美国妇产科医师协会(ACOG)日前表示，尽管超重或肥胖的单胎孕妇不宜增重超过25磅(11.34 kg)，但只要胎儿生长情况正常，低于这一幅度的增重都是安全的。与此同时，不必采用医学干预手段来使孕妇达到医学研究所(IOM)2009年推荐的体重目标(2013;121:210-2)。

　　2009年IOM关于孕妇增重的建议并未得到普遍认可，很多医生感觉对于超重或肥胖女性的建议不够严密。为了评估该建议，ACOG产科实践委员会回顾分析了关于超重与肥胖孕妇及其胎儿结局的文献，并在《产科学与妇科学》1月刊上发表文章指出：“如果一名肥胖孕妇的增重幅度低于建议范围，但其胎儿生长良好，那么目前没有证据表明依据IOM指南让孕妇增重将会改善母婴结局。”

　　委员会表示：“一些医生认为，建议的增重目标过高，而且没有解决对产后体重维持的担忧。此外，该指南并未专门对肥胖(尤其是病态肥胖)女性提出建议。”确定孕妇的体重目标必须权衡风险与获益。肥胖母亲更可能发生妊娠188bet在线平台网址 和先兆子痫，更多地采取剖宫产，伤口感染和静脉血栓栓塞风险也更高。肥胖母亲的婴儿更可能发生出生缺陷，包括神经管缺陷风险加倍，死产和巨大儿更常见，后者又导致剖宫产风险增加。

　　在回顾分析IOM建议和现有文献之后，ACOG就超重或肥胖孕妇的处理提出了自己的建议(Obstet. Gynecol. 2013;121:213-7)。

　　在怀孕之前：

　　 使患者了解肥胖可给母婴双方都带来风险，鼓励患者在妊娠之前降低体重。

　　 进行营养学评估，开具运动处方。

　　在妊娠期间：

　　 在首次产前就诊时评估身高、体重和体重指数(BMI)，向其解释IOM增重建议，并在此后每次就诊时再次评估。

　　 持续进行营养学咨询和锻炼。

　　 对于曾接受减肥手术的患者，使用额外的铁、维生素B12、叶酸、维生素D和钙补充剂。

　　在分娩时：

　　 提前就麻醉问题进行商议，因为硬膜外麻醉和全身麻醉对于肥胖患者具有同等的难度。

　　 对于接受剖宫产的患者，考虑使用高于常规量的抗生素预防伤口感染。

　　 评估每例患者的血栓栓塞风险，在符合适应证的情况下使用气动压缩、普通肝素或低分子量肝素。

　　 考虑在剖宫产之后缝合关闭皮下脂肪层，这一做法有助于降低术后伤口开裂风险。

　　在产后：

　　 鼓励患者在尝试再次妊娠之前降低体重——寻求专家的帮助。

　　所有ACOG委员会成员都必须遵循该学会有关利益冲突的指南。

　　Although overweight or obese women should gain no more than 25 pounds in a singleton pregnancy, there is no harm in their gaining less, as long as the fetus is growing as it should, according to the American College of Obstetricians and Gynecologists.

　　There is no medical need to increase weight gain just to meet the goals the Institute of Medicine recommended in 2009, according to ACOG.

"For an obese pregnant woman who is gaining less weight than recommended, but who has an appropriately growing fetus, no evidence exists that encouraging increased weight to conform with the updated IOM guidelines will improve maternal or fetal outcomes," ACOG’s Committee on Obstetric Practice wrote in the January issue of Obstetrics and Gynecology (2013;121:210-2). The committee made a similar statement about overweight pregnant women.

　　In examining the IOM recommendations, ACOG reviewed the extant literature on maternal and fetal outcomes in overweight and obese women. The 2009 weight gain recommendations have not been universally embraced, the group said, because many clinicians feel they aren’t strict enough for overweight or obese women.

　　"The [recommendations] have met with controversial reactions from some physicians who believe that the weight gain targets are too high," the committee wrote. "Also, these perceived high weight gain targets do not address concerns regarding postpartum weight retention. In addition, concerns have been raised that the guidelines do not differentiate degrees of obesity, especially for morbidly obese women."

　　Setting weight goals for any pregnancy means balancing risks and benefits for two patients simultaneously, the committee noted. Obese mothers are more likely to develop gestational diabetes and preeclampsia. They have more cesarean births, and with those, a greater risk of wound infection and venous thromboembolism.

　　The infants of these mothers are more likely to have birth defects, including a doubling of the risk for neural tube defects. Stillbirth is more common, as is fetal macrosomia, a prime driver of an increased risk for cesarean section and its attendant maternal risks.

　　After reviewing both the IOM recommendations and the current literature, ACOG made several of its own recommendations for managing overweight or obese pregnant patients (Obstet. Gynecol. 2013;121:213-7).

　　In the preconceptional period:

　　Include information about the risks obesity poses to both mother and infant, and encourage the patient to lose weight before becoming pregnant.

　　Offer a nutritional assessment and exercise prescription.

　　During pregnancy:

　　Assess height, weight, and body mass index at the first prenatal visit, and explain the IOM weight gain recommendations. Review them at each visit.

　　Continue with nutritional counseling and exercise.

　　For patients who have undergone bariatric surgery, prescribe additional iron, vitamin B12, folate, vitamin D, and calcium.

　　During labor and delivery:

　　Get an early anesthesia consult, as both epidurals and general anesthesia are uniquely challenging in obese patients.

　　For patients undergoing a cesarean, consider a higher-than-usual dose of prophylactic antibiotics to ward off wound infections.

　　Assess each patient for thromboembolism potential; use pneumatic compression, unfractionated heparin, or low-molecular-weight heparin as indicated.

　　Consider suture closure of the subcutaneous fat layer after a cesarean, as this could help reduce the risk of postoperative wound disruption.

　　Post partum:

　　Encourage the patient to lose weight before attempting another pregnancy – enlist the help of a specialist.

　　All ACOG committee members are required to follow the college’s guidelines for relationships with the health care industry, according to the ACOG website.