Influence of weight gain on risk for cesarean delivery in obese pregnant women by class of obesity: pregnancy risk assessment monitoring system (PRAMS)

Physical activity, gestational weight gain in obese patients with early gestational diabetes and the perinatal outcome - a randomised-controlled trial

BACKGROUND

Excessive gestational weight gain, especially among women with gestational diabetes, is associated with several adverse perinatal outcomes. Our study aimed to analyse the impact of the use of pedometers to supervise physical activity on maternal health and the obstetric outcomes of pregnant women with obesity and early gestational diabetes.

METHODS

124 pregnant patients were enrolled in the presented research.

INCLUSION CRITERIA

singleton pregnancy, age > 18 years, gestational diabetes diagnosed in the first half of pregnancy (< 20th week of pregnancy), obesity according to the American Endocrine Society criteria. Each patient was advised to take at least 5000 steps daily. Patients were randomly assigned to pedometers (N = 62), and were recommended to monitor daily the number of steps. The group without pedometers (N = 62) was not observed. Visit (V1) was scheduled between the 28th and 32nd gestational week (GW), and visit (V2) occurred between the 37th and 39th GW. Anthropometric measurements and blood samples were collected from all patients at each appointment. Foetal and maternal outcomes were analysed at the end of the study.

RESULTS

In the group supervised by pedometers, there were significantly fewer newborns with macrosomia (p = 0,03). Only 45% of patients satisfied the recommended physical activity guidelines. Patients who walked more than 5000 steps per day had significantly higher body weight at baseline (p = 0,005), but weight gain was significantly lower than in the group that did not exceed 5000 steps per day (p < 0,001). The perinatal outcome in the group of patients performing more than 5000 steps did not demonstrate significant differences with when compared to less active group. ROC curve for weight gain above the guidelines indicated a statistically substantial cut-off point for this group at the level of 4210 steps/day (p = 0.00001).

CONCLUSIONS

Monitoring the activity of pregnant patients with gestational diabetes and obesity by pedometers did not have a significantly impact on their metabolic control and weight gain. However, it contributed to less macrosomia. Furthermore, physical activity over 5,000 steps per day positively affects weight loss, as well as contributes to improved obstetric and neonatal outcomes.

The relationship between body mass index and perceived control over labor

BACKGROUND

Individuals with an increased body mass index (BMI) (≥ 30 kg/m2) experience higher rates of perinatal mental health disorders than individuals with BMI < 30. Personal experience of decreased control over labor has been associated with the development postpartum mood and anxiety disorders. However, no studies have investigated the association between BMI and experience of control over labor. This study aimed to assess perceived control over labor and compare patients with BMI ≥ 30 to those with BMI < 30.

METHODS

We performed a secondary analysis of a cross-sectional study of postpartum patients who delivered at term (37-41 weeks gestation). Postpartum, participants completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor/birth. Demographic, maternal health history and obstetric/neonatal outcomes were abstracted from the patient chart. Bivariate analyses were performed between those with BMI < 30 and those with BMI ≥ 30 using Fisher's exact test. Continuous LAS scores were compared between patients with BMI < 30 and BMI ≥ 30 using Wilcoxon rank-sum tests. Higher LAS scores indicate higher perceived control over labor. Multivariable linear regression was then performed to account for confounding factors identified a priori.

RESULTS

There was no difference in LAS between those with BMI ≥ 30 and BMI < 30. When stratified by World Health Organization (WHO) class of BMI, those with BMI ≥ 40 had a significantly lower LAS scores than those with BMI < 30 (147 vs. 163, p = 0.02), however, this finding was no longer significant after controlling for length of labor and cesarean birth.

CONCLUSION

Only participants with the highest BMI experienced decreased control over labor, and this finding was no longer significant after controlling for mode of delivery and length of labor. Further research into the experience of birthing people with BMI ≥ 30 is critical to understand the increased risk of perinatal mood disorders among this population.

Body Mass Index and Perceived Labor Control: Could weight stigma explain differences in birth experience?

Background

Individuals with a body mass index (BMI) of ≥ 30 kg/m2 experience weight stigma when interacting with the healthcare system. There is limited data on how weight stigma impacts patient's experience of obstetric care. This study aims to assess perceived control over the birth process and compare patients with BMI ≥ 30 to those with BMI < 30.

Methods

We performed a secondary analysis of a cross-sectional study of term patients. Postpartum, participants completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor/birth. Continuous LAS scores were compared between patients with BMI < 30 and BMI ≥ 30.

Results

There was no difference in LAS between those with BMI ≥ 30 and BMI < 30. When stratified by World Health Organization (WHO) class of BMI, those with BMI ≥ 40 had a significantly lower LAS scores than those with BMI < 30 (147 vs. 163, p = 0.02), however, this finding was no longer significant after controlling for length of labor and cesarean birth.

Conclusion

Only participants with the highest BMI experienced decreased control over labor, and this finding was no longer significant after controlling for mode of delivery and length of labor. Further research is necessary into how weight stigma influences birthing people's experience.

Gestational weight gain and mode of delivery by the class of obesity: A meta-analysis

The association between gestational weight gain (GWG) and mode of delivery in females with different obesity classes is not clear. We conducted a meta-analysis to evaluate the association between GWG, categorized according to the 2009 Institute of Medicine (IOM) guidelines, and the risk of cesarean section (CS) or operative vaginal delivery (OVD) in females with different obesity classes. Eight studies were identified. The pooled odds ratios (ORs) (95% confidence interval [CI]) of CS for females with GWG above the recommendations were 1.27 (1.20-1.33) for obesity class I, 1.22 (1.20-1.23) for class II, and 1.17 (1.15-1.19) for class III. Also, the pooled ORs (95% CI) of OVD were 1.21 (1.005-1.46) for obesity class I, 1.12 (1.04-1.21) for class II, and 1.10 (1.001-1.22) for obesity class III. GWG below the recommendations was associated with lower risk of CS for females with obesity class I (OR 0.87, 95% CI 0.82-0.92), class II (OR 0.84, 95% CI 0.77-0.90), and class III (OR 0.86, 95% CI 0.79-0.93). Pregnant participants gaining weight above the 2009 IOM guidelines were at higher risk for CS and OVD regardless of obesity classes. Gaining weight below the guidelines was associated with a lower risk of CS among females in any obesity class.

Gestational Weight Gain Below Instead of Within The Guidelines per Class of Maternal Obesity: A Systematic Review and Meta-Analysis of Obstetrical and Neonatal Outcomes

OBJECTIVE

To systematically investigate a wide range of obstetrical and neonatal outcomes with respect to gestational weight gain (GWG) below the current IOM and ACOG guidelines compared to within the guidelines and to stratify outcomes by the class of obesity and by the type of study analysis.

DATA SOURCES

We systematically searched studies on PubMed, Scopus, Embase, and Cochrane Library from 2009 to April 30, 2021.

STUDY ELIGIBILITY CRITERIA

Studies reporting on obstetrical and neonatal outcomes of singleton pregnancies with respect to GWG below the current IOM and ACOG guidelines compared to within the guidelines, investigated in obesity overall (BMI> 30 kg/m²), and/or class of obesity (I: BMI 30-34.9 kg/m², II: BMI 35-39.9 kg/ m² and III: BMI> 40 kg/m²).

METHODS

Among the studies that met criteria, multiple obstetrical and neonatal outcomes were tabulated and compared between pregnancies with weight gain below the guidelines and those with weight gain within the guidelines, further classified by the class of obesity if applicable. Primary outcomes included small for gestational age (SGA), large for gestational age (LGA), preeclampsia (PE), and gestational diabetes mellitus (GDM). Secondary outcomes included cesarean section (CS), preterm birth (PTB), postpartum weight retention, and composite neonatal morbidity. Meta-analysis of univariate and adjusted multivariate analysis studies were conducted. The random-effect model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I² value. Newcastle Ottawa Scale (NOS) was used to assess individual study quality.

RESULTS

Total of 54 studies reporting on 30,245,946 pregnancies were included, of which 11,515,411 pregnancies were in the univariate analysis and 18,730,535 pregnancies in the adjusted multivariate analysis. In the meta-analysis of univariate studies, compared to women who gained within the guidelines, those who gained below the guidelines had higher odds for SGA in obesity class I and II (OR:1.30 (95% CI 1.17, 1.45), I² 0%, P<0.00001, and OR: 1.56 (95% CI 1.31, 1.85), I² 0%, P<0.00001), respectively), however, the incidence of SGA was below the expected limits (<10%) and was not associated with increased neonatal morbidity. Furthermore, after adjusting for covariates, that difference was no statistically significant anymore. The difference was not statistically significant for class III obesity. Following adjusted multivariate analysis, no significant differences in SGA rates were noted for all classes of obesity between groups. Significantly lower odds for LGA were seen in GWG below guidelines in obesity class I, II, and III (OR: 0.69 (95% CI 0.64, 0.73), I² 0%, P<0.00001, OR: 0.68 (95% CI 0.63, 0.74), I² 0%, P<0.00001, and OR: 0.65 (95% CI 0.57, 0.75), I² 34%, P<0.00001, respectively), and similar findings were seen in the adjusted multivariate analysis. Women with weight gain below guidelines had significantly lower odds for PE in obesity class I, II, and III (OR: 0.71 (95% CI 0.63, 0.79),), I² 0%, P<0.00001, OR: 0.82 (95% CI 0.73, 0.91), I² 0%, P<0.00001, and OR: 0.82 (95% CI 0.70, 0.94), I² 0%, P=0.006, respectively), and similar findings were seen in the adjusted multivariate analysis. No significant differences were seen in GDM between groups. Regarding PTB, available univariate analysis studies only reported on overall obesity and mixed iatrogenic and spontaneous PTB showing significant increase in the odds of PTB (OR: 1.42 (95% CI 1.40, 1.43), I² 0%, P<0.00001) in women with low weight gain, while adjusted multivariate studies in overall obesity and in all three classes and showed no significant differences of PTB between groups. Women with low weight gain had significantly lower odds for CS in obesity class I, II, and III (OR: 0.76 (95% CI 0.72, 0.81), I² 0%, P<0.00001, OR: 0.82 (95% CI 0.77, 0.87), I² 0%, P<0.00001, and OR: 0.87 (95% CI 0.82, 0.91), I² 0%, P<0.00001, respectively), and similar findings were seen in the adjusted multivariate analysis. There was significantly lower odds for postpartum weight retention (OR: 0.20 (95% CI 0.05, 0.82)), I² 0%, P=0.03) and lower odds for composite neonatal morbidity in the overall obesity group with low GWG (OR: 0.93 (95% CI 0.87, 0.99)), I² 19.6%, P=0.04).

CONCLUSION

Contrary to previous reports, the current systematic review and meta-analysis showed no significant increase in SGA rates in pregnancies with weight gain below the current guidelines for all classes of maternal obesity. Furthermore, gaining below the guidelines was associated with lower LGA, PE, and CS rates. Our study provides the evidence that the current recommended GWG is high for all classes of obesity. These results provide pertinent information supporting the notion to revisit the current GWG recommendations for women with obesity and furthermore to classify them by the class of obesity rather than one overall obesity category as is done in the current recommendations.