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Cross sectional study of gestational weight gain and Cross sectional study of gestational weight gain and Document Transcript

  • Cross-sectional study of gestational weight gain and perinatal outcomes in pregnant women at a tertiary care center in southern India Usha Radhakrishnan1 , Geeta Kolar1 and Praveen K. Nirmalan2 1 Department of Fetal Medicine and Ultrasonography and 2 Clinical Research Unit, Fernandez Hospital, Hyderabad, India Abstract Aim: The aim of this study was to determine maternal and neonatal outcomes of less than recommended or excess gestational weight gain (GWG) based on the recommended Institute of Medicine (IOM) guidelines. Material and Methods: Using a cross-sectional study design, GWG was assessed for 1462 pregnant women presenting to a tertiary care perinatal institute in India. Body mass index at baseline, co-existing morbidities, fetal growth, details of delivery, and maternal and fetal outcomes were determined and documented. Appro- priate GWG for each woman was determined based on the revised IOM guidelines. Outcome measures included the proportion of pregnant women compliant with IOM guidelines for GWG and associations of less than recommended or excess GWG with maternal and neonatal outcomes. Results: A total of 547 (37.41%, 95% confidence interval [CI]: 34.96–39.92) pregnant women gained less than recommended and 313 (21.41%, 95%CI: 19.36–23.57) pregnant women gained more than the recommended weight. Preterm deliveries were associated with less than optimal weight gain (adjusted odds ratio 3.58, 95%CI: 1.75–7.32) after adjusting for gestational age at delivery. GWG was not associated with neonatal outcomes in this population. Conclusions: The lack of associations with perinatal outcomes indicates that the IOM guidelines may not be the appropriate standard for monitoring GWG in this population. Key words: body mass index, gestational weight gain, Institute of Medicine guidelines, perinatal outcome, pregnancy. Introduction The Institute of Medicine (IOM) guidelines developed in 1990 recommended a maternal weight gain of 25–35 pounds for women with normal weight for height to optimize fetal growth and maternal/infant outcomes.1 Many key aspects of the reproductive health of women of child-bearing age have since changed, especially increasing advanced maternal age, a rising prevalence of obesity, diabetes, hypertension and other chronic non-communicable diseases, prompting a revision of the IOM guidelines in 2009.2 The revised recommenda- tions provide a specific range of weight gain for over- weight and obese women that was previously lacking. The wide acceptance and adoption of the IOM guide- lines has not, however, translated into optimal gesta- tional weight gain (GWG) with studies reporting that 37% of normal-weight women and 64% of over- weight women gain more than IOM recommenda- tions.3,4 GWG that exceeds the IOM recommended levels is associated with complications in delivery (cesarean section deliveries), large-for-gestational-age Received: September 24 2012. Accepted: February 27 2013. Reprint request to: Dr Geeta Kolar, Department of Fetal Medicine and Ultrasonography, Fernandez Hospital, Hyderabad 500001, India. Email: geetkolar@gmail.com; drgeeta@fernandezhospital.com bs_bs_banner doi:10.1111/jog.12115 J. Obstet. Gynaecol. Res. Vol. 40, No. 1: 25–31, January 2014 © 2013 The Authors 25 Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
  • (macrosomic) babies, obesity in offspring by age 3 years, greater postpartum weight retention and an increased risk of being overweight in the future, and may co-exist with other maternal lifestyle diseases like hypertension and diabetes.5–15 The National Family Health Survey-III from India, which includes the health of women of child-bearing age, reports that 33% of women have a body mass index (BMI) below normal, 14.8% of women are over- weight or obese and 57.9% of pregnant women are anemic.16 Appropriate GWG may help optimize maternal and fetal outcomes in pregnant women who may be undernourished at conception. To the best of our knowledge, there is little or no information from India on GWG, the adherence to or usefulness of the IOM recommendations for GWG in this population and the effects of GWG on fetal outcomes and mater- nal health. The current study was designed to deter- mine the distribution of adherence of GWG to the IOM recommendations and its appropriateness in a population of pregnant women booked for antenatal care at a tertiary care perinatal institute in southern India. Methods The study was initiated after the study protocol was approved by the Institutional Review Board of the study institute, which is an advanced tertiary care peri- natal teaching institute that carries out approximately 5000 deliveries each year. Pregnant women aged 18 years or older, booked for antenatal care at the study institute prior to 22 gestational weeks with the gesta- tional age confirmed by ultrasound dating and with a singleton fetus were considered as eligible for inclu- sion in the study. Pregnant women who did not meet the inclusion criteria and pregnant women whose maternal health necessitated termination of pregnancy prior to 25 gestational weeks or did not provide informed consent were excluded from the study. Written informed consent was obtained from each par- ticipant prior to recruitment. Details of antenatal care at the study institute, based on standardized clinical care protocols, were initially entered into a medical case record and subsequently transferred into an electronic database. Maternal and neonatal morbidity were identified and documented using standard clinical definitions and categories. Every pregnant woman was assessed for height using a measuring tape, weight using a calibrated electronic weighing machine, blood pressures in the seated posi- tion, medical, surgical and obstetric history, personal risk behavior and nutrition assessments. Baseline investigations included, but were not limited to, hemo- globin, blood sugar levels (including a 2-h 75-g oral glucose tolerance test between 24 and 28 weeks of ges- tation based on the International Association of the Dia- betes and Pregnancy Study Groups [IADPSG] criteria), screening for thyroid disorders and trimester-specific ultrasound exams. The BMI for each woman was esti- mated as the weight in kg divided by height in m2 . The weight gain during each trimester was assessed at 20–24 weeks and at 30–35 weeks using the same weigh- ing machine. The presence of medical co-morbidities, gestational age at delivery, details of delivery (includ- ing mode of delivery and complications associated with delivery) and neonatal outcomes were routinely recorded. Consistent with the IOM guidelines, a BMI < 18.5 kg/m2 was considered as lean, 18.5– 24.9 kg/m2 as normal, 25–29.9 kg/m2 as overweight and 30 kg/m2 or above as obese. The IOM guidelines (revised in 2009) developed for the US population rec- ommends a GWG of 12.5–18, 11.5–16, 7–11.5 and 5–9 kg as appropriate for women with pre-pregnancy BMI considered as lean, normal, overweight and obese, respectively.2 Overweight and obese pregnant women and women with gestational diabetes or diabetes mel- litus were referred for nutritional counseling as part of routine antenatal care. However, pregnant women with a lean pre-pregnancy BMI were sent for nutri- tional counseling based on the discretion of the treating clinician. Fetal growth was assessed through serial ultrasound measurements by trained sonologists. The Voluson with curved array transabdominal transducer AB 2–7 MHz with multihertz and harmonic capability and HP machine with transabdominal probe was used for the ultrasound exams with images stored in digital imaging media. These images were available for retro- spective assessment and re-measurement of all fetal parameters as needed. The first-trimester scan was done at 11–13+6 weeks of gestation for nuchal translu- cency and dating of gestational age by measuring crown–rump length. The second-trimester targeted imaging for fetal anomalies scan was done at 19–24 weeks of gestation. Dating of pregnancy was done during this period if it was not done earlier. The third- trimester scan (fetal well-being scan) was done at 30–35 weeks of gestation and the growth of the fetus was plotted on the population-based growth curves. The biparietal diameter, head circumference, abdominal U. Radhakrishnan et al. 26 © 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
  • circumference, and femur length taken using standard planes of ultrasound were considered and used as a combination of these variables to derive an estimated fetal weight and growth pattern of the given fetus. Population-based growth curves (from Sonocare soft- ware developed by Mediscan systems at Chennai) for a south Indian population were used to determine the type of fetal growth. Fetuses whose growth parameters were in between the 5th and 95th centiles were consid- ered as average for gestational age, fetuses whose growth parameters were on the 95th centile or above were considered as large for gestational age and fetuses whose growth parameters were on the 5th centile or lower were considered as small for gestational age. The Open Epi-Epidemiologic Calculator was used to estimate a sample size of 1015 pregnant women based on a two-sided significance level (1-alpha) of 95% and a hypothesized frequency of inappropriate GWG (greater than or lower than recommended weight gain guidelines) of 70 Ϯ 5% in an estimated 5000 annual deliveries at Fernandez Hospital.17 A potential dropout rate of 30% was considered to further revise the esti- mated sample size to 1320 pregnant women. Statistical analysis was performed using stata statis- tical software (version 9.0). The distribution and the 95% confidence intervals (95%CI) around the point estimates for women who had optimal, less than rec- ommended or more than recommended GWG based on the IOM guidelines were determined. The distribu- tion of gestational medical co-morbidities, mode of delivery and complications, and neonatal outcomes were compared between the three groups. The c2 -test or Fisher’s exact test were used to compare categorical variables and a one-way anova test was used to compare continuous variables. A multivariate logistic regression model (that adjusted for factors found sig- nificant in a bivariate analysis) was used to explore associations of the different GWG categories with maternal and neonatal outcomes. A P-value < 0.05 was considered as statistically significant. Results The study included 1462 pregnant women booked at Fernandez Hospital for antenatal care from June 2010 to April 2011. The mean (standard deviation) age of study participants was 27.30 (4.27) years (range 18–44 years). The mean (standard deviation) weight gain during pregnancy was 10.51 (4.46) kg (range 1–28 kg). An optimal weight gain based on the IOM recommen- dations was present for 602 (41.18%, 95%CI: 38.67– 43.72) of the pregnant women. A total of 547 (37.41%, 95%CI: 34.96–39.92) pregnant women gained less than recommended and 313 (21.41%, 95%CI: 19.36, 23.57%) pregnant women gained more than the recommended weight. Table 1 presents the characteristics of the 1462 pregnant women in the study stratified by GWG. The distribution of maternal and neonatal outcomes with GWG is presented in Tables 2 and 3, respectively. Preterm deliveries (<37 weeks of gestation) were sig- nificantly more common in women with less than optimal weight gain (see Table 2). Gestational hyper- tension was less common in women with less than optimal weight gain; however, this difference was not statistically significant (see Table 2). Babies born to mothers with less than optimal weight gain had sig- nificantly lower mean birthweights (see Table 3) and were more likely to be low birthweight (<1.5 kg) although this association was not statistically signifi- cant. Babies born to mothers with more than optimal weight gain were significantly more likely to be large for gestational age (see Table 3). In a multivariate regression model that adjusted for age of mother, parity, gestational age at delivery and BMI, preterm deliveries were significantly associated (adjusted odds ratio 3.58, 95%CI: 1.75–7.32) with less than optimal weight gain in pregnancy (see Table 4). Gestational weight gain, categorized as per the revised IOM guide- lines, was not significantly associated with other mater- nal or neonatal outcomes. Discussion The results of the study indicate a lower than optimal adherence in this population to the IOM recommen- dations for appropriate GWG. Overall, more than one in three pregnant women gained less than the recom- mended weight and one in five pregnant women gained more than the recommended weight during pregnancy. In this study, 59.07% of pregnant women with a lean BMI at baseline gained less than recom- mended weight and 36.24% and 29.27% of over- weight and obese pregnant women gained more than the recommended weight during pregnancy. Lower than optimal weight gain was associated with increased preterm births and lower mean birth- weights, even after adjusting for gestational age at delivery. However, it is possible that the less-than- optimal weight gain and lower birthweights were an effect rather than cause of prematurity. Gestational weight gain © 2013 The Authors 27 Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
  • Consistent with previous studies, it was found that women with gestational diabetes gained less than rec- ommended weight during pregnancy.18,19 It is possible that the lower-than-recommended weight gain is attributable to stricter nutritional counseling when we consider that the majority (86.03%) of pregnant women with gestational diabetes in this study were on a com- bination of diet control and exercise. The association of hypertensive disorders in pregnancy with more-than- recommended weight gain is consistent with available knowledge, although our study design does not allow us to comment on a cause-and-effect correlation.18,20 The influence of edema and fluid retention on mea- sured weight in hypertensive disorders of pregnancy needs further study. Similar to other studies, more- than-recommended weight gain during pregnancy was associated with an increased incidence of operative deliveries through a cesarean section.2,6 Maternal weight gain more than the IOM recom- mendations has been reported with an increased risk of Table 1 Characteristics of the 1462 pregnant women included in the study Characteristics Optimal weight gain (n = 602) Less-than-optimal weight gain (n = 547) Excess weight gain (n = 313) Total (n = 1462) Lean BMI at baseline 35 (33.33%) 62 (59.05%) 8 (7.62%) 105 (7.18%) Optimal BMI at baseline 277 (40.26%) 337 (48.98%) 74 (10.76%) 688 (47.06%) Overweight BMI at baseline 217 (42.97%) 105 (20.79%) 183 (36.24%) 505 (34.54%) Obese BMI at baseline 73 (44.51%) 43 (26.22%) 48 (29.27%) 164 (11.22%) Previous cesarean section 128 (21.26%) 134 (24.50%) 56 (17.89%) 318 (21.75%) Chronic hypertension 13 (2.16%) 18 (3.29%) 5 (1.60%) 36 (2.46%) Diabetes mellitus 8 (1.33%) 18 (3.29%) 11 (3.51%) 37 (2.53%) Prior hypothyroid 53 (8.80%) 42 (7.68%) 28 (8.95%) 123 (8.41%) Prior renal disease 12 (1.99%) 8 (1.46%) 8 (2.56%) 28 (1.92%) Prior CVS disease 2 (0.33%) 9 (1.65%) 2 (0.64%) 13 (0.89%) Primigravida 266 (44.19%) 170 (31.08%) 147 (46.96%) 583 (39.88%) Nulliparous 333 (55.32%) 223 (40.77%) 202 (64.54%) 758 (51.85%) Pre-eclampsia 21 (3.49%) 17 (3.11%) 13 (4.15%) 51 (3.49%) Eclampsia 4 (0.66%) 2 (0.37%) 1 (0.32%) 7 (0.48%) Gestational hypertension 17 (2.82%) 9 (1.65%) 14 (4.47%) 40 (2.74) Gestational diabetes 137 (22.76%) 143 (26.14%) 78 (24.92%) 358 (24.49%) Screen hypothyroid (detected during antenatal care) 25 (4.15%) 30 (5.48%) 13 (4.15%) (4.65%) BMI, body mass index; CVS, cardiovascular system. Table 2 Maternal outcomes and gestational weight gain Maternal outcomes Optimal weight gain (n = 602) Less-than-optimal weight gain (n = 547) Excess weight gain (n = 313) P-value* Preterm (<37 weeks) 54 (8.97%) 96 (17.55%) 25 (7.99%) <0.001 Postpartum hemorrhage 11 (1.83%) 3 (0.55%) 5 (1.60%) 0.14 Cesarean section† 255 (48.76%) 221 (45.38%) 155 (54.96%) 0.04 Assisted vaginal delivery† 79 (22.77%) 59 (18.15%) 29 (18.59%) 0.28 Preterm premature rupture of membranes† 16 (2.89%) 13 (2.57%) 6 (2.17%) 0.83 Premature rupture of membranes† 48 (8.19%) 41 (7.69%) 37 (12.05%) 0.08 Pre-eclampsia† 21 (3.70%) 17 (3.28%) 13 (4.44%) 0.70 Eclampsia† 4 (0.73%) 2 (0.40%) 1 (0.36%) 0.69 Gestational hypertension† 17 (3.01%) 9 (1.76%) 14 (4.76%) 0.05 Gestational diabetes mellitus† 137 (23.06%) 143 (27.03%) 78 (25.83%) 0.29 Screen-detected hypothyroid† 25 (4.58%) 30 (5.94%) 13 (4.58%) 0.54 *P-values determined using the c2 -test and Fisher’s exact test. Fisher’s exact test was used where category counts were <5. A P-value < 0.05 was considered as significant. †Denominator includes those categorized as normal for that category. U. Radhakrishnan et al. 28 © 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
  • neonatal complications like macrosomia, hypoglyce- mia and hyperbilirubinemia (jaundice).21 Jaundice and hypoglycemia in neonates were more common in women with excess weight gain; however, neonatal outcomes did not vary significantly across BMI catego- ries after stratification by pre-pregnancy BMI. The number of stillbirths and perinatal deaths was not sufficiently large enough to explore for any statistical Table 3 Neonatal outcomes and gestational weight gain categories Neonatal outcomes Optimal weight gain (n = 602) Less-than-optimal weight gain (n = 547) Excess weight gain (n = 313) P-value* Mean birthweight in kg 2.99 (0.49) 2.79 (0.56) 3.07 (0.51) <0.001 Low Apgar at 5 min 5 (0.84%) 2 (0.37%) 1 (0.32%) 0.47 Stillborn 5 (0.83%) 6 (1.1%) 2 (0.64%) 0.77 Neonatal death 2 (0.33%) 2 (0.37%) 2 (0.64%) 0.77 Small for gestational age† 30 (5.44%) 31 (6.05%) 11 (4.09%) 0.51 Large for gestational age† 51 (8.92%) 35 (6.78%) 44 (14.57%) 0.001 Birthweight < 1.5 kg 7 (1.16%) 17 (3.11%) 5 (1.60%) 0.05 Jaundice 286 (47.51%) 254 (46.44%) 163 (52.08%) 0.26 Sepsis 27 (4.49%) 31 (5.67%) 9 (2.88%) 0.17 Congenital anomalies 18 (2.99%) 22 (4.02%) 9 (2.88%) 0.54 Hypoglycemia 9 (1.50%) 10 (1.83%) 10 (3.19%) 0.21 Respiratory distress 18 (2.99%) 27 (4.94%) 9 (2.88%) 0.15 Birth asphyxia 5 (0.83%) 3 (0.55%) 0 (0.00%) 0.27 *P-values were determined using the c2 -test and Fisher’s exact test for categorical variables and one-way anova test for continuous variables. Fisher’s exact test was used where category counts were <5. A P-value < 0.05 was considered significant. †Denominator includes those categorized as normal for that category. Table 4 Multivariate logistic regression model† for associations of gestational weight gain with maternal and neonatal outcomes Maternal outcomes Less-than-optimal weight gain Adjusted OR (95%CI) Excess weight gain Adjusted OR (95%CI) Preterm (<37 weeks) 3.58 (1.75–7.32) 0.42 (0.14–1.25) Cesarean section 0.82 (0.47–1.44) 1.56 (0.86–2.82) Assisted vaginal delivery 0.75 (0.42–1.31) 1.03 (0.44–2.36) Preterm premature rupture of membranes 0.5 (0.13–1.87) 2.25 (0.42–12.08) Premature rupture of membranes 1.15 (0.57–2.31) 2.52 (1.20–5.28) Pre-eclampsia 0.89 (0.40–1.96) 1.88 (0.72–4.90) Eclampsia 0.09 (0.001–6.06) 0.58 (0.01–22.69) Gestational hypertension 0.63 (0.26–1.52) 0.71 (0.25–2.00) Low Apgar at 5 min 0.20 (0.02–1.60) — Stillborn 2.00 (0.18–22.05) — Neonatal death 0.59 (0.09–3.87) 1.00 Small for gestational age 0.99 (0.51–1.95) 0.52 (0.20–1.36) Large for gestational age 0.64 (0.33–1.25) 1.49 (0.86–2.60) Birthweight < 1.5 kg 3.00 (0.59–15.01) 0.33 (0.01–5.96) Jaundice 0.95 (0.70–1.30) 1.39 (0.96–1.99) Sepsis 1.02 (0.42–2.45) 1.24 (0.40–3.84) Congenital anomalies 1.04 (0.47–2.30) 0.79 (0.23–2.63) Hypoglycemia 0.95 (0.23–3.78) 3.90 (0.97–15.62) Respiratory distress 1.07 (0.42–2.75) 0.98 (0.30–3.16) Birth asphyxia 0.34 (0.05–2.23) — †Adjusted for age of mother, parity, gestational age at delivery and body mass index, reference category is optimal weight gain and normal for each category of morbidity. CI, confidence interval; OR, odds ratio. Gestational weight gain © 2013 The Authors 29 Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
  • significance. Stillbirths were more common in women with less-than-optimal weight gain although this may be associated with preterm deliveries. Consistent with several other studies, less-than- optimal weight gain was associated with preterm deliveries and lower birthweights.2,6,22,23 However, it is not possible to suitably comment on causation attribut- able to less-than-optimal weight gain as data on GWG by gestational age in weeks was not collected. A strati- fied analysis of weight gain by gestational age may provide more information that can support a possible causal mechanism. Nearly two-thirds of pregnant women with lean BMI at baseline had a less-than-optimal weight gain in this tertiary care center. This statistic is important when one considers that approximately one in three women of childbearing age in India has a lean BMI.16 The study design does not allow us to attribute reasons for the less-than-optimal weight gain in the subgroup of women with lean BMI. An exploration of any potential beliefs or practices pertaining to reduced obstetrical complications (if GWG was not in excess) was not performed.24 The subgroup of preg- nant women with lean BMI is not prioritized for nutritional counseling, thus, possibly affecting appro- priate weight gain. The study highlights several areas of concern. From a clinical perspective, it is necessary to develop and evaluate appropriate GWG criteria in this population based on associations with maternal and fetal out- comes. This study shows that the IOM guidelines may not be appropriate for use in this population as they were developed on a different population. Addition- ally, the IOM guidelines are not based on associations with improved clinical outcomes. The proportion of women with lean BMI and less-than-optimal weight gain is a matter of concern in India. Any impact of appropriate nutritional counseling and adherence to recommended GWG guidelines on women with lean BMI and preterm births in this population needs further study. The representativeness of the study population to the general population of southern India is a limita- tion of the study. The proportion of pregnant women with lean BMI at baseline in this study is much lower than the general population and the proportion of pregnant women that were overweight or obese at baseline is much higher than the distribution in the general population.16 India has recently revised the BMI cut-offs for Asian Indians25 with a BMI > 25 kg/m2 considered as obese leading to a sub- stantial increase in the proportion of pregnant women categorized as obese. A previous study from the study institute has shown an increase in the prevalence of obesity from 19.49% to 54.63% when the revised guidelines are used as the upper limits of what was previously considered a normal BMI (BMI of 23.0– 24.9 kg/m2 ) is now considered as overweight.25,26 However, there has been no revision of limits for lean BMI.25 Obstetricians caring for pregnant Asian Indian women may need to consider the revised BMI catego- ries to determine overweight/obese pregnant women in their clinical practice, although these revised BMI categories did not consider obstetric outcomes during their development. The ‘re-categorization’ necessitates a change in the appropriate BMI-based GWG guide- lines that can be applied for Asian Indian women. A larger study is necessary to develop appropriate guidelines for GWG by gestational weeks and trimes- ter. It is possible that the associations we find might change in direction and/or strength if we use the revised BMI categories for India. We could not, however, test for shifts in associations, as weight gain guidelines based on the revised BMI categories for Asian Indians are not available. The higher incidence of gestational diabetes mellitus can be attributed to the use of the IADPSG criteria for the detection of gestational diabetes. The lack of repre- sentativeness may be attributed to the tertiary care referral nature of the study institute with nearly 60% of pregnant women presenting at the institute referred from other practices. The results of this study may not be generalizable to the larger community of pregnant women in southern India. In conclusion, there is a lower-than-optimal adher- ence to recommended IOM guidelines for GWG in this population. Less-than-optimal GWG is associated with preterm births, even if the pregnant women are overweight or obese at baseline. The lack of significant associations of less than or more than optimal weight gain with clinical perinatal outcomes indicates that the IOM standards for GWG may not be appropriate for this population. Further studies are required to determine appropriate GWG criteria for this population based on clinical perinatal outcomes. Acknowledgments Dr U.R. was involved with all aspects of the study including data collection and writing of the manu- script, Authors G.K. and P.K.N. were involved with the U. Radhakrishnan et al. 30 © 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
  • design, analysis, interpretation of results and writing of the manuscript. The manuscript has been read and approved by all the authors; the requirements for authorship have been met by all authors; and each author believes that the manuscript represents honest work. The study protocol was approved by the Institu- tional Review Board of Fernandez Hospital, Hydera- bad through the protocol number EC Ref # 18_2010 R1 and approved on 31 May 2010. Disclosure None of the authors have any conflict of interest or financial disclosures pertaining to this manuscript to report. References 1. Institute of Medicine. Subcommittee on Nutritional Status and Weight Gain during Pregnancy. Nutrition during Pregnancy. Washington, DC: National Academy of Sciences, 1990. 2. Committee to Reexamine IOM Pregnancy Weight Guidelines. Food and Nutrition Board, and Board on Children, Youth, and Families. Weight Gain during Pregnancy: Reexamining the Guidelines. Washington, DC: Institute of Medicine, 2009. 3. 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Am J Public Health 1986; 76: 1396–1399. 25. Misra A, Chowbey P, Makkar BM et al. Consensus Group. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009; 57: 163–170. 26. Surapaneni T, Fernandez E. Obesity in gestational diabetes: Emerging twin challenge for perinatal care in India. Int J Infert Fetal Med 2010; 1: 35–39. Gestational weight gain © 2013 The Authors 31 Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology