“Double Jeopardy” The Impact of Maternal Obesity on Mother and Infant Outcome Terry S. Johnson,...

“Double Jeopardy” The Impact of Maternal Obesity on

Mother and Infant Outcome

Terry S. Johnson, APN, NNP-BC, CLEC, MNNeonatal Nurse Practitioner

Founder, Lode Star Enterprises, Inc.

Disclosure Statement• Terry S. Johnson, APN, NNP-BC, CLEC, MN

– In addition to any clinical practice, education and consulting services I provide

• I am currently on the speaker's bureau and/or consult with these industry partners

• Prolacta Bioscience and Abbott Nutrition Health Institute• I receive financial reimbursement for those services

– Images & photographs used in this presentation come from publicly accessed sources

– I will make no recommendations for an off label use of any drug, product or medical device

– I am honored to be here today

Maternal Obesity

• ACOG“In the United States, more than one third

of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese, putting them at a greater risk of pregnancy complications.”

ACOG Committee Opinion Number 549, Obesity in Pregnancy, January 20133

Obesity By Definition• Quantified for clinical purposes by a BMI of >30

– Institute of Medicine (IOM) published revised pregnancy weight gain guidelines based on WHO pre-pregnancy BMI ranges

– These ranges are independent of age, parity, smoking history, race, and ethnic background

– Normal weight as a BMI of 18.5–24.9– Overweight as a BMI of 25–29.9– Obesity as a BMI of 30 or greater

CDC. Vital signs: State-specific prevalence of obesity among adults – United States, 2009. MMWR 2010;59:1-5.Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press; 2009.

Obesity By Geography• Percentage of Female Obesity (BMI > 30)

“Pre-pregnancy, 72 percent of

German women were at a

healthy weight, compared with just 47 percent

for the Americans.”

http://www.reuters.com/article/2015/07/01/us-health-pregnancy-obesity-idUSKCN0PB5DB20150701

Obesity Trends Among U.S. Adults Between 1985 and 2010

• Adult Obesity Facts– More than one-third of U.S. adults (35.7%) are obese – Obesity-related conditions include heart disease, stroke,

type 2 diabetes and certain types of cancer, some of the leading causes of preventable death

– In 2008, medical costs associated with obesity were estimated at $147 billion; the medical costs for people who are obese were $1,429 higher than those of normal weight.

– The South had the highest prevalence of obesity (29.5%), followed by the Midwest (29.0%), the Northeast (25.3%) and the West (24.3%)

CDC. Vital signs: State-specific prevalence of obesity among adults – United States, 2009. MMWR 2010;59:1-5.


• Adult Obesity Facts– Non-Hispanic blacks have the highest age-adjusted

rates of obesity (49.5%) compared with Mexican Americans (40.4%), all Hispanics (39.1%) and non-Hispanic whites (34.3%)

– Higher income women are less likely to be obese than low-income women

– There is no significant relationship between obesity and education among men. Among women, however, there is a trend—those with college degrees are less likely to be obese compared with less educated women


Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011

*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

CA

MT

ID

NVUT

AZNM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

ILOH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

PRGUAM

NHMARICTNJDEMDDC

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%



CA

MT

ID

NVUT

AZNM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

ILOH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

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AK

NHMARICTNJDEMDDC

PRGUAM

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%



CA

MT

ID

NVUT

AZNM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

ILOH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

NHMARICTNJDEMDDC

PRGUAM


• Review of Data– In 1990, among states participating in the

Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no state had prevalence equal to or greater than 15%.

– By 2000 , no state had a prevalence of obesity less than 10%, 23 states had a prevalence between 20–24%, and no state had prevalence equal to or greater than 25%.



• Review of Data– In 2010, no state had a prevalence rate of obesity

less than 20%. Thirty-six states had a prevalence rate equal to or greater than 25%;

– 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia) had a prevalence rate equal to or greater than 30%.


Obesity Associated Mortality• Maternal Morbidity: CV Disease

– BMI greater than 30 kg/m2

• Higher rates of maternal hypertension• Risk of preeclampsia 3 times that of normal weight

– BMI greater than 35 kg/m2 • Risk of preeclampsia 5 times greater

– Etiology – influenced by maternal weigh• Insulin resistance• Inflammatory changes• Oxidative stress• Altered vascular bed

– Increase the lifetime risk for CV diseaseKriebs, J. M., (2014). Obesity in pregnancy. Journal Perinatal & Neonatal Nursing, 28(1), 32-39.

Impact of Maternal Obesity

• Currently, 1 in 5 pregnant women in the United States is obese– Maternal obesity results in higher rates of

cesarean section, higher rates of infant birth defects and a three-fold higher incidence of neonatal death.

– Babies born to obese mothers, even if born at a normal weight, have been shown to have multiple metabolic problems with lifelong consequences.


• Currently, 1 in 5 pregnant women in the United States is obese– Maternal obesity results in higher rates of

cesarean section, higher rates of infant birth defects and a three-fold higher incidence of neonatal death.

– Babies born to obese mothers, even if born at a normal weight, have been shown to have multiple metabolic problems with lifelong consequences.


• Currently, 1 in 5 pregnant women in the United States is obese

• Maternal obesity results in higher rates of cesarean section, higher rates of infant birth defects and a three-fold higher incidence of neonatal death.

• Babies born to obese mothers, even if born at a normal weight, have been shown to have multiple metabolic problems with lifelong consequences.

Obesity in Pregnancy

• Definitions of Obesity in PregnancyBody Mass Index and Obesity

Definition BMI kg/m2 Obesity Class

Underweight < 18.5

Normal 18.5 – 24.9 Normal

Overweight 25.0 – 29.9 Pre-Obese

Obese 30.0 – 34.9 I

35.0 – 39.9 II

Extremely Obese ≥ 40 III

Pi-Sunyer FX, Becker DM, Bouchard C, et al. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: evidence report: NIH publication #4083.

http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdfGunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.

http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf

Maternal Obesity and Pregnancy

Nodine PM & Tolsema MH Maternal obesity: improving

pregnancy outcomes (2012). MCN, 37(2);110-115.

Pathophysiology of Maternal Obesity in Pregnancy

Obesity in PregnancyObstetric Complications by Maternal BMI

Obesity vs. Control Class III Obesity vs. Control

Outcome ADJ OR (95% CI) P Value ADJ OR (95% CI) P Value

Gestational DM 2.6 (2.1-3.4) <.0001 1.7 (1.2-2.2) <.01

Gestational HTN 2.5 (2.1-3.0) <.0001 3.2 (2.8-4.0) <.01

Preeclampsia 1.6 (1.1-2.25) .007 3.3 (2.4-4.5) <.01

BW > 4500 g 2.0 (1.4-3.0) .0006 2.4 (1.5-3.8) <.01

BW > 4000 g 1.7 (1.4—2.0) <.0001 1.9 (1.5-2.3) <.01

Preterm Delivery 1.1 (0.9—1.5) .4 1.5 (1.1-2.1) .01

Adapted from Weiss JL et al Am J Obstet Gynecol. 2004;190:1091–1097Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.

Obesity in PregnancyObstetric Complications by Maternal BMI

Obesity vs. Control Class III Obesity vs. Control

Outcome ADJ OR (95% CI) P Value ADJ OR (95% CI) P Value

Operative Vaginal Del. 1.0 (0.8-1.3) .9 1.7 (1.2-2.2) <.01

PPROM 1.3 (0.9-2.0) .14 1.3 (0.8-2.2) .2

IUGR 0.9 (0.5-1.6) .82 0.8 (0.4-1.8) .6

Placenta Previa 1.3 (0.7-2.5) .4 0.7 (0.3-2.0) .6

Placenta Abruption 1.0 (0.6-1.9) .9 1.0 (0.5-2.2) .9

Cesarean Delivery 1.7 (1.4-2.2) <.01 3.0 (2.2-4.0) <.01

Adapted from Weiss JL et al Am J Obstet Gynecol. 2004;190:1091–1097Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.


• Antenatal Management– Early ultrasound

• Confirm viability, assign EGA, Assess for multiples

– Thorough history• Coexistence, severity of comorbidities• DM, thyroid disorders, hypertension, liver & gall

bladder disease, orthopedic issues

– Baseline serum chemistries• Uric acid, creatinine, hepatic transaminases• 24-hour urine for proteinuria

Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.


• Antenatal Management– Maternal ECHO

• Evaluate for cardiomyopathy

– Sleep disorder evaluation• Obesity is one of strongest risk factors for obstructive sleep

apnea – associated with a 2-fold risk for HTN, stroke, cardiac dysfunction

– Hypertension evaluation• Strong positive correlation between pre-pregnancy BMI and the

risk of preeclampsia even when additional co-exisiting risk factors were excluded

• Risk of preeclampsia doubles for each 5-7 kg/m2 increase in pre-pregnancy BMI



• Gestational Weight Recommendations– Dietary counseling

• Ideally, preconceptual normal BMI• Limited weight gain, rather than weight loss• < 10 pounds of gestational weight gain in class II & III

women decreases risk for preeclampsia, C/S, SGA, LGA • IOM Recommendations for Gestational Weight Gain

– IOM Recommendations for Gestational Weight Gain• Upper limit weight gain for obese women of 20 lbs/9kg• Lower limit weight gain from 11 lbs/5kg



• Second Trimester Care– Medical, Nursing, Dietary Optimization

• Monitoring for congenital anomalies• Obese African American woman has a 6-fold greater

likelihood for fetal congenital cardiac malformations• Detailed fetal anatomy ultrasound mid-trimester• Consider fetal ECHO between 22-24 weeks gestation• Complete fetal anatomic survey could only be completed

50% of time due to maternal obese body habitus• If anomaly present – amniocentesis, CVS



• Third Trimester Care– Critical Period

• Monitor for preterm labor 2° obesity related conditions• Higher risk for post-date pregnancy• Monitor for superimposed preeclampsia• Repeat 50 g 1-hour oral glucose challenge• 2- to 3-fold increased risk of intrauterine fetal death• Higher risk for hypoxic-apneic episodes• Monitor for fetal macrosomia or growth-restriction• Sonographic fetal growth assessment every 4-6 weeks



• Labor and Delivery Management– Failed Induction of Labor

• IOL trial where patients stratified by BMI– Median dose & duration of pre-delivery oxytocin was greater– BMI > 40 kg/m2 = 5.0 units and 8.5 hours– Normal BMI = 2.6 units and 6.5 hours

• European series of > 200,000 deliveries– BMI of > 40 kg/m2 associated with a 4 times risk of C/S because

of failed labor with/without augmentation



• Labor and Delivery Management– Failed Induction of Labor

• Prospective study of 509 nulliparous women with IOL– As maternal weight ↑ the rate of cervical dilatation ↓– Associated with ↑ induction to delivery interval

• Slower active phase of labor in overweight/obese women– Adjusted for labor augmentation, oxytocin use, epidural

analgesia, gestational weight gain, and fetal size– Normal weight women – 6.2 hours– Overweight women – 7.5 hours– Obese women – 7.9 hours– ? Role of leptin in inhibiting uterine contractions



• Labor and Delivery Management– Risk of Surgical Delivery

• Likelihood of operative vaginal delivery– (X1.5 in BMI > 30 kg/m2 and X2 in BMI > 40 kg/m2)– Associated with higher maternal and fetal morbidity– Shoulder dystocia (obesity a 2.7-fold risk)

• Macrosomia also increases risk– Birth trauma– Perineal lacerations– Postpartum hemorrhage

• “An attempted operative vaginal delivery in an obese patient must be made judiciously with informed consent.”



• Labor and Delivery Management– Increased Risk of Elective or Emergent C/S

• Study of >16,000 Pre-pregnancy BMI and Weight Gain– C/S rate for control non-obese patients was 20.7%– C/S rate for obese (BMI 30-34.99 kg/m2) was 33.8%– C/S rate for extremely obese women (BMI >35 kg/m2) was 50%

• Risk is further augmented by– Obesity-related pregnancy complications– Inherent perioperative risks from surgery

• C/S complicates management of future pregnancies– Uterine rupture, placenta previa, placenta acreta, perioperative

morbidity, hemorrhage Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.


• Intrapartum Management– Bariatric Obstetrics

• Unit equipment needs– Bariatric bed and frame with trapeze (eg, 1000- pound capacity)– Toilet able to accommodate 500+ pounds– Inflatable mattress– Extra-wide wheelchairs

• Intraoperative equipment needs– Extra-large blood pressure cuffs; fetal monitoring equipment– Extra-large inflatable sequential compression devices– Larger belts and straps to secure patient– Extra-long surgical instruments, self-retaining retractor


Obesity in Pregnancy• Intrapartum Management

– Anesthesia Considerations• More likely to have anesthesia failures

– Initial failed epidural– Subsequent epidural placement– Higher rates of difficult intubation– Inadvertent puncture

• Intraoperative equipment needs– Up to 75% of all anesthesia-related deaths occur

among obese pregnant women!


Anesthesia Risk

• Mallampatti Test 2 – Correlates tongue size to pharyngeal size– Performed with the patient in the sitting position,

head in a neutral position, the mouth wide open and the tongue protruding to its maximum

– Classification is assigned according to the extent the base of tongue is able to mask the visibility of pharyngeal structures into three classes

Anesthesia Risk• Mallampatti Test 2

http://www.openanesthesia.org/index.php?title=Airway_Management

Modified Mallapatti Test Scoring:Class 1: Full visibility of tonsils, uvula and soft palateClass 2: Visibility of hard and soft palate, upper portion of tonsils and uvulaClass 3: Soft and hard palate and base of the uvula are visibleClass 4: Only Hard Palate visible

Used to predict the ease of intubation by examining the anatomy of the oral cavity.

http://www.google.com/url?sa=i&rct=j&q=Mallampatti+Test+2&source=images&cd=&cad=rja&docid=6JXQnS16ETsFSM&tbnid=V94JZLZVt3telM:&ved=0CAUQjRw&url=http://www.sciencedirect.com/science/article/pii/S1043181007000358&ei=x449UaSHPM6tygGx2YGwDg&bvm=bv.43287494,d.aWc&psig=AFQjCNG8W3_g013bhAt3UTTADsKQ-9KLqw&ust=1363075126456987


• Intrapartum Management– Anesthesia Considerations

• Early anesthesia consultation– During third trimester or on admission to labor and delivery of

any Class III obese women– Early placement of prophylactic epidural catheter– Option for “awake” intubation– Fiber-optic laryngoscopes, intubating laryngeal airways– Emergency cricothyroidotomy kit– Up to 75% of all anesthesia-related deaths occur among

obese pregnant women!


Obesity-Related Peripartum Complications

Obesity-Related Peripartum Complications

↑ Respiratory work and myocardial oxygen requirement

Epidural anesthesia, supplemental oxygen, left-lateral laboring

Difficult peripheral IV access

Central intravenous catheter

Inaccurate blood pressure monitoring

Appropriate sized cuff, arterial line

Increased risk of general anesthesia

Anesthesia consultation, early epidural

Anticipated difficulty with intubation

Capability for awake/fiber-optic intubation

Difficulty with patient transfers

Bariatric lifts and inflatable mattresses, additional personnel


Obesity-Related Peripartum ComplicationsObesity-Related Peripartum Complications

Prolonged cesarean operative time

Combined spinal-epidural anesthesia

Poor operative exposure Evaluation of maternal anthropometry, periumbilical skin incision, atraumatic self-retaining retractor

Enhanced risk of hemorrhage

Blood typed and crossed for transfusion, ligate large subcutaneous vessels, meticulous surgical technique

Enhanced aspiration risk Prophylactic epidural, H2 antagonist, sodium citrate with citric acid, metoclopramide, NPO in labor

Enhanced thromboembolic risk

Early postoperative ambulation, sequential pneumatic compression, heparin until fully ambulatory

Enhanced infectious morbidity

Thorough skin preparation, adequate antimicrobial prophylaxis, meticulous surgical technique, ? SQ drain

Enhanced risk of C/S Informed consent, monitoring labor curve, intervention for labor dystocia



• Postpartum Management– Elevated Risk in Postpartum Period

• ↑ Rate of wound infection, thromboembolism, fluid retention• Postpartum depression (as high as 40% in Class III)• Treatment strategies

– Close inspection of surgical wound (? Skin staple removal)– Monitor vital signs closely– Early ambulation and incentive spirometry– Early follow-up (1-2 weeks)– PD screening– Contraception counseling

• Obese mother’s have a 5- to 16-fold increase in hospital costs


The H.A.P.O. StudyTranslating Evidence Into Best Practice:

Hyperglycemia Adverse Pregnancy Outcome (H.AP.O. Study)Research Findings Implications for Practice Best Practice (Action Step)

Obese women without history of elevated GTT or GD are at an increased risk for delivering a macrosomic or LGA infant

Macrosomia and LGA are associated with C/S, shoulder dystocia, birth trauma, and increased need for NICU

The NICU should be notified when obese mothers are admitted to labor and delivery and when birth is expected

The HAPO Study Cooperative Research GroupN Engl J Med 2008; 358:1991-2002 May 8, 2008 DOI: 10.1056/NEJMoa0707943

Jorgensen AM NICU Currents June 2010, volume1, Issue 1.



Maternal hyperglycemia, with levels below those diagnostic of GD is associated with fetal hyperinsulinemia

Fetal hyperinsulinemia has a well known association with delayed surfactant synthesis and excretion, which may result in respiratory distress syndrome

Infants of obese mothers, especially LPI (born 34-36 6/7 weeks gestation) should be carefully monitored for signs and symptoms of respiratory distress syndrome





Infants of obese women are at an increased risk for neonatal hypoglycemia

Fetal hyperinsulinemia is well known to result in neonatal hypoglycemia. Glucose is the primary fuel for the newborn brain. Prolonged neonatal hypoglycemia can result in jitteriness, hypotonia, lethargy, respiratory distress, cyanosis, seizures and neurodevelopmental impairment.

Infants of obese mothers should be closely monitored for hypoglycemia, beginning at 1-2 hours after birth and extended through the first day of life if warranted





Maternal hyperglycemia is associated with fetal hyperinsulinemia and hyperbilirubinemia

Fetal hyperinsulinemia drives catabolism of the oversupply of fuel, uses energy and depletes O2 stores resulting in fetal RBC hyperplasia and increased hematocrit

Infants of obese mothers should have bilirubin screening and continued monitoring and follow-up after discharge, if warranted





Obese women without history of elevated GTT or GD are at an increased risk for delivering a macrosomic or LGA infant

Macrosomia and LGA are associated with C/S, shoulder dystocia, birth trauma, and increased need for NICU

The NICU should be notified when obese mothers are admitted to labor and delivery and when birth is expected

Maternal hyperglycemia, with levels below those diagnostic of GD is associated with fetal hyperinsulinemia

Fetal hyperinsulinemia has a well known association with delayed surfactant synthesis and excretion, which may result in respiratory distress syndrome

Infants of obese mothers, especially LPI (born 34-36 6/7 weeks gestation) should be carefully monitored for signs and symptoms of respiratory distress syndrome



Maternal Obesity Impact on Infants

“By the time pregnancy is generally diagnosed, the fetus already has been exposed to the potentially “toxic metabolic environment” that is seen with obesity, and impaired organogenesis may have already occurred. Additionally, the degree of weight loss required to substantially modify important health parameters (blood pressure, blood glucose, and lipid levels) cannot occur safely in pregnancy without concern for the fetus. It cannot be overstated that the ideal time for intervention is before conception”.


Nodine PM & Tolsema MH Maternal obesity: improving pregnancy outcomes MCN 2012 37(2);110-115.

Fat Cells Release FFAs + Plasminogen-activator Inhibitor-1

↑ FFAs → Liver Produces More Glucose/Triglycerides + Pancreas ↑ Insulin Secretion

Hyperinsulinemia + Insulin Resistance

Hyperinsulinemia + ↑ FFA’s Contribute to Hypertension↑ Proinflammatory Cytokines

↑ Liver Production of Fibrinogen Prothrombotic State

Hyperlipidemia + ↑ Circulating Glucose + Insulin Resistance + Pro-inflammatory State

↑

↑

Placental Dysfunction

↑

↑

↑

Obesity and Congenital AnomaliesObesity and Congenital Anomalies

Overweight Obesity

Congenital Anomaly ADJ OR (95% CI) P Value ADJ OR (95% CI) P Value

Neural Tube Defects 1.2 (1.04-1.38) .01 1.87 (1.62-2.15) <.001

CV Anomalies 1.17 (1.03-1.34) .02 1.3 (1.12-1.51) .03

Cleft Lip and Palate 1.0 (0.87-1.15) >.99 1.2 (1.03-1.4) .02

Anorectal Atresia 1.19 (0.91-1.54) .2 1.48 (1.12-1.97) .006

Craniosynostosis 1.24 (0.98-1.58) .07 1.18 (0.89-1.56) .25

Diaphragmatic Hernia 0.95 (0.72-1.26) .72 1.28 (0.95-1.71) .1

Gastroschisis 0.83 (0.39-1.77) .63 0.17 (0.1-0.3) <.001

Adapted from Stothard KJ, Tennant PW, Bell R, Rankin J. JAMA. 2009;301:636–650 Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.

Obesity and Congenital AnomaliesObesity and Congenital Anomalies

Overweight Obesity

Congenital Anomaly ADJ OR (95% CI) P Value ADJ OR (95% CI) P Value

Hydrocephaly 1.28 (0.93-1.75) .13 1.68 (1.192.36) .003

Hypospadius 1.13 (0.94-1.35) .21 1.08 (0.86-1.34) .52

Limb Reduction 1.22 (0.97-1.53) .09 1.34 (1.03-1.73) .03

Microcephaly 1.21 (0.85-1.73) .3 1.10 (0.82-1.48) .54

Micro/anotia 0.97 (0.69-1.37) .86 1.11 (0.75-1.63) .61

Esophageal Atresia 0.89 (0.66-1.21) .46 1.27 (0.60-2.67) .54

Adapted from Stothard KJ, Tennant PW, Bell R, Rankin J. JAMA. 2009;301:636–650 Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.

Maternal Obesity and the Newborn• Infants Born to Obese Mothers

– Increased risk • Fetal or neonatal death

– Late fetal death (> 28 weeks) 4X greater than infants born to normal-weight women

– Twice as likely to die in first year of life

• For delivery room resuscitation requiring bag and mask or intubation

– NICU admission (~3.5 to 5.0 times more likely)– LOS

• Etiology probably multifactorial– Endogenous hyperinsulinemia →Rapid fetal growth →

Functional placental insufficiency → Relative fetal hypoxia Jorgensen AM NICU Currents June 2010, volume1, Issue 1 ANHI.

Infants of Diabetic Mothers

• Diabetes Mellitus– Type I: Insulin Dependent

• Genetic/environmental influences/auto-immune• Destruction of pancreatic β cells

– Type 2: Non-Insulin Dependent• Insulin resistance; impact of advancing age, obesity,

previous history of gestational diabetes

– Type 3: Gestational Diabetes• Increase glucose levels/intolerance during pregnancy• Disappears after pregnancy; 35-60% go on to Type 2Rubarth, L. B. (2013).Back to basics: infants of diabetic mothers Neonatal Network, 32(6), 416-418.

Infants of Diabetic Mothers

• Maternal/Neonatal Mortality Rates

Rubarth, L. B. (2013).Back to basics: infants of diabetic mothers Neonatal Network, 32(6), 416-418.

Type 1 Diabetes

Gestational Diabetes

No Glucose Issues

Delivery <37 weeks 21.0% 8.6% 5.1%Stillbirth 1.5% 0.4% 0.3%RDS 1.0% 0.3% 0.2%LGA 31.0% 15.1% 3.6%Erb’s Palsy 2.1% 0.7% 0.2%

Infants of Diabetic Mothers• Macrosomia


1• Maternal hyperglycemia• Glucose – not insulin –crosses the placenta• Fetal hyperglycemia

2 • Increased fetal insulin production• Pancreatic islet cell hyperplasia• Fetal hyperinsulinemia

3• Insulin is a growth hormone• Hyperinsulinemia accelerates

growth/macrosoma• Enlarged liver, spleen, heart, ↑ hepatic

fat/glycogen stores

Complications in IDMs


Complication Associated Problems

Macrosomia • ↑C/S delivery for failure to descend• LGA• ↑Birth trauma (fractures, palsy)• Cardiomegaly• Cardiac septal hypertrophy

Metabolic Abnormalities • Hypoglycemia• Hypocalcemia• Hypomagnesemia

Relative Hypoxia • Polycythemia/hyperviscosity• Renal vein thrombosis• Hyperbilirubinemai

Respiratory Distress Syndrome • Surfactant deficiency• Flaring, retractions, grunting

Complications in IDMs


Complication Associated Problems

Congenital Anomalies• Glucose as a teratogen• Seen in 4-12% of IDMs born to

Type I mothers

• Neural tube defects• Caudal or sacral agenesis• Cardiac defects (VSD, septal hypertrophy)• Small left colon syndrome• Genitourinary abnormalities

Outcomes • Multifactorial, cumulative effects• Anomalies resulting in death, morbidity asphyxia, hyperviscosity, hypoxemia, and metabolic acidosis at delivery• Persistent hypoglycemia resulting in

neurodevelopmental issues

Long Term Impact of Maternal Obesity • Center for Disease Control and Prevention

About 2 percent of American Schoolchildren were diagnosed with autism disorders in 2011 and 2012,

a 72 percent increase from the previous five years. The current data show that 1 in 50 children have been

diagnosed with autism or a related disorder.

Center for Disease Control and Prevention, March 20, 2013

http://www.google.com/url?sa=i&rct=j&q=autism&source=images&cd=&cad=rja&docid=tP3xQjCanvvq3M&tbnid=uFkxr5fLBPsbxM:&ved=0CAUQjRw&url=http://www.matthewreardon.org/resources/autism-a-l-a-r-m/&ei=QZdKUbOtJI3K9QTH1oC4BA&bvm=bv.44158598,d.eWU&psig=AFQjCNGtx4xw5iKwkVUKLDcnF7exPXoh8A&ust=1363929242350858

Long Term Impact of Maternal Obesity • UC Davis MIND Institute

– Over 60 percent of U.S. women of childbearing age are overweight; 34 percent are obese; and 16 percent have metabolic syndrome

– Nearly 9 percent of U.S. women of childbearing age are diabetic, and more than 1 percent of U.S. pregnancies were complicated by chronic hypertension

– Found strong links between maternal diabetes and obesity and the likelihood of having a child with autism spectrum disorder (ASD) or another developmental disorder

Krakowiak P, et al. Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders. Pediatrics, April 2012 DOI: 10.1542/peds.2011-2583

http://dx.doi.org/10.1542/peds.2011-2583

Long Term Impact of Maternal Obesity• UC Davis MIND Institute

– Included 1,004 mother/child pairs – Enrolled in the Childhood Autism Risks from

Genetics and the Environment Study (CHARGE) between January 2003 - June 2010

– Children between 24 and 60 months old, born in California and resided with at least one biological parent who spoke either English or Spanish



Long Term Impact of Maternal Obesity• UC Davis MIND Institute

– Relationship of maternal metabolic conditions & risk of neurodevelopmental disorders

– Mothers who were obese• 67 percent more likely to have a child with ASD than

normal-weight mothers without diabetes or HTN• More than twice as likely to have a child with another

developmental disorder



Long Term Impact of Maternal Obesity

• UC Davis MIND Institute– Relationship of maternal metabolic conditions & risk

of neurodevelopmental disorders– Mothers with diabetes

• Nearly 67 percent more likely to have a child with developmental delays as healthy mothers

• Children of diabetic mothers who had ASD were more disabled - greater deficits in language comprehension and adaptive communication




• UC Davis MIND Institute


“Over a third of U.S. women in their childbearing years are obese, and nearly one-tenth have gestational or type 2 diabetes

during pregnancy. Our finding that these maternal conditions may be linked with neurodevelopmental problems in children raises concerns and therefore may have serious public-health

implications. And while the study does not conclude that diabetes and obesity cause ASD and developmental delays, it suggests that fetal exposure to elevated glucose and maternal

inflammation levels adversely affect fetal development."


Hypoglycemia Screening

• Neonatal Glucose Homeostasis In Utero– Glucose main energy source for fetus– Facilitated transfusion from mother to fetus– Insulin does not cross the placenta– Fetal glucose levels reflect maternal levels– Fetus producing insulin at 13 weeks gestation– Unused glucose stores in the liver as glycogen– Birth disrupts maternal-fetal glucose transfer– Umbilical venous plasma glucose ~ 60-80% of maternal

Gustafsson J Indian Journal of Medical Research 2009; 130:618Rozance P & Hay WW Early Human Development 2010:86:275


• Neonatal Glucose Homeostasis After Birth– Glycogenolysis stimulated– ↓ Levels of insulin coincide with ↑ levels of

catecholamines and glucagon• Full term 4-6 mg/kg/min • Fetus and preterm 8-9 mg/kg/min

– Fat mobilization• Full term 15% to 16% of body weight• Preterm infant 2% of body weight• Liver can only store 50 to 75 grams of glycogen per kilogram

equivalent of 200 to 300 caloriesGustafsson J Indian Journal of Medical Research 2009; 130:618Rozance P & Hay WW Early Human Development 2010:86:275


• Definition– Controversial

• Variables – SGA, IUGR, “stressed”• 40-ish• S.T.A.B.L.E. Program 50 mg/dL• “Symptomatic” vs. “Assymptomatic”

– “Whipple’s Triad”• Accurate measurement of a low blood glucose level• Presence of signs of hypoglycemia• Resolution of signs of hypoglycemia after rrestoration of a

normal blood sugar


• Jitteriness, irritability, or tremors

• Lethargy• Hypotonia• Temperature instability• High-pitched/ weak cry• Tachypnea• Apnea

• Poor suck, poor coordination of feeding

• Vomiting• Tachycardia/bradycardia• Cyanosis• Eye-rolling/Doll’s sign• Seizures• Coma

Clinical Presentation of Hypoglycemia in the Newborn

Management of Hypoglycemia• American Academy of Pediatrics (2012)

http://www.google.com/url?sa=i&rct=j&q=AAp+Algorithim+for+Postnatal+Glucose+Management&source=images&cd=&cad=rja&docid=nBEGJmIu4VUYTM&tbnid=TJClIUrMlIk29M:&ved=0CAUQjRw&url=http://vuneo.org/nplatepretermpathway.htm&ei=Sxg-Ua7hFIaHywGCwIDAAQ&bvm=bv.43287494,d.aWc&psig=AFQjCNEoZ4_TAMGl15iZM6xQ2t0RYYlCsQ&ust=1363110344840609

Management of Hypoglycemia

• Treatment of Symptomatic Neonatal Hypoglycemia– AAP

• IV glucose initiated immediately for infants with symptomatic hypoglycemia

• To achieve a plasma glucose level of 40-50 mg/dL – 200 mg/kg (dextrose 10% at 2 mL/kg) or – IV infusions of 5-8 mg/kg/min (80-100 mL/kg per day)

• Blood glucose should be checked every 30-60 minutes after the start of therapy

• Glucose therapy decreased gradually as enteral feedings advanced

• If higher concentration of glucose required – central line

Management of Hypoglycemia

• Treatment of Resistant Neonatal Hypoglycemia– Persistent Glucose Levels Below 40 mg/dL

• Evaluate for hyperinsulinemic hypoglycemia• If higher concentration of glucose required – central line• Obtain insulin levels• Consult endocrinology• Potential medications:

– Corticosteroids– Glucagon– Diazoxide

Milic T & Nash P Neonatal Network 2008;27:203.

Wilker R: Hypoglycemia and hyperglycemia In: Cloherty J, Eichenwald E, Stark A, eds. Manual of Neonatal Care ed.6. Philadelphia: Lippincott Williams & Wilkins, 2008..

The H.A.P.O Study

• Increased Maternal Glucose Concentration– 25,505 pregnant women at 15 centers in 9 countries– 75-g oral glucose-tolerance testing at 24-32 weeks– “Clarify risk of maternal glucose intolerance less

severe than that in overt diabetes”


The H.A.P.O Study

• Increased Maternal Glucose Concentration– Found associations between increasing levels of fasting, 1-

hour, and 2-hour plasma glucose obtained on oral glucose-tolerance testing and

• BW > than 90th percentile• Cord blood serum C-peptide level > than 90th percentile

– Weaker associations• Primary cesarean section delivery• Clinical neonatal hypoglycemia• Premature delivery, shoulder dystocia or birth injury, neonatal

intensive care, hyperbilirubinemia, and preeclampsiaThe HAPO Study Cooperative Research Group

N Engl J Med 2008; 358:1991-2002 May 8, 2008 DOI: 10.1056/NEJMoa0707943

What Happens Here…

• “Programming”– The term "programming"

refers to the concept that an insult or stimulus applied at a critical or sensitive period may have long-term or lifetime effects on the structure or function of an organism

Lucas A Journal of Perinatology (2005) 25, S2–S6. doi:10.1038/sj.jp.7211308

Virtually all forms of organ injury

start with molecular or

structural alteration in cells.

PL Pokorski University of Michigan Department of Natural Sciences


• Long Term Health Outcomes

“Recently, mounting epidemiologic evidence suggests that infants of obese mothers are at greater risk for lifelong metabolic complications that include diabetes mellitus, heart disease, and obesity through intriguing mechanisms of “in-utero programming” of adult disease.”

Hypotheses Linking Early Events/Risk of Obesity

Koletzko,B Impact of Maternal Obesity on Long-Term Health Outcomes 112th Abbott Nutrition Research Conference Pregnancy Nutrition and Later Health Outcomes www.ANHI.org

Benefit of Breastfeeding in Reducing Obesity

Koletzko,B Impact of Maternal Obesity on Long-Term Health Outcomes 112th Abbott Nutrition Research Conference Pregnancy Nutrition and Later Health Outcomes www.ANHI.org

Maternal Obesity and Breastfeeding

Translating Evidence Into Best PracticeResearch Findings Research Study Best Practice

Fewer obese women initiated breast feeding, compared to normal weight women

Donath & Amir, 2000Li, Jewel & Grummer-Strawn, 2003

Obese women need educational efforts aimed at promoting breast feeding

Obese women breastfed their infants for less time (weeks and months), compared to normal weight women

Oddy et al, 2006Li, Jewel, & Grummer-Strawn, 2003

Early and on-going lactation support should be provided for all obese mothers



Translating Evidence Into Best PracticeResearch Findings Research Study Best Practice

Obese women are more likely to have delayed onset of lactogenesis (defined as milk coming in > 72 hours after birth), compared to non-obese women

Hilson, Rasmussen, & Kjolhede, 2004

Because delayed lactogenesis may pose a significant risk for dehydration, thermal stability, hypoglycemia, and extreme hyperbilirubinemia, exclusively breastfed infants of obese mothers, especially those born LPI should have

Jorgensen AM NICU Currents June 2010 volume1, Issue 1. ANHI


Translating Evidence Into Best PracticeBest Practice

Because delayed lactogenesis may pose a significant risk for dehydration, thermal stability, hypoglycemia, and extreme hyperbilirubinemia, exclusively breastfed infants of obese mothers, especially those born LPI should have:

• Glucose screening at 1-2 hours of life and continued monitoring if warranted• Bilirubin screening at 48 hours of life and continued monitoring if warranted• Daily weight assessment and weight loss criteria: LPI – weight loss < 7% of birth weight Term infants – weight loss < 10% of birth weight• Infants of obese mothers may require supplementation banked human milk feeding

or formula until the mother’s breast milk is enough to meet the infant’s nutritional requirements

Jorgensen AM NICU Currents June 2010 volume1, Issue 1. ANHI


“The practitioner of contemporary obstetrics needs no

“p value” or “relative risk” statistics to be keenly aware of the

prevalence of obesity within the pregnant population and the

complications and challenges that are posed by obesity in the care of

these patients.”Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.

http://www.google.com/url?sa=i&rct=j&q=medical+risks&source=images&cd=&cad=rja&docid=1Kh_HfrvKvt6oM&tbnid=N7z4l6oHJKVAiM:&ved=0CAUQjRw&url=http://barbarabrenner.net/?p%3D136&ei=7rs9UYbxDIWbygGfgoG4DA&bvm=bv.43287494,d.aWc&psig=AFQjCNEhRf9OMEsecg9thUKpKDX-WrISIQ&ust=1363086672221604

Presenter

Terry S. Johnson, APN, NNP-BC, CLEC, MN

Neonatal Nurse PractitionerFounder, Lode Star Enterprises, Inc.7709 Knottingham Lane Downers Grove, IL 60516

Phone: 630.881.2606Email: [email protected]

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“Double Jeopardy” The Impact of Maternal Obesity on Mother and Infant Outcome Terry S. Johnson,...

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