Obesity in pregnancy: what's next? Long-term cardiovascular morbidity in a follow-up period of more than a decade

Maternal body mass index and cerebral palsy in children: A systematic review and dose-response meta-analysis

BACKGROUND

Accumulating studies indicate that maternal obesity is associated with the risk of cerebral palsy (CP); however, their conclusions have been inconsistent.

OBJECTIVES

To quantitatively estimate the association between maternal body mass index (BMI) and CP in offspring.

DATA SOURCES

PubMed, Embase and Web of Science.

STUDY SELECTION AND DATA EXTRACTION

Articles published up to 18 September 2022 were searched that reported the correlation between maternal BMI and CP in children. Two reviewers independently extracted data and critically assessed articles.

SYNTHESIS

Pooled relative risks (RR) and 95% confidence intervals (CI) were estimated by the random-effects model. Subgroup analysis and meta-regression were performed to explore sources of heterogeneity.

RESULTS

In total, 11 articles (8,407,668 participants) were identified for inclusion in our meta-analysis. For maternal underweight, no significant association was found with CP risk (RR 1.11, 95% CI 0.90, 1.38). The risk of CP was increased by 25% (RR 1.25, 95% CI 1.06, 1.47), 38% (RR 1.38, 95% CI 1.18, 1.61) and 127% (RR 2.27, 95% CI 1.82, 2.83) for maternal overweight, obesity and obesity grade 3, respectively. In addition, we observed a positive linear dose-response relationship, with the pooled risk of cerebral palsy in offspring increasing by 3% with each unit increase in maternal BMI.

CONCLUSION

This meta-analysis indicates that the risk of CP in offspring grew with maternal overweight or obesity grades increasing, and was positively correlated with maternal BMI.

Epigenome-wide association study of DNA methylation in maternal blood leukocytes with BMI in pregnancy and gestational weight gain

OBJECTIVES

We aimed to discover CpG sites with differential DNA methylation in peripheral blood leukocytes associated with body mass index (BMI) in pregnancy and gestational weight gain (GWG) in women of European and South Asian ancestry. Furthermore, we aimed to investigate how the identified sites were associated with methylation quantitative trait loci, gene ontology, and cardiometabolic parameters.

METHODS

In the Epigenetics in pregnancy (EPIPREG) sample we quantified maternal DNA methylation in peripheral blood leukocytes in gestational week 28 with Illumina's MethylationEPIC BeadChip. In women with European (n = 303) and South Asian (n = 164) ancestry, we performed an epigenome-wide association study of BMI in gestational week 28 and GWG between gestational weeks 15 and 28 using a meta-analysis approach. Replication was performed in the Norwegian Mother, Father, and Child Cohort Study, the Study of Assisted Reproductive Technologies (MoBa-START) (n = 877, mainly European/Norwegian).

RESULTS

We identified one CpG site significantly associated with GWG (p 5.8 × 10-8) and five CpG sites associated with BMI at gestational week 28 (p from 4.0 × 10-8 to 2.1 × 10-10). Of these, we were able to replicate three in MoBa-START; cg02786370, cg19758958 and cg10472537. Two sites are located in genes previously associated with blood pressure and BMI. DNA methylation at the three replicated CpG sites were associated with levels of blood pressure, lipids and glucose in EPIPREG (p from 1.2 × 10-8 to 0.04).

CONCLUSIONS

We identified five CpG sites associated with BMI at gestational week 28, and one with GWG. Three of the sites were replicated in an independent cohort. Several genetic variants were associated with DNA methylation at cg02786379 and cg16733643 suggesting a genetic component influencing differential methylation. The identified CpG sites were associated with cardiometabolic traits.

CLINICALTRIALS

GOV REGISTRATION NO

Not applicable.

The Long-Term Effect of Maternal Obesity on the Cardiovascular Health of the Offspring-Systematic Review

Maternal obesity may affect offspring's cardiovascular health. Our literature search using PubMed, Web of Sciences included original English research and Google Scholar articles published over the past ten years, culminating in 96 articles in this topic. A mother's obesity during pregnancy has a negative impact on the cardiovascular risk for their offspring. Dependence was observed in relation to hypertension, coronary artery disease, stroke, and heart failure. The adverse impact of an abnormal diet in pregnant mice on heart hypertrophy was observed, and was also confirmed in human research. Pregnant women with obesity were at greater risk of having a child with innate heart disease than pregnant women with normal mass. To conclude: mother's obesity has a negative impact on the long-term cardiovascular consequences for their offspring, increasing their risk of high blood pressure, coronary heart disease, stroke and heart failure. It also increases the probability of heart hypertrophy and innate heart defects.

Obesity in pregnancy is a predictor of persistent subclinical myocardial dysfunction over postpartum period

PURPOSE

No previous study provided a complete functional evaluation of all cardiac chambers in pregnant women with obesity. Moreover, the impact of cardiovascular changes associated with obesity in pregnancy on maternal outcome is unclear.

METHODS

46 consecutive pregnant women with obesity, defined by body mass index (BMI) ≥ 30 Kg/m2, and 83 age- (35.5 ± 4.1 vs. 34.1 ± 5.1 yrs, p = 0.11), ethnicity- (caucasian 65.2 vs. 66.3%, p = 0.90) and gestational week-matched (36.3 ± 1.7 vs. 36.5 ± 1.5 wks, p = 0.49) pregnant women without obesity (BMI < 30 Kg/m2) were examined in the first trimester (12-14 weeks), third trimester (36-38 weeks) and 6-10 weeks postpartum. All women underwent obstetric visit, blood tests and transthoracic echocardiography implemented with two-dimensional speckle tracking echocardiography analysis of biventricular and biatrial myocardial deformation indices at the three time points. Outcome was persistent subclinical myocardial dysfunction, defined as an absolute value of left ventricular global longitudinal strain (LV-GLS) less negative than - 20%, in postpartum.

RESULTS

Despite normal biventricular systolic function, all myocardial strain indices were significantly lower in pregnant women with obesity than controls. At 8.2 ± 2.2 weeks postpartum, LV-GLS remained less negative than - 20% in 86.9% of women with obesity in pregnancy. Maternal age (OR 1.68, 95%CI 1.14-2.48), third trimester BMI (OR 7.17, 95%CI 1.77-28.9) and third trimester neutrophil-to-lymphocyte ratio (NLR) (OR 1.75, 95%CI 1.22-2.51) were independently associated with outcome. Maternal age ≥ 35 years, BMI ≥ 30 Kg/m2 and NLR ≥ 5.5 were the optimal cut-off values for predicting persistent subclinical myocardial dysfunction in postpartum.

CONCLUSIONS

Pregnant women with obesity, age ≥ 35 yrs and low chronic inflammation have significantly increased risk of persistent subclinical myocardial dysfunction over postpartum.

Maternal obesity and offspring's cardiovascular morbidity - Results from a population based cohort study

OBJECTIVE

To investigate whether maternal obesity poses a risk for long-term cardiovascular morbidity in the offspring.

STUDY DESIGN

Data were analyzed from a non-selective population of all infants born between the years 1991-2014 at the tertiary Soroka University Medical Center (SUMC), the sole hospital in the southern region of Israel. Offspring's cardiovascular morbidity from childbirth up to eighteen years old was compared among children whom their mothers were with and without obesity (maternal pre-pregnancy body mass index (BMI) ≥30 kg/m2). Kaplan-Meier survival curve was used to compare cumulative incidence of cardiovascular hospitalizations. Cox proportional hazards model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for long-term cardiovascular hospitalizations.

RESULTS

A total of 242,342 deliveries met the inclusion criteria, 3290 (1.36%) had a BMI > 30 kg/m2. Total cardiovascular hospitalizations were comparable between the study groups (1.1% vs. 0.6%, OR = 1.79; 1.28-2.50). The Kaplan-Meier survival curve exhibited a difference in the cumulative incidence of total cardiovascular hospitalizations of the offspring (log-rank test, p < 0.001). In the Cox multi-variable analysis, a significant association was noted between obesity and cardiovascular morbidity even after adjustment for confounders such as maternal age, gestational age, hypertension and diabetes (adjusted HR = 1.59, 95% Cl 1.14-2.21).

CONCLUSION

Maternal obesity is an independent risk factor for long-term cardiovascular morbidity in the offspring.

Maternal Chronic Hypertension Elevates the Risk for Long-Term Selected Endocrine and Metabolic Morbidity in the Offspring, Particularly Childhood Obesity

Background: Maternal hypertensive disorders during pregnancy are known to be associated with high rates of perinatal complications for both mother and child. We aimed at determining whether maternal chronic hypertension impacts long-term pediatric endocrine and metabolic morbidity. Methods: A population-based, retrospective cohort study was performed. Exposure was defined as the presence of maternal chronic hypertension. Hospitalizations of the offspring up to the age of 18 years involving endocrine and metabolic morbidity were evaluated. A Kaplan-Meier survival curve was employed to compare the cumulative morbidity incidence between both groups (exposed and unexposed offspring). Cox proportional hazards models were used to control for confounders. Results: During the study period, 232,841 singleton deliveries met the inclusion criteria. Of them, 1.1% (n = 2655) were exposed to maternal chronic hypertension during pregnancy. Total hospitalization rate involving endocrine-metabolic morbidities was doubled in the hypertensive group (1% vs. 0.5% in the normotensive group, p < 0.001). Specifically, childhood obesity was significantly more common in offspring of mothers with chronic hypertension (0.7% vs. 0.2%, respectively, p < 0.001). The survival curve demonstrated significantly higher cumulative incidence of total endocrine and metabolic morbidity in the exposed group (log rank p = 0.002). In a Cox regression model, maternal chronic hypertension exhibited an independent association with long-term childhood endocrine or metabolic morbidity (adjusted hazard ratio = 1.5, 95% confidence interval 1.01-2.2, p = 0.045). Conclusions: Maternal chronic hypertension appears to be an independent and a significant risk factor for long-term pediatric endocrine and metabolic morbidity, and specifically for childhood obesity, in the offspring.

Metabolic flexibility is impaired in women who are pregnant and overweight/obese and related to insulin resistance and inflammation

CONTEXT

Maternal obesity is a significant public health concern that contributes to unfavorable outcomes such as inflammation and insulin resistance. Women with obesity may have impaired metabolic flexibility (i.e. an inability to adjust substrate metabolism according to fuel availability). Impaired metabolic flexibility during pregnancy may mediate poor pregnancy outcomes in women with obesity.

PURPOSE

The purposes of this study were to: 1) compare metabolic flexibility between overweight/obese and lean women; and 2) determine the relationships between metabolic flexibility, inflammation following a high-fat meal, and maternal metabolic health outcomes (i.e. gestational weight gain and insulin resistance).

PROCEDURES

This interventional physiology study assessed lipid oxidation rates via indirect calorimetry before and after consumption of a high-fat meal. The percent change in lipid metabolism was calculated to determine 'metabolic flexibility.' Maternal inflammatory profiles (CRP, IL-6, IL-8, IL-10, IL-12, TNF-α) and insulin resistance (HOMA-IR) were determined via plasma analyses.

MAIN FINDINGS

64 women who were pregnant (lean = 35, overweight/obese = 29) participated between 32 and 38 weeks gestation. Lean women had significantly higher metabolic flexibility compared to overweight/obese women (lean 48.0 ± 34.1% vs overweight/obese 29.3 ± 34.3%, p = .035). Even when controlling for pre-pregnancy BMI, there was a negative relationship between metabolic flexibility and percent change in CRP among the overweight/obese group (r = -0.526, p = .017). Metabolic flexibility (per kg fat free mass) was negatively correlated with postprandial HOMA-IR (2 h: r = -0.325, p = .016; 4 h: r = -0.319, p = .019).

CONCLUSIONS

Overweight and obese women who are pregnant are less 'metabolically flexible' than lean women, and this is related to postprandial inflammation and insulin resistance.

Maternal obesity and long-term neuropsychiatric morbidity of the offspring

OBJECTIVE

To evaluate the long-term pediatric neuropsychiatric morbidity of children born to obese patients.

STUDY DESIGN

A population-based cohort analysis was performed comparing all deliveries of obese (maternal pre-pregnancy body mass index of 30 kg/m² or more) and non-obese patients between 1991 and 2014 at a single tertiary medical center. Hospitalizations of the offspring up to the age of 18 years involving neuropsychiatric morbidities were evaluated according to a pre-defined set of ICD-9 codes, including autistic, eating, sleeping and movement disorders, cerebral palsy, developmental disorders, and more. A Kaplan-Meier survival curve was used to compare cumulative hospitalization rate in exposed and unexposed offspring. A Cox regression model was used to control for confounders.

RESULTS

During the study period, 242,342 deliveries met the inclusion criteria. Of them, 3290 were children of obese mothers. Hospitalizations involving neuropsychiatric morbidities were higher in children born to obese mothers compared with those born to non-obese mothers (3.95% vs. 3.10%, p < 0.01). Specifically, offspring of obese mothers had higher rates of autism spectrum disorders and psychiatric disorders. The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of neuropsychiatric-related hospitalizations in the obese group (Fig. 1, log rank p < 0.05). Using a cox proportional hazard model, controlling for maternal age, preterm labor, maternal diabetes, hypertensive disorders of pregnancy, and birthweight, maternal obesity was found to be independently associated with long-term neuropsychiatric morbidity of the offspring (adjusted HR 1.24, 95% CI 1.04-1.47, p < 0.05).

CONCLUSION

Maternal obesity is an independent risk factor for long-term neuropsychiatric morbidity of the offspring.

Offspring of women following bariatric surgery and those of patients with obesity are at an increased risk for long-term pediatric endocrine morbidity

OBJECTIVE

To assess whether offspring of women following bariatric surgery as well as offspring of obese women are at an increased risk for long-term pediatric endocrine morbidity.

SETTING

This study was conducted at the university hospital.

METHODS

A population-based cohort study compared the incidence of long-term (up to the age of 18 years) occurrence of endocrine morbidity between offspring of mothers following bariatric surgery and obese mothers, as compared with parturients without obesity and without prior bariatric surgery.

RESULTS

During the study period 220,563 newborns met the inclusion criteria; 1001 were delivered by patients following bariatric surgery, 2275 were delivered by obese women and 217,287 were delivered by normal weight women without prior bariatric surgery. Long-term endocrine morbidity was more common in the bariatric group (2.3%) and the obesity group (1.5%) as compared with the comparison group (0.5%; P < 0.001). Specifically, pediatric obesity was significantly more common in children of mothers following bariatric surgery (1.8%) and of mothers with obesity (1.2%) as compared with the comparison group (0.2%; P < 0.001). Children born to women following bariatric surgery as well as obese women had higher cumulative incidence of pediatric endocrine morbidity (Log rank, P < 0.001). The results remained significant when controlling for maternal factors, adjusted HR 6.25, 95% CI 4.10-9.50; P < 0.001 for women following bariatric surgery and aHR 2.40 95% CI 1.69-3.40; P < 0.001 for obese women.

CONCLUSION

Offspring of women following bariatric surgery as well as those of obese women are at an increased risk for long-term pediatric endocrine morbidity.

Maternal Obesity and Offspring Long-Term Infectious Morbidity

Obesity is a leading cause of morbidity world-wide. Maternal obesity is associated with adverse perinatal outcomes. Furthermore, Obesity has been associated with increased susceptibility to infections. The purpose of this study was to evaluate long-term pediatric infectious morbidity of children born to obese mothers. This population-based cohort analysis compared deliveries of obese (maternal pre-pregnancy BMI ≥ 30 kg/m²) and non-obese patients at a single tertiary medical center. Hospitalizations of the offspring up to the age of 18 years involving infectious morbidities were evaluated according to a predefined set of ICD-9 codes. A Kaplan–Meier survival curve was used to compare cumulative hospitalization incidence between the groups and Cox proportional hazards model was used to control for possible confounders. 249,840 deliveries were included. Of them, 3399 were children of obese mothers. Hospitalizations involving infectious morbidity were significantly more common in children born to obese mothers compared with non-obese patients (12.5% vs. 11.0%, p < 0.01). The Kaplan–Meier survival curve demonstrated a significantly higher cumulative incidence of infectious-related hospitalizations in the obese group (log rank p = 0.03). Using the Cox regression model, maternal obesity was found to be an independent risk factor for long-term infectious morbidity of the offspring (adjusted HR = 1.125, 95% CI 1.021–1.238, p = 0.017).

Optimizing Health: Weight, Exercise, and Nutrition in Pregnancy and Beyond

Pregnancy complications provide insight into women's future health risks and have long term implications for maternal and child health. Obesity has been associated with adverse perinatal outcomes and is a risk factor for chronic disease. Excessive weight gain during pregnancy often translates into postpartum weight retention, increasing women's risk for obesity. Pregnancy and the postpartum period provides a unique opportunity to discuss health beyond pregnancy, emphasize interconception care, and implement appropriate prevention strategies. We aim to review the impact of obesity, gestational weight gain, postpartum weight retention, and role of nutrition and exercise on pregnancy and lifelong health.

Antepartum Care of Women Who Are Obese During Pregnancy: Systematic Review of the Current Evidence

INTRODUCTION

Nearly 40% of US women of childbearing age are obese. Obesity during pregnancy is associated with multiple risks for both the woman and fetus, yet clinicians often feel unprepared to provide optimal antepartum care for this group of women. We collected and reviewed current evidence concerning antepartum care of women who are obese during pregnancy.

METHODS

We conducted a systematic review using PRISMA guidelines. Current evidence relating to the pregnancy care of women with a prepregnancy body mass index of 30kg/m2 or higher was identified using MEDLINE databases via PubMed, Embase, and Web of Science Core Collection between January 2012 and February 2018.

RESULTS

A total of 354 records were located after database searches, of which 63 met inclusion criteria. Topic areas for of included studies were: pregnancy risk and outcomes related to obesity, communication between women and health care providers, gestational weight gain and activity/diet, diabetic disorders, hypertensive disorders, obstructive sleep apnea, mental health, pregnancy imaging and measurement, late antepartum care, and preparation for labor and birth.

DISCUSSION

Midwives and other health care providers can provide better antepartum care to women who are obese during pregnancy by incorporating evidence from the most current clinical investigations.

How to improve health literacy to reduce short- and long-term consequences of maternal obesity?

Aim: To demonstrate the global challenge of maternal obesity and to propose models to increase awareness and health literacy. Methods: The regional perinatal data base and the international literature were reviewed to demonstrate the rising rates of maternal overweight and obesity causing major public health problems in low and high-resourced countries. A preliminary systematic review analyzing interventions in maternal obesity and a fact box based on a recent Cochrane review on dietary interventions were performed. Results: Between 2000 and 2015, the regional rates of maternal overweight and obesity have significantly increased, and the rate of morbid maternal obesity has even doubled. Pregnant women were insufficiently informed about the health risks and international recommendations for weight gain associated with pre-pregnancy body mass index. Scientific publications and guidelines of professional boards have not yet interrupted the vicious cycle of transgenerational transfer of associated health risks for the offspring. For the first time we propose a fact box to translate the results from a Cochrane review about dietary interventions into a transparent information for health care providers and patients which could help to improve awareness. Conclusions: Improving health literacy and translating clinical science into models which are understandable by policy makers, health care providers and parents is a challenge mainly if health risks are modifiable during gestation and could prevent the increasing burden of obesity for future societies.

Pregnancy: An Underutilized Window of Opportunity to Improve Long-term Maternal and Infant Health-An Appeal for Continuous Family Care and Interdisciplinary Communication

Physiologic adaptations during pregnancy unmask a woman's predisposition to diseases. Complications are increasingly predicted by first-trimester algorithms, amplify a pre-existing maternal phenotype and accelerate risks for chronic diseases in the offspring up to adulthood (Barker hypothesis). Recent evidence suggests that vice versa, pregnancy diseases also indicate maternal and even grandparent's risks for chronic diseases (reverse Barker hypothesis). Pub-Med and Embase were reviewed for Mesh terms "fetal programming" and "pregnancy complications combined with maternal disease" until January 2017. Studies linking pregnancy complications to future cardiovascular, metabolic, and thrombotic risks for mother and offspring were reviewed. Women with a history of miscarriage, fetal growth restriction, preeclampsia, preterm delivery, obesity, excessive gestational weight gain, gestational diabetes, subfertility, and thrombophilia more frequently demonstrate with echocardiographic abnormalities, higher fasting insulin, deviating lipids or clotting factors and show defective endothelial function. Thrombophilia hints to thrombotic risks in later life. Pregnancy abnormalities correlate with future cardiovascular and metabolic complications and earlier mortality. Conversely, women with a normal pregnancy have lower rates of subsequent diseases than the general female population creating the term: "Pregnancy as a window for future health." Although the placenta works as a gatekeeper, many pregnancy complications may lead to sickness and earlier death in later life when the child becomes an adult. The epigenetic mechanisms and the mismatch between pre- and postnatal life have created the term "fetal origin of adult disease." Up to now, the impact of cardiovascular, metabolic, or thrombotic risk profiles has been investigated separately for mother and child. In this manuscript, we strive to illustrate the consequences for both, fetus and mother within a cohesive perspective and thus try to demonstrate the complex interrelationship of genetics and epigenetics for long-term health of societies and future generations. Maternal-fetal medicine specialists should have a key role in the prevention of non-communicable diseases by implementing a framework for patient consultation and interdisciplinary networks. Health-care providers and policy makers should increasingly invest in a stratified primary prevention and follow-up to reduce the increasing number of manifest cardiovascular and metabolic diseases and to prevent waste of health-care resources.

Altered maternal lipid metabolism is associated with higher inflammation in obese women during late pregnancy

Inflammation is elevated in obese pregnant women and is associated with adverse maternal and neonatal outcomes. Maternal lipid metabolism and its relationships with maternal inflammation, insulin resistance and neonatal metabolic health are poorly understood in obese pregnant women. 18 lean (age: 26.1 ± 5.0 years, pre-pregnancy BMI: 21.5 ± 1.9 kg/m²) and 16 obese (age: 25.0 ± 4.8 years, pre-pregnancy BMI: 36.3 ± 4.3 kg/m²) women participated in this case-control study during the third trimester of pregnancy. Maternal plasma markers of insulin resistance (HOMA-IR) and inflammation (C-reactive protein (CRP)) were measured at rest, and lipid concentration and kinetics (lipid oxidation rate and lipolysis) were measured at rest, during a 30-minute bout of low-intensity (40% VO_2peak) exercise, and during a recovery period. Umbilical cord blood was collected for measurement of neonatal plasma insulin sensitivity, inflammation, and lipid concentration. Neonatal body composition was measured via air displacement plethysmography. Pregnant obese women had higher plasma CRP (9.1 ± 4.0 mg/L versus 2.3 ± 1.8 mg/L, p<0.001) and higher HOMA-IR (3.8 ± 1.9 versus 2.3 ± 1.5, p=0.009) compared to pregnant lean women. Obese women had higher lipid oxidation rates during recovery from low-intensity exercise (0.13 ± 0.03 g/min versus 0.11 ±0.04 g/min, p=0.02) that was associated with higher maternal CRP (r=0.55, p=0.001). Maternal CRP was positively associated with maternal HOMA-IR (r=0.40, p<0.02) and systolic blood pressure (r=0.40, p<0.02). Maternal lipid metabolism-associated inflammation may contribute to insulin resistance and higher blood pressure in obese women during pregnancy.

Obesity during pregnancy and long-term risk for ophthalmic morbidity - a population-based study with a follow-up of more than a decade

OBJECTIVE

To investigate whether patients with a history of obesity during pregnancy have an increased risk for subsequent long-term ophthalmic complications, after controlling for diabetes and preeclampsia.

METHODS

A population-based study compared the incidence of long-term maternal ophthalmic complications in a cohort of women with and without a history of obesity during pregnancy. Deliveries occurred between the years 1988 and 2013, with a mean follow-up duration of 12 years.

RESULTS

During the study period 106 220 deliveries met the inclusion criteria; 2.2% (n = 2353) occurred in patients with a diagnosis of obesity during at least one of their pregnancies. These patients had a significantly higher incidence of ophthalmic complications in total and specifically of diabetic retinopathy. Using a Kaplan-Meier survival curve, we found that patients with a history of obesity during pregnancy had a significantly higher cumulative incidence of ophthalmic complications. Using a Cox proportional hazards model, adjusted for confounders such as maternal age, preeclampsia and diabetes mellitus, we found obesity during pregnancy remained independently associated with ophthalmic complications (adjusted HR, 2.4; 95% CI, 1.4-4.2; p = 0.003).

CONCLUSION

Obesity during pregnancy is an independent risk factor for long-term ophthalmic complications, and specifically diabetic retinopathy.