A précised short summary of Obesity in Obstetrics

1. Obesity in Obstetrics

2. Contents
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3. 3
Keys points
 Definitions
 Prevalence
 Adipose Pathophysiology
 Metabolic Syndrome
 Nonalcoholic Fatty Liver Disease -
 Obesity-Associated Morbidity
 Obesity Treatment
• Underweight: <18.5 kg/m2
• Normal: 18.5 to 24.9
• Overweight: 25.0 to 29.9
• Obese ≥ 30 kg/m2
– C I: 30 – 34.9,
– CII: 35-39.9
– CIII: ≥40
o Supermorbid obesity: ≥50 kg/m2
• slightly more women than men were
designated obese—36 versus 34 percent
• common among all socioeconomic levels,
the overall severity advances with
increasing poverty
• Genetic predisposition has been identified
from several gene loci

4. • Many fattissue cells communicate with all
other tissues via endocrine and paracrine
factors, which are cytokines specifically termed
adipocytokines (adipokines)
• Adipokines that enhances insulin sensitivity
– Adiponectin
– It enhances insulin sensitivity, blocks hepatic
glucose release, and has cardioprotective effects
on circulating plasma lipids
– adiponectin deficit → diabetes, hypertension,
endothelial cell activation, and cardiovascular
disease
– adiponectin has antiinflammatory and insulin-
sensitizing roles and is negatively regulated by fat
mass
• Adipokines that enhance insulin resistance
– inflammatory cytokines
– leptin, resistin,TNF-α, and IL-6
– higher during pregnancy
• type 2 diabetes, dyslipidemia, and hypertension
• Criteria for Diagnosis of the Metabolic
Syndrome
– Waist circumference is the preferred
measurement for screening
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5. • visceral adiposity correlates with hepatic fat content
• With obesity, excessive fat accumulates in the liver -
hepatic steatosis (nonalcoholic fatty liver
disease (NAFLD))
• In persons with the metabolic syndrome, steatosis
can progress to nonalcoholic steatohepatitis (NASH)
and cirrhosis, as well as hepatocellular carcinoma
• Cause ¼ of CLD cases worldwide
• strongly associated with both fatal and nonfatal
cardiovascular disease
• glucose intolerance, hypertension, dyslipidemia, and
metabolic syndrome
• Insulin resistance and metabolic syndrome
– cardiovascular disease: myocardial infarction, atrial
fibrillation, heart failure, and stroke
– structural cerebral changes and lower executive
functioning and memory in adults
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• Waist circumference positively correlates with
abdominal fat content, which is a risk factor
for poor health outcomes
• Waist circumference is measured at the level
of the iliac crests at the end of normal
expiration
– Values > 35 inches (88 cm) are considered elevated

6. • weight loss in obese adult women
– behavioral, pharmacological, and surgical
techniques
• Dietary changes and exercise
– reduce weight and rates of the associated
metabolic syndrome
– When used in conjunction with bariatric surgery,
glucose control in those with type 2 diabetes is
improved
• In both surgical and medical interventions are
associated with appreciable long-term failure
rates—up to 50% in patients with type 2
diabetes undergoing bariatric surgery
• a 10% weight loss within 6 months is realistic
– AHA: suitable options
– 1200 to 1500 kcal/day or diets that incorporate a
500 or 750-kcal/d deficit
– No single diet plan is gold standard, but ideal
regimen is one that can be adhered to
• when weight loss is the desired goal, a calorie-
restricted diet should be combined with less
sedentary time and increased physical activity;
the activity should be gradually increased over
time as tolerated
Orlistat (Xenical)
– is a reversible inhibitor of gastric and pancreatic
lipases and leads to a 30% blockage of dietary at
absorption
• 120-mg capsule PoTID taken with meals
– Associated malabsorption can lead to deficiencies
of the fat-soluble vitamins A, D, E, and K
– So all patients should receive a daily supplement
enriched with these vitamins
Lorcaserin (Belviq)
– is a serotonin 2C receptor agonist used to
suppress appetite
– One 10-mg tablet Po – BID
– Phentermine and topiramate
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7. – Rx
• Life style and dietary changes
• Pharmacologic for those
1. with known CVD,
2. with LDL cholesterol ≥ 190 mg/dL,
3. aged 40 to 75 years with diabetes & LDL
cholesterol ≥ 70 mg/dL and an estimated
10-year risk of a cardiovascular event that is
at least 7.5%
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Dyslipidemia
• is an abnormal amount of lipids (e.g.
triglycerides, cholesterol and/or fat phospholipids)
in the blood
• Hypercholesterolemia
– LDL is the primary atherogenic agent
• HDL versus LDL cholesterol
– two main types of cholesterol
– HDL - “good cholesterol”
• transports cholesterol to → helps in
removal of excess cholesterol
– LDL - “bad cholesterol”
• takes cholesterol to your arteries, where
it may collect in artery walls
• If excess → atherosclerosis

8. Reproductive disadvantages
• difficulty in achieving pregnancy
• early and recurrent pregnancy loss
• preterm delivery
• Several obstetrical, medical, and surgical
complications with pregnancy, labor, delivery,
and the puerperium
• oral contraceptive failure may be more likely in
overweight women
– contraceptive patch (OrthoEvra) is less effective in
those weighing > 90 kg
– Last, due to its risk for associated weight gain,
depot medroxyprogesterone acetate (Depo-
Provera) may be an unpopular choice in women
trying to lose weight
• Infants & later, adult children of obese mothers
have correspondingly higher morbidity rates
Super-morbid obesity
• ↑rates of maternal and neonatal complications
– preeclampsia, fetal overgrowth, and cesarean
delivery
– meconium aspiration, ventilator support, and
neonatal death
• obesity & metabolic syndrome → insulin
resistance, which causes low-grade
inflammation and endothelial activation ➔ play
a central role in preeclampsia
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9. NAFLD
• ↑ preeclampsia, preterm birth, low-
birthweight neonates, cesarean
delivery, and gestational diabetes
• LDL-III predominance is a hallmark of
ectopic liver fat accumulation that is
typical of NAFLD
Perinatal Mortality
• ↑ Stillbirths
• weight loss between pregnancies for
overweight women lowers this risk
Perinatal Morbidity
• ↑ fetal and neonatal complications
Long-Term Offspring Morbidity
• Obese women beget obese children
• central obesity, elevated systolic blood
pressure, increased insulin resistance,
and lipid abnormalities
• fetal programming ?
• epigenetics
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10. MaternalWeight Gain
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Prepregnancy BMI Total weight gain in kg
Mean (range) in
kg/week – 2nd
& 3rd
tm
Underweight (<18.5
kg/m
2
)
12.5 to 18 0.51 (0.44 to 0.58)
Normal weight (18.5 to
24.9 kg/m
2
)
11.5 to 16 0.42 (0.35 to 0.50)
Overweight (25.0 to 29.9
kg/m
2
)
7 to 11.5 0.28 (0.23 to 0.33)
Obese (≥30.0 kg/m
2
) 5 to 9 0.22 (0.17 to 0.27)
Dietary Intervention
• lifestyle interventions and physical activity
– Maternal and neonatal outcomes did not differ between
groups
– Cochrane database analysis suggests that lifestyle
interventions confer only a modest reduction in maternal
weight gain, and their benefits for fetal overgrowth,
cesarean delivery rate, and adverse neonatal outcome are
not significant
• Regarding neonatal outcomes, the poor success of
lifestyle interventions during pregnancy
–  early gene expression within the placenta has already
been programmed
Prenatal Care
• early signs of diabetes or hypertension
• Accurate fetal growth surveillance in obese women
usually requires serial sonographic assessment

11. Labor Induction
• BMI >30 kg/m2 had a longer duration of and slower
early progression in first-stage labor
• twice as likely to experience a failed induction
Anesthesia Risks
• anesthesia challenges that include difficult epidural
and spinal analgesia placement and complications
from failed or difficult intubations.
• Evaluation of super-morbidly obese gravidas by the
anesthesiologist is recommended during prenatal
care or upon arrival to the labor unit
• Regional analgesia for morbidly obese women is
associated with longer neuraxial procedure times
and more failed placement attempts
• But, spinal analgesia in obese women for cesarean
delivery does not appear to have benefits over
combined spinal-epidural
• If regional analgesia is complicated by relative
hypotension
– delayed delivery ➔ neonatal acidemia
↑ Cesarean Delivery
• overweight (34 percent), class I (38 percent), class II
(43 percent), and class III (50 percent)
• Abdominal incision
– vertical incision – preferred
– low transverse abdominal incision, with or without
rostral taping of the pendulous abdomen
• wound infections
– Preventive
– Closure of subcutaneous tissue ≥ 2 cm deep
– higher doses of perioperative prophylactic antibiotics: 3-g
dose of cefazolin
– Prophylactic Negative-pressure wound therapy (NPWT) -
did not significantly lower
• lower thromboembolic complications
– Graduated compression stockings,
– Hydration
– Early mobilization
– Some also recommend “mini-dose” heparin prophylaxis,
but we do not routinely
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12. • Initial treatment
– Comprehensive lifestyle intervention
– Dietary therapy
– Exercise
– Behavior modification
• Subsequent treatment
– Drug therapy
– Devices: Intragastric balloon therapy
• soft saline- or gas-filled balloon in the stomach to
promote a feeling of satiety and restriction
– Bariatric surgery
Bariatric surgery
• Indications
– BMIs > 40 or
– BMIs > 35 + other co-morbid conditions
(hypertension, impaired glucose tolerance, diabetes
mellitus, dyslipidemia, sleep apnea)
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I. Restrictive Surgeries (limit intake)
– Laparoscopic adjustable silicone gastric banding (LASGB)
procedures: LAPBAND and REALIZE
• place a band 2 cm below the gastroesophageal junction to create
a small stomach pouch above the ring
• Deflation during pregnancy has higher risk
– sleeve gastrectomy partitions of the lateral stomach by a
staple line
II. Bypass surgery: promotes malabsorptive weight
loss
– Serious complications are uncommon
– however, upper abdominal pain is frequent in pregnancy
and often associated with internal herniation, which is
protrusion of the bowel through a mesentery defect
• Upper abdominal pain complicated 46 percent, and a third of
these had internal herniation
• Bowel obstruction is notoriously difficult to diagnose
– popular, and many women subsequently become pregnant

13. Roux-en-Y gastric bypass
• proximal stomach is completely transected to leave a 30-mL
pouch
• proximal end of the distal jejunum is then connected to the
small pouch
• At a site 60 cm distal to this gastrojejunostomy, a Roux-en-
Y enteroenterostomy is also completed to allow drainage of
secretions from the unused stomach and duodenum
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• In nonpregnant patients, these procedures improve or
resolve diabetes, hyperlipidemia, hypertension, and
obstructive sleep apnea and reduce risks of myocardial
infarction and death
• Pregnancy Outcomes Following Bariatric Surgery

14. • women who have undergone bariatric surgery be assessed for
vitamin and nutritional sufficiency
– When indicated, vitamins B12 and D, folic acid, and calcium
supplementation are given
– Vitamin A deficiency is also possible
– Women with a gastric band should be monitored by their bariatric
team during pregnancy because adjustments of the band may be
necessary.
– Finally, special vigilance is appropriate for signs of internal herniation
with intestinal obstruction
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15. • Super morbid obesity is:
– BMI ≥ 50 kg/m2
• What percentage of women are obese? 36%
• Which of the following does not cause insulin
resistance?
– a. IL-6 b. Leptin c.TNF-α d.Adiponectin
• Which of the following is not a constituent of the
metabolic syndrome?
– a. Dyslipidemia
– b. Hypertension
– c.Type 2 diabetes
– d. Chronic renal disease
• To diagnose metabolic syndrome, a patient must
have at least 3 diagnostic criteria.Which of the
following is not one of the criteria?
– a. Elevated waist circumference
– b. HDL >50 mg/dL in females
– c. Fasting glucose ≥100 mg/dL
– d. Systolic blood pressure ≥130 mm Hg
• Up to 50% of patients with type 2 diabetes who
undergo bariatric surgery fail to maintain the weight
loss long term?
• Obesity increases the risk for maternal death by 4X
• Which of the following is not associated with
nonalcoholic fatty liver disease?
– a. Preeclampsia
– b. Preterm birth
– c. Hypoglycemia
– d. Low birthweight
• What is the prevalence of wound infection in obese
(BMI > 30 kg/m2) pregnant women? 1%
• What is the odds ratio for preeclampsia in obese
(body mass index >30 kg/m2) pregnant women? 3
• What is the highest ranking modifiable risk factor
for stillbirth?
– a. Obesity
– b. Cocaine use
– c. Mental illness
– d.Vitamin deficiencies
• Why have lifestyle interventions such as exercise in
obese pregnant women not been shown to
significantly improve neonatal outcomes?
– Early gene expression within the placenta has
already been programmed
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16. • You are following a 28-year-old G3P2 pregnant woman. She
has a body mass index of 55 kg/m2.You question the
accuracy of the fundal heights you are measuring.What is
the best management plan to ensure appropriate fetal
growth?
– a. Serial ultrasounds for rate of growth
– b. Do not measure fundal heights and instead perform weekly
NSTs
– c. Measure the fundal height three times each visit and average the
results
– d. Follow the change in fundal height each visit instead of the
absolute number
• Obese women are twice as likely to have a failed
induction
• Which of the following statements about anesthesia in
obese women is true?
– a. Spinal is better than combined spinal-epidural
– b. Combined spinal-epidural is better than spinal
– c. General anesthesia is better than regional anesthesia
– d. Combined spinal-epidural and spinal anesthesia can be
placed with equal expediency and function
• What is the likely reason that obese pregnant women who
become hypotensive from anesthesia more frequently have
acidotic neonates than normal weight pregnant women?
– Delayed delivery
• What is the optimal location for
placement of the skin incision for cesarean
section in a morbidly obese pregnant
woman? B
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17. • What is the increase in risk for wound infection in
supermorbidly obese pregnant women compare to nonobese
pregnant women? 3-fold
• You are going to perform a cesarean section on a woman with
a body mass index of 40 kg/m2.You want to minimize her risk
for wound infection.Which of the following interventions has
not been shown to help with this?
– a. Exercising good sterile technique
– b. Prophylactic negative-pressure wound therapy
– c. Increasing perioperative prophylactic antibiotics
– d. Closing subcutaneous tissue when it is ≥ 2 cm deep
• All except which of the following is associated with lower
rates when comparing Roux-en-Y gastric bypass to gastric
banding?
– a. Hypertension
– b. Cesarean section
– c. Low birthweight
– d. Gestational diabetes
• Compared to maintenance of an inflated gastric band during
pregnancy, full deflation of a gastric band results in all except
which of the following?
– a. Increased macrosomia
– b. Increased birthweight
– c. Increased mean weight gain
– d. Increased fetal cerebral hemorrhage
• What is the most common procedure for gastric restriction
and selective malabsorption?
– a. REALIZE
– b. LAPBAND
– c. Gastric sleeve
– d. Roux-en-Y gastric bypass
• Roux-en-Y gastric is frequently associated with which of the
following symptoms in pregnancy?
– a. Headache
– b. Constipation
– c. Lower abdominal pain
– d. Upper abdominal pain
• In women hoping to become pregnant after bariatric surgery,
counseling should include all except which of the following
points?
– a. Fertility rates are increased.
– b. Obstetric complications are reduced.
– c. Large-for-gestational-age neonates are less common.
– d. Rates of small-for-gestational-age neonates remain the
same.
• Which of the following vitamins is of least concern in pregnant
women who have undergone bariatric surgery?
– a. Folic acid
– b.Vitamin D
– c.Vitamin C
– d.Vitamin B12
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