Search

INTRODUCTION Since 2013, various guidelines for hypertension in pregnancy have been refined, no longer requiring proteinuria as a requisite criterion for preeclampsia. We aimed to evaluate the impact of the new definition on preterm birth (PTB) and adverse pregnancy outcomes. MATERIAL AND METHODS Women delivering in Ontario between April 2012 and November 2016 were included. Delivery

OBJECTIVE To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes. DESIGN A population-based retrospective cohort study (2007-2017). SETTING Ontario, Canada. METHODS Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies. RESULTS For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively. CONCLUSIONS We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds. TWEETABLE ABSTRACT Potential twin-specific OGTT thresholds for GDM were identified.

Background The safest delivery mode of extremely preterm breech singletons is unknown. Objectives To determine safest delivery mode of actively resuscitated extremely preterm breech singletons. Search strategy We searched Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov from January 1994 to May 2017. Selection criteria We included studies comparing outcomes by delivery mode in actively resuscitated breech infants between 23+0 and 27+6 weeks. Data collection and analysis We synthesised data using random effects, generated odds ratios, 95% confidence intervals and number-needed-to-treat (NNT). Our primary outcomes were death (neonatal, before discharge, or by 6 months) and severe intraventricular haemorrhage (grades III/IV), stratified by gestational age (23+0–24+6, 25+0–26+6, 27+0–27+6 weeks). Main results We included 15 studies with 12 335 infants. We found that caesarean section was associated with a 41% decrease in odds of death between 23+0 and 27+6 weeks [odds ratio (OR) 0.59, 95% CI 0.36–0.95, NNT 8], with the greatest decrease at 23+0–24+6 weeks (OR 0.58, 95% CI 0.44–0.75, NNT 7). The OR at 25+0–26+6 and 27+0–27+6 weeks were 0.72 (95% CI 0.34–1.52) and 2.04 (95% CI 0.20–20.62), respectively. We found that caesarean section was associated with 49% decrease in odds of severe intraventricular haemorrhage between 23+0 and 27+6 weeks (OR 0.51, 95% CI 0.29–0.91, NNT 12), whereas the OR at 25+0–26+6 and 27+0–27+6 was 0.29 (95% CI 0.07–1.12) and 0.91 (95% CI 0.27–3.05), respectively. Conclusions Caesarean section was associated with reductions in the odds of death by 41% and of severe intraventricular haemorrhage by 49% in actively resuscitated breech singletons < 28 weeks of gestation. The data are mostly observational, which may be inherently biased, and scarce on other morbidities, necessitating thorough discussion between parents and clinicians. Tweetable abstract Caesarean section associated with lower odds of death and severe intraventricular haemorrhage in actively resuscitated breech singletons

BACKGROUND The genetic influence on child obesity has not been fully elucidated. OBJECTIVE This study investigated the parental and child contributions of 83 adult body mass index (BMI)-associated single-nucleotide polymorphisms (SNPs) to obesity-related traits in children from birth to 5 years old. METHODS A total of 1402 individuals were genotyped for 83 SNPs. An unweighted genetic risk score (GRS) was generated by the sum of BMI-increasing alleles. Repeated weight and length/height were measured at birth, 1, 2, 3 and 5 years of age, and age-specific and sex-specific weight and BMI Z-scores were computed. RESULTS The GRS was significantly associated with birthweight Z-score (P = 0.03). It was also associated with weight/BMI Z-score gain between birth and 5 years old (P = 0.02 and 6.77 × 10-3 , respectively). In longitudinal analyses, the GRS was associated with weight and BMI Z-score from birth to 5 years (P = 5.91 × 10-3 and 5.08 × 10-3 , respectively). The maternal effects of rs3736485 in DMXL2 on weight and BMI variation from birth to 5 years were significantly greater compared with the paternal effects by Z test (P = 1.53 × 10-6 and 3.75 × 10-5 , respectively). CONCLUSIONS SNPs contributing to adult BMI exert their effect at birth and in early childhood. Parent-of-origin effects may occur in a limited subset of obesity predisposing SNPs.

Objective The effects of maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG) on maternal and offspring obesity traits, as well as the maternal and offspring genetic contribution to GWG and postpartum weight retention, were examined. Methods Blood samples from mothers (n = 608) and offspring (n = 541) were genotyped for 83 BMI-associated SNPs and 47 waist-to-hip ratio (WHR)-associated SNPs. Linear regression and mixed-effects regression models were performed to examine clinical epidemiological and genetic associations with unweighted and weighted BMI and WHR genetic risk scores (GRS). Results Prepregnancy BMI was positively associated with offspring weight and BMI Z-score from birth to 5 years. GWG was positively associated with maternal postpartum weight retention at 1 and 5 years and with offspring weight Z-score from birth to 5 years old. The maternal unweighted BMI GRS was associated with prepregnancy BMI, postpartum weight retention at 5 years, and offspring weight Z-score from birth to 5 years old, but not associated with GWG. Both maternal and offspring unweighted WHR GRSs were negatively associated with GWG. Conclusions Maternal BMI-associated SNPs may contribute to the genetic link between prepregnancy BMI variation, long-term postpartum weight retention, and offspring birth weight and longitudinal weight. Maternal and offspring WHR-associated SNPs may contribute to GWG variation.

Morbidly obese (Class III, body mass index [BMI] ≥ 40 kg m(-2)) women constitute 8% of reproductive-aged women and are an increasing proportion; however, their pregnancy risks have not yet been well understood. Hence, we performed meta-analyses following the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) guideline, searching Medline and Embase from their inceptions. To examine graded relationships, we compared Class III obesity to Class I and I/II, and separately to normal weight. We found important effects on all three primary outcomes in morbidly obese women: preterm birth

A systematic review was conducted to determine the risk of adverse pregnancy outcomes with gestational weight gain (GWG) below the 2009 Institute of Medicine guidelines compared with within the guidelines in obese women. MEDLINE, Embase, Cochrane Register, CINHAL and Web of Science were searched from 1 January 2009 to 31 July 2014. Quality was assessed using a modified Newcastle-Ottawa scale. Three primary outcomes were included: preterm birth, small for gestational age (SGA) and large for gestational age (LGA). Eighteen cohort studies were included. GWG below the guidelines had higher odds of preterm birth (adjusted odds ratio [AOR] 1.46; 95% confidence interval [CI] 1.07-2.00) and SGA (AOR 1.24; 95% CI 1.13-1.36) and lower odds of LGA (AOR 0.77; 95% CI 0.73-0.81) than GWG within the guidelines. Across the three obesity classes, the odds of SGA and LGA did not show any notable gradient and remained unexplored for preterm birth. Decreased odds were noted for macrosomia (AOR 0.64; 95% CI 0.54-0.77), gestational hypertension (AOR, 0.70; 95% CI 0.53-0.93), pre-eclampsia (AOR 0.90; 95% CI 0.82-0.99) and caesarean (AOR 0.87; 95% CI 0.82-0.92). GWG below the guidelines cannot be routinely recommended but might occasionally be individualized for certain women, with caution, taking into account other known risk factors.

Objective Given that intention to breastfeed is a strong predictor of breastfeeding initiation and duration, the objectives of this study were to estimate the population-based prevalence and the factors associated with the intention to breastfeed. Design Retrospective population-based cohort study. Setting All hospitals in Ontario, Canada (1 April 2009–31 March 2010). Population Women who gave birth to live, term, singletons/twins. Methods Patient, healthcare provider, and hospital factors that may be associated with intention to breastfeed were analysed using univariable and multivariable regression. Main outcome measures Population-based prevalence of intention to breastfeed and its associated factors. Results The study included 92 364 women, of whom 78 806 (85.3%) intended to breastfeed. The odds of intending to breastfeed were higher amongst older women with no health problems and women who were cared for exclusively by midwives (adjusted OR 3.64, 95% CI 3.13–4.23). Being pregnant with twins (adjusted OR 0.73, 95% CI 0.57–0.94), not attending antenatal classes (adjusted OR 0.58, 95% CI 0.54–0.62), having previous term or preterm births (adjusted OR 0.79, 95% CI 0.78–0.81, and adjusted OR 0.87, 95% CI 0.82–0.93, respectively), and delivering in a level–1 hospital (adjusted OR 0.85, 95% CI 0.77–0.93) were associated with a lower intention to breastfeed. Conclusions In this population-based study ~85% of women intended to breastfeed their babies. Key factors that are associated with the intention to breastfeed were identified, which can now be targeted for intervention programmes aimed at increasing the prevalence of breastfeeding and improving overall child and maternal health.

Excess gestational weight gain has numerous negative health outcomes for women and children, including high blood pressure, diabetes, and cesarean section (maternal) and high birth weight, trauma at birth, and asphyxia (infants). Excess weight gain in pregnancy is associated with a higher risk of long‐term obesity in both mothers and children. Despite a concerted public health effort, the proportion of pregnant women gaining weight in excess of national guidelines continues to increase. To understand this phenomenon and offer suggestions for improving interventions, we conducted a systematic review of qualitative research on pregnant women's perceptions and experiences of weight gain in pregnancy. We used the methodology of qualitative meta‐synthesis to analyze 42 empirical qualitative research studies conducted in high‐income countries and published between 2005 and 2015. With this synthesis, we provide an account of the underlying factors and circumstances (barriers, facilitators, and motivators) that pregnant women identify as important for appropriate weight gain. We also offer a description of the strategies identified by pregnant women as acceptable and appropriate ways to promote healthy weight gain. Through our integrative analysis, we identify women's common perception on the struggle to enact health behaviors and physical, social, and environmental factors outside of their control. Effective and sensitive interventions to encourage healthy weight gain in pregnancy must consider the social environment in which decisions about weight take place.

Summary Although data showing adverse effects with high and low gestational weight gain (GWG) come from a large number of countries, a variety of guidelines about the GWG exist. Our objectives were to compare existing GWG and energy recommendations across various countries, as well as the rationale or evidence on which they were based. We used the United Nations' Human Developmental Index to determine the ranking of the country to ensure broad sampling and then searched for guidelines. We first searched the national government websites, and if necessary searched Medline and EMBASE, Global Health databases, and bibliographies of published articles for both guidelines and the studies on which they were based. We found guidelines for 31% of the countries, and 59% of these had a GWG recommendation, 68% had an energy intake recommendation (EIR), and 36% had both. About half of the GWG guidelines are similar to the 2009 American Institutes of Medicine (IOM) and 73% of the EIRs are similar to the 2006 IOM. Despite the documented relationship between both high GWG and adverse outcomes for women and infants and low GWG and adverse outcomes in infants, there are a wide variety of guidelines for GWG and energy recommendations by different countries around the world.

Background Evidence from RCTs shows that magnesium sulfate reduces the risk of seizures and mortality for women with pre-eclampsia/eclampsia. However, it has been argued that outcomes within trials may not reflect real-world outcomes with the same intervention. Objective To assess whether outcomes for women with pre-eclampsia/eclampsia who received magnesium sulfate in the real world were comparable to those in RCTs. Search strategy EMBASE and MEDLINE were searched (January 1990–July 2010). Selection criteria Cohort, before-and-after, and serial cross-sectional studies were included. Participants were women with eclampsia who received magnesium sulfate or another anticonvulsant, and women with pre-eclampsia who received magnesium sulfate or no anticonvulsant. Primary outcomes were death (maternal, fetal, neonatal) or recurrent seizures. Data collection and analysis Data were extracted independently by 2 reviewers. Main results Six studies (1831 women with eclampsia) were included, from academic centers in Bangladesh, India, Pakistan, and Nigeria, together with 2 population-based UK studies. Magnesium sulfate for eclampsia was associated with lower risks of maternal death, recurrent seizure, and major morbidity; for pre-eclampsia, it was associated with lower risks of eclampsia. Conclusion Improvements in maternal outcome with magnesium sulfate for pre-eclampsia/eclampsia in real-world use are comparable to those reported in RCTs.

BACKGROUND: Low gestational weight gain is common, with potential adverse perinatal outcomes. OBJECTIVE: To determine the relation between low gestational weight gain and preterm birth and low birthweight in singletons in developing and developed countries. DATA SOURCES: Medline, EMBASE and reference lists were searched, identifying 6,283 titles and abstracts. METHODS OF STUDY SELECTION: Following the MOOSE consensus statement, two assessors independently reviewed titles, abstracts, full articles, extracted data and assessed quality. RESULTS: Fifty-five studies, 37 cohort and 18 case-control, were included, involving 3,467,638 women. In the cohort studies (crude data, generally supported where available by adjusted data and case-control studies), women with low total gestational weight gain had increases in preterm birth

While active maternal tobacco smoking has well established adverse perinatal outcomes, the effects of passive maternal smoking, also called environmental tobacco exposure (ETS), are less well studied and less consistent.To determine to the effect of ETS on perinatal outcomes.Medline, EMBASE and reference lists were searched.Studies comparing ETS-exposed pregnant women with those unexposed which adequately addressed active maternal smoking.Two reviewers independently assessed titles, abstracts, full studies, extracted data and assessed quality. Dichotomous data were pooled using odds ratios (OR) and continuous data with weighted mean differences (WMD) using a random effects model.Seventy-six articles were included with a total of 48,439 ETS-exposed women and 90,918 unexposed women. ETS-exposed infants weighed less [WMD -60 g, 95% confidence interval (CI) -80 to -39 g], with a trend towards increased low birthweight (LBW,2,500 g; RR 1.16; 95% CI 0.99-1.36), although the duration of gestation and preterm delivery were similar (WMD 0.02 weeks, 95% CI -0.09 to 0.12 weeks and RR 1.07; 95% CI 0.93-1.22). ETS-exposed infants had longer infant lengths (1.75 cm; 95% CI 1.37-2.12 cm), increased risks of congenital anomalies (OR 1.17; 95% CI 1.03-1.34) and a trend towards smaller head circumferences (-0.11 cm; 95% CI -0.22 to 0.01 cm).ETS-exposed women have increased risks of infants with lower birthweight, congenital anomalies, longer lengths, and trends towards smaller head circumferences and LBW.