Gestational diabetes, pre-pregnancy obesity and pregnancy weight gain in relation to excess fetal growth: variations by race/ethnicity

Intrauterine growth in chromatinopathies: A long road for better understanding and for improving clinical management

BACKGROUND

Chromatinopathies are a heterogeneous group of genetic disorders caused by pathogenic variants in genes coding for chromatin state balance proteins. Remarkably, many of these syndromes present unbalanced postnatal growth, both under- and over-, although little has been described in the literature. Fetal growth measurements are common practice in pregnancy management and values within normal ranges indicate proper intrauterine growth progression; on the contrary, abnormalities in intrauterine fetal growth open the discussion of possible pathogenesis affecting growth even in the postnatal period.

METHODS

Among the numerous chromatinopathies, we have selected six of the most documented in the literature offering evidence about two fetal overgrowth (Sotos and Weaver syndrome) and four fetal undergrowth syndromes (Bohring Opitz, Cornelia de Lange, Floating-Harbor, and Meier Gorlin syndrome), describing their molecular characteristics, maternal biochemical results and early pregnancy findings, prenatal ultrasound findings, and postnatal characteristics.

RESULTS/CONCLUSION

To date, the scarce data in the literature on prenatal findings are few and inconclusive, even though these parameters may contribute to a more rapid and accurate diagnosis, calling for a better and more detailed description of pregnancy findings.

Prevalence of macrosomic newborn and maternal and neonatal complications in a high-risk maternity

Objective

Evaluate the prevalence of macrosomic newborns (birth weight above 4000 grams) in a high-risk maternity from 2014 to 2019, as well as the maternal characteristics involved, risk factors, mode of delivery and associated outcomes, comparing newborns weighing 4000-4500 grams and those weighing above 4500 grams.

Methods

This is an observational study, case-control type, carried out by searching for data in hospital's own system and clinical records. The criteria for inclusion in the study were all patients monitored at the service who had newborns with birth weight equal than or greater than 4000 grams in the period from January 2014 to December 2019, being subsequently divided into two subgroups (newborns with 4000 to 4500 grams and newborns above 4500 grams). After being collected, the variables were transcribed into a database, arranged in frequency tables. For treatment and statistical analysis of the data, Excel and R software were used. This tool was used to create graphs and tables that helped in the interpretation of the results. The statistical analysis of the variables collected included both simple descriptive analyzes as well as inferential statistics, with univariate, bivariate and multivariate analysis.

Results

From 2014 to 2019, 3.3% of deliveries were macrosomic newborns. The average gestational age in the birth was 39.4 weeks. The most common mode of delivery (65%) was cesarean section. Diabetes mellitus was present in 30% of the deliveries studied and glycemic control was absent in most patients. Among the vaginal deliveries, only 6% were instrumented and there was shoulder dystocia in 21% of the cases. The majority (62%) of newborns had some complication, with jaundice (35%) being the most common.

Conclusion

Birth weight above 4000 grams had a statistically significant impact on the occurrence of neonatal complications, such as hypoglycemia, respiratory distress and 5th minute APGAR less than 7, especially if birth weight was above 4500 grams. Gestational age was also shown to be statistically significant associated with neonatal complications, the lower, the greater the risk. Thus, macrosomia is strongly linked to complications, especially neonatal complications.

Mediating effect of gestational weight gain on the preventive effect of exercise during pregnancy on macrosomia: a randomized clinical trial

OBJECTIVE

We sought to investigate the impact of individualized exercise guidance during pregnancy on the incidence of macrosomia and the mediating effect of gestational weight gain (GWG).

DESIGN

A prospective randomized clinical trial.

SETTING

A Hospital in Xingtai District, Hebei Province.

POPULATION

Older than 20 years of age, mid-pregnancy, and singleton pregnant women without contraindications to exercise during pregnancy.

METHODS

A randomized clinical trial was conducted from December 2021 to September 2022 to compare the effects of standard prenatal care with individualized exercise guidance on the incidence of macrosomia.

MAIN OUTCOME MEASURE

Incidence of macrosomia.

RESULTS

In all, 312 singleton women were randomized into an intervention group (N = 162) or a control group (N = 150). Participants who received individualized exercise guidance had a significantly lower incidence of macrosomia (3.73% vs. 13.61%, P = 0.002) and infants large for gestational age (9.94% vs. 19.73%, P = 0.015). However, no differences were observed in the rate of preterm birth (1.86% vs. 3.40%, P = 0.397) or the average gestational age at birth (39.14 ± 1.51 vs. 38.69 ± 1.85, P = 0.258). Mediation analysis revealed that GWG mediated the effect of exercise on reducing the incidence of macrosomia.

CONCLUSION

Individualized exercise guidance may be a preventive tool for macrosomia, and GWG mediates the effect of exercise on reducing the incidence of macrosomia. However, evidence does not show that exercise increases the rate of preterm birth or affects the average gestational age at birth.

TRIAL REGISTRATION

The trial is registered at www.clinicaltrails.gov [registration number: NCT05760768; registration date: 08/03/2023 (retrospectively registered)].

Diet, lifestyle and gut microbiota composition among Malaysian women with gestational diabetes mellitus: a prospective cohort study

The study addressed a significant gap in the profiling and understanding of the gut microbiota's influence on Malaysian Malay women with gestational diabetes mellitus (GDM). This prospective cohort study aimed to explore the intricate relationship between gut microbiota, dietary choices, and lifestyle factors among Malay women, both with and without GDM. The research specifically focused on participants during the second (T0) and third (T1) trimesters of pregnancy in Johor Bahru, Malaysia. In Part 1 of the study, a diverse pool of pregnant women at T0 was categorized into two groups: those diagnosed with GDM and those without GDM, with a total sample size of 105 individuals. The assessments encompassed demographic, clinical, lifestyle, and dietary factors at the T0 and T1 trimesters. Part 2 of the study delved into microbiome analysis, targeting a better understanding of the gut microbiota among the participants. Stool samples were randomly collected from 50% of the individuals in each group (GDM and non-GDM) at T0 and T1. The collected samples underwent processing, and 16s rRNA metagenomic analysis was employed to study the microbial composition. The results suggested an association between elevated body weight and glucose levels, poor sleep quality, lack of physical activity, greater intake of iron and meat, and reduced fruit consumption among women with GDM compared to non-GDM groups. The microbiome analysis revealed changes in microbial composition over time, with reduced diversity observed in the GDM group during the third trimester. The genera Lactiplantibacillus, Parvibacter, Prevotellaceae UCG001, and Vagococcus positively correlated with physical activity levels in GDM women in the second trimester. Similarly, the genus Victivallis exhibited a strong positive correlation with gravida and parity. On the contrary, the genus Bacteroides and Roseburia showed a negative correlation with omega-3 polyunsaturated fatty acids (PUFAs) in women without GDM in the third trimester. The study highlighted the multifaceted nature of GDM, involving a combination of lifestyle factors, dietary choices, and changes in gut microbiota composition. The findings emphasized the importance of considering these interconnected elements in understanding and managing gestational diabetes among Malaysian Malay women. Further exploration is essential to comprehend the mechanisms underlying this relationship and develop targeted interventions for effective GDM management.

Impact of COVID-19 mandatory lockdown on maternal gestational weight gain and neonatal macrosomia rate at an academic medical center in Israel

BACKGROUND

In an effort to prevent the spread of coronavirus disease 2019 (COVID-19), governments restricted outdoor activities and imposed lockdown quarantine. This change in lifestyle probably affected individuals' eating habits and physical activity.

OBJECTIVE

To examine the effect of lockdown due to the COVID-19 pandemic on maternal antenatal weight gain, neonatal macrosomia, and other maternal and neonatal outcomes of women delivering at an academic medical center in Israel.

METHOD

A retrospective, two-period cohort study conducted at a university teaching medical center in Afula, Israel. The study period was between April and September 2020. This period signifies worsening in pandemic situations, during which citizens experienced strict prolonged lockdown measures. The parallel unexposed period (control period) was between April and September 2019. Singleton pregnancies delivered at >24 weeks were eligible. Primary outcome was incidence of macrosomia. Secondary outcomes included gestational weight gain, body mass index (BMI) at delivery, rates of gestational diabetes mellitus (GDM), mode of delivery, postpartum hemorrhage (PPH), and neonatal outcomes reflecting neonatal birth weight and condition at delivery.

RESULTS

A total of 4,765 women were included, 2,442 in the study group and 2,323 in the control group. The incidence of macrosomia was significantly higher in 2020 (6.2%) than in 2019 (4.9%), (p = .048; OR: 1.29; 95% CI: 1.002- 1.65). Women gained significantly more weight (median 1 kg more), weighed more at delivery (median 1 kg), and had higher BMI at delivery in 2020 compared with those in 2019 (p < .01). The incidence of GDM was 9.5% and 8.5% in the study and control groups respectively (p = .26; OR: 1.12; 95% CI: 0.92-1.37). Greater percentage of women did not perform the glucose challenge test in 2020 (9.9%) compared with those in 2019 (7.5%) (p = .003, OR: 1.36; 95% CI: 1.11-1.67). The incidence of any hypertension related to pregnancy was significantly higher in 2020 compared to 2019 (5.8% vs 4.4% respectively, (p = .042; OR: 1.32; 95% CI: 1.02-1.71). The proportion of women who smoked during pregnancy was also significantly higher in 2020 than in 2019 (5.1% vs 3.7%, respectively, p = .02; OR: 1.40; 95% CI: 1.06-1.86). Delivery mode did not differ, while the incidence of PPH was significantly higher in 2020 than in 2019 (5.6% vs 3.4%, respectively, p = .001; OR: 1.65; 95% CI: 1.25-2.19). Neonatal condition at delivery was comparable.

CONCLUSION

COVID-19-related lockdown was associated with the increased rate of macrosomic infants. This indirect effect of the pandemic is probably related to poorer maternal antenatal metabolic health status. Long-term consequences should be further examined.

Association between Maternal Body Composition in Second Trimester and Risk of Fetal Macrosomia: A Population-Based Retrospective Study in China

(1) Background: Female body composition undergoes significant changes to support fetal growth and development during pregnancy. This study investigated the association of maternal body composition in the second trimester and macrosomia and explored whether body-composition-related indicators could be used to predict macrosomia. (2) Methods: This study was conducted in China from December 2016 to December 2021. Women with singleton pregnancies, gestational ages between 37 and 42 weeks, and an absence of pregnancy complications were included. In the second trimester, bioelectric impedance analysis (BIA) was used to measure body-composition-related indicators. Logistic regression analysis was performed to explore the risk factors for macrosomia. The predictive performance of maternal body composition and clinical indicators for macrosomia were assessed using the area under the receiver-operating-characteristics curve (AUC). (3) Results: This retrospective study involved 43,020 pregnant women; we collected 2008 cases of macrosomia. Gravidity, gestational age, body mass index (BMI), gestational weight gain (GWG), total body water, fat mass, fat-free mass (FFM), skeletal muscle mass, and visceral fat level were risk factors for macrosomia (p < 0.05 for all). In the prediction model, the AUC of FFM for predicting macrosomia was the largest (0.742). (4) Conclusions: Body-composition-related indicators associated with macrosomia and body composition measurements in the second trimester can predict the risk of macrosomia, enabling clinicians to implement interventions earlier to reduce adverse perinatal outcomes.

Combined Effect of Maternal Obesity and Diabetes on Excessive Fetal Growth: Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 2012-2015

Introduction

Obesity and dysregulation in glucose metabolism are risk factors for excessive fetal growth, but their combined effects are not often examined in a single study.

Methods

Data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System Phase 7 (2012-2015) were used. Logistic regression was used to investigate the association between maternal prepregnancy BMI and pre-existing diabetes/gestational diabetes on the odds of delivering a large-for-gestational-age infant or an infant with macrosomia.

Results

Complete data for 128,199 singleton births were used. The proportions of large-for-gestational-age infants and infants with macrosomia increased with the degree of obesity (p<0.001) and were higher in women with diabetes than in those without (p<0.001). Compared with the AOR among normal-weight women, the AOR of delivering large-for-gestational-age infants and infants with macrosomia among women with morbid obesity (BMI≥40) were 2.82 (p<0.001) and 2.67 (p<0.001), respectively. Compared with the AOR among nondiabetic women, the AOR of delivering a large-for-gestational-age infant was 1.88 (p<0.001) among those with pre-existing diabetes and 1.49 (p<0.001) among those with gestational diabetes. Except for the underweight group, women with pre-existing diabetes were nearly twice as likely to deliver a large-for-gestational-age infant as those with similar BMI without diabetes. Women with morbid obesity and gestational diabetes were twice as likely to have a large-for-gestational-age infant and an infant with macrosomia as nondiabetic women with normal BMI.

Conclusions

We have shown that when maternal obesity and diabetes, particularly pre-existing diabetes, occur together, the risk of delivering large-for-gestational-age and macrosomia increases significantly. Our findings call for public health attention to address maternal obesity and diabetes to minimize suboptimal fetal growth.

A Vegetable, Oil, and Fruit Dietary Pattern in Late Pregnancy is Linked to Reduced Risks of Adverse Birth Outcomes in a Predominantly Low-Income Hispanic and Latina Pregnancy Cohort

BACKGROUND

Studies examining diet and its links to birth outcomes among socioeconomically disadvantaged populations in the United States are scarce.

OBJECTIVES

We aimed to identify prenatal dietary patterns, examine their relationships with birth outcomes, and evaluate the variation of these associations by maternal diabetes status [no diabetes, gestational diabetes mellitus (GDM), preexisting diabetes].

METHODS

Women in the Maternal and Developmental Risks from Environmental and Social Stressors (MADRES) study (n = 465)-an ongoing, prospective pregnancy cohort of predominantly low-income Hispanic/Latina women in Los Angeles-completed up to two 24-hour dietary recalls in the third trimester of pregnancy. We identified prenatal dietary patterns via factor analysis and evaluated their associations with infant birth weight and gestational age at birth (GA) z-scores, separately, using linear regression, as well as the associations of the dietary patterns with premature births, having an infant that was small for gestational age (SGA), and having an infant that was large for gestational age, using logistic regression and adjusting for relevant covariates. We additionally tested interaction terms between prenatal dietary patterns and maternal diabetes status in separate models. We adjusted for multiple comparisons using the false discovery rate.

RESULTS

We identified 2 dietary patterns: 1) a dietary pattern of solid fats, refined grains, and cheese (SRC); and 2) a dietary pattern of vegetables, oils, and fruit (VOF). Comparing the highest to lowest quartiles, the VOF was significantly associated with a greater infant birth weight (β = 0.40; 95% CIs: 0.10, 0.70; Ptrend = 0.011), a greater GA (β = 0.32; 95% CIs: 0.03, 0.61; Ptrend = 0.036), lower odds of a premature birth (OR = 0.31; 95% CIs: 0.10, 0.95; Ptrend = 0.049), and lower odds of having an infant that was SGA (OR = 0.18; 95% CIs: 0.06, 0.58; Ptrend = 0.028). Only among women with GDM, a 1-SD score increase in the prenatal SRC was significantly associated with a lower infant birth weight (β = -0.20; 95% CIs -0.39, -0.02; Pinteraction = 0.040).

CONCLUSIONS

Among low-income Hispanic/Latina pregnant women, greater adherence to the prenatal VOF may lower the risk of a premature birth and having an infant that is SGA. Greater adherence to the SRC, however, may adversely affect newborn birth weight among mothers with GDM, but future research is needed to verify our findings.

Ethnic differences in the impact of gestational diabetes on macrosomia

BACKGROUND

Previous studies reported an ethnic disparity in gestational diabetes mellitus-associated birth outcomes, with some suggesting that macrosomia increases to a lesser extent in groups at high risk, the opposite of the pattern observed by others. Our aim was to evaluate ethnic variation in the impact of gestational diabetes mellitus (GDM).

METHODS

A case-control study evaluating pregnancy outcomes was conducted in women with and without GDM from five ethnic groups. Data on GDM were collected between January 2004 and July 2017. Women giving birth between May 2013 and July 2017 in whom pre-existing diabetes had been ruled out served as controls. A multivariate logistic regression analysis was performed to determine factors independently associated with macrosomia.

RESULTS

Overall, 852 GDM women and 3,803 controls were included. In Caucasian and East-Asian women excessive gestational weight gain (OR 2.273, 95% CI 1.364-3.788 and OR 3.776, 95% CI 0.958-14.886) was an independent predictor of macrosomia. In Latin-American and Moroccan women, obesity (OR 1.774, 95% CI 1.219-2.581 and OR 1.656, 95% CI 1.054-2.601), GDM (OR 2.440; 95% CI 1.048-5.679 and OR 3.249, 95% CI 1.269-8.321) and gestational weight gain but only for Latin-American women (OR 2.365, 95% CI 1.039-5.384) were associated with macrosomia. In South-Central Asian women, only GDM was associated with macrosomia (OR 3.701, 95% CI 1.437-9.532).

CONCLUSIONS

GDM is an independent predictor of macrosomia in Latin-American, South-Central Asian and Moroccan women but not in Caucasian or East-Asian women in whom other factors play a more important role.

Prediction of large-for-gestational-age infant by fetal growth charts and hemoglobin A1c level in pregnancy complicated by pregestational diabetes

OBJECTIVES

To compare the ability of three fetal growth charts (Fetal Medicine Foundation (FMF), Hadlock and National Institutes of Child Health and Human Development (NICHD) race/ethnicity-specific) to predict large-for-gestational age (LGA) at birth in pregnant individuals with pregestational diabetes, and to determine whether inclusion of hemoglobin A1c (HbA1c) level improves the predictive performance of the growth charts.

METHODS

This was a retrospective analysis of individuals with Type-1 or Type-2 diabetes with a singleton pregnancy that resulted in a non-anomalous live birth. Fetal biometry was performed between 28 + 0 and 36 + 6 weeks of gestation. The primary exposure was suspected LGA, defined as estimated fetal weight ≥ 90^th percentile using the Hadlock (Formula C), FMF and NICHD growth charts. The primary outcome was LGA at birth, defined as birth weight ≥ 90^th percentile, using 2017 USA natality reference data. The performance of the three growth charts to predict LGA at birth, alone and in combination with HbA1c as a continuous measure, was assessed using the area under the receiver-operating-characteristics curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

Of 358 assessed pregnant individuals with pregestational diabetes (34% with Type 1 and 66% with Type 2), 147 (41%) had a LGA infant at birth. Suspected LGA was identified in 123 (34.4%) by the Hadlock, 152 (42.5%) by the FMF and 152 (42.5%) by the NICHD growth chart. The FMF growth chart had the highest sensitivity (77% vs 69% (NICHD) vs 63% (Hadlock)) and the Hadlock growth chart had the highest specificity (86% vs 76% (NICHD) and 82% (FMF)) for predicting LGA at birth. The FMF growth chart had a significantly higher AUC (0.79 (95% CI, 0.74-0.84)) for LGA at birth compared with the NICHD (AUC, 0.72 (95% CI, 0.68-0.77); P < 0.001) and Hadlock (AUC, 0.75 (95% CI, 0.70-0.79); P < 0.01) growth charts. Prediction of LGA improved for all three growth charts with the inclusion of HbA1c measurement in comparison to each growth chart alone (P < 0.001 for all); the FMF growth chart remained more predictive of LGA at birth (AUC, 0.85 (95% CI, 0.81-0.90)) compared with the NICHD (AUC, 0.79 (95% CI, 0.73-0.84)) and Hadlock (AUC, 0.81 (95% CI, 0.76-0.86)) growth charts.

CONCLUSIONS

The FMF fetal growth chart had the best predictive performance for LGA at birth in comparison with the Hadlock and NICHD race/ethnicity-specific growth charts in pregnant individuals with pregestational diabetes. Inclusion of HbA1c improved further the prediction of LGA for all three charts. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The metabolic conditioning of obesity: A review of the pathogenesis of obesity and the epigenetic pathways that "program" obesity from conception

Understanding the developmental origins of health and disease is integral to overcome the global tide of obesity and its metabolic consequences, including atherosclerotic cardiovascular disease, type 2 diabetes, hyperlipidemia, and nonalcoholic fatty liver disease. The rising prevalence of obesity has been attributed, in part, to environmental factors including the globalization of the western diet and unhealthy lifestyle choices. In this review we argue that how and when such exposures come into play from conception significantly impact overall risk of obesity and later health outcomes. While the laws of thermodynamics dictate that obesity is caused by an imbalance between caloric intake and energy expenditure, the drivers of each of these may be laid down before the manifestation of the phenotype. We present evidence over the last half-century that suggests that the temporospatial evolution of obesity from intrauterine life and beyond is, in part, due to the conditioning of physiological processes at critical developmental periods that results in maladaptive responses to obesogenic exposures later in life. We begin the review by introducing studies that describe an association between perinatal factors and later risk of obesity. After a brief discussion of the pathogenesis of obesity, including the systemic regulation of appetite, adiposity, and basal metabolic rate, we delve into the mechanics of how intrauterine, postnatal and early childhood metabolic environments may contribute to adult obesity risk through the process of metabolic conditioning. Finally, we detail the specific epigenetic pathways identified both in preclinical and clinical studies that synergistically "program" obesity.

What is the "cost" of reducing adverse pregnancy outcomes in patients with gestational diabetes mellitus - risk factors for perinatal complications in a retrospective cohort of pregnant women with GDM

BACKGROUND

Gestational diabetes mellitus (GDM) is a frequent pregnancy complication, affecting the maternal and neonatal health. The new diagnostic strategy for GDM, proposed by the International Association of Diabetes and Pregnancy Study Groups in 2010 and World Health Organization in 2013, raised hope to reduce perinatal complications. The purpose of the study was to compare risk factors influencing maternal and foetal outcomes in a group of pregnant women diagnosed with GDM, and in a group of pregnant women without GDM, regardless of the adopted diagnostic criteria. Also, the aim of the study was to evaluate the impact of risk factors on perinatal results and the "cost" of reducing adverse pregnancy outcomes in patients with GDM.

METHODS

It was a retrospective study based on the analysis of births given after 37 weeks of pregnancy at the 2nd Department of Obstetrics and Gynaecology, Warsaw Medical University during the years 2013 to 2015. All pregnant women had a 75 g OGTT between the 24th and 28th weeks of pregnancy. The study compared risk factors for perinatal complications in 285 GDM patients and in 202 randomly selected women without GDM. The impact of selected risk factors on perinatal outcomes was analysed.

RESULTS

Both the diagnosis of GDM and maternal BMI prior to pregnancy, significantly modified the risk of excessive and insufficient weight gain during pregnancy. The parameters significantly influencing the risk of the composite adverse maternal outcome were the maternal abdominal circumference [OR: 1.08 (1.04; 1.11)] and multiparity, which reduced the risk by almost half [OR: 0.47 (0.30; 0.75)]. The maternal abdominal circumference before the delivery was a strong factor correlating with the occurrence of perinatal complications in both the mother and the foetus in the entire cohort. A circumference over 100 cm increased the risk of at least one maternal complication (increased blood loss, soft tissue injury, pre-eclampsia) by almost 40% (OR 1.38, p < 0.001).

CONCLUSIONS

No differences were found in maternal and foetal outcomes in GDM and non-GDM women except gestational weight gain below Institute of Medicine recommendations. The only "cost" of reducing adverse pregnancy outcomes in GDM patients seems to be lowering gestational weight gain, the future impact of which on GDM pregnant population should be assessed. The maternal abdominal circumference measured before delivery not the severity of carbohydrate intolerance, remained the main predictor for significant perinatal complications.

Racial variations of adverse perinatal outcomes: A population-based retrospective cohort study in Ontario, Canada

Introduction

Racial differences in adverse maternal and birth outcomes have been studied in other countries, however, there are few studies specific to the Canadian population. In this study, we sought to examine the inequities in adverse perinatal outcomes between Black and White pregnant people in Ontario, Canada.

Methods

We conducted a population-based retrospective cohort study that included all Black and White pregnant people who attended prenatal screening and had a singleton birth in any Ontario hospital (April 1^st, 2012-March 31^st, 2019). Poisson regression with robust error variance models were used to estimate the adjusted relative risks of adverse perinatal outcomes for Black people compared with White people while adjusting for covariates.

Results

Among 412,120 eligible pregnant people, 10.1% were Black people and 89.9% were White people. Black people were at an increased risk of gestational diabetes mellitus, preeclampsia, placental abruption, preterm birth (<37, <34, <32 weeks), spontaneous preterm birth, all caesarean sections, emergency caesarean section, low birth weight (<2500g, <1500g), small-for-gestational-age (<10th percentile, <3^rd percentile) neonates, 5-minute Apgar score <4 and <7, neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment but had lower risks of elective caesarean section, assisted vaginal delivery, episiotomy, 3rd and 4th degree perineal tears, macrosomia, large-for-gestational-age neonates, and arterial cord pH≤7.1, as compared with White people. No difference in risks of gestational hypertension and placenta previa were observed between Black and White people.

Conclusion

There are differences in several adverse perinatal outcomes between Black and White people within the Ontario health care system. Findings might have potential clinical and health policy implications, although more studies are needed to further understand the mechanisms.

Nomogram-based risk prediction of macrosomia: a case-control study

Background

Macrosomia is closely associated with poor maternal and fetal outcome. But there is short of studies on the risk of macrosomia in early pregnancy. The purpose of this study is to establish a nomogram for predicting macrosomia in the first trimester.

Methods

A case-control study involving 1549 pregnant women was performed. According to the birth weight of newborn, the subjects were divided into macrosomia group and non-macrosomia group. The risk factors for macrosomia in early pregnancy were analyzed by multivariate logistic regression. A nomogram was used to predict the risk of macrosomia.

Results

The prevalence of macrosomia was 6.13% (95/1549) in our hospital. Multivariate logistic regression analysis showed that prepregnancy overweight (OR: 2.13 95% CI: 1.18–3.83)/obesity (OR: 3.54, 95% CI: 1.56–8.04), multiparity (OR:1.88, 95% CI: 1.16–3.04), the history of macrosomia (OR: 36.97, 95% CI: 19.90–68.67), the history of GDM/DM (OR: 2.29, 95% CI: 1.31–3.98), the high levels of HbA1c (OR: 1.76, 95% CI: 1.00–3.10) and TC (OR: 1.36, 95% CI: 1.00–1.84) in the first trimester were the risk factors of macrosomia. The area under ROC (the receiver operating characteristic) curve of the nomogram model was 0.807 (95% CI: 0.755–0.859). The sensitivity and specificity of the model were 0.716 and 0.777, respectively.

Conclusion

The nomogram model provides an effective mothed for clinicians to predict macrosomia in the first trimester.

Associations of Gestational Diabetes Mellitus and Excessive Gestational Weight Gain with Offspring Obesity Risk

OBJECTIVE

Gestational diabetes mellitus (GDM) and gestational weight gain (GWG) are important risk factors that are known to affect offspring growth, but these outcomes are inconsistent and it remains unknown if both risk factors have a synergetic effect on early childhood growth. The present study aimed to conduct offspring body mass index-for-age Z-scores (BMIZ) trajectories and to evaluate the independent and interactive effect of the status of GDM and excessive GWG on the risks of overweight/obesity from birth to 24 months of age.

METHODS

A total of 7949 mother-child pairs were enrolled in this study. The weight and length of children were measured at birth, 6, 12, and 24 months of age to calculate BMIZ.

RESULTS

The status of GDM was positively associated with offspring BMIZ and risk of macrosomia at birth but was not associated with offspring BMIZ or the risks of overweight/obesity at 6, 12, and 24 months of age. In contrast, excessive GWG was positively linked to offspring BMIZ, the stable high BMIZ trajectory pattern, and risks of overweight/obesity in the first 24 months of age. These two risk factors also had a significant synergistic effect on macrosomia at birth, but the interactive effect was only significant in boys during the follow-up years in the sex-stratified analyses.

CONCLUSION

The maternal GWG was a more pronounced predictor than GDM with relation to BMIZ and risk of overweight/obesity in early childhood. The interactive effect between these risk factors on offspring overweight/obesity may vary by sex.

Managing idiopathic intracranial hypertension in pregnancy: practical advice

Idiopathic intracranial hypertension (IIH) is more common in women of reproductive age who have obesity, yet there is little information on its management specifically in pregnancy. Women with IIH should plan their pregnancy including discussing contraception before pregnancy, recognising that hormonal contraceptives are not contraindicated. Potentially teratogenic medications including acetazolamide and topiramate are not recommended during pregnancy or in those with immediate plans to conceive; prescribing acetazolamide in pregnancy must only follow discussion with the patient and their obstetrician. Ideally, patients should aim to achieve disease remission or control before pregnancy, through optimising their weight. Although weight gain is expected in pregnancy, excessive weight gain may exacerbate IIH and increase maternal and fetal complications; evidence-based recommendations for non-IIH pregnancies may help in guiding optimal gestational weight gain. The vast majority of women with IIH can have a normal vaginal delivery, with spinal or epidural anaesthesia if needed, provided the papilloedema is stable or the IIH is in remission.

Growth patterns of uninfected children born to women living with perinatally versus nonperinatally acquired HIV

OBJECTIVE

The aim of this study was to compare long-term growth between HIV-exposed uninfected children (CHEU) born to women with perinatally acquired HIV (CHEU-PHIV) and CHEU born to women with nonperinatally acquired HIV (CHEU-NPHIV).

DESIGN

A longitudinal analysis of anthropometric measurements from a U.S.-based multisite prospective cohort study enrolling CHEU and their mothers since April 2007.

METHODS

CHEU were evaluated for growth annually from birth through age 5 and again at age 7 years. Z-scores were calculated using U.S. growth references for weight (WTZ), height (HTZ), and weight-for-length or BMI-for-age (WLZ/BMIZ). Mid-upper arm circumference (MUACZ) and triceps skinfold thickness (TSFZ) Z-scores were obtained from ages 1 and 2, respectively, through age 7 years. Piecewise mixed-effects models, overall and stratified by race and sex, were fit to assess differential growth patterns across age by maternal PHIV status.

RESULTS

One thousand four hundred fifty-four singleton infants (286 CHEU-PHIV and 1168 CHEU-NPHIV) were included. CHEU-PHIV had slower growth rates than CHEU-NPHIV for WTZ and WLZ/BMIZ at earlier ages and continued to have lower mean WTZ [-0.27, 95% confidence interval (95% CI): -0.50, -0.04] and WLZ/BMIZ (-0.39, 95% CI: -0.67, -0.11) through age 7. Among non-Black boys, CHEU-PHIV had slightly lower WTZ and WLZ/BMIZ at birth than CHEU-NPHIV and these growth deficits persisted through age 7 years.

CONCLUSION

Compared with CHEU-NPHIV, CHEU-PHIV had diminished growth in early childhood with differences most pronounced among non-Black male children. Further longitudinal follow-up of CHEU-PHIV into young adulthood is needed to understand whether these early effects of maternal PHIV status on growth persist and have other health consequences.

Gestational Diabetes Mellitus Among Asians - A Systematic Review From a Population Health Perspective

OBJECTIVE

Since Asians are particularly vulnerable to the risk of gestational diabetes mellitus (GDM), the lifecourse health implications of which are far beyond pregnancy, we aimed to summarize the literature to understand the research gaps on current GDM research among Asians.

METHODS

We systematically searched the articles in PubMed, Web of Science, Embase, and Scopus by 30 June 2021 with keywords applied on three topics, namely "GDM prevalence in Asians", "GDM and maternal health outcomes in Asians", and "GDM and offspring health outcomes in Asians".

RESULTS

We observed that Asian women (natives and immigrants) are at the highest risk of developing GDM and subsequent progression to type 2 diabetes among all populations. Children born to GDM-complicated pregnancies had a higher risk of macrosomia and congenital anomalies (i.e. heart, kidney and urinary tract) at birth and greater adiposity later in life.

CONCLUSION

This review summarized various determinants underlying the conversion between GDM and long-term health outcomes in Asian women, and it might shed light on efforts to prevent GDM and improve the lifecourse health in Asians from a public health perspective.

SYSTEMATIC REVIEW REGISTRATION

Prospero, CRD42021286075.

Changes in Diet and Exercise in Pregnant Women after Diagnosis with Gestational Diabetes: Findings from a Longitudinal Prospective Cohort Study

BACKGROUND

Lifestyle changes are recommended for women diagnosed with gestational diabetes mellitus (GDM), yet there are few data available documenting whether women change their diet and exercise after GDM diagnosis.

OBJECTIVE

The aim of this study was to assess whether, and to what extent, pregnant women receiving usual prenatal care change their diet and exercise after a GDM diagnosis.

DESIGN

This study was a post-hoc secondary analysis using data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Singletons (2009-2013), a prospective pregnancy cohort study.

PARTICIPANTS/SETTING

Pregnant US women without major chronic medical conditions were enrolled from 12 participating hospital centers at 8 to 13 weeks' gestation. Diet analyses were based on 5,194 dietary recalls from 1,371 women. Exercise analyses were based on 6,440 physical activity assessments from 1,875 women. GDM was ascertained from medical records according to Carpenter and Coustan criteria. Women completed 24-hour dietary recalls and exercise assessments at weeks 16 to 22, 24 to 29, 30 to 33, 34 to 37, and 38 to 41 (exercise only).

MAIN OUTCOME MEASURES

The main outcome was the diet and exercise change from before to after GDM diagnosis or screening.

STATISTICAL ANALYSES

Diet and exercise changes with 95% CIs from before to after GDM diagnosis or screening for women with and without GDM were estimated using weighted multivariable linear mixed models.

RESULTS

Women with GDM (n = 72) significantly reduced their total energy intake (-184 kcal/d; 95% CI -358 to -10 kcal/d) and carbohydrate intake (-47.6 g/d; 95% CI -71.4 to -23.7 g/d) from before to after GDM diagnosis; these changes were unique to women with GDM and not observed among women without GDM (n = 1,299). Women with GDM decreased intakes of juice (-0.4 cups/d; 95% CI -0.7 to -0.2 cups/d) and added sugar (-3.2 teaspoons/d; 95% CI -5.5 to -0.5 teaspoons/d) and increased cheese (0.3 cups/d; 95% CI 0.1 to 0.6 cups/d) and artificially sweetened beverages (0.2 cups/d; 95% CI 0.0 to 0.3 cups/d). Women with GDM (n = 84) did not change their exercise duration after diagnosis; women without GDM (n = 1,791) significantly decreased moderate (-19.5 min/wk; 95% CI -24.7 to -14.3 min/wk) and vigorous exercise (-8.8 min/wk; 05% CI -10.6 to -6.9 min/wk) after GDM screening.

CONCLUSIONS

Women with GDM made modest dietary improvements and maintained their prediagnosis exercise routine, yet opportunities remain to further improve dietary intake and exercise after a diagnosis of GDM.

Induction of labor for a suspected large-for-gestational-age/macrosomic fetus

Fetal macrosomia is defined as a birth weight of >4000 g, while the term large for gestational age (LGA) is defined as an estimated fetal weight >90th centile for gestational age. Current data indicate that a significant proportion of the babies are LGA. Pregnancies involving LGA babies are associated with increased maternal and perinatal morbidity including caesarean section, postpartum hemorrhage, shoulder dystocia, and birth trauma. To reduce these complications, labor induction has been suggested as a possible solution. However, despite some high-quality evidence in favor of labor induction for suspected macrosomia/LGA, existing guidelines do not support routine induction of labor in this population. The aim of this paper is to critically appraise the available evidence and clinical practice recommendations and highlight the importance of shared decision making and individualized care based on clear counselling regarding the lack of a sensitive diagnostic tool for estimating fetal weight in the third trimester.

Factors associated with early gestational weight gain among women with pre-pregnancy overweight or obesity

The present study aimed to document the prevalence of and identify factors associated with excessive gestational weight gain (GWG) in early pregnancy among women with pre-pregnancy overweight or obesity. Women with pre-pregnancy overweight or obesity (n = 247) were recruited between 12 and 20 weeks of gestation and completed questionnaires and were weighed to estimate early GWG. Nearly one-third of women met (17%, n = 42) or exceeded (13%, n = 33) guidelines for total GWG in early pregnancy. Univariate analyses showed race, income, and pre-pregnancy weight status to be significantly related to GWG category in early pregnancy (p < .009). Only race and pre-pregnancy weight status remained significant in a multivariate model, with Black women and women with pre-pregnancy obesity having higher odds of having met or exceeded guidelines for total GWG in early pregnancy compared with White women and women with pre-pregnancy overweight (p < .04). These findings highlight the need for early intervention to reduce weight-related complications among pregnant women.Impact statementWhat is already known on this subject? Women with pre-pregnancy overweight or obesity who gain excessive gestational weight early in pregnancy are at unique risk for pregnancy complications and adverse birth outcomes.What do the results of this study add? The present study adds to a growing body of literature documenting that a notable amount of women are gaining excessive gestational weight early in pregnancy. The present study further documents that Black women and women with pre-pregnancy obesity are at particular risk of gaining excessive gestational weight early in pregnancy.What are the implications of these findings for clinical practice and/or further research? Additional work examining modifiable risk factors, particularly among Black women and women with pre-pregnancy obesity, that contribute to excessive gestational weight gain (GWG) in the first half of pregnancy is warranted and will be necessary to inform interventions aimed at promoting weight loss during the preconception and interconception periods or encouraging appropriate GWG across the entire course of pregnancy.

Gestational diabetes: Implications for fetal growth, intervention timing, and treatment options

Maternal gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy, which can adversely affect the short- and long-term health of mothers and newborns. In recent years, several studies have revealed the early impact of maternal hyperglycemia on fetal growth trajectory and birth weight abnormalities in GDM-exposed pregnancies. However, an intense debate continues regarding the mode and optimal timing of diagnosis and treatment of this condition. The purpose of this review is to provide a brief overview of the understanding of GDM and its implications for fetal growth, addressing the modulatory role of medical nutrition therapy and available pharmacological antidiabetic agents (i.e. insulin, metformin, and glyburide), and to identify gaps in current knowledge toward which future research should be directed.

Adverse pregnancy outcomes associated with moderate elevations in blood pressure or blood glucose in Ugandan women; a prospective cohort study

BACKGROUND

The association between overt hypertension and diabetes and adverse pregnancy outcomes is well documented. Recent evidence suggests that even moderate elevations in blood pressure or blood glucose may confer a significant risk in a dose-dependent manner. However, these studies have primarily been undertaken in white populations in high-income settings. Hypertension and diabetes are emerging as major public health issues in sub-Saharan Africa as the region undergoes rapid urbanization. It is therefore important to understand how such noncommunicable conditions contribute to pregnancy outcomes in these populations.

OBJECTIVE

This study aimed to determine the association between stage 1 hypertension or fasting blood glucose in the gestational diabetes mellitus-range and adverse pregnancy outcomes in Uganda, and to describe the effects of other contributing factors such as maternal obesity.

STUDY DESIGN

This was a prospective cohort study of 2857 women at 5 major hospitals in urban and semiurban central Uganda. Women were enrolled at 24 to 28 weeks' gestation. Data about the maternal demographics, anthropometrics, fasting venous blood glucose, blood pressure, and pregnancy outcomes were collected. Moderate elevations in blood pressure and blood glucose were defined using the latest American College of Cardiology and American Heart Association definition of stage 1 hypertension and the World Health Organization's criteria for fasting blood glucose in the gestational diabetes mellitus-range. The primary outcomes of interest were perinatal death and large birthweight for gestational age, and the secondary outcomes were preterm birth, cesarean delivery, and neonatal admission. A multivariable logistic regression analysis was used.

RESULTS

Stage 1 hypertension increased the odds of perinatal death by more than 2-fold (adjusted odds ratio, 2.68; 95% confidence interval, 1.36-5.29), with a positive but insignificant association with preterm birth. Hyperglycemia in the gestational diabetes mellitus-range was associated with cesarean delivery only (adjusted odds ratio, 1.65; 95% confidence interval, 1.20-2.27). Maternal obesity increased the risk of having large birthweight babies (adjusted odds ratio, 2.30; 95% confidence interval, 1.74-3.02), a cesarean delivery (adjusted odds ratio, 2.75; 95% confidence interval, 2.17-3.48), and neonatal admission (adjusted odds ratio, 1.63; 95% confidence interval, 1.16-2.30).

CONCLUSION

Moderate elevations in blood pressure and maternal obesity are stronger predictors of adverse maternal and neonatal outcomes than moderate elevations in blood glucose levels and should be the focus of intervention in these resource-poor settings. Further research is needed to determine the cost-effectiveness of identifying and managing moderate elevations in blood pressure and maternal obesity.

Interventricular Septal Thickness as a Diagnostic Marker of Fetal Macrosomia

Serious complications in both mother and newborn arising as a result of fetal macrosomia indicate the need for early diagnosis and prevention. Unfortunately, current predictors, such as fetal biometry, fundal height, and amniotic fluid index, appear to be insufficient. Therefore, we decided to assess the predictive potential of interventricular septal thickness (IVST), as measured at ≥33 weeks of gestation. Two hundred and ninety-nine patients met the inclusion criteria: complete medical history including all necessary measurements—namely, IVST obtained by M-mode echocardiography, fetal biometry, and birth weight. The Statistica 13.1 PL software was used to generate the receiver operating curve. The optimal cut-off point (IVST of 4.7 mm) was selected using the Youden index method. The analysis of fetal biometry abnormalities resulted in 46.6% of macrosomia cases being correctly predicted; however, IVST analysis detected 71.4% of cases. IVST at ≥4.7 mm appears to have a higher sensitivity and negative predictive value (NPV) than routine ultrasound.

Comparison of adverse perinatal outcomes between Asians and Caucasians: a population-based retrospective cohort study in Ontario

BACKGROUND

Racial disparities in adverse perinatal outcomes have been studied in other countries, but little has been done for the Canadian population. In this study, we sought to examine the disparities in adverse perinatal outcomes between Asians and Caucasians in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study that included all Asian and Caucasian women who attended a prenatal screening and resulted in a singleton birth in an Ontario hospital (April 1st, 2015-March 31st, 2017). Generalized estimating equation models were used to estimate the independent adjusted relative risks and adjusted risk difference of adverse perinatal outcomes for Asians compared with Caucasians.

RESULTS

Among 237,293 eligible women, 31% were Asian and 69% were Caucasian. Asians were at an increased risk of gestational diabetes mellitus, placental previa, early preterm birth (< 32 weeks), preterm birth, emergency cesarean section, 3rd and 4th degree perineal tears, low birth weight (< 2500 g, < 1500 g), small-for-gestational-age (<10th percentile, <3rd percentile), neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment, but had lower risks of preeclampsia, macrosomia (birth weight > 4000 g), large-for-gestational-age neonates, 5-min Apgar score < 7, and arterial cord pH ≤7.1, as compared with Caucasians. No difference in risk of elective cesarean section was observed between Asians and Caucasians.

CONCLUSION

There are significant differences in several adverse perinatal outcomes between Asians and Caucasians. These differences should be taken into consideration for clinical practices due to the large Asian population in Canada.

Prenatal exposure to fine particulate matter and fetal growth: a cohort study from a velocity perspective

BACKGROUND

Reduced growth velocity before birth increases the risk of adverse health outcomes in adult life. However, until recently, there has been a lack of studies demonstrating the impact of prenatal PM_2.5 exposure on fetal growth velocity.

METHODS

The current study was embedded in a previous cohort built between January 1, 2014, and April 30, 2015, in Shanghai First Maternity and Infant Hospital, China, in 6129 eligible singleton pregnancies. The PM_2.5 concentration was estimated by an inverse distance weighted method according to the residential addresses of the participants. Repeated fetal biometry measurements, including head circumference (HC), abdominal circumference (AC), femur length (FL), and biparietal diameter (BPD), were measured through ultrasound between 14 and 41 gestational weeks. A principal component analysis through conditional expectation for sparse longitudinal data was used to estimate the corresponding velocities.

RESULTS

A total of 22782 ultrasound measurements were conducted among 6129 participants with a median of 2 and a maximum of 9 measurements. With each 10 μg/m³ increase in cumulative PM_2.5 exposure, the velocity of HC, AC FL and BPD decreased by 0.12 mm/week, 0.17 mm/week, 0.02 mm/week and 0.02 mm/week, respectively, on average. The results of the Generalized Functional Concurrent Model showed that the velocity decreased significantly with PM_2.5 exposure between 22 and 32 gestational weeks, which might be the potential sensitive exposure window.

CONCLUSIONS

There are negative associations between prenatal exposure to PM_2.5 and fetal growth velocity, and the late second trimester and early third trimester might be the potential sensitive window.

Caucasian and Asian difference in role of type 1 diabetes on large-for-gestational-age neonates

INTRODUCTION

Racial differences in the association between type 1 diabetes mellitus (T1DM) and large-for-gestational-age (LGA) neonates remain unclear. The objective of this study was to compare the effect of T1DM on LGA neonates between Caucasian and Asian women.

RESEARCH DESIGN AND METHODS

A population-based retrospective cohort study was conducted among Caucasian and Asian women who had prenatal screening and gave a singleton live birth in an Ontario hospital between April 2015 and March 2018. Multivariable log-binomial regression models were used to estimate the adjusted relative risks (aRRs) and 95% CIs of T1DM on LGA for Caucasian and Asian women. Relative contribution of T1DM to LGA was examined by multivariable logistic regression model, stratified by Caucasian and Asian women.

RESULTS

A total of 232 503 women (69.4% Caucasians and 30.6% Asians) were included in the final analysis. The rate of T1DM was higher in Caucasians (0.5%) than in Asians (0.2%), and the rate of LGA neonates was also higher in Caucasians (11.0%) than in Asians (5.0%). The association between T1DM and LGA in Caucasians (aRR 4.18, 95% CI (3.84 to 4.55)) was more robust than that in Asians (aRR 2.11, 95% CI (1.24 to 3.59)). T1DM was the fourth strongest contributor to LGA in Caucasians, while T1DM was the seventh contributor to LGA in Asians.

CONCLUSIONS

T1DM plays a more substantial role in LGA among Caucasians than Asians. Clinicians should be aware of the Caucasian-Asian differences of effects of T1DM on LGA when developing pregnancy management strategies.

Circulating metal concentrations, inflammatory cytokines and gestational weight gain: Shanghai MCPC cohort

OBJECTIVES

Based on a prospective birth cohort, we aimed to investigate the associations between maternal circulating metals exposure and gestational weight gain (GWG) across pregnancy, and explore whether maternal inflammatory cytokines could contribute to the GWG changes associated with metals exposure.

METHODS

A total of 234 pregnant women from the Shanghai Maternal-Child Pairs cohort were enrolled in this panel study. 547 blood and serum samples were collected from pregnant women during three follow-up visits, and the circulating concentrations of 27 metals were determined by using the ICP-MS method. Five inflammatory cytokines in serum samples were measured through multiplexed immunoassays. The linear mixed models were used to estimate the association between each ln-transformed metal concentration and GWG across pregnancy. Robust generalized linear regression models were used to estimate the associations among circulating metals, GWG, and inflammatory cytokines.

RESULTS

The GWG during pregnancy was 13.76 ± 1.40 kg. The concentrations Co, Zn, Mo, B, Ag and Te in second or third trimesters were significantly higher than those in early second trimester. The concentration of Mg decreased with the increase of pregnant weeks and no significant statistical differences were found in the concentrations of other metals in different trimesters. Among the detected 26 metals, Li and Sr concentrations were positively associated with GWG in the third trimester. The GWG increased by 0.100 kg (95% CI 0.005, 0.195) and 0.120 kg (95% CI 0.009, 0.232) with each one ln-concentration increase in circulating Li and Sr concentrations, respectively. Concentrations of Li and Sr in the third trimester were positively associated with tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-6, but negatively associated with growth differentiation factor-15 (GDF-15) significantly. Besides, IL-6 and GDF-15 levels were associated with the increase or decrease of overall pregnancy GWG, respectively.

CONCLUSIONS

Results showed that maternal exposure to Li and Sr were associated with increased GWG, in which maternal IL-6 and GDF-15 could contribute to the associations between metal exposures and GWG in pregnant women.

The role of neighbourhood socioeconomic status in large for gestational age

OBJECTIVE

To determine whether neighbourhood socioeconomic status (SES) was associated with large for gestational age (LGA) while considering key sociodemographic and clinical confounding factors.

SETTING AND PATIENT

All singleton infants whose parents were living in the city of Marseilles, France, between 2013 and 2016.

METHOD

Population-based study based on new-born hospital birth admission charts from the French National Uniform Hospital Discharge Data Set Database. LGA infants were compared to appropriate-for-gestational-age (AGA) infants. Multiple generalized logistic model analysis was used to examine factors associated with LGA.

RESULTS

A total of 43,309 singleton infants were included, and 4,747 (11%) were born LGA. LGA infants were more likely to have metabolic and respiratory diseases and to be admitted to the neonatal intensive care unit. Multiparity, advanced maternal age, obesity and diabetes were associated with an increased risk of LGA. Lower neighbourhood SES was associated with LGA (aOR = 1.24, 95% CI: 1.14; 1.36; p<0.0001) independent of age, diabetes, obesity, maternal smoking and multiparity. The strength of this association increased with maternal age, reaching an aOR of 1.50 (95% CI: 1.26; 1.78; p<0.0001) for women > 35 years old.

CONCLUSION

Neighbourhood SES could be considered an important factor for clinicians to better identify mothers at risk of having LGA births in addition to well-known risk factors such as maternal diabetes, obesity and age. The intensification of the association between SES and LGA with increasing maternal age suggests that neighbourhood disadvantage may act on LGA cumulatively over time.

Fetal macrosomia in a Hispanic/Latinx predominant cohort and altered expressions of genes related to placental lipid transport and metabolism

Fetal overgrowth, termed fetal macrosomia when birth weight is greater than 4000 grams, is the major concern in the treatment of gestational diabetes mellitus (GDM). However, to date, the underlying mechanisms of fetal macrosomia have not been understood completely. Placental lipid metabolism is emerging as a critical player in fetal growth. In this study, we hypothesized that fatty acid transport and metabolism in the placental tissue was impaired in GDM women, dependent on fetal sex. To test this hypothesis, we analyzed the incidence of GDM, fetal macrosomia, and obesity in a large cohort consisting of 17995 pregnant subjects and majority of subjects being Hispanic/Latinx, and investigated expression of genes related to lipid transport and metabolism in placenta from obese women with or without GDM, and with or without fetal macrosomia. The main findings include: 1) There is a higher incidence of GDM and obesity in Hispanic subjects compared to non-Hispanic subjects, but not fetal macrosomia; 2) Expressions of most of genes related to placental lipid transport and metabolism are not altered by the presence of GDM, fetal macrosomia, or fetal sex; 3) Expression of FABP4 is increased in obese women with GDM and fetal macrosomia, and this occurred in male placentas; 4) Expression of LPL is decreased in obese women with GDM despite fetal macrosomia, and this occurred in male placentas; 5) Expression of ANGPTL3 is decreased in obese women with GDM and fetal macrosomia, but is not altered when fetal sex is included in the analysis. This study indicates that there is race disparity in GDM with higher incidence of GDM in obese Hispanic women, although fetal macrosomia disparity is not present. Moreover, altered placental lipid transport may contribute to fetal overgrowth in obese women with GDM.

Racial differences in contribution of prepregnancy obesity and excessive gestational weight gain to large-for-gestational-age neonates

OBJECTIVES

To examine the racial differences in the population attributable fraction (PAF) of prepregnancy obesity and excessive gestational weight gain to large-for-gestational-age (LGA) neonates.

METHODS

We conducted a population-based retrospective cohort study among all women who had prenatal screening and had a singleton live birth in a hospital (1 April 2016-31 March 2017) using data from Ontario birth registry in Canada. We used multivariable log-binomial regression models to estimate the PAF and 95% confidence interval (CI) of LGA neonates due to prepregnancy obesity and excessive gestational weight gain. All models were stratified by race (White, Asian, and Black).

RESULTS

Of the 74,402 eligible women, the prevalence of prepregnancy obesity, excessive gestational weight gain, and LGA neonate was 21.1%, 60.0%, and 11.3%, respectively, for Whites; 9.3%, 45.9%, and 5.4%, respectively, for Asians; and 28.6%, 52.4%, and 7.9%, respectively, for Blacks. The association of prepregnancy obesity was greater than that of excessive gestational weight gain on LGA for all racial groups. Excessive gestational weight gain contributed more than prepregnancy obesity in Whites (PAF 32.9%, 95% CI [30.3-35.5%] and 16.6%, 95% CI [15.3-17.9%], respectively, for excessive gestational weight gain and prepregnancy obesity) and in Asians (PAF 32.1%, 95% CI [27.2-36.7%] and 11.8%, 95% CI [9.5-14.1%], respectively, for excessive gestational weight gain and prepregnancy obesity). Prepregnancy obesity (PAF 22.8%, 95% CI [17.1-28.1%]) and excessive gestational weight gain (PAF 20.1%, 95% CI [4.7-33.0%]) contributed to LGA neonates almost the same in Blacks.

CONCLUSIONS

Excessive gestational weight gain contributed more to LGA neonates than prepregnancy obesity in Whites and Asians, while there was no difference between excessive gestational weight gain and prepregnancy obesity in their contributions to the LGA neonates in Blacks. The differences are mostly driven by the differential prevalence of the two risk factors across racial groups.

Maternal lipids are associated with newborn adiposity, independent of GDM status, obesity and insulin resistance: a prospective observational cohort study

OBJECTIVE

To determine the association between maternal lipaemia and neonatal anthropometrics in Malaysian mother-offspring pairs.

DESIGN

Prospective observational cohort study.

SETTING

Single tertiary multidisciplinary antenatal clinic in Malaysia.

POPULATION

A total of 507 mothers: 145 with gestational diabetes mellitus (GDM); 94 who were obese with normal glucose tolerance (NGT) (pre-gravid body mass index, BMI ≥ 27.5 kg/m² ), and 268 who were not obese with NGT.

METHODS

Maternal demographic, anthropometric, and clinical data were collected during an interview/examination using a structured questionnaire. Blood was drawn for insulin, C-peptide, triglyceride (Tg), and non-esterified fatty acid (NEFA) during the 75-g 2-hour oral glucose tolerance test (OGTT) screening, and again at 36 weeks of gestation. At birth, neonatal anthropometrics were assessed and data such as gestational weight gain (GWG) were extracted from the records.

MAIN OUTCOME MEASURES

Macrosomia, large-for-gestational-age (LGA) status, cohort-specific birthweight (BW), neonatal fat mass (NFM), and sum of skinfold thickness (SSFT) > 90th centile.

RESULTS

Fasting Tg > 95th centile (3.6 mmol/L) at screening for OGTT was independently associated with LGA (adjusted odds ratio, aOR 10.82, 95% CI 1.26-93.37) after adjustment for maternal glucose, pre-gravid BMI, and insulin sensitivity. Fasting glucose was independently associated with a birthweight ratio (BWR) of >90th centile (aOR 2.06, 95% CI 1.17-3.64), but not with LGA status, in this well-treated GDM cohort with pre-delivery HbA1c of 5.27%. In all, 45% of mothers had a pre-gravid BMI of <23 kg/m² and 61% had a pre-gravid BMI of ≤ 25 kg/m² , yet a GWG of >10 kg was associated with a 4.25-fold risk (95% CI 1.71-10.53) of BWR > 90th centile.

CONCLUSION

Maternal lipaemia and GWG at a low threshold (>10 kg) adversely impact neonatal adiposity in Asian offspring, independent of glucose, insulin resistance and pre-gravid BMI. These may therefore be important modifiable metabolic targets in pregnancy.

TWEETABLE ABSTRACT

Maternal lipids are associated with adiposity in Asian babies independently of pre-gravid BMI, GDM status, and insulin resistance.

Mechanism associated with aberrant lncRNA MEG3 expression in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a common metabolic condition during pregnancy. Long non-coding RNAs (lncRNAs) have been found to seve critical roles in GDM development; however, the role of lncRNA maternally expressed gene 3 (MEG3) in GDM remains unclear. Therefore, the aim of the present study was to investigate the expression and role of MEG3 in GDM, and to further explore the underlying mechanism. The levels of lncRNA MEG3 in the blood and placental villous tissues of pregnant women with GDM was measured using reverse transcription-quantitative PCR. Bioinformatics analysis and dual luciferase reporter assays were performed to investigate the association between lncRNA MEG3 and microRNA (miR)-345-3p. Transfection was subsequently performed on HTR-8/SVneo cells, a human chorionic trophoblast cell line, to assess the role of lncRNA MEG3 in GDM. In particular, cell viability, cellular migratory/invasive ability and cell apoptosis were analyzed using MTT assay, Transwell assay and flow cytometry, respectively. Compared with pregnant women without GDM, lncRNA MEG3 levels were significantly elevated in the blood and placental villous tissues of GDM pregnant women. miR-345-3p was identified to be a direct target of lncRNA MEG3 using dual luciferase reporter assay, which was found to be reduced in pregnant women with GDM. Further analysis demonstrated that lncRNA MEG3 overexpression significantly inhibited HTR-8/SVneo cell viability, and prevented cell migration and invasion in addition to inducing cell apoptosis. In contrast, lncRNA MEG3 knockdown significantly enhanced HTR-8/SVneo cell viability, promoted cell migration/invasion and reduced cell apoptosis. Inhibiting miR-345-3p expression negated all the observed physiological effects of lncRNA MEG3 knockdown on HTR-8/SVneo cells. In conclusion, lncRNA MEG3 levels were abnormally upregulated in GDM, which participated in the development and progression of GDM by regulating human chorionic trophoblast cell physiology. Therefore, lncRNA MEG3 may be a potential diagnostic and therapeutic target for GDM.

Gestational growth trajectories derived from a dynamic fetal-placental scaling law

Fetal trajectories characterizing growth rates in utero have relied primarily on goodness of fit rather than mechanistic properties exhibited in utero. Here, we use a validated fetal-placental allometric scaling law and a first principles differential equations model of placental volume growth to generate biologically meaningful fetal-placental growth curves. The growth curves form the foundation for understanding healthy versus at-risk fetal growth and for identifying the timing of key events in utero.

Effects of maternal obesity, excessive gestational weight gain and fetal macrosomia on the frequency of cesarean deliveries among migrant and non-migrant women - a prospective study

Background Maternal obesity, excessive gestational weight gain and fetal macrosomia may affect the health of the mother and the newborn, and are associated with cesarean delivery. Pregnant women with a migration background have a higher risk of obesity but nevertheless a lower frequency of cesarean deliveries than women from the majority population. This study assesses which of these factors most influence the risk of a cesarean delivery and whether their prevalence can explain the lower cesarean rates in migrant women. Methods A total of 2256 migrant women and 2241 non-immigrant women subsequently delivering in three hospitals of Berlin/Germany participated. Multivariate logistic regression analysis was conducted to assess the effects of obesity, excessive gestational weight gain and macrosomia on cesarean delivery. Standardized coefficients (STB) were used to rank the predictors. Results Obesity was more frequent in immigrant than among non-immigrant women. The mean gestational weight gain was independent of migration status. The frequency of macrosomia increased with maternal weight. Obesity and excessive gestational weight gain were the most important predictors of cesarean besides older age; fetal macrosomia played a much smaller role. Despite similar distributions of the three risk factors, the frequency of cesarean deliveries was lower in migrant than in non-immigrant women. Conclusion The presence of obesity and/or excessive gestational weight gain is associated with an increased risk of a cesarean delivery; fetal macrosomia does not increase the risk when obesity and weight gain are considered. The distribution of these risk factors is similar in migrant and non-immigrant women, so they cannot explain the lower frequency of cesarean deliveries in migrant women.

Association of first-trimester HbA1c levels with adverse pregnancy outcomes in different ethnic groups

AIM

To determine, in a multi-ethnic cohort, the association of first-trimester HbA1c levels with the development of pregnancy complications.

METHODS

A prospective study between April 2013-October 2016. Participants were stratified in five ethnic groups. Women had an HbA1c measurement added to their first antenatal bloods. Primary outcome was macrosomia and secondary outcomes included preeclampsia and large-for-gestational age (LGA). A multivariate logistic regression analysis was performed to adjust for potential confounders in determining the association between different HbA1c cut-off points and obstetric outcomes on each ethnic group.

RESULTS

1,882 pregnancies were included. Analysis was limited to the three main ethnic groups: Caucasian (54.3%), South-Central Asian (19%) and Latin-American (12.2%). There was no association between HbA1c levels and obstetric outcomes among Caucasians. In Latin-Americans, an HbA1c ≥ 5.8% (40 mmol/mol) was associated with higher risk of macrosomia, whereas an HbA1c ≥ 5.9% (41 mmol/mol) was associated with LGA. In South-Central Asian, an HbA1c ≥ 5.7% (39 mmol/mol) was associated with increased risk of macrosomia and a continuous graded relationship between HbA1c levels and preeclampsia and LGA was detected starting at HbA1c levels of 5.4% (36 mmol/mol).

CONCLUSION

First-trimester HbA1c levels perform as a suitable predictor of pregnancy complications in South-Central Asian and Latin-American women whereas in Caucasian no significant associations were found.

The Association between Advanced Maternal Age and Macrosomia: A Meta-Analysis

PURPOSE

The aim of our meta-analysis was to explore whether advanced maternal age (AMA) is regarded as an important risk factor for predicting macrosomia or not.

METHODS

Three databases were systematically reviewed and reference lists of relevant articles were checked. Meta-analysis of published cohort studies was done comparing whether AMA was associated with macrosomia and adjusting for potential confounding factors. Calculations of pooled estimates were conducted in random-effects models. Heterogeneity was tested by using chi-square test and I² statistics. Publication bias was estimated from Egger's test (linear regression method) and Begg's test (rank correlation method).

RESULTS

Twelve cohort studies met the inclusion criteria. The meta-analysis showed that AMA was associated with macrosomia as an important risk factor. The adjusted odds ratio calculated for 12 studies (compared aged 35-39 years to aged <30 years) was 1.42, 95% confidence interval (CI) (1.25-1.60) for random-effect model and 6 studies (compared aged ≥40 years to aged <30 years) was 1.40, 95% CI (1.02-1.78) for random-effect model. There was no indication of a publication bias either from the result of Egger's test or Begg's test.

CONCLUSION

Regardless of the underlying mechanism, our finding indicated that AMA should be considered as an important risk factor for macrosomia. To adequately evaluate the clinical evolution of AMA, the effect of AMA on macrosomia need to be carefully assessed and monitored.

Associations of Maternal Diabetes and Body Mass Index With Offspring Birth Weight and Prematurity

IMPORTANCE

Maternal obesity, pregestational type 1 diabetes, and gestational diabetes have been reported to increase the risks for large birth weight and preterm birth in offspring. However, the associations for insulin-treated diabetes and non-insulin-treated type 2 diabetes, as well as the associations for joint diabetes disorders and maternal body mass index, with these outcomes are less well documented.

OBJECTIVE

To examine associations of maternal diabetes disorders, separately and together with maternal underweight or obesity, with the offspring being large for gestational age and/or preterm at birth.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used nationwide registries to examine all live births (n = 649 043) between January 1, 2004, and December 31, 2014, in Finland. The study and data analysis were conducted from April 1, 2018, to October 10, 2018.

EXPOSURES

Maternal prepregnancy body mass index, pregestational diabetes with insulin treatment, pregestational type 2 diabetes without insulin treatment, and gestational diabetes.

MAIN OUTCOMES AND MEASURES

Offspring large for gestational age (LGA) at birth and preterm delivery. Logistic regression models were adjusted for offspring birth year; parity; and maternal age, country of birth, and smoking status.

RESULTS

Of the 649 043 births, 4000 (0.62%) were delivered by mothers who had insulin-treated diabetes, 3740 (0.57%) by mothers who had type 2 diabetes, and 98 568 (15.2%) by mothers who had gestational diabetes. The mean (SD) age of mothers was 30.15 (5.37) years, and 588 100 mothers (90.6%) were born in Finland. Statistically significant interactions existed between maternal body mass index and diabetes on offspring LGA and prematurity (insulin-treated diabetes: LGA F = 3489.0 and prematurity F = 1316.4 [P < .001]; type 2 diabetes: LGA F = 147.3 and prematurity F = 21.9 [P < .001]; gestational diabetes: LGA F = 1374.6 and prematurity F = 434.3 [P < .001]). Maternal moderate obesity, compared with normal-weight mothers with no diabetes, was associated with a mildly increased risk of having an offspring LGA (1069 [3.5%] vs 5151 [1.5%]; adjusted odds ratio [aOR], 2.45; 95% CI, 2.29-2.62), and mothers with insulin-treated diabetes had markedly elevated risks of having an offspring LGA (1585 [39.6%] vs 5151 [1.5%]; aOR, 43.80; 95% CI, 40.88-46.93) and a preterm birth (1483 [37.1%] vs 17 481 [5.0%]; aOR, 11.17; 95% CI, 10.46-11.93). Mothers who were moderately obese with type 2 diabetes were at increased risks of LGA (132 [16.4%] vs 5151 [1.5%]; aOR, 12.44; 95% CI, 10.29-15.03) and prematurity (83 [10.3%] vs 17 481 [5.0%]; aOR, 2.14; 95% CI, 1.70-2.69). Mothers who were moderately obese with gestational diabetes had a milder risk of LGA (1195 [6.7%] vs 5151 [1.5%]; aOR, 4.72; 95% CI, 4.42-5.04). Among spontaneous deliveries, the risks were strongest for moderately preterm births, but insulin-treated diabetes was associated with an increased risk also for very and extremely preterm births.

CONCLUSIONS AND RELEVANCE

Maternal insulin-treated diabetes appeared to be associated with markedly increased risks for LGA and preterm births, whereas obesity in mothers with type 2 diabetes had mild to moderately increased risks; these findings may have implications for counseling and managing pregnancies.

Second-trimester maternal lipid profiles predict pregnancy complications in an age-dependent manner

PURPOSE

Our objective was to investigate the combinatorial effect of maternal age and second-trimester maternal lipid profiles for pregnancy complications.

METHODS

With 1:4 matching, this retrospective study selected 499 advanced maternal age women and 1996 younger controls. Logistic regression analysis was used to estimate the correlation between second-trimester lipid profiles [total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C)] and pregnancy complications [gestational diabetes mellitus (GDM), pregnancy-induced hypertension syndrome (PIH), preterm labor (PTL), and macrosomia]. Optimal cutoff points were determined by ROC curve analysis.

RESULTS

In women aged 20-34 years, TG are a risk factor for PIH (OR 1.54, 95% CI 1.16-2.04) and PTL (OR 1.34, 95% CI 1.04-1.72). LDL-C was positively associated with macrosomia (OR 1.25, 95% CI 1.04-1.50), while HDL-C was negatively associated with PIH (OR 0.45, 95% CI 0.21-0.93). The optimal cutoff points for TG predicting PIH and PTL were separately ≥ 2.135 and 2.305 mmol/L. The optimal cutoff point for HDL-C identifying PIH was ≤ 1.995 mmol/L and for LDL-C identifying macrosomia was ≥ 3.425 mmol/L. As for advanced maternal age, only TG was an independent risk factor for PIH (OR 1.60, 95% CI 1.01-2.54), and its optimal cutoff point was ≥ 2.375 mmol/L.

CONCLUSIONS

Second-trimester lipid profiles might predict pregnancy complications varied by maternal age. This suggested that individualized prenatal care strategies should be established for women with advanced and normal maternal age to prevent pregnancy complications.

Pregnancy phthalate metabolite concentrations and infant birth weight by gradations of maternal glucose tolerance

BACKGROUND

Higher birth weight is an important adverse outcome associated with hyperglycemia in pregnancy. Recent studies suggest that phthalate exposure is associated with elevated glucose levels in pregnant women, with implications for higher birth weight in the offspring. No study to date has investigated the association between prenatal phthalate exposure on infant high birth weight accounting for the range of pregnancy glucose levels.

METHODS

A total of 350 women participating in an ongoing pregnancy cohort had data available on urinary phthalate metabolite concentrations at up to four time points across pregnancy. Urinary phthalate metabolites were averaged across pregnancy and log-transformed, specific gravity-adjusted and analyzed in quartiles. Birth weight was examined continuously (in grams), as well as dichotomized as large for gestational age (>90^th percentile). Glucose levels were assessed based on Results from 50-g glucose challenge tests as a part of screening for gestational diabetes conducted at 24-28 weeks gestation, and grouped into 3 categories <120 mg/dL, 120-<140 mg/dL and ≥140 mg/dL. Multivariable linear regression was performed, adjusting for potential confounders in the overall population and stratified by pregnancy glucose levels.

RESULTS

Approximately 20% of infants born to women with glucose levels ≥140 mg/dL were large for gestational age. Average mono-ethyl phthalate (MEP) concentrations were higher among women who had glucose levels ≥140 mg/dL (geometric mean 140.9 μg/L; 95% CI: 91.6-216.8); however, higher MEP concentrations were not associated with higher birth weight. When stratified by maternal glucose levels, there was a suggestive association between higher concentrations of mono-(3-carboxypropyl) phthalate (MCPP) and higher birth weight among women with glucose levels ≥140 mg/dL (adj. birth weight: 569.2 g; 95% CI: 14.1, 1178.2).

CONCLUSIONS

Higher urinary phthalate metabolite concentrations were not significantly associated with higher birth weight. Counter to our hypothesis, women with higher glucose levels and higher urinary phthalate metabolites did not deliver babies with higher birth weight.

A retrospective analysis of the relationship between race/ethnicity, age at delivery and the risk of gestational diabetes mellitus

Objectives: To investigate the relationship between maternal race/ethnicity, maternal age at delivery, and the risk of gestational diabetes mellitus (GDM).Research design: Patients of Henry Ford Health System who delivered a live singleton child and were diagnosed with or without GDM in 2010-2015 were included. Maternal race/ethnicity, age, body mass index (BMI), parity, GDM in previous pregnancy, smoking status, and insurance membership were collected from the electronic health records. Neighborhood median family income data were obtained from US Census Bureau. Logistic regression analysis was performed to explore the effects of maternal race/ethnicity and age at delivery on the GDM outcome after adjusting for covariates including maternal BMI, parity, previous GDM, smoking status, and neighborhood family income.Results: There were 16,258 women included in the study. Of those, 1801 women (12.5%) were diagnosed with GDM. Delivery at older ages (≥23 years) was associated with a significantly higher risk of a GDM diagnosis than younger ages [<23 years, OR (95% CI) = 2.24 (1.84, 2.73)-5.02 (4.18, 6.03)], however, the risk was not as profound in African American women (OR = 1.65) compared to non-African American women (OR = 2.07). In a multivariable model controlling for age, BMI, parity, previous GDM, smoking status, and the neighborhood family income, the risks of a GDM diagnosis were significantly higher in Asians [OR (95% CI) = 2.81 (2.28, 3.48)], Hispanics [OR (95% CI) = 1.27 (1.05, 1.55)], and Arab Americans [OR (95% CI) = 1.46 (1.20, 1.78)] and lower in African Americans [OR (95% CI) = 0.64 (0.56, 0.74)] as compared to whites.Conclusions: Asians, Hispanics, and Arab Americans have higher risk and African Americans have lower risk of a GDM diagnosis compared to whites. Delivery at an older maternal age increases the risk of GDM diagnosis. Race/ethnicity moderates the association between older maternal age and risk of GDM diagnosis. This study provides information for public health professionals, health practitioners, and pregnant women to be aware of and better understand the risk of GDM as related to race/ethnicity and maternal age.

Is fasting plasma glucose in early pregnancy a better predictor of adverse obstetric outcomes than glycated haemoglobin?

OBJECTIVES

To determine, in a multi-ethnic cohort, the suitability of first-trimester fasting plasma glucose and HbA1c levels in non-diabetic range to identify women without diabetes at increased pregnancy risk.

STUDY DESIGN

A retrospective analysis of a prospective cohort between April 2013 and September 2015. Universal testing for fasting plasma glucose and HbA1c levels at the first antenatal blood sampling was performed and women were screened for gestational diabetes mellitus at 24-28 weeks' gestation. Primary outcomes were macrosomia and pre-eclampsia, and secondary outcomes preterm delivery, Caesarean section and large-for-gestational age. Different fasting plasma glucose and HbA1c cut-off levels were assessed for associations with outcomes.

RESULTS

1,228 pregnancies were included for outcome analysis. After adjustment for potential confounders, no association was found between fasting plasma glucose levels and pregnancy outcomes. Women with an HbA1c ≥5.8% (39.9 mmol/mol) showed an increased risk of macrosomia (OR 2.69, 95% CI 1.16-6.24); an HbA1c ≥5.9% (41 mmol/mol) threshold was independently associated with a three-fold risk of pre-eclampsia (95% CI 1.03-9.9) and an HbA1c ≥6.0% (42.1 mmol/mol) with a four-fold risk of large-for-gestational age (95% CI 1.49-11.07).

CONCLUSIONS

In a multi-ethnic population, first-trimester fasting plasma glucose levels were not a better predictor of pregnancy complications than HbA1c. Further, an early HbA1c ≥5.8% (39.9 mmol/mol) threshold is already associated with an increased risk of macrosomia.

A Slow-Digesting, Low-Glycemic Load Nutritional Beverage Improves Glucose Tolerance in Obese Pregnant Women Without Gestational Diabetes

BACKGROUND

Obesity is a risk factor for gestational diabetes (gestational diabetes). Low-glycemic index diets attenuate hyperglycemia. We designed a study to determine whether a slow-digesting, low-glycemic load (SD-LGL) beverage improves glucose tolerance in obese pregnant women without GDM.

METHODS

This was a 3-arm comparison study comparing the effects of an SD-LGL nutritional beverage (glycemic load [GL] 730), an isocaloric control beverage (GL 1124), and habitual diet on glycemia in obese pregnant women. Sixteen women (mean body mass index 37 kg/m²) were recruited at 24-28 weeks to receive either the SD-LGL or eucaloric control beverage. This was consumed with breakfast and as a midafternoon snack over 2 days with a controlled diet. Following a 2-day washout period of habitual diet, women completed 2 days on the alternative beverage with controlled diet. A 10-h fast preceded each intervention phase. Twenty-four hour glucose was measured using continuous glucose monitoring.

RESULTS

Consumption of the lower GL beverage was associated with improved measures of glycemia, compared with the control beverage and habitual diet at different time periods. Glucose estimates for control versus SD-LDL at 24 h (0.23 mmol/L [0.16 to 0.31], P < 0.001), daytime (0.26 mmol/L [0.18 to 0.34], P < 0.001), and nighttime (0.05 mmol/L [-0.01 to 0.11], P = 0.09). Postprandial glucose was lower after breakfast but not after dinner, compared with the control beverage (0.09 mmol/L [0.01 to 0.18], P = 0.03).

CONCLUSION

A slow-digesting, low-glycemic nutritional beverage may facilitate improved glucose control in obese pregnant women. To address potential benefit for clinical outcomes, a randomized controlled trial is warranted.

Addressing cultural, racial and ethnic discrepancies in guideline discordant gestational weight gain: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature and describe the discrepancies in achieving the 2009 Institute of Medicine (IOM) gestational weight gain (GWG) guidelines across cultures.

METHODS

Ten databases were searched from inception to April 2018. Observational cohort studies were included that examined adult women; reported on a measure of culture; compared cultural groups, and reported on GWG. Articles were broken down into papers that used the current 2009 IOM GWG guidelines and those that used others. A meta-analysis was conducted for studies using the 2009 guidelines examining the prevalence of discordant GWG across cultural groups.

RESULTS

The review included 86 studies. Overall, 69% of women experienced discordant GWG irrespective of culture. White women experienced excessive GWG most often, and significantly more than Asian and Hispanic women; Black women had a higher prevalence of excessive GWG than Hispanic and Asian women; however, this difference was not significant.

CONCLUSIONS

The majority of women experience excessive GWG, with White women experiencing this most often. Culturally diverse GWG guidelines are needed to individualize antenatal care and promote optimal maternal-fetal health outcomes across cultural groups.

Impact of gestational weight gain and prepregnancy body mass index on the prevalence of large-for-gestational age infants in two cohorts of women with type 1 insulin-dependent diabetes: a cross-sectional population study

OBJECTIVES

Despite improvements in treatment modalities, large-for-gestational age (LGA) prevalence has remained between 30% and 40% among infants of mothers with type 1 insulin-dependent diabetes mellitus (TIDM). Our objective was to estimate LGA prevalence and examine the association between gestational weight gain (GWG) and prepregnancy body mass index (BMI) with LGA among mothers with TIDM.

DESIGN

Cross-sectional study.

SETTING

Regional data in Cincinnati, Ohio, from the Diabetes in Pregnancy Program Project (PPG), a prospective cohort for the period 1978-1993; national data from Consortium on Safe Labor (CSL), a multicentre cross-sectional study for the period 2002-2008.

PARTICIPANTS

The study included 333 pregnancies in the PPG and 358 pregnancies in the CSL. Pregnancies delivered prior to 23 weeks' gestation were excluded. Women with TIDM in the PPG were identified according to physician confirmation of ketoacidosis, and/or c-peptide levels, and by International Classification of Diseases, ninth version codes within the CSL. LGA was identified as birth weight >90th percentile according to gestational age, race and sex.

MAIN OUTCOME MEASURES

LGA at birth.

RESULTS

Mean±SD maternal age at delivery was 26.4±5.1 years for PPG women and 27.5±6.0 years for CSL women, p=0.008. LGA prevalence did not significantly differ between cohorts (PPG: 40.2% vs CSL: 36.6%, p=0.32). More women began pregnancy as overweight in the later cohort (PPG (16.8%) vs CSL (27.1%), p<0.001). GWG exceeding Institute of Medicine (IOM) guidelines was higher in the later CSL (56.2%) vs PPG (42.3%) cohort, p<0.001. Normal-weight women with GWG within IOM guidelines had a lower LGA prevalence in CSL (PPG: 30.6% vs CSL: 13.7%), p=0.001.

CONCLUSIONS

Normal-weight women with GWG within IOM guidelines experienced a lower LGA prevalence, supporting the importance of adherence to IOM guidelines for GWG to reduce LGA. High BMI and GWG may be hindering a reduction in LGA prevalence.

IGF2 stimulates fetal growth in a sex- and organ-dependent manner

BackgroundInsulin-like growth factor 2 (IGF2) is a key determinant of fetal growth, and the altered expression of IGF2 is implicated in fetal growth disorders and maternal metabolic derangements including gestational diabetes. Here we studied how increased levels of IGF2 in late pregnancy affect fetal growth.MethodsWe employed a rat model of repeated intrafetal IGF2 administration in late pregnancy, i.e., during GD19-GD21, and measured the consequences on fetal organ weight and expression of insulin/IGF-axis components.ResultsIGF2 treatment tended to increase fetal weight, but only weight increase of the fetal stomach reached significance (+33±9%; P<0.01). Sex-dependent data analysis revealed a sexual dimorphism of IGF2 action. In male fetuses, IGF2 administration significantly increased fetal weight (+13±3%; P<0.05) and weight of fetal stomach (+42±10%; P<0.01), intestine (+26±5%; P<0.05), liver (+13±4%; P<0.05), and pancreas (+25±8%; P<0.05). Weights of heart, lungs, and kidneys were unchanged. In female fetuses, IGF2 increased only stomach weight (+26±9%; P<0.05). Furthermore, gene expression of insulin/IGF axis in the heart, lungs, liver, and stomach was more sensitive toward IGF2 treatment in male than in female fetuses.ConclusionData suggest that elevated circulating IGF2 in late pregnancy predominantly stimulates organ growth of the digestive system, and male fetuses are more susceptible toward the IGF2 effects than female fetuses.

Use of a clinical-laboratory score to guide treatment of gestational diabetes

OBJECTIVE

To assess the outcomes of implementing a clinical-laboratory score in the treatment of pregnant women with gestational diabetes.

METHODS

A retrospective before-and-after implementation analysis was undertaken using data and neonatal outcomes for pregnant women with gestational diabetes treated before (January 2011-December 2012; control group) and after (January 2013-December 2014; score group) introduction of a newly developed score. To evaluate the effects of score adoption, odds ratios with 95% confidence intervals were calculated after adjustment for confounding factors.

RESULTS

The control group included a greater proportion of women treated with diet alone (170/312 [54.5%]) than the study group did (122/391 [31.2%]; P<0.001). By contrast, more women in the study group received metformin (172 [44.0%] vs 77 [24.7%]; P<0.001). The neonatal outcomes, including low Apgar scores at 1 minute and at 5 minutes and neonatal intensive care unit admission, were similar in both groups. Multivariate logistic regression analysis showed that the adoption of the score did not significantly affect the choice of treatment or the birth weight rating.

CONCLUSION

The score served well as an orientation tool in therapeutic decision making and had no negative effect on the treatment choice and perinatal outcomes.