Pregnancy care in women with BMI>35Pregnancy care in women with BMI>35Dr S Sharma, Dr A Mahmud and Dr N Manheri-OthayothDr S Sharma, Dr A Mahmud and Dr N Manheri-Othayoth - University Hospital of Wales, Cardiff UKUniversity Hospital of Wales, Cardiff UK

AIMTo re-audit the care of pregnant women with BMI>35

STANDARDSSTANDARDS•Cardiff and Vale NHS Trust Policy and Guideline for management of women with high

BMI dated 20082008•CMACE/RCOG Joint Guideline - Management of Women with Obesity in Pregnancy

- March 20102010

METHODS•Prospective audit•Proforma developed•Duration: 12th May 2011 to 20th June 2011 •Cases identified: 36•All Inpatients with BMI>35 were included•Results analysed•Compared to previous Audit 2008 (74 cases – 1 year)

02468

10121416

Age 18-25 Age26-30Age31-35

Age 36-40

5

15

11

5

Demographic Distribution AgeDemographic Distribution Age

70% 18-30yrs 2008 55.5% 18-30yrs 201170% 18-30yrs 2008 55.5% 18-30yrs 2011

ParityParity

Booking BMIBooking BMI

ANC - Referral to healthy living classesANC - Referral to healthy living classes

Folic acid and vitamin D supplementationFolic acid and vitamin D supplementation

CMACE/RCOG

Women with a BMI ≥30 wishing to become pregnant should be advised to take 5mg folic acid supplementation daily, starting at least one month before conception and continuing during the first trimester of pregnancy.

B

CHealth professionals should take particular care to check that women with a booking BMI ≥30 are following advice to take 10 micrograms Vitamin D supplementation daily during pregnancy and while breastfeeding. 32

80% GTT 2008

ANC - GTTANC - GTT

GTT performed in 34 cases(97.1%) - 1 case could not attend due to child care issues

- 1 case note from other hospital no mention of GTT

ANC - GTTANC - GTT

For BMI >45 or previous GDM- 2 cases performed at 9 weeks- 1 case at 18 weeks- 1 case at 25 and 29 weeks

For BMI 36 - 44- 2 cases performed at 12 and 14 weeks- rest mostly at 26 - 28 weeks

None performed at 14 weeks (as per guidelines)

ANC Anaesthetic ReviewANC Anaesthetic Review

Pregnant women with a booking BMI ≥40 should have an antenatal consultation with an obstetric anaesthetist, so that potential difficulties with venous access, regional or general anaesthesia can be identified. An anaesthetic management plan for labour and delivery should be discussed and documented in the medical records.

CMACE/RCOG

CMACE/RCOG

Pregnant women with a booking BMI ≥30 should be assessed at their first antenatal visit and throughout pregnancy for the risk of thromboembolism. Antenatal and post delivery thromboprophylaxis should be considered in accordance with the RCOG Clinical Green Top Guideline No. 37. 41

Antenatal ThromboprophylaxisAntenatal Thromboprophylaxis

•Out of 36 women 5 were prescribed aspirin or Enoxaparin as per thromboprophylaxis policy

•One case of 36 BMI missed h/o DVT

B

Both =

15 out of 36 = 41.6%

Obstetric Medical ProblemsObstetric Medical Problems

ANCANCReview at 36 weeks: - Out of 36 cases 31 were reviewed in ANC (86.1%) - USG was done in 29 cases (80.580.5%) while EFBW was stated in 5 cases only

Intrapartum Sheet:- Blank 14 cases- Complete 10 cases- 50% Completion 14 cases

78% 2008USG 7% 2008

60% in 2008

Intrapartum CareIntrapartum Care

TEDS in labour: - 20 cases had TEDS in all

- 2 cases of SVD - 18 cases of C-section or Instrumental delivery

Weight on Admission:

- Only 3 cases - 1st case BMI = 78 Repeat 83 - 2nd case BMI = 56 Repeat 61 - 3rd case BMI = 40 Repeat 44

3 cases in 2008

(13.8%)

Intrapartum care – IOL (19)Intrapartum care – IOL (19)

Mode of DeliveryMode of Delivery

SVD 43% C/s 42% Instrumental 15%

2008

Intrapartum ComplicationsIntrapartum Complications

16% PPH 200816% PPH 2008

Overall Blood LossOverall Blood Loss

Baby WeightBaby Weight

Postnatal Thromboprophylaxis (36)Postnatal Thromboprophylaxis (36)

Postnatal Thromboprophylaxis (21)Postnatal Thromboprophylaxis (21)

116

1

1 2

Clexane/TEDS

36-40

41-45

46-50

51-55

>55

Only 4 cases had clexane prescribed BD

All women with a BMI ≥40 should be offered postnatal thromboprophylaxis regardless of their mode of delivery.

CMACE/RCOG

58.3%48% cases in

2008

CONCLUSION

•36 cases in 38 days indicates the proportion of large BMI women that deliver at UHW

•We are following trust guidelines in most cases i.e. Early booking GTT, Anaesthesia review, 36 week follow-up, etc.

We still are falling short on: 1. Documentation

2. Assessment

Referral to healthy living/weight loss Vitamin D &

Folic AcidIntrapartum sheets

ThromboprophylaxisWeight on Admission

36 week USG

Primi 36% 2008Primi 36% 2008

RECOMMENDATIONS

• Knowledge and awareness of BMI Guideline is essential • Documentation on Intrapartum sheet vital• Friday teaching – as guideline updates• Update current Health Board Guideline • Re-Audit• Wide implementation of new Thromboprophylaxis Risk Assessment tool

PPH 1

Raised BP in labour 7(19%)

Raised Temperature 6

Difficult Toco/CTG monitoring 3

Meconium 5

Shoulder Dystocia 3

Folic acid Dose

Given Not mentioned

400ug 13 23

5mg 0 36

Vitamin D GivenNot mentioned

4 32

B

Indication Examples Number

Medical reasons PIH/PET/GDM 5

Postdates VBAC 7

Obstetric reasons SROM/PROM/Unstable lie 6

Patient request Recurrent miscarriage 1