1Department of Obstetrics & Gynaecology, Royal Hospital, Muscat, Oman; 2Family & Community Medicine Residency Programme, Oman Medical Specialty Board, Muscat, Oman *Corresponding Author’s e-mail: santhosh.jayasree@yahoo.com اآلثار املرتتبة للبدانة يف احلمل املبكر على صحة األم و اجلنني والطفل حديث الوالدة دراسة استعادية جملموعة من عمان انيتا زوت�سي، جيارسي �سانتو�ض، جويل �سيخ، فريحة نعيم، اأحمد احلامدي، �سهالخان، ا�ستياق ال�سعيد abstract: Objectives: This study aimed to determine the prevalence of early pregnancy obesity among Omani women and to review maternal antenatal complications, intrapartum and postpartum events and neonatal com- plications among such women in comparison to women of normal weight. Methods: This retrospective cohort study included 2,652 pregnant Omani women who delivered at the Royal Hospital, Muscat, Oman, between November 2011 and April 2012. The patients’ electronic medical records were reviewed for antenatal, intrapartum and post- partum data. Body mass index was measured during the first trimester (≤12 gestational weeks) and classified according to the World Health Organization categories. Maternal and neonatal complications were compared between obese women and those of normal weight. Obstetric outcomes in uncomplicated pregnancies were also compared. Results: In the study cohort, there were 901 (34%) obese women and 912 (34.4%) women of normal weight; of these, 440 (48.8%) and 672 (73.7%) had uncomplicated pregnancies, respectively. Obese women had a significantly increased incidence of gestational diabetes (relative risk [RR]: 2.23; 95% confidence interval [CI]: 1.70–2.92; P <0.01), gestational hypertension (RR: 3.04; 95% CI: 1.63–5.65; P <0.01), Caesarean delivery (RR: 1.48; 95% CI: 1.08–2.03; P <0.01), postpartum haemorrhage (RR: 2.10; 95% CI: 1.11–4.10; P = 0.01) and fetal macrosomia (RR: 2.71; 95% CI: 1.21–6.09; P <0.01). Conclusion: Approximately one-third of the studied Omani women were obese. These women had a significantly increased risk of various maternal antenatal complications, intrapartum and postpartum events and neonatal complications. Keywords: Obesity; Pregnancy; First Trimester; Pregnancy Complications; Obstetric Labor Complications; Fetal Diseases; Oman. امللخ�ص: الهدف: هدفت الدرا�سة اإىل حتديد معدل انت�سار البدانة يف مرحلة احلمل املبكر بني الن�ساء العمانيات ومراجعة امل�ساعفات اثناء احلمل والتبعات اثناء الوالدة وبعدها وم�ساعفات االأطفال حديثي الوالدة بني الن�ساء البدينات باملقارنة مع الن�ساء ذوات الوزن الطبيعي. الطريقة: �سملت هذه الدرا�سة االأ�ستعادية جمموعة من 2,652 امراأة عاملة حامل يف امل�ست�سفى ال�سلطاين، م�سقط، عمان، بني نوفمرب 2011 واأبريل 2012. متت مراجعة ال�سجالت الطبية االإلكرتونية للمر�سى للح�سول على بيانات الن�ساء يف مراحل ما قبل واثناء وبعد الوالدة. مت قيا�ض موؤ�رص كتلة اجل�سم خالل االأ�سهر الثالثة االأوىل )12≥ اأ�سبوعا للحمل( ومت ت�سنيف الن�ساء ايل فئات وفقا ملنظمة ال�سحة العاملية. قام الباحثون مبقارنة امل�ساعفات يف االأمهات واملواليد بني الن�ساء البدينات وذوات الوزن الطبيعي. كما مت مقارنة نتائج التوليد يف حاالت لن�ساء بدينات و 912 حالة )%34.4( من الن�ساء ذوات احلمل غري املعقدة. النتائج: يف جمموعة الدرا�سة، كانت هناك 901 حالة )34%( الوزن الطبيعي. من بني هوؤالء، كانت هناك 440 حالة )%48.8( و 672 حالة )%73.7( لديهم حاالت حمل غري معقدة، على التوايل. وجد لدى الن�ساء البدينات زيادة كبرية يف معدل االإ�سابة ب�سكري احلمل )اخلطر الن�سبي: 2.23؛ فا�سل الثقة %95: 2.92-1.70؛ القيمة االحتمالية اأقل )P >0.01 (، ارتفاع �سغط الدم اأثناء احلمل )اخلطر الن�سبي3.04، فا�سل الثقة %95: 5.65-1.63؛ القيمة االحتمالية اأقل عنP >0.01 عن الوالدة القي�رصية ) اخلطر الن�سبي: 1.48؛ فا�سل الثقة %95: 2.03-1.08؛ القيمة االحتمالية اأقل عن P >0.01( النزيف بعد الوالدة ) اخلطر الن�سبي: 2.10؛ فا�سل الثقة %95: 4.10-1.11؛ القيمة االحتمالية اأقل عن P = 0.01( زيادة وزن اجلنني )اخلطر الن�سبي: 2.71؛ فا�سل الثقة %95: 6.09-1.21؛ القيمة االحتمالية اأقل عن P >0.01(. اخلال�صة: يعاين ما يقرب من ثلث الن�ساء العمانيات الالتي خ�سعن للدرا�سة من ال�سمنة املفرطة. وكان لدى هوؤالء الن�ساء خطر متزايد ب�سكل كبري حلدوث خمتلف امل�ساعفات اأثناء احلمل، واالحداث اأثناء الوالدة وبعد الوالدة وم�ساعفات االأطفال حديثي الوالدة. الكلمات املفتاحية: ال�سمنة؛ احلمل؛ الثلث االأول للحمل؛ م�ساعفات احلمل؛ م�ساعفات الوالدة؛ اأمرا�ض اجلنني؛ عمان. Implications of Early Pregnancy Obesity on Maternal, Fetal and Neonatal Health Retrospective cohort study from Oman Anita Zutshi,1 *Jayasree Santhosh,1 Julie Sheikh,1 Fareeha Naeem,1 Ahmed Al-Hamedi,2 Shahla Khan,1 Eishthiag Al-Said1 clinical & basic research Sultan Qaboos University Med J, February 2018, Vol. 18, Iss. 1, pp. e47–53, Epub. 4 Apr 18 Submitted 11 Aug 17 Revisions Req. 4 Oct, 28 Nov & 18 Dec 17; Revisions Recd. 8 Nov & 5 Dec 17 & 2 Jan 18 Accepted 7 Jan 18 doi: 10.18295/squmj.2018.18.01.008 Advances in Knowledge - This study found that approximately one-third of Omani women delivering at a tertiary care hospital were obese. - Moreover, early pregnancy obesity was identified as a significant risk factor for subsequent antenatal, intrapartum and postpartum complications. Implications of Early Pregnancy Obesity on Maternal, Fetal and Neonatal Health Retrospective cohort study from Oman e48 | SQU Medical Journal, February 2018, Volume 18, Issue 1 The presence of excess body fat can critically impair both health and longevity, with an increased risk of hypertension, diabetes, heart disease, stroke and cancer among obese individuals.1 Among women of reproductive age, obes- ity can lead to infertility; moreover, obesity in preg- nancy is a recognised risk factor for many adverse maternal and neonatal outcomes, including an inc- reased rate of Caesarean section delivery, fetal macro- somia, pre-eclampsia and gestational diabetes mellitus (GDM).2,3 Obesity has also been identified as a risk factor for maternal death.4 Moreover, obesity in early pregnancy has been associated with fetal and infant death independent of congenital anomalies and maternal pre-GDM.5 Body mass index (BMI) is often used as a screen- ing tool for obesity. According to the World Health Organization (WHO), individuals with a BMI of <18.5 kg/m2 are classified as underweight, those with a BMI of 18.5–24.9 kg/m2 are deemed of normal weight, those with a BMI of 25.0–29.9 kg/m2 are overweight/pre-obese and individuals with a BMI of ≥30.0 kg/m2 are considered obese.1 Obesity is further classified into class I (BMI of 30–34.9 kg/m2), class II (BMI of 35.0–39.9 kg/m2) and class III (BMI of ≥40.0 kg/m2). Individuals in the latter category are considered morbidly obese.1 Despite its inclusion in the International Class- ification of Diseases in 1948, obesity was not recog- nised as a global epidemic by the WHO until 1997.6 Worldwide, there were more than 600 million obese adults in 2014.7 In the Omani population, the prop- ortion of obese adults increased from 48% in 1991 to 51% in 2000; among women, obesity decreased slightly from 25.1% to 23.8% in the same period.8 However, there are few data from Oman addressing the issue of obesity-related morbidity among obstetric patients. Therefore, this study aimed to determine the preva- lence of early pregnancy obesity among Omani women at a tertiary care hospital and to compare maternal, fetal and neonatal complications among obese women and women of normal weight. Methods This retrospective cohort study took place at the Royal Hospital, Muscat, Oman, between November 2011 and April 2012. All pregnant Omani women with available weight/height or BMI data at <12 gestational weeks who delivered at the Royal Hospital during the study period were included. In total, 3,482 deliveries occurred during this time; however, women of other nationalities (n = 199), those with multiple pregnancies (n = 51) and women with no weight records during their first tri- mester (n = 580) were excluded from the study. There- fore, the final sample included 2,652 women. Maternal antenatal complications were compared between obese women and those of normal weight. Subsequently, the rate of intrapartum and postpartum events and neo- natal complications were compared among obese and normal weight women with uncomplicated preg- nancies [Figure 1]. As pre-pregnancy BMI measurements were often not available, BMI measurements during the first trimester (i.e. ≤12 gestational weeks) were used to determine early pregnancy obesity, as these do not change significantly during the first three months of pregnancy.9 Antenatal complications were documented from the patients’ antenatal record cards, including the incidence of GDM, hypertensive disorders of preg- nancy, post-term pregnancy and induction of labour. Intrapartum and postpartum events were determined from the electronic hospital records. The intrapartum variables included the incidence of labour augment- ation, meconium-stained liquor, mode of delivery and the rate of vaginal birth after a previous Caesarean section delivery. Maternal postpartum events, such as the incidence of postpartum haemorrhage and obst- etric anal sphincter injuries (OASIS), along with neo- natal outcomes, including perinatal mortality, congenital anomalies, birth weight and cord pH at delivery and neonatal intensive care unit (NICU) admission, were also compared. The data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 17 (IBM Corp., Armonk, New York, USA) and OpenEpi software (Emory University, Atlanta, Georgia, USA). Frequency distributions were calculated for each variable separately. Categorical variables were summarised as percent- ages while continuous variables were presented as means and standard deviations. The relative risk (RR) and 95% confidence interval (CI) for each outcome variable was calculated. A P value of <0.05 was deemed statistically significant. Ethical approval for this study was obtained from the Medical Ethics & Scientific Research Committee at the Royal Hospital (MESRC #60). Application to Patient Care - Awareness about maternal obesity and its complications may be useful to primary healthcare practitioners in Oman during the provision of preventative care and pre-pregnancy counselling services. Additionally, appropriate clinical management strategies can be planned to minimise maternal and neonatal morbidity and mortality among women with early pregnancy obesity. Anita Zutshi, Jayasree Santhosh, Julie Sheikh, Fareeha Naeem, Ahmed Al-Hamedi, Shahla Khan and Eishthiag Al-Said Clinical and Basic Research | e49 Results A total of 2,652 women were included in the study. Of these, 901 (34%) were obese, 96 (3.6%) were under- weight, 912 (34.4%) were of normal weight and 743 (28%) were overweight. Among the obese women, 549 (60.9%) were class I, 225 (25%) were class II and 127 (14.1%) were class III. Obesity was more common with increased age and parity [Figure 2]. With regards to maternal antenatal complications, obese women had a significantly increased risk of GDM (RR: 2.23; 95% CI: 1.70–2.92; P <0.01) and gestational hypertension (RR: 3.04; 95% CI: 1.63–5.65; P <0.01). However, the incidence of preterm labour, post-term pregnancy and induction of labour were comparable among obese women and those of normal weight [Table 1]. A total of 440 obese (48.8%) and 672 normal weight (73.7%) women had uncomplicated pregnancies. Intrapartum and postpartum events were comp- ared among the women with uncomplicated preg- nancies. There were no statistically significant differ- ences in the incidence of continuous intrapartum monitoring, fetal scalp electrode placement, prolonged labour, labour augmentation or meconium-stained liquor between the groups. Obese women had a signif- icantly higher incidence of intrapartum hypertension (RR: 2.40; 95% CI: 1.24–4.46; P <0.01). Postpartum hypertension was six times more common among obese women than women of normal weight (RR: 6.11; 95% CI: 0.69–54.47; P = 0.04). There was a significant Figure 1: Diagram showing the total number of deliveries during the study period and the application of exclusion and inclusion criteria to determine the final sample used in the current study. RH = Royal Hospital; LSCS = lower-segment Caesarean section; TOLAC = trial of labour after Caesarean section. *During the first trimester (≤12 gestational weeks). Figure 2: Distribution according to (A) body mass index, (B) age and (C) parity of pregnant Omani women deliv- ering at the Royal Hospital, Muscat, Oman (N = 2,652). BMI = body mass index. Implications of Early Pregnancy Obesity on Maternal, Fetal and Neonatal Health Retrospective cohort study from Oman e50 | SQU Medical Journal, February 2018, Volume 18, Issue 1 increase in the risk of postpartum haemorrhage among obese women (RR: 2.10; 95% CI: 1.11–4.10; P = 0.01). Obese women had significantly lower episiotomy rates (RR: 0.63; 95% CI: 0.52–0.77; P <0.01). Among women with vaginal deliveries, no statistically significant incidence in OASIS was noted between the groups (0.2% versus 0.5% among normal weight and obese women, respectively; P = 0.19). The incidence of instrumental delivery in the obese group was half that of the normal weight group (RR: 0.52; 95% CI: 0.29–1.00; P = 0.02). Obese women were 1.4-times more likely to have a lower-segment Caesarean section (LSCS) delivery than women of normal weight (RR: 1.48; 95% CI: 1.08–2.03; P <0.01) [Table 2]. The most common indications for LSCS deliveries in both groups were pathological fetal heart tracing and nonprogressive labour. The mean estimated blood loss was greater in obese women, irrespective of mode of delivery [Table 3]. Among those who had an LSCS delivery, mean hospital stay duration was longer for obese women than normal weight women (4.11 ± 1.60 days versus 3.62 ± 1.08 days). In terms of neonatal outcomes, there was no difference in the rates of perinatal mortality, NICU admission or low cord pH at birth between the obese and normal weight groups. The incidence of congenital anomalies was higher among obese women, although this was not statist- ically significant (RR: 1.36; 95% CI: 0.70–2.63; P = 0.18). However, obese women had a significantly lower incidence of low-birth-weight babies (RR: 0.57; 95% CI: 0.37–0.88; P <0.01) and a 2.7-times increased like- lihood of fetal macrosomia (RR: 2.71; 95% CI: 1.21–6.09; P <0.01) [Table 4]. Among women with at least one previous LSCS delivery, obese women were more likely to have a failed trial of labour and a repeat Caesarean section delivery (RR: 1.37; 95% CI: 0.88–2.14; P = 0.07). Morbidly obese women also had a significantly higher rate of repeat LSCS delivery (RR: 2.30; 95% CI: 1.33–3.96; P <0.01). Table 1: Maternal antenatal complications among pregnant Omani women delivering at the Royal Hospital, Muscat, Oman (N = 2,652) Complication n (%) RR (95% CI) P value Normal weight women (n = 912) Obese women (n = 901) GDM 69 (7.6) 152 (16.9) 2.23 (1.70–2.92) <0.01 GHTN 13 (1.4) 39 (4.3) 3.04 (1.63–5.65) <0.01 Pre-eclampsia 5 (0.5) 8 (0.9) 1.62 (0.53–4.93) 0.21 Preterm labour 43 (4.7) 41 (4.6) 0.97 (0.64–1.47) 0.43 Post-term pregnancy 189 (20.7) 154 (17.1) 0.82 (0.68–1.00) 0.02 Induction of labour 73 (8) 67 (7.4) 0.93 (0.68–1.28) 0.32 Eclampsia 2 (0.2) 2 (0.2) 1.01 (0.14–7.17) 0.49 RR = relative risk; CI = confidence interval; GDM = gestational diabetes mellitus; GHTN = gestational hypertension. Table 2: Maternal intrapartum and postpartum events among pregnant Omani women delivering at the Royal Hospital, Muscat, Oman (N = 2,652) n (%) RR (95% CI ) P value Normal weight women* (n = 672) Obese women* (n = 440) Event Continuous fetal monitoring 198 (29.5) 145 (33) 1.12 (0.94–1.34) 0.11 Fetal scalp electrode placement 59 (8.8) 43 (9.8) 1.11 (0.77–1.62) 0.29 Slow/ prolonged stage I labour 70 (10.4) 52 (11.8) 1.14 (0.81–1.59) 0.23 Slow/ prolonged stage II labour 18 (2.7) 8 (1.8) 0.68 (0.30–1.55) 0.18 Labour augmentation 99 (14.7) 61 (13.9) 0.94 (0.70–1.27) 0.35 Meconium- stained liquor 61 (9.1) 41 (9.3) 1.13 (0.77–1.63) 0.28 Intrapartum HTN 14 (2.1) 22 (5) 2.40 (1.24–4.46) <0.01 Postpartum haemorrhage 15 (2.2) 21 (4.8) 2.10 (1.11–4.10) 0.01 Postpartum HTN 1 (0.2) 4 (0.9) 6.11 (0.69–54.47) 0.04 Mode of delivery SVD 566 (84.2) 361 (82) 0.97 (0.92–1.03) 0.17 Instrumental delivery 38 (5.7) 13 (3) 0.52 (0.29–1.00) 0.02 LSCS 68 (10.1) 66 (15) 1.48 (1.08–2.03) <0.01 Episiotomy† 241 (39.9) 94 (25.1) 0.63 (0.52–0.77) <0.01 OASIS† 1 (0.2) 2 (0.5) 3.22 (0.29–35.50) 0.19 RR = relative risk; CI = confidence interval; HTN = hypertension; SVD = spontaneous vaginal delivery; LSCS = lower-segment Caesarean section; OASIS = obstetric anal sphincter injuries. *Including only those with uncomplicated pregnancies. †The total dataset for this variable was 604 for women of normal weight and 374 for obese women. Anita Zutshi, Jayasree Santhosh, Julie Sheikh, Fareeha Naeem, Ahmed Al-Hamedi, Shahla Khan and Eishthiag Al-Said Clinical and Basic Research | e51 Among the obese women, one patient had a scar rupture and another had an urgent evacuation due to a wound haematoma. There were no cases of maternal mortality in the study cohort. Discussion In general, women tend to gain weight as age and parity increases.10 Due to the association between obesity and hyperlipidaemia, hyperinsulinaemia and insulin resistance, obese pregnant women are more likely to develop pre-eclampsia and GDM.11 In the current study, obese women had a two-fold increase in GDM and a three-fold increase in gestational hyper- tension. In a meta-analysis of 20 studies, Chu et al. suggested that the risk of developing GDM increases with obesity, with an odds ratio (OR) of 2.14, 3.56 and 8.56 for overweight, obese and morbidly obese women, respectively.12 Similar observations have been previously noted in Oman.13 A prospective study in Saudi Arabia also reported an increased risk of GDM and pre-eclampsia with obesity.14 In a large population- based 15-year cohort study, obese women showed an increased risk of pregnancy-induced hypertension, with an adjusted OR of 2.38 and 3.00 for moderate and severe obesity, respectively.15 McDonald et al. conducted a systematic review and meta-analysis of 84 studies (including 64 cohort and 20 case-control studies) on 1,095,834 women; the authors concluded that obese women had a higher risk of preterm delivery (OR: 1.24; 95% CI: 1.13–1.27).16 A Danish National Birth Cohort study reported that being overweight or obese before pregnancy increased the risk of preterm premature rupture of the mem- branes.17 Usha Kiran et al. reported that obese preg- nant women were more likely to undergo induction of labour (OR: 1.6; 95% CI: 1.3–1.9), while Ray et al. observed that morbidly obese women were signif- icantly more likely to require invasive fetal (27% versus 0%; P <0.001) and uterine contraction (30% versus 0%; P <0.001) monitoring.18,19 In addition, the overall dur- ation of labour has been reported to be longer in obese women, with slower progression of the early first stage of labour.20 However, such associations were not observed in the current study. It has been postulated that obesity may impair the ability of the uterus to contract in labour.21 In agreement with the findings of the present study, Sebire et al. reported a higher incidence of postpartum haemorrhage in overweight (OR: 1.16; 95% CI: 1.12–1.21) and obese (OR: 1.39; 95% CI: 1.32–1.46) women.22 Another study indicated an unadjusted OR of 2.37 (95% CI: 2.01–2.79) for post- partum haemorrhage in obese women.23 Obesity may be protective against third- and fourth-degree perineal lacerations, independent of parity, race, birth weight and mode of delivery.24 In the current study, the obese cohort had a significantly lower episiotomy rate, with a non-significant increase in Table 3: Blood loss and hospital stay according to mode of delivery among pregnant Omani women delivering at the Royal Hospital, Muscat, Oman (N = 2,652) Mode of delivery Normal weight women* (n = 672) Obese women* (n = 440) n (%) Mean blood loss in mL ± SD Mean hospital stay in days ± SD n (%) Mean blood loss in mL ± SD Mean hospital stay in days ± SD SVD 566 (84.2) 169.53 ± 71.27 2.00 ± 1.07 361 (82) 195.91 ± 165.30 2.04 ± 1.20 Instrumental delivery 38 (5.7) 207.57 ± 119.25 3.08 ± 2.70 13 (3) 269.23 ± 288.34 3.00 ± 1.38 LSCS 68 (10.1) 419.11 ± 135.77 3.62 ± 1.08 66 (15) 538.27 ± 257.00 4.11 ± 1.60 SD = standard deviation; SVD = spontaneous vaginal delivery; LSCS = lower-segment Caesarean section. * Including only those with uncomplicated pregnancies. Table 4: Neonatal outcomes among obese and normal weight pregnant Omani women delivering at the Royal Hospital, Muscat, Oman (N = 2,652) Outcome n (%) RR (95% CI) P value Normal weight women* (n = 672) Obese women* (n = 440) Perinatal mortality 8 (1.2) 3 (0.7) 0.57 (0.15–2.15) 0.21 Congenital anomalies 18 (2.7) 16 (3.6) 1.36 (0.70–2.63) 0.18 Birth weight of <2,500 g 72 (10.7) 27 (6.1) 0.57 (0.37–0.88) <0.01 Birth weight of >4,000 g 9 (1.3) 16 (3.6) 2.71 (1.21–6.09) <0.01 Cord pH of <7.2 16 (2.4) 8 (1.8) 0.76 (0.33–1.77) 0.27 NICU admission 54 (8) 31 (7) 0.88 (0.57–1.34) 0.27 RR = relative risk; CI = confidence interval; NICU = neonatal intensive care unit. Implications of Early Pregnancy Obesity on Maternal, Fetal and Neonatal Health Retrospective cohort study from Oman e52 | SQU Medical Journal, February 2018, Volume 18, Issue 1 OASIS among obese women. Overall, obese women were significantly more likely to have a Caesarean delivery; this finding has been reflected in previous studies reporting ORs of 2–2.9.25,26 During a Caesarean section procedure, obese women face a greater risk of anaesthetic complications, technical difficulties during the surgery, increased blood loss, wound infection and deep vein thrombosis.3 In the current study, only one obese woman with a history of previous LSCS deliveries suffered a wound haematoma and none of the women experienced deep vein thrombosis. Such reduced morbidity rates may be due to the fact that the study was conducted in a tertiary care centre with strict intrapartum monitoring protocols and a greater availability of senior obstetricians. However, such find- ings may also be due to the size of the cohort. Ante- partum monitoring, administration of timely thrombo- prophylaxis and intra- and postpartum management with input from senior obstetricians and anaesthes- iologists are recommended to aid in reducing comp- lications in these high-risk pregnancies. The instrumental delivery rate for obese women was almost half that of the normal weight women included in the present study. The apparent reluctance among obstetricians to proceed with instrumental delivery in obese women could be due to expected errors in fetal weight estimation and the increased risk of shoulder dystocia. The instrumental delivery rate in singleton deliveries among obese women has been reported to be 7.6% compared to 12.2% in a general maternity unit.27 Regardless of the mode of delivery, longer post-delivery hospital stays have been reported among obese women compared to women of normal weight (14.3% versus 4.7%; OR: 1.42; 95% CI: 1.07–1.89).28 In the current study, mean hospital stays were longer only for those obese women who underwent an LSCS delivery. No significant differences were found in the rates of perinatal mortality, cord pH, NICU admission or congenital abnormalities among neonates of obese women. Indeed, rates of low cord pH, low Apgar scores and shoulder dystocia have been reported as similar for women of all BMI categories.29,30 In the current study, obese mothers had a 2.7- times higher incidence of fetal macrosomia (i.e. babies with a birth weight of >4,000 g). For birth weights above the 90th centile, Zhang et al. reported the RR to be 1.57 (95% CI: 1.50–1.64) and 2.36 (95% CI: 2.23–2.50) for overweight and obese mothers, respect- ively.21 In the present study, the risk of having a low-birth-weight baby for obese women was half that of normal weight women. In their systematic review and meta-analysis, McDonald et al. also reported that the overall risk of having an infant with low birth weight was lower in overweight and obese women.16 In the current study, both obese and morbidly obese women with a history of previous Caesarean section deliveries had a significantly higher rate of repeat LSCS deliveries. This observation is supported by previous research.31,32 The implementation of national guidelines for early pregnancy obesity at local health centres in Oman is recommended to facilitate appropriate interventions and encourage the timely referral of obese mothers to specialist services to ensure safe outcomes. Community healthcare providers should identify obesity among young women in order to recommend pre-pregnancy counselling and weight reduction strategies. Moreover, obesity education and dietary counselling should be included in adolescent health programmes as a method of primary obesity prevention. Conclusion Overall, approximately one-third of the Omani preg- nant women in the current study were obese. Obesity was significantly associated with GDM, gestational hypertension, intrapartum and postpartum hyper- tension, postpartum haemorrhage, instrumental delivery, LSCS, episiotomies, low birth weight and fetal macro- somia. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest. f u n d i n g No funding was received for this study. References 1. World Health Organization. Obesity: Preventing and managing the global epidemic. From: www.who.int/nutrition/publications/ obesity/WHO_TRS_894/en/ Accessed: Jan 2018. 2. 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