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The adverse consequences of untreated perinatal depression highlight the need to identify populations to target in order to increase treatment rates. The authors sought to evaluate treatment initiation for a new diagnosis of depression during pregnancy or postpartum and to describe racial-ethnic differences in initiation and type (psychotherapy, antidepressants) of treatment in a large health care system with universal perinatal depression screening.This retrospective cohort study included women who delivered a live birth in the Kaiser Permanente Northern California system between October 2012 and May 2017. Black, Latina, Asian, and White women ages ≥15 years were eligible. New depression diagnoses were defined by usingIn total, 13,637 women with a new depression diagnosis (prenatal: N=7,041, 51.6%; postpartum: N=6,596, 48.4%) were identified. Of the pregnant women, 31.4% initiated treatment, and of the postpartum women, 73.1% initiated treatment. Latina and Asian women were less likely than White women to initiate treatment postpartum. During pregnancy and postpartum, non-White women were more likely to initiate psychotherapy. White women were more likely to initiate antidepressant medication during pregnancy and postpartum or a combination of antidepressant medication and psychotherapy during the postpartum period.Research is warranted to identify patient-, provider-, and system-level barriers that contribute to racial-ethnic disparities in perinatal mental health care.

Background Daily 24-h sleep–wake cycles have important implications for health, however researcher preferences in choice and location of wearable devices for behavior measurement can make 24-h cycles difficult to estimate. Further, missing data due to device malfunction, improper initialization, and/or the participant forgetting to wear one or both devices can complicate construction of daily behavioral compositions. The Method for Activity Sleep Harmonization (MASH) is a process that harmonizes data from two different devices using data from women who concurrently wore hip (waking) and wrist (sleep) devices for ≥ 4 days. Methods MASH was developed using data from 1285 older community-dwelling women (ages: 60–72 years) who concurrently wore a hip-worn ActiGraph GT3X + accelerometer (waking activity) and a wrist-worn Actiwatch 2 device (sleep) for ≥ 4 days (N = 10,123 days) at the same time. MASH is a two-tiered process using (1) scored sleep data (from Actiwatch) or (2) one-dimensional convolutional neural networks (1D CNN) to create predicted wake intervals, reconcile sleep and activity data disagreement, and create day-level night-day-night pairings. MASH chooses between two different 1D CNN models based on data availability (ActiGraph + Actiwatch or ActiGraph-only). MASH was evaluated using Receiver Operating Characteristic (ROC) and Precision-Recall curves and sleep–wake intervals are compared before (pre-harmonization) and after MASH application. Results MASH 1D CNNs had excellent performance (ActiGraph + Actiwatch ROC-AUC = 0.991 and ActiGraph-only ROC-AUC = 0.983). After exclusions (partial wear [n = 1285], missing sleep data proceeding activity data [n = 269], and Conclusions Implementing MASH to harmonize concurrently worn hip and wrist devices can minimizes data loss and correct for disagreement between devices, ultimately improving accuracy of 24-h compositions necessary for time-use epidemiology.

Background: Understanding how sleep, sedentary behavior (SED), and physical activity (PA) (24-h movement profile) changes across pregnancy in individuals with prepregnancy overweight or obesity and how parity (previous births) impacts these changes can help inform interventions. Methods: In 155 participants, movement was measured using wrist-worn accelerometers, and sleep was self-reported in early (8–15 wk) and late (29–38 wk) pregnancy. The 24-hour movement profiles were analyzed using compositional analyses. Results: Nulliparous participants (no previous births) spent 33.95%, 38.14%, 25.32%, and 2.58% of the 24-hour day in early pregnancy in sleep, SED, light-intensity PA, and moderate/vigorous-intensity PA, respectively. Multiparous participants (≥1 previous birth) spent 2.50 percentage points less in SED (mean log-ratio difference = −0.068; 95% confidence interval [CI], −0.129 to −0.009) and 2.73 percentage points more in light-intensity PA (mean log-ratio difference = 0.102; 95% CI, 0.035 to 0.180). From early to late pregnancy, participants decreased the proportion of the 24-hour day spent asleep by 1.67 percentage points (mean log-ratio difference = −0.050; 95% CI, −0.092 to −0.011) and increased light-intensity PA by 1.56 percentage points (mean log-ratio difference = 0.057; 95% CI, 0.003 to 0.108), with no change in other behaviors. Conclusions: Nulliparous and multiparous individuals with prepregnancy overweight or obesity both had high levels of SED, with no change across pregnancy, and may require interventions to reduce SED.

Examine bidirectional associations between daytime napping and nighttime sleep among pregnant individuals with insomnia disorder.We used baseline data from a randomized controlled trial of insomnia treatment during pregnancy (n=116). Participants in their second or third trimester of pregnancy self-reported daytime napping and nighttime sleep parameters using a sleep diary and wore an Actiwatch-2 during the same seven-day period. Linear regression models, accounting for intraindividual correlation, were used to estimate associations between daytime napping and nighttime sleep parameters (duration, efficiency, quality, awakenings). Models were also stratified by trimester of pregnancy.Sixty-three percent of participants reported napping on at least one day. Among participants in the second trimester (65%), napping 15-59 minutes was associated with 6.3% greater self-reported sleep efficiency (95% CI: 2.3, 10.2) and 0.5 units greater self-reported sleep quality (95% CI: 0.0, 0.9) that night; napping 60+ minutes was associated with 0.6 hours shorter actigraphy-measured sleep duration (95% CI: -1.0, -0.2). Napping was not associated with nighttime sleep overall or during the third trimester. Nighttime sleep parameters were not associated with napping duration the following day.Among pregnant individuals with insomnia in the second trimester, short napping duration was associated with higher self-reported sleep efficiency and quality; long napping duration was associated with shorter actigraphy-measured sleep duration. Additional research is needed to examine the interaction between nap duration and nap timing. In the future, these results may lead to more nuanced recommendations for daytime napping among pregnant individuals with insomnia disorder.Registry: ClinicalTrials.gov; Title: Treatment for Insomnia during Pregnancy; Identifier: NCT01846585; URL: https://clinicaltrials.gov/ct2/show/NCT01846585.

Background Physical activity (PA) has the potential to attenuate cardiovascular disease risk in midlife women through multiple pathways, including improving lipid profiles. Longitudinal patterns of PA and blood lipid levels have not been studied in midlife women. Our study identified trajectories of PA and blood lipids across midlife and characterized the associations between these trajectories. Methods We evaluated 2,789 participants from the Study of Women’s Health Across the Nation (SWAN), a longitudinal cohort study with follow-up over the menopause transition. Women reported PA using the Kaiser Physical Activity Survey at seven study visits across 17 years of follow-up. Serum high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides were measured at eight study visits across the same 17-year follow-up period. We used group-based trajectory models to characterize trajectories of PA and blood lipids over midlife and dual trajectory models to determine the association between PA and blood lipid trajectories adjusted for race/ethnicity, body mass index category, smoking, and lipid-lowering medication use. Results Women were 46 years old, on average, at study entry. Forty-nine percent were non-Hispanic white; 32 % were Black; 10 % were Japanese; and 9 % were Chinese. We identified four PA trajectories, three HDL cholesterol trajectories, four LDL cholesterol trajectories, and two triglyceride trajectories. The most frequently occurring trajectories were the consistently low PA trajectory (69 % of women), the low HDL cholesterol trajectory (43 % of women), the consistently moderate LDL cholesterol trajectory (45 % of women), and the consistently low triglycerides trajectory (90 % of women). In dual trajectory analyses, no clear associations were observed between PA trajectories and HDL cholesterol, LDL cholesterol, or triglycerides trajectories. Conclusions The most frequently observed trajectories across midlife were characterized by low physical activity, low HDL cholesterol, moderate LDL cholesterol, and low triglycerides. Despite the absence of an association between long-term trajectories of PA and blood lipids in this study, a large body of evidence has established the importance of clinical and public health messaging and interventions targeted at midlife women to promote regular and sustained PA during midlife to achieve other cardiovascular and metabolic benefits.

OBJECTIVES: It is important to understand relationships of gestational weight gain with adverse pregnancy outcomes in women with chronic hypertension, given their high baseline risk of adverse outcomes. We assessed associations of gestational weight gain with adverse pregnancy outcomes in women with chronic hypertension by pre-pregnancy body mass index categories. STUDY DESIGN: We identified 14,369 women with chronic hypertension using electronic health records from 3 integrated health care delivery systems (2005-2014). Gestational weight gain-for-gestational age charts were used to calculate gestational weight gain z-scores, which account for gestational age. Modified Poisson regression models using generalized estimating equations were used to calculate relative risks and 95% confidence intervals, adjusted for sociodemographic and medical characteristics. MAIN OUTCOME MEASUREMENTS: Preeclampsia, preterm delivery, cesarean delivery, neonatal intensive care unit admission, birthweight (extracted from the electronic health record) RESULTS: In women with normal weight or overweight, low gestational weight gain (z-score1) was associated with 40-90% greater risk of preeclampsia and 59-113% greater risk of LGA. In women with obesity, low GWG was associated with 27-54% lower risk of several adverse pregnancy outcomes, including preeclampsia and cesarean delivery. CONCLUSIONS: In women with chronic hypertension and normal weight or overweight, moderate gestational weight gain may confer the lowest risk of adverse outcomes. In women with chronic hypertension and obesity, low gestational weight gain may be necessary for the lowest risk of adverse pregnancy outcomes.

Background Associations of excessive gestational weight gain (GWG) with greater birthweight and childhood obesity may be confounded by shared familial environment or genetics. Sibling comparisons can minimize variation in these confounders because siblings grow up in similar environments and share the same genetic predisposition for weight gain. Methods We identified 96 289 women with live births in 2008–2014 at Kaiser Permanente Northern California. Fifteen percent of women (N = 14 417) had at least two births during the study period for sibling analyses. We assessed associations of GWG according to the Institute of Medicine (IOM) recommendations with birthweight and obesity at age 3 years, using conventional analyses comparing outcomes between mothers and sibling analyses comparing outcomes within mothers, which control for stable within-family unmeasured confounders such as familial environment and genetics. We used generalized estimating-equations and fixed-effects models. Results In conventional analyses, GWG above the IOM recommendations was associated with 88% greater odds of large-for-gestational age birthweight [95% confidence interval (CI): 1.80, 1.97] and 30% greater odds of obesity at 3 years old (95% CI: 1.24, 1.37) compared with GWG within the IOM recommendations. In sibling analyses, GWG above the IOM recommendations was also associated with greater odds of large-for-gestational age [odds ratio (OR): 1.36; 95% CI: 1.20, 1.54], but was not associated with obesity at 3 years old (OR = 0.98; 95% CI: 0.84, 1.15). Conclusions GWG likely has a direct impact on birthweight; however, shared environmental and lifestyle factors within families may play a larger role in determining early-childhood weight status and obesity risk than GWG.

Background: Maternal leisure time physical activity (LTPA) and sedentary time during pregnancy may influence programming of infant growth in a sex-specific manner. Materials and Methods: Participants (N = 35,212) from the Danish National Birth Cohort reported moderate/vigorous LTPA (hours/week) in early (conception to mean 16 weeks of gestation) and late pregnancy (mean 31 weeks of gestation to delivery) during interviews at 16 weeks of gestation and 6 months postpartum. Participants reported screen time at work and time spent watching television/videos (hours/day) in early pregnancy. Infant weight at 12 months of age was reported by mothers. Weight-for-length was categorized using sex-specific international standards. Results: Participants reported on average 1 hour per week of early pregnancy moderate/vigorous LTPA, 0.5 hour per week of late pregnancy LTPA, and 3 hours per day of early pregnancy sedentary time. Early pregnancy LTPA category was not associated with infant weight (p for trend = 0.62). There were suggested associations of early pregnancy sedentary time above the first quartile with greater odds of infant underweight (odds ratio = 1.15-1.27; p for trend = 0.27). Associations were similar in male and female infants. Conclusions: There is no clear relationship between early or late pregnancy LTPA and infant weight at 12 months in our study. Maternal early pregnancy sedentary time may be associated with infant underweight at 12 months.

Nearly 30% of individuals with gestational diabetes (GDM) do not achieve glycemic control with lifestyle modification alone and require medication treatment. Oral agents, such as glyburide, have several advantages over insulin for the treatment of GDM, including greater patient acceptance; however, the effectiveness of glyburide for the treatment of GDM remains controversial.To compare the perinatal and neonatal outcomes associated with glyburide vs insulin using causal inference methods in a clinical setting with information on glycemic control.The population-based cohort study included patients with GDM who required medication treatment from 2007 to 2017 in Kaiser Permanente Northern California. Machine learning and rigorous casual inference methods with time-varying exposures were used to evaluate associations of exposure to glyburide vs insulin with perinatal outcomes. Data analysis was conducted from March 2018 to July 2017.Time-varying exposure to glyburide vs insulin during pregnancy.Outcomes evaluated separately included neonatal hypoglycemia, jaundice, shoulder dystocia, respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, size-for-gestational age, and cesarean delivery. Inverse probability weighting (IPW) estimation was used to separately compare perinatal outcomes between those initiating glyburide and insulin. This approach was combined with Super Learning for propensity score estimation to account for both baseline and time-dependent confounding in both per-protocol (primary) and intention-to-treat (secondary) analyses to evaluate sustained exposure to the same therapy.From 2007 to 2017, 11 321 patients with GDM (mean [SD] age, 32.9 [4.9] years) initiated glyburide or insulin during pregnancy. In multivariate models, the risk of neonatal respiratory distress was 2.03 (95% CI, 0.13-3.92) per 100 births lower and the risk of NICU admission was 3.32 (95% CI, 0.20-6.45) per 100 births lower after continuous exposure to glyburide compared with insulin. There were no statistically significant differences in glyburide vs insulin initiation in risk for neonatal hypoglycemia (0.85 [95% CI, -1.17 to 2.86] per 100 births), jaundice (0.02 [95% CI, -1.46 to 1.51] per 100 births), shoulder dystocia (-1.05 [95% CI, -2.71 to 0.62] per 100 births), or large-for-gestational age categories (-2.75 [95% CI, -6.31 to 0.80] per 100 births).Using data from a clinical setting and contemporary causal inference methods, our findings do not provide evidence of a difference in the outcomes examined between patients with GDM initiating glyburide compared with those initiating insulin.

Background Pregnant patients with overweight or obesity are at high risk for perinatal complications. Excess gestational weight gain (GWG) further exacerbates this risk. Mobile health (mHealth) lifestyle interventions that leverage technology to facilitate self-monitoring and provide just-in-time feedback may motivate behavior change to reduce excess GWG, reduce intervention costs, and increase scalability by improving access. Objective This study aimed to test the acceptability and feasibility of a pilot mHealth lifestyle intervention for pregnant patients with overweight or obesity to promote moderate intensity physical activity (PA), encourage guideline-concordant GWG, and inform the design of a larger pragmatic cluster randomized controlled trial. Methods We conducted a mixed methods acceptability and feasibility randomized controlled trial among pregnant patients with a prepregnancy BMI of 25 to 40 kg/m2. Patients with singletons at 8 to 15 weeks of gestation who were aged ≥21 years and had Wi-Fi access were recruited via email from 2 clinics within Kaiser Permanente Northern California and randomized to receive usual prenatal care or an mHealth lifestyle intervention. Participants in the intervention arm received wireless scales, access to an intervention website, activity trackers to receive automated feedback on weight gain and activity goals, and monthly calls from a lifestyle coach. Surveys and focus groups with intervention participants assessed intervention satisfaction and ways to improve the intervention. PA outcomes were self-assessed using the Pregnancy Physical Activity Questionnaire, and GWG was assessed using electronic health record data for both arms. Results Overall, 33 patients were randomly assigned to the intervention arm, and 35 patients were randomly assigned to the usual care arm. All participants in the intervention arm weighed themselves at least once a week, compared with 20% (7/35) of the participants in the usual care arm. Participants in the intervention arm wore the activity tracker 6.4 days per week and weighed themselves 5.3 times per week, and 88% (29/33) of them rated the program “good to excellent.” Focus groups found that participants desired more nutrition-related support to help them manage GWG and would have preferred an app instead of a website. Participants in the intervention arm had a 23.46 metabolic equivalent of task hours greater change in total PA per week and a 247.2-minute greater change in moderate intensity PA per week in unadjusted models, but these effects were attenuated in adjusted models (change in total PA: 15.55 metabolic equivalent of task hours per week; change in moderate intensity PA: 199.6 minutes per week). We found no difference in total GWG (mean difference 1.14 kg) compared with usual care. Conclusions The pilot mHealth lifestyle intervention was feasible, highly acceptable, and promoted self-monitoring. Refined interventions are needed to effectively affect PA and GWG among pregnant patients with overweight or obesity. Trial Registration ClinicalTrials.gov NCT03936283; https://clinicaltrials.gov/ct2/show/NCT03936283

BACKGROUND Pregnant patients with overweight or obesity are at high risk for perinatal complications. Excess gestational weight gain (GWG) further exacerbates this risk. Mobile health (mHealth) lifestyle interventions that leverage technology to facilitate self-monitoring and provide just-in-time feedback may motivate behavior change to reduce excess GWG, reduce intervention costs, and increase scalability by improving access. OBJECTIVE This study aimed to test the acceptability and feasibility of a pilot mHealth lifestyle intervention for pregnant patients with overweight or obesity to promote moderate intensity physical activity (PA), encourage guideline-concordant GWG, and inform the design of a larger pragmatic cluster randomized controlled trial. METHODS We conducted a mixed methods acceptability and feasibility randomized controlled trial among pregnant patients with a prepregnancy BMI of 25 to 40 kg/m2. Patients with singletons at 8 to 15 weeks of gestation who were aged ≥21 years and had Wi-Fi access were recruited via email from 2 clinics within Kaiser Permanente Northern California and randomized to receive usual prenatal care or an mHealth lifestyle intervention. Participants in the intervention arm received wireless scales, access to an intervention website, activity trackers to receive automated feedback on weight gain and activity goals, and monthly calls from a lifestyle coach. Surveys and focus groups with intervention participants assessed intervention satisfaction and ways to improve the intervention. PA outcomes were self-assessed using the Pregnancy Physical Activity Questionnaire, and GWG was assessed using electronic health record data for both arms. RESULTS Overall, 33 patients were randomly assigned to the intervention arm, and 35 patients were randomly assigned to the usual care arm. All participants in the intervention arm weighed themselves at least once a week, compared with 20% (7/35) of the participants in the usual care arm. Participants in the intervention arm wore the activity tracker 6.4 days per week and weighed themselves 5.3 times per week, and 88% (29/33) of them rated the program “good to excellent.” Focus groups found that participants desired more nutrition-related support to help them manage GWG and would have preferred an app instead of a website. Participants in the intervention arm had a 23.46 metabolic equivalent of task hours greater change in total PA per week and a 247.2-minute greater change in moderate intensity PA per week in unadjusted models, but these effects were attenuated in adjusted models (change in total PA: 15.55 metabolic equivalent of task hours per week; change in moderate intensity PA: 199.6 minutes per week). We found no difference in total GWG (mean difference 1.14 kg) compared with usual care. CONCLUSIONS The pilot mHealth lifestyle intervention was feasible, highly acceptable, and promoted self-monitoring. Refined interventions are needed to effectively affect PA and GWG among pregnant patients with overweight or obesity. CLINICALTRIAL ClinicalTrials.gov NCT03936283; https://clinicaltrials.gov/ct2/show/NCT03936283

Highlights • Walking during pregnancy provides several health benefits to both mother and child. • Walking appears resistant to many barriers that impede other physical activity modalities during pregnancy. • Walking interventions may increase physical activity behavior among pregnant women. • Developing valid methods to measure walking and activity among pregnant women is crucial to increasing their physical activity. • Though they are desperately needed, few pregnancy-focused walking initiatives exist., Walking is the most commonly chosen type of physical activity (PA) during pregnancy and provides several health benefits to both mother and child. National initiatives have promoted the importance of walking in general, but little emphasis is directed toward pregnant women, the majority of whom are insufficiently active. Pregnant women face a variety of dynamic barriers to a physically active lifestyle, some of which are more commonly experienced during specific times throughout the pregnancy experience. Walking is unique in that it appears resistant to a number of these barriers that limit other types of PA participation, and it can be meaningfully integrated into some transportation and occupational activities when leisure-time options are unavailable. Preliminary intervention work suggests that walking programs can be effectively adopted into a typical pregnancy lifestyle. However, a great deal of work remains to administer successful pregnancy walking interventions, including developing and using validated methods of PA and walking assessment. This narrative review discusses the unique advantages of walking during pregnancy, provides recommendations for future intervention work, and outlines the need for pregnancy-focused community walking initiatives. Standard search procedures were followed to determine sources from the literature specific to walking during pregnancy for use in each section of this review.

PURPOSE: To explore the attitudes of reproductive endocrinology and infertility (REI) and maternal–fetal medicine (MFM) subspecialists regarding the necessity and appropriateness of body mass index (BMI) cutoffs for women seeking fertility treatment. METHODS: Members of the Society for Reproductive Endocrinology and Infertility (SREI) and the Society for Maternal Fetal Medicine (SMFM) were invited to participate in a survey querying their knowledge of existing institutional or clinic BMI policies and personal opinions regarding upper and lower BMI cutoffs for a range of fertility treatments, including oral ovulation agents, gonadotropins, and in vitro fertilization. RESULTS: Respondents included 398 MFMs and 201 REIs. The majority of REI and MFM providers agreed with upper limit BMI cutoffs (72.5% vs 68.2%, p = 0.29), but REIs were twice as likely to support lower limit BMI restrictions compared to MFMs (56.2% vs 28.4%, p

There is a renewed call to address preventable foetal deaths in high-income countries, especially where progress has been slow. The Centers for Disease Control and Prevention released publicly, for the first time, the initiating cause and estimated timing of foetal deaths in 2014. The objective of this study is to describe risk and characteristics of antepartum versus intrapartum stillbirths in the U.S., and frequency of pathological examination to determine cause.We conducted a cross-sectional study of singleton births (24-43 weeks) using 2014 U.S. Fetal Death and Natality data available from the National Center for Health Statistics. The primary outcome was timing of death (antepartum (n = 6200), intrapartum (n = 453), and unknown (n = 5403)). Risk factors of interest included maternal sociodemographic, behavioural, medical and obstetric factors, along with foetal sex. We estimated gestational week-specific stillbirth hazard, risk factors for intrapartum versus antepartum stillbirth using multivariable log-binomial regression models, conditional probabilities of intrapartum and antepartum stillbirth at each gestational week, and frequency of pathological examination by timing of death.The gestational age-specific stillbirth hazard was approximately 2 per 10,000 foetus-weeks among preterm gestations and 3 per 10,000 foetus-weeks among term gestations. Both antepartum and intrapartum stillbirth risk increased in late-term and post-term gestations. The risk of intrapartum versus antepartum stillbirth was higher among those without a prior live birth, relative to those with at least one prior live birth (RR 1.32; 95% CI 1.08-1.61) and those with gestational hypertension, relative to those with no report of gestational hypertension (RR 1.47; 95% CI 1.09-1.96), and lower among Black, relative to white, individuals (RR 0.70; 95% CI 0.55-0.89). Pathological examination was not performed/planned in 25% of known antepartum stillbirths and 29% of known intrapartum stillbirths.These findings suggest greater stillbirth risk in the late-term and post-term periods. Primiparous mothers had greater risk of intrapartum than antepartum still birth, suggesting the need for intrapartum interventions for primiparous mothers in this phase of pregnancy to prevent some intrapartum foetal deaths. Efforts are needed to improve understanding, prevention and investigation of foetal deaths as well as improve stillbirth data quality and completeness in the United States.

Highlights • 3% of high-risk midlife women participated in lifestyle-related resources. • Lifestyle-related resource use was associated with more physical activity. • Lifestyle-related resource use was associated with lower weight in obese women. • Lifestyle-related resource use was associated with lower glucose in some women., Health plan-based resources are promising avenues for decreasing cardiovascular disease risk. This study examined associations of lifestyle-related resource utilization within a healthcare delivery system and cardiovascular biomarkers among midlife women with low physical activity. Midlife women (45-55 years old) with

Objective To compare maternal and infant outcomes with different antihypertensive medications in pregnancy. Design Retrospective cohort study. Setting Kaiser Permanente, a large healthcare system in the United States. Population Women aged 15–49 years with a singleton birth from 2005–2014 treated for hypertension. Methods We identified medication exposure from automated pharmacy data based on the earliest dispensing after the first prenatal visit. Using logistic regression, we calculated weighted outcome prevalences, adjusted odds ratios (aORs) and 95% confidence intervals, with inverse probability of treatment weighting to address confounding. Main outcome measures Small for gestational age, preterm delivery, neonatal and maternal intensive care unit (ICU) admission, preeclampsia, and stillbirth or termination at > 20 weeks. Results Among 6346 deliveries, 87% with chronic hypertension, the risk of the infant being small for gestational age (birthweight < 10th percentile) was lower with methyldopa than labetalol (prevalence 13.6% vs. 16.6%; aOR 0.77, 95% CI 0.63 to 0.92). For birthweight < 3rd percentile the aOR was 0.57 (0.39 to 0.80). Compared with labetalol (26.0%), risk of preterm delivery was similar for methyldopa (26.5%; aOR 1.10 [0.95 to 1.27]) and slightly higher for nifedipine (28.5%; aOR 1.25 [1.06 to 1.46]) and other β-blockers (31.2%; aOR 1.58 [1.07 to 2.23]). Neonatal ICU admission was more common with nifedipine than labetalol (25.9% vs. 23.3%, aOR 1.21 [1.02 to 1.43]) but not elevated with methyldopa. Risks of other outcomes did not differ by medication. Conclusions Risk of most outcomes was similar comparing labetalol, methyldopa and nifedipine. Risk of the infant being small for gestational age was substantially lower for methyldopa, suggesting this medication may warrant further consideration.

Preterm birth (PTB) remains a leading cause of neonatal mortality and long-term morbidity. Individual factors have been linked to PTB risk. The impact of a healthy lifestyle, with multiple modifiable prenatal factors, remains unknown.We aimed to examine the associations of preconceptional and early-pregnancy low-risk modifiable factors (individually and in combination) with PTB risk.This prospective cohort study included 2449 women with singleton pregnancies in the Pregnancy Environment and Lifestyle Study. PTB was defined as ultrasound-confirmed obstetric estimate-based gestational age at delivery37 wk. A set of low-risk modifiable factors were identified: healthy weight (prepregnancy BMI: 18.5-24.9 kg/m2) based on clinical measurements and high-quality diet (Alternate Healthy Eating Index-Pregnancy score ≥75th percentile) and low-to-moderate stress during early pregnancy (Perceived Stress Scale score75th percentile) assessed at gestational weeks 10-13. Poisson regression estimated adjusted relative risk (aRR) of PTB in association with individual and combined low-risk modifiable prenatal factors, adjusting for sociodemographic, clinical, and other prenatal factors.One hundred and sixty women (6.5%) delivered preterm. Risk of PTB was lower among women who had a healthy weight (aRR: 0.58; 95% CI: 0.39, 0.86), high-quality diet (aRR: 0.68; 95% CI: 0.39, 0.99), and low-to-moderate stress (aRR: 0.60; 95% CI: 0.41, 0.88). Women with 1, 2, or 3 low-risk modifiable prenatal factors compared with none had a 38% (aRR: 0.72; 95% CI: 0.45, 1.16), 51% (aRR: 0.49; 95% CI: 0.29, 0.84), or 70% (aRR: 0.30; 95% CI: 0.13, 0.70) lower PTB risk, respectively. Associations of having ≥1 low-risk factor with PTB risk were more pronounced for medically indicated than for spontaneous PTB and for late than for early or moderate PTB. Associations also varied by race or ethnicity, although with overlapping 95% CIs.A healthy prenatal lifestyle with multiple low-risk modifiable factors was associated with lower risk of PTB. Our findings may inform multicomponent preconceptional or early-pregnancy prevention strategies to mitigate PTB risk.

Women with a history of gestational diabetes (GDM) are at high risk for developing type 2 diabetes, which may be further increased with weight gain after pregnancy. Our objective was to determine associations of long-term weight changes after a GDM pregnancy and type 2 diabetes risk. We used data on a cohort of 139 women with a GDM pregnancy identified though the Kaiser Permanente Northern California (KPNC) GDM registry (1986-2009) who completed a follow-up study visit an average of 16 years later (2011-2013). Type 2 diabetes was identified through the KPNC diabetes registry, self-report during follow-up visit recruitment, or at least one abnormal value on a 75-gram, 2-hour oral glucose tolerance test (2015 ADA criteria) conducted at the follow-up visit. Clinically measured weights extracted from the electronic health record were used to calculate average BMI change per year between delivery and either type 2 diabetes identification date or follow-up visit date. We used modified Poisson regression to estimate relative risks of type 2 diabetes associated with BMI change categories. Twenty-six percent of women lost weight [mean -0.3 BMI units/year, equivalent to -0.8 kg/year for a woman of the average height in our cohort (1.6 m)], 24% maintained their weight ( Disclosure S.E. Badon: None. F. Xu: None. C. Quesenberry: None. A. Ferrara: None. M.M. Hedderson: None. Funding National Institutes of Health (R01HD065904)

Wellness counseling resources have the potential to decrease diabetes risk in high risk populations. Midlife women are at high risk for diabetes because of menopause and aging, and diabetes risk is further increased in women with low levels of physical activity (PA). We determined whether referral to wellness counseling was associated with diabetes risk among midlife women with low PA levels. We identified 64,350 women members of Kaiser Permanente Northern California who were 45-55 years old, did not have diabetes, and reported Disclosure S.E. Badon: None. N. Nance: None. M.M. Hedderson: None. L. Avalos: None. Funding Kaiser Permanente; National Institutes of Health (T32DK116684)

Aim: Investigate associations of leisure time physical activity (LTPA) with DNA methylation and miRNAs during pregnancy. Patients & methods: LTPA, candidate DNA methylation and circulating miRNAs were measured (average 15 weeks gestation) in pregnant women (n = 92). Results: Each additional hour of prepregnancy LTPA duration was associated with hypermethylation in C1orf212 (β = 0.137, 95% CI: 0.004–0.270) and higher circulating miR-146b-5p (β = 0.084, 95% CI: 0.017–0.151). Each additional metabolic equivalent hour of early-pregnancy LTPA energy expenditure was associated with higher circulating miR-21-3p (β = 0.431, 95% CI: 0.089–0.772) in women carrying female offspring, and lower circulating miR-146b-5p (β = -0.285, 95% CI: -0.528 to -0.043) and miR-517-5p (β = -0.406, 95% CI: -0.736 to -0.076) in women carrying male offspring. Conclusion: Our findings suggest that LTPA may influence maternal epigenetic biomarkers, possibly in an offspring sex-specific manner.

Context Previous studies have not examined the ability of multiple preconception biomarkers, considered together, to improve prediction of gestational diabetes mellitus (GDM). Objective To develop a preconception biomarker risk score and assess its association with subsequent GDM. Design A nested case-control study among a cohort of women with serum collected as part of a health examination (1984 to 1996) and subsequent pregnancy (1984 to 2009). Biomarkers associated with GDM were dichotomized into high/low risk. Setting Integrated health care system. Participants Two controls were matched to each GDM case (n = 256 cases) on year and age at examination, age at pregnancy, and number of pregnancies between examination and index pregnancy. Main Outcome Measure GDM. Results High-risk levels of sex hormone-binding globulin (SHBG; 90 mg/dL), total adiponectin (3.9) were independently associated with 2.34 [95% confidence interval (CI): 1.50, 3.63], 2.03 (95% CI: 1.29, 3.19), 1.83 (95% CI: 1.16, 2.90), and 1.67 (95% CI: 1.07, 2.62) times the odds of GDM and included in the biomarker risk score. For each unit increase in the biomarker risk score, odds of GDM were 1.94 times greater (95% CI: 1.59, 2.36). A biomarker risk score including only SHBG and glucose was sufficient to improve prediction beyond established risk factors (age, race/ethnicity, body mass index, family history of diabetes, previous GDM; area under the curve = 0.73 vs 0.67, P = 0.002). Conclusions The improved, predictive ability of the biomarker risk score beyond established risk factors suggests clinical use of the biomarker risk score in identifying women at risk for GDM before conception for targeted prevention strategies.

Objective Determine associations of cardiorespiratory fitness, exercise systolic blood pressure (SBP) and heart rate recovery (HRR) following a maximal exercise test performed years preceding pregnancy with odds of preterm birth (PTB; Design Prospective, longitudinal. Setting Multi-site, observational cohort study initially consisting of 2787 black and white women aged 18-30 at baseline (1985-86) and followed for 25 years (Y25; 2010-2011). Population 768 nulliparous women at baseline who reported ≥1 live birth by the Y25 exam. Methods We used Poisson regression to determine associations of exposures with PTB/SGA. Main outcome measures PTB and/or SGA births. Results Women with PTB (n = 143) and/or SGA (n = 88) were younger, had completed fewer years of education and were more likely to be black versus women without PTB/SGA (n = 546). Women with PTB/SGA had lower fitness (501 ± 9 versus 535 ± 6 seconds, P Conclusions Neither fitness nor haemodynamic responses to exercise a median of 5 years preceding pregnancy, were associated with PTB/SGA. These findings indicate excess likelihood of PTB/SGA is not detectable by low fitness or exercise haemodynamic responses 5 years preceding pregnancy, but exercise testing, especially HRR and submaximal SBP, may be more useful when conducted closer to the onset of pregnancy. Tweetable abstract Exercise testing conducted >5 years before pregnancy may not detect women likely to have PTB/SGA.

Previous studies have found associations between individual healthy behaviors and reduced risk of gestational diabetes mellitus (GDM); however, the association of composite healthy lifestyle during pregnancy with GDM has not been examined. Participants in the Omega Study (n = 3,005), a pregnancy cohort study conducted in Washington State (1996-2008), reported information on diet, physical activity, smoking, and stress during early pregnancy. Lifestyle components were dichotomized into healthy/unhealthy and then combined into a total lifestyle score (range, 0-4). Regression models were used to determine relative risk of GDM (n = 140 cases) in relation to healthy lifestyle. Twenty percent of participants had a healthy diet, 66% were physically active, 95% were nonsmokers, and 55% had low stress. Each 1-point increase in lifestyle score was associated with a 21% lower risk of GDM (95% confidence interval: 0.65, 0.96) after adjustment for age, race, and nulliparity. Adjustment for prepregnancy body mass index, prepregnancy physical activity, and prepregnancy smoking attenuated the associations slightly. Associations were similar in normal-weight and overweight/obese women. In this study, a composite measure of healthy lifestyle during early pregnancy was associated with substantially lower GDM risk. Public health messaging and interventions promoting multiple aspects of a healthy lifestyle during early pregnancy should be considered for GDM prevention.

PURPOSE: Individual maternal lifestyle factors during pregnancy have been associated with offspring birthweight; however, associations of combined lifestyle factors with birthweight and potential differences by offspring sex have not been examined. MATERIALS AND METHODS: Participants (N=2,924) were identified from a pregnancy cohort in Washington State. Lifestyle factors during early pregnancy were dichotomized based on Alternate Healthy Eating Index score ≥62, leisure time physical activity (LTPA) ≥150 minutes/ week, not smoking during pregnancy, and Perceived Stress Scale score ≤3, then combined into a lifestyle score (0–4). Regression models were run overall and stratified by offspring sex, pre-pregnancy overweight/obese (BMI≥25kg/m(2)), and pre-pregnancy LTPA. RESULTS: Overall, 20% of participants had healthy diet, 95% were non-smokers, 55% had low stress levels, and 66% were physically active. Lifestyle score was not associated with birthweight (β=3.3g; 95% CI: -14.5, 21.0); however, associations differed by offspring sex (P=0.009). For each unit increase in lifestyle score, there was a suggested 22.4g higher birthweight (95% CI: -2.7, 47.6) among males and 14.6g lower birthweight (95% CI: -39.9, 10.7) among females. Pre-pregnancy BMI and LTPA did not modify associations. CONCLUSIONS: Healthy lifestyle score in early pregnancy may be associated with greater birthweight among male offspring, but lower birthweight among female offspring.

Vitamin D has pleiotropic functions that regulate fetal growth and development. We investigated associations of common placental genetic variations in vitamin D metabolism with birthweight.The study was conducted among participants (506 maternal-infant pairs) of a pregnancy cohort study. Data were collected using interviewer-administered questionnaires and post-delivery medical record abstraction. DNA, extracted from placental samples collected at delivery, was genotyped for eight single nucleotide polymorphisms (SNPs) in five vitamin D metabolism genes (CUBN, LRP2, VDR, GC, and CYP2R1). Linear and logistic regression models were used to evaluate associations of SNPs with birthweight and risk of low birthweight, respectively. Effect modification of associations by infant sex was examined using stratified analyses and interaction terms in regression models.Mean (standard-deviation) birthweight among all, male, and female infants was 3482.1 (549.9), 3544.6 (579.0) and 3419.2 (512.5) grams, respectively. Each copy of the minor allele of rs2282679 (GC) was associated with a 68.6 g (95%CI:3.1134.7 g) increase in birthweight overall. Sex-specific associations were observed for SNP rs4667591 (LRP2) (p-value for interaction 0.001). Each copy of the minor allele of rs4667591 was associated with a 124.7 g (95%CI:20.1229.0 g) increase in birthweight among female infants, and a suggested 81.6 g decrease in birthweight among male infants (95%CI:-183.7,20.5 g).Our study identified overall and sex-specific associations between placental genetic variations in vitamin D metabolism and birthweight. If confirmed by larger replication studies, observed associations may provide insight into mechanistic underpinnings of the relationships between placental vitamin D metabolism and birth size.

Objective To incorporate blood pressure (BP), diagnoses codes, and medication fills from electronic medical records (EMR) to identify pregnant women with hypertension. Study design A retrospective cohort study of singleton pregnancies at three US integrated health delivery systems during 2005–2014. Main outcome measures Women were considered hypertensive if they had any of the following: (1) ≥2 high BPs (≥140/90 mmHg) within 30 days during pregnancy (High BP); (2) an antihypertensive medication fill in the 120 days before pregnancy and a hypertension diagnosis from 1 year prior to pregnancy through 20 weeks gestation (Treated Chronic Hypertension); or (3) a high BP, a hypertension diagnosis, and a prescription fill within 7 days during pregnancy (Rapid Treatment). We described characteristics of these pregnancies and conducted medical record review to understand hypertension presence and severity. Results Of 566,624 pregnancies, 27,049 (4.8%) met our hypertension case definition: 24,140 (89.2%) with High BP, 5,409 (20.0%) with Treated Chronic Hypertension, and 5,363 (19.8%) with Rapid Treatment (not mutually exclusive). Of hypertensive pregnancies, 19,298 (71.3%) received a diagnosis, 9,762 (36.1%) received treatment and 11,226 (41.5%) had a BP ≥ 160/110. In a random sample (n = 55) of the 7,559 pregnancies meeting the High BP criterion with no hypertension diagnosis, clinical statements about hypertension were found in medical records for 58% of them. Conclusion Incorporating EMR BP identified many pregnant women with hypertension who would have been missed by using diagnosis codes alone. Future studies should seek to incorporate BP to study treatment and outcomes of hypertension in pregnancy.

Background: Depression is associated with weight change outside of pregnancy. We assessed associations of prepregnancy or early pregnancy onset depression with gestational weight gain (GWG) rate overall and according to Institute of Medicine (IOM) recommendations. Materials and Methods: Depression from 6 months prepregnancy through 20 weeks gestation was identified in a health care system in northern California with perinatal depression screening (2011–2016; n = 87,600). GWG rate (lbs/week) was calculated using weight at delivery and at diagnosis or depression screening ≤20 weeks. Results: Compared to women without prepregnancy or early pregnancy depression, women with prepregnancy onset depression had 11% greater risk of GWG rate IOM recommendations (95% CI: 1.01–1.05), with a stronger association for >IOM in normal weight women. Early pregnancy onset depression was associated with 0.04 lbs/week greater GWG rate (95% CI: 0.02–0.07) and 4% greater risk of GWG rate >IOM recommendations (95% CI: 1.02–1.07) compared to no prepregnancy or early pregnancy depression, with stronger associations in obese women. Conclusions: Women with prepregnancy onset depression may be at higher risk for GWG both below and above recommendations. Women with early onset prenatal depression may be at slightly higher risk for GWG rate above recommendations. Our results suggest that the relationship between depression and GWG may vary based on timing of depression onset, prepregnancy body mass index category, and antidepressant use. Additional research should identify factors that predict how a woman's lifestyle behaviors and weight change after depression diagnosis.

Women with sleep disturbances before or during pregnancy may be at high risk for gestational diabetes (GDM) due to poor sleep-related increases in insulin resistance. To estimate associations of habitual snoring and other sleep disturbances before and during early pregnancy with GDM risk, we combined data collected as part of two prospective pregnancy cohort studies at Kaiser Permanente Northern California that used the same sleep questionnaires (N=3,646, 2011-2018). In early pregnancy (7-22 weeks gestation) participants self-reported snoring frequency in the 12 months before becoming pregnant and since becoming pregnant. Snoring most or some of the time was considered habitual snoring. Participants also reported if they had trouble falling asleep in early pregnancy. Three hundred four (8%) women were diagnosed with GDM based on laboratory glucose values meeting the Carpenter and Coustan criteria. Forty-four percent of women reported habitual snoring prior to pregnancy and 45% in early pregnancy. Thirty-one percent of women reported trouble falling asleep in early pregnancy. In logistic regression models adjusted for maternal age, race/ethnicity, pre-pregnancy BMI, and parity, habitual snoring prior to pregnancy was associated with a 33% greater odds of GDM (OR [95% CI]: 1.33 [1.00, 1.77]) compared to no snoring. Habitual snoring in early pregnancy was not statistically significantly associated with GDM (1.14 [0.84, 1.53]). Trouble falling asleep in early pregnancy was borderline significantly associated with greater GDM risk (1.27 [0.98, 1.66]). Our findings suggest that snoring prior to pregnancy and other sleep disturbances during early pregnancy are associated with greater risk of GDM. Studies with objective measures of sleep are needed to confirm these findings and prior to designing interventions to reduce sleep disturbances to decrease risk for GDM. Disclosure S.E. Badon: None. F. Xu: None. A. Ferrara: None. M.M. Hedderson: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (T32DK11668401 to S.E.B.)

Insulin resistance increases starting in midlife due to decreasing estrogen production and other aging-related factors. Higher intensity physical activity (PA) has the potential to attenuate rising insulin resistance; however, longitudinal associations of PA and insulin resistance have not been studied in midlife women. We used data from the Study of Women’s Health Across the Nation (SWAN, N=3,230), a cohort study with up to 17 years of follow-up, to estimate longitudinal associations of higher intensity PA with insulin resistance. Women reported PA using the Kaiser Physical Activity Survey at 7 study visits (V0, V3, V5, V6, V9, V12, V13). We used the sports and exercise physical activity index score (range: 1-5) to assess leisure-time moderate to vigorous intensity PA (MVPA). SWAN measured glucose and insulin in blood collected at 8 study visits (V0, V1, V3-V7, V12, V13). We used generalized estimating equations to estimate the adjusted longitudinal associations of MVPA with homeostatic model assessment of insulin resistance (HOMA-IR) overall, by baseline body mass index (BMI) category, and by race/ethnicity. Women were 46 (SD=3) years old at baseline. Forty-seven percent were non-Hispanic white; 28% black; 9% Japanese; 8% Chinese, and 8% Hispanic. Each additional one-unit increase in reported MVPA was associated with an average 0.2 unit lower HOMA-IR (95% CI: -0.3, -0.1) over time. Associations differed by baseline BMI (interaction P Disclosure S.E. Badon: None. K. Pettee Gabriel: None. C.A. Karvonen-Gutierrez: None. B. Sternfeld: None. J. Lee: None. E. Gold: None. E. Waetjen: None. M. Hedderson: None. Funding National Institutes of Health; U.S. Department of Health and Human Services; National Institute on Aging; National Institute of Nursing Research; Office of Research on Women’s Health (U01NR004061, U01AG012505, U01AG012535, U01AG012531, U01AG012539, U01AG012546, U01AG012553, U01AG012554, U01AG012495); National Center for Research Resources; National Center for Advancing Translational Sciences (UCSF-CTSI UL1RR024131)

Introduction Napping is common in pregnant women; however, characteristics associated with napping in pregnant women with insomnia have not been studied. Methods We used baseline data from a randomized controlled trial of insomnia treatment during pregnancy for this cross-sectional analysis (n=159). Women self-reported sociodemographic characteristics (age, race/ethnicity, education, income, employment), pregnancy-related characteristics (parity, trimester), sleep-related characteristics (7-day sleep diary including total napping time per day, Insomnia Severity Index), and depression symptoms (Edinburgh Postnatal Depression Scale). Women were categorized as non-nappers (0 days with napping), infrequent nappers (1–3 days with napping), and frequent nappers (≥4 days with napping). Characteristics were compared across napping categories using descriptive statistics and multinomial logistic regression. Results Eighteen percent of women were frequent nappers, 53% were infrequent nappers, and 30% were non-nappers. Average time spent napping on days with naps was 67 minutes (SD=35). In unadjusted analyses, frequent nappers were more likely to have a high school diploma or less (36% vs 19%), be unemployed (57% vs 41%), and be nulliparous (21% vs 13%) than non-nappers. Infrequent nappers were more likely to have a 4-year college degree (32% vs 11%), have a household income $100k or more (58% vs 45%), be working full time (51% vs 39%), and be nulliparous (26% vs 13%) than non-nappers. Age, race/ethnicity, trimester, sleep-related characteristics, and depression symptoms were similar across napping categories. In analyses adjusted for education and trimester, being unemployed (OR=3.6; 95% CI: 0.8, 15.4), working part time (OR=2.3; 95% CI: 0.5, 11.2), and nulliparity (OR=2.4; 95% CI: 0.4, 14.6) were most strongly associated with frequent napping (though confidence intervals were wide) but were not associated with infrequent napping. Sleep-related characteristics were not associated with frequent or infrequent napping in adjusted analyses. Conclusion Among pregnant women with insomnia, frequent napping was associated with characteristics that suggest greater feasibility of napping (not working, working part time, pregnant with first child), but was not associated with nocturnal sleep parameters or insomnia severity. Given napping can reduce homeostatic sleep drive at bedtime, it should be addressed during insomnia treatment in pregnant women, particularly among women with greater opportunity to nap. Support (if any) National Institutes of Health (K99HD100585, R01NR013662)

Objectives An optimal gestational weight gain is essential for maternal health and to reduce adverse birth outcomes. Current guidelines to monitor gestational weight gain are based on pre-pregnancy body mass index (BMI). However, middle-upper arm circumference (MUAC) is increasingly used as an alternative nutritional status measure for pregnant women. Hence, this study aimed to determine associations of MUAC and pre-pregnancy BMI with gestational weight gain rate among Malaysian pregnant women. Study design A cross-sectional study was conducted among 444 pregnant women (≥20 weeks gestation). Main outcomes measures Women completed questionnaires on sociodemographic data, maternal characteristics and pre-pregnancy weight. Height, current weight and MUAC were measured at study visit (from 1st February 2016 to 31st January 2017). Results About a third (34.24%) of pregnant women were overweight or obese prior to pregnancy. MUAC was inversely associated with an inadequate rate of gestational weight gain (OR = 0.77; 95% CI: 0.68, 0.87) as compared to normal gestational weight gain. In contrast, a higher MUAC was associated with a higher odds ratio (OR = 1.28; 95% CI: 1.11, 1.49) of having excessive rate of gestational weight. No associations were found for pre-pregnancy BMI categories for gestational weight gain rate. Conclusion Our findings revealed that women with low MUAC were more likely to have an inadequate gestational weight gain rate during pregnancy whereas higher MUAC was associated with an excessive gestational weight gain rate. MUAC may be a useful indicator of nutritional status associated with GWG. Routine measurement of MUAC in pregnant women may help health professionals, particularly in middle-income countries, to counsel women about gestational weight gain.

Objective: Hypertension is a major risk factor for poor pregnancy outcomes. Many observational studies have relied on diagnosis codes, particularly from the delivery hospitalization, to identify hypertension in pregnancy. We augmented diagnosis codes with electronic blood pressure (BP) data to improve the identification of pregnant women with hypertension. Methods: We studied pregnant women aged 15-49 years enrolled in three Kaiser Permanente health plans who delivered during 2005-2014. Using diagnosis codes, BP values, and antihypertensive medication dispensings, we defined hypertension as: (1) ≥ 2 high BPs (≥ 140/90 mmHg) within 30 days of each other (2highBPs); or (2) ≥ 1 antihypertensive medication fill with ≥1 hypertension diagnosis code from 120 days prior to pregnancy through 20 weeks gestation (chronicHTN); or (3) ≥ 1 high BP, a hypertension diagnosis code, and an antihypertensive fill within 7 days (RapidTx). Among women meeting our study definition, we examined receipt of hypertension diagnosis codes and prevalence of severe hypertension (1+ BP ≥160/110 mmHg). Results: Among 553,477 eligible women, 29,933 (5%) met our definition of hypertension, including 26,855 identified via 2highBPs, 5,774 via chronicHTN and 6,198 via RapidTx (not mutually exclusive). Among women meeting our hypertension definition overall, only 64% had 1+ hypertension diagnosis code assigned during pregnancy, and 49% had one at delivery. Among hypertensive women identified via 2highBPs, only 60% (16,057/26,855) had a hypertension diagnosis code in pregnancy and 45% (12,131/ 26,855) at delivery. However, 53% of our hypertensive women (14,972/ 29,933) overall and 56% (14,972/ 26,855) of the 2highBPs women had severe hypertension at some time during pregnancy. Conclusion: Incorporating BP values identifies additional pregnant women with hypertension who would have been missed by approaches using diagnosis codes alone. Women identified by our method frequently had severely elevated BP, showing the importance of including these women in future studies of hypertension during pregnancy.

Individual preconception biomarkers have been associated with future gestational diabetes mellitus (GDM) risk. Creating a biomarker risk score incorporating several biomarkers may enhance identification of women at high risk for GDM before pregnancy. The objective of this study was to develop a preconception biomarker risk score and assess its association with subsequent GDM. We conducted a nested case-control study within a cohort of 4,098 women with serum and questionnaire data collected as part of a health checkup (1984-1996) and a subsequent pregnancy (1984-2009) in northern California. Two controls were matched to each GDM case (N=256 cases) on year and age at serum collection, age at pregnancy, and number of pregnancies between serum collection and index pregnancy. Biomarkers associated with GDM in univariable models were dichotomized into high/low risk using quartiles. A biomarker risk score was created by summing the number of high risk biomarkers that were significantly associated with GDM in a multivariable model. Receiver-operating-characteristic curve analyses were used to assess the incremental predictive value of the biomarker risk score beyond conventional GDM risk factors obtained from medical records (age, race/ethnicity, BMI, family history, previous GDM). Compared to low risk, high risk levels of total adiponectin (3.9) were each independently associated with 2.03 (95% CI: 1.37, 3.02), 2.78 (95% CI: 1.87, 4.13), and 2.07 (95% CI: 1.40, 3.06) times the odds of GDM and thus included in the biomarker risk score. For each one unit increase in the biomarker risk score, odds of GDM were 2.04 times greater (95% CI: 1.62, 2.56). The biomarker risk score had relative incremental predictive value beyond conventional GDM risk factors (AUC= 0.73 vs. 0.67, P Disclosure S.E. Badon: None. A. Ferrara: None. Y. Zhu: None. S.B. Sridhar: None. C. Lee: None. S. Ehrlich: None. C. Quesenberry: None. M. Hedderson: None.

Background Sedentary behavior is associated with adverse health outcomes in the general population. Whether sedentary behavior during pregnancy is associated with newborn outcomes, such as birth size, is not established, and previous studies have been inconsistent. While previous research suggests that male and female fetuses respond differently to maternal behaviors, such as physical activity, the role of infant sex in sedentary behavior-birth size associations has not been examined. Methods Participants in the Omega study, a cohort in Washington State (1996–2008), reported leisure time sedentary behavior (non-work time spent sitting), light intensity physical activity, and moderate/vigorous leisure time physical activity duration in the year before pregnancy (N = 1373) and in early pregnancy (N = 1535, mean 15 weeks). Offspring birth size was abstracted from delivery records. Non-parametric calibration weighting was used to assign adjustment weight (matching the distribution of sociodemographic and medical characteristics of the full cohort (N = 4128)) to participants with available sedentary behavior data. Weighted linear regression models were used to estimate mean differences in offspring birthweight, head circumference, and ponderal index (birthweight/length3) associated with leisure time sedentary behavior. Regression models were run overall and stratified by offspring sex. Isotemporal substitution modeling was used to determine mean differences in birthweight associated with replacing sedentary behavior with light or moderate/vigorous physical activity. Results On average, women spent 2.3 and 2.6 h/day in leisure time sedentary behavior during pre- and early pregnancy, respectively. There were no associations of pre-pregnancy leisure time sedentary behavior with mean birthweight, head circumference, or ponderal index (adjusted β = − 12, 95% CI: -28, 4.1; β = 0.0, 95% CI: -0.04, 0.1; and β = 0.1, 95% CI: -0.2, 0.4, respectively). Early pregnancy sedentary behavior was not associated with mean birth size. Associations of sedentary behavior with mean birth size did not differ by offspring sex. Replacing sedentary time with light or moderate/vigorous physical activity was not associated with mean birthweight. Conclusions We did not observe associations of maternal sedentary behavior during pre- or early pregnancy with mean offspring birth size. Pre-pregnancy and early pregnancy sedentary behavior may have important adverse effects on maternal health, but our results do not support associations with mean offspring birth size.

Although perinatal walking and yoga have been associated with decreased risks of pregnancy complications, associations with offspring birth size have been inconsistent. We investigated associations of prepregnancy and early pregnancy leisure-time light/moderate walking and yoga practice with birth size.Study participants (N = 3687) reported leisure-time physical activity duration (hours per week) in the year before pregnancy and early pregnancy. Birth size was abstracted from medical records. Regression was used to determine mean differences in birth weight, head circumference, and ponderal index. Interaction terms were used to assess effect modification by offspring sex.About one-third of women reported light/moderate leisure-time walking and about 10% reported yoga practice. Women in the highest tertile for prepregnancy (mean: 2.9 h/wk; range: 1.4-20 h/wk) or early pregnancy (mean: 5.9 h/wk; range: 3.1-24 h/wk) light/moderate walking had offspring with 0.9 and 1.5 kg/mLight/moderate leisure-time walking may be associated with greater offspring ponderal index.

Objectives Associations of gestational weight gain (GWG) during specific periods of pregnancy with infant birth size have been inconsistent. Infant sex-specific differences in these associations are unknown Methods Information on GWG (kg) [total, early (\20 weeks gestation), and late (C20 weeks gestation)] and indices of infant birth size including birthweight (BW), ponderal index (PI), crown-heel length (CHL), and head circumference (HC) was collected from 3,621 pregnant women. We calculated adjusted mean differences and 95 % confidence intervals (CIs) relating total, early and late GWG to infant birth size using multivariable linear regression procedures. We used stratified analyses and interaction terms to test whether associations differed by infant sex. Results One-kg increases in total, early or late GWG were associated with BW increases of 17.2 g (95 % CI 13.8‐18.9), 14.1 g (95 % CI 10.3‐18.0), and 21.0 g (95 % CI 16.7‐25.4), respectively. Early GWG‐BW and late GWG‐BW associations were different (p = 0.026). Sexstratified total GWG‐BW associations were similar to overall results. There were sex-specific differences in early GWG‐BW and late GWG‐BW associations. Among females, early GWG‐BW (12.0 g, 95 % CI 6.7‐17.2) and late GWG‐BW (24.2 g, 95 % CI 18.2‐30.3) associations differed (p = 0.0042); the corresponding associations did not differ among males. Total, early, and late GWG were associated with CHL and HC, but not with PI. Associations did not differ for early or late GWG. Conclusions for Practice For comparable GWG, lateGWG-related BW increase is greater than early-GWG-related BW increase, particularly among female infants.

Background— The concept of cardiovascular health (CVH) was introduced as a global measure of one's burden of cardiovsacular risk factors. Previous studies established the relationship between neighborhood characteristics and individual cardiovascular risk factors. However, the relationship between neighborhood environment and overall CVH remains unknown. Methods and Results— We analyzed data from the Multi-Ethnic Study of Atherosclerosis baseline examination (2000–2002). Mean age was 61.6 years, and 52% were women. Ideal, intermediate, and poor categories of cholesterol, body mass index, diet, physical activity, fasting glucose, blood pressure, and smoking were defined according to the American Heart Association 2020 Strategic Goals, assigned an individual score, and summed to create an overall score. CVH scores were categorized into ideal (11–14 points), intermediate (9–10), and poor (0–8). Neighborhood exposures included favorable food store and physical activity resources densities (by 1-mile buffer), reported healthy food availability, walking/physical activity environment, safety, and social cohesion (by census tract). Multinomial logistic regression was used to determine the association of each characteristic with ideal and intermediate CVH, adjusted for demographics and neighborhood socioeconomic status. Over 20% of Multi-Ethnic Study of Atherosclerosis participants had an ideal CVH score at baseline. In fully adjusted models, favorable food stores (odds ratio=1.22; 1.06–1.40), physical activity resources (odds ratio=1.19; 1.08–1.31), walking/physical activity environment (odds ratio=1.20; 1.05–1.37), and neighborhood socioeconomic status (odds ratio=1.22; 1.11–1.33) were associated with higher odds of having an ideal CVH score. Conclusions— Neighborhood environment including favorable food stores, physical activity resources, walking/physical activity environment, and neighborhood socioeconomic status are associated with ideal CVH. Further research is needed to investigate the longitudinal associations between neighborhood environment and CVH.

To examine the associations between gestational weight gain (GWG) exceeding Institute of Medicine (IOM) guidelines and neonatal adiposity in the five North American field centers of the Hyperglycemia and Adverse Pregnancy Outcome study.GWG was categorized as less than, within, or greater than 2009 IOM guidelines. Birthweight, body fat percentage, cord serum C-peptide, and sum of neonatal flank, subscapular, and triceps skin fold thicknesses were dichotomized as90th percentile or ≤90th percentile obtained by quantile regression. Logistic regression analysis was used.Of the 5297 participants, 11.6% gained less, 31.9% gained within, and 56.5% gained more than the recommendation. With adjustment for glucose tolerance levels, normal and overweight women who gained more than the recommendation had increased odds of delivering infants with sum of skin folds90th percentile (OR = 1.75 and 4.77, respectively) and percentage body fat90th percentile (OR = 2.41 and 2.59, respectively), and normal weight and obese women who gained more than the recommendation had increased odds of delivering infants with birthweight90th percentile (OR = 2.80 and 1.93, respectively) compared to women who gained within the recommendation.This analysis showed independent associations between exceeding IOM GWG recommendations and neonatal adiposity in normal and overweight women, controlling for glucose tolerance levels.