Szymanski, Linda M.

Abstract Background The potential risks and benefits of moderate‐intensity exercise in the management of fetal growth restriction (FGR) are controversial. Objective We sought to evaluate fetal responses to a 30‐min bout of moderate‐intensity exercise in pregnancies complicated by FGR. Study design This prospective study included 28 participants at a single academic institution. Pregnant individuals between 28w0d and 36w6d gestation with a diagnosis of FGR with normal Dopplers were enrolled. FGR was defined as total estimated fetal weight less than 10th percentile for estimated gestational age or abdominal circumference less than 10th percentile. Participants were excluded for body mass index (BMI) > 40, tobacco or substance use, hypertension on medications, or other contraindications to exercise. Participants exercised on a treadmill at a moderate intensity monitored using rate of perceived exertion (Borg scale) for 30 min. Fetal umbilical artery (UA), middle cerebral artery (MCA), aortic Dopplers, and maternal uterine artery Dopplers were sampled immediately before and after exercise. Biophysical profile and non‐stress tests were also performed. Maternal vital signs and rate of perceived exertion were monitored throughout exercise. Cerebro‐placental ratios (CPRs) were calculated after sampling. We hypothesized that there is no significant difference in fetal well‐being or Doppler flow in fetuses with FGR immediately after a 30‐min bout of moderate‐intensity maternal exercise compared to pre‐exercise. Results Biophysical profiles and non‐stress tests were reassuring before and after exercise. The primary outcome of UA Doppler values did not differ from pre‐ to post‐exercise. There was no difference in MCA, aortic Dopplers, or CPR. There was an increase in fetal heart rate ( p < 0.05) post‐exercise, which returned to baseline within several minutes. There was a decrease in uterine artery Dopplers ( p < 0.05) post‐exercise, which was driven by a non‐significant decrease in systolic flow and an increase in diastolic flow. Conclusions In this cohort, there were no acute adverse changes in fetal status after a single bout of moderate‐intensity maternal exercise with fetuses with FGR. These findings add to the limited available data in pregnancies complicated by FGR with normal Dopplers. Additional studies are needed to investigate the fetal and maternal effects of vigorous‐intensity and chronic exercise in this population or in populations with more evidence of placental dysfunction. Clinical trial registration NCT06039319.

ABSTRACT Early-life nutrition profoundly influences long-term metabolic health, and breast milk not only provides nutrients but also conveys maternal signals shaping infant metabolic development. While postpartum exercise by lactating women benefits maternal health, its impact on milk-borne signaling remains largely undefined. Small extracellular vesicles (sEVs) in breast milk are key mediators of maternal–infant communication because of their selectively packaged bioactive cargo and resistance to infant digestive enzymes and acids, enabling delivery of their cargo to peripheral tissues. Here, we show that a single session of moderate-intensity postpartum aerobic exercise robustly increases human breast milk sEV concentration, which persists for multiple post-exercise milk collections. Exercise enriches breast milk with sEVs containing regulatory metabolic cargo (proteins, miRNAs, and metabolites), which translates into enhanced mitochondrial capacity in neonatal-stage cells. These findings implicate sEVs as an exercise-responsive signaling compartment in breast milk capable of connecting postpartum maternal physical activity to beneficial infant metabolic programming. Highlights Acute moderate-intensity exercise increases human breast milk sEV concentration The exercise-mediated sEV increase lasts for multiple subsequent milk expressions Exercise coordinates a multi-omic enrichment of sEVs in breast milk Exercised breast milk sEVs enhance mitochondrial respiration in UC-MSCs

Importance Prepregnancy care and counseling optimize maternal health before conception to improve outcomes for mothers and infants. In the US, 66.4% of reproductive-aged women have at least 1 modifiable risk factor for adverse pregnancy outcomes. Observations For all individuals desiring pregnancy, recommended interventions include folic acid supplementation; cessation of tobacco, alcohol, cannabis, and opioids; immunizations against hepatitis B virus, varicella, and rubella; and screening for syphilis and HIV. Folic acid use before pregnancy is associated with reduced fetal neural tube defects (relative risk [RR], 0.67; 95% CI, 0.52-0.87). Maternal tobacco smoking is associated with increased risks of stillbirth (summary RR [sRR], 1.46; 95% CI, 1.38-1.54), neonatal death (sRR, 1.22; 95% CI, 1.14-1.30), and perinatal death (sRR, 1.33; 95% CI, 1.25-1.41). Screening for and treatment of syphilis and HIV prior to and during pregnancy decrease rates of fetal and neonatal infection. Prepregnancy immunizations against hepatitis B virus, varicella, and rubella decrease neonatal infection and mortality. Individuals using tobacco, alcohol, cannabis, and opioids should receive counseling and treatment prior to pregnancy (eg, buprenorphine or methadone for opioid use disorder). For individuals with chronic disease, routine health examinations and contraceptive care in the year before conception can optimize pregnancy timing and are associated with decreased risk of severe maternal morbidity. Compared with planned pregnancies, unintended pregnancies are associated with increased risk of postpartum depression (15.7% vs 9.6%; adjusted odds ratio [aOR], 1.51; 95% CI, 1.40-1.70), preterm birth (9.4% vs 7.7%; aOR, 1.21; 95% CI, 1.12-1.31), and low infant birth weight (7.3% vs 5.2%; aOR, 1.09; 95% CI, 1.02-1.21). Weight loss prior to conception is recommended for individuals with a body mass index of 25 or greater because overweight and obesity are associated with increased risk of gestational diabetes, gestational hypertension, and cesarean delivery. Among patients with pregestational diabetes (type 1 or 2), hemoglobin A 1c of less than 6.5% is associated with a decreased risk of fetal anomaly compared with hemoglobin A 1c of 6.5% or greater. Cardiovascular complications such as hypertension and heart failure occur in 15% of pregnancies and are more common among those with preexisting cardiovascular disease. These patients should receive counseling on maternal and neonatal risk, monitoring, and medication management by specialists in cardiology and maternal fetal medicine. Conclusions and Relevance Prepregnancy counseling and care reduce maternal morbidity and neonatal morbidity and mortality. Primary care–based discussion of reproductive goals, immunizations, screening for infections and substance use, and risk-reducing interventions such as folate supplementation can optimize outcomes in individuals contemplating pregnancy.

Abstract Introduction The prevalence of pre‐pregnancy obesity, including pre‐pregnancy class 3 obesity, has increased over time, with significant implications for maternal and neonatal well‐being. Regular physical activity may mitigate these risks. Available data suggest that most pregnant individuals do not meet the recommended physical activity guidelines of accumulating at least 150 min of moderate‐intensity exercise per week. Importantly, limited data are available regarding physical activity patterns in individuals with higher body mass index (BMI), particularly for those with class 3 obesity (BMI ≥ 40 kg/m 2 ). The aim of this study was to evaluate whether pregnant individuals are meeting physical activity guidelines. We assessed self‐reported physical activity across BMI categories including those with class 3 obesity, further subdivided into BMI of 40–49.9 and ≥ 50 kg/m 2 . Methods This is a retrospective cohort study of individuals at an academic hospital system who delivered between May 1, 2018 and May 1, 2023. To be included, individuals had to respond to the following two‐item physical activity questionnaire early in pregnancy: (1) “On average, how many days per week do you engage in moderate to strenuous exercise?” And (2) “On average, how many minutes do you engage in exercise at this level?” From these two questions, total minutes per week of activity were calculated. Individuals met physical activity guidelines if they engaged in ≥ 150 min of physical activity per week. Data were analyzed using Kruskal–Wallis and Chi‐square tests. Results A total of 6884 individuals were incl uded in the cohort. A total of 510 individuals met the criteria for class 3 obesity, with 61 having a pre‐pregnancy BMI ≥ 50 kg/m 2 . Among normal weight individuals (BMI 18.5–24.9 kg/m 2 ), 34% met physical activity guidelines. Overweight and obese individuals were significantly less physically active than those with normal BMI ( p < 0.05). Only 22% of those with BMI 40–49.9 kg/m 2 and 18% of those with BMI ≥ 50 kg/m 2 reported sufficient physical activity. Conclusion Our results are consistent with existing data, showing that pregnant individuals are not meeting physical activity goals. Pregnant individuals who are overweight or obese engage in significantly less physical activity compared to those with a BMI in the normal range, with the lowest levels of activity observed among individuals with class 3 obesity. More data are needed on physical activity among pregnant individuals with class 3 obesity, including evaluation of potential interventions to increase activity as well as barriers to participation. Increasing physical activity in this group may positively impact both maternal and neonatal health.

Abstract Obstetric training programs typically offer limited formal education on placental pathology; yet, in practice, obstetric providers are expected to incorporate placental pathology findings into the overall evaluation of obstetric complications. In this narrative review, we briefly review pathology classifications and then delve deeper into pathology findings that may change clinical decision‐making, specifically highlighting pathologic lesions with a recurrence risk and recommended management for subsequent pregnancies. Last, we present specific recommendations on how to improve clinical interpretability and utility of placental pathology reports for obstetrical practice.