Maternal deaths are extremely rare in the UK comparedto the international average: 149 women died fromobstetric-related causes between 2003 and 2005, a rate of seven deaths per 100 000 maternities.1 Globally, thevast majority of women die from obstetric bleeding,obstructed labour, infection, eclampsia and the conse-quences of illegal abortion. However, in the UK the mostcommon causes were thromboembolism and cardiac disease, although maternal deaths directly related to diabetes were extremely rare. In general, the womenwho died were in poorer overall health, smoked moreand tended to be overweight or obese.

History relates...Obesity in women has been known for at least 25 000years, as demonstrated by a series of prehistoric figurines– the most famous of which is the Venus of Willendorf –which, ironically, were thought to represent fertility symbols. Even Hippocrates was aware of the seriousnature of the obese state, recognising that obese womenactually tend to be infertile. Over recent centuries, menof science have discovered and mapped out the clinicalbasis to these observations.

In 1751, Dr Thomas Mead made an amazingly pre-scient statement in ‘Monita et praecepta medica’, predictingby 250 years the discovery that foetal neural and meta-bolic pathways are laid down in pregnancy, dependingon the mother’s lifestyle, which already predispose theunborn child to obesity and reduced life expectancy. Hedescribed ‘…the sloth and luxury of the rich! ... theirvicious inclinations [which] render them obnoxious tovarious diseases … Their children are tainted in theirmother’s womb, with distempers which affect theirwhole lives, and hardly permit them, diseased anddecrepid, to arrive at the threshold of old age.’

In 1765, Joannes Baptista Morgagni recognised notonly that obesity is linked to disease, but also, byanatomical dissection, that the position of the fat wascrucial.2 He described a female patient with severe obesity and virili aspectu (manly, or virile aspect) – whatwe now recognise as polycystic ovarian syndrome(PCOS). The abdomen is noted to be prominent andcontain a large amount of fat accumulated in the intra-abdominal spaces and at the mediastinal level, with araised diaphragm.

In 1795, Dr William Buchan, author of ‘DomesticMedicine’, linked poor lifestyle choices in ‘women of agross or full habit’ with gynaecological disorders –‘obstruction of the menses’ – and infertility: ‘Takingimproper food, violent affections of the mind, or catch-ing cold at this period, is often sufficient to ruin thehealth, or to render the female ever after incapable ofprocreation … We would therefore recommend it to allwho wish to escape these calamities, to avoid indolenceand inactivity, as their greatest enemies, and to be asmuch abroad in the open air as possible. Another thingwhich proves very hurtful to girls about this period oflife, is unwholesome food. Fond of all manner of trash,

they often indulge in it, till their whole humours arequite vitiated: ... Accordingly we find, that such girls aslead an indolent life, and eat great quantities of trash,are not only subject to obstructions of the menses, butlikewise glandular obstructions; as the scrophula orking’s evil, &c.’

...and the latest CEMACH report findingsThe Confidential Enquiry into Maternal and ChildHealth (CEMACH) report, ‘Saving Mothers’ Lives’,1 waslaunched in December 2007, and serves not only tohighlight the possible reasons for maternal mortality, butalso to expose the limitations of clinical management inmany cases, and make recommendations to avoid similarpitfalls in the future.

A maternal death is defined as the death of a womanwhile pregnant or within six weeks after pregnancy –whatever the outcome of that pregnancy may be (live orstillbirth, a spontaneous or induced abortion or ectopicpregnancy) – from any cause related to or aggravated bythe pregnancy or its management, but excluding accidental or incidental causes. Put simply, it is a mater-nal death if the woman would not have died had she notbeen pregnant. Direct maternal deaths result from conditions which are unique to pregnancy, and indirectmaternal deaths result from previously existing diseaseor disease that develops during pregnancy, but notdirectly due to obstetric causes – examples are epilepsy,diabetes, and cardiovascular disease. A major theme run-ning through the report – as a contributor to mortalityrates – is maternal obesity.

Risks associated with maternal obesityObesity increases the risk of every major complication ofpregnancy, but is also a significant cause of infertility,interfering with normal reproductive function leading toirregular and anovulatory cycles. Obesity and overweightshould not be ignored in the evaluation of infertility, andweight management should be first-line treatment. Notonly is fertility affected by obesity, but the chances ofundergoing successful IVF treatment are reduced. Even ifIVF treatment is successful, obese women have a higherrisk of complications and miscarriage. Women with abody mass index (BMI) of 30–35 have a 50% extra risk; women with a BMI >35 have up to double the risk of miscarriage.

The risk of the pregnant mother being hospitalisedduring pregnancy increases four-fold in the presenceobesity. If the BMI is >35, the risks increase to six- orseven-fold. In America, the Surgeon General’s Call toAction on obesity pointed out:• Obesity during pregnancy is associated with increasedrisk of death in both the baby and the mother andincreases the risk of maternal high blood pressure by 10 times.• In addition to many other complications, women whoare obese during pregnancy are more likely to have gesta-tional diabetes and problems with labour and delivery.

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• Infants born to women who are obese during preg-nancy are more likely to be high birthweight and, there-fore, may face a higher risk of Caesarian section deliveryand low blood glucose (which can be associated withbrain damage and seizures).• Obesity during pregnancy is associated with increasedrisk of birth defects, particularly neural tube defects suchas spina bifida.

A study3 of 100 000 primigravidas demonstrated thatobese women had a five-fold risk of being diagnosedwith gestational diabetes, and were three times as likelyto have pre-eclampsia or eclampsia. Overweight womenwere nearly twice as likely to have a Caesarian sectioncompared to their lean counterparts, and obese womenhad a three-fold risk. However, the study also suggestedthat deliberate weight loss prior to pregnancy made little difference to the outcome – only not having beenobese or overweight in the first place was protective.Furthermore, weight loss during the first month ofpregnancy actually increases the risk of neural tubedefects. Despite these facts, CEMACH recommendsthat, where possible, obese women should be helped to lose weight prior to conception or any form ofassisted reproduction in order to reduce the inequali-ties in pregnancy outcomes that currently exist betweenthe most advantaged and the most vulnerable mothersand babies.

Other risks to the foetus include macrosomia, even innon-diabetic mothers, growth retardation, stillbirth, andbirth defects including neural tube abnormalities.4Other congenital abnormalities include cardiac defects,orofacial clefts, club foot and abdominal wall defects.There is a three-fold increase in musculoskeletal andcraniofacial abnormalities when the pregnant motherhas both obesity and diabetes. Obese mothers have twicethe risk of stillbirth, as well as more chance of meconiumileus, late decelerations and shoulder dystocia.5 Otherstudies have demonstrated different complications,including increased risk of urinary tract infections andthrombophlebitis, operative risk such as increased anaes-thetic requirement, wound infection, dehiscence andthromboembolic events.3,5,6–9

Respiratory complications occur more in obesewomen during pregnancy. These include obstructivesleep apnoea, hypoxia, and hypercapnia, which maylead to intrauterine growth retardation in the foetus,and hypertension and increased cardiovascular risk inthe mother.10

Abdominal obesity is a physical sign of seriousunderlying pathology, and the complex physiologicalprocesses are common to diabetes, cardiovascular disease, PCOS, non-alcoholic steatohepatitis and othertraditional, as well as less well recognised, constituentsof the metabolic syndrome. Nearly 40% of women with PCOS have been reported as having impaired glucose tolerance or overt type 2 diabetes,11 and PCOSis also associated with raised LDL-C, reduced HDL-C,and hypertension. Obesity is a risk factor for bothdirect and indirect causes of maternal death as definedby CEMACH.

Avoidable deaths due to obesity and/or diabetesMore than half of all the women who died during theperiod of the CEMACH report (2003–2005) were eitheroverweight or obese, and more than 15% were morbidlyor super-morbidly obese. Excess weight was particularlyclosely linked with cardiac disease, thrombosis and infec-tion, although the risk was raised for all causes of mortal-ity. Moreover, the report exposes the fact that manydeaths were potentially avoidable, if recommended practices had been observed – including adequate pre-pregnancy counselling, and care during pregnancy andlabour, especially for those with obesity or diabetes. Thereport states: ‘The assessors were struck by the numberof health care professionals who appeared to fail to beable to identify and manage common medical condi-tions or potential emergencies outside their immediatearea of expertise. Resuscitation skills were also consid-ered poor in an unacceptably high number of cases.’

Although deaths relating to diabetes were rare, oneparticular case study demonstrates such shortcomings.One woman developed diabetes in pregnancy which, inretrospect, had probably been the first manifestation oftype 1 diabetes. Unfortunately, she did not receive anymedical follow up after delivery, insulin was stopped andshe died of diabetic ketoacidosis. Women who developdiabetes in pregnancy must have adequate assessment oftheir glycaemic status after delivery. Women whodevelop gestational diabetes are at higher risk for diabetes in later life, although there is no formal mecha-nism for recurrent screening, and there is often noadvice to patients that they should continue to managetheir weight carefully, and request screening forimpaired glycaemic control throughout life.

Further guidanceBecause of the risk associated with excess weight in preg-nancy, the National Institute for Health and ClinicalExcellence (NICE) has recommended that every preg-nant woman should have her BMI checked at her firstantenatal visit and that women with a BMI >35 are notsuitable for routine midwifery-led care.12 These guide-lines are frequently ignored, although one motherwhose death is reported by CEMACH had a BMI of 62, and another five had BMIs >40, two of whom hadmidwife-only care, in contravention of NICE guidance.The CEMACH report recommends: ‘Because of their co-morbidity, morbidly obese women are unsuitable formidwife-only care.’ Furthermore, ‘Pre-conception coun-selling and support, both opportunistic and planned,should be provided for women of childbearing age withpre-existing serious medical or mental health conditionsthat may be aggravated by pregnancy. This includes obesity. This recommendation especially applies towomen prior to having assisted reproduction and otherfertility treatments.

‘The commoner conditions that require pre-preg-nancy counselling and advice include:• ‘Epilepsy.• ‘Diabetes.• ‘Congenital or known acquired cardiac disease.• ‘Auto-immune disorders.

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• ‘Obesity: a BMI of 30 or more.• ‘Severe pre-existing or past mental illness.’

CEMACH also calls urgently for guidelines for the management of the obese pregnant woman, and is in theprocess of formulating these. • Effective pathways must be established so that physi-cians and obstetricians can communicate properly totreat pregnant women, both in acute illness and duringregular antenatal care.• Regular antenatal care is best managed in a combinedmedical obstetric antenatal clinic.• The consultant obstetrician on call should be toldabout all sick pregnant women in hospital whether theyhave a medical or an obstetric problem.• Multiple attendances and/or readmission without diag-nosis are danger signs of serious undiagnosed disease.• All women with serious medical conditions must bereferred by their midwives or general practitioners forspecialist opinion as early in pregnancy as possible, evenif this means breaking traditional rules about referralpathways and timing.

ConclusionIn summary, pre-existing illnesses or risk factors, includ-ing diabetes and obesity, should be carefully assessed priorto, during, and after pregnancy by a multidisciplinaryteam. Whilst there has been a growth of multidisciplinaryclinics for the management of the more common medicalconditions that might affect pregnant women – such asepilepsy, diabetes and cardiac disease – some of thewomen who died still did not receive such care.

David Haslam, MB, BS, General Practitioner, Clinical Director of the National Obesity Forum, Watton-at-Stone, and Physician in Obesity Medicine,Luton & Dunstable Hospital, Hertfordshire, UK

References1. Lewis G (ed). The Confidential Enquiry into Maternal

and Child Health (CEMACH). Saving Mothers’ Lives:reviewing maternal deaths to make motherhood safer –2003–2005. The Seventh Report on ConfidentialEnquiries into Maternal Deaths in the United Kingdom.London: CEMACH, 2007.

2. ‘Epistola anatoma clinica XXI’ De Sedibuset Causis Morborum perAnatomen indagata. [The Seats and Causes of DiseasesInvestigated by Anatomy].

3. Baeten JM, Bukusi EA, Lambe M. Pregnancy complicationsand outcomes among overweight and obese nulliparouswomen. Am J Public Health 2001; 91: 436–440.

4. Hendricks KA, Nuno OM, Suarez L, et al. Effects of hyper-insulinemia and obesity on risk of neural tube defectsamong Mexican Americans. Epidemiol 2001; 12: 630–635.

5. Garbaciak JA, Richter M, Miller S, et al. Maternal weight andpregnancy complications. Am J Obstet Gynecol 1985; 152:238–245.

6. Galtier-Dereure F, Boegner C, Bringer J. Obesity and preg-nancy: complications and cost. Am J Clin Nutr 2000; 71:1242S–1248S.

7. Kumari AS. Pregnancy outcome in women with morbidobesity. Int J Gynecol Obstet 2001; 73: 101–107.

8. Calandra C, Abell DA, Beischer NA. Maternal obesity inpregnancy. Obstet Gynecol 1981; 57: 8–12.

9. Edwards LE, Dickes WF, Alton IR, et al. Pregnancy in themassively obese. Course, outcome, and obesity prognosis ofthe infant. Am J Obstet Gynecol 1978; 131: 479–483.

10.Vaughan RW, Engelhardt RC, Wise L. Postoperativehypoxemia in obese patients. Ann Surg 1974; 180:877–882.

11.Guzick DS. Cardiovascular Risk in PCOS. J Clin EndocrinolMetab 2004; 89(8): 3694–3695 [accessed at http://www.jcem.endojournals.org/cgi/content/full/89/8/3694]

12. National Collaborating Centre for Women’s and Children’sHealth commissioned by the National Institute for ClinicalExcellence. Antenatal care: routine care for the healthy pregnantwoman. London: RCOG Press, 2003. Available at http://www.nice.org.uk

LEADER

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