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Introduction
The prevalence of obesity among women of reproductive
age has increased dramatically over recent years. In 2007
2008, 68% of United States adults and 59.5% of women of
reproductive age met criteria for being categorized as
overweight or obese [1]. With the rising prevalence of
obesity, recent studies have highlighted the increased risks
associated with obesity in pregnancy, including increased
risks of cesarean delivery, stillbirth, hypertensive disorders
of pregnancy, fetal structural malformations, and gestational diabetes; however, controversy remains over optimal
management of the pre-gravid obese women during
pregnancy, including recommendations for weight gain
during pregnancy [2].
Gestational diabetes mellitus (GDM) which is defined as
glucose intolerance during pregnancy affects approximately 135,000 women or 4% of all pregnancies per year
in the United States [3]. Pregnancies complicated with
GDM are also at increased risk for many maternal and fetal
complications, including cesarean delivery, macrosomia,
neonatal hypoglycemia, stillbirth, and neonatal intensive
care unit (NICU) admission [4]. The combination of pregravid obesity and GDM has been shown to be associated
with an increased risk of adverse pregnancy outcomes over
either disorder alone [5,6].
Methods
The study population was identified retrospectively from a
large centralized perinatal database containing de-identified clinical information collected between July 2000 and
July 2009 from pregnant women diagnosed with GDM and
enrolled in an outpatient GDM education, surveillance,
and management program provided by Alere (formerly
Matria Healthcare). All women provided written consent
for outpatient services and for the later use of their deidentified personal health information for research and
reporting purposes. Each patients healthcare provider
made the diagnosis of GDM, and outpatient services were
prescribed as an adjunct to routine prenatal care. Maternal
characteristics (including pre-pregnancy height and
weight), and medical/obstetric history were collected
during the initial referral process. A perinatal nurse
Correspondence: Ashley Roman, MD, MPH, 1245 Madison Avenue, New York, NY 10128, USA. Tel: 1-212-722-7426. Fax: 1-212-722-7185.
E-mail: aroman@mfmnyc.com
Presented at the 30th Annual Meeting of the Society for MaternalFetal Medicine. Chicago, IL, 16, February 2010. Poster # 0242.
ISSN 1476-7058 print/ISSN 1476-4954 online 2011 Informa UK, Ltd.
DOI: 10.3109/14767058.2010.521871
724
A. S. Roman et al.
collected pregnancy outcomes from each patient approximately 26 weeks after delivery.
Women carrying singleton gestations diagnosed with
GDM by their healthcare provider who were enrolled in
an outpatient GDM education, surveillance, and management program and had documented pre-pregnancy
BMI and delivery information were included in analysis.
The GDM education, surveillance, and management
program consisted of one-on-one GDM education and
counseling with individualized plan of care regarding
diet, exercise, self-care, and blood glucose testing.
Women were instructed on daily testing of blood glucose
levels with fasting and 1- or 2-h postprandial blood
glucose testing. Daily evaluation of blood glucose and
ketone values by a certified diabetes educator was
performed. Reports were administered to the patients
healthcare provider on a weekly basis or more frequently
as needed.
Maternal pre-pregnancy BMI was calculated as weight
in kilograms divided by height in meters squared.
Maternal and neonatal pregnancy outcomes were compared for obese (BMI 30 kg/m2) and non-obese
(BMI 5 30 kg/m2) women and for women across five
increasing pre-pregnancy BMI categories: underweight
(518.5 kg/m2), normal weight (18.524.9 kg/m2), overweight (2529.9 kg/m2), obese (3039.9 kg/m2), and
morbidly obese ( 40 kg/m2). Maternal outcomes evaluated were need for pharmacologic treatment of GDM,
cesarean delivery, and pregnancy-related hypertension
(defined as gestational hypertension or preeclampsia).
Neonatal outcomes evaluated included gestational age at
delivery, preterm birth, birth weight, stillbirth, number of
days in the nursery, NICU admission, birth trauma
(injury identified in the neonate attributed to mechanical
forces of birth, e.g. bruises, lacerations, hematomas,
fractures), shoulder dystocia, hypoglycemia, and
jaundice.
The primary outcome was composite neonatal morbidity
defined as the presence of one or more of the following:
birth weight greater than 4000 g, birth trauma, shoulder
dystocia, hypoglycemia, and jaundice.
Data were compared using Pearsons chi-square, Mann
Whitney U test and KruskalWallis H test statistics as
indicated with two-sided p-values of 50.05 considered
Results
Three thousand seven hundred ninety-eight patients with
GDM met criteria for inclusion in this analysis. All
patients had health insurance (private or Medicaid
coverage) and were receiving prenatal care at enrollment.
Of these patients, 2028 non-obese and 1770 obese were
identified. Maternal obesity was significantly associated
with higher blood glucose levels and need for increased
interventions (Table I). Adverse maternal and neonatal
outcomes were significantly increased in obese women
when compared with women of normal weight or
underweight (Table II). The mean gestational age at
delivery for stillborn infants was 35.9 + 5.0 weeks. A
significant linear trend with increasing BMI was observed
in rates of adverse maternal and neonatal outcomes
(Table III).
The risk of composite neonatal morbidity was significantly increased with increasing BMI (Figure 1).
Logistic regression analysis was used to assess the
impact of the individual variables on composite neonatal
morbidity (Table IV). Among the variables examined in
this study, it appears that four were independently and
significantly associated with developing at least one of the
composite neonatal outcomes: delivery prior to 37 weeks,
obesity, an FBG 4109, and exposure to oral glycemic
agents. Of these four, delivery prior to 37 weeks and
fasting blood glucose greater than 109 had the strongest
association with the composite outcome with an odds
ratio of 1.7. Furthermore, the independent impact of
increasing pre-pregnancy BMI was above and beyond the
harmful effects of having a fasting blood glucose of 109,
an indicator of glycemic control. However, the R2 value of
0.046 indicates that 95% of the variation in the dependent
variable of composite neonatal outcome was not explained by the variables examined in this studys data.
Therefore, there may be additional factors that have an
impact on neonatal morbidity that are not accounted for
in this study.
BMI 5 30 (n 2028)
p-value
OR (95% CI)
50.001
0.002
0.749
0.651
50.001
50.001
50.001
50.001
50.001
50.001
0.004
50.001
50.001
7.9%
5.2%
14.9%
11.8%
50.001
50.001
Data presented as mean + SD, median (min, max) or percentage as indicated. BMI, body mass index; BG, blood glucose.
725
GA at delivery (weeks)
Delivery 537 weeks
Late PTB (3436 weeks)
Pregnancy-related HTN
Cesarean delivery
Birth weight (g)
Birth weight 44000 g
Stillbirth
Nursery days
NICU admission
Birth trauma
Shoulder dystocia
Hypoglycemia
Jaundice
BMI 5 30 (n 2028)
p-value
50.001
0.002
0.013
50.001
50.001
50.001
50.001
0.019
50.001
0.003
0.847
0.038
0.009
0.002
OR (95% CI)
1.3
1.3
3.0
1.7
2.4
5.2
1.3
1.1
6.9
1.5
1.3
(1.1,
(1.0,
(2.5,
(1.5,
(1.9,
(1.1,
(1.1,
(0.3,
(0.8,
(1.1,
(1.1,
1.6)
1.5)
3.7)
2.0)
3.0)
24.0)
1.6)
4.6)
57.3)
2.0)
1.6)
Data presented as mean + SD, median (min, max) or percentage as indicated. GA, gestational age; PTB, preterm birth; HTN,
hypertension.
Underweight,
518.5 (n 66)
Normal,
18.524.9
(n 958)
Overweight,
2529.9
(n 1004)
Obese, 3040
(n 1294)
Morbidly
obese, 440
(n 476)
p-value
4.5%
7.4%
12.0%*
21.7%*
31.5%*
50.001{{
33.3%
2984 + 548,
2948
(1616, 4000)
0
0
3.6 + 3.5, 2
(1, 19)
12.1%
0
0
0
13.6%
36.3%
3163 + 515,
3175
(964, 5091)
4.6%
0.1%
3.2 + 3.5, 2
(1, 45)
9.8%
0.2%
0.1%
4.3%
13.3%
42.6%*
3279 + 525,
3260
(992, 4819)*
7.2%
0.1%
3.5 + 4.7, 2
(1, 58)
12.1%
0.2%
0
4.2%
13.8%
50.0%*
3343 + 615,
3364
(624, 5318)*
12.4%*
0.6%
3.9 + 6.3, 3
(1, 135)*
13.9%
0.2%
0.2%
5.2%
15.8%
60.9%*
3406 + 645,
3455
(514, 5641)
13.7%
0.2%
4.1 + 8.9, 3
(1, 160)
14.9%
0.4%
0.8%
8.0%
20.8%
50.001{{
50.001
50.001{{
0.110{, 0.099{
50.001
0.022{, 0.001{
0.856{, 0.593{
0.009{, 0.012{
0.005{, 0.001{
0.003{, 50.001{
Discussion
As the obesity epidemic in the United States continues
unchecked, maternal obesity is increasingly recognized as
an independent risk factor for adverse maternal and fetal
outcomes. The prevalence of GDM has been shown to
increase with increasing pre-pregnancy BMI, with a 46%
prevalence for women with a BMI of 3034.9, 68%
prevalence with BMI of 3539.9, and 1012% prevalence
with BMI greater than 40 [7]. Few studies, however, have
evaluated the risks of adverse pregnancy outcomes in the
setting of both obesity and GDM.
In this study, we found that maternal obesity is
significantly associated with worse maternal and neonatal
outcomes. Obese women were also more likely to require
medication for optimal blood sugar control than women
726
A. S. Roman et al.
p-value
OR (95% CI)
50.001
50.001
0.005
0.024
0.117
0.198
0.403
0.777
1.7
1.2
1.7
1.3
1.1
1.2
1.1
1.0
(1.4,
(1.1,
(1.2,
(1.0,
(1.0,
(0.9,
(0.9,
(0.8,
2.1)
1.3)
2.4)
1.7)
1.3)
1.5)
1.3)
1.3)
Acknowledgments
Niki Istwan and Debbie Rhea are employees of Alere, the
company that provided the diabetic services described in
the manuscript and compiled the database used for analysis
in the manuscript. Daniel Saltzman and Andrei Rebarber
are members of the Alere speakers bureau and have served
as consultants for Alere. Chad Klauser has been a member
of Aleres speakers bureau in the past but is not currently a
member. Nathan Fox and Ashley Roman report no
declarations of interest.
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