CMECNE

Recommended Weight Gain and Obesity Management in Pregnancy

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Recall IOM recommendations for target weight gain based on BMI
2. Plan labor management based on obesity criteria

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2019, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

Nutritional counseling is a central element of preconception care and the initial parental visit. The following are the weight gain recommendations, based on the Institute of Medicine (IOM) 2009 guidelines.

IOM Recommendations for Weight Gain in Pregnancy

Singleton pregnancy:

Underweight – BMI less than 18.5
- Total weight gain: 28-40 lbs
- Rate of gain in 2nd & 3rd trimesters: 1 lb/wk
Normal weight: BMI between 18.5–24.9
- Total weight gain: 25-35 lbs
- Rate of gain in 2nd & 3rd trimesters: 1 lb/wk
Overweight: BMI between 25-29.9 lbs
- Total weight gain: 15-25 lbs
- Rate of gain in 2nd & 3rd trimesters: 0.6 lb/wk
Obesity (all classes, I – III): BMI 30 and greater
- Total weight gain: 11-20 lbs
- Rate of gain in 2nd & 3rd gain: 0.5 lb/wk

Twin pregnancy:

Normal weight: BMI between 18.5–24.9
- Total weight gain: 37-54 lbs
- Rate of gain in 2nd & 3rd trimesters: 1 lb/wk
Overweight: BMI between 25-29.9 lbs
- Total weight gain: 31-50 lbs
- Rate of gain in 2nd & 3rd trimesters: 0.6 lb/wk
Obesity (all classes, I – III): BMI 30 and greater
- Total weight gain: 25-42 lbs
- Rate of gain in 2nd & 3rd gain: 0.5 lb/wk

Perinatal Risks for Not Meeting IOM Weight Gain Targets in Singletons (Goldstein et al., JAMA 2017)

Gestational weight gain below the recommendations

Increased risk for SGA (odds ratio [OR], 1.53 [95% CI, 1.44-1.64]; absolute risk difference [ARD], 5% [95% CI, 4%-6%])
Increased risk for preterm birth (OR, 1.70 [1.32-2.20]; ARD, 5% [3%-8%]) and
Decreased risk for LGA (OR, 0.59 [0.55-0.64]; ARD, -2% [-10% to -6%])
Decreased risk for macrosomia (OR, 0.60 [0.52-0.68]; ARD, -2% [-3% to -1%]);
No difference for cesarean delivery (OR, 0.98 [0.96-1.02]; ARD, 0% [-2% to 1%])

Gestational weight gain above the recommendations

Decreased risk for SGA (OR, 0.66 [0.63-0.69]; ARD, -3%; [-4% to -2%])
Decreased risk for preterm birth (OR, 0.77 [0.69-0.86]; ARD, -2% [-2% to -1%])
Higher risk of LGA (OR, 1.85 [1.76-1.95]; ARD, 4% [2%-5%])
Higher risk for macrosomia (OR, 1.95 [1.79-2.11]; ARD, 6% [4%-9%]),
Higher risk for cesarean delivery (OR, 1.30 [1.25-1.35]; ARD, 4% [3%-6%])

SYNOPSIS:

In a systematic review of over 1 million pregnant women, most did not meet the IOM targets, with 47% gaining more and 23% gaining less than IOM recommendations. ACOG recommends using judgment and individualized care. Medications for weight management are not recommended during the time of conception or during pregnancy. Rather, dietary control, exercise and behavioral modification are the primary weight management strategies during pregnancy.

KEY POINTS:

Obese women should be screened early for glucose intolerance and obstructive sleep apnea
The optimal control of obesity should begin before conception because weight loss before pregnancy is the most effective intervention to improve medical comorbidities
Management in labor and delivery
- Allow a longer first stage of labor before performing a cesarean section for labor arrest
- Obtain an early anesthesia consult
- Consider early epidural placement
- Consider using a higher preoperative antibiotic dose
- Closure of the subcutaneous tissue with depth greater than 2 cm can significantly decrease the incidence of wound disruption
- Consider pharmacologic thromboprophylaxis in addition to pneumatic compression devices for prevention of venous thromboembolism