Pregnant women with obesity or previous bariatric surgery ... protocols and... · • The woman should be seen in the Antenatal clinic at 41 weeks if she has not delivered. The midwife/doctor

Pregnant women with obesity or previous bariatric surgery -

Management Guideline (GL791)

Approval Approval Group Job Title, Chair of Committee Date Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

3rd January 2020

Change History

Version Date Author, job title Reason 7.0 July

2019 F Wong (ST4 O&G) Reviewed – minor changes plus

section added for pregnancy post-bariatric surgery. Also combined with GL959 Guideline on the management of the super obese woman (BMI >=50 at booking)

Now includes GL959 – Management of the super obese woman (BMI >=50 at booking)

Author: Flora Wong Date: January 2020 Job Title: ST4 O&G Review Date: January 2022 Policy Lead: Group Director Urgent Care Version: V7.0 ratified 3/1/20 Location: Policy hub/ Clinical/ Maternity/ Medical conditions & complications/ GL791

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Pregnant women with obesity or previous bariatric surgery – Management (GL791) January 2020

Overview: 50% of child bearing women are overweight or obese. 25% of women who die in childbirth are obese. Obesity DOUBLES the risk of maternal: Gestational diabetes, Miscarriage, Pregnancy induced Hypertension/PET, Thromboembolism, post-partum haemorrhage, Instrumental delivery and caesarean section. Maternal obesity TRIPLES the Fetal risks of Still Birth and Childhood Obesity. This guideline is divided into sub-sections according to the women’s BMI:

Normal 18.5 - 24.9 (General advice for all women Pg 2) Overweight 25.0 - 29.9 Obesity >30-34.9

35 – 39.9 40 – 49.9

(Pg 3) (Pg 3-4) (Pg 5-6)

Super obesity >50 (Pg 6 - 9) Women with previous bariatric surgery (Pg 10) Antenatal Booking (All women) 1. Measure and record height, weight and BMI. (BMI = weight (kg) / height (m)2

e.g. for a weight of 90kg and a height of 1.5m, BMI = 90 ÷ (1.5x1.5) = 40) 2. Ensure correct blood pressure cuff size by measuring the woman’s upper arm

circumference. Record this in her handheld records. a) Arm circumference > 33cm - cuff size 12x23cm b) Arm circumference 33-41cm - cuff size 33x15cm c) Arm circumference = / > 41cm - cuff size 18x36cm

3. Assess and record VTE and PET (pre-eclampsia) risk score 4. Give dietary advice with regard to healthy eating. Slimming world is a suitable

diet for pregnant mothers. Postnatal care (All women)

• VTE assessment +/ - low molecular weight heparin (LMWH) TTO if required • Perform Waterlow scoring assessment and consider need for pressure

relieving mattress • Encourage and support breast feeding. • Contraceptive advice should reflect the high-risk of thromboembolic disease • Advise on importance of mobilisation, exercise and compliance with

prescribed treatment


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BMI 30.0 - 34.9 Antenatal Care 5. Book GP/MW care if no other comorbidities 6. Advise folic acid supplement of 5mg for the 1st trimester. 7. Advise 10mcg vitamin D daily during pregnancy and whilst breast feeding. 8. Arrange OGTT at 28 weeks gestation in addition to routine 28 week bloods Antenatal admissions and Intrapartum care

• Perform and record a Waterlow assessment and provide pressure area care • If no comorbidities, can be admitted to Midwifery Led Unit and intermittent

auscultation may be used for fetal monitoring • Encourage the woman to be mobile • Keep well hydrated

BMI 35 - 39.9 Antenatal Care 9. Book consultant care. Make antenatal clinic appointment for 34 weeks. 10. Advise folic acid (5mg), vitamin D (10mcg daily) and OGTT as above 11. Complete Bariatric Checklist and give information leaflets (see Appendix 2) 12. Consider growth scans: RCOG recommends serial growth scans from 26-

28/40 for women where SFH is inaccurate e.g. BMI > 35 (good practice point) 13. BMI >/= 35 is a moderate risk factor for PET. Complete PET risk assessment

+/- prescribe 150mg of Aspirin daily, from 12 weeks until delivery if indicated. 14. The woman should be assessed by the clinic midwife at 34 weeks gestation

she should: Perform a complete antenatal examination Check OGTT result. If BM =/>7.0mmol refer to Diabetic midwife Place anaesthetic alert into records so that patient is seen by the on-call

anaesthetist on admission to the delivery suite/midwifery led unit Consider presentation scan if head difficult to palpable Primips should deliver on the Delivery suite Multips with other co-morbidities should deliver on the Delivery Suite.

Antenatal admission and Intrapartum Care:

• All women with co-morbidities should deliver on the Delivery Suite • All Primips to deliver on Delivery Suite • Please refer to Labour risk assessment GL863 for recommendations on

appropriate fetal monitoring


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• If unable to auscultate the fetal heart using IA, continuous fetal monitoring should be recommended using fetal scalp electrode if necessary

• Active management of the 3rd stage 15. Follow any anaesthetic advice documented in the maternity record 16. Perform and record a Waterlow assessment 17. Ensure care is taken to prevent pressure damage to skin 18. Complete VTE risk assessment sheet on a daily basis +/- prescribe LMWH 19. Appropriate thromboprophylaxis on admission. If TED stockings are to be

used then the woman’s legs must be measured accurately and the correct size stockings applied. If the correct size is not available do NOT use stockings.

Multips with No co-morbidities • Multips who have had a previous vaginal delivery and no other co-morbidities

can be cared for and delivered on the Midwifery Led Unit. • If unable to auscultate the fetal heart using IA, transfer to delivery suite for

continuous fetal monitoring should be recommended using fetal scalp electrode if necessary

• Principles of Care as above

BMI of 40 – 49.9 Antenatal Care

• Refer for consultant care at 24 weeks • As above: advise aspirin, folic acid (5mg), vitamin D (10mcg daily), OGTT and

complete bariatric checklist (see Appendix 2). Also consider serial growth scans from 26-28/40 as per RCOG (good practice point).

• Refer to Anaesthetist for assessment + Provide leaflet ‘Why do I need to see an anaesthetist during my pregnancy’

• A risk assessment should be carried out and documented in the records with regard to manual handling, safe working loads, skin care, PET and VTE assessment.

• Advise to deliver on the Delivery Suite • The woman should be assessed by the clinic midwife at 34 weeks gestation: Perform a complete antenatal examination Check 28 week OGTT result. If BM >7.0mmol refer to Diabetic midwife Place anaesthetic alert into records so that patient is seen by the on-call

anaesthetist on admission to the delivery suite/midwifery led unit


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Consider presentation scan and EFW if head difficult to palpate Inform Iffley ward to prepare Bariatric furniture e.g. toilet and chairs

Antenatal Admission and Intrapartum Care

• As above: Waterlow assessment, pressure area care, TED stockings and daily VTE assessment, active management of the 3rd stage

• All women should deliver on the delivery suite • Venous access on admission • Take bloods for group and save and FBC • Give regular antacid • Continuous CTG in labour • May need Fetal scalp electrode

20. Follow any anaesthetic advice documented in the maternity record 21. Inform theatre of any woman who exceeds 120k

• The woman should be seen in the Antenatal clinic at 41 weeks if she has not delivered. The midwife/doctor will perform a stretch and sweep and arrange induction of labour for 42 weeks.

Intraoperative Care in theatre

• Inform senior anaesthetists and obstetricians if a woman with a BMI of 40 and above requires a caesarean.

• Ensure adequate staff available for transfer between bed and theatre table • The theatre table in Theatre 17 is the table of choice for any woman > 135kg • Ensure that a large blood pressure cuff is available • Consider an arterial line if non-invasive blood pressure management is

problematic • Extra dose Antibiotic Prophylaxis i.e. 1.2g Augmentin + 1g Amoxicillin (or

Clindamycin and Gentamicin) • Assess the need for Hover Mattress • Assess the need for Table extension • Consider use of Alexis O Ring Retractor • Consider PDS/Nylon for closure of rectus sheath • PICO wound dressing • Prescribe correct Dose and duration of Tinzaparin • Use Flotrons in Recovery


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Safe Working Loads (SWL) of equipment If woman exceeds the Safe Working Loads (Appendix 1) of any of our equipment contact Manual handling ext. 6805 who can provide advice and support. Please check SWL of equipment prior to use.

• Assess for any manual handling issues. If the woman has reduced mobility or special requirements record in the notes

• If a woman is likely to exceed the SWL, a specialist bed /theatre table may need to be hired/borrowed for delivery.

• Contact Manual Handling for advice ext. 6805 Or you can find all necessary advice and forms for accessing equipment both in and out of hours from the following links:

o https://www.royalberkshire.nhs.uk/health%20safety/Bariatric%20Equipment%20inventory.pdf.

o https://www.royalberkshire.nhs.uk/Downloads/MANUAL%20HANDLING%20-%20INTRANET/Practice/Nov.%202017-Options%20to%20hire%20out%20of%20hours.pdf

• A poster is displayed on each ward showing available equipment, its safe working load and where it is in the department.

Super Obesity BMI >/= 50 Overview: Morbid obesity has a significant impact on pregnancy outcome. The worldwide incidence of mothers with a BMI>50kg/m2 has increased fivefold in the last twenty years. There are increased incidences of pulmonary embolism and PPH in this group, regardless of mode of delivery, and there is an increased risk of stillbirth. (30% of stillbirths and neonatal deaths reported to CEMACE in 2005 were of babies whose mothers had a BMI in excess of 30kg/m2.

They are three times more likely to require abdominal delivery than a woman with a BMI in the range 20-25kg/m2. There are surgical, anaesthetic and logistical challenges in caring for these women. (Mochado 2012) Weight loss programmes during pregnancy should not be advocated, but sensible healthy eating should be encouraged.

Super obese mothers are at an increased risk of nutritionally deficient diets and should be offered high dose folic acid (5mg daily) in additional to usual healthy eating information.3


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https://www.royalberkshire.nhs.uk/health%20safety/Bariatric%20Equipment%20inventory.pdf


https://www.royalberkshire.nhs.uk/Downloads/MANUAL%20HANDLING%20-%20INTRANET/Practice/Nov.%202017-Options%20to%20hire%20out%20of%20hours.pdf




Booking: Refer for consultant care. At the first hospital appointment, the ‘Bariatric Protocol’ should be employed, outlining the counselling, care package and logistical arrangements for pregnancy and delivery.

• The midwife in the hospital antenatal clinic must ensure that a bariatric referral is sent to the manual handling team who will provide a report to go into the woman’s records containing the relevant advice on obtaining equipment as it is likely that not much of the equipment routinely available will be safe for these mothers to use. Please ensure copies of the referral are filed in the maternity records and that the Delivery suite manager has the EDD and M number record for her files.

• The operating table can hold up to 450 kg but with a maximum lateral tilt of 5 degrees.

Antenatal care: • Care should be in accordance with local guidelines for any inter-current

medical condition

• BMI equal to or > 35 is a moderate risk factor for pre-eclampsia. Complete Pre-Eclampsia risk assessment tool to assess whether there is an indication for 75mgs of Aspirin daily, from 12 weeks until delivery.

• ALL mothers must be advised to see a consultant anaesthetist during pregnancy and an appointment made before 28 weeks

• ALL mothers should be prescribed prophylactic low molecular weight heparins, dose to be calculated based on weight.

• Women should be screened for gestational diabetes at 28 weeks in line with local arrangements for testing and follow up.

• Re-measurement of maternal weight during the third trimester will allow appropriate plans to be made.

An ultrasound scan at 37 weeks to confirm fetal lie may be helpful.

Planning delivery: Nearly half of all mothers whose BMI is over 35kg/m2 will be delivered by caesarean section. It is estimated that the risk of an intrapartum caesarean is up to five times greater in morbidly obese mothers when compared to women with a normal BMI. There is little evidence to support a routine recommendation for abdominal delivery over an attempt at vaginal birth. However, planning delivery is key.


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• Suitable equipment such as chairs, beds, lavatories need to be sourced. Manual Handling have an inventory for equipment that the Trust owns, this is available https://www.royalberkshire.nhs.uk/health%20safety/Bariatric%20Equipment%20inventory.pdf. Ward furniture should be sourced and be available from 37 weeks’ gestation, until the mother is delivered and discharged.

• Delivery beds need to be booked with 1st Call Mobility who supply the Baros bariatric / plus size birthing bed: this can be done through the Manual Handling / Equipment Library teams. See Appendix 3 for details. This bed, with one extension wing, will pass through all doors in the maternity and surgical blocks: with both out, it will not.

• Currently our Trust is using equipment to hire during out of hours as link below: https://www.royalberkshire.nhs.uk/Downloads/MANUAL%20HANDLING%20-%20INTRANET/Practice/Nov.%202017-Options%20to%20hire%20out%20of%20hours.pdf

• There are ‘single person usage ‘ hover mattresses for super obese patients: please ask the Theatre Manager to supply one for the patient and put it on the delivery bed when the mother is admitted to Delivery Suite

• Anaesthetic and surgical times are significantly increased in super-obese mothers and should be considered when booking either inductions or caesarean sections

• ALL MOTHERS should be given IV carbetocin to manage the third stage of labour, irrespective of mode of delivery.

Caesarean section: • For those mothers who require a planned Caesarean section, these should be

booked into lists where there are no other mothers as a theatre time of three hours plus is common. Recent experience has identified the need for 8-10 people to transfer mothers on hover mattresses. The bariatric theatre table can, with lateral extension mattresses, and straps across legs and chest, accommodate a mother weighing up to 290kg. Lithotomy poles for bariatric patients are located in the bariatric theatre in South Wing theatres.

• A consultant obstetrician should be present throughout. The resident anaesthetist MUST discuss with the consultant before the procedure is commenced to allow for deployment of suitably senior personnel. A neonatologist MUST be present at delivery


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• A combined epidural /spinal approach is advised if regional anaesthesia is proposed. The Oxford pillow does not fit well under super obese women: ramping with six pillows has been ‘tested with the bed at its lowest height and works well.’

• Wedging should be deployed to prevent / reduce aorto-caval compression

• Good venous access is essential, and arterial lines may be required to measure maternal BP.

• The literature suggests that a lower transverse abdominal incision may be associated with problems of;

o Maternal respiratory embarrassment due to the weight of the panniculus on the chest

o Maternal hypotension (and thus fetal compromise) o Surgical access

But a midline incision is associated with; o More postoperative pain o Postoperative atelectasis o Fascial and wound dehiscence

• Obstetricians are advised to deploy two assistants, one of whom should be an experienced obstetrician (ST3 or higher), PLUS appropriate aides to access including;

o The extra-large Alexis ring, plus a Doyen’s or Deever’s retractor o Abdominal rolls (or Montgomery type straps) clipped to the support

bars. (Machado, 2012)

• Closure of the subcutaneous fat has been shown to reduce the risk of postoperative wound infection, compared to non-closure. Drains in the fat layer are of no benefit. Up to 30% of super-obese women will have a post-op wound complication however. (Alanis et al 2010)

• PICO dressings should be applied to the incision


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Pregnancy after Bariatric Surgery Pregnancies after bariatric surgery are considered high-risk and require consultant-led antenatal care (RCOG good practice point). After bariatric surgery, women are recommended to wait at least 12-18 months before trying to conceive. Even if their current BMI is in the ‘normal’ range they are still at increased risks of: nutritional deficiencies, anaemia, altered maternal glucose metabolism and SGA babies. Bariatric surgery can be restrictive (gastric band, sleeve gastrectomy), malabsorptive, or both (e.g. Roux-en-Y gastric bypass, bilio-pancreatic diversion with duodenal switch BPD/DS). See Appendix 4 for diagrams illustrating common bariatric surgical techniques.

Recommendations:

• Folic acid until 12/40 (400mcg if healthy weight/ 5mg if obese or diabetic)

• Take a pregnancy specific vitamin and mineral supplement o Suitable OTC options: Pregnacare, Seven Seas Pregnancy, Boots

Pregnancy support, Tesco Complete Multivitamins Plus Minerals for Pregnancy

• Iron: 45 – 60mg elemental iron/ day; e.g. ferrous sulphate 200mg or ferrous fumerate 210mg daily. Nearly 50% of patients will have iron deficiency post-bariatric surgery.

• Calcium/ Vitamin D: Continue with maintenance therapy: usually at least 800mg calcium + 20mcg vitamin D/ day e.g. Adcal D3 2 tabs OD or 1 tab BD

• Vitamin B12: Continue with regular 1g 3 monthly injections (bypass/ sleeve)

• Nutritional screening every trimester: Ferritin, folate, vitamin B12, calcium and fat soluble vitamins

o Malabsorptive procedures: risk of low vitamin A (and possibly E and K) retinol form especially in the first trimester (teratogenic).

• GDM screening: Avoid OGTT in those who have had a gastric bypass (risk of dumping syndrome) – contact the diabetic midwives to arrange home BM monitoring as an alternative

o Meter readings for 2 days over a one week period. 6 readings each day - fasting, 1 hr. post-breakfast, pre-lunch, 1 hr. post-lunch, pre-dinner and 1hr post-dinner

• Consider serial growth scans due to increased risk of SGA

• Contact patient’s surgical team for details of surgery and any specific advice

• If current BMI >30 please also see previous sections of this guideline


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References: 1. DOH (2004) the National Framework for Children, Young People and Maternity

Services. Standard 11, clause 1.4 Department of Health. London

2. NICE clinical guideline 55 Intrapartum Care (updated 2017) https://www.nice.org.uk/guidance/cg190

3. Thromboprophylaxis during Pregnancy, Labour and after Vaginal Delivery. RCOG Green-top guideline no. 37a. (updated 2015)

4. Care of Women with Obesity in Pregnancy. Green-top guideline No, 72. Nov 2018.

5. The Investigation and Management of the Small-for-Gestational-Age fetus. RCOG Green-top guideline No. 31. 2nd Edition. Feb 2013.

6. www.apec.org.uk

7. Mochado Lovina SM, Caesarean section in morbidly obese parturients: practical implications and complications, N Am J Med Sci: Jan 2012; 4(1): 13-16

8. Alanis MC, Villiers MS, Law TL et al. Complications of caesarean delivery in the massively obese parturient Sept 2010; Am J Obstet Gynecol 203 (3): 271.e1-7

9. Case of megaloblastic arrest and refractory thrombocytopaenia in mother with booking BMI of 50kg/m2 due to folate deficiency diagnosed around time of third LSCS 2015

10. BOMSS Guidelines on peri-operative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery. Sept 2014. https://www.bomss.org.uk/wp-content/uploads/2014/09/BOMSS-guidelines-Final-version1Oct14.pdf

11. Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Mechanick et al. Obesity 2013 Mar; 21(01): S1-27

12. Nutrition in Pregnancy Following Bariatric Surgery. Slater et al. Nutrients. 2017 Dec; 9(12):1338.

13. Pregnancy after bariatric surgery: a narrative literature review and discussion of impact on pregnancy management and outcome. Falcone et al. BMC Pregnancy and Childbirth 18, 507 (2018)


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https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/199953/Getting_the_right_start_-_National_Service_Framework_for_Children_Standard_for_Hospital_Services.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/199953/Getting_the_right_start_-_National_Service_Framework_for_Children_Standard_for_Hospital_Services.pdf

https://www.nice.org.uk/guidance/cg190

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg37a/

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg72/



http://www.apec.org.uk/

https://www.bomss.org.uk/wp-content/uploads/2014/09/BOMSS-guidelines-Final-version1Oct14.pdf

https://www.bomss.org.uk/wp-content/uploads/2014/09/BOMSS-guidelines-Final-version1Oct14.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142593/


14. Weight-loss surgery and risk of pregnancy and birth complications. Source: European Association for the Study of Obesity. Published on Science Daily Apr 27, 2019 https://www.sciencedaily.com/releases/2019/04/190427201949.htm

15. Sheffield Teaching Hospitals NHS Foundation Trust. Information for patients. Pregnancy advice following weight loss surgery https://www.sth.nhs.uk/clientfiles/File/PregnancyAdviceFollowingWeightLossSurgery.pdf

16. University Hospitals Plymouth NHS Trust. Pregnancy and bariatric surgery. https://www.plymouthhospitals.nhs.uk/pregnancy-and-bariatric-surgery


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https://www.sciencedaily.com/releases/2019/04/190427201949.htm

https://www.sth.nhs.uk/clientfiles/File/PregnancyAdviceFollowingWeightLossSurgery.pdf

https://www.sth.nhs.uk/clientfiles/File/PregnancyAdviceFollowingWeightLossSurgery.pdf

https://www.plymouthhospitals.nhs.uk/pregnancy-and-bariatric-surgery


Appendix 1 - Safe Working Loads Ward beds Enterprise 500 250kg Maternity Theatre 235kgx1 250kgx1 450kg x1 Delivery Bed Hill ROM Affinity 227kg Hoist in room 14 160kg Trolley 160kg Bariatric Trolley Promotal Room C DAU 300kg Clinic Scales 150kg / 300kg Day Assessment Unit Scales 300kg DAU Couches Room A & Scan Room Sonnesta 180kg Room B Huntleigh 180kg Space 1 Bristol Maid 190kg Clinic Couches Hoskins 178kg USS Couches Akron 180kg Bariatric couch 325kg Chairs Day Assessment Unit, Delivery Suite non-reclining 158kg Reclining 127kg Iffley ward Teal 747xx 318kg Wheelchair Bradfern 133kg Toilets 133kg


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Appendix 2 – Bariatric Care Plan (click page below for link to printable version)

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Appendix 3 – Baros birthing bed (user instructions)

Click on picture to open PDF file


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Appendix 4. Common bariatric surgical techniques:

1 . Gastric band (Restrictive): Adjustable band around stomach to create a smaller stomach pouch. In pregnancy may need band adjustments for

appropriate weight gain and fetal health Hyperemesis may be pathological and caused

by an internal hernia or band slip

2. Sleeve gastrectomy (Restrictive): A large part of the stomach is removed so it is much smaller than before.

3. Roux-en-Y gastric bypass (RYGB or RNY, Restrictive + Malabsorptive): Surgical staples are used to create a small stomach pouch, which is connected to the small intestines, bypassing most of the stomach and the duodenum

Risk of dumping syndrome (OGTT not suitable) Risk of nutritional deficiencies: e.g. iron, calcium

fat-soluble vitamins (e.g. A, D, E) – usually absorbed in the duodenum. Also risks of protein, zinc and vitamin B12/ thiamine deficiencies

4. Biliopancreatic diversion with duodenal switch (BPD/DS, Restrictive + Malabsorptive): Sleeve gastrectomy + bypasses the majority of the small intestine Higher surgical risks and risks of nutritional

deficiencies (protein, vitamin, minerals). Risk of dumping syndrome (OGTT not suitable)

Images from Bariatric Surgery Source website: https://www.bariatric-surgery-source.com/types-of-bariatric-surgery.html#procedure


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https://www.bariatric-surgery-source.com/types-of-bariatric-surgery.html%23procedure

https://www.bariatric-surgery-source.com/types-of-bariatric-surgery.html%23procedure

Documents

Pregnant women with obesity or previous bariatric surgery ... protocols and... · • The woman should be seen in the Antenatal clinic at 41 weeks if she has not delivered. The midwife/doctor