Obesity and pregnancy

09.12.2016

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Obez Gebelerde Obstetrik Sorunlar

Dr Tevfik YoldemirMarmara Üniversitesi Tıp Fakültesi Kadın Hastalıkları ve Doğum A.D.

Üreme Endokrinolojisi ve İnfertilite B.D.

[email protected]

classification

Obesity related risks Maternal Complications

• Hypertensive Disorders of Pregnancy

• a twofold increase in risk for mild or severe preeclampsia for overweight women (BMI 25.0–29.9),

• approximately a threefold increase for obese women (BMI 30.0–34.9), and

• a fivefold increase in the risk for preeclampsia for severely obese women (BMI 35.0–39.9)

Medical Journal of Australia, 2006;184, 56–59.

Epidemiology, 2007:18(2), 234–239. Obstetrics and Gynecology, 2004;103, 219–224.

• Evidence from the Framingham Heart Study, a prospective population-based cohort study, demonstrated that hypertension and coronary artery disease were more common in obese and

overweight individuals at all ages.

• Relative risk (RR) for hypertension in overweightadults was found to be 1.5 to 1.7.

• RR was found to be 2.2 to 2.6 for obese adults.

• It is important to establish baseline blood pressure values in early pregnancy, and care should be taken to use properly properly sizedsized blood pressure cuffs blood pressure cuffs in order to ensure accurate measurements.

• Additionally, evaluation of end-organ effects of hypertensive disease, such as heart failure or nephropathy, should be considered.

• Comprehensive evaluation of cardiac function may require electrocardiographic orelectrocardiographic or echocardiographicechocardiographic testingtesting.

• Renal function is commonly assessed by a 2424--hour urinehour urineevaluation to measure total protein excretion.

Journal of the American Medical Association, 2003:290, 199–206.

Blood Pressure Monitor, 2001: 6, 17–20.

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Diabetes Mellitus

• The second trimester of pregnancy is a physiologic stateof insulin resistanceinsulin resistance. Hormones produced by the placenta lead to mild levels of maternal hyperglycemia in order to promote adequate fetal growth and

development.

• Most gravidas adapt readily to this event. In somewomen, however, pancreatic insulin secretion is not adequate to counter the diabetogenic hormones.

• Women who have normal serum glucose levels prior to pregnancy demonstrate abnormally high postprandial and fasting serum glucose levels during pregnancy.

Gestational diabetes

• This transient disease process is known as gestational diabetes.

• Preeclampsia, disordered fetal growth, neonatal metabolic complications such as hyperbilirubinemia

and hyperglycemia, and even fetal death are the adverse effects.

• Adipocytes participate in several important signaling pathways that influence insulin sensitivity in the peripheral tissues. As a result, obese women are at increased risk for developing gestational diabetes.

American Journal of Physiology, 2001: Endocrinology and

Metabolism, 280, E827–E847

Gestational diabetes

• The relative risk of developing gestational diabetes

in obese women (prepregnancy BMI 25 to 30) was reported to be 1.68 (99% confidence interval [CI] 1.53 to 1.84)

• severely obese women (prepregnancy BMI greater than 30) to be 3.6 (99% CI 3.25 to 3.98)

International Journal of Obesity Related Metabolic Disorders,25, 1175–1182

• Obese women (BMI greater than 29) demonstrated a relative risk for developing gestational diabetes of 4.53 (95% CI 1.25 to 16.43).

American Journal of Epidemiology, 2007:165, 302–308.

Diabetes

• weight gain between the age of 18 years and the study pregnancy of greater than or equal to 10

kilograms conferred a relative risk of 3.43 (95% CI 1.60 to 7.37) when compared with women who had

less than a 3-kilogram weight change over the same period

American Journal of Epidemiology, 2007:165, 302–308

• A linear relationship exits between increasing BMI and increasing incidence of diabetes.

Diabetes

• Even after adjusting for family history, levels of exercise, and dietary habits, the relative risk of future development of type II diabetes was 11.2 for women in the top tenth percentile of BMI when compared

with women in the lowest tenth percentile.

• The relative risk for a diagnosis of diabetes during

pregnancy for overweight women (prepregnancyBMI 25 to 30) was found to be 3.4 (95% CI 1.7 to 6.8)

and for severely obese women (prepregnancy BMIgreater than 30) was found to be 15.3 (95% CI 8.2 to 28.6) when compared with normal weight women

The Nurses’ Health Study. American Journal of Epidemiology, 1997:145, 614–619

Obstetrics and Gynecology, 2005:105, 537–542

• A large number of obese women may in fact have undiagnosed Type II diabetes, which is manifest by abnormal glucose tolerance testing prior to 20 weeks of gestation.

• For obese women who develop gestational diabetes, promoting tight controltight control of blood glucose of blood glucose values optimizes both maternal and fetal outcomes.

• The most successful management approaches are multidisciplinarymultidisciplinary and include physicians, nurse-educators, and dietitians.

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Nutrition & Weight Gain

• those with a high prepregnancy BMI were more than four times as likely to report target gains above IOM guidelines.

• weight gains above the IOM recommendations were observed for

• 23% of the underweight women,

• 49% of the normal weight women,

• 70% of the overweight women, and

• 57% of the obese women.

Obstetrics and Gynecology, 2005;105, 633–638

Obstetrics and Gynecology, 1995; 86, 170–176.American Journal of Public Health, 1997;87, 1984–1988

• 30% weighed less one year after delivery than they did before pregnancy, 56% gained 0 to 5 kilograms over the same time period, and 14% gained more than 5 kilograms.

• Risk factors for postpartum weight retention in thisstudy were excessive pregnancy weight gain, high

prepregnancy BMI, and maternal age greater than

36 years

• It appears that overweight and obese women are at increased risk for excessive pregnancy weight gain

and elevated postpartum weight retention.International Journal of Obesity, 1990;14, 159–173.

Fetal Complications

• Macrosomia

• It is associated with shoulder dystocia, birth trauma,

and/or Cesarean delivery.

• ACOGs recommendation for the term fetal macrosomia, on the other hand, is that it should be reserved for those infants weighing more than 4,000 or 4,500 grams at birth

ACOG Technical Bulletin Number 22–November 2000.

Obstetrics and Gynecology, 96, 341–345.

• Factors that may predispose to fetal macrosomiainclude: pregestational or gestational diabetes, prepregnancy maternal obesity or overweight

status, excessive weight gain during pregnancy,

multiparity, male fetus, as well as constitutional factors such as ethnicity, maternal birth weight, and maternal height.

• Increasing maternal weight is an independent

variable for a macrosomic or large for gestational

age infantAmerican Journal of Obstetrics and Gynecology, 2004; 191, 964–968.

Obstetrics and Gynecology, 2003;102, 1022–1027.

• odds ratios for large for gestational age infants to be increased for women with

• a BMI 29.1 to 35 OR 2.20 (95% CI 2.14 to 2.26),

• a BMI 35.1 to 40 OR 3.11 (95% CI 2.96 to 3.27), and

• women with a BMI greater than 40 OR 3.82 (3.56 to 4.16).


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Congenital anomalies

• The overall incidence ranges from 2 to 4% of all pregnancies.

• The most common anomalies are neural tube

defects, congenital cardiac malformations, orofacial

clefts, and Trisomy 21.

• Obese women are at higher risk for having an infantwith congenital cardiac defects, orofacial clefts, andneural tube defects.

Morbidity and Mortality Weekly 2006;Report, 54, 1301–1305.

American Journal of Obstetrics and Gynecology, 1994;170, 541–548Paediatric Perinatal Epidemiology, 2000;14, 234–239.

• Obese women (BMI greater than or equal to 30) were more likely to have an infant with a neural tube

defect (OR: 3.5, 95% CI: 1.2 to 10.3), omphalocele

(OR: 3.3; 95% CI: 1.0 to 10.3), heart defects (OR: 2.0;

95% CI: 1.2 to 3.4), or multiple anomalies (OR: 2.0; 95% CI: 1.0 to 3.8).

• Overweight women (BMI 25 to 29.9) also were more likely than average-weight women to have infants

with heart defects (OR: 2.0; 95% CI: 1.2 to 3.1) and multiple anomalies (OR:1.9; 95% CI: 1.1 to 3.4).

Pediatrics, 2003;111, 1152–1158

• The rate of incomplete or suboptimalincomplete or suboptimal visualization visualization of the fetal cardiac structures was as high as 37.3% in obese women, compared with only 18.7% in average-weight women.

• Similar findings were documented for craniospinal

structures, with a suboptimalsuboptimal visualization visualization rate of 42.8% compared with 29.5% in average-weightwomen

International Journal of Obesity Related Metabolic Disorders, 2004; 28, 1607–1611

Fetal Demise

• Fetal problems, including congenital anomalies,account for 25% of antepartum fetal deaths.

• Maternal problems, including preeclampsia anddiabetes, account for another 10%.

• Placental or umbilical cord problems such as

placental abruption or true knots in the umbilical cord account for 25% to 30% of intrauterine fetal

deaths.

• The odds ratio of 2.7 (95% CI 1.5 to 5.0) for the risk of fetal death in overweight women (BMI 25.0 to 29.9), and 2.8 (95% CI, 1.3 to 6.0) for obese women (BMI greater than or equal to 30) were reported.

American Journal of Obstetrics and Gynecology, 2001;184, 463–469.

• An odds ratio of 2.8 (95% CI: 1.5 to 5.3) for stillbirth

in obese gravidas compared with women of normal weight was detected.

British Journal of Obstetrics and Gynecology, 2005;112, 403–408

Childhood obesity• Barker hypothesis

• There is also a well-established link between maternal obesity and large for gestational age

infants, who are also at increased risk for developing obesity later in life.

• dysregulation of central nervous system control of appetite regulation,

• peripheral changes in insulin sensitivity and

• alterations in pancreatic response to hyperglycemia.

Obesity Research, 2003;11, 496–506.

Clinical Science, 1998; 95, 115–128.Obstetrics and Gynecology, 1998; 91, 97–102

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Intrapartum Complications

• Induction of Labor

• higher incidence of medical comorbidities such as hypertension and diabetes, as well as a higher

incidence of post-dates pregnancy

• Failure of induction of labor in morbidly obese

gravidas (weight greater than 120 kilograms at initiation of prenatal care) as 40%, which was

significantly higher than the rates of 19% for womenwith normal weight (55 to 75 kilograms)

British Journal of Obstetrics and Gynecology, 2005;112, 768–772.


• Obese women demonstrate abnormalities in the second stage of labor more frequently, and require operative assistance due to soft tissue dystocia and poor maternal pushing efforts more frequently than

women with normal BMI.

• Obese women are less likely to have a successful medical induction of labor and may require an operative delivery

American Journal of Obstetrics and Gynecology, 2004; 91,928–932.

Cesarean Delivery

• 386 obese women (BMI 30 to 34.9) and 196 morbidly obese (BMI greater than or equal to 35) nulliparous women demonstrated Cesarean delivery rates of 33.8% and 47.4%, respectively.

• These rates were significantly higher than the Cesarean delivery rate of 20.7% in nulliparouspatients with normal BMI

British Journal of Obstetrics and Gynecology, 2005; 112, 768–772.

Obstetrics and Gynecology, 2005;106, 1357–1364.American Journal of Obstetrics and Gynecology, 2004;91,928–932.


Paediatric Perinatal Epidemiology, 2004;18, 196–201.

• For obese women requiring Cesarean deliveryCesarean delivery, and particularly those with co-existing medical conditions, consideration should be given to placement of an arterialarterial lineline for accurate assessment

of hemodynamic status.

• This is particularly important since operative deliveryis more complicated in the obese patient as operative times tend to be longer and blood loss

greater

•• SSupraupra--umbilical incisionsumbilical incisions to decrease rates of woundseparation and infectious morbidities.

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•• DDrains rains are recommended when the subcutaneous space was greater than or equal to 2 cm.

• Obese women are at increased risk of airway

complications, cardiopulmonary dysfunction,

perioperative morbidity and mortality, and also pose technical anesthesia challenges

•• Epidural analgesia Epidural analgesia can be successfully used in obesepatients, but the placement of the epidural cathetermay be complicated by improper positioning and difficulty identifying the midline in very obese women

Anaesthesia, 2006;61, 36–48.


• The incidence of difficult intubation in pregnant women over 136 kg was reported in one retrospective case-control study to be as high as 35%, compared with 0% among normal-weight

women

Anesthesiology, 1993;79, 1210–1218.

• a rate of 80% for successful trial of labor successful trial of labor in women weighing less than 90 kg, with rates decreasing to 57% for women weighing 90 to 136kg and a rate of vaginal delivery of only 13% in women weighing more than 136 kg

American Journal of Obstetrics and Gynecology,2003;188,1516–1520.

Shoulder Dystocia

• Dystocia is a rare complication, occurring in approximately0.5% to 1.5% of vaginal deliveries


• Maternal obesity, because of its relationship with higher rates of fetal macrosomia and gestational diabetes, has consistently been found to be a predisposing factor for

shoulder dystocia.

Journal of Midwifery and Womens Health, 2005:50, 485–497.

American Journal of Obstetrics and Gynecology, 1993;168,1732–1737

European Journal of Obstetrics, Gynecology and Reproductive Biology,2006;126,11–15

Acta Obstetricia Et Gynecologica Scandinavica, 2006; 85, 567–570

Fetal Monitoring

•• Proper placement of the transducers Proper placement of the transducers for fetal heart rate and maternal uterine activity assessment and/or maintenance of an adequate tracing may be difficult in women with central obesity and an unusually thick

anterior abdominal wall or a large abdominal pannus

• During labor, there can be similar problems obtaininga continuous fetal heart rate tracing continuous fetal heart rate tracing with externalfetal heart rate monitors for very obese women.

•• InternalInternal fetal scalp electrodes fetal scalp electrodes should be considered if there is an inability to adequately document fetal well-being.

Postpartum Complications

• Tromboembolism

• obesity (BMI greater than 30) conferred an additional risk for thromboembolic events with an

odds ratio of 4.4 (95% CI 3.4 to 5.7).American Journal of Obstetrics and Gynecology, 2006;194, 1311–1315.

• both overweight status (BMI 25–29.9) and obesity

(BMI greater than 30) conferred an additional risk, with odds ratios 1.8 (95% CI 1.3 to 2.5) and 2.0 (95% CI 1.3 to 3.1)

Seminars in Perinatology, 2002; 26,42–50.

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• Medical conditions that predispose to thromboembolic events during pregnancy include diabetes, hypertension, heart disease,

antiphospholipid syndrome, lupus, sickle cell disease,

inherited thrombophilias, and a history of a previous

thromboembolic event

Wound Disruption and Infection After Cesarean Delivery

• Postpartum infectious complications are quite common; endometritis affects approximately 4% to 6% of delivered women and wound infection complicates 2% to 16%.

• Patient characteristics that pose additional risk for surgical site include many conditions more commonly found in obese gravidas such as prolonged labor,

diabetes, anemia, smoking, and poor nutritional status.

• Abdominal wall thickness greater than 3 cm, more frequently found in obese women, is associated with almost a three-fold increase in risk for postoperative wound infection

Nursing Standard, 2007;21, 57–58, 60, 62


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Health & Medicine

Obesity and pregnancy