Maternal-Foetal Complications in Pregnant Women with Obesity: a predictive model

doi:10.21203/rs.3.rs-4691249/v1

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Maternal-Foetal Complications in Pregnant Women with Obesity: a predictive model

https://doi.org/10.21203/rs.3.rs-4691249/v1

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Background

Obesity is a recognised global epidemic with serious consequences, including increased risk of morbidity and reduced life expectancy. It is a chronic, multifactorial disease defined by a Body Mass Index ≥ 30 kg/m². It also imposes a significant economic burden on individuals, families and countries. During pregnancy, maternal obesity is a significant risk factor, making pregnancy a vulnerable period for obese women, potentially worsening its course and having adverse effects on both mother and foetus. In addition, the offspring of obese pregnant women are at increased risk of obesity in childhood and adulthood. Therefore, the aim of this study was to describe the maternal and neonatal consequences and morbidity associated with maternal obesity in pregnant women in the community of Cantabria, northern Spain, in the post-pandemic era.

Methods

This was achieved through a retrospective observational descriptive study of pregnant women who gave birth at the Marqués de Valdecilla University Hospital in Cantabria during the years 2021 and 2022. STROBE's COREQ recommendations were followed.

Results

No significant differences were found in the incidence of diseases during pregnancy and postpartum between 2021 and 2022. However, a significant difference was found in the need for Neonatal Intensive Care Unit admission, with a higher proportion of newborns admitted to the Neonatal Intensive Care Unit in 2022. The classification model suggests that diseases during pregnancy, especially Hypertension arterial, complications during labor (with hemorrhage as the main one), and the reason for cesarean section, Risk of Foetal Well-being Loss, are significant predictors of the type of delivery. A significant increase in the frequency of all treatments was observed during the puerperium compared to gestation.

Conclusions

Obesity increases the risk of presenting diseases and complications during pregnancy, childbirth and neonatal risks. Therefore the pregnancy is a conflict for public health because it increases obstetric.

Pregnant women

Maternal obesity

Obstetric complications

Maternal morbidity

Neonatal morbidity

As a summary, it should be noted that in this study significant results were found in the sense that obese pregnant women have a higher risk of diseases during pregnancy, complications during childbirth and a significant increase in the frequency of all treatments during the postpartum compared to pregnancy.

Obesity is a serious public health problem, refered to as the new non-communicable epidemic of the 21st century and defined by The Obesity Society as a disease that not only underlies major chronic diseases, but is also a severely debilitating condition in its own right.[1] During pregnancy, maternal obesity emerges as a major risk factor. This period, characterised by transient physiological changes, becomes even more sensitive when combined with obesity, which may exacerbate risks for both mother and fetus.[2, 3]

Maternal complications associated with obesity during pregnancy include pre-eclampsia, gestational diabetes, venous thromboembolism and postpartum haemorrhage.[4, 5, 6, 7, 8] For the foetus, complications can range from heart defects to metabolic problems and even increase the risk of congenital anomalies and foetal death.[9, 10] In addition, children of obese women are at increased risk of obesity in childhood and adulthood [11] and may be at increased risk of congenital anomalies and metabolic complications. [12, 13, 14]

The COVID-19 pandemic has introduced additional challenges, affecting health systems and potentially altering obesity rates in pregnant women. [15] Understanding how the pandemic has affected the prevalence and management of obesity in this group is essential to tailor clinical interventions to meet the changing needs of these women. [16]

Therefore, the aim of this study is to analyse the maternal and neonatal consequences and morbidities associated with maternal obesity in the community of Cantabria, northern Spain, during the post-pandemic period (2021–2022). This knowledge will help health professionals to be aware of the risks associated with maternal obesity and to develop effective strategies to manage pregnancy in obese women, in order to reduce or prevent complications in both mother and child.

Study design

A retrospective observational descriptive study was conducted in 2021 and 2022 among pregnant women who gave birth at the Marqués de Valdecilla University Hospital, a public hospital in northern Spain.

Study subjects

The sample selected was all women who had given birth at the hospital and who had a body mass index (BMI) greater than or equal to 30 before pregnancy. STROBE's COREQ recommendations were followed.

Inclusion and exclusion criteria

Inclusion criteria were women with a pre-pregnancy BMI greater than or equal to 30 (obesity) who gave birth in 2021 and 2022 at the Marqués de Valdecilla University Hospital, Cantabria Health Service.

Exclusion criteria were women who fulfilled the main condition of not being considered obese at the time of pre-pregnancy (BMI greater than or equal to 30) or whose BMI was not recorded in the Altamira computer programme (Electronic Health Record of the Cantabrian Health System).

Variables

Gestational variables: Whether they had received any treatment during pregnancy and, if so, the most common treatments were examined, including anticoagulants, antihypertensives and insulin. Variables on any illness during pregnancy were also collected, looking at the most common conditions such as gestational hypertension (PIH), gestational diabetes mellitus (GDM), hypothyroidism and hyperthyroidism. With regard to ultrasound scans performed during pregnancy, the results of ultrasound pathologies, foetal growth abnormalities, mean foetal percentile and number of fetuses diagnosed were studied.

Labour: The type of delivery, vaginal or caesarean, was analysed. For vaginal deliveries, the prevalence of ectopic and instrumental deliveries and the reasons for dystocia were studied. For caesarean section, the reasons for caesarean section were examined, distinguishing between emergency caesarean section and planned caesarean section. Any complications during labour were also recorded in detail.

Postpartum: complications such as anaemia, pre-eclampsia, hypertensive disorders, infection, wound dehiscence or bleeding, urinary pathology, postpartum fever, sepsis and postpartum haemorrhage were studied. Treatment during this period was also analysed, the most common being anticoagulants and antihypertensives.

Neonatal variables: Whether they required admission to the neonatal intensive care unit (NICU) and, if so, the most common reasons, such as respiratory distress, prematurity, neonatal jaundice, low birth weight, hypoglycaemia, maternal admission to NICU, infection, hypotonia, and neonatal death.

Data Collection Procedure

Data collection was carried out from February to May 2023 using the Altamira Software Program of the Cantabrian Health Service. All healthcare episodes recorded in the patients' medical records providing relevant information on the subject were systematically reviewed.

Ethical considerations

With regard to ethical considerations, authorisation has been obtained from the Research Ethics Committee of the Community of Cantabria (code: 2022.344 and date of approval: 16/12/2022), the Head of the Gynaecology Service and the Head of the Maternity Unit of the Marqués de Valdecilla University Hospital for the collection of data relating to her pregnancy, delivery and postpartum history. The data will be processed in such a way as to guarantee the confidentiality of the data and information contained in the study, in accordance with current Spanish legislation. The regulations of the ethics committee of the Cantabrian Health Service as well as the regulations in Spain establish that the authorisation of the hospital and the ethics committee is required exclusively for the collection of clinical history data, given that the data accessed by the researcher are disaggregated when obtained from the computer system: they do not contain personal data and therefore authorisation cannot be requested, as they are collected retroactively. The researchers are responsible for ensuring that the data obtained cannot be used for other purposes.

Statistical analysis

SPSS v.22 was used. A statistical significance level of α = 0.05 was used to assess the importance of the differences observed and to determine whether the results were statistically significant. Appropriate statistical tests were used, such as Chi-square tests for categorical variables and Student's t-tests or analysis of variance (ANOVA) for continuous variables, as appropriate. Correlation studies between the variables as well as logistic regression modelling were carried out to determine possible predictive values.

A total of 920 records meeting the criteria were collected, of which 479 were from 2021 and 439 from 2022. The total number of deliveries attended was 2,768 in 2021 and 2,679 in 2022, giving a total of 5,447 deliveries. Therefore, the percentage of pregnant women with obesity was 17.30% in 2021 and 16.38% in 2022.

A comparison of proportions test was performed to determine whether there were significant differences in the incidence of pregnancy-related morbidity, postpartum complications, and the need for NICU admission between 2021 and 2022. No significant differences were found in the incidence of diseases during pregnancy between 2021 and 2022 (p > 0.05). Similarly, no significant differences were observed in the prevalence of postpartum complications between the two years (p > 0.05). However, a significant difference was found in the need for NICU admission between 2021 and 2022 (p < 0.05), with a higher proportion of newborns admitted to the NICU in 2022.

Gestational stage

Table 1 shows the variables collected in relation to diseases presented during this period, pathologies detected by ultrasound and foetal growth abnormalities. The mean ultrasound percentile was 63 (SD: 28.23). The mean number of foetuses diagnosed by ultrasound was 1.028 (SD: 0.18).

Table 1

Variables of the Gestational Stage (N = 920).
Gestational Stage
Diseases during pregnancy	No diseases 37.8%	PIH 37.8%	GDM 10.1%	Gestational hypothyroi dism 10.1%	Gestational hyperthyroidism 3.7%
Pathologies in Ultrasound	No pathologies 88%	Yes, they had pathologies 11.1%	Placental alteration 0.5%	Foetal static alteration 0,4%
T Foetal Growth Abnormalities	No abnormalities 69.8%	Macrosomia 23.8%	Intrauterine growth restriction 3.6%	Small for gestational age 1.9%

Labor

A classification model was developed using gestational and labor variables to predict the type of delivery (eutocic, instrumental, or cesarean). The results of the model identified the following significant predictor variables: Diseases during pregnancy (p = .021); Complications during labor (p = .003), and reason for cesarean section (p = .012).

The classification model suggests that diseases during pregnancy, especially Hypertension arterial (HTN), complications during labor (with hemorrhage as the main one), and the reason for cesarean section, Risk of Foetal Well-being Loss (RFWL), are significant predictors of the type of delivery.

A regression analysis was conducted using gestational and ultrasound variables to predict the mean foetal percentile. Significant predictor variables were: Diseases during pregnancy (β = − .27, p = .004), Pathologies in ultrasound (β = − .21, p = .019), Complications during labor (β = − .19, p = .032).

Adjusted R^2 = .362. The regression analysis suggests that diseases during pregnancy (especially HTN), pathologies in ultrasound (placental alteration), and complications during labor (hemorrhage) are significant predictors of the mean foetal percentile.

Table 2 lists the variables collected regarding the type of delivery, reasons for instrumentalized delivery, cesarean deliveries, and the reason and complications.

Table 2

Birth variables (N = 920).
BIRTH
Type of delivery	Eutocic 63.7%	Instrumental 7.0%	Cesarean 29.3%	Total vaginal delivery 70.7%
Instrumentalized delivery	Metal suction cup 3.2%	Kiwi Suction Cup 3.1%	Forceps 0.8%
Reasons for instrumentalized delivery	RFWL 47.5%	Stationary delivery 49.2%	Induction failure 1.7%
Cesarean deliveries	Urgent 20.9%	Programmed 8.4%
Reason cesarean deliveries	RFWL 27.5%	Stationary delivery 14.7%	Induction failure 18.5%	Cephalopelvic disproportion 14.7%	Buttocks 19.4%
Complications	No 87.8%	Yes 12.2%
Type of complications	Postpartum hemorrhage 4.8%	Hypertensive state 0.5%	Others 6.9%

Postpartum

Postpartum complications 61.2% had some type of pathology compared with 38.8% of women who had no postpartum complications. Of the women with postpartum complications, most had anaemia (82.8%). About 35.5% had pre-eclampsia and 27.4% had HTN. Regarding the Caesarean wound, 13.1% had infection, 6.3% had dehiscence and 1.4% had bleeding from the incision. Eight per cent had some type of urinary pathology, mainly infection or urinary retention. Among obese postpartum women, 7.3% had puerperal fever, 1.7% had sepsis, 1.2% had severe puerperal haemorrhage and 15.6% had other pathologies.

Logistic regression analysis was performed to determine whether there was a significant association between antenatal conditions and postpartum complications. A significant association was found between the presence of gestational disorders (such as PIH, GDM and anaemia) and the likelihood of complications in the puerperium (F(1,92) = 13.25, p = .02). For example, women with PIH had an increased risk of developing pre-eclampsia during the puerperium (up to 2 times higher). A multinomial logistic regression model was run to see if ultrasound pathologies had any effect on the mode of delivery. We found that ultrasound pathologies (such as foetal growth abnormalities) were significantly associated with the type of delivery (ectopic, instrumental or caesarean) (F (1,92) = 21.57, p < .001). For example, fetuses diagnosed with macrosomia (weight greater than 4000 grams) were more likely to be delivered by caesarean section (up to 0.9 times more likely) than fetuses without foetal growth restriction. A logistic regression model was constructed using the presence of complications during the puerperium as the dependent variable and the predictor variables mentioned above. The results of the model were the following significant predictor variables: Presence of illness during gestation (β = 1.25, p < .001); Type of delivery (β = .87, p = .003); Pathologies on ultrasound (β = 0.94, p = .002) and complications during labour (β = 1.10, p < .001). Adjusted R^2 = .421 (indicating that the model explains 42.1% of the variability in the presence of complications during the puerperium). The corrected logistic regression model suggests that the presence of gestational disease (especially HTN) and complications during labour (notably haemorrhage) are the strongest predictors of postpartum complications.

Medication

Table 3 shows the most frequent pharmacological treatments both during pregnancy and postpartum. The most frequent were anticoagulants, iron, antihypertensives and insulin. In the postpartum period all treatments increased markedly, especially anticoagulants and iron, which more than doubled.

Table 3

Pharmacological treatment in pregnancy and puerperium (N = 920).
	Treatment during gestation	Treatment during puerperium
Has taken any treatment	41.4%	43.6%
Anticoagulant	33.9%	64.6%
Iron	20.7%	62.7%
Antihypertensive	14.6%	17.6%
Insulin	9.0%	11.2%

Significant differences were found in the frequency of drug treatments (anticoagulants, iron, antihypertensives and insulin) between gestation and puerperium (F (1,36) = 11.32, p = .03). Specifically, a significant increase in the frequency of all treatments was observed during the puerperium compared to gestation (p = .032).

Newborn

After birth in the delivery room, the immediate puerperium lasted approximately one and a half hours, during which time the vast majority of newborns did not require admission to the NICU in 91.8% of cases, and 8.2% required admission to the NICU. Once this period had elapsed and the mother and newborn were transferred to the maternity ward, 11.8% of newborns were admitted to the NICU and 88.2% did not require admission.

Regarding the reasons for admission of newborns to the intensive care unit, the most frequent was respiratory distress in 22.1% of the babies, followed by 15% for prematurity, and neonatal jaundice in 12.4%. Also, 11.5% of babies born to obese mothers were admitted for low neonatal weight, 9.7% for hypoglycaemia, 8.8% because the mother had to be admitted to the intensive care unit, 3.5% for hypotonia, 1.8% for infection and 13.3% for other types of reasons. Neonatal death occurred in 1.8% of infants born to obese mothers.

A logistic regression analysis was performed to investigate whether maternal obesity has any significant impact on the need for NICU admission and reasons for admission. Maternal obesity was found to be significantly associated with the need for NICU admission (F (1,69) = 28.21, p < .001). In addition, infants born to obese mothers were found to be at increased risk of NICU admission due to conditions such as respiratory distress and prematurity (up to 1.2 times higher).

We will make a comparative study of the results of the variables both in gestation, labour and puerperium of the present study with those of other authors.

The results of the gestational pathologies examined in our study show that only 37.8% had no pathology. The main pathologies were PIH, GDM, gestational hypothyroidism and gestational hyperthyroidism. The literature found [2, 17, 18, 19, 20] all point in the same direction: obese pregnant women have a significantly higher risk of obstetric complications than pregnant women with a normal BMI. These articles report that in terms of maternal complications, the risk of developing PIH, GDM, pre-eclampsia, hypothyroidism, hyperthyroidism, post-term pregnancy, caesarean section, preterm birth, post-partum haemorrhage, pelvic infection, urinary tract infection and macrosomia. Studies [2, 21, 22, 23] mainly conclude an increased risk of developing GDM and PIH in overweight or obese pregnant women. In addition, Manrique Camasca LV [24] found that urinary tract infection was the most common obstetric complication, followed by anaemia and pre-eclampsia. Regarding ultrasound during pregnancy, in our study, 88% of ultrasounds performed during pregnancy showed no pathology, and the most common changes found were in the placenta and foetal statics. In our study, 23.8% of the foetal growth abnormalities were diagnosed as macrosomic foetuses, 3.6% as foetal growth restriction foetuses and 1.9% as Small for gestational age foetuses (SGA). The articles studied show that foetal weight was higher in overweight and obese pregnant women than in normal weight women. Foetal macrosomia, defined as was more frequent in overweight and obese pregnant women compared to normal weight pregnant women.[17] A higher incidence of foetal macrosomia is observed in obese pregnant women.[25] A relationship with shoulder dystocia has also been found.[26]

The results of the variables relating to labour show that in our study most women had a vaginal delivery, the majority of which were ectopic vaginal deliveries. Caesarean section was 29.3%. Regarding vaginal delivery, in our study, the majority of reasons for instrumental delivery were due to induction failure, RFWL and induction failure. Evidence [27] suggests that there appears to be evidence of reduced uterine contractility in obese pregnant women compared to normal weight pregnant women. In the study by Medero Canela et al [28] carried out in Andalusia on obese pregnant women, the mode of delivery was mainly vaginal in 71.5% compared with 28.6% that ended in caesarean section. The complications that led to instrumental deliveries were mainly obstructed labour (49.2%) and foetal distress (47.5%). In the study by Kutchi et al [13] obese women were 4.69 times more likely to experience prolonged labour. In this study, instrumental deliveries were more common in non-obese subjects, although not statistically significant, while most researchers, [22, 23] found an increased risk of operative vaginal deliveries in obese subjects. BMI at the end of pregnancy was lower in women with successful vaginal delivery, as in most studies. [29, 30] This means that the higher the maternal weight, the lower the probability of vaginal delivery. Regarding caesarean delivery, in our study, the main reason for indicating caesarean delivery is for RFWL, followed by mal breech position, induction failure, stationary delivery and Cephalopelvic disproportion. Most of the articles found are along the same lines. In particular, obesity is a significant risk for both planned and emergency caesarean deliveries [31]. Studies have consistently shown higher rates of caesarean section in obese women compared to those with a normal BMI. [17, 32] In relation to the type of delivery, several studies conducted in Spain and other countries [17, 33] show an increased risk of instrumental deliveries and caesarean sections in overweight and obese pregnant women compared to those of normal weight, which increases as the BMI increases.

In terms of complications during labour, our article details that the majority of women did not have any type of complication, compared to 12.2% who had complications during this process. The most common complications were postpartum haemorrhage and hypertensive disorders. In the study by Kutchi et al [13] postpartum haemorrhage was found to be 2.21 times more common in obese subjects, while the risk of pre-eclampsia increased 9.2 times.[34] Concluded in their study that obese nulliparous women have twice the risk of major postpartum haemorrhage, regardless of the mode of delivery. The increased postpartum haemorrhage may be due to a larger placental implantation surface area or a large volume of distribution and reduced bioavailability of uterotonic agents. A systematic review [35] concluded that overweight or obese mothers have a higher risk of preterm birth than mothers with a normal BMI. Obese pregnant women [36] are at increased risk of a range of maternal and perinatal complications, and this risk increases with the degree of obesity.

Obesity in the postpartum period has short and long-term consequences for both the mother and the newborn. The following are the results found in the different studies: Regarding maternal complications in the postpartum period in our study, as detailed in the results, 61.2% had some type of pathology. Among these, a significant association was found between the presence of gestational disorders (such as PIH, GDM and anaemia) and the likelihood of having complications in the puerperium. With regard to the caesarean wound, the main complications were infection and dehiscence. It should also be noted that all treatments increased dramatically in the postpartum period, especially anticoagulant treatments and iron, which more than doubled.

Several articles deal with this issue and find similar results. In the study by Medero Canela et al [28] in the postpartum period, 2.6% had wound infection, 1.6% haemorrhage and 0.7% suture dehiscence. In the study of the Hospital de Loreto, [32] 46.2% of pregnant women with grade I obesity presented some obstetric complication. The most frequent complications were urinary tract infection (40.4%), caesarean section (38.5%), anaemia (23.1%), perineal tear (19.2%), PIH (13.5%) and pre-eclampsia (13.5%). In other studies, [37] showed that postpartum haemorrhage is more frequent in obese women. In the "Obstetric care protocol on obesity and pregnancy" by the S.E.G.O.[38] the main causes of maternal mortality, such as pre-eclampsia, postpartum haemorrhage and obstructed labour are significantly increased by obesity. Therefore, there is an indirect influence between obesity and maternal or foetal mortality. In the study by Rodriguez Mantilla [39] one of the factors that was not associated with anaemia in postpartum women was gestational obesity. In the study by Kutchi et al, [13] the risk of GDM was 4.85 times higher among obese pregnant women with 12.46 times higher risk of requiring insulin. The postpartum period,[40] remains a high-risk period for obese women (endomyometritis, wall infection and thromboembolism). Universal assessment of thrombotic risk in the immediate postpartum period should be performed in all pregnant women.

Regarding neonatal complications, our study found that maternal obesity is significantly associated with the need for NICU admission. In addition, neonates born to obese mothers were found to have an increased risk of NICU admission due to conditions such as respiratory distress and prematurity (up to 1.2 times higher). Much of the literature reviewed shows that infants born to obese mothers require more admissions to the neonatal unit and therefore more associated complications. Based on the literature consulted⁴¹ there is no doubt that there is a positive relationship between maternal obesity and perinatal outcomes, which put not only the life of the pregnant woman at risk but also the development of the foetus and neonate at birth. The meta-analysis of Camacho Prieto et al, [41] demonstrated an increase in foetal weight and foetal macrosomia in overweight and obese pregnant women. The risk of foetal macrosomia increases with BMI. These same results have been corroborated by other authors [33] and are independent of weight gained during pregnancy and of GDM. Different studies [18, 19, 42, 43] report an increased risk for obese women to have affected offspring. Rougée LR et al [44] concluded that maternal obesity was significantly associated with elevated neonatal unconjugated bilirubin levels. Furthermore, newborns in the obese group were 3.26 times more likely to be admitted to the NICU. Callaway LK et al, [45] in their study concluded that respiratory distress was not significantly different between the obese and non-obese group of mothers, while the need for mechanical ventilation increased significantly with increasing maternal BMI. A meta-analysis [46] concludes that unexplained foetal mortality is 50% higher in overweight patients and twice as frequent in those with obesity.

Limitations

A fundamental limitation of the study is that, despite the fact that the sample represents practically the entire population of Cantabria, it was not possible to collect the sample from Laredo Hospital or Mompía Hospital because the women's BMI was not recorded. It was not possible to collect the sample from Laredo Hospital or Mompía Hospital because the BMI of the women was not recorded, these being the other two hospitals in Cantabria where deliveries take place. In any case, Laredo Hospital had 257 deliveries in 2021 and 306 in 2022 and refers most of the obese pregnant women to the reference hospital, the Hospital Universitario Marqués de Valdecilla. Mompía Hospital had 198 deliveries per year in 2021 and 174 in 2022. While in the Marqués de Valdecilla University Hospital, there were 2768 deliveries in 2021, representing 85.88% of all deliveries in Cantabria, and 2679 deliveries in 2022, representing 84.80%.

Obesity in pregnancy is a conflict for public health because it increases obstetric and neonatal risks, [47] increases the risk of presenting diseases and complications during pregnancy and childbirth [48] and in the fetus the disorders include: Foetal macrosomia, respiratory distress syndrome, SGA foetuses, prematurity, genetic malformations and increased risk of foetal death.[49] Maternal obesity [46] contributes significantly to poorer outcomes for both mother and baby during labour and in the immediate postpartum period. National clinical guidelines for the management of obese pregnant women and public health interventions are urgently needed to protect the health of mothers and their babies.

Funding Declaration. This study has not been funded.

The authors declare that they have no conflict of interest.

ANOVA: Analysis of Variance

BMI: Body Mass Index

GDM: Gestational Diabetes Mellitus

HTN: Hypertension arterial

NICU: Neonatal Intensive Care Unit

SGA: Small for gestational age

PIH: Gestational hypertension or pregnancy-induced hypertension

RFWL: Risk of Foetal Well-being Loss

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Funding Declaration. This study has not been funded.

The authors declare that they have no conflict of interest.

AUTHOR CONTRIBUTION

Study design: Alba DIEZ-IBARBIA, Juan Manuel ODRIOZOLA-FEU, Carmen SARABIA-COBO.

Data collection: Alba DIEZ-IBARBIA.

Data analysis: Alba DIEZ-IBARBIA, Carmen SARABIA-COBO.

Study supervision: Carmen SARABIA-COBO, Juan Manuel ODRIOZOLA-FEU.

Manuscript writing: Carmen SARABIA-COBO, Eva DIEZ-PAZ.

Critical revisions for important intellectual content: Juan Manuel ODRIOZOLA-FEU, Carmen SARABIA-COBO.

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Maternal-Foetal Complications in Pregnant Women with Obesity: a predictive model

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Abstract

Background

Methods

Results

Conclusions

INTRODUCTION

METHODOLOGY

Study design

Study subjects

Inclusion and exclusion criteria

Variables

Data Collection Procedure

Ethical considerations

Statistical analysis

RESULTS

Gestational stage

Labor

Postpartum

Medication

Newborn

DISCUSSION

Limitations

CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1