In the name of GOD The Compassionate & The Merciful

1. In the name of GOD The Compassionate &The Merciful

2. Impact of obesity on pregnancy Fahimeh Ramezani Tehrani Professor Reproductive Endocrinology Research Center ShahidBeheshti University of Medical Sciences 2014

3. Global prevalence of obesity (BMI 30)

5. Women of Childbearing AgePercentOverweight or Obese Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-41.

8. Sub-fertility & Infertility • Ovulatory dysfunction • PCOS • Poorer out come of infertility treatments • Adverse effect on implantation? • Higher doses of ovulation inducing agent • Higher risk of OHSS

10. Spontaneous abortion • OR of miscarriage foe obese women was 1.8(95%CI 1.14-3.13) in meta analysis conducted in 2008. • Chromosomal abnormality? • PCOS • Poor endometrial receptivity • Confounding factors age, S.E status

17. Maternal Complications • Higher Rates of Cesarean Section and labor dysfunction • Gestational Hypertension • Pre-eclampsia • preterm birth • Gestational Diabetes • LGA and Shoulder dystocia • Stillbirth • DVT/PE • Anesthetic complications

18. Risk of Cesarean Section • Increased risk due to: • Dysfunctional labor • Monitoring challenges • Increased rates of pre-eclampsia, hypertension and LGA babies all contribute to likelihood of cesarean section

19. Cesarean Section – Clinical Challenges • Access to lower uterine segment can be challenging • Higher rate of wound complications after surgery • Higher risk of anesthetic complications

20. Difficulties with Regional Anesthesia • 150 kg • Difficult veins • Unable to curve lumbar spine • Impalpable iliac crests • Impalpable vertebral spines

21. Aortocaval Compression 120 kg 150 kg

22. Gestational Hypertension • Pre-existing hypertension is more common among obese women • Among those without hypertension at baseline, increased risk of developing gestational hypertension

23. Gestational Hypertension • Population-based study in the Netherlands • Increased rates of gestational hypertension among obese women (BMI >35), with odds ratio 4.67 Gaillard R et al. Associations of maternal obesity with blood pressure and the risks of gestational hypertensive disorders. Journal of Hypertension 2011, 29:937-944.

24. Gestational Hypertension: A UK population-based study • Among extremely obese women (BMI >50): • 1 in 5 develop hypertensive disorder in pregnancy • 1 in ten develop pre-eclampsia • Among women with less severe obesity, risk is increased but to a lesser degree Knight, M et al. Extreme Obesity in Pregnancy in the UK. Obstet Gynecol, Vol 115, No 5. May 2010.

25. Pre-eclampsia • Risk of pre-eclampsia is increased in obese pregnant women • Pre-eclampsia can lead to compromised fetal perfusion and to medically-indicated preterm birth. • In population-based study in Netherlands, increased risk of pre-eclampsia was observed for obese women (BMI >35), with odds ratio of 2.5.

26. Gestational Diabetes • Gestational diabetes is more common in obese pregnant women • In addition, there is a higher rate of pre-existing diabetes in obese pregnant women

27. Gestational Diabetes: A UK population-based study • Among extremely obese women, 11% developed gestational diabetes • Of those, 70% required insulin • Risk of developing diabetes was seven times higher than in non-obese controls • Among women with less severe obesity, risk is increased but to a lesser degree Knight, M et al. Extreme Obesity in Pregnancy in the UK. Obstet Gynecol, Vol 115, No 5. May 2010

28. Cohort Study of Rates of Stillbirth • There was significant racial disparity, with higher rates of stillbirth among black women than white women • Disparity widened with increasing BMI, with disproportionately highest stillbirth among extremely obese black women (BMI > 40). Salihu, HM et al. Extreme Obesity and Risk of Stillbirth Among Black and White Gravidas. Obstet Gynecol 2007; 110:552-7.

29. DVT/PE • Immobilization and pregnancy are both risk factors for DVT/PE • Obese pregnant women often have decreased mobility, particularly with extreme obesity • Cesarean delivery further increases the risk

31. Multi-fetal pregnancy • Increase incidence of dizygotic not monzygotic • Elevated FSH

32. Obstructive sleep apnea • May be associated with hypertensive disorder and impaired fetal growth • Post operative respiratory depression after receiving opiates

33. Urinary tract infection • 42% increase in risk of UTI • Not more frequent UTI screening for asymptomatic bacteriuria

34. Placenta and cord • No increase placenta previa • No increase abruption of placenta • No cord accident

35. Fetal and Neonatal Complications Cedergren, MI. Maternal Morbid Obesity and the Risk of Adverse Pregnancy Outcome. ObstetGynecol, Vol 103, No 2. Feb 2004.

36. Fetal and Neonatal Complications • As maternal BMI has risen, there has been a significant increase in the number of babies born with high birth weight. • Larger babies have more adipose tissue. Surkan PJ, Hsieh CC, Johansson AL, Dickman PW, Cnattingius S. Reasons for increasing trends in large for gestational age births. ObstetGynecol 2004; 104: 720-6.

39. What happens later in life for children born to obese mothers? • Children born to obese mothers are twice as likely to be obese and develop type 2 diabetes in adult life. • Higher maternal gestational weight gain has been associated with high blood pressure in offspring. One study showed an association between maternal BMI and the hepatic lipid content in the infants. • The increased lipid content in the liver may initiate programming of the metabolic syndrome in utero The Influence of Maternal Body Mass Index on Infant Adiposity and Hepatic Lipid Content. Pediatric Research,2011

40. Clinic Challenges • Identifying fetal heart tones • Assessing fetal growth • Fundal height difficult to obtain • Assessing for hypertension • Blood pressure cuffs may be of inadequate size • Difficulty in reliable sonographic assessment • Difficulty in anesthesia procedures • Difficulty in surgical procedures

41. Recommended total weight gain ranges for pregnant women by pre-pregnancy BMI

42. Excess Gestational Weight Gain Health Impacts on Neonates & Children: • Low 5-minute Apgar scores • Neonatal seizures • Hypoglycemia • Large for gestational age infants • Meconium aspiration • NICU admission • 4-fold increased lifetime risk of overweight/obesity • Lifelong elevated risk for diabetes, hypertension, cardiovascular disease, cancer, early death

43. Excess Gestational Weight Gain Health Impacts on Women: • Postpartum weight retention • Long-term weight gain • Excess body fat • Sleep apnea • Pre-diabetes/diabetes • Coronary heart disease

44. Attitude to weight gain • For women who normally restrain their eating to preserve their figures, the inevitable change of shape during pregnancy serve as justification for “letting themselves go”. • They should “eat for two”. • Depriving themselves, depriving their child

45. Change of body image • Mothers who more dissatisfied with their bodies postpartum, increase energy intake following pregnancy • Mothers who more dissatisfied with their bodies postpartum, higher long term weight gain

46. Figure Rating Scale

47. Risk factors associated with postpartum period • Psychological factors • Depression • Self-esteem • Stress • Social support

48. Depression • As a result of obesity • As modifier of biological or behavioral process that affect body weight • Compensatory action of “comfort eating”

49. Postpartum weight loss (kg) ingroups with different lactation scores.

50. Recommendation • Weight restriction may diminish the risk of maternal obesity but may have negative effect on fetus development • Preconception weight reduction and limitation of maternal weight gain in obese gravidas is recommended