Naomi E. Stotland

Gestational Weight Gain and Adverse Neonatal Outcome Among Term Infants

OBJECTIVE: To examine the relationship between gestational weight gain and adverse neonatal outcomes among infants born at term (37 weeks or more). METHODS: This was a retrospective cohort study of 20,465 nondiabetic, term, singleton births. We performed univariable and multivariable analyses of the associations between gestational weight gain and neonatal outcomes. We categorized gestational weight gain by the Institute of Medicine guidelines as well as extremes of gestational weight gain (less than 7 kg and more than 18 kg). RESULTS: Gestational weight gain above the Institute of Medicine guidelines was more common than gestational weight gain below (43.3% compared with 20.1%). In multivariable analyses, gestational weight gain above guidelines was associated with a low 5-minute Apgar score (adjusted odds ratio [AOR] 1.33, 95% confidence interval [CI] 1.01–1.76), seizure (AOR 6.50, 95% CI 1.43–29.65), hypoglycemia (AOR 1.52, 95% CI 1.06–2.16), polycythemia (AOR 1.44, 95% CI 1.06–1.94), meconium aspiration syndrome (AOR 1.79, 95% CI 1.12–2.86), and large for gestational age (AOR 1.98, 95% CI 1.74–2.25) compared with women within weight gain guidelines. Gestational weight gain below guidelines was associated with decreased odds of neonatal intensive care unit admission (AOR 0.66, 95% CI 0.46–0.96) and increased odds of small for gestational age (SGA; AOR 1.66, 95% CI 1.44–1.92). Gestational weight gain less than 7 kg was associated with increased risk of seizure, hospital stay more than 5 days, and SGA. Gestational weight gain more than 18 kg was associated with assisted ventilation, seizure, hypoglycemia, polycythemia, meconium aspiration syndrome, and large for gestational age. CONCLUSION: Gestational weight gain above guidelines was common and associated with multiple adverse neonatal outcomes, whereas gestational weight gain below guidelines was only associated with SGA status. Public health efforts among similar populations should emphasize prevention of excessive gestational weight gain. LEVEL OF EVIDENCE: II-2

Body Mass Index, Provider Advice, and Target Gestational Weight Gain

OBJECTIVE: To study the relationships among prepregnancy body mass index (BMI), womens target gestational weight gain, and provider weight gain advice. METHODS: Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women in the San Francisco Bay area. We excluded subjects with preterm birth, multiple gestation, or maternal diabetes. RESULTS: Among overweight women (prepregnancy BMI 26.1–29.0), 24.1% reported a target weight gain above the Institute of Medicine (IOM) guidelines, compared with 4.3% of normal weight women (P < .001). Among women with a low prepregnancy BMI (< 19.8), 51.2% reported a target weight gain below the guidelines, compared with 10.4% of normal weight women (P < .001). These patterns persisted in a multivariate analysis. Latina ethnicity, lower maternal education, low prepregnancy BMI (< 19.8), lack of provider advice about weight gain, and provider advice to gain below guidelines were all independently associated with a target weight gain below IOM guidelines. Prepregnancy BMI more than 26, multiparity, lower age, and provider advice to gain above guidelines were all associated with a target gain above IOM guidelines. CONCLUSION: Womens beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain. LEVEL OF EVIDENCE: II-2

Risk factors and obstetric complications associated with macrosomia

Macrosomia is associated with adverse maternal outcomes. The objective of this study was to characterize the epidemiology of macrosomia and related maternal complications.

Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain

Objective: Gestational weight gain consistent with the Institute of Medicines recommendations is associated with better maternal and infant outcomes. The objective was to quantify the effect of pre‐pregnancy factors, pregnancy‐related health conditions, and modifiable pregnancy factors on the risks of inadequate and excessive gestational weight gain. Method: A longitudinal cohort of pregnant women (N = 1100) who completed questions about diet and weight gain during pregnancy and delivered a singleton, full‐term infant. Results: Gestational weight gain was inadequate for 14% and excessive for 53%. Pre‐pregnancy factors contributed 74% to excessive gain, substantially more than pregnancy‐related health conditions (15%) and modifiable pregnancy factors (11%). Pre‐pregnancy factors, pregnancy‐related health conditions, and modifiable pregnancy factors contributed fairly equally to the risk of inadequate gain. Conclusion: Interventions to prevent excessive gestational gain may need to start before pregnancy. Women at risk for inadequate gain would also benefit from interventions directed toward modifiable factors during pregnancy.

Preventing excessive weight gain in pregnancy: how do prenatal care providers approach counseling?

BACKGROUND Excessive weight gain during pregnancy is becoming more common and is associated with many adverse maternal and infant outcomes. There is a paucity of data on how weight gain counseling is actually provided in prenatal care settings. Our objective was to study prenatal care providers and their knowledge, attitudes, and practices regarding prevention of excessive weight gain during pregnancy and, secondarily, their approach to nutrition and physical activity counseling during pregnancy. METHODS We conducted seven focus groups of general obstetrician/gynecologists, midwives, and nurse practitioners. We analyzed data using qualitative methods. RESULTS Providers agreed to participate because they were unsure of the effectiveness of their counseling efforts and wanted to learn new techniques for counseling patients about weight gain, nutrition, and physical activity. We identified several barriers to weight gain counseling, including insufficient training, concern about the sensitivity of the topic, and the perception that counseling is ineffective. Providers all agreed that weight gain was an important topic with short-term and long-term health consequences, but they described widely disparate counseling styles and approaches. CONCLUSIONS Prenatal care providers are deeply concerned about excessive weight gain and its sequelae in their patients but encounter barriers to effective counseling. Providers want new tools to help them address weight gain counseling during pregnancy.

Maternal ethnicity, paternal ethnicity, and parental ethnic discordance: predictors of preeclampsia.

Objective: To examine the association of maternal and paternal ethnicity as well as parental ethnic discordance with preeclampsia. Methods: Retrospective cohort study of all low-risk women delivered from 1995 to 1999 within a mature managed care organization. Rates of preeclampsia were calculated for maternal, paternal, and combined ethnicity using both univariate and multivariate analyses. Results: Among the 127,544 low-risk women, when examining maternal ethnicity in a multivariate model controlling for maternal age, parity, education, and gestational age, we found that the rates of preeclampsia were higher among African American (5.2%; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25–1.62) women and lower among Latina (4.0%; OR 0.90, 95% CI 0.84–0.97) and Asian women (3.5%; OR 0.79, 95% CI 0.72–0.88), with all results being statistically significant as compared with white women. When paternal ethnicity was controlled for separately, however, the difference in the rate of preeclampsia among Asian women disappeared, the effect of African-American maternal ethnicity increased slightly (OR 1.49, 95% CI 1.33–1.72), and Asian paternity was found to be associated with the lowest rate of preeclampsia (3.2%; OR 0.76, 95% CI 0.68–0.85). Further, parental ethnic discordance was associated with an increase in the rate of preeclampsia (OR 1.13, 95% CI 1.02 - 1.26). Conclusion: We found that rates of preeclampsia were lower with Asian paternal ethnicity. We also found that having a differing paternal and maternal ethnicity was associated with increased rates of preeclampsia. For every 1,000 pregnancies, there would be approximately 10 fewer cases of preeclampsia in the setting of Asian paternity and 5 more cases of preeclampsia in the setting of parental ethnic discordance. These differences may be useful in further investigation of the cause of preeclampsia. Level of Evidence: II-2

Improving diet and exercise in pregnancy with Video Doctor counseling: a randomized trial.

OBJECTIVE To determine if an interactive, computerized Video Doctor counseling tool improves self-reported diet and exercise in pregnant women. METHODS A randomized trial comparing a Video Doctor intervention to usual care in ethnically diverse, low-income, English-speaking pregnant women was conducted. Brief messages about diet, exercise, and weight gain were delivered by an actor-portrayed Video Doctor twice during pregnancy. RESULTS In the Video Doctor group (n=158), there were statistically significant increases from baseline in exercise (+28 min), intake of fruits and vegetables, whole grains, fish, avocado and nuts, and significant decreases in intake of sugary foods, refined grains, high fat meats, fried foods, solid fats, and fast food. In contrast, there were no changes from baseline for any of these outcomes in the usual care group (n=163). Nutrition knowledge improved significantly over time in both groups but more so in the Video Doctor group. Clinician-patient discussions about these topics occurred significantly more frequently in the Video Doctor group. There was no difference in weight gain between groups. CONCLUSION A brief Video Doctor intervention can improve exercise and dietary behaviors in pregnant women. PRACTICE IMPLICATIONS The Video Doctor can be integrated into prenatal care to assist clinicians with effective diet and exercise counseling.

Denial of pregnancy

Abstract Pregnancy, in its advanced stages, would appear to be the most undeniable of states. Yet repeatedly there are women who deliver at term without having given—or aroused—any sign of recognition that they were pregnant. Unexpected deliveries happen even to multiparous women whose previous pregnancies were acknowledged. Some of these cases seem to end happily, with a woman who presented complaining of unexplained abdominal pain going home as a surprised, but contented, mother. Other cases end in tragedy, with a newborn dead in the toilet, in the trash, or literally out the window. The psychiatric explanations range from naivete to psychosis to sociopathy. But it is the obstetrician/gynecologist who is confronted with the clinical emergency and who must decide whether to call the police, the child welfare authorities, and/or the psychiatrist.

Weight gain and spontaneous preterm birth: the role of race or ethnicity and previous preterm birth.

OBJECTIVE: To study how the relationship between gestational weight gain and spontaneous preterm birth interacts with maternal race or ethnicity and previous preterm birth status. METHODS: This was a retrospective cohort study of singleton births to women of normal or low prepregnancy body mass index. Gestational weight gain was measured as total weight gain divided by weeks of gestation at delivery, and weight gain was categorized as low (less than 0.27 kg/wk,), normal (0.27–0.52 kg/wk), or high (more than 0.52 kg/wk). Univariable and multivariable analyses were performed on the relationship between weight gain categories and spontaneous preterm birth, stratified by maternal race or ethnicity and history of previous preterm birth. RESULTS: Overall, low weight gain was associated with spontaneous preterm birth (adjusted odds ratio [AOR] 2.5, 95% confidence interval [CI] 2.0–3.1). Although low gain was consistently associated with increased spontaneous preterm birth, some differences were found in subgroup analysis. Among African Americans with a previous preterm birth, both low and high weight gain were associated with increased odds of spontaneous preterm birth (AOR for low weight gain 4.3, 95% CI 1.2–15.5; AOR for high weight gain 6.1, 95% CI 1.8–20.2). For all other groups, high weight gain was not associated with spontaneous preterm birth. Among Asians with a previous preterm birth, low weight gain was not statistically significantly associated with spontaneous preterm birth (AOR 1.9, 95% CI 0.5–7.7). Among Asians there was also a non–statistically significant inverse relationship between high weight gain and spontaneous preterm birth (AOR 0.5, 95% CI 0.3–1.1). CONCLUSION: These results confirm an association between low maternal weight gain and spontaneous preterm birth. The effect modification of maternal race or ethnicity and history of previous preterm birth on this association deserves further study. LEVEL OF EVIDENCE: II-2

Maternal and paternal race/ethnicity are both associated with gestational diabetes

OBJECTIVE The objective of the study was to examine the rates of gestational diabetes mellitus (GDM) associated with both maternal and paternal race/ethnicity. STUDY DESIGN This was a retrospective cohort study of all women delivered within a managed care network. Rates of GDM were calculated for maternal, paternal, and combined race/ethnicity. RESULTS Among the 139,848 women with identified race/ethnicity, Asians had the highest rate (P < .001) of GDM (6.8%) as compared with whites (3.4%), African Americans (3.2%), and Hispanics (4.9%). When examining race/ethnicity controlling for potential confounders, we found that the rates of GDM were higher among Asian (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.4-1.6) and Hispanic (aOR, 1.2; 95% CI, 1.1-1.4) women as well as Asian (aOR, 1.4; 95% CI, 1.3-1.5) and Hispanic (aOR, 1.3; 95% CI, 1.2-1.4) men as compared with their white counterparts. CONCLUSION We found that rates of GDM are affected by both maternal and paternal race/ethnicity. In both Asians and Hispanics, maternal and paternal race are equally associated with an increase in GDM. These differences may inform further investigation of the pathophysiology of GDM.