Prepregnancy Obesity and Risks of Stillbirth

Maternal pre-pregnancy overweight or obesity and risk of birth defects in offspring: Population-based cohort study

INTRODUCTION

Maternal obesity, a health condition increasingly prevalent worldwide, has been suggested to be associated with a higher risk of birth defects in offspring, whereas evidence from population-based data from China was largely lacking. Additionally, the role of gestational diabetes in the association between maternal obesity and birth defects remains unclear. We aimed to investigate the association of maternal pre-pregnancy overweight or obesity with any and different types of birth defects in offspring and the interaction between pre-pregnancy overweight or obesity and gestational diabetes.

MATERIAL AND METHODS

We conducted a population-based cohort study including 257 107 singletons born between 2015 and 2021 in Longgang District, Shenzhen, China, using data from the Shenzhen Maternal and Child Health Management System. Poisson regression was conducted to estimate the associations of maternal pre-pregnancy overweight or obesity, as well as the interaction between pre-pregnancy overweight or obesity and gestational diabetes, with the risk of birth defects. Models were adjusted for maternal age at delivery, educational level, type of household registration, and gravidity.

RESULTS

Maternal pre-pregnancy overweight was associated with a higher risk of any birth defect (risk ratio [RR] 1.21, 95% confidence interval [CI] 1.12 to 1.31) as well as of congenital malformations of the circulatory system (RR 1.26, 95% CI 1.12 to 1.41), eye/ear/face/neck (RR 1.42, 95% CI 1.04 to 1.94), and musculoskeletal system (RR 1.21, 95% CI 1.01 to 1.44). Maternal pre-pregnancy obesity was associated with a higher risk of any birth defect (RR 1.38, 95% CI 1.18 to 1.63) and congenital malformations of the circulatory system (RR 1.61, 95% CI 1.30 to 1.98). Infants born to overweight or obese mothers with gestational diabetes had a higher risk of congenital malformations of the circulatory system than infants born to overweight or obese mothers without gestational diabetes.

CONCLUSIONS

Maternal pre-pregnancy overweight or obesity was associated with a higher risk of birth defects, particularly congenital malformations of the circulatory system, in offspring. Gestational diabetes interacts additively with pre-pregnancy overweight or obesity on modifying the risk of congenital malformations of the circulatory system. The importance of improving weight management and assessment of glucose and metabolic functions was emphasized among women planning for pregnancy who are overweight or obese.

Levels, Trends, and Risk Factors for Stillbirths in the United States: 2000-2017

OBJECTIVE

 This study documents 2000 to 2017 trends in stillbirth rates and changes in associations between known maternal and fetal risk factors and stillbirths for 2000 to 2002 versus 2015 to 2017 in the United States.

STUDY DESIGN

 We conducted a retrospective, population-based analysis of stillbirths and live-births using national vital statistics data. We calculated annual stillbirth rates overall and by gestational age; and examined stillbirth rates by maternal age, race-ethnicity, and state for 2000 to 2002 versus 2015 to 2017. We used Chi-squared tests to examine associations between maternal and fetal risk factors separately for early (20-27 weeks) and late (28+ weeks) stillbirths compared with live-births for 2000 to 2002 versus 2015 to 2017.

RESULTS

 Stillbirth rates declined by 7.5% (p < 0.001) during 2000 to 2006 but remained flat at approximately 6 stillbirths per 1,000 births thereafter. Throughout 2000 to 2017, there were significant improvements in stillbirth rates at 39+ weeks nationally (p < 0.001), but rates varied greatly between and within states. Sociodemographic (advanced maternal age, Black race, low education, unmarried status, and rural residence), obstetric, and other medical factors (>3 births, use of infertility treatment, maternal obesity, diabetes, chronic hypertension, eclampsia, no prenatal care, and tobacco use) were significantly more prevalent in women with late than early stillbirths or live births. Notably, late and total stillbirth rates were approximately 30% higher for women >35 years than for women <35 years and twice as high for non-Hispanic Black than non-Hispanic White women; American Indian/Alaska Native women represented the only racial-ethnic group with significantly higher late stillbirth rates in 2015 to 2017 than in 2000 to 2002. Pregnancy and fetal factors (multiple pregnancy, male fetus, and breech presentation) were more prevalent in women with early than late stillbirths or live births.

CONCLUSION

 U.S. stillbirth rates have plateaued since 2006. There are persistent differential risk profiles for early versus late stillbirths which can inform stillbirth prevention strategies (e.g., close observation of women with risk factors for stillbirth) and new research into the causes of stillbirths by gestational age.

KEY POINTS

· U.S. stillbirth rates have plateaued since 2006.. · Stillbirth rates vary between and within U.S. states and by maternal and fetal factors.. · Early versus late stillbirths have different risk profiles which can guide stillbirth prevention strategies..

Non-linear associations of maternal pre-pregnancy body mass index with risk of stillbirth, infant, and neonatal mortality in over 28 million births in the USA: a retrospective cohort study

Background

Higher maternal pre-pregnancy body mass index (BMI) has been associated with higher risk of stillbirth, infant and neonatal mortality. Studies exploring underweight have varied in their conclusions. Our aim was to examine the risk of stillbirth, infant and neonatal mortality across the BMI distribution and establish a likely healthy BMI range.

Methods

In this retrospective cohort study, we used publicly available datasets (covering 1st January 2014 to 31st December 2021) from the US National Center for Health Statistics National Vital Statistics System. All births were eligible; analyses included those with non-missing data. Fractional polynomial multivariable logistic regression was used to examine the associations of maternal pre-pregnant BMI with stillbirth (birth with no signs of life at ≥24 weeks), infant mortality (death of a live born baby aged <365 days) and neonatal mortality (death of a live born baby aged <28 days).

Findings

There were 77,896/28,310,154 (2.8 per 1000 births) stillbirths, 143,620/28,231,807 (5.1 per 1000 live births) infant deaths and 94,246/28,231,807 (3.3 per 1000 live births) neonatal deaths among complete cases. Mean (SD) BMI was 27.1 kg/m2 (6.7 kg/m2). We found non-linear associations between BMI and all three outcomes; risk was elevated at both low and high BMIs although, for stillbirth, the increased risk at low BMI was less marked than for infant/neonatal mortality. The lowest risk was at a BMI of 21 kg/m2 for infant and neonatal mortality and 19 kg/m2 for stillbirth.

Interpretation

Public health messaging for preconception and postnatal care should focus on healthy weight to maximise maternal and child health, and not focus solely on maternal overweight or obesity.

Funding

European Research Council, US National Institute of Health, UK Medical Research Council and National Institute for Health and Care Research.

Obesity as a potential risk factor for stillbirth: The Japan Environment and Children's Study

The relationship between high body mass index (BMI) >25 kg/m2 and risk for stillbirth in the Japanese population remains unclear. This study aimed to estimate the impact of maternal obesity on the risk of stillbirth in a Japanese population. This prospective cohort study used data from the Japan Environment and Children's Study, which recruited pregnant individuals between 2011 and 2014. A total of 93,772 fetuses were considered eligible for inclusion in this study. Stillbirth (fetal death before or during labor at ≥22 completed weeks of gestation) rates were compared among four pre-pregnancy BMI groups: underweight (<18.5 kg/m2), reference (18.5 to <25.0 kg/m2), overweight (25.0 to <30.0 kg/m2), and obese (≥30.0 kg/m2). The association between pre-pregnancy BMI and the risk of stillbirth was estimated using multiple logistic regression analyses. The overall stillbirth incidence was 0.33% (305/93,722). Compared with the reference group, the risk of stillbirth was significantly higher in the overweight group (adjusted odds ratio [aOR]: 1.55; 95% confidence interval [CI]: 1.08-2.23) and the obese group (aOR: 2.60; 95% CI: 1.59-4.24). The overall incidence of early stillbirth (i.e., <28 weeks) was 0.17% (155/93,722). Similarly, after adjusting for potential confounding factors, the risk of early stillbirth was significantly higher in the obese group (aOR: 4.33; 95% CI: 2.44-7.70). Increased maternal BMI was associated with an increased risk of stillbirth in the Japanese population. Therefore, counselling women planning for pregnancy on the importance of an appropriate pre-pregnancy BMI to minimize the risk of stillbirth is important.

Hispanic Ethnicity, Nativity and the Risk of Stillbirth

The objective of this study was to examine stillbirth risk by nativity and Hispanic ethnicity. We analyzed births and fetal deaths among women of Hispanic origin within gestational ages of 20-42 weeks from the 2014-2019 Birth and Fetal Death. Foreign-born Hispanic mothers were 8% less likely (HR 0.92, 95% CI 0.90-0.95) to experience stillbirth than their counterparts. Stratified by ethnicity, foreign-born Mexican and Central/South American women had a lower risk of stillbirth (HR 0.85, 95% CI 0.81-0.88 and HR 0.68, 95% CI 0.63-0.75, respectively) while foreign-born Puerto Rican women were more likely to experience stillbirth (HR 1.37, 95% CI 1.24-1.51) than their native-born counterparts. While overall foreign-born Hispanic mothers were less likely to experience stillbirth than native-born Hispanic mothers, this differed depending on ethnicity. Counseling regarding risk of stillbirth among Hispanic women should take into consideration nativity and country of origin as influential factors.

Maternal asthma during pregnancy and extremes of body mass index increase the risk of perinatal mortality: a retrospective cohort study

OBJECTIVE

Asthma during pregnancy and extremes of body mass index (BMI) are independently associated with adverse pregnancy outcomes but the impact of the two conditions combined are currently unknown. The aim of this study was to determine the contribution of maternal BMI to adverse birth outcomes in pregnancies complicated by asthma.

METHODS

The study utilized the routinely collected perinatal data on births at the Mater Mother's Hospital Brisbane, Australia, from January 2008 to December 2019. BMI was grouped as underweight (<18.5), normal weight (18.5-<24.99), overweight (25-29.99), and obese (≥30) and the population split by the presence and absence of maternal asthma. The comparison group was normal BMI, non-asthmatic pregnant women. A modified Poisson regression with robust variance was used to estimate the relative risk.

RESULTS

In a retrospective cohort study of 110,057 pregnant women, 17.08% of women had asthma. Asthma and BMI were associated with an increased risk of poor fetal and neonatal outcomes. Asthma significantly increased the risk of stillbirth in underweight [adjusted RR: 2.22 (95% CI: 1.25-3.94] and obese [1.74 (1.11-2.71)]; neonatal death in underweight [3.41 (1.89-6.16)] and obese [2.22 (1.37-3.59)] and perinatal death in underweight [2.34 (1.50-3.66)] and obese [1.92 (1.38-2.67)] women. Admission to the neonatal intensive care unit was increased in neonates of underweight [1.65 (1.44-1.89)] and obese [1.26 (1.14-1.40)] asthmatic women.

CONCLUSIONS

Extremes of BMI, specifically underweight and obesity, increased the risk of adverse perinatal outcomes among asthmatic women highlighting the importance of accounting for BMI during pre-conception and pregnancy related management of asthmatic women.

Timing of delivery in obese women and risk of stillbirth

PURPOSE

Increased body mass index (BMI) is an independent risk factor for stillbirth. The purpose of this study was to determine an optimal time of delivery at term in obese women in order to decrease the risk of stillbirth in this population.

METHODS

We conducted a retrospective population-based cohort study using the CDC's Period Linked Birth-Infant Death and Fetal Death data. The study population included all singleton, term births with a recorded pre-pregnancy BMI that occurred between 2014 and 2017. Unconditional logistic regression analyses were used to estimate the risk of stillbirth in each BMI class at each gestational week from 37 weeks and onwards comparing with births to normal-weight women at 41 weeks.

RESULTS

Of 12,742,980 births in our cohort, 46.8% were to women with a normal BMI, 26.9% were to women who were classified as overweight, 14.5% were to women in obesity class I, 7.3% in obesity class II, and 4.8% in obesity class III. Within each BMI class, the risk of stillbirth increased with gestational age, with the most pronounced rises in risk occurring at later gestational ages. In a dose-response relationship, the risk of stillbirth exceeded that of a normal BMI pregnancy at 41 weeks at the following gestational age and BMI category: obese class 1 at 39 weeks (OR 1.15 95% CI 1.00-1.31), obese class II at 38 weeks (OR 1.21 95% CI 1.04-1.41) and obese class III at 37 weeks (OR 1.30 95% CI 1.11-1.52).

CONCLUSION

Compared to women with a normal BMI at 41 weeks, there was a higher risk of stillbirth at term in women with each increase in BMI class. Consideration should be given to early induction among these women to reduce the risk of stillbirth.

Obesity and Gestational Diabetes in Pregnant Care and Clinical Practice

Obesity and Gestational Diabetes Mellitus (GDM) are the most frequent pathologies affecting mothers and offspring during pregnancy. Both conditions have shown a sustained increase in their prevalence in recent years, and they worsen the outcome of pregnancy and the long-term health of mothers. Obesity increases the risk of GDM and pre-eclampsia during pregnancy and elevates the risk of developing metabolic syndrome in later life. Offspring of obese mothers have an increased risk of obstetric morbidity and mortality and, consistent with the developmental origins of health and disease, a long term risk of childhood obesity and metabolic dysfunction. On the other hand, GDM also increases the risk of pre-eclampsia, caesarean section, and up to 50% of women will develop type 2 diabetes later in life. From a fetal point of view, it increases the risk of macrosomia, large-for-gestational-age fetuses, shoulder dystocia and birth trauma. The insulin resistance and inflammatory mediators released by a hypoxic trophoblast are mainly responsible for the poor pregnancy outcome in obese or GDM patients. The adequate management of both pathologies includes modifications in the diet and physical activity. Drug therapy should be considered when medical nutrition therapy and moderate physical activity fail to achieve treatment goals. The antenatal prediction of macrosomia is a challenge for physicians. The timing and the route of delivery should consider adequate metabolic control, gestational age, and optimal conditions for a vaginal birth. The best management of these pathologies includes pre-conception planning to reduce the risks during pregnancy and improve the quality of life of these patients.

Incidence and Causes of Stillbirth in Omdurman Maternity Hospital, Sudan: A Prospective Cross-Sectional Study

BACKGROUND

Stillbirth is an important indicator of the quality of antenatal health services. This study aimed to identify the incidence and causes of stillbirths among Sudanese women.

METHOD

This is a descriptive cross-sectional hospital-based study that was conducted at Omdurman Maternity Hospital during the period from December 1, 2019 to May 30, 2020. The study sample comprised 285 women who presented with stillbirths. Data were collected using a structured questionnaire administered to women after taking informed consent. Data were analyzed using descriptive statistics [Statistical Package for Social Sciences (SPSS) version 24 (IBM Corp., Armonk, NY)].

RESULTS

The incidence of stillbirths was 16/1000. Idiopathic causes were the most frequent causes which accounted for 20% (n=57), followed by pre-eclampsia 18.6% (n=53), congenital abnormalities 15.1% (n=43), and abruption placentae 14.4% (n=41). In addition, the less common causes were eclampsia 4.6% (n=13), ruptured uterus 4.2% (n=12), twin-twin transfusion 4.2% (n=12), cord prolapse 3.5% (n=10), uncontrolled diabetes mellitus (DM) 3.5% (n=10), malpresentation 2.6% (n=8), gestational DM 2.5%(n=7), anemia 2.5%(n=7), sepsis 2.1 (n=6), placenta previa 1.4% (n=4), renal disease 0.4% (n=1), and toxoplasmosis 0.4% (n=1).

CONCLUSION

The incidence of stillbirths was 16/1000. Unexplained causes of stillbirths were the most common causes which accounted for 20% of all deaths. In contrast, explainable causes were responsible for 80% of fetal deaths. Among explainable causes, pre-eclampsia and its consequences (abruption, eclampsia) remain the most common cause.

Obstetrician-Gynecologists' Strategies for Patient Initiation and Maintenance of Antiobesity Treatment with Glucagon-Like Peptide-1 Receptor Agonists

Obesity is a chronic disease affecting women at higher rates than men. In an obstetrics and gynecology setting, frequently encountered obesity-related complications are polycystic ovary syndrome, fertility and pregnancy complications, and increased risk of breast and gynecological cancers. Obstetrician-gynecologists (OBGYNs) are uniquely positioned to diagnose and treat obesity, given their role in women's primary health care and the increasing prevalence of obesity-related fertility and pregnancy complications. The metabolic processes of bodyweight regulation are complex, which makes weight-loss maintenance challenging, despite dietary modifications and exercise. Antiobesity medications (AOMs) can facilitate weight loss by targeting appetite regulation. There are four AOMs currently approved for long-term use in the United States, of which liraglutide 3.0 mg is among the most efficacious. Liraglutide 3.0 mg, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), is superior to placebo in achieving weight loss and improving cardiometabolic profile, in both clinical trial and real-world settings. In addition, women with fertility complications receiving liraglutide 1.8–3.0 mg can benefit from improved ovarian function and fertility. Liraglutide 3.0 mg is generally well tolerated, but associated with transient gastrointestinal side effects, which can be mitigated. In this review, we present the risks of obesity and benefits of weight loss for women, and summarize clinical development of GLP-1 RAs for weight management. Finally, we provide practical advice and recommendations for OBGYNs to open the discussion about bodyweight with their patients, initiate lifestyle modification and GLP-1 RA treatment, and help them persist with these interventions to achieve optimal weight loss with associated health benefits.

The Risks Associated With Obesity in Pregnancy

BACKGROUND

Approximately one-third of all women of childbearing age are overweight or obese. For these women, pregnancy is associated with increased risks for both mother and child.

METHODS

This review is based on pertinent publications retrieved by a selective search of PubMed, with special attention to current population-based cohort studies, systematic reviews, meta-analyses, and controlled trials.

RESULTS

Obesity in pregnancy is associated with unfavorable clinical outcomes for both mother and child. Many of the risks have been found to depend linearly on the body-mass index (BMI). The probability of conception declines linearly, starting from a BMI of 29 kg/m2, by 4% for each additional 1 kg/m2 of BMI (hazard ratio 0.96, 95% confidence interval: [0.91; 0.99]). A 10% increase of pregravid BMI increases the relative risk of gestational diabetes and that of preeclampsia by approximately 10% each. A 5 kg/m2 increase of BMI elevates the relative risk of intrauterine death to 1.24 [1.18; 1.30]. An estimated 11% of all neonatal deaths can be attributed to the consequences of maternal overweight and obesity. Nonetheless, in most randomized controlled trials, nutritional and lifestyle interventions did not bring about any clinically relevant reduction in the incidence of gestational diabetes and fetal macrosomia.

CONCLUSION

The risks associated with obesity in pregnancy cannot necessarily be influenced by intervention. Preventive measures aimed at normalizing body weight before a woman becomes pregnant are, therefore, all the more important.

Adverse perinatal outcomes for obese women are influenced by the presence of comorbid diabetes and hypertensive disorders

Maternal obesity often occurs together with comorbid diabetes and hypertensive disorders. All three conditions are independently associated with negative perinatal outcomes. Our objective was to determine the risk and burden of adverse perinatal outcome that could be attributed to maternal obesity in combination with a comorbid status. We analyzed data from 324'664 singleton deliveries in Switzerland between 2005 and 2016. For the association of maternal obesity in the presence or absence of comorbidities with various perinatal outcomes, we estimated adjusted relative risk (RR) using multivariable regression modeling and determined the multivariable-adjusted attributable fraction of the population (AFp). Obesity was a main predictor for macrosomia, fracture of the clavicle, failure to progress in labor and prolonged labor. By stratifying women based on comorbidities, we identified significantly increased risk for preterm birth and early neonatal death only for women diagnosed with a comorbidity. However, various other outcomes were independently associated with either obesity or comorbidities. The AFp showed greatest reduction in comorbidities (15.4/15.0/13.2%), in macrosomia (6.3%) and in shoulder dystocia (4.8%) if all women were to become non-obese. We suggest that comorbidities such as diabetes and hypertensive disorders should be considered when relating maternal obesity to adverse perinatal outcomes.

Causes of intrauterine fetal death are changing in recent years

OBJECTIVE

To investigate, how causes of intrauterine fetal death (IUFD) have changed in recent years with the advancement of prenatal diagnosis at a single perinatal center in Japan.

METHODS

Medical records were retrospectively reviewed for all cases of IUFDs that occurred between 2001 and 2014. The most commonly associated causes of fetal deaths were compared between 2001-2007 and 2008-2014.

RESULTS

The number of IUFD after 20 weeks' gestation/all deliveries in our center was 38/6878 cases (0.53%) in 2001-2007 and 35/7326 (0.48%) in 2008-2014. The leading cause of IUFD in 2001-2007 was fetal abnormalities (43.2%), the prevalence of which was only 8.6% in 2008-2014 (P<0.01). Meanwhile, the prevalence of umbilical cord abnormalities was relatively increased from 30.0% in 2001-2007 to 54.5% in 2008-2014 (P=0.06). In 2001-2007, chromosomal abnormalities were frequently observed (56% of IUFDs due to fetal abnormalities). Hyper-coiled cord (HCC) and umbilical ring constrictions were the most frequent cause of IUFD in both periods. The relatively decreased prevalence of IUFD due to velamentous cord insertion and umbilical cord entanglement, HCC and umbilical cord constriction was increased.

CONCLUSIONS

The prevalence of IUFD due to fetal abnormalities was reduced, but IUFD associated with umbilical cord abnormalities tended to increase relatively.

Obesity in Pregnancy: Optimizing Outcomes for Mom and Baby

Obesity is common in women of childbearing age, and management of this population around the time of pregnancy involves specific challenges. Weight and medical comorbidities should be optimized both before and during pregnancy. During pregnancy, gestational weight gain should be limited, comorbidities should be appropriately screened for and managed, and fetal health should be monitored. Consideration should be given to the optimal timing of delivery and to reducing surgical and anesthetic complications. In the postpartum period, breastfeeding and weight loss should be promoted. Maternal obesity is associated with adverse metabolic effects in offspring, promoting an intergenerational cycle of obesity.

'The obesity paradox': a reconsideration of obesity and the risk of preterm birth

OBJECTIVE

The association between obesity and spontaneous preterm births (sPTBs) has been shown to be influenced by obesity-attendant comorbidities. Our objective was to better understand the complex relationship of obesity and its attendant comorbidities with sPTBs.

STUDY DESIGN

A retrospective analysis utilizing maternally linked hospital and birth certificate records of 2 049 196 singleton California deliveries from 2007 to 2011. Adjusted relative risks (aRRs) for sPTBs were estimated using multivariate Poisson regression modeling.

RESULTS

Obese women had higher aRRs for sPTBs than their normal body mass index (BMI) controls. aRRs (95% confidence interval) increased with increasing BMI category: Obese I=1.10 (1.08 to 1.12); Obese II=1.15 (1.12 to 1.18); and Obese III=1.26 (1.22 to 1.30). When comparing only obese women without comorbidities to their normal BMI controls, aRRs reversed, that is, obese women had lower aRRs of sPTBs: Obese I=0.96 (0.94 to 0.98), Obese II=0.95 (0.91 to 0.98); and Obese III=0.98 (0.94 to 1.03). This same reversal of aRR direction was also observed among women with comorbidities: 0.92 (0.89 to 0.96); 0.89 (0.85 to 0.93); and 0.89 (0.85 to 0.93), respectively. Increasing BMI increased the aRRs for sPTBs among patients with gestational diabetes (P<0.05), while decreasing the risk among patients with chronic hypertension and pregnancy-related hypertensive disease (P<0.05).

CONCLUSIONS

The obesity and preterm birth paradox is an example of what has been described as 'Simpson's Paradox'. Unmeasured confounding factors mediated by comorbidities may explain the observed protective effect of obesity upon conditioning on the presence or absence of comorbidities and thus resolve the paradox.

Risk of major congenital malformations in relation to maternal overweight and obesity severity: cohort study of 1.2 million singletons

Objective To estimate the risks of major congenital malformations in the offspring of mothers who are underweight (body mass index (BMI) <18.5), overweight (BMI 25 to <30), or in obesity classes I (BMI 30 to <35), II (35 to <40), or III (≥40) compared with offspring of normal weight mothers (BMI 18.5 to <25) in early pregnancy.Design Population based cohort study.Setting Nationwide Swedish registries.Participants 1 243 957 liveborn singleton infants from 2001 to 2014 in Sweden. Data on maternal and pregnancy characteristics were obtained by individual record linkages.Exposure Maternal BMI at the first prenatal visit.Main outcome measures Offspring with any major congenital malformation, and subgroups of organ specific malformations diagnosed during the first year of life. Risk ratios were estimated using generalised linear models adjusted for maternal factors, sex of offspring, and birth year.Results A total of 43 550 (3.5%) offspring had any major congenital malformation, and the most common subgroup was for congenital heart defects (n=20 074; 1.6%). Compared with offspring of normal weight mothers (risk of malformations 3.4%), the proportions and adjusted risk ratios of any major congenital malformation among the offspring of mothers with higher BMI were: overweight, 3.5% and 1.05 (95% confidence interval 1.02 to 1.07); obesity class I, 3.8% and 1.12 (1.08 to 1.15), obesity class II, 4.2% and 1.23 (1.17 to 1.30), and obesity class III, 4.7% and 1.37 (1.26 to 1.49). The risks of congenital heart defects, malformations of the nervous system, and limb defects also progressively increased with BMI from overweight to obesity class III. The largest organ specific relative risks related to maternal overweight and increasing obesity were observed for malformations of the nervous system. Malformations of the genital and digestive systems were also increased in offspring of obese mothers.Conclusions Risks of any major congenital malformation and several subgroups of organ specific malformations progressively increased with maternal overweight and increasing severity of obesity. For women who are planning pregnancy, efforts should be encouraged to reduce adiposity in those with a BMI above the normal range.

Going to sleep in the supine position is a modifiable risk factor for late pregnancy stillbirth; Findings from the New Zealand multicentre stillbirth case-control study

Objective

Our objective was to test the primary hypothesis that maternal non-left, in particular supine going-to-sleep position, would be a risk factor for late stillbirth (≥28 weeks of gestation).

Methods

A multicentre case-control study was conducted in seven New Zealand health regions, between February 2012 and December 2015.

Cases (n = 164) were women with singleton pregnancies and late stillbirth, without congenital abnormality. Controls (n = 569) were women with on-going singleton pregnancies, randomly selected and frequency matched for health region and gestation.

The primary outcome was adjusted odds of late stillbirth associated with self-reported going-to-sleep position, on the last night. The last night was the night before the late stillbirth was thought to have occurred or the night before interview for controls. Going-to-sleep position on the last night was categorised as: supine, left-side, right-side, propped or restless. Multivariable logistic regression adjusted for known confounders.

Results

Supine going-to-sleep position on the last night was associated with increased late stillbirth risk (adjusted odds ratios (aOR) 3.67, 95% confidence interval (CI) 1.74 to 7.78) with a population attributable risk of 9.4%. Other independent risk factors for late stillbirth (aOR, 95% CI) were: BMI (1.04, 1.01 to 1.08) per unit, maternal age ≥40 (2.88, 1.31 to 6.32), birthweight <10^th customised centile (2.76, 1.59 to 4.80), and <6 hours sleep on the last night (1.81, 1.14 to 2.88). The risk associated with supine-going-to-sleep position was greater for term (aOR 10.26, 3.00 to 35.04) than preterm stillbirths (aOR 3.12, 0.97 to 10.05).

Conclusions

Supine going-to-sleep position is associated with a 3.7 fold increase in overall late stillbirth risk, independent of other common risk factors. A public health campaign encouraging women not to go-to-sleep supine in the third trimester has potential to reduce late stillbirth by approximately 9%.

Perspectives in obesity and pregnancy

Obesity is currently recognized as a health epidemic worldwide. Its prevalence has doubled in the last three decades. Obesity is a complex clinical picture associated with physical, physiologic, hormonal, genetic, cultural, socioeconomic and environmental factors. The rate of obesity is also increasing in the pregnant women population. Maternal obesity is associated with less than optimal obstetrical, fetal and neonatal outcomes. It is also associated with significant adverse long-term effects on both obese parturients and the infants born from obese women. A number of guidelines have been published to educate health care workers and the general population in an attempt to develop effective interventions on a large scale to prevent obesity. These guidelines are multiple, confusing and inconsistent. There are no standard recommendations regarding gestational weight gaining goals, nutrients and additional elements necessary for certain obese women who have been treated with bariatric surgical procedures, screening for metabolic diseases such as diabetes, additional preventive health care services indicated for obese women in the pregnancy planning stages, during prenatal care, in the immediate post-partum period and as a long-term approach for health preservation. In 2013, the American Medical Association supported by several US national medical specialty organizations published Resolution 420 (A-13) recognizing obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to improve its prevention and treatment. The goal of this decision was to encourage a broader spectrum of health care benefits insurance coverage for the prevention and treatment of obesity. There are a number of myths and misconceptions associated with obesity. These perspectives present our views and clinical experience with a partial review of recent bibliography addressing the associations between obese reproductive age women and their risks during pregnancy.