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- [00:42]
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Dr. Sam (Host of Clinical Pearls Podcast)
It's so isolating. How do you really feel during your pregnancy? I'm angry. I ate a cupcake out of the.
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Dr. Sam (Host of Clinical Pearls Podcast)
I can't. So there's this new movie on Netflix called Kinda Pregnant. Not a sponsor. And it's a quirky, funny, heartfelt reality check into the joys of pregnancy and the ups and downs in the emotional roller coaster that come with that, including changes in appetite. Now, we're not trying to minimize anything. I get it, I get it. It's a very complex state. A lot of highs and lows, a lot of things going on. And after all, you're eating for two, right? So you got to increase your calorie intake. But the catch is to try to do that in a healthy way. Because as a country, remember, our BMIs are actually getting bigger. We've talked about this many times on the show. So as of right now, According to the CDC stats, listen to this, guys. One in five women, one in five here in the U.S. enter pregnancy with a BMI of 30 or more. One in five. Now remember, wait just a minute, because we're not talking about pre pregnancy birth weight in this birth weight, pre pregnancy weight, maternal weight. In this episode, we're talking about maternal weight gain, otherwise known as gestational weight gain or gwg. But I'm going somewhere, so hang on, hang in here for just a minute. All right, so one in five women start pregnancy with a BMI of 30 or more. That's right out of the CDC. Now, one in five women gain more than 40 pounds during pregnancy, which is more than any woman should gain. So in this case, the numbers kind of match. It's kind of easy to remember. One in five start with a BMI of 30. One in five will gain more than 40 pounds. That's four, zero, guys. That's a lot of weight. About one third of women so One out of three gained the actual recommended amount that is stated by the CDC and ACOG and SMFM and the Institute of Medicine. That's only about a third. Now, we know that gestational weight gain is a big deal. Gaining too much weight during pregnancy, of course, increases the risk of certain metabolic abnormalities in the patient and the mother. Like hypertensive disorders of pregnancy, gestational diabetes, it increases the chance of fetal macrosomia. It can cause complications at birth because of that, like shoulder dystocia. And there's also an association between excessive maternal weight gain and preterm birth. So starting out pregnancy with a high BMI is not good. Gaining too much is not good because of a variety of medical complications and intrapartum complications. We get that. But here's the question. Now, this comes from one of our podcast family members, and it's a fantastic question, and the answer is very complex and not what you would think. So follow me here for a minute. All right, here's a question. All right, so if we take a look at ACOG's committee opinion, the guidance on antepartum fetal surveillance, it's very clear that antepartum fetal surveillance, according to committee opinion 828 is based on pre pregnancy BMI. Right? Nothing new. We get that. We've covered that committee opinion828 from 2021, many, many times BMI, pre pregnancy BMI of 35 to 39.9, you can start surveillance at 37 weeks. But a pre pregnancy BMI of greater than 40, you start antepartum surveillance at 34 weeks. Now that's based on BMI pre pregnancy weight alone, not including that there's another kind of medical complications that you do surveillance for. Right? So everybody remember Pre pregnancy BMI 35 to 39.9 start at 36. Seven, if your BMI is over 40 or at 40 or more, you start at 34 weeks. Why? Because it's very clear in a separate practice bulletin from the college on obesity and pregnancy that obesity by itself is an independent risk factor for stillbirth. Okay, so we all get this pre pregnancy BMI independent risk factor for stillbirth. And that odds ratio, actually the hazard ratio goes up based on type of obesity. So it's elevated at BMI of 1, is even more elevated with a BMI category of obesity, class two, and then even more elevated with a BMI obesity category of 3. Okay, so it is increasing based on how bad the bmi is over 30. So remember, antepartum fetal surveillance committee opinion 828 from 2021 is based on pre pregnancy BMI. But here's a question that one of our podcast family members had and it's a great one. It' and why. Honestly, I've been asked this by other residents in the past, but from our podcast family community, we hadn't really had this and it's interesting that we've lasted this long without this. It's a great question. Well, what if a patient comes into pregnancy with a BMI that's okay, like let's say it's high end of normal or just on the cusp of overweight, but then gains so much weight that it throws off the bmi? In other words, gestational weight gain. Here's a question guys. Is gestational weight gain an indication for antepartum fetal surveillance and is that linked to stillbirth? Well, the easiest answer, but with a very complicated rationale for what. What that answer is is no. That's why in the indications for end upon fetal surveillance there is nothing on there regarding GWG gestational weight gain. It's all based on pre pregnancy. What you enter the game with. However, even though gestational weight gain is linked to those maternal complications that we already talked about, the question is this. What is the relationship between gestational weight gain and stillbirth? It's not what you think. So we're going to explain that very complicated answer in a very simple way using very recent six articles. We're going to walk down our timeline. You know how we do this starting all the way back like in 2001 and then ending more in present day. Because one of the last big population based studies that looked at this was out of BMC pregnancy and childbirth in 2019. We're going to answer this very interesting relationship between gestational weight gain and stillbirth. And it's not what you think. All right, I think I've set it up enough. Let's get to it in just a moment. This is clinical Pearls Sam sa.
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Dr. Sam (Host of Clinical Pearls Podcast)
All right, so once again, kinda pregnant. Kind of a fun movie. Not a sponsor, but I just couldn't resist that little clip. It was so funny. I ate a cupcake from the trash can. That is pregnancy hormone driven and I don't recommend eating cupcakes out of the trash, just FYI. So we're gonna walk down this timeline, guys, starting in 2001 and ending in 2019. So 18 years worth of stuff. Trust me, it's gonna go fast because it's very easy when all the data seems to point in one direction. Okay, so remember, the question that we're trying to answer here is gestational weight gain, the amount of weight a patient gains linked to stillbirth. And I said it's not what you think because it's not what you think. It's very interesting and intriguing. This kind of weird almost U shaped little graph there of pregnancy weight gain when that weight gain happens or when it does not. Okay, now remember, we're all basing this back on ACOG's committee opinion on antepartum fetal surveillance, which was 828 back in 2021. That does not list gestational weight gain as an indication for surveillance. And there's a reason for that. So let's start in The Gray Journal, that's the American journal of OB GYN back in 2001. And I promise I remember my commitment to try to ramble less and just answer the question. Right. So that was from our podcast, Family Member. Does maternal weight gain actually affect this thing? Well, I'm going to tell you, based on a bulk of data for like 18 years, why gestational weight gain is not listed on that table for antepartum surveillance. So let's start back in ajog. There used to be a section called fetus, placenta and newborn. It's no longer there, but this comes out of February 2001. So almost to the date, 24 years ago is an article titled maternal weight, pregnancy, weight gain and the risk of Antepartum stillbirth. That's exactly what we're talking about here. Right? This is what we want to do on a population level. And this is a population population based cross control study. Although it didn't use like thousands of women, it used 649 women who had endopartum stillbirth and 690 control. And this was out of a Swedish database. All right, now remember, if you notice things keep repeating in the literature, there's the Danes and the Danish database, the Swedes with their Swedish database. It's a great way to do Dana mining. And we've talked about this many times before in the show. So in 2001, basically taking like let's just say 650 in one camp and 650 in the other and looking specifically at the amount of weight gain that a patient had and risk of stillbirth. Now remember, pre pregnancy weight is one thing because we already know what you start pregnancy with in terms of bmi. That elevates risk, especially if you start obese. Okay, but listen to this very quickly on this population case control study very quickly because we've got other things to go through. Let me just read you the conclusion here of what they found regarding antepartum fetal death. Right, so stillbirth, quote, maternal overweight condition, increase the risk of Antepartum stillbirth. Okay, we get that. Especially term Antepartum stillbirth. So that's going into pregnancy. None of that's new. That's why pre pregnancy BMI is on the table. But here it is, guys, here's the catch. Here's the clinical pearl. Whereas. Did y' all get that? Let's do that again. Maternal overweight condition increase the risk of Antepartum stillbirth, especially term antepartum stillbirth or whereas weight gain during pregnancy was not associated with any risk. End quote. So let's stop there for a minute. Even though there's a lot to dissect in there, trust me, we got other fish to fry. So for right now, in 2021, as we set the stage, as we start to this travel down the road, 2021 says, hey, look, we took a look. Yes, BMI when you start pregnancy is a big deal, but it doesn't seem to be made a lot worse over the background. Risk of just bad based on gestational weight gain. Now there's complications of pregnancy. Nobo doubts that. Hypertensive disorder, pregnancy, gdm, shoulder dystocia, LG babies. We get that. But in terms of stillbirth, which is the focus of our episode here, it does not seem to increase that issue, which is good news. Now, leaving that and going six years ahead in a separate journal. So we leave the gray journal and go to a journal called Obesity. Now there's a journal called obesity in 2012 pretty much found almost the same thing. But let's go over that data because we're building a case here as to why gestational weight gain is important. Super important, especially because it's harder to drop that after the kid is born. But in terms of stillbirth, gestational weight gain probably is not what you think it is in terms of its relationship to fetal loss. Right. So anyway, out of the journal Obesity, the title of this second publication is Risk Factors and Outcomes of Maternal Obesity and Excessive Weight Gain during Pregnancy. So there it is. This is the exact same thing. We're looking for those women who gain like a lot, a lot of pounds to see what their risk for stillbirth was. Now this was using some data out of Rotterdam, out of their Healthcare foundation, who did this data mining set to give the answer here of does excessive maternal weight gain in pregnancy lead to stillbirth? So very quickly, let's just give you this because again, we've got lots of things to do and then we're going to give you some practical information at the Our study shows that maternal obesity and excessive weight gain during pregnancy are associated with sociodemographic, lifestyle and genetic factors with an increased risk of adverse maternal, fetal and childhood outcomes. End quote. All right, so all of those. I get that that sounds bad and it does. We talked about these adverse issues, including childhood obesity. However, in terms of gestational weight gain by itself, here's what they have to say. Quote, as compared to pre pregnancy, overweight and obesity status, y' all get that? As compared to entering pregnancy, either overweight or obese, excessive gestational weight gain has a limited influence on adverse pregnancy outcome, end quote. So isn't that interesting? So it seems that the biggest risk is what you enter pregnancy with, because that's again, if you're deconditioned when you start the game, outcomes are already going to be hindered, you're already going to be behind the ball. And what you add on to that in terms of gestational weight doesn't seem to be that big of a deal because you already are elevated based on being overweight or obese at pre pregnancy. Y' all get the story we're trying to lay out here? So gestational weight gain, super important just for overall health and ability to drop that weight postpartum. But in terms of stillbirth, doesn't seem to be that big of a deal. But hold on, it's slightly more complicated than that and I'm going to show you that in a minute. So now we go from 2012 to 2013, which is ACOG's weight gain during pregnancy. None of that has changed, guys. That came out in 2013, 10 years later in 2023 and that was still reaffirmed. So the same pregnancy weight gain amount that are recommended based on bmi, which all goes back to the Institute of Medicine, National Academy of Sciences, all of that is the same, Nothing has changed. But I'm just trying to lay out the chronology here. And 2013 is where ACOG released that and reaffirmed that original statement on maternal weight gain in pregnancy. First out in 2013, reaffirmed in 2023. Okay, so we're not going to go into that because everybody gets those recommendations. But that's again just part of our timeline. That takes us to 2017 out of BJOG. Okay, so British Journal of Obstetrics and Gynecology now four years after ACOG's release of weight gain in pregnancy. So this is yet another population based data set. So where do you think this comes from? What did I just say? Danish or Swedish? It's gotta be one of those two, right? Because they've got great databases, even though there's others, there's other countries that you know can do data mining like this on a population scale. But case in point, this comes from the Swedish folks out of their database. Right, so this is scanning an interval from 2008 to 2014. Okay, remember this was 2017 when it was published. So very easy as the objective that we're trying to lay out here, guys, in this episode is, quote, to study the association between total and and early pregnancy, weight gain and risk of stillbirth. End quote. Exactly what we're talking about. That's the title as well, which is Pregnancy Weight Gain by Gestational age and stillbirth. A population based cohort study. So same deal again. I know we're moving quick because I'm trying to rattle less and just get right to where I say rattle. How do you rattle? I mean, what am I trying to say? Mumble? Is that what I'm saying? Mumble, rattle, rattle, whatever. My point is I'm trying to do this quickly, to do this so that it doesn't take two hours of an episode, which we've never done, nor do I plan on doing, but we're trying to do this quickly. So here it is, guys. Does maternal weight gain lead to stillbirth? Well, very quickly, According to this 2017 publication out of Swedish population database, quote, we found no association between total or early pregnancy weight gain and stillbirth across the range of weight gain experienced by most women, end quote. Well, there you go. Oh, look, they even have a tweetable abstract. It's quote, there was no association between maternal weight gain during pregnancy and stillbirth among most women, end quote. All right, so very helpful to know, not that it's a free pass to gain whatever you want to in pregnancy because that's going to come back to haunt you later, but in terms of stillbirth risk, probably not a result, but remember I said it's complicated and we're getting there, guys, because we're going to do another one from 2017 and one from 2019 where, where they say, hey, there is an association between maternal weight and stillbirth, but not with excessive. Here it is, guys, a little sneak peek. Let me just ruin it right now as a clinical pearl, but for those who are underweight and gain less than the recommended, that weight gain, which is not excessive but is still under gestational weight gain, those who are underweight and don't gain the weight that they should, that has a higher risk of stillbirth. Just the opposite of what we're talking about here. All right, the question is regarding excessive gwg, but those who have low GWG and are beginning to be underweight at the start of pregnancy, higher risk, why? Bad placental function, probably not enough micronutrients to have healthy development. You all get this. So yes, it is crucial to follow some kind of guideline and healthy eating during pregnancy, because not gaining the desired amount of weight is not good either. Okay. Especially if you are underweight. We'll get to that in just a minute. But still sticking around in 2017. And then we'll take a little quick break here, guys. But in 2017, out of the annals of Epidemiology, here it is. The title is the association between Gestational Weight Gain and Risk of Stillbirth. Yet another population based cohort study. Now, oddly enough, not from Sweden and not from the Danes, this is actually out of the US So this was actually out of University of Maryland in Baltimore, along with people out of Philly, out of Drexel. There is also an author listed from Oregon Health and Science University. All right, so this is us. The association between Gestational Weight Gain and the Risk of stillbirth, a population based cohort study. Now we're going to get into this very quickly. Actually, why don't we take a quick little break. I'm going to give you this results from this US cohort, tell you 2019 or do some practical information regarding this and then we'll wrap it up. So take a quick break. We'll be right back. Hey, we're glad you're part of our podcast community. You're listening to Clinical Pearls.
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Dr. Sam (Host of Clinical Pearls Podcast)
All right everyone, we are back. And this results the results from 2017 out of the US out of annals of Epidemiology. Little complicated, but it makes a lot of sense when you just process it, let it sit in and then digest it and go, oh yeah, okay, I get that, but let me just read it first. Because if I just read it and just don't explain it. It's gonna be a little confusing. Remember, so far we're saying gestational weight gain. Excessive gestational weight gain doesn't seem to be related overall with a stillbirth risk by itself. Now if there's other things going on, that's something different. Right? But in general, gestational weight gain doesn't add much to risk outside of what the BMI was when they entered pregnancy. Okay, that's, that's our working hypothesis here. We're going to do this one from 2019 and then wrap it up with 2019 and then practical advice and then we'll call it a day. So here it is. Quote, stillbirth risk increased with inadequate weight gain and weight loss in all BMI classes except the morbidly obese group, where weight demonstrated a protective effect. End quote. Let's stop there for a minute because there's a lot there. So stillbirth risk increased with inadequate weight or weight loss across all BMI categories. So not a time to be on a diet. All right, so we get that. That makes sense. Now, whether that was deliberate or nutritional or socio. Demographic, whatever, we don't know. But inadequate weight gain or weight loss, not good regardless of BMI. Except, except in those who were Class 3 obese, where nothing really seemed to happen. Because like, hey, there's probably maybe a little benefit there, a little protective effect. If you went from class three, maybe to class two, does that make sense? But again, very niche, very small population. So there just the opposite was found. Inadequate weight gain seemed to be worse for stillbirth risk. Now hold on, there's one more little caveat here. Quote, Conversely, excessive weight gain was associated with higher risk of stillbirth among the obese and the morbidly obese women. But again, excessive weight gain was protective against stillbirth in those with lower weight at initiation. End quote. What so confusing, right? So short of it, is excessive weight in those who are already morbidly obese. Yes, that was not good for stillbirth risk. But it's hard to separate and tease that out among those who had morbid obesity just entering pregnancy who are already at increased risk. Does that make sense? So that's a very difficult confounder there, but interesting. What they found is that in those who were underweight at start and then had excessive weight gain actually was protective against stillbirth in those lower weight women. How about that? So did I tell you it's complicated or what? So the short answer is, does excessive weight gain affect stillbirth Risk. The next question should be, well, wait a minute, can you please break that down? What kind of BMI category are we talking about? Because excessive maternal weight gain in those who are very, very underweight, like a subnormal BMI when they start, that actually may be protective against stillbirth. But it doesn't really seem that gaining too much weight is a risk factor for stillbirth, unless you are already morbidly obese, where nothing additional is going to be helpful, including stillbirth risk. Did I try to make that simple or what? All right, so you get that. So excessive weight is. Is somewhat dependent on where the woman started in her BMI class. Underweight could actually be helpful as a protective effect against ill birth. Although again, gaining too much weight is not good for a patient overall because of the metabolic consequences. Y', all, we're almost done here. We're coming to 2019 with BMC pregnancy and childbirth, and we're going to call it a wrap and give some practical implications here. But going back to our podcast, family member's question is excessive gestational weight gain. Okay, so GWG gestational weight gain, is that linked to stillbirth? No, it doesn't seem to be. Unless they are super obese, which already comes with its own set of problems, which probably is not the additional weight gain. It's just how they started off, which they get behind the ball. Okay, and actually, excessive weight gain in those who are underweight may be protective. So that brings us now to BMC Pregnancy and Childbirth. And the title of this 2019 publication is the association between Gestational Weight and Z Score and Stillbirth. This was a case control study. Now, I very similar to like BMDs and Z scores in terms of standard deviations, rather than doing direct BMI weight gains or in terms of actual weight like pounds or kilos, they did this in the category of a Z score. Still go with it, guys. It's very easy. I'm not going to explain it, but because the. The results are very clear in and of themselves. Okay. But it is interesting that they use this issue of a Z score to kind of normalize trends based on weight classes in a population. So I do like it. So let me make this very easy because this can very, very easily, without a lot of effort. Get go left. So let me just read this very quickly and then we're going to be done, quote, in adjusted analyses, which is what you want to do. You want to control for things. The odds of stillbirth were elevated for women with Very low gwg, very low gestational weight gain based on those Z scores. Right. So based on. Basically on buckets. All right. Or brackets. Did you all get that? The odds of stillbirth were elevated for women with low gestational weight gain. So here it is. Let's keep going. In addition, although excess gestational weight gain has been linked to many adverse maternal outcomes, we've already said that we get that gestational diabetes, large for gestational age, hypertensive disorders of pregnancy, yada yada. Hold on, here it is. Quote, a gestational weight gain level that is harmful for the mother may not always be harmful for the fetus. End quote. What? So, yes, mom, you get gestational diabetes. Yes, mom, you eat a lot. Like eating cupcakes from the trash, you get hypertensive disorders in pregnancy. Yes, it's gonna be hard for you to drop that weight. But outside of shoulder dystocia, which really does suck for the kid, but in terms of stillbirth risk. Quote, it may not always be harmful for the fetus. End quote. Wow. I mean, come on, y'. All this pretty fascinating. Let me just wrap this up, let me give you the last part of the conclusion, and then we'll do some practical stuff, then we'll be done. Quote, in stratified analysis, our findings differed slightly by pre pregnancy bmi. Our sensitivity analysis also suggested that the association between high gestational weight gain Z scores and stillbirth may differ between women with class one obesity versus class two to three obesity, end quote. In other words, just as we already stated, you see all the data pretty much saying the same thing, that even though really there doesn't seem to be affected with gestational weight gain and stillbirth for the child, maybe that's a little bit different if you are class one obese versus class two to three obese. Is this fascinating or what? But in general, does excessive gestational weight gain gwg, is that linked to stillbirth? No, it's linked to other bad things, but not necessarily stillbirth. Fascinating. So all of this came out because we had a recent question again from our podcast, family Member. Should we be doing surveillance if patients gained a bunch of weight during pregnancy? Well, no, probably not. Surveillance, probably it's a good idea to get rid of growth ultrasounds so that if you find that your kid is like 6 kilos, you probably need a C section. Sarcasm thrown in there. But in general, it does not need antepartum fetal surveillance, y'. All. We have covered, including the ACOG practice guidance from 2013 that was reaffirmed in 2023. Six big pieces of data. Now, I know there's others, trust me, because we looked at all of them that are small little case cohorts, but these are the ones that I chose that are population based across 18 years. Guys thinks about 18 years all pretty much saying the same thing, that unless you're underweight and have poor weight gain, that where the risk of stillbirth is higher. Gaining a lot of weight doesn't seem to be linked to stillbirth risk, though. It's linked to other maternal metabolic derailments and derangements. All right, does that make sense? So, podcast family, we have answered the question, does excessive maternal weight gain or GWG increase stillbirth? The answer is likely no. That's why we don't do antepartum fetal surveillance. In that case. All right, podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've said all that, let's get ready to take it home and we'll see you on another episode of Clinical Pearls. Podcast family, we really are thankful for you. We hope you enjoyed this episode. We'll see you next time on Clinical Pearls Jam.