IOM Issues New Recommendations for Weight Gain During Pregnancy

May 28, 2009 — The Institute of Medicine and the National Research Council today released a report recommending new guidelines for weight gain during pregnancy. The report updates guidelines that were last set in 1990 and takes into account changing US demographics, particularly the increase in the numbers of women of childbearing age who are overweight and obese.

The new guidelines are available on the Institute of Medicine's Web site.

"The earlier guidelines recommended weight gain that would be optimal for the baby. These new guidelines take into account the well-being of the mother as well. This is a fundamental and important change," Kathleen M. Rasmussen, ScD, professor of nutrition at Cornell University and chair of the guidelines committee, said at a press briefing where the new recommendations were announced.

The 2009 guidelines also differ from those issued 2 decades ago in 2 other ways. They are based on World Health Organization cutoff points for body mass index (BMI) categories, unlike the earlier guidelines, which were based on weight categories taken from the Metropolitan Life Insurance tables. They also recommend a more narrow range of weight gain for obese women.

The recommended weight gain for each category of prepregnancy BMI is as follows:

• Underweight (<>2); total weight gain range: 28 to 40 pounds
• Normal weight (18.5 - 24.9 kg/m²); total weight gain range: 25 to 35 pounds
• Overweight (25.0 - 29.9 kg/m²); total weight gain range: 15 to 25 pounds
• Obese (≥ 30.0 kg/m²); total weight gain range: 11 to 20 pounds

"Women who gain within these guidelines will do better than if they gain outside of them. We have good evidence for this," said Dr. Rasmussen.

Read IOM press release

Calculate your Body Mass Index (BMI)

Early Predictors of Successful Pregnancy

May, 2009

Successful pregnancy can be predicted with up to 94% accuracy between days 33 and 36 using transvaginal ultrasound to detect 3 markers, according to new findings presented by Dr. Soyoung Bae at the American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting in Chicago, Illinois.

The predictors include ultrasound findings between 33 and 36 days after conception in otherwise healthy women:

• gestational sac at least 12 mm in diameter
• yolk sac with a diameter of 2 to 6 mm
• presence of fetal cardiac activity

Dr. Bae said. "These markers were associated with favorable pregnancy outcome even in the poor prognostic subgroups of women of advanced maternal age and those with recurrent pregnancy loss."

Read entire article

Diabetes May Double Risk of Perinatal Depression

Pregnant women and new mothers that have diabetes, whether the diabetes was discovered during pregnancy or before, are twice as likely to experience depression than women who do not have diabetes (Kozhimannil, 2009).

The authors reviewed the medical records of 11,024 low-income women who delivered in New Jersey between 2004-2006. 657 women had diabetes. 15% of those with diabetes had or developed depression, whereas only 8% of women without diabetes had or developed depression.

Perinatal depression (i.e. depression "around" the time of giving birth) is under-diagnosed and, therefore, inadequately treated. Clinicians, family members and expecting and new mothers should be aware of this risk and pay particular attention to evolving mental health issues - especially in women with diabetes.

Read article abstract HERE.

Reference:
Kozhimannil KB, Pereira MA, Harlow BL. Association between diabetes and perinatal depression. JAMA 2009 Feb 25;301(8):842-7

USPSTF Recommends Folic Acid Supplements for Women of Child-Bearing Age

By Laurie Barclay, MD

May 12, 2009 — New observational evidence supports previous evidence from a randomized controlled trial that folic acid–containing supplements lower the risk for pregnancies affected by neural tube defects, according to a US Preventive Services Task Force (USPSTF) statement and review of evidence reported in the May 5 issue of the Annals of Internal Medicine. The review suggests that the previously noted association of folic acid use with twin gestation may be confounded by fertility interventions.

Based on the evidence, the USPSTF has issued a grade A recommendation that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 - 800 µg) of folic acid.

Regarding benefits of this preventive measure, the USPSTF found convincing evidence that taking supplements containing 0.4 to 0.8 mg (400 - 800 µg) of folic acid during the periconceptional period lowers the risk for neural tube defects....

Read complete article.

Effect of Food Intake During Labor

There is an ongoing international debate about food consumption during labor. The current rationale for women fasting during labor is to protect them from pulmonary aspiration should general anesthesia be needed for an emergency cesarean delivery. Other concerns include increased cesarean rate (Scheeper, 2002) or prolongation of labor (Tranmer, 2005) should women be allowed to eat while laboring.

On March 24, 2009 the British Medical Journal published a well-done randomized controlled trial (O'Sullivan, 2009) of over 2000 women suggests we should revisit current practices of not allowing women to eat while in labor.

Historical perpective:
1946: CL Mendelson published a paper in The American Journal of Obstetrics and Gynecology (1946) entitled: The aspiration of stomach contents into the lungs during obstetric anesthesia. Mendelson described acid pulmonary aspiration and an increase in maternal death due to choking if women consumed solid food while in labor and needed a cesarean delivery.

2007: The American Society of Anesthesiologists published obstetric guidelines stating that "the oral intake of solids during labor increases maternal complications....solid foods should be avoided in laboring patients and that the oral intake of modest amounts of clear liquids (e.g. water, clear tea, black coffee and sports drinks) may be allowed for uncomplicated laboring patients."

Recent advances in intrapartum care (e.g. increased use of epidural anesthesia, antacids and better training of obstetric anesthetists) have caused a dramatic decline in pulmonary aspiration.

Some countries now challenge the practice of mandatory fasting for all laboring women - more so in Europe than in the United States.


O'Sullivan study:

• This study was performed in a London hospital between June 2001 and April 2006.
• 2426 women were randomized to eating vs. water-only group.
• All women were experiencing their first delivery.
• Primary outcome was the rate of spontaneous vaginal delivery.
• Secondary maternal outcomes included the duration of labor, use of IV oxytocin, use of inhaled or epidural analgesia.
• Secondary neonatal outcomes included fetal weight, Apgar scores and admission the the neonatal intensive care unit.
• Women in the eating group were advised to consume a low fat, low residue diet at will during labor. Suggested foods included fruits and vegetables, breads, soup, low fat yogurt, fruit juices and sports drinks.

Results:

• No difference in vaginal delivery vs. cesarean delivery rate between the two groups (30% cesarean delivery rate in both groups).
• No difference in length of labor.
• No difference in Apgar scores or admission to the neonatal ICU.
• No cases of aspiration pneumonia (However, because aspiration is so rare, a much larger study would have been needed to see one case.)
• One maternal death occurred in the water-only group due to a brain hemorrhage.

Interpretation:

• Feeding in labor does not increase or decrease risk of cesarean delivery.
• Feeding in labor does not shorten or lengthen labor.
• Obstetrical and neonatal outcomes are not altered based upon whether women are allowed to eat during labor.
• Some clinicians may decide, in low risk laboring women, that the consumption of a light diet could be left to the woman's discretion.

Side note:
The UK Confidential Enquiries into Maternal and Child Health reviewed 2,113, 831 deliveries between 2003-2005. Six anesthesia-related deaths occurred, none of which was associated with pulmonary aspiration. Similar findings were reported by the Australian Anesthesia Incident Monitoring Study. This supports the statement that aspiration pneumonia is exceedingly rare.

References:

1. O'Sullivan G, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ 2009;338:b784

2. American Society of Anesthesiologist’s Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia. Anesthesiology 2007;106:843-63.

3. Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.

4. Scheepers HCJ, Thans MCJ, de Jong PA, Essed GG, Le Cessie S, Kanhai HH. A double-blinded randomised, placebo controlled study on the influence of carbohydrate solution intake during labor. Br J Obstet Gynecol 2002;109:178-81.

5. Tranmer JE, Hodnett ED, Hannah ME, Stevens BJ. The effect of unrestricted oral carbohydrate intake on labor progress. J Obstet Gynecol Neonatal Nurs 2005;34:319-28.

6. Lewis G, ed. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003-2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH, 2007.

Fibroids and Infertility

Q: Do fibroids cause infertility?

Fibroids are common benign tumors of the uterus. They occur predominantly in premenopausal women, and their growth appears to be hormone (estradiol, progesterone) dependent. They may grow towards the uterine cavity (submucosal) or towards the abdominal cavity (subserosal), or they may be located within the uterine wall (intramural). Fibroids may be asymptomatic or could be associated with a variety of complaints. Symptoms, such as irregular bleeding, pelvic pressure, urinary frequency, constipation, and pain, are associated with size, number, and location of the fibroids.

It has long been suspected that fibroids that distort the uterine cavity (submucosal or intramural) are associated with infertility and miscarriages. The association between fibroids and reproductive failure (infertility, pregnancy loss) has been studied by several groups. However, the majority of these studies have been too small to yield meaningful results. In addition, few studies have addressed the benefits of treatment in a well-designed manner. To further complicate the issue, several treatment options -- medical, surgical, radiologic -- are available, but their effects would need to be assessed separately.

New Research: A Meta-Analysis

This combined analysis is based on the results of 23 studiesthat evaluated fibroids and their effect on reproductive success. The results suggest that fibroids, in general, regardless of location, were associated with a 15% reduction in pregnancy rates, a 30% reduction in live birth rates, and a 67% increase in miscarriage rates when compared with controls without fibroids. The effect was especially pronounced when submucous fibroids were analyzed (64% reduction in pregnancy rates, 69% reduction in live birth rates, and 67% increase in miscarriage rate). The effect of intramural fibroids was significant but less pronounced (22% decrease in live birth rates, 89% increase in miscarriage rates). Subserosal fibroids did not affect pregnancy rates or pregnancy outcome. The analysis did not demonstrate a consistent effect on pregnancy rates and outcomes.

Myomectomy (surgical removal of fibroids) was associated with improved pregnancy outcome when submucosal myomas were evaluated. The pregnancy rate was significantly higher after myomectomy when compared with women with fibroids left in place. On the basis of a small number of cases, the removal of intramural fibroids was not associated with improved pregnancy outcome. More studies of better quality are needed to assess the benefits of removing intramural and subserosal fibroids.

Pritts EA, Parker WH, Olive DL. Fertil Steril 2009;91:1215-1223.
Epub 2008 Mar 12.