Rating the seriousness of maternal and child health outcomes linked with pregnancy weight gain

Gestational weight gain below recommendations and adverse maternal and child health outcomes for pregnancies with overweight or obesity: a US cohort study

BACKGROUND

The current Institute of Medicine pregnancy weight gain guidelines were developed using the best available evidence, but were limited by substantial knowledge gaps. Some have raised concern that the guidelines for individuals affected by overweight or obesity are too high and contribute to short- and long-term complications for the mother and child.

OBJECTIVE

To determine the association between pregnancy weight gain below the lower limit of the current Institute of Medicine (IOM) recommendations and risk of 10 adverse maternal and child health outcomes among individuals with overweight and obesity.

METHODS

We used data from a prospective cohort study of US nulliparae with prepregnancy overweight (n=955) or obesity (n=897) followed from the first trimester to 2-7 years postpartum. We used multivariable Poisson regression to relate pregnancy weight gain z-scores with a severity-weighted composite outcome consisting of ≥1 of 10 adverse outcomes (gestational diabetes, preeclampsia, unplanned cesarean delivery, maternal postpartum weight increase >10kg, maternal postpartum metabolic syndrome, infant death, stillbirth, preterm birth, small-for-gestational age birth, and childhood obesity).

RESULTS

Pregnancy weight gain z-scores below, within, and above the IOM-recommended ranges occurred in 5%, 13%, and 80% of pregnancies with overweight and 17%, 13%, and 70% of pregnancies with obesity. There was a positive association between pregnancy weight gain z-scores and all adverse maternal outcomes, childhood obesity, and the composite outcome. Pregnancy weight gain z-scores below the lower limit of the recommended ranges (<6.8 kg for overweight, <5 kg for obesity) were not associated with the severity-weighted composite outcome. For example, compared with the lower limit, adjusted rate ratios (95% confidence interval) for z-scores of -2 standard deviations in pregnancies with overweight (equivalent to 3.6kg at 40 weeks) and obesity (-2.8kg at 40 weeks) were 0.99 (0.91, 1.06) and 0.97 (0.87, 1.07).

CONCLUSIONS

These findings support arguments to decrease the lower limit of recommended weight gain ranges in these prepregnancy BMI groups.

Safety of low weight gain or weight loss in pregnancies with class 1, 2, and 3 obesity: a population-based cohort study

BACKGROUND

There are concerns that current gestational weight gain recommendations for women with obesity are too high and that guidelines should differ on the basis of severity of obesity. In this study we investigated the safety of gestational weight gain below current recommendations or weight loss in pregnancies with obesity, and evaluated whether separate guidelines are needed for different obesity classes.

METHODS

In this population-based cohort study, we used electronic medical records from the Stockholm-Gotland Perinatal Cohort study to identify pregnancies with obesity (early pregnancy BMI before 14 weeks' gestation ≥30 kg/m2) among singleton pregnancies that delivered between Jan 1, 2008, and Dec 31, 2015. The pregnancy records were linked with Swedish national health-care register data up to Dec 31, 2019. Gestational weight gain was calculated as the last measured weight before or at delivery minus early pregnancy weight (at <14 weeks' gestation), and standardised for gestational age into z-scores. We used Poisson regression to assess the association of gestational weight gain z-score with a composite outcome of: stillbirth, infant death, large for gestational age and small for gestational age at birth, preterm birth, unplanned caesarean delivery, gestational diabetes, pre-eclampsia, excess postpartum weight retention, and new-onset longer-term maternal cardiometabolic disease after pregnancy, weighted to account for event severity. We calculated rate ratios (RRs) for our composite adverse outcome along the weight gain z-score continuum, compared with a reference of the current lower limit for gestational weight gain recommended by the US Institute of Medicine (IOM; 5 kg at term). RRs were adjusted for confounding factors (maternal age, height, parity, early pregnancy BMI, early pregnancy smoking status, prepregnancy cardiovascular disease or diabetes, education, cohabitation status, and Nordic country of birth).

FINDINGS

Our cohort comprised 15 760 pregnancies with obesity, followed up for a median of 7·9 years (IQR 5·8-9·4). 11 667 (74·0%) pregnancies had class 1 obesity, 3160 (20·1%) had class 2 obesity, and 933 (5·9%) had class 3 obesity. Among these pregnancies, 1623 (13·9%), 786 (24·9%), and 310 (33·2%), respectively, had weight gain during pregnancy below the lower limit of the IOM recommendation (5 kg). In pregnancies with class 1 or 2 obesity, gestational weight gain values below the lower limit of the IOM recommendation or weight loss did not increase risk of the adverse composite outcome (eg, at weight gain z-score -2·4, corresponding to 0 kg at 40 weeks: adjusted RR 0·97 [95% CI 0·89-1·06] in obesity class 1 and 0·96 [0·86-1·08] in obesity class 2). In pregnancies with class 3 obesity, weight gain values below the IOM limit or weight loss were associated with reduced risk of the adverse composite outcome (eg, adjusted RR 0·81 [0·71-0·89] at weight gain z-score -2·4, or 0 kg).

INTERPRETATION

Our findings support calls to lower or remove the lower limit of current IOM recommendations for pregnant women with obesity, and suggest that separate guidelines for class 3 obesity might be warranted.

FUNDING

Karolinska Institutet and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Do current pregnancy weight gain guidelines balance risks of adverse maternal and child health in a United States cohort?

BACKGROUND

The Institute of Medicine pregnancy weight gain guidelines were developed without evidence linking high weight gain to maternal cardiometabolic disease and child obesity. The upper limit of current recommendations may be too high for the health of the pregnant individual and child.

OBJECTIVES

The aim of this study was to identify the range of pregnancy weight gain for pregnancies within a normal body mass index (BMI) range that balances the risks of high and low weight gain by simultaneously considering 10 different health conditions.

METHODS

We used data from an United States prospective cohort study of nulliparae followed until 2 to 7 y postpartum (N = 2344 participants with a normal BMI). Pregnancy weight gain z-score was the main exposure. The outcome was a composite consisting of the occurrence of ≥1 of 10 adverse health conditions that were weighted for their seriousness. We used multivariable Poisson regression to relate weight gain z-scores with the weighted composite outcome.

RESULTS

The lowest risk of the composite outcome was at a pregnancy weight gain z-score of -0.6 SD (standard deviation) (equivalent to 13.1 kg at 40 wk). The weight gain ranges associated with no more than 5%, 10%, and 20% increase in risks were -1.0 to -0.2 SD (11.2-15.3 kg), -1.4 to 0 SD (9.4-16.4 kg), and -2.0 to 0.4 SD (7.0-18.9 kg). When we used a lower threshold to define postpartum weight increase in the composite outcome (>5 kg compared with >10 kg), the ranges were 1.6 to -0.7 SD (8.9-12.6 kg), -2.2 to -0.3 SD (6.3-14.7 kg), and ≤0.2 SD (≤17.6 kg). Compared with the ranges of the current weight gain guidelines (-0.9 to -0.1 SD, 11.5-16 kg), the lower limits from our data tended to be lower while upper limits were similar or lower.

CONCLUSIONS

If replicated, our results suggest that policy makers should revisit the recommended pregnancy weight gain range for individuals within a normal BMI range.

Weight Loss, Stability, and Low Weight Gain during Pregnancy among Individuals with Obesity: Associations with Adverse Perinatal Outcomes: An Observational Study

OBJECTIVE

 The safety of weight loss and low weight gain during pregnancy remains unclear. To determine how different patterns of gestational weight gain (GWG), including weight loss, stability, and low GWG relate to perinatal outcomes by prepregnancy obesity class.

STUDY DESIGN

 The study population included 29,408 singleton livebirths among pregnant people with obesity from Kaiser Permanente Northern California (2008-2013). Clinically measured GWG was grouped into meaningful categories (Adequate: reference, met 2009 National Academy of Medicine [NAM] Guidelines [5-9.1 kg], Excessive [>9.1 kg], Low [1-4.9 kg], Stable [±1 kg], Weight Loss [>1 kg]) or GWG Z-score quintiles. Modified Poisson regression was used to estimate risk of adverse outcomes, stratified by obesity class. Electronic health record data were used to define outcomes, including cesarean delivery, preterm birth, admission to the neonatal intensive care unit, small- and large-for-gestational age infants.

RESULTS

 Prevalence of weight stability and weight loss was 3.8 and 3.4%, respectively. Compared with those who gained within NAM, increased risk of small-for-gestational age was observed among those with weight loss among obesity class I (Risk Ratio (RR): 1.57, 95% confidence interval [CI]: 1.12, 2.19), obesity class II (RR: 2.18, 95% CI: 1.52, 3.13), and obesity class III (RR: 1.72, 95% CI: 1.21, 2.45). Weight loss was associated with a decreased risk of cesarean delivery among obesity class III, compared with NAM.

CONCLUSION

 Weight loss during pregnancy is associated with increased risk of small-for-gestational age among all obesity classes, but not other adverse perinatal outcomes and may reduce risk of cesarean delivery. Low weight gain and weight stability are not associated with risk of adverse outcomes among those with class III obesity. GWG guidelines may need to vary by obesity class.

KEY POINTS

· Weight loss during pregnancy is associated with increased risk of small-for-gestational age among all obesity classes; but weight loss was not associated with other adverse perinatal outcomes.. · Among class III, low weight gain and weight stability are not associated with adverse perinatal outcomes.. · GWG guidelines may need to vary by obesity class..

Identifying optimal ranges of weight gain at the end of the second trimester result from a population-based cohort study

OBJECTIVE

To identify the optimal weight gain at the end of the second trimester.

DESIGN

This was a population-based cohort study from the antenatal care system in Tianjin, China. We calculated gestational weight gain (GWG) based on the weight measured in the first trimester and the end of the second trimester. Restricted cubic spline analysis was performed to model the possible non-linear relationships between GWG and adverse outcomes. The optimal GWG was defined as the value of the lowest risk. Non-inferiority margins and the shape of the spline curves identified the recommended ranges in Chinese-specific BMI categories.

SETTING

Tianjin Maternal and Child Health Cohort.

PARTICIPANTS

Singleton pregnant women aged 18-45 years.

RESULTS

In total, 69 859 pregnant women were included. Adverse outcome (including stillbirth, preterm birth, hypertensive disorders of pregnancy, gestational diabetes mellitus, small and large for gestational age) was significantly associated with GWG at the end of the second trimester. The risk score was non-linearly correlated with GWG in the underweight, normal weight and overweight groups. GWG at the end of the second trimester should not be < 7 kg in underweight group. For most normal-weight women, a GWG of about 8 kg is optimal. Pregnant women who are overweight should not have a GWG of more than 9 kg. We advised women with overweight and obesity to keep positive growth of GWG (> 0 kg) in the first and second trimesters.

CONCLUSIONS

According to the comprehensive adverse maternal and infant outcomes, we recommend the optimal GWG at the end of the second trimester. This study may provide a considerable reference for weight management.

Associations between antidepressant use patterns during pregnancy and birth outcomes among periconception antidepressant users

BACKGROUND

Little is known about antidepressant medication use patterns during pregnancy among periconception (before and immediately following conception) users. Additionally, the associations between these patterns and birth outcomes is unclear, after taking into account underlying depression severity.

OBJECTIVE

This study describes patterns of antidepressant use among periconception users and examines associations between usage patterns and birth outcomes.

STUDY DESIGN

This retrospective cohort study included pregnant Kaiser Permanente Northern California (KPNC) members with a live birth between 2014 and 2017 and an antidepressant medication fill that overlapped the 8th week of pregnancy. Outcomes were preterm birth and neonatal intensive care unit (NICU) admission. Data were extracted from KPNC's electronic health records. Modified Poisson regression was conducted.

RESULTS

Of the 3637 pregnancies meeting inclusion criteria, 33% (n = 1204) continued antidepressant use throughout the pregnancy (refilled throughout pregnancy), 47% (n = 1721) discontinued use (no refills), and 20% (n = 712) stopped and reinitiated use (refill after 30+ day gap in supply). Women who continued use had 1.86 (95% confidence interval (CI) 1.53, 2.27) times the risk of preterm birth and 1.76 (95% CI: 1.42, 2.19) times the risk of NICU admission, compared to women who discontinued use during pregnancy. Similarly, women with continued use had 1.66 (95% CI: 1.27, 2.18) times the risk of preterm birth and 1.85 (95% CI: 1.39, 2.46) times the risk of NICU admission, compared to women who stopped and reinitiated use. This relationship held when examining continuous exposure; the relationship between continuous exposure and preterm delivery was stronger in later trimesters.

CONCLUSIONS

Periconception antidepressant users who continue use during pregnancy, particularly into the second and third trimesters, may be at higher risk of adverse birth outcomes. This evidence should be considered alongside the risks associated with depression relapse.

The impact of panel composition and topic on stakeholder perspectives: Generating hypotheses from online maternal and child health modified-Delphi panels

Introduction

Multistakeholder engagement is crucial for conducting health services research. Delphi‐based methodologies combining iterative rounds of questions with feedback on and discussion of group results are a well‐documented approach to multistakeholder engagement. This study develops hypotheses about the impact of panel composition and topic on the propensity and meaningfulness of response changes in multistakeholder modified‐Delphi panels.

Methods

We conducted three online modified‐Delphi (OMD) multistakeholder panels using the same protocol. We assigned 60 maternal and child health professionals to a homogeneous (professionals only) panel, 60 pregnant or postpartum women (patients) to a homogeneous panel, and 30 professionals and 30 patients to a mixed panel. In Round 1, participants rated the seriousness of 11 maternal and child health outcomes using a 0–100 scale and explained their ratings. In Round 2, participants saw their own and their panel's Round 1 results and discussed them using asynchronous, anonymous discussion boards moderated by the study investigators. In Round 3, participants revised their original ratings. Our outcome measures included binary indicators of response changes to ratings of the low, medium and high severity maternal and child health outcomes and their meaningfulness, measured by a change of 10 or more points.

Results

Participants changed 818 of 1491 (55%) of responses; the majority of response changes were meaningful. Patterns of response changes were different for patients and professionals and for different levels of outcome seriousness. Using study results and the literature, we developed three hypotheses. First, OMD participants, regardless of their stakeholder group, are more likely to change their responses on preference‐sensitive topics where there is a range of viable alternatives or perspectives. Second, patients are more likely to change their responses and to do so meaningfully in mixed panels, whereas professionals are more likely to do so in homogeneous panels. Third, the association between panel composition and response change varies according to the topic (e.g., the level of outcome seriousness).

Conclusions

Results of our work not only helped generate empirically derived hypotheses to be tested in future research but also offer practical recommendations for designing multistakeholder OMD panels.

Patient or Public Contribution

Pregnant or postpartum women were involved in this study.