Obesity

Complications that are more prevalent among obese women before and during pregnancy

**Prepregnancy Menstrual disorders, infertility **Early pregnancy Miscarriage, fetal anomalies, difficult and less accurate ultrasound examination **Antenatal Pregnancy-induced hypertension, pre-eclampsia, gestational diabetes, venous thromboembolism **Intrapartum Induction of labour, shoulder dystocia, caesarean section, operative anaesthetic difficulties **Postpartum Haemorrhage, infection, VTE **Fetal Macrosomia, fetal distress, perinatal morbidity and mortality, birth injury

Local guidelines

All maternity units should have accessible multidisciplinary guidelines which are communicated to all individuals and organisations providing care to pregnant women with a booking BMI 30. These guidelines should include consideration of: • Referral criteria • Facilities and equipment • Care in pregnancy • Place of birth and care in labour • Provision of anaesthetic services • Management of obstetric emergencies • Postnatal advice

Conclusion and recommendations

• It is essential that obstetricians have guidelines for management of the obese woman.Obesity is a risk factor for both gynaecological and obstetric complications. • A multidisciplinary approach to management is necessary to decrease the risks of morbidity and mortality. • There are a number of recommendations for clinical management prior to and during pregnancy: • Provide prepregnancy counselling for morbidly obese women (in primary care/subfertility/ recurrent miscarriage/diabetic clinics). • Consider high doses of folic acid (5 mg). • A healthy diet and exercise are important in pregnancy: refer to a dietician, advise to avoid excessive weight gain, consider screening for diabetes. • Provide an early booking visit to plan pregnancy management. • Prescribe low-dose aspirin in the presence of additional clinical risk factors for pre-eclampsia. • Consider antenatal thromboprophylaxis if there are additional clinical risk factors for venous thromboembolic disease. • Recommend a detailed anomaly scan and serum screening for congenital abnormality. • Consider glucose tolerance testing at 28 weeks, with the potential for repeating it in later pregnancy.

Antenatal care RCOG

• Management of women with obesity in pregnancy should be integrated into all antenatal clinics, with clear policies and guidelines for care available. • All pregnant women should have their weight and height measured using appropriate equipment, and their body mass index calculated at the antenatal booking visit. Measurements should be recorded in the handheld notes and electronic patient information system. • Women with a booking BMI 30 should be provided with accurate and accessible information about the risks associated with obesity in pregnancy and how they may be minimised. • Pregnant women with a booking BMI > 40 should have an antenatal consultation with an obstetric anaesthetist, so that potential difficulties with venous access, regional or general anaesthesia can be identified. An anaesthetic management plan for labour and delivery should be discussed and documented in the medical records. ( risk assess) • Women with a booking BMI >40 should have a documented assessment in the third trimester of pregnancy by an appropriately qualified professional to determine manual handling requirements for childbirth and consider tissue viability issues. -Women with a booking BMI 30 should be assessed at their first antenatal visit and throughout pregnancy for the risk of VTE. Antenatal and post delivery thromboprophylaxis should be considered in : 1 • A woman with a BMI >30 who also has two or more additional risk factors for thromboembolism should be considered for prophylactic low molecular weight heparin (LMWH) antenatally. This should begin as early in pregnancy as practical. 2 • All women receiving LMWH antenatally should usually continue prophylactic doses of LMWH until 6 weeks postpartum, but a postnatal risk assessment should be made. 3 • Women with a BMI >30 who have one or more additional persisting risk factors for thromboembolism should also be considered for LMWH for seven days after delivery. 4 • Women with a BMI >30 who have two or more additional persisting risk factors should be given graduated compression stockings in addition to LMWH. -Women with a BMI 30 should be encouraged to mobilise as early as practicable -All women with a BMI > 40 should be offered postnatal thromboprophylaxis regardless of their mode of delivery. -Women with a booking BMI 35 have an increased risk of pre-eclampsia • Women with a booking BMI 35 who also have at least one additional risk factor for pre-eclampsia should have referral early in pregnancy for specialist input to care. {Additional risk factors include: first pregnancy, previous pre-eclampsia, 10 years since last baby, 40 years, family history of pre-eclampsia, booking diastolic BP 80mmHg, booking proteinuria 1+ on more than one occasion or 0.3g/24 hours, multiple pregnancy, and certain underlying medical conditions such as antiphospholipid antibodies or pre-existing hypertension, renal disease or diabetes.} • Women with a booking BMI 35 with no additional risk factor can have community monitoring for preeclampsia at a minimum of 3 weekly intervals between 24 and 32 weeks gestation, and 2 weekly intervals from 32 weeks to delivery. • Women with a booking BMI 30 should be screened for gestational diabetes.

Intrapartum issues

• Obese women have higher rates of induction of labour and failed induction Caesarean section rates in nulliparous obese women are higher than in lean women . • A higher rate of obstetric complications among obese women has been reported, including operative vaginal delivery , shoulder dystocia and third/fourth-degree lacerations, The frequency of both elective and emergency caesarean section is almost doubled for very obese women compared with the normal BMI group. • From the anaesthetic perspective, the risks of failed epidurals, increased aspiration during general anaesthesia and difficulty with intubation

Postnatal care and follow-up after pregnancy

• Women with a booking BMI > 30 should receive appropriate specialist advice and support antenatally and postnatally regarding the benefits, initiation and maintenance of breastfeeding. • Women with a booking BMI > 30 should continue to receive nutritional advice following childbirth. • All women with a booking BMI >30 who have been diagnosed with gestational diabetes should have a test of glucose tolerance approximately 6 weeks after giving birth. and annual screening for cardio-metabolic risk factors, and be offered lifestyle and weight management advice. • Women with a booking BMI >30 and gestational diabetes who have a normal test of glucose tolerance following childbirth, should have regular follow up with the GP to screen for the development of type 2 diabetes.

Antenatal health issues Ultrasound and obesity Hypertension Gestational diabetes mellitus and obesity

• Obesity is associated with an increased risk of first trimester and recurrent miscarriage and fetal anomaly, in both women with PCO and those with normal ovarian morphology. • The incidence of spontaneous miscarriage has been reported to rise as insulin resistance increases. It has been suggested that insulin sensitising agents, such as metformin, also reduce miscarriage rates. It has been suggested that plasminogen activator inhibitor-type 1 (PAI-1) is associated with increased rates of miscarriage in association with maternal obesity.Treatment with metformin appears to reduce PAI-1 and miscarriage rates. • Up to a two-fold increase in risk for neural tube defects where there is prepregnancy maternal obesity. The greater the maternal BMI, the higher the risk of congenital malformation ****Ultrasound and obesity**** • A worrying consequence of maternal obesity, consequently, is the reduced sensitivity of ultrasound as a screening test for fetal anomaly. women with a BMI greater than the 90th centile during the second and third trimester had a 14.5% reduction in visualisation of organs compared with lean women. This reduction was most marked when visualising the fetal heart, umbilical cord and spine. *****Hypertension******* • HTN Independent of pregnancy, hypertensive disorders are more prevalent in obese women than in their lean counterparts. • -Elevated prepregnancy BMI is an independent risk factor for the development of pregnancy-induced hypertension. • -a two- to three-fold increase in the risk of pre-eclampsia with a BMI 30.Waist circumference has also been reported to be a sensitive predictive marker of possible pregnancy hypertensive complications. • -The risk of pregnancy-induced hypertension was approximately doubled and of pre-eclampsia tripled in association with central obesity. ***Gestational diabetes mellitus and obesity****** • GDM affects about 5% of all pregnancies. In the NICE consultation document on diabetes and pregnancy, a BMI 30 is considered a risk factor for the development of GDM . The policy has changed from offering no screening for GDM to targeted screening in the healthy maternal population, using clinical risk factors

Key content

• Prepregnancy obesity is increasingly common. • More than half of all women who died from direct or indirect causes in the 2003-05 report, Saving Mothers' Lives,were overweight or obese. • Obese mothers have an increased risk of complications. Learning objectives: • To learn about the increased incidence of miscarriage, congenital malformation and metabolic complications. • To learn about the increased risks of intrapartum complications.

Pre-pregnancy care RCOG

• Primary care services should ensure that all women of childbearing age have the opportunity to optimise their weight before pregnancy. Advice on weight and lifestyle should be given during family planning consultations, and weight, body mass index and waist circumference should be regularly monitored. • Women of childbearing age with a BMI 30 should receive information and advice about the risks of obesity during pregnancy and childbirth, and be supported to lose weight before conception. • Women with a BMI 30 wishing to become pregnant should be advised to take 5 mg folic acid supplementation daily, starting at least one month before conception and continuing during the first trimester of pregnancy. • Women with a booking BMI at or >30 are following advice to take 10 micrograms Vitamin D supplementation daily during pregnancy and while breastfeeding

Introduction

• The 2003-05 report of the Confidential Enquiries into Maternal Deaths in the United Kingdom highlighted obesity as a significant risk for maternal death. • More than half of all women who died from direct or indirect causes were either overweight or obese. • For the mother, obesity increases the risk of obstetric complications during the antenatal, intrapartum and postnatal period, as well as contributing to technical difficulties with fetal assessment . The offspring of obese mothers also have a higher rate of perinatal morbidity and an increased risk of long-term health problems. • defined as a body mass index (BMI) 30 kg/m2

Postpartum issues

• The leading cause of maternal mortality remains VTE and the postpartum period is the time of greatest risk, secondary to vascular damage at childbirth.

Care during childbirth

• Women with a BMI 35 should give birth in a consultant-led obstetric unit with appropriate neonatal services. • In the absence of other obstetric or medical indications, obesity alone is not an indication for induction of labour and a normal birth should be encouraged. • The duty anaesthetist covering labour ward should be informed when a woman with a BMI 40 is admitted to the labour ward if delivery or operative intervention is anticipated. This communication should be documented by the attending midwife in the notes. • Operating theatre staff should be alerted regarding any woman whose weight > 120kg and who is due to have an operative intervention in theatre. • Women with a BMI 40 who are in established labour should receive continuous midwifery care. • Women with a BMI 40 should have venous access established early in labour. • All women with a BMI 30 should be recommended to have active management of the third stage of labour. This should be documented in the notes. • Women with a BMI 30 having a caesarean section have an increased risk of wound infection, and should receive prophylactic antibiotics at the time of surgery. • women undergoing caesarean section who have more than 2cm subcutaneous fat, should have suturing of the subcutaneous tissue space in order to reduce the risk of wound infection and wound separation.

Planning labour and delivery

• Women with a booking BMI 30 should have an informed discussion antenatally about possible intrapartum complications associated with a high BMI, and management strategies considered. This should be documented in the notes. • Women with a booking BMI 30 should have an individualised decision for VBAC following informed discussion and consideration of all relevant clinical factors.

Implications for the fetus of the obese mother Short-term Long-term

•••Short-term •Lower Apgar scores have been reported in the neonates of obese mothers, Macrosomia increases the risk of shoulder dystocia, birth injury and the incidence of low Apgar scores and perinatal death.Infants born to obese mothers are more likely to require admission to a neonatal intensive care unit (NICU). •Maternal obesity was associated with almost a three-fold increased risk of stillbirth and neonatal death. •••Long-term Men whose mothers had a high BMI in pregnancy had an increased risk of coronary heart disease.