Pregnancy and weight

More Americans than ever have a weight problem. So it’s not surprising that more women find themselves a few sizes bigger at the beginning of pregnancy than they would like. Being overweight increases a woman’s health risks, but big women can improve their chances for a complication-free pregnancy and healthy baby.

A recent study on obesity and pregnancy in Alabama showed that the average weight of women during their first prenatal visit increased from 144 pounds in 1980 to 172 pounds in 1999. Dr. George C. Lu and colleagues at the University of Alabama at Birmingham, using a computerized database to look at the medical records of more than 53,000 women, also found that by the end of the study, nearly 25 percent more pregnant women were having problems with the body’s use of blood sugar, a disorder known as gestational diabetes. A similar increase was recorded in the number of larger-than-normal newborns.

At what point does extra weight affect a pregnancy? Health care providers look to the body mass index. BMI is a measure of body fat based on height and weight. Some people’s numbers are skewed (by being very muscular, for instance), but if a woman’s BMI is 30 or higher, she is considered medically obese. BMI can be calculated at the Heart, Lung and Blood Institute Web site (www.nhlbisupport.com/bmi).

No doubt about it: The list of potential problems connected with obesity is scary. The U.S. surgeon general’s Web site summarizes the risks that overweight and obese women face during pregnancy:

• Gestational diabetes.

• Heightened blood pressure, which can lead to seizures, premature delivery, fetal distress and death.

• Labor and delivery difficulties that result in Caesarean births or even death for both the baby and the mother.

An overweight mother also brings risks for the baby:

• Heavy women are more likely to deliver big babies, and a high birth weight — in the 90th percentile or higher — can make delivery difficult. Complications include having the baby get stuck as it descends through the birth canal and nerve damage to the child.

• Studies published in the Journal of the American Medical Association in the 1990s implicate obesity as a contributing factor to neural tube defects such as spina bifida. In May 2003, researchers at the Centers for Disease Control and Prevention reported a connection between maternal obesity and other birth defects, including heart problems. The study compared about 1,000 women.

“A woman who is technically obese is not necessarily a complicated pregnancy,” says Diana Taylor, a certified nurse-midwife with the Maternity Center in Bethesda.

Goulda A. Downer, who works with the March of Dimes, echoes Ms. Taylor. “You can be obese and be healthy,” she says, “but the extra weight puts a strain on the heart and other organs. It’s [a] delicate time for the mother and baby.”

Easing the way

What can a woman do to ease her risks? Do not start a weight-reduction diet while pregnant. It may be the only time in her life that a woman is instructed not to lose weight; some weight gain is essential to a healthy pregnancy.

The Institute of Medicine, an arm of the National Academy of Sciences, has recommended that women with a “normal range” BMI gain 25 to 35 pounds; overweight women should settle on a gain of 15 to 25 pounds.

Rather than indulge and “eat for two,” though, pregnant women generally need just 300 calories more per day than usual. The calories should be nutritional — not a couple of pieces of chocolate.

“We always emphasize excellent nutrition for everyone,” Ms. Taylor says. “They need to make sure they get enough protein, fruits and vegetables, milk products for calcium and whole grains. An overweight woman could cut back on starches.”

“Often, women don’t lose the weight they put on during pregnancy,” Ms. Downer says. “The biggest message is: Plan ahead and think ahead.” She emphasizes that women should make a connection between food and their babies.

Once upon a time, Robin Bourjaily carried a trim 127 pounds on her 5-foot-5 frame. It didn’t last. Ten years later, she says, she got pregnant with baby No. 1 with a starting weight of 186.

“I easily gained 50 pounds during the pregnancy, and while it was an easy pregnancy, it was a difficult delivery of a big baby,” the Bethesda mom explains. “We joked that he should have been named Benjamin Gerald, after the ice cream I ate so much of during that pregnancy.”

Because the baby was late, Ms. Bourjaily’s labor was induced. She ended up being in labor 22 hours, pushing for three hours and having the doctors use forceps to help deliver the 9-pound, 7-ounce baby.

Two years later, she found herself at 216 pounds. She lost 30 pounds — which put her at the same starting point as before conceiving baby No. 1 — before getting pregnant with baby No. 2.

“This time, I only gained about 30 pounds, had a smaller baby [7 pounds, 10 ounces] and a natural delivery — no drugs at all,” she says. “Since her birth, I’ve lost all of that weight and more.”

She used the Maternity Center in Bethesda for prenatal care, and the midwives there didn’t reproach her about putting on 50 pounds during the first pregnancy. On her second, they were more concerned that she was losing weight during her first trimester.

“I’d just lost weight, and I didn’t want to regain it,” she says.

In retrospect, Ms. Bourjaily wishes she had been pushed a little about holding her weight down during the first go-round.

“I blew up like a balloon at the end of my pregnancy. I thought it was normal to be so tired and ache, but I was very, very heavy,” she says.

She was more comfortable during her second pregnancy.

“We try to help people from gaining too much,” Ms. Taylor says. “Obese women should not be stigmatized. They should be considered as normal — although monitored early and perhaps more often — and treated with respect.”

Possible problems

High blood pressure is an ongoing concern for many overweight pregnant women.

Nancy Bruno of Lorton tried unsuccessfully for years to have a baby. Her doctor pinpointed the problem as her hormone levels, so, after a divorce and remarriage, she didn’t think much about contraception. Then — surprise, surprise — she learned she was pregnant. She weighed 213 pounds.

Her doctor didn’t give her grief over the situation. In fact, he focused much more heavily on the risks stemming from her being older than 35. He did keep an eye out for heightened blood pressure, though.

Blood pressure measures how strongly blood being pumped through the body pushes against the walls of the blood vessels. If blood pressure becomes too high, it can cut off oxygen and blood supplies to mother and baby. Consequences for the woman include kidney problems; breathing problems; seizures; strokes; and even, in very rare cases, death. The baby might not be able to grow properly without a normal flow of blood through the placenta.

Complications of Caesarean delivery, such as wound infection and life-threatening pulmonary embolus, are also more likely to occur in heavier women, Ms. Taylor says.

Gestational diabetes can strike any pregnant woman, but extra pounds can increase the risk. Nearly 135,000 pregnant women (of all sizes) get the condition every year.

A short, plump woman, Marcia Wise of Vienna had given up on losing weight by the time she became pregnant the third time. When her blood-sugar test halfway through her pregnancy revealed gestational diabetes, her doctor put her on a “frequent eating” diet. The most unpleasant part was having to prick her finger often to test her glucose level. Gestational diabetes typically does not require insulin injections.

The body breaks down sugar into glucose, which provides energy. A hormone called insulin moves the glucose out of the blood and into the body’s cells. In women with gestational diabetes, the glucose can’t get into the cells, so the amount of glucose in the blood gets higher and higher. After the baby is born, the body functions normally again.

Once a person has had gestational diabetes, she’s likely to develop it again in subsequent pregnancies and to have type 2 diabetes later in life.

Both held true for Ms. Wise. It turned up early in her fourth pregnancy, and recently (nine years later), she was diagnosed with type 2 diabetes, which she controls well with diet.

Maternal obesity has been associated with defects in the spinal cord or brain of the baby (neural tube defects). Taking a daily dose of 400 micrograms of folic acid is recommended. A study published in the March 2004 issue of the journal Obstetrics and Gynecology indicates that folic-acid fortification is working even better than experts expected in combating neural tube defects.

Smooth sailing

Eileen Blake of Falls Church has struggled with her weight all her life.

When she got pregnant with her second child, she weighed about 90 pounds more than she wanted to; she dropped to less than 250 with her third pregnancy. Her weight didn’t affect her pregnancies, however.

“I never felt better than when I was pregnant, in terms of mood and how my body felt,” Mrs. Blake says. “It was miraculous.

“People think that if you’re overweight, you’re not healthy, but to be honest, when I was 140, I bruised more easily, and I was always cold. I’d love to drop below 200, but not everybody has the same ideal weight.”

She didn’t have gestational diabetes, and all her tests during pregnancy came back in the normal range. Her deliveries were quick; it was 90 minutes from the time her water broke until her second son was delivered, for example.

“I’ve got a birthing-baby body,” she says with a laugh.

Health care providers agree that being healthy and fit is the best way to prepare for being pregnant. Generally, women don’t know for several weeks that they have conceived.

Vows to “eat better,” for example, once you’re expecting can be sidelined by morning sickness. To avoid inadvertently harming an unborn child, the March of Dimes suggests the following:

• Get early prenatal care, even before you’re pregnant.

• Eat a well-balanced diet.

• Get 400 micrograms (0.4 milligrams) of folic acid each day.

• Exercise. (Clear it with your doctor.)

• Quit drinking, smoking and any recreational drug use.

• Cut down on caffeine.

• Avoid X-rays, hot tubs and saunas.

• Avoid infections.

You also can check your rubella immunity, have your doctor review all medications and check into insurance coverage.

The New York Online Access to Health site offers an extensive list of articles on planning for pregnancy (www.noah-health.org/english/pregnancy/pregnancy.html).”

— Lois M. Baron

MORE INFO:

BOOKS —

• “CARRYING A LITTLE EXTRA: A GUIDE TO HEALTHY PREGNANCY FOR THE PLUS-SIZE WOMAN,” BY PAULA BERNSTEIN, MARLENE CLARK AND NETTY LEVINE, BERKLEY PUBLISHING GROUP, 2003. THIS BOOK FOR PLUS-SIZE MOMS-TO-BE COVERS TOPICS INCLUDING GESTATIONAL DIABETES, NUTRITION, EXERCISE AND EMOTIONAL ISSUES.

• “THE PREGNANCY DIET: A HEALTHY WEIGHT CONTROL PROGRAM FOR PREGNANT WOMEN,” BY EILEEN BEHAN, POCKET BOOKS, 1999. THIS BOOK ANSWERS WOMEN’S QUESTIONS ABOUT HEALTHY WEIGHT GAIN DURING PREGNANCY.

ASSOCIATIONS —

• MARCH OF DIMES BIRTH DEFECTS FOUNDATION, 1275 MAMARONECK AVE., WHITE PLAINS, NY 10605; 800/367-6630. WEB SITE: WWW.MARCHOFDIMES.COM.

• AMERICAN DIETETIC ASSOCIATION, 120 S. RIVERSIDE PLAZA, SUITE 2000, CHICAGO, IL 60606; 800/366-1655, FROM 10 A.M. TO 5 P.M. CENTRAL TIME. REGISTERED DIETITIANS ARE AVAILABLE. WEB SITE: WWW.EATRIGHT.ORG.

• AMERICAN DIABETES ASSOCIATION, NATIONAL SERVICE CENTER, 1660 DUKE ST., ALEXANDRIA, VA 22314; 703/549-1500. WEB SITE: WWW.DIABETES.ORG.

ONLINE —

• ONE AREA OF THE NATIONAL AGRICULTURE LIBRARY’S WEB SITE OFFERS A COMPREHENSIVE RESOURCE LIST COVERING NUTRITION DURING PREGNANCY AND BREAST-FEEDING (WWW.NAL.USDA.GOV/FNIC/PUBS/BIBS/TOPICS/PREGNANCY/PREGCON.HTML).

• A CHILDBIRTH EDUCATOR AND FREE-LANCE WRITER HAS DEVELOPED THE PLUS-SIZE PREGNANCY WEB SITE (WWW.PLUS-SIZE-PREGNANCY.ORG/INDEX.HTML). A WELL-RESEARCHED SITE, IT ADDRESSES THE FEARS AND CONCERNS OF OVERWEIGHT WOMEN IN A STRAIGHTFORWARD WAY. INCLUDED ARE SECTIONS ON MAKING SURE ULTRASOUNDS GO SMOOTHLY, PRENATAL TESTING, TIPS FOR A BETTER BIRTH AND POSTPARTUM ISSUES.