updated review about obesity in pregnancy: management and its complications

1. Hashem Yaseen 112017 4th year OG resident KAUH JUST

2.  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 112017 4th year OG resident KAUH JUST

3.  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 112017 4th year OG resident KAUH JUST

4. Antepartum
Intrapartum
Postpartum
Offspring
Hashem Yaseen 112017 4th year OG resident KAUH JUST

5. 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 112017 4th year OG resident KAUH JUST

6. Intrapartum
• Induction
• Progress of labor
• Cesarean delivery
• Trial of labor after cesarean delivery
• Difficulties with anesthesia
• Complications related to macrosomia
Hashem Yaseen 112017 4th year OG resident KAUH JUST

7. Postpartum
• Venous thromboembolism
• Infection
• Postpartum depression
Hashem Yaseen 112017 4th year OG resident KAUH JUST

8. Offspring
• Congenital anomalies
• Death
• Prematurity
• Large for gestational age
• Asthma
• Childhood obesity
• Neurodevelopment
Hashem Yaseen 112017 4th year OG resident KAUH JUST

9. PRE-PREGNANCY
MANAGEMENT
PREGNANCY
MANAGEMENT
Hashem Yaseen 112017 4th year OG resident KAUH JUST

10.  Preconception counseling, evaluation, and
care:
●Information about:
1. the adverse effects of obesity on fertility
2. 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 112017 4th year OG resident KAUH JUST

11.  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 112017 4th year OG resident KAUH JUST

12. First trimester:
• Baseline assessments
• Counseling
• Gestational weight gain
• Exercise
• Fetal aneuploidy screening
• Referrals
Second trimester:
Low-dose aspirin
Fetal 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
Cesarean delivery:
.Thromboprophylaxis
. Antibiotic prophylaxis
. Technical issues
Hashem Yaseen 112017 4th year OG resident KAUH JUST

13. Hashem Yaseen 112017 4th year OG resident KAUH JUST

14.  First trimester
 Baseline assessments
1. Maternal weight and body mass index (BMI).
2. Blood pressure using an appropriately sized cuff
3. Early ultrasound -> gestational age a multifetal gestation
4. 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 112017 4th year OG resident KAUH JUST

15.  First trimester
 Counseling:
1. pregnancy risks associated with obesity
2. diet
3. gestational weight gain
4. Exercise } Review frequently
throughout pregnancy
Hashem Yaseen 112017 4th year OG resident KAUH JUST

16.  First trimester
 Gestational weight gain :
Hashem Yaseen 112017 4th year OG resident KAUH JUST

17.  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 112017 4th year OG resident KAUH JUST

18.  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 112017 4th year OG resident KAUH JUST

19.  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 112017 4th year OG resident KAUH JUST

20. Hashem Yaseen 112017 4th year OG resident KAUH JUST

21.  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)
Hashem Yaseen 112017 4th year OG resident KAUH JUST
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 ≥35
5. personal factors (eg, low
birth weight or small for
gestational age, previous
adverse pregnancy
outcome, >10-year
pregnancy interval)

22.  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 112017 4th year OG resident KAUH JUST

23.  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 112017 4th year OG resident KAUH JUST

24. Hashem Yaseen 112017 4th year OG resident KAUH JUST

25.  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 112017 4th year OG resident KAUH JUST

26. Hashem Yaseen 112017 4th year OG resident KAUH JUST

27.  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 112017 4th year OG resident KAUH JUST

28.  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.
Hashem Yaseen 112017 4th year OG resident KAUH JUST

29. Hashem Yaseen 112017 4th year OG resident KAUH JUST

30.  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 112017 4th year OG resident KAUH JUST

31.  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
Hashem Yaseen 112017 4th year OG resident KAUH JUST

32.  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 112017 4th year OG resident KAUH JUST

33.  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 112017 4th year OG resident KAUH JUST

34. Hashem Yaseen 112017 4th year OG resident KAUH JUST
Mass closure of incisions

35.  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 112017 4th year OG resident KAUH JUST

36. Hashem Yaseen 112017 4th year OG resident KAUH JUST

37.  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.
Hashem Yaseen 112017 4th year OG resident KAUH JUST

38. Hashem Yaseen 112017 4th year OG resident KAUH JUST