Height and weight should be recorded on all pregnant women at the initial prenatal visit to allow calculation of the BMI . If the gestation is beyond the first trimester an estimate of the pregravid weight should be made to calculate the BMI.

Below are classifications of BMI and recommended pregnancy weight gain by the Institute of Medicine in 1990:

Underweight-              <18 BMI                     28-40 pounds

Normal weight -         18.5-24.9 BMI            25-35 pounds

Overweight-                25-29.9    BMI                        15-25 pounds

Obesity -                     >30 BMI                     15 pounds

Patients carrying twins should gain approximately 35-45 pounds of weight. Adolescents and black women should aim for the higher end of the ranges given.

 

Obese women are at increased risk for several pregnancy complications: spontaneous abortion, birth defects, macrosomia, shoulder dystocia. Obese women may have other co-morbidities including hypertension and diabetes. Obesity contributes to perioperative morbidity including anesthesia complications, thromboembolism and wound infection/breakdown.

 

Weight should be recorded at each prenatal visit and overall weight gain/loss noted. The presence of ketonuria or glycosuria on urine dip should be noted.

Pattern of weight gain is also important with 2-6 pounds of weight gain expected in the first trimester and one pound per week in the second and third trimesters.

Most pregnant women will require 2200- 2900 kcal per day tailored to their BMI.

Averaging an additional 300 kcal/day from pre-pregnancy consumption, (one healthy snack per day) will achieve appropriate weight gain. Only 30-40% of women gain within recommended ranges. Excessive weight gain is a more common problem than less than recommended weight gain.

 

Recommendations:

 

1.     A weight gain of 4 or more pounds per week should be investigated as should persistent weight loss.

2.     Patients who are underweight or overweight should receive nutritional counseling.

3.     Patients with abnormal weights should be evaluated for :

a.      High risk health history

b.     Eating disorders such as hyperemesis,  anorexia or bulimia

c.      Fad diet or pica

d.     Availability of adequate nutrition

4.     Monitor closely the risk indicators associated with nutritional disorders such as anemia, edema etc

5.     Consult with medical provider as indicated.

6.     Women with excessive weight gain during pregnancy that persists post partum should be referred for nutritional counseling.

 

References:

March of dimes.com

ACOG Committee Opinion # 315 “Obesity in pregnancy”

Olson CM. “Achieving a healthy weight gain in pregnancy”. Annu Rev Nutr 28: 2008.

Kaiser L,  Allen LH. “Position of the American dietetic association: nutrition and lifestyle for a healthy pregnancy outcome” Journal of the American Dietetic Association 2008:108,553.

 

 

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

 

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.

 

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.