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Gestational Diabetes Mellitus complicates 2-9% of pregnancies and is associated with obesity and hypertension. Accurate measurement of blood pressure requires the use of an arm cuff customised to the mid-arm circumference (MAC). A large cuff should be used for an MAC > 33.0cm. The authors compared the Mid-Arm Circumference (MAC) between women attending our Diabetic and standard antenatal clinics. After the blood pressure was measured, the MAC was measured. The Body Mass Index (BMI) was calculated at the first antenatal visit. In the standard clinic (n=101), the mean BMI was 25.1kg/m2 and the mean MAC was 28.7cm. In the Diabetic Clinic (n=39), the mean BMI was 29.2kg/m2 and the mean MAC was 31.5cm. The number of women with a MAC >33.0cm was 23% in the Diabetic Clinic compared with 12% in the standard clinic (p 33.0cm while in the BMI >35.0kg/m2 category, 92% had a MAC >33.0cm. Ideally, all women should have a MAC measurement at their initial antenatal visit. Based on this study, 1 in 4 women attending the Diabetic Clinic and 1 in 8 women attending standard antenatal clinics should have their blood pressure measured using a large cuff.

Maternal weight gain during pregnancy is associated with increasing birth weight. It is uncertain how much fat mass (FM) and fat-free mass (FFM) contributes to this association. The authors examined the influence of different maternal body composition parameters on birth weight. The study was confined to non-diabetic Caucasian women with a singleton pregnancy. Weight and height were measured in the first trimester. Maternal body composition was measured at 28 and 37 weeks using advanced bioelectrical impedance analysis. At delivery the baby was weighed and the clinical details recorded. Of the 178 women, the mean body mass index (BMI) was 28.2 kg/m 2 . Birth weight did not correlate with early pregnancy BMI but did correlate with gestational weight gain (r=0.230; p=0.002). Maternal FM did not correlate with birth weight, however maternal FFM did (r=0.247; p In non-diabetic pregnancies gestational weight gain, and not early pregnancy BMI, is the more important determinant of birth weight. Furthermore, it is the increase in maternal fat free mass and not fat mass that influences birth weight.

Objective The objective of this analysis, as part of the multicentre prospective PORTO Trial, was to determine whether increasing maternal BMI decreases the accuracy of sonographic fetal weight estimation in IUGR pregnancies. Study design The PORTO Trial recruited 1,118 consecutive ultrasound-dated singleton IUGR pregnancies, defined as EFW Results Of the 1,076 recruited patients with complete records, 693 (64%) were of normal weight (BMI Conclusion These data show that ultrasound is reliable in the assessment of fetal weight in IUGR in the presence of increased maternal BMI.

Objective The objective of this analysis, as part of the multicentre prospective PORTO Trial, was to study the effect of increasing maternal BMI on perinatal outcome in IUGR pregnancies. Study design The PORTO Trial recruited 1,118 consecutive ultrasound-dated singleton IUGR pregnancies, defined as EFW Results Of the 1,076 recruited patients with complete records, 693 (64%) were of normal weight (BMI Conclusion Maternal obesity has a significant adverse impact on pregnancy outcomes with increased risk of Caesarean delivery, coupled with an increased perinatal morbidity and NICU admission rate.

Background Despite both Ireland and the United Kingdom providing free maternity care to all women, adverse fetal and maternal outcomes remain closely linked to social disadvantage and lack of support during pregnancy. A European survey found 42.4% of respondents had limited functional health literacy, closely liked to economic deprivation. Written information remains the main medium of communication for maternity services. It is likely that many of these messages are not adequately communicated to those most at risk. Objectives This study examined the use of digital media by pregnant women to access healthcare information for pregnancy. Methods A survey was distributed to all antenatal patients attending clinics at a large Dublin maternity hospital. Results Of the 218 women surveyed, 81% attended public clinics and 19% attended private clinics, 60% lived in Dublin and 40% were from surrounding counties, 18% were unemployed. Overall 94% used the internet to access information about pregnancy; 100% of unemployed women use the internet to access healthcare information and 75% of women have a smartphone. Newspapers were read by only 29% of women. All women wanted some form of online/digital support during their pregnancy, including weekly text messages about pregnancy stage-specific issues (cited by 45%), a maternity smartphone App (44%) and a website for feedback regarding their care (42%). Conclusion Digital media use is widespread across all socioeconomic groups. Healthcare communication in pregnancy should focus on digital communication channels.

Objective To profile longitudinal changes in the fetal mid thigh muscle and subcutaneous tissue measurements in fetuses with a normal growth velocity in euglycemic pregnancies and evaluate the association between mid thigh parameters and birthweight. Methods A prospective longitudinal study of 351 singleton fetuses in euglycemic pregnancies. Reliability of fetal abdominal subcutaneous tissue (FAST) measurements and mid thigh indices including thigh muscle (TM) and thigh fat (TF) between two operators was also reviewed. Results The FAST and fetal mid thigh muscle and fat in AGA fetuses show a significant increase with gestational age. At 28 weeks gestation the Abdominal circumference, TF, FAST and EFW centile were all found to be statistically significant predictors of birthweight. Using backwards stepwise linear regression to find the optimal multivariate model for predicting birthweight a combination of EFW centile and TF were found to be the best predictors. At 37 weeks optimal multivariate model for BW prediction was EFW centile, FAST and TF. The results reveal acceptable reproducibility for fetal mid thigh muscle and fat for a single operator and between operators. Conclusion This prospective study provides reference ranges for fetal mid thigh fat and muscle throughout gestation in fetuses with a normal growth velocity. The inclusion of fetal mid thigh fat in the birthweight algorithm improves the predictive power of birthweight estimation at 28 weeks and 37 weeks. This information is important to explore the role of fetal mid thigh in the detection of fetal IUGR at point estimations of EFW within normal centiles.

Objective The objective of this analysis, as part of the multicentre prospective PORTO Trial, was to describe and compare perinatal outcomes of IUGR pregnancies with normal and abnormal umbilical artery (UA) Doppler studies. Study design The PORTO Trial recruited over 1,100 consecutive ultrasound-dated singleton IUGR pregnancies, defined as EFW th centile. All fetuses underwent serial sonographic assessment until birth. Perinatal outcomes were documented for all participants. Results Of the 1,118 recruited patients, 606 (54%) had normal UA Doppler studies and 512 (46%) had abnormal UA Dopplers, defined as UA PI > 95 th centile or AREDF. The group with abnormal UA Doppler was delivered earlier and more commonly by CS, had more admissions to NICU and adverse perinatal outcomes (Table 1). The 4 mortalities with normal Doppler all had EFW rd centile. Conclusion IUGR fetuses with normal UA Doppler studies have better perinatal outcomes than those with abnormal UA Doppler, however adverse perinatal outcome can occur with normal UA in more severe IUGR cases (EFW

Introduction Concerns about maternal obesity have led to new American recommendations on gestational weight gain (GWG). However, there are few prospective longitudinal studies on GWG and changes in maternal body composition as pregnancy advances. This study analysed maternal body composition changes during pregnancy and the puerperium. Methods Women were enrolled at their convenience in the first trimester. Weight and height were measured and Body Mass Index calculated. Maternal body composition was measured using bioelectrical impedance analysis at 9-14 weeks, 16-21 weeks, 23-25 weeks, 28-30 weeks, 32-34 weeks, 37-40 weeks gestation and 12 weeks postpartum. Results There were 101 women enrolled in our study. The mean GWG was 12.2 SD+/- 4.7 kg. GWG was associated with increases in fat and fat-free measurements. Over two thirds of gestational weight gain occurred before the third trimester of pregnancy. There was a greater increase in maternal fat measurements in the second trimester than in the third trimester. There was a greater increase in total body water measurements in the third trimester compared with the second trimester. Of the 74 women that attended at 12 weeks postpartum 7 women weighed less than at their first antenatal visit and the mean weight gain was 4.1 +/- 4.9 kg. More women were overweight or obese postpartum than at the first visit based on their BMI (n=42). Conclusion Maternal body composition changes during pregnancy. GWG can be attributed to fat deposition, increased total body water, and intrauterine growth. These changes can affect overweight and obesity rates.

Objective We evaluated screening with a diagnostic oral glucose tolerance test earlier than 20 weeks gestation in women with moderate to severe obesity. Design Prospective observational study. Setting Large university teaching hospital. Population We enrolled 100 women booking for antenatal care in the first trimester at their convenience. Methods Height and weight were measured and body mass index calculated. Only women with a body mass index > 34.9 kg/m(2) were included. Women were booked for a 100 g oral glucose tolerance test before 20 weeks and, if normal, another test at 28 weeks gestation. Main outcome measures Impaired glucose tolerance and gestational diabetes mellitus. Results Of the 100 women given an appointment for an oral glucose tolerance test before 20 weeks gestation, 92 attended. Of these, 10 (10.8%) women had an abnormal result, with impaired glucose tolerance in five (5.4%) cases and gestational diabetes mellitus in five (5.4%) cases. Of those with a normal result at 20 weeks, 81 attended for a repeat test at 28 weeks gestation. A further four (4.9%) had impaired glucose tolerance and four (4.9%) had gestational diabetes mellitus. A total of 18 (20.5%) of the 88 women who complied with screening had an abnormal test. Conclusions Women who have moderate/severe obesity have a one in five chance of having an abnormal diagnostic oral glucose tolerance test when screened for gestational diabetes mellitus. To optimize maternal glycemic control in pregnancy, we suggest that women with a body mass index > 34.9 kg/m(2) may need to be screened early in pregnancy and, if the test is normal, again at 28 weeks gestation.

Gestational weight gain (GWG) in pregnancy has become an important issue in modern obstetrics. Concerns about rising obesity levels and the effect of excessive GWG are so great that the Institute of Medicine (IOM) has published new guidelines for weight gain during pregnancy. The purpose of this study was to prospectively analyse GWG according to the IOM recommendations for each BMI category. Maternal weight and height were measured and BMI calculated in early pregnancy. Women were recruited at term, weight was measured and GWG calculated. The IOM recommends GWG of 12.7–18.1kg for normal weight, 11.4–15.9kg for overweight and 5.0–9.1kg for obese women. At recruitment women were asked whether they received advice about GWG from a healthcare provider. Of the 604 women enrolled the mean age was 29.5 (5.1) years, the mean parity was 0.8 (SD1.0) and the mean BMI was 26.7 (5.6) kg/m2. The mean GWG was 12.6 (5.7) kg, 11.9 (5.2) kg, and 9.3 (6.6) kg for normal weight, overweight and obese women respectively. Appropriate GWG occurred in 32.9%, 34.1% and 28.1% of the groups respectively. More than the recommended GWG occurred in 10.7%, 20.1% and 53.8% of normal weight, overweight and obese women respectively. Only 6.5% of women received advice on GWG by a healthcare professional. We found that despite lower mean GWG one third of overweight and obese women attending our antenatal services gained more than the IOM recommendations for GWG. Furthermore, very few women received advice regarding GWG in pregnancy.

Pre-eclampsia is a hypertensive disorder unique to pregnancy. Accurate prediction of the development of pre-eclampsia is still elusive. Uterine artery Doppler provides information regarding blood flow within the vascular system. Information on the elasticity in the vessel wall is obtained from pulse pressure analysis. The purpose of this prospective study was to compare uterine artery Doppler indices with pulse pressure waveform analysis in the prediction of pre-eclampsia in low-risk pregnancy. Patients were recruited from the antenatal clinic. Each patient had uterine artery Doppler and pulse pressure waveform analysis performed in the second trimester. Data on pregnancy outcomes were obtained and the main outcome measure was the development of pre-eclampsia. Logistic regression was used to evaluate the parameters as predictors of pre-eclampsia. Forty one patients were recruited into the study. Pre-eclampsia occurred in 2 (4.9%) of the pregnancies which equates to a prior risk of 1 in 21. Small artery elasticity (p=0.02) and systemic vascular resistance (p=0.005) were shown to differ in patients with pre-eclampsia as did the mean arterial pressure (p=0.01). There was no difference seen in uterine artery Doppler pulsatility index in the pre-eclamptic pregnancies compared to normal pregnancy. Pulse pressure waveform analysis shows promise as a screening tool for pre-eclampsia. This study is the first to compare elasticity, using the diastolic phase of the cardiac cycle, and uterine artery Doppler ultrasound in pregnancy as a predictor of pre-eclampsia. A larger study should be undertaken to further evaluate pulse pressure waveform analysis.

Introduction There has been a relentless rise in the caesarean section (CS) rate in Ireland. The reasons for this increase are multifactorial and complex. This prospective observational study examined whether the variation in CS rates in European women can be explained by differences in maternal adiposity. Study design Women were recruited after first trimester sonographic confirmation of an ongoing singleton pregnancy. Maternal adiposity was assessed indirectly by Body Mass Index (BMI) and directly by bioelectrical impedance analysis (BIA). Irish women were compared with other women born in the 14 countries who joined the EU before 2004, and with women born in the countries who joined following enlargement in 2004(EU 12). Results Of the 2811 women enrolled, 2235 women were born in Ireland, 100 in the EU 14 and 476 in the EU 12 countries. Based on a BMI >29.9 kg/m2, maternal obesity was higher in Irish (19.8%) and EU 14(19.0%) women compared with EU 12 women (9.5%), p Conclusion We found variation in CS rates in primigravidas based on the mother9s country of birth, which was associated with maternal adiposity. Differences in maternal adiposity between nationalities may be hereditary in origin, but may be related to prepregnancy lifestyle.

Prediction of hypertensive disease in pregnancy remains a challenge in modern obstetrics. Risk factor based screening, ultrasound and serum markers have been used with varying success. As pre-eclampsia would appear to occur due to changes in the vasculature, the vessel wall has been investigated as a predictor of hypertension in pregnancy. This study looked at pulse pressure wave analysis, using the diastolic portion of the cardiac cycle, in the prediction of hypertensive disease of pregnancy. Women were recruited from the antenatal clinic. Women with known cardiac disease were excluded. All women had pulse pressure waveform analysis performed in the first half of pregnancy. The primary outcome studied was the development of hypertensive disease of pregnancy. Pulse wave analysis was performed on 600 patients. The elasticity of the arterial vessel wall differed in hypertensive pregnancies and in particular in pregnancies subsequently complicated by pre-eclampsia. In early pregnancy, the mean arterial pressure (p=0.02), large artery elasticity (p=0.01), small artery elasticity (p=0.02) and systemic vascular resistance (p=0.02) were all significantly different in women who later developed pre-eclampsia compared to normal pregnancy. In pregnancies complicated by pregnancy induced hypertension, mean arterial pressure measurements were significantly different in early pregnancy but arterial elasticity did not differ. Pulse pressure waveform analysis may be a useful screening tool in the prediction of hypertensive disease and in particular, pre-eclampsia. Use of this technology in combination with other screening tools may aid in the selection of high risk pregnancy for more intensive antenatal care.

Objective The purpose of this study was to examine the influence of obesity on vaginal birth after caesarean section, when body mass index (BMI) was based on the accurate measurement rather than self-reporting of maternal weight and height. Study design We enrolled women at their convenience after a sonogram confirmed an ongoing singleton pregnancy in the first trimester. Weight and height were measured digitally and BMI calculated. Clinical and demographic details were recorded prospectively. Results Out of 2300 women enrolled, 2209 subsequently delivered in the hospital a baby weighing 500 g or more. There were 50.5% (n=1161) primigravidas and 49.5% (n=1139) multigravidas. There were 188 women who had a previous delivery by caesarean section. The overall VBAC success rate in labour was 66.9%. Of the women that attempted a vaginal birth after previous caesarean section the success rate was 63.2% in Class 1 obese women and 80.0% in Class 2–3 obese women compared with 71.4% in women in the normal BMI category. Conclusion Our study showed that successful VBAC rates after one previous caesarean section are similar in obese (BMI>29.9 kg/m2) and non-obese women.

Objective We analysed the influence of body mass index (BMI) on caesarean section (CS) rates when BMI was based on the accurate measurement rather than self-reporting of maternal weight and height. Study design We enrolled women at their convenience after ultrasound confirmed an ongoing pregnancy in the first trimester. Weight and height were measured and BMI calculated. Clinical and demographic details were recorded prospectively. Results Out of 2000 women enrolled, 1927 subsequently delivered in our hospital. There were 50.4% primigravidas and 49.6% multigravidas. The overall CS rate was 21.2%. The incidence of maternal obesity was 17.3%. The CS rate was almost twice as high in obese women compared with women in the normal BMI category. There was a higher rate of emergency sections in obese primigravidas (p In obese primigravidas a CS was required in 20.6% for fetal distress compared with 9.8% in the normal BMI category (p=0.005). This may be due to a higher rate of induction of labour in these women. 17.2% of obese multigravidas had an elective repeat CS compared with 7.7% in the normal weight category. Conclusion Our results suggest that in obese women induction of labour in primigravidas and VBAC rates in multigravidas need further review. The increased CS rate in obese women was less than studies where BMI was based on self-reporting, showing that self-reporting exaggerates the risks of obesity.

Objective The purpose of the study was to examine the relationship between mode of delivery in primigravidas and visceral fat measured in early pregnancy. Study design We enrolled women at their convenience between July 2008 and April 2010 after a sonogram confirmed they had an ongoing singleton pregnancy in the first trimester. Visceral fat was measured using bioelectrical impedence analysis (Tanita 180, Tokyo). Clinical and demographic details were recorded at the first antenatal visit and at delivery. Visceral fat centiles had previously been derived for a white European population.1 Results Out of 1008 primigravidas enrolled, 973 subsequently delivered in the hospital a baby weighing 500 g or more. In women with a visceral fat >7, there was an increase in the mean age, mean birth weight and rate of induction of labour (p=0.01). There was a higher rate of emergency caesarean section in women with a visceral fat measurement >7 compared to women with a visceral fat measurement ≤7 (p=0.01). This was due to higher rates of fetal distress (p=0.01) in labour. Conclusion Our study showed an association between increased caesarean section rates and maternal obesity based on the visceral fat measurement in the first trimester.

Background Hypertension in pregnancy is an important cause of pregnancy complications for both mother and baby in about 8% of pregnancies. Epidemiological reviews have reported an association between pre-eclampsia and maternal obesity, based on a body mass index (BMI) > 29.9 kg/m2. However, BMI measurements were usually based on self-reporting of maternal weight and height which has been shown to be inaccurate, particularly in pregnancy and in obese women. The purpose of this prospective cross-sectional study was to compare the incidence of pre-eclampsia in the different WHO BMI categories in both primigravidas and multigravidas. Methods Women were recruited at their convenience in the first trimester. Height and weight were measured digitally and BMI calculated. Pre-eclampsia was defined as hypertension (a systolic blood pressure of ≥140 mm Hg and/or a diastolic blood pressure of ≥90 mm Hg) measured on at least two separate occasions at least 6 h apart with proteinuria (≥300 mg over 24 h) after 20 weeks. Results Of the 2230 women, the mean age was 28.2 years and mean parity was 1.0. The mean gestation at recruitment was 11.2 weeks and the mean BMI was 25.6 kg/m2. The incidence of obesity was 17.4%. The incidence of pre-eclampsia analysed by BMI category is show in table 1. In both primigravidas and multigravidas, there was no increase in pre-eclampsia with obesity (p=0.23, p=0.07). Conclusions When maternal BMI is calculated accurately in early pregnancy, contrary to previous reports, there is no association between maternal obesity and pre-eclampsia.

Changes in maternal blood pressure are seen in normal pregnancy. Mean arterial pressure falls until the end of the second trimester and then rises again to prepregnancy levels in the late third trimester. The aetiology of hypertensive disease of pregnancy remains elusive but may involve changes in the arterial vessel wall. We investigated what changes in arterial elasticity occur during pregnancy. Subjects were recruited from the antenatal clinic at their first visit to the hospital. Using the HDI/Pulsewave CR-2000 Research Cardiovascular Profiling System, we analysed the radial artery pulse pressure waveform on 660 occasions in 100 uncomplicated pregnancies between 8 and 40 weeks gestation. Reflective and capacitive arterial compliance was calculated from the pulse pressure waveform contour using a modified Windkessel model of the circulation (electrical analogue model). Centiles for artery elasticity throughout gestation were calculated and fitted using linear mixed effect modelling appropriate to longitudinal data. We found that reflective arterial compliance changes with advancing gestation. The median reflective arterial compliance is 7.6 ml/mm Hg×100 at 16 weeks gestation rising to a peak of 7.8 ml/mm Hg×100 at 20 weeks gestation and then declining to a median value of 5.8 ml/mm Hg×100 at 40 weeks gestation. We also found that capacitive artery elasticity only changes minimally with advancing gestation with a median value of 13.3 ml/mm Hg×10 at all gestations. Changes in small artery vessel wall elasticity are reciprocal to the changes in blood pressure throughout pregnancy. The increase in elasticity seen in the second trimester may contribute to the fall in mean arterial pressure. Further study is needed to clarify the aetiology of these physiological changes.

Maternal obesity has emerged as a major public health issue however, a paucity of information regarding Body Mass Index (BMI) and body composition specifically in fathers during pregnancy. This study aims to determine the BMI and the body composition of fathers-to-be and to compare the findings with the mother-to-be during pregnancy. The authors conducted a prospective observational study in a large university teaching hospital. The authors enrolled men whose partner booked for antenatal care in the first trimester of pregnancy. The height and weight of both parents-to-be were measured digitally and BMI calculated. The body composition of the couple was analysed using bioelectrical impedance. Of 167 fathers-to-be, 14% were obese (BMI >29.9 kg/m2) compared with 16% of mothers-to-be (NS). However, 50% were overweight (BMI 25.0 – 29.9 kg/m2) compared with 26% of mothers-to-be (p Our findings show a high level of obesity in fathers-to-be, which has implications not only for the men themselves but also their families. The authors suggest that public health obesity interventions may need to be family-centred.

Maternal obesity is associated with an increase in childhood obesity, but causation remains uncertain. The authors studied the relationship between maternal and fetal body composition in the third trimester. The study was confined to Caucasian non-diabetic women with a singleton pregnancy. Weight and height were measured in the first trimester. At 28- and 37-week maternal body composition was analysed using advanced bioelectrical impedance, and fetal parameters and soft tissue measurements were measured by ultrasound. Of the 178 women, the mean body mass index was 28.2 kg/m2 and 66.7% were obese. Fetal adiposity measurements at 28-week gestation did not correlate with maternal body composition. The fetal abdominal circumference (AC) and not abdominal adiposity at 37 weeks correlated with maternal fat mass (FM). Fetal thigh adiposity at 37 weeks correlated with maternal FM. Increase in maternal arm FM and not leg FM correlated with the AC and fetal thigh adiposity measurements at 37 weeks. Fetal AC and thigh adiposity measurements are influenced by maternal obesity. This supports that the intrauterine environment predisposes the fetus to childhood obesity.