Association between maternal body mass index and congenital heart defects in infants: A meta-analysis

Paternal peri-conceptional physical activity and the risk of congenital heart disease in offspring: A case-control study

BACKGROUND

Genetic and environmental factors have been shown to contribute to the development of congenital heart disease (CHD). To date, the focus of scientific articles has primarily centered on genetics and maternal environmental factors, with comparatively less attention given to paternal risk factors.

OBJECTIVES

This study aims to investigate the potential association between paternal pre-conceptional physical activity levels (PA), along with paternal peri-conceptional smoking and alcohol consumption, and the risk of CHD in offspring.

MATERIALS AND METHODS

An observational case-control study was conducted in Lebanon, with 279 participants, aiming to investigate potential risk factors for CHD. We included children with confirmed CHD, born between 2012 and 2022. Controls born in the same timeframe were selected randomly from the general population using online questionnaire forms. Mean age of children included was 6 years old (0-10). The pre-conceptional PA was assessed using the Global Physical Activity Questionnaire validated in Arabic. In addition, paternal smoking, alcohol consumption, and maternal risk factors were collected.

RESULTS

The study included 128 CHD cases (45.9%) and their parents, as well as 151 healthy infants (54.1%) and their parents. There were no statistically significant variations in the alcohol consumption noted between the fathers in the case and control groups (p = 0.18). The paternal involvement in recreational-related PA during the peri-conception period was associated with a reduced risk of the CHD development in offspring by 46.9% (OR = 0.531, 95% CI: 0.301-0.936, p = 0.029). Additionally, increasing paternal total sitting time by 1 h above the average, which was approximately 260 min (4 h), increased the risk of CHD in offspring by 0.4% (p = 0.001). Moreover, paternal smoking exhibited an apparent association with a 56% increased risk of offspring developing CHD, notwithstanding that the confidence intervals included the null (OR = 1.56, 95% CI: 0.86-2.8, p = 0.136).

DISCUSSION AND CONCLUSION

This observational study is the first to report a potential association between paternal PA, and CHD in offspring. This study aligns with previous reports, advocating for the paternal engagement in PA and the adoption of healthy lifestyle habits, especially during the critical stages of conception. Such practices are strongly recommended to enhance fertility and promote optimal health for offspring. However, due to the subjectivity in reporting PA and lack of molecular proof, additional prospective and molecular studies are required to validate these findings.

Systematic Review and Meta-analysis of Prenatal Risk Factors for Congenital Heart Disease: Part 1, Maternal Chronic Diseases and Parental Exposures

BACKGROUND

There is considerable heterogeneity in studies on prenatal risk factors for congenital heart diseases (CHDs). We performed a meta-analysis of all nongenetic factors of CHDs. This report presents results of factors related to maternal chronic diseases and parental exposures.

METHODS

A systematic search encompassing concepts of CHD and risk factors was used, using the following inclusion criteria: (1) original peer-reviewed articles, (2) quantifying the effects of risk factors for CHDs, (3) between 1989 and 2022. Pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated using a random-effect model.

RESULTS

Inclusion criteria were met for 170 studies. There was an association between being overweight or obese and CHDs (OR, 1.26; 95% CI, 1.15-1.37), with a dose-effect relationship. Pregestational diabetes (PGDM) was associated with CHDs (OR, 3.51; 95% CI, 2.86-4.3), without difference between type 1 and type 2 PGDM. The effect size of gestational diabetes was less than that of PGDM (OR, 1.38; 95% CI, 1.18-1.61). There was an association between CHDs and pre-eclampsia (OR, 2.01; 95% CI, 1.32-3.05), paternal smoking (OR, 1.32; 95% CI, 1.03-1.70), and alcohol use (OR, 1.50; 95% CI, 1.08-2.08). A smaller association was found with maternal smoking and advanced maternal age.

CONCLUSIONS

There exists robust evidence for increased risk of CHD in the presence of obesity, maternal diabetes, maternal smoking, and increased maternal age. The effect sizes were relatively modest, except for PGDM. The robustness of the evidence decreased when CHDs were divided into subgroups or when the analyses were restricted to severe CHDs.

Maternal modifiable factors and risk of congenital heart defects: systematic review and causality assessment

OBJECTIVE

Primary prevention strategies are critical to reduce the global burden of congenital heart defects (CHDs); this requires robust knowledge of causal agents. We aimed to review associations between CHDs and maternal advanced age, obesity, diabetes, hypertension, smoking and alcohol consumption and assess the causal nature of the associations.

DESIGN

Systematic review of reviews with application of a Bradford Hill criteria score-based causal assessment system.

DATA SOURCES

We searched PubMed, Embase and Episteminokos (January 1990-April 2023).

ELIGIBILITY CRITERIA

Systematic reviews of original epidemiological studies reporting association (relative risk) between one or more of the above maternal factors and CHDs overall (any type) in subsequent offspring.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers selected eligible reviews, assessed the risk of bias and assigned the strength of evidence for causality.

RESULTS

There was strong evidence of a causal relationship between CHDs and maternal obesity (prepregnancy and early pregnancy) and pre-existing diabetes (six of seven Bradford Hill criteria met). For pre-existing hypertension (strength and biological gradient not met), and advanced age (strength, consistency and biological gradient not met), causal evidence was moderate. Evidence for the causal contribution of gestational diabetes, gestational hypertension, smoking and alcohol consumption was weak (strength, consistency, temporality and biological gradient not met).

CONCLUSIONS

CHDs can be reduced with stronger action to reduce maternal obesity and pre-existing diabetes prevalence. Investigating environmental exposures that have received limited attention, such as air pollutants and chemical exposures, is important to further inform prevention.

Maternal obesity, interpregnancy weight changes and congenital heart defects in the offspring: a nationwide cohort study

OBJECTIVE

To evaluate the association between maternal BMI and congenital heart defects (CHDs) in the offspring when including live births, stillbirths, aborted and terminated pregnancies and to investigate if maternal interpregnancy weight changes between the first and second pregnancy influences the risk of foetal CHDs.

METHODS

A nationwide cohort study of all singleton pregnancies in Denmark from 2008 to 2018. Data were retrieved from the Danish Foetal Medicine Database, which included both pre- and postnatal diagnoses of CHDs. Children or foetuses with chromosomal aberrations were excluded. Odds ratios were calculated with logistic regression models for CHDs overall, severe CHDs and five of the most prevalent subtypes of CHDs.

RESULTS

Of the 547 105 pregnancies included in the cohort, 5 442 had CHDs (1.0%). Risk of CHDs became gradually higher with higher maternal BMI; for BMI 25-29.9 kg/m2, adjusted odds ratio (aOR) 1.17 (95% CI 1.10-1.26), for BMI 30-34.9 kg/m2, aOR 1.21 (95% CI 1.09-1.33), for BMI 35-39.9 kg/m2, aOR 1.29 (95% CI 1.11-1.50) and for BMI ≥ 40 kg/m2, aOR 1.85 (95% CI 1.54-2.21). Data was adjusted for maternal age, smoking status and year of estimated due date. The same pattern was seen for the subgroup of severe CHDs. Among the atrioventricular septal defects (n = 231), an association with maternal BMI ≥ 30 kg/m2 was seen, OR 1.67 (95% CI 1.13-2.44). 109 654 women were identified with their first and second pregnancies in the cohort. Interpregnancy BMI change was associated with the risk of CHDs in the second pregnancy (BMI 2 to < 4 kg/m2: aOR 1.29, 95% CI 1.09-1.53; BMI ≥ 4 kg/m2: aOR 1.36, 95% CI 1.08-1.68).

CONCLUSION

The risk of foetal CHDs became gradually higher with higher maternal BMI and interpregnancy weight increases above 2 BMI units were also associated with a higher risk of CHDs.

Suboptimal Imaging on Obstetric Ultrasound Should Prompt Early Referral for Fetal Echocardiography

Recent studies suggest that suboptimal cardiac imaging on routine obstetric anatomy ultrasound (OB-scan) is not associated with a higher risk for congenital heart disease (CHD) and, therefore, should not be an indication for fetal echocardiography (F-echo). We aim to determine the incidence of CHD in patients referred for suboptimal imaging in a large catchment area, including regions that are geographically distant from a tertiary care center. We conducted a retrospective chart review of patients referred to Seattle Children's Hospital (SCH) and SCH Regional Cardiology sites (SCH-RC) from 2011 to 2021 for F-echo with the indication of suboptimal cardiac imaging by OB-scan. Of 454 patients referred for suboptimal imaging, 21 (5%) of patients were diagnosed with CHD confirmed on postnatal echo. 10 patients (2%) required intervention by age one. Mean GA at F-echo was significantly later for suboptimal imaging compared to all other referral indications (27.5 ± 3.9 vs 25.2 ± 5.2 weeks, p < 0.01). Mean GA at F-echo was also significantly later at SCH-RC compared to SCH (29.2 ± 4.6 vs 24.2 ± 2.9 weeks; p < 0.01). In our experience, CHD in patients referred for suboptimal imaging is higher (5%) than previously described, suggesting that routine referral for is warranted. Furthermore, while suboptimal imaging was associated with a delayed F-echo compared to other indications, this delay was most striking for those seen at regional sites. This demonstrates a potential disparity for these patients and highlights opportunities for targeted education in cardiac assessment for primary providers in these regions.

Association of maternal weight gain in early pregnancy with congenital heart disease in offspring: a China birth cohort study

OBJECTIVES

Little study has reported the association of maternal weight gain in early pregnancy with fetal congenital heart disease (CHD). We aimed to explore the potential relationship based on a China birth cohort while adjusting by multiple factors.

DESIGN

Cohort study.

SETTING

China birth cohort study conducted from 2017 to 2021.

PARTICIPANTS

The study finally included 114 672 singleton pregnancies in the 6-14 weeks of gestation, without missing data or outliers, loss to follow-up or abnormal conditions other than CHD. The proportion of CHD was 0.65% (749 cases).

PRIMARY AND SECONDARY OUTCOME MEASURES

Association between maternal pre-pregnancy weight gain and CHD in the offspring were analysed by multivariate logistic regression, with the unadjusted, minimally adjusted and maximally adjusted methods, respectively.

RESULTS

The first-trimester weight gain showed similar discrimination of fetal CHD to that period of maternal body mass index (BMI) change (DeLong tests: p=0.091). Compared with weight gain in the lowest quartile (the weight gain less than 0.0 kg), the highest quartile (over 2.0 kg) was associated with a higher risk of fetal CHD in unadjusted (OR 1.36, 95% CI: 1.08 to 1.72), minimally adjusted (adjusted OR (aOR) 1.29, 95% CI: 1.02 to 1.62) and maximally adjusted (aOR 1.29, 95% CI: 1.02 to 1.63) models. The association remains robust in pregnant women with morning sickness, normal pre-pregnancy BMI, moderate physical activity, college/university level, natural conception or with folic acid (FA) and/or multivitamin supplementation.

CONCLUSIONS AND RELEVANCE

Although the association of maternal pre-pregnancy weight gain on fetal CHD is weak, the excessive weight gain may be a potential predictor of CHD in the offspring, especially in those with morning sickness and other conditions that are routine in the cohort, such as normal pre-pregnancy BMI, moderate physical activity, college/university level, natural conception or with FA and/or multivitamin supplementation.

Obesity in prenatal medicine: a game changer?

Obesity is recognized by the World Health Organization (WHO) as a disease in its own right. Moreover, obesity is an increasingly concerning public health issue across the world and its prevalence is rising amongst women of reproductive age. The fertility of over-weight and obese women is reduced and they experience a higher rate of miscarriage. In pregnant women obesity not only increases the risk of antenatal complications, such as preeclampsia and gestational diabetes, but also fetal abnormalities, and consequently the overall feto-maternal mortality. Ultrasound is one of the most valuable methods to predict and evaluate pregnancy complications. However, in overweight and obese pregnant women, the ultrasound examination is met with several challenges, mainly due to an impaired acoustic window. Overall obesity in pregnancy poses special challenges and constraints to the antenatal care and increases the rate of pregnancy complications, as well as complications later in life for the mother and child.

Risk of major congenital heart disease in pregestational maternal diabetes is modified by hemoglobin A1c

OBJECTIVES

The association between pregestational diabetes mellitus (PDM) and risk of congenital heart disease (CHD) is well recognized; however, the importance of glycemic control and other coexisting risk factors during pregnancy is less clear. We sought to determine the relative risk (RR) of major CHD (mCHD) among offspring from pregnancies complicated by PDM and the effect of first-trimester glycemic control on mCHD risk.

METHODS

We determined the incidence of mCHD (requiring surgery within 1 year of birth or resulting in pregnancy termination or fetal demise) among registered births in Alberta, Canada. Linkage of diabetes status, maximum hemoglobin A1c (HbA1c) at < 16 weeks' gestation and other covariates was performed using data from the Alberta Perinatal Health Program registry. Risk of mCHD according to HbA1c was estimated as an adjusted RR (aRR), calculated using log-binomial modeling.

RESULTS

Of 1412 cases of mCHD in 594 773 (2.37/1000) births in the study period, mCHD was present in 48/7497 with PDM (6.4/1000; RR, 2.8 (95% CI, 2.1-3.7); P < 0.0001). In the entire cohort, increased maternal age (aRR, 1.03 (95% CI, 1.02-1.04); P < 0.0001) and multiple gestation (aRR, 1.37 (95% CI, 1.1-1.8); P = 0.02) were also associated with mCHD risk, whereas maternal prepregnancy weight > 91 kg was not. The stratified risk for mCHD associated with HbA1c ≤ 6.1%, > 6.1-8.0% and > 8.0% was 4.2/1000, 6.8/1000 and 17.1/1000 PDM/gestational diabetes mellitus births, respectively; the aRR of mCHD associated with PDM and HbA1c > 8.0% was 8.5 (95% CI, 5.0-14.4) compared to those without diabetes and 5.5 (95% CI, 1.6-19.4) compared to PDM with normal HbA1c (≤ 6.1%).

CONCLUSIONS

PDM is associated with a RR of 2.8 for mCHD, increasing to 8.5 in those with HbA1c > 8%. These data should facilitate refinement of referral indications for high-risk pregnancy screening. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence and Pattern of Birth Defects in Saudi Arabia: A Systematic Review of Observational Studies

INTRODUCTION

Birth defects are a significant concern since they can lead to permanent disability and death. This study comprehensively reviews the prevalence and patterns of birth defects in Saudi Arabia.

METHODS

A systematic analysis of the literature retrieved from three databases (Pub Med, Science Direct, and the Saudi digital library) published between 1989 and 2022 was performed. Observational studies that addressed the prevalence and patterns of birth defects in Saudi Arabia were chosen based on the eligibility criteria, while systematic reviews, review articles, non-relevant articles, and studies that did not fulfill the eligibility criteria were excluded. Quality and risk of bias were evaluated based on the JBI and GRADE tools, respectively.

RESULTS

We identified 26 eligible publications of 1277 records that included 297,668 patients from different regions of Saudi Arabia. The highest overall prevalence of birth defects was 46.5 per 1000 live births compared to a lowest rate of 8.6 per 1000 in one study. Several studies have reported positive associations of consanguinity, maternal folic acid supplementation, family history of birth defects or genetic abnormalities, and maternal co-morbidities. The most frequent birth defects include cardiac, genitourinary, craniofacial, and nervous system defects.

CONCLUSION

Robust findings have improved our understanding of the prevalence and pattern of birth defects in Saudi Arabia. Importantly, future studies will likely require multicenter collaboration to arrive at appropriate sample sizes in the context of the effects of risk factors on elevated prevalence. Furthermore, quantitative data require careful evaluation in more complex statistical models.

Congenital heart disease: changes in recorded birth prevalence and cardiac interventions over the past half-century in Sweden

AIMS

Our objective was to assess changes in the birth prevalence of CHD over a half-century in a high-resource, nationwide setting, as well as changes in the prevalence of cardiac interventions in this population.

METHODS AND RESULTS

The Swedish National Patient and Cause of Death registers were linked to estimate the annual rates of CHD and cardiac interventions among live-born infants from 1970 to 2017. Additionally, separate estimates were obtained by lesion complexity, from mild to the most complex forms of CHD. Overall, the numbers of live-born infants with a CHD identified varied from 624 to 2459 annual cases, with rates increasing steadily from 5.7 to an average of 20 per 1000 live births at the end of the study period, and with a more pronounced increase from 1996 to 2005. The largest increase over time was observed for mild CHD lesions. Overall, the proportion of cardiac interventions among patients with CHD declined from 40.7% in 1970 to below 15.0% after 2014. However, in the most complex CHD lesion groups, overall cardiac interventions increased from 57.1 to 76.8% in patients with conotruncal defects and from 32.8 to 39.5% in those with severe non-conotruncal defects.

CONCLUSION

The live-birth prevalence of CHD in Sweden more than tripled during the past half-century, most likely resulting from more accurate diagnostic capabilities. The largest increase over time was observed among patients with simple defects. During the same period, overall cardiac interventions decreased whereas interventions for the most complex CHD groups increased.

Association Between Maternal Factors and Risk of Congenital Heart Disease in Offspring: A Systematic Review and Meta-Analysis

INTRODUCTION

This study aimed to summarize the evidence describing the relationship between maternal factors during gestation and risk of congenital heart disease (CHD) in offspring.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched for potentially relevant reports from inception to May 2021. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) calculated by the random-effects model were used to evaluate the association between maternal factors and CHD risk.

RESULTS

There was a significant association between CHD risk and obesity in pregnancy (OR 1.29, 95% CI 1.22-1.37; P < 0.001), smoking in pregnancy (OR 1.16, 95% CI 1.07-1.25; P < 0.001), maternal diabetes (OR 2.65, 95% CI 2.20-3.19; P < 0.001), and exposure of pregnant women to organic solvents (OR 1.82, 95% CI 1.23-2.70; P = 0.003). No correlations were revealed between CHD susceptibility and advanced maternal age (OR 1.04, 95% CI 0.96-1.12; P = 0.328), underweight (OR 1.02, 95% CI 0.96-1.08; P = 0.519), alcohol intake in pregnancy (OR 1.08, 95% CI 0.95-1.22; P = 0.251), coffee intake (OR 1.18, 95% CI 0.97-1.44; P = 0.105), and exposure to irradiation (OR 1.80, 95% CI 0.85-3.80; P = 0.125).

DISCUSSION

Maternal factors including maternal obesity, smoking in pregnancy, maternal diabetes and exposure to organic solvents might predispose the offspring to CHD risk.

An Exploratory Analysis of Maternal Health Variables Increasing the Severity of Congenital Heart Disease in Infants

BACKGROUND

Congenital heart defects (CHD) are the most prevalent birth anomaly and leading cause of infant morbidity and mortality worldwide. Heart defects are often attributed to chromosomal abnormality or environmental factors, but most causes remain unknown. The purpose of this analysis was to explore maternal health variables and the relationships to birth outcomes in infants with CHD.

METHODS

Secondary analysis of data from the Wisconsin Pediatric Cardiac Registry.

RESULTS

Maternal history of CHDs (odds ratio [OR] = 2.38; 95% confidence interval [CI], 1.42-3.98) and serious health conditions (OR = 1.537; 95%: CI, 1.08-2.17) increase infant risk and CHD severity. Maternal history of hypertension, serious health conditions, CHD, obesity, and income were predictors of birth weight (R² = 0.049, P < .05). Maternal history of hypertension, influenza, serious health conditions, and housing were predictors of gestational age (R2 = 0.045, P < .05). Birth weight (BW) and gestational age (GA) did not correlate to the severity of CHD in this study (simple vs complex, BW = -0.014, GA = 0.011, r).

DISCUSSION

Maternal well-being influences the health of infants born with CHD. Positive maternal health contributes to near-normal birth weight and gestational age.

CONCLUSION

Nurses must discuss optimal reproductive life planning strategies for decreasing risk of CHD and other infant disorders.

Maternal genetic factors in the development of congenital heart defects

Congenital heart defects (CHDs) are among the most common, serious birth defects. However, the cause of CHDs is unknown for approximately half of affected individuals and there are few prevention strategies. Although not extensively investigated, maternal genes may contribute to CHD etiology by modifying the effects of maternal exposures (e.g. medications, nutrients), contributing to maternal phenotypes that are associated with an increased risk of CHDs in offspring (e.g. diabetes), or acting as maternal effect genes. Since maternal genes could serve as a target for the primary prevention of CHDs, efforts to further define the contribution of the maternal genome to CHD etiology are warranted.

Assessment of evidence on reported non-genetic risk factors of congenital heart defects: the updated umbrella review

BACKGROUND

Congenital heart defect (CHD) is the leading cause of birth defects globally, which results in a great disease burden. It is still imperative to detect the risk factors of CHD. This umbrella review aimed to comprehensively summarize the evidence and grade the evidence of the associations between non-genetic risk factors and CHD.

METHODS

Databases including Medline, Embase, Web of Science, Cochrane Library, and four Chinese databases were searched from inception to 18 Jan 2022. The reference lists of systematic reviews (SR) and meta-analyses (MA) were screened, which aimed to explore the non-genetic risk factors of CHD. Subsequently, titles and abstracts of identified records and full texts of selected SR/MA were screened by two independent reviewers based on predefined eligibility criteria. A priori developed extraction form was used to abstract relative data following the PRISMA 2020 and MOOSE guidelines. The risk of bias was assessed with the AMSTAR2 instrument. Data were synthesized using fixed-effects and random-effects meta-analyses, respectively. Finally, the evidence on the association of non-genetic risk factors and CHD was graded using Ioannidis's five-class evidence grade.

RESULTS

A total of 56 SRs, encompassing 369 MAs, were identified. The risk factors included relative factors on air pollution, reproductive-related factors, parental age and BMI, parental life habits, working and dwelling environment, maternal drug exposure, and maternal disease. Based on AMSTAR2 criteria, only 16% (9/56) of SRs were classified as "Moderate". One hundred and two traceable positive association MAs involving 949 component individual studies were included in further analysis and grading of evidence. Family genetic history, number of abortions, maternal obesity, especially moderate or severe obesity, decoration materials, harmful chemicals, noise during pregnancy, folic acid supplementation, SSRIs, SNRIs, any antidepressants in the first trimester, maternal DM (including both PGDM and GDM), and gestational hypertension were convincing and highly suggestive factors for CHD. After sensitivity analyses based on cohort studies, some grades of evidence changed.

CONCLUSION

The present umbrella review will provide evidence-based information for women of childbearing age before or during pregnancy to prevent CHD. In addition, sensitivity analysis based on cohort studies showed the changed evidence levels. Therefore, future SR/MA should concern the sensitivity analysis based on prospective birth cohort studies and case-control studies.

Environmental and Genetic Risk Factors of Congenital Anomalies: an Umbrella Review of Systematic Reviews and Meta-Analyses

BACKGROUND

The prevalence of congenital anomalies in newborns in South Korea was 272.9 per 100,000 in 2005, and 314.7 per 100,000 in 2006. In other studies, the prevalence of congenital anomalies in South Korea was equivalent to 286.9 per 10,000 livebirths in 2006, while it was estimated 446.3 per 10,000 births during the period from 2008 to 2014. Several systematic reviews and meta-analyses analyzing the factors contributing to congenital anomalies have been reported, but comprehensive umbrella reviews are lacking.

METHODS

We searched PubMed, Google Scholar, Cochrane, and EMBASE databases up to July 1, 2019, for systematic reviews and meta-analyses that investigated the effects of environmental and genetic factors on any type of congenital anomalies. We categorized 8 subgroups of congenital anomalies classified according to the 10th revision of the International Statistical Classification of Diseases (ICD-10). Two researchers independently searched the literature, retrieved the data, and evaluated the quality of each study.

RESULTS

We reviewed 66 systematic reviews and meta-analyses that investigated the association between non-genetic or genetic risk factors and congenital anomalies. Overall, 269 associations and 128 associations were considered for environmental and genetic risk factors, respectively. Congenital anomalies based on congenital heart diseases, cleft lip and palate, and others were associated with environmental risk factors based on maternal exposure to environmental exposures (air pollution, toxic chemicals), parental smoking, maternal history (infectious diseases during pregnancy, pregestational and gestational diabetes mellitus, and gestational diabetes mellitus), maternal obesity, maternal drug intake, pregnancy through artificial reproductive technologies, and socioeconomic factors. The association of maternal alcohol or coffee consumption with congenital anomalies was not significant, and maternal folic acid supplementation had a preventive effect on congenital heart defects. Genes or genetic loci associated with congenital anomalies included MTHFR, MTRR and MTR, GATA4, NKX2-5, SRD5A2, CFTR, and 1p22 and 20q12 anomalies.

CONCLUSION

This study provides a wide perspective on the distribution of environmental and genetic risk factors of congenital anomalies, thus suggesting future studies and providing health policy implications.

Risk of neural tube defects according to maternal body mass index: a systematic review and meta-analysis

INTRODUCTION

The aim of our systematic review and meta-analysis was to evaluate the risk of neural tube defects (NTDs) according to the pre-pregnancy body mass index.

MATERIALS AND METHODS

Electronic databases were searched (MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library). Selection criteria included prospective and retrospective cohort studies reporting the prevalence of fetal NTDs in obese, overweight, and underweight pregnant women. Odds ratios (ORs) comparing risk among these subsets of pregnancies with normal weight mothers were determined with 95% confidence intervals (CI). The evaluated outcome was the association between maternal underweight, overweight, and obesity and the risk of NTDs.

RESULTS

We included ten studies published between 2000 and 2017, including underweight, overweight, and obese pregnant women with fetal NTD (cases) and pregnant women with recommended BMI with fetal NTD (controls). Compared with normal BMI women, obese mothers were at significantly higher risk of fetal NTDs (0.53 vs. 0.33%; OR 1.62 95% CI 1.32-1.99, p < .0001), while no difference for the risk of NTDs was found when comparing overweight (0.34 vs. 0.32%; OR 1.09 95% CI 0.92-1.3, p = .3) and underweight (0.65 vs. 0.24%; OR 1.34 95% CI 0.73-2.47, p = .34) with normal weight pregnant women.

DISCUSSION

Obese pregnant women are at significantly higher risk NTDs, while no significant difference has been found in overweight and underweight pregnant women. Key message Obese pregnant women are at significantly higher risk of NTDs, such as spina bifida compared with normal weight women. No difference was found when comparing overweight and underweight with normal weight women.

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.

Health-Related Quality of Life in Children and Adolescents with Simple Congenital Heart Defects before and after Transcatheter Intervention Therapy: A Single-Center Study

Objective: To explore the health-related quality of life (HRQoL) of children and adolescents with simple congenital heart defects before and after the transcatheter intervention.

Methods: The Pediatric Quality of Life Inventory 4.0 scale was used to assess the quality of life of 78 children and adolescents before and after the transcatheter intervention and to evaluate the parents’ perception of their children’s quality of life.

Results: In all, 76 patients were completed the study. The results showed that the scores of the four dimensions and the total score for the quality of life of the patients significantly improved 1 month after the intervention. At 6 months after treatment, the scores in all dimensions continued to improve. From the parents’ perspective, the scores of the patients in all dimensions improved significantly at 1 month and 6 months after treatment. In terms of the quality of life assessment, the self-assessment results of the patients were more positive than those of their parents.

Conclusions: The results showed that the quality of life of children and adolescents with simple congenital heart defects can be positively affected by the transcatheter intervention. Moreover, this improvement is not transient and seems to increase over time.

Environmental Risk Factors and Congenital Heart Disease: An Umbrella Review of 165 Systematic Reviews and Meta-Analyses With More Than 120 Million Participants

Background: The etiology of congenital heart disease (CHD) has been extensively studied in the past decades. Therefore, it is critical to clarify clear hierarchies of evidence between types of environmental factors and CHD. Methods: Electronic searches in PubMed, Embase, Web of Science, Cochrane database were conducted from inception to April 20, 2020 for meta-analyses investigating the aforementioned topic. Results: Overall, 41 studies including a total of 165 meta-analyses of different environmental factors and CHD were examined, covering a wide range of risk factors. The summary random effects estimates were significant at P < 0.05 in 63 meta-analyses (38%), and 15 associations (9%) were significant at P < 10^-6. Of these meta-analyses, eventually one risk factor (severe obesity; relative risk: 1.38, 95% confidence interval: 1.30-1.47) had significant summary associations at P < 10^-6, included more than 1,000 cases, had 95% prediction intervals excluding the null value, and were not suggestive of large heterogeneity (I ² < 50%), small-study effects (P-value for Egger's test > 0.10), or excess significance (P > 0.10). Eight associations (5%) (including maternal lithium exposure, maternal obesity, maternal alcohol consumption, and maternal fever) had results that were significant at P < 10^-6, included more than 1,000 cases, and had 95% prediction intervals excluding the null value (highly suggestive). Conclusion: This umbrella review shows that many environmental factors have substantial evidence in relation to the risk of developing CHD. More and better-designed studies are needed to establish robust evidence between environmental factors and CHD. Systematic Review Registration: [PROSPERO], identifier [CRD42020193381].

Impact of Obesity on Outcomes of Pregnancy in Women With Heart Disease

BACKGROUND

Women with heart disease are at risk for complications during pregnancy. This study sought to examine the effect of maternal obesity on pregnancy complications in women with heart disease.

OBJECTIVES

The objective was to determine the incidence of adverse cardiac events (CE) in pregnant women with heart disease and obesity.

METHODS

Adverse CE during pregnancy were examined in a prospective cohort of women with heart disease. CE were a composite of the following: cardiac death/arrest, arrhythmias, heart failure, myocardial infarction, stroke, aortic dissection, and thromboembolic events. Pre-eclampsia and post-partum hemorrhage were also studied. Outcomes were examined according to body mass index (BMI). To identify additional predictors of CE, a baseline risk score (CARPREG [Canadian Cardiac Disease in Pregnancy Study] II score) for predicting cardiac complications was calculated for all pregnancies and included in a multivariable logistic regression model.

RESULTS

Of 790 pregnancies, 19% occurred in women with BMI ≥30 kg/m² (obesity), 25% in women with BMI 25 to 29.9 kg/m² (overweight), 53% in women with BMI 18.5 to 24.9 kg/m² (normal weight), and 3% in women with BMI <18.5 kg/m² (underweight). Women with obesity were at higher risk of CE when compared with women with normal weight (23% vs. 14%; p = 0.006). In a multivariable model, obesity (odds ratio: 1.7; 95% confidence interval: 1.0 to 2.7) and higher CARPREG II risk scores (odds ratio: 1.7; 95% confidence interval: 1.5 to 1.9) predicted CE. Pre-eclampsia was more frequent in women with obesity compared with those with normal weight (8% vs. 2%; p = 0.001).

CONCLUSIONS

Obesity increases the risk of maternal cardiovascular complications in pregnant women with heart disease. This modifiable risk factor should be addressed at the time of preconception counseling.

Unintended pregnancy-related factors and the occurrence of offspring congenital heart disease: a multi-site case-control study in China

OBJECTIVES

The aim of this study was to explore the association between unintended pregnancy and related factors among congenital heart defects (CHDs) in infants.

METHODS

A total of 1197 cases with isolated CHDs and 1125 controls without any abnormalities were analysed in this multicentre study at seven hospitals in China. According to the pregnancy intention, cases were divided into two groups: planned and unintended pregnancies. The adjusted odds ratio (AOR) was calculated by logistic regression analysis to assess the association between unintended pregnancy and CHD occurrence. The time to prepare for pregnancy and the influencing factors were also compared in this article.

RESULTS

The risk for CHD occurrence was significantly associated with unintended pregnancy (AOR: 1.42; 95%CI: 1.16-1.73), which may increase the risks for each subtype of CHD occurrence. Risks such as parental smoking, housing renovation, accidental alcohol consumption, lack of health check-ups, and no folic acid supplementation before pregnancy were distributed differently among the planned and unintended pregnancy groups and were associated with CHD occurrence. However, there was no significant association between the duration of planned pregnancy and the risk of CHDs.

CONCLUSIONS

Unintended pregnancy increased the risk of CHDs in infants. This risk may be related to some known and unknown factors.

SYNOPSIS

Some unintended pregnancy related factors may increase the risk for foetal CHDs. The duration of planning pregnancy may not be associated with the risk of CHDs.

Pre-pregnancy obesity and risk of congenital abnormalities of the kidney and urinary tract (CAKUT)-systematic review, meta-analysis and ecological study

BACKGROUND

There is increasing evidence that maternal obesity is associated with several structural birth defects. Congenital abnormalities of the kidney and urinary tract (CAKUT) account for 30 to 50% of children starting kidney replacement therapy (KRT). We conducted a systematic review, meta-analysis and ecological study to explore the relationship between maternal obesity and CAKUT.

METHODS

A systematic literature search was conducted in EMBASE, MEDLINE, Global Health, The Cochrane Library, Scopus and Web of Science. Study quality was assessed for bias and confounding. A meta-analysis using a random effect model was carried out to obtain a summary odds ratio (OR) and 95% confidence interval (CI). In the ecological study, country-level data were used to examine the correlation of secular trends in female obesity, CAKUT incidence and incidence of KRT.

RESULTS

Eight epidemiological studies were included in the review-4 cohort studies and 4 case-control studies-7 of which were included in the meta-analysis. There was evidence of a positive association between obesity during pregnancy and the risk of CAKUT, with a summary OR = 1.14 (1.02-1.27). No association was seen with overweight, nor a dose response with increasing obesity. There was an increasing trend in countries' proportion of female obesity and an increasing trend in reported CAKUT incidence with specific rises seen in congenital hydronephrosis (CH) and multicystic kidney dysplasia (MCKD).

CONCLUSIONS

Our findings suggest that pre-pregnancy obesity may be associated with increased risk of CAKUT at population level. Graphical abstract.

Prenatal exposure to traffic-related air pollution and risk of congenital diseases in South Korea

BACKGROUND

Previous studies have suggested links between exposure to ambient air pollutants and increased risk of congenital heart defects. However, few studies have investigated the association between other congenital diseases and traffic-related air pollution. In this study, we assessed the relationship between prenatal exposure to fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) with congenital diseases in South Korea.

METHODS

Patients with one or more congenital diseases and a control group of patients with non-infective gastroenteritis and colitis with a case:control ratio of 1:3 were obtained from the National Health Insurance Service data for 2008-2013 in South Korea. We estimated the associations of PM_2.5 and NO₂ exposures with congenital diseases using generalized estimation equations after controlling for covariates.

RESULTS

Maternal PM_2.5 exposure during the first and second trimester showed positive associations with overall congenital diseases, with changes of 14.7% (95% confidence intervals (CI), 9.3%, 20.3%) and 16.2% (95% CI, 11.0%, 21.7%), respectively, per 11.1 μg/m³ and 10.2 μg/m³ increase of PM_2.5 interquartile range (IQR). Similarly, NO₂ exposure during the first and second trimester was associated with increased numbers of overall congenital anomalies, with 8.2% (95% CI, 4.2%, 12.3%) and 15.6% (95% CI, 9.3%, 22.2%) more cases, respectively, per 10.6 ppb increase of NO₂. We found that maternal PM_2.5 exposure during the first and second trimesters of pregnancy was significantly associated with increased risk of specific congenital diseases, including subtypes affecting the circulatory, genitourinary, and musculoskeletal system. However, no significant associations were observed during the third trimester. Maternal NO₂ exposure across the entire pregnancy was associated with malformations of the musculoskeletal system.

CONCLUSIONS

Our study identified significant links between in utero exposure to PM_2.5 and NO₂ and certain congenital diseases, and suggests that stricter controls on PM_2.5 and NO₂ concentrations are required.

Maternal Obesity and Diabetes Mellitus as Risk Factors for Congenital Heart Disease in the Offspring

Congenital heart disease (CHD) is the most common anatomical malformation occurring live‐born infants and an increasing cause of morbidity and mortality across the lifespan and throughout the world. Population‐based observations have long described associations between maternal cardiometabolic disorders and the risk of CHD in the offspring. Here we review the epidemiological evidence and clinical observations relating maternal obesity and diabetes mellitus to the risk of CHD offspring with particular attention to mechanistic models of maternal‐fetal risk transmission and first trimester disturbances of fetal cardiac development. A deeper understanding of maternal risk factors holds the potential to improve both prenatal detection of CHD by identifying at‐risk pregnancies, along with primary prevention of disease by improving preconception and prenatal treatment of at‐risk mothers.

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.

Caracterización de la exposición prenatal de un grupo de niños de 0 a 5 años con cardiopatía congénita atendidos en Cali, Colombia. La importancia del ácido fólico

Introducción. Con una prevalencia estimada de 4 a 9 casos por cada 1 000 nacimientos, las cardiopatías congénitas (CC) tienen gran impacto en la morbimortalidad pediátrica. La variabilidad de prevalencia se ha atribuido a diferencias regionales en cuanto a factores genéticos, ambientales, entre otros.Objetivo. Obtener datos sobre variables de exposición prenatales de pacientes con CC atendidos en Cali, Colombia.Materiales y métodos. Se aplicó una encuesta a las madres de 30 pacientes de 0 a 5 años con CC atendidos en 2 clínicas de alta complejidad (tercer y cuarto nivel) de Cali. La encuesta estaba orientada a múltiples variables de exposición y la información recolectada fue digitalizada en una base de datos en el programa Microsoft Excel para hacer un análisis estadístico descriptivo.Resultados. Se evidenciaron varias exposiciones potencialmente asociadas a CC, tales como índice de masa corporal alterado, administración inadecuada de suplementos de ácido fólico y exposición a vitamina A, rayos X, alcohol y cigarrillo.Conclusión. El consumo insuficiente o inoportuno de ácido fólico podría facilitar la generación de efectos teratogénicos de sustancias oxidantes. Por lo tanto, se debe educar a las mujeres de Cali sobre la importancia de una ingesta adecuada de ácido fólico y sobre los riesgos de la exposición a agentes teratogénicos durante el embarazo para reducir las tasas de incidencia de CC en esta ciudad.

Maternal Overweight and Obesity and Risk of Congenital Heart Defects

BACKGROUND

Congenital heart defects are more frequent in offspring of mothers with overweight or obesity. However, associations between maternal overweight and obesity, and risks of complex and specific heart defects are not clear.

OBJECTIVES

This study sought to analyze associations between maternal overweight and obesity severity and rates of complex and specific heart defects.

METHODS

This was a population-based cohort study in Sweden, including 2,050,491 live singleton infants born between 1992 and 2012. Data on maternal and infant characteristics, and diagnoses of congenital heart defects were retrieved from nationwide registries. Maternal body mass index (BMI) was categorized as underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5 to <25 kg/m²), overweight (BMI 25 to <30 kg/m²), obesity class I (BMI 30 to <35 kg/m²), class II (BMI 35 to <40 kg/m²), and class III (BMI ≥40 kg/m²). Outcomes included complex heart defects (tetralogy of Fallot, transposition of the great arteries, atrial septal defects [ASD], aortic arch defects, and single-ventricle heart) and subgroups of specific heart defects diagnosed up to 5 years of age. The authors calculated adjusted prevalence rate ratios (PRRs) with 95% confidence intervals.

RESULTS

A total of 28,628 (1.40%, N = 2,050,491) children had at least 1 congenital heart defect. PRRs of aortic arch defects increased with maternal obesity severity. Compared with offspring of normal weight mothers, PRRs of aortic arch defects and transposition of the great arteries were doubled in offspring of mothers with severe obesity. PRRs of ASD and persistent ductus arteriosus in term infants increased with maternal BMI.

CONCLUSIONS

PRRs of aortic branch defects, ASD, and persistent ductus arteriosus increase with maternal obesity severity.

Predictive and diagnostic biomarkers for gestational diabetes and its associated metabolic and cardiovascular diseases

Gestational diabetes mellitus (GDM) is defined as the presence of high blood glucose levels with the onset, or detected for the first time during pregnancy, as a result of increased insulin resistance. GDM may be induced by dysregulation of pancreatic β-cell function and/or by alteration of secreted gestational hormones and peptides related with glucose homeostasis. It may affect one out of five pregnancies, leading to perinatal morbidity and adverse neonatal outcomes, and high risk of chronic metabolic and cardiovascular injuries in both mother and offspring. Currently, GDM diagnosis is based on evaluation of glucose homeostasis at late stages of pregnancy, but increased age and body-weight, and familiar or previous occurrence of GDM, may conditionate this criteria. In addition, an earlier and more specific detection of GDM with associated metabolic and cardiovascular risk could improve GDM development and outcomes. In this sense, 1st-2nd trimester-released biomarkers found in maternal plasma including adipose tissue-derived factors such as adiponectin, visfatin, omentin-1, fatty acid-binding protein-4 and retinol binding-protein-4 have shown correlations with GDM development. Moreover, placenta-related factors such as sex hormone-binding globulin, afamin, fetuin-A, fibroblast growth factors-21/23, ficolin-3 and follistatin, or specific micro-RNAs may participate in GDM progression and be useful for its recognition. Finally, urine-excreted metabolites such as those related with serotonin system, non-polar amino-acids and ketone bodies, may complete a predictive or early-diagnostic panel of biomarkers for GDM.

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.

Neonatal outcomes of singleton live births with vanishing twin syndrome following double embryos transfer in assisted reproductive technology: a retrospective cohort study

Background

Women with vanishing twin syndrome are associated with increased risks of adverse neonatal outcomes, such as preterm birth (PTB) and low birthweight (LBW), compared with those in singleton live births following single embryo transfer (SET) in assisted reproductive technology (ART).

Methods

Anonymized data on all cycles performed in China were obtained from the Reproductive Medicine Department at the Third Affiliated Hospital of Zhengzhou University, which had involved 127597 cycles following double embryos transfer (DET), including 54585 fresh embryos transfer (ET) cycles and 73012 frozen embryos transfer (FET) cycles. In addition, the obstetric outcomes, such as gestation age, PTB, small for gestation age (SGA), birthweight (BW), LBW, congenital malformation, pediatric admission and Neonatal Intensive Care Unit (NICU) admission in the fresh ET and FET cycles, were analyzed. Moreover, logistic regression analysis was performed to adjust the confounders, including age of women, body weight index (BMI), value of AMH, infertile years, current cycle, antral follicles, cause of infertility, number of oocytes retrieved, endometrial thickness at the date of transplantation, number of high-quality embryos, and embryo stage.

Results

In the fresh ET cycles, the BW and gestational age in study group were lower than those in control group, which were (2962.4 ± 563.1vs. 3104.9 ± 498. 5, p = 0.000) and (262.8 ± 8.4 vs. 268.9 ± 13.9, p = 0.000), respectively. Relative to control group, the study group was linked with increased risks of PTB (adjusted odds ratio (aOR) 2.45, 95% CI:1.98–3.03, adjusted p = 0.000), LBW (aOR2.11, 95% CI:1.67–2.65, adjusted p = 0.000), pediatric admission (aOR 2.55, 95% CI2.07–3.13, adjusted p = 0.000), and NICU admission (aOR 1.98, 95% CI1.32–2.96, adjusted p = 0.001), but there were no statistically significant differences in the risks of SGA (aOR 1.09, 95% CI0.82–1.45, adjusted p = 0.960) and congenital malformation (aOR 0.94, 95% CI0.53–1.68, adjusted p = 0.640) between the two groups. In the FET cycles, the gestational age and BW in study group were lower than those in control group, which were (263.0 ± 15.7vs. 273.0 ± 10.5, p = 0.000) and (3099 ± 662.1vs. 3352 ± 671.5), respectively. The study group was associated with increased risks of PTB (aOR2. 45, 95% CI: 2.23–3.43, adjusted p = 0.000), LBW (aOR 2.67, 95% CI: 2.13–3.34, adjusted p = 0.000), pediatric admission (aOR2.62, 95% CI2.14–3.21, adjusted p = 0.000), and NICU admission (aOR 2.22, 95% CI1.43, 3.46, adjusted p = 0.001) compared with those in control group, but differences in the risks of SGA (aOR 0.98, 95% CI0.71–1.36, adjusted p = 0.730) and congenital malformation (aOR 0.99, 95% CI 0.60,1.63, adjusted p = 0.940) between the two groups were not statistically significant.

Conclusions

Our study finds that singleton live births with VTS have higher risks of LBW, PTB, pediatric admission and NICU admission than those without VTS in both the fresh and frozen cycles, even after adjusting for confounders. However, no increased risks of SGA or congenital malformation are observed in singleton live births in both the fresh and frozen ART cycles following DET.

Maternal Body Mass Index and Risk of Congenital Heart Defects in Infants: A Dose-Response Meta-Analysis

Objective

The exact shape of the dose-response relationship between maternal body mass index (BMI) and the risk of congenital heart defects (CHDs) in infants has not been clearly defined yet. This study aims to further clarify the relationship between maternal obesity and the risk of CHDs in infants by an overall and dose-response meta-analysis.

Methods

PubMed, Embase, and Web of Science databases were searched to identify all related studies. The studies were limited to human cohort or case-control studies in English language. Random-effect models and dose-response meta-analysis were used to synthesize the results. Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were also assessed.

Results

Nineteen studies with 2,416,546 participants were included in our meta-analysis. Compared with the mothers with normal weight, the pooled relative risks (RRs) of infants with CHDs were 1.08 (95% CI=1.03-1.13) in overweight and 1.23 (95% CI=1.17-1.29) in obese mothers. According to the findings from the linear meta-analysis, we observed an increased risk of infants with CHDs (RR=1.07, 95% CI=1.06-1.08) for each 5 kg/m² increase in maternal BMI. A nonlinear relationship between maternal BMI and risk of infants with CHDs was also found (p=0.012).

Conclusion

The results from our meta-analysis indicate that increased maternal BMI is related to increased risk of CHDs in infants.

Management of Preexisting Diabetes in Pregnancy: A Review

IMPORTANCE

The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes.

OBSERVATIONS

Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated.

CONCLUSIONS AND RELEVANCE

Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.

Associations of trace elements in blood with the risk of isolated ventricular septum defects and abnormal cardiac structure in children

This study sought to determine correlations between the presence of isolated ventricular septum defects (VSDs) and blood levels of trace elements. A total of 144 patients with VSDs and 144 controls were recruited for cross-sectional assessment of trace elements and examination of cardiac structures in the Jiangsu and Anhui provinces between 2016 and 2018. Logistic regression was performed to explore the relationships between VSDs and trace elements. Additionally, general linear regression models were used to investigate relationships between trace elements and echocardiography indicators. Relative to the lowest zinc (Zn) concentrations, the highest Zn concentrations may be associated with lower odds of VSD development (OR = 0.03, 95% confidence interval [CI] = 0.01-0.29, P < 0.001). However, no significant relationships between the concentrations of other trace elements and the risk of VSD were identified. Aorta (AO) diameters were markedly smaller in the VSD group, whereas no significant between-group differences were observed for other echocardiography indicators. After adjusting for age and gender, linear regression indicated a significant association between Zn level and mean AO diameter (beta coefficient = 0.247, 95% CI = 0.126-0.367). Zn deficiency was observed in patients with isolated VSDs. Further work to explore the mechanisms by which Zn deficiency leads to VSDs is warranted.