Maternal obesity and depression reported at the first antenatal visit.

BACKGROUND: Maternal obesity and depression are common and both have been associated with adverse pregnancy outcomes. AIMS: The aim of this observational study was to examine the relationship between maternal body mass index (BMI) category and self-reported depression at the first antenatal visit. METHODS: Women who delivered a baby weighing ≥ 500 g over nine years 2009-2017 were included. Self-reported sociodemographic and clinical details were computerised at the first antenatal visit by a trained midwife, and maternal BMI was calculated after standardised measurement of weight and height. RESULTS: Of 73,266 women, 12,304 (16.7%) had obesity, 1.6% (n = 1126) reported current depression and 7.5% (n = 3277) multiparas reported a history of postnatal depression. The prevalence of self-reported maternal depression was higher in women who had obesity, > 35 years old, were socially disadvantaged, smokers, had an unplanned pregnancy and used illicit drugs. After adjustment for confounding variables, obesity was associated with an increased odds ratio (aOR) for current depression in both nulliparas (aOR 1.7, 95% CI 1.3-2.3, p < 0.001) and multiparas (aOR 1.8, 95% CI 1.5-2.1, p < 0.001) and postnatal depression in multiparas (aOR 1.4, 95% CI 1.3-1.5, p < 0.001). The prevalence of current depression was higher in women with moderate/severe obesity than in women with mild obesity (both p < 0.001). CONCLUSIONS: We found that self-reported maternal depression in early pregnancy was independently associated with obesity. The prevalence of depression increased with the severity of obesity. Our findings highlight the need for implementation of strategies and provision of services for the prevention and treatment of both obesity and depression.

The interaction between maternal smoking, illicit drug use and alcohol consumption associated with neonatal outcomes.

BACKGROUND: The adverse effects of smoking on neonatal outcomes, such as small-for-gestational-age (SGA), has been extensively studied however, the consequences of smoking combined with alcohol and/or drug use is less clear. METHODS: This retrospective observational study analyzed clinical and sociodemographic details of 40156 women who delivered a singleton baby between the years 2011 and 2015. RESULTS: Compared with women who had never smoked, smokers who did not engage in alcohol or drug use had an odds ratio (OR) of delivering a baby who was SGA of 3.2 (95% CI: 3.1-3.5). Smokers who used illicit drugs in isolation or in combination with alcohol during pregnancy had higher ORs for SGA (1.4, 95% CI: 1.1-1.7, P = 0.006 and 1.8, 95% CI: 1.2-2.7, P = 0.007) compared to women who smoked but did not engage in alcohol or drug use in pregnancy. These women also delivered babies with lower mean birthweights (125 g, P < 0.001 and 181.4 g, P = 0.003) and head circumferences (0.4 cm, P < 0.001 and 0.3 cm, P = 0.048). Women who smoked and used alcohol, but not illicit drugs were not associated adverse outcomes above that of smoking in isolation. CONCLUSION: Illicit drug use combined with maternal smoking during pregnancy increases the risk of adverse neonatal outcomes above that of smoking in isolation.

Does maternal obesity explain trends in caesarean section rates? Evidence from a large Irish maternity hospital.

BACKGROUND: A feature of contemporary obstetrics in wealthy countries has been both the continuing increase in caesarean section (CS) rates and the emergence of high levels of maternal obesity. AIMS: The purpose of this study was to examine whether the increasing CS rate in a large university maternity hospital was attributable in part to maternal obesity. METHODS: We studied all women who delivered a baby weighing ≥ 500 g from 2009 to 2014 in one of the largest maternity hospitals in Europe. Logistic regression techniques were employed to examine the contribution of trends in maternal BMI on the prevalence of CS. RESULTS: Obese women were more likely to be delivered by CS in 2014 than in 2009. Multivariate analysis shows that the increase in CS rates could not be explained by changes in obesity levels in either nulliparas or multiparas. The increase in CS rates during the 6 years was strongly associated with advancing maternal age, particularly for nulliparas. CONCLUSIONS: The study found that although the prevalence of being overweight or obese changed little over the period, the odds of having a CS if a woman is obese have increased for multiparas. For nulliparas, increasing CS rates were found to be strongly associated with an increase in maternal age over the period which is important because of the evidence that Irish women are choosing to defer having their first baby until later in life.

A Medically Supervised Pregnancy Exercise Intervention in Obese Women: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether an intensive, medically supervised exercise intervention improved maternal glycemia and gestational weight gain in obese pregnant women when compared with routine prenatal care. METHODS: This randomized controlled trial compared a medically supervised exercise intervention with routine prenatal care. The primary outcome was a reduction in mean maternal fasting plasma glucose in the intervention group by 6.9 mg/dL at the time of a 75-g oral glucose tolerance test at 24-28 weeks of gestation. Secondary outcomes included excessive gestational weight gain. The intervention consisted of 50-60 minutes of exercise: warm-up, resistance or weights, aerobic exercises, and cool-down. All women received routine prenatal care. Power calculation determined that 24 women were required per group to detect a difference of 6.9 mg/dL in fasting plasma glucose between groups based on an independent-sample t test for statistical power of 80% at a type I error rate of 0.05. A sample size of 44 per group was planned to allow a dropout rate of 33%. RESULTS: From November 2013 through August 2015, 88 women were randomized: 44 each to the exercise and control groups. Eight women in the control group and 11 in the intervention group did not complete the trial at 6 weeks postpartum (P=.61), but 43 in each group attended the 24- to 28-week glucose screen. There were no baseline maternal differences between groups. Classes commenced at a mean of 13 4/7±1 2/7 weeks of gestation. In early pregnancy, 51.1% (n=45/88) had an elevated fasting plasma glucose (92-125 mg/dL). There was no difference in the mean fasting plasma glucose at 24-28 weeks of gestation: 90.0±9.0 mg/dL (n=43) compared with 93.6±7.2 mg/dL (n=43) (P=.13) or in the incidence of gestational diabetes mellitus at 24-28 weeks of gestation: 48.8% (n=21/43) compared with 58.1% (n=25/43) (P=.51) in the control and exercise groups, respectively. At 36 weeks of gestation, excessive gestational weight gain greater than 9.1 kg was lower in the exercise group, 23.5% compared with 45.2% in the control group (P<.05). CONCLUSION: An intensive, medically supervised exercise intervention for obese women from early pregnancy did not improve maternal glycemia. Pregnant women who are obese, however, should be advised to exercise because it attenuates excessive gestational weight gain. CLINICAL TRIAL REGISTRATION: International Standard Randomised Controlled Trials (ISRCTN) registry, ISRCTN 31045925.

Maternal body mass index and the prevalence of spontaneous and elective preterm deliveries in an Irish obstetric population: a retrospective cohort study.

OBJECTIVE: To estimate the association between maternal body mass index (BMI) and risk of spontaneous preterm delivery (sPTD) and elective preterm delivery (ePTD) in singleton and multiple pregnancies. DESIGN: Retrospective cohort study. SETTING: Electronic records of all deliveries from 2009 through 2013 in a tertiary university hospital were abstracted for demographic and obstetrical information. PARTICIPANTS: A total of 38 528 deliveries were included. Participants with missing data were excluded from the study. BMI was calculated from the measurement of height and weight at the first prenatal visit and categorised. Sonographic confirmation of gestational age was standard. OUTCOME MEASURES: Primary outcomes, sPTD and ePTD in singleton and multiple pregnancies, were evaluated by multinomial logistic regression analyses, stratified by parity, controlling for confounding variables. RESULTS: Overall rate of PTD was 5.9%, from which 2.7% were sPTD and 3.2% ePTD. The rate of PTD was 50.4% in multiple pregnancies and 5.0% in singleton pregnancies. The risk of sPTD was increased in obese nulliparas (adjusted OR (aOR) 2.8, 95% CI 1.7 to 4.4) and underweight multiparas (aOR 2.2, 95% CI 1.3 to 3.8). The risk of ePTD was increased in underweight nulliparas (aOR 1.8; 95% CI 1.04 to 3.4) and severely obese multiparas (aOR 1.4, 95% CI 1.02 to 3.8).Severe obesity increased the risk of both sPTD (aOR 1.4; 95% CI 1.01 to 2.1) and ePTD (aOR 1.4; 95% CI 1.1 to 1.8) in singleton pregnancies. Obesity did not influence the rate of either sPTD or ePTD in multiple pregnancies. CONCLUSION: Maternal obesity is an independent risk factor for PTD in singleton pregnancies but not in multiple pregnancies. Obesity and nulliparity increase the risk of sPTD, whereas obesity and multiparity increase the risk of ePTD.

The Prevention of Gestational Diabetes Mellitus With Antenatal Oral Inositol Supplementation: A Randomized Controlled Trial.

OBJECTIVE: This study investigated if inositol in a combination of myo-inositol and D-chiro-inositol would prevent gestational diabetes mellitus (GDM) in women with a family history of diabetes. RESEARCH DESIGN AND METHODS: This was a randomized controlled trial that examined whether inositol from the first antenatal visit prevents GDM. The trial was carried out in a single-center tertiary referral center. Women with a family history of diabetes were enrolled at the first antenatal visit. They were randomized to the intervention group, which received a combination of 1,100 mg myo-inositol, 27.6 mg D-chiro-inositol, and 400 µg folic acid, or to the control group, which received 400 µg folic acid only. All women had an oral glucose tolerance test between 24 and 28 weeks' gestation. The primary end point was the incidence of GDM. Statistical analysis was carried out using SPSS Statistical Package version 20. RESULTS: Two hundred forty women, 120 in each arm, were recruited between January 2014 and July 2015. There were no differences in characteristics between the groups. The incidence of GDM was 23.3% (n = 28) in the intervention group compared with 18.3% (n = 22) in the control group (P = 0.34). The mean fasting plasma glucose at the glucose tolerance test was 81 mg/dL in both groups. CONCLUSIONS: Commencing an inositol combination in early pregnancy did not prevent GDM in women with a family history of diabetes. Further studies are required to examine whether inositol supplements at varying doses may prevent GDM.

Impact of Implementing Preanalytical Laboratory Standards on the Diagnosis of Gestational Diabetes Mellitus: A Prospective Observational Study.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with adverse pregnancy outcomes, but risk is reduced with identification and early treatment. Glucose measurements are affected by preanalytical sample handling, such as temperature of storage, phlebotomy-analysis interval, and use of a glycolysis inhibitor. We evaluated glucose concentrations and the incidence of GDM after strict implementation of the American Diabetes Association (ADA) preanalytical guidelines, compared with usual hospital conditions. METHODS: Women screened selectively for GDM at 24-32 weeks' gestation were recruited at their convenience before a 75-g oral glucose tolerance test. Paired samples were taken: the first sample followed ADA recommendations and was transferred to the laboratory on an iced slurry for immediate separation and analysis (research conditions), and the second sample was not placed on ice and was transferred according to hospital practice (usual conditions). RESULTS: Of samples from 155 women, the mean fasting, 1-h, and 2-h results were 90.0 (12.6) mg/dL [5.0 (0.7) mmol/L], 142.2 (43.2) mg/dL [7.9 (2.4) mmol/L], and 102.6 (32.4) mg/dL [5.7 (1.8) mmol/L], respectively, under research conditions, and 81 (12.6) mg/dL [4.5 (0.7) mmol/L], 133.2 (41.4) mg/dL [7.4 (2.3) mmol/L], and 99 (32.4) mg/dL [5.5 (1.8) mmol/L] under usual conditions (all P < 0.0001). GDM was diagnosed in 38.1% (n = 59) under research conditions and 14.2% (n = 22) under usual conditions (P < 0.0001). The phlebotomy-analysis interval for the fasting, 1-h, and 2-h samples was 20 (9), 17 (10), and 17 (9) min under research conditions and 162 (19), 95 (23), and 32 (19) min under usual conditions (all P < 0.0001). All cases of GDM were diagnosed on fasting or 1-h samples; the 2-h test diagnosed no additional cases. CONCLUSIONS: Implementation of ADA preanalytical glucose sample handling recommendations resulted in higher mean glucose concentrations and 2.7-fold increased detection of GDM compared with usual hospital practices.

The clinical outcomes of unplanned pregnancy in severely obese women.

OBJECTIVE: The objective of this study was to compare the clinical outcomes of unplanned pregnancies among severely obese women with those of planned pregnancies. METHODS: This prospective cohort study included severely obese women (Body Mass Index [BMI] ≥ 40.0 kg/m(2)) who delivered a baby weighing ≥ 500 g over 5 years 2009-2013 in a large university hospital. Maternal weight and height were measured and BMI was calculated at the first prenatal visit. RESULTS: Of the 650 women, the mean BMI was 43.8 kg/m(2), mean age was 31.6 years, and 30.0% (n = 195) were nulliparous. Prenatal complications including gestational diabetes mellitus (GDM), hypertensive and thromboembolic disorders occurred in 56.6% (n = 368). Compared with planned pregnancies (58.2%, n = 378), those that were unplanned (41.8%, n = 272) were associated with increased prepregnancy risk factors including essential hypertension (4.0% versus 1.6%, p = 0.03) and depression (6.6% versus 3.2%, p = 0.03). Unplanned pregnancy was associated with a higher macrosomia rate (birthweight > 4.5 kg) compared with planned pregnancies (p = 0.03). This was not explained by a higher GDM rate in unplanned pregnancies. Compared with planned pregnancies, unplanned pregnancies were not associated with increased adverse fetomaternal outcomes. CONCLUSION: Despite increased prepregnancy risk factors, in severely obese women, unplanned pregnancies were not associated with increased prenatal complications or adverse pregnancy outcomes compared with planned pregnancies.

An analysis of folic acid supplementation in women presenting for antenatal care.

BACKGROUND: Neural tube defects (NTDs) are major congenital malformations that are potentially preventable if the woman takes periconceptional folic acid (FA) supplements. A recent report found that NTD incidence had increased in Ireland. This study examined the usage of FA supplementation in women presenting for antenatal care in a maternity hospital. METHODS: Women were recruited at their convenience in the first trimester. Their clinical and sociodemographic details were computerized. Maternal weight and height were measured before calculating body mass index. Detailed FA questionnaires were completed under supervision of a trained researcher. RESULTS: While 96.1% (n = 564) out of 587 reported that they took FA after they became pregnant, only 24.7% (n = 145) took it for >12 weeks preconceptionally as recommended. Only 5.7% (n = 6) of obese women took high-dose FA as recommended. On univariate analysis, the strongest predictors of preconceptional FA usage were higher maternal age, higher education and income, being married, being nulliparous, not smoking, infertility treatment and planned pregnancy. On multivariate analysis, both planned pregnancy and nulliparity were the most important predictors of preconceptional FA use. CONCLUSIONS: Our study shows that current recommendations to prevent NTDs by FA supplementation pre-pregnancy are not being fully implemented in Ireland. We recommend a review of current public health policies on FA supplementation.

Trends in maternal obesity in a large university hospital 2009-2013.

INTRODUCTION: Maternal obesity has been identified as an important clinical priority in contemporary obstetrics. This study aimed to determine the incidence of maternal obesity in early pregnancy and track recent trends in body mass index (BMI) categories over 5 years 2009-2013. MATERIAL AND METHODS: This prospective observational study included all women who delivered an infant weighing ≥500 g during the 5 years 2009-2013 in a large university teaching hospital in Ireland. Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Trends in maternal obesity were tracked over 5 years and epidemiological associations with obesity were examined using logistic regression, adjusted for confounding variables. RESULTS: Of 42 362 women, 99.0% (n = 41 927) were eligible for analysis with a mean BMI of 25.5 kg/m(2) , mean age of 30.7 years and 40.7% (n = 17054) primigravidas. The absolute number of cases of severe obesity (BMI ≥40.0 kg/m(2) ) increased by 48.5% from 2009 to 2013 (p < 0.001). After multivariate logistic regression analyses, obesity incidence increased with increasing parity, advancing age and socioeconomic disadvantage. The maternal obesity rate among women born in the 13 European Union Accession countries was 8.6%, nearly half that of those born in existing European Union countries (p < 0.001). CONCLUSION: It is concerning that while the overall obesity rate remained stable, the number of cases of severe obesity increased over 5 years. We recommend renewed public health efforts addressing obesity rates before pregnancy and reinforcing attempts to optimize a woman's weight after delivery.

The relationship between unplanned pregnancy and maternal body mass index 2009-2012.

OBJECTIVE: To analyse the relationship between unplanned pregnancy and maternal Body Mass Index (BMI). METHODS: A prospective case-control study of planned vs. unplanned pregnancies among women who delivered an infant weighing ≥ 500 g during the four years 2009-2012 in a large maternity hospital in Ireland. Maternal weight and height were measured at the first antenatal visit before calculation of BMI. Clinical and sociodemographic details were computerised. BMI was categorised according to the World Health Organization. The epidemiological associations were examined using logistic regression, adjusted for confounding variables. RESULTS: Between 2009 and 2012, 34,377 women were included, 31.7% (n = 10,894) reported an unplanned pregnancy and 16.6% (n = 5647) were obese. The odds ratios of unplanned pregnancy were greater among obese women compared with those of normal BMI (unadjusted Odds Ratio (OR) 1.3; 95% Confidence Interval (CI) 1.3-1.4 p < 0.001). These ratios increased with increasing BMI (mild unadjusted OR 1.3; CI 1.2-1.4 p < 0.001; moderate unadjusted OR 1.4; CI 1.2-1.6 p < 0.001; severe obesity unadjusted OR 1.7; CI 1.4-2.0 p < 0.001). The higher rate of unplanned pregnancy among obese women was associated with a lower rate of contraception usage and a higher rate of contraceptive failure. Only 37.6% (n = 2112) of obese women took preconceptional folic acid to prevent neural tube defects compared with 46.1% (n = 8176) of women with a normal BMI (p < 0.001). CONCLUSION: Higher rates of unplanned pregnancy among obese women compared with women with a normal BMI is associated with compromised prepregnancy care in this high-risk population.

Maternal folic acid supplementation trends 2009-2013.

OBJECTIVE: We analyzed trends in folic acid supplementation among women booking for antenatal care between 2009 and 2013. DESIGN: Prospective observational study. SETTING: Large university teaching hospital. POPULATION: We included all women who delivered an infant ≥500 g from 1 January 2009 to 31 December 2013. METHODS: Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Multivariate logistic regression analyses were applied to determine the correlates of periconceptional folic acid supplementation. MAIN OUTCOME MEASURES: Rates and correlates of folic acid supplementation. RESULTS: Of 42 362 women, 99.2% (n = 42 042) were suitable for analysis. The mean age was 30.7 years and mean body mass index was 25.6 kg/m(2) , 40.7% (n = 17 054) were primigravidas and 70.6% (n = 29 741) were Irish-born. Overall, 43.9% (n = 18 473) took periconceptional (preconceptional and postconceptional) folic acid, 49.4% (n = 20 782) took postconceptional folic acid only, and 6.6% (n = 2787) took no folic acid. The women most likely to take folic acid were those who planned their pregnancy and were >30 years old, non-obese, Irish-born and employed professionally. The periconceptional folic acid rate decreased from 45.1% in 2009 to 43.1% in 2013 (p = 0.01). Over five years, periconceptional folic acid supplementation decreased among women who were multiparous (43.8-41.6%, p = 0.02), aged 30-39 years (58.9-55.0%, p < 0.001), Irish-born (50.1-47.1%, p < 0.001) and obese (38.6-36.9%, p = 0.02). CONCLUSION: Overall, the rate of periconceptional folic acid supplementation decreased in the five years 2009-2013, particularly among women who were multiparous, aged 30-39 years, Irish-born and obese.

Maternal bacteremia and the Irish maternity early warning system.

OBJECTIVE: To assess whether introduction of the Irish maternity early warning system (IMEWS) in 2013 has improved the recording of vital signs among women with proven maternal bacteremia. METHODS: In a mixed retrospective and prospective study at a single center in Dublin, Ireland, the patient records of all cases of maternal bacteremia between January 1, 2009, and March 31, 2014, were reviewed. The IMEWS chart was applied retrospectively to records of vital signs from January 2009 to March 2013, and prospectively from April 2013 to March 2014. RESULTS: For the 61 cases from the period before IMEWS introduction, vital signs were recorded inconsistently on multiple pages. The frequency of recordings was not standardized. Respiratory rate, in particular, was under-recorded. Among the 17 cases between April 2013 and March 2014 that were eligible for IMEWS chart use, 14 women had vital signs recorded on an IMEWS chart. As compared with the period before IMEWS introduction, there was an improvement in respiratory rate recording as part of the first set of observations. CONCLUSION: Among pregnant women with proven bacteremia, introduction of IMEWS has been associated with an improvement in the recording of vital signs, particularly respiratory rate.

The interplay between maternal obesity and gestational diabetes mellitus.

There is a strong epidemiological association between maternal obesity and gestational diabetes mellitus (GDM). Since the publication of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study on women with mild hyperglycemia in 2008, new criteria have been introduced in maternity services internationally for the diagnosis of GDM. As a result, the diagnosis of GDM may be made in one-third of obese women (n=68). The aim of this review was to examine the interplay between maternal obesity and GDM in light of the HAPO study and the subsequent revised diagnostic criteria. Obesity and GDM are important obstetric risk factors because they both are potentially modifiable. However, the new international criteria for the diagnosis of GDM have serious resource implications for maternity services provided to the large number of women attending for care in developed countries. Further consideration needs to be given as to whether obese women with mild hyperglycemia need to be referred to a multidisciplinary team antenatally if they do not require insulin treatment.

A longitudinal study of unplanned pregnancy in a maternity hospital setting.

OBJECTIVE: To review family planning in a cohort of women who delivered a second child within 3 years of their first. METHODS: A longitudinal, observational study included women aged at least 18 years who had delivered a singleton weighing at least 500 g in 2009 after their first pregnancy at a hospital in Dublin, Ireland, and who returned to the hospital for prenatal care for a second pregnancy before January 2012. Logistic regression analyses were performed to examine the effect of maternal characteristics on pregnancy intention. RESULTS: Of 3284 primigravidas who delivered in 2009, 1220 (37.1%) returned with a second pregnancy. The second pregnancy was unplanned in 248 (20.3%) women, and both pregnancies were unplanned in 124 (10.2%). The second pregnancy was more likely to be unplanned in women whose first pregnancy was also unplanned than in those whose first was planned (adjusted odds ratio 6.5; 95% confidence interval 4.6-8.4; P<0.001). Among the 99 women with recurrent unplanned pregnancy who had not been using contraception before the first pregnancy, 85 (85.9%) were also not using contraception before the second. CONCLUSION: Women whose first pregnancy is unplanned are at increased risk of subsequent unplanned pregnancies. Postnatal contraceptive advice in this high-risk group should be prioritized.