Obesity in Pregnancy: Is it a Big Problem? Joseph R. Biggio, M.D. Objectives • Become familiar with the physiologic alterations in obese pregnant women • Understand the medical and obstetric complications associated with obesity in pregnancy • Become familiar with long-term consequences of maternal obesity for the woman and her offspring • Discuss risk-reducing strategies for obesityrelated complications Obesity • Major medical and public health problem • Significant morbidity and mortality • Health care expenditures: • By 2030, 16-18% of all healthcare expenditures related Wang et al, Obesity 2008 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000 1990 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Among U.S. Adults BRFSS, 2013 WA MT OR ME ND ID MN VT SD WI IA NE NV PA IL UT CO MO OK NM KY AR SC TX AL GA LA FL HI GUAM 15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35% VA NC TN MS AK OH IN WV KS CA AZ NY MI WY PR NH MA RI CT NJ DE MD DC Obesity in Women BMI 25-29.9 30-39.9 >40 2001-02 28.2 33.2 6.5 2011-12 29.7 36.1 8.3 NHANES, Health E-Stat, Fryar et al, CDC NCHS, Sept 2014 Obesity: Race/ethnicity effect Non-Hispanic White Non-Hispanic Black Asian Hispanic 2011-12 32.8 56.6 11.4 44.4 • 75% of AA women BMI >25 NHANES, Health E-Stat, Fryar et al, CDC NCHS, Sept 2014; NCVS, Flegal et al, 2010 Economic Costs—Medical Care • Increased utilization of resources • Prenatal visits • Ultrasounds and fetal surveillance • Medications dispensed • Increased • Comorbid conditions • Hospitalizations • Prolonged hospital stays • Maternal and neonatal ICU admissions • Adds approximately $5.4-6 billion annually in healthcare cost in UK Chu et al., NEJM, 2008; Heslehurst, Obes Rev 2008; Dennison et al., BJOG. 2009 Physiologic Changes: Cardiovascular • Blood volume, Cardiac output increase in proportion to fat and tissue mass • CO increase 30-35 ml/min per 100 gm fat • Diminished progesterone-induced vascular compliance • Increase risk for LV hypertrophy • Intimal hyperplasia and medial thickening Veille JC et al, AJOG 1994; Perlow J, Obstetric Intensive Care Manual, 2003 Physiologic Changes: Pulmonary PO2, chest wall/lung compliance • 50% lower compliance than non-obese • Work of breathing 3x higher than normal • Risk for sleep apnea • Pulmonary hypertension Juvin et al, Anesth Analges, 2003; Perlow J, Obstetric Intensive Care Manual, 2003 OSA, Co-morbidities & Outcomes 50 44 40 33 30 OSA 30 20 10 Obese 11 9 3 9 8 Normal Wt 1 58 60 0 CHTN Diabetes Asthma 50 40 40 30 20 10 30 19 11 7 10 12 15 12 1 4 0 Pre-E <37 wk <32 wk Cesarean Louis et al, AJOG 2010; 202(3):261 Antenatal Complications • Infertility • Spontaneous Abortion • Congenital Malformations • Perinatal Mortality Infertility • Fecundity reduced • Overweight 8% • Obese 18% • Possible Etiologies • HPO axis disruption • Increased leptin • Insulin resistance with androgen, SHBG • fat, estrone • Endometrial abnormalities Gesink et al, Hum Repro, 2007; Pasquali et al, Hum Repro Update, 2003; Haslam, Lancet, 2005 Spontaneous Abortion • Increased loss rate OR 1.7 (1.3 – 2.3) • After ovulation induction: OR 5.1 (1.8 – 14.8) • ? Related to estrogen and luteal phase defect with progesterone • ? diabetes Metwally et al, Fertil Ster, 2008 Congenital Anomaly and Obesity • Multiple studies demonstrate increased risk • Multiple different types involved • Dose-response relationship • Undiagnosed diabetes suggested as potential contributor Stothard et al, 2009; Shaw et al, 2008; Biggio et al, 2010 Obesity and Anomalies NTD Cardiac Cleft Anal atresia Cystic kidney Omphalocele BMI ≥30 2.04 (1.5-2.7) 1.17 (1.1-2.2) 1.26 (1.1-2.0) 1.87 (1.4-2.5) 1.40 (1.0-1.9) 2.03 (1.4-2.9) Blomberg & Kallen, 2010 Dose-Dependent BMI 30-34.9 35-39.9 ≥40 NTD 1.8 (1.3-2.5) 2.1 (1.1-3.5) 4.1 (1.9-7.8) Cardiac 1.1 (1.0-1.2) 1.3 (1.1-1.4) 1.5(1.2-1.8) Cleft 1.1 (0.9-1.3) 1.6 (1.3-2.1) 1.9 (1.3-2.9) Anal atresia 1.8 (1.3-2.4) 1.5 (0.7-2.6) 3.7 (1.7-7.1) Blomberg & Kallen, 2010 Perinatal Mortality 5 Stillbirth after 28 weeks Early Neonatal Death Adjusted OR* 4 3 2 1 0 19.8 – 26.0 29.1 – 35.0 35.1 – 40.0 BMI (kg/m2) Cedergren – Obstet Gynecol 2004 > 40.0 Perinatal Complications • Preeclampsia • Preterm birth • Gestational diabetes • Fetal macrosomia • Fetal Demise Pre-eclampsia 5 Adjusted OR* 4 3 2 1 0 19.8 – 26.0 29.1 – 35.0 35.1 – 40.0 BMI (kg/m2) Cedergren – Obstet Gynecol 2004 > 40.0 Pre-eclampsia • Each BMI unit increases risk 0.5% • Normal weight 2-4% • BMI ≥ 30 8-12% O’Brien et al, Epidemiology, 2003 • Similar magnitude regardless of race Bodnar et al, Epidemiology, 2007 Preterm Birth • Conflicting literature • Multiple studies suggest protective against SPTB • Obesity characterized by inflammation • Large meta-analysis of overweight and obese women • PTB <37 wk RR 1.06 (0.87 – 1.3) • SPTB RR 0.93 (0.85 – 1.01) • Indicated PTB RR 1.30 (1.23 – 1.37) McDonald et al, 2010 Preterm Birth • Swedish Birth Registry • SPTB • Extremely PTB (22-27 wk) increases with BMI BMI 25-<30 1.12 (1.0-1.2) 30-<35 35-<40 ≥40 1.22 (1.04-1.44) 1.73 (1.35-2.21) 2.71 (1.95-3.78) • No increase in 28-31 or 32-36 wk • Indicated PTB • Increased for all GA and all BMI >25 • Highest risk BMI ≥40 Cnattingius et al, 2013 Gestational Diabetes 4 Odds Ratio 3 2 1 0 20 - 24.9 25 – 29.9 BMI (kg/m2) Sebire 2001 >30 LGA/Macrosomia 4 Odds Ratio 3 2 1 0 29.1 – 35 35.1 – 40 BMI (kg/m2) Cedergren, Obstet Gynecol, 2004 >40 Fetal Demise • Mechanism unclear • Meta-analysis • Overweight 1.5 (1.1 – 1.9) • Obese 2.1 (1.6 – 2.7) • Translate to 1.4% SB rate Chu et al, 2007 • Ethnic disparity in risk • Caucasian 1.4 (1.3 – 1.5) • AA 1.9 (1.7 – 2.1) Salihu et al, 2007 Fetal Demise • Stillbirth Collaborative Network • Obesity/overweight independently associated • aOR 1.72 (1.22 – 2.43) • Danish Birth Cohort • 28-36 wk • 37-39 wk • ≥40 wk HR 2.1 (1.0 – 4.4) HR 3.5 (1.9 – 6.4) HR 4.6 (1.6 – 1.3) Stillbirth Network, 2011; Nohr et al, 2005 Peripartum Complications • Labor induction • Cesarean delivery • Labor dysfunction • Postpartum hemorrhage • Shoulder dystocia • Wound complications • Neonatal complications Induction of Labor 2.5 Odds ratio 2 1.5 1 0.5 0 BMI 29.1-35 BMI 35.1-40 BMI > 40 Cedergren, Obstet Gyncecol, 2004 Cesarean Delivery 3 Odds ratio 2.5 2 1.5 1 0.5 0 BMI 29.1-35 BMI 35.1-40 BMI > 40 Cedergren, Obstet Gyncecol, 2004 % Women with Wound Infections Cesarean: Wound Infections 5 4 3 p < 0.0001 2 1 0 < 100 lb 100 – 199 lb NICHD MFMU C/S Registry 2002 200 – 299 lb ≥ 300 lb C/S Contributors • Inductions • Co-morbidities • Presumed macrosomia • Fetal decompensation intrapartum • Dysfunctional labor • 3.5X rate of CS in first stage of labor • Increased need for augmentation and higher doses of oxytocin • In vitro—poor myometrial contractility Zhang et al, BJOG, 2007 Odds ratio Postpartum Hemorrhage 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 BMI 29.1-35 BMI 35.1-40 BMI > 40 Cedergren, Obstet Gyncecol, 2004 Anesthesia risks • Failed intubation 4-6x • Soft tissue mass • Ventilation difficulties • Breast mass • Decreased lung volumes • Failed /difficult regional Juvin et al, Anesth Analges, 2003; Jordan et al, AJOG, 2004 Long-term Risks • Increasing maternal obesity • Co-morbidities • Developmental origins of obesity • Childhood obesity • Metabolic syndrome Post-Partum Weight Retention • Gestational weight gain retention • Mean 11.8 lb at 6 months • GWG > IOM • 15 – 20 lb retention • >40% of women with >20 lb retention • >50% overweight women are obese by 1 yr postpartum IOM, 2009; Gould Rothberg, AJOG, 2011 Breastfeeding • Obese women less likely to breastfeed • BMI 25-30 0.86 (0.84 – 0.88) • BMI >30 0.58 (0.56 – 0.60) • Missed potential benefits • Maternal • Infant Sebire et al, Intl J Obesity, 2001; Li et al, Am J Pub Health, 2002 Childhood Obesity • Maternal obesity correlates with neonatal fat mass • Obesity in offspring of obese mothers • BMI >95th percentile at ages 2-4 • OR 2.4 – 2.7 • ↑ Central obesity, lipid abnormalities, hypertension–age 7 Whitaker RC, Pediatrics, 2004; Oken et al, AJOG, 2007; Catalano et al, AJOG 2003, 2004 Summary of Problem • Scope of the problem is far-reaching • Pregnancy • Life-long • Next generation Optimizing Perinatal Outcomes Initial Antepartum Evaluation • Assessment for co-morbidities • Metabolic syndrome: • Hypertension • Glucose intolerance/Diabetes • Hyperlipidemia • Sleep apnea • Early dating US • Oligo-ovulation LMP unreliable Optimizing Outcomes: Gestational Weight Gain • Education • Dietary Intake • Exercise • Set goals and plot weight gain • Only ~250 kcal/d increase needed for normal weight Optimizing Outcomes: Gestational Weight Gain • Total Weight Gain • 11-20 lb • 0.5 lb/wk in 2nd & 3rd trimesters • Nearly 2/3 of obese women exceed recommended GWG Gestational Weight Gain • Excess weight gain associated with • Macrosomia • Operative delivery • NICU • Weight gain <15 lb associated with lower rates of: • Pre-eclampsia • Cesarean • LGA/SGA Kiel et al, 2007 Pre-E: Effect of Weight Gain • Overweight and Obese women • Weight gain <15 lb OR 0.5 – 1 > 25 lb OR 1.2 – 1.7 Kiel et al, 2007 Optimizing Outcomes: Early GDM Screening • Lack of evidence of cost-effectiveness • Target population • Previous history GDM • Family history of DM • Prior macrosomic infant • Treatment may lower risks • HgbA1C and risk assessment for other complications Catalano, 2007 Optimizing Outcomes: Reducing pre-eclampsia • Patients with GDM—Improved glycemic control, lower risk pre-e • ACHOIS—18% vs 12% • MFMU—13.6 % vs 8.6% Landon et al, 2009; Crowther et al, 2005 Optimizing Outcomes: OSA • CPAP • Improves symptoms, mood • BP, pre-eclampsia • Birthweight • Minimize use of narcotic pain relief • Anesthesia consultation • If not confirmed, monitor O2 sats • Sleep Medicine referral Franklin et al, 2000; Poyares et al, 2007; Guilleminault et al, 2007 Anatomic Assessment • U/S Visualization • Completion of anatomic assessment declines with increasing BMI <25 25-29.9 30-34.9 35-39.9 ≥40 Basic 72% 68% 57% 41% 30% Targeted 97% 91%obesity75% 88% 75% • 10% decrement per class Dashe et al, 2009; Thornburg et al, 2009; Weichert and Hartge, 2010; Hendler et al, 2004; Becker and Wegner, 2006 •Detection rate decreases with increasing BMI •Residual anomaly risk increases with BMI FASTER Trial • Detection aOR 0.70 (0.6-0.9) Dashe et al, 2009; Aagaard et al, 2010 Optimizing Outcomes: Anatomic Assessment • 11-14 week scan • Lack of evidence in obese women • Combined TA and TV approach • 82% complete anatomy • 3.7% anomaly detection • 84.2% heart defect detection Ebrashy et al, 2010; Becker and Wegner, 2006 Optimizing Outcomes: Prenatal Diagnosis • NIPT • Fetal fraction lower • Adipose cell death • Inflammation • Redraw rates • Diagnostic Procedures • BMI ≥40 2-fold increase loss after amnio Ashoor et al, 2013; Haghiac et al, 2012; Harper et al, 2012 Fetal Fraction in Relation to BMI Ashoor et al, 2013 Optimizing Outcomes: Growth Surveillance • Macrosomia • 2-fold increase • IUGR • Mainly in women with hypertension or pre-eclampsia • Fundal height • Limited accuracy • Biometry q4-6 weeks Ehrenberg et al, 2004; Neilson, 2000; Morse et al, 2009; ACOG CO #549, 2013 Optimizing Outcomes: Antenatal Testing • Placental histology • Placental dysfunction OR 5.2 • Vigilance for hypertension, diabetes • Antenatal surveillance • Even in absence of other indications Catalano, 2007; Nohr et al, 2005 Optimizing Outcomes: Mode of Delivery • Labor dysfunction • Increased oxytocin dose • 5.0 units vs 2.6 units • Longer labor duration • 8.5 vs 6.5 hours • Impaired myometrial contractility • Leptin inhibitory effect • Not oxytocin receptor mediated Pevzner et al, 2009; Quenby wt al, 2011; Zhang et al, 2007, 2011; Moynihan et al, 2006; Grotegut et al, 2013 Vaginal vs Cesarean • Swedish birth registry • Neonatal outcomes by mode of delivery • 2-4 fold increase for BMI ≥40 : • Birth injury • RDS • Sepsis • Hypoglycemia • Similar risk vaginal vs. elective cesarean Blomberg, 2013 Optimizing Outcomes: Mode of Delivery • Lack of evidence • Factors to consider • Increased need for cesarean • Ability to monitor fetal status • Time from skin to delivery increased Gunatilake and Perlow, 2011 VBAC Success • MFMU Cesarean Registry • >14,000 VBAC attempts Failed TOL LOS ≥4d Endometritis Rupture/ dehiscence 18.5-24.9 25.0-29.9 15.2 22.3 9.4 13.0 1.6 0.9 2.6 1.5 30-39.9 29.9 18.9 ≥40 39.3 30.3 p <0.001 <0.001 3.0 1.4 4.6 2.1 <0.001 0.03 Hibbard et al, 2006 Perioperative Antibiotics • Reduces risk of puerperal fever • Endomyometritis • Wound infection • Weight-based dosing modification • Cefazolin • ≤80 kg 1 gm • 81-160 kg 2 gm • ≥160 kg 3 gm JCAHO, SCIP recommendations; Smaill et al, 2010; Cefazolin in obese • 29 scheduled C/S; 2 gm cefazolin • Adipose concentration inversely related to BMI • BMI ≥30 • BMI ≥40 20% less than MIC for GNR up to 44% less than MIC Pevzner et al, 2011 Optimizing Outcomes: Intraoperative management • • • • Incision type Fascial Closure Subcutaneous closure Appropriate Equipment • Bed • Instruments • Transfer apparatus Incision Type and Placement • Pfannenstiel – Less adipose depth – Access to LUS – More stable closure – Moist, anaerobic, microbe-rich – Cava compression – Respiratory impairment intraop • Vertical • Avoid under pannus • More room • Cut through thicker part of panniculus • Placement difficult • Increased likelihood of vertical hysterotomy • Pulmonary issues post • Less stable closure Wall et al,2003; Alanis et al, 2010; Bell et al, 2011 Pfannenstiel vs Vertical • 194 women BMI >50 • 30% wound complication • Vertical incision OR 2.2 (1.2 – 4.3) • 239 women BMI > 35 • 12% wound complication • Vertical incision OR 12.4 (3.9 – 39.3) Alanis et al, AJOG, 2010; Wall et al, Obstet Gynecol, 2003 Optimizing Outcomes: Subcutaneous Space Management • Meta-analysis • Depth >2 cm • Wound disruption RR 0.66 (0.48-0.91) • Reduction in wound seroma RR 0.42 • No added benefit to drain Chelmow et al, 2004; Magann et al, 2002; Ramsey et al, 2005 Optimizing Outcomes: Intrapartum management • Minimize induction of labor, as possible • Anticipate longer length of labor and need for higher doses of oxytocin • Early epidural placement for analgesia • Decision on best mode of delivery • Fetal monitoring capability • Prior C/S • EFW Optimizing Outcomes: Intrapartum management • Prophylactic cesarean considered for macrsomia • Prepare for pp hemorrhage regardless of mode of delivery • Choose surgical approach and instruments to facilitate exposure and technique ACOG Practice Bulletin 22, 2000 Optimizing Outcomes: Thromboprophylaxis • Obesity major risk factor • OR 4.4 (3.4 – 5.7) for VTE • No RCT with benefit of UFH vs LMWH vs pneumatic compression device • At least one form recommended • High risk patients--heparin plus pneumatic • Vascular disease, thrombophilia, severe pre-e • Early ambulation James et al, 2006; Bates et al, 2008; Tooher et al, 2010 Summary • Obesity is associated with an increased risk of a number of maternal obstetric and medical complications • Good evidence is available to minimize the risk of many complications associated with obesity • Although data are lacking on how to prevent a number of these complications, careful preparation and anticipation may minimize the risks and improve outcomes in the current and future pregnancies