Use of non-governmental maternity services and pregnancy outcomes among undocumented women: a cohort study from Norway.

BACKGROUND: In 2011 Norway granted undocumented women the right to antenatal care and to give birth at a hospital but did not include them in the general practitioner and reimbursement schemes. As a response to limited access to health care, Non-Governmental Organizations (NGO) have been running health clinics for undocumented migrants in Norway's two largest cities. To further facilitate universal health coverage, there is a need to investigate how pregnant undocumented women use NGO clinics and how this affects their maternal health. We therefore investigated the care received, occurrence of pregnancy-related complications and pregnancy outcomes in women receiving antenatal care at these clinics. METHODS: In this historic cohort study we included pregnant women aged 18-49 attending urban NGO clinics from 2009 to 2020 and retrieved their medical records from referral hospitals. We compared women based on region of origin using log-binominal regression to estimate relative risk of adverse pregnancy outcomes. RESULTS: We identified 582 pregnancies in 500 women during the study period. About half (46.5%) the women sought antenatal care after gestational week 12, and 25.7% after week 22. The women had median 1 (IQR 1-3) antenatal visit at the NGO clinics, which referred 77.7% of the women to public health care. A total of 28.4% of women were referred for induced abortion. In 205 retrieved deliveries in medical records, there was a 45.9% risk for any adverse pregnancy outcome. The risk of stillbirth was 1.0%, preterm birth 10.3%, and emergency caesarean section 19.3%. CONCLUSION: Pregnant undocumented women who use NGO clinics receive substandard antenatal care and have a high risk of adverse pregnancy outcomes despite low occurrence of comorbidities. To achieve universal health coverage, increased attention should be given to the structural vulnerabilities of undocumented women and to ensure that adequate antenatal care is accessible for them.

Public health nurses' encounters with undocumented migrant mothers and children.

OBJECTIVES: Undocumented migrant children (UMC) are often affected by policies and practices that do not take their best interests into account. The aim of this study was to describe how public health nurses (PHNs) experienced challenges and dilemmas in ensuring the best interests of the undocumented migrant child. DESIGN: This study had a qualitative descriptive design. SAMPLE: Focus group interviews and semi-structured interviews were conducted with seven PHNs in four different child health centers (CHCs). RESULTS: Qualitative content analysis was applied. Three main themes were identified: building trust, ensuring the best interests of the child, and dilemmas and challenges in ensuring the best interests of the child. The study revealed examples of immigration policy being prioritized over the best interests of the child. PHNs experienced frustration when the best interests of the child were not taken into account. Strategies for managing these conflicting demands were identified. CONCLUSION: Conflicting demands appeared when national immigration policies collided with fundamental human rights and ethical standards. Rules that exclude certain groups are incompatible with PHNs professional ethics.

Pregnancy and advanced maternal age-The associations between regular exercise and maternal and newborn health variables.

INTRODUCTION: Despite the associations between delayed childbearing and poorer maternal and perinatal outcomes, little is known about these issues in regular exercisers and in women with healthy lifestyles. The aims of the present study were to: (a) compare lifestyle variables and exercise, pregnancy and birth outcomes in women ≥35 years and women <35 years of age, and (b) investigate the associations between regular exercise and maternal health and newborn variables in women of advanced maternal age. MATERIAL AND METHODS: Healthy pregnant women (≥35 years, n = 104 and <35 years, n = 362) were allocated to the study from Rikshospitalet, Oslo University Hospital, Norway. The participants completed a validated self-administered questionnaire, the Physical Activity Pregnancy Questionnaire (PAPQ) in gestational weeks 32-36. Prepregnancy body weight (kg) was self-reported, whereas maternal weight (kg) was measured at gestational weeks 14-16, 22-24, 30-32, and 36-38. Details of the delivery (gestational week at delivery, mode of delivery, Apgar score) and birthweight (g) were obtained from the hospital's medical records. RESULTS: More women <35 than ≥35 years of age reported to have exercised prepregnancy (83.7% vs 74.0%, P = 0.04) and in the 1st trimester (71.2% vs 61.5%, P = 0.05). At gestational week 36, fewer than 50% were exercising regularly, with no group differences (P = 0.74). Current alcohol use (10.5% vs 3.3%, P = 0.02) and tobacco use (5.8% vs 1.7%, P = 0.02) were higher among women ≥35 than women <35 years, whereas for healthy diet the result was reversed (<35 years 67.1% and ≥35 years 80.8%, P = 0.02). There were higher rates of post-term birth (13.5% vs 6.4%, P = 0.02) and induction of labor (40.5% vs 27.9%, P = 0.02) in the ≥35 years group, otherwise no other differences were observed in perinatal outcomes. In women with advanced maternal age, exercising ≥2 times weekly was associated with less pelvic girdle pain (40.0% vs 61.1%, P = 0.02), lower gestational weight gain (12.7 ± 4.0 kg vs 15.5 ± 5.5 kg, P < 0.01), fewer had gestational weight gain ≥16 kg (22.0% vs 51.9%, P < 0.01) and a newborn with macrosomia (10.0% vs 37.0%, P < 0.01). The results were unchanged after adjusting for recognized confounders. CONCLUSIONS: The results indicate that regular exercise is associated with improvement in some of the risks of advanced maternal age.

Shape information from glucose curves: functional data analysis compared with traditional summary measures.

BACKGROUND: Plasma glucose levels are important measures in medical care and research, and are often obtained from oral glucose tolerance tests (OGTT) with repeated measurements over 2-3 hours. It is common practice to use simple summary measures of OGTT curves. However, different OGTT curves can yield similar summary measures, and information of physiological or clinical interest may be lost. Our mean aim was to extract information inherent in the shape of OGTT glucose curves, compare it with the information from simple summary measures, and explore the clinical usefulness of such information. METHODS: OGTTs with five glucose measurements over two hours were recorded for 974 healthy pregnant women in their first trimester. For each woman, the five measurements were transformed into smooth OGTT glucose curves by functional data analysis (FDA), a collection of statistical methods developed specifically to analyse curve data. The essential modes of temporal variation between OGTT glucose curves were extracted by functional principal component analysis. The resultant functional principal component (FPC) scores were compared with commonly used simple summary measures: fasting and two-hour (2-h) values, area under the curve (AUC) and simple shape index (2-h minus 90-min values, or 90-min minus 60-min values). Clinical usefulness of FDA was explored by regression analyses of glucose tolerance later in pregnancy. RESULTS: Over 99% of the variation between individually fitted curves was expressed in the first three FPCs, interpreted physiologically as "general level" (FPC1), "time to peak" (FPC2) and "oscillations" (FPC3). FPC1 scores correlated strongly with AUC (r=0.999), but less with the other simple summary measures (-0.42≤r≤0.79). FPC2 scores gave shape information not captured by simple summary measures (-0.12≤r≤0.40). FPC2 scores, but not FPC1 nor the simple summary measures, discriminated between women who did and did not develop gestational diabetes later in pregnancy. CONCLUSIONS: FDA of OGTT glucose curves in early pregnancy extracted shape information that was not identified by commonly used simple summary measures. This information discriminated between women with and without gestational diabetes later in pregnancy.

'Goodbye and good luck' Midwifery care to pregnant undocumented migrants in Norway: A qualitative study.

OBJECTIVE: To explore community midwives' experiences caring for pregnant undocumented migrants seeking prenatal care in Norway. METHOD: Due to the relatively limited previous research and number of pregnant undocumented migrants we used an explorative approach through qualitative method. Ten community midwives were interviewed after snowball sampling in Oslo, the capital of Norway. The main themes emerged through a qualitative analysis of the transcripts, and meaning units were extracted. RESULTS: Midwives with no prior experience with pregnant undocumented migrants expressed uncertainty regarding the women's rights. In contrast, those midwives who had had prior experience with this group, developed their own solutions and enacted certain strategies to help them without any guidelines from their employer. All the midwives found it challenging to provide follow-up care to the undocumented migrants during pregnancy and postpartum. They also expressed concerns regarding increasing challenges creating clinical trusting relationships and restrictions and practices at public hospitals. CONCLUSIONS: To ensure adequate perinatal care, it is needed to reassure pregnant undocumented migrants free and safe care at all stages in the birth giving process. Community midwives need professional support in establishing trusting clinical relationships with pregnant undocumented migrants to reduce maternal stress and facilitate continuity in perinatal care.

Assessing body composition in healthy newborn infants: reliability of dual-energy x-ray absorptiometry.

Dual-energy X-ray absorptiometry (DXA) is used to measure body composition in newborns; however, data on DXA accuracy are limited. We investigated the reliability of body composition measurements by DXA. The present study included 207 normal-term newborn babies, recruited from a larger study on the determinants of birth weight in healthy pregnancies (STORK) between 2005 and 2008. Reliability analysis of total fat mass (FM(DxA)), fat-free mass, lean mass (LM(DxA)), bone mineral content (BMC), and bone mineral density (BMD) were based on 2 DXA scans of 50 neonates. We also performed a comparison analysis for DXA (FM(DxA)) measurements and caliper (CLP) or circumference (CF) measurements of trunk and extremities (performed on all neonates, n=207). Reliability: All intraclass correlation coefficients (ICC) were satisfactory to excellent for total body and the extremity-compartment FM(DxA), LM(DxA), BMD, and BMC; ICC ranged from 0.86 to 0.96 but with a lower ICC for trunk FM(DxA). For comparison analysis, the Pearson correlation coefficients for CLP vs DXA and CF vs DXA ranged from 0.48 to 0.79 and 0.41 to 0.77, respectively. Quadriceps CLP and CF measurements correlated best with the most reliable DXA results, whereas more modest correlations were found for the trunk region. DXA measurements of body composition demonstrated good reliability and can be used as a reference method in neonates. CLP and CF measurements are appropriate for larger cohorts or when DXA is unavailable, and they provide fair rough estimations of fat mass.

The STORK Groruddalen research programme: A population-based cohort study of gestational diabetes, physical activity, and obesity in pregnancy in a multiethnic population. Rationale, methods, study population, and participation rates.

BACKGROUND: Gestational diabetes mellitus (GDM) and obesity may cause adverse pregnancy outcomes for mothers and offspring. We have set up a research programme to identify predictors for GDM and fetal growth in a multiethnic population in Oslo to improve the identification of high risk pregnancies and reduce adverse short and long-term outcomes for mothers and offspring. AIMS: To present the rationale, methods, study population and participation rates. METHODS: Population-based cohort study of pregnant women attending the Child Health Clinics (CHC) in Groruddalen, Oslo, and their offspring. Questionnaire data, blood pressure, anthropometric measurements, and fasting blood and urine samples are collected (gestational weeks 8-20 and 28, and 12 weeks postpartum) and an oral glucose tolerance test (28 weeks). Physical activity is measured, three ultrasound measurements are performed and paternal questionnaire data collected. Routine hospital data are available for all mothers and offspring. Umbilical venous blood and placentas are collected, sampled, and stored and neonatal anthropometric measurements performed. Ethnicity is self-reported country of birth. RESULTS: 823 women were included, 59% of non-Western origin. The participation rate was 74% (64-83% in main ethnic groups), mean age 29.8 years (95% CI 29.5-30.1) and median parity 1 (inter-quartile range 1). The cohort is representative for women attending the CHC with respect to ethnicity and age. A slight selection towards lower parity (South Asians) and age (Africans) was found. Few were lost to follow-up. CONCLUSIONS: Unique information is collected from a representative group of multiethnic women to address important public health problems and mechanisms of disease. Participation rates are high in all ethnic groups.

Why do pregnant women stop exercising in the third trimester?

UNLABELLED: Current exercise guidelines recommend pregnant women to exercise throughout pregnancy. However, a high percentage of pregnant women are sedentary, and there is an increasing decline of physical activity and exercise, especially in the third trimester. OBJECTIVE: The aim of the present study was to compare demographic and health-related factors in pregnant women exercising and not exercising in the third trimester. DESIGN: Cross-sectional design comparing exercisers and non-exercisers. SETTING: Rikshospitalet University Hospital and Norwegian School of Sport Sciences, Oslo, Norway. POPULATION: Healthy pregnant women (n = 467) were successively allocated from the application form for birth at Rikshospitalet University Hospital. METHODS: A questionnaire, including questions about demographic variables, physical activity level, common pregnancy complaints, social modeling, attitudes and barriers towards exercise participation was answered between gestation-week 32 and 36. MAIN OUTCOME MEASURES: Demographic variables, pregnancy related health factors and social modeling, including exercise counseling by health care providers, were tested using binary logistic regression analysis. RESULTS: Less than 11% were defined as regular exercisers in the third trimester. Having high gestational weight gain and no social role models with respect to exercise behavior during childhood were inversely associated with third trimester exercise. Pre-pregnancy exercise was the strongest predictor of regular exercise at late gestation. Not receiving advice about exercise from health professionals was borderline significant. Pelvic girdle pain and sick-leave were not statistically significant factors. CONCLUSIONS: Pre-pregnancy exercise was strongly related to exercise at late gestation. This study indicates a need for more information and motivation for moderate exercise before and throughout pregnancy.

Birth complications, overweight, and physical inactivity.

OBJECTIVE: Maternal lifestyle factors are potential predictors of pregnancy complications. We examined relations between modifiable factors and delivery complications. DESIGN: Prospective cohort. SETTING: University hospital antenatal clinic, Oslo, Norway. SAMPLE: A cohort of 553 women followed through pregnancy and delivery. MAIN OUTCOME MEASURES: Pre-specified birth complications: cesarean section (CS), operative vaginal deliveries (VDs), third and fourth degree of perineal lacerations and hemorrhage (> or =1,000 ml). METHODS: Univariate and multiple logistic regression analyses were performed. Besides high birthweight (> or =4,200 g), modifiable predictors (high body mass index (BMI), fasting glucose and physical inactivity) and non-modifiable predictors (parity, maternal age, gestational age, and gender) were considered. RESULTS: Significant predictors for induction of labor were parity (odds ratio (OR): 2.1; 95% CI 1.3-3.5), maternal age (OR: 2.0; 1.2-3.4), gestational age (OR: 1.9; 1.1-3.1), and BMI > or =30 (OR: 4.2; 2.2-7.8, p<0.01). High birthweight and high BMI were overrepresented among CSs. Emergency CS was associated with birthweight (OR: 3.7; 1.7-8.1), parity (OR: 3.5; 1.7-7.2), maternal age (OR: 2.6; 1.3-5.3), and induction of labor (OR: 4.8; 2.6-9.1). After excluding CS, operative VD was associated with parity (OR: 8.7; 3.8-20) and gender (OR: 2.2; 1.2-14.1). Perineal laceration was associated with pre-gestational physical inactivity (OR: 6.1; 1.6-22.9) and operative VD (OR: 5.1; 1.5-17.6). Hemorrhage was associated with high birthweight (OR: 4.2; 1.2-4.7) and BMI > or =30 (OR: 4.6; 1.2-17.7). CONCLUSIONS: Pre-gestational physical inactivity increased the risk of perineal lacerations and male infants were associated with higher risk of vaginal operative delivery.

Association between aerobic fitness in late pregnancy and duration of labor in nulliparous women.

It is established that the level of physical activity in the population generally is too low, and data indicate that pregnant women are no exception. Studies of the effects of aerobic fitness on delivery outcomes are limited. In this observational study, we investigated the effect of aerobic fitness on duration of labor in nulliparous women who started labor spontaneously. Maximal oxygen uptake was measured in 40 nulliparous women at 35-37 weeks of gestation. Duration of labor was defined as the time between 3 cm cervical dilation with regular uterine contractions and delivery. The mean (SD) maximal oxygen uptake was 2.1 (0.3) L/min and duration of labor 583 (317) minutes. Duration of labor was inversely associated with maximal oxygen uptake after adjusting for birthweight (p = 0.034). We conclude that measurement of maximal oxygen uptake is safe in pregnancy at 35-37 weeks and that increased aerobic fitness was associated with shorter labor in nulliparous women who started labor spontaneously.

Modifiable determinants of fetal macrosomia: role of lifestyle-related factors.

BACKGROUND: Newborn macrosomia is associated with both short- and long-term health risks for the infant, and increases the prevalence of birth complications. Parity, maternal age and gender of the child are known variables that influence fetal growth. The purpose of the present investigation was to evaluate prospectively the contributions of modifiable maternal predictors of fetal macrosomia (> or =4,200 g), which included lifestyle-related factors, such as nutritional intake, physical activity, and plasma glucose values, in addition to overweight and pregnancy weight gain. METHODS: Some 553 women were followed through pregnancy. Predictive variables were subjected to univariate and multiple logistic regression analysis. Among these were: body mass index (BMI), weight gain, maternal subcutaneous fat (mm), fasting and 2-h plasma glucose, self-reported physical activity before and during pregnancy, and nutritional intake of macronutrients. Gestational age, parity and gender were also included in the model. All continuous variables were dichotomized using the upper quartile as the cut-off point in most cases. RESULTS: If physical activity was left out of the analyses, BMI, weight gain, plasma glucose and gestational age were independent determinants of macrosomia. After including low level pre-gestational physical activity in the model, we found that this was now a significant determinant of delivering a macrosomic infant with an OR=2.9 (95% CI: 1.9, 7.3). CONCLUSION: The present study indicates that a low level of pre-gestational physical activity adds to the modifiable determinants of newborn macrosomia.

Attitudes and awareness towards weight gain among normal weight and overweight pregnant women.

OBJECTIVES: (1) To evaluate the proportion who correctly classify- or misclassify maternal weight gain; (2) to investigate weight gain attitudes, and (3) to compare weight gain attitudes with weight gain recommendations by the Institute of Medicine (IOM), as well as background and lifestyle factors. METHODS: This is secondary analysis of cohort data collected as part of a prospective study of determinants of macrosomic infants in Norway (the STORK project). The participants (n = 467) answered a self-administered questionnaire, including report on maternal weight gain and attitudes towards weight gain, in mean gestation week 36.4 (SD = 1.7). The women were also weighted (kg) at the hospital using a digital beam scale. RESULTS: A significant discrepancy was found between self-reported and measured maternal weight gain. About 76% reported to be satisfied with maternal weight gain while 24% were dissatisfied. Women reporting to be dissatisfied were significantly more likely to be sedentary, sick-listed, reporting poor eating habits and to be multiparous. CONCLUSIONS: Most women reported to be satisfied with their maternal weight gain, but had gained excessively according to recommended weight gain ranges issued by IOM. Pregnant women may need targeted advice on their specific weight gain and impact of increased weight gain on health variables for mother and child.

ß-cell dysfunction in women with previous gestational diabetes is associated with visceral adipose tissue distribution.

CONTEXT: Glucose intolerance in pregnancy predicts an increased risk of future type 2 diabetes. OBJECTIVE: The aim of the study was to evaluate glucose metabolism in women with and without gestational diabetes mellitus (GDM) at 5 years follow-up and identify risk factors associated with disturbed glucose metabolism post-partum. DESIGN: This follow-up study included 300 consecutively enrolled women from a previous population-based cohort study. The participants underwent oral glucose tolerance test under pregnancy and in the follow-up study, in addition to dual-energy X-ray absorptiometry in the follow-up study. RESULTS: Fifty-two women (17.7%) were found to have GDM in pregnancy with an odds ratio of 4.8 developing prediabetes 5 years later. ß-cell function, but not insulin resistance or sensitivity, was reduced in the follow-up study after adjusting for known risk factors. Furthermore, visceral fat content at follow-up was increased in GDM women compared to non-GDM women, and the ß-cell function declined with increasing visceral fat in both groups but was more pronounced in the women with previous GDM. CONCLUSIONS: Women with GDM are at increased risk of developing prediabetes and have a decreased ß-cell function 5 years post-partum that is associated with increased visceral fat mass.

Stages of change model for participation in physical activity during pregnancy.

BACKGROUND: The transtheoretical model (TTM) has been successful in promoting health behavioral change in the general population. However, there is a scant knowledge about physical activity in relation to the TTM during pregnancy. Hence, the aims of the present study were (1) to assess readiness to become or stay physically active according to the TTM and (2) to compare background and health variables across the TTM. METHODS: Healthy pregnant women (n = 467) were allocated to the study from Oslo University Hospital, Norway. The participants filled in a validated self-administered questionnaire, physical activity pregnancy questionnaire (PAPQ) in gestation, weeks 32-36. The questionnaire contained 53 questions with one particular question addressing the TTM and the five stages: (1) precontemplation stage, (2) contemplation stage, (3) preparation stage, (4) action stage, and (5) maintenance stage. RESULTS: More than half of the participants (53%) were involved in regular exercise (stages 4-5); however, only six specified that they had recently started an exercise program (stage 4). About 33% reported engaging in some physical activity, but not regularly (stage 3). The results showed that receiving advice from health professionals to exercise during pregnancy increased the likeliness of being in stages 4-5, while higher age, multiparity, pregravid overweight, unhealthy eating habits, pelvic girdle pain, and urinary incontinence were more prevalent with low readiness to change exercise habits (stages 1-3). CONCLUSION: According to the TTM, more than half of the participants reported to be physically active. Moreover, most of the participants classified as inactive showed a high motivational readiness or intention to increase their physical activity level. Hence, pregnancy may be a window of opportunity for the establishment of long-term physical activity habits.

Newborn body fat: associations with maternal metabolic state and placental size.

BACKGROUND: Neonatal body composition has implications for the health of the newborn both in short and long term perspective. The objective of the current study was first to explore the association between maternal BMI and metabolic parameters associated with BMI and neonatal percentage body fat and to determine to which extent any associations were modified if adjusting for placental weight. Secondly, we examined the relations between maternal metabolic parameters associated with BMI and placental weight. METHODS: The present work was performed in a subcohort (n = 207) of the STORK study, an observational, prospective study on the determinants of fetal growth and birthweight in healthy pregnancies at Oslo University Hospital, Norway. Fasting glucose, insulin, triglycerides, free fatty acids, HDL- and total cholesterol were measured at week 30-32. Newborn body composition was determined by Dual-Energy X-Ray Absorptiometry (DXA). Placenta was weighed at birth. Linear regression models were used with newborn fat percentage and placental weight as main outcomes. RESULTS: Maternal BMI, fasting glucose and gestational age were independently associated with neonatal fat percentage. However, if placental weight was introduced as a covariate, only placental weight and gestational age remained significant. In the univariate model, the determinants of placenta weight included BMI, insulin, triglycerides, total- and HDL-cholesterol (negatively), gestational weight gain and parity. In the multivariable model, BMI, total cholesterol HDL-cholesterol, gestational weight gain and parity remained independent covariates. CONCLUSION: Maternal BMI and fasting glucose were independently associated with newborn percentage fat. This effect disappeared by introducing placental weight as a covariate. Several metabolic factors associated with maternal BMI were associated with placental weight, but not with neonatal body fat. Our findings are consistent with a concept that the effects of maternal BMI and a number of BMI-related metabolic factors on fetal fat accretion to a significant extent act by modifying placental weight.

Umbilical cord levels of sclerostin, placental weight, and birth weight are predictors of total bone mineral content in neonates.

CONTEXT: During pregnancy, changes occur in the maternal calcium homeostasis to fulfill fetal demand. We hypothesized that the fibroblast growth factor 23 (FGF23) system and Wnt signaling pathway are important for normal skeletal development in the offspring. AIMS: Circulating α-klotho, FGF23, sclerostin, and 25-hydroxyvitamin D (25(OH)D) at the fetal and maternal sides of the placenta were measured to investigate associations with newborn bone mass independent of maternal BMI, calcium and phosphate levels, placental weight, and birth weight. METHODS: In a prospective cohort of healthy pregnant women, the total body bone mineral content (BMC) in 202 newborns was measured by dual-energy X-ray absorptiometry. Maternal circulating levels of the biomarkers were measured at gestational weeks 30-32 and in umbilical cord plasma (UCP) at birth. RESULTS: Mean α-klotho and sclerostin concentrations in the UCP were significantly higher than maternal levels (3004 vs 1077  pg/ml; P<0.001 and 629 vs 346  pg/ml; P<0.001 respectively), and mean 25(OH)D was lower (31 vs 45  nmol/l; P<0.001). The UCP and maternal FGF23 levels were similar. No significant effects of maternal biomarkers on BMC were found in regression analyses. Among UCP biomarkers, only UCP sclerostin was significantly associated with BMC in univariate analyses, and the effect remained significant after adjustment for birth weight and other confounders. CONCLUSIONS: We found that UCP sclerostin levels, birth weight, and placental weight were significant predictors of neonatal BMC but found no evidence for a main role of maternal levels of α-klotho, FGF23, sclerostin, or 25(OH)D nor of UCP levels of α-klotho, FGF23, or 25(OH)D.

Fetal growth versus birthweight: the role of placenta versus other determinants.

INTRODUCTION: Birthweight is used as an indicator of intrauterine growth, and determinants of birthweight are widely studied. Less is known about determinants of deviating patterns of growth in utero. We aimed to study the effects of maternal characteristics on both birthweight and fetal growth in third trimester and introduce placental weight as a possible determinant of both birthweight and fetal growth in third trimester. METHODS: The STORK study is a prospective cohort study including 1031 healthy pregnant women of Scandinavian heritage with singleton pregnancies. Maternal determinants (age, parity, body mass index (BMI), gestational weight gain and fasting plasma glucose) of birthweight and fetal growth estimated by biometric ultrasound measures were explored by linear regression models. Two models were fitted, one with only maternal characteristics and one which included placental weight. RESULTS: Placental weight was a significant determinant of birthweight. Parity, BMI, weight gain and fasting glucose remained significant when adjusted for placental weight. Introducing placental weight as a covariate reduced the effect estimate of the other variables in the model by 62% for BMI, 40% for weight gain, 33% for glucose and 22% for parity. Determinants of fetal growth were parity, BMI and weight gain, but not fasting glucose. Placental weight was significant as an independent variable. Parity, BMI and weight gain remained significant when adjusted for placental weight. Introducing placental weight reduced the effect of BMI on fetal growth by 23%, weight gain by 14% and parity by 17%. CONCLUSION: In conclusion, we find that placental weight is an important determinant of both birthweight and fetal growth. Our findings indicate that placental weight markedly modifies the effect of maternal determinants of both birthweight and fetal growth. The differential effect of third trimester glucose on birthweight and growth parameters illustrates that birthweight and fetal growth are not identical entities.

Impact of ethnicity on gestational diabetes identified with the WHO and the modified International Association of Diabetes and Pregnancy Study Groups criteria: a population-based cohort study.

OBJECTIVE: The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently proposed new criteria for diagnosing gestational diabetes mellitus (GDM). We compared prevalence rates, risk factors, and the effect of ethnicity using the World Health Organization (WHO) and modified IADPSG criteria. METHODS: This was a population-based cohort study of 823 (74% of eligible) healthy pregnant women, of whom 59% were from ethnic minorities. Universal screening was performed at 28±2 weeks of gestation with the 75 g oral glucose tolerance test (OGTT). Venous plasma glucose (PG) was measured on site. GDM was diagnosed as per the definition of WHO criteria as fasting PG (FPG) ≥7.0 or 2-h PG ≥7.8 mmol/l; and as per the modified IADPSG criteria as FPG ≥5.1 or 2-h PG ≥8.5 mmol/l. RESULTS: OGTT was performed in 759 women. Crude GDM prevalence was 13.0% with WHO (Western Europeans 11%, ethnic minorities 15%, P=0.14) and 31.5% with modified IADPSG criteria (Western Europeans 24%, ethnic minorities 37%, P< 0.001). Using the WHO criteria, ethnic minority origin was an independent predictor (South Asians, odds ratio (OR) 2.24 (95% confidence interval (CI) 1.26-3.97); Middle Easterners, OR 2.13 (1.12-4.08)) after adjustments for age, parity, and prepregnant body mass index (BMI). This increased OR was unapparent after further adjustments for body height (proxy for early life socioeconomic status), education and family history of diabetes. Using the modified IADPSG criteria, prepregnant BMI (1.09 (1.05-1.13)) and ethnic minority origin (South Asians, 2.54 (1.56-4.13)) were independent predictors, while education, body height and family history had little impact. CONCLUSION: GDM prevalence was overall 2.4-times higher with the modified IADPSG criteria compared with the WHO criteria. The new criteria identified many subjects with a relatively mild increase in FPG, strongly associated with South Asian origin and prepregnant overweight.

Increased risk of macrosomia among overweight women with high gestational rise in fasting glucose.

OBJECTIVES: Maternal overweight is a risk factor for gestational diabetes (GDM) and for newborn macrosomia. Among women without GDM, it is not well understood why some women with high body mass index (BMI) give birth to macrosomic newborns while others do not. We wanted to explore the effect of BMI and fasting plasma glucose (FPG), fasting plasma insulin (FPI) and insulin resistance (HOMA-IR) on the risk of newborn macrosomia. METHODS: A cohort of 553 Caucasian women was followed throughout pregnancy. The dependent variable was high birth weight (>or=4200 g). Independent variables included gestational age, intake of macronutrients and energy, maternal BMI, weight gain, FPG, FPI and HOMA-IR. RESULTS: FPG in late pregnancy (30-32 weeks) remained a significant determinant of newborn macrosomia in multiple regression analysis (OR: 1.9, 95% CI: [1.1, 3.4]), whereas FPI and HOMA-IR did not. The women in the highest BMI quartile (>or=27 kg/m(2)) who gave birth to macrosomic newborns had higher increase in FPG and HOMA-IR from early to late pregnancy. Among women in this BMI category, the risk for delivering a macrosomic infant was higher among those with an increase in FPG above 0.60 mmol/l (upper quartile) (OR = 4.5, 95% CI: [1.7, 12.5]). CONCLUSION: Fasting plasma glucose at week 30-32, but not fasting plasma insulin or insulin resistance, is a determinant of newborn macrosomia. Overweight women with high increase in fasting plasma glucose from early to late pregnancy had a 4.5-fold increase in risk of newborn macrosomia compared to the remaining group with high BMI.