Clinical and epidemiological aspects of obesity during pregnancy and the puerperium

Objective: To study different aspects of obesity during pregnancy, birth and the puerperium. Paper I is an intervention study of obese pregnant women. Paper II compares fatty acid (FA) patterns in breast milk and neonates ́ plasma phospholipids in normal-weight mothers and an intervention group of obese mothers. Paper III reports the risk of obstetric anal sphincter la - cerations in relation to maternal obesity among primiparas. Paper IV compares health care consumption and sick-listing among obese and normal-weight pregnant women. Methods: Paper I is a pilot clinical study of women with BMI ≥ 30, included during a first-tri - mester prenatal visit. Twenty-five pregnant women were included in the intervention program, comprising visits to midwife, obstetrician and dietician, as well as weekly water gymnastics. Paper II is a randomized observational study of 41 obese and 41 normal-weight pregnant wo - men. Twenty-nine obese women participating in a weight reduction program were included for comparison. FA were analyzed with capillary gas chromatography of lipids in breast milk collected at three and 10 days and one and two months postnatally, as well as in infants’ plasma sampled three days after birth. Paper III is a nationwide register-based study including 210,678 primiparas who gave vagi - nal birth to a singleton, identified from the Swedish Medical Birth Register between Janua - ry 1, 2003 and December 31, 2008. Body Mass Index (BMI) was categorized into four classes, according to World Health Organization (WHO) guidelines. Paper IV is a nationwide register-based study of 108,103 pregnant women, identified from the Swedish Medical Birth Register, the Maternal Health Care Register and the Swedish National Inpatient Register between January 1, 2003 and December 31, 2008. The women were catego - rized into four BMI classes, according to WHO guidelines. Results: Paper I : Fourteen (56 %) of the women had a gestational weight gain of ≤ 6 kg (study goal). There were no cases of gestational diabetes. Three (12 %) women had mild hyperten - sion. Three women (12 %) were delivered by emergency cesarean section. All babies were healthy and had normal birth weights. Paper II : The concentrations of omega-3 FA were lower and the omega - 6 / omega - 3 ratio was higher in neonates and in consecutive samples of breast milk from obese mothers, compared to normal- weight mothers. FA patterns were more similar to those in normal-weight mothers when obese mothers participated in an intervention program with dietary advice and physical activity. Paper III : In multivariate analyses, increasing BMI showed a nearly dose-response-type pro - tective effect against grade III-IV sphincter lacerations. Paper IV : Obese women made more visits to midwives, doctors and the specialized an-tenatal care unit. They also complained of fear of childbirth more often. They had longer in-hospital stays and were sick-listed more often during pregnancy. Conclusions: Obese pregnant women use more healthcare recourses during pregnancy. During delivery the risk for anal sphincter lacerations decreases with higher BMI. There might be an effect at eating and exercise habits with intervention and the results suggest the importance of health promoting guidance of obese pregnant women also influencing the early fatty acids pattern of their infants

Prolonged pregnancy and stillbirth among women with overweight or obesity – a population-based study in Sweden including 64,632 women

Abstract Background The proportion of overweight or obese pregnant women is increasing in many countries and babies born to a mother who is overweight or obese are at higher risk for complications. Our primary objective was to describe sociodemographic and obstetric factors across Body Mass Index (BMI) classifications, with secondary objective to investigate stillbirth and other pregnancy outcomes in relation to BMI classifications and gestational week. Methods This population-based cohort study with data partly based on a cluster-randomized controlled trial includes 64,632 women with singleton pregnancy, giving birth from 28 weeks’ gestation. The time period was January 2016 to 30 June 2018 (2.5 years). Women were divided into five groups according to BMI: below 18.5 underweight, 18.5–24.9 normal weight, 25.0–29.9 overweight, 30.0–34.9 obesity, 35.0 and above, severe obesity. Results Data was obtained for 61,800 women. Women who were overweight/obese/severely obese had lower educational levels, were to a lesser extent employed, were more often multiparas, tobacco users and had maternal diseases to a higher extent than women with normal weight. From 40 weeks’ gestation, overweight women had a double risk of stillbirth compared to women of normal weight (RR 2.06, CI 1.01–4.21); the risk increased to almost four times higher for obese women (RR 3.97, CI 1.6–9.7). Women who were obese or severely obese had a higher risk of almost all pregnancy outcomes, compared to women of normal weight, such as Apgar score < 7 at 5 min (RR1.54, CI 1.24–1.90), stillbirth (RR 2.16, CI 1.31–3.55), transfer to neonatal care (RR 1.38, CI 1.26–1.50), and instrumental delivery (RR 1.26, CI 1.21–1.31). Conclusions Women who were obese or severely obese had a higher risk of almost all adverse pregnancy outcomes and from gestational week 40, the risk of stillbirth was doubled. The findings indicate a need for national guidelines and individualized care to prevent and reduce negative pregnancy outcomes in overweight/obese women. Preventive methods including preconception care and public health policies are needed to reduce the number of women being overweight/obese when entering pregnancy

Changing diagnostic criteria for gestational diabetes in Sweden-a stepped wedge national cluster randomised controlled trial-the CDC4G study protocol

Background: The optimal criteria to diagnose gestational diabetes mellitus (GDM) remain contested. The Swedish National Board of Health introduced the 2013 WHO criteria in 2015 as a recommendation for initiation of treatment for hyperglycaemia during pregnancy. With variation in GDM screening and diagnostic practice across the country, it was agreed that the shift to new guidelines should be in a scientific and structured way. The aim of the Changing Diagnostic Criteria for Gestational Diabetes (CDC4G) in Sweden (www.cdc4g.se/en) is to evaluate the clinical and health economic impacts of changing diagnostic criteria for GDM in Sweden and to create a prospective cohort to compare the many long-term outcomes in mother and baby under the old and new diagnostic approaches. Methods: This is a stepped wedge cluster randomised controlled trial, comparing pregnancy outcomes before and after the switch in GDM criteria across 11 centres in a randomised manner. The trial includes all pregnant women screened for GDM across the participating centres during January–December 2018, approximately two thirds of all pregnancies in Sweden in a year. Women with pre-existing diabetes will be excluded. Data will be collected through the national Swedish Pregnancy register and for follow up studies other health registers will be included. Discussion: The stepped wedge RCT was chosen to be the best study design for evaluating the shift from old to new diagnostic criteria of GDM in Sweden. The national quality registers provide data on the whole pregnant population and gives a possibility for follow up studies of both mother and child. The health economic analysis from the study will give a solid evidence base for future changes in order to improve immediate pregnancy, as well as long term, outcomes for mother and child. Trial registration: CDC4G is listed on the ISRCTN registry with study ID ISRCTN41918550 (15/12/2017