Prevalence and Trends in Prepregnancy Normal Weight - 48 States, New York City, and District of Columbia, 2011-2015

Association of maternal pre-pregnancy or first trimester body mass index with neurodevelopmental impairment or death in extremely low gestational age neonates

OBJECTIVE

To compare the rates of death or survival with severe neurodevelopmental impairment (sNDI) at 2 years among extremely preterm infants in relation to pre-pregnancy or first-trimester maternal body mass index (BMI).

METHODS

This retrospective cohort study included extremely preterm infants (gestational age 220/7-266/7 weeks). The study was conducted at National Institute of Child Health and Human Development Neonatal Research Network sites. The primary outcome was death or sNDI at 2 years.

RESULTS

Data on the primary outcome were available for 1208 children. Death or sNDI was not different among the three groups: 54.9% in normal, 56.1% in overweight, and 53.4% in obese group (p = 0.39). There was no significant difference in mortality, sNDI, moderate/severe cerebral palsy, Bayley Scales of Infant Development (BSID)-III cognitive composite score <70, BSID-III language composite score <70 in adjusted models.

CONCLUSION

Neurodevelopmental outcome was not significantly associated with maternal pre-pregnancy BMI among extreme preterm infants.

Maternal body mass index and necrotizing enterocolitis: A case-control study

INTRODUCTION

Our aim was to determine if maternal body mass index (BMI) is associated with necrotizing enterocolitis (NEC) in a large urban delivery center.

METHODS

This single center retrospective case-control study included 291 infants under gestational age of 33 weeks admitted to the neonatal intensive care unit (NICU) during a 10-year period. Cases of stage 2 and 3 NEC were matched at a ratio of 2 controls (n = 194) to 1 case (n = 97). Maternal BMI was categorized as normal (≤24.9), overweight (25-29.9) and obese (≥30). Chi-square and stepwise logistic regression were used for analysis. A power analysis was performed to determine if sample size was sufficient to detect an association.

RESULTS

Stepwise logistic regression demonstrated no association between NEC and maternal obesity. Maternal hypertension, pre-eclampsia, premature rupture of membranes, maternal exposure to antibiotics, placental abruption and gestational diabetes were not associated with NEC. Power analysis showed the sample size was sufficient to detect an association of NEC with maternal BMI in three groups analyzed. In this case-control study, there was an association between NEC and maternal overweight but not obesity at delivery.

DISCUSSION

Our results did not show a significant association of NEC with maternal obesity. The percent of overweight and obese mothers prior to pregnancy and at delivery was significantly higher in our population than the national average and may be responsible for the limited ability to reveal any association between maternal obesity and NEC.

Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors

INTRODUCTION

In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly.

METHODS

Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches.

RESULTS

Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty.

CONCLUSIONS

The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.

Diabetes in Pregnancy, Neonatal Morbidities, and Early Growth in Moderate or Late Preterm Infants

OBJECTIVES

To compare differences in short term morbidities and early growth among moderate and late preterm infants of mothers with and without diabetes (DM) in pregnancy.

METHODS

In a longitudinal analysis using data from the Pediatrix Clinical Data Warehouse of preterm infants (born 32 0/7 to 36 6/7 weeks) discharged from neonatal intensive care units from 2008 to 2019, health characteristics were compared between DM exposure groups. Change in growth from birth to discharge were compared using linear mixed effects modeling.

RESULTS

Among 301 499 moderate and late preterm infants in the analysis, 14% (N = 42 519) were exposed to DM in pregnancy. Incidence of congenital anomalies, hypoglycemia, and hyperbilirubinemia were higher in DM-group (P < .001), and DM-group was more likely to need respiratory support in the first postnatal days (P = .02). Percent weight change from birth differed by gestational age, such that 36-week DM-group infants remained on average 2% (95% confidence interval [CI]: 1.57 to 2.41) below birth weight on day 14, whereas 32-week DM-group infants were on average 2.1% (95% CI: 1.69 to 2.51) above birth weight on day 14. In the regression analysis, DM-group had faster weight loss in the first postnatal week when stratified by gestational age. The adjusted difference in weight velocity (g per day) from days 0 to 3 was -4.5 (95% CI: -5.1 to -3.9), -6.5 (95% CI: -7.4 to -5.7), and -7.2 (95% CI: -8.2 to -6.2) for infants born 34-, 35-, and 36-weeks, respectively.

CONCLUSIONS

In moderate or late preterm infants, diabetes in pregnancy is associated with common neonatal morbidities. Examination of intensive care nutritional practices may identify reasons for observed differences in weight trajectories by gestational age and diabetes exposure.

Maternal Body Mass Index Trends and Weight Gain in Singleton Pregnancies at the Time of Fetal Anatomic Survey: Changes in the Last Decade and New Trends in the Modern Era

(1) Background: the worldwide impact of overweight and obesity is rising, increasingly resembling an epidemic (a price we have to pay for our new way of living). (2) Methods: our study aims to evaluate the temporal trends and patterns of singleton pregnant women's BMI (body mass index) in our region during a 12-year time frame between 2010 and 2021. (3) Results: We noticed a statistically significant difference between the BMIs of nulliparous and multiparous women and a significantly increased pregestational BMI in women with previous ART (assisted reproductive technology) procedures. Smoking pregnant women had a higher second trimester weight gain, regardless of parity. Women with folic acid supplementation alone had a higher BMI than those with folic acid and multivitamin intake. The weight of both nulliparous and multiparous women with chronic hypertension was statistically significantly higher in all three timeframes. Global weight gain did not reveal any statistically significant changes concerning women with pregestational diabetes, regardless of parity and the pregnancy trimester. (4) Conclusions: our article describes the trends in obesity and overweight in our middle-income country, in which this pathology is continuously growing, negatively influencing our reproductive-aged women and future generations.

Maternal Pre-Existing Diabetes: A Non-Inherited Risk Factor for Congenital Cardiopathies

Congenital heart defects (CHDs) are the most common form of birth defects in humans. They occur in 9 out of 1000 live births and are defined as structural abnormalities of the heart. Understanding CHDs is difficult due to the heterogeneity of the disease and its multifactorial etiology. Advances in genomic sequencing have made it possible to identify the genetic factors involved in CHDs. However, genetic origins have only been found in a minority of CHD cases, suggesting the contribution of non-inherited (environmental) risk factors to the etiology of CHDs. Maternal pregestational diabetes is associated with a three- to five-fold increased risk of congenital cardiopathies, but the underlying molecular mechanisms are incompletely understood. According to current hypotheses, hyperglycemia is the main teratogenic agent in diabetic pregnancies. It is thought to induce cell damage, directly through genetic and epigenetic dysregulations and/or indirectly through production of reactive oxygen species (ROS). The purpose of this review is to summarize key findings on the molecular mechanisms altered in cardiac development during exposure to hyperglycemic conditions in utero. It also presents the various in vivo and in vitro techniques used to experimentally model pregestational diabetes. Finally, new approaches are suggested to broaden our understanding of the subject and develop new prevention strategies.

Trends in Maternal Weight Disparities: Statewide Differences in Rural and Urban Minnesota Residents From 2012 to 2019

INTRODUCTION

Despite research showing substantial weight disparities along the rural-urban continuum, little work has attempted to identify differences in prepregnancy weight status or gestational weight gain (GWG) outcomes between rural and urban birthing people. As such, the goals of this research were to 1) document the prevalence of prepregnancy overweight and obesity and excessive GWG in rural and urban birthing people and 2) examine changes in rural and urban prepregnancy overweight or obesity and excessive GWG over time.

METHODS

Birth certificate data provided sociodemographic variables, prepregnancy body mass index, GWG, and rurality status on 465,709 respondents who gave birth in Minnesota from 2012 to 2019. A series of regression models estimated risk differences in 1) prepregnancy weight status and 2) excessive GWG between rural and urban respondents over time, controlling for relevant covariates.

RESULTS

Rural individuals had a 4.9 percentage-point (95% confidence interval, 4.5-5.3) higher risk of having prepregnancy overweight or obesity compared with urban individuals, and a 2.6 percentage-point (95% confidence interval, 1.9-3.3) higher risk of gaining excessive gestational weight. The disparities in prepregnancy overweight or obesity and excessive gestational weight between rural and urban individuals widened over time.

CONCLUSIONS

These findings contribute to accumulating evidence documenting notable health disparities between rural and urban individuals during the perinatal period and support the need to develop prevention and treatment efforts focused on improving the weight-related health of individuals living in rural communities.

Digital Self-Monitoring Tools for the Management of Gestational Weight Gain: Protocol for a Systematic Review

BACKGROUND

Gestational weight gain (GWG) exceeding the recommendations of the Institute of Medicine (in the United States) is associated with numerous adverse maternal and infant health outcomes. While many behavioral interventions targeting nutrition and physical activity have been developed to promote GWG within the Institute of Medicine guidelines, engagement and results are variable. Technology-mediated interventions can potentially increase the feasibility, acceptability, and reach of interventions, particularly for pregnant women, for whom integration of interventions into daily life may be critical to retention and adherence. Previous reviews highlight GWG self-monitoring as a common intervention component, and emerging work has begun to integrate digital self-monitoring into technology-mediated interventions. With rapid advances in technology-mediated interventions, a focused synthesis of literature examining the role of digital self-monitoring tools in managing GWG is warranted to guide clinical practice and inform future studies.

OBJECTIVE

The proposed review aims to synthesize the emerging research base evaluating digital GWG self-monitoring interventions, primarily focusing on whether the intervention is effective in managing GWG. Depending on the characteristics of the included research, secondary focus areas will comprise intervention recruitment and retention, feasibility, acceptability, and differences between stand-alone and multicomponent interventions.

METHODS

This protocol was developed following the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines for systematic review protocols. The proposed review would use a planned and systematic approach to identify, evaluate, and synthesize relevant and recent empirical quantitative studies (reported in English) examining the use of digital weight self-monitoring tools in the context of technology-mediated interventions to manage GWG in pregnant US adults, with at least 2 instances of data collection. Literature eligible for inclusion will have a publication date between January 2010 and July 2020. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies will be used to assess the methodological quality of included studies across various domains, and results will be synthesized and summarized per the synthesis without meta-analysis guidelines.

RESULTS

The initial queries of 1150 records have been executed and papers have been screened for inclusion. Data extractions are expected to be finished by December 2023. Results are expected in 2024. The systematic review that will be generated from this protocol will offer evidence for the use of digital self-monitoring tools in the management of GWG.

CONCLUSIONS

The planned, focused synthesis of relevant literature has the potential to inform the use of digital weight self-monitoring tools in the context of future technology-mediated interventions to manage GWG. In addition, the planned review has the potential to contribute as part of a broader movement in research toward empirically supporting the inclusion of specific components within more extensive, multicomponent interventions to balance parsimony and effectiveness.

TRIAL REGISTRATION

PROSPERO CRD42020204820; https://tinyurl.com/ybzt6bvr.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50145.

Maternal risk factors in offspring with congenital anomalies of the kidney and urinary tract in Asian women

BACKGROUND

Congenital anomalies of the kidney and urinary tract (CAKUT) are the primary cause of pediatric chronic kidney disease. Maternal body mass index (BMI) before pregnancy, pregestational diabetic mellitus (DM), and gestational diabetic mellitus (GDM) are potential modifiable risk factors for CAKUT in offspring.

METHODS

In this case control study, 4619 neonates were enrolled during 2012-2020 from Kaohsiung Veterans General Hospital in Taiwan. Maternal risk factors before and during pregnancy were compared in children with and without CAKUT. The yearly incidence of CAKUT in offspring and maternal overweight were recorded.

RESULTS

In total, 73 (1.6%) cases of CAKUT in offspring were identified. Maternal overweight before pregnancy (BMI ≥ 24 kg/m2) was an independent risk factor for CAKUT in offspring. No associations of pregestational DM and GDM with CAKUT in offspring were observed. The incidence rates of CAKUT and maternal obesity have increased in the past 10 years.

CONCLUSIONS

Maternal obesity before pregnancy is associated with CAKUT in offspring and should be addressed to ensure better outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.

Association of prepregnancy body mass index and gestational weight gain on severity of optic nerve hypoplasia

BACKGROUND

Optic nerve hypoplasia (ONH) is a birth defect of unknown etiology and a leading cause of visual impairment in developed countries. Recent studies suggest that factors of deprivation and exposures of poor nutritional status, such as lower gestational weight gain (GWG), may be associated with increased risk of ONH. The present study describes the prenatal features of mothers of ONH cases, including prepregnancy BMI and GWG, and the associations with clinical features of disease severity.

METHODS

Retrospective study of prenatal records for cases of ONH enrolled in a research registry. Prepregnancy BMI and GWG were compared to maternal characteristics and clinical findings of ONH severity including bilaterality, hypopituitarism, and neuroradiographic abnormalities.

RESULTS

Compared to population-based normative data of births in the United States, mothers of ONH cases (n = 55) were younger (23.3 vs. 25.8 years; p = 0.03), with higher incidence of inadequate GWG (34.0% vs. 20.4%; p = 0.03) predominantly in the first and second trimesters. The presence of major brain malformations was associated with younger maternal age (21.6 [IQR 19.4, 24.7] vs. 24.9 years [IQR 22.1, 28.5] [p = 0.02]), primiparity (44.1% vs. 13.3%; p = 0.05) and decreased prepregnancy BMI (20.9 kg/m2 [19, 22.5] vs. 25.5 kg/m2 [21.3, 28.2]; p < 0.01).

CONCLUSION

Decreased prepregnancy BMI and inadequate GWG correlated with clinical features of ONH severity, specifically bilateral disease and presence of major brain malformations.

Weight gain patterns among pregnancies with obesity and small- and large-for-gestational-age births

OBJECTIVE

This case-cohort study estimated associations between gestational weight gain (GWG) and small-for-gestational-age (SGA) and large-for-gestational-age (LGA) births stratified by obesity class (I: 30-34.9 kg/m2 ; II: 35-39.9 kg/m2 ; III: ≥40 kg/m2 ) (Magee-Womens Hospital, Pittsburgh, Pennsylvania, 1998-2011).

METHODS

First-trimester GWG was categorized as being below (<0.2 kg), within (0.2-2.0 kg), or above (>2.0 kg) the Institute of Medicine recommendations. For second- and third-trimester GWG, four linear trajectories were derived: approximating maintenance (slope -0.05 ± 0.03 kg/wk), approximating the recommendations (0.27 ± 0.01 kg/wk; reference), higher than the recommendations (0.54 ± 0.01 kg/wk), and highest among those above the recommendations (0.91 ± 0.02 kg/wk).

RESULTS

For classes I, II, and III, respectively, there were 1290, 1247, and 1198 pregnancies in the subcohort; 262, 171, and 123 SGA cases; and 353, 286, and 257 LGA cases. First-trimester GWG was not associated with SGA/LGA births. Second- and third-trimester weight maintenance was associated with potentially lower LGA risk (risk ratio [RR]: 0.80; 95% confidence interval [CI]: 0.55-1.1) but not higher SGA risk (RR: 0.98; 95% CI: 0.64-1.5) for class III. In addition, some sensitivity analyses supported no increased SGA risk with second- and third-trimester weight maintenance for classes I and II.

CONCLUSIONS

Second- and third-trimester weight maintenance may be associated with more optimal birth weight for gestational age. However, how this could be achieved (e.g., through diet and exercise interventions) is unclear, given the observational design of our study.

Impact of Co-Occurrence of Obesity and SARS-CoV-2 Infection during Pregnancy on Placental Pathologies and Adverse Birth Outcomes: A Systematic Review and Narrative Synthesis

Obesity is a risk factor for severe COVID-19 disease during pregnancy. We hypothesized that the co-occurrence of high maternal body mass index (BMI) and gestational SARS-CoV-2 infection are detrimental to fetoplacental development. We conducted a systematic review following PRISMA/SWiM guidelines and 13 studies were eligible. In the case series studies (n = 7), the most frequent placental lesions reported in SARS-CoV-2(+) pregnancies with high maternal BMI were chronic inflammation (71.4%, 5/7 studies), fetal vascular malperfusion (FVM) (71.4%, 5/7 studies), maternal vascular malperfusion (MVM) (85.7%, 6/7 studies) and fibrinoids (100%, 7/7 studies). In the cohort studies (n = 4), three studies reported higher rates of chronic inflammation, MVM, FVM and fibrinoids in SARS-CoV-2(+) pregnancies with high maternal BMI (72%, n = 107/149; mean BMI of 30 kg/m2) compared to SARS-CoV-2(−) pregnancies with high BMI (7.4%, n = 10/135). In the fourth cohort study, common lesions observed in placentae from SARS-CoV-2(+) pregnancies with high BMI (n = 187 pregnancies; mean BMI of 30 kg/m2) were chronic inflammation (99%, 186/187), MVM (40%, n = 74/187) and FVM (26%, n = 48/187). BMI and SARS-CoV-2 infection had no effect on birth anthropometry. SARS-CoV-2 infection during pregnancy associates with increased prevalence of placental pathologies, and high BMI in these pregnancies could further affect fetoplacental trajectories.

Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial

BACKGROUND

Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m², particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population.

METHODS

This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m². The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (34^0/7-36^6/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling.

DISCUSSION

This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m². This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04258709.

Maternal first trimester metabolic profile in pregnancies with transposition of the great arteries

BACKGROUND

Higher maternal body mass index (BMI) and abnormal glucose metabolism during early pregnancy are associated with congenital heart defects in the offspring, but the exact mechanisms are unknown.

METHODS

We evaluated the association between maternal first trimester metabolic profile and transposition of the great arteries (TGA) in the offspring in a matched case-control study with 100 TGA mothers and 200 controls born in Finland during 2004-2014. Cases and controls were matched by birth year, child sex, and maternal age and BMI. Serum samples collected between 10- and 14-weeks of gestation were analyzed for 73 metabolic measures. Conditional logistic regression was used to assess the risk for TGA in the offspring, and a subgroup analysis among mothers with high BMI was conducted.

RESULTS

Higher concentrations of four subtypes of extremely large very-low-density lipoprotein (VLDL) particles and one of large VLDL particles were observed in TGA mothers. This finding did not reach statistical significance after multiple testing correction. The pooled odds ratio (OR) of the all metabolic variables was slightly higher in TGA mothers in the subgroup with maternal BMI over 25 (OR 1.25) and significantly higher in the subgroup with maternal BMI over 30 (OR 1.95) compared to the original population (OR 1.18).

CONCLUSIONS

Our findings indicate that an abnormal maternal early pregnancy metabolic profile might be associated with TGA in the offspring, especially in obese mothers. A trend indicating altered VLDL subtype composition in TGA pregnancies warrants further research.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Maternal diet disrupts the placenta-brain axis in a sex-specific manner

High maternal weight is associated with detrimental outcomes in offspring, including increased susceptibility to neurological disorders such as anxiety, depression and communicative disorders. Despite widespread acknowledgement of sex biases in the development of these disorders, few studies have investigated potential sex-biased mechanisms underlying disorder susceptibility. Here, we show that a maternal high-fat diet causes endotoxin accumulation in fetal tissue, and subsequent perinatal inflammation contributes to sex-specific behavioural outcomes in offspring. In male offspring exposed to a maternal high-fat diet, increased macrophage Toll-like receptor 4 signalling results in excess microglial phagocytosis of serotonin (5-HT) neurons in the developing dorsal raphe nucleus, decreasing 5-HT bioavailability in the fetal and adult brains. Bulk sequencing from a large cohort of matched first-trimester human samples reveals sex-specific transcriptome-wide changes in placental and brain tissue in response to maternal triglyceride accumulation (a proxy for dietary fat content). Further, fetal brain 5-HT levels decrease as placental triglycerides increase in male mice and male human samples. These findings uncover a microglia-dependent mechanism through which maternal diet can impact offspring susceptibility for neuropsychiatric disorder development in a sex-specific manner.

Prenatal medication use in a prospective pregnancy cohort by pre-pregnancy obesity status

BACKGROUND

The association between obesity (body mass index (BMI) ≥ 30 kg/m2) and pattern of medication use during pregnancy in the United States is not well-studied. Higher pre-pregnancy BMI may be associated with increases or decreases in medication use across pregnancy as symptoms (e.g. reflux) or comorbidities (e.g. gestational diabetes) requiring treatment that may be associated with higher BMI could also change with advancing gestation.

OBJECTIVES

To determine whether prenatal medication use, by the number and types of medications, varies by pre-pregnancy obesity status.

METHODS

In a secondary data analysis of a racially/ethnically diverse prospective cohort of pregnant women with low risk for fetal abnormalities enrolled in the first trimester of pregnancy and followed to delivery (singleton, 12 United States clinical sites), free text medication data were obtained at enrollment and up to five follow-up visits and abstracted from medical records at delivery.

RESULTS

In 436 women with obesity and 1750 women without obesity (pre-pregnancy BMI, 19-29.9 kg/m2), more than 70% of pregnant women (77% of women with and 73% of women without obesity) reported taking at least one medication during pregnancy, respectively (adjusted risk ratio (aRR)=1.10, 95% confidence interval (CI)=1.01, 1.20), with 81% reporting two and 69% reporting three or more. A total of 17 classes of medications were identified. Among medication classes consumed by at least 5% of all women, the only class that differed between women with and without obesity was hormones and synthetic substitutes (including steroids, progesterone, diabetes, and thyroid medications) in which women with obesity took more medications (11 vs. 5%, aRR = 1.9, 95% CI = 1.38, 2.61) compared to women without obesity. Within this class, a higher percentage of women with obesity took diabetes medications (2.3 vs. 0.7%) and progesterone (3.4 vs. 1.3%) than their non-obese counterparts. Similar percentages of women with and without obesity reported consuming medications in the remaining medication classes including central nervous system agents (50 and 46%), gastrointestinal drugs (43 and 40%), anti-infective agents (23 and 21%), antihistamines (20 and 17%), autonomic drugs (10 and 9%), and respiratory tract agents (7 and 6%), respectively (p > 0.05 for all adjusted comparisons). There were no differences in medication use by obesity status across gestation. Since the study exclusion criteria limited the non-obese group to women without thyroid disease, in a sensitivity analysis we excluded all women who reported thyroid medication intake and still a higher proportion of women with obesity took the hormones and synthetic substitutes class compared to women without obesity.

CONCLUSION

Our findings suggest that pre-pregnancy obesity in otherwise healthy women is associated with a higher use of only selected medications (such as diabetes medications and progesterone) during pregnancy, while the intake of other more common medication types such as analgesics, antibiotics, and antacids does not vary by pre-pregnancy obesity status. As medication safety information for prenatal consumption is insufficient for many medications, these findings highlight the need for a more in-depth examination of factors associated with prenatal medication use.

Maternal Pre-Pregnancy Body Mass Index, Gestational Weight Gain and Children’s Cognitive Development: A Birth Cohort Study

To investigate the joint effect of maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) on children’s cognitive development. We recruited 1685 mother–child pairs from the Ma’anshan Birth Cohort in China. Pre-pregnancy BMI and GWG were calculated based on the height and weights measured at multiple antenatal checkups. Children’s cognition was assessed by Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition. Poisson regression model was used to analyze the association between maternal pre-pregnancy BMI and children’s cognitive dimensions under different GWG categories. Women with overweight or obese before pregnancy were more likely to obtain excessive GWG. When women had excessive GWG, pre-pregnancy overweight was associated with low children’s PSI (OR = 1.69, 95%CI: 1.02–2.81) and pre-pregnancy obesity was related to poor VCI in children (OR = 3.71, 95%CI: 1.49–9.22), after adjusting for potential confounders. In pre-pregnancy underweight mothers, adequate GWG reduced the risk of below-average VSI in children (OR = 0.22, 95%CI: 0.05–0.92), but excessive GWG was related to low FSIQ in children (OR = 2.53, 95%CI: 1.34–4.76). In women with excessive GWG, maternal pre-pregnancy BMI displays an inverted U-shape association with children’s cognition. Moreover, adequate GWG in women with pre-pregnancy underweight was beneficial for children’s cognition.

Gestational weight gain adequacy among twin pregnancies in France

The objective of this paper is to describe gestational weight gain (GWG), to assess the applicability of the 2009 Institute of Medicine (IOM) guidelines, and to derive a GWG adequacy classification within a French cohort. We included twins from the national, prospective, population-based JUmeaux MODe d'Accouchement (JUMODA) cohort study (2014-2015). Following the IOM approach, we selected a 'standard' population of term pregnancies with 'optimal' birthweight (≥2500 g; n = 2562). GWG adequacy (insufficient; adequate; excessive) was defined using IOM recommendations (normal body mass index [BMI]: 16.8-24.5 kg [also utilized for underweight BMI]; overweight: 14.1-22.7 kg; obese: 11.4-19.1 kg). Additionally, using the IOM approach, we determined the 25th and 75th percentiles of GWG in our standard population to create a JUMODA-derived GWG adequacy classification. GWG and GWG adequacy were described, overall and by BMI and parity. In the JUMODA standard population of term twin livebirths with optimal birthweight, mean GWG was 16.1 kg (standard deviation 6.3). Using IOM recommendations, almost half (46.5%) of the women had insufficient and few (10.0%) had excessive GWG, with similar results regardless of BMI or parity. The 25th and 75th percentiles of GWG in the JUMODA standard population (underweight: 13-21 kg; normal weight: 13-20 kg; overweight: 11-19 kg; obese: 7-16 kg) were lower than the IOM recommendations. The IOM recommendations classified a relatively high percentage of French women as having insufficient and a low percentage as having excessive GWG. Additional research to evaluate recommendations in relation to adverse perinatal outcomes is needed to determine whether the IOM recommendations or the JUMODA-derived classification is more appropriate for French twin gestations.

Early Growth and Cognitive Development in Children Born Preterm: Relevance of Maternal Body Mass Index

OBJECTIVE

Maternal prepregnancy body mass index (BMI) represents a surrogate marker of fetal exposures to the maternal metabolism during pregnancy. Yet, it remains poorly understood whether this marker indicates risk of altered trajectories in postnatal growth and development in children born preterm. This study aimed to determine whether maternal prepregnancy BMI is associated with altered growth and development in children born preterm.

STUDY DESIGN

A retrospective cohort study evaluated prepregnancy BMI as the exposure for childhood outcomes using linear regression and mixed effects models. The 38 children included in this follow-up evaluation originally participated in a prospective, observational cohort study to determine longitudinal levels of lipid species in preterm human milk expressed by women who delivered prior to 32 weeks. Childhood outcomes in this study were anthropometric measures during hospitalization (n = 38), after discharge through 36 months (n = 34) and Bayley-III developmental scores through 18 months corrected age (n = 26).

RESULTS

In 38 children born prior to 32 weeks, higher maternal prepregnancy BMI was independently associated with higher preterm infant growth velocity during hospitalization, but not associated with in-hospital change in length or head circumference and/or postdischarge growth. In univariate linear regression models, higher maternal BMI was associated with lower cognitive scores at 18 months corrected age. This significant association remained in an adjusted model accounting for relevant influences on early childhood development.

CONCLUSION

Increasing maternal prepregnancy BMI may reflect risk of altered growth and cognitive development in children born preterm.

KEY POINTS

· Maternal BMI was associated with early preterm infant weight gain.. · Maternal BMI was not associated with postdischarge growth.. · Increased maternal BMI may be associated with lower cognitive function scores in offspring..

Zac1 and the Imprinted Gene Network program juvenile NAFLD in response to maternal metabolic syndrome

BACKGROUND AND AIMS

Within the next decade, NAFLD is predicted to become the most prevalent cause of childhood liver failure in developed countries. Predisposition to juvenile NAFLD can be programmed during early life in response to maternal metabolic syndrome (MetS), but the underlying mechanisms are poorly understood. We hypothesized that imprinted genes, defined by expression from a single parental allele, play a key role in maternal MetS-induced NAFLD, due to their susceptibility to environmental stressors and their functions in liver homeostasis. We aimed to test this hypothesis and determine the critical periods of susceptibility to maternal MetS.

APPROACH AND RESULTS

We established a mouse model to compare the effects of MetS during prenatal and postnatal development on NAFLD. Postnatal but not prenatal MetS exposure is associated with histological, biochemical, and molecular signatures of hepatic steatosis and fibrosis in juvenile mice. Using RNA sequencing, we show that the Imprinted Gene Network (IGN), including its regulator Zac1, is up-regulated and overrepresented among differentially expressed genes, consistent with a role in maternal MetS-induced NAFLD. In support of this, activation of the IGN in cultured hepatoma cells by overexpressing Zac1 is sufficient to induce signatures of profibrogenic transformation. Using chromatin immunoprecipitation, we demonstrate that Zac1 binds the TGF-β1 and COL6A2 promoters, forming a direct pathway between imprinted genes and well-characterized pathophysiological mechanisms of NAFLD. Finally, we show that hepatocyte-specific overexpression of Zac1 is sufficient to drive fibrosis in vivo.

CONCLUSIONS

Our findings identify a pathway linking maternal MetS exposure during postnatal development to the programming of juvenile NAFLD, and provide support for the hypothesis that imprinted genes play a central role in metabolic disease programming.

The association of maternal obesity with fetal pH in parturients undergoing cesarean delivery under spinal anesthesia

OBJECTIVE

The aim of this study was to examine the relationship between maternal obesity and fetal umbilical arterial pH in a cohort of parturients that received a prophylactic phenylephrine infusion for management of spinal anesthesia induced hypotension during cesarean delivery.

METHODS

This was a retrospective cohort study of cesarean deliveries at a single academic tertiary care institution between January 2012 and March 2019. All scheduled nonlaboring cesarean deliveries of singleton live neonate performed under spinal anesthesia between 37 and 41 weeks gestational age were included. The primary outcome was umbilical arterial pH. Multiple regression models were used to test the relationship between umbilical arterial pH, and maternal body mass index (BMI), race, dose of phenylephrine, baseline systolic blood pressure, maximum decrease in systolic blood pressure, induction of anesthesia to delivery time and uterine incision to delivery time.

RESULTS

Seven hundred and sixty-one mother neonate pairs were included in the study. The univariate analysis showed a decrease in mean umbilical arterial pH with increasing maternal BMI (p = <.01). A multivariate regression model indicated that maximum decrease in systolic blood pressure, induction of anesthesia to delivery time, and uterine incision to delivery time accounted for 11% of the variance in the outcome, R² = 0.11. BMI was not a significant predictor of low umbilical arterial pH (p = .36). The significant predictors of low umbilical arterial pH in the model were maximum decrease in systolic blood pressure (p < .001), induction of anesthesia to delivery time (p = .04), and uterine incision to delivery time (p < .001).

CONCLUSIONS

Maternal BMI is not associated with lower umbilical arterial pH in women having scheduled cesarean delivery under spinal anesthesia. Severity of spinal anesthesia induced hypotension is greater with increasing BMI and may be responsible for the observed decrease in umbilical arterial pH.

Changes in the Incidence of Childhood Obesity

OBJECTIVES

Examine childhood obesity incidence across recent cohorts.

METHODS

We examined obesity incidence and prevalence across 2 cohorts of children in the United States 12 years apart using the Early Childhood Longitudinal Studies, parallel data sets following the kindergarten cohorts of 1998 and 2010 with direct anthropometric measurements at multiple time points through fifth grade in 2004 and 2016, respectively. We investigated annualized incidence rate and cumulative incidence proportion of obesity (BMI z-score ≥95th percentile based on Centers for Disease Control and Prevention weight-for-age z-scores).

RESULTS

Among children who did not have obesity at kindergarten entry, there was a 4.5% relative increase in cumulative incidence of new obesity cases by end of fifth grade across cohorts (15.5% [14.1%-16.9%] vs 16.2% [15.0%-17.3%]), though annual incidence did not change substantially. The risk of incident obesity for children who had normal BMI at kindergarten entry stayed the same, but the risk of incident obesity among overweight kindergartners increased slightly. Social disparities in obesity incidence expanded: incidence of new cases during primary school among non-Hispanic Black children increased by 29% (95% confidence interval, 25%-34%), whereas risk for other race-ethnic groups plateaued or decreased. Children from the most socioeconomically disadvantaged households experienced 15% higher cumulative incidence across primary school in 2010 than 1998.

CONCLUSIONS

Incidence of childhood obesity was higher, occurred at younger ages, and was more severe than 12 years previous; thus, more youths may now be at risk for health consequences associated with early onset of obesity.

Weight gain during pregnancy: A narrative review on the recent evidences

Gestational weight gain is necessary for the normal fetus development, in fact a series of studies have evidenced that both low and excessive gestational weight gain is associated with negative fetal-neonatal outcomes. So, evidences on the optimal gestational weight gain across the ranges of the pre-pregnancy maternal body mass index are necessary. In this context, while for normal weight and underweight the recommendations of IOM are clearly stated and supported by well designed and conducted clinical studies, those for the obese pregnant women are even today debated. Pre-pregnancy obesity is associated with high risk to develop hypertension, gestational diabetes, cesarean section and high birth weight. The Institute of Medicine guidelines, in 2009, recommended that women with obesity gain 11-20 lb at a rate of 0.5 lb/week during the second and third trimesters of pregnancy. Successively, taking into account a series of meta-analysis, the American College of Obstetricians and Gynecologists emphasized that the IOM weight gain targets for obese pregnant women are too high. However the high risk to have babies small for gestational age, related to a low weight gain or a losing of weight during pregnancy, has also been demonstrated. More recent studies have taken into consideration the maternal and fetal outcomes of obese pregnant women with different obesity class (I,II,III) and different weight gain during pregnancy. The analysis of these studies, discussed in this narrative review, show that the appropriate gestational weight gain should be personalized considering the three obesity class; furthermore both an upper and lower limit of gestational weight gain should be reconsidered in order to prevent the negative maternal and fetal outcomes in these women.

Trends and outcomes for deliveries with hypertensive disorders of pregnancy from 2000 to 2018: A repeated cross-sectional study

OBJECTIVE

To analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP).

DESIGN

Repeated cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

US hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest.

MAIN OUTCOME MEASURES

Prevalence of HDP, risk factors for HDP and associated adverse outcomes.

RESULTS

Of 73.1 million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased.

CONCLUSION

Hypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased.

TWEETABLE ABSTRACT

While hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.

"There's a Lot of Like, Contradicting Stuff"-Views on Healthy Living during Pregnancy and Postpartum

The transition from pregnancy through early postpartum can be a particularly vulnerable time for women as they adjust to the changes of motherhood. This study aimed to provide a detailed account of additional health challenges that mothers are facing throughout motherhood during the pandemic. Data obtained can be utilized to create tailored interventions to aid women during their reproductive years. A sequential approach was utilized, collecting health-related information via survey and subsequent focus groups or interviews to further examine health experiences during pregnancy or postpartum. Fifty-seven participants completed the online survey, 73.5% were postpartum. The healthy eating index of the cohort was low, 50.5 ± 10.3%. Prior to pregnancy, 54.5% were classified as overweight/obese. Following pregnancy, 71.1% were classified as overweight or obese. Emergent qualitative themes from focus groups (n = 3) and interviews (n = 6) included (1) value and desire for healthy eating, (2) desire to make well-informed health-based decisions, and (3) role of social networks during pregnancy and postpartum. Pregnant/postpartum women desire to lead a healthy lifestyle but experience barriers to accomplishing intended goals. Upstream resources and policies that promote healthy living for pregnant/postpartum women can reduce chronic disease throughout the lifespan following childbirth.

Should body mass index replace age to drive the decision for endometrial sampling in premenopausal women with abnormal uterine bleeding?

OBJECTIVE

This study aimed to evaluate risk factors for endometrial intraepithelial neoplasia/malignancy in premenopausal women with abnormal uterine bleeding or oligomenorrhea. Specifically, we aimed to elucidate whether body mass index (BMI) or age confers a higher risk.

STUDY DESIGN

A retrospective cohort study was performed at a large academic center examining risk factors for endometrial hyperplasia/malignancy in premenopausal women undergoing endometrial sampling.

RESULTS

Of the 4170 women ages 18-51 who underwent endometrial sampling from 1987 to 2019, 77 (1.85%) were found to have endometrial intraepithelial neoplasia or malignancy. Clinical predictors of EIN/malignancy in this population included obesity (OR: 3.84, 95%, p < .001), Body mass index [(OR30 vs. 25:2.11, p < .001) and OR35 vs. 30: 1.65, p < .001], Diabetes (OR: 3.6, p-value <.001), hormonal therapy use (OR: 2.93, p < .001), personal history of colon cancer (OR: 9.90, p = .003), family history of breast cancer (OR: 2.65, p < .001), family history of colon cancer (OR: 3.81, p < .001), and family history of endometrial cancer (OR: 4.92, p = .033). Age was not significantly associated with an increased risk of disease. Adjusting for other factors, a model using BMI to predict the risk of EIN/malignancy was more discriminative than a model based on age.

CONCLUSIONS

Increased BMI, may be more predictive of endometrial hyperplasia/malignancy than age in premenopausal women with abnormal uterine bleeding. Modification of evaluation guidelines in a contemporary demographic setting could be considered.

The Influence of Maternal Weight and Alcohol Exposure on Infant Physical Characteristics and Neurodevelopmental Outcomes

•

Maternal weight was inversely related with infant dysmorphology score.

•

The rate of change was similar among all infants regardless of maternal weight.

•

Maternal weight may be protective but does not eliminate adverse effects of alcohol.

•

Regardless of maternal weight during pregnancy, alcohol remains a teratogen.

Background

Mothers of children with fetal alcohol spectrum disorders tend to have lower weight compared to other mothers. Yet how alcohol and maternal weight may predispose infants to poorer physical growth and neurodevelopmental trajectories is relatively unexplained.

Methods

South African mothers (n = 406) were recruited prenatally and their offspring were provided standardized dysmorphology and neurodevelopment examinations at 6 weeks and 9 months of age. Maternal weight was obtained postpartum, and linear mixed modeling determined whether postpartum maternal weight and prenatal alcohol exposure significantly influenced infant growth, dysmorphology, and neurodevelopment within the first year of life.

Results

Postpartum maternal weight was positively associated with birth length, weight, and head circumference centile, but the rate of growth from birth to nine months was similar among all infants. Maternal weight was inversely associated with dysmorphology. Many infants in this population were performing within the borderline or extremely low range. Higher maternal weight was associated with significantly better cognitive and motor performance at 6 weeks; however, the rate of developmental growth was similar among all infants, regardless of postpartum maternal weight.

Conclusion

Higher postpartum maternal weight may be a protective factor but does not eliminate the adverse effects of alcohol on infant growth and dysmorphology. Regardless of maternal weight, alcohol remains a powerful teratogen and moderate to high use prenatally can result in adverse infant physical and neurocognitive development.

Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: a narrative review

The global prevalence of overweight and obesity in pregnancy is rising and this represents a significant challenge for the management of pregnancy and delivery. Women who have a pre‐pregnancy body mass index greater than 25 kg m^–2 are more likely than those with a body mass index in the ideal range (20–24.99 kg m^–2) to have problems conceiving a child and are at greater risk of miscarriage and stillbirth. All pregnancy complications are more likely with overweight, obesity and excessive gestational weight gain, including those that pose a significant threat to the lives of mothers and babies. Labour complications arise more often when pregnancies are complicated by overweight and obesity. Pregnancy is a stage of life when women have greater openness to messages about their lifestyle and health. It is also a time when they come into greater contact with health professionals. Currently management of pregnancy weight gain and the impact of overweight tends to be poor, although a number of research studies have demonstrated that appropriate interventions based around dietary change can be effective in controlling weight gain and reducing the risk of pregnancy complications. The development of individualised and flexible plans for avoiding adverse outcomes of obesity in pregnancy will require investment in training of health professionals and better integration into normal antenatal care.

Overweight and obesity before pregnancy and excessive gestational weight gain are major determinants of risk for pregnancy loss, gestational diabetes, hypertensive conditions, labour complications and maternal death.

Pregnancy is regarded as a teachable moment when women are at their most receptive to messages about their health. However, unclear guidance on diet and physical activity, weight stigma from health professionals, inexperience and reluctance among professionals about raising issues about weight, and stretched resources put the health of women and babies at risk.

Excessive weight gain in pregnancy and post‐partum weight retention compromise future fertility and increase risk for future pregnancies.

Large randomised controlled trials have had little success in addressing excessive gestational weight gain or antenatal complications. Individualised, culturally sensitive and responsive interventions appear to have greater success.

Dietary fat: a potent microglial influencer

Poor nutrition, lack of exercise, and genetic predisposition all contribute to the growing epidemic of obesity. Overweight/obesity create an environment of chronic inflammation that leads to negative physiological and neurological outcomes, such as diabetes, cardiovascular disease, and anxiety/depression. While the whole body contributes to metabolic homeostasis, the neuroimmune system has recently emerged as a key regulator of metabolism. Microglia, the resident immune cells of the brain, respond both directly and indirectly to dietary fat, and the environment in which microglia develop contributes to their responsiveness later in life. Thus, high maternal weight during pregnancy may have consequences for microglial function in offspring. Here, we discuss the most recent findings on microglia signaling in overweight/obesity with a focus on perinatal programming.

Prepare Randomized Clinical Trial: Acceptability, Engagement, and Lifestyle Effects of a Weight Loss Intervention Beginning in Pre‐pregnancy

Background

Healthier lifestyles in early pregnancy are associated with lower rates of pregnancy complications, childhood adiposity, and maternal and child cardiovascular risks. However, it is not known whether lifestyle coaching initiated prior to pregnancy can affect behavior and attitudes during pregnancy.

Methods

Three hundred and twenty six women planning pregnancy within 2 years with BMI ≥27 kg/m² were randomized to a behavioral weight loss intervention or to usual care. Analyses reported here examined the intervention’s impact on mid‐pregnancy diet quality and activity levels; program acceptability; and effects of pregnancy on intervention engagement.

Results

One hundred and sixty eight participants experienced pregnancy during the study (intervention: 91; usual care: 77). From randomization to mid‐pregnancy, participants who received the intervention had larger increases in fruit intake than usual care participants (+0.67 vs. +0.06 cups; p = 0.02) and engaged in more vigorous‐intensity activity (3.9 [5.5] vs. 1.2 [3.0] Met‐hr/week p = 0.002) and sports/exercise (17.0 [14.1] vs. 11.0 [9.5] Met‐hr/week; p = 0.03); the groups also differed in changes in sedentary time (−4.9 [15.0] vs. +0.5 [7.6] Met‐hr/week; p = 0.02). Intervention satisfaction was high (>80%), and experiencing pregnancy during the intervention was associated with higher engagement.

Conclusion

A coaching‐based intervention beginning in pre‐pregnancy successfully helped women attain healthier diet and exercise habits in mid‐pregnancy.

Clinical trials registration

Registered with ClinicalTrials.gov, NCT02346162, first registered on January 26, 2015, before date of initial participant enrollment (May 2015), https://clinicaltrials.gov/ct2/show/NCT02346162.

Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance

Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.

The Association of Prepregnancy Body Mass Index with Pregnancy Outcomes in Chinese Women

Our study was to evaluate the association between prepregnancy body mass index (BMI) and pregnancy outcomes. A total of 1546 women who attended prenatal care clinics and delivered at the Peking University International Hospital, Beijing, China, from October 2018 to April 2020 was included. This research explored gestational, perinatal, and postpartum outcomes, including gestational diabetes, anemia, preeclampsia, preterm premature rupture of membranes (PPROM), and postpartum hemorrhage. Participants were divided into underweight (BMI < 18.5 kg/m²), normal weight (18.5 kg/m² ≤ BMI ≤ 23.9 kg/m²), overweight (24 kg/m² ≤ BMI ≤ 27.9 kg/m²), and obese (BMI ≥ 28 kg/m²) groups. Logistic regression analysis was used to analyze the association between prepregnancy BMI and pregnancy outcomes, and odds ratio (OR) with 95% confidence interval (95% CI) was calculated. After adjusting potential confounders, the risk of PPROM was higher in the underweight group than the normal weight group (OR = 1.864, 95% CI: 1.269-2.737, P < 0.01). Prepregnancy obesity was associated with higher odds of gestational diabetes (OR = 2.649, 95% CI: 1.701-4.126, P < 0.001) and preeclampsia (OR = 3.654, 95% CI: 1.420-9.404, P < 0.01) than the normal weight group, whereas it correlated with the lower risk of anemia (OR = 0.300, 95% CI: 0.128-0.704, P < 0.01). Our findings may provide evidence for the importance of keeping normal weight for Chinese women when preparing for pregnancy.

Association of Gestational Weight Gain With Infant Morbidity and Mortality in the United States

IMPORTANCE

The associations of gestational weight gain (GWG) with infant morbidity and mortality are unclear, and the existing recommendations for GWG have not been stratified by the severity of obesity.

OBJECTIVES

To identify optimal GWG ranges associated with reduced risks of infant morbidity and mortality across maternal body mass index (BMI) categories.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used US nationwide, linked birth and infant death data between 2011 and 2015 to assess the associations of GWG in 2.0-kg groups with infant morbidity and mortality and identified optimal GWG ranges associated with reduced risks of both outcomes, using multivariable logistic regression models. Statistical analysis was performed from February 11 to October 14, 2021.

EXPOSURE

Gestational weight gain equivalent to 40 weeks.

MAIN OUTCOMES AND MEASURES

The 2 main outcomes were (1) significant morbidity of the newborn infant, defined as any presence of assisted ventilation, admission to the neonatal intensive care unit, surfactant therapy, antibiotic therapy, or seizures; and (2) infant mortality younger than 1 year of age (<1 hour, 1-23 hours, 1-6 days, 7-27 days, or 28-365 days after birth).

RESULTS

In this study of 15 759 945 mother-infant dyads, the mean (SD) age of the women was 28.1 (5.9) years. Women gained a mean (SD) of 14.1 (7.3) kg during pregnancy, and the mean (SD) GWG decreased with BMI categories (underweight, 15.7 [6.4] kg; normal weight, 15.4 [6.2] kg; overweight, 14.2 [7.4] kg; obesity class 1, 12.2 [8.0] kg; obesity class 2, 10.3 [8.4] kg; obesity class 3, 8.2 [9.2] kg; P < .001). A total of 8.8% of the newborns experienced significant morbidity, with the lowest prevalence among infants delivered by women in the normal weight BMI class (8.0%) and the highest among infants delivered by women with class 3 obesity (12.4%); 0.34% of infants died within 1 year of birth, with the lowest prevalence among infants delivered by women in the normal weight BMI class (0.28%) and the highest among infants delivered by women with class 3 obesity (0.58%). Optimal GWG ranges were 12.0 to less than 24.0 kg for underweight and normal weight women, 10.0 to less than 20.0 kg for overweight women, 8.0 to less than 16.0 kg for women with class 1 obesity, 6.0 to less than 16.0 kg for class 2 obesity, and 6.0 to less than 10.0 kg for class 3 obesity. The lower bounds of the optimal GWG ranges appeared to be higher than the existing recommendations for overweight women (10.0 vs 7.0 kg) and for those with class 1 (8.0 vs 5.0 kg), class 2 (6.0 vs 5.0 kg), and class 3 (6.0 vs 5.0 kg) obesity.

CONCLUSIONS AND RELEVANCE

This study analyzed the associations of GWG with infant morbidity and mortality across BMI categories and found that inadequate GWG was associated with increased risks of adverse infant outcomes even for women with obesity. The results suggested that weight maintenance or weight loss should not be used as routine guidelines.

Maternal and fetal outcomes in pregnancies with obstructive sleep apnea

OBJECTIVES

Obstructive sleep apnea (OSA) is linked to many health comorbidities. We aimed to ascertain if OSA correlates with a rise in poor obstetrical outcomes.

METHODS

Employing the United States' Healthcare Cost and Utilization Project - National Inpatient Sample, we performed our retrospective cohort study including all women who delivered between 2006 and 2015. ICD-9 codes were used to characterize women as having a diagnosis of OSA. Temporal trends in pregnancies with OSA were studied, baseline features were evaluated among gravidities in the presence and absence of OSA, and multivariate logistic regression analysis was utilized in assessing consequences of OSA on patient and newborn outcomes.

RESULTS

Of a total 7,907,139 deliveries, 3,115 belonged to patients suffering from OSA, resulting in a prevalence of 39 per 100,000 deliveries. Rates rose from 10.14 to 78.12 per 100,000 deliveries during the study interval (p<0.0001). Patients diagnosed with OSA were at higher risk of having pregnancies with preeclampsia, OR 2.2 (95% CI 2.0-2.4), eclampsia, 4.1 (2.4-7.0), chorioamnionitis, 1.4 (1.2-1.8), postpartum hemorrhage, 1.4 (1.2-1.7), venous thromboembolisms, 2.7 (2.1-3.4), and to deliver by caesarean section, 2.1 (1.9-2.3). Cardiovascular and respiratory complications were also more common among these women, as was maternal death, 4.2 (2.2-8.0). Newborns of OSA patients were at elevated risk of being premature, 1.3 (1.2-1.5) and having congenital abnormalities, 2.3 (1.7-3.0).

CONCLUSIONS

Pregnancies with OSA were linked to an elevated risk of poor maternal and neonatal outcomes. During pregnancy, OSA patients should receive attentive follow-up care in a tertiary hospital.

Barriers and Facilitators to Healthy Eating and Physical Activity Postpartum: A Qualitative Systematic Review

BACKGROUND

Postpartum weight retention increases the risk of long-term overweight and obesity and associated comorbidities. Healthy eating and physical activity are important lifestyle behaviors for achieving and maintaining a healthy weight. However, these habits may be hard for women to adopt or maintain during the postpartum period.

OBJECTIVE

To identify and describe barriers and facilitators to healthy eating and physical activity among postpartum women in the United States.

METHODS

A qualitative systematic review was conducted. Qualitative studies on women's experiences with weight loss, healthy eating, and physical activity in the postpartum period were identified using a comprehensive search strategy. The quality of included studies was assessed using the Critical Appraisal Skills Programme checklist. Data were qualitatively analyzed using thematic synthesis. Resulting themes were mapped onto components of the Social-Ecological Model for Food and Physical Activity Decisions.

RESULTS

Thirteen qualitative studies were included in the review. Barriers and facilitators to healthy eating and physical activity during the postpartum period included individual factors (emotional and mindless eating, physical limitations, and social support), settings and sectors (food environments, childcare needs, and structured information and support), and social and cultural norms (time constraints, and prioritization of maternal responsibilities).

CONCLUSIONS

Researchers and practitioners should consider how factors within various levels of the Social-Ecological Model may influence healthy eating and physical activity in the postpartum period.

Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy

OBJECTIVE

The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy.

STUDY DESIGN

This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m²) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities.

RESULTS

The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00.

CONCLUSION

Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period.

KEY POINTS

· Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

Obesity and reproduction: a committee opinion

The purpose of this American Society for Reproductive Medicine Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled "Obesity and reproduction: an educational bulletin" last published in 2015 (Fertil Steril 2015;104:1116-26).

Isolated fetal neural tube defects associate with increased risk of placental pathology: Evidence from the Collaborative Perinatal Project

INTRODUCTION

Neural tube defects (NTDs) are amongst the most common congenital anomalies and are associated with significant postnatal morbidity, but also with a higher incidence of low birthweight and fetal growth restriction. Despite the placenta being a critical determinant of fetal growth, placental development has not been extensively studied in fetuses with NTDs.

METHODS

We performed a matched case-cohort study using data from the Collaborative Perinatal Project to assess the risk of placental pathology in pregnancies with an isolated fetal NTD (cases; n = 74) compared to those without any congenital anomalies (controls; n = 148). We hypothesised that cases would be at an increased risk of placental pathology compared to controls. Data were analysed using adjusted generalized linear and nominal logistic regression models. Results are presented as adjusted β or adjusted odds ratio (aOR; 95% confidence interval).

RESULTS

Cases had lower placental weight (β = -22.2 g [-37.8 to -6.6]), surface area (β = -9.6 cm² [-18.3 to -1.0]) and birth length z-scores (β = -0.4 [-0.7 to -0.001]) compared to controls. Cases were more likely to have a single umbilical artery (vs. two; 6 [8.1%] vs. 1 [0.7%]; aOR = 301 [52.6-1726]), placental hypermaturity (9 [12.2%] vs. 5 [3.4%]; aOR = 6.8 [3.1-14.7]), many (vs. few) Hofbauer cells (9 [12.2%] vs. 7 [4.7%]; aOR = 3.02 [1.2-7.3]), and stromal fibrosis (9 [12.2%] vs. 10 [6.8%]; aOR = 3.0 [1.4-6.3]) in placental terminal villi compared to controls.

CONCLUSIONS

Fetuses with isolated NTDs may be at increased risk of placental pathology, which could be contributing to poor fetal growth in these pregnancies and subsequent postnatal morbidities.

A Matter of Time: Does Gestational Age Affect the Duration of the Fetal Anatomic Survey?

OBJECTIVE

To assess the average duration of detailed fetal anatomic surveys in pregnancy in relation to gestational age (GA) and the maternal body mass index (BMI) to determine optimal timing of the examination.

METHODS

This was a retrospective cohort study of gravidae presenting for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding examinations expected to have longer duration (ie, multifetal, major fetal anomalies), there were a total of 6522 examinations performed between GAs of 18 weeks 0 days and 22 weeks 0 days. Women were grouped by BMI, and results were analyzed by logistic regression.

RESULTS

Gravidae of normal weight (BMI, 18.5-24.9 kg/m² ) had a decrease of 47.47 seconds of the examination time with each increasing week of gestation (P = .036). Overweight (BMI, 25-29.9 kg/m² ) gravidae similarly had a decrease of 66.31 seconds of the examination time with each additional week of gestation (P = .017). Underweight (BMI, 8.5 kg/m² ) and obese (BMI, ≥30 kg/m² ) gravidae did not have differences in the examination time with increasing GA. Increases in suboptimal examinations were noted with an increasing BMI (P < .001). There was a decreased frequency of suboptimal examinations in obese gravidae with a BMI of 40 kg/m² or higher with increasing GA (P = .037).

CONCLUSIONS

The duration of detailed fetal anatomic examinations decreased with increasing GA in normal-weight and overweight gravidae but not in obese gravidae. Performing the anatomy scan earlier in class I and II obese gravidae (BMI, 30-40 kg/m² ) may enable improved pregnancy management options without increasing the examination duration or likelihood of a suboptimal evaluation.

Modification of the association between diabetes and birth defects by obesity, National Birth Defects Prevention Study, 1997-2011

BACKGROUND

Maternal pregestational diabetes and obesity are risk factors for birth defects. Diabetes and obesity often occur together; it is unclear whether their co-occurrence compounds birth defect risk.

METHODS

We analyzed 1997-2011 data on 29,671 cases and 10,963 controls from the National Birth Defects Prevention Study, a multisite case-control study. Mothers self-reported height, pregestational weight, and diabetes (pregestational and gestational; analyzed separately). We created four exposure groups: no obesity or diabetes (referent), obesity only, diabetes only, and both obesity and diabetes. We estimated odds ratios (ORs) using logistic regression and the relative excess risk due to interaction (RERI).

RESULTS

Among mothers with pregestational obesity without diabetes, modest associations (OR range: 1.1-1.5) were observed for neural tube defects, small intestinal atresia, anorectal atresia, renal agenesis/hypoplasia, omphalocele, and several congenital heart defects. Pregestational diabetes, regardless of obesity, was strongly associated with most birth defects (OR range: 2.0-75.9). Gestational diabetes and obesity had a stronger association than for obesity alone and the RERI (in parentheses) suggested additive interaction for hydrocephaly (1.2; 95% confidence interval [CI]: -0.1, 2.5), tetralogy of Fallot (0.9; 95% CI: -0.01, 1.8), atrioventricular septal defect (1.1; 95% CI: -0.1, 2.3), hypoplastic left heart syndrome (1.1; 95% CI: -0.2, 2.4), and atrial septal defect secundum or not otherwise specified (1.0; 95% CI: 0.3, 1.6; only statistically significant RERI).

CONCLUSIONS

Our results do not support a synergistic relationship between obesity and diabetes for most birth defects examined. However, there are opportunities for prevention by reducing obesity and improving glycemic control among women with pregestational diabetes before conception.

Mismatch between obesogenic intrauterine environment and low-fat postnatal diet may confer offspring metabolic advantage

OBJECTIVE

Mismatch between a depleted intrauterine environment and a substrate-rich postnatal environment confers an increased risk of offspring obesity and metabolic syndrome. Maternal diet-induced obesity (MATOB) is associated with the same outcomes. These experiments tested the hypothesis that a mismatch between a nutrient-rich intrauterine environment and a low-fat postnatal environment would ameliorate offspring metabolic morbidity.

METHODS

C57BL6/J female mice were fed either a 60% high-fat diet (HFD) or a 10% fat control diet (CD) for 14-week pre-breeding and during pregnancy/lactation. Offspring were weaned to CD. Weight was evaluated weekly; body composition was determined using EchoMRI. Serum fasting lipids and glucose and insulin tolerance tests were performed. Metabolic rate, locomotor, and sleep behavior were evaluated with indirect calorimetry.

RESULTS

MATOB-exposed/CD-weaned offspring of both sexes had improved glucose tolerance and insulin sensitivity compared to controls. Males had improved fasting lipids. Females had significantly increased weight and body fat percentage in adulthood compared to sex-matched controls. Females also had significantly increased sleep duration and reduced locomotor activity compared to males.

CONCLUSIONS

Reduced-fat dietary switch following intrauterine and lactational exposure to MATOB was associated with improved glucose handling and lipid profiles in adult offspring, more pronounced in males. A mismatch between a high-fat prenatal and low-fat postnatal environment may confer a metabolic advantage. The amelioration of deleterious metabolic programming by strict offspring adherence to a low-fat diet may have translational potential.

Maternal characteristics associated with gestational weight gain in France: a population-based, nationally representative study

OBJECTIVES

To provide nationally representative estimates of gestational weight gain (GWG) and identify maternal characteristics associated with inadequate GWG in France.

DESIGN

A population-based study using data from the French National Perinatal Survey: 2010 and 2016.

SETTING

All maternity units in metropolitan, mainland France (n=535 in 2010; n=493 in 2016).

PARTICIPANTS

Singleton live births with GWG data (N=24 850).

PRIMARY OUTCOME MEASURES

GWG was calculated as end of pregnancy minus pre-pregnancy weight (kg) and categorised as 'insufficient', 'adequate', or 'excessive' using 2009 Institute of Medicine thresholds. Classification accounted for pre-pregnancy body mass index (BMI) (kg/m²; underweight (<18.5), normal weight (18.5-24.9), overweight (25-29.9), obese (≥30)) and gestational age at birth. We estimated average GWG and the percentage of women in each GWG category. Polytomous logistic regression identified characteristics associated with GWG adequacy.

RESULTS

Average GWG was 13.0 kg (SD 5.6), with 26.8% of women gaining insufficiently, 37.0% adequately and 36.1% excessively. Among other factors, insufficient GWG was associated with underweight (vs normal weight; adjusted OR (aOR) 1.4, 95% CI 1.2 to 1.5) and obese (aOR 1.5, 95% CI 1.4 to 1.7) BMI. Excessive GWG was associated with overweight (aOR 2.8, 95% CI 2.6 to 3.1) and obese BMI (aOR 3.3, 95% CI 2.9 to 3.6). Examining obesity classes separately, odds of insufficient GWG increased from obesity class I to III, while odds of excessive GWG decreased from obesity class I to III. Primiparity (insufficient: aOR 0.9, 95% CI 0.9 to 1.0; excessive: aOR 1.2, 95% CI 1.2 to 1.3), maternal characteristics indicative of lower socioeconomic status, and continuing or quitting smoking during pregnancy were also associated with inadequate GWG.

CONCLUSIONS

In France, insufficient and excessive GWG are common. For optimal outcomes, clinician education, with special attention to the needs of higher risk/vulnerable groups, is needed to ensure all women receive appropriate advice for recommended GWG.

Timing of delivery in obese women and risk of stillbirth

PURPOSE

Increased body mass index (BMI) is an independent risk factor for stillbirth. The purpose of this study was to determine an optimal time of delivery at term in obese women in order to decrease the risk of stillbirth in this population.

METHODS

We conducted a retrospective population-based cohort study using the CDC's Period Linked Birth-Infant Death and Fetal Death data. The study population included all singleton, term births with a recorded pre-pregnancy BMI that occurred between 2014 and 2017. Unconditional logistic regression analyses were used to estimate the risk of stillbirth in each BMI class at each gestational week from 37 weeks and onwards comparing with births to normal-weight women at 41 weeks.

RESULTS

Of 12,742,980 births in our cohort, 46.8% were to women with a normal BMI, 26.9% were to women who were classified as overweight, 14.5% were to women in obesity class I, 7.3% in obesity class II, and 4.8% in obesity class III. Within each BMI class, the risk of stillbirth increased with gestational age, with the most pronounced rises in risk occurring at later gestational ages. In a dose-response relationship, the risk of stillbirth exceeded that of a normal BMI pregnancy at 41 weeks at the following gestational age and BMI category: obese class 1 at 39 weeks (OR 1.15 95% CI 1.00-1.31), obese class II at 38 weeks (OR 1.21 95% CI 1.04-1.41) and obese class III at 37 weeks (OR 1.30 95% CI 1.11-1.52).

CONCLUSION

Compared to women with a normal BMI at 41 weeks, there was a higher risk of stillbirth at term in women with each increase in BMI class. Consideration should be given to early induction among these women to reduce the risk of stillbirth.

A retrospective cohort study of race/ethnicity, pre-pregnancy weight, and pregnancy complications

OBJECTIVE

To examine the relationship between race/ethnicity, pre-pregnancy overweight/obesity status, and pregnancy complications.

METHODS

We conducted a retrospective cohort study among mothers with singleton live births using data from hospitals contributing to the Obstetrical Care Outcomes Assessment Program database (N = 72,697). Race was categorized as Non-Hispanic (NH) White, NH African-American, Hispanic, NH Asian, NH American Indian/Alaskan Native, and NH Native-Hawaiian/Other Pacific Islander. Pre-pregnancy overweight/obesity status was defined as body mass index (BMI)≥25 kg/m². Pregnancy complications evaluated were gestational diabetes, pre-eclampsia, and cesarean delivery. We fitted adjusted and unadjusted stratified Poisson regression models with robust standard errors. Interaction terms were used to assess statistical significance of interactions between race/ethnicity and pre-pregnancy overweight/obesity status.

RESULTS

Most women were NH White (52.1%) and more than half had overweight/obesity (54.3%). Among women with overweight/obesity, Hispanics had a lower risk of cesarean delivery as compared to NH White (adjusted relative risk, aRR:0.89; 95%CI:0.84-0.93). Similarly, among women with overweight/obesity, Hispanic and NH Native-Hawaiian/Other Pacific Islander had a lower risk of preeclampsia (aRR:0.74; 95%CI:0.66-0.82 and aRR:0.64; 95%CI:0.44-0.92, respectively) and NH African-American had a greater risk of gestational diabetes (aRR:1.23; 95%CI:1.07-1.42) when compared with NH White women. These associations were not present among normal-weight women. Women with overweight/obesity, when compared with women of normal-weight, had an increased risk of gestational diabetes and cesarean delivery among all race/ethnicities except NH American Indian/Alaskan Native and NH Native-Hawaiian/Other Pacific Islander, respectively (p-values < .05). The multiplicative interaction terms between race/ethnicity and overweight/obesity status were significant for all three complications (interaction p-values < .05).

CONCLUSION

Pre-pregnancy overweight/obesity status modifies associations of race/ethnicity with pregnancy complications. Conversely, race/ethnicity modifies associations of pre-pregnancy overweight/obesity status with pregnancy complications. Our findings have implications for public health and clinical practice, supporting the focus on healthy preconception weight and risk stratification across racial/ethnic groups.

Maternal body-mass-index and neonatal brachial plexus palsy in a California cohort

OBJECTIVE

To evaluate risk factors and describe the association between maternal pre-pregnancy body-mass-index (BMI) and neonatal brachial plexus palsy (BPP) in vaginal deliveries with and without shoulder dystocia.

METHODS

This is a retrospective cohort study of singleton, non-anomalous, term vaginal deliveries in California (2007-2011). Deliveries were classified as with or without shoulder dystocia. Our primary outcome was BPP and the independent variable of interest was maternal pre-pregnancy BMI, which was categorized as underweight (<18.5 kg/m²), normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), obesity I (30-34.9 kg/m²), obesity II (35-39.9 kg/m²) and obesity III (≥40 kg/m²). We evaluated demographics, maternal, labor, and neonatal characteristics using chi-squared tests and assessed the association of pre-pregnancy BMI with BPP using multivariable logistic regression models.

RESULTS

In our cohort of 1,395,761 women, there were 21,463 deliveries with shoulder dystocia and 1,374,298 deliveries without shoulder dystocia. Among deliveries with shoulder dystocia, BPP was observed more frequently in neonates born to women with BMI categorized as overweight (32% vs. 29%; p < .001), obesity I (22% vs. 14%; p < .001), obesity II (10% vs. 6%; p < .001), and obesity III (8% vs. 3%; p < .001). After adjusting for confounders, the odds of BPP in deliveries with shoulder dystocia was significantly higher for women who were overweight (aOR = 1.65; 95% CI: 1.35-2.01), obesity I (aOR = 2.33; 95% CI: 1.86-2.90), obesity II (aOR = 2.56; 95% CI: 1.92-3.40), and obesity III (aOR = 3.80; 95% CI: 2.75-5.25). In deliveries without shoulder dystocia, BPP was more common in women with a BMI that was overweight (29% vs. 25%; p < .001), obesity I (17% vs. 11%; p < .001), obesity II (9% vs. 4%; p < .001), and obesity III (8% vs. 2%; p < .001). In this cohort, multivariable regression model showed similar results in women with a BMI that was overweight (aOR = 1.47; 95% CI: 1.19-1.81), obesity I (aOR = 1.99; 95% CI: 1.55-2.54), obesity II (aOR = 2.79; 95% CI: 2.04-3.83), and obesity III (aOR = 5.05; 95% CI: 3.63-7.03).

CONCLUSION

Rising maternal pre-pregnancy BMI is associated with an increased risk of BPP in vaginal deliveries with and without shoulder dystocia. Preconception interventions targeting weight management may be beneficial in reducing BPP in all deliveries.

Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category.

OBJECTIVE

To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation.

DATA SOURCES

Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021.

STUDY SELECTION

Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating with dual review.

MAIN OUTCOMES AND MEASURES

Gestational weight-related outcomes; maternal and infant morbidity and mortality; harms.

RESULTS

Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], -1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, -2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, -1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, -1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, -1.02 kg [95% CI, -1.30 to -0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, -7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, -0.63 kg [95% CI, -1.44 to -0.01]). Data on harms were limited.

CONCLUSIONS AND RELEVANCE

Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons. In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%). Reported rates of overweight and obesity are higher among Black, Alaska Native/American Indian, and Hispanic women and lower among White and Asian women. Excess weight at the beginning of pregnancy and excess gestational weight gain have been associated with adverse maternal and infant health outcomes such as a large for gestational age infant, cesarean delivery, or preterm birth.

OBJECTIVE

The USPSTF commissioned a systematic review to evaluate the benefits and harms of behavioral counseling interventions to prevent adverse health outcomes associated with obesity during pregnancy and to evaluate intermediate outcomes, including excess gestational weight gain. This is a new recommendation.

POPULATION

Pregnant adolescents and adults in primary care settings.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons.

RECOMMENDATION

The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. (B recommendation).

Diet-induced dysbiosis of the maternal gut microbiome in early life programming of neurodevelopmental disorders

The maternal gut microbiome plays a critical role in fetal and early postnatal development, shaping fundamental processes including immune maturation and brain development, among others. Consequently, it also contributes to fetal programming of health and disease. Over the last decade, epidemiological studies and work in preclinical animal models have begun to uncover a link between dysbiosis of the maternal gut microbiome and neurodevelopmental disorders in offspring. Neurodevelopmental disorders are caused by both genetic and environmental factors, and their interactions; however, clinical heterogeneity, phenotypic variability, and comorbidities make identification of underlying mechanisms difficult. Among environmental factors, exposure to maternal obesity in utero confers a significant increase in risk for neurodevelopmental disorders. Obesogenic diets in humans, non-human primates, and rodents induce functional modifications in maternal gut microbiome composition, which animal studies suggest are causally related to adverse mental health outcomes in offspring. Here, we review evidence linking maternal diet-induced gut dysbiosis to neurodevelopmental disorders and discuss how it could affect pre- and early postnatal brain development. We are hopeful that this burgeoning field of research will revolutionize antenatal care by leading to accessible prophylactic strategies, such as prenatal probiotics, to improve mental health outcomes in children affected by maternal diet-induced obesity.