obesity in pregnancy - final

8/9/2019 Obesity in Pregnancy - Final

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OBESITY INPREGNANCY

Presenters: Lecturer:- Umesh Shanker Aiyar - Dr Neena- Ngiam Sin Yee- Dharini Subramaniam


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Introduction Obesity is a complex costly and debilitatin!

condition" Causes si!ni#cant complications $or t%e mot%er and

t%e $etus T%e mec%anism seems to be related to t%e

endocrine milieu associated &it% obesity ' increasedle(els o$ insulin andro!ens and leptin)" Obese &omen s%ould be encoura!ed to underta*e a

&ei!%t mana!ement pro!ram prior to an attempt atconception"

T%ey s%ould also try to maintain or ac%ie(e a normalB+I bet&een pre!nancies to minimi,e ris*s o$ad(erse pre!nancy outcomes in t%e $uture as &ellas t%e !eneral %ealt% ris*s o$ obesity"


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+aternal &ei!%t and &ei!%t !ain-e#nitions and !uidelines"

- In .//0 t%e Institute o$ +edicine 'IO+)recommended t%at B+I to be used to de#nematernal &ei!%t !roups"

- Obesity &as de#ned as B+I 1 23*!4m2

Pre(alence o$ obesity durin! pre!nancy

-

5aries $rom 67238 dependin! on de#nition yearc%aracteristics o$ study population- -ata $rom 20097200: National ;ealt% < Nutrition

Examination Sur(ey 'N;A=ES) s%o&ed t%at 23"/8o$ &omen o$ reproducti(e a!e &ere obese 'B+I 190) and 38 &ere extremely obese 'B+I 1 :0)


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All maternity units s%ould %a(e accessiblemultidisciplinary !uidelines &%ic% are communicated toall indi(iduals and or!anisations pro(idin! care topre!nant &omen &it% a boo*in! B+I >90" T%ese

!uidelines s%ould include consideration o$?@ Re$erral criteria@ acilities and e uipment@ Care in pre!nancy@ Place o$ birt% and care in labour@ Pro(ision o$ anaest%etic ser(ices@ +ana!ement o$ obstetric emer!encies@ Postnatal ad(ice

Obesity in pre!nancy is reco!nised by t%e N;Siti!ation Aut%ority 'N;S A)Ds Clinical Ne!li!ence

Sc%eme $or Trusts as one o$ t%e %i!% ris* conditions re uirin! t%e

a(ailability o$ a local !uideline at all maternity units"


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ertility and early pre!nancyissues

." Sub$ertility +ost commonly related to o(ulatory dys$unction andis also related to polycystic o(ary syndrome 'PCOS)"Increasin! obesity is associated &it% decreasin!spontaneous pre!nancy rates and increasin! time to

pre!nancy"+ec%anism may be related to ad(erse e ects o$ele(ated insulin le(els on o(arian $unction"Also %as ne!ati(e impact on t%e outcome o$ treatmento$ $ertility"

=ei!%t loss can lead to $a(ourable %ormonal c%an!esand impro(ement in $ertility

2" Spontaneous AbortionIncreased ris* o$ miscarria!e may be because obese

&omen o$ten %a(e PCOS or isolated insulin resistance


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Antepartum issues

." Gestational and pre!estational diabetesFris* o$ T2-+ related to insulin resistance in t%e obesestate"American -iabetes Association recommends boo*in! 4. st trimester screenin! $or G-+ in obese pre!nant

&omen"Glucose intolerance associated &it% G-+ resol(espostpartum %o&e(er t%ere is a 2x Fpre(alence o$subse uent T2-+ compared to lean &omen

2" Pre!nancy associated %ypertension+ec%anism is not *no&n" It is su!!ested t%atpat%op%ysiolo!ic c%an!es related to cardio(ascular ris*'Insulin resistance %yperlipidemia subclinicalinHammation) are also responsible $or t%e increased

incidence o$ preeclampsia in obese !ra(idas"


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9" Preterm birt%Increased ris* primarily associated &it% obesity relatedcomplications rat%er t%an an intrinsic predisposition tospontaneous preterm birt%"

:" Post term pre!nancy 7 Increased ris*

" +ulti$etal pre!nancy

F incidence o$ di,y!otic but not mono,y!otic t&ins%a(e been reported" T%is association %as been attributed to ele(ated S;le(els"

6" +acrosomia and subse uent &ei!%tF prepre!nancy &ei!%t %as a linear relations%ip &it%birt% &ei!%t as a result F ris* o$ deli(erin! GA in$ant"

T%is relations%ip is independent o$ t%e increasedpre(alence o$ G-+ in obese &omen"


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J" T%romboembolic complications"Pre!nancy itsel$ is a prot%rombotic state &it% F inplasma concentration o$ $actors . J 3 < .0 a K

in protein s and in%ibition o$ #brinolysis resultin!in L ris* o$ (enous t%rombosis"Obesity &it% B+I 1 90 F ris* o$ t%rombosis 2L"

3" Con!enital anomalies"F ris* o$ con!enital anomalies especially neuraltube de$ects and ris*s may F&it% increasin!maternal &ei!%t"+ec%anism not *no&n but li*ely related toaltered nutritional milieu $or $etal de(elopment"Anomalies are more diMcult to detect &it%prenatal SG in obese &omen resultin! in $e&erantepartum dia!noses and more a ected li(e

borns and stillborns amon! birt%s to obese&omen"


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INTRAPARTUMISSUES

Increased ris* o$ prolon!ed labour Increased rate o$ induction o$

labour due to G-+ and

%ypertension ;i!%er incidences o$ prolon!ed

pre!nancy 5a!inal deli(eries a$ter caesarean

deli(ery less li*ely to be success$ul Increased incidences o$

instrumental deli(eries


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Increase in electi(e andemer!ency caesarean section

due to CP- 4 $ailure to pro!ress Complications durin! caesarean

section?

7 Prolon!ed incision to deli(eryinter(al 7 blood loss 1.000ml 7 lon!er operati(e time 7 &ound in$ection 7 t%romboembolism 7 endometritis


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ANEST ETI!MANA"EMENT

consultation &it% an obstetricanaest%etist

Obese pre!nant &omen %a(e ? 7 more initial epidural $ailure

rate 7 increased rate o$ diMcult

intubation 7 problems &it% placement o$

cat%eters


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#ther c$m%&icati$ns

macrosomia S%oulder dystocia +alpresentation

;emorr%a!e : t% de!ree perineal lacerations


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P#STPARTUM ISSUES IN'E!TI#N - increased ris* o$ &ound

episiotomy endometritis - &ound in$ection? poor

(ascularity o$ subcutaneous$ats and $ormation o$ seromasand %ematoma


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P#STPARTUM EM#RR A"E 7 due to increased incidence o$

macrosomia7 or reduced bioa(ailability o$

uterotonic a!ents at standard doses

(REAST'EEDIN" - increased $ailure to initiatelactation < decreased duration o$lactation

7 obese mot%ers %a(e lo&erprolactin response to suc*lin! in t%e. st &ee* postpartum


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PERINATAL#UT!#MES

Increased incidences o$ stillbirt%sdue to? 7

7 %i!%er rates o$ diabetes and

%ypertension 7 metabolic c%an!es suc% as

%yperlipidemia reduced prostacyclinproduction

7 decreased a&areness o$ $etalmo(ement7 nocturnal apnea &it% transient

oxy!en desaturation


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RE!#MMENDATI#NS Recommendations $or &ei!%t !ain

durin! pre!nancy

Glucose tolerance test 6 &ee*s a$terc%ildbirt% $or t%ose dia!nosed &it%G-+ re!ular $ollo& up a$ter t%at

DES!RIPTI#N =EIG;T GAIN

nder&ei!%t .2"J .3"2 *!

Normal ..": . "/ *!O(er&ei!%t 6"3 ..": *!

Obese 6"3*!


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Exercise durin! pre!nancy 7 minimum 90 minutes $or

most days o$ t%e &ee* i$ note(ery day

7 primary pre(ention o$

!estational diabetes 7 %elp$ul ad uncti(e t%erapy

&%en eu!lycemia is not

ac%ie(ed by diet alone


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T%romboprop%ylaxis

=omen &it% a boo*in! B+I >90re uirin! p%armacolo!icalt%romboprop%ylaxis s%ould be prescribeddoses appropriate $or maternal &ei!%t

7 /.7.90*! ? 60 m! Enoxaparin J 00 units-alteparin J000 units Tin,aparin daily

7 .9.7.J0 *! ? 30 m! Enoxaparin .0000 units-alteparin /000 units Tin,aparin daily

7 1.J0*! ? 0"6 m!4*!4day Enoxaparin Junits4*!4day -alteparin J units4*!4day

Tin,aparin


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mobilise as early as practicable$ollo&in! c%ildbirt% to reduce

t%e ris* o$ t%romboembolism All &omen &it% a B+I >:0

s%ould be o ered postnatal

t%romboprop%ylaxis re!ardlesso$ t%eir mode o$ deli(ery


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Recommendations $or all&omen7 record %ei!%t and &ei!%t at

initial prenatal (isit tocalculate B+I

7 discuss t%e recommended&ei!%t !ain durin! pre!nancy

7


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E)ects $* e+cess ,eightgain materna& ,eight $n $) s%ring :

+aternal o(er nutrition4 ;i!% B+I

Increased $etal plasma !lucose andinsulin concentrations

Increased leptin synt%esis

obesity in pregnancy - final

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