"Is It Realistic?": A Qualitative Study of the Experiences of Elite Women Athletes Considering Parenthood.

BACKGROUND AND OBJECTIVE: As the visibility and acceptance of athlete-mothers increase, so does the number of women athletes considering parenthood. Yet, many athletes struggle with the decision to become a parent while competing at the elite level due to the significant changes and uncertainties that have been reported by pregnant and parenting athletes. The experiences of women athletes considering parenthood are under-represented in the vast sport literature but are necessary for developing evidenced-based policies and practices that can support women's equitable participation in high-performance sport contexts. Thus, the purpose of this qualitative study was to describe the experiences of elite women athletes that are considering parenthood. METHODS: Participants were ten elite North American athletes (29-36 years) who are considering becoming parents in the next 5 years. Each participant self-identified as a woman and competed at the highest level in their respective sport. Data were generated via one-on-one semi-structured interviews that were audio-recorded, transcribed verbatim, and analyzed through a process of content analysis. RESULTS: The experiences of elite women athletes considering parenthood are represented by five themes: (a) calls for essential mandates and leadership, (b) how do you support yourself?, (c) hesitation of body changes, (d) age inequities, and (e) being proactive about reproductive health. Such findings support an in-depth understanding of gender-specific stressors that limit women's equitable participation in high-performance contexts. CONCLUSION: This research is grounded in the voices of elite women athletes and identifies actionable steps necessary for research and culture change. Findings provide necessary evidence to inform the development of sport policies to support those athletes that are considering becoming parents.

A comparison among oscillometric waveforms in healthy nonpregnant women, pregnancy and hypertensive disorders of pregnancy.

OBJECTIVE: Understanding of how oscillometric waveforms (OMW) vary between pregnant and nonpregnant individuals remains low. An exploratory analysis was completed to assess for quantitative and qualitative changes in OMW and oscillometric envelope features in pregnancy. DESIGN AND METHODS: Eighteen pregnant individuals (over 20 weeks gestational age) and healthy, nonpregnant (HNP) women were recruited. Six HNP were matched to six healthy pregnant (HP) women, and six pregnant women with a hypertensive disorder of pregnancy (HDP) by age, arm circumference, and cuff size. Blood pressure measurements were completed per the International Organization for Standardization (ISO) protocol using a custom-built oscillometric device as the test device and two-observer mercury auscultation as the reference measurement. Auscultatory blood pressure and blood pressure derived from slope-based and fixed ratio algorithms were determined. OMW and envelope features were compared among groups. RESULTS: In HNP, HP, and HDP groups respectively: mean auscultatory blood pressure (systolic mean ± SD/diastolic mean ± SD) was 103.4 ±â€…12.2/67.1 ±â€…7.9; 109.5 ±â€…3.1/58.1 ±â€…6.4; 135.6 ±â€…18.9/85.1 ±â€…14.2 mmHg. HDP had significantly higher auscultatory systolic and diastolic blood pressure than the HP group (P = 0.001). The pregnant groups had a lower average pulse width (mean ± SD: HNP = 0.8 ±â€…0 s, HP = 0.6 ±â€…0.1 s, HDP = 0.6 ±â€…0.1 s; HP vs. HNP mean difference [adjusted P value]: 0.2 [P = 0.004], HDP vs. HNP 0.1 [P = 0.018]) compared with the HNP group. The HDP group had a larger area under the OMW envelope than the HNP group (mean ± SD: HNP = 22.6 ±â€…3.4; HDP = 28.5 ±â€…4.2; HDP vs. HNP mean difference [adjusted P value]: 5.9 P = 0.05). CONCLUSION: In this exploratory work, differences in the OMW morphology and parameters were found in pregnancy and in hypertensive disorders of pregnancy compared with healthy controls. Even small differences may have important implications in algorithm development; further work comparing OMW envelopes in pregnancy is needed to optimize the algorithms used to determine blood pressure in pregnancy.

Filling the evidence void: exploration of coach and healthcare provider experiences working with pregnant and postpartum elite athletes - a qualitative study.

OBJECTIVE: Recent research grounded in the experiences of elite female athletes has shed light on the complex challenges of navigating sport environments that do not support or value pregnant or postpartum athletes. The purpose of this study was to explore the unique experiences of coaches and healthcare providers working with pregnant and postpartum elite athletes, and to identify actionable steps for research, policy and culture change to support them. METHODS: Sixteen participants (five coaches, three physicians and eight physiotherapists), who have worked with pregnant and/or postpartum elite athletes within the last 5 years, participated in this qualitative study. Thirteen participants self-identified as women, and three as men. Data were generated via semistructured one-on-one interviews that were audiorecorded, transcribed verbatim and analysed through a process of content analysis. RESULTS: The findings of this research are represented by five main themes: (a) lack of female athlete reproductive research, (b) need for evidence-informed education and training, (c) need to develop evidence-based progression for sport participation in pregnancy and postpartum, (d) open communication to support athlete-centred care and (e) essential supports and changes required for pregnant/postpartum athletes. CONCLUSION: Findings from this study, which are grounded in the unique perspectives of coaches and healthcare providers, outline specific recommendations to inform policy and practices that support athletes through the perinatal period, such as developing evidence-based return-to-sport protocols.

Optimizing Blood Glucose Control through the Timing of Exercise in Pregnant Individuals Diagnosed with Gestational Diabetes Mellitus.

This study aimed to evaluate the effectiveness of moderate intensity walking on postprandial blood glucose control for pregnant individuals with (GDM) and without gestational diabetes mellitus (NON-GDM). Using a randomized cross-over design, individuals completed 5 days of exercise (three 10-min walks immediately after eating (SHORT), or one 30-min walk (LONG) outside of 1 h after eating). These protocols were preceded and separated by 2-days of habitual exercise (NORMAL). Individuals were instrumented with a continuous glucose monitor, a physical activity monitor for 14-days, and a heart rate monitor during exercise. Participants completed a physical activity enjoyment scale (PACES) to indicate their protocol preference. The GDM group had higher fasting, 24-h mean, and daily peak glucose values compared to NON-GDMs across all conditions (effect of group, p = 0.02; p = 0.02; p = 0.03, respectively). Fasting, 24-h mean, and daily peak glucose were not influenced by the SHORT or LONG exercise (effect of intervention, p > 0.05). Blood glucose values were higher among the GDM group for at least 1 h after eating, yet the exercise intervention had no effect on 1 or 2 h postprandial glucose values (effect of intervention, p > 0.05). Physical activity outcomes (wear time, total activity time, and time spent on each intensity) were not different between the groups nor interventions (effect of group, p > 0.05; effect of intervention, p > 0.05,). There were no differences between the groups or interventions for the PACES score (effect of group, p > 0.05; effect of intervention, p > 0.05). To conclude, there were no differences between the groups or exercise protocols on blood glucose control. More research is warranted to elucidate higher exercise volumes in this outcome for individuals with GDM.

We're not Superhuman, We're Human: A Qualitative Description of Elite Athletes' Experiences of Return to Sport After Childbirth.

BACKGROUND: A growing number of athletes return to elite sport following childbirth. Yet, they face significant barriers to do so safely and successfully. The experiences of elite athletes returning to sport following delivery are necessary to support evidence-informed policy. OBJECTIVE: The purpose of this qualitative description was to describe the experiences of elite athletes as they returned to sport following childbirth, and to identify actionable steps for research, policy and culture-change to support elite athlete mothers. METHODS: Eighteen elite athletes, primarily from North America, who had returned to sport following childbirth in the last 5 years were interviewed. Data were generated via one-on-one semi-structured interviews that were audio-recorded, transcribed verbatim, and analyzed through a process of content analysis. RESULTS: The findings of this study are represented by one overarching theme: Need for More Time, and five main themes: (a) Training "New Bodies" Postpartum, (b) Injuries and Safe Return to Sport, (c) Breastfeeding While Training, (d) Critical Supports for Return to Sport, (e) Navigating Motherhood and Sport. The athletes identified the urgent need to develop best-practice policies and funding to support return to sport, as well as develop evidence-based return-to-sport protocols to support a safe and injury-free return. CONCLUSION: Athletes shared detailed stories highlighting the challenges, barriers and successes elite athletes experience returning to elite-level sport following childbirth. Participants provided clear recommendations for policy and research to better support the next generation of elite athlete mothers.

Pushing for change: a qualitative study of the experiences of elite athletes during pregnancy.

OBJECTIVES: Athletes train and compete at the elite level during their reproductive years, yet sport policies that support pregnant athletes are lacking. The experiences of elite athletes during pregnancy are vastly under-represented, and such voices are needed to support evidence-informed policy. Thus, the purpose of this qualitative study was to describe the experiences of elite female athletes as they navigate pregnancy, and to identify sport policy considerations regarding participation during pregnancy. METHODS: Twenty athletes (mean age 35±5 years) who, within the last 5 years, had trained or competed at the elite level immediately prior to becoming pregnant were included. Data were generated via one-on-one semistructured interviews that were audio-recorded, transcribed verbatim and analysed through a process of content analysis. RESULTS: The findings of this study are represented by one overarching message: mother versus athlete, and five main themes: (1) pregnancy planning and fertility, (2) pregnancy disclosure and discrimination, (3) training pregnant athletic bodies, (4) safety concerns, and (5) supportive network and equitable funding. CONCLUSION: In-depth stories shared by participants highlight the many significant decisions athletes must make as they navigate pregnancy alongside elite sport participation. The shared experiences of pregnant athletes highlight clear challenges that should be considered in the development of sport policy and practices that are inclusive and supportive of female athletes.

Shared decision making in pregnancy in inflammatory bowel disease: design of a patient orientated decision aid.

BACKGROUND: Research has indicated a lack of disease-specific reproductive knowledge among patients with Inflammatory Bowel Disease (IBD) and this has been associated with increased "voluntary childlessness". Furthermore, a lack of knowledge may contribute to inappropriate medication changes during or after pregnancy. Decision aids have been shown to support decision making in pregnancy as well as in multiple other chronic diseases. A published decision aid for pregnancy in IBD has not been identified, despite the benefit of pre-conception counselling and patient desire for a decision support tool. This study aimed to develop and test the feasibility of a decision aid encompassing reproductive decisions in the setting of IBD. METHODS: The International Patient Decision Aid Standards were implemented in the development of the Pregnancy in IBD Decision Aid (PIDA). A multi-disciplinary steering committee was formed. Patient and clinician focus groups were conducted to explore themes of importance in the reproductive decision-making processes in IBD. A PIDA prototype was designed; patient interviews were conducted to obtain further insight into patient perspectives and to test the prototype for feasibility. RESULTS: Issues considered of importance to patients and clinicians encountering decisions regarding pregnancy in the setting of IBD included fertility, conception timing, inheritance, medications, infant health, impact of surgery, contraception, nutrition and breastfeeding. Emphasis was placed on the provision of preconception counselling early in the disease course. Decisions relating to conception and medications were chosen as the current focus of PIDA, however content inclusion was broad to support use across preconception, pregnancy and post-partum phases. Favourable and constructive user feedback was received. CONCLUSIONS: The novel development of a decision aid for use in pregnancy and IBD was supported by initial user testing.

The Impact of Hospitalization on Physical Activity During Pregnancy.

The concept of prenatal physical activity has transitioned from a potentially risky behaviour to a prescription to improve maternal-fetal health. Pregnant women who are hospitalized because of a complication should continue to engage in light activities of daily living given the known adverse effects of maternal bedrest. Because the amount physical activity performed by pregnant women while in hospital not been documented; we compared levels of physical activity between women who were and were not hospitalized during pregnancy. We found that hospitalized pregnant women self-impose bedrest even in the absence of a medical recommendation.

Physical Activity Behaviors and Barriers in Multifetal Pregnancy: What to Expect When You're Expecting More.

The health benefits of prenatal physical activity (PA) are established for singleton pregnancies. In contrast, individuals with multifetal pregnancies (twins, triplets or more) are recommended to restrict or cease PA. The objectives of the current study were to determine behaviors and barriers to PA in multifetal pregnancies. Between 29 May and 24 July 2020, individuals with multifetal pregnancies participated in an online survey. Of the 415 respondents, there were 366 (88%) twin, 45 (11%) triplet and 4 (1%) quadruplet pregnancies. Twenty-seven percent (n = 104/388) of respondents completed no PA at all during pregnancy, 57% (n = 220/388) completed PA below current recommendations, and 16% (n = 64/388) achieved current recommendations (150-min per week of moderate-intensity activity). Most respondents (n = 314/363 [87%]) perceived barriers to PA during multifetal pregnancy. The most prominent were physical symptoms (n = 204/363 [56%]) and concerns about risks to fetal wellbeing (n = 128/363 [35%]). Sixty percent (n = 92/153) felt that these barriers could be overcome but expressed the need for evidence-based information regarding PA in multifetal pregnancy. Individuals with multifetal pregnancies have low engagement with current PA recommendations but remain physically active in some capacity. There are physical and psychosocial barriers to PA in multifetal pregnancy and future research should focus on how these can be removed.

Health Outcomes after Pregnancy in Elite Athletes: A Systematic Review and Meta-analysis.

PURPOSE: This study aimed to evaluate postpartum maternal health and training outcomes of females who were competing or training as elite athletes before or during pregnancy. METHODS: Online databases were searched up to August 26, 2020. Studies of any design and language were eligible if they contained information on the relevant population (postpartum athletes [any period after pregnancy]), exposure (engaged in the highest level of sport immediately before or during pregnancy), comparators (sedentary/active controls), and outcomes: maternal (breastfeeding initiation and duration, postpartum weight retention or loss, bone mineral density, low back or pelvic girdle pain, incontinence [prevalence or severity of stress, urge or mixed urinary incontinence, fecal incontinence], injury, anemia, diastasis recti, breast pain, depression, anxiety) and training (<6 wk time to resume activity, training volume or intensity, performance level). RESULTS: Eleven studies (n = 482 females, including 372 elite athletes) were included. We identified "very low" certainty evidence demonstrating a higher rate of return to sport before 6 wk postpartum among elite athletes compared with nonelite athletes (n = 145, odds ratio = 6.93, 95% confidence interval = 2.73-17.63, I2 = 11). "Very low" certainty evidence from three studies (n = 179) indicated 14 elite athletes obtained injuries postpartum (7 stress fractures, 9 "running injuries"). "Very low" certainty evidence from five studies (n = 262) reported that 101 (40.5%) elite athletes experienced improved performance postpartum. CONCLUSION: Compared with controls, "very low" quality evidence suggests that elite athletes return to physical activity early in the postpartum period and may have an increased risk of injury. Additional high-quality evidence is needed to safely guide return to sport of elite athletes in the postpartum period.

Cardiovascular function during triplet pregnancy.

Pregnancy is recognized as a natural physiological stressor to the maternal cardiovascular system. Cardiovascular adaptation is markedly greater in twin pregnancy compared with singleton pregnancy; however, these changes are sparsely documented in triplet pregnancy. The aim of this case series was to compare maternal cardiac function, cardioautonomic regulation, and blood pressure reactivity in healthy singleton, twin, and triplet pregnancies. Resting cardiac structure and function (echocardiography), beat-by-beat blood pressure variability (BPV; photoplethysmography), and heart rate variability (HRV; electrocardiogram) were measured in two triplet, three twin, and three singleton pregnancies (matched for maternal age, prepregnancy body mass index, and gestational age). Hemodynamic responses to a 3-min cold pressor test were also recorded to assess blood pressure reactivity. Due to the small sample size of this case series, statistical comparisons were not made between groups. Compared with singleton and twin pregnancies, individuals pregnant with triplets had greater resting cardiac output but lower cardiac deformation (longitudinal strain, basal circumferential strain, and torsion), sympathetic dominance in cardioautonomic regulation (lower HRV and higher BPV), and elevated blood pressure reactivity in response to the cold pressor test. Taken together, these observations suggest that females with triplet pregnancies may have reduced cardiovascular function, which may contribute to the heightened risk of complications in multifetal pregnancies.NEW & NOTEWORTHY Individuals with healthy triplet pregnancies had greater resting cardiac output but lower left ventricular mechanics when compared with singleton and twin pregnancies matched for gestational age. In addition, triplet pregnancies had greater blood pressure variability and lower overall heart rate variability compared with singleton pregnancies, as well as greater blood pressure reactivity to the cold pressor test. Healthy triplet pregnancies may have reduced cardiovascular function as well as a greater sympathetic contribution to cardiac control.

Cardioautonomic control in healthy singleton and twin pregnancies.

In conjunction with significant cardiovascular adaptation, changes in cardioautonomic balance, specifically greater sympathetic activation and vagal withdrawal, are considered normal adaptations to healthy singleton pregnancy. Cardiovascular adaptation to twin pregnancy is more profound than that of singleton pregnancies; however, the changes in cardioautonomic control during multifetal gestation are unknown. To address this gap, beat-by-beat blood pressure (photoplethysmography) and heart rate (lead II electrocardiogram) were measured continuously in 25 twin pregnancies and 25 singleton pregnancies (matched for age, prepregnancy body mass index, and gestational age) during 10 min of rest. Data extracted from a 3- to 5-min period were used to analyze heart rate variability (HRV), blood pressure variability (BPV), cardiovagal baroreflex gain, and cardiac intervals as indicators of cardioautonomic control. Independent t tests were used to determine statistical differences between groups (α = 0.05), and the false rate discovery was determined to adjust for multiple comparisons. Resting heart rate was greater in twin compared with singleton pregnancies (91 ± 10 vs. 81 ± 10 beats/min; P = 0.001), but blood pressure was not different. Individuals with twin pregnancies had lower HRV, evidenced by lower standard deviation of R-R intervals (32 ± 11 vs. 47 ± 18 ms; P = 0.001), total power (1,035 ± 810 vs. 1,945 ± 1,570 ms2; P = 0.004), and high frequency power (224 ± 262 vs. 810 ± 806 ms2; P < 0.001) compared with singleton pregnancies. There were no differences in cardiac intervals, BPV, and cardiovagal baroreflex gain between groups. Our findings suggest that individuals with twin pregnancies have greater sympathetic and lower parasympathetic contributions to heart rate and that cardiac, but not vascular, autonomic control is impacted during twin compared with singleton pregnancy.NEW & NOTEWORTHY Individuals with healthy twin pregnancies had lower overall heart rate variability compared with those with singleton pregnancies at similar gestational ages. These results suggest a greater sympathetic and reduced parasympathetic contribution to cardiac control in twin pregnancies. Baseline heart rate was elevated, while arterial pressure and spontaneous cardiovagal baroreflex gain were not different between groups. This was result of the upward resetting of the cardiovagal baroreflex during healthy twin pregnancy, thus maintaining arterial pressure.

Preeclampsia is not associated with elevated muscle sympathetic reactivity.

To determine whether increased chemoreflex tonic activity is associated with augmented muscle sympathetic nervous system activity (MSNA) in women diagnosed with preeclampsia. Women with preeclampsia (n = 19; 32 ± 5 yr old, 31 ± 3 wk of gestation) were matched by age and gestational age with pregnant women (controls, n = 38, 32 ± 4 yr old, 31 ± 4 wk gestation; 2:1 ratio). MSNA (n = 9 preeclampsia) was assessed during baseline, peripheral chemoreflex deactivation (hyperoxia), and a cold pressor test (CPT). Baroreflex gain and diastolic blood pressure at which there is a 50% likelihood of MSNA occurring (T50) and plasma noradrenaline concentrations were measured. Baseline mean arterial pressure (MAP: 106 ± 11 vs. 87 ± 10 mmHg, P < 0.0001), noradrenaline concentrations (498 ± 152 pg/mL vs. 326 ± 147, P = 0.001), and T50 (79 ± 7 vs. 71 ± 9 mmHg, P = 0.02) were greater in women with preeclampsia than in controls. However, baseline MSNA (burst incidence [BI]: 41 ± 16 vs. 45 ± 13 bursts/100 hb, P = 0.4) was not different between groups. Responses to hyperoxia (ΔBI -5 ± 7 vs. -1 ± 8 bursts/100 hb, P = 0.1; ΔMAP -1 ± 3 vs. -2 ± 3 mmHg, P = 0.7) and CPT (ΔBI 15 ± 7 vs. 12 ± 11 bursts/100 hb, P = 0.6; ΔMAP 10 ± 4 vs. 12 ± 11 mmHg, P = 0.6) were not different between groups. Our findings question the assumption that increased MSNA contributes to hypertension in women with preeclampsia. The chemoreflex does not appear to contribute to an increase in MSNA in women with preeclampsia.NEW & NOTEWORTHY We wanted to determine whether increased chemoreflex tonic activity is associated with augmented muscle sympathetic nervous system activity (MSNA) in women diagnosed with preeclampsia. The chemoreflex does not contribute to increased MSNA in women with preeclampsia. Our data also challenge the belief that preeclampsia is associated with sympathetic neural hyperactivity. Thus, targeting sympathetic neural hyperactivity as therapeutic strategy is unlikely to be the most efficacious approach to treatment and management.

Thyroid Laboratory Testing and Management in Women on Thyroid Replacement Before Pregnancy and Associated Pregnancy Outcomes.

Background: Women with hypothyroidism before pregnancy often require an increase in their levothyroxine dosage to maintain a euthyroid state during pregnancy. The objectives of this study were to investigate: (i) the frequency and distribution of thyrotropin (TSH) testing and levothyroxine dosage adjustment by gestational age, (ii) the magnitude of levothyroxine increase by the underlying etiology of hypothyroidism, and (iii) the relationship of overtreatment or undertreatment during pregnancy with adverse pregnancy outcomes among women using thyroid replacement before pregnancy. Methods: A retrospective cohort study of pregnancies in women on thyroid replacement before pregnancy in Alberta, Canada, was performed. Women using thyroid replacement anytime during the two years before pregnancy who delivered between October 2014 and September 2017 were included. Delivery records, physician billing, and laboratory and pharmacy administrative data were linked. Outcomes included characteristics of TSH testing, levothyroxine dosing, and pregnancy outcomes. The frequency and gestational timing of TSH testing and levothyroxine adjustments were calculated. Multiple logistic regression was used to test whether pregnancies with TSH <0.10 mIU/L (overtreatment) or TSH ≥10.00 mIU/L (undertreatment) compared with control pregnancies (TSH 0.10-4.00 mIU/L) were associated with adverse pregnancy and neonatal outcomes. Results: Of the 10,680 deliveries, 8774 (82.2%) underwent TSH testing at least once during pregnancy, at a median gestational age of six weeks. An adjustment of levothyroxine dosage was made for 4321 (43.7%) during pregnancy. TSH in pregnancy below 0.10 mIU/L increased the odds of preterm delivery when compared with control pregnancies (adjusted odds ratio, 2.14 [95% confidence interval 1.51-2.78]). TSH ≥10.00 mIU/L during pregnancy was not associated with any adverse pregnancy or neonatal outcomes in the multivariable analysis. Conclusions: Although most women on thyroid replacement before conception had TSH measured at some point during pregnancy, it is concerning that 17.8% did not. Levothyroxine overtreatment in pregnancy was associated with preterm delivery. These findings suggest that clinicians should be careful to avoid overtreatment with levothyroxine in pregnancy.

Sympathetic nervous system activity and reactivity in women with gestational diabetes mellitus.

INTRODUCTION: Gestational diabetes mellitus (GDM) is associated with vascular dysfunction. Sympathetic nervous system activity (SNA) is an important regulator of vascular function, and is influenced by glucose and insulin. The association between GDM and SNA (re)activity is unknown. We hypothesize that women with GDM would have increased SNA during baseline and during stress. METHODS: Eighteen women with GDM and 18 normoglycemic pregnant women (controls) were recruited. Muscle SNA (MSNA; peroneal microneurography) was assessed at rest, during a cold pressor test (CPT) and during peripheral chemoreflex deactivation (hyperoxia). Spontaneous sympathetic baroreflex gain was quantified versus diastolic pressure at rest and during hyperoxia. RESULTS: Age, gestational age (third trimester) and pre-pregnancy body mass index and baseline MSNA was not different among the groups. Women with GDM had a similar increase in MSNA, but a greater pressor response to CPT compared to controls (% change in MAP 17 ± 7% vs. 9 ± 9%; p = .004). These data are consistent with a greater neurovascular transduction in GDM (% change in total peripheral resistance/% change in burst frequency [BF]: 15.9 ± 30.2 vs. -5.2 ± 16.4, p = .03). Interestingly, women with GDM had a greater reduction in MSNA during hyperoxia (% change in BF -30 ± 19% vs. -6 ± 17%; p = .01). CONCLUSION: Women diagnosed with GDM have similar basal SNA versus normoglycemic pregnant women, but greater neurovascular transduction, meaning a greater influence of the sympathetic nerve activity in these women. We also document evidence of chemoreceptor hyperactivity, which may influence SNA in women with GDM but not in controls.

Thyroid function testing and management during and after pregnancy among women without thyroid disease before pregnancy.

BACKGROUND: Screening in pregnancy for subclinical hypothyroidism, often defined as thyroid-stimulating hormone (TSH) greater than 2.5 mIU/L or greater than 4.0 mIU/L, is controversial. We determined the frequency and distribution of TSH testing by gestational age, as well as TSH values associated with treatment during pregnancy and the frequency of postpartum continuation of thyroid hormone therapy. METHODS: We performed a retrospective cohort study of pregnancies in Alberta, Canada. We included women without thyroid disease who delivered between October 2014 and September 2017. We used delivery records, physician billings, and pharmacy and laboratory administrative data. Our key outcomes were characteristics of TSH testing and the initiation and continuation of thyroid hormone therapy. We calculated the proportion of pregnancies with thyroid testing and the frequency of each specific thyroid test. RESULTS: Of the 188 490 pregnancies included, 111 522 (59.2%) had at least 1 TSH measurement. The most common time for testing was at gestational week 5 to 6. Thyroid hormone therapy was initiated at a median gestational age of 7 (interquartile range 5-12) weeks. Among women with first TSH measurements of 4.01 to 9.99 mIU/L who were not immediately treated, the repeat TSH measurement was 4.00 mIU/L or below in 67.9% of pregnancies. Thyroid hormone was continued post partum for 44.6% of the women who started therapy during their pregnancy. INTERPRETATION: The findings of our study suggest that current practice patterns may contribute to overdiagnosis of hypothyroidism and overtreatment during pregnancy and post partum.

Moms Are Not OK: COVID-19 and Maternal Mental Health.

Introduction: Depression and anxiety affect one in seven women during the perinatal period, and are associated with increased risk of preterm delivery, reduced mother-infant bonding, and delays in cognitive/emotional development of the infant. With this survey we aimed to rapidly assess the influence of the COVID-19 pandemic and subsequent physical distancing/isolation measures on the mental health and physical activity of pregnant and postpartum women. Methods: Between April 14 and May 8, 2020, we recruited women who were pregnant or within the first year after delivery to participate in an online survey. This included questionnaires on self-reported levels of depression/depressive symptoms (Edinburgh Postnatal Depression Survey; EPDS), anxiety (State-Trait Anxiety Inventory; STAI-State), and physical activity. Current and pre-pandemic values were assessed for each. Results: Of 900 eligible women, 520 (58%) were pregnant and 380 (42%) were in the first year after delivery. Sixty-four percent of women reported reduced physical activity with the onset of isolation measures, while 15% increased, and 21% had no change to their physical activity. An EPDS score >13 (indicative of depression) was self-identified in 15% of respondents pre-pandemic and in 40.7% currently (mean ± SD; 7.5 ± 4.9 vs. 11.2 ± 6.3, respectively; p < 0.01, moderate effect). Moderate to high anxiety (STAI-state score >40) was identified in 29% of women before the pandemic (mean STAI = 34.5 ± 11.4) vs. 72% of women currently (mean STAI = 48.1 ± 13.6; p < 0.01, large effect). However, women engaging in at least 150 min of moderate intensity physical activity (meeting current guidelines) during the pandemic had significantly lower scores for both anxiety and depression than those who did not (p < 0.01, large and small effect, respectively). Discussion: This rapid response survey identifies a substantial increase in the likelihood of maternal depression and anxiety during the COVID-19 pandemic. This highlights the strong need for heightened assessment and treatment of maternal mental health. However, these data also suggest that physical activity, which has previously been shown to reduce depression and depressive symptoms in pregnancy, may be associated with better mental health during the pandemic.

The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis.

OBJECTIVE: Data: An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. The purpose of this study was to examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes. STUDY: Studies of all designs (except case studies and reviews) that contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birthweight, small for gestational age, miscarriage, gestational hypertension, preeclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction) were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Five electronic databases and 3 gray literature sources were searched up to March 15, 2019. RESULTS: Eighty observational studies (N=853,149) were included. Low-to-very low certainty evidence revealed that lifting objects ≥11 kg was associated with an increased odds ratio of miscarriage (odds ratio, 1.31; 95% confidence interval, 1.08-1.58; I2=79%), and preeclampsia (odds ratio, 1.35; 95% confidence interval, 1.07-1.71; I2=0%). Lifting objects for a combined weight of ≥100 kg per day was associated with an increased odds of preterm delivery (odds ratio, 1.31; 95% confidence interval, 1.11-1.56; I2=0%) and having a low birthweight neonate (odds ratio, 2.08; 95% confidence interval, 1.06-4.11; I2=73%). Prolonged standing was associated with increased odds of preterm delivery (odds ratio, 1.11; 95% confidence interval, 1.02-1.22; I2=30%) and having a small-for-gestational-age neonate (odds ratio, 1.17; 95% confidence interval, 1.01-1.35; I2=41%). A heavy physical workload was associated with increased odds of preterm delivery (odds ratio, 1.23; 95% confidence interval, 1.07-1.41; I2=32%) and having a low birthweight neonate (odds ratio, 1.79; 95% confidence interval, 1.11-2.87; I2=87%). All other associations were not statistically significant. Dose-response analysis showed women stand for >2.5 hours per day (vs no standing) had a 10% increase in the odds of having a preterm delivery. CONCLUSION: Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.