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Background Approximately one in five pregnant women have obesity. Obesity is associated with an increased risk of antenatal, intrapartum, and perinatal complications, but many women with obesity have uncomplicated pregnancies. At a time where maternity services are advocating for women to make informed choices, knowledge of the chance of having an uncomplicated (healthy) pregnancy is essential. The objective of this study was to calculate the rate of uncomplicated pregnancy in women with obesity and evaluate factors associated with this outcome. Methods This prospective cohort study was conducted using the Ontario birth registry dataset in Canada (703,115 women, April 2012–March 2017). The rate of uncomplicated or complicated composite pregnancy outcomes (hypertensive disorders of pregnancy, gestational diabetes, preterm birth, neonate small- or large- for gestational age at birth, congenital anomaly, fetal death, antepartum bleeding or preterm prelabour membrane rupture) were calculated for women with and without obesity. Associations between uncomplicated pregnancy and maternal characteristics were explored in a population of women with obesity but without other pre-existing co-morbidities (e.g., essential hypertension) or obstetric risks identified in the first trimester (e.g., multiple pregnancy), using log binomial regression analysis. Results Of the studied Ontario maternity population (body mass index not missing) 17·7% (n = 117,236) were obese. Of these 20·6% had pre-existing co-morbidities or early obstetric complicating factors. Amongst women with obesity but without early complicating factors, 58·2% (n = 54,191) experienced pregnancy without complication; this is in comparison to 72·7% of women of healthy weight and no early complicating factors. Women with obesity and no early pregnancy complicating factors are more likely to have an uncomplicated pregnancy if they are multiparous, younger, more affluent, of White or Black ethnicity, of lower weight, with normal placental-associated plasma protein-A and/or spontaneously conceived pregnancies. Conclusions The study demonstrates that over half of women with obesity but no other pre-existing medical or early obstetric complicating factors, proceed through pregnancy without adverse obstetric complication. Care in lower-risk settings can be considered as their outcomes appear similar to those reported for low-risk nulliparous women. Further research and predictive tools are needed to inform stratification of women with obesity.

Objectives: The aim of this study was to compare the standard ultrasound (US) estimated fetal weight (EFW) and MRI volume-derived methods for the midtrimester fetus. Methods: Twenty-five paired US and MRI scans had the EFW calculated (gestational age [GA] range = 20–26 weeks). The intra- and interobserver variability of each method was assessed (2 operators/modality). A small sub-analysis was performed on 5 fetuses who were delivered preterm (mean GA 29 +3 weeks) and compared to the actual birthweight. Results: Two MRI volumetry EFW formulae under-measured compared to US by −10.9% and −14.5% in the midpregnancy fetus (p < 0.001) but had excellent intra- and interobserver agreement (intraclass correlation coefficient = 0.998 and 0.993). In the preterm fetus, the mean relative difference (MRD) between the MRI volume-derived EFW (MRI-EFW) and actual expected birthweight (at the scan GA) was −13.7% (−159.0 g, 95% CI: −341.7 to 23.7 g) and −17.1% (−204.6 g, 95% CI: −380.4 to −28.8 g), for the 2 MRI formulae. The MRD was smaller for US at 5.3% (69.8 g, 95% CI: −34.3 to 173.9). Conclusions: MRI-EFW results should be interpreted with caution in midpregnancy. Despite excellent observer agreement with MRI volumetry, refinement of the EFW formula is needed in the second trimester, for the small and for the GA and preterm fetus to compensate for lower fetal densities.

Objective Identify early pregnancy associations of congenital heart disease (CHD) in a multiethnic cohort. Methods This retrospective observational cohort study compared the general obstetric population to women who gave birth at a referral centre in Australia between 2012 and 2017, after 20 weeks' of gestation, with a pregnancy affected by CHD. We defined mood disorder and anxiety as a history of self-reported or medically diagnosed anxiety, depression, postpartum depression or bipolar disorder. Results We compared epidemiological factors between 30 842 general obstetric patients and 470 obstetric patients with a fetus affected by CHD. Multivariate analysis showed independent associations between CHD and use of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) in the first trimester (relative risk [RR] 4.14, 95% CI 2.58-6.65), history of anxiety or mood disorder with no SSRI/SNRI first trimester (RR 2.26, 95% CI 1.82-2.82), folate and/or pregnancy multivitamin use in the first trimester (RR 0.68, 95% CI 0.54-0.86) and increased risk with maternal age >40 years (RR 2.30, 95% CI 1.57-3.38). Conclusions Our data show maternal mood disorders with and without SSRI or SNRI use, maternal age >40 years and lack of multivitamin/folate use to be independently associated with CHD in pregnancy. This article is protected by copyright. All rights reserved.

IntroductionGestational diabetes (GDM) contributes substantially to the population burden of type 2 diabetes (T2DM), with a high long-term risk of developing T2DM. This study will assess whether a structured lifestyle modification programme for women immediately after a GDM pregnancy, delivered via customised text messages and further individualised using data from activity monitors, improves T2DM risk factors, namely weight, physical activity (PA) and diet.Methods and analysisThis multicentre randomised controlled trial will recruit 180 women with GDM attending Westmead, Campbelltown or Blacktown hospital services in Western Sydney. They will be randomised (1:1) on delivery to usual care with activity monitor (active control) or usual care plus activity monitor and customised education, motivation and support delivered via text messaging (intervention). The intervention will be customised based on breastfeeding status, and messages including their step count achievements to encourage PA. Messages on PA and healthy eating will encourage good lifestyle habits. The primary outcome of the study is healthy lifestyle composed of weight, dietary and PA outcomes, to be evaluated at 6 months. The secondary objectives include the primary objective components, body mass index, breastfeeding duration and frequency, postnatal depression, utilisation of the activity monitor, adherence to obtaining an oral glucose tolerance test post partum and the incidence of dysglycaemia at 12 months. Relative risks and their 95% CIs will be presented for the primary objective and the appropriate regression analysis, adjusting for the baseline outcome results, will be done for each outcome.Ethics and disseminationEthics approval has been received from the Western Sydney Local Health District Human Research Ethics Committee (2019/ETH13240). All patients will provide written informed consent. Study results will be disseminated via the usual channels including peer-reviewed publications and presentations at national and international conferences.Trial registration numberACTRN12620000615987; Pre-results.

BackgroundMaternal obesity may increase offspring risk of cardiovascular disease. We assessed the impact of maternal obesity on cardiac structure and function in newborns as a marker of fetal cardiac growth.MethodsNeonates born to mothers of healthy weight (body mass index (BMI) 20–25 kg/m2, n=56) and to mothers who were obese (BMI ≥30 kg/m2, n=31) underwent 25-minute continuous ECG recording and non-sedated, free-breathing cardiac MRI within 72 hours of birth.ResultsMean (SD) heart rate during sleep was higher in infants born to mothers who were versus were not obese (123 (12.6) vs 114 (9.8) beats/min, p=0.002). Heart rate variability during sleep was lower in infants born to mothers who were versus were not obese (SD of normal-to-normal R-R interval 34.6 (16.8) vs 43.9 (16.5) ms, p=0.05). Similar heart rate changes were seen during wakefulness. Left ventricular end-diastolic volume (2.35 (0.14) vs 2.54 (0.29) mL/kg, p=0.03) and stroke volume (1.50 (0.09) vs 1.60 (0.14), p=0.04) were decreased in infants born to mothers who were versus were not obese. There were no differences in left ventricular end-systolic volume, ejection fraction, output or myocardial mass between the groups.ConclusionMaternal obesity was associated with increased heart rate, decreased heart rate variability and decreased left ventricular volumes in newborns. If persistent, these changes may provide a causal mechanism for the increased cardiovascular risk in adult offspring of mothers with obesity. In turn, modifying antenatal and perinatal maternal health may have the potential to optimise long-term cardiovascular health in offspring.

Objective: Nonalcoholic fatty liver disease has been associated with the development of gestational diabetes (GDM). We sought to determine whether abnormal liver enzyme levels and indices of hepatic steatosis and fibrosis in an entire pregnant population are associated with GDM development. Methods: A retrospective cohort study was conducted on adult women (≥18 years) who delivered at 2 teaching hospitals in Sydney Australia from January 2016 to December 2017. Liver enzymes (aspartate aminotransaminase (AST), alanine aminotransaminase (ALT), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), albumin (ALB) and bilirubin (BIL)) obtained 12 months pre-gravid, or during pregnancy but prior to GDM screening, were extracted from the hospital pathology database and linked with oral glucose tolerance test results. The Fibrosis-4 (FIB-4) and Hepatic Steatosis Index (HSI) were calculated. Univariate analysis was undertaken to determine the association between deranged liver enzymes, FIB-4, HSI and GDM. Multiple logistic regression, with adjustment for age, ethnicity, pre-gravid body mass index (BMI), parity, prior GDM and family history of diabetes, was conducted to determine if any of these were independent predictors of GDM. Results: Over 2 years, 1429 women had liver enzymes collected. As per IADPSG (2010) criteria, 255 had diagnosed GDM, of which 82 (32.2%) were obese (BMI >30kg/m2), 243 (82.4%) were multiparous, and 223 (87.5%) had prior GDM. Elevated GGT (>35IU/L, p=0.006) and HSI (p=0.005) were associated with development of GDM, whilst low ALB (110IU/L), ALT (>35IU/L), AST (>35IU/L), BIL (>19umol/L) and FIB-4 were not. On adjustment for confounders, elevated GGT (AOR 1.1, 95% CI 0.32-3.8, p=0.88) and HSI (AOR 0.6, 95% CI 0.26-1.3, p=0.21) were not independent predictors of GDM. Conclusions: Our results indicate deranged liver enzymes or clinical indices of hepatic steatosis and fibrosis were not associated with GDM. Disclosure T. Y. L. Chai: None. D. Pasupathy: None. J. George: None. N. Cheung: None.

IntroductionThe aim of the cervical ripening at home or in-hospital—prospective cohort study and process evaluation (CHOICE) study is to compare home versus in-hospital cervical ripening to determine whether home cervical ripening is safe (for the primary outcome of neonatal unit (NNU) admission), acceptable to women and cost-effective from the perspective of both women and the National Health Service (NHS).Methods and analysisWe will perform a prospective multicentre observational cohort study with an internal pilot phase. We will obtain data from electronic health records from at least 14 maternity units offering only in-hospital cervical ripening and 12 offering dinoprostone home cervical ripening. We will also conduct a cost-effectiveness analysis and a mixed methods study to evaluate processes and women/partner experiences. Our primary sample size is 8533 women with singleton pregnancies undergoing induction of labour (IOL) at 39+0 weeks’ gestation or more. To achieve this and contextualise our findings, we will collect data relating to a cohort of approximately 41 000 women undergoing IOL after 37 weeks. We will use mixed effects logistic regression for the non-inferiority comparison of NNU admission and propensity score matched adjustment to control for treatment indication bias. The economic analysis will be undertaken from the perspective of the NHS and Personal Social Services (PSS) and the pregnant woman. It will include a within-study cost-effectiveness analysis and a lifetime cost–utility analysis to account for any long-term impacts of the cervical ripening strategies. Outcomes will be reported as incremental cost per NNU admission avoided and incremental cost per quality adjusted life year gained.Research ethics approval and disseminationCHOICE has been funded and approved by the National Institute of Healthcare Research Health Technology and Assessment, and the results will be disseminated via publication in peer-reviewed journals.Trial registration numberISRCTN32652461.

The health benefits of breastfeeding are well recognised, but breastfeeding rates worldwide remain suboptimal. Breastfeeding outcomes have yet to be explored among women who give birth to macrosomic (birthweight ≥4000 g) infants, a cohort for whom the benefits of breastfeeding may be particularly valuable, offering protection against later-life morbidity associated with macrosomia. This longitudinal prospective cohort study aimed to identify whether women who give birth to macrosomic infants are at greater risk of breastfeeding non-initiation or exclusive breastfeeding (EBF) cessation. A total of 328 women in their third trimester were recruited from hospital and community settings and followed to 4 months post-partum. Women gave birth to 104 macrosomic and 224 non-macrosomic (

Metabolic-associated fatty liver disease (MAFLD) is a leading cause of chronic liver disease with increasingly recognised associations with gestational diabetes (GDM), including within the antenatal period.To assess the relationship between MAFLD in pregnancy and development of GDM.Fifty pregnant women were enrolled before 24 weeks gestation from a multiethnic obstetrics service in Sydney, Australia. Two FibroScan® assessments were performed, one prior to 24 weeks and one after 30 weeks gestation, to assess hepatic steatosis and stiffness. A control attenuated parameter (CAP) score ≥ 233.5 dB/m signified MAFLD. GDM was determined by an antenatal 75-g oral glucose tolerance testing.Six (12%) women had evidence of FibroScan®-detected MAFLD in early pregnancy, while none had abnormal hepatic stiffness. Sixteen (32%) women developed GDM. No significant difference was observed in GDM rates (50% vs 29.5%; P = 0.37) between those with MAFLD in early pregnancy and those without. At the second scan (completed by 34 women), those who developed GDM had a lower observed mean increase in CAP scores (11.1 ± 23.3 dB/m vs -14.9 ± 26.0 dB/m; P = 0.004) and lower maternal weight gain (0.6 ± 0.2 kg/week vs 0.4 ± 0.2 kg/week; P = 0.04).There was no statistically significant association between FibroScan®-detected MAFLD in early pregnancy and subsequent development of GDM in this pilot study. Maternal weight gain may be associated with changes in the CAP scores, which reflect steatosis, during pregnancy.

Background Waterbirth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits. However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water. This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced waterbirth and the odds of key maternal and neonatal complications associated with giving birth in water. Methods Data were obtained from three population level electronic datasets linked together for the purposes of a national audit of maternity care. The study cohort included women who had no risk factors requiring them to give birth in an obstetric unit according to national guidelines. Multivariate logistic regression models were used to examine maternal (postpartum haemorrhage of 1500mls or more, obstetric anal sphincter injury (OASI)) and neonatal (Apgar score less than 7, neonatal unit admission) outcomes associated with waterbirth. Results 46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 (adjusted odds ratio (adjOR) for age group 35–39 1.27, 95% confidence interval (1.15,1.41)) and less common in women under 25 (adjOR 18–24 0.76 (0.70, 0.82)), those of higher parity (parity ≥3 adjOR 0.56 (0.47,0.66)) or who were obese (BMI 30–34.9 adjOR 0.77 (0.70,0.85)). Waterbirth was also less likely in black (adjOR 0.42 (0.36, 0.51)) and Asian (adjOR 0.26 (0.23,0.30)) women and in those from areas of increased socioeconomic deprivation (most affluent versus least affluent areas adjOR 0.47 (0.43, 0.52)). There was no association between delivery in water and low Apgar score (adjOR 0.95 (0.66,1.36)) or incidence of OASI (adjOR 1.00 (0.86,1.16)). There was an association between waterbirth and reduced incidence of postpartum haemorrhage (adjOR 0.68 (0.51,0.90)) and neonatal unit admission (adjOR 0.65 (0.53,0.78)). Conclusions In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.

Background The use of electronic patient records for assessing outcomes in clinical trials is a methodological strategy intended to drive faster and more cost-efficient acquisition of results. The aim of this manuscript was to outline the data collection and management considerations of a maternity and perinatal clinical trial using data from electronic patient records, exemplifying the DESiGN Trial as a case study. Methods The DESiGN Trial is a cluster randomised control trial assessing the effect of a complex intervention versus standard care for identifying small for gestational age foetuses. Data on maternal/perinatal characteristics and outcomes including infants admitted to neonatal care, parameters from foetal ultrasound and details of hospital activity for health-economic evaluation were collected at two time points from four types of electronic patient records held in 22 different electronic record systems at the 13 research clusters. Data were pseudonymised on site using a bespoke Microsoft Excel macro and securely transferred to the central data store. Data quality checks were undertaken. Rules for data harmonisation of the raw data were developed and a data dictionary produced, along with rules and assumptions for data linkage of the datasets. The dictionary included descriptions of the rationale and assumptions for data harmonisation and quality checks. Results Data were collected on 182,052 babies from 178,350 pregnancies in 165,397 unique women. Data availability and completeness varied across research sites; each of eight variables which were key to calculation of the primary outcome were completely missing in median 3 (range 1–4) clusters at the time of the first data download. This improved by the second data download following clarification of instructions to the research sites (each of the eight key variables were completely missing in median 1 (range 0–1) cluster at the second time point). Common data management challenges were harmonising a single variable from multiple sources and categorising free-text data, solutions were developed for this trial. Conclusions Conduct of clinical trials which use electronic patient records for the assessment of outcomes can be time and cost-effective but still requires appropriate time and resources to maximise data quality. A difficulty for pregnancy and perinatal research in the UK is the wide variety of different systems used to collect patient data across maternity units. In this manuscript, we describe how we managed this and provide a detailed data dictionary covering the harmonisation of variable names and values that will be helpful for other researchers working with these data. Trial registration Primary registry and trial identifying number: ISRCTN 67698474. Registered on 02/11/16.

Background Fetal hydrops is excessive extravasation of fluid into the third space in a fetus, which could be due to a wide differential of underlying pathology. IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked) syndrome primarily affects males. It is a monogenic primary immunodeficiency syndrome of X-linked recessive inheritance due to FOXP3 gene variants. It is characterised by the development of multiple autoimmune disorders in affected individuals. Case presentation We present a rare cause of male fetal hydrops in the context of IPEX syndrome and discuss FOXP3 gene variants as a differential for ‘unexplained’ fetal hydrops that may present after the first trimester. Discussion and conclusions In all similar cases, the pathological process begins during intrauterine life. Furthermore, there are no survivors described. Consequently, this variant should be considered as a severe one, associated with intrauterine life onset and fatal course, i.e., the most severe IPEX phenotype.

Objective To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period. Design Cohort study. Setting Maternity and intensive care units in England and Wales. Population or sample A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit. Methods Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data. Main outcome measures Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth. Results In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups. Conclusions Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission. Tweetable abstract Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.

ObjectiveThe aim of this review was to summarise the current evidence on the costing of resource use within UK maternity care, in order to facilitate the estimation of incremental resource and cost impacts potentially attributable to maternity care interventions.MethodsA systematic review of economic evaluations was conducted by searching Medline, the Health Management Information Consortium, the National Health Service (NHS) Economic Evaluations Database, CINAHL and National Institute for Health and Care Excellence (NICE) guidelines for economic evaluations within UK maternity care, published between January 2010 and August 2019 in the English language. Unit costs for healthcare activities provided to women within the antenatal, intrapartum and postnatal period were inflated to 2018–2019 prices. Assessment of study quality was performed using the Quality of Health Economic Analyses checklist.ResultsOf 5084 titles or full texts screened, 37 papers were included in the final review (27 primary research articles, 7 review articles and 3 economic evaluations from NICE guidelines). Of the 27 primary research articles, 21 were scored as high quality, 3 as medium quality and 3 were low quality. Variation was noted in cost estimates for healthcare activities throughout the maternity care pathway: for midwife-led outpatient appointment, the range was £27.34–£146.25 (mean £81.78), emergency caesarean section, range was £1056.44–£4982.21 (mean £3508.93) and postnatal admission, range was £103.00–£870.10 per day (mean £469.55).ConclusionsWide variation exists in costs applied to maternity healthcare activities, resulting in challenges in attributing cost to maternity activities. The level of variation in cost calculations is likely to reflect the uncertainty within the system and must be dealt with by conducting sensitivity analyses. Nationally agreed prices for granular unit costs are needed to standardise cost-effectiveness evaluations of new interventions within maternity care, to be used either for research purposes or decisions regarding national intervention uptake.PROSPERO registration numberCRD42019145309.

Gestational diabetes mellitus is associated with higher risk for developing type 2 diabetes. Breastfeeding is protective against the development of type 2 diabetes after gestational diabetes. There are no data regarding the effect of breastfeeding on the development of recurrent gestational diabetes.Investigate the relationship of previous breastfeeding duration and intensity with the recurrence of gestational diabetes, and second pregnancy glucose tolerance test results.We conducted a questionnaire-based pilot cohort study, enrolling 210 women during a subsequent second pregnancy, after a gestational diabetes-affected first pregnancy. Models for length and intensity of breastfeeding as predictors of the oral glucose tolerance test and for diagnosis of gestational diabetes in second pregnancy were fitted and then adjusted for possible confounders.Recurrent gestational diabetes rate in the study cohort was 70% (n = 146). In a fully adjusted model high intensity breastfeeding was associated with a lower 2-hour glucose level on the oral glucose tolerance test (by 0.66 mmol/L, 95% CI [0.15-1.17]; p = 0.01) and breastfeeding greater than six months with a lower 1-hour glucose on the oral glucose tolerance test (by 0.67 mmol/L, 95% CI [0.16-1.19]; p = 0.01), compared to women who breastfed less intensively or for a shorter duration respectively. There was an 18% reduction in the risk of gestational diabetes if a woman breastfed for more than six months (RR 0.82, 95% CI [0.69-0.98]; p = 0.03). The association was attenuated in the fully adjusted model (RR 0.89, 95% CI [0.78-1.02]; p = 0.09).We found the risk of recurrent gestational diabetes was reduced by both increased duration and intensity of breastfeeding. Antenatal lactation education should be embedded into care pathways for women diagnosed with gestational diabetes.

Gestational diabetes, the most common medical disorder in pregnancy, is defined as glucose intolerance resulting in hyperglycaemia that begins or is first diagnosed in pregnancy. Gestational diabetes is associated with increased pregnancy complications and long-term metabolic risks for the woman and the offspring. However, the current diagnostic and management strategies recommended by national and international guidelines are mainly focused on short-term risks during pregnancy and delivery, except the Carpenter-Coustan criteria, which were based on the risk of future incidence of type 2 diabetes post-gestational diabetes. In this Personal View, first, we summarise the evidence for long-term risk in women with gestational diabetes and their offspring. Second, we suggest that a shift is needed in the thinking about gestational diabetes; moving from the perception of a short-term condition that confers increased risks of large babies to a potentially modifiable long-term condition that contributes to the growing burden of childhood obesity and cardiometabolic disorders in women and the future generation. Third, we propose how the current clinical practice might be improved. Finally, we outline and justify priorities for future research.

Aims To further explore the relationship between non–alcoholic fatty liver disease (NAFLD) and gestational diabetes mellitus (GDM) by determining the prevalence of GDM in women diagnosed with NAFLD antepartum. Methods Electronic databases were searched using specific keywords. Original studies of adult women reporting NAFLD (confirmed on imaging) and GDM (confirmed via oral glucose tolerance test) prevalence were included. Studies involving women with pre-gestational pre-diabetes, type 1/type 2 diabetes, chronic liver disease/cirrhosis unrelated to NAFLD were excluded. The prevalence of GDM occurring in women with NAFLD was calculated along with pooled odds ratios and 95% confidence intervals (CI) using the random effects model. Results Seven studies (total 2299 participants) were included. The prevalence of GDM in women with NAFLD was 26.0% (95% CI 20.9–31.7%, I2 = 48%, τ2 = 0.06). The odds of having GDM were 2.9 times higher in pregnant women diagnosed with NAFLD compared with non-NAFLD women, although a high degree of heterogeneity existed (unadjusted OR 2.9, 95% CI 1.0–8.4, I2 = 81%, τ2 = 0.83, p Conclusion Our study provides further insight into the prevalence of GDM in pregnant women diagnosed with NAFLD. There is a current lack of well-conducted studies examining this complex association between NAFLD and GDM.

ObjectiveTo describe the accuracy of coding of ethnicity in National Health Service (NHS) administrative hospital records compared with self-declared records in maternity booking systems, and to assess the potential impact of misclassification bias.DesignSecondary analysis of data from records of women giving birth in England (2015–2017).SettingNHS Trusts in England participating in a national audit programme.Participants1 237 213 women who gave birth between 1 April 2015 and 31 March 2017.Primary and secondary outcome measures(1) Proportion of women with complete ethnicity; (2) agreement on coded ethnicity between maternity (maternity information systems (MIS)) and administrative hospital (Hospital Episode Statistics (HES)) records; (3) rates of caesarean section and obstetric anal sphincter injury by ethnic group in MIS and HES.Results91.3% of women had complete information regarding ethnicity in HES. Overall agreement between data sets was 90.4% (κ=0.83); 94.4% when collapsed into aggregate groups of white/South Asian/black/mixed/other (κ=0.86). Most disagreement was seen in women coded as mixed in either data set. Rates of obstetrical events and complications by ethnicity were similar regardless of data set used, with the most differences seen in women coded as mixed.ConclusionsLevels of accuracy in ethnicity coding in administrative hospital records support the use of ethnicity collapsed into groups (white/South Asian/black/mixed/other), but findings for mixed and other groups, and more granular classifications, should be treated with caution. Robustness of results of analyses for associations with ethnicity can be improved by using additional primary data sources.

Pregnancy can alter a woman’s weight gain trajectory across the life course and contribute to the development of obesity through retention of weight gained during pregnancy. This study aimed to identify modifiable determinants associated with postpartum weight retention (PPWR, calculated by the difference in pre-pregnancy and 6 month postpartum weight) in 667 women with obesity from the UPBEAT study. We examined the relationship between PPWR and reported glycaemic load, energy intake, and smoking status in pregnancy, excessive gestational weight gain (GWG), mode of delivery, self-reported postpartum physical activity (low, moderate, and high), and mode of infant feeding (breast, formula, and mixed). At the 6 month visit, 48% (n = 320) of women were at or above pre-pregnancy weight. Overall, PPWR was negative (−0.06 kg (−42.0, 40.4)). Breastfeeding for ≥4 months, moderate or high levels of physical activity, and GWG ≤9 kg were associated with negative PPWR. These three determinants were combined to provide a modifiable factor score (range 0–3), for each added variable, a further reduction in PPWR of 3.0 kg (95% confidence interval 3.76, 2.25) occurred compared to women with no modifiable factors. This study identified three additive determinants of PPWR loss. These provide modifiable targets during pregnancy and the postnatal period to enable women with obesity to return to their pre-pregnancy weight.

Context Offspring exposed in utero to maternal obesity have an increased risk of later obesity; however, the underlying mechanisms remain unknown. Objective To assess the effect of an antenatal lifestyle intervention in obese women on the offspring’s cord blood metabolic profile and to examine associations of the cord blood metabolic profile with maternal clinical characteristics and offspring anthropometry at birth and age 6 months. Design Randomized controlled trial and cohort study. Setting The UK Pregnancies Better Eating and Activity Trial. Participants Three hundred forty-four mother-offspring pairs. Intervention Antenatal behavioral lifestyle (diet and physical activity) intervention. Main Outcome Measures Targeted cord blood metabolic profile, including candidate hormone and metabolomic analyses. Results The lifestyle intervention was not associated with change in the cord blood metabolic profile. Higher maternal glycemia, specifically fasting glucose at 28 weeks gestation, had a linear association with higher cord blood concentrations of lysophosphatidylcholines (LPCs) 16.1 (β = 0.65; 95% confidence interval: 0.03 to 0.10) and 18.1 (0.52; 0.02 to 0.80), independent of the lifestyle intervention. A principal component of cord blood phosphatidylcholines and LPCs was associated with infant z scores of birth weight (0.04; 0.02 to 0.07) and weight at age 6 months (0.05; 0.00 to 0.10). Cord blood insulin growth factor (IGF)-1 and adiponectin concentrations were positively associated with infant weight z score at birth and at 6 months. Conclusions Concentrations of LPCs and IGF-1 in cord blood are related to infant weight. These findings support the hypothesis that susceptibility to childhood obesity may be programmed in utero, but further investigation is required to establish whether these associations are causally related.

Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal–placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.

SUMMARYBackground Haemolytic disease of the fetus and newborn (HDFN) occurs when maternal IgG alloantibodies to fetal red blood cell antigens cross the placenta, causing haemolysis in the fetus and/or neonate. After delivery, the main concern is hyperbilirubinaemia, which can cause neurological damage. Objectives To summarise our current management and outcome data to inform health-care professionals counselling women whose pregnancies are at risk of HDFN and to compare these data with relevant studies. Methods This is a retrospective descriptive study of all high-risk pregnancies at risk of HDFN at Guy's and St. Thomas' NHS Foundation Trust (GSTFT) Maternity Unit over a 7-year period. We defined high-risk pregnancies as those in whom anti-D, anti-c, anti-K or high (>32 or doubling strength) titres of all other antibodies were identified. Results A total of 130 pregnancies in 112 women were followed up. A single alloantibody was found in 93 pregnancies (71.5%) and multiple alloantibodies in 37 pregnancies (28.5%). Anti-D was most commonly encountered (n = 48, 36.9%), followed by anti-c (n = 31, 23.8%) and anti-E (n = 15, 11.5%). In 65 of 130 pregnancies (50%), antibody concentrations triggered scans to screen for fetal anaemia. Of 130 pregnancies, 6 (4.6%) required intrauterine transfusions, and 31 of 130 (26%) neonates required post-natal intervention. Overall, morbidity was 0.1% and mortality 0.002%. Conclusions This study demonstrates that morbidity and mortality caused by HDFN is minimal. These results are reassuring for women at risk of HDFN as even severely affected cases are successfully managed in most instances. Further studies are needed to identify predictors of disease severity.

Current management guidelines of diabetes within pregnancy do not differentiate between the underlying physiological dysfunctions that lead to dysglycaemia and provide generic guidance. Specific forms of diabetes in pregnancy require targeted treatment. Maturity onset diabetes of the young (MODY), caused by single gene mutations, is the most common identifiable variant and presents a significant challenge if the mutation is possessed by mother and not inherited by the fetus. Greater awareness of MODY and its subtypes will allow earlier detection and a better prognosis. Although genetic testing is rare, analysis by clinical phenotyping can provide a sensitive and cost effective solution.

Objectives:Randomised controlled trials are required to address causality in the reported associations between maternal influences and offspring adiposity. The aim of this study was to determine whether an antenatal lifestyle intervention, associated with improvements in maternal diet and reduced gestational weight gain (GWG) in obese pregnant women leads to a reduction in infant adiposity and sustained improvements in maternal lifestyle behaviours at 6 months postpartum.Subjects and methods:We conducted a planned postnatal follow-up of a randomised controlled trial (UK Pregnancies Better Eating and Activity Trial (UPBEAT)) of a complex behavioural intervention targeting maternal diet (glycaemic load (GL) and saturated fat intake) and physical activity in 1555 obese pregnant women. The main outcome measure was infant adiposity, assessed by subscapular and triceps skinfold thicknesses. Maternal diet and physical activity, indices of the familial lifestyle environment, were assessed by questionnaire.Results:A total of 698 (45.9%) infants (342 intervention and 356 standard antenatal care) were followed up at a mean age of 5.92 months. There was no difference in triceps skinfold thickness z-scores between the intervention vs standard care arms (difference −0.14 s.d., 95% confidence interval −0.38 to 0.10, P=0.246), but subscapular skinfold thickness z-score was 0.26 s.d. (−0.49 to −0.02; P=0.03) lower in the intervention arm. Maternal dietary GL (−35.34; −48.0 to −22.67; P

Objective To compare early pregnancy clinical and biomarker risk factors for later development of preeclampsia between women with obesity (body mass index, BMI ≥30 kg/m2 ) and those with a normal BMI (20-25 kg/m2 ). Methods In 3,940 eligible nulliparous women from the Screening for Pregnancy Endpoints (SCOPE) study, a total of 53 biomarkers of glucose and lipid metabolism, placental function, and known markers of preeclampsia were measured at 14 to 16 weeks' gestation. Logistic regression was performed to identify clinical and biomarker risk factors for preeclampsia in women with and without obesity. Results Among 834 women with obesity and 3,106 with a normal BMI, 77 (9.2%) and 105 (3.4%) developed preeclampsia, respectively. In women with obesity, risk factors included a family history of thrombotic disease, low plasma placental growth factor, and higher uterine artery resistance index at 20 weeks. In women with a normal BMI, a family history of preeclampsia or gestational hypertension, mean arterial blood pressure, plasma endoglin and cystatin C, and uterine artery resistance index were associated with preeclampsia, while high fruit intake was protective. Conclusions Women with obesity and a normal BMI have different early pregnancy clinical and biomarker risk factors for preeclampsia.