Calcium and Vitamin D Supplementation for Prevention of Preeclampsia: A Systematic Review and Network Meta-Analysis

An altered gut microbiome in pre-eclampsia: cause or consequence

Hypertensive disorders of pregnancy, including pre-eclampsia, are a leading cause of serious and debilitating complications that affect both the mother and the fetus. Despite the occurrence and the health implications of these disorders there is still relatively limited evidence on the molecular underpinnings of the pathophysiology. An area that has come to the fore with regard to its influence on health and disease is the microbiome. While there are several microbiome niches on and within the body, the distal end of the gut harbors the largest of these impacting on many different systems of the body including the central nervous system, the immune system, and the reproductive system. While the role of the microbiome in hypertensive disorders, including pre-eclampsia, has not been fully elucidated some studies have indicated that several of the symptoms of these disorders are linked to an altered gut microbiome. In this review, we examine both pre-eclampsia and microbiome literature to summarize the current knowledge on whether the microbiome drives the symptoms of pre-eclampsia or if the aberrant microbiome is a consequence of this condition. Despite the paucity of studies, obvious gut microbiome changes have been noted in women with pre-eclampsia and the individual symptoms associated with the condition. Yet further research is required to fully elucidate the role of the microbiome and the significance it plays in the development of the symptoms. Regardless of this, the literature highlights the potential for a microbiome targeted intervention such as dietary changes or prebiotic and probiotics to reduce the impact of some aspects of these disorders.

A meta-analysis on first-trimester blood count parameters-is the neutrophil-to-lymphocyte ratio a potentially novel method for first-trimester preeclampsia screening?

Objective

Meta-analysis focusing on the role of first-trimester neutrophil-to-lymphocyte ratio (NLR) in the prediction of preeclampsia.

Data sources

PubMed, Scopus, Web of Science, Cochrane Library, and Embase databases were queried from inception up to December 31, 2022.

Study eligibility criteria

The study included all types of original research that was conducted in humans and values of NLR were measured during the first trimester, among patients who later developed preeclampsia, compared to the values of control groups.

Study appraisal and synthesis methods

Two reviewers independently performed data abstraction and quality appraisal, and disagreements were resolved by consensus and, if necessary, by the opinion of a third reviewer. During the analysis, PRISMA and MOOSE guidelines were followed. All statistical analyses were made with R.

Results

For the research on the predictive role of NLR values in the first trimester for preeclampsia, a total of 6 studies were selected for analysis, covering 2,469 patients. The meta-analysis revealed a 95% confidence interval (CI) for the effect size of 0.641 to 1.523, with a prediction interval of 0.027 to 2.137.

Conclusion

Based on the analysis, NLR is a promising biochemical marker for future pieces of research that try to find new screening methods for first-trimester preeclampsia. We encourage other researchers to examine NLR's predictive value combined with other markers in preeclampsia screening, this way being able to find new and affordable protocols for first-trimester preeclampsia screening.

Systematic review registration

identifier CRD42023392663.

[Preeclampsia: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate).

CONCLUSION

The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.

Maternal-neonatal events resulting from medications for preventing hypertensive disorders in high-risk pregnant women: A systematic review and network meta-analysis

BACKGROUND

There have been few studies reporting on maternal and neonatal events in high-risk pregnant women receiving medications for preventing hypertensive disorders of pregnancy (HDP).

OBJECTIVE

To identify placental abruption, postpartum hemorrhage, neonatal intraventricular hemorrhage, and neonates with small for gestational age (SGA) or growth restriction resulting from medications for preventing HDP in high-risk pregnant women using a network meta-analysis.

SEARCH STRATEGY

All randomized controlled trials comparing the most commonly used medications (antiplatelet agents, anticoagulants, antioxidants, nitric oxide, and calcium) for preventing HDP in high-risk pregnant women were searched from the Cochrane Pregnancy and Childbirth's Specialized Register of Controlled Trials until July 31, 2020, without language restriction.

SELECTION CRITERIA

Two of the authors independently selected the eligible trials.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the methodological quality of the included trials. Pairwise and network meta-analyses were used to determine comparative risk ratios and 95% confidence intervals.

MAIN RESULTS

The 51 included trials involved 69 669 pregnant women. Compared with placebo/no treatment, antioxidants slightly reduced placental abruption with high-certainty evidence. Antiplatelet agents probably reduced SGA with low-certainty evidence and slightly increased neonatal intraventricular hemorrhage with moderate-certainty evidence.

CONCLUSION

Antiplatelet agents probably reduce SGA, but neonatal intraventricular hemorrhage should be monitored.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018096276.

Hypertensive Disorders in Pregnancy: Global Burden From 1990 to 2019, Current Research Hotspots and Emerging Trends

Hypertensive disorders in pregnancy (HDP) constitute a worldwide health problem for pregnant women and their infants. This study provided HDP burden over 1990 to 2019 by region and age distribution, and predicted changes in related values for the next 25 years. We then conducted an econometric analysis of the author distribution, collaborative networks, keyword burst clustering, and spatio-temporal analysis of HDP-related publications from 2012 to 2022 to access current scientific developments and hotspots. The number of pregnant women with HDP has been increasing over the past 30 years, with regional and age-stratified differences in the burden of disease. Additionally, projections suggest an increase of deaths due to maternal HDP among adolescents younger than 20 years. Current research is mostly centered on pre-eclampsia, with hot keywords including trophoblast, immune tolerance, frozen-thawed embryo transfer, aspirin, gestational diabetes association, and biomarkers. Researches on the pathological mechanism, classification, and subtypes of HDP need to be further advanced.

Causal relationship association of cheese intake with gestational hypertension and diabetes result from a Mendelian randomization study

BACKGROUND

The evidence from observational studies has been inconclusive on the causal relationship between cheese intake and gestational hypertension or diabetes.

AIM

To determine whether cheese consumption was causally related to hypertension and diabetes during pregnancy.

METHODS

This was a two-sample Mendelian randomized (MR) study. Summary-level genetic data for cheese intake was exposure and corresponding outcome data for gestational hypertension and gestational diabetes were extracted from the IEU OpenGWAS database. MR analysis was conducted using inverse variance weighting. For sensitivity analyses, MR-Egger regression, weighted median, weighted mode, and leave-one-out methods were conducted. A fixed-effect model was used to meta-analyze two sample MR estimates. The traits of gestational hypertension were pregnancy hypertension (123579 individuals) and oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium (123579 individuals), and traits of gestational diabetes were gestational diabetes (123579 individuals) and diabetes mellitus in pregnancy (116363 individuals), respectively.

RESULTS

Cheese intake per standard deviation increase has causally reduced the risks of gestational hypertension [odds ratio (OR) = 0.60, 95% confidence interval (CI): 0.47-0.76, P < 0.001] and gestational diabetes (OR = 0.41, 95%CI: 0.30-0.55, P < 0.001) in inverse variance weighted analysis. Sensitivity analysis showed no heterogeneity (all P > 0.05) nor horizontal pleiotropy (all P > 0.05) in the relationship between cheese intake and gestational hypertension, but heterogeneity presented (all P < 0.05) in relation to gestational diabetes in the two-sample MR analysis.

CONCLUSION

Cheese intake was inversely associated with gestational hypertension and gestational diabetes in MR analysis, suggesting that cheese consumption may be beneficial in preventing hypertension and diabetes during pregnancy.

A nutritional supplement taken during preconception and pregnancy influences human milk macronutrients in women with overweight/obesity and gestational diabetes mellitus

Rational

Maternal overweight/obesity and gestational diabetes mellitus (GDM) are associated with an increased risk of their offspring developing overweight/obesity or type 2 diabetes later in life. However, the impacts of maternal overweight/obesity and dysglycemia on human milk (HM) macronutrient composition are not well understood.

Objective

Through a double-blind randomised controlled trial, we investigated the effects of maternal supplementation from preconception throughout pregnancy until birth on HM macronutrient concentrations, in association with maternal and infant factors including maternal pre-pregnancy body mass index (BMI) and GDM status. In addition, we aimed to characterise longitudinal changes in HM macronutrients.

Methods

The control supplement contained calcium, iodine, iron, β-carotene, and folic acid. The intervention supplement additionally contained zinc, vitamins B2, B6, B12, and D3, probiotics, and myo-inositol. HM samples were collected across seven time points from 1 week to 12 months from Singapore and/or New Zealand. HM macronutrient concentrations were measured using a MIRIS Human Milk Analyser. Potential differences in HM macronutrient concentrations were assessed using linear mixed models with a repeated measures design.

Results

Overall, HM macronutrient concentrations were similar between control and intervention groups. Among the control group, overweight/obesity and GDM were associated with higher HM fat and energy concentrations over the first 3 months. Such associations were not observed among the intervention group. Of note, mothers with GDM in the intervention group had lower HM fat by 10% (p = 0.049) and energy by 6% (p = 0.029) than mothers with GDM in the control group. Longitudinal changes in HM macronutrient concentrations over 12 months of lactation in New Zealand showed that HM fat and energy decreased in the first 6 months then increased until 12 months. HM lactose gradually decreased from 1 week to 12 months while crude protein decreased from 1 week to 6 months then remained relatively constant until 12 months of lactation.

Conclusion

Maternal overweight/obesity or GDM were associated with increased HM fat and energy levels. We speculate the intervention taken during preconception and pregnancy altered the impact of maternal BMI or GDM status on HM macronutrient composition. Further studies are required to identify the mechanisms underlying altered HM macronutrient concentration in the intervention group and to determine any long-term effects on offspring health.

Clinical trial registration

ClinicalTrials.gov, NCT02509988, Universal Trial Number U1111-1171-8056. Registered on 16 July 2015. This is an academic-led study by the EpiGen Global Research Consortium.

An evidence review and nutritional conceptual framework for pre-eclampsia prevention

Pre-eclampsia is a serious complication of pregnancy, and maternal nutritional factors may play protective roles or exacerbate risk. The tendency to focus on single nutrients as a risk factor obscures the complexity of possible interactions, which may be important given the complex nature of pre-eclampsia. An evidence review was conducted to compile definite, probable, possible and indirect nutritional determinants of pre-eclampsia to map a nutritional conceptual framework for pre-eclampsia prevention. Determinants of pre-eclampsia were first compiled through an initial consultation with experts. Second, an expanded literature review was conducted to confirm associations, elicit additional indicators and evaluate evidence. The strength of association was evaluated as definite relative risk (RR) < 0·40 or ≥3·00, probable RR 0·40-0·69 or 1·50-2·99, possible RR 0·70-0·89 or 1·10-1·49 or not discernible RR 0·90-1·09. The quality of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation. Twenty-five nutritional factors were reported in two umbrella reviews and twenty-two meta-analyses. Of these, fourteen were significantly associated with pre-eclampsia incidence. Higher serum Fe emerged as a definite nutritional risk factors for pre-eclampsia incidence across populations, while low serum Zn was a risk factor in Asia and Africa. Maternal vitamin D deficiency was a probable risk factor and Ca and/or vitamin D supplementation were probable protective nutritional factors. Healthy maternal dietary patterns were possibly associated with lower risk of developing pre-eclampsia. Potential indirect pathways of maternal nutritional factors and pre-eclampsia may exist through obesity, maternal anaemia and gestational diabetes mellitus. Research gaps remain on the influence of household capacities and socio-cultural, economic and political contexts, as well as interactions with medical conditions.

Recent Advances in the Prevention and Screening of Preeclampsia

Throughout the history of medicine, preeclampsia has remained an enigmatic field of obstetrics. In 2023, despite its prevalence and impact, preeclampsia's exact cause and effective treatment remain elusive; the current options are limited to delivery. The purpose of this review is to summarize the knowledge of the possible novel prophylactic therapies and screening methods for preeclampsia, thereby providing valuable insights for healthcare professionals and researchers. Aspirin and LMWH have already been widely used; meanwhile, calcium, vitamin D, and pravastatin show promise, and endothelin receptor antagonists are being explored. Stress reduction, dietary changes, and lifestyle modifications are also being investigated. Another interesting and fast-growing area is AI- and software-based screening methods. It is also key to find novel biomarkers, which, in some cases, are not only able to predict the development of the disease, but some of them hold promise to be a potential therapeutic target. We conclude that, while a definitive cure for preeclampsia may not be eligible in the near future, it is likely that the assessment and enhancement of preventive methods will lead to the prevention of many cases. However, it is also important to highlight that more additional research is needed in the future to clarify the exact pathophysiology of preeclampsia and to thus identify potential therapeutic targets for more improved treatment methods.

Micronutrient Gaps and Supplement Use in a Diverse Cohort of Pregnant Women

BACKGROUND

Micronutrition in pregnancy is critical to impact not only fetal growth and development but also long-term physical and psychiatric health outcomes.

OBJECTIVE

Estimate micronutrient intake from food and dietary supplements in a diverse cohort of pregnant women and compare intake to the Dietary Reference Intakes (DRIs).

DESIGN

Secondary analysis of women enrolled in a multi-site clinical trial of docosahexaenoic acid (DHA) supplementation who provided their dietary intake using the diet history questionnaire-II (n = 843) or multiple 24 h recalls (n = 178) at baseline and their intake of nutritional supplements at baseline through 30 days postpartum.

PARTICIPANTS/SETTING

1021 participants from the parent trial who had reliable data for dietary intake, supplement intake, or both.

MAIN OUTCOME MEASURES

Micronutrient intake from dietary and supplement sources and percentage of intakes meeting the DRIs for pregnancy.

STATISTICAL ANALYSES PERFORMED

Percent of participants whose intake was below the estimated average requirement (EAR) or adequate intake (AI) and above the tolerable upper limit (UL).

RESULTS

Dietary intakes of choline, folate, iron, vitamin D, zinc, vitamin E, magnesium, and potassium, were below the AI or EAR for 30-91% of the participants; thiamin and vitamin B6 were also below the AI or EAR for non-Hispanic/Latina women. Supplement intake improved the intake for most; however, 80% of the group remained below the AI for choline and 52.5% for potassium while 30% remained below the EAR for magnesium. Folate and iron intakes were above the UL for 80% and 19%, respectively.

CONCLUSIONS

Dietary supplements, despite their variability, allowed the majority of this cohort of pregnant women to achieve adequate intakes for most micronutrients. Choline, magnesium, and potassium were exceptions. Of interest, folate intake was above the tolerable UL for the majority and iron for 16.8% of the participants. Clinicians have the opportunity to address the most common nutrient deficits and limits with advice on food sources that provide choline, magnesium, and potassium and to ensure folate is not overabundant. More research is needed to determine if these findings are similar in a cross-sectional population.

The prevalence of trimester-specific dietary supplements and associated factors during pregnancy: An observational study

Objectives: This study aimed to assess the prevalence of trimester-specific dietary supplements (DS)s use and their possible correlates during pregnancy.

Method: Pregnant women were convenience sampled and recruited from a comprehensive obstetric care center in Shanghai, China. Data relating to the use of DS during pregnancy, social support and other social-demographic and obstetric data were collected. Trimester-specific DS use and factors related DS were explored.

Results: Of the 2803 women participating in this study, 94.8%, 96.2%, 93.8%, and 94.4% reported the use of at least one DS during pregnancy (all trimesters) and in the first, second, and third trimesters of pregnancy, respectively. Significant differences were noted in the use of DS containing folic acid, calcium, iron, vitamins, and docosahexaenoic acid (DHA), during the three trimesters of pregnancy. A higher proportion of DS use was negatively associated with certain categories of pregnant woman, including unemployed/housewife, low education level, obese, and low social support. A positive association was identified with gestational age.

Conclusion for practice: Considering the high prevalence of DS use during pregnancy, future studies are needed to evaluate the accuracy and suitability of DS usage during pregnancy.

Correlation between meteorological factors and vitamin D status under different season

Pregnant women with low vitamin D levels tend to have poor clinical outcomes. Meteorological factors were associated with vitamin D. Here, we aimed to study the current status of 25-Hydroxy vitamin D (25(OH)D) concentrations in pregnant women in Kunshan city and investigate the meteorological factors associated with 25(OH)D levels under different seasons. The correlation between meteorological factors and 25(OH)D levels was estimated by cross-correlation analysis and multivariate logistic regression. A restrictive cubic spline method was used to estimate the non-linear relationship. From 2015 to 2020, a total of 22,090 pregnant women were enrolled in this study. Pregnant women with 25(OH)D concentrations below 50 nmol/l represent 65.85% of the total study population. There is a positive correlation between temperature and 25(OH)D. And there is a protective effect of the higher temperature on vitamin D deficiency. However, in the subgroup analysis, we found that in autumn, high temperatures above 30 °C may lead to a decrease in 25(OH)D levels. This study shows that vitamin D deficiency in pregnant women may widespread in eastern China. There is a potential inverted U-shaped relationship between temperature and 25(OH)D levels, which has implications for understanding of vitamin D changes under different seasons.

[Hematologic and nutritional states are associated with the development of preeclampsia in a Mexican population]

Introduction

Introduction: nutrient and trace element deficiency are risk factors for the development of preeclampsia; these nutrients induce changes in the hematologic state, which can be used to prevent complications during pregnancy. Objective: this research will analyze the nutritional and hematological status during the 3 trimesters of gestation in pregnant women with preeclampsia to evaluate its association with gestational alterations. Method: a cross-sectional, descriptive, and analytic study was conducted on 78 pregnant women who attended a prenatal control clinic, 11 of whom were diagnosed with preeclampsia. The hematological parameters were determined through hematometry. To get the nutritional intake profile of the pregnant women, a frequency of food consumption questionnaire was used. Results: the normotensive group´s arterial pressure (PA) was significantly lower than that of pregnant women with preeclampsia. The hematological profile changed during pregnancy, and platelet value was much higher in preeclamptic women. The nutritional status of pregnant women in the third trimester consumed more macronutrients and micronutrients than in the first and second trimesters, and this pattern was observed in pregnant women with preeclampsia. When compared to pregnant women with preeclampsia, normotensive women received more minerals and vitamins. Conclusion: hematological values are modified during each trimester of gestation, and pregnant women with preeclampsia had high platelet values compared to normotensive women. Our data show a greater intake of minerals and vitamins in normotensive pregnant women as compared to those who developed preeclampsia; therefore, it is recommended that pregnant women be provided with nutritional guidance in order to prevent pregnant complications.

Association between Vitamin D receptor (VDR) gene polymorphisms and hypertensive disorders of pregnancy: a systematic review and meta-analysis

Background

Hypertensive disorders of pregnancy (HDP) are currently one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Recent studies provide evidence that maternal Vitamin D receptor (VDR) gene polymorphisms probably play a key role by affecting the biological function of vitamin D in some adverse pregnancy outcomes, while the relationship between the VDR gene polymorphisms and the risk of HDP remains controversial in current studies. This systematic review and meta-analysis aimed to comprehensively evaluate the association of the VDR gene polymorphisms with HDP susceptibility.

Methods

This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and a protocol has been registered in the PROSPERO (ID: CRD42022344383) before commencing this review. PubMed, Web of Science, Embase, and the Cochrane Library databases were searched until January 21, 2023. Case-control and cohort studies that reported the association of the VDR gene polymorphisms with HDP were included. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS) for non-randomized studies. The odds ratios (ORs) with corresponding 95% confidence intervals (CIs) of the five models (allele model, dominant model, recessive model, homozygous model, heterozygous model) were pooled respectively, and subgroup analysis was performed based on ethnicity.

Results

A total of ten studies were included. The VDR gene ApaI polymorphism was associated with HDP susceptibility in the dominant model (OR: 1.38; 95% CI [1.07-1.79]; P = 0.014) and the heterozygote model (OR: 1.48; 95% CI [1.12-1.95]; P = 0.006). In subgroup analysis, the heterozygote model (OR: 2.06; 95% CI [1.21-3.52]; P = 0.008) of the ApaI polymorphism was associated with HDP in Asians, but not in Caucasians.

Conclusion

The VDR gene ApaI polymorphism may be associated with HDP susceptibility. Insufficient evidence to support the existence of ethnic differences in this association.

Skipping breakfast during pregnancy and hypertensive disorders of pregnancy in Japanese women: the Tohoku medical megabank project birth and three-generation cohort study

BACKGROUND

Hypertensive disorders of pregnancy (HDP) adversely affect the prognosis of mother and child, and the prognosis depends on the subtype of HDP. Skipping breakfast may be associated with increased blood pressure due to disruption of the circadian clock, but the association with the development of HDP has not been studied. The purpose of this study was to examine the association between skipping breakfast and the development of HDP and HDP subtypes in Japanese pregnant women.

METHODS

Of the pregnant women who participated in the Tohoku Medical Megabank Project Three-Generation Cohort Study, 18,839 who answered the required questions were included in the analysis. This study had a cross-sectional design. The breakfast intake frequency from pre-pregnancy to early pregnancy was classified into four groups: daily, 5-6 times per week, 3-4 times per week, and 0-2 times per week. HDP was classified into gestational hypertension (GH), chronic hypertension (CH), preeclampsia (PE), and severe preeclampsia (SuPE). Multiple logistic regression analysis and multinomial logistic analysis were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for breakfast intake frequency and development of HDP or HDP subtypes. We performed a stratified analysis based on energy intake.

RESULTS

Of the participants, 74.3% consumed breakfast daily, and 11.1% developed HDP. Women who consumed breakfast 0-2 times per week had a higher risk of HDP (OR: 1.33, 95% CI: 1.14-1.56), CH (OR: 1.63, 95% CI: 1.21-2.19), and PE (OR: 1.68, 95% CI: 1.27-2.21) than those who consumed breakfast daily. No association was found between skipping breakfast and the risk of developing GH (OR: 1.26, 95% CI: 0.99-1.61) and SuPE (OR: 0.91, 95% CI: 0.55-1.49). Stratified analysis showed that the risk of developing HDP due to skipping breakfast was highest in the group with the highest daily energy intake.

CONCLUSIONS

Skipping breakfast during pre-to early pregnancy is associated with the development of HDP. Further longitudinal studies are required to clarify the causal association between skipping breakfast and HDP.

Calcium for pre-eclampsia prevention: A systematic review and network meta-analysis to guide personalised antenatal care

BACKGROUND

Calcium supplementation reduces the risk of pre-eclampsia, but questions remain about the dosage to prescribe and who would benefit most.

OBJECTIVES

To evaluate the effectiveness of high (≥1 g/day) and low (<1 g/day) calcium dosing for pre-eclampsia prevention, according to baseline dietary calcium, pre-eclampsia risk and co-interventions, and intervention timing.

SEARCH STRATEGY

CENTRAL, PubMed, Global Index Medicus and CINAHL, from inception to 2 February 2021, clinical trial registries, reference lists and expert input (CRD42018111239).

SELECTION CRITERIA

Randomised controlled trials of calcium supplementation for pre-eclampsia prevention, for women before or during pregnancy. Network meta-analysis (NMA) also included trials of different calcium doses.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted published data. The meta-analysis employed random-effects models and the NMA, a Bayesian random-effects model, to obtain direct and indirect effect estimates.

MAIN RESULTS

The meta-analysis included 30 trials (N = 20 445 women), and the NMA to evaluate calcium dosage included 25 trials (N = 15 038). Calcium supplementation prevented pre-eclampsia similarly with a high dose (RR 0.49, 95% CI 0.36-0.66) or a low dose (RR 0.49, 95% CI 0.36-0.65). By NMA, high-dose (vs low-dose) calcium did not differ in effect (RR 0.79, 95% CI 0.43-1.40). Calcium was similarly effective regardless of baseline pre-eclampsia risk, vitamin D co-administration or timing of calcium initiation, but calcium was ineffective among women with adequate average baseline calcium intake.

CONCLUSIONS

Low- and high-dose calcium supplementation are effective for pre-eclampsia prevention in women with low calcium intake. This has implications for population-level implementation where dietary calcium is low, and targeted implementation where average intake is adequate.

TWEETABLE ABSTRACT

A network meta-analysis of 25 trials found that low-dose calcium supplementation (<1 g/day) is as effective as high-dose calcium supplementation (≥1 g/day) in halving the risk of pre-eclampsia when baseline calcium intake is low.

Dietary and serum vitamin D and preeclampsia risk in Chinese pregnant women: a matched case-control study

The effect of vitamin D (VD) on the risk of preeclampsia (PE) is uncertain. Few of previous studies focused on the relationship between dietary VD intake and PE risk. Therefore, we conducted this 1:1 matched case-control study to explore the association of dietary VD intake and serum VD concentrations with PE risk in Chinese pregnant women. A total of 440 pairs of participants were recruited during March 2016 to June 2019. Dietary information was obtained using a seventy-eight-item semi-quantitative FFQ. Serum concentrations of 25(OH)D₂ and 25(OH)D₃ were measured by liquid chromatography-tandem MS. Multivariate conditional logistic regression was used to estimate OR and 95 % CI. Restricted cubic splines (RCS) were plotted to evaluate the dose-response relationship of dietary VD intake and serum VD concentrations with PE risk. Compared with the lowest quartile, the OR of the highest quartile were 0·45 (95 % CI 0·29, 0·71, P_trend = 0·001) for VD dietary intake and 0·26 (95 % CI 0·11, 0·60, P_trend = 0·003) for serum levels after adjusting for confounders. In addition, the RCS analysis suggested a reverse J-shaped relationship between dietary VD intake and PE risk (P-nonlinearity = 0·02). A similar association was also found between serum concentrations of total 25(OH)D and PE risk (P-nonlinearity = 0·02). In conclusion, this study provides evidence that higher dietary intake and serum levels of VD are associated with the lower risk of PE in Chinese pregnant women.

Medications for preventing hypertensive disorders in high-risk pregnant women: a systematic review and network meta-analysis

OBJECTIVES

To determine the relative effectiveness of medications for preventing hypertensive disorders in high-risk pregnant women and to provide a ranking of medications using network meta-analysis.

METHODS

All randomized controlled trials comparing the most commonly used medications to prevent hypertensive disorders in high-risk pregnant women that are nulliparity and pregnant women having family history of preeclampsia, history of pregnancy-induced hypertension in previous pregnancy, obstetric risks, or underlying medical diseases. We received the search results from the Cochrane Pregnancy and Childbirth's Specialised Register of Controlled Trials, searched on 31st July 2020. At least two review authors independently selected the included studies and extracted the data and the methodological quality. The comparative risk ratios (RR) and 95% confidence intervals (CI) were analyzed using pairwise and network meta-analyses, and treatment rankings were estimated by the surface under the cumulative ranking curve for preventing preeclampsia (PE), gestational hypertension (GHT), and superimposed preeclampsia (SPE). Safety of the medications is also important for decision-making along with effectiveness which will be reported in a separate review.

RESULTS

This network meta-analysis included 83 randomized studies, involving 93,864 women across global regions. Three medications, either alone or in combination, probably prevented PE in high-risk pregnant women when compared with a placebo or no treatment from network analysis: antiplatelet agents with calcium (RR 0.19, 95% CI 0.04 to 0.86; 1 study; low-quality evidence), calcium (RR 0.61, 95% CI 0.47 to 0.80; 13 studies; moderate-quality evidence), antiplatelet agents (RR 0.69, 95% CI 0.57 to 0.82; 31 studies; moderate-quality evidence), and antioxidants (RR 0.77, 95% CI 0.63 to 0.93; 25 studies; moderate-quality evidence). Calcium probably prevented PE (RR 0.63, 95% CI 0.46 to 0.86; 11 studies; moderate-quality evidence) and GHT (RR 0.89, 95% CI 0.84 to 0.95; 8 studies; high-quality evidence) in nulliparous/primigravida women. Few included studies for the outcome of superimposed preeclampsia were found.

CONCLUSION

Antiplatelet agents, calcium, and their combinations were most effective medications for preventing hypertensive disorders in high-risk pregnant women when compared with a placebo or no treatment. Any high-risk characteristics for women are important in deciding the best medications. The qualities of evidence were mostly rated to be moderate.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018096276.

Dietary factors that affect the risk of pre-eclampsia

Pre-eclampsia affects 3%–5% of pregnant women worldwide and is associated with a range of adverse maternal and fetal outcomes, including maternal and/or fetal death. It particularly affects those with chronic hypertension, pregestational diabetes mellitus or a family history of pre-eclampsia. Other than early delivery of the fetus, there is no cure for pre-eclampsia. Since diet or dietary supplements may affect the risk, we have carried out an up-to-date, narrative literature review to assess the relationship between nutrition and pre-eclampsia. Several nutrients and dietary factors previously believed to be implicated in the risk of pre-eclampsia have now been shown to have no effect on risk; these include vitamins C and E, magnesium, salt, ω-3 long-chain polyunsaturated fatty acids (fish oils) and zinc. Body mass index is proportionally correlated with pre-eclampsia risk, therefore women should aim for a healthy pre-pregnancy body weight and avoid excessive gestational and interpregnancy weight gain. The association between the risk and progression of the pathophysiology of pre-eclampsia may explain the apparent benefit of dietary modifications resulting from increased consumption of fruits and vegetables (≥400 g/day), plant-based foods and vegetable oils and a limited intake of foods high in fat, sugar and salt. Consuming a high-fibre diet (25–30 g/day) may attenuate dyslipidaemia and reduce blood pressure and inflammation. Other key nutrients that may mitigate the risk include increased calcium intake, a daily multivitamin/mineral supplement and an adequate vitamin D status. For those with a low selenium intake (such as those living in Europe), fish/seafood intake could be increased to improve selenium intake or selenium could be supplemented in the recommended multivitamin/mineral supplement. Milk-based probiotics have also been found to be beneficial in pregnant women at risk. Our recommendations are summarised in a table of guidance for women at particular risk of developing pre-eclampsia.

Fetal Cerebral Hemodynamic Changes in Preeclampsia Patients by Ultrasonic Imaging under Intelligent Algorithm

This study was aimed at evaluating the adoption value of ultrasound imaging features on fetal cerebral hemodynamics in preeclampsia patients based on the partial difference algorithm and the hybrid segmentation network (HSegNet) algorithm. Forty pregnant women with preeclampsia diagnosed by ultrasound examination were selected as the research objects, and another forty normal pregnant women were selected as the control. Then, by using the partial differential algorithm, the imaging of fetal cerebral hemodynamics in preeclampsia patients was enhanced and optimized, and the general clinical data and experimental results were collected. The results showed that the automatic labeling of fetal cerebral artery in fetal middle cerebral artery (MCA) hemodynamic images was realized by HSegNet algorithm model, and the final accuracy was 97.3%, which had a good consistency with the manual annotation of doctors. Education level was a protective factor for preeclampsia (odds ratio (OR) = 0.535). Body mass index (BMI) and family history of hypertension during pregnancy were independent risk factors for preeclampsia (OR = 1.286, and 2.774, respectively). MCA end-diastolic volume (EDV) of preeclampsia fetuses was higher than that of normal fetuses. The MCA systolic-diastolic ratio (S/D), the pulsatility index (PI), and the resistive index (RI) in the preeclampsia group were significantly lower than those in the normal pregnancy group. The results showed that MCA PI, MCA RI, and MCA S/D had certain predictive values for the occurrence of adverse pregnancy outcomes (P < 0.05). In summary, the intelligent algorithm-based fetal MCA hemodynamic ultrasound image in the study could effectively predict pregnancy outcomes of patients and provide certain theoretical support for the subsequent reduction of adverse pregnancy outcomes in patients with preeclampsia.

Vitamin D stimulates placental L-type amino acid transporter 1 (LAT1) in preeclampsia

Vitamin D insufficiency/deficiency has been linked to an increased risk of preeclampsia. Impaired placental amino acid transport is suggested to contribute to abnormal fetal intrauterine growth in pregnancies complicated by preeclampsia. However, if vitamin D-regulated amino acid transporter is involved in the pathophysiologic mechanism of preeclampsia has not been clarified yet. The aberrant expression of key isoform of L-type amino acid transporter LAT1 was determined by western blot and immunohistochemistry in the placenta from normotensive and preeclamptic pregnancies. The role for vitamin D on placental LAT1 expression was investigated through the exposure of HTR-8/SVneo human trophoblast cells to the biologically active 1,25(OH)₂D₃ and the oxidative stress-inducer cobalt chloride (CoCl₂). Our results showed that placental LAT1 expression was reduced in women with preeclampsia compared to normotensive pregnancies, which was associated with decreased expression of vitamin D receptor (VDR). 1,25(OH)₂D₃ significantly upregulated LAT1 expression in placental trophoblasts, and also prevented the decrease of mTOR activity under CoCl₂-induced oxidative stress. siRNA targeting VDR significantly attenuated 1,25(OH)₂D₃-stimulated LAT1 expression and mTOR signaling activity. Moreover, treatment of rapamycin specifically inhibited the activity of mTOR signaling and resulted in decrease of LAT1 expression. In conclusion, LAT1 expression was downregulated in the placenta from women with preeclampsia. 1,25(OH)₂D₃/VDR could stimulate LAT1 expression, which was likely mediated by mTOR signaling in placental trophoblasts. Regulation on placental amino acid transport may be one of the mechanisms by which vitamin D affects fetal growth in preeclampsia.

Vitamin D Levels in Early and Middle Pregnancy and Preeclampsia, a Systematic Review and Meta-Analysis

Vitamin D (VitD) shows a beneficial role in placentation, the immune system, and angiogenesis, and thus, VitD status may link to the risk of preeclampsia. A meta-analysis was conducted to investigate the association between VitD status in early and middle pregnancy and the risk of preeclampsia. A total of 22 studies with 25,530 participants were included for analysis. Women with VitD insufficiency or deficiency had a higher preeclampsia rate compared to women with replete VitD levels (OR 1.58, 95% CI 1.39–1.79). Women with VitD deficiency had a higher preeclampsia rate compared to women with replete or insufficient VitD levels (OR 1.35, 95% CI 1.10–1.66). Women with insufficient VitD levels had a higher preeclampsia rate compared to women with replete VitD levels (OR 1.44, 95% CI 1.24–1.66). Women with deficient VitD levels had a higher preeclampsia rate compared to women with replete VitD levels (OR 1.50, 95% CI 1.05–2.14). Sensitivity analysis showed the results were stable after excluding any one of the included studies. In conclusion, our systematic review suggested that VitD insufficiency or deficiency was associated with an increased risk of preeclampsia.

Risk of preeclampsia by gestational weight gain in women with varied prepregnancy BMI: A retrospective cohort study

INTRODUCTION

Despite the important clinical significance, limited data on the joint contribution of prepregnancy body mass index (BMI) and gestational weight gain (GWG) to preeclampsia, the second leading cause of maternal mortality worldwide. This study aimed to estimate the risk of preeclampsia by GWG among women with varied prepregnancy BMI.

METHODS

We conducted a retrospective cohort study using data of 117 738 singleton pregnant women aged 18-49 years from 150 maternity hospitals in China between 2015 and 2018. GWG was calculated as the measured weight at the time of preeclampsia assessment minus prepregnancy weight; GWG velocity was calculated as the GWG divided by the gestational age at weighing. The non-linear associations of GWG with preeclampsia were examined by restricted cubic spline regression analysis according to prepregnancy BMI. The association of the GWG categories with preeclampsia was further examined by performing robust Poisson regression stratified by the prepregnancy BMI categories.

RESULTS

Among participants, 2426 (2.06%) were diagnosed with preeclampsia. Compared to women with normal BMI, those who were overweight and obese had 1.92- fold (95%CI, 1.73-2.14) and 5.06- fold (95%CI, 4.43-5.78) increased risks for preeclampsia, respectively. The association of GWG velocity with preeclampsia was presented as a J-shaped curve with the varied inflexion point (where the rate of preeclampsia was 2%), which was 0.54, 0.38, and 0.25 kg/week in women with normal BMI, overweight, and obesity, respectively; a steep risk rise was observed along with GWG velocity beyond the inflexion points. The overall adjusted relative risk for preeclampsia was calculated among women with the different GWG categories of GWG.

CONCLUSIONS

The findings highlight that high prepregnancy BMI and exceed GWG contributed to increased risk of preeclampsia with a superimposed effect and underscore the need to optimize the recommendations for GWG for women with different prepregnancy BMI.

Vitamin D and Multiple Health Outcomes: An Umbrella Review of Observational Studies, Randomized Controlled Trials, and Mendelian Randomization Studies

Observational studies, randomized controlled trials (RCTs), and Mendelian randomization (MR) studies have yielded inconsistent results on the associations of vitamin D concentrations with multiple health outcomes. In the present umbrella review we aimed to evaluate the effects of low vitamin D concentrations and vitamin D supplementation on multiple health outcomes. We summarized current evidence obtained from meta-analyses of observational studies that examined associations between vitamin D concentrations and multiple health outcomes, meta-analyses of RCTs that investigated the effect of vitamin D supplementation on multiple health outcomes, and MR studies that explored the causal associations of vitamin D concentrations with various diseases (international prospective register of systematic reviews PROSPERO registration number CRD42018091434). A total of 296 meta-analyses of observational studies comprising 111 unique outcomes, 139 meta-analyses of RCTs comprising 46 unique outcomes, and 73 MR studies comprising 43 unique outcomes were included in the present umbrella review. Twenty-eight disease outcomes were identified by both meta-analyses of observational studies and MR studies. Seventeen of these reported disease outcomes had consistent results, demonstrating that lower concentrations of vitamin D were associated with a higher risk for all-cause mortality, Alzheimer's disease, hypertension, schizophrenia, and type 2 diabetes. The combinations of consistent evidence obtained by meta-analyses of observational studies and MR studies together with meta-analyses of RCTs showed that vitamin D supplementation was associated with a decreased risk for all-cause mortality but not associated with the risk for Alzheimer's disease, hypertension, schizophrenia, or type 2 diabetes. The results indicated that vitamin D supplementation is a promising strategy with long-term preventive effects on multiple chronic diseases and thus has the potential to decrease all-cause mortality. However, the current vitamin D supplementation strategy might not be an efficient intervention approach for these diseases, suggesting that new strategies are highly needed to improve the intervention outcomes.

Could Vitamin D Be Effective in Prevention of Preeclampsia?

Prevention of preeclampsia (PE) remains one of the most significant problems in perinatal medicine. Due to the possible unpredictable course of hypertension in pregnancy, primarily PE and the high complication rate for the mother and fetus/newborn, it is urgent to offer pregnant women in high-risk groups effective methods of preventing the PE development or delaying its appearance. In addition, due to the association of PE with an increased risk of developing cardiovascular diseases (CVD) in later life, effective preeclampsia prevention could also be important in reducing their incidence. Ideal PE prophylaxis should target the pathogenetic changes leading to the development of PE and be safe for the mother and fetus, inexpensive and freely available. Currently, the only recognized method of PE prevention recommended by many institutions around the world is the use of a small dose of acetylsalicylic acid in pregnant women with risk factors. Unfortunately, some cases of PE are diagnosed in women without recognized risk factors and in those in whom prophylaxis with acetylsalicylic acid is not adequate. Hence, new drugs which would target pathogenetic elements in the development of preeclampsia are studied. Vitamin D (Vit D) seems to be a promising agent due to its beneficial effect on placental implantation, the immune system, and angiogenic factors. Studies published so far emphasize the relationship of its deficiency with the development of PE, but the data on the benefits of its supplementation to reduce the risk of PE are inconclusive. In the light of current research, the key issue is determining the protective concentration of Vit D in a pregnant woman. The study aims to present the possibility of using Vit D to prevent PE, emphasizing its impact on the pathogenetic elements of preeclampsia development.

Dried small fish provide nutrient densities important for the first 1000 days

Inadequate nutrient intakes are prevalent among many populations in sub-Saharan Africa and increasing fish consumption among pregnant/lactating women and children is one strategy to improve diets and address nutrient deficiencies. We report the nutrient content of two fish-based recipes-fish powder and fish chutney-that contain dried small fish available in local markets in Zambia. The contribution of a serving of each recipe to the recommended daily intakes of iron, zinc, calcium and docosahexaenoic acid (DHA) for pregnant/lactating women and children 6-24 months was calculated because these nutrients are commonly deficient in African diets. We found that one 10-g serving of fish powder provides 20% or more of the daily calcium recommendation and 37% or more of the daily DHA recommendation for both pregnant/lactating women and children. A 30-g serving of fish chutney provides over 40% of the daily calcium recommendation for pregnant women and over 50% for lactating women. Additionally, we investigated the nutrient density (nutrients per kilocalorie) of the fish powder and compared it with the nutrient density of a small-quantity lipid-based nutrient supplement plus (SQ-LNS-plus). SQ-LNS-plus is designed to enhance children's diets by providing micronutrients and DHA. Fish powder is similar to SQ-LNS-plus in iron and zinc density and even higher in calcium and DHA density. Consuming dried small fish as part of a daily meal can be a viable strategy for combatting nutrient deficiencies in the first 1000 days.

Is Supplementation with Micronutrients Still Necessary during Pregnancy? A Review

INTRODUCTION

Proper nutrition during pregnancy is important to prevent nutritional imbalances that interfere with pregnancy. Micronutrients play critical roles in embryogenesis, fetal growth, and maternal health, as energy, protein, vitamin, and mineral needs can increase during pregnancy. Increased needs can be met by increasing the intake of dietary micronutrients. Severe micronutrient deficiency or excess during pregnancy can have negative effects on fetal growth (intrauterine growth retardation, low birth weight, or congenital malformations) and pregnancy development (pre-eclampsia or gestational diabetes). We investigate whether it is necessary to continue micronutrient supplementation during pregnancy to improve women's health in this stage and whether this supplementation could prevent and control pathologies associated with pregnancy.

AIM

The present review aims to summarize evidence on the effects of nutritional deficiencies on maternal and newborn morbidity.

METHODS

This aim is addressed by critically reviewing results from published studies on supplementation with different nutrients during pregnancy. For this, major scientific databases, scientific texts, and official webpages have been consulted. PubMed searches using the terms "pregnancy" OR "maternal-fetal health" AND "vitamins" OR "minerals" OR "supplementation" AND "requirement" OR "deficiency nutrients" were performed.

RESULTS

There are accepted interventions during pregnancy, such as folic acid supplementation to prevent congenital neural tube defects, potassium iodide supplementation to correct neurodevelopment, and oral iron supplementation during the second half of pregnancy to reduce the risk of maternal anemia and iron deficiency. A number of micronutrients have also been associated with pre-eclampsia, gestational diabetes mellitus, and nausea and vomiting in pregnancy. In general, experimental studies are necessary to demonstrate the benefits of supplementation with different micronutrients and to adjust the recommended daily doses and the recommended periconceptional nutrition for mothers.

CONCLUSIONS

Presently, there is evidence of the benefits of micronutrient supplementation in perinatal results, but indiscriminate use is discouraged due to the fact that the side effects of excessive doses are not known. Evidence supports the idea that micronutrient deficiencies negatively affect maternal health and the outcome of pregnancy. No single micronutrient is responsible for the adverse effects; thus, supplementing or correcting one deficiency will not be very effective while other deficiencies exist.

Feasibility of epidural injection of ropivacaine and dexamethasone for labor analgesia in women with preeclampsia

OBJECTIVE

This study aimed to investigate the feasibility of epidural injection of ropivacaine (Rop) and dexamethasone (Dex) for labor analgesia in women with preeclampsia.

METHODS

A total of 80 women with preeclampsia delivered in our hospital were enrolled, and were divided into a study group (n=41, Rop + Dex) and a control group (n=39, Rop alone). The changes in pain level, sedation, catecholamine hormone levels and vital signs were compared between the two groups after intervention. The motor blockade score and the incidence of adverse reactions after administration of anesthesia were compared in both groups.

RESULTS

Pain level [visual analogue scale (VAS) score], sedation (Ramsay score), adrenaline (AD), norepinephrine (NE), heart rate (HR), and mean arterial pressure (MAP) did not differ significantly between the two groups at pre-analgesia (T0) (P>0.05), and Ramsay score in the study group was significantly higher than that in the control group at 30 min (T1), 60 min (T2), 120 min after analgesia (T3), and cessation of analgesia (T4), and VAS score, AD, NE, HR, MAP in the study group were significantly lower than those in the control group during all stages of labor.

CONCLUSION

The epidural injection of Rop + Dex in women with preeclampsia can play a better analgesic and sedative effect, stabilize maternal hemodynamic index and improve postpartum motor blockade.

Calcium-Deficiency during Pregnancy Affects Insulin Resistance in Offspring

Prenatal malnutrition is known to affect the phenotype of the offspring through changes in epigenetic regulation. Growing evidence suggests that epigenetics is one of the mechanisms by which nutrients and minerals affect metabolic traits. Although the perinatal period is the time of highest phenotypic plasticity, which contributes largely to developmental programming, there is evidence of nutritional influence on epigenetic regulation during adulthood. Calcium (Ca) plays an important role in the pathogenesis of insulin resistance syndrome. Cortisol, the most important glucocorticoid, is considered to lead to insulin resistance and metabolic syndrome. 11β-hydroxysteroid dehydrogenase-1 is a key enzyme that catalyzes the intracellular conversion of cortisone to physiologically active cortisol. This brief review aims to identify the effects of Ca deficiency during pregnancy and/or lactation on insulin resistance in the offspring. Those findings demonstrate that maternal Ca deficiency during pregnancy may affect the epigenetic regulation of gene expression and thereby induce different metabolic phenotypes. We aim to address the need for Ca during pregnancy and propose the scaling-up of clinical and public health approaches that improved pregnancy outcomes.

Lifestyle, Maternal Nutrition and Healthy Pregnancy

Healthy lifestyle habits spanning from preconception to postpartum are considered as a major safeguard for achieving successful pregnancies and for the prevention of gestational diseases. Among preconception priorities established by the World Health Organization (WHO) are healthy diet and nutrition, weight management, physical activity, planned pregnancy and physical, mental and psychosocial health. Most studies covering the topic of healthy pregnancies focus on maternal diet because obesity increases the risks for adverse perinatal outcomes, including gestational diabetes mellitus, large for gestational age newborns, or preeclampsia. Thus, foods rich in vegetables, essential and polyunsaturated fats and fibre-rich carbohydrates should be promoted especially in overweight, obese or diabetic women. An adequate intake of micronutrients (e.g. iron, calcium, folate, vitamin D and carotenoids) is also crucial to support pregnancy and breastfeeding. Moderate physical activity throughout pregnancy improves muscle tone and function, besides decreasing the risk of preeclampsia, gestational diabesity (i.e. diabetes associated with obesity) and postpartum overweight. Intervention studies claim that an average of 30 min of exercise/day contributes to long-term benefits for maternal overall health and wellbeing. Other factors such as microbiome modulation, behavioural strategies (e.g. smoking cessation, anxiety/stress reduction and sleep quality), maternal genetics and age, social class and education might also influence the maternal quality of life. These factors contribute to ensure a healthy pregnancy, or at least to reduce the risk of adverse maternal and foetal outcomes during pregnancy and later in life.

Vitamin D stimulates miR-26b-5p to inhibit placental COX-2 expression in preeclampsia

Vitamin D insufficiency or deficiency during pregnancy has been associated with an increased risk of preeclampsia. Increased placental cyclooxygenase-2 (COX-2) activity was proposed to contribute to the inflammatory response in preeclampsia. This study was to investigate if vitamin D can benefit preeclampsia by inhibiting placental COX-2 expression. Placenta tissues were obtained from 40 pregnant women (23 normotensive and 17 preeclampsia). miR-26b-5p expression was assessed by quantitative PCR. Vitamin D receptor (VDR) expression and COX-2 expression were determined by immunostaining and Western blot. HTR-8/SVneo trophoblastic cells were cultured in vitro to test anti-inflammatory effects of vitamin D in placental trophoblasts treated with oxidative stress inducer CoCl₂. 1,25(OH)₂D₃ was used as bioactive vitamin D. Our results showed that reduced VDR and miR-26b-5p expression, but increased COX-2 expression, was observed in the placentas from women with preeclampsia compared to those from normotensive pregnant women. Transient overexpression of miR-26b-5p attenuated the upregulation of COX-2 expression and prostaglandin E₂ (PGE₂) production induced by CoCl₂ in placental trophoblasts. 1,25(OH)₂D₃ treatment inhibited CoCl₂-induced upregulation of COX-2 in placental trophoblasts. Moreover, miR-26b-5p expression were significantly upregulated in cells treated with 1,25(OH)₂D₃, but not in cells transfected with VDR siRNA. Conclusively, downregulation of VDR and miR-26b-5p expression was associated with upregulation of COX-2 expression in the placentas from women with preeclampsia. 1,25(OH)₂D₃ could promote miR-26b-5p expression which in turn inhibited COX-2 expression and PGE₂ formation in placental trophoblasts. The finding of anti-inflammatory property by vitamin D through promotion of VDR/miR-26b-5p expression provides significant evidence that downregulation of vitamin D/VDR signaling could contribute to increased inflammatory response in preeclampsia.

Maternal and fetal vitamin D and their roles in mineral homeostasis and fetal bone development

During pregnancy, female physiology adapts to meet the additional mineral demands of the developing fetus. Meanwhile, the fetus actively transports minerals across the placenta and maintains high circulating levels to mineralize the rapidly developing skeleton. Most of this mineral is accreted during the last trimester, including 30 g of calcium, 20 g of phosphate and 0.8 g of magnesium. Given the dependence of calcium homeostasis on vitamin D and calcitriol in the adult and child, it may be expected that vitamin D sufficiency would be even more critical during pregnancy and fetal development. However, the pregnant mother and fetus appear to meet their mineral needs independent of vitamin D. Adaptations in maternal mineral and bone metabolism during pregnancy appear to be invoked independent of maternal vitamin D, while fetal mineral metabolism and skeletal development appear to be protected from vitamin D deficiency and genetic disorders of vitamin D physiology. This review discusses key data from both animal models and human studies to address our current knowledge on the role of vitamin D and calcitriol during pregnancy and fetal development.

The impact of micronutrient deficiency on pregnancy complications and development origin of health and disease

Due to the spread of the western style diet, which is characterized by high intake of processed food, micronutrients (vitamins and minerals) deficiency is increasing in the Japanese population of all ages and genders. During pregnancy, the elevated demand for micronutrients put pregnant women at even higher risk of micronutrients deficiency. Some micronutrients are relatively famous such that women with reproductive age are recommended to take folic acid supplementation for the prevention of neural tube defect. However, it is not generally known that folate is also important for fetal growth throughout the pregnancy course and for prevention of pregnancy complications, and that pregnant women should continue to take supplementation during pregnancy and lactation. The types of micronutrients and the duration of supplementation are both important factors to maintain normal pregnancies. This review focused on four micronutrients that are commonly deficient in Japanese pregnant women, folate, vitamin B12, vitamin D, calcium, and magnesium. The detrimental effects of homocysteine accumulation associated with the above micronutrient defects and its link to catechol-o-methyltransferase insufficiency are described. We also discussed possible molecular mechanisms of pregnancy complications and the development origin of health and disease (DOHaD) regarding micronutrient deficiencies from the point of view of one carbon metabolism.

Vitamin D Concentrations at Term Do Not Differ in Newborns and Their Mothers with and without Polycystic Ovary Syndrome

Studies suggest that non-pregnant women with polycystic ovary syndrome (PCOS) may be at elevated risk of 25 hydroxyvitamin D (25(OH)D) deficiency. Furthermore, there is evidence suggesting that 25(OH)D may also play an important role during pregnancy. Data regarding 25(OH)D deficiency during pregnancy in PCOS patients and its association with perinatal outcome is scarce. The aim of the study was to investigate whether mothers with and without PCOS have different 25(OH)D levels at term, how maternal 25(OH)D levels are reflected in their offspring, and if 25(OH)D levels are associated with an adverse perinatal outcome. Therefore, we performed a cross-sectional observational study and included 79 women with PCOS according to the ESHRE/ASRM 2003 definition and 354 women without PCOS and an ongoing pregnancy ≥ 37 + 0 weeks of gestation who gave birth in our institution between March 2013 and December 2015. Maternal serum and cord blood 25(OH)D levels were analyzed at the day of delivery. Maternal 25(OH)D levels did not differ significantly in women with PCOS and without PCOS (p = 0.998), nor did the 25(OH)D levels of their respective offspring (p = 0.692). 25(OH)D deficiency (<20 ng/mL) was found in 26.9% and 22.5% of women with and without PCOS (p = 0.430). There was a strong positive correlation between maternal and neonatal 25(OH)D levels in both investigated groups (r ≥ 0.79, p < 0.001). Linear regression estimates of cord blood 25(OH)D levels are about 77% of serum 25(OH)D concentrations of the mother. Compared to healthy controls, the risk for maternal complications was increased in PCOS women (48% vs. 65%; p = 0.009), while there was no significant difference in neonatal complications (22% and 22%; p = 1.0). However, 25(OH)D levels were similar between mothers and infants with and without perinatal complications. Although the share of women and infants with 25(OH)D deficiency was high in women with PCOS and without PCOS, it seems that the incidence of adverse perinatal outcome was not affected. The long-term consequences for mothers and infants with a 25(OH)D deficiency have to be investigated in future studies.

Effects of Maternal Nutritional Supplements and Dietary Interventions on Placental Complications: An Umbrella Review, Meta-Analysis and Evidence Map

The placenta is a vital, multi-functional organ that acts as an interface between maternal and fetal circulation during pregnancy. Nutritional deficiencies during pregnancy alter placental development and function, leading to adverse pregnancy outcomes, such as pre-eclampsia, infants with small for gestational age and low birthweight, preterm birth, stillbirths and maternal mortality. Maternal nutritional supplementation may help to mitigate the risks, but the evidence base is difficult to navigate. The primary purpose of this umbrella review is to map the evidence on the effects of maternal nutritional supplements and dietary interventions on pregnancy outcomes related to placental disorders and maternal mortality. A systematic search was performed on seven electronic databases, the PROSPERO register and references lists of identified papers. The results were screened in a three-stage process based on title, abstract and full-text by two independent reviewers. Randomized controlled trial meta-analyses on the efficacy of maternal nutritional supplements or dietary interventions were included. There were 91 meta-analyses included, covering 23 types of supplements and three types of dietary interventions. We found evidence that supports supplementary vitamin D and/or calcium, omega-3, multiple micronutrients, lipid-based nutrients, and balanced protein energy in reducing the risks of adverse maternal and fetal health outcomes. However, these findings are limited by poor quality of evidence. Nutrient combinations show promise and support a paradigm shift to maternal dietary balance, rather than single micronutrient deficiencies, to improve maternal and fetal health. The review is registered at PROSPERO (CRD42020160887).

Is serum vitamin D deficiency before gestational 20 weeks a risk factor for preeclampsia?

OBJECTIVE

Our aim was to assess whether serum vitamin D deficiency before gestational 20 weeks was associated with an increased risk of preeclampsia.

METHODS

We investigated the serum levels of 25(OH)D before gestational 20 weeks, and analyzed associations between the 25(OH)D and the risk of preeclampsia. 7976 pregnant women were enrolled in this study between January 2017 and July 2019 at the Obstetrics & Gynecology Hospital of Fudan University. Adjusted smoothing spline plots, subgroup analysis and multivariate logistic regression analysis was conducted to estimate the relative risk between 25(OH)D and preeclampsia.

RESULTS

After fully adjusting the confounding factors, serum vitamin D is a protective factor in preeclampsia (OR = 0.85, P = 0.04). Compared with adequate vitamin D, vitamin D deficiency (OR = 1.55, P = 0.031), deficiency (OR = 1.50, P = 0.049) and severe deficiency (OR = 2.6, P = 0.005) are independent of preeclampsia in pregnant women Risk factors.

CONCLUSION

Vitamin D deficiency before gestational 20 weeks is a risk factor for preeclampsia.

Prenatal vitamin D supplementation reduces blood pressure and improves placental angiogenesis in an animal model of preeclampsia

BACKGROUND

Preeclampsia (PE), a pregnancy complication, is characterized by abnormal placental angiogenesis. The current study examines the effect of vitamin D deficiency/supplementation on pregnancy outcome and placental angiogenesis using an animal model of PE.

METHODS

Pregnant Wistar rats were divided into four groups: Control; PE; Vitamin D deficient with PE (VDD-PE) and Vitamin D supplemented with PE (VDS-PE). PE was induced by administering l-nitroarginine methyl ester (l-NAME) at the dose of 50 mg per kg body weight per day from day 14 to day 19 gestation in all the 4 groups. During the pre-pregnancy and pregnancy period, the rats from the Control and PE groups were fed a control diet, the VDD-PE group received a vitamin D deficient diet and the VDS-PE group received a vitamin D supplemented diet. Dams were sacrificed at d20 of gestation.

RESULTS

l-NAME administration increased systolic as well as diastolic blood pressure in both PE and VDD-PE groups as compared to the control (p < 0.01). Vitamin D supplementation was beneficial in reducing the blood pressure. Vitamin D deficiency also lowered the placental protein levels of pro-angiogenic proteins VEGF and Flt-1 (p < 0.05 and p < 0.01, respectively), while the levels of these proteins in the VDS-PE group were similar to those in the control group. Vitamin D status did not influence the levels of PlGF and Hif1α.

CONCLUSION

A low dose vitamin D supplementation given from pre-pregnancy and throughout pregnancy was beneficial in reducing the blood pressure and normalizing the placental levels of VEGF and Flt-1. This has implications for reducing the severity of preeclampsia.

Maternal Hypertensive Disorders in Pregnancy and Postpartum Plasma B Vitamin and Homocysteine Profiles in a High-Risk Multiethnic U.S., Population

Background: Hypertensive disorders of pregnancy are a recognized risk factor of a woman's future cardiovascular risk. The potential role of micronutrients in mitigating hypertensive disorders is not fully understood. This study examined maternal postpartum plasma B vitamin profiles by hypertensive disorders of pregnancy in a high-risk multiethnic U.S. population. Materials and Methods: The analyses included 2584 mothers enrolled within 3 days postpartum at the Boston Medical Center. Hypertensive disorders of pregnancy included gestational hypertension and pre-eclampsia disorders (pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes, and/or low platelets syndrome) as documented in the medical records. Plasma folate, vitamin B12, and homocysteine levels were measured in blood samples collected at enrollment. Kernel density plots and multivariable regressions were used to examine the relationship between hypertensive disorders and postpartum B vitamin profiles. Results: Of the 2584 mothers, 10% had pre-eclampsia disorders that were associated with significantly lower plasma folate (adjusted beta coefficient (aβ): -0.10; 95% CI: -0.22 to -0.06) and increased homocysteine (aβ: 0.08; 95% CI: 0.04-0.13), but not with vitamin B12 concentrations. These associations remained robust after adjusting for a range of pertinent covariables and were more pronounced in non-Hispanic Black women compared with other groups. However, gestational hypertension was not significantly associated with any postpartum biomarker. Conclusions: We found that pre-eclampsia disorders, but not gestational hypertension, was associated with lower folate and higher homocysteine levels postpartum, especially among Black mothers. This finding, if further confirmed, may have implications for postpartum care, including attention to maternal micronutrient status to reduce and prevent hypertensive disorders in pregnancy-associated consequences in subsequent pregnancies and lifespan. Registration date: July 25, 2017; Registry website: https://clinicaltrials.gov/ct2/show/NCT03228875.

Secondary hyperparathyroidism is associated with postpartum blood pressure in preeclamptic women and normal pregnancies

BACKGROUND

Preeclampsia has been associated with features of secondary hyperparathyroidism. In this study, we examine the relationships of calcium metabolism with blood pressure (BP) in preeclamptic women and in a control group of normal (NORM) pregnancies in the postpartum.

METHODS

Sixty-three consecutive preeclamptic women (age 35 ± 6 years) were studied 4 weeks after delivery. We collected clinical and lab information on pregnancy and neonates and measured plasma and urinary calcium and phosphate, plasma parathyroid hormone (PTH) and 25-hydroxy vitamin D [25(OH)D], and performed 24-h ambulatory BP monitoring. BP and calcium metabolism of 51 preeclamptic were compared with 17 NORM pregnant women that matched for age, race, and postpartum BMI.

RESULTS

25(OH)D deficiency (<10 ng/ml) was found in 3% of preeclamptic women, insufficiency (10-30 ng/ml) in 67%, and NORM values (31-100 ng/ml) in the remaining 30%. Elevated plasma PTH (≥79 pg/ml) was found in 24% of preeclamptic women who had 25(OH)D plasma levels of 21.4 ± 8.3 ng/ml. In these women, PTH levels was independently associated with 24-h SBP and DBP and daytime and night-time DBP. Prevalence of nondippers and reverse dippers was elevated (75% and 33%, respectively). No associations between calcium metabolism and neonates' characteristics of preeclamptic women were observed. Prevalence of vitamin D deficiency and insufficiency and of elevated plasma PTH levels were comparable in matched groups. Considering preeclamptic women and matched controls as a whole group, office SBP and DBP levels were associated with PTH independently of preeclampsia and other confounders.

CONCLUSION

Features of secondary hyperparathyroidism are common in the postpartum. Preeclampsia and increased PTH levels were both independent factors associated with increased BP after delivery, and both might affect the future cardiovascular risk of these women.

Vitamin-D dysregulation in early- and late-onset preeclampsia: A gestational-age matched study

Vitamin D deficiency has been associated with preeclampsia, however, vitamin D supplementation studies have shown equivocal data on amelioration of this disease. We hypothesize that women with preeclampsia have an altered endogenous vitamin D homeostasis that counteracts the beneficial effects of vitamin D supplementation. Our study population consisted of 66 maternal/neonate dyads: 16 early-onset (<34 weeks) preeclampsia (EOP), 16 early-onset controls (EOC), 17 late-onset (≥34 weeks) preeclampsia (LOP), and 17 late-onset controls (LOC). Plasma levels of 25-OH-D and the bioactive metabolite 1α,25-(OH)₂-D were studied by ELISA. Placental expression of vitamin D transporters (cubulin and megalin), metabolic genes (CYP2R1, CYP27B1, CYP24A1), and vitamin D binding protein (GC), were studied by real-time PCR, and the nuclear and cytosolic levels of the vitamin D receptor (VDR) protein were analyzed by immunoblotting. Maternal admission, maternal postpartum, and umbilical cord blood levels of 1α,25-(OH)₂-D and placental nuclear vitamin D receptor protein levels, were significantly lower in EOP compared to EOC. In contrast LOP was characterized by lower 25-OH-D levels in maternal postpartum and cord blood, and decreased placental cubulin expression compared to LOC. Both EOP and LOP showed decreased placental expression of CYP2R1 and GC compared to controls. Multivariable linear regression analysis demonstrated that preeclampsia was a significant predictor of decreased 1α,25-(OH)₂-D levels in early-onset subjects, while maternal BMI, but not preeclampsia, was the main predictor of decreased 25-OH-D in late-onset subjects. The highest positive correlation between the two vitamin D metabolites was observed in LOC umbilical cord blood. Finally, paired analysis of maternal metabolites before and after delivery indicated that women without preeclampsia had better maintenance of vitamin D levels. We conclude that EOP is characterized by decreased bioactivation of vitamin D and VDR in association with fetal growth restriction (FGR). In contrast, LOP is characterized by decreased 25-OH-D levels in association with decreased placental CYP2R1 and cubulin expression; and uncoupling of the 25-OH-D with the 1α,25-(OH)₂-D metabolite.

Early pregnancy vitamin D and the risk of adverse maternal and infant outcomes: a retrospective cohort study

Background

Previous evidence has suggested that lower gestational vitamin D levels might increase the risks of adverse pregnancy and birth outcomes. The results remain inconsistent and require further exploration.

Methods

A total of 2814 Chinese mother-infant pairs were included in this retrospective cohort study. Serum concentrations of 25(OH)D were reviewed in early pregnancy (16.3 ± 2.3 weeks). Outcomes of maternal gestational diabetes mellitus (GDM), cesarean section, fetal distress, preterm birth, low birth weight (LBW), and macrosomia were extracted from the medical records. Cox regression analysis was used to explore these associations.

Results

In total, 19.3% of mothers were pregnant at an advanced age (≥35 years), and 40.3% of pregnant women had vitamin D deficiency (< 50 nmol/L). After adjusting for potential covariates, the hazard ratio (HR) (95% CI) per standard deviation (SD) increase of serum 25(OH)D concentrations was 0.86 (0.779, 0.951) for GDM, 0.844 (0.730, 0.976) for preterm birth, and 0.849 (0.726, 0.993) for LBW. Similar protective associations were found for GDM, cesarean section, and preterm birth for a better vitamin D status when compared with vitamin D deficiency.

Conclusion

Higher early pregnancy vitamin D was associated with a lower risk of GDM, cesarean section, preterm birth, and LBW.

The relationship among vitamin D, TLR4 pathway and preeclampsia

Preeclampsia is a pregnancy-specific syndrome that has been the greatest cause of maternal and fetal morbidity and mortality. The impaired outcomes are related to maternal and the offspring healthy in the short and long-term. Although preeclampsia origins remain unclear, it is well known that there is impaired trophoblast invasion with culminant abnormal immune response. The early and late-onset preeclampsia have been studied, the subtypes have the same difference in the placentation and inflammatory features. Dietary compounds can stimulate or inhibit the activation of immune cells. Low vitamin D intake has been linked to impaired fetal development, intrauterine growth restriction, and preeclampsia. Vitamin D has been described as an anti-inflammatory effect. It can downregulate pro-inflammatory cytokines expression by the inhibition of the Nuclear Factor-ĸB pathway signaling cascade. High vitamin D levels could attenuate the immune response. On the other hand, vitamin D deficiency may contribute to increasing pro-inflammatory state. In preeclampsia, there is a reduced expression of vitamin D receptor and its metabolism is disrupted. In this review, we aimed to discuss the role of vitamin D as an anti-inflammatory agent in relation to the pro-inflammatory process of preeclampsia through the activation of the TLR4 pathway. Although there are limited studies showing the relation between vitamin D and lower risk of preeclampsia, the maternal status of vitamin D seems to influence the risk of PE development. Therefore, vitamin D supplementation in women may be a strategy to improve pregnancy outcomes.

A mushroom diet reduced the risk of pregnancy-induced hypertension and macrosomia: a randomized clinical trial

Background

Pregnancy-induced hypertension (PIH) is a disease characterized by high blood pressure detected after 20 weeks of pregnancy, affecting approximately 10% of pregnant women worldwide. Effective strategies are imperatively needed to prevent and treat PIH.

Methods

Subjects were required to consume 100 g mushroom daily from pre-pregnancy to the 20th week of gestation. The gestational hypertension and related primary and secondary outcomes of the mushroom diet (MD) group and placebo group were investigated to compare the intervention of a MD on the PIH and preeclampsia-associated maternal and child health conditions.

Results

A total of 582 and 580 subjects belonging to the MD group and placebo group were included for the analysis, respectively. Compared to the placebo, the MD significantly reduced the incidence of gestational hypertension (P = 0.023), preeclampsia (P = 0.014), gestational weight gain (P = 0.017), excessive gestational weight gain (P = 0.032) and gestational diabetes (P = 0.047). Stratified analysis showed that the MD lowered the risk of PIH for overweighed women (P = 0.036), along with the percentage of macrosomia (P = 0.007).

Conclusion

An MD could serve as a preventative strategy for lowering the risk of PIH and could control newborn birthweight while reducing comorbidities including gestational weight gain, diabetes etc.

A scoping review of network meta-analyses assessing the efficacy and safety of complementary and alternative medicine interventions

BACKGROUND

Network meta-analysis (NMA) has rapidly grown in use during the past decade for the comparison of healthcare interventions. While its general use in the comparison of conventional medicines has been studied previously, to our awareness, its use to assess complementary and alternative medicines (CAM) has not been studied. A scoping review of the literature was performed to identify systematic reviews incorporating NMAs involving one or more CAM interventions.

METHODS

An information specialist executed a multi-database search (e.g., MEDLINE, Embase, Cochrane), and two reviewers performed study selection and data collection. Information on publication characteristics, diseases studied, interventions compared, reporting transparency, outcomes assessed, and other parameters were extracted from each review.

RESULTS

A total of 89 SR/NMAs were included. The largest number of NMAs was conducted in China (39.3%), followed by the United Kingdom (12.4%) and the United States (9.0%). Reviews were published between 2010 and 2018, with the majority published between 2015 and 2018. More than 90 different CAM therapies appeared at least once, and the median number per NMA was 2 (IQR 1-4); 20.2% of reviews consisted of only CAM therapies. Dietary supplements (51.1%) and vitamins and minerals (42.2%) were the most commonly studied therapies, followed by electrical stimulation (31.1%), herbal medicines (24.4%), and acupuncture and related treatments (22.2%). A diverse set of conditions was identified, the most common being various forms of cancer (11.1%), osteoarthritis of the hip/knee (7.8%), and depression (5.9%). Most reviews adequately addressed a majority of the PRISMA NMA extension items; however, there were limitations in indication of an existing review protocol, exploration of network geometry, and exploration of risk of bias across studies, such as publication bias.

CONCLUSION

The use of NMA to assess the effectiveness of CAM interventions is growing rapidly. Efforts to identify priority topics for future CAM-related NMAs and to enhance methods for CAM comparisons with conventional medicine are needed. SYSTEMATIC REVIEW REGISTRATION: https://ruor.uottawa.ca/handle/10393/35658.

Dietary total antioxidant capacity during pregnancy and birth outcomes

PURPOSE

To investigate the effect of maternal dietary total antioxidant capacity (DTAC) and main food sources on the risk of preterm birth (PB) and offspring birth size.

METHODS

Cohort study that included 733 Brazilian mother-child pairs. Two 24 h dietary recalls were obtained during pregnancy and the usual intake was estimated through the Multiple Source Method. Data of the offspring were extracted from the national live births information system. Adjusted multivariable logistic regression models were used to investigate the relationship that energy-adjusted DTAC and food sources have with the outcomes.

RESULTS

In total, 9.7% of the children were PBs, 6.0% were born with low birth weight (LBW), 6.7% with macrosomia, 9.3% were small for gestational age (SGA) and 16.4% large for gestational age (LGA). The mean energy-adjusted DTAC ± SD was 4.7 ± 2.1 mmol. The adjusted OR (95%CI) of PB for each increasing tertile of maternal DTAC were 0.71 (0.41, 1.30) and 0.54 (0.29, 0.98), when compared with the lowest intake. For LBW, these were 0.25 (0.09, 0.65) and 0.63 (0.28, 1.41). A likelihood of lower odds for PB was found for a higher intake of fruits [0.66 (0.39, 1.09)]. Women with a higher consumption of milk were less likely to have a child with LBW [0.48 (0.23, 1.01)], and children whose mothers reported a higher intake of beans had lower odds of being born LGA [0.61 (0.39, 0.93)].

CONCLUSION

The data suggest that a higher intake of foods with antioxidant activity during pregnancy might reduce the chance of adverse birth outcomes.

Chronic Kidney Disease and Pregnancy

Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.

Effect of Calcium and Vitamin D Co-supplementation on Blood Pressure: A Systematic Review and Meta-Analysis

PURPOSE

Vitamin D and calcium insufficiency has been related to elevated blood pressure (BP) and cardiovascular complications. This systematic review and meta-analysis investigates the effect of calcium and vitamin D co-supplementation on BP.

METHODS

A systematic search was conducted of electronic databases, including Web of Sciences, MEDLINE, Scopus, EMBASE, and the Cochrane Library, along with searches of gray literature and reference lists from included trials. There were no language restrictions, and the databases were searched from inception to October 2019. Randomized controlled trials, using calcium and vitamin D co-supplementation and reporting mean systolic BP and/or diastolic BP (DBP) with SDs, were included in the systematic review. Articles were evaluated independently by 2 researchers based on inclusion and exclusion criteria. A random effects model was conducted to synthesize the data.

FINDINGS

Eight trials were included in the meta-analysis. Meta-analysis of these 8 trials indicated a nonsignificant reduction in systolic BP in the calcium and vitamin D co-supplementation group compared with control (standardized mean difference, -0.23; 95% CI, -0.52 to 0.06). Conversely, there was a statistically significant decrease in DBP (standardized mean difference, -0.29; 95% CI, -0.55 to -0.02). Subgroup analysis suggested that young adults achieve a greater reduction in DBP than other age groups.

IMPLICATIONS

Calcium and vitamin D co-supplementation can modulate DBP and should be investigated more specifically in large, well-designed trials of hypertensive populations. (Clin Ther. 2020;42:XXX-XXX) © 2020 Elsevier HS Journals, Inc.