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Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
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Weight Gain During Pregnancy: Reexaming the Guidelines
APPENDIX F
Data Tables
APPROACH TO GATHERING EVIDENCE
In order to review the most relevant scientific literature available, the committee and staff conducted thorough searches of several online bibliographic databases, including Medline, Science Direct, and WorldCat/First Search. General searches on pregnancy, gestational weight gain, and outcomes of pregnancy were first conducted to identify primary literature. Using the results of the primary search, key search terms were developed and secondary searches were then conducted. Search terms were chosen based on relevance to the report outline and topics included in the previous Institute of Medicine (IOM) report, Nutrition During Pregnancy (IOM, 1990). Although initial searches were general, subsequent searches focused on retrieving studies that were not covered by the evidence-based review conducted by Viswanathan et al. (2008). To identify studies that fell outside of the scope of that report, searches were limited to publication dates prior to 1990 and after October 2007. Similar to the methodology used by Viswanathan et al. (2008), searches were limited to English. As the study progressed, focused searches were conducted as needed and general searches were carried out to identify newly published articles. See Box F-1 for an example of how searches were conducted.The focus of this appendix is literature that addresses the consequences of gestational weight gain. Table F-1 includes studies on the consequences of gestational weight gain for the mother and for the child, as discussed in Chapter 5, Consequences of Gestational Weight Gain for the Mother, and Chapter 6, Consequences
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of Gestational Weight Gain for the Child. This table is not inclusive of all the literature covered in this report nor does the report address each of the studies listed in the table. The table only includes studies that examined the consequences of gestational weight gain that were considered by the committee throughout the duration of the project.
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Weight Gain During Pregnancy: Reexaming the Guidelines
BOX F-1
Examples of Searches Using Key Words to Identify Relevant Literature (PubMed)
General search (limited to English)
#1 Search Pregnancy
#2 Search Weight Gain
#3 Search #1 and #2
#4 Search gestational weight
#5 Search #3 OR #4
#6 Search #5 AND obesity
#7 Search #5 AND BMI OR body mass index
Focused search: Consequences of GWG for the Mother (limited to publication date prior to 1990 or after October 2007 and English)
#8 Search #5 AND antepartum outcomes
#9 Search #5 AND consequences
#10 Search #1 AND maternal age
#11 Search #1 AND BMI OR body mass index
#12 Search #5 AND depression OR mental health
#13 Search #5 AND delivery OR cesarean section OR labor OR induced labor OR complications at delivery OR hemorrhage OR anesthesia OR coagulation OR forceps OR infection OR protracted labor
#14 Search #13 AND obesity OR BMI
#15 Search #7 AND weight retention OR postpartum weight
#16 Search #6 AND lactation
#17 Search #5 AND maternal health OR chronic disease OR morbidity
#18 Search #5 AND maternal mortality
Focused search: Consequences of GWG for the Child (limited to publication date prior to 1990 or after October 2007 and English)
#19 Search #5 AND child outcomes OR infant outcomes
#20 Search #5 AND small-for-gestational age OR SGA OR IUGR
#21 Search #5 AND large-for-gestational age OR LGA
#22 Search #20 AND cognitive development OR neurodevelopment OR academic performance OR school OR cognition OR neurology
#23 Search #21 AND obesity OR child obesity OR metabolic syndrome
#24 Search #5 AND preterm birth
#25 Search #5 AND fetal growth OR fetal development OR body composition
#26 Search #7 AND infant outcomes
#27 Search #5 AND child mental health
#28 Search #5 AND birth defects OR congenital anomalies
#29 Search #5 AND fetal death OR infant death OR neonatal death OR miscarriage OR stillbirth OR infant mortality
#30 Search #5 AND child health OR infant health OR asthma OR cancer OR chronic disease OR morbidity
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Weight Gain During Pregnancy: Reexaming the Guidelines
STUDIES ON CONSEQUENCES OF GESTATIONAL WEIGHT GAIN FOR THE MOTHER AND CHILD
TABLE F-1 Consequences of Gestational Weight Gain
Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Abrams et al., 1989
Design:
Cohort
Retrospective
Preterm birth: delivery between 26-37 weeks’ gestation
Country/Setting:
USA (Perinatal Nutrition Project, San Diego, CA)
Gestational age: maternal estimate of the last menstrual period, antenatal sonography before 28 weeks’ gestation, Dubowitz score, or a combination of these.
Total Study N:
2,163
Group Description:
G1: Preterm births
G2: Term births
Enrollment period:
Jan 1978 to Dec 1986
Prepregnancy weight: maternal recall at first visit (prepregnancy weight for height based on the 1959 Metropolitan Insurance standards of desirable weight).
Study Objective:
To examine the relationship between maternal weight gain and preterm delivery.
Group N:
G1: 118
G2: 2,045
Inclusion criteria:
Low income
Prepregnancy underweight or prepregnancy obesity
Low pregnancy weight gain
Anemia
History of obstetric complications
Concurrent medical complication
Total pregnancy weight gain: estimated by subtracting the prepregnancy weight from the last measured weight before delivery.
Exclusion criteria:
Antepartum death
Twin gestation
Major congenital anomalies
Induced deliveries (not preceded by spontaneous labor or rupture of membranes)
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Outcomes/Results/Confounders
Outcomes description:
Maternal weight gain
Preterm delivery
Results:
Women with low rate of weight gain (< 0.27 kg/wk) had a 60% higher risk for spontaneous preterm birth compared with those with average weight gain (0.27-0.52 kg/wk). They were also more than twice as likely to deliver preterm as women with a high rate of gain (> 0.52 kg/wk) (OR = 2.54; 95% CI 1.49, 4.88).
Maternal confounders/effect modifiers:
Dietary intake
Use of cigarettes, alcohol, and illicit drugs
Pre-pregnancy weight/height
Age
Income
Marital status
Race
Use of vitamin supplements
Whether or not pregnancy was planned
Infant and child confounders/effect modifiers:
NR
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Weight Gain During Pregnancy: Reexaming the Guidelines
Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Abrams and Laros, 1986
Design:
Cohort
Pregnancy weight gain = measured weight at last prenatal visit − reported prepregnancy weight
Total Study N:
2,946
Country/Setting:
USA (San Francisco, CA)
Low gain: total gain of < 7 kg
Excessive gain: total gain of > 20 kg
Group Description:
G1: Prepregnancy, underweight
G2: Prepregnancy, ideal weight
G3: Prepregnancy, moderately overweight
G4: Prepregnancy, very overweight
Enrollment period:
Sept 1980 to Dec 1983
Study Objective:
To study the effect of maternal weight gain on birth weight.
Group N:
G1: 268
G2: 1,535
G3: 901
G4: 224
Inclusion criteria:
Singleton pregnancies
≥ 37 weeks’ gestation
Live infant was delivered at study hospital
Exclusion criteria:
Maternal transfers
Transports
Intrauterine transfusions
Fetal surgeries
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Weight Gain During Pregnancy: Reexaming the Guidelines
Outcomes/Results/Confounders
Outcomes description:
Total maternal weight gain
Infant birth weight
Results:
Mean weight gain (kg)
G1: 14.3
G2: 15.2
G3: 15.2
G4: 14.1
Maternal confounders/effect modifiers:
Race
Parity
Maternal age
Number of cigarettes smoked/day
Prepregnancy weight/height
SES
Birth weight (gm)
G1: 3,290
G2: 3,414
G3: 3,521
G4: 3,593
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Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Berkowitz, 1981
Design:
Case-control
Demographics:
G1:
Married: 64%
Race:
White, 65.7%
Black, 29.1%
Hispanic, 4.0%
Mean age: 24.9
Country/Setting:
USA
Total Study N:
488
Enrollment period:
1977
Group Description:
G1: preterm deliveries, < 37 weeks
G2: term deliveries, 37 weeks or later
Study Objective:
To study the epidemiology of preterm delivery.
G2:
Married: 77.3%
Race:
White, 72.8%
Black, 22.7%
Hispanic, 3.2%
Mean age: 26.2
Group N:
G1: 175
G2: 313
Inclusion criteria:
Singleton infants
Delivered before 37 wks gestation
Spoke English
Were interviewed during postpartum stay
Had not placed infant up for adoption
Exclusion criteria:
Deliveries that were induced or surgically assisted without prior spontaneous labor or spontaneous rupture of membranes
Women who were referred to outlying hospitals or physicians
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Outcomes/Results/Confounders
Outcomes description:
Risk factors associated with preterm delivery
Results:
The following risk factors carried the highest relative risk for a preterm delivery: Previous preterm (OR = 29.8)
Antepartum hemorrhage and placental abnormalities (OR = 25.9)
Third trimester urinary tract infection (OR = 6.2)
Low SES (OR = 5.5)
Previous pregnancy terminating in an induced abortion (OR = 4.6)
Inadequate GWG (OR = 4.3)
Maternal confounders/effect modifiers:
Race/ethnicity
Age
Marital status
SES
Age of menarche onset
Gravidity
Pregnancy order
Birth order
Range of menstrual cycles
Infertility history
History of induced abortion
Infant and child confounders/ effect modifiers:
NR
Other significant risk factors included: low pregravid weight, history of infertility, vaginal bleeding during pregnancy, lack of leisure time activity during pregnancy, alcohol consumption prior to third trimester, and negative attitude toward pregnancy.
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Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Billewicz and Thomson, 1957
Design:
Cohort
Weight was recorded at first antenatal visit and again 4-6 wks later. Most were weighed monthly from 28-30 wks, and more often during final weeks. Data from first trimester is sparse.
Total Study N:
4,214
Country/Setting:
UK
Group Description:
G1: Preeclampsia with albuminuria
G2: Other hypertensive complications
G3: Normotensive
Enrollment period:
1949-1954
Study Objective:
To examine the clinical significance of weight trends during pregnancy.
Group %:
G1: 6.5
G2: 25.4
G3: 68.1
Inclusion criteria:
Women pregnant with first child
Residents of Aberdeen, delivered at Aberdeen Maternity Hospital
Exclusion criteria:
Multiple gestations
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Outcomes/Results/Confounders
Outcomes description:
Preeclampsia with or without albuminuria
Other hypertensive complications
Results:
Women with preeclampsia tended to have an increased rate of gain as the pregnancy progressed, and was greater in all stages than in the normotensive group. The incidence of preeclampsia also increases as the rate of gain increases. Favorable outcomes in women with preeclampsia are seen when the rate of gain is moderate, at least in the second half of pregnancy.
Maternal confounders/effect modifiers:
Social class
Height
Age
Infant and child confounders/ effect modifiers:
NR
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Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Varma, 1984
Design:
Cohort
Retrospective
Maternal booking weight: recorded under standardized conditions in clinic, every 4 wks up to 28 wks then every 2 wks from 28-36 wks and weekly from 36 wks-delivery.
Country/Setting:
UK (London)
Total Study N:
3,002
Enrollment period:
1978-1980
Group Description:
G1: GWG ≤ 2.5 kg
G2: GWG 2.5-5.9 kg
G3: GWG 6.0-10.9 kg
G4: GWG 11.0-15.9 kg
G5: 16.0-20.9 kg
G6: 21+ kg
Study Objective:
To assess the relationship between maternal weight at booking in the first trimester and the total weight gain during pregnancy and birth weight, complications, and mode of delivery.
Group N:
G1: 182
G2: 272
G3: 1,114
G4: 1,028
G5: 252
G6: 154
Inclusion criteria:
Seen in antenatal clinic during first trimester
Exclusion criteria:
Diabetes
Multiple pregnancy
Polyhydramnios
Gastrointestinal disorders
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Outcomes/Results/Confounders
Outcomes description:
Total weight gain
Maternal weight
Pregnancy complications
Mode of delivery
Birth weight
Fetal status in labor (cardiotocographic tracing and fetal scalp pH)
Maternal confounders/effect modifiers:
NR
Infant and child confounders/ effect modifiers:
NR
Results:
Preeclampsia
G1: 8.8%
G2: 5.9%
G3: 9.7%
G4: 9.7%
G5: 10.3%
G6: 11.1%
Preexisting hypertension
G1: 4.4%
G2: 4.4%
G3: 6.1%
G4: 6.8%
G5: 11.9%
G6: 13.9%
IUGR
G1: 29.7%
G2: 14.7%
G3: 5.8%
G4: 7.0%
G5: 6.3%
G6: 6.9%
Premature Labor
G1: 8.8%
G2: 4.4%
G3: 2.5%
G4: 2.5%
G5: 2.4%
G6: 4.1%
Antepartum hemorrhage
G1: 5.5%
G2: 3.3%
G3: 2.5%
G4: 3.1%
G5: 3.2%
G6: 3.5%
Fetal distress in labor
G1: 12.1%
G2: 5.1%
G3: 4.1%
G4: 4.9%
G5: 6.3%
G6: 6.3%
Normal delivery
G1: 73.6%
G2: 73.5%
G3: 72.4%
G4: 68.6%
G5: 69.8%
G6: 55.6%
Forceps delivery
G1: 13.2%
G2: 14.7%
G3: 13.1%
G4: 16.9%
G5: 17.4%
G6: 27.8%
C-Section
G1: 13.2%
G2: 11.8%
G3: 14.5%
G4: 14.4%
G5: 15.1%
G6: 16.6%
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Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Voldner et al., 2008
Design:
Cohort
Prospective
BMI and maternal anthropometric measures were collected at each visit.
Country/Setting:
Norway
Gestational age, gender of child, parity, maternal age, maternal height, smoking habits, marital status, education level, work outside the home
Total Study N:
553
Enrollment period:
2002-2005
Inclusion criteria:
Healthy women
Singleton pregnancies
Scandinavian heritage
Delivered at study hospital
Study Objective:
To examine the modifiable determinants of fetal macrosomia, specifically lifestyle-related factors.
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Outcomes/Results/Confounders
Outcomes description:
Macrosomic infant (≥ 4,200 g)
Results:
Weight gain < 10.2 kg
Univariate analyses: OR = 1.0
Multivariate analyses: OR = 1.0
Weight gain ≥ 10.2 kg
Univariate analyses: OR = 1.7 (95% CI 1.0-2.8; p value 0.04)
Multivariate analyses: OR = 1.7 (95% CI 0.9-3.2; p value 0.09)
Maternal confounders/effect modifiers:
Maternal BMI
Maternal subcutaneous fat at visit one
Weight gain in pregnancy
Plasma glucose values (visit one and three)
Intake of energy and energy providing nutrients
Smoking and level of physical activity before and during pregnancy
BMI, weight gain, plasma glucose and gestational age were independent determinants of macrosomia (if physical activity was left out of the analysis). Once physical activity was included (low level, prepregnancy), this became a significant determinant for macrosomia (OR 2.9, 95% CI 1.9, 7.3).
Infant and child confounders/ effect modifiers:
Gestational age
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Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Wolff et al., 2008
Design:
Randomized control trial
Weight, height, blood pressure and heart rate were measured at inclusion and at 27 and 36 weeks’ gestation.
Country/Setting:
Denmark
Total Study N:
50
Prepregnancy weight, weight gain from 36 weeks’ gestation until delivery, and postpartum weight (1st, 2nd, and 3rd weeks), were self reported. Weight at 4 weeks postpartum was measured at the department.
Enrollment period:
NR
Group Description:
G1: Intervention (nondiabetic obese pregnant women)
G2: Control
Study Objective:
To examine the effects of dietary counseling on GWG and glucose metabolism in obese pregnant women.
Group N:
G1: 23
G2: 27
Total GWG was calculated as the difference between self-reported prepregnancy weight and weight just before delivery.
Inclusion criteria:
Obese pregnant women (BMI ≥ 30 kg/m2)
Nondiabetic
15 ± 3 weeks’ gestation at enrollment
G1: received 10 one-hour consultations with a trained dietician during the pregnancy; were instructed to eat a healthy diet; and limit energy intake based on individual requirements (estimated by energetic cost of fetal growth).
Exclusion criteria:
Smoked
Age < 18 years or > 45 years
Multiple pregnancy
Medical complications known to affect fetal growth or weight gain
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Weight Gain During Pregnancy: Reexaming the Guidelines
Outcomes/Results/Confounders
Outcomes description:
Dietary intake and weight development
Glucose metabolism
Birth outcome
Maternal confounders/effect modifiers:
NR
Infant and child confounders/ effect modifiers:
NR
Results:
G1: Average GWG = 6.6 ± 5.5 kg
G2: Average GWG = 13.3 ± 7.5 kg
(mean difference of 6.7 kg; 95% CI 2.6-10.8, P = 0.002)
Placental weight (g)
G1: 701 ± 131
G2: 771 ± 161
Head circumference (cm)
G1: 35 ± 1
G2: 36 ± 2
Abdominal circumference (cm)
G1: 35 ± 1
G2: 34 ± 2
GDM
G1: 0 (0%)
G2: 3 (10%)
Pregnancy-induced hypertension
G1: 1 (4%)
G2: 4 (1%)
Preeclampsia
G1: 0 (0%)
G2: 1 (4%)
Prolonged pregnancy
G1: 3 (13%)
G2: 4 (15%)
Cesarean delivery
G1: 2 (9%)
G2: 3 (11%)
G1: Average gain/wk = 0.26 ± 0.15 kg/wk
G2: Average gain/wk = 0.44 ± 0.21 kg/wk
(mean difference of 0.18 kg/wk (95% CI 0.07-0.30, P = 0.02)
G1 also had a 20% reduction in both s-insulin and s-leptin as compared to G2 at week 27.
Birth weight (g)
G1: 3,757 ± 617
G2: 3,895 ± 485
Infant length (cm)
G1: 52 ± 3
G2: 53 ± 2
Gestational age (days)
G1: 281 ± 13
G2: 280 ± 11
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Study Description
Study Design/Patient Population/Inclusion-Exclusion Criteria
Protocol Including: Pregravid Weight (how measured), Total Weight Gain (how measured), and Baseline Characteristics
Author, year:
Wrotniak et al., 2008
Design:
Cohort
Retrospective
Prepregnancy weight was self-reported at enrollment.
Country/Setting:
USA
(National Collaborative Perinatal Project)
GWG and height were measured at time of delivery and were used to calculate GWG.
Total Study N:
10,226
Inclusion criteria:
Singleton, term pregnancies
Median Prepregnancy BMI: 21.9 kg/m2
Median Age: 23 yrs
Race:
Black, 47.4%
White, 50.5%
Hispanic, 1.3%
Other, 0.8%
Enrollment period:
1595 to 1972
Exclusion criteria:
Mothers with GDM
Gestational age < 37 weeks or > 42 weeks
Study Objective:
To examine the association of GWG with offspring overweight at 7 years of age.
NR = Not reported.
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Outcomes/Results/Confounders
Outcomes description:
Offspring overweight status
GWG
Results:
Median GWG: 9.5 kg
Median birth weight: 3,230 g
Median gestational age: 40 wks
Median BMI at 7 yr assessment: 15.7 kg/m2
Overweight status at 7 yr assessment (BMI at or above 95th percentile): 5.7%
Maternal confounders/effect modifiers:
Race
Age
Prepregnancy BMI
Number of cigarettes smoked/day
Infant and child confounders/effect modifiers:
Sex
First-born status
Study site
Gestational age
Adjusted Association between GWG and overweight at 7 yrs
GWG by 1 kg of weight gain:
OR 1.03 (95% CI 1.02, 1.05)
Excessive GWG vs Recommended GWG (IOM):
OR 1.48 (95% CI 1.06, 2.06)
Insufficient weight gain vs Recommended weight gain (IOM):
OR 0.88 (95% CI 0.68, 1.14)
The association between GWG and overweight in offspring was strongest for women underweight before pregnancy.
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Rudra C. B., I. O. Frederick and M. A. Williams. 2008. Pre-pregnancy body mass index and weight gain during pregnancy in relation to preterm delivery subtypes. Acta Obstetricia et Gynecologica Scandinavica 87(5): 510-517.
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Weight Gain During Pregnancy: Reexaming the Guidelines
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