Obesity and Pregnancy presentation by Chanel Tyler, MD

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2012 Dialogue presentation by Chanel Tyler, MD – Assistant Professor, Department of Obstetrics and Gynecology at the UW School of Medicine and Public Health

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  • The amount of preconception counseling is inadequate for most women. Infertility is a huge problem for many women who are overweight/obese and when pregnant, miscarriage rates are higher for obese women. This trend continues
  • C-section rates reaching 50% for women whose BMI exceeds 40 (ACOG).  Excess GWG is the strongest predictor of postpartum weight retention, long-term weight gain, excess body fat, and long term risk of maternal obesity (Weisman, 2010).  Excess GWG is further associated with intrauterine fetal macrosomia, neonatates that are large for gestational age, and overweight during infancy.  This leads to a variety of long-term health risks including increased risk for diabetes, cancers, and excess cardiovascular disease In addition to the increased risk for obesity, children whose mothers experienced excess GWG also have higher levels of fat mass, systolic blood pressure, C-reactive protein, and interleukin-6, as well as lower HDL cholesterol and apolipoprotein levels during childhood - all of which are cardiovascular and metabolic risk markers (Fraser, et al. 2010 Most disturbing, newer data from human studies finds that intrauterine exposure to excess fat and calories predisposes to obesity in postnatal life, an effect which is magnified when combined with maternal diabetes (Pirkola, 2010).  This has lead investigators to posit that intrauterine genomic programming may exist, such that postnatal maladaptive metabolism leads to the presence of overweight and obesity later in life (Tamashiro, 2010).   
  • Excess GWG is further associated with intrauterine fetal macrosomia, neonatates that are large for gestational age, and overweight during infancy.  This leads to a variety of long-term health risks including increased risk for diabetes, cancers, and excess cardiovascular disease
  • Obesity and Pregnancy presentation by Chanel Tyler, MD

    1. 1. Wisconsin Women’s HealthFoundation’s 2012 Dialogue Chanel T. Tyler, MD Assistant Professor University of Wisconsin School of MedicineDepartment of Obstetrics and Gynecology Division of Maternal Fetal Medicine
    2. 2. • 23 Million (1/3 of )adult women in the United States are obese • Non-Hispanic black women 49% • Mexican-American women 38% • Non-Hispanic white women 31%• 18% of obstetric causes of maternal death related to obesity• 80% of anesthesia-related maternal mortality related to obesity
    3. 3. Women of Childbearing Age Percent Overweight or ObeseFlegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008.JAMA 2010;303:235-41.
    4. 4. • Increased risk of gestational diabetes – Primarily related to an exaggerated increase in insulin resistance in the obese state – Women who are obese during pregnancy and develop gestational diabetes have a 2-fold increased prevalence of subsequent type2 diabetes• Increased risk of gestational hypertension
    5. 5. • Increased risk of preeclampsia – Among the morbidly obese this is almost 5-fold• Prevalence of LGA infants is almost 4 times as high among the morbidly obese than those with normal BMI.• Increased risk of having SGA infant, however after adjusting for preeclampsia the risk is no longer statistically significant.• Increased risk of antepartum stillbirths – Almost 3-fold (Cedergren et al)
    6. 6. Additional Risks• Puerperium deep venous thrombosis• Endomyometritis• Postpartum hemorrhage• Prolonged hospitalizations• Wound infections• Dehiscence
    7. 7. Waller et al• Found in a population-based control study that for every incremental unit increase (kg/m2) in BMI, the risk of NTD increased by 7%
    8. 8. Wolfe et al Heart 50.5% BMI Visualization Umbilical 25.8%Less than cord 10th % 90.2% Diaphragm 17% 97.5th % 63% Kidneys 10%
    9. 9. Risk of Induction• Increased risk of post-term pregnancy• Subsequently there is an increased incidence of labor induction estimated to be between 1.7-2.2 fold.
    10. 10. Weiss et al 2004• Increased risk of operative delivery – Instrumental delivery increased by 18% in women with BMI 35.1-40 – Increased 34% in women with BMI >40• Cesarean delivery more common: 47.4% compared to control patients 20.7%
    11. 11. VBAC• The success rate for VBAC in the massively obese patient has been found to be just 15%• More than 50% of these VBAC attempts are complicated by infectious morbidity – Jordan h. Perlow Obstetric Intensive Care Manual second edition 2004
    12. 12. Operative Risks• Increased operative times – Found in the morbidly obese compared to normal and obese women (p<0.05) As BMI rose there was an exponential increase in EBL and OR time. A linear increase in skin incision to uterus time and a linear decline in umbilical artery pH
    13. 13. • Inaccurate or difficult blood pressure monitoring• Reduced functional residual capacity• Sleep apnea syndrome• Increased reflux• Aortocaval compression.
    14. 14. Aortocaval Compression120 kg 150 kg
    15. 15. Difficulties with Regional Anesthesia • 150 kg • Difficult veins • Unable to curve lumbar spine • Impalpable iliac crests • Impalpable vertebral spines
    16. 16. Difficulties with General Anesthesia• Rapid desaturation on induction• Risk of regurgitation• Potential difficult intubation• Potential difficult ventilation• Difficult tracheostomy
    17. 17. Excess Gestational Weight GainHealth Impacts on Women: • Postpartum weight retention • Long-term weight gain • Excess body fat • Sleep apnea • Pre-diabetes/diabetes • Coronary heart disease
    18. 18. Excess Gestational Weight GainHealth Impacts on Neonates & Children: • Low 5-minute Apgar scores • Neonatal seizures • Hypoglycemia • Large for gestational age infants • Meconium aspiration • NICU admission • 4-fold increased lifetime risk of overweight/obesity • Lifelong elevated risk for diabetes, hypertension, cardiovascular disease, cancer, early death
    19. 19. • More than a 2-fold increased risk from fetal distress and low APGARS• Meconium aspiration occurred more often in infants of morbidly obese women
    20. 20. Maternal Benefits of Breastfeeding• Decreased risk of breast15-17 and ovarian cancer18,19• Decreased risk of type 2 diabetes. 20• Returns of uterine tone,21;22• Stopping post-birth bleeding,21• Temporarily suppressing ovulation which aids the spacing of children.21;23
    21. 21. Breastfeeding Decreases Infant Risks of• Ear1-3 and respiratory infections.4• Atopic dermatitis5• Gastroenteritis6• Necrotizing enterocolitis7• Type 2 diabetes8• Sudden infant death syndrome (SIDS) 9- 14 .

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