Omega-3 fatty acid supply in pregnancy for risk reduction of preterm and early preterm birth.

This clinical practice guideline on the supply of the omega-3 docosahexaenoic acid and eicosapentaenoic acid in pregnant women for risk reduction of preterm birth and early preterm birth was developed with support from several medical-scientific organizations, and is based on a review of the available strong evidence from randomized clinical trials and a formal consensus process. We concluded the following. Women of childbearing age should obtain a supply of at least 250 mg/d of docosahexaenoic+eicosapentaenoic acid from diet or supplements, and in pregnancy an additional intake of ≥100 to 200 mg/d of docosahexaenoic acid. Pregnant women with a low docosahexaenoic acid intake and/or low docosahexaenoic acid blood levels have an increased risk of preterm birth and early preterm birth. Thus, they should receive a supply of approximately 600 to 1000 mg/d of docosahexaenoic+eicosapentaenoic acid, or docosahexaenoic acid alone, given that this dosage showed significant reduction of preterm birth and early preterm birth in randomized controlled trials. This additional supply should preferably begin in the second trimester of pregnancy (not later than approximately 20 weeks' gestation) and continue until approximately 37 weeks' gestation or until childbirth if before 37 weeks' gestation. Identification of women with inadequate omega-3 supply is achievable by a set of standardized questions on intake. Docosahexaenoic acid measurement from blood is another option to identify women with low status, but further standardization of laboratory methods and appropriate cutoff values is needed. Information on how to achieve an appropriate intake of docosahexaenoic acid or docosahexaenoic+eicosapentaenoic acid for women of childbearing age and pregnant women should be provided to women and their partners.

Screening and treatment of iron deficiency anemia in pregnancy: A review and appraisal of current international guidelines.

Iron deficiency anemia (IDA) in pregnancy is a common diagnosis that is associated with adverse obstetric and neonatal outcomes. There remains uncertainty regarding how best to screen for, prevent, and treat established IDA in pregnancy. There is no consensus on the benefits of routine iron supplementation in pregnancy, with concerns regarding potential harmful effects of routine iron supplementation in women who are iron replete. Fourteen international guidelines were selected and appraised and compared by a multidisciplinary team. The AGREE II GRS tool was used. Each reviewer independently made their own assessment, and the scores from 1 to 7 were also collated and averaged for an overall score incorporating seven domains: process of development, clarity of presentation, completeness of reporting, clinical validity, and overall quality. The reviewers' scores were also individually compared according to discipline. The mean score across all the guidelines was 4.4 (range 3.5-6.5). Only half of the guidelines recommend routine iron in pregnancy. In terms of screening recommendations, five guidelines recommend screening with ferritin in addition to a full blood count in pregnancy, two recommend selective screening with ferritin for at risk groups only, and one guideline suggests using ferritin where feasible. Although many of the guidelines recommend similar doses of oral elemental iron of 100-200 mg daily for the treatment of established IDA in pregnancy, two recommend twice or three times daily dosing. Only five guidelines give hemoglobin rises to expect within specific timeframes. There remains a need to clarify the optimal screening method, dosing regimen, timing, and route of iron supplementation in pregnancy. Robust randomized controlled data are needed to guide appropriate prevention and management.

Pregnancy Nutrition Core Outcome Set (PRENCOS): A core outcome set development study.

OBJECTIVE: To develop a core outcome set for pregnancy nutrition. DESIGN: Mixed-methods core outcome set development study. SETTING: Online. POPULATION: Healthcare professionals, researchers and women with experience of pregnancy. METHODS: Candidate outcomes were identified from a systematic review of intervention and observational studies. One-to-one semi-structured interviews with women with experience of pregnancy (n = 26) were transcribed and analysed using inductive thematic analysis. Outcomes were consolidated, organised into domains and categorised using the Core Outcome Measures in Effectiveness Trials taxonomy. A two-round, modified Delphi survey (May-August 2021) was conducted. Participants voted on how critical each outcome was to include using a nine-point Likert scale. All outcomes that did not reach consensus were discussed at a consensus meeting. MAIN OUTCOME MEASURES: Critical outcomes to include in the core outcome set. RESULTS: A total of 53 091 articles were identified. Outcomes were extracted from 427 articles. The qualitative data yielded 45 outcomes. An additional 24 outcomes came from the literature. In round one, 82 participants ranked 30 outcomes. One new outcome was included in round two, during which participants (n = 60) voted 12/31 outcomes as critical to include. The remaining 20 outcomes were discussed at the consensus meeting and two outcomes were included. Maternal outcomes included: pregnancy complications; delivery complications; maternal wellbeing; gestational weight change; maternal vitamin and mineral status; mental health; diet quality; nutritional intakes; need for treatments, interventions, medications and supplements; pregnancy loss or perinatal death; birth defects or congenital anomalies; neonatal complications; and newborn anthropometry and body composition. CONCLUSIONS: The use of the Pregnancy Nutrition Core Outcome Set (PRENCOS) will ensure researchers measure what matters most from the perspective of key stakeholders.

Nutritional interventions to ameliorate the effect of endocrine disruptors on human reproductive health: A semi-structured review from FIGO.

BACKGROUND: Endocrine disrupting chemicals have harmful effects on reproductive, perinatal, and obstetric outcomes. OBJECTIVE: To analyze the evidence on nutritional interventions to reduce the negative effects of endocrine disruptors on reproductive, perinatal, and obstetric outcomes. SEARCH STRATEGY: A search of MEDLINE (PubMed), Allied Health Literature (CINAHL), EMBASE, Web of Science, and the Cochrane Database was conducted from inception to May 2021. SELECTION CRITERIA: Experimental studies on human populations. DATA COLLECTION AND ANALYSIS: Data were collected from eligible studies. Risk of bias assessment was completed using the Cochrane risk of bias tool and the ROBINS-I Tool. RESULTS: Database searches yielded 15 362 articles. Removing 11 181 duplicates, 4181 articles underwent abstract screening, 26 articles were eligible for full manuscript review, and 16 met full inclusion criteria. Several interventions were found to be effective in reducing exposure to endocrine disruptors: avoidance of plastic containers, bottles, and packaging; avoidance of canned food/beverages; consumption of fresh and organic food; avoidance of fast/processed foods; and supplementation with vitamin C, iodine, and folic acid. There were some interventional studies examining therapies to improve clinical outcomes related to endocrine disruptors. CONCLUSION: Dietary alterations can reduce exposure to endocrine disruptors, with limited data on interventions to improve endocrine-disruptor-related clinical outcomes. This review provides useful instruction to women, their families, healthcare providers, and regulatory bodies.

The impact of probiotic supplementation on metabolic health in healthy women of reproductive age: a systematic review.

Products containing probiotics are targeted at healthy or at-risk individuals as a preventative measure to minimise disease risk. Most studies assessing the efficacy of probiotics in humans include a mixture of healthy and unhealthy populations, while studies that focus solely on female populations are largely limited to pregnancy or those with health conditions. Pre-conception is a significant time-point during the life-course, and improving female health status during this period may positively influence future offspring. The objective of this review is to assess the effect of probiotics administered in oral capsule formulation, on metabolic and immune markers in healthy, non-pregnant women of reproductive age. This review followed the PRISMA guidelines. Pubmed, EMBASE, CINAHL, and Web of Science were searched for relevant studies. English language articles relating to randomised-controlled trials were included. The search returned 3250 publications after duplicates were removed. Title (2516), abstract (642), and full text (87) screening excluded 3993 studies from consideration. Five papers were identified with outcomes of interest, and analysis of these showed no conclusive evidence that probiotic capsule supplementation elicited positive effects in this healthy population. This study highlights the need for further research to investigate the role that probiotics play during the pre-conception period, on female metabolic and immune health.

Midwives' and obstetricians' level of knowledge of appropriate gestational weight gain recommendations for pregnancy: A systematic review.

BACKGROUND: Excessive gestational weight gain (GWG) is a modifiable risk factor associated with maternal and infant health, and pregnancy outcomes. However, several factors influence the provision of health promotion advice including professional knowledge. This review aims to summarize published evidence relating to midwives' and obstetricians' knowledge of GWG guidelines. METHODS: Electronic database searches were carried out using EMBASE, CINAHL, PubMed, Web of Science, and Cochrane Database. English-language studies and quantitative results were included. Identified studies were screened by two authors independently. Disagreements were discussed with a third reviewer. A review protocol was submitted for registration with PROSPERO in May 2019. RESULTS: From 10 960 records identified in preliminary searches, 12 studies reporting on 2652 midwives and obstetricians collectively were included. All studies were conducted in high-income countries. Synthesis of data was difficult as guidelines and methods for assessing knowledge varied. Midwives were mainly reported as the leading participant, with limited data available on obstetrician knowledge. Both groups demonstrated insufficient knowledge of GWG guidelines. Self-reported knowledge was significantly higher than those assessed by direct knowledge. CONCLUSIONS: This review highlights a substantial gap in health care professionals' knowledge of GWG guideline content which needs to be addressed. Differences between professionals' direct knowledge and self-reported knowledge are important for clinical practice as it may inhibit the provision of evidence-based advice. It is important to accurately assess knowledge in this area to develop further training for midwives and obstetricians to improve health promotion during pregnancy.

Association between vitamin D status in early pregnancy and atopy in offspring in a vitamin D deplete cohort.

BACKGROUND: Vitamin D status may play a role in the development of atopic diseases due to its action on lung development and immune system development and function. AIMS: Our objective was to assess whether 25-hydroxyvitamin D (25OHD) levels in maternal blood in pregnancy were associated with atopy in children. METHODS: We analysed 279 mother-child pairs from the ROLO study conducted in Dublin, Ireland. Serum 25OHD was measured at 13 and 28 weeks of pregnancy. Development of childhood atopy was self-reported by mothers at follow-up appointments at 6 months, 2 years or 5 years. Logistic regression analysis was used to evaluate associations between maternal 25OHD status and development of atopy. RESULTS: The mean (SD) 25OHD levels in early and late pregnancy were 41.9 (19.2) nmol/L and 40.2 (21.6) nmol/L, respectively. Maternal 25OHD status in early pregnancy, but not in late pregnancy, was associated with a reduced risk of atopy at 2 years (OR 0.972, CI 0.946-0.999). In early pregnancy, those with serum 25OHD levels < 30 nmol/L compared with those with 25OHD > 50 nmol/L had significantly greater risk of developing atopy at 2 years (OR 4.76, CI 1.38-16.47). CONCLUSIONS: The development of childhood atopy may be associated with maternal vitamin D deficiency in early pregnancy among a cohort of women at risk of vitamin D deficiency. Further research is required to explore the relationship between vitamin D and atopy, particularly among women with poor vitamin D status, and whether supplementation should be prioritised in early pregnancy to reduce childhood atopy.

Do the concepts of "life course approach" and "developmental origins of health and disease" underpin current maternity care? Study protocol.

OBJECTIVE: To explore the knowledge of Developmental Origins of Health and Disease (DOHaD) concepts among midwives and obstetricians and to identify barriers and facilitators for clinicians to engage women and their partners before or early in pregnancy on risk factors associated with DOHaD, and thus to embed the concept of DOHaD in routine clinical practice. METHODS: A qualitative study using semi-structured interviews will be conducted in Ghana, India, Pakistan, Brazil, the UK, and USA in collaboration with the International Confederation of Midwives and the International Federation of Obstetricians and Gynecologists. Participants will be contacted via email and telephone interviews will be conducted until data saturation followed by inductive thematic analysis. RESULTS: Findings from this exploratory study will provide new knowledge about the perspectives of midwives and obstetricians on DOHaD and their role in preventing the intergenerational passage of non-communicable disease (NCD) risk and improving preconception care. CONCLUSION: This study will help us understand the current use of DOHaD principles in international maternity care and how this can be improved. Bringing DOHaD to clinical practice will help healthcare practitioners adopt a long-term approach in the prevention of NCDs and childhood obesity and will help women to enter pregnancy in optimum health.

Maternal metabolic response to dietary treatment for impaired glucose tolerance and gestational diabetes mellitus.

BACKGROUND: Dietary advice is a standard component of treatment for pregnant women with impaired glucose tolerance (IGT) and gestational diabetes (GDM), yet few studies report glycemic profiles in response to dietary therapies and the optimal dietary approach remains uncertain. AIM: To assess changes in maternal glycemic profile and pregnancy outcomes among women with diet-controlled IGT and GDM. METHODS: Pregnant women who had one or more elevated values on a 3-h oral glucose tolerance test were enrolled. All participants received dietary advice and glucose monitoring as part of routine clinical care. Fasting and 1-h post-prandial blood samples, collected prior to initiation of clinical treatment and repeated 4-6 weeks later, were analyzed for glucose, insulin, and C-peptide. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. Women who required pharmacological therapy for glucose control were excluded from analyses. RESULTS: Participants (N = 93) were of moderately older age (mean 33 years), with a high rate of overweight/obesity (mean body mass index (BMI) = 28.65 kg/m2), and were diagnosed late in gestation (mean 29 weeks). Fasting (mean ± SD 4.82 ± 0.53 to 4.60 ± 0.42 mmol/l; p < 0.001) and post-prandial glucose (7.01 ± 1.19 to 6.47 ± 1.10; p = 0.004) decreased significantly following the intervention. Baseline HOMA-IR was elevated (3.12 ± 1.03) but did not significantly decrease (2.78 ± 1.52; p = 0.066). There were high rates of macrosomia (24.7%) and cesarean delivery (32.3%). CONCLUSIONS: Although improvements in blood glucose levels were observed among women with diet-controlled IGT and GDM, this was insufficient to significantly affect insulin resistance or perinatal outcome. Late diagnosis and treatment of IGT/GDM may have contributed to such outcomes.

Calcium intake in winter pregnancy attenuates impact of vitamin D inadequacy on urine NTX, a marker of bone resorption.

PURPOSE: Pregnancy is characterised by increased bone turnover, but high bone turnover with resorption exceeding formation may lead to negative maternal bone remodelling. Recent studies are conflicting regarding the effect of calcium on skeletal health in pregnancy. The aim of this study was to examine the seasonal effect of serum 25-hydroxyvitamin D (25OHD) and dietary calcium on a marker of bone resorption. METHODS: This was prospective study of 205 pregnant women [two cohorts; early pregnancy at 13 weeks (n = 96), and late pregnancy at 28 weeks (n = 109)]. Serum 25OHD and urine cross-linked N-telopeptides of type I collagen (uNTX) were measured at both time points. Intakes of vitamin D and calcium were recorded using 3-day food diaries at each trimester. RESULTS: Compared to summer pregnancies, winter pregnancies had significantly lower 25OHD and significantly higher uNTX. Higher calcium intakes were negatively correlated with uNTX in winter, but not summer. In late pregnancy, compared to those reporting calcium intakes ≥1000 mg/day, intakes of <1000 mg/day were associated with a greater increase in uNTX in winter pregnancies than in summer (41.8 vs. 0.9%). Increasing calcium intake in winter by 200 mg/day predicted a 13.3% reduction in late pregnancy uNTX. CONCLUSIONS: In late pregnancy, during winter months when 25OHD is inadequate, intakes of dietary calcium <1000 mg/day were associated with significantly increased bone resorption (uNTX). Additional dietary calcium is associated with reduced bone resorption in late pregnancy, with greater effect observed in winter. Further research regarding optimal dietary calcium and 25OHD in pregnancy is required, particularly for women gestating through winter.

Maternal low glycaemic index diet, fat intake and postprandial glucose influences neonatal adiposity--secondary analysis from the ROLO study.

BACKGROUND: The in utero environment is known to affect fetal development however many of the mechanisms by which this occurs remain unknown. The aim of this study was to examine the association between maternal dietary macronutrient intake and lifestyle throughout pregnancy and neonatal weight and adiposity. METHODS: This was an analysis of 542 mother and infant pairs from the ROLO study (Randomised cOntrol trial of LOw glycaemic index diet versus no dietary intervention to prevent recurrence of fetal macrosomia). Food diaries as well as food frequency and lifestyle and physical activity questionnaires were completed during pregnancy. Maternal anthropometry was measured throughout pregnancy and neonatal anthropometry was measured at birth. RESULTS: Multiple linear regression analysis revealed the main maternal factor associated with increased birth weight was greater gestational weight gain R2adj 23.3% (F = 11.547, p < 0.001). The main maternal factor associated with increased birth length was non-smoking status R2adj 27.8% (F = 6.193, p < 0.001). Neonatal central adiposity (determined using waist:length ratio) was negatively associated with maternal age, and positively associated with the following parameters: smoking status, maternal pre-pregnancy arm circumference, percentage energy from saturated fat in late pregnancy, postprandial glucose at 28 weeks gestation and membership of the control group with a positive trend towards association with trimester 2 glycaemic load R2adj 38.1% (F = 8.000, p < 0.001). CONCLUSIONS: Several maternal diet and lifestyle factors were associated with neonatal anthropometry . Low glycaemic index dietary intervention in pregnancy was found to have a beneficial effect on neonatal central adiposity. Additionally, central adiposity was positively associated with maternal dietary fat intake and postprandial glucose highlighting the important role of healthy diet in pregnancy in promoting normal neonatal adiposity. TRIAL REGISTRATION: Current Controlled Trials ISRCTN54392969.

The relationship between maternal and fetal vitamin D, insulin resistance, and fetal growth.

Evidence for a role of vitamin D in maintaining normal glucose homeostasis is inconclusive. We sought to clarify the relationship between maternal and fetal insulin resistance and vitamin D status. This is a prospective cohort study of 60 caucasian pregnant women. Concentrations of 25-hydroxyvitamin D (25-OHD), glucose, insulin, and leptin were measured in early pregnancy and at 28 weeks. Ultrasound at 34 weeks assessed fetal anthropometry including abdominal wall width, a marker of fetal adiposity. At delivery birth weight was recorded and fetal 25-OHD, glucose, C-peptide, and leptin measured in cord blood. Insulin resistance was calculated using the Homeostasis Model Assessment (HOMA) equation. We found that those with lower 25-OHD in early pregnancy had higher HOMA indices at 28 weeks, (r = -.32, P = .02). No significant relationship existed between maternal or fetal leptin and 25-OHD, or between maternal or fetal 25-OHD and fetal anthropometry or birth weight. The incidence of vitamin D deficiency was high at each time point (15%-45%). These findings lend support to routine antenatal supplementation with vitamin D in at risk populations.