Obesity in pregnancy

1. Obesity
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
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2. Prevelences
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5. Maternal mortalities (2006-2008)
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6. Mortality and morbidity reports
• 29 % Direct deaths obese
• 26% Indirect deaths obese
• Obesity is independently associated with high
odds of maternal death
• 30 % of major obstetric haemorrhage obese
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7. Obesity classification
Category BMI range – kg/m2
Emaciation less than 14.9
Underweight from 15 to 18.4
Normal from 18.5 to 24.9
Overweight from 25 to 29.9
Obese from 30 to 39.9
Morbidly Obese greater than 40
BMI is a poor prognostic for individual health but a useful tool for population heath of the same
ethinicity
Metabolic risk for Caucasian with BMI 30 is the same as south Asian with BMI 25
22% of women with BMI >35 had at least one coexisting condition prior to pregnancy (DM, HTN,
Sleep apnea, VTE,…)
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8. Antenatal complications
• 1st trimester miscarriage
• Recurrent miscarriage
• Nutritional deficiencies (vit D)
• Fetal anomalies
• PET
• GDM
• VTE
• PTL: 1.5
• SGA
• Macrosomia
• SB
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9. Fetal anomalies
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10. Intrapartum
• Handling difficulties
• Anesthetic complications
• Prolonged labour
• Fetal distress
• Difficult monitoring
• Traumatic birth
• Shoulder dystocia
• CS and emergency CS
• PPH
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11. Postpartum and neonatal
• wound infection- thromboembolism -post partum
hge
• Increased NICU
• Obesity is associated with low breastfeeding
initiation and maintenance rates.
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12. Hospitalization
• Significant increase in mean hospital stay as BMI
increased:
– 2.4 days for ideal BMI versus 3.3 days for Morbidly obese
women
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13. Progress in labour
• Efficient uterine activity is required to not only
expel the fetus and placenta but also to maintain
haemostasis.
• Lack progress in labour X2 in obese women
• increased risk of caesarean section in the first stage
of labour
• Increased need for oxytocin
• Increased need of epidural
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14. CS and BMI
• The myometrium in obese women doesn’t work as non
obese women elbohoty 14

15. Obesity complications
Maternal Medical complications Technical complications
Management
Pre-pregnancy Menstrual disorders, infertility Vitamin D 10micrograms /day during pregnancy and
breastfeeding.
Folic acid 5 mg/day 1 month before pregnancy and
during 1st trimester.
An appropriate size of arm cuff*
Early pregnancy Miscarriage, fetal anomalies Difficult ultrasound
Folic acid 5 mg/day
Antenatal Pregnancy-induced hypertension, pre-eclampsia
Gestational diabetes
Venous thromboembolic disease
BMI greater than 35 kg/m²With any moderate risk
factor add 150 mg Aspirin
OGTT at 24-28 weeks
VTE prophylaxis according to the number of risk
factors
Intrapartum Induction of labour, caesarean section Operative issues, anaesthetic issues
Women undergoing caesarean section, who have
more than 2cm subcutaneous fat, should have
suturing of the subcutaneous tissue
Postpartum Haemorrhage
infection
Venous thromboembolic disease
active management of the third stage of labour
women with a BMI 40 should be offered postnatal
thromboprophylaxis regardless of their mode of
delivery
Fetal Macrosomia, fetal distress, perinatal morbidity/mortality Birth injury
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16. Preconceptional care
• Primary care services: optimise weight of all women of childbearing age before pregnancy.
• Advice on weight and lifestyle should be given during preconception counselling or
contraceptive consultations.
• Weight and BMI should be measured
• Women of childbearing age with a BMI 30 kg/m2 or greater should receive information and
advice about the risks of obesity during pregnancy and childbirth, and be supported to lose
weight before conception and between pregnancies
• Women should be informed that weight loss between pregnancies reduces the risk of
stillbirth, hypertensive complications and fetal macrosomia. (Weight loss >4.5 kg before 2nd
pregnancy reduce the risk of GDM up to 40%) (Weight loss increases the chances of
successful vaginal birth after caesarean (VBAC) section)
• Assessment of other medical problem
• Consider screening for type 2 DM
• Contraception
• Obese women should take 5 mg folic acid supplementation daily, starting at least 1 month
before conception and continuing during the first trimester of pregnancy.
• Obese women are at high risk of vitamin D deficiency. Vit D 10 microgram daily
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17. Management of obesity-related
infertility should include
• Diet, exercise, cognitive behavioral interventions
• Adjunctive pharmacotherapy
• Bariatric surgery may benefit morbidly obese
women who struggle to lose weight otherwise.
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19. Pharmacologic management
• It should be used as part of an overall weight
management plan.
• An anti-obesity drug should be considered only for
those with a BMI of 30 kg/m2, in whom diet, exercise
and behavior changes fail to achieve a realistic
reduction in weight.
• In the presence of associated risk factors, it may be
appropriate to prescribe an anti-obesity drug to
individuals with a BMI of 28 kg/m2.
• A vitamin and mineral supplement may also be
considered if there is concern about inadequate
micronutrient intake, particularly for vulnerable groups
such as in the elderly and younger patients.
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20. Orlistat
• Anti-absorptive drugs include orlistat (Xenical),
which is a potent inhibitor of pancreatic lipase
leading to interference with the absorption of fat
and fat soluble vitamins from the gut.
• The recommended dose is 120 mg taken
immediately before, during, or up to 1 hour after
each meal (maximum 120 mg three times daily).
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21. Side effects
• Common SE: flatulence, steatorrhoea and fecal
urgency. Prolonged administration can lead to
malabsorption, and vitamin deficiency syndromes.
• Orlistat should, therefore, be used for longer than
12 weeks only if weight loss exceeds 5% of the
initial bodyweight and after counselling patients
about the potential risks and benefits.
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22. Insulin-sensitising agents
• Such as metformin, decrease circulating insulin and
androgen levels and may be associated with a
modest decrease in body weight and visceral fat.
Two studies have shown benefit from combining
metformin with a hypocaloric diet for reducing
weight and visceral fat.
• However, the effectiveness of metformin alone for
reducing weight in obese PCOS patients has not
been demonstrated.
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23. Metformin use in PCOs
• Metformin is used as adjunctive treatment for
ovulation induction in PCOS patients, it is more
effective in those that are lean than it is in obese PCOS
patients.
• The recommended dose is 1500–2000 mg/day and the
main side-effects are gastrointestinal upset and rarely,
lactic acidosis in patients with hepatic and renal
impairment.
• In the UK, metformin is not licensed as an anti-obesity
drug and although it has been widely used in
management of PCOS, this is still an unlicensed
indication
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24. Effects on pregnancy
• No evidence of any increase in the relative risk of
major malformation was observed in women who
used orlistat in early pregnancy
• It is, however, recommended that anti-obesity
drugs are stopped once pregnancy is achieved.
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25. Other no favorable medications
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26. Phentermine/topiramate
• It promotes appetite reduction and decreases food
consumption.
• The exact mechanism of action of topiramate on weight
loss is not known but may be related to appetite
suppression and increased satiety.
• Use of topiramate in pregnancy is linked to oral clefts.
• Topiramate and phentermine are also individually excreted
in breast milk and, therefore, the combination of
phentermine/topiramate may also be present in breast
milk.
• Treatment with either medication is therefore not
recommended during lactation due to unknown risks on
the infant.
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27. Lorcaserin hydrochloride
• A serotonin receptor agonist that is highly selective for the
specific serotonin receptor, 5-HT2C, which is involved in the
regulation of appetite
• It is believed that lorcaserin promotes satiety and results in
weight loss from decreased overall food consumption.
• There are no data on the safety of lorcaserin in human
pregnancy. In animal studies, although exposure to
lorcaserin during embryogenesis has not demonstrated
teratogenicity or embryolethality, exposure in late
pregnancy did result in lower birthweight of offspring,
which persisted to adulthood.
• Lorcaserin is therefore contraindicated in pregnancy
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28. previous bariatric surgery
• A minimum waiting period of 12–18 months after
bariatric surgery is recommended before
attempting pregnancy to allow stabilisation of
body weight and to allow the correct
identification and treatment of any possible
nutritional deficiencies that may not be evident
during the first months.
• Women with previous bariatric surgery have
high-risk pregnancies and should have
consultantled antenatal care.
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29. • Women with previous bariatric surgery should have
nutritional surveillance and screening for deficiencies
during pregnancy (Iron, vit B12, folic acid, other fat
soluble vitamines
• Woman with previous bariatric surgery should be
referred to a dietician for advice with regard to their
specialised nutritional needs.
• Women who have undergone previous gastric band
insertion should have consideration of deflation for the
duration of pregnancy dependent upon the
circumstances of the woman
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30. Principles of ANC
• An appropriate size of arm cuff should be used for blood pressure measurements taken at
the booking visit and all subsequent antenatal consultations. The cuff size used should be
documented in the medical records.
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31. All maternity units should have a documented environmental risk assessment
regarding the availability of facilities to care for pregnant women with a booking
BMI ≥30. This risk assessment should address the following issues:
• Circulation space
• Accessibility including doorway widths and thresholds
• Safe working loads of equipment (up to 250kg) and floors
• Appropriate theatre gowns
• Equipment storage
• Transportation
• Staffing levels
• Availability of, and procurement process for, specific equipment:
– large blood pressure cuffs o sit-on weighing scale large chairs without arms
– large wheelchairs
– ultrasound scan couches o ward and delivery beds
– theatre trolleys
– operating theatre tables
– lifting and lateral transfer equipment
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32. Weight management during pregnancy
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33. 3/21/20 elbohoty 33

34. Booking visit counseling
• Folic acid 5 mg
• Vitamin D 10 Mcg
• If there is another moderate PET risk to BMI>35:
add 150 mg aspirin from 12 weeks until birth of the
baby
• VTE:
– If there is a sum of score of 4 for VTE start VTE
pharmacologic prophylaxis
– If there is a sum of score of 3 for VTE start VTE
pharmacologic prophylaxis at 28 weeks
• Difficulties of doing scans
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35. ANC
• Dietitian and reweigh in 3rd trimester
• OGT
• If there is another moderate PET risk to BMI>35: add 150 mg aspirin from 12 weeks until
birth of the baby
• Increased surveillance for hypertension
• Fetal screening:
– All women should be offered antenatal screening for chromosomal anomalies.
– Consider the use of transvaginal ultrasound in women in whom it is difficult to obtain
nuchal translucency measurements transabdominally.
– Those with unsuccessful first trimester screening should be offered second trimester
screening with serum markers.
– screening for trisomies with NIPT is less effective for obese pregnant women.
– Screening for structural anomalies should be offered However they are more limited in
obese pregnant women.
– BMI >35 is a major risk for SGA: serial biometry scan with UAD from 26 weeks
– BMI from 25- 35 is a minor risk for SGA: if there is additional 3 risk factors ……..
• Women with BMI 30 kg/m2 or greater are at increased risk of mental health problems and
should therefore be screened for these in pregnancy.
• BMI> 40 anaethetic referral , 3rd trimester assessment for manual handling requirements
and tissue viability
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36. Fetal surveillance
• For BMI < 35: SFH is recommended at each
antenatal appointment from 24 weeks of gestation
• Women with a BMI greater than 35 kg/m2 should
be referred for serial assessment of fetal size using
ultrasound.
• Where external palpation is technically difficult or
impossible to assess fetal presentation, ultrasound
can be considered as an alternative or
complementary method.
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37. 3/21/20 elbohoty 37

38. Delivery planning
• Class I and II maternal obesity is not a reason in itself for advising birth within a
CLU, but indicates that further consideration of birth setting may be required.
• Elective induction of labour at term in obese women may reduce the chance of
caesarean birth without increasing the risk of adverse outcomes; the option of
induction should be discussed with each woman on an individual basis.
• Where macrosomia is suspected, induction of labour may be considered. Parents
should have a discussion about the options of induction of labour and expectant
management.
• Women with a booking BMI 30 kg/m2 or greater should have an individualised
decision for VBAC following informed discussion and consideration of all relevant
clinical factors
• An early epidural may be advisable depending on the clinical scenario.
• All women with a BMI ≥30 should be recommended to have active management of
the third stage of labour
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39. For women with BMI > = 40
• Women with class III obesity who are in established
labour should receive continuous midwifery care, with
consideration of additional measures to prevent
pressure sores and monitor the fetal condition.
• The on-duty anaesthetist covering the labour ward
should be informed of all women with class III obesity
admitted to the labour ward for birth. This
communication should be documented by the
attending midwife in the notesWhen she is in
established labour, she should receive continuous
midwifery care.
• Women with a BMI 40 kg/m2 or greater should have
venous access established early in labour and
consideration should be given to the siting of a second
cannula.3/21/20 elbohoty 39

40. Special cosiderations for CS
• Incision
– Transverse
– Supraumblical (but the uterine incision should be upper
segment)
• Assistants
• Retractors
– Self retaining
• S.C fat:
– 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
• Dressings: -ve pressure dressing3/21/20 elbohoty 40

41. Mode of delivery of morbid obese
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42. Postpartum
• Women with a booking BMI ≥30 should continue to receive
nutritional advice following childbirth from an
appropriately trained professional, with a view to weight
reduction.
• Women with a booking BMI ≥30 should receive appropriate
specialist advice and support antenatally and postnatally
regarding the benefits, initiation and maintenance of
breastfeeding.
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43. bariatric surgery
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44. When to offer?
• The primary goal of bariatric surgery is to
ameliorate medical problems related to obesity.
• These operations are therefore generally offered to
women with a BMI of >40 kg/m2 or >35 kg/m2 with
serious coexisting medical complications aggravated
by obesity and who are highly motivated but have
struggled to achieve their target body weight with
conventional dietary and behavioural therapy.
• The NICE guidelines recommend early consideration
of bariatric surgery in patients with a new diagnosis
of type II diabetes and BMI 30–35 kg/m2 and even
lower BMI in patients of Asian origin.
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45. Counselling
• The women selected should be fully aware of the complications
associated with the operation, including an overall mortality rate
of 1%.
• Data from multiple meta-analyses indicate that women with a
preoperative BMI of >40 kg/m2 can be expected to lose 20–40 kg
over 2 years and to maintain their reduced weight for 10 years.
• Pregnancy is therefore generally not recommended for 12–18
months after bariatric surgery, when most of the weight loss
occurs, to avoid nutritional deficiencies.
• These women should receive a follow-up care package for a
minimum of 2 years, including monitoring of nutritional intake,
physical activity and comorbidities and the provision of
psychological support.
• Evidence of the effects of bariatric surgery on infertility and IVF is
sparse: a recent observational study has shown an improvement in
the number of oocytes retrieved in obese women after bariatric
surgery3/21/20 elbohoty 45

46. Types of bariatric surgeries
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47. RESTRICTIVE SURGERIES
•
type : reduce caloric intake by reducing gastric capacity ( band adjustement)
•
• Technique : LAGB:laparoscopic adjustable gastric banding
• SRG: silastic ring.
• VBG: vertical binded gastroplasty
• sleeve gasterectomy
potential complication
• gastric proplapse--remove band by laoarotomy
• band slippage---vomiting
• stromal obstruction,
• pouch dilataion
• gastric erosion and necrosis
• Leakage
• obstetric complication
increase NTD
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48. 3/21/20 elbohoty 48

49. mal-absoptive surgeries
• Technique : BPD: bilo-pancreatic diversion
• JB: jejunal bypass
• potential complication :
• high morbidity &mortality
• mal absorptive $
• hepatic and renal failure
• obstetric complication
• increase miscarriage
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50. 3/21/20 elbohoty 50

51. MIXED TYPE
technique: shortening the length of G.I.T
RYGB: roux -en - y gastric bypass
• potential complication
• dumping $
• stomal stenosis,ulcers, intestinal hernias
,nutrional deficiency
• obstetric complication
• decrease birth weight
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52. • LAGB & gastric bypass were the least harmful
regarding maternal and neonatal outcome
• PPROM is positively correlated with REYB
• effect on fertility
• NICE recommends bariatric surgery as an option in
morbidly obese patients ( BMI more than 40
Kg/m2), where lifestyle and medications found to
be ineffective
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53. effect of bariatric surgery on
pregnancy
• obstetric risks:
preterm delivery- spontaneous miscarriage -PPROM
• medical disorders:
dumping $ - decrease PIH & chronic HTN
• breast feeding:
decrese. energy content - postnatal growth of the
baby.
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54. effect of pregnancy on bariatric
surgery
• Incidence epigastric pain and vomiting
• Band leakage
• Intestinal hernia (most common, from
previous adhesions), intestinal obstruction.
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55. management
preconceptional
• 1) advise delay pregnancy for - at least- 1 year following surgery.
reliable contraception -preferred not to be oral)
till a decent degree of stabilization)
rapid weight loss in this period- Nutritional deficiencies and electrolyte imbalances can arise
• 2) follow up with nutriotnist/dietician to monitor nutritional
status and weight gain
• 3) multi vitamin supplementation esp folic ,vit B12, ,Fe ,Ca (
plasma pr.)
• Regular blood tests may be required following malabsorptive
surgery to check for micronutrient deficiency.
• Weigh the individual at every visit to monitor gestational weight
gain (GWG). Active band management following a laparoscopic
adjustable gastric band procedure results in the least GWG.
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56. 3/21/20 elbohoty 56

57. antenatal ( multi-disciplinary team)
• 1)nutiriotnist: base line-monitor adherence to supplements-tailor needs
to type of surgery-------------- keep optImal GWG( 7-11).
• 2) bariatric surgeon: active band management following surgery.
if slight suspicion of Intestinal obstruction ------perform exam,imaging ----
------------------ low threshold for exploration
• 3) anathesist &pediatrician : notified.
• 4)obstetrician: Fasting & postprandial monitor for a week instead of OGTT
(26-28wk)
screen NTD ( AFP, NT) and serial US, ( for IUGR, anomalies)
anticipation for possible complications
assess for possiblility of thromo-prophylaxis
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58. delivery:( multidisciplinary team
• CS reserved for obstetric indications
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59. post natal Management
• adequate pain control- early mobilization,
thromboprophylaxis, physiotherapy.
• encourage breast feeding
• follow up with nutritionist
• if considering body conturing $ post bariatric
$---- should complete her family first
• 80 % express their wish , 12% already go
through
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60. Questions ( true or false)
• With regard to perinatal outcome following bariatric
surgery:
1)The prematurity rate differs significantly in the pre- &post surgery
pregnancies
2)Adverse outcomes are higher in women who have had previous LAGB & GB.
Procedures as compared with obese groups.
3)There is a positive association between PPROM and bariatric surgery.
4) Congeneital malformation are not much higher following a biliopancreaic
Diversion compared to obese controls.
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61. Questions ( true or false)
• With regard to perinatal outcome following bariatric
surgery:
1)The prematurity rate differs significantly in the pre- &post surgery
pregnancies TRUE
2)Adverse outcomes are higher in women who have had previous LAGB & GB.
Procedures as compared with obese groups. FALSE
3)There is a positive association between PPROM and bariatric surgery.
TRUE
4) Congeneital malformation are not much higher following a biliopancreaic
Diversion compared to obese controls. TRUE
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62. • According to the 2003-2005 confidential
Enquiery into maternal & child health report
1) Approximately 35% of maternal deaths were
linked with obesity
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63. • According to the 2003-2005 confidential
Enquiery into maternal & child health report
1) Approximately 35% of maternal deaths were
linked with obesity false( 28%)
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64. With regard to nutritional deficiencies in pregnancy
postbariatric surgery
• Gastric bypass & LAGB present minimal risk for nutrient
problems.
• Mild nutrional deficiencies are infrequent after bariatric
surgery.
• Addititonal multivitamin supplementation is often not
required.
• The standard 75 g glucose tolerance test has not been shown
to have any untoward effects in pregnant women who have
undergone RYGB.
3/21/20 elbohoty 64

65. With regard to nutritional deficiencies in pregnancy
postbariatric surgery
• Gastric bypass & LAGB present minimal risk for nutrient
problems. False
• Mild nutrional deficiencies are infrequent after bariatric
surgery. false
• Addititonal multivitamin supplementation is often not
required. false
• The standard 75 g glucose tolerance test has not been shown
to have any untoward effects in pregnant women who have
undergone RYGB. false
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66. With regard to maternal outcome in pregnancies following
bariatric surgery
• There is no satistically significant difference between
obstetrical complications following different types of bariatric
surgery.
• There is a lower incidence of pregnancy induced hypertension
compared with those who have not had any surgery.
3/21/20 elbohoty 66

67. With regard to maternal outcome in pregnancies following
bariatric surgery
• There is no satistically significant difference between
obstetrical complications following different types of bariatric
surgery. false
• There is a lower incidence of pregnancy induced hypertension
compared with those who have not had any surgery.
true
3/21/20 elbohoty 67

68. With regard to cosmetic surgery for contouring following
bariatric surgery
• approximately 50% of patients state a desire to undergo
plastic surgery.
• It is important to properly assess and address medical
problems and psychosexual issues in those undergoing this
type of surgery.
3/21/20 elbohoty 68

69. With regard to cosmetic surgery for contouring following
bariatric surgery
• approximately 50% of patients state a desire to undergo
plastic surgery. False – 80%
• It is important to properly assess and address medical
problems and psychosexual issues in those undergoing this
type of surgery. true
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70. With regard to the management of obese pregnant women
following bariatric surgery
• clear guidance exists in the UK.
• Optimal education is vital to enable the women to make well
informed decisions.
3/21/20 elbohoty 70

71. With regard to the management of obese pregnant women
following bariatric surgery
• clear guidance exists in the UK. true
• Optimal education is vital to enable the women to make well
informed decisions. true
3/21/20 elbohoty 71

72. Current recommendations for the timing of pregnancy in women
after bariatric surgery include
• Delaying pregnancy for 24 months. false
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73. With regard to surgical complications during pregnancy
• band leakage is reported in 50% of post –LAGB pregnancies.
• The most commonly reported complication is intestinal
obstruction.
• It is easy to diagnose intestinal obstruction.
• Computed tomography scan with contrast is suggested to be
reliable in the diagnosis of intestinal obstruction.
3/21/20 elbohoty 73

74. With regard to surgical complications during pregnancy
• band leakage is reported in 50% of post –LAGB pregnancies
false - 24%
• The most commonly reported complication is intestinal
obstruction. False- intestinal hernia
• It is easy to diagnose intestinal obstruction.
false
• Computed tomography scan with contrast is suggested to be
reliable in the diagnosis of intestinal obstruction.
true
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75. • PG with booking BMI 47 and her weight has increased
30 kg during this pregnancy. She is now 38 weeks and
her baby is cephalic presentation. Her estimated fetal
weight by the scan is 4 .1 Kg
• What is your advice for the delivery:
a. Await spontaneous labour
b. Elective CS at 39 weeks
c. Elective CS at 39 weeks
d. Induction of labour at 38
e. Induction of labour at 40 weeks.
DM
Hypertension
Her age 41
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76. •THANK YOU
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