Association between infant birth weight and gestational weight gain in Japanese women with diabetes mellitus

Kei Fujikawa Shingu; Masako Waguri; Mitsuyoshi Takahara; Aurélie Piedvache; Naoto Katakami; Iichiro Shimomura

doi:10.1111/jdi.14177

. 2024 Mar 6;15(7):906–913. doi: 10.1111/jdi.14177

Association between infant birth weight and gestational weight gain in Japanese women with diabetes mellitus

Kei Fujikawa Shingu ^1,², Masako Waguri ², Mitsuyoshi Takahara ^3,^✉, Aurélie Piedvache ⁴, Naoto Katakami ¹, Iichiro Shimomura ¹

PMCID: PMC11215693 PMID: 38445817

ABSTRACT

Aims/Introduction

In 2021, the guidelines on gestational weight gain (GWG) were revised and increased by 2–3 kg in Japan. This study aimed to investigate whether the revised guidelines would increase the incidence of babies with excessive birth weight in mothers with diabetes.

Materials and Methods

This retrospective study included 369 deliveries of women with diabetes whose pre‐pregnancy body mass index was below 30 kg/m² between 1982 and 2021. The primary outcome measure was large for gestational age (LGA). We compared the incidence of LGA between women who gained weight within the previous guidelines and women who gained weight within the revised guidelines. We also compared the incidence of macrosomia, preeclampsia, small for gestational age (SGA), and low birth weight.

Results

The incidence of LGA was not significantly different between women who gained weight within the revised guidelines and those within the previous guidelines (34.6% [95% confidence interval 25.6–44.6%] for the revised guidelines vs 28.9% [21.6–37.1%] for the previous guidelines; P = 0.246). Neither was the incidence of macrosomia or preeclampsia significantly different (8.7% [4.0–15.8%] vs 5.6% [2.5–10.8%] and 5.8% [2.1–12.1%] vs 6.3% [2.9–11.7%]; P = 0.264 and 0.824, respectively), while women who gained weight within the revised guidelines had a lower incidence of SGA (1.9% [0.2–6.8%] vs 10.6% [6.0–16.8%]; P = 0.001) and low birth weight (1.0% [0.02–5.2%] vs 7.0% [3.4–12.6%]; P = 0.023).

Conclusions

The revised GWG guidelines could be beneficial in women with diabetes in terms of delivering babies with appropriate birth weight.

Keywords: Birth weight, Diabetes mellitus, Gestational weight gain

Compared with women with diabetes who gained weight within the previous guidelines, women with diabetes who gained weight within the revised guidelines had a lower incidence of small for gestational age (SGA) and low birth weight. On the other hand, the incidence of large for gestational age (LGA), macrosomia, or preeclampsia was not significantly different.

graphic file with name JDI-15-906-g002.jpg

INTRODUCTION

Insufficient gestational weight gain (GWG) increases the risk of small for gestational age at birth (SGA) and low birth weight ¹ , ² , ³ , ⁴ . SGA and low birth weight are not only associated with perinatal mortality or morbidity, but also increase the risk of obesity, type 2 diabetes, and other metabolic disease in later adulthood ⁵ , ⁶ . SGA and low birth weight are the leading healthcare issues to be addressed.

In Japan, a high incidence of low birth weight has become a chronic problem in recent years; the domestic incidence of low birth weight increased from 4.2% in 1980 to 9.5% in 2015 ⁷ , ⁸ . This high incidence of low birth weight was attributed at least partially to the domestic guidelines for GWG ⁹ , ¹⁰ . The GWG targets previously recommended in Japan were lower than those recommended by the Institute of Medicine (IOM) ¹¹ , which are the most commonly adopted in the world, not only in Caucasians but also in Asians. The previous guidelines in Japan might have unnecessarily restricted GWG and increased the incidence of low birth weight. In March 2021, the Japanese Society of Obstetrics and Gynecology released the new GWG guidelines, in which the targets for women with a pre‐pregnancy body mass index (BMI) <30 kg/m² were increased by approximately 2–3 kg compared with the previous guidelines ¹² , ¹³ , ¹⁴ . The increase in GWG targets is expected to reduce the domestic incidence of low birth weight.

The increase of GWG will, however, in turn increase the risk of large for gestational age at birth (LGA) and macrosomia ¹ , ² , ³ , ⁴ . Children born with excessive birth weight also have a high risk of obesity and type 2 diabetes in adulthood ⁵ , ⁶ ; excessive birth weight is another challenge in healthcare fields. Since macrosomia has been rare in a general population in Japan (0.9% in Japan ¹⁵ vs 5–10% in other developed countries ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ ), a 2–3 kg increase in GWG targets is expected to have little affect on the absolute incidence of excessive birth weight in a general population. In contrast, LGA and macrosomia are much more common in pregnancy with diabetes in Japan; the incidence of LGA and macrosomia was approximately 30 and 5%, respectively ²⁰ . The current revision of the GWG guidelines would further increase the risk of LGA and macrosomia in women with diabetes.

This study aimed to determine whether the revision of GWG guidelines would increase the incidence of excessive birth weight in women with diabetes.

MATERIALS AND METHODS

Study population

The present study analyzed pregnant women with diabetes who delivered at Osaka Women's and Children's Hospital, Izumi City, Osaka Prefecture, Japan, between 1982 and 2021. The inclusion criteria were pregnant women diagnosed with either type 1 diabetes or type 2 diabetes, whose pre‐pregnancy BMI was below 30 kg/m² and who delivered between 37 and 41 weeks of gestation. The exclusion criteria included women from abroad, women with a multiple pregnancy, or women whose GWG was unclear. We restricted the study population to women with a pre‐pregnancy BMI below 30 kg/m² because the GWG target is unchanged for women with a pre‐pregnancy BMI ≥30 kg/m².

Weight management during pregnancy at the center was conducted in accordance with domestic consensuses including the guidelines of the Japan Society of Obstetrics and Gynecology ¹⁰ , ¹² , ¹⁴ , ²¹ or the Ministry of Health, Labour and Welfare ⁹ , ¹³ , although the details for individual pregnant women were unknown.

Clinical data were extracted from the medical records of the hospital. The study protocol was in accordance with the Helsinki Declaration and approved by the institutional review boards of Osaka Women's and Children's Hospital and Osaka University Hospital (approval number 1409 and 20489, respectively). We applied the opt‐out method, offering opportunities for refusal via the institutional website instead of obtaining individual informed consent.

Definitions

Information on the mothers’ pre‐pregnancy body weight was routinely collected using an interview sheet at their first visit to our hospital, and was based on self‐report. The maternal pre‐pregnancy BMI was calculated as the pre‐pregnancy weight in kilograms divided by the height in meters squared. BMIs of <18.5 kg/m², ≥18.5 and <25 kg/m², and ≥25 and <30 kg/m² were defined as underweight, normal weight, and overweight, respectively ¹² , ¹³ , ²² . GWG was calculated by subtracting the maternal pre‐pregnancy body weight from the maternal weight at the delivery. The revised GWG guidelines (vs the previous ones) were 12–15 kg (vs 9–12 kg previously), 10–13 kg (vs 7–12 kg), and 7–10 kg (vs 0–5 kg) in underweight, normal weight, and overweight populations, respectively ⁹ , ¹⁰ , ¹² , ¹³ .

LGA and SGA were defined as the sex‐ and parity‐specific birth weight for gestational age above the 90th and 10th percentile of Japanese fetal growth curves, respectively ²³ . Macrosomia and low birth weight were defined as weight at birth of ≥4,000 g and <2,500 g regardless of his or her gestational age, respectively ⁸ , ¹⁰ . Preeclampsia was defined as the onset of elevated blood pressure (≥140/90 mmHg [19/12 kPa]) and proteinuria (>300 mg/24 h or ≥2+ on two random urine samples collected at least 4 h apart) ²⁴ .

In reference to previous studies on birth weight ²⁵ , ²⁶ , ²⁷ , maternal glycemic control was evaluated using mean HbA1c values during the third trimester, because the third trimester HbA1c value is the most predictive of birth weight among all trimesters. In Japan, the method of HbA1c measurement was not standardized by the Japan Diabetes Society (JDS) until 1995; therefore, we excluded the data measured before 1995. HbA1c (JDS) was converted to HbA1c (National Glycohemoglobin Standardization Program) units ²⁸ . Maternal HbA1c was routinely measured every month in clinical settings at the hospital.

Outcome measures

The primary outcome measure was the incidence of large for gestational age (LGA). Secondary outcome measures included the incidences of macrosomia, preeclampsia, low birth weight, and small for gestational age (SGA).

Statistical analysis

Data are presented as frequencies (percentages) for dichotomous variables and as mean ± standard deviation (SD) for continuous variables. Two‐sided P‐values of <0.05 were considered significant. All statistical analyses were performed using R version 4.2.1 (R Development Core Team, Vienna, Austria).

We categorized the study population in two ways: according to the previous guidelines and according to the revised guidelines. Maternal characteristics and perinatal outcomes were compared between the subset within the previous guidelines and those within the revised guideline, using the partially overlapping t‐test for continuous variables and the partially overlapping z test for dichotomous variables (Partiallyoverlapping package in R), to take into account dependency between observations. The sample size of this study had a power of 80% to detect the intergroup difference in the incidence of LGA with a two‐sided significance level of 5%, assuming that the incidence rate of LGA was 30% and that the incidence was 15% higher in subsets within the revised guidelines than in those within the previous guidelines.

As sensitivity analyses, we performed the analysis, (1) excluding the second and subsequent deliveries, to address the potential impact of more than one delivery from one mother, and (2) adding preterm deliveries (between 28 and 36 weeks of gestation) to the study population, to minimize potential selection bias. During the second sensitivity analysis, GWG was evaluated using the expected GWG at 40 weeks of gestation, because GWG was considerably affected by the weeks of gestation. The expected GWG at 40 weeks of gestation was calculated from GWG at delivery, using the method proposed by Naho Morisaki, which assumes a linear increase in weight throughout the pregnancy and predicts weight at specific weeks ²⁹ . Since this method is applicable only to women who delivered between 28 and 41 weeks of gestation, we did not include women who delivered before 28 weeks or after 41 weeks of gestation.

Interaction effects of maternal characteristics on the difference in incidence of LGA between the revised and previous guidelines were investigated using a generalized linear mixed effects model with a Poisson function (lme4 package in R), where the inter‐delivery variability was treated as the random effects. During the analysis, the population was limited to women who gained weight within the previous guidelines, within the revised guidelines, or both.

RESULTS

This study included 369 deliveries from 276 women; 164 deliveries (44.4%) had type 1 diabetes and 205 (55.6%) had type 2 diabetes. Table 1 shows their maternal characteristics. The mean age of delivery was 32.5 ± 4.9 years old. The mean BMI was 23.8 ± 3.3 kg/m². Underweight, normal weight, and overweight accounted for 3.3% (n = 12), 60.2% (n = 222), and 36.6% (n = 135) of the study population. The mean GWG was 9.3 ± 5.1 kg.

Table 1.

Maternal characteristics

Number of deliveries	369
Number of women	276
Type of diabetes mellitus
Type 1 diabetes mellitus	164 (44.4%)
Type 2 diabetes mellitus	205 (55.6%)
Age (years)	32.5 ± 4.9
Duration of diabetes (years)	8.0 ± 8.2
BMI (kg/m²)	23.8 ± 3.3
BMI category
Underweight	12 (3.3%)
Normal weight	222 (60.2%)
Overweight	135 (36.6%)
HbA1c (%)	6.2 ± 0.8
HbA1c (mmol/mol)	44.0 ± 9.3
GWG (kg)	9.3 ± 5.1
Underweight group	12.5 ± 3.6
Normal weight group	10.4 ± 4.6
Overweight group	7.2 ± 5.3

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Data on HbA1c values were missing in 80 deliveries. Underweight, pre‐pregnancy BMI <18.5 kg/m²; normal, pre‐pregnancy BMI ≥18.5 and <25 kg/m²; overweight, pre‐pregnancy BMI ≥25 and <30 kg/m². BMI, body mass index; GWG, gestational weight gain.

The proportions of women whose GWG was below, within, or above the previous and revised guidelines are shown in Figure 1. The revised guidelines categorized fewer women into those gaining weight within and above guidelines and more women into those below guidelines than the previous guidelines (P < 0.001 by McNemar's test). Numbers for the overall sample and stratified by pre‐pregnancy BMI are in Table S1. As summarized in Table 2, 142 deliveries were within the previous guidelines and 104 within the revised ones. The maternal characteristics were not different between women within the previous GWG guidelines and those within the revised guidelines, except for the GWG, which was higher in women within the revised guidelines (P < 0.001).

The proportion of women who gained weight below, within, or above guidelines. The revised guidelines categorized fewer women into those gaining weight within and above guidelines and more women into those below guidelines than the conventional guidelines (P < 0.001 by McNemar's test).

Table 2.

Comparisons of maternal characteristics between women with appropriate gestational weight gain based on the previous guidelines and the revised guidelines

	Within the previous guidelines	Within the revised guidelines	P value
Number of deliveries	142	104	‐
Type 1 diabetes mellitus	67 (47.2%)	52 (50.0%)	0.597
Age (years)	32.5 ± 5.0	32.2 ± 5.2	0.648
Duration of diabetes (years)	9.6 ± 9.1	9.3 ± 8.0	0.725
BMI (kg/m²)	23.4 ± 3.1	23.4 ± 3.3	0.866
HbA1c (%)	6.1 ± 0.87	6.2 ± 0.79	0.512
HbA1c (mmol/mol)	43 ± 10	44 ± 9
GWG (kg)	7.5 ± 3.3	10.4 ± 1.9	<0.001

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P values were derived from the partially overlapping t‐test for continuous variables, and the partially overlapping z test for dichotomous variables. BMI, body mass index; GWG, gestational weight gain.

Of 369 deliveries, 120 children were LGA (32.5%), 23 children had macrosomia (6.2%), 27 children were SGA (7.3%), 19 children were low birth weight (5.1%), and 25 women had preeclampsia (6.8%). The proportions for each perinatal outcome according to the GWG guideline (previous vs revised) are presented in Figure 2. As illustrated in Figure 2a, the incidence (95% confidence intervals) of LGA was 28.9% (21.6–37.1%) for women whose GWG was within the previous guidelines and 34.6% (25.6–44.6%) for those within the revised guidelines, with no significant difference (P = 0.246). Neither was the incidence of macrosomia or preeclampsia significantly different (5.6% [2.5–10.8%] vs 8.7% [4.0–15.8%] and 6.3% [2.9–11.7%] vs 5.8% [2.1–12.1%]; P = 0.264 and 0.824; Figure 2b,c, respectively). On the other hand, the incidence of SGA was significantly lower in women with GWG within the revised guidelines compared with the previous guidelines (10.6% [6.0–16.8%] vs 1.9% [0.2–6.8%]; P = 0.001; Figure 2d). The incidence of low birth weight was also lower in women with GWG within the revised guidelines (7.0% [3.4–12.6%] vs 1.0% [0.02–5.2%]; P = 0.023; Figure 2e). Numbers and incidences for the overall sample and stratified by pre‐pregnancy BMI categories are shown in Table S2.

Comparisons of perinatal outcomes (LGA [a], macrosomia[b], preeclampsia [c], SGA [d], and LBW [e]) between the women who gained weight within the previous and revised guidelines. P values were derived from the partially overlapping z test. See Table 2 for participant characteristics. Error bars indicate 95% confidence intervals. LBW, low birth weight; LGA, large for gestational age; SGA, small for gestational age.

As illustrated in Figure 3, no maternal characteristics significantly affected the difference in the incidence of LGA between women who achieved GWG targets according to the previous and revised guidelines (all P > 0.05).

Incidence risk ratio of large for gestational age (LGA) in women who gained weight within the revised guidelines relative to that in women within the previous guidelines. P values for interaction were derived from the generalized linear mixed model with a Poisson function. Error bars indicate 95% confidence intervals.

Sensitivity analysis

Analysis limited to the first delivery provided similar results. The incidence of LGA, macrosomia, and preeclampsia was not significantly different between the groups, while the incidence of SGA and low birth weight was significantly lower in women within the revised guidelines (Table S3). Inclusion of pre‐term deliveries (28–36 weeks) whom the GWG at 40 weeks has been estimated showed no significant difference in perinatal outcome incidences (Table S4).

DISCUSSION

The present study revealed that the incidence of LGA was not significantly different between women who gained weight within the revised guidelines than in women who gained weight within the previous guidelines in Japanese women with diabetes mellitus whose pre‐pregnancy BMI was below 30 kg/m². Neither was the incidence of macrosomia or preeclampsia significantly different, while that of SGA and low birth weight was lower in women within the revised GWG guidelines.

In general, GWG is positively correlated to birth weight; excessive GWG is associated with an increased risk of LGA and macrosomia, and insufficient GWG is associated with an increased risk of SGA and low birth weight. Excessive GWG also increases the risk of preeclampsia. This correlation has been proved by a number of epidemiological studies ¹ , ² , ³ , ⁴ . However, the underlying pathophysiological mechanisms have remained unclear. The present study demonstrated that the increase in GWG according to the revised guidelines instead of the previous guidelines in women with diabetes mellitus would not increase the incidence of LGA, macrosomia or preeclampsia, while decreasing the incidence of SGA and low birth weight. Similar findings were observed when the population was limited to the first delivery (Table S3), indicating that multiple deliveries from the same women would not largely affect the primary findings.

Since the recommended GWG in the guidelines is tailored for full‐term pregnancies, we primarily excluded women who delivered before 37 weeks of gestation. However, as pre‐term delivery is a critical perinatal outcome linked to insufficient GWG, and low birth weight is more common in pre‐term deliveries, we conducted a sensitivity analysis including pre‐term deliveries, using estimated GWG at 40 weeks (Table S4). In this analysis, the incidence of SGA and low birth weight was not significantly different between women within the revised guidelines and those within the previous guidelines, which might be due to insufficient statistical power to detect such differences, or because the estimated weight gain at 40 weeks may not accurately reflect the actual weight gain at this stage of gestation.

The pathophysiological mechanisms of the correlation of GWG to birth weight have not been fully understood. It remains unknown why the increase in GWG guidelines did not significantly change the incidence of excessive birth weight, while it significantly decreased the incidence of insufficient birth weight. However, epidemiological studies demonstrated that babies with excessive birth weight can be born with some frequency even if mothers achieve GWG targets, although the frequency is lower than with mothers with excessive GWG ³ , ⁴ , ³⁰ , ³¹ . Those findings supported an idea that the risk of excessive birth weight would not be determined solely by GWG, but that there would be other main contributors to excessive birth weight. In women with diabetes mellitus, hyperglycemia during pregnancy is a well‐known contributor to excessive birth weight ³² ; the impact of GWG on excessive birth weight would be relatively limited in the population.

Both insufficient and excessive birth weights increase the risk of cardiometabolic complications in adulthood, including obesity, type 2 diabetes mellitus, hypertensive disorder, and cardiovascular disease ⁵ , ⁶ , ³³ , ³⁴ , ³⁵ . However, several studies reported that low birth weight had a stronger impact on the development of such complications than macrosomia ³⁴ , ³⁵ , suggesting that a strategy for lowering the incidence of insufficient birth weight would be clinically more important than a strategy for lowering the incidence of excessive birth weight. The revised guidelines, decreasing the risk of insufficient birth weight but not significantly increasing the risk of excessive birth weight, might be more beneficial for children born of mothers with diabetes mellitus.

Another important finding from our study would be that most women with diabetes failed to achieve GWG targets. Most women with diabetes require insulin treatment during pregnancy, which could cause excessive GWG ³⁶ . On the other hand, excessive restriction of food intake to achieve strict glycemic control would increase the risk of insufficient GWG. Further studies are needed to determine the best practical interventions to achieve both GWG targets and glycemic goals in women with diabetes.

Our study has several limitations. First, this was a retrospective study. We did not analyze the effect of an intervention to GWG; we just demonstrated the association between appropriate GWG and perinatal outcomes. Furthermore, women with diabetes whose GWG were above the guidelines were at a high risk of LGA, who were not included in the comparison between the previous and revised guidelines. Future clinical trials that enroll women at risk of excessive GWG and control their GWG are warranted to address this issue. Second, detailed data on maternal weight gain during pregnancy were not available. The speed of GWG in each trimester, which would be associated with the incidence of perinatal complications ³⁷ , ³⁸ , ³⁹ remain to be revealed. Third, the sample size was so small that the present study could not detect the difference in LGA incidence smaller than 15%. It remains unknown whether there would be a smaller difference between the revised and previous guidelines. Future studies with a larger sample size will be warranted. Fourth, we used HbA1c levels as the index of glycemic control in the supplementary risk analysis, according to previous relevant epidemiological studies. However, HbA1c levels falsely elevate due to iron deficiency in the third trimester ⁴⁰ , ⁴¹ . In addition, frequent hypoglycemia falsely lowers HbA1c levels, even if high glucose is observed in other time points. HbA1c levels would not accurately reflect the real glycemic control. Fifth, other clinical outcomes including neonatal respiratory distress syndrome were not analyzed in the present study. Finally, the pre‐pregnancy body weight was self‐reported and may not be accurate.

In conclusion, the revised guidelines on GWG could considerably reduce the incidence of SGA and low birth weight, without significantly increasing the incidence of LGA, macrosomia, or preeclampsia in women with diabetes whose pre‐pregnancy BMI was below 30 kg/m² and who had appropriate GWG based on the guidelines in Japan. Controlling GWG according to the revised guidelines would be beneficial in the population.

DISCLOSURE

The authors declare no conflict of interest.

Approval of the research protocol: The study protocol was in accordance with the Helsinki Declaration of 2013 and was approved by the institutional review boards of Osaka Women's and Children's Hospital and Osaka University Hospital.

Informed consent: Since we used the existing data retrospectively, the requirement for informed consent was waived. Instead, we applied the opt‐out method, offering opportunities for refusal via the website of Osaka Women's and Children's Hospital.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

Supporting information

Table S1 | Number of deliveries by pre‐pregnancy BMI and gestational weight gain categories

Table S2 | Incidence of perinatal outcome stratified by pre‐pregnancy BMI category in women within the previous and revised guidelines

Table S3 | Comparison of maternal characteristics and perinatal outcomes between women who gained weight within the previous guidelines and those within the revised guidelines, limiting the population to the first deliveries

Table S4 | Comparison of maternal characteristics and perinatal outcomes between women who gained weight within the previous guidelines and those within the revised guidelines, extending the population to the deliveries between 28 and 41 weeks of gestation

JDI-15-906-s001.docx^{(41.4KB, docx)}

ACKNOWLEDGMENTS

We extend our deepest gratitude to Dr Naho Morisaki, M.D., Ph.D. for her invaluable supervision regarding the analytical methods used in this study.

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35. Maguolo A, Olivieri F, Zusi C, et al. The risk of metabolic derangements is higher in children and adolescents with overweight or obesity born small for gestational age. Nutr Metab Cardiovasc Dis 2021; 31: 1903–1910. [DOI] [PubMed] [Google Scholar]
36. Russell‐Jones D, Khan R. Insulin‐associated weight gain in diabetes—Causes, effects and coping strategies. Diabetes Obes Metab 2007; 9: 799–812. [DOI] [PubMed] [Google Scholar]
37. Sridhar SB, Fei X, Hedderson MM. Trimester‐specific gestational weight gain and infant size for gestational age. PLoS One 2016; 11: e0159500. [DOI] [PMC free article] [PubMed] [Google Scholar]
38. Pugh SJ, Albert PS, Kim S, et al. Patterns of gestational weight gain and birth weight outcomes in the NICHD Fetal Growth Study – Singletons: A prospective study. Am J Obstet Gynecol 2017; 217: 346.e1–346.e11. [DOI] [PMC free article] [PubMed] [Google Scholar]
39. Darling AM, Werler MM, Cantonwine DE, et al. Timing and amount of gestational weight gain in association with adverse birth outcomes. Epidemiology 2019; 30: 695–705. [DOI] [PMC free article] [PubMed] [Google Scholar]
40. Hashimoto K, Noguchi S, Morimoto Y, et al. A1C but not serum glycated albumin is elevated in late pregnancy owing to iron deficiency. Diabetes Care 2008; 31: 1945–1948. [DOI] [PMC free article] [PubMed] [Google Scholar]
41. Hashimoto K, Osugi T, Noguchi S, et al. A1C but not serum glycated albumin is elevated because of iron deficiency in late pregnancy in diabetic women. Diabetes Care 2010; 33: 509–511. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1 | Number of deliveries by pre‐pregnancy BMI and gestational weight gain categories

Table S2 | Incidence of perinatal outcome stratified by pre‐pregnancy BMI category in women within the previous and revised guidelines

JDI-15-906-s001.docx^{(41.4KB, docx)}

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PERMALINK

Association between infant birth weight and gestational weight gain in Japanese women with diabetes mellitus

Kei Fujikawa Shingu

Masako Waguri

Mitsuyoshi Takahara

Aurélie Piedvache

Naoto Katakami

Iichiro Shimomura