• 1.
  

  a) T b) T c) F d) F e) T

NCDs are one of the most important causes of mortality around the world, including middle and low-income countries (nearly 80% of all cases). 90% of mortality due to NCDs are in patients lower than 60 years in the middle and low-income countries. The proportion >60 years is much greater in developed countries. Any person can develop NCDs but women who have pregnancy complications such as diabetes or hypertension are more vulnerable.

• 2.
  

  a) T b) T c) T d) T e) T

All of the mentioned factors have very important influences on the genomic process and can be responsible for a lot of illnesses in adult life. There is evidence that these factors have strong influence on the genome by affecting trans-methylation processes and induction of epigenetic pathways.

• 3.
  

  a) T b) T c) T d) T e) T

This matter must be tackled by collaborative strategies; promoting good health, improving social conditions and economic support would pay dividends. For example, under nutrition has many origins and all of them must be analysed and corrected. The role of society is to improve economic wellbeing and raise levels of education. These steps can then help strategies to reduce the pre-pregnancy, pregnancy and post pregnancy influences.

• 4.
  

  a) F b) T c) T d) F e) F

FIGO is a charity but is also a Scientific Society and aims to promote women’s health. It has members with adequate expertise to provide education and training to reduce pregnancy related influences that can impact on NCDs. FIGO is responsible for programmes and projects around the world and focuses its attention on perinatal care. FIGO’s statements and recommendations are very well accepted by the majority of countries with good health services. FIGO can focus on projects with a view to preventing NCDs by treating factors that can be responsible for some of the epigenetic influences. FIGO must do much more than helping to maintain registries of some indicators. Health is a human right. FIGO emphasises that especially in relation to pregnancy, labour and delivery to avoid maternal morbidity and mortality. However, more strategies and projects are needed to prevent NCDs.

• 5.
  

  a) F b) T c) T d) T e) T

There is currently no evidence that neonates born to a mother with diabesity have an increased proportion of lean body mass. It is the hallmark of neonates born to a mother with diabesity that they have accumulated more relative body fat than neonates born to normal pregnancies. It has been well established for more than 60 years that cord blood insulin levels are elevated in most of the pregnancies characterized by maternal diabetes. The elevated fetal insulin levels stimulate fetal aerobic metabolism and thus enhance fetal oxygen consumption. Since the proportion of glycosylated maternal haemoglobin is higher in these pregnancies and glycosylated haemoglobin has a higher oxygen affinity, fetal oxygen demands cannot be adequately covered leading to fetal hypoxia. The low oxygen levels stimulate fetal erythropoiesis and erythropoietin synthesis.

• 6.
  

  a) F b) T c) F d) F e) T

The placenta has a high capacity for transporting glucose from the maternal to the fetal circulation. The increased glucose flux in situations of maternal diabesity is the result of the steeper maternal-fetal glucose concentration gradient and not accounted for by any placental contribution, let alone a limitation of glucose flux. It is true that the placenta will enhance its vascularization and, therefore, become hypervascularized as the result of fetal hypoxia. This will go along with enhanced fetal erythropoiesis to adequately cover fetal oxygen demands.

The placenta does not produce insulin itself. The enhanced vascularization is a structural change of the placenta.

• 7.
  

  a) T b) T c) T d) T e) F

Maternal glucose and insulin affect distinct biological processes such as activation of matrix-metalloproteinase 14 and changes in trophoblast proliferation. These are involved in early placental development. Insulin in the fetal pancreas has indeed been found as early as week 8-9 of gestation. In the amniotic fluid it has been measured at week 14 of gestation. Placental volume at week 14 and changes in its volume between week 14 and week 17 are associated with fetal anthropometrics at week 3 of gestation. Although associations of amniotic fluid insulin at week 32-34 of gestation with risks of childhood obesity have been demonstrated, there is no evidence so far for an association of fetal insulin early in gestation with childhood obesity risk. However, this cannot be ruled out and awaits studies.

• 8.
  

  a) F b) F c) T d) F e) F

Drug discoveries are generally not desirable in human development as there are few promising drug targets. Genetic screening has not accounted for the majority of risk at a population level. A lifecourse approach, focusing on different opportunities in different contexts is the only realistic approach as it is so multi-factorial. More widespread use of treatments in affected older adults may be beneficial to treated individuals but is not likely to reduce risk in the next generation. Meeting the challenge of climate change will address a contributory factor but clearly will not address the whole problem.

• 9.
  

  a) F b) T c) F d) F e) F

High iron intake in pregnancy increases the risk of GDM especially in non-anaemic women and routine iron supplementation should be reconsidered in this group of women. Higher pre-pregnancy intake of dietary heme iron and raised serum ferritin levels are also associated with an increased risk of GDM.

• 10.
  

  a) T b) F c) T d) T e) F

Anaemia in pregnancy, defined as haemoglobin concentration (Hb) <110 g/L, affects more than 56 million pregnant women globally, two thirds from Asia. Nutritional iron deficiency anaemia (IDA) is the commonest cause of anaemia and is associated with increased maternal and perinatal morbidity and mortality, and long-term adverse effects in the newborn. Studies show a significantly higher risk of LBW (adjusted odds ratio (aOR) 1.29, [95% confidence intervals (CI) 1.09, 1.53]) and preterm birth (aOR1.21, [95% CI-1.13, 1.30]) with anaemia in the first or second trimester. Iron supplementation during pregnancy significantly lowers the incidence of LBW (RR 0.80 [95% CI 0.71, 0.90]) but has no effect on incidence of preterm or SGA birth.

• 11.
  

  a) T b) T c) T d) T e) T

Women with severe anaemia have a higher risk of pre-eclampsia compared to women with no anaemia (OR 3.6 [95% CI 1.4, 9.1] p < 0.007). Severe anaemia is also associated with preterm delivery (OR 6.6 [95% CI 2.7, 16.3] p < 0.001), LBW (OR 8.0 [95%CI 3.8, 16.0] p < 0.001) and SB (OR 4.3 [95%CI 1.9, 9.1; p < 0.001]) [16]. Based on data from the World Health Organization Global Survey for Maternal and Perinatal Health, Zhang et al concluded that multiparous women with severe anaemia were at increased risk of gestational hypertension (aOR 1.58 [95% CI 1.15, 2.19]). Severe anaemia also had a significant association with preeclampsia/eclampsia for nulliparous (aOR 3.55 [95% CI 2.87, 4.41]) and multiparous women (aOR 3.94 [95% CI 3.05, 5.09]).

• 12.
  

  a) F b) T c) F d) F e) F

A Cochrane review in 2013 concluded that folate supplementation during pregnancy did not lower the risk of preterm births, stillbirths, neonatal deaths, LBWs, pre-delivery anaemia in the mother or improve mean birth weight compared with placebo treatment. B12-deficiency in pregnancy is associated with higher insulin resistance and a higher incidence of GDM, as well as a higher prevalence of type 2 diabetes at 5 years. Among B12-deficient women, the incidence of GDM increases with rising folate concentration. Low circulating levels of vitamin B12 in folate replete mothers is associated with “thin fat” offspring and a high prevalence of insulin resistance, indicating future risk of type 2 diabetes.

• 13.
  

  a) T b) T c) T d) T e) T

Studies from around the world show high rates of vitamin D deficiency among women of reproductive age or during pregnancy. A systematic review of first trimester 25(OH) D levels and adverse pregnancy outcomes in 2010 concluded that the evidence of the association between Vitamin D levels and pregnancy complications such as preeclampsia and diabetes is inconclusive. However, a recent systematic review and meta-analysis including some new studies concluded that Vitamin D insufficiency is associated with an increased risk of gestational diabetes, pre-eclampsia, SGA and LBW infants.

• 14.
  

  a) F b) F c) T d) F e) T

Combined answers for 14 after question 15.

• 15.
  

  a) T b) T c) T d) T e) T

Complications of overweight and obesity during pregnancy include hypertensive disorders, coagulopathies, GDM, respiratory problems and foetal complications such as large-for-gestational-age (LGA) babies, congenital malformations, stillbirth, and shoulder dystocia. Women overweight in early pregnancy have a 2–3-fold increased risk of pre-eclampsia. Obesity is associated with increased risk of pre eclampsia (aOR 4.46), induction of labour (1.97), post-partum haemorrhage (3.04), intensive care admission (3.86), GDM (7.89), thrombosis (infinity), shoulder dystocia (1.89), C-section (3.50), maternal infection (3.35), prolonged hospital stay (2.84), and instrumental delivery (1.17).

• 16.
  

  a) F b) T c) T d) T e) F

Several markers such as age, race/ethnicity, BMI, history of type 2 diabetes in first degree relatives, history of GDM, macrosomia, unexplained stillbirth, spontaneous abortion in previous pregnancies, excessive weight gain, presence of polycystic ovary syndrome, metabolic syndrome, polyhydramnios and suspected macrosomia during the current pregnancy have all been described to clinically identify women with a high risk of GDM. In practice they fail to correctly identify more than half the women with GDM. Haemorrhage, hypertensive disorders, obstructed labour, and infection / sepsis are among the leading global causes of maternal mortality. High blood pressure and gestational hyperglycaemia are linked directly or indirectly to all of them. In pregnancy, particularly for overweight and obese women, the major contributor to insulin resistance is weight gain and accumulation of adipose tissue which acts as an active organ causing increased release of adipokines and leptins which in concert with placental hormones and other hormones create a state of insulin resistance. Weight maintenance or loss and physical activity can prevent, arrest or reverse this process. GLUT4 is a glucose transporter activated by and during exercise.

• 17.
  

  a) F b) T c) F d) F e) T

Worldwide high blood pressure with or without proteinuria is a major cause of maternal morbidity and mortality and hypertensive pregnancy disorders (HPD) account for 10 and 15% of maternal deaths in low-/middle income countries, as well as to increased perinatal morbidity and mortality as a consequence of prematurity and poor foetal growth. Although the incidence varies in different parts of the world, overall nearly 10% of normotensive women experience abnormally elevated blood pressure at some point during pregnancy. There is no consensus about the definition of HPDs and several classifications have been proposed. The broad categories generally accepted are: (a) gestational hypertension or pregnancy-induced hypertension – hypertension without proteinuria; (b) pre-eclampsia – hypertension with proteinuria; (c) chronic hypertension, or essential hypertension – pre-existing hypertension; and (d) chronic hypertension with superimposed pre-eclampsia. There is no such condition called chronic pre-eclampsia. Pre-eclampsia/eclampsia has the highest impact on mortality and morbidity, including renal or liver failure, clotting disorders, stroke, pre-term delivery, stillbirth or neonatal death and C-section, especially emergency C–section.

• 18.
  

  a) T b) T c) F d) T e) T

Severe pre-eclampsia is a life-threatening multisystem disease associated with eclampsia; HELLP syndrome (haemolysis, elevated liver enzymes, low platelets); acute kidney injury; pulmonary oedema; placental abruption and intrauterine foetal death. Impaired glucose tolerance leading to GDM increases the risk of pre-eclampsia.

• 19.
  

  a) T b) T c) T d) T e) T

The optimal time in which pregnancy related care should be initiated is well prior to conception. The greatest impact of many of the preventable hazards occur during early pregnancy, usually when women are unaware of pregnancy, or if aware, have not yet initiated prenatal care. The risk of congenital abnormalities is proportional to glycaemic control at conception so this needs to be optimised before pregnancy. Similarly disease activity at conception in SLE and the underlying degree of renal failure are strong predictors of adverse outcome. Many anti-epileptic drugs (AEDS) are teratogenic and control of seizures tends to become more difficult in pregnancy so this all needs discussion. Cyanotic heart disease poses a substantial risk to maternal and fetal health and the degree of functional loss and the associated risks should be discussed well before pregnancy is contemplated.

• 20.
  

  a) T b) T c) T d) T e) T

Physicians providing routine and primary health care have the best opportunity to provide preventive medicine, including pre-conceptual care – i.e. obstetricians/gynecologists, pediatricians, family physicians and general practitioners and input from medical specialists relevant to the pre-existing condition are all important. Ideally a team approach is needed according to the identified risk factors.

• 21.
  

  a) T b) T c) T d) T e) T

Diabetes mellitus is a model disease for the efficacy of preconceptual care, as maternal, perinatal and neonatal risks are closely related to the level of metabolic control prior to and during pregnancy. If glycemic control is optimized prior to and throughout gestation, a normal pregnancy outcome may be achieved. The primary implications of deranged glucose control prior to pregnancy are congenital malformations, miscarriages, perinatal or neonatal death and adverse pregnancy outcome – preeclampsia, macrosomia, small for gestational age and preterm delivery

• 22.
  

  a) T b) F c) T d) T e) T

Pregnancy is diagnosed in most patients after 6-8 weeks of gestation and organogenesis finalises at about 10-11 weeks of gestation. Maternal weight tends to increase with subsequent pregnancies. Decrease in weight between the first and second pregnancy is associated with a decreased risk of PET and CS. Decrease in weight between first and second pregnancy is associated with decreased risk of GDM.

• 23.
  

  a) T b) T c) T d) T e) F

Spontaneous abortions are more prevalent in obese patients due to adverse influences on the embryo, the endometrium or both. There is also an association with recurrent miscarriage which may be related to obesity seen with PCOS. As the proportion of obese women who have polycystic ovary syndrome or ovulation problems is high the prevalence of infertility is high among obese women. Some malformations are found to be in higher prevalence in the obese population and the risk may increase with increasing maternal weight. The mechanism for this association in not known but may well be related to undiagnosed diabetes and hyperglycaemia. There is no increased risk of chromosomal anomalies in obese women.

• 24.
  

  a) F b) T c) T d) F e) T

Obese women are more likely than normal-weight women to have an induction of labour as there is both an increased rate of obstetric complications and prolonged pregnancy in an apparent dose-dependent manner with increasing class of obesity. The magnitude of this risk ranges from a 1.6-2.2 fold increase. Obese women are more likely to have an inadequate contraction pattern during the first stage of labour, and subsequently have a longer first stage. The exact mechanism of dysfunctional labour in obese women is not completely understood. Obese women, even in the presence normal glucose tolerance, have almost twice the likelihood of a macrosomic infant. Obesity is associated with an increased risk for operative vaginal delivery (OVD), probably in a dose-dependent manner. The odds Ratio may be up to 1.7 for OVD for women with class III obesity in comparison to normal BMI patients. Shoulder dystocia is especially associated with large babies and GDM, both of which are much more common in obese women.

• 25.
  

  a) T b) F c) T d) T e) T

The prevalence of GDM does indeed vary in direct proportion to the prevalence of type 2 DM. The prevalence of these entities does depend on the ethnic population being studied but the relationship between them does not change. Socio-economic aspects, malnutrition and overnutrition (the new disease of the poor) are all thought to contribute to the relatively high prevalence of diabetes in low resource countries.

• 26.
  

  a) T b) F c) F d) F e) F

The DPP involved an intensive intervention not easily administered in a clinical setting. Goals of the lifestyle intervention were at least a 7% reduction in enrollment weight, a low-calorie, low-fat diet, and at least 150 minutes/week of moderate-intensity physical activity. The DPP was conducted an average of 12 years after the gestational diabetes mellitus (GDM) diagnosis. The DPP was a randomized trial and therefore important diabetes risk factors were randomly distributed between the study arms. There was no need to adjust for confounding factors in this context. The number of participants was more than adequate.

• 27.
  

  a) F b) F c) T d) F e) T

Only one study to date examined the impact of the lifestyle intervention on breastfeeding among women with prior GDM. Specifically, Ferrara et al. found that the difference in percent of women partially or exclusively breastfeeding between the intervention and control arms was 15%. To date, the majority of studies have been single centre pilot studies.

Only one newly launched study, Estudio Parto, is being conducted in a specific ethnic group (Hispanic women) and will evaluate whether a culturally-modified intervention will be effective in reducing diabetes risk in Latinas with GDM. To date, the majority of randomized controlled trials of lifestyle interventions in women with GDM designed to prevent type 2 diabetes have been limited to pilot or feasibility studies.

• 28.
  

  a) T b) T c) T d) F e) T

A review of studies examined the risk perceptions and health behaviours of women with previous GDM and found low risk perceptions for future type 2 diabetes in this group. The majority of studies reveal a distinct knowledge-behaviour gap among the postpartum population as well as a lack of knowledge regarding necessary lifestyle modifications. Focus groups among women with a history of GDM suggest that interventions which integrate the entire family and influence family members, along with the participant, to adopt health promoting behaviours may be particularly successful. To address transportation barriers, home-based interventions conducted via mail, telephone, internet/e-mail, and text-messaging, or involving home visits by health educators may be more feasible and acceptable to women in the postpartum period.

• 29.
  

  a) F b) T c) F d) F e) F

Physical activity is not considered a cause of infertility; to the contrary obese subjects will improve their chances of fertility after they engage in exercise and lose some weight. Multiple studies have demonstrated that individuals who engage in physical activities prior to pregnancy reduce their risk significantly of developing gestational diabetes in pregnancy. Furthermore, physically active women are proven to develop less complications and thus require less clinic visits. 150/min/week or more of physical activity and judicious diets has been shown to result in weight loss and prevent/delay type 2 diabetes. For individuals who have no chronic disease prior to pregnancy and who do not have symptoms (chest pains or pressure or joint pain) do not require medical clearance to engage in a light or moderate exercise program.

• 30.
  

  a) F b) F c) F d) T e) T

All major specialty organizations have endorsed exercise as a safe adjunctive intervention to prevent or manage gestational diabetes. Sedentary behavior in pregnancy used to be prescribed in previous decades and has been proven to be detrimental.