\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{Relationship between maternal pre-pregnancy weight and fetomaternal
outcomes in twin pregnancies: an original research}



\author[1]{Leandra Nagler}%
\author[1]{Carmen Eissmann}%
\author[1]{Ammar Al Naimi}%
\author[1]{Marita Wasenitz}%
\author[1]{Franz Bahlmann}%
\affil[1]{Burgerhospital und Clementine Kinderhospital gemeinnutzige GmbH}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: To examine the influence of maternal pre-pregnancy body
weight on fetomaternal outcomes in twin pregnancies. Study design:
Retrospective study. Setting: Department of Obstetrics and Gynecology,
Buergerhospital Frankfurt Population: 2,449 women delivering twins
between 2005 and 2020 at the Buergerhospital Frankfurt. Methods: The
mothers were categorized according to their pre-gravid body mass index
into underweight, normal weight, overweight, obese, and obesity classes
I -- III. Main outcome measures: Gestational diabetes mellitus (GDM),
preeclampsia/HELLP syndrome, intrauterine death (IUD), cesarean section
or vaginal delivery, wound healing disorders, postpartum hemorrhage
(PPH), uterine atony, preterm birth, birth weight discordance, admission
to the neonatal intensive care unit (NICU), pH of the umbilical artery,
and a 5'-APGAR score \textless{}7. Results: Obese mothers had a
significantly higher risk for GDM (OR = 0.36; 95\% CI 0.19 -- 0.7
compared to underweight; OR = 0.32; 95\% CI 0.23 -- 0.43 compared to
normal weight; OR = 0.47; 95\% CI 0.33 -- 0.69 compared to overweight),
and wound healing disorders (OR = 0.19; 95\% CI 0.09 -- 0.4 compared to
normal weight). Neonates of obese mothers showed significant results for
umbilical artery pH of 7.01 -- 7.1 (OR = 0.45; 95\% CI 0.24 -- 0.86
compared to overweight). Neonates of obesity class III mothers had a
significantly higher risk for NICU admission (OR = 0.38; 95\% CI 0.17 --
0.83 compared to obesity class I). No significant results for the
remaining main outcome measures. Conclusions: Obesity, and overweight
represent risk factors for adverse fetomaternal outcome in twin
pregnancies.%
\end{abstract}%



\sloppy


\emph{Title page:}

\emph{Title:} Relationship between maternal pre-pregnancy weight and
fetomaternal outcomes in twin pregnancies: an original research

\emph{Authors:} Leandra NAGLER, Ms.; Carmen EI\selectlanguage{ngerman}ßMANN, Ms.; Ammar AL
NAIMI, M.D.; Marita WASENITZ, Ms.; Franz BAHLMANN, Prof.

\emph{Authors affiliations:}

Ms. Leandra NAGLER

Goethe University Frankfurt am Main, Frankfurt, Hessen, Germany

Ms. Carmen EIßMANN

Department of Obstetrics and Gynecology, Buergerhospital - Dr.
Senckenbergische Stiftung, Frankfurt am Main, Hessen, Germany

Ammar AL NAIMI, M.D.

Department of Obstetrics and Gynecology, University Hospital, Goethe
University Frankfurt, Frankfurt am Main, Hessen, Germany

Department of Obstetrics and Gynecology, Buergerhospital - Dr.
Senckenbergische Stiftung, Frankfurt am Main, Hessen, Germany

Ms. Marita WASENITZ

Department of Obstetrics and Gynecology, Buergerhospital - Dr.
Senckenbergische Stiftung, Frankfurt am Main, Hessen, Germany

Prof. Franz BAHLMANN

Department of Obstetrics and Gynecology, Buergerhospital - Dr.
Senckenbergische Stiftung, Frankfurt am Main, Hessen, Germany

\emph{Corresponding author:} Ms. Leandra Nagler

\begin{itemize}
\tightlist
\item
  Address: Department of Obstetrics and Gynecology, Buergerhospital -
  Dr. Senckenbergische Stiftung, Nibelungenallee 37-41, D-60318
  Frankfurt am Main, Hessen, Germany
\item
  Work phone number: +49 69 1500-412
\item
  Fax Number: +49 69 1500-400
\item
  Email address: leandra.nagler@gmail.com
\end{itemize}

\emph{Short title:} Maternal pre-gravid BMI and fetomaternal outcomes in
twin pregnancies.\emph{}

\emph{Abstract:}

\emph{Objectives:} To examine the influence of maternal pre-pregnancy
body weight on fetomaternal outcomes in twin pregnancies.

\emph{Study design:} Retrospective study.

\emph{Setting:} Department of Obstetrics and Gynecology, Buergerhospital
Frankfurt am Main, Hessen, Germany

\emph{Population:} 2,449 women delivering twins between 2005 and 2020 at
the Buergerhospital Frankfurt, Gemany.

\emph{Methods:} The mothers were categorized according to their
pre-gravid body mass index into underweight, normal weight, overweight,
obese, and obesity classes I -- III.

\emph{Main outcome measures:} Gestational diabetes mellitus (GDM),
preeclampsia/HELLP syndrome, intrauterine death (IUD), cesarean section
or vaginal delivery, wound healing disorders, postpartum hemorrhage
(PPH), uterine atony, preterm birth, birth weight discordance, admission
to the neonatal intensive care unit (NICU), pH of the umbilical artery,
and a 5'-APGAR score \textless{}7.

\emph{Results:} Obese mothers had a significantly higher risk for GDM
(OR~= 0.36; 95\% CI 0.19 -- 0.7 compared to underweight; OR~=~0.32; 95\%
CI 0.23 -- 0.43 compared to normal weight; OR~=~0.47; 95\% CI 0.33 --
0.69 compared to overweight), and wound healing disorders (OR~=~0.19;
95\% CI 0.09 -- 0.4 compared to normal weight). Neonates of obese
mothers showed significant results for umbilical artery pH of 7.01 --
7.1 (OR~=~0.45; 95\% CI 0.24 -- 0.86 compared to overweight). Neonates
of obesity class III mothers had a significantly higher risk for NICU
admission (OR~=~0.38; 95\% CI 0.17 -- 0.83 compared to obesity class I).
No significant results were observed for the remaining main outcome
measures.

\emph{Conclusions:} Obesity, and overweight represent risk factors for
adverse fetomaternal outcomes in twin pregnancies.

\emph{Keywords:} twin pregnancies; maternal obesity; pre-pregnancy
weight; fetomaternal outcome; gestational diabetes mellitus; neonatal
intensive care unit; umbilical artery pH; wound healing disorders\emph{}

\emph{Main text:}

\emph{Introduction:}

Twinning rates were subject to many changes in the past few decades,
almost doubling between 1980 -- 1985 and 2010 -- 2015. This is mainly
due to increasing rates of assisted reproductive technology (ART) and
increasing maternal age, the latter being accompanied by a higher
likelihood for multiple pregnancies. In addition, a body mass index
(BMI) \selectlanguage{english}[?]30~kg/m\textsuperscript{2} is associated with a higher risk for
twin pregnancies. With the prevalence of obese people worldwide almost
tripling in the last three decades, it is no surprise that twinning
rates rise in the context with increasing overweight and obesity
incidences.

Although the relationship between maternal weight and the likelihood for
twins has been investigated, the risks of overweight and obesity on
fetomaternal outcomes have been subject to only few studies, especially
regarding the impact of the three obesity classes as defined by the WHO.
In singleton pregnancies, overweight and obesity lead to a 18 -- 47\%
higher risk for obstetric complications.

The incidence of overweight and obese women of child-bearing age in
Germany is at a distressing level. Thus, this study aims to examine the
impact of maternal weight and especially obesity on fetomaternal
complications and outcomes in twin pregnancies, hypothesizing that an
increasing BMI and an increasing obesity class lead to a higher
likelihood for adverse fetomaternal outcomes.

\emph{Methods:}

\emph{Study design}

This retrospective study included 2,586 pregnant women delivering twins
between 2005 and 2020 at the Buergerhospital in Frankfurt, Germany.
Thereof, 2,449 women fulfilled the two primary inclusion criteria,
diamnionicity and an available pre-pregnancy BMI (calculated as weight
{[}kg{]} divided by the square of height {[}m\textsuperscript{2}{]}) and
were analyzed for maternal outcomes.

For the neonatal analysis, 246 twin pairs of mothers being analyzed were
excluded because of gestational age less than 24 weeks, stillbirth,
congenital malformation, twin-to-twin transfusion syndrome, twin anemia
polycythemia sequence, medically indicated abortions and hospitalization
for less than 72 hours after birth.

The mothers were subdivided according to their pre-pregnancy BMI based
on WHO standards (underweight \textless{}18.5~kg/m\textsuperscript{2},
normal weight 18.5 -- 24.9~kg/m\textsuperscript{2}, overweight 25 --
29.9~kg/m\textsuperscript{2}, obese \selectlanguage{english}[?]30~kg/m\textsuperscript{2}, obesity
class I 30 -- 34.9~kg/m\textsuperscript{2}, obesity class II 35 --
39.9~kg/m\textsuperscript{2} and obesity class III
\selectlanguage{english}[?]40~kg/m\textsuperscript{2}). The obese group consisted of 265 women,
whereof 171 were in obesity class I, 58 in obesity class II and 36 in
obesity class III.

\emph{Outcomes}

Maternal and pregnancy outcomes examined included gestational diabetes
mellitus (GDM), preeclampsia or HELLP syndrome (hemolysis, elevated
liver enzymes and low platelets syndrome), intrauterine death (IUD) of
at least one twin, cesarean or vaginal delivery, wound healing
disorders, postpartum hemorrhage (PPH), including those in need of blood
transfusions, uterine atony with the necessity of Sulprostone or a
tamponade, and preterm birth.

GDM was diagnosed according to the guidelines of the American Diabetes
Association. Every gravida underwent a 75~g oral glucose tolerance test
between 24 and 28 weeks of gestation. GDM was diagnosed when at least
one limiting value was exceeded (fasting: 92~mg/dL, 1 hour: 180~mg/dL, 2
hours: 153~mg/dL). Preeclampsia was defined according to the Practice
Bulletin of the American College of Obstetricians and Gynecologists
(ACOG) as a blood pressure of \selectlanguage{english}[?]140/90~mmHg and proteinuria or at least
one sign of organ damage. IUD was defined according to the Royal College
of Obstetricians \& Gynaecologists as missing signs of life in utero
after 24 completed weeks of gestation. PPH was defined as bleeding
\textgreater{}1,000~ml or blood loss with signs of hypovolemia within 24
hours after birth. Gestational age was calculated through measurement of
the fetal crown-rump length using ultrasound and categorized into groups
of \selectlanguage{english}[?]27+6, 28 -- 31+6 and 32 -- 36+6 weeks of gestation.

Neonatal outcomes analyzed were birth weight discordance between twins,
admission to the neonatal intensive care unit (NICU), pH of the
umbilical artery and an APGAR score value below seven after five
minutes.

Birth weight discordance was defined according to Practice Bulletin of
the ACOG, estimated for every neonate, and classified into three groups
of \textless{}20\%, 20 -- 24,9\% and \selectlanguage{english}[?]25\%. Fetuses with a birth weight
discordance above 20\% were monitored more intensively. Admission to
NICU was defined as admission of at least one twin. The arterial
umbilical pH was subdivided into categories of \selectlanguage{english}[?]7.0, 7.01 -- 7.1 and
7.11 -- 7.2.

\emph{Statistical analysis}

Shapiro-Wilk-Test was used to determine whether continuous variables
were normally distributed. Obese women were compared for categorical
variables with underweight, normal weight and overweight women using
Pearson's \selectlanguage{greek}χ\selectlanguage{english}\textsuperscript{2} test or Craddock's Flood
\selectlanguage{greek}χ\selectlanguage{english}\textsuperscript{2} test. The same tests were used for the analysis of
the obesity groups. A mixed effects Cox regression model was used to
determine the impact of maternal BMI on the length of stay in the NICU
between the weight categories.

All analyses were completed using BiAS. (Version 11.12, epsilon Verlag,
Frankfurt, Germany) and RStudio (Version 4.1.1, RStudio Team (2020).
RStudio: Integrated Development for R. RStudio, PBC, Boston, MA, USA). A
Bonferroni correction was used to adjust \emph{p} values. Therefore,
a\emph{p} value \textless{}0.003 was considered significant for maternal
outcomes and \textless{}0.005 for neonatal outcomes. Odds ratios and
relative risks were calculated with a 95\% confidence interval.

\emph{Results:}

\emph{Maternal characteristics}

A total of 2,449 mothers were analyzed. The median age of the population
was 34 years (IQR 30.01 -- 37) and the median BMI was
22.96~kg/m\textsuperscript{2} (IQR 20.76 -- 25.95). Baseline
characteristics of the mothers are shown in Table 1. Pregnancies
resulting from ART were most common in the underweight group and lowest
in the obese group. While rates of primiparas were similar in
underweight and normal weight mothers, they decreased in overweight and
obese mothers. Within the obese group, the highest rate was among
obesity class I mothers. Rates of history of cesarean sections increased
parallel to weight classes. Rates of underlying hypertension and
diabetes mellitus were the highest among obesity class II mothers.

\emph{Maternal and obstetric outcomes}

Maternal and obstetric outcomes were compared between underweight,
normal weight, overweight and obese women and between obesity classes
(Tables 2 and 3). GDM was significantly associated with maternal weight
in the comparison of all four weight groups (\emph{p} ~\textless{}0.001;
Pearson's coefficient C~=~0.15). Obese mothers had a significantly
higher risk for GDM when compared to underweight (\emph{p} ~=~0.003;
OR~= 0.36; 95\% CI 0.19 -- 0.7), normal weight (\emph{p}
~\textless{}0.001; OR~=~0.32; 95\% CI 0.23 -- 0.43) and overweight
(\emph{p} ~\textless{}0.001; OR~=~0.47; 95\% CI 0.33 -- 0.69) mothers.
Among obese mothers, there was a significantly higher rate for GDM in
obesity class III when compared to obesity class I (\emph{p~} =~0.037;
OR~=~0.45; 95\% CI 0.21 -- 0.95). Wound healing disorders were
significantly associated with both maternal weight in general (\emph{p~}
\textless{}0.001; Pearson's coefficient C~=~0.09) and obesity (\emph{p}
~\textless{}0.001; Pearson's coefficient C~=~0.26). Obese women had a
significantly increased risk for wound healing disorders compared to
women of normal weight (\emph{p} ~\textless{}0.001; OR~=~0.19; 95\% CI
0.09 -- 0.4), as well as mothers with obesity class III when compared to
class I (\emph{p} ~\textless{}0.001; OR~=~0.05; 95\% CI 0.01 -- 0.23).
Preterm delivery was not associated with maternal weight or obesity.
Nonetheless, mothers with obesity class III had the highest rate of
delivery between 32 and 36+6 weeks of gestation (56\%, compared to 40\%
in class I) in the obesity comparison. Interestingly, in the overall
analysis, underweight mothers had the highest rate of delivery between
32 and 36+6 weeks of gestation (49\%, compared to 42\% in obese
mothers). There was no significant association between maternal weight
and preeclampsia or HELLP syndrome, IUD, and uterine atony with the
necessity of Sulprostone or a Bakri balloon. Despite not being
statistically significant, rates of PPH increased with rising BMI,
albeit the highest rate occurring in obesity class I within the obese
group. The normal weight and overweight groups had the highest rates of
blood transfusions. There was no significant difference in rates of
cesarean section or vaginal delivery between the weight groups or in the
obesity analysis.

\emph{Neonatal outcomes}

Neonatal outcomes were analyzed equally (Tables 2 and 3). There was no
significant association between maternal weight and birth weight
discordance of any severity, a pH of the umbilical artery of 7.11 -- 7.2
or [?]7.0 and a five-minute APGAR score below seven. There was, however, a
significantly increased risk for a pH of the umbilical artery of 7.01 --
7.1 in neonates of obese women when compared to overweight women
(\emph{p} ~=~0.016; OR~=~0.45; 95\% CI 0.24 -- 0.86). Albeit not being
associated with maternal weight or obesity classes, there was a
significantly higher risk for neonate admission to NICU for obesity
class III in comparison to obesity class I (\emph{p} ~=~0.015;
OR~=~0.38; 95\% CI 0.17 -- 0.83) and a significantly increased rate of
admission to the NICU of the firstborn of mothers with obesity class III
when compared to mothers with obesity class I (\emph{p~} =~0.02;
OR~=~0.4; 95\% CI 0.18 -- 0.89). Maternal BMI did not significantly
influence the length of stay in the NICU.

\emph{Discussion:}

\emph{Main findings}

The study population consisted of 2,449 mothers, whereof 11\% were
obese. Both maternal weight and obesity were significantly associated
with GDM and wound healing disorders, obese mothers having a
significantly higher risk for GDM and post-cesarean wound healing
disorders. Preterm birth, preeclampsia or HELLP syndrome, IUD, uterine
atony, PPH and rates of cesarean sections or vaginal delivery showed no
significant results. In the analysis of the neonatal outcomes, neonates
of obese mothers had a significantly higher risk for an umbilical artery
pH of 7.01 -- 7.1. Furthermore, neonates of mothers with obesity class
III had a significantly higher risk for NICU admission, especially for
the firstborn. Birth weight discordance of any severity, umbilical
artery pH of [?]7.0 or 7.11 -- 7.2 and a five-minute APGAR \textless{}7
was not significantly associated with maternal weight or obesity.

\emph{Strengths and limitations}

This study contributes to the still small range of studies on the
effects of obesity and overweight on fetomaternal outcomes in twin
pregnancies. By analyzing the outcomes wound healing disorders, uterine
atony, postpartum hemorrhage, and asphyxia, four topics were included,
which have not yet been addressed frequently or at all in studies on the
impact of maternal weight on twin pregnancies. Many studies are
conducted analyzing the impact of obesity in general. In this study,
obesity has been analyzed further by subdividing this weight group into
the three obesity classes as defined by the WHO, allowing a more
detailed view on their impacts on fetomaternal outcomes in twin
pregnancies. Furthermore, underweight mothers and their offspring were
analyzed as well, their risk in twin pregnancies also only being topic
to few studies.

The limitations include the retrospective nature of the study. The study
population is comparatively small, which might explain why some of the
results were not significant in contrast to findings of other similar
studies. Furthermore, no statistical analyses to adjust for confounding
variables have been performed. The Buergerhospital Frankfurt being a
tertiary referral center with the second highest birth rate in Germany
and a specialization on multiple pregnancies and their complications,
might bias the rates of pregnancy and postpartum complications.

\emph{Interpretation}

Twin pregnancies are at a higher risk for gestational diabetes than
singleton pregnancies, every additional fetus in multiple pregnancies
increasing the risk for GDM by 1.8 times. Consistent with these studies,
data of this analysis also showed a significant association between
obesity and GDM, with significantly increasing rates within obesity
classes. With GDM increasing the risks for cesarean sections,
preeclampsia, and preterm birth, and considering the increasing rates of
GDM worldwide, prevention and information on the risks of gestational
diabetes should be extended.

Obesity has been established as an important risk factor for surgical
site infections after cesarean sections. Almost a third of severely
obese patients were described to suffer from wound complications after a
cesarean section. This study confirms these findings, showing an
association between maternal weight in general and especially obesity
and wound complications. Furthermore, Olsen et al. and Wall et al.
showed that missing antibiotic prophylaxis is an independent risk factor
for wound infections and that patients with vertical skin incisions have
a significantly increased incidence of wound complications. At the
Buergerhospital Frankfurt, all cesarean sections are performed under
antibiotic prophylaxis with a transverse skin incision, possibly
explaining the low rates of wound healing disorders in our study.

PPH is the most important reason for pregnancy-related morbidity, 70\%
of all PPH being caused by uterine atony or inadequate uterine
contraction. Maternal obesity and multiple pregnancies are considered
being important risk factors for PPH, multifetal gestations possibly
leading into uterine overdistension, and consequently into uterine atony
with the risk of PPH. To our knowledge, this study was the first to
assess the direct influence of maternal weight on uterine atony both
with the necessity of Sulprostone and intervention with a Bakri Balloon
in twin pregnancies. In contrast to the studies mentioned afore, rates
of PPH did not reach significance in this study, however, women with
obesity class I had a threefold risk for PPH compared to obesity class
II and a twofold risk for PPH compared to obesity class III.

Paidas Teefey et al. investigated rates of cesarean deliveries
especially for obesity class III women in singleton pregnancies, finding
rates of nearly 50\% for obesity class III women and 66\% for women with
a BMI of at least 50 kg/m\textsuperscript{2}. Albeit not statistically
significant, this study confirmed these findings, showing that cesarean
sections were more common with rising BMI, especially in the obese
group.

Despite being a study conducted in singleton pregnancies and thus only
partially applicable to twins, Bicocca et al. observed a higher risk for
hypertensive pregnancy disorders, including preeclampsia, with
increasing obesity classes. In twin pregnancies, findings on
preeclampsia are inconsistent. On one hand, a BMI
[?]30~kg/m\textsuperscript{2} is considered as a significant risk factor
for preeclampsia, on the other hand, the risk for preeclampsia might
only be significantly increased in obesity class III. Potentially due to
low rates of preeclampsia in this study population, findings of this
study contrast the studies mentioned afore, showing no significant
risks.

In singleton pregnancies, obesity was shown to be the second biggest
risk factor for stillbirth. Similarly, Salihu et al. described a 60\%
higher risk for fetal death of both twins in obese women. Both these
findings contrast the results of this study, possibly because of low
rates of IUD in this study in general and similar rates in all weight
groups.

Neonatal outcomes in twin pregnancies have only been investigated in a
few studies, while having been analyzed thoroughly in singleton
pregnancies. Obesity or increasing BMI were shown to be associated with
higher rates of fetomaternal complications as well as admission to NICU
in singleton pregnancies. Confirming these findings, a significantly
higher risk for admission to NICU in neonates of obesity class III
mothers and especially for their firstborn was observed. Maternal weight
did not have an impact on the mean length of stay in the NICU.

Only a few studies have been conducted in twins investigating the topic
of asphyxia and low umbilical artery pH, concluding that the second twin
is at a significantly higher risk for asphyxia, low umbilical artery pH
values or low APGAR scores. To our knowledge, this study is the first
one to assess the impact of maternal weight and obesity on the umbilical
artery pH and asphyxia in twins. Significantly higher rates of pH values
of 7.01 -- 7.1 in neonates of obese mothers were observed in this study.
Considering the sparse number of studies on this topic, the impact of
obesity on the risk for asphyxia in twins should be analyzed in further
investigations. Regarding the five-minute APGAR score, our findings
confirmed those of Bautista et al., showing no association between
maternal BMI and a low five-minute APGAR score.

\emph{Conclusion:}

With twin pregnancies already being at high risk for adverse outcomes
regardless of the maternal pre-pregnancy weight, this study supports
findings of other studies on the additional impact of overweight and
obesity on both mother and twins. However, this study also shows a lower
rate of complications in contrast to some studies mentioned afore, most
likely due to the health care system in Germany and the Buergerhospital
Frankfurt being a tertiary referral center with a joined NICU. This
results in better and continuous monitoring from the very start of the
pregnancy and thus complications being diagnosed earlier with the option
to intervene sooner. Furthermore, an antibiotic prophylaxis before
cesarean sections is standard in Germany and therefore also leading to
lower post-cesarean maternal complications.

With increasing incidences of overweight and obesity worldwide, the
associated risks for twin pregnancies need to be addressed more to
create a foundation for better understanding and enhanced prevention of
overweight and obesity both in general and especially in regard to
pregnancies. However, underweight has also shown to have a great impact
on adverse fetomaternal outcomes in twin pregnancies, implicating the
need for information in this area as well.

\emph{Acknowledgments:}

This study was supported by the Dr. Senckenbergische Stiftung.

\emph{Disclosure of interests:}

The authors report no conflict of interest.

\emph{Contribution to Authorship:}

LN, MW and FB designed and conducted the study. LN and MW collected
data, the statistical analysis was conducted by LN and AAN. Data
interpretation and drafting of the manuscript were by LN, with support
by MW. The literary research was conducted by CE. All authors revised
the manuscript critically for important intellectual content. FB
supervised the study and revised the final draft. All authors approved
of the final manuscript and are accountable for all aspects of the work.

\emph{Ethics Approval:}

This study has been approved by the ethics committee of the Medical
Association of Hesse (January 3\textsuperscript{rd}, 2022, reference
number: 2021-2675-evBO).

\emph{Funding:}

This study was conducted without sources of financial support or
funding. \emph{}

\emph{}

\emph{Tables:}

Table 1. Maternal characteristics\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Characteristics\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Underweight (n=101, 4.1\%)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Normal weight (n=1577, 64.4\%)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Overweight (n=506, 20.7\%)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Obese (n=265, 10.8\%)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Obese (n=265, 10.8\%)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Obese (n=265, 10.8\%)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Obese (n=265, 10.8\%)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Total\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Class I\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Class II\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Class III\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
n (\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Age (years)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
32.25\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
33.56\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
32.5\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
32.81\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
31.85\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
32.08\textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
BMI {[}kg/m\textsuperscript{2}{]}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
17.99\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21.78\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
26.7\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
33.56\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
32\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
36.98\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
43.45\textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
ART\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
38 (38\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
589 (37\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
177 (35\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
76 (29\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
50 (29\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14 (24\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12 (33\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Primipara\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
65 (64\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1038 (66\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
286 (57\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
137 (52\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
92 (54\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
31 (53\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14 (39\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
MCDA twins\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
28 (28\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
353 (22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
121 (24\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
59 (22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
36 (21\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
16 (28\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (19\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
DCDA twins\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
73 (72\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1224 (78\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
386 (76\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
206 (78\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
135 (79\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
42 (72\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
29 (81\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
History of abortion\textsuperscript{c}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
142 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
57 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
37 (14\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
23 (13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (17\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4 (11\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
History of C-section\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
149 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
77 (15\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
53 (20\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
31 (18\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10 (17\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12 (33\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Smoker\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pre-existing HTN\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2 (6\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pre-existing DM\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
13 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1 (3\%)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: ART, assisted reproductive technology; BMI, body mass
index; C-section, cesarean section; DCDA twins, dichorionic diamniotic
twins; DM, diabetes mellitus; HTN, hypertension; MCDA twins,
monochorionic diamniotic twins\textsuperscript{a}Mean
result\textsuperscript{b}Median result\textsuperscript{c}At least two
abortions

\emph{\textsuperscript{d}Diabetes mellitus type 1 and 2}

Table 2. Obstetric and neonatal outcome in underweight, normal weight,
overweight and obese mothers\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Outcome\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Underweight n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Normal weight n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Overweight n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
Obese n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.16\columnwidth}\raggedright\strut
\emph{p} Value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Obstetric outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=101)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=1577)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=506)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=265)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
GDM\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
152 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
70 (14\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
67 (25\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{} 0.001\textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PE/HELLP syndrome\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
106 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
42 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
22 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.54\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
IUD\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
49 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
23 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.36\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
C-Section\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
70 (69\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1099 (70\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
368 (73\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
201 (76\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.16\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Vaginal delivery\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
27 (27\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
340 (22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
102 (20\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
50 (19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.37\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Wound healing disorders\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11 (4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{} 0.001\textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PPH\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
133 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
43 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
23 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.84\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Uterine atony + Sulprostone\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
23 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.61\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Uterine atony + BBT\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.38\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Delivery [?]27+6 weeks\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
55 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
25 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.32\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Delivery 28 -- 31+6 weeks\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
98 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
29 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
20 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Delivery 32 -- 36+6 weeks\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
49 (49\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
721 (46\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
228 (45\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
112 (42\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.68\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Neonatal outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=94)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=1432)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=443)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(n=234)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
WD \textless{}20\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
77 (82\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1162 (81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
360 (81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
195 (83\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.88\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
WD 20 -- 24.9\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
109 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
40 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
17 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.78\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
WD [?]25\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
161 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
43 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
22 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Admission to NICU\textsuperscript{c}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
32 (17\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
576 (20\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
169 (19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
101 (22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.52\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
pH 7.11 -- 7.2\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
15 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
271 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
89 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
52 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.57\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
pH 7.01 -- 7.1\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
80 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
18 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
20 (4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.05\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
pH [?]7.0\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
26 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.86\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5'-APGAR \textless{}7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
45 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.6\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: BBT, Bakri balloon tamponade; HELLP syndrome, hemolysis,
elevated liver enzymes and low platelets syndrome; IUD, intrauterine
death; GDM, gestational diabetes mellitus; PE, preeclampsia; PPH,
postpartum hemorrhage; NICU, neonatal intensive care unit; WD, weight
discordance

\textsuperscript{a}Significant after Bonferroni correction

\emph{\textsuperscript{b}IUD of at least one
twin\textsuperscript{c}Admission to NICU of at least one twin}

\emph{\textsuperscript{d}pH of the umbilical artery}

Table 3. Obstetric and neonatal outcome in obese mothers\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Outcome\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Obesity class I n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Obesity class II n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Obesity class III n (\%)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\emph{p} Value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Obstetric outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(n=171)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(n=58)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(n=36)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
GDM\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38 (22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15 (26\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14 (39\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.11\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
PE/HELLP syndrome\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15 (9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
IUD\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
C-Section\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
125 (73\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
47 (81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29 (81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.37\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Vaginal delivery\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
36 (21\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (12\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.32\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Wound healing disorders\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8 (14\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{} 0.001\textsuperscript{a}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
PPH\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.16\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Uterine atony + Sulprostone\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.43\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Uterine atony + BBT\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.33\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Delivery [?]27+6 weeks\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6 (4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.53\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Delivery 28 -- 31+6 weeks\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Delivery 32 -- 36+6 weeks\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68 (40\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24 (41\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20 (56\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.22\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Neonatal outcome}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(n=155)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(n=48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
(n=31)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
WD \textless{}20\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
132 (85\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
39 (81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24 (77\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.52\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
WD 20 -- 24.9\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11 (7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.84\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
WD [?]25\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12 (8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6 (13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.48\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Admission to NICU\textsuperscript{c}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58 (19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
21 (22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
22 (35\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
pH 7.11 -- 7.2\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
33 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11 (11\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8 (13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.87\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
pH 7.01 -- 7.1\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13 (4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.37\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
pH [?]7.0\textsuperscript{d}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.73\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5'-APGAR \textless{}7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.49\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: BBT, Bakri balloon tamponade; HELLP syndrome, hemolysis,
elevated liver enzymes and low platelets syndrome; IUD, intrauterine
death; GDM, gestational diabetes mellitus; PE, preeclampsia; PPH,
postpartum hemorrhage; NICU, neonatal intensive care unit; WD, weight
discordance

\textsuperscript{a}Significant after Bonferroni correction

\emph{\textsuperscript{b}IUD of at least one
twin\textsuperscript{c}Admission to NICU of at least one twin}

\emph{\textsuperscript{d}pH of the umbilical artery}

\selectlanguage{english}
\FloatBarrier
\end{document}

