Association between pre-pregnancy obesity and the risk of cesarean delivery

Perinatal Outcomes Among Patients Using OB Teleflex, A Hybrid Prenatal Telemedicine Program

OBJECTIVES

To assess obstetric outcomes among participants of the OB Teleflex program, in which roughly half of prenatal care was virtual, compared to those who were eligible, but elected traditional prenatal care.

METHODS

This retrospective cohort study of patients who delivered between October 1, 2021, and September 30, 2022, compared OB Teleflex participation to routine prenatal care. Low-risk patients with a singleton, viable, non-anomalous fetus, and without hypertension requiring medication, were eligible for OB Teleflex and included in the study. Inverse-probability weighting was used to obtain unbiased estimates of the program effect on a composite of adverse outcomes that included primary cesarean delivery, neonatal intensive care unit admission, preterm birth, insufficient gestational weight gain, and hypertensive disorders of pregnancy.

RESULTS

Out of 674 patients who delivered at our centre during the study period, 347 were eligible for OB Teleflex and met the study criteria. Of the 347 patients eligible for OB Teleflex, 63 (18%) chose to participate in the program. Those who elected OB Teleflex compared to those who did not, differed by race, parity, and history of cesarean deliveries. In both adjusted and unadjusted analyses of the composite of adverse outcomes, there was no difference between OB Teleflex participants and those receiving standard care.

CONCLUSIONS

Hybrid prenatal telemedicine did not differ from standard prenatal care in the rate of adverse maternal and perinatal outcomes. Programs like OB Teleflex may help to remove barriers from care without worsening birth outcomes. Larger studies are needed to investigate whether hybrid prenatal care can improve outcomes.

Intrapartum care and management of complications in women with obesity

Pregnant women with obesity are at considerable risk during their labor and delivery. The aim of obstetric care is the safe delivery of the baby and the maintenance of good health of the mother while providing an ongoing support for the family unit. The awareness and mitigation of risks associated with caring for women who are obese is vital in ensuring continued good outcomes. Transfer of women for labor care, presence of senior staff, bariatric resources, understanding of the progress of labor with an increase in body mass index, and preparation for complications are covered in this chapter.

Impact of prepregnancy body mass index on adverse pregnancy outcomes: analysis from the Longitudinal Indian Family hEalth cohort study

BACKGROUND

Both high and low maternal prepregnancy body mass index can lead to suboptimal fetal growth and risk of pregnancy complications. In developed countries, nearly half of all women of childbearing age are either overweight or obese, and most data linking maternal body mass index and adverse pregnancy complications are limited to these populations.

OBJECTIVE

This study aimed to prospectively evaluate the relationships between prepregnancy body mass index and adverse pregnancy outcomes using the Longitudinal Indian Family hEalth (LIFE) study.

STUDY DESIGN

We modeled the relationships between prepregnancy body mass index and adverse pregnancy outcomes such as low birthweight, preterm birth, cesarean delivery, intrauterine growth restriction, miscarriage, and fetal death among 675 women aged 15 to 35 years with singleton pregnancies in the Longitudinal Indian Family hEalth study, a population-based prospective pregnancy cohort study conducted in Telangana, India. Prepregnancy body mass index was calculated as weight in kilograms divided by height in meters squared and was classified into 4 categories using the World Health Organization recommendations for Asian adults. Prepregnancy body mass index was assessed at a mean of 12.3 months before pregnancy. Odds ratios and 95% confidence intervals of adverse pregnancy outcomes were modeled and adjusted for confounders.

RESULTS

Obese women had a 3-fold increased risk of cesarean delivery (odds ratio, 3.13; 95% confidence interval, 1.56-6.29) compared with normal-weight women. Those who were overweight also had a marginally increased risk of cesarean delivery, albeit not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.61-2.24). Underweight women had a modestly increased risk of low birthweight, compared with normal-weight women (odds ratio, 1.12; 95% confidence interval, 0.71-1.77), although results were not significant. Conversely, obese (odds ratio, 0.71; 95% confidence interval, 0.28-1.77) and overweight (odds ratio, 0.61; 95% confidence interval, 0.24-1.51) women had a marginally decreased risk of low birthweight.

CONCLUSION

Our data suggest that women with elevated prepregnancy body mass index may have a higher risk of adverse pregnancy outcomes, especially cesarean delivery. Although this study has limited generalizability, our findings are generalizable to rural to periurban regions of India. Further studies exploring the translatability of these findings to other populations are needed. In addition, targeted prepregnancy intervention studies and programs that include counseling on optimization of preconception health and lifestyle modification for improvement of subsequent pregnancy outcomes among overweight and obese women are needed.

The association between adolescent obesity and later gestational diabetes in military personnel: A retrospective cohort study

BACKGROUND

The association between body mass index (BMI) in adolescence and gestational diabetes mellitus (GDM) has not been completely delineated. The purpose of our study was to determine the extent by which adolescent obesity increases the risk for developing GDM later in life.

METHODS

A retrospective cohort study including all army personnel pregnancies occurring between the years 2009-2019 was conducted. Adolescent BMI of participants was available using pre-recruitment army records. GDM and other pregnancy outcomes were compared between two groups: adolescent BMI below 30 (comparison group) and that of 30 or more (exposed group). Multivariable models were adjusted for sociodemographic factors.

RESULTS

Following exclusion of cases with missing or partial glucose tests, and undocumented BMI, 6877 deliveries were included in the analysis. GDM rates were higher in the exposed group (4.9% vs. 2.9%, p value-0.09). GDM rates were twice as common in the exposed group (4.9% vs. 2.9%, p value-0.09). The multivariable model, adjusted for country of birth, socio-economic class, medical profile score, maternal age, and follow-up time, confirmed an independent association between adolescent obesity and later GDM, with an adjusted odds ratio of 2.22 (CI 1.1-4.5, p value - 0.03).

CONCLUSION

Obesity during the adolescent years is independently associated with gestational diabetes later in life.

Contractions: Traditional concepts and their role in modern obstetrics

Contractions are produced through a complex interplay of hormonal, mechanical, and electrical factors. In labor, contractions are measured using the Montevideo unit. Clinical considerations in labor wherein contraction assessment becomes paramount include the care of women whose labor is complicated by abnormal progress or tachysystole. In an era of obstetrics in which the high cesarean rate is a major issue of concern, there remain many questions as to how to best incorporate contraction monitoring into practice in order to optimize care. Technological advancement has led to the development on new modalities that can be used to study contraction physiology, and there may be an opportunity in the future to apply these methods for use in the clinical setting. This article also makes a case for the need to reevaluate the current measures of uterine contractile activity and the definition of contraction adequacy using updated definitions of normal labor progress.

Successful versus unsuccessful instrumental deliveries-Predictors and obstetric outcomes

OBJECTIVE

The purpose of this study was to examine instrumental births in a multi-ethnic population to assess the factors associated with success and failure in instrumental births.

STUDY DESIGN

This was a large retrospective study of 7954 women that underwent either a successful or an unsuccessful instrumental delivery in a single centre over a 10 year period.

RESULTS

Logistic regression analysis showed that women with a BMI of more than 30, attempted Forceps delivery, having a prolonged second stage, Macrosomia (birth weight more than 4 kg) and a senior obstetrician performing the procedure increase the risk of a failed instrumental delivery. While age, ethnicity, type of anaesthesia, use of oxytocin or induction of labour did not provide a significant outcome. Results also showed that patients are likely to bleed more and neonates need admission in failed instrumental deliveries when compared to successful attempts.

CONCLUSION

This is one of a very few studies comparing a large cohort of successful instrumental births with unsuccessful attempts at an instrumental birth. The rate of failure has been difficult to reduce, and the analysis shows that many of the factors associated with failure are not modifiable in labour. We should consider studies with use of ultrasound assessment before application or consideration of instruments to facilitate birth. This will allow us to objectively come up with an algorithm to predict success or failure and consider if it is suitable to attempt an instrumental birth. Our data can be used to counsel women about the difficulty in predicting success and failure rate of instrumental births.

A cohort study of maternal cardiometabolic risk factors and primary cesarean delivery in an integrated health system

BACKGROUND

Maternal cardiometabolic risk factors (i.e., hyperglycemia, pre-existing hypertension and high body mass index) impact fetal growth and risk of having a cesarean delivery. However, the independent and joint contribution of maternal cardiometabolic risk factors to primary cesarean section is unclear. We aimed to elucidate the degree to which maternal cardiometabolic risk factors contribute to primary cesarean deliveries and whether associations vary by infant size at birth in an integrated health system.

METHODS

A cohort study of 185,045 singleton livebirths from 2001 to 2010. Poisson regression with robust standard errors provided crude and adjusted relative risks (RR) and 95% confidence intervals (CIs) for cesarean delivery risk associated with risk factors. We then estimated the proportion of cesarean sections that could be prevented if the cardiometabolic risk factor in pregnant women were eliminated (the population-attributable risk [PAR]).

RESULTS

In a single multivariable model, maternal cardiometabolic risk factors were independently associated with cesarean delivery: RR (95% CI) abnormal glucose screening 1.04 (1.01-1.08); gestational diabetes 1.18 (1.11-1.18) and pre-existing diabetes 1.60 (1.49-1.71); pre-existing hypertension 1.16 (1.10-1.23); overweight 1.27 (1.24-1.30); obese class I 1.46 (1.42-1.51); obese class II 1.73 (1.67-1.80); and obese class III 1.97 (1.88-2.07); adjusting for established risk factors, medical facility and year. The associations between maternal cardiometabolic risk factors and primary cesarean delivery remained among infants with appropriate weights for gestational age. The PARs were 17.4% for overweight/obesity, 7.0% for maternal hyperglycemia, 2.0% for pre-existing hypertension and 20.5% for any cardiometabolic risk factor.

CONCLUSIONS

Maternal cardiometabolic risk factors were independently associated with risk of primary cesarean delivery, even among women delivering infants born at an appropriate size for gestational age. Effective strategies to increase the proportion of women entering pregnancy at an optimal weight with normal blood pressure and glucose before pregnancy could potentially eliminate up to 20% of cesarean deliveries.

The Association Between Low 50 g Glucose Challenge Test Values and Adverse Pregnancy Outcomes

BACKGROUND

The implications of low values on the 50 g glucose challenge test (GCT) in pregnancy are not clearly defined. Few studies have evaluated the influence of maternal low GCT values on obstetrical outcomes. This study aimed to compare pregnancy outcomes between women with low 50 g GCT values and those with normal values.

MATERIALS AND METHODS

Women undergoing gestational diabetes mellitus screening at 24-28 weeks of gestational age between January 2010 and December 2016 were retrospectively evaluated. Women with multifetal pregnancies, prepregnancy type I or II diabetes, GCT performed before 24 or after 28 weeks of gestational age, and women undergoing multiple GCTs in the same pregnancy were excluded. Low GCT values and normal GCT values were defined as ≤85 mg/dL and 86-130 mg/dL, respectively.

RESULTS

Of 3875 screened subjects, 519 (13.4%) women were included in the low GCT group and 3356 (86.6%) in the normal GCT group. Low GCT women had a significantly higher rate of small for gestational age (SGA) infants than normal GCT women (10.8% vs. 7.9%, p = 0.02). Cesarean section and postpartum hemorrhage (PPH) were less frequent in low GCT women than in normal women (32.6% vs. 42.8%, p < 0.01 and 0.2% vs. 1.2%, p = 0.03, respectively). Low GCT women had a 1.38-fold increased risk of bearing SGA infants (95% confidence intervals: 1.01-1.88, p = 0.04).

CONCLUSIONS

Rate of SGA infants was significantly higher and cesarean delivery and PPH rates were significantly lower in women with low GCT values. Low GCT values were independently associated with an increased risk of SGA.

Indications for primary cesarean delivery relative to body mass index

BACKGROUND

Obesity is a known risk factor for cesarean delivery. Limited data are available regarding the reasons for the increased rate of primary cesarean in obese women. It is important to identify the factors leading to an increased risk of cesarean to identify opportunities to reduce the primary cesarean rate.

OBJECTIVE

We evaluated indications for primary cesarean across body mass index (kg/m(2)) classes to identify the factors contributing to the increased rate of cesarean among obese women.

STUDY DESIGN

In the Consortium of Safe Labor study from 2002 through 2008, we calculated indications for primary cesarean including failure to progress or cephalopelvic disproportion, nonreassuring fetal heart tracing, malpresentation, elective, hypertensive disease, multiple gestation, placenta previa or vasa previa, failed induction, HIV or active herpes simplex virus, history of uterine scar, fetal indication, placental abruption, chorioamnionitis, macrosomia, and failed operative delivery. For women with primary cesarean for failure to progress or cephalopelvic disproportion, dilation at the last recorded cervical examination was evaluated. Women were categorized according to body mass index on admission: normal weight (18.5-24.9), overweight (25.0-29.9), and obese classes I (30.0-34.9), II (35.0-39.9), and III (≥40). Cochran-Armitage trend test and χ(2) tests were performed.

RESULTS

Of 66,502 nulliparous and 76,961 multiparous women in the study population, 19,431 nulliparous (29.2%) and 7329 multiparous (9.5%) women underwent primary cesarean. Regardless of parity, malpresentation, failure to progress or cephalopelvic disproportion, and nonreassuring fetal heart tracing were the common indications for primary cesarean. Regardless of parity, the rates of primary cesarean for failure to progress or cephalopelvic disproportion increased with increasing body mass index (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 33.2%, 41.6%, 46.4%, 47.4%, and 48.9% [P < .01] and multiparous women: 14.5%, 20.3%, 22.8%, 27.2%, and 25.3% [P < .01]), whereas the rates for malpresentation decreased (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 23.7%, 17.2%, 14.6%, 12.0%, and 9.1% [P < .01] and multiparous women: 35.6%, 30.6%, 26.5%, 24.3%, and 22.9% [P < .01]). Rates of primary cesarean for nonreassuring fetal heart tracing were not statistically different for nulliparous (P > .05) or multiparous (P > .05) women. Among nulliparous women who had a primary cesarean for failure to progress or cephalopelvic disproportion, rates of cesarean prior to active labor (6 cm) increased as body mass index increased, accounting for 39.3% of women with class I, 47.1% of women with class II, and 56.8% of women with class III obesity compared to 35.2% for normal-weight women (P < .01).

CONCLUSION

Similar to normal-weight women, the indication of cesarean for failure to progress or cephalopelvic disproportion was the major factor contributing to the increase in primary cesarean in obese women, but was even more prevalent with increasing obesity class. The rates of intrapartum primary cesarean prior to achieving active labor increased with increasing obesity class in nulliparous women.

Gestational diabetes in the United States: temporal changes in prevalence rates between 1979 and 2010

OBJECTIVE

To examine age-period-cohort effects on trends in gestational diabetes mellitus (GDM) prevalence in the US, and to evaluate how these trends have affected the rates of stillbirth and large for gestational age (LGA)/macrosomia.

DESIGN

Retrospective cohort study.

SETTING

USA, 1979-2010.

POPULATION

Over 125 million pregnancies (3 337 284 GDM cases) associated with hospitalisations.

METHODS

Trends in GDM prevalence were examined via weighted Poisson models to parse out the extent to which GDM trends can be attributed to maternal age, period of delivery, and maternal birth cohort. Multilevel models were used to assess the contribution of population effects to the rate of GDM. Log-linear Poisson regression models were used to estimate the contributions of the increasing GDM rates to changes in the rates of LGA and stillbirth between 1979-81 and 2008-10.

MAIN OUTCOME MEASURES

Rates and rate ratios (RRs).

RESULTS

Compared with 1979-1980 (0.3%), the rate of GDM has increased to 5.8% in 2008-10, indicating a strong period effect. Substantial age and modest cohort effects were evident. The period effect is partly explained by period trends in body mass index (BMI), race, and maternal smoking. The increasing prevalence of GDM is associated with a 184% (95% CI 180-188%) decline in the rate of LGA/macrosomia and a 0.75% (95% CI 0.74-0.76) increase in the rate of stillbirths for 2008-10, compared with 1979-81.

CONCLUSIONS

The temporal increase in GDM can be attributed to period of pregnancy and age. Increasing BMI appears to partially contribute to the GDM increase in the US.

TWEETABLE ABSTRACT

The increasing prevalence of GDM can be attributed to period of delivery and increasing maternal age.

The risk of emergency cesarean section after failure of vaginal delivery according to prepregnancy body mass index or gestational weight gain by the 2009 Institute of Medicine guidelines

Objective

To evaluate the risk of emergency cesarean section according to the prepregnancy body mass index (BMI) and gestational weight gain per the 2009 Institute of Medicine guidelines.

Methods

A retrospective analysis of data from 2,765 women with singleton full-term births (2009 to 2012) who attempted a vaginal delivery was conducted. Pregnancies with preeclampsia, chronic hypertension, diabetes, planned cesarean section, placenta previa, or cesarean section due to fetal anomalies or intrauterine growth restriction were excluded. Odds ratios (ORs) and confidence intervals (CIs) for emergency cesarean section were calculated after adjusting for prepregnancy BMI or gestational weight gain.

Results

Three-hundred and fifty nine (13.0%) women underwent emergency cesarean section. The adjusted OR for overweight, obese, and extremely obese women indicated a significantly increased risk of cesarean delivery. Gestational weight gain by Institute of Medicine guidelines was not associated with an increased risk of cesarean delivery. However, inadequate and excessive weight gain in obese women was highly associated with an increased risk of emergency cesarean section, compared to these in normal BMI (OR, 5.56; 95% CI, 1.36 to 22.72; OR, 3.63; 95% CI, 1.05 to 12.54; respectively), while there was no significant difference between normal BMI and obese women with adequate weight gain.

Conclusion

Obese women should be provided special advice before and during pregnancy for controlling weight and careful consideration should be needed at the time of vaginal delivery to avoid emergency cesarean section.

Obesity and normal birth: A qualitative study of clinician's management of obese pregnant women during labour

BACKGROUND

Currently one-fifth of women in the UK are obese. Obese, pregnant woman are at an increased risk of experiencing complications of labour and serious morbidity. However, they are also more likely to undergo medical interventions such as induction of labour and caesarean section which in themselves confer additional health risks for obese women such as wound infection and deep vein thrombosis. Reducing unnecessary interventions and increasing normal birth rates for obese women would substantially improve their postnatal health and wellbeing and reduce the burden of NHS resources required to care for them post operatively. This research aimed to explore practitioners' experiences of and strategies for providing intrapartum care to obese women.

METHOD

A qualitative methodology was adopted, focus groups and individual interviews were conducted with health professionals. Audio recordings were transcribed verbatim and data analysed using a framework approach.

RESULTS

Twenty-four health professionals participated; Six Consultant Obstetricians two Consultant Anaesthetists and 16 midwives. Three key themes emerged from the data: medicalisation of obese birth; promotion of normal obese birth; and the complexities and contradictions in staff attitudes and behaviours. The overall interpretation is that positive approaches to obese birth offer opportunities to promote normal birth. However, many health professionals find the provision of intrapartum care to obese women challenging, and attitudes and behaviours towards the promotion of normal birth are heterogeneous, complex and contradictory.

CONCLUSION

The care of obese women during labour is generally medicalised and focussed on the associated risks. However, although there are conflicting views on how to care for obese women, some practitioners do strive to promote normality and optimise the potential for normal birth by challenging current practices and utilise some 'interventions' in order to facilitate normality and mobility during childbirth. Obesity is a major and growing health problem and a major cause of morbidity and mortality for pregnant women. It is essential that more positive proactive guidelines are available to maximise normal birth if the postnatal health of obese women is to be improved.

Prevalence and Associated Risk Factors for Obesity During Pregnancy Over Time

Objective: The increasing prevalence of obesity is having an impact on morbidity worldwide. Since young mature women are equally affected by the general increase in weight, the aim of the study was to evaluate the prevalence of obesity together with associated maternal risk factors, complications during pregnancy, and fetal outcomes in a local cohort for the years 2006 and 2011. Study Design: Maternal and fetal records of women who delivered at the University of Würzburg, with a 5-year interval (2006 and 2011) between investigations, were retrospectively analyzed. Descriptive statistics included prevalence of obesity, maternal weight gain, as well as several complications during pregnancy and fetal characteristics. The association between maternal or fetal complications and extent of maternal obesity was analyzed. Results: Our analysis included 2838 mothers with singleton pregnancies who delivered in 2006 (n = 1293) or 2011 (n = 1545) in our department. We found that neither pre-pregnancy body mass index (23.77 ± 4.85 vs. 24.09 ± 5.10 kg/m², p = 0.25) nor weight gain (14.41 ± 5.77 vs. 14.78 ± 5.65 kg; p = 0.09) increased significantly over time. But the majority of all overweight (71 %) or obese (60.4 %) mothers gained more weight than generally recommended. The prevalence of gestational diabetes, gestational hypertension, and preeclampsia increased significantly and was associated with high pre-pregnancy body mass index, as was delivery by cesarean section. However, obesity was not associated with prolonged pregnancy and did not seem to negatively affect fetal outcome. Conclusion: There is a trend to increasing weight gain during pregnancy, and the majority of mothers, especially those with a high pre-pregnancy body mass index, exceeded the weight gain recommendations. Associated risk factors such as gestational diabetes, hypertension, and delivery by cesarean section are increasing.

Large for Gestational Age Births Among South Indian Women: Temporal Trend and Risk Factors from 1996 to 2010

BACKGROUND/PURPOSE

Mean birth weight is a good health indicator for any population. In the recent past, there have been many reports in the West indicating that there has been an increase in the proportion of large for gestational age (LGA) babies. The objective is to describe the change in the incidence of LGA babies from 1996 to 2010 in South India and the maternal risk factors.

METHODS

A rotational sampling scheme was used, i.e., the 12 months of the year were divided into 4 quarters and a month was from each quarter was selected rotationally. All deliveries for that month were considered. Only deliveries that occurred between 28 and 42 weeks of pregnancy were considered. The association between risk variables was studied using multivariable logistic regression.

RESULTS

There were 35,718 deliveries that occurred during these 15-year-study period in the gestational age 28-42 weeks were registered through the outpatient clinics. The incidence of LGA was 9.4 % that has mostly remained at the same level. The incidence of LGA in mothers with gestational diabetes was 6.7, 3 and 17.6 % in overweight, obese and gestational l diabetes mothers. Overweight, obesity in pregnant women and cesarean section were significant risk factors.

CONCLUSION

Unlike in Western countries, where the incidence of LGA babies has spiraled upward, has remained nearly at the same level over one and a half decades, in South India. The risk factors for giving birth to LGA babies in South India were similar to other studies.

Effect of oleic acid supplementation on prostaglandin production in maternal endometrial and fetal allantochorion cells isolated from late gestation ewes

INTRODUCTION

Elevated circulating non-esterified fatty acids including oleic acid (OA) are associated with many pregnancy related complications. Prostaglandins (PGs) play crucial roles during parturition. We investigated the effect of OA supplementation on PG production using an in vitro model of ovine placenta.

METHODS

Maternal endometrium (ME) and fetal allantochorion (FC) were collected in late pregnancy (day 135). Confluent cells were cultured in serum-free medium supplemented with 0, 20 or 100 μM OA and challenged with control medium, oxytocin (OT, 250 nM), lipopolysaccharide (LPS, 0.1 μg/ml) or dexamethasone (DEX, 5 μM). Spent medium was harvested at 2 and 24 h after challenge for quantifying PGs.

RESULTS

In ME cells OA increased PGE2 production moderately but attenuated PGF2α production leading to a doubling of the PGE2:PGF2α ratio (E:F) (P < 0.01). Without OA, both OT and LPS stimulated PG production for about 3-fold (P < 0.01) without changing the E:F ratio. In the ME cells challenged with OT, OA decreased both PGE2 and PGF2α production by up to 70% (P < 0.01) whereas in LPS treated cells OA increased the E:F ratio. In FC cells PGE2 production at 2 h was stimulated by 100 μM OA (P < 0.05). In these cells LPS caused a 3-fold increase in PGE2 (P < 0.01), an effect which was completely inhibited by DEX.

DISCUSSION

OA supplementation favours basal PGE2 production in both ME and FC. In ME OA increased E:F ratios and antagonized the stimulatory effect of OT on PG production. This suggests that raised circulating OA may affect both the initiation and progression of parturition.

The effects of morbid obesity on maternal and neonatal health outcomes: a systematic review and meta-analyses

Morbidly obese (Class III, body mass index [BMI] ≥ 40 kg m(-2)) women constitute 8% of reproductive-aged women and are an increasing proportion; however, their pregnancy risks have not yet been well understood. Hence, we performed meta-analyses following the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) guideline, searching Medline and Embase from their inceptions. To examine graded relationships, we compared Class III obesity to Class I and I/II, and separately to normal weight. We found important effects on all three primary outcomes in morbidly obese women: preterm birth <37 weeks was 31% higher compared with Class I (relative risk [RR] 1.31 [1.19, 1.43]) and 20% higher than Class I/II (RR 1.20 [1.13, 1.27]), large-for-gestational age was higher (RR 1.37 [1.29, 1.45] and RR 1.30 [1.24, 1.36] compared with Class I and I/II, respectively), while small-for-gestational age was lower (RR 0.89 [0.84, 0.93] compared with Class I, with nearly identical reductions for Class I/II). Morbidly obese women have higher risks of preterm birth, large-for-gestational age and numerous other adverse maternal and infant health outcomes, relative to not only normal weight but also Class I or I/II obese women. These findings have important implications for screening and care of morbidly obese pregnant women, to try to decrease adverse outcomes.

Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis

OBJECTIVE

To determine whether caesarean delivery in the first pregnancy is a risk factor for unexplained antepartum stillbirth in a second pregnancy.

DESIGN

A population-based retrospective cohort study and meta-analysis.

SETTING

All maternity units in Scotland.

PARTICIPANTS

A cohort of 128 585 second births, 1999-2008.

METHODS

Time-to-event analysis and random-effects meta-analysis.

MAIN OUTCOME MEASURE

Risk of unexplained antepartum stillbirth in a second pregnancy.

RESULTS

There were 88 stillbirths among 23 688 women with a previous caesarean delivery (2.34 per 10 000 women per week) and 288 stillbirths in 104 897 women who had previously delivered vaginally (1.67 per 10 000 women per week, P = 0.002). When analysed by cause, women with a previous caesarean delivery had an increased risk of unexplained stillbirth (hazard ratio, HR 1.47; 95% confidence interval, 95% CI 1.12-1.94; P = 0.006) and, as previously observed, the excess risk was apparent from 34 weeks of gestation onwards. The risk did not differ in relation to the indication of the caesarean delivery, and was independent of maternal characteristics and previous obstetric complications. We identified three other comparable studies (two in North America and one in Europe), and meta-analysis of these studies showed a statistically significant association between previous caesarean delivery and the risk of antepartum stillbirth in the second pregnancy (pooled HR 1.40; 95% CI 1.10-1.77; P = 0.006).

CONCLUSIONS

Women who have had a previous caesarean delivery are at increased risk of unexplained stillbirth in the second pregnancy.

TWEETABLE ABSTRACT

Caesarean first delivery is associated with an increased risk of unexplained stillbirth in the next pregnancy.

Clinical and sonographic parameters at mid-trimester and the risk of cesarean delivery in low-risk nulliparas

BACKGROUND

To examine the potential clinical and sonographic parameters at mid-trimester that predict the risk of intrapartum cesarean delivery at term among low-risk nulliparas.

METHODS

This prospective study recruited nulliparas with singleton low-risk pregnancies at 20.0-24.0 weeks. Sonographic measurement of the cervical length and fetal biometry was performed. The data collected at enrollment included maternal age, measured weight at first prenatal visit to the hospital, current weight, height, fetal biometric parameters, and cervical length. A multivariate analysis was conducted, with control for known intra- and postpartum confounding factors associated with cesarean delivery, including sex of the fetus.

RESULTS

Based on multivariate analyses of 652 women, of all variables at mid-trimester, only maternal height was significantly associated with increased risk of cesarean delivery (61, 9.4%), whereas for intra- or postpartum variables, induction of labor, epidural analgesia, male gender, and nightshift delivery showed statistically significant association with the risk of cesarean delivery.

CONCLUSIONS

Maternal height and fetal gender, as measured at mid-trimester, are potential independent predictors for the risk of intrapartum cesarean delivery at term in low-risk nulliparas; however, sonographic measurements of the cervical length, fetal biometric ratio, maternal age, and current weight at mid-trimester were not predictive of cesarean delivery at term. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:235-242, 2015.

The risk of prelabor and intrapartum cesarean delivery among overweight and obese women: possible preventive actions

OBJECTIVE

The purpose of this study was to investigate prelabor and intrapartum cesarean delivery in overweight and obese women by parity, previous cesarean delivery, and labor induction to assess what preventive actions might be possible.

STUDY DESIGN

We modeled relative risks (RRs) and risk differences of prelabor and intrapartum cesarean delivery by prepregnancy body mass index (obese, ≥30 kg/m(2); overweight, 25-29.9 kg/m(2); normal weight, 18.5-24.9 kg/m(2)) in a nationally representative sample of 12,297 French women. Models were stratified by parity and previous cesarean status. Covariates included maternal sociodemographic characteristics, medical conditions, pregnancy complications, and induction of labor.

RESULTS

Risks of prelabor cesarean delivery were elevated only for obese multiparous women. This reflected not only a higher prevalence of previous cesarean delivery (26.4% vs 17.9% for normal-weight women) but also higher risks of prelabor cesarean delivery for multiparous women with no previous cesarean delivery after adjustment for medico-obstetric factors (RR, 1.82; 95% confidence interval [CI], 1.25-2.64). Obese primiparous women and multiparous women with no previous cesarean delivery had similarly increased adjusted RRs for intrapartum cesarean delivery (RR, 1.64; 95% CI, 1.36-1.98; and RR, 1.66; 95% CI, 1.15-2.39, respectively), but the risk difference was higher for primiparous women, with an absolute increase of 0.10 (95% CI, 0.05-0.14) compared with 0.02 (95% CI, 0.00-0.04) for multiparous women. Increased intrapartum cesarean delivery risks for primiparous women were related to more frequent labor induction (42.6% vs 23.8% for normal-weight women).

CONCLUSION

It may be possible to reduce primary and thus repeat cesarean delivery rates among obese women by preventive actions targeting labor induction in primiparous women and prelabor cesarean deliveries in multiparous women. Further research is needed on the impact of limiting inductions on cesarean delivery risks for obese primiparous women.

Behaviours of overweight and obese women during pregnancy who achieve and exceed recommended gestational weight gain

BACKGROUND

Excessive gestational weight gain (GWG) is associated with increased risk of pregnancy-related complications, postpartum weight retention, and long-term obesity. Little is known about the behavioural habits of pregnant women who achieve and exceed recommended GWG.

METHOD

In 2011, qualitative interviews were conducted in Pennsylvania with postpartum women who were overweight or obese prior to pregnancy to ascertain their behaviours and attitudes regarding dietary habits, physical activity, and self-monitoring during pregnancy. Thematic analysis identified the habits of women who achieved and exceeded recommended GWG guidelines.

RESULTS

Of the 29 women interviewed, 11 had appropriate GWG and 18 had excessive GWG. Women achieving appropriate GWG reported modest increases in caloric intake if at all, with deliberate meal and snack planning, while women with excessive GWG described "eating-for-two." Nearly all women with excessive GWG reported exercising less during pregnancy (or remaining sedentary), while women with appropriate GWG largely increased or maintained pre-pregnancy physical activity levels. About half of the sample reported self-monitoring weight gain during pregnancy, but women achieving recommended GWG tied their weight monitoring with GWG goals consistent with recommended guidelines.

CONCLUSIONS

Women who achieved appropriate GWG reported deliberate dietary habits and physical activity planning, with appropriate GWG goals during pregnancy. Women exceeding recommended GWG described "eating-for-two," were sedentary, and either had no goals for GWG or intended to gain more weight than recommended.

Labor length among overweight and obese women undergoing induction of labor

OBJECTIVE

Maternal weight is thought to impact labor. With rising rates of obesity and inductions, we sought to evaluate labor times among induced women by body mass index (BMI) category.

METHODS

Retrospective cohort study of term inductions from 2005 to 2010. BMI categories were: normal weight (NW), overweight (OW), and obese (Ob) (18.5-24.9, 25-29.9, ≥30 kg/m(2)). Kruskal-Wallis tests compared median latent labor (LL) length and active labor (AL) length. Chi-square determined associations. Multivariable logistic regression controlled for confounders. Analyses were stratified by parity.

RESULTS

A total of 448 inductions were analyzed. For nulliparas, there was no difference in LL by BMI category (p = 0.22). However, OW nulliparas had a longer AL compared to NW and Ob nulliparas (3.2, 1.7, 2.0 h, p = 0.005). For multiparas, NW had the shortest LL (5.5 h, p = 0.025) with no difference in AL among BMI categories (p = 0.42). The overall cesarean rate was 23% with no difference by BMI category (p = 0.95). However, Ob women had a greater percentage of first stage cesareans (41%) and NW had a greater percentage of second stage cesareans (55%), p = 0.06.

CONCLUSION

The association between BMI and labor length among inductions differs by phase of labor and parity. BMI also influences the stage of labor in which a cesarean occurs.

Induction of labour and intrapartum care in obese women

The rising incidence of obesity in pregnancy has a significant impact on the provision of health services around the world. Due to the pathophysiological processes associated with the condition, the obese pregnant woman is at increased risks of induction of labour, caesarean section, post-partum haemorrhage, infection, longer hospital stay, macrosomia and higher perinatal morbidity and mortality. Labour is more likely to be prolonged and dysfunctional, leading to the requirements for higher doses of oxytocin and increased risks of operative deliveries and morbidity. A multidisciplinary approach to the planning of antenatal, intrapartum and postnatal care is vital to ensure a safe outcome for the obese pregnant woman and her baby. The need for supervision and attendance by senior obstetric staff is increased, emphasising the need to identify the appropriate place of birth for this high-risk group of women, placing a significant strain on the resources of health-care providers.

Variation in caesarean section rates in the US: outliers, damned outliers, and statistics

Gordon C. Smith discusses the study by Katy Kozhimannil and colleagues that examines variations in cesarean section rates in the US and argues for the need for high-quality routine data collection to better understand the reasons for these variations. Please see later in the article for the Editors' Summary.

Shoulder dystocia: risk factors, predictability, and preventability

Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16-48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common. The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.

Pregnancy after laparoscopic gastric banding: maternal and neonatal outcomes

INTRODUCTION

Laparoscopic Adjustable Gastric Banding (LAGB) is a safe and effective treatment for obesity. A strong evidence links weight loss with improved fertility outcomes and reduced gestational complications in subsequent pregnancies. Our aim is to describe the impact of LAGB on maternal and neonatal outcomes.

METHODS

Data were collected retrospectively from the database of our University Center for the Multicentric Treatment of Severe Obesity. From January 2006 to December 2011, 438 patients underwent LAGB. Of these, 140 women of reproductive age (18-46 years old) were included in our study. The following parameters were registered during follow-up: number of pregnancies, delivery and miscarriage, time from LAGB to pregnancy, band adjustments, weight gain during pregnancy, gestational and obstetrical complications (gestational diabetes mellitus, hypertensive disorders, prolonged labor), mode of delivery, neonatal birth weight and complications (low birth weight, IUGR, prematurity, macrosomy).

RESULTS

We registered 26 pregnancies with a total of 22 babies born and 4 miscarriages. The mean time from LAGB to pregnancy was 15.8 months. Band adjustments were performed in 100% of patients during the first trimester; the average weight gain at the end of pregnancy was 14.66 kg. None presented gestational or obstetrical complications. One patient presented band slippage, which required surgery, and one patient presented iron-deficiency anemia. 100% of deliveries were by cesarean section. No perinatal complications or malformations were recorded, and the average baby weight was 3027 g.

CONCLUSION

LAGB is a safe procedure, well tolerated during pregnancy and without negative implications on both the mother and the baby. According to our experience and recent studies, band loosening should be reserved to symptomatic patients to avoid unhealthy weight gain.

Mode of birth and social inequalities in health: the effect of maternal education and access to hospital care on cesarean delivery

Access to health care is an important factor in explaining health inequalities. This study focuses on the issue of access to health care as a driving force behind the social discrepancies in cesarean delivery using data from 707 newborn children in the 2006-2011 birth cohorts of the German Socio-Economic Panel Study (SOEP). Data on individual birth outcomes are linked to hospital data using extracts of the quality assessment reports of nearly all German hospitals. Geographic Information Systems (GIS) are used to assess hospital service clusters within a 20-km radius buffer around mother׳s homes. Logistic regression models adjusting for maternal characteristics indicate that the likelihood to deliver by a cesarean section increases for the least educated women when they face constraints with regard to access to hospital care. No differences between the education groups are observed when access to obstetric care is high, thus a high access to hospital care seems to balance out health inequalities that are related to differences in education. The results emphasize the importance of focusing on unequal access to hospital care in explaining differences in birth outcomes.

Body mass index, gestational weight gain, and obstetric complications in Moroccan population

OBJECTIVES

To evaluate the impact of the body mass index (BMI) before pregnancy and the weight gain during pregnancy, on the occurrence of maternal and neonatal morbidity in the Moroccan population, as well as to analyze the quality of the weight gain depending on the BMI.

METHODS

A study was carried out over a period of one year from October 1, 2010 to October 1, 2011, using data collected from a descriptive-transversal study. We recruited nondiabetic women without several HTAs, delivering singletons from 37 completed weeks up to 42 weeks gestation.

RESULTS

Total of 1408 were analyzed. The risks of moderate hypertension, macrosomia, dystocia, and resort to cesarean section were higher among overweight or obese women, as well as among women whose weight gain was >16 kg. The differences were significant <0.05.

CONCLUSION

This study demonstrates that overweight women before pregnancy and weight gain during pregnancy are associated with higher risks of maternal and neonatal complications. These data provide ideas on prevention opportunities.

Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis

STUDY QUESTION

Is there an association between a Caesarean section and subsequent fertility?

SUMMARY ANSWER

Most studies report that fertility is reduced after Caesarean section compared with vaginal delivery. However, studies with a more robust design show smaller effects and it is uncertain whether the association is causal.

WHAT IS KNOWN ALREADY

A previous systematic review published in 1996 summarizing six studies including 85 728 women suggested that Caesarean section reduces subsequent fertility. The included studies suffer from severe methodological limitations.

STUDY DESIGN, SIZE, DURATION

Systematic review and meta-analysis of cohort studies comparing subsequent reproductive outcomes of women who had a Caesarean section with those who delivered vaginally.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Searches of Cochrane Library, Medline, Embase, CINAHL Plus and Maternity and Infant Care databases were conducted in December 2011 to identify randomized and non-randomized studies that compared the subsequent fertility outcomes after a Caesarean section and after a vaginal delivery. Eighteen cohort studies including 591 850 women matched the inclusion criteria. Risk of bias was assessed by the Newcastle-Ottawa scale (NOS). Data extraction was done independently by two reviewers. The meta-analysis was based on a random-effects model. Subgroup analyses were performed to assess whether the estimated effect was influenced by parity, risk adjustment, maternal choice, cohort period, and study quality and size.

MAIN RESULTS AND THE ROLE OF CHANCE

The impact of Caesarean section on subsequent pregnancies could be analysed in 10 studies and on subsequent births in 16 studies. A meta-analysis suggests that patients who had undergone a Caesarean section had a 9% lower subsequent pregnancy rate [risk ratio (RR) 0.91, 95% confidence interval (CI) (0.87, 0.95)] and 11% lower birth rate [RR 0.89, 95% CI (0.87, 0.92)], compared with patients who had delivered vaginally. Studies that controlled for maternal age or specifically analysed primary elective Caesarean section for breech delivery, and those that were least prone to bias according to the NOS reported smaller effects.

LIMITATIONS, REASONS FOR CAUTION

There is significant variation in the design and methods of included studies. Residual bias in the adjusted results is likely as no study was able to control for a number of important maternal characteristics, such as a history of infertility or maternal obesity.

WIDER IMPLICATIONS OF THE FINDINGS

Further research is needed to reduce the impact of selection bias by indication through creating more comparable patient groups and applying risk adjustment.

The effects of an increasing gradient of maternal obesity on pregnancy outcomes

BACKGROUND

Maternal obesity is becoming more prevalent in obstetrics and has been linked with pregnancy complications and perinatal outcomes. The gradient of association of increasing maternal obesity and pregnancy outcome is less well studied.

AIMS

To determine the influence of an increasing gradient of obesity, categorised by the body mass index (BMI), on pregnancy outcomes and to determine the BMI thresholds at which pregnancy complications occur.

MATERIALS AND METHODS

Secondary analysis of an observational study on pregnancy and obesity. The BMI at the first prenatal visit was grouped into BMI categories (<18.5, 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, 40-44.9, and ≥45) and compared with the normal category (BMI 18.5-25) for pregnancy outcomes and adjusted for known cofounders.

RESULTS

A total of 4,490 women were stratified into the pre-pregnancy BMI categories: <18.5 (n = 276), 18.5-24.9 (n = 1965), 25-29.9 (n = 1072), 30-34.9 (n = 551), 35-39.9 (n = 317), 40-44.9 (n = 167), and ≥45 (n = 142). The maternal demographics were significantly different between BMI groups (P < 0.001). Compared to women with a normal BMI, different BMI thresholds convey an increased risk for specific pregnancy complications: BMI≥25 for gestational diabetes (P < 0.001), induction of labour (P < 0.001), caesarean delivery (P < 0.001) and large for gestational age neonate (P < 0.001); BMI≥30 for pre-eclampsia (P < 0.001), wound infection (P = 0.001), shoulder dystocia (P < 0.001) and meconium (P = 0.006); BMI≥35 for urinary tract infection (P < 0.001) and postpartum haemorrhage (P < 0.001); BMI≥40 for endometritis (P < 0.001).

CONCLUSIONS

Body mass index thresholds exist at which pregnancy complications significantly increase and they vary depending on outcome ranging from BMI ≥25 to a BMI ≥40.

The adverse impact of maternal obesity on intrapartum and perinatal outcomes

Background. Confidential enquiries into maternal deaths in the UK have repeatedly highlighted increased maternal morbidity and mortality associated with maternal obesity. Objective. To determine the impact of increased body mass index (BMI) on intrapartum outcomes. Materials and Methods. A retrospective case-control analysis of intrapartum outcomes of the study group (100 women), with a BMI above 40 kg/m² (class III Obesity) at booking and a control group (100 women) with a booking BMI between 20 and 25 kg/m² was performed. Results. A statistically significant increase in delivery by caesarean section (OR 2.32, 95% CI 1.26–4.29), minor and major postpartum haemorrhage (OR 5.93, 95% CI 2.34–11.98, OR 16.11, 95% CI 2.08–125.09, resp.), perineal trauma (OR 2.59, 95% CI 1.44–4.69), and fetal macrosomia (OR 3.11, 95% CI 1.25–7.79) was noted in the study group. Babies also had an increased risk of having a lower APGAR scores in the study group as compared to the control group (OR 3.09, 95% CI 1.07–8.94). Conclusion. Women with a BMI > 40 kg/m² experience increased incidence of intrapartum complications and hence, input of skilled birth attendants during labour is essential to improve intrapartum outcomes.

Relationship between fetal station and successful vaginal delivery in nulliparous women

OBJECTIVE

To study the relationship between fetal station and successful vaginal delivery in nulliparous women.

STUDY DESIGN

This was a secondary analysis from a previously reported trial of pulse oximetry. Vaginal delivery rates were evaluated and compared with respect to the fetal station. Spontaneous labor and induction of labor groups were evaluated separately. Multivariable logistic regression analysis was performed to adjust for confounding factors.

RESULTS

Successful vaginal delivery was more frequent with an engaged vertex for spontaneous labor (86.2% versus 78.6%; p = 0.01) and induced labor (87.7% versus 66.1%; p < 0.01). After adjustment, engaged fetal vertex was not associated with vaginal delivery for spontaneous labor (odds ratio [OR] 1.5; 95% confidence interval [CI] 0.95 to 2.3; p = 0.08) or for women with induced labor (OR 2.2; 95% CI 0.96 to 5.1; p = 0.06).

CONCLUSION

Among nulliparous women enrolled in the FOX randomized trial in spontaneous labor or for labor induction, an engaged fetal vertex does not affect their vaginal delivery rate.

Maternal obesity and contraction strength in the first stage of labor

OBJECTIVE

The purpose of this study was to determine whether maternal obesity is associated with cesarean delivery and decreased contraction strength in the first stage of labor.

STUDY DESIGN

We studied a retrospective cohort of women who delivered within a single healthcare system from 2007-2009; we included 5410 women with an intrauterine pressure catheter during the last 2 hours of the first stage of labor and who either had a vaginal delivery or cesarean delivery for dystocia. Logistic regression was used to determine how body mass index was associated with cesarean delivery or mean Montevideo units of ≥200.

RESULTS

Although obese women were at significantly greater odds of cesarean delivery than normal-weight women (odds ratio, 2.4; 95% confidence interval, 1.9-3.1), they were equally able to achieve Montevideo units of ≥200. Among women with a vaginal delivery, obese women had a longer first stage of labor compared with normal-weight women (597 vs 566 min; P = .003).

CONCLUSION

Obese women have longer labors but are equally able to achieve adequate Montevideo units as normal-weight women.

Large conductance, calcium- and voltage-gated potassium (BK) channels: regulation by cholesterol

Cholesterol (CLR) is an essential component of eukaryotic plasma membranes. CLR regulates the membrane physical state, microdomain formation and the activity of membrane-spanning proteins, including ion channels. Large conductance, voltage- and Ca²⁺-gated K⁺ (BK) channels link membrane potential to cell Ca²⁺ homeostasis. Thus, they control many physiological processes and participate in pathophysiological mechanisms leading to human disease. Because plasmalemma BK channels cluster in CLR-rich membrane microdomains, a major driving force for studying BK channel-CLR interactions is determining how membrane CLR controls the BK current phenotype, including its pharmacology, channel sorting, distribution, and role in cell physiology. Since both BK channels and CLR tissue levels play a pathophysiological role in human disease, identifying functional and structural aspects of the CLR-BK channel interaction may open new avenues for therapeutic intervention. Here, we review the studies documenting membrane CLR-BK channel interactions, dissecting out the many factors that determine the final BK current response to changes in membrane CLR content. We also summarize work in reductionist systems where recombinant BK protein is studied in artificial lipid bilayers, which documents a direct inhibition of BK channel activity by CLR and builds a strong case for a direct interaction between CLR and the BK channel-forming protein. Bilayer lipid-mediated mechanisms in CLR action are also discussed. Finally, we review studies of BK channel function during hypercholesterolemia, and underscore the many consequences that the CLR-BK channel interaction brings to cell physiology and human disease.

Pregnancy outcome of the obese in Ilorin

BACKGROUND

Obesity is a nutritional disorder that is fast becoming a public health issue in the developing world. It is associated with increased incidence of maternal complications and adverse perinatal outcome.

METHODS AND RESULTS

This is a case-control study of obesity in pregnancy carried out in the maternity wing of University of Ilorin Teaching Hospital, Nigeria. The subjects and controls were 156 obese and 80 non-obese women booked at this hospital for antenatal care. The controls were matched for age and parity. Obesity occurred more commonly among the well educated (P = 0.00) and those in social classes I and II (P = 0.00). The occurrence of other medical conditions was not significantly different. The obese women also had more caesarean sections (P = 0.00), more assisted vaginal deliveries (P = 0.00) and fewer spontaneous vaginal deliveries (P = 0.00) than the non-obese parturients. The mean birth weight of infants of the obese mothers was 4.06 ± 0.13 kg (mean±SD) while the mean for the controls was 3.36 ± 0.49 kg. The difference was statistically significant (P = 0.000). Also, the obese parturients had more macrosomic babies (defined as birth weight >4.2 kg) than the non-obese (P = 0.00). The risks of perinatal asphyxia, birth trauma, neonatal admission and low birth weight were not increased among obese women in this study.

CONCLUSION

This study suggests that in our community, obesity occurs more commonly among women of high socioeconomic status and is a risk factor for maternal and fetal complications.

Associations between high prepregnancy body mass index, breast-milk expression, and breast-milk production and feeding

BACKGROUND

Breast-milk expression is widely practiced by American mothers, but little is known about who expresses milk, how expression affects breastfeeding, or whether overweight or obese women, who have less breastfeeding success than do normal-weight women, express milk differently.

OBJECTIVES

We investigated 1) whether breast-milk expression behavior differed by body mass index (BMI; in kg/m(2)) category and 2) whether the different breastfeeding behaviors of overweight (BMI: ≥25 and <30) and obese (BMI: ≥30) women resulted in different breastfeeding outcomes.

DESIGN

The subjects (n = 2288) provided information on BMI and breast-milk production, feeding, and expression in mail-in questionnaires as part of the Infant Feeding Practices Study II. Longitudinal and cross-sectional data were analyzed by using regression procedures adjusted for confounding.

RESULTS

Women of different BMI categories overall did not differ in whether, when, or why they expressed breast milk. Before 2 mo postpartum, however, obese women were more likely (P = 0.04, unadjusted) to try milk expression and were less likely (P = 0.01, unadjusted) to express milk successfully. In addition, overweight or obesity was associated (P < 0.03, unadjusted) with a shorter duration of breast-milk production only in women who never expressed milk. In overweight or obese women, those who ever expressed milk had longer durations of breastfeeding (P < 0.003, unadjusted) than did those who never expressed milk.

CONCLUSIONS

Breast-milk expression behaviors may differ by maternal BMI category only in the early postpartum period. In addition, breast-milk expression may reduce differences between BMI categories in the duration of breastfeeding and support longer durations of breastfeeding.