelihood for a CS. The CS rate was 10.2% in women with a normal BMI, and increased to 15.8% for overweight and 24.9% for obese women (p<0.001). The increasing BMI did not affect the instrumental delivery rates in our cohort. The Apgar scores at one and five minutes were significantly lower in overweight and obese women compared to women with a normal BMI.

CONCLUSIONS

We show that an increasing BMI in women with induced labour was associated with increased CS rates and lower Apgar scores. These findings highlight the important role of midwives in engaging women in weight management before they get pregnant.

Effects of maternal anthropometrics on pregnancy outcomes in South Asian women: a systematic review

AIM

This systematic review investigates associations between maternal pre-pregnancy/early-pregnancy anthropometrics (e.g. weight and body fat), anthropometric change and pregnancy outcomes in South Asian and White women.

METHODS

Twelve electronic literature databases, reference lists and citations of all included studies were searched. Observational studies published in the English language were included. Descriptive synthesis was used to summarize the evidence base.

RESULTS

Twenty-two studies met the inclusion criteria (403,609 births [351,856 White and 51,753 South Asian]). Nine were prospective cohort studies, nine were retrospective cohort studies and two were cross-sectional studies. Results suggested that in South Asian women, maternal pre-pregnancy/early-pregnancy anthropometrics were associated with anthropometric change, birthweight, mode of delivery and gestational diabetes mellitus (GDM). Gestational anthropometric change was found to be associated with GDM. There was limited evidence to suggest that there may be associations between maternal pre-anthropometrics/early anthropometrics and hypertensive disorders, stillbirth, congenital anomalies, post-natal weight retention and post-natal impaired glucose tolerance. The evidence suggested a combined effect of pre-pregnancy/early-pregnancy anthropometrics and gestational anthropometric change on both GDM and post-natal weight retention.

CONCLUSION

The increased risk of adverse pregnancy outcomes in South Asian women should be considered in guidelines for weight management before and during pregnancy.

The impact of maternal body mass index on external cephalic version success

OBJECTIVE

The purpose of this study is to determine the association between body mass index (BMI) and success of ECV.

METHODS

This is a cross-sectional analysis of singleton live births in the USA from 2010 to 2014 using birth certificate data. Patients were assigned a BMI category according to standard WHO classification. Comparisons of success of ECV between the BMI categories were made using chi-square analysis with normal BMI as the reference group. Cochran-Armitage test was performed to look for a trend of decreasing success of ECV as BMI increased. The odds for successful ECV were estimated using multivariate logistic regression analysis, adjusting for possible confounders.

RESULTS

A total of 51,002 patients with documented ECV were available for analysis. There was a decreased success rate for ECV as BMI increased (p < .01). Women with a BMI of 40 kg/m² or greater had a 58.5% success rate of ECV; women with a normal BMI had 65.0% success rate of ECV. Multivariate analyses demonstrated significant decrease in success of ECV in women with BMI of 40 kg/m² or greater (OR 0.621, CI 0.542-0.712). Among women with BMI of 40 kg/m² or greater with successful ECV, 59.5% delivered vaginally. In contrast, 81.0% of women with normal BMI and successful ECV delivered vaginally.

CONCLUSIONS

Morbidly obese women have decreased success rate of ECV as BMI increases and decreased vaginal delivery rates after successful ECV.

Pre-pregnancy Body Mass Index and Third-Trimester Depressive Symptoms in a Healthy Privately Insured Sample

Objectives  While being overweight (body mass index [BMI] >25) prior to pregnancy is linked to antenatal depression, whether weight is confounded by socioeconomic and/or medical risks is unclear. Study Design  We assessed 66 healthy privately insured pregnant women at M = 35.0 ± 3.3 weeks for symptoms of depression (Inventory for Depressive Symptoms-Self-Report (IDS-SR 30), lifetime history of depression and other psychiatric conditions (Mini International Neuropsychiatric Interview), and pre-pregnancy BMI derived from pre-pregnancy weight (by recall) and directly measured height. Pre-pregnancy overweight (BMI > 25) and antenatal depression (score of mild or greater [14] on the IDS-SR 30) were assessed using logistic regression, controlling for past major depressive disorder (MDD) and demographic factors showing significant between group differences. Results  Pre-pregnancy overweight ( n  = 17; 25.8%) was associated with an increased risk of third trimester depression, independent of past MDD and marital status (odds ratio = 7.47; 95% confidence interval [2.09-26.68]; B (standard error) = 2.010 [0.650]). Conclusion  Replication in a larger sample is suggested to confirm an independent effect of pregravid overweight on third trimester depression.

A pilot intervention to reduce postpartum weight retention and central adiposity in first-time mothers: results from the mums OnLiNE (Online, Lifestyle, Nutrition & Exercise) study

BACKGROUND

Postpartum weight retention (PPWR) increases the risk for obesity and complications during subsequent pregnancies. Few interventions have been successful in limiting PPWR in mothers. The present study assessed the effectiveness of the mums OnLiNE (Online, Lifestyle, Nutrition & Exercise) intervention with respect to reducing PPWR and improving diet, physical activity and sedentary behaviour.

METHODS

A subsample of first-time mothers enrolled in the Extended Melbourne Infant Feeding Activity and Nutrition Trial (InFANT Extend) completed the nonrandomised mums OnLiNE intervention. Women in the intervention (I) group (n = 28) received access to an online calorie tracking program, smartphone app, three telephone counselling calls with a dietitian and written material. Women in two comparison groups (CI and C2) (n = 48; n = 43) were from the control (C1) and intervention (C2) arms of InFANT Extend and received no additional support. Weight and waist circumference were measured objectively. Written surveys assessed diet and physical activity. Sedentary behaviour was self-reported. Linear and logistic regression assessed changes in outcomes between groups from 9 to 18 months postpartum.

RESULTS

Mean PPWR decreased in the (I) group (-1.2 kg) and the C2 group (-1.2 kg), although the changes were not significant. Mean waist circumference for all groups exceeded recommendations at baseline but decreased to below recommendations for women in the (I) group (78.3 cm) and significantly for the (I) group (-6.4 cm) compared to C1 (-1.1 cm; P = 0.002) and C2 (-3.3 cm; P = 0.001). Changes in diet, physical activity or sedentary behaviour were not significant.

CONCLUSIONS

The online intervention reported in the present study shows promise with respect to reducing waist circumference in postpartum women. Further evidence of strategies that may improve weight and related behaviours in this target group is needed.

The views of first time mothers completing an intervention to reduce postpartum weight retention: A qualitative evaluation of the mums OnLiNE study

BACKGROUND

maternal postpartum weight retention (PPWR) has implications for short and long term weight-related health of both the mother and child. Little is known about how mothers perceive they may be best supported to achieve a healthy postpartum weight and healthy lifestyle behaviours. Evaluating existing postpartum weight focussed intervention strategies is an important step in the planning of future programs aimed at supporting new mothers.

AIM

to describe the perspectives of women who completed the mums OnLiNE pilot intervention, regarding the acceptability and effectiveness of a program which aimed to limit PPWR and promote healthy diet and physical activity behaviours in new mothers.

METHOD

descriptive qualitative research methods utilising semi-structured interview questions to explore new mothers' views regarding their participation in the mums OnLiNE intervention were used. All women who completed the intervention were invited to participate in one-on-one interviews via telephone. Interviews were digitally recorded and transcribed verbatim. Data were analysed utilising thematic analysis for common, emerging themes.

FINDINGS

twelve women participated in the interviews. Six main themes including program usefulness, intervention components, walking, self-monitoring, barriers and challenges and future recommendations described women's views of the mums OnLiNE intervention. Women felt well supported being part of the program and their reported awareness of healthy eating increased. Telephone support was the most valued and helpful component of the intervention and the smartphone application for self-monitoring was used more often than the website. Walking was by far the most preferred activity as it was considered enjoyable and achievable and some reported that their incidental walking increased as a result of being part of the program. Lack of time and motivation were the main barriers to participation in the program. Suggestions for future programs included encouraging group support and mother-baby exercise sessions.

CONCLUSION

women perceived the mums OnLiNE intervention to be useful in promoting a healthy lifestyle and valued the support provided. Whilst barriers to participation in healthy lifestyle programs exist, well planned interventions which consider time constraints of new mothers, utilize one-on-one support and offer social engagement with other new mothers may further support women in their attainment of healthy postpartum weight and lifestyle behaviours.

Gestational diabetes mellitus and interpregnancy weight change: A population-based cohort study

BACKGROUND

Being overweight is an important risk factor for Gestational Diabetes Mellitus (GDM), but the underlying mechanisms are not understood. Weight change between pregnancies has been suggested to be an independent mechanism behind GDM. We assessed the risk for GDM in second pregnancy by change in Body Mass Index (BMI) from first to second pregnancy and whether BMI and gestational weight gain modified the risk.

METHODS AND FINDINGS

In this observational cohort, we included 24,198 mothers and their 2 first pregnancies in data from the Medical Birth Registry of Norway (2006-2014). Weight change, defined as prepregnant BMI in second pregnancy minus prepregnant BMI in first pregnancy, was divided into 6 categories by units BMI (kilo/square meter). Relative risk (RR) estimates were obtained by general linear models for the binary family and adjusted for maternal age at second delivery, country of birth, education, smoking in pregnancy, interpregnancy interval, and year of second birth. Analyses were stratified by BMI (first pregnancy) and gestational weight gain (second pregnancy). Compared to women with stable BMI (-1 to 1), women who gained weight between pregnancies had higher risk of GDM-gaining 1 to 2 units: adjusted RR 2.0 (95% CI 1.5 to 2.7), 2 to 4 units: RR 2.6 (2.0 to 3.5), and ≥4 units: RR 5.4 (4.0 to 7.4). Risk increased significantly both for women with BMI below and above 25 at first pregnancy, although it increased more for the former group. A limitation in our study was the limited data on BMI in 2 pregnancies.

CONCLUSIONS

The risk of GDM increased with increasing weight gain from first to second pregnancy, and more strongly among women with BMI < 25 in first pregnancy. Our results suggest weight change as a metabolic mechanism behind the increased risk of GDM, thus weight change should be acknowledged as an independent factor for screening GDM in clinical guidelines. Promoting healthy weight from preconception through the postpartum period should be a target.

Maternal obesity and obstetric outcomes in a tertiary referral center

BACKGROUND AND AIM

Obese women are at an increased risk of various adverse pregnancy outcomes. The aim of our study was to evaluate the impact of obesity on maternal and neonatal outcomes in a tertiary referral center and to compare obstetric outcomes by the level of maternal obesity.

MATERIALS AND METHODS

A cohort study included 3247 women with singleton gestations who gave birth at the Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, in 2010. Pregnancy complications and neonatal outcomes were identified using the hospital Birth Registry database in normal weight (body mass index [BMI] 18.5-24.9kg/m², n=3107) and prepregnancy obese (BMI ≥30kg/m², n=140) women. Pregnancy outcomes were compared according to the level of obesity (BMI 30-34.9kg/m², n=94 and BMI ≥35kg/m², n=46).

RESULTS

Obese women were significantly more likely to have gestational hypertension (OR=8.59; 95% CI, 5.23-14.14; P<0.0001), preeclampsia (OR=2.06; 95% CI, 1.14-3.73; P<0.0001), gestational diabetes (OR=5.56; 95% CI, 3.66-8.49; P<0.0001), dystocia (OR=2.14; 95% CI, 1.36-3.38; P<0.0001), induced labor (OR=2.64; 95% CI, 1.83-3.80; P<0.0001), failed induction of labor (OR=18.06; 95% CI, 8.85-36.84; P<0.0001), cesarean delivery (OR=1.76; 95% CI, 1.25-2.49; P=0.001), large-for-gestational-age newborns (OR=3.68; 95% CI, 2.51-5.39; P<0.0001). Significantly increased risk of gestational diabetes, preeclampsia, dystocia and newborns with Apgar score ≤7 after 5min was only observed in women with BMI ≥35kg/m².

CONCLUSIONS

Maternal obesity is significantly associated with an increased risk of gestational hypertension, preeclampsia, gestational diabetes, dystocia, labor induction, failed induction of labor, large-for-gestational-age newborns and cesarean delivery.