A new care pathway to optimize gestational weight gain in twin pregnancies

Abstract

Maternal gestational weight gain (GWG) is an important determinant of pregnancy outcomes and may have an even greater role in twin pregnancies due to the higher rate of pregnancy complications and greater nutritional demands. However, data on the optimal week-specific GWG in twin pregnancies and interventions that should be taken in cases of inadequate GWG are limited. To determine whether a new care pathway that involves monitoring GWG using a week-specific chart along with a standardized protocol for managing cases with inadequate GWG can optimize maternal GWG in twin pregnancies. In this study, patients with twin pregnancies followed in a single tertiary center between Feb-2021 and May-2022 were exposed to the new care pathway (post-intervention group). GWG and clinical outcomes were compared with a previously described cohort of patients with twins followed in our clinic before the implementation of the new care pathway (pre-intervention group). The new care pathway targeted patients and care providers and included educational material, a newly developed BMI-group-specific GWG chart, and a stepwise management algorithm in cases of inadequate GWG. The BMI-group-specific GWG charts were divided into three zones: (1) green zone (optimal GWG, at 25th-75th centiles); (2) yellow zone (suboptimal GWG, at 5th-24th or 76th-95th centiles); and (3) gray zone (abnormal GWG, at <5th or >95th centile). The primary outcome was the overall proportion of patients achieving optimal GWG at birth. A total of 123 patients were exposed to the new care pathway and were compared with 1079 patients from the pre-intervention period. Patients in the post-intervention group were more likely to achieve optimal GWG at birth (60.2% vs. 47.7%; adjusted odds ratio [aOR] 1.91, 95%-confidence interval [CI] 1.28.2.86) and were less likely to achieve low suboptimal GWG (7.3% vs. 14.7%; aOR 0.41, 95%-CI 0.20-0.85) or any suboptimal GWG (26.8% vs. 34.8%; aOR 0.60, 95%-CI 0.39-0.93) at birth. In addition, patients in the post-intervention group were less likely to experience low-abnormal GWG anytime during gestation (18.9% vs. 29.1%, p=0.017) and were more likely to experience normal GWG throughout pregnancy (21.3% vs. 14.0%, p=0.031) or high-abnormal GWG anytime during gestation (18.0% vs. 11.1%, p=0.025), suggesting that the care pathway is more effective than the standard care in preventing patients from moving into the low-abnormal zone than the high-abnormal zone. Furthermore, the new care pathway was more effective than the standard care in correcting high-suboptimal GWG and high-abnormal GWG. Our findings suggest that the new care pathway may be effective in optimizing maternal GWG in twin gestations, which may, in turn, contribute to better clinical outcomes. This is a simple, low-cost intervention that can be easily disseminated among providers caring for patients with twin pregnancies.