Interpregnancy weight change and adverse pregnancy outcomes: a systematic review and meta-analysis

Quantifying the effect of interpregnancy maternal weight and smoking status changes on childhood overweight and obesity in a UK population-based cohort

BACKGROUND

Maternal preconception and pregnancy exposures have been linked to offspring adiposity. We aimed to quantify the effect of changes in maternal weight and smoking status between pregnancies on childhood overweight/obesity (≥ 85th centile) and obesity (≥ 95th centile) rates in second children.

METHODS

Records for 5612 women were drawn from a population-based cohort of routinely collected antenatal healthcare records (2003-2014) linked to measured child body mass index (BMI) age 4-5 years. We applied the parametric G-formula to estimate the effect of hypothetical changes between pregnancy-1 and pregnancy-2 compared to the natural course scenario (without change) on child-2 BMI.

RESULTS

Observed overweight/obesity and obesity in child-2 at age 4-5 years were 22.2% and 8·5%, respectively. We estimated that if all mothers started pregnancy-2 with BMI 18·5-24·9 kg/m² and all smokers stopped smoking, then child-2 overweight/obesity and obesity natural course estimates of 22.3% (95% CI 21.2-23.5) and 8·3% (7·6-9·1), would be reduced to 18.5% (17.4-19.9) and 6.2% (5.5-7.0), respectively. For mothers who started pregnancy-1 with BMI 18·5-24·9 kg/m², if all smokers stopped smoking, child-2 overweight/obesity and obesity natural course estimates of 17.3% (16.0-18.6) and 5·9% (5·0-6·7) would be reduced to 16.0% (14.6-17.3) and 4·9% (4·1-5·7), respectively. For mothers who started pregnancy-1 with BMI ≥30 kg/m², if BMI was 18·5-24·9 kg/m² prior to pregnancy-2, child-2 overweight/obesity and obesity natural course estimates of 38.6% (34.7-42.3) and 17·7% (15·1-20·9) would be reduced to 31.3% (23.8-40.0) and 12.5 (8.3-17.4), respectively. If BMI was 25.0-29.9 kg/m² prior to pregnancy-2, these estimates would be 34.5% (29.4-40.4) and 14.6% (11.2-17.8), respectively.

CONCLUSION

Interventions supporting women to lose/maintain weight and quit smoking between pregnancies could help reduce rates of overweight/obesity and obesity in second children. The most effective interventions may vary by maternal BMI prior to the first pregnancy.

Interpregnancy maternal weight change is not associated with offspring weight and obesity at age 2 years

BACKGROUND

Weight retention between pregnancies is associated with increased risk of perinatal complications, but it is unclear whether there is an association with offspring weight status. This study aimed to determine whether maternal interpregnancy weight change is associated with offspring overweight/obesity, controlling for confounding variables.

SUBJECTS/METHODS

Routinely collected linked data from perinatal and child datasets, in Flanders, Belgium were used. Women having their first and second live births between 2009-2018 were included. The association between maternal interpregnancy weight change and overweight/obesity in the second child at 2 years was examined by logistical regression models.

RESULTS

A total of 33,172 women were included. 52.7% (n = 17478) had a stable interpregnancy BMI, 24.1% (n = 8024) and 8.5% (n = 2821) had moderate and substantial BMI increases respectively. At 2 years, 91.6% (n = 30383) of the second offspring had a healthy weight, 0.6% (n = 210), 7.0% (n = 2312) and 0.8% (n = 267) were in the underweight, overweight and obesity BMI categories respectively. Multivariate analysis showed no statistical evidence that maternal interpregnancy BMI change is independently associated with overweight/obesity in the second child. The strongest independent factors were the first child (sibling) being in the obesity category at 2 years (odds ratio [OR] 7.2, [95% CI, 5.49-9.45] and being born Large for Gestational Age (LGA) (2.13 [1.92-2.37]). The following variables were also independently associated with the outcome measure: maternal African origin (1.90 [1.59-2.26]), maternal obesity at start of first pregnancy (1.33 [1.16-1.53]), excessive gestational weight gain in the second pregnancy (1.15 [1.04-1.28]), being born after a < 1-year interpregnancy time interval (1.17 [1.05-1.30]) and not being exclusively breastfed at 12 weeks old (1.29 [1.10-1.52]).

CONCLUSION

Sibling obesity and being born LGA were most strongly independently associated with overweight/obesity at 2 years. This supports the need for family interventions and to address risk factors for development of LGA infants. There was no independent association with interpregnancy weight gain, contrary to what was hypothesised.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gestational weight trajectory and risk of adverse pregnancy outcomes among women with gestational diabetes mellitus: A retrospective cohort study

The aim of this study was to explore gestational weight gain (GWG) trajectories and their associations with adverse pregnancy outcomes. A retrospective cohort study including 11,064 women with gestational diabetes mellitus (GDM) was conducted between 2015 and 2019 in China. The latent class trajectory model was used to identify GWG trajectories, and logistic regression was performed to examine odds ratio (OR) of pregnancy outcomes. Three trajectories of GWG were identified in these 11,604 women with GDM. Trajectory 1: 64.02% of women had sustained moderate GWG throughout pregnancy; Trajectory 2: 17.75% of women showed a high initial GWG but followed by a low GWG from the third trimester until delivery; Trajectory 3: 18.23% had low initial GWG but followed by drastic GWG from the second trimester until delivery. Compared with pregnant women with Trajectory 1, women with Trajectory 2 had a higher risk of large for gestational age (adjusted odds ratio [AOR]: 1.29, 95% confidence interval [CI]: 1.12-1.48) but at a lower risk of having hypertensive disorders of pregnancy (AOR: 0.76, 95% CI: 0.57-0.96). Women in Trajectory 3 were more likely to develop small for gestational age (AOR: 2.12, 95% CI: 1.62-2.78), low birthweight (AOR: 1.49, 95% CI: 1.07-2.08), preterm birth (AOR: 1.28, 95% CI: 1.05-1.63), caesarean section (AOR: 1.26, 95% CI: 1.112-1.42) and hypertensive disorders of pregnancy (AOR: 2.24, 95% CI: 1.82-2.76). The association of GWG trajectory with adverse pregnancy outcomes differs across prepregnancy body mass index and GWG categories. Women with a slow initial GWG but followed by drastic GWG had higher risks of adverse pregnancy outcomes. Early clinical recognition of poor GWG trajectory will contribute to early intervention in high-risk groups to minimise adverse outcomes.

Impact of interpregnancy weight changes and perinatal outcomes: A retrospective study in Japan

Previous studies have shown that interpregnancy weight fluctuations impact perinatal outcomes. In order to examine this in Japanese women, we analyzed the data of 2,861 women in their first and second pregnancies who delivered singletons between 2000 and 2022. We compared the second pregnancy perinatal outcomes of women whose interpregnancy body mass index (BMI) change was -1 to 1 unit with those of women whose BMI change was < -1 or ≥ 1 unit. An interpregnancy BMI change ≥ 1 unit was associated with an increased risk of developing gestational diabetes mellitus (adjusted odds ratio [aOR], 1.51; 95% confidence interval [CI], 1.18-1.95) and delivering a large for gestational age neonate (aOR, 1.67; 95% CI, 1.15-2.42) but a decreased risk of preterm birth (aOR, 0.66; 95% CI, 0.46-0.95). An interpregnancy BMI change < -1 unit was associated with a decreased risk of developing gestational diabetes mellitus (aOR, 0.51; 95% CI, 0.31-0.85). In a subgroup analysis of three groups divided according to prepregnancy BMI, interpregnancy BMI changes ≥ 1 unit in women with a BMI of < 18.5 kg/m2 before their first pregnancy were associated with a remarkable risk reduction of developing preterm birth (aOR, 0.30; 95% CI, 0.11-0.81). Interpregnancy BMI changes < -1 unit in women with a BMI of ≥ 25 kg/m2 before their first pregnancy were associated with a remarkable risk reduction of developing gestational diabetes mellitus (aOR, 0.33; 95% CI, 0.12-0.88). Weight gain during interpregnancy period was related to an increased risk of gestational diabetes mellitus and delivery of a large-for-gestational-age neonate, whereas weight loss was related to a decreased risk of developing gestational diabetes mellitus. These results indicate the importance of interpregnancy weight control as part of preconception care; therefore, women considering additional pregnancies should be educated on the importance of maintaining a healthy weight.

Preconception maternal gastric bypass surgery and the impact on fetal growth parameters

BACKGROUND

Bariatric surgery is increasingly performed in women of reproductive age. As bariatric surgery will result in postoperative rapid catabolic weight loss which potentially leads to fetal malnutrition and directly related impaired intra-uterine growth, it is advised to postpone pregnancy for at least 12-18 months after surgery.

OBJECTIVES

To investigate the consequences of preconception gastric bypass surgery (pGB) on fetal growth parameters and maternal pregnancy outcome.

SETTING

Maasstad Hospital, The Netherlands, general hospital and Erasmus Medical Center, The Netherlands, university hospital.

METHODS

We included 97 pGB pregnancies (Maasstad hospital) and 440 non-bariatric pregnancies (Rotterdam Periconception cohort, Erasmus Medical Center). Longitudinal second and third trimester fetal growth parameters (head circumference, biparietal diameter, femur length, abdominal circumference, estimated fetal weight) were analyzed using linear mixed models, adjusting for covariates and possible confounders. Fetal growth and birthweight in pGB pregnancies were compared to non-bariatric pregnancies and Dutch reference curves. Maternal pregnancy outcome in the pGB group was compared to non-bariatric pregnancies.

RESULTS

All fetal growth parameters of pGB pregnancies were significantly decreased at 20 weeks' gestation (P < .001) and throughout the remaining part of pregnancy (P < .05) compared with non-bariatric pregnancies (crude and adjusted models). In our cohort, gestational weight gain was not significantly associated with birthweight corrected for gestational age. Birthweight was significantly lower in pGB pregnancies (estimate -241 grams [95% CI, -342.7 to -140.0]) with a 2-fold increased risk of small-for-gestational-age (SGA) (adjusted odds ratio 2.053 [95% CI, 1.058 to 3.872]). Compared to the non-bariatric pregnancies, we found no significant differences in maternal pregnancy outcome.

CONCLUSIONS

PGB is associated with overall reduced fetal growth trajectories and a 2-fold increased risk of SGA, without significant adverse consequences for maternal pregnancy outcome. We recommend close monitoring of fetal growth after pGB.

Interpregnancy weight change and risks of stillbirth and infant mortality: a protocol of a systematic review and meta-analysis

INTRODUCTION

Interpregnancy weight change may impact two important adverse perinatal outcomes: stillbirth and infant mortality. This systematic review aims to synthesise the existing evidence on the association between interpregnancy weight change and stillbirth and infant mortality.

METHODS AND ANALYSIS

This systematic review and meta-analysis will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols guidelines and has been registered in the International Prospective Register of Systematic Reviews (PROSPERO). A comprehensive literature search of four online databases (Embase, Cochrane Libraries, Web of Science and Medline) will be conducted from inception to October 2023. Observational (longitudinal, cohort, case-control) and randomised controlled trials will be included. Interpregnancy weight/body mass index change between two consecutive pregnancies will be the exposure. The primary outcomes will be the incidence of stillbirth and infant mortality in subsequent pregnancy. The Cochrane Risk of Bias tool will be used to assess the risk of bias in the randomised controlled studies and the Risk of Bias in Non-Randomised Studies of Interventions tool will be used for observational studies. If there are sufficient data, a meta-analysis will be conducted to estimate the pooled effect size. Otherwise, qualitative descriptions of individual studies will be summarised. The heterogeneity will be statistically assessed using a χ2 test and I2 statistic.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study as all results will be based on published papers. No primary data collection will be needed. Study findings will be presented at scientific conferences or published in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

A registration for this review has been submitted to PROSPERO under CRD42020222977.

Interpregnancy weight change as a potential risk factor for large-for-gestational-age infants: the Japan Environment and Children's Study

OBJECTIVE

This study aimed to estimate the impact of interpregnancy weight change from the first to the second pregnancy on the risk of infants being large for gestational age (LGA).

METHODS

This nationwide prospective birth cohort analysis included 3245 women who delivered their first two live singletons between 2011 and 2014. Interpregnancy weight change was calculated as the difference between the prepregnancy body mass index (BMI) of the first and second pregnancies. LGA infants were compared among three interpregnancy weight change groups: weight loss (a BMI loss >1 unit), weight gain (a BMI gain >1 unit), and stable weight (BMI maintained within - 1 to <1 unit). Interpregnancy weight change was assessed in mothers with a BMI <25 and ≥25 kg/m², and adjusted odds ratios (ORs) were calculated for LGA infants by multiple logistic regression.

RESULTS

The incidence of LGA infants was 8.6% (279 out of 3245). Compared with the stable weight group, interpregnancy weight gain was associated with an increased risk of infants being LGA (adjusted OR: 1.69, 95% confidence interval: 1.21-2.36) in the normal BMI (<25 kg/m²) group. In contrast, in the overweight/obese BMI (≥25 kg/m²) group, interpregnancy BMI was not a significant risk factor for LGA infants.

CONCLUSIONS

Accurate risk stratification using interpregnancy BMI could assist the clinical management of women with a normal BMI who are at risk of delivering LGA infants.

Maternal Body Mass Index Trends and Weight Gain in Singleton Pregnancies at the Time of Fetal Anatomic Survey: Changes in the Last Decade and New Trends in the Modern Era

(1) Background: the worldwide impact of overweight and obesity is rising, increasingly resembling an epidemic (a price we have to pay for our new way of living). (2) Methods: our study aims to evaluate the temporal trends and patterns of singleton pregnant women's BMI (body mass index) in our region during a 12-year time frame between 2010 and 2021. (3) Results: We noticed a statistically significant difference between the BMIs of nulliparous and multiparous women and a significantly increased pregestational BMI in women with previous ART (assisted reproductive technology) procedures. Smoking pregnant women had a higher second trimester weight gain, regardless of parity. Women with folic acid supplementation alone had a higher BMI than those with folic acid and multivitamin intake. The weight of both nulliparous and multiparous women with chronic hypertension was statistically significantly higher in all three timeframes. Global weight gain did not reveal any statistically significant changes concerning women with pregestational diabetes, regardless of parity and the pregnancy trimester. (4) Conclusions: our article describes the trends in obesity and overweight in our middle-income country, in which this pathology is continuously growing, negatively influencing our reproductive-aged women and future generations.

A pre-conception clinical trial to reduce intergenerational obesity and diabetes risks: The NDPP-NextGen trial protocol

BACKGROUND

Intrauterine exposure to maternal overweight/obesity or diabetes transmits risks to offspring, perpetuating a disease cycle across generations. Prenatal interventions to reduce maternal weight or dysglycemia have limited impact, while postpartum interventions can alter the intrauterine environment only if child-bearing continues. Efficacious preconception interventions are needed, especially for underserved populations, and with the potential to be scaled up sustainably. Research is also needed to assess intervention effects at conception, throughout pregnancy, and among offspring.

METHODS

This two-arm, parallel randomized clinical trial will include 360 biological females with overweight/obesity and moderate-to-high likelihood of pregnancy within 24 months. Participants will be randomized 1:1 to a yearlong pre-conception lifestyle intervention based on the National Diabetes Prevention Program (NDPP-NextGen) or usual care. Data collection will occur at enrollment (before conception), post-conception (<8 weeks gestation), late pregnancy (28-32 weeks gestation), and delivery (before discharge) for participants who become pregnant within 24 months of enrollment. Main outcomes are post-conception body mass index (<8 weeks gestation; primary outcome), post-conception fasting glucose (<8 weeks gestation; secondary outcome), and neonatal adiposity (<2 days post-birth). Additional clinical, behavioral, perinatal and offspring data will be collected, and biospecimens (blood, urine, stool, cord blood) will be banked for future ancillary studies.

CONCLUSION

This clinical trial will evaluate an intervention model (NDPP-NextGen) with potential to improve maternal health among the >50% of US females with overweight/obesity or diabetes risks in pregnancy. If successful, it can be scaled among >1800 organizations delivering NDPP in the United States to benefit the health of future generations.

Maternal and child nutrition programme of investigation within the 100 Million Brazilian Cohort: study protocol

INTRODUCTION

There is a limited understanding of the early nutrition and pregnancy determinants of short-term and long-term maternal and child health in ethnically diverse and socioeconomically vulnerable populations within low-income and middle-income countries. This investigation programme aims to: (1) describe maternal weight trajectories throughout the life course; (2) describe child weight, height and body mass index (BMI) trajectories; (3) create and validate models to predict childhood obesity at 5 years of age; (4) estimate the effects of prepregnancy BMI, gestational weight gain (GWG) and maternal weight trajectories on adverse maternal and neonatal outcomes and child growth trajectories; (5) estimate the effects of prepregnancy BMI, GWG, maternal weight and interpregnancy BMI changes on maternal and child outcomes in the subsequent pregnancy; and (6) estimate the effects of maternal food consumption and infant feeding practices on child nutritional status and growth trajectories.

METHODS AND ANALYSIS

Linked data from four different Brazilian databases will be used: the 100 Million Brazilian Cohort, the Live Births Information System, the Mortality Information System and the Food and Nutrition Surveillance System. To analyse trajectories, latent-growth, superimposition by translation and rotation and broken stick models will be used. To create prediction models for childhood obesity, machine learning techniques will be applied. For the association between the selected exposure and outcomes variables, generalised linear models will be considered. Directed acyclic graphs will be constructed to identify potential confounders for each analysis investigating potential causal relationships.

ETHICS AND DISSEMINATION

This protocol was approved by the Research Ethics Committees of the authors' institutions. The linkage will be carried out in a secure environment. After the linkage, the data will be de-identified, and pre-authorised researchers will access the data set via a virtual private network connection. Results will be reported in open-access journals and disseminated to policymakers and the broader public.

Exploring Health Behaviours, Attitudes and Beliefs of Women and Men during the Preconception and Interconception Periods: A Cross-Sectional Study of Adults on the Island of Ireland

Preconception health is increasingly seen as a key target for improving population health in the UK and Ireland, yet little is known about the attitudes and beliefs of adults regarding preconception care strategies. This online cross-sectional survey aimed to explore the health behaviours, attitudes and beliefs of adults of reproductive age in regard to preconception health and care. The survey was developed by reviewing the previous literature and engaging with those from the target group. It is one of the first surveys to assess the attitudes and beliefs of adults of reproductive age across the Island of Ireland regarding preconception health and care. Results from 386 individuals with a mean age of 29.9 ± 10.3 years were included. A variety of health behaviours, attitudes and beliefs were investigated, with differences being identified between women and men and between participants with or without children (i.e., in the preconception or interconception stage). The majority of respondents held beliefs that preconception care was important, but there was greater emphasis on women than men in terms of the need to engage in health-promoting preconception health behaviours. This study highlights the need to improve preconception health awareness in women and men in the preconception and interconception stage. Findings indicate that efforts to improve preparation for pregnancy among adults of childbearing age are needed, to ensure optimal engagement in preconception health behaviours, with efforts being tailored based on sex and parental status.

Addressing inequalities and improving maternal and infant outcomes: the potential power of nutritional interventions across the reproductive cycle

Maternal nutrition is essential for optimal health and well-being of women and their infants. This review aims to provide a critical overview of the evidence-base relating to maternal weight, obesity-related health inequalities and dietary interventions encompassing the reproductive cycle: preconception, pregnancy, postnatal and interpregnancy. We provide an overview of UK data showing that overweight and obesity affects half of UK pregnancies, with increased prevalence among more deprived and minoritised ethnic populations, and with significant health and cost implications. The existing intervention evidence-base primarily focuses on the pregnancy period, where extensive evidence demonstrates the power of interventions to improve maternal diet behaviours, and minimise gestational weight gain and postnatal weight retention. There is a lack of consistency in the intervention evidence-base relating to interventions improving pregnancy health outcomes, although there is evidence of the potential power of the Mediterranean and low glycaemic index diets in improving short- and long-term health of women and their infants. Postnatal interventions focus on weight loss, with some evidence of cost-effectiveness. There is an evidence gap for preconception and interpregnancy interventions. We conclude by identifying that interventions do not address cumulative maternal obesity inequalities and overly focus on individual behaviour change. There is a lack of a joined-up approach for interventions throughout the entire reproductive cycle, with a current focus on specific stages (i.e. pregnancy) in isolation. Moving forward, the potential power of nutritional interventions using a more holistic approach across the different reproductive stages is needed to maximise the benefits on health for women and children.

Trends in Gestational Weight Gain in Louisiana, March 2019 to March 2022

Importance

Average gestational weight gain (GWG) increased during the COVID-19 pandemic, but it is not known whether this trend has continued.

Objective

To examine patterns of GWG during the COVID-19 pandemic by delivery and conception timing through the second year of the pandemic.

Design, Setting, and Participants

This cohort study is a retrospective review of birth certificate and delivery records from 2019 to 2022. Electronic health records were from the largest delivery hospital in Louisiana. Participants included all individuals giving birth from March 2019 to March 2022. Data analysis was performed from October 2022 to July 2023.

Exposure

Delivery date (cross-sectionally) and conception before the pandemic (March 2019 to March 2020) and during the peak pandemic (March 2020 to March 2021) and late pandemic (March 2021 to March 2022).

Main Outcomes and Measures

The primary outcome was GWG (total GWG and adherence to the 2009 Institute of Medicine recommendations) analyzed using linear and log-linear regression with control for covariates.

Results

Among 23 012 total deliveries (8763 Black individuals [38.1%]; 11 774 White individuals [51.2%]; mean [SD] maternal age, 28.9 [5.6] years), 3182 individuals (42.0%) exceeded the recommended weight gain in the year proceeding the pandemic, 3400 (45.4%) exceeded recommendations during the peak pandemic, and 3273 (44.0%) exceeded recommendations in the late pandemic. Compared with those who delivered before the pandemic (reference), participants had higher total GWG if they delivered peak or late pandemic (adjusted β [SE], 0.38 [0.12] kg vs 0.19 [0.12] kg; P = .007). When cohorts were defined by conception date, participants who conceived before the pandemic but delivered after the pandemic started had higher GWG compared with those whose entire pregnancy occurred before the pandemic (adjusted β [SE], 0.51 [0.16] kg). GWG was lower in the pregnancies conceived after the pandemic started and the late pandemic (adjusted β [SE], 0.29 [0.12] kg vs 0.003 [0.14] kg; P = .003) but these participants began pregnancy at a slightly higher weight. Examining mean GWG month by month suggested a small decrease for March 2020, followed by increased mean GWG for the following year. Individuals with 2 pregnancies (1289 individuals) were less likely to gain weight above the recommended guidelines compared with their prepandemic pregnancy, but this association was attenuated after adjustment.

Conclusions and Relevance

In this cohort, individuals with critical time points of their pregnancy during the COVID-19 pandemic gained more weight compared with the previous year. The increased GWG leveled off as the pandemic progressed but individuals were slightly heavier beginning pregnancy.

Physical Activity as a Modern Intervention in the Fight against Obesity-Related Inflammation in Type 2 Diabetes Mellitus and Gestational Diabetes

Diabetes is one of the greatest healthcare problems; it requires an appropriate approach to the patient, especially when it concerns pregnant women. Gestational diabetes mellitus (GDM) is a common metabolic condition in pregnancy that shares many features with type 2 diabetes mellitus (T2DM). T2DM and GDM induce oxidative stress, which activates cellular stress signalling. In addition, the risk of diabetes during pregnancy can lead to various complications for the mother and foetus. It has been shown that physical activity is an important tool to not only treat the negative effects of diabetes but also to prevent its progression or even reverse the changes already made by limiting the inflammatory process. Physical activity has a huge impact on the immune status of an individual. Various studies have shown that regular training sessions cause changes in circulating immune cell levels, cytokine activation, production and secretion and changes in microRNA, all of which have a positive effect on the well-being of the diabetic patient, mother and foetus.

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

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

Association between prepregnancy weight change and risk of gestational diabetes mellitus in Chinese pregnant women

BACKGROUND

Evidence regarding prepregnancy weight change and gestational diabetes mellitus (GDM) is lacking among East Asian women.

OBJECTIVE

Our study aimed to investigate the association between weight change from age 18 years to pregnancy and GDM in Chinese pregnant women.

METHODS

Our analyses included 6972 pregnant women from the Tongji-Shuangliu Birth Cohort. Body weights were recalled for age 18 years and the time point immediately before pregnancy, while height was measured during early pregnancy. Prepregnancy weight change was calculated as the difference between weight immediately before pregnancy and weight at age 18 years. GDM outcomes were ascertained by 75-g oral glucose tolerance test. Multivariable logistic regression models were used to estimate the association between prepregnancy weight change and risk of GDM.

RESULTS

501 (7.2%) developed GDM in the cohort. After multivariable adjustments, prepregnancy weight change was linearly associated with a higher risk of incident GDM (P < 0.001). Compared with participants with stable weight (weight change within 5.0 kg) before pregnancy, multivariable-adjusted odds ratios and 95% confidence intervals were 1.55 (1.22, 1.98) and 2.24 (1.78, 2.83) for participants with moderate (weight gain of 5-9.9 kg) and high (weight gain ≥ 10 kg) weight gain, respectively. In addition, overweight/obesity immediately before pregnancy mediated 17.6% and 31.7% of the associations of moderate and high weight gain with GDM risk, while weekly weight gain during pregnancy mediated 21.1% and 22.7% of the associations.

CONCLUSIONS

Weight gain from age 18 years to pregnancy was significantly associated with a higher risk of GDM. Maintaining weight stability, especially prevention of excessive weight gain from early adulthood to pregnancy could be a potential strategy to reduce GDM risk.

Distribution and association of interpregnancy weight change with subsequent pregnancy outcomes in Asian women

The extent of interpregnancy weight change and its association with subsequent pregnancy outcomes among Asians remain unclear. We examined changes in maternal body mass index (BMI) between the first two deliveries and outcomes in the second delivery. Medical records of women with their first two consecutive deliveries between 2015 and 2020 at KK Women's and Children's Hospital, Singapore were retrieved. Gestational-age-adjusted BMI was determined by standardising to 12 weeks gestation and interpregnancy BMI change was calculated as the difference between both pregnancies. Pregnancy outcomes were analysed using modified Poisson regression models. Of 6264 included women with a median interpregnancy interval of 1.44 years, 40.7% had a stable BMI change within ± 1 kg/m², 10.3% lost > 1 kg/m², 34.3% gained 1-3 kg/m² and 14.8% gained ≥ 3 kg/m². Compared to women with stable BMI change, those with > 1 kg/m² loss had higher risk of low birthweight (adjusted risk ratio [RR] 1.36; 95% confidence interval 1.02-1.80), while those with 1-3 kg/m² gain had higher risks of large-for-gestational-age birth (1.16; 1.03-1.31), gestational diabetes (1.25; 1.06-1.49) and emergency Caesarean delivery (1.16; 1.03-1.31); these risks were higher in those with ≥ 3 kg/m² gain. Our study strengthens the case for interpregnancy weight management to improve subsequent pregnancy outcomes.

Weight Cycling in Women: Adaptation or Risk?

Obesity, dieting, and weight cycling are common among reproductive-age women. Weight cycling refers to intentional weight loss followed by unintentional weight regain. Weight loss is accompanied by changes in gut peptides, adipose hormones, and energy expenditure that promote weight regain to a tightly regulated set point. While weight loss can improve body composition and surrogate markers of cardiometabolic health, it is hypothesized that the weight regain can result in an overshoot effect, resulting in excess weight gain, altered body composition, and negative effects on surrogate markers of cardiometabolic health. Numerous observational studies have examined the association of weight cycling and health outcomes. There appears to be modest association between weight cycling with type 2 diabetes mellitus and dyslipidemia in women, but no association with hypertension, cardiovascular events, and overall cancer risk. Interestingly, mild weight cycling may be associated with a decreased risk of overall and cardiovascular mortality. Little is known about the effects of weight cycling in the preconception period. Although obesity and weight gain are associated with pregnancy complications, preconception weight loss does not appear to mitigate the risk of most pregnancy complications related to obesity. Research on preconception weight cycling may provide insight into this paradox.

Interpregnancy weight change: associations with severe maternal morbidity and neonatal outcomes

BACKGROUND

Prepregnancy body mass index and gestational weight gain have been linked with severe maternal morbidity, suggesting that weight change between pregnancies may also play a role, as it does for neonatal outcomes.

OBJECTIVE

This study assessed the association of changes in prepregnancy body mass index between 2 consecutive singleton pregnancies with the outcomes of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants in the subsequent pregnancy.

STUDY DESIGN

This observational study was based on birth records from 1,111,032 consecutive pregnancies linked to hospital discharge records in California (2007-2017). Interpregnancy body mass index change between the beginning of an index pregnancy and the beginning of the subsequent pregnancy was calculated from self-reported weight and height. Severe maternal morbidity was defined based on the Centers for Disease Control and Prevention index, including and excluding transfusion-only cases. We used multivariable log-binomial regression models to estimate adjusted risks, overall and stratified by prepregnancy body mass index at index birth.

RESULTS

Substantial interpregnancy body mass index gain (≥4 kg/m2) was associated with severe maternal morbidity in crude but not adjusted analyses. Substantial interpregnancy body mass index loss (>2 kg/m2) was associated with increased risk of severe maternal morbidity (adjusted relative risk, 1.13; 95% confidence interval (1.07-1.19), and both substantial loss (adjusted relative risk, 1.11 [1.02-1.19]) and gain (≥4 kg/m2; adjusted relative risk, 1.09 [1.02-1.17]) were associated with nontransfusion severe maternal morbidity. Substantial loss (adjusted relative risk, 1.17 [1.05-1.31]) and gain (1.26 [1.14-1.40]) were associated with stillbirth. Body mass index gain was positively associated with large-for-gestational-age infants and inversely associated with small-for-gestational-age infants.

CONCLUSION

Substantial interpregnancy body mass index changes were associated with modestly increased risk of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants.

Annual Body Mass Index Gain and Risk of Gestational Diabetes Mellitus in a Subsequent Pregnancy

Introduction

Weight change during the interpregnancy is related to gestational diabetes mellitus (GDM) in the subsequent pregnancy. In interpregnancy care/counseling, the timeframe for goal setting is important, while the timing of the next conception is unpredictable and preventing age-related body weight gain is difficult. This study aimed to investigate the association between annual weight gain during the interpregnancy, which provide clearer timeframe, and GDM in subsequent pregnancies.

Methods

This multicenter retrospective study was conducted by collecting data on two pregnancies of the same women in 2009-2019. The association between annual BMI gain and GDM during the subsequent pregnancy was examined.

Results

This study included 1,640 pregnant women. A history of GDM [adjusted odds ratio (aOR), 26.22; 95% confidence interval (CI), 14.93-46.07] and annual BMI gain (aOR, 1.48; 95% CI, 1.22-1.81) were related to GDM during the subsequent pregnancy. In the women with a pre-pregnant BMI of <25.0 kg/m2 and without GDM during the index pregnancy, an annual BMI gain of ≥0.6 kg/m2/year during the interpregnancy were associated with GDM in subsequent pregnancies; however, in the other subgroups, it was not associated with GDM in subsequent pregnancies.

Conclusions

For women with a pre-pregnant BMI of <25.0 kg/m2 and without GDM during the index pregnancy, maintaining an annual BMI gain of <0.6 kg/m2/year may prevent GDM during the subsequent pregnancy.

Preconception exposures and adverse pregnancy, birth and postpartum outcomes: Umbrella review of systematic reviews

BACKGROUND

Preconception exposures have been associated with adverse pregnancy, birth and postpartum outcomes. However, the reports, statements and guidelines of national and international health organisations vary in what they recommend individuals should monitor, avoid, reduce or practise in the preconception period.

OBJECTIVES

To synthesise and evaluate the evidence across systematic reviews for associations between exposures before conception and adverse pregnancy, birth and postpartum outcomes.

DATA SOURCES

MEDLINE, Embase, Epistemonikos (to May 2020) and reference lists of included reviews, without language or date restrictions.

STUDY SELECTION, DATA EXTRACTION AND SYNTHESIS

Systematic literature reviews of observational and/or interventional studies reporting associations between preconception exposures in women and/or men of reproductive age and pregnancy, birth or postpartum health outcomes were included. The methodological quality of reviews and the certainty of the evidence underlying each exposure-outcome association were assessed using AMSTAR 2 and the GRADE approach.

RESULTS

We identified 53 eligible reviews reporting 205 unique exposure-outcome associations. Methodological quality was generally low with only two reviews rated as 'high' quality and two as 'moderate'. We found high-certainty, randomised trial evidence that maternal folate supplementation reduces the risk of neural tube defects and anomaly-related terminations. Moderate-certainty, observational evidence was found that maternal physical activity is associated with reduced risk of pre-eclampsia and gestational diabetes, and that paternal age of ≥40 years and maternal body mass index (BMI) and interpregnancy weight gain are associated with increased risk of various adverse pregnancy and birth outcomes. Low- and very low-certainty evidence was found for other associations.

CONCLUSIONS

Clinicians and policymakers can be confident that maternal folate supplementation should be encouraged during the preconception period. There is moderate certainty in the evidence base that maternal physical activity, BMI and interpregnancy weight gain and advanced paternal age are important preconception considerations. High-quality research is required to better understand other exposure-outcome associations.

Interpregnancy weight gain and childhood obesity: analysis of a UK population-based cohort

BACKGROUND

Maternal obesity increases the risk of adverse long-term health outcomes in mother and child including childhood obesity. We aimed to investigate the association between interpregnancy weight gain between first and second pregnancies and risk of overweight and obesity in the second child.

METHODS

We analysed the healthcare records of 4789 women in Hampshire, UK with their first two singleton live births within a population-based anonymised linked cohort of routine antenatal records (August 2004 and August 2014) with birth/early life data for their children. Measured maternal weight and reported height were recorded at the first antenatal appointment of each pregnancy. Measured child height and weight at 4-5 years were converted to age- and sex-adjusted body mass index (BMI z-score). Log-binomial regression was used to examine the association between maternal interpregnancy weight gain and risk of childhood overweight and obesity in the second child. This was analysed first in the whole sample and then stratified by baseline maternal BMI category.

RESULTS

The prevalence of overweight/obesity in the second child was 19.1% in women who remained weight stable, compared with 28.3% in women with ≥3 kg/m2 weight gain. Interpregnancy gain of ≥3 kg/m2 was associated with increased risk of childhood overweight/obesity (adjusted relative risk (95% CI) 1.17 (1.02-1.34)), with attenuation on adjusting for birthweight of the second child (1.08 (0.94-1.24)). In women within the normal weight range at first pregnancy, the risks of childhood obesity (≥95th centile) were increased with gains of 1-3 kg/m2 (1.74 (1.07-2.83)) and ≥3 kg/m2 (1.87 (1.18-3.01)).

CONCLUSION

Children of mothers within the normal weight range in their first pregnancy who started their second pregnancy with a considerably higher weight were more likely to have obesity at 4-5 years. Supporting return to pre-pregnancy weight and limiting weight gain between pregnancies may achieve better long-term maternal and offspring outcomes.

Does prepregnancy weight change have an effect on subsequent pregnancy health outcomes? A systematic review and meta-analysis

International guidelines recommend women with an overweight or obese body mass index (BMI) aim to reduce their body weight prior to conception to minimize the risk of adverse perinatal outcomes. Recent systematic reviews have demonstrated that interpregnancy weight gain increases women's risk of developing adverse pregnancy outcomes in their subsequent pregnancy. Interpregnancy weight change studies exclude nulliparous women. This systematic review and meta-analysis was conducted following MOOSE guidelines and summarizes the evidence of the impact of preconception and interpregnancy weight change on perinatal outcomes for women regardless of parity. Sixty one studies met the inclusion criteria for this review and reported 34 different outcomes. We identified a significantly increased risk of gestational diabetes (OR 1.88, 95% CI 1.66, 2.14, I²  = 87.8%), hypertensive disorders (OR 1.46 95% CI 1.12, 1.91, I²  = 94.9%), preeclampsia (OR 1.92 95% CI 1.55, 2.37, I²  = 93.6%), and large-for-gestational-age (OR 1.36, 95% CI 1.25, 1.49, I²  = 92.2%) with preconception and interpregnancy weight gain. Interpregnancy weight loss only was significantly associated with increased risk for small-for-gestational-age (OR 1.29 95% CI 1.11, 1.50, I²  = 89.9%) and preterm birth (OR 1.06 95% CI 1.00, 1.13, I²  = 22.4%). Our findings illustrate the need for effective preconception and interpregnancy weight management support to improve pregnancy outcomes in subsequent pregnancies.

Accelerated developmental adipogenesis programs adipose tissue dysfunction and cardiometabolic risk in offspring born to dams with metabolic dysfunction

This study determined if a perturbation in in utero adipogenesis leading to later life adipose tissue (AT) dysfunction underlies programming of cardiometabolic risk in offspring born to dams with metabolic dysfunction. Female mice heterozygous for the leptin receptor deficiency (Het_db) had 2.4-fold higher prepregnancy fat mass and in late gestation had higher plasma insulin and triglycerides compared with wild-type (Wt) females (P < 0.05). To isolate the role of the intrauterine milieu, wild-type (Wt) offspring from each pregnancy were studied. Differentiation potential in isolated progenitors and cell size distribution analysis revealed accelerated adipogenesis in Wt pups born to Het_db dams, accompanied by a higher accumulation of neonatal fat mass. In adulthood, whole body fat mass by NMR was higher in male (69%) and female (20%) Wt offspring born to Het_db versus Wt pregnancies, along with adipocyte hypertrophy and hyperlipidemia (all P < 0.05). Lipidomic analyses by gas chromatography revealed an increased lipogenic index (16:0/18:2n6) after high-fat/fructose diet (HFFD). Postprandial insulin, ADIPO-IR, and ex vivo AT lipolytic responses to isoproterenol were all higher in Wt offspring born to Het_db dams (P < 0.05). Intrauterine metabolic stimuli may direct a greater proportion of progenitors toward terminal differentiation, thereby predisposing to hypertrophy-induced adipocyte dysfunction.NEW & NOTEWORTHY This study reveals that accelerated adipogenesis during the perinatal window of adipose tissue development predisposes to later life hypertrophic adipocyte dysfunction, thereby compromising the buffering function of the subcutaneous depot.

Pregnancy Outcomes after Preeclampsia: The Effects of Interpregnancy Weight Change

OBJECTIVE

This study aimed to examine the effects of interpregnancy weight change on pregnancy outcomes, including recurrent preeclampsia, preterm birth, small-for-gestational age (SGA), large-for-gestational age (LGA), and cesarean delivery, among women with a history of preeclampsia. We also evaluated whether these associations were modified by prepregnancy body mass index (BMI) category in the first pregnancy (BMI < 25 vs. ≥25 kg/m²) and if associations were present among women who maintained a healthy BMI category in both pregnancies.

STUDY DESIGN

We conducted a population-based retrospective cohort study including 15,108 women who delivered their first two nonanomalous singleton live births in Missouri (1989-2005) and experienced preeclampsia in the first pregnancy. We performed Poisson regression with robust error variance to estimate relative risks and 95% confidence intervals for outcomes of interest after controlling for potential confounders.

RESULTS

Interpregnancy weight gain was associated with increased risk of recurrent preeclampsia, LGA, and cesarean delivery. These risks increased in a "dose-response" manner with increasing magnitude of interpregnancy weight gain and were generally more pronounced among women who were underweight or normal weight in the first pregnancy. Interpregnancy weight loss exceeding 1 BMI unit was associated with increased risk of SGA among underweight and normal weight women, while interpregnancy weight loss exceeding 2 BMI units was associated with reduced risk of recurrent preeclampsia among overweight and obese women.

CONCLUSION

Even small changes in interpregnancy weight may significantly affect pregnancy outcomes among formerly preeclamptic women. Appropriate weight management between pregnancies has the potential to attenuate such risks.

KEY POINTS

· Interpregnancy weight change among formerly preeclamptic women significantly affects pregnancy outcomes.. · Interpregnancy weight gain is associated with increased risk of recurrent preeclampsia, large-for-gestational-age and cesarean delivery.. · Interpregnancy weight loss is associated with increased risk of small-for-gestational age and recurrent preeclampsia..

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

Objective

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

Methods

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

Results

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

Conclusion

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

Practice nurse-supported weight self-management delivered within the national child immunisation programme for postnatal women: a feasibility cluster RCT

BACKGROUND

Pregnancy is a high-risk time for excessive weight gain. The rising prevalence of obesity in women, combined with excess weight gain during pregnancy, means that there are more women with obesity in the postnatal period. This can have adverse health consequences for women in later life and increases the health risks during subsequent pregnancies.

OBJECTIVE

The primary aim was to produce evidence of whether or not a Phase III trial of a brief weight management intervention, in which postnatal women are encouraged by practice nurses as part of the national child immunisation programme to self-monitor their weight and use an online weight management programme, is feasible and acceptable.

DESIGN

The research involved a cluster randomised controlled feasibility trial and two semistructured interview studies with intervention participants and practice nurses who delivered the intervention. Trial data were collected at baseline and 3 months later. The interview studies took place after trial follow-up.

SETTING

The trial took place in Birmingham, UK.

PARTICIPANTS

Twenty-eight postnatal women who were overweight/obese were recruited via Birmingham Women's Hospital or general practices. Nine intervention participants and seven nurses were interviewed.

INTERVENTIONS

The intervention was delivered in the context of the national child immunisation programme. The intervention group were offered brief support that encouraged self-management of weight when they attended their practice to have their child immunised at 2, 3 and 4 months of age. The intervention involved the provision of motivation and support by nurses to encourage participants to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. The role of the nurse was to provide regular external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a record card in their child's health record ('red book') or using the online programme. The behavioural goal was for women to lose 0.5-1 kg per week. The usual-care group received a healthy lifestyle leaflet.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of a Phase III trial to test the effectiveness of the intervention, as assessed against three traffic-light stop-go criteria (recruitment, adherence to regular self-weighing and registration with an online weight management programme).

RESULTS

The traffic-light criteria results were red for recruitment (28/80, 35% of target), amber for registration with the online weight loss programme (9/16, 56%) and green for adherence to weekly self-weighing (10/16, 63%). Nurses delivered the intervention with high fidelity. In the qualitative studies, participants indicated that the intervention was acceptable to them and they welcomed receiving support to lose weight at their child immunisation appointments. Although nurses raised some caveats to implementation, they felt that the intervention was easy to deliver and that it would motivate postnatal women to lose weight.

LIMITATIONS

Fewer participants were recruited than planned.

CONCLUSIONS

Although women and practice nurses responded well to the intervention and adherence to self-weighing was high, recruitment was challenging and there is scope to improve engagement with the intervention.

FUTURE WORK

Future research should focus on investigating other methods of recruitment and, thereafter, testing the effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12209332.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 49. See the NIHR Journals Library website for further project information.

First and second pregnancy outcomes in women with class III obesity: An observational cohort study

INTRODUCTION

Class III obesity (BMI ≥ 40 kg/m²) during pregnancy predisposes mother and offspring to a range of adverse pregnancy complications and outcomes. Risk profiles vary between pregnancies and are affected by interpregnancy weight gain. We evaluated the risk of adverse outcomes in women with BMI ≥ 40 kg/m² in first and second pregnancies, and the impact of interpregnancy weight change on this risk.

MATERIALS AND METHODS

Data were extracted for all women with BMI ≥ 40 kg/m² at first antenatal visit, who completed antenatal and delivery care for first and second pregnancies in NHS Lothian between 1/1/2009-31/12/2018. Multiple pregnancies and recipients of bariatric surgery were excluded.

RESULTS

442 pregnancies among 221 women were included. In first pregnancy, median (interquartile range) weight was 117 kg (108.5-126.7), age 28 years (24-31) and BMI 42 kg/m² (41.0-44.5), 14.4% had gestational diabetes (GDM), 11.3% had pregnancy-induced hypertension and 44.6% had a post-partum haemorrhage (PPH). 20.8% of babies were large for gestational age (LGA, ≥97% centile at birth). In second pregnancy, women were heavier with a median weight of 119.9 kg (109.0-130.0, p = 0.00) with 19.9% gaining over 10 kg. Women were more likely to develop GDM (21.6%, p = 0.02). Babies were heavier with 40% of babies LGA (p < 0.0001). Interpregnancy weight change had no significant impact on GDM, pregnancy induced hypertension, PPH, perinatal mortality or LGA.

CONCLUSIONS

In a population of women with BMI ≥ 40 kg/m², pregnancy complications are common and risk is higher in second pregnancy. The interpregnancy period is a critical time to engage women in health improvement and weight loss strategies to maximise outcomes for mother and offspring.

Prevention of Gestational Diabetes: The Role of Dietary Intake, Physical Activity, and Weight before, during, and between Pregnancies

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy and a significant clinical and public health problem with lifelong and intergenerational adverse health consequences for mothers and their offspring. The preconception, early pregnancy, and interconception periods represent opportune windows to engage women in preventive and health promotion interventions. This review provides an overview of findings from observational and intervention studies on the role of diet, physical activity, and weight (change) during these periods in the primary prevention of GDM. Current evidence suggests that supporting women to increase physical activity and achieve appropriate weight gain during early pregnancy and enabling women to optimize their weight and health behaviors prior to and between pregnancies have the potential to reduce rates of GDM. Translation of current evidence into practice requires further development and evaluation of co-designed interventions across community, health service, and policy levels to determine how women can be reached and supported to optimize their health behaviors before, during, and between pregnancies to reduce GDM risk.

Interpregnancy Weight Change and Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aimed to synthesize evidence regarding the association between interpregnancy weight change (IPWC) and gestational diabetes mellitus (GDM) in the subsequent pregnancy.

METHODS

MEDLINE, EMBASE, Cochrane Library, and Web of Science were searched from inception to May 10, 2020. This review included studies that reported the association between IPWC and GDM in the subsequent pregnancy without restriction on study design, IPWC classification, or parity. The "no weight change" interpregnancy category was defined by each study, and data were synthesized to analyze the risk of GDM according to weight change.

RESULTS

Thirteen observational studies were included. A higher risk of GDM in the subsequent pregnancy when there was interpregnancy weight gain (odds ratio [OR] = 1.56; 95% CI: 1.30-1.83; I²  = 82.30%) was found. However, interpregnancy weight loss was associated with lower risk of GDM in the subsequent pregnancy (OR = 0.83; 95% CI: 0.68-0.98; I²  = 58.10%), but the decrease in the risk of GDM in the subsequent pregnancy was greater among women with pregestational BMI higher than 25 kg/m² (OR = 0.58; 95% CI: 0.39-0.77; I²  = 0.00%).

CONCLUSIONS

The risk of GDM in the subsequent pregnancy increases with interpregnancy weight gain, whereas it decreases with interpregnancy weight loss.

Trimester-Specific and Total Gestational Weight Gain in Two Consecutive Pregnancies

OBJECTIVE

This retrospective study aimed to characterize trimester-specific and total gestational weight gain (GWG) over the course of two consecutive pregnancies, as well as maternal determinants associated with interpregnancy weight change (IPWC) and excessive GWG in the second pregnancy.

METHODS

We analyzed the electronic medical records of women who delivered their first two consecutive infants at term between 2001 and 2017.

RESULTS

Weight gain trajectories differed between the first and second pregnancy for the 1497 women included in this study, with lower second- and third-trimester weight gain in the second pregnancy. Respectively, 53% and 41% of women had excessive GWG in the first and second pregnancies, with a higher proportion of excessive GWG found in women with a higher body mass index (BMI). Most women (55%) experienced interpregnancy weight gain. Maternal determinants of IPWC were BMI before first pregnancy, first-trimester and total GWG in the first pregnancy, and interpregnancy interval (P < 0.0001). Maternal risk factors associated with excessive GWG in the second pregnancy were excessive total GWG in the first pregnancy (OR 6.23; 95% CI 4.67-8.32), interpregnancy weight gain (OR 1.58; 95% CI 1.19-2.09), and interpregnancy interval (OR 1.18; 95% CI 1.07-1.29) as well as BMI before the second pregnancy (OR 1.04, 95% CI 1.02-1.07).

CONCLUSION

Weight gain trajectories differ between consecutive pregnancies. GWG in the first pregnancy is a key determinant for IPWC and GWG in the second pregnancy.

Open versus Closed Surgery for Axillary Osmidrosis: A Meta-Analysis of Articles Published in Four Languages

Background

Individuals with axillary osmidrosis suffer detrimental effects to their psychosocial functioning. In Asian nations, major operations for axillary osmidrosis include subdermal excision (open surgery) and suction-curettage (closed surgery).

Objective

The aim of this meta-analysis was to determine which of these two procedures is most favorable in terms of safety and efficacy.

Methods

According to the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guideline, we searched electronic databases for articles published in English, Japanese, Korean, and Chinese languages. Fixed-effects model meta-analyses of odds ratios (OR) and 95% confidence intervals (CI) were conducted, and the I² was used to assess heterogeneity. Complication rates, recurrence/ineffectiveness rates, and patient satisfaction data were extracted and compared between open and closed surgeries.

Results

Our search yielded 8 articles that include 1,179 patients; 560 underwent open surgery, and 619 underwent closed surgery. Our meta-analysis revealed that suction-curettage had a significantly lower risk of acute adverse events than open excision (OR, 0.15; 95% CI, 0.07~0.32), whereas open excision was significantly superior to suction-curettage for recurrence/ineffectiveness rate (OR, 2.90; 95% CI, 1.37~6.15). Patient satisfaction was equally high with both treatments (OR, 1.58; 95% CI, 0.69~3.60).

Conclusion

Since surgical treatments for axillary osmidrosis have been performed mostly in East Asian nations, it was meaningful to review articles published in four languages. This meta-analysis revealed that closed surgery was safer but less effective than open surgery. However, both patient groups expressed high satisfaction with the outcomes. Our results may be helpful for deciding surgical treatment options.

Preoperative iron treatment in anaemic patients undergoing elective total hip or knee arthroplasty: a systematic review and meta-analysis

OBJECTIVES

Preoperative anaemia is associated with increased risks of postoperative complications, blood transfusion and mortality. This meta-analysis aims to review the best available evidence on the clinical effectiveness of preoperative iron in anaemic patients undergoing elective total hip (THR) or total knee replacement (TKR).

DESIGN

Electronic databases and handsearching were used to identify randomised and non-randomised studies of interventions (NRSI) reporting perioperative blood transfusion rates for anaemic participants receiving iron before elective THR or TKR. Searches of CENTRAL, MEDLINE, Embase, PubMed and other databases were conducted on 17 April 2019 and updated on 15 July 2020. Two investigators independently reviewed studies for eligibility and evaluated risk of bias using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and a modified Newcastle-Ottawa scale for NRSIs. Data extraction was performed by ABS and checked by AB. Meta-analysis used the Mantel-Haenszel method and random-effects models.

RESULTS

807 records were identified: 12 studies met the inclusion criteria, of which 10 were eligible for meta-analyses (one RCT and nine NRSIs). Five of the NRSIs were of high-quality while there were some concerns of bias in the RCT. Meta-analysis of 10 studies (n=2178 participants) showed a 39% reduction in risk of receiving a perioperative blood transfusion with iron compared with no iron (risk ratio 0.61, 95% CI 0.50 to 0.73, p<0.001, I²=0%). There was a significant reduction in the number of red blood cell units transfused with iron compared with no iron (mean difference -0.37units, 95% CI -0.47 to -0.27, p<0.001, I²=40%); six studies (n=1496). Length of stay was significantly reduced with iron, by an average of 2.08 days (95% CI -2.64 to -1.51, p<0.001, I²=40%); five studies (n=1140).

CONCLUSIONS

Preoperative iron in anaemic, elective THR or TKR patients, significantly reduces the number of patients and number of units transfused and length of stay. However, high-quality, randomised trials are lacking.

PROSPERO REGISTRATION NUMBER

CRD42019129035.

Temporal Leptin to Determine Cardiovascular and Metabolic Fate throughout the Life

Leptin links peripheral adiposity and the central nervous system (CNS) to regulate cardiometabolic physiology. Within the CNS, leptin receptor-expressing cells are a counterpart to circulating leptin, and leptin receptor-mediated neural networks modulate the output of neuroendocrine and sympathetic nervous activity to balance cardiometabolic homeostasis. Therefore, disrupted CNS leptin signaling is directly implicated in the development of metabolic diseases, such as hypertension, obesity, and type 2 diabetes. Independently, maternal leptin also plays a central role in the development and growth of the infant during gestation. Accumulating evidence points to the dynamic maternal leptin environment as a predictor of cardiometabolic fate in their offspring as it is directly associated with infant metabolic parameters at birth. In postnatal life, the degree of serum leptin is representative of the level of body adiposity/weight, a driving factor for cardiometabolic alterations, and therefore, the levels of blood leptin through the CNS mechanism, in a large part, are a strong determinant for future cardiometabolic fate. The current review focuses on highlighting and discussing recent updates for temporal dissection of leptin-associated programing of future cardiometabolic fate throughout the entire life.

Maternal weight change between successive pregnancies: an opportunity for lifecourse obesity prevention

Maternal obesity is a major risk factor for adverse health outcomes for both the mother and the child, including the serious public health problem of childhood obesity which is globally on the rise. Given the relatively intensive contact with health/care professionals following birth, the interpregnancy period provides a golden opportunity to focus on preconception and family health, and to introduce interventions that support mothers to achieve or maintain a healthy weight in preparation for their next pregnancy. In this review, we summarise the evidence on the association between interpregnancy weight gain with birth and obesity outcomes in the offspring. Gaining weight between pregnancies is associated with an increased risk of large-for-gestational age (LGA) birth, a predictor of childhood obesity, and weight loss between pregnancies in women with overweight or obesity seems protective against recurrent LGA. Interpregnancy weight loss seems to be negatively associated with birthweight. There is some suggestion that interpregnancy weight change may be associated with preterm birth, but the mechanisms are unclear and the direction depends if it is spontaneous or indicated. There is limited evidence on the direct positive link between maternal interpregnancy weight gain with gestational diabetes, pre-eclampsia, gestational hypertension and obesity or overweight in childhood, with no studies using adult offspring adiposity outcomes. Improving preconception health and optimising weight before pregnancy could contribute to tackling the rise in childhood obesity. Research testing the feasibility, acceptability and effectiveness of interventions to optimise maternal weight and health during this period is needed, particularly in high-risk and disadvantaged groups.

Independent influences of maternal obesity and fetal sex on maternal cardiovascular adaptation to pregnancy: a prospective cohort study

Background/Objectives

Successful pregnancy requires the de novo creation of low-resistance utero-placental and feto-placental circulations and incomplete remodeling of this vasculature can lead to maternal or fetal compromise. Maternal BMI and fetal sex are known to influence vascular compliance and placental development, but it is unknown if these are independent or synergistic effects. Here we aim to investigate the impact of maternal obesity, fetal sex, and any interaction thereof on maternal cardiovascular adaptation to pregnancy, by assessing the physiological drop of uterine artery doppler pulsatility (UtA-PI) and umbilical artery doppler pulsatility index (UA-PI) over gestation.

Subjects/Methods

Nulliparous women with a singleton pregnancy participating in a prospective cohort study (n = 4212) underwent serial UtA-PI and UA-PI measurements at 20-, 28- and 36-weeks gestation. Linear mixed regression models were employed to investigate the influence of maternal BMI, fetal sex and interactions thereof on the magnitude of change in UtA-PI and UA-PI.

Results

Throughout gestation, UtA-PI was higher for male fetuses and UA-PI was higher for female fetuses. The physiological drop of UtA-PI was significantly smaller in overweight (change −24.3% [95%CI −22.3, −26.2]) and obese women (change −21.3% [−18.3, −24.3]), compared to normal-weight women (change −25.7% [−24.3, −27.0]) but did not differ by fetal sex. The physiological drop in UA-PI was greater for female than male fetuses (–32.5% [−31.5, −33.5] vs. −30.7% [−29.8, −31.7]) but did not differ by maternal BMI. No interactions between maternal BMI and fetal sex were found.

Conclusions

Maternal cardiovascular adaptation to pregnancy is independently associated with maternal BMI and fetal sex. Our results imply sexual dimorphism in both maternal cardiovascular adaptation and feto-placental resistance.

The impact of interpregnancy weight change on perinatal outcomes in women and their children: A systematic review and meta-analysis

Prepregnancy overweight and obesity are associated with higher risk of perinatal complications. However, the effect of weight change prior to pregnancy on perinatal outcome is largely unknown. Therefore, it is aimed to examine the impact on perinatal outcomes of interpregnancy BMI change in women of different BMI categories. The MEDLINE, EMBASE, LILACS, and CINAHL databases were searched (1990-August 2019). Observational studies on interpregnancy BMI change were selected. Outcomes evaluated were gestational diabetes mellitus (GDM), preeclampsia, gestational hypertension (GH), cesarean section, preterm birth, and newborns being large (LGA) or small (SGA) for gestational age. Meta-analyses and meta-regression analyses were executed. Thirty studies were included (n > 1 million). Interpregnancy BMI gain was associated with a higher risk of GDM (for BMI gain ≥3 kg/m² : OR 2.21; [95%CI 1.53-3.19]), preeclampsia (1.77 [1.53-2.04]), GH (1.78 [1.61-1.97]), cesarean section (1.32 [1.24-1.39]), and LGA (1.54 [1.28-1.86]). The effects of BMI gain were most pronounced in women with BMI <25 kg/m² before the first pregnancy regarding GDM, GH, and cesarean section. Except for LGA, interpregnancy BMI loss did not result in a decreased risk of perinatal complications. In this study, women of normal weight who gain weight before pregnancy were identified as a high-risk population for perinatal complications. This emphasizes that weight management is important for women of all BMI categories and a pregnancy wish.

Change in prepregnancy body mass index and gastroschisis

PURPOSE

Maternal body mass index (BMI) is inversely associated with gastroschisis, but a causal relationship has not been established. As data demonstrating that a change in exposure status is related to a change in the frequency of the outcome can add to the evidence for causality, we conducted a case-control study of change in maternal BMI, assessed using interpregnancy change in BMI (IPC-BMI), and gastroschisis.

METHODS

Data for 258 gastroschisis cases and 2561 controls were obtained from the Texas Birth Defects Registry and vital records (2006-2012). Logistic regression was used to estimate the adjusted association between IPC-BMI and gastroschisis.

RESULTS

The continuous IPC-BMI variable was inversely associated with gastroschisis (adjusted odds ratio [aOR] = 0.90, 95% confidence interval [CI]: 0.86, 0.95). When assessed as a six-level categorical variable, with weight stable women as the referent, the odds of gastroschisis were higher following a BMI decrease of greater than 1 unit (aOR = 1.37, 95% CI: 0.91, 2.06) and lower after a BMI increase of ≥3 units (aOR = 0.62, 95% CI: 0.42, 0.94).

CONCLUSIONS

Our findings suggest that maternal change in BMI is associated with gastroschisis and, thus, add to the epidemiological evidence that can be used to inform our understanding of the relationship between BMI and gastroschisis.

Maternal interpregnancy weight change and premature birth: Findings from an English population-based cohort study

Background

The relationship between maternal weight change between pregnancies and premature birth is unclear. This study aimed to investigate whether interpregnancy weight change between first and second, or second and third pregnancy is associated with premature birth.

Methods

Routinely collected data from 2003 to 2018 from one English maternity centre was used to produce two cohorts. The primary cohort (n = 14,961 women) consisted of first and second live-birth pregnancies. The secondary cohort (n = 5,108 women) consisted of second and third live-birth pregnancies. Logistic regression models were used to examine associations between interpregnancy BMI change and premature births adjusted for confounders. Subgroup analyses were carried out, stratifying by initial pregnancy BMI groups and analysing spontaneous and indicated premature births separately.

Results

In the primary cohort, 3.4% (n = 514) of births were premature compared to 4.2% (n = 212) in the secondary cohort, with fewer indicated than spontaneous premature births in both cohorts.

Primary cohort

Weight loss (>3kg/m²) was associated with increased odds of premature birth (adjusted odds ratio (aOR):3.50, 95% CI: 1.78–6.88), and spontaneous premature birth (aOR: 3.34, 95%CI: 1.60–6.98), in women who were normal weight (BMI 18.5-25kg/m²) at first pregnancy. Weight gain >1kg/m² was not associated with premature birth regardless of starting BMI.

Secondary cohort

Losing >3kg/m² was associated with increased odds of premature birth (aOR: 2.01, 95%CI: 1.05–3.87), when analysing the whole sample, but not when restricting the analysis to women who were overweight or obese at second pregnancy.

Conclusions

Normal-weight women who lose significant weight (>3kg/m²) between their first and second live pregnancies have greater odds of premature birth compared to normal-weight women who remain weight stable in the interpregnancy period. There was no evidence of association between weight change in women who were overweight or obese at the start of their first pregnancy and premature birth.

Effect of interpregnancy weight change on perinatal outcomes: systematic review and meta-analysis

Background

Although obesity is a well-known risk factor for adverse pregnancy outcomes, evidence is sparse about the effects of interpregnancy weight change on the risk of adverse perinatal complications in a subsequent pregnancy. The current study aims to assess the effect of interpregnancy weight change on the risk of developing gestational diabetes, pre-eclampsia, pregnancy induced hypertension, preterm birth, or delivering a large- or small-for-gestational age neonate.

Methods

Pubmed, Ovid Embase, ClinicalTrial.gov and the Cochrane library were systematically searched up until July 24th, 2019. Interpregnancy weight change was defined as the difference between pre-pregnancy weight of an index pregnancy and a consecutive pregnancy. Inclusion criteria included full text original articles reporting quantitative data about interpregnancy weight change in multiparous women with any time interval between consecutive births and the risk of any perinatal complication of interest. Studies reporting adjusted odds ratios and a reference group of − 1 to + 1 BMI unit change between pregnancies were harmonised by meta-analysis.

Results

Twenty-three cohort studies identified a total of 671,906 women with two or more consecutive pregnancies. Seven of these studies were included in the meta-analysis (280,672 women). Interpregnancy weight gain was consistently associated with a higher risk of gestational diabetes, pre-eclampsia, pregnancy induced hypertension and large-for-gestational age births. In contrast, interpregnancy weight loss was associated with a lower risk of delivering a large-for-gestational age neonate. The effect magnitude (relative risk) of interpregnancy weight gain on pregnancy induced hypertension or delivering a large-for-gestational age neonate was greater among women with a normal BMI in the index pregnancy compared to women with a starting BMI ≥25 kg/m².

Conclusion

These findings confirm that interpregnancy weight change impacts the risk of developing perinatal complications in a subsequent pregnancy. This provides evidence in support of guidelines encouraging women to achieve post-partum weight loss, as their risk of perinatal complications might be minimised if they return to their pre-pregnancy weight before conceiving again.

Prospectively registered with PROSPERO (CRD42017067326).

Effect of Maternal Obesity and Preconceptional Weight Loss on Male and Female Offspring Metabolism and Olfactory Performance in Mice

According to the “developmental origins of health and disease” (DOHaD) concept, maternal obesity predisposes the offspring to non-communicable diseases in adulthood. While a preconceptional weight loss (WL) is recommended for obese women, its benefits on the offspring have been poorly addressed. We evaluated whether preconceptional WL was able to reverse the adverse effects of maternal obesity in a mouse model, exhibiting a modification of foetal growth and of the expression of genes encoding epigenetic modifiers in liver and placenta. We tracked metabolic and olfactory behavioural trajectories of offspring born to control, obese or WL mothers. After weaning, the offspring were either put on a control diet (CD) or a high-fat (HFD). After only few weeks of HFD, the offspring developed obesity, metabolic alterations and olfactory impairments, independently of maternal context. However, male offspring born to obese mother gained even more weight under HFD than their counterparts born to lean mothers. Preconceptional WL normalized the offspring metabolic phenotypes but had unexpected effects on olfactory performance: a reduction in olfactory sensitivity, along with a lack of fasting-induced, olfactory-based motivation. Our results confirm the benefits of maternal preconceptional WL for male offspring metabolic health but highlight some possible adverse outcomes on olfactory-based behaviours.

Interpregnancy change in body mass index and infant outcomes in Texas: a population-based study

Background

Maternal prepregnancy body mass index (BMI) is associated with several infant outcomes, but it is unclear whether these associations reflect causal relationships. We conducted a study of interpregnancy change in BMI (IPC-BMI) to improve understanding of the associations between BMI and large for gestational age (LGA), small for gestational age (SGA), and preterm birth (PTB).

Methods

Birth certificate data from 2481 linked sibling pairs (Texas, 2005–2012) were used to estimate IPC-BMI and evaluate its association with LGA, SGA, and PTB in the younger sibling of the pair. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) using data from the full sample and within strata defined by prepregnancy BMI for the older sibling.

Results

On average, women gained 1.1 BMI units between pregnancies. In the full sample, interpregnancy BMI decreases were associated with reduced odds of LGA and increased odds of SGA and PTB (IPC-BMI < -1 versus 0 to < 1: LGA aOR 0.7, 95% CI 0.4, 1.1; SGA aOR 1.6, 95% CI 1.0, 2.7; PTB aOR 1.9, 95% CI 1.3, 2.8). In stratified analyses, similar associations were observed in some, but not all, strata. Findings for interpregnancy BMI increases were less consistent, with little evidence for associations between these outcomes and the most extreme IPC-BMI increases.

Conclusions

There is growing evidence that interpregnancy BMI decreases are associated with LGA, SGA, and PTB. However, taken as a whole, the literature provides insufficient evidence to establish causal links between maternal BMI and these outcomes.

Early life environment influences the trajectory of post-partum weight loss in adult female rats

RESEARCH QUESTION

The physiological processes of pregnancy and lactation require profound changes in maternal metabolism and energy balance. The timescale of metabolic reversion after pregnancy, in particular post-partum weight loss, is highly variable between individuals. Currently, mechanisms influencing post-partum metabolic recovery are not well understood. The hypothesis tested here is that, in common with other metabolic and obesity-related outcomes, capacity for post-partum weight loss is influenced by developmental programming.

DESIGN

Adult female Wistar rats exposed to a maternal low-protein diet in utero then weaned onto a control diet post-natally (recuperated group) were compared with controls. Adult females from both groups underwent pregnancy at 3 months of age. Weight changes and metabolic parameters during pregnancy and lactation were compared between control and recuperated groups, and also with non-pregnant littermates.

RESULTS

Pregnancy weight gain was not different between the control and recuperated groups, but post-partum recuperated animals remained significantly heavier than both post-partum control animals (P<0.05) and their non-pregnant recuperated littermates (P<0.05) at the end of lactation. Post-partum recuperated animals had more intra-abdominal fat mass (P<0.05) and higher serum triglyceride concentrations (P<0.01) than controls. Post-partum recuperated animals also had increased expression of IL6, NRF2 and ALOX12 (key regulators of inflammation and lipoxygenase activity) in the intra-abdominal adipose tissue compared with control groups.

CONCLUSIONS

Mothers who themselves have been exposed to adverse early life environments are likely to have slower metabolic recovery from pregnancy than controls. Failure to return to pre-pregnancy weight after delivery predisposes to persisting sequential inter-pregnancy weight gain, which can represent a significant metabolic burden across a life course involving several pregnancies.

Programming of Vascular Dysfunction in the Intrauterine Milieu of Diabetic Pregnancies

With the rising global tide of obesity, gestational diabetes mellitus (GDM) burgeoned into one of the most common antenatal disorders worldwide. Macrosomic babies born to diabetic mothers are more likely to develop risk factors for cardiovascular disease (CVD) before they reach adulthood. Rodent studies in offspring born to hyperglycemic pregnancies show vascular dysfunction characterized by impaired nitric oxide (NO)-mediated vasodilation and increased production of contractile prostanoids by cyclooxygenase 2 (COX-2). Vascular dysfunction is a key pathogenic event in the progression of diabetes-related vascular disease, primarily attributable to glucotoxicity. Therefore, glucose-induced vascular injury may stem directly from the hyperglycemic intrauterine environment of GDM pregnancy, as evinced by studies showing endothelial activation and inflammation at birth or in childhood in offspring born to GDM mothers. This review discusses potential mechanisms by which intrauterine hyperglycemia programs dysfunction in the developing vasculature.