Search

Aims To evaluate the effect of maternal body mass index (BMI) on gestational diabetes (GDM) and the risk of adverse pregnancy outcomes in women who are overweight or obese. Methods A prospective cohort study nested within the LIMIT randomised controlled trial. A total of 1030 women were recruited between 10 and 20 weeks’ gestation, with a BMI ≥ 25 kg/m2, and were grouped into BMI subclasses utilising World Health Organisation criteria. Women underwent a fasting oral glucose tolerance test at 26–28 weeks’ gestation, and a diagnosis of GDM was made if fasting blood glucose was ≥5.5 mmol/L or ≥7.8 mmol/L after 2 h. Maternal and neonatal health outcomes were evaluated. Results The prevalence of GDM increased with increasing maternal BMI (6.74% overweight vs 13.42% obese subclass 1 vs 12.79% obese subclass 2 vs 20.00% obese subclass 3). Women who were diagnosed with GDM were significantly less likely to give birth to an infant with birth weight above 4 kg (RR 0.60; 95% CI 0.36 to 1.00; p = 0.05). The need for caesarean delivery (RR 1.27; 95% CI 1.07 to 1.50; p = 0.006) and incidence of birth weight >90% (RR 1.38; 95% CI 1.07 to 1.77; p = 0.01) was significantly increased in women who were obese, independent of GDM. Conclusion Increasing maternal BMI is a significant risk factor for the development of GDM, and our findings demonstrate a considerably higher prevalence than has been previously described. Raised maternal BMI is a risk factor for high infant birth weight, which may be modified by lifestyle intervention.

Overweight and obesity represent a significant health burden during pregnancy, placing women and their infants at increased risk of adverse health outcomes. Although there is considerable observational literature describing the effect of gestational weight gain in pregnancy, research efforts have focused on limiting gestational weight gain among pregnant women who are overweight or obese, with limited reporting of clinical outcomes.The LIMIT randomized trial recruited 2212 pregnant women with a BMI at least 25 kg/m2. Providing an antenatal dietary and lifestyle intervention was associated with significant improvements in maternal diet and physical activity patterns, and a significant reduction in the risk of infants being born with high birth weight.The findings of the LIMIT randomized trial provide the first evidence that changes in maternal diet and physical activity during pregnancy can reduce the risk of high infant birth weight among women who are overweight or obese, and from a public health perspective, may represent a significant strategy to tackle the increasing problem of childhood and adulthood obesity.

BACKGROUND: Multiple pregnancy is a strong risk factor for preterm birth, and more than 50% of women with a twin pregnancy will give birth prior to 37 weeks' gestation. Infants born preterm are recognised to be at increased risk of many adverse health outcomes, contributing to more than half of overall perinatal mortality. Progesterone is produced naturally in the body and has a role in maintaining pregnancy, although it is not clear whether administering progestogens to women with multiple pregnancy at high risk of early birth is effective and safe. Since publication of this new review in Issue 10, 2017, we have now moved one study (El‐Refaie 2016) from included to studies awaiting classification, pending clarification about the study data. OBJECTIVES: To assess the benefits and harms of progesterone administration for the prevention of preterm birth in women with a multiple pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2016) and reference lists of retrieved studies. SELECTION CRITERIA: We included randomised controlled trials examining the administration of a progestogen by any route for the prevention of preterm birth in women with multiple pregnancy. We did not include quasi‐randomised or cross‐over studies. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed reports identified by the search for eligibility, extracted data, assessed risk of bias and graded the quality of the evidence. MAIN RESULTS: We included 16 trials, which all compared either vaginal or intramuscular (IM) progesterone with a placebo or no treatment, and involved a total of 4548 women. The risk of bias for the majority of included studies was low, with the exception of three studies that had inadequate blinding, or significant loss to follow‐up or both, or were not reported well enough for us to make a judgement. We graded the evidence low to high quality, with downgrading for statistical heterogeneity, design limitations in some of the studies contributing data, and imprecision of the effect estimate. 1 IM progesterone versus no treatment or placebo More women delivered at less than 34 weeks' gestation in the IM progesterone group compared with placebo (risk ratio (RR) 1.54, 95% confidence interval (CI) 1.06 to 2.26; women = 399; studies = 2; low‐quality evidence). Although the incidence of perinatal death in the progesterone group was higher, there was considerable uncertainty around the effect estimate and high heterogeneity between studies (average RR 1.45, 95% CI 0.60 to 3.51; infants = 3089; studies = 6; I(2) = 71%; low‐quality evidence). No studies reported maternal mortality or major neurodevelopmental disability at childhood follow‐up. There were no clear group differences found in any of the other maternal or infant outcomes (preterm birth less than 37 weeks (RR 1.05, 95% CI 0.98 to 1.13; women = 2010; studies = 5; high‐quality evidence); preterm birth less than 28 weeks (RR 1.08, 95% CI 0.75 to 1.55; women = 1920; studies = 5; moderate‐quality evidence); infant birthweight less than 2500 g (RR 0.99, 95% CI 0.90 to 1.08; infants = 4071; studies = 5; I(2) = 76%, moderate‐quality evidence)). No childhood outcomes were reported in the trials. 2 Vaginal progesterone versus no treatment or placebo by dose There were no clear group differences in incidence of preterm birth before 34 weeks (average RR 0.90, 95% CI 0.66 to 1.23; women = 1503; studies = 5; I(2) = 36%; low‐quality evidence). Although fewer births before 34 weeks appeared to occur in the progesterone group, the CIs crossed the line of no effect. Incidence of perinatal death was higher in the progesterone group, although there was considerable uncertainty in the effect estimate and the quality of the evidence was low for this outcome (RR 1.23, 95% CI 0.74 to 2.06; infants = 2287; studies = 3; low‐quality evidence). No studies reported maternal mortality or major neurodevelopmental disability at childhood follow‐up. There were no clear group differences found in any of the other maternal or infant outcomes (preterm birth less than 37 weeks (average RR 0.97, 95% CI 0.89 to 1.06; women = 1597; studies = 6; moderate‐quality evidence); preterm birth less than 28 weeks (RR 1.53, 95% CI 0.79 to 2.97; women = 1345; studies = 3; low‐quality evidence); infant birthweight less than 2500 g (average RR 0.95, 95% CI 0.84 to 1.07; infants = 2640; studies = 3; I(2) = 66%, moderate‐quality evidence)). No childhood outcomes were reported in the trials. For secondary outcomes, there were no clear group differences found in any of the other maternal outcomes except for caesarean section, where women who received vaginal progesterone did not have as many caesarean sections as those in the placebo group, although the difference between groups was not large (8%) (RR 0.92, 95% CI 0.86 to 0.98; women = 1919; studies = 5; I(2) = 0%). There were no clear group differences found in any of the infant outcomes except for mechanical ventilation, which was required by fewer infants whose mothers had received the vaginal progesterone (RR 0.70, 95% CI 0.52 to 0.94; infants = 2695; studies = 4). AUTHORS' CONCLUSIONS: Overall, for women with a multiple pregnancy, the administration of progesterone (either IM or vaginal) does not appear to be associated with a reduction in risk of preterm birth or improved neonatal outcomes. Future research could focus on a comprehensive individual participant data meta‐analysis including all of the available data relating to both IM and vaginal progesterone administration in women with a multiple pregnancy, before considering the need to conduct trials in subgroups of high‐risk women (for example, women with a multiple pregnancy and a short cervical length identified on ultrasound).

BackgroundNeonatal respiratory distress syndrome, as a consequence of preterm birth, is a major cause of early mortality and morbidity. The withdrawal of progesterone, either actual or functional, is thought to be an antecedent to the onset of labour. There remains limited information on clinically relevant health outcomes as to whether vaginal progesterone may be of benefit for pregnant women with a history of a previous preterm birth, who are at high risk of a recurrence. Our primary aim was to assess whether the use of vaginal progesterone pessaries in women with a history of previous spontaneous preterm birth reduced the risk and severity of respiratory distress syndrome in their infants, with secondary aims of examining the effects on other neonatal morbidities and maternal health and assessing the adverse effects of treatment.MethodsWomen with a live singleton or twin pregnancy between 18 to FindingsMost women used their allocated study treatment (740 women, 94.0%), with median use similar for both study groups (51.0 days, interquartile range [IQR] 28.0-69.0, in the progesterone group versus 52.0 days, IQR 27.0-76.0, in the placebo group). The incidence of respiratory distress syndrome was similar in both study groups-10.5% (42/402) in the progesterone group and 10.6% (41/388) in the placebo group (adjusted relative risk [RR] 0.98, 95% confidence interval [CI] 0.64-1.49, p = 0.912)-as was the severity of any neonatal respiratory disease (adjusted treatment effect 1.02, 95% CI 0.69-1.53, p = 0.905). No differences were seen between study groups for other respiratory morbidities and adverse infant outcomes, including serious infant composite outcome (155/406 [38.2%] in the progesterone group and 152/393 [38.7%] in the placebo group, adjusted RR 0.98, 95% CI 0.82-1.17, p = 0.798). The proportion of infants born before 37 weeks' gestation was similar in both study groups (148/406 [36.5%] in the progesterone group and 146/393 [37.2%] in the placebo group, adjusted RR 0.97, 95% CI 0.81-1.17, p = 0.765). A similar proportion of women in both study groups had maternal morbidities, especially those related to preterm birth, or experienced side effects of treatment. In 9.9% (39/394) of the women in the progesterone group and 7.3% (28/382) of the women in the placebo group, treatment was stopped because of side effects (adjusted RR 1.35, 95% CI 0.85-2.15, p = 0.204). The main limitation of the study was that almost 9% of the women did not start the medication or forgot to use it 3 or more times a week.ConclusionsOur results do not support the use of vaginal progesterone pessaries in women with a history of a previous spontaneous preterm birth to reduce the risk of neonatal respiratory distress syndrome or other neonatal and maternal morbidities related to preterm birth. Individual participant data meta-analysis of the relevant trials may identify specific women for whom vaginal progesterone might be of benefit.Trial registrationCurrent Clinical Trials ISRCTN20269066.

Background When a woman has had a previous caesarean birth and requires induction of labour for a subsequent pregnancy, two options are available for her care: an elective repeat caesarean and planned induction of labour. Although risks and benefits are associated with both elective repeat caesarean birth and planned induction of labour, current sources of information are limited to non-randomised cohort studies, and studies designed in this way have significant potential for bias. Consequently, any conclusions based on results of these studies are limited in their reliability and should be interpreted with caution. Objectives To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section versus a policy of induction of labour for women with a previous caesarean birth who require induction of labour for a subsequent pregnancy. Primary outcomes include success of induction of labour, need for caesarean section, maternal and neonatal mortality, and maternal and neonatal morbidity. Search methods We searched the Cochrane Pregnancy and Childbirth Trials Register (31 May 2017) and planned to search reference lists of retrieved studies. Selection criteria Randomised controlled trials with reported data on comparison of outcomes in mothers and babies between women who planned an elective repeat caesarean section and women who planned induction of labour when a previous birth was performed by caesarean. Cluster trials and quasi-randomised trials were also eligible for inclusion. We would consider trials published only as abstracts if they provided enough information to meet review inclusion criteria. Data collection and analysis We performed no data extraction. For future updates, if randomised controlled trials are identified, two review authors will independently assess trials for inclusion and risk of bias, and will extract data and check extracted data for accuracy. Review authors will assess the quality of the evidence using the GRADE approach. Main results Review authors identified no randomised controlled trials. Authors' conclusions Both planned elective repeat caesarean section and planned induction of labour for women with a prior caesarean birth are associated with benefits and harms. Evidence for these care practices has been drawn from non-randomised studies, which are associated with potential bias. Therefore, any results and conclusions presented must be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned induction of labour for women with a previous caesarean birth.

To evaluate whether Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) for timing subsequent intrauterine transfusions (IUTs) in fetuses that had undergone one IUT for anemia secondary to red-cell alloimmunization is non-inferior to timing based on expected decrease in fetal hematocrit (Hct) or fetal hemoglobin level, without compromising infant hemoglobin at birth.This was an international, pragmatic multicenter randomized controlled trial. Women with a pregnancy complicated by fetal anemia secondary to red-cell alloimmunization (due to any antibody alone or in combination), as indicated by the need to undergo a single IUT, were eligible for inclusion. Women were randomized to the determination of timing of further transfusion(s) by Doppler measurement of MCA-PSV (MCA-PSV Group), with a serial upward trend of values1.5 multiples of the median considered indicative of the need for another IUT, or timing of transfusion by a decrease in fetal Hct (fetal Hct Group), with subsequent IUTs timed according to an estimated fall in fetal Hct of 1% per day or fetal hemoglobin of 0.3 g/dL per day, to maintain fetal hemoglobin level between 7 and 10 g/dL. The primary outcome was infant hemoglobin level measured at birth.A total of 71 women were randomized, 36 to the MCA-PSV Group and 35 to the fetal Hct Group. Median gestational age at randomization was 30.3 weeks, the majority of women were Caucasian and non-smokers, 9.9% of women had Kell alloimmunization, and 14% of fetuses were hydropic at their first IUT. No statistically significant differences between the two treatment groups were observed with regard to mean hemoglobin levels at birth (MCA-PSV Group, 10.36 ± 3.82 g/dL vs fetal Hct Group, 12.03 ± 3.14 g/dL; adjusted mean difference -1.56 g/dL (95% CI, -3.24 to 0.13 g/dL); P = 0.070), or the number of IUTs performed after randomization (MCA-PSV Group, 1.75 ± 1.79 vs fetal Hct Group 1.80 ± 1.32; adjusted relative risk 0.88 (95% CI, 0.61-1.26); P = 0.474). There was no statistically significant difference between the two groups with respect to the risk of adverse infant outcomes related to alloimmunization or procedure-related complications.Both Doppler measurement of MCA-PSV and estimation of the decrease in fetal Hct or hemoglobin can be used to determine the timing of second and subsequent IUTs in fetuses with red-cell alloimmunization. Copyright © 2017 ISUOG. Published by John WileySons Ltd.

The contribution of paternal obesity to pregnancy outcomes has been little described. Our aims were to determine whether the effect of an antenatal maternal dietary and lifestyle intervention among women who are overweight or obese on newborn adiposity, was modified by paternal obesity. We conducted a secondary analysis of a multicenter randomised trial. Pregnant women with BMI ≥25 kg/m2 received either Lifestyle Advice or Standard Care. Paternal anthropometric measures included height, weight, BMI; waist, hip, calf and mid-upper arm circumferences; biceps and calf skinfold thickness measurements (SFTM); and percentage body fat. Newborn anthropometric outcomes included length; weight; head, arm, abdominal, and chest circumferences; biceps, triceps, subscapular, suprailiac, thigh, and lateral abdominal wall SFTM; and percentage body fat. The effect of an antenatal maternal dietary and lifestyle intervention among women who were overweight or obese on neonatal anthropometric measures, was significantly modified by paternal BMI ≥35.0 kg/m2, with a significantly smaller infant triceps, suprailiac, and thigh SFTM, and percent fat mass, compared with that observed in offspring of lean fathers. Further research is required to determine whether our observed associations are causal, and whether paternal weight loss prior to conception is a potential strategy to reduce the intergenerational effects of obesity.

To systematically examine the evidence around the combination of interventions to prevent preterm birth.Without language restrictions, we searched clinicaltrials.gov and five electronic databases (Medline, EMBASE, CINAHL, Cochrane CENTRAL, and Web of Science) up to July 7, 2016. We included randomized and non-randomized studies where asymptomatic women at risk of preterm birth received any combination of progesterone, cerclage, or pessary compared with either one or no intervention. Primary outcomes were preterm birth34 and37 weeks and neonatal death. Two independent reviewers extracted data using a piloted form and assessed risk and direction of bias. We pooled data with unlikely or unclear bias using random-effects meta-analyses. Comparisons with likely bias (e.g., confounding by indication) were not pooled.We screened 1335 results and assessed 154 full texts, including seven studies. In singletons, we found no differences in preterm birth34 weeks when comparing pessaryprogesterone with pessary alone (RR 1.30, 95% CI 0.70-2.42) or progesterone alone (RR 1.16, 95% CI 0.79-1.72). Similarly, we found no differences in preterm birth37 weeks when comparing cerclageprogesterone with cerclage alone (RR 1.04, 95% CI 0.56-1.93) or with progesterone alone (RR 0.82, 95% CI 0.57-1.19) nor between pessaryprogesterone and pessary alone (RR 1.04, 95% CI 0.62-1.74). No data were available for neonatal death in singletons.Despite being a common clinical practice, evidence to support the combined use of multiple versus single interventions for preventing preterm birth is scarce.

Background The aim of this individual participant data meta-analysis (IPDMA) is to evaluate the effects of dietary and lifestyle interventions among pregnant women who are overweight or obese on later maternal and early childhood outcomes at ages 3–5 years. Methods/design We will build on the established International Weight Management in Pregnancy (i-WIP) IPD Collaborative Network, having identified researchers who have conducted randomised dietary and lifestyle interventions among pregnant women who are overweight or obese, and where ongoing childhood follow-up of participants has been or is being undertaken. The primary maternal outcome is a diagnosis of maternal metabolic syndrome. The primary childhood outcome is BMI above 90%. We have identified 7 relevant trials, involving 5425 women who were overweight or obese during pregnancy, with approximately 3544 women and children with follow-up assessments available for inclusion in the meta-analysis. Discussion The proposed IPDMA provides an opportunity to evaluate the effect of dietary and lifestyle interventions among pregnant women who are overweight or obese on later maternal and early childhood health outcomes, including risk of obesity. This knowledge is essential to effectively translate research findings into clinical practice and public health policy. Systematic review registration This IPD has been prospectively registered (PROSPERO), ID number CRD42016047165. Electronic supplementary material The online version of this article (doi:10.1186/s13643-017-0442-6) contains supplementary material, which is available to authorized users.

Background Preterm birth (PTB) is the leading cause of infant death, but it is unclear which intervention is best to prevent it. Objectives To compare progesterone, cerclage and pessary, determine their relative effects and rank them. Search strategy We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL and Web of Science (to April 2016), without restrictions, and screened references of previous reviews. Selection criteria We included randomised trials of progesterone, cerclage or pessary for preventing PTB in women with singleton pregnancies at risk as defined by each study. Data collection and analysis We extracted data by duplicate using a piloted form and performed Bayesian random-effects network meta-analyses and pairwise meta-analyses. We rated evidence quality using GRADE, ranked interventions using SUCRA and calculated numbers needed to treat (NNT). Main results We included 36 trials (9425 women; 25 low risk of bias trials). Progesterone ranked first or second for most outcomes, reducing PTB < 34 weeks [odds ratio (OR) 0.44; 95% credible interval (CrI) 0.22–0.79; NNT 9; low quality]

Background Maternal overweight and obesity during pregnancy is associated with insulin resistance, hyperglycaemia, hyperlipidaemia and a low-grade state of chronic inflammation. The aim of this pre-specified analysis of secondary outcome measures was to evaluate the effect of providing antenatal dietary and lifestyle advice on cardiometabolic and inflammatory biomarkers. Methods We conducted a multicentre trial in which pregnant women who were overweight or obese were randomised to receive either Lifestyle Advice or Standard Care. We report a range of pre-specified secondary maternal and newborn cardiometabolic and inflammatory biomarker outcomes. Maternal whole venous blood was collected at trial entry (mean 14 weeks gestation; non-fasting), at 28 weeks gestation (fasting), and at 36 weeks gestation (non-fasting). Cord blood was collected after birth and prior to the delivery of the placenta. A range of cardiometabolic and inflammatory markers were analysed (total cholesterol, triglycerides, non-esterified fatty acids, high-density lipoprotein cholesterol, insulin, glucose, leptin, adiponectin, C-reactive protein, granulocyte macrophage-colony stimulating factor, interferon gamma, TNF-α, and interleukins 1β, 2, 4, 5, 6, 8, and 10). Participants were analysed in the groups to which they were randomised, and were included in the analyses if they had a measure at any time point. Results One or more biological specimens were available from 1951 women (989 Lifestyle Advice and 962 Standard Care), with cord blood from 1174 infants (596 Lifestyle Advice and 578 Standard Care). There were no statistically significant differences in mean cardiometabolic and inflammatory marker concentrations across pregnancy and in infant cord blood between treatment groups. Estimated treatment group differences were close to zero, with 95% confidence intervals spanning a range of differences that were short of clinical relevance. There was no evidence to suggest that the intervention effect was modified by maternal BMI category. Conclusions Despite our findings, it will be worth considering potential relationships between cardiometabolic and inflammatory markers and clinical outcomes, including longer-term infant health and adiposity. Trial Registration Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426; Date Registered 09/03/2007). Electronic supplementary material The online version of this article (doi:10.1186/s12916-017-0790-z) contains supplementary material, which is available to authorized users.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of progesterone administration for the prevention of preterm birth in women with a singleton pregnancy who are considered to be at increased risk of preterm birth.

BackgroundDiet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes.ObjectivesTo assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions.Data sourcesMEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search).Review methodsResearchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions.ResultsDiet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI –0.92 to –0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate –0.10 kg, 95% CI –0.14 to –0.06 kg) and multiparity (summary estimate –0.73 kg, 95% CI –1.24 to –0.23 kg).LimitationsThe findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies.ConclusionDiet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes.Future workThe differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation.Study registrationThis study is registered as PROSPERO CRD42013003804.FundingThe National Institute for Health Research Health Technology Assessment programme.

Maternal obesity is associated with a well-documented increase in risk of adverse health outcomes for both women and their infants. However, robust evidence about the effect of interventions for pregnant women to limit gestational weight gain on such health outcomes has been lacking. The LIMIT randomized trial recruited 2,212 pregnant women with a BMI ≥25 kg/m2 from public maternity hospitals in South Australia. Providing an antenatal intervention significantly improved maternal diet and physical activity and significantly reduced the risk of infants being born with high birth weight. The findings of the LIMIT trial provide the first evidence that changes in maternal diet and physical activity during pregnancy can reduce the risk of high infant birth weight among women who are overweight or obese. Importantly, the latter was achieved in the absence of changes in maternal gestational weight gain and may represent a significant strategy to tackle obesity from a population health perspective.

Overweight and obesity during pregnancy are common and are associated with an increased risk of adverse health outcomes for both the mother and the infant. However, robust evidence about the effect of antenatal dietary and lifestyle interventions on health outcomes is lacking. We conducted a multicenter, randomized trial, recruiting 2,212 women (from 3 public maternity hospitals across South Australia) with a singleton pregnancy between 10+0 and 20+0 weeks' gestation and a BMI ≥25. The women were randomized to lifestyle advice (n = 1,108) or standard care (n = 1,104). Women randomized to lifestyle advice participated in a comprehensive dietary and lifestyle intervention over the course of their pregnancy (delivered by research staff), while women randomized to standard care received pregnancy care according to local guidelines, which did not include such information. Provision of the lifestyle intervention was associated with a significant 18% relative risk reduction in the chance of infants being born with a birth weight above 4 kg. No other significant differences were identified in maternal pregnancy and birth outcomes between the two treatment groups. Observational studies highlight the association between a high infant birth weight and the subsequent risk of childhood and adulthood obesity. Antenatal interventions that are effective in reducing high infant birth weights therefore represent a significant strategy to tackle obesity from a population health perspective, while ongoing interrogation of the biospecimens and measurements, including ongoing childhood follow-up, will provide a unique opportunity to evaluate the mechanistic pathways of maternal-to-infant/childhood obesity.

There is little information available describing how women who are overweight or obese in pregnancy perceive their bodies, and in particular the effect of body image dissatisfaction on gestational weight gain.To describe how women who are overweight or obese in pregnancy perceive their body, and the effect of body image on gestational weight gain.This prospective nested cohort study evaluated self estimation of body weight, preferred body shape, dieting behavior, satisfaction with body weight and shape, and gestational weight gain in pregnant women who were overweight or obese, through self-completed questionnaire in early pregnancy in South Australia from October 2010 to February 2012.Of the 442 women who completed the questionnaire, 25.8% correctly identified their BMI, with 70.1% under-estimating and 4.1% over-estimating their BMI. Women who were obese were significantly less likely to correctly identify their BMI, as were younger women. Women who incorrectly identified their BMI were significantly more likely to have higher gestational weight gain (P0.001). Approximately 45% of women indicated dissatisfaction with their weight or body shape, with this being more common in women of higher parity and higher BMI. Dissatisfaction was significantly related to gestational weight gain.Women who report increasing dissatisfaction with their body size and shape are more likely to gain excessive weight during pregnancy. Further research should explore insights about maternal body image and diet related behaviors.

There is contradictory research assessing physical activity patterns during pregnancy and postpartum among women who are overweight or obese. The aim of this study was to evaluate physical activity among overweight and obese women over the course of pregnancy and the initial postpartum period.Three hundred and five overweight or obese pregnant women completed physical-activity questionnaires at three time points during pregnancy and at 4-months postpartum.Physical activity declined between early pregnancy and 28-weeks gestation (P0.001) and declined further at 36-weeks gestation (P0.001) before increasing significantly at 4-months postpartum (P0.001). However, reported activity at 4-months postpartum remained significantly lower than that reported in early pregnancy (P0.001). There was no significant difference either cross-sectionally or for changes over pregnancy and postpartum for total levels or categories of physical activity for women with different body mass index (BMI) or gestational weight gain (GWG). BMI was the only independent predictor of the change in total physical activity over the study and GWG, with women with higher BMI having larger decline of physical activity (β=0.114, s.e.=0.750, P=0.032) and less GWG (β=-0.253, s.e.=0.063, P0.001).Physical activity declined significantly between early pregnancy and 28-weeks gestation, with a further decline to 36-weeks gestation. At 4-months postpartum, physical activity significantly increased but not to the level of that reported at early pregnancy. SO WHAT?: The promotion of appropriate physical activity should be implemented early in pregnancy and postpartum to prevent the decline in activity we have observed in overweight and obese women. Future research should also explore the barriers and enablers to women engaging in exercise during pregnancy and the postpartum period.

BACKGROUND High Body Mass Index (BMI) during pregnancy is associated with an increased risk of adverse health outcomes. Making healthy change during pregnancy is beneficial, especially for overweight and obese women. AIMS The aim of this study was to explore the barriers and enablers identified by overweight and obese women that preclude and facilitate making healthy change during pregnancy. METHOD Twenty-six women who were overweight or obese during pregnancy were interviewed at 28 weeks gestational age. Interviews were transcribed verbatim and the analysis is based on the thematic analysis methodology. RESULTS The core concept of "being pregnant" indicated women consider this specific time as both a reason not to make healthy change as well as a motivation for change. Overweight and obese women cited the following barriers to making healthy change during pregnancy: physiological (e.g. pregnancy complications and tiredness); emotional (e.g. preference and mood); cognitive (e.g. lack knowledge); interpersonal (e.g. lack support); and environmental (e.g. availability of healthy choice). Similar enablers were identified by overweight and obese women: physiological (e.g. relief of pregnancy symptoms); emotional (e.g. approval and commitment); cognitive (e.g. knowledge and belief); interpersonal (e.g. family support); and environmental (e.g. help from others). More barriers than enablers were given, indicating that women were more sensitive to barriers than the enablers for making healthy change. Factors viewed by some women as barriers were viewed as enablers by others. CONCLUSION When designing interventions to promote healthy eating and physical activity during pregnancy, individually focused interventions must be implemented in conjunction with environmental-level interventions to facilitate behaviour change.

Pre-eclampsia is a significant health issue in pregnancy, complicating between 2-8% of pregnancies. L-arginine is an important mediator of vasodilation with a potential preventative role in pregnancy related hypertensive diseases. We aimed to systematically review randomised trials in the literature assessing the role of L-arginine in prevention and treatment of pre-eclampsia. We searched the Cochrane Controlled Trials Register, PUBMED, and the Australian and International Clinical Trials Registry, to identify randomised trials involving pregnant women where L-arginine was administered for pre-eclampsia to improve maternal and infant health outcomes. We identified eight randomised trials, seven of which were included. The methodological quality was fair, with a combined sample size of 884 women. For women at risk of pre-eclampsia, L-arginine was associated with a reduction in pre-eclampsia (RR: 0.34, 95% CI: 0.21-0.55), when compared with placebo and a reduction in risk of preterm birth (RR: 0.48 and 95% CI: 0.28 to 0.81). For women with established hypertensive disease, L-arginine was associated with a reduction in pre-eclampsia (RR: 0.21; 95% CI: 0.05-0.98). L-arginine may have a role in the prevention and/or treatment of pre-eclampsia. Further well-designed and adequately powered trials are warranted, both in women at risk of pre-eclampsia and in women with established disease.

Overweight and obesity during pregnancy is associated with risk of a range of adverse health outcomes. While intervention studies aim to promote behavioral change, little is known about the underlying psychological mechanisms facilitating and hindering change. The aim of this study was to evaluate overweight and obese women's perceptions of making behavior change during pregnancy. We explored beliefs through self-administrated questionnaires (n = 464) and semi-structured face-to-face interviews (n = 26). Questions were designed according to the Health Belief Model. A triangulation protocol was followed to combine quantitative and qualitative data. A total of 269 women (58 %) indicated that high gestational weight gain is a concern, with 348 (75 %) indicating excessive weight gain is associated with complications during pregnancy or child birth. Women were aware of maternal complications associated with high gestational weight gain, but had more limited awareness of neonatal complications. While most women indicated in questionnaires that healthy eating and physical activity were associated with improved health during pregnancy, they were unable to identify specific benefits at interview. Barriers to making healthy behavior changes were highly individualized, the main barrier being lack of time. While the majority (91 %) of women indicated that they would make behavior changes if the change made them feel better, only half felt confident in their ability to do so. Interventions for overweight and obese pregnant women should incorporate education about neonatal health consequences and benefits of healthy behavior change in addition to incorporating strategies to enhance self-efficacy.

Background About half of twin pregnancies deliver preterm, and it is unclear whether any intervention reduces this risk. Objectives To assess the evidence for the effectiveness of progesterone, cerclage, and pessary in twin pregnancies. Search strategy We searched Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and ISI Web of Science, without language restrictions, up to 25 January 2016. Selection criteria Randomised controlled trials of progesterone, cerclage, or pessary for preventing preterm birth in women with twin pregnancies, without symptoms of threatened preterm labour. Data collection and analysis Two independent reviewers extracted data using a piloted form. Study quality was appraised with the Cochrane Risk of Bias tool. We performed pairwise inverse variance random-effects meta-analyses. Main results We included 23 trials (all but three were considered to have a low risk of bias) comprising 6626 women with twin pregnancies. None of the interventions significantly reduced the risk of preterm birth overall at

Optimizing maternal diet during pregnancy improves maternal and infant health. This study assessed the effect of an antenatal lifestyle intervention for women with overweight or obesity on dietary patterns during pregnancy and post partum.This study is a secondary analysis of a randomized controlled trial in which pregnant women (BMI ≥ 25 kg/mThe dietary pattern analysis revealed two distinct patterns: "prudent" and "Western." There was a significant difference between groups in the change over time for both patterns (P 0.001). For the prudent score, the lifestyle group had higher scores at all times after trial entry compared with standard care, while for the Western score, the lifestyle group had a lower score at 28 weeks. The intervention effect differed based on trial entry BMI (P = 0.043) and smoking (P = 0.019), with higher prudent scores for women with obesity compared with overweight and smokers compared with nonsmokers.The provision of an antenatal lifestyle intervention for women with overweight and obesity was associated with an improvement in dietary patterns that persisted post partum. This has important implications for the future consideration of optimal dietary intervention components to include in antenatal lifestyle interventions.

Background Preterm prelabour rupture of the membranes (PPROM) complicates approximately 2% of pregnancies and can be either spontaneous or iatrogenic in nature. Complications of PPROM include prematurity, chorioamnionitis, neonatal sepsis, limb position defects, respiratory distress syndrome, pulmonary hypoplasia chronic lung disease, periventricular leukomalacia and intraventricular haemorrhage. A number of different sealing techniques have been employed which aim to restore a physical barrier against infection and encourage the re-accumulation of amniotic fluid. Routine use of sealants is currently not recommended due to a lack of sufficient evidence to support the safety and effectiveness of such interventions. Objectives To assess the effects of sealing techniques following PPROM against each other, or versus standard care (including no sealant), on maternal and neonatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 May 2016) and reference lists of retrieved studies. Selection criteria Randomised and quasi-randomised controlled trials comparing different techniques for sealing preterm prelabour ruptured membranes. Cluster-randomised trials and trials using a cross-over design were not eligible for inclusion in this review. We planned to include abstracts when sufficient information was provided. Data collection and analysis Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. Main results We included two studies (involving 141 women - with data from 124 women). We considered both studies as being at high risk of bias. Meta-analysis was not possible because the included studies examined different interventions (both in comparison with standard care) and reported on few, but different, outcomes. One study compared cervical adapter (mechanical sealing), and the other study examined an immunological membrane sealant. Neither of the included studies reported on this review's primary outcome of interest - perinatal mortality. Similarly, data were not reported for the majority of this review's secondary infant and maternal outcomes. Cervical adapter (mechanical sealing) versus standard care (one study, data from 35 participants) No data were reported for this review's primary outcome - perinatal mortality. Data were reported for few of this review's infant or maternal secondary outcomes. There was no clear difference between the mechanical sealing group and the standard care control in relation to the incidence of neonatal sepsis (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.28 to 5.09 (very low-quality evidence)) or chorioamnionitis (RR 1.19, 95% CI 0.28 to 5.09 (very low-quality evidence)). Oral immunological membrane sealant versus standard care (one study, data from 94 participants) No data were available for perinatal mortality (this review's primary outcome) or for the majority of this review's infant and maternal secondary outcomes. Compared to standard care, the immunological membrane sealant was associated with a reduction in preterm birth less than 37 weeks (RR 0.48, 95% CI 0.34 to 0.68 (very low-quality evidence)) and a reduction in neonatal death (RR 0.38, 95% CI 0.19 to 0.75 (very low-quality evidence)). However, there was no clear difference between groups in terms of neonatal sepsis (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)) or respiratory distress syndrome (RR 0.64, 95% CI 0.28 to 1.46 (very low-quality evidence)). Authors' conclusions There is insufficient evidence to evaluate sealing procedures for PPROM. There were no data relating to this review's primary outcome (perinatal mortality) and the majority of our infant and maternal secondary outcomes were not reported in the two included studies. There was limited evidence to suggest that an immunological membrane sealant was associated with a reduction in preterm birth at less than 37 weeks and neonatal death, but these results should be interpreted with caution as this is based on one small study, with a high risk of bias, and the intervention has not been tested in other studies. Although midtrimester PPROM is not a rare occurrence, there are only a small amount of published data addressing the benefits and risks of sealing procedures. Most of these studies are retrospective and cohort based and could therefore not be included in our data-analysis. This review highlights the paucity of prospective randomised trials in this area. Current evidence provides limited information both on effectiveness and safety for the interventions described. Given the paucity of high-quality data, we recommend that future research efforts focus on the conduct of randomised trials assessing the effect of promising interventions that have been only evaluated to date in cohort studies (e.g. amniopatch). Future trials should address outcomes including perinatal mortality, preterm birth, neonatal death, respiratory distress syndrome, neonatal sepsis and developmental delay. They should also evaluate maternal outcomes including sepsis, mode of delivery, length of hospital stay and emotional well-being.

Obesity is a significant global health problem, with approximately 50% of women entering pregnancy having a body mass index greater than or equal to 25 kg/m2. Obesity during pregnancy is associated with a well-recognised increased risk of adverse health outcomes both for the woman and her infant. Currently available data from large scale randomised trials and systematic reviews highlight only modest effects of antenatal dietary and lifestyle interventions in limiting gestational weight gain, with little impact on clinically relevant pregnancy outcomes. Further information evaluating alternative strategies is required. The aims of this randomised controlled trial are to assess whether the use of metformin as an adjunct therapy to dietary and lifestyle advice for overweight and obese women during pregnancy is effective in improving maternal, fetal and infant health outcomes. Design: Multicentre randomised, controlled trial. Inclusion Criteria: Women with a singleton, live gestation between 10+0-20+0 weeks who are obese or overweight (defined as body mass index greater than or equal to 25 kg/m2), at the first antenatal visit. Trial Entry & Randomisation: Eligible, consenting women will be randomised between 10+0 and 20+0 weeks gestation using an online computer randomisation system, and randomisation schedule prepared by non-clinical research staff with balanced variable blocks. Stratification will be according to maternal BMI at trial entry, parity, and centre where planned to give birth. Treatment Schedules: Women randomised to the Metformin Group will receive a supply of 500 mg oral metformin tablets. Women randomised to the Placebo Group will receive a supply of identical appearing and tasting placebo tablets. Women will be instructed to commence taking one tablet daily for a period of one week, increasing to a maximum of two tablets twice daily over four weeks and then continuing until birth. Women, clinicians, researchers and outcome assessors will be blinded to the allocated treatment group. All women will receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant), and three telephone calls over the course of their pregnancy, in which they will be provided with dietary and lifestyle advice, and encouraged to make change utilising a SMART goals approach. Primary Study Outcome: infant birth weight >4000 grams. Sample Size: 524 women to detect a difference from 15.5% to 7.35% reduction in infants with birth weight >4000 grams (p = 0.05, 80% power, two-tailed). This is a protocol for a randomised trial. The findings will contribute to the development of evidence based clinical practice guidelines. Australian and New Zealand Clinical Trials Registry ACTRN12612001277831 , prospectively registered 10th of December, 2012.

Background Caesarean section involves making an incision in the woman's abdomen and cutting through the uterine muscle. The baby is then delivered through that incision. Difficult caesarean birth may result in injury for the infant or complications for the mother. Methods to assist with delivery include vacuum or forceps extraction or manual delivery utilising fundal pressure. Medication that relaxes the uterus (tocolytic medication) may facilitate the birth of the baby at caesarean section. Delivery of the impacted head after prolonged obstructed labour can be associated with significant maternal and neonatal complication; to facilitate delivery of the head the surgeon may utilise either reverse breech extraction or head pushing. Objectives To compare the use of tocolysis (routine or selective use) with no use of tocolysis or placebo and to compare different extraction methods at the time of caesarean section for outcomes of infant birth trauma, maternal complications (particularly postpartum haemorrhage requiring blood transfusion), and long-term measures of infant and childhood morbidity. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. Selection criteria All published, unpublished, and ongoing randomised controlled trials comparing the use of tocolytic agents (routine or selective) at caesarean section versus no use of tocolytic or placebo at caesarean section to facilitate the birth of the baby. Use of instrument versus manual delivery to facilitate birth of the baby. Reverse breech extraction versus head pushing to facilitate delivery of the deeply impacted fetal head. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results Seven randomised controlled trials, involving 582 women undergoing caesarean section were included in this review. The risk of bias of included trials was variable, with some trials not adequately describing allocation or randomisation. Three comparisons were included. 1. Tocolysis versus no tocolysis A single randomised trial involving 97 women was identified and included in the review. Birth trauma was not reported. There were no cases of any maternal side-effect reported in either the nitroglycerin or the placebo group. No other maternal and infant health outcomes were reported. 2. Reverse breech extraction versus head push for the deeply impacted head at full dilation at caesarean section Four randomised trials involving 357 women were identified and included in the review. The primary outcome of birth trauma was reported by three trials and there was no difference between reverse breech extraction and head push for this rare outcome (three studies, 239 women, risk ratio (RR) 1.55, 95% confidence interval (CI) 0.42 to 5.73). Secondary outcomes including endometritis rate (three studies, 285 women, average RR 0.52, 95% CI 0.26 to 1.05, Tau I² = 0.22, I² = 56%), extension of uterine incision (four studies, 357 women, average RR 0.23, 95% CI 0.13 to 0.40), mean blood loss (three studies, 298 women, mean difference (MD) -294.92, 95% CI -493.25 to -96.59; I² = 98%) and neonatal intensive care unit (NICU)/special care nursery (SCN) admission (two studies, 226 babies, average RR 0.53, 95% CI 0.23 to 1.22, Tau I² = 0.27, I² = 74%) were decreased with reverse breech extraction. No differences were observed between groups for many of the other secondary outcomes reported (blood loss > 500 mL; blood transfusion; wound infection; mean hospital stay; average Apgar score). There was significant heterogeneity between the trials for the outcomes mean blood loss, operative time and mean hospital stay, making comparison difficult. However the operation duration was significantly shorter for reverse breech extraction, which may correspond with ease of delivery and therefore, the amount of tissue trauma and therefore, significantly less blood loss. Given the heterogeneity, we cannot define the amount of difference in blood loss, operative time or hospital stay however. 3. Instrument (vacuum or forceps) versus manual extraction at elective caesarean section Two randomised trials involving 128 women were identified and included in the review. Only one trial reported maternal and infant health outcomes as prespecified in this review. This trial reported birth trauma as an outcome but there were no instances of birth trauma in either comparison group. There were no differences found in mean fall in haemoglobin (Hb) between groups (one study, 44 women, MD 0.03, 95% CI -0.53 to 0.59), or in uterine incision extension (one study, 44 women, RR 0.70, 95% CI 0.13 to 3.73). Authors' conclusions There is currently insufficient information available from randomised trials to support or refute the routine or selective use of tocolytic agents or instrument to facilitate infant birth at the time of difficult caesarean section. There is limited evidence that reverse breech extraction may improve maternal and fetal outcomes, though there was no difference in primary outcome of infant birth trauma. Further randomised controlled trials are needed to answer these questions.

Twin pregnancies are at increased risk of stillbirth. Uncomplicated twin pregnancies are commonly delivered earlier to prevent stillbirth; however, there is a risk of neonatal complications associated with being born prior to 39 weeks’ gestation. The optimal gestational age for delivery in twin pregnancies is unknown and likely varies by chorionicity. The present study aimed to determine the prospective risk of stillbirth in women with uncomplicated monochorionic and dichorionic twin pregnancies, and neonatal mortality risks, when delivered beyond 34 weeks of gestation. Data on twin pregnancies that reported rates of stillbirth were obtained from MEDLINE, EMBASE, and Cochrane Library. Separate analyses for risks of stillbirth and neonatal death in monochorionic and dichorionic twin pregnancies were undertaken from 34 weeks’ gestation and further and early preterm (

Ensuring adequate dietary intake during pregnancy has important implications for optimising maternal and fetal health. It is not known whether diet quality is altered over pregnancy and the post-partum period.The aim of this study was to perform a comprehensive assessment of diet quality in overweight and obese women during pregnancy and early post-partum.In a prospective cohort study, n=301 overweight or obese pregnant women completed a food frequency questionnaire at study entry (10-20 weeks gestation), 28 weeks gestation, 36 weeks gestation and 4 months post-partum for assessment of macronutrient and micronutrient intake and diet quality by the Healthy Eating Index (HEI).Energy, macronutrient and dietary sources of micronutrients did not alter across pregnancy or post-partum. The HEI was of below average quality in 31.0% of women at baseline. This decreased from week 28 (P0.001) and was maintained at a lower level post-partum such that HEI levels were lower compared with study entry (53.3±12.7 versus 56.7±10.1, P0.001). The HEI decrease occurred in association with decreases in the milk, meat and unsaturated oil components, and increases in the proportion of energy from solid fats, alcohol and added sugars (P0.001), and was independently predicted by the socioeconomic index for areas score (β=-0.011, s.e.=0.011, P=0.031).We report for the first time that dietary quality decreases across pregnancy and is maintained at this reduced level in the early post-partum period in overweight and obese women. Dietary interventions aimed at improving diet quality should be targeted to early pregnancy and post-partum.

Background. Women who are overweight or obese during pregnancy are at increased risk of a number of adverse pregnancy outcomes. Objective. To review the literature systematically to assess the benefits and harms of an exercise intervention for pregnant women who are overweight or obese. Search strategy. A literature search of PUBMED, SCOPUS, the Cochrane Controlled Trials Register (CENTRAL) and the Australian and International Clinical Trials Registers was performed, as well as an additional hand search through bibliographies of various publications. There were no date or language restrictions. Selection criteria. Studies included were randomized controlled trials comparing supervised antenatal exercise intervention with routine standard antenatal care in women who were overweight or obese during pregnancy. The primary outcome was maternal gestational weight gain. The quality of each study was assessed utilizing standard Cochrane systematic review methodology. Data collection and analysis. Six randomized controlled trials and one quasi-randomized trial were identified and included, involving a total of 276 women who were overweight or obese during pregnancy. Results. Provision of a supervised antenatal exercise intervention was associated with lower gestational weight gain (five trials, 216 participants, mean difference of −0.36 kg, 95% confidence interval −0.64 to −0.09 kg) when compared with standard antenatal care. Conclusions. A monitored physical activity intervention appears to be successful in limiting gestational weight gain; however, the effect on maternal and infant health is less certain.

Overweight and obesity are significant and increasing health problems associated with increased risks of morbidity, quality of life, and metabolic and reproductive health consequences. In women, being overweight or obese is associated with impaired fertility and decreased chance of conception both in natural and assisted reproductive technology births. During pregnancy, overweight and obesity are associated with increased risk of adverse maternal and infant health outcomes. Attention to weight loss before conception may improve fertility and maternal and infant health outcomes during pregnancy.

Objective To evaluate maternal and neonatal outcomes associated with birth at term by week of gestational age and also by onset of labor. Design Cohort study. Setting A state-wide perinatal outcome database. Population 28,626 women with spontaneous onset of labor, induction of labor for recognized indications and induction of labor for non-recognized indications. Methods Cohort study utilizing a validated dataset comparing outcomes with type of onset of labor using a log binomial model. Main outcome measures Cesarean section, assisted vaginal birth, important measures of maternal and neonatal morbidity. Results Induction of labor for non-recognized indications was associated with a significantly increased risk of a range of outcomes, including cesarean section (RR 1.67, 95% CI 1.55-1.80). The lowest risk of adverse maternal and infant outcome occurred with birth between 38 and 39 weeks and with the spontaneous onset of labor. Conclusions Induction of labor for non-recognized indications at term is associated with an increased risk of adverse outcomes. Caution is warranted with a liberal policy of induction of labor at term in an otherwise uncomplicated pregnancy.

Summary. Objective: To conduct a pilot randomized controlled trial of unfractionated heparin (UFH) in women considered at high risk of placental insufficiency in the second trimester. Methods: Women with either false-positive first trimester (pregnancy-associated placental protein-A [PAPP-A] 2.0 MoM, inhibin > 3.0 MoM, human chorionic gonadotropin > 4.0 MoM) serum screening tests or medical/obstetric risk factors were screened for placental insufficiency by sonographic evaluation of the placenta and uterine artery Doppler between 18 and 22 weeks. Thrombophilia screen-negative women with two or three abnormal test categories were randomized by 23+6 weeks to self-administration of subcutaneous unfractionated heparin (UFH) 7500 IU twice daily until birth or 34 weeks, or to standard care. Maternal anxiety and other maternal-infant outcomes were determined. Results: Thirty-two out of 41 eligible women consented, with 16 women randomized to UFH and 16 to standard care. There was no statistically significant difference identified between the two treatment groups (standard care vs. UFH) for the following: maternal anxiety score (mean [standard deviation]), 14.2 [± 1.6] vs. 14.0 [± 1.8]; birth weight (median [range]), 1795 [470–3295]g vs. 1860 [730–3050]g; perinatal death, 3 vs. 0; severe preeclampsia, 2 vs. 6; placental weight

Cesarean delivery is common and increasing over time. A prior cesarean birth increases the risk of both elective and emergency cesarean births and uterine rupture in a subsequent pregnancy. A range of factors, including labor characteristics, may influence the risk of these outcomes in the next pregnancy. Intrapartum factors associated with successful vaginal birth and lower risk of uterine rupture include the spontaneous onset of labor and advanced cervical dilatation. In contrast, need for induction and augmentation of labor are both factors associated with an increased likelihood of unsuccessful vaginal birth and risk of uterine rupture.

Cesarean section is one of the most commonly performed procedures for women, with almost a third of women in many developed countries experiencing cesarean section when they give birth. The rate of cesarean section births is increasing and the reasons for this are complex. There are well-documented risks for the woman and her infant with cesarean section birth, both in the current pregnancy and in a subsequent pregnancy. Modifiable risk factors must be addressed if we are to avoid an increasing number of women experiencing serious cesarean-related health complications.

Aims: To determine the effect of increasing maternal body mass index (BMI) during pregnancy on maternal and infant health outcomes. Methods: The South Australian Pregnancy Outcome Unit’s population database, 2008 was accessed to determine pregnancy outcomes according to maternal BMI. Women with a normal BMI (18.5–24.9 kg/m2) formed a reference population, to which women in other BMI categories were compared utilising risk ratios and 95% confidence intervals. Results: Overweight and obese women had an increased risk of gestational diabetes, hypertension and iatrogenic preterm birth. Labour was more likely to be induced, and the risk of caesarean birth was increased. Infants were more likely to require resuscitation at birth and to have birth weight in excess of 4 kg. The risk increased with increasing maternal BMI. Conclusions: There is a well-documented increased risk of maternal and perinatal health complications for women who are overweight or obese during pregnancy.

The development of effective anticoagulant drugs available for use in pregnancy has resulted in dramatic improvements for a number of potentially life-threatening conditions. These include the treatment and prevention of venous thromboembolism and the thrombotic complications of antiphospholipid antibody syndrome, as well as the management of pregnant women with mechanical heart valves. The most commonly used class of drug includes heparin, a highly-charged macro-molecule that does not cross the placenta, in contrast to the potentially teratogenic and fetotoxic oral drug warfarin. This review will focus on our current lack of understanding of the wider actions of heparin and examines the possibility that large numbers of pregnant women are presently being treated inappropriately with heparin.

The aim of our study was to evaluate associations between maternal dietary factors and fetal growth and adiposity in overweight and obese women. Women randomised to the &lsquo, Standard Care&rsquo, group of the LIMIT trial were included. Maternal dietary factors including Healthy Eating Index, total energy, fat, carbohydrates, protein, glycaemic load and index were measured using the Harvard semi-quantitative Food Frequency questionnaire at time of study entry, 28 and 36 weeks&rsquo, gestation. Fetal ultrasound measurements of biometry and adiposity were obtained at 28 and 36 weeks&rsquo, gestation. Linear regression models were used to associate between dietary factors and fetal growth and adiposity measurements. There were 721 women included in this exploratory analysis. A 10 unit increase in the log total energy was associated with a reduction in mid-thigh lean mass by 4.94 mm at 28 weeks (95% CI &minus, 9.57 mm, &minus, 0.32 mm, p = 0.036) and 7.02 mm at 36 weeks (95% CI &minus, 13.69 mm, &minus, 0.35 mm, p = 0.039). A 10 unit increase in Healthy Eating Index score was associated with a reduced mean subscapular skin fold measure at 28 weeks by 0.17 mm (95% CI &minus, 0.32 mm, &minus, 0.03 mm, p = 0.021). We did not identify consistent associations between maternal diet and measures of fetal growth and adiposity in overweight and obese women.

Please cite this paper as: Dodd J, Grivell R, Crowther C, Robinson J. Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials. BJOG 2010;117:1316–1326. Background Overweight and obesity during pregnancy is an increasing health problem. Objective A systematic review to assess the benefits and harms of antenatal dietary or lifestyle interventions for pregnant women who are overweight or obese. Search strategy The Cochrane Controlled Trials Register (CENTRAL) was searched (last search January 2010). Reference lists of retrieved studies were searched by hand. No date or language restrictions were used. Selection criteria Randomised controlled trials comparing antenatal dietary and/or lifestyle or other interventions with no treatment for overweight or obese women were considered. Studies were evaluated independently for appropriateness for inclusion and methodological quality. The primary outcome was large-for-gestational-age infants. Data collection and analysis Nine randomised controlled trials were included involving 743 women who were overweight or obese during pregnancy. Seven trials compared a dietary intervention with standard antenatal care. Main results There were no statistically significant differences identified between women who received an antenatal intervention and those who did not for the large-for-gestational-age infant outcome (three studies; 366 women; risk ratio 2.02; 95% CI 0.84, 4.86) or mean gestational weight gain [four studies; 416 women; weighted mean difference −3.10 kg; 95% CI −8.32, 2.13 (random-effects model)]. There were no statistically significant differences identified for other reported outcomes. Author’s conclusions The effect of providing an antenatal dietary intervention for overweight or obese pregnant women on maternal and infant health outcomes remains unclear.

Cesarean section is one of the most common surgical operations performed on women worldwide, and rates are increasing in all developed countries. There are many proposed causes of the increased rates. Although much safer than in the 1500s when it was first performed, cesarean section is still associated with significant short- and long-term morbidity for a woman and her infant. The issues of maternal obesity, induction of labor, continuous fetal heart rate monitoring in labor, vaginal birth after cesarean section, decision-making for the primary cesarean section and cesarean section for nonmedical indications must be addressed if we are to curb the concerning increase in this procedure.

IntroductionObesity represents a significant health burden, and WHO recognises the importance of preventing weight gain and subsequent development of obesity among adults who are within the healthy weight range. Women of reproductive age have demonstrated high rates of weight gain during pregnancy placing them at risk of becoming overweight or obese. We will evaluate the effects of dietary and physical activity advice on maternal, fetal and infant health outcomes, among pregnant women of normal body mass index (BMI).Methods and analysisWe will conduct a randomised controlled trial, consenting and randomising women with a live singleton pregnancy between 10+0and 20+0weeks and BMI 18.5–24.9 kg/m2at first antenatal visit, from a tertiary maternity hospital. Women randomised to theLifestyle Advice Groupwill receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant) and three telephone calls over pregnancy, in which they will be provided with dietary and lifestyle advice and encouraged to make change using a SMART goals approach. Women randomised to theStandard Care Groupwill receive routine antenatal care. The primary outcome is infant birth weight >4 kg. Secondary outcomes will include adverse infant and maternal outcomes, maternal weight change, maternal diet and physical activity changes, maternal quality of life and emotional well-being, fetal growth and costs of healthcare. We will recruit 624 women to detect a reduction from 8.72% to 3.87% (alpha 0.05 (two-tailed); power 70%) in infants with birth weight >4 kg. Analyses will be intention to treat with estimates reported as relative risks and 95% CIs.Ethics and disseminationEthical approval has been obtained from the Women’s and Children’s Hospital ethics committee. Findings will be disseminated widely via journal publication and conference presentation(s), and participants informed of results.Trial registration numberACTRN12614000583640.

To compare a profile of placental function between the first and second trimesters in pregnancies at high risk of adverse perinatal outcomes attributable to placental insufficiency.Prospective cohort study in 61 singleton pregnancies. Uterine artery Doppler and placental morphology (shape and texture) were determined at 11-13(+6) weeks and at 18-23(+6) weeks. First trimester (pregnancy-associated placental protein-A [PAPP-A]) and second trimester (total hCG and alpha fetoprotein [AFP]) serum biochemistry were determined. The two screening periods were compared for the prediction of a range of severe adverse perinatal outcomes (intrauterine growth restriction [IUGR], abruption, severe pre-eclampsia/HELLP syndrome, delivery32 weeks, or stillbirth).Adverse perinatal outcomes occurred in 14 (23%) women; 3 (4.9%) losses20 weeks, 2 (3.3%) stillbirths20 weeks, 4 (6.6%) IUGR, 7 (11.5%) severe pre-eclampsia/HELLP syndrome, and 10 (16.4%) deliveries32 weeks. Abnormal second trimester placental morphology was significantly associated with adverse outcome [+LR: 3.6, 95% CI: 1.3-8.5; -LR: 0.63, 95% CI: 0.36-0.93; p=0.025], as wasor = 1 abnormal second trimester tests [+LR: 5.9, 95% CI: 1.6-24; -LR: 0.68, 95% CI: 0.59-0.89; p=0.005] oror = 2 abnormal second trimester tests [+LR: 3.6, 95% CI: 1.3-7.7; -LR: 0.58, 95% CI: 0.27-0.94; p=0.035]. No combination of first trimester tests significantly predicted severe adverse perinatal outcomes. A study sample size of 822 women with similar high-risk characteristics would be needed in order to refute the conclusion that present methods of first trimester screening are not inferior to second trimester screening for severe placental insufficiency (p=0.05, power 80%, z-test).In clinically high-risk pregnancies, prediction of adverse perinatal outcomes using placental function testing is more effective in the second compared with the first trimester.

Background Congenital diaphragmatic hernia (CDH), is an uncommon but severe condition in which there is a developmental defect in the fetal diaphragm, resulting in liver and bowel migrating to the chest cavity and impairing lung development and function for the neonate. This condition can be diagnosed during pregnancy and as such, is potentially amenable to in-utero prenatal intervention. Neonatal surgical repair is possible, but even with early surgical repair and improving neonatal management, neonatal morbidity and mortality is high. Prenatal interventions described to date have included maternal antenatal corticosteroid administration and fetal tracheal occlusion, with both methods aiming to improve lung growth and maturity. However surgical procedures have potential maternal complications, as the uterus and amniotic sac are breached in order to gain access to the fetus. Objectives To compare the effects of prenatal versus postnatal interventions for CDH on perinatal mortality and morbidity, longer-term infant outcomes and maternal morbidity, and to compare the effects of different prenatal interventions with each other. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference lists of retrieved studies. Selection criteria All published (including those published in abstract form), unpublished, and ongoing randomised controlled trials comparing prenatal and postnatal interventions for fetuses with CDH. Quasi-RCTs were eligible for inclusion but none were identified. Trials using a cross-over design are not eligible for inclusion. Data collection and analysis Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently. Data were checked for accuracy. Main results We identified 11 studies for potential inclusion. Of those, we included three studies involving 97 women. Two additional studies are ongoing. Two trials examined in-utero fetal tracheal occlusion with standard (postnatal) care in fetuses with severe diaphragmatic hernia. Whilst the trials utilised fetal interventions that were similar, there were important differences in how access was gained to the fetus and in the timing and mode of delivery. Therefore, we did not combine these trials in meta-analysis and the results are examined in separate comparisons. One trial examined the effect of antenatal corticosteroids versus placebo. Overall, the methodological quality of the trials was variable and no data were available for a number of this review's secondary outcomes. In-utero fetal occlusion by maternal laparotomy versus standard postnatal management (one trial, 24 women) For the primary infant outcome (perinatal mortality), there were no data suitable for inclusion in the analysis. There was no difference between groups in terms of long-term infant survival (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.66 to 1.69). In-utero fetal occlusion by minimally invasive fetoscopy versus standard postnatal management (one trial, 41 women) The primary infant outcome (perinatal mortality) was not reported. Minimally invasive fetoscopy was associated with a small reduction in the mean gestational age at birth (mean difference (MD) -1.80 weeks, 95% CI -3.13 to -0.47), but there was no clear difference in the risk of preterm birth before 37 weeks (RR 1.75, 95% CI 0.78 to 3.92). Long-term infant survival (three to six months) (RR 10.50, 95% CI 1.48 to 74.71) was increased with the intervention when compared with standard management, and there was a corresponding reduction in pulmonary hypertension (RR 0.58, 95% CI 0.36 to 0.93) associated with the intervention. There was no difference between groups in terms of preterm ruptured membranes (< 37 weeks) (RR 1.47, 95% CI 0.56 to 3.88) or maternal infectious morbidity (RR 3.14, 95% CI 0.14 to 72.92), and there were no maternal blood transfusions. Antenatal corticosteroids versus placebo (one trial, 32 women) We also included one trial (involving 32 women) examining the effect of antenatal corticosteroids versus placebo. There was no clear difference in the incidence of perinatal mortality (our primary infant outcome) between the group of women who received antenatal corticosteroids and the placebo control (RR 1.24, 95% CI 0.50 to 3.08). Data (mean only) were reported for two of our secondary outcomes (mechanical ventilation and days of hospital admission) but standard deviations (SDs) were not provided. For the purposes of this review and to permit further analysis we have estimated the SDs based on the reported P values reported in the trial report, although our estimation does assume that the SD is the same in both the intervention and control groups. There were no differences between the antenatal corticosteroid group and the placebo control in terms of days of mechanical ventilation (MD 18.00 days, 95% CI -14.77 to 50.77) or days of hospital admission (MD 17.00 days, 95% CI -13.93 to 47.93) . Authors' conclusions There is currently insufficient evidence to recommend in-utero intervention for fetuses with CDH as a part of routine clinical practice. We identified three small studies, with only one study adequately reporting on the primary outcome of this review - perinatal mortality, and there were few data pertaining to many of this review's secondary outcomes. WIth regard to the administration of antenatal corticosteroids, there remains a gap in current research, and a large multicentre trial with adequate statistical power should be undertaken to answer this unresolved question. More studies are needed to further examine the effect of in-utero fetal tracheal occlusion on important neonatal outcomes and long-term infant survival and health. Long-term follow-up is of particular importance, and should include morbidity and mortality measures. Further studies should examine the benefits of an in-utero intervention on subgroups with moderate and severe congenital diaphragmatic hernia. Indeed, there are three ongoing studies, being conducted by European, North and South American fetal medicine centres, which will contribute to this gap. Ongoing research and any implementation into clinical practice should include standardisation of the procedure, inclusion criteria and long-term childhood follow-up.

Background Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants. Objectives To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. Selection criteria All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors). Data collection and analysis Two of the review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy. We graded the quality of the evidence using GRADEpro software. Main results Findings were based on the results of a single study with some design limitations. Data were available from one study involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, we are uncertain whether specialised antenatal clinics makes any difference compared to standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03; 324 infants, very low quality evidence). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81; 162 women, moderate quality evidence). Data were not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20; 133 women, very low quality evidence), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68; 123 women, very low quality evidence), stillbirth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39) (324 infants). Authors' conclusions There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Background When couples are faced with the dilemma of a higher-order multiple pregnancy there are three options. Termination of the entire pregnancy has generally not been acceptable to women, especially for those with a past history of infertility. Attempting to continue with all the fetuses is associated with inherent problems of preterm birth, survival and long-term morbidity. The other alternative relates to reduction in the number of fetuses by selective termination. The acceptability of these options for the couple will depend on their social background and underlying beliefs. This review focused on reduction in the number of fetuses. Objectives To assess a policy of multifetal reduction with a policy of expectant management of women with a multiple pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015). Selection criteria Randomised controlled trials with reported data that compared outcomes in mothers and babies who were managed expectantly with outcomes in women who underwent selective fetal reduction of a multiple pregnancy. Data collection and analysis We planned that two review authors would independently assess trials for inclusion and risk of bias, extract data and check them for accuracy. However, no randomised trials were identified. Main results There were no randomised controlled trials identified. Authors' conclusions We found no available data from randomised trials to inform the risks and benefits of pregnancy reduction procedures for women with a multiple pregnancy. While randomised controlled trials will provide the most reliable evidence about the risks and benefits of fetal reduction procedures, reduction in the number of fetuses by selective termination may not be acceptable to women, particularly couples with a past history of infertility. The acceptability of this option, and willingness to undergo randomisation will depend on the couple's social background and beliefs, and consequently, recruitment to such a trial may prove exceptionally difficult.