Debbie Rhea

The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes.

Objective. To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM). Methods. Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI ≥ 30 kg/m2) and non-obese (pre-pregnancy BMI < 30 kg/m2) women and for women across five increasing pre-pregnancy BMI categories. Results. A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes. Conclusion. In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

The Impact of Maternal Obesity on the Incidence of Adverse Pregnancy Outcomes in High-Risk Term Pregnancies

We investigated the impact of maternal obesity on pregnancy outcomes. Women with normal or obese body mass index (BMI) who delivered singleton infants at term were identified from a perinatal database. Rates of pregnancy complications and neonatal outcomes were compared between women with normal prepregnancy BMI (20 to 24.9 kg/m (2), N = 9171) and those with an obese prepregnancy BMI (> or = 30, N = 3744). Rates of pregnancy complications and neonatal outcomes were also evaluated by the level of obesity (obese [30 to 34.9 kg/m (2), N = 2106], severe obesity [35 to 39.9 kg/m (2), N = 953], and morbid obesity [> or = 40 kg/m (2), N = 685]). Rates of gestational diabetes (12.0% versus 3.7%, P < 0.001, odds ratio [95% confidence interval] = 3.5 [3.0, 4.1]) and gestational hypertension (30.9% versus 9.0%, P < 0.001, odds ratio [95% confidence interval] = 4.5 [4.1, 5.0]) were higher for obese versus normal BMI gravidas, respectively. Women with morbid or severe obesity had a greater incidence of gestational diabetes than women with an obese (30 to 34.9 kg/m (2)) or normal BMI (14.1%, 16.4%, 9.6%, and 3.7%, respectively; P < 0.05). The incidence of gestational hypertension increased with maternal BMI (9.0% normal, 25.5% obese, 33.7% severe, 43.4% morbid; all pairwise comparisons P < 0.05). Obese versus normal BMI was associated with more higher-level nursery admissions (8.2% versus 5.8%) and large-for-gestational age infants (12.3% versus 6.5%; P < 0.001). Obesity places a term pregnancy at risk for adverse maternal and neonatal outcomes.

A Randomized Multicenter Study to Determine the Efficacy of Activity Restriction for Preterm Labor Management in Patients Testing Negative for Fetal Fibronectin

OBJECTIVE:To assess the impact of activity restriction (AR) on the incidence of preterm birth in women treated for preterm labor testing negative for fetal fibronectin (fFN).STUDY DESIGN:Women who were diagnosed with preterm labor and tocolyzed with magnesium sulfate were concurrently screened with fFN for the purpose of subsequent management. Included were consenting patients with negative fFN, gestational age 23 0/7–33 6/7 weeks, cervical dilation ≤3 cm, and minimal vaginal bleeding. Patients were randomized to AR or no AR. Primary study outcome was incidence of preterm delivery and interval from randomization to delivery.RESULTS:A total of 73 women with negative fFN were randomized (36 with AR, 37 without AR). The overall preterm birth rate was 40%, with 44.4% of patients with AR and 35.1% of patients without AR delivering preterm, p=0.478.CONCLUSION:Maternal AR did not impact pregnancy outcome. The incidence of preterm birth in symptomatic women testing fFN negative was higher than previously reported.

The effect of new antepartum weight gain guidelines and prepregnancy body mass index on the development of pregnancy-related hypertension.

We evaluated the impact of adherence to the new Institute of Medicine weight gain guidelines within each prepregnancy body mass index (PPBMI) category on the development of pregnancy-related hypertension (PRH). Patients with singleton term deliveries (≥37 weeks) with documented PPBMI and pregnancy weight gain information were identified from a database of women enrolled for outpatient nursing services. Included were women without history of cardiovascular disease, PRH, or diabetes at initiation of services (N = 7676). Data were stratified by PPBMI (underweight = < 18.5 kg/m(2); normal weight = 18.5 to 24.9 kg/m(2); overweight = 25.0 to 29.9 kg/m(2); obese = ≥ 30.0 kg/m(2)). PRH rates were compared overall and within each PPBMI group for those women gaining less than recommendations, within recommendations, and above recommendations using Pearsons chi-square and Kruskal-Wallis H test statistics. Overall, PRH rates were 5.0%, 5.4%, and 10.8% for less than, within, and above recommendation groups, respectively (P < 0.001). Above recommendation weight gain resulted in higher PRH incidence in each PPBMI category (underweight 7.6%, normal weight 6.2%, overweight 12.4%, and obese 17.0%), reaching statistical significance in all but the underweight PPBMI group. Excessive weight gain above established guidelines was associated with increased rates of PRH. Regardless of PPBMI, women should be counseled to avoid excessive weight gain during pregnancy.

The Coexistence of Gestational Hypertension and Diabetes: Influence on Pregnancy Outcome

Gestational hypertension (GHTN) and gestational diabetes mellitus (GDM) are both insulin resistance states. Perinatal outcome of GHTN or GDM alone are well established, but their combined effect on pregnancy outcome is underinvestigated. Our objective was to determine if pregnancies complicated by GHTN/GDM have higher rates of morbidity. We identified nulliparous women with singleton pregnancies delivering at 37 to 40 weeks of gestation from 1995 to 2004 from a database. Outcomes of pregnancies complicated by GHTN only, GDM only, or combined GHTN/GDM were compared with controls. Data analysis included the Mann-Whitney U test, the Kruskal-Wallis H test, and analysis of variance. Multivariate analysis was used to adjust for confounders. Of 14,880 patients, there were 11,349 controls, 2604 GHTN, 728 GDM, and 199 GHTN/GDM. After controlling for covariates, GHTN significantly increased cesarean section (C/S) rate (odd ratio [OR], 1.62; confidence interval [CI], 1.47 to 1.78), rates of admittance to the neonatal intensive care unit (NICU), and birth of large for gestational age (LGA) infants. GDM significantly increased C/S (OR, 1.42; CI 1.21 to 1.66), rates of NICU admission (OR, 1.32; CI, 1 to 1.75), birth of LGA (OR, 1.51; CI 1.14 to 1.98), and macrosomic infants (OR, 1.53; CI, 1.12 to 2.08). Rates of LGA infants (OR, 1.85; CI, 1.19 to 2.86) and C/S (OR, 2.03; CI, 1.52 to 2.71) were significantly increased with GHTN/GDM. We concluded that GHTN or GDM is associated with increased rates of adverse outcomes. Their coexistence further increases adverse perinatal outcomes.

The association of gestational weight gain per institute of medicine guidelines and prepregnancy body mass index on outcomes of twin pregnancies.

OBJECTIVE To determine if current recommendations for weight gain in twin pregnancies according to maternal prepregnancy body mass index (PPBMI) influence perinatal outcomes. METHODS We identified women with twins enrolled in a maternity risk screening and education program with initial screening and prenatal care initiated at <20 weeks and delivery at >23.9 weeks. Women with normal, overweight, or obese PPBMI were included (n = 5129). Pregnancy outcomes were compared between those women with weight gain meeting or exceeding 2009 Institute of Medicine recommendations and patients who did not meet weight gain guidelines. RESULTS Rates of spontaneous preterm delivery at <35 weeks were higher in all PPBMI groups for those with weight gain below guidelines. In all PPBMI groups, numbers of pregnancies with both infants weighing >2500 g or >1500 g were significantly higher for women gaining weight at or above guidelines. Logistic regression analysis was utilized to assess multivariate impact on outcome of spontaneous preterm delivery at <35 weeks showing that regardless of PPBMI level, women who gain below recommended guidelines are 50% more likely to deliver spontaneously at <35 weeks. CONCLUSION In twin pregnancies, weight gain below recommended guidelines determined by maternal PPBMI is associated with higher rates of spontaneous preterm delivery at <35 weeks.

Indicated and non-indicated preterm delivery in twin gestations: impact on neonatal outcome and cost.

OBJECTIVE:To identify the etiology and impact of preterm delivery in twin gestations.STUDY DESIGN:Twin gestations delivered at 33.0 to 36.9 weeks were identified in a perinatal database, and categorized by indication for delivery. Deliveries were identified as indicated, or non-indicated (discretionary). Neonatal outcomes were measured by birth weight, length of stay, NICU admission, and ventilator utilization. Data were divided and analyzed by indicated or discretionary delivery, and gestational age at delivery.RESULTS:Analyzed were 3252 twin gestations (6504 infants), with 78% having indicated delivery. Of the 22% with discretionary delivery, nearly 40% required NICU admission. With each advancing week of gestation, there was a significant decrease in incidence of NICU admission and nursery days.CONCLUSION:The majority of preterm deliveries were indicated, though 22% were discretionary. It is vital to consider neonatal morbidity and costs related to gestational age when choosing discretionary delivery.

Treatment of Severe Nausea and Vomiting of Pregnancy with Subcutaneous Medications

We examined treatment outcomes in women with severe nausea and vomiting of pregnancy (NVP) receiving outpatient nursing support and either subcutaneous metoclopramide or subcutaneous ondansetron via a microinfusion pump. Among women receiving outpatient nursing services, we identified those diagnosed with severe NVP having a Pregnancy-Unique Quantification of Emesis (PUQE) score of greater than 12 at enrollment and prescribed either metoclopramide (N = 355) or ondansetron (N = 521) by their physician. Maternal characteristics, response to treatment, and start versus stop values were compared between the medication groups. Allocation to group was based on intention-to-treat protocol. Maternal characteristics were similar between the groups. Days to reduction in PUQE score levels were similar (median 2 days, metoclopramide; 3 days, ondansetron; P = 0.206). Alteration from metoclopramide to ondansetron (31.8%) was more frequent than alteration from ondansetron to metoclopramide (4.4%; P < 0.001). Improvement of NVP symptoms and reduced need for hospitalization was noted with both medications. Treatment with either metoclopramide or ondansetron resulted in significant improvement of NVP symptoms with half of women showing a reduction from severe symptoms to moderate or mild symptoms within 3 days of treatment initiation. Alteration in treatment was significantly greater in patients initially prescribed metoclopramide.

The reliability of patient-reported pregnancy outcome data.

Pregnancy and neonatal outcome information is frequently used in disease management to evaluate the cost-effectiveness of prenatal interventions and for other research and reporting activities. The purpose of this study was to determine if a telephone interview process is a reliable methodology for collecting pregnancy outcomes. High-risk patients from a large maternal-fetal medicine practice who received outpatient preterm labor management services from January 1996 to June 2001 were identified. Patient-reported pregnancy outcome data for 285 mothers and 478 infants were collected via a telephone interview by a perinatal nurse and compared to pregnancy outcome data abstracted from the maternal and infant hospital records. Overall, concordance and/or Kappa coefficients between maternal report and the medical record were high for delivery date (96.4%), birth weight within 100 grams (88.9%), Cesarean delivery (99.0%, Kappa = 0.98), and high-level nursery admission (91.2%, Kappa = 0.82). Both singleton and multiple gestation types accurately reported pregnancy outcome information. A telephone interview with a skilled nurse can be a reliable methodology for collection of valuable clinical and research data related to pregnancy outcome. Data collected in this manner and maintained in a database may be used with a high level of confidence by health care providers, payers, and researchers.

Adverse pregnancy outcomes in women with nausea and vomiting of pregnancy

Abstract Objective: To examine the influence of nausea and vomiting of pregnancy (NVP) on pregnancy outcomes. Methods: Outcomes were compared for primigravidas with a current singleton gestation enrolled at <20 weeks’ gestation in a maternity risk screening and education program (n = 81 486). Patient-reported maternal characteristics and pregnancy outcomes were compared for women with and without NVP and within the NVP group for those with and without poor weight gain. Results: 6.4% of women reported NVP as a pregnancy complication. Women reporting NVP were more likely to be younger, obese, single and smoke. They had higher rates of preterm delivery, pregnancy-induced hypertension and low birth weight <2500 g. Almost one-quarter of women with NVP had lower than recommended weight gain. Poor weight gain was associated with a higher incidence of adverse outcomes. Obesity, tobacco use and poor pregnancy weight gain independently increased the odds of an adverse outcome. Conclusion: NVP and subsequent poor weight gain may be associated with adverse pregnancy outcomes.