OBESITY --IT’S EFFECT IN OBSTETRICS & GYNAECOLOGYProf. M.C.Bansal.

MBBS. M.S. FICOG. MICOG.Founder Principal & Controller ;

Jhalwar Medical College And Hospital, Jhalwar.

Ex. Principal & Controller ;Mahatma Gandhi Medical College &

hospital;Sitapura , Jaipur.

Dr. Ridhi KathuriaPG Student (NIMS MEDICAL COLLEGE, JAIPUR)

Obesity

• Body weight more than 20% the normal weight for his or her optimal height of an individual .

• Body mass index (BMI) is weight in KG divided by height in meters squared. (weight in Kg / Height in square meter e.g. surface area of body ).

Massive Obesity

Apple shape Pear shape Obesity

Epidomology

• Obesity is rapidly increasing all over the world , more so in developed countries and in effluent society of developing countries like India too., owing to over eating . Fast food , soft drinks and marked decrease in physical activities .

• 5% population in India is suffering from Morbid Obesity. 15% women are obese in India.

• Obesity is more common in young women . • Child of normal weight has 10% chances of developing

obesity. • If both parents are obese than there are 80% chances if

obesity development.

Increase In Prevalence Of obesity

Physiology of Adipose Tissue

• Part of “Obesity"• Adipose tissue serves three general functions:• Adipose tissue is a storehouse of energy.• Fat serves as a cushion from trauma.• Adipose tissue plays a role in the regulation of

body heat.

>obesity is a consequence of the fat imbalance inherent in high-calorie diets.>The mechanism for mobilizing energy from fat involves various enzymes and neurohormonal agents. >Following ingestion of fat and its breakdown by gastric and pancreatic lipases, absorption of long-chain triglycerides and free fatty acids takes place in the small bowel. >Chylomicrons (microscopic particles of fat) transferred through lymph channels into the systemic venous circulation are normally removed by hepatic parenchymal cells where a new lipoprotein is released into the circulation.> When this lipoprotein is exposed to adipose tissue, lipolysis takes place through the action of lipoprotein lipase, an enzyme derived from the fat cells themselves. >The fatty acids that are released then enter the fat cells where they are reesterified with glycerophosphate into triglycerides. >Because alcohol diverts fat from oxidation to storage, body weight is directly influenced

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Metabolic Syndrome and Pregnancy

• Pregnant women with metabolic syndrome having Glucose intolerance develop Frank Type 2 diabetes; superimposed PIH ? HEllP syndrome / eclampsia at early mid trimester and need early evaluation , investigations and appropriate / optimal control.

• These women need pre conception counseling for weight loss/ modification of life style , balanced low calorie diet and regular exercise.

Adult Treatment Panel III (ATP III): Criteria for Diagnosis of the Metabolic Syndrome

Patients with three or more of the following:1.Abdominal obesity: waist circumference > 88 cm (34.7 in) in women or > 102 cm (40.2 in) in men2.Hypertriglyceridemia: 150 mg/dL3.High-density lipoprotein (HDL): < 50 mg/dL in women or < 40 mg/dL in men4.High blood pressure: 130/85 mm Hga

5.High fasting glucose: 110 mg/dLa

Causes of Obesity• Familial. • Hyperinsulinism .• Hyper adrenocorticism.• Hypogonadism .• Hypothyroidism• Abnormal Eating Behaviour ---Hormones which

control eating are –ghrelin from stomach, Insulin from pancreas; leptin from fat , PYY-3-36 from colon ; satiety center in hypothalamus control satiety .

Complications Of Obesity during pregnancy

• General – difficulty in work , Fatigue, backache, Depression. • Surgical Problems– Ventral Hernia, Incisional Hernia ,

gallstones , burst abdomen , Fat necrosis , delayed recovery from anaesthesia, difficulty in intra tracheal intubation, difficulty in positioning for spinal / epidural anesthesia

• Obstetrical – miscarriage, stillbirths , PIH, type 2 Diabetes ,IUGR/ large & over weight baby, Preterm baby, Dystocia / prolong labor / increased operative deliveries/ LSCS.

• New Born– Birth trauma , NTDs , pre term birth ,early neonatal deaths

Obesity And Pregnancy

• Marked obesity is equivocally hazardous to the pregnant women and her fetus.

Increased incidence of diabetes and hypertension with increased BMI

Pre conception Treatment

• Counseling –psychoanalysis and psychotherapy, modification in life style .

• Diet – low calorie balanced diet- as per advise o f dietician and proper monitoring for gradual weight loss without developing mal nutrition.

• Regular exercise to burn fat.• Drug treatment ;• Weight loosing Surgery.

Most legitimate non surgical methods are fraught with frequent

failures ;Legitimate weight loss approaches include behavioral

pharmacological and surgical techniques.

Ante Natal Check Ups • She is a case of high risk pregnancy.• Early diagnosis, Thorough History taking , general physical

, systemic and obstetrical examination with special care for early detection of HT/ PIH / Hyper glycaemia/ Type 2 diabetes , not to allow weight loss as well as excessive weight gain through out the pregnancy.

• Diet monitoring.• Appropriate exercise –brisk walking, swimming , bicycling ,

yoga and deep breathing exercise are permitted.• regular fetal monitoring with USG, color Doppler ,

laboratory Tests and bio physical profile of fetus in utero as and when needed.

Intrapartum Problems related to Obesity

Intra Partum Management• Avoid Prematurity as well as post datism.• Mode / timing of delivery is to be decided by considering following points

---- Age and Parity. Previous Obstetrical history –bad ?/ Good. Present complications . Appropriate time to conduct delivery is when 37 weeks are completed (as far

as possible ). Active management of labor by observing universal aseptic technique ; if

Vaginal delivery Decided ( no trial of labor ); possibility of shoulder dystocia should always be anticipated.

LSCS if decided on obstetrical grounds with definite indication should be done liberally by experienced obstetrician in presence of senior anesthesiologist and pediatrician.

post delivery 24 -48 hours are crucial when complication like diabetes, PIH , pre/post term delivery, PROM , LSCS anemia or PPH occur.

Early breast feeding , neonatal care in NICU may be needed. early mobilization of patient to avoid Complications of DVTand Pulmonary

embolism etc.

Gynaecological problems with obesity• Early onset of menarche .• Adoloscent menstrual problems ---PCOD, oligo-hypo menorrhea,

amenorrhoea, DUB ( metropathia type), Hirsuitism.• Infertility—PCOD , Anovulation , delayed marriage , Often partner is also

obese., flowr seminis.Subfertilty in obese woman is due to increased insulin resistance .impaired fecundity in woman with BMI >30Kg/ sq meter---in IVF and ICSI has been reported

• Endometrial hyperplasia– carcinoma.• Hyperestrogenic state--- increased DVT, HT, OCP;s side effects are more.• Delayed onset of Menopause ---post menopausal bleeding ---endometrial

polyps ; hyperplasia; carcinoma situ .• Ovarian , vulval malignancy ,• Infertile fat female is prone to have more incidence of fibroids.• Vaginitis , vulvo-vaginitis ---pre diabetic or frank diabetic women.• UTI.

TREATMENT

Exercise

Balanced diet

Treatment of Obesity• General --- counseling for diet and exercise . • Drugs --- oristat( selective inhibitor of gastric and pancreatic

lipase that inhibits absorption of lipids in intestine) , Sibuttraminen (non adrenaline and 5HT reuptake inhibitor acts as appetite inhibitor ).Metformin.• Surgery ---(Bariatric Surgery ) 1. Restrictive --- vertical banded gastroplasty , laparoscopic

adjustable gastric banding , jaw wiring . 2. Malabsorptive – Bilo pancreative diversion ; bilo pancreatic

diversion with duodenal switch . 3. Combine –Jejuno-ileal by pass--- roux-en – Y gastric by pass

by open method / by laparoscopy.

BASIC ANALOGUE TO TREAT OBESITY

When To Plan” Weight loosing surgery”?

• Morbid obese women have failed to bring down their BMI with Medical Management.

• It is absolutely contra indicated in Pregnancy.• Weight loosing surgery should be done well (at least 1 year )

before planning Pregnancy .• If BMI returns to normal range and if there is no element of mal

nutrition the obstetrical out come in terms of maternal and fetal morbidity and mortality also returns to that in normal gravid women .

• If early pregnancy occurs and maternal weight loss continues ---- adverse effect on intra uterine fetal growth --- poor / bad Fetal outcome .

Maternal Mortality increases as BMI increases

PNMR in obese pregnant women

• 1.6-2.6 fold increase in still births. • Early neonatal deaths are nearly doubled in

Primi gravida ---IUFD rate increase as BMI increase .

• Over all PNMR is 2 times more in obese women as compared to non obese pregnant women .

fetal morbidity• 3.5 fold increase in NTDs. • 2-3 fold increase in omphalocoele , heart defects and

other multiple anomalies . • Associated hypertension and diabetes are to main

contributory factors for these anomalies.• Maternal Obesity and childhood obesity in offspring

---- Children of such mothers have obesity , hyperglycemia, hyper lipidaemia(HDL) and insulin resistance ; the definite criteria of having developed metabolic syndrome.

Contraception & future Pregnancy• After present delivery / miscarriage obese woman should be

advised to continue the weight loosing / maintenance therapy as before., as future conception when planned will give better results.

• Birth spacing for 1-2 years is advisable.• OCs carry high rate of side effects( DVT,PE, HT , deranged

glucose and lipid profile ; cardio vascular accidents , gallstones, intra hepatic cholestasis etc ) as well as failure rates directly proportional to increased BMI.

• Progestin bearing IUCD are safe and effective method of contraception as compared to barrier methods.

• After completion of family size husband can go for vasectomy.