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46 weeks of care – sharing the patient journey through pregnancy to 6 weeks post-partum

46 weeks of care – sharing the patient journey through pregnancy to 6 weeks post-partum. 3rd November 2012 CHWC The Canberra Hospital. Management of Obesity in pregnancy. Steven Adair Clinical Director O&G CHWC, Canberra. Definitions.

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46 weeks of care – sharing the patient journey through pregnancy to 6 weeks post-partum

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  1. 46 weeks of care – sharing the patient journey through pregnancy to 6 weeks post-partum 3rd November 2012 CHWC The Canberra Hospital

  2. Management of Obesityin pregnancy Steven Adair Clinical Director O&G CHWC, Canberra

  3. Definitions BMI is the most commonly used indicator of maternal weight (wt in kg/height in m2 ) The usual categories are; BMI 18.5 to 25 is normal weight range BMI > 25 is overweight BMI > 30 is obese BMI > 35 is severe obesity BMI > 40 is morbid obesity BMI > 50 is extreme morbid obesity

  4. Demographics One and a half billion adults worldwide are overweight, and half a billion are obese Australia now has one of the highest rates of overweight and obesity in the world Latest figures show that 21.7% of the population is obese (60% are overweight) One in four Australian women are obese

  5. Extreme Morbid Obesity BMI: 71.8

  6. AMOSS conditions 2010-2011 Antenatal pulmonary embolism Amniotic fluid embolism Eclampsia Extreme morbid obesity (BMI >50) Influenza A with admission to ICU Peripartum hysterectomy Placenta accreta

  7. AMOSS surveillance 2010–2011

  8. AMOSS Surveillance Data collection was suspended after 10 months due to data overload 357 cases reported from > 170,000 births (approximately 2 per 1000) 179 (53.7%) had a c/section Elective c/section 94 (53%) Emergency c/section 85 (47%)

  9. BMI in pregnancy Pre-pregnancy BMI is not routinely collected (studies use maternal recall) End of pregnancy BMI is altered by weight gain in pregnancy BMI at booking visit (often 12 to 20 wks) is accessible data

  10. 2011 figures from The Canberra Hospital Many units in the Canberra region will transfer women with BMI > 35 for birth In 2011 (2577 / 2805) BMI > 30 in 515 20% (43 per month) BMI > 35 in 230 9% (20 per month) BMI > 45 in 28 1% (>2 per month) This means that each week there are 2 or 3 women birthing with morbid obesity

  11. Recent Evidence October 2012 • Editorial: “The increasing impact of maternal obesity on obstetric practice.” • Pre-pregnancy BMI • Intra-pregnancy weight gain • IOM guidelines for weight gain in 1st T of <1.5kg in obese.

  12. Pregnancy Consequences Congenital anomalies Diabetes Stillbirth

  13. Congenital Anomalies The data showing an increased risk of congenital anomalies are inconsistent Possible explanations include; Relative folate deficiency Higher rates of undiagnosed type 2 DM Later diagnosis of severe anomalies may increase birth prevalence

  14. Gestational Diabetes Clear association between BMI and risk of GDM Women with BMI > 40 have a 10% risk Strongly linked to need for insulin, fetal macrosomia and c/s

  15. Stillbirth Maternal overweight & obesity are very significant modifiable risk factors for stillbirth The top PARs (Population Attributable Risk) for stillbirth at >22 weeks in HIC are; Overweight/obesity (7.7 to 17.6%) Maternal age (7.5 to 11.1%) Smoking (3.9 to 6.2%) Flenady et al (2011), Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis Lancet 377, 1331-1340

  16. Association of overweight and obesity with stillbirth in High Income Countries (HIC) Flenady et al (2011), Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis Lancet 377, 1331-1340

  17. Birth Consequences Timing of birth? Place of birth? Mode of birth?

  18. Place of birth Many low-risk units will preferentially transfer women with BMI > 35 Anaesthetic risks Surgical risks This policy causes much maternal distress and family dislocation Possible to triage based on fetal size and previous obstetric history

  19. Mode of birth All studies show higher c/section rates in obese women Why is this so? Bigger babies Less efficient uterine activity More iatrogenic intervention?

  20. Birth outcomes TCH 2011 Caesarean Section Rate (26.1%) BMI >35 40.43% BMI >45 42.85%

  21. Implications for Maternity Services Increased workload in relation to GDM Special clinics/models of care for women with high BMI Dietitian/psychologist/physiotherapist Protocols for managing surgical and anaesthetic risks for women with BMI > 50 Need for transfer for women deemed to be at higher risk

  22. Clinical Practice Guidelines Antenatal Care – Module 1 Draft for AHMAC February 2012

  23. Clinical Practice Guidelines Antenatal Care – Module 1 Draft for AHMAC February 2012 7.2 Weight and body mass index

  24. 7.2 Weight and body mass index • ‘Pre-pregnancy weight and weight gain during pregnancy are important determinants of both mother and baby.’ • Measure women’s weight and height at the first antenatal visit and calculate their BMI. (B) • Repeated weighting during pregnancy should be confined to circumstances that are likely to influence clinical management. (pp) • Give women advice about appropriate weight gain during pregnancy in relation to their BMI. (B) • Taking a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. (pp)

  25. 7.2 Weight and body mass index • ‘Pre-pregnancy weight and weight gain during pregnancy are important determinants of both mother and baby.’ • Measure women’s weight and height at the first antenatal visit and calculate their BMI. (B) • Repeated weighting during pregnancy should be confined to circumstances that are likely to influence clinical management. (pp) • Give women advice about appropriate weight gain during pregnancy in relation to their BMI. (B) • Taking a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. (pp)

  26. 7.2 Weight and body mass index • ‘Pre-pregnancy weight and weight gain during pregnancy are important determinants of both mother and baby.’ • Measure women’s weight and height at the first antenatal visit and calculate their BMI. (B) • Repeated weighting during pregnancy should be confined to circumstances that are likely to influence clinical management. (pp) • Give women advice about appropriate weight gain during pregnancy in relation to their BMI. (B) • Taking a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. (pp)

  27. 7.2 Weight and body mass index • ‘Pre-pregnancy weight and weight gain during pregnancy are important determinants of both mother and baby.’ • Measure women’s weight and height at the first antenatal visit and calculate their BMI. (B) • Repeated weighting during pregnancy should be confined to circumstances that are likely to influence clinical management. (pp) • Give women advice about appropriate weight gain during pregnancy in relation to their BMI. (B) • Taking a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. (pp)

  28. 7.2 Weight and body mass index • ‘Pre-pregnancy weight and weight gain during pregnancy are important determinants of both mother and baby.’ • Measure women’s weight and height at the first antenatal visit and calculate their BMI. (B) • Repeated weighting during pregnancy should be confined to circumstances that are likely to influence clinical management. (pp) • Give women advice about appropriate weight gain during pregnancy in relation to their BMI. (B) • Taking a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. (pp)

  29. 7.2 Weight and body mass index • ‘Pre-pregnancy weight and weight gain during pregnancy are important determinants of both mother and baby.’ • Measure women’s weight and height at the first antenatal visit and calculate their BMI. (B) • Repeated weighting during pregnancy should be confined to circumstances that are likely to influence clinical management. (pp) • Give women advice about appropriate weight gain during pregnancy in relation to their BMI. (B) • Taking a respectful, postiive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management. (pp)

  30. Possible interventions Pre-pregnancy counselling many pregnancies are unplanned sub-fertility in overweight/obese women assisted reproduction technology (ART) Reducing weight gain in pregnancy dietician involvement and routine weighing Maximising inter-pregnancy weight loss breastfeeding

  31. Possible birth interventions There are a number of ‘birth choices’ for overweight and obese women that are yet to be properly trialled Early v standard timing of birth Spontaneous v induced labour Emergency v elective caesarean section?

  32. Timing of birth There is pressure to intervene due to the increased risk of stillbirth, and GDM Does more intervention lead to greater complications? How should standard IOL policies be modified by maternal BMI?

  33. Eat Less & Do More!

  34. Placental Responses to Obesity and Pregnancy Outcomes Study PROPOS Principal Investigators- Prof Christopher Nolan Prof Jane Dahlstrom Prof David Ellwood A/Prof Alison Kent

  35. PROPOS The PROPOS study will evaluate the effects of obesity on placental structure and function and how this affects pregnancy outcomes

  36. PROPOS For the women it involves- • Recruitment if eligible prior to 12 weeks gestation • 4 weekly visits to TCH from 12 weeks gestation • Dietary and exercise advice • Fetal Medicine Unit ultrasound assessments at 12, 20, 28 and 36 weeks gestation • Maternal anthropometric/ metabolic assessments at 16, 24, 32 weeks gestation • Maternal and cord blood taken at delivery • Detailed study of placenta (appearance, histology, metabolism, gene expression) • Neonatal anthropometric/ metabolic assessment and review at 12 months • All maternal and fetal/neonatal adverse outcomes will be carefully documented

  37. PROPOS Dyslipidaemia Hyperglycaemia Maternal obesity Systemic Hypertension Abnormal adipokines Inflammation Other factors ? ? Altered placental function and/or structure Harmful placental adaptations Beneficial placental adaptations Adverse outcomes Normal outcomes 38

  38. PROPOSSelection Criteria for PROPOS Subjects • Inclusion criteria study A: • Age 20-38 • <12 weeks gestation • Previous C-section • Lean BMI 18.5-25.0 • Obese BMI  30.0 • Inclusion criteria study B: • Age 20-38 • <12 weeks gestation • Nulliparous • Obese BMI  30.0 • Exclusion Criteria: • Pre-existing diabetes, chronic hypertension, active smokers, delivering at hospital other than TCH, induced conception For further information or patient referral, please contact:  Endocrinology Unit, The Canberra Hospital on 6244 2228 or Anthea Oon, Research Coordinator, Clinical Trials Unit 6244 3687

  39. Eat Less & Do More!

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