Pre-pregnancy Obesity as a Modifier of Gestational Diabetes and Birth Defects Associations: A Systematic Review

Maternal physical activity, sitting, and risk of non-cardiac birth defects

BACKGROUND

The relationship between maternal physical activity (PA)/sitting and birth defects is largely unexplored. We examined whether pre-pregnancy PA/sitting were associated with having a pregnancy affected by a birth defect.

METHODS

We used data from two United States population-based case-control studies: 2008-2011 deliveries from the National Birth Defects Prevention Study (NBDPS; 9 states) and 2014-2018 deliveries from the Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS; 7 states). Cases with one of 12 non-cardiac birth defects (n = 3798) were identified through population-based registries. Controls (n = 2682) were live-born infants without major birth defects randomly sampled using vital/hospital records. Mothers self-reported pre-pregnancy PA/sitting. Unconditional logistic regression models estimated associations between PA/sitting categories and the 12 birth defects.

RESULTS

Mothers engaging in pre-pregnancy PA was associated with a reduced odds of five (spina bifida, cleft palate, anorectal atresia, hypospadias, transverse limb deficiency) and a higher odds of two (anencephaly, gastroschisis) birth defects. Mothers spending less time sitting in pre-pregnancy was associated with a reduced odds of two (anorectal atresia, hypospadias) and a higher odds of one (cleft lip with or without cleft palate) birth defect.

CONCLUSIONS

Reasonable next steps include replication of these findings, improved exposure assessment, and elucidation of biologic mechanisms.

IMPACT

Using data from two population-based case-control studies, we found that mothers engaging in different types of physical activity in the 3 months before pregnancy had an infant with a reduced odds of five and a higher odds of two birth defects. Mothers spending less time sitting in the 3 months before pregnancy had an infant with a reduced odds of two and a higher odds of one birth defect. Clarification and confirmation from additional studies are needed using more precise exposure measures, distinguishing occupational from leisure-time physical activity, and elucidation of mechanisms supporting these associations.

Decomposing the rural-urban disparities in overweight and obesity among women of reproductive age in Nigeria

BACKGROUND

Overweight and obese women face various reproductive and other health challenges, and in some cases, even mortality. Despite evidence of rural-urban disparities in overweight and obesity among women of reproductive age, there is limited evidence regarding the predictors of these disparities. This study aims to investigate the factors associated with overweight and obesity and examine the contributors to rural-urban disparities in overweight and obesity among women of reproductive age in Nigeria.

METHODS

We utilized the 2018 Nigeria Demographic and Health Survey dataset. The survey employed a two-stage cluster sampling technique based on Nigeria's 2006 census enumeration areas for sample selection. Overweight and obesity were defined as a body mass index (BMI) ≥ 25. Data analyses were conducted using the Logistic Regression Model and the threefold Blinder-Oaxaca decomposition model (α0.05).

RESULTS

The study revealed that older women (OR = 2.44; CI = 2.11-2.83), those with higher wealth (OR = 2.05; CI = 1.81-2.31), contraceptive users (OR = 1.41; CI = 1.27-1.57), and residents of the South-South region (OR = 1.24; CI = 1.07-1.45) were more likely to be overweight/obese. The decomposition analysis indicated that the mean predicted prevalence of overweight and obesity is 35.5% in urban areas, compared to 21.1% in rural areas of Nigeria. Factors such as wealth status, educational level, media exposure, and contraceptive use were identified as significant contributors to these disparities.

CONCLUSION

The findings underscore the importance of addressing socioeconomic disparities when designing healthcare interventions to reduce the burden of overweight and obesity, particularly in urban areas. Prioritizing these factors can facilitate efforts to promote healthier lifestyles and enhance overall well-being.

Melatonin associated with a high-fat diet during pregnancy and lactation prevents liver changes in the offspring

In the present study, we set out to determine whether melatonin combined with a high-fat diet during pregnancy and lactation can prevent liver disorders in offspring. Forty rats were divided into four groups: DC - pregnant rats submitted to the standard diet; DC + Mel - pregnant rats submitted to the standard diet combined with melatonin; HFD - pregnant rats submitted to a high-fat diet; HFD + Mel - pregnant rats submitted to a high-fat diet combined with melatonin. Morphophysiological and biochemical parameters were analyzed. Melatonin (5 mg/kg) was administered intraperitoneally. The HFD group offspring showed an increase in AST, ALT, alkaline phosphatase, cholesterol, triglycerides, LDL and glucose levels, and a reduction in HDL and lipase levels. In the liver obseved steatosis, hepatocellular ballooning, increased lobular parenchyma and reduced non-lobular parenchyma, beside reduced liver glycogen and fibrosis. These changes were not observed in the HFD + Mel group. In conclusion, melatonin combined with a high-fat diet preserves the liver architecture and function in the offspring.

A review of key terminology and definitions used for birth defects globally

Birth defects, also known as congenital disorders, are a significant health issue impacting at least five million births annually worldwide. For policymakers to mount a relevant healthcare response to care for those affected, the burden of disease of these conditions must be quantified. Estimates of the contribution of birth defects to under-5 child mortality and morbidity are generated by several groups globally. These estimates often differ, causing confusion for policymakers. While some differences may be attributed to the data sources and methods used, much is due to a lack of clarity in the terminology used for the group of disorders classed as "congenital". This study aimed to gain insight into the diversity of terms and definitions for birth defects, including those used routinely by relevant international/national organisations and in the peer-reviewed literature. This two-part study included (1) scoping review of peer-reviewed literature to identify terms and definitions in use for birth defects and (2) review of key websites and grey literature to identify terms and definitions used. The results of this study indicate a wide variety of terms being used, often interchangeably and undefined, in peer-reviewed publications, on institutional websites and related literature. This suggests a lack of clarity related to terminology and sets the scene for further discussion, recommending that the community of practice working on birth defects comes to a consensus on standard terminology and definitions for global uptake and implementation. Such standardisation will facilitate a common understanding of the burden of these disorders globally, regionally and within countries so that action can be taken to support affected children and their families.

Pregestational Diabetes and Congenital Heart Defects

Studies have consistently shown a significant increase in the risk of congenital heart defects in the offspring of diabetic mothers compared with those of nondiabetic pregnancies. Evidence points that all types of pregestational diabetes have the capacity of generating cardiac malformations in a more accentuated manner than in gestational diabetes, and there seems to be an increased risk for all congenital heart defects phenotypes in the presence of maternal diabetes. Currently, the application of some therapies is under study in an attempt to reduce the risks inherent to diabetic pregnancies; however, it has not yet been possible to fully prove their effectiveness. The present review aims to better understand the mechanisms that govern the association between pregestational diabetes and congenital heart defects and how maternal diabetes interferes with fetal cardiac development, as there is still a long way to go in the investigation of this complex process.

Morbidity and psychomotor development of offspring of women with gestational diabetes: a 5-year follow-up

Background

Gestational diabetes mellitus (GDM) represents a risk factor for both mother and her offspring in a short-term (perinatal morbidity) and long-term horizon (postpartum diabetes or foetal programming). Several studies focused at peri/postnatal outcomes of GDM mother´s offspring, however relatively few (and none in Czech population) were designed as prospective. The aim of the study was to ascertain eventual anthropometric and developmental abnormalities and/or morbidity in offspring of GDM mothers compare to controls in a 5-year follow-up using a parent-reported parameters related to psychomotor development and common paediatric morbidities including a sub-study of offspring of GDM mothers experiencing adverse perinatal outcomes.

Methods

A 5 year follow up study of offspring of GDM mothers (n = 26) vs those with a normal pregnancy (n = 63). An electronic questionnaire was used to obtain the parameters (such as growth, psychomotor development, vaccination, morbidity history etc.) available to parents from the parent-held infant health record. Data on pregnancy and delivery were available from the previous study.

Results

Offspring of GDM mothers had delayed psychomotor development in early childhood, but in 5 years of age they seemed to gradually achieve results of a control group. Children with macrosomia had a higher percentile of weight-for-height and were significantly more frequently ill than those with a normal birth weight. Offspring of obese mothers had worse verbal language skills in early childhood and a higher percentile of weight-for-height.

Conclusion

Maternal gestational diabetes and obesity can be considered an important determinant of postnatal offspring development and health status, which further advocates for broader implementation of preventive strategies.

Relationships between Women's and Men's Modifiable Preconception Risks and Health Behaviors and Maternal and Offspring Health Outcomes: An Umbrella Review

Parental health before conception effects maternal and offspring health outcomes. Preconception care provides healthcare to prospective parents addressing modifiable preconception risks and health behaviors. This umbrella review aimed to consolidate evidence on women's and men's modifiable preconception risks or health behaviors associated with maternal and offspring health outcomes. MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, and PsycINFO were searched from March 4, 2010, to March 4, 2020. Eligible studies were systematic reviews or meta-analyses of observational studies examining associations between modifiable preconception risks or health behaviors and maternal and offspring health outcomes. Screening, data extraction, and methodological quality assessment (AMSTAR 2) occurred independently by two reviewers. Degree of overlap was examined. Findings were summarized for evidence synthesis. Twenty-seven systematic reviews were included. Modifiable preconception risks and health behaviors were identified across categories: body composition (e.g., overweight, obesity), lifestyle behaviors (e.g., caffeine, smoking), nutrition (e.g., micronutrients), environmental exposures (e.g., radiation), and birth spacing (e.g., short interpregnancy intervals). Outcomes associated with exposures affected embryo (e.g., embryonic growth), maternal (e.g., gestational diabetes mellitus), fetal/neonate (e.g., preterm birth), and child (e.g., neurocognitive disorders) health. For real-world practice and policy relevance, evidence-based indicators for preconception care should include body composition, lifestyle, nutrition, environmental, and birth spacing.

Association between maternal exposure to indoor air pollution and offspring congenital heart disease: a case–control study in East China

Background

Previous research suggested an association between maternal exposure to ambient air pollutants and the risk of congenital heart disease (CHD). However, the effect of individual prenatal exposure to indoor air pollutants on CHD occurrence was not reported.

Methods

We performed a hospital-based case–control study to investigate the association between personal air pollution exposure during pregnancy and the risk of CHD in offspring. A total of 44 cases and 75 controls were included from two hospitals in East China. We investigated maternal and residential environmental characteristics using a questionnaire and obtained personal indoor air samples to assess particulate matter (PM) and volatile organic compounds (VOCs) from 22–30 gestational weeks. Formaldehyde, benzene, toluene, xylene, total volatile organic compounds (TVOCs), PM_2.5, and PM₁₀ were assessed. Logistic regression was performed to assess associations and interactions between individual indoor air pollutants and CHD after adjusting for confounders. The potential residential environmental factors affecting the risks of indoor air pollutants on CHD were also assessed.

Results

Median TVOC (0.400 vs. 0.005 mg/m³, P < 0.001) exposure levels in cases were significantly higher than controls. A logistic regression model adjusted for confounders revealed that exposure to high levels of indoor TVOCs (AOR 7.09, 95% CI 2.10–23.88) during pregnancy was associated with risks for CHD and the occurrence of some major CHD subtype in offspring. These risk effects were enhanced in pregnant women living in a newly renovated house but were mitigated by household use of smoke ventilators when cooking. We observed a positive interaction of maternal exposure to TVOCs and PM_2.5 and the risk for CHD.

Conclusions

Maternal exposure to indoor VOCs and PMs may increase the risk of giving birth to foetuses with CHD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13174-0.

A Comparative Prevalence of Birth Defects between Newborns of Immigrant and Native-Born Mothers in Taiwan: Ten Years of Population-Based Data

In recent years, newborns born to immigrant mothers have accounted for about 10% of the total births in Taiwan. However, little is known about whether there are differences between newborns of immigrant and native-born mothers regarding the prevalence and the possible causes of birth defects. By combining four nationwide databases and assessing all newborns between 2005 and 2014 in Taiwan as research subjects, this study determined the prevalence of birth defects stratified into nine categories (neuronal, facial, cleft, circulatory, respiratory, digestive, urogenital, musculoskeletal and chromosomal abnormalities) in the newborns of immigrant mothers and native-born mothers. We found that the prevalence of any birth defects in newborns of immigrant mothers (ranging from 0.98 to 1.24%) was lower than that of native-born mothers (2.86%). Skeletomuscular system defects are the most common among newborns of women from the main immigrant countries (0.24–0.42%), while circulatory system defects were the most common among newborns of Taiwanese women (0.92%). The risks of all defects remained lower for newborns of immigrant mothers (AORs ranged from 0.37 to 0.47) after controlling for possible confounding variables. The higher rates of birth defects among newborns of native-born mothers may be attributed to an older maternal age at childbirth and a higher prevalence of diabetes than that of immigrant mothers. The findings from this study imply that the prevalence of birth defects between newborns of immigrant and native-born mothers is not similar, as evidenced by a decade of population-based data.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal obesity and metabolic disorders associate with congenital heart defects in the offspring: A systematic review

BACKGROUND

Congenital heart defects (CHDs) are the most common congenital malformations. The aetiology of CHDs is complex. Large cohort studies and systematic reviews and meta-analyses based on these have reported an association between higher risk of CHDs in the offspring and individual maternal metabolic disorders such as obesity, diabetes, hypertension, and preeclampsia, all conditions that can be related to insulin resistance or hyperglycaemia. However, the clinical reality is that these conditions often occur simultaneously. The aim of this review is, in consequence, both to evaluate the existing evidence on the association between maternal metabolic disorders, defined as obesity, diabetes, hypertension, preeclampsia, dyslipidaemia and CHDs in the offspring, as well as the significance of combinations, such as metabolic syndrome, as risk factors.

METHODS

A systematic literature search of papers published between January 1, 1990 and January 14, 2021 was conducted using PubMed and Embase. Studies were eligible if they were published in English and were case-control or cohort studies. The exposures of interest were maternal overweight or obesity, hypertension, preeclampsia, diabetes, dyslipidaemia, and/or metabolic syndrome, and the outcome of interest was CHDs in the offspring. Furthermore, the studies were included according to a quality assessment score.

RESULTS

Of the 2,250 identified studies, 32 qualified for inclusion. All but one study investigated only the individual metabolic disorders. Some disorders (obesity, gestational diabetes, and hypertension) increased risk of CHDs marginally whereas pre-gestational diabetes and early-onset preeclampsia were strongly associated with CHDs, without consistent differences between CHD subtypes. A single study suggested a possible additive effect of maternal obesity and gestational diabetes.

CONCLUSIONS

Future studies of the role of aberrations of the glucose-insulin homeostasis in the common aetiology and mechanisms of metabolic disorders, present during pregnancy, and their association, both as single conditions and-particularly-in combination, with CHDs are needed.

Maternal Obesity and Risk of Low Birth Weight, Fetal Growth Restriction, and Macrosomia: Multiple Analyses

The associations between maternal pre-pregnancy obesity and low birth weight (LBW, <2500 g) remain inconclusive. Therefore, birth weight in a Polish prospective cohort of 912 mothers was investigated depending on the pre-pregnancy body mass index (BMI). The whole cohort and the subgroup of gestational weight gain (GWG) in the range of the Institute of Medicine (IOM) recommendations, as well as 'healthy' women (who did not develop diabetes or hypertension in this pregnancy) were investigated. Adjusted odds ratios (AOR) of the newborn outcomes (with 95% confidence intervals, CI) for obesity (BMI ≥ 30 kg/m²) vs. normal BMI (18.5-24.9 kg/m²) were calculated using multiple logistic regression. Risk profiles (in the Lowess method) were presented for BMI values (kg/m²) and threshold BMI values were calculated. (1) In the cohort, LBW affected 6.6% of pregnancies, fetal growth restriction (FGR) 2.3%, and macrosomia 10.6%. (2) The adjusted risk of macrosomia was more than three-fold higher for obesity compared to normal BMI in the whole cohort (AOR = 3.21 (1.69-6.1), p < 0.001) and the result was maintained in the subgroups. A 17-fold higher adjusted LBW risk for obesity was found (AOR = 17.42 (1.5-202.6), p = 0.022), but only in the normal GWG subgroup. The FGR risk profile was U-shaped: in the entire cohort, the risk was more than three times higher for obesity (AOR = 3.12 (1.02-9.54), p = 0.045) and underweight (AOR = 3.84 (1.13-13.0), p = 0.031). (3) The risk profiles showed that the highest BMI values were found to be associated with a higher risk of these three newborn outcomes and the threshold BMI was 23.7 kg/m² for macrosomia, 26.2 kg/m² for LBW, and 31.8 kg/m² for FGR. These results confirm the multidirectional effects of obesity on fetal growth (low birth weight, fetal growth restriction, and macrosomia). The results for LBW were heavily masked by the effects of abnormal gestational weight gain.

Prediction Method of Gestational Diabetes Based on Electronic Medical Record Data

At present, the secondary application of electronic medical records is focused on auxiliary medical diagnosis to improve the accuracy of clinical diagnosis. The main research in this article is the prediction method of gestational diabetes based on electronic medical record data. In the original data, the ID number of the medical examiner did not match the medical examination record. In order to ensure the accuracy of the data, this part of the record was removed. First, the preparation stage before building the model is to determine the baseline accuracy of the original data, test the effectiveness of the machine learning algorithm, and then balance the target data set to solve the bias caused by the imbalance between data classes and the illusion of excessive model prediction results. Then, the disease prediction model is constructed by dividing the data set, selecting parameters and algorithms, and visualizing the model. Finally, the effect of predictive model construction is comprehensively judged based on multiple evaluation indicators and control experimental models. In this paper, the RF model can be used to rank the importance of the feature importance of the output feature on the importance of the classification result of the input feature. In order to test the accuracy of regression prediction, the experiment uses absolute mean error and root mean square error to evaluate the accuracy of fasting blood glucose prediction. A logistic regression model is constructed through the training set, and the test set data are brought into the prediction model for prediction. Experimental data show that when the features filtered by WBFS are used, the accuracy, F1 value, and AUC value of logistic regression are 0.809, 0.881, and 0.825, respectively, which is an increase of about 12% compared with when the feature is not used. The results show that the electronic medical record data drive can effectively improve the accuracy of predicting gestational diabetes.

Gestational Diabetes Mellitus and Developmental Programming

During normal pregnancy, increased insulin resistance acts as an adaptation to enhance materno-foetal nutrient transfer and meet the nutritional needs of the developing foetus, particularly in relation to glucose requirements. However, about 1 in 6 pregnancies worldwide is affected by the inability of the mother's metabolism to maintain normoglycaemia, with the combination of insulin resistance and insufficient insulin secretion resulting in gestational diabetes mellitus (GDM). A growing body of epidemiologic work demonstrates long-term implications for adverse offspring health resulting from exposure to GDM in utero. The effect of GDM on offspring obesity and cardiometabolic health may be partly influenced by maternal obesity; this suggests that improving glucose and weight control during early pregnancy, or better still before conception, has the potential to lessen the risk to the offspring. The consequences of GDM for microbiome modification in the offspring and the impact upon offspring immune dysregulation are actively developing research areas. Some studies have suggested that GDM impacts offspring neurodevelopmental and cognitive outcomes; confirmatory studies will need to separate the effect of GDM exposure from the complex interplay of social and environmental factors. Animal and human studies have demonstrated the role of epigenetic modifications in underpinning the predisposition to adverse health in offspring exposed to suboptimal hyperglycaemic in utero environment. To date, several epigenome-wide association studies in human have extended our knowledge on linking maternal diabetes-related DNA methylation marks with childhood adiposity-related outcomes. Identification of such epigenetic marks can help guide future research to develop candidate diagnostic biomarkers and preventive or therapeutic strategies. Longer-term interventions and longitudinal studies will be needed to better understand the causality, underlying mechanisms, or impact of GDM treatments to optimize the health of future generations.

Risk factors for anorectal and associated malformations in German children: A 10-year analysis

BACKGROUND

Incidences of anorectal malformations (ARM) occur in 1 of 2000-5000 live births and up to 64% have associated malformations (ARMa). The aim of the study was to evaluate possible prenatal risk factors for ARM in a tertiary hospital.

METHODS

A case-control design was used to compare risk factors in ARM (n = 44) to a control group (CG; n = 26). We used modified prenatal questionnaires, analyzed mothers' prenatal records and participants completed a structured interview. Endpoints were medical history, drug consumption, occupational risk factors, and time point of diagnosis, associated malformations and sensitivity of radiological imaging.

RESULTS

Our results showed that ARM couples had a significantly higher age difference (p = 0.028) compared to CG. ARM mothers had more abnormalities during pregnancy (p = 0.002), more positive vaginal smears of group B streptococci (p = 0.024), urogenital infections (p = 0.005), gestosis (p = 0.03), emesis (p = 0.025) and higher numbers of chronic diseases (p = 0.018). ARM mothers took less medication during pregnancy (p = 0.013) than CG mothers including folic acid (p = 0.041); their intake of iodine tablets was significantly higher (p = 0.035) and they continued smoking for longer (p = 0.036) than CG mothers, and they had more stillbirths (p = 0.035). In using illegal drug and alcohol use, the groups did not show significant differences. ARMa was present in 68.1% (n = 30), of which 45.5% were of urogenital origin (n = 20). ARM diagnosis was made on the first day of life in 72.7% (n = 32), while diagnosis was delayed in 12 patients (27.3%).

CONCLUSION

A combination of different risk factors seem to be associated with the development of ARM, which takes place at an early stage (<7th week) of pregnancy. Therefore, risk factors influencing fetal development must be critically considered. We advocate an interdisciplinary assessment in unclear clinical findings on first day of life to optimize the therapy and positively influence the outcome.

Demographic and Clinical Features of Small-for-Gestational-Age Infants Born to Mothers With Gestational Diabetes Mellitus

We studied the demographic and clinical characteristic, risk factors, outcomes of full-term small-for-gestational-age (SGA) infants born to mothers with gestational diabetes mellitus (GDM) in China. A retrospective case-control study that included 1981 SGA infants was conducted; the demographic and clinical data between SGA infants born to mothers with and without GDM were compared. Of 383 SGA infants born to mothers with GDM, 221 (57.7%) were female, and the incidence of these infants was 1 in 155 live births. The risk of SGA siblings (RR, 1.88; 95% CI, [1.23-2.86]), low 1- and 5-min Apgar scores (RR,2.04 and 4.21; 95%CI [1.05-4.00] and [1.05-16.89], respectively), early thrombocytopenia (RR, 3.39; 95%CI, [1.33-8.64]), hypoglycemia(RR, 2.49; 95%CI, [1.55-3.98]), and hypoxic-ischemic encephalopathy (RR,5.61; 95%CI, [1.25-25.18]) were increased in SGA infants born to mothers with GDM compared to SGA infants born to mothers without GDM. SGA girls born to mothers with GDM had a significantly higher ratio of catch-up growth (CUG) (RR, 1.73; 95%CI, [1.18-2.54]) in the first year of life. These results show that genetic factors may be one of the etiologies of SGA infants born to mothers with GDM; and these infants have more adverse perinatal outcomes compared to SGA infants born to mothers without GDM. SGA girls born to mothers with GDM had accelerated CUG in the first year of life.

Early Screening for Gestational Diabetes Using IADPSG Criteria May Be a Useful Predictor for Congenital Anomalies: Preliminary Data from a High-Risk Population

Background: Our aim was to investigate whether the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) glycemic thresholds used for detecting hyperglycemia in pregnancy can be predictive for malformations in women with hyperglycemia detected in early pregnancy. Methods: a single-center, retrospective observational trial of 125 mother-infant pairs from singleton pregnancies with hyperglycemia according to the IADPSG criteria diagnosed at the gestational age below 16 weeks. Glucose values obtained from 75-g OGTT (oral glucose tolerance test) were investigated as predictors for congenital malformations in newborns. Results: Characteristics of the cohort: maternal age: 31.5 ± 5.2, pre-pregnancy body mass index (BMI) ≥ 30 kg/m²: 42.0%, gestational age at diagnosis (weeks): 12.0 ± 4.0, and newborns with congenital malformations: 8.8%. Fasting blood glycemia (FBG) and HbA1c (Haemoglobin A1c) at baseline significantly predicted the outcome (expB: 1.06 (1.02–1.1), p = 0.007 and expB: 2.05 (1.24–3.38), p = 0.005, respectively). Both the fasting blood glucose (FBG) value of 5.1 mmol/dL (diagnostic for gestational diabetes mellitus (GDM)) and 5.5 mmol/dL (upper limit for normoglycemia in the general population) significantly increased the likelihood ratio (LR) for fetal malformations: 1.3 (1.1; 1.4) and 1.5 (1.0; 2.4), respectively. Conclusions: (1) Fasting glycemia diagnostic for GDM measured in early pregnancy is associated with a significantly elevated risk for congenital malformations. (2) Our data suggest that women at elevated risks of GDM/diabetes in pregnancy (DiP) should have their fasting blood glucose assessed before becoming pregnant, and the optimization of glycemic control should be considered if the FBG exceeds 5.1 mmol/dL.

First trimester biomarkers for prediction of gestational diabetes mellitus

PURPOSE

To develop a first trimester prediction model for gestational diabetes mellitus (GDM) using obesity, placental, and inflammatory biomarkers.

METHODS

We used a first trimester dataset of the ASPRE study to evaluate clinical and biochemical biomarkers. All biomarkers levels (except insulin) were transformed to gestational week-specific medians (MoMs), adjusted for maternal body mass index (BMI), maternal age, and parity. The MoM values of each biomarker in the GDM and normal groups were compared and used for the development of a prediction model assessed by area under the curve (AUC).

RESULTS

The study included 185 normal and 20 GDM cases. In the GDM group, compared to the normal group BMI and insulin (P = 0.003) were higher (both P < 0.003). The MoM values of uterine artery pulsatility index (UtA-PI) and soluble (s)CD163 were higher (both P < 0.01) while pregnancy associated plasma protein A (PAPP-A), placental protein 13 (PP13), and tumor-necrosis factor alpha (TNFα) were lower (all P < 0.005). There was no significant difference between the groups in placental growth factor, interleukin 6, leptin, peptide YY, or soluble mannose receptor (sMR/CD206). In screening for GDM in obese women the combination of high BMI, insulin, sCD163, and TNFα yielded an AUC of 0.95, with detection rate of 89% at 10% false positive rate (FPR). In non-obese women, the combination of sCD163, TNFα, PP13 and PAPP-A yielded an AUC of 0.94 with detection rate of 83% at 10% FPR.

CONCLUSION

A new model for first trimester prediction of the risk to develop GDM was developed that warrants further validation.

In ovo hyperglycemia causes congenital limb defects in chicken embryos via disruption of cell proliferation and apoptosis

While the correlation between diabetes during pregnancy and birth defects is well-established, how hyperglycemia causes developmental abnormalities remains unclear. In this study, we developed a novel "hyperglycemic" chicken embryonic model by administrating various doses of glucose to fertilized eggs at embryonic stages HH16 or HH24. When the embryos were collected at HH35, the LD50 was 1.57 g/Kg under HH16 treatment and 0.93 g/Kg under HH24 treatment, indicating that "hyperglycemic" environments can be lethal for the embryos. When exposed to a dose equal to or higher than 1 g/Kg glucose at HH16 or HH24, more than 40% of the surviving chicken embryos displayed heart defects and/or limb defects. The limb defects were associated with proliferation defects of both the wing and leg buds indicated by reduced numbers of p-H3S10 labeled cells. These limb defects were also associated with ectopic apoptosis in the leg bud and expression changes of key apoptotic genes. Furthermore, glucose treatment induced decreased expression of genes involved in Shh-signaling, chondrogenesis, and digit patterning in the limb bud. In summary, our data demonstrated that a high-glucose environment induces congenital heart and limb defects associated with disrupted cell proliferation and apoptosis, possibly through depressed Shh-signaling.

Risk factors for congenital heart disease: The Baby Hearts Study, a population-based case-control study

We investigated the role of maternal environmental factors in the aetiology of congenital heart disease (CHD). A population-based case-control study (242 CHD cases, 966 controls) was conducted using an iPad questionnaire for mother with linkage to maternity and first trimester prescription records. Risk of CHD was associated with low maternal education (OR adjusted for confounders 1.59; 95% confidence interval [CI], 1.02-2.49), pregestational diabetes (OR 4.04; 95% CI 1.00-16.28), self-reported maternal clotting disorders (adjOR 8.55, 95%CI 1.51-48.44), prescriptions for the anticlotting medication enoxaparin (adjOR 3.22, 95%CI 1.01-10.22) and self-reported vaginal infections (adjOR 1.69, 95%CI 1.01-2.80). There was no strong support for the hypothesis that periconceptional folic acid supplements have a protective effect, but there was a protective effect of frequent consumption of folate rich fruits (adjOR 0.64, 95%CI 0.47-0.89). Compared to the most common pre-pregnancy dietary pattern, CHD risk was associated with a poor diet low in fruit and vegetables (adjOR 1.56, 95%CI 1.05-2.34). Mothers of cases reported more pregnancy related stress (adjOR 1.69; 95% CI 1.22-2.34) and multiple stressors (adjOR 1.94, 95%CI 0.83-4.53). We found no supportive evidence for CHD risk being associated with obesity, smoking, depression or antidepressant use in this population. Our findings add to the previous evidence base to show potential for public health approaches to help prevent CHD in future by modifying environmental factors. Independent confirmation should be sought regarding elevated CHD risk associated with maternal blood clotting disorders and their treatment, since we are the first to report this.

Atypical antipsychotic use during pregnancy and birth defect risk: National Birth Defects Prevention Study, 1997-2011

PURPOSE

To examine the prevalence of, and factors associated with, atypical antipsychotic use among U.S. pregnant women, and potential associations between early pregnancy atypical antipsychotic use and risk for 14 birth defects.

METHODS

We analyzed data from the National Birth Defects Prevention Study (1997-2011), a U.S. population-based case-control study examining risk factors for major structural birth defects.

RESULTS

Atypical antipsychotic use during pregnancy was more common among women with pre-pregnancy obesity, and women who reported illicit drug use before and during pregnancy, smoking during pregnancy, alcohol use during pregnancy, or use of other psychiatric medications during pregnancy. We observed elevated associations (defined as a crude odds ratio [cOR] ≥2.0) between early pregnancy atypical antipsychotic use and conotruncal heart defects (6 exposed cases; cOR: 2.3, 95% confidence interval [CI]: 0.9-6.1), and more specifically Tetralogy of Fallot (3 exposed cases; cOR: 2.5, 95% CI: 0.7-8.8), cleft palate (4 exposed cases, cOR: 2.5, 95% CI: 0.8-7.6), anorectal atresia/stenosis (3 exposed cases, cOR: 2.8, 95% CI: 0.8-9.9), and gastroschisis (3 exposed cases, cOR: 2.1, 95% CI: 0.6-7.3).

CONCLUSIONS

Our findings support the close clinical monitoring of pregnant women using atypical antipsychotics. Women treated with atypical antipsychotics generally access healthcare services before pregnancy; efforts to reduce correlates of atypical antipsychotic use might improve maternal and infant health in this population.

Physical activity pattern in early pregnancy and gestational diabetes mellitus risk among low-income women: A prospective cross-sectional study

Objective:

Gestational diabetes mellitus is increasing worldwide, mainly in developing countries, and physical activity has not been studied in gestational diabetes mellitus prevention among low-income population. This prospective cross-sectional study assessed the gestational diabetes mellitus risk related to physical activity in early pregnancy among low-income women.

Methods:

A prospective cross-sectional study with 544 low-income pregnant women was conducted at the Instituto de Medicina Integral Prof. Fernando Figueira, Brazil. Gestational diabetes mellitus was diagnosed using the International Association of Diabetes and Pregnancy Study Groups criteria. Physical activity was assessed during early pregnancy using the Pregnancy Physical Activity Questionnaire and categorized as sedentary, light, moderate, or vigorous intensity.

Results:

Gestational diabetes mellitus occurred in 95 of 544 women (17.4%). Body mass index was higher in the gestational diabetes mellitus group. Nearly half of all pregnant women studied were physically inactive, and none of them were classified as vigorous physical active. Sedentary physical activity pattern was associated with a higher odds of gestational diabetes mellitus (odds ratio = 1.8, 95% confidence interval = 1.1–2.9), which did not change after adjusting for several covariates (odds ratio = 1.9, 95% confidence interval = 1.2–3.1).

Conclusion:

Physical inactivity in early pregnancy is associated with a higher risk of gestational diabetes mellitus among low-income women.

Estimation of the preventable proportion of congenital anomalies by selected risk factors in mothers: A case study in Iran

Background: Worldwide, 1-6 percent of infants have at least one congenital anomaly that can lead to long-term consequences. This may have significant impacts on individuals, families, health-care systems, and societies. The aim of this study was to estimate the Population Attributable Fraction (PAF) of some congenital anomalies by three selected risk factors (obesity, diabetes and smoking) in the northwest of Iran and to estimate the number of preventable defects at birth in the population if we could reduce 50 percent of the exposure rate to these three risk factors at population level.

Methods: The regional data on smoking, obesity, and diabetes were entered in Population Estimate of Attributable Fraction of Congenital Conditions Everywhere (PEACE) software developed by International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR). It calculates the PAF for congenital anomalies attributed to exposure to those three risk factors.

Results: This study showed that main anomalies attributed to "obesity" include Spina Bifida 40.1% (95% CI: 31.7-47.7), Hydrocephaly 26.8 (95% CI: 9.3-42.3) and Anencephaly 17.4 (95% CI: 1.6-31.9). The highest attributable defect to "smoking" was Cleft lip w/out Palate 5.8% (95% CI: 4.3-7.4), whereas for "diabetes" it was Tetralogy of Fallot 33.3 (95% CI: 17.2-49.5). A similar pattern was found when assumed in the model, the impact of 50 percent reduction in the exposure to each of the risk factors on preventable cases of birth defects in the population.

Conclusion: Obesity, diabetes, and smoking in women of childbearing age increased the risk of occurrence of congenital anomalies. However, obesity and diabetes had a remarkably greater impact compared to smoking. More studies are needed to investigate the role of passive smoking as a risk factor for the occurrence of birth defects.

Intergenerational Effects of Health Issues Among Women of Childbearing Age: a Review of the Recent Literature

PURPOSE OF REVIEW

This review summarizes the latest scientific evidence, primarily from systematic reviews/meta-analyses and large cohort studies, on the impact of health issues among women of childbearing age and their effect on their offspring during pregnancy and from birth to adulthood.

RECENT FINDINGS

Women of childbearing age with overweight/obesity, diabetes, and hypertension prior to pregnancy are at increased risk for adverse outcomes during pregnancy, such as excessive gestational weight gain, gestational diabetes mellitus, and hypertensive disorders of pregnancy. These adverse outcomes could complicate delivery and put their offspring at risk of developing overweight/obesity, diabetes, and hypertension (i.e., intergenerational transmission of health issues). Interventions should target women of childbearing age, especially those who wish to conceive, in order to possibly stop the transmission of women's health issues to the offspring and favor a healthy pregnancy from the start. This could be one of the best strategies to promote both maternal and child health.

Gestational diabetes and adiposity are independent risk factors for perinatal outcomes: a population based cohort study in Sweden

AIMS

To evaluate the interaction effects of gestational diabetes (GDM) with obesity on perinatal outcomes.

METHODS

A population-based cohort study in Sweden excluding women without pre-gestational diabetes with a singleton birth between 1998 and 2012. Logistic regression was performed to evaluate the potential independent associations of GDM and BMI with adverse perinatal outcomes as well as their interactions. Main outcome measures were malformations, stillbirths, perinatal mortality, low Apgar score, fetal distress, prematurity and Erb's palsy.

RESULTS

Some 1,294,006 women were included, with a GDM prevalence of 1% (n = 14,833). The rate of overweight/obesity was 67.7% in the GDM-group and 36.1% in the non-GDM-group. No significant interaction existed. Offspring of women with GDM had significantly increased risk of malformations, adjusted odds ratio (aOR) 1.16 (95% confidence intervals 1.06-1.26), prematurity, aOR 1.86 (1.76-1. 98), low Apgar score, aOR 1.36 (1.10-1.70), fetal distress, aOR 1.09 (1.02-1.16) and Erb's palsy aOR 2.26 (1.79-2.86). No risk for stillbirth or perinatal mortality was seen. Offspring of overweight (BMI 25-29.9 kg/m² ), obese (BMI 30-34.9 kg/m² ) and severely obese women (BMI ≥ 35.0 kg/m² ) had significantly increased risks of all outcomes including stillbirth 1.51 (1.40-1.62) to 2.85 (2.52-3.22) and perinatal mortality 1.49 (1.40-1.59) to 2.83 (2.54-3.15).

CONCLUSIONS

There is no interaction effect between GDM and BMI for the studied outcomes. Higher BMI and GDM are major independent risk factors for most serious adverse perinatal outcomes. More effective pre-pregnancy and antenatal interventions are required to prevent serious adverse pregnancy outcomes among women with either GDM or high BMI.

The risk stratification of adverse neonatal outcomes in women with gestational diabetes (STRONG) study

AIMS

To assess the risk of adverse neonatal outcomes in women with gestational diabetes (GDM) by identifying subgroups of women at higher risk to recognize the characteristics most associated with an excess of risk.

METHODS

Observational, retrospective, multicenter study involving consecutive women with GDM. To identify distinct and homogeneous subgroups of women at a higher risk, the RECursive Partitioning and AMalgamation (RECPAM) method was used. Overall, 2736 pregnancies complicated by GDM were analyzed. The main outcome measure was the occurrence of adverse neonatal outcomes in pregnancies complicated by GDM.

RESULTS

Among study participants (median age 36.8 years, pre-gestational BMI 24.8 kg/m²), six miscarriages, one neonatal death, but no maternal death was recorded. The occurrence of the cumulative adverse outcome (OR 2.48, 95% CI 1.59-3.87), large for gestational age (OR 3.99, 95% CI 2.40-6.63), fetal malformation (OR 2.66, 95% CI 1.00-7.18), and respiratory distress (OR 4.33, 95% CI 1.33-14.12) was associated with previous macrosomia. Large for gestational age was also associated with obesity (OR 1.46, 95% CI 1.00-2.15). Small for gestational age was associated with first trimester glucose levels (OR 1.96, 95% CI 1.04-3.69). Neonatal hypoglycemia was associated with overweight (OR 1.52, 95% CI 1.02-2.27) and obesity (OR 1.62, 95% CI 1.04-2.51). The RECPAM analysis identified high-risk subgroups mainly characterized by high pre-pregnancy BMI (OR 1.68, 95% CI 1.21-2.33 for obese; OR 1.38 95% CI 1.03-1.87 for overweight).

CONCLUSIONS

A deep investigation on the factors associated with adverse neonatal outcomes requires a risk stratification. In particular, great attention must be paid to the prevention and treatment of obesity.

Association between maternal overweight or obesity and cerebral palsy in children: A meta-analysis

CONTEXT

There is no consensus regarding the association between maternal obesity or overweight and cerebral palsy (CP) in children.

OBJECTIVES

To investigate whether maternal obesity or overweight is associated with CP and identify the factors that explain the differences in the study results.

DATA SOURCES

We conducted a meta-analysis of studies published in English with titles or abstracts that discussed the relationships between maternal obesity or overweight and CP before August 23, 2017, using Ovid Medline, EMBASE and Web of Science.

STUDY SELECTION

Of 2699 initially identified studies, 8 studies that addressed the association between maternal obesity and CP met our final inclusion criteria.

DATA EXTRACTION

Information from the individual studies was abstracted using standardized forms by 2 independent observers who were blinded to the authors' names and journal titles.

DATA SYNTHESIS

According to a random effects model, maternal overweight was significantly associated with CP in offspring [RR = 1.29 (95% CI, 1.04-1.60), heterogeneity (I2 = 45.5%, P = 0.103)]; maternal obesity was significantly associated with CP in offspring [RR = 1.45 (95% CI, 1.25-1.69), heterogeneity (I2 = 24.1%, P = 0.253)]; and maternal obesity III was significantly associated with CP in offspring [RR = 2.25 (95% CI, 1.82-2.79), heterogeneity (I2 = 0%, P = 0.589)]. However, maternal underweight was not significantly associated with CP in offspring [RR = 1.11 (95% CI, 0.88-1.38), low heterogeneity (I2 = 0%, P = 0.435)]. Factors that explained the differences in the meta-analysis results included study design, study location, and whether individual studies adjusted for potential confounders.

CONCLUSION

This study suggests that maternal obesity and overweight increase the risk of CP in offspring. Further studies are required to confirm these results and determine the influence of variables across studies.

Estimated global overweight and obesity burden in pregnant women based on panel data model

Objective

To estimate the global and country-level burden of overweight and obesity among pregnant women from 2005 to 2014.

Methods

Publicly accessible country-level data were collected from the World Health Organization, the World Bank and the Food and Agricultural Organization. We estimated the number of overweight and obese pregnant women among 184 countries and determined the time-related trend from 2005 to 2014. Based on panel data model, we determined the effects of food energy supply, urbanization, gross national income and female employment on the number of overweight and obese pregnant women.

Results

We estimated that 38.9 million overweight and obese pregnant women and 14.6 million obese pregnant women existed globally in 2014. In upper middle income countries and lower middle income countries, there were sharp increases in the number of overweight and obese pregnant women. In 2014, the percentage of female with overweight and obesity in India was 21.7%, and India had the largest number of overweight and obese pregnant women (4.3 million), which accounted for 11.1% in the world. In the United States of America, a third of women were obese, and the number of obese pregnant women was 1.1 million. In high income countries, caloric supply and urbanization were positively associated with the number of overweight and obese pregnant women. The percentage of employment in agriculture was inversely associated with the number of overweight and obese pregnant women, but only in upper middle income countries and lower middle income countries.

Conclusion

The number of overweight and obese pregnant women has increased in high income and middle income countries. Environmental changes could lead to increased caloric supply and decreased energy expenditure among women. National and local governments should work together to create a healthy food environment.

The impact of expanded health insurance coverage for unauthorized pregnant women on prenatal care utilization

OBJECTIVE

The objective of this study was to investigate the effect of expanding Medicaid health insurance coverage for unauthorized women on prenatal care utilization.

DESIGN AND SAMPLE

A natural experiment design was used. We examined the prenatal care utilization of 20,876 unauthorized women from Nebraska, which expanded Medicaid coverage for unauthorized women, and South Carolina, which has never expanded coverage.

MEASURES

Measurements of prenatal care utilization included adequate prenatal care using the Kotelchuck Index and the number of prenatal care visits. The policy independent variable of interest was an interaction between the policy years (2007-2009) and Nebraska residence. Demographic characteristics were included as covariates. Analysis entailed a difference-in-difference approach to compare prenatal care utilization by state, both before and after legislation was passed to fund care among unauthorized women in Nebraska.

RESULTS

Women with insurance coverage were more likely to utilize prenatal services. Unauthorized women living in Nebraska during Medicaid expansion were 28% more likely to receive adequate prenatal care (OR = 1.28, p < 0.01) and had about one more prenatal care visit (IRR = 1.05, p < 0.01) than women who did not have expanded Medicaid coverage.

CONCLUSIONS

Findings have important public health policy implications to support improved birth outcomes among native-born infants of unauthorized women.

A Path to Implement Precision Child Health Cardiovascular Medicine

Congenital heart defects (CHDs) affect approximately 1% of live births and are a major source of childhood morbidity and mortality even in countries with advanced healthcare systems. Along with phenotypic heterogeneity, the underlying etiology of CHDs is multifactorial, involving genetic, epigenetic, and/or environmental contributors. Clear dissection of the underlying mechanism is a powerful step to establish individualized therapies. However, the majority of CHDs are yet to be clearly diagnosed for the underlying genetic and environmental factors, and even less with effective therapies. Although the survival rate for CHDs is steadily improving, there is still a significant unmet need for refining diagnostic precision and establishing targeted therapies to optimize life quality and to minimize future complications. In particular, proper identification of disease associated genetic variants in humans has been challenging, and this greatly impedes our ability to delineate gene–environment interactions that contribute to the pathogenesis of CHDs. Implementing a systematic multileveled approach can establish a continuum from phenotypic characterization in the clinic to molecular dissection using combined next-generation sequencing platforms and validation studies in suitable models at the bench. Key elements necessary to advance the field are: first, proper delineation of the phenotypic spectrum of CHDs; second, defining the molecular genotype/phenotype by combining whole-exome sequencing and transcriptome analysis; third, integration of phenotypic, genotypic, and molecular datasets to identify molecular network contributing to CHDs; fourth, generation of relevant disease models and multileveled experimental investigations. In order to achieve all these goals, access to high-quality biological specimens from well-defined patient cohorts is a crucial step. Therefore, establishing a CHD BioCore is an essential infrastructure and a critical step on the path toward precision child health cardiovascular medicine.