obesity and pregnancy

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  • 09.12.2016

    1

    Obez Gebelerde Obstetrik Sorunlar

    Dr Tevfik YoldemirMarmara niversitesi Tp Fakltesi Kadn Hastalklar ve Doum A.D.

    reme Endokrinolojisi ve nfertilite B.D.

    tevfik@yoldemir.com

    classification

    Obesity related risks Maternal Complications

    Hypertensive Disorders of Pregnancy

    a twofold increase in risk for mild or severe preeclampsia for overweight women (BMI 25.029.9),

    approximately a threefold increase for obese women (BMI 30.034.9), and

    a fivefold increase in the risk for preeclampsia for severely obese women (BMI 35.039.9)

    Medical Journal of Australia, 2006;184, 5659.

    Epidemiology, 2007:18(2), 234239. Obstetrics and Gynecology, 2004;103, 219224.

    Evidence from the Framingham Heart Study, a prospective population-based cohort study, demonstrated that hypertension and coronary artery disease were more common in obese and

    overweight individuals at all ages.

    Relative risk (RR) for hypertension in overweightadults was found to be 1.5 to 1.7.

    RR was found to be 2.2 to 2.6 for obese adults.

    It is important to establish baseline blood pressure values in early pregnancy, and care should be taken to use properly properly sizedsized blood pressure cuffs blood pressure cuffs in order to ensure accurate measurements.

    Additionally, evaluation of end-organ effects of hypertensive disease, such as heart failure or nephropathy, should be considered.

    Comprehensive evaluation of cardiac function may require electrocardiographic orelectrocardiographic or echocardiographicechocardiographic testingtesting.

    Renal function is commonly assessed by a 2424--hour urinehour urineevaluation to measure total protein excretion.

    Journal of the American Medical Association, 2003:290, 199206.

    Blood Pressure Monitor, 2001: 6, 1720.

  • 09.12.2016

    2

    Diabetes Mellitus

    The second trimester of pregnancy is a physiologic stateof insulin resistanceinsulin resistance. Hormones produced by the placenta lead to mild levels of maternal hyperglycemia in order to promote adequate fetal growth and

    development.

    Most gravidas adapt readily to this event. In somewomen, however, pancreatic insulin secretion is not adequate to counter the diabetogenic hormones.

    Women who have normal serum glucose levels prior to pregnancy demonstrate abnormally high postprandial and fasting serum glucose levels during pregnancy.

    Gestational diabetes

    This transient disease process is known as gestational diabetes.

    Preeclampsia, disordered fetal growth, neonatal metabolic complications such as hyperbilirubinemiaand hyperglycemia, and even fetal death are the adverse effects.

    Adipocytes participate in several important signaling pathways that influence insulin sensitivity in the peripheral tissues. As a result, obese women are at increased risk for developing gestational diabetes.

    American Journal of Physiology, 2001: Endocrinology and

    Metabolism, 280, E827E847

    Gestational diabetes

    The relative risk of developing gestational diabetesin obese women (prepregnancy BMI 25 to 30) was reported to be 1.68 (99% confidence interval [CI] 1.53 to 1.84)

    severely obese women (prepregnancy BMI greater than 30) to be 3.6 (99% CI 3.25 to 3.98)

    International Journal of Obesity Related Metabolic Disorders,25, 11751182

    Obese women (BMI greater than 29) demonstrated a relative risk for developing gestational diabetes of 4.53 (95% CI 1.25 to 16.43).

    American Journal of Epidemiology, 2007:165, 302308.

    Diabetes

    weight gain between the age of 18 years and the study pregnancy of greater than or equal to 10 kilograms conferred a relative risk of 3.43 (95% CI 1.60 to 7.37) when compared with women who had

    less than a 3-kilogram weight change over the same period

    American Journal of Epidemiology, 2007:165, 302308

    A linear relationship exits between increasing BMI and increasing incidence of diabetes.

    Diabetes

    Even after adjusting for family history, levels of exercise, and dietary habits, the relative risk of future development of type II diabetes was 11.2 for women in the top tenth percentile of BMI when compared

    with women in the lowest tenth percentile.

    The relative risk for a diagnosis of diabetes during pregnancy for overweight women (prepregnancyBMI 25 to 30) was found to be 3.4 (95% CI 1.7 to 6.8)

    and for severely obese women (prepregnancy BMIgreater than 30) was found to be 15.3 (95% CI 8.2 to 28.6) when compared with normal weight women

    The Nurses Health Study. American Journal of Epidemiology, 1997:145, 614619

    Obstetrics and Gynecology, 2005:105, 537542

    A large number of obese women may in fact have undiagnosed Type II diabetes, which is manifest by abnormal glucose tolerance testing prior to 20 weeks of gestation.

    For obese women who develop gestational diabetes, promoting tight controltight control of blood glucose of blood glucose values optimizes both maternal and fetal outcomes.

    The most successful management approaches are multidisciplinarymultidisciplinary and include physicians, nurse-educators, and dietitians.

  • 09.12.2016

    3

    Nutrition & Weight Gain

    those with a high prepregnancy BMI were more than four times as likely to report target gains above IOM guidelines.

    weight gains above the IOM recommendations were observed for

    23% of the underweight women,

    49% of the normal weight women,

    70% of the overweight women, and

    57% of the obese women.

    Obstetrics and Gynecology, 2005;105, 633638

    Obstetrics and Gynecology, 1995; 86, 170176.American Journal of Public Health, 1997;87, 19841988

    30% weighed less one year after delivery than they did before pregnancy, 56% gained 0 to 5 kilograms over the same time period, and 14% gained more than 5 kilograms.

    Risk factors for postpartum weight retention in thisstudy were excessive pregnancy weight gain, high prepregnancy BMI, and maternal age greater than 36 years

    It appears that overweight and obese women are at increased risk for excessive pregnancy weight gainand elevated postpartum weight retention.

    International Journal of Obesity, 1990;14, 159173.

    Fetal Complications

    Macrosomia

    It is associated with shoulder dystocia, birth trauma, and/or Cesarean delivery.

    ACOGs recommendation for the term fetal macrosomia, on the other hand, is that it should be reserved for those infants weighing more than 4,000 or 4,500 grams at birth

    ACOG Technical Bulletin Number 22November 2000.

    Obstetrics and Gynecology, 96, 341345.

    Factors that may predispose to fetal macrosomiainclude: pregestational or gestational diabetes, prepregnancy maternal obesity or overweight

    status, excessive weight gain during pregnancy,

    multiparity, male fetus, as well as constitutional factors such as ethnicity, maternal birth weight, and maternal height.

    Increasing maternal weight is an independent

    variable for a macrosomic or large for gestational age infant

    American Journal of Obstetrics and Gynecology, 2004; 191, 964968.

    Obstetrics and Gynecology, 2003;102, 10221027.

    odds ratios for large for gestational age infants to be increased for women with

    a BMI 29.1 to 35 OR 2.20 (95% CI 2.14 to 2.26),

    a BMI 35.1 to 40 OR 3.11 (95% CI 2.96 to 3.27), and

    women with a BMI greater than 40 OR 3.82 (3.56 to 4.16).

    Obstetrics and Gynecology, 2004;103, 219224.

  • 09.12.2016

    4

    Congenital anomalies

    The overall incidence ranges from 2 to 4% of all pregnancies.

    The most common anomalies are neural tube defects, congenital cardiac malformations, orofacial

    clefts, and Trisomy 21.

    Obese women are at higher risk for having an infantwith congenital cardiac defects, orofacial clefts, andneural tube defects.

    Morbidity and Mortality Weekly 2006;Report, 54, 13011305.

    American Journal of Obstetrics and Gynecology, 1994;170, 541548Paediatric Perinatal Epidemiology, 2000;14, 234239.

    Obese women (BMI greater than or equal to 30) were more likely to have an infant with a neural tube defect (OR: 3.5, 95% CI: 1.2 to 10.3), omphalocele(OR: 3.3; 95% CI: 1.0 to 10.3), heart defects (OR: 2.0;

    95% CI: 1.2 to 3.4), or multiple anomalies (OR: 2.0; 95% CI: 1.0 to 3.8).

    Overweight women (BMI 25 to 29.9) also were more likely than average-weight women to have infants

    with heart defects (OR: 2.0; 95% CI: 1.2 to 3.1) and multiple anomalies (OR:1.9; 95% CI: 1.1 to 3.4).

    Pediatrics, 2003;111, 11521158

    The rate of incomplete or suboptimalincomplete or suboptimal visualization visualization of the fetal cardiac structures was as high as 37.3% in obese women, compared with only 18.7% in average-weight women.

    Similar findings were documented for craniospinalstructures, with a suboptimalsuboptimal visualization visualization rate of 42.8% compared with 29.5% in average-weightwomen

    International Journal of Obesity Related Metabolic Disorders, 2004; 28, 16071611

    Fetal Demise

    Fetal problems, including congenital anomalies,account for 25% of antepartum fetal deaths.

    Maternal problems, including preeclampsia anddiabetes, account for another 10%.

    Placental or umbilical cord problems such as

    placental abruption or true knots in the umbilical cord account for 25% to 30% of intrauterine fetal deaths.

    The odds ratio of 2.7 (95% CI 1.5 to 5.0) for the risk of fetal death in overweight women (BMI 25.0 to 29.9), and 2.8 (95% CI, 1.3 to 6.0) for obese women (BMI greater than or equal to 30) were reported.

    American Journal of Obstetrics and Gynecology, 2001;184, 4

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