Outcomes In Obese Women Research Articles

ASSOCIATION OF BODY MASS INDEX WITH EMBRYONIC PLOIDY IN PATIENTS UNDERGOING IN VITRO FERTILIZATION WITH PREIMPLANTATION GENETIC TESTING FOR ANEUPLOIDY

Preimplantation genetic testing for aneuploidy (PGT-A) offers a unique opportunity to investigate genetic etiologies for impaired reproductive outcomes associated with obesity in women who undergo in vitro fertilization (IVF). It is currently unknown whether inferior IVF outcomes in obese women are caused by an impaired uterine environment, compromised oocyte quality, or a combination of the two. To date, attempts to isolate the effect of body mass index (BMI) on IVF outcomes using the donor IVF model have produced inconclusive results.

The vertical dimension of obesity: adverse pregnancy outcomes in the short obese versus tall obese parturient

The objective of this study was to examine the effect of maternal height on adverse perinatal outcomes in obese parturients. This retrospective study was conducted from January 2015 to December 2015. Patients with BMI ≥ 35.0 kg/m2 before delivery were included and divided into 2 groups based on height. Patients ≤63 inches were in the short stature group and those > 63 inches were in the tall stature group. One hundred and twenty-five patients were in the short stature cohort and 124 in the tall stature cohort. Patients in short cohort had a significantly higher risk of preterm delivery <37 weeks (RR = 4.21 [1.24, 12.88]), spontaneous rupture of membranes (RR 1.47 [1.01–2.16]), and second stage caesarean delivery (CD) (RR 2.64 [1.1–6.39]). After multiple regression analysis, Hispanic race and short stature were independent predictors of preterm birth for obese patients. IMPACT STATEMENT What is already known on this subject? Compared to normal weight individuals, those who are obese have at a higher risk of adverse obstetric and perinatal outcomes including gestational diabetes, hypertension, pre-eclampsia, thromboembolism, macrosomia, higher incidence of caesarean deliveries and perinatal mortality. What do the results of this study add? Our findings show that short stature is an independent predictor for adverse perinatal outcomes in obese women. Specifically, short obese patients had significantly higher risk of preterm delivery before 37 weeks and second stage CD. What are the implications of the findings for clinical practice and/or further research? Our findings highlight the need for formulating a tailored plan for preconception health including pregnancy weight goals in short obese women. Additionally, maternal fat distribution and its effect on pro-inflammatory cytokine profiles is a potential area for future research, as maternal body composition may be a better predictor of perinatal outcome than BMI.

Effect of a Low-Glycemic Load Diet Intervention on Maternal and Pregnancy Outcomes in Obese Pregnant Women.

The increased prevalence of obese, pregnant women who have a higher risk of glucose intolerance warrants the need for nutritional interventions to improve maternal glucose homeostasis. In this study, the effect of a low-glycemic load (GL) (n = 28) was compared to a high-GL (n = 34) dietary intervention during the second half of pregnancy in obese women (body mass index (BMI) > 30 or a body fat >35%). Anthropometric and metabolic parameters were assessed at baseline (20 week) and at 28 and 34 weeks gestation. For the primary outcome 3h-glucose-iAUC (3h-incremental area under the curve), mean between-group differences were non-significant at every study timepoint (p = 0.6, 0.3, and 0.8 at 20, 28, and 34 weeks, respectively) and also assessing the mean change over the study period (p = 0.6). Furthermore, there was no statistically significant difference between the two intervention groups for any of the other examined outcomes (p ≥ 0.07). In the pooled cohort, there was no significant effect of dietary GL on any metabolic or anthropometric outcome (p ≥ 0.2). A post hoc analysis comparing the study women to a cohort of overweight or obese pregnant women who received only routine care showed that the non-study women were more likely to gain excess weight (p = 0.046) and to deliver large-for-gestational-age (LGA) (p = 0.01) or macrosomic (p = 0.006) infants. Thus, a low-GL diet consumed during the last half of pregnancy did not improve pregnancy outcomes in obese women, but in comparison to non-study women, dietary counseling reduced the risk of adverse outcomes.

936 Sociodemographic factors and maternal and neonatal outcomes in obese women (BMI≥30)

Sociodemographic (SD) factors and obesity (BMI>30) are correlated, and both are associated with poor perinatal outcomes including preeclampsia, preterm birth, low birthweight, and perinatal death. Which specific SD factors are associated with poor outcomes in these women is understudied. We evaluated SD factors independently associated with poor maternal and neonatal outcomes in obese women. This was a retrospective cohort study of Medicaid funded women offered enhanced social and nutritional services through the Strong Start Program (1/2013-12/2015). We included women with singletons and BMI≥30 at first prenatal visit. Primary outcomes were composite maternal and neonatal morbidity (Figure). We evaluated 24 maternal and partner sociodemographic and other characteristics for association with maternal and neonatal morbidity (Table). Chi-square, Fisher’s exact, Student’s t-test, and Wilcoxon rank sum tests were used to compare outcomes across exposures. We used multivariable logistic regression models with backward selection to determine most significant SD factors associated with maternal and neonatal morbidity. 411 women were included for analysis: 243 (59%) with maternal morbidity, 195 (47%) with neonatal morbidity. Multiple sociodemographic factors were significantly associated with maternal and neonatal morbidity (see table for bolded exposures), all with p<0.01. After multivariable analyses, high school education, and paternal unemployment as well as multiparity chronic hypertension, and pre-gestational diabetes, were factors most associated with maternal outcomes (Figure). Family financial support and paternal full time employment as well as the medical co-morbidities were associated with neonatal outcomes (Figure). In low-income women with BMI≥30, specific maternal and partner social factors and preexisting medical conditions are independently associated with adverse outcomes. This suggests poor outcomes in these women may arise from a complex interplay of lack of financial/social support and medical comorbidities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

637 Gestational age specific risks for obese women with and without other risk factors

Obesity is one of the most preventable pre-pregnancy risk factors for adverse perinatal events. Despite this, there are few body-mass-index (BMI) specific prognostic models for timing of delivery associated with the lowest number of adverse perinatal events. Our aim was to build a model to estimate gestational age-specific rates of adverse perinatal outcomes in obese women with and without additional risk factors. This was a retrospective cohort study of all singleton births at ≥34 weeks’ gestation in British Columbia, Canada, 2008-2017. Data were obtained from the British Columbia Perinatal Database Registry. A multivariable Cox proportional hazards model including demographic and obstetric risk factors was used to estimate gestational age specific risk of composite perinatal mortality and severe morbidity for women at various weight classes. Interactions between obesity and other important risk factors were assessed on both the additive and multiplicate scales. Among all women (n=283,697), 13.1% were obese (pre-pregnancy BMI ≥30m/kg2), and 60.1% had normal BMI (18.5-24.9 m/kg2). As a fraction of ongoing pregnancies, adverse outcomes increased with increasing gestational age at delivery in women of all weights. There was a dose-response relationship with increasing BMI with those morbidly obese (BMI ≥ 40m/kg2) at the highest risk. Other key risk factors included nulliparity, chronic hypertension and diabetes mellitus. Obese women with any of these additional risk factors exhibited far worse outcomes than those without with increasing disparities at later delivery. There was additive interaction between nulliparity, chronic hypertension and diabetes mellitus and obesity, but no multiplicate interactions. Obese women are at increased risk of worse perinatal outcomes at all gestational ages. These risks are compounded by other known risk factors of adverse perinatal outcomes, especially closer to term.

Biological and Psychological Stress Correlates Are Linked to Glucose Metabolism, Obesity, and Gender Roles in Women

Objectives: Psychological stress affects central as well as peripheral metabolism and hormone trafficking via the hypothalamic-pituitary-adrenal axis. Stress thereby plays a decisive role in the etiology and progression of overweight and obesity, leading to several chronic diseases, such as diabetes, and mental health disorders. The interplay of biological and psychometric correlates of stress, anthropometric, immunological, and metabolic parameters and psychosocial factors such as gender roles, however, remains poorly understood. Methods: In this exploratory study, 43 healthy women were assessed for glucose metabolism by an oral glucose tolerance test and computation of functional parameters for insulin secretion, sensitivity, and resistance. Further, the fatty liver index (FLI) and anthropometric parameters body mass index (BMI), waist-to-hip ratio, body fat, and lean mass were assessed. Psychological stress assessment included the “Brief Symptom Inventory” (BSI), the “Burnout Dimensions Inventory” (BODI), and Perceived Stress Scale (PSS). Biological stress response was evaluated with heart rate variability and cortisol levels. Finally, gender role self-identification was assessed with the “Bem Sex-Role Inventory” (BSRI). Generalized linear models were computed for exploratory association with psychometric outcome. Uncorrected p values are reported. Results: Burnout and PSS scores were associated with insulin secretion, sputum cortisol, thyroid-stimulating hormone, anthropometric measures, and gender role. BSI ratings for psychiatric symptom dimensions were associated with insulin resistance, sex hormones, anthropometric measures, and gender role. Female self-identification was associated with higher BMI as well as body fat and a higher FLI. Conclusions: Considering the increased risk of unfavorable metabolic, cardiovascular, and also mental health outcome in obese women, a higher BMI in women with predominant female gender self-identification may be relevant for clinical risk assessment. The broad range of interacting biological, psychological, and gender-related parameters calls for an integrative management of both mental and endocrinological health. However, the exploratory nature of the study requires replication in larger samples before definite conclusion can be drawn.

Impact of obesity on clinical outcomes in hormone receptor-positive breast cancer: a systematic review.

The relationship between obesity and prognosis of early breast cancer is complex. Increased levels of aromatase present in adipose tissue of obese postmenopausal women may lead to suboptimal suppression of systemic estrogens. However, studies have been mixed with respect to the association between use of aromatase inhibitors (AIs) and clinical outcomes in obese women with early breast cancer. We conducted a systematic literature review following PRISMA guidelines to examine the impact of obesity on the efficacy of AIs in early-stage hormone receptor-positive breast cancer. Primary outcome measures included disease-free survival, relapse-free survival, distant recurrence-free survival, breast cancer-free survival, and overall survival. Of 491 studies identified, eight studies met criteria for inclusion: three retrospective cohort studies, one prospective cohort study and four randomized controlled trials. Four studies limited eligibility to postmenopausal women. Percentage of obese patients in studies ranged from 10 to 30%. Two studies examined use of AIs alone while the remainder included patients treated with either AIs or tamoxifen. Five out of seven studies suggested a negative impact of obesity on AI efficacy. The results of our systematic review highlight a need for further research exploring the optimal endocrine therapies for obese women. There is insufficient evidence at present to recommend tailoring adjuvant endocrine therapy with use of specific AIs or for dosing modifications of AIs in this patient population.

The Impact of COVID-19 Lockdown on Weight Loss Program in Infertile Polycystic Ovary Syndrome Women with Obesity

Introduction: Lockdown due to the COVID-19 pandemic has caused gym closures and adjustments to ongoing weight loss programs were needed in order to keep the programs running. Little is known whether adjustments affected the success of weight reduction. Weight reduction of at least 5% is related to improved fertility and better pregnancy outcomes in obese women. This study compared success of the weight loss program in infertile polycystic ovary syndrome women with obesity who attended the program before and during lockdown due to COVID-19 pandemic. Furthermore, we checked whether there were any differences in spontaneous pregnancy rates between both groups at the end of the program. Methods: Altogether, 27 women were prospectively included to the weight loss program. Twelve women attended the 8 – week program before COVID-19 pandemic. Fifteen women began the program before the lockdown and ended it during lockdown. Due to lockdown, the program was prolonged for 4 weeks and taken online. Results: On average, prior to lockdown women achieved a BMI reduction of 6.8% whereas women that attended the program during the lockdown reduced their BMI for 3.7%. This difference was not statistically significant. No significant differences were seen in other measured anthropometric and endocrine parameters between both groups. Furthermore, there were no differences in spontaneous pregnancy rates between both groups. In women who reduced their BMI for 5% or more, spontaneous pregnancy rate was 29.4%. Discussion/Conclusions: Although statistical significance has not been reached in the present study, we have shown that lockdown due to COVID-19 pandemic has led to almost half lower BMI reduction despite adaptations and longer duration of the weight loss program. On average, BMI in the group of women that attended the program during lockdown was 3.7% lower after the end of the weight loss program. This means they did not reach the wanted 5% reduction which is known to improve fertility. We have also shown that weight reduction is the correct approach for treating infertile women with obesity, as almost 30% of those who reduced their body weight by 5% or more conceived spontaneously.

Maternal exercise alters rat fetoplacental stress response: Minimal effects of maternal growth restriction and high-fat feeding

IntroductionFetal growth restriction complicates 10% of pregnancies and increases offspring (F1) risk of metabolic disorders, including obesity and gestational diabetes mellitus (GDM). This disease predisposition can be passed onto the next generation (F2). Importantly, the risk of pregnancy complications in obese women can be exacerbated by a stressful pregnancy. Exercise can reduce adiposity and improve health outcomes in obese women and those with GDM. This study investigated the impacts of maternal growth restriction, obesity, exercise, and stress on fetal and placental endocrine function. MethodsUteroplacental insufficiency (Restricted) or sham (Control) surgery was induced on embryonic day (E) 18 in F0 Wistar-Kyoto rats. F1 offspring were fed a Chow or High-fat (HFD) diet from weaning and, at 16 weeks, were randomly allocated an exercise protocol; Sedentary, Exercised prior to and during pregnancy (Exercise), or Exercised only during pregnancy (PregEx). Females were mated and further randomly allocated to either undergo (Stress), or not undergo (Unstressed), physiological measurements during pregnancy. On E20, F2 fetal plasma (steroid hormones), tissues (brain, liver), and placentae (morphology, stress genes) were collected. ResultsMaternal growth restriction and high-fat feeding had minimal impact on fetoplacental endocrine function. PregEx and Exercise increased cross-sectional labyrinth and junctional zone areas. PregEx, but not Exercise, increased fetal deoxycorticosterone concentrations and reduced placental Hsd11b2 and Nr3c2 gene abundance. Maternal stress increased fetal corticosterone concentrations in Sedentary HFD dams and increased placental cross-sectional areas in PregEx mothers. DiscussionPregEx and Stress independently dysregulates the endocrine status of the developing fetus, which may program future disease.

A Review of the Impact of Bariatric Surgery in Women With Polycystic Ovary Syndrome.

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in reproductive-age women that causes infertility. Obesity and insulin resistance are closely tied to the pathophysiology of PCOS. Current first-line treatments include lifestyle modifications, hormone modulators, and laparoscopic ovarian drilling, but little attention has been given to bariatric surgery as a viable option. A detailed review of the literature regarding the outcomes of obese women with PCOS after bariatric surgery is necessary. All studies were found in the PubMed database, limited to females and humans, and selected due to relevancy and quantitative data. Bariatric surgery promotes significant weight loss within one year, which is associated with amelioration of insulin resistance, hyperandrogenism, menstrual irregularity, and ovulatory dysfunction. Surgery successfully mediates the regression of PCOS and promotes successful pregnancy. Thus, we recommend the consideration of bariatric surgery as part of the main treatment considerations in obese patients with PCOS. However, more focused and comprehensive research with better study designs are still needed in the future to investigate PCOS and bariatric surgery.

Prognostic associations of plasma hepcidin in women with early breast cancer.

Iron is essential to energy metabolism, cell proliferation and DNA synthesis, and sufficient iron availability may be required for tumor growth. The hormone hepcidin is a systemic regulator of iron concentration in plasma. Intra-tumor RNA expression of hepcidin has been linked to shorter metastasis-free survival in women with early breast cancer, but the prognostic implications of this inflammatory marker and iron-regulating plasma peptide in the blood are unknown. Using an ELISA assay, hepcidin was measured in the banked blood of 518 women who were recruited from 1989 to 1996 for a prospective cohort study of diet and lifestyle factors in breast cancer. Blood samples were obtained 4-12weeks post-operatively, prior to treatment with chemotherapy or tamoxifen. Hepcidin was not associated with time to distant breast cancer recurrence (primary outcome) nor time to death from any cause. However, a pre-planned interaction test of body mass index (BMI) was statistically significant (p < 0.01). Among obese women (BMI > 30kg/m2), higher hepcidin was associated with a shorter time to distant breast cancer recurrence in both uni- and multivariable analyses (adjusted HR 1.84; 95% CI 1.04-3.25). For overall survival, a similar pattern was seen in the univariable model but the effect was diminished in a multivariable analysis. Plasma hepcidin was not associated with high-sensitivity C-reactive protein, but it was significantly associated (r ≥ 0.32) with iron indices, including total iron (p < 0.01), transferrin (p < 0.01) and soluble transferrin receptor (p < 0.01). Hepcidin may be associated with poor breast cancer outcome in obese women, however, replication is required. The biologic basis for this prognostic association requires further research.

Performance of early pregnancy HbA1c for predicting gestational diabetes mellitus and adverse pregnancy outcomes in obese European women

AimsTo investigate the performance of early pregnancy HbA1c for predicting gestational diabetes mellitus (GDM) and adverse pregnancy outcomes in obese women. MethodsPost hoc analysis using data from the Vitamin D And Lifestyle Intervention for GDM prevention trials conducted across 9 European countries (2012–2014). Pregnant women (BMI ≥ 29 kg/m2) underwent a baseline HbA1c and oral glucose tolerance tests at < 20 weeks, 24–28 weeks, and 35–37 weeks. Women with GDM were referred for treatment. ResultsAmong the 869 women tested, the prevalence of GDM was 25.9% before 20 weeks, with a further 8.6% at 24–28 weeks. The areas under the curves for HbA1c at the two time points were 0.55 (0.50–0.59) and 0.54 (0.47–0.61), respectively. An early HbA1c ≥ 5.7% (39 mmol/mol) (N = 111) showed low sensitivity (18.2%) with 89.1% specificity for GDM before 20 weeks, at 24–28 weeks (sensitivity of 8.0% and specificity of 88.6% after excluding early GDM), and throughout gestation (sensitivity of 15.9% and specificity of 89.4%). The ≥ 5.7% (39 mmol/mol) threshold was significantly associated with concurrent GDM before 20 weeks (adjusted OR (aOR) 2.77(1.39–5.51)) and throughout gestation (aOR 1.72 (1.02–2.89)), but not adverse pregnancy outcomes. ConclusionsEarly pregnancy HbA1c is of limited use for predicting either GDM or adverse outcomes in overweight/obese European women.

OR11-04 Effect of Preconception Intensive vs. Standard Lifestyle Intervention on Birth Outcomes in Obese Women With Unexplained Infertility: A Multicenter Randomized Trial

We hypothesized that weight loss with an intensive preconception lifestyle (IL) intervention of caloric restriction with meal replacements, daily orlistat and increased physical activity in women with obesity and unexplained infertility (UI) was more likely to result in Good Birth Outcome than a standard lifestyle modification (SL) with increased physical activity alone. The 16 week period of lifestyle modification was followed by an open label empiric infertility treatment regimen of 3 cycles of ovarian stimulation with clomiphene, ovulation triggering with hCG and intrauterine insemination. We randomized 379 obese women 18-40y with UI (regular menses, normal ovarian reserve, patent reproductive tract and normal male factor). A Good Birth Outcome (GBO) was the primary outcome, defined as a live birth of an infant born at ≥37wks with a birthweight between 2500-4000g and no major congenital anomaly. Key secondary outcomes were live birth, pregnancy loss and pregnancy complication rates. The study had 80% power and an alpha of 0.05 to detect an absolute 15% difference in GBO. An Intention-to-Treat analysis was used. Both groups (SL N=191, IL N =188) were well matched at baseline(e.g. weight (kg), mean ± SD, SL:107±21, IL: 108 ±23). Women in the IL arm lost significantly more weight preconception than SL (SL -0.3±3.4 vs IL -7.3±6.6 kg, P<.001) with similar decreases in associated biometric and biochemical parameters. Overall 59.4% of the IL group lost >5% weight vs 6.5% in SL group(P<.001). Despite achieving the targeted weight loss, GBO rate between groups was not significantly different (IL12.2% vs SL 15.2%, IL Rate Ratio, 95% CI: 0.8, 0.5-1.3) or in live birth (IL 20.2% vs SL 22.0%, IL RR: 0.9, 0.6-1.4). Pregnancy loss among women who conceived trended higher in the IL group (IL 38.1% vs SL 23.7%, IL RR:1.6, 0.9-2.8) but miscarriage rates (loss after visualized intrauterine pregnancy), were significantly higher in IL (IL 20.6% vs SL 3.4%, IL RR: 6.1, 1.4-25.8, P=0.005). Birthweights were similar in both groups (IL: 3199±712 vs SL: 3106±794g). Major pregnancy complications trended lower in IL: Preterm Labor (IL 3.2% vs SL 10.2%), Pre-eclampsia (IL 6.3% vs SL 11.9%), Gestational DM (IL 9.5% vs SL 16.9%). Adverse events were more common in the IL group, i.e. increased GI side effects of bloating, flatulence, diarrhea and steatorrhea, likely related to use of orlistat. Moderate weight loss prior to conception does not improve live birth or GBO rates compared to exercise alone in obese women. Of concern, early pregnancy loss is more common when conception occurs after IL intervention. However a benefit to IL modification preconception may be lower perinatal morbidity, although further larger studies are necessary to confirm this potential benefit.

Placental function in maternal obesity.

Maternal obesity is associated with pregnancy complications and increases the risk for the infant to develop obesity, diabetes and cardiovascular disease later in life. However, the mechanisms linking the maternal obesogenic environment to adverse short- and long-term outcomes remain poorly understood. As compared with pregnant women with normal BMI, women entering pregnancy obese have more pronounced insulin resistance, higher circulating plasma insulin, leptin, IGF-1, lipids and possibly proinflammatory cytokines and lower plasma adiponectin. Importantly, the changes in maternal levels of nutrients, growth factors and hormones in maternal obesity modulate placental function. For example, high insulin, leptin, IGF-1 and low adiponectin in obese pregnant women activate mTOR signaling in the placenta, promoting protein synthesis, mitochondrial function and nutrient transport. These changes are believed to increase fetal nutrient supply and contribute to fetal overgrowth and/or adiposity in offspring, which increases the risk to develop disease later in life. However, the majority of obese women give birth to normal weight infants and these pregnancies are also associated with activation of inflammatory signaling pathways, oxidative stress, decreased oxidative phosphorylation and lipid accumulation in the placenta. Recent bioinformatics approaches have expanded our understanding of how maternal obesity affects the placenta; however, the link between changes in placental function and adverse outcomes in obese women giving birth to normal sized infants is unclear. Interventions that specifically target placental function, such as activation of placental adiponectin receptors, may prevent the transmission of metabolic disease from obese women to the next generation.

Early gestational diabetes screening in obese women: a randomized controlled trial

Although in 2013 the American College of Obstetricians and Gynecologists recommended early screening for gestational diabetes in obese women, no studies demonstrate an improvement in perinatal outcomes with this strategy. We sought to determine whether early screening for gestational diabetes improves perinatal outcomes in obese women. Randomized controlled trial comparing early gestational diabetes screening (14-20 weeks) to routine screening (24-28 weeks) in obese women (body mass index ≥30 kg/m2) at 2 tertiary care centers in the United States. Screening was performed using a 50-g, 1-hour glucose challenge test followedby a 100-g, 3-hour glucose tolerance test if the initial screen was ≥135 mg/dL. Gestational diabetes was diagnosed usingCarpenter-Coustan criteria. Women not diagnosed at 14 to 20weeks were rescreened at 24 to 28 weeks. Exclusion criteria werepre-existing diabetes, major medical illness, bariatric surgery, andprior cesarean delivery. The primary outcome was a compositeofmacrosomia (>4000 g), primary cesarean delivery, hypertensive disease of pregnancy, shoulder dystocia, neonatal hyperbilirubinemia, and neonatal hypoglycemia (assessed within 48 hours of birth). A total of 962 women were randomized, and outcomes were available for 922. Of these 922 women, 459 (49.8%) were assigned to early screen and 463 (50.2%) to routine screen. Baseline characteristics were balanced between groups. In the early screening group, 69 (15.0%; 95% confidence interval, 11.9-18.6%) were diagnosed with gestational diabetes: 29 (6.3%; 95% confidence interval, 4.3-8.9%) at <20 weeks and 40 (8.7%; 95% confidence interval, 6.3-11.7%) at >24 weeks. Of those randomized to routine screening, 56 (12.1%; 95% confidence interval, 9.3-15.4%) had gestational diabetes. Early screening did not reduce the incidence of the primary outcome (56.9% in the early screen versus 50.8% in the routine screen, P= .07; relative risk, 1.12; 95% confidence interval, 0.99-1.26). Early screening for gestational diabetes in obese women did not reduce the composite perinatal outcome.

205: Effect of weight gain on delivery mode in obese women with normal estimated fetal weight

To study the effect of excessive gestational weight gain (EGWG) on the mode of delivery (MOD) and maternal outcomes in obese women with a normal estimated fetal weight (EFW) who delivered at term. A multi-center observational retrospective cohort study using electronic health record chart review of obese women who delivered at term from October 2016 to June 2019 in UPMC Pinnacle associated hospitals and had a fetal growth ultrasound within 3 weeks of delivery with an EFW within 2500 to 4500 grams. Obese women with normal EFW were compared on the basis of weight gain. EGWG was defined as weight gain of more than 20lbs during the pregnancy by the American College of Obstetrics and Gynecology. Weight gain of more than 20 pounds had no significant effect on MOD in obese women with a normal EFW. Obese women who had EGWG had a significantly lower pre-gravid body mass index (BMI) when compared to obese women with significantly higher pre-gravid BMI (p< 0.0001). Obese women who were delivered by cesarean section had a significantly higher BMI at the time of delivery when compared to the same group who had a vaginal delivery (p=0.0403). There was no significant difference on the MOD between women with class I, class II, and class III obesity. There was no significant difference in the demographics and co-morbidities between the study groups who delivered by cesarean section versus vaginal delivery. Maternal obesity and EGWG has been associated with adverse pregnancy outcomes, large for gestational age infants and cesarean delivery. To our knowledge, the relationship between EGWG in the setting of a normal EFW and MOD had not been previously reported. Our study shows that weight gain in excess of the 20lbs recommended for obese women (class I-III) had no significant effect on the MOD in the setting a normal EFW.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

547: Perinatal outcomes in obese women with 1 abnormal value on 3-hour glucose tolerance test

547: Perinatal outcomes in obese women with 1 abnormal value on 3-hour glucose tolerance test

IL-1β is associated with decreased expression of GREM1 in obese women undergoing in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI)

To investigate obesity associated inflammatory factors in follicular fluid that may affect gene expression in cumulus cells of women undergoing IVF-ICSI. Prospective cohort study. Follicular fluid and cumulus cells were collected during oocyte retrieval in women undergoing IVF-ICSI, and grouped based on body mass index (BMI). Cytokine levels were measured from the follicular fluid using enzyme-linked immunosorbent assay (ELISA). Expression of 4 genes (GREM1, HAS2, PTGS2, VCAN), which have been positively correlated with oocyte maturity and/or pregnancy outcome in cumulus cells, was determined by quantitative reverse transcription polymerase chain reaction (RT-qPCR). Mann Whitney tests were utilized to compare cohorts by BMI and reported as medians with interquartile ranges. Cumulus cells of normal BMI (21.1 kg/m2 to 23.6 kg/m2) women were cultured with IL-1β to investigate its impact on gene expression. Change in gene expression following IL-1β was analyzed by paired t test. P values <0.05 were considered significant. A total of 68 women were included in the ELISA analysis. Women were grouped based on BMI with 57 women having BMI <35 kg/m2 and 11 women having BMI ≥35 kg/m2. Women with BMI ≥35 kg/m2 had increased levels of IL-1β in the follicular fluid as compared to women with lower BMI (5.18 pg/mL vs 1.92 pg/mL, p=0.02). Gene expression from cumulus cells was measured from a representative cohort based on BMI, with 6 in the normal group (BMI 21.1 kg/m2 to 23.6 kg/m2) and 6 in the obese group (35.6 kg/m2 to 42.0 kg/m2). The obese group had a significantly lower relative expression of GREM1 compared to the normal group (0.51 [0.38, 0.74] vs 1.01 [0.66, 1.40], p=0.03). No differences were seen with HAS2 (0.73 [0.49, 1.17] vs 1.06 [0.65, 1.78], p=0.39), PTGS2 (1.54 [1.09, 3.11] vs 0.58 [0.47, 4.19], p=0.22), or VCAN (0.88 [0.61, 1.56] vs 0.93 [0.63, 1.56], p=0.82). Given increased levels of IL-1β in follicular fluid of obese women, cumulus cells from women with normal BMI were cultured with IL-1β to investigate the impact on GREM1 expression. Following IL-1β incubation, GREM1 levels significantly decreased in cumulus cells of normal BMI women (p=0.02) similar to the obese cohort. Compared to women with normal BMI, obese women had higher levels of pro-inflammatory IL-1β in the follicular fluid and had lower cumulus cell expression of GREM1. Decreased expression of GREM1 in cumulus cells of normal BMI women following culture with IL-1β suggests that this pro-inflammatory cytokine may play a role in suppressing GREM1 levels in obese women. These molecular discrepancies may give insight into physiologic differences in oocyte development and cycle outcomes in obese women undergoing IVF-ICSI. Further studies are required to correlate these molecular findings to clinical outcomes.

Guideline No. 386-Gynaecologic Surgery in the Obese Patient.

To provide gynaecologic surgeons with a contemporary review on the pre-, intra-, and postoperative issues of the obese patient and to provide guidance for optimization and strategies for safer surgical care. Physicians, including gynaecologists, family physicians, general surgeons; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. Adult women (18 years and older) meeting criteria for obesity (body mass index ≥30) and undergoing gynaecologic surgery. Physiologic changes and comorbid conditions associated with obesity; the evidence for the impact of obesity on gynaecologic surgery; and preoperative, intraoperative, and postoperative interventions to reduce risk. For this guideline, relevant studies were searched in the PubMed, EMBASE, Medline, and Cochrane databases. MeSH search terms included Gynecology, Obesity, Obesity/morbid, Overweight, Body mass index, Surgery, Laparoscopy, Laparotomy, Anesthesia, Intraoperative complications, Postoperative complications, Morbidity, and Mortality. The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. Obesity affects 1 in 5 Canadian adults. This guideline outlines strategies to improve outcomes in obese women undergoing gynaecologic surgery. This SOGC clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. This guideline was developed with resources funded by the SOGC. RECOMMENDATIONS.

689: Pregnancy outcomes in the setting of super obesity and super-super obesity

We sought to determine differences in pregnancy outcomes associated with maternal super obesity (Body Mass Index [BMI] ≥50) and super-super obesity (BMI ≥60) when compared with maternal morbid obesity (BMI ≥40) and obesity (BMI ≥30). We conducted a retrospective cohort study of 2,333,788 women with singleton, vertex, non- anomalous gestations and BMI ≥30, then examined rates of cesarean delivery, gestational hypertension, gestational diabetes, preterm birth, macrosomia, and Apgar score. Pre-pregnancy BMI was divided into 4 sub-groups (obese, morbidly obese, super obese, and super-super obese). Multivariate regression analyses and chi-square tests were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. Overall, increased BMI was associated with a statistically significant increase in all investigated outcomes. After controlling for multiple confounders, super-super obese women were found to be more likely than obese women to deliver via cesarean (odds ratio [OR], 2.60; 95% confidence interval [CI], 2.42-2.79), deliver preterm (OR, 1.18; 95%CI, 1.05-1.33), have gestational hypertension (OR, 2.0; 95%CI, 1.80-2.22), have gestational diabetes (OR, 1.15; 95%CI, 1.05-1.24), macrosomia (OR, 1.61; 95%CI, 1.37-1.88) and 5-minute Apgar below 7 (OR, 2.16; 95%CI, 1.88- 2.48). Women with BMI ≥60 are at higher risk of pregnancy complications than women with lower levels of obesity. Though baseline obesity has been a standard indicator of risk in pregnancy, this data suggests that any reduction in obesity category could have an important impact on perinatal outcomes in obese women.