Ashley N. Battarbee

Background/Objectives: Obesity and excessive gestational weight gain (EGWG) are known risk factors for adverse outcomes in pregnancy, but the comparative risk is less well defined and increasingly relevant in an era of increasing use of weight loss medications. We aimed to determine whether EGWG was associated with adverse maternal and neonatal outcomes, compared with prepregnancy obesity. Methods: Multicenter retrospective cohort study of pregnant patients who delivered a singleton within a single university health system from 2019–2024. Patients with missing prepregnancy body mass index (BMI) data, BMI < 18.5 kg/m², or pregestational diabetes were excluded. Logistic regression with propensity score weights and g-computation were used to evaluate if the incidence of several adverse maternal and neonatal outcomes were impacted by prepregnancy obesity and gestational weight gain (GWG). p values were adjusted for multiple comparisons. Results: Among the 129,615 pregnancies included, 28,516 (22.0%) had prepregnancy obesity, 36,943 (28.5%) were overweight prior to pregnancy, and 64,156 (49.5%) had a normal BMI prior to pregnancy. When compared to patients with obesity, patients with normal prepregnancy BMI and EGWG had a lower risk of adverse maternal and neonatal outcomes, including gestational diabetes, gestational hypertension, preeclampsia, eclampsia, cesarean delivery, and postpartum hemorrhage, as well as large and small for gestational age birthweight, stillbirth, neonatal intensive care unit admission, neonatal mechanical ventilation, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis. Beneficial effects were attenuated for patients with overweight prepregnancy BMI or for larger EGWG. Conclusions: Lower prepregnancy BMI, even with the potential unintended consequence of EGWG, may be more favorable than untreated prepregnancy obesity with regard to perinatal outcomes.

To assess the mechanisms by which intrauterine exposure to maternal obesity and/or gestational diabetes mellitus (GDM) contribute to offspring adiposity and dysmetabolism. Prospective cohort study at two U.S. centers that enrolled pregnant individuals carrying non-anomalous, singletons at 36 to 40 weeks who met criteria for three groups: (1) normal BMI without GDM, (2) obesity without GDM, and (3) GDM. We collected fasting maternal blood at enrollment; neonatal anthropometrics, air displacement plethysmography, and umbilical cord blood at delivery; and infant body composition at 3 months. Biomarkers and outcomes were compared between maternal exposure groups. Multivariable regression with backward selection identified predictors of offspring outcomes. Of 283 participants enrolled, 278 were included in the final analysis: 95 (34.2%) had normal BMI, 104 (37.4%) had obesity without GDM, and 79 (28.4%) had GDM. Maternal biomarkers differed between groups with highest HbA1c, insulin, glucose, triglycerides, and free fatty acids in GDM. Leptin, IL-6, and CRP were highest with obesity, and adiponectin was highest with normal BMI. Neonates born to participants with GDM had higher birthweight, head and abdominal circumferences, and higher C-peptide and leptin levels. No differences were observed between fat free mass, fat mass, percent fat or body mass. By 3 months, only head circumference remained different between groups. Maternal triglycerides was a predictor of multiple neonatal outcomes including birthweight, head and abdominal circumference and leptin. Marital status and delivery gestational age were also associated with multiple outcomes whereas maternal age, gestational weight gain, HbA1c, and cholesterol were only associated with one outcome. Chronic hypertension, income, and IL-6 were not associated with any outcomes. Maternal obesity and GDM are associated with neonatal overgrowth, and hypertriglyceridemia may be an important contributor. These findings underscore the importance of metabolic optimization (weight loss, glycemic control, lipid management) before conception to mitigate intergenerational transmission of obesity and metabolic disease.

Glucose monitoring is arguably one of the most important components of diabetes management in pregnancy. In this review, the application of continuous glucose monitoring (CGM) in managing diabetes during pregnancy is explored with a focus on gestational diabetes mellitus (GDM) and type 2 diabetes (T2D). It highlights the expanding applications of CGM technology, starting with evidence from the landmark CONCEPTT trial. The review examines normative CGM data in uncomplicated pregnancies and emphasizes the emerging evidence for CGM in GDM management. Finally, it addresses the limited but growing data on CGM in T2D pregnancies. Although CGM offers promising new opportunities to overcome the limitations of traditional SMBG testing, knowledge gaps persist. Further research is needed to determine how to effectively use this novel technology in pregnant patients with GDM and T2D to maximize maternal glycemic control and optimize pregnancy outcomes.

Among the most pressing topics in neonatal-perinatal medicine today is intensive care for infants born at ≤24 weeks’ gestation. Infants born at 22–24 weeks comprise ~1 in 500 live births, with ~7500 liveborn infants annually in the U.S.—more common than Down syndrome or critical congenital heart disease—and make up 1 in 5 U.S. infant deaths. Major uncertainties exist about clinical decisions, including regarding obstetric care, delivery room procedures, incubator management, nutrition, respiratory support, and the optimal developmental environment. Partnering with families, we can develop a sound basis for safe and effective medical care of pregnant women and infants affected by birth at ≤24 weeks.

Background: Early relational health (ERH) is thought to buffer the association between early life stress (ELS) and child psychopathology, but limited work has directly tested this hypothesis. Objective: We evaluate mother-infant emotional connection, a facet of ERH, as a buffer of combined and individual impacts of specific ELS exposures (maternal mental health and interpartner conflict) on child psychopathology. Methods: Participants included mother-infant dyads (n=100) followed longitudinally in the COMBO cohort, a convenience sample recruited during the COVID-19 pandemic. ERH was assessed via a remote mother-infant face-to-face interaction at ~4mo postpartum coded for emotional connection. An ELS Index was estimated using measures of maternal self-reported postpartum anxiety, depression, stress, and inter-partner conflict. Mothers rated emerging signs of child psychopathology symptoms at 2-3yrs on the Child Behavior Checklist for Ages 1½−5 (CBCL/1½−5). Main and interactive effects of ELS and ERH on emerging signs of child psychopathology were tested in generalized linear models. Results: Greater ELS Index scores were associated with a higher rate of emerging psychopathology symptoms (aRR=1.32, p<.001), but this association was moderated by a significant interaction between the ELS Index and emotional connection (aRR=0.99, p=.03), such that at higher levels of emotional connection, the association of ELS with child psychopathology symptoms was weaker (aRR=1.16, p <.001). Conclusion: Parent-infant emotional connection may buffer the impact of ELS exposure in infancy on child emerging symptoms of psychopathology in toddlerhood, supporting efforts to invest in pediatric interventions that target ERH.

The Society for Maternal–Fetal Medicine and American College of Obstetricians and Gynecologists recommend delivery of gravidae with pregestational diabetes at 36 to 396/7 weeks based on glycemic control and vascular complications. The optimal gestational age within this wide range is unknown. Our objective was to evaluate the risk of adverse outcomes with delivery versus expectant management at increasing gestational ages. Retrospective cohort study of gravidae with pregestational diabetes who delivered a nonanomalous singleton at ≥36 weeks (2012–2022). The primary outcome was composite neonatal morbidity: hypoglycemia, hyperbilirubinemia, shoulder dystocia, and perinatal death. Secondary outcomes included composite components, composite severe neonatal morbidity, large-for-gestational-age, small-for-gestational-age (SGA), NICU admission, and cesarean. Poisson regression with robust error variance estimated the association between delivery at 36, 37, and 38 weeks and outcomes, compared with expectant management. Eight hundred forty-three gravidae met inclusion criteria: 235 (28%) type 1 diabetes and 602 (71%) type 2 diabetes. Overall, 146 (17%) delivered at 36 weeks, 283 (34%) at 37 weeks, 217 (26%) at 38 weeks, and 197 (23%) at ≥39 weeks. Compared with expectant management, delivery at 36 weeks was associated with higher odds of composite morbidity (adjusted risk ratio: 1.31; 95% confidence interval: 1.11–1.55) as well as hypoglycemia, hyperbilirubinemia, SGA, and NICU admission. At 37 and 38 weeks, there was no significant difference in composite morbidity among those delivered versus expectantly managed. However, delivery at 37 weeks was associated with higher odds of hyperbilirubinemia, compared with expectant management. No other outcomes differed between delivery versus expectant management at 37 or 38 weeks. Few associations differed by diabetes type. Based on these results and supporting literature, elective delivery at 36 weeks should be avoided unless necessary. Although the data are inconclusive regarding delivery at 37 weeks, delivery at 38 weeks should be evaluated further for gravidae with pregestational diabetes. Confirmation in a large, contemporary cohort or a randomized trial is needed.