Duration of periconceptional folic acid supplementation in women booking for antenatal care.

OBJECTIVE: To provide accurate estimates of the commencement time, duration and dosage of folic acid (FA) supplementation taken by Irish women in the periconceptional period. The study also aimed to establish the factors associated with optimal FA supplementation practices. DESIGN: Cross-sectional observational study. Women's clinical and sociodemographic details were computerised. Maternal weight and height were measured before calculating BMI. Detailed FA supplementation questionnaires were completed under the supervision of a trained researcher. SETTING: A large university maternity hospital, Republic of Ireland, January 2014-April 2016. SUBJECTS: Women (n 856) recruited at their convenience in the first trimester. RESULTS: While almost all of the women (97 %) were taking FA at enrolment, only one in four women took FA for at least 12 weeks preconceptionally (n 208). Among the 44 % of women who were supplementing with FA preconceptionally, 44 % (162/370) reported taking FA for less than the 12 weeks required to achieve optimal red-blood-cell folate levels for prevention of neural tube defects. On multivariate analysis, only planned pregnancy and nulliparity were associated with taking FA for at least 12 weeks preconceptionally. Among women who only took FA postconceptionally, almost two-thirds commenced it after day 28 of their pregnancy when the neural tube had already closed. CONCLUSIONS: As the timing of FA was suboptimal both before and after conception, we recommend that current national FA guidelines need to be reviewed.

Impact of Implementing Preanalytical Laboratory Standards on the Diagnosis of Gestational Diabetes Mellitus: A Prospective Observational Study.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with adverse pregnancy outcomes, but risk is reduced with identification and early treatment. Glucose measurements are affected by preanalytical sample handling, such as temperature of storage, phlebotomy-analysis interval, and use of a glycolysis inhibitor. We evaluated glucose concentrations and the incidence of GDM after strict implementation of the American Diabetes Association (ADA) preanalytical guidelines, compared with usual hospital conditions. METHODS: Women screened selectively for GDM at 24-32 weeks' gestation were recruited at their convenience before a 75-g oral glucose tolerance test. Paired samples were taken: the first sample followed ADA recommendations and was transferred to the laboratory on an iced slurry for immediate separation and analysis (research conditions), and the second sample was not placed on ice and was transferred according to hospital practice (usual conditions). RESULTS: Of samples from 155 women, the mean fasting, 1-h, and 2-h results were 90.0 (12.6) mg/dL [5.0 (0.7) mmol/L], 142.2 (43.2) mg/dL [7.9 (2.4) mmol/L], and 102.6 (32.4) mg/dL [5.7 (1.8) mmol/L], respectively, under research conditions, and 81 (12.6) mg/dL [4.5 (0.7) mmol/L], 133.2 (41.4) mg/dL [7.4 (2.3) mmol/L], and 99 (32.4) mg/dL [5.5 (1.8) mmol/L] under usual conditions (all P < 0.0001). GDM was diagnosed in 38.1% (n = 59) under research conditions and 14.2% (n = 22) under usual conditions (P < 0.0001). The phlebotomy-analysis interval for the fasting, 1-h, and 2-h samples was 20 (9), 17 (10), and 17 (9) min under research conditions and 162 (19), 95 (23), and 32 (19) min under usual conditions (all P < 0.0001). All cases of GDM were diagnosed on fasting or 1-h samples; the 2-h test diagnosed no additional cases. CONCLUSIONS: Implementation of ADA preanalytical glucose sample handling recommendations resulted in higher mean glucose concentrations and 2.7-fold increased detection of GDM compared with usual hospital practices.

An analysis of folic acid supplementation in women presenting for antenatal care.

BACKGROUND: Neural tube defects (NTDs) are major congenital malformations that are potentially preventable if the woman takes periconceptional folic acid (FA) supplements. A recent report found that NTD incidence had increased in Ireland. This study examined the usage of FA supplementation in women presenting for antenatal care in a maternity hospital. METHODS: Women were recruited at their convenience in the first trimester. Their clinical and sociodemographic details were computerized. Maternal weight and height were measured before calculating body mass index. Detailed FA questionnaires were completed under supervision of a trained researcher. RESULTS: While 96.1% (n = 564) out of 587 reported that they took FA after they became pregnant, only 24.7% (n = 145) took it for >12 weeks preconceptionally as recommended. Only 5.7% (n = 6) of obese women took high-dose FA as recommended. On univariate analysis, the strongest predictors of preconceptional FA usage were higher maternal age, higher education and income, being married, being nulliparous, not smoking, infertility treatment and planned pregnancy. On multivariate analysis, both planned pregnancy and nulliparity were the most important predictors of preconceptional FA use. CONCLUSIONS: Our study shows that current recommendations to prevent NTDs by FA supplementation pre-pregnancy are not being fully implemented in Ireland. We recommend a review of current public health policies on FA supplementation.

Maternal folic acid supplementation trends 2009-2013.

OBJECTIVE: We analyzed trends in folic acid supplementation among women booking for antenatal care between 2009 and 2013. DESIGN: Prospective observational study. SETTING: Large university teaching hospital. POPULATION: We included all women who delivered an infant ≥500 g from 1 January 2009 to 31 December 2013. METHODS: Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Multivariate logistic regression analyses were applied to determine the correlates of periconceptional folic acid supplementation. MAIN OUTCOME MEASURES: Rates and correlates of folic acid supplementation. RESULTS: Of 42 362 women, 99.2% (n = 42 042) were suitable for analysis. The mean age was 30.7 years and mean body mass index was 25.6 kg/m(2) , 40.7% (n = 17 054) were primigravidas and 70.6% (n = 29 741) were Irish-born. Overall, 43.9% (n = 18 473) took periconceptional (preconceptional and postconceptional) folic acid, 49.4% (n = 20 782) took postconceptional folic acid only, and 6.6% (n = 2787) took no folic acid. The women most likely to take folic acid were those who planned their pregnancy and were >30 years old, non-obese, Irish-born and employed professionally. The periconceptional folic acid rate decreased from 45.1% in 2009 to 43.1% in 2013 (p = 0.01). Over five years, periconceptional folic acid supplementation decreased among women who were multiparous (43.8-41.6%, p = 0.02), aged 30-39 years (58.9-55.0%, p < 0.001), Irish-born (50.1-47.1%, p < 0.001) and obese (38.6-36.9%, p = 0.02). CONCLUSION: Overall, the rate of periconceptional folic acid supplementation decreased in the five years 2009-2013, particularly among women who were multiparous, aged 30-39 years, Irish-born and obese.

Trends in maternal obesity in a large university hospital 2009-2013.

INTRODUCTION: Maternal obesity has been identified as an important clinical priority in contemporary obstetrics. This study aimed to determine the incidence of maternal obesity in early pregnancy and track recent trends in body mass index (BMI) categories over 5 years 2009-2013. MATERIAL AND METHODS: This prospective observational study included all women who delivered an infant weighing ≥500 g during the 5 years 2009-2013 in a large university teaching hospital in Ireland. Body mass index was calculated using early pregnancy weight and height measured at first antenatal visits. Sociodemographic and clinical data were gathered prospectively. Trends in maternal obesity were tracked over 5 years and epidemiological associations with obesity were examined using logistic regression, adjusted for confounding variables. RESULTS: Of 42 362 women, 99.0% (n = 41 927) were eligible for analysis with a mean BMI of 25.5 kg/m(2) , mean age of 30.7 years and 40.7% (n = 17054) primigravidas. The absolute number of cases of severe obesity (BMI ≥40.0 kg/m(2) ) increased by 48.5% from 2009 to 2013 (p < 0.001). After multivariate logistic regression analyses, obesity incidence increased with increasing parity, advancing age and socioeconomic disadvantage. The maternal obesity rate among women born in the 13 European Union Accession countries was 8.6%, nearly half that of those born in existing European Union countries (p < 0.001). CONCLUSION: It is concerning that while the overall obesity rate remained stable, the number of cases of severe obesity increased over 5 years. We recommend renewed public health efforts addressing obesity rates before pregnancy and reinforcing attempts to optimize a woman's weight after delivery.

The interplay between maternal obesity and gestational diabetes mellitus.

There is a strong epidemiological association between maternal obesity and gestational diabetes mellitus (GDM). Since the publication of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study on women with mild hyperglycemia in 2008, new criteria have been introduced in maternity services internationally for the diagnosis of GDM. As a result, the diagnosis of GDM may be made in one-third of obese women (n=68). The aim of this review was to examine the interplay between maternal obesity and GDM in light of the HAPO study and the subsequent revised diagnostic criteria. Obesity and GDM are important obstetric risk factors because they both are potentially modifiable. However, the new international criteria for the diagnosis of GDM have serious resource implications for maternity services provided to the large number of women attending for care in developed countries. Further consideration needs to be given as to whether obese women with mild hyperglycemia need to be referred to a multidisciplinary team antenatally if they do not require insulin treatment.

The Prevention of Gestational Diabetes Mellitus With Antenatal Oral Inositol Supplementation: A Randomized Controlled Trial.

OBJECTIVE: This study investigated if inositol in a combination of myo-inositol and D-chiro-inositol would prevent gestational diabetes mellitus (GDM) in women with a family history of diabetes. RESEARCH DESIGN AND METHODS: This was a randomized controlled trial that examined whether inositol from the first antenatal visit prevents GDM. The trial was carried out in a single-center tertiary referral center. Women with a family history of diabetes were enrolled at the first antenatal visit. They were randomized to the intervention group, which received a combination of 1,100 mg myo-inositol, 27.6 mg D-chiro-inositol, and 400 µg folic acid, or to the control group, which received 400 µg folic acid only. All women had an oral glucose tolerance test between 24 and 28 weeks' gestation. The primary end point was the incidence of GDM. Statistical analysis was carried out using SPSS Statistical Package version 20. RESULTS: Two hundred forty women, 120 in each arm, were recruited between January 2014 and July 2015. There were no differences in characteristics between the groups. The incidence of GDM was 23.3% (n = 28) in the intervention group compared with 18.3% (n = 22) in the control group (P = 0.34). The mean fasting plasma glucose at the glucose tolerance test was 81 mg/dL in both groups. CONCLUSIONS: Commencing an inositol combination in early pregnancy did not prevent GDM in women with a family history of diabetes. Further studies are required to examine whether inositol supplements at varying doses may prevent GDM.

A Medically Supervised Pregnancy Exercise Intervention in Obese Women: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether an intensive, medically supervised exercise intervention improved maternal glycemia and gestational weight gain in obese pregnant women when compared with routine prenatal care. METHODS: This randomized controlled trial compared a medically supervised exercise intervention with routine prenatal care. The primary outcome was a reduction in mean maternal fasting plasma glucose in the intervention group by 6.9 mg/dL at the time of a 75-g oral glucose tolerance test at 24-28 weeks of gestation. Secondary outcomes included excessive gestational weight gain. The intervention consisted of 50-60 minutes of exercise: warm-up, resistance or weights, aerobic exercises, and cool-down. All women received routine prenatal care. Power calculation determined that 24 women were required per group to detect a difference of 6.9 mg/dL in fasting plasma glucose between groups based on an independent-sample t test for statistical power of 80% at a type I error rate of 0.05. A sample size of 44 per group was planned to allow a dropout rate of 33%. RESULTS: From November 2013 through August 2015, 88 women were randomized: 44 each to the exercise and control groups. Eight women in the control group and 11 in the intervention group did not complete the trial at 6 weeks postpartum (P=.61), but 43 in each group attended the 24- to 28-week glucose screen. There were no baseline maternal differences between groups. Classes commenced at a mean of 13 4/7±1 2/7 weeks of gestation. In early pregnancy, 51.1% (n=45/88) had an elevated fasting plasma glucose (92-125 mg/dL). There was no difference in the mean fasting plasma glucose at 24-28 weeks of gestation: 90.0±9.0 mg/dL (n=43) compared with 93.6±7.2 mg/dL (n=43) (P=.13) or in the incidence of gestational diabetes mellitus at 24-28 weeks of gestation: 48.8% (n=21/43) compared with 58.1% (n=25/43) (P=.51) in the control and exercise groups, respectively. At 36 weeks of gestation, excessive gestational weight gain greater than 9.1 kg was lower in the exercise group, 23.5% compared with 45.2% in the control group (P<.05). CONCLUSION: An intensive, medically supervised exercise intervention for obese women from early pregnancy did not improve maternal glycemia. Pregnant women who are obese, however, should be advised to exercise because it attenuates excessive gestational weight gain. CLINICAL TRIAL REGISTRATION: International Standard Randomised Controlled Trials (ISRCTN) registry, ISRCTN 31045925.

The clinical outcomes of unplanned pregnancy in severely obese women.

OBJECTIVE: The objective of this study was to compare the clinical outcomes of unplanned pregnancies among severely obese women with those of planned pregnancies. METHODS: This prospective cohort study included severely obese women (Body Mass Index [BMI] ≥ 40.0 kg/m(2)) who delivered a baby weighing ≥ 500 g over 5 years 2009-2013 in a large university hospital. Maternal weight and height were measured and BMI was calculated at the first prenatal visit. RESULTS: Of the 650 women, the mean BMI was 43.8 kg/m(2), mean age was 31.6 years, and 30.0% (n = 195) were nulliparous. Prenatal complications including gestational diabetes mellitus (GDM), hypertensive and thromboembolic disorders occurred in 56.6% (n = 368). Compared with planned pregnancies (58.2%, n = 378), those that were unplanned (41.8%, n = 272) were associated with increased prepregnancy risk factors including essential hypertension (4.0% versus 1.6%, p = 0.03) and depression (6.6% versus 3.2%, p = 0.03). Unplanned pregnancy was associated with a higher macrosomia rate (birthweight > 4.5 kg) compared with planned pregnancies (p = 0.03). This was not explained by a higher GDM rate in unplanned pregnancies. Compared with planned pregnancies, unplanned pregnancies were not associated with increased adverse fetomaternal outcomes. CONCLUSION: Despite increased prepregnancy risk factors, in severely obese women, unplanned pregnancies were not associated with increased prenatal complications or adverse pregnancy outcomes compared with planned pregnancies.

A prospective cohort study of the morbidity associated with operative vaginal deliveries performed by day and at night.

OBJECTIVE: To evaluate maternal and neonatal outcomes associated with operative vaginal deliveries (OVDs) performed by day and at night. DESIGN: Prospective cohort study. SETTING: Urban maternity unit in Ireland with off-site consultant staff at night. POPULATION: All nulliparous women requiring an OVD with a term singleton fetus in a cephalic presentation from February to November 2013. METHODS: Delivery outcomes were compared for women who delivered by day (08:00-19:59) or at night (20:00-07:59). MAIN OUTCOME MEASURES: The main outcomes included postpartum haemorrhage (PPH), anal sphincter tear and neonatal unit admission. Procedural factors included operator grade, sequential use of instruments and caesarean section. RESULTS: Of the 597 women who required an OVD, 296 (50%) delivered at night. Choice of instrument, place of delivery, sequential use of instruments and caesarean section did not differ significantly in relation to time of birth. Mid-grade operators performed less OVDs by day than at night, OR 0.60 (95% CI 0.43 to 0.83), and a consultant supervisor was more frequently present by day, OR 2.26 (95% CI 1.05 to 4.83). Shoulder dystocia occurred more commonly by day, OR 2.57 (95% CI 1.05 to 6.28). The incidence of PPH, anal sphincter tears, neonatal unit admission, fetal acidosis and neonatal trauma was similar by day and at night. The mean decision to delivery intervals were 12.0 and 12.6 min, respectively. CONCLUSIONS: There was no evidence of an association between time of OVD and adverse perinatal outcomes despite off-site consultant obstetric support at night.