CHAPTER TWO (LITERATURE REVIEW)

2.0 LITERATURE REVIEW

2.1 INTRODUCTION

This chapter deals with the review of relevant literature. The relevant literature was

reviewed under the following headings;

Conceptual Review to include;

Concept of gestational weight gain

Recommendation/ guidelines for gestational weight gain

Excessive gestational weight gain

Risk factors for excessive gestational weight gain

Risks/complications of excessive gestational gain.

Summary of literature review

2.2 CONCEPTUAL REVIEW

CONCEPT OF GESTATIONAL WEIGHT GAIN

Institute of Medicine USA? (IOM) (2009) defined gestational weight gain as the weight

just before delivery minus weight just before conception or the total weight gain minus

the infants birth weight or weight gained over a specified period divided by the duration

of that period per week. According to Cedegren (2007), it is the total weight gain during

pregnancy.

The knowledge of the components of total gestational weight gain was derived from the

calculations of Hytten who based his calculations mainly on data from two British studies

published in the 1950s (Ferrara, 2007). The average total gestational weight gain is

12.5kg at 40 weeks gestation in healthy primiparas whose weight gain was not restricted.
 This average weight gain was composed of products of conception which include; the

foetus 3.4kg, placenta 0.65kg and amniotic fluid 0.8kg. Increase in maternal tissues also

contribute. They include the uterus 0.97kg, breasts 0.405kg, blood volume 1.45kg

extracellular extravascular fluid 1.48kg and fat tissue 3.45kg (Schauberger 2012). Foetal

weight gain is normally slow in the first half of the pregnancy and increases more rapidly

in the second 20 weeks, while the increase in the placenta is rapid in the first 20 weeks

and slows down after then. Amniotic fluid increases rapidly from the 10 th week, from

300mls at 20 weeks, to a peak of 1000mls at 35 weeks, after which it declines slightly.

The weight of the uterus increases rapidly in the first 20 weeks and that of the breast and

blood volume increase steadily throughout pregnancy. At 30 weeks, most of the fat is

deposited and most of the fluid is also retained (Fraser & Cooper, 2009).

The rate of weight gain is usually slowest during the first trimester of pregnancy, fairly

constant during the second and third trimester and slightly slower towards the end of third

trimester (Institute of Medicine, 2009).

2.3 RECOMMENDATIONS/ GUIDELINES FOR GESTATIONAL WEIGHT GAIN

The recommendations for optimal gestational weight gain, maternal and foetal outcomes

were reviewed by the Institute of Medicine (2009). According to this review, there are

numerous studies that showed that both high and low gestational weight gains are

associated with higher risks of adverse outcomes. Between these low and high weight

gains, there seems to be an optimal range for weight gain which is associated with the

best maternal and foetal outcomes. Based on this and in an effort to encourage

appropriate weight gain during pregnancy, the Institute of Medicine (2009) revised her

weight gain recommendations. The Institute of Medicine (IOM) recommended that the
 amount of weight a woman gains in pregnancy be guided by her pre-pregnancy body

mass index (BM1). Women with a higher BM1 prior to pregnancy are to gain less than

those with a lower BM1. The IOMs recommendations are also specified by trimester of

pregnancy. During the first trimester, women usually gain weight only 1 to 3.5kg. During

the second and third trimesters, an average weight gain of 0.5kg per week is

recommended for underweight women, 0.4kg per week for normal weight women and

0.3kg for overweight women. Weight gain of 16 to 20kg is recommended for women

expecting twins (IOM, 2009)

The recommendations for gestational weight gain are shown in table 1 below:

Pre-pregnancy Recommended range of total weight Mean rate of weight

BM1 Gain Gain in 2nd & 3rd

trimester

Kg Pounds (Lb) Kg/week 1b/week

Underweight 12.5-18 28-40 0.5 1.0

B,1<18.5

Normal weight 11.5-16.0 25-35 0.4 1.0

BM118.5-24.9

Overweight BM1 7-11.5 15.21 0.3 0.6

25-29.9

Obesed 5.7 11.20 0.2 0.4

BM1>30
Based on evidence, it has been confirmed that gestational weight gain within the Institute of

Medicines recommendations is associated with the best foetal and maternal outcomes (Jain,

2007; Rode et.al, 2007). Additionally high gestational weight gain has recently been associated

with higher risk of gestational diabetes mellitus.

2.4 EXCESSIVE GESTATIONAL WEIGHT GAIN

Excessive gestational weight gain is weight gained in excess of the 2009 Institute of

Medicines recommendation for gestational weight gain (Siega-Ritz, Siega-Ritz &

Laraia, 2009). Carreno et al(2012) also defined it as gestational weight gain greater than

the upper range of the Institute of Medicines guidelines based on prepregnancy BMI.

Excessive gestational weight is defined in this work as being above ones recommended

weight guideline as outlined by Institute of Medicine. Gaining too much weight during

pregnancy has been linked with poor pregnancy outcomes.

2.5 RISK FACTORS FOR EXCESSIVE GESTATIONAL WEIGHT GAIN

Several factors have been associated with excessive weight gain. These are the factors

that could predispose pregnant mothers to gaining weight more than recommended. They

are grouped into demographic characteristics: higher prepregnancy body mass index, age,

parity, positive family history, and occupation. Other factors are: dietary habits and

physical inactivity.

2.6 DEMOGRAPHIC CHARACTERISTICS

Higher pre-pregnancy BMI: Pre-pregnancy BMI seems to be the most important

maternal factors affecting the risk of gaining excessive weight during pregnancy. Several

studies suggest that overweight and obese women (BMI> 26 kg/m2) are more likely to
gain weight in excess of the Institute of Medicine recommendations (Brawarsky et. al.

2005; Wells et al 2006). In these studies, about 45 to 83% of overweight and 41 to 57%

of obesed women exceeded their recommendation, while the corresponding proportions

among underweight and normal weight women were 11 to 38% and 35 to 52%

respectively.

Overweight and obese women gain weight in excess of the recommendations due to the

fact that the average gestational weight gain is usually lower among overweight and

obese women than among lighter women (Deierlain, Siega- Ritz& Herring, 2008) and

weight gain recommendations are lower for overweight and obese women. Some studies

also suggested that higher level of hormones associated with obesity such as leptin,

insulin and ghrelin could be associated with higher gestational weight gain (Palik,

Baranyi, MelczerAudikovszky, et.al. 2007).

Age

Dawes and Grudzinskas, (2010), reported a higher mean weight gain among older (> 25

years) than among younger women (<20years) but Wells et.al. (2006) found no

association. Hedderson, Gunderson and Ferrara (2010) found that overweight was more

likely in women who were older than 25 years of age. This may be as a result of

reduction in the rate at which the body burns calories.

Parity: Lederman (2007) reviewed literature on obesity and parity, the report concluded

that women gaining about 13.6kg during first pregnancy were about 2.7kg heavier at the

onset of the next pregnancy. Moreover, women who have a high weight gain during their

first pregnancy and retain it into the second one also gain and retain more weight during

the next pregnancy and puerperium. Even a modest increase of body mass index (BMI)
 between the first and the second pregnancy can result in an adverse pregnancy outcome

(Villamor & Cnattingius, (2006).This suggests that aging was the major determinant of

weight increase associated with parity. Excessive weight gain in pregnancy has been

found to be more in women with 2 or more previous live births.

Positive family history: High gestational weight gain has been positively related to a

genetic predisposition to accumulate excess tissue during child bearing stage. It is

believed that a woman with an overweight relative will likely become overweight herself

in pregnancy. It is likely that genetic factors influencing the regulation of fat metabolism,

both during and after pregnancy may contribute to the sustained increase body weight

related to childbearing (Bhattadiarya, Campbell, liston & Bhattacharya, 2007)

Occupation: very sedentary or sedentary style of occupation has been found to be a

predisposing factor to excessive weight gain in pregnancy while women whose

occupation were active gained less (Bhattadiarya et.al. 2007). This may be as a result of

imbalance in energy intake and energy expenditure. The rate of weight gain increases

when the women do not engage in physical activity after work or during their leisure time

(Clatfelter, 2010).

2.7 PHYSICAL INACTIVITY

Pregnancy is a time of physiological changes and often uncomfortable. The last thing on

many expectant mothers minds is exercise which they may not know that it keeps the bodys

metabolism active and helps manage weight gain (Clatfelter, 2010). Women who reduced the

amount of physical activity during pregnancy developed higher average of gestational weight

gain (Olson &Strawderman, 2006). It has been observed that women who exercised less than

20 minutes per week during third trimester had greater weight gain than physically more
active women (Haakstadt, Volder, Henriksen & BQ, 2007). Villamor, Msamanga and Urassa

(2006) reported that physical inactivity in pregnancy was a risk factor for overweight among

blacks in South Africa. In Nigeria, physical inactivity or sedentary life has been recognized

as a risk factor for excessive gestational weight gain (Chigbu & Aja, 2012).

Other studies have found no association between physical activity and weight gain during

pregnancy (Butte, Wong, Treuth, Ellis & smith, 2004; Watson & McDonald, 2007).

Diet

Based on data available by 2009, the Institute of Medicine concluded that energy intake is a

determinant of gestational weight gain. It is well known that during pregnancy the nutritional

requirement is enhanced and that women in general attend this demand by increasing their

food intake. However, cultural beliefs, such as "eating for two" may contribute to a caloric

intake above the ordinary demands of pregnancy, hence predisposing the pregnant women to

gaining excess weight (Tanentsapf, Heitmann & Adegboye. 2011). Many women see

pregnancy as a ticket to eat insatiable amounts of high calorie foods without concern for the

effects that over consumption may have on their immediate and potentially their subsequent

perinatal comfort. Increased caloric intake without a proportionate increase in caloric

expenditure results in increasing overall weight gain. There has been found an association

between higher energy intake and higher total gestational weight gain. Weight gain was

found to correlate positively with the intake of fatty foods (Olafsdottir, Brawarsky et. al.

2005; Wells et al 2006). An increase in the amount of food during pregnancy has been

associated with greater mean weight gain and higher risk for excessive gestational weight

gain. More recent studies have suggested that higher intake of fat and high caloric foods are
 associated with increased risk of gestational diabetes mellitus independent of prepregnancy

BMI (Brawarsky et. al. 2005; Wells et al 2006).

2.8 Risks/Complications of Excessive Gestational weight

This will be discussed under risks faced by the mother and neonate/infant as a result of

excessive weight gain in pregnancy more than the Institute of Medicines

recommendations based on the womans prepregnancy body mass index.

Maternal Risks: Increase in the prevalence of excessive gestational weight gain is

putting women at greater risks for several adverse pregnancy outcomes. Women whose

weight gain during pregnancy is beyond the recommended weight for their body mass

index prior to pregnancy may experience various negative pregnancy outcomes. These

adverse outcomes are experienced during pregnancy, labour and postpartum periods.

During Pregnancy

Hypertensive Disorders of pregnancy (HDP): Hypertensive disorders include;

pregnancy induced hypertension, preeclampsia and eclampsia. Pregnancy induced

hypertension (PIH) or gestational hypertension refers to high blood pressure that

develops during pregnancy in a woman who previously did not have high blood pressure

and may subside after delivery. Hypertensive disorders during pregnancy are the second

leading cause of maternal mortality in the United States after embolism, accounting for

approximately 15% of such deaths. It has been found that the risk of PIH is significantly

greater in overweight or obesed pregnant women (Yogev & Catalano, 2009).

Pre-eclampsia risk also increases among women who are overweight. It has an incidence

of 3-7%. It is a condition that starts after the 20th week of pregnancy and is related to
increased blood pressure and proteinuria. This condition affects the placenta, kidneys,

liver and brain. Preeclampsia is about twice as prevalent among overweight women and

three times as prevalent among obese women and the severity of the disease increases as

BMI increases. It can cause seizures or eclampsia and death (Yogev & Catalano, 2009).

Gestational Diabetes Mellitus (GDM): GDM is a form of diabetes mellitus that appears

during pregnancy in a woman who previously did not have diabetes and usually goes

away after baby is born (Reece, 2008). It is also defined as a glucose intolerance that

typically occurs during the second and third trimester of pregnancy. Although pregnancy

is frequently accompanied by a pronounced physiological decrease in peripheral insulin

sensitivity, the combination of decreased peripheral sensitivity and beta cells dysfunction

can lead to the development of abnormal glucose tolerance during pregnancy. It is well

established that women who are overweight tend to develop a more pronounced insulin

resistance and are at greater risk for gestational diabetes than normal weight women

(Chu, Callaghan, Bish, & DAngello, 2007). They also reported that gaining weight

excessively during pregnancy can increase the risk of gestational diabetes by 50%. This

often results in larger babies, injuries during birth or ceasarean section.

Thromboembolic complications: Thrombosis is the formation or presence of blood clot

in a blood vessel. Pregnancy increases the risk of thrombosis through venous stasis,

changes in blood coagulobility and damage to vessels (British Medical Bulletin, 2012).

Overweight pregnant women are 2- times more likely to develop thrombosis which can

travel to the lungs and a potentially deadly pulmonary embolism (Becattini, Brighton, &

Selby, 2008)
Miscarriage/ Preterm Labour: It is the termination of pregnancy before the 28th week

of gestation. It has been found that obese or overweight women experience miscarriage

more than normal weight women due to other complications like preclampsia (Guelinckx,

Devlieger, Beckers & Vansant, 2008).

During Labour

Labour Induction: Labour induction is the process of ripening the cervix and initiating

uterine contractions through the use of synthetic hormones to start the process of labour.

Overweight in pregnancy has been associated with longer gestation and significant

increase risk of post term delivery which contributes to the greater need for induction of

labour for prolonged pregnancy, (Arrowsmith, wray & Quenby 2011). Induction of

labour in overweight women is associated with a high risk of ceasarian section and its

attendant complications which include: infection, haemorrhage, and thrombosis

(Arrowsmith et.al. 2011).

Operative vaginal deliveries: Operative vaginal deliveries such as vacuum assisted

vaginal delivery (VAVD) and forceps assisted vaginal delivery (FAVD) are defined,

respectively, as the act of placing a vacuum (polyethylene cup) on the foetal head and

helping with fetal descent and delivery while the mother continues to push, resulting in

the baby being delivered vaginally; and the act of placing obstetrical forceps on the foetal

head and helping with dissension and delivery while the mother continues to push,

resulting in the baby being delivered vaginally(Wegner & Bernestein, 2013). The

prevalence of operative vaginal delivery is high in women that are overweight in

pregnancy. The risk for assisted vaginal delivery in overweight women is increased

significantly in comparison to women who are either underweight or of normal weight.

This may be due to big baby or hypertensive disorders. The complications associated

with operative vaginal delivery include; genital laceration, postpartum haemorrhage, skin

bruises, cephalohaematoma, Erbs palsy or foetal death (Wegner & Bernestein, 2013).

Caesarean section (CS): It is a surgical procedure in which the abdomen and uterus are

incised and baby is delivered transabdominally. Dietz, Callaghan, Morrow and Cogswell

(2005) reported that CS is common among overweight/obese women. This is because of

other obesity related complications like hypertensive disorders, macrosomic babies,

cephalopelvic disproportion or failed induction of labour. Women who are overweight

have an increased risk of having CS rather than vaginal birth and the more overweight a

women is, the more likely she will need a CS. Normal weight women experience a CS

rate of 12.0 -15.0%, overweight womens rate is 19.0%, obese women experience CS

23.0% of the time, severely obese women at 26.5% and very severely obese women

undergo CS in 31.0% of labours (Barau, Robillard, Hulsey, Dedecker, Lafitte &

Grardin, 2006).

Postpartum period

Postpartum Haemorrhage (PPH): PPH is excessive bleeding following the birth of a

baby which may occur right after delivery but can occur later as well. Perry,

Hockkenberry, Lowdermilk and Wilson, (2010) defined PPH as maternal loss of

excessive amounts of blood (greater than 500ml in a vaginal delivery or greater than

1000ml in a Cesarean section delivery) after the delivery of the newborn. The risk for

excessive blood loss despite delivery method among obese women was 13.3% - 23.6%

whereas non-obese womens risk for postpartum haemorrhage was 6.8% - 9.5%

(Bhattacharya, Campbell, Liston & Bhattacharya, 2007). Ferrer, Roberts, Sydenham,

Blackhall and Shakur (2009) indicated that uterine atony is the major cause of postpartum

haemorrhage. Uterine atony may be caused by over distended uterus due to large baby,

overweight, use of forceps or vaccum assisted delivery.

Eleine, Thompson, Ngaire, Groom and Lesley (2012) conducted retrospective study

using 7238 (63.7%) women with normal BM1, 2631 (23. 2%) overweight found out that

PPH was increased in overweight and obesed women compared with normal weight

women. This was due to reduced uterine contractility.

Postpartum Weight Retention: Immediately after delivery, the woman loses the weight

from foetus, placenta and amniotic fluid. In the subsequent days to weeks, the increase in

the womans extracellular and extra vascular water that occurred during pregnancy is lost

and her plasma volume should return to prepregnancy values. But when the amount of

weight that remains at this later time is greater than the womans pregravid weight,

postpartum weight retention occurs. It could result from the weight of any increased

breast tissue being used for lactation or any remaining fat mass gained during pregnancy

(Rasmussen &Yaktine, 2009). The Institute of Medicines (2009) report stated that

women with gestational weight gain well beyond the recommended ranges are more

likely to retain weight postpartum and are at increased risk for subsequent obesity.

Excessive weight gain in pregnancy has been consistently linked to higher weight

retention in both the immediate postpartum period and within two years (Siega-Ritz et. al.

2009). Herring, Platek, Elliot, Riley, Stuebe and Oken (2010) in a study of 65, 000

women showed that women with a gestational weight gain above the recommended

retained 3 and 4.7kg more after 3 and 15 year postpartum respectively. This is more than

those who gained within the recommended weight.

Poor Breastfeeding outcomes: Perinatal Health Program (2009) reported that breast

feeding at discharge was significantly lower among mothers who were overweight

compared to those with normal BMI. Also that women who were overweight planned to

breastfeed for a shorter period, were less likely to initiate breastfeeding, had delayed

lactogenesis and breastfed for shorter durations compared with women with normal BMl

Fetal outcomes /Neonatal outcomes

Macrosomia: This is used to describe babies that weigh more than 4kg at birth (Yogev &

Catalano, 2009). Crane and colleagues (2009) determined that excess weight gain in

pregnancy regardless of pre-pregnancy BMI, increased womens risk of delivering a

macrosomic infant. For women of a normal prepregnancy BMI the risk increased by

21.0%, while women who were overweight had an increased risk of 30% (Crane, White,

Murphy, Burrage & Hutchins, 2009). Foetal macrosomia is associated with a change in

foetal body composition. Sewell, Presley, Super and Catalano (2006), reported that the

average fat mass of infants that were born to normal weight women was 334 grams,

whereas the infants of women with a BMI > 25kg/m2 had a mean fat mass of 416 grams.

This difference equates to a change in body fat composition of 11.6%. Clearly this

observed increase in birth weight and macrosomic foetus in this group can result in

cephalopelvic disproportion resulting in the observed increase in caesarean section rate.

Macrosomia is also a powerful predictor of shoulder dystocia, neurological injury to the

infant (Perinatal Health program (PHP), 2009). Infants of heavier women are more likely

to be born large for gestational age, experience birth injury, have increased adiposity and

insulin resistance and be at risk for subsequent obesity, higher blood pressure and type 2

diabetes (Alton, 2012; Isreal, Akanni & Nwadiuto, 2011).

 Perinatal Mortality/Morbidity: Still birth has been found to be more common among

women who are overweight after adjusting for factors like maternal age, parity etc. (PHP,

2009). Alton (2012) also reported that maternal overweight also increased the risk of

congenital malformations intrauterine death and still birth. Excessive maternal weight

gain has been associated with early neonatal death which is the death of a live-born baby

within the first seven days of life. Infants of women who are overweight are more likely

to have low APGAR scores, hypoglycaemia, require resuscitation and to be admitted to a

Neonatal Intensive Care Unit (PHP, 2009).

Congenital Malformations: There has been an association between maternal overweight

and obesity and birth defects. It has been associated with spina bifida, anencephaly,

hydrocephaly, heart defects, diaphragmatic hernia, gastroschisis, omphalocele and

hypospadias (PHP, 2009; Saskachewan Prevention Institute, 2010; Alton, 2012).

Maternal obesity is associated also with an increased risk of neural tube defect (NTD) in

the offspring. The mechanism underlying the increased risk of NTD in pregnancies

complicated by maternal overweight is unknown. However, a number of theories have

been proposed, including a reduction in the amount of folic acid reaching the developing

embryo due to insufficient absorption and greater maternal metabolic demands, chronic

hypoxia, and increased circulating levels of triglycerides, uric acid, estrogen, and insulin

due to increased insulin resistance (Leddy, Power &Schulkin, 2008).

2.9 SUMMARY OF LITERATURE REVIEW

From the reviewed literature, gestational weight gain is necessary for positive maternal

and neonatal outcomes. It was discovered that there were appropriate weight gain

recommendation in pregnancy. It was also discovered that gaining excess weight in

pregnancy is on the increase worldwide. From the literatures there were risk factors that

predispose women to excess gestational weight gain like diet, physical inactivity and

others. The literature also revealed the complications of excessive gestational weight gain

like hypertensive disorders, gestational diabetes, induction of labour, macrosomia etc.

which could jeopardize the maternal and neonatal wellbeing.

Studies were more concentrated on the complication of excessive gestational weight gain

and associated risk factors. Moreover, literature on the complications and risk factors

were unable to explore whether these women have the actual knowledge of the pregnancy

weight gain guidelines, the implication of gaining more than required and if there were

risk factors that predispose them to gaining more than recommended.

To remedy this, more studies are advised to be carried out in areas where research works

on excessive gestational weight are few or do not exist. Hence the research is aimed at

determining the knowledge of and associated risk factors for excessive gestational weight

gain in hospitals within Enugu Metropolis and with focus on knowledge of pregnancy

weight gain guidelines, knowledge of the complications of excessive gestational weight

gain and the demographic characteristics, dietary and physical inactivity habits that could

predispose the pregnant women to excessive gestational weight gain.