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The Journal of Maternal-Fetal and Neonatal Medicine, May 2011; 24(5): 723727

The effect of maternal obesity on pregnancy outcomes in women


with gestational diabetes
ASHLEY S. ROMAN1, ANDREI REBARBER1, NATHAN S. FOX1, CHAD K. KLAUSER1, NIKI ISTWAN2,
DEBBIE RHEA2, & DANIEL SALTZMAN1
Maternal Fetal Medicine Associates, PLLC, New York, NY, USA, and 2Alere Womens and Childrens Health,
Clinical Research, Atlanta, GA, USA
1

(Received 29 June 2010; revised 1 September 2010; accepted 3 September 2010)


Objective. To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with
gestational diabetes mellitus (GDM).
Methods. Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and
management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy
BMI  30 kg/m2) and non-obese (pre-pregnancy BMI 5 30 kg/m2) women and for women across five increasing prepregnancy BMI categories.
Results. A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral
hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean
delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia,
need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing
BMI was significantly associated with the same adverse maternal and neonatal outcomes.
Conclusion. In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal
outcomes.
Keywords: Gestational diabetes, obesity, body mass index, adverse outcomes

Introduction
The prevalence of obesity among women of reproductive
age has increased dramatically over recent years. In 2007
2008, 68% of United States adults and 59.5% of women of
reproductive age met criteria for being categorized as
overweight or obese [1]. With the rising prevalence of
obesity, recent studies have highlighted the increased risks
associated with obesity in pregnancy, including increased
risks of cesarean delivery, stillbirth, hypertensive disorders
of pregnancy, fetal structural malformations, and gestational diabetes; however, controversy remains over optimal
management of the pre-gravid obese women during
pregnancy, including recommendations for weight gain
during pregnancy [2].
Gestational diabetes mellitus (GDM) which is defined as
glucose intolerance during pregnancy affects approximately 135,000 women or 4% of all pregnancies per year
in the United States [3]. Pregnancies complicated with
GDM are also at increased risk for many maternal and fetal
complications, including cesarean delivery, macrosomia,
neonatal hypoglycemia, stillbirth, and neonatal intensive
care unit (NICU) admission [4]. The combination of pregravid obesity and GDM has been shown to be associated
with an increased risk of adverse pregnancy outcomes over
either disorder alone [5,6].

The objective of this study was to examine the impact


of increased maternal pre-pregnancy body mass index
(BMI), including overweight, obese, and morbidly
obese categories, on maternal and neonatal outcomes
in pregnancies complicated with GDM, enrolled in
an outpatient GDM education and management
program.

Methods
The study population was identified retrospectively from a
large centralized perinatal database containing de-identified clinical information collected between July 2000 and
July 2009 from pregnant women diagnosed with GDM and
enrolled in an outpatient GDM education, surveillance,
and management program provided by Alere (formerly
Matria Healthcare). All women provided written consent
for outpatient services and for the later use of their deidentified personal health information for research and
reporting purposes. Each patients healthcare provider
made the diagnosis of GDM, and outpatient services were
prescribed as an adjunct to routine prenatal care. Maternal
characteristics (including pre-pregnancy height and
weight), and medical/obstetric history were collected
during the initial referral process. A perinatal nurse

Correspondence: Ashley Roman, MD, MPH, 1245 Madison Avenue, New York, NY 10128, USA. Tel: 1-212-722-7426. Fax: 1-212-722-7185.
E-mail: aroman@mfmnyc.com
Presented at the 30th Annual Meeting of the Society for MaternalFetal Medicine. Chicago, IL, 16, February 2010. Poster # 0242.
ISSN 1476-7058 print/ISSN 1476-4954 online 2011 Informa UK, Ltd.
DOI: 10.3109/14767058.2010.521871

724

A. S. Roman et al.

collected pregnancy outcomes from each patient approximately 26 weeks after delivery.
Women carrying singleton gestations diagnosed with
GDM by their healthcare provider who were enrolled in
an outpatient GDM education, surveillance, and management program and had documented pre-pregnancy
BMI and delivery information were included in analysis.
The GDM education, surveillance, and management
program consisted of one-on-one GDM education and
counseling with individualized plan of care regarding
diet, exercise, self-care, and blood glucose testing.
Women were instructed on daily testing of blood glucose
levels with fasting and 1- or 2-h postprandial blood
glucose testing. Daily evaluation of blood glucose and
ketone values by a certified diabetes educator was
performed. Reports were administered to the patients
healthcare provider on a weekly basis or more frequently
as needed.
Maternal pre-pregnancy BMI was calculated as weight
in kilograms divided by height in meters squared.
Maternal and neonatal pregnancy outcomes were compared for obese (BMI  30 kg/m2) and non-obese
(BMI 5 30 kg/m2) women and for women across five
increasing pre-pregnancy BMI categories: underweight
(518.5 kg/m2), normal weight (18.524.9 kg/m2), overweight (2529.9 kg/m2), obese (3039.9 kg/m2), and
morbidly obese ( 40 kg/m2). Maternal outcomes evaluated were need for pharmacologic treatment of GDM,
cesarean delivery, and pregnancy-related hypertension
(defined as gestational hypertension or preeclampsia).
Neonatal outcomes evaluated included gestational age at
delivery, preterm birth, birth weight, stillbirth, number of
days in the nursery, NICU admission, birth trauma
(injury identified in the neonate attributed to mechanical
forces of birth, e.g. bruises, lacerations, hematomas,
fractures), shoulder dystocia, hypoglycemia, and
jaundice.
The primary outcome was composite neonatal morbidity
defined as the presence of one or more of the following:
birth weight greater than 4000 g, birth trauma, shoulder
dystocia, hypoglycemia, and jaundice.
Data were compared using Pearsons chi-square, Mann
Whitney U test and KruskalWallis H test statistics as
indicated with two-sided p-values of 50.05 considered

statistically significant. A logistic regression model was


used to control for the independent effects of factors that
were significant after univariate analyses.

Results
Three thousand seven hundred ninety-eight patients with
GDM met criteria for inclusion in this analysis. All
patients had health insurance (private or Medicaid
coverage) and were receiving prenatal care at enrollment.
Of these patients, 2028 non-obese and 1770 obese were
identified. Maternal obesity was significantly associated
with higher blood glucose levels and need for increased
interventions (Table I). Adverse maternal and neonatal
outcomes were significantly increased in obese women
when compared with women of normal weight or
underweight (Table II). The mean gestational age at
delivery for stillborn infants was 35.9 + 5.0 weeks. A
significant linear trend with increasing BMI was observed
in rates of adverse maternal and neonatal outcomes
(Table III).
The risk of composite neonatal morbidity was significantly increased with increasing BMI (Figure 1).
Logistic regression analysis was used to assess the
impact of the individual variables on composite neonatal
morbidity (Table IV). Among the variables examined in
this study, it appears that four were independently and
significantly associated with developing at least one of the
composite neonatal outcomes: delivery prior to 37 weeks,
obesity, an FBG 4109, and exposure to oral glycemic
agents. Of these four, delivery prior to 37 weeks and
fasting blood glucose greater than 109 had the strongest
association with the composite outcome with an odds
ratio of 1.7. Furthermore, the independent impact of
increasing pre-pregnancy BMI was above and beyond the
harmful effects of having a fasting blood glucose of 109,
an indicator of glycemic control. However, the R2 value of
0.046 indicates that 95% of the variation in the dependent
variable of composite neonatal outcome was not explained by the variables examined in this studys data.
Therefore, there may be additional factors that have an
impact on neonatal morbidity that are not accounted for
in this study.

Table I. Maternal characteristics and GDM treatments.

Pre-pregnancy BMI (kg/m2)


Married
Maternal age (years)
Age  35 years
Nulliparous
Mean fasting BG
499
4109
GA at enrollment (weeks)
GA at discharge (weeks)
Days in program
GDM diet only
Medications for BG control
(insulin and/or orals)
Insulin
Oral agents

BMI 5 30 (n 2028)

Obese BMI  30 (n 1770)

p-value

OR (95% CI)

24.6 + 3.3, 24.9 (11.5, 29.9)


57.4%
30.9 + 5.8, 31 (16, 51)
27.0%
36.5%
85.3 + 11.9, 84.3 (50.8, 176.2)
9.3%
3.1%
30.3 + 4.5, 30.6 (6.6, 39.1)
33.4 + 4.1, 33.6 (11.0, 41.7)
21.8 + 17.4, 19 (1, 210)
87.7%
12.3%

37.3 + 6.2, 35.6 (30.0, 68.8)


52.4%
31.0 + 5.5, 31 (16, 46)
27.6%
29.2%
92.1 + 13.9, 91.0 (59.2, 229.0)
21.6%
7.6%
29.0 + 5.9, 30.3 (6.7, 38.7)
32.4 + 5.5, 33.6 (8.7, 41.4)
23.6 + 20.9, 19 (1, 182)
75.2%
24.8%

50.001
0.002
0.749
0.651
50.001
50.001
50.001
50.001
50.001
50.001
0.004
50.001
50.001

0.82 (0.72, 0.93)

7.9%
5.2%

14.9%
11.8%

50.001
50.001

2.0 (1.7, 2.5)


2.4 (1.9, 3.1)

0.72 (0.62, 0.82)

2.7 (2.2, 3.3)


2.6 (1.9, 3.7)

0.43 (0.36, 0.51)


2.4 (2.0, 2.8)

Data presented as mean + SD, median (min, max) or percentage as indicated. BMI, body mass index; BG, blood glucose.

725

Effect of maternal obesity on pregnancy outcomes


Table II. Neonatal outcomes of women diagnosed with GDM.

GA at delivery (weeks)
Delivery 537 weeks
Late PTB (3436 weeks)
Pregnancy-related HTN
Cesarean delivery
Birth weight (g)
Birth weight 44000 g
Stillbirth
Nursery days
NICU admission
Birth trauma
Shoulder dystocia
Hypoglycemia
Jaundice

BMI 5 30 (n 2028)

Obese BMI  30 (n 1770)

p-value

38.3 + 1.7, 38.7 (25.9, 43.3)


14.6%
12.5%
9.6%
39.3%
3214 + 525, 3232 (964, 5091)
5.7%
2 (0.1%)
3.3 + 4.1, 2 (1, 58)
11.0%
0.2%
1 (0.0%)
4.1%
13.6%

38.1 + 1.9, 38.4 (21.1, 44.9)


18.3%
15.3%
24.4%
52.9%
3360 + 623, 3374 (514, 5642)
12.8%
9 (0.5%)
4.0 + 7.1, 3 (1, 160)
14.2%
0.2%
6 (0.3%)
5.9%
17.1%

50.001
0.002
0.013
50.001
50.001
50.001
50.001
0.019
50.001
0.003
0.847
0.038
0.009
0.002

OR (95% CI)

1.3
1.3
3.0
1.7
2.4
5.2
1.3
1.1
6.9
1.5
1.3

(1.1,
(1.0,
(2.5,
(1.5,

(1.9,
(1.1,

(1.1,
(0.3,
(0.8,
(1.1,
(1.1,

1.6)
1.5)
3.7)
2.0)
3.0)
24.0)
1.6)
4.6)
57.3)
2.0)
1.6)

Data presented as mean + SD, median (min, max) or percentage as indicated. GA, gestational age; PTB, preterm birth; HTN,
hypertension.

Table III. Maternal and neonatal outcomes by advancing pre-pregnancy BMI.

Developed pregnancyrelated HTN


Cesarean delivery
Birth weight (g)

Birth weight 44000gms


Stillbirth
Nursery days
NICU admission
Birth trauma
Shoulder dystocia
Hypoglycemia
Jaundice

Underweight,
518.5 (n 66)

Normal,
18.524.9
(n 958)

Overweight,
2529.9
(n 1004)

Obese, 3040
(n 1294)

Morbidly
obese, 440
(n 476)

p-value

4.5%

7.4%

12.0%*

21.7%*

31.5%*

50.001{{

33.3%
2984 + 548,
2948
(1616, 4000)
0
0
3.6 + 3.5, 2
(1, 19)
12.1%
0
0
0
13.6%

36.3%
3163 + 515,
3175
(964, 5091)
4.6%
0.1%
3.2 + 3.5, 2
(1, 45)
9.8%
0.2%
0.1%
4.3%
13.3%

42.6%*
3279 + 525,
3260
(992, 4819)*
7.2%
0.1%
3.5 + 4.7, 2
(1, 58)
12.1%
0.2%
0
4.2%
13.8%

50.0%*
3343 + 615,
3364
(624, 5318)*
12.4%*
0.6%
3.9 + 6.3, 3
(1, 135)*
13.9%
0.2%
0.2%
5.2%
15.8%

60.9%*
3406 + 645,
3455
(514, 5641)
13.7%
0.2%
4.1 + 8.9, 3
(1, 160)
14.9%
0.4%
0.8%
8.0%
20.8%

50.001{{
50.001

50.001{{
0.110{, 0.099{
50.001
0.022{, 0.001{
0.856{, 0.593{
0.009{, 0.012{
0.005{, 0.001{
0.003{, 50.001{

Data presented as mean + SD, median (min, max) or percentage as indicated.


*p-value 50.0125 vs. previous BMI group (adjusted for multiple comparisons).
{Pearsons chi-square.
{Chi-square for linear trend.

Discussion
As the obesity epidemic in the United States continues
unchecked, maternal obesity is increasingly recognized as
an independent risk factor for adverse maternal and fetal
outcomes. The prevalence of GDM has been shown to
increase with increasing pre-pregnancy BMI, with a 46%
prevalence for women with a BMI of 3034.9, 68%
prevalence with BMI of 3539.9, and 1012% prevalence
with BMI greater than 40 [7]. Few studies, however, have
evaluated the risks of adverse pregnancy outcomes in the
setting of both obesity and GDM.
In this study, we found that maternal obesity is
significantly associated with worse maternal and neonatal
outcomes. Obese women were also more likely to require
medication for optimal blood sugar control than women

Figure 1. Composite neonatal morbidity. Presence of one or more


of the following: birth weight 44000 g, birth trauma, shoulder
dystocia, hypoglycemia, or jaundice (p 5 0.001).

726

A. S. Roman et al.

Table IV. Logistic regression model results assessing composite


neonatal morbidity as the dependent variable (estimated model
R2 0.046).
Parameter

p-value

OR (95% CI)

Delivery 537 weeks


Pre-pregnancy BMI
FBG 4109
Oral glycemic agent
Cesarean delivery
Insulin
Pregnancy-related HTN
FBG 499

50.001
50.001
0.005
0.024
0.117
0.198
0.403
0.777

1.7
1.2
1.7
1.3
1.1
1.2
1.1
1.0

(1.4,
(1.1,
(1.2,
(1.0,
(1.0,
(0.9,
(0.9,
(0.8,

2.1)
1.3)
2.4)
1.7)
1.3)
1.5)
1.3)
1.3)

BMI, body mass index; FBG, fasting blood glucose; HTN,


hypertension. The pre-pregnancy BMI parameter compares the
following groups: underweight (518.5); normal (18.524.9),
overweight (2529.9), obese (3040), morbidly obese (440).

with a BMI less than 30. Furthermore, the risks of both


maternal and neonatal morbidity increase significantly with
increasing pre-pregnancy BMI, particularly the risks of
pregnancy-related hypertension, cesarean delivery, and
composite neonatal morbidity. The highest risks of these
outcomes were seen in women with morbid obesity
(BMI 440), but even women with a BMI in the overweight
range (BMI 2529.9) had higher risks of cesarean delivery
and pregnancy-related hypertension than women with a
normal BMI.
These findings are consistent with prior studies [5,6]
that found the combination of obesity and GDM is
associated with an increased risk of adverse pregnancy
outcomes and pregnancy-related hypertension. Unlike
previous studies, however, we found that obese women
had significantly higher fasting blood sugar results, were
more likely to require medication for blood sugar management, and were more likely to require cesarean delivery. In
our study, this increased risk of cesarean delivery was not
only just seen in obese women but also in women in the
overweight category. These findings are consistent with
prior studies on the impact of obesity on pregnancy [8].
Additionally, they are medically plausible as higher insulin
resistance as seen in the setting of obesity has been shown
to be related to hypertensive disorders.
Our study is unique in that it is the first study of women
with GDM that stratifies outcomes not just by the presence
or absence of obesity, but by degree of obesity as defined by
BMI and is the first to examine the effect of morbid obesity
on pregnancy outcomes. The advantage to this approach is
that our findings allow for more targeted patient counseling. The other strengths of our study include the large
sample size, the detailed short-term neonatal outcomes,
and the inclusion of underweight women as a comparison
group. Aside from its retrospective design, the primary
weakness of this study is that data were obtained from
patient report over the phone and were not verified by
reviewing each individual patients medical record. Additionally, this study evaluated short-term neonatal outcomes only. Some data indicate that fetal exposure to
maternal obesity and diabetes do not have only short term
effects on offspring but also have life-long consequences,
including an increased risk of obesity and type 2 diabetes in
childhood and adolescence [9]. Both human and animal
data suggest that the risk of childhood diabetes in these
offspring cannot be explained by the childs obesity alone
and may also be mediated via beta-cell dysfunction

[1012]. However, within the confines of this study, we


were unable to assess long-term effects of obesity
and GDM.
Finally, it should be noted that, while the logistic
regression model used in this study is a good fit for the
study data (goodness-of-fit test p 0.307), 95% of the
variation in the dependent variable of composite neonatal
outcome is not explained by the variables examined in this
studys data. Therefore, more studies are needed to assess
other variables not collected in this study that may have
additional impact on neonatal outcome.
In conclusion, our study indicates that women with GDM
who have a pre-pregnancy BMI of 30 are at increased risk
of a number of adverse maternal and neonatal outcomes.
Moreover, even women in the overweight category (BMI 25
29.9) who are diagnosed with GDM are at increased risk for
maternal complications such as cesarean delivery and
pregnancy-related hypertension. Among women who are
obese, the risk of adverse outcomes increases with increasing
BMI, with women who are classified as morbidly obese
(BMI  40) at the highest risk of maternal and neonatal
morbidities. This information is particularly useful in counseling obese women regarding the cumulative risks associated with both pre-pregnancy obesity and gestational
diabetes. It also supports the goal of normalizing or even
simply reducing BMI within the obese range prior to
conceiving to reduce the risk of adverse pregnancy outcomes.

Acknowledgments
Niki Istwan and Debbie Rhea are employees of Alere, the
company that provided the diabetic services described in
the manuscript and compiled the database used for analysis
in the manuscript. Daniel Saltzman and Andrei Rebarber
are members of the Alere speakers bureau and have served
as consultants for Alere. Chad Klauser has been a member
of Aleres speakers bureau in the past but is not currently a
member. Nathan Fox and Ashley Roman report no
declarations of interest.

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