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Lee SJ, Hashmi AH, Min AM, Gilder ME, Tun NW, Wah LL, Wah M, Win E, Ner M, Charunwatthana P, Nosten FH, Carrara VI, McGready R. Short maternal stature and gestational weight gain among refugee and migrant women birthing appropriate for gestational age term newborns: a retrospective cohort on the Myanmar-Thailand border, 2004-2016. BMJ Glob Health 2021; 6:bmjgh-2020-004325. [PMID: 33597278 PMCID: PMC7893649 DOI: 10.1136/bmjgh-2020-004325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/22/2020] [Accepted: 01/14/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction To examine the interactions between short maternal stature, body mass index (BMI) and gestational weight gain (GWG) among appropriate for gestational age (AGA) term newborns in a population of refugees and migrants in Southeast Asia. Methods This is a retrospective cohort study from 2004 to 2016, including women delivering term, singleton newborns, with first trimester height, weight and gestation dated by ultrasound and a last body weight measured within 4 weeks of birth. AGA newborns were those not classified as small for gestational age or large for gestational age by either INTERGROWTH-21st or Gestation Related Optimal Weight standards. The influence of maternal stature on GWG in delivering an AGA newborn was analysed, with GWG compared with existing National Academy of Medicine (NAM) recommendations. Results 4340 women delivered AGA newborns. Mean maternal height (SD) was 151.5 cm (5.13), with 58.5% of women considered too short by INTERGROWTH-21st standards. Only one in four women (26.5%, 1150/4340) had GWG within NAM recommendations. Women of shorter stature had a significantly lower mean GWG compared with taller women in underweight and normal BMI categories (p<0.001 for both BMI categories). Mean GWG of overweight and obese women did not differ by height (p=1.0 and p=0.85, respectively) and fell within the lower range of NAM recommendations. Conclusion These results suggest that short maternal stature can be an important predictor of GWG and should be considered with prepregnancy BMI. Limited-resource settings and special populations need robust GWG recommendations that reflect height and BMI.
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Affiliation(s)
- Sue J Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Ahmar H Hashmi
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Aung Myat Min
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | | | - Nay Win Tun
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Lay Lay Wah
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Mu Wah
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Elsi Win
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Ma Ner
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - François H Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Verena I Carrara
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK .,Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, Thailand
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Gaudet L, Ferraro ZM, Wen SW, Walker M. Maternal obesity and occurrence of fetal macrosomia: a systematic review and meta-analysis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:640291. [PMID: 25544943 PMCID: PMC4273542 DOI: 10.1155/2014/640291] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 11/09/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine a precise estimate for the contribution of maternal obesity to macrosomia. DATA SOURCES The search strategy included database searches in 2011 of PubMed, Medline (In-Process & Other Non-Indexed Citations and Ovid Medline, 1950-2011), and EMBASE Classic + EMBASE. Appropriate search terms were used for each database. Reference lists of retrieved articles and review articles were cross-referenced. METHODS OF STUDY SELECTION All studies that examined the relationship between maternal obesity (BMI ≥30 kg/m(2)) (pregravid or at 1st prenatal visit) and fetal macrosomia (birth weight ≥4000 g, ≥4500 g, or ≥90th percentile) were considered for inclusion. TABULATION, INTEGRATION, AND RESULTS Data regarding the outcomes of interest and study quality were independently extracted by two reviewers. Results from the meta-analysis showed that maternal obesity is associated with fetal overgrowth, defined as birth weight ≥ 4000 g (OR 2.17, 95% CI 1.92, 2.45), birth weight ≥4500 g (OR 2.77,95% CI 2.22, 3.45), and birth weight ≥90% ile for gestational age (OR 2.42, 95% CI 2.16, 2.72). CONCLUSION Maternal obesity appears to play a significant role in the development of fetal overgrowth. There is a critical need for effective personal and public health initiatives designed to decrease prepregnancy weight and optimize gestational weight gain.
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Affiliation(s)
- Laura Gaudet
- University of Ottawa, Faculty of Medicine, 451 Smyth Road, Ottawa, ON, Canada K1H 8M5
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
- Ottawa Hospital Research Institute, Ottawa, ON, Canada K1H 8L6
| | - Zachary M. Ferraro
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
- Healthy Active Living and Obesity (HALO) Research Group, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, Canada K1H 8L1
| | - Shi Wu Wen
- Ottawa Hospital Research Institute, Ottawa, ON, Canada K1H 8L6
| | - Mark Walker
- University of Ottawa, Faculty of Medicine, 451 Smyth Road, Ottawa, ON, Canada K1H 8M5
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6
- Ottawa Hospital Research Institute, Ottawa, ON, Canada K1H 8L6
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Obstetrical Management of an Extremely Overweight Pregnant Woman (184 kg bw) with Special Attention on Thromboprophylaxis. Case Rep Obstet Gynecol 2013; 2013:689549. [PMID: 23533867 PMCID: PMC3603639 DOI: 10.1155/2013/689549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/27/2013] [Indexed: 11/18/2022] Open
Abstract
The 27-year-old pregnant woman has been overweight since her childhood. Endocrinological assessments did not confirm hormonal disease. Her pregnancy was without complication. A signs of intrauterine distress were observed and elective caesarean section was performed under heparin protection because of anatomy unsuitable for delivery per vias naturals. The mother's bodyweight was 184 kg. By monitoring the change in fX activity LMWH treatment (Enoxaparin) initiated with a dose of 120 mg twice daily and then the dose was gradually elevated to 200 mg twice daily thereby achieving the lower range of the desired therapeutic effect. Apart from mild disorder of wound healing, the recovery was free of complication. The patient suffered from thrombophilia (extremely overweight, pregnant, thrombophlebitis under the knee, surgery, and postoperative immobilization). In case of quite extreme bodyweight there is no dosage recommendation or clinical practice for LMWH. Because of the extreme overweight and the therapeutic dose titration test of heparin, monitoring of fX activity by measurement of inhibition, dosage of heparin other than the recommended (abdominal wall instead of upper arm SC), and the very fluctuating heparin dosage which is well correlating with clinical practice, it is reasonably expected that this case will take interest.
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Alavi N, Haley S, Chow K, McDonald SD. Comparison of national gestational weight gain guidelines and energy intake recommendations. Obes Rev 2013; 14:68-85. [PMID: 23107337 DOI: 10.1111/j.1467-789x.2012.01059.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 09/19/2012] [Accepted: 09/20/2012] [Indexed: 12/29/2022]
Abstract
Although data showing adverse effects with high and low gestational weight gain (GWG) come from a large number of countries, a variety of guidelines about the GWG exist. Our objectives were to compare existing GWG and energy recommendations across various countries, as well as the rationale or evidence on which they were based. We used the United Nations' Human Developmental Index to determine the ranking of the country to ensure broad sampling and then searched for guidelines. We first searched the national government websites, and if necessary searched Medline and EMBASE, Global Health databases, and bibliographies of published articles for both guidelines and the studies on which they were based. We found guidelines for 31% of the countries, and 59% of these had a GWG recommendation, 68% had an energy intake recommendation (EIR), and 36% had both. About half of the GWG guidelines are similar to the 2009 American Institutes of Medicine (IOM) and 73% of the EIRs are similar to the 2006 IOM. Despite the documented relationship between both high GWG and adverse outcomes for women and infants and low GWG and adverse outcomes in infants, there are a wide variety of guidelines for GWG and energy recommendations by different countries around the world.
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Affiliation(s)
- N Alavi
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
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Luther JS, Redmer DA, Reynolds LP, Wallace JM. Nutritional paradigms of ovine fetal growth restriction: Implications for human pregnancy. HUM FERTIL 2009; 8:179-87. [PMID: 16234203 DOI: 10.1080/14647270500320121] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Low birth weight and prematurity are associated with short inter-pregnancy intervals, low pre-pregnancy weights, insufficient maternal weight gains during pregnancy, multifetal pregnancies and a young maternal age. Improvements in maternal nutritional status are arguably imperative for ensuring an appropriate pregnancy outcome in these vulnerable groups, but ethical boundaries limit these investigations. Experimental paradigms using the pregnant sheep have been widely used to identify the nutritionally sensitive periods of conceptus development. In adult sheep, severe undernutrition during the periconceptual period accelerates maturation of the fetal hypothalamic-pituitary adrenal axis and results in pre-term delivery. Low pre-pregnancy weight, followed by undernutrition during mid-pregnancy, results in reduced placental growth and lower birth weights at term. Studies that have restricted nutrients during mid-gestation only reveal variable effects on the placental and fetal growth trajectory, however if undernutrition is prolonged during late-pregnancy, fetal growth is compromised, particularly in twin pregnancies. In contrast, overnourishing the adolescent sheep to promote rapid maternal growth, results in the premature delivery of low birth weight lambs. These effects are mediated by impaired placental growth, uteroplacental blood flows and fetal nutrient uptakes. At the other end of the nutritional spectrum, undernourishing the adolescent sheep to gradually deplete nutrient reserves, results in fetal growth restriction which is independent of alterations in placental mass.
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Complications during pregnancy, labor and puerperium in women with increased BMI at pregnancy term. Open Med (Wars) 2009. [DOI: 10.2478/s11536-009-0001-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractThe aim of this study was to analyse perinatal complications in woman with increased BMI at pregnancy term. Study included 23190 women who gave singleton birth during a 10-year period in our institution. Maternal databases were reviewed for pregnancy, labor and delivery complications and early maternal postpartum morbidity. Women with increased BMI at pregnancy term had a significantly higer incidence of postterm pregnancy, gestational diabetes, pregnancy-induced hypertension and third trimester hemorrhage, compared to normal weight women (p 0.000). Women with increased BMI had significantly more labor induction with prostaglandins (p 0.001 and 0.000) and elective caesarean (p 0.025 and 0.000). Also, overweight and obese women had higher incidence of operative delivery: caesarean section (p 0.000) and vacuum extraction (p 0.000). The incidences of postpartum febrility (p 0.057, 0.000, 0.002) and trombophlebits (p 0.013) were also significantly higher. We can conclude that prepregnancy normal weight women with increased BMI during pregnancy need special follow-up and counseling in pregnancy and delivery.
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Hänseroth K, Distler W, Kamin G, Nitzsche K. Geburtshilfe bei Adipositas permagna. GYNAKOLOGE 2006. [DOI: 10.1007/s00129-006-1912-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Obesity has become a major health problem all over the world and during pregnancy is associated with an increased risk of complications, including gestational diabetes, preeclampsia, and delivery complications such as macrosomia, shoulder dystocia and higher rates of cesarean sections and infections. Maternal obesity may also be an independent risk factor for neural tube defects and fetal mortality. This review focuses on the consequences of maternal obesity during pregnancy.
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Affiliation(s)
- Johannes Dietl
- Department of Obstetrics and Gynecology, University Hospital, Würzburg, Germany.
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Abstract
Obesity is increasing rapidly among women all over the world, and more women in fertile ages become overweight and obese. Among all other problems, women who are obese have higher rates of amenorrhoea and infertility. Obese women have a higher risk of complications during pregnancy such as hypertensive diagnoses and gestational diabetes, and delivery complications such as higher rates of caesarean sections and prolonged time of delivery. The aim of this article is to review the consequences of being obese during the reproductive life of a woman.
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Affiliation(s)
- Y Linné
- Obesity Unit, Huddinge University Hospital, SE-141 86 Stockholm, Sweden.
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Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, Regan L, Robinson S. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes (Lond) 2001; 25:1175-82. [PMID: 11477502 DOI: 10.1038/sj.ijo.0801670] [Citation(s) in RCA: 998] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2000] [Revised: 01/29/2001] [Accepted: 02/13/2001] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m(2)) in a large unselected geographical population. DESIGN Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking. SUBJECTS A total of 287,213 completed singleton pregnancies were studied including 176,923 (61.6%) normal weight (BMI 20--24.9), 79 014 (27.5%) moderately obese (BMI 25--29.9) and 31,276 (10.9%) very obese (BMI> or =30) women. MEASUREMENTS Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables. RESULTS Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25--30 and BMI> or =30 respectively): gestational diabetes mellitus (1.68 (1.53--1.84), 3.6 (3.25--3.98)); proteinuric pre-eclampsia (1.44 (1.28--1.62), 2.14 (1.85--2.47)); induction of labour (2.14 (1.85--2.47), 1.70 (1.64--1.76)); delivery by emergency caesarian section (1.30 (1.25--1.34), 1.83 (1.74--1.93)); postpartum haemorrhage (1.16 (1.12--1.21), 1.39 (1.32--1.46)); genital tract infection (1.24 (1.09--1.41), 1.30 (1.07--1.56)); urinary tract infection (1.17 (1.04-1.33), 1.39 (1.18--1.63)); wound infection (1.27 (1.09--1.48), 2.24 (1.91--2.64)); birthweight above the 90th centile (1.57 (1.50--1.64), 2.36 (2.23--2.50)), and intrauterine death (1.10 (0.94--1.28), 1.40 (1.14--1.71)). However, delivery before 32 weeks' gestation (0.73 (0.65--0.82), 0.81 (0.69--0.95)) and breastfeeding at discharge (0.86 (0.84--0.88), 0.58 (0.56--0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk. CONCLUSION Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.
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Affiliation(s)
- N J Sebire
- Department of Obstetrics and Gynaecology, Imperial College School of Medicine at St Mary's Hospital, London, UK
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Zhou W, Olsen J. Gestational weight gain as a predictor of birth and placenta weight according to pre-pregnancy body mass index. Acta Obstet Gynecol Scand 1997; 76:300-7. [PMID: 9174421 DOI: 10.1111/j.1600-0412.1997.tb07982.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To study the association between gestational weight gain and different birth weight indicators considering the pre-pregnancy body mass index. It was hypothesized that a high body mass index (BMI) would modify the effect of gestational weight gain and support the advice of keeping gestational weight gain at a moderate level in case of obesity. STUDY DESIGN A follow-up study of consecutively recruited women in two well defined geographical areas in Denmark. The recruitment lasted from 1984 to 1987 and 11,850 pregnant women and newborns were included in the study. The remaining analyses were restricted to non-diabetic women who gave birth between weeks 37 and 42 of gestation for whom weight gain was reported-altogether 7,122 women. RESULTS Birth and placenta weight were associated with gestational weight gain but with lower regression coefficients at higher BMI. The proportion of newborns with a birth weight of 4,500 grams or more increased with increasing gestational weight gain, especially in women with a BMI above 26. CONCLUSION The potential benefit of a high gestational weight gain in obese patients should be balanced by the higher risk of giving birth to babies with a birth weight of more than 4,500 grams and the risk of exaggerating a pre-existing state of obesity.
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Affiliation(s)
- W Zhou
- Department of Epidemiology and Social Science, Danish Epidemiology Science Centre, Aarhus University, Denmark
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Abstract
OBJECTIVE Our purpose was to determine the impact of massive maternal obesity (weight > 300 pounds) on perioperative morbidity among patients undergoing cesarean section. STUDY DESIGN A case-control study was conducted on 43 massively obese pregnant women, identified by perinatal database search, who were delivered by cesarean section between Jan. 1, 1987, and Dec. 31, 1991, at Long Beach Memorial Women's Hospital. Forty-three randomly selected patients who underwent cesarean delivery served as the control group. Medical records were abstracted for perioperative variables and compared between groups. Student t test, chi 2, and Fisher's exact statistical analysis were used where appropriate. RESULTS No significant differences were observed between groups for maternal age, parity, use of prophylactic antibiotics, length of recovery room stay, or wound dehiscence. The massively obese group was observed to be at significantly increased risk for emergency cesarean section (32.6% vs 9.3%, p = 0.02), prolonged delivery interval (25.6% vs 4.6%, p = 0.01), and total operative time (48.8% vs 9.3%, p < 0.0001), blood loss > 1000 ml (34.9% vs 9.3%, p = 0.009), multiple epidural placement failures (14.0% vs 0%, p = 0.02), postoperative endometritis (32.6% vs 4.9%, p = 0.002), and prolonged hospitalization (34.9% vs 2.3%, p = 0.0003). CONCLUSION Massively obese pregnant women undergoing cesarean section are at significantly increased risk for perioperative morbidity.
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Affiliation(s)
- J H Perlow
- Department of Obstetrics and Gynecology, Long Beach Memorial Medical Center Women's Hospital, California
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Perlow JH, Morgan MA, Montgomery D, Towers CV, Porto M. Perinatal outcome in pregnancy complicated by massive obesity. Am J Obstet Gynecol 1992; 167:958-62. [PMID: 1415432 DOI: 10.1016/s0002-9378(12)80019-6] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Our objective was to determine the impact of massive obesity during pregnancy, defined as maternal weight > 300 pounds, on perinatal outcome. STUDY DESIGN A case-controlled study was conducted. Between Jan. 1, 1986, and Dec. 31, 1990, 111 pregnant women weighing > 300 pounds who were delivered at Long Beach Memorial Women's Hospital were identified with a perinatal data base search. A control group matched for maternal age and parity was selected, and perinatal variables were compared between groups. To control for potential confounding medical complications, massively obese patients with diabetes and/or chronic hypertension antedating the index pregnancy were excluded from the obese group, and the data were reanalyzed. The Student t test chi 2, and Fisher's exact statistical analysis were used where appropriate. RESULTS Massively obese pregnant women are significantly more likely to have a multitude of adverse perinatal outcomes, including primary cesarean section (32.4% vs 14.3%, p = 0.002), macrosomia (30.2% vs 11.6%, p = 0.0001), intrauterine growth retardation (8.1% vs 0.9%, p = 0.03), and neonatal admission to the intensive care unit (15.6% vs 4.5%, p = 0.01). They also are significantly more likely to have chronic hypertension (27.0% vs 0.9%, p < 0.0001) and insulin-dependent diabetes mellitus (19.8% vs 2.7%, p = 0.0001). However, when those massively obese pregnant women with diabetes and/or hypertension antedating pregnancy are excluded from analysis, no statistically significant differences in perinatal outcome persisted. CONCLUSION Massively obese pregnant women are at high risk for adverse perinatal outcome; however, this risk appears to be related to medical complications of obesity.
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Affiliation(s)
- J H Perlow
- Department of Obstetrics and Gynecology, Long Beach Memorial Medical Center Women's Hospital, California
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