Obesity in PregnancyObesity in Pregnancy

Erin Shaw, CNM, MSErin Shaw, CNM, MS

Certified Nurse-Midwives at Certified Nurse-Midwives at

St. Anthony Central HospitalSt. Anthony Central Hospital

ObjectivesObjectives

Define overweight/obesity based on Define overweight/obesity based on NIH/WHO guidelinesNIH/WHO guidelines

List 3 maternal medical complications List 3 maternal medical complications associated with obesityassociated with obesity

List 3 potential obstetrical risks associated List 3 potential obstetrical risks associated with obesity with obesity

Discuss challenges associated with Discuss challenges associated with assessment of both mother and fetus assessment of both mother and fetus during the AP/IP and PP periodduring the AP/IP and PP period

NIH/WHO definitionsNIH/WHO definitions

• Underweight BMI < 19.8Underweight BMI < 19.8

• Normal weight BMI 19.8 – 26.0Normal weight BMI 19.8 – 26.0

• Overweight BMI 26.1 – 29.0Overweight BMI 26.1 – 29.0

• ObeseObese BMI > 29.0 BMI > 29.0

Calculation of BMI:Calculation of BMI:

BMI = weight in kg / height in meters sqBMI = weight in kg / height in meters sq

Incidence Incidence

In US 56% of non-pregnant women of child-In US 56% of non-pregnant women of child-bearing age are overweight (BMI 26-29)bearing age are overweight (BMI 26-29)

30% of non-pregnant women of childbearing 30% of non-pregnant women of childbearing age are obese (BMI >29)age are obese (BMI >29)

• Worldwide BMI > 30 15 – 20%Worldwide BMI > 30 15 – 20%

Accounts for 2 – 7% of total healthcare costsAccounts for 2 – 7% of total healthcare costs

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2007

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

In the US:In the US:

• Thinnest state: Colorado with 18.4% of Thinnest state: Colorado with 18.4% of adults who are obeseadults who are obese

• Next five: Hawaii, Connecticut, Next five: Hawaii, Connecticut, Massachusetts, Vermont and Rhode Island Massachusetts, Vermont and Rhode Island all at 21%all at 21%

• Most obese state: Mississippi with 31.7% Most obese state: Mississippi with 31.7% obesity rateobesity rate

• Next five: W. Virginia 31%; Alabama & Next five: W. Virginia 31%; Alabama & Louisiana 30%; S. Carolina & Tennessee 29%Louisiana 30%; S. Carolina & Tennessee 29%

Info from “F as in Fat: How Obesity Policies are Failing in America” report – their data come Info from “F as in Fat: How Obesity Policies are Failing in America” report – their data come from CDC 2005-2007 Behavior Risk Factor Surveillance Surveysfrom CDC 2005-2007 Behavior Risk Factor Surveillance Surveys

Current weight gain Current weight gain recommendationsrecommendations(Institute of Medicine)(Institute of Medicine)

• For underweight women: 28 – 40 lbsFor underweight women: 28 – 40 lbs

• For normal weight women: 25 – 35 For normal weight women: 25 – 35 lbslbs

• For overweight women: 15 – 25 lbsFor overweight women: 15 – 25 lbs

• For obese women: 15 lbsFor obese women: 15 lbs

Maternal medical risks Maternal medical risks associated with obesityassociated with obesity

Increased incidence of: Increased incidence of: • Metabolic syndrome (dyslipidemia, HTN, Metabolic syndrome (dyslipidemia, HTN,

insulin resistance)insulin resistance)• Type II diabetesType II diabetes• Coronary artery diseaseCoronary artery disease• Gallbladder diseaseGallbladder disease• OsteoarthritisOsteoarthritis• Sleep apneaSleep apnea• Cancer: breast, colon, endometrialCancer: breast, colon, endometrial

Antepartum risks associated Antepartum risks associated with obesitywith obesity

• Gestational diabetesGestational diabetes

• Gestational hypertensionGestational hypertension

• Pre-eclampsiaPre-eclampsia

• Early increased risk of miscarriageEarly increased risk of miscarriage

• Increased incidence of congenital Increased incidence of congenital defectsdefects

(heart defects and neural tube (heart defects and neural tube defects)defects)

Intrapartum risks associated Intrapartum risks associated with obesitywith obesity

Increased incidence of:Increased incidence of:

induction of laborinduction of labor

longer laborlonger labor

less successful VBAC ratesless successful VBAC rates

cesarean delivery (CPD and FTP)cesarean delivery (CPD and FTP)

shoulder dystociashoulder dystocia

Postpartum risks associated Postpartum risks associated with obesitywith obesity

Increased incidence of:Increased incidence of:

Infection – wound, episiotomy, endometritisInfection – wound, episiotomy, endometritisPostpartum hemorrhagePostpartum hemorrhageDVTDVT

Obesity and excess gestational weight gain Obesity and excess gestational weight gain are associated with an increased risk of are associated with an increased risk of

failure to initiate lactation and decreased failure to initiate lactation and decreased duration of lactation.duration of lactation.

Perinatal outcomesPerinatal outcomes

Congenital anomaliesCongenital anomalies– Neural tube defectsNeural tube defects– Heart defectsHeart defects

PrematurityPrematurity

Stillbirth (diabetes, decreased Stillbirth (diabetes, decreased awareness of fetal movement)awareness of fetal movement)

MacrosomiaMacrosomia

Challenges associated with Challenges associated with assessing both mother and assessing both mother and babybaby• Estimating fetal weightEstimating fetal weight

• Auscultating FHRAuscultating FHR

• Taking maternal BPTaking maternal BP

• Anesthesia problemsAnesthesia problems

• Cesarean deliveryCesarean delivery

• Monitoring uterine contractionsMonitoring uterine contractions

• Ultrasound Ultrasound

Estimated fetal weight Estimated fetal weight assessmentassessment

Difficulty with Leopold’s maneuverDifficulty with Leopold’s maneuver try to determine the outline of the uterustry to determine the outline of the uterus and establish the fundus firstand establish the fundus first

Ask mom where she feels fetal movementAsk mom where she feels fetal movement and use information to establish fetal and use information to establish fetal

contourscontours

When in doubt – try ultrasound, but When in doubt – try ultrasound, but remember accuracy of EFW by US remember accuracy of EFW by US decreases with increasing gestational age!decreases with increasing gestational age!

Auscultating FHRAuscultating FHR

In AP period, try to establish location of In AP period, try to establish location of fetal back first, if difficulty with fetal back first, if difficulty with doppler, try monitordoppler, try monitor

In IP period, if unable to auscultate, In IP period, if unable to auscultate, may need an FSE (remember may need an FSE (remember increased risk of infection)increased risk of infection)

Assessing maternal BPAssessing maternal BP

Important to use appropriate size cuffImportant to use appropriate size cuff

Have large cuff available in clinic Have large cuff available in clinic setting as well as IP settingsetting as well as IP setting

Anesthesia issuesAnesthesia issues

May be difficult to place epidural or spinal May be difficult to place epidural or spinal anesthesia, requiring multiple attemptsanesthesia, requiring multiple attempts

General anesthesia risks include difficult General anesthesia risks include difficult intubation, and post partum sleep intubation, and post partum sleep apnea.apnea.

Anesthesia consult before labor may be Anesthesia consult before labor may be helpful.helpful.

Risks associated with Cesarean Risks associated with Cesarean deliverydelivery

• Longer incision to delivery timeLonger incision to delivery time

• Increased incidence of postpartum Increased incidence of postpartum hemorrhagehemorrhage

• DVTDVT

• Increased incidence of wound infection Increased incidence of wound infection and delayed healingand delayed healing

• Anesthesia issues as mentioned aboveAnesthesia issues as mentioned above

Difficulty in assessing uterine Difficulty in assessing uterine contraction activitycontraction activity

Often difficult to assess using external Often difficult to assess using external monitormonitor

Also sometimes difficult to palpate Also sometimes difficult to palpate accuratelyaccurately

Consider use of IUPCConsider use of IUPC

Problems associated with Problems associated with ultrasound in the obese motherultrasound in the obese mother

Suboptimal imagesSuboptimal images

May be difficult to visualize fetal May be difficult to visualize fetal defectsdefects

US assessments are often necessary to US assessments are often necessary to evaluate fetal growthevaluate fetal growth

Surgical interventions including Surgical interventions including gastric bypass and lap band gastric bypass and lap band proceduresprocedures• Advantages:Advantages:

– Decreased incidence of GDMDecreased incidence of GDM– Decreased incidence of macrosomiaDecreased incidence of macrosomia– Decreased incidence of cesarean sectionDecreased incidence of cesarean section

• Disadvantages:Disadvantages:−Increased risk of anemiaIncreased risk of anemia−B12 deficiencyB12 deficiency−Increased risk of IUGR, prematurity, neural Increased risk of IUGR, prematurity, neural

tube defect, and GI bleedtube defect, and GI bleed

RecommendationsRecommendations

• Calculate BMI on all patients at first Calculate BMI on all patients at first OB visitOB visit

• Offer nutritional counseling and Offer nutritional counseling and exercise recommendations and stress exercise recommendations and stress importance of appropriate weight gainimportance of appropriate weight gain

• Early GDM screening Early GDM screening • Review potential problems associated Review potential problems associated

with assessmentwith assessment

Nutrition.Nutrition.....

The Key The Key to Your to Your HealthHealth

ReferencesReferencesCatalano, P. Management of Obesity in Pregnancy. Obstetrics & Gynecology 2007; Catalano, P. Management of Obesity in Pregnancy. Obstetrics & Gynecology 2007;

109(2) part I; 419-433.109(2) part I; 419-433.

Myles, T., Gooch, J., Santolaya, J. Obesity as an Independent Risk Factor for Infectious Myles, T., Gooch, J., Santolaya, J. Obesity as an Independent Risk Factor for Infectious Morbidity in Patients Who Undergo Cesarean Delivery. Obstetrics & Gynecology Morbidity in Patients Who Undergo Cesarean Delivery. Obstetrics & Gynecology 2002; 100(5); 959-964.2002; 100(5); 959-964.

Ockenden, J. Obesity and complications of pregnancy and birth. The Practicing Midwife Ockenden, J. Obesity and complications of pregnancy and birth. The Practicing Midwife 2008; 36-39.2008; 36-39.

Robinson, H., O’Connell, C., Joseph, K., McLeod, N. Maternal Outcomes in Pregnancies Robinson, H., O’Connell, C., Joseph, K., McLeod, N. Maternal Outcomes in Pregnancies Complicated by Obesity. Obstetrics & Gynecology 2005; 106(6); 1357-1364.Complicated by Obesity. Obstetrics & Gynecology 2005; 106(6); 1357-1364.

Rouse, D., Nuthalapaty, F. The Impact of Obesity on Fertility and Pregnancy. Retrieved Rouse, D., Nuthalapaty, F. The Impact of Obesity on Fertility and Pregnancy. Retrieved June 17, 2008 from Up to Date Website: June 17, 2008 from Up to Date Website: http://www.utdol.com/online/content/topic.do?topicKey=antenatl/19564&view=print.http://www.utdol.com/online/content/topic.do?topicKey=antenatl/19564&view=print.

Smith, S., Hulsey, T., Goodnight, W. Effects of Obesity of Pregnancy. JOGNN 2008; 176-Smith, S., Hulsey, T., Goodnight, W. Effects of Obesity of Pregnancy. JOGNN 2008; 176-184.184.