Rosalie M Grivell

Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial

Objective To determine the effect of antenatal dietary and lifestyle interventions on health outcomes in overweight and obese pregnant women. Design Multicentre randomised trial. We utilised a central telephone randomisation server, with computer generated schedule, balanced variable blocks, and stratification for parity, body mass index (BMI) category, and hospital. Setting Three public maternity hospitals across South Australia. Participants 2212 women with a singleton pregnancy, between 10+0 and 20+0 weeks’ gestation, and BMI ≥25. Interventions 1108 women were randomised to a comprehensive dietary and lifestyle intervention delivered by research staff; 1104 were randomised to standard care and received pregnancy care according to local guidelines, which did not include such information. Main outcome measures Incidence of infants born large for gestational age (birth weight ≥90th centile for gestation and sex). Prespecified secondary outcomes included birth weight >4000 g, hypertension, pre-eclampsia, and gestational diabetes. Analyses used intention to treat principles. Results 2152 women and 2142 liveborn infants were included in the analyses. The risk of the infant being large for gestational age was not significantly different in the two groups (lifestyle advice 203/1075 (19%) v standard care 224/1067 (21%); adjusted relative risk 0.90, 95% confidence interval 0.77 to 1.07; P=0.24). Infants born to women after lifestyle advice were significantly less likely to have birth weight above 4000 g (lifestyle advice 164/1075 (15%) v standard care 201/1067 (19%); 0.82, 0.68 to 0.99; number needed to treat (NNT) 28, 15 to 263; P=0.04). There were no differences in maternal pregnancy and birth outcomes between the two treatment groups. Conclusions For women who were overweight or obese, the antenatal lifestyle advice used in this study did not reduce the risk delivering a baby weighing above the 90th centile for gestational age and sex or improve maternal pregnancy and birth outcomes. Trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials.

Please cite this paper as: Dodd J, Grivell R, Crowther C, Robinson J. Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials. BJOG 2010;117:1316–1326.

Maternal and perinatal health outcomes by body mass index category

Aims:  To determine the effect of increasing maternal body mass index (BMI) during pregnancy on maternal and infant health outcomes.

Uterine arteriovenous malformations : A review of the current literature

Uterine arteriovenous malformation (AVM) is a rare but potentially life-threatening condition. AVMs often present with intractable bleeding and commonly are seen in association with pregnancy and uterine trauma. Ultrasound is the most common form of initial investigation, and computed tomography and magnetic resonance imaging are being used with greater frequency. Despite this, angiography remains the gold standard for diagnostic evaluation. Embolization has become a more acceptable form of treatment and allows more invasive forms of treatment, particularly hysterectomy, to be avoided. Numerous medical therapies have also been used in the management of patients with uterine AVM. Reports of successful pregnancies after diagnosis and treatment of a uterine AVM are still uncommon, but increasingly good outcomes are being reported after successful treatment of a confirmed uterine AVM. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe the many and varied clinical manifestations of a uterine arteriovenous malformation (AVM), summarize the best ways to manage an acute hemorrhage from an AVM, and identify the current best way to diagnose an AVM.

The effects of antenatal dietary and lifestyle advice for women who are overweight or obese on maternal diet and physical activity: the LIMIT randomised trial

BackgroundOverweight and obesity is a significant health concern during pregnancy. Our aim was to investigate the effect of providing antenatal dietary and lifestyle advice to women who are overweight or obese on components of maternal diet and physical activity.MethodsWe conducted a randomised controlled trial, in which pregnant women with a body mass index ≥25 kg/m2, and singleton gestation between 10+0 to 20+0 weeks were recruited and randomised to Lifestyle Advice (involving a comprehensive dietary and lifestyle intervention over their pregnancy) or Standard Care. Within the intervention group, we conducted a nested randomised trial in which a subgroup of women were further randomised to receive access to supervised group walking sessions in addition to the standard information presented during the intervention contacts (the Walking group) or standard information only.The outcome measures were maternal dietary intake, (including food groups, macronutrient and micronutrient intake, diet quality (using the Healthy Eating Index; HEI), dietary glycaemic load, and glycaemic index) and maternal physical activity. Women completed the Harvard Semi-Structured Food Frequency Questionnaire, and the Short Questionnaire to Assess Health-enhancing Physical Activity (SQUASH), at trial entry, 28 and 36 weeks’ gestational age, and 4 months postpartum.Analyses were performed on an intention-to-treat basis, using linear mixed effects models with adjustment for the stratification variables.ResultsWomen randomised to Lifestyle Advice demonstrated a statistically significant increase in the number of servings of fruit and vegetables consumed per day, as well as increased consumption of fibre, and reduced percentage energy intake from saturated fats (P < 0.05 for all). Maternal HEI was significantly improved at both 28 (73.35 ± 6.62 versus 71.86 ± 7.01; adjusted difference in means 1.58; 95% CI 0.89 to 2.27; P < 0.0001) and 36 (72.95 ± 6.82 versus 71.17 ± 7.69; adjusted difference in means 1.77; 95% CI 1.01 to 2.53; P < 0.0001) weeks. There were no differences in dietary glycaemic index or glycaemic load. Women randomised to Lifestyle Advice also demonstrated greater total physical activity (adjusted difference in means 359.76 metabolic equivalent task units (MET) minutes/week; 95% CI 74.87 to 644.65; P = 0.01) compared with women receiving Standard Care. The supervised walking group was poorly utilised.ConclusionsFor women who are overweight or obese, antenatal lifestyle advice improves maternal diet and physical activity during pregnancy.Please see related articles: http://www.biomedcentral.com/1741-7015/12/163 and http://www.biomedcentral.com/1741-7015/12/201.Trial registrationAustralian and New Zealand Clinical Trials Registry (http://ACTRN12607000161426)

Antenatal exercise to improve outcomes in overweight or obese women: A systematic review

Background. Women who are overweight or obese during pregnancy are at increased risk of a number of adverse pregnancy outcomes. Objective. To review the literature systematically to assess the benefits and harms of an exercise intervention for pregnant women who are overweight or obese. Search strategy. A literature search of PUBMED, SCOPUS, the Cochrane Controlled Trials Register (CENTRAL) and the Australian and International Clinical Trials Registers was performed, as well as an additional hand search through bibliographies of various publications. There were no date or language restrictions. Selection criteria. Studies included were randomized controlled trials comparing supervised antenatal exercise intervention with routine standard antenatal care in women who were overweight or obese during pregnancy. The primary outcome was maternal gestational weight gain. The quality of each study was assessed utilizing standard Cochrane systematic review methodology. Data collection and analysis. Six randomized controlled trials and one quasi‐randomized trial were identified and included, involving a total of 276 women who were overweight or obese during pregnancy. Results. Provision of a supervised antenatal exercise intervention was associated with lower gestational weight gain (five trials, 216 participants, mean difference of −0.36 kg, 95% confidence interval −0.64 to −0.09 kg) when compared with standard antenatal care. Conclusions. A monitored physical activity intervention appears to be successful in limiting gestational weight gain; however, the effect on maternal and infant health is less certain.

Pregnancy outcomes for nulliparous women of advanced maternal age in South Australia, 1998–2008

Child bearing in the later reproductive years has become increasingly common in Australia with potential implications for clinical practice.

The effects of antenatal dietary and lifestyle advice for women who are overweight or obese on neonatal health outcomes: the LIMIT randomised trial

BackgroundOverweight and obesity during pregnancy represents a considerable health burden. While research has focused on interventions to limit gestational weight gain, there is little information describing their impact on neonatal health. Our aim was to investigate the effect on a range of pre-specified secondary neonatal outcomes of providing antenatal dietary and lifestyle advice to women who are overweight or obese.MethodsWe report a range of pre-specified secondary neonatal outcomes from a large randomised trial in which antenatal dietary and lifestyle advice was provided to women who were overweight or obese. Pregnant women were eligible for participation with a body mass index of 25 kg/m2 or over, and singleton gestation between 10+0 and 20+0 weeks. Outcome measures included gestational age at birth; Apgar score below 7 at 5 minutes of age; need for resuscitation at birth; birth weight above 4.5 kg or below 2.5 kg; birth weight, length and head circumference (and Z-scores); admission to the nursery; respiratory distress syndrome; and postnatal length of stay. Data relating to the primary outcome (large for gestational age infants defined as birth weight above the 90th centile) and birth weight above 4 kg have been reported previously. Analyses used intention-to-treat principles.ResultsIn total, 2,142 infants were included in the analyses. Infants born to women following lifestyle advice were significantly less likely to have birth weight above 4.5 kg (2.15% versus 3.69%; adjusted risk ratio (aRR) = 0.59; 95% confidence interval (CI) 0.36 to 0.98; P = 0.04), or respiratory distress syndrome (1.22% versus 2.57%; aRR = 0.47; 95% CI 0.24 to 0.90; P = 0.02), particularly moderate or severe disease, and had a shorter length of postnatal hospital stay (3.94 ± 7.26 days versus 4.41 ± 9.87 days; adjusted ratio of means 0.89; 95% CI 0.82 to 0.97; P = 0.006) compared with infants born to women who received Standard Care.ConclusionsFor women who are overweight or obese, antenatal dietary and lifestyle advice has health benefits for infants, without an increase in the risk of harm. Continued follow-up into childhood will be important to assess the longer-term effects of a reduction in high infant birth weight on risk of child obesity.Please see related articles: http://www.biomedcentral.com/1741-7015/12/161 and http://www.biomedcentral.com/1741-7015/12/201.Clinical trial registrationAustralian and New Zealand Clinical Trials Registry (http://ACTRN12607000161426)

Maternal and neonatal outcomes following induction of labor: a cohort study

Objective. To evaluate maternal and neonatal outcomes associated with birth at term by week of gestational age and also by onset of labor. Design. Cohort study. Setting. A state‐wide perinatal outcome database. Population. 28 626 women with spontaneous onset of labor, induction of labor for recognized indications and induction of labor for non‐recognized indications. Methods. Cohort study utilizing a validated dataset comparing outcomes with type of onset of labor using a log binomial model. Main outcome measures. Cesarean section, assisted vaginal birth, important measures of maternal and neonatal morbidity. Results. Induction of labor for non‐recognized indications was associated with a significantly increased risk of a range of outcomes, including cesarean section (RR 1.67, 95%CI 1.55–1.80). The lowest risk of adverse maternal and infant outcome occurred with birth between 38 and 39 weeks and with the spontaneous onset of labor. Conclusions. Induction of labor for non‐recognized indications at term is associated with an increased risk of adverse outcomes. Caution is warranted with a liberal policy of induction of labor at term in an otherwise uncomplicated pregnancy.

The role of L-arginine in the prevention and treatment of pre-eclampsia: a systematic review of randomised trials

Pre-eclampsia is a significant health issue in pregnancy, complicating between 2–8% of pregnancies. L-arginine is an important mediator of vasodilation with a potential preventative role in pregnancy related hypertensive diseases. We aimed to systematically review randomised trials in the literature assessing the role of L-arginine in prevention and treatment of pre-eclampsia. We searched the Cochrane Controlled Trials Register, PUBMED, and the Australian and International Clinical Trials Registry, to identify randomised trials involving pregnant women where L-arginine was administered for pre-eclampsia to improve maternal and infant health outcomes. We identified eight randomised trials, seven of which were included. The methodological quality was fair, with a combined sample size of 884 women. For women at risk of pre-eclampsia, L-arginine was associated with a reduction in pre-eclampsia (RR: 0.34, 95% CI: 0.21–0.55), when compared with placebo and a reduction in risk of preterm birth (RR: 0.48 and 95% CI: 0.28 to 0.81). For women with established hypertensive disease, L-arginine was associated with a reduction in pre-eclampsia (RR: 0.21; 95% CI: 0.05–0.98). L-arginine may have a role in the prevention and/or treatment of pre-eclampsia. Further well-designed and adequately powered trials are warranted, both in women at risk of pre-eclampsia and in women with established disease.