Long-term Maternal Outcomes Research Articles

The global agenda on obesity: what does this mean for Singapore?

The global agenda on obesity: what does this mean for Singapore?

Pulmonary disorders in pregnancy: Bronchiectasis, cystic fibrosis, sarcoidosis and interstitial diseases.

This chapter aims to provide expert guidance to obstetricians, general practitioners, allied health staff and women with lung disease about the interactions between pregnancy and different lung diseases. This chapter will cover other airway diseases such as bronchiectasis and cystic fibrosis (CF) together with sarcoidosis and interstitial lung disease (ILD), noting that another chapter covers asthma. The physiological changes which occur in pregnancy, such as the changes in airway physiology, resting ventilation and sleep, are summarised in another chapter. This chapter extends the evidence-based approach and clinical expertise of the recent European Respiratory Society/Thoracic Society of Australia and New Zealand (ERS/TSANZ) taskforce. The papers selected were based on the population (pregnant women with lung disease other than asthma) and the effects of these diseases on risks of pregnancy-associated complications and miscarriages, breastfeeding, nutritional considerations, lung function, long-term maternal outcomes and management considerations during pregnancy. As there are very few randomised control trials in the area, the majority of the literature consists of observational studies (prospective or retrospective), cross-sectional surveys and case series. Other guidelines have also recently been published, which may be helpful to the reader.

Dietary Supplement Intake and Fecundability in a Singapore Preconception Cohort Study

Subfertility is a global problem affecting millions worldwide, with declining total fertility rates. Preconception dietary supplementation may improve fecundability, but the magnitude of impact remains unclear. This prospective cohort study aimed to examine the association of preconception micronutrient supplements with fecundability, measured by time to pregnancy (TTP). The study was conducted at KK Women's and Children's Hospital, Singapore, between February 2015 and October 2017, on 908 women aged 18-45 years old, who were trying to conceive and were enrolled in the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO). Baseline sociodemographic characteristics and supplement intake were collected through face-to-face interviews. The fecundability ratio (FR) was estimated using discrete-time proportional hazard modelling. Adjusting for potentially confounding variables, folic acid (FA) (FR 1.26, 95% confidence interval 1.03-1.56) and iodine (1.28, 1.00-1.65) supplement users had higher fecundability compared to non-users. Conversely, evening primrose oil supplement users had lower fecundability (0.56, 0.31-0.99) than non-users. In this study, preconception FA and iodine supplementation were associated with shortened TTP, while evening primrose oil use was associated with longer TTP. Nonetheless, the association between supplement use and the magnitude of fecundability changes will need to be further confirmed with well-designed randomised controlled trials.

Perinatal and neonatal outcomes of adolescent pregnancies over a 10-year period.

Poor overall neonatal outcomes, small neonatal head circumference, neonatal hypoglycemia, need for Neonatal Intensive Care Unit and late-onset neonatal sepsis are more common in adolescents. The aim of this study is to draw attention to the outcomes of adolescent pregnancies. This retrospective study was conducted in adolescent singleton pregnancies with maternal age < 15 years (n = 20, group 1), 16-19 years (n = 1929, group 2), and 20 years (n = 866, group 3). Age, gravidity, parity, and body mass index (BMI) measurements of mothers; mode of delivery, maternal and neonatal outcomes were evaluated and compared. The rate of preterm birth, postpartum hemorrhage, asymmetrical intra-uterine growth restriction (IUGR, as 3% percentile), macrosomia, and height of newborn of Group 3 was significantly higher. The rate of asymmetrical IUGR (as 10% percentile) was significantly lower in Group 3. The rate of severe preeclampsia and cesarean section was significantly higher in Group 3. The rate of Small for Gestational Age newborn, neonatal hypoglycemia, and late-onset neonatal sepsis was significantly higher in Group 1. Neonatal problems with poor obstetric outcomes are common in adolescent pregnant women, so that a family planning and baby care social trainings are important in achieving good long-term maternal and neonatal outcomes.

Sleep characteristics modify the associations of physical activity during pregnancy and gestational weight gain.

Excessive gestational weight gain (eGWG) is associated with adverse long-term maternal outcomes. Most lifestyle interventions that incorporate physical activity have been ineffective at reducing eGWG. The purpose of this study was to determine if sleep modified the relationships between physical activity change from the 2nd to 3rd trimester and the odds of excessive gestational weight gain (eGWG). This was a secondary data analysis of a prospective cohort study of pregnant birthing people with overweight or obesity (n = 105). We estimated physical activity energy expenditure (PAEE) in the 2nd and 3rd trimesters of pregnancy and sleep characteristics (i.e., sleep quality, daytime dysfunction, sleep efficiency, sleep duration) in the 2nd trimester of pregnancy with validated measures. We used regression models with sleep and PAEE change (increase/stable vs. decrease) interaction terms to examine the impact of sleep on PAEE change and eGWG. Mean GWG was 37.02 ± 16.76 lbs. and 80% of participants experienced eGWG. Eighteen percent of participants increased their PAEE from the 2nd to the 3rd trimester. Increasing (vs. decreasing) PAEE was associated with lower log-odds of eGWG only among participants that slept at least 8h/night (p = 0.06), had at least 85% sleep efficiency (p = 0.03), or reported less daytime dysfunction (p = 0.08). Sleep quality did not moderate the association between PAEE change and eGWG. Weight management interventions in pregnancy should consider screening for and addressing poor sleep in the second trimester.

Impact of Risk Factors on Short and Long-Term Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: A Prospective Longitudinal Cohort Study.

AimsUniversal screening of gestational diabetes mellitus (GDM) in women with no risk factors (RF) for GDM remains controversial. This study identified the impact of the presence of RF on perinatal and postpartum outcomes.MethodsThis prospective cohort study included 780 women with GDM. GDM RF included previous GDM, first grade family history of type 2 diabetes, high-risk ethnicity and pre-pregnancy overweight/obesity (OW/OB). Outcomes included obstetrical, neonatal and maternal metabolic parameters during pregnancy and up to 1 year postpartum.ResultsOut of 780 patients, 24% had no RF for GDM. Despite this, 40% of them needed medical treatment and they had a high prevalence of glucose intolerance of 21 and 27% at 6-8 weeks and 1-year postpartum, respectively. Despite similar treatment, women with RF had more neonatal and obstetrical complications, but they had especially more frequent adverse metabolic outcomes in the short- and long-term. The most important RF for poor perinatal outcome were previous GDM and pre-pregnancy OW/OB, whereas high-risk ethnicity and pre-pregnancy OW/OB were RF for adverse postpartum metabolic outcomes. Increasing number of RF were associated with worsened perinatal and long-term postpartum outcomes except for pregnancy-induced hypertension, C-section delivery and neonatal hypoglycaemia.ConclusionWomen with no RF had a high prevalence of adverse perinatal and postpartum outcomes, while the presence of RF particularly increased the risk for postpartum adverse metabolic outcomes. This calls for a RF-based long-term follow-up of women with GDM.

Sequential Screening Strategy in Early, Middle, and Late Pregnancy in Women at High Risk of Hyperglycemia.

BackgroundHyperglycaemia in pregnancy (HIP) is closely associated with short- and long-term adverse fetal and maternal outcomes. However, the screening and diagnostic strategies for pregnant women with risk factors for HIP are not set. This prospective study aimed to explore a screening strategy for women at high risk for HIP.MethodsA total of 610 pregnant women were divided into experimental (n=305) and control (n=305) groups. Pregnant women underwent a 75-g OGTT in early (<20 weeks), middle (24–28 weeks), and late pregnancy (32–34 weeks) in the experimental group and only in middle pregnancy in the control group. The general conditions, HIP diagnosis, and perinatal outcomes of the two groups were compared.ResultsIn the experimental group, HIP was diagnosed in 29.51% (90/305), 13.44% (41/305), and 10.49% (32/305) of patient in early, middle, and late pregnancy, respectively. The total HIP diagnosis rate was significantly higher in the experimental group (53.44% vs. 35.74%, P<0.001). Multivariate logistic regression analysis revealed that previous gestational diabetes mellitus (GDM) (odds ratio, OR=9.676, P<0.001), pre-pregnancy body mass index (BMI) ≥23 kg/m2 (OR=4.273, P<0.001), and maternal age ≥35 years (OR=2.377, P=0.010) were risk factors for HIP diagnosis in early pregnancy. Previous GDM (OR=8.713, P=0.002) was a risk factor for HIP diagnosis in late pregnancy. No significant differences in perinatal clinical data were observed between the experimental and control groups. The gestational age at delivery was significantly earlier in the experimental subgroup with early-HIP than in the experimental and control subgroups with normal blood glucose (NBG). The weight gain during pregnancy was lower in the experimental early-HIP, middle-HIP, and control NBG subgroups.ConclusionsWe recommend sequential screening in early and middle pregnancy for high-risk pregnant women with maternal age ≥35 years or pre-pregnancy BMI ≥23 kg/m2, and in early, middle, and late pregnancy for high-risk pregnant women with a previous history of GDM.Trial RegistrationThis study was registered in the Chinese Clinical Trial Registry (no. ChiCTR2000041278).

Automated Machine Learning (AutoML)-Derived Preconception Predictive Risk Model to Guide Early Intervention for Gestational Diabetes Mellitus.

The increasing prevalence of gestational diabetes mellitus (GDM) is contributing to the rising global burden of type 2 diabetes (T2D) and intergenerational cycle of chronic metabolic disorders. Primary lifestyle interventions to manage GDM, including second trimester dietary and exercise guidance, have met with limited success due to late implementation, poor adherence and generic guidelines. In this study, we aimed to build a preconception-based GDM predictor to enable early intervention. We also assessed the associations of top predictors with GDM and adverse birth outcomes. Our evolutionary algorithm-based automated machine learning (AutoML) model was implemented with data from 222 Asian multi-ethnic women in a preconception cohort study, Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO). A stacked ensemble model with a gradient boosting classifier and linear support vector machine classifier (stochastic gradient descent training) was derived using genetic programming, achieving an excellent AUC of 0.93 based on four features (glycated hemoglobin A1c (HbA1c), mean arterial blood pressure, fasting insulin, triglycerides/HDL ratio). The results of multivariate logistic regression model showed that each 1 mmol/mol increase in preconception HbA1c was positively associated with increased risks of GDM (p = 0.001, odds ratio (95% CI) 1.34 (1.13–1.60)) and preterm birth (p = 0.011, odds ratio 1.63 (1.12–2.38)). Optimal control of preconception HbA1c may aid in preventing GDM and reducing the incidence of preterm birth. Our trained predictor has been deployed as a web application that can be easily employed in GDM intervention programs, prior to conception.

Natalizumab treatment and pregnancy in multiple sclerosis: A reappraisal of maternal and infant outcomes after 6 years

Objectives: To assess the impact of timing of natalizumab cessation/redosing on long-term maternal and infant outcomes in 72 out of the original 74 pregnancies of the Italian Pregnancy Dataset in multiple sclerosis (MS). Methods: Maternal outcomes in patients who received natalizumab until conception and restarted the drug within 1 month after delivery (“treatment approach,” (TA)) and patients who stopped natalizumab before conception and/or restarted the drug later than 1 month after delivery (“conservative approach,” (CA)) were compared through multivariable Cox regression analyses. Pediatric outcomes were assessed through a semi-structured questionnaire. Results: After a mean follow-up of 6.1 years, CA (hazard ratio (HR) = 4.1, 95% CI 1.6–10.6, p = 0.003) was the only predictor of relapse occurrence. Worsening on the Expanded Disability Status Scale (EDSS) was associated with higher annualized relapse-rate during the follow-up (HR = 3.3, 95% CI 1.4–7.9 p = 0.007). We found no major development abnormalities in children. Discussion: Our data confirm that TA reduces the risk of disease activity; we did not observe an increase in major development abnormalities in the child.

The Risk of Complications in Second Pregnancy by Maternal BMI: The Role of First-pregnancy Complications, Pregestational Diabetes and Chronic Hypertension

(Acta Obstet Gynecol Scand. 2021;100:489–496. doi: 10.1111/aogs.14028. Epub November 2, 2020) Obesity, increased pregnancy body mass index (BMI), and past pregnancy complications are associated with future pregnancy complications and adverse short- and long-term maternal and neonatal outcomes. Gestational diabetes (GDM), gestational hypertension (GH), and preeclampsia (PE) are common pregnancy-associated complications. Recurrence of these complications increases when pregestational DM and/or chronic hypertension (cHTN) are present, though little research has been done on how adiposity and prior-pregnancy complications impact the risk of second-pregnancy complications. This study analyzes how complications in the first pregnancy and chronic conditions impact subsequent pregnancy complications and the role of maternal BMI.

Prepregnancy adherence to plant-based diet indices and exploratory dietary patterns in relation to fecundability

Modest associations have been reported between specific food groups or nutrients and fecundability [measured by time to pregnancy (TTP)]. Examining overall diets provides a more holistic approach towards understanding their associations with fecundability. It is not known whether plant-based diets indices or exploratory dietary patterns are associated with fecundability. We examine the associations between adherence to 1) plant-based diet indices; and 2) exploratory dietary patterns and fecundability among women planning pregnancy. Data were analyzed from the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) study. Prepregnancy diet was assessed using a semi-quantitative FFQ from which the overall, healthful, and unhealthful plant-based diet indices (oPDI, hPDI, and uPDI, respectively) were calculated. Exploratory dietary patterns were derived using factor analysis based on 44 predefined food groups. Participants were categorized into quintiles based on their dietary pattern scores. TTP (expressed in menstrual cycles) was ascertained within a year from the prepregnancy dietary assessment. Discrete-time proportional hazard models, adjusted for confounders, were used to estimate fecundability ratios (FRs) and 95% CIs, with FR>1 indicating a shorter TTP. Among 805 women, 383 pregnancies were confirmed by ultrasound scans. Compared with women in the lowest quintile, those in the highest quintile of the uPDI had reduced fecundability (FR of Q5 compared with Q1, 0.65; 95% CI, 0.46-0.91; P trend, 0.009). Conversely, greater adherence to the hPDI was associated with increased fecundability (1.46; 95% CI, 1.02-2.07; P trend, 0.036). The oPDI was not associated with fecundability. Among the 3 exploratory dietary patterns, only greater adherence to the Fast Food and Sweetened Beverages (FFSB) pattern was associated with reduced fecundability (0.61; 95% CI, 0.40-0.91; P trend, 0.018). Greater adherence to the uPDI or the FFSB dietary pattern was associated with reduced fecundability among Asian women. Greater adherence to the hPDI may be beneficial for fecundability, though this requires confirmation by future studies.

Metabolic health status and fecundability in a Singapore preconception cohort study

Obesity compromises metabolic health and female fertility, yet not all obese women are similar in metabolic status. The extent to which fecundability is influenced by the metabolic health status of women who are overweight or obese before conception is unknown. This study aimed to: (1) determine the metabolic health status, and (2) examine the association between metabolic health status and fecundability of overweight and obese women trying to conceive in the Singapore PREconception Study of long-Term maternal and child Outcomes cohort study. We conducted a prospective preconception cohort study of Asian women (Chinese, Malay, and Indian) aged 18 to 45 years trying to conceive who were treated from 2015 to 2017 in KK Women's and Children's Hospital in Singapore (n=834). We defined women to have metabolically unhealthy status if they: (1) met 3 or more modified Joint Interim Statement metabolic syndrome criteria; or (2) had homeostasis model assessment-insulin resistance index ≥2.5. Body mass index was categorized as normal (18.5-22.9 kg/m2), overweight (23-27.4 kg/m2), or obese (≥27.5 kg/m2) on the basis of cutoff points for Asian populations. Fecundability was measured by time to pregnancy in menstrual cycles within a year of enrolment. Discrete-time proportional hazards models were used to estimate fecundability odds ratios, with adjustment for confounders and accounting for left truncation and right censoring. Of 232 overweight women, 28 (12.1%) and 25 (10.8%) were metabolically unhealthy by metabolic syndrome ≥3 criteria and homeostasis model assessment-insulin resistance ≥2.5, respectively. Of 175 obese women, 54 (30.9%) and 93 (53.1%) were metabolically unhealthy by metabolic syndrome ≥3 criteria and homeostasis model assessment-insulin resistance ≥2.5, respectively. Compared with metabolically healthy normal-weight women, lower fecundability was observed in metabolically unhealthy overweight women on the basis of metabolic syndrome criteria (fecundability odds ratios, 0.38 [95% confidence interval, 0.15-0.92]) and homeostasis model assessment-insulin resistance (fecundability odds ratios, 0.68 [95% confidence interval, 0.33-1.39]), with metabolic syndrome criteria showing a stronger association. Metabolically unhealthy obese women showed lower fecundability than the healthy normal-weight reference group by both metabolic syndrome (fecundability odds ratios, 0.35; 95% confidence interval, 0.17-0.72) and homeostasis model assessment-insulin resistance criteria (fecundability odds ratios, 0.43; 95% confidence interval, 0.26-0.71). Reduced fecundability was not observed in overweight or obese women who showed healthy metabolic profiles by either definition. Overweight or obesity was not synonymous with having metabolic syndrome or insulin resistance. In our preconception cohort, metabolically unhealthy overweight and obese women showed reduced fecundability, unlike their counterparts who were metabolically healthy. These findings suggest that metabolic health status, rather than simply being overweight and obese per se, plays an important role in fecundability.

Interpregnancy weight gain and childhood obesity: analysis of a UK population-based cohort

BackgroundMaternal obesity increases the risk of adverse long-term health outcomes in mother and child including childhood obesity. We aimed to investigate the association between interpregnancy weight gain between first and second pregnancies and risk of overweight and obesity in the second child.MethodsWe analysed the healthcare records of 4789 women in Hampshire, UK with their first two singleton live births within a population-based anonymised linked cohort of routine antenatal records (August 2004 and August 2014) with birth/early life data for their children. Measured maternal weight and reported height were recorded at the first antenatal appointment of each pregnancy. Measured child height and weight at 4–5 years were converted to age- and sex-adjusted body mass index (BMI z-score). Log-binomial regression was used to examine the association between maternal interpregnancy weight gain and risk of childhood overweight and obesity in the second child. This was analysed first in the whole sample and then stratified by baseline maternal BMI category.ResultsThe prevalence of overweight/obesity in the second child was 19.1% in women who remained weight stable, compared with 28.3% in women with ≥3 kg/m2 weight gain. Interpregnancy gain of ≥3 kg/m2 was associated with increased risk of childhood overweight/obesity (adjusted relative risk (95% CI) 1.17 (1.02–1.34)), with attenuation on adjusting for birthweight of the second child (1.08 (0.94–1.24)). In women within the normal weight range at first pregnancy, the risks of childhood obesity (≥95th centile) were increased with gains of 1–3 kg/m2 (1.74 (1.07–2.83)) and ≥3 kg/m2 (1.87 (1.18–3.01)).ConclusionChildren of mothers within the normal weight range in their first pregnancy who started their second pregnancy with a considerably higher weight were more likely to have obesity at 4–5 years. Supporting return to pre-pregnancy weight and limiting weight gain between pregnancies may achieve better long-term maternal and offspring outcomes.

Peripartum Cardiomyopathy. Medical Support Strategy

Peripartum cardiomyopathy (PPCM) is an idiopathic myocardial insufficiency that occurs in the absence of any diagnosed heart disease during the last month of pregnancy or during the first 5 months after delivery.&#x0D; The aim. To improve immediate and long-term maternal outcomes in patients with PPCM by establishing an optimal strategy for its diagnosis, treatment, delivery and medical support during the postpartum period.&#x0D; Materials and methods. The article presents the experience of multidisciplinary medical care for 11 pregnant wo-men and postpartum women with dilated cardiomyopathy (DCM) on the basis of the National Amosov Institute of Cardio-vascular Surgery and the Institute of Pediatrics, Obstetrics and Gynecology named after acad. O. M. Lukianova of NAMS of Ukraine. After the differential diagnosis, 8 women were defined as patients with PPCM, and 3 women had family history of the disease (DCM in relatives). All the patients were examined according to the protocol using the history, examination, and instrumental and laboratory findings.&#x0D; Results. After in-hospital treatment there was an increase in the left ventricular ejection fraction (LVEF) in the group of patients with PPCM from 28.3 ± 9.3% to 37.6 ± 7.6% and a decrease in end-diastolic volume (EDV) from 196.7 ± 47.7 ml to 181.3 ± 59.7 ml, end-systolic volume (ESV) from 104.25 ± 33.3 ml to 94.2 ± 35.1 ml. In four cases, patients with severe left ventricular (LV) dysfunction underwent urgent preterm Cesarean section in the second trimester of pregnancy. There were no early maternal losses, there were two perinatal losses of extremely premature infants (16 and 27 weeks of gesta-tion). In the follow-up period (23.5 ± 11.6 months), LVEF further increased up to 42.9 ± 8.4% and EDV and ESV decreased up to 170.1 ± 49.5 and 82.7 ± 40.6 ml, respectively. In 7 (87.5%) patients with PPCM, a significant improvement in clini-cal condition and pumping function of the heart was registered at the time of discharge from the hospital, and there was further improvement in the indicators for another 12 months, but complete recovery of cardiac function was achieved only in 3 (37.5%) patients. In patients from the group of family type DCM, complete recovery of LV myocardial function was not observed in any of the 3 studied cases.&#x0D; The article discusses the timing of the occurrence and diagnosis of PPCM, the main clinical, instrumental and labora-tory signs of the pathology, methods of cardiological, cardiosurgical and obstetric support of such pregnant women.&#x0D; Conclusions. The terms of the onset of PPCM manifestations may be wider (earlier) according to our observations and should be the subject of further research. The strategy of medical care for pregnant women doesn’t particularly depend on the type of DCM. However, obstetric tactics aimed at early delivery of a patient with PPCM with severe myocardial insufficiency are feasible in combination with interruption of lactation and in most cases allow to achieve compensation of circulation and partial recovery of LV function. Prescription of bromocriptine for this purpose seems appropriate. The use of repeated courses of levosimendan in patients with PPCM is feasible and helps to improve the LV function in the early postpartum period.

Retinal microvasculature and time to pregnancy in a multi-ethnic pre-conception cohort in Singapore

Abstract STUDY QUESTION Can abnormalities in retinal microvasculature representing adverse microcirculatory perfusion and inflammation shed light on the pathophysiology of female fecundability? SUMMARY ANSWER In our prospective study, abnormalities in retinal vascular geometric morphology (i.e. sparser arteriolar fractal and larger venular bifurcation) during pre-conception phase are temporarily associated with a prolonged time-to-pregnancy (TTP). WHAT IS KNOWN ALREADY Suboptimal retinal microcirculatory morphology has been associated with obesity, psychological stress and hypertension, all of which are known risk factors for reduced female fecundability. STUDY DESIGN, SIZE, DURATION A total of 652 women of Chinese, Malay or Indian ethnicity 18–45 years of age and planning to conceive spontaneously within the next 12 months were recruited during the pre-conception period into the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO), from February 2015 to October 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS During recruitment, we collected information on socio-demographic factors, menstrual characteristics and lifestyle behaviors and made anthropometric measurements. We assessed the following retinal microvascular features: caliber, branching angle and fractal dimension. We conducted follow-up telephone surveys to track each participant’s pregnancy status at 6, 9 and 12 months after enrolment. We ascertained clinical pregnancies via ultrasonography, with TTP measured by the number of menstrual cycles required to achieve a clinical pregnancy over a 1-year follow-up. Then, we performed discrete-time proportional hazards models to estimate the fecundability odds ratio (FOR) and 95% CI for each retinal microvascular feature in association with TTP, after adjusting for major confounders, including body mass index and fasting glycemic level at study entry. MAIN RESULTS AND THE ROLE OF THE CHANCE Among 652 recruited women, 276 (42.3%) successfully conceived within 1 year of follow-up. The mean (and SD) was 1.24 (0.05) Df for retinal arteriolar dimension fraction and 78.45 (9.79) degrees for retinal venular branching angle, respectively. Non-linear relationship testing was performed before multiple adjustment in all associations and a non-monotonic association was detected between retinal venular branching angle and TTP. Compared with women in the highest tertile of retinal arteriolar fractal dimension, women in the second tertile had a prolonged TTP (FOR: 0.68; 95% CI: 0.51–0.92), as did women in the lowest tertile (FOR: 0.73; 95% CI: 0.55–0.98). Compared with women in the middle tertile of retinal venular branching angle, women in the highest tertile had a borderline prolonged TTP (FOR: 0.75; 95% CI: 0.56–1.02). No other retinal vascular features were significantly associated with TTP. LIMITATIONS, REASONS FOR CAUTION We were unable to adjust for other potential confounding factors such as female sexual function (e.g. frequency of sexual intercourse), which might introduce a residual bias. Moreover, even though this is a prospective cohort design, our findings can identify the temporal relationship but not necessarily infer a causal relationship between maternal microvasculature and TTP. Lastly, our study involving mainly Chinese, Malay and Indian ethnicities might not be generalizable to other races or ethnicities. WIDER IMPLICATIONS OF THE FINDINGS Suboptimal microcirculation may lead to reduced female fecundability. In the future, in addition to conventional ultrasonographic evaluation of ovarian and uterine physiological function, assessing the retinal microvasculature might be useful for assessment of ovarian age, fertility prediction and endometrial evaluation before assisted reproductive techniques for fertility treatments. STUDY FUNDING/COMPETING INTEREST(S) This research is supported by the Singapore National Research Foundation (NRF) under its Translational and Clinical Research (TCR) Flagship Programme and administered by the Singapore Ministry of Health’s National Medical Research Council (NMRC) (Singapore-NMRC/TCR/004-NUS/2008; NMRC/TCR/012-NUHS/2014) and Singapore National Medical Research Council Transition Award (NMRC TA/0027/2014). The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT03531658.

An Update on Screening Strategies for Gestational Diabetes Mellitus: A Narrative Review.

Gestational diabetes mellitus (GDM) is a frequent medical complication during pregnancy. Screening and diagnostic practices for GDM are inconsistent across the world. This narrative review includes data from 87 observational studies and randomized controlled trials (RCTs), and aims to give an overview of the current evidence on screening strategies and diagnostic criteria for GDM. Screening in early pregnancy remains controversial and studies show conflicting results on the benefit of screening and treatment of GDM in early pregnancy. Implementing the one-step “International Association of Diabetes and Pregnancy Study Groups” (IADPSG) screening strategy at 24–28 weeks often leads to a substantial increase in the prevalence of GDM, without conclusive evidence regarding the benefits on pregnancy outcomes compared to a two-step screening strategy with a glucose challenge test (GCT). In addition, RCTs are needed to investigate the impact of treatment of GDM diagnosed with IADPSG criteria on long-term maternal and childhood outcomes. Selective screening using a risk-factor-based approach could be helpful in simplifying the screening algorithm but carries the risk of missing significant proportions of GDM cases. A two-step screening method with a 50g GCT and subsequently a 75g oral glucose tolerance test (OGTT) with IADPSG could be an alternative to reduce the need for an OGTT. However, to have an acceptable sensitivity to screen for GDM with the IADPSG criteria, the threshold of the GCT should be lowered from 7.8 to 7.2 mmol/L. A pragmatic approach to screen for GDM can be implemented during the COVID-19 pandemic, using fasting plasma glucose (FPG), HbA1c or even random plasma glucose (RPG) to reduce the number of OGTTs needed. However, usual guidelines and care should be resumed as soon as the COVID pandemic is controlled.

Women’s Knowledge About risk of excessive Gestational Weight Gain Risks at Selected Maternal and Child Health Centers at Minia District

Background: Obesity and overweight are on the rise in all age groups around the world, particularly in low- and middle-income countries. Given the connection between pre-pregnancy and obesity (BMI 30 kg/m2), excessive gestational weight gain (GWG), and post-partum weight retention (PPWR), these conditions are being viewed as emerging public health threats, with negative short- and long-term maternal and child outcomes. Aim of the study: To assess women’s knowledge about risk of excessive gestational weight gin risks at selected maternal and child health centers at Minia district. Design: a descriptive research design. Setting: The study was conducted in Maternal and Child Health centers (MCH) at Samalut and Matay Centers affiliated to Minia Governorate. Sample: A convenient sample of 332 pregnant women was selected. Two Tools were used: the first tool isinterviewing questionnaire was developed by the investigator to collect data and consist of two parts;Part (I): includes personal Character Part (II): knowledge of women regarding maternal nutrition during pregnancy. Second tool is Knowledge Assessment tool contains knowledge about weight gain during pregnancy to assess pregnant women knowledge about excessive weight gain during pregnancy and its risks. Results: 30.7% of pregnant women their age ranged from 20-24 years with a mean age 32.5 ± 0.939, while 10.2% of them their age ranged from 35-39 years. Half percent of pregnant women their body weight ranged from 50 to 70 kg, the mean body weight was73.8 ± 11.7 kg and the mean height was164.2± 11.7 cm. More than three quarters of pregnant women have unsatisfactory knowledge score. There is no statistically significant correlation between pregnant women knowledge and pregnancy complication. Conclusion: The level of knowledge about excessive weight gain during pregnancy and its effects was unsatisfactory. Recommendation: suggested that health education services be developed as a primary prevention of excessive weight gain in high-risk pregnant women.

Fecundability in reproductive aged women at risk of sexual dysfunction and associated risk factors: a prospective preconception cohort study

BackgroundFemale sexual dysfunction (FSD) is a prevalent problem, affecting up to 41% of reproductive aged women worldwide. However, the association between female sexual function (FSF) and fecundability in women attempting to conceive remains unclear. We aimed 1) to examine the association between FSF in reproductive-aged preconception Asian women and fecundability, as measured by time-to-pregnancy in menstrual cycles, and 2) to examine lifestyle and behavioral factors associated with FSF.MethodsFrom the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) prospective cohort, we evaluated FSF using the 6-item Female Sexual Function Index (FSFI-6) and ascertained time-to-pregnancy within a year of baseline assessment. We estimated fecundability ratio (FR) and 95% confidence interval (CI) using the discrete-time proportional hazards model, accounting for left-truncation and right censoring. We used multivariable logistic and linear regression models to identify potential factors related to FSF.ResultsAmong 513 participants, 58.9% had low FSF as defined by a total FSFI-6 score at or below the median value of 22. Compared to women with high FSF, those with low FSF had a 27% reduction in fecundability (FR 0.73; 95% CI 0.54, 0.99), with adjustment for age, ethnicity, education, parity and body mass index. Overall, the FRs generally reduced with decreasing FSFI-6 scores. Physical activity, obesity, absence of probable depression and anxiety were independently associated with reduced odds of low FSF and increased FSFI-6 scores, after adjusting for sociodemographic characteristics.ConclusionsLow FSF is associated with a longer time-to-pregnancy. Early evaluation and optimization of FSF through increased physical activity and optimal mental health may help to improve female fecundity. The finding of obese women having improved FSF remains uncertain which warrants further investigations on plausibly mechanisms. In general, the current finding highlights the importance of addressing FSF in preconception care service for general women, which is currently lacking as part of the fertility promotion effort in the country.

Counseling Women With Peripartum Cardiomyopathy About Subsequent Pregnancies

Peripartum cardiomyopathy (PPCM) is a potentially catastrophic form of heart failure caused by left ventricular systolic dysfunction that develops during pregnancy or in the early postpartum period. After the initial diagnosis and treatment, many women desire another pregnancy; however, risks of a subsequent pregnancy need to be considered, as PPCM may lead to significant adverse outcomes for both mother and fetus. The goal of this review is to provide information about risk stratification prior to subsequent pregnancy, strategies to mitigate the risk of subsequent pregnancy, and long-term maternal outcomes. The degree of myocardial recovery is currently the most effective predictor of heart failure relapse and adverse outcomes during a subsequent pregnancy. Women with persistent left ventricular systolic dysfunction have worse maternal and fetal outcomes during subsequent pregnancy. Pharmacologic options for the acute management of heart failure during pregnancy are limited to diuretics, beta-blockers, hydralazine, isosorbide dinitrate, and digoxin. After delivery, however, most guideline-directed heart failure medications can be used safely, including in women who are breastfeeding. Because of the risks of subsequent pregnancy, options for contraception should be discussed with women with PPCM. Finally, women with PPCM should be under the care of a multidisciplinary cardio-obstetrics team for preconception counseling and management during a subsequent pregnancy. An essential component of caring for women with PPCM includes detailed counseling about the risks of a subsequent pregnancy.

Clinical outcomes of maternal and neonate with COVID-19 infection – Multicenter study in Saudi Arabia

BackgroundTo this end, the influence of COVID-19 on pregnant women and their neonates is not completely clear. Therefore, the main aim of this study is to investigate maternal and neonatal clinical outcomes with confirmed COVID-19 infection. Besides, it investigates the likelihood of vertical transmission of COVID-19 infection from pregnant women to their neonates. MethodsA retrospective descriptive study was conducted in three medical centers during the period from March to November 2020. Data were collected from the available medical records in the respective hospitals using a standardized questionnaire on maternal and neonatal clinical outcomes. All pregnant women with confirmed COVID-19 infection across the three hospitals and their neonates were eligible to participate in this study. Descriptive statistics were presented as a median and interquartile range (IQR) or frequencies and percentages as appropriate using SPSS 24.0 software. ResultsThis study has identified a total of 288 pregnant women with confirmed COVID-19 infection over the study period of a median age of 30 years and median GA at diagnosis 38 weeks (IQR: 39 -33) as well as 27% of them were obese (n=78). The majority of pregnant women were symptomatic with cough (n=92, 31.9%) being the most frequent COVID-19 symptom followed by fever and dyspnea (n=36, 12.5%). Two-hundred and four pregnant delivered (70.84%) and caesarean sections were prevalent among 35.8% of them. The most common adverse pregnancy outcome was premature (n=31, 15.5%), followed by fetal distress (n=13, 6.5%), preeclampsia (n=4, 2.0%), and one pregnant woman died. The laboratory results exhibit that temperature higher than 38 (n=27), leukopenia (n=19), neutropenia (n=54), ALT (n=12), AST (n=31), and thrombocytopenia (n=35) were less frequent among pregnant women while lymphopenia (n=126), hemoglobin levels lower than 13.0 (n=218), deceased albumin levels (n=195) were most frequent among them. However, a small proportion of pregnant women were admitted to the ICU (3.8%). The most frequent maternal treatments were antibiotics (n=81), antiviral (n=49), and corticosteroid (n=24). Of 204 neonates, four had died and all the remaining neonates were alive. The median gestational age at delivery was 39 weeks (IQR: 35–40). Most neonates had normal laboratory results. However, 14 had lymphopenia (7.0%), 22 had neutropenia (11.0%), and 11 had thrombocytopenia (5.5%). Four infants had low hemoglobin levels of less than 13.0 (2.0%) and 81 had hyperbilirubinemia (e.g., total bilirubin of higher than 23; 40.5%). Approximately less than one-half of neonates required admission to the NICU (n=86, 43%), 7% of them required respiratory support of mechanical ventilation, and none of them get infected with COVID-19 disease. ConclusionThis multicenter study suggests that the majority of pregnant women had mild or moderate disease symptoms. Nevertheless, this study did not find any evidence of possible vertical transmission of COVID-19 infection from mothers to their babies. This study may provide a baseline for further studies focusing on investigating long-term maternal and neonate's outcomes and possible vertical transmission of COVID-19 from mothers to their newborn babies.