Effect of a cholesterol-lowering diet on maternal, cord, and neonatal lipids, and pregnancy outcome: a randomized clinical trial

Cerebrovascular and ischemic heart disease in young adults born preterm: a population-based Swedish cohort study

Preterm birth is associated with overall cardiovascular mortality in young adulthood, but which specific conditions that underlie this association is unknown. We studied mortality and morbidity from cerebrovascular and ischemic heart disease in individuals born preterm. In a nationwide Swedish study, we included 1,306,943 individuals without congenital malformations born between 1983 and 1995, followed from 15 years of age to December 31st, 2010. Of these, 73,489 (5.6 %) were born preterm (<37 weeks of gestation). Cox proportional hazards regression analysis was used to calculate hazard ratios (HR) with 95 % confidence intervals (CI), after adjusting for maternal characteristics and birth weight for gestational age. Of 955 incident cases of cerebrovascular disease, 58 (6.1 %) occurred in preterm born subjects. The corresponding numbers of ischemic heart disease cases were 180 and 13 (7.2 %), respectively. Birth before 32 weeks was associated with a nearly twofold increased risk of cerebrovascular disease; adjusted HR, (95 % CI) = 1.89 (1.01-3.54) compared to term born individuals, whereas individuals born at 32-36 weeks were not at increased risk. Preterm birth was not associated with later ischemic heart disease; no cases of ischemic heart disease were recorded among those born before 32 weeks and the HR (95 % CI) for those born at 32-36 weeks of gestation was 1.45 (0.81-2.57), compared to term-born individuals. Birth before 32 weeks is associated with increased risk of cerebrovascular disease in young adulthood. Our data suggest that cardiovascular health promotion in follow-up programs after very preterm birth may be beneficial.

Management of reproduction and pregnancy complications in maternal obesity: which role for dietary polyphenols?

Obesity is a global and dramatic public health problem; maternal obesity represents one of the main risk factors of infertility and pregnancy complications as it is associated with adverse maternal and offspring outcomes. In the last few years, adipose tissue dysfunction associated with altered adipocytokine secretion has been suggested to play a critical role in all the phases of reproductive process. Obesity is a nutrition-related disorder. In this regard, dietary intervention strategies, such as high intake of fruit and vegetables, have shown significant effects in both preserving health and counteracting obesity-associated diseases. Evidence has been provided that polyphenols, important constituents of plant-derived food, can influence developmental program of oocyte and embryo, as well as pregnancy progression by modulating several cellular pathways. This review will examine the controversial results so far obtained on adipocytokine involvement in fertility impairment and pregnancy complications. Furthermore, the different effects exerted by polyphenols on oocyte, embryo, and pregnancy development will be also taken in account.

Maternal dietary counseling reduces total and LDL cholesterol postpartum

OBJECTIVE

The aim of this study was to investigate the effects of dietary counseling on blood lipid concentrations during and after pregnancy.

METHODS

Partcipants (N = 256) were randomized into three study groups: dietary counseling with probiotics or placebo and a control group at first trimester of pregnancy. Diet quality was evaluated from food records by an index of healthy eating and total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, apolipoproteins A-I and B, and lipoprotein (a) were measured at the first and third trimesters of pregnancy and 1, 6, and 12 mo postpartum.

RESULTS

During pregnancy, no differences in lipid values were noted among the groups, but postpartum TC and LDL-C were lower in both dietary counseling groups compared with controls (P = 0.027 and P = 0.012, respectively). Higher points on the healthy eating index, normal weight, and regular exercise were associated with a more favorable lipid profile at 12 mo after delivery.

CONCLUSION

Maternal dietary counseling may lower maternal TC and LDL-C levels postpartum. A healthy lifestyle during pregnancy and postpartum may benefit women's cardiovascular health.

Maternal serum cholesterol levels are elevated from the 1st trimester of pregnancy: a cross-sectional study

Cholesterol is monitored in the non-pregnant adult population, where normal values are established. Although reported to be elevated in pregnancy, cholesterol is neither routinely measured nor treated. We aimed to investigate cholesterol levels throughout pregnancy and to establish reference values for cholesterol in healthy pregnant women. This was a cross-sectional analysis of serum cholesterol in healthy women with an uncomplicated singleton pregnancy. Pregnant women attending for antenatal care were recruited and cholesterol levels assayed at 12, 20, 28 and 36 weeks' gestation and on day 1-3 postpartum. A total of 222 women were recruited. The majority (95%) were white Irish, with a median age of 31 years (range 16-46). Median BMI was 25.9 kg/m2 (range 18-40) and 16% were smokers. Cholesterol levels were elevated in all trimesters of pregnancy, with median values from 1st trimester raised outside the non-pregnant adult range. High-density lipoprotein (HDL) levels ranged from 0.9 to 3.7 mmol/l and low-density lipoprotein (LDL) levels ranged from 1.3 to 6.1 mmol/l. Fasting, smoking and obesity did not have any significant effects on results. Total and LDL-cholesterol levels were raised throughout pregnancy. Levels were above non-pregnant adult ranges as early as the 1st trimester. The implications of this on fetus and mother are undetermined and deserve further investigation.

Maternal dietary nutrient intake and risk of preterm delivery

OBJECTIVE

To examine maternal dietary intake and preterm delivery.

STUDY DESIGN

Data included 5738 deliveries from the National Birth Defects Prevention Study. Odds ratios (ORs) reflected risks of delivery at <32, 32-34, or 35-36 versus ≥ 37 weeks for maternal intake in the lowest or highest quartile of nutrient intake compared with the middle two.

RESULTS

Among deliveries < 32 weeks, many ORs were ≥ 1.5 or ≤ 0.7, but few confidence intervals excluded one. ORs were ≥ 1.5 for lowest quartiles of protein, thiamin, riboflavin, choline, vitamin A, α-carotene, β-carotene, vitamin E, iron, copper, and zinc and for highest quartiles of carbohydrate, glycemic index, and Mediterranean Diet Score. ORs were ≤ 0.7 for lowest quartiles of glycemic index and betaine and for highest quartiles of protein, alanine, methionine, vitamin B6, betaine, and calcium. Few ORs met these criteria for later preterm deliveries.

CONCLUSIONS

Results suggested an association of nutrient intake with earlier preterm deliveries.

The Alberta Pregnancy Outcomes and Nutrition (APrON) cohort study: rationale and methods

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.

Methodological aspects of the study of dietary patterns during pregnancy and maternal and infant health outcomes. A systematic review

The objective of the present study was to systematically review the literature exploring the associations between different dietary patterns obtained from Food Frequency Questionnaires during pregnancy and the development of health-related maternal and infant outcomes in the Framework of the EURRECA Network of Excellence. A systematic search was conducted on Pubmed for literature published up to September 2009. The search strategy resulted in an initial amount of 2048 articles. After applying the selection criteria, seven studies were finally identified. Five articles were based on prospective cohort studies and the other two were case-control studies. The methods used to elaborate the dietary pattern could be classified as hypothesis-oriented (three studies) or empirically-derived (four studies). The different food frequency questionnaires used for diet assessment were self-administered, semi-quantitative and had been previously validated, but just four studies employed questionnaires validated specifically for their use in a pregnant population. The divergent methods used to assess the dietary patterns make it difficult to compare results. However, some resulting recommendations can be applied when dietary patterns during pregnancy are analyzed: to employ a validated food frequency questionnaire designed for use in pregnancy, to consider the special role exerted by mineral and vitamin supplements in this particular population group, to adequately select the time in which dietary data is collected, to adjust the results for life-style and educational characteristics, and in the case of hypothesis-oriented dietary patterns, to correctly choose the components comprising the score.

Maternal lipids at mid-pregnancy and the risk of preterm delivery

OBJECTIVE

This study examined associations between maternal lipid levels at mid-pregnancy and preterm delivery, medically indicated or spontaneous.

DESIGN

Prospective cohort study.

SETTING

Women were recruited from 52 clinics in five Michigan, USA communities (1998-2004).

POPULATION

Pregnant women were enrolled at 15-27 weeks' gestation and followed to delivery (n=3019).

METHODS

A single blood sample was obtained at study enrollment. Blood lipids, i.e. total cholesterol (TC), high-density lipoprotein (HDLc), low-density lipoprotein (LDLc) cholesterol, and triglycerides (TG), were measured on a sub-cohort (n=1309).

MAIN OUTCOME MEASURES

There were 221 spontaneous, 100 medically indicated preterm deliveries and 988 term deliveries. Polytomous logistic regression models examined relationships among cholesterol levels (Low: <10(th) percentile, Referent: 10(th) -<70(th) percentile, High: ≥70(th) percentile), quartiles of TG (Referent: first quartile) and delivery outcome (Referent: term).

RESULTS

Odds of medically indicated preterm delivery were increased among women with low TC (adjusted odds ratio (aOR)=2.04, 95% confidence interval (CI): 1.12, 3.72), low HDLc (aOR=1.89, 95%CI: 1.04, 3.42) or low LDLc (aOR=1.96, 95%CI: 1.09, 3.54). Odds of spontaneous preterm delivery were increased among women with high TC (aOR=1.51, 95%CI: 1.06, 2.15), high LDLc (aOR=1.42, 95%CI: 0.99, 2.04) or high TG (aOR=1.90, 95%CI: 1.21, 2.97 and aOR=1.72, 95%CI: 1.06, 2.78 for third and fourth quartiles, respectively).

CONCLUSIONS

Extremely low TC, HDLc, and LDLc were associated with a modest increase in risk of medically indicated preterm delivery, whereas high TC, LDLc and TG modestly increased the risk of spontaneous preterm delivery. Further research is needed to uncover explanations for these associations and to identify optimal ranges for maternal lipids.

Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence

OBJECTIVE

To evaluate the effects of dietary and lifestyle interventions in pregnancy on maternal and fetal weight and to quantify the effects of these interventions on obstetric outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Major databases from inception to January 2012 without language restrictions.

STUDY SELECTION

Randomised controlled trials that evaluated any dietary or lifestyle interventions with potential to influence maternal weight during pregnancy and outcomes of pregnancy.

DATA SYNTHESIS

Results summarised as relative risks for dichotomous data and mean differences for continuous data.

RESULTS

We identified 44 relevant randomised controlled trials (7278 women) evaluating three categories of interventions: diet, physical activity, and a mixed approach. Overall, there was 1.42 kg reduction (95% confidence interval 0.95 to 1.89 kg) in gestational weight gain with any intervention compared with control. With all interventions combined, there were no significant differences in birth weight (mean difference -50 g, -100 to 0 g) and the incidence of large for gestational age (relative risk 0.85, 0.66 to 1.09) or small for gestational age (1.00, 0.78 to 1.28) babies between the groups, though by itself physical activity was associated with reduced birth weight (mean difference -60 g, -120 to -10 g). Interventions were associated with a reduced the risk of pre-eclampsia (0.74, 0.60 to 0.92) and shoulder dystocia (0.39, 0.22 to 0.70), with no significant effect on other critically important outcomes. Dietary intervention resulted in the largest reduction in maternal gestational weight gain (3.84 kg, 2.45 to 5.22 kg), with improved pregnancy outcomes compared with other interventions. The overall evidence rating was low to very low for important outcomes such as pre-eclampsia, gestational diabetes, gestational hypertension, and preterm delivery.

CONCLUSIONS

Dietary and lifestyle interventions in pregnancy can reduce maternal gestational weight gain and improve outcomes for both mother and baby. Among the interventions, those based on diet are the most effective and are associated with reductions in maternal gestational weight gain and improved obstetric outcomes.

Inflammation and cardiovascular risk in women with preterm labor

BACKGROUND

Women with a history of preterm delivery have about twice the normal risk of cardiovascular disease (CVD). Mechanisms underlying this association are not well understood. The aim of the present study was to evaluate the relationships between selected metabolic CVD risk factors and markers of both systemic inflammation and endothelial dysfunction in women with spontaneous preterm labor (sPL).

METHODS

This was a case-control study in a university tertiary referral center. Forty pregnant women with sPL were compared to 50 controls during gestation. Maternal serum triglycerides, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol, glycemia, insulinemia, homeostasis model assessment (HOMA), leptin, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), soluble vascular cell adhesion molecule (sVCAM), soluble intercellular adhesion molecule (sICAM), selectin, and myeloperoxidase (MPO) were measured.

RESULTS

Gestational age at study was similar in both groups (31.56±3.14 weeks of gestation vs. 31.27±2.14 weeks of gestation, p=0.62, for the control and the sPL groups, respectively). Body mass index (BMI) (21.72±2.99 vs. 23.56±3.80, p=0.01), all cholesterol fractions (HDL-C 53.44±18.22 vs. 68.32±18.38, p=0.0003; LDL-C 125.71±35.56 vs. 142.15±36.07, p=0.03, and total cholesterol 219.55±32.29 vs. 240.38±40.01, p=0.009) and MPO (3.07±0.63 vs. 3.48±0.32, p=0.0009) were significantly lower in women with sPL. Serum levels of IL-6 (0.61±0.46 vs. 0.33±0.46, p=0.007) and the ratio of total cholesterol/HDL-C (4.52±1.48 vs. 3.77±1.37, p=0.01) were significantly increased and correlated each other (r=0.21, p=0.04). Logistic regression showed that the best predictive model for sPL (R(2)=0.36, p=0.001) included BMI and total cholesterol.

CONCLUSIONS

A combination of low maternal BMI, low cholesterol levels, and high total cholesterol/HDL-C ratio is present in women with sPL and is related to inflammation.

Effect of dietary factors in pregnancy on risk of pregnancy complications: results from the Norwegian Mother and Child Cohort Study

There has been a thrilling development , as well as profound changes, in our understanding of the effect of fetal nutrition on the development and health of the child. The Norwegian Mother and Child Cohort Study (MoBa) is an ongoing nationwide population-based pregnancy cohort study that between 1999 and 2008 recruited 90,723 women with 106,981 pregnancies and 108,487 children. The objective of MoBa is to test specific etiologic hypotheses by estimating the association between exposures and diseases with a special focus on disorders that may originate in early life. An important aspect in this regard is maternal diet and nutritional status during pregnancy. Nutritional factors have long been considered to be important determinants of maternal and fetal health, and dietary information is currently being collected in a number of pregnancy cohorts in Europe and the United States. Thus far, pregnancy complications studied in MoBa are preterm birth, preeclampsia, and fetal growth; and the aim of this article is to report results of recently published studies of dietary factors in relation to these outcomes. Numerous studies are planned using MoBa data, and the aim is to add to the knowledge of the interplay between dietary factors, nonnutrients, and toxic dietary substances and epigenetic modulation on fetal development and health later in life.

Birth characteristics and subsequent risks of maternal cardiovascular disease: effects of gestational age and fetal growth

BACKGROUND

Prior studies showing an inverse relationship between low birth weight in offspring and maternal risks of cardiovascular diseases (CVD) are limited by lack of information on gestational age and/or insufficient adjustment for confounders.

METHODS AND RESULTS

In a nationwide Swedish study, we included information on 923 686 women and their first singleton births between 1983 and 2005. Cox proportional hazards models were used to study associations between gestational length, fetal growth, and maternal incident hospitalization or death from CVD (coronary heart disease, cerebrovascular events, and heart failure). Multivariable adjusted models accounted for birth year, income, education, country of birth, smoking, diabetes mellitus, hypertension, and preeclampsia. The risk of maternal CVD increased with decreasing gestational age whereas the risk increase related to fetal growth appeared to be restricted to very small-for-gestational-age (SGA) infants. Compared with mothers of non-SGA infants born at term, the hazard ratio of CVD ranged from 1.39 (95% confidence interval 1.22-1.58) to 2.57 (95% confidence interval 1.97-3.34) among mothers to moderately and very preterm infants, respectively. There was a significant interaction between preterm birth and fetal growth with respect to mothers' risk of CVD (P<0.001). Among mothers to very SGA infants, the hazard ratio of CVD ranged from 1.38 (95% confidence interval 1.15-1.65) to 3.40 (95% confidence interval 2.26-5.11) in mothers to term and very preterm infants, respectively.

CONCLUSIONS

Delivery of a preterm or SGA infant is associated with later life maternal hospitalization or death from CVD even after accounting for socioeconomic factors, smoking, and pregnancy-related complications.

Cholesterol in pregnancy: a review of knowns and unknowns

Cholesterol forms part of every cell in the human body, and also helps make and metabolize hormones, bile acids and vitamin D. Human plasma cholesterol levels are determined by production in the liver and by dietary intake. Lipoproteins carry cholesterol around the body, and facilitate it crossing the placenta. Cholesterol is carefully monitored in the non-pregnant adult population, where its association with atherosclerosis and cardiovascular disease is well understood. Although it is known that cholesterol rises in pregnancy, at present it is not routinely measured or treated. The effects of maternal high cholesterol on pregnancy and on fetal development are not yet fully understood. However, a growing body of evidence from animal and human studies suggests adverse consequences of high cholesterol levels in pregnancy.

Maternal nutrition and perinatal outcomes

Diet and patterns of eating during pregnancy can affect perinatal outcomes through direct physiologic effects or by stressing the fetus in ways that permanently affect phenotype. Supplements are not a magic nutritional remedy, and evidence of profound benefit for most supplements remains inconclusive. However, research supports calcium supplements to decrease preeclampsia. Following a low glycemic, Mediterranean-type diet appears to improve ovulatory infertility, decrease preterm birth, and decrease the risk of gestational diabetes. Although women in the United States have adequate levels of most nutrients, subpopulations are low in vitamin D, folate, and iodine. Vitamin D has increasingly been shown to be important not only for bone health, but also for glucose regulation, immune function, and good uterine contractility in labor. To ensure adequate vitamin and micronutrient intake, especially of folate before conception, all reproductive age women should take a multivitamin daily. In pregnancy, health care providers need to assess women's diets, give them weight gain recommendations based on their body mass index measurement, and advise them to eat a Mediterranean diet rich in omega-3 fatty acids (ingested as low-mercury risk fatty fish or supplements), ingest adequate calcium, and achieve adequate vitamin D levels through sun exposure or supplements. Health care providers should continue to spend time on nutrition assessment and counseling.

Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study

CONTEXT

Metformin is widely prescribed to pregnant women with polycystic ovary syndrome (PCOS) in an attempt to reduce pregnancy complications. Metformin is not approved for this indication, and evidence for this practice is lacking.

OBJECTIVES

Our objective was to test the hypothesis that metformin, from first trimester to delivery, reduces pregnancy complications in women with PCOS.

DESIGN AND SETTING

We conducted a randomized, placebo-controlled, double-blind, multicenter study at 11 secondary care centers.

PARTICIPANTS

The participants were 257 women with PCOS, in the first trimester of pregnancy, aged 18-42 yr.

INTERVENTION

We randomly assigned 274 singleton pregnancies (in 257 women) to receive metformin or placebo, from first trimester to delivery.

MAIN OUTCOME MEASURES

The prevalence of preeclampsia, gestational diabetes mellitus, preterm delivery, and a composite of these three outcomes is reported.

RESULTS

Preeclampsia prevalence was 7.4% in the metformin group and 3.7% in the placebo group (3.7%; 95% CI, -1.7-9.2) (P=0.18). Preterm delivery prevalence was 3.7% in the metformin group and 8.2% in the placebo group (-4.4%; 95%, CI, -10.1-1.2) (P=0.12). Gestational diabetes mellitus prevalence was 17.6% in the metformin group and 16.9% in the placebo group (0.8%; 95% CI, -8.6-10.2) (P=0.87). The composite primary endpoint prevalence was 25.9 and 24.4%, respectively (1.5%; 95% CI, -8.9-11.3) (P=0.78). Women in the metformin group gained less weight during pregnancy compared with those in the placebo group. There was no difference in fetal birth weight between the groups.

CONCLUSIONS

Metformin treatment from first trimester to delivery did not reduce pregnancy complications in PCOS.

Metabolic syndrome in early pregnancy and risk of preterm birth

The authors determined the association between metabolic syndrome in early pregnancy (mean, 11.96 weeks) and the risk of preterm birth in the mother-child cohort study ("Rhea" Study) in Crete, Greece, 2007-2009. Maternal fasting serum samples were collected, and blood pressure was measured at the time of the first major ultrasound examination (n = 625). Multivariable log-binomial regression models were used. Women with metabolic syndrome were at high risk for preterm birth (relative risk (RR) = 2.93, 95% confidence interval (CI): 1.53, 5.58), with the highest risk observed for medically indicated preterm births (RR = 5.13, 95% CI: 1.97, 13.38). Among the components of metabolic syndrome, the most significant risk factor was hypertension (RR = 2.32, 95% CI: 1.28, 4.20). An elevation of 10 mm Hg in diastolic blood pressure increased the relative risk for preterm birth by 29% (RR = 1.29, 95% CI: 1.08, 1.53), while a per unit increase in the low density lipoprotein/high density lipoprotein cholesterol ratio increased this risk by 19% (RR = 1.19, 95% CI: 1.02, 1.39). Fetal weight growth restriction was associated with elevated levels of insulin (RR = 1.14, 95% CI: 1.08, 1.20) and diastolic blood pressure (RR = 1.27, 95% CI: 1.00, 1.61) in early pregnancy. These findings suggest that women with metabolic syndrome in early pregnancy had higher risk for preterm birth.

A dietary pattern characterized by high intake of vegetables, fruits, and vegetable oils is associated with reduced risk of preeclampsia in nulliparous pregnant Norwegian women

Several dietary substances have been hypothesized to influence the risk of preeclampsia. Our aim in this study was to estimate the association between dietary patterns during pregnancy and the risk of preeclampsia in 23,423 nulliparous pregnant women taking part in the Norwegian Mother and Child Cohort Study (MoBa). Women participating in MoBa answered questionnaires at gestational wk 15 (a general health questionnaire) and 17-22 (a FFQ). The pregnancy outcomes were obtained from the Medical Birth Registry of Norway. Exploratory factor analysis was used to assess the associations among food variables. Principal component factor analysis identified 4 primary dietary patterns that were labeled: vegetable, processed food, potato and fish, and cakes and sweets. Relative risks of preeclampsia were estimated as odds ratios (OR) and confounder control was performed with multiple logistic regression. Women with high scores on a pattern characterized by vegetables, plant foods, and vegetable oils were at decreased risk [relative risk (OR) for tertile 3 vs. tertile 1: 0.72; 95% CI: 0.62, 0.85]. Women with high scores on a pattern characterized by processed meat, salty snacks, and sweet drinks were at increased risk [OR for tertile 3 vs. tertile 1: 1.21; 95% CI: 1.03, 1.42]. These findings suggest that a dietary pattern characterized by high intake of vegetables, plant foods, and vegetable oils decreases the risk of preeclampsia, whereas a dietary pattern characterized by high consumption of processed meat, sweet drinks, and salty snacks increases the risk.

Vasculopathic and thrombophilic risk factors for spontaneous preterm birth

BACKGROUND

Mothers who give birth to preterm infants are at increased risk of mortality from coronary heart disease and stroke, but the biological pathways underlying these associations have not been explored.

METHODS

We carried out a case-control study nested in a large (n = 5337) prospective, multicentre cohort. All cohort women had an interview, examination and venipuncture at 24-26 weeks. Frozen plasma samples in spontaneous preterm births (n = 207) and 444 term controls were analysed for plasma homocysteine, folate, cholesterol (total, low-density lipoprotein and high-density lipoprotein) and thrombin-antithrombin (TAT) complexes. DNA was extracted and analysed for seven gene polymorphisms involved in thrombophilia or folate or homocysteine metabolism. Fresh placentas were fixed, stained and blindly assessed for histologic evidence of infarction and decidual vasculopathy.

RESULTS

High (above the median) plasma homocysteine and HDL cholesterol were significantly and independently associated with the risk of spontaneous preterm birth [adjusted odds ratios (OR)s = 1.9 (95% 1.1-3.3) and 0.5 (0.3-0.9), respectively]. A higher proportion of women with high homocysteine concentrations had decidual vasculopathy [(13.0 vs 6.8%; OR = 1.9 (1.1-3.5)], although the positive association between decidual vasculopathy and preterm birth did not achieve statistical significance [OR = 1.5 (0.9-2.7)]. No significant associations were observed with the DNA polymorphisms or with plasma TAT or folate levels.

CONCLUSIONS

Similar vasculopathic risk factors may underlie preterm birth and adult coronary heart disease and stroke.

Intrauterine risk factors for precocious atherosclerosis

Evidence from noninvasive ultrasound studies of the neonatal aorta and fetal and early childhood postmortem studies indicates that impaired fetal growth, in utero exposure to maternal hypercholesterolemia, and diabetic macrosomia may all be important risk factors for vascular changes consistent with the earliest physical signs of atherosclerosis. Although the exact mechanisms that underlie these associations remain unclear, animal models have suggested that the use of antioxidant, lipid-lowering, and other innovative therapies may counteract the impact of these intrauterine risk factors for cardiovascular disease. This review summarizes the current evidence for intrauterine factors that have a direct impact on atherosclerosis and provides potential treatment and prevention strategies.

Nutritional counseling for vegetarians during pregnancy and lactation

A woman's nutritional status directly affects pregnancy outcome and the quality of breast milk after birth. Clinicians who provide prenatal care have an important role in assessing the nutritional status of women and directing them to appropriate resources while respecting their choices. Vegetarian and vegan diets may present with unique nutrient deficiencies that can be addressed during prenatal nutritional counseling.

Prevention of recurrent fetal growth restriction

Fetal growth restriction is associated with multiple short- and long-term consequences for the infant. A woman with a prior gestation complicated by fetal growth restriction has nearly a 20% risk of recurrence. Strategies to predict and prevent the recurrence are critical in obstetric management. Effective interventions for prevention of recurrent fetal growth restriction include the following: a reproductive plan because spacing of pregnancies impacts their outcome, optimization of maternal medical conditions, smoking cessation, accurate dating by first-trimester sonography and monitoring of fetal growth with serial sonograms, and low-dose aspirin (80-160 mg) started before 20 weeks. In women with nutritional deficiencies, optimizing caloric intake with low-protein (less than 25%) supplementation of 500-1,000 calories may prevent recurrent fetal growth restriction. In women living in areas endemic for malaria, antimalarial prophylaxis diminishes risk of recurrent fetal growth restriction.

Early pregnancy lipid concentrations and spontaneous preterm birth

OBJECTIVE

Women who deliver preterm infants may be at increased risk for cardiovascular disease, perhaps related to dyslipidemia.

STUDY DESIGN

In a nested case control study of women with spontaneous preterm birth, cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides were evaluated. Lipid concentrations and gestational changes, as well as risk for preterm birth, were evaluated in women who delivered <34 (n = 23), >or=34-<37 (n = 67), and >or=37 weeks (n = 199).

RESULTS

High cholesterol or triglycerides <or=15 weeks were associated with a 2.8-fold (1.0-7.9) and 2.0-fold (1.0-3.9) increased risk for preterm birth <34 weeks and >or=34-<37 weeks, respectively. Overweight women who delivered <34 weeks had particularly elevated early pregnancy concentrations of cholesterol and low-density lipoprotein; lean women with moderate preterm birth had elevated triglycerides. There was a reduced triglyceride response in the first half of pregnancy among women who delivered <34 weeks.

CONCLUSION

Our results indicate the presence of dyslipidemia in women with spontaneous preterm birth.

Maternal and fetal variation in genes of cholesterol metabolism is associated with preterm delivery

OBJECTIVE

To examine the contribution of variants in fetal and maternal cholesterol metabolism genes in preterm delivery (PTD).

STUDY DESIGN

A total of 40 single-nucleotide polymorphisms (SNPs) in 16 genes related to cholesterol metabolism were examined for 414 preterm infants (gestational ages 22 to 36 weeks; comprising 305 singletons and 109 twins) and at least 1 parent. Fetal effects were assessed using the transmission disequilibrium test (TDT) for each SNP, followed by a log linear model-based approach to utilize families with missing parental genotypes for those SNPs showing significance under TDT. Genetic variant effects were examined for a role in PTD, gestational age and birth weight. Maternal effects were estimated using a log linear model-based approach.

RESULT

Among singleton gestations, suggestive association (P<0.01 without adjusting for multiple comparisons) was found between birth weight and fetal DHCR7 gene/SNP combinations (rs1630498, P=0.002 and rs2002064, P=0.003). Among all gestations, suggestive associations were found between PTD and fetal HMGCR (rs2303152, P=0.002) and APOA1 (rs 5070, P=0.004). The result for HMGCR was further supported by the log linear model-based test in the single births (P=0.007) and in all births (P=0.006). New associations (APOE and ABCA1) were observed when birth weight was normalized for gestational age suggesting independent effects of variants on birth weight separate from effects on PTD. Testing for maternally mediated genetic effects has identified suggestive association between ABCA1 (rs4149313, P=0.004) and decreased gestational age.

CONCLUSION

Variants in maternal and fetal genes for cholesterol metabolism were associated with PTD and decreased birth weight or gestational age in this study. Genetic markers may serve as one mechanism to identify high-risk mothers and fetuses for targeted nutritional treatment and/or prevention of low birth weight or PTD.

Adverse birth outcome among mothers with low serum cholesterol

OBJECTIVE

The objective of this study was to assess whether low maternal serum cholesterol during pregnancy is associated with preterm delivery, impaired fetal growth, or congenital anomalies in women without identified major risk factors for adverse pregnancy outcome.

METHODS

Mother-infant pairs were retrospectively ascertained from among a cohort of 9938 women who were referred to South Carolina prenatal clinics for routine second-trimester serum screening. Banked sera were assayed for total cholesterol; <10th percentile of assayed values (159 mg/dL at mean gestational age of 17.6 weeks) defined a "low total cholesterol" prenatal risk category. Eligible women were aged 21 to 34 years and nonsmoking and did not have diabetes; neonates were liveborn after singleton gestations. Total cholesterol values of eligible mothers were adjusted for gestational age at screening before risk group assignment. The study population included 118 women with low total cholesterol and 940 women with higher total cholesterol. Primary analyses used multivariate regression models to compare rates of preterm delivery, fetal growth parameters, and congenital anomalies between women with low total cholesterol and control subjects with mid-total cholesterol values >10th percentile but <90th percentile.

RESULTS

Prevalence of preterm delivery among mothers with low total cholesterol was 12.7%, compared with 5.0% among control subjects with mid-total cholesterol. The association of low maternal serum cholesterol with preterm birth was observed only among white mothers. Term infants of mothers with low total cholesterol weighed on average 150 g less than those who were born to control mothers. A trend of increased microcephaly risk among neonates of mothers with low total cholesterol was found. Low maternal serum cholesterol was unassociated with risk for congenital anomalies.

CONCLUSIONS

Total serum cholesterol <10th population percentile was strongly associated with preterm delivery among otherwise low-risk white mothers in this pilot study population. Term infants of mothers with low total cholesterol weighed less than control infants among both racial groups.

Lipids and lactate in human immunodeficiency virus-1 infected pregnancies with or without protease inhibitor-based therapy

OBJECTIVE

To evaluate the effect of protease inhibitors on lipid and lactate levels and gastrointestinal symptoms in pregnancy.

METHODS

Acquired Immunodeficiency Syndrome (AIDS) Clinical Trials Group (ACTG) A5084 was an observational cohort study of human immunodeficiency virus (HIV)-infected pregnant women. Women recruited between 20 and 34 weeks of gestation were required to be on a stable, highly active antiretroviral therapy (HAART) regimen, stratified by protease inhibitor compared with no protease inhibitor regimens. Interval history was assessed, and lipid and lactate levels were drawn every 8 weeks during pregnancy and 12 weeks postpartum, with levels closest to delivery and postpartum used for analysis. Statistical comparisons used Kruskal-Wallis and Fisher exact tests.

RESULTS

One-hundred fifty-eight women were evaluated. Total cholesterol levels (median 230 mg/dL, interquartile range [197, 259], compared with 212 [179, 246] mg/dL, P=.042) and triglycerides (median 224 mg/dL, interquartile range [187, 288], compared with 185 [142, 230] mg/dL, P<.001] were elevated in the protease inhibitor group during pregnancy and remained higher in this group after delivery (total cholesterol 185 [163, 224] mg/dl compared with 171 [140, 190] mg/dL, P<.004; triglycerides 122 [87, 175] mg/dL compared with 89 [66, 150] mg/dL, P=.02). No difference was seen in lactate levels or rates of gastrointestinal symptoms between groups. Obstetric outcomes were similar between the two groups. A higher number of low birth weight infants were born to women in the highest twentieth percentile of triglycerides compared with the lowest across medication groups.

CONCLUSION

Cholesterol and triglycerides were higher in protease inhibitor-treated women in pregnancy. Lactate and gastrointestinal symptoms were not different. A higher number of low birth weight infants were noted in women with high triglycerides, but other elevated lipid levels did not affect pregnancy outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00017797

LEVEL OF EVIDENCE

II.

Effect of a cholesterol-lowering diet during pregnancy on maternal and fetal Doppler velocimetry: the CARRDIP study

OBJECTIVE

The purpose of this study was to evaluate the effect of a low-cholesterol low-saturated fat diet on Doppler indices in the fetus and mother.

STUDY DESIGN

Two hundred ninety nonsmoking white women, aged 21-38 years, without previous pregnancy complications and carrying a single fetus were assigned randomly to continue their usual diet (control subjects; n = 149) or to adopt a low-cholesterol low-saturated fat diet (intervention group; n = 141) from gestational week 17-20 to birth. Doppler velocimetry of the umbilical artery and both uterine arteries were assessed at gestational weeks 24, 30, and 36.

RESULTS

The physiologic gestational decrease in umbilical artery pulsatility index (PI) from week 24-30 was more pronounced in the intervention group, compared with the control group, with median values (interquartile range) of -0.17 (-0.29, -0.06) and -0.11 (-0.25, 0.01), respectively (P = .048). Assignment to the intervention diet did not influence the changes in mean PI value of the 2 uterine arteries (P = .3). The change in umbilical artery PI and mean PI value of the uterine arteries between weeks 24 and 36 were not significantly different between the 2 groups (P = 1.0 and .2 respectively).

CONCLUSION

Our study shows that a cholesterol-lowering diet during pregnancy may modify fetoplacental circulation in mid pregnancy.

Effects of an antiatherogenic diet during pregnancy on markers of maternal and fetal endothelial activation and inflammation: the CARRDIP study

Objective

To study the effect of an antiatherogenic diet on maternal and cord blood concentrations of systemic biomarkers of endothelial cell activation, haemostasis and inflammation.

Design

Single blinded randomised controlled clinical trial.

Setting

Obstetric outpatient clinic and maternity unit of a university hospital in Norway.

Population

Nonsmoking pregnant women aged 21–38 years carrying a single fetus and with no previous pregnancy-related complications.

Methods

Subjects (n = 290) were randomised to continue their usual diet or to adopt a diet low in saturated fat and cholesterol from gestational week 17–20 to birth. Soluble forms of cellular adhesion molecules, high-sensitivity C-reactive protein (CRP) and haemostatic markers were measured at 17–20 weeks of gestation (baseline) and subsequently up to week 36. All the above, except CRP, were also measured in cord blood.

Main outcome measures

Concentrations of maternal and fetal biomarkers and maternal CRP.

Results

All biomarkers except CRP levels increased significantly during the study period in both the intervention and control groups. None of the maternal or fetal biomarkers were influenced by the intervention (P > 0.05) except for a tendency to lower concentrations of cord blood tissue plasminogen activator antigen in the intervention group compared with the control group, median (interquartile range) 5.4 ng/ml (3.1–7.7) versus 5.8 ng/ml (3.5–11.8), P = 0.05.

Conclusion

An antiatherogenic diet in pregnancy did not significantly influence maternal or fetal blood concentrations of a range of biomarkers for inflammation. Thus, the previously reported effects of a cholesterol-lowering diet on maternal lipid profile and preterm delivery (<37 complete weeks of gestation) do not seem to involve changes in the systemic inflammatory responses of pregnancy.

Duration of pregnancy in relation to fish oil supplementation and habitual fish intake: a randomised clinical trial with fish oil

OBJECTIVE

To examine the effect of fish oil supplementation on duration of pregnancy, conditional on the woman's habitual fish intake.

DESIGN

Multicentre 1:1 randomised clinical trial of effect of fish oil in a high-risk population of pregnant women in whom habitual fish intake was assessed at randomisation.

SETTING

Nineteen university delivery wards in seven European countries.

SUBJECTS

Pregnant women with preterm delivery, intrauterine growth retardation (IUGR), or pregnancy-induced hypertension (PIH) in a previous pregnancy (group 1, n=495); with twin pregnancies (group 2, n=367); or with suspicion of IUGR or threatening preeclampsia in the current pregnancy (group 3, n=106). Women were stratified into low, middle, or high fish consumers.

METHODS

The intervention group received fish oil capsules providing 2.7 g long-chain n-3 fatty acids per day (n-3 poly unsaturated fatty acids (PUFA)) from around week 20 (groups 1 and 2) or 6.3 g n-3 PUFA from week 33 (group 3). The control regimen was capsules with olive oil. Effect on timing of spontaneous delivery was examined by Cox regression, assuming elective delivery (occurring in 40%) as a censoring event. Analyses of effect of fish oil were intention to treat, and all analyses were adjusted for maternal smoking, age, and parity.

RESULTS

In group 1, fish oil reduced the hazard rate of spontaneous delivery (HR) by 44% (95% confidence interval 14-64%) and 39% (16-56%) in low and middle fish consumers, respectively, with no detectable effect (-56 to 33%) in high fish consumers. In groups 2 and 3, no significant effect of fish oil was detected in any of the sub-strata defined by baseline fish consumption.

CONCLUSIONS

In pregnant women with previous pregnancy complications, fish oil supplementation delayed onset of delivery in low and middle, but not in high, fish consumers.

SPONSORSHIP

March of Dimes Birth Defects Foundation, Concerted Action (ERB-BMH1-CT92-1906) and PECO (ERB-CIPD-CT94-0235) programmes of the European Commission, and the Danish National Research Foundation. Lube Ltd donated the oil capsules.

Marked changes in plasma lipids and lipoproteins during pregnancy in women with familial hypercholesterolemia

Serum lipids increase during pregnancy. However, data are scarce for lipid changes in pregnant women with heterozygous familiar hypercholesterolemia (FH). The purpose of the present study was to examine plasma lipids and lipoproteins during pregnancy in women with FH. In 22 pregnant women blood samples were collected at gestational weeks 17-20 (baseline), 24, 30 and 36. Total- and LDL cholesterol increased significantly between baseline and gestational week 36 by 29% and 30%, respectively, compared to 25% and 34% in a reference group of 149 healthy pregnant women. Notably, the plasma lipid concentrations in the FH women were much higher than in the reference women. Triglycerides increased (P<0.05) by 116% and 103%, in the FH group and reference group, respectively. HDL cholesterol was unchanged in both groups. Moreover, apolipoprotein B increased significantly during pregnancy in the FH women, whereas apolipoprotein A1 and lipoprotein (a) were unchanged. Pregnancy outcomes in the FH group did not differ significantly from those in the reference group. In conclusion, the relative increase in plasma lipids was similar in pregnant women with FH and in healthy women, but the absolute magnitude was considerably larger in pregnant FH women.

Supplementation of n-3 fatty acids during pregnancy and lactation reduces maternal plasma lipid levels and provides DHA to the infants

OBJECTIVE

Docosahexaenoic acid (DHA, 22:6 n-3) is considered an essential fatty acid for the fetus and newborn infant, but the optimal level of supply is not known. We studied the effect of supplementing pregnant and lactating women with marine n-3 polyunsaturated fatty acids (PUFAs) as compared to n-6 PUFAs related to maternal and infant lipid levels.

STUDY DESIGN

Five hundred and ninety pregnant women in weeks 17-19 of pregnancy were recruited. They were given either 10 mL cod liver oil (n-3 PUFAs) or corn oil (n-6 PUFAs) daily until three months after delivery, and 341 women took part in the study until giving birth.

RESULTS

Maternal supplementation with cod liver oil increased the concentration of DHA in maternal as well as infant plasma and umbilical tissue phospholipids, as compared to corn oil. The maternal plasma triacylglycerol increase during pregnancy was less pronounced in women supplemented with cod liver oil as compared to corn oil. The concentration of high-density lipoprotein (HDL)-cholesterol was unchanged during pregnancy in the cod liver oil group, whereas it decreased in the corn oil group, promoting a greater increase in the ratio of total cholesterol/HDL-cholesterol in the corn oil group.

CONCLUSION

Maternal supplementation with n-3 fatty acids during pregnancy and lactation provides more DHA to the infant and reduces maternal plasma lipid levels compared to supplementation with n-6 fatty acids.

Altered hemostatic balance and endothelial activation in pregnant women with familial hypercholesterolemia

INTRODUCTION

Patients with familial hypercholesterolemia (FH) are prone to premature cardiovascular disease. During pregnancy plasma lipids reach higher absolute values in FH than in healthy women. Pregnancy is associated with activation of coagulation and possibly also of vascular endothelium, which might further increase the risk of cardiovascular disease in FH. However, whether hemostatic and endothelial activation markers are increased in pregnant FH women compared with non-FH pregnancies, is unknown.

MATERIALS AND METHODS

Activation markers of hemostasis and endothelium were analyzed in blood samples collected prospectively from 22 heterozygous FH women during pregnancy and compared with those of a reference group of 149 healthy, pregnant women.

RESULTS

A procoagulant pattern was detected in both groups, but was more evident among FH women at least partly due to their enhanced thrombin generation, and because tissue factor pathway inhibitor type 1 increased in the reference group only. Furthermore, plasminogen activator inhibitor type 2 antigen increased more in FH than in the reference group. Whereas C-reactive protein, intercellular adhesion marker-1 and E-selectin did not change appreciably, vascular endothelial cell adhesion molecule 1 rose markedly in FH.

CONCLUSION

Increased lipid levels as well as a net procoagulant activity and an enhanced endothelial activation possibly confer additional risks of cardiovascular disease among pregnant FH women.