Early Gestational Weight Gain and the Risk of Preeclampsia in Dichorionic Twin Pregnancies.

OBJECTIVE: The purpose of our study was to evaluate the body mass index (BMI)-specific association between early gestational weight gain (GWG) in dichorionic twin pregnancies and the risk of preeclampsia. STUDY DESIGN: We conducted a retrospective cohort study of all dichorionic twin pregnancies from 1998 to 2013. Data were obtained from a perinatal database and chart abstraction. Prepregnancy BMI was categorized as normal (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2). Early GWG was defined as the last measured weight from 160/7 to 196/7weeks' gestation minus prepregnancy weight. GWG was standardized for gestational duration using BMI-specific z-score charts for dichorionic pregnancies. Preeclampsia was diagnosed using American College of Obstetricians and Gynecologists criteria and identified with International Classification of Diseases-9 coding. Early GWG z-score was modeled as a three-level categorical variable (≤ - 1 standard deviation [SD], 0, 3 +1 SD), where -1 to +1 was the referent group. We estimated risk differences and 95% confidence intervals (CIs) via marginal standardization. RESULTS: We included 1,693 dichorionic twin pregnancies in the cohort. In adjusted analysis, the incidence of preeclampsia increased with increasing early GWG among women with normal BMI. Women with normal BMI and a GWG z-score < - 1 (equivalent to 2.6 kg by 20 weeks) had 2.5 fewer cases of preeclampsia per 100 births (95% CI: -4.7 to - 0.3) compared with the referent; those with GWG z-score > +1 (equivalent to gaining 9.8 kg by 20 weeks) had 2.8 more cases of preeclampsia per 100 (95 % CI: 0.1-5.5) compared with the referent. In adjusted analyses, early GWG had minimal impact on the risk of preeclampsia in women with overweight or obesity. CONCLUSION: GWG of 2.6 kg or less by 20 weeks was associated with a decreased risk of preeclampsia among women pregnant with dichorionic twins and normal prepregnancy BMI. Current GWG guidelines focus on optimizing fetal weight and gestational length. Our findings demonstrate the importance of considering other outcomes when making GWG recommendations for twin pregnancy. KEY POINTS: · Early GWG decreased with increasing BMI category.. · Among women with normal weight, as early GWG increased so did the risk of preeclampsia.. · There was no association between early GWG and preeclampsia among women with overweight or obesity..

Patient Opinions About Foreign Body Contraceptives.

Background: Prior studies have noted patient reluctance to use contraceptive devices that require insertion into their bodies. We sought to better understand this "foreign body" concern, as well as to clarify how women perceive long-acting reversible contraception (LARC) devices compared with other implanted medical devices. Materials and Methods: We performed semistructured qualitative individual interviews with female obstetric/gynecologic patients and probed their opinions regarding LARC devices. Trained coders analyzed interview content using an inductive iterative approach and identified key themes. Results: We found three major themes in our analysis. First, women frequently expressed uncertainty about where in the body intrauterine devices reside and the impact of a foreign body in that space. Second, women expressed discomfort with the invisibility of the device itself and the "set and forget" feature of LARCs. Finally, when asked to consider contraceptive devices in the context of other implantable medical devices, patients highlighted that contraceptive devices are elective and have alternative options. Conclusions: When women express concerns about contraceptive devices "up in them," they are expressing concerns about how these devices interact with their anatomy and the possibilities of harm and failure. These perceived risks of LARCs may not compare favorably with other contraceptive methods that are not foreign bodies. Understanding this perspective improves our ability to participate in shared decision-making.

Perinatal Outcomes Associated with Early Diabetes Testing in Pregnancies Complicated by Obesity.

OBJECTIVE: This study aimed to determine whether early diabetes testing is associated with differences in perinatal outcomes among pregnant women with obesity (body mass index ≥30 kg/m2). STUDY DESIGN: We conducted a retrospective cohort study of singleton pregnancies from 2012 to 2014 at a large academic medical center which examined the association of diabetes testing (HBA1c, 50 g glucose challenge test, or 100 g oral glucose tolerance test) before 24 weeks with perinatal outcomes using propensity score modeling and logistic regression. RESULTS: Among women with obesity, 790 out of 2,698 (29.3%) underwent early diabetes testing. Propensity score modeling demonstrated that early testing was associated with higher rates of diabetes diagnosis (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.10-2.37, p = 0.01) and a trend toward small for gestational age birth weight (OR: 1.38, 95% CI: 1.00-1.90, p = 0.05) and neonatal composite morbidity (OR: 1.25, 95% CI: 1.00-1.57, p = 0.05) compared with routine testing. Women with inadequate weight gain were more likely a small for gestational age (SGA) infant if they underwent early testing compared with those with routine testing alone (19.8 vs. 11.6%, p = 0.01). CONCLUSION: Early testing targets higher risk women and yields a higher diabetes diagnosis rate, but inadequate weight gain in these women may increase risk SGA birth weight and neonatal morbidity. Randomized clinical trials are urgently needed to assess whether early diabetes testing improves outcomes in women with obesity.

Antibiotic Use in Pregnancy, Abnormal Fetal Growth, and Development of Gestational Diabetes Mellitus.

OBJECTIVE: Antibiotics are commonly used in pregnancy. Prior studies have indicated that antibiotic use in pregnancy may affect birth weight, whereas data in nonpregnant individuals suggest that antibiotic exposure may increase diabetes risk. We evaluated the impact of antibiotic prescriptions during pregnancy on the prevalence of small for gestational age (SGA) and large for gestational age (LGA) birth weight and gestational diabetes mellitus (GDM). STUDY DESIGN: This retrospective cohort study of 12,551 women who delivered at a large academic medical center between 2012 and 2014 assessed the number and type of antibiotic prescriptions prior to GDM testing using the electronic medical record. SGA and LGA birth weight and GDM rates were compared among women who were or were not prescribed antibiotics. RESULTS: Overall, 3,991 (31.8%) of 12,551 patients received at least one antibiotic prescription. After covariate adjustment, no differences existed in risk of SGA (adjusted odds ratio [aOR]: 1; 95% confidence interval [CI]: 0.88-1.15; p = 0.94), LGA (aOR: 1; 95% CI: 0.86-1.17; p = 0.97), or GDM (aOR: 0.90; 95% CI: 0.72-1.13; p = 0.36) between women who were or were not prescribed antibiotics. CONCLUSION: Antibiotic use does not affect the risk of SGA or LGA birth weight or GDM in pregnant women. These results provide reassurance regarding the use of antibiotics when clinically indicated in pregnancy.

Antenatal Magnesium Sulfate Exposure and Ponderal Index in Preterm Infants.

OBJECTIVE: Antenatal magnesium sulfate (MgSO4) is known to affect the central nervous system of preterm infants, and there is biologic rationale for influence on other phenotypes. This study investigated the effect of MgSO4 exposure on the trajectory of ponderal index (PI, kg/m3) from birth to 2 years of age. STUDY DESIGN: A secondary analysis of a U.S. randomized controlled trial investigating MgSO4 versus placebo administration among women at high risk for preterm delivery was performed. Multivariable logistic regression was used to assess the relationship between PI from birth to 2 years of age and exposure to MgSO4 versus placebo. RESULTS: There was a larger decrement in PI from birth to 2 years of age in infants exposed to MgSO4 compared with placebo (p = 0.032). There was a statistically significant one-way interaction between newborn sex and treatment group (p = 0.019). Change in PI in males exhibited a greater decrement in those exposed to MgSO4 versus placebo (p = 0.227), whereas female infants exposed to MgSO4 had a smaller decrement (p = 0.04). CONCLUSION: MgSO4 exposure in preterm infants is associated with a larger decrease in PI from birth to 2 years of age. In addition, the direction of effect of MgSO4 on the change in PI over the first 2 years of life is different by sex.

Early Pregnancy Diabetes Screening and Diagnosis: Prevalence, Rates of Abnormal Test Results, and Associated Factors.

OBJECTIVE: To evaluate the prevalence of early diabetes screening in pregnancy, rates of abnormal diabetes test results before 24 weeks of gestation, and factors associated with early diabetes screening. METHODS: This was a retrospective cohort study of all singleton deliveries from 2012 to 2014 among diverse clinical practices at a large academic medical center. We assessed rates of early (less than 24 weeks of gestation) and routine (at or beyond 24 weeks of gestation) diabetes screening, with abnormal test results defined using the Carpenter-Coustan criteria, a 50-g glucose challenge test result greater than 200 mg/dL, or a hemoglobin A1C level greater than 6.5%. Univariate and multivariate analyses were used to evaluate clinical and demographic determinants of screening and diagnosis. RESULTS: Overall, 1,420 of 11,331 (12.5%) women underwent early screening. Increasing body mass index (BMI) category, race, public insurance, history of gestational diabetes mellitus, a family history of diabetes, and chronic hypertension were associated with early screening. Early screening rates rose with increasing BMI category, but only 268 of 551 (48.6%) of women with class III obesity underwent early screening. Among those screened early, 2.0% of normal-weight women, 4.0% of overweight women, 4.2% of class I obese women, 3.8% of class II obese women, and 9.0% of class III obese women had abnormal early test results (P<.001). CONCLUSION: Early diabetes screening is used inconsistently, and many women with risk factors do not undergo early screening. A significant proportion of women with class III obesity will test positive for gestational diabetes mellitus before 24 weeks of gestation, and studies are urgently needed to assess the effect of early diabetes screening and diagnosis on perinatal outcomes in high-risk women.