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Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc)


Sue Brydon Clinical Educator Obstetrics April 2013 2 Version 1 July 2012 July 2015 All pregnant women with a low BMI This guideline describes the management of women with BMI of <18 Antenatal, low BMI 2a

Contact Name and Job Title (author) Directorate & Speciality Implementation date Version Supersedes Date of submission Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract

Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process

Maternity guideline group Target audience Obstetricians and midwives

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Body mass index (BMI) is calculated as weight (kg) divided by height (m) squared. For example: 55kg divided by (55x55)=21.4. There is no universal definition of low BMI and the range varies from <18.0 to <21 kg/m2. For the purpose of this guideline, the definition referred to in the NICE Antenatal care Guideline (2008), BMI <18. kg/m2 will be used. Although pregnancy complications in overweight women are well documented, the evidence in relation to problems encountered in the low BMI group is less clear. There is little available population based data reporting the effect of extremes of Body Mass index (high or low) on pregnancy outcomes. Low BMI before pregnancy has a genetic as well as notional component and is considered a marker for minimal tissue nutrient reserves. In women with low BMI, there is evidence to show that a normal weight gain during pregnancy (in excess of 12kgs) will increase the likelihood of a good pregnancy outcome. (Spinollo et al,1998, Shieve et al, 2000).

The most recent evidence indicates that there is an association with low BMI and low birth weight babies (Bhattacharya et al 2007). There is also some evidence of a small increase in the risk of pre-term birth (before 37 completed weeks) but no increase in the risk of severe preterm birth (before 33 weeks)

In one large retrospective Cohort study involving 24,241 women, of which 11.7% had a body mass index < 19.9 kg/m2, it was found that a low BMI was associated with a younger age group, smoking and single status without a partner when compared with women with a normal BMI. Low BMI women were also more likely to have low socio-economic status than women with a normal BMI. (Bhattacharya et al 2007). This study also found that the risks associated with low BMI were few, despite the association with adverse socio-economic factors and that the pregnancy outcome for such women is better than that of women with a normal BMI (20-24.9 kg/m2) and markedly better than the outcomes for women with high BMI (>35kg/m2) . It was found that low BMI was associated with a low risk of many pregnancy and labour complications, including diabetes, fetal macrosomia, pre-eclampsia, postpartum hemorrhage, and the need for induction of labour. There was no evidence of any association with pre-term birth and this finding was supported by other studies (Sebire et al 2001, Cnattingius et al 1998) It has been suggested that there is an association with low plasma volume in low BMI women and low birth weight. Low plasma volume results in lowered cardiac output which in turn results in lower uteroplacental blood flow with consequent decrease in the nutrient transfer to the growing fetus. ((Rosso et al 1994)

Some studies have shown an association with low BMI and pre-term birth in association with low weight gain (>0.37kgs/week) in pregnancy (Spinollo et al,1998, Shieve et al, 2000).

Targeted antenatal care.

At Booking 1. Record height, weight and BMI for all women. 2. Refer women with BMI18kg/m2 for consultant led care. Although low BMI may reflect a normal body/weight condition, rule out other causes that may benefit from intervention. Potential causes include: Psychological issues, Alcohol and drug abuse, Disturbed eating behaviours. Nicotine from cigarette smoking suppresses appetite and may contribute to being underweight. Where possible address the causes of low pre-pregnancy BMI. A low BMI may reflect poor nutrition and inadequate nutrient stores. Consider referral to a dietitian/nutritionist for dietary assessment and counselling. Advise multivitamin and consider iron supplementation if clinically indicated (HB below 10.5g/dl).

From 20 weeks Monitor weight gain and symphysis-fundal height (SFH) at each antenatal assessment. The sympysis-fundal height should be plotted on a graph. Between 20 and 28 weeks average weight gain is 1.6Kg (0.2 Kg/week). Low average weekly maternal weight gain (< 0.2 kg) has a positive predictive value of 13% for detecting small for gestational age infants. (NICE 2008) At time of detailed scan Review in consultant clinic At 25 weeks Review by community midwife At 28 weeks refer for Ultrasound scan assessment of growth if any of the following are present: Weight gain less than 1.6Kg between 20 and 28 weeks (0.2Kg/wk) Symphysis-fundal height measurements on or below the 10th centile Static or restricted growth as suggested by SFH measurement In most women with a low BMI clinical assessment is sufficient in order to assess fetal growth. If poor fetal growth is suspected or the

woman is at high risk of growth problems due to other reasons, then an ultrasound scan may be considered for which a review in the hospital consultant clinic is required. Labour If the woman has remained well during the pregnancy and the evidence from symphysis-fundal measurements and ultrasound indicates that the fetus is normally grown then referral for Midwifery led intrapartum care can be considered.

References Bhattacharya Sohinee, Cambell Doris, Liston William: Effect of Body Mass index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007, 7:168 National Institute of Clinical Excellence, Antenatal Care: routine care for the healthy pregnant women, Clinical Guideline 62, London; March, 2008 Sebire NJ, Jolly M, Harris JP, Regan L, Robinson S Is maternal underweight really a risk factor for adverse pregnancy outcome? A population based study in London. BJOG 2001, 108:61-66.

Siega-Riz AM, Adair LS, Hobel CJ. Maternal underweight status and inadequate rate of weight gain during the third trimester of pregnancy increases the risk of preterm delivery. Journal of Nutrition 1996; 126:14653. Spinollo A, Capuzzo E, Piazzi G, Ferrari A, Morales V, DiMario M Risk for spontaneous preterm delivery by combined body mass index and gestational weight gain patterns. Acta Obstet Gynecol Scand 1998, 77:32-36