Accepted Manuscript

Association between gestational weight gain and perinatal outcomes in women with
chronic hypertension

Lynn M. Yee, MD, MPH, Aaron B. Caughey, MD, PhD, Yvonne W. Cheng, MD, PhD

PII: S0002-9378(17)30623-3
DOI: 10.1016/j.ajog.2017.05.016
Reference: YMOB 11663

To appear in: American Journal of Obstetrics and Gynecology

Received Date: 5 December 2016

Revised Date: 19 April 2017
Accepted Date: 7 May 2017

Please cite this article as: Yee LM, Caughey AB, Cheng YW, Association between gestational weight
gain and perinatal outcomes in women with chronic hypertension, American Journal of Obstetrics and
Gynecology (2017), doi: 10.1016/j.ajog.2017.05.016.

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 ACCEPTED MANUSCRIPT

Association between gestational weight gain and perinatal outcomes in women with chronic
hypertension

Lynn M. Yee, MD, MPH (1), Aaron B. Caughey, MD, PhD (2), and Yvonne W. Cheng, MD, PhD (3)
1. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,

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Northwestern University Feinberg School of Medicine, Chicago, IL
2. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon

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Health & Science University, Portland, OR
3. Division of Maternal-Fetal Medicine, California Pacific Medical Center, San Francisco, CA

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This abstract was presented as a poster presentation at the 2016 Society for Maternal-Fetal Medicine
36th Annual Meeting, in Atlanta, GA, February 2016 (Abstract #811).

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SHORT TITLE: Gestational weight gain and chronic hypertension
DISCLOSURES: The authors report no conflicts of interest.
FUNDING: LMY is supported by the NICHD K12 HD050121-11.
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ABSTRACT WORD COUNT: 459

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MAIN TEXT WORD COUNT: 3011

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CORRESPONDING AUTHOR:
Lynn M. Yee, MD, MPH
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Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology

Northwestern University Feinberg School of Medicine
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250 E. Superior Street, #5-2191

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Chicago, IL 60611
Phone: 312-472-0119
Fax: 312-472-4687
lynn.yee@northwestern.edu

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CONDENSATION: Among women with chronic hypertension, weight gain below guidelines is associated

with SGA status, whereas weight gain above guidelines is associated with cesarean delivery, eclampsia,

NICU admission, and LGA status.

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SHORT TITLE: Chronic hypertension and gestational weight gain

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ABSTRACT

Background: Gestational weight gain above or below the 2009 Institute of Medicine guidelines has been

associated with adverse maternal and neonatal outcomes. Although it has been well established that

excess gestational weight gain is associated with the development of gestational hypertension and

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preeclampsia, the relationship between gestational weight gain and adverse perinatal outcomes among

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women with pregestational (chronic) hypertension is less clear.

Objective: The objective of this study was to examine the relationship between gestational weight gain

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above and below IOM guidelines and perinatal outcomes in a large, population-based cohort of women

with chronic hypertension.

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Study Design: This is a population-based retrospective cohort study of women with chronic hypertension
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who had term, singleton, vertex births in the United States between 2012 and 2014. Pre-pregnancy

body mass index was calculated using self-reported pre-pregnancy weight and height. Women were
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categorized into 4 groups based on gestational weight gain and pre-pregnancy body mass index 1)
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weight gain less than, 2) weight gain within, 3) weight gain 1-19 lbs in excess of, and 4) weight gain 20

lbs in excess of the Institute of Medicine guidelines. Chi-square tests and multivariable logistic
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regression analysis were used for statistical comparisons. Stratified analyses by body mass index
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category were additionally performed.

Results: In this large birth cohort, 101,259 women met criteria for inclusion. Compared to hypertensive
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women who had gestational weight gain within guidelines, hypertensive women with weight gain 20
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lbs over Institute of Medicine guidelines were more likely to have eclampsia (adjusted odds ratio [aOR]

1.93, 95% confidence interval [CI] 1.54-2.42) and cesarean delivery (aOR 1.60, 95% CI 1.50-1.70). Excess

weight gain 20 lbs over Institute of Medicine guidelines was also associated with increased odds of 5-

minute Apgar <7 (aOR 1.29, 95% CI 1.13-1.47), neonatal intensive care unit admission (aOR 1.23, 95% CI

1.14-1.33), and large for gestational age neonates (aOR 2.41, 95% CI 2.27-2.56) as well as decreased

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odds of small for gestational age status (aOR 0.52, 95% CI 0.46-0.58). Weight gain 1-19 lbs over

guidelines was associated with similar fetal growth outcomes though with a smaller effect size. In

contrast, weight gain less than Institute of Medicine guidelines was not associated with adverse

maternal outcomes but was associated with increased odds of small for gestational age (aOR 1.31, 95%

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CI 1.21-1.52) and decreased odds of large for gestational age status (aOR 0.86, 95% CI 0.81-0.92).

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Analysis of maternal and neonatal outcomes stratified by body mass index demonstrated similar

findings.

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Conclusion: Women with chronic hypertension who gain less weight than Institute of Medicine

guidelines experience increased odds of small for gestational age neonates, whereas excess weight gain

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20 lbs over Institute of Medicine guidelines is associated with cesarean delivery, eclampsia, 5-minute
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Apgar <7, neonatal intensive care unit admission, and large for gestational age neonates.
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KEY WORDS: chronic hypertension, gestational weight gain, perinatal outcomes

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INTRODUCTION

Gestational weight gain is an important assessment of maternal health with implications for

short- and long-term maternal and child health outcomes.1 As the rates of obesity in the United States

population have increased, there has been mounting attention to the importance of optimizing

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gestational weight gain to balance maternal and neonatal health needs. In 2009, the Institute of

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Medicine (IOM), now called the National Academy of Medicine, released new guidelines for gestational

weight gain based on a mothers pre-pregnancy body mass index (BMI).2 These guidelines were

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intended to consider this balance of maternal and neonatal health as well as to offer specific, narrow

ranges of weight gain recommendations for obese women.2

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Since the 2009 IOM guidelines, a number of studies have examined outcomes associated with
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weight gain outside of recommendations, generally demonstrating that women who gain weight above

recommendations are at increased risk of hypertensive disorders of pregnancy.3,4 In addition, excess

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weight gain has been associated with cesarean delivery, macrosomia, large-for-gestational-age (LGA)

status and other neonatal adverse outcomes.3-7 Furthermore, although inadequate weight gain has been
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associated with decreased likelihood of hypertensive disorders and some maternal adverse outcomes, it
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has been associated with greater likelihood of small-for-gestational-age (SGA) status neonates.1,3,4,7
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Thus, observational evidence suggests potential negative impact related to either weight gain above or

below IOM guidelines, although further work to refine the guidelines based on maternal BMI may be
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warranted.1
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The IOM guidelines do not provide specific recommendations for women with chronic medical

conditions that may alter their perinatal risk profile or metabolic needs. Some studies have investigated

gestational weight gain among women with pre-existing diabetes mellitus8-11, but data have not yet

examined whether these guidelines are appropriate for women with chronic hypertension. Although it

has been well established that excess gestational weight gain is associated with higher likelihood of

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gestational hypertension and preeclampsia among women without chronic hypertension,4 the

relationship between weight gain and adverse perinatal outcomes among women with chronic

hypertension is unclear. We hypothesized women with chronic hypertension may require an even

narrower window of gestational weight gain to balance competing maternal and neonatal risks. Thus,

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the aim was to examine the relationship between gestational weight gain and perinatal outcomes

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among women with chronic hypertension.

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METHODS

This is a population-based, retrospective cohort study of women with chronic hypertension who

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gave birth to term, singleton vertex neonates in the United States between 2012 and 2014. Data were
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from the Vital Statistics Natality birth certificate registry, which is provided and maintained by the

Centers for Disease Control and Preventions (CDC) National Center for Health Statistics (NCHS). This
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data set includes births to U.S. and non-U.S. residents that occurred in the 50 United States, the District
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of Columbia, and New York City. Data were compiled using either the 2003 Revision or the 1989 Revision

of U.S. Standard Certificate of Live Birth. Forty-seven states and the District of Columbia (DC), Guam,
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Puerto Rico and the Northern Marianas had implemented the 2003 revised birth certificate as of January
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1, 2014. These localities included: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware,

Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland,
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Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New

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Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon,

Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington,

West Virginia, Wisconsin, and Wyoming.12,13 These states represent 96.2% of live births in the U.S.

during the study period.12,13

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The 2003 Revision includes a specific item for prepregnancy hypertension. Such information is

collected using checkbox format, which allows trained personnel to report more than one risk factor in

pregnancy as well as the option of none.12 Information on risk factors in this pregnancy is

recommended to be collected directly from the medical record, including prenatal care record, using the

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facility worksheet (Guide to Completing the Facility Worksheets for the Certificate of Live Birth and

Report of Fetal Death - 2003 Revision).14 The diagnosis of prepregnancy hypertension is captured

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when keywords such as chronic hypertension, benign essential hypertension, essential

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hypertension, and/or preexisting hypertension are present in the parturients medical record.14 Study

eligibility criteria included women with a diagnosis of prepregnancy hypertension as identified in the

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birth certificate records.15 Nulliparous and multiparous women were included. Women with pre-
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gestational diabetes (type 1 or type 2 diabetes mellitus) or with fetal anomalies were excluded.

Collection of maternal demographic information, including race/ethnicity, education, marital

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status, and pre-pregnancy height and weight, was by direct self-report via the Mothers Worksheet for
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the Childs Birth Certificate (available at http://www.cdc.gov/nchs/data/dvs/momswkstf_improv.pdf).

Specifically, questions regarding height and pre-pregnancy weight included what is your height and
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what was your pre-pregnancy weight, that is, your weight immediately before you became pregnant
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with this child? Using this information, pre-pregnancy body mass index (BMI) calculated using reported

height and weight using the standard formula.16 Gestational weight gain was calculated as the difference
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between the mothers pre-pregnancy weight and her weight at delivery. All maternal and neonatal
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outcomes data were collected directly from the medical records using the delivering facilitys worksheet.

Women were categorized based on gestational weight gain and pre-pregnancy BMI: 1) weight

gain below IOM guidelines (Table 1), 2) weight gain within IOM guidelines; 3) weight gain 1-19 lbs above

IOM guidelines; and 4) weight gain 20 lbs above IOM guidelines.2 Weight gain 20 lbs above IOM

guidelines was examined as a separate category given the wide range of weight gain that can occur

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above the upper limit and thus to differentiate between those with minimal weight gain above

guidelines versus those with extreme excess weight gain.

Perinatal outcomes were compared between the four weight gain groups. Maternal outcomes

examined included eclampsia, cesarean delivery, chorioamnionitis, postpartum hemorrhage requiring

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blood transfusion, and maternal intensive care unit (ICU) admission. Eclampsia was investigated as an

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outcome rather than preeclampsia because these data combine gestational hypertension and

preeclampsia into a single pregnancy-associated hypertension category (which included pregnancy-

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associated hypertension, preeclampsia, eclampsia, transient hypertension, and HELLP syndrome) that is

mutually exclusive with chronic hypertension.14 Specifically, the instructions for the 2003 Revision state

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If hypertension is present, check either prepregnancy or gestational hypertension. Do not check
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both.14 Neonatal outcomes examined included 5 minute Apgar <7, mechanical ventilation greater than

6 hours, neonatal seizures, admission to the neonatal intensive care unit (NICU), neonatal transfer of
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care to a higher level nursery/facility, large-for-gestational age status (LGA; >90th percentile) and SGA

status (<10th percentile).

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Chi-squared tests were used to compare outcomes and multivariable logistic regression analysis
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was used to control for potential confounding variables. Women with weight gain within IOM goals
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were designated as the referent. An additional stratified analysis by BMI group (underweight, normal

weight, overweight, and obese) was performed. Covariates included in the multivariable logistic
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regression models included: maternal age, race/ethnicity, education, marital status, and medical
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insurance/payer status. A p-value 0.001 (given the large sample size) and 95% confidence intervals (CI)

were used to designate statistical significance. Finally, in order to further understand the potential

confounding effects of comorbidities, we performed three sensitivity analyses. First, we excluded

patients with a diagnosis of eclampsia in order to assess whether the findings persist with the exclusion

of women who may have had extreme gestational weight gain due to edema. Second, we analyzed the

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primary outcomes controlling for gestational age at delivery. Third, we analyzed the primary outcomes

controlling for prior cesarean delivery. As Natality data is publicly available and de-identified of patient

privacy information, this study was exempt for institutional review board (IRB) at Oregon Health &

Science University and Northwestern University.

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RESULTS

In this analysis, 101,259 women met study inclusion/exclusion criteria. Of these, 20,198 (20.0%)

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gained less weight than IOM guidelines, 25,476 (25.2%) gained within IOM guidelines, 38,931 (38.5%)

gained 1-19 lbs over IOM guidelines, and 16,654 (16.5%) gained 20 lbs over IOM guidelines. In this

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cohort, women who were nulliparous, younger (<20 years and 20-34 years), non-Hispanic black or non-
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Hispanic white, unmarried, or had no college education were more likely to gain 20 lbs over IOM

guidelines (Table 2). Women who were overweight or obese were also more likely to gain over IOM
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guidelines. Characteristics associated with weight gain in concordance with IOM guidelines included
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older maternal age, pre-pregnancy normal BMI, Asian or Hispanic race/ethnicity, being married, and

private or other (non-public) insurance.

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First, with regard to maternal outcomes, compared to women with chronic hypertension who
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gained above or below guidelines, women who gained weight within guidelines had the lowest

frequency of eclampsia and cesarean delivery but the highest frequency of maternal ICU admission
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(Table 3). Compared to women who gained weight within guidelines, women with weight gain below
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guidelines were not at statistically significantly (at p<0.001 level for the multivariable model) increased

or decreased odds of adverse maternal outcomes. On multivariable regression analysis, women who

gained weight above IOM guidelines were at increased odds of eclampsia (for 20 lbs above guidelines)

and cesarean delivery (for 1-19 lbs and 20 lbs above guidelines). Weight gain 1-19 lbs and 20 lbs

above guidelines were not associated with odds of chorioamnionitis, blood transfusion, or unplanned

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hysterectomy on multivariable logistic regression. Notably, women who experienced weight gain within

guidelines experienced the highest frequency of maternal ICU admission.

Regarding neonatal outcomes, women with chronic hypertension who gained weight below IOM

guidelines experienced increased frequency of SGA status and decreased frequency of LGA status (Table

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4). Both of these findings persisted on multivariable regression analysis when controlling for potential

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confounders. In contrast, women who experienced weight gain above guidelines (both 1-19 lbs and 20

lbs above guidelines) experienced decreased frequency of SGA status and increased frequency of LGA

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status. On multivariable logistic regression, weight gain 20 lbs above guidelines was associated with

increased odds of 5-minute Apgar score <7 and NICU admission (at p<0.001 for multivariable model).

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Both weight gain 1-19 lbs and 20 lbs above IOM guidelines remained associated with increased odds of
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LGA status and decreased odds of SGA status on regression analysis, with the strongest association

between fetal growth abnormalities and excess gestational weight gain noted for those with weight gain
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20 lbs above guidelines.

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Next, we performed a stratified analysis by BMI category (Table 5), with findings demonstrating

few differences by BMI category. Among normal weight and obese women, weight gain 20 lbs above
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IOM guidelines was associated with increased odds of eclampsia. For women at all BMI categories,
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excess weight gain 20 lbs above guidelines was associated with increased odds of cesarean delivery.

Other maternal adverse outcomes largely did not differ from the primary analysis when stratified by
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maternal BMI category. Regarding neonatal outcomes, excess weight gain 20 lbs above guidelines was
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associated with NICU admission at all BMI categories, but was only associated with 5-minute Apgar <7

for normal weight and obese women. For normal weight, overweight, and obese women, excess weight

gain both 1-19 lbs and 20 lbs above guidelines was associated with increased odds of LGA and

decreased odds of SGA status, whereas weight gain below guidelines was associated with the inverse

relationships.

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Lastly, three sensitivity analyses were performed. First, we assessed both maternal and neonatal

outcomes in a cohort that excluded women with eclampsia (N=695); findings in this cohort were

unchanged from the primary analysis. Next, we assessed maternal and neonatal outcomes controlling

for gestational age at delivery, and there were no differences in outcomes. Finally, we assessed

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maternal and neonatal outcomes controlling for prior cesarean delivery, and again found no meaningful

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differences in the odds of adverse outcomes.

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COMMENT

The Institute of Medicine 2009 document Gestational Weight Gain: Reexamining the

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Guidelines established target weight gain ranges for women based on their pre-pregnancy BMI and
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plurality, but not based on other medical comorbidities.2 In this large, contemporary birth cohort of

United States women, while mothers who experienced weight gain below guidelines were not at
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increased odds of adverse maternal outcomes, neonates born to women with chronic hypertension who
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gained less weight than guidelines experienced increased odds of SGA status. Given the risks associated

with SGA status, including perinatal morbidity and mortality as well as long-term associations with
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neurodevelopmental disorders and chronic diseases, these data suggest women with chronic
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hypertension should be cautioned against inadequate weight gain. In contrast, women who gained 20

lbs of weight above guidelines experienced increased odds of LGA status and NICU admission, as well as
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increased odds of maternal adverse events such as cesarean delivery and eclampsia. The strength of the
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associations between excess weight gain and adverse maternal and neonatal outcomes was particularly

pronounced for women with weight gain 20 lbs above guidelines. Findings stratified by BMI suggest

there are few differences in odds of adverse outcome when stratifying by BMI category.

The findings in this cohort suggest that for women with chronic hypertension, gestational

weight gain within the BMI-based guidelines proposed by the IOM may appropriately balance the risks

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of adverse maternal and neonatal outcomes that can occur with extremes of weight gain. These findings

also suggest that there is a potential dose-response effect for gestational weight gain among women

with chronic hypertension, with women experiencing the most excessive (20 lbs above guidelines)

weight gain at greatest risk for adverse outcomes. Our findings are comparable to those of populations

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without chronic hypertension, in which excess weight gain has been associated with maternal

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hypertensive disorders and cesarean delivery, and inadequate weight gain has been associated with SGA

status.4 However, one substantial difference between our study cohort of women with chronic

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hypertension and that of normotensive population is the absolute frequency of adverse maternal and

neonatal events. For example, work by Johnson et al demonstrated that women who had weight gain

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above IOM guidelines had a frequency of cesarean delivery of 27.2%, whereas our findings
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demonstrated nearly 40% of women with chronic hypertension who had 20 lbs of weight gain beyond

IOM guidelines underwent cesarean delivery.4 These differences are consistent with prior literature
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demonstrating that women with chronic hypertension have a greater risk of cesarean delivery compared

to women without hypertension.15 Of note, one unanticipated finding in contrast to those discussed
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above was that women with weight gain within guidelines experienced the highest frequency of
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maternal intensive care unit admission. Although this association did not have a p<0.001 for the
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multivariable model, suggesting it may have been due to the performance of multiple comparisons, the

trend towards increased frequency of ICU admission for women weight gain within guidelines warrants
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further exploration, particularly since these women did not experience greater odds of eclampsia,
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cesarean delivery, blood transfusion, or hysterectomy.

Strengths of this study include a large population-based cohort of women with chronic

hypertension. Prior work has been unable to assess rare maternal and neonatal outcomes with sufficient

statistical power due to smaller sample sizes. In addition, this study population is representative of the

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majority of the United States, and represents a diverse cohort of women giving birth. Thus, the study

findings likely can be validly inferred to a broader population of women with chronic hypertension.

However, there are several limitations to consider. Importantly, the Natality data do not contain

information on use of antihypertensive medications, so we are unable to account for severity of

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hypertensive disease or treatment of hypertension as potential confounders in our analyses. Similarly,

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the 2003 Revision does not distinction between prepregnancy hypertension and gestational

hypertension; thus, it is not possible to specifically investigate superimposed preeclampsia in this

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cohort. This limitation is important, as women with preeclampsia may have a rapid rise in gestational

weight gain at the end of pregnancy due to preeclampsia-associated edema. It is therefore impossible to

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know to what degree the incidence of superimposed preeclampsia contributed to the outcomes.
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Although the sensitivity analysis excluding women with eclampsia attempted to address this limitation,

future work would benefit from additional exploration of preeclampsia in databases without this
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restriction. Additionally, limitations of the database also precluded investigation of gestational diabetes
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mellitus; after a diagnosis of gestational diabetes, parturients commonly experience a lower rate of

gestational weight gain or even gestational weight loss, in response to therapies implemented for
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diabetes. Thus, in databases such as this in which data about weight gain at specific time points during
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gestation, including before and after the diagnosis of gestational diabetes, are unavailable, it is not

possible to accurately estimate the relationship between gestational weight gain and gestational
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diabetes, due to this issue of reversed causality. Further, we limited this study to women delivering at
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term in order to focus on those who had the maximal opportunity for gestational weight gain and

because it was not possible to study the incidence of preeclampsia, which is likely to be a frequent

contributor to preterm births in this population; future work warrants investigation of gestational

weight gain and prematurity in this population. In addition, pre-pregnancy BMI was determined by self-

reported height and weight. While there are limitations to self report, prior work suggests self-reported

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height and weight are valid measures.17,18 Finally, given the retrospective study design, there is a

possibility of confounding bias that we attempted to account for using multivariable regression analyses;

however, unmeasured or unobservable factors that we cannot account for in the analysis may exist.

In summary, term neonates born to mothers with chronic hypertension who gain weight less

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than IOM guidelines experienced increased frequency of adverse neonatal events with regard to fetal

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growth. Mothers gaining weight above IOM guidelines, particularly those who gain 20 lbs above

guidelines, experienced greater frequency of eclampsia and cesarean delivery, and their neonates

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experience greater frequency of LGA status, NICU admission, and 5-minute Apgar score <7. Adverse

maternal and neonatal outcomes were more frequent among women with weight gain 20 lbs above

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guidelines compared to women with weight gain 1-19 lbs above guidelines. Given the importance of
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optimizing gestational weight gain to appropriately balance the risks of maternal and neonatal adverse

outcomes during pregnancy, these data provide evidence to support the application of IOM
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recommendations for gestational weight gain in women who have chronic hypertension. While further
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work is needed to understand if an even narrower range of weight gain would be beneficial, these

findings may be clinically useful in providing guidance to women with chronic hypertension.
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REFERENCES

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Guidelines: National Academy of Sciences; 2009.
3. Truong Y, Yee L, Caughey A, Cheng Y. Weight gain in pregnancy: does the Institute of
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2015;212:362.e1-8.
4. Johnson J, Clifton R, Roberts J, et al. Pregnancy outcomes with weight gain above or
below the 2009 Institute of Medicine guidelines. Obstetrics and Gynecology

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2013;121:969-75.
5. Hedderson M, Weiss N, Sacks D, et al. Pregnancy weight gain and risk of neonatal
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Gynecology 2006;108:1153-61.
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neonatal outcome among term infants. Obstetrics and Gynecology 2006;108:635-43.
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2011;117:812-8.
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gain and gestational diabetes mellitus: perinatal outcomes. Obstetrics and Gynecology
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2008;112:1015-22.
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outcomes in women with type 2 diabetes mellitus using the 2009 Institute of Medicine
guidelines. American Journal of Obstetrics and Gynecology 2011;205:257.e1-6.
10. Siegel A, Tita A, Biggio J, Harper L. Evaluating gestational weight gain recommndations in
pregestational diabetes. American Journal of Obstetrics and Gynecology
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2015;213:563.e1-5.
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after a diagnosis of gestational diabetes and pregnancy outcomes. American Journal of
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Perinatology 2015;32:239-46.
12. User guide to the 2013 Natality Public Use File. 2014. 2016, at
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Ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/us
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13. User guide to the 2014 Natality Public Use File. 2015. (Accessed October 26, 2016, 2016,
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14. Guide to completing the facility worksheets for the Certificate of Live Birth and Report
of Fetal Death (2003 revision). 2016 update. National Center for Health Statistics, 2006.
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15. American College of Obstetricians and Gynecologists Task Force on Hypertension in

Pregnancy. Hypertension in Pregnancy. Washington, DC: American College of
Obstetricians and Gynecologists; 2013.
16. Calculate your body mass index. National Institutes of Health, 2016. (Accessed August
19, 2016, 2016, at www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.html.)
17. Brunner Huber L. Validity of self-reported height and weight in women of reproductive

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Table 1: 2009 Institute of Medicine Guidelines2

Pre-Pregnancy BMI Total weight gain range Rates of weight gain, 2nd & 3rd
BMI (kg/m2) (lbs) trimesters
(mean range, lbs/wk)

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Underweight < 18.5 28-40 1 (1-1.3)

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Normal weight 18.5 24.9 25-35 1 (0.8-1)

Overweight 25.0 29.9 15-25 0.6 (0.5-0.7)

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Obese 30.0 11-20 0.5 (0.4-0.6)

BMI, body mass index

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Table 2: Cohort characteristics stratified by gestational weight gain adherence to IOM guidelines
Below Within 1-19 lbs 20 lbs p-value
(N=20,198) (N=25,476) above above
(N=38,931) (N=16,654)
Parity <0.001
Nulliparous (n=36,387) 16.3% 23.0% 40.6% 20.1%

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Multiparous (n=64,872) 22.0% 26.4% 37.2% 14.4%
Maternal age <0.001
<20 (n=2,746) 16.4% 20.5% 39.4% 23.7%

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20-34(n=71,491) 19.4% 24.4% 38.9% 17.4%
35-39 (n=20,259) 21.5% 27.1% 37.7% 13.6%
40 (n=6,763) 22.8% 29.6% 35.6% 12.0%

SC
Race/ethnicity <0.001
Non-Hispanic white (n=54,446) 18.5% 24.7% 40.0% 16.9%
Non-Hispanic black (n=27,262) 22.1% 24.0% 36.1% 17.9%

U
Hispanic (n=11,535) 20.0% 28.0% 38.2% 13.8%
Asian (n=1,143) 25.6% 36.1% 31.6% 6.7%
AN
Other (n=6,873) 21.2% 16.9% 38.0% 13.5%
Education <0.001
No college education (n=37,009) 22.0% 24.5% 36.1% 17.5%
M

Some college or greater (n=63,656) 18.8% 25.6% 39.9% 15.8%

Marital status <0.001
Married (n=59,967) 19.9% 26.4% 39.3% 14.4%
D

Unmarried (n=41,292) 20.0% 23.3% 37.2% 19.5%

Payer type <0.001
TE

Medicaid (n=43,875) 21.5% 23.9% 36.2% 18.4%

Private (n=51,594) 18.7% 26.2% 40.3% 14.8%
Self-pay (n=2,723) 19.1% 24.6% 39.3% 17.0%
EP

Other (n=3,067) 20.1% 26.9% 38.1% 14.9%

BMI subgroup <0.001
Underweight (n=904) 31.4% 26.4% 24.3% 7.9%
C

Normal weight (n=18,788) 21.1% 34.7% 34.2% 10.0%

Overweight (n=22,695) 11.5% 23.8% 43.1% 21.6%
AC

Obese (n=58,872) 22.7% 22.5% 38.2% 16.7%

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Table 3: Frequency and odds of maternal morbidity by weight gain, compared to weight gain within
Institute of Medicine guidelines, for women with chronic hypertension
Below Within (N=25,476) 1-19 lbs above 20 lbs above
(N=20,198) (N=38,931) (N=16,654)

PT
N(%) aOR * N(%) aOR* N(%) aOR* N(%) aOR*
(95% CI) (95% CI) (95% CI) (95% CI)

RI
Eclampsia 112 1.03 136 Ref 263 1.23 184 1.93**
(0.55%) (0.80-1.33) (0.36%) (0.68%) (1.00-1.52) (1.10%) (1.54-2.42)

SC
Cesarean delivery 2,602 1.06 3,370 Ref 6,107 1.23** 3,260 1.60**
(26.3%) (1.00-1.13) (26.2%) (31.3%) (1.17-1.30) (38.6%) (1.50-1.70)
Chorioamnionitis 209 0.89 312 Ref 594 1.18 262 1.12
(1.04%) (0.74-1.06)

U
(1.23%) (1.53%) (1.03-1.36) (1.57%) (0.94-1.32)
AN
Blood transfusion 105 1.35 98 Ref 158 1.07 49 0.95
(0.52%) (1.02-1.78) (0.39%) (0.41%) (0.83-1.38) (0.35%) (0.68-1.31)
Unplanned hysterectomy 13 1.47 11 Ref 22 1.44 10 1.72
M

(0.06%) (0.66-3.28) (0.04%) (0.06%) (0.70-2.98) (0.06%) (0.73-4.08)

Maternal intensive care 50 0.63 101 Ref 91 0.61 45 0.71
D

unit admission (0.25%) (0.44-0.89) (0.40%) (0.23%) (0.46-0.82) (0.27%) (0.49-1.01)

TE

aOR, adjusted odds ratio; CI, confidence interval

*Adjusting for maternal age, parity, race/ethnicity, marital status, education, and payer type.
**Indicates p<0.001 for the regression model
C EP
AC

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Table 4: Frequency and odds of neonatal morbidity by weight gain, compared to weight gain within
Institute of Medicine guidelines, for women with chronic hypertension
Below Within (N=25,476) 1-19 lbs above 20 lbs above
(N=20,198) (N=38,931) (N=16,654)

PT
N(%) aOR* N(%) aOR* N(%) aOR * N(%) aOR*
(95% CI) (95% CI) (95% CI) (95% CI)

RI
5-minute Apgar <7 360 0.97 475 Ref 770 1.04 430 1.29**
(1.78%) (0.84-1.11) (1.87%) (1.98%) (0.93-1.17) (2.6%) (1.13-1.47)

SC
Ventilation >6 hours 126 1.02 155 Ref 251 1.04 135 1.30
(0.63%) (0.81-1.30) (0.61%) (0.65%) (0.85-1.27) (0.81%) (1.03-1.64)

U
Neonatal seizures 8 0.65 16 Ref 18 0.72 9 0.80
AN
(0.04%) (0.28-1.51) (0.06%) (0.05%) (0.37-1.41) (0.05%) (0.35-1.83)
NICU admission 1,141 0.99 1,457 Ref 2,375 1.06 1,193 1.23**
(5.66%) (0.91-1.07) (5.73%) (6.11%) (0.99-1.14) (7.18%) (1.14-1.33)
M

Neonatal transfer to 161 0.99 210 Ref 335 1.03 186 1.33
higher level care (0.80%) (0.81-1.22) (0.82%) (0.86%) (0.87-1.23) (1.12%) (1.09-1.63)
D

LGA > 90%ile 1,542 0.86** 2,253 Ref 4,768 1.47** 2,875 2.41**
TE

(7.67%) (0.81-0.92) (8.89%) (12.34%) (1.40-1.56) (17.5%) (2.27-2.56)

SGA < 10%ile 1,273 1.31** 1,222 Ref 1,394 0.72** 465 0.52**
(6.32%) (1.21-1.52) (4.81%) (3.59%) (0.67-0.78) (2.80%) (0.46-0.58)
EP

aOR, adjusted odds ratio; CI, confidence interval; NICU, neonatal intensive care unit; LGA, large-for-
gestational-age; SGA, small-for-gestational-age
C

*Adjusting for maternal age, parity, race/ethnicity, marital status, education, and payer type.
** indicates p<0.001 for the regression model
AC

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Table 5: BMI stratification of maternal and neonatal outcomes associated with gestational weight gain by IOM guidelines, compared to weight
gain within IOM guidelines, for women with chronic hypertension
Underweight Normal weight Overweight Obese

PT
Below 1-19lb 20lb above Below 1-19lb 20lb Below 1-19lb 20lb Below 1-19lb above 20lb above
above above above above above

RI
Maternal outcomes

SC
Eclampsia 1.08 0.90 1.91 0.67 1.05 1.91 1.28 1.23 1.48 1.22 1.39 2.41
(0.26-4.44) (0.19-4.27) (0.32-11.32) (0.38-1.18) (0.69-1.60) (1.16-3.14) (0.72-2.28) (0.80-1.89) (0.92-2.36) (0.86-1.72) (1.02-1.89) (1.75-3.32)

U
Cesarean 1.06 1.35 2.42 0.97 1.20 1.60 0.88 1.11 1.49 0.99 1.17 1.44

AN
delivery (0.56-2.00) (0.70-2.60) (1.02-5.75) (0.84-1.12) (1.07-1.35) (1.36-1.89) (0.75-1.04) (0.99-1.24) (1.31-1.69) (0.91-1.07) (1.09-1.25) (1.32-1.56)
Chorioamnionitis 0.27 0.30 1.60 0.83 1.24 1.15 1.10 1.29 1.10 0.94 1.19 1.19
(0.06-1.32) (0.06-1.47) (0.30-8.47) (0.59-1.17) (0.94-1.62) (0.78-1.69) (0.72-1.67) (0.97-1.72) (0.79-1.53) (0.73-1.20) (0.97-1.46) (0.93-1.51)

M
Blood 3.69 -- 14.98 1.68 1.18 1.66 1.91 1.13 0.71 1.07 1.06 0.91
transfusion (0.37-36.45) (1.20-187.59) (1.00-2.82) (0.70-1.97) (0.85-3.22) (1.00-3.65) (0.65-1.96) (0.34-1.48) (0.73-1.58) (0.74-1.50) (0.58-1.42)

D
Unplanned -- -- -- 1.42 2.19 3.67 0.66 1.56 1.60 1.75 1.15 1.32
hysterectomy (0.28-7.09) (0.54-8.85) (0.72-18.53) (0.07-6.39) (0.40-6.07) (0.31-8.15) (0.59-5.24) (0.39-3.44) (0.35-4.93)

TE
Maternal ICU 2.72 -- -- 0.42 0.52 0.70 1.49 1.05 0.94 0.89 1.00 1.28
admission (0.21-34.54) (0.25-0.71) (0.33-0.82) (0.36-1.35) (0.53-3.66) (0.48-2.29) (0.37-2.41) (0.51-1.57) (0.62-1.63) (0.73-2.22)
Neonatal outcomes
EP
5-minute Apgar 1.18 2.09 1.18 1.05 0.98 1.69 0.93 1.02 0.98 0.92 1.01 1.29
C

<7 (0.29-4.85) (0.56-7.78) (0.12-11.45) (0.76-1.45) (0.74-1.30) (1.20-2.39) (0.65-1.34) (0.80-1.32) (0.80-1.31) (0.77-1.09) (0.87-1.18) (1.09-1.53)
Ventilation >6 2.37 -- -- 1.06 1.01 1.21 1.00 1.08 1.29 0.94 1.03 1.32
AC

hours (0.42-13.44) (0.63-1.80) (0.64-1.60) (0.64-2.26) (0.51-1.96) (0.67-1.73) (0.76-2.18) (0.70-1.26) (0.80-1.34) (0.98-1.77)
Neonatal -- -- -- 1.56 -- -- 1.40 1.29 -- 0.34 0.52 0.92
seizures (0.10-25.00) (0.23-8.46) (0.33-5.04) (0.11-1.05) (0.23-1.17) (0.38-2.19)
NICU admission 1.23 1.66 1.87 1.19 1.17 1.35 1.01 1.02 1.13 0.89 1.02 1.21
(0.62-2.44) (0.84-3.29) (1.03-3.17) (1.00-1.41) (1.00-1.37) (1.09-1.67) (0.82-1.24) (0.88-1.18) (0.96-1.34) (0.81-0.99) (0.92-1.12) (1.09-1.34)

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Neonatal -- --- -- 1.08 0.74 1.33 1.29 1.35 1.57 0.82 0.98 1.24
transfer to (0.69-1.68) (0.48-1.13) (0.78-2.27) (0.71-2.31) (0.88-2.07) (0.98-2.52) (0.64-1.08) (0.79-1.22) (0.96-1.60)
higher level care
LGA > 90%ile 0.44 1.86 3.07 0.70 1.54 3.32 0.62 1.56 2.85 0.80 1.33 1.98
(0.11-1.67) (0.70-4.97) (0.96-9.85) (0.57-0.86) (1.32-1.79) (2.77-3.97) (0.50-0.78) (1.37-1.77) (2.48-3.26) (0.74-0.86) (1.25-1.42)

PT
(1.83-2.13)
SGA < 10%ile 1.73 0.65 -- 1.70 0.71 0.56 1.25 0.64 0.44 1.30 0.85 0.62
(1.09-2.74) (0.45-1.17) (1.46-1.97) (0.61-0.84) (0.43-0.73) (1.04-1.50) (0.55-0.75) (0.36-0.55) (1.15-1.47) (0.76-0.96) (0.53-0.73)

RI
BMI, body mass index; NICU, neonatal intensive care unit; LGA, large-for-gestational-age; SGA, small-for-gestational-age
Empty cells were unable to be calculated due to small cell sizes

SC
Data displayed as adjusted odds ratios (95% confidence intervals). Adjusted for maternal age, parity, race/ethnicity, marital status, education,
and payer type.

U
AN
M
D
TE
C EP
AC

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PT
RI
U SC
AN
M
D
TE
EP
C
AC

23