Acta Obstetricia et Gynecologica.

2010; 89: 924930

MAIN RESEARCH ARTICLE

Maternal super-obesity (body mass index 50) and adverse pregnancy

outcomes

MARK CHRISTOPHER ALANIS1, WILLIAM H. GOODNIGHT2, ELIZABETH G. HILL3,

CHRISTOPHER J. ROBINSON1, MARGARET S. VILLERS1 & DONNA D. JOHNSON1
1

Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston USA, 2Department of
Obstetrics and Gynecology, University of North Carolina, Chapel Hill, USA, and 3Department Biostatistics,
Bioinformatics, and Epidemiology, Medical University of South Carolina, Charleston, USA

Abstract
Objective. To determine if pregnancy complications are increased in super-obese (a body mass index (BMI) of 50 or more)
compared to other, less obese parturients. Design. Cross-sectional study. Setting and population. All 19,700 eligible women,
including 425 (2.2%) super-obese women with singleton births between 1996 and 2007 delivering at a tertiary referral center,
identied using a perinatal research database. Methods. Bivariate and trend analyses were used to assess the relation between
super-obesity and various pregnancy complications compared to other well-established BMI categories. Adjusted odds ratios
(ORs) were calculated using multivariable logistic regression techniques. Main outcome measures. Outcomes for adjusted and
unadjusted analyses were small-for-gestational age (SGA) birth, large-for-gestational age (LGA) birth, preeclampsia,
gestational diabetes mellitus (GDM), fetal death, preterm birth, placental abruption, cesarean delivery, and Apgar
scores < 7. Results. Compared to all other obese and non-obese women, super-obese women had the highest rates of
preeclampsia, GDM, LGA, and cesarean delivery (all p < 0.05 for trend test). Super-obesity was also associated with a
44% reduction in SGA compared to all other women (OR 0.55, 95% condence interval (CI) 0.400.76) and a 25% reduction
compared to other, less obese women (OR 0.75, 95% CI 0.541.03). Super-obesity was positively associated with LGA,
GDM, preeclampsia, cesarean delivery, and a 5-minute Apgar score < 7 compared to all other women after controlling
for important confounders. Conclusion. Super-obesity is associated with higher rates of pregnancy complications compared
to women of all other BMI classes, including other obese women.

Key words: Obesity, super-obesity, pregnancy complications, cesarean, small-for-gestational age

Introduction
Obstetricians are increasingly concerned regarding the
prevalence and morbidity associated with obesity in
reproductive aged women (1). According to results
from the 2004 National Health and Nutrition Examination Survey (NHANES), the rate of obese reproductive-aged women, dened by a body mass index (BMI)
of 30, was 28.9% (2). Obesity during pregnancy is
associated with increased morbidity for both the mother
and baby (3). In addition, obese women have a 3-fold
risk of death or near-death morbidity during pregnancy

compared to women with a normal BMI (4). In women

with spontaneous conceptions, recurrent rst or second trimester miscarriage is increased 3.5-fold compared to women with a normal BMI (5). The risk of fetal
death after 20 weeks of gestation increases in a
dose-dependent fashion with BMI, with the highest
risk being in women with extreme obesity ( 40) (6).
While obesity is a well-known risk factor for fetal
overgrowth (7), a dual risk for intrauterine growth
restriction (IUGR) remains controversial. In a study
of the Danish National Birth Cohort including 54,505
patients, the birthweights of fetal deaths were lower

Correspondence: Mark Christopher Alanis, Department of Obstetrics and Gynecology, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 634,
Charleston, South Carolina 29425, USA. E-mail: alanis@musc.edu
(Received 13 May 2009; accepted 25 January 2010)
ISSN 0001-6349 print/ISSN 1600-0412 online  2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/00016341003657884

Maternal super-obesity
among women with obesity compared to the entire
median cohort (8). These cases of fetal deaths were
also ve times as likely to be related to placental
dysfunction compared to normal weight individuals.
Observational and cross-sectional studies report
mixed ndings, with some studies reporting increased
odds of IUGR among obese mothers and others
reporting no relation between obesity and IUGR.
Most studies examining the relation between obesity and adverse pregnancy outcomes, including fetal
growth disturbances, have treated obesity as a dichotomous outcomes (BMI 30 or not), despite it being
well established that obesity, as measured by the BMI,
is related to worse pregnancy outcomes in a dosedependent fashion. It remains unclear, however, ifthere
is a threshold of severe obesity beyond which pregnancy
complications do not increase. The maximum obesity
severity in current classication schema is 40 or more.
While the prevalence of obesity has stabilized since
2004, the severity of obesity among those who are
already obese continues to climb. Between 1986 and
2000, the rate of individuals with a BMI 50 quintupled
(9). The term super-obese was rst coined by Mason
et al. in 1987 to classify patients with a BMI 50 to
highlight their increased risk for poor outcomes following vertical banded gastroplasty (10). Given the
increased risk these individuals have for co-morbidities
such as chronic hypertension, diabetes, diabetes mellitus, asthma, and obstructive sleep apnea compared to
other obese individuals (11), it is plausible that superobesity may have special implications in pregnant
women. A search of the medical literature revealed
no published studies regarding the risk of super-obesity
in relation to pregnancy (MEDLINE Database
19502009 search on October 18, 2009). This studys
primary objective was to determine if delivery of a smallfor-gestational age (SGA) or large-for-gestational age
(LGA) infant is increased in women with a BMI 50
compared to all other women or to other, less obese
women. Secondary objectives included comparing
the rates of adverse pregnancy outcomes, including
preeclampsia, gestational diabetes, cesarean delivery,
and low Apgar scores, in super-obese women to other,
less obese women.

Material and methods

This cross-sectional study included maternal-neonatal
pairs delivered between January 1, 1996 and December
31, 2007 at the Medical University of South Carolina,
the regions tertiary referral center (approved by the
Institutional Review Board). The women and babies
were identied by the centers validated perinatal
research database (12). Inclusion criteria included

925

women with recorded height and weight at the time

of admission for delivery, singleton gestation, and
recorded birthweight (g). Height was determined by
measurements taken earlier during the womans prenatal care, and maternal weight was determined by the
last weight recorded during outpatient prenatal care or
by patient recall. Gestational age was determined by
the last menstrual period or by ultrasound dating,
according to the American College of Obstetrics and
Gynecology (13). Subjects with missing maternal
height and weight, birthweight, and births < 20 or
44 weeks of gestation were excluded.
BMI (kg/m2) was calculated from maternal height and
weight and characterized into one of seven classes according to modied guidelines reported jointly by the
National Heart, Lung, and Blood Institute and the
National Institute of Diabetes and Digestive and Kidney
Diseases: underweight (< 18.5), normal ( 18.5 and
< 25), overweight ( 25 and < 30), obese class I
( 30 and < 35), obese class II ( 35 and < 40), and obese
class III (40 and < 50) (14). In addition, super-obese
was dened as a BMI 50. SGA and LGA were
calculated by a birthweight < 10th or > 90th percentile for gestational age, respectively, according to the
smoothed population birthweight percentiles by
Alexander et al. (15).
All covariates were dichotomous (yes or no) except
maternal age at delivery (years) and gestational age
(weeks). Pregestational diabetes was determined by
the patients medical history of type 1 or type 2
diabetes. Gestational diabetes was determined by
abnormal diagnostic testing during pregnancy
according to guidelines published by the American
Diabetes Association (16). Chronic hypertension was
dened by the personal medical history, or by 2
elevated blood pressures (systolic 140 mmHg or
diastolic 90 mmHg) on at least two separate occasions before 20 weeks. Preeclampsia was dened by
new-onset hypertension (systolic blood pressure 140
mmHg or diastolic blood pressure 90 mmHg on
at least two separate occasions) and proteinuria
( 300 mg in a 24-hour collection or 1+ on a
catheterized urine specimen in the acute setting) after
20 weeks according to published guidelines from the
American College of Obstetricians and Gynecologists
(17) and determined by an attending physician.
Congenital anomaly included any birth defect and
was determined during the neonatal period by the
pediatrician or pediatric subspecialist.

Statistical Analysis
Measures of center and spread for continuous variables were reported using median and interquartile

926

M.C. Alanis et al.

model was assessed by the Hosmer-Lemeshow
goodness-of-t test.
To address the secondary objectives of the study,
associations between all BMI classes and adverse
pregnancy outcomes were evaluated using the
Cochran Armitage test for trend. These adverse
outcomes included preeclampsia, gestational diabetes, cesarean delivery, and low 5-minutes Apgar
scores. Multivariable regression analyses were also
used to assess the relation between super-obesity
and these adverse pregnancy outcomes relative to
other, less obese women. Given the wide range of
pregnancy complications studied, each regression
model included an individualized set of covariates
selected based on their well-known association with
the dependent variable. Tests for interaction and
goodness-of-t were equivalent to the primary multivariable analyses previously mentioned. Two-tailed
p-values < 0.05 were considered signicant for all
tests. Statistical analyses were performed with SAS
V9.1 (SAS Institute, Inc. Cary, North Carolina,
USA).

Results
There were 19,700 eligible maternal-neonatal pairs
during the study period. During this period, the
incidences of obesity and super-obesity were 49.5%
(n = 9,749) and 2.2% (n = 425), respectively. The
lowest median birthweight occurred in underweight
women, and the median birthweight steadily
increased with increasing BMI class (Figure 1).

4000
3000
2000
0

1000

Birth weight (g)

5000

6000

range. Univariate summaries for categorical variables

were reported as frequencies and percents. The primary exposure was super-obesity (yes or no), and the
two primary outcomes were SGA (yes or no) and LGA
(yes or no). Bivariable analyses were performed to
assess associations between covariates and the two
primary outcomes among all women in the study
and also among obese women only. Wilcoxon rank
sum tests and chi-squared tests were used to assess
associations between continuous variables and dichotomous categorical variables with both SGA and LGA,
respectively. Pregestational and gestational diabetes
were analyzed as a single, combined variable for bivariate analyses. Multivariable logistic regression analyses
were performed in order to assess the effect of superobesity on delivery of an SGA or LGA infant, while
controlling for black race, any smoking during
pregnancy, and congenital anomaly. These covariates
were chosen based on their well-known association
with birthweight. Adjusted odds ratios (ORs) and
95% condence intervals (CIs) were reported for the
association between super-obesity and SGA and
between super-obesity and LGA compared to all
women. In addition, associations between superobesity and SGA and LGA were determined after
restricting the analyses to only obese women. Because
diabetes, preeclampsia, and chronic hypertension are
part of the causal pathway from maternal obesity to
effects on birth weight, these covariates were not
included in these regression analyses. The BreslowDay test was performed for all possible two-way interactions between dichotomous covariates used in
multivariable analyses. The t of each multivariable

<18.5

18.5 - 24.9

25 - 29.9

30 - 34.9

35 - 39.9

40 - 49.9

50+

BMI (kg/m2)
Figure 1. Box-and-Whiskers plots of birth weight by BMI class. The median birthweight clearly increases with increasing BMI class.
Note: BMI, body mass index.

927

Maternal super-obesity
Table 1. Summary of associations between patient factors and SGA and LGA in all included women (n = 19,700).
SGA

Variable
Maternal age at
delivery (years)
Gestational age (weeks)
Parity
Super-obesity
Black race
Smoking
Chronic hypertension
Diabetes mellitus
Preeclampsia
Preterm birth
Congenital anomaly

LGA

No
Yes
(n = 2,967)a (n = 16,733)a p-Valueb
23 (2029)
38
1.0
1.5
66.1
16.7
6.5
4.6
11.8
23.2
8.5

OR
(95% CI)

24 (2030) < 0.001c

(3739)
39 (3740)
(02)
1.0 (02)
(44)
2.3 (381)
(1,960) 51.1 (8,552)
(496)
10.2 (1,713)
(194)
4.2 (701)
(135)
6.8 (1,137)
(349)
5.4 (909)
(689)
16.4 (2,748)
(253)
4.2 (695)

< 0.001c
0.02
0.006
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001

NA

0.65
1.86
1.76
1.60
0.65
2.32
1.54
2.15

Yes
No
(n = 1,246)a (n = 18,454)a p-Valueb
27 (2232)

24 (2030)

NA
39 (3840) 39 (3740)
NA
1.0 (12)
1.0 (02)
(0.470.88) 5.1 (64)
2.0 (361)
(1.722.02) 33.3 (415)
54.7 (10,097)
(1.581.96) 6.3 (79)
11.5 (2,130)
(1.361.89) 5.6 (70)
4.5 (825)
(0.540.79) 18.9 (236)
5.6 (1,036)
(2.042.64) 5.6 (70)
6.4 (1,188)
(1.401.69) 4.3 (53)
18.3 (3,384)
(1.85250) 3.5 (44)
4.9 (904)

OR
(95% CI)

< 0.001c
< 0.001c
0.005
< 0.001
< 0.001
< 0.001
0.06
< 0.001
0.25
< 0.001
0.03

NA

2.7
0.41
0.52
1.27
3.93
0.87
0.20
0.71

NA
NA
(2.073.56)
(0.370.47)
(0.410.65)
(0.981.63)
(3.364.59)
(0.681.11)
(0.150.26)
(0.520.97)

Continuous variables are described by medians (IQR), and categorical variables are described in terms of column percents (number of
observations).
b
p-Values for categorical variables calculated with the use of the chi-square test unless stated otherwise.
c
Wilcoxon rank sum test.
Note: SGA, small-for-gestational age; LGA, large-for-gestational age; OR, odds ratio; CI, condence interval.

confounding and interaction terms, super-obesity

resulted in a 44% reduction in the odds of delivering an SGA infant (adjusted OR = 0.55, 95%
CI 0.400.76; p < 0.001) compared to all other
women and a non-signicant 25% reduction compared to other, less obese (BMI 30.049.9) women
(adjusted OR = 0.75, 95% CI 0.541.03; p = 0.07).
Super-obesity increased the odds of delivering an
LGA infant 3.5-fold (adjusted OR 3.49, 95% CI
9.122.0; p < 0.001) compared to all other women

Overall, the rates of SGA and LGA during the

study period were 15.1 and 6.3%, respectively.
Tables 1 and 2 demonstrate the rates of covariates
with and without SGA and with and without LGA
among all included women and obese women
only, respectively. There was signicant interaction
between black race and smoking and black race
and congenital anomaly on SGA (Breslow-Day test
p < 0.001 and p = 0.01, respectively). There were no
interaction terms for LGA. After controlling for

Table 2. Summary of associations between patient factors and SGA and LGA in obese women only (n = 9,749).
SGA

Variable
Maternal age at
delivery (years)
Gestational age (weeks)
Parity
Super-obesity
Black race
Smoking
Chronic hypertension
Diabetes mellitus
Preeclampsia
Preterm Birth
Congenital anomaly
a

Yes
(n = 1,159)a
25 (2130)
38
1.0
3.8
70.8
15.6
11.9
8.2
16.8
24.4
9.2

(3739)
(02)
(44)
(821)
(181)
(138)
(95)
(195)
(283)
(106)

LGA

No
(n = 8590)a p-Valueb
25 (2130)
39
1.0
4.44
56.3
9.7
7.1
10.5
7.8
14.2
4.1

(3840)
(02)
(381)
(4,839)
(834)
(613)
(905)
(669)
(1218)
(353)

OR
(95% CI)

0.38
< 0.001c
< 0.001
0.32
< 0.001
< 0.001
< 0.001
0.01
< 0.001
< 0.001
< 0.001

NA

0.85
1.88
1.72
1.76
0.76
2.40
1.95
2.35

Yes
(n = 914)a
27 (2332)

No
(n = 8835)a p-Valueb

OR
(95% CI)

25 (2130) < 0.001c

NA

NA
39 (3840) 39 (3740)
NA
1.0 (02)
1.0 (02)
(0.611.17) 7.0 (64)
4.1 (361)
(1.652.15) 37.8 (345)
60.2 (5,315)
(1.452.05) 6.4 (58)
10.8 (957)
(1.452.14) 7.4 (68)
7.7 (683)
(0.610.95) 22.7 (207)
9.0 (793)
(2.012.85) 7.1 (65)
9.0 (799)
(1.692.27) 4.1 (37)
16.6 (1,464)
(1.872.95) 3.5 (32)
4.8 (427)

< 0.001c
< 0.001
< 0.001
< 0.001
< 0.001
0.75
< 0.001
0.05
< 0.001
0.07

1.8
0.40
0.56
0.96
2.97
0.77
0.21
0.71

NA
NA
(1.342.32)
(0.350.46)
(0.420.73)
(0.741.24)
(2.503.52)
(0.591.00)
(0.150.30)
(0.501.03)

Continuous variables are described by medians (IQR), and categorical variables are described in terms of column percents (number of
observations).
b
p-Values for categorical variables calculated with the use of the chi-square test unless stated otherwise.
c
Wilcoxon rank sum test.
Note: SGA, small-for-gestational age; LGA, large-for-gestational age; OR, odds ratio; CI, condence interval.

928

M.C. Alanis et al.

and 2-fold when compared to other, less obese

women (adjusted OR = 2.18, 95% CI 1.652.89;
p < 0.001). Results from the Hosmer-Lemeshow test
indicated adequate goodness of t for the multivariable models, except for LA among only obese women
(p = 0.02).
The highest rates of black race, chronic hypertension, pregestational and gestational diabetes mellitus,
preeclampsia, LGA, and cesarean delivery were
demonstrated in the super-obese group of women
(Table 3). Apgar scores < 7 at 1-minute were highest
in this group of women as well, but there was no
signicant trend at 5 minutes (Table 2). The greatest
incidence of smoking, nulliparity, preterm birth,
placental abruption, and SGA occurred in underweight women (Table 3). There was signicant
declining risk of stillbirth with increasing BMI class,
but this observation was limited by very small numbers among underweight and super-obese women
(Table 3). Results of multivariable logistic regression

analyses exploring the effect of super-obesity on

these adverse pregnancy outcomes relative to other
obese (BMI 30.049.9) women are presented
in Table 4. Super-obesity increased the risk significantly for preeclampsia, gestational diabetes, congenital anomalies, cesarean delivery and low Apgar
scores.

Discussion
This study shows that super-obesity is associated with
adverse pregnancy outcomes and fetal overgrowth,
which may explain the increased rate of cesarean
delivery in these women compared to other obese
and non-obese women. Clearly, the risk of preeclampsia, gestational diabetes, delivering an LGA infant and
cesarean delivery does not peak at levels of severe
obesity traditionally described. Therefore, superobesity has immediate clinical implications for

Table 3. Selected dichotomous background and outcome variables by BMI class with trend analyses (n = 19,700).

Variablea

Underweight Normal Overweight Obese I

Obese II Obese III Super-obese
(n = 63) (n = 3235) (n = 6,653) (n = 4,977) (n = 2,644) (n = 1,703) (n = 425)

Maternal age 35 y/o

(n = 2,020)
Nulliparous (n = 7,971)

47.6 (30)

Black race (n = 10,512)

58.7 (37)

Hispanic ethnicity (n = 2,793)

15.9 (10)

Smoking (n = 2,209)

15.9 (10)

0 (0)

1.6 (1)

46.6
(1,508)
52.7
(1,705)
12.2
(393)
13.1
(424)
1.1 (34)

0 (0)

0.3 (10)

Chronic hypertension
(n = 895)
Pregestational diabetes
(n = 455)
Stillbirth (n = 287)
Neonatal death (n = 285)
Preterm birth (n = 3,437)

3.2 (2)
4.8 (3)
38.1 (24)

SGA (n = 2,967)

28.6 (18)

LGA (n = 1,246)
Gestational diabetes (n = 819)
Preeclampsia (n = 1,258)
Placental abruption (n = 153)
Cesarean delivery (n = 5,070)

0
1.6
4.8
3.2
20.3

Congenital anomaly (n = 948)

1-Minute Apgar < 7 (n = 3,438)
5-Minute Apgar < 7 (n = 1,164)

7.9 (5)
23.8 (15)
11.1 (7)

7.8 (252) 10.3 (687)

(0)
(1)
(3)
(2)
(13)

10.3 (514) 10.7 (284)

< 0.001

< 0.001

43.4 (2,887) 38.0

35.6 (942) 34.7 (591) 29.2 (124)
(1,889)
46.8 (3,110) 52.2
60.8
66.8
74.6 (317)
(2,598)
(1,608)
(1,137)
17.0 (1,128) 16.8 (836) 11.0 (292)
6.9 (117) 4.0 (17)

< 0.001

< 0.001

11.4 (760)

< 0.001

11.1 (551) 10.1 (268)

9.3 (158)

8.9 (38)

1.6 (109)

3.5 (175)

8.1 (213)

14.3 (244) 28.0 (119)

< 0.001

1.2 (81)

2.3 (113)

3.6 (95)

6.3 (107) 11.5 (49)

< 0.001

1.0 (51)
1.2 (32)
1.2 (61)
1.6 (43)
711 (14.3) 16.4 (434)

1.8 (30)
0.9 (4)
1.2 (20)
2.1 (9)
16.2 (276) 18.8 (80)

0
0
0

0.005
0.292
< 0.001

11.9 (593) 12.1 (320)

11.9 (202) 10.4 (44)

< 0.001

(64)
(55)
(74)
(3)
(238)

0
0
0
0
0

< 0.001
< 0.001
< 0.001
< 0.001
< 0.001

7.1 (30)
26.6 (113)
9.4 (40)

0
37
27

0.672
< 0.001
0.222

2.4 (77) 1.4 (91)

1.9 (61) 1.3 (88)
25.0 (809) 16.6
(1,103)
22.6 (730) 15.9
(1,060)
1.5 (47) 4.3 (285)
1.1 (34) 2.2 (146)
3.0 (97) 4.42 (294)
1.3 (41) 0.8 (56)
15.8 (511) 21.5
(1,428)
5.0 (162) 4.8 (322)
17.0 (548) 15.7 (1,043)
7.0 (226) 5.3 (353)

7.6 (379) 10.2 (269) 11.9 (202)

4.5 (224) 6.8 (180) 10.5 (179)
6.5 (324) 9.4 (249) 12.7 (217)
0.5 (26)
0.6 (16)
0.53 (9)
27.2
32.9 (869) 38.64 (658)
(1,353)
4.4 (217) 4.7 (125)
5.1 (87)
16.9 (839) 19.2 (507) 22.0 (373)
5.1 (253) 6.3 (166)
7.0 (119)

Dichotomous variables represented by column percents (frequencies).

Cochrane Armitage test for trend unless otherwise noted (two-tailed values).
Note: BMI, body mass index.
b

12.4 (211) 16.9 (72)

Missing
data
(n) p-Valueb

15.1
12.9
17.4
0.7
56.0

Maternal super-obesity

929

Table 4. Association between adverse pregnancy outcomes and super-obesity versus women with BMI 30.049.9 (n = 9,749).
Outcome variable
Stillbirth
Preterm birth
Preeclampsia
Gestational diabetes
Congenital anomaly
Placental abruption
Cesarean delivery
Apgar 1-minute < 7
Apgar 5-minute < 7

Super-obese
(n = 425)
0.9
18.8
17.4
12.9
7.1
0.7
56.0
26.6
9.4

(4)
(80)
(74)
(55)
(30)
(3)
(238)
(113)
(40)

BMI 30.049.9
(n = 19,275)
1.2
15.2
8.5
6.3
4.6
0.8
30.9
18.5
5.8

(113)
(1,421)
(790)
(583)
(429)
(150)
(2,880)
(1,719)
(538)

Unadjusted ORa
0.77
1.29
2.28
2.23
1.57
0.91
2.85
1.60
1.70

Unadjusted
95% CIa
0.282.11
1.001.66
1.752.96
1.662.99
1.072.31
0.292.85
2.343.47
1.282.00
1.212.37

Adjusted OR

Adjusted
95% CI

0.68
1.21
2.14
1.90
1.47
N/A
2.86
1.59
1.74

0.251.86
0.941.56
1.642.80
1.405.57
1.002.16
N/A
2.353.49
1.262.01
1.192.55

Categorical variables described by column percents (frequencies).

a
p-Values and unadjusted ORs (95% CIs) calculated by Wald chi-square
Models controlling for: stillbirth- maternal age, black race, smoking; preterm birth- black race, smoking, parity; preeclampsia- maternal age,
black race, smoking, parity; gestational diabetes-maternal age, black race or Hispanic ethnicity; congenital anomaly-maternal age; cesarean
delivery- nulliparity, congenital anomaly, gestational age; 5-minute Apgar < 7-gestational age.
Note: BMI, body mass index; SGA, small for gestational age; LGA, large for gestational age; OR, odds ratio; CI, condence interval.

obstetricians with regards to minimizing and evaluating risks during the antepartum and intrapartum
periods.
In addition, it does not appear that super-obesity
has a dual-fold impact on increased rates of both SGA
and LGA compared to normal-BMI women. Contrary to previous publications (18,19), obesity was not
positively associated with SGA. While super-obesity
was protective against delivering an SGA infant compared to all other women, rates of SGA were not
different between super-obese and other, less obese
women. Therefore, increasing BMI beyond mild obesity results in increasing delivery rates of LGA infants
while not further affecting rates of SGA. It had been
hypothesized that the delivery rate of SGA infants
would be increased in super-obese women compared
to women with a normal BMI, presumably related to
high rates of placental dysfunction. Other studies
agree with our observations of the effect of BMI on
rates of LGA and SGA (20,21). Potential explanations for differences in ndings between studies
include variations in the clinical setting from which
study patients were derived, differences in data analysis and denitions of SGA. For example, the study by
Rode et al. included women from a racially and
ethnically homogenous population (Denmark) who
delivered after 37 weeks gestation, and known confounders for fetal growth restriction, including smoking, race, and congenital anomaly were not controlled
for in the analysis (18). In addition, the rate of low
birthweight infants (dened as < 2500 g) was much
lower (1.02.8%) than the rate reported in the present
investigation (15.1%), reecting differences in patients
and settings. Likewise, the study by Rosenberg et al. did
not have the maternal height available (19) and their
analyses did not control for gestational age.

Therefore, obesity appears to be associated with

excessive fetal growth and not undergrowth. There
may be subpopulations of obese women who are at
increased risk for fetal growth restriction that have yet
to be identied. While Nhr et al. demonstrated a
signicantly lower birthweight among stillbirths from
obese mothers compared to the cohort median (8),
there were too few stillbirths among super-obese
women to make these comparisons in our study.
The strengths of the present study include a single
institution analysis and a relatively large number of
study patients. In addition, these ndings are consistent with the known risks of obesity and adverse
pregnancy complications. Study limitations include
the cross-sectional design and the unavailability in
the perinatal database of certain variables, including
maternal gestational weight gain, pre-pregnancy
weight, and postpartum maternal and neonatal complications. While gestational weight gain is likely to
result in an increase in BMI classication during
pregnancy for women with low pre-pregnancy BMI,
obese women are unlikely to demonstrate similar shifts
(22). We feel, therefore, that the use of BMI at delivery,
which takes into account insufcient or excessive gestational weight gain, is appropriate for the outcomes
which we described. However, our results may not be
readily comparable to other studies that use the prepregnancy BMI as the primary exposure variable.
Future studies to examine the effect of super-obesity
and other degrees of obesity on fetal growth patterns
should include prospective ultrasound measurements
before fetal death may occur, as well as birthweight and
follow-up studies of growth during childhood. In addition investigations into the impacts of modiable behaviors (e.g. maternal weight gain during pregnancy) on
obesity-related pregnancy outcomes should focus on

930

M.C. Alanis et al.

super-obesity, as these women appear to have the

highest rates of pregnancy complications.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.

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