Exercise during pregnancy for preventing gestational diabetes mellitus and hypertensive disorders: An umbrella review of randomised controlled trials and an updated meta-analysis

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association between embryo transfer season and the risks of hypertensive disorders of pregnancy and gestational diabetes mellitus

PURPOSE

To explore the impact of seasonal variations on the risks of hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) in women who undergo in vitro fertilization (IVF) treatment.

METHODS

We retrospectively included a total of 21,469 women who achieved singleton delivery during their first cycles of IVF, the risks of HDP and GDM were compared in different seasonal groups according to the time of embryo transfer and the time of oocyte retrieval.

RESULTS

After adjustment via multivariable logistic regression, women who underwent embryo transfer in spring with the expected date of confinement in winter had a higher risk of HDP (4.9% vs. 3.8%; adjusted odds ratio (aOR), 1.34; 95% confidence interval (CI), 1.09-1.64; P = 0.005) than those underwent embryo transfer in winter with the expected date of confinement in autumn. There were no seasonal variations in the risk of HDP according to the time of oocyte retrieval or in the risk of GDM regardless of the time of embryo transfer or the time of oocyte retrieval. After subgroup analysis, the seasonal variations in the risk of HDP remained in frozen embryo transfer (FET) cycles but not in fresh embryo transfer (FreET) cycles.

CONCLUSIONS

The risk of HDP was increased in women who underwent embryo transfer in spring compared to those who underwent embryo transfer in winter. The risk of HDP is more likely to be affected by the season at the time of embryo transfer in FET cycles compared to FreET cycles.

Antenatal Physical Activity Interventions and Pregnancy Outcomes: A Systematic Review and Meta-Analysis With a Focus on Trial Quality

BACKGROUND

Guidelines recommending regular physical activity in pregnancy for improving pregnancy outcomes are informed by published meta-analyses. Inclusion of randomised trials of poor methodological quality may bias effect estimates.

OBJECTIVES

To assess the validity of these recommendations by focusing on trial quality.

SEARCH STRATEGY

Systematic search of PubMed, PubMed Central, Ovid Medline, Embase, Cochrane Central Register of Controlled Trials, and CINAHL from inception to 14 December 2023.

SELECTION CRITERIA

Randomised trials evaluating an antenatal physical activity intervention alone, compared with no such intervention.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed using the Cochrane Risk of Bias tool. Independent of this, studies were grouped based on degree of deviation from the intention to treat principle. Sequential meta-analysis was performed in which greater degrees of potential bias were allowed. Between intervention group comparisons used, relative risks or mean differences with 95% confidence intervals for dichotomous outcomes and continuous outcomes, respectively.

MAIN RESULTS

Overall, the quality of trial reporting was low. Only 5 trials (12.5%) were performed and analysed in keeping with the intention to treat principle. When considering only those trials performed rigorously, there was no evidence that antenatal physical activity improves pregnancy outcomes or limits gestational weight gain (WMD -0.60 kg; 95% CI -2.17, 0.98 WMD -0.60 kg; 95% CI -2.17, 0.98).

CONCLUSIONS

When considering only trials at no/negligible risk of bias, antenatal physical activity interventions were not associated with improved pregnancy outcomes. Most trials were not methodologically rigorous. Incorporation of such meta-analyses into pregnancy care guidelines may result in inaccurate recommendations.

Effects of group communication norms on daily steps in a team-based financial incentive mobile phone intervention in Shanghai, China

BACKGROUND

Mobile technology offers great potential for physical activity promotion, especially by facilitating online communication, however, the impact of group communication norms on intervention effectiveness remains unclear. This study aimed to evaluate the effect on daily steps of a team-based social norms-related intervention using a mobile application.

METHODS

The 13-week quasi-experimental study was conducted in Shanghai, China, from September to November 2019, involving 2,985 employees from 32 worksites. For the intervention group (n = 2,049), participants set a goal of 10,000 steps per day. The teams and individual members would receive points for meeting the daily goal, contributing to team-based rankings and financial rewards for the teams and their members. In addition, the intervention teams created dedicated WeChat groups to facilitate communication, which were also used to collect group chat messages. The communication type in these groups was classified into four types: (1) nudging - encouraging team members to be more active, (2) sharing - exchanging the completion of daily step goals, (3) feedback - providing responses or suggestions to team members, and (4) other -diverse topics that could not be classified otherwise. The control group only tracked their steps online.

RESULTS

The weekly average steps of the intervention group increased by 2,523 steps, while the control group increased by 470 steps. In the first 3 weeks of follow-up, the frequency of nudging of 7-18 times/week had a positive cumulative effect on the step counts. Sharing more than 3 times/week had a positive cumulative effect. Over 6 and 13 weeks of follow-up, nudging 19 times/week or more had a positive cumulative effect while sharing and feedback at any frequency negatively affected average weekly steps.

CONCLUSIONS

Communication types within a team affected team-based step counts in a financial incentive intervention. The team-level social norms related to communications might have different cumulative effects on team-level physical activity. 'nudging' messages had a significant association with the change in individual-level step counts in the medium or long term.

TRIAL REGISTRATION

Pilot Project of the application of walking incentive technology in occupational groups, 2019, ChiCTR1900023813. Registered 13 June 2019,  https://www.chictr.org.cn/showproj.html?proj=39858 .

Research Progress of Risk Factors Associated with Gestational Diabetes Mellitus

Gestational Diabetes Mellitus (GDM) is a common endocrine condition associated with adverse pregnancy outcomes. In recent years, a growing number of risk factors associated with gestational diabetes mellitus have been defined. GDM poses a serious threat to maternal health. The etiology is complex and multifactorial and can be divided into inherent and modifiable factors. The inherent factors have been described in other literature, while the modifiable factors are mainly the risk of lifestyle habits. In this study, we performed a narrative review of the progress of risk factors associated with gestational diabetes mellitus.

Hypertensive disorders of pregnancy in Hunan Province, China, 2012-2022

Objective

To explore the relationship between hypertensive disorders of pregnancy (HDP) and adverse pregnancy outcomes and explore the risk factors for HDP.

Methods

Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Chi-square trend tests (χ2 trend) were used to determine trends in prevalence by year. Unadjusted odds ratios (uORs) were used to examine the association between HDP and adverse pregnancy outcomes. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for HDP.

Results

Our study included 780,359 pregnant women, and 38,397 women with HDP were identified, with a prevalence of 4.92% (95% CI 4.87-4.97). The prevalence of preeclampsia-eclampsia, gestational hypertension, chronic hypertension, and chronic hypertension with superimposed preeclampsia was 2.28% (95% CI 2.25-2.31), 2.04% (95% CI 2.00-2.07), 0.43% (95% CI 0.41-0.44), and 0.18% (95% CI 0.17-0.19), respectively. From 2012 to 2022, the prevalence of HDP increased from 3.11 to 7.39%, showing an upward trend (χ 2 trend = 2220.88, p < 0.01). HDP was associated with the following adverse pregnancy outcomes: maternal deaths (uOR =4.05), maternal near-miss (uOR =6.37), preterm birth (uOR =2.51), stillbirth and neonatal death (uOR =1.45), low birthweight (uOR =4.37), abruptio placentae (uOR =4.45), uterine atony (uOR =1.49), retained placenta (uOR =1.54), puerperal infections (uOR =2.14), abdominal surgical site infections (uOR =2.50), urinary tract infections (uOR =1.60), upper respiratory tract infections (uOR =1.75), heart disease (uOR =2.76), embolism (uOR =2.66), liver disease (uOR =1.25), anemia (uOR =1.38), diabetes mellitus (uOR =2.35), renal disease (uOR =4.66), and pulmonary disease (uOR =4.70, p < 0.05). Results of multivariate logistic regression analysis showed risk factors for HDP: maternal age > 30 years (aOR > 1, p < 0.05), gravidity > = 4 (aOR =1.10, 95% CI 1.05-1.14), primipara (aOR > 1, p < 0.05), and previous cesarean sections (aOR =1.27, 95% CI 1.24-1.31).

Conclusion

The prevalence of HDP was relatively high in Hunan Province. HDP was associated with many adverse pregnancy outcomes. Advanced maternal age, high gravidity, primipara, and previous cesarean section were risk factors for HDP.

Physical Activity Self-Efficacy Among Pregnant Women at High Risk for Gestational Diabetes Mellitus in China: A Cross-Sectional Study

Background

Physical activity could decrease the odds of pregnant women at high risk for gestational diabetes mellitus (GDM) developing GDM. Physical activity self-efficacy was the key predictor of physical activity. This study aimed to examine physical activity self-efficacy and identify its predictors among pregnant women at high risk for GDM in mainland China.

Methods

A cross-sectional study was conducted in Zhengzhou, China, from October 2021 to February 2022. Two hundred fifty-two pregnant women at high risk for GDM completed the Pregnancy Physical Activity Self-efficacy Scale, the Social Support for Physical Activity Scale, the Knowledge of Physical Activity Questionnaire, the 7-item Generalized Anxiety Disorder Scale, the Edinburgh Postnatal Depression Scale, and a socio-demographic data sheet. Multiple linear regression was used.

Results

Chinese pregnant women at high risk for GDM reported a moderate level of physical activity self-efficacy. The best-fit regression analysis revealed four predictors. Social support for physical activity was the strongest predictor, followed by knowledge of physical activity, intention to do physical activity, and anxiety symptoms.

Conclusion

The study found that Chinese pregnant women at high risk for GDM had a moderate level of physical activity self-efficacy, which had 4 predictors. Healthcare professionals should make efforts to enhance pregnant women's social support, knowledge, and intention to do physical activity and decrease their anxiety symptoms to improve their physical activity self-efficacy.

Maternal adiposity and perinatal and offspring outcomes: an umbrella review

Maternal adiposity deleteriously affects obstetrical health and has been associated with long-term adverse consequences in offspring. Here we conducted an umbrella review encompassing 194 observational meta-analyses, 10 Mendelian randomization studies and 748 interventional meta-analyses to appraise the published evidence on the associations between maternal adiposity and perinatal and offspring outcomes. Evidence grading suggested that 17 (8.8%) observational meta-analyses were supported by convincing evidence for 12 outcomes: maternal adiposity was associated with an increased risk of caesarean delivery following labour induction, infant mortality, Apgar score <7 at 1 min, antenatal depression, offspring overweight and obesity, early timing of puberty onset in daughters, attention deficit hyperactivity disorder, cerebral palsy, congenital heart disease and spina bifida (OR/RR ranging from 1.14 to 2.31), as well as increased offspring body fat percent and fat mass (SMD 0.31 and 0.35, respectively). Among these outcomes, interventional meta-analyses supported that maternal weight loss interventions significantly reduced the risk of antenatal depression but not low Apgar scores; these interventions also could not reduce offspring fat mass or body fat percent. Evidence from Mendelian randomization studies supported a causal relationship between maternal adiposity and gestational diabetes mellitus, preeclampsia, birth size and offspring adiposity. Our findings highlight that while observational meta-analyses reveal associations between maternal adiposity and various adverse perinatal and offspring outcomes, convincing, unbiased evidence or support from Mendelian randomization studies is limited. Maternal pre-conceptional and prenatal weight loss interventions can reduce some, but not all, of these adverse effects.

Exercise Intervention to Mitigate the Cardiovascular Sequence of Pregnancy Complications

Pregnancy issues such as gestational hypertension, preeclampsia, and gestational diabetes mellitus (GDM) are significant contributors to long-term cardiovascular diseases (CVDs) in women. Recent research has proved the impact of exercise on improving cardiovascular outcomes, particularly in women with pregnancy-related disorders. This review explores the outcomes of various exercise interventions on cardiovascular health in pregnant women. Among these, aerobic exercise has been widely studied, with results from observational studies and randomized controlled trials (RCTs) showing its positive outcomes on cardiovascular health in pregnant women, especially with complications. It has been found that regular aerobic exercise has been associated with reduced hypertension and improved endothelial function, particularly in women with a history of preeclampsia. Evidently, aerobic exercise results in better blood pressure regulation and enhanced vascular health that directly attends to the risk of cardiovascular diseases associated with pregnancy complications. Another form of exercise is resistance training, which despite being studied less, has shown potential benefits as well. Some advantages of resistance exercise have been found to improve muscle strength and overall enhancement in metabolic control. This is important, especially in women with GDM whereby improvement in insulin sensitivity reduces the overall risk of type 2 diabetes and future CVDs. Combined exercise that incorporates both aerobic and resistance elements has been known to offer the most comprehensive benefits. Various studies suggest that a combinatory approach maximizes the positive cardiovascular effects. Practicing women have experienced better overall heart health, with improved blood pressure regulation, enhanced endothelial function, and reduced metabolic risks. However, despite these findings, there are challenges such as small sample sizes and limited follow-up durations that hinder the generalizability of current research. Importantly, previous studies targeting exercise interventions for women experiencing complications during pregnancy have been limited in evidence by small sample sizes, short follow-ups, and lack of diversity. Such broader, more diverse populations were needed to reflect the various health risks and responses to exercise. Future research must include multi-center RCTs, diverse exercise regimens, and digital health tools for monitoring exercise adherence. This warrants future large-scale, multicenter trials that are necessary to establish more definitive evidence. Additionally, clinicians should consider including tailored exercise programs in care plans for women with pregnancy complications to mitigate long-term cardiovascular risks.

Relationship between life's essential 8 and the risk of gestational diabetes among us adults

OBJECTIVE

The purpose of this study is to explore the relationship between Life's Essential 8 (LE8) and the risk of gestational diabetes among US adults.

METHOD

We used National Health and Nutrition Examination Surveys 2007-2018 data to perform this study. LE8 scores comprised 4 health behaviors (diet, physical activity, nicotine exposure, and sleep duration) and 4 health factors (BMI, non-high-density lipoprotein [HDL] cholesterol, blood glucose, and blood pressure). Then, LE8 were categorized into low CVH (0 to 49 scores), moderated CVH (50 to 79 scores), and high CVH (80 to 100 scores). Weighted multivariate Logistic regression analysis model were used to estimate the relationship between LE8 and gestational diabetes.

RESULT

A total of 3,189 participants were included, and the portion of gestational diabetes was 15.33%, 11.46%, 7.71% in low CVH, moderate CVH, and high CVH, respectively. Adjustment for covariates, we found that high CVH (OR: 0.49, 95%CI: 0.29-0.83, p = 0.01) was associated with decreased of gestational diabetes, not moderate CVH (OR: 0.78, 95%CI: 0.50-1.20, p = 0.25). This inverse associations were dose-response dependent (p-nonlinear = 0.982). This inverse associations were significant in subgroup. Significant interaction between CVH and family diabetes with the risk of gestational diabetes was found (P for interaction = 0.04). High CVH (OR: 0.357, 95%CI: 0.176-0.724, p = 0.005) could significantly decrease the risk of gestational diabetes in the population with family diabetes. The results were generally robust in sensitivity analyses after excluding of ASCVD participants.

CONCLUSION

The high CVH could decrease the risk of gestational diabetes, especially in the population of family diabetes.

Impact of physical activity on preeclampsia and angiogenic markers in the Finnish Genetics of Pre-eclampsia Consortium (FINNPEC) cohort

INTRODUCTION

Effect of physical activity in pregnancy on preeclampsia (PE) and angiogenic markers is not well understood. We studied the association of physical activity and PE in a case-control setting and assessed whether exercise in PE and non-PE women associate with maternal serum concentrations of soluble fms-like tyrosine kinase 1 (s-Flt-1), placental growth factor (PlGF) and soluble endoglin (sEng) and sFlt-1/PlGF ratio in the Finnish Genetics of Pre-eclampsia Consortium (FINNPEC) cohort.

MATERIALS AND METHODS

Participants completed a questionnaire on their background information and serum samples were collected from a subset. Questionnaire data on physical activity were available from 708 PE women and 724 non-PE women. Both first trimester serum samples and questionnaire data on physical activity were available from 160 PE women and 160 non-PE women, and second/third trimester serum samples and questionnaire data on physical activity were available from 139 PE women and 47 non-PE women. The PE and non-PE women were divided into categories of physically active (exercise 2 - 3 times/week or more) and physically inactive (exercise less than 2 - 3 times/week).

RESULTS

A total of 43.4% of the PE women and 42.4% of the non-PE women were categorized as physically active. There were no differences in physical activity and exercise habits between the groups. The physically active women were more often nulliparous and non-smokers and had a lower body mass index. There were no differences in the concentrations of angiogenic markers (sFlt-1, PlGF and sEng and sFlt-1/PlGF ratio) between the groups who exercised more or less than 2 - 3 times/week.

CONCLUSIONS

In the FINNPEC study cohort, there was no association between physical activity and PE and no associations of physical activity in pregnant women with and without PE with maternal serum concentrations of sFlt-1, PlGF and sEng and sFlt-1/PlGF ratio.

Opinions and Knowledge of Midwives Regarding Physical Exercise During Pregnancy: Insights and Implications for Midwifery Practice

Background Physical exercise during pregnancy offers significant benefits for maternal and fetal health, improving cardiovascular fitness, managing weight, and reducing risks of gestational diabetes and hypertension. Despite these benefits, the role of midwives in promoting exercise is critical but often underexplored. Materials and methods This cross-sectional quantitative study surveyed 172 midwives using a structured questionnaire to assess their knowledge and attitudes towards physical exercise during pregnancy. Descriptive and inferential statistics, including chi-square tests, were used to analyze the data. Data collected through the questionnaires were analyzed using IBM SPSS Statistics v. 29 (IBM Corp., Armonk, NY). Results Among the 172 participants, 97.7% were female with a median age of 36 years. While 65.1% engaged in physical exercise themselves, only 26.7% recommended exercise during pregnancy to their patients. The knowledge level of midwives about the benefits of exercise was high, with 95.3% recognizing its role in maintaining hormonal balance and 88.4% understanding its benefits in reducing gestational diabetes. However, 32.6% of midwives reported not feeling confident in guiding pregnant women on how to exercise. Statistically significant correlations were found between midwives' opinion level and their knowledge of exercise benefits, including proper weight gain (rho = 0.263, p = 0.01) and reduced likelihood of gestational diabetes (rho = 0.492, p = 0.01). Conclusions Midwives recognize the importance of exercise during pregnancy but require more training to provide effective guidance. Enhancing midwives' education on exercise can improve maternal and fetal health outcomes by promoting physical activity during pregnancy.

Impact of an exercise program combined with dietary advice on avoiding insulin prescription in women with gestational diabetes: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of an exercise intervention, in addition to standard care, in preventing or delaying insulin prescription in women with gestational diabetes mellitus (GDM).

DESIGN

Randomised controlled trial.

SETTING

University hospital.

POPULATION

Pregnant women at 25-35 weeks of gestation diagnosed with GDM.

METHODS

Women in the intervention group participated in weekly, supervised, 30-45 min exercise sessions and were encouraged to accumulate more than 5000 steps per day, tracked by a pedometer, in addition to receiving usual care. The control group received standard care only.

MAIN OUTCOME MEASURE

Insulin prescription.

RESULTS

From February 2008 through April 2013, 109 women were randomized into the intervention group (n = 57) or the usual care group (n = 52). Two women in the intervention group were excluded from the analysis (one was randomised in error and one was lost to follow-up). Six women never attended the exercise sessions, and two attended fewer than two sessions. However, two-third of women were considered as compliant to the intervention (attended more than 50% of sessions and/or averaged more than 5000 steps/day). The incidence of insulin prescription did not differ between the groups: 31 women (56%) in the intervention group versus 24 women (46%) in the control group (RR 1.22, 95% CI 0.84 to 1.78). The median time from randomization to insulin prescription was also similar between groups (14 days in the intervention group and 13 days in the control group).

CONCLUSION

This study did not demonstrate that an exercise program reduces or delays insulin prescription in women with GDM. Low adherence to the intervention, a small sample size, and the short duration of the program may explain the lack of observed benefit.

REGISTERED

At clinicaltrials.gov, NCT03174340, 02/06/2017.

Can short- and long-term maternal and infant risks linked to hypertension and diabetes during pregnancy be reduced by therapy?

Hypertensive disorders of pregnancy (HDP), especially preeclampsia, and diabetes during pregnancy pose significant risks for both maternal and infant health, extending to long-term outcomes such as early-onset cardiovascular disease and metabolic disorders. Current strategies for managing HDP focus on screening, prevention, surveillance, and timely intervention. No disease-modifying therapies exist so far for established preeclampsia; delivery remains the definitive resolution. Preventive measures-including early pregnancy screening, exercise, and low-dose aspirin-show promise. Antihypertensive treatments reduce severe hypertension risks, whereas magnesium sulfate remains the standard for preventing eclampsia. Planned delivery from gestational week 37 can balance maternal benefits and neonatal risks in women with established preeclampsia. Delivery between 34 and 37 weeks gestation in women with preeclampsia has to balance risks for mother and infant. Lifestyle interventions-particularly diet and physical activity-are pivotal in managing gestational diabetes mellitus and type 2 diabetes. The oral antidiabetic metformin has shown benefits in glycaemic control and reducing maternal weight gain, although its long-term effects on offspring remain uncertain. The safety of other peroral antidiabetics in pregnancy is less studied. Advancements in glucose monitoring and insulin administration present encouraging prospects for enhancing outcomes in women with diabetes types 1 and 2. Both HDP and diabetes during pregnancy necessitate vigilant management through a combination of lifestyle modifications, pharmacological interventions, and timely obstetric care. Although certain treatments such as low-dose aspirin and metformin show efficacy in risk reduction, further research is ongoing to ensure safety for both mothers and their offspring to reduce short- and long-term adverse effects.

Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'

Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.

Hemodynamic, ventilatory and gas exchange responses to exercise using a cycle ergometer and the incremental shuttle walk test in pregnant women

BACKGROUND

Cardiovascular disease, including hypertension, in pregnant women is a leading cause of morbidity and mortality globally. The development of reference intervals for cardiovascular responses using exercising testing to measure oxygen utilisation (V̇O2) with cardiopulmonary exercise testing (CPET), and distances walked using the incremental shuttle walk test (ISWT), may be promising methods to assess and stratify pregnant women regarding their risk of adverse pregnancy outcomes, to encourage exercise during pregnancy, and to improve exercise prescriptions during pregnancy. We aimed to determine the reference intervals for V̇O2 at rest, anaerobic threshold (AT), and submaximal exercise using CPET, and the reference interval for the ISWT, to develop a correlation equitation that predicts submaximal V̇O2 from the distance walked in the ISWT, and to explore the relationship between hemoglobin (Hb) and ferritin concentration and V̇O2 at AT in women in second trimester.

METHODS

After prospective IRB approval (HREC 15/23) and clinical trials registration (ANZCTR ACTRN12615000964516), and informed written consent, we conducted CPET and the ISWT according to international guidelines in a university associated tertiary referral obstetric and adult medicine hospital, in healthy pregnant women in second trimester (14 to 27 gestational weeks). Hemoglobin and ferritin concentrations were recorded from pathology results in the participants' medical records at the time of exercise testing. Adverse events were recorded.

RESULTS

About 90 participants undertook CPET, 28 of which also completed the ISWT. The mean ± SD age and body mass index (BMI) were 32 ± 3.2 years, and 25 ± 2.7 kg/m2. Median (IQR) gestation was 23 (22-24) weeks. One in 4 women were 24 weeks or greater gestation. The reference intervals for V̇O2 at rest, AT, and submaximal exercise were 2.9 to 5.3, 8.1 to 20.7, and 14.1 to 30.5 mL/kg/min respectively. The reference interval for the ISWT was 218 to 1058 meters. The correlation equation to predict submaximal V̇O2 from the distance walked in the ISWT was submaximal V̇O2 (mL/kg/min) = 0.012*distance walked in ISWT (m) + 14.7 (95%CI slope 0.005-0.070, Pearson r = 0.5426 95%CI 0.2126-0.7615, P = .0029). Hemoglobin concentration was positively correlated with V̇O2 at AT (AT V̇O2 (mL/kg/min) = 0.08*Hb (g/L) + 4.9 (95%CI slope 0.0791-0.143, Pearson r = 0.2538 95%CI 0.049-0.438, P = .016). There was no linear association between ferritin and submaximal V̇O2 (Pearson r = 0.431 P = .697). There were no maternal or fetal complications.

CONCLUSIONS

CPET and ISWT are safe and feasible in women in second trimester including those at or beyond 24 weeks gestation. We have established the reference interval for V̇O2 at rest, AT, and submaximal exercise by CPET, the reference interval for the distance walked for the ISWT, and a correlation equation to predict submaximal V̇O2 for use in clinical practice and research. Hemoglobin rather than ferritin is likely correlated with exercise capacity in pregnancy suggesting vigilance to correct lower hemoglobin levels may positively impact maternal health.

CLINICAL TRIALS REGISTRY

The study was prospectively registered with the Australian and New Zealand Clinical Date of registration - 15/9/2015; Date of initial participant enrolment - 4/11/2015; Clinical trial identification number; ACTRN12615000964516; URL of the registration site - https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369216.

Impact of COVID-19 on gestational diabetes pregnancy outcomes in the UK: A multicentre retrospective cohort study

OBJECTIVE

To determine the impact of implementing emergency care pathway(s) for screening, diagnosing and managing women with gestational diabetes (GDM) during COVID-19.

DESIGN

Retrospective multicentre cohort.

SETTING

Nine National Health Service (NHS) Hospital Trusts/Health boards in England and Scotland.

POPULATION

4915 women with GDM pre-pandemic (1 April 2018 to 31 March 2020), and 3467 women with GDM during the pandemic (1 May 2020 to 31 March 2021).

METHODS

We examined clinical outcomes for women with GDM prior to and during the pandemic following changes in screening methods, diagnostic testing, glucose thresholds and introduction of virtual care for monitoring of antenatal glycaemia.

MAIN OUTCOME MEASURES

Intervention at birth, perinatal mortality, large-for-gestational-age infants and neonatal unit admission.

RESULTS

The new diagnostic criteria more often identified GDM women who were multiparous, had higher body mass index (BMI) and greater deprivation, and less frequently had previous GDM (all p < 0.05). During COVID, these women had no differences in the key outcome measures. Of the women, 3% were identified with pre-existing diabetes at antenatal booking. Where OGTT continued during COVID, but virtual care was introduced, outcomes were also similar pre- and during the pandemic.

CONCLUSIONS

Using HbA1c and fasting glucose identified a higher risk GDM population during the pandemic but this had minimal impact on pregnancy outcomes. The high prevalence of undiagnosed pre-existing diabetes suggests that women with GDM risk factors should be offered HbA1c screening in early pregnancy.

Effective interventions in preventing gestational diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Lifestyle choices, metformin, and dietary supplements may prevent GDM, but the effect of intervention characteristics has not been identified. This review evaluated intervention characteristics to inform the implementation of GDM prevention interventions.

METHODS

Ovid, MEDLINE/PubMed, and EMBASE databases were searched. The Template for Intervention Description and Replication (TIDieR) framework was used to examine intervention characteristics (who, what, when, where, and how). Subgroup analysis was performed by intervention characteristics.

RESULTS

116 studies involving 40,940 participants are included. Group-based physical activity interventions (RR 0.66; 95% CI 0.46, 0.95) reduce the incidence of GDM compared with individual or mixed (individual and group) delivery format (subgroup p-value = 0.04). Physical activity interventions delivered at healthcare facilities reduce the risk of GDM (RR 0.59; 95% CI 0.49, 0.72) compared with home-based interventions (subgroup p-value = 0.03). No other intervention characteristics impact the effectiveness of all other interventions.

CONCLUSIONS

Dietary, physical activity, diet plus physical activity, metformin, and myoinositol interventions reduce the incidence of GDM compared with control interventions. Group and healthcare facility-based physical activity interventions show better effectiveness in preventing GDM than individual and community-based interventions. Other intervention characteristics (e.g. utilization of e-health) don't impact the effectiveness of lifestyle interventions, and thus, interventions may require consideration of the local context.

Determinants of Physical Activity Among Black Women During Pregnancy

OBJECTIVE

To describe associations among background determinants of physical activity, modifiable theoretical determinants of physical activity, and measures of physical activity during the second and third trimesters of pregnancy among Black women.

DESIGN

Longitudinal cohort.

SETTING

Medical center obstetric clinic.

PARTICIPANTS

Pregnant Black women (n = 40 in second trimester, n = 38 in third trimester) METHODS: We measured background determinants (demographic and pregnancy characteristics, discrimination, and neighborhood walkability) during the second trimester. We measured modifiable theoretical determinants (self-efficacy and social support) and physical activity using self-report and device measures during the second and third trimesters. We used paired t tests to determine differences in the modifiable theoretical determinants from the second trimester to third trimester and used Pearson correlations among background and modifiable determinants and physical activity measures during the second trimester.

RESULTS

Participants' physical activity levels were low during the second and third trimesters (32% and 22% met recommendation, respectively). We found no changes in self-efficacy or social support between trimesters and found no associations between these modifiable determinants and actual physical activity. We found a positive correlation between previous pregnancies and physical activity measured by devices, r(36) = .33, p = .048. Pregnancy-specific stress, r(38) = -.40, p = .013, was negatively correlated, and age, r(38) = .38, p = .017, was positively correlated with self-reported physical activity.

CONCLUSIONS

Low levels of physical activity during pregnancy coupled with the absence of an association with modifiable factors affecting pregnancy physical activity indicate a need to further examine the social, cultural, and environmental determinants of physical activity.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Rural-urban disparities in pregestational and gestational diabetes in pregnancy: Serial, cross-sectional analysis of over 12 million pregnancies

OBJECTIVE

To compare trends in pregestational (DM) and gestational diabetes (GDM) in pregnancy in rural and urban areas in the USA, because pregnant women living in rural areas face unique challenges that contribute to rural-urban disparities in adverse pregnancy outcomes.

DESIGN

Serial, cross-sectional analysis.

SETTING

US National Center for Health Statistics (NCHS) Natality Files from 2011 to 2019.

POPULATION

A total of 12 401 888 singleton live births to nulliparous women aged 15-44 years.

METHODS

We calculated the frequency (95% confidence interval [CI]) per 1000 live births, the mean annual percentage change (APC), and unadjusted and age-adjusted rate ratios (aRR) of DM and GDM in rural compared with urban maternal residence (reference) per the NCHS Urban-Rural Classification Scheme overall, and by delivery year, reported race and ethnicity, and US region (effect measure modification).

MAIN OUTCOME MEASURES

The outcomes (modelled separately) were diagnoses of DM and GDM.

RESULTS

From 2011 to 2019, there were increases in both the frequency (per 1000 live births; mean APC, 95% CI per year) of DM and GDM in rural areas (DM: 7.6 to 10.4 per 1000 live births; APC 2.8%, 95% CI 2.2%-3.4%; and GDM: 41.4 to 58.7 per 1000 live births; APC 3.1%, 95% CI 2.6%-3.6%) and urban areas (DM: 6.1 to 8.4 per 1000 live births; APC 3.3%, 95% CI 2.2%-4.4%; and GDM: 40.8 to 61.2 per 1000 live births; APC 3.9%, 95% CI 3.3%-4.6%). Individuals living in rural areas were at higher risk of DM (aRR 1.48, 95% CI 1.45%-1.51%) and GDM versus those in urban areas (aRR 1.17, 95% CI 1.16%-1.18%). The increased risk was similar each year for DM (interaction p = 0.8), but widened over time for GDM (interaction p < 0.01). The rural-urban disparity for DM was wider for individuals who identified as Hispanic race/ethnicity and in the South and West (interaction p < 0.01 for all); and for GDM the rural-urban disparity was generally wider for similar factors (i.e. Hispanic race/ethnicity, and in the South; interaction p < 0.05 for all).

CONCLUSIONS

The frequency of DM and GDM increased in both rural and urban areas of the USA from 2011 to 2019 among nulliparous pregnant women. Significant rural-urban disparities existed for DM and GDM, and increased over time for GDM. These rural-urban disparities were generally worse among those of Hispanic race/ethnicity and in women who lived in the South. These findings have implications for delivering equitable diabetes care in pregnancy in rural US communities.

Influence of Physical Activity during Pregnancy on Maternal Hypertensive Disorders: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Gestational hypertension is a notable concern with ramifications for maternal and fetal health. Preemptive measures, including physical activity (PA), are crucial. There is a pressing need for comprehensive investigations into the impact of various forms of PA on hypertensive disorders. A systematic review and meta-analysis (CRD42022372468) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Our review exclusively considered randomized clinical trials (RCTs) between 2010 and 2023, using the following databases: EBSCO, including Academic Search Premier, Education Resources Information Center, PubMed/MEDLINE, SPORTDiscus, and OpenDissertations; Clinicaltrials.gov; Web of Science; Scopus; the Cochrane Database of Systematic Reviews; and the Physiotherapy Evidence Database (PEDro). The primary outcome was hypertensive disorders occurring during pregnancy (14 studies). Diagnosed preeclampsia (15 studies) and blood pressure levels were also examined (17 studies). PA during pregnancy was significantly associated with a reduced risk of hypertensive disorders (RR = 0.44, 95% CI = 0.30, 0.66). The data also indicate a positive correlation between PA during pregnancy and both systolic (MD = -2.64, 95% CI = -4.79, -0.49) and diastolic (MD = -1.99, 95% CI = -3.68, -0.29) blood pressure levels. The relationship between PA and the incidence of diagnosed preeclampsia did not demonstrate a statistically significant association (RR = 0.81, 95% CI = 0.59, 1.11; p = 0.20). Random effects were used for all analyses. PA during pregnancy promises to improve maternal health by reducing the risk of gestational hypertension and positively affecting systolic and diastolic blood pressure.

Cellular and molecular overview of gestational diabetes mellitus: Is it predictable and preventable?

BACKGROUND

In contrast to overt diabetes mellitus (DM), gestational DM (GDM) is defined as impaired glucose tolerance induced by pregnancy, which may arise from exaggerated physiologic changes in glucose metabolism. GDM prevalence is reported to be as high as 20% among pregnancies depending on the screening method, gestational age, and the population studied. Maternal and fetal effects of uncontrolled GDM include stillbirth, macrosomia, neonatal diabetes, birth trauma, and subsequent postpartum hemorrhage. Therefore, it is essential to find the potential target population and associated predictive and preventive measures for future intensive peripartum care.

AIM

To review studies that explored the cellular and molecular mechanisms of GDM as well as predictive measures and prevention strategies.

METHODS

The search was performed in the Medline and PubMed databases using the terms “gestational diabetes mellitus,” “overt diabetes mellitus,” and “insulin resistance.” In the literature, only full-text articles were considered for inclusion (237 articles). Furthermore, articles published before 1997 and duplicate articles were excluded. After a final review by two experts, all studies (1997-2023) included in the review met the search terms and search strategy (identification from the database, screening of the studies, selection of potential articles, and final inclusion).

RESULTS

Finally, a total of 79 articles were collected for review. Reported risk factors for GDM included maternal obesity or overweight, pre-existing DM, and polycystic ovary syndrome. The pathophysiology of GDM involves genetic variants responsible for insulin secretion and glycemic control, pancreatic β cell depletion or dysfunction, aggravated insulin resistance due to failure in the plasma membrane translocation of glucose transporter 4, and the effects of chronic, low-grade inflammation. Currently, many antepartum measurements including adipokines (leptin), body mass ratio (waist circumference and waist-to-hip ratio], and biomarkers (microRNA in extracellular vesicles) have been studied and confirmed to be useful markers for predicting GDM. For preventing GDM, physical activity and dietary approaches are effective interventions to control body weight, improve glycemic control, and reduce insulin resistance.

CONCLUSION

This review explored the possible factors that influence GDM and the underlying molecular and cellular mechanisms of GDM and provided predictive measures and prevention strategies based on results of clinical studies.

Development and feasibility of a theory-guided and evidence-based physical activity intervention in pregnant women with high risk for gestational diabetes mellitus: a pilot clinical trial

BACKGROUND

Physical activity has been utilized as an effective strategy to prevent gestational diabetes mellitus (GDM). However, most pregnant women with high risk for GDM did not achieve the recommended physical activity level. Furthermore, relevant physical activity protocols have varied without theory-guided and evidence-based tailored to pregnant women with high risk for GDM. This study aimed to develop and pilot test a theory-guided and evidence-based physical activity intervention protocol for pregnant women with high risk for GDM.

METHODS

The study design was guided by the Medical Research Council Framework for Developing and Evaluating Complex Intervention (the MRC framework). The preliminary protocol for physical activity intervention was developed based on self-efficacy theory, research evidence identified from systematic reviews and clinic trials, stakeholder engagement, context, and economic considerations. The preliminary intervention protocol was validated through a content validity study by an expert panel of 10 experts. A single-blinded randomized controlled trial (RCT) was designed to test the feasibility and acceptability of the intervention.

RESULTS

The validity of the preliminary intervention protocol was excellent as consensus was achieved. The final 13 sessions of self-efficacy enhancing physical activity intervention protocol were developed, including knowledge education, exercise clinic visits and video, and group discussions with face-to-face and online blended sessions. In the feasibility study, 34 pregnant women with high risk for GDM were randomized for the intervention (n = 17) or the control group (n = 17). The recruitment and retention rates were 82.9% and 58.9%, respectively. Women in the intervention group had a lower incidence of GDM (26.7% vs. 36.5%) than the control group (P >0.05). All participants were satisfied with the intervention and agreed that the intervention was helpful.

CONCLUSIONS

The developed self-efficacy-enhancing physical activity intervention is a feasible and acceptable intervention for enhancing physical activity among pregnant women with high risk for GDM and is ready to be tested in a more extensive RCT study.

TRIAL REGISTRATION

The study was registered on 4 February 2022 (ChiCTR2200056355) by the Chinese Clini Trial Registry (CHiCTR).

Hypertension in Pregnancy: A Diagnostic and Therapeutic Overview

Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality. It is important to distinguish between pre-existing (chronic) hypertension and gestational hypertension, developing after 20 weeks of gestation and usually resolving within 6 weeks postpartum. There is a consensus that systolic blood pressure ≥ 170 or diastolic blood pressure ≥ 110 mmHg is an emergency and hospitalization is indicated. The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. The current European guidelines recommend initiating drug treatment in pregnant women with persistent elevation of blood pressure ≥ 150/95 mmHg and at values > 140/90 mmHg in women with gestational hypertension (with or without proteinuria), with pre-existing hypertension with the superimposition of gestational hypertension, and with hypertension with subclinical organ damage or symptoms at any time during pregnancy. Methyldopa, labetalol, and calcium antagonists (the most data are available for nifedipine) are the drugs of choice. The results of the CHIPS and CHAP studies are likely to reduce the threshold for initiating treatment. Women with a history of hypertensive disorders in pregnancy, particularly those with pre-eclampsia, are at high risk of developing cardiovascular disease later in life. Obstetric history should become a part of the cardiovascular risk assessment in women.

Effects of prenatal exercise on gestational weight gain, obstetric and neonatal outcomes: FitMum randomized controlled trial

BACKGROUND

To investigate the effects of two different exercise interventions during pregnancy on gestational weight gain (GWG) and obstetric and neonatal outcomes compared to standard care. Additionally, we aimed to improve standardization of GWG measurements by developing a model to estimate GWG for a standardized pregnancy period of 40 weeks and 0 days accounting for individual differences in gestational age (GA) at delivery.

METHODS

In a randomized controlled trial we compared the effects of structured supervised exercise training (EXE) three times per week throughout pregnancy versus motivational counselling on physical activity (MOT) seven times during pregnancy with standard care (CON) on GWG and obstetric and neonatal outcomes. Uniquely, to estimate GWG for a standardized pregnancy period, we developed a novel model to predict GWG based on longitudinally observed body weights during pregnancy and at admission for delivery. Observed weights were fitted to a mixed effects model that was used to predict maternal body weight and estimate GWG at different gestational ages. Obstetric and neonatal outcomes, among them gestational diabetes mellitus (GDM) and birth weight, were obtained after delivery. GWG and the investigated obstetric and neonatal outcomes are secondary outcomes of the randomized controlled trial, which might be underpowered to detect intervention effects on these outcomes.

RESULTS

From 2018-2020, 219 healthy, inactive pregnant women with median pre-pregnancy BMI of 24.1 (21.8-28.7) kg/m² were included at median GA 12.9 (9.4-13.9) weeks and randomized to EXE (n = 87), MOT (n = 87) or CON (n = 45). In total 178 (81%) completed the study. GWG at GA 40 weeks and 0 days did not differ between groups (CON: 14.9 kg [95% CI, 13.6;16.1]; EXE: 15.7 kg [14.7;16.7]; MOT: 15.0 kg [13.6;16.4], p = 0.538), neither did obstetric nor neonatal outcomes. For example, there were no differences between groups in the proportions of participants developing GDM (CON: 6%, EXE: 7%, MOT: 7%, p = 1.000) or in birth weight (CON: 3630 (3024-3899), EXE: 3768 (3410-4069), MOT: 3665 (3266-3880), p = 0.083).

CONCLUSIONS

Neither structured supervised exercise training nor motivational counselling on physical activity during pregnancy affected GWG or obstetric and neonatal outcomes compared to standard care.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03679130; 20/09/2018.

Pre-Pregnancy Adherence to Mediterranean Diet and Risk of Gestational Diabetes Mellitus: A Prospective Cohort Study in Greece

Gestational Diabetes Mellitus (GDM) is a growing epidemic affecting pregnant women and their offspring. This study aimed to identify the relationship between adherence to a Mediterranean diet (MD) before conception and the risk of GDM in a contemporary Greek pregnant cohort. A prospective cohort of pregnant women was recruited at the routine first trimester visit. Nutritional intake was evaluated using a population specific validated food frequency questionnaire (FFQ). Pre-pregnancy adherence to MD was derived using two different scoring systems, the Mediterranean diet index score (MDS), and a modified version. Adjusted odds ratios (aOR) were computed using multiple logistic regression models for each score derived. Of 743 participating women, 112 (15.1%) developed GDM. The MDS index showed that scoring 5-9 points (high adherence) was associated with a lower GDM incidence (aOR: 0.57 95% CI (0.32, 0.90), p = 0.02), while the modified MDS index showed no significant association for any level of adherence. Pre-pregnancy consumption of "meat and derivatives" and "fatty meat and processed meat" was associated with a higher risk of GDM, with both scoring systems (p = 0.008, p = 0.004, respectively). A higher adherence to a MD pre-pregnancy, especially with less meat consumption, may have a protective effect on the occurrence of GDM.