Weight retention at six weeks postpartum and the risk of gestational diabetes mellitus in a second pregnancy

Effect of mode of delivery on postpartum weight retention: A systematic review and meta-analysis

OBJECTIVE

Retention of weight gained over pregnancy increases the risk of long-term obesity and related health concerns. While many risk factors for this postpartum weight retention have been examined, the role of mode of delivery in this relationship remains controversial. We carried out a systematic review and meta-analysis to determine the effect of mode of delivery on postpartum weight retention.

METHODS

Ten electronic databases including PubMed, Cochrane Library, EMBASE, Web of Science, MEDLINE, CINAHL, China National Knowledge Infrastructure (CNKI), Wan-Fang database, the VIP database and China Biology Medicine Database (CBM) were searched from inception through November 2022. Review Manager 5.4 was used to pool the study data and calculate effect sizes. For dichotomous data, the odds ratio and 95 % confidence interval were used to report the results. For continuous data, the mean difference (MD) and 95 % confidence interval were used to report the results. The outcomes were the amount of postpartum weight retention and the number or proportion of women who experienced postpartum weight retention. The Newcastle- Ottawa Scale (NOS) and GRADE Guidelines were used to assess the methodological quality of the included studies.

FINDINGS

A total of 16 articles were included in the systematic review and 13 articles were included in the meta-analysis. The results showed that the mode of delivery had a significant effect on postpartum weight retention, women who delivered by caesarean section were more likely to experience postpartum weight retention compared to those who delivered vaginally. Sensitivity analysis showed that the results were stable and credible.

CONCLUSION

Due to the limitations of this study, the findings need to be treated with caution. And, to better prevent the postpartum weight retention, future practice and research need to further focus on upstream modifiable factors.

Dietary patterns and their associations with postpartum weight retention: results of the MINA cohort study

PURPOSE

To examine the association of prepregnancy dietary patterns with postpartum weight retention at 6 months (PPWR6) among Lebanese and Qatari women.

METHODS

Data for this study were derived from the Mother and Infant Nutrition Assessment (MINA) prospective cohort study conducted in Lebanon and Qatar. Pregnant women were recruited during their first trimester and were followed up for three years. For the purpose of this study, data belonging to sociodemographic characteristics of participants, prepregnancy dietary intake, prepregnancy BMI as well as weight retention at 6 months were used. Dietary intake was examined using a 98-item food frequency questionnaire. Principal component analysis was used for the derivation of dietary patterns. The associations of dietary patterns with PPWR6 were examined using simple and multiple linear regressions.

RESULTS

Data was available for 177 participants (Lebanon: 93; Qatar: 84). Mean PPWR6 was 4.05 ± 5.29 kg. Significantly higher PPWR6 was observed among participants with pre-pregnancy overweight/obesity and among those with excessive gestational weight gain. Two dietary patterns were identified: the "Western" and the "Varied" patterns. After adjustment for confounders, a positive association was observed between the 'Western' pattern scores and PPWR6 (ß = 1.27; 95% CI 0.68-1.86; p value: < 0.0001).

CONCLUSION

Higher adherence to the Western pattern was associated with higher PPWR6 amongst women, hence underscoring the importance of public health interventions aimed at fostering healthier dietary habits during this crucial stage of the lifecycle.

The impact of self-monitoring physical and mental health via an mHealth application on postpartum weight retention: Data from the INTER-ACT RCT

Background

Postpartum weight retention (PPWR) has many health risks. Digital self-monitoring of weight can potentially make postpartum weight management easier. We aim to test to what extent the self-monitoring of weight, steps and mental health through an mHealth application increases postpartum weight loss and reduces the odds of substantial PPWR (≥5 kg).

Methods

Participants were mothers in the intervention arm of the INTER-ACT multicenter randomized controlled trial (RCT), an inter-pregnancy lifestyle intervention among mothers with excessive gestational weight gain. Participants (n=288) had access to an mHealth application to log their weight, steps and mental health between 6 weeks and 6 months postpartum. A linear multiple regression model and a logistic regression model were run to test to what extent self-monitoring via the app increases postpartum weight loss and reduces the risk of substantial PPWR.

Results

Women who logged their weight more often lost more weight (B=0.03, β=0.26, CIB =[0.01,0.05], P<0.01), and had reduced odds of substantive PPWR (OR=0.99, CIOR =[0.98, 0.999], P<.05). Mental health logging reduced the odds of substantive PPWR (OR=0.98, CIOR =[0.97, 1.00], P<0.05), but was unrelated to the amount of weight loss. Steps logging was unrelated to either weight loss or substantive PPWR.

Conclusion

Mothers with excessive gestational weight gain can benefit from app-based lifestyle interventions to reduce PPWR by self-monitoring their weight. More attention to mental health in PPWR interventions is needed.

Plasma lipidomic profiling reveals metabolic adaptations to pregnancy and signatures of cardiometabolic risk: a preconception and longitudinal cohort study

BACKGROUND

Adaptations in lipid metabolism are essential to meet the physiological demands of pregnancy and any aberration may result in adverse outcomes for both mother and offspring. However, there is a lack of population-level studies to define the longitudinal changes of maternal circulating lipids from preconception to postpartum in relation to cardiometabolic risk factors.

METHODS

LC-MS/MS-based quantification of 689 lipid species was performed on 1595 plasma samples collected at three time points in a preconception and longitudinal cohort, Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO). We mapped maternal plasma lipidomic profiles at preconception (N = 976), 26-28 weeks' pregnancy (N = 337) and 3 months postpartum (N = 282) to study longitudinal lipid changes and their associations with cardiometabolic risk factors including pre-pregnancy body mass index, body weight changes and glycaemic traits.

RESULTS

Around 56% of the lipids increased and 24% decreased in concentration in pregnancy before returning to the preconception concentration at postpartum, whereas around 11% of the lipids went through significant changes in pregnancy and their concentrations did not revert to the preconception concentrations. We observed a significant association of body weight changes with lipid changes across different physiological states, and lower circulating concentrations of phospholipids and sphingomyelins in pregnant mothers with higher pre-pregnancy BMI. Fasting plasma glucose and glycated haemoglobin (HbA1c) concentrations were lower whereas the homeostatic model assessment of insulin resistance (HOMA-IR), 2-h post-load glucose and fasting insulin concentrations were higher in pregnancy as compared to both preconception and postpartum. Association studies of lipidomic profiles with these glycaemic traits revealed their respective lipid signatures at three physiological states. Assessment of glycaemic traits in relation to the circulating lipids at preconception with a large sample size (n = 936) provided an integrated view of the effects of hyperglycaemia on plasma lipidomic profiles. We observed a distinct relationship of lipidomic profiles with different measures, with the highest percentage of significant lipids associated with HOMA-IR (58.9%), followed by fasting insulin concentration (56.9%), 2-h post-load glucose concentration (41.8%), HbA1c (36.7%), impaired glucose tolerance status (31.6%) and fasting glucose concentration (30.8%).

CONCLUSIONS

We describe the longitudinal landscape of maternal circulating lipids from preconception to postpartum, and a comprehensive view of trends and magnitude of pregnancy-induced changes in lipidomic profiles. We identified lipid signatures linked with cardiometabolic risk traits with potential implications both in pregnancy and postpartum life. Our findings provide insights into the metabolic adaptations and potential biomarkers of modifiable risk factors in childbearing women that may help in better assessment of cardiometabolic health, and early intervention at the preconception period.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03531658.

Elevated HbA1c on universal prenatal screening is associated with decreased postpartum weight retention

OBJECTIVE

To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes.

METHODS

This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016-2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7-6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c.

RESULTS

2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant (B = -0.86, p < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines.

CONCLUSION

Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Genomics and Epigenomics of Gestational Diabetes Mellitus: Understanding the Molecular Pathways of the Disease Pathogenesis

One of the most common complications during pregnancy is gestational diabetes mellitus (GDM), hyperglycemia that occurs for the first time during pregnancy. The condition is multifactorial, caused by an interaction between genetic, epigenetic, and environmental factors. However, the underlying mechanisms responsible for its pathogenesis remain elusive. Moreover, in contrast to several common metabolic disorders, molecular research in GDM is lagging. It is important to recognize that GDM is still commonly diagnosed during the second trimester of pregnancy using the oral glucose tolerance test (OGGT), at a time when both a fetal and maternal pathophysiology is already present, demonstrating the increased blood glucose levels associated with exacerbated insulin resistance. Therefore, early detection of metabolic changes and associated epigenetic and genetic factors that can lead to an improved prediction of adverse pregnancy outcomes and future cardio-metabolic pathologies in GDM women and their children is imperative. Several genomic and epigenetic approaches have been used to identify the genes, genetic variants, metabolic pathways, and epigenetic modifications involved in GDM to determine its etiology. In this article, we explore these factors as well as how their functional effects may contribute to immediate and future pathologies in women with GDM and their offspring from birth to adulthood. We also discuss how these approaches contribute to the changes in different molecular pathways that contribute to the GDM pathogenesis, with a special focus on the development of insulin resistance.

Associations of dietary inflammatory potential with postpartum weight change and retention: Results from a cohort study

OBJECTIVE

This study examined the associations of Dietary Inflammatory Index (DII) with weight outcomes within 1 year post partum.

METHODS

This analysis included women who participated in a cohort study in South China (n = 468). The assessments included maternal height, weight, and dietary intake. The latter variable was based on three consecutive 24-hour food records collected at 2 weeks and 1 year after childbirth and was used to calculate the energy-adjusted DII (EDII) scores during and after puerperium, respectively. A general linear regression was performed to examine the relationships between the EDII scores and postpartum weight outcomes after adjusting for confounders.

RESULTS

In an analysis adjusted for confounders, the EDII during puerperium was positively associated with the weight change from 3 to 42 days (β: 0.42, 95% CI: 0.11-0.70). The EDII after puerperium was positively correlated with the weight changes from 42 days to 1 year (β: 0.52, 95% CI: 0.02-1.02) and from 3 days to 1 year (β: 0.63, 95% CI: 0.13-1.14), as well as with the postpartum weight retention at 1 year after childbirth (β: 0.75, 95% CI: 0.29-1.22).

CONCLUSIONS

The results indicate that a diet with a high EDII score might minimize postpartum weight loss and promote higher postpartum weight retention.

Relationship between weight retention at 6 weeks postpartum and the risk of large-for-gestational age birth in a second pregnancy in China: a retrospective cohort study

OBJECTIVE

We aimed to investigate the association between weight retention at 6 weeks postpartum after the first pregnancy and large-for-gestational age (LGA) risk in a subsequent pregnancy.

STUDY DESIGN

A retrospective cohort study.

SETTING

A tertiary hospital of China.

PARTICIPANTS

5950 Chinese singleton pregnancies that delivered their second singletons between 28 and 42 weeks of gestation.

OUTCOMES MEASURES

We calculated the weight retention at 6 weeks postpartum after the first pregnancy (the body mass index (BMI) at 6 weeks after the first birth minus the prepregnant BMI of the first pregnancy) and the gestational weight gain in the second pregnancy. We used the logistic regression to obtain adjusted OR. We determined the relationship between maternal BMI change at 6 weeks after the first pregnancy and LGA risk in the second pregnancy.

RESULTS

Relative to other categories of BMI change at 6 weeks postpartum, women who gained ≥3 kg/m² compared with the prepregnancy BMI were at increased LGA risk. The stratified analysis showed that LGA risk was increased in the second pregnancy in underweight and normal weight women who gained ≥3 kg/m² when using remain stable women as the reference group (OR=3.35, 95% CI 1.11 to 10.12 for underweight women; OR=2.23, 95% CI 1.43 to 3.45 for normal weight women) at 6 weeks postpartum. For the women who gained ≥3 kg/m² at 6 weeks postpartum, LGA risk was increased in normal weight women with an adequate (OR=3.21, 95% CI 1.10 to 9.33) and excessive (OR=2.62, 95% CI 1.02 to 6.76) gestational weight in the second pregnancy when using obese women as the reference.

CONCLUSION

Postpartum weight retention at 6 weeks after the first pregnancy provides us a new early window to identify LGA risk in a subsequent pregnancy and allows us to implement primary preventative strategies.

Postpartum Metabolism: How Does It Change from Pregnancy and What are the Potential Implications?

BACKGROUND

Metabolic dysfunction after pregnancy may have serious consequences for a new mother. The purpose of the study was to characterize basic changes that occur in metabolic profiles from late pregnancy through 4-6 months postpartum. A secondary purpose was to determine metabolic factors that may be contributing to postpartum weight retention.

METHODS

Participants (n=25) came in for 2 visits: late pregnancy (~34 weeks gestation) and postpartum (4-6 months). Resting metabolic rate (RMR), respiratory quotient (RQ), and substrate oxidation values were assessed for 15 minutes during fasted conditions. Blood was drawn and skinfold anthropometry was performed to assess additional outcomes (inflammation, insulin resistance, lipid profiles, body composition). The participants completed a number of surveys that examined other lifestyle and demographic data of interest. At the postpartum visit, additional assessments regarding sleep and breastfeeding habits were administered.

RESULTS

RMR was lower during postpartum (1517.2±225.1 kcal/day) compared to pregnancy (1867.9±302.6 kcal/day) (p<0.001), and remained lower when expressing RMR per kg body weight (postpartum: 22.3±2.7 vs pregnant: 23.7±3.4 kcal/kg, (p=0.034). Relative RMR (RMR per kg body weight) was negatively correlated to insulin resistance (HOMA-IR) during postpartum (r=-.463, p=0.034). Maternal HOMA-IR, inflammation (CRP), triglycerides (TAG), and carbohydrate oxidation were all positively correlated to postpartum weight retention (HOMA-IR: r=0.617, p=0.004; CRP: r=0.477, p=0.039, TAG: r=0.463, p=0.040; Carbohydrate Oxidation: (r=0.469, p=0.018).

CONCLUSION

Metabolic rate is lower during postpartum compared to pregnancy, and may be connected to insulin resistance. Maternal insulin resistance, inflammation, blood lipids, and substrate metabolism are all related to postpartum weight retention.

Changes in maternal anthropometric measurements in the first postpartum month and associated factors

OBJECTIVE

Maternal anthropometry offers a rapid, inexpensive, and non-invasive method for assessing nutritional status during pregnancy. We aimed to assess the changes in maternal anthropometric measurements in the first month after delivery and to investigate the factors associated with longitudinal changes in maternal postpartum nutritional status.

DESIGN

This prospective longitudinal study included 147 mothers who were on the 5th postpartum day applied to outpatient clinics, from January 2018 through January 2020. Each mother completed a structured questionnaire and baseline anthropometric measurements were performed at the postpartum 5th day and re-evaluated at the end of the first month after delivery.

PARTICIPANTS

Mother-infant pairs (n = 147).

RESULTS

At the end of the first postpartum month, maternal body weight (relative change -5.1%, 95% CI: -5.6%;-4.6%), muscle mass ratio (-1.6%, 95% CI: -2.4%;-0.9%) and body fluid ratio (-2.4%, 95% CI: -3.1%;-1.7%) decreased, whereas fat mass ratio increased (10.3%, 95% CI: 9.0%;11.6%).There was a significant association between infants' feeding type and maternal BMI, weight, muscle mass ratio, body fluid ratio, triceps, and biceps skinfold thickness in mothers (p < .05). We also found a significant relationship between maternal smoke exposure and BMI, maternal weight, fat-mass ratio (p < .05).

CONCLUSIONS

There are some important alterations in maternal anthropometric parameters during the postpartum period. This study will help further our understanding of the factors influencing changes in maternal body composition after delivery.

Ambient air pollution exposure during pregnancy and gestational diabetes mellitus in Shenyang, China: a prospective cohort study

The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. Reports of the association between air pollution exposure and GDM have been inconsistent in previous studies. We conducted a cohort study to investigate the associations between air pollution exposure and GDM in the city of Shenyang in Northeast China for the first time. We studied interactions with different air pollutant exposures and conducted a stratified analysis according to folic acid intake, age, body mass index (BMI), primiparity, and sleep quality. We found significant associations between prenatal exposure to NO_x and SO₂ and the development of GDM during the second trimester: the largest effect on GDM was exposure to SO₂ (odds ratio (OR): 1.77, 95% confidence interval (CI): 1.23-2.56) in the largest quartile compared with the lowest quartile. Significant interactions between age, BMI, parity, sleep quality, and air pollution exposures were observed; stratified analysis showed stronger associations between GDM and high air pollutant exposure in pregnant women with older age, larger BMI, poorer sleep quality, and more parity. We found that air pollution exposure during the second trimester was significantly associated with GDM in a prospective birth cohort study in Northeast China. SO₂, oxynitride (NOX, NO₂, NO), CO, and O₃ all showed a linear trend effect on GDM. Interactions between prenatal air pollution exposure and other factors, such as age at pregnancy, BMI before pregnancy, primiparity, folic acid intake, and sleep quality, during the second trimester might exist.

Tracking of Maternal Diet from Pregnancy to Postpregnancy: A Systematic Review of Observational Studies

We systematically reviewed studies to examine changes in women's diets from pregnancy to the postpregnancy period and sought to understand the characteristics of women making these changes. From a search of 4 databases and up to November 2019, 17 studies met our inclusion criteria. They reported changes in various dietary aspects. Mixed findings were reported for changes in energy and micronutrient intakes. Most studies reported significant decreases in fruit and vegetable consumption, diet quality, and adherence to a healthier dietary pattern during the transition from pregnancy to postpregnancy, whereas increases in discretionary food and fat intakes were observed. Women with lower education level, lower income, and/or who worked full-time tended to have poorer dietary behaviors postpregnancy. Further research, with better aligned dietary measurement time points during pregnancy and postpartum and standardization of dietary assessment tools, is needed for future studies to be comparable. The systematic review protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews as CRD42020158033.

Epicardial adipose tissue thickness as a potential predictor of gestational diabetes mellitus: a prospective cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common metabolic disorder that can occur during pregnancy and is associated with a long-term risk of both maternal and neonatal comorbidities. This study aimed to investigate the association between echocardiographic epicardial adipose tissue (EAT) and the risk for GDM during the early second trimester of pregnancy.

METHOD

We recruited all singleton pregnancies between January 2014 and December 2018 at 16 weeks + 0 days to 19 weeks + 6 days. We then used generalized linear models to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for EAT as a potential predictor for GDM. Receiver-operating-characteristic (ROC) analysis was then conducted to investigate the discriminative capacity of any individual maternal factor for the prediction of GDM.

RESULTS

In total, our study involved 314 pregnant women with GDM and 1832 pregnant women without GDM. Multivariate regression analysis revealed that EAT thickness (OR = 2.87; 95% CI: 2.49-3.31) was significantly associated with the presence of GDM (P < 0.001). Furthermore, EAT thickness was also significantly associated with a range of adverse outcomes in the GDM group, including large size for gestational age, neonatal hypoglycemia, admission to the neonatal intensive care unit, preterm delivery, and hyperbilirubinemia (P < 0.001). ROC analysis revealed that the area under the curve was 0.790 (95% CI: 0.768-0.812). When the cutoff value for EAT thickness was set to 5.49 mm, the sensitivity was 95.2% and the specificity was 50.5%.

CONCLUSIONS

Echocardiographic EAT thickness is positively and significantly associated with both the risk of GDM and adverse outcomes related to GDM. Echocardiographic EAT has the potential to predict GDM prior to actual clinical diagnosis.

Evaluation of weight retention four weeks after delivery as a risk factor for gestational diabetes mellitus in a subsequent pregnancy

AIM

We aimed to assess the association between postpartum weight retention (PPWR) in the fourth week after delivery and the risk of gestational diabetes mellitus (GDM) in a subsequent pregnancy.

METHODS

We performed a retrospective cohort study of the obstetric records of women who gave birth to their second singleton between 32 and 41 weeks of gestation at the National Hospital Organization Kofu National Hospital between January 2013 and September 2019. The exclusion criteria were missing data, twin pregnancy, diabetes in pregnancy, and delivery before 22 weeks in the first pregnancy. We calculated PPWR as the BMI 4 weeks after the first birth minus the BMI before the first pregnancy and grouped the subjects into the stable PPWR (gain of <1 BMI unit) and non-stable PPWR groups (gain of ≥1 BMI units). We used the χ2 test and multivariable logistic regression analysis to investigate the association between weight retention at the postpartum checkup and GDM.

RESULTS

We included 566 women in this study (mean age, 31.7±4.8 years; mean maternal pre-pregnancy BMI, 21.3±3.5 kg/m2; term delivery, n = 544 [96.1%]). The overall prevalence of GDM during the second pregnancy was 7.4% (42/566), and 33.9% (192/566) of women had stable PPWR. Non-stable PPWR was not significantly associated with GDM in the second pregnancy (adjusted odds ratio, 1.93; 95% confidence interval, 0.84-4.46) after controlling for each variable.

CONCLUSION

PPWR measured in the fourth week after delivery was not associated with an increased risk of GDM in the second pregnancy.