Weight gain in pregnancy: can metformin steady the scales?

OBJECTIVE: Metformin has been associated with modest weight reduction in the non-pregnant population. Our hypothesis is that metformin exposure will lead to a higher incidence of appropriate weight gain during pregnancy. STUDY DESIGN: This was a retrospective cohort study in a single center between 2009 and 2019. We included all pregnant women with type 2 diabetes or prediabetes. We compared women exposed to metformin in any trimester. The primary outcome was appropriate weight gain defined by the Institute of Medicine guidelines. Secondary outcomes included excessive weight gain, weight loss, suspected fetal growth restriction (FGR), and mean birth weight. Adjusted odds ratios or group differences were calculated using logistic or linear regression, controlling for confounders. RESULTS: Of 41,472 deliveries during the study period, 511 pregnancies met inclusion criteria. 284 pregnancies had no metformin exposure; 227 did have metformin exposure, of which 169 (72.2%) were initiated on metformin in the first trimester. Women exposed to metformin in any trimester were statistically not more likely to have appropriate weight gain (aOR 1.53 (95% CI 1.00-2.34, p = .048), but did have less excess weight gain (aOR 0.45, 95% CI 0.30-0.66, p < .001), and more maternal weight loss (aOR 2.17, 95% CI 1.18-3.98, p = .012) than the unexposed group. Women exposed to metformin in the first trimester of pregnancy were less likely to have excess weight gain (aOR 0.39, 95% CI 0.25-0.61, p < .001) and more likely to have maternal weight loss (aOR 2.56, 95% CI 1.30-5.07, p = .007) than the unexposed cohort. There was no difference in FGR (5.3% vs 2.5% p = .094) or mean birth weight (3235.6 vs 3352.4 gm p = .122) in the metformin exposed group vs non-exposed groups, respectively. CONCLUSIONS: Metformin exposure in pregnancy was associated with less excess weight gain and a higher rate of weight loss. There was no difference in FGR or mean birth weight in metformin exposed neonates. This suggests that metformin may help avoid excess weight gain and its associated comorbidities.

Postoperative Respiratory Compromise following Cesarean Birth: The Impact of Obesity and Systemic Opioids.

Objective The aim of this study was to measure the effect of obesity and systemic opioids on respiratory events within the first 24 hours following cesarean. Methods Opioid-naive women undergoing cesarean between January 2016 and December 2017 were included in this retrospective cohort study. The primary outcome was the proportion of women experiencing at least one composite respiratory outcome (oxygen saturation less than 95% lasting 30+ seconds or need for respiratory support) within 24 hours of cesarean. The impact of obesity and total systemic opioid dose in 24 hours (measured in morphine milligram equivalents [MMEs]) on the composite respiratory compromise outcome were evaluated. Results Of 2,230 cesarean births, 790 women had at least one composite respiratory event. Predictors of the composite respiratory outcome included body mass index (BMI) as a continuous variable (odds ratio = 1.063 for every one unit increase in BMI [95% confidence interval (CI): 1.021-1.108], p = 0.003), and MME (odds ratio = 1.005 [95% CI: 1.002-1.008], p = 0.003), adjusting for magnesium sulfate use. The interaction between obesity and opioid dose demonstrated an odds ratio of 1.000 (95% CI: 0.999-1.000, p = 0.030). Conclusion The proportion of women experiencing respiratory events following cesarean birth increases with the degree of obesity and opioid dose. Key Points Respiratory events increase with obesity.Respiratory events increase with systemic opioid use.Odds ratio of respiratory events is 1.063/unit BMI increase.

Metformin Exposure and Risk of Hypertensive Disorders of Pregnancy in Patients with Type 2 Diabetes.

OBJECTIVE: Metformin has been found to have a role in promoting vascular remodeling and angiogenesis which may reduce the risk of developing preeclampsia. Prior studies have shown a decrease in the incidence of hypertensive disorders of pregnancy in patients with type 2 and gestational diabetes taking metformin. We hypothesize metformin exposure decreases the risk of developing hypertension in patients with type 2 diabetes. STUDY DESIGN: Retrospective cohort study from 2009 to 2019 of singleton pregnancies was complicated by type 2 diabetes. We compared patients who received metformin throughout pregnancy to those with no metformin exposure. The primary outcome was a hypertension composite defined as gestational hypertension, preeclampsia with or without severe features, HELLP syndrome, or eclampsia. Individual hypertensive outcomes and neonatal outcomes were secondarily evaluated. Logistic regression was used to adjust for confounding variables. RESULTS: A total of 254 pregnancies were included. Women exposed to metformin were significantly less likely to develop hypertension composite compared with nonexposed women (22.7 vs. 33.1%, aOR 0.53, 95% CI 0.29-0.96). The incidence of preeclampsia with severe features was also significantly lower in those who received metformin compared with those who did not (12.1 vs. 20.7%, aOR 0.38, 95% CI 0.18-0.81). There were no differences in preterm birth prior to 34 or 37 weeks, fetal growth restriction, or birth weight between the study groups. A subgroup analysis of women without chronic hypertension also had a significantly lower risk of developing preeclampsia with severe features (7.6 vs. 17.8%, aOR 0.35, 95% CI 0.13-0.94). CONCLUSION: Metformin exposure was associated with a decreased risk of composite hypertensive disorders of pregnancy in patients with pregestational type 2 diabetes. These data suggest that there may be benefit to metformin administration beyond glycemic control in this patient population. KEY POINTS: · Metformin use showed a decreased risk of a hypertension composite.. · Results were consistent in patients without chronic hypertension.. · Metformin may show benefit beyond glycemic control in women with type 2 diabetes..

Lidocaine patches for postcesarean pain control in obese women: a pilot randomized controlled trial.

BACKGROUND: Obesity increases the risk of opioid-related morbidity. Lidocaine patches have been shown to reduce postoperative pain after noncesarean surgeries. OBJECTIVE: This study aimed to determine whether the application of lidocaine patches around the cesarean incision in women with obesity reduces the total dose of opioids administered in the first 24 hours after cesarean delivery. STUDY DESIGN: This was a pilot single-blind randomized controlled trial of 61 women with obesity undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. After cesarean delivery, the allocated patches (either 5% lidocaine patches or placebo patches) were applied superior and lateral to the incision dressing and remained in place for 12 hours. The average cumulative opioid dose received within the first 24 hours after cesarean delivery was measured in morphine milligram equivalents. We also assessed pain and patient satisfaction. A sample size of 60 (30 per group) was determined to be adequate to inform a future appropriately powered randomized controlled trial. The primary outcome of morphine milligram equivalents was compared using the Student t test, and pain scores were compared using the Wilcoxon rank sum test. RESULTS: Of the 146 women screened between February 2019 and September 2019, 61 consented and were analyzed: 30 women were allocated to lidocaine patch and 31 were allocated to placebo (hydrocolloid patch). Women who were allocated to the lidocaine patch used an average of 87.0 (standard deviation, 35.8) morphine milligram equivalents of opioids in the first 24 hours compared with an average of 83.9 (standard deviation, 27.5) morphine milligram equivalents among women who were allocated to the placebo patch (P=.702). Women who were allocated to the lidocaine vs placebo patches reported median pain scores of 3.0 (interquartile range, 2.1-4.9) and 3.5 (interquartile range, 2.5-5.0), respectively (P=.217). The time to the first dose of opioids, total number of opioid doses, and total morphine milligram equivalents in 48 hours and for the entire hospital stay did not differ. Patient satisfaction with both patches was high and not statistically different. CONCLUSION: This pilot suggests that 5% lidocaine patches applied superior and lateral to the cesarean incision are not effective at reducing the average total dose of morphine milligram equivalents administered in the first 24 hours after cesarean delivery among women with obesity, and they did not seem to improve median pain scores. An appropriately powered randomized trial would not be expected to demonstrate reduction in opioid use or pain.

A Matter of Time: Does Gestational Age Affect the Duration of the Fetal Anatomic Survey?

OBJECTIVE: To assess the average duration of detailed fetal anatomic surveys in pregnancy in relation to gestational age (GA) and the maternal body mass index (BMI) to determine optimal timing of the examination. METHODS: This was a retrospective cohort study of gravidae presenting for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding examinations expected to have longer duration (ie, multifetal, major fetal anomalies), there were a total of 6522 examinations performed between GAs of 18 weeks 0 days and 22 weeks 0 days. Women were grouped by BMI, and results were analyzed by logistic regression. RESULTS: Gravidae of normal weight (BMI, 18.5-24.9 kg/m2 ) had a decrease of 47.47 seconds of the examination time with each increasing week of gestation (P = .036). Overweight (BMI, 25-29.9 kg/m2 ) gravidae similarly had a decrease of 66.31 seconds of the examination time with each additional week of gestation (P = .017). Underweight (BMI, 8.5 kg/m2 ) and obese (BMI, ≥30 kg/m2 ) gravidae did not have differences in the examination time with increasing GA. Increases in suboptimal examinations were noted with an increasing BMI (P < .001). There was a decreased frequency of suboptimal examinations in obese gravidae with a BMI of 40 kg/m2 or higher with increasing GA (P = .037). CONCLUSIONS: The duration of detailed fetal anatomic examinations decreased with increasing GA in normal-weight and overweight gravidae but not in obese gravidae. Performing the anatomy scan earlier in class I and II obese gravidae (BMI, 30-40 kg/m2 ) may enable improved pregnancy management options without increasing the examination duration or likelihood of a suboptimal evaluation.

Detailed Fetal Anatomic Ultrasound Examination Duration and Association With Body Mass Index.

OBJECTIVE: To evaluate the association of the duration of the detailed fetal anatomic ultrasound examination with maternal body mass. METHODS: This was a retrospective chart review of patients presenting to our clinic for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding multifetal pregnancies and other examinations expected to have a longer duration, a total of 6,522 examinations were performed between 18 0/7 and 22 0/7 weeks of gestation. Results were analyzed using analysis of variance and Student's t-test. RESULTS: Mean (SD) body mass index (BMI) was 29.3 (±7.7), and mean examination time was 51.5 (±10.4) minutes. We found that mean examination time was 48.8 (±9.6) minutes for patients with normal BMIs, 50.6 (±10.0) minutes for overweight patients, 52.2 (±10.4) minutes for patients with class I obesity, 54.6 (±10.3) minutes for patients with class II obesity, and 57.7 (±10.3) minutes for patients with class III obesity (P<.001). The duration of the detailed fetal anatomic ultrasound examination increased continuously with BMI (r=0.285, P<.001). CONCLUSION: We found that the duration of detailed fetal anatomic examinations increased with BMI. Examinations for gravid patients with class III obesity lasted 8.9 minutes longer than those for gravid patients with normal BMIs; examinations for gravid patients with BMIs of 50 or higher lasted 13.5 minutes longer. This information may be useful for fetal ultrasound examination scheduling.