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Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Please cite this paper as: Anderson N, McCowan L, Fyfe E, Chan E, Taylor R, Stewart A, Dekker G, North R, on behalf of the SCOPE Consortium. The impact of maternal body mass index on the phenotype of pre-eclampsia: a prospective cohort study. BJOG 2012;119:589-595. Objective We hypothesised that among nulliparous women with pre-eclampsia, overweight or obese women would have a different phenotype of pre-eclampsia compared with normal weight women with pre-eclampsia. Specifically, they are more likely to develop term pre-eclampsia and less likely to have indicators of impaired placental perfusion, e.g. abnormal uterine artery Doppler or a small-for-gestational-age (SGA) infant. Design Prospective, multicentre, cohort SCOPE study ( n = 3170). Setting New Zealand and Australia. Population Nulliparous women who developed pre-eclampsia. Methods Participants were interviewed at 14-16 weeks of gestation, uterine artery Doppler studies were performed at 19-21 weeks and pregnancy outcome was tracked prospectively. Main outcome measures Rates of abnormal uterine artery Doppler indices, term/preterm birth and SGA infants were compared between normal, overweight and obese women with pre-eclampsia. Multivariable analysis was performed to examine the association between body mass index (BMI) and term pre-eclampsia. Results Of 178 women with pre-eclampsia, one underweight woman was excluded and 66 (37%) were normal weight, 52 (29%) were overweight and 59 (34%) were obese. Pre-eclampsia developed preterm in 26% of women and at term in 74% of women. There were no differences in the rates of term/preterm pre-eclampsia, abnormal uterine artery Doppler indices or SGA infants between BMI groups ( P > 0.10). No independent association between BMI and term pre-eclampsia was found ( P = 0.56). Conclusions Among women with pre-eclampsia, those who are overweight or obese in early pregnancy are not more likely to have term pre-eclampsia compared with women with a normal BMI. Overweight and obese women require vigilant surveillance for the development of preterm as well as term pre-eclampsia. [ABSTRACT FROM AUTHOR]

Background: Maternal overweight and obesity are associated with slower labour progress and increased caesarean delivery for failure to progress. Obesity is also associated with hyperlipidaemia and cholesterol inhibits myometrial contractility in vitro. Our aim was, among overweight and obese nulliparous women, to investigate 1. the role of early pregnancy serum cholesterol and 2. clinical risk factors associated with first stage caesarean for failure to progress at term., Methods: Secondary data analysis from a prospective cohort of overweight/obese New Zealand and Australian nullipara recruited to the SCOPE study. Women who laboured at term and delivered vaginally (n=840) or required first stage caesarean for failure to progress (n=196) were included. Maternal characteristics and serum cholesterol at 14-16 weeks' of gestation were compared according to delivery mode in univariable and multivariable analyses (adjusted for BMI, maternal age and height, obstetric care type, induction of labour and gestation at delivery ≥41 weeks)., Results: Total cholesterol at 14-16 weeks was not higher among women requiring first stage caesarean for failure to progress compared to those with vaginal delivery (5.55 ± 0.92 versus 5.67 ± 0.85 mmol/L, p= 0.10 respectively). Antenatal risk factors for first stage caesarean for failure to progress in overweight and obese women were BMI (adjusted odds ratio [aOR (95% CI)] 1.15 (1.07-1.22) per 5 unit increase, maternal age 1.37 (1.17-1.61) per 5 year increase, height 1.09 (1.06-1.12) per 1cm reduction), induction of labour 1.94 (1.38-2.73) and prolonged pregnancy ≥41 weeks 1.64 (1.14-2.35)., Conclusions: Elevated maternal cholesterol in early pregnancy is not a risk factor for first stage caesarean for failure to progress in overweight/obese women. Other clinically relevant risk factors identified are: increasing maternal BMI, increasing maternal age, induction of labour and prolonged pregnancy ≥41 weeks' of gestation.

Background: One in four New Zealand (NZ) women undergo caesarean section (CS); however, little is understood about how ethnicity influences CS rates. Previous NZ studies do not include many of NZ's ethnic groups and have been unable to account comprehensively for clinical risk factors., Aim: To investigate ethnicity as an independent risk factor for elective and emergency CS in nulliparous women at term. We hypothesised that compared with European, Māori and Pacific women would have a lower risk of elective CS, but there would be no ethnic differences in emergency CS., Methods: This was a retrospective cohort analysis of prospectively recorded maternity data at National Women's Health, Auckland, NZ from 2006 to 2009. The study population was 11 848 singleton, nulliparous, term births. Multivariable logistic regression analysis was performed for elective and emergency CS, accounting for comprehensive confounding factors., Results: The overall CS rate was 31.2% (elective 7.8%, n = 923 and emergency 23.4%, n = 2770). Compared with European ethnicity, Pacific and Chinese women had a reduced odds of elective CS (adjusted odds ratios, aOR 0.42, [95% CI 0.24-0.73] and 0.68, [0.49-0.94], respectively), while Indian women had an increased odds of emergency CS (aOR 1.54, [1.26-1.88]). Rates of elective or emergency CS for other ethnicities were similar to European., Conclusions: After adjustment for confounding, we report ethnic differences in elective and emergency CS rates, which may be related to patient and/or care provider factors. Further prospective research is recommended to examine reasons for these ethnic differences in CS rates., (© 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Infants born small for gestational age (SGA) by customised birthweight centiles are at increased risk of adverse outcomes compared with those SGA by population centiles. Risk factors for customised SGA have not previously been described in a general obstetric population., Aim: To determine independent risk factors for customised SGA in a multi-ethnic New Zealand population., Methods: We performed a retrospective cohort analysis of prospectively recorded maternity data from 2006 to 2009 at National Women's Health, Auckland, New Zealand. After exclusion of infants with congenital anomalies and missing data, our final study population was 26,254 singleton pregnancies. Multivariable logistic regression analysis adjusted for ethnicity, body mass index, maternal age, parity, smoking status, social deprivation, hypertensive disease, antepartum haemorrhage (APH), diabetes and relevant pre-existing medical conditions., Results: Independent risk factors for SGA included obesity (adjusted odds ratio 1.24 [95% CI 1.11-1.39] relative to normal weight), maternal age ≥ 35 years (1.16 [1.05-1.30] relative to 20-29 years), nulliparity (1.13 [1.04-1.24] relative to parity 1), cigarette smoking (2.01 [1.79-2.27]), gestational hypertension (1.46 [1.21-1.75]), pre-eclampsia (2.94 [2.49-3.48]), chronic hypertension (1.68 [1.34-2.09]), placental abruption (2.57 [1.74-3.78]) and APH of unknown origin (1.71 [1.45-2.00]). Gestational diabetes (0.80 [0.67-0.96]) and type 1 diabetes (0.26 [0.11-0.64]) were associated with reduced risk., Conclusions: We report independent pregnancy risk factors for customised SGA in a general obstetric population. In contrast to population SGA, obesity is associated with increased risk. Our findings may help identify pregnancies that require increased fetal growth surveillance., (© 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Pre-eclampsia rates are reported to vary by ethnicity; however, few studies include body mass index (BMI). Increasing BMI has a dose-dependent relationship with pre-eclampsia, and rates of overweight and obesity as well as ratios of body fat to muscle mass differ between ethnicities. We hypothesised that after adjusting for confounders, including ethnic-specific BMI, ethnicity would not be an independent risk factor for pre-eclampsia., Aim: To assess independent pre-eclampsia risk factors in a multiethnic New Zealand population., Methods: We performed a retrospective cohort analysis of prospectively recorded maternity data from 2006 to 2009 at National Women's Health, Auckland, New Zealand. After exclusion of infants with congenital anomalies and missing data, our final study population was 26 254 singleton pregnancies. Multivariable logistic regression analysis adjusted for ethnicity, BMI, maternal age, parity, smoking, social deprivation, diabetes, chronic hypertension and relevant pre-existing medical conditions was performed., Results: Independent associations with pre-eclampsia were observed in Chinese (adjusted odds ratio (aOR) 0.56, [95% CI 0.41-0.76]) and Māori (aOR 1.51, [1.16-1.96]) compared with European women. Other independent risk factors for pre-eclampsia were overweight and obesity, nulliparity, type 1 diabetes, chronic hypertension and pre-existing medical conditions., Conclusions: Contrary to our hypothesis, we report an independent reduced risk of pre-eclampsia in Chinese and increased risk of pre-eclampsia in Māori women. Prospective studies are required to further explore these relationships. Other independent risk factors are consistent with international literature. Our findings may assist clinicians to stratify risk of pre-eclampsia in clinical practice., (© 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Increasing rates of postpartum haemorrhage in developed countries over the past two decades are not explained by corresponding changes in risk factors and conjecture has been raised that maternal obesity may be responsible. Few studies investigating risk factors for PPH have included BMI or investigated PPH risk among nulliparous women. The aim of this study was to determine in a cohort of nulliparous women delivering at term whether overweight and obesity are independent risk factors for major postpartum haemorrhage (PPH ≥1000ml) after vaginal and caesarean section delivery., Methods: The study population was nulliparous singleton pregnancies delivered at term at National Women's Hospital, Auckland, New Zealand from 2006 to 2009 (N=11,363). Multivariable logistic regression was adjusted for risk factors for major PPH., Results: There were 7238 (63.7%) women of normal BMI, 2631 (23.2%) overweight and 1494 (13.1%) obese. Overall, PPH rates were increased in overweight and obese compared with normal-weight women (n=255 [9.7%], n=233 [15.6%]), n=524 [7.2%], p <.001) respectively. There was an approximate twofold increase in risk in obese nulliparous women that was independent of confounders, adjusted odds ratio [aOR (95% CI)] for all deliveries 1.86 (1.51-2.28). Being obese was a risk factor for major PPH following both caesarean 1.73 (1.32-2.28) and vaginal delivery 2.11 (1.54-2.89) and the latter risk was similar after exclusion of women with major perineal trauma and retained placentae. Three additional factors were consistently associated with risk for major PPH regardless of mode of delivery: increasing infant birthweight, antepartum haemorrhage and Asian ethnicity., Conclusion: Nulliparous obese women have a twofold increase in risk of major PPH compared to women with normal BMI regardless of mode of delivery. Higher rates of PPH among obese women are not attributable to their higher rates of caesarean delivery. Obesity is an important high risk factor for PPH, and the risk following vaginal delivery is emphasised. We recommend in addition to standard practice of active management of third stage of labour, there should be increased vigilance and preparation for PPH management in obese women.

Objective: We hypothesised that among nulliparous women with pre-eclampsia, overweight or obese women would have a different phenotype of pre-eclampsia compared with normal weight women with pre-eclampsia. Specifically, they are more likely to develop term pre-eclampsia and less likely to have indicators of impaired placental perfusion, e.g. abnormal uterine artery Doppler or a small-for-gestational-age (SGA) infant., Design: Prospective, multicentre, cohort SCOPE study (n = 3170)., Setting: New Zealand and Australia., Population: Nulliparous women who developed pre-eclampsia., Methods: Participants were interviewed at 14-16 weeks of gestation, uterine artery Doppler studies were performed at 19-21 weeks and pregnancy outcome was tracked prospectively., Main Outcome Measures: Rates of abnormal uterine artery Doppler indices, term/preterm birth and SGA infants were compared between normal, overweight and obese women with pre-eclampsia. Multivariable analysis was performed to examine the association between body mass index (BMI) and term pre-eclampsia., Results: Of 178 women with pre-eclampsia, one underweight woman was excluded and 66 (37%) were normal weight, 52 (29%) were overweight and 59 (34%) were obese. Pre-eclampsia developed preterm in 26% of women and at term in 74% of women. There were no differences in the rates of term/preterm pre-eclampsia, abnormal uterine artery Doppler indices or SGA infants between BMI groups (P > 0.10). No independent association between BMI and term pre-eclampsia was found (P = 0.56)., Conclusions: Among women with pre-eclampsia, those who are overweight or obese in early pregnancy are not more likely to have term pre-eclampsia compared with women with a normal BMI. Overweight and obese women require vigilant surveillance for the development of preterm as well as term pre-eclampsia., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Objective: To estimate in a cohort of nulliparous women in labor at term whether cesarean delivery rates are increased in first and second stages of labor in overweight and obese women and whether being overweight or obese is an independent risk factor for cesarean delivery., Methods: Nulliparous women recruited to the prospective Screening for Pregnancy Endpoints study who went into labor after 37 weeks of gestation were categorized according to ethnicity-specific body mass index (BMI) criteria as normal, overweight, or obese. Normal BMI was the referent. Multivariable analysis, adjusting for known confounders for obesity and cesarean delivery, was performed to estimate if being overweight or obese was associated with an increased risk of cesarean in labor (all cesarean deliveries and in first stage of labor)., Results: Of 2,629 participants, 1,416 (54%) had normal BMIs, 773 (29%) were overweight, and 440 (17%) were obese. First-stage cesarean delivery was increased in overweight (n=149 [19%]) and obese (n=137 [31%]) women compared with normal-weight women (n=181 [13%; P<.001), whereas second-stage cesarean delivery was similar (normal BMI 76 [6.2%], overweight 45 [7.2%], obese 23 [7.6%], P=.87). Being overweight or obese was an independent risk factor for all cesarean deliveries in labor with adjusted odds ratio (OR) of 1.34 (95% confidence interval [CI] 1.07-1.67) and 2.51 (95% CI 1.94-3.25), respectively. Similarly, being overweight (adjusted OR 1.39; 95% CI 1.09-1.79) or obese (adjusted OR 2.89; 95% CI 2.19-3.80) was associated with increased cesarean delivery during the first stage. Risks of cesarean delivery were similar regardless of whether ethnicity-specific or World Health Organization (WHO) BMI criteria were used., Conclusion: Among nulliparous women in labor at term, being overweight or obese by either WHO or ethnicity-specific BMI criteria is an independent risk factor for cesarean delivery in the first stage but not the second stage of labor., Clinical Trial Registration: Australian New Zealand Clinical Trials Registry, www.anzctr.org.au, ACTRN12607000551493.

The prevalence of overweight and obese people worldwide has dramatically increased in the last decades and is yet to peak. At the same time and partly due to obesity and associated assisted reproduction, twinning rates showed a clear rise in the last years. Adverse fetomaternal outcomes are known to occur in singleton and twin pregnancies in overweight and obese women. However, the impact of the obesity levels as defined by the World Health Organization on the outcomes of twin pregnancies has not been thoroughly studied. Therefore, the purpose of this study is to examine how maternal overweight, and the level of obesity affect fetomaternal outcomes in twin pregnancies, hypothesizing a higher likelihood for adverse outcomes with overweight and each obesity level. This is a retrospective cohort study with 2,349 twin pregnancies that delivered at the Buergerhospital Frankfurt, Germany between 2005 and 2020. The mothers were divided into exposure groups depending on their pre-gestational body mass index; these were normal weight (reference group), overweight and obesity levels I, II, and III. A multivariate logistic regression analysis was performed to assess the influence of overweight and obesity on gestational diabetes mellitus, preeclampsia, postpartum hemorrhage, intrauterine fetal death, and a five-minutes Apgar score below seven. The adjusted odds ratio for gestational diabetes compared to normal weight mothers were 1.47, 2.79, 4.05, and 6.40 for overweight and obesity levels I, II and III respectively (p = 0.015 for overweight and p < 0.001 for each obesity level). Maternal BMI had a significant association with the risk of preeclampsia (OR 1.04, p = 0.028). Overweight and obesity did not affect the odds of postpartum hemorrhage, fetal demise, or a low Apgar score. While maternal overweight and obesity did not influence the fetal outcomes in twin pregnancies, they significantly increased the risk of gestational diabetes and preeclampsia, and that risk is incremental with increasing level of obesity. [ABSTRACT FROM AUTHOR]

Background: Conservative surgical methods in the management of postpartum hemorrhage (PPH) cover operations that preserve fertility and prevent the need for a hysterectomy. They provide simplicity, safety and efficacy. Efficacy is defined as the ability to stop the bleeding after the hemostatic technique has been performed. This study aimed to assess the effectiveness of conservative surgical methods in the reduction of blood loss and management of PPH to avoid hysterectomy. Methods: Stepwise uterine devascularization and uterine compressive sutures were performed for 78 patients in this interventional cohort study to control intractable PPH not responding to classic management. This study entailed four procedures: compressive sutures, bilateral uterine artery ligation, bilateral utero-ovarian artery ligation and internal iliac artery ligation. All patients were divided into four groups, and we did one single procedure in each group, so if bleeding was not controlled by one procedure a second procedure was done then third and fourth procedure until bleeding stopped. Results: We found that the success rate of uterine compression suture + ovarian artery ligation + uterine artery ligation was 25.9%. Finally, the success rate of the combined four methods of conservative surgical management was 75%, the most prevalent intraoperative and postoperative complications are bladder injury and admission to the intensive care unit (ICU) (7.8 and 14 % of cases respectively). Conclusions: To achieve a high success rate of conservative surgical management for early PPH, we recommend that obstetricians decide to perform early conservative surgical procedures. [ABSTRACT FROM AUTHOR]

The small-for-gestational-age (SGA) condition often causes serious problems. Therefore, identifying the risk factors for SGA is important. Traditional statistical methods such as stepwise logistic regression (LR) have been widely utilized to discover possible risk factors. However, other feature selection methods from machine learning field have rarely been employed for the task. In this paper, a comparison of five feature selection methods from both fields for SGA risk factors analysis is conducted for the first time. To evaluate their performance, four classification algorithms are used to construct SGA prediction models. The evaluation criteria are precision and the area under the receiver operator characteristic curve. Stepwise LR achieves the best performance among the five feature selection methods, because it conducts both a univariate significance test and a model significance test, which make it more suitable for handling the complex relations among features. The top 20 features selected by each feature selection method and the 27 features selected by four or five of them could assist physicians to revise traditional SGA evaluation models. Ensemble method is also exploited to build effective SGA prediction models based on the feature subsets, which is indeed superior compared with the individual ones shown in the results. [ABSTRACT FROM AUTHOR]

Objective: To compare pre‐eclampsia risk factors identified by clinical practice guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre‐eclampsia prevention. Design: Our search strategy provided hierarchical evidence of relationships between risk factors and pre‐eclampsia using Medline (Ovid), searched from January 2010 to January 2021. Setting: Published studies and CPGs. Population Pregnant women. Methods: We evaluated the strength of association and quality of evidence (GRADE). CPGs (n = 15) were taken from a previous systematic review. Main outcome measure: Pre‐eclampsia. Results: Of 78 pre‐eclampsia risk factors, 13 (16.5%) arise only during pregnancy. Strength of association was usually 'probable' (n = 40, 51.3%) and the quality of evidence was low (n = 35, 44.9%). The 'major' and 'moderate' risk factors proposed by 8/15 CPGs were not well aligned with the evidence; of the ten 'major' risk factors (alone warranting aspirin prophylaxis), associations with pre‐eclampsia were definite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5) or very low (n = 1) quality evidence. Obesity ('moderate' risk factor) was definitely associated with pre‐eclampsia (high‐quality evidence). The other ten 'moderate' risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre‐eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) quality. Three risk factors not identified by the CPGs had probable associations (high quality): being overweight; 'prehypertension' at booking; and blood pressure of 130–139/80–89 mmHg in early pregnancy. Conclusions: Pre‐eclampsia risk factors in CPGs are poorly aligned with evidence, particularly for the strongest risk factor of obesity. There is a lack of distinction between risk factors identifiable in early pregnancy and those arising later. A refresh of the strategies advocated by CPGs is needed. Linked article: This article is commented on by Stefan C. Kane et al., pp. 63 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471‐0528.17311. [ABSTRACT FROM AUTHOR]

To compare the perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section. A retrospective analysis of 6 years of data was performed. Exclusions were cases with gestational ages <24 weeks, placenta accreta spectrum, polyhydramnios, or multiple gestations. The study included 494 patients whose body mass index (BMI) exceeded 40 kg/m2 at delivery. Of these, 469 were morbidly obese (BMI 40–49.9; mean, 42.9 ± 2.4), and 25 were super obese (BMI >50; mean, 54.5 ± 4.2). Twenty-four (5.1%) morbidly obese women received general anesthesia. The other 445 patients (94.9%) in the morbid obesity group underwent cesarean delivery under regional anesthesia; however, some (2.2%; 10/445) received general anesthesia after regional anesthesia failed. In the super-obesity group, 23 patients (92.0%) received regional anesthesia, while two patients (8.0%) received general anesthesia. There were no cases of pulmonary aspiration, maternal deaths, or difficult or failed intubation. There was one episode of cardiac arrest in a patient with a BMI of 47.9. Among the morbidly obese and super-obese women given regional anesthesia, the super-obese patients had significantly greater volumes of ephedrine and norepinephrine consumption (p = 0.027 and 0.030), intravenous fluids (p = 0.006), and bleeding during surgery (p = 0.017). They also had more hypotensive episodes (p = 0.038). The two groups' incidences of neonatal birth asphyxia, postpartum hemorrhage, blood transfusion, and uterine atony did not differ significantly. The lengths of stay in the hospital were also comparable. Among the women receiving regional anesthesia, the super-obese parturients had greater intraoperative bleeding, a higher proportion of hypotensive episodes, and a greater vasopressor requirement than the morbidly obese parturients. Anesthesiologists must prepare for the adverse perioperative events that such women risk experiencing during a delivery by cesarean section. ID: NCT04657692. Super obesity parturients are at a significantly higher risk of intraoperative bleeding, maternal hypotension, and higher vasopressor requirement compared to parturients with morbid obesity undergoing cesarean delivery. We additionally found a weak positive correlation between patient body weight and intraoperative blood loss in a patient with morbid obesity regardless of anesthetic technique. [ABSTRACT FROM AUTHOR]

Background: Gestational weight gain (GWG) is a risk factor for adverse pregnancy outcomes, future obesity and chronic diseases among women. However, has not received much attention in many low and middle-income countries such as Nigeria. We investigated the pattern, associated factors and pregnancy outcomes of GWG in Ibadan, Nigeria, using the Ibadan Pregnancy Cohort Study (IbPCS). Methodology: The IbPCS is a multicentre prospective cohort study conducted among 1745 pregnant women recruited from four health facilities in Ibadan, Nigeria. GWG, the primary outcome, was categorised according to the Institute of Medicine's classification into insufficient, adequate and excessive weight gain. Pregnancy outcomes were the secondary outcome variables. Logistic regression analysis (Adjusted odds ratios and 95% confidence interval CI) was used to examine associations, and Poisson regression analyses were used to investigate associations with outcomes. Results: Only 16.9% of women had optimal GWG, 56.8% had excessive GWG, and 26.9% had insufficient GWG. Excessive GWG was associated with high income '> #20,000-' (AOR: 1.64, 95% CI: 1.25–2.17), being overweight (AOR: 2.12, 95% CI: 1.52–2.95) and obese (AOR: 1.47, 95% CI: 1.02–2.13) after adjusting for confounders. In contrast, increased odds of insufficient GWG have associated women with depression (AOR: 1.70, 95% CI 1.17–2.47). There was no significant association between inappropriate GWG and pregnancy outcomes However, there was an increased odds for postpartum haemorrhage (AOR: 2.44, 95% CI 1.14–5.22) among women with obesity and excessive GWG. Conclusions: Excessive GWG was the most typical form of GWG among our study participants and was associated with high maternal income, and being overweight or obese. GWG needs to be monitored during antenatal care, and interventions that promote appropriate GWG should be implemented among pregnant women in Nigeria. [ABSTRACT FROM AUTHOR]

We aimed to evaluate the association between obesity and postpartum hemorrhage (PPH) after cesarean delivery (CD). This was a retrospective cohort study using a multicenter database of 20 hospitals in the United States. We analyzed 27,708 patients undergoing CD from 2015 to 2019. The exposure of interest was BMI, and the primary outcome was PPH (estimated blood loss [EBL] ≥ 1000 mL). Simple logistic regression was used to evaluate the relationship between obesity and intrapartum complications. Multivariable logistic regression was used to adjust for any confounding demographic variables. Hosmer and Lemeshow's purposeful selection algorithm was adapted to develop a multivariable logistic regression model of PPH. Analyses were conducted using STATA 16.1 (College Station, Texas) with p ≤ 0.05 considered significant. BMI exerted a significant effect on the frequency of PPH (p = 0.004). Compared to patients with BMI 18.5–24.9 kg/m2, patients with BMI between 25 and 59.9 kg/m2 had an increased odds of PPH. The odds of PPH in patients with BMI > 60 kg/m2 was not increased compared to patients with BMI 18.5–24.9 kg/m2. Obesity was associated with a decreased odds of blood transfusion (aOR 0.73, 95% CI 0.55–0.97). In conclusion, higher BMI was associated with PPH yet a lower odds of transfusion after CD. [ABSTRACT FROM AUTHOR]

Introduction: Caesarean section (C-section) is a life-saving procedure when medically indicated but unmet need and overuse can add to avoidable morbidity and mortality. It is not clear whether C-section has a negative impact on breastfeeding and there is limited data available on rates of C-section or breastfeeding from Northern Cyprus, an emerging region in Europe. This study aimed to investigate prevalence, trends and associations of C-section and breastfeeding in this population. Methods: Using self-reported data from the representative Cyprus Women's Health Research (COHERE) Initiative, we used 2,836 first pregnancies to describe trends in C-section and breastfeeding between 1981 and 2017. Using modified Poisson regression, we examined the relationship between year of pregnancy and C-section and breastfeeding, as well as the association between C-section and breastfeeding prevalence and duration. Results: C-section prevalence in first pregnancies increased from 11.1% in 1981 to 72.5% in 2017 with a relative risk of 2.60 (95%CI; 2.14–2.15) of babies being delivered by C-section after 2005 compared to before 1995, after full adjustment for demographic and maternal medical and pregnancy related factors. Prevalence of ever breastfeeding remained steady throughout the years at 88.7% and there was no significant association between breastfeeding initiation and the year of pregnancy, or demographic and maternal medical and pregnancy related variables. After full adjustment, women who gave birth after 2005 were 1.24 (95%CI; 1.06–1.45) times more likely to breastfeed for >12 weeks compared to women who gave birth before 1995. There was no association between C-section and breastfeeding prevalence or length. Conclusion: Prevalence of C-section in this population is much higher than WHO recommendations. Public awareness campaigns surrounding choice during pregnancy and change in legal framework to allow for midwife-led continuity models of birthing care should be implemented. Further research is required to understand the reasons and drivers behind this high rate. [ABSTRACT FROM AUTHOR]

Objective: To estimate the impact of body mass index (BMI) categories on duration of the nonstress test (NST), and the need for additional tests of fetal wellbeing or interventions. Methods: We conducted a retrospective cohort study of women with singleton pregnancies who had an NST for the indications of severe obesity (BMI ≥40 kg/m2), diabetes (pre-gestational or gestational), hypertensive disorders (chronic, gestational, and preeclampsia), and others between 1 January 2015 until 31 December 2016. NST durations (<30 and ≥30 min) were compared between groups first based on BMI (kg/m2) categories (<30, 30–39, 40–49, and ≥50) and then based on BMI and comorbidities: (1) severe obesity alone, (2) severe obesity and comorbidities, and (3) comorbidities alone. We compared the results of the NSTs, any subsequent fetal testing or interventions, and pregnancy outcomes among groups. Demographic information was compared using t-tests for continuous data and χ2 analyses or Fisher's exact test, if the cells sizes were small, for categorical data. NST durations based on BMI groups, as well as BMI and comorbidities groups, were compared using linear mixed models and ANOVA. Results: Three hundred and fifty-one women underwent 1665 NSTs during the study period. After excluding women <18 and >50 years, gestational age <30 weeks, fetal anomalies, and NSTs lasting longer than 60 min, the study population included 313 women and 1471 NSTs. The mean NST duration in minutes of the BMI ≥50 (32.2 ± 9.6) category was significantly longer than the NST duration of the other BMI categories (BMI <30: 29.4 ± 8.3; BMI 30–39: 29.7 ± 8.9; BMI 40–49: 29.9 ± 8.3) (p=.05). Additionally, there was an increased percentage of NSTs lasting ≥30 min as the BMI category increased (p=.005). Women in the severe obesity and comorbidities group (n = 79) were less likely to have a reactive NST than women with severe obesity alone (n = 56) or comorbidities alone (n = 178) (92% vs. 97% vs. 98%, p<.0001). They were also more likely to need a biophysical profile (BPP) (8% vs. 3% vs. 2%, p<.0001). Of the 25 women that were sent to the labor and delivery unit for evaluation, 20 (80%) were admitted and delivered. The reasons for delivery were hypertension (n = 9, 45%), an abnormal NST (n = 5, 25%), oligohydramnios (n = 4, 20%), and labor (n = 2, 10%). Conclusions: We found an increase in NST duration as the BMI increased. Women with severe obesity and a comorbidity were more likely to have a nonreactive NST and require a subsequent BPP. Of the 20 patients delivered due to NST surveillance, the most common indication for delivery was hypertension. [ABSTRACT FROM AUTHOR]

Objectives: To examine the association between race and pre‐eclampsia and gestational hypertension after adjustment for factors in maternal characteristics and medical history in a screening study from the Fetal Medicine Foundation (FMF) in England, and to perform a systematic review and meta‐analysis of studies on pre‐eclampsia. Design: Prospective observational study and systematic review with meta‐analysis. Setting: Two UK maternity hospitals. Population: A total of 168 966 women with singleton pregnancies attending for routine ultrasound examination at 11–13 weeks of gestation without major abnormalities delivering at 24 weeks or more of gestation. Methods: Regression analysis examined the association between race and pre‐eclampsia or gestational hypertension in the FMF data. Literature search to December 2021 was carried out to identify peer‐reviewed publications on race and pre‐eclampsia. Main outcome measure: Relative risk of pre‐eclampsia and gestational hypertension in women of black, South Asian and East Asian race by comparison to white women. Results: In black women, the respective risks of total‐pre‐eclampsia and preterm‐pre‐eclampsia were 2‐fold and 2.5‐fold higher, respectively, and risk of gestational hypertension was 25% higher; in South Asian women there was a 1.5‐fold higher risk of preterm pre‐eclampsia but not of total‐pre‐eclampsia and in East Asian women there was no statistically significant difference in risk of hypertensive disorders. The literature search identified 19 studies that provided data on several million pregnancies, but 17 were at moderate or high‐risk of bias and only three provided risks adjusted for some maternal characteristics; consequently, these studies did not provide accurate contributions on different racial groups to the prediction of pre‐eclampsia. Conclusion: In women of black and South Asian origin the risk of pre‐eclampsia, after adjustment for confounders, is higher than in white women. In women of black and South Asian origin the risk of pre‐eclampsia, after adjustment for factors in maternal characteristics and medical history, is higher than in white women. This article includes Author Insights, a video abstract available at: https://vimeo.com/bjogabstracts/authorinsights17240 [ABSTRACT FROM AUTHOR]

Background: Obesity in pregnancy is common, with more than 50% of pregnant women being overweight or obese. Obesity has been identified as an independent predictor of dysfunctional labor and is associated with increased risk of failed induction of labor resulting in cesarean section. Leptin, an adipokine, is secreted from adipose tissue under the control of the obesity gene. Concentrations of leptin increase with increasing percent body fat due to elevated leptin production from the adipose tissue of obese individuals. Interestingly, the placenta is also a major source of leptin production during pregnancy. Leptin has regulatory effects on neuronal tissue, vascular smooth muscle, and nonvascular smooth muscle systems. It has also been demonstrated that leptin has an inhibitory effect on myometrial contractility with both intensity and frequency of contractions decreased. These findings suggest that leptin may play an important role in dysfunctional labor and be associated with the outcome of induction of labor at term. Our aim is to determine whether maternal plasma leptin concentration is indicative of the outcome of induction of labor at term. We hypothesize that elevated maternal plasma leptin levels are associated with a failed term induction of labor resulting in a cesarean delivery. Methods: In this case-control study, leptin was measured in 3rd trimester plasma samples. To analyze labor outcomes, 174 women were selected based on having undergone an induction of labor (IOL), (115 women with successful IOL and 59 women with a failed IOL). Plasma samples and clinical information were obtained from the UI Maternal Fetal Tissue Bank (IRB# 200910784). Maternal plasma leptin and total protein concentrations were measured using commercially available assays. Bivariate analyses and logistic regression models were constructed using regression identified clinically significant confounding variables. All variables were tested at significance level of 0.05. Results: Women with failed IOL had higher maternal plasma leptin values (0.5 vs 0.3 pg, P = 0.01). These women were more likely to have obesity (mean BMI 32 vs 27 kg/m2, P = 0.0002) as well as require multiple induction methods (93% vs 73%, p = 0.008). Logistic regression showed Bishop score (OR 1.5, p < 0.001), BMI (OR 0.92, P < 0.001), preeclampsia (OR 0.12, P = 0.010), use of multiple methods of induction (OR 0.22, P = 0.008) and leptin (OR 0.42, P = 0.017) were significantly associated with IOL outcome. Specifically, after controlling for BMI, Bishop Score, and preeclampsia, leptin was still predictive of a failed IOL with an odds ratio of 0.47 (P = 0.046). Finally, using leptin as a predictor for fetal outcomes, leptin was also associated with of fetal intolerance of labor, with an odds ratio of 2.3 (P = 0.027). This association remained but failed to meet statistical significance when controlling for successful (IOL) (OR 1.5, P = 0.50). Conclusions: Maternal plasma leptin may be a useful tool for determining which women are likely to have a failed induction of labor and for counseling women about undertaking an induction of labor versus proceeding with cesarean delivery. [ABSTRACT FROM AUTHOR]

Objective: To compare pre-eclampsia risk factors identified by clinical practice guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre-eclampsia prevention., Design: Our search strategy provided hierarchical evidence of relationships between risk factors and pre-eclampsia using Medline (Ovid), searched from January 2010 to January 2021., Setting: Published studies and CPGs., Population: Pregnant women., Methods: We evaluated the strength of association and quality of evidence (GRADE). CPGs (n = 15) were taken from a previous systematic review., Main Outcome Measure: Pre-eclampsia., Results: Of 78 pre-eclampsia risk factors, 13 (16.5%) arise only during pregnancy. Strength of association was usually 'probable' (n = 40, 51.3%) and the quality of evidence was low (n = 35, 44.9%). The 'major' and 'moderate' risk factors proposed by 8/15 CPGs were not well aligned with the evidence; of the ten 'major' risk factors (alone warranting aspirin prophylaxis), associations with pre-eclampsia were definite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5) or very low (n = 1) quality evidence. Obesity ('moderate' risk factor) was definitely associated with pre-eclampsia (high-quality evidence). The other ten 'moderate' risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre-eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) quality. Three risk factors not identified by the CPGs had probable associations (high quality): being overweight; 'prehypertension' at booking; and blood pressure of 130-139/80-89 mmHg in early pregnancy., Conclusions: Pre-eclampsia risk factors in CPGs are poorly aligned with evidence, particularly for the strongest risk factor of obesity. There is a lack of distinction between risk factors identifiable in early pregnancy and those arising later. A refresh of the strategies advocated by CPGs is needed., (© 2022 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Purpose: To assess the independent and joint contribution of the individual components of metabolic syndrome, and known risk factors for gestational diabetes (GDM), on risk of GDM. Methods: Two thousand nine hundred and fifteen women from Australia and New Zealand, who participated in The Screening for Pregnancy Endpoints Study (SCOPE), were included. Using the SCOPE clinical data set and biomarkers obtained at 14–16 weeks' gestation, a logistic regression model was fitted to the binary outcome GDM, with individual metabolic syndrome components (waist circumference, blood pressure, glucose, HDL-C, triglycerides), recruitment site, and other established factors associated with GDM. Hierarchical partitioning was used to assess the relative contribution of each variable. Results: Of the 2915 women, 103 women (3.5%) developed GDM. The deviance explained by the logistic regression model containing all variables was 18.65% and the AUC was 0.809. Seventy percent of the independent effect was accounted for by metabolic syndrome components. The highest independent relative contribution to GDM was circulating triglycerides (17 ± 3%), followed by waist circumference (13 ± 3%). Glucose and maternal BMI contributed 12 ± 2% and 12 ± 3%, respectively. The remaining factors had an independent relative contribution of < 10%. Conclusion: Triglyceride concentrations had the highest independent relative importance for risk of GDM. Increased focus for lowering triglycerides as an important risk factor for GDM is warranted. [ABSTRACT FROM AUTHOR]

Many factors can negatively impact perinatal outcomes, including inappropriate gestational weight gain (GWG). Despite having the greatest potential to influence maternal and infant health, there is a lack of consensus regarding the GWG consistent with a healthy pregnancy. To date, GWG in Northern Tasmania remains understudied. We investigated how maternal pre-pregnancy body mass index (BMI) is related to weight gain during pregnancy and weight retention post-partum, and how maternal pre-pregnancy BMI is related to the mode of delivery. Approximately 300 Tasmanian mothers (n = 291 for mode of delivery and n = 282 for GWG) were included in this study. Analysis of variance and chi square tests were conducted to assess differences in BW of mothers across BMI categories and differences between categorical variables; respectively. Based on pre-pregnancy BMI, mothers were assigned to one of three groups, with healthy weight (<25 kg m-2), with overweight (25–29.9 kg m-2), or with obesity (>30 kg m-2). Pre-pregnancy BMI and body weight (BW) were significantly associated (p<0.001) with post-partum BW at 3 and 6 months. Only 25% of mothers with a normal weight BMI, 34% with overweight and 13% with obesity, achieved the Institute of Medicine (IOM) recommendation for GWG. Interestingly, a number of women in our cohort lost weight during gestation (1.5, 9 and 37% in <25, 25–29.9 and >30 kg m-2 groups, respectively). Further, women with obesity showed the lowest level of BW fluctuation and retained less weight post-partum. The highest number of caesarean sections were observed in mothers who exceeded GWG recommendations. Most mothers either exceeded or failed to achieve IOM recommendations for GWG. To improve the generalisability of these findings, this study should be replicated in a larger representative sample of the Tasmanian maternal population. [ABSTRACT FROM AUTHOR]

Background: It is a common misconception that women with active anorexia nervosa (AN) are less likely to conceive. Pregnancies in women with AN are considered high risk. The purpose of this systematic review was to explore pregnancy complications in women with active AN, including maternal, fetal, and neonatal complications. Methods: The authors conducted a systematic review in accordance with PRISMA statement guidelines with stringent selection criteria to include studies on patients with active AN during pregnancy. Results: There were 21 studies included in our review. Anaemia, caesarean section, concurrent recreational substance use, intrauterine growth restriction, preterm birth, small-for-gestation (SGA) birth, and low birth weight were the most reported pregnancy complications in women with active AN, while the rates of gestational diabetes and postpartum haemorrhage were lower. Discussion: Women with active AN have a different profile of pregnancy complications comparing to malnourished women and women in starvation. We recommend early discussion with women diagnosed with AN regarding their fertility and pregnancy complications. We recommend clinicians to aim to improve physical and psychological symptoms of AN as well as correction of any nutritional deficiency ideally prior to conception. Management of pregnancies in women with active AN requires regular monitoring, active involvement of obstetricians and psychiatrist. Paediatric follow-up postpartum is recommended to ensure adequate feeding, wellbeing and general health of the infants. Psychiatric follow-up is recommended for mothers due to risk of worsening symptoms of AN during perinatal period. Plain English summary: It is a common myth that women with active anorexia nervosa are less likely to become pregnant. Generally, pregnancies in women with active anorexia nervosa are considered high risk. This review looked at pregnancy complications in women with active anorexia nervosa that affect the mothers as well as unborn and newborn babies. There are number of complications reported, most commonly, anaemia, increased chance of birth by C-section, increased risk of substance use in mothers, poor growth of unborn babies, and smaller babies at birth. Mothers with anorexia nervosa are less likely to suffer from pregnancy related diabetes and postpartum haemorrhage. Interestingly, women with active anorexia nervosa tend to have different pregnancy complications comparing to women without adequate nutrition and women in starvation. It is important to mention that although women with anorexia nervosa carry higher risk of complications during pregnancy, the risk can be reduced with the help of obstetricians and psychiatrists. After birth, paediatrician visits can help identify any issue with the baby. Symptoms of anorexia nervosa could potentially get worse after delivering a baby. It is important to continue regular visits to a psychiatrist. [ABSTRACT FROM AUTHOR]

Objective  We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. Study Design  This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m 2) and nonobese (<30 kg/m 2) women. Indication for cesarean was also evaluated. Results  A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p  = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34–2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p  = 0.01) without a difference in arrest of active phase (p  = 0.39), arrest of descent (p  = 0.95) or fetal indication (p  = 0.32), despite adherence to a standardized labor protocol. Conclusion  Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. Key Points Even with a standardized induction protocol, women with obesity are at higher risk of cesarean. In particular, women with obesity are at increased risk of cesarean for failed induction. These findings support a possible biologic relationship between obesity and failed induction. [ABSTRACT FROM AUTHOR]

Background: Maternal obesity is a significant risk factor for unfavourable outcomes during pregnancy. However, the extent of this relationship is poorly defined in Irish mothers. Aims: This study was to compare maternal and perinatal outcomes between obese and non-obese mothers in an Irish population. Methods: A retrospective comparative study was conducted in a secondary level maternity unit for births recorded between January 2018 and January 2019 and 2,793 women were included. BMI calculated at booking visit was used to compare obese (BMI ≥ 30 kg/m2) and non-obese mothers (BMI < 30 kg/m2). Results: Of 2,793 women included in this study, 2111 had a BMI < 30 kg/m2 and 682 had a BMI ≥ 30 kg/m2. Obese women were less likely to experience spontaneous onset of labour (33.4% vs. 48.1%, p < 0.001) and more likely to be induced (37.2% vs. 31.0%, p = 0.002). Obesity was associated with a statistically significant increase in stillbirth, fetal macrosomia and emergency caesarean birth rates, whereas operative vaginal deliveries were significantly decreased. Miscarriage, shoulder dystocia, post-partum haemorrhage and spontaneous vaginal deliveries were reduced while elective caesarean birth and low birth weight incidence were increased in obese mothers; however, these results were not statistically significant. Conclusions: This study highlights the magnitude of obstetric risks that are associated with maternal obesity within Irish population. Implementation of effective intervention strategies to reduce the number of obese women in pregnancy may have beneficial effects on pregnancy outcomes in Ireland. [ABSTRACT FROM AUTHOR]

Background: Being born small for gestational age is a strong predictor of the short- and long-term health of the neonate, child, and adult. Variation in the rates of small for gestational age have been identified across population groups in high income countries, including Australia. Understanding the factors contributing to this variation may assist clinicians to reduce the morbidity and mortality associated with being born small. Victoria, in addition to New South Wales, accounts for the largest proportion of net overseas migration and births in Australia. The aim of this research was to analyse how migration was associated with small for gestational age in Victoria.Methods: This was a cross sectional population health study of singleton births in Victoria from 2009 to 2018 (n = 708,475). The prevalence of being born small for gestational age (SGA; <10th centile) was determined for maternal region of origin groups. Multivariate logistic regression analysis was used to analyse the association between maternal region of origin and SGA.Results: Maternal region of origin was an independent risk factor for SGA in Victoria (p < .001), with a prevalence of SGA for migrant women of 11.3% (n = 27,815) and 7.3% for Australian born women (n = 33,749). Women from the Americas (aOR1.24, 95%CI:1.14 to 1.36), North Africa, North East Africa, and the Middle East (aOR1.57, 95%CI:1.52 to 1.63); Southern Central Asia (aOR2.58, 95%CI:2.50 to 2.66); South East Asia (aOR2.02, 95%CI: 1.95 to 2.01); and sub-Saharan Africa (aOR1.80, 95%CI:1.69 to 1.92) were more likely to birth an SGA child in comparison to women born in Australia.Conclusions: Victorian woman's region of origin was an independent risk factor for SGA. Variation in the rates of SGA between maternal regions of origin suggests additional factors such as a woman's pre-migration exposures, the context of the migration journey, settlement conditions and social environment post migration might impact the potential for SGA. These findings highlight the importance of intergenerational improvements to the wellbeing of migrant women and their children. Further research to identify modifiable elements that contribute to birthweight differences across population groups would help enable appropriate healthcare responses aimed at reducing the rate of being SGA. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to estimate second stage duration and its effects on labor outcomes in obese versus nonobese nulliparous women. Study Design  This was a secondary analysis of a cohort of nulliparous women who presented for labor at term and reached complete cervical dilation. Adjusted relative risks (aRR) were used to estimate the association between obesity and second stage characteristics, composite neonatal morbidity, and composite maternal morbidity. Effect modification of prolonged second stage on the association between obesity and morbidity was assessed by including an interaction term in the regression model. Results  Compared with nonobese, obese women were more likely to have a prolonged second stage (aRR: 1.48, 95% CI: 1.18–1.85 for ≥3 hours; aRR: 1.65, 95% CI: 1.18–2.30 for ≥4 hours). Obesity was associated with a higher rate of second stage cesarean (aRR: 1.78, 95% CI: 1.34–2.34) and cesarean delivery for fetal distress (aRR: 2.67, 95% CI: 1.18–3.58). Obesity was also associated with increased rates of neonatal (aRR: 1.38, 95% CI: 1.05–1.80), but not maternal morbidity (aRR: 1.06, 95% CI: 0.90–1.25). Neonatal morbidity risk was not modified by prolonged second stage. Conclusion  Obesity is associated with increased risk of neonatal morbidity, which is not modified by prolonged second stage of labor. [ABSTRACT FROM AUTHOR]

Background: Adverse pregnancy outcomes are more common in women with hyperglycaemia. Many women have suboptimal uptake of HbA1c testing postdelivery. Aims: To compare pregnancy outcomes among multi‐ethnic women with different degrees of hyperglycaemia during pregnancy, and their association with postnatal HbA1c uptake after the introduction of email reminders. Materials and Methods: A retrospective and prospective single‐centre study was conducted in South Auckland in 2639 women with early gestational diabetes mellitus (GDM) (diagnosed < 20 weeks), late GDM (diagnosed ≥ 20 weeks), overt diabetes in pregnancy, or known type 2 diabetes (T2DM) during pregnancy. Automated email reminders were sent to general practitioners to increase postnatal HbA1c screening. Results: HbA1c during pregnancy increased across the late GDM (n = 1425), early GDM (n = 148), overt diabetes (n = 573) and T2DM (n = 493) groups (P < 0.001). Stillbirth was least common in the late GDM group (0, 0.7, 0.5, and 1.9%, respectively, P < 0.001), as were caesarean delivery (32.7, 45.1, 39.4, and 53.5%, respectively, P < 0.001), large for gestational age (LGA) (14.7, 18.2, 22.3, and 30.5%, respectively, P < 0.001), small for gestational age (8.8, 16.7, 11.0, and 11.1%, respectively, P = 0.02), and preeclampsia/eclampsia (7.7, 9.2, 13.0, and 14.8%, respectively, P < 0.001). LGA and preeclampsia/eclampsia were more common among Pacific and Māori women than European women (LGA, 30.1, 22.7, 10.3%, respectively, P < 0.001; preeclampsia/eclampsia, 13.5, 14.0, and 8.1%, respectively, P < 0.001). Postpartum HbA1c screening increased among women with GDM/overt diabetes after the introduction of the reminder emails (39.6% vs 34.0%, P = 0.03). Conclusions: Women with late GDM are least likely to experience adverse outcomes. Email reminders to improve postpartum HbA1c screening warrant further investigation. [ABSTRACT FROM AUTHOR]

Study Question: Does publicly funded assisted reproductive technology result in improved maternal and infant outcomes?Summary Answer: Publicly funded ART in Quebec was associated with reduced risks of preeclampsia, cesarean delivery, preterm birth, low birth weight and other adverse outcomes.What Is Known Already: Publicly funded ART programs that provide free access to single embryo transfer are known to decrease the rate of multiple pregnancy, but the impact on other pregnancy outcomes is unknown.Study Design, Size, Duration: We conducted a pre- and post-comparison study of 597 416 pregnancies conceived between July 2008 and September 2015 in Quebec, Canada, a region where public funding of ART began in August 2010.Participants/materials, Setting, Methods: We included all pregnant women who conceived by ART (n = 14 309) or spontaneously (n = 583 107) and delivered a live or stillborn infant in hospitals of Quebec. The main exposure measure was conception before versus during the publicly funded ART program. Outcomes included measures of maternal and infant morbidity and mortality. We estimated risk ratios (RR) and 95% confidence intervals for the association of publicly funded ART with maternal and infant outcomes using log-binomial regression models adjusted for maternal characteristics.Main Results and the Role Of Chance: In this study, 2638 pregnancies were conceived by ART before, and 11 671 were conceived by ART, during public funding. Compared with no public funding, ART funding was associated with reduced risks of severe maternal morbidity (RR 0.64, 95% CI 0.50-0.83), preeclampsia (RR 0.55, 95% CI 0.44-0.68), cesarean delivery (RR 0.83, 95% CI 0.77-0.89), preterm birth (RR 0.67, 95% CI 0.60-0.75), low birth weight (RR 0.63, 95% CI 0.55-0.72), severe neonatal morbidity (RR 0.75, 95% CI 0.57-0.99) and neonatal intensive care unit admission (RR 0.65, 95% CI 0.53-0.78). When multiple pregnancies were excluded, ART funding continued to be associated with a lower risk of preeclampsia (RR 0.61, 95% CI 0.48-0.79) and preterm birth (RR 0.85, 95% CI 0.73-0.99). However, ART funding was associated with increased risk of gestational diabetes.Limitations, Reasons For Caution: We had no information on the type of ART, number of in-vitro fertilization cycles or number of embryos transferred. We lacked data on body mass index, ethnicity and smoking and cannot rule out residual confounding.Wider Implication Of the Findings: Our findings suggest that publicly funded ART programs that encourage single embryo transfer may have substantial benefits for a range of maternal and infant outcomes, beyond prevention of multiple births.Study Funding/competing Interest(s): This study was supported by grant 6D02363004 from the Public Health Agency of Canada. N.A. acknowledges a career award from the Fonds de recherche du Québec-Santé (34695). The authors declare no competing interests.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Background: Preeclampsia is a significant cause of maternal morbidity and mortality, affecting up to 8% of pregnancies globally. Although the precise etiology is still under study, the literature suggests that vascular changes reduce placental perfusion and affect the remodeling of spiral arteries to create the hallmark feature of preeclampsia: elevated blood pressure. Screening for preeclampsia is currently recommended for all pregnant women, particularly if risk factors exist. A noted risk factor codified in guidelines is "African-American race." Content: We summarize the racial disparities in preeclampsia incidence, morbidity, and mortality. We consider the limitations of using race to understand disparities by also examining multiethnic, immigration, and international studies. We then critically evaluate laboratory analytes associated with racial disparities of preeclampsia and explore other mechanisms of action, such as socioeconomic status, stress, and access to care. Summary: Black and African-American women are consistently at higher risk of preeclampsia incidence, morbidity, and mortality than their white counterparts. Asian women are consistently at lower risk of preeclampsia, whereas the association for Hispanic women remains unclear. When these broad racial categories are subdivided by geographic or cultural origin, preeclampsia disparities within racial groups are identified. The limited literature suggests that sub-Saharan African immigrants tend to have a higher risk of preeclampsia than US-born white populations but a lower risk than US-born Black women. Existing studies seeking to identify racial differences in analytes have limited research designs and tend to operationalize race as a proxy for biologically inherent (i.e., genetic) differences between races despite a plethora of other possible explanatory mechanisms. [ABSTRACT FROM AUTHOR]

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Objective: To evaluate the impact of obesity on maternal and neonatal outcome. Study Design: Comparative cross sectional study. Place and Duration of Study: Department of Gynaecology and Obstetrics, Pakistan Naval Ship, Shifa Hospital Karachi, from Nov 2016 to Oct 2017. Methodology: All singleton pregnant women of normal prepregnancy body mass index (BMI) and obese women having ≥30 body mass index, delivering newborn at 28-42 weeks of gestation were included. Comparison of antenatal complications and neonatal outcomes was done among both groups. Results: Obese women significantly developed gestational hypertension (OR=7.4 95% CI, 4.84-11.4), preeclampsia (OR=2.22 95% CI, 1.36-3.6), gestational diabetes mellitus (OR=5.2; 95% CI, 3.57-7.58), labor induction (OR= 2.79 95% CI, 2.03-3.84), failed induction of labor (OR = 5.3 95% CI, 8.05-29.38), cesarean delivery (OR=1.89 95% CI, 1.41-2.5), large for gestational age newborn (OR=3.97 95% CI, 2.87-5.50). But there was no statistically significant difference in small for gestational age newborn (OR=0.91 95% CI, 0.42-1.98), new born with APGAR score ≤7after 5 min after delivery (OR=2.168 95% CI, 0.97-4.82) among obese and normal weight pregnant women. Conclusion: There is increased risk of gestational hypertension, preeclampsia, gestational diabetes, failed induction of labor, dystocia, cesarean delivery and large for gestational age newborns in obese women. [ABSTRACT FROM AUTHOR]

Background: Maternal nutrition is one of the most influential factors that affect the health of the mother and her offspring and remains a significant public health challenge globally. There is a lack of studies evaluating the trends of maternal nutrition and its impact on the burden of pregnancy complications from low-income countries, including Bangladesh. We aimed to determine the burden of early-pregnancy nutrition status based on body mass index (BMI), and the associations of nutritional status with pregnancy-induced hypertension (PIH), cesarean section (CS) delivery, perineal tear and postpartum hemorrhage (PPH) in a rural area in Bangladesh.Methods: This prospective study analyzed data from two cohorts: the Maternal, Neonatal, and Child Health (MNCH) project carried out from January 2008 to June 2010, and the Preterm and Stillbirth Study, Matlab (PreSSMat) conducted from October 2015 to March 2018. In total, information of 9287 women who gave birth from the two cohorts was available for analysis. Early-pregnancy BMI was categorized into underweight, normal-weight, and overweight groups. The change in the burden of malnutrition between two cohort periods and the associations between women's BMI and maternal health outcomes were presented in odds ratios (ORs) with their 95% confidence interval (CI).Results: Between the two cohort periods, the prevalence of underweight decreased from 17.5% to 15.4%, and overweight increased from 10.8% to 20.9%. The risk of being overweight in pregnant women was about two times (OR = 2.19; 95% CI = 1.94-2.46) higher in the PreSSMat cohort than in the MNCH cohort. After multivariate-adjustment for socio-demographic factors, the pooled ORs of PIH, CS delivery, perineal tear, and PPH were 2.41 (95% CI = 1.95-2.99), 2.12 (95% CI = 1.86-2.41), 2.46 (95% CI = 1.54-3.92), and 1.68 (95% CI = 1.12-2.53), respectively, in women with overweight compared to the normal-weight group.Conclusions: The results confirmed the existence of a double burden of malnutrition in rural women in Bangladesh. Women with overweight had an increased risk of selected pregnancy complications. The findings call for the adoption of appropriate prenatal counseling and preparedness tailored to women's nutritional status to prevent possible adverse health outcomes. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: The aim of this study was to determine whether presence of the metabolic syndrome in pregnancy associates with child telomere length or child anthropometry (weight, BMI) and BP, measured at 10 years of age. Methods: The Screening for Pregnancy Endpoints study (SCOPE) was a multicentre, international prospective cohort of nulliparous pregnant women recruited from Australia, New Zealand, Ireland and the UK (N = 5628). The current analysis is a 10 year follow-up of SCOPE pregnant women and their children, from the Australian cohort. Clinical data collected at 14–16 weeks' gestation during the SCOPE study were used to diagnose the metabolic syndrome using IDF criteria. Telomere length, a biomarker of ageing, was assessed by quantitative PCR from children's saliva collected at 10 years of age. Results: In women who completed follow-up (n = 255), 20% had the metabolic syndrome in pregnancy. After adjusting for a range of confounders, children of mothers who had the metabolic syndrome in pregnancy had 14% shorter telomeres than children of mothers without the metabolic syndrome in pregnancy (mean difference −0.36 [95% CI −0.74, 0.01]). Height- and weight-for-age, and BMI z scores were similar in children of mothers who did and did not have the metabolic syndrome during pregnancy. Conclusions/interpretation: Children of mothers who had the metabolic syndrome in pregnancy have shorter telomeres, a biomarker of accelerated ageing. These findings warrant further studies in larger cohorts of children, as well as investigations into whether telomere length measured in cord blood associates with telomere length in childhood. [ABSTRACT FROM AUTHOR]

Placental weight is a valuable indicator of its function, predicting both pregnancy outcome and lifelong health. Population-based centile charts of weight-for-gestational-age and parity are useful for identifying extremes of placental weight but fail to consider maternal size. To address this deficit, a multiple regression model was fitted to derive coefficients for predicting normal placental weight using records from healthy pregnancies of nulliparous/multiparous women of differing height and weight (n = 107,170 deliveries, 37–43 weeks gestation). The difference between actual and predicted placental weight generated a z-score/individual centile for the entire cohort including women with pregnancy complications (n = 121,591). The association between maternal BMI and placental weight extremes defined by the new customised versus population-based standard was investigated by logistic regression, as was the association between low placental weight and pregnancy complications. Underweight women had a greater risk of low placental weight [<10thcentile, OR 1.84 (95% CI 1.66, 2.05)] and obese women had a greater risk of high placental weight [>90th centile, OR 1.98 (95% CI 1.88, 2.10)] using a population standard. After customisation, the risk of high placental weight in obese/morbidly obese women was attenuated [OR 1.17 (95% CI 1.09, 1.25)]/no longer significant, while their risk of low placental weight was 59%–129% higher (P < 0.001). The customised placental weight standard was more closely associated with stillbirth, hypertensive disease, placental abruption and neonatal death than the population standard. Our customised placental weight standard reveals higher risk of relative placental growth restriction leading to lower than expected birthweights in obese women, and a stronger association between low placental weight and pregnancy complications generally. Further, it provides an alternative tool for defining placental weight extremes with implications for the placental programming of chronic disease. [ABSTRACT FROM AUTHOR]

Background: Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. Aim: To identify risk factors for severe PPH. Materials and Methods: Population‐based retrospective cohort study of all women who gave birth in Victoria in 2009–2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). Results: Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in‐labour caesarean section, birth at a gestation other than 37–41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre‐labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors. Conclusions: Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity. [ABSTRACT FROM AUTHOR]

Preeclampsia (PE) is a multisystem pregnancy disease inflecting maternal and fetal mortality and morbidity. This case-control study aims to determine the biochemical changes in lipid profile, hepatic and renal functions among sixty late-onset preeclamptic women compared to sixty age-matching normotensive pregnant women from the Maternity Hospital in Sétif, Algeria. Several biomarkers were collected and have been determined by appropriate kits. Association between various parameters was evaluated using Pearson's correlation coefficient, with significance at p<0.05. The PE women showed a significant increase in serum aminotransferase, gamma-glutamyl-transferase, alkaline phosphatase, as well as total cholesterol, triglycerides, urea, uric acid, and creatinine levels. However, a significant decrease in platelets, total protein, albumin, and plasma sodium levels was found in PE group. A positive correlation between aminotransferases and renal biomarkers was observed. PE has deleterious effects on liver and renal functions, and complication's progression could be predicted by evaluating hepatic and renal biomarkers as well as lipid profile. Further studies on maternal and neonatal outcomes in cases of PE are needed for a better understanding of this disease's pathophysiology in Algeria. [ABSTRACT FROM AUTHOR]

Introduction: Obese primiparous women with induction of labor are at high risk for a cesarean section. There are contradictory results regarding time in induced labor in relation to maternal body mass index (BMI). It is important to characterize the course of induced labor to prevent unnecessary cesarean section. We aimed to evaluate whether the duration of labor was associated with maternal BMI in primiparous women with induction of labor.Material and Methods: A national retrospective cohort study, including 15 259 primiparae with a single term pregnancy, admitted for induction of labor from January 2014 to August 2017. Data were obtained from the Swedish Pregnancy Registry. Cox regression analyses were used to illustrate the association between BMI and active labor and between BMI and time from admission until start of active labor.Results: Duration of active labor was shorter in underweight women and prolonged in women with BMI ≥40 kg/m2 compared with women in other BMI classes, illustrated by Cox regression graphs (P < .001). The median durations of active labor in underweight women were 6.1 and 7.4 hours in women with BMI ≥40 kg/m2 . The time from admission until start of active labor increased with maternal BMI, illustrated by Cox regression graphs (P < .001) and the median duration increased from 12.9 hours in underweight women to 22.6 hours in women with BMI ≥40 kg/m2 . The cesarean section rate in active labor increased significantly with BMI (P < .001) from 7.4% in underweight women to 22.0% in women with BMI ≥40 kg/m2 . Obese and normal weight women had similar rates of spontaneous vaginal delivery (69.9% in the total study population).Conclusions: The duration of active labor was associated with maternal BMI for underweight women and women with BMI ≥40 kg/m2 . Although women with BMI ≥40 kg/m2 who reached the active phase of labor had the same chance for a spontaneous vaginal delivery as normal weight women, the duration of active labor and the cesarean section rate were increased. The time from admission until start of active labor increased successively with maternal BMI. [ABSTRACT FROM AUTHOR]

Background: Prevalence of obesity among women of reproductive age is increasing worldwide. As the prevalence increases among the women of reproductive age group, so it does among pregnant females. This study was conducted with the aim to assess obesity-related adverse maternal, neonatal and perinatal outcomes using new Asian Indian guidelines. Methodology: Pregnant women up to 16-week gestation on first visit were enrolled. There were two exposure groups: one with BMI < 25 kg/m2 and second with BMI ≥ 25 kg/m2 matched for maternal age and parity, 100 in each group. The study focused on development of various adverse maternal and foetal/perinatal complications. Comparative analysis of data was done to estimate the odds of each outcome taking non-obese group as reference. Results: There was a significant increase in risk among obese mothers compared to non-obese mothers for maternal complications like hypertensive disorders of pregnancy{OR 3.83}, preeclampsia{OR 9.2}, gestational diabetes mellitus{OR 4.85} and insulin requirement{OR 12.46}, induction of labour{OR 2.71}, caesarean section post induction{OR 8.50}, prolonged labour{OR 4.69}, caesarean sections{OR 5.18} and postpartum haemorrhage{OR 2.21}. Also, there was a significant increase in risk among obese mothers compared to non-obese mothers for foetal and perinatal complications like miscarriages{OR 4.85}, preterm newborns{OR 4.63}, medically indicated preterm{OR 6.59}, shoulder dystocia{OR could not be calculated}, large for gestational age{OR 5.91}, hyperbilirubinaemia {OR 4.26} and neonatal intensive care unit admissions{OR 3.26}. Conclusion: It was concluded that obesity defined by Asian Indian guidelines (BMI ≥ 25 kg/m2) is associated with adverse pregnancy outcomes at odds comparable to western studies with obesity taken as BMI ≥ 30 kg/m2. [ABSTRACT FROM AUTHOR]

Aims: To evaluate plasma kisspeptin‐10 (KP‐10) as a marker for preeclampsia and assess its relation to altered reproductive hormones in preeclamptic pregnant women. Methods: First time pregnant women (n = 100) at 20 weeks of gestation participated in this study and divided into preeclamptics (n = 60) and normotensives (n = 40). KP‐10, luteinizing hormone (LH), follicle stimulating hormone (FSH), beta‐human chorionic gonadotropin (β‐hCG), estradiol (E2) and progesterone were evaluated during 2nd and 3rd trimesters of pregnancy for all women. Results: Kisspeptin‐10 levels were reduced in preeclampsia (PE) women compared with normotensive pregnancies. In the 2nd trimester, area under receiver–operator characteristic (ROC) curve was 0.662, positive and negative predictive values were 32.8 and 94.6, and test sensitivity and specificity were 55% and 87.5%, respectively. In the 3rd trimester, area under ROC curve was 0.747 positive and negative predictive values were 22.2 and 97.3, and test sensitivity and specificity were 83.3% and 67.5%, respectively. In PE patients, plasma KP‐10 demonstrated an inverse correlation with E2 (during the 2nd trimester), LH and FSH (during the 3rd trimester), and positively correlated with β‐hCG (during the 3rd trimester). Conclusion: This study showed significantly reduced plasma KP‐10 levels in PE women. This suggests that KP‐10 may play an important role in the pathophysiology of PE. Therefore, combined with previous studies, to diagnose the PE, testing for maternal KP‐10 plasma levels may be useful as an effective screening, but because of low positive predictive value and inadequate test sensitivity, screening cannot be recommended. Furthermore, KP‐10 in PE patients demonstrated significant positive correlation with β‐hCG. [ABSTRACT FROM AUTHOR]