Obesity in Pregnancy

1. Obesity in Pregnancy Erin Shaw, CNM, MS Certified Nurse-Midwives at St. Anthony Central Hospital

2. Objectives Define overweight/obesity based on NIH/WHO guidelines List 3 maternal medical complications associated with obesity List 3 potential obstetrical risks associated with obesity Discuss challenges associated with assessment of both mother and fetus during the AP/IP and PP period

3. NIH/WHO definitions • Underweight BMI < 19.8 • Normal weight BMI 19.8 – 26.0 • Overweight BMI 26.1 – 29.0 • Obese BMI > 29.0 Calculation of BMI: BMI = weight in kg / height in meters sq

4. Incidence In US 56% of non-pregnant women of child-bearing age are overweight (BMI 26-29) 30% of non-pregnant women of childbearing age are obese (BMI >29) • Worldwide BMI > 30 15 – 20% Accounts for 2 – 7% of total healthcare costs

5. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1998 1990 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. In the US: • Thinnest state: Colorado with 18.4% of adults who are obese • Next five: Hawaii, Connecticut, Massachusetts, Vermont and Rhode Island all at 21% • Most obese state: Mississippi with 31.7% obesity rate • Next five: W. Virginia 31%; Alabama & Louisiana 30%; S. Carolina & Tennessee 29% Info from “F as in Fat: How Obesity Policies are Failing in America” report – their data come from CDC 2005-2007 Behavior Risk Factor Surveillance Surveys

7. Current weight gain recommendations(Institute of Medicine) • For underweight women: 28 – 40 lbs • For normal weight women: 25 – 35 lbs • For overweight women: 15 – 25 lbs • For obese women: 15 lbs

8. Maternal medical risks associated with obesity Increased incidence of: • Metabolic syndrome (dyslipidemia, HTN, insulin resistance) • Type II diabetes • Coronary artery disease • Gallbladder disease • Osteoarthritis • Sleep apnea • Cancer: breast, colon, endometrial

9. Antepartum risks associated with obesity • Gestational diabetes • Gestational hypertension • Pre-eclampsia • Early increased risk of miscarriage • Increased incidence of congenital defects (heart defects and neural tube defects)

10. Intrapartum risks associated with obesity Increased incidence of: induction of labor longer labor less successful VBAC rates cesarean delivery (CPD and FTP) shoulder dystocia

11. Postpartum risks associated with obesity Increased incidence of: Infection – wound, episiotomy, endometritis Postpartum hemorrhage DVT Obesity and excess gestational weight gain are associated with an increased risk of failure to initiate lactation and decreased duration of lactation.

12. Perinatal outcomes Congenital anomalies • Neural tube defects • Heart defects Prematurity Stillbirth (diabetes, decreased awareness of fetal movement) Macrosomia

13. Challenges associated with assessing both mother and baby • Estimating fetal weight • Auscultating FHR • Taking maternal BP • Anesthesia problems • Cesarean delivery • Monitoring uterine contractions • Ultrasound

14. Estimated fetal weight assessment Difficulty with Leopold’s maneuver try to determine the outline of the uterus and establish the fundus first Ask mom where she feels fetal movement and use information to establish fetal contours When in doubt – try ultrasound, but remember accuracy of EFW by US decreases with increasing gestational age!

16. Auscultating FHR In AP period, try to establish location of fetal back first, if difficulty with doppler, try monitor In IP period, if unable to auscultate, may need an FSE (remember increased risk of infection)

17. Assessing maternal BP Important to use appropriate size cuff Have large cuff available in clinic setting as well as IP setting

18. Anesthesia issues May be difficult to place epidural or spinal anesthesia, requiring multiple attempts General anesthesia risks include difficult intubation, and post partum sleep apnea. Anesthesia consult before labor may be helpful.

19. Risks associated with Cesarean delivery • Longer incision to delivery time • Increased incidence of postpartum hemorrhage • DVT • Increased incidence of wound infection and delayed healing • Anesthesia issues as mentioned above

20. Difficulty in assessing uterine contraction activity Often difficult to assess using external monitor Also sometimes difficult to palpate accurately Consider use of IUPC

21. Problems associated with ultrasound in the obese mother Suboptimal images May be difficult to visualize fetal defects US assessments are often necessary to evaluate fetal growth

22. Surgical interventions including gastric bypass and lap band procedures • Advantages: • Decreased incidence of GDM • Decreased incidence of macrosomia • Decreased incidence of cesarean section • Disadvantages: • Increased risk of anemia • B12 deficiency • Increased risk of IUGR, prematurity, neural tube defect, and GI bleed

23. Recommendations • Calculate BMI on all patients at first OB visit • Offer nutritional counseling and exercise recommendations and stress importance of appropriate weight gain • Early GDM screening • Review potential problems associated with assessment

24. Nutrition...The Key to Your Health

25. References Catalano, P. Management of Obesity in Pregnancy. Obstetrics & Gynecology 2007; 109(2) part I; 419-433. Myles, T., Gooch, J., Santolaya, J. Obesity as an Independent Risk Factor for Infectious Morbidity in Patients Who Undergo Cesarean Delivery. Obstetrics & Gynecology 2002; 100(5); 959-964. Ockenden, J. Obesity and complications of pregnancy and birth. The Practicing Midwife 2008; 36-39. Robinson, H., O’Connell, C., Joseph, K., McLeod, N. Maternal Outcomes in Pregnancies Complicated by Obesity. Obstetrics & Gynecology 2005; 106(6); 1357-1364. Rouse, D., Nuthalapaty, F. The Impact of Obesity on Fertility and Pregnancy. Retrieved June 17, 2008 from Up to Date Website: http://www.utdol.com/online/content/topic.do?topicKey=antenatl/19564&view=print. Smith, S., Hulsey, T., Goodnight, W. Effects of Obesity of Pregnancy. JOGNN 2008; 176-184.