Asthma and pregnancy.

Managing asthma during pregnancy is crucial for both the mother and the developing child. Adequate control lowers risks as do continuation of prescribed medication and maintaining of regular check-ups. Signs of deterioration should not be ignored and treating asthma during pregnancy should follow guidelines for non-pregnant women with asthma as described in this review. Effective medication and counseling are essential for a safe pregnancy, emphasizing that well-controlled asthma is key.

Receiving gestational weight gain recommendations and associated risks: A qualitative study among low-income women.

Appropriate weight gain goals promote healthy gestational weight gain (GWG). Despite receiving recommendations from their providers, most women do not know how much weight they should gain during pregnancy. This study sought to describe the experiences of pregnant women when given GWG recommendations. The research proceeded using a phenomenological approach. With Institutional Review Board approval, primigravida women with a healthy singleton pregnancy at 8-20 weeks gestation were recruited from the community and purposively from a low-income obstetrics clinic. Within 60-minutes, trained interviewers 1) presented GWG recommendations and associated risks; and 2) interviewed participants using a semi-structured guide. Participants received a $40 gift card. Interviews were recorded and transcribed. Two trained coders used Braun and Clarke's (2020) reflexive thematic analysis procedures. When presented with GWG information, participants (n = 29, Mage = 25.5, 4.7 SD) proceeded to: 1) make sense of the information, 2) evaluate the credibility of the information, 3) weigh the importance of the information, 4) predict likely outcomes, and 5) plan behaviors. Participants who were able to understand the information, found it to be credible and important, and who predicted adverse outcomes for failing to adhere to recommendations reported intentions for health promoting behaviors. Future research should test GWG counseling methods based on these cognitive processes. Clinicians should consider these 5 cognitive processes when providing initial GWG counseling.

A review of dairy food intake for improving health for black women in the US during pregnancy, fetal development, and lactation.

Pregnancy and lactation are special life stages that require regular nutritional and medical attention to help protect the health of the mother and promote the growth and development of the offspring. Despite an increased focus on maternal and fetal health over the last several decades, the rates of pregnancy-related morbidity and mortality are increasing in the United States (US). On average, Black women who are pregnant or lactating face greater health disparities and birth complications than other racial/ethnic groups in the US. The issues contributing to these disparities are multi-faceted and include sociocultural, economic, medical, and dietary factors. For example, Black women face greater rates of food insecurity, worse access to healthcare, and lower nutrient status when compared to White women. A growing body of research suggests that consuming a healthier dietary pattern is one of the most potent modifiable risk factors associated with improved fertility and reducing pregnancy-related complications. Recent publications have also shed light on the role of dairy foods in improving diet quality and nutrient status among Black women and for impacting maternal and fetal health outcomes, such as preeclampsia, spontaneous abortion, preterm birth, and fetal growth. To support healthy pregnancy and lactation, the current national dietary guidelines recommend the consumption of 3 servings of dairy foods per day. However, the vast majority of Black women in the US are falling short of these recommendations and are not meeting nutrient requirements for calcium and vitamin D. Therefore, strategies that target misconceptions surrounding lactose intolerance and focus on the health value of adequate dairy intake among Black women of child-bearing age may benefit both prenatal and postpartum health. This review presents the current evidence on health disparities faced by pregnant and lactating Black women in the US, and the role of dairy foods in supporting healthy pregnancy, fetal development, and lactation outcomes in this population.

Galletas de tomate (lycopersicon esculentum) como intervención para el manejo de la anemia en mujeres embarazadas / Tomato (lycopersicon esculentum) cookies as an intervention for handling anaemia in pregnant women

Objetivo: Este estudio tiene como objetivo determinar el efecto de las galletas de tomate en los niveles de hierro de las mujeres embarazadas en ciertas áreas de Indonesia. Métodos: Este estudio utilizó un diseño de grupo de control cuasi-experimental antes y después de la prueba. Se tomó una muestra de 102 personas con igual número por grupo mediante muestreo aleatorio simple. Se dieron cinco piezas de galletas de tomate (@20 gramos) todos los días/durante siete días. Los niveles de hierro se midieron antes y después de la prueba. Se utilizaron hojas de observación, procedimientos operativos estándar y niveles de hemoglobina basados en pruebas de laboratorio. Análisis de datos usando la prueba T pareada y la prueba T independiente. Resultados: La mayoría de los encuestados tenían entre 20 y 35 años (90,4 %), tercer trimestre (58,1 %) y multigrávida (83,9 %). El grupo de control no mostró diferencias significativas entre los niveles de hemoglobina antes y después de la prueba (p = 0,317). Hubo un aumento en el nivel de Hb de las mujeres embarazadas después de dar galletas de tomate hasta 1,77 g/dL con p=0,011. Hubo una diferencia significativa en los niveles de hemoglobina entre los grupos de control y de intervención (p=0,025). Conclusiones: La provisión de galletas de tomate aumenta efectivamente los niveles de Hb de las mujeres embarazadas. Esta intervención puede ser una alternativa para la prevención y tratamiento de la anemia en mujeres embarazadas. Las mujeres embarazadas pueden consumir galletas de tomate junto con el consumo de tabletas de hierro (AU)

Primary Goal: This study aims to determine the effect of tomato cookies on the iron levels of pregnant women in certain areas in Indonesia. Methods: This study used a quasi-experimental pretest and posttest control group design. A sample of 102 people with the same number per group was taken using simple random sampling. Tomato biscuits were given five pieces (@20 grams) every day/for seven days. Iron levels were measured during the pretest and posttest. Observation sheets, standard operating procedures, and haemoglobin levels based on laboratory tests were used. In comparison, data Analysis using Paired T-Test and Independent T-Test. Results: The majority of respondents were aged 20-35 years (90.4%), third trimester (58.1%), and multigravida (83.9%). The control group showed no significant difference between pretest and posttest haemoglobin levels (p=0.317). There was an increase in the Hb level of pregnant women after giving tomato Cookies as much as 1.77 g/dL with p=0.011. There was a significant difference in haemoglobin levels between the control and intervention groups (p=0.025). Conclusions: The provision of tomato cookies effectively increases the Hb levels of pregnant women. This intervention can be an alternative for preventing and treating anaemia in pregnant women. Pregnant women can consume tomato cookies together with the consumption of iron tablets (AU)

Potential impact on using aspirin as the primary prevention of adverse pregnancy outcomes in twins conceived using ART.

With the development of assisted reproductive technology, the number of twin pregnancies is increasing year by year. Given the increased risk of pregnancy complications associated with twin pregnancies, and the fact that these babies are rare and difficult to obtain through assisted reproductive technology, clinicians urgently require finding effective and safe drugs to improve pregnancy outcomes. Low-dose aspirin can not only promote placental blood supply, but also effectively anti-inflammatory. Whether Low-dose aspirin can effectively reduce the risk of pregnancy complications in this special group needs to be clarified. We therefore retrospectively analyzed 665 twin pregnancies from assisted reproduction technology, grouped according to aspirin use, and followed pregnancy outcomes to assess bleeding risk. Low-dose aspirin was found to be effective in preventing preeclampsia without a significant risk of bleeding. However, aspirin does not prevent specific complication in twin pregnancies and seems to have a better preventive effect only when the mother is under 30, which should alarm clinicians should not blindly using aspirin in this particular group.

Using Prevention Research to Reduce Racial Disparities in Health Through Innovative Funding Strategies: The Case of Doula Care.

Racial disparities in maternal birth outcomes are substantial even when comparing women with similar levels of education. While racial differences in maternal death at birth or shortly afterward have attracted significant attention from researchers, non-fatal but potentially life-threatening pregnancy complications are 30-40 times more common than maternal deaths. Black women have the worst maternal health outcomes. Only recently have health researchers started to view structural racism rather than race as the critical factor underlying these persistent inequities. We discuss the economic framework that prevention scientists can use to convince policymakers to make sustainable investments in maternal health by expanding funding for doula care. While a few states allow Medicaid to fund doula services, most women at risk of poor maternal health outcomes arising from structural racism lack access to culturally sensitive caregivers during the pre-and post-partum periods as well as during birth. We provide a guide to how research in health services can be more readily translated to policy recommendations by describing two innovative ways that cost-benefit analysis can help direct private and public funding to support doula care for Black women and others at risk of poor birth outcomes.

Pregnancy and tobacco: Practice and knowledge of French midwives.

OBJECTIVES: Evaluate the midwives' practices and knowledges with regard to the management of the smoking cessation in pregnant women and analyse the profile of midwives prescribing nicotine replacement therapy (NRT). METHODS: A national practice survey amongst 23,541 French midwives was conducted from 1 September 2020 to 15 September 2021 using an online self-administered questionnaire. RESULTS: The analysis of the 1,216 usable questionnaires (97, 7% women, mostly aged 30 to 49 years and non-smokers) showed that 93.4% of midwives frequently questioned pregnant women about their smoking consumption during pregnancy. The minimal counselling was known and practiced by 91% of midwives, the Fagerström test by 26.9% and the measurement of exhaled CO by 27.1%. Concerning NRT, 60% of the midwives prescribed them in a usual way and 36.8% were aware of the possibility of prescribing them to the pregnant woman's entourage. The profile of midwives prescribing NRT was significantly more concerned with smoking cessation in pregnant women; worked more frequently in a hospital; carried out 25% or more of antenatal monitoring consultations; and had significantly better knowledge of the evaluation tools, without influence of sex or smoking status. CONCLUSIONS: Improving the training of midwives in the screening and management of smoking cessation during pregnancy seems necessary.

Pregnancy-associated cardiovascular risks and postpartum care; an opportunity for interventions aiming at health preservation and disease prevention.

Cardiovascular disease (CVD) is the leading cause of premature death and disability for female individuals around the world and the rates are increasing in those aged 35-44 years. Certain pregnancy complications (Pregnancy-associated Cardiovascular Risks (P-CVR))are linked to an increased risk of future CVD making pregnancy and the postpartum period as an ideal time to screen individuals for underlying, often unrecognized, cardiovascular risk factors. Pregnancy complications associated with an increased risk of future CVD including the hypertensive disorders of pregnancy, gestational diabetes, idiopathic preterm birth, delivery of a growth restricted baby and a placental abruption that leads to delivery. A number of guidelines and research groups recommend postpartum CVR screening, counseling and lifestyle intervention for all those who have had one or more of P-CVRs starting within the first six months postpartum. An individualized plan for postpartum screening should be created with the individual and lifestyle interventions discussed.

A retrospective comparative study of antenatal healthy lifestyle service interventions for women with a raised body mass index.

BACKGROUND: Women with obesity are more likely to gain excessive gestational weight; with both obesity and excessive weight gain linked to adverse outcomes for mothers and their infant. Provision of antenatal healthy lifestyle services is currently variable, with uncertainty over the most effective gestational healthy lifestyle interventions. AIM: To compare pregnancy and birth outcomes among women who experienced an antenatal health lifestyle service with a cohort who did not receive this service. METHODS: A retrospective comparative cohort study was undertaken in women with a BMI ≥ 40 kg/m² attending maternity care in two NHS Trusts. One Trust provided an antenatal healthy lifestyle service, while the comparison Trust provided routine maternity care. Data was collected from medical records. FINDINGS: No differences were observed between the antenatal healthy lifestyle service and comparison cohorts for average gestational weight gain [adjusted mean difference (aMD) - 0.70 kg (95%CI -2.33, 0.93)], rate of weight gain [aMD - 0.02 kg/week (95%CI -0.08, 0.04)] or weight gain in accordance with recommendations. The proportion of women breastfeeding at discharge was higher for the antenatal healthy lifestyle service than the comparison cohort (42.4% vs 29.8%). No other clinical outcomes were enhanced with the antenatal healthy lifestyle service. CONCLUSION: Internal audit had suggested the antenatal healthy lifestyle service was successful at managing gestational weight gain in women with a BMI ≥ 40 kg/m². However, no benefit on gestational weight gain was evident once the service was evaluated against a comparison cohort with adequate adjustment for confounders. It is essential that future services are evaluated against a relevant comparison group.

Mortalidad Materna en Venezuela: aspectos médicos y Políticas (1940 - 2016) / Materna Mortality in Venezuela: medical issues and Public Policy (1940 - 2016)

En la actualidad Venezuela se encuentra en una crisis social y económica sin precedentes. La mortalidad materna(MM) es un indicador en salud importante, debido a que permite tener idea de la atención médica de un país; se mide a través de dos indicadores: Razón de Mortalidad Materna (RMM) y Tasa de Mortalidad Materna (TMM). Objetivo: Revisar y compararla evolución de ambos indicadores de MM desde la década de 1930 hasta la década 2000. Métodos: Se realizó una revisión de la literatura y de informes técnicos de organismos gubernamentales y no gubernamentales para el análisis de la situación previa y reciente de esta situación en Venezuela. Los resultados señalan que existe una notable disminución de las cifras de MM como ha de esperarse con el mejoramiento de la tecnología desde la década de 1930 hasta el año 2000; posteriormente ocurre un retroceso de la sanidad pública con cifras comparables a la década de 1960. Concluimos que la MM ha sido desde tiempos pasados un problema constante en la salud pública; al pasar los años y gobiernos, se han implementado numerosas políticas públicas para mejorar esta situación, muchas de estas estrategias han sido fallidas debido a la falta de su continuidad y de su cumplimiento pleno.

Venezuela is currently in an unprecedented socialand economic crisis. Maternal mortality is an important health indicator because it provides an idea of a country's medical care. Maternal mortality is usually measured through two indicators: Maternal Mortality Ratio (MMR) and Maternal Mortality Rate. Objective: Review and compare the evolution of both healthindicators from the 1930s to 2016. Methods: A review of the literature and technical reports from governmental andnon-governmental organizations was carried out to analyze theprevious and recent situation. of this situation in Venezuela. Theresults indicate that there is a notable decrease in the figures ofmaternal mortality, as should be expected with the improvementof technology from the 1930s to the year 2000. Subsequently, there is a decline in public health with figures comparable to the1960s. We conclude that maternal mortality has been a constant problem in public health since ancient times. Over the years and governments, numerous public policies have been implementedto improve this situation. Many of these strategies have beenfailed due to lack of continuity and in the absence of its full compliance.

Effects of an antenatal dietary intervention in women with obesity or overweight on child outcomes at 8-10 years of age: LIMIT randomised trial follow-up.

BACKGROUND: The LIMIT randomised controlled trial looked at the effect of a dietary and lifestyle intervention compared with routine antenatal care for pregnant women with overweight and obesity on pregnancy outcomes. While women in the intervention group improved diet and physical activity with a reduction of high birth weight, other outcomes were similar. We have followed the children born to women in this study at birth, 6 and 18 months and 3-5 years of age and now report follow-up of children at 8-10 years of age. METHODS: Children at 8-10 years of age who were born to women who participated in the LIMIT randomised trial, and whose mother provided consent to ongoing follow-up were eligible for inclusion. The primary study endpoint was the incidence of child BMI z-score > 85th centile for child sex and age. Secondary study outcomes included a range of anthropometric measures, neurodevelopment, child dietary intake, and physical activity. Analyses used intention to treat principles according to the treatment group allocated in pregnancy. Outcome assessors were blinded to the allocated treatment group. RESULTS: We assessed 1,015 (Lifestyle Advice n = 510; Standard Care n = 505) (48%) of the 2,121 eligible children. BMI z-score > 85th percentile was similar for children of women in the dietary Lifestyle Advice Group compared with children of women in the Standard Care Group (Lifestyle Advice 479 (45%) versus Standard Care 507 (48%); adjusted RR (aRR) 0.93; 95% CI 0.82 to 1.06; p = 0.302) as were secondary outcomes. We observed that more than 45% of all the children had a BMI z-score > 85th percentile, consistent with findings from follow-up at earlier time-points, indicating an ongoing risk of overweight and obesity. CONCLUSIONS: Dietary and lifestyle advice for women with overweight and obesity in pregnancy has not reduced the risk of childhood obesity, with children remaining at risk of adolescent and adult obesity. Other strategies are needed to address the risk of overweight and obesity in children including investigation of preconception interventions to assess whether this can modify the effects of maternal pre-pregnancy BMI. The LIMIT randomised controlled trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Nurturing through Nutrition: Exploring the Role of Antioxidants in Maternal Diet during Pregnancy to Mitigate Developmental Programming of Chronic Diseases.

Chronic diseases represent one of the major causes of death worldwide. It has been suggested that pregnancy-related conditions, such as gestational diabetes mellitus (GDM), maternal obesity (MO), and intra-uterine growth restriction (IUGR) induce an adverse intrauterine environment, increasing the offspring's predisposition to chronic diseases later in life. Research has suggested that mitochondrial function and oxidative stress may play a role in the developmental programming of chronic diseases. Having this in mind, in this review, we include evidence that mitochondrial dysfunction and oxidative stress are mechanisms by which GDM, MO, and IUGR program the offspring to chronic diseases. In this specific context, we explore the promising advantages of maternal antioxidant supplementation using compounds such as resveratrol, curcumin, N-acetylcysteine (NAC), and Mitoquinone (MitoQ) in addressing the metabolic dysfunction and oxidative stress associated with GDM, MO, and IUGR in fetoplacental and offspring metabolic health. This approach holds potential to mitigate developmental programming-related risk of chronic diseases, serving as a probable intervention for disease prevention.

How effective is public health policy in Scotland on vitamin D deficiency during pregnancy?

OBJECTIVE: To evaluate the uptake of universal vitamin D supplementation during pregnancy, its effectiveness in preventing vitamin D deficiency and the factors associated with these. DESIGN: The regional public health organisation in Ayrshire, Scotland has a policy of universal provision of vitamin D supplements (10 µg/d) to all pregnant women for the duration of their pregnancy. Pregnant women in this area were recruited at their 12-week antenatal appointment. Blood samples were collected at the 12-week and 34-week appointments. To account for the seasonal variation, women were recruited in two cohorts: summer and winter. Telephone interviews were conducted at 34 weeks to assess the uptake of vitamin D supplements during pregnancy. Other variables were obtained from medical records. SETTING: The study was conducted in the NHS Ayrshire and Arran Health Board in Scotland. PARTICIPANTS: 612 pregnant women (aged 15-44 years) living in Ayrshire (latitude 55°), Scotland. RESULTS: Sixty-six percentage took supplementation as recommended. Consumption of supplementation was significantly associated with a higher median serum 25-hydroxyvitamin D concentrations at 34 weeks. Despite this at 34 weeks, 33 % of the summer cohort had insufficient or deficient vitamin D status, while 15 % of the winter cohort had insufficient or deficient status. In multivariable analysis, only adherence and season were independent predictors of vitamin D status. CONCLUSIONS: While supplementation improved and maintained vitamin D status during pregnancy, it was not adequate to ensure all those insufficient at 12 weeks achieved sufficient status at the end of pregnancy.

Documento de consenso de la Sociedad Española de Obstetricia y Ginecologia (SEGO) y el Comité Español Interdisciplinario para la Prevención Vascular (CEIPV). Ventana de oportunidad: prevención del riesgo vascular en la mujer. Resultados adversos del embarazo y riesgo de enfermedad vascular / Consensus document of the Spanish Society of Obstetrics and Gynecology (SEGO) and the Spanish Interdisciplinary Committee for Vascular Prevention (CEIPV). Opportunity window: vascular risk prevention in women. Adverse pregnancy outcomes and risk of vascular disease

Este documento resume la evidencia que existe entre los resultados adversos del embarazo (RAE), tales como son los trastornos hipertensivos, el parto pretérmino, la diabetes gestacional, los defectos en el crecimiento fetal (feto pequeño para la edad gestacional y/o restricción del crecimiento), el desprendimiento de placenta y la pérdida fetal, y el riesgo que tiene una persona gestante de desarrollar factores de riesgo vascular (RV) que pueden terminar provocando enfermedad vascular (EV) futura: cardiopatía coronaria, accidente cerebrovascular, enfermedad vascular periférica e insuficiencia cardíaca. Asimismo, este documento destaca la importancia de saber reconocer los RAE cuando se evalúa el RV en mujeres. Un antecedente de RAE es un indicador suficiente para hacer una prevención primaria de EV. De hecho, adoptar una dieta saludable y aumentar la actividad física entre las mujeres con RAE, de inicio en el embarazo y/o postparto y manteniéndolo a lo largo de la vida, son intervenciones importantes que permiten disminuir el RV. Por otro lado, la lactancia materna también puede disminuir el RV posterior de la mujer, incluyendo menos riesgo de mortalidad. Estudios futuros que evalúen el uso del ácido acetilsalicílico, las estatinas y la metformina, entre otros, en las mujeres con antecedentes de RAE podrían reforzar las recomendaciones sobre el uso de la farmacoterapia en la prevención primaria de la EV entre estas pacientes. Existen diferentes opciones dentro de los sistemas de salud para mejorar la transición de la atención de las mujeres con RAE entre los diferentes profesionales e implementar estrategias para reducir su RV a largo plazo. Una posible estrategia podría ser la incorporación del concepto delcuarto trimestre en las recomendaciones clínicas y las políticas de atención de la salud.(AU)

This document summarises the evidence regarding the association between adverse pregnancy outcomes (APOs), such as hypertensive disorders, preterm birth, gestational diabetes, fetal growth defects (small for gestational age and/or fetal growth restriction), placental abruption, fetal loss, and the risk that a pregnant individual in developing vascular risk factors (VR) that may lead to future vascular disease (VD): coronary heart disease, stroke, peripheral vascular disease, and heart failure. Furthermore, this document emphasises the importance of recognising APOs when assessing VR in women. A history of APOs serves as a sufficient indicator for primary prevention of VD. In fact, adopting a healthy diet and increasing physical activity among women with APOs, starting during pregnancy and/or postpartum, and maintaining it throughout life are significant interventions that can reduce VR. On the other hand, breastfeeding can also reduce the future VR of women, including a lower risk of mortality.Future studies evaluating the use of aspirin, statins, and metformin, among others, in women with a history of APOs could strengthen recommendations regarding pharmacotherapy for primary prevention of VD in these patients. Various healthcare system options exist to improve the transition of care for women with APOs between different healthcare professionals and implement longterm VR reduction strategies. One potential process could involve incorporating the fourth-trimester concept into clinical recommendations and healthcare policies.(AU)

Folic Acid Supplementation to Prevent Neural Tube Defects: US Preventive Services Task Force Reaffirmation Recommendation Statement.

Importance: Neural tube defects are among the most common congenital malformations in the US, with an estimated 3000 pregnancies affected each year. Many of these neural tube defects are caused by low folate levels in the body. Objective: The US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update on the benefits and harms of folic acid supplementation. Population: Persons who are planning to or could become pregnant. Evidence Assessment: The USPSTF concludes that, for persons who are planning to or could become pregnant, there is high certainty that folic acid supplementation has a substantial net benefit to prevent neural tube defects in their offspring. Recommendation: The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (A recommendation).

Folic Acid Supplementation to Prevent Neural Tube Defects: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Neural tube defects are among the most common birth defects in the US. Objective: To review new evidence on the benefits and harms of folic acid supplementation for the prevention of neural tube defects to inform the US Preventive Services Task Force. Evidence Review: Sources included PubMed, Cochrane Library, Embase, and trial registries from July 1, 2015, through July 2, 2021; references; and experts, with surveillance through February 10, 2023. Two investigators independently reviewed English-language randomized studies and nonrandomized cohort studies in very highly developed countries that focused on the use of folic acid supplementation for the prevention of neural tube defect-affected pregnancies; methodological quality was dually and independently assessed. Findings: Twelve observational studies (reported in 13 publications) were eligible for this limited update (N = 1 244 072). Of these, 3 studies (n = 990 372) reported on the effect of folic acid supplementation on neural tube defects. For harms, 9 studies were eligible: 1 randomized clinical trial (n = 431) reported on variations in twin delivery, 7 observational studies (n = 761 125) reported on the incidence of autism spectrum disorder, and 1 observational study (n = 429 004) reported on maternal cancer. Two cohort studies and 1 case-control study newly identified in this update reported on the association between folic acid supplementation and neural tube defects (n = 990 372). One cohort study reported a statistically significant reduced risk of neural tube defects associated with folic acid supplementation taken before pregnancy (adjusted relative risk [aRR], 0.54 [95% CI, 0.31-0.91]), during pregnancy (aRR, 0.62 [95% CI, 0.39-0.97]), and before and during pregnancy (aRR, 0.49 [95% CI, 0.29-0.83]), but this association occurred for only the later of 2 periods studied (2006-2013 and not 1999-2005). No other statistically significant benefits were reported overall. No study reported statistically significant harms (multiple gestation, autism, and maternal cancer) associated with pregnancy-related folic acid exposure. Conclusions and Relevance: New evidence from observational studies provided additional evidence of the benefit of folic acid supplementation for preventing neural tube defects and no evidence of harms related to multiple gestation, autism, or maternal cancer. The new evidence was consistent with previously reviewed evidence on benefits and harms.

Prenatal Care for the Obese and Severely Obese Pregnant Patient.

Modifications of prenatal care will be needed in expected weight gain, nutritional recommendations, screening tests, thromboprophylaxis, ultrasound, antenatal testing, and timing and mode of delivery.

Key Components of Antenatal Lifestyle Interventions to Optimize Gestational Weight Gain: Secondary Analysis of a Systematic Review.

Importance: Randomized clinical trials have found that antenatal lifestyle interventions optimize gestational weight gain (GWG) and pregnancy outcomes. However, key components of successful interventions for implementation have not been systematically identified. Objective: To evaluate intervention components using the Template for Intervention Description and Replication (TIDieR) framework to inform implementation of antenatal lifestyle interventions in routine antenatal care. Data Sources: Included studies were drawn from a recently published systematic review on the efficacy of antenatal lifestyle interventions for optimizing GWG. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, MEDLINE, and Embase were searched from January 1990 to May 2020. Study Selection: Randomized clinical trials examining efficacy of antenatal lifestyle interventions in optimizing GWG were included. Data Extraction and Synthesis: Random effects meta-analyses were used to evaluate the association of intervention characteristics with efficacy of antenatal lifestyle interventions in optimizing GWG. The results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data extraction was performed by 2 independent reviewers. Main Outcomes and Measures: The main outcome was mean GWG. Measures included characteristics of antenatal lifestyle interventions comprising domains related to theoretical framework, material, procedure, facilitator (allied health staff, medical staff, or researcher), delivery format (individual or group), mode, location, gestational age at commencement (<20 wk or ≥20 wk), number of sessions (low [1-5 sessions], moderate [6-20 sessions], and high [≥21 sessions]), duration (low [1-12 wk], moderate [13-20 wk], and high [≥21 wk]), tailoring, attrition, and adherence. For all mean differences (MDs), the reference group was the control group (ie, usual care). Results: Overall, 99 studies with 34 546 pregnant individuals were included with differential effective intervention components found according to intervention type. Broadly, interventions delivered by an allied health professional were associated with a greater decrease in GWG compared with those delivered by other facilitators (MD, -1.36 kg; 95% CI, -1.71 to -1.02 kg; P < .001). Compared with corresponding subgroups, dietary interventions with an individual delivery format (MD, -3.91 kg; 95% CI -5.82 to -2.01 kg; P = .002) and moderate number of sessions (MD, -4.35 kg; 95% CI -5.80 to -2.89 kg; P < .001) were associated with the greatest decrease in GWG. Physical activity and mixed behavioral interventions had attenuated associations with GWG. These interventions may benefit from an earlier commencement and a longer duration for more effective optimization of GWG. Conclusions and Relevance: These findings suggest that pragmatic research may be needed to test and evaluate effective intervention components to inform implementation of interventions in routine antenatal care for broad public health benefit.

Timing and Preventability of Cardiovascular-Related Maternal Death.

OBJECTIVE: To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths. METHODS: We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups. RESULTS: During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman. CONCLUSION: Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.