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Obesity in pregnancy: Complications and maternal management
Summary of Literature review in Nov 2016 from UpToDate.com
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen MBBS 4th year OG resident
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
INTRODUCTION
Pregnancy-specific definition of obesity??
The prevalence - varies widely ( > black)
In northern Jordan was 53.1% for women
~ Pubmed 2010
Increase risk of childhood and adult obesity
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PATHOBIOLOGY
Dysregulatory effects on metabolic, vascular, and inflammatory pathways (e.g. obesity-related insulin resistance – preeclampsia)
Maternal genotype Fetal exposure to increased levels of
glucose, lipids, and inflammatory cytokines → Epigenetic changes
(fetal origins of adult disease theory [Barker hypothesis])
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
POTENTIAL ISSUES IN PREGNANCY
Antepartum
Intrapartum
Postpartum
Offspring
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
POTENTIAL ISSUES IN PREGNANCY
Antepartum
• Early pregnancy loss • Occult type 2 diabetes
• Gestational diabetes• Pregnancy associated hypertension • Indicated and spontaneous preterm
birth• Post-term pregnancy • Multifetal pregnancy
• Obstructive sleep apnea • Carpal tunnel syndrome
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
POTENTIAL ISSUES IN PREGNANCY
Intrapartum
• Induction • Progress of labor
• Cesarean delivery • Trial of labor after cesarean
delivery • Difficulties with anesthesia
• Complications related to macrosomia
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
POTENTIAL ISSUES IN PREGNANCY
Postpartum
• Venous thromboembolism
• Infection • Postpartum depression
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
POTENTIAL ISSUES IN PREGNANCY
Offspring
• Congenital anomalies • Death
• Prematurity • Large for gestational age
• Asthma • Childhood obesity
• Neurodevelopment
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PRE-PREGNANCY MANAGEMENT
PREGNANCY MANAGEMENT
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREPREGNANCY MANAGEMENT
Preconception counseling, evaluation, and care:
●Information about:1. the adverse effects of obesity on fertility2. the potential pregnancy complications
associated with obesity●Evaluation for obesity-associated medical
comorbidities ●Counseling about the benefits of weight loss
before attempting to conceive
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREPREGNANCY MANAGEMENT
Prepregnancy weight loss: Diet, exercise, behavior modification Possibly adjunctive medical therapy
(should not be used during pregnancy) Bariatric surgery, if indicated→ beneficial effects on reproductive function, pregnancy
outcome, and overall health
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester:•Baseline assessments•Counseling •Gestational weight gain• Exercise •Fetal aneuploidy screening•Referrals
Second trimester:Low-dose aspirinFetal ultrasound
survey Screening for
gestational diabetes
Third trimester :Assessment of fetal
growth Assessment of fetal well-
being External cephalic version
Delivery and labour:•Equipment and instruments •Fetal monitoring •Anesthesia consultation•Timing and route of delivery
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester Baseline assessments1. Maternal weight and body mass index (BMI).2. Blood pressure using an appropriately sized cuff3. Early ultrasound -> gestational age \ a multifetal
gestation4. Medication review, oral anti-hyperglycemic drugs, which
are often discontinued in favor of insulin therapy. 5. Diabetes screening 6. Consider quantitative urine protein, KFT, platelet count,
and liver function tests -> (Baseline values evaluation for preeclampsia. Obesity is a known risk factor for nonalcoholic fatty liver disease (NASH). )
7. Bariatric surgery -> evaluate for and treat nutritional deficiencies
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester Counseling:1. pregnancy risks associated with obesity 2. diet 3. gestational weight gain 4. Exercise } Review frequently
throughout pregnancy
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester Gestational weight gain :
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester Exercise: Pregnant women can initiate an exercise
program or continue most prepregnancy exercise programs, which can help control gestational weight gain
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester Fetal aneuploidy screening The same as that for the general Obese women are not at increased risk for fetal aneuploidy Obesity can affect screening test performance:1. Cell-free fetal DNA screening is more likely to result in test
failure.2. Serum-based screening tests are adjusted for maternal
weight; thus, obesity does not affect test performance 3. Accurate nuchal translucency measurement may be more
difficult to obtain -> (transvaginal probe)4. Diagnostic procedures (amniocentesis, chorionic villus
sampling) are more challenging technically -> (a low-frequency transducer \ vaginal probe in the umbilicus)
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
First trimester Referrals : If underlying cardiopulmonary disease is
suspected, cardiology or pulmonology referral should be considered for additional testing and diagnosis
To a sleep specialist ? (symptoms) To a registered dietician ?
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
Second trimester Low-dose aspirin : BMI ≥30 kg/m2, →moderate risk
factor for preeclampsia Obese women with additional risk
factors for development of preeclampsia may benefit from treatment with low dose aspirin (81 mg)
Other Moderate risk factors: 1. nulliparity,2. family history of
preeclampsia (mother or sister)
3. sociodemographic characteristics (African American race, low socioeconomic status)
4. maternal age ≥355. personal factors (eg, low
birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval)
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
Second trimester Fetal ultrasound survey: A detailed fetal anatomic survey is performed at 18 to 24
weeks Due to the limitations of ultrasound with increasing degrees of
obesity → concomitant use of maternal serum alpha fetoprotein to screen for neural tube and other relevant congenital defects
maternal obesity as not an indication for fetal echocardiography → unless the detailed obstetric ultrasound assessment of the heart was not optimal.
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
Second trimester Screening for gestational diabetes : Is recommended at 24 to 28 weeks of gestation Bariatric surgery → maternal dumping syndrome →
use different approach ?
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT Third trimester
Assessment of fetal growth Clinical assessment vs Ultrasound assessment
Assessment of fetal well-being Although the frequency of fetal demise appears to be increased
in pregnancies of obese women, the value of antenatal fetal surveillance with nonstress tests or biophysical profile scoring in this setting has not been studied
External cephalic version obesity is not a contraindication to ECV, A successful ECV is
particularly beneficial in obese women, given the significant surgical risks of cesarean delivery in these patients.
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT Labor and delivery
Equipment and instruments Ensure that the labor and delivery unit has appropriate physical
resources (eg, gowns, beds, operating room table) for caring for severely obese women.
Fetal monitoring Placement of an internal fetal scalp electrode Anesthesia consultation Evaluation by an anesthesiologist prior to labor or in early labor
is recommended for all obese parturients because of their higher risk of anesthetic complications. For patients planning a vaginal birth, early placement of an epidural or intrathecal catheter may obviate the need for general anesthesia if emergency cesarean is needed
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
Labor and delivery Timing and route of delivery Delivery by the estimated due date has been
recommended to reduce the risk of stillbirth and complications from continued fetal growth.
Acta Obstet Gynecol Scand. 2014 Jun;93(6):590-5. Epub 2014 Apr 30
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
Cesarean delivery Thromboprophylaxis : Use of pneumatic compression devices at the time
of cesarean delivery For obese women with additional risk factors for
venous thromboembolism, we suggest use of both pharmacologic and mechanical thromboprophylaxis (Grade 2C). ~ACOG
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT
Cesarean delivery Antibiotic prophylaxis : Preoperative antibiotic prophylaxis for all women
undergoing cesarean delivery (Grade 1A) An appropriate dose of prophylactic antibiotics
should be administered based on maternal weight
Technical issues
OPERATIVE PROCEDURE 1
Type of incision: For women who weigh under 170 kg, we suggest a Pfannenstiel
incision if the pannus can be adequately retracted cephalad (Grade 2C). For women who weigh over 170 kg , we suggest a transverse supraumbilical incision with the pannus displaced caudally (Grade 2C)
Incision technique: When making the skin incision, attention to the distorted
landmarks in obese women is very important. The umbilicus is often anatomically directly over the lower uterine segment because the large pannus draws it caudally; however, the position of the symphysis pubis is reliable
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
OPERATIVE PROCEDURE 2
Fascial closure: The fascia can be closed using a Smead-Jones or
comparable interrupted technique or mass continuous closure with nonabsorbable or slowly absorbable suture. This is especially important for supraumbilical incisions. Both approaches are equally effective for reducing the risk of dehiscence or hernia formation.
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Mass closure of incisions
OPERATIVE PROCEDURE 3
Subcutaneous closure: We recommend closure of subcutaneous tissue
greater than 2 cm thick (Grade 1A). We also recommend avoiding placement of subcutaneous drains (Grade 1A).
Skin closure: We suggest skin closure with staples rather than
stitches (Grade 2C).
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
PREGNANCY MANAGEMENT Postpartum:
If cesarean was performed, postcesarean care should be modified to reduce the risk of obesity-associated postsurgical complications.
Encourage breastfeeding and provide additional support. since obese women are prone to difficulty with lactation
Intrauterine contraception is safe and effective, and may be safer and more effective in this population than estrogen-progestin contraceptives, although the latter are also an acceptable choice
Women with a gestational diabetes should be screened for glucose intolerance 6 to 12 weeks after delivery.
Obesity in pregnancy: Complications and maternal management
Summary of Literature review in Nov 2016 from UpToDate.com
Hashem Yaseen 1\1\2017 4th year OG resident KAUH\ JUST
Hashem Yaseen MBBS 4th year OG resident