The Changing Obstetrical Landscape: Obesity and Environmental Exposures

1. The Changing Obstetrical Landscape: Obesity and Environmental Exposures April Bleich, MD, FACOG Maternal Fetal Medicine Physician Obstetrix Medical Group of Texas

2. Objectives • Discuss maternal, fetal, and neonatal complications associated with obesity in pregnancy • Review current immunization recommendations during pregnancy and how to address parental concerns regarding these immunizations • Discuss potential environmental toxins

3. Definition of Obesity • Overweight • BMI 25-29.9 kg/m2 • Obesity • Class 1 BMI 30-34.9 • Class 2 BMI 35-39.9 • Class 3 BMI > 40

4. Obesity: An epidemic • Prevalence in 2009-2010 35.9% • >100% increase from 1976-1980 • >50% increase from 1988-1994

5. http://www.cdc.gov/obesity/data/adult.html

6. http://www.cdc.gov/obesity/data/adult.html

7. Financial Impact • Finkelstein et al • Estimated costs of obesity may be $147 billion per year, approximately 10% of annual medical expenditures • 27% of increase in medical expenditures from 1987-2001 was secondary to increased prevalence and cost of obesity

8. Impact of Obesity on Pregnancy • Fertility rates • Pregnancy complications • Gestational hypertension • Pre-eclampsia • Overt/gestational diabetes • Complications with anesthesia • Infection • DVT/PE • More likely to require cesarean delivery

9. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and cesarean delivery rate--a population-based screening study. FASTER Research Consortium. Am J Obstet Gynecol 2004;190:1091–7. 

10. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and cesarean delivery rate--a population-based screening study. FASTER Research Consortium. Am J Obstet Gynecol 2004;190:1091–7. 

11. Surgical complications • Technically more difficult • Pfannenstiel versus vertical skin incision • Reaching lower uterine segment • Wound infection • Venous thrombosis • Decreased mobility • Anesthetic complications • Placement of regional analgesia • Shorter duration of regional analgesia • Airway access

12. Fetal/Neonatal Impact • Miscarriage • Congenital malformations • Neural tube defects • Cardiac • Ultrasound less accurate in diagnosis • Stillbirth (2.1 -4.3 fold increase), reason unknown • Abnormal growth • Large for gestational age/macrosomia) • Shoulder dystocia

13. Neonatal/Childhood Impact • Obese mothers less likely to breast feed • Increased childhood obesity

14. As adults, children of obese mothers are twice as likely to be obese and twice as likely to develop type II diabetes • Increased maternal weight gain during pregnancy associated with hypertension in offspring

15. Impact on Providers • Ability to provide appropriate patient care • Blood pressure cuff size

16. Blood pressure and obesity • Graves (2001) • Women with BMI >34 • 2.2 fold increased risk of being classified as hypertensive and 1.4 fold increased risk of being classified as borderline hypertensive when standard cuff was used versus appropriate size (large or thigh)

17. Acceptable BP cuff bladder dimensions Perloff D, Grim C, Flack J, et al. Circulation (1993;88:2460-2467) Table adapted from http://www.americanheart.org/presenter.jhtml?identifier=3000861

18. Impact on Providers • Ability to provide appropriate patient care • Blood pressure cuff size • Assessment of fundal height • Fetal monitoring • Operating room tables • Work place injuries • Moving/transporting obese patients

19. What can we do? • Education • Healthy eating habits • Exercise • Normal weight gain in pregnancy • Counseling should start pre-conceptually and continue throughout pregnancy • Discussion of healthy behavior at each visit helps facilitate an open dialogue • Early 1 hour glucose tolerance test • Be aware (BP cuff size, prepare anesthesia, VTE prophylaxis)

20. Institute of Medicine Weight Gain in Pregnancy From the Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academics Press;2009.

21. Questions????

22. Environmental Exposure • National Health and Nutrition Examination Survey data, 2003-04 • Pregnant women in US exposed to at least 43 different chemicals • National Center Institute • “to a disturbing extent babies are born ‘pre-polluted’”

23. Adverse Trends in the US Exposure to toxic environmental agents. Supplement, ACOG Committee Opinion No 575

24. Adverse Trends in the US Exposure to toxic environmental agents. Supplement, ACOG Committee Opinion No 575

25. Environmental exposure • General concerns • List some chemicals of concern

26. Bisphenol A (BPA) • Chemical intermediate for polycarbonate plastic and resins • Endocrine disruptor • Sources • Food, consumer products, packaging materials • Exposure occurs through inhalation, ingestion, and dermal absorption • Health Effects • Recurrent miscarriage • Aggression and hyperactivity in female children

27. Mercury • Natural occurring element that is a liquid a room temperature • Sources of Exposure • Largest man-made source in US- coal-fired power plants • Primary exposure in humans-consuming contaminated seafood • Health Effects • Reduced cognitive performance • Impaired neurodevelopment

28. Fish Consumption in Pregnancy • Fish to avoid • Shark • Swordfish • King Mackerel • Tilefish • Up to 12 ounces a week of fish and shellfish lower in mercury • Shrimp, canned light tuna, salmon, pollock, and catfish • Albacore “white” tuna has more mercury than canned light tuna so limit to six oz per week

29. Questions????

30. Immunization Recommendations in Pregnancy • Recommended • Inactivated influenza during flu season • Typically October through March • Pertussis (Tdap) • Ideally given at 27-36 weeks gestation • To be given if indicated • Hepatitis A • Hepatitis B • Meningococcal • Pneumococcal

31. Immunization Recommendations in Pregnancy • Contraindicated • HPV (under investigation) • Nasal influenza • MMR • Varicella

33. Influenza • Affects 10-20% of population • Pregnant women with increased risk of severe disease and death • Routine vaccination recommended for all women who are pregnant during flu season (usually October-March) • Inactivated vaccine • Protects mother and infant in first six months of life

34. Pertussis • Airborne virus that initially causes mild cough, sneezing, runny nose followed by 1-2 week period of severe cough • Infected infants with 19 x increased risk of serious morbidity and mortality (1% infant death rate) • tdap • Tetanus, diphtheria, pertussis • ACOG • Women should receive tdap during EACH pregnancy, ideally around 28 weeks (27-36 weeks)

35. Toxins…. • Influenza Concerns • Need for annual dosing • Belief that flu is “not that bad” • Belief that flu shot causes the flu • Vaccine is pregnancy category B or C (limited human data) • Additives-mercury, formaldehyde, etc • Tdap concerns • Additives-aluminum, formaldehyde, etc • Fear of side effects • Systemic reactions more common • Concern for animal tissue extract • Even Dr. Sears says to get this one!

36. Vitamin K • Vitamin K plays an important role in clotting • Limited placental transfer • Infant levels lower than those in adult predisposing to vitamin K deficiency bleeding (VKDB) • Classified into early, classic, and late • Since 1961, AAP has recommended IM vitamin K at birth • Incidence of late VKDB 81 fold higher if vitamin K not received • Tennessee cases • Why do parents refuse? • Our role-patient education

37. What is our role? • Patient education • Encourage open discussion

38. Questions????

39. References • ACOG Practice Bulletin No 105. June 2009 • Finkelstein EA, Khavjou OA, Thompson H et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med 2012. • Exposure to toxic environmental agents. Committee Opinion No 575. American College of Obstetricians and Gynecologists. ObstetGynecol 2013;122:931-5. • Chu SY, Bachman DJ, Callaghan WM, et al. Association between obesity during pregnancy and increased use of health care. N Engl J Med 2008;358:1444-53. • Cunningham, Leveno, Bloom, et al (2010). Williams Obstetrics. New York: McGraw Hill. • Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012. • Graves J. Prevalence of blood pressure cuff sizes in a referral practice of 430 consecutive adult hypertensives. Blood Press Monit 2001 Feb;6(1):17-20. • Sears RW. The Vaccine Book: Making the Right Decisions for Your Child. New York: Little, Brown and Company. • Warren M, Miller A, Traylor J, Sidonio R, et al. Notes from the Field: Late Vitamin K Deficiency Bleeding in Infants Whose Parents Declined Vitamin K Prophylaxis — Tennessee, 2010. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a4.htm3 • Weiss JL, Malone FD, Emig D et al. Obesity, obstetric complications and cesarean delivery rate-A population-based screening study. Am J ObstetGynecol 2004;190:1091-7.