medicina 53 (2017) 109–113

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Original Research Article

Maternal obesity and obstetric outcomes in a tertiary

referral center

Gitana Ramonienė a, Laima Maleckienė a,*, Rūta Jolanta Nadišauskienė a,

Eglė Bartusevičienė a, Dalia Regina Railaitė a, Regina Mačiulevičienė a,
Almantas Maleckas b,c
a
Department of Obstetrics and Gynecology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
b
Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
c
Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Sahlgrenska Academy,
University of Gothenburg, Gothenburg, Sweden

article info abstract

Article history: Background and aim: Obese women are at an increased risk of various adverse pregnancy
Received 4 April 2016 outcomes. The aim of our study was to evaluate the impact of obesity on maternal and
Received in revised form neonatal outcomes in a tertiary referral center and to compare obstetric outcomes by the
28 March 2017 level of maternal obesity.
Accepted 30 March 2017 Materials and methods: A cohort study included 3247 women with singleton gestations who
Available online 19 April 2017 gave birth at the Department of Obstetrics and Gynecology, Lithuanian University of Health
Sciences, in 2010. Pregnancy complications and neonatal outcomes were identified using the
Keywords: hospital Birth Registry database in normal weight (body mass index [BMI] 18.5–24.9 kg/m2,
Obesity n = 3107) and prepregnancy obese (BMI ≥30 kg/m2, n = 140) women. Pregnancy outcomes were
Pregnancy compared according to the level of obesity (BMI 30–34.9 kg/m2, n = 94 and BMI ≥35 kg/m2, n = 46).
Large-for-gestational-age newborn Results: Obese women were significantly more likely to have gestational hypertension
Gestational diabetes (OR = 8.59; 95% CI, 5.23–14.14; P < 0.0001), preeclampsia (OR = 2.06; 95% CI, 1.14–3.73;
Cesarean delivery P < 0.0001), gestational diabetes (OR = 5.56; 95% CI, 3.66–8.49; P < 0.0001), dystocia (OR = 2.14;
95% CI, 1.36–3.38; P < 0.0001), induced labor (OR = 2.64; 95% CI, 1.83–3.80; P < 0.0001), failed
induction of labor (OR = 18.06; 95% CI, 8.85–36.84; P < 0.0001), cesarean delivery (OR = 1.76; 95%
CI, 1.25–2.49; P = 0.001), large-for-gestational-age newborns (OR = 3.68; 95% CI, 2.51–5.39;
P < 0.0001). Significantly increased risk of gestational diabetes, preeclampsia, dystocia and
newborns with Apgar score ≤7 after 5 min was only observed in women with BMI ≥35 kg/m2.
Conclusions: Maternal obesity is significantly associated with an increased risk of gestational
hypertension, preeclampsia, gestational diabetes, dystocia, labor induction, failed induction
of labor, large-for-gestational-age newborns and cesarean delivery.
© 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier
Sp. z o.o. This is an open access article under the CC BY-NC-ND license (http://creative-
commons.org/licenses/by-nc-nd/4.0/).

* Corresponding author at: Department of Obstetrics and Gynecology, Medical Academy, Lithuanian University of Health Sciences, Eivenių
2, 50161 Kaunas, Lithuania.
E-mail address: laima_maleckiene@yahoo.com (L. Maleckienė).
http://dx.doi.org/10.1016/j.medici.2017.03.003
1010-660X/© 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
110 medicina 53 (2017) 109–113

Maternal characteristics including age, parity, marital

1. Introduction
status (married vs. unmarried, including single, divorced,
widowed, and separated), educational level, GWG and preg-
The prevalence of obesity in the general population and nancy outcomes were compared between obese and normal
among women of childbearing age has increased dramatically weight women. Furthermore obese women were subcategor-
during past 25 years [1,2]. More than one-third of women of ized into two groups (BMI 30–34.9 kg/m2, n = 94 and BMI ≥35 kg/
reproductive age are overweight or obese in middle or high m2, n = 46) and pregnancy outcomes were compared between
income countries [3–6]. Being overweight or obese increases these and normal weight women. Maternal outcomes of
maternal and neonatal morbidity and obese women have interest included gestational hypertension, preeclampsia,
higher infertility rates and are at increased risk of various gestational diabetes, induction and augmentation of labor,
adverse pregnancy outcomes [1,2,5–8]. Moreover, the perinatal failed induction, dystocia and cesarean section rate. Neonatal
nutritional environment may have a direct impact on outcomes of interest included gestational age at delivery,
development of obesity later in the life [9]. birthweight, preterm delivery, stillbirth and low Apgar score at
Most of the studies that investigated the relation of obesity 5 min.
with adverse perinatal outcomes were done in Western Gestational age at delivery was based on early ultrasound
countries [1–4]. Few data exist about new European Union and recorded day of last menstrual period. Low Apgar score
member states. Obesity is a burden for any healthcare system was defined as a score ≤7 at 5 min after delivery. A stillbirth
that should not be underestimated. When resources are was defined as the death of a fetus at any time of pregnancy
limited it is important to identify risk groups which may and delivery after 22 completed weeks of gestation. Large-for-
benefit most from target interventions. Analysis of adverse gestational-age (LGA) newborn or fetal macrosomia was
pregnancy outcomes in relation to obesity class allows a better defined as birthweight above the 90th percentile adjusted
understanding of the risks and thus interventions can be for newborn gender and gestational age. Small for gestational
concentrated on the population that needs them most. age newborns were defined as those with a weight less than
The objective of our study was to evaluate the impact of the 10th percentile at birth adjusted for newborn gender and
obesity on maternal and neonatal outcomes in the tertiary gestational age. Newborns were weighted immediately upon
referral center and to compare pregnancy outcomes by the delivery in the nursery.
level of maternal obesity. Gestational hypertension was defined as a blood pressure
elevation ≥140 mmHg systolic or ≥90 mmHg diastolic mea-
sured on two occasions 6 h apart in previously normotensive
2. Materials and methods women after ≥20 weeks of gestation. Preeclampsia was
diagnosed when woman developed gestational hypertension
A cohort study was conducted at the Department of Obstetrics and proteinuria ≥300 mg of protein in a 24-h urine specimen. A
and Gynecology of the Lithuanian University of Health fasting glucose screening test was done at initial prenatal visit.
Sciences, in Kaunas, Lithuania. The department is a tertiary An oral glucose tolerance test (OGTT) was done in all
referral center where mainly high-risk pregnant women prepregnancy obese women. OGTT in women with normal
receive perinatal services. Pregnancy was considered as BMI was carried out according to institutional policy if women
high-risk for a variety of maternal and fetal reasons: had the following risk factors: age ≥35 years, familial history of
preexisting maternal medical illness, history of complications diabetes, prior history of gestational diabetes (GDM), glycos-
and poor outcomes during previous pregnancies, various uria, history of unexplained stillbirth, previously delivered
obstetrical complications during current pregnancy, etc. LGA newborn. OGTT was conducted with a loading glucose
Women who delivered singleton newborns at 22–42 weeks dose of 75 g between 24th and 28th weeks of gestation. The
of gestation between January 1 and December 31, 2010, were diagnosis of GDM was made on the basis of a 2-h plasma
retrospectively identified (n = 3371) using the Birth Registry, a glucose level of ≥7.8 mmol per liter. Class A1 GDM was
computerized database in which all deliveries at the depart- diagnosed when dietary modification was sufficient to control
ment have been registered. Data are entered into the registry blood glucose level. Class A2 GDM was diagnosed when
by the trained midwife assisting at the delivery. Maternal additional therapy with insulin was required. Failed induction
demographic characteristics, medical and obstetrical history of labor was diagnosed when physical and pharmacological
and pregnancy outcomes were collected from Birth Registry methods did not generate regular uterine contractions and
database along with manual retrieval from medical charts and lead to vaginal delivery. Dystocia was defined as a failure to
labor records using standardized data collection forms. progress in labor either because of uterine dysfunction, pelvic
Height and prepregnancy weight was obtained from the contraction or disproportion between the head of the fetus and
prenatal records or was self-reported upon admission for the birth canal.
delivery. Body mass index (BMI) was calculated from weight in
kilograms divided by height in meters squared (kg/m2). 2.1. Statistical analysis
Prepregnancy obese women (BMI ≥30 kg/m2, n = 140) and
normal weight women (BMI 18.5–24.9 kg/m2, n = 3107) were Statistical analyses were performed using the SPSS (Statistical
included. Gestational weight gain (GWG) was ascertained Package for the Social Sciences) version 17.0 (Chicago, IL, USA) for
according to self-reported data at the time of delivery or Windows. Descriptive statistics are presented as the arithme-
documented weight at last prenatal visit subtracted from tic mean  standard deviation (SD). The Pearson chi-squared
prepregnancy weight. test was used for analysis of categorical variables. The Fisher
 medicina 53 (2017) 109–113 111

exact and Student t tests were used when applicable to and 0.7% of normal weight women, respectively. Labor
compare continuous variables. Odds ratios (OR) and 95% induction was more often in obese women when compared
confidence intervals (95% CI) were calculated. A value of with normal BMI women. The most common indications for
P < 0.05 was considered significant. labor induction in both groups were postterm pregnancy (10
days after estimated date of delivery) and preeclampsia. Failed
2.2. Ethics induction of labor also was more common in obese women.
Total cesarean delivery rate in obese women was more
The study was approved by Kaunas Regional Ethics Committee common than in normal weight women. Emergency cesarean
(Protocol No. BE-2-6). section was performed in 19.3% of obese and 13.6% of women
with normal BMI, a non-significant difference. Fetal distress
and dystocia were the most common indications for cesarean
3. Results
delivery in both groups of parturients.
The neonatal outcomes are summarized in Table 3. Mean
The study population consisted of 19 (0.6%) underweight, 3107 birthweight and newborn gender was similar in both groups.
(92.1%) normal weight, 105 (3.1%) overweight, and 140 (4.2%) LGA newborns were significantly more common in obese
obese parturients. Maternal characteristics are presented in women compared with normal weight women. Low Apgar
Table 1. The mean age of the obese women was significantly score at 5 min, preterm birth, small for gestational age
higher than that of normal weight women. Mean parity was 2.4 newborns and stillbirth rates in both groups were not
in obese and 2.1 in normal weight women, mean gestational significantly different. Pregnancy outcomes in women with
age was 39 weeks in both groups. Marital status was similar BMI 30–34.9 kg/m2 and BMI ≥35 kg/m2 are presented in Table 4.
among obese and normal weight women. The range of weight Significantly increased risk of gestational diabetes, preeclamp-
gain during pregnancy was 4.8–32.4 kg in obese, while among sia, dystocia and newborns with Apgar score ≤7 after 5 min
the normal weight females it was 2.0–28.0 kg. Educational level was only observed in women with BMI ≥35 kg/m2.
was significantly higher in normal weight women.
Obese women were more likely to develop gestational
4. Discussion
hypertension, preeclampsia and GDM (Table 2). Cesarean
section, induced labor, failed induction of labor and dystocia
rates were significantly higher in obese women. Class A1 and Women who are obese before pregnancy have an increased
A2 GDM was diagnosed in 17.8% and 5.8% of obese and in 4.5% risk of hypertensive disorders and GDM [7,10–14]. GDM

Table 1 – Maternal characteristics.

Characteristics Obese women Normal weight women P
N = 140 N = 3107
Nulliparous 50 (35.7) 1126 (36.2) 0.929
Multiparous 90 (64.3) 1981 (63.8)
Living place
Urban 78 (55.7) 2411 (77.6) <0.0001
Rural 62 (44.3) 696 (22.4)
Education level
Primary–secondary 103 (73.6) 1839 (59.2) 0.0006
Higher education 37 (26.4) 1268 (40.8)
Maternal age, mean  SD, years 30.7  5.9 28.7  5.2 <0.0001
Weight gain during pregnancy, mean  SD, kg 11.6  6.5 14.3  4.7 <0.0001
Prepregnancy body mass index, mean  SD, kg/m2 36.1  3.4 22.8  0.9 <0.0001
Values are number (percentage) unless otherwise stated.

Table 2 – Maternal outcomes.

Outcome Obese women Normal weight women OR (95% CI) P
N (%) N (%) (n = 3107)
(n = 140)
Gestational diabetes 33 (23.6) 160 (5.1) 5.56 (3.66–8.49) <0.0001
Gestational hypertension 24 (17.1) 73 (2.3) 8.59 (5.23–14.14) <0.0001
Preeclampsia 13 (9.3) 147 (4.7) 2.06 (1.14–3.73) 0.017
Dystocia 24 (17.1) 274 (8.8) 2.14 (1.36–3.38) 0.001
Induced labor 46 (32.8) 486 (15.6) 2.64 (1.83–3.80) <0.0001
Failed induction of labor 14 (10) 19 (0.6) 18.06 (8.85–36.84) <0.0001
Augmentation of labor 51 (36.4) 987 (31.7) 1.23 (0.87–1.75) 0.248
Cesarean delivery 60 (42.8) 927 (29.8) 1.76 (1.25–2.49) 0.001
112 medicina 53 (2017) 109–113

Table 3 – Neonatal outcomes.

Outcome Maternal BMI Maternal BMI OR (95% CI) P
≥30 kg/m2 18.5–24.9 kg/m2
n (%) n (%)
Apgar score ≤7 after 5 min 4 (2.8) 51 (1.6) 1.76 (0.63–4.9) 0.282
Preterm birth 15 (10.7) 387 (12.4) 0.84 (0.49–1.46) 0.541
Stillbirth 3 (2.1) 34 (1.1) 1.98 (0.6–6.52) 0.262
Small-for-gestational-age newborn 4 (2.8) 121 (3.9) 0.73 (0.26–1.99) 0.534
Large-for-gestational-age newborn 41 (29.3) 314 (10.1) 3.68 (2.51–5.39) <0.0001
BMI, body mass index.

Table 4 – Pregnancy outcomes according to the maternal obesity level.

Outcome Normal BMI versus BMI Normal BMI versus
30–34.9 kg/m2 BMI ≥35 kg/m2
(n = 94) (n = 46)

OR (95% CI) P OR (95% CI) P

Gestational diabetes 1.95 (0.96 –3.95) 0.0634 20.09 (11.03–6.61) <0.0001
Gestational hypertension 7.27 (3.94–13.43) <0.0001 11.55 (5.52–24.15) <0.0001
Preeclampsia 0.89 (0.32–2.47) 0.83 4.89 (2.32–10.34) <0.0001
Dystocia 1.37 (0.72–2.6) 0.335 5.84 (2.93–11.67) <0.0001
Induced labor 2.79 (1.79–4.31) <0.0001 2.36 (1.25–4.45) 0.008
Failed induction of labor 17.21 (7.57–39.15) <0.0001 19.82 (7.06–55.64) <0.0001
Cesarean delivery 1.74 (1.15–2.64) 0.009 1.81 (1.01–3.26) 0.048
Apgar score ≤7 after 5 min 0.65 (0.09–4.74) 0.2924 3.97 (1.20–13.19) 0.0243
Preterm birth 0.94 (0.50–1.77) 0.85 0.70 (0.25–1.95) 0.70
Stillbirth 1.94 (0.46–8.21) 0.37 1.99 (0.27–14.82) 0.50
Small for gestational age infant 0.82 (0.26–2.62) 0.74 0.56 (0.08–4.08) 0.57
Large-for-gestational-age newborn 3.05 (1.89–4.92) <0.0001 5.21 (2.83–9.59) <0.0001
BMI, body mass index.

generally is diagnosed in 4%–7% of pregnant population. Obese cesarean and operative vaginal delivery in obese parturients
women have the risk of GDM three to eightfold higher when [5–7,18,19]. Cesarean section rate in women with obesity in our
compared with normal weight pregnant women [6,10,11]. In study was 42.8%, very similar to reported in other studies [19].
our study GDM was diagnosed in 23.6% of obese women and In general, a nearly two-fold increased risk of cesarean
OR increased dramatically among the women with prepreg- delivery in women who are obese even after controlling for
nancy BMI of 35 kg/m2 and more (OR 20.1). Our results also other factors is reported [14,20]. In our study fetal distress and
show an association between increased prepregnancy BMI and dystocia were the most common causes for cesarean section
hypertensive disorders. The OR for gestational hypertension among normal weight and obese patients.
and preeclampsia in our patients population with BMI ≥35 kg/ Obese women have 18%–26% increased chance of deliver-
m2 was 11.55 and 4.9, respectively. The risk of hypertensive ing macrosomic newborns [6,21]. In our study 29.3% rate of LGA
disorders and GDM is much higher as compared to the data newborns was even higher than noted in previous studies.
published in the literature and maybe due to different Crane et al. found an increased risk of fetal macrosomia with
definitions and also because of the fact that the data for the increasing maternal BMI [7]. Similarly, we found significantly
current study were obtained from tertiary referral center increased OR of LGA newborns in women with BMI 30–34.9 kg/
where more pregnant woman with pregnancy complications m2 and BMI ≥35 kg/m2 as compared to normal weight women,
are referred. 3.1 and 5.2 respectively. LGA newborns are at increased risk of
Obese women more commonly have postterm pregnancy shoulder dystocia, birth trauma and meconium aspiration
and are less likely to have spontaneous onset of labor, more [13,21,22]. Neonates born to obese women have a higher rate of
likely to require induction of labor, and more likely to have a low Apgar score and more common admittance to an intensive
failed induction of labor [15–17]. The results from our study care unit [7]. In our study women with BMI ≥35 kg/m2 had an
show that induction of labor was registered more often among increased risk of delivering newborns with Apgar score ≤7 at
the women with pregestational BMI >30 kg/m2. The OR of 5 min.
failed induction of labor was significantly higher in women The major limitation of the study is that our department is
with BMI 30–34.9 kg/m2 and increased only slightly among the a tertiary referral center. High-risk pregnancy cases consist
women with BMI ≥35 kg/m2, 17.2 and 19.8, respectively. Failure almost two-thirds of our patients. Thus the rates of compli-
of labor induction, narrowing of the birth canal by increased cated obstetric outcomes related to obesity maybe higher in
maternal pelvic soft tissue and associated dystocia, fetal our study population and this could be a potentially
macrosomia and cephalopelvic disproportion increase risk of confounding factor that may have influenced the results.
 medicina 53 (2017) 109–113 113

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