Weight Loss Instead of Weight Gain within the Guidelines in Obese Women during Pregnancy: A Systematic Review and Meta-Analyses of Maternal and Infant Outcomes

<div><p>Background</p><p>Controversy exists about how much, if any, weight obese pregnant women should gain. While the revised Institute of Medicine guidelines on gestational weight gain (GWG) in 2009 recommended a weight gain of 5–9 kg for obese pregnant women, many studies suggested even gestational weight loss (GWL) for obese women.</p><p>Objectives</p><p>A systematic review was conducted to summarize pregnancy outcomes in obese women with GWL compared to GWG within the 2009 Institute of Medicine guidelines (5–9 kg).</p><p>Design</p><p>Five databases were searched from 1 January 2009 to 31 July 2014. The Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA Statement were followed. A modified version of the Newcastle-Ottawa scale was used to assess individual study quality. Small for gestational age (SGA), large for gestational age (LGA) and preterm birth were our primary outcomes.</p><p>Results</p><p>Six cohort studies were included, none of which assessed preterm birth. Compared to GWG within the guidelines, women with GWL had higher odds of SGA <10^th percentile (adjusted odds ratio [AOR] 1.76; 95% confidence interval [CI] 1.45–2.14) and SGA <3^rd percentile (AOR 1.62; 95% CI 1.19–2.20) but lower odds of LGA >90^th percentile (AOR 0.57; 95% CI 0.52–0.62). There was a trend towards a graded relationship between SGA <10^th percentile and each of three obesity classes (I: AOR 1.73; 95% CI 1.53–1.97; II: AOR 1.63; 95% CI 1.44–1.85 and III: AOR 1.39; 95% CI 1.17–1.66, respectively).</p><p>Conclusion</p><p>Despite decreased odds of LGA, increased odds of SGA and a lack of information on preterm birth indicate that GWL should not be advocated in general for obese women.</p></div

Pooled results of the studies that reported the odds of infants being small for gestational age (<10^th percentile, multivariable) for obese mothers with gestational weight loss compared to gestational weight gain within the 2009 Institute of Medicine guideline.

<p>Pooled results of the studies that reported the odds of infants being small for gestational age (<10^th percentile, multivariable) for obese mothers with gestational weight loss compared to gestational weight gain within the 2009 Institute of Medicine guideline.</p

Pooled results of the studies that reported the odds of infants being large for gestational age (>90^th percentile, multivariable) for obese mothers with gestational weight loss compared to gestational weight gain within the 2009 Institute of Medicine guideline.

<p>Pooled results of the studies that reported the odds of infants being large for gestational age (>90^th percentile, multivariable) for obese mothers with gestational weight loss compared to gestational weight gain within the 2009 Institute of Medicine guideline.</p

Characteristics of included cohort studies in systematic review of gestational weight loss in obese women and adverse pregnancy outcomes.

<p>^a All had a retrospective cohort study design</p><p>Abbreviations: ACOG = American College of Obstetricians and Gynecologists, BMI = body mass index, GDM = gestational diabetes mellitus, LBW = low birth weight, LGA = large for gestational age, NICU = neonatal intensive care unit, NR = not reported, SGA = small for gestational age, USA = United States of America, WIC = Women, Infants, and Children.</p><p>Characteristics of included cohort studies in systematic review of gestational weight loss in obese women and adverse pregnancy outcomes.</p

Funnel plots for effect of weight loss with LGA (>90^th percentile multivariable), in a systematic review of gestational weight loss in obese women and adverse pregnancy outcomes.

<p>Funnel plots for effect of weight loss with LGA (>90^th percentile multivariable), in a systematic review of gestational weight loss in obese women and adverse pregnancy outcomes.</p

Flow diagram of study selection process.

<p>Flow diagram of study selection process.</p

Summary of multivariable pooled odds ratios (95% confidence intervals) for the association between gestational weight loss and adverse pregnancy outcomes in obese women, compared to gestational weight gain within the 2009 Institute of Medicine guideline.

<p>Summary of multivariable pooled odds ratios (95% confidence intervals) for the association between gestational weight loss and adverse pregnancy outcomes in obese women, compared to gestational weight gain within the 2009 Institute of Medicine guideline.</p

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial

Background: A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown. Methods/design: This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children’s hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality. Discussion: This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children. Trial registration: ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.Medicine, Faculty ofNon UBCMedicine, Department ofPediatrics, Department ofRespiratory Medicine, Division ofReviewedFacult