Managing Pregnancy and
Delivery for women with obesity
A/Prof Leonie Callaway
GOAL: A PRACTICAL OUTLINE
MATERNAL OBESITY IS IMPORTANT
AND COMMON
Queensland: Where Australia shines!
Maternal Obesity in Queensland
• 2006: 33% overweight and obese (Callaway et
al, MJA, 2006)
• 2008: 50.5% overweight and obese (QH
statbites)
Importance
• UK Confidential Enquiry into
Maternal and Child Health
• Obesity is a significant risk
factor for maternal
mortality
• 35% of all mothers who
died were obese (10-18.9%
of the UK obstetric
population are obese)
HOW DO WOMEN BECOME OBESE?
Reduced Physical Activity
Increased consumption
processed foods
Low breastfeeding rates
Social changes
Sleep debt
Endocrine disrupters
Decreased variability in
ambient temperatures
Decreased smoking
Increased use of steroids and
antipsychotics
Pregnancy at older age in
overweight women
Demographic changes with
older people, ethnic changes
Chronic stress
Micronutrient deficiency
Keith et al, Int J
Obesity, 2006
What do obese pregnant women eat?
Energy intake (n=50)
• 3 Day food recall, administered by trained
dieticians
• All participants were within 10% of
recommended daily caloric intake
Dietary intake of obese pregnant
women at 12 weeks gestation (n=50)
Serves / day
Recommended
Mean
St Dev
Minimum
Maximum
Breads & cereals
6
2.60
1.12
0.50
5.40
Vegetables
5
3.05
1.76
0.50
9.30
Fruit
3
3.06
2.21
0.00
9.80
Dairy
2
1.76
1.40
0.00
5.90
Meat &
alternatives
2
2.17
1.15
0.00
6.80
Extras
0-2
4.62
2.68
1.40
15.00
Dietary folate
(micrograms)
600
284
104
64
541
Croaker S et al, Nutrition and Dietetics, 2010.
THE COMPLICATIONS?
Maternal Complications
•
•
•
•
Thromboembolism
Hypertensive disorders of pregnancy
Gestational diabetes
Abnormal liver function tests
Obstetric Complications
•
•
•
•
Increased IOL
Higher rate of failed VBAC
Dramatically increased rates of C Section
Increased rates of complicated normal vaginal
delivery
– Shoulder dystocia
– Third/fourth degree lacerations
– Failure to progress
Anaesthetic Complications
• Epidural analgesia during labour is more likely
to fail as BMI increases
• General anaesthesia complicated by:
– Postpartum sleep apnoea
– Difficult intubation
Practical Difficulties
• Inaccurate assessment of growth, lie,
presentation
• Blood pressure cuffs/automated blood pressure
devices
• Vascular access
• Theatre beds/trolleys/staff
• Ultrasonography
• Monitoring during labour
Peripartum Neonatal Monitoring
• Maternal obesity associated with:
– Difficulties obtaining an adequate CTG
– Increased rates of fetal distress
– Increased rates of meconium aspiration
Perioperative complications
• Increased post partum haemorrhage
• Endometritis
• Wound breakdown and infection
Perinatal Complications
• Length of stay>5 days
– Overweight OR 1.36
– Class I and II Obese OR 1.49
– Class III Obese 3.18 (Callaway et al, 2006)
• For obese women:
–
–
–
–
–
–
Chest infection OR 1.34
Genital infection OR 1.3
Wound infection OR 1.34
UTI OR 1.39
PUO OR 1.29
Prolonged postnatal stay OR 1.48
(Sebire et al, 2001)
Neonatal Complications
•
•
•
•
Macrosomia
Lower rates of breastfeeding
Increased rates of congenital anomalies
Stillbirth, neonatal death
WHAT CAN WE DO ABOUT IT?
Interesting Issues from Guidelines
•
American College of O&G (2005)
– Height and weight measured in all
women
– Weight gain guidelines (IOM)
– Dietary advice
– Consider screen for GDM at
presentation
– Consider cardiac evaluation if BMI>35
– Anaesthetic consultation
– Careful thromboembolism prophylaxis
– If not pregnant –preconception
counselling, provision of information
regarding risk, weight loss prior to
pregnancy
•
RCOG Consensus View (2007)
– BMI should be measured in all pregnant
women, and weight measured at every
clinic visit; interpregnancy weight
change should also be recorded
– Diet, exercise and psychopathology
should be attended to
– Women with a BMI of over 35 should
not have infertility investigation or
treatment until their BMI is less than
35, and ART should be reserved for
women with a BMI under 30.
– Aspirin 75 mg/day from 12 weeks if
BMI>35
– Consider high dose folic acid (5mg per
day)
– Consider antenatal thromboprophylaxis
if additional risk factors
– Detailed anomaly scan
– GTT at 28 weeks
Interventions during pregnancy:
Monitoring/Screening
•
•
•
•
•
Weighing pregnant women
Early OGTT, early ELFTs
Early screening for vascular disease
Anomaly screening
High risk model of care with regular screening for
preeclampsia –early urinary protein estimation and
baseline blood pressure measurement
All based on expert opinion, underpinned by
good data about increased risk in obese
pregnant women
When we see women at the beginning
of pregnancy, can we effectively
prevent complications in obese
women?
•
•
•
•
Preeclampsia: No good evidence yet
GDM: Maybe
Excessive weight gain: Yes
Neonatal morbidity: No evidence yet
Therapeutic options
•
•
•
•
•
•
Metformin –unstudied
Diet
Exercise
Lifestyle intervention
CPAP
Probiotics
Dietary intervention to prevent weight
gain
– 10 x 1 hour nutrition
consultations
– Fat 30%, protein 1520%, Carb 50-55%
– Caloric restriction
(individual
calculation)
Intervention
N=23
Control
N=27
P
kJ per
day
27
weeks
7319
9867
<0.001
Total
weight
gain
6.6kg
13.3kg
0.002
Wolff et al, 2008, Int J Obesity.
Diet intervention in obese pregnant women
• RCT 257 women, BMI>30
• Study group:
– Dietitian review,
– 18-24 kcal/kg,
– F30,P30,C40,
– all >2000 cal
• Gained less weight (11 vs 31 lbs)
• Retained less weight
• No ketonuria
• Less gestational hypertension
• No difference in perinatal outcomes
Thornton et al, J Nat Med Ass 2009
Lifestyle intervention
Control
Passive
Active
p
Calories
2nd
trimester
kCal/day
2020
1891
1880
<0.004
Weight
gain
kg
6.8
7.12
7.14
0.47
• No difference in
physical activity
• No difference in
any maternal,
obstetric,
neonatal
outcomes
• 35 F/10P/55C
Guelinckx et al, AJCN 2009
Lifestyle intervention
• RCT 100 women stratified for
BMI
• Intervention group:
– Dietitian visit, F30,P30,C40
– Advice re moderate intensity
exercise 5 times per week
• Weight gain reduced in
intervention group
Absee et al, Obstet Gynecol 2009
Exercise in Obese Pregnant Women
• RCT, n=50
• Individually tailored,
goal directed
intervention
• At 28 weeks:
– 16/22 in intervention
met targets
– 8/19 in control met
targets
– No difference in HOMA
18
16
14
12
10
8
6
4
2
0
P=0.047
>900 kCal
per week
<900 kCal
per week
Callaway et al, Diabetes Care, 2010.
Is screening for and aggressive
management of complications
effective?
• Hypertensive disorders?
• GDM: Yes
• Congenital anomalies?
GDM treatment prevents preeclampsia
Crowther et al, NEJM; 2005.
Interventions during pregnancy:
Models of Care
• Guidelines support:
– Multidisciplinary care (obstetricians, physicians,
ultrasonographers, maternal-fetal medicine
specialists, dieticians, physios, anaesthetists)
– Physical requirements (beds, theatre beds etc)
– High risk pregnancy care
• Need for health services research and detailed
economic analysis of models of care
• Potential to examine the impact of models of care
on pregnancy and neonatal outcomes
Interventions in Pregnancy:
Postpartum care
• Guidelines and expert opinions suggest:
– Timely uterotonics
– Thromboprophylaxis
– Surveillance for infections
– Expert lactation support
Interconception Care
• Modest amounts of weight loss between
pregnancies can reduce the risk of GDM in
subsequent pregnancies
• Guidelines suggest:
–
–
–
–
Nutrition counselling
Exercise programs
Weight management support
Follow up of complications of pregnancy (eg
hypertension, gestational diabetes)
• Important time in shaping family habits
• Potential for high quality interconception care
trials
A PRACTICAL APPROACH
First Visit
• First visit:
– Detailed history and physical examination –consider
hypothyroidism, PCOS, endocrinopathies, depression.
– FBC, ELFT’s, OGTT, urine protein creatinine ratio
– Advice regarding diet, exercise, weight gain, smoking
cessation
– Consider higher dose folic acid and aspirin
– Refer to obstetrician and anaesthetist
– Midwife support essential
– Consider risk factors for thromboprophylaxis
– Multidisciplinary care
– Consider appropriate facility for delivery
Subsequent visits
•
•
•
•
•
Breastfeeding information
28 week OGTT
Monitor weight gain
Expert USS of fetus at 18-20 weeks
Ward test urine and blood pressure at every
visit –low threshold for further tests for
preeclampsia
• Ensure anaesthetic review
At delivery
• Skills of health care professionals and the
capacity of the facility
• Monitoring and IV access issues
• Uterotonics
• IV antibiotic prophylaxis
• Thromboprophylaxis
• Breastfeeding support
Post partum
• Breastfeeding support which takes much
longer than in normal weight women
• Watch carefully for infections
• Thromboprophylaxis
• Advise regarding weight loss and follow up for
pregnancy complications