Obesity in pregnancy

Obesity in pregnancy: Complications and maternal management

Summary of Literature review in Nov 2016 from UpToDate.com

Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST

Hashem Yaseen MBBS 4th year OG resident


INTRODUCTION

Pregnancy-specific definition of obesity??

The prevalence - varies widely ( > black)

In northern Jordan was 53.1% for women

~ Pubmed 2010

Increase risk of childhood and adult obesity


PATHOBIOLOGY

Dysregulatory effects on metabolic, vascular, and inflammatory pathways (e.g. obesity-related insulin resistance – preeclampsia)

Maternal genotype Fetal exposure to increased levels of

glucose, lipids, and inflammatory cytokines → Epigenetic changes

(fetal origins of adult disease theory [Barker hypothesis])


POTENTIAL ISSUES IN PREGNANCY

Antepartum

Intrapartum

Postpartum

Offspring



Antepartum

• Early pregnancy loss • Occult type 2 diabetes

• Gestational diabetes• Pregnancy associated hypertension • Indicated and spontaneous preterm

birth• Post-term pregnancy • Multifetal pregnancy

• Obstructive sleep apnea • Carpal tunnel syndrome



Intrapartum

• Induction • Progress of labor

• Cesarean delivery • Trial of labor after cesarean

delivery • Difficulties with anesthesia

• Complications related to macrosomia



Postpartum

• Venous thromboembolism

• Infection • Postpartum depression



Offspring

• Congenital anomalies • Death

• Prematurity • Large for gestational age

• Asthma • Childhood obesity

• Neurodevelopment


PRE-PREGNANCY MANAGEMENT

PREGNANCY MANAGEMENT


PREPREGNANCY MANAGEMENT

Preconception counseling, evaluation, and care:

●Information about:1. the adverse effects of obesity on fertility2. the potential pregnancy complications

associated with obesity●Evaluation for obesity-associated medical

comorbidities ●Counseling about the benefits of weight loss

before attempting to conceive


PREPREGNANCY MANAGEMENT

Prepregnancy weight loss: Diet, exercise, behavior modification Possibly adjunctive medical therapy

(should not be used during pregnancy) Bariatric surgery, if indicated→ beneficial effects on reproductive function, pregnancy

outcome, and overall health



First trimester:•Baseline assessments•Counseling •Gestational weight gain• Exercise •Fetal aneuploidy screening•Referrals

Second trimester:Low-dose aspirinFetal ultrasound

survey Screening for

gestational diabetes

Third trimester :Assessment of fetal

growth Assessment of fetal well-

being External cephalic version

Delivery and labour:•Equipment and instruments •Fetal monitoring •Anesthesia consultation•Timing and route of delivery




First trimester Baseline assessments1. Maternal weight and body mass index (BMI).2. Blood pressure using an appropriately sized cuff3. Early ultrasound -> gestational age \ a multifetal

gestation4. Medication review, oral anti-hyperglycemic drugs, which

are often discontinued in favor of insulin therapy. 5. Diabetes screening 6. Consider quantitative urine protein, KFT, platelet count,

and liver function tests -> (Baseline values evaluation for preeclampsia. Obesity is a known risk factor for nonalcoholic fatty liver disease (NASH). )

7. Bariatric surgery -> evaluate for and treat nutritional deficiencies



First trimester Counseling:1. pregnancy risks associated with obesity 2. diet 3. gestational weight gain 4. Exercise } Review frequently

throughout pregnancy



First trimester Gestational weight gain :



First trimester Exercise: Pregnant women can initiate an exercise

program or continue most prepregnancy exercise programs, which can help control gestational weight gain



First trimester Fetal aneuploidy screening The same as that for the general Obese women are not at increased risk for fetal aneuploidy Obesity can affect screening test performance:1. Cell-free fetal DNA screening is more likely to result in test

failure.2. Serum-based screening tests are adjusted for maternal

weight; thus, obesity does not affect test performance 3. Accurate nuchal translucency measurement may be more

difficult to obtain -> (transvaginal probe)4. Diagnostic procedures (amniocentesis, chorionic villus

sampling) are more challenging technically -> (a low-frequency transducer \ vaginal probe in the umbilicus)



First trimester Referrals : If underlying cardiopulmonary disease is

suspected, cardiology or pulmonology referral should be considered for additional testing and diagnosis

To a sleep specialist ? (symptoms) To a registered dietician ?




Second trimester Low-dose aspirin : BMI ≥30 kg/m2, →moderate risk

factor for preeclampsia Obese women with additional risk

factors for development of preeclampsia may benefit from treatment with low dose aspirin (81 mg)

Other Moderate risk factors: 1. nulliparity,2. family history of

preeclampsia (mother or sister)

3. sociodemographic characteristics (African American race, low socioeconomic status)

4. maternal age ≥355. personal factors (eg, low

birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval)



Second trimester Fetal ultrasound survey: A detailed fetal anatomic survey is performed at 18 to 24

weeks Due to the limitations of ultrasound with increasing degrees of

obesity → concomitant use of maternal serum alpha fetoprotein to screen for neural tube and other relevant congenital defects

maternal obesity as not an indication for fetal echocardiography → unless the detailed obstetric ultrasound assessment of the heart was not optimal.



Second trimester Screening for gestational diabetes : Is recommended at 24 to 28 weeks of gestation Bariatric surgery → maternal dumping syndrome →

use different approach ?



PREGNANCY MANAGEMENT Third trimester

Assessment of fetal growth Clinical assessment vs Ultrasound assessment

Assessment of fetal well-being Although the frequency of fetal demise appears to be increased

in pregnancies of obese women, the value of antenatal fetal surveillance with nonstress tests or biophysical profile scoring in this setting has not been studied

External cephalic version obesity is not a contraindication to ECV, A successful ECV is

particularly beneficial in obese women, given the significant surgical risks of cesarean delivery in these patients.



PREGNANCY MANAGEMENT Labor and delivery

Equipment and instruments Ensure that the labor and delivery unit has appropriate physical

resources (eg, gowns, beds, operating room table) for caring for severely obese women.

Fetal monitoring Placement of an internal fetal scalp electrode Anesthesia consultation Evaluation by an anesthesiologist prior to labor or in early labor

is recommended for all obese parturients because of their higher risk of anesthetic complications. For patients planning a vaginal birth, early placement of an epidural or intrathecal catheter may obviate the need for general anesthesia if emergency cesarean is needed



Labor and delivery Timing and route of delivery Delivery by the estimated due date has been

recommended to reduce the risk of stillbirth and complications from continued fetal growth.

Acta Obstet Gynecol Scand. 2014 Jun;93(6):590-5. Epub 2014 Apr 30




Cesarean delivery Thromboprophylaxis : Use of pneumatic compression devices at the time

of cesarean delivery For obese women with additional risk factors for

venous thromboembolism, we suggest use of both pharmacologic and mechanical thromboprophylaxis (Grade 2C). ~ACOG

http://cursoenarm.net/UPTODATE/contents/._grade_6?title=Grade%202C



Cesarean delivery Antibiotic prophylaxis : Preoperative antibiotic prophylaxis for all women

undergoing cesarean delivery (Grade 1A) An appropriate dose of prophylactic antibiotics

should be administered based on maternal weight

Technical issues

http://cursoenarm.net/UPTODATE/contents/._grade_1?title=Grade%201A

OPERATIVE PROCEDURE 1

Type of incision: For women who weigh under 170 kg, we suggest a Pfannenstiel

incision if the pannus can be adequately retracted cephalad (Grade 2C). For women who weigh over 170 kg , we suggest a transverse supraumbilical incision with the pannus displaced caudally (Grade 2C)

Incision technique: When making the skin incision, attention to the distorted

landmarks in obese women is very important. The umbilicus is often anatomically directly over the lower uterine segment because the large pannus draws it caudally; however, the position of the symphysis pubis is reliable





Fascial closure: The fascia can be closed using a Smead-Jones or

comparable interrupted technique or mass continuous closure with nonabsorbable or slowly absorbable suture. This is especially important for supraumbilical incisions. Both approaches are equally effective for reducing the risk of dehiscence or hernia formation.



Mass closure of incisions


Subcutaneous closure: We recommend closure of subcutaneous tissue

greater than 2 cm thick (Grade 1A). We also recommend avoiding placement of subcutaneous drains (Grade 1A).

Skin closure: We suggest skin closure with staples rather than

stitches (Grade 2C).







PREGNANCY MANAGEMENT Postpartum:

If cesarean was performed, postcesarean care should be modified to reduce the risk of obesity-associated postsurgical complications.

Encourage breastfeeding and provide additional support. since obese women are prone to difficulty with lactation

Intrauterine contraception is safe and effective, and may be safer and more effective in this population than estrogen-progestin contraceptives, although the latter are also an acceptable choice

Women with a gestational diabetes should be screened for glucose intolerance 6 to 12 weeks after delivery.

Obesity in pregnancy: Complications and maternal management

Summary of Literature review in Nov 2016 from UpToDate.com


Hashem Yaseen MBBS 4th year OG resident

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Obesity in pregnancy

Health & Medicine