Risk of Pregnancy Complications in Relation to Maternal Prepregnancy Body Mass Index: Population-Based Study from Finland 2006-10

Impact of multiple obesity metrics on hypertensive disorders of pregnancy: a meta-analysis and Mendelian randomisation study

BACKGROUND

The relationships between various obesity measures and hypertensive disorders of pregnancy (HDP) remain inadequately explored, and their causal links are not well understood. This study aims to clarify these associations and investigate the mediating role of triglycerides.

METHODS

We conducted a comprehensive meta-analysis of observational studies alongside Mendelian randomisation (MR) analysis to assess the impact of 10 obesity measures on HDP risk. Additionally, we evaluated the mediating effect of triglycerides.

RESULTS

Our meta-analysis revealed significant associations between maternal prepregnancy overweight/obesity and increased risks of gestational hypertension (GH) (overweight: OR=1.98, 95% CI 1.83 to 2.15; obesity: OR=3.77, 95% CI 3.45 to 4.13) and pre-eclampsia (overweight: OR=1.78, 95% CI 1.67 to 1.90; obesity: OR=3.46, 95% CI 3.16 to 3.79). Higher maternal waist circumference (WC) was also linked to increased pre-eclampsia risk (OR=1.45, 95% CI 1.14 to 1.83). MR analyses indicated that each 1-SD increase in genetically predicted obesity measures (whole body fat mass, body fat percentage, trunk fat mass, trunk fat percentage, body mass index, WC, hip circumference) was associated with higher risks of GH and pre-eclampsia. Triglycerides mediated 4.3%-14.1% of the total genetic effect of these obesity measures on GH and pre-eclampsia risks.

CONCLUSIONS

This study demonstrates that various obesity measures are causally linked to increased HDP risk and highlights the mediating role of triglycerides. These findings could inform clinical practices and public health strategies aimed at reducing HDP through targeted obesity and triglyceride management.

Maternal obesity and metabolic (dysfunction) associated fatty liver disease in pregnancy: a comprehensive narrative review

INTRODUCTION

Obesity and metabolic-associated fatty liver disease (MAFLD) during pregnancy constitute significant problems for routine antenatal care, with increasing prevalence globally. Similar to obesity, MAFLD is associated with a higher risk for maternal complications (e.g. pre-eclampsia and gestational diabetes) and long-term adverse health outcomes for the offspring. However, MAFLD during pregnancy is often under-recognized, with limited management/treatment options.

AREAS COVERED

PubMed/MEDLINE, EMBASE, and Scopus were searched based on a search strategy for obesity and/or MAFLD in pregnancy to identify relevant papers up to 2024. This review summarizes the pertinent evidence on the relationship between maternal obesity and MAFLD during pregnancy. Key mechanisms implicated in the underlying pathophysiology linking obesity and MAFLD during pregnancy (e.g. insulin resistance and dysregulated adipokine secretion) are highlighted. Moreover, a diagnostic approach for MAFLD diagnosis during pregnancy and its complications are presented. Finally, promising relevant areas for future research are covered.

EXPERT OPINION

Research progress regarding maternal obesity, MAFLD, and their impact on maternal and fetal/offspring health is expected to improve the relevant diagnostic methods and lead to novel treatments. Thus, routine practice could apply more personalized management strategies, incorporating individualized algorithms with genetic and/or multi-biomarker profiling to guide prevention, early diagnosis, and treatment.

The association between body mass index and live birth and maternal and perinatal outcomes after in-vitro fertilization: a national cohort study

Objective

To investigate the association between female body mass index (BMI) and live birth rates and maternal and perinatal outcomes after in-vitro fertilization (IVF).

Methods

We performed a national, population-based cohort study including women undergoing IVF between 2002 and 2020. The cohort included 126,620 fresh cycles and subsequent frozen embryo transfers between 2007 and 2019 (subpopulation 1) and 58,187 singleton deliveries between 2002 and 2020 (subpopulation 2). Exposure was female BMI (kg/m2) categorized according to the World Health Organization as underweight (<18.5), normal weight (18.5-24.9, reference), overweight (25.0-29.9), class I obesity (30.0-34.9), class II obesity (35.0-39.9), and class III obesity (≥40.0). The primary outcome in subpopulation 1 was cumulative live birth per started fresh IVF cycle, including fresh and subsequent frozen embryo transfers. Primary outcomes in subpopulation 2 were hypertensive disorders of pregnancy and preterm birth at less than 37 weeks. Risk ratios (RRs) with 95% confidence intervals (CIs) for the association between BMI class and outcomes were calculated using generalized linear models after adjustment for relevant confounders.

Results

The cumulative live birth rate decreased significantly with increasing BMI from 32.6% in normal-weight women to 29.4% in overweight women, 27.0% in women in obesity class I, 21.8% in women in obesity class II, and 7.6% in women in obesity class III. The risk of hypertensive disorders of pregnancy increased significantly and progressively with increasing BMI, from 4.6% in normal-weight women to 7.8% in overweight women and 12.5%, 17.9%, and 20.3% in women in obesity classes I, II, and III. The risk of preterm birth followed a similar pattern, from 6.3% in normal-weight women to 7.5% in overweight women and 8.9%, 9.9%, and 15.3% in women in obesity classes I, II, and III. The risks of other perinatal complications, such as perinatal death, showed an even more pronounced increase.

Conclusion

Using a large and complete national cohort of women undergoing IVF, we demonstrate a dose-dependent decrease in live birth rate and a substantial increase in maternal and perinatal complications with increasing BMI. Strategies to improve this situation are warranted.

Medical and obstetric comorbidities and delivery outcomes in overweight and obese parturients: a retrospective analysis

BACKGROUND

Research on obesity in women of reproductive age is heterogeneous in gestational age and body mass index (BMI) classification and focused mostly on pregnancy-related rather than medical comorbidities. We studied the prevalences of pre-pregnancy BMI, chronic maternal and obstetric comorbidities, and delivery outcomes.

METHODS

Retrospective analysis of real-time data collected during deliveries in a single tertiary medical center. Pre-pregnancy BMI was classified into seven groups (kg/m²): underweight (BMI < 18.5), normal weight 1 (18.5 ≤ BMI < 22.5), normal weight 2 (22.5 ≤ BMI < 25.0), overweight 1 (25.0 ≤ BMI < 27.5), overweight 2 (27.5 ≤ BMI < 30.0), obese (30.0 ≤ BMI < 35.0), and morbidly obese (BMI ≥ 35.0). Data were collected on maternal demographics, chronic medical and obstetric comorbidities, and delivery outcomes.

RESULTS

Included were 13,726 women aged 18-50 years, with a gestational age of 24^0/7-41^6/7 weeks. Pre-pregnancy weights were 61.4% normal, 19.8% overweight, 7.6% obese, and 3.3% morbidly obese. Smoking was more prevalent among morbidly obese than among normal weight women. Obese and morbidly obese women were older and had more diabetes mellitus, hypertension, preeclampsia/eclampsia, and prior cesarean deliveries than normal weight parturients. Obese and morbidly obese women were also less likely to have a non-spontaneous conception, enter labor spontaneously (observed in the full study population and in a subgroup of term parturients), and were more likely to undergo cesarean rather than vaginal delivery. Subgroup analysis of primiparous women yielded similar results.

CONCLUSIONS

We identified a potential association between pre-pregnancy obesity and morbid obesity and higher rates of obstetric comorbidities, less natural conception and spontaneous labor, and more cesarean deliveries and adverse delivery outcomes. It remains to be seen if these findings remain after adjustment and whether they are related to obesity, treatment, or both.

Preeclampsia is associated with reduced renin, aldosterone, and PlGF levels, and increased sFlt-1/PlGF ratio, and specific angiotensin-converting enzyme Ins-Del gene variants

We investigated the association of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism with preeclampsia (PE) in Tunisian women. ACE I/D genotyping was done by PCR in 342 pregnant women with PE and 289 healthy pregnant women. The association between ACE I/D and PE and associated features were also evaluated. Decreased active renin concentration, plasma aldosterone concentration, and placental growth factor (PlGF) were observed in PE cases, while soluble fms-like tyrosine kinase-1 (sFlt-1)/PlGF ratio was significantly higher in the PE group. Distribution of ACE I/D alleles and genotypes were comparable between women with PE and control women. A significant difference in the frequency of the I/I genotype was seen between PE cases and control women according to the recessive model, with a trend towards association in the codominant model. Carriers of the I/I genotype had significantly higher infant birth weights compared to the I/D and the D/D genotype carriers. A dose-dependent relationship was also seen in VEGF and PlGF plasma levels and specific ACE I/D genotypes, with the lowest VEGF levels seen in the I/I genotype carriers compared to the D/D genotype carriers. Similarly, the I/I genotype carriers had the lowest PlGF levels compared to I/D and D/D genotype carriers. Furthermore, when studying the linkage between PE features, we found a positive correlation between PAC and PIGF. Our study suggests a role for ACE I/D polymorphism in the pathogenesis of PE, possibly through modulating VEGF and PlGF levels and infant birth weight, and highlights the relationship between PAC and PlGF.

Body mass index implications in intrahepatic cholestasis of pregnancy and placental histopathological alterations

INTRODUCTION AND OBJECTIVES

Intrahepatic cholestasis is a frequent disease during pregnancy. It is unknown if liver function alterations produce specific placental lesions. The aim of this study was to evaluate placental histopathological changes in patients with intrahepatic cholestasis of pregnancy (ICP), and to explore correlations between the placental histopathology and hepatic function alteration or patient comorbidities, and body mass index.

PATIENTS AND METHODS

A retrospective cohort study included women with ICP, most of them showing comorbidities such as overweight/obesity, preeclampsia and gestational diabetes. They were attended at the National Institute of Perinatology in Mexico City for three years. Placental histopathological alterations were evaluated according to the Amsterdam Placental Workshop Group Consensus Statement. Data was analyzed using Graph-Pad Prism 5.

RESULTS

The results indicated that the placenta of ICP patients showed many histopathological alterations; however, no correlations were observed between the increase in bile acids or liver functional parameters and specific placental lesions. The most frequent comorbidities found in ICP patients were obesity, overweight and preeclampsia. Surprisingly, high percentage of ICP patients did not respond to UDCA treatment independently of the BMI group to which they belonged.

CONCLUSION

The data suggest that ICP contribute to placental lesions. In addition, in patients with normal weight, an increase of chorangiosis and a reduced accelerated villous maturation without syncytial knots were observed in comparison with overweight and obese patients. It is necessary to improve the medical strategies in the treatment and liver disfunction surveillance of ICP patients.

Incidence of obese parturients and the outcomes of their pregnancies: A nationwide register study in Finland

OBJECTIVES

We analyzed the incidence of obese and severely obese parturients and the impact of maternal obesity on mode of delivery, perinatal and neonatal mortality, and neonatal health.

STUDY DESIGN

We included all singleton births from the medical birth register of Finland from 2004 to 2018 (n = 792 437). Maternal body mass index (BMI) was categorized into three classes: non-obese (BMI < 30 kg/m²), obese (BMI 30 - 39.9 kg/m²), and morbidly obese (BMI 40 kg/m² or more). The yearly incidence of obese and severely obese parturients per 10000 births was calculated. Logistic regression was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Between 2004 and 2018, the incidence of obese and morbidly obese parturients increased by 44% and 103%, respectively. Cesarean section rates were 23.6% and 30%, respectively (aOR 1.63 CI 1.61 - 1.66 and 2.33 CI: 2.23 - 2.44). Neonates born to morbidly obese parturients had an increased need for intensive care unit treatment (aOR 2.21 CI: 2.10 - 2.32), higher perinatal mortality (aOR 1.65 CI: 1.28 - 2.14), and higher neonatal mortality (aOR 1.68 CI: 1.04 - 2.72). The need for neonatal intensive care (aOR 1.50 CI: 1.47 - 1.53), perinatal mortality (aOR 1.25 CI: 1.13 - 1.39), and neonatal mortality (aOR 1.33 CI: 1.09 - 1.62) increased also among obese parturients.

CONCLUSIONS

We report a worrying increase in obese and morbidly obese parturients. Neonates born to these parturients were more likely delivered by cesarean sections and had higher rates of perinatal and neonatal mortality, and intensive care unit treatment. This highlights the importance of preventing obesity among fertile-aged females.

The Influence of Laparoscopic Sleeve Gastrectomy on Pregnancy, Delivery, and Infant: Does Timing of Pregnancy Following Laparoscopic Sleeve Gastrectomy Affect Outcomes?

PURPOSE

Maternal obesity is associated with newborn morbidity and mortality; however, the literature discussing bariatric surgical effects on women's fertility and pregnancy has reached diverse conclusions. We examined the effect of laparoscopic sleeve gastrectomy (LSG) on pregnancy, birth, and newborn outcomes regarding the time of conception.

MATERIALS AND METHODS

We conducted a retrospective review of women who had LSG and conceived between 2007 and 2017. Data included maternal parameters, pregnancy progression, delivery, and newborn status. Pregnancies were divided into subgroups according to surgery to conception interval (≤ 12, 12-24, ≥ 24 months).

RESULTS

We reviewed 68 patients: 48 (70%) conceived once, 13 (19%) conceived twice, 7 women (10%) conceived three times. There were 95 pregnancies and 80 live births. The group sizes were 18 (18.9%), 29 (30.5%), and 48 (50.5%) pregnancies for ≤ 12, 12-24, and 24 months after surgery, respectively. No difference was found between the subgroups regarding basic characteristics at time of surgery (age (p = 0.100), weight (p = 0.180), BMI (p = 0.616); and at beginning of pregnancy weight (p = 0.309), BMI (p = 0.707), %EBMIL (p = 0.321)). No significant differences were found concerning pregnancy progression, complications, and the newborns' weight (p = 0.41), GCT (p > 0.99), preeclampsia (p = 0.492), eclampsia (p > 0.99), Pre-term (p = 0.428), live birth (p = 0.432), LGA (p > 0.99), SGA (p = 0.732). A statistically significant trend of increased rates of caesarean section in subject with longer surgery-to-conception intervals was detected (P = 0.022).

CONCLUSIONS

Our results did not show that the interval between LSG and conception affects the pregnancy and newborn outcomes. Therefore, we believe that early conception following LSG does not increase the risk of maternal or neonatal morbidity or mortality.

Diet Modification before or during Pregnancy on Maternal and Foetal Outcomes in Rodent Models of Maternal Obesity

The obesity epidemic has serious implications for women of reproductive age; its rising incidence is associated not just with health implications for the mother but also has transgenerational ramifications for the offspring. Increased incidence of diabetes, cardiovascular disease, obesity, and kidney disease are seen in both the mothers and the offspring. Animal models, such as rodent studies, are fundamental to studying maternal obesity and its impact on maternal and offspring health, as human studies lack rigorous controlled experimental design. Furthermore, the short and prolific reproductive potential of rodents enables examination across multiple generations and facilitates the exploration of interventional strategies to mitigate the impact of maternal obesity, both before and during pregnancy. Given that obesity is a major public health concern, it is important to obtain a greater understanding of its pathophysiology and interaction with reproductive health, placental physiology, and foetal development. This narrative review focuses on the known effects of maternal obesity on the mother and the offspring, and the benefits of interventional strategies, including dietary intervention, before or during pregnancy on maternal and foetal outcomes. It further examines the contribution of rodent models of maternal obesity to elucidating pathophysiological pathways of disease development, as well as methods to reduce the impact of obesity on the mothers and the developing foetus. The translation of these findings into the human experience will also be discussed.

Predictors of Adverse Pregnancy Outcomes in Pregnant Women Living with Obesity: A Systematic Review

Obesity is a well-recognized risk factor for pregnancy complications. Most studies to date are in large cohorts, with results presented in a way that assumes all women living with obesity are at equal risk. This study investigates which women living with obesity are at higher risk of specific pregnancy complications. A systematic search of MEDLINE and Embase identified 7894 prospective or retrospective cohort studies exploring predictors of adverse outcomes among pregnant women living with obesity. Following screening, 61 studies were deemed eligible. Studies were selected if the effects of exposure to any predictor amongst pregnant women living with obesity could be collected. Maternal characteristics assessed for association with adverse outcomes included maternal age, race/ethnicity, maternal height, mode of conception, complement activation factors, and history of various comorbidities/procedures. Gestational diabetes mellitus was the most studied outcome (n = 32), followed by preterm birth (n = 29), preeclampsia (n = 27), low birthweight infants (n = 20), small for gestational age newborns (n = 12), and stillbirth (n = 7). This review identified important characteristics that should be considered during the screening and follow-up sessions of pregnant women living with obesity, including pre-existing type 1 diabetes, maternal age < 20 years or ≥35 years, non-White ethnicity, abdominal adiposity obesity, and history of bariatric surgery.

Metformin impairs bile acid homeostasis in ethinylestradiol-induced cholestasis in mice

Metformin, an oral antidiabetic drug, recently demonstrated a reducing effect on bile acids (BA) plasma concentrations in one patient with intrahepatic cholestasis of pregnancy (ICP) by unknown mechanism. Therefore, the aim of the present study was to examine the effect of metformin on BA homeostasis and related molecular pathways in the liver and intestine using a mouse model of ICP. The cholestasis was induced in female C57BL/6 mice by repeated administration of ethinylestradiol (10 mg/kg BW s.c.) and/or metformin (150 mg/kg BW orally) over 5 consecutive days with subsequent bile collection and molecular analysis of samples. We demonstrated that metformin significantly increased the rate of bile secretion in control mice. This increase was BA dependent and was produced both by increased liver BA synthesis via induced cholesterol 7α-hydroxylase (Cyp7a1) and by increased BA reabsorption in the ileum via induction of the apical sodium-dependent BA transporter (Asbt). In contrast, metformin further worsened ethinylestradiol-induced impairment of bile secretion. This reduction was also BA dependent and corresponded with significant downregulation of Bsep, and Ntcp, major excretory and uptake transporters for BA in hepatocytes, respectively. The plasma concentrations of BA were consequently significantly increased in the metformin-treated mice. Altogether, our data indicate positive stimulation of bile secretion by metformin in the intact liver, but this drug also induces serious impairment of BA biliary secretion, with a marked increase in plasma concentrations in estrogen-induced cholestasis. Our results imply that metformin should be used with caution in situations with hormone-dependent cholestasis, such as ICP.

Urinary total arsenic and arsenic methylation capacity in pregnancy and gestational diabetes mellitus: A case-control study

Previous studies suggest arsenic exposure may increase the risk of gestational diabetes mellitus (GDM). However, prior assessments of total arsenic concentrations have not distinguished between toxic and nontoxic species. Our study aimed to investigate the relationships between inorganic arsenic exposure, arsenic methylation capacity, and GDM. Sixty-four cases of GDM and 237 controls were analyzed for urinary concentrations of inorganic arsenic species and their metabolites (arsenite (As3), arsenate (As5), monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA)), and organic forms of arsenic. Inorganic arsenic exposure was defined as the sum of inorganic and methylated arsenic species (iSumAs). Methylation capacity indices were calculated as the percentage of inorganic arsenic species [iAs% = (As3 + As5)/iSumAs, MMA% = MMA/iSumAs, and DMA% = DMA/iSumAs]. Multivariable logistic regression was performed to evaluate the association between inorganic arsenic exposure, methylation capacity indices, and GDM. We did not observe evidence of a positive association between iSumAs and GDM. However, women with GDM had an increased odds of inefficient methylation capacity when comparing the highest and lowest tertiles of iAs% (adjusted odds ratio (aOR) = 1.48, 95% CI 0.58-3.77) and MMA% (aOR = 1.95 (95% CI 0.81-4.70) and a reduced odds of efficient methylation capacity as indicated by DMA% (aOR = 0.62 (95% CI 0.25-1.52), though the confidence intervals included the null value. While the observed associations with arsenic methylation indices were imprecise and warrant cautious interpretation, the direction and magnitude of the relative measures reflected a pattern of lower detoxification of inorganic arsenic exposures among women with GDM.

Placental mobilization of free fatty acids contributes to altered materno-fetal transfer in obesity

BACKGROUND

Metabolic changes in obese pregnant women, such as changes of plasma lipids beyond physiological levels, may subsequently affect fetal development in utero. These metabolic derangements may remain in the offspring and continue throughout life. The placenta mediates bidirectional exchange of nutrients between mother and fetus. The impact of prepregnancy obesity on placental transfer of lipids is still unknown.

OBJECTIVE

We aimed to examine materno-to-fetal free fatty acid (FFA) transfer by a combined experimental and modeling approach. Flux of ¹³C-labeled FFA was evaluated by ex vivo perfusion of human placentae as a function of prepregnancy obesity. Mathematical modeling complemented ex vivo results by providing FFA kinetic parameters.

RESULTS

Obesity was strongly associated with elevated materno-to-fetal transfer of applied ¹³C-FFA. Clearance of polyunsaturated ¹³C-docosahexaenoic acid (DHA) was most prominently affected. The use of the mathematical model revealed a lower tissue storage capacity for DHA in obese compared with lean placentae.

CONCLUSION

Besides direct materno-to-fetal FFA transfer, placental mobilization accounts for the fetal FA supply. Together, with metabolic changes in the mother and an elevated materno-fetal FFA transfer shown in obesity, these changes suggest that they may be transmitted to the fetus, with yet unknown consequences.

Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world

Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.

The risk of complications in second pregnancy by maternal BMI: The role of first-pregnancy complications, pregestational diabetes and chronic hypertension

INTRODUCTION

Maternal obesity is associated with an increased risk of several pregnancy complications. In the second pregnancy, previous pregnancy and other medical history provide additional information about individual morbidity risk. In this study, we assess the risk of pregnancy complications in the second pregnancy by maternal body mass index (BMI) and evaluate how first-pregnancy complications and preexisting conditions modify these associations.

MATERIAL AND METHODS

We have used nationwide data on all women (n = 48 963) experiencing their first and second pregnancy between 2006 and 2013 in Finland. The associations between the full scale of maternal BMI and pregnancy complications (gestational diabetes, gestational hypertension and preeclampsia) were analyzed using logistic regression and restricted cubic spline regression models and interactions between BMI and first-pregnancy complications, pregestational diabetes or chronic hypertension were tested.

RESULTS

The risk of pregnancy complications increased with adiposity. Unadjusted probability of second-pregnancy gestational diabetes with BMI of 25 kg/m² was 56% and 8.4% among women with and without first-pregnancy gestational diabetes, respectively. The corresponding figures with BMI of 30 kg/m² were 64% and 17%. Adjusted odds ratio (OR) (95% CI) for second-pregnancy gestational diabetes with BMI of 25 kg/m² was 45 (34-59) and 3.3 (2.6-4.0) among women with and without first-pregnancy gestational diabetes, respectively, when compared with women with BMI of 20 kg/m² and no first-pregnancy gestational diabetes. Adjusted OR (95% CI) for second-pregnancy gestational hypertension among women with BMI of 25 kg/m² was 42 (26-66) and 2.3 (1.4-3.8) among women with and without first-pregnancy hypertensive disorder, respectively, when compared with women with BMI of 20 kg/m² and no first-pregnancy hypertensive disorder. The risk of preeclampsia increased with adiposity independent of first-pregnancy complications. Pregestational diabetes or chronic hypertension did not modify the association between adiposity and any of the second-pregnancy complications.

CONCLUSIONS

As maternal BMI increases, the risk of complications increases in the second pregnancy. The risk of gestational diabetes and hypertension is, however, highest among women with complications in the first pregnancy.

Pregnancy complications in women of Russian, Somali, and Kurdish origin and women in the general population in Finland

Objective:

We compared the prevalence of gestational diabetes and hypertensive disorders in the most recent pregnancy among women of Russian, Somali, and Kurdish origin and women in the general population in Finland.

Methods:

The study groups were selected from population-based samples of 18- to 64-year-old women. The women were of Russian (n = 318), Somali (n = 583), and Kurdish (n = 373) origin or from the general population (n = 243), and had given birth in Finland between 2004 and 2014. The data were obtained from the National Medical Birth Register and the Hospital Discharge Register. Data on gestational diabetes and hypertensive disorders were extracted based on relevant International Classification of Diseases, Tenth Revision codes. The main statistical methods were logistic regression analyses adjusted for age, parity, body mass index, socioeconomic status, and smoking.

Results:

The prevalence of gestational diabetes was 19.1% in Kurdish, 14.4% in Somali, 9.3% in Russian, and 11.8% in the general population. The prevalence of hypertensive disorders was 5.4% in the general population, 3.8% in Somali, 3.1% in Kurdish, and 1.7% in Russian. When adjusted for confounders, Kurdish women had two-fold odds for gestational diabetes (odds ratio = 1.98; 95% confidence interval = 1.20–3.32) compared with the general population, but the odds for hypertensive disorders did not differ between groups.

Conclusion:

Women of Kurdish origin were more likely to develop gestational diabetes. Studies with larger samples are required to confirm these findings to develop prevention strategies for later development of type 2 diabetes. Future research including other migrant groups is recommended to identify differences in pregnancy complications among the women in migrant and general population.

Artificial intelligence-assisted prediction of preeclampsia: Development and external validation of a nationwide health insurance dataset of the BPJS Kesehatan in Indonesia

Background

We developed and validated an artificial intelligence (AI)-assisted prediction of preeclampsia applied to a nationwide health insurance dataset in Indonesia.

Methods

The BPJS Kesehatan dataset have been preprocessed using a nested case-control design into preeclampsia/eclampsia (n = 3318) and normotensive pregnant women (n = 19,883) from all women with one pregnancy. The dataset provided 95 features consisting of demographic variables and medical histories started from 24 months to event and ended by delivery as the event. Six algorithms were compared by area under the receiver operating characteristics curve (AUROC) with a subgroup analysis by time to the event. We compared our model to similar prediction models from systematically reviewed studies. In addition, we conducted a text mining analysis based on natural language processing techniques to interpret our modeling results.

Findings

The best model consisted of 17 predictors extracted by a random forest algorithm. Nine∼12 months to the event was the period that had the best AUROC in external validation by either geographical (0.88, 95% confidence interval (CI) 0.88–0.89) or temporal split (0.86, 95% CI 0.85–0.86). We compared this model to prediction models in seven studies from 869 records in PUBMED, EMBASE, and SCOPUS. This model outperformed the previous models in terms of the precision, sensitivity, and specificity in all validation sets.

Interpretation

Our low-cost model improved preliminary prediction to decide pregnant women that will be predicted by the models with high specificity and advanced predictors.

Funding

This work was supported by grant no. MOST108-2221-E-038-018 from the Ministry of Science and Technology of Taiwan.

Ursodeoxycholic acid enriches intestinal bile salt hydrolase-expressing Bacteroidetes in cholestatic pregnancy

Ursodeoxycholic acid (UDCA) treatment can reduce itch and lower endogenous serum bile acids in intrahepatic cholestasis of pregnancy (ICP). We sought to determine how it could influence the gut environment in ICP to alter enterohepatic signalling. The gut microbiota and bile acid content were determined in faeces from 35 pregnant women (14 with uncomplicated pregnancies and 21 with ICP, 17 receiving UDCA). Faecal bile salt hydrolase activity was measured using a precipitation assay. Serum fibroblast growth factor 19 (FGF19) and 7α-hydroxy-4-cholesten-3-one (C4) concentrations were measured following a standardised diet for 21 hours. Women with a high ratio of Bacteroidetes to Firmicutes were more likely to be treated with UDCA (Fisher’s exact test p = 0.0178) than those with a lower ratio. Bile salt hydrolase activity was reduced in women with low Bacteroidetes:Firmicutes. Women taking UDCA had higher faecal lithocholic acid (p < 0.0001), with more unconjugated bile acids than women with untreated ICP or uncomplicated pregnancy. UDCA-treatment increased serum FGF19, and reduced C4 (reflecting lower bile acid synthesis). During ICP, UDCA treatment can be associated with enrichment of the gut microbiota with Bacteroidetes. These demonstrate high bile salt hydrolase activity, which deconjugates bile acids enabling secondary modification to FXR agonists, enhancing enterohepatic feedback via FGF19.

Effect of prepregnancy maternal BMI on adverse pregnancy and neonatal outcomes: results from a retrospective cohort study of a multiethnic population in Qatar

BACKGROUND

Given the small number of studies on the topic, we aimed to identify the impact of prepregnancy maternal body mass index (BMI) on adverse pregnancy outcomes (POs) in a low-risk, multiethnic population, and to calculate related population attributable fractions (PAFs).

METHODS

This retrospective cohort study included 1134 nulliparous women of 50 nationalities (classified into Arab and non-Arab ethnicity) in Qatar who had their first antenatal visit at a Primary Healthcare Corporation (PHCC) facility in June 2016-March 2017 and their PO at a Hamad Medical Corporation facility before 10 November 2017. We used multiple imputation to handle missing values and multivariate logistic regression to calculate adjusted ORs (aORs) for adverse POs in overweight and women with obesity.

RESULTS

Overweight Arab women and women with obesity were at high risk for gestational diabetes mellitus (GDM) (aOR=2.38, 95% CI 1.51 to 3.84) and caesarean section (aOR=1.57, 95% CI 1.00 to 2.48). Non-Arab women with obesity were at high risk for pre-eclampsia (aOR=3.83, 95% CI 1.00 to 15.00). PAFs showed that 41.63% of pre-eclampsia, 17.36% of pregnancy-induced hypertension, 17.17% of large for gestational age, 15.89% of preterm deliveries, 14.75% of GDM and 13.99% of caesarean sections could be avoided if all mothers had normal prepregnancy BMI. There were no major differences in PAFs by ethnicity.

CONCLUSION

Adverse POs were attributable to maternal obesity. This suggests that, in contrast to existing PHCC protocol, overweight and women with obesity in Qatar should be targeted earlier in their pregnancy; preferably prior to getting pregnant. We observed ethnic differences in the risk of adverse POs.

Diet induced maternal obesity affects offspring gut microbiota and persists into young adulthood

Accumulating evidence suggests that diet could shape the host gut microbiome composition. Herein, we investigated the effects of maternal high fat diet (HFD) consumption on the gut microbiota and serum profile of mice offspring, and attempted to explore the beneficial roles of maternal probiotics intervention. Female C57BL/6J mice were fed with normal diet, HFD or HFD with daily probiotics (B. breve DM8310, L. acidophilus DM8302, L. casei DM8121 and S. thermophilus DM8309) by gavage starting 6 weeks prior to breeding and continued throughout gestation and lactation. Pups of HFD dams had higher levels of total cholesterol (TC), low-density lipoprotein (LDL), glucose, insulin and leptin compared to those of chow-fed dams. Maternal probiotics intervention resulted in a decrease in the lipid levels in all the pups, while the glucose, insulin and leptin levels were decreased only in adult female pups compared to those from HFD-fed dams; the decreased levels were similar to those in the pups of chow-fed dams. In line with these plasma changes, maternal HFD persistently altered the composition of the offspring gut microbiota in a sex specific way. Maternal probiotics intervention could ameliorate gut microbiota dysbiosis in the offspring. Such intervention showed better effects particularly for the female pups at adulthood. In conclusion, maternal HFD-induced gut microbiota dysbiosis and metabolic disorder could persist through the adulthood of the offspring. Maternal probiotics intervention can negate the detrimental effects of maternal HFD on the gut microbiota and metabolism in the offspring in a sex specific way.

The relationship between maternal weight gain in pregnancy and newborn weight

AIM

This study investigated the impacts of different pre-pregnancy body mass indexes and gestational weight gain on the risk of delivering a high birth weight infant in China.

METHODS

A retrospective cohort study was conducted from 2013 to 2014 in the Maternal and Child Health Care Hospital of Jinan City, Shandong Province and 2415 women who had a singleton birth were included in the study. A logistic regression model and restricted cubic spline regression were used to analyse the association.

FINDINGS

The risk of delivering a high birth weight infant increases when the mother's pre-pregnancy body mass index exceeds 24kg/m². Compared with women whose pre-pregnancy body mass index was 21kg/m², the adjusted risk of delivering a high birth weight infant doubled when the mother's pre-pregnancy body mass index was 29kg/m², and nearly tripled when the mother's pre-pregnancy body mass index was 31kg/m². Compared with women who had a gestational weight gain of 12.0kg, women having a gestational weight gain of 20.0kg, 22.0kg, and 26.0kg had a 1.7-, 2.2-, and 3.5-fold increased risk of delivering a high birth weight infant. When the mother experiences a gestational weight gain greater than 27kg, the risk of delivering a high birth weight infant is at least 4-fold greater than that for a mother who has a gestational weight gain of 12.0kg.

CONCLUSIONS

Proposed strategies to raise public awareness of the risks to infants posed by high maternal pre-pregnancy body mass index and gestational weight gain are required. All clinical recommendations and measures are for all pregnant women, not just overweight and obese pregnant women.

Population-level factors associated with maternal mortality in the United States, 1997-2012

Background

In contrast to peer nations, the United States is experiencing rapid increases in maternal mortality. Trends in individual and population-level demographic factors and health trends may play a role in this change.

Methods

We analyzed state-level maternal mortality for the years 1997–2012 using multilevel mixed-effects regression grouped by state, using publicly available data including whether a state had adopted the 2003 U.S. Standard Certificate of Death, designed to simplify identification of pregnant and recently pregnant decedents. We calculated the proportion of the increase in maternal mortality attributable to specific factors during the study period.

Results

Maternal mortality was associated with higher population prevalence of obesity and high school non-completion among women of childbearing age; these factors explained 31.0% and 5.3% of the attributable increase in maternal mortality during the study period, respectively. Among delivering mothers, prevalence of diabetes (17.0%), attending fewer than 10 prenatal visits (4.9%), and African American race (2.0%) were also associated with higher maternal mortality, as was time-varying state adoption of the 2003 death certificate (31.1%).

Conclusions

Our findings indicate that, in addition to better case ascertainment of maternal deaths, adverse changes in chronic diseases, insufficient healthcare access, and social determinants of health represent identifiable risks for maternal mortality that merit prompt attention in population-directed interventions and health policies.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5935-2) contains supplementary material, which is available to authorized users.

Fasting glucose concentrations and associations with reproductive history over 40 years of follow-up

Gestational diabetes mellitus (GDM) is the onset or first recognition of diabetes that occurs during pregnancy. We aimed to assess for trends in fasting blood glucose levels across the life-course among a cohort of women by reproductive history: nulligravid women, gravid women with and without a history of GDM. Women who had participated in the Bogalusa Heart Study as children were interviewed about their reproductive history, including GDM (n = 358). We compared fasting blood glucose (mg/dL) measured after last pregnancy (or after age 40 among nulligravid women) across reproductive history groups in linear models adjusted for prepregnancy fasting blood glucose, body mass index, race, parity, and age at outcome measure. We fit a log-Poisson model to estimate the associations with prediabetes risk after age 40. After adjustments, mean fasting glucose after age 40 was not different between gravid women without GDM history and nulligravid women. However, women with a history of GDM had mean fasting glucose 27 mg/dL greater than nulligravid women (95% CI = 12.35, 41.64). Heterogeneity by race indicated Black women with a history of GDM had disproportionately elevated mean fasting glucose after age 40. Fasting blood glucose trends over the life-course differ among women by reproductive history and race.

The Impact of Prepregnancy Body Mass Index and Gestational Weight Gain on Perinatal Outcomes for Women With Gestational Diabetes Mellitus

BACKGROUND

Gestational diabetes mellitus (GDM), an obstetric disease that affects the health of pregnant women, is one of the key factors associated with perinatal mortality or disease.

AIMS

To explore the impact of prepregnancy body mass index (BMI) and gestational weight gain (GWG) on perinatal outcomes for women with GDM.

METHODS

With a retrospective study design, women were recruited who received prenatal checkups, gave birth at two teaching hospitals in southern Taiwan from 1995 to 2011, and received a diagnosis of GDM by an obstetrician. A trained research assistant collected the participants' data in each hospital's archives room. The researcher used a retrospective case study method to identify women who received a GDM diagnosis between 1995 and 2011.

RESULTS

Women with GDM and with an overweight prepregnancy BMI were more likely to have cesarean deliveries and to use glucose-lowering medicines after delivery. Their newborns also had a higher birth weight. In addition, gestational hypertension and cesarean delivery were more common in women with GDM and with excessive GWG than in women with GDM and with normal GWG. The newborns of women with GDM and with excessive GWG had higher birth weights and more nuchal cord than those of women with GDM and with normal GWG. More women with GDM and with excessive GWG underwent blood glucose monitoring than did women with GDM and with normal GWG.

LINKING EVIDENCE TO ACTION

The prepregnancy weight and GWG significantly affected perinatal outcomes in both the women with GDM themselves and their newborns. Healthcare professionals must provide childbearing women with additional health education in the areas of health promotion, nutrition, weight control, exercise, and maintaining regular everyday lives.

Adiponectin and leptin as first trimester markers for gestational diabetes mellitus: a cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) is increasing partly due to the obesity epidemic. Adipocytokines have thus been suggested as first trimester screening markers for GDM. In this study we explore the associations between body mass index (BMI) and serum concentrations of adiponectin, leptin, and the adiponectin/leptin ratio. Furthermore, we investigate whether these markers can improve the ability to screen for GDM in the first trimester.

METHODS

A cohort study in which serum adiponectin and leptin were measured between gestational weeks 6+0 and 14+0 in 2590 pregnant women, categorized into normal weight, moderately obese, or severely obese.

RESULTS

Lower concentrations of adiponectin were associated with GDM in all BMI groups; the association was more pronounced in BMI<35 kg/m2 (p=0.30 for interaction). Leptin was inversely associated with GDM in severely obese (p=0.033), but showed no association in women with BMI<35 kg/m2. The adiponectin/leptin ratio was associated with GDM in women with BMI<35 kg/m2 but not in severely obese women (p=0.79). In regard to predicting GDM, maternal characteristics combined with adiponectin alone, adiponcetin and leptin, and adiponcetin/leptin ratio had the strongest associations in women with BMI<35 kg/m2. These models had a detection rate of 77.3%-80.3% when the false positive rate was fixed at 25%.

CONCLUSIONS

Low adiponectin measured in the first trimester is associated with the development of GDM; higher BMI was associated with lower performance of adiponectin, though this was insignificant. Leptin had an inverse relationship with GDM in severely obese women and did not improve the ability to predict GDM.

Gestational diabetes mellitus and interpregnancy weight change: A population-based cohort study

BACKGROUND

Being overweight is an important risk factor for Gestational Diabetes Mellitus (GDM), but the underlying mechanisms are not understood. Weight change between pregnancies has been suggested to be an independent mechanism behind GDM. We assessed the risk for GDM in second pregnancy by change in Body Mass Index (BMI) from first to second pregnancy and whether BMI and gestational weight gain modified the risk.

METHODS AND FINDINGS

In this observational cohort, we included 24,198 mothers and their 2 first pregnancies in data from the Medical Birth Registry of Norway (2006-2014). Weight change, defined as prepregnant BMI in second pregnancy minus prepregnant BMI in first pregnancy, was divided into 6 categories by units BMI (kilo/square meter). Relative risk (RR) estimates were obtained by general linear models for the binary family and adjusted for maternal age at second delivery, country of birth, education, smoking in pregnancy, interpregnancy interval, and year of second birth. Analyses were stratified by BMI (first pregnancy) and gestational weight gain (second pregnancy). Compared to women with stable BMI (-1 to 1), women who gained weight between pregnancies had higher risk of GDM-gaining 1 to 2 units: adjusted RR 2.0 (95% CI 1.5 to 2.7), 2 to 4 units: RR 2.6 (2.0 to 3.5), and ≥4 units: RR 5.4 (4.0 to 7.4). Risk increased significantly both for women with BMI below and above 25 at first pregnancy, although it increased more for the former group. A limitation in our study was the limited data on BMI in 2 pregnancies.

CONCLUSIONS

The risk of GDM increased with increasing weight gain from first to second pregnancy, and more strongly among women with BMI < 25 in first pregnancy. Our results suggest weight change as a metabolic mechanism behind the increased risk of GDM, thus weight change should be acknowledged as an independent factor for screening GDM in clinical guidelines. Promoting healthy weight from preconception through the postpartum period should be a target.

Maternal childhood cardiometabolic risk factors and pregnancy complications

PURPOSE

The influence of childhood health on later-life health outcomes is increasingly hypothesized but rarely tested. We examined the relationship between cardiometabolic indicators in childhood and risk of pregnancy-induced hypertension, preeclampsia, and gestational diabetes.

METHODS

Childhood measurements from 755 women in the Bogalusa Heart Study included body mass index, systolic and diastolic blood pressure (SBP and DBP), low- and high-density lipoprotein cholesterol, total cholesterol, triglycerides, insulin, and glucose. Average childhood values were estimated by area under the curve computed from longitudinal quadratic random-effects growth models to account for the unequally spaced repeated measures. Women reported pregnancy complications, and medical records were linked to interview data where possible. Log-Poisson models predicted adjusted risk associated with an interquartile range increase in cardiometabolic indicators.

RESULTS

Elevated childhood insulin was associated with 10%-15% increased risk across the three outcomes. Elevated childhood SBP was associated with preeclampsia (SBP RR = 1.50, 95% CI: 1.13, 2.01) and SBP, DBP, and body mass index predicted pregnancy-induced hypertension (SBP RR = 2.15, 95% CI: 1.65, 2.82; DBP RR = 1.83, 95% CI: 1.38, 2.43; BMI RR = 1.67, 95% CI: 1.41, 1.98). Blood pressure mediated the association between childhood body mass index and pregnancy-induced hypertension.

CONCLUSIONS

Results suggest the potential long-term impact of early-life cardiometabolic profiles on complications of pregnancy.

Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management

Bariatric surgery is today the most effective long-term therapy for the management of patients with severe obesity, and its use is recommended by the relevant guidelines of the management of obesity in adults. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. In the present recommendations, the basic notions needed to provide first-level adequate medical care to post-bariatric patients are summarised. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. A short list of clinical practical recommendations is included for each item. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations.

Utilization of Large Data Sets in Maternal Health in Finland: A Case for Global Health Research

In recent years, the use of large data sets, such as electronic health records, has increased. These large data sets are often referred to as "Big Data," which have various definitions. The purpose of this article was to summarize and review the utilization, strengths, and challenges of register data, which means a written record containing regular entries of items or details, and Big Data, especially in maternal nursing, using 4 examples of studies from the Finnish Medical Birth Register data and relate these to other international databases and data sets. Using large health register data is crucial when studying and understanding outcomes of maternity care. This type of data enables comparisons on a population level and can be utilized in research related to maternal health, with important issues and implications for future research and clinical practice. Although there are challenges connected with register data and Big Data, these large data sets offer the opportunity for timely insight into population-based information on relevant research topics in maternal health. Nurse researchers need to understand the possibilities and limitations of using existing register data in maternity research. Maternal child nurse researchers can be leaders of the movement to utilize Big Data to improve global maternal health.

Health beliefs and stages of changes to improve behaviors among obese and overweight women undergoing preconception care

Background:

Beginning and continuing pregnancy with obesity and being overweight has some known side effects for the mother and the fetus. Preventing these complications requires medical interventions before pregnancy. Because designing health improvement interventions requires understanding of the related factors of the behavior, the aim of this study was to determine the relation between health beliefs of women regarding the risks of obesity for pregnancy and stages of behavioral changes in women under preconception care.

Materials and Methods:

This study was a cross-sectional study that was conducted on 120 obese and overweight women under preconception care. Health belief structures including perceived sensitivity/intensity, perceived benefits, perceived barriers, and perceived self-efficacy were measured using a questionnaire, and its relation with stages of nutrition and physical activity behavior changes was evaluated according to a transtheoretical model.

Results:

Results showed a significant correlation between the stage of nutrition behavioral change and perceived sensitivity/intensity, perceived benefits, and self-efficacy (P < 0.05). In addition, the stage of physical activity behavioral change showed a negative and significant correlation with perceived barriers and a positive and low-to-moderate significant correlation with other health belief structures (P < 0.05). Furthermore, the relation of perceived sensitivity/intensity with perceived benefits and self-efficacy was positive and significant, and that with perceived barriers was negative and significant (P < 0.01).

Conclusions:

Results showed that a health belief model could be a predictor of weight adjustment behaviors including nutrition and physical activity behaviors. Therefore, educational interventions based on a health belief model could be effective for improvement of these behaviors in obese and overweight women under preconception care.