1. Obesity and Hypertension in Pregnancy: Does it matter afterwards? Prof Leonie Callaway

2. Overview The landscape of obstetric medicine research at RBWH Metabolic issues in pregnancy Why weight matters in pregnancy and afterwards Why hypertension matters in pregnancy and afterwards

3. Why Obstetric Medicine? Major Changes in Pregnancy Care Increasing age of first time mothers Increasing BMI of pregnant women Increasing numbers of women who survive childhood illness and decide to have children Increasing numbers of women who proceed with pregnancy despite significant medical problems

4. Research focus Preconception Pregnancy Lifelong health

5. Research Themes Pre Pregnancy Preconception Care Interconception Care Pregnancy Prevention of Pregnancy Complications Pregnancy as a Metabolic Stress Test Long term health Neonatal body composition, metabolism and future health Long term maternal health

6. SPRING RCT CRICOS Provider No 00025B

7. A metabolic miracle

8. Metabolic Issues in Pregnancy 1.Pregnancy is a “Metabolic Stress Test” 2.Increasing BMI and age underpin the rising incidence of gestational diabetes 3.BMI is an important predictor of pre- eclampsia, macrosomia, neonatal body composition

9. Pregnancy as a “Metabolic Stress Test” Gestational Diabetes Type 2 Diabetes Cardiovascular disease Gestational Hypertension Hypertension Cardiovascular disease Preeclampsia Hypertension Renal Impairment Type 2 Diabetes Cardiovascular disease

10. Remote prognosis of HDP? Over time, women with HDP gain consistently more weight than women who do not experience HDP (Callaway et al, AJE; 2007)

11. Women who experience HDP have a higher incidence of remote diabetes: MUSP Cohort n=3639 HDP n=333 (9.15%) OR for Diabetes after HDP95% CI Unadjusted Model1.911.32, 2.78 Adjusted for age, parity, smoking, family income, physical activity, pre pregnancy BMI 1.601.08, 2.40 Adjusted for all of the above, as well as current BMI 1.61.11, 2.42 Callaway et al, AJOG 2008

12. Women with HDP do not have adequate follow up HDP (n=191) No HDP (n=1921)OR (95% CI)* Hypertension n(%)62 (32.4)280 (14.6)4.09 (2.76, 6.07) Inadequately identified or managed hypertension n(%) 33 (17.8)167 (8.7)3.56 (2.06, 3.59) Pre-hypertension 68 (35.6) 513 (26.7) 2.45 (1.68, 3.58) Callaway et al, ANZJOG 2012

13. The tricky problem of obesity in pregnancy

14. Queensland: Where Australia shines!

15. Maternal Obesity in Queensland 2006: 33% overweight and obese (Callaway et al, MJA, 2006) 2008: 50.5% overweight and obese (QH statbites)

16. Pregnancy weight gain Institute of Medicine Guidelines

17. What to do? Preconception Care Pregnancy Care Long term health

18. Is obesity surgery prior to pregnancy effective? Does massive weight loss make a difference?

19. Copyright restrictions may apply. Maggard, M. A. et al. JAMA 2008;300:2286-2296. Observational Studies on Maternal Pregnancy Outcomes Following Bariatric Surgery

20. Does weight loss prior to pregnancy reduce the risk? The case of bariatric surgery: – Case control study – 79 cases mean BMI 45.9 pre LAGB, mean weight loss 28.3 kg pre pregnancy – 79 matched controls, mean BMI 43.7 Dixon et al, Obstet Gynecol; 2005

21. Is preconception care effective?

22. Table I: Baseline Characteristics of surveyed women (n=412) Age31.4 (5.4) Gestation19.5 (6.2) Pre Pregnancy BMI23.8 (5.37) BMI 1 Year Pre Pregnancy (n=380) (%)24.0 (5.75) Gravidity1.7 (1.7) Parity0.8 (1.0) Nulliparous (%)179 (43.4) Planned pregnancy n (%)266 (64.6) Periconceptual folic acid supplementation (%)232 (56.3) Pre conception health check (%)220 (53.4) Completed secondary school (%)300 (72.9) Tertiary degree (%)144 (34.9) Public (%)255 (61.9) Born in (%)310 (75.2) Smoked during pregnancy (%)91 (22.1) BMI Pre Pregnancy BMI 1 Year Pre Pregnancy (n=380) (%) <18.57.1 18.5-2562.6 25.01-3018.4 >3011.9 BMI Pre Pregnancy (n=380) (%) <18.532 (8.4) 18.5-25233 (61.3) 25.01-3065 (17.1) >3050 (13.2) Values are Mean (SD) unless otherwise indicated. Callaway et al, MJA, 2009

23. Table II: Self recorded category of weight according to BMI category (n=380) BMI Category Prior to Pregnancy% of each BMI category <18.5 (n=32) Categorized self as underweight12 (37.5) Categorized self as normal weight20 (62.5) 18.5-24.99 (n=233) Categorized self as underweight9 (3.4) Categorized self as normal weight208 (89.3) Categorized self as overweight16 (6.9) 25 -29.99 (n=65) Categorized self as normal weight23 (35.9) Categorized self as overweight41 (62.5) Categorized self as obese1 (1.6) ≥30 (n=50) Categorized self as normal weight4 (8) Categorized self as overweight38 (76) Categorized self as obese8 (16) Callaway et al, MJA, 2009

24. Table III: Number (%)of normal, overweight and obese women reporting weight loss attempts, actual weight loss, advice regarding weight loss and a preconception health care check (n=348). Normal weight (n=233) Overweight (n=65) Obese (n=50)p value Tried to lose weight57 (24.5)32 (49.2)32 (64.0)<0.001 Actually lost weight70(30.0)29(44.6)23(46.0).0.04 Advised to lose weight (any source)7 (3.0)9 (13.8)21 (42.0)<0.001 Pre conception health check with doctor121 (51.9)26 (40.0)39 (78.0)0.7 Doctor advised to lose weight pre pregnancy8(3.4)6 (9.2)14 (28.0)<0.001 Callaway et al, MJA, 2009

25. Barriers to Preconception Care Inadequate pregnancy planning Inadequate compliance with simple pre pregnancy interventions (eg folic acid) Inadequate recognition of overweight and obesity Unsuccessful attempts at pre pregnancy weight loss Callaway et al, MJA, 2009

26. Can pregnancy interventions effectively prevent obesity in the future?

27. Gillman et al, Diabetes Care, 2010: ACHOIS follow up.