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Cohort Study of High Maternal Body Mass Index and the Risk of Adverse Pregnancy and Delivery Outcomes in Scotland

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Cohort Study of High Maternal Body Mass Index and the Risk of Adverse Pregnancy and Delivery Outcomes in Scotland Open access Original research BMJ Open: first published as 10.1136/bmjopen-2018-026168 on 20 February 2020. Downloaded from Cohort study of high maternal body mass index and the risk of adverse pregnancy and delivery outcomes in Scotland Lawrence Doi ,1 Andrew James Williams ,2 Louise Marryat ,3,4 John Frank3,5 To cite: Doi L, Williams AJ, ABSTRACT Strengths and limitations of this study Marryat L, et al. Cohort Objective To examine the association between high study of high maternal maternal weight status and complications during pregnancy ► This study used a large, retrospectively accessed body mass index and the and delivery. risk of adverse pregnancy but cohort- structured, national database covering Setting Scotland. and delivery outcomes some of the major maternal and neonatal outcomes Participants Data from 132 899 first- time singleton in Scotland. BMJ Open in Scotland over eight recent years. deliveries in Scotland between 2008 and 2015 were used. 2020;10:e026168. doi:10.1136/ ► Analyses were adjusted for some of the key potential Women with overweight and obesity were compared with bmjopen-2018-026168 confounders to estimate impact of high maternal- women with normal weight. Associations between maternal ► Prepublication history and weight status on each outcome. body mass index and complications during pregnancy and 2 additional material for this ► All women with body mass index (BMI) of 30 kg/m delivery were evaluated. paper are available online. To or more were considered as having obesity; it is like- Outcome measures Gestational diabetes, gestational view these files, please visit ly that differentiating morbid obesity or obesity class hypertension, pre- eclampsia, placenta praevia, placental the journal online (http:// dx. doi. II and III from obesity would have generated more abruption, induction of labour, elective and emergency org/ 10. 1136/ bmjopen- 2018- precise estimates. 026168). caesarean sections, pre- term delivery, post- term delivery, ► The completeness of the recording of BMI increased low Apgar score, small for gestational age and large for during the study period (2008 to 2015) from 69% Received 22 August 2018 gestational age. to 98%. Using data from the earlier years when the Revised 22 December 2019 Results In the multivariable models controlling for potential Accepted 05 February 2020 BMI was missing more often might have biassed the confounders, we found that, compared with women with http://bmjopen.bmj.com/ study sample if it was the case that BMI was not normal weight, the odds of the following outcomes were missing at random. significantly increased for women with overweight and obesity (overweight adjusted ORs; 95% CI, followed by the same for women with obesity): gestational hypertension (1.61; 1.49 to 1.74), (2.48; 2.30 to 2.68); gestational diabetes and offspring.1 2 For instance, in terms of preg- (2.14; 1.86 to 2.46), (8.25; 7.33 to 9.30); pre- eclampsia nancy complications, a systematic review and (1.46; 1.32 to 1.63) (2.07; 1.87 to 2.29); labour induction meta-analysis involving 11 cohort studies found (1.28; 1.23 to 1.33), (1.69; 1.62 to 1.76) and emergency caesarean section (1.82; 1.74 to 1.91), (3.14; 3.00 to 3.29). that caesarean delivery risk increased by 50% on September 26, 2021 by guest. Protected copyright. Conclusions Women with overweight and obesity in in pregnant women who were overweight and Scotland are at greater odds of adverse pregnancy and was more than double for women who were delivery outcomes. The odds of these conditions increases obese compared with women with normal with increasing body mass index. Health professionals should BMI.3 High BMI during pregnancy could lead be empowered and trained to deliver promising dietary and to future chronic disease such as diabetes, lifestyle interventions to women at risk of overweight and heart disease and hypertension.4 Surviving obesity prior to conception, and control excessive weight gain offspring are also more prone to long- term in pregnancy. obesity, hypertension, coronary heart disease, diabetes, stroke and asthma.4 5 © Author(s) (or their employer(s)) 2020. Re- use INTRODUCTION Both immediate and long- term health impli- permitted under CC BY. The increasing global prevalence of overweight cations of high BMI during pregnancy have Published by BMJ. and obesity makes it more likely that a growing economic consequences. For example, a recent For numbered affiliations see number of women with high body mass index study examining infant health utilisation and end of article. (BMI) are becoming pregnant. High maternal costs on the National Health Service (NHS) Correspondence to BMI during pregnancy has immediate impli- in the UK of infants born to women with over- Dr Lawrence Doi; cations for pregnancy complications as well as weight or obesity found that total mean addi- larry. doi@ ed. ac. uk long- term health implications for both women tional resource cost for infants born to women Doi L, et al. BMJ Open 2020;10:e026168. doi:10.1136/bmjopen-2018-026168 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-026168 on 20 February 2020. Downloaded from who are overweight was £65.13, and £1138.11 for infants Scotland between January 2008 and December 2015. The born to women who are obese.6 women and infants were identified within three electronic Maternal weights are currently high in Scotland: a medical record databases: the Scottish Morbidity Record recent study reported that 31.5% of mothers were over- (SMR) 01 and 02 and Scottish Birth Record (SBR). SMR01 weight and a further 23.6% were affected by obesity.7 A is generated for patients receiving inpatient or day care in retrospective cohort study using Scottish obstetrical data the General or Acute specialities, while SMR02 is gener- from 2003 to 2010 examining the impact of maternal BMI ated for patients receiving inpatient or day care in the on clinical complications, inpatient admissions and addi- Obstetrical Specialities. The SBR records all of a baby's tional short- term costs to the NHS in Scotland revealed neonatal care in Scotland. Relevant outcome variables that maternal BMI influences maternal and neonatal are recorded in these databases according to the WHO’s morbidity, the number and duration of maternal and International Classification of Diseases, Tenth Revision neonatal admissions and health service costs.8 The study (ICD-10) or NHS Scotland classifications.11 Further also showed that in comparison with women of normal description of the content of these databases is available12 weight, women who were overweight, obese or severely and in the online supplementary file 1. The study was obese had an increased risk of essential hypertension designed as a clinical audit so did not require approval (1.87 (1.18 to 2.96), 11.90 (7.18 to 19.72) and 36.10 from a Research Ethics Committee. However, approval (18.33 to 71.10)), pregnancy‐induced hypertension was obtained from the Public Benefit and Privacy Panel (1.76 (1.60 to 1.95), 2.98 (2.65 to 3.36) and 4.48 (3.57 via the national Electronic Data Research and Innovation to 5.63)), gestational diabetes (3.39 (2.30 to 4.99), 11.90 Service to use the anonymised data collected by these (7.54 to 18.79) and 67.40 (37.84 to 120.03)), emergency registries. As a clinical audit making secondary use of caesarean section (1.94 (1.71 to 2.21), 3.40 (2.91 to 3.96) anonymised electronic patient records, it was necessary and 14.34 (9.38 to 21.94)) and elective caesarean section to account for missing data which was relevant to this (2.06 (1.84 to 2.30), 4.61 (4.06 to 5.24) and 17.92 (13.20 research study (see the online supplementary file 2 for to 24.34)).8 Smith et al,9 using data from a retrospective the flow diagram illustrating how the final sample size was cohort study of 187 290 women in Scotland to examine reached). The large number of variables involved in this the risk of maternal obesity in early pregnancy and the study and a low likelihood that missingness was at random risk of pre- term delivery, found that among nulliparous meant that imputation methods would have been compli- women, the risk of an elective pre- term delivery increased cated and a complete case analysis was more suitable for with increasing BMI. The study also observed that 40% of this population- wide study. morbidly obese nulliparous women who experienced an elective pre- term delivery had been diagnosed with pre- Patient and public involvement eclampsia, in contrast with only 2.6% of the remaining Patients were not involved in the design, analyses and 9 study population. Maternal obesity has also been linked interpretation of this study. http://bmjopen.bmj.com/ to low Apgar score and pre- term and post- term delivery as well as the risk of intrapartum complications, such as Exposure variable placenta praevia and placental abruption.2 10 It is likely More than 80% of pregnant women in Scotland present that any risk of intrapartum complications may necessitate themselves for antenatal care during the first trimester labour induction or more frequent caesarean delivery. of their pregnancy.13 Height and weight are usually In the current study, we hypothesised, based on previous measured by the midwife at the first antenatal visit, typi- studies elsewhere, that women with obesity and their cally before 12 weeks of pregnancy. BMI was calculated 2 babies experience higher rates of virtually all perinatal using the formula weight (kg)/height (m ). BMI cate- on September 26, 2021 by guest.
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