Pregnancy Outcomes after Preeclampsia: The Effects of Interpregnancy Weight Change

Preventive Primary Care in the Postpartum Year: The Role of Medicaid Delivery System Reform

INTRODUCTION

Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year.

METHODS

The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024.

RESULTS

Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation.

CONCLUSIONS

Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse.

Interpregnancy weight change and neonatal and infant outcomes: A systematic review and meta-analysis

PURPOSE

To synthesize evidence regarding the association between interpregnancy weight change (IPWC) in consecutive pregnancies and neonatal or infant outcomes in the subsequent pregnancy.

METHODS

Search strategy was implemented in MEDLINE, EMBASE, Web of Science, Scopus and Cochrane Library from their inception to 13 November 2023. The most adjusted odds ratio (OR) or risk ratio estimates provided by original studies were used to calculate pooled risk ratios and their corresponding 95 % confidence intervals (CI) with the DerSimonian and Laird random effects method. Publication bias was assessed by funnel plots and Egger's method, and risk of bias was assessed with The NewcastleOttawa Quality Assessment Scale.

RESULTS

Thirty-seven observational studies were included. Interpregnancy weight loss or gain were associated with large for gestational age (OR: 0.89; 95 % CI: 0.84-0.94; I2 = 83.6 % and OR: 1.33; 95 % CI:1.26-1.40; I2 = 98.9 %), and stillbirth risk (OR: 1.10; 95 % CI: 1.01-1.18; I2 = 0.0 % and OR: 1.21; 95 % CI: 1.09-1.33; I2 = 60.2 %,).

CONCLUSIONS

Findings highlight the importance of managing weight between interpregnancy periods, although these findings should be interpreted cautiously because of the possible influence of social determinants of health and other factors.

Pre-gestational counselling for women living with CKD: starting from the bright side

Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.

Pre-pregnancy body mass index combined with peripheral blood PLGF, DCN, LDH, and UA in a risk prediction model for pre-eclampsia

Objective

This study analyzes the levels of peripheral blood placental growth factor (PLGF), body mass index (BMI), decorin (DCN), lactate dehydrogenase (LDH), uric acid (UA), and clinical indicators of patients with preeclampsia (PE), and establishes a predictive risk model of PE, which can provide a reference for early and effective prediction of PE.

Methods

81 cases of pregnant women with PE who had regular prenatal checkups and delivered in Jinshan Branch of Shanghai Sixth People's Hospital from June 2020 to December 2022 were analyzed, and 92 pregnant women with normal pregnancies who had their antenatal checkups and delivered at the hospital during the same period were selected as the control group. Clinical data and peripheral blood levels of PLGF, DCN, LDH, and UA were recorded, and the two groups were subjected to univariate screening and multifactorial logistic regression analysis. Based on the screening results, the diagnostic efficacy of PE was evaluated using the receiver operating characteristic (ROC) curve. Risk prediction nomogram model was constructed using R language. The Bootstrap method (self-sampling method) was used to validate and produce calibration plots; the decision curve analysis (DCA) was used to assess the clinical benefit rate of the model.

Results

There were statistically significant differences in age, pre-pregnancy BMI, gestational weight gain, history of PE or family history, family history of hypertension, gestational diabetes mellitus, and history of renal disease between the two groups (P < 0.05). The results of multifactorial binary logistic stepwise regression revealed that peripheral blood levels of PLGF, DCN, LDH, UA, and pre-pregnancy BMI were independent influences on the occurrence of PE (P < 0.05). The area under the curve of PLGF, DCN, LDH, UA levels and pre-pregnancy BMI in the detection of PE was 0.952, with a sensitivity of 0.901 and a specificity of 0.913, which is better than a single clinical diagnostic indicator. The results of multifactor analysis were constructed as a nomogram model, and the mean absolute error of the calibration curve of the modeling set was 0.023, suggesting that the predictive probability of the model was generally compatible with the actual value. DCA showed the predictive model had a high net benefit in the range of 5% to 85%, suggesting that the model has clinical utility value.

Conclusion

The occurrence of PE is related to the peripheral blood levels of PLGF, DCN, LDH, UA and pre-pregnancy BMI, and the combination of these indexes has a better clinical diagnostic value than a single index. The nomogram model constructed by using the above indicators can be used for the prediction of PE and has high predictive efficacy.

Navigating the Role of Anti-Obesity Agents Prior to Pregnancy: A Narrative Review

Utilization of anti-obesity agents is rising in reproductive-age females with some planning for future pregnancy. Lifestyle-induced weight loss has been shown to increase spontaneous conception rate, improve rates of fertility intervention complications, and decrease pregnancy comorbidities. However, the definitive role of assisting weight loss with medication prior to pregnancy remains to be established. The implications of anti-obesity agent used prior to pregnancy are explored in this narrative review, considering benefits of weight loss as well as available evidence for use and risks of anti-obesity agents prior to pregnancy.

Preeclampsia: Maternal cardiovascular function and optimising outcomes

Preeclampsia is associated with cardiac dysfunction, not only during the clinical phase of the disease, but also after delivery, with long term implications for both maternal and neonatal cardiovascular health. An abnormal cardiovascular phenotype also precedes conception, indicating that pre-existing cardiovascular dysfunction is associated with the development of preeclampsia. This review summarises the changes in cardiovascular function in preeclampsia, examining the evidence for when cardiovascular dysfunction develops and presenting the evidence for two phenotypes - one associated with fetal growth restriction, low cardiac output and high peripheral resistance, and a second associated with normal fetal growth, high cardiac output and low peripheral resistance. The presence of a cardiovascular phenotype that precedes conception demonstrates the potential for prevention of preeclampsia through cardiovascular optimisation at this stage. The two phenotypes mean therapy can be targeted to optimising cardiovascular function. The prevention and effective treatment of preeclampsia are essential aspects of improving maternal and neonatal cardiovascular health in the long term.

Dietary factors that affect the risk of pre-eclampsia

Pre-eclampsia affects 3%–5% of pregnant women worldwide and is associated with a range of adverse maternal and fetal outcomes, including maternal and/or fetal death. It particularly affects those with chronic hypertension, pregestational diabetes mellitus or a family history of pre-eclampsia. Other than early delivery of the fetus, there is no cure for pre-eclampsia. Since diet or dietary supplements may affect the risk, we have carried out an up-to-date, narrative literature review to assess the relationship between nutrition and pre-eclampsia. Several nutrients and dietary factors previously believed to be implicated in the risk of pre-eclampsia have now been shown to have no effect on risk; these include vitamins C and E, magnesium, salt, ω-3 long-chain polyunsaturated fatty acids (fish oils) and zinc. Body mass index is proportionally correlated with pre-eclampsia risk, therefore women should aim for a healthy pre-pregnancy body weight and avoid excessive gestational and interpregnancy weight gain. The association between the risk and progression of the pathophysiology of pre-eclampsia may explain the apparent benefit of dietary modifications resulting from increased consumption of fruits and vegetables (≥400 g/day), plant-based foods and vegetable oils and a limited intake of foods high in fat, sugar and salt. Consuming a high-fibre diet (25–30 g/day) may attenuate dyslipidaemia and reduce blood pressure and inflammation. Other key nutrients that may mitigate the risk include increased calcium intake, a daily multivitamin/mineral supplement and an adequate vitamin D status. For those with a low selenium intake (such as those living in Europe), fish/seafood intake could be increased to improve selenium intake or selenium could be supplemented in the recommended multivitamin/mineral supplement. Milk-based probiotics have also been found to be beneficial in pregnant women at risk. Our recommendations are summarised in a table of guidance for women at particular risk of developing pre-eclampsia.

Primary Care-Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.

Does interpregnancy BMI change affect the risk of complications in the second pregnancy? Analysis of pooled data from Aberdeen, Finland and Malta

Objective

Weight management interventions during pregnancy have had limited success in reducing the risk of pregnancy complications. Focus has now shifted to pre-pregnancy counselling to optimise body weight before subsequent conception. We aimed to assess the effect of interpregnancy body mass index (BMI) change on the risk of perinatal complications in the second pregnancy.

Methods

A cohort study was performed using pooled maternity data from Aberdeen, Finland and Malta. Women with a BMI change of ±2 kg/m² between their first and second pregnancies were compared with those who were BMI stable (remained within ±2 kg/m²). Outcomes assessed included pre-eclampsia (PE), intrauterine growth restriction (IUGR), preterm birth, birth weight, and stillbirth in the second pregnancy. We also assessed the effect of unit change in BMI for PE and IUGR. Logistic regression was used to calculate odds ratios with 95% confidence intervals.

Results

An increase of ≥2 kg/m² between the first two pregnancies increased the risk of PE (1.66 (1.49–1.86)) and high birthweight (>4000 g) (1.06 (1.03–1.10)). A reduction of ≥2 kg/m² increased the chance of IUGR (1.15 (1.01–1.31)) and preterm birth (1.14 (1.01–1.30)), while reducing the risk of instrumental delivery (0.75 (0.68–0.85)) and high birthweight (0.93 (0.87–0.98)). Reducing BMI did not significantly decrease PE risk in women with obesity or those with previous PE. A history of PE or IUGR in the first pregnancy was the strongest predictor of recurrence independent of interpregnancy BMI change (5.75 (5.30–6.24) and (7.44 (6.71–8.25), respectively).

Conclusion

Changes in interpregnancy BMI have a modest impact on the risk of high birthweight, PE and IUGR in contrasting directions. However, a prior history of PE and IUGR is the dominant predictor of recurrence at second pregnancy.