Transcript of "Obesity it’s effect in obstetrics & gynaecology"
OBESITY --IT’S EFFECT IN
OBSTETRICS & GYNAECOLOGY
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 Kathuria
PG Student (NIMS MEDICAL COLLEGE, JAIPUR)
• Body weight more than 20% the normal
weight for his or her optimal height of an
• 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
• 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
• If both parents are obese than there are 80% chances if
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
>obesity is a consequence of the fat imbalance inherent in high-calorie
>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
> 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
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
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 men
2.Hypertriglyceridemia: 150 mg/dL
3.High-density lipoprotein (HDL): < 50 mg/dL in women or <
40 mg/dL in men
4.High blood pressure: 130/85 mm Hga
5.High fasting glucose: 110 mg/dLa
Causes of Obesity
• Hyperinsulinism .
• Hyper adrenocorticism.
• Hypogonadism .
• 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
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
• Obstetrical – miscarriage, stillbirths , PIH, type 2
Diabetes ,IUGR/ large & over weight baby, Preterm
baby, Dystocia / prolong labor / increased operative
• 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
• Diet monitoring.
• Appropriate exercise –brisk walking, swimming
, bicycling , yoga and deep breathing exercise are
• regular fetal monitoring with USG, color Doppler
, laboratory Tests and bio physical profile of fetus in
utero as and when needed.
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
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.
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.
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 .
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
• Over all PNMR is 2 times more in obese
women as compared to non obese pregnant
• 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
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
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