creased even more . Some other factors have shifted significantly during the pandemic . Factors such as maternal hypertension were significantly higher among SGA mothers during the pandemic compared to their PC peers . Fewer mothers of LGA newborns during the pandemic had type 2 DM , however , more mothers who gave birth to LGA infants were diagnosed with gestational diabetes mellitus ( GDM ). This finding supports those of another recently published cohort of pregnant women with increased rates of GDM during the COVID-19 pandemic . 14 We suspect the etiology of increased GDM to be multifactorial and likely related to changes in exercise , dietary habits , access to medical care , and other lifestyle factors among expectant mothers during the COVID-19 pandemic .
A growing but still limited literature provides consistent support for an association between exercise during pregnancy and improved maternal health . The ACOG Committee ’ s opinion on “ Physical Activity and Exercise During Pregnancy and the Postpartum Period ” referenced observational studies of women who exercised during pregnancy . Benefits were noted from physical activity , particularly from moderate cycling exercise by decreased risk of maternal GDM , cesarean births , and operative vaginal delivery as well as decreased birth weight . 15 There have been no studies showing an improvement in neonatal outcomes in women placed on activity restriction , including bed rest , and multiple studies have demonstrated negative psychosocial effects on mothers and families when pregnant women have routine activity restricted . 16
Maternal health risk behaviors were also significantly different during the pandemic , including a higher proportion of cannabis and opiate use . The rates of tobacco , cannabis , and opioid use from our population was lower than that reported by Umer et al , 17 possibly secondary to a higher socioeconomic / education status in the area surrounding one of the state ’ s land grant universities . Our data also showed a decrease in the proportion of SGA newborns during the ongoing C period despite an increase in maternal smoking and hypertension . Continued monitoring of issues of pregnancy and fetal well-being during this period is warranted .
Signs of anxiety and depression also seem to have increased during the pandemic , which may impact maternal health behaviors . Berthelot and colleagues discovered that pregnant women assessed during the pandemic reported more distress and psychiatric symptoms , most commonly depression and anxiety . 18 A study by Kinser et al evaluated predictors for depressive symptoms and anxiety and found the most common predictors were job insecurity , family concerns , eating comfort foods , sleep , and use of social and news media . 19 Emotional eating may also play a role in maternal weight gain during pregnancy in the pandemic . Zhang and colleagues reported that emotional eating did occur during the pandemic and is associated with excess gestational weight gain . 20 This suggests that increased food intake , in addition to decreased physical activity , may play a role in gestational weight gain . Attention to increased counseling regarding diet and exercise during imposed restrictions due to pandemics is worthy of study .
Regarding another major change in medical practice during the pandemic , face-toface prenatal care may have been limited during the C period as many clinicians were modifying their traditional ultrasound and follow-up visit schedules to minimize virus exposure risks . In a May 2020 article published in the American Journal of Obstetrics and Gynecology , it is recommended to perform any visits via telehealth when able and appropriate ; a recommendation for a modified routine ultrasound schedule that may include fewer and less frequent ultrasounds is also included . 21 Telehealth recommendations for high-risk pregnancies during the COVID-19 pandemic were published in May 2020 , 22 however these guidelines did not include recommendations for women whose pregnancies were complicated by hypertension , DM , and / or substance use disorder . These issues were most notable from the SGA cohort , like a report from Israel . 23 The increases in cannabis and opioid use documented in our cohort suggests this may also be an indication for specific recommendations regarding telehealth surveillance for this population during a pandemic . Limitations to the number of in-person visits , while potentially necessary to avoid the risks of viral spread , may provide fewer opportunities for surveillance of fetal growth and fewer opportunities for clinicians to provide guidance to mothers regarding lifestyle modifications that may prevent or lessen growth abnormalities in their fetuses .
Barker ’ s observational studies , which have been confirmed by other studies , showed that infants who were born with low birth weight had a high incidence of coronary heart disease , DM , hyperinsulinemia , and hypercholesterolemia as an adult . 24 – 29 One recent study of an Australian Aboriginal community showed that birth weights < 2.5 kg were associated with higher rates of natural death after adjustment for year of birth and sex . 30 LGA neonates are at an increased risk of becoming overweight and obese later in life compared to their normal-weight counterparts . 31 , 32 Newborns born greater than 4,000g have a 50 % increased risk of becoming overweight later in life . 33 In addition , LGA newborns born greater than 4500g have a 19 % increase in risk of developing type 2 DM as an adult compared to those with birth weights between 4,000g and 4,500g . 34
CONCLUSION
Compared to the pre-COVID era , we have noted an increase in LGA infant births and a decrease in SGA infant births at our center during the COVID-19 era . Maternal obesity , a chronic problem in Appalachia , has seemed to worsen during this pandemic , and these maternal issues may be passed on to their infants . These findings suggest an increased need for close prenatal monitoring , education , and counseling , especially during pandemics . Our observations illustrate the need for continued antenatal monitoring and fetal assessment during a pandemic such as COVID-19 and emphasize the need for innovative approaches to pregnancy care that can be provided within the confines of social distancing to limit viral spread . Efforts should be directed toward ongoing follow up of these infants .
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