Summary of draft recommendations and practice points
Clinical Practice Guidelines: Pregnancy careRecently reviewed topicsCONSULTATION DRAFT — 1 June 2020Contents TOC \t "Heading 1,2,Section,1" Summary of draft recommendations and practice points PAGEREF _Toc41914128 \h 2Introduction PAGEREF _Toc41914129 \h 2Lifestyle considerations PAGEREF _Toc41914130 \h 21Nutrition and physical activity PAGEREF _Toc41914131 \h 2Clinical assessments PAGEREF _Toc41914132 \h 22Weight and body mass index PAGEREF _Toc41914133 \h 2Appendices PAGEREF _Toc41914134 \h 2AMembership and terms of reference of the Expert Working Group PAGEREF _Toc41914135 \h 2BAdministrative report PAGEREF _Toc41914136 \h 2CSummary of the literature reviews PAGEREF _Toc41914137 \h 2DTopics currently under review PAGEREF _Toc41914138 \h 2ETopics covered in the pregnancy care guidelines PAGEREF _Toc41914139 \h 2Acronyms and abbreviations PAGEREF _Toc41914140 \h 2List of tables TOC \t "TableName,4" Definition of grades of recommendations PAGEREF _Toc41914141 \h 2Draft recommendations and practice points PAGEREF _Toc41914142 \h 2GRADE levels of evidence PAGEREF _Toc41914143 \h 2Table 1:Recommended number of daily serves during pregnancy PAGEREF _Toc41914144 \h 2Table 2:Practical advice on nutritious foods during pregnancy PAGEREF _Toc41914145 \h 2Table 3: Definition of levels of physical activity PAGEREF _Toc41914146 \h 2Table 4: Classification of adult underweight, overweight and obesity according to BMI PAGEREF _Toc41914147 \h 2Table 5:Recommendations for weight gain in pregnancy (kg) PAGEREF _Toc41914148 \h 2Table B.1: Assessment of quality of systematic literature reviews PAGEREF _Toc41914149 \h 2Table B.2: Assessment of limitations of randomised controlled trials PAGEREF _Toc41914150 \h 2Table B.3: Assessment of limitations of observational studies PAGEREF _Toc41914151 \h 2Table B.4: Domains that contribute to the strength of a recommendation PAGEREF _Toc41914152 \h 2Table B.6: Expert Working Group competing interests PAGEREF _Toc41914153 \h 2Table C1: Mapping of searches to research questions and type of review PAGEREF _Toc41914154 \h 2Table C2: Outcomes for meta-analysis of evidence on probiotics PAGEREF _Toc41914155 \h 2Table C3: Outcomes for meta-analysis of evidence on weight monitoring PAGEREF _Toc41914156 \h 2Table C4: Outcomes for meta-analysis of evidence on interventions to prevent weight gain PAGEREF _Toc41914157 \h 2Summary of draft recommendations and practice pointsThe recommendations in this document were developed by the methodologists (Philippa Middleton and Jenny Ramson) in consultation with the Expert Working Group (EWG) Chairs (Caroline Homer and Jeremy Oats). They were then refined and graded following input from the broader EWG. Where evidence was limited or lacking, consensus-based recommendations (CBRs) were developed. For areas beyond the scope of the systematic reviews, practice points (PPs) were developed.Definition of grades of recommendations TypeDefinitionEvidence-based recommendation (EBR)Body of evidence can be trusted to guide practiceQualified evidence-based recommendation (QEBR)Body of evidence can be trusted to guide practice in most situationsCBRRecommendation formulated in the absence of quality evidence (where a systematic review of the evidence was conducted as part of the search strategy)PPArea is beyond the scope of the systematic literature review and advice was developed by the EACDraft recommendations and practice pointsRecommendation/practice point GradeSectionLifestyle considerationsNutrition AEating the recommended number of daily serves of the five food groups and drinking plenty of water is important during pregnancy and breastfeeding.PP REF _Ref38009791 \r \h 1.1Nutritional supplements1Recommend dietary supplementation of 500 micrograms per day folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy to reduce the risk of neural tube defects.EBR REF _Ref497398531 \r \h 1.22Advise women that taking vitamin A, C or E supplements is of little or no benefit in pregnancy and may cause harm.EBR REF _Ref497398531 \r \h \* MERGEFORMAT 1.23Only advise iron supplementation to pregnant women if their dietary iron intake is low or they have iron-deficiency anaemia.EBR REF _Ref497398531 \r \h 1.24Advise pregnant women with low dietary iron intake that intermittent supplementation is as effective as daily supplementation in preventing iron-deficiency anaemia, with fewer adverse effects.EBR REF _Ref497398531 \r \h 1.25Advise pregnant women to take a low-dose calcium supplement.EBR REF _Ref497398531 \r \h 1.2IAdvise pregnant women to take an iodine supplement of 150?micrograms each day. Women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement.CBR REF _Ref497398531 \r \h 1.26Advise pregnant women that supplementation with omega3 long-chain polyunsaturated fatty acids may reduce their risk of preterm birth.EBR REF _Ref497398531 \r \h 1.2Physical activity7Advise women that regular moderate-intensity physical activity during pregnancy is associated with a range of health benefits and is generally not associated with adverse outcomes.EBR REF _Ref38009848 \r \h 1.3Weight and body mass indexIIMeasure women’s weight and height at the first antenatal visit and calculate their body mass index (BMI) and give them advice about the benefits of gaining weight within the recommended weight gain range for their BMI.CBR REF _Ref35956544 \r \h 2.3IIIAt every antenatal visit, offer women the opportunity to be weighed so that low or high gestational weight gain is identified and risk of associated adverse outcomes monitored. CBR REF _Ref35956544 \r \h 2.38At every antenatal visit, give women tailored advice on weight gain, including the benefits of a healthy diet, regular physical activity and self-monitoring.EBR REF _Ref35956544 \r \h 2.3BAdopting a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. This should be informed by appropriate education for health professionals.PP REF _Ref35956544 \r \h 2.3GRADE levels of evidenceHigh certainty:?We are very confident that the true effect lies close to that of the estimate of the effectModerate certainty:?We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially differentLow certainty:?Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effectVery low certainty:?We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effectIntroductionThe Australian Clinical Practice Guidelines: Pregnancy Care provide evidence-based recommendations to support high quality, safe pregnancy care and contribute to improved outcomes for all mothers and babies. To ensure that the recommendations are current, an ongoing process for evaluation of the evidence is in progress. Stage 1 of the most recent review was completed in October 2017, with National Health and Medical Research Council (NHMRC) approval of recommendations on a range of topics. This is the second round of topics being reviewed as part of Stage 2 of the review. This document provides current guidance on nutrition, nutritional supplements, physical activity and weight assessment and monitoring. The membership of the Expert Working Group involved in development of this guidance is listed in Appendix A, the process is described in Appendix B and the review of the literature is summarised in Appendix C. The remaining topics in Stage 2 are still under review and are listed in Appendix?D. A full list of topics covered in the Guidelines is included in Appendix E. Application of the GuidelinesObjective of the GuidelinesThe Guidelines aim to improve the health and wellbeing of both mothers and babies, and ensure women consistently receive high quality, evidence-based pregnancy care. They provide a summary of the current evidence on aspects of care and are intended to complement the education and skills of health professionals. It is expected that implementation of the Guidelines will improve maternal, fetal, newborn and family outcomes in the short and longer terms.ScopeThe Guidelines cover the antenatal care of healthy pregnant women (ie women who do not have identified pre-existing conditions and are not at higher risk of complications such as in multiple pregnancy). They are intended for use in all settings where antenatal care is provided, including primary care, obstetric and midwifery practice and public and private hospitals. The Guidelines do not include:information on preconception or postnatal careadvice on clinical management of women and babies when risks are identified through testing or clinical assessment discussion of specific topics where a practice is already established (eg testing of blood group) or where the topic was not considered a priority for inclusion in these Guidelines and advice is given by other organisations (eg vaginal discharge, backache).Intended audienceThe Guidelines are intended for all health professionals who contribute to antenatal care, including midwives, general practitioners (GPs), obstetricians, maternal and child health nurses, Aboriginal and Torres Strait Islander Health Practitioners; Aboriginal and Torres Strait Islander Health Workers, multicultural health workers, practice nurses, allied health professionals, childbirth and parenting educators and sonographers. The way in which different professionals use these Guidelines will vary depending on their knowledge, skills and role, as well as the setting in which care is provided. These Guidelines will be of interest and relevance to pregnant women in Australia. In addition, it is expected that policy makers will be able to draw on the Guidelines in the development of policy and the planning and delivery of health services.Dissemination and reviewFollowing approval by the NHMRC, the chapters in this document will replace the previous versions of the chapters in the online version of the Guidelines.Lifestyle considerationsNutrition and physical activity Consuming a wide variety of nutritious foods during pregnancy is important to ensure that the nutritional requirements of both mother and baby are met. While supplementation of vitamins and minerals is common during pregnancy, only some supplements are beneficial. Regular moderate-intensity physical activity has benefits for mother and baby and is safe.Nutrition The nutritional status of a woman before and during pregnancy plays a vital role in fetal growth and development. The basic principles of healthy eating remain the same, though requirements for some nutrients (eg iron, folic acid) may increase.BackgroundKnowledge about healthy eating during pregnancyObservational studies carried out in Australia have found:low levels of awareness of dietary guidelines during pregnancy among women PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Bookari et al 2016; Lee et al 2016) low levels of women meeting dietary recommendations for the five food groups PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYWxlazwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Mishra et al 2015; Malek et al 2016a; Bookari et al 2017; Lee et al 2018a)low levels of knowledge of foods to avoid during pregnancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcnlhbnQ8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Bryant et al 2017)limited dietary counselling by health professionals PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (NHMRC 2000c; NT DHCS 2007; Harrison et al 2010; Landrigan & Pollard 2011).Socioeconomic status: In some urban centres, there is less access to supermarkets and greater access to fast food outlets than in more socioeconomically advantaged areas ADDIN EN.CITE <EndNote><Cite><Author>Ball</Author><Year>2009</Year><RecNum>611</RecNum><DisplayText>(<style font="Century Gothic" size="8">Burns & Inglis 2007; Ball et al 2009</style>)</DisplayText><record><rec-number>611</rec-number><foreign-keys><key app="EN" db-id="2ffadw0vnezppfeafavp0t2pw2fxf0x0rtte">611</key><key app="ENWeb" db-id="TfsF3QrtqgYAADLBKoE">611</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ball, K.</author><author>Timperio, A.</author><author>Crawford, D.</author></authors></contributors><titles><title>Neighbourhood socioeconomic inequalities in food access and affordability</title><secondary-title>Health & place</secondary-title></titles><periodical><full-title>Health & place</full-title></periodical><pages>578–585</pages><volume>15</volume><number>2</number><dates><year>2009</year></dates><publisher>Elsevier</publisher><isbn>1353-8292</isbn><urls></urls></record></Cite><Cite><Author>Burns</Author><Year>2007</Year><RecNum>612</RecNum><record><rec-number>612</rec-number><foreign-keys><key app="EN" db-id="2ffadw0vnezppfeafavp0t2pw2fxf0x0rtte">612</key><key app="ENWeb" db-id="TfsF3QrtqgYAADLBKoE">612</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Burns, CM</author><author>Inglis, AD</author></authors></contributors><titles><title>Measuring food access in Melbourne: access to healthy and fast foods by car, bus and foot in an urban municipality in Melbourne</title><secondary-title>Health & Place</secondary-title></titles><periodical><full-title>Health & place</full-title></periodical><pages>877–885</pages><volume>13</volume><number>4</number><dates><year>2007</year></dates><publisher>Elsevier</publisher><isbn>1353-8292</isbn><urls></urls></record></Cite></EndNote>(Burns & Inglis 2007; Ball et al 2009). Aboriginal and Torres Strait Islander women: Diet and nutritional status of Aboriginal and Torres Strait Islander people are influenced by many factors, such as socioeconomic disadvantage and geographical, environmental and social factors ADDIN EN.CITE <EndNote><Cite><Author>Lee</Author><Year>2018</Year><RecNum>1842</RecNum><DisplayText>(<style font="Century Gothic" size="8">Lee & Ride 2018</style>)</DisplayText><record><rec-number>1842</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1586754493">1842</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lee, A.,</author><author>Ride, K.,</author></authors></contributors><titles><title>Review of nutrition among Aboriginal and Torres Strait Islander people</title><secondary-title>Australian Indigenous Health Bulletin</secondary-title></titles><periodical><full-title>Australian Indigenous Health Bulletin</full-title></periodical><volume>18</volume><number>1</number><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>(Lee & Ride 2018). Very few Aboriginal and Torres Strait Islander people meet dietary recommendations for intake of healthy foods ADDIN EN.CITE <EndNote><Cite><Author>Lee</Author><Year>2018</Year><RecNum>1842</RecNum><DisplayText>(<style font="Century Gothic" size="8">Lee & Ride 2018</style>)</DisplayText><record><rec-number>1842</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1586754493">1842</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lee, A.,</author><author>Ride, K.,</author></authors></contributors><titles><title>Review of nutrition among Aboriginal and Torres Strait Islander people</title><secondary-title>Australian Indigenous Health Bulletin</secondary-title></titles><periodical><full-title>Australian Indigenous Health Bulletin</full-title></periodical><volume>18</volume><number>1</number><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>(Lee & Ride 2018). A high proportion (41%) of daily energy intake is derived from unhealthy ‘discretionary’ foods and drinks that are high in saturated fat, added sugar and salt, compared to 35% among non-Indigenous Australians. The current nutritional health of Aboriginal and Torres Strait Islander people is in marked contrast to the situation prior to European settlement in Australia, when Aboriginal and Torres Strait Islander peoples were generally healthy and enjoyed a varied traditional diet low in energy density and rich in nutrients ADDIN EN.CITE <EndNote><Cite><Author>Lee</Author><Year>2018</Year><RecNum>1842</RecNum><DisplayText>(<style font="Century Gothic" size="8">Lee & Ride 2018</style>)</DisplayText><record><rec-number>1842</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1586754493">1842</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lee, A.,</author><author>Ride, K.,</author></authors></contributors><titles><title>Review of nutrition among Aboriginal and Torres Strait Islander people</title><secondary-title>Australian Indigenous Health Bulletin</secondary-title></titles><periodical><full-title>Australian Indigenous Health Bulletin</full-title></periodical><volume>18</volume><number>1</number><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>(Lee & Ride 2018).Migrant and refugee women: Following migration, dietary behaviour may be influenced by post-migration environments, culture, religion and food-related beliefs and perceptions PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZ29uZ2FsYWg8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFy
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ADDIN EN.CITE.DATA (Ngongalah et al 2018). Similarly, financial and language difficulties may affect access to education and employment opportunities, which then affects income, health and nutrition literacy, and access to nutritious foods. Some migrant people experience disadvantages such as social isolation and poor housing, which can affect access to safe food and safe preparation of food, and are generally in a relatively vulnerable position in their new environments, regardless of the type of migration ADDIN EN.CITE <EndNote><Cite><Author>WHO</Author><Year>2010</Year><RecNum>7942</RecNum><DisplayText>(<style font="Century Gothic" size="8">WHO 2010</style>)</DisplayText><record><rec-number>7942</rec-number><foreign-keys><key app="EN" db-id="vzsv50d9v5f5a2ep2afp0df9fzwzd5pz0wts">7942</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>WHO,</author></authors><secondary-authors><author>Erik Blas</author><author>Anand Sivasankara Kurup</author></secondary-authors></contributors><titles><title>Equity, Social Determinant and Public Health Programmes</title></titles><dates><year>2010</year></dates><pub-location>Geneva</pub-location><publisher>World Health Organization</publisher><urls></urls></record></Cite></EndNote>(WHO 2010). Discussing nutritionAustralian dietary guidelines for pregnant womenAs outlined in the Australian Dietary Guidelines ADDIN EN.CITE <EndNote><Cite><Author>NHMRC</Author><Year>2013</Year><RecNum>8</RecNum><DisplayText>(<style font="Century Gothic" size="8">NHMRC 2013a</style>)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="d0fferpwwwssdves0d9xte2ietxt2esa2r9e" timestamp="1584674796">8</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>NHMRC,</author></authors></contributors><titles><title>Australian Dietary Guidelines</title></titles><dates><year>2013</year></dates><pub-location>Canberra</pub-location><publisher>National Health and Medical Research Council</publisher><urls><related-urls><url>;(NHMRC 2013a), consuming a variety of nutritious foods is particularly important during pregnancy and breastfeeding. Vegetables, legumes/beans and fruit: Consumption of vegetables and fruit before and during pregnancy make important contributions to health outcomes for women and their children. Grain (cereal) foods: Wholegrain foods are a valuable source of iron and zinc and fibre. Most bread in Australia is fortified with folic acid and made with iodised salt.Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans: Lean red meat and chicken are good sources of protein, iron and zinc. Maternal consumption of fish during pregnancy is likely to have a range of health benefits for women and their children but the fish should be low in mercury (see Table?2). Nuts, seeds and legumes/beans are important foods for people who choose vegetarian or vegan dietary patterns and meals without meat, as they can provide an alternative source of nutrients. For several nutrients, including iron, calcium and vitamin B12, care needs to be taken to include a variety of alternatives if animal foods are excluded.Milk, yoghurt and cheese and/or their alternatives: Milk, yoghurt and cheese or their alternatives are good sources of calcium. Water: Pregnant women require more water to support fetal circulation, amniotic fluid and a higher blood volume. Practice pointEating the recommended number of daily serves of the five food groups and drinking plenty of water is important during pregnancy and breastfeeding. Table 1:Recommended number of daily serves during pregnancy Food groupSample servePregnancyBreastfeeding<19 yrs19–50 yrs<19 yrs19–50 yrsVegetables of different types and colours, and legumes/ beans? cup cooked green or orange vegetables; ? cup legumes; 1 cup raw green leafy vegetables; ? medium potato (or sweet potato, taro or cassava); ? cup sweet corn; 1?medium tomato555 ? 7 ? Fruit1 medium apple, banana, orange or pear; 2 small apricots, kiwi fruits or plums; 1 cup diced or canned fruit (no sugar)2222Grain (cereal) foods, mostly wholegrain and/or high cereal fibre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley1 slice bread; ? medium roll or flat bread; ? cup cooked rice, pasta, noodles, polenta or quinoa; ? cup porridge; 2/3 cup wheat cereal flakes; ? cup muesli; 3 crispbreads88 ?99Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans65 g cooked lean red meat; 80?g?cooked chicken; 100?g?cooked fish fillet; 2 large eggs; 1 cup cooked lentils or canned beans; 170 g tofu; 30?g?nuts, seeds, peanut or almond butter or tahini3 ?3 ?2 ? 2 ? Milk, yoghurt, cheese and/or their alternatives (mostly reduced fat)1 cup milk; 200 g yoghurt; 40 g hard cheese; ? cup ricotta cheese; 1 cup soy, rice or other cereal drink with added calcium3 ?2 ?42 ? Approximate number of additional serves from the five food groups or discretionary choices0–30–2 ?0–30–2 ?Source: ADDIN EN.CITE <EndNote><Cite><Author>NHMRC</Author><Year>2013</Year><RecNum>7943</RecNum><DisplayText>(<style font="Century Gothic" size="8">NHMRC 2013a</style>)</DisplayText><record><rec-number>7943</rec-number><foreign-keys><key app="EN" db-id="vzsv50d9v5f5a2ep2afp0df9fzwzd5pz0wts">7943</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>NHMRC,</author></authors></contributors><titles><title>Australian Dietary Guidelines</title></titles><dates><year>2013</year></dates><pub-location>Canberra</pub-location><publisher>National Health and Medical Research Council</publisher><urls><related-urls><url>;(NHMRC 2013a).Table 2:Practical advice on nutritious foods during pregnancyFood groupConsiderationsVegetables, legumes/ beans and fruitMany women need to increase their consumption of vegetables, legumes/beans and fruitDue to the risk of listeriosis, pre-prepared or pre-packaged cut fruit or vegetables should be cooked. Pre-prepared salad vegetables (eg from salad bars) should be avoidedGrain (cereal) foodsWhile bread in Australia contains iodine and folate, supplementary folate is recommended preconception and in the first trimester and iodine should be supplemented preconception and throughout pregnancy and breastfeedingLean meats and poultry, fish, eggs, tofu, nuts and seeds, legumes/beansRaw or undercooked meat, chilled pre-cooked meats, and p?té and meat spreads should be avoided during pregnancy due to risk of listeriosisCare needs to be taken with consumption of some fish species (eg?shark/flake, marlin or broadbill/swordfish, orange roughy and catfish) due to the potentially higher mercury contentFoods containing raw eggs should be avoided due to the risk of salmonellaNuts need only be avoided if the woman has an allergy to themMilk, yoghurt, cheese and/or alternativesUnpasteurised dairy products and soft, semi-soft and surface-ripened cheese should be avoided due to the risk of listeriosisWomen who avoid milk products should consume alternative calcium-fortified productsWaterFluid need is 750–1,000 mL a day above the estimated daily intake of 2.1 L.Source: ADDIN EN.CITE <EndNote><Cite><Author>NHMRC</Author><Year>2013</Year><RecNum>7943</RecNum><DisplayText>(<style font="Century Gothic" size="8">NHMRC 2013a</style>)</DisplayText><record><rec-number>7943</rec-number><foreign-keys><key app="EN" db-id="vzsv50d9v5f5a2ep2afp0df9fzwzd5pz0wts">7943</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>NHMRC,</author></authors></contributors><titles><title>Australian Dietary Guidelines</title></titles><dates><year>2013</year></dates><pub-location>Canberra</pub-location><publisher>National Health and Medical Research Council</publisher><urls><related-urls><url>;(NHMRC 2013a).Recent evidence on dietary patternsDietary patterns associated with positive outcomes are generally characterised by high intake of fruits, vegetables, legumes, wholegrains, fish, seafood, lean meats, low-fat dairy and water. 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ADDIN EN.CITE.DATA (Martin et al 2016; Schoenaker et al 2016; Assaf-Balut et al 2017; Zareei et al 2018; Pham et al 2019)gestational hypertension PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2hvZW5ha2VyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVh
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ADDIN EN.CITE.DATA (Schoenaker et al 2014; Gresham et al 2016; Ikem et al 2019)antenatal depression ADDIN EN.CITE <EndNote><Cite><Author>Miyake</Author><Year>2018</Year><RecNum>1464</RecNum><DisplayText>(<style font="Century Gothic" size="8">Miyake et al 2018</style>)</DisplayText><record><rec-number>1464</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1574039610">1464</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miyake, Yoshihiro</author><author>Tanaka, Keiko</author><author>Okubo, Hitomi</author><author>Sasaki, Satoshi</author><author>Furukawa, Shinya</author><author>Arakawa, Masashi</author></authors></contributors><titles><title>Dietary patterns and depressive symptoms during pregnancy in Japan: Baseline data from the Kyushu Okinawa Maternal and Child Health Study</title><secondary-title>Journal of Affective Disorders</secondary-title></titles><periodical><full-title>Journal of Affective Disorders</full-title></periodical><pages>552-558</pages><volume>225</volume><section>552</section><dates><year>2018</year></dates><isbn>01650327</isbn><urls></urls><electronic-resource-num>10.1016/j.jad.2017.08.073</electronic-resource-num></record></Cite></EndNote>(Miyake et al 2018).Conversely, an unhealthy dietary pattern may increase the risk of gestational diabetes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GbHlubjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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Tm90ZT4A
ADDIN EN.CITE.DATA (Shin et al 2015; Flynn et al 2016) and antenatal depression PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXNraW48L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXNraW48L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Baskin et al 2017).The evidence is inconsistent on the association between dietary pattern in pregnancy and:preterm birth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYWdoYXZhbjwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+
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ADDIN EN.CITE.DATA (Englund-Ogge et al 2014; Rasmussen et al 2014; Saunders et al 2014; Smith et al 2015; Assaf-Balut et al 2017; Assaf-Balut et al 2018; Chia et al 2018; Chia et al 2019; Raghavan et al 2019)fetal growth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGlhPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Martin et al 2015; Flynn et al 2016; Gresham et al 2016; Assaf-Balut et al 2017; Chia et al 2018; Emond et al 2018; Martínez-Galiano et al 2018; Assaf-Balut et al 2019; Chia et al 2019; Englund-Ogge et al 2019)childhood growth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVuIEJyb2VrPC9BdXRob3I+PFllYXI+MjAxNTwv
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ADDIN EN.CITE.DATA (van den Broek et al 2015; Fernandez-Barres et al 2016; Chatzi et al 2017; Fernandez-Barres et al 2019)childhood cardiometabolic health PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWVybWFrZXJzPC9BdXRob3I+PFllYXI+MjAxNzwvWWVh
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ADDIN EN.CITE.DATA (Fernandez-Barres et al 2016; Chatzi et al 2017; Leermakers et al 2017) childhood wheeze PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbHZhcmV6IFphbGxvPC9BdXRob3I+PFllYXI+MjAxODwv
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ADDIN EN.CITE.DATA (Castro-Rodriguez et al 2016; Alvarez Zallo et al 2018; Zhang et al 2019).In systematic reviews of outcomes among women who choose vegan-vegetarian diets, findings on birthweight were inconsistent, duration of pregnancy between vegan-vegetarian and omnivorous diets was similar and there was a suggestion of risk of iron, vitamin?B12 ADDIN EN.CITE <EndNote><Cite><Author>Piccoli</Author><Year>2015</Year><RecNum>1473</RecNum><DisplayText>(<style font="Century Gothic" size="8">Piccoli et al 2015</style>)</DisplayText><record><rec-number>1473</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1574039648">1473</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Piccoli, G. B.</author><author>Clari, R.</author><author>Vigotti, F. N.</author><author>Leone, F.</author><author>Attini, R.</author><author>Cabiddu, G.</author><author>Mauro, G.</author><author>Castelluccia, N.</author><author>Colombi, N.</author><author>Capizzi, I.</author><author>Pani, A.</author><author>Todros, T.</author><author>Avagnina, P.</author></authors></contributors><titles><title>Vegan-vegetarian diets in pregnancy: danger or panacea? A systematic narrative review</title><secondary-title>BJOG: An International Journal of Obstetrics & Gynaecology</secondary-title></titles><periodical><full-title>BJOG: An International Journal of Obstetrics & Gynaecology</full-title></periodical><pages>623-633</pages><volume>122</volume><number>5</number><section>623</section><dates><year>2015</year></dates><isbn>14700328</isbn><urls></urls><electronic-resource-num>10.1111/1471-0528.13280</electronic-resource-num></record></Cite></EndNote>(Piccoli et al 2015) and zinc deficiency PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QaWNjb2xpPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Glazier et al 2018).Recent evidence on consumption of specific foods/food categories during pregnancyFruit, vegetables and legumesThere is evidence from observational studies that eating vegetables, fruit and legumes during pregnancy is beneficial to both mother and baby, witha reduction in risk of neural tube defects (OR 0.32; 95%CI 0.14 to 0.71; n=918) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYW5nPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Wang et al 2015a)possible associations with improvements in glucose tolerance (p<0.05; n=180) ADDIN EN.CITE <EndNote><Cite><Author>Soto</Author><Year>2015</Year><RecNum>1753</RecNum><DisplayText>(<style font="Century Gothic" size="8">Soto et al 2015</style>)</DisplayText><record><rec-number>1753</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1582757924">1753</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Soto, R.</author><author>Guilloty, N.</author><author>Anzalota, L.</author><author>Rosario, Z.</author><author>Cordero, J. F.</author><author>Palacios, C.</author></authors></contributors><titles><title>Association between maternal diet factors and hemoglobin levels, glucose tolerance, blood pressure and gestational age in a Hispanic population</title><secondary-title>Arch Latinoam Nutr</secondary-title></titles><periodical><full-title>Arch Latinoam Nutr</full-title></periodical><pages>86-96</pages><volume>65</volume><number>2</number><edition>2016/01/29</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Blood Glucose/*analysis</keyword><keyword>Blood Pressure/*physiology</keyword><keyword>Diabetes, Gestational/prevention & control</keyword><keyword>Dietary Supplements</keyword><keyword>Feeding Behavior/*physiology</keyword><keyword>Female</keyword><keyword>*Gestational Age</keyword><keyword>Glucose Tolerance Test</keyword><keyword>Hemoglobins/*analysis</keyword><keyword>Humans</keyword><keyword>Pregnancy</keyword><keyword>*Prenatal Nutritional Physiological Phenomena</keyword><keyword>Prospective Studies</keyword><keyword>Puerto Rico/ethnology</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Young Adult</keyword></keywords><dates><year>2015</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0004-0622 (Print)
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ADDIN EN.CITE.DATA (Torjusen et al 2014; Mi et al 2019), preterm birth (OR 0.67; 95%CI 0.50 to 0.91; n=923) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGlhPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Alvarez Zallo et al 2018). Low fruit intake is associated with higher prevalence of major depressive disorder (PR 1.43, 95%CI 1.04 to 1.95; n=712) and low intake of legumes is associated with generalised anxiety disorder (PR 1.40, 95%CI 1.01 to 1.93; n=712) (n=712) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXNrdWxpbjwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Paskulin et al 2017). A lower risk of childhood leukaemia is associated with maternal consumption of fruit (OR: 0.81, 95% CI: 0.67 to 0.99), vegetables (OR: 0.51, 95% CI: 0.28 to 0.94) and legumes (OR?0.76, 95% CI: 0.62 to 0.94) (n=903) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZXNzeXByaXM8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy
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ADDIN EN.CITE.DATA (Dessypris et al 2017). Total daily fruit and vegetable consumption during pregnancy does not appear to be associated with maternal sleep duration (? -0.03; 95%CI -0.07 to 0.00; n=2,951) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EdWtlPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Duke et al 2017).DairyThere is evidence from observational studies that higher maternal intake of all dairy products (255 vs 32 g/day) is associated with a reduced risk of eczema in babies (aOR 0.64; 95%CI 0.42 to 0.98) ADDIN EN.CITE <EndNote><Cite><Author>Miyake</Author><Year>2015</Year><RecNum>1465</RecNum><DisplayText>(<style font="Century Gothic" size="8">Miyake et al 2015</style>)</DisplayText><record><rec-number>1465</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1574039613">1465</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miyake, Y.</author><author>Tanaka, K.</author><author>Okubo, H.</author><author>Sasaki, S.</author><author>Arakawa, M.</author></authors></contributors><titles><title>Intake of dairy products and calcium and prevalence of depressive symptoms during pregnancy in Japan: a cross-sectional study</title><secondary-title>BJOG</secondary-title></titles><periodical><full-title>BJOG</full-title></periodical><pages>336-43</pages><volume>122</volume><number>3</number><section>336</section><dates><year>2015</year></dates><isbn>14700328</isbn><urls></urls><electronic-resource-num>10.1111/1471-0528.12972</electronic-resource-num></record></Cite></EndNote>(Miyake et al 2015). Maternal milk intake is associated with reduced risk of neural tube defects (1-2 vs <1 time/week; OR 0.50; 95%CI 0.28 to 0.88; n=918) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYW5nPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Tuokkola et al 2016). Higher yoghurt intake (80 g vs 4 g a day) is associated with lower prevalence of depressive symptoms during pregnancy (aOR 0.69; 95%CI 0.48 to 0.99, p for trend 0.03; n=1,745) ADDIN EN.CITE <EndNote><Cite><Author>Miyake</Author><Year>2015</Year><RecNum>1465</RecNum><DisplayText>(<style font="Century Gothic" size="8">Miyake et al 2015</style>)</DisplayText><record><rec-number>1465</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1574039613">1465</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miyake, Y.</author><author>Tanaka, K.</author><author>Okubo, H.</author><author>Sasaki, S.</author><author>Arakawa, M.</author></authors></contributors><titles><title>Intake of dairy products and calcium and prevalence of depressive symptoms during pregnancy in Japan: a cross-sectional study</title><secondary-title>BJOG</secondary-title></titles><periodical><full-title>BJOG</full-title></periodical><pages>336-43</pages><volume>122</volume><number>3</number><section>336</section><dates><year>2015</year></dates><isbn>14700328</isbn><urls></urls><electronic-resource-num>10.1111/1471-0528.12972</electronic-resource-num></record></Cite></EndNote>(Miyake et al 2015). Potential allergensThere is evidence from observational studies that a lower risk of peanut allergy in the infant is associated with maternal peanut consumption during the first trimester (OR 0.53; 95%CI 0.30 to 0.94; n=1,227) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdW55YXZhbmljaDwvQXV0aG9yPjxZZWFyPjIwMTQ8L1ll
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ADDIN EN.CITE.DATA (Bunyavanich et al 2014) or pre-pregnancy and during pregnancy (≥5 times vs <1 time per month: OR 0.31; 95% CI 0.13 to 0.75; P(trend)=0.004; n=8,205) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmF6aWVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmF6aWVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Frazier et al 2014). Maternal wheat intake during the second trimester may reduce atopic dermatitis in the infant (OR 0.64; 95%CI 0.46 to 0.90; n=1,227) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdW55YXZhbmljaDwvQXV0aG9yPjxZZWFyPjIwMTQ8L1ll
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ADDIN EN.CITE.DATA (Lombardi et al 2015).FishThere is evidence from systematic reviews of observational studies that maternal fish intake may be associated with positive neurodevelopmental outcomes (qualitative review; 8 studies) ADDIN EN.CITE <EndNote><Cite><Author>Starling</Author><Year>2015</Year><RecNum>1738</RecNum><DisplayText>(<style font="Century Gothic" size="8">Starling et al 2015</style>)</DisplayText><record><rec-number>1738</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1582506270">1738</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Starling, P.</author><author>Charlton, K.</author><author>McMahon, A. T.</author><author>Lucas, C.</author></authors></contributors><auth-address>School of Medicine, University of Wollongong, NSW 2522, Australia. pd266@uow.edu.au.
School of Medicine, University of Wollongong, NSW 2522, Australia. karenc@uow.edu.au.
School of Medicine, University of Wollongong, NSW 2522, Australia. amcmahon@uow.edu.au.
School of Medicine, University of Wollongong, NSW 2522, Australia. cjl623@uowmail.edu.au.</auth-address><titles><title>Fish intake during pregnancy and foetal neurodevelopment--a systematic review of the evidence</title><secondary-title>Nutrients</secondary-title></titles><periodical><full-title>Nutrients</full-title></periodical><pages>2001-14</pages><volume>7</volume><number>3</number><edition>2015/03/21</edition><keywords><keyword>Animals</keyword><keyword>*Cognition</keyword><keyword>*Diet</keyword><keyword>Female</keyword><keyword>*Fetal Development</keyword><keyword>*Fishes</keyword><keyword>Humans</keyword><keyword>Mercury/*adverse effects</keyword><keyword>Pregnancy</keyword><keyword>Prenatal Exposure Delayed Effects</keyword><keyword>*Seafood</keyword></keywords><dates><year>2015</year><pub-dates><date>Mar 18</date></pub-dates></dates><isbn>2072-6643 (Electronic)
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ADDIN EN.CITE.DATA (Dessypris et al 2017). It does not appear to affect the risk of infant eczema (RR 0.88; 95%CI 0.75 to 1.04; 10 studies), wheeze (RR 0.94; 95%CI 0.83 to 1.07; 8 studies), allergic rhinitis (RR 0.95; 95%CI 0.62 to 1.45; 3 studies) or asthma (RR 0.94; 95%CI 0.75 to 1.18; 4?studies) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aaGFuZzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aaGFuZzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Zhang et al 2017). Observational studies have found positive associations between maternal seafood intake during pregnancy and language and communication scales in the infant (n=38,351) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZWpydXA8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Stratakis et al 2016; van den Berg et al 2016).There is evidence from observational studies that low intake of seafood may be associated with increased risk of antenatal depression (aOR 1.54; 95%CI 1.25 to 1.89; n=12,418) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbW1ldHQ8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Mohanty et al 2016) found a possible association between lean fish intake and preterm birth (RR?1.55; 95% CI 1.04 to 2.30). The study noted that studies of mechanisms and potential contributing factors (including seafood preparation and nutrient contaminant content) are warranted. There was no association between fatty fish intake and preterm birth and no association between other pregnancy complications and either lean or fatty fish consumption. While fish consumption during pregnancy may have benefits for the women and child, high fetal exposure to mercury through maternal fish consumption is associated with low birthweight (MD -34 g; 95%CI -46 g to -22 g; n=56,988) and small-for-gestational age (aOR 1.19; 95%CI 1.08 to 1.30; n=56,988) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZWpydXA8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZWpydXA8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Vejrup et al 2014), delayed language and communication skills in a generally low exposed population (n=46,750 mother-child pairs) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZWpydXA8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Stratakis et al 2020). Types of fish that should be avoided during pregnancy due to potential high mercury content are listed in Table 2.CarbohydratesThere is RCT evidence that, in obese women with impaired glucose tolerance, a lower carbohydrate intake in late pregnancy is associated with a lower fat mass in the baby at birth (188 vs 238?g/day; ptrend=0.006; n=222) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZW5hdWx0PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Castro-Rodriguez et al 2016; Alvarez Zallo et al 2018).ProteinThere is evidence from observational studies that maternal protein intake may be associated with a higher risk of gestational diabetes (OR highest vs lowest quartile of intake 2.15; 95% CI 1.27 to 3.62; p=0.016; n=980) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYW5nPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Tielemans et al 2017), may reduce newborn abdominal adipose tissue (-0.18 mL; 95%CI -0.35 to -0.001 mL per 1% protein-to-carbohydrate substitution and -0.25 mL; 95%CI 0.46 to -0.04 mL per 1% protein-to-fat substitution; n=320 mother-child pairs) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGVuPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Switkowski et al 2016).FatsThere is evidence from observational studies that women with uncomplicated pregnancies had lower daily fat intake (32.1%) than women who developed gestational diabetes (36.2%) (p=0.0251; n=55) ADDIN EN.CITE <EndNote><Cite><Author>Mizgier</Author><Year>2019</Year><RecNum>1466</RecNum><DisplayText>(<style font="Century Gothic" size="8">Mizgier et al 2019</style>)</DisplayText><record><rec-number>1466</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1574039617">1466</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mizgier, M.,</author><author>Jarzabek-Bielecka, G.,</author><author>Mruczyk, K.,</author></authors></contributors><titles><title>Maternal diet and gestational diabetes mellitus development</title><secondary-title>J Maternal-Fetal Neonat Med</secondary-title></titles><periodical><full-title>J Maternal-Fetal Neonat Med</full-title></periodical><pages>1-10</pages><section>1</section><dates><year>2019</year></dates><isbn>1476-7058
1476-4954</isbn><urls></urls><electronic-resource-num>10.1080/14767058.2019.1598364</electronic-resource-num></record></Cite></EndNote>(Mizgier et al 2019) and that an additional 10 g/day fat intake was associated with a lower birthweight (MD -8 g; 95%CI -16 to -0.3; p=0.04; n=1,196), with the authors concluding that balancing intake of dietary carbohydrate and fat during pregnancy could support optimal birthweight PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFybWE8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Sharma et al 2018).Sweetened foods and beveragesThere is evidence from an RCT that higher consumption of foods and drinks that contribute to intake of added sugars (2 times daily versus <1 time/week) is associated with higher gestational weight gain (MD 5.4 kg; 95% CI 2.1 to 8.7; n=342) ADDIN EN.CITE <EndNote><Cite><Author>Renault</Author><Year>2015</Year><RecNum>1414</RecNum><DisplayText>(<style font="Century Gothic" size="8">Renault et al 2015b</style>)</DisplayText><record><rec-number>1414</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1567995300">1414</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Renault, K.M.,</author><author>Carlsen, E.M.,</author><author>N?rgaard, K.,</author><author>Nilas, L.,</author><author>Pryds, O.,</author><author>Secher, N.J.,</author><author>Olsen, S.F.,</author><author>Halldorsson, T.I.,</author></authors></contributors><titles><title>Intake of sweets, snacks and soft drinks predicts weight gain in obese pregnant women: detailed analysis of the results of a randomised controlled trial</title><secondary-title>Plos One</secondary-title></titles><periodical><full-title>PLoS One</full-title></periodical><volume>10</volume><number>7</number><section>e0133041</section><dates><year>2015</year></dates><isbn>1932-6203</isbn><urls></urls><electronic-resource-num>10.1371/journal.pone.0133041</electronic-resource-num></record></Cite></EndNote>(Renault et al 2015b). Observational studies report an association between sugar-sweetened foods and drinks and impaired glucose tolerance (p<0.05; n=180) ADDIN EN.CITE <EndNote><Cite><Author>Soto</Author><Year>2015</Year><RecNum>1753</RecNum><DisplayText>(<style font="Century Gothic" size="8">Soto et al 2015</style>)</DisplayText><record><rec-number>1753</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1582757924">1753</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Soto, R.</author><author>Guilloty, N.</author><author>Anzalota, L.</author><author>Rosario, Z.</author><author>Cordero, J. F.</author><author>Palacios, C.</author></authors></contributors><titles><title>Association between maternal diet factors and hemoglobin levels, glucose tolerance, blood pressure and gestational age in a Hispanic population</title><secondary-title>Arch Latinoam Nutr</secondary-title></titles><periodical><full-title>Arch Latinoam Nutr</full-title></periodical><pages>86-96</pages><volume>65</volume><number>2</number><edition>2016/01/29</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Blood Glucose/*analysis</keyword><keyword>Blood Pressure/*physiology</keyword><keyword>Diabetes, Gestational/prevention & control</keyword><keyword>Dietary Supplements</keyword><keyword>Feeding Behavior/*physiology</keyword><keyword>Female</keyword><keyword>*Gestational Age</keyword><keyword>Glucose Tolerance Test</keyword><keyword>Hemoglobins/*analysis</keyword><keyword>Humans</keyword><keyword>Pregnancy</keyword><keyword>*Prenatal Nutritional Physiological Phenomena</keyword><keyword>Prospective Studies</keyword><keyword>Puerto Rico/ethnology</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Young Adult</keyword></keywords><dates><year>2015</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0004-0622 (Print)
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ADDIN EN.CITE.DATA (Donazar-Ezcurra et al 2018). It is also associated with an increased prevalence of major depressive disorder (adjusted prevalence ratio [aPR] 1.91; 95%CI 1.19 to 3.07; n=712) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXNrdWxpbjwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXNrdWxpbjwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Paskulin et al 2017). Fetal and child growth is also affected by higher intake of sweetened foods and drinks, with increased risks of large for gestational age (aRR 1.57; 95%CI 1.05 to 2.35; n=918 mother-child pairs) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aaHU8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Zhu et al 2017). Maternal consumption of sweetened foods and beverages is also associated with infant atopy (OR for highest versus lowest quintile of sugar intake 1.38, 95%CI 1.06 to 1.78; per quintile p-trend=0.006; n=8,956) and asthma (OR 2.01, 95% CI 1.23-3.29; per quintile p-trend=0.004 n=8,956) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWRhcmQ8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Lombardi et al 2015).CaffeineThere is insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birth weight or other pregnancy outcomes ADDIN EN.CITE <EndNote><Cite><Author>Jahanfar</Author><Year>2015</Year><RecNum>1845</RecNum><DisplayText>(<style font="Century Gothic" size="8">Jahanfar & Jaafar 2015</style>)</DisplayText><record><rec-number>1845</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1586822664">1845</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jahanfar, S.</author><author>Jaafar, S. H.</author></authors></contributors><auth-address>Department of Public Health, School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Colombia, Canada, VT6 1Z3.</auth-address><titles><title>Effects of restricted caffeine intake by mother on fetal, neonatal and pregnancy outcomes</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD006965</pages><number>6</number><edition>2015/06/11</edition><keywords><keyword>Birth Weight/*drug effects</keyword><keyword>Caffeine/administration & dosage/*pharmacology</keyword><keyword>Central Nervous System Stimulants/administration & dosage/*pharmacology</keyword><keyword>*Coffee</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Small for Gestational Age</keyword><keyword>Pregnancy/*drug effects</keyword><keyword>Pregnancy Outcome</keyword><keyword>Premature Birth/etiology</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2015</year><pub-dates><date>Jun 9</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>26058966</accession-num><urls><related-urls><url>;(Jahanfar & Jaafar 2015). Food Standards Australia and New Zealand suggests limiting intake during pregnancy to 200 mg of caffeine ADDIN EN.CITE <EndNote><Cite><Author>FSANZ</Author><Year>2019</Year><RecNum>1844</RecNum><DisplayText>(<style font="Century Gothic" size="8">FSANZ 2019</style>)</DisplayText><record><rec-number>1844</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1586761094">1844</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>FSANZ,</author></authors></contributors><titles><title>Caffeine</title></titles><number>13 April 2020</number><dates><year>2019</year></dates><urls><related-urls><url>;(FSANZ 2019), noting that caffeine is present in coffee, tea, colas, energy drinks and chocolate.There is evidence from observational studies that the risks of preterm birth (OR per 100 mg/d caffeine increase 1.28; 95%CI 1.03 to 1.58; P=0.03; n=858) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Pa3VibzwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Greenop et al 2014) increase with caffeine intake. Nutritional supplementsThe evidence supports routine supplementation with folic acid preconception and in the first trimester. NHMRC advises iodine supplementation preconception and during pregnancy and breastfeeding. Iron supplementation may prevent iron deficiency in women with limited dietary iron intake and calcium supplementation may be beneficial in women with low dietary intake. Vitamin B12 supplementation may be needed if a woman has a vegetarian or vegan diet. Vitamin D supplementation, which is discussed in Chapter?47, may be a consideration for women with vitamin D levels lower than 50?nmol/L. VitaminsFolic acid (vitamin B9)BackgroundA survey of pregnant women conducted in Sydney found that 30.6% were taking a folic acid supplement PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFuZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Shand et al 2016). A cross-sectional study that included national and South Australian cohorts found that, while awareness of recommendations on folic acid supplementation was high (90%), adherence was low (27%) ADDIN EN.CITE <EndNote><Cite><Author>Malek</Author><Year>2016</Year><RecNum>1437</RecNum><DisplayText>(<style font="Century Gothic" size="8">Malek et al 2016b</style>)</DisplayText><record><rec-number>1437</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1571626245">1437</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Malek, Lenka</author><author>Umberger, Wendy</author><author>Makrides, Maria</author><author>Zhou, Shao J.</author></authors></contributors><titles><title>Poor adherence to folic acid and iodine supplement recommendations in preconception and pregnancy: a cross-sectional analysis</title><secondary-title>Australian and New Zealand Journal of Public Health</secondary-title></titles><periodical><full-title>Australian and New Zealand Journal of Public Health</full-title></periodical><pages>424-429</pages><volume>40</volume><number>5</number><section>424</section><dates><year>2016</year></dates><isbn>13260200</isbn><urls></urls><electronic-resource-num>10.1111/1753-6405.12552</electronic-resource-num></record></Cite></EndNote>(Malek et al 2016b).In an Australian cohort study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Livock et al 2017), 19-46% of women did not meet the recommended daily intake for folate. Conversely, 15-19 % of women consumed beyond the recommended upper limit for folate. Dietary sources of folate include green vegetables (eg spinach), legumes, rice, avocado, fruit and beef liver and fortified products (many breakfast cereals, bread, fruit juice, vegemite).Summary of the evidenceThere is high certainty evidence that folic acid supplementation in pregnancy is associated with a reduction in risk of neural tube defects (RR 0.31; 95%CI 0.17 to 0.58; 5 RCTs; n=6,708) and low certainty evidence that it may also reduce the risk of cleft palate (RR 0.73; 95%CI 0.05 to 0.89; 3 RCTs; n=5,612) ADDIN EN.CITE <EndNote><Cite><Author>De-Regil</Author><Year>2015</Year><RecNum>1430</RecNum><DisplayText>(<style font="Century Gothic" size="8">De-Regil et al 2015</style>)</DisplayText><record><rec-number>1430</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1571626206">1430</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>De-Regil, L. M.</author><author>Pena-Rosas, J. P.</author><author>Fernandez-Gaxiola, A. C.</author><author>Rayco-Solon, P.</author></authors></contributors><auth-address>Research and Evaluation, Micronutrient Initiative, 180 Elgin Street, Suite 1000, Ottawa, ON, Canada, K2P 2K3.</auth-address><titles><title>Effects and safety of periconceptional oral folate supplementation for preventing birth defects</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD007950</pages><number>12</number><edition>2015/12/15</edition><keywords><keyword>Dietary Supplements</keyword><keyword>Female</keyword><keyword>Folic Acid/*administration & dosage</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Neural Tube Defects/*prevention & control</keyword><keyword>Preconception Care</keyword><keyword>Pregnancy</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Vitamin B Complex/*administration & dosage</keyword></keywords><dates><year>2015</year><pub-dates><date>Dec 14</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>26662928</accession-num><urls><related-urls><url>;(De-Regil et al 2015). Evidence from observational studies suggests it may reduce congenital heart defects (RR 0.72; 95%CI 0.63 to 0.82 ADDIN EN.CITE <EndNote><Cite><Author>Feng</Author><Year>2015</Year><RecNum>1432</RecNum><DisplayText>(<style font="Century Gothic" size="8">Feng et al 2015</style>)</DisplayText><record><rec-number>1432</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1571626218">1432</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Feng, Y.</author><author>Wang, S.</author><author>Chen, R.</author><author>Tong, X.</author><author>Wu, Z.</author><author>Mo, X.</author></authors></contributors><auth-address>Department of Cardiothoracic Surgery, The Affiliated Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
Atherosclerosis Research Center, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, Jiangsu, China.</auth-address><titles><title>Maternal folic acid supplementation and the risk of congenital heart defects in offspring: a meta-analysis of epidemiological observational studies</title><secondary-title>Sci Rep</secondary-title></titles><periodical><full-title>Sci Rep</full-title></periodical><pages>8506</pages><volume>5</volume><edition>2015/02/18</edition><keywords><keyword>*Dietary Supplements</keyword><keyword>Female</keyword><keyword>Folic Acid/*adverse effects</keyword><keyword>Heart Defects, Congenital/*epidemiology/*etiology</keyword><keyword>Humans</keyword><keyword>*Maternal Exposure</keyword><keyword>Odds Ratio</keyword><keyword>Pregnancy</keyword><keyword>*Prenatal Exposure Delayed Effects</keyword><keyword>Risk</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb 17</date></pub-dates></dates><isbn>2045-2322 (Electronic)
2045-2322 (Linking)</isbn><accession-num>25687545</accession-num><urls><related-urls><url>;(Feng et al 2015); OR 0.60; 95%CI 0.49 to 0.71 ADDIN EN.CITE <EndNote><Cite><Author>Xu</Author><Year>2016</Year><RecNum>1618</RecNum><DisplayText>(<style font="Century Gothic" size="8">Xu et al 2016</style>)</DisplayText><record><rec-number>1618</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576726470">1618</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Xu, A.</author><author>Cao, X.</author><author>Lu, Y.</author><author>Li, H.</author><author>Zhu, Q.</author><author>Chen, X.</author><author>Jiang, H.</author><author>Li, X.</author></authors></contributors><auth-address>Prenatal Screening Diagnosis Center, Nantong Maternal and Child Health Hospital.</auth-address><titles><title>A meta-analysis of the relationship between maternal folic acid supplementation and the risk of congenital heart defects</title><secondary-title>Int Heart J</secondary-title></titles><periodical><full-title>Int Heart J</full-title></periodical><pages>725-728</pages><volume>57</volume><number>6</number><edition>2016/11/11</edition><keywords><keyword>*Dietary Supplements</keyword><keyword>Female</keyword><keyword>Folic Acid/*therapeutic use</keyword><keyword>Heart Defects, Congenital/*prevention & control</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Pregnancy</keyword><keyword>Prenatal Care</keyword><keyword>Vitamin B Complex/*therapeutic use</keyword></keywords><dates><year>2016</year><pub-dates><date>Dec 2</date></pub-dates></dates><isbn>1349-3299 (Electronic)
1349-2365 (Linking)</isbn><accession-num>27829639</accession-num><urls><related-urls><url>;(Xu et al 2016)). There is evidence from systematic reviews of observational studies that folic acid supplementation during pregnancy may reduce the risk of acute myeloid leukaemia (OR 0.52; 95%CI 0.31 to 0.89) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZXRheWVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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Tm90ZT4A
ADDIN EN.CITE.DATA (Wang et al 2017).The evidence suggests that folic acid supplementation during pregnancy does not affect the risk of early or late miscarriage (RR?0.97; 95%CI 0.65 to 1.44; 1 RCT; n=903), stillbirth (RR 0.67; 95%CI 0.11 to 4.02; 1 RCT; n=903), total fetal loss (RR?0.95; 95%CI 0.64 to 1.40; 1 RCT; n=903) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWxvZ3VuPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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PgB=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWxvZ3VuPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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PgB=
ADDIN EN.CITE.DATA (Balogun et al 2016), preterm birth (RR?0.99; 95%CI 0.82 to 1.18; 1 RCT; n=1,654 PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYWNjb25lPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE.DATA (Saccone & Berghella 2016); RR 0.80; 95%CI 0.63 to 1.02; 3 studies; n=3,089 ADDIN EN.CITE <EndNote><Cite><Author>Lassi</Author><Year>2013</Year><RecNum>1435</RecNum><DisplayText>(<style font="Century Gothic" size="8">Lassi et al 2013</style>)</DisplayText><record><rec-number>1435</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1571626233">1435</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lassi, Zohra S.</author><author>Salam, Rehana A.</author><author>Haider, Batool A.</author><author>Bhutta, Zulfiqar A.</author></authors></contributors><titles><title>Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2013</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD006896.pub2</electronic-resource-num></record></Cite></EndNote>(Lassi et al 2013)), infant asthma (RR?1.04; 95%CI 0.94 to 1.16; 3 observational studies) or infant wheeze (RR?1.04; 95%CI 0.94 to 1.16; 3 observational studies) ADDIN EN.CITE <EndNote><Cite><Author>Wang</Author><Year>2015</Year><RecNum>1616</RecNum><DisplayText>(<style font="Century Gothic" size="8">Wang et al 2015b</style>)</DisplayText><record><rec-number>1616</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576725325">1616</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wang, Ting</author><author>Zhang, Hong-Ping</author><author>Zhang, Xin</author><author>Liang, Zong-An</author><author>Ji, Yu-Lin</author><author>Wang, Gang</author></authors></contributors><titles><title>Is folate status a risk factor for asthma or other allergic diseases?</title><secondary-title>Allergy, Asthma & Immunology Research</secondary-title></titles><periodical><full-title>Allergy, Asthma & Immunology Research</full-title></periodical><volume>7</volume><number>6</number><section>538</section><dates><year>2015</year></dates><isbn>2092-7355
2092-7363</isbn><urls></urls><electronic-resource-num>10.4168/aair.2015.7.6.538</electronic-resource-num></record></Cite></EndNote>(Wang et al 2015b). There is unclear evidence on the effect of folic acid supplementation on gestational hypertension, pre-eclampsia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdWE8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Hua et al 2016; Bulloch et al 2018; Liu et al 2018a; Wen et al 2018) and acute lymphoblastic leukaemia in the infant PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZXNzeXByaXM8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy
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ADDIN EN.CITE.DATA (Metayer et al 2014; Dessypris et al 2017).Evidence-based recommendation Recommend dietary supplementation of 500 micrograms per day folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy to reduce the risk of neural tube defects.Other vitaminsVitamin B6: There is insufficient evidence to detect clinical benefits in pregnancy ADDIN EN.CITE <EndNote><Cite><Author>Salam</Author><Year>2015</Year><RecNum>1602</RecNum><DisplayText>(<style font="Century Gothic" size="8">Salam et al 2015</style>)</DisplayText><record><rec-number>1602</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576555048">1602</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Salam, R. A.</author><author>Zuberi, N. F.</author><author>Bhutta, Z. A.</author></authors></contributors><auth-address>Division of Women and Child Health, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Sind, Pakistan, 74800.</auth-address><titles><title>Pyridoxine (vitamin B6) supplementation during pregnancy or labour for maternal and neonatal outcomes</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD000179</pages><number>6</number><edition>2015/06/04</edition><keywords><keyword>Birth Weight</keyword><keyword>Dental Caries/prevention & control</keyword><keyword>*Dietary Supplements</keyword><keyword>Eclampsia/prevention & control</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Labor, Obstetric</keyword><keyword>Pre-Eclampsia/prevention & control</keyword><keyword>*Pregnancy</keyword><keyword>Pregnancy Outcome</keyword><keyword>Pyridoxine/*administration & dosage</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Vitamin B Complex/*administration & dosage</keyword></keywords><dates><year>2015</year><pub-dates><date>Jun 3</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>26039815</accession-num><urls><related-urls><url>;(Salam et al 2015), although it appears to be of benefit in reducing nausea (MD in nausea score -3.7; 95%CI -6.9 to -0.5; very low certainty) ADDIN EN.CITE <EndNote><Cite><Author>Sridharan</Author><Year>2018</Year><RecNum>1577</RecNum><DisplayText>(<style font="Century Gothic" size="8">Sridharan & Sivaramakrishnan 2018</style>)</DisplayText><record><rec-number>1577</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576536337">1577</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sridharan, Kannan</author><author>Sivaramakrishnan, Gowri</author></authors></contributors><titles><title>Interventions for treating nausea and vomiting in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials</title><secondary-title>Expert Review of Clinical Pharmacology</secondary-title></titles><periodical><full-title>Expert Review of Clinical Pharmacology</full-title></periodical><pages>1143-1150</pages><volume>11</volume><number>11</number><section>1143</section><dates><year>2018</year></dates><isbn>1751-2433
1751-2441</isbn><urls></urls><electronic-resource-num>10.1080/17512433.2018.1530108</electronic-resource-num></record></Cite></EndNote>(Sridharan & Sivaramakrishnan 2018). See also Chapter 54.Vitamin B12: The evidence on vitamin B12 supplementation in pregnancy is of insufficient certainty to draw conclusions, although it may be of benefit for women with vegetarian or vegan diets, who often have low vitamin B12 concentrations ADDIN EN.CITE <EndNote><Cite><Author>Pawlak</Author><Year>2014</Year><RecNum>1599</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pawlak et al 2014</style>)</DisplayText><record><rec-number>1599</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576555028">1599</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pawlak, R.</author><author>Lester, S. E.</author><author>Babatunde, T.</author></authors></contributors><auth-address>Department of Nutrition Science, East Carolina University, Greenville, NC, USA.</auth-address><titles><title>The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature</title><secondary-title>Eur J Clin Nutr</secondary-title></titles><periodical><full-title>Eur J Clin Nutr</full-title></periodical><pages>541-8</pages><volume>68</volume><number>5</number><edition>2014/03/29</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Diet, Vegetarian</keyword><keyword>Dietary Supplements</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Nutritional Status</keyword><keyword>Pregnancy</keyword><keyword>Prevalence</keyword><keyword>Vitamin B 12/*blood</keyword><keyword>Vitamin B 12 Deficiency/*epidemiology</keyword><keyword>Young Adult</keyword></keywords><dates><year>2014</year><pub-dates><date>May</date></pub-dates></dates><isbn>1476-5640 (Electronic)
0954-3007 (Linking)</isbn><accession-num>24667752</accession-num><urls><related-urls><url>;(Pawlak et al 2014).Vitamin C: The evidence does not support routine vitamin C supplementation for preventing fetal loss (RR 1.28; 95%CI 0.58 to 2.83; 2 RCTs; n=224) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWxvZ3VuPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ZE5vdGU+
ADDIN EN.CITE.DATA (Rumbold et al 2015b), intrauterine growth restriction (RR 1.56; 95%CI 0.63 to 3.89; 1?RCT; n=159; high certainty), preterm birth (RR 1.06; 95%CI 0.75 to 1.48; 5 RCTs; n=1,685; high certainty) or pre-eclampsia (RR 0.88; 95%CI 0.48 to 1.61; 3 RCTs; n=1,191) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdW1ib2xkPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ZE5vdGU+
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdW1ib2xkPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ZE5vdGU+
ADDIN EN.CITE.DATA (Rumbold et al 2015b). Further research is required to clarify the possible role of vitamin C in the prevention of placental abruption and prelabour rupture of membranes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdW1ib2xkPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdW1ib2xkPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Fu et al 2018).Vitamins C and E combined: Supplementation with vitamins C and E during pregnancy appears to reduce the risk of placental abruption (RR 0.64; 95% CI 0.44 to 0.93, 7 RCTs, n=14,922; high certainty) but increases the risk of term prelabour rupture of the membranes (RR 1.77; 95% CI 1.37 to 2.28, 2 RCTs, n=2,504) ADDIN EN.CITE <EndNote><Cite><Author>Rumbold</Author><Year>2015</Year><RecNum>1294</RecNum><DisplayText>(<style font="Century Gothic" size="8">Rumbold et al 2015a</style>)</DisplayText><record><rec-number>1294</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1565223630">1294</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rumbold, A.</author><author>Ota, E.</author><author>Hori, H.</author><author>Miyazaki, C.</author><author>Crowther, C. A.</author></authors></contributors><auth-address>The Robinson Research Institute, The University of Adelaide, Ground Floor, Norwich Centre, 55 King William Road, Adelaide, NT, Australia, SA 5006.</auth-address><titles><title>Vitamin E supplementation in pregnancy</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD004069</pages><number>9</number><edition>2015/09/08</edition><keywords><keyword>Antioxidants/*administration & dosage/adverse effects</keyword><keyword>*Dietary Supplements/adverse effects</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Small for Gestational Age</keyword><keyword>Pre-Eclampsia/*prevention & control</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Complications/prevention & control</keyword><keyword>Pregnancy Outcome</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Vitamin E/*administration & dosage/adverse effects</keyword></keywords><dates><year>2015</year><pub-dates><date>Sep 7</date></pub-dates></dates><isbn>1469-493X (Electronic)
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ADDIN EN.CITE.DATA (Rumbold et al 2015a; Balogun et al 2016; Vahdaninia M. et al 2017; Fu et al 2018; Tenorio et al 2018). Combined vitamins C and E may reduce the risk of preterm birth (RR 0.76; 95% CI 0.58 to 0.99) and placental abruption (RR 0.09; 95% CI 0.00 to 0.87) in pregnant women who smoke PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYnJhbW92aWNpPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYnJhbW92aWNpPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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O0RlcGFydG1lbnQgb2YgT2JzdGV0cmljcyBhbmQgR3luZWNvbG9neSwgQ29sdW1iaWEgVW5pdmVy
c2l0eSwgTmV3IFlvcmssIE5ZLCBVU0EuJiN4RDtEZXBhcnRtZW50IG9mIE9ic3RldHJpY3MgYW5k
IEd5bmVjb2xvZ3ksIFVuaXZlcnNpdHkgb2YgTm9ydGggQ2Fyb2xpbmEgYXQgQ2hhcGVsIEhpbGws
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TCwgVVNBLiYjeEQ7RGVwYXJ0bWVudCBvZiBPYnN0ZXRyaWNzIGFuZCBHeW5lY29sb2d5LCBUaGUg
T2hpbyBTdGF0ZSBVbml2ZXJzaXR5LCBDb2x1bWJ1cywgT0gsIFVTQS4mI3hEO0RlcGFydG1lbnQg
b2YgT2JzdGV0cmljcyBhbmQgR3luZWNvbG9neSwgRHJleGVsIFVuaXZlcnNpdHksIFBoaWxhZGVs
cGhpYSwgUEEsIFVTQS4mI3hEO0RlcGFydG1lbnQgb2YgT2JzdGV0cmljcyBhbmQgR3luZWNvbG9n
eSwgV2FrZSBGb3Jlc3QgVW5pdmVyc2l0eSBIZWFsdGggU2NpZW5jZXMsIFdpbnN0b24tU2FsZW0s
IE5DLCBVU0EuJiN4RDtEZXBhcnRtZW50IG9mIE9ic3RldHJpY3MgYW5kIEd5bmVjb2xvZ3ksIFVu
aXZlcnNpdHkgb2YgVGV4YXMgTWVkaWNhbCBCcmFuY2gsIEdhbHZlc3RvbiwgVFgsIFVTQS4mI3hE
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dmVyc2l0eSwgRGV0cm9pdCwgTUksIFVTQS48L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5Q
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b2NpYXRlZCB3aXRoIHJlZHVjZWQgcGxhY2VudGFsIGFicnVwdGlvbiBhbmQgcHJldGVybSBiaXJ0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ADDIN EN.CITE.DATA (Abramovici et al 2015).Vitamin A: The evidence does not support vitamin A supplementation for the prevention of fetal loss (RR?1.05; 95%CI 0.90 to 1.23; 3 RCTs; n=52,480) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWxvZ3VuPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWxvZ3VuPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48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ADDIN EN.CITE.DATA (Balogun et al 2016), maternal mortality (RR 0.88; 95%CI 0.65 to 1.20; 4 RCTs; n=154,039; high certainty), perinatal mortality (RR 1.01; 95%CI 0.95 to 1.07; 1?RCT, n=76,178; high certainty) or preterm birth (RR 0.98; 95%CI 0.94 to 1.01; 5 RCTs, n=48,007; high certainty) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0NhdWxleTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
PFJlY051bT4xMzA1PC9SZWNOdW0+PERpc3BsYXlUZXh0Pig8c3R5bGUgZm9udD0iQ2VudHVyeSBH
b3RoaWMiIHNpemU9IjgiPk1jQ2F1bGV5IGV0IGFsIDIwMTU8L3N0eWxlPik8L0Rpc3BsYXlUZXh0
PjxyZWNvcmQ+PHJlYy1udW1iZXI+MTMwNTwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkg
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ADDIN EN.CITE.DATA (McCauley et al 2015). The evidence on the role of vitamin A supplementation in reducing risk of maternal clinical infection (RR?0.45; 95%CI 0.20 to 0.99; 5 RCTs; n=17,313; low certainty) and preventing anaemia (RR 0.64; 95%CI 0.43 to 0.94; 3?RCTs; n=15,649; moderate certainty) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0NhdWxleTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA (McCauley et al 2015) may not be generalisable to the Australian context. Evidence-based recommendation Advise women that taking vitamin A, C or E supplements is of little or no benefit in pregnancy and may cause harm.MineralsIronBackgroundAustralian studies have investigated rates of iron supplementation, intake and anaemia among Australian women during pregnancy. In an Australian cohort study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Livock et al 2017) 68-82% of women did not meet the recommended daily intake level for iron; conversely, 11-24% of women consumed beyond the recommended upper limit for iron. Australian cross-sectional studies have found that levels of iron-only supplementation are relatively low in general (7-30%) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFuZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Chatterjee et al 2016; Shand et al 2016) and among women with diagnosed iron deficiency (65%) or with diagnosed anaemia (62%) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGF0dGVyamVlPC9BdXRob3I+PFllYXI+MjAxNjwvWWVh
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ADDIN EN.CITE.DATA (Chatterjee et al 2016).Studies among Aboriginal and Torres Strait Islander women have found very low levels of women meeting the estimated average requirement for iron in some areas PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Bokhari et al 2012). Absorption is aided by vitamin C and limited by tea and coffee ADDIN EN.CITE <EndNote><Cite><Author>Marsh</Author><Year>2009</Year><RecNum>8356</RecNum><DisplayText>(<style font="Century Gothic" size="8">Marsh et al 2009</style>)</DisplayText><record><rec-number>8356</rec-number><foreign-keys><key app="EN" db-id="vzsv50d9v5f5a2ep2afp0df9fzwzd5pz0wts">8356</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marsh, K.</author><author>Zeuschner, C.</author><author>Saunders, A.</author><author>Reid, M.</author></authors></contributors><auth-address>Northside Nutrition & Dietetics, Sydney, New South Wales.</auth-address><titles><title>Meeting nutritional needs on a vegetarian diet</title><secondary-title>Aust Fam Physician</secondary-title><alt-title>Australian family physician</alt-title></titles><periodical><full-title>Aust Fam Physician</full-title><abbr-1>Australian family physician</abbr-1></periodical><alt-periodical><full-title>Aust Fam Physician</full-title><abbr-1>Australian family physician</abbr-1></alt-periodical><pages>600-2</pages><volume>38</volume><number>8</number><edition>2009/11/07</edition><keywords><keyword>*Diet, Vegetarian</keyword><keyword>Humans</keyword><keyword>*Nutritional Requirements</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0300-8495 (Print)
0300-8495 (Linking)</isbn><accession-num>19893782</accession-num><urls><related-urls><url>;(Marsh et al 2009). Where iron-rich foods are not available (eg due to geographical location or socioeconomic factors), women may be at high risk of iron deficiency. Summary of the recent evidenceThere is moderate certainty evidence that iron supplementation in pregnancy may reduce the risk of preterm birth (RR 0.93; 95%CI 0.84 to 1.03, 13 RCTs, n=19,286) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYnJhaGE8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Pe?a-Rosas et al 2015; Abraha et al 2019). There is low certainty evidence that iron supplementation in pregnancy reduces the risk of maternal anaemia at term (RR 0.30; 95%CI 0.19 to 0.46, 14 RCTs, n=2,199 ADDIN EN.CITE <EndNote><Cite><Author>Pe?a-Rosas</Author><Year>2015</Year><RecNum>1636</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pe?a-Rosas et al 2015</style>)</DisplayText><record><rec-number>1636</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576734362">1636</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pe?a-Rosas, Juan Pablo</author><author>De-Regil, Luz Maria</author><author>Garcia-Casal, Maria N.</author><author>Dowswell, Therese</author></authors></contributors><titles><title>Daily oral iron supplementation during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD004736.pub5</electronic-resource-num></record></Cite></EndNote>(Pe?a-Rosas et al 2015); RR 0.38; 95% CI 0.27 to 0.33; 13 RCTs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYnJhaGE8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Abraha et al 2019)) and iron deficiency at term (RR 0.43; 95%CI 0.27 to 0.66, 7 RCTs, n=1,256) ADDIN EN.CITE <EndNote><Cite><Author>Pe?a-Rosas</Author><Year>2015</Year><RecNum>1636</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pe?a-Rosas et al 2015</style>)</DisplayText><record><rec-number>1636</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576734362">1636</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pe?a-Rosas, Juan Pablo</author><author>De-Regil, Luz Maria</author><author>Garcia-Casal, Maria N.</author><author>Dowswell, Therese</author></authors></contributors><titles><title>Daily oral iron supplementation during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD004736.pub5</electronic-resource-num></record></Cite></EndNote>(Pe?a-Rosas et al 2015). There is also low certainty evidence that iron supplementation has no clear effect on neonatal death (RR?0.91; 95%CI 0.71 to 1.18, 4 RCTs, n=16,603 ADDIN EN.CITE <EndNote><Cite><Author>Pe?a-Rosas</Author><Year>2015</Year><RecNum>1636</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pe?a-Rosas et al 2015</style>)</DisplayText><record><rec-number>1636</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576734362">1636</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pe?a-Rosas, Juan Pablo</author><author>De-Regil, Luz Maria</author><author>Garcia-Casal, Maria N.</author><author>Dowswell, Therese</author></authors></contributors><titles><title>Daily oral iron supplementation during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD004736.pub5</electronic-resource-num></record></Cite></EndNote>(Pe?a-Rosas et al 2015); RR 0.93; 0.72 to 1.20; 7 RCTs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYnJhaGE8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Abraha et al 2019)) or congenital anomalies (RR 0.88, 95%CI 0.58 to 1.33, 4 RCTs, n=14,636) ADDIN EN.CITE <EndNote><Cite><Author>Pe?a-Rosas</Author><Year>2015</Year><RecNum>1636</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pe?a-Rosas et al 2015</style>)</DisplayText><record><rec-number>1636</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576734362">1636</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pe?a-Rosas, Juan Pablo</author><author>De-Regil, Luz Maria</author><author>Garcia-Casal, Maria N.</author><author>Dowswell, Therese</author></authors></contributors><titles><title>Daily oral iron supplementation during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD004736.pub5</electronic-resource-num></record></Cite></EndNote>(Pe?a-Rosas et al 2015). There is very low certainty evidence that iron supplementation in pregnancy has no clear effect on the risk of maternal death (RR 0.33; 95%CI 0.01 to 8.19, 2 RCTs, n=12,560) ADDIN EN.CITE <EndNote><Cite><Author>Pe?a-Rosas</Author><Year>2015</Year><RecNum>1636</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pe?a-Rosas et al 2015</style>)</DisplayText><record><rec-number>1636</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576734362">1636</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pe?a-Rosas, Juan Pablo</author><author>De-Regil, Luz Maria</author><author>Garcia-Casal, Maria N.</author><author>Dowswell, Therese</author></authors></contributors><titles><title>Daily oral iron supplementation during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD004736.pub5</electronic-resource-num></record></Cite></EndNote>(Pe?a-Rosas et al 2015) or maternal adverse effects (RR?1.29; 95%CI 0.83 to 2.02, 11 RCTs, n=2,423 ADDIN EN.CITE <EndNote><Cite><Author>Pe?a-Rosas</Author><Year>2015</Year><RecNum>1636</RecNum><DisplayText>(<style font="Century Gothic" size="8">Pe?a-Rosas et al 2015</style>)</DisplayText><record><rec-number>1636</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576734362">1636</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pe?a-Rosas, Juan Pablo</author><author>De-Regil, Luz Maria</author><author>Garcia-Casal, Maria N.</author><author>Dowswell, Therese</author></authors></contributors><titles><title>Daily oral iron supplementation during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD004736.pub5</electronic-resource-num></record></Cite></EndNote>(Pe?a-Rosas et al 2015); RR 1.42; 95%CI 0.91 to 2.21; 12?RCTs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYnJhaGE8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Jayasinghe et al 2018).Evidence-based recommendation Only advise iron supplementation to pregnant women if their dietary iron intake is low or they have iron-deficiency anaemia.There is low certainty evidence that intermittent versus daily iron supplementation in pregnancy has no clear effect on preterm birth (RR 1.03; 95%CI 0.76 to 1.39; n=1,177; 5 RCTs), birthweight (MD 5.13 g; 95%CI -29.46 to 39.72; n=1,939; 9 RCTs) or low birthweight (RR 0.82; 95%CI 0.55 to 1.22; n=1,898; 8 RCTs) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZW5hLVJvc2FzPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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ADDIN EN.CITE.DATA (Pena-Rosas et al 2015). There is very low certainty evidence that maternal adverse effects such as constipation and nausea (RR?0.56; 95%CI 0.37 to 0.84; n=1,777; 1 RCT) are reduced with intermittent versus daily iron supplementation with no clear effect on the risk of maternal anaemia at term (RR 1.22; 95%CI 0.84 to 1.80; n=676; 4 RCTs), maternal iron-deficiency at term (RR 0.71; 95%CI 0.08 to 6.63; 1 RCT) or neonatal death (RR 0.49; 95%CI 0.04 to 5.42; n=795; 1 RCT) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZW5hLVJvc2FzPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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ADDIN EN.CITE.DATA (Pena-Rosas et al 2015). Evidence-based recommendationAdvise pregnant women with low dietary iron intake that intermittent supplementation is as effective as daily supplementation in preventing iron-deficiency anaemia, with fewer adverse effects.Testing for and treating anaemia is discussed in Chapter 30.CalciumBackgroundA survey of pregnant women conducted in Sydney found that 13% were taking a calcium supplement PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFuZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Shand et al 2016).Dietary sources of calcium include dairy products, canned fish and tofu.Summary of recent evidenceThere is consistent evidence from systematic reviews that calcium supplementation reduces the risk of gestational hypertension PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2ZtZXlyPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48
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ADDIN EN.CITE.DATA (Hofmeyr et al 2014; Khaing et al 2017; Hofmeyr et al 2018; Sun et al 2019). High-dose calcium supplementation (≥1?g/day) reduces the risk of gestational hypertension (RR 0.65; 95%CI 0.53 to 0.81; 12 RCTs; n=15,470), with a clearer effect among women with low dietary calcium (RR 0.44; 95%CI 0.28 to 0.70; 7 RCTs; n=10,418) than among women with adequate dietary calcium (RR 0.90; 95%CI 0.81 to 0.99; 4 RCTs; n=5,022) ADDIN EN.CITE <EndNote><Cite><Author>Hofmeyr</Author><Year>2018</Year><RecNum>1316</RecNum><DisplayText>(<style font="Century Gothic" size="8">Hofmeyr et al 2018</style>)</DisplayText><record><rec-number>1316</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1566798243">1316</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hofmeyr, G. Justus</author><author>Lawrie, Theresa A.</author><author>Atallah, ?lvaro N.</author><author>Torloni, Maria Regina</author></authors></contributors><titles><title>Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2018</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD001059.pub5</electronic-resource-num></record></Cite></EndNote>(Hofmeyr et al 2018). High-dose calcium also reduces the risk of pre-eclampsia (RR 0.45; 95CI 0.31 to 0.65; 13 trials; n=15,730; low certainty). Low-dose calcium (<1 g/day) also reduces the risk of gestational hypertension (RR 0.57; 95%CI 0.39 to 0.82; 3?RCTs; n=558) ADDIN EN.CITE <EndNote><Cite><Author>Hofmeyr</Author><Year>2018</Year><RecNum>1316</RecNum><DisplayText>(<style font="Century Gothic" size="8">Hofmeyr et al 2018</style>)</DisplayText><record><rec-number>1316</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1566798243">1316</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hofmeyr, G. Justus</author><author>Lawrie, Theresa A.</author><author>Atallah, ?lvaro N.</author><author>Torloni, Maria Regina</author></authors></contributors><titles><title>Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2018</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD001059.pub5</electronic-resource-num></record></Cite></EndNote>(Hofmeyr et al 2018) and pre-eclampsia (RR 0.36; 95%CI 0.23 to 0.57; 4 RCTs; n=980) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2ZtZXlyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Hofmeyr et al 2014).A Cochrane review ADDIN EN.CITE <EndNote><Cite><Author>Hofmeyr</Author><Year>2018</Year><RecNum>1316</RecNum><DisplayText>(<style font="Century Gothic" size="8">Hofmeyr et al 2018</style>)</DisplayText><record><rec-number>1316</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1566798243">1316</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hofmeyr, G. Justus</author><author>Lawrie, Theresa A.</author><author>Atallah, ?lvaro N.</author><author>Torloni, Maria Regina</author></authors></contributors><titles><title>Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2018</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD001059.pub5</electronic-resource-num></record></Cite></EndNote>(Hofmeyr et al 2018) found a reduction in risk of preterm birth <37 weeks with high-dose calcium among all women (RR 0.76; 95%CI 0.60 to 0.97; 11 trials, n=15,275; low certainty. Another Cochrane review of calcium supplementation trials not specifically targeted at preventing pre-eclampsia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXBwYXNpcmk8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy
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ADDIN EN.CITE.DATA (Buppasiri et al 2015) found no clear difference in risk of preterm birth <34 weeks (RR 1.04; 95%CI 0.80 to 1.36; 4?RCTs, n=5,669; moderate certainty).Calcium supplementation does not appear to be of benefit in preventing low birthweight (RR 0.93; 95%CI 0.81 to 1.07; 6?RCTs; n=14,162; moderate certainty) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXBwYXNpcmk8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy
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ADDIN EN.CITE.DATA (Meertens et al 2018).Evidence-based recommendation Advise pregnant women to take a low-dose calcium supplement.IodineBackgroundIodine deficiency re‐emerged in Australia in the 1990s, motivating mandatory fortification of bread with iodised salt in 2009. The AIHW reports that, while mandatory fortification delivered sufficient amounts of iodine to the general population, intakes for many pregnant and breastfeeding women were insufficient due to their increased requirements ADDIN EN.CITE <EndNote><Cite><Author>AIHW</Author><Year>2016</Year><RecNum>1201</RecNum><DisplayText>(<style font="Century Gothic" size="8">AIHW 2016</style>)</DisplayText><record><rec-number>1201</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1559691299">1201</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>AIHW,</author></authors></contributors><titles><title>Monitoring the health impacts of mandatory folic acid and iodine fortification</title></titles><dates><year>2016</year></dates><pub-location>Canberra</pub-location><publisher>Australian Institute of Health and Welfare</publisher><work-type>Cat. no. PHE 208</work-type><urls><related-urls><url>;(AIHW 2016).In a review of Australian cohort studies post-fortification (7 studies) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdXJsZXk8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Hurley et al 2019), three studies found that the pregnant women in their studies were iodine replete and four found that pregnant women were in the mild-to-moderate iodine deficiency category. Only two studies, documented iodine sufficiency among pregnant women in the absence of iodine supplementation. The NHMRC (2010) NHMRC Public Statement: Iodine Supplementation for Pregnant and Breastfeeding Women advises pregnant women to take an iodine supplement of 150?micrograms each day to avoid poor infant neurodevelopment. A survey of pregnant women conducted in Sydney found that 6.3% were taking an iodine supplement PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFuZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Shand et al 2016). A study conducted in Gippsland Victoria, a mildly iodine deficient area, found that only 18.9% of participants followed the NHMRC recommendation, with 42.3% of participants not taking any supplements (or supplements with no iodine or insufficient iodine) ADDIN EN.CITE <EndNote><Cite><Author>Mitchell</Author><Year>2018</Year><RecNum>1328</RecNum><DisplayText>(<style font="Century Gothic" size="8">Mitchell et al 2018</style>)</DisplayText><record><rec-number>1328</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1566948734">1328</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mitchell, E. K. L.</author><author>Martin, J. C.</author><author>D'Amore, A.</author><author>Francis, I.</author><author>Savige, G. S.</author></authors></contributors><auth-address>Rural Health, Monash University, Victoria, Australia. eleanor.mitchell@monash.edu.
Rural Health, Monash University, Victoria, Australia.
Public Health and Preventive Medicine, Monash University, Victoria, Australia.
Victorian Clinical Genetics Services, Royal Children's Hospital, Victoria, Australia.</auth-address><titles><title>Maternal iodine dietary supplements and neonatal thyroid stimulating hormone in Gippsland, Australia</title><secondary-title>Asia Pac J Clin Nutr</secondary-title></titles><periodical><full-title>Asia Pac J Clin Nutr</full-title></periodical><pages>848-852</pages><volume>27</volume><number>4</number><edition>2018/07/27</edition><dates><year>2018</year></dates><isbn>0964-7058 (Print)
0964-7058 (Linking)</isbn><accession-num>30045430</accession-num><urls><related-urls><url>;(Mitchell et al 2018). The remaining women (38.7%) were taking supplements with doses of iodine much higher (200-300 μg) than the NHMRC recommended dose or were taking multiple supplements containing iodine. In a South Australian study, 85.9% women met the estimated average requirement (≥160 μg/day) for iodine intake from food and supplements PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db25kbzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Condo et al 2017). When iodine from supplements was excluded, 44.5% of women met the estimated average requirement for iodine intake during pregnancy. In a Western Australian study, 66% of pregnant women were taking iodine supplements ADDIN EN.CITE <EndNote><Cite><Author>Hine</Author><Year>2018</Year><RecNum>1331</RecNum><DisplayText>(<style font="Century Gothic" size="8">Hine et al 2018</style>)</DisplayText><record><rec-number>1331</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1566950067">1331</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hine, T.</author><author>Zhao, Y.</author><author>Begley, A.</author><author>Skeaff, S.</author><author>Sherriff, J.</author></authors></contributors><auth-address>School of Public Health, Curtin University, Perth, Western Australia.
Department of Human Nutrition, University of Otago, Dunedin, New Zealand.</auth-address><titles><title>Iodine-containing supplement use by pregnant women attending antenatal clinics in Western Australia</title><secondary-title>Aust N Z J Obstet Gynaecol</secondary-title></titles><periodical><full-title>Aust N Z J Obstet Gynaecol</full-title></periodical><pages>636-642</pages><volume>58</volume><number>6</number><edition>2018/02/08</edition><keywords><keyword>*foetal development</keyword><keyword>*iodine</keyword><keyword>*pregnancy</keyword><keyword>*public health</keyword><keyword>*supplementation</keyword></keywords><dates><year>2018</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1479-828X (Electronic)
0004-8666 (Linking)</isbn><accession-num>29411357</accession-num><urls><related-urls><url>;(Hine et al 2018). A Tasmanian study (n=255) found that, despite recommendations for iodine supplementation, pregnant Tasmanian women remain at risk of iodine deficiency PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IeW5lczwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Hynes et al 2019).An analysis of cross-sectional data from two Australian longitudinal studies pre- and post-fortification of iodine (n=368) ADDIN EN.CITE <EndNote><Cite><Author>Singh</Author><Year>2019</Year><RecNum>1200</RecNum><DisplayText>(<style font="Century Gothic" size="8">Singh et al 2019</style>)</DisplayText><record><rec-number>1200</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1559690614">1200</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Singh, G. R.</author><author>Davison, B.</author><author>Ma, G. Y.</author><author>Eastman, C. J.</author><author>Mackerras, D. E.</author></authors></contributors><auth-address>Menzies School of Health Research, Darwin, NT.
Western Sydney University School of Medicine, Penrith, NSW.
Sydney Thyroid Clinic, Sydney, NSW.
Sydney Medical School, Sydney, NSW.
Food Standards Australia New Zealand, Canberra, ACT.</auth-address><titles><title>Iodine status of Indigenous and non-Indigenous young adults in the Top End, before and after mandatory fortification</title><secondary-title>Med J Aust</secondary-title></titles><periodical><full-title>Med J Aust</full-title></periodical><pages>121-125</pages><volume>210</volume><number>3</number><edition>2019/02/18</edition><keywords><keyword>Food fortification</keyword><keyword>Iodine</keyword><keyword>Longitudinal studies</keyword></keywords><dates><year>2019</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1326-5377 (Electronic)
0025-729X (Linking)</isbn><accession-num>30772938</accession-num><urls><related-urls><url>;(Singh et al 2019) found that the median urinary iodine concentration of pregnant Indigenous women in remote locations remains low and targeted interventions are needed to ensure healthy fetal development. In a cross-sectional study in Western Australia (n=425) ADDIN EN.CITE <EndNote><Cite><Author>Sherriff</Author><Year>2019</Year><RecNum>1853</RecNum><DisplayText>(<style font="Century Gothic" size="8">Sherriff et al 2019</style>)</DisplayText><record><rec-number>1853</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587613792">1853</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sherriff, J.</author><author>Hine, T.</author><author>Begley, A.</author><author>Zhao, Y.</author><author>Black, L.</author><author>Dunlop, E.</author><author>Skeaff, S.</author></authors></contributors><auth-address>School of Public Health, Curtin University, Perth, Western Australia, Australia.
Department of Nutrition and Dietetics, St John of God Hospital, Midland, Western Australia, Australia.
Department of Human Nutrition, University of Otago, Dunedin, New Zealand.</auth-address><titles><title>Iodine-containing food practices of Western Australian pregnant women and ethnicity: An observational study</title><secondary-title>Nutr Diet</secondary-title></titles><periodical><full-title>Nutr Diet</full-title></periodical><edition>2019/10/11</edition><keywords><keyword>Western Australia</keyword><keyword>ethnicity</keyword><keyword>iodine</keyword><keyword>iodine fortification</keyword><keyword>pregnancy</keyword></keywords><dates><year>2019</year><pub-dates><date>Oct 10</date></pub-dates></dates><isbn>1747-0080 (Electronic)
1446-6368 (Linking)</isbn><accession-num>31600028</accession-num><urls><related-urls><url>;(Sherriff et al 2019) ethnicity was associated with iodised salt use, with 76% of Asian women used iodised salt compared with 33% of Caucasian women. In a national survey of maternity care providers, while 71% were aware of the NHMRC advice on iodine supplementation, fewer were aware of the recommended dose (38%) or duration (44%), with 73% advising iodine supplements in pregnancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdWVzczwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Guess et al 2017).Summary of recent evidenceThere is low certainty evidence that, in settings with mild to moderate iodine deficiency, iodine supplementation may reduce the risk of postpartum hyperthyroidism (average RR 0.32; 95%CI 0.11 to 0.91; three RCTs; n=543 women) with very low certainty evidence of an increased likelihood of gastrointestinal intolerance during pregnancy (average RR 15.33; 95%CI 2.07 to 113.70; one RCT; n=76) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJkaW5nPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48
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ADDIN EN.CITE.DATA (Harding et al 2017; Farebrother et al 2018). RCTs have reported that iodine supplementation:increased maternal urinary iodine levels in areas with iodine deficiency (p<0.05) ADDIN EN.CITE <EndNote><Cite><Author>Chawanpaiboon</Author><Year>2019</Year><RecNum>1849</RecNum><DisplayText>(<style font="Century Gothic" size="8">Chawanpaiboon 2019</style>)</DisplayText><record><rec-number>1849</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587613770">1849</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chawanpaiboon, S.,</author></authors></contributors><titles><title>A randomized controlled trial of the correlation between iodine supplementation in pregnancy and maternal urine iodine and neonatal thyroid stimulating hormone levels</title><secondary-title>Siriraj Medical Journal</secondary-title></titles><periodical><full-title>Siriraj Medical Journal</full-title></periodical><volume>71</volume><number>1</number><dates><year>2019</year></dates><isbn>2629995X
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ADDIN EN.CITE.DATA (Censi et al 2019)decreased maternal thyroglobulin levels (p=0.02) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DZW5zaTwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Censi et al 2019)decreased median neonatal thyroid stimulating hormone levels (p<0.05) ADDIN EN.CITE <EndNote><Cite><Author>Chawanpaiboon</Author><Year>2019</Year><RecNum>1849</RecNum><DisplayText>(<style font="Century Gothic" size="8">Chawanpaiboon 2019</style>)</DisplayText><record><rec-number>1849</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587613770">1849</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chawanpaiboon, S.,</author></authors></contributors><titles><title>A randomized controlled trial of the correlation between iodine supplementation in pregnancy and maternal urine iodine and neonatal thyroid stimulating hormone levels</title><secondary-title>Siriraj Medical Journal</secondary-title></titles><periodical><full-title>Siriraj Medical Journal</full-title></periodical><volume>71</volume><number>1</number><dates><year>2019</year></dates><isbn>2629995X
22288082</isbn><urls></urls><electronic-resource-num>10.33192/Smj.2019.10</electronic-resource-num></record></Cite></EndNote>(Chawanpaiboon 2019)had no effect on child neurodevelopment at age 5–6 years in mildly iodine-deficient pregnant women ADDIN EN.CITE <EndNote><Cite><Author>Gowachirapant</Author><Year>2017</Year><RecNum>1199</RecNum><DisplayText>(<style font="Century Gothic" size="8">Gowachirapant et al 2017</style>)</DisplayText><record><rec-number>1199</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1559622618">1199</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gowachirapant, S.,</author><author>Jaiswal, N.,</author><author>Melse-Boonstra, A.,</author><author>Galetti, V.,</author><author>Stinca, S.,</author><author>Mackenzie, I.,</author><author>Thomas, S.,</author><author>Thomas, T.,</author><author>Winichagoon, P.,</author><author>Srinivasan, K.,</author><author>Zimmermann, M.B.,</author></authors></contributors><titles><title>Effect of iodine supplementation in pregnant women on child neurodevelopment: a randomised, double-blind, placebo-controlled trial</title><secondary-title>The Lancet Diabetes & Endocrinology</secondary-title></titles><periodical><full-title>The Lancet Diabetes & Endocrinology</full-title></periodical><pages>853-63</pages><volume>5</volume><number>11</number><section>853</section><dates><year>2017</year></dates><isbn>22138587</isbn><urls></urls><electronic-resource-num>10.1016/s2213-8587(17)30332-7</electronic-resource-num></record></Cite></EndNote>(Gowachirapant et al 2017).Consensus-based recommendationAdvise pregnant women to take an iodine supplement of 150?micrograms each day. Women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement.ZincBackgroundA survey of pregnant women conducted in Sydney found that 5.6% were taking a zinc supplement PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFuZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Livock et al 2017) 17-24% of pregnant women did not meet the recommended daily intake for zinc. Summary of recent evidenceThere is moderate certainty evidence that zinc supplementation may play a role in reducing the risk of preterm birth (RR 0.86; 95%CI 0.76 to 0.97; 16 RCTS; n=7,637) ADDIN EN.CITE <EndNote><Cite><Author>Ota</Author><Year>2015</Year><RecNum>1193</RecNum><DisplayText>(<style font="Century Gothic" size="8">Ota et al 2015</style>)</DisplayText><record><rec-number>1193</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1559532928">1193</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ota, E.,</author><author>Mori, R.,</author><author>Middleton, P.,</author><author>Tobe-Gai, R.,</author><author>Mahomed, K.,</author><author>Miyazaki, C.,</author><author>Bhutta, Z.A.,</author></authors></contributors><titles><title>Zinc supplementation for improving pregnancy and infant outcome</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2015</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD000230.pub5</electronic-resource-num></record></Cite></EndNote>(Ota et al 2015), with no clear effect on low birthweight (RR 0.93; 95%CI 0.78 to 1.12; 14 RCTs; n=5,643) (RR 0.76, 95%CI: 0.52 to 1.11) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PdGE8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Ota et al 2015; Liu et al 2018b). Zinc supplementation does not appear to increase or reduce the risk of other outcomes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PdGE8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxSZWNO
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Pn==
ADDIN EN.CITE.DATA (Nossier et al 2015; Ota et al 2015; Zahiri Sorouri et al 2016; Oh et al 2020). Other mineralsThere is insufficient high-certainty evidence to show whether dietary magnesium supplementation during pregnancy is beneficial ADDIN EN.CITE <EndNote><Cite><Author>Makrides</Author><Year>2014</Year><RecNum>1192</RecNum><DisplayText>(<style font="Century Gothic" size="8">Makrides et al 2014</style>)</DisplayText><record><rec-number>1192</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1559283572">1192</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Makrides, Maria</author><author>Crosby, Danielle D.</author><author>Shepherd, Emily</author><author>Crowther, Caroline A.</author></authors></contributors><titles><title>Magnesium supplementation in pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2014</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD000937.pub2</electronic-resource-num></record></Cite></EndNote>(Makrides et al 2014).There is insufficient evidence to draw conclusions on selenium supplementation in pregnancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYXJhPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Shand et al 2016)42% of participants used pregnancy multivitamins, with 26.8% using multivitamins in combination with individual micronutrients and 9.8% using specific micronutrient supplements; nulliparous women were more likely to take supplements ADDIN EN.CITE <EndNote><Cite><Author>McAlpine</Author><Year>2020</Year><RecNum>1814</RecNum><DisplayText>(<style font="Century Gothic" size="8">McAlpine et al 2020</style>)</DisplayText><record><rec-number>1814</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1583726454">1814</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McAlpine, J. M.</author><author>Vanderlelie, J. J.</author><author>Vincze, L. J.</author><author>Perkins, A. V.</author></authors></contributors><auth-address>School of Nursing and Midwifery, Griffith University Logan Campus, Brisbane, Queensland, Australia.
School of Medical Science, Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Southport, Queensland, Australia.
The Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Southport, Queensland, Australia.</auth-address><titles><title>Use of micronutrient supplements in pregnant women of south-east Queensland</title><secondary-title>Aust N Z J Obstet Gynaecol</secondary-title></titles><periodical><full-title>Aust N Z J Obstet Gynaecol</full-title></periodical><edition>2020/01/07</edition><keywords><keyword>dietary supplements</keyword><keyword>guidelines</keyword><keyword>pregnancy</keyword><keyword>pregnancy trimester</keyword><keyword>third</keyword><keyword>trace elements</keyword></keywords><dates><year>2020</year><pub-dates><date>Jan 5</date></pub-dates></dates><isbn>1479-828X (Electronic)
0004-8666 (Linking)</isbn><accession-num>31903555</accession-num><urls><related-urls><url>;(McAlpine et al 2020)83% of women took a multivitamin during pregnancy, with 90% of women with post-secondary education and 64% of women with secondary education only using these supplements PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYWxlazwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Malek et al 2018)pregnancy-specific multivitamin use was reported by 47% of women in the first trimester, 51% in the second trimester and 46% in the third trimester and general multivitamin use was reported by 31% of women in the first trimester, 27% in the second trimester and 35% in the third trimester PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXZvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Livock et al 2017).Summary of recent evidenceThere is high certainty evidence from studies conducted in low- to middle-income countries that the use of multiple micronutrients (including iron and folic acid) during pregnancy reduces the risk of low birthweight and may reduce the risk of stillbirth but does not affect the risk of perinatal or neonatal mortality PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWF0czwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Keats et al 2019). There is moderate certainty evidence of a reduction in risk of small for gestational age and a possible reduction in risk of preterm birth (<37 weeks) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWF0czwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Keats et al 2019). There is evidence that multiple micronutrient use is associated with a reduction in risk of early preterm birth (<34 weeks), a possible reduction in risk of miscarriage, with no effect on maternal mortality, maternal anaemia, caesarean section or congenital anomalies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWF0czwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Wolf et al 2017).Omega-3 fatty acidsBackgroundIn an Australian cross-sectional study, 12% of women took fish oil (which contains omega-3 fatty acids) during pregnancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFuZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Shand et al 2016).Summary of the evidenceThere is high certainty evidence that rates of preterm birth <37 weeks (10.1% versus 8.1%%; RR 0.89, 95%CI 0.82 to 0.97; 30 RCTs, n=21,271) and early preterm birth <34 weeks (2.6% vs 1.6%; RR 0.64, 95%CI 0.44 to 0.93; 11 RCTs, n=15,750) are lower in women receiving omega-3 long-chain polyunsaturated fatty acids compared with no omega-3 ADDIN EN.CITE <EndNote><Cite><Author>Middleton</Author><Year>2018</Year><RecNum>1149</RecNum><DisplayText>(<style font="Century Gothic" size="8">Middleton et al 2018</style>)</DisplayText><record><rec-number>1149</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1558664665">1149</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Middleton, Philippa</author><author>Gomersall, Judith C.</author><author>Gould, Jacqueline F.</author><author>Shepherd, Emily</author><author>Olsen, Sjurdur F.</author><author>Makrides, Maria</author></authors></contributors><titles><title>Omega-3 fatty acid addition during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2018</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD003402.pub3</electronic-resource-num></record></Cite></EndNote>(Middleton et al 2018). There is moderate-certainty evidence that prolonged pregnancy >42 weeks is probably increased with omega-3 fatty acid supplementation (RR 1.61 95%CI 1.11 to 2.33; n=5,141; 6 RCTs) but insufficient evidence to determine the effect of supplementation on induction post-term ADDIN EN.CITE <EndNote><Cite><Author>Middleton</Author><Year>2018</Year><RecNum>1149</RecNum><DisplayText>(<style font="Century Gothic" size="8">Middleton et al 2018</style>)</DisplayText><record><rec-number>1149</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1558664665">1149</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Middleton, Philippa</author><author>Gomersall, Judith C.</author><author>Gould, Jacqueline F.</author><author>Shepherd, Emily</author><author>Olsen, Sjurdur F.</author><author>Makrides, Maria</author></authors></contributors><titles><title>Omega-3 fatty acid addition during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2018</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD003402.pub3</electronic-resource-num></record></Cite></EndNote>(Middleton et al 2018). There is high certainty evidence of a reduced risk of low birthweight (15.6% vs 14%; RR 0.90, 95%CI 0.82 to 0.99; 15 trials, n=8,449;) and moderate certainty evidence for a possible reduced risk of perinatal death (RR 0.75, 95%CI 0.54 to 1.03; 10 RCTs, n=7,416), neonatal care admission (RR 0.92, 95%CI 0.83 to 1.03; 9 RCTs, n=6,920) and a possible small increase in risk of large-for-gestational age babies (RR?1.15, 95%CI 0.97 to 1.36; 6 RCTs, n=3,722) with omega-3 fatty acid supplementation ADDIN EN.CITE <EndNote><Cite><Author>Middleton</Author><Year>2018</Year><RecNum>1149</RecNum><DisplayText>(<style font="Century Gothic" size="8">Middleton et al 2018</style>)</DisplayText><record><rec-number>1149</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1558664665">1149</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Middleton, Philippa</author><author>Gomersall, Judith C.</author><author>Gould, Jacqueline F.</author><author>Shepherd, Emily</author><author>Olsen, Sjurdur F.</author><author>Makrides, Maria</author></authors></contributors><titles><title>Omega-3 fatty acid addition during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2018</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD003402.pub3</electronic-resource-num></record></Cite></EndNote>(Middleton et al 2018).Evidence-based recommendationAdvise pregnant women that supplementation with omega-3 long-chain polyunsaturated fatty acids may reduce their risk of preterm birth.ProbioticsA meta-analysis of RCTs conducted to inform these Guidelines ADDIN EN.CITE <EndNote><Cite><Author>Ramson</Author><Year>2020</Year><RecNum>1826</RecNum><DisplayText>(<style font="Century Gothic" size="8">Ramson et al 2020</style>)</DisplayText><record><rec-number>1826</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1584421281">1826</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Ramson, J.A.,</author><author>Middleton P,</author><author>Bowman, A.,</author></authors></contributors><titles><title><style face="italic" font="default" size="100%">Evidence Evaluation Report: Diet, Exercise and Weight Management in Pregnancy</style></title></titles><dates><year>2020</year></dates><publisher>Prepared by South Australian Health and Medical Research Institute and Ampersand Health Science Writing for the Australian Government Department of Health</publisher><urls></urls></record></Cite></EndNote>(Ramson et al 2020) found low certainty evidence that supplementation with probiotics may be associated with a possible reduction in caesarean section (RR?0.92; 95%CI 0.81 to 1.05; 15 RCTs; n=2,650), and very low certainty evidence of a reduction in Group B streptococcus colonisation (RR?0.76; 95%CI 0.61 to 0.97; n=244) and a possible reduction in risk of gestational diabetes (RR 0.87; 95%CI 0.71 to 1.08; 8 RCTs; n=1,722). There is very low or low certainty evidence that probiotic supplementation has no clear effect on gestational hypertension (RR 1.24; 95%CI 0.74 to 2.06; 4 RCTs; n=955), pre-eclampsia (RR 1.88; 95%CI 0.96 to 3.71; 2 RCTs; n=598), bacterial vaginosis (RR 1.73; 95%CI 0.89 to 3.38; 2 RCTs; n=509), perinatal death (RR 1.17; 95%CI 0.62 to 2.24; 6 RCTs; n=1,670), preterm birth (RR 1.10; 95%CI 0.81 to 1.50; 16 RCTs; n=3,671), small for gestational age (RR 1.04; 95%CI 0.55 to 1.94; 3 RCTs; n=318), large for gestational age (RR 0.95; 95%CI 0.47 to 1.93; 3 RCTs; n=316) or macrosomia (RR 1.06; 0.85 to 1.33; 7 RCTs; n=1,407).Herbal preparationsBackgroundAn Australian cohort study (n=1,835) found that 34.4% of women were using herbal preparations during pregnancy, of whom 77.9% were self-prescribing these products PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmF3bGV5PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Frawley et al 2015). Women were more likely to use herbal medicine if they had anxiety (OR 1.30; 95%CI, 1.02 to 1.64; p=0.031), sleeping problems (OR 1.55; 95%CI 1.15 to 2.11; p=0.005) or fatigue (OR 1.32; 95%CI 1.04 to 1.68; p=0.025) and less likely to use herbal medicine if they had nausea (OR 0.71; 95%CI 0.56 to 0.91; p=0.007). Women who used herbal preparations viewed them as a preventative measure, were looking for something holistic and were concerned about evidence of clinical efficacy when considering the use of these products during pregnancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmF3bGV5PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE.DATA (Frawley et al 2016).?Summary of the evidenceThe evidence on the efficacy and safety of herbal preparations during pregnancy is limited. There is moderate certainty evidence that ginger reduces nausea (MD -4.2 nausea score; 95%CI -6.5 to -1.9), with a low risk of adverse effects (OR?0.4; 95%CI 0.1 to 0.9) ADDIN EN.CITE <EndNote><Cite><Author>Sridharan</Author><Year>2018</Year><RecNum>1577</RecNum><DisplayText>(<style font="Century Gothic" size="8">Sridharan & Sivaramakrishnan 2018</style>)</DisplayText><record><rec-number>1577</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576536337">1577</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sridharan, Kannan</author><author>Sivaramakrishnan, Gowri</author></authors></contributors><titles><title>Interventions for treating nausea and vomiting in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials</title><secondary-title>Expert Review of Clinical Pharmacology</secondary-title></titles><periodical><full-title>Expert Review of Clinical Pharmacology</full-title></periodical><pages>1143-1150</pages><volume>11</volume><number>11</number><section>1143</section><dates><year>2018</year></dates><isbn>1751-2433
1751-2441</isbn><urls></urls><electronic-resource-num>10.1080/17512433.2018.1530108</electronic-resource-num></record></Cite></EndNote>(Sridharan & Sivaramakrishnan 2018). There is very low certainty evidence that chamomile is also effective in reducing nausea (MD -4.2; 95%CI -6.7 to -1.7; 1 RCT) ADDIN EN.CITE <EndNote><Cite><Author>Sridharan</Author><Year>2018</Year><RecNum>1577</RecNum><DisplayText>(<style font="Century Gothic" size="8">Sridharan & Sivaramakrishnan 2018</style>)</DisplayText><record><rec-number>1577</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576536337">1577</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sridharan, Kannan</author><author>Sivaramakrishnan, Gowri</author></authors></contributors><titles><title>Interventions for treating nausea and vomiting in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials</title><secondary-title>Expert Review of Clinical Pharmacology</secondary-title></titles><periodical><full-title>Expert Review of Clinical Pharmacology</full-title></periodical><pages>1143-1150</pages><volume>11</volume><number>11</number><section>1143</section><dates><year>2018</year></dates><isbn>1751-2433
1751-2441</isbn><urls></urls><electronic-resource-num>10.1080/17512433.2018.1530108</electronic-resource-num></record></Cite></EndNote>(Sridharan & Sivaramakrishnan 2018). There is evidence from a systematic review that garlic may reduce gestational hypertension (RR 0.50; 95%CI 0.25 to 1.00) but does not affect the risk of pre-eclampsia (RR 0.78, 95% CI 0.31 to 1.93) or caesarean section (RR 1.35, 95% CI 0.93 to 1.95), with odour likely to be experienced (RR 8.50, 95%CI 2.07 to 34.88) ADDIN EN.CITE <EndNote><Cite><Author>Meher</Author><Year>2006</Year><RecNum>1562</RecNum><DisplayText>(<style font="Century Gothic" size="8">Meher & Duley 2006</style>)</DisplayText><record><rec-number>1562</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576536271">1562</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Meher, S.</author><author>Duley, L.</author></authors></contributors><auth-address>University of Liverpool, Division of Perinatal and Reproductive Medicine, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK L8 7SS. s.meher@liv.ac.uk</auth-address><titles><title>Garlic for preventing pre-eclampsia and its complications</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD006065</pages><number>3</number><edition>2006/07/21</edition><keywords><keyword>Female</keyword><keyword>*Garlic</keyword><keyword>Humans</keyword><keyword>Odorants</keyword><keyword>*Phytotherapy/adverse effects</keyword><keyword>Pre-Eclampsia/*prevention & control</keyword><keyword>Pregnancy</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2006</year><pub-dates><date>Jul 19</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>16856110</accession-num><urls><related-urls><url>;(Meher & Duley 2006). There is insufficient evidence on the efficacy and safety of Echinacea and elderberry during pregnancy ADDIN EN.CITE <EndNote><Cite><Author>Holst</Author><Year>2014</Year><RecNum>1559</RecNum><DisplayText>(<style font="Century Gothic" size="8">Holst et al 2014</style>)</DisplayText><record><rec-number>1559</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1576536260">1559</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Holst, L.</author><author>Havnen, G. C.</author><author>Nordeng, H.</author></authors></contributors><auth-address>Department of Global Public Health and Primary Care and Centre for Pharmacy, Faculty of Medicine and Dentistry, University of Bergen Bergen, Norway.
Regional Medicines Information and Pharmacovigilance Centre (RELIS), Oslo University Hospital Oslo, Norway.
Department of Pharmacy, Faculty of Mathematics and Natural Sciences, School of Pharmacy, University of Oslo Oslo, Norway.</auth-address><titles><title>Echinacea and elderberry-should they be used against upper respiratory tract infections during pregnancy?</title><secondary-title>Front Pharmacol</secondary-title></titles><periodical><full-title>Front Pharmacol</full-title></periodical><pages>31</pages><volume>5</volume><edition>2014/03/14</edition><keywords><keyword>Cam</keyword><keyword>Echinacea</keyword><keyword>Elderberry</keyword><keyword>efficacy</keyword><keyword>pregnancy</keyword><keyword>respiratory infection</keyword><keyword>safety</keyword></keywords><dates><year>2014</year></dates><isbn>1663-9812 (Print)
1663-9812 (Linking)</isbn><accession-num>24624087</accession-num><urls><related-urls><url>;(Holst et al 2014).Physical activityBackgroundPhysical activity can be defined as any body movement that involves the use of one or more large muscle groups and raises the heart rate. This includes sport, exercise and recreational activities and incidental activity that accrues throughout the day (eg walking to the shops, climbing stairs).Levels of physical activity in AustraliaData specific to pregnant women are not available but results from national surveys give some indication of patterns of physical activity and sedentary behaviour. In 2014–15, an estimated 52% of adults aged 18–64 did less than the recommended 150 minutes of moderate intensity physical activity, or 75 minutes of vigorous intensity physical activity, across 5 or more sessions each week. An estimated 70% of adults did no strength-based activities. Only 19% of adults aged 18–64 did the recommended amount of physical activity and strength-based training ADDIN EN.CITE <EndNote><Cite><Author>AIHW</Author><Year>2018</Year><RecNum>1828</RecNum><DisplayText>(<style font="Century Gothic" size="8">AIHW 2018</style>)</DisplayText><record><rec-number>1828</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1584926367">1828</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>AIHW,</author></authors></contributors><titles><title><style face="italic" font="default" size="100%">Australia’s Health 2018</style></title></titles><dates><year>2018</year></dates><pub-location>Canberra</pub-location><publisher>Australian Institute of Health and Welfare</publisher><urls></urls></record></Cite></EndNote>(AIHW 2018).An Australian cross-sectional study found that fewer women participated in exercise during pregnancy (61%) compared to before pregnancy (87%) and that they exercised at a significantly lower frequency (p<0.05), intensity (p<0.05) and for a shorter time/duration (p<0.05) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXltYW48L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Hayman et al 2016).In a survey of regionally-based Australian women (n=142) ADDIN EN.CITE <EndNote><Cite><Author>Hayman</Author><Year>2019</Year><RecNum>1934</RecNum><DisplayText>(<style font="Century Gothic" size="8">Hayman et al 2019</style>)</DisplayText><record><rec-number>1934</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588657693">1934</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hayman, M.</author><author>Reaburn, P.</author><author>Alley, S.</author><author>Cannon, S.</author><author>Short, C.</author></authors></contributors><auth-address>Central Queensland University, School of Health, Medical and Applied Sciences, Australia. Electronic address: m.j.hayman@cqu.edu.au.
Bond University, Faculty of Health Sciences and Medicine, Exercise and Sport Science, Australia.
Central Queensland University, School of Health, Medical and Applied Sciences, Australia.
The University of Melbourne, Melbourne School of Psychological Sciences, Australia.</auth-address><titles><title>What exercise advice are women receiving from their healthcare practitioners during pregnancy?</title><secondary-title>Women Birth</secondary-title></titles><periodical><full-title>Women Birth</full-title></periodical><edition>2019/08/31</edition><keywords><keyword>Advice</keyword><keyword>Exercise</keyword><keyword>Physical activity</keyword><keyword>Practitioner</keyword><keyword>Pregnant</keyword></keywords><dates><year>2019</year><pub-dates><date>Aug 26</date></pub-dates></dates><isbn>1878-1799 (Electronic)
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ADDIN EN.CITE.DATA (Harrison et al 2018).Discussing physical activityGuidelines on physical activity in pregnancyThe Australian Physical Activity and Sedentary Behaviour Guidelines ADDIN EN.CITE <EndNote><Cite><Author>DoH</Author><Year>2014</Year><RecNum>1827</RecNum><DisplayText>(<style font="Century Gothic" size="8">DoH 2014</style>)</DisplayText><record><rec-number>1827</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1584926085">1827</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>DoH,</author></authors></contributors><titles><title><style face="italic" font="default" size="100%">Australian Physical Activity and Sedentary Behaviour Guidelines</style></title></titles><dates><year>2014</year></dates><pub-location>Canberra</pub-location><publisher>Australian Government Department of Health</publisher><urls><related-urls><url>;(DoH 2014) recommend that pregnant women do some physical activity every day and accumulate 150–300 minutes of moderate-intensity physical activity each week. Women are advised to talk with their health professional regarding the best form of activity and to check with them before undertaking vigorous intensity physical activity.Table 3: Definition of levels of physical activityModerate intensityPhysical activity that requires some effort, but still allows the person to speak easily while undertaking the activity. Examples include active play, brisk walking, recreational swimming, dancing, social tennis, or riding a bike.Vigorous intensityPhysical activity that requires more effort and makes the person breathe harder and faster (“huff and puff”). Examples include running, fast cycling, many organised sports or tasks that involve lifting, carrying or digging.Source: ADDIN EN.CITE <EndNote><Cite><Author>DoH</Author><Year>2014</Year><RecNum>1827</RecNum><DisplayText>(<style font="Century Gothic" size="8">DoH 2014</style>)</DisplayText><record><rec-number>1827</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1584926085">1827</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>DoH,</author></authors></contributors><titles><title><style face="italic" font="default" size="100%">Australian Physical Activity and Sedentary Behaviour Guidelines</style></title></titles><dates><year>2014</year></dates><pub-location>Canberra</pub-location><publisher>Australian Government Department of Health</publisher><urls><related-urls><url>;(DoH 2014)Recent evidence on the effects of leisure-time physical activity during pregnancyPhysical fitness and quality of lifeThere is a possible increase in physical fitness associated with exercise in pregnancy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYWx2b3JzZW48L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy
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ADDIN EN.CITE.DATA (Hopkins et al 2010; de Oliveria Melo et al 2012; Halvorsen et al 2013; Bisson et al 2015; Guelfi et al 2016; Seneviratne et al 2016; Cai et al 2020) and rates of injury appear to be low (4.1 per 1,000 exercise hours; n=1,469). The evidence on the effect on quality of life suggests an improvement with physical activity PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdXN0YWZzc29uPC9BdXRob3I+PFllYXI+MjAxNjwvWWVh
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ADDIN EN.CITE.DATA (Montoya Arizabaleta et al 2010; Gustafsson et al 2016; Haakstad et al 2016; Prabha et al 2019; Rodriguez-Blanque et al 2020). Effect on common conditions in pregnancyGlycaemic control: An acute bout of exercise is associated with a decrease in maternal blood glucose from before to during exercise (MD -0.94 mmol/L, 95%CI -1.18 to -0.70;6 studies, n=123) and following exercise (MD 0.57 mmol/L, 95% CI -0.72 to -0.41; n=333) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZlbnBvcnQ8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFy
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ADDIN EN.CITE.DATA (Davenport et al 2018).Pelvic girdle and low back pain: There is evidence from systematic reviews PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZlbnBvcnQ8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFy
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ADDIN EN.CITE.DATA (Shiri et al 2018; Davenport et al 2019b), an RCT PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ta2xlbXBlIEtva2ljPC9BdXRob3I+PFllYXI+MjAxNzwv
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ta2xlbXBlIEtva2ljPC9BdXRob3I+PFllYXI+MjAxNzwv
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ZD48L0NpdGU+PC9FbmROb3RlPgB=
ADDIN EN.CITE.DATA (Sklempe Kokic et al 2017) and a cohort study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HamVzdGxhbmQ8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy
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ADDIN EN.CITE.DATA (Gjestland et al 2013) that physical activity during pregnancy is associated with a possible reduction in risk of low back (RR 0.91, 95%CI 0.83 to 0.99; 7 studies; n=1,175) and lumbopelvic pain (RR 0.96, 95%CI 0.90 to 1.02; 8 studies; n=1,737) and a reduction in severity of pain during pregnancy (SMD -1.03; 95%CI -1.58 to -0.48; 10 studies; very low to moderate certainty). The evidence on the effect of exercise on pelvic girdle pain and pain in the postpartum period is unclear. Sleep: Moderate to vigorous exercise during pregnancy appears to improve sleep quality PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2RyaWd1ZXotQmxhbnF1ZTwvQXV0aG9yPjxZZWFyPjIw
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ADDIN EN.CITE.DATA (Yang et al 2020).Effect on labourOne systematic review ADDIN EN.CITE <EndNote><Cite><Author>Kramer</Author><Year>2006</Year><RecNum>633</RecNum><DisplayText>(<style font="Century Gothic" size="8">Kramer & McDonald 2006</style>)</DisplayText><record><rec-number>633</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1540425550">633</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kramer, Michael S.</author><author>McDonald, Sheila W.</author></authors></contributors><titles><title>Aerobic exercise for women during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2006</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD000180.pub2</electronic-resource-num></record></Cite></EndNote>(Kramer & McDonald 2006) and eleven RCTs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWNpdWs8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Salvesen & Morkved 2004; Baciuk et al 2008; Barakat et al 2008; Salvesen et al 2014; Perales et al 2016a; Perales et al 2016b; Taniguchi & Sato 2016; Barakat et al 2018; Sanda et al 2018; Rodriguez-Blanque et al 2019a; Perales et al 2020) reported on duration of labour among women who had participated in a physical activity intervention during pregnancy and those who had not. The systematic review found no clear difference in length of the first (MD?2.00; 95%CI -1.15 to 5.15; 1 study; n=18) or second (MD 5.72; 95%CI -15.22 to 3.78; 1 study; n=18) stage of labour ADDIN EN.CITE <EndNote><Cite><Author>Kramer</Author><Year>2006</Year><RecNum>633</RecNum><DisplayText>(<style font="Century Gothic" size="8">Kramer & McDonald 2006</style>)</DisplayText><record><rec-number>633</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1540425550">633</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kramer, Michael S.</author><author>McDonald, Sheila W.</author></authors></contributors><titles><title>Aerobic exercise for women during pregnancy</title><secondary-title>Cochrane Database of Systematic Reviews</secondary-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title></periodical><dates><year>2006</year></dates><isbn>14651858</isbn><urls></urls><electronic-resource-num>10.1002/14651858.CD000180.pub2</electronic-resource-num></record></Cite></EndNote>(Kramer & McDonald 2006). With some exceptions, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJha2F0PC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48
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ADDIN EN.CITE.DATA (Salvesen et al 2014; Perales et al 2016a; Barakat et al 2018; Rodriguez-Blanque et al 2019a; Perales et al 2020), the RCTs found no clear difference in duration of any stage of labour.Five RCTs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWNpdWs8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Baciuk et al 2008; Barakat et al 2009; Salvesen et al 2014; Taniguchi & Sato 2016; Sanda et al 2018) reported on pain relief during labour among women who had participated in a physical activity intervention during pregnancy and those who had not. One study reported fewer requests for analgesia in labour (RR 0.42; 95%CI 0.23 to 0.77; n=71) ADDIN EN.CITE <EndNote><Cite><Author>Baciuk</Author><Year>2008</Year><RecNum>679</RecNum><DisplayText>(<style font="Century Gothic" size="8">Baciuk et al 2008</style>)</DisplayText><record><rec-number>679</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1540526890">679</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baciuk, E. P.</author><author>Pereira, R. I.</author><author>Cecatti, J. G.</author><author>Braga, A. F.</author><author>Cavalcante, S. R.</author></authors></contributors><auth-address>Department of Obstetrics and Gynecology, University of Campinas, Sao Paulo, Brazil. ericaxba@.br</auth-address><titles><title>Water aerobics in pregnancy: Cardiovascular response, labor and neonatal outcomes</title><secondary-title>Reprod Health</secondary-title></titles><periodical><full-title>Reprod Health</full-title></periodical><pages>10</pages><volume>5</volume><edition>2008/11/26</edition><dates><year>2008</year><pub-dates><date>Nov 21</date></pub-dates></dates><isbn>1742-4755 (Electronic)
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ADDIN EN.CITE.DATA (Salvesen & Morkved 2004; Salvesen et al 2014; Garnaes et al 2016; Seneviratne et al 2016; Rodriguez-Blanque et al 2019b) reported on perineal tears among women who had participated in a physical activity intervention during pregnancy and those who had not. One study found higher rates of intact perineum among the intervention group (aOR 8.57; 95% CI 1.85 to 39.68) ADDIN EN.CITE <EndNote><Cite><Author>Rodriguez-Blanque</Author><Year>2019</Year><RecNum>1916</RecNum><DisplayText>(<style font="Century Gothic" size="8">Rodriguez-Blanque et al 2019b</style>)</DisplayText><record><rec-number>1916</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588481006">1916</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rodriguez-Blanque, R.</author><author>Sanchez-Garcia, J. C.</author><author>Sanchez-Lopez, A. M.</author><author>Exposito-Ruiz, M.</author><author>Aguilar-Cordero, M. J.</author></authors></contributors><titles><title>Randomized clinical trial of an aquatic physical exercise program during pregnancy</title><secondary-title>J Obstet Gynecol Neonatal Nurs</secondary-title></titles><periodical><full-title>J Obstet Gynecol Neonatal Nurs</full-title></periodical><pages>321-331</pages><volume>48</volume><number>3</number><edition>2019/04/07</edition><keywords><keyword>*childbirth</keyword><keyword>*episiotomy</keyword><keyword>*exercise</keyword><keyword>*perineum</keyword><keyword>*pregnancy</keyword><keyword>*tear</keyword></keywords><dates><year>2019</year><pub-dates><date>May</date></pub-dates></dates><isbn>1552-6909 (Electronic)
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ADDIN EN.CITE.DATA (Davenport et al 2019c) and appears to be protective against macrosomia (aOR 0.77; 95%CI 0.61 to 0.96; n=36,896) ADDIN EN.CITE <EndNote><Cite><Author>Owe</Author><Year>2009</Year><RecNum>815</RecNum><DisplayText>(<style font="Century Gothic" size="8">Owe et al 2009</style>)</DisplayText><record><rec-number>815</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540495">815</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Owe, Katrine Mari</author><author>Nystad, Wenche</author><author>B?, Kari</author></authors></contributors><titles><title>Association Between Regular Exercise and Excessive Newborn Birth Weight</title><secondary-title>Obstetrics & Gynecology</secondary-title></titles><periodical><full-title>Obstetrics & Gynecology</full-title></periodical><pages>770-776</pages><volume>114</volume><number>4</number><section>770</section><dates><year>2009</year></dates><isbn>0029-7844</isbn><urls></urls><electronic-resource-num>10.1097/AOG.0b013e3181b6c105</electronic-resource-num></record></Cite></EndNote>(Owe et al 2009) and low birthweight, with women who did not exercise before and during pregnancy having an increased risk of very low birthweight (OR 1.75; 95%CI 1.50 to 2.04; n=2,245) ADDIN EN.CITE <EndNote><Cite><Author>Leiferman</Author><Year>2003</Year><RecNum>1271</RecNum><DisplayText>(<style font="Century Gothic" size="8">Leiferman & Evenson 2003</style>)</DisplayText><record><rec-number>1271</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1562982773">1271</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Leiferman, J. A.</author><author>Evenson, K. R.</author></authors></contributors><auth-address>Department of Human Nutrition, Foods, and Exercise, Virginia Tech University, Blacksburg, Virginia 24061, USA. jleif@vt.edu</auth-address><titles><title>The effect of regular leisure physical activity on birth outcomes</title><secondary-title>Matern Child Health J</secondary-title></titles><periodical><full-title>Matern Child Health J</full-title></periodical><pages>59-64</pages><volume>7</volume><number>1</number><edition>2003/04/25</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Data Collection</keyword><keyword>*Exercise</keyword><keyword>Female</keyword><keyword>Gestational Age</keyword><keyword>*Health Behavior</keyword><keyword>Humans</keyword><keyword>*Infant, Low Birth Weight</keyword><keyword>Infant, Newborn</keyword><keyword>*Leisure Activities</keyword><keyword>Obstetric Labor, Premature/epidemiology</keyword><keyword>Odds Ratio</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Outcome/*epidemiology</keyword><keyword>Pregnant Women/*psychology</keyword><keyword>Regression Analysis</keyword><keyword>Sampling Studies</keyword><keyword>Socioeconomic Factors</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2003</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1092-7875 (Print)
1092-7875 (Linking)</isbn><accession-num>12710801</accession-num><urls><related-urls><url>;(Leiferman & Evenson 2003). Cohort studies suggest a positive association between physical activity during pregnancy and offspring neurodevelopment (4 studies) ADDIN EN.CITE <EndNote><Cite><Author>Nino Cruz</Author><Year>2018</Year><RecNum>567</RecNum><DisplayText>(<style font="Century Gothic" size="8">Nino Cruz et al 2018</style>)</DisplayText><record><rec-number>567</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1535933807">567</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nino Cruz, G. I.</author><author>Ramirez Varela, A.</author><author>da Silva, I. C. M.</author><author>Hallal, P. C.</author><author>Santos, I. S.</author></authors></contributors><auth-address>Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rio Grande do Sul, Brazil.</auth-address><titles><title>Physical activity during pregnancy and offspring neurodevelopment: A systematic review</title><secondary-title>Paediatr Perinat Epidemiol</secondary-title></titles><periodical><full-title>Paediatr Perinat Epidemiol</full-title></periodical><pages>369-379</pages><volume>32</volume><number>4</number><edition>2018/05/05</edition><keywords><keyword>childhood</keyword><keyword>infancy</keyword><keyword>neurodevelopment</keyword><keyword>physical activity</keyword><keyword>pregnancy</keyword></keywords><dates><year>2018</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1365-3016 (Electronic)
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ADDIN EN.CITE.DATA (Kong et al 2016).Adverse effectsThe evidence did not support an association between:any exercise during pregnancy and:risk of miscarriage (OR 0.69; 95%CI 0.40 to 1.22; 10 studies) or perinatal mortality (OR 0.79; 95%CI 0.26 to 2.38; 6?studies) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZlbnBvcnQ8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFy
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ADDIN EN.CITE.DATA (Davenport et al 2019a)adverse impact on fetal heart rate or uteroplacental blood flow metrics (9 studies; 4,651 women) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ta293PC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Hoffmann et al 2019)risk of preterm birth with exercise in the first (OR 0.80; 95%CI 0.48 to 1.35) or second trimester (OR 0.52; 95%CI 0.24 to 1.11; n=1,699) ADDIN EN.CITE <EndNote><Cite><Author>Evenson</Author><Year>2002</Year><RecNum>851</RecNum><DisplayText>(<style font="Century Gothic" size="8">Evenson et al 2002</style>)</DisplayText><record><rec-number>851</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540638">851</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Evenson, K. R.</author><author>Siega-Riz, A. M.</author><author>Savitz, D. A.</author><author>Leiferman, J. A.</author><author>Thorp, J. M., Jr.</author></authors></contributors><auth-address>Department of Epidemiology, School of Public Health, University of North Carolina-Chapel Hill, NC 27514, USA. kelly_evensen@unc.edu</auth-address><titles><title>Vigorous leisure activity and pregnancy outcome</title><secondary-title>Epidemiology</secondary-title></titles><periodical><full-title>Epidemiology</full-title></periodical><pages>653-9</pages><volume>13</volume><number>6</number><edition>2002/11/01</edition><keywords><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant Mortality</keyword><keyword>Infant, Low Birth Weight</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Premature</keyword><keyword>*Leisure Activities</keyword><keyword>North Carolina/epidemiology</keyword><keyword>Physical Exertion</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Outcome/*epidemiology</keyword><keyword>Pregnancy Trimester, First</keyword><keyword>Pregnancy Trimester, Second</keyword></keywords><dates><year>2002</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1044-3983 (Print)
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ADDIN EN.CITE.DATA (Jukic et al 2012)risk of post-term birth with exercise in the first (OR 0.93; 95%CI 0.45 to 1.89) or second (OR 1.15; 95%CI 0.47 to 2.79) trimester (n=1,699) ADDIN EN.CITE <EndNote><Cite><Author>Evenson</Author><Year>2002</Year><RecNum>851</RecNum><DisplayText>(<style font="Century Gothic" size="8">Evenson et al 2002</style>)</DisplayText><record><rec-number>851</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540638">851</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Evenson, K. R.</author><author>Siega-Riz, A. M.</author><author>Savitz, D. A.</author><author>Leiferman, J. A.</author><author>Thorp, J. M., Jr.</author></authors></contributors><auth-address>Department of Epidemiology, School of Public Health, University of North Carolina-Chapel Hill, NC 27514, USA. kelly_evensen@unc.edu</auth-address><titles><title>Vigorous leisure activity and pregnancy outcome</title><secondary-title>Epidemiology</secondary-title></titles><periodical><full-title>Epidemiology</full-title></periodical><pages>653-9</pages><volume>13</volume><number>6</number><edition>2002/11/01</edition><keywords><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant Mortality</keyword><keyword>Infant, Low Birth Weight</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Premature</keyword><keyword>*Leisure Activities</keyword><keyword>North Carolina/epidemiology</keyword><keyword>Physical Exertion</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Outcome/*epidemiology</keyword><keyword>Pregnancy Trimester, First</keyword><keyword>Pregnancy Trimester, Second</keyword></keywords><dates><year>2002</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1044-3983 (Print)
1044-3983 (Linking)</isbn><accession-num>12410006</accession-num><urls><related-urls><url>;(Evenson et al 2002)supine exercise and low birthweight (3 RCTs; very low to low certainty) ADDIN EN.CITE <EndNote><Cite><Author>Mottola</Author><Year>2019</Year><RecNum>1226</RecNum><DisplayText>(<style font="Century Gothic" size="8">Mottola et al 2019</style>)</DisplayText><record><rec-number>1226</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1562472156">1226</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mottola, Michelle F.</author><author>Nagpal, Taniya S.</author><author>Bgeginski, Roberta</author><author>Davenport, Margie H.</author><author>Poitras, Veronica J.</author><author>Gray, Casey E.</author><author>Davies, Gregory A.</author><author>Adamo, Kristi B.</author><author>Slater, Linda G.</author><author>Barrowman, Nick</author><author>Barakat, Ruben</author><author>Ruchat, Stephanie-May</author></authors></contributors><titles><title>Is supine exercise associated with adverse maternal and fetal outcomes? A systematic review</title><secondary-title>British Journal of Sports Medicine</secondary-title></titles><periodical><full-title>British Journal of Sports Medicine</full-title></periodical><pages>82-89</pages><volume>53</volume><number>2</number><section>82</section><dates><year>2019</year></dates><isbn>0306-3674
1473-0480</isbn><urls></urls><electronic-resource-num>10.1136/bjsports-2018-099919</electronic-resource-num></record></Cite></EndNote>(Mottola et al 2019) swimming or aqua aerobics and:risk of miscarriage <22 weeks (19-22 weeks HR 0.9; 95%CI 0.4 to 1.9; n=92,671) ADDIN EN.CITE <EndNote><Cite><Author>Madsen</Author><Year>2007</Year><RecNum>890</RecNum><DisplayText>(<style font="Century Gothic" size="8">Madsen et al 2007</style>)</DisplayText><record><rec-number>890</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540794">890</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Madsen, M.</author><author>Jorgensen, T.</author><author>Jensen, M. L.</author><author>Juhl, M.</author><author>Olsen, J.</author><author>Andersen, P. K.</author><author>Nybo Andersen, A. M.</author></authors></contributors><auth-address>Department of Child Health, National Institute of Public Health, Copenhagen K, Denmark.</auth-address><titles><title>Leisure time physical exercise during pregnancy and the risk of miscarriage: a study within the Danish National Birth Cohort</title><secondary-title>BJOG</secondary-title></titles><periodical><full-title>BJOG</full-title></periodical><pages>1419-26</pages><volume>114</volume><number>11</number><edition>2007/09/20</edition><keywords><keyword>Abortion, Spontaneous/epidemiology/*etiology</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Denmark/epidemiology</keyword><keyword>Epidemiologic Methods</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Leisure Activities</keyword><keyword>Maternal Age</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Outcome/epidemiology</keyword></keywords><dates><year>2007</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1471-0528 (Electronic)
1470-0328 (Linking)</isbn><accession-num>17877774</accession-num><urls><related-urls><url>;(Madsen et al 2007) risk of spina bifida (aOR 0.68; 95%CI 0.47 to 0.99; n=8,655) ADDIN EN.CITE <EndNote><Cite><Author>Agopian</Author><Year>2013</Year><RecNum>901</RecNum><DisplayText>(<style font="Century Gothic" size="8">Agopian et al 2013</style>)</DisplayText><record><rec-number>901</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540824">901</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Agopian, A. J.</author><author>Lupo, Philip J.</author><author>Canfield, Mark A.</author><author>Mitchell, Laura E.</author></authors></contributors><titles><title>Swimming pool use and birth defect risk</title><secondary-title>American Journal of Obstetrics and Gynecology</secondary-title></titles><periodical><full-title>American Journal of Obstetrics and Gynecology</full-title></periodical><pages>219.e1-219.e9</pages><volume>209</volume><number>3</number><section>219.e1</section><dates><year>2013</year></dates><isbn>00029378</isbn><urls></urls><electronic-resource-num>10.1016/j.ajog.2013.04.033</electronic-resource-num></record></Cite></EndNote>(Agopian et al 2013)significant increase in maternal body temperature (mean increase 0.16±0.35°C; n=109) ADDIN EN.CITE <EndNote><Cite><Author>Brearley</Author><Year>2015</Year><RecNum>840</RecNum><DisplayText>(<style font="Century Gothic" size="8">Brearley et al 2015</style>)</DisplayText><record><rec-number>840</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540586">840</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brearley, Amanda L.</author><author>Sherburn, Margaret</author><author>Galea, Mary P.</author><author>Clarke, Sandy J.</author></authors></contributors><titles><title>Pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic classes conducted in pools heated up to 33 degrees Celsius: an observational study</title><secondary-title>Journal of Physiotherapy</secondary-title></titles><periodical><full-title>Journal of Physiotherapy</full-title></periodical><pages>199-203</pages><volume>61</volume><number>4</number><section>199</section><dates><year>2015</year></dates><isbn>18369553</isbn><urls></urls><electronic-resource-num>10.1016/j.jphys.2015.08.004</electronic-resource-num></record></Cite></EndNote>(Brearley et al 2015).However, a cohort study (n=92,671) ADDIN EN.CITE <EndNote><Cite><Author>Madsen</Author><Year>2007</Year><RecNum>890</RecNum><DisplayText>(<style font="Century Gothic" size="8">Madsen et al 2007</style>)</DisplayText><record><rec-number>890</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540794">890</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Madsen, M.</author><author>Jorgensen, T.</author><author>Jensen, M. L.</author><author>Juhl, M.</author><author>Olsen, J.</author><author>Andersen, P. K.</author><author>Nybo Andersen, A. M.</author></authors></contributors><auth-address>Department of Child Health, National Institute of Public Health, Copenhagen K, Denmark.</auth-address><titles><title>Leisure time physical exercise during pregnancy and the risk of miscarriage: a study within the Danish National Birth Cohort</title><secondary-title>BJOG</secondary-title></titles><periodical><full-title>BJOG</full-title></periodical><pages>1419-26</pages><volume>114</volume><number>11</number><edition>2007/09/20</edition><keywords><keyword>Abortion, Spontaneous/epidemiology/*etiology</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Denmark/epidemiology</keyword><keyword>Epidemiologic Methods</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Leisure Activities</keyword><keyword>Maternal Age</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Outcome/epidemiology</keyword></keywords><dates><year>2007</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1471-0528 (Electronic)
1470-0328 (Linking)</isbn><accession-num>17877774</accession-num><urls><related-urls><url>;(Madsen et al 2007) found that bicycling and horseback riding may be associated with miscarriage at 11-14 weeks (HR 1.7; 95%CI 1.4 to 2.0) but not at other times before 22 weeks.The same study suggested an increase in risk of miscarriage <18 weeks with high impact exercise (jogging, ball games and racket sports) or workout/fitness training (75-269 minutes/week). However, the authors noted that it is too early to draw any public health inferences on this basis.A systematic review noted that there was insufficient evidence to ascertain whether maternal exercise in the supine position is safe or should be avoided during pregnancy ADDIN EN.CITE <EndNote><Cite><Author>Mottola</Author><Year>2019</Year><RecNum>1226</RecNum><DisplayText>(<style font="Century Gothic" size="8">Mottola et al 2019</style>)</DisplayText><record><rec-number>1226</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1562472156">1226</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mottola, Michelle F.</author><author>Nagpal, Taniya S.</author><author>Bgeginski, Roberta</author><author>Davenport, Margie H.</author><author>Poitras, Veronica J.</author><author>Gray, Casey E.</author><author>Davies, Gregory A.</author><author>Adamo, Kristi B.</author><author>Slater, Linda G.</author><author>Barrowman, Nick</author><author>Barakat, Ruben</author><author>Ruchat, Stephanie-May</author></authors></contributors><titles><title>Is supine exercise associated with adverse maternal and fetal outcomes? A systematic review</title><secondary-title>British Journal of Sports Medicine</secondary-title></titles><periodical><full-title>British Journal of Sports Medicine</full-title></periodical><pages>82-89</pages><volume>53</volume><number>2</number><section>82</section><dates><year>2019</year></dates><isbn>0306-3674
1473-0480</isbn><urls></urls><electronic-resource-num>10.1136/bjsports-2018-099919</electronic-resource-num></record></Cite></EndNote>(Mottola et al 2019).Evidence-based recommendationAdvise women that regular moderate-intensity physical activity during pregnancy is associated with a range of health benefits and is generally not associated with adverse outcomes.Recent evidence on the effects of occupational physical activity during pregnancyThe evidence on risks associated with occupational physical activity during pregnancy is unclear. Heavy lifting (eg >200 kg/day) may be associated with an increased risk of pelvic pain (201-500 kg/day: aOR 1.45; 95%CI 1.31 to 1.60; n=50,143) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYXJzZW48L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Larsen et al 2013), stillbirth among women with a previous fetal loss (201-975 kg per day: adjusted hazard ratio [aHR] 2.87; 95%CI 1.37 to 6.01; n=68,086) ADDIN EN.CITE <EndNote><Cite><Author>Juhl</Author><Year>2013</Year><RecNum>1228</RecNum><DisplayText>(<style font="Century Gothic" size="8">Juhl et al 2013</style>)</DisplayText><record><rec-number>1228</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1562472199">1228</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Juhl, M.</author><author>Strandberg-Larsen, K.</author><author>Larsen, P. S.</author><author>Andersen, P. K.</author><author>Svendsen, S. W.</author><author>Bonde, J. P.</author><author>Nybo Andersen, A. M.</author></authors></contributors><auth-address>Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark. metjuhl@</auth-address><titles><title>Occupational lifting during pregnancy and risk of fetal death in a large national cohort study</title><secondary-title>Scand J Work Environ Health</secondary-title></titles><periodical><full-title>Scand J Work Environ Health</full-title></periodical><pages>335-42</pages><volume>39</volume><number>4</number><edition>2012/12/05</edition><keywords><keyword>Adult</keyword><keyword>Denmark</keyword><keyword>Female</keyword><keyword>*Fetal Death</keyword><keyword>Humans</keyword><keyword>*Lifting</keyword><keyword>*Occupational Health</keyword><keyword>Pregnancy</keyword><keyword>Proportional Hazards Models</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2013</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1795-990X (Electronic)
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ADDIN EN.CITE.DATA (Pompeii et al 2005; Snijder et al 2012; Juhl et al 2014) or low birthweight PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TbmlqZGVyPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Snijder et al 2012). There is a possible association between occupational standing and increased risk of miscarriage (>6 hours a day: RR?1.16; 95%CI 1.01 to 1.32; 30 studies) or preterm birth ADDIN EN.CITE <EndNote><Cite><Author>Ritsmitchai</Author><Year>1997</Year><RecNum>1792</RecNum><DisplayText>(<style font="Century Gothic" size="8">Ritsmitchai et al 1997</style>)</DisplayText><record><rec-number>1792</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1583299791">1792</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ritsmitchai, S.,</author><author>Geater, A.F.,</author><author>Chongsuviwatvong, V.,</author></authors></contributors><titles><title>Prolonged standing and physical exertion at work during pregnancy increases the risk of preterm birth for Thai mothers.</title><secondary-title>J Occup Health</secondary-title></titles><periodical><full-title>J Occup Health</full-title></periodical><pages>217-22</pages><volume>39</volume><dates><year>1997</year></dates><urls></urls></record></Cite></EndNote>(Ritsmitchai et al 1997) (>3?hours per day: OR 1.25; 95%CI 0.99 to 1.57; 11 studies) but no clear difference in small-for-gestational age, birthweight ADDIN EN.CITE <EndNote><Cite><Author>Eunhee</Author><Year>2002</Year><RecNum>1495</RecNum><DisplayText>(<style font="Century Gothic" size="8">Eunhee et al 2002</style>)</DisplayText><record><rec-number>1495</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1574314249">1495</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eunhee, H.,</author><author>Cho, S-I.,</author><author>Park, H.,</author><author>Chen, D.,</author><author>Chen, C.,</author><author>Wang., L.,</author><author>Xu, X.,</author><author>Christiani, D.C.,</author></authors></contributors><titles><title>Does standing at work during pregnancy result in reduced infant birth weight?</title><secondary-title>JOEM</secondary-title></titles><periodical><full-title>JOEM</full-title></periodical><pages>815-21</pages><volume>44</volume><number>9</number><dates><year>2002</year></dates><urls></urls></record></Cite></EndNote>(Eunhee et al 2002) or pelvic pain ADDIN EN.CITE <EndNote><Cite><Author>Juhl</Author><Year>2005</Year><RecNum>880</RecNum><DisplayText>(<style font="Century Gothic" size="8">Juhl 2005</style>)</DisplayText><record><rec-number>880</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540751">880</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Juhl, M.</author></authors></contributors><titles><title>Psychosocial and physical work environment, and risk of pelvic pain in pregnancy. A study within the Danish national birth cohort</title><secondary-title>J Epidemiol & Community Health</secondary-title></titles><periodical><full-title>J Epidemiol & Community Health</full-title></periodical><pages>580-585</pages><volume>59</volume><number>7</number><section>580</section><dates><year>2005</year></dates><isbn>0143-005X</isbn><urls></urls><electronic-resource-num>10.1136/jech.2004.029520</electronic-resource-num></record></Cite></EndNote>(Juhl 2005). There is insufficient evidence to draw conclusions on strenuous occupational physical exertion in pregnancy but it may be associated with preterm premature rupture of the membranes (OR 1.72; 95%CI 1.16 to 2.56; n=2,929) ADDIN EN.CITE <EndNote><Cite><Author>Newman</Author><Year>2001</Year><RecNum>1231</RecNum><DisplayText>(<style font="Century Gothic" size="8">Newman et al 2001</style>)</DisplayText><record><rec-number>1231</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1562472229">1231</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Newman, R. B.</author><author>Goldenberg, R. L.</author><author>Moawad, A. H.</author><author>Iams, J. D.</author><author>Meis, P. J.</author><author>Das, A.</author><author>Miodovnik, M.</author><author>Caritis, S. N.</author><author>Thurnau, G. R.</author><author>Dombrowski, M. P.</author><author>Roberts, J.</author></authors></contributors><titles><title>Occupational fatigue and preterm premature rupture of membranes</title><secondary-title>American Journal of Obstetrics and Gynecology</secondary-title></titles><periodical><full-title>American Journal of Obstetrics and Gynecology</full-title></periodical><pages>438-446</pages><volume>184</volume><number>3</number><section>438</section><dates><year>2001</year></dates><isbn>00029378</isbn><urls></urls><electronic-resource-num>10.1067/mob.2001.110312</electronic-resource-num></record></Cite></EndNote>(Newman et al 2001) and pelvic pain (OR 1.47; 95%CI 1.17 to 1.84; n=2,758) ADDIN EN.CITE <EndNote><Cite><Author>Juhl</Author><Year>2005</Year><RecNum>880</RecNum><DisplayText>(<style font="Century Gothic" size="8">Juhl 2005</style>)</DisplayText><record><rec-number>880</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540751">880</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Juhl, M.</author></authors></contributors><titles><title>Psychosocial and physical work environment, and risk of pelvic pain in pregnancy. A study within the Danish national birth cohort</title><secondary-title>J Epidemiol & Community Health</secondary-title></titles><periodical><full-title>J Epidemiol & Community Health</full-title></periodical><pages>580-585</pages><volume>59</volume><number>7</number><section>580</section><dates><year>2005</year></dates><isbn>0143-005X</isbn><urls></urls><electronic-resource-num>10.1136/jech.2004.029520</electronic-resource-num></record></Cite><Cite><Author>Juhl</Author><Year>2005</Year><RecNum>880</RecNum><record><rec-number>880</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1541540751">880</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Juhl, M.</author></authors></contributors><titles><title>Psychosocial and physical work environment, and risk of pelvic pain in pregnancy. A study within the Danish national birth cohort</title><secondary-title>J Epidemiol & Community Health</secondary-title></titles><periodical><full-title>J Epidemiol & Community Health</full-title></periodical><pages>580-585</pages><volume>59</volume><number>7</number><section>580</section><dates><year>2005</year></dates><isbn>0143-005X</isbn><urls></urls><electronic-resource-num>10.1136/jech.2004.029520</electronic-resource-num></record></Cite></EndNote>(Juhl 2005).Practice summary: nutrition and physical activityNutritionWhen: All antenatal visitsWho: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; accredited dietitian; nutritionistAssess levels of nutrition: Ask women about their current eating patterns.Provide advice: Explain the benefits of healthy nutrition for the mother and baby. Give examples of culturally appropriate foods in the five food groups, sample serves for each group, how many serves are recommended a day and ‘eating a rainbow’. Discuss foods that are rich in iron (eg meat, seafood and poultry, vegetarian or vegan options), dietary factors that aid or limit absorption, and supplementing iron if the woman has a low dietary intake.Discuss use of nutritional supplements with women: Explain that some supplements (folic acid, iodine, calcium) are recommended for all women during some stages of pregnancy, while others (vitamins A, C and E) are not of benefit and may be harmful and that iron should only be supplemented if a deficiency is identified. Consider referral: Referral to an accredited dietitian may be a consideration if there is concern about the quality of nutritional intake, the woman would like information about nutrition for herself and her family, clinical assessment confirms underweight or overweight of the woman or there are other factors of concern (eg diabetes, gastrointestinal disorders).Take a holistic approach: Tailor dietary advice to the individual woman. Consider the availability and affordability of foods appropriate to the woman’s cultural practices and preferences and the need and affordability of supplements. Physical activityWhen: All antenatal visits.Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; physiotherapist or accredited exercise physiologist.Assess levels of activity: Ask women about their current levels of physical activity, including the amount of time spent being active and the intensity of activity.Provide advice: Explain the benefits of regular moderate-intensity physical activity. Give examples of activities that are of sufficient intensity to achieve health benefits (eg brisk walking, swimming, cycling). Advise women to discuss their plans with a health professional before starting or continuing a program of physical activity.Provide information: Give information about local supports for physical activity (eg women’s walking groups, swimming clubs). Advise women to avoid exercising in the heat of the day and to drink plenty of water when active.Take a holistic approach: Assist women to identify ways of being physically active that are appropriate to their cultural beliefs and practices (eg activities they can do at home).ResourcesNutritionFSANZ (2011) Mercury in Fish. Food Standards Australia New Zealand. FSANZ (2018) Listeria. Food Standards Australia New Zealand. NHMRC (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council.NHMRC (2010) NHMRC Public Statement: Iodine Supplementation for Pregnant and Breastfeeding Women. Canberra: National Health and Medical Research Council. NHMRC (2006) Nutrient Reference Values for Australia and New Zealand. Canberra: National Health and Medical Research Council. 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Int J Epidemiol 46(5): 1499-508.Clinical assessmentsWeight and body mass indexBody mass index (prior to pregnancy or at the first antenatal visit) and weight gain during pregnancy are among the important determinants of the health of both mother and baby.BackgroundWeight classificationBody mass index (BMI) is commonly used to classify adults as being underweight, of healthy weight, overweight or obese. It is calculated by dividing weight by the square of height: weight?(kg)/height (m)2. The WHO classification of BMI classification is given in Table 4. Table 4: Classification of adult underweight, overweight and obesity according to BMI BMI (kg/m2)Classification<18.50Underweight18.5–24.9Healthy weight 25.0–29.9Overweight >30.0ObeseWeight classification during pregnancy in AustraliaAmong women who gave birth in Australia in 2018 ADDIN EN.CITE <EndNote><Cite><Author>AIHW</Author><Year>2020</Year><RecNum>1974</RecNum><DisplayText>(<style font="Century Gothic" size="8">AIHW 2020</style>)</DisplayText><record><rec-number>1974</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1590724334">1974</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>AIHW</author></authors></contributors><titles><title>Australia’s mothers and babies 2018: in brief</title><secondary-title>Perinatal statistics series no. 36. Cat. no. PER 108</secondary-title></titles><dates><year>2020</year></dates><pub-location>Canberra</pub-location><publisher>Australian Institute of Health and Welfare</publisher><urls></urls></record></Cite></EndNote>(AIHW 2020):3.8% were underweight, 49.5% were in the healthy weight range, 26.0% were overweight but not obese and 21.0% were obese at the beginning of their pregnancyAboriginal and Torres Strait Islander women were more likely than non-Indigenous women to be either obese (31.0% vs 21.0%) or underweight (6.8% vs 3.8%) and less likely to be in the healthy weight range (38% vs 49.5%), with a similar likelihood of being overweight but not obese (24%)compared to women in the highest socioeconomic status quintile, those in the most disadvantaged quintile were more likely to be obese (26.7 vs 12.4%), less likely to be in the healthy weight range (42.0 vs 60.3%) and had a similar likelihood of being overweight (27.1 vs 23.1%) or underweight (both 4.2%)obesity was most common in very remote areas (27.1 vs 18.7% in major cities), prevalence of overweight was similar across geographical regions, prevalence of healthy weight decreased with increasing remoteness (51.7% in major cities to 39.2% in very remote areas) and underweight was more common in very remote areas (7.1 vs 3.8% in major cities).Assessing BMI Measuring height and weight and calculating BMI Routine measurement of women’s weight and height and calculation of BMI at the first antenatal contact allows identification of women who require additional care during pregnancy. When there is an accurate record of a woman’s pre-pregnancy BMI, this may be used to estimate gestational weight gain (see Section? REF _Ref35956544 \r \h 2.3). Note that the BMI can be less accurate for assessing healthy weight in certain groups due to variations in muscle mass and fat mass (eg cut-offs lower than the WHO classifications may be appropriate for women from Asian backgrounds and higher cut-offs for women from the Pacific Islands). Risks associated with a low or high BMILow pre-pregnancy BMISystematic reviews are consistent in finding that low pre-pregnancy BMI is associated with an increased risk of:preterm birth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYW48L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Han et al 2011; Liu et al 2016)small for gestational age PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Yu et al 2013; Liu et al 2016; Goto 2017; Liu et al 2019) low birthweight PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Balsells et al 2016) and placental abruption ADDIN EN.CITE <EndNote><Cite><Author>Adane</Author><Year>2019</Year><RecNum>1858</RecNum><DisplayText>(<style font="Century Gothic" size="8">Adane et al 2019</style>)</DisplayText><record><rec-number>1858</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587794110">1858</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Adane, A.A.,</author><author>Shepherd, C.C.J.</author><author>Lim, F.J.</author><author>White, S.W.</author><author>Farrant, B.M.</author><author>Bailey, H.D.</author></authors></contributors><titles><title>The impact of pre-pregnancy body mass index and gestational weight gain on placental abruption risk: a systematic review and meta-analysis</title><secondary-title>Arch Gynecol Obstet</secondary-title></titles><periodical><full-title>Arch Gynecol Obstet</full-title></periodical><pages>1201-1210</pages><volume>300</volume><number>5</number><section>1201</section><dates><year>2019</year></dates><isbn>0932-0067
1432-0711</isbn><urls></urls><electronic-resource-num>10.1007/s00404-019-05320-8</electronic-resource-num></record></Cite></EndNote>(Adane et al 2019) and a decreased risk of gestational diabetes ADDIN EN.CITE <EndNote><Cite><Author>Torloni</Author><Year>2009</Year><RecNum>1865</RecNum><DisplayText>(<style font="Century Gothic" size="8">Torloni et al 2009</style>)</DisplayText><record><rec-number>1865</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587794175">1865</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Torloni, M. R.</author><author>Betran, A. P.</author><author>Horta, B. L.</author><author>Nakamura, M. U.</author><author>Atallah, A. N.</author><author>Moron, A. F.</author><author>Valente, O.</author></authors></contributors><auth-address>Department of Emergency and Evidence Based Medicine, Sao Paulo Federal University, Sao Paulo, Brazil.</auth-address><titles><title>Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis</title><secondary-title>Obes Rev</secondary-title></titles><periodical><full-title>Obes Rev</full-title></periodical><pages>194-203</pages><volume>10</volume><number>2</number><edition>2008/12/06</edition><keywords><keyword>*Body Mass Index</keyword><keyword>Diabetes, Gestational/*epidemiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Pregnancy</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2009</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1467-789X (Electronic)
1467-7881 (Linking)</isbn><accession-num>19055539</accession-num><urls><related-urls><url>;(Torloni et al 2009). There was no clear effect on risk of congenital heart defects ADDIN EN.CITE <EndNote><Cite><Author>Zhu</Author><Year>2018</Year><RecNum>1908</RecNum><DisplayText>(<style font="Century Gothic" size="8">Zhu et al 2018</style>)</DisplayText><record><rec-number>1908</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588208212">1908</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zhu, Y.</author><author>Chen, Y.</author><author>Feng, Y.</author><author>Yu, D.</author><author>Mo, X.</author></authors></contributors><auth-address>Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China.
Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Soochow, China.</auth-address><titles><title>Association between maternal body mass index and congenital heart defects in infants: A meta-analysis</title><secondary-title>Congenit Heart Dis</secondary-title></titles><periodical><full-title>Congenit Heart Dis</full-title></periodical><pages>271-281</pages><volume>13</volume><number>2</number><edition>2018/01/25</edition><keywords><keyword>*Body Mass Index</keyword><keyword>Female</keyword><keyword>Global Health</keyword><keyword>Heart Defects, Congenital/epidemiology/*etiology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Maternal Exposure/*adverse effects</keyword><keyword>Obesity/*complications</keyword><keyword>Odds Ratio</keyword><keyword>Pregnancy</keyword><keyword>Risk Factors</keyword><keyword>congenital heart defects</keyword><keyword>maternal body mass index</keyword><keyword>meta-analysis</keyword></keywords><dates><year>2018</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1747-0803 (Electronic)
1747-079X (Linking)</isbn><accession-num>29363266</accession-num><urls><related-urls><url>;(Zhu et al 2018).High pre-pregnancy BMISystematic reviews are consistent in finding that pre-pregnancy overweight and obesity is associated with: large for gestational age PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Yu et al 2013; Liu et al 2016; Liu et al 2019)macrosomia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaXU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Yu et al 2013; Liu et al 2016; Liu et al 2019) childhood overweight/obesity PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ZdTwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA (Yu et al 2013; Voerman et al 2019).Systematic reviews have also found associations between high pre-pregnancy BMI and:increased risk of gestational diabetes ADDIN EN.CITE <EndNote><Cite><Author>Torloni</Author><Year>2009</Year><RecNum>1865</RecNum><DisplayText>(<style font="Century Gothic" size="8">Torloni et al 2009</style>)</DisplayText><record><rec-number>1865</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587794175">1865</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Torloni, M. R.</author><author>Betran, A. P.</author><author>Horta, B. L.</author><author>Nakamura, M. U.</author><author>Atallah, A. N.</author><author>Moron, A. F.</author><author>Valente, O.</author></authors></contributors><auth-address>Department of Emergency and Evidence Based Medicine, Sao Paulo Federal University, Sao Paulo, Brazil.</auth-address><titles><title>Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis</title><secondary-title>Obes Rev</secondary-title></titles><periodical><full-title>Obes Rev</full-title></periodical><pages>194-203</pages><volume>10</volume><number>2</number><edition>2008/12/06</edition><keywords><keyword>*Body Mass Index</keyword><keyword>Diabetes, Gestational/*epidemiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Pregnancy</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2009</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1467-789X (Electronic)
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ADDIN EN.CITE.DATA (Cai et al 2014; Zhu et al 2018)reduced risk of small for gestational age ADDIN EN.CITE <EndNote><Cite><Author>Goto</Author><Year>2017</Year><RecNum>1862</RecNum><DisplayText>(<style font="Century Gothic" size="8">Goto 2017</style>)</DisplayText><record><rec-number>1862</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587794145">1862</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Goto, E.</author></authors></contributors><auth-address>a Department of Medicine and Public Health , Nagoya Medical Science Research Institute , Nagoya , Japan.</auth-address><titles><title>Dose-response association between maternal body mass index and small for gestational age: a meta-analysis</title><secondary-title>J Matern Fetal Neonatal Med</secondary-title></titles><periodical><full-title>J Matern Fetal Neonatal Med</full-title></periodical><pages>213-218</pages><volume>30</volume><number>2</number><edition>2016/03/24</edition><keywords><keyword>*Body Mass Index</keyword><keyword>Body Weight/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>*Infant, Small for Gestational Age</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Complications</keyword><keyword>Risk Factors</keyword><keyword>*Anthropometry</keyword><keyword>*meta-analysis</keyword><keyword>*risk</keyword><keyword>*small for gestational age</keyword></keywords><dates><year>2017</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1476-4954 (Electronic)
1476-4954 (Linking)</isbn><accession-num>27002363</accession-num><urls><related-urls><url>;(Goto 2017) and placental abruption ADDIN EN.CITE <EndNote><Cite><Author>Adane</Author><Year>2019</Year><RecNum>1858</RecNum><DisplayText>(<style font="Century Gothic" size="8">Adane et al 2019</style>)</DisplayText><record><rec-number>1858</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1587794110">1858</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Adane, A.A.,</author><author>Shepherd, C.C.J.</author><author>Lim, F.J.</author><author>White, S.W.</author><author>Farrant, B.M.</author><author>Bailey, H.D.</author></authors></contributors><titles><title>The impact of pre-pregnancy body mass index and gestational weight gain on placental abruption risk: a systematic review and meta-analysis</title><secondary-title>Arch Gynecol Obstet</secondary-title></titles><periodical><full-title>Arch Gynecol Obstet</full-title></periodical><pages>1201-1210</pages><volume>300</volume><number>5</number><section>1201</section><dates><year>2019</year></dates><isbn>0932-0067
1432-0711</isbn><urls></urls><electronic-resource-num>10.1007/s00404-019-05320-8</electronic-resource-num></record></Cite></EndNote>(Adane et al 2019).Systematic reviews found a decreased likelihood of initiating breastfeeding among obese women PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdWFuZzwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Garcia et al 2016; Huang et al 2019).Discussing weight with womenWomen who have a BMI that is below or above the healthy range are likely to require additional care and support during pregnancy. For women with an elevated BMI, there may be additional implications for care during pregnancy (eg the potential for poor ultrasound visualisation) and the birth (eg need for the birth to take place in a larger centre, difficulties with fetal monitoring). Relevant risks associated with a woman’s BMI should be explained and the woman given the opportunity to discuss these and how they might be minimised. Assessment of fetal growth is discussed in Section 22.1 and assessment for risk of preterm birth in Chapter 23. Monitoring weight gainWhile BMI prior to or early in pregnancy is independently associated with pregnancy outcomes, the amount of weight gained during pregnancy is also a contributing factor. The US Institute of Medicine (IOM) provides guidance on weight gain in pregnancy based on pre-pregnancy BMI. The IOM recommendations are consensus-based and were written in 2009. More recently, the US Centers for Disease Control and Prevention (CDC) have provided recommendations on gestational weight gain, which are also consensus-based.Table 5:Recommendations for weight gain in pregnancy (kg)Pre-pregnancy BMI (kg/m2)IOM recommendationsCDC 2019 recommendationsUnderweight12.5–18.016.0-18.0Healthy weight11.5–16.016.0-18.0Overweight7.0–11.512.0-16.0Obese5.0–9.06.0-9.0Note: The recommended weight gain ranges are indicative only and provide suggested limits rather than specific goals.Sources: ADDIN EN.CITE <EndNote><Cite><Author>NHMRC</Author><Year>2013</Year><RecNum>1308</RecNum><DisplayText>(<style font="Century Gothic" size="8">NHMRC 2013b</style>)</DisplayText><record><rec-number>1308</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1486418469">1308</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>NHMRC</author></authors></contributors><titles><title>Australian Dietary Guidelines</title></titles><dates><year>2013</year></dates><pub-location>Canberra</pub-location><publisher>National Health and Medical Research Council</publisher><urls><related-urls><url>.au</url></related-urls></urls></record></Cite></EndNote>(NHMRC 2013b) based on (IOM 2009) and ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2019</Year><RecNum>1973</RecNum><DisplayText>(<style font="Century Gothic" size="8">CDC 2019</style>)</DisplayText><record><rec-number>1973</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1589852220">1973</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>CDC,</author></authors></contributors><titles><title>Weight Gain During Pregnancy</title></titles><number>19 May 2020</number><dates><year>2019</year></dates><urls><related-urls><url>;(CDC 2019).An individual participant-level meta-analysis (25 cohort studies; n=196,670) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaWZlQ3ljbGUgUHJvamVjdC1NYXRlcm5hbDwvQXV0aG9y
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ADDIN EN.CITE.DATA (Arora & Tamber Aeri 2019) highlighted the need for gestational weight gain recommendations across the different body mass index levels specifically for Indian women and other Asian populations.A retrospective cohort study in China (n=8,209) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KaWFuZzwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Jiang et al 2019) found that the lowest accumulated risk of low birthweight and macrosomia was not always achieved among women who gained weight within recommendations and suggested that the IOM weight gain ranges are too high for Chinese women.A cohort study in the United States (n=181,948) ADDIN EN.CITE <EndNote><Cite><Author>Khanolkar</Author><Year>2020</Year><RecNum>1970</RecNum><DisplayText>(<style font="Century Gothic" size="8">Khanolkar et al 2020</style>)</DisplayText><record><rec-number>1970</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588903235">1970</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Khanolkar, A. R.</author><author>Hanley, G. E.</author><author>Koupil, I.</author><author>Janssen, P. A.</author></authors></contributors><auth-address>Centre for Health Equity Studies (CHESS), Stockholm University, Stockholm, Sweden.
Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
GOS Institute of Child Health, University College London, London, UK.
School of Population and Public Health and the Child and Family Research Institute, University of British Columbia, Vancouver, Canada.</auth-address><titles><title>2009 IOM guidelines for gestational weight gain: how well do they predict outcomes across ethnic groups?</title><secondary-title>Ethn Health</secondary-title></titles><periodical><full-title>Ethn Health</full-title></periodical><pages>110-125</pages><volume>25</volume><number>1</number><edition>2017/11/15</edition><keywords><keyword>Iom</keyword><keyword>Weight gain</keyword><keyword>ethnicity</keyword><keyword>maternal health</keyword><keyword>neonatal outcomes</keyword><keyword>pregnancy</keyword></keywords><dates><year>2020</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1465-3419 (Electronic)
1355-7858 (Linking)</isbn><accession-num>29132221</accession-num><urls><related-urls><url>;(Khanolkar et al 2020) found that adherence to the 2009 IOM guidelines for weight gain during pregnancy reduced risk for various adverse maternal outcomes in all ethnic groups studied. However, the guidelines were better at predicting small and large for gestational age than other infant outcomes.Consensus-based recommendationMeasure women’s weight and height at the first antenatal visit and calculate their body mass index (BMI) and give them advice about the benefits of gaining weight within the recommended weight gain range for their BMI.Determinants of gestational weight gainWeight gain below guidelinesA systematic review found that women with lower educational attainment had an increased risk of inadequate weight gain (OR 1.3; 95% CI 1.0 to 1.6, p=0.017) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PJmFwb3M7QnJpZW48L0F1dGhvcj48WWVhcj4yMDE5PC9Z
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ADDIN EN.CITE.DATA (Mendez et al 2014; Headen et al 2015; Mendez et al 2016) have found that African American women, Hispanic women and women in socially disadvantaged areas are more likely to experience inadequate weight gain. Weight gain exceeding guidelinesSystematic reviews have found associations between weight gain exceeding recommendations and:lower educational attainment PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PJmFwb3M7QnJpZW48L0F1dGhvcj48WWVhcj4yMDE5PC9Z
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ADDIN EN.CITE.DATA (Hartley et al 2015; Kapadia et al 2015a) lack of social support PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJ0bGV5PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Hartley et al 2015; Kapadia et al 2015a), stress PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJ0bGV5PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Hartley et al 2015) or social support ADDIN EN.CITE <EndNote><Cite><Author>Ratan</Author><Year>2020</Year><RecNum>1972</RecNum><DisplayText>(<style font="Century Gothic" size="8">Ratan et al 2020</style>)</DisplayText><record><rec-number>1972</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588904831">1972</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratan, B. M.</author><author>Garbarino, A. H.</author><author>Sellner, A. A.</author><author>Miao, D.</author><author>Hollier, L. M.</author></authors></contributors><auth-address>Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.
Texas Children's Health Plan, The Center for Children and Women, Houston, Texas.</auth-address><titles><title>Social determinants of gestational weight gain in an obese, low-income population</title><secondary-title>Am J Perinatol</secondary-title></titles><periodical><full-title>Am J Perinatol</full-title></periodical><pages>296-303</pages><volume>37</volume><number>3</number><edition>2019/02/12</edition><dates><year>2020</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1098-8785 (Electronic)
0735-1631 (Linking)</isbn><accession-num>30743269</accession-num><urls><related-urls><url>;(Ratan et al 2020)parity (r 0.04, 95%CI 0.10 to 0.16, p=0.61; 17 studies), including after adjusting for pre-pregnancy BMI (r 0.08, 95%CI 0.19 to 0.03, p=0.16; 16 studies) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IaWxsPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Hill et al 2017)The evidence of an association between weight gain exceeding recommendations and depression was inconsistent PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJ0bGV5PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Hartley et al 2015; Kapadia et al 2015a).Protective factors included a perception of control over weight gain, lower than recommended target weight gain and higher self-efficacy for healthy eating PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXBhZGlhPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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PC9FbmROb3RlPgB=
ADDIN EN.CITE.DATA (Hulman et al 2016)There was no clear association in cohort studies between weight gain exceeding guidelines and:experiencing hardship in childhood (OR 1.45, 95%CI 0.99 to 2.14), in adulthood (OR 0.72; 95%CI 0.41 to 1.26) or in pregnancy (OR 1.09; 95%CI 0.43 to 2.76) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qcm92ZW56YW5vPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qcm92ZW56YW5vPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh
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ADDIN EN.CITE.DATA (Provenzano et al 2015)maternal age (<30 vs ≥30) (OR 1.02; 95%CI 0.98 to 1.02; p=0.89) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3Jpc3NldDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Morisset et al 2017)household income (<CAN$60,000 vs ≥CAN$60,000) (OR 1.06; 95%CI 0.71 to 1.26; p=0.71) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3Jpc3NldDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Morisset et al 2017)education level (<university vs ≥university degree) (OR 1.26; 95%CI 0.93 to 1.70; p=0.14) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3Jpc3NldDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3Jpc3NldDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Morisset et al 2017)country of birth (other countries vs Canada) (OR 1.05; 95%CI 0.78 to 1.41; p=0.73).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3Jpc3NldDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3Jpc3NldDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Schumacher et al 2018) found that 54% of women had weight gain exceeding recommendations.Risks associated with low or high gestational weight gainA meta-analysis of individual participant data (n=265,270) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW50b3M8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Santos et al 2019) found that low or high gestational weight gain was associated with pregnancy complications across all BMI classifications.Weight gain among women of any BMIWeight gain lower than recommendationsIn a systematic review of cohort studies of pregnant women of any BMI (23 studies; 1,309,136 women) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2xkc3RlaW48L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy
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Tm90ZT4A
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Tm90ZT4A
ADDIN EN.CITE.DATA (Goldstein et al 2017), weight gain lower than recommendations was associated with an increased risk of:preterm birth (OR 1.70; 95%CI 1.32 to 2.20) small for gestational age babies (OR 1.53; 95% CI 1.44 to 1.64).There was an association between weight gain lower than recommendations and a lower likelihood of:large-for-gestational-age babies (OR 0.59; 95%CI 0.55 to 0.64) macrosomia (OR 0.60; 95%CI 0.52 to 0.68).There was an association between weight gain lower than recommendations and a possible lower likelihood of caesarean section (OR 0.98; 95%CI 0.96 to 1.02).In an analysis of individual participant data from the control arms of 36 RCTs (n=4,429) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2dvemluc2thPC9BdXRob3I+PFllYXI+MjAxOTwvWWVh
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ADDIN EN.CITE.DATA (Rogozinska et al 2019) the odds of preterm birth (aOR 1.94; 95%CI 1.31 to 2.28) and small-for-gestational-age babies (aOR 1.52; 95%CI 1.18 to 1.96) were increased with gestational weight gain lower than recommendations. Findings on caesarean section and large-for-gestational-age babies were inconclusive.Weight gain higher than recommendationsThe systematic review of cohort studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2xkc3RlaW48L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy
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Tm90ZT4A
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Tm90ZT4A
ADDIN EN.CITE.DATA (Goldstein et al 2017) found that weight gain higher than recommendations was associated with an increased risk of:large-for-gestational age babies (OR 1.85; 95%CI 1.76 to 1.95)macrosomia (OR 1.95; 95%CI 1.79 to 2.11)caesarean section (OR 1.30; 95%CI 1.25 to 1.35).There was an association between weight gain higher than recommendations and lower likelihood of small-for-gestational-age babies (OR 0.66; 95%CI 0.63 to 0.69) and preterm birth (OR 0.77; 95%CI 0.69 to 0.86).The analysis of individual participant data from the control arms of RCTs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2dvemluc2thPC9BdXRob3I+PFllYXI+MjAxOTwvWWVh
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ADDIN EN.CITE.DATA (Rogozinska et al 2019) found that weight gain higher than recommendations was associated with increased odds of caesarean section (aOR 1.50; 95%CI 1.25 to 1.80), large-for-gestational-age babies (aOR 2.00; 95%CI 1.58 to 2.54), and reduced odds of small-for-gestational-age babies (aOR 0.66; 0.50 to 0.87). No significant effect on preterm birth was detected. A meta-analysis of individual participant data (37 studies, 162,129 mothers and children) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Wb2VybWFuPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48
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ADDIN EN.CITE.DATA (Voerman et al 2019) found that, relative to the effect of maternal pre-pregnancy BMI, excessive gestational weight gain only slightly increased the risk of childhood overweight/obesity within each clinical BMI category (p-values for interactions of maternal BMI with gestational weight gain: p=0.038, p<0.001, and p=0.637 in early, mid, and late childhood, respectively). Systematic reviews of cohort studies have found that:the risk of urinary incontinence increased with each 10 kg of weight gain (RR 1.34; 95%CI 1.11 to 1.62) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BdW5lPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Aune et al 2019)weight gain exceeding recommendations may increase the risk of autism spectrum disorder (OR 1.23; 95%CI 1.09 to 1.38; p=0.0008) but more studies are needed to confirm this result PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaWFuPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Tian et al 2019).High weight gain in early pregnancyA secondary analysis of an RCT (n=7,895) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJyZW5vPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJyZW5vPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Carreno et al 2012) found that among women who gained weight exceeding the IOM guidelines by week 15-18, 93% exceeded the recommended total gestational weight gain. In contrast, only 55% of women with early gestational weight gain within recommendations had total gestational weight gain higher than recommendations (p<0.001). Women with excessive early gestational weight gain had higher rates of gestational diabetes (OR 1.4; 95%CI 1.1 to 1.9), large-for-gestational-age babies (OR 1.4; 95%CI 1.2 to 1.6), and macrosomia >4,000 g (OR 1.5; 95%CI 1.3 to 1.8).Outcomes among women from US/Europe and AsiaWeight gain lower than recommended was associated with preterm birth among women from the USA/Europe (OR 1.35; 95%CI 1.17 to 1.56) but not women from Asia (OR 1.06; 95%CI 0.78 to 1.44) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2xkc3RlaW48L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFy
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ADDIN EN.CITE.DATA (Goldstein et al 2018). It was associated with an increase in risk of small-for-gestational-age babies among women from both groups. Weight gain higher than recommended was associated with large-for-gestational age babies, macrosomia and caesarean section among women from both groups.Gestational weight gain among underweight womenA meta-analysis of individual participant data (n=265,270) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW50b3M8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Santos et al 2019) found that among underweight women:low weight gain was associated with an increased risk of preterm birth and small for gestational age (both p<0.001) and a reduced risk of gestational hypertension (p<0.05) and large for gestational age (p<0.001)high weight gain was associated with a reduced risk of small for gestational age (p<0.05).Gestational weight gain among women with healthy pre-pregnancy weightIn the meta-analysis of individual participant data (n=265,270) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW50b3M8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Santos et al 2019), among women with healthy pre-pregnancy BMI:low weight gain was associated with an increased risk of preterm birth and small for gestational age and a reduced risk of large for gestational age (all p<0.001)high weight gain was associated with an increased risk of gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth and large for gestational age and a reduced risk of small-for-gestational age (all p<0.001).Gestational weight gain among overweight womenIn the meta-analysis of individual participant data (n=265,270) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW50b3M8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Santos et al 2019), among overweight women:low weight gain was associated gestational diabetes, gestational hypertension, pre-eclampsia, small for gestational age (all p<0.001) and preterm birth (p<0.05)high weight gain was associated with gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth and large for gestational age (all p<0.001).Gestational weight gain among obese pregnant womenIn the meta-analysis of individual participant data (n=265,270) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW50b3M8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Santos et al 2019), among obese women both low and high weight gain were associated with increased risk of gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth and large for gestational age (all p<0.001).Weight gain lower than recommendationsA retrospective cohort study in the United States (n=~12,000,000 birth records) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaG9tcHNvbjwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaG9tcHNvbjwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+
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ADDIN EN.CITE.DATA (Thompson & Thompson 2019) found that weight gain lower than the IOM guidelines among obese women reduced the risk of gestational hypertension, eclampsia, induction of labour and Caesarean section but was also associated with increased risks for multiple adverse neonatal outcomes with macrosomia the exception.A systematic review of cohort studies of obese pregnant women (18 cohort studies; 99,723 women) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXBhZGlhPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Kapadia et al 2015b) found that weight gain lower than recommendations was associated with an increase in risk of:preterm birth (aOR 1.46; 95%CI 1.07 to 2.00)small-for-gestational-age babies (OR?1.24; 95%CI 1.13 to 1.36).Weight gain lower than recommendations was associated with a lower likelihood of:large-for-gestational-age babies (aOR 0.77; 95%CI 0.73 to 0.81)macrosomia (aOR 0.64; 95%CI 0.54 to 0.77)gestational hypertension (aOR, 0.70; 95%CI 0.53 to 0.93) pre-eclampsia (aOR 0.90; 95%CI 0.82 to 0.99). caesarean section (aOR 0.87; 95%CI 0.82 to 0.92). There was no difference in risk of gestational diabetes (aOR?1.15; 95%CI 0.91 to 1.45), low birthweight (aOR1.08; 95%CI 0.76 to 1.54), Apgar score <7 at 5 minutes (aOR 0.92; 95%CI 0.67 to 1.27) or postpartum weight retention (MD?-5.3 kg; 95%CI -9.0 to 1.17).Weight lossA systematic review of cohort studies (n=60,913) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXBhZGlhPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48
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ADDIN EN.CITE.DATA (Kapadia et al 2015c) found that, among women who were obese, gestational weight loss compared to weight gain within the guidelines:increased the risk of small-for-gestational-age babies (aOR 1.76; 95%CI 1.45 to 2.14; 2 studies) and low birthweight (aOR 1.68; 95%CI 1.10 to 2.57; 1 study) was associated with a lower likelihood of large for gestational age (aOR 0.57; 95%CI 0.52 to 0.62; 2 studies), macrosomia (aOR 0.58; 95%CI 0.38 to 0.89; 1?study) and caesarean section (aOR 0.73; 95%CI 0.67 to 0.80; 2?studies). There was a possible reduction in risk of pre-eclampsia (aOR 0.82; 95%CI 0.66 to 1.02; 1 study) and no clear difference in risk of gestational diabetes (aOR 0.88; 95%CI 0.62 to 1.25; 1 study) or Apgar score <7 at 5 minutes (aOR 1.08; 95%CI 0.81 to 1.44; 2 studies). No studies reported on preterm birth.Consensus-based recommendationAt every antenatal visit, offer women the opportunity to be weighed so that low or high gestational weight gain is identified and risk of associated adverse outcomes monitored.Women’s views on advice on weight gain during pregnancy A systematic review of qualitative studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WYW5zdG9uZTwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+
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ADDIN EN.CITE.DATA (Vanstone et al 2017) found that women are highly motivated to change their behaviour to improve fetal health but may not recognise the link between excess gestational weight gain and negative fetal health outcomes. Regular, clear, sensitive counselling geared to individual circumstances was frequently mentioned as a strong facilitator of healthy weight gain in pregnancy.An Australian cross-sectional study (n=536) ADDIN EN.CITE <EndNote><Cite><Author>Hill</Author><Year>2019</Year><RecNum>1762</RecNum><DisplayText>(<style font="Century Gothic" size="8">Hill et al 2019</style>)</DisplayText><record><rec-number>1762</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1582867169">1762</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hill, B.</author><author>Hayden, M.</author><author>McPhie, S.</author><author>Bailey, C.</author><author>Skouteris, H.</author></authors></contributors><auth-address>School of Public Health and Preventive Medicine, Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia.
School of Psychology, Centre for Social and Early Emotional Development, Deakin University, Geelong, Victoria, Australia.</auth-address><titles><title>Preconception and antenatal knowledge and beliefs about gestational weight gain</title><secondary-title>Aust N Z J Obstet Gynaecol</secondary-title></titles><periodical><full-title>Aust N Z J Obstet Gynaecol</full-title></periodical><pages>634-640</pages><volume>59</volume><number>5</number><edition>2019/01/27</edition><keywords><keyword>*beliefs</keyword><keyword>*gestational weight gain</keyword><keyword>*knowledge</keyword><keyword>*parity</keyword><keyword>*preconception</keyword><keyword>*pregnancy</keyword></keywords><dates><year>2019</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1479-828X (Electronic)
0004-8666 (Linking)</isbn><accession-num>30680719</accession-num><urls><related-urls><url>;(Hill et al 2019) found that only half of pregnant women were aware of IOM recommendations on gestational weight gain.Cross-sectional studies from overseas have found that:more than half (57%) of women reported that their healthcare provider talked to them about personal weight gain limits during pregnancy and a third of these women were counselled regularly; among those not counselled, over half (56%) reported that healthcare provider guidance would have been helpful to achieve their target weight ADDIN EN.CITE <EndNote><Cite><Author>Weeks</Author><Year>2020</Year><RecNum>1780</RecNum><DisplayText>(<style font="Century Gothic" size="8">Weeks et al 2020</style>)</DisplayText><record><rec-number>1780</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1582867351">1780</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weeks, A.</author><author>Halili, L.</author><author>Liu, R. H.</author><author>Deonandan, R.</author><author>Adamo, K. B.</author></authors></contributors><auth-address>Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.
School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.
School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada. Electronic address: kadamo@uottawa.ca.</auth-address><titles><title>Gestational weight gain counselling gaps as perceived by pregnant women and new mothers: Findings from the electronic maternal health survey</title><secondary-title>Women Birth</secondary-title></titles><periodical><full-title>Women Birth</full-title></periodical><pages>e88-e94</pages><volume>33</volume><number>1</number><edition>2019/03/11</edition><keywords><keyword>Gestational weight gain</keyword><keyword>Healthcare provider communication</keyword><keyword>Pregnancy</keyword><keyword>Prenatal counselling</keyword><keyword>Prenatal healthcare</keyword></keywords><dates><year>2020</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1878-1799 (Electronic)
1871-5192 (Linking)</isbn><accession-num>30852187</accession-num><urls><related-urls><url>;(Weeks et al 2020)two-thirds (67%) of women received advice on gestational weight gain as part of antenatal care and women who reported following this advice had lower odds of weight gain exceeding recommendations (OR?0.18; 95%CI 0.03 to 0.91) (n=91) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Mb3Blei1DZXBlcm88L0F1dGhvcj48WWVhcj4yMDE4PC9Z
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ADDIN EN.CITE.DATA (Allen-Walker et al 2017).Health professional’s views on weight monitoring as part of pregnancy careAn Australian focus group that examined barriers and enablers to the regular weighing of women throughout pregnancy (n=44) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXN0ZWQ8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Hasted et al 2016) found that, while most health professionals supported regular weighing, various concerns were raised. These included access to resources and staff, the ability to provide appropriate counselling and evidence-based interventions, and the impact of weighing on women and the therapeutic relationship.In an Australian study following introduction of a pregnancy weight gain chart (n=42) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5kZSBKZXJzZXk8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFy
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ADDIN EN.CITE.DATA (Wilkinson et al 2019).A cohort study in the United States (n=733) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW5kYmVyZzwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW5kYmVyZzwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+
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ADDIN EN.CITE.DATA (Lindberg & Anderson 2014) found that introduction of a "best practice alert" into an electronic medical record system improved the rate of gestational weight counselling (p<0.001), documented weight gain (p<0.001) and weight gain consistent with guidelines (p=0.003).Recent evidence on regular weighingA systematic literature review found no clear difference in weekly weight gain (MD -0.00 kg; 95%CI -0.03 to 0.02) or weight gain exceeding the IOM guidelines for women who were underweight (OR 1.50; 95%CI 0.14 to 16.54), in the healthy weight range (OR 0.72; 95%CI 0.48 to 1.09), overweight (OR 0.85; 95%CI 0.45 to 1.62) or obese (OR 1.60; 95%CI 0.72 to 3.54) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GZWFseTwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Brownfoot et al 2016a) and the other involved self-weighing ADDIN EN.CITE <EndNote><Cite><Author>Jeffries</Author><Year>2009</Year><RecNum>7</RecNum><DisplayText>(<style font="Century Gothic" size="8">Jeffries et al 2009</style>)</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="d9fe29a0aewersev003pr29s5z0r99sdpstf" timestamp="1582517496">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jeffries, K.,</author><author>Walker, S.P.,</author><author>Hiscock, R.,</author><author>Permezel, M.,</author></authors></contributors><titles><title>Reducing excessive weight gain in pregnancy: a randomised controlled trial</title><secondary-title>MJA</secondary-title></titles><pages>429–33</pages><volume>191</volume><number>8</number><dates><year>2009</year></dates><urls></urls></record></Cite></EndNote>(Jeffries et al 2009).The systematic literature review conducted to inform these Guidelines ADDIN EN.CITE <EndNote><Cite><Author>Ramson</Author><Year>2020</Year><RecNum>1826</RecNum><DisplayText>(<style font="Century Gothic" size="8">Ramson et al 2020</style>)</DisplayText><record><rec-number>1826</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1584421281">1826</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Ramson, J.A.,</author><author>Middleton P,</author><author>Bowman, A.,</author></authors></contributors><titles><title><style face="italic" font="default" size="100%">Evidence Evaluation Report: Diet, Exercise and Weight Management in Pregnancy</style></title></titles><dates><year>2020</year></dates><publisher>Prepared by South Australian Health and Medical Research Institute and Ampersand Health Science Writing for the Australian Government Department of Health</publisher><urls></urls></record></Cite></EndNote>(Ramson et al 2020) focused on weighing by a health professional and included three studies. An Australian RCT (n=782) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ccm93bmZvb3Q8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFy
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ADDIN EN.CITE.DATA (Brownfoot et al 2016a). Among a subset of women who provided feedback (n=586), 73% were comfortable with being weighed routinely ADDIN EN.CITE <EndNote><Cite><Author>Brownfoot</Author><Year>2016</Year><RecNum>1701</RecNum><DisplayText>(<style font="Century Gothic" size="8">Brownfoot et al 2016b</style>)</DisplayText><record><rec-number>1701</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1581916923">1701</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brownfoot, F. C.</author><author>Davey, M. A.</author><author>Kornman, L.</author></authors></contributors><auth-address>Department of Obstetrics and Gynaecology, Royal Women's Hospital, The University of Melbourne, Parkville, Vic., Australia.
Judith Lumley Centre, Science Health and Engineering College, La Trobe University, Melbourne, Vic., Australia.</auth-address><titles><title>Women's opinions on being weighed at routine antenatal visits</title><secondary-title>BJOG</secondary-title></titles><periodical><full-title>BJOG</full-title></periodical><pages>263-70</pages><volume>123</volume><number>2</number><edition>2016/02/04</edition><keywords><keyword>Adult</keyword><keyword>Anxiety/*epidemiology</keyword><keyword>Australia/epidemiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Patient Satisfaction/*statistics & numerical data</keyword><keyword>Pregnancy</keyword><keyword>Pregnant Women/*psychology</keyword><keyword>Prenatal Care/*methods</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Weight Gain/*physiology</keyword><keyword>Gestational weight gain</keyword><keyword>weighing</keyword><keyword>women's opinions</keyword></keywords><dates><year>2016</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1471-0528 (Electronic)
1470-0328 (Linking)</isbn><accession-num>26841341</accession-num><urls><related-urls><url>;(Brownfoot et al 2016b).A pilot study in the United Kingdom (n=76) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYWxleTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Daley et al 2019), which also found no clear difference in weight gain exceeding IOM guidelines, depression or anxiety.When these three trials were pooled, there was no difference in weight gain exceeding guidelines (RR?1.01 95% CI 0.92 to 1.12; 3 RCTs; n=1,327; very low certainty) or mean weekly weight gain (MD 0.01 kg per week 95%CI –0.03 to 0.05; 2 RCTs; n=711; very low certainty). When the two United Kingdom studies were pooled, there was a small reduction in the risk of depression (MD -0.77; 95%CI -1.44 to -0.09; low certainty) and anxiety (MD -0.77; 95%CI -1.48 to 0.06; low certainty). There was no indication in the three trials that either excessive gestational weight gain or mean gestational weight gain differed in women in the healthy weight range at the beginning of pregnancy compared with women who were overweight or obese.Preventing weight gain that exceeds recommendationsThe literature review conducted to inform these Guidelines ADDIN EN.CITE <EndNote><Cite><Author>Ramson</Author><Year>2020</Year><RecNum>1826</RecNum><DisplayText>(<style font="Century Gothic" size="8">Ramson et al 2020</style>)</DisplayText><record><rec-number>1826</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1584421281">1826</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Ramson, J.A.,</author><author>Middleton P,</author><author>Bowman, A.,</author></authors></contributors><titles><title><style face="italic" font="default" size="100%">Evidence Evaluation Report: Diet, Exercise and Weight Management in Pregnancy</style></title></titles><dates><year>2020</year></dates><publisher>Prepared by South Australian Health and Medical Research Institute and Ampersand Health Science Writing for the Australian Government Department of Health</publisher><urls></urls></record></Cite></EndNote>(Ramson et al 2020) analysed the results of randomised controlled trials that compared usual care to:dietary intervention: common themes in dietary advice provided included increasing consumption of fruit and vegetables, protein and fibre and reducing intake of saturated fats, carbohydrates and sugar (eg in soft drinks) exercise intervention: interventions mostly involved aerobic (treadmill, stationary cycling, walking, dance, circuit training, swimming) and muscle strengthening exercises (including pelvic floor exercises) for around 60?minutes, three times a week at an intensity of 60-80% of maximum heart rate or 12-14 on the Borg scale and continued to 36 to 39 weeks pregnancylifestyle counselling intervention: most interventions involved counselling with a focus on gestational weight gain, diet and exercise with weight gain recommendations based on IOM guidelines and encouraged some form of self-monitoring (eg through weight gain charts, log books, pedometers). Mean gestational weight gain was lower among women participating in a dietary intervention (MD -3.76 kg; 95%CI -6.38 to -1.13; 6 RCTs; n=1,432; very low certainty), exercise intervention (MD -0.95 kg; 95%CI -1.20 to -0.69; 29 RCTs; n=5,680; moderate certainty) or lifestyle counselling (MD -1.25 kg; 95%CI -1.64 to -0.86; 36 RCTs; n=9,083; low certainty). The risk of weight gain exceeding guidelines was also reduced by dietary intervention (RR 0.65; 95%CI 0.54 to 0.77; 4 RCTs; n=538; very low certainty), exercise intervention (RR 0.77; 95%CI 0.69 to 0.87; 16 RCTs; n=4,333; low certainty) and lifestyle counselling intervention (RR 0.83; 95%CI 0.78 to 0.89; 29 RCTs; n=7,905; low certainty). The risk of postnatal weight retention was reduced with lifestyle counselling (MD -1.19 kg; 95%CI -1.62 to -0.76; 11 RCTs; n=2,483; moderate certainty). There was no clear difference in postnatal weight retention with a dietary intervention (MD -0.55 kg; 95%CI -2.02 to 0.92; 2 RCTs; n=556; very low certainty) or exercise intervention (MD –0.20 kg; 95%CI –1.48 to 1.09; 5 RCTs; n=388; moderate certainty).Risk of gestational diabetes was reduced by exercise interventions (RR 0.74; 95%CI 0.60 to 0.90; 20 RCTs; n=5,592; low certainty), probably reduced by lifestyle counselling (RR 0.90; 95%CI 0.81 to 1.01; 26 RCTs; n=9,011; moderate certainty) with no differences seen with dietary interventions (RR 0.86; 95%CI 0.64 to 1.17; 6 RCTs; n=1,424; very low certainty). There was a reduction in risk of gestational hypertension with dietary intervention (RR 0.29; 95%CI 0.13 to 0.61; 3?RCTs; n=429; moderate certainty) or exercise intervention (RR 0.51; 95%CI 0.37 to 0.71; 7 RCTs; n=3,060; moderate certainty) but no difference was seen with lifestyle counselling (RR 0.99; 95%CI 0.77 to 1.28; 13 RCTs; n=4,890; low certainty). No difference in risk of pre-eclampsia was seen with any type of intervention (low to moderate certainty).Risk of caesarean section was reduced with exercise intervention (RR 0.85; 95%CI 0.74 to 0.98; 25 RCTs; n=5,704; moderate certainty) and probably reduced with lifestyle counselling (RR 0.95; 95%CI 0.89 to 1.02; 25 RCTs; n=9,049; low certainty). There was no difference in risk of caesarean section with a dietary intervention (RR 0.85; 95%CI 0.64 to 1.11; 6 RCTs; n=1,461; very low certainty).The risk of antenatal depression was reduced with exercise intervention (RR 0.44; 95%CI 0.32 to 0.61; 6 RCTs; n=798; moderate certainty) but not lifestyle counselling (RR 0.99; 95%CI 0.80 to 1.22; 2 RCTs; n=2,908; low certainty). The risk of postnatal depression was reduced with exercise intervention (RR 0.47; 95%CI 0.34 to 0.65; 5 RCTs; n=1,613; moderate certainty).The risk of preterm birth was reduced with a dietary intervention (RR 0.43; 95%CI 0.24 to 0.79; 4 RCTs; n=1,296; moderate certainty), probably reduced with lifestyle counselling (RR 0.85; 95%CI 0.72 to 1.01; 18 RCTs; n=7,497; moderate certainty) but not changed by exercise intervention (RR 0.95; 95%CI 0.74 to 1.22; 15 RCTs; n=4,388; moderate certainty). There was no difference in risk of macrosomia >4,000g with dietary intervention (RR 0.97; 95%CI 0.84 to 1.11; 3?RCTs; n=1,138; very low certainty) but there was a reduction with exercise intervention (RR 0.75; 95%CI 0.59 to 0.96; 15 RCTs; n=4,759; moderate certainty) and a probable reduction with lifestyle counselling (RR 0.91; 95%CI 0.82 to 1.01; 17 RCTs; n=7,664; low certainty). There was also a reduction of risk of macrosomia >4,500 g with lifestyle counselling (RR 0.67; 95%CI 0.46 to 0.97; 5 RCTs; n=3,435; moderate certainty). There was no difference seen in risk of low birthweight with an exercise intervention (RR?0.94; 95%CI 0.68 to 1.28; 11 RCTs; n=3,247; moderate certainty) or lifestyle counselling (RR 0.87; 95%CI 0.65 to 1.17; 4 RCTs; n=3,665; low certainty). There was a possible reduction in risk of large-for-gestational age with lifestyle counselling (RR?0.89; 95%CI 0.79 to 1.00; 22 RCTs; n=8,455; moderate certainty) but no clear difference in risk with the other interventions.There was no clear difference in risk of small-for-gestational age, Apgar score <7 at 5 minutes or weight in early childhood with any intervention.A systematic review that assessed cost-effectiveness analyses of lifestyle counselling interventions compared with usual care found that results were inconsistent and further research is required to determine the effective components of lifestyle interventions ADDIN EN.CITE <EndNote><Cite><Author>Bailey</Author><Year>2020</Year><RecNum>1927</RecNum><DisplayText>(<style font="Century Gothic" size="8">Bailey et al 2020</style>)</DisplayText><record><rec-number>1927</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588572425">1927</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bailey, C.,</author><author>Skouteris, H.,</author><author>Teede, H.,</author><author>Hill, B.,</author><author>De Courten, B.,</author><author>Walker, R.,</author><author>Liew, D.,</author><author>Thangaratinam, S.,</author><author>Ademi, Z.,</author></authors></contributors><titles><title>Are lifestyle interventions to reduce excessive gestational weight gain cost effective? A systematic review</title><secondary-title>Current Diabetes Reports</secondary-title></titles><periodical><full-title>Current Diabetes Reports</full-title></periodical><volume>20</volume><number>2</number><dates><year>2020</year></dates><isbn>1534-4827
1539-0829</isbn><urls></urls><electronic-resource-num>10.1007/s11892-020-1288-1</electronic-resource-num></record></Cite></EndNote>(Bailey et al 2020). Cost-effectiveness studies from overseas found that lifestyle interventions were cost-effective for gestational weight gain PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ccm9la2h1aXplbjwvQXV0aG9yPjxZZWFyPjIwMTg8L1ll
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ADDIN EN.CITE.DATA (Oostdam et al 2012; Broekhuizen et al 2018) and a better understanding of the short- and long-term costs of large for gestational age and weight gain exceeding IOM recommendations is necessary ADDIN EN.CITE <EndNote><Cite><Author>O'Sullivan</Author><Year>2020</Year><RecNum>1924</RecNum><DisplayText>(<style font="Century Gothic" size="8">O'Sullivan et al 2020</style>)</DisplayText><record><rec-number>1924</rec-number><foreign-keys><key app="EN" db-id="exvasrfx2dtraoesasxp2szsxa2df502592x" timestamp="1588569546">1924</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>O'Sullivan, E. J.</author><author>Rokicki, S.</author><author>Kennelly, M.</author><author>Ainscough, K.</author><author>McAuliffe, F. M.</author></authors></contributors><auth-address>UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital Ireland, Dublin, Ireland.
School of Biological and Health Sciences, Technological University Dublin, Dublin, Ireland.
Geary Institute for Public Policy, University College Dublin, Dublin, Ireland.
Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, United States.
UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital Ireland, Dublin, Ireland. fionnuala.mcauliffe@ucd.ie.</auth-address><titles><title>Cost-effectiveness of a mobile health-supported lifestyle intervention for pregnant women with an elevated body mass index</title><secondary-title>Int J Obes (Lond)</secondary-title></titles><periodical><full-title>Int J Obes (Lond)</full-title></periodical><pages>999-1010</pages><volume>44</volume><number>5</number><edition>2020/01/23</edition><dates><year>2020</year><pub-dates><date>May</date></pub-dates></dates><isbn>1476-5497 (Electronic)
0307-0565 (Linking)</isbn><accession-num>31965073</accession-num><urls><related-urls><url>;(O'Sullivan et al 2020).Evidence-based recommendationAt every antenatal visit, give women tailored advice on weight gain, including the benefits of a healthy diet, regular physical activity and self-monitoring.Practice pointAdopting a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. This should be informed by appropriate education for health professionals.Nutrition and physical activity in pregnancy are discussed in Chapter 11.Other considerations includeThe potential for sub-optimal visualisation on ultrasound for women with elevated BMI (delaying the ultrasound until 20 to 22 weeks pregnancy for women with BMI ≥30 may provide better results but needs to be balanced against the possibility of a delayed diagnosis of structural anomalies) (SOGC 2010).Antenatal consultation with an obstetric anaesthetist to identify any potential difficulties with venous access, regional or general anaesthesia for women with a BMI ≥40.For women with a high BMI, ongoing nutritional advice following childbirth from an appropriate health professional, with a view to weight reduction and maintenance.Practice summary: measuring weight and BMIWhen: At all antenatal visitsWho: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health workerExplain the purpose of assessing weight and weight gain during pregnancy: For women with a BMI outside the healthy range, discuss the risks associated with a woman’s weight being below or above the healthy range before, during pregnancy and in between pregnancies.Engage women in discussions about weight gain: Offer women the opportunity to be weighed and to discuss their weight gain since the last antenatal visit. Use the IOM recommendations to give women advice about the risks of inadequate or excessive weight gain. Provide advice on nutrition and exercise based on the Australian dietary and physical activity guidelines and encourage self-monitoring. Take a holistic approach: Provide women with culturally appropriate advice on the benefits of a healthy diet and regular physical activity.Consider referral: Women who are gaining weight at a rate below or above recommendations for gestational weight gain may benefit from referral for nutrition and lifestyle advice (eg from an accredited practising dietitian). ResourcesHealth professionalsCMACE & RCOG (2010) CMACE & RCOG Joint Guideline. Management of Women with Obesity in Pregnancy. London: Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologists.IOM (2009) Weight Gain During Pregnancy. Re-examining the Guidelines. Institute of Medicine and National Research Council. Washington DC: National Academies Press.NHMRC (2013) Australian Dietary Guidelines: Providing the Scientific Evidence for Healthier Australian Diets. Canberra: Commonwealth of Australia.NHMRC (2005) Nutrient Reference Values for Australia and New Zealand. Canberra: National Health and Medical Research Council. NICE (2010) Dietary Interventions and Physical Activity Interventions for Weight Management Before, During and After Pregnancy. NICE public health guidance 27. London: National Institute for Health and Clinical Excellence.SOGC (2010) Obesity in pregnancy. J Obstet Gynaecol Can 32(2): 165–73. Women and familiesDoHA (2014) Australia’s Physical Activity & Sedentary Behaviour Guidelines for Adults (18-64 years). Accessed 25 August 2016. NHMRC/DoHA (2015) Australian Guide to Healthy Eating. Accessed 25 August 2016. NHMRC/DoHA (2015) Healthy Eating When You’re Pregnant or Breastfeeding. Accessed 25 August 2016. 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Congenit Heart Dis 13(2): 271-81.AppendicesAMembership and terms of reference of the Expert Working GroupMembershipExpert Working Group MembersDiscipline/expertise/special InterestPosition and organisationLocationCo-chairsProfessor Jeremy Oats Obstetrics & GynaecologyObstetrics and gynaecology specialistProfessorial Fellow Melbourne School of Population & Global Health, University of MelbourneVICProfessor Caroline Homer AOMidwiferyCo-DirectorMaternal and Child Health Program, Burnet InstituteDistinguished Professor of Midwifery, University of Technology SydneyVICMembersAssociate Professor Martin ByrneGP ObstetricsRACGPQLDMs Ann Catchlove (Jorgensen)Consumer representativeVICDr Marilyn ClarkeAboriginal and Torres Strait Islander representativeObstetrics and gynaecology specialist,Grafton and Coffs HarbourNSWMs Leah HardimanConsumer representativeQLDMs Tracy MartinMidwiferyMidwifery Director Statewide Obstetric Support Unit, Women and Newborn Health Service, WA Department of HealthWAAdjunct Professor Sue McDonaldMidwifery, Perinatal HealthProfessor of Midwifery, La Trobe UniversityVICAssociate Professor Philippa MiddletonPerinatal EpidemiologyPrincipal Research Fellow, Women and Kids, SA Health and Medical Research Institute/The University of AdelaideSAMs Natalija NesvadbaMigrant and refugee women representativeManager, Multicultural Services, Mercy?HealthVICProfessor Michael PermezelObstetrics & GynaecologyRANZCOG (former RANZCOG President)VICMs Alecia StainesConsumer representativeDirector, Maternity Consumer NetworkQLDMs Cindy TurnerMidwiferyAustralian College of MidwivesNTAustralian Government Department of Health (Project management and secretariat)Ms Samantha DiplockAssistant Director, Maternity Policy Team, Chronic Disease Management Section, Health Services Division, Department of HealthMs Anita SoarPolicy/Project Officer, Maternity Policy Team, Chronic Disease Management Section, Health Services Division, Department of HealthMethodologistsAssociate Prof Philippa MiddletonPrincipal Research Fellow, SA Health and Medical Research Institute/The University of AdelaideMs Jenny RamsonAmpersand Health Science WritingTechnical writerMs Jenny RamsonAmpersand Health Science WritingTerms of referenceThe Expert Working Group will oversee the review and revision of the National Evidence‐based Clinical Practice Guidelines — Antenatal Care (incorporating both Modules I and II of the Guidelines). The role of the Expert Working Group will include:providing advice, expertise and direction in relation to the combining of the two modules, and the review of the Guidelines to promote optimal care for pregnant women across Australia;reviewing the existing Guidelines to identify topics and guidelines that require updating;advising on the review of national and international literature on antenatal care to inform amendments required to the existing Guidelines;identifying any new topics and drafting new evidence‐based guidelines for inclusion in the Guidelines;developing a plan and strategies to promote and disseminate the finalised Guidelines to ensure clinical uptake of the Guidelines; advising on the development of a consultation strategy (in the event that the review results in major changes to the existing Guidelines or the inclusion of new guidelines); andensuring the review is conducted in accordance with the National Health and Medical Research Council’s (NHMRC) protocols and submitted to the NHMRC for approval.BAdministrative reportB1Scope and purposeObjectiveHealth intentsThe Guidelines aim to improve the health and wellbeing of both mothers and babies, and ensure women consistently receive high quality, evidence-based pregnancy care.Expected benefits/outcomesIt is expected that implementation of the Guidelines will improve maternal, fetal, newborn and family outcomes in the short and longer terms.Target populationThe Guidelines cover the antenatal care of healthy pregnant women (ie women who do not have identified pre-existing conditions and are not at higher risk of complications such as in multiple pregnancy).QuestionsIdentification of topics for reviewThe topics for review were identified by the Expert Working Group (EWG) established to guide the review. Members identified twelve topics (nutrition, nutritional supplements and physical activity, weight and body mass index, anaemia, diabetes, syphilis, chlamydia, cytomegalovirus, group B streptococcus, cervical abnormalities and prolonged pregnancy) from the pregnancy care guidelines as high priorities for review as it was more than 5 years since the previous review. Members also agreed that four new topics (cervical length measurement to predict preterm birth, ultrasound assessment for women who have cell-free DNA testing for chromosomal anomalies, vaccines and genetic carrier screening) should be examined. These topics were selected to provide evidence-based advice on emerging practices. The list of proposed review topics and research questions was then sent to three key professional colleges (Australian College of Midwives, Royal Australian and New Zealand College of Obstetricians and Gynaecologists and Royal Australian College of General Practitioners) for comment. The Colleges agreed with the proposed topics and questions.Chapters on syphilis, chlamydia, cytomegalovirus and prolonged pregnancy were revised and approved by the NHRMC in October 2017 as were new sections on cervical length measurement and progesterone treatment for inclusion in the chapter on preterm birth. This document includes revised chapters on nutrition and physical activity and on weight and body mass index.The remaining topics remain under review (see Appendix D).Research questionsFor topics already included in the Guidelines, the original research questions were used, with some additional questions developed by the EWG to capture evidence on emerging practices. Questions for new topics were developed by the EWG. All questions were reviewed by three professional colleges (Australian College of Midwives, Royal Australian and New Zealand College of Obstetricians and Gynaecologists and Royal Australian College of General Practitioners). Research questions for each topic are included in Appendix C.PopulationAs noted above, the Guidelines cover the antenatal care of healthy pregnant women (ie women who do not have identified pre-existing conditions and are not at higher risk of complications such as in multiple pregnancy).B2Stakeholder involvementGroup membershipIn establishing the EWG for this review, the Department of Health approached the Australian College of Midwives (ACM) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and invited them to nominate representatives to be on the EWG. The Chief Nursing and Midwifery Officer and the Chair of the Maternity Services Inter-Jurisdictional Committee (which concluded in June 2016) were also included in the EWG, along with the consumer representative and methodologist who had been involved in the development of earlier reviews. Where possible, it was considered desirable to include EWG members involved in earlier stages of the development of the Guidelines on the EWG as this would provide continuity to the project. A range of academics and practitioners working in obstetrics and midwifery who were previously involved in the project were therefore contacted and accepted invitations to be on the EWG. An additional consumer representative was also included.A list of the EWG members and the Terms of Reference for the EWG is included in Appendix A. Target population preferences and viewsCapturing consumer perspectives A two-pronged strategy was used to capture the perspectives of consumers, including ensuring consumer representation on the EWG and inviting comment through public consultation.The establishment of the EWG with dedicated consumer representation was considered fundamental to the inclusion of consumer perspectives in the development of the Guidelines. Further perspectives of consumers will be gathered through the consultation process. Capturing perspectives of specific population groupsA three-pronged strategy was used to capture the perspectives of specific population groups.Aboriginal and Torres Strait Islander women and migrant and refugee women were represented on the EWG. These representatives had been involved in development of previous versions of the Guidelines as members of the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care and the Working Group for Migrant and Refugee Women’s Antenatal Care, respectively.The review of the literature for all topics included a research question on additional considerations for Aboriginal and Torres Strait Islander women. Specific searches of Australian Indigenous Healthinfonet were conducted for each topic. This resource is a bulletin rather than a database so each relevant topic was scanned rather than searching specific terms (as this would likely have missed relevant material). A research question on additional considerations for migrant and refugee women was included. Where available, epidemiological information was included describing differences in risks and outcomes between:Aboriginal and Torres Strait Islander women and non-Indigenous womenwomen born overseas and those born in Australiawomen of different socioeconomic status women living in different geographical regions (eg rural and remote vs metropolitan and/or by jurisdiction). Target usersThe Guidelines are intended for all health professionals who contribute to antenatal care, including midwives, general practitioners (GPs), obstetricians, maternal and child health nurses, Aboriginal and Torres Strait Islander health practitioners; Aboriginal and Torres Strait Islander health workers, multicultural health workers, practice nurses, allied health professionals, childbirth and parenting educators and sonographers. The way in which different professionals use these Guidelines will vary depending on their knowledge, skills and role, as well as the setting in which care is provided. These Guidelines will be of interest and relevance to pregnant women in Australia. In addition, it is expected that policy makers will be able to draw on the Guidelines in the development of policy and delivery of health services.B3Rigour of developmentSearch methodsSearches were conducted in Pubmed, Ovid, EMBASE, PsychInfo, Scopus, Informit, CINAHL, the Cochrane Database of Systematic Reviews and Australian Indigenous HealthInfoNet. Search terms were searched for as keywords, exploded where possible, and as free text within the title and/or abstract, in the EMBASE and Medline databases, with modifications to suit the keywords and descriptors of other search platforms. The reference lists of included papers were reviewed to identify any peer-reviewed evidence that may have been missed in the literature search. Titles and abstracts of identified studies were screened by two methodologists (PM and AB) and full text articles were reviewed by a third methodologist (JR). Time periods searched varied for each research question, depending on when previous reviews were conducted. Time periods searched for each topic are included in Appendix C.Full search strategies and search terms are included in the Technical Report, which will be available from the NHMRC and Department of Health websites following approval of the new guideline topics by the NHMRC. Evidence selection criteriaInclusion criteria applied to studies were:specific to healthy pregnant women (ie women who do not have identified pre-existing conditions and are not at higher risk of complications such as in multiple pregnancy)specific to the antenatal care settingin English.Due to the size of the body of evidence, some searches were limited to systematic reviews and randomised controlled trials.Exclusion criteria applied to studies were:narrative review or opinion paper (editorial, letter, summary, comment, interview) or background information (eg guidelines, statements not based on systematic review)not specific to target population (eg specific to non-pregnant women or high-risk women) or care setting (eg not specific to antenatal care)wrong interventionwrong study designwrong outcomeswrong comparatorsystematic literature review with all studies included in another systematic reviewincluded in high quality systematic reviewdoes not answer research questionduplicate.Strengths and limitations of the evidenceThe evaluation of the strengths and limitations of the evidence used GRADE and other methods for critical analysis of the literature, with the aim of providing a robust assessment of the relevance and quality of the evidence that met the requirements of the Procedures and Requirements for Meeting the 2011 NHMRC Standard for clinical practice guidelines (2011) ADDIN EN.CITE <EndNote><Cite><Author>NHMRC</Author><Year>2011</Year><RecNum>1543</RecNum><DisplayText>(<style font="Century Gothic" size="8">NHMRC 2011</style>)</DisplayText><record><rec-number>1543</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1491534982">1543</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>NHMRC</author></authors></contributors><titles><title>Procedures and Requirements for Meeting the 2011 NHMRC Standard for Clinical Practice Guidelines</title></titles><dates><year>2011</year></dates><pub-location>Melbourne</pub-location><publisher>National Health and Medical Research Council</publisher><urls></urls></record></Cite></EndNote>(NHMRC 2011).Data extractionData extraction tables were created for each research question and listed the study design; sample size; aim/population/methods/outcomes reported; result and limitations (as assessed using adapted NHMRC criteria for quality assessment of systematic reviews [see Table B.2] and GRADE criteria for quality assessment of randomised controlled trials and observational studies [see Table B.3]).Table B.1: Assessment of quality of systematic literature reviewsConsiderations in assessing quality of systematic reviewsQuestions and methods clearly statedSearch procedure sufficiently rigorous to identify all relevant studiesReview includes all the potential benefits and harms of the interventionReview only includes randomised controlled trialsMethodological quality of primary studies assessedData summarised to give a point estimate of effect and confidence intervalsDifferences in individual study results are adequately explainedExamination of which study population characteristics (disease subtypes, age/sex groups) determine the magnitude of effect of the intervention is includedReviewers’ conclusions are supported by data citedSources of heterogeneity are exploredSource:Adapted from ADDIN EN.CITE <EndNote><Cite><Author>NHMRC</Author><Year>2000</Year><RecNum>1545</RecNum><DisplayText>(<style font="Century Gothic" size="8">NHMRC 2000b; NHMRC 2000a; SIGN 2004</style>)</DisplayText><record><rec-number>1545</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1491625647">1545</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>NHMRC</author></authors></contributors><titles><title>How to Review the Evidence: Systematic Identification and Review of the Scientific Literature</title></titles><dates><year>2000</year></dates><pub-location>Canberra</pub-location><publisher>National Health and Medical Research Council</publisher><urls></urls></record></Cite><Cite><Author>NHMRC</Author><Year>2000</Year><RecNum>1546</RecNum><record><rec-number>1546</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1491625700">1546</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>NHMRC</author></authors></contributors><titles><title>How to use the Evidence: Assessment and Application of Scientific Evidence</title></titles><dates><year>2000</year></dates><pub-location>Canberra</pub-location><publisher>National Health and Medical Research Council</publisher><urls></urls></record></Cite><Cite><Author>SIGN</Author><Year>2004</Year><RecNum>1547</RecNum><record><rec-number>1547</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1491625925">1547</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>SIGN,</author></authors></contributors><titles><title>Methodology Checklist 1: Systematic Reviews and Meta-analyses</title></titles><dates><year>2004</year></dates><pub-location>Edinburgh</pub-location><publisher>Scottish Intercollegiate Guidelines Network</publisher><urls></urls></record></Cite></EndNote>(NHMRC 2000b; NHMRC 2000a; SIGN 2004).Table B.2: Assessment of limitations of randomised controlled trials Study limitationExplanationLack of allocation concealment Those enrolling patients are aware of the group (or period in a crossover trial) to which the next enrolled patient will be allocated (a major problem in “pseudo” or “quasi” randomised trials with allocation by day of week, birth date, chart number, etc.). Lack of blinding Patient, caregivers, those recording outcomes, those adjudicating outcomes, or data analysts are aware of the arm to which patients are allocated (or the medication currently being received in a crossover trial). Incomplete accounting of patients and outcome events Loss to follow-up and failure to adhere to the intention-to-treat principle in superiority trials; or in noninferiority trials, loss to follow-up, and failure to conduct both analyses considering only those who adhered to treatment, and all patients for whom outcome data are available. The significance of particular rates of loss to follow-up, however, varies widely and is dependent on the relation between loss to follow-up and number of events. The higher the proportion lost to follow-up in relation to intervention and control group event rates, and differences between intervention and control groups, the greater the threat of bias. Selective outcome reporting Incomplete or absent reporting of some outcomes and not others on the basis of the results. Other limitations Stopping trial early for benefit. Substantial overestimates are likely in trials with fewer than 500 events and large overestimates are likely in trials with fewer than 200 events. Empirical evidence suggests that formal stopping rules do not reduce this bias. Use of unvalidated outcome measures (e.g. patient-reported outcomes) Carryover effects in crossover trial Recruitment bias in cluster-randomised trials Source: ADDIN EN.CITE <EndNote><Cite><Author>Schünemann</Author><Year>2013</Year><RecNum>1548</RecNum><DisplayText>(<style font="Century Gothic" size="8">Schünemann et al 2013</style>)</DisplayText><record><rec-number>1548</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1491626232">1548</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Schünemann, H.,</author><author>Bro?ek, J.,</author><author>Guyatt, G.,</author><author>Oxman, A.,</author></authors></contributors><titles><title>GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations</title></titles><dates><year>2013</year></dates><publisher>Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group </publisher><urls></urls></record></Cite></EndNote>(Schünemann et al 2013). Table B.3: Assessment of limitations of observational studies Study limitationExplanationFailure to develop and apply appropriate eligibility criteria (inclusion of control population) Under- or over-matching in case-control studies Selection of exposed and unexposed in cohort studies from different populations Flawed measurement of both exposure and outcome Differences in measurement of exposure (e.g. recall bias in case-control studies) Differential surveillance for outcome in exposed and unexposed in cohort studies Failure to adequately control confounding Failure of accurate measurement of all known prognostic factors Failure to match for prognostic factors and/or adjustment in statistical analysis Incomplete or inadequately short follow-up Especially within prospective cohort studies, both groups should be followed for the same amount of time. Source: ADDIN EN.CITE <EndNote><Cite><Author>Schünemann</Author><Year>2013</Year><RecNum>1548</RecNum><DisplayText>(<style font="Century Gothic" size="8">Schünemann et al 2013</style>)</DisplayText><record><rec-number>1548</rec-number><foreign-keys><key app="EN" db-id="r0fwxaz05vavvyexrs5vxa5r2tr0afxwvt2w" timestamp="1491626232">1548</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Schünemann, H.,</author><author>Bro?ek, J.,</author><author>Guyatt, G.,</author><author>Oxman, A.,</author></authors></contributors><titles><title>GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations</title></titles><dates><year>2013</year></dates><publisher>Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group </publisher><urls></urls></record></Cite></EndNote>(Schünemann et al 2013). Selection of outcomes for GRADE analysisThe methodologists identified outcomes reported in the evidence for each topic. These were then reviewed and agreed upon by the Co-chairs and the EWG.Assessing the evidenceFor many research questions, the evidence was observational and heterogeneous and did not allow meta-analysis. For these questions, findings were tabulated and summarised in the text of the reviews and, in some cases, consensus-based recommendations were developed. For research questions where comparable outcomes were reported, these were pooled using Revman 5 and the pooled results transferred to GRADE evidence tables, which take into account the risk of bias (the degree to which included studies have a high likelihood of protection against bias), inconsistency (the degree to which included studies find the same direction or magnitude of effect), imprecision (the confidence in the estimates of effect), indirectness (degree to which the evidence can be linked to important health outcomes) and the potential for publication bias (degree to which non-reporting or selective analysis of results may influence interpretation of study results). The evidence tables provided a basis for development of GRADE Summary of Findings tables, which give anticipated absolute effects (usually in terms of numbers per 1,000) and relative risk, and provide a summation of the quality of the evidence. Evidence summaries were also developed based on the Summary of Findings tables to facilitate understanding of the implications of the evidence. The evidence-based recommendations developed were worded and graded based on this summation.Synthesising the evidenceA summary of the evidence was developed for each research question for which studies were identified. This noted the study designs included (ie whether searches were limited to systematic reviews, RCTs or included observational studies) and the quality of the studies that contributed to the body of evidence and listed the studies of greatest relevance. Formulation of recommendationsThe methodologists engaged to conduct the review searched the literature, evaluated the evidence and developed Technical Reports for each topic. The technical writer then revised or drafted a chapter based on the evidence. Each Technical Report and associated draft chapter was then reviewed by the Co-Chairs and draft recommendations and practice points were developed in consultation with the methodologists. Documents were then circulated for comment from the EWG by email and comments collated by the Department. The EWG was guided by the methodologists and technical writer in the approach to evaluating the evidence and developing recommendations (ie wording was to be in plain English, specific, unambiguous, clearly describe the action/s to be taken by users and match the strength of the body of evidence). An iterative approach was taken to finalising the wording. Consensus-based recommendations and practice points were also agreed using the same process. Recommendations and practice points will be further refined to incorporate feedback from health professionals and consumers through the public consultation process.Grading recommendationsGrading of recommendations was conducted by the EWG with advice from the methodologists. Grades were based on the GRADE summation of the evidence and key factors influencing the direction and strength of a recommendation as outlined below.Table B.4: Domains that contribute to the strength of a recommendationDomainCommentBalance between desirable and undesirable outcomes (trade-offs) taking into account:best estimates of the magnitude of effects on desirable and undesirable outcomesimportance of outcomes (estimated typical values and preferences)The larger the differences between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower certainty for that benefit, the more likely a qualified recommendation is warrantedConfidence in the magnitude of estimates of effect of the interventions on important outcomes (overall quality of evidence for outcomes)The higher the quality of evidence, the more likely a strong recommendation is warrantedConfidence in values and preferences and their variabilityThe greater the variability in values and preferences, or uncertainty about typical values and preferences, the more likely a qualified recommendation is warrantedResource useThe higher the costs of an intervention (the more resources consumed), the less likely a strong recommendation is warrantedThe GRADE method supports two types of evidence-based recommendation — ‘strong’ and ‘weak’. The EWG agreed that preferable terminology was ‘recommendation’ and ‘qualified recommendation’, using the following definitions:Recommendation — implies that most/all individuals will be best served by the recommended course of action; used when confident that desirable effects clearly outweigh undesirable effects; used when confident that undesirable effects clearly outweigh desirable effectsQualified recommendation —?implies that not all individuals will be best served by the recommended course of action; used when desirable effects probably outweigh undesirable effects; used when undesirable effects probably outweigh desirable effects.Note that no new recommendations were graded as ‘qualified’. The principles applied in wording recommendations are outlined in Section B4. Consideration of harms and benefitsThe topics under review related to assessing risk or information provision rather than intervention. The harms of not assessing/testing/providing information and the health benefits of doing so are outlined in Appendix C. These are based on information provided in the body of the Guidelines.Link between evidence and recommendationsSee Appendix C.External reviewAGREE appraisalThe Guidelines and associated technical reports will be assessed against the AGREE II instrument by two independent reviewers. Following review, any changes suggested will be made to the Guidelines and summarised in this appendix.Independent peer reviewPeer review will be sought from two clinicians with expertise in antenatal care. Following review, any changes suggested will be made to the Guidelines and summarised in this appendix.Independent methodological reviewIndependent methodological review will be sought to assess whether the Guidelines meets the NHMRC Standards for Clinical Practice Guidelines. Following review, any changes suggested will be made to the Guidelines and summarised in this appendix.Updating proceduresDue to the number of topics considered in the Guidelines, the EWG has prioritised topics for future reviews, which will be conducted sequentially. The reviews will be conducted using the same methodology as employed in the current review. It is anticipated that the online version of the Guidelines will be updated as revised or new chapters are developed and that all topics will be reviewed within 5 years of publication.B4Clarity of presentationSpecific and unambiguous recommendationsThe evidence-based and consensus-based recommendations were worded based on the following principles:recommendations are succinct and action-orientedthe action recommended is clearly articulated and matches the strength of the body of evidencewomen to whom the recommendation relates are identifiedwhere relevant, timing of the action is included.Management optionsThe Guidelines clearly state that information on management is beyond their scope and external resources providing guidance on management are listed for most topics. Identifiable key recommendationsThe evidence-based recommendations and consensus-based recommendations are clearly identified by colour coding and use of separate numbering systems. A summary of recommendations is included. B5ApplicabilityFacilitators and barriersThe broad membership of the EWG means that it is well-placed to identify barriers to implementation of the recommendations across a range of antenatal care settings. Potential barriers to implementation include:time required for providing women with additional informationpreferences for existing practices.While potential barriers were considered, the final recommendations were based on the evidence for the optimal outcomes for women and babies.The early involvement of key stakeholder organisations (eg RANZCOG and ACM) in the development process will facilitate uptake of the recommendations by their respective memberships.The implications of implementing each recommendation are included in Appendix C.Implementation advice/toolsFor each topic in these Guidelines, a practice summary is provided, which outlines practical information on when to act, who should act and how to implement the advice provided. A list of resources (including information on management) is also provided. Each chapter lists specific topics to be discussed with women.The new Guideline chapters will be incorporated into the online version of the Guidelines, which is available in a mobile-device friendly version. Resource implicationsThe reviews identified some studies that reported on cost-effectiveness.Calcium supplementation: There is some evidence from the Netherlands that routine calcium supplementation in pregnancy is more cost-effective than selective supplementation.Lifestyle counselling to prevent weight gain exceeding recommendations: A systematic review that assessed cost-effectiveness analyses of lifestyle counselling interventions compared with usual care found that results were inconsistent and further research is required to determine the effective components of lifestyle interventions. Cost-effectiveness studies from overseas found that lifestyle interventions were cost-effective for gestational weight gain but not blood glucose levels, insulin resistance or infant weight, were inconsistent regarding quality-adjusted life years and a better understanding of the short- and long-term costs of large for gestational age and weight gain exceeding IOM recommendations is necessary.These findings were reported in the Guidelines but did not influence the recommendations, which are based on the evidence for the optimal outcomes for women and babies.Monitoring/auditing criteriaA process for evaluating uptake of the Guidelines is under development.B6Editorial independenceFunding bodyThe Australian Government Department of Health funded the updating of these guidelines. The Australian Government Department of Health also provided project management and secretariat services to support the review.The content of the Guidelines was not influenced by the funding peting interestsAt the outset of the Guideline development process, all representatives were informed of the importance of managing competing interests and ensuring that any potential conflicts of interest were identified in advance of any meeting (as evidenced in meeting minutes). Competing interests were considered to include authorship of evidence supporting proposed recommendations and financial interest in a company potentially profiting from a recommendation (eg producers of a specific screening test). Processes put in place to manage any potential competing interests were as follows.All EWG members were required to complete a Declaration of Interest Form (as per the NHMRC requirements). These signed and scanned forms were reviewed and held by the Department.At the beginning of each meeting, EWG members were informed of the arising agenda items and asked to declare any potential competing interests. When competing interests were identified, the EWG member was asked to leave the room while the evidence was discussed.Any arising competing interests and strategies for managing these (if required) were adjudicated by the Co-Chairs and documented in meeting minutes. A competing interest held by a Co-Chair was managed by the other Co-Chair and the area of conflict clearly stated. Table B.6: Expert Working Group competing interestsNameCompeting interestProfessor Caroline HomerNilProfessor Jeremy Oats NilDr Martin ByrneNilDr Marilyn ClarkeNilMs Leah HardimanNilMs Tracy MartinNilProfessor Sue McDonaldNilAssociate Prof Philippa MiddletonLead author of a Cochrane review of omega-3 fatty acid supplementation during pregnancyCo-author of Cochrane reviews of dietary interventions for preventing gestational diabetes, combined diet and exercise interventions for preventing gestational diabetes, exercise for preventing gestational diabetes and zinc supplementation for improving pregnancy and infant outcomesMs Natalija NesvadbaNilProfessor Michael PermezelNilMs Alecia StainesNilMs Cindy TurnerNilB7ConsultationPublic consultationThe draft guidelines were released for a 45-day public consultation. While a 30-day consultation is required in Section 14A of the NHMRC Act 1992 and accompanying regulations, it was agreed to hold a longer consultation period due to the COVID-19 pandemic, which may affect the ability of some individuals to provide a submission. The public consultation began on 2 June 2020 and will formally end on 17 July 2020. Key stakeholders were contacted via email and directed to the Department of Health Consultation Hub where papers could be accessed. Stakeholders were also asked to forward the information to other contacts who may be interested.?The Department of Health also promoted the public consultation process via their Facebook posts and the Department’s webpage hosting the guidelines.Following public consultation, submissions will be combined into a single report and considered by the EWG. The Guidelines will be revised to incorporate comments and a summary of changes made will be included in this appendix.B8Dissemination and implementation DisseminationFollowing NHMRC approval of the new recommendations, the revised chapters will be incorporated into the Guidelines. The Guidelines are available online, including in a mobile-device friendly version. The Guidelines are also be listed on the NHMRC portal and accessible by searching the portal.PromotionA number of activities were undertaken to promote the release of the previous review of the pregnancy care guidelines. It is anticipated that similar activities will be undertaken following approval of the recommendations in this review by the NHMRC. These activities include:Guidelines launch by the Minister for Healthemail notification about the release of the review to stakeholders development of summary sheets for health professionals and womenpromotion on social mediapresentations delivered by EWG members at relevant conferences and media opportunitiessummary article published in the Medical Journal of Australia highlighting changes in practice resulting from the revised recommendationsinviting relevant stakeholders to provide a link or web icon to the Guidelines on their websitesdistribution of a general article for inclusion in newsletters of relevant organisations. ImplementationThe EWG considered methods of providing supporting materials related to the Guidelines. Development of summary documents for health professionals and consumers (which will be available from the Department of health’s website) are among the strategies being considered. Discussions with the key professional colleges and funding will inform decisions relating to implementation. ADDIN EN.SECTION.REFLIST CSummary of the literature reviewsThis section includes research questions, search dates, evidence summaries and implications for implementation of recommendations. The search terms, full search strategies, evidence tables and GRADE summaries of the evidence are included in the Technical Reports, which will be available from the NHMRC and Department of Health websites when the guideline chapters have been approved. Research questionsNutrition adviceQ1What dietary advice should be provided to women in pregnancy, including population-specific groups? Q2Which foods should be promoted and which avoided during pregnancy? Q3What are the harms and benefits of vitamin and mineral supplementation in pregnancy? Q4What are the harms and benefits of nutritionally based complementary medicines in pregnancy? Physical activity adviceQ5What are the harms and benefits of physical activity during pregnancy? Q6What physical activities are associated with adverse maternal and perinatal outcomes? Weight assessmentQ7When should maternal weight and height be measured and BMI calculated in pregnant women?Q8What specific risk assessments are required for pregnant women with high or low BMI at the first antenatal visit?InterventionsQ9What lifestyle interventions are effective in preventing excessive weight gain and other adverse outcomes in pregnant women?Additional considerationsQ10What are the additional considerations for Aboriginal and Torres Strait Islander women? Q11What are the additional considerations for migrant and refugee women?Table C1: Mapping of searches to research questions and type of reviewQuestionSearchTypes of studies includedReview typeQuestion 1Diet and pregnancySystematic reviews, RCTs, observational studiesNarrative reviewQuestion 2Diet and pregnancySystematic reviews, RCTs, observational studiesNarrative reviewQuestion 3Folic acidSystematic reviews, RCTs, Australian observational studiesNarrative reviewB vitaminsSystematic reviews, RCTs, Australian observational studiesNarrative reviewVitamin CSystematic reviews, RCTs, Australian observational studiesNarrative reviewVitamin ESystematic reviews, RCTs, Australian observational studiesNarrative reviewVitamin ASystematic reviews, RCTs, Australian observational studiesNarrative reviewMultiple micronutrientsSystematic reviews, RCTs, Australian observational studiesNarrative reviewIron Systematic reviews, RCTs, Australian observational studiesNarrative reviewCalciumSystematic reviews, RCTs, Australian observational studiesNarrative reviewIodineSystematic reviews, RCTs, Australian observational studiesNarrative reviewZincSystematic reviews, RCTs, Australian observational studiesNarrative reviewMagnesium Systematic reviews, RCTs, Australian observational studiesNarrative reviewSeleniumSystematic reviews, RCTs, Australian observational studiesNarrative reviewQuestion 4Omega-3 fatty acidsRecent Cochrane reviewSummary of Cochrane reviewHerbal preparationsSystematic reviews, RCTs, observational studiesNarrative reviewProbioticsSystematic reviews of RCTs, RCTsMeta-analysisQuestion 5Physical activity and pregnancySystematic reviews, RCTs, observational studiesNarrative reviewQuestion 6Physical activity and pregnancySystematic reviews, RCTs, observational studiesNarrative reviewQuestion 7Gestational weight gainDeterminants of gestational weight gain; women’s and health professionals’ views on gestational weight gain: Systematic reviews, observational studiesRisks associated with low or high gestational weight gain: Systematic reviews, RCTs Narrative reviewWeight monitoringSystematic reviews of RCTs, RCTsMeta-analysisQuestion 8Risk assessmentsSystematic reviews of RCTs, RCTsNarrative reviewQuestion 9Diet and pregnancySystematic reviews of RCTs, RCTsMeta-analysisPhysical activity and pregnancyQuestion 10All searchesAll identified studies relevant to Australian contextNarrative reviewQuestion 11PICO criteria for inclusion of studies in meta-analysesProbioticsPopulationInterventionComparatorOutcomesStudy designsPregnant women who are apparently healthy in early pregnancyProbiotic supplementPlacebo or usual careHealth or clinical outcomes, including longer term outcomes for the mother and childRCTsSystematic reviews of RCTsWeight assessmentPopulationInterventionComparatorOutcomesStudy designsPregnant women who are apparently healthy in early pregnancyRegular weighing as part of antenatal care plus advice on weight gainUsual careHealth or clinical outcomes, including longer term outcomes for the mother and childRCTsSystematic reviews of RCTsInterventions to prevent gestational weight gainPopulationInterventionComparatorOutcomesStudy designsPregnant women who are apparently healthy in early pregnancyIntervention related to changes in dietUsual careHealth or clinical outcomes, including longer term outcomes for the mother and childRCTsSystematic reviews of RCTsIntervention to increase physical activityCombined intervention with dietary and physical activity componentsSelection of outcomes for GRADE analysis Table C2: Outcomes for meta-analysis of evidence on probiotics Outcome — Maternal ImportanceInclusionGestational diabetes9Gestational hypertension9Pre-eclampsia5Bacterial vaginosis5Group B streptococcus7Caesarean section9Outcome —?Infant ImportanceInclusionPerinatal death9Preterm birth9Small for gestational age9Large for gestational age9Macrosomia9Table C3: Outcomes for meta-analysis of evidence on weight monitoring Outcome — MaternalImportanceInclusionExcess gestational weight gain5Mean gestational weight gain (weekly)5Gestational diabetes9Hypertensive disorders of pregnancy5Depression7Anxiety5Macrosomia9Table C4: Outcomes for meta-analysis of evidence on interventions to prevent weight gain Outcome — MaternalImportanceInclusionMean gestational weight gain5Excess gestational weight gain5Gestational diabetes9Hypertensive disorders of pregnancy5Caesarean section9Depression (antenatal and postnatal)7Postnatal weight retention5Outcome — InfantImportanceInclusionPreterm birth9Low birthweight9Macrosomia9Large for gestational age9Small for gestational age9Apgar score <7 at 5 minutes7Early childhood weight5 Key:1 – 3 less important; 4 – 6 important but not critical for making a decision; 7 – 9 critical for making a decisionLinking evidence with recommendations Diet and pregnancyQ1What dietary advice should be provided to women in pregnancy, including population-specific groups?Search strategyPublication date range: 01/01/2014 to 04/06/2019Databases searched: Embase, Cinahl, PubMed, Informit: Indigenous peoples, Scopus, CochraneEvidence statementsAustralian cross-sectional studies have identified low levels of awareness of dietary guidelines during pregnancy among women and limited dietary counselling by health professionals.Studies investigating outcomes associated with dietary patterns were heterogeneous in the patterns that they identified. However, dietary patterns associated with positive outcomes were generally characterised by high intake of fruits, vegetables, legumes, wholegrains, fish, seafood, lean meats, low-fat dairy and water. Dietary patterns associated with poorer outcomes included those high in sweetened foods and beverages, foods high in saturated fats (eg fried foods), red and processed meats and refined grains. Outcomes positively affected by a healthy dietary pattern and negatively affected by an unhealthy dietary pattern included gestational diabetes, gestational hypertension and antenatal depression. The evidence was inconsistent on the association between dietary pattern in pregnancy and preterm birth, fetal and childhood growth, cardiometabolic health and childhood wheeze.In systematic reviews of vegan-vegetarian diets, findings on birthweight were inconsistent, duration of pregnancy between vegan-vegetarian and omnivorous diets was similar and there was a suggestion of risk of iron, zinc and vitamin?B12 deficiency with vegan-vegetarian diets.A systematic review found that fasting during Ramadan among well-nourished women did not increase the risk of preterm birth or low birth weight.No recommendations developedQ2 Which foods should be promoted and which avoided during pregnancy?Search strategyPublication date range: 01/01/2014 to 04/06/2019Databases searched: Embase, Cinahl, PubMed, Informit: Indigenous peoples, Scopus, CochraneEvidence statementsThe evidence on specific food components that should be promoted or avoided during pregnancy generally aligns with the findings for question 1. No evidence was identified that contradicts the findings of the systematic review undertaken to inform the Australian Dietary Guidelines.Fruit, vegetables and legumesThere is evidence from observational studies that eating vegetables, fruit and legumes during pregnancy is beneficial to both mother and baby. There are possible associations with improvements in glucose tolerance and fetal growth and reductions in risk of neural tube defects, pre-eclampsia, preterm birth, depression and anxiety, allergy or asthma in the child and some childhood cancers.MeatThere is evidence from observational studies that low meat consumption may be protective against wheeze in the child and that limiting intake of cured meats may reduce the risk of some childhood cancers.FishThere is evidence from systematic reviews of observational studies that higher maternal fish intake may be associated with positive neurodevelopmental outcomes and a reduced risk of childhood leukaemia and does not appear to affect the risk of infant eczema, wheeze, allergic rhinitis or asthma. There is evidence from observational studies that high intake of seafood may be associated with reduced risk of antenatal depression and low birth weight but that high fetal exposure to mercury is associated with low birth weight, small-for-gestational age and delayed language and communication skills.The evidence on an association between maternal fish intake and preterm birth is insufficient for conclusions to be drawn and findings of observational studies on the effect of maternal seafood intake on child growth are inconsistent. DairyThere is evidence from observational studies that higher maternal intake of all dairy products is associated with a reduced risk of infantile eczema, higher maternal milk intake is associated with reduced risk of neural tube defects, asthma, allergic rhinitis and cow’s milk allergy in children, higher yoghurt intake is associated with lower prevalence of depressive symptoms during pregnancy, and daily butter intake may be associated with increased risk of infant eczema.CarbohydratesThere is evidence from analysis of RCT participants that, in obese women with impaired glucose tolerance, a moderate carbohydrate intake during pregnancy is associated with a lower fat mass in their baby at birth. There is evidence from cohort studies that high maternal carbohydrate consumption may be associated with increases in birth weight and with infant wheeze.ProteinThere is evidence from observational studies that a higher maternal protein intake may be associated with a higher risk of gestational diabetes, may increase fat-free mass in the infant and reduce new born abdominal adipose tissue and the risk of rapid infant growth.FatsThere is evidence from observational studies that a higher daily fat intake is associated with increased risk of gestational diabetes and lower birth weight.Sweetened foods and beveragesThere is evidence from an RCT that higher consumption of foods and drinks that contribute to intake of added sugars is associated with gestational weight gain. There is evidence from observational studies of an association between sugar-sweetened foods and drinks and impaired glucose tolerance and gestational diabetes, major depressive disorder, large for gestational age, increases in infant BMI z score and overweight at 1 year and 7 years of age, and infant atopy and asthma.Fast foodsThere is evidence from cohort studies that fast food consumption is associated with an increased risk of gestational diabetes, infant dermatitis and asthma.CaffeineThere is insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birth weight or other pregnancy outcomes.Potential allergensThere is evidence from observational studies that maternal peanut consumption may reduce the risk of peanut allergy in the infant and higher maternal wheat intake during the second trimester may reduce atopic dermatitis in the infant.No recommendations developedQ3 What are the harms and benefits of vitamin and mineral supplementation in pregnancy?Folic acidSearch strategyPublication date range: 31/12/12 to 24/06/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementsThere is high certainty evidence that folic acid supplementation in pregnancy is associated with a reduction in risk of neural tube defects and lower certainty evidence that it may also reduce the risk of orofacial clefts and congenital heart defects. There is evidence from systematic reviews of observational studies that folic acid supplementation during pregnancy may reduce the risk of acute myeloid leukaemia, brain and spinal cord tumours in the child and autism spectrum disorders.The evidence suggests that folic acid supplementation does not affect the risk of early or late miscarriage, stillbirth, fetal loss, preterm birth, low birth weight, perinatal death, or asthma or wheeze in the infant. The evidence is inconsistent on the effect of folic acid supplementation on gestational hypertension, pre-eclampsia and acute lymphoblastic leukaemia in the infant.Evidence-based recommendationRecommend dietary supplementation of 500 micrograms per day folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy to reduce the risk of neural tube defects.Harms and health benefits associated with the recommendationHarms: The evidence suggests that folic acid supplementation is not associated with adverse effects.Health benefits: Reduction in risk of neural tube defects.Implications for implementationThis recommendation was included in the previous version of the chapter and will not change practice.B vitaminsSearch strategyPublication date range: 2014 to 30/09/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementsThere is insufficient evidence to detect clinical benefits of vitamin B6 in pregnancy, although it appears to be of benefit in reducing nausea.The evidence on vitamin B12 supplementation in pregnancy is of insufficient quality to draw conclusions.No recommendations developedVitamin CSearch strategyPublication date range: 31/03/15 to 19/06/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementsThe evidence does not support routine vitamin C supplementation for the prevention of fetal or neonatal death, poor fetal growth, preterm birth or pre-eclampsia. Further research is required to clarify the possible role of vitamin C in the prevention of placental abruption and prelabour rupture of membranes.Vitamin ESearch strategyPublication date range: 31/03/15 to 19/06/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementsThe evidence on vitamin E supplementation is of insufficient quality to draw conclusions.Supplementation with vitamins C and E during pregnancy appears to reduce the risk of placental abruption and increase the risk of term PROM. It does not appear to affect other perinatal outcomes. Combined vitamins C and E may reduce the risk of preterm birth and placental abruption in pregnant women who smoke.Vitamin ASearch strategyPublication date range: 31/03/15 to 20/06/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementThe evidence does not support vitamin A supplementation for the prevention of fetal loss, maternal mortality, perinatal mortality or preterm birth. The evidence on the role of vitamin A supplementation in reducing risk of maternal clinical infection and anaemia may not be generalisable to the Australian context.Evidence-based recommendationAdvise women that taking vitamin A, C or E supplements is of little or no benefit in pregnancy and may cause harm.Harms and health benefits associated with the recommendationHarms: The evidence suggests that taking vitamin A, C or E supplements may be associated with adverse effects.Health benefits: Reduction in risk of adverse effects associated with vitamin A, C or E supplementation.Implications for implementationThis recommendation was included in the previous version of the chapter and will not change practice.Multiple micronutrientsSearch strategyPublication date range: 01/01/15 to 21/01/20Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementThere is high certainty evidence from studies conducted in low- to middle-income countries that multivitamin use during pregnancy reduces the risk of low birth weight and may reduce the risk of stillbirth but does not affect the risk of perinatal or neonatal mortality. There is moderate certainty evidence of a reduction in risk of small for gestational age and a possible reduction in risk of preterm birth (<37 weeks). There is evidence of unspecified certainty that multivitamin use is associated with a reduction in risk of very preterm birth (<34 weeks), a possible reduction in risk of miscarriage and has no effect on maternal mortality, maternal anaemia, caesarean section or congenital anomalies. These findings may not be generalisable to the Australian context.There is very low to low certainty evidence that prenatal multivitamin supplementation among women in high income countries is associated with a reduced risk of small for gestational age and some congenital anomalies and a possible reduced risk of preterm birth.No recommendations developedIronSearch strategyPublication date range: 10/01/15 to 01/07/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementThere is moderate certainty evidence that iron supplementation in pregnancy has no clear effect on the risk of preterm birth. There is low certainty evidence that iron supplementation in pregnancy reduces the risk of maternal anaemia and iron deficiency at term and has no clear effect on maternal infection, neonatal death, congenital anomalies or low birth weight. There is very low certainty evidence that iron supplementation in pregnancy has no clear effect on the risk of maternal death or maternal side effects. There is evidence from a systematic review of RCTs that iron supplementation has no clear effect on infant neurodevelopment.There is low certainty evidence that intermittent versus daily iron supplementation in pregnancy has no clear effect on preterm birth, birth weight or low birthweight. There is very low certainty evidence that maternal side effects are reduced with intermittent versus daily iron supplementation and that there is no clear difference in maternal anaemia at term, maternal iron-deficiency at term or neonatal death. Evidence-based recommendationsOnly advise iron supplementation to pregnant women if their dietary iron intake is low or they have iron-deficiency anaemia.Advise pregnant women with low dietary iron intake that intermittent supplementation is as effective as daily supplementation in preventing iron-deficiency anaemia, with fewer adverse effects.Harms and health benefits associated with the recommendationHarms: If low dietary iron intake is not identified, women who could benefit from supplementation may not be advised to take a supplement (note that dietary sources or iron are discussed in the guidelines). Health benefits: Reduction in risk of maternal anaemia and iron-deficiency at term and maternal side effects.Implications for implementationThese recommendations were included in the previous version of the chapter and will not change practice.CalciumSearch strategyPublication date range: 30/09/14 to 02/07/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementThere is consistent evidence from systematic reviews that calcium supplementation reduces the risk of pre-eclampsia and gestational hypertension. Calcium supplements do not appear to be of benefit in preventing low birth weight and their role in preventing preterm birth is unclear. There is evidence that routine calcium supplementation is more cost-effective than selective supplementation.Evidence-based recommendationAdvise pregnant women to take a low-dose calcium supplement.Harms and health benefits associated with the recommendationHarms: No harms identified.Health benefits: Reduction in risk of pre-eclampsia and gestational hypertension.Implications for implementationThere may be cost implications for women.IodineSearch strategyPublication date range: 18/11/16 to 16/01/19Top-up search date: 12 March 2020Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementThere is low certainty evidence that, in settings with mild to moderate iodine deficiency, iodine supplementation may reduce the risk of postpartum hyperthyroidism and very low certainty evidence of an increased likelihood of gastrointestinal intolerance during pregnancy. There is low certainty evidence that iodine supplementation does not appear to increase or decrease the likelihood of other outcomes or side effects for mothers or infants. Consensus-based recommendationAdvise pregnant women to take an iodine supplement of 150?micrograms each day. Women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement.Harms and health benefits associated with the recommendationHarms: No harms identified.Health benefits: Reduction in risk of pre-eclampsia.Implications for implementationThere may be cost implications for women.ZincSearch strategyPublication date range: 01/11/14 to 16/01/19Top-up search date: 12 March 2020Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane Evidence statementThere is moderate certainty evidence that zinc supplementation may play a role in reducing the risk of preterm birth but has no clear effect on low birthweight. Supplementation does not appear to increase or reduce the risk of other outcomes. There is insufficient evidence to support a recommendation on zinc supplementation.No recommendations developedMagnesiumSearch strategyPublication date range: 31/03/13 to 13/02/19Top-up search date: 12 March 2020Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane, PsychinfoEvidence statementThere is insufficient evidence to draw conclusions on magnesium supplementation in pregnancy.No recommendations developedSeleniumSearch strategyPublication date range: 01/01/2000 to 28/02/19Top-up search date: 12 March 2020Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, Cochrane, PsychinfoEvidence statementThere is insufficient evidence to draw conclusions on selenium supplementation in pregnancy.No recommendations developedQ4 What are the harms and benefits of nutritionally based complementary medicines in pregnancy?Omega-3 fatty acidsSearch strategySummary of Cochrane reviewEvidence statementsThere is high certainty evidence that rates of preterm birth <37 weeks and early preterm birth <34 weeks are lower in women receiving omega-3 LCPUFA compared with no omega-3. There is moderate-certainty evidence that prolonged pregnancy >42 weeks is probably increased with omega-3 fatty acid supplementation. There is high certainty evidence of a reduced risk of low birth weight and moderate certainty evidence for a possible reduced risk of perinatal death, neonatal care admission and a possible small increase in risk of large-for-gestational age babies with omega-3 LCPUFA.Evidence-based recommendationAdvise pregnant women that supplementation with omega3 long-chain polyunsaturated fatty acids may reduce their risk of preterm birth.Harms and health benefits associated with the recommendationHarms: Possible increase in risk of prolonged pregnancy and large for gestational age.Health benefits: Reduction in risk of preterm birth, low birthweight, perinatal death and neonatal care admission.Implications for implementationThis recommendation may have cost implications for womenProbioticsSearch strategyPublication date range: 2014 to 18/10/19Databases searched: Embase, Cinahl, Scopus, Cochrane, Australian Indigenous HealthInfoNetEvidence statementsThere is low certainty evidence that supplementation with probiotics may be associated with a possible reduction in caesarean section and very low certainty evidence of a reduction in Group B streptococcus colonisation and a possible reduction in risk of gestational diabetes. There is very low or low certainty evidence that probiotic supplementation has no effect on gestational hypertension, pre-eclampsia, bacterial vaginosis, perinatal death, preterm birth, small for gestational age, large for gestational age or macrosomia.No recommendations developedHerbal preparationsSearch strategyPublication date range: 2014 to 05/08/20Databases searched: Embase, Cinahl, Scopus, Cochrane, Australian Indigenous HealthInfoNetEvidence statementsThe evidence on the efficacy and safety of herbal preparations during pregnancy is limited. There is moderate certainty evidence that ginger reduces nausea, with a low risk of adverse effects. There is very low certainty evidence that chamomile is also effective in reducing nausea.There is evidence from a systematic review that garlic may reduce gestational hypertension but does not have an effect on pre-eclampsia or caesarean section, with a high likelihood of experiencing odour.There is insufficient evidence on the efficacy and safety of echinacea and elderberry during pregnancy.No recommendations developedPhysical activityQ5 What are the harms and benefits of physical activity during pregnancy?Search strategyPublication date range: 1998 to 06/07/18Top-up search: 12 March 2020Databases searched: Embase, Cinahl, PubMed, Cochrane, Australian Indigenous HealthInfoNetEvidence statementsThere is a possible increase in physical fitness associated with exercise in pregnancy and rates of injury appear to be low. The evidence on the effect on quality of life suggests an improvement with physical activity.There is evidence from systematic reviews, an RCT and a cohort study of a possible reduction in risk of low back and lumbopelvic pain and a reduction in severity of pain during pregnancy. The evidence on the effect of exercise on pelvic girdle pain and pain in the postpartum period is unclear. Moderate to vigorous exercise during pregnancy appears to improve sleep quality but is not effective in treating insomnia in pregnancy.There is no clear difference in the duration of labour, pain during labour or perineal tears between women who exercise during pregnancy and those who don’t, although some RCTs have reported a shorter duration of labour, fewer requests for analgesia and lower risk of perineal tears among women who exercised during pregnancy.There is no clear association between leisure-time exercise during pregnancy and congenital anomalies and it appears to be protective against macrosomia and low birth weight. It does not appear to affect childhood weight but cohort studies suggest a positive association between physical activity during pregnancy and offspring neurodevelopment.Q6 What physical activities are associated with adverse maternal and perinatal outcomes?Search strategyPublication date range: 1998 to 06/07/18Top-up search: 12 March 2020Databases searched: Embase, Cinahl, PubMed, Cochrane, Australian Indigenous HealthInfoNetEvidence statementsNo evidence was identified to support an association between adverse effects in the woman or fetus and exercise, vigorous exercise or swimming during pregnancy. There is insufficient evidence to ascertain whether maternal exercise in the supine position is safe or should be avoided during pregnancy. Bicycling and horseback riding may be associated with miscarriage at 11-14 weeks.The evidence on risks associated with occupational physical activity during pregnancy is unclear. Heavy lifting (eg >200 kg/day) may be associated with an increased risk of pelvic pain, stillbirth among women with a previous fetal loss and preterm birth among primigravid women but is not associated with small-for-gestational age or low birth weight. There is a possible association between occupational standing and increased risk of miscarriage (>6 hours a day) or preterm birth (>3 hours a day) but no clear difference in small-for-gestational age, birth weight or pelvic pain. There is insufficient evidence to draw conclusions on strenuous occupational physical exertion in pregnancy but it may be associated with preterm premature rupture of the membranes and pelvic pain.Evidence-based recommendationAdvise women that regular moderate-intensity physical activity during pregnancy is associated with a range of health benefits and is generally not associated with adverse outcomes.Harms and health benefits associated with the recommendationHarms: Physical activity in pregnancy is not generally associated with adverse outcomes.Health benefits: Regular moderate-intensity physical activity during pregnancy is associated with increased physical fitness and improved quality of life as well as a reduction in some adverse outcomes of pregnancy (see question 9; page? PAGEREF _Ref40870478 \h 2)Implications for implementationThis recommendation does not change the advice given in the previous version of the chapter. It may increase consultation time.Gestational weight gainQ7 When should maternal weight and height be measured and BMI calculated in pregnant women?Search strategyPublication date range: 2014 to 09/04/19Top-up search: 12 March 2020Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, HealthInfoNet, CochraneEvidence statementsWomen’s and health professionals’ views on gestational weight gainThere is evidence from a systematic review that women are highly motivated to change their behaviour to improve fetal health, but may not recognise the link between excess gestational weight gain and negative fetal health outcomes. There is evidence from cross-sectional studies that women lack accurate knowledge on gestational weight gain and would welcome advice from health professionals.There is evidence from cross-sectional studies that health professionals would welcome more training in providing appropriate counselling and that resources and time are other barriers to discussing weight gain.Weight monitoringSearch strategyPublication date range: 01/01/14 to 02/12/19Databases searched: PubMed, Ovid Medline, Embase, CINAHL, Scopus, Health Infonet, CochraneEvidence statementsThere is very low certainty evidence that regular weighing as part of antenatal care has no clear effect on mean weekly weight gain, total weight gain exceeding guidelines, gestational diabetes, hypertensive disorders of pregnancy or macrosomia but low certainty evidence that it may reduce the risk of depression and anxiety.Consensus-based recommendationMeasure women’s weight and height at the first antenatal visit and calculate their body mass index (BMI) and give them advice about the benefits of gaining weight within the recommended weight gain range for their BMI.Harms and health benefits associated with the recommendationHarms: No harms identified.Health benefits: Optimising gestational weight gain reduces the risk of some adverse outcomes (see also research question 8; page PAGEREF _Ref40870696 \h 2).Implications for implementationThis recommendation does not change the advice given in the previous version of the chapter. It may increase consultation time.Q8 What specific risk assessments are required for pregnant women with high or low BMI at the first antenatal visit?Search strategyPublication date range: All to 28/02/20Databases searched: PubMed, Ovid, Embase, Cinahl, Scopus, Cochrane, Australian Indigenous HealthInfoNetEvidence statementsDeterminants of gestational weight gainThere is evidence from systematic reviews of association between weight gain exceeding guidelines and body image dissatisfaction and lack of social support but not anxiety, stress, self-efficacy, self-esteem of parity. The evidence on depression was inconsistent.There is evidence from cohort studies of association between weight gain exceeding guidelines and pre-pregnancy BMI and stopping smoking but not maternal age, household income, education level or country of birth or experience of hardship in childhood, adulthood or during pregnancy.Risks associated with weight gain lower or higher than recommendationsThere is high certainty evidence that, among women with any BMI, gestational weight gain lower than recommendations increases the risk of preterm birth and small-for gestational-age babies and weight gain higher than recommendations increases the risk of large for gestational age, macrosomia and caesarean section (high certainty).There is RCT evidence that weight gain higher than recommendations in early pregnancy (15-18 weeks) increases the risk of total gestational weight gain exceeding recommendations, gestational diabetes, large-for-gestational-age babies and macrosomia.There is evidence from meta-analysis of individual participant data that, among underweight women, low weight gain is associated with increased risk of preterm birth and small for gestational age.There is evidence from meta-analysis of individual participant data that, among women with healthy pre-pregnancy weight, low weight gain is associated with increased risk of preterm birth and small for gestational age and high weight gain is associated with an increased risk of gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth and large for gestational age.There is evidence from meta-analysis of individual participant data that, among overweight women, low weight gain is associated with increased risk of gestational diabetes, gestational hypertension, pre-eclampsia, small for gestational age and preterm birth and high weight gain is associated with gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth and large for gestational age.There is evidence from meta-analysis of individual participant data that, among obese women, both low and high weight gain were associated with increased risk of gestational diabetes, gestational hypertension, pre-eclampsia and preterm birth. There is high-certainty evidence that, compared to weight gain within recommendations, gestational weight gain higher than recommendations increases the risk of large-for-gestational-age babies, macrosomia and caesarean section. There is evidence from a systematic review of cohort studies that, while gestational weight loss among obese women decreased the risk of large-for-gestational-age babies, macrosomia and caesarean section, it increased the risk of small-for-gestational-age babies and low birth weight and no studies reported on preterm birth.Consensus-based recommendationAt every antenatal visit, offer women the opportunity to be weighed so that low or high gestational weight gain is identified and risk of associated adverse outcomes monitored.Harms and health benefits associated with the recommendationHarms: No harms identified.Health benefits: Optimising gestational weight gain reduces the risk of some adverse outcomes.Implications for implementationThis recommendation does not change the advice given in the previous version of the chapter. It may increase consultation time.Q9 What lifestyle interventions are effective in preventing excessive weight gain and other adverse outcomes in pregnant women?Search strategy: physical activityPublication date range: 1998 to 06/07/18Top-up search: 12 March 2020Databases searched: Embase, Cinahl, PubMed, Cochrane, Australian Indigenous HealthInfoNetSearch strategy: dietPublication date range: 01/01/2014 to 04/06/2019Databases searched: Embase, Cinahl, PubMed, Informit: Indigenous peoples, Scopus, CochraneEvidence statementsThe evidence shows a lower mean gestational weight gain among women participating in a dietary intervention (very low certainty), exercise intervention (moderate certainty) or lifestyle counselling intervention (low certainty). These interventions also lowered the risk of weight gain exceeding guidelines (very low to low certainty). There was no clear difference in postnatal weight retention with a dietary intervention (very low certainty) or exercise intervention (single study) and a reduction with lifestyle counselling (moderate certainty).Dietary interventions showed no clear difference in risk of gestational diabetes (very low certainty), exercise interventions showed reduced risk (low certainty) and lifestyle counselling showed a probable reduction in risk (moderate certainty). There was a reduction in risk of gestational hypertension with dietary intervention or exercise intervention (moderate certainty) but no clear difference in risk with lifestyle counselling (low certainty). There was no clear difference in risk of pre-eclampsia with any type of intervention (low to moderate certainty).There was no clear difference in risk of caesarean section with a dietary intervention (very low certainty) but a reduction in risk with exercise intervention (moderate certainty) and a probable reduction in risk with lifestyle counselling (low certainty).There was a reduction in risk of antenatal depression with exercise intervention (moderate certainty) but not lifestyle counselling (low certainty). The risk of postnatal depression was reduced with exercise intervention.The risk of preterm birth was reduced with a dietary intervention (moderate certainty), probably reduced with lifestyle counselling (moderate certainty) but not exercise intervention (moderate certainty). There was no clear difference in risk of macrosomia >4,000g with dietary intervention (very low certainty) but a reduction in risk with exercise intervention (moderate certainty) and a probable reduction in risk with lifestyle counselling (low certainty). There was a reduction of risk of macrosomia >4,500 g with lifestyle counselling (moderate certainty). There was no clear difference in risk of low birth weight with an exercise intervention (moderate certainty) or lifestyle counselling (low certainty). There was a possible reduction in risk of large-for-gestational age with lifestyle counselling (moderate certainty) but no clear difference in risk with the other interventions.There was no clear difference in risk of small-for-gestational age, Apgar score <7 at 5 minutes or weight in early childhood with any intervention Evidence-based recommendationAt every antenatal visit, give women tailored advice on weight gain, including the benefits of a healthy diet, regular physical activity and self-monitoring.Harms and health benefits associated with the recommendationHarms: No harms identified.Health benefits: Physical activity and healthy diet reduce gestational weight gain, alone or in combination. There is also a range of other health benefits for woman and baby.Implications for implementationThis recommendation may increase consultation time.DTopics currently under reviewLifestyle considerationsVaccines (including influenza, pertussis, varicella)Clinical assessmentsPre-eclampsiaMaternal health testingDiabetesAnaemiaGroup B streptococcusGenetic carrier screeningCervical abnormalitiesFetal chromosomal anomaliesUltrasound assessment for women who have cell-free DNA testing for chromosomal anomaliesETopics covered in the pregnancy care guidelinesOptimising antenatal carePrinciples of careProviding woman-centred careAntenatal care for Aboriginal and Torres Strait Islander womenAntenatal care for migrant and refugee womenAntenatal care for women with mental health disordersPopulation groups with specific care needsClinical care duriNG pregnancyCore practices in antenatal careAntenatal visitsPreparing for pregnancy, childbirth and parenthoodPreparing for breastfeedingLifestyle considerationsNutritionNutritional supplementsPhysical activityTobacco smokingAlcoholMedicinesSexual activityTravelOral healthClinical assessmentsGestational ageWeight and body mass indexBlood pressureProteinuriaPsychosocial factors affecting mental healthDepression and anxietyDomestic violenceFetal development and anatomyFetal growth and wellbeingRisk of pre-eclampsiaRisk of preterm birthMaternal health screeningDiabetesHuman immunodeficiency virusHepatitis BHepatitis CRubellaChlamydiaSyphilisGonorrhoeaTrichomoniasisAsymptomatic bacteriuriaAsymptomatic bacterial vaginosisAnaemiaHaemoglobin disordersVitamin D deficiencyGroup B streptococcusToxoplasmosisCytomegalovirusCervical abnormalitiesThyroid dysfunctionScreening for fetal chromosomal abnormalitiesCommon conditionsReflux (heartburn) HaemorrhoidsVaricose veinsPelvic girdle painCarpal tunnel syndromeNausea and vomitingConstipationClinical assessments in late pregnancyFetal presentationProlonged pregnancyAcronyms and abbreviationsAIHWAustralian Institute of Health and WelfareaHRadjusted hazard ratioaORadjusted odds ratioaPRadjusted prevalence ratioBMIbody mass indexCBRconsensus-based recommendationCDCUS Centers for Disease Control and PreventionCIconfidence intervalEBRevidence-based recommendationEWGExpert Working GroupGPgeneral practitionerIOMUS Institute of MedicineNHMRCNational Health and Medical Research CouncilORodds ratioPPpractice pointQEBRqualified evidence-based recommendation RCTrandomised controlled trialRRrelative riskWHOWorld Health Organization ................
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