Obstetrics complications in obese pregnant women

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Obez Gebelerde
Obstetrik Sorunlar
Dr Tevfik Yoldemir
Marmara Üniversitesi Tıp Fakültesi
Kadın Hastalıkları ve Doğum A.D.
Üreme Endokrinolojisi ve İnfertilite B.D.
tevfik@yoldemir.com
classification
Obesity related risks Maternal Complications
• Hypertensive Disorders of Pregnancy
• a twofold increase in risk for mild or severe
preeclampsia for overweight women (BMI 25.0–29.9),
• approximately a threefold increase for obese women
(BMI 30.0–34.9), and
• a fivefold increase in the risk for preeclampsia for
severely obese women (BMI 35.0–39.9)
Medical Journal of Australia, 2006;184, 56–59.
Epidemiology, 2007:18(2), 234–239.
Obstetrics and Gynecology, 2004;103, 219–224.
• Evidence from the Framingham Heart Study, a
prospective population-based cohort study,
demonstrated that hypertension and coronary artery
disease were more common in obese and
overweight individuals at all ages.
• Relative risk (RR) for hypertension in overweight
adults was found to be 1.5 to 1.7.
• RR was found to be 2.2 to 2.6 for obese adults.
• It is important to establish baseline blood pressure values in
early pregnancy, and care should be taken to use properlyproperly
sizedsized blood pressure cuffsblood pressure cuffs in order to ensure accurate
measurements.
• Additionally, evaluation of end-organ effects of hypertensive
disease, such as heart failure or nephropathy, should be
considered.
• Comprehensive evaluation of cardiac function may require
electrocardiographic orelectrocardiographic or echocardiographicechocardiographic testingtesting.
• Renal function is commonly assessed by a 2424--hour urinehour urine
evaluation to measure total protein excretion.
Journal of the American Medical Association, 2003:290, 199–206.
Blood Pressure Monitor, 2001: 6, 17–20.

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Diabetes Mellitus
• The second trimester of pregnancy is a physiologic state
of insulin resistanceinsulin resistance. Hormones produced by the
placenta lead to mild levels of maternal hyperglycemia
in order to promote adequate fetal growth and
development.
• Most gravidas adapt readily to this event. In some
women, however, pancreatic insulin secretion is not
adequate to counter the diabetogenic hormones.
• Women who have normal serum glucose levels prior to
pregnancy demonstrate abnormally high postprandial
and fasting serum glucose levels during pregnancy.
Gestational diabetes
• This transient disease process is known as
gestational diabetes.
• Preeclampsia, disordered fetal growth, neonatal
metabolic complications such as hyperbilirubinemia
and hyperglycemia, and even fetal death are the
adverse effects.
• Adipocytes participate in several important signaling
pathways that influence insulin sensitivity in the
peripheral tissues. As a result, obese women are at
increased risk for developing gestational diabetes.
American Journal of Physiology, 2001: Endocrinology and
Metabolism, 280, E827–E847
Gestational diabetes
• The relative risk of developing gestational diabetes
in obese women (prepregnancy BMI 25 to 30) was
reported to be 1.68 (99% confidence interval [CI]
1.53 to 1.84)
• severely obese women (prepregnancy BMI greater
than 30) to be 3.6 (99% CI 3.25 to 3.98)
International Journal of Obesity Related Metabolic Disorders,
25, 1175–1182
• Obese women (BMI greater than 29) demonstrated a
relative risk for developing gestational diabetes of
4.53 (95% CI 1.25 to 16.43).
American Journal of Epidemiology, 2007:165, 302–308.
Diabetes
• weight gain between the age of 18 years and the
study pregnancy of greater than or equal to 10
kilograms conferred a relative risk of 3.43 (95% CI
1.60 to 7.37) when compared with women who had
less than a 3-kilogram weight change over the same
period
American Journal of Epidemiology, 2007:165, 302–308
• A linear relationship exits between increasing BMI
and increasing incidence of diabetes.
Diabetes
• Even after adjusting for family history, levels of
exercise, and dietary habits, the relative risk of future
development of type II diabetes was 11.2 for women
in the top tenth percentile of BMI when compared
with women in the lowest tenth percentile.
• The relative risk for a diagnosis of diabetes during
pregnancy for overweight women (prepregnancy
BMI 25 to 30) was found to be 3.4 (95% CI 1.7 to 6.8)
and for severely obese women (prepregnancy BMI
greater than 30) was found to be 15.3 (95% CI 8.2 to
28.6) when compared with normal weight women
The Nurses’ Health Study. American Journal of Epidemiology, 1997:145, 614–619
Obstetrics and Gynecology, 2005:105, 537–542
• A large number of obese women may in fact have
undiagnosed Type II diabetes, which is manifest by
abnormal glucose tolerance testing prior to 20 weeks
of gestation.
• For obese women who develop gestational diabetes,
promoting tight controltight control of blood glucoseof blood glucose values
optimizes both maternal and fetal outcomes.
• The most successful management approaches are
multidisciplinarymultidisciplinary and include physicians, nurse-
educators, and dietitians.

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Nutrition & Weight Gain
• those with a high prepregnancy BMI were more than
four times as likely to report target gains above IOM
guidelines.
• weight gains above the IOM recommendations were
observed for
• 23% of the underweight women,
• 49% of the normal weight women,
• 70% of the overweight women, and
• 57% of the obese women.
Obstetrics and Gynecology, 2005;105, 633–638
Obstetrics and Gynecology, 1995; 86, 170–176.
American Journal of Public Health, 1997;87, 1984–1988
• 30% weighed less one year after delivery than they
did before pregnancy, 56% gained 0 to 5 kilograms
over the same time period, and 14% gained more
than 5 kilograms.
• Risk factors for postpartum weight retention in this
study were excessive pregnancy weight gain, high
prepregnancy BMI, and maternal age greater than
36 years
• It appears that overweight and obese women are at
increased risk for excessive pregnancy weight gain
and elevated postpartum weight retention.
International Journal of Obesity, 1990;14, 159–173.
Fetal Complications
• Macrosomia
• It is associated with shoulder dystocia, birth trauma,
and/or Cesarean delivery.
• ACOGs recommendation for the term fetal
macrosomia, on the other hand, is that it should be
reserved for those infants weighing more than 4,000
or 4,500 grams at birth
ACOG Technical Bulletin Number 22–November 2000.
Obstetrics and Gynecology, 96, 341–345.
• Factors that may predispose to fetal macrosomia
include: pregestational or gestational diabetes,
prepregnancy maternal obesity or overweight
status, excessive weight gain during pregnancy,
multiparity, male fetus, as well as constitutional
factors such as ethnicity, maternal birth weight, and
maternal height.
• Increasing maternal weight is an independent
variable for a macrosomic or large for gestational
age infant
American Journal of Obstetrics and Gynecology, 2004; 191, 964–968.
Obstetrics and Gynecology, 2003;102, 1022–1027.
• odds ratios for large for gestational age infants to be
increased for women with
• a BMI 29.1 to 35 OR 2.20 (95% CI 2.14 to 2.26),
• a BMI 35.1 to 40 OR 3.11 (95% CI 2.96 to 3.27), and
• women with a BMI greater than 40 OR 3.82 (3.56 to
4.16).
Obstetrics and Gynecology, 2004;103, 219–224.

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Congenital anomalies
• The overall incidence ranges from 2 to 4% of all
pregnancies.
• The most common anomalies are neural tube
defects, congenital cardiac malformations, orofacial
clefts, and Trisomy 21.
• Obese women are at higher risk for having an infant
with congenital cardiac defects, orofacial clefts, and
neural tube defects.
Morbidity and Mortality Weekly 2006;Report, 54, 1301–1305.
American Journal of Obstetrics and Gynecology, 1994;170, 541–548
Paediatric Perinatal Epidemiology, 2000;14, 234–239.
• Obese women (BMI greater than or equal to 30)
were more likely to have an infant with a neural tube
defect (OR: 3.5, 95% CI: 1.2 to 10.3), omphalocele
(OR: 3.3; 95% CI: 1.0 to 10.3), heart defects (OR: 2.0;
95% CI: 1.2 to 3.4), or multiple anomalies (OR: 2.0;
95% CI: 1.0 to 3.8).
• Overweight women (BMI 25 to 29.9) also were more
likely than average-weight women to have infants
with heart defects (OR: 2.0; 95% CI: 1.2 to 3.1) and
multiple anomalies (OR:1.9; 95% CI: 1.1 to 3.4).
Pediatrics, 2003;111, 1152–1158
• The rate of incomplete or suboptimalincomplete or suboptimal visualizationvisualization of
the fetal cardiac structures was as high as 37.3% in
obese women, compared with only 18.7% in
average-weight women.
• Similar findings were documented for craniospinal
structures, with a suboptimalsuboptimal visualizationvisualization rate of
42.8% compared with 29.5% in average-weight
women
International Journal of Obesity Related Metabolic Disorders, 2004; 28, 1607–1611
Fetal Demise
• Fetal problems, including congenital anomalies,
account for 25% of antepartum fetal deaths.
• Maternal problems, including preeclampsia and
diabetes, account for another 10%.
• Placental or umbilical cord problems such as
placental abruption or true knots in the umbilical
cord account for 25% to 30% of intrauterine fetal
deaths.
• The odds ratio of 2.7 (95% CI 1.5 to 5.0) for the risk
of fetal death in overweight women (BMI 25.0 to
29.9), and 2.8 (95% CI, 1.3 to 6.0) for obese women
(BMI greater than or equal to 30) were reported.
American Journal of Obstetrics and Gynecology, 2001;184, 463–469.
• An odds ratio of 2.8 (95% CI: 1.5 to 5.3) for stillbirth
in obese gravidas compared with women of normal
weight was detected.
British Journal of Obstetrics and Gynecology, 2005;112, 403–408
Childhood obesity
• Barker hypothesis
• There is also a well-established link between
maternal obesity and large for gestational age
infants, who are also at increased risk for developing
obesity later in life.
• dysregulation of central nervous system control of
appetite regulation,
• peripheral changes in insulin sensitivity and
• alterations in pancreatic response to hyperglycemia.
Obesity Research, 2003;11, 496–506.
Clinical Science, 1998; 95, 115–128.
Obstetrics and Gynecology, 1998; 91, 97–102

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Intrapartum Complications
• Induction of Labor
• higher incidence of medical comorbidities such as
hypertension and diabetes, as well as a higher
incidence of post-dates pregnancy
• Failure of induction of labor in morbidly obese
gravidas (weight greater than 120 kilograms at
initiation of prenatal care) as 40%, which was
significantly higher than the rates of 19% for women
with normal weight (55 to 75 kilograms)
British Journal of Obstetrics and Gynecology, 2005;112, 768–772.
Obstetrics and Gynecology, 2005;106, 1357–1364
• Obese women demonstrate abnormalities in the
second stage of labor more frequently, and require
operative assistance due to soft tissue dystocia and
poor maternal pushing efforts more frequently than
women with normal BMI.
• Obese women are less likely to have a successful
medical induction of labor and may require an
operative delivery
American Journal of Obstetrics and Gynecology, 2004; 91,928–932.
Cesarean Delivery
• 386 obese women (BMI 30 to 34.9) and 196
morbidly obese (BMI greater than or equal to 35)
nulliparous women demonstrated Cesarean delivery
rates of 33.8% and 47.4%, respectively.
• These rates were significantly higher than the
Cesarean delivery rate of 20.7% in nulliparous
patients with normal BMI
British Journal of Obstetrics and Gynecology, 2005; 112, 768–772.
Obstetrics and Gynecology, 2005;106, 1357–1364.
American Journal of Obstetrics and Gynecology, 2004;91,928–932.
American Journal of Obstetrics and Gynecology, 2004;191, 969–974.
Paediatric Perinatal Epidemiology, 2004;18, 196–201.
• For obese women requiring Cesarean deliveryCesarean delivery, and
particularly those with co-existing medical
conditions, consideration should be given to
placement of an arterialarterial lineline for accurate assessment
of hemodynamic status.
• This is particularly important since operative delivery
is more complicated in the obese patient as
operative times tend to be longer and blood loss
greater
•• SSupraupra--umbilical incisionsumbilical incisions to decrease rates of wound
separation and infectious morbidities.

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•• DDrainsrains are recommended when the subcutaneous
space was greater than or equal to 2 cm.
• Obese women are at increased risk of airway
complications, cardiopulmonary dysfunction,
perioperative morbidity and mortality, and also pose
technical anesthesia challenges
•• Epidural analgesiaEpidural analgesia can be successfully used in obese
patients, but the placement of the epidural catheter
may be complicated by improper positioning and
difficulty identifying the midline in very obese women
Anaesthesia, 2006;61, 36–48.
American Journal of Obstetrics and Gynecology, 1994;170, 560–565.
• The incidence of difficult intubation in pregnant
women over 136 kg was reported in one
retrospective case-control study to be as high as
35%, compared with 0% among normal-weight
women
Anesthesiology, 1993;79, 1210–1218.
• a rate of 80% for successful trial of laborsuccessful trial of labor in women
weighing less than 90 kg, with rates decreasing to
57% for women weighing 90 to 136kg and a rate of
vaginal delivery of only 13% in women weighing
more than 136 kg
American Journal of Obstetrics and Gynecology,2003;188,1516–1520.
Shoulder Dystocia
• Dystocia is a rare complication, occurring in approximately
0.5% to 1.5% of vaginal deliveries
Obstetrics and Gynecology, 2002;100, 1045–1050
• Maternal obesity, because of its relationship with higher
rates of fetal macrosomia and gestational diabetes, has
consistently been found to be a predisposing factor for
shoulder dystocia.
Journal of Midwifery and Womens Health, 2005:50, 485–497.
American Journal of Obstetrics and Gynecology, 1993;168,1732–1737
European Journal of Obstetrics, Gynecology and Reproductive Biology,2006;126,11–15
Acta Obstetricia Et Gynecologica Scandinavica, 2006; 85, 567–570
Fetal Monitoring
•• Proper placement of the transducersProper placement of the transducers for fetal heart
rate and maternal uterine activity assessment and/or
maintenance of an adequate tracing may be difficult
in women with central obesity and an unusually thick
anterior abdominal wall or a large abdominal pannus
• During labor, there can be similar problems obtaining
a continuous fetal heart rate tracingcontinuous fetal heart rate tracing with external
fetal heart rate monitors for very obese women.
•• InternalInternal fetal scalp electrodesfetal scalp electrodes should be considered if
there is an inability to adequately document fetal
well-being.
Postpartum Complications
• Tromboembolism
• obesity (BMI greater than 30) conferred an
additional risk for thromboembolic events with an
odds ratio of 4.4 (95% CI 3.4 to 5.7).
American Journal of Obstetrics and Gynecology, 2006;194, 1311–1315.
• both overweight status (BMI 25–29.9) and obesity
(BMI greater than 30) conferred an additional risk,
with odds ratios 1.8 (95% CI 1.3 to 2.5) and 2.0 (95%
CI 1.3 to 3.1)
Seminars in Perinatology, 2002; 26,42–50.

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• Medical conditions that predispose to
thromboembolic events during pregnancy include
diabetes, hypertension, heart disease,
antiphospholipid syndrome, lupus, sickle cell disease,
inherited thrombophilias, and a history of a previous
thromboembolic event
Wound Disruption and Infection
After Cesarean Delivery
• Postpartum infectious complications are quite
common; endometritis affects approximately 4% to 6%
of delivered women and wound infection complicates
2% to 16%.
• Patient characteristics that pose additional risk for
surgical site include many conditions more commonly
found in obese gravidas such as prolonged labor,
diabetes, anemia, smoking, and poor nutritional status.
• Abdominal wall thickness greater than 3 cm, more
frequently found in obese women, is associated with
almost a three-fold increase in risk for postoperative
wound infection
Nursing Standard, 2007;21, 57–58, 60, 62
Obstetrics and Gynecology, 2005;105, 967–973.
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