Thank you, Aroon. Your additions are timely and accurate. I appreciate the clarifications because, as you say, there are other special needs that should be considered. Also, BMI is not a perfect measurement of fat percentage and when calculated merely by weight and height can be somewhat inaccurate. The entire clinical picture, including age, race, ethnicity, stature and muscle mass must be considered. A woman who is fit, even though her BMI may be on the high side, may be at less risk than someone who is in a “normal” BMI range but who does get adequate exercise. Multiple gestation also demands special attention and these cases have often been treated the same as singletons except with regard to the delivery method and potential for prematurity. Vitamins and nutritional status have not always been appropriately adjusted. I recommend the book, When You’re Expecting Twins, Triplets or Quads by Barbara Luke and Tamara Eberlein. The adjusted nutritional recommendations, based on evidence-based research, are addressed in this text and with multiple gestation pregnancies on the rise this is a timely and important matter for consideration.
I also appreciate your comments regarding the decreasing age of menarche and high rate of teen pregnancy with accompanying judgment in this population. There is certainly an element of negativity that often is conveyed, likely interfering with patient-provider relations and compliance. Developmentally they are also at risk for behaviors that could be harmful in pregnancy including poor judgment, substance use, immaturity and poor nutrition. These patients would, as you said, feel especially vulnerable if they are also obese, or perhaps suffering from an eating disorder. This would be a high risk situation for many reasons, including a increased likelihood of depression in both the antepartum and postpartum period. These young women also require special consideration and attention because of the additional challenges they will face as young parents (or relinquishing mothers) in addition to the physical and emotional demands of pregnancy. Sensitivity must be paramount and referrals for adjunct care might be essential to a good outcome. These challenges could even be a subject for another entire blog discussion.
Thank you for your thoughtful and relevant reminders of the need for individualized health care. People do not always fit into neat little charts and it is important to remember the art as well as the science involved. Confusion is often the result of conflicting data, changing recommendations and media reports.