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  • Slide 1
  • High Risk Pregnancy - 2010
  • Slide 2
  • High Risk Pregnancies Disordered Eating Obesity Hypertensive Disorders Gestational Diabetes
  • Slide 3
  • Disordered Eating & Pregnancy: Prevalence Few data on prevalence of disordered eating in pregnancy Difficult to adequately capture this information from women. Women may have needs for secrecy and denial so information about history of eating disorders is often not given to health care providers during pregnancy Some published numbers for disordered eating in the population ( (Mitchell et al. J midwifery & womens health, 2006) Prevalence of binge eating disorder ~ 1.2%-4.5% Prevalence of anorexia nervosa in young females is 0.03% About 25% of individuals with anorexia nervosa develop a chronic course.
  • Slide 4
  • Diagnostic Criteria: Anorexia Nervosa (American Psychiatric Association) Refusal to maintain body weigh at or above normal weight for age and height Intense fear of gaining weight or becoming fat, even through underweight Disturbance in the way in which ones body weigh or shape is experienced, Undue influence of body weigh or self-evaluation or denial of the seriousness of current low body weight In postmenarcheal females, amenorrhea (absence of at least three consecutive menstrual cycles)
  • Slide 5
  • Diagnostic Criteria: Bulimia Nervosa (American Psychiatric Association) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: In a discrete period of time, eating an amount of food definitely larger than most people would eat A sense of lack of control over eating during the episode Recurrent inappropriate compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications. Binge eating and inappropriate compensatory behaviors occur at least twice a week for 3 months Self-evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during anorexia nervosa.
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  • Diagnostic Criteria: Not otherwise specified (American Psychiatric Association) For females, all the criteria for AN are met, except that the individual has regular menstrual cycles. All criteria for AN is met, except the weight is WNL, despite significant weight loss Regular use of inappropriate compensatory behaviors in an individual of normal weight after eating small amounts of food Repeated chewing and spitting out food, but not swallowing Binge-eating disorder: recurrent episodes of binge eating in the absence of regular use of compensatory behaviors characteristic of BN
  • Slide 7
  • Disordered Eating & Pregnancy Results of published studies are inconsistent Developmental tasks of pregnancy are often about the same issues that arise in some women with eating disorders Body changes Alterations in roles Concerns about a womans own mothering and needs for psychological separation.
  • Slide 8
  • Pregnancy and Eating Disorders: A review and clinical Implications (Franko and Walton, Int.J. Eating Disorders, 1993) British report on 6 of 327 women who had attended eating disorder clinic and got pregnant Median BMI was 16.8 (range 14.9-18.1) Median length of time with AN was 15 years (range 11-17) Average weight gain was 8 kg (range 5-14) - recommendations for low BMI are 13-18 Poor third trimester fetal growth was found in all 5 babies who were monitored Babies had some catch up in infancy
  • Slide 9
  • Pregnancy Outcome and Disordered Eating (Abraham et al J Psychosom Obstet Gynecol, 1994) 24 women reported previous problems with disordered eating. These women had higher rates of antenatal complications such as IUGR, PIH, edema, GDM, vaginal bleeding (p
  • Infant Outcomes Large infants - effect is independent of maternal diabetes- rates of macrosomia (>4000 g): Normal weight women: 8 % Obese women: 13% Morbidly obese women: 15% Increased infant mortality - RR for infants born to obese women was 4.0 compared to women with BMI < 20
  • Slide 39
  • Long Term Risks to Infant Children born to obese mothers twice as likely to be above 95 th percentile BMI at age 2 Metabolic syndrome in at age 11: Hazard ratio = 2.19 (1.25-3.82) if LGA Hazard ratio = 1.81 (1.03-3.19) if maternal obesity
  • Slide 40
  • Swedish population-based study (Cedergren, 2004) n=805,275 Morbid obesity (BMI>40) compared to normal weight 5 fold risk of preeclampsia 3 fold risk of still birth after 28 weeks 4 fold risk of LGA BMI >35,
  • Cost Costs were 3.2 times higher for women with BMI > 35 Longer hospitalizations
  • Slide 42
  • ADA Position Statement, 2009 Given the detrimental influence of maternal overweight and obesity on reproductive and pregnancy outcomes for the mother and child, it is the position of the ADA and the American Society for Nutrition that all overweight and obese women of reproductive age should receive counseling prior to pregnancy, during pregnancy, and in the interconceptional period on the roles of diet and physical activity in reproductive health, in order to ameliorate these adverse outcomes.
  • Slide 43
  • Emerging Issues: Bariatric Surgery Outcomes Challenges of studies: Appropriate control groups? Outcomes to measure? Selection bias Changes in procedures over time Clinical recommendations
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  • Outcomes After Malabsorptive Procedures such as Roux-en-Y (Bernert et al. Diabetes Metab. 2007; Catalono. Obstet Gynecol, 2007) Associated Complications: Small bowel ischemia Nutrient deficiencies (iron, folate, B 12) Fetal abnormalities SGA & preterm birth Cesarean delivery
  • Slide 45
  • Pregnancy Outcomes after Gastric-Bypass Surgery Dao, et al. Am J Surg, 2006 N= 21 pregnant within first year post- surgery; 13 pregnant after first year (Texas) Author's conclusions: Pregnancy outcomes within the first year after weight-loss surgery revealed no significant episodes of malnutrition, adverse fetal outcomes or pregnancy complications.
  • Slide 46
  • Pregnancy following gastric-bypass (Dao, 2006) < 1 year (21)> 1 year (13) Mean BMI: At surgery At pregnancy 49 35 46 28 Mean weight gain4 #34# Mean birthweight2868 g (2 sets twins) 2727 g (3 sets twins) Major pregnancy complications 51 Minor pregnancy complications 53
  • Slide 47
  • Birth Outcomes in Obese Women After Laparoscopic Adjustable Gastric Banding Dixon et al. Obstet Gynecology. 2005 N=79 (Australia) Mean maternal weight gain= 9.6 +/- 9.0 kg Mean birthweight = 3,397 Incidence of PIH, GDM, stillbirth, preterm delivery low and high birth weights more similar to population than obese women.
  • Slide 48
  • Dixon Conclusions: Pregnancy outcomes after LAGB are consistent with general community outcomes rather than outcomes from severely obese women. The adjustability of the LABG assists in achieving these outcomes.
  • Slide 49
  • Pregnancy after Bariatric Surgery: A comprehensive review. Sheiner. Arch Gynecology Obstet. 2008. Post surgery women at increased risk for poor perinatal outcomes. Clinicians should be aware that data collected on this subject are often gathered from post-op pregnant women provided with good prenatal care and screening for nutritional deficiencies.
  • Slide 50
  • Clinical Management of Pregnancy Following Bariatric Sugary ( ACOG Committee and Catalano, Obstet Gynecology, 2007) 1.Advise women about risk of unexpected pregnancy following LAGB & need for contraception 2.Delay pregnancy for 12-18 months avoid rapid weight loss phase and catabolic state 3.Close monitoring during pregnancy by both ob and surgeon to allow for adjustments of gastric bands 4.Supplement with folate, calcium, B 12
  • Slide 51
  • Hypertensive Disorders During Pregnancy Incidence Definitions Etiology/pathophysiology Role of Nutrition
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  • Incidence Second leading cause of maternal mortality in US 15% of maternal deaths (eclampsia: disseminated intravascular coagulation, cerebral hemorrhgae, hepatic failure, acute renal failure) Hypertensive disorders occur in 6 to 8% of pregnancies Contribute to neonatal morbitity and mortality
  • Slide 53
  • High Risk Women Under age 20 or over 40 Poor nutritional status Smoking Overweight Other health problems such as renal disease, endocrine disorders (diabetes), autoimmune diseases (lupus) Multiple gestation Some fetal anomalies History of preeclampsia Risk 10% with mild preeclampsia late in pregnancy Risk 40% with severe preeclampsia started early in pregnancy
  • Slide 54
  • Risk Also Associated with: Primigravidity Genetic disease factors Familial predisposition family history of hypertension
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  • Use of PIH Public Health Population-based prevention vs. Medical Clinical Treatment New WIC risk criteria to be implemented in 2011: The term pregnancy induced hypertension includes gestational hypertension, preeclampsia and eclampsia. OG of Canada, 2008 Clinical treatment guidelines: The term PIH (pregnancy induced hypertension) should be abandoned as its meaning in clinical practice is unclear.
  • Slide 56
  • WORKING GROUP REPORT ON HIGH BLOOD PRESSURE IN PREGNANCY N A T I O N A L I N S T I T U T E S O F H E A L T H N A T I O N A L H E A R T, L U N G, A N D B L O O D I N S T I T U T E July 2000
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