Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 34e38

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Taiwanese Journal of Obstetrics & Gynecology

journal homepage: www.tjog-online.com

Original Article

The effect of obesity on the onset of spontaneous labor and scheduled

delivery rates in term pregnancies
Sedat Akgol a, Agnese Maria Chiara Rapisarda b, *, Mehmet Sukru Budak a,
~ oz c, Li-Te Lin d, e, f,
Salvatore Caruso b, Antonio Cianci b, Enrique Reyes-Mun
_Ilker Kahramanoglu a

a
Department of Obstetrics and Gynecology, Health Sciences University Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
b
Unit of Gynecology and Obstetrics, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
c
Department of Endocrinology, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
d
Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
e
Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
f
Department of Biological Science, National Sun Yat-sen University, Kaohsiung, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the effect of obesity on the onset of spontaneous labor, scheduled delivery rates
Accepted 18 September 2019 and perinatal outcomes in term pregnancies.
Material and methods: 242 obese and 244 non-obese pregnant women
37 gestational weeks were
Keywords: compared in terms of the onset of spontaneous labor, scheduled delivery rates and perinatal outcomes.
Pregnancy Results: Obese pregnant women had statistically significantly lower onset of spontaneous labor and
Obesity
higher rates of scheduled delivery. No difference was determined in respect of the type of delivery, 1st
Delivery
and 5th minutes APGAR scores and the need for intensive care. Higher values of birth weight, large for
Labor
Pregnancy outcomes
gestational age, macrosomia, gestational diabetes mellitus and preeclampsia were determined in obese
women.
Conclusion: The onset of spontaneous labor rates in term obese pregnancies were lower and scheduled
delivery rates were higher than in the non-obese pregnancies. However, more extensive studies are
needed to better understand this relationship.
© 2020 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction associated with an increased risk of uterine fibroids, which may

affect pregnancy outcomes and require specific clinical manage-
With increased prevalence over the last century, obesity in women ment [15,16]. There has also been reported to be an increase in
of reproductive age has become a major health problem in Turkey as it obesity-related post-term pregnancy rates [17,18]. Although the
has throughout the world [1e4]. Obesity and central adiposity are precise cause of the increase in the incidence of post-term preg-
particularly frequent in women with PCOS and type 2 diabetes with an nancies in obese pregnancies is not fully known, it has been sug-
increased risk of pregnancy-related complications [5,6]. gested that it could be due to a decrease in the onset of spontaneous
Maternal and neonatal complications such as gestational dia- labor rates [19,20]. The effect mechanism of obesity on the onset of
betes mellitus, pregnancy-induced hypertension, labor induction, spontaneous labor rate is not fully understood, but may be due to
failure of labor induction, cesarean delivery, macrosomia, shoulder abnormal myometrial contractility caused by obesity, as this effect
dystocia and admission to neonatal intensive care units have been has been shown in invitro studies [21]. To date, only a few studies
reported to increase with obesity [7e14]. Furthermore, obesity is have investigated the role of obesity on the onset of spontaneous
labor and scheduled delivery rates in term pregnancies [19,22,23].
The primary aim of this study was to determine the effect of obesity
on the onset of spontaneous labor and scheduled delivery rates in
* Corresponding author. Unit of Gynecology and Obstetrics, Department of
General Surgery and Medical Surgical Specialties, University of Catania, Via Santa term pregnancies. A secondary aim was to compare perinatal out-
Sofia 78, 95124, Catania, Italy. comes between obese and non-obese pregnancies.
E-mail address: [email protected] (A.M.C. Rapisarda).

https://doi.org/10.1016/j.tjog.2019.10.002
1028-4559/© 2020 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 S. Akgol et al. / Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 34e38 35

Material and methods diastolic blood pressure, SGA, LGA, macrosomia, GDM, and pre-
eclampsia. A value of p < 0.05 was accepted as statistically
This prospective cohort study was conducted between January significant.
20, 2018 and February 20, 2018 at the Health Sciences University
Diyarbakır Gazi Yaşargil Training and Research Hospital, where the Results
annual number of births exceeds 25,000. The study was approved
by the Local Ethics Committee (n.13, January 19, 2018) and prepared A total of 486 patients were considered eligible for the study
in accordance with the STrengthening the Reporting of OBserva- (Fig. 1). The clinical characteristics and perinatal outcomes of patients
tional studies in Epidemiology (STROBE) guidelines [24]. Informed are summarized in Table 1. Statistically significant differences were
consent was obtained from all participants. Consecutive patients determined between the obese and non-obese women in terms of
were recruited as they were admitted for labor. Women with pre- age, gravida, parity, diastolic blood pressure, systolic blood pressure,
term births (<37 weeks), multiple pregnancies, previous uterine onset of spontaneous labor, scheduled delivery, birth weight, LGA,
(cesarean or myomectomy etc.) or vaginal surgery (cystorectocele macrosomia, GDM and pre-eclampsia rates. No statistically signifi-
repair, prolapse, or incontinence surgery) and stillbirth were cant differences were determined in terms of gestational age, term
excluded from the study. Body mass index (BMI) was calculated by pregnancy, post-term pregnancy, vaginal delivery, cesarean delivery,
measuring height and weight at the time of admission to the de- instrumental vaginal delivery, 1-min APGAR score, 5-min APGAR
livery room. BMI of
30 kg/m2 was accepted as obesity [25]. The score, SGA and NICU hospitalization rates.
study included a total of 496 pregnant women at
37 gestational The rates of onset of spontaneous labor and scheduled delivery
weeks who were admitted to the delivery room, of whom 242 were in the different groups of BMI values are summarized in Table 2. As
obese. Obstetric ultrasound was performed on all patients at the BMI increased, there was seen to be a significantly lower rate of
time of admission to the delivery room for labor. The date of the last onset of spontaneous labor and a significantly higher rate of
menstrual period and/or the first trimester obstetric ultrasound scheduled delivery.
measurements was used to determine the gestational age. Logistic regression analysis revealed that obese women were
The primary outcome of this study was to compare the rates of almost 2-fold more likely to have scheduled delivery (Table 3).
onset of spontaneous labor and scheduled delivery, between the When the analysis was stratified for the different BMI categories, a
groups separated according to weight. Additional comparisons of trend toward higher obesity levels was revealed, showing that
the obese and non-obese pregnant women were made in terms of severely obese women were most associated with scheduled
mean age, gravida, parity, systolic and diastolic blood pressure delivery.
values, gestational week, post-term pregnancy (
42 gestational
weeks), onset of spontaneous labor, scheduled delivery (defined as Discussion
initiation of induction of labor for an obstetric reason such as early
membrane rupture, pre-eclampsia, post-term), birth type (vaginal, The findings of this study showed that the rates of onset of
cesarean or instrumental vaginal delivery), birth weight, 1 and spontaneous labor in term obese pregnancies were lower and
5 min APGAR scores, small for gestational age (SGA: birth weight scheduled delivery rates were higher than in non-obese pregnan-
<10th percentile according to gestational age), large for gestational cies. Furthermore, as BMI increased, lower rates of onset of spon-
age (LGA: birth weight >90th percentile according to gestational taneous labor and higher rates of scheduled delivery were
age), macrosomia (baby weight of
4000 g), pre-eclampsia and determined. There are only a few studies in literature on this sub-
admission to neonatal intensive care unit rates. The rates of onset of ject and in those studies, the rate of onset of spontaneous labor in
spontaneous labor and scheduled delivery were calculated within term obese pregnant patients has been shown to be lower than in
different scales of BMI. term non-obese pregnant patients, which is similar to the current
study results [19,22,23]. When considering these studies in terms
Sample size of the onset of spontaneous labor rates in term pregnancies, Frolova
et al. [19]reported a rate of 50.7%, Denison et al., 77% [22], and
Sample size was calculated to find a difference of 10% in the Hermesch et al., 78% [23]. In the current study, the onset of spon-
proportion of onset of spontaneous labor between obese and non- taneous labor rates in term obese pregnancies were similar to the
obese pregnant women, considering an alpha of 0.05, and beta of results of Denison et al. [22] and Hermesch et al. [23], but higher
20% using a one-sided test. A sample size of 197 women per group than the results of Frolova et al. [19] (Table 4). Although the path-
was required. ophysiology of this decrease in the onset of spontaneous labor rates
in term obese pregnancies compared to non-obese pregnancies is
Statistical analysis not fully understood, in vitro studies have shown that obese women
have abnormal contractility in the myometrium [21] and that when
Data obtained in the study were analyzed statistically using SAS oxytocin is required, higher doses are used in obese pregnancies
version 9.2 software. Descriptive statistics (mean, standard devia- [26]. Therefore, this decrease in the onset of spontaneous labor
tion, minimum, median, maximum) were used to describe rates in obese pregnancies may be due to this abnormal myometrial
continuous variables. The Mann Whitney U-test was used to contractility [21].
compare two groups of independent variables not showing normal In a study by Frolova et al., the post-term pregnancy rate was
distribution. The ChieSquare test or Fisher Exact test, as appro- found to be significantly higher in obese pregnancies than in non-
priate, was applied to examine the relationship between categorical obese pregnancies (10.8% vs 8%) [19]. In contrast, in the current
variables. Univariate and multivariate logistic regression analyses study, the post-term pregnancy rate was not significantly higher in
were performed to determine the association between the primary obese pregnancies than in non-obese pregnancies. The results of
variable of exposure (obesity and weight categories) and the the current study support the hypothesis that the factors deter-
outcome of interest (onset of spontaneous labor and scheduled mining the length of gestational age are not fully known.
delivery). The associations were expressed as odds ratios (OR) and In the current study, the mean age in obese pregnancies was
95% confidence intervals (CI); multivariate analysis was adjusted significantly higher than in non-obese pregnancies. Similar to these
for potential confounding factors, such as age, parity, systolic and results, Frolova et al. [19] also showed this difference. In addition,
36 S. Akgol et al. / Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 34e38

Fig. 1. Flow diagram of the study.

Table 1
Clinical characteristics and perinatal outcomes of obese and non-obese pregnancies.

BMI
30 kg/m2 n ¼ 242 BMI<30 kg/m2 n ¼ 244 P-value

Age (years),[mean ± SD] 28.02 ± 6.4 25.8 ± 5.9 < 0.001

Gravida, [mean ± SD] 3.2 ± 2.03 2.79 ± 1.9 0.004
Parity, [mean ± SD] 2.05 ± 1.9 1.62 ± 1.8 0.005
Blood pressure (mmHg), [mean ± SD]
Diastolic 66.9 ± 8.3 65.1 ± 7.2 0.002
Systolic 107.8 ± 12 104.8 ± 10.3 0.016
Gestational age (w),[mean] 38.9 ± 1.1 38.8 ± 1.2 0.535
Onset of spontaneous labor, n (%) 180 (74.4) 206 (84.4) 0.009
Scheduled delivery, n (%) 62 (25.6) 38 (15.6) 0.008
Term pregnancya, n (%) 222 (91.7) 229 (93.9) 0.445
Post-term pregnancyb, n (%) 18 (7.4) 14 (5.7) 0.565
Type of delivery, n (%)
vaginal 217 (89.7) 227 (93.0) 0.257
cesarean 22 (9.1) 15 (6.1) 0.281
Instrumental vaginal 3 (1.2) 2 (0.8) 0.989
Birth weight (g), [mean ± SD] 3370.7 ± 406.1 3256.6 ± 419.3 0.007
First minute APGAR score [mean ± SD] 7.9 ± 0.7 7.9 ± 0.7 0.288
Fifth minute APGAR score [mean ± SD] 8.9 ± 0.6 8.9 ± 0.4 0.342
SGA, n (%) 3 (1.2) 11 (4.5) 0.056
LGA, n (%) 36 (14.9) 15 (6.1) 0.002
Macrosomia, n (%) 19 (7.8) 8 (3.3) 0.03
GDM, n (%) 25 (10.3) 12 (4.9) 0.037
Pre-eclampsia, n (%) 18 (8.0) 5 (2.0) 0.005
NICU, n (%) 9 (3.7) 3 (1.2) 0.087

w: week, d:day, g:gram, BMI: body mass index,SGA: small for gestational age, LGA: large for gestational age, GDM: gestational diabetes mellitus, NICU: neonatal intensive care
unit.
Bold values indicate p < 0.05.
a
37w0d-41w6d.
b

42w0d.

Table 2
Onset of spontaneous labor and scheduled delivery rates in different scales of BMI.

Onset of Spontaneous Labor n, (%) Scheduled Delivery n, (%) P value

BMI (<25 kg/m2), n ¼ 54 47 (87%) 7 (13%) < 0.001

BMI (25e29.9 kg/m2), n ¼ 190 159 (83.6%) 31 (16.4%)
BMI (30e34.9 kg/m2), n ¼ 182 145 (79.6%) 37 (20.4%)
BMI (
35 kg/m2), n ¼ 60 35 (58.3%) 25 (41.7%)

Bold value indicates p < 0.05.

 S. Akgol et al. / Taiwanese Journal of Obstetrics & Gynecology 59 (2020) 34e38 37

Table 3 pregnancies was higher than non-obese pregnancies in the current

Association between onset of delivery, obesity and BMI status. study. Moreover, Zoet et al. [29] reported that the prevalence of
Scheduled delivery, OR (95% CI) obesity increased with increasing parity. Likewise, the gravida and
Model 1a Model 2b
parity rates were higher in obese pregnancies than non-obese
pregnancies in the current study.
Obesity status
The results of this prospective study presented here are of a
Non-obese (BMI<30 kg/m2) 1 1
Obese (BMI
30 kg/m2) 1.88 (1.20e2.96) 1.91 (1.15e3.18) sufficient series of patients in a tertiary -level birth center, and have
BMI status generated valuable data. The main limitations of this study were
Normal 1 1 the monocentric design and that deliveries were performed by
Overweight 2.47 (0.56e10.90) 3.13 (0.64e15.37)
different midwives and physicians; another limitation was that BMI
Obese 3.40 (0.77e14.93) 4.65 (0.94e22.85)
Severely obese 15.17 (3.05e75.52) 15.83 (2.72e91.85) was calculated at term of pregnancy.
P for trend <0.001 <0.001
a
Univariate analysis. Conclusion
b
Multivariate analysis adjusted for age, parity, systolic and diastolic blood pres-
sure, SGA, LGA, macrosomia, GDM, and pre-eclampsia.
In conclusion, the onset of spontaneous labor rates in term
obese pregnancies were significantly lower and scheduled delivery
Table 4
rates were significantly higher than in non-obese pregnancies,
The rates of onset of spontaneous labor of obese pregnancies in different studies. while some perinatal complications were found to increase. Preg-
nant women should be informed about the negative effect of
BMI
30 kg/m2
obesity at the time of delivery. However, further, more extensive
Onset of Spontaneous Labor Scheduled Delivery prospective studies are required to better understand this effect of
Frolova et al. [19] 50.7% 49.3% obesity on the onset of spontaneous labor and scheduled delivery
Denison et al. [22] 77% 23% rates in term pregnancies.
Hermesch et al. [23] 78% 22%
Current study 74.4% 25.6%
Declaration of Competing Interest
BMI:body mass index.

The authors declare no conflict of interests.

Caderlund et al. [27] reported that obesity frequency increases with
increasing age, which supports the significant increase in age in Acknowledgements
obese pregnancies in the current study. Furthermore, the gravida
and parity rates in the current study patients were significantly No specific funding was obtained for this study.
higher in the obese group, which may also be due to the older age of
this group.
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