Eugene Oteng-Ntim

Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis.

BackgroundOverweight and obesity pose a big challenge to pregnancy as they are associated with adverse maternal and perinatal outcome. Evidence of lifestyle intervention resulting in improved pregnancy outcome is conflicting. Hence the objective of this study is to determine the efficacy of antenatal dietary, activity, behaviour or lifestyle interventions in overweight and obese pregnant women to improve maternal and perinatal outcomes.MethodsA systematic review and meta-analyses of randomised and non-randomised clinical trials following prior registration (CRD420111122 http://www.crd.york.ac.uk/PROSPERO) and PRISMA guidelines was employed. A search of the Cochrane Library, EMBASE, MEDLINE, CINAHL, Maternity and Infant care and eight other databases for studies published prior to January 2012 was undertaken. Electronic literature searches, study selection, methodology and quality appraisal were performed independently by two authors. Methodological quality of the studies was assessed according to Cochrane risk of bias tool. All appropriate randomised and non-randomised clinical trials were included while exclusions consisted of interventions in pregnant women who were not overweight or obese, had pre-existing diabetes or polycystic ovarian syndrome, and systematic reviews. Maternal outcome measures, including maternal gestational weight gain, gestational diabetes and Caesarean section, were documented. Fetal outcomes, including large for gestational age and macrosomia (birth weight > 4 kg), were also documented.ResultsThirteen randomised and six non-randomised clinical trials were identified and included in the meta-analysis. The evidence suggests antenatal dietary and lifestyle intervention in obese pregnant women reduces maternal pregnancy weight gain (10 randomised clinical trials; n = 1228; -2.21 kg (95% confidence interval -2.86 kg to -1.59 kg)) and a trend towards a reduction in the prevalence of gestational diabetes (six randomised clinical trials; n = 1,011; odds ratio 0.80 (95% confidence interval 0.58 to 1.10)). There were no clear differences reported for other outcomes such as Caesarean delivery, large for gestational age, birth weight or macrosomia. All available studies were assessed to be of low to medium quality.ConclusionAntenatal lifestyle intervention is associated with restricted gestational weight gain and a trend towards a reduced prevalence of gestational diabetes in the overweight and obese population. These findings need to be interpreted with caution as the available studies were of poor to medium quality.

Effect of body mass index on IVF treatment outcome: an updated systematic review and meta-analysis

There is conflicting evidence regarding the effect of raised body mass index (BMI) on the outcome of assisted reproductive technology. In particular, there is insufficient evidence to describe the effect of BMI on live birth rates. We carried out a systematic review and meta-analysis of studies to evaluate the effect of raised BMI on treatment outcome following IVF/ICSI treatment. Subgroup analysis on overweight and obese patients was performed. Literature searches were conducted on MEDLINE, EMBASE and the Web of Science from 1966 to 2010. Thirty-three studies including 47,967 treatment cycles were included. Results indicated that women who were overweight or obese (BMI ≥ 25) had significantly lower clinical pregnancy (RR=0.90, P<0.0001) and live birth rates (RR=0.84, P=0.0002) and significantly higher miscarriage rate (RR=1.31, P < 0.0001) compared to women with a BMI < 25 following treatment. A subgroup analysis of overweight women (BMI ≥ 25-29.9) revealed lower clinical pregnancy (RR=0.91, P=0.0003) and live birth rates (RR=0.91, P=0.01) and higher miscarriage rate (RR=1.24, P < 0.00001) compared to women with normal weight (BMI < 25). In conclusion, raised BMI is associated with adverse pregnancy outcome in women undergoing IVF/ICSI treatment, including lower live birth rates. This effect is present in overweight as well as obese women.

Development and validation of a measure of health literacy in the UK: the newest vital sign

BackgroundHealth literacy (HL) is an important public health issue. Current measures have drawbacks in length and/or acceptability. The US-developed Newest Vital Sign (NVS) health literacy instrument measures both reading comprehension and numeracy skills using a nutrition label, takes 3 minutes to administer, and has proven to be acceptable to research subjects. This study aimed to amend and validate it for the UK population.MethodsWe used a three-stage process; (1) a Delphi study with academic and clinical experts to amend the NVS label to reflect UK nutrition labeling (2) community-based cognitive testing to assess and improve ease of understanding and acceptability of the test (3) validation of the NVS-UK against an accepted standard test of health literacy, the Test of Functional Health Literacy in Adults (TOFHLA) (Pearson’s r and the area under the Receiver Operating Characteristic (ROC) curve) and participant educational level. A sample size calculation indicated that 250 participants would be required. Inclusion criteria were age 18–75 years and ability to converse in English. We excluded people working in the health field and those with impaired vision or inability to undertake the interview due to cognitive impairment or inability to converse in English.ResultsIn the Delphi study, 28 experts reached consensus (3 cycles). Cognitive testing (80 participants) yielded an instrument that needed no further refinement. Validation testing (337 participants) showed high internal consistency (Cronbach’s Alpha = 0.74). Validation against the TOFHLA demonstrated a Pearson’s r of 0.49 and an area under the ROC curve of 0.81.ConclusionsThe NVS-UK is a valid measure of HL. Its acceptability and ease of application makes it an ideal tool for use in the UK. It has potential uses in public health research including epidemiological surveys and randomized controlled trials, and in enabling practitioners to tailor care to patient need.

Adverse maternal and perinatal outcomes in pregnant women with sickle cell disease: systematic review and meta-analysis.

A systematic review and meta-analysis of observational studies were conducted to quantify the association between sickle cell disease in pregnancy and adverse maternal and perinatal outcomes. Data sources (Medline, Embase, Maternity and Infant care, Cochrane, Web of Science, Popline) were searched for publications to June 2014. Eligibility criteria included observational studies reporting maternal and perinatal health outcomes in pregnant women with sickle cell disease against a comparative group of pregnant women without sickle cell disease. Twenty-one studies (including 26,349 women with sickle cell disease; 26,151,746 women without sickle cell disease) were eligible for inclusion. Pregnancies in women with HbSS genotype, compared with women without sickle cell disease, were at increased risk of maternal mortality (relative risk [RR], 5.98; 95% confidence interval [CI], 1.94-18.44), preeclampsia (RR, 2.43; 95% CI, 1.75-3.39), stillbirth (RR, 3.94; 95% CI, 2.60-5.96), preterm delivery (RR, 2.21; 95% CI, 1.47-3.31), and small for gestational age infants (RR, 3.72; 95% CI, 2.32-5.98). Meta-regression demonstrated that genotype (HbSS vs HbSC), low gross national income, and high study quality were associated with increased RRs. Despite advances in the management of sickle cell disease, obstetrics, and neonatal medicine, pregnancies complicated by the disease remain associated with increased risk of adverse maternal and perinatal outcomes.

The obstetric management of sickle cell disease.

Sickle cell disease (SCD) is the most common inherited disease worldwide and is associated with anaemia and intermittent severe pain. Pregnant women who are affected have increased maternal and fetal mortality and morbidity. In view of this obstetricians should have an awareness of this condition and its complications, and pregnancies in women with SCD should be managed by a multidisciplinary team with experience of high risk pregnancies. Ideally women should be seen preconceptually for optimisation of their SCD and partner screening. Antenatal care should include regular outpatient visits with regular monitoring for pre-eclampsia and of fetal growth. Blood transfusion should be used for the treatment of acute anaemia, acute chest syndrome or acute stroke but there is not sufficient evidence currently to recommend its use prophylactically. There is an increased prevalence of sickle crisis during pregnancy and patients should be monitored carefully throughout this time.

Impact of obesity on pregnancy outcome in different ethnic groups: calculating population attributable fractions.

Objectives To quantify the proportion of adverse pregnancy outcome attributable to maternal obesity. Design Cross sectional analysis of routine obstetric dataset. Setting Guy’s and St Thomas’s NHS Foundation Trust (GSTFT). Population 23,668 women who had singleton deliveries at GSTFT between 2004 and 2008. Methods Logistic regression was used to estimate the association between BMI and outcome in different ethnic groups. Adjusted odds ratios, and the proportions of obese women, were used to calculate population attributable risk fractions (PAFs). Main Outcome Measures (i) Maternal outcomes: diabetes, type of delivery, post-partum haemorrhage, and preterm delivery. (ii) Perinatal outcomes: macrosomia, low birth weight, admission to neonatal intensive care/special care baby unit, and perinatal death. Results The prevalence of maternal obesity was 14%. Increasing BMI was independently associated with increasing risk of adverse obstetric and neonatal outcome. At the individual level, the effect of obesity on diabetes was highest in Asian women compared to white women (p for interaction = 0.03). Calculation of population attributable risk fractions demonstrated that one third of diabetes cases and one in six Caesarean sections could be avoided in this population if all obese women were of normal BMI. At the population level, the contribution of obesity to diabetes was highest for Black women (42%), and lowest for oriental women (8%). Seven percent of neonatal macrosomia in all the population, and 13% in Black mothers, were attributable to obesity. Conclusions Preventing obesity prior to pregnancy will substantially reduce the burden of obstetric and neonatal morbidity in this population. This reduction will be higher in Black women.

Pregnancy outcome in patients with sickle cell disease in the UK – a national cohort study comparing sickle cell anaemia (HbSS) with HbSC disease

We describe the findings from a national study of maternal and fetal outcomes of pregnancy in women with sickle cell disease (SCD). Data were collected via the United Kingdom Obstetric Surveillance System between 1 February 2010 and 31 January 2011 from 109 women, of whom 51 (46·8%) had HbSS and 44 (40·4%) had HbSC. Data included antenatal, maternal and fetal outcomes. Comparisons were made between women with HbSS and HbSC. Incidence of complications were acute pain (57%), blood transfusion (26%), urinary tract infection (UTI; 12%) and critical care unit admission (23%) and these were all more common in women with HbSS than HbSC. There was no difference in the incidence of acute chest syndrome, hypertension and venous thromboembolism between HbSS and HbSC. Women with HbSS were more likely to deliver at <37 weeks gestation (P = 0·01) and their babies were more likely to have reduced birth weight. Delivery at <34 weeks was increased in both HbSS and HbSC women (5·9% vs. 4·6%) compared to national data. This study confirms a high rate of maternal and fetal complications in mothers with SCD, even in women with HbSC, which has previously been considered to have a more benign phenotype in pregnancy.

Influence of BMI on risk of miscarriage after single blastocyst transfer

BACKGROUND Debate exists regarding the effect of raised BMI on the outcome of pregnancies after assisted reproduction technology. We assessed the effect of BMI on the risk of miscarriage in women conceiving following single blastocyst transfer (SBT) after controlling for confounding factors. METHODS Fresh and cryo-thawed cycles of SBT that resulted in a pregnancy between January 2006 and March 2010 were included. Patients with BMI < 18.5 kg/m(2) or older than 40 years were excluded. Patients were grouped according to their BMI at the start of treatment cycle. The main outcome measure was the miscarriage rate before 23 weeks gestation. Confounding variables examined included female age, duration and cause of infertility, previous miscarriage, smoking status and quality of blastocyst replaced. RESULTS A total of 413 women conceived following SBT in fresh (n = 325) or cryo-thawed (n = 88) IVF cycles, of whom 244 had a normal BMI (18.5-24.9) and 169 had a raised BMI of ≥ 25. Overall, 27% (113/413) of women miscarried before 23 weeks gestation. Women with a BMI of ≥ 25 had more than double the risk of miscarriage compared with women who had normal BMI [38 versus 20%, odds ratio (OR): 2.4, 95% confidence interval (CI) 1.6-3.8, P < 0.001, respectively]. After adjusting for confounding variables, having a BMI of ≥ 25 significantly increased the risk of clinical miscarriage before 23 weeks gestation in both fresh (adjusted OR = 2.7, 95% CI 1.5-4.9, P = 0.001) and cryo-thawed IVF cycles (OR = 6.8, 95% CI 1.5-31.1, P = 0.012). CONCLUSIONS Raised BMI is independently associated with higher miscarriage rate after IVF treatment.

Obstetric anal sphincter injury

#### Summary points Anal sphincter injury during childbirth is a leading cause of anal incontinence. In a study of more than 20 000 consecutive vaginal deliveries, clinically diagnosed obstetric anal sphincter injury occurred in 2.9% of primiparous women and 0.8% of multiparous ones.1 Of women who have sustained such an injury, 60-80% are asymptomatic at 12 months, of whom most report incontinence of flatus only, rather than faeces.2 w1 w2 Establishing a correct diagnosis at time of injury will facilitate adequate repair and may prevent future incontinence.3 In one epidemiological study, only a third of people with faecal incontinence had ever discussed the problem with a doctor because of embarrassment or fear of stigma.4 This review outlines the determinants, diagnosis, and management of obstetric anal sphincter injury. Women affected by obstetric anal sphincter injury require acute management at the time of delivery, together with follow-up or referral when newly presenting with symptoms months or years after childbirth. This review is relevant to all who provide care during childbirth and to doctors and healthcare professionals to whom women may subsequently present. #### Sources and selection criteria We searched Medline and PubMed from 1980 to 2009, focusing on evidence based publications on obstetric anal sphincter injury and randomised trials for management of such injury. We supplemented these sources with selected systematic reviews and good …

Developing a community-based maternal obesity intervention: a qualitative study of service providers' views

Please cite this paper as: Oteng‐Ntim E, Pheasant H, Khazaezadeh N, Mohidden A, Bewley S, Wong J, Oke B. Developing a community‐based maternal obesity intervention: a qualitative study of service providers’ views. BJOG 2010;117:1651–1655.