Excessive weight gain and hypertensive disorders of pregnancy in the obese patient

The First-Trimester Gestational Weight Gain Associated With de novo Hypertensive Disorders During Pregnancy: Mediated by Mean Arterial Pressure

The relationship between first-trimester GWG (_T1GWG) and risk of hypertensive disorders of pregnancy (HDP) remained uncertain. This study aimed to investigate the association between _T1GWG and risk of de novo HDP. Meanwhile, we explored the mediated effect and constructed an early GWG category to evaluate the predictive capacity for HDP. _T1GWG was defined as the weight difference between 13 ± 1 gestational weeks and pre-conception. HDP group was defined as having diagnosis of de novo HDP, including gestational hypertension or de novo pre-eclampsia (PE) during the current pregnancy. Early GWG category was constructed according to the risk of HDP within each pre-pregnancy body mass index (BMI) group. Cox regression model was utilized to check the association between the _T1GWG and HDP. Serial mediation model was adopted to evaluate the potential mediators including mean arterial pressure (MAP) at 13th and 20th week. The logistic regression model with bootstrap was performed to assess the predictive capacity of Early GWG category and MAP for the risk of HDP. A total of 17,901 pregnant women (mean age, 29.0 years) were recruited from 2013 to 2017 at the Tongzhou Maternal and Child Health Hospital in Beijing, China. Compared to women in Class 1 of early GWG category, women in the Class 2, 3, 4 have increased risks of HDP by 1.42, 4.27, and 4.62 times, respectively (hazard ratio [HR] = 2.42, 95% CI: 2.11–2.77; HR = 5.27, 95% CI: 4.05–6.86; HR = 5.62, 95% CI: 4.05–7.79). The MAP measured at 13th and 20th week totally mediated 33.1 and 26.7% of association between _T1GWG GWG and HDP in total participants and overweight/obesity pregnancies, respectively. The area under receiver operator characteristic curve for predictive model utilizing early GWG category and MAP measured at 13th and 20th week for the risk of HDP is 0.760 (95% CI: 0.739–0.777). The _T1GWG was associated with de novo HDP, which was partially mediated by MAP measured at 13th and 20th week. Early GWG category showed a better predictive capacity for the risk of HDP compared to the National Academy of Medicine criteria for _T1GWG.

A mushroom diet reduced the risk of pregnancy-induced hypertension and macrosomia: a randomized clinical trial

Background

Pregnancy-induced hypertension (PIH) is a disease characterized by high blood pressure detected after 20 weeks of pregnancy, affecting approximately 10% of pregnant women worldwide. Effective strategies are imperatively needed to prevent and treat PIH.

Methods

Subjects were required to consume 100 g mushroom daily from pre-pregnancy to the 20th week of gestation. The gestational hypertension and related primary and secondary outcomes of the mushroom diet (MD) group and placebo group were investigated to compare the intervention of a MD on the PIH and preeclampsia-associated maternal and child health conditions.

Results

A total of 582 and 580 subjects belonging to the MD group and placebo group were included for the analysis, respectively. Compared to the placebo, the MD significantly reduced the incidence of gestational hypertension (P = 0.023), preeclampsia (P = 0.014), gestational weight gain (P = 0.017), excessive gestational weight gain (P = 0.032) and gestational diabetes (P = 0.047). Stratified analysis showed that the MD lowered the risk of PIH for overweighed women (P = 0.036), along with the percentage of macrosomia (P = 0.007).

Conclusion

An MD could serve as a preventative strategy for lowering the risk of PIH and could control newborn birthweight while reducing comorbidities including gestational weight gain, diabetes etc.

Gestational Weight Gain: Update on Outcomes and Interventions

PURPOSE OF REVIEW

Gestational weight gain is a modifiable risk factor for adverse perinatal outcomes. After the Institute of Medicine (IOM) released updated recommendations for gestational weight gain in 2009, a multitude of studies were released examining the recommendations, particularly for women with obesity. As the obesity epidemic continues, many physicians are interested in minimizing gestational weight gain for all women. Our aim was to review the evidence for the association of gestational weight gain and perinatal outcomes, particularly for weight gain outside the IOM guidelines.

RECENT FINDINGS

Gestational weight gain is associated with several adverse perinatal outcomes including fetal growth, preterm delivery, cesarean delivery, gestational diabetes, hypertensive disorders of pregnancy, and infant mortality as well as with long-term offspring metabolic health outcomes. Multiple randomized controlled trials have been conducted evaluating the efficacy of lifestyle intervention on gestational weight gain, and while lifestyle interventions may alter gestational weight gain, they have not been associated with improvement in perinatal outcomes. Weight loss during pregnancy is associated with decreased risks of macrosomia and cesarean delivery; however, given an association with low birth weight, it is not currently recommended. Excessive gestational weight gain is known to be associated with multiple adverse fetal and maternal outcomes. Lifestyle interventions during pregnancy may be helpful in decreasing excessive weight gain, but have not shown to be beneficial for most adverse pregnancy outcomes. More research is needed before making recommendations for weight loss in women with obesity during pregnancy.

Serum level of 25-hydroxyvitamin D and obesity among early pregnant women

AIM

To assess serum 25-hydroxyvitamin D 25(OH)D level in obese pregnant Sudanese women in early pregnancy.

METHODS

A match case-control study was conducted in Saad Abualila Hospital (Khartoum, Sudan). The cases were obese (body mass index [BMI] ≥ 30.0 kg/m² ) women. Controls were women with normal BMI (18.5-24.9 kg/m² ) matched for age, parity and gestational age. The 25(OH)D level was measured using ELISA.

RESULTS

There was no significant difference between the two groups in their age, parity or gestational age. There was no significant difference in the median (interquartile) level of the serum (25(OH)D between obese pregnant women and normal weight pregnant women (3.05 [11.100-15.937] ng/ml vs 13.05 [10.950-17.362] ng/ml, P = 0.237). There was no significant correlation between BMI and 25(OH)D level (r = -0.133, P = 0.149).

CONCLUSION

There was no significant difference in the 25(OH)D level between the obese pregnant women and normal weight pregnant women in this study.

Higher prepregnancy body mass index is a risk factor for developing preeclampsia in Maya-Mestizo women: a cohort study

AIM

Preeclampsia and obesity are two closely related syndromes. The high maternal prepregnancy body mass index (BMI) is a risk factor for present preeclampsia, independently of the ethnic background of the studied population. The aim of this study was to analyse in a prospective cohort study the relation between prepregnancy BMI and development of preeclampsia in Maya-Mestizo women.

DESIGN

This is a prospective cohort study of 642 pregnant women that were included in the first trimester of the pregnancy (gestational age ≤12 weeks at the first antenatal visit) and all of them were of Maya-Mestizo ethnic origin from the state of Yucatán, México. We assessed the potential risk factors for preeclampsia and documented the prepregnancy BMI (kg/m²) that was based on measured height and maternal self-report of prepregnancy weight at the initial visit. Besides, in the antenatal visit we documented if the pregnant women developed preeclampsia.

RESULTS

Of the 642 pregnant Maya-Mestizo women, 49 developed preeclampsia, with an incidence of 7.6% (44.9% had severe and 55% mild). The prepregnancy BMI was higher in women with developed preeclampsia than in those with normal pregnancies. Women with overweight or obesity in comparison with normal weight presented a RR = 2.82 (95% CI: 1.32-6.03; P = 0.008) and RR= 4.22 (95% CI: 2.07-8.61; P = 0.001), respectively.

CONCLUSIONS

Our findings expand the previous studies to show that the higher prepregnancy BMI is a strong, independent risk factor for preeclampsia.

Obesity and Weight Gain in Pregnancy and Postpartum: an Evidence Review of Lifestyle Interventions to Inform Maternal and Child Health Policies

Background: Maternal obesity, excessive gestational weight gain (GWG) and post-partum weight retention (PPWR) constitute new public health challenges, due to the association with negative short- and long-term maternal and neonatal outcomes. The aim of this evidence review was to identify effective lifestyle interventions to manage weight and improve maternal and infant outcomes during pregnancy and postpartum. Methods: A review of systematic reviews and meta-analyses investigating the effects of lifestyle interventions on GWG or PPWR was conducted (Jan 2009-2018) via electronic searches in the databases Medline, Pubmed, Web of Science and Cochrane Library using all keywords related to obesity/weight gain/loss, pregnancy or postpartum and lifestyle interventions;15 relevant reviews were selected. Results: In healthy women from all BMI classes, diet and physical activity interventions can decrease: GWG (mean difference -1.8 to -0.7 kg, high to moderate-quality evidence); the risks of GWG above the IOM guidelines (risk ratio [RR] 0.72 to 0.80, high to low-quality evidence); pregnancy-induced hypertension (RR 0.30 to 0.66, low to very low-quality evidence); cesarean section (RR 0.91 to 0.95; high to moderate-quality evidence) and neonatal respiratory distress syndrome (RR 0.56, high-quality evidence); without any maternal/fetal/neonatal adverse effects. In women with overweight/obesity, multi-component interventions can decrease: GWG (-0.91 to -0.63 kg, moderate to very low-quality evidence); pregnancy-induced hypertension (RR 0.30 to 0.66, low-quality evidence); macrosomia (RR 0.85, 0.73 to 1.0, moderate-quality evidence) and neonatal respiratory distress syndrome (RR 0.47, 0.26 to 0.85, moderate-quality evidence). Diet is associated with greater reduction of the risks of GDM, pregnancy-induced hypertension and preterm birth, compared with any other intervention. After delivery, combined diet and physical activity interventions reduce PPWR in women of any BMI (-2.57 to -2.3 kg, very low quality evidence) or with overweight/obesity (-3.6 to -1.22, moderate to very low-quality-evidence), but no other effects were reported. Conclusions: Multi-component approaches including a balanced diet with low glycaemic load and light to moderate intensity physical activity, 30-60 min per day 3-5 days per week, should be recommended from the first trimester of pregnancy and maintained during the postpartum period. This evidence review should help inform recommendations for health care professionals and women of child-bearing age.

Pre-pregnancy BMI, gestational weight gain and risk of preeclampsia: a birth cohort study in Lanzhou, China

BACKGROUND

To evaluate the independent and joint effects of maternal pre-pregnancy BMI and gestational weight gain (GWG) on the risk of preeclampsia and its subtypes.

METHODS

A birth cohort study was conducted from 2010 to 2012 in Lanzhou, China. Three hundred fourty seven pregnant women with preeclampsia and 9516 normotensive women at Gansu Provincial Maternity and Child Care Hospital were included in the present study. Unconditional logistic regression models were used to evaluate the associations between pre-pregnancy BMI, GWG, and risk of preeclampsia and its subtypes.

RESULTS

Compared to women with normal pre-pregnancy BMI, those who were overweight/obese had an increased risk of preeclampsia (OR = 1.81; 95%CI: 1.37-2.39). Women with excessive GWG had an increased risk of preeclampsia (OR = 2.28; 95%CI: 1.70-3.05) compared to women with adequate GWG. The observed increased risk was similar for mild-, severe- and late-onset preeclampsia. No association was found for early-onset preeclampsia. Overweight/obese women with excessive GWG had the highest risk of developing preeclampsia compared to normal weight women with no excessive weight gain (OR = 3.78; 95%CI: 2.65-5.41).

CONCLUSIONS

Our results suggested that pre-pregnancy BMI and GWG are independent risk factors for preeclampsia and that the risk might vary by preeclampsia subtypes. Our study also proposed a potential synergistic effect of pre-pregnancy BMI and GWG that warrants further investigation.

Gestational weight gain in obese pregnancy: impact on maternal and foetal metabolic parameters and birthweight

The aim of this prospective, observational study was to investigate the impact of gestational weight gain (GWG) among euglycaemic obese pregnant women on maternal and foetal metabolic parameters and neonatal outcome. Total GWG was recorded for 101 obese, non-diabetic women with a singleton pregnancy. At 28 weeks of gestation, fasting maternal blood samples were analysed for glucose, insulin, c-peptide and lipids. Cord bloods were collected at delivery for analysis of glucose, c-peptide and lipids. GWG (mean ± SD =10.9 ± 5.5 kg) was greatest among those of younger age and lower body mass index and 58% of women exceeded the Institute of Medicine GWG recommendations of 5-9 kg for obese pregnancy. GWG was significantly positively associated with increased risk of birthweight >4 kg, cord c-peptide levels and inversely associated with cord total cholesterol. This study identified that higher GWG in obese pregnancy may increase the risk of macrosomia and neonatal hyperinsulinaemia, within a euglycaemic maternal cohort. Impact statement Excess gestational weight gain (GWG) and maternal obesity frequently co-occur with adverse consequences for maternal and neonatal health; however, little is known of the underlying biological pathways which may be affected to contribute to adverse outcomes. Greater understanding of the biological mechanisms involved may help guide future studies to develop targeted interventions for more effective clinical outcomes. This study identified that higher GWG among obese pregnant women resulted in foetal hyperinsulinaemia even in the absence of maternal hyperglycaemia, potentially representing a biological pathway for larger birthweight babies. These results may highlight the need for more intensive dietary and lifestyle interventions among obese women who would not normally receive additional counselling beyond standard antenatal care if not diagnosed with glucose intolerance in pregnancy.

Effect of Obesity on Gestational and Perinatal Outcomes

Purpose To assess the impact of pre-pregnancy obesity (body mass index [BMI] ≥ 30 kg/m2) on the gestational and perinatal outcomes. Methods Retrospective cohort study of 731 pregnant women with a BMI ≥ 30 kg/m2 at the first prenatal care visit, comparing them with 3,161 women with a BMI between 18.5 kg/m2 and 24.9 kg/m2. Maternal and neonatal variables were assessed. Statistical analyses reporting the demographic features of the pregnant women (obese and normal) were performed with descriptive statistics followed by two-sided independent Student's t tests for the continuous variables, and the chi-squared (χ2) test, or Fisher's exact test, for the categorical variables. We performed a multiple linear regression analysis of newborn body weight based on the mother's BMI, adjusted by maternal age, hyperglycemic disorders, hypertensive disorders, and cesarean deliveries to analyze the relationships among these variables. All analyses were performed with the R (R Foundation for Statistical Computing, Vienna, Austria) for Windows software, version 3.1.0. A value of p < 0.05 was considered statistically significant. Results Obesity was associated with older age [OR 9.8 (7.8-12.2); p < 0.01], hyperglycemic disorders [OR 6.5 (4.8-8.9); p < 0.01], hypertensive disorders [OR 7.6 (6.1-9.5); p < 0.01], caesarean deliveries [OR 2.5 (2.1-3.0); p < 0.01], fetal macrosomia [OR 2.9 (2.3-3.6); p < 0.01] and umbilical cord pH [OR 2.1 (1.4-2.9); p < 0.01). Conversely, no association was observed with the duration of labor, bleeding during labor, Apgar scores at 1 and 5 minutes after birth, gestational age, stillbirth and early neonatal mortality, congenital malformations, and maternal and fetal injury. Conclusion We observed that pre-pregnancy obesity was associated with maternal age, hyperglycemic disorders, hypertension syndrome, cesarean deliveries, fetal macrosomia, and fetal acidosis.

Evaluation of Institute of Medicine Guidelines for Gestational Weight Gain in Women with Chronic Hypertension

Objective  To assess the impact of gestational weight gain (GWG) outside the Institute of Medicine (IOM) recommendations on perinatal outcomes in pregnancies complicated by chronic hypertension (HTN). Methods  The study consisted of a retrospective cohort of all singletons with HTN from 2000 to 2014. Maternal outcomes examined were superimposed preeclampsia and cesarean delivery. Neonatal outcomes were small for gestational age (SGA), large for gestational age (LGA), and preterm birth (PTB). Groups were compared using analysis of variance and chi-squared test for trend. Backward stepwise logistic regression was adjusted for confounding factors. Results  Of 702 subjects, 106 (15.1%) gained within, 176 (25.0%) gained less, and 420 (59.8%) gained more weight than the IOM recommendations. After adjusting for confounders, GWG above IOM recommendations remained associated with LGA (adjusted odds ratio [AOR]: 2.53, confidence interval [CI] 95%:1.29-4.95). Weight gain less than recommended was associated with a decreased risk of superimposed preeclampsia (AOR: 0.49, CI 95%: 0.26-0.93) without increasing the risk of SGA (AOR: 1.03, CI 95%: 0.57-1.86). Conclusion  Women with pregnancies complicated by chronic HTN should be counseled regarding the association of LGA with excessive GWG. Additionally, they should be counseled that weight gain below recommendations may be associated with a decreased risk of superimposed preeclampsia; however, this association deserves further investigation.

The effect of interpregnancy interval on obesity/overweight among women in the first trimester of pregnancy

OBJECTIVE

To determine the effect of interpregnancy interval (IPI) on obesity/overweight among pregnant Sudanese women in early pregnancy.

METHODS

A cross-sectional study was conducted at Saad Abu-Alela Hospital, Khartoum, Sudan, from January to December 2015. Women with a singleton pregnancy and at least one previous pregnancy were enrolled in the first trimester. A questionnaire was used to collect clinical and sociodemographic data from the participants, and current body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters.

RESULTS

Among 1045 participants, 344 (32.9%), 424 (40.6%), and 277 (26.5%) women had short (<18 months), normal (18-30 months), and long IPIs (>30 months), respectively. BMI indicated 18 (1.7%), 408 (39.0%), 381 (36.5%), and 238 (22.8%) women were underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0), respectively. Age and proportion using contraceptives were increased among women with long IPI (both P<0.001). When compared with women of normal weight, overweight women and obese women were more likely to have a long IPI (odds ratio 1.72, 95% confidence interval 1.08-2.93; and 1.71, 1.05-2.94, respectively).

CONCLUSION

Long IPI was associated with obesity and overweight, which were prevalent among pregnant Sudanese women.

Exercise during pregnancy protects against hypertension and macrosomia: randomized clinical trial

BACKGROUND

The prevalence of all pregnancies with some form of hypertension can be up to 10%, with the rates of diagnosis varying according to the country and population studied and the criteria used to establish the diagnosis. Prepregnancy obesity and excessive gestational weight gain (GWG) of all body mass index (BMI) categories have been associated with maternal hypertensive disorders and linked to macrosomia (>4000 g) and low birthweight (<2500 g). No large randomized controlled trial with high adherence to an exercise program has examined pregnancy-induced hypertension and these associated issues. We investigated whether women adherent (≥80% attendance) to an exercise program initiated early showed a reduction in pregnancy-induced hypertension and excessive GWG in all prepregnancy BMI categories, and determined if maternal exercise protected against macrosomia and low birthweight.

OBJECTIVE

We sought to examine the impact of a program of supervised exercise throughout pregnancy on the incidence of pregnancy-induced hypertension.

STUDY DESIGN

A randomized controlled trial was used. Women were randomized into an exercise group (N = 382) or a control group (N = 383) receiving standard care. The exercise group trained 3 d/wk (50-55 min/session) from gestational weeks 9-11 until weeks 38-39. The 85 training sessions involved aerobic exercise, muscular strength, and flexibility.

RESULTS

High attendance to the exercise program regardless of BMI showed that pregnant women who did not exercise are 3 times more likely to develop hypertension (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.29-6.81, P = .01) and are 1.5 times more likely to gain excessive weight if they do not exercise (OR, 1.47; 95% CI, 1.06-2.03, P = .02). Pregnant women who do not exercise are also 2.5 times more likely to give birth to a macrosomic infant (OR, 2.53; 95% CI, 1.03-6.20, P = .04).

CONCLUSION

Maternal exercise may be a preventative tool for hypertension and excessive GWG, and may control offspring size at birth while reducing comorbidities related to chronic disease risk.

High risk for obstructive sleep apnea and other sleep disorders among overweight and obese pregnant women

BACKGROUND

Obstructive sleep apnea (OSA), a common and serious disorder in which breathing repeatedly stops during sleep, is associated with excess weight and obesity. Little is known about the co-occurrence of OSA among pregnant women from low and middle-income countries.

METHODS

We examined the extent to which maternal pre-pregnancy overweight or obesity status are associated with high risk for OSA, poor sleep quality, and excessive daytime sleepiness in 1032 pregnant women in Lima, Peru. The Berlin questionnaire was used to identify women at high risk for OSA. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to examine sleep quality and excessive daytime sleepiness, respectively. Multinomial logistic regression procedures were employed to estimate odds ratios (aOR) and 95% confidence intervals (CI) adjusted for putative confounding factors.

RESULTS

Compared with lean women (<25 kg/m(2)), overweight women (25-29.9 kg/m(2)) had 3.69-fold higher odds of high risk for OSA (95% CI 1.82-7.50). The corresponding aOR for obese women (≥30 kg/m(2)) was 13.23 (95% CI: 6.25-28.01). Obese women, as compared with their lean counterparts had a 1.61-fold higher odds of poor sleep quality (95% CI: 1.00-2.63).

CONCLUSION

Overweight or obese pregnant women have increased odds of sleep disorders, particularly OSA. OSA screening and risk management may be indicated among pregnant women in low and middle income countries, particularly those undergoing rapid epidemiologic transitions characterized by increased prevalence of excessive adult weight gain.

Validation of serum biomarkers derived from proteomic analysis for the early screening of preeclampsia

AIM

To examine the potential value of previously identified biomarkers using proteomics in early screening for preeclampsia (PE).

METHODS

24 blood samples from women who subsequently developed PE and 48 from uncomplicated pregnancies were obtained at 11-13 weeks and analysed after delivery. Cystatin-C, sVCAM-1, and Pappalysin-1 were quantified by ELISA. Maternal characteristics and medical history were recorded.

RESULTS

Median values of Cystatin-C, sVCAM-1, and Pappalysin-1 in the PE group as compared to controls were 909.1 gEq/mL versus 480.0 gEq/mL, P = .000, 832.0 gEq/mL versus 738.8 gEq/mL, P = .024, and 234.4 gEq/mL versus 74.9 gEq/mL, P = .064, respectively. Areas under the receiver-operating characteristic curves (AUC, standard error (SE)) for predicting PE were Cystatin-C: 0.90 (SE 0.04), VCAM-1: 0.66 (SE 0.074), and Pappalysin-1: 0.63 (SE 0.083). To discriminate between cases at risk for PE and normal controls, cut-off values of 546.8 gEq/mL for Cystatin-C, 1059.5 gEq/mL for sVCAM-1, and 220.8 gEq/mL for Pappalysin-1 were chosen, providing sensitivity of 91%, 41%, and 54% and specificity of 85%, 100%, and 95%, respectively.

CONCLUSIONS

sVCAM-1 and Pappalysin-1 do not improve early screening for PE. Cystatin-C, however, seems to be associated with subsequent PE development, but larger studies are necessary to validate these findings.