Jacqueline Boyle

Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis

Importance Body mass index (BMI) and gestational weight gain are increasing globally. In 2009, the Institute of Medicine (IOM) provided specific recommendations regarding the ideal gestational weight gain. However, the association between gestational weight gain consistent with theIOM guidelines and pregnancy outcomes is unclear. Objective To perform a systematic review, meta-analysis, and metaregression to evaluate associations between gestational weight gain above or below the IOM guidelines (gain of 12.5-18 kg for underweight women [BMI <18.5]; 11.5-16 kg for normal-weight women [BMI 18.5-24.9]; 7-11 kg for overweight women [BMI 25-29.9]; and 5-9 kg for obese women [BMI ≥30]) and maternal and infant outcomes. Data Sources and Study Selection Search of EMBASE, Evidence-Based Medicine Reviews, MEDLINE, and MEDLINE In-Process between January 1, 1999, and February 7, 2017, for observational studies stratified by prepregnancy BMI category and total gestational weight gain. Data Extraction and Synthesis Data were extracted by 2 independent reviewers. Odds ratios (ORs) and absolute risk differences (ARDs) per live birth were calculated using a random-effects model based on a subset of studies with available data. Main Outcomes and Measures Primary outcomes were small for gestational age (SGA), preterm birth, and large for gestational age (LGA). Secondary outcomes were macrosomia, cesarean delivery, and gestational diabetes mellitus. Results Of 5354 identified studies, 23 (n = 1 309 136 women) met inclusion criteria. Gestational weight gain was below or above guidelines in 23% and 47% of pregnancies, respectively. Gestational weight gain below the recommendations was associated with higher risk of SGA (OR, 1.53 [95% CI, 1.44-1.64]; ARD, 5% [95% CI, 4%-6%]) and preterm birth (OR, 1.70 [1.32-2.20]; ARD, 5% [3%-8%]) and lower risk of LGA (OR, 0.59 [0.55-0.64]; ARD, −2% [−10% to −6%]) and macrosomia (OR, 0.60 [0.52-0.68]; ARD, −2% [−3% to −1%]); cesarean delivery showed no significant difference (OR, 0.98 [0.96-1.02]; ARD, 0% [−2% to 1%]). Gestational weight gain above the recommendations was associated with lower risk of SGA (OR, 0.66 [0.63-0.69]; ARD, −3%; [−4% to −2%]) and preterm birth (OR, 0.77 [0.69-0.86]; ARD, −2% [−2% to −1%]) and higher risk of LGA (OR, 1.85 [1.76-1.95]; ARD, 4% [2%-5%]), macrosomia (OR, 1.95 [1.79-2.11]; ARD, 6% [4%-9%]), and cesarean delivery (OR, 1.30 [1.25-1.35]; ARD, 4% [3%-6%]). Gestational diabetes mellitus could not be evaluated because of the nature of available data. Conclusions and Relevance In this systematic review and meta-analysis of more than 1 million pregnant women, 47% had gestational weight gain greater than IOM recommendations and 23% had gestational weight gain less than IOM recommendations. Gestational weight gain greater than or less than guideline recommendations, compared with weight gain within recommended levels, was associated with higher risk of adverse maternal and infant outcomes.

Prevalence of polycystic ovary syndrome in a sample of Indigenous women in Darwin, Australia

Objective: To document the prevalence of polycystic ovary syndrome (PCOS) and its associated characteristics in a sample of urban Indigenous women.

Inflammatory and Other Biomarkers: Role in Pathophysiology and Prediction of Gestational Diabetes Mellitus.

Understanding pathophysiology and identifying mothers at risk of major pregnancy complications is vital to effective prevention and optimal management. However, in current antenatal care, understanding of pathophysiology of complications is limited. In gestational diabetes mellitus (GDM), risk prediction is mostly based on maternal history and clinical risk factors and may not optimally identify high risk pregnancies. Hence, universal screening is widely recommended. Here, we will explore the literature on GDM and biomarkers including inflammatory markers, adipokines, endothelial function and lipids to advance understanding of pathophysiology and explore risk prediction, with a goal to guide prevention and treatment of GDM.

Prevalence of Infertility and Use of Fertility Treatment in Women with Polycystic Ovary Syndrome: Data from a Large Community-Based Cohort Study

BACKGROUND Polycystic ovary syndrome (PCOS) affects 6%-21% of women. PCOS is the primary cause of anovulatory infertility, with major health and economic costs, yet we are unaware of any community-based, natural history studies on fertility and fertility treatments published to date. We aim to compare infertility, fertility treatment use, and relationship to body mass index (BMI) in women reporting PCOS to women not reporting PCOS in a community-based population. METHODS This is a cross-sectional analysis of a longitudinal cohort study, the Australian Longitudinal Study on Womens Health (ALSWH). For the ALSWH, women from the general community were randomly selected from the national public insurance database. Mailed survey data were collected at multiple time points. At survey 4, there were 9145 respondents aged 28-33 years. Of 8612 women with known PCOS status, 478 women reported having PCOS. Information regarding fertility status was available for 4856 women. This was the subgroup used in this analysis. The main outcomes measures are self-reported PCOS status, BMI, infertility, and use of fertility therapies including ovulation induction and in vitro fertilization (IVF). Logistic regression was used to examine factors associated with infertility and use of fertility treatment. RESULTS Self-reported PCOS prevalence was 5.8% (95% confidence interval [CI]: 5.3%-6.4%). Infertility was noted by 72% of 309 women reporting PCOS, compared with 16% of 4547 women not reporting PCOS (p<0.001). Infertility was 15-fold higher in women reporting PCOS (adjusted odds ratio 14.9, 95% CI 10.9-20.3), independent of BMI. Of women reporting infertility, there was greater use of fertility hormone treatment, (62%, n=116 vs. 33%, n=162, p<0.001) in women reporting PCOS; however, IVF use was similar. CONCLUSIONS In this community-based cohort of women, infertility and use of fertility hormone treatment was significantly higher in women reporting PCOS. Considering the prevalence of PCOS and the health and economic burden of infertility, strategies to optimize fertility are important.

Contraception use and pregnancy outcomes in women with polycystic ovary syndrome: data from the Australian Longitudinal Study on Women's Health

STUDY QUESTION Do contraception use, pregnancy outcome and number of children differ in women with and without polycystic ovary syndrome (PCOS)? SUMMARY ANSWER Women with PCOS were less likely to report use of contraception and more likely to report a miscarriage, whilst number of children was similar between groups. WHAT IS KNOWN ALREADY The oral contraceptive pill is used in the management of PCOS, but the patterns of contraception use in women with PCOS is not known. In women with PCOS who undergo assisted reproduction, the risk of pregnancy loss appears higher, yet pregnancy loss and family size among community-based women with PCOS is not known. STUDY DESIGN, SIZE AND DURATION This is a cross-sectional analysis of a longitudinal cohort study. Mailed survey data were collected at five time points (years 1996, 2000, 2003, 2006 and 2009). Data from respondents to Survey 4 (2006), aged 28-33 (n = 9145, 62% of the original cohort aged 18-23 years) were analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS This study was conducted in a general community setting. Data from participants who responded to the questions on PCOS, contraception and pregnancy outcome were analysed. The main outcome measures were self-reported PCOS, body mass index (BMI), contraception use, pregnancy loss and number of children. MAIN RESULTS AND THE ROLE OF CHANCE In women aged 28-33 years, women with PCOS were less likely to be using contraception (61 versus 79%, P < 0.001) and more likely to be trying to conceive (56 versus 45%, P < 0.001), compared with women not reporting PCOS. A greater proportion of women with PCOS reported pregnancy loss (20 versus 15%, P = 0.003). PCOS was not independently associated with pregnancy loss; however, BMI was independently associated with pregnancy loss in the overweight and obese groups (OR 1.2, 95% CI 1.04-1.4, P = 0.02 and OR 1.4, 95% CI 1.1-1.6, P = 0.001, respectively). Fertility treatment use was also independently associated with pregnancy loss (adjusted OR 3.2, 95% CI 2.4-4.2, P < 0.001). There was no significant difference in number of children between women with and without PCOS. LIMITATIONS, REASON FOR CAUTION PCOS, contraception use and pregnancy outcome data were self-reported. Attrition occurred, but is reasonable compared with similar longitudinal cohort studies. WIDER IMPLICATIONS OF THE FINDINGS This community-based cohort aged 28-33 years provides insights into the contraceptive use, pregnancy loss and family size of a large cohort of unselected women. Women reporting PCOS had lower rates of contraception use and were more likely to be currently trying to conceive, suggesting that they may be aware of potential fertility challenges, yet in those not planning to conceive, contraceptive use was low and further education may be required. Despite prior reports of higher rates of pregnancy loss in PCOS, usually from infertility services, in this community-based population, PCOS was not independently associated with pregnancy loss, yet independent risk factors for pregnancy loss included higher BMI, were higher in PCOS. The number of children per woman was similar in the both groups, albeit with more infertility treatment in PCOS. This may reassure women with PCOS that with access to fertility treatment, family sizes appear similar to women not reporting PCOS.

The Emerging Role of Chronic Low-Grade Inflammation in the Pathophysiology of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) has become increasingly common over recent years and is associated with reproductive features as well as cardiometabolic risk factors, including visceral obesity, dyslipidemia and impaired glucose homeostasis, and potentially cardiovascular disease. Emerging evidence suggests that these long-term metabolic effects are linked to a low-grade chronic inflammatory state with the triad of hyperinsulinemia, hyperandrogenism, and low-grade inflammation acting together in a vicious cycle in the pathophysiology of PCOS. Dysregulation of the sympathetic nervous system may also act as an important component, potentially creating a tetrad in the pathophysiology of PCOS. The aim of this review is to examine the role of chronic inflammation and the sympathetic nervous system in the development of obesity and PCOS and review potential therapeutic options to alleviate low-grade inflammation in this setting.

Women’s experiences of polycystic ovary syndrome diagnosis

BACKGROUND Polycystic ovary syndrome (PCOS) is a common and complex endocrine condition affecting women across the lifespan. Diagnosis experience may impact on physical and emotional well-being and engagement with evidence-based management and treatment. OBJECTIVE To explore the perceived experience of PCOS diagnosis, prior to development of an evidence-based guideline for PCOS assessment and management. METHODS Cross-sectional study, involving devised questionnaires completed by a national, community-based sample of 210 women with a previous medical diagnosis of PCOS, aged 18-45 years, in Australia. Main outcome measures included time to diagnosis, number of health professionals seen and information provision. RESULTS Mean age (± standard deviation) was 31 (±5.8) years and median body mass index (interquartile range) was 30 (12) kg/m(2). For 24% of women, PCOS diagnosis took >2 years and 39% saw three or more health professionals before diagnosis was made. The majority (60%) reported they were not given or referred to information sources at time of diagnosis, 20% reported receiving information and 20% were given information but felt it was inadequate. Of those who reported provision of information at diagnosis, 62% felt dissatisfied with or indifferent to information provided about PCOS, 79% reported being provided with information about lifestyle management, 89% reported being provided with information about medical therapy, 83% about long-term complications and 95% about potential infertility. CONCLUSIONS PCOS diagnosis experience can be lengthy, involve many health professionals and leave unmet information needs. The current findings inform the need for evidence-based PCOS resources for women and health professionals.

Risk stratification in early pregnancy for women at increased risk of gestational diabetes

AIM To evaluate the addition of fasting glucose and lipids to a simple, validated risk prediction tool for gestational diabetes (GDM) applied in early pregnancy. METHODS Women at risk of developing GDM on a validated risk prediction tool were recruited in early pregnancy into a large randomised controlled trial. Outcome measures included fasting biochemical markers (glucose, lipids) at 12-15 weeks gestation and GDM diagnosis (28 weeks gestation). Multivariable logistic regression was used to identify additional predictive biochemical variables for GDM, with corresponding receiver operator characteristic (ROC) curves generated. Unadjusted and adjusted models were derived for both the Australasian Diabetes in Pregnancy (ADIPS) and the International Association for Diabetes in Pregnancy Study Group (IADPSG) GDM diagnostic criteria. RESULTS 51 (23%) Women were diagnosed with GDM based on ADIPS criteria, with 60 (30%) diagnosed based on IADPSG criteria. In all four regression models, fasting glucose was the strongest predictor for GDM development with an odds ratio range of 4.7-6.3 (ADIPS) and 8.8-10 (IADPSG). ROC curves revealed an area under the curve of 0.79 (95% CI: 0.72-0.86) for ADIPS criteria and 0.83 (95% CI: 0.77-0.90) for IADPSG criteria for adjusted models. CONCLUSIONS In a two-step approach, when applied with a validated risk prediction tool, fasting glucose in early pregnancy was predictive of GDM and incrementally improved risk identification, presenting potential for an early pregnancy, GDM risk screening strategy for streamlining of pregnancy care and opportunity for preventive intervention.

Polycystic ovary syndrome: a common hormonal condition with major metabolic sequelae that physicians should know about.

Polycystic ovary syndrome (PCOS) is a prevalent, chronic and heterogeneous endocrine condition, with reproductive, metabolic and psychological features. Insulin resistance and hyperandrogenaemia are the key pathophysiological hormonal abnormalities. Insulin resistance is a significant contributor to the reproductive and metabolic complications of PCOS, both independently and in the setting of excess bodyweight. While the diagnostic criteria are now internationally uniformly accepted, individual components of the criteria are ill‐defined, making diagnosis challenging. This, along with low awareness of PCOS, has resulted in a significant proportion of women remaining undiagnosed. While reproductive features are best recognised in PCOS and form the basis of the diagnostic criteria, awareness of psychological and metabolic features, recommended screening protocols, and management strategies to prevent metabolic complications are important. In this review, we focus on diagnostic criteria, and reproductive, metabolic and psychological features of PCOS, as well as recommended screening and management strategies suggested by national and international evidence‐based guidelines.

Hypertension in Reproductive-Aged Women With Polycystic Ovary Syndrome and Association With Obesity.

BACKGROUND Polycystic ovary syndrome (PCOS) is a common disorder with metabolic complications, yet the prevalence of hypertension is unclear. We aim to assess hypertension prevalence and the impact of obesity in women reporting PCOS compared to those not reporting PCOS. METHODS This is a cross-sectional analysis of data from a large longitudinal study, the Australian Longitudinal Study on Womens Health (ALSWH). Women from the general community were randomly selected from the national health insurance database. Standardized data collection occurred at 6 survey time points. Data from Survey 4 in 2006 (n = 8,612, age: 28-33 years) were examined for this study. The main outcome measures studied were self-reported PCOS and hypertension. RESULTS Reported PCOS prevalence was 5.8% (95% confidence interval (CI): 5.3%-6.4%). Women with PCOS had higher body mass index (BMI). Hypertension prevalence was 5.5% (95% CI: 3.3-7.7) in women reporting PCOS and 2.0% (95% CI: 1.6-2.3) in women not reporting PCOS (P < 0.001). Hypertension was associated with BMI (odds ratio: 1.07, 95% CI: 1.05-1.10, P < 0.001) with a trend towards an association with PCOS (P = 0.09). On subgroup analysis, hypertension was not associated with BMI in women reporting PCOS but was associated in those not reporting PCOS. CONCLUSIONS In this large community-based cohort, we note increased prevalence of hypertension and higher BMI in young women reporting PCOS. BMI association with hypertension appeared clear in women not reporting PCOS. Yet in women with PCOS, hypertension appeared to not be associated with BMI, akin to observations on diabetes risk in PCOS, suggesting that metabolic abnormalities in PCOS may be independent of BMI.