Original Article A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women Julie A. QUINLIVAN, 1 Laurence T. LAM 1 and Jane FISHER 2 1 College of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia, and 2 Key Centre for Women’s Health in Society, Melbourne School of Population Health, University of Melbourne, Victoria, Australia Background: Obesity is common in pregnancy and results in morbidity to mother and newborn. Aim: To evaluate whether a four-step multidisciplinary protocol of antenatal care for overweight and obese women would reduce the incidence of gestational diabetes. Methods: Pregnant women were approached at their first antenatal visit, and body mass index (BMI) was calculated to determine whether they were overweight or obese (BMI > 25). Eligible women were randomised to standard obstetric antenatal care or four-step multidisciplinary antenatal care. Clinic protocol included (i) continuity of obstetric provider; (ii) weighing on arrival at each visit; (iii) a five brief minute intervention by a food technologist who asked about the women’s eating habits of the previous day, provided information on reading food labels, shopping lists of affordable foods available from local shops and recipes for a healthy pregnancy diet; and (iv) clinical psychology management to assess symptoms of depression and anxiety, stressful life events and determine whether psychological factors were involved in eating patterns. Labour and delivery data were audited from the medical records to determine the final incidence of gestational diabetes. The primary outcomes were gestational diabetes and weight gain. Results: The intervention was associated with a significant reduction in the incidence of gestational diabetes (6 versus 29%, OR 0.17 95% CI 0.03–0.95, P = 0.04). It was also associated with reduced weight gain in pregnancy (7.0 versus 13.8 kg, P < 0.0001). Despite this, birthweight of newborns was similar [3.5 (0.1) kg versus 3.4 (0.1) kg P = 0.16]. Conclusion: A four-step management plan adopted with obese women reduces the incidence of gestational diabetes. Key words: gestational diabetes, obesity, pregnancy, randomised trial. Introduction A National Health and Medical Research Council (NHMRC) Australia review on the management of overweight and obesity in adults in Australia 1 reported that young adult women were a group at high risk for weight gain. 2 In particular, childbirth is a risk for weight gain. 3,4 Up to 20% of women gain more than 5 kg by 6–18 months post-partum. 5 Most recent estimates of the Australian population indicate that 35.1% of women aged 25–34 years are either overweight or obese. 1 Weight gain during pregnancy occurs because of the growing weight of the fetus, placenta, breast growth and expanded blood volume and has been calculated to be around 9.1 kg. 6 Any additional gestational weight gain has been considered to represent an energy reserve for the mother. 7 However, in high-income industrialised nations, the average pregnancy weight gain has dramatically increased. 8 Recent reviews put pregnancy weight gain as 13–15 kg. 9 The increase in pre-pregnancy weight, and in weight gain during pregnancy itself, has had implications for pregnancy outcome with an increase in obstetric complications, most notable of which is gestational diabetes. 10 Whilst it is generally thought that 1–3% of women with a normal body mass index develop gestational diabetes, obese women have a higher risk of approximately 17%. 11 Even overweight women with a BMI of 25–30 have a 6.5-fold risk of developing gestational diabetes. 12–14 An audit at our institution in 2004 found an incidence of gestational diabetes of 33% in our overweight and obese pregnant population (unpublished data). Obesity is also linked to many other adverse pregnancy outcomes, including hypertensive disease, increased antenatal and intrapartum intervention, assisted delivery and caesarean section, wound infection and clotting disorders. 7 The aim of this study was to trial a four-step multidisciplinary approach to the management of obese pregnant women. The four-steps were as follows: Correspondence: Professor Julie Quinlivan, College of Medicine, University of Notre Dame Australia, Vice Chancellery build- ing, 19 Mouat St, Fremantle, WA 6959, Australia. Email: juliequinlivan@nd.edu.au There are no conflicts or disclosure of interest in relation to this study. Received 3 February 2010; accepted 11 November 2010. Ó 2011 The Authors 141 Australian and New Zealand Journal of Obstetrics and Gynaecology Ó 2011 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Australian and New Zealand Journal of Obstetrics and Gynaecology 2011; 51: 141–146 DOI: 10.1111/j.1479-828X.2010.01268.x he Australian and New Zealand Journal of Obstetrics and Gynaecology