Just Accepted by The Journal of Maternal-Fetal & Neonatal Medicine Effects of Maternal Obesity on Antenatal, Perinatal, and Neonatal Outcomes Muhittin Eftal Avcı, Fatih Şanlıkan, Mehmet Çelik, Anıl Avcı, Mustafa Kocaer, Ahmet Göçmen doi: 10.3109/14767058.2014.978279 Abstract
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Objective: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy. Methods: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI) < 18.5 kg/m2 was underweight, 18.5–24.9 kg/m2 was normal weight, 25–29.9 kg/m2 was overweight, and ≥ 30 kg/m2 was obese. The effects of obesity on fetal and maternal outcomes were investigated. Results: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal heart rate pattern, and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normal-weight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia, and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p < 0.01). Conclusion: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality.
© 2014 Informa UK Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication.
Effects of Maternal Obesity on Antenatal, Perinatal, and Neonatal Outcomes 1
2*
2
3
1
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Muhittin Eftal Avcı , Fatih Şanlıkan , Mehmet Çelik , Anıl Avcı , Mustafa Kocaer , Ahmet Göçmen
2
1
Tepecik Training and Research Hospital, Department of Perinatology, Yenişehir, Izmir, Turkey
2
Ümraniye Education and Research Hospital, Department of Obstetrics and Gynecology İstanbul, Turkey
3
Gaziemir State Hospital, İzmir, Turkey
*
Corresponding author: Fatih Şanlıkan
Address: Adem Yavuz Cad. No 1 Kadın Hastalıkları ve Doğum Kliniği, Ümraniye, Turkey. Tel.: +90 216 632 18 18; fax: +90 (0216) 632 71 24
E-mail: [email protected] Short Title: Outcomes of obesity during pregnancy Keywords: obesity, pregnancy outcomes, body mass index ABSTRACT Objective: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy.
Methods: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI) < 18.5 kg/m2 was underweight, 18.5–24.9
1
kg/m2 was normal weight, 25–29.9 kg/m2 was overweight, and ≥ 30 kg/m2 was obese. The effects of obesity on fetal and maternal outcomes were investigated.
Results: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
heart rate pattern, and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normalweight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia, and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p < 0.01). Conclusion: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality. INTRODUCTION Obesity, which has physical, psychological, and social consequences, is an important public health problem worldwide. Obesity has been known for > 2500 years and is defined by the WHO as abnormal or excess fat accumulation that presents a health risk [1]. Obesity is currently the second-most important health problem, after smoking. The prevalence of obesity and overweight is increasing in most industrial countries, and is becoming an epidemic. Obesity prevalence is 54.8% in females and 17.2% in males in Turkey [2]. The increased prevalence in females may be due to excess weight gain during pregnancy, oral contraceptive use, an effect of estrogen, or due to a limited social life and physical activity.
2
Anthropometric measurements such as body mass index (BMI), which is a practical and reasonably correct objective method, are used to diagnose obesity.
Obesity
is
associated
with
increased rates of pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), venous thromboembolism, and postpartum hemorrhage risk during pregnancy and the intrapartum period [3,4]. Additionally, emergency and elective cesarean rates, labor induction rates, risk of preterm birth, shoulder
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
dystocia, macrosomia, newborn intensive care unit (ICU) requirement, fetal and neonatal death, and the risk of low APGAR scores increase in obese pregnant females [3-6]. Antenatal medical care expenses also increase significantly in obese and overweight females [7]. In this study, we identified obesity-related pregnancy complications.
MATERIALS AND METHODS Patients whose antenatal follow-up was performed at Ümraniye Teaching and Research Hospital between March 2012 and March 2013 were evaluated. The patients were at the onset of labor and were hospitalized for follow-up of labor. Demographic characteristics, weight before pregnancy, height and BMI (kg/m2), weight just before delivery, weight gain during pregnancy, and diseases during pregnancy were recorded. Blood was drawn to evaluate hemoglobin (Hb) and hematocrit (Htc) levels before delivery. Patients whose medical history could not be obtained, those with multiple gestations, birth before gestational week 24, and those who had children with fetal anomalies were excluded; thus, 931 cases were divided into four groups based on BMI before pregnancy: BMI < 18.5 kg/m2 was underweight, 18.5–24.9 kg/m2 was normal weight, 25–29.9 kg/m2 was overweight, and ≥ 30 kg/m2 was obese. Age, weight before pregnancy, height, weight just before delivery, BMI, and complete blood count were determined as initial measurements. GDM, PIH, placental abruption, placenta previa, preterm birth, meconium-stained amniotic fluid, fetal heart rate pattern before birth, premature rupture of membranes (PROM), delivery method, cesarean delivery due to fetal distress, cesarean delivery due to cephalopelvic
3
disproportion (CPD) and abnormal labor progress, reduced Hb and Htc during the first day postpartum, small for gestational age (SGA) infant, large for gestational age (LGA) infant, APGAR scores at 1 and 5 min, perinatal death, and newborn ICU requirement rates were assessed as final outcomes. These four groups were compared in terms of maternal and fetal outcomes. The Number Cruncher Statistical System 2007 & PASS 2008 statistical software (SAS Institute,
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Cary, NC, USA) were used for the statistical analysis. Means and standard deviations were used for descriptive data. One-way analysis of variance was conducted to compare normally distributed quantitative data, and Tukey’s HSD test was used to identify group differences. The Kruskal–Wallis test was used to compare groups with non-normally distributed data, and the Mann–Whitney U-test was used to identify group differences. The chi-squared test was used to compare qualitative data. A p < 0.05 was considered to indicate significance.
RESULTS This study was conducted with 931 cases (mean age, 27.04 ± 5.40 yr; range, 16–45 yr) between March 2012 and March 2013. Mean age, gravidity, and parity of the group with a BMI ≥ 30 kg/m 2 were significantly higher than in the other groups (p < 0.01). GDM and PIH rates were significantly higher in the BMI ≥ 30 kg/m2 group than in the other groups (p < 0.01). We did not encounter eclampsia or HELLP syndrome. Chronic hypertension rates were significantly higher in the BMI ≥ 30 kg/m2 group than in the other groups (p < 0.01). The placental abruption rate was significantly higher in the BMI < 18.5 kg/m2 group than in the other groups (p < 0.01). No significant differences were observed for intrauterine growth restriction or polyhydramnios rates among the groups. The birth method in 25.8% of the cases (n = 248) was cesarean section. The most common indication for cesarean section was a previous cesarean delivery (n = 74), followed by fetal distress (n = 61), and abnormal progression of labor (n = 27). The vaginal delivery rate was significantly higher in the BMI < 18.5 kg/m2 group than in the other groups (p
4000 g had shoulder dystocia, whereas 0.93% of infants whose birth weight was < 4000 g had shoulder dystocia. Similar to our results, Owens et al. found shoulder dystocia in 4.1% of infants whose birthweight was >
6
4000 g and in 0.2% of infants whose birthweight was < 4000 g [15]. We found no differences between the decreased Htc and Hb levels between the groups. Athukorala et al. did not find a difference in postpartum hemorrhage rate between normal and obese groups [16]. We identified 22 post-partum infection cases. The post-partum infection rate in the obese group was significantly and markedly higher than that in the other groups. Meher-un-nisa et al. reported that the
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
post-partum infection rate was significantly higher in an obese group compared to non-obese groups [14]. The duration of hospital stay was longer in the obese group in our study. The high cesarean rate and increased hospital stay because of increased morbidity due to increased PIH and diabetes rates in obese patients were associated with this outcome. The preterm birth rate was significantly and markedly higher in the obese group than in the other groups. Driul et al. [11] also found that the preterm birth rate was significantly higher in an obese group. In our study, LGA infant rate in the BMI ≥ 30 kg/m2 group and the SGA infant rate in BMI < 18.5 kg/m2 group were significantly higher than those in the other groups. Athukorala et al. [16] also reported a significantly higher LGA infant rate in an obese group. High GDM prevalence in the obese group resulted in a high macrosomic infant rate. Liu et al. revealed a significantly higher SGA infant rate in the BMI < 18.5 kg/m2 group [17]. Choi et al. emphasized that GDM, hypertensive disorder, LGA, meconiumstained amniotic fluid, and low APGAR scores are common among mothers who are overweight and obese before pregnancy, based on BMI [18]. In our study, meconium-stained amniotic fluid, hypoglycemia, newborn ICU requirement, low APGAR scores, and perinatal death rate were higher in the obese group than in the other groups. Meher-un-nisa et al. reported significantly higher perinatal death rates in an obese group [14]. A high hypoglycemia rate was associated with a high GDM rate in the obese group. Callaway et al. reported that newborn ICU requirement was significantly and markedly higher in an obese group than in the other groups [19]. Because a high rate of pregnancy-related complications, transient tachypnea in the newborn, and respiratory distress were common in obese pregnant females,
7
newborn follow-up rates in the prematurity department were higher. The number of newborns with hypoglycemia was greater because of GDM and high macrosomic infant rates. CONCLUSION Awareness of BMI before pregnancy is important for a healthy outcome. Furthermore, knowledge of the BMI before pregnancy is important to regulate maternal weight gain during pregnancy. Our
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
findings revealed that obesity is an important factor related to increased maternal-fetal morbidity and mortality. Maternal obesity can be avoided by maintaining proper weight during the non-pregnant period. The majority of the adverse effects of pregnancy can likely be prevented by reaching an optimal weight before, and controlling weight gain during, pregnancy. Acknowledgments There is no acknowledgment
Declaration of Interest The authors have no conflicts of interest to declare.
References
[1] World Health Organization: Obesity, preventing and managing the global epidemic. Technical Report 894, WHO, Geneva, 2000; 256. [2] Kozan O, Oğuz A, Abacı A et al. Prevalence of the metabolic syndrome among Turkish adults. European Journal of Clinical Nutrition 2007; 61(4): 548-553. [3] John E, Cassidy DM, Playle R et al. Healthy eating and lifestyle in pregnancy (HELP): a protocol for a cluster randomised trial to evaluate the effectiveness of a weight management intervention in pregnancy. BMC Public Health 2014;14:439. 8
[4] Scott-Pillai R, Spence D, Cardwell C, Hunter A, Holmes V: The impact of body mass index on maternal and neonatal outcomes: a retrospective study in a UK obstetric population, 2004-2011. BJOG 2013;120:932–939. [5] Usha Kiran T, Hemmadi SJB, Evans J: Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005;112:768–772.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
[6] Minsart AF, Buekens P, De Spiegelaere M, Englert Y: Neonatal outcomes in obese mothers: a population- based analysis. BMC Pregnancy Childbirth 2013;13(36). [7] Galtier-Dereure F, Boegner C, Bringer J: Obesity and pregnancy: complications and cost. Am J Clin Nutr 2000;71:1242S–1248S. [8] Hancke K, Gundelach T, Hay B, Sander S, Reister F, Weiss JM. Pre-pregnancy obesity compromises obstetric and neonatal outcomes. J Perinat Med. 2014 Jun 25. pii: /j/jpme.ahead-of-print/jpm-2014-0069/jpm-2014-0069.xml.
doi:
10.1515/jpm-2014-0069.
[Epub ahead of print]. [9] Weiss JL, Malone FD, Emig D et al. Obesity, obstetric complications and cesarean delivery rate: A population-based screening study. Am J Obstet Gynecol 2004;190:1091-7. [10] Aaron B. Deutsch, O’Neill Lynch et al. Increased Risk of Placental Abruption in Underweight Women. Am J Perinatol 2010;27: 235–240. [11]
Driul L, Cacciaguerra G, Citossi A, Martina MD, Peressini L, Marchesoni D:
Prepregnancy body mass index and adverse pregnancy outcomes. Arch Gynecol Obstet 2008;278: 23-26. [12] Morken NH, Klungsøyr K, Magnus P, Skjærven R. Pre-pregnant body mass index, gestational weight gain and the risk of operative delivery. Acta Obstet Gynecol Scand 2013;92:809-15. 9
[13] Zhang Y, Wang ZL, Liu B, Cai J. Pregnancy outcome of overweight and obese Chinese women with gestational diabetes. J Obstet Gynaecol 2014; 9:1-4. [14] Meher-un-nisa, Muhammad Aslam, Salah Rosdy Ahmed, Maamon Rajab, Lina Kattea. Impact of obesity on fetomaternal outcome in pregnant Saudi females. International Journal of Health Sciences Qassim University 2009;3:187-195.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
[15] Owens LA, O’Sullıvan EP, Kırwan B, Avalos G, Gaffney G, Dunne F. ATLANTIC DIP: the impact of obesity on pregnancy outcome in glucose-tolerant women. Diabetes Care 2010;33:577–579. [16] Athukorala C, Rumbold AR, Willson KJ, Crowther CA: The risk of adverse pregnancy outcomes in women who are overweight or obese. BMC Pregnancy and Childbirth 2010;10:56. [17] Liu X, Du J, Wang G, Chen Z, Wang W, Xi Q. Effect of pre-pregnancy body mass index on adverse pregnancy outcome in North of China. Arch Gynecol Obstet 2011;283: 6570. [18] Choi SK, Park IY, Shin JC: The effects of pre-pregnancy body mass index and gestational weight gain on perinatal outcomes in Korean women: a retrospective cohort study. Reproductive Biology and Endocrinology 2011;9:6. [19] Callaway LK, Prins JB, Chang AM, Mclntyre HD. The prevalence and impact of overweight and obesity in an Australian obstetric population. The Medical Journal of Australia 2006;184:56-59.
10
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Table 1: Demographic characteristics and maternal adverse effects according to BMI in cases
MBI groups
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Objective: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy. Methods: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI) < 18.5 kg/m2 was underweight, 18.5–24.9 kg/m2 was normal weight, 25–29.9 kg/m2 was overweight, and ≥ 30 kg/m2 was obese. The effects of obesity on fetal and maternal outcomes were investigated. Results: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal heart rate pattern, and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normal-weight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia, and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p < 0.01). Conclusion: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality.
© 2014 Informa UK Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication.
Effects of Maternal Obesity on Antenatal, Perinatal, and Neonatal Outcomes 1
2*
2
3
1
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Muhittin Eftal Avcı , Fatih Şanlıkan , Mehmet Çelik , Anıl Avcı , Mustafa Kocaer , Ahmet Göçmen
2
1
Tepecik Training and Research Hospital, Department of Perinatology, Yenişehir, Izmir, Turkey
2
Ümraniye Education and Research Hospital, Department of Obstetrics and Gynecology İstanbul, Turkey
3
Gaziemir State Hospital, İzmir, Turkey
*
Corresponding author: Fatih Şanlıkan
Address: Adem Yavuz Cad. No 1 Kadın Hastalıkları ve Doğum Kliniği, Ümraniye, Turkey. Tel.: +90 216 632 18 18; fax: +90 (0216) 632 71 24
E-mail: [email protected] Short Title: Outcomes of obesity during pregnancy Keywords: obesity, pregnancy outcomes, body mass index ABSTRACT Objective: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy.
Methods: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI) < 18.5 kg/m2 was underweight, 18.5–24.9
1
kg/m2 was normal weight, 25–29.9 kg/m2 was overweight, and ≥ 30 kg/m2 was obese. The effects of obesity on fetal and maternal outcomes were investigated.
Results: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
heart rate pattern, and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normalweight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia, and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p < 0.01). Conclusion: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality. INTRODUCTION Obesity, which has physical, psychological, and social consequences, is an important public health problem worldwide. Obesity has been known for > 2500 years and is defined by the WHO as abnormal or excess fat accumulation that presents a health risk [1]. Obesity is currently the second-most important health problem, after smoking. The prevalence of obesity and overweight is increasing in most industrial countries, and is becoming an epidemic. Obesity prevalence is 54.8% in females and 17.2% in males in Turkey [2]. The increased prevalence in females may be due to excess weight gain during pregnancy, oral contraceptive use, an effect of estrogen, or due to a limited social life and physical activity.
2
Anthropometric measurements such as body mass index (BMI), which is a practical and reasonably correct objective method, are used to diagnose obesity.
Obesity
is
associated
with
increased rates of pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), venous thromboembolism, and postpartum hemorrhage risk during pregnancy and the intrapartum period [3,4]. Additionally, emergency and elective cesarean rates, labor induction rates, risk of preterm birth, shoulder
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
dystocia, macrosomia, newborn intensive care unit (ICU) requirement, fetal and neonatal death, and the risk of low APGAR scores increase in obese pregnant females [3-6]. Antenatal medical care expenses also increase significantly in obese and overweight females [7]. In this study, we identified obesity-related pregnancy complications.
MATERIALS AND METHODS Patients whose antenatal follow-up was performed at Ümraniye Teaching and Research Hospital between March 2012 and March 2013 were evaluated. The patients were at the onset of labor and were hospitalized for follow-up of labor. Demographic characteristics, weight before pregnancy, height and BMI (kg/m2), weight just before delivery, weight gain during pregnancy, and diseases during pregnancy were recorded. Blood was drawn to evaluate hemoglobin (Hb) and hematocrit (Htc) levels before delivery. Patients whose medical history could not be obtained, those with multiple gestations, birth before gestational week 24, and those who had children with fetal anomalies were excluded; thus, 931 cases were divided into four groups based on BMI before pregnancy: BMI < 18.5 kg/m2 was underweight, 18.5–24.9 kg/m2 was normal weight, 25–29.9 kg/m2 was overweight, and ≥ 30 kg/m2 was obese. Age, weight before pregnancy, height, weight just before delivery, BMI, and complete blood count were determined as initial measurements. GDM, PIH, placental abruption, placenta previa, preterm birth, meconium-stained amniotic fluid, fetal heart rate pattern before birth, premature rupture of membranes (PROM), delivery method, cesarean delivery due to fetal distress, cesarean delivery due to cephalopelvic
3
disproportion (CPD) and abnormal labor progress, reduced Hb and Htc during the first day postpartum, small for gestational age (SGA) infant, large for gestational age (LGA) infant, APGAR scores at 1 and 5 min, perinatal death, and newborn ICU requirement rates were assessed as final outcomes. These four groups were compared in terms of maternal and fetal outcomes. The Number Cruncher Statistical System 2007 & PASS 2008 statistical software (SAS Institute,
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
Cary, NC, USA) were used for the statistical analysis. Means and standard deviations were used for descriptive data. One-way analysis of variance was conducted to compare normally distributed quantitative data, and Tukey’s HSD test was used to identify group differences. The Kruskal–Wallis test was used to compare groups with non-normally distributed data, and the Mann–Whitney U-test was used to identify group differences. The chi-squared test was used to compare qualitative data. A p < 0.05 was considered to indicate significance.
RESULTS This study was conducted with 931 cases (mean age, 27.04 ± 5.40 yr; range, 16–45 yr) between March 2012 and March 2013. Mean age, gravidity, and parity of the group with a BMI ≥ 30 kg/m 2 were significantly higher than in the other groups (p < 0.01). GDM and PIH rates were significantly higher in the BMI ≥ 30 kg/m2 group than in the other groups (p < 0.01). We did not encounter eclampsia or HELLP syndrome. Chronic hypertension rates were significantly higher in the BMI ≥ 30 kg/m2 group than in the other groups (p < 0.01). The placental abruption rate was significantly higher in the BMI < 18.5 kg/m2 group than in the other groups (p < 0.01). No significant differences were observed for intrauterine growth restriction or polyhydramnios rates among the groups. The birth method in 25.8% of the cases (n = 248) was cesarean section. The most common indication for cesarean section was a previous cesarean delivery (n = 74), followed by fetal distress (n = 61), and abnormal progression of labor (n = 27). The vaginal delivery rate was significantly higher in the BMI < 18.5 kg/m2 group than in the other groups (p
4000 g had shoulder dystocia, whereas 0.93% of infants whose birth weight was < 4000 g had shoulder dystocia. Similar to our results, Owens et al. found shoulder dystocia in 4.1% of infants whose birthweight was >
6
4000 g and in 0.2% of infants whose birthweight was < 4000 g [15]. We found no differences between the decreased Htc and Hb levels between the groups. Athukorala et al. did not find a difference in postpartum hemorrhage rate between normal and obese groups [16]. We identified 22 post-partum infection cases. The post-partum infection rate in the obese group was significantly and markedly higher than that in the other groups. Meher-un-nisa et al. reported that the
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
post-partum infection rate was significantly higher in an obese group compared to non-obese groups [14]. The duration of hospital stay was longer in the obese group in our study. The high cesarean rate and increased hospital stay because of increased morbidity due to increased PIH and diabetes rates in obese patients were associated with this outcome. The preterm birth rate was significantly and markedly higher in the obese group than in the other groups. Driul et al. [11] also found that the preterm birth rate was significantly higher in an obese group. In our study, LGA infant rate in the BMI ≥ 30 kg/m2 group and the SGA infant rate in BMI < 18.5 kg/m2 group were significantly higher than those in the other groups. Athukorala et al. [16] also reported a significantly higher LGA infant rate in an obese group. High GDM prevalence in the obese group resulted in a high macrosomic infant rate. Liu et al. revealed a significantly higher SGA infant rate in the BMI < 18.5 kg/m2 group [17]. Choi et al. emphasized that GDM, hypertensive disorder, LGA, meconiumstained amniotic fluid, and low APGAR scores are common among mothers who are overweight and obese before pregnancy, based on BMI [18]. In our study, meconium-stained amniotic fluid, hypoglycemia, newborn ICU requirement, low APGAR scores, and perinatal death rate were higher in the obese group than in the other groups. Meher-un-nisa et al. reported significantly higher perinatal death rates in an obese group [14]. A high hypoglycemia rate was associated with a high GDM rate in the obese group. Callaway et al. reported that newborn ICU requirement was significantly and markedly higher in an obese group than in the other groups [19]. Because a high rate of pregnancy-related complications, transient tachypnea in the newborn, and respiratory distress were common in obese pregnant females,
7
newborn follow-up rates in the prematurity department were higher. The number of newborns with hypoglycemia was greater because of GDM and high macrosomic infant rates. CONCLUSION Awareness of BMI before pregnancy is important for a healthy outcome. Furthermore, knowledge of the BMI before pregnancy is important to regulate maternal weight gain during pregnancy. Our
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Dicle Univ. on 11/08/14 For personal use only.
findings revealed that obesity is an important factor related to increased maternal-fetal morbidity and mortality. Maternal obesity can be avoided by maintaining proper weight during the non-pregnant period. The majority of the adverse effects of pregnancy can likely be prevented by reaching an optimal weight before, and controlling weight gain during, pregnancy. Acknowledgments There is no acknowledgment
Declaration of Interest The authors have no conflicts of interest to declare.
References
[1] World Health Organization: Obesity, preventing and managing the global epidemic. Technical Report 894, WHO, Geneva, 2000; 256. [2] Kozan O, Oğuz A, Abacı A et al. Prevalence of the metabolic syndrome among Turkish adults. European Journal of Clinical Nutrition 2007; 61(4): 548-553. [3] John E, Cassidy DM, Playle R et al. Healthy eating and lifestyle in pregnancy (HELP): a protocol for a cluster randomised trial to evaluate the effectiveness of a weight management intervention in pregnancy. BMC Public Health 2014;14:439. 8
[4] Scott-Pillai R, Spence D, Cardwell C, Hunter A, Holmes V: The impact of body mass index on maternal and neonatal outcomes: a retrospective study in a UK obstetric population, 2004-2011. BJOG 2013;120:932–939. [5] Usha Kiran T, Hemmadi SJB, Evans J: Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005;112:768–772.
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Table 1: Demographic characteristics and maternal adverse effects according to BMI in cases
MBI groups
