Association between weight gain during 24 gestational weeks and pregnancy outcomes: A retrospective study in Chinese population

doi:10.21203/rs.3.rs-2954352/v1

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Research Article

Association between weight gain during 24 gestational weeks and pregnancy outcomes: A retrospective study in Chinese population

https://doi.org/10.21203/rs.3.rs-2954352/v1

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Background

Although the association between inadequate or excessive gestational weight gain (GWG) and adverse pregnancy outcomes has been investigated in China, most studies use the Institute of Medicine (IOM) guidelines, which might not be suitable for Chinese women characteristics. Besides, studies exploring association between GWG in the second trimester and pregnancy outcomes are relatively few.

Methods

A total of 976 cases of live-birth singleton pregnancies at the Shanghai General Hospital were included in this retrospective observational study. Patients were classified into three groups including GWG during 24 gestational weeks (G24WG) within, below and above the Standard of Recommendation for Weight Gain during Pregnancy Period published by Maternal and Child Health Standards Professional Committee of National Health Commission (NHC), China PR in 2022 (2022 Chinese GWG guidelines), which specifies the recommended value of weight gain of natural singleton pregnancy in China. Binary logistic regression was used to estimate the adjusted odds ratio (OR) and 95% confidence intervals (CIs) of adverse pregnancy outcomes among three G24WG groups.

Results

Of the 976 women analyzed, 12.6% had G24WG below the 2022 Chinese GWG guidelines, while 37.2% had G24WG above the 2022 Chinese GWG guidelines. Women with G24WG below the 2022 Chinese GWG guidelines had a higher risk of Small for Gestational Age (SGA, Adjusted OR = 2.690, 95% CI: 1.334–5.427, P = 0.006) and a lower risk of Large for Gestational Age (LGA, Adjusted OR = 0.435, 95% CI: 0.228–0.829, P = 0.011) than women who had G24WG within the 2022 Chinese GWG guidelines.

Conclusions

G24WG is a strong predictor of newborn anthropometric outcomes and help doctors provide appropriate nutritional counseling for pregnant women in China.

gestational weight gain

small for gestational age

large for gestational age

preeclampsia

Weight management before and during pregnancy plays an important role in prenatal care because both maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) are associated with increased risks of maternal and fetal metabolic diseases or other adverse pregnancy outcomes(1, 2). Generally, GWG in the first trimester is mainly attributed to expansion of maternal blood volume and early placental development, instead of fat deposits, while physiologic weight gain at term is comprised of fetus, fat stores, increased blood volume, increased extravascular fluid volume, amniotic fluid, breast enlargement, uterine hypertrophy and placenta(3, 4). GWG reflects the growth of the fetus and the health status of the mother(5). Most of the GWG takes place in the second and third trimesters, contributing to about 80–90% of the total GWG(5). Women with inadequate GWG tend to have increased risks of low birth weight(6), small for gestational age (SGA)(7) and preterm birth(8), while excessive GWG in pregnant women has been associated with the occurrence of gestational diabetes mellitus (GDM)(9), pre-eclampsia (PE)(10), large for gestational age (LGA)(11), and caesarean section(12).

In 2009, the Institute of Medicine (IOM) published specific recommendations regarding the optimal GWG for each of the pre-pregnancy BMI groups, which have been widely adopted by studies exploring the relationship between adverse pregnancy outcomes and GWG since then(5). A systematic review and meta-analysis including over 1 million pregnant women suggested that GWG was above the IOM recommended weight gain range in 47% of pregnancies and 23% of pregnant women had GWG less than IOM recommendations(8). Despite the prevalence of IOM guideline, the recommendations cannot be applicable all over the world mainly due to different ethnicities and lifestyles(13).

The IOM guideline’s generalizability to Asian women was limited because it was originally designed based on the Caucasian population data(14, 15). For example, the IOM recommended GWG range may be too great for Chinese pregnant women regarding each BMI category(16). Thus it is necessary to study the correlation between GWG and pregnancy outcomes in Chinese pregnant women using GWG guidelines designed specific for Chinese population. What’s more, Studies exploring associations of second-trimester GWG with perinatal outcomes have been relatively few. In this study, we will study the effect of GWG during 24 gestational weeks on pregnancy outcomes based on the Standard of Recommendation for Weight Gain during Pregnancy Period published by Maternal and Child Health Standards Professional Committee of National Health Commission (NHC), China PR in 2022(17).

Study population

In this retrospective study, the hospital records of a total of 1000 women giving birth at the Department of Obstetrics, Shanghai General Hospital between January 2021 and December 2021 were abstracted in a standardized fashion. Information about anthropological characteristics, obstetrical risk factors, delivery methods and maternal and neonatal outcomes were collected during prenatal visits, at time of delivery and at infant hospital discharge. Prenatal system at the Shanghai General Hospital includes scheduled appointments (eight prenatal visits and five ultrasounds on average) starting from 6 to 13 weeks of gestation. The typical schedule of routine antenatal visits are at weeks 11–13, week 24, week 28, and weeks 31–32 and, thereafter, every second week until birth.

All women included in this study must be ≥ 18 years old and have a live-birth singleton pregnancy. Besides, all fetuses need to be delivered at ≥ 28 weeks of gestation and have a birth weight > 1,000 g. Among the 1,000 women who met the inclusion criteria, 21 cases without pre-pregnancy body mass index (BMI; kg/m2) or no gestational weight gain measurement and 3 cases complicated by the congenital malformation of the fetus or stillbirth were excluded. Ultimately, 976 cases were included in the analysis.

This study was approved by the Ethics Committee of the Shanghai General Hospital. Informed consent was not required due to the retrospective nature of the study design.

BMI and weight gain

The eligible data collected in this study were obtained from self-reported pre-pregnancy weight (kg) and height (cm), while weight at gestational week 24 was routinely measured using the available electronic weighing device with a calibrated scale of 0.1 kg in the hospital. Pre-pregnancy body mass index (BMI; kg/m²) was calculated as pre-pregnancy weight (kg) divided by height (m)², while weight gain during 24 gestational weeks was calculated as weight at gestational week 24 minus pre-pregnancy weight.

Considering our study is based on data of Chinese women, we use the Standard of Recommendation for Weight Gain during Pregnancy Period published by Maternal and Child Health Standards Professional Committee of National Health Commission (NHC), China PR in 2022, which specifies the recommended value of weight gain of natural singleton pregnancy in China(18). According to the 2022 Chinese guidelines, we stratified pre-pregnancy BMI into four categories: underweight (BMI < 18.5), normal weight (BMI 18.5–23.9), overweight (BMI 24–27.9) and obese (BMI ≥ 28) (18). In addition, the 2022 recommendations suggest that range of gestational weight gain (GWG) in the first trimester (0–13 weeks) is 0–2.0 kg for all BMI categories, while range of recommended weekly weight gain for women in the second and third trimester is 0.37–0.56 kg/week for the underweight group, 0.26–0.48 kg/week for the normal weight group, 0.22–0.37 kg/week for the overweight group, and 0.15–0.30 kg/week for the obesity group(18). Therefore, range of weight gain during 24 gestational weeks = range of gestational weight gain in first trimester + range of recommended weekly weight gain in the second trimester * (24 − 13) weeks. Accordingly, optimal weight gain during 24 gestational weeks is 4.07–8.16 kg for the underweight group, 2.86–7.28 kg for the normal weight group, 2.42–6.07 kg for the overweight group, and 1.65–5.3 kg for the obese group. In this study, women whose weight gain during 24 gestational weeks (G24WG) is among the recommended range were classified as “Average” group, while those below the recommended range were classified as “Below” group and those above the recommended range were classified as “Above” group.

Outcome

The outcomes included gestational diabetes mellitus (GDM), gestational hypertension, preeclampsia (PE), caesarean section, postpartum hemorrhage (PPH), Large for Gestational Age (LGA), Small for Gestational Age (SGA), macrosomia (birth weight > 4000 g) and low birth weight (birth weight ≤ 2500 g).

LGA refers to infants who weigh more than 90% of newborns of the same gestational age (GA) at birth (above the 90th percentile)(19). Similarly, SGA is defined as newborns whose birth weight is below the 10th percentile for their GA(20). PPH is defined as blood loss in excess of 500 mL following vaginal delivery or more than 1000 mL following cesarean delivery(21).

Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder, where pregnant women’s glucose value fall at or above the following thresholds: fasting 5.1 mmol/L, 1 hour 10.0 mmol/L and 2 hour 8.5 mmol/L, with first recognition during pregnancy and has caused a tremendous healthy and economic burden in China(22, 23). All women included in this study received a 75 g Oral Glucose Tolerance Test (OGTT) during 24–28 weeks of gestation. Gestational hypertension is defined as new onset hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg) on 2 occasions at least 4 hours apart after 20 weeks of gestation(24). Preeclampsia (PE) is defined as hypertension (BP ≥ 140/90 mmHg) with proteinuria (excretion of 0.3 g protein or higher in the 24-hour urine collection) or other end-organ influence, including thrombocytopenia < 100 × 10⁹ / L, renal insufficiency, impaired liver function, pulmonary edema, and new onset headache or visual symptoms(25). The incidence of adverse pregnancy outcomes were examined among three WG24 groups.

Statistical analyses

Maternal demographic characteristics were compared among three WG24 groups. Categorical variables were described by frequencies (%), while continuous variables were described by mean with standard deviation (SD). Categorical data were analyzed by chi-square tests or Fisher’s exact tests, while continuous data were analyzed by one-way analysis of variance or Kruskal-Wallis H tests. Binary logistic regression was used to estimate the adjusted odds ratio (OR) and 95% confidence intervals (CIs) of SGA among three WG24 groups. P value < 0.05 was considered statistically significant. All analyses were performed using Statistical Package for the Social Sciences (SPSS 26).

Overall, data of a total of 976 pregnant women following the inclusion criteria were analyzed in this study. According to the 2022 Chinese GWG recommendations, 123 (12.6%), 490 (50.2%), and 363 (37.2%) pregnant women had inadequate (Below group), adequate (Average group), and excessive G24WG (Above group), respectively. As shown in Table 1, 8.6% of the pregnant women were underweight (BMI < 18.5 kg/m²), 16.7% were overweight (BMI 24–27.9 kg/m²), and 8.0% were obese (BMI ≥ 28 kg/m²). Women with inadequate G24WG and women with excessive G24WG were more likely to have a higher pre-pregnancy BMI compared with women with adequate G24WG. The proportion of women with G24WG below the 2022 Chinese GWG guidelines was similar in the underweight (10.7%) and normal weight (9.7%) categories, while the proportion was much higher in the overweight (16.6%) and obese (30.8%) categories. The proportion of women with G24WG within the 2022 Chinese GWG guidelines was highest in underweight (61.9%) category, followed by 53.1% in the normal weight category, 41.7% in the overweight category, and 30.8% in the obese category. The proportion of women with G24WG above the 2022 Chinese GWG guidelines was lowest in the underweight category and highest in the overweight category (27.4% and 41.7%, respectively). Maternal age, parity and fetal gender among the three groups did not have significant difference. Women with excessive G24WG tended to have more gravidity compared with two other groups. Baby's birth weight of women with inadequate G24WG was significantly less than that of women with adequate G24WG, while women with excessive G24WG tended to have heavier babies.

Table 1

Study population baseline characteristics overall and by status of GWG during 24 gestational weeks
	GWG during 24 gestational weeks (2022 Chinese GWG guidelines)
	Below (n = 123, 12.6%)	Average (n = 490, 50.2%)	Above (n = 363, 37.2%)	P value	Total (n = 976)
Maternal age (year), mean ± SD	31.42 ± 4.48	31.32 ± 4.13	31.58 ± 4.73	0.699	31.43 ± 4.40
Gravidity, mean ± SD	2.24 ± 1.22	2.22 ± 1.30	2.32 ± 1.34	0.026^*	2.32 ± 1.34
Parity				0.363
Primiparity, n(%)	60(11.4)	273(51.9)	193(36.7)		526
Multiparity, n(%)	63(14)	217(48.2)	170(37.8)		450
Height (cm)	159.30 ± 4.99	160.15 ± 5.21	160.65 ± 5.18	0.040^*	160.23 ± 5.18
Weight (kg)	61.00 ± 11.98	56.03 ± 8.76	57.96 ± 9.70	0.000^*	57.38 ± 9.70
Pre-pregnancy BMI(kg/m2),mean ± SD	23.95 ± 4.26	21.83 ± 3.19	22.60 ± 3.35	0.000^*	22.39 ± 3.47
Pre-pregnancy BMI categories, n(%)				0.000^*
Underweight (< 18.5 kg/m²)	9(10.7)	52(61.9)	23(27.4)		84 (8.6)
Normal weight (18.5–23.9 kg/m2)	63(9.7)	346(53.1)	242(37.2)		651 (66.7)
Overweight (24-27.9 kg/m2)	27(16.6)	68(41.7)	68(41.7)		163 (16.7)
obese (≥ 28 kg/m2)	24(30.8)	24(30.8)	30(38.5)		78 (8.0)
GWG at gestational week 24 by BMI categories (kg), mean ± SD
All women	0.58 ± 2.50	5.06 ± 1.39	9.80 ± 5.69	0.000^*	6.15 ± 3.62
Underweight (< 18.5 kg/m²)	1.50 ± 3.68	6.37 ± 1.12	10.07 ± 1.58	0.000^*	6.86 ± 2.98
Normal weight (18.5–23.9 kg/m2)	1.22 ± 1.45	5.13 ± 1.29	9.58 ± 1.98	0.000^*	6.41 ± 3.12
Overweight (24-27.9 kg/m2)	(-0.06) ± 3.09	4.28 ± 1.04	9.57 ± 3.15	0.000^*	5.77 ± 4.33
Obese (≥ 28 kg/m2)	(-0.71) ± 2.87	3.31 ± 1.02	8.35 ± 5.46	0.001^*	4.01 ± 5.33
Baby's birth weight (kg)	3.14 ± 0.44	3.26 ± 0.46	3.32 ± 0.48	0.001^*	3.27 ± 0.47
Gender				0.610
Female, n(%)	65(13.4)	246(50.7)	174(35.9)		485
Male, n(%)	58(11.8)	244(49.7)	189(38.5)		491
OGTT level
OGTT (0 h)(mmol/L)	4.70 ± 0.88	4.59 ± 0.58	4.59 ± 0.61	0.197	4.60 ± 0.64
OGTT (1 h)(mmol/L)	8.50 ± 2.12	8.03 ± 2.01	7.78 ± 1.90	0.002^*	8.00 ± 1.99
OGTT (2 h)(mmol/L)	7.29 ± 1.99	6.94 ± 1.76	6.89 ± 1.86	0.100	6.96 ± 1.83
*, P value < 0.05 was considered statistically significant. The data are presented as the mean ± standard deviation, the number and frequency, or the number and percentage. GWG: gestational weight gain, SD: standard deviation, BMI: body mass index, OGTT: oral glucose tolerance test. The 2022 Chinese GWG guidelines provided recommended ranges of weekly GWG rate during the 2nd and 3rd trimesters (kg/week) by pre-pregnancy BMI status: 0.37––0.56 kg/week for underweight (BMI < 18.5 kg/m²), 0.26–0.48 kg/week for normal body weight (18.5 kg/m² ≤ BMI < 24.0 kg/m²), 0.22–0.37 kg/week for overweight (24.0 kg/m² ≤ BMI < 28.0 kg/m²), and 0.15–0.30 kg/week for obesity (BMI ≥ 28.0 kg/m²). The recommended ranges of gestational weight gain in the first trimester were 0–2.0 kg for all BMI categories. BMI categories were defined based on Chinese women characteristics.

G24WG-related characteristics and adverse pregnancy outcomes were summarized in Table 2. With respect to the pregnancy outcomes, a total of 271 cases of GDM, 70 cases of PE, 99 cases of gestational hypertension, 46 cases of LBW, 50 cases of macrosomia, 159 cases of LGA, and 60 cases of SGA, were observed (Table 2). The proportion of PE patients (50%) was highest in the G24WG group above the 2022 Chinese guidelines, which was similar for gestational hypertension (45.5%). However, the proportion of SGA, LGA, GDM and LBW were highest in the G24WG group within the 2022 Chinese guidelines (48.3%, 49.1%, 49.1%, and 52.2%, respectively). The proportion of macrosomia (44%) was highest in the G24WG group above the 2022 Chinese guidelines.

Table 2

Summary characteristics of pregnancy outcomes in the study population overall and by G24WG status
Adverse pregnancy outcome		GWG at gestational week 24 (G24WG)			Total n = 976
Adverse pregnancy outcome		Below, n (%)	Average, n (%)	Above, n (%)	Total n = 976
GDM	P	44 (16.2)	133 (49.1)	94 (34.7)	271
GDM	N	79 (11.2)	357 (50.6)	269 (38.2)	705
PE	P	8 (11.4)	27 (38.6)	35 (50)	70
PE	N	115 (12.7)	463 (51.1)	328 (36.2)	907
Gestational hypertension	P	13 (13.1)	41 (41.4)	45 (45.5)	99
Gestational hypertension	N	110 (12.5)	449 (51.2)	318 (36.3)	877
Macrosomia	P	3 (6.0)	22 (44)	25 (50)	50
Macrosomia	N	120 (13.0)	468 (50.5)	338 (36.5)	726
Low birth weight	P	6 (13.0)	24 (52.2)	16 (34.8)	46
Low birth weight	N	117 (12.6)	466 (50.1)	347 (37.3)	930
SGA	P	14 (23.3)	29 (48.3)	17 (28.3)	60
SGA	N	109 (11.9)	461 (50.3)	346 (37.8)	916
LGA	P	14 (8.8)	78 (49.1)	67 (42.1)	159
LGA	N	109 (13.3)	412 (50.4)	296 (36.2)	817
P: positive, N: negative, G24WG: gestational weight gain during 24 gestational weeks, GDM: gestational diabetes mellitus, PE: preeclampsia, SGA: small for gestational age, LGA: large for gestational age

As shown at Table 3, the result of univariate logistic regression showed that excessive G24WG significantly increased the risk of PE compared with the average group (crude OR = 1.830, 95% CI: 1.086–3.083, P = 0.023), which is consistent with a previous study(26). However, after adjusting pre-pregnancy BMI, maternal age, primiparity and gravidity, there was no statistical significance in the risk of PE between the excessive group and the average group (Adjusted OR = 1.566, 95% CI: 0.908–2.702, P = 0.107). The reason for this contradiction might be that parity is a strong confounding factor for the occurrence of PE because PE status in a woman’s first pregnancy strongly predicts her risks of PE in subsequent pregnancies(27).

Table 3

Associations between G24WG and adverse pregnancy outcomes
Pregnancy outcomes, odds ratio (95% CI), P value
Groups	GDM	PE	Gestational hypertension	Macrosomia	LBW	SGA	LGA
Below (Crude ORs)	1.495 (0.983–2.273) p = 0.060	1.193 (0.528–2.695) p = 0.671	1.294 (0.670–2.499) p = 0.442	0.532 (0.157–1.806) p = 0.311	0.996 (0.398–2.492) p = 0.993	2.042 (1.044–3.995) p = 0.037	0.678 (0.370–1.245) p = 0.210
Average (Crude ORs)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)
Above (Crude ORs)	0.938 (0.689–1.276) p = 0.684	1.830 (1.086–3.083) p = 0.023^*	1.550 (0.991–2.423) p = 0.055	1.573 (0.872–2.838) p = 0.132	0.895 (0.468–1.711) p = 0.828	0.781 (0.422–1.444) p = 0.431	1.196 (0.835–1.712) p = 0.329
Below (Adjusted ORs)	0.939 (0.594–1.485) p = 0.788	0.663 (0.277–1.583) p = 0.354	0.747 (0.366–1.523) p = 0.422	0.333 (0.094–1.173) p = 0.087	1.125 (0.441–2.868) p = 0.805	2.690 1.334–5.427 0.006^*	0.435 (0.228–0.829) 0.011^*
Average (Adjusted ORs)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)	Ref (OR = 1.00)
Above (Adjusted ORs)	1.301 (0.7938–1.804) p = 0.115	1.566 (0.908–2.702) p = 0.107	1.344 (0.840–2.150) p = 0.218	1.404 (0.765–2.574) p = 0.273	0.936 (0.486–1.801) p = 0.843	0.885 (0.473–1.653) 0.701	1.062 (0.732–1.541) 0.751
*, P value < 0.05 was considered statistically significant. G24WG: gestational weight gain during 24 gestational weeks, OR: odds ratio, CI: confidence interval, Ref: reference, GDM: gestational diabetes mellitus, PE: preeclampsia, SGA: small for gestational age, LGA: large for gestational age, LBW: low birth weight

Compared to the reference group with average G24WG, women with inadequate G24WG had a significantly higher risk of SGA (Adjusted OR = 2.690, 95% CI: 1.334–5.427, P = 0.006) and a a significantly lower risk of LGA (Adjusted OR = 0.435, 95% CI: 0.228–0.829, P = 0.011), which was consistent with a previous study demonstrating that inadequate second-trimester GWG might be associated with increased risk of SGA in underweight women(28). There was also a higher risk of LBW and a lower risk of macrosomia in the group below the 2022 Chinese guideline without statistical significance. For the group of excessive G24WG, no significant difference in risks was observed across the outcomes including GDM, LBW, macrosomia, PE, gestational hypertension, SGA or LGA compared to the reference group (Table 3), which was inconsistent with previous studies demonstrating that excessive total GWG significantly increased the risk of LGA and GDM (29, 30). It was possible that the amount of GWG difference between excessive vs. average GWG groups in our study may not be sufficient enough to detect a significant difference in outcome risks due to a relatively small sample size.

In this study, we found that women with inadequate weight gain during 24 gestational weeks (G24WG) had a significantly higher risk of SGA and a significantly lower risk of LGA. The significant effect of excessive G24WG on the increased risk of PE was counteracted after considering the influence of maternal age, primiparity, gravidity and pre-pregnancy BMI.

No significant difference in risks of adverse pregnancy outcomes between excessive and average G24WG group was observed, which may be due to the limited sample in this study.

Associations between inadequate or excessive weight gain during the whole pregnancy and outcomes for mothers and infants have been well described(31–34). A systemic review demonstrated that GWG was below or above the IOM guidelines in 23% and 47% of pregnancies, respectively. The 23% of women who gained inadequate weight had an increased risk of SGA compared with those whose gestational weight gain was within the IOM guidelines(8). However, the IOM recommendations are based on population information from North America, which restricts its use among populations from different countries and different ethnicities (35). Asian women usually have a lower pre-pregnancy BMI compared with those in Western countries, so the BMI criteria in the IOM guidelines are not appropriate for Asian populations, which might result in error of classification. Previous studies have shown that Asians have increased risk of diabetes or cardiovascular diseases, which are all obesity-related, at lower BMI levels than Caucasians(36, 37). Therefore, lower BMI cut-off and lower recommended GWG should be more suitable for Asian populations. Many Asian countries including Singapore(38), Japan(39), and Korea(15) have proposed their own recommendations of GWG, which implies that the optimal GWG may vary due to different population characteristics and each country should consider its own optimal GWG range. Thus in this study, we use the Standard of Recommendation for Weight Gain during Pregnancy Period published by Maternal and Child Health Standards Professional Committee of National Health Commission (NHC), China PR in 2022(17). According to the IOM guideline, pre-pregnancy BMI is classified as: underweight (BMI < 18.5 kg/m²), normal weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25.0-29.9 kg/m²), and obese (BMI ≥ 30 kg/m²), which might be too big for Chinese women. In the 2022 Chinese standard, pre-pregnancy BMI is stratified into four categories: underweight (BMI < 18.5 kg/m²), normal weight (BMI 18.5–23.9 kg/m²), overweight (BMI 24–27.9 kg/m²) and obese (BMI ≥ 28 kg/m²).

This study has some strengths compared with other studies reported in the literature. First, we applied the Standard of Recommendation for Weight Gain during Pregnancy Period designed specific for Chinese pregnant women instead of the 2009 IOM guidelines more suitable for Caucasian people. Second, the study contains detailed clinical data including pre-pregnancy weight and weight measurements during 24 gestational weeks, which made it possible to study GWG in the second trimester. In addition, it is difficult to disentangle the

effect caused by GWG from the effect caused by duration of pregnancy due to the strong correlation between GWG and gestational duration. However, the use of gestational weight gain during 24 gestational weeks (G24WG) in our study can overcome this limitation, ensuring that the weight gain of women who experience adverse pregnancy outcomes would be

compared with the weight gain of women without adverse outcomes at the same point in pregnancy. Besides, studies exploring the effect of GWG during the second trimester on adverse pregnancy outcomes are relatively few. Our study fill this gap.

There are also limitations in our study. First, the pre-pregnancy weight data in this study was self-reported at the first prenatal visit within the first 13 weeks of pregnancy, which may lead to recalling bias. Second, we only investigated the short-term perinatal outcomes, without considering long-term complications such as cardiometabolic diseases and obesity in later life. Third, the nature of our study is a single-centered retrospective study. In the future, more powered randomized trials are needed.

Our findings may have clinical implications. We have demonstrated that inadequate GWG during 24 gestational weeks (in the mid-pregnancy period) may affect subsequent maternal and neonatal outcomes. To mitigate the harms of inadequate weight gain, doctors need to take measures to increase the proportion of women who adhere to the 2022 Chinese guidelines for weight gain during pregnancy, including appropriate nutritional supplement, exercise, counseling and a variety of mobile technology interventions. Maintaining the appropriate amount of weight gain during the second trimester may be a driver to prevent pregnancy complications and should be integrated into routine prenatal care.

In this investigation, we found that women with inadequate weight gain during 24 gestational weeks (G24WG) had a significantly higher risk of SGA and a significantly lower risk of LGA using the Standard of Recommendation for Weight Gain during Pregnancy Period published by Maternal and Child Health Standards Professional Committee of National Health Commission (NHC), China PR in 2022, which is more suitable for Chinese women. Our study is the first study to demonstrate the association between weight gain during 24 gestational weeks and pregnancy outcomes using the 2022 Chinese guidelines based on Chinese population and help doctors provide appropriate nutritional counseling. In the future, more multi-centered, randomized controlled trials are needed to make appropriate gestational weight gain guidelines for Chinese people.

GWG

gestational weight gain

G24WG

weight gain during 24 gestational weeks

odds ratio

confidence interval

standard deviation

GDM

gestational diabetes mellitus

SGA

small for gestational age

LGA

large for gestational age

BMI

body mass index

preeclampsia

OGTT

oral glucose tolerance test

NHC

National Health Commission

IOM

Institute of Medicine

PPH

postpartum hemorrhage

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Shanghai General Hospital. All methods were carried out in accordance with the Declaration of Helsinki. Written informed consent was waived by Shanghai General Hospital Ethic committee due to the retrospective nature of this study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Shanghai Jiao Tong University Trans-Med Awards Research (STAR) (Major Project) (20210201)

Authors' contributions

Xian-Ming Xu and Jie Ma designed the study; De-Cui Cheng and Jie Ma provided study materials; Dong-Mei Zhou, Shi-Tong Zhan, Hao-Yi Jia collected and assembled data; Xue-Qing Liu and Yi Lin performed data analysis and interpretation; Xiao-Wei Wei and Chuan-Mei Qin wrote the manuscript; All authors reviewed the manuscript.

Acknowledgements

Not applicable.

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No competing interests reported.

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Association between weight gain during 24 gestational weeks and pregnancy outcomes: A retrospective study in Chinese population

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BMI and weight gain

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