Tommy’s research centre in Edinburgh

Tommy’s third research centre at the Royal Infirmary of Edinburgh was opened in April 2008. Led by Professor Jane Norman, the focus of the team is on discovering ways to alleviate the risks and problems caused by maternal obesity. Other areas of research interest include blood vessel and tissue remodelling, fetal ‘programming’, inflammation, and the process of labour and childbirth.

Situated in the state-of-the-art buildings of the Queen’s Medical Research Institute, the centre is a huge boost to our research objectives and means Tommy’s maternal and fetal research network is now a truly major force worldwide. It has 23 staff and in the last year published 70 scientific papers in peer-reviewed medical journals.

The centre opened the Tommy’s Metabolic Clinic in August 2008 and it is already providing specialised care to around 200 women per year.

Although the Edinburgh centre is in its infancy, core funding from Tommy’s has already permitted the development of new research threads crucial for better understanding and treatment of complications associated with pregnancy.

Current research areas

Do conditions in the womb ‘programme’ problems in later life?
Many studies have shown that the conditions experienced by the baby in the womb can increase the risk of various diseases in later life. Maternal obesity can also increase the risk of obesity, diabetes and heart disease in the offspring. We are investigating the mechanisms by which maternal obesity affects the long-term health of the offspring.

The effects of stress hormones in obese and non-obese women
Over-exposure of the developing baby to the steroid stress hormone cortisol results in low birthweight. The levels of this hormone increase during normal pregnancy and they are also altered in obesity, but we need to understand how they change in obese pregnant women.

Understanding the link between obesity and pre-eclampsia
Obesity is now recognised as a major risk factor for pre-eclampsia. The mechanisms through which obesity increases the risk are unclear, but we believe it may affect the function of the blood vessels connecting mother and baby. We thus want to analyse this in the laboratory to see whether it can be treated.

The link between obesity and the maternal immune system
One of the reasons why obesity may impact on pregnancy is by hampering the mother’s immune system. So our scientists are investigating this process to see whether there is a way to alleviate the problem.

Progesterone: could it prevent preterm birth?

Although the main focus of the centre is on obesity, it is also handling a major clinical trial (the OPPTIMUM trial) to see whether giving high-risk women progesterone between 22 and 34 weeks of gestation will reduce the incidence of preterm birth.

The Edinburgh Metabolic Clinic

The effects of maternal obesity
With around half the women of childbearing age in the UK now overweight or obese, the impact of obesity in pregnancy continues to be a major issue, both to the immediate outcome in pregnancy and to the long-term health of the child. Government projections for Scotland suggest that, without clear action, obesity figures will rise to almost nine in ten adults and two-thirds of children by 2050. This matters because of the severe impact being overweight or obese can have on an individual’s health – both are associated with an increased risk of diabetes, cancer, heart disease and massive complications during pregnancy. In addition, a report by CEMACH (Confidential Enquiry into Maternal Deaths) has shown that obese pregnant women are probably at four or five times greater risk of maternal death than a woman of normal weight – and the same for their babies dying.

The associated risks in pregnancy for obese women include increased chances of miscarriage, stillbirth, pre-eclampsia, gestational diabetes, neonatal obesity and preterm birth. These preterm babies are at much greater risk of blindness, deafness, cerebral palsy and developmental delay – disabilities which can bring a lifetime of suffering.

Emerging evidence also suggests that maternal obesity has long-term consequences for the baby, including childhood obesity and increased risk of developing heart disease and diabetes in later life. Studies have shown that part of the reason behind this is the poor diet of the mother while pregnant, which in turn makes the baby more likely to crave a similar diet themselves. The baby is, as such, ‘programmed’ in the womb by an adverse fetal environment during pregnancy.

Consequently, this is the first generation in human history where the health of the children will be worse than that of their parents and the cycle of disadvantage is passed from one generation to the next.

The importance of additional clinical care
There is very little help available for people who are obese and pregnant in Scotland. Health professionals rarely intervene, partly because there are very limited options available to help obese people and partly because it often impacts on the midwife or doctor/patient relationship, making individuals less likely to see their midwife or doctor. The situation is exacerbated during pregnancy as women tend to increase weight from one pregnancy to the next.

Tommy’s is determined to tackle the problems of maternal obesity, both through research and through providing high-quality clinical care. The first major achievement of the Edinburgh centre has been to open a new ‘Metabolic Clinic’, jointly funded by Tommy’s, Lothian Health Board and the University of Edinburgh, at which obese mothers are monitored throughout their pregnancy. In addition to providing valuable data for our research scientists, our clinic ensures that these women get a far higher standard of care than they would otherwise.

The clinic is now well established: we currently see about ten women per week and are getting three or four new referrals every week. We are on course to see around 200 women a year, but this may well be exceeded. The clinic is multidisciplinary, with care being provided by obstetricians, endocrinologists, dieticians and a psychiatrist (where appropriate).

Midwifery support underpins the success of the clinic. The midwife liaises with the women, engaging their support to attend the clinic. The care package is arranged by the midwife and tailored to the individual needs of the women. We also have support from the community midwives and the majority of referrals to the clinic come from them.

The enhanced care package includes additional detailed scans and growth scans, glucose tolerance tests (a test for gestational diabetes), post-dates monitoring, a thorough anaesthetist’s assessment, and the prescribing of drugs to prevent deep vein thrombosis.

We are now also setting up post-natal follow-up clinics for mothers and babies who attended the Metabolic Clinic. During these consultations we discuss any problems which occurred during pregnancy, reinforce healthy lifestyle advice for both mother and baby, and discuss issues for future pregnancy.

We are in advanced discussions with Edinburgh Leisure to set up a tailored exercise package for the women attending the Metabolic Clinic. We hope that if we can encourage obese women to take regular exercise during pregnancy then this will have health benefits for them not only during pregnancy but also in the long term for them and their children.

During the initial clinic set-up we sought informal feedback from the women who attended the clinic. This was very positive, with women appreciating the care and additional support provided for them by the clinic.

Meet our Edinburgh research team