|Year : 2022 | Volume
| Issue : 2 | Page : 63-68
Association of total gestational weight gain and maternal and perinatal outcomes among pregnant patients using the institute of medicine 2009 gestational weight gain guidelines in a tertiary hospital
Francesca Debbie L. Liu, Maria Michelle G. Borbe
Department of Obstetrics and Gynecology, Chinese General Hospital and Medical Center, 286 Blumentrit Road, Santa Cruz, Manila 1014 MetroManila, Philippines
|Date of Submission||15-Apr-2022|
|Date of Acceptance||30-Apr-2022|
|Date of Web Publication||5-Jul-2022|
Francesca Debbie L. Liu
MD, Department of Obstetrics and Gynecology, Chinese General Hospital and Medical Center, Manila
Source of Support: None, Conflict of Interest: None
BACKGROUND: The aim of the study was to determine the association between total gestational weight gain (TGWG) and maternal and perinatal outcomes based on the Institute of Medicine 2009 gestational weight gain (GWG) guidelines among pregnant patients of the department of obstetrics and gynecology in a tertiary hospital.
METHODOLOGY: Our analysis was carried out in a private hospital in Metro Manila, specifically in a tertiary hospital, in a prospective cohort study that included 565 pregnant women from June 1, 2020, to April 30, 2021. Body mass index (BMI) at initial prenatal visit <14 weeks' age of gestation and upon admission, birth weight, comorbidities were all assessed and recorded. Our main outcome measures were TGWG, perinatal outcomes (small for gestational age, large for gestational age, intrauterine fetal demise, and admission to neonatal intensive care unit), and maternal outcomes (gestational diabetes mellitus, gestational hypertension, preeclampsia/eclampsia, and preterm birth). The baseline anthropometric, maternal and neonatal outcomes were analyzed using mean, standard deviation, range and chi-square test was used to correlate total gestational weight gain against maternal and perinatal outcomes and a P-value less than 0.05 was statistically significant.
RESULTS: In this study, the mean BMI was 23.6 kg/m2, and based on BMI classification, 8% were underweight, whereas 28.1% and 9% were overweight and obese, respectively. Based on the recommendations of TGWG on each BMI category, using Chi-square test, there was a significant association of having excess GWG and inadequate GWG against maternal and perinatal outcomes.
CONCLUSION: Based on the study, women having excess or inadequate TGWG has effects on maternal and perinatal outcomes. Furthermore, women that are classified as overweight and obese in the first trimester have a higher risk of developing comorbidities.
Keywords: Gestational weight gain, obesity, overweight, pregnancy
|How to cite this article:|
Liu FD, Borbe MM. Association of total gestational weight gain and maternal and perinatal outcomes among pregnant patients using the institute of medicine 2009 gestational weight gain guidelines in a tertiary hospital. Philipp J Obstet Gynecol 2022;46:63-8
|How to cite this URL:|
Liu FD, Borbe MM. Association of total gestational weight gain and maternal and perinatal outcomes among pregnant patients using the institute of medicine 2009 gestational weight gain guidelines in a tertiary hospital. Philipp J Obstet Gynecol [serial online] 2022 [cited 2022 Aug 18];46:63-8. Available from: https://www.pogsjournal.org/text.asp?2022/46/2/63/349899
| Introduction|| |
Overweight and obesity carry a worldwide population epidemic rate that affects both genders, especially women, most significantly pregnant women, influencing one's daily routine and activities.[1-3]
In recent years, increased interest in gestational weight gain (GWG) led to the search for an optimal range of values, from the first prenatal visit of the woman until delivery, as it is seen a modifiable risk factor that may lower the incidence of maternal and neonatal adverse outcomes. The proposed guideline is by the Institute of Medicine (IOM) GWG 2009, by measuring prepregnancy body mass index (BMI, a measure of body fat based on weight and height) category and the World Health Organization (WHO) BMI classification for both international and Asian categories.,,,,, This value can be influenced by demographic status (e.g., age, ethnicity, marital status, socioeconomic status, gravidity and parity, educational level, and occupation), medical conditions (e.g., bronchial asthma, hypertension, Type 2 diabetes mellitus, or any autoimmune diseases), and finally, maternal and fetal adverse outcomes (e.g., maternal: increased risk to develop gestational diabetes mellitus and gestational hypertension; fetal: small or large gestational age).,,,,,,,,
However, the most published studies are on Western populations with scarce and scattered data from East Asian countries, and no established local evidence on BMI and GWG is available, which has led to this proposed study.
The significance of the study is to be able to gather and collate local data among obstetric patients from a tertiary hospital using a standardized and validated guideline for those who are excessively gaining weight and diagnosed during prenatal visits with gestational diabetes mellitus and gestational hypertension and referring them to a nutritionist and internist for proper management. Data are then analyzed to see which variables improve maternal and fetal outcomes.
Objectives of the study
- To determine the association of total GWG (TGWG) and maternal and perinatal outcomes based on the IOM 2009 GWG guidelines among pregnant patients of the department of obstetrics and gynecology in a tertiary hospital.
- To determine the association between TGWG and maternal outcomes among pregnant patients of the department of obstetrics and gynecology in a tertiary hospital
- To determine the association between TGWG and perinatal outcomes among pregnant patients of the department of obstetrics and gynecology in a tertiary hospital
- To determine the incidence of underweight, overweight, and obesity among pregnant patients and analyze its relation to maternal and neonatal outcomes.
| Methodology|| |
This study is a prospective cohort study among pregnant patients in a tertiary hospital, department of obstetrics and gynecology.
Setting of the study
The study was conducted in a tertiary hospital, department of obstetrics and gynecology from June 1, 2020, to April 30, 2021.
Study subject and target population
The study included pregnant patients who had their first prenatal checkup <14 weeks' age of gestation for both charity and pay divisions in the department of obstetrics and gynecology and those who were admitted and delivered in the delivery room complex from June 1, 2020, to April 30, 2021. Written informed consents were obtained from all participants. The results and patient information were kept strictly confidential.
- At least 18 years old
- Singleton pregnancy
- Primigravid or multigravid
- ≤14 weeks' age of gestation on the first prenatal checkup.
- More than 14 weeks' age of gestation on the first prenatal checkup
- Multifetal pregnancy
- Patients delivered ≤29 weeks' age of gestation
- With the previous history of congenital anomaly, stillbirth, intrauterine growth restriction, preterm birth, small and large for gestational age neonate, and assisted reproductive technology
- With noted comorbidities such as hypertension, diabetes mellitus, bronchial asthma, and other medical conditions on the first prenatal checkup
- Confirmed fetal congenital anomalies on ultrasound during pregnancy
- Patients with known uterine tumor and malformation.
Sample size calculation
Using Epi Info 7, the sample size was computed using a 95% confidence level, 80% power, 37% GWG above the guidelines in Asia, and 1.63 risks of large for gestation age (LGA) among neonates from the study by Goldstein et al. (2018). The minimum sample size needed is 542 Filipino mothers [Figure 1].
|Figure 1: Unmatched cohort and cross-sectional studies (exposed and nonexposed)|
Click here to view
Data collection procedure
Participants were screened at our outpatient department during their first prenatal checkup held every Monday, Wednesday, and Friday; and also, was interviewed during admission at the delivery room complex. Appropriate informed consent form was discussed and given to the patient. Sociodemographic status of the participants such as age, height, weight, gravidity or parity, occupation, education status, and past medical history were obtained. At the first prenatal checkup and/or during admission, BMI was calculated as the first weight (in kg)/height (in m2). First visit BMI was used as an estimate for the first trimester BMI with the assumption that there was negligible weight gain in the early trimester. Similarly, on admission of the participants, weight (in kg) and height (in m2) were taken and used to calculate the third trimester BMI. Those participants who met the inclusion criteria were included in the study population and will be followed up postpartum for maternal and perinatal outcomes.
Descriptive analysis of the baseline, anthropometric, and maternal and neonatal outcomes will be determined. The continuous variable will be described using mean, standard deviation, and range. The categorical variables will be described using frequency and percentage. Logistic regression will be used to determine the association between the sociodemographic and clinical factors with maternal and neonatal outcomes. The odds ratio and 95% confidence interval will be used to measure the association. A P < 0.05 is statistically significant.
| Results|| |
There were 565 pregnant women attending prenatal care in a tertiary hospital that was included in this study. The average age of pregnant women was 29.6 years, with 33.5 percent being 25–29 years old; 90.4 percent were Filipinos, with the majority being gravida 1 (60.7 percent), parity 0 (60.7 percent), 71.7 percent employed, 81.8 percent college graduate, 4.4 percent prior smokers, and 0.7 percent present alcohol drinker [Table 1]. Based on World Health Organization (WHO) BMI classification, there were 28.1% overweight and 9% obese among pregnant women included. Majority of participants had normal pre-pregnancy BMI (54.9%) [Table 2].
|Table 1: Sociodemographic characteristics of pregnant women attending prenatal care|
Click here to view
|Table 2: Distribution of study population based on the World Health Organization body mass index classification|
Click here to view
The TGWG with reference to the IOM recommendations for different BMI groups was significant using Chi-square test with P = 0.033. There were 83% or 15% had excess GWG, and 13% with inadequate GWG. Forty-nine percent of those who had excess GWG were those with a normal prepregnancy BMI and had a mean GWG of 13.3 (3.4) kg [Table 3].
|Table 3: Total gestational weight gain with reference Institute of Medicine recommendations for different body mass index groups|
Click here to view
Perinatal outcomes were associated with TGWG with 100% of excess GWG had large for gestational age neonates, and 41% of those were admitted to the neonatal intensive care unit (NICU) [Table 4].
|Table 4: Association of total gestational weight gain and perinatal outcomes|
Click here to view
There was a significant association between TGWG and maternal outcomes such as gestational diabetes mellitus, preeclampsia/eclampsia, and preterm birth. Thirty percent of pregnant women included in the study with excess GWG had gestational diabetes mellitus, followed by 9.6% developed gestational hypertension, 1.2% had preeclampsia/eclampsia, and 1.2% had preterm birth [Table 5].
|Table 5: Association of total gestational weight gain and adverse maternal outcome|
Click here to view
| Discussion|| |
According to the IOM and National Research Council in 2009, the newly revised guidelines for GWG in pregnancy were established based on prepregnancy BMI. Wherein the prepregnancy BMI was categorized into four groups: underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥30.0 kg/m2). Each category has its corresponding weight gain range for the entire duration of pregnancy.
Several studies mentioned prepregnancy weight has a substantial contribution to maternal and neonatal outcomes classified as underweight has been linked to a higher risk of preterm delivery, low birth weight, intrauterine growth restriction, and small gestational age neonates.,,,, On the other hand, classified under overweight or obese also has presented with large gestational age, macrosomic neonates, and in turn, higher risk to undergo labor induction, cesarean, or operative vaginal deliveries. Moreover, studies observed having excess GWG has increased in the development of gestational diabetes mellitus, gestational hypertension, or preeclampsia.,,,,,
In this study, 565 Filipino pregnant were included, and the mean BMI was 23.6 kg/m2; based on BMI classification, there were 28.1% overweight and 9% obese. Using a Chisquare test with a P < 0.05, it was discovered that having an excess GWG was associated with 30.1 percent gestational diabetes mellitus, 9.6 percent gestational hypertension, 1.2 percent preeclampsia and preterm birth, and 100% of neonates were large gestational age, with 41% of these LGA neonates being admitted to the NICU. Meanwhile, inadequate weight gain was also significant of having small gestational weight neonate and preterm birth of 91% and 21.9%, respectively.
These results highlight the importance of proper weight management during pregnancy and further drive the point that excessive weight gain during pregnancy increases the risk for adverse maternal and neonatal outcomes.,,,,,,,,,, Results also reflected the same concerns and associations between TGWG and adverse outcomes found in different studies. These local data show evidence that these issues are present, and advocacies on specific interventions and policies on weight gain in pregnancy are needed to further drive home the point and effects of TGWG and adverse maternal and neonatal outcomes.
| Conclusion|| |
The present study showed that when a pregnant woman is categorized as underweight, overweight, and obese, they are already at risk of having maternal and perinatal outcomes. The data outcome suggests that there is an association between TGWG versus to its maternal outcomes (developing gestational diabetes, gestational hypertension, preeclampsia, and preterm birth) and perinatal outcomes (small or large for gestational age, intrauterine fetal demise, and admission to the NICU). The study also shows that there was a significant percentage of women who has excess GWG even in low-risk pregnancies with a normal prepregnancy BMI and a higher risk of having large for gestational age neonates. As further elaborated above, these local data might jumpstart for other studies to be done on TGWG and other causal effects.
Limitations and recommendations of the study
This study recommends a larger sample size, wherein pregnant women can be classified into low-risk and high-risk groups and can be correlated well with socioeconomic status and levels of support during the course of pregnancy. In addition, a follow-up study can also be done on the route of delivery against TGWG. Women, who are at higher risk of developing complicated medical conditions postpartum, can be referred to a specialist for further evaluation and management.
Being a prospective study, there are no physical potential risks to research subjects, however, some personal information of the subjects will be obtained as well as some sensitive information may be asked, so there may be risks associated with loss of privacy.
As this is a prospective study, there are no physical potential benefits to individual research subjects. Potential benefits may be to further study the incidence of excessive GWG based on the IOM 2009 GWG guidelines among pregnant patients in a tertiary hospital at risk of having maternal and perinatal outcomes. Furthermore, this study may also help obstetricians on how to deal with patients at the risk of having maternal and neonatal adverse outcomes and know when to refer to other services for comanagement.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gilmore LA, Redman LM. Weight gain in pregnancy and application of the 2009 IOM Guidelines: Toward a uniform approach. Obesity (Silver Spring) 2015;23:507-11.
Zheng W, Huang W, Zhang Z, Zhang L, Tian Z, Li G, et al.
Patterns of gestational weight gain in women with overweight or obesity and risk of large for gestational age. Obes Facts 2019;12:407-15.
Yu Z, Han S, Zhu J, Sun X, Ji C, Guo X. Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: A systematic review and meta-analysis. PLoS One 2013;8:e61627.
Institute of Medicine. Weight Gain during Pregnancy: Reexamining the Guidelines. Washington, DC: Institute of Medicine; 2009.
Soltani H, Lipoeto N, Fair F, Kilner K, Yusrawati Y. Pre-pregnancy body mass index and gestational weight gain and their. Effects on pregnancy and birth outcomes: a cohort study in West Sumatra, Indonesia. BMC Women's Health 2018;17:102. DOI 10.1186/s12905-017-0455-2.
Kominiarek M, Peaceman A. Gestational weight gain. Am J Obstet Gynecol 2017;217:642-51.
Sahin ME, Madendag IC. Effect of gestational weight gain on perinatal outcomes in low risk pregnancies with normal prepregnancy body mass index. Hindawi Biomed Res Int 2019;2019:3768601.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63.
Li C, Liu Y, Zhang W. Joint and independent associations of gestational weight gain and pre-pregnancy body mass index with outcomes of pregnancy in Chinese women: A retrospective cohort study. PLoS One 2015;10:e0136850.
Gondwe A, Ashorn P, Ashorn U, Dewey KG, Maleta K, Nkhoma M, et al
. Pre-pregnancy body mass index (BMI) and maternal gestational weight gain are positively associated with birth outcomes in Rural Malawi. PLoS One 2019;13:e0206035.
Kominiarek M, Saade G, Mele L, Bailit J, Reddy UM, Wapner RJ, et al.
Association between gestational weight gain and perinatal outcomes. Obstet Gynecol 2018;132:875-81.
Goldstein RF, Abell SK, Ranasinha S, Misso M, Boyle JA, Black MH, et al.
Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis. JAMA 2017;317:2207-25.
Goldstein RF, Abell SK, Ranasinha S, Misso ML, Boyle JA, Harrison CL, et al
. Gestational weight gain across continents and ethnicity: Systematic review and meta-analysis of maternal and infant outcomes in more than 1 million women. BMC Med 2018;16:153.
Ramakrishnan U, Grant F, Goldberg T, Zongrone A, Martorell R. Effect of womens nutrition before and during early pregnancy on maternal and infant outcomes: A systematic review. Paediatr Perinat Epidemiol 2012;26 Suppl 1:285-301.
Hsieh TT, Liou JD, Hsu JJ, Lo LM, Chen SF, Hung TH. Advanced maternal age and adverse perinatal outcomes in an Asian population. Eur J Obstet Gynecol Reprod Biol 2010;148:21-6.
Diemert A, Leziu S, Pagenkemper M, Hansen G, Drozdowska A, Hecher K, et al.
Maternal nutrition, inadequate gestational weight gain and birth weight: Results from a prospective birth cohort. BMC Pregnancy Childbirth 2016;16:224.
Johansson K, Hutcheon JA, Bodnar LM, Cnattingius S, Stephansson O. Pregnancy weight gain by gestational age and stillbirth: A population-based cohort study. BJOG 2018;125:973-81.
Han Z, Mulla S, Beyene J, Liao G, McDonald SD; Knowledge Synthesis Group. Maternal underweight and the risk of preterm birth and low birth weight: A systematic review and meta analyses. Int J Epidemiol 2011;40:65-101.
Ben Naftali Y, Solt I, Lowenstein L, Chermesh I. Gestational weight gain and its relationship with maternal characteristics. Isr Med Assoc J 2017;19:309-12.
Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al
. Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer: 2006-08. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. Int J Obstet Gynaecol (BJOG) 2011;118 Suppl 1:1-203.
Lean SC, Derricott H, Jones RL, Heazell AE. Advanced maternal age and adverse pregnancy outcomes: A systematic review and meta-analysis. PLoS One 2017;12:e0186287.
Samura T, Steer J, Michelis LD, Carroll L, Holland E, Perkins R. Factors associated with excessive weight gestational weight gain: Review of current literature. Global Adv Health Med 2016;5:87-93.
Kanade AN, Rao S, Kelkar RS, Gupte S. Maternal nutrition and birth size among urban affluent and rural women in India. J Am Coll Nutr 2008;27:137-45.
Lartey A. Maternal nutrition and birth size among urban affluent and rural woman in India. Proc Nutr Soc 2008;67:105-8.
Yang W, Han F, Gao X, Chen Y, Ji L, Cai X. Relationship between gestational weight gain and pregnancy complications or delivery outcomes. Sci Rep 2017;7:12531.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]