Gestational weight gain and patterns of breastfeeding among patients with class III obesity.

BACKGROUND: Maternal obesity is associated with delayed lactogenesis and shorter duration of breastfeeding compared to patients with a normal BMI. RESEARCH AIM/QUESTION: We investigated the impact of excessive gestational weight gain, defined as greater than the Institute of Medicine guidelines (>9.1 kg), on the initiation and duration of breastfeeding in patients with class III obesity. METHODS: Retrospective cohort of patients with body mass index ≥40 in first trimester, delivering a singleton term infant at a tertiary care center between July 2013 and December 2017. Primary outcome was exclusive breastfeeding at discharge and at postpartum visit. Secondary outcomes included any breastfeeding at discharge and postpartum visit, and cessation of breastfeeding by the postpartum visit. Descriptive statistics were used to compare those whose gestational weight gain exceeded (eIOM) versus met (mIOM) Institute of Medicine guidelines. Regression models were performed to adjust for baseline confounding factors. RESULTS: Of 294 women included, 117(39.8%) were in the eIOM group. These women were more likely to be primigravida, have a higher delivery BMI, greater delivery blood loss, and have a neonate admitted to the intensive care unit. Exclusive breastfeeding at discharge was not different between eIOM and mIOM (66.7% vs 70.9%, p = .44), nor did eIOM impact likelihood of exclusive breastfeeding at postpartum visit (40.1% vs 34.2%, p = .31). When controlling for confounding factors, breastfeeding at discharge (aOR 1.54 95% CI [0.68-3.49]) or postpartum visit (aOR 0.67[0.31-1.47]) did not differ between eIOM compared to mIOM. CONCLUSIONS: Among women with class III obesity, excessive gestational weight gain did not impact the rate of exclusive breastfeeding at discharge or postpartum visit.

Understanding Patient Evaluation of Abnormal Uterine Bleeding (AUB): A Standardized Patient Case on AUB for OB/GYN Clerkship Students.

INTRODUCTION: The differential diagnosis for abnormal uterine bleeding (AUB) among reproductive-age women is broad and includes common and life-threatening conditions. Recognition and accurate diagnosis of AUB are important but can be challenging for medical students. We developed a standardized patient (SP) encounter for medical students during their OB/GYN clerkship. METHODS: We implemented two SP encounters, on AUB and dyspareunia, that included a postencounter note and SP evaluations. Here, we describe the implementation of the SP encounter on AUB. Students received formative feedback on their interpersonal and history-taking skills, differential diagnosis, and management plan from the SP as well as OB/GYN residents and faculty. Student cumulative feedback was obtained mid-clerkship and following the clerkship. Summary statistics and qualitative data for students' experiences are reported. RESULTS: SP cases were implemented at the Duke University School of Medicine with 101 second-year medical students who completed the encounter from September 2018 to July 2019. Regarding the AUB case, SPs identified students as adequate history takers, with a mean evaluation score of 3.45 (SD = 0.15) out of 5. Most students (94%) correctly identified at least one diagnosis and provided evidence. Endometrial cancer/hyperplasia (63%) and uterine leiomyoma (60%) were most likely to be identified. Regarding both SP encounters, of the 82 students (81%) completing the end-of-clerkship survey, 57% indicated that the experience enhanced their overall learning at least adequately well or better. DISCUSSION: The AUB case provided students with the opportunity to exercise their diagnostic and management skills.

Gestational Weight Gain and Postpartum Depression in Women with Class III Obesity.

OBJECTIVE: We investigated the association between gestational weight gain (GWG) and postpartum depression (PPD) in women with class III obesity. STUDY DESIGN: This is a retrospective cohort of women with body mass index (BMI) ≥ 40 kg/m2 at entry to care, first prenatal visit ≤14 weeks gestation, with singleton, nonanomalous pregnancies who delivered at term from July 2013 to December 2017. Women missing data regarding PPD were excluded. Primary outcome was PPD; classified as Edinburgh Postnatal Depression Scale (EPDS) score >13/30 or provider's report of depression. Participants were classified, according to Institute of Medicine GWG guidelines (11-20 pounds), as either less than 11 pounds (LT11) or at/more than 11 pounds (GT11). Bivariate statistics compared demographics and pregnancy characteristics. Logistic regression used to estimate odds of primary outcome. RESULTS: Of 275 women, 96 (34.9%) gained LT11 and 179 (65.1%) gained GT11 during pregnancy. The rate of PPD was 8.7% (n = 24), 9 (9.4%) in the LT11 group and 15 (8.4%) in the GT11 group (p = 0.82, odds ratio: 1.13, 95% confidence interval [CI]: 0.48, 2.69). When controlling for entry BMI and multiparity, adjusted odds of PPD was 1.07 (95% CI: 0.44, 2.63). No correlation was found between GWG and EPDS. CONCLUSION: A relationship between GWG and PPD in class III obese women was not found in this cohort.

Postpartum Weight Loss in Women with Class-III Obesity: Do They Lose What They Gain?

OBJECTIVE: Excessive gestational weight gain (GWG) increases risk of postpartum weight retention in normal and overweight women but little is known about weight retention in morbidly obese women. We evaluated the impact of GWG on postpartum weight retention in women with class-III obesity. STUDY DESIGN: This is a retrospective cohort of pregnancies at a single institution from July 2013 to December 2017 complicated by body mass index (BMI) ≥ 40 at entry to care. Women were classified as GWG within (WITHIN), less than (LESS), or greater than (MORE) Institute of Medicine's (IOM) recommendations. Women were excluded for multiples, late prenatal care, preterm birth, fetal anomalies, intrauterine demise, weight loss, and missing data. Primary outcome was achievement of intake weight at the postpartum visit. Logistic regression was used to adjust for confounding factors. RESULTS: Among 338 women, 93 (28%) gained WITHIN, 129 (38%) LESS, and 144 (43%) MORE. Women in the MORE group were less likely to achieve their intake weight at the postpartum visit (adjusted odds ratio [AOR] = 0.09 95% confidence interval [CI]: 0.05-0.17, p < 0.01). Women gaining MORE were the only group who did not lose weight from intake to postpartum (Median weight change [LESS: -14 lbs (IQR: -20 to -7)] vs. [WITHIN: -7 lbs (IQR: -13 to -1)] vs. [MORE: 5 lbs (IQR: 0-15)]; p < 0.01). CONCLUSION: Excessive GWG in women with class-III obesity is associated with postpartum weight retention.