A Behavioral Weight Gain Intervention in Pregnancy: A Cost-Benefit Analysis

OBJECTIVE: Prior studies have demonstrated that behavioral interventions during pregnancy could prevent excessive gestational weight gain. This study investigates the cost of such interventions, taking into account the costs and benefits associated with outcomes of gestational weight gain according to the 2009 Institute of Medicine (IOM) weight gain recommendations. STUDY DESIGN: A decision analytic model was built using TreeAge software that compared routine prenatal care vs. routine prenatal care plus a behavioral intervention to prevent excessive gestational weight gain in the 1,528,000 normal weight women who are pregnant each year in the U.S. The Fit for Delivery Study protocol was used to estimate the effect of treatment on gestational weight gain and the costs of intervention. Outcomes included: gestational diabetes, preeclampsia, macrosomia (\u3e4500g), small-for-gestational age, postterm delivery, cesarean delivery, postpartum weight retention, and child obesity. RESULTS: In addition to reducing gestational weight gain among normal weight women, the intervention was cheaper, $15,965 versus$16,122 without intervention. With lower costs and better outcomes, such a behavioral intervention is a dominant strategy. In addition, it would lead to 7,579 fewer cesareans each year, 6,830 fewer cases of macrosomia, and 10,925 fewer cases of postpartum weight retention at 1 year (see table). CONCLUSION: A behavioral intervention added to routine prenatal care is cost-beneficial (leads to lower costs and more than recovers the cost of intervention) as compared to routine prenatal care alone among normal weight women. A proven intervention may have even greater impact in overweight and obese women. Further research in this area could lead to both better outcomes and economic benefits at a societal level

The Economic Impact of Gestational Weight Gain According to IOM Guidelines

OBJECTIVE: We sought to estimate the costs and outcomes associated with keeping gestational weight gain within the 2009 Institute of Medicine (IOM) recommendations. STUDY DESIGN: A decision analytic model was built using TreeAge software that compared the cost of gestational weight gain categorized by staying within versus exceeding the IOM guidelines in normal weight and obese women. We assumed the obesity prevalence from the most recent data in 2008 and applied to the estimated 4,000,000 million births per year. Outcomes included: gestational diabetes, preeclampsia, macrosomia (\u3e4500g), small-forgestational age, postterm delivery, cesarean delivery, postpartum weight retention, and child obesity. RESULTS: Normal weight women who gained within the IOM recommendations incurred $2,502 less costs than normal weight women who exceeded the IOM recommendations. Obese women who gained within the IOM recommendations incurred$6,501 less costs than obese women who exceeded the IOM recommendations. With lower costs and better outcomes adhering to IOM guidelines for gestational weight gain is a dominant strategy. When applied to the U.S. population, gaining within IOM guidelines could lead to $12.7 billion dollars of savings. In addition, staying within the IOM guidelines would result in 76,400 fewer cesarean deliveries for normal weight women and 408,000 for obese women (see table). CONCLUSION: From a societal standpoint, there is economic benefit to staying within the IOM guidelines for gestational weight gain. With such an enormous potential impact on economic and clinical outcomes, further research into accomplishing these guidelines should be widespread

First trimester growth delay: An early marker of triploidy

Triploidy is one the most common chromosomal abnormality in humans, complicating about 1% of all human pregnancies. Most affected conceptions undergo spontaneous abortion in the first trimester, making the prevalence of second trimester triploidy low. Viable triploidy is associated with high rates of maternal morbidity, including hypertensive disorders, hemorrhage, and persistent trophoblasic disease, as well as fetal and neonatal severe adverse outcomes. Given these complications, early identification of triploidy in ongoing pregnancies may inform patient counseling and management

The growth-restricted fetus: risk of mortality by each additional week of expectant management

<p><b>Objective:</b> To compare fetal/infant mortality risk associated with each additional week of expectant management with the infant mortality risk of immediate delivery in growth-restricted pregnancies.</p> <p><b>Methods:</b> A retrospective cohort study was conducted of singleton, nonanomalous pregnancies from the 2005–2008 California Birth Registry comparing pregnancies affected and unaffected by growth restriction, defined using birth weights as a proxy for fetal growth restriction (FGR). Birth weights were subdivided as greater than the 90th percentile, between the 10th percentile and 90th percentile, and less than the 10th percentile. Cases greater than the 90th percentile were excluded from analysis. Cases less than the 10th percentile were considered to have FGR and were further subcategorized into <10th percentile, <5th percentile, and <3rd percentile. We compared the risk of infant death at each gestational age week against a composite risk representing the mortality risk of one additional week of expectant management.</p> <p><b>Results:</b> We identified 1,641,000 births, of which 110,748 (6.7%) were less than 10th percentile. The risk of stillbirth increased with gestational age with the risk of stillbirth at each week of gestation inversely proportional to growth percentile. The risks of fetal and infant mortality with expectant management outweighed the risk of infant death for all FGR categories analyzed beginning at 38 weeks. However, the absolute risks differed by growth percentiles, with the highest risks of infant death and stillbirth in the <3rd percentile cohort. At 39 weeks, absolute risks were low, although the number needed to deliver to prevent 1 death ranged from 413 for <3rd percentile to 2667 in unaffected pregnancies.</p> <p><b>Conclusion:</b> At 38 weeks, the mortality risk of expectant management for one additional week exceeds the risk of delivery across all growth-restricted cohorts, despite variation in absolute risk by degree of growth restriction.</p

When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers?

<div><p></p><p><i>Objective</i>: To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.</p><p><i>Methods</i>: A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10 000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature. Strategies involving expectant management accounted for the probabilities of stillbirth, spontaneous delivery and induction of labor for UAD absent or reversed end-diastolic flow (AREDF) at each successive week. Outcomes included short- and long-term neonatal morbidity and mortality with quality-adjusted life years (QALYs) generated based on these outcomes. Base case, sensitivity analyses and a Monte Carlo simulation were performed.</p><p><i>Results</i>: The optimal GA for delivery is 35 weeks, which minimized perinatal deaths and maximized total QALYs. Earlier delivery became optimal once the risk of stillbirth was threefold our baseline assumption; our model was also robust until the risk of AREDF at 35 weeks was half our baseline assumption, after which delivery at 36 weeks was preferred. Delivery at 35 weeks was the optimal strategy in 77% of trials in Monte Carlo multivariable sensitivity analysis.</p><p><i>Conclusions</i>: Weighing the risks of iatrogenic prematurity against the poor outcomes associated with AREDF, the ideal GA to deliver late preterm IUGR fetuses with elevated UAD indices is 35 weeks.</p></div