Feasibility and Acceptability of Home-Delivered Medically Tailored Meals for Treatment of Diabetes in Pregnancy.

BACKGROUND: Diabetes complicates ≤7% of pregnancies in the United States. Although medical nutrition therapy is the mainstay of diabetes treatment, many barriers exist to the successful implementation of dietary modifications. Home-delivered medically tailored meals (MTMs) are promising to overcome such barriers. OBJECTIVE: The objective of this study was to evaluate the feasibility and acceptability of home-delivered MTM in pregnant patients with diabetes. METHODS: We performed a prospective cohort study of home-delivered MTM for pregnant patients with diabetes using a mixed-methods approach. Participants <35 wk of gestation at the time of enrollment received weekly home delivery of diabetes-specific meals. Qualitative semistructured interviews were conducted to gain insight into participants' experience. Diabetes self-efficacy was assessed pre- and postintervention using the Diabetes Self-Efficacy Scale and 2-Item Diabetes Distress Screening Scale. The difference in mean scores was compared using t-tests with P value of <0.05 considered significant. Feasibility and acceptability were evaluated through participants' attitude toward MTM in qualitative interviews and indirectly evaluated through diabetes self-efficacy surveys. RESULTS: Twenty pregnant people with diabetes who received home-delivered MTM during pregnancy were interviewed postpartum. Participants found this program convenient for various reasons, including reduced time for grocery shopping and preparing meals. Participants were satisfied with meals, citing a positive impact on diabetes management, accessibility of healthy foods, reduced stress with meal planning, and greater perceived control of blood glucose. Most participants shared meals with their families or received specific meals for their dependents, which was positively received. Reduced financial and mental stress was also widely reported. Diabetes self-efficacy was significantly improved postintervention with MTM. CONCLUSION: Home-delivered MTM is feasible and acceptable in pregnant patients with diabetes and may improve diabetes self-efficacy. Individual experiences offered insight into various barriers overcome by using this service. Home-delivered MTM may help ensure an accessible, healthy diet for pregnant patients with diabetes.

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance.

OBJECTIVE: There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN: This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS: Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION: Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Risk of Cesarean Delivery for Women with Obesity Using a Standardized Labor Induction Protocol.

OBJECTIVE: We aimed to determine the risk of cesarean among women with obesity undergoing labor induction within a prospective trial that utilized a standardized labor protocol. STUDY DESIGN: This was a secondary analysis of a randomized trial of induction methods. Term (≥37 weeks) women with intact membranes undergoing induction with an unfavorable cervix (Bishop's score ≤6 and dilation ≤2 cm) were included. The trial utilized a labor protocol that standardized induction and active labor management, with recommendations for interventions at particular time points. Only women with a recorded body mass index (BMI) at prenatal care start were included in this analysis. The primary outcome was cesarean delivery compared between obese (≥30 kg/m2) and nonobese (<30 kg/m2) women. Indication for cesarean was also evaluated. RESULTS: A total of 465 women were included: 207 (44.5%) obese and 258 (55.5%) nonobese. Women with obesity had a higher risk of cesarean compared with women without obesity (33.3 vs. 23.3%, p = 0.02), even when adjusting for parity, weight change over pregnancy, and indication for induction (adjusted relative risk [aRR] = 1.79, 95% confidence interval [CI]: [1.34-2.39]). Compared with women without obesity, women with obesity had a higher risk of failed induction (47.8 vs. 26.7%, p = 0.01) without a difference in arrest of active phase (p = 0.39), arrest of descent (p = 0.95) or fetal indication (p = 0.32), despite adherence to a standardized labor protocol. CONCLUSION: Compared with women without obesity, women with obesity undergoing an induction are at increased risk of cesarean, in particular a failed induction, even within the context of standardized induction management. As standardized practices limit provider variation in labor management, this study may support physiologic differences in labor processes secondary to obesity. KEY POINTS: · Even with a standardized induction protocol, women with obesity are at higher risk of cesarean.. · In particular, women with obesity are at increased risk of cesarean for failed induction.. · These findings support a possible biologic relationship between obesity and failed induction..

Pregnant and hungry: addressing food insecurity in pregnant women during the COVID-19 pandemic in the United States.

Food insecurity is a major social determinant of health affecting more than 10% of Americans. Social determinants of health are increasingly recognized as a driving force of health inequities. It is well established that food insecurity leads to adverse health outcomes outside of pregnancy, such as obesity, hypertension, diabetes mellitus, and mental health problems. However, limited data exist about the impact of food insecurity during pregnancy on maternal and neonatal outcomes. Food insecurity and other social determinants of health are rarely addressed as part of routine obstetrical care. The COVID-19 pandemic has only exacerbated the crisis of food insecurity across the country, disproportionally affecting women and racial and ethnic minorities. Women's health providers should implement universal screening for maternal food insecurity and offer resources to women struggling to feed themselves and their families. Reducing maternal health inequities in the United States involves recognizing and addressing food insecurity, along with other social determinants of health, and advocating for public policies that support and protect all women's right to healthy food during pregnancy.

Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity.

OBJECTIVE: To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. METHODS: This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. RESULTS: There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). CONCLUSIONS: In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.

Adverse Maternal Outcomes Differ between Obese and Nonobese Women with Severe Preeclampsia.

OBJECTIVE: This article evaluates the differences in adverse maternal outcomes related to severe preeclampsia in obese versus nonobese women. STUDY DESIGN: Retrospective cohort study and planned secondary analysis of women with severe preeclampsia comparing a composite adverse maternal outcome related to preeclampsia among obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese (BMI < 30 kg/m2) women. The composite outcome was defined as ≥ 1 of the following prior to discharge: renal failure, liver abnormality, thrombocytopenia, blood transfusion, pulmonary edema, disseminated intravascular coagulation, stroke, or eclampsia. Multivariable logistic regression was used to control for confounders. RESULTS: Of the 152 women included, 37.5% were obese and 62.5% were nonobese. The prevalence of the primary outcome was 15.8% with obese women less likely to have the composite outcome compared with nonobese women (7% vs. 21.1%, p = 0.02). This remained after adjusting for confounders including maternal age, race, and chronic hypertension (adjusted odds ratio, 0.33 [0.12-0.89], p = 0.03). Obese women were, however, more likely to require intravenous antihypertensive medication peripartum compared with nonobese women (49.1% vs. 28.4%, p = 0.01). CONCLUSION: Obese women with severe preeclampsia may have a different phenotype of severe preeclampsia that is more associated with severe hypertension rather than end-organ damage.

Predicting persistent impaired glucose tolerance in patients with gestational diabetes: The role of high sensitivity CRP and adiponectin.

BACKGROUND: To evaluate whether maternal serum adiponectin and high-sensitivity C-reactive protein (hsCRP) levels at the time of gestational diabetes mellitus (GDM) diagnosis are associated with persistent glucose intolerance in GDM women at 6 to 12 weeks postpartum. METHODS: This is a secondary analysis of prospective randomized trial of GDM women enrolled in a behaviour education programme. Women with a GDM diagnosis ≥20 weeks were included. At the time of randomization, serum adiponectin and hsCRP levels were drawn. After delivery, women underwent a 2-hour 75-g oral glucose tolerance test at 6 to 12 weeks postpartum. Persistent impaired glucose tolerance (P-IGT) was defined as impaired fasting glucose, impaired glucose tolerance, or a diagnosis of type 2 diabetes mellitus. Regression models and receiver operator curves were used to evaluate the association between midpregnancy adiponectin and hsCRP and persistent impaired glucose tolerance. RESULTS: Of 100 women in the trial, 63 completed postpartum glucose testing. Twenty (31.7%) of the women had P-IGT. Median hsCRP levels were higher at randomization (22-34 wk) in women with persistent impaired glucose tolerance compared with women with normal glucose tolerance (5.1 vs 3.8, P = .01). After adjustment for the original study intervention, the association between hsCRP and P-IGT persisted (odds ratio, 3.45; 95% confidence interval, 1.34-8.92; P = .01) and had good diagnostic performance with an area under the curve of 0.73. There was no difference in median adiponectin levels between groups (44.8 vs 52.0, P = .57) or in odds of P-IGT (odds ratio, 0.81; 95% confidence interval, 0.33-1.99; P = .65), and area under the curve = 0.54. CONCLUSIONS: Midpregnancy high sensitivity CRP is a potential predictor of persistent impaired glucose tolerance diagnosed on the postpartum 2-hour 75-g oral glucose tolerance test in GDM women in the immediate postpartum period. Further investigation is needed in a larger population of women prior to using specific cut-offs for diagnostic purposes. High-sensitivity C-reactive protein levels in the immediate postpartum period should be seen as an adjunct, not a replacement, for the standard long-term screening of women with a history of a GDM pregnancy.

Implementation of a universal cervical length screening program: identifying factors associated with decline rates.

PURPOSE: Cervical length (CL) measurement is now accepted as a screening strategy for identifying women at risk for preterm birth (PTB). However, patient acceptability may limit its implementation. Our objective was to identify characteristics associated with women who decline this screening. MATERIALS AND METHODS: This is a secondary analysis of a prospective cohort study of women offered UCL screening from January 2012 to June 2012. Women with a singleton gestation 18 0/7-23 6/7 weeks at the time of anatomy scan were included. Trained sonographers were instructed to perform UCL screening on all eligible patients using an "opt-out" approach. Chi square statistics and Wilcoxon rank sum tests were used to compare categorical and continuous data, where appropriate. Logistic regression was used to calculate odds ratio for factors associated with declining UCL screening Results: 1348 women were offered CL screening; 131 (9.7%) declined. Overall, multiparous women were more than twice as likely to decline UCL screening compared to primiparous women [OR 2.4 (1.6-3.8)]. Patient acceptance of screening was significantly dependent on the sonographer (p < .05). CONCLUSION: Multiparous women are less likely to accept this strategy of PTB prevention. A standardized counseling approach may improve patient acceptance and mitigate variability in acceptance rates observed amongst sonographers.

Strategies to reduce disparities in maternal morbidity and mortality: The role of obesity and metabolic disease.

Maternal obesity, excessive gestational weight gain, and preexisting diabetes are known risk factors for increased maternal and neonatal morbidity. These conditions are more prevalent in certain racial and ethnic minorities. Identification and acknowledgement of racial and ethnic inequalities related to maternal metabolic disease is crucial for clinicians to provide the most comprehensive care in pregnancy. Research and clinical efforts should focus on implementation of healthy lifestyle interventions preconceptually and risk reduction efforts in disease complications during pregnancy. In addition, obstetrical providers can provide the framework and ongoing support for sustainable lifestyle modifications, thereby, improving a woman's long-term metabolic health.

Obesity and the association with maternal mental health symptoms.

OBJECTIVE: To evaluate the association between maternal obesity and mood disorders including depression, anxiety, stress, and pregnancy-specific stress during pregnancy. STUDY DESIGN: This was a planned secondary analysis of a prospective cohort study investigating factors associated with preterm delivery. The cohort included women who initiated prenatal care before 20 weeks with a singleton pregnancy. Maternal mental health was assessed using four standard psychosocial behavioral measures to screen for depression, pregnancy-specific stress, anxiety, and stress. Screen positive scores for each tool were established based on previously published "high" scores. RESULTS: Of the 1010 women included in the cohort, 355 (35.1%) were obese. There was no significant difference in the number of obese women with stress (64.2% versus 68.4%, p = 0.18), pregnancy-specific stress (26.2% versus 22.1%, p = 0.15), or anxiety (38.6% versus 41.2%, p = 0.42); however, a greater number of obese women did report symptoms consistent with major depression when compared to women with BMIs <30 (30.4% versus 21.2%, p < 0.01). CONCLUSION: Obese women had higher rates of depression in early pregnancy compared to nonobese women. As many of the health behavior interventions for obese women during pregnancy have proven ineffective, incorporating depression screening and treatment into prenatal care may improve perinatal outcomes.

The Effect of Early Excessive Weight Gain on the Development of Hypertension in Pregnancy.

Background Previous studies have shown an association between total excessive gestational weight gain and hypertension in pregnancy. However, this may be a reflection of excessive water retention associated with the pathophysiology of hypertensive disorders of pregnancy. Early excessive weight gain, prior to the third trimester, results in greater maternal fat deposition and inflammation, which has also been associated with the development of hypertension. By focusing on early excessive weight gain, the association between maternal weight gain and the future development of hypertension can be examined. Objective To evaluate the association between early excessive maternal weight gain and the development of hypertension during pregnancy. Study Design This was a secondary analysis of a longitudinal cohort study of 1,441 women without chronic hypertension who were enrolled in a prospective study evaluating maternal angiogenic factors and the prediction of preeclampsia. Initial body mass index (BMI) was calculated by weight and height at the first study visit. Early excessive maternal weight gain was defined as weight gain by 28 weeks that exceeded the Institute of Medicine (IOM) guidelines and was calculated utilizing the maximum amount of weight gain per week recommended by the IOM based on the patient's starting BMI (normal: 0.45 kg; overweight: 0.32 kg; obese: 0.27 kg). Hypertension was defined as a sustained systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg. Logistic regression was used to determine the association between early excessive weight gain, initial BMI, and the development of hypertension, including gestational hypertension and preeclampsia, during pregnancy. Results Of 1,441 women, 767 (53.2%) had weight gain that exceeded the IOM guidelines in the first 28 weeks and 154 (10.8%) developed hypertension during pregnancy. Women whose weight gain exceeded the IOM guidelines were more likely to develop hypertension even after adjusting for relevant confounders (12.5 vs. 8.6%; p = 0.02; adjusted odds ratio [OR] = 1.70; 95% confidence interval [CI]: 1.18-2.44; p < 0.01). Obese women had a 2.4-fold increased risk of developing hypertension, even after controlling for excessive weight gain (adjusted OR = 2.44; 95% CI: 1.66-3.59; p < 0.01) Conclusions Early excessive maternal weight gain and initial BMI are independently associated with the diagnosis of a hypertensive disorder of pregnancy. Women should be counseled regarding the benefits of achieving a normal BMI prior to pregnancy and appropriate weight gain during pregnancy, as well as the potential harms of excessive weight gain related to perinatal outcomes.

A Randomized Clinical Trial of an Intensive Behavior Education Program in Gestational Diabetes Mellitus Women Designed to Improve Glucose Levels on the 2-Hour Oral Glucose Tolerance Test.

Objective To evaluate whether women with gestational diabetes mellitus (GDM) enrolled in an intensive behavior education program (IBEP) demonstrate lower mean fasting glucose levels on the 2-hour 75 g oral glucose tolerance test (2-hour OGTT) at 6 to 12 weeks postpartum compared with women who undergo routine GDM management. Study Design A prospective randomized controlled trial of women diagnosed with GDM was conducted. Exclusion criteria were GDM diagnosis ≥ 33 weeks or < 20 weeks. Women were randomly assigned to one of two treatment arms: (1) routine GDM management or (2) an IBEP. Women underwent a 2-hour OGTT at 6 to 12 weeks postpartum. Fisher exact test, t-test, and Wilcoxon rank sum test were used as appropriate. Results Of the 101 women randomized, 49 were assigned to IBEP and 52 received routine GDM management. There was no difference in mean fasting and 2-hour glucose levels on the postpartum 2-hour OGTT between the IBEP and routine management group (88.5 ± 22.9 mg/dL vs. 85.2 ± 13.3 mg/dL, p = 0.49 and 109.8 ± 38.5 mg/dL vs. 109.4 ± 40.8 mg/dL, p = 0.97, respectively). Conclusion GDM women enrolled in a healthy lifestyle intervention program did not demonstrate lower glucose values on the postpartum 2-hour OGTT.

Placental microRNA Expression Is Not Altered by Maternal Obesity and Fetal Overgrowth.

Objective The epigenetic mechanisms underlying fetal metabolic programming are poorly understood. We studied whether obesity is associated with alterations in placental miRNA expression. Study Design A cross-sectional study was performed, including (1) normal-weight women (BMI 20-24.9 kg/m2) and normal-birth-weight (BW) infants (2,700-3,500 g) (n = 20), (2) normal-weight and macrosomic infants (BW ≥ 4,000 g) (n = 10), (3) obese (BMI ≥ 35 kg/m2) and normal BW infants (n = 16), and (4) obese and macrosomic infants (n = 10). All had term deliveries (37-41 weeks) and normal glucose tolerance (1 hour GCT < 7.2 mmol/L [130 mg/dL]). The expression of 5,639 placental miRNAs was assessed using miRNA microarray. Differential miRNA expression was determined using two-way ANOVA and pairwise contrasts, with the Benjamini-Hochberg (BH) correction. MiRNAs with Z-scores ≥ 2 and false discovery rate (FDR) < 20% were considered significant. Results Principal components analysis demonstrated similar global miRNA expression profiles among groups. Of 5,639 miRNAs, only 5 were significantly different between obese and controls, which were not validated by quantitative polymerase reaction. Conclusion There was no difference in placental miRNA expression associated with obesity or overgrowth. Aberrant placental miRNA expression is an unlikely mechanism underlying fetal metabolic programming related to maternal obesity.

Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy.

OBJECTIVE: The objective of this study is to evaluate a woman's risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy. METHODS: A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed. RESULTS: Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (p = 0.004 and 0.005, respectively) and hypertension later in life (p = 0.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (p = 0.006 and 0.002, respectively). CONCLUSIONS: Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.

A prediction score to assess the risk of delivering a large for gestational age infant among obese women.

OBJECTIVE: To create a prediction score incorporating both maternal clinical characteristics and sonographic measurements in an effort to more accurately determine the risk of a large for gestational age (LGA) infant in the obese gravida. METHODS: We performed a retrospective cohort study of obese women with singleton pregnancies who had a fetal ultrasound performed between 32 and 36 weeks from 1/2008 to 12/2011. LGA was defined as birth weight (BW) ≥ 90%. Clinical characteristics associated with fetal overgrowth were included in a multivariable logistic model and stepwise backwards regression was performed to identify which risk factors generated the most parsimonious predictive model. Adjusted odds ratios of covariates in the final model were used to estimate weights for each risk factor that were summed to generate a predictive score. RESULTS: Six-hundred and sixty-nine obese women were included. The incidence of LGA infants was 11.8%. Ultrasound estimation of fetal weight alone accurately predicted LGA in 17.7 % of cases (AUC = 0.58). The most parsimonious model to accurately predict LGA at birth included 3rd trimester ultrasound EFW >90th percentile, interval from scan to delivery, and maternal history of diabetes mellitus (DM) (AUC = 0.74). A positive prediction score test result was associated with 92% specificity and 89% negative predictive value. CONCLUSIONS: A clinical prediction rule was developed and internally validated to predict the risk of an LGA infant among obese women. The ability to calculate a prediction score at the time of delivery is appealing to the clinician in order to accurately counsel women regarding the risks surrounding the delivery.

The multidisciplinary approach to the care of the obese parturient.

Maternal obesity in pregnancy is associated with increased maternal and fetal risks. Pregnancy management should include counseling, screening, and optimization of maternal health, increased fetal surveillance, and preparation for parturition. A multidisciplinary approach should be implemented including collaboration from obstetricians, nutritionists, anesthesiologists, social workers, and neonatologists to optimize perinatal outcomes. Pregnancy is an ideal window of opportunity to influence both the patient's long-term health and the health of the offspring.

Excessive weight gain and hypertensive disorders of pregnancy in the obese patient.

OBJECTIVE: To evaluate the association between excessive weight gain and pregnancy-related hypertension (PRH) among obese women (body mass index (BMI) ≥30 kg/m(2)). METHODS: We performed a case control study among women with (n = 440) and without (n = 600) PRH from 2005 to 2007. Height and weight were recorded at initial and final prenatal visits. 695 women had BMI recorded at ≤18 weeks of gestation, of which 257 (36.9%) were obese. Obese women were divided into three categories based on 2009 Institute of Medicine (IOM) guidelines: (1) below recommended amount (under weight gain - UWG); (2) more than recommended (excessive weight gain - EWG) or (3) within recommended amount (normal weight gain - NWG). PRH was defined as gestational hypertension, mild or severe preeclampsia. Patients with and without PRH were prospectively identified. The association between weight gain category and development of PRH was analyzed. RESULTS: We noticed a 1.5-fold higher odds of having PRH with an initial BMI ≥30 kg/m(2) compared to BMI <30 kg/m(2) (OR 1.64, 95% CI 1.2-2.2, p = 0.002). Among obese women, we noted a 2-fold higher odds of having PRH with EWG compared to NWG (OR 2.52, 95% CI 1.2-3.9, p = 0.012). The increased odds persisted after adjusting for race, chronic hypertension and diabetes, and length of gestation (AOR 2.61, 95% CI 1.4-4.9, p = 0.003). Among obese women with PRH, those with EWG had a 76% decreased odds of having severe disease compared to NWG (OR = 0.242 [0.07-0.79], p = 0.019). CONCLUSION: We have demonstrated that EWG among obese patients increases overall risk of PRH.

The Effect of an Obesogenic Maternal Environment on Expression of Fetal Umbilical Cord Blood miRNA.

OBJECTIVE: Exposure to maternal obesity in utero predisposes offspring to obesity and metabolic disease. This study investigated whether maternal obesity is associated with alterations in expression of fetal microRNA (miRNA). STUDY DESIGN: A cohort study of women with body mass index (BMI) ≥35 kg/m(2) (n = 16) versus those with normal BMI 20 to 24.9 (n = 20) was performed. All participants had normal glucose tolerance (1-hour glucose challenge test <130) and normally grown neonates (2700-3500 g). Umbilical cord samples were collected immediately after delivery. Expression of miRNA was assessed using Affymetrix GeneChip miRNA 3.0 Arrays. Differential miRNA expression was determined using Student t tests with Benjamini-Hocherg correction. RESULTS: For 1733 human mature miRNAs, the expression levels were not statistically different in umbilical cord blood samples from pregnancies of obese women compared to controls. CONCLUSION: Expression of fetal miRNA is not altered in umbilical cord blood in response to in utero exposure to obesity. Alternate mechanisms underlying the fetal effects of maternal obesity should be explored.

Insulin analogues in the treatment of gestational diabetes mellitus.

Rapid-acting insulin analogues are the preferred choice for short-acting insulin due to their superior pharmacologic profiles, leading to greater flexibility and convenience of dosing. This has lead to greater patient satisfaction and improved quality of life. Clinical experience with rapid-acting insulin analogues in pregnancy is increasing. Currently, there is limited data available on the use of long-acting insulin analogues in pregnancy. The focus of this review is to discuss the role of insulin analogue therapy in the treatment of the woman with gestational diabetes.

Reversed end-diastolic flow in the middle cerebral artery preceding death in a normally grown fetus.

BACKGROUND: Reversed diastolic flow in the middle cerebral artery has been described as a terminal sign in the growth-restricted fetus. The implication of this in a normally grown fetus is unknown. CASE: Middle cerebral artery Doppler velocimetry was performed at 28 weeks of gestation in the setting of decreased fetal movement and a category 2 fetal heart tracing. The middle cerebral artery pulsatility index was elevated, and follow-up studies revealed reversed flow. The fetus had appropriate growth, with mild polyhydramnios and no signs of cardiomegaly, effusion, or hydrops. Fetal death was diagnosed 4 days later in the setting of extensive intracranial hemorrhage. CONCLUSION: Regardless of fetal growth, persistent reversed middle cerebral artery Doppler with an elevated pulsatility index may be a feature of impending death.