COVID-19 mitigation measures increase preterm birth and low birth weight in the public healthcare system in Uruguay.

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on preterm birth (PB) and low birth weight (LBW), comparing public and private healthcare systems of the National Integrated Health System in Uruguay, where the mitigation measures for the COVID-19 pandemic generated an immediate socioeconomic and psychological crisis, which caused a sharp widening of existing socioeconomic inequalities. METHODS: A national observational study was conducted comparing perinatal outcomes in the first 6 months of 2020 (period of the pandemic without pregnancy infections), which was the beginning of the pandemic, with the same period of the previous year 2019 (pre-pandemic period with no mitigation measures) among pregnant women from the public and private health systems. Data were retrieved from the national database (Informatic Perinatal System) and analyzed by healthcare system category. RESULTS: A total of 36 559 deliveries were assessed: 18 563 in the 2019 study period and 17 996 in the 2020 study period. In the public system, there was a significant increase in the risk of LBW (adjusted relative risk [aRR] 1.12, 95% confidence interval [CI] 1.05-1.36) and of the composite outcome (PB or LBW) (aRR 1.15, 95% CI 1.04-1.26). In the private system, by contrast, there was a non-statistically significant decrease of LBW and there were no changes in the incidence of PB and the composite outcome in 2020. CONCLUSION: The different evolution of birth outcomes in the public and private systems suggests an unequal impact of mitigation measures on populations of different socioeconomic levels. Given that no COVID-19 infections were identified in pregnant women during the study period, this research offers an opportunity to differentiate the biologic effects of the virus from the psychological and social impacts derived from containment measures. GOV IDENTIFIER: NCT05087160.

Associations between obesity candidate gene polymorphisms (fat mass and obesity-associated (FTO), melanocortin-4 receptor (MC4R), leptin (LEP) and leptin receptor (LEPR)) and dietary intake in pregnant women.

Genetic variants associated with dietary intake may be important as factors underlying the development of obesity. We investigated the associations between the obesity candidate genes (fat mass and obesity-associated (FTO), melanocortin-4 receptor (MC4R), leptin (LEP) and leptin receptor) and total energy intake and percentage of energy from macronutrients and ultra-processed foods before and during pregnancy. A sample of 149 pregnant women was followed up in a prospective cohort in Rio de Janeiro, Brazil. A FFQ was administered at 5-13 and 30-36 weeks of gestation. Genotyping was performed using real-time PCR. Associations between polymorphisms and the outcomes were investigated through multiple linear regression and ANCOVA having pre-pregnancy dietary intake as a covariate. The A-allele of FTO-rs9939609 was associated with a -6·5 % (95 % CI -12·3, -0·4) decrease in the percentage of energy from protein and positively associated with the percentage of energy from carbohydrates before pregnancy (ß=2·6; 95 % CI 0·5, 4·8) and with a 13·3 % (95 % CI 0·7, 27·5) increase in the total energy intake during pregnancy. The C-allele of MC4R-rs17782313 was associated with a -7·6 % (95 % CI -13·8, -1·0) decrease in the percentage of energy from protein, and positively associated with the percentage of energy from ultra-processed foods (ß=5·4; 95 % CI 1·1, 9·8) during pregnancy. ANCOVA results revealed changes in dietary intake from pre-pregnancy to pregnancy for FTO-rs9939609 (percentage of energy from ultra-processed foods, P=0·03), MC4R-rs17782313 (total energy intake, P=0·02) and LEP-rs7799039 (total energy intake, P=0·04; percentage of energy from protein, P=0·04). These findings suggest significant associations between FTO-rs9939609, MC4R-rs17782313 and LEP-rs7799039 genes and the components of dietary intake in pregnant women.

A systematic review of the associations between maternal nutritional biomarkers and depression and/or anxiety during pregnancy and postpartum.

BACKGROUND: Nutritional requirements need to be met in order to adapt to pre- and postnatal changes. Our aim was to systematically review the evidence of associations between nutritional biomarkers and psychological distress during pregnancy and in the first postnatal year. METHODS: MEDLINE, EMBASE, PsycINFO, Scielo, LILACS, clinicaltrials.gov, International Clinical Trials Registry, Cochrane Library, Scopus and Web of Science databases were searched for articles from inception to 4/15/2016. Studies of maternal nutritional biomarkers in blood (fatty acids/micronutrients/amino acids) and associations with psychological distress (depression/anxiety/stress) were included. Two independent reviewers extracted data based on study designs, participants, outcomes, exposures, and association measures. RESULTS: Thirty-eight studies were included. A total of 13 studies showed divergent or no associations between serum/plasma/erythrocyte fatty acid concentrations and depression/anxiety during pregnancy and postpartum. Changes in serum cholesterol levels from pregnancy to postpartum showed a significant inverse correlation with depression in one out of three studies. Five out of seven studies found an inverse association between serum vitamin D levels and pre- and postnatal depression. Plasma tryptophan levels were inversely correlated with postnatal depression scores in three out of four studies. We identified that one out of two studies presented no significant association between vitamin B12/folate/ferritin concentrations and depression in postpartum. LIMITATIONS: There was higher variability between association measures, time and scales of depression and anxiety assessments. CONCLUSIONS: The majority of high-quality studies suggest that lower vitamin D levels may be associated with postpartum depression. However, further evidence is needed for guiding clinical practice on nutritional biomarkers.

Polymorphisms in the leptin (rs7799039) gene are associated with an increased risk of excessive gestational weight gain but not with leptin concentration during pregnancy.

Single nucleotide polymorphisms (SNPs) in leptin (LEP) and leptin receptor (LEPR) have been shown to be linked to obesity-related metabolic markers and phenotype. Therefore, we hypothesized that the LEP-rs7799039 and LEPR-rs1137101 SNPs are related to the risk of pre-pregnancy overweight/obesity (body mass index ≥25 kg/m2) as well as to excessive gestational weight gain (GWG) and high concentrations of leptin throughout pregnancy. We investigated a prospective cohort of 147 Brazilian pregnant women through weeks 5-13, 20-26, and 30-36 of gestation. Genetic variants of LEP and LEPR were analyzed by real-time polymerase chain reaction and leptin by enzyme-linked immunosorbent assay. Statistical analyses included multiple linear regression, linear mixed effects, and Poisson regression models. Genotype AA carriers for the LEP-rs7799039 gene maintained a lower body weight throughout pregnancy compared with those with genotypes GG or GA + GG (ßAAvsGG = -7.91 kg; 95% confidence interval [CI], -14.21 to -1.61; P = .01; and ßAAvsGA + GG = -7.66 kg; 95% CI, -14.07 to -1.25; P = .02). The A allele was significantly associated with an increased risk for excessive GWG (relative riskLEP-GAvsGG, 2.16; 95% CI, 1.23-3.80; and relative riskLEP-AAvsGG, 2.37; 95% CI, 1.04-5.39). Neither the LEP-rs7799039 nor LEPR-rs1137101 SNP was significantly associated with pre-pregnancy overweight/obesity risk and leptin concentrations during pregnancy. In conclusion, our results indicate that women who had the AA genotype for LEP-rs7799039 displayed a lower body weight throughout pregnancy compared with GG or GA + GG carriers. LEP-rs7799039 was significantly associated with an increased risk for excessive GWG, but the results do not support significant associations of the LEP-rs7799039 and LEPR-rs1137101 polymorphisms with pre-pregnancy overweight/obesity risk and leptin concentrations throughout pregnancy.

Association between plasma concentrations of vitamin D metabolites and depressive symptoms throughout pregnancy in a prospective cohort of Brazilian women.

Plasma concentrations of vitamin D metabolites can be inversely associated with depressive symptoms. However, few longitudinal studies have investigated this association, especially during pregnancy. The aim of this study was to investigate the association between concentrations of 25-hydroxyvitamin D [25(OH)D] and 1,25-dihydroxivitamin D [1,25(OH)2D] with the occurrence of depressive symptoms throughout pregnancy. A prospective cohort of 179 women was followed at 5th-13th, 20th-26th and 30th-36th gestational weeks. At each trimester of pregnancy, the plasma concentrations of 25(OH)D and 1,25(OH)2D were analyzed by liquid chromatography tandem mass spectroscopy. Vitamin D status was categorized according to the Endocrine Society Practice Guidelines and the Institute of Medicine. Depressive symptoms were measured at each trimester using the Edinburgh Postnatal Depressive Scale (cutoff ≥13). Statistical analyses included random intercept logistic regression models for longitudinal analyses. In the first trimester, the prevalence of 25(OH)D <75, <50 and <30 nmol/L were 69.3%, 14.0% and 1.7%, respectively. Prevalence of depressive symptoms were 20.1%, 14.7% and 7.8% for the first, second and third trimesters, respectively. The probability of occurrence of depressive symptoms decreased throughout pregnancy (p-value = 0.005). Women with higher concentrations of 25(OH)D in the first trimester presented a lower odds ratio (OR) for the development of depressive symptoms during pregnancy (OR = 0.98; 95%CI: 0.96 to 0.99, p-value = 0.047) in the adjusted model. In conclusion, there was a higher prevalence of vitamin D inadequacy and depressive symptoms during the first trimester. Higher 25(OH)D concentrations in the first trimester were associated with a decrease of 2% in the odds for presenting depressive symptoms throughout pregnancy.

Criterios diagnósticos y efectividad de intervenciones para el manejo de diabetes gestacional / Critérios diagnósticos e efetividade de intervenções para o manejo do diabetes gestacional / Diagnostic criteria and effectiveness of interventions for the management of gestational diabetes

Diabetes mellitus gestacional es definida como intolerancia a los carbohidratos con distintos grados de severidad y detectada por primera vez en el embarazo. Es un problema importante de salud pública por su alta prevalencia que va en aumento y también, por la morbilidad materna y morbimortalidad fetal. Sin embargo, existen todavía controversias en su forma de tamizaje y criterio diagnóstico usados. En esta editorial, se pretende abordar los diferentes tamizajes y criterios diagnósticos, junto con la efectividad en el manejo de mujeres diagnosticadas con diabetes mellitus gestacional.

Association of the FTO (rs9939609) and MC4R (rs17782313) gene polymorphisms with maternal body weight during pregnancy.

OBJECTIVE: The fat mass and obesity (FTO) and melanocortin-4 receptor (MC4R) genes have been consistently associated with the risk for obesity, but few studies have examined the association of the obesity risk alleles with gestational outcomes. The aim of this study was to evaluate the association between single nucleotide polymorphisms (SNPs) of the FTO (rs9939609) and MC4R (rs17782313) genes with changes in maternal body weight during pregnancy. METHODS: A sample of 136 pregnant women were followed in a prospective cohort at 5 to 13, 20 to 26, and 30 to 36 wk gestation and 30 to 45 d postpartum. SNPs were analyzed by real-time polymerase chain reaction. Associations between polymorphisms and the outcomes were investigated through longitudinal linear mixed-effects models, multiple linear regression models, and Poisson regression models. RESULTS: An SNP in the FTO (rs9939609) gene but not in the MC4R (rs17782313) gene was significantly associated with prepregnancy body mass index (BMI) ≥25 kg/m(2) (relative riskFTO = 2.1; 95% confidence interval [CI], 1.4-3.1). SNPs were not statistically associated with excessive gestational weight gain (GWG) or postpartum weight retention (PPWR). For the FTO (rs9939609) gene, women with the AA genotype were heavier in the body weight trajectory of pregnancy, but not when their weight had been adjusted for prepregnancy BMI (ßFTO = 0.5 kg; 95% CI, -1.9 to 3). These women started pregnancy heavier but gained less weight (FTO*gestational age = -0.1; 95% CI, -0.2 to 0.03) compared with those who had at least one T allele. CONCLUSIONS: The FTO (rs9939609) AA genotype is positively associated with prepregnancy excessive weight. We found no evidence of a significant effect of the MC4R (rs17782313) or the FTO (rs9939609) gene polymorphisms on the GWG and PPWR.

Impact of the International Association of Diabetes and Pregnancy Study Groups criteria for gestational diabetes.

AIMS: To evaluate the diagnostic criteria of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and alternative criteria in terms of resultant prevalence of gestational diabetes mellitus (GDM) and measures of diagnostic impact. METHODS: The Brazilian Gestational Diabetes Study (EBDG) is a cohort of pregnant women enrolled consecutively in prenatal care clinics of the Brazilian National Health Service from 1991 to 1995, a time and setting in which those with lesser than diabetes hyperglycemia rarely received drug treatment. Eligibility criteria were age ≥20 years, gestational age 20-28 weeks and no history of diabetes outside pregnancy. After interview and anthropometric measurements, a standardized 2h 75g OGTT was scheduled. Women were followed through early postpartum. RESULTS: Prevalence of GDM defined by IADPSG criteria was 18.0% (95% CI 16.9-19.0), ranging from 2.7 to 17.0% with the alternative criteria. Relative risks for large for gestational age (LGA) and preeclampsia were generally small. The diagnostic impact assessed by pre- to post-test gain in the probability of an outcome was also small (3.6% for LGA and 0.5% for preeclampsia). Alternative criteria reached maximum gains of 9.7% and 5.3%, respectively. The fractions of LGA births and preeclampsia attributable to GDM by the IADPSG criteria were small, 6.7% and 3.5%, respectively. CONCLUSIONS: The IADPSG criteria identify more women as having GDM but their diagnostic and population impacts with respect to adverse outcomes are small. Alternative definitions, although also presenting small diagnostic and population impacts, showed advantages which may be useful in specific settings.

Effectiveness of gestational diabetes treatment: a systematic review with quality of evidence assessment.

AIMS: To evaluate the effectiveness of gestational diabetes (GDM) treatment compared to usual antenatal care, in the prevention of adverse pregnancy outcomes. Additionally, to assess the quality of the evidence to support GDM treatment according to GRADE guidelines. METHODS: Fourteen electronic databases and reference lists of relevant literature were searched for articles published from inception to February, 2012. Controlled clinical trials comparing GDM treatment to usual antenatal care were included. Independent extraction of articles was done by two authors using predefined data fields. RESULTS: Seven trials involving 3157 women were included. We found high quality evidence that treatment of GDM reduces macrosomia (RR=0.47; 95% CI, 0.34-0.65; NNT=11.4) and large for gestational age birth (RR=0.57; 95% CI, 0.47-0.71; NNT=12.2); moderate quality evidence that treatment reduces preeclampsia (RR=0.61; 95% CI, 0.46-0.81; NNT=21.0) and hypertensive disorders in pregnancy (RR=0.64; 95% CI, 0.51-0.81; NNT=18.1); and low quality evidence that treatment reduces shoulder dystocia (RR=0.41; 95% CI, 0.22-0.76; NNT=48.8). No statistically significant reduction was seen for caesarean section. No increase in small for gestational age or preterm birth was found. CONCLUSIONS: Treatment of GDM is effective in reducing macrosomia (high quality evidence), preeclampsia and shoulder dystocia.

Gestational diabetes and pregnancy outcomes--a systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria.

BACKGROUND: Two criteria based on a 2 h 75 g OGTT are being used for the diagnosis of gestational diabetes (GDM), those recommended over the years by the World Health Organization (WHO), and those recently recommended by the International Association for Diabetes in Pregnancy Study Group (IADPSG), the latter generated in the HAPO study and based on pregnancy outcomes. Our aim is to systematically review the evidence for the associations between GDM (according to these criteria) and adverse outcomes. METHODS: We searched relevant studies in MEDLINE, EMBASE, LILACS, the Cochrane Library, CINHAL, WHO-Afro library, IMSEAR, EMCAT, IMEMR and WPRIM. We included cohort studies permitting the evaluation of GDM diagnosed by WHO and or IADPSG criteria against adverse maternal and perinatal outcomes in untreated women. Only studies with universal application of a 75 g OGTT were included. Relative risks (RRs) and their 95% confidence intervals (CI) were obtained for each study. We combined study results using a random-effects model. Inconsistency across studies was defined by an inconsistency index (I2) > 50%. RESULTS: Data were extracted from eight studies, totaling 44,829 women. Greater risk of adverse outcomes was observed for both diagnostic criteria. When using the WHO criteria, consistent associations were seen for macrosomia (RR = 1.81; 95%CI 1.47-2.22; p < 0.001); large for gestational age (RR = 1.53; 95%CI 1.39-1.69; p < 0.001); perinatal mortality (RR = 1.55; 95% CI 0.88-2.73; p = 0.13); preeclampsia (RR = 1.69; 95%CI 1.31-2.18; p < 0.001); and cesarean delivery (RR = 1.37;95%CI 1.24-1.51; p < 0.001). Less data were available for the IADPSG criteria, and associations were inconsistent across studies (I2 ≥ 73%). Magnitudes of RRs and their 95%CIs were 1.73 (1.28-2.35; p = 0.001) for large for gestational age; 1.71 (1.38-2.13; p < 0.001) for preeclampsia; and 1.23 (1.01-1.51; p = 0.04) for cesarean delivery. Excluding either the HAPO or the EBDG studies minimally altered these associations, but the RRs seen for the IADPSG criteria were reduced after excluding HAPO. CONCLUSIONS: The WHO and the IADPSG criteria for GDM identified women at a small increased risk for adverse pregnancy outcomes. Associations were of similar magnitude for both criteria. However, high inconsistency was seen for those with the IADPSG criteria. Full evaluation of the latter in settings other than HAPO requires additional studies.

Impacto del programa de inmunización anti-virus de hepatitis B (VHB) en pacientes sometidos a diálisis en la Habana, Cuba / Impact of the anti-hepatitis B immunization program in patients submitted to dialysis in the Habana, Cuba

Se evalúa la efectividad de un programa especial de vacunación, mediante el seguimiento evolutivo de marcadores del virus de la hepatitis B (VHB) en poblaciones seleccionadas de alto riesgo de infección, como son los pacientes de servicios de hemodiálisis peritoneal. Se estudiaron marcadores de infección viral en cortes transversales de prevalencia de toda la población de pacientes, además de registrarse los reportes de casos clínicos de hepatitis B en esos grupos ocurridos durante este período. El programa de prevención consistió en la vacunación de todos los pacientes que resultaran negativos a los marcadores virales y la indicación de vacunarse en el período de la enfermedad previo al inicio del tratamiento en las unidades de hemodialisis para los casos nuevos, además de todos los individuos susceptibles de infección que ya estuvieran incluidos en el programa, independientemente del estadio de la enfermedad. Los resultados muestran el beneficio de la vacunación en estos pacientes, pero es más efectiva en el período previo al tratamiento dialítico donde la posibilidad de exposición al virus es menor y el sistema inmune es aún competente. Después de establecido el programa a los 6 años de seguimiento no se han reportado casos nuevos de hepatitis B y la incidencia de la enfermedad ha ido disminuyendo