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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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 biblio- graphic databases, including Medline, Science Direct, and WorldCat/First Search. General searches on pregnancy, gestational weight gain, and out- comes 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 pre- vious 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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 WEIGHT GAIN DURING PREGNANCY 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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 APPENDIX F 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 publica- tion 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 miscar- riage 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 STUDIES ON CONSEQUENCES OF GESTATIONAL WEIGHT GAIN FOR THE MOTHER AND CHILD TABLE F-1 Consequences of Gestational Weight Gain Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Preterm birth: delivery between 26- Author, year: Design: Abrams et al., 1989 • Cohort 37 weeks’ gestation • Retrospective Gestational age: maternal estimate of Country/Setting: USA (Perinatal the last menstrual period, antenatal Total Study N: Nutrition Project, San 2,163 sonography before 28 weeks’ Diego, CA) gestation, Dubowitz score, or a Group Description: combination of these. G1: Preterm births Enrollment period: Jan 1978 to Dec 1986 G2: Term births Prepregnancy weight: maternal recall at first visit (prepregnancy Study Objectie: Group N: weight for height based on the 1959 To examine the G1: 118 Metropolitan Insurance standards of relationship between G2: 2,045 desirable weight). maternal weight gain Inclusion criteria: and preterm delivery. Total pregnancy weight gain: • Low income estimated by subtracting the • Prepregnancy prepregnancy weight from the last underweight or measured weight before delivery. prepregnancy obesity • Low pregnancy weight gain • Anemia • History of obstetric complications • Concurrent medical complication Exclusion criteria: • Antepartum death • Twin gestation • Major congenital anomalies • Induced deliveries (not preceded by spontaneous labor or rupture of membranes)

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 APPENDIX F Outcomes/Results/Confounders Outcomes description: Results: Maternal confounders/effect • Maternal weight gain Women with low rate of modifiers: weight gain (< 0.27 kg/wk) • Preterm delivery • Dietary intake had a 60% higher risk for • Use of cigarettes, alcohol, spontaneous preterm birth and illicit drugs compared with those with • Pre-pregnancy weight/height average weight gain (0.27- • Age 0.52 kg/wk). They were also • Income more than twice as likely to • Marital status deliver preterm as women • Race with a high rate of gain • Use of vitamin supplements (> 0.52 kg/wk) (OR = 2.54; • Whether or not pregnancy 95% CI 1.49, 4.88). was planned Infant and child confounders/ effect modifiers: NR continued

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 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Pregnancy weight gain = measured Author, year: Design: weight at last prenatal visit - Abrams and Laros, • Cohort 1986 reported prepregnancy weight Total Study N: Low gain: total gain of < 7 kg 2,946 Country/Setting: Excessive gain: total gain of > 20 kg USA (San Francisco, Group Description: CA) G1: Prepregnancy, underweight Enrollment period: Sept 1980 to Dec G2: Prepregnancy, ideal 1983 weight G3: Prepregnancy, Study Objectie: moderately overweight To study the effect of G4: Prepregnancy, very maternal weight gain overweight 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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 APPENDIX F Outcomes/Results/Confounders Outcomes description: Results: Maternal confounders/effect • Total maternal weight Mean weight gain (kg) modifiers: gain G1: 14.3 • Race • Infant birth weight G2: 15.2 • Parity G3: 15.2 • Maternal age G4: 14.1 • Number of cigarettes smoked/day Birth weight (gm) • Prepregnancy weight/height G1: 3,290 • SES G2: 3,414 G3: 3,521 G4: 3,593 continued

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 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Author, year: Design: Demographics: Berkowitz, 1981 • Case-control G1: Married: 64% Country/Setting: Total Study N: Race: USA 488 White, 65.7% Black, 29.1% Enrollment period: Group Description: G1: preterm deliveries, < 37 1977 Hispanic, 4.0% weeks Mean age: 24.9 Study Objectie: G2: term deliveries, 37 To study the G2: weeks or later epidemiology of Married: 77.3% preterm delivery. Race: Group N: G1: 175 White, 72.8% G2: 313 Black, 22.7% Hispanic, 3.2% Inclusion criteria: Mean age: 26.2 • 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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 APPENDIX F Outcomes/Results/Confounders Outcomes description: Results: Maternal confounders/effect • Risk factors associated The following risk factors modifiers: with preterm delivery carried the highest relative • Race/ethnicity risk for a preterm delivery: • Age Previous preterm (OR = • Marital status 29.8) • SES Antepartum hemorrhage • Age of menarche onset and placental abnormalities • Gravidity (OR = 25.9) • Pregnancy order Third trimester urinary tract • Birth order infection (OR = 6.2) • Range of menstrual cycles Low SES (OR = 5.5) • Infertility history Previous pregnancy • History of induced abortion terminating in an induced Infant and child confounders/ abortion (OR = 4.6) effect modifiers: Inadequate GWG (OR = NR 4.3) 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. continued

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0 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Weight was recorded at first Author, year: Design: Billewicz and • Cohort antenatal visit and again 4-6 wks Thomson, 1957 later. Most were weighed monthly Total Study N: from 28-30 wks, and more often 4,214 Country/Setting: during final weeks. Data from first UK trimester is sparse. Group Description: G1: Preeclampsia with Enrollment period: 1949-1954 albuminuria G2: Other hypertensive Study Objectie: complications To examine the G3: Normotensive clinical significance of weight trends during Group %: pregnancy. 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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 APPENDIX F Outcomes/Results/Confounders Outcomes description: Results: Maternal confounders/effect • Preeclampsia with or Women with preeclampsia modifiers: without albuminuria tended to have an increased • Social class • Other hypertensive rate of gain as the • Height complications pregnancy progressed, and • Age was greater in all stages Infant and child confounders/ than in the normotensive effect modifiers: group. The incidence of NR 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. continued

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 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Maternal booking weight: recorded Author, year: Design: Varma, 1984 • Cohort under standardized conditions in • Retrospective clinic, every 4 wks up to 28 wks Country/Setting: then every 2 wks from 28-36 wks UK (London) Total Study N: and weekly from 36 wks-delivery. 3,002 Enrollment period: 1978-1980 Group Description: G1: GWG ≤ 2.5 kg Study Objectie: G2: GWG 2.5-5.9 kg To assess the G3: GWG 6.0-10.9 kg relationship between G4: GWG 11.0-15.9 kg maternal weight at G5: 16.0-20.9 kg booking in the first G6: 21+ kg trimester and the total weight gain during Group N: pregnancy and birth G1: 182 weight, complications, G2: 272 and mode of delivery. 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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 APPENDIX F Outcomes/Results/Confounders Outcomes description: Maternal confounders/effect • Total weight gain modifiers: • Maternal weight NR • Pregnancy complications Infant and child confounders/ • Mode of delivery effect modifiers: • Birth weight NR • Fetal status in labor (cardiotocographic tracing and fetal scalp pH) Fetal distress in labor Results: Preeclampsia G1: 12.1% G1: 8.8% G2: 5.1% G2: 5.9% G3: 4.1% G3: 9.7% G4: 4.9% G4: 9.7% G5: 6.3% G5: 10.3% G6: 6.3% G6: 11.1% Normal delivery Preexisting hypertension G1: 73.6% G1: 4.4% G2: 73.5% G2: 4.4% G3: 72.4% G3: 6.1% G4: 68.6% G4: 6.8% G5: 69.8% G5: 11.9% G6: 55.6% G6: 13.9% Forceps delivery IUGR G1: 13.2% G1: 29.7% G2: 14.7% G2: 14.7% G3: 13.1% G3: 5.8% G4: 16.9% G4: 7.0% G5: 17.4% G5: 6.3% G6: 27.8% G6: 6.9% C-Section Premature Labor G1: 13.2% G1: 8.8% G2: 11.8% G2: 4.4% G3: 14.5% G3: 2.5% G4: 14.4% G4: 2.5% G5: 15.1% G5: 2.4% G6: 16.6% G6: 4.1% Antepartum hemorrhage G1: 5.5% G2: 3.3% G3: 2.5% G4: 3.1% continued G5: 3.2% G6: 3.5%

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 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics BMI and maternal anthropometric Author, year: Design: Voldner et al., 2008 • Cohort measures were collected at each visit. • Prospective Gestational age, gender of child, Country/Setting: Norway parity, maternal age, maternal Total Study N: 553 height, smoking habits, marital Enrollment period: status, education level, work outside 2002-2005 Inclusion criteria: the home • Healthy women Study Objectie: • Singleton pregnancies To examine • Scandinavian heritage the modifiable • Delivered at study determinants of hospital fetal macrosomia, specifically lifestyle- related factors.

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 APPENDIX F Outcomes/Results/Confounders Outcomes description: Results: Maternal confounders/effect Weight gain < 10.2 kg • Macrosomic infant modifiers: (≥ 4,200 g) Univariate analyses: • Maternal BMI OR = 1.0 • Maternal subcutaneous fat Multivariate analyses: at visit one OR = 1.0 • Weight gain in pregnancy Weight gain ≥ 10.2 kg • Plasma glucose values (visit Univariate analyses: one and three) OR = 1.7 (95% CI 1.0-2.8; • Intake of energy and energy p value 0.04) providing nutrients Multivariate analyses: • Smoking and level of OR = 1.7 (95% CI 0.9-3.2; physical activity before and p value 0.09) during pregnancy BMI, weight gain, plasma Infant and child confounders/ glucose and gestational effect modifiers: age were independent • Gestational age 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). continued

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00 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Weight, height, blood pressure Author, year: Design: Wolff et al., 2008 • Randomized control trial and heart rate were measured at inclusion and at 27 and 36 weeks’ Country/Setting: Total Study N: gestation. Denmark 50 Prepregnancy weight, weight gain Enrollment period: Group Description: from 36 weeks’ gestation until NR G1: Intervention delivery, and postpartum weight (nondiabetic obese (1st, 2nd, and 3rd weeks), were Study Objectie: pregnant women) To examine the effects self reported. Weight at 4 weeks G2: Control of dietary counseling postpartum was measured at the on GWG and glucose department. Group N: metabolism in obese G1: 23 Total GWG was calculated as the pregnant women. G2: 27 difference between self-reported prepregnancy weight and weight just Inclusion criteria: • Obese pregnant women before delivery. (BMI ≥ 30 kg/m2) G1: received 10 one-hour • Nondiabetic consultations with a trained • 15 ± 3 weeks’ gestation dietician during the pregnancy; were at enrollment instructed to eat a healthy diet; and limit energy intake based on Exclusion criteria: • Smoked individual requirements (estimated • Age 45 by energetic cost of fetal growth). years • Multiple pregnancy • Medical complications known to affect fetal growth or weight gain

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0 APPENDIX F Outcomes/Results/Confounders Outcomes description: Maternal confounders/effect • Dietary intake and weight modifiers: development NR • Glucose metabolism Infant and child confounders/ • Birth outcome effect modifiers: NR Placental weight (g) Results: G1: Average GWG = 6.6 ± G1: 701 ± 131 G2: 771 ± 161 5.5 kg G2: Average GWG = 13.3 Head circumference (cm) ± 7.5 kg G1: 35 ± 1 G2: 36 ± 2 (mean difference of 6.7 kg; 95% CI 2.6-10.8, Abdominal circumference P = 0.002) (cm) G1: 35 ± 1 G1: Average gain/wk = 0.26 G2: 34 ± 2 ± 0.15 kg/wk GDM G2: Average gain/wk = 0.44 G1: 0 (0%) ± 0.21 kg/wk G2: 3 (10%) (mean difference of 0.18 kg/ Pregnancy-induced wk (95% CI 0.07-0.30, P hypertension = 0.02) G1: 1 (4%) G1 also had a 20% G2: 4 (1%) reduction in both s-insulin Preeclampsia and s-leptin as compared to G1: 0 (0%) G2 at week 27. G2: 1 (4%) Prolonged pregnancy Birth weight (g) G1: 3 (13%) G1: 3,757 ± 617 G2: 4 (15%) G2: 3,895 ± 485 Cesarean delivery Infant length (cm) G1: 2 (9%) G1: 52 ± 3 G2: 3 (11%) G2: 53 ± 2 Gestational age (days) G1: 281 ± 13 G2: 280 ± 11 continued

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0 WEIGHT GAIN DURING PREGNANCY TABLE F-1 Continued Protocol Including: Study Design/ Pregravid Weight (how measured), Patient Population/ Total Weight Gain (how measured), Study Description Inclusion-Exclusion Criteria and Baseline Characteristics Prepregnancy weight was self- Author, year: Design: Wrotniak et al., 2008 • Cohort reported at enrollment. • Retrospective GWG and height were measured at Country/Setting: USA time of delivery and were used to Total Study N: (National 10,226 calculate GWG. Collaborative Median Prepregnancy BMI: Inclusion criteria: Perinatal Project) 21.9 kg/m2 • Singleton, term pregnancies Median Age: 23 yrs Enrollment period: 1595 to 1972 Race: Exclusion criteria: Black, 47.4% • Mothers with GDM Study Objectie: White, 50.5% • Gestational age < 37 To examine the Hispanic, 1.3% weeks or > 42 weeks association of GWG Other, 0.8% with offspring overweight at 7 years of age. NR = Not reported.

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0 APPENDIX F Outcomes/Results/Confounders Outcomes description: Results: Maternal confounders/effect • Offspring overweight Median GWG: 9.5 kg modifiers: status Median birth weight: 3,230 • Race • GWG g • Age Median gestational age: 40 • Prepregnancy BMI wks • Number of cigarettes Median BMI at 7 yr smoked/day assessment: 15.7 kg/m2 Infant and child confounders/ Overweight status at 7 effect modifiers: yr assessment (BMI at or • Sex above 95th percentile): • First-born status 5.7% • Study site • Gestational age Adjusted Association between GWG and oerweight at  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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0 APPENDIX F Nohr E. A., M. Vaeth, J. L. Baker, T. Sorensen, J. Olsen and K. M. Rasmussen. 2008. Com- bined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. American Journal of Clinical Nutrition 87(6): 1750-1759. Papiernik E. and M. Kaminski. 1974. Multifactorial study of the risk of prematurity at 32 weeks of gestation. I. A study of the frequency of 30 predictive characteristics. Journal of Perinatal Medicine 2(1): 30-36. Rodriguez A., J. Miettunen, T. B. Henriksen, J. Olsen, C. Obel, A. Taanila, H. Ebeling, K. M. Linnet, I. Moilanen and M. R. Jarvelin. 2008. Maternal adiposity prior to pregnancy is associated with ADHD symptoms in offspring: evidence from three prospective preg- nancy cohorts. International Journal of Obesity (London) 32(3): 550-557. 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 Scandinaica 87(5): 510-517. Scott A., V. Moar and M. Ounsted. 1981. The relative contributions of different maternal factors in small-for-gestational-age pregnancies. European Journal of Obstetrics, Gyne- cology, and Reproductie Biology 12(3): 157-165. Segal P., J. K. Hamilton, M. Sermer, P. W. Connelly, A. J. Hanley, B. Zinman and R. Retna- karan. 2008. Maternal obesity and familial history of diabetes have opposing effects on infant birth weight in women with mild glucose intolerance in pregnancy. Journal of Maternal-Fetal & Neonatal Medicine 21(1): 73-79. Shepard M. J., K. G. Hellenbrand and M. B. Bracken. 1986. Proportional weight gain and complications of pregnancy, labor, and delivery in healthy women of normal prepregnant stature. American Journal of Obstetrics and Gynecology 155(5): 947-954. Tavris D. R. and J. A. Read. 1982. Effect of maternal weight gain on fetal, infant, and child- hood death and on cognitive development. Obstetrics and Gynecology 60(6): 689-694. Tenovuo A. H., P. O. Kero, H. J. Korvenranta, R. U. Erkkola, P. J. Klemi and J. Tuominen. 1988. Risk factors associated with severely small for gestational age neonates. American Journal of Perinatology 5(3): 267-271. Tilton Z., M. I. Hodgson, E. Donoso, A. Arteaga and P. Rosso. 1989. Complications and outcome of pregnancy in obese women. Nutrition 5(2): 95-99. Udal J. N., G. G. Harrison, Y. Vaucher, P. D. Walson and G. Morrow, 3rd. 1978. Interaction of maternal and neonatal obesity. Pediatrics 62(1): 17-21. Varma T. R. 1984. Maternal weight and weight gain in pregnancy and obstetric outcome. International Journal of Gynaecology and Obstetrics 22(2): 161-166. Voldner N., K. F. Froslie, K. Bo, L. Haakstad, C. Hoff, K. Godang, J. Bollerslev and T. Henrik- sen. 2008. Modifiable determinants of fetal macrosomia: role of lifestyle-related factors. Acta Obstetricia et Gynecologica Scandinaica 87(4): 423-429. Wolff S., J. Legarth, K. Vangsgaard, S. Toubro and A. Astrup. 2008. A randomized trial of the effects of dietary counseling on gestational weight gain and glucose metabolism in obese pregnant women. International Journal of Obesity (London) 32(3): 495-501. Wrotniak B. H., J. Shults, S. Butts and N. Stettler. 2008. Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study. American Journal of Clinical Nutrition 87(6): 1818-1824.

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