Skin and subcutaneous fascia closure at caesarean section to reduce wound complications: the closure randomised trial

Background: Wound infection is a common complication following caesarean section. Factors influencing the risk of infection may include the suture material for skin closure, and closure of the subcutaneous fascia. We assessed the effect of skin closure with absorbable versus non-absorbable suture, and closure versus non-closure of the subcutaneous fascia on risk of wound infection following Caesarean section. Methods: Women undergoing caesarean birth at an Adelaide maternity hospital were eligible for recruitment to a randomised trial using a 2 × 2 factorial design. Women were randomised to either closure or non-closure of the subcutaneous fascia and to subcuticular skin closure with an absorbable or non-absorbable suture. Participants were randomised to each of the two interventions into one of 4 possible groups: Group 1 - non-absorbable skin suture and non-closure of the subcutaneous fascia; Group 2 - absorbable skin suture and non-closure of the subcutaneous fascia; Group 3 - non-absorbable skin suture and closure of the subcutaneous fascia; and Group 4 - absorbable skin suture and closure of the subcutaneous fascia. The primary outcomes were reported wound infection and wound haematoma or seroma within the first 30 days after birth. Results: A total of 851 women were recruited and randomised, with 849 women included in the analyses (Group 1: 216 women; Group 2: 212 women; Group 3: 212 women; Group 4: 211 women). In women who underwent fascia closure, there was a statistically significant increase in risk of wound infection within 30 days post-operatively for those who had skin closure with an absorbable suture (Group 4), compared with women who had skin closure with a non-absorbable suture (Group 3) (adjusted RR 2.17; 95% CI 1.05, 4.45; p = 0.035). There was no significant difference in risk of wound infection for absorbable vs non-absorbable sutures in women who did not undergo fascia closure. Conclusion: The combination of subcutaneous fascia closure and skin closure with an absorbable suture may be associated with an increased risk of reported wound infection after caesarean section.Amanda J. Poprzeczny, Rosalie M. Grivell, Jennie Louise, Andrea R. Deussen and Jodie M. Dod

Effect of metformin in addition to an antenatal diet and lifestyle intervention on fetal growth and adiposity: the GRoW randomised trial

Background: The infants born to women who are overweight or obese in pregnancy are at an increased risk of being born macrosomic or large for gestational age. Antenatal dietary and lifestyle interventions have been shown to be ineffective at reducing this risk. Our aim was to examine the effects of metformin in addition to a diet and lifestyle intervention on fetal growth and adiposity among women with a BMI above the healthy range. Methods: Women who had a body mass index ≥25 kg/m² in early pregnancy, and a singleton gestation, were enrolled in the GRoW trial from three public maternity hospitals in metropolitan Adelaide. Women were invited to have a research ultrasounds at 28 and 36 weeks' gestation at which ultrasound measures of fetal biometry and adiposity were obtained. Fetal biometry z-scores and trajectories were calculated. Measurements and calculations were compared between treatment groups. This secondary analysis was pre-specified. Results: Ultrasound data from 511 women were included in this analysis. The difference in femur length at 36 weeks' gestation was (0.07 cm, 95% CI 0.01-0.14 cm, p = 0.019) and this was was statistically significant, however the magnitude of effect was small. Differences between treatment groups for all other fetal biometry measures, z-scores, estimated fetal weight, and adiposity measures at 28 and 36 weeks' gestation were similar. Conclusions: The addition of metformin to dietary and lifestyle advice in pregnancy for overweight and obese women has no clinically relevant effect on ultrasound measures of fetal biometry or adiposity.Amanda J. Poprzeczny, Jennie Louise, Andrea R. Deussen and Jodie M. Dod

Standardising definitions for the pre-eclampsia core outcome set: A consensus development study

Objectives To develop consensus definitions for the core outcome set for pre-eclampsia. Study design Potential definitions for individual core outcomes were identified across four formal definition development initiatives, nine national and international guidelines, 12 Cochrane systematic reviews, and 79 randomised trials. Eighty-six definitions were entered into the consensus development meeting. Ten healthcare professionals and three researchers, including six participants who had experience of conducting research in low- and middle-income countries, participated in the consensus development process. The final core outcome set was approved by an international steering group. Results Consensus definitions were developed for all core outcomes. When considering stroke, pulmonary oedema, acute kidney injury, raised liver enzymes, low platelets, birth weight, and neonatal seizures, consensus definitions were developed specifically for low- and middle-income countries because of the limited availability of diagnostic interventions including computerised tomography, chest x-ray, laboratory tests, equipment, and electroencephalogram monitoring. Conclusions Consensus on measurements for the pre-eclampsia core outcome set will help to ensure consistency across future randomised trials and systematic reviews. Such standardization should make research evidence more accessible and facilitate the translation of research into clinical practice

Maternal Overweight and Obesity: Effect on Fetal Growth and Adiposity

Background: Maternal overweight and obesity are associated with well-documented maternal and infant risks, including high infant birth weight and delivery of an infant large for gestational age. However, less is known about the impact of maternal BMI on fetal growth and adiposity, and growth and adiposity trajectories. There is limited information regarding the effects of antenatal interventions to limit gestational weight gain on fetal growth and adiposity. Methods: This thesis examines the effect of maternal BMI on fetal growth and adiposity, antenatal contributors to fetal growth and adiposity, and the effect of antenatal interventions on fetal growth and adiposity using data from a set of three harmonised randomised trials conducted between June 2008 and April 2017. Women were invited to attend for a research ultrasound at 28 and 36 weeks of gestation, where fetal biometry and adiposity measures were obtained. The analyses reported in this thesis investigate: 1. The effect of maternal BMI, across the BMI spectrum, on fetal growth and adiposity; 2. Whether this effect is mediated by (diagnosed and treated) GDM; 3. How fetal growth and adiposity is altered among infants born LGA; and 4. The effect of antenatal interventions to limit gestational weight gain on fetal growth and adiposity. Results: The analyses reported in this thesis find that: 1. Maternal BMI exerts a strong, continuous positive effect on fetal growth and adiposity measures, from as early as 20 weeks’ gestation; 2. Among women who are overweight or obese, there is no evidence of a mediated effect by diagnosed and treated GDM; 3. Infants born LGA demonstrate larger fetal biometry and adiposity measures from as early as 20 weeks’ gestation; and 4. There is no evidence that the antenatal interventions investigated in this thesis are sufficient to alter fetal growth and adiposity. Conclusions: Overall, the findings presented in this thesis suggest fetal growth patterns are determined early in pregnancy, and any antenatal interventions to prevent the effects of maternal overweight and obesity on fetal growth will need to be commenced earlier in pregnancy, or prior to conception, to be effective in preventing the intergenerational inheritance of overweight and obesity.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 202

Implications of maternal obesity on fetal growth and the role of ultrasound

Introduction: Over fifty percent of women entering pregnancy are overweight or obese. This has a significant impact on short and long term maternal and infant health outcomes, and the intergenerational effects of obesity are now a major public health problem globally. Areas covered: There are two major pathways contributing to fetal growth. Glucose and insulin directly affect growth, while other substrates such as leptin, adiponectin and insulin-like growth factors indirectly influence growth through structural and morphological effects on the placenta, uteroplacental blood flow, and regulation of placental transporters. Advances in ultrasonography over the past decade have led to interest in the prediction of the fetus at risk of overgrowth and adiposity utilizing both standard ultrasound biometry and fetal body composition measurements. However, to date there is no consensus regarding the definition of fetal overgrowth, its reporting, and clinical management. Expert commentary: Maternal dietary intervention targeting the antenatal period appear to be too late to sufficiently affect fetal growth. The peri-conceptual period and early pregnancy are being evaluated to determine if the intergenerational effects of maternal obesity can be altered to improve newborn, infant and child health.Cecelia M O'brien, Amanda Poprzeczny, Jodie M Dod

The mediating effects of gestational diabetes on fetal growth and adiposity in women who are overweight and obese: secondary analysis of the LIMIT randomised trial

Published Online 14 June 2018Objective: To describe the mediating effect of maternal gestational diabetes on fetal biometry and adiposity measures among overweight or obese pregnant women. Design: Secondary analysis of the LIMIT randomised trial. Setting: Public hospitals, metropolitan Adelaide, South Australia. Population: Pregnant women with body mass index (BMI) ≥25 kg/m2 and singleton gestation. Methods: Fetal ultrasound measures at 36 weeks of gestation and baseline BMI from women randomised to the LIMIT trial Standard Care group (n = 912 women) were used to conduct causal mediation analyses using regression‐based methods. Main outcomes measures: Ultrasound measures of fetal biometry and adiposity at 36 weeks of gestation. Results: Increased maternal BMI was associated with increased measures of fetal head circumference [direct (unmediated) effect 0.18 (95% CI: 0.05–0.31), P = 0.005; total effect 0.17 (95% CI: 0.02–0.31), P = 0.018], abdominal circumference [direct effect 0.26 (95% CI: 0.11–0.41), P = 0.001; total effect 0.26 (95% CI: 0.11–0.42), P = 0.001] and estimated fetal weight [direct effect 0.22 (95% CI: 0.08–0.35), P = 0.002; total effect 0.22 (95% CI: 0.08–0.35), P = 0.002], with no evidence of mediation by treated gestational diabetes. There was no apparent association between maternal BMI and fetal adiposity measures, or mediation by treated gestational diabetes. Conclusions: We show an important association between increased maternal BMI and fetal growth, not mediated by treated gestational diabetes. There was no association between increased maternal BMI and fetal adiposity measures, or mediation by treated gestational diabetes. Whether these findings represent ‘saturation’ in the effect of maternal BMI on fetal growth or the effect of treatment of GDM is unclear.AJ Poprzeczny, J Louise, AR Deussen, JM Dod

Maternal overweight and obesity during pregnancy: strategies to improve outcomes for women, babies, and children

Published online: 29 Jun 2022Introduction: Women with overweight and obesity, and their children, are at increased risk of adverse pregnancy, birth, and longer term health outcomes, believed to be compounded by excessive gestational weight gain (GWG). Research to date has focused on interventions to reduce excessive GWG through changes to maternal diet and/or lifestyle. Areas covered: Current clinical recommendations for GWG vary according to a woman’s early pregnancy body mass index, based on assumptions that associations between GWG and adverse pregnancy outcomes are causal in nature, and modifiable. While there are small differences in GWG following pregnancy interventions, there is little evidence for clinically relevant effects on pregnancy, birth, and longer term childhood outcomes. This review considers interventional studies targeting women with overweight or obesity to reduce GWG in an effort to improve maternal and infant health, and the current evidence for interventions prior to conception. Expert opinion: GWG is not modifiable via diet and lifestyle change, and continued efforts to find the ‘right’ intervention for women with overweight and obesity during pregnancy are unjustified. Researchers should focus on gathering evidence for interventions prior to pregnancy to optimize maternal health and weight to improve pregnancy, birth, and longer term health outcomes associated with obesity.Jodie M. Dodda, Andrea R. Deussen, Megan Mitchell, Amanda J. Poprzeczny, and Jennie Louis