Research

ajog.org

OBSTETRICS

Weight gain in pregnancy: does the Institute

of Medicine have it right?
Yen N. Truong, MD, MPH; Lynn M. Yee, MD, MPH; Aaron B. Caughey, MD, PhD;
Yvonne W. Cheng, MD, PhD
OBJECTIVE: We aimed to examine whether women who adhered to

Institute of Medicine (IOM) guidelines for gestational weight gain

(GWG) had improved perinatal outcomes.
STUDY DESIGN: This is a population-based retrospective cohort study

of nulliparous women with term singleton vertex births in the United

States from 2011 through 2012. Women with medical or obstetric
complications were excluded. Prepregnancy body mass index was
calculated using reported weight and height. Women were categorized
into 4 groups based on GWG and prepregnancy body mass index: (1)
weight gain less than, (2) weight gain within, (3) weight gain 1-19 lb in
excess of, and (4) weight gain
20 lb in excess of the IOM guidelines.
The c2 test and multivariable logistic regression analysis were used for
statistical comparisons.
RESULTS: Compared to women who had GWG within the IOM guidelines, women with excessive weight gain, particularly
20 lb, were
more likely to have adverse maternal outcomes (preeclampsia: adjusted

odds ratio [aOR], 2.78; 95% confidence interval [CI], 2.82e2.93;

eclampsia: aOR, 2.51; 95% CI, 2.27e2.78; cesarean: aOR, 2.1; 95%
CI, 2.14e2.19), blood transfusion (aOR, 1.22; 95% CI, 1.11e1.33),
and neonatal outcomes (5-minute Apgar <4: aOR, 1.22; 95% CI,
1.14e1.31; ventilation use >6 hours: aOR, 1.24; 95% CI, 1.15e1.33;
seizure: aOR, 1.53; 95% CI, 1.24e1.89). Women who gained less than
IOM guidelines had lower risks of hypertensive disorders of pregnancy
and obstetric interventions but were more likely to have small-forgestational-age neonates (aOR, 1.55; 95% CI, 1.52e1.59).
CONCLUSION: Women whose GWG is in excess of IOM guidelines have

higher risk of adverse maternal and neonatal outcomes, particularly in

women with
20 lb excess weight gain above guidelines while women
who had weight gain below the IOM guidelines were less likely to have
maternal morbidity but had higher odds of small for gestational age.
Key words: gestational weight gain, Institute of Medicine, perinatal
outcomes

Cite this article as: Truong YN, Yee LM, Caughey AB, et al. Weight gain in pregnancy: does the Institute of Medicine have it right? Am J Obstet Gynecol
2015;212:362.e1-8.

n 2009, the Institute of Medicine

(IOM) put forth new guidelines
regarding how much weight women
should gain during pregnancy.1 The
impetus for the update was partly due to
the increasing availability of data on the
effect of gestational weight gain (GWG)
on perinatal outcomes as well as the
changing obstetric population over time
since its last recommendation in 1990.2

In particular, the 1990 guidelines did not

give an upper limit for weight gain in
obese patients whereas the revised 2009
guidelines gave a specic recommended
range for obese women. Compared to
decades prior, women in the United States
today are more likely to delay childbearing, have greater access to assisted
reproductive technology, have multifetal
gestations, have greater racial/ethnic

From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University
of California, Davis, School of Medicine, Sacramento, CA (Drs Truong and Cheng); Division of
Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine,
Northwestern University, Chicago, IL (Dr Yee); and Department of Obstetrics and Gynecology,
Oregon Health & Science University, Portland, OR (Dr Caughey).
Received Nov. 15, 2014; revised Dec. 13, 2014; accepted Jan. 19, 2015.
The authors report no conict of interest.
Presented in oral format at the 35th annual meeting of the Society for Maternal-Fetal Medicine,
San Diego, CA, Feb. 2-7, 2015. The racing ag logo above indicates that this article was rushed to
press for the benet of the scientic community.
Corresponding author: Yen N. Truong, MD, MPH. yen.truong@ucdmc.ucdavis.edu
0002-9378/$36.00  2015 Elsevier Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2015.01.027

362.e1 American Journal of Obstetrics & Gynecology MARCH 2015

diversity, and be overweight or obese.3 All

of these factors contribute to the fact that
up to 70% of pregnant women gain weight
in excess of current IOM guidelines.4
Previous studies have shown that
increasing GWG is associated with higher
risk of gestational hypertension,4-7
preeclampsia,4,6,8-12
and
cesarean
delivery.4-6,8,9,13 Additionally, some studies
have shown that increased GWG is associated with adverse neonatal outcomes
such as fetal macrosomia,4-6,8,9,13-15 low
Apgar
score,13
hypoglycemia,5,13,14
admission to the neonatal intensive care
unit (NICU),13 and prolonged hospital
stay.13 There are additional studies associating higher GWG and increased risks of
childhood obesity.16
Since the release of the IOM guidelines
on GWG in 2009, data remain scarce
regarding whether adherence to the
guidelines is associated with improved
perinatal outcomes. Moreover, obesity
and excessive GWG continue to be
growing public health problems, yet it

ajog.org

Obstetrics

remains unclear whether there are

increasing odds of adverse outcomes with
increasing GWG above IOM guidelines.
Thus, we designed a population-based,
retrospective cohort study to examine
GWG classied by the IOM guidelines
and associated perinatal outcomes. Our
hypothesis was that women who had
GWG below or above the IOM guidelines
were at higher risk of maternal and
neonatal morbidity compared to women
whose weight gain was in accordance with
the IOM guidelines, particularly in the
obese women.

M ATERIALS

AND

M ETHODS

This is a population-based retrospective

cohort study of low-risk nulliparous
women with term singleton vertex live
births in the United States from 2011
through 2012 using the Vital Statistics
Natality birth certicate registry provided and maintained by the Centers for
Disease Control and Prevention National Center for Health Statistics. This
data set included births to US and nonUS residents that occurred in the 50
United States, and the District of
Columbia. The 2011 through 2012 birth
data were compiled using either the 2003
Revision or the 1989 Revision of US
Standard Certicate of Live Birth.
Thirty-six states and the District of
Columbia had implemented the revised
birth certicate in 2011: California,
Colorado, Delaware, Florida, Georgia,
Idaho, Illinois, Indiana, Iowa, Kansas,
Kentucky, Louisiana, Maryland, Michigan, Missouri, Montana, Nebraska,
Nevada, New Hampshire, New Mexico,
New York, North Carolina, North
Dakota, Ohio, Oklahoma, Oregon,
Pennsylvania, South Carolina, South
Dakota, Tennessee, Texas, Utah, Vermont, Washington, Wisconsin, and
Wyoming. These states represent 83% of
live births to US citizens in 2011.17 In
2012, 2 additional states, Massachusetts
and Minnesota, also compiled birth data
using the 2003 Revision of US Standard
Certicate of Live Birth; these 38 states as
well as the District of Columbia represent 86.3% of births to US citizens in
2012.18 Since information on prepregnancy weight and height was collected in
the 2003 Revision of US Standard

Research

TABLE 1

2009 Institute of Medicine gestational weight gain guidelines

Total weight
gain range, lb

Rates of weight gain in

second and third trimester,
mean (range), lb/wk

28e40

1 (1e1.3)

18.5e24.9

25e35

1 (0.8e1)

25e29.9

15e25

0.6 (0.5e0.7)

11e20

0.5 (0.4e0.6)

Prepregnancy
BMI

Variable

<18.5

Underweight
Normal weight
Overweight
Obese (all classes)

30

BMI, body mass index.

Truong. Gestational weight gain and associated perinatal outcomes. Am J Obstet Gynecol 2015.

Certicate of Live Birth but not in the

1989 Revision, women who gave birth in
states using the 1989 Revision in 2011 or
2012 were excluded from analysis.
Additionally, we excluded women with
medical or obstetric conditions (prepregnancy diabetes mellitus, chronic
hypertension, prior preterm birth, and
history of poor pregnancy outcome) as
well as women who had missing information regarding prepregnancy weight,
height, or weight gain in pregnancy.
Collection of information on
maternal height and prepregnancy
weight was by direct self-report via the
Mothers Worksheet for the Childs Birth
Certicate (available at http://www.cdc.
gov/nchs/data/dvs/momswkstf_improv.
pdf). More specically, questions
regarding height and prepregnancy
weight were: What is your height? and
What was your prepregnancy weight,
that is, your weight immediately before
you become pregnant with this child?
Information on mothers weight at delivery was collected directly from the
medical record. The acceptable range of
maternal weight values is 50-400 lb;
values out of this range were edited to
not stated in the natality data and
treated as missing, thus not included for
the analysis. GWG in pregnancy was
calculated by subtracting each individual
mothers prepregnancy weight from her
weight at delivery. Prepregnancy body
mass index (BMI) was calculated using
the below formula:

Women were categorized into 4

groups based on prepregnancy BMI and
GWG relative to the IOM guidelines
(Table 1): (1) weight gain below, (2)
weight gain within, (3) weight gain 1-19
lb above, and (4) weight gain
20 lb
above the IOM guidelines.
Perinatal outcomes were compared
between the 4 groups of women who
had GWG below, within, 1-19 lb
above, or
20 lb above the IOM
guidelines. Maternal outcomes examined included gestational diabetes
mellitus (GDM), gestational hypertension/preeclampsia, eclampsia, induction of labor, cesarean delivery,
chorioamnionitis, antibiotics use,
postpartum hemorrhage requiring
blood transfusion, and intensive care
unit (ICU) admission. Neonatal outcomes examined were 5-minute Apgar
<4, mechanical ventilation use >6
hours, neonatal seizures, NICU
admission, birth trauma, antibiotics
use, neonatal transfer to higher-level
nursery, large for gestational age
(LGA) (>97th percentile), and small
for gestational age (SGA) (<3rd
percentile). The c2 test was used to
compare dichotomous outcomes and
multivariable logistic regression analysis was used to control for potential
confounding. Women whose gestational weight fell within the IOM
guidelines were designated as the
referent. Covariates included in the
multivariable
logistic
regression

prepregnancy weight flbg=height fing2  703

MARCH 2015 American Journal of Obstetrics & Gynecology

362.e2

Research

ajog.org

Obstetrics

TABLE 2

Maternal characteristics associated with gestational weight gain relative to IOM guidelines
Below IOM guidelines

Within IOM guidelines

1e19 lb above
IOM guidelines

20 lb above
IOM guidelines

<19 (n 355,594)

21.2%

28.3%

36.4%

14.1%

20e34 (n 1,590,329)

16.3%

30.3%

40.1%

13.3%

35 (n 159,719)

18.1%

34.2%

37.8%

9.9%

Caucasian (n 1,275,772)

15.1%

29.6%

41.0%

14.3%

Characteristic

P value

Age, y
< .001

Race/ethnicity
African American (n 281,397)

21.4%

27.1%

36.8%

14.7%

Latina (n 348,030)

19.8%

31.5%

37.8%

10.9%

Asian (n 154,091)

22.7%

39.5%

32.8%

5.0%

Other (n 43,352)

16.5%

26.7%

39.9%

16.8%

0e11 (n 298,365)

23.0%

28.6%

35.0%

13.4%

12 (n 499,297)

18.2%

28.0%

38.7%

15.1%

13e15 (n 452,344)

16.0%

27.7%

40.8%

15.5%

16 (n 833,601)

15.3%

33.6%

40.4%

10.7%

Not married (n 983,187)

18.6%

27.8%

38.3%

15.3%

Married (n 1,119,455)

16.1%

32.5%

40.1%

11.3%

Medicaid (n 842,514)

19.1%

28.1%

38.0%

14.8%

Private (n 1,133,311)

15.8%

32.0%

40.3%

11.9%

Self-pay (n 55,663)

16.9%

29.1%

39.9%

14.1%

Other (n 71,154)

19.1%

29.9%

38.1%

12.9%

<18.5 (n 103,939)

28.3%

44.6%

22.8%

4.3%

18.5e24.9 (n 1,116,536)

20.0%

36.9%

35.9%

7.2%

9.8%

20.7%

46.8%

22.7%

16.1%

19.7%

43.7%

20.5%

2011 (n 1,039,921)

17.2%

30.2%

39.4%

13.2%

2012 (n 1,062,721)

17.4%

30.3%

39.1%

13.1%

< .001

Education, y
< .001

Marital status
< .001

Insurance payer type

< .001

BMI weight category, kg/m2

25.0e29.9 (n 489,996)

30.0 (n 392,171)

< .001

Birth year
< .001

BMI, body mass index; IOM, Institute of Medicine.

Truong. Gestational weight gain and associated perinatal outcomes. Am J Obstet Gynecol 2015.

model included: maternal age, race/

ethnicity, education, marital status,
and
medical
insurance/payment
source. A P value < .05 and 95%
condence intervals (CIs) were used
to designate statistical signicance. As

the Natality data are publically available and de-identied of patient privacy information, this study was
deemed exempt from review by the
institutional review board at the Oregon Health & Science University.

362.e3 American Journal of Obstetrics & Gynecology MARCH 2015

R ESULTS
Of the 2,102,642 women who met study
criteria, 17.3% had weight gain less than,
30.3% had weight gain within, 39.3%
gained 1-19 lb above, and 13.2% gained

20 lb above the IOM guidelines. In this

ajog.org

Obstetrics

Research

TABLE 3

Maternal outcomes associated with gestational weight gain according to Institute of Medicine guidelines
Variable

Below

1e19 lb
above

Within

20 lb
above

Below
aOR (95% CI)

1e19 lb above
aOR (95% CI)

20 lb above
aOR (95% CI)

GHTN or preeclampsia

2.85%

3.23%

5.41%

9.10%

0.88 (0.86e0.91)

1.68 (1.65e1.71)

2.78 (2.82e2.93)

Eclampsia

0.11%

0.11%

0.18%

0.30%

0.96 (0.85e1.08)

1.55 (1.42e1.70)

2.51 (2.27e2.78)

Induction of labor

26.7%

27.8%

32.6%

38.6%

0.95 (0.94e0.96)

1.23 (1.22e1.24)

1.56 (1.54e1.57)

Cesarean delivery

20.9%

22.8%

28.9%

37.6%

0.90 (0.89e0.91)

1.41 (1.40e1.42)

2.16 (2.14e2.19)

Chorioamnionitis
Antibiotics use

2.10%
19.2%

2.64%
19.6%

2.92%
22.0%

2.85%
24.9%

0.79 (0.77e0.81)

1.16 (1.13e1.18)

1.19 (1.16e1.22)

0.96 (0.95e0.97)

1.15 (1.14e1.16)

1.33 (1.32e1.34)

Blood transfusion

0.21%

0.22%

0.25%

0.27%

0.96 (0.88e1.05)

1.11 (1.04e1.19)

1.22 (1.11e1.33)

Maternal ICU admit

0.08%

0.10%

0.09%

0.09%

0.73 (0.64e0.84)

0.93 (0.84e1.04)

0.97 (0.84e1.12)

Gestational DM

4.93%

3.72%

3.28%

3.26%

1.39 (1.36e1.41)

0.92 (0.91e0.94)

0.99 (0.96e1.01)

CI, confidence interval; DM, diabetes mellitus; GHTN, gestational hypertension; ICU, intensive care unit.
Truong. Gestational weight gain and associated perinatal outcomes. Am J Obstet Gynecol 2015.

cohort, women age 19 years at time of

delivery were more likely to gain below
the IOM guidelines (21.2%) compared
to other age groups (16.3-18.1%, P <
.001) (Table 2). Characteristics associated with GWG in concordance with the
IOM guidelines included age
35 years,
Asian race/ethnicity,
16 years of education, being married, and having private health insurance as well as BMI
within normal range (18.5-24.9 kg/m2;
P < .001) (Table 2). Characteristics
associated with GWG above IOM
guidelines included age 20-34 years, 15
years of education, being unmarried,

and prepregnancy BMI within overweight and obese range (
25 kg/m2; P <
.001 for all) (Table 2). The proportion
of women who gained below, within,
and above the IOM guidelines were
relatively stable during the study period
(Table 2).
Compared to women who had weight
gain within the IOM guidelines, the
women who gained below the IOM
guidelines were more likely to have been
diagnosed with GDM (4.93% vs 3.72%;
adjusted odds ratio [aOR], 1.39; 95% CI,
1.36e1.42) (Table 3). The risk of gestational hypertension/preeclampsia was

greater in women who had GWG above

IOM guidelines (1-19 lb above guidelines: 5.41% vs 3.23%, respectively; aOR,
1.68; 95% CI, 1.65e1.71;
20 lb above
guidelines: 9.10% vs 3.23%, aOR, 2.78;
95% CI, 2.82e2.93) (Table 3). Similarly,
the odds of eclampsia was higher with
GWG 1-19 lb or
20 lb above the IOM
guidelines (1-19 lb above guidelines:
aOR, 1.55; 95% CI, 1.42e1.70;
20 lb
above the IOM guidelines: aOR, 2.51;
95% CI, 2.27e2.78) (Table 3). In
contrast, women who gained below the
guidelines were less likely to undergo
induction of labor or cesarean delivery,

TABLE 4

Neonatal outcomes associated with gestational weight gain according to Institute of Medicine guidelines
Variable

Below

Within

1e19 lb
above

20 lb
above

Below
aOR (95% CI)

1e19 lb above
aOR (95% CI)

20 lb above
aOR (95% CI)

5-min Apgar <4

0.35%

0.33%

0.37%

0.43%

1.01 (0.94e1.08)

1.08 (1.02e1.15)

1.22 (1.14e1.31)

Mechanical ventilation >6 h

0.33%

0.33%

0.36%

0.43%

0.99 (0.93e1.07)

1.07 (1.01e1.13)

1.24 (1.15e1.33)

Neonatal seizure

0.03%

0.03%

0.04%

0.05%

1.02 (0.81e1.27)

1.13 (0.95e1.35)

1.53 (1.24e1.89)

NICU admission

4.70%

4.53%

4.81%

5.30%

1.02 (0.99e1.04)

1.08 (1.06e1.09)

1.19 (1.17e1.22)

Birth trauma

0.05%

0.06%

0.08%

0.10%

0.83 (0.70e0.99)

1.23 (1.09e1.40)

1.56 (1.34e1.83)

Antibiotics use

1.61%

1.77%

2.01%

2.20%

0.90 (0.87e0.93)

1.14 (1.12e1.17)

1.25 (1.21e1.29)

Neonatal transfer

0.70%

0.61%

0.67%

0.78%

1.14 (1.09e1.20)

1.06 (1.02e1.11)

1.20 (1.13e1.26)

LGA >97th centile

0.43%

0.57%

1.33%

3.10%

0.80 (0.75e0.85)

2.33 (2.24e2.42)

5.68 (5.46e5.92)

SGA <3rd centile

3.72%

2.25%

1.50%

1.14%

1.55 (1.52e1.59)

0.66 (0.65e0.68)

0.48 (0.46e0.50)

CI, confidence interval; LGA, large for gestational age; NICU, neonatal intensive care unit; SGA, small-for-gestational age.
Truong. Gestational weight gain and associated perinatal outcomes. Am J Obstet Gynecol 2015.

MARCH 2015 American Journal of Obstetrics & Gynecology

362.e4

Below
aOR (95% CI)

1e19 lb above
aOR (95% CI)

20 lb above
aOR (95% CI)
Below
aOR (95% CI)

1e19 lb above
aOR (95% CI)

20 lb above
aOR (95% CI)

0.92 (0.91e0.94) 1.12 (1.11e1.13) 1.26 (1.23e1.28) 0.95 (0.92e0.97) 1.10 (1.08e1.12) 1.24 (1.22e1.27) 1.01 (0.98e1.03) 1.06 (1.04e1.08) 1.17 (1.15e1.20)

Antibiotics use

362.e5 American Journal of Obstetrics & Gynecology MARCH 2015

1.50 (1.45e1.54) 0.79 (0.77e0.82) 0.97 (0.92e1.02) 1.07 (1.02e1.12) 0.64 (0.61e0.66) 0.55 (0.52e0.57) 1.18 (1.14e1.22) 0.72 (0.69e0.74) 0.60 (0.57e0.62)

Gestational DM

Truong. Gestational weight gain and associated perinatal outcomes. Am J Obstet Gynecol 2015.

BMI, body mass index; CI, confidence interval; DM, diabetes mellitus; GHTN, gestational hypertension; ICU, intensive care unit.

0.60 (0.50e0.71) 0.89 (0.78e1.02) 0.81 (0.63e1.04) 0.87 (0.60e1.27) 0.83 (0.65e1.07) 0.99 (0.74e1.33) 1.01 (0.71e1.45) 1.24 (0.94e1.65) 1.31 (0.95e1.81)

Maternal ICU
admission

Blood transfusion 0.95 (0.85e1.06) 1.16 (1.06e1.26) 1.27 (1.10e1.47) 0.99 (0.78e1.26) 1.03 (0.88e1.21) 1.26 (1.05e1.50) 1.07 (0.85e1.36) 1.20 (0.99e1.45) 1.29 (1.04e1.60)

0.76 (0.73e0.78) 1.18 (1.15e1.21) 1.20 (1.15e1.26) 0.83 (0.77e0.89) 1.12 (1.07e1.17) 1.18 (1.12e1.24) 0.88 (0.82e0.95) 1.09 (1.03e1.15) 1.09 (1.03e1.16)

Chorioamnionitis

Cesarean delivery 0.85 (0.84e0.86) 1.32 (1.31e1.33) 1.98 (1.95e2.02) 0.81 (0.79e0.83) 1.22 (1.20e1.24) 1.71 (1.67e1.74) 0.90 (0.88e0.92) 1.14 (1.12e1.16) 1.49 (1.46e1.52)

Induction of labor 0.90 (0.89e0.91) 1.20 (1.19e1.21) 1.55 (1.52e1.57) 0.93 (0.92e0.96) 1.14 (1.12e1.15) 1.39 (1.37e1.42) 1.01 (0.99e1.03) 1.04 (1.02e1.06) 1.17 (1.15e1.20)

0.84 (0.71e1.01) 1.48 (1.30e1.69) 2.59 (2.18e3.08) 0.82 (0.60e1.13) 1.39 (1.14e1.68) 1.91 (1.55e2.34) 1.00 (0.80e1.25) 1.23 (1.03e1.47) 1.77 (1.47e2.13)

20 lb above
aOR (95% CI)

Eclampsia

1e19 lb above
aOR (95% CI)

BMI 30 (n [ 393,171)

0.81 (0.79e0.84) 1.64 (1.60e1.68) 2.85 (2.76e2.95) 0.81 (0.76e0.86) 1.38 (1.33e1.43) 2.26 (2.17e2.35) 0.84 (0.80e0.87) 1.25 (1.21e1.29) 1.74 (1.68e1.80)

Below
aOR (95% CI)

BMI 25e29.9 (n [ 489,996)

GHTN or
preeclampsia

Variable

BMI 18.5e24.9 (n [ 1,116,536)

BMI stratification of maternal outcomes associated with gestational weight gain by Institute of Medicine guidelines

TABLE 5

Research
Obstetrics
ajog.org

be diagnosed with chorioamnionitis,

require antibiotics use, or be admitted to
the ICU. Women who gained above the
IOM guidelines were more likely to have
obstetric interventions and maternal
morbidity (Table 3).
Next, we examined neonatal outcomes associated with GWG. Compared
to weight gain within the IOM guidelines, neonates born to women who
gained above the guidelines had a higher
likelihood of having 5-minute Apgar <4
(1-19 lb above guidelines: 0.37% vs
0.33%, respectively; aOR, 1.08; 95% CI,
1.02e1.15;
20 lb above guidelines:
0.43% vs 0.33%, respectively; aOR, 1.22;
95% CI, 1.14e1.31) (Table 4). Likewise,
the odds of mechanical ventilation >6
hours for respiratory support, NICU
admission, birth trauma, and antibiotics
use were higher for neonates born to
women with weight gain in excess of,
particularly
20 lb above, the IOM
guidelines (Table 4). Neonates born to
women who gained below the guidelines
were less likely to be LGA >97th centile
(aOR, 0.80; 95% CI, 0.75e0.85) but
more likely to be SGA <3rd centile
(aOR, 1.55; 95% CI, 1.52e1.59)
(Table 4). Conversely, neonates of
women who gained above the IOM
guidelines were more likely to be LGA
>97th centile and less likely to be SGA
<3rd centile (Table 4).
We examined perinatal outcomes
associated with GWG stratied by BMI
categories. This analysis provided information regarding obese women and
their GWG relative to the IOM 2009
recommendation of 11-20 lb whereas the
1990 IOM guidelines recommended at
least 15 lb without an upper ceiling.1,2
Regardless of prepregnancy BMI categories, all women who gained more than
the IOM guidelines had higher risk of
maternal morbidity except for GDM
diagnosis (Table 5). Converse association was observed for women who had
weight gain below the IOM guidelines
across the prepregnancy BMI groups
(Table 5). Women who had a prepregnancy BMI in the normal range
(18.5-24.9 kg/m2) had higher odds of
hypertensive disorders of pregnancy,
induction of labor, cesarean delivery,
chorioamnionitis, and antibiotic use if

2.05 (1.90e2.20) 0.62 (0.55e0.69) 0.51 (0.40e0.66) 1.23 (1.15e1.31) 0.65 (0.62e0.69) 0.42 (0.39e0.46) 1.14 (1.07e1.22) 0.76 (0.71e0.81) 0.56 (0.52e0.61)

Truong. Gestational weight gain and associated perinatal outcomes. Am J Obstet Gynecol 2015.

BMI, body mass index; CI, confidence interval; LGA, large for gestational age; NICU, neonatal intensive care unit; SGA, small-for-gestational age.

SGA <3rd centile

LGA >97th centile 0.65 (0.59e0.72) 2.40 (2.26e2.54) 6.37 (5.96e6.81) 0.81 (0.69e0.94) 1.89 (1.72e2.06) 4.59 (4.20e5.01) 0.82 (0.74e0.90) 1.57 (1.46e1.68) 2.94 (2.73e3.16)

0.85 (0.82e0.89) 1.11 (1.08e1.15) 1.17 (1.11e1.24) 0.89 (0.82e0.97) 1.14 (1.08e1.20) 1.23 (1.16e1.31) 0.99 (0.91e1.07) 1.11 (1.04e1.18) 1.19 (1.11e1.27)

1.16 (1.08e1.24) 1.05 (0.99e1.12) 1.18 (1.07e1.29) 1.03 (0.90e1.18) 0.98 (0.89e1.08) 1.02 (0.92e1.14) 1.09 (0.98e1.22) 0.93 (0.88e1.02) 0.99 (0.89e1.10)

Antibiotics use

0.75 (0.59e0.95) 1.22 (1.03e1.45) 1.46 (1.12e1.90) 0.92 (0.58e1.46) 1.16 (0.86e1.57) 1.51 (1.09e2.09) 0.98 (0.65e1.47) 1.30 (0.94e1.78) 1.63 (1.15e2.30)

Birth trauma

Neonatal transfer

1.02 (0.99e1.05) 1.06 (1.04e1.08) 1.14 (1.10e1.18) 0.98 (0.93e1.03) 0.99 (0.96e1.03) 1.07 (1.03e1.11) 0.96 (0.91e1.00) 1.01 (0.98e1.05) 1.09 (1.04e1.13)

NICU admission

20 lb above
aOR (95% CI)

1.09 (0.81e1.46) 1.04 (0.81e1.33) 1.29 (0.88e1.89) 0.81 (0.46e1.41) 0.71 (0.49e1.04) 1.08 (0.72e1.60) 1.05 (0.64e1.73) 1.39 (0.94e2.06) 1.57 (1.02e2.42)

1e19 lb above
aOR (95% CI)

Neonatal seizure

Below
aOR (95% CI)

0.96 (0.88e1.06) 1.02 (0.94e1.10) 1.15 (1.01e1.30) 1.00 (0.83e1.22) 1.06 (0.92e1.20) 1.21 (1.05e1.41) 0.98 (0.83e1.15) 1.08 (0.95e1.23) 1.17 (1.01e1.35)

20 lb above
aOR (95% CI)

Mechanical
ventilation >6 h

1e19 lb above
aOR (95% CI)

0.96 (0.88e1.06) 1.01 (0.94e1.10) 1.18 (1.04e1.34) 1.17 (0.97e1.40) 1.18 (1.03e1.34) 1.19 (1.03e1.38) 1.00 (0.86e1.18) 1.04 (0.91e1.18) 1.15 (1.00e1.33)

Below
aOR (95% CI)

5-min Apgar <4

20 lb above
aOR (95% CI)

BMI 30 (n [ 391,132)

Below
aOR (95% CI)

1e19 lb above
aOR (95% CI)

BMI 25e29.9 (n [ 488,574)

Variable

BMI 18.5e24.9 (n [ 1,112,952)

Stratified analysis of neonatal outcomes associated with gestational weight gain according to Institute of Medicine guidelines

TABLE 6

ajog.org
Obstetrics

Research

they had GWG above the IOM guidelines

compared to those who gained within
guidelines. Women with normal prepregnancy BMI who gained
20 lb
above guidelines had greater odds of
gestational hypertension/eclampsia and
eclampsia compared to overweight or
obese women who also had GWG above
the guidelines (Table 5).
Similarly, when we examined neonatal
outcomes, the odds of mechanical
ventilation >6 hours, NICU admission,
and birth trauma were increased in
women of all BMI categories who gained

20 lb above the IOM guidelines,
compared to their counterparts who
gained weight within the IOM guidelines
(Table 6). While the odds of having LGA
(>97th centile) neonates were increased
in all women who gained weight in
excess of, particularly if
20 lb above,
the IOM guidelines, the magnitude of
association was highest in women of
normal prepregnancy BMI who gained

20 lb above the IOM guidelines (aOR,
6.37; 95% CI, 5.96e6.81) (Table 6).

C OMMENT

In this large population-based cohort of

low-risk nulliparous women with
singleton term vertex deliveries in the
United States from 2011 through 2012,
we observed that GWG above the 2009
IOM guidelines was associated with
higher odds of adverse maternal and
neonatal outcomes compared to women
who had weight gain in concordance
with the IOM guidelines. Further, the
magnitude of association for perinatal
morbidity was higher in women who
gained
20 lb above the guidelines than
those who gained 1-19 lb above the
guidelines. This suggests that the relationship between excess GWG and
perinatal morbidity is a continuum as
opposed to stepwise thresholds. The direction and magnitude of association
remained relatively similar regardless of
prepregnancy BMI category, suggesting
that prepregnancy BMI is likely not an
effect modier in the association between GWG and perinatal morbidity.
However, BMI does appear to be an
effect modier for fetal macrosomia.
Women of normal prepregnancy BMI
who gained in excess of
20 lb above the

MARCH 2015 American Journal of Obstetrics & Gynecology

362.e6

Research

ajog.org

Obstetrics

IOM guidelines had a 6-fold increase in

the odds of macrosomic neonates (LGA
>97th centile) compared to their counterparts who gained within the IOM
guidelines, while overweight and obese
women who gained
20 lb had a 3- to 4fold increase in odds compared to those
who gained within the guidelines. Our
ndings highlight the importance of
adherence to the 2009 IOM weight gain
guidelines to optimize maternal and
neonatal outcomes, regardless of prepregnancy BMI.
Consistent with ndings from 2 prior
studies,4,10 we observed that for women
who had GWG in excess of the 2009 IOM
guidelines, the odds of being diagnosed
with gestational hypertension, preeclampsia, or eclampsia was approximately 1.5-fold higher in women who
gained 1-19 lb above and approximately
2.5-fold higher in women who gained

20 lb above the IOM guidelines
compared to weight gain within the
guidelines. While the precise origin of
preeclampsia has not been well elucidated, some studies suggest that preeclampsia/eclampsia can manifest as a
result of a generalized inammatory state
and maternal metabolic conditions.19,20
It is possible that excessive GWG may
lead to an increase in maternal inammatory response and a transient state
akin to metabolic syndrome, thereby
increasing the risk of preeclampsia/
eclampsia. Alternatively, the association
may be due to reverse causality. As
women with preeclampsia experience
third-spacing of uid prior to delivery, it
is usual for them to experience rapid
weight gain via uid retention. The association between excess GWG and hypertensive disorders of pregnancy as well
as its potential causal mechanism requires further elucidation and specic
examination of the timing of weight gain.
In this cohort, women who had GWG
below the IOM guidelines had a higher
prevalence of GDM compared to women
whose weight gain was within the IOM
guidelines. Ideally, information regarding
timing of GDM diagnosis relative to
weight gain would further clarify this
association, but such data were not
available. It is likely that less GWG in
women with GDM was partly due to

increased dietary counseling, increased

awareness of weight gain, and more
intense monitoring of diet and weight
gain.21,22 While we did not observe total
weight gain above the IOM guideline
associated with the diagnosis of GDM,
one study reported that weight gain in
excess of the IOM guidelines per week
after the diagnosis of GDM was associated
with adverse pregnancy outcomes.23
Neonates born to mothers who gained
more weight than recommended by the
IOM were at increased risk of short-term
morbidity. While the exact causes of
adverse outcome were unclear from this
analysis, it could be partly due to
increased maternal morbidity (eg, preeclampsia, eclampsia, and puerperal
infection) associated with excess weight
gain in pregnancy. As weight gain above
the IOM guidelines is associated with
higher likelihood of LGA >97th centile
and thus labor dystocia,24,25 whether
excess weight gain also alters placental
physiology or in-utero programming
remains less clear in human beings,
although such a relationship has been
demonstrated in animal models.26,27
In our study, we examined SGA as an
undesirable neonatal outcome. We
acknowledge that while SGA customarily
has been dened as birthweight <10th
centile for gestational age,28 not all neonates diagnosed as SGA are pathologically small.29 As literature suggests that
infants whose birthweight is 3rd centile for gestational age have increased
neonatal mortality and morbidity,30 we
chose this threshold to identify neonates
more likely to be pathologically small
and its association with GWG recommendations. Although we cannot denitively differentiate those constitutionally
small from those pathologically so, neonates who were SGA <3rd centile born
to women underweight with less than
IOM recommended weight gain had
higher odds 5-minute Apgar score <4
(aOR, 2.10; 95% CI, 1.69e2.61), mechanical ventilation >6 hours for respiratory support (aOR, 2.73; 95% CI,
2.23e3.35), and NICU admission (aOR,
3.52; 95% CI, 3.34e3.72) compared to
those not SGA. Indeed, a multicentered
prospective cohort study conducted by
the Eunice Kennedy Shriver National

362.e7 American Journal of Obstetrics & Gynecology MARCH 2015

Institute of Child Health and Human

Development Maternal-Fetal Medicine
Units Network also observed that inadequate weight gain in overweight and
obese women is associated with
increased risk of SGA and decreased
neonatal fat mass, lean mass, and head
circumference.31
As a population-based cohort study
representative of women giving birth in
the United States during the study
period, this large cohort of women provided adequate statistical power to
examine rare perinatal morbidity. Yet,
this study has limitations. As we
included only low risk, nulliparous
women who delivered term singleton
fetuses in cephalic presentation, our
study ndings cannot be inferred to
other populations. Secondly, prepregnancy BMI was calculated based on selfreported height and weight. While
several studies have validated the use of
self-reported height and weight,4,32 selfreport remains a limitation of the data.
Additionally, since weight at time of delivery was clinically obtained, this would
have possibly placed the mother in a
lower BMI category and overestimated
the GWG. This potential misclassication would bias the effect estimates towards the null. Thus, the reported
ndings could be more conservative
than the true effect. Given the retrospective cohort study design, our analysis would be prone to confounding and
missing data biases. We employed
multivariable logistic regression and
stratication analyses to minimize confounding, but there might be unmeasured or unobservable confounding that
we could not or would not have
accounted for in our analysis.
In summary, GWG in excess of the
2009 IOM guidelines was associated
with an increased risk of adverse
maternal and neonatal outcomes. As a
large proportion of women in the United
States have GWG in excess of the IOM
guidelines, dietary and activity counseling is an integral part of prenatal care
to optimize pregnancy and neonatal
outcomes. Best practices regarding
counseling for weight gain in pregnancy
are unclear and warrant further investigation. Furthermore, with the growing

ajog.org
obesity epidemic in the United States
and worldwide, future studies on GWG
in different World Health Organization
(WHO) obesity classes are needed,
particularly as the current IOM guidelines on GWG have been criticized for
not providing nuanced recommendations for women who fall under WHO
obesity class II (BMI 35-35.99) and class
III (BMI
40).33-35
-

REFERENCES
1. Institute of Medicine: National Research
Council Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight gain during
pregnancy: reexamining the guidelines. Washington, DC: National Academies Press, National
Academy of Sciences; 2009.
2. Institute of Medicine Committee on Nutritional
Status During Pregnancy and Lactation. Nutrition during pregnancy, part I, weight gain: part II,
nutrient supplements. Washington, DC: National
Academies Press, National Academy of Sciences; 1990.
3. Ogden CL, Carroll MD, Kit BK, Flegal KM.
Prevalence of childhood and adult obesity in the
United States, 2011-2012. JAMA 2014;311:
806-14.
4. Johnson J, Clifton RG, Roberts JM, et al.
Pregnancy outcomes with weight gain above or
below the 2009 Institute of Medicine guidelines.
Obstet Gynecol 2013;121:969-75.
5. Crane JM, White J, Murphy P, Burrage L,
Hutchens D. The effect of gestational weight gain
by body mass index on maternal and neonatal
outcomes. J Obstet Gynaecol Can 2009;31:
28-35.
6. DeVader SR, Neeley HL, Myles TD, Leet TL.
Evaluation of gestational weight gain guidelines
for women with normal prepregnancy body
mass index. Obstet Gynecol 2007;110:745-51.
7. Saftlas A, Wang W, Risch H, Woolson R,
Hsu C, Bracken M. Prepregnancy body mass
index and gestational weight gain as risk factors
for preeclampsia and transient hypertension.
Ann Epidemiol 2000;10:475.
8. Kiel DW, Dodson EA, Artal R, Boehmer TK,
Leet TL. Gestational weight gain and pregnancy
outcomes in obese women: how much is
enough? Obstet Gynecol 2007;110:752-8.
9. Cedergren M. Effects of gestational weight
gain and body mass index on obstetric outcome

Obstetrics
in Sweden. Int J Gynaecol Obstet 2006;93:
269-74.
10. de la Torre L, Flick AA, Istwan N, et al. The
effect of new antepartum weight gain guidelines
and prepregnancy body mass index on the
development of pregnancy-related hypertension. Am J Perinatol 2011;28:285-92.
11. Fortner RT, Pekow P, Solomon CG,
Markenson G, Chasan-Taber L. Prepregnancy
body mass index, gestational weight gain, and
risk of hypertensive pregnancy among Latina
women. Am J Obstet Gynecol 2009;200:167.
e1-7.
12. Swank ML, Caughey AB, Farinelli CK, et al.
The impact of change in pregnancy body mass
index on the development of gestational hypertensive disorders. J Perinatol 2014;34:
181-5.
13. Stotland NE, Cheng YW, Hopkins LM,
Caughey AB. Gestational weight gain and
adverse neonatal outcome among term infants.
Obstet Gynecol 2006;108:635-43.
14. Hedderson MM, Weiss NS, Sacks DA, et al.
Pregnancy weight gain and risk of neonatal
complications: macrosomia, hypoglycemia, and
hyperbilirubinemia. Obstet Gynecol 2006;108:
1153-61.
15. Swank ML, Caughey AB, Farinelli CK, et al.
The impact of change in pregnancy body mass
index on macrosomia. Obesity (Silver Spring)
2014;22:1997-2002.
16. Oken E, Taveras EM, Kleinman KP, RichEdwards JW, Gillman MW. Gestational weight
gain and child adiposity at age 3 years. Am J
Obstet Gynecol 2007;196:322.e1-8.
17. Centers for Disease Control and Prevention.
User guide to the 2011 natality public use le.
Available at: http://www.cdc.gov/nchs/nvss.
htm. Accessed July 19, 2013.
18. Centers for Disease Control and Prevention.
User guide to the 2008 natality public use le.
Available at: http://www.cdc.gov/nchs/nvss.
htm. Accessed June 10, 2014.
19. Chaiworapongsa T, Chaemsaithong P,
Yeo L, Romero R. Pre-eclampsia part 1: current
understanding of its pathophysiology. Nat Rev
Nephrol 2014;10:466-80.
20. Lau SY, Guild SJ, Barrett CJ, et al. Tumor
necrosis factor-alpha, interleukin-6, and
interleukin-10 levels are altered in preeclampsia:
a systematic review and meta-analysis. Am J
Reprod Immunol 2013;70:412-27.
21. Landon MB, Spong CY, Thom E, et al.
A multicenter, randomized trial of treatment for
mild gestational diabetes. N Engl J Med
2009;361:1339-48.

Research

22. Crowther CA, Hiller JE, Moss JR,

McPhee AJ, Jeffries WS, Robinson JS. Effect of
treatment of gestational diabetes mellitus on
pregnancy outcomes. N Engl J Med 2005;352:
2477-86.
23. Harper LM, Tita A, Biggio JR. The Institute
of Medicine guidelines for gestational weight
gain after a diagnosis of gestational diabetes
and pregnancy outcomes. Am J Perinatol 2014
[Epub ahead of print].
24. Cheng YW, Shaffer BL, Bryant AS,
Caughey AB. Length of the rst stage of labor and
associated perinatal outcomes in nulliparous
women. Obstet Gynecol 2010;116:1127-35.
25. Harper LM, Caughey AB, Roehl KA,
Odibo AO, Cahill AG. Dening an abnormal rst
stage of labor based on maternal and neonatal
outcomes. Am J Obstet Gynecol 2014;210:536.
e1-7.
26. Thame M, Osmond C, Bennett F, Wilks R,
Forrester T. Fetal growth is directly related to
maternal anthropometry and placental volume.
Eur J Clin Nutr 2004;58:894-900.
27. Sohlstrom A, Fernberg P, Owens JA,
Owens PC. Maternal nutrition affects the ability
of treatment with IGF-I and IGF-II to increase
growth of the placenta and fetus, in guinea pigs.
Growth Horm IGF Res 2001;11:392-8.
28. American College of Obstetricians and Gynecologists. Fetal growth restriction. ACOG
Practice bulletin no. 134. Obstet Gynecol
2013;121:1122-33.
29. Galan HL. Timing delivery of the growthrestricted fetus. Semin Perinatol 2011;35:262-9.
30. McIntire DD, Bloom SL, Casey BM,
Leveno KJ. Birth weight in relation to morbidity
and mortality among newborn infants. N Engl J
Med 1999;340:1234-8.
31. Catalano PM, Mele L, Landon MB, et al.
Inadequate weight gain in overweight and obese
pregnant women: what is the effect on fetal
growth? Am J Obstet Gynecol 2014;211:137.
e1-7.
32. Brunner Huber LR. Validity of self-reported
height and weight in women of reproductive
age. Matern Child Health J 2007;11:137-44.
33. Artal R, Lockwood CJ, Brown HL. Weight
gain recommendations in pregnancy and the
obesity epidemic. Obstet Gynecol 2010;115:
152-5.
34. American College of Obstetricians and Gynecologists. Weight gain during pregnancy.
ACOG Committee opinion no. 548. Obstet
Gynecol 2013;121:210-2.
35. Catalano PM. Management of obesity in
pregnancy. Obstet Gynecol 2007;109:419-33.

MARCH 2015 American Journal of Obstetrics & Gynecology

362.e8