Gestational weight gain in women with type 1 and type 2 diabetes mellitus is related to both general and diabetes-related clinical characteristics.

PURPOSE: To assess predictors of gestational weight gain (GWG), according to the Institute of Medicine (IOM) 2009, in women with type 1 and type 2 diabetes. METHODS: This was a retrospective cohort study conducted at a tertiary center. GWG based on the IOM was assessed both uncorrected and corrected for gestational age. General and diabetes-related clinical characteristics were analyzed as predictors. RESULTS: We evaluated 633 pregnant women with type 1 and type 2 diabetes. GWG uncorrected for gestational age was inadequate (iGWG) in 20.4%, adequate in 37.1%, and excessive (eGWG) in 42.5% of the women. Predictors included general (height, prepregnancy body mass index category, and multiple pregnancy) and diabetes-related clinical characteristics. Neuropathy and follow-up length were associated with iGWG (odds ratio (OR) 3.00, 95% CI 1.22-7.37; OR 0.92, 95% CI 0.86-0.97, respectively), while pump use and third-trimester insulin dose were associated with eGWG (OR 1.68, 95% CI 1.07-2.66; OR 3.64, 95% CI 1.88-7.06, respectively). Independent predictors for corrected GWG and sensitivity analyses also included general and diabetes-related clinical characteristics. CONCLUSION: In this cohort of women with type 1 and type 2 diabetes, non-adequate GWG was common, mainly due to eGWG, and associated clinical characteristics were both general and diabetes-related. Current clinical care of these women during pregnancy may favor weight gain.

Association between inadequate weight gain according to the institute of medicine 2009 guidelines and pregnancy outcomes in women with thyroid disorders.

PURPOSE: Gestational weight gain (GWG) is an important contributor to pregnancy outcomes in the general obstetric population and different subgroups. The corresponding information in women with thyroid conditions is limited. We aimed to evaluate the relationship between GWG according to institute of medicine (IOM) and pregnancy outcomes in women with thyroid disorders. METHODS: We performed a retrospective analysis of 620 pregnant women either treated with levothyroxine (N = 545) or attended because of hyperthyroidism during pregnancy (N = 75). RESULTS: The associations between GWG according to IOM and pregnancy outcomes were present both in women treated with thyroid hormone and women followed by hyperthyroidism, most of them related to the fetal outcomes. In women treated with levothyroxine, insufficient GWG was associated with gestational diabetes mellitus (GDM) (odds ratio (OR) 2.32, 95% confidence interval (CI) 1.18, 4.54), preterm birth (OR 2.31, 95% CI 1.22, 4.36), small-for-gestational age newborns (OR 2.38, 95% CI 1.09, 5.22) and respiratory distress (OR 6.89, 95% CI 1.46, 32.52). Excessive GWG was associated with cesarean delivery (OR 1.66, 95% CI 1.10, 2.51) and macrosomia (OR 2.75, 95% CI 1.38, 5.49). Large-for-gestational age newborns were associated with both insufficient GWG (OR 0.25, 95% CI 0.11, 0.58) and excessive GWG (OR 1.80, 95% CI 1.11, 2.92). In women followed by hyperthyroidism, excessive GWG was associated with large-for-gestational age newborns (OR 5.56, 95% CI 1.03, 29.96). CONCLUSION: GWG according to IOM is associated with pregnancy outcomes both in women treated with thyroid hormone and women followed by hyperthyroidism.

Gestational weight gain and pregnancy outcomes in women with type 1 and type 2 diabetes mellitus.

AIMS: We aimed to explore the relationship between gestational weight gain (GWG) after Institute of Medicine (IOM) and pregnancy outcomes in women with type 1 and type 2 diabetes. METHODS: Retrospective cohort study at a tertiary medical center (1981-2011). OUTCOME VARIABLES: 2 maternal and 14 fetal. Main exposure variable: GWG according to IOM. We calculated crude and adjusted ORs as well as population attributable (PAF) and preventable fractions (PPF) for significant positive and negative associations, respectively. RESULTS: We evaluated 633 pregnant women with type 1 or type 2 diabetes. GWG was insufficient (iGWG) in 16.7% and excessive (eGWG) in 50.7%. In the adjusted analysis, GWG according to IOM was significantly associated with maternal outcomes (pregnancy-induced hypertension and cesarean delivery) and four fetal outcomes (large-for-gestational age, macrosomia, small-for-gestational age and neonatal respiratory distress). The association with large-for-gestational age newborns was negative for iGWG (0.48, CI 95% 0.25-0.94) and positive for eGWG (1.76, CI 95% 1.18-2.63). In addition, iGWG was associated with a higher risk of small-for-gestational age newborns and respiratory distress and eGWG with a higher risk of pregnancy-induced hypertension, caesarean delivery and macrosomia. PAF and PPF ranged from the 20.4% PPF of iGWG for large-for-gestational age to 56.5% PAF of eGWG for macrosomia. CONCLUSION: In this cohort of women with type 1 or type 2 diabetes, inadequate GWG after IOM was associated with adverse pregnancy outcomes; associations were unfavorable for eGWG and mixed for iGWG. The attributable fractions were not moderate, pointing to the potential impact of modifying inadequate GWG.

Gestational weight gain adequacy and intrapartum oxytocin and cesarean section use: Observational population-based study in France.

INTRODUCTION: Research on maternal prepregnancy weight suggests adiposity is associated with dysfunctional labor, but knowledge about how gestational weight gain (GWG) affects labor is sparse. Our objective was to evaluate associations between GWG adequacy and intrapartum obstetric interventions (oxytocin administration; cesarean section) necessitated by labor dysfunction. MATERIAL AND METHODS: Using national, population-based French National Perinatal Survey 2016 data, we included term cephalic singleton pregnancies involving trial of labor (n = 9724). For the intrapartum oxytocin administration analysis, we included only women with spontaneous labor (n = 7352). GWG was calculated as the difference between end of pregnancy and prepregnancy weight (both self-reported) and categorized as insufficient, adequate (reference group), or excessive by prepregnancy body mass index (BMI; underweight <18.5, normal weight 18.5-24.9, overweight 25-29.9, obese ≥30 kg/m2 ) using the 2009 Institute of Medicine thresholds. Multilevel generalized estimating equation logistic regression models, unadjusted and adjusted for a priori confounders, evaluated intervention-GWG adequacy associations within BMI categories (under/normal weight combined), stratified by parity (primiparas; multiparas). RESULTS: GWG adequacy was associated with oxytocin use among under/normal weight women (primiparas: insufficient 57.3%, adequate 60.8%, excessive 65.0%, p = 0.014; multiparas: insufficient 27.2%, adequate 29.1%, excessive 36.2%, p < 0.001) and overweight primiparas (insufficient 56.0%, adequate 58.7%, excessive 72.5%, p = 0.002). In unadjusted and adjusted models, trends of increased odds of oxytocin administration among women with excessive GWG were found regardless of parity and prepregnancy BMI. Similarly, among under/normal weight women, GWG adequacy was associated with intrapartum cesarean section (primiparas: insufficient 10.7%, adequate 12.7%, excessive 15.3%, p = 0.014; multiparas: insufficient 3.1%, adequate 3.5%, excessive 6.3%, p < 0.001) with increased cesarean section among multiparas with excessive GWG persisting in adjusted models (adjusted odds ratio 1.9, 95% confidence interval 1.3-2.7). However, intrapartum cesarean section was reduced among multiparas with overweight and obese prepregnancy BMI and excessive GWG. CONCLUSIONS: Excessive GWG was associated with intrapartum oxytocin administration, regardless of parity or prepregnancy BMI, and cesarean section among women with under/normal weight prepregnancy BMI, providing evidence for benefits of healthy GWG for normal labor progression. Additional research is needed to verify our findings and understand differences by BMI.

Optimal gestational weight gain in women with twin pregnancies and gestational diabetes mellitus: a population-based study in the United States.

BACKGROUND: There is limited evidence regarding optimal gestational weight gain in women with twin pregnancies and gestational diabetes mellitus. OBJECTIVE: This study aimed to examine the association between gestational weight gain and perinatal outcomes among women with gestational diabetes mellitus and twin pregnancies and to explore the gestational weight gain targets by prepregnancy body mass index category. STUDY DESIGN: A national population-based cohort study of twin pregnancies with gestational diabetes mellitus was conducted between 2014 and 2020. Women with gestational diabetes mellitus aged between 18 and 45 years with live-born twins without congenital malformations between 24 and 42 weeks of gestation were included in the analysis. Two approaches were used to determine the optimal gestational weight gain targets by body mass index category: an interquartile range method to calculate targets in low-risk gestational diabetes mellitus pregnancies and a logistic model method to identify the odds ratio targets at which a composite adverse outcome decreased. RESULTS: Of 29,308 women with gestational diabetes mellitus and twin pregnancies, 8239 (28.1%) were normal-weight, 7626 (26.0%) were overweight, and 13,443 (45.9%) were obese. The continuous standardized gestational weight gain by 36 weeks was associated with preterm birth <36 weeks, large-for-gestational-age infants, small-for-gestational-age infants, and gestational hypertensive disorders. The interquartile range targets were 13.6 to 20.9 kg, 10.9 to 20.4 kg, and 7.7 to 17.7 kg for normal-weight, overweight, and obese women, respectively. The odds ratio targets were 14.1 to 20.0 kg, 12.1 to 16.0 kg, and 6.1 to 12.0 kg for normal-weight, overweight, and obese women, respectively. Gestational weight gain outside these targets was associated with preterm birth <36 weeks, large-for-gestational-age and small-for-gestational-age infants, and gestational hypertensive disorders, and exhibited significant population attributable fractions for preterm birth <36 weeks, large-for-gestational-age infants, and gestational hypertensive disorders across body mass index categories. CONCLUSION: Compared with the Institute of Medicine guidelines, more stringent gestational weight gain targets would be beneficial for improved perinatal outcomes in women with gestational diabetes mellitus and twin pregnancies.

Gestational weight gain adequacy among twin pregnancies in France.

The objective of this paper is to describe gestational weight gain (GWG), to assess the applicability of the 2009 Institute of Medicine (IOM) guidelines, and to derive a GWG adequacy classification within a French cohort. We included twins from the national, prospective, population-based JUmeaux MODe d'Accouchement (JUMODA) cohort study (2014-2015). Following the IOM approach, we selected a 'standard' population of term pregnancies with 'optimal' birthweight (≥2500 g; n = 2562). GWG adequacy (insufficient; adequate; excessive) was defined using IOM recommendations (normal body mass index [BMI]: 16.8-24.5 kg [also utilized for underweight BMI]; overweight: 14.1-22.7 kg; obese: 11.4-19.1 kg). Additionally, using the IOM approach, we determined the 25th and 75th percentiles of GWG in our standard population to create a JUMODA-derived GWG adequacy classification. GWG and GWG adequacy were described, overall and by BMI and parity. In the JUMODA standard population of term twin livebirths with optimal birthweight, mean GWG was 16.1 kg (standard deviation 6.3). Using IOM recommendations, almost half (46.5%) of the women had insufficient and few (10.0%) had excessive GWG, with similar results regardless of BMI or parity. The 25th and 75th percentiles of GWG in the JUMODA standard population (underweight: 13-21 kg; normal weight: 13-20 kg; overweight: 11-19 kg; obese: 7-16 kg) were lower than the IOM recommendations. The IOM recommendations classified a relatively high percentage of French women as having insufficient and a low percentage as having excessive GWG. Additional research to evaluate recommendations in relation to adverse perinatal outcomes is needed to determine whether the IOM recommendations or the JUMODA-derived classification is more appropriate for French twin gestations.

Correlation between 25-hydroxy vitamin D levels in women and in vitro fertilization outcomes: A cross-sectional study.

Background: Vitamin D has recently raised a great deal of controversy, not because of its traditional role of absorbing calcium and maintaining bone health, but because of its unconventional role as an endocrine factor and the extent of its impact when linked to its specific receptors (VDR) found in different tissues. Research has raced trying to find its different roles in those tissues and its association with different clinical or medical conditions, and among these cases, its role in reproductive functions and fertility in women, these studies conflicted between supporting and denying the role of vitamin D in reproductive function and rejecting this hypothesis according to the results of their study. Materials and methods: The in vitro fertilization process allowed us to study the possible hypotheses, as this technique provides an opportunity to study the relationship between vitamin D levels with the in vitro fertilization outcomes, thus providing us with an idea of the relationship of vitamin D with fertility in women. In order to study this relationship, we designed our research as a cross-sectional study to confirm or deny this claim. Vitamin D was measured in the blood and in the follicular fluid for all cases using the electrochemiluminescence immunoassay (ECLIA) for the assay of total vitamin D, then IVF outcomes were compared with the levels of vitamin D in the blood. Results: the levels of vitamin D are not related to the criteria of eggs such as the number of eggs and the maturity rate (MR) of eggs, but they are correlated in a statistically significant manner with the fertility rate (FR), and at the same time the levels of vitamin D in the blood were completely independent of the clinical pregnancy rate (CPR). Conclusion: blood vitamin D levels will affect the FR when its levels in the blood drop below a specified value, vitamin D did not correlate with the CPR. In the long run, there is scope for more research projects on vitamin D. Future research could include case-control studies of patients on vitamin D supplementation, and the study of its correlation with IVF outcomes.

Associations of Gestational Weight Gain with Perinatal Outcomes in Western Brazilian Amazon.

OBJECTIVE: To investigate the association between gestational weight gain (GWG) and perinatal outcomes in pregnant Amazonian women. METHODS: Data from 1305 mother-child pairs from the MINA-Brazil population-based birth cohort study were used. GWG was classified according to two methods, the Institute of Medicine (IOM) guidelines and INTERGROWTH-21st standards. Poisson and linear regression analyses were conducted to evaluate associations with perinatal outcomes. RESULTS: Following IOM guidelines (n = 1305), the rates of insufficient and excessive GWG were found to be similar (32%). Excessive GWG was associated with higher new-born birthweight (BW) z-scores; increased risks of macrosomia, large for gestational age (LGA), and caesarean delivery; and lower risks of low birthweight (LBW) and being small for gestational age (SGA). Insufficient GWG was associated with lower new-born BW z-scores. Among women with normal pre-pregnancy body mass indices (BMIs, n = 658), inappropriate GWG was high following both methods (IOM: 41.2% insufficient, 24.8% excessive; INTERGROWTH-21st: 25.2% below - 1 z-score, 16.9% above 1 z-score). Both methods also indicated that new-borns of women with excessive GWG had higher BW z-scores and increased risk of macrosomia and LGA. Women with GWG below the INTERGROWTH-21st standards were more likely to deliver an infant SGA and with lower BW z-scores. CONCLUSIONS: Inappropriate GWG remains a health concern irrespective of the method used to classify weight gain. GWG above the recommendations of both methods and below the INTERGROWTH-21st standard was associated with adverse perinatal outcomes. Therefore, INTERGROWTH-21st standards seem to be a better fit for healthy women in this population.

Gestational weight gain during the second and third trimesters and adverse pregnancy outcomes, results from a prospective pregnancy cohort in urban Tanzania.

BACKGROUND: Appropriate gestational weight gain (GWG) is important for optimal pregnancy outcomes. This study prospectively evaluated the associations between GWG during the second and third trimesters of pregnancy and adverse pregnancy outcomes in an urban Tanzanian pregnancy cohort. METHODS: We used data from a randomized clinical trial conducted among pregnant women recruited by 27 weeks of gestation in Dar es Salaam, Tanzania (N = 1230). Women's gestational weight was measured at baseline and at monthly antenatal visits. Weekly GWG rate during the second and third trimesters was calculated and characterized as inadequate, adequate, or excessive, in conjunction with measured or imputed early-pregnancy BMI status according to the 2009 Institute of Medicine (IOM) GWG guidelines. We used multivariable Poisson regression with a sandwich variance estimator to calculate risk ratios (RR) for associations of GWG with low birth weight, preterm birth, small for gestational age (SGA), and large for gestational age (LGA). Degree of appropriate GWG defined using additional metrics (i.e., percentage of adequacy, z-score) and potential effect modification by maternal BMI were additionally evaluated. RESULTS: According to the IOM guidelines, 517 (42.0%), 270 (22.0%), and 443 (36.0%) women were characterized as having inadequate, adequate, and excessive GWG, respectively. Overall, compared to women with adequate GWG, women with inadequate GWG had a lower risk of LGA births (RR = 0.54, 95% CI: 0.36-0.80) and a higher risk of SGA births (RR = 1.32, 95% CI: 0.95-1.81). Women with inadequate GWG as defined by percentage of GWG adequacy had a higher risk of LBW (OR = 1.93, 95% CI: 1.03-3.63). In stratified analyses by early-pregnancy BMI, excessive GWG among women with normal BMI was associated with a higher risk of preterm birth (RR = 1.59, 95% CI: 1.03-2.44). CONCLUSIONS: A comparatively high percentage of excessive GWG was observed among healthy pregnant women in Tanzania. Both inadequate and excessive GWGs were associated with elevated risks of poor pregnancy outcomes. Future studies among diverse SSA populations are warranted to confirm our findings, and clinical recommendations on optimal GWG should be developed to promote healthy GWG in SSA settings. TRIAL REGISTRATION: This trial was registered as "Prenatal Iron Supplements: Safety and Efficacy in Tanzania" (NCT01119612; http://clinicaltrials.gov/show/NCT01119612 ).

Pregnancy is a critical lifetime event for both mother and the offspring, with implications in short-term and long-term health consequences. Gestational weight gain (GWG) is an important modifiable factor for pregnancy outcomes related to infant body size and weight and prematurity. Countries in sub-Saharan Africa (SSA) have long had poor rates of insufficient GWG and pregnancy complications associated with insufficient GWG. Nevertheless, some SSA countries are experiencing economic transitions accompanied with changes in lifestyle and nutrition, which might impact pregnancy experiences, including GWG and pregnancy outcomes. This study aimed to characterize recent GWG patterns and the associations of both inadequate and excessive GWG with adverse pregnancy outcomes, using an urban pregnancy cohort in Tanzania. This study found that 42.0%. 22.0%, and 36.0% of women had insufficient, adequate, and excessive GWG, respectively. Insufficient GWG was associated with higher risks of small infant size and low infant body weight, and excessive GWG was associated with higher risk of preterm birth, particularly among women with body mass index 18.5­25.0 kg/m². Results from the present study highlight that both insufficient and excessive GWG are of potential public health concerns in urban centers of SSA, concerning upward trends in obesity and possibly obesity-related pregnancy consequences. Local public health practitioners should continue to advocate longitudinal GWG monitoring and care among African pregnant women, and optimal GWG with feasible and effective clinical guidelines should be developed to prevent both over- and under-gaining of maternal weight during pregnancy.

Three trajectories of gestational weight gain identified in an Australian twin study.

OBJECTIVES: Gestational weight gain (GWG) has been associated with maternal and child health outcomes, but knowledge of appropriate GWG for twin gestations is limited. STUDY DESIGN: The Peri/Postnatal Epigenetic Twins Study is a prospective twin cohort study of 250 women and their twin children in Melbourne, Australia. We modeled trajectories of GWG using group-based growth modeling and compared these trajectories to GWG categories (within, above, or below current GWG recommendations for twin pregnancy). We fitted robust linear and Poisson regression models to assess associations of maternal pre-pregnancy and gestational exposures with risk of gaining weight outside the recommendations. RESULTS: Of the 250 women enrolled in the PETS, GWG measures were available for 172 women. Forty-seven percent of women had GWG within the current recommendations. We identified three GWG trajectories - 23.6% of women had low GWG throughout pregnancy, 34.5% had average GWG throughout pregnancy, and 42.0% had average initial GWG, followed by high GWG from trimester two until delivery. Gestational diabetes mellitus (GDM) was associated with increased risk of inadequate GWG (RR: 2.40, 95%CI: 1.53, 3.75). Pre-pregnancy obesity (RR: 1.88, 95%CI: 1.09, 3.26) and hypertensive disorders of pregnancy (RR: 2.64, 95%CI: 1.20, 5.81) were associated with increased risk of excessive GWG. CONCLUSIONS: More than half of the women in the PETS did not meet the current GWG recommendations. Women with GDM or hypertensive disorders were more likely to gain weight outside these guidelines. More research is needed to establish comprehensive guidelines for twin pregnancies.

Weight gain rate in the second and third trimesters and fetal growth in women with gestational diabetes mellitus: a retrospective cohort study.

BACKGROUND: Controversial evidence regarding the applicability of the IOM's gestational weight gain (GWG) targets for women with gestational diabetes mellitus (GDM) has been reported. However, little is known about the weight gain rate (WGR) during the second and third trimesters. Moreover, previous studies failed to assess the effect modification of pre-pregnancy BMI because of the limited sample size. Therefore, we aimed to assess the applicability of the IOM recommendation for the WGR in women with GDM in different pre-pregnancy BMI categories. METHODS: We conducted this retrospective cohort study of 5275 women with GDM who delivered at Guangzhou Women and Children's Medical Center (GWCMC) between January 2017 and January 2021. Demographic and clinical information was collected from the electronic medical record system. The primary exposure was the WGR in the late second and third trimesters; they were classified as below, within, and above the IOM standard. The outcomes were fetal growth indicators, including large-for-gestational-age (LGA), macrosomia, small-for-gestational-age (SGA), and low birth weight (LBW). The associations between the WGR and such outcomes were assessed using multiple logistic regression. RESULTS: A WGR below the IOM standard was associated with the decreased odds of LGA (adjusted OR 0.74; 95% CI 0.49-1.13) and macrosomia (adjusted OR 0.54, 95% CI 0.32-0.92) for women with GDM in the normal weight BMI class. Such decreases were observed greater for women with GDM in the overweight/obese class, with adjusted ORs of 0.34 (95% CI 0.09-0.88) for LGA and 0.31 (95% CI 0.01-0.84) for macrosomia, respectively. No significant difference was observed in the odds ratios of SGA and LBW across the different WGR groups. CONCLUSION: LGA and macrosomia are the main outcomes associated with the WGR in the late second and third trimesters, and a WGR below the IOM standard was associated with a decreased odds of such outcomes compared with a WGR within the IOM standard in women with GDM in the normal weight and overweight/obese classes. Our findings suggest that a stricter WGR target than that of the current IOM standard may be more beneficial for women with GDM.

Multivitamin Supplementation Is Associated with Greater Adequacy of Gestational Weight Gain among Pregnant Women in Tanzania.

BACKGROUND: Gestational weight gain (GWG) is a modifiable risk factor associated with adverse birth outcomes. Studies have shown that the provision of multiple micronutrient supplements to pregnant women reduces the risk of low birth weight. However, the effect of multiple micronutrient supplements on GWG has been understudied. OBJECTIVES: We examined the effect of daily supplementation of pregnant women with multivitamins on GWG in relation to the GWG recommendation by the Institute of Medicine (IOM). METHODS: Pregnant women with gestational age between 12 and 27 wk were randomly assigned to receive daily multivitamins or placebo until delivery. Weight was measured at enrollment and every follow-up visit. Percentage adequacy of GWG was calculated as actual GWG divided by the recommended GWG according to the IOM recommendation. Binary outcomes included severely inadequate (<70%), inadequate (<90%), and excessive GWG (≥125%). The analysis included 7573 women with singleton pregnancies. Multiple linear regression models were used to examine the association between multivitamin supplementation and percentage adequacy of GWG, and log-binomial models were used for binary outcomes. RESULTS: The mean percentage adequacy of GWG was 96.7% in the multivitamin arm and 94.4% in the placebo arm, with a mean difference of 2.3% (95% CI: 0.3%, 4.2%; P = 0.022). Compared with women in the placebo arm, those who received multivitamins had a lower risk of severely inadequate GWG (RR: 0.90; 95% CI: 0.83, 0.97; P = 0.008) and inadequate GWG (RR: 0.95; 95% CI: 0.91, 0.99; P = 0.018). No significant difference was found in excessive GWG. CONCLUSIONS: Multivitamin supplementation increased GWG and reduced the risk of severely inadequate and inadequate GWG among pregnant women in Tanzania. Together with previously reported beneficial effects of the supplements on birth outcomes in low- and middle-income countries, our findings support scaling up the use of prenatal supplements that include multivitamins in addition to iron and folic acid.This trial was registered at clinicaltrials.gov as NCT00197548.

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.

Comparison between American Institute of Medicine Guidelines and Local Recommendation for Gestational Weight Gain in Taiwanese Primiparous Women.

OBJECTIVES: American Institute of Medicine (IOM) recommends different ranges of gestational weight gain (GWG) based on pre-pregnancy body mass index (BMI). In Taiwan, IOM guidelines are implemented concurrently with the local recommendation for GWG (10-14 kg). This study compared between the two sets of guidelines in relation to adverse perinatal outcomes. METHODS: We analyzed 31,653 primiparas with singletons from 2011 to 2016 annual National Breastfeeding Surveys. Logistic regressions for preterm birth, small for gestational age (SGA), large for gestational age (LGA), cesarean section and excessive postpartum weight retention (EPWR) were fitted separately for GWG categorized according to IOM and Taiwan ranges. Areas under the receiver-operator curves (AUC) and the predicted probabilities for each outcome were compared in each BMI group. RESULTS: AUC for both guidelines ranged within 0.51-0.73. Compared to Taiwan recommendation, IOM ranges showed lower probabilities of SGA for underweight (0.11-0.15 versus 0.14-0.18), of LGA for obese (0.12-0.15 versus 0.15-0.18), of EPWR for overweight (0.19-0.30 versus 0.27-0.39), and obese (0.15-0.22 versus 0.25-0.36); and higher probabilities of EPWR for underweight (0.17-0.33 versus 0.14-0.22). CONCLUSIONS FOR PRACTICE: Discriminative performance of IOM and Taiwan recommendations was poor for the five adverse birth outcomes, and no preference for either set of recommendations could be inferred from our results. In the absence of specific GWG guidelines, health care workers may provide inconsistent information to their patients. Future research is needed to explore optimal GWG ranges that can reliably predict locally relevant perinatal outcomes for mother and child.

Value-based focused global population health management.

In 2018, approximately 18 million people worldwide were diagnosed with cancer and are predicted to double by 2040. The global quality chasm in improving health care worldwide requires "systems thinking" as the key to success. Aligning the goal around person-centered care captures the total needs of care of a population and not just disease categories. The integration of the Institute of Medicine's (IOM) six aims of quality termed "value-based focused" and population health management (PHM) provides all health care leaders grappling with improving the health care of the populations a framework for the communities they serve. In this context, the question becomes finding solutions to providing high quality, compassionate and patient-centered health care delivery. Over the last two decades, three paradigms have emerged; the six aims of quality, outcome-focused population health, and the "Quadruple Aim". We have termed the intersection of these concepts as Value-based focused Population Health Management (VBPHM). This review applies VBPHM across the geographic county and community levels in the United States. Specifically, we examine VBPHM at the county or county-equivalents and community levels within the United States. Lastly, the potential role of Community-based Participatory Research and it is applicability to our framework is discussed. VBPHM can comparably be applied globally to improve population health, especially in preventing and treating cancer better.

Institute of Medicine Recommendations on the Rate of Gestational Weight Gain and Perinatal Outcomes in Rural Bangladesh.

Although validated in other parts of the world, the suitability of the U.S. Institute of Medicine (IOM) 2009 recommendations on gestational weight gain (GWG) for Bangladeshi women remains to be examined. We evaluated the association between the weekly rate of weight gain during the second and third trimester of pregnancy, categorized according to IOM recommendations, and adverse perinatal outcomes among 1569 pregnant women with singleton live births in rural Matlab, Bangladesh. Gaining weight at rates below the IOM recommendations was associated with higher odds of preterm birth (adjusted odds ratio (AOR) = 2.0, 95% CI: 1.1-3.6), low birth weight (AOR = 1.4, 95% CI: 1.03-2.0), small-for-gestational-age newborns (AOR = 1.3, 95% CI: 1.04-1.7), and poor neonatal outcome (severe neonatal morbidity or death, AOR = 2.4, 95% CI: 1.03-5.6). A GWG rate above the recommendations was associated with higher odds of cesarean delivery (AOR = 1.7, 95% CI: 1.1-2.6), preterm birth (AOR = 2.2, 95% CI: 1.1-4.4), large-for-gestational-age newborns (AOR = 5.9, 95% CI: 1.5-23.1), and poor neonatal outcome (AOR = 2.7, 95% CI: 1.04-7.0). Our results suggest that the IOM 2009 recommendations on GWG rate during the second and third trimester may be suitable for guiding rural Bangladeshi women in the prenatal period, although the women should aim for rates near the lower bound of the range.

Association between gestational weight gain in women with gestational diabetes mellitus and adverse pregnancy outcomes: a retrospective cohort study.

BACKGROUND: To examine association between gestational weight gain (GWG) in women with gestational diabetes mellitus (GDM) and adverse pregnancy outcomes (APOs). METHODS: This retrospective cohort study enrolled women with GDM who delivered at 2010-2020 in Changzhou, Jiangsu. Total GWG, rates of GWG in second trimester and third trimesters were stratified into three categories according to IOM guidelines: within, below, and above IOM guidelines. Univariable and multivariable logistic regression analyses were used. RESULTS: Overall, 1606 women with GDM fulfilled inclusion criteria. Compared with within IOM guidelines and after adjusting for confounders, total GWG above IOM guidelines in pregnancy was associated with an increased odds of caesarean delivery [adjusted odds ratio (aOR) = 1.34, 95% confidence interval (CI): 1.04-1.72], hypertensive disorders of pregnancy (HDP) (aOR = 2.00, 1.28-3.12), preeclampsia (aOR = 2.06, 1.01-3.12), macrosomia (aOR = 1.55, 1.13-2.13) and large for gestational age (LGA) (aOR = 2.82, 1.94-3.23), and a decreased odds of premature rupture of membrane (PROM) (aOR = 0.46, 0.36-0.60) and preterm birth (aOR = 0.35, 0.26-0.44); total GWG below IOM guidelines in pregnancy was associated with an increased risk of preterm birth (aOR = 1.96, 1.44-2.66), small for gestational age (SGA) (aOR = 1.32, 1.11-1.50) and a decreased odds of macrosomia (aOR = 0.35, 0.23-0.53) and LGA (aOR = 0.54, 0.42-0.72). Further, in both second and third trimesters of pregnancy, rates of GWG above IOM guidelines was found to be associated with a high odds of HDP (aOR = 2.55, 1.86-3.38; aOR = 1.93, 1.08-2.98), preeclampsia (aOR = 2.28, 1.21-3.81; aOR = 2.17, 1.35-4.37), macrosomia (aOR = 1.20, 1.02-1.82; aOR = 2.02, 1.51-2.64) and LGA (aOR = 1.42, 1.24-1.97; aOR = 1.79, 1.51-2.54). Rates of GWG above IOM guidelines in third trimester of pregnancy also increased odds of caesarean delivery (aOR = 1.48, 1.16-2.34) when compared with within IOM guidelines. While rates of GWG below IOM guidelines in both second and third trimesters of pregnancy was associated with a decreased odds of macrosomia (aOR = 0.66, 95% CI: 0.52-0.78; aOR = 0.52, 0.39-0.63) and LGA(aOR = 0.71, 0.51-0.82; aOR = 0.67, 0.55-0.79). In addition, rate of GWG below IOM guidelines in third trimester of pregnancy was associated with an increased odds of preterm birth (aOR = 1.52, 1.12-2.05) and SGA (aOR = 1.21, 1.10-1.69). CONCLUSION: GWG, outside IOM guidelines has increased risks of APOs among women with GDM, implying that careful surveillance for GWG during different stages of pregnancy is warranted.

Identifying Healthcare Professional Roles in Developing Palliative Care: A Mixed Method.

Background: Creating a holistic approach in healthcare services is the ultimate aim for the integrated healthcare system. Theoretically, healthcare policy makers constantly expected optimal operations within the hospitals through capitalizing the maximum potential of healthcare expertise, professionals, practitioners, and supporting staff. The objective of this study is to explore the role of healthcare individuals to sustain effective palliative care programs in a safe environment with high-quality of care. Methods: This study employed a mixed method (qualitative and quantitative) to accomplish the set objective. For this purpose, a balanced sampling technique was adopted and 28 healthcare professionals were selected in two stages (last week of January and the 1st week of February, 2020). These respondents were playing significant role in palliative care policy making process. In the first stage, respondents were classified into three parallel groups to document the major factors affecting palliative care reforms. To minimize the chance of individual biases, each group was supervised by an independent healthcare professional who was not involved in the study. Then, in the second stage, respondents were divided into two clusters for further abstraction of themes to analysis the data. In this phase, each group was comprised on 14 individuals. Data were transcribed, coded, and analyzed (subjectively and objectively) by using NVivo 12 to extract the final themes. These themes were described and analyzed quantitatively for further catchphrases abstraction to identify significant components. Findings: The initial results incorporated 36 key factors in building effective and sustained palliative healthcare centers. The domains were feasible and practical as they homogeneously patterned within cultural change. These were quality of care, effective management, institute of medicine criteria, and health governance. The Spearman correlation matrix showed significant relationships between the four critical components (P < 0.01 and P < 0.05). Conclusions: This study explored and identified the significant factors that healthcare professional might consider to make their role more productive and effective in palliative care centers. The key findings also indicated the need of comprehensive periodic assessment especially from the perspective of managerial implications and quality of care.

Suggested Gestational Weight Gain for Chinese Women and Comparison with Institute of Medicine Criteria: A Large Population-Based Study.

OBJECTIVE: To establish suggested gestational weight gain (GWG) using several distinct methods in a Chinese population. METHODS: This study analyzed data from the medical records of singleton pregnancy women during 2011-2017 in Beijing, China. Suggested GWG was calculated using four distinct methods. In method 1, suggested GWG was identified by the interquartile method. Subsequently, risk models for small for gestational age (SGA) and large for gestational age (LGA) with respect to GWG were constructed. GWG was treated as a continuous variable in method 2, and as a categorized variable in methods 3 and 4. RESULTS: An average GWG of 15.78 kg with a prevalence of LGA at 19.34% and SGA at 2.12% was observed among the 34,470 participants. Methods 1 and 2 did not yield clinically applicable results. The suggested GWGs were 11-17/11-16 kg, 9-19/9-15 kg, 4-12/4-10 kg, and 0-12/0-6 kg by method 3/method 4 for underweight, normal-weight, overweight, and obese women, respectively. The GWG range suggested by method 3 resulted in a larger proportion of participants (62.03%) within range, while the suggested GWG range by method 4 was associated with a lower risk of LGA compared to that conferred by the Institute of Medicine (IOM) criteria. CONCLUSION: This study suggests a modest GWG goal compared to IOM recommendations based on a large Chinese cohort.

Gestational weight gain in twin pregnancies in Korea: application of the 2009 Institute of Medicine recommendations.

OBJECTIVE: To investigate the effect of gestational weight gain (GWG) on maternal and neonatal outcomes based on the Institute of Medicine (IOM) guidelines for twin pregnancies. METHODS: This study included women with twin pregnancies who delivered at Seoul National University Bundang Hospital. Based on the weight gain per gestational week according to the 2009 IOM guidelines, the subjects were divided into the following 3 groups: inadequate, adequate, and excessive GWG. We compared the maternal and neonatal outcomes of each group. RESULTS: A total of 1,738 twin pregnancies were included in our study. Of these cases, 881, 694, and 163 (50.7%, 39.9%, and 9.4%, respectively) twin pregnancies were categorized into the inadequate, adequate, and excessive GWG groups, respectively. In the inadequate GWG group, the risks of preterm birth <34 weeks (aOR, 2.33, 95% confidence interval [CI], 1.63-3.34) and delivering neonates who were small for gestational age (aOR, 1.92, 95% CI, 1.42-2.60) were increased, and the risk of preeclampsia (aOR, 0.49, 95% CI, 0.32-0.76) was decreased. The excessive GWG group had an increased risk of the neonates being large for gestational age (aOR, 1.79, 95% CI, 1.15-2.81). CONCLUSION: The 2009 IOM recommendations for GWG can be applied to Korean women with twin pregnancies to help achieve optimal maternal and neonatal outcomes. However, more than half of the women were categorized as having inadequate weight gain according to the guidelines. Further studies should be performed to obtain Korean national references for GWG in twin pregnancies.