Microbiome and Malnutrition in Pregnancy (MMiP)

Active, not recruiting

• Conditions: Weight Gain, Pregnancy; Pregnancy Related; Malnutrition in Pregnancy; Microbial Colonization; Pregnancy Loss; Breastfeeding; Pregnancy Complications; Pregnancy; Parasitic Disease; Parasitic Disease; Infant Malnutrition

• Registration Number: NCT05108675
• Lead Sponsor: Aga Khan University

Brief Summary

Nutritional status during pregnancy plays an important role in maternal health and birth outcomes. While few factors impacting nutritional status during pregnancy have been identified, studies of undernutrition in children have revealed a key role for the gut microbiome. Remarkably, studies examining the dynamics of the maternal gut microbiome before and during pregnancy and its impact on birth outcomes are limited.

This study is being conducted to investigate how a mother's nutritional status and her gut microbiome during pregnancy contribute to the birth outcomes and health of her baby. The gut microbiome is the totality of microorganisms (e.g. bacteria, viruses, fungi) living in the gastrointestinal tract. This study will focus on married pregnant women 24 years and younger living in Matiari District in Pakistan. The focus is on younger women due to their vulnerability to undernutrition. Pregnant participants, and upon delivery, their newborns will be followed throughout pregnancy and for a year afterwards. Throughout this period, the investigators will collect stool samples, rectal swabs, blood samples, health assessments, nutritional and dietary assessments and birth/ labour details. The goal is to define the relationship between a mother's nutritional status and her microbiome dynamics during pregnancy and how they contribute to the birth outcomes and growth of her newborn. Investigators hypothesizes that alterations of the microbiota in the maternal gut (dysbiosis) is exacerbated by nutritional status or pathogen exposure during pregnancy. This impacts weight gain because of impaired nutrient absorption, and can lead to corresponding negative birth outcomes.

Detailed Description

This project represents the first systematic investigation of the impact of the microbiome on nutritional status during pregnancy in young women and directly aligns with global health initiatives focused on this vulnerable cohort. The goal of the study is to define the relationships between host nutritional status and microbiome dynamics during pregnancy and how they contribute to birth outcomes. The gut microbiome has a profound influence on host nutritional status. Dysbiosis (loss of diversity/beneficial microbes and gain of pathobionts) has emerged as a major factor in the development of undernutrition. Despite the importance of nutrition during pregnancy, few studies have examined the role of the microbiome on maternal health and birth outcomes. Further, little is known concerning the influence of enteric eukaryotic microbes, such as parasites, on the bacterial microbiome and host nutrition.

At the core of this study are two complementary cohorts of young women that provide an exceptional opportunity to obtain longitudinal samples to monitor the dynamic relationships between microbiome community structure and function with gut health and host nutritional status. This registration is for the Matiari, Pakistan cohort of the study, where there is known to be a high prevalence of undernutrition among young women. This cohort is expected to yield insights into the influence of eukaryotic microbes that are often viewed as asymptomatic. The target demographic of the study is young, married mothers, ≤24 years in Matiari District within the province of Sindh, Pakistan. Matiari District is representative of rural settings in Pakistan The investigators have identified this younger demographic due to the lack of knowledge on the microbiome of young women, and their vulnerability to undernutrition. A second complementary cohort will be based Toronto, Canada. This project will yield insights into the relationships between prokaryotic and eukaryotic microbes in the gut and their associations with maternal health and birth outcomes.

The central hypothesis of the study is that alterations of the microbiota in the maternal gut (dysbiosis) exacerbated by nutritional status or pathogen exposure during pregnancy, impacts weight gain because of impaired nutrient absorption, leading to corresponding negative birth outcomes.

The study will be a prospective, longitudinal, observational study to investigate the impact and relationship between prokaryotic and eukaryotic microbes in the gut and their association with maternal health and birth outcomes among married young women ≤24 years residing in Matiari District. . The study will aim to recruit 400 women into two groups based on BMI at time of recruitment (normal BMI will be defined as between 20 and 24.9 kg/m2 and low BMI will be defined as less than 20 kg/m2). With a goal of having 200 participants within the normal BMI group and 200 participants within the low BMI group. Although this is the recruitment aim, in the event that the investigators are unable to recruit 200 women with a low BMI, more women will be recruited that fall within the normal BMI range. The study will follow women and their infants over the course of their pregnancy and for a year postpartum, collecting stool, rectal and blood samples, nutritional information, heath assessments, anthropometric measurements and empowerment metrics at different time points.

Study Timeline

• Study First Submitted: 2021-09-22
• Study First Submitted QC: 2021-11-02
• Study First Posted: 2021-11-05
• Study Start: 2021-11-24
• Status Verified: 2023-07
• Last Update Submitted: 2024-07-12
• Last Update Posted: 2024-07-15
• Primary Completion: 2024-12-31
• Study Completion: 2024-12-31

Recruitment & Eligibility

• Status: ACTIVE_NOT_RECRUITING
• Sex: Female
• Target Recruitment: 400

Inclusion Criteria

• Consent provided
• Married female aged 17-24 years
• In good general health, with no comorbidities
• Absence of COVID19 symptoms
• Intend to comply with study procedures and follow up

Exclusion Criteria

• Women who do not meet the enrollment age criteria
• Women participating in interventional clinical trials
• Women who intend to leave the study area
• Women who cannot comply with study procedure's and follow-up
• Illness and other co-morbidities
• Signs of potential COVID19 infection
• BMI higher than 24.9 kg/m2
• Women who already have a member of their household participating
• Women who have taken antibiotics within the past 3 months
• Women who are past 16 weeks post- conception

Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
To determine the correlation between maternal microbiome dysbiosis during pregnancy and birth weight.	At birth	The primary endpoint will be change in birthweight measured in kilograms.
To determine the correlation between maternal microbiome dysbiosis during pregnancy and infant growth	3month, 6month and 12month postpartum	The primary endpoint will be change in WHO z-scores during first year of infant's life. These z-scores will be calculated for weight (measured in kg), length and head circumference (measured in cm).
To assess if alterations of the microbiota in the maternal gut (dysbiosis) are corelated with changes in maternal gestational weight gain	8-20 weeks post-conception, 30-34 weeks post-conception	The primary endpoint will be the change in maternal gestational weight gain (GWG) during pregnancy, measured between the first (8-16 weeks post-conception) and second time point (30-34 weeks post-conception)

Secondary Outcome Measures

Name	Time	Method
Infant morbidity	at 3 months, 6 months and 12 months	Assessed through infant health assessment questionnaire
Infant growth: weight	within 72 hours of birth, 3 months, 6 months and 12 months	Measured in kg
Infant growth: length	within 24 hours of birth, 3 months, 6 months and 12 months	Measured in cm
Infant growth: mid upper arm circumference	within 72 hours of birth, 3 months, 6 months and 12 months	Measured in cm
Infant growth: triceps skinfold thickness	within 72 hours of birth, 3 months, 6 months and 12 months	Measured in mm
Maternal age	8-16 weeks post conception	Age between 17-24 years documented through national ID card, school certificate or through maternal recall
Delivery Assessment	at birth within 72 hours of birth	Questionnaire, mode of delivery, place of birth and other description around delivery
Anthropometrics: Maternal height	8-16 weeks post conception, 30-34 weeks post conception, delivery, 3 months post-partum and 12 months post partum	measured in cm
Maternal blood biomarker-4	8-16 weeks post-conception, 30-34 weeks post-conception, and 12 months post-partum	Concentration of CRP in blood, measured in mg/dL, marker of inflammation .
Anthropometrics	8-16 weeks post-conception, 30-34 weeks post-conception, delivery, 3-months post-partum, 6 months post-partum and 12 months post-partum ]	Maternal BMI
Infant blood biomarker-1	1 year infant age	Concentration of HB in g/dL, marker of anemia.
Infant blood biomarker-3	1 year infant age	Concentration of Ferritin in serum measured in ng/mL, marker of iron stores in blood.
Perceived parental stress	3 months post-partum and 12 months post partum	Perceived parental stress will be measured using the Perceived Stress Scale (PSS-10)
Small for gestational age	At birth within 72 hours	Small-for-gestational-age (\<10th percentile of weight-for-gestational-age and sex as defined by Intergrowth standards)
Maternal stool biomarkers-1	At baseline 8-16 weeks post conception and 30-34 weeks post conception	Level of Calprotectin in stool a marker of intestinal inflammation, measured in μg/g.
Maternal: metabolomic profile of stool [Metabolites involved in central metabolism as analysed by Mass Specttrometry]	Baseline, 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum	Analysis of the core metabolites involved in central metabolism. These metabolites will be analysed through Mass Spec and include short chain fatty acids, amino acids, intermediates in energy metabolism and nucleotide biosynthesis
Maternal bacterial gene expression profile	Baseline 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum ]	as measured through whole microbiome RNASeq (metatranscriptomics) - The output of these analyses are readouts of microbial gene expression detailing biochemical activities as well as the taxa responsible.
Anthropometrics: Maternal middle upper arm circumference	8-16 weeks post-conception, 30-34 weeks post-conception, 3-months post-partum,and 12 months post-partum	Measured in cm
Maternal blood biomarker-3	8-16 weeks post-conception, 30-34 weeks post-conception, and 12 months post-partum	Concentration of Ferritin in serum measured in ng/mL, marker of iron stores in blood.
Infant blood biomarker-2	1 year infant age	Level of MCV in whole blood measured in femtoliters (fL).
Infant blood biomarker-4	1 year infant age	Concentration of CRP in blood, measured in mg/dL, marker of inflammation .
Maternal morbidity	8-16 weeks post-conception, 30-34 weeks post-conception, 3 months post-partum, 6 months post-partum and 12 months post-partum	Assessed through health assessment questionnaire
Reported Maternal medicinal use	8-16 weeks post-conception, 30-34 weeks post-conception, 3-months post-partum, 6 months post-partum and 12 months post-partum	Questionnaire
Household annual food insecurity	3 months post-partum and 12 months post-partum	Food insecurity will be assessed using the Household Food Insecurity Access Scale (HFIAS)
Perceived social support	3 months post-partum and 12 months post partum	Perceived social support will be measured using the Multi-dimensional Scale of Perceived Social Support (MSPSS), developed by Zimet et al.
Preterm Births	At birth within 72 hours	Gestational age at birth in weeks
Anthropometrics: Maternal triceps skinfold thickness	8-16 weeks post-conception, 30-34 weeks post-conception, 3-months post-partum, and 12 months post-partum	Measured in mm
Anthropometrics: Maternal weight	8-16weeks post conception, 30-34 weeks post conception, delivery, 3 months post-partum and 12 months post-partum	measured in kg
Maternal blood biomarker-2	8-16 weeks post-conception, 30-34 weeks post-conception, and 12 months post-partum	Level of MCV in whole blood measured in femtoliters (fL).
Gestational age at birth	Within 72 hours of birth	Measured in weeks
Food insecurity	Baseline 8-16 weeks post conception, 3 months post partum and 12 months post partum	Questionnaire developed by Hager, E.R., et al., Development and validity of a 2-item screen to identify families at risk for food insecurity.
Maternal: incidence of pathobionts	Baseline, 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum	As identified through 16S, 18S and ITS rDNA surveys
Maternal gut bacteria profile	Baseline, 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum	Measured through 16S rDNA sequence surveys
Maternal: blood metallomics profile	Baseline, 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum	Measured through ICP-MS (https://www.metabolomicscentre.ca/new_service/25) - TMIC platform of metabolmics
Maternal eukaryotic microbiome profile	Baseline 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum ]	as measured through 18S and ITS rDNA sequence surveys
Maternal blood biomarker-1	8-16 weeks post-conception, 30-34 weeks post-conception, and 12 months post-partum	Concentration of HB in g/dL, marker of anemia.
Breast feeding	at birth within 72 hours, 3 months, 6 months and 12 months	amount and initiation of breast feeding, top milk, formula milk and complementary feeding Based off of WHO 2010 Guidelines: Indicators for assessing infant and young child feeding practices (Part 2 Measurement)
Reported Infant medication use	at birth within 72 hours, 3 months, 6 months and 12 months	Questionnaire
Maternal dietary intake Assessed through ASA 24 HR Dietary Recall system, completed 2x each time point	Baseline 8-16 weeks post conception, 30-34 weeks post conception and 12 months post partum	Assessed through ASA 24 HR Dietary Recall system
Perceived decision making	3 months post-partum and 12 months post partum	Questions pertaining to perceived decision-making are from the Pakistan Demographic and Health Survey (PDHS)
Maternal demographics	Baseline 8-16 weeks post-conception	Questions pertaining to demographic data are adapted from the Pakistan Demographic and Health Survey (PDHS)
Infant dietary intake	Infant age 1 year	NutricheQ Questionnaire: a tool designed for toddlers aged 1 to 3 years of age, with a focus on markers for inadequate or excessive intake and dietary imbalances
Maternal stool biomarkers-2	At baseline 8-16 weeks post conception, 30-34 weeks post conception	Concentration of Claudin 15 in stool a marker of intestinal permeability measured in ng/mL.
Maternal stool biomarkers-3	At baseline 8-16 weeks post conception and 30-34 weeks post conception	Concentration of Lipocalin in stool, a marker of gut inflammation, measured in μg/mL.
Infant: incidence of pathobionts	3 and 12 month	As identified through 16S, 18S and ITS rDNA surveys
Maternal metabolic pathway expression profile	Baseline 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum	as measured through whole microbiome RNASeq (metatranscriptomics)
Infant eukaryotic microbiome profile	3 & 12 Months	as measured through 18S and ITS rDNA sequence surveys
Large for gestational age	At birth within 72 hours	\>90th percentile of weight-for-gestational-age and sex as defined by Intergrowth standards)
Infant sex	At birth	Male Female
Infant growth: head circumference	within 72 hours of birth, 3 months, 6 months and 12 months	Measured in cm
Dietary diversity	Baseline 8-16 weeks post conception, 30-34 weeks post conception, 3 months post-partum and 12 months post partum	Minimum Dietary Diversity Score for Women (MDD-W)
Generalized Self-efficacy	3 months post-partum and 12 months post partum	Self-efficacy will be measured using the Generalized Self-Efficacy scale, developed by Schwarzer and Jerusalem. A 10 item psychometric scale.
Infant: blood metallomics profile	Infant age 1 year	as measured through ICP-MS (https://www.metabolomicscentre.ca/new_service/25) Through TMIC platform
Infant: gut bacterial profile	3 month and 12 month	Measured through 16S rDNA sequence surveys
Maternal: microbiome taxonomic alpha and beta diversity	Baseline 8-16 weeks post conception, 30-34 weeks post conception, 3 months post partum and 12 months post partum ]	To define taxonomic diversity, species profiles from 16S, 18S and ITS rDNA data will be clustered to identify differences in community structure across samples. Alpha diversity will be measured through indices such as Chao, Shannon and Simpson indices. Beta diversity will be measured through standard indices such as Bray-Curtis distances.
Infant: microbiome taxonomic alpha and beta diversity	3 and 12 months postpartum	To define taxonomic diversity, species profiles from 16S, 18S and ITS rDNA data will be clustered to identify differences in community structure across samples. Alpha diversity will be measured through indices such as Chao, Shannon and Simpson indices. Beta diversity will be measured through standard indices such as Bray-Curtis distances.

Trial Locations

Locations (1)

Research and Training Centre Matiari, Aga Khan University; 🇵🇰 Karachi, Sindh, Pakistan