In overweight and obese pregnant women, these changes are magnified; insulin resistance is more severe than in normal weight women, substantially raising the risk of impaired glucose tolerance and frank gestational diabetes mellitus. This increased risk of impaired glucose tolerance has consequences for the fetus since glucose freely crosses the placenta; specifically, in pregnant women who have hyperglycemia, the fetus also experiences hyperglycemia.
In a hypothesized sequence that Freinkel et al. This increase is manifest as larger size at birth, which translates into higher rates of LGA and lower rates of SGA newborns see discussion below kilbrive in Chapter 3. Presumably through developmental programming mechanisms, increased fetal adiposity also in increased adiposity in the growing. Other fuels besides glucose may also be involved. Crowther et al. This same impaired physiologic milieu may also increase the risk for long-term complications, particularly obesity and its metabolic sequelae.
Observational studies suggest that this may be the case. For example, among 5- to 7-year-old children in two American health plans, Hillier et al. However, long-term babu follow-up studies and relevant randomized trials are necessary to conclusively determine if treatment of GDM or babt glucose intolerance during pregnancy can reduce adiposity and related physiology. Most of the evidence in support of the Freinkel hypothesis comes from animal experiments, such as those of van Assche and colleaguesand more recently Plagemann and colleagues By pharmacologically induced GDM in rats, both groups of researchers observed fetal hyperglycemia and hyperinsulinemia, as hypothesized, as well as changes in the hypothalamus that give rise to hyperphagia, overweight, and impaired glucose tolerance in maturing offspring.
Another way to induce offspring metabolic derangement in rats is through overfeeding the pregnant dam. For example, Samuelsson et al. Earlier work by Dorner et al. In their review of animal studies, Aerts and Van Assche demonstrate that these intergenerational physiologic effects are maternally transmitted, most likely through epigenetic processes. Seemingly paradoxically, in animal experiments it is also possible to produce offspring that have insulin resistance, features of the metabolic syndrome, and diabetes, including GDM, by reducing energy or macronutrient intake of the mother during pregnancy.
This situation can also result in intergenerational amplification of obesity and its consequences. For example, in rats, Benyshek et al. In summary, animal experiments show that offspring obesity and related metabolic sequelae can be induced experimentally, either through pharmacological induction of GDM or through either over- or underfeeding pregnant dams as well as through mechanical means like uterine artery ligation.
Epigenetic modifications likely explain many of these phenomena Simmons, A human counterpart to the animal experimental work is epidemiologic studies showing that higher birth weight is related to later obesity and eas 2 diabetes while lower birth weight is associated with central obesity, the metabolic syndrome, and indeed, type 2 diabetes as well Gillman, In other Find a woman for free in Logan New Mexico, a U-shape relationship exists between birth weight and obesity-related health outcomes.
The extent to which these observations on metabolic dysfunction and offspring obesity have relevance for GWG guidelines is still unclear. Few animal studies directly assess the influence of GWG on short- or long-term offspring outcomes. Animal experimentalists typically do not measure weight gain during pregnancy, and it is not clear Lonely women wants casual sex Elgin appropriate hj models exist to study GWG and offspring obesity-related outcomes.
Tj baby east kilbride, human population studies that rely on birth weight or its components, duration of gestation, and size at birth as predictors of later outcomes e. Further, intervention studies to treat GDM do not in themselves provide evidence for making recommendations for appropriate GWG. Only randomized trials that alter weight gain during pregnancy can address that goal directly. In a randomized controlled trial of reduced weight gain among obese pregnant women, Wolff and colleagues bagy that reduced weight gain led to reduced insulin and leptin concentrations but that glucose values were hardly altered.
Mean weight gain in the intervention group was 6.
Although the study was small, with only 50 participants, the nonetheless raise the possibility that moderating GWG may reduce the risk of GDM and, in turn, childhood obesity, but larger and longer-term studies are needed to address this question directly. The literature on GWG in relation to these outcomes remains more limited, with the exception of its influence on fetal growth Cedergren, ; Kiel et al. Obesity and extreme obesity: new insights into the black-white disparity in neonatal mortality.
Obstetrics and Gynecology 6 : — Reprinted more Naeye and NCHS showed that women with both low prepregnancy BMI and low GWG tended to have elevated risk of fetal or perinatal mortality a combination of stillbirth and neonatal mortality and that women with both elevated prepregnancy BMI and excessive GWG experienced increased kilbbride of the same adverse outcomes.
Many studies on the potential association between GWG and stillbirths have been limited by confounding factors. For example, an analysis from the Californi Health and Development Studies of the School of Public Health, University of California, Gj Tavris and Read, found a strong inverse association between total GWG and fetal death, but the association was found to be an artifact of using cumulative weight gain beautiful nude women north bend oregon the predictor; so it reflected the fact tj baby east kilbride duration of gestation for stillbirths was notably shorter than gestational duration of live births, not that lower GWG predicted fetal death.
A case-control study of stillbirths in Sweden reported a strong positive association between prepregnancy BMI and stillbirth, with odds ratios approaching 3. In summary, the research on GWG and stillbirth remains quite limited in eats and quality. In addition to considering prepregnancy BMIthere is a need to avoid the error of comparing total GWG in pregnancies resulting in stillbirths with those resulting in live births because of the time in pregnancy when stillbirth is likely to occur.
Although early studies suggested adverse effects of low GWG among women with low prepregnancy BMI and also of high GWG among women with elevated prepregnancy BMI, more detailed studies have not been done to corroborate or refute this pattern. Recent, better studies largely do not support an association between GWG and stillbirth. Since the etiologic period for congenital defects is so early in pregnancy, GWG is not likely to be causally relevant.
Although the literature on prepregnancy BMI and congenital defects now suggests an increased risk of birth defects with increasing BMI Watkins et al. Shaw reported that infants born to mothers who kilbbride less than either 5 or 10 kg during pregnancy were at increased risk of neural tube defects. An additional report indicated that dieting to lose weight during pregnancy was associated with an increased risk of neural tube defects Carmichael et al. It seems more likely that an association of GWG and birth defects would result from reverse causality abnormal fetal development affecting weight gain rather than a direct causal effect of GWG on risk of birth defects.
Kilbfide fact, concern with fetal growth and preterm birth as health outcomes stems largely from the known relationships between those outcomes and infant mortality as well as morbidity ; studies that directly address mortality can be helpful in interpreting the patterns seen with those other, intermediate outcomes such as preterm birth or growth restriction.
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jilbride However, very limited research assessing GWG and infant mortality exists. Since then, there has been only one additional study. Among underweight and normal-weight women, low GWG was associated with a marked increase in infant mortality, with relative risks on the order of 3—4 compared to those with the highest GWG; the effects were more modest among overweight and obese women, with both lower and higher GWG associated with about two-fold increases in the risk of infant mortality.
In all cases, the patterns were stronger for neonatal deaths in the first 30 days of life than for post-neonatal deaths those occurring after 1 month but before the completion of 1 year. In the lowest weight gain group, the relative risks for neonatal death were 3. In the highest GWG group, the relative risks for neonatal mortality for underweight, normal weight, overweight, bxby obese women were 1. Maternal age at delivery Women want sex tonight Beaver Bay Minnesota not affect neonatal mortality.
After adjusting for gestational age at delivery, no association was found between teenage pregnancy and neonatal mortality. The same general pattern was seen tj baby east kilbride postneonatal deaths but was less pronounced see Table More studies of infant mortality are needed, but the evidence from Chen et al.
Although this study did not link GWG to those intermediate outcomes or intermediate outcomes Ladies seeking nsa Van Wert mortality, the strength of the patterns and their parallels easr studies of fetal growth add credibility to the presumption that a causal chain from GWG to adverse birth outcomes to death is operative.
Based on a limited volume of research, but one well-done study, the committee considered Beautiful woman want real sex Pismo Beach evidence for a link to infant mortality to be moderate. The association was deemed killbride of lengthy consideration eat, as noted in IOM and by others, smaller size at birth is associated with increased fetal and infant mortality, cerebral palsy, hypoglycemia, hypocalcemia, polycythemia and birth asphyxia, persistent deficits in size, and persistent deficits in neurocognitive performance Pryor et al.
Adverse health outcomes associated with small size at birth tend to follow a dose-response relationship with elevated relative risks at the lowest weights. Large size causes delivery complications, including shoulder dystocia haby other forms of birth injury, as well as cesarean delivery, maternal death, and fistulae IOM, Birth weight is a function of both duration of gestation and rate of fetal growth, so that studies using birth weight alone as a health outcome are less informative than those that distinguish between these processes.
In order to isolate fetal growth rate from duration of gestation, studies often use SGA and LGA instead of tj baby east kilbride weight as measures of fetal growth rather than birth weight. Most commonly, infants in the lowest and highest 10th percentiles of birth weight for gestational age are classified as SGA and LGA, respectively, although some researchers use the kulbride extreme values of the 5th percentile or two standard deviations or more below or above the mean.
Such differences are not immutable, however, because health disparities are strongly influenced by social and behavioral factors. Among obese women, the association between increased GWG and increased birth weight was questionable. kilbridw
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The patterns of influence of GWG on fetal growth were evident both for mean birth weight and for the tails of the birth-weight-by-gestational-age distribution, which are usually referred to as intrauterine growth restriction IUGR and macrosomia, respectively. Thus may not be comparable across studies when different indices are used.
In addition, observational studies have consistently Married couples looking fucking fetish inadequate GWGespecially in underweight and normal weight women, with increased risk for SGAand excessive weight gain, especially in overweight and obese women, with increased risk of LGA and its sequelae. A series of early randomized trials of dietary supplements, carefully reviewed by Susserprovide evidence causally linking improved nutrition to GWG and to fetal kilbfide but only for women who were near starvation.
The evidence provides very little support for the argument that increased energy or protein intake during pregnancy enhances fetal growth in general; for other groups of pregnant women i. In contrast, from a Cochrane systematic review suggested that supplementation consistently reduced kilbide of SGA, although this does not necessarily mean that such benefits were mediated by GWG Kramer and Kakuma, Another set of recent randomized tj baby east kilbride have focused directly on the impact of limiting GWG to determine whether this in short-term metabolic effects or improved clinical outcomes.
Polley et al. The intervention yielded benefits in preventing excessive GWG only among normal weight women. Women whose GWG was moderated had infants that weighed 93 g less on average than controls. Fewer of the treated developed GDM or had cesarean deliveries.
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In summary, the issue of whether the association between GWG and fetal growth is causal cannot be answered with certainty based on the available evidence. Observational data provide replicated indications of a strong association between lower GWG and increased risk of SGAespecially in underweight and normal weight women, and between higher GWG and increased risk of LGAparticularly among overweight and obese women.
If either of the two non-causal explanations is correct, then manipulating GWG will not affect fetal growth directly. However, if the same behavioral changes that produce a more optimal GWG also happen to result in a more optimal fetal growth, then fetal growth would be affected. The available randomized trials are either only indirectly applicable because they are from less-relevant populations and time periods or involved only a particular form of supplement, e.
In the absence of clear evidence on the causal pathway and in an effort to ensure that the newly recommended guidelines tj baby east kilbride protective of the health of the fetus and infant, the committee pd that the relationship between GWG and fetal growth was causal. Every one of those studies demonstrated an association between higher GWG and higher infant birth weight. Although there was substantial variability in magnitude of effect across studies, in general birth weight differed by about g between the lowest and highest GWG.
The fewer studies that considered weight gain by trimester tended to show a smaller increase in birth weight per Interracial swingers in San Diego California increase in GWG in the third than in the first or second trimesters. Although the magnitude of association varied substantially across studies, in general the highest GWG category had roughly half the risk of an LBW infant compared to the lowest GWG category.
Recognizing the variability in definitions of macrosomia and GWGthe committee found that the studies showed a consistent trend for increased risk of macrosomia with increasing GWG. Relative risks were 2—3 for macrosomia in the highest compared to Mature horny in Mandaug lowest GWG category.
These consistently indicate that the relationship of GWG to birth weight applies across the full range of weights and is not limited to the low or high end of the distribution. However, because birth weight is a combination of fetal growth and duration of gestation, studies that separate these two components are Lonely wives seeking hot sex Akron informative.
It is difficult to provide quantitative estimates of the magnitude of this effect given variable study methods andbut as for LBWrelative risks were on the order of 2—3 across extreme GWG. In the 10 studies in which GWG and LGA were considered, there was reasonably consistent support for a positive association. First, Lof et al. Second, Segal et al. This large, carefully done study is important not only because it quantifies the magnitude of effect of GWG on birth weight, but also because it is consistent with the large body of evidence demonstrating an overall shift of fewer SGA and more LGA births and higher mean birth weight with increasing GWG see Appendix GPart I.
The magnitudes of association between GWG and SGA are striking, with more than a fold gradient in risk from lowest to highest weight gain for underweight women, and a 3- to 4-fold gradient in risk for women in the other BMI see Table It appears that the entire birth weight distribution is shifted upward with increased GWG, reducing the risk of SGA and increasing the risk of LGA as the mean birth weight rises. The evidence that this pattern is enhanced among women with low prepregnancy BMI is moderately strong as well.
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It is not yet clear, however, whether the associations between GWG and birth weight for gestational age is impacted by factors other than prepregnancy BMI. The IOM report suggested consideration of a different relationship between GWG and fetal growth among young mothers, but studies conducted since then have failed to provide any additional support for the differential effects by maternal age group.
Research on the potentially differential Sweet women wants real sex Tahlequah of GWG on fetal growth according to ethnicity, smoking status, or other maternal attributes has been sparse, and the few studies summarized in the AHRQ review inconsistent. In addition tj baby east kilbride prepregnancy BMI, the only other factor that appears to impact the association between GWG and birth weight for gestational age is time during pregnancy that GWG occurs, with modest support for a stronger effect of GWG that occurs during the first or second trimester than during the third trimester GWG Viswanathan et al.
Morbidity risks associated with preterm birth include acute respiratory, central nervous system, and gastrointestinal disorders, long-term deficits in neurobehavioral development IOM,and possibly adverse cardiometabolic outcomes Hofman et al. At the time of the IOM report, the volume and quality of literature on preterm birth was quite limited. Several studies suggested that low GWG was associated with increased risk of preterm birth, but much of that may babt resulted from the simple error of failing to recognize that the shortened period of pregnancy i.
Eastt total GWG between preterm and term klbride is meaningless since preterm birth, by definition, involves a shorter period of gestation, thereby truncating the opportunity for weight gain compared to term births. The of that effort suggested a modest U-shaped relationship between rate of net weight gain kilbrode only proper measure to compare pregnancies of varying duration and risk of preterm birth. The studies show a consistently increased risk of preterm birth among women in both the lowest and highest GWG.
It is difficult to summarize the quantitative impact because the studies used varying definitions of high and low rates of weight gain and different analytic methods to characterize the relationship with preterm birth.
In those studies that provided relative risks comparing higher and lower GWG to the yj range, the relative risks were on the order of 1. The authors of these studies consistently reported a stronger effect of a lower rate of GWG on preterm delivery among underweight women. Four of the five studies that applied the IOM guidelines to define adequacy of GWG reported increased risk of preterm birth associated with inadequate GWG among underweight and normal weight women.
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