Maternal weight gain and neonatal outcomes in women with class III obesity.

OBJECTIVE: Obesity in the USA continues to be a prominent medical and public health concern. Due to increasing rates of maternal obesity, the current Institute of Medicine (IOM) guidelines recommend 11-20 pounds of total weight gain during pregnancy in women with a BMI ≥30 kg/m2. The impact of maternal obesity on adverse perinatal outcomes has been well documented however, there is minimal data on the effect of gestational weight gain on neonatal outcomes. In this study, we assessed the association between gestational weight gain (GWG) and neonatal outcomes at term in women with class III obesity. STUDY DESIGN: A retrospective cohort of women delivering at a tertiary care institution between July 2013 and December 2017 with a first-trimester baseline BMI ≥40 kg/m2 was studied. Pregnancies complicated by multiple gestations, preterm delivery, fetal anomalies, intrauterine fetal demise or with missing data were excluded. The primary outcome was a composite of adverse neonatal outcomes including 5 min Apgar <7, neonatal intubation, grade 3 or 4 intraventricular hemorrhage (IVH), confirmed neonatal sepsis or Neonatal Intensive Care Unit (NICU) admission. Secondary outcomes included individual components of composite and NICU admission for >7 days. Demographic, pregnancy complications & delivery characteristics of women who gained more than IOM guidelines (>20 lbs.) were compared to women who gained at or less than IOM guidelines (≤20 lbs.) using bivariate statistics. Stepwise backward regression was used to estimate the odds of outcomes as appropriate. RESULTS: Of 374 women included, 144 (39.5%) gained more than guidelines. Women who gained above IOM recommendations were less likely to be multiparous and use tobacco. Additional demographic, obstetric and delivery characteristics, including BMI at the entry to care, did not differ. The neonatal composite occurred in 30 (8.0%) of all neonates; corresponding to 11.1% of women who gained more than IOM recommendations and 6.1% of those who gained at or below recommendations (p = .12, OR = 1.71, 95%CI 0.74-3.96). Additionally, neonates born to women gaining more than IOM recommendations were more likely to be admitted to the NICU (10.4 vs. 4.3%, p = .03) and have a NICU length of stay >7 days (6.9 vs. 2.2%, p = .03). When adjusted for mode of delivery, delivery BMI, tobacco use, and chorioamnionitis, women who gained more were not more likely to have an adverse neonatal outcome (1.54, 95%CI 0.62-3.80), they were 3.6 times more likely to have a neonate admitted to the NICU for more than 7 days (95%CI 1.00-13.42). CONCLUSIONS: In women with class III obesity, excess gestational weight gain was associated with increased odds of NICU stay >7 days, with trends toward increased NICU admission risk, further emphasizing the importance of appropriate weight gain counseling in this population at risk.

Impact of a Multifaceted Educational Program to Improve Provider Skills for Lupus Pregnancy Planning and Management: A Mixed-Methods Approach.

OBJECTIVE: To bring recent advances in pregnancy management in lupus to women nationwide, this multidimensional educational intervention sought to equip community rheumatologists with the needed skills, attitudes, and confidence to manage contraceptive decisions and pregnancy planning for women with lupus. METHODS: The program included an in-person didactic, training in use of a comprehensive handout to guide contraception and pregnancy conversations, a simulated clinical experience, and access to an innovative website (www.lupuspregnancy.org). The program was analyzed using mixed methods, which included a quantitative survey by e-mail before and after program completion and multiple qualitative interviews about attendees' experiences integrating created resources into practice. RESULTS: The analysis included 68 preintervention surveys and 55 postintervention surveys. For qualitative analysis, eight interviews were completed until thematic saturation was achieved. After completion of the program, there was an increase in providers reporting a systematic approach to preparing a woman with lupus for pregnancy (from 45.6% to 94.6%; P < 0.0001). Confidence in choosing both appropriate contraception and pregnancy-compatible medications improved significantly. As expected, change in knowledge about contraception was limited. Qualitative themes included the utility of the printable handouts, enthusiasm for the program, increased confidence and, importantly, increased empathy for the patients. CONCLUSION: We created a valuable implementation tool that improves self-reported provider skills and confidence in managing women with lupus who desire pregnancy. Providers now have access to a unique curriculum and resources that encourage providers to have open and accurate conversations about pregnancy, thus creating lasting clinical change.