This document discusses obesity in pregnancy and provides recommendations for management. It covers the effects of obesity on antepartum, intrapartum, postpartum periods and childhood. It finds increased risks of complications including gestational diabetes, preeclampsia, stillbirth, macrosomia, cesarean delivery, and maternal and neonatal morbidity. Management involves weight control before and during pregnancy, screening and treatment of comorbidities, allowing more time in labor, and ensuring proper equipment and facilities for obese pregnant women and mothers.

1. Obesity in Pregnancy
ACOG, 2015
Prof. Aboubakr Elnashar
Benha university Hospital, EgyptABOUBAKR ELNASHAR

2. CONTENTS
I. EPIDEMIOLOGY
II. EFFECTS
1. Antepartum
2. Intraparum
3. Postpartum
4. Fetal and childhood
III. MANAGEMENT
Equipments and facilities
1. Preconceptional care
2. Antepartum care
3. Intrapartum care
4. Operative care
5. Postpartum care
6. Inter pregnancy care
 CONCLUSION
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3. Prevalence of female obesity in Egypt
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4. Egyptians are the fattest Africans
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5. II. EFFECTS ON PREGNANCY
1. Anteparum complications
1. Increased risk of spontaneous abortion
(odds ratio [OR], 1.2; 95% confidence interval [CI], 1.01–1.46)
and recurrent miscarriage (OR, 3.5; 95% CI, 1.03–12.01)
The risk of gastroschisis in the neonates among
obese gravidas, however, was significantly reduced
(OR,0.17; 95% CI, 0.10–0.30)
2. Increased risk of congenital anomalies
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7. 3. Increased risk of SB
Obese gravidas are 40% more likely to experience
stillbirth compared with nonobese gravidas
(adjusted hazard ratio, 1.4; 95% CI, 1.3–1.5)
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9. 4. Increased risk of
Cardiac dysfunction
Proteinuria
Sleep apnea
Nonalcoholic fatty liver disease
Gestational diabetes mellitus
Preeclampsia
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10. 2. Intrapartum Complications
1. Increased indicated PTB
the data conflict as to whether a similar association exists for
spontaneous PTB
2. Increased risk of
CS
Failed trial of labor
Endometritis
Wound rupture or dehiscence
Venous thrombosis
3. Obese gravidas undergoing a trial of VBAC
2fold increase in maternal morbidity
5fold increased risk of neonatal injury
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11. 3. Postpartum Complications and Long-Term
Outcomes
1. Postpartum weight retention
46% of obese pregnant women have excess
gestational weight gain
: increases the risk of
metabolic dysfunction
pregravid obesity in future pregnancies.
2. Pregravid obesity:
Early termination of breastfeeding,
Postpartum anemia
Depression
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12. 4. Fetal and Childhood complications
1. Fetuses of obese gravidas are at increased risk of
Macrosomia
Impaired growth
2. Infants of obese women tend to have
more body fat than infants of normal-weight
women.
3. Child of obese women: an increased risk
Metabolic syndrome
Obesity
Asthma
Altered behavior
increased risk of autism spectrum disorders, childhood
developmental delay, and attention-deficit/hyperactivity
disorder
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13. III. MANAGEMENT
FACILITIES AND EQUIPMENT
1. Birthing beds
capable of supporting an obese gravida for a vaginal delivery
with appropriate monitoring equipment
2. large chairs, blood pressure cuffs, and wheelchairs
3. Motorized lifts
Will make it easier to assist the obese patient onto the
operating table
4. The operating table
accommodate the size and weight of the patient, or two tables
joined together may be required
able to accommodate various positions to the satisfaction of
anesthesia and obstetric staff, as well as patient safety.
5. Long instruments
 may be necessary to facilitate the surgeon’s access to proper
tissue planes. ABOUBAKR ELNASHAR

14. I. PRECONCEPTIONAL CARE
1. Screen for
DM and optimization of glucose control
Thyroid disease.
Rubella and varicella vaccination
Prenatal vitamins
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15. 2. Weight loss
Effects.
weight loss of 5–7%
significantly improve pregnancy outcomes
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16. Methods:
1. Life style modification
a. Hypo-caloric diet:
1000-1500 Kcal/d
Containing:
50% CHO
30% lipid
20% Pr.
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17. b. Exercise program
(Goodyear & Kahan,1998; Kennedy et al,1999)
 150 min/w of aerobic exercise in divided sessions
 Risk of anovulatory infertility decreased by 5% with
each h/w of vigrous physical activity
(Edwards et al, 2002)
Mechanisms
 independent of weight loss: reduces insulin resistance
1. Reducing abdominal fat.
2. Increasing muscle capillarity.
3. Restoring both the level & function of glucose transporter
4.
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18. 2. Medication.
 Indications:
 Failure to lose 10% wt despite life style changes
and diet control
(Mathys, 2005)
Not recommended
during the time of conception
during pregnancy
{safety concerns and adverse effects}
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19. 3. Bariatric surgery: 3rd -line treatment option
 Indications: (NICE, 2013)
1. Morbid obese
failed to lose wt by other means
2. Moderate obesity
with significant co-morbid condition that could
be improved by wt loss
 Most suitable technique:
laparoscopic adjustable gastric band
{tightness of the band can be adjusted to
accommodate for increased demands of
pregnancy}
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20. 3. Women who have undergone bariatric surgery
To avoid pregnancy for at least 6–12 months after
bariatric surgery
 Optimize weight loss
 Reduce adverse effect of post- bariatric surgical
nutritional deficiencies.
(Uptodate, 2016)
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21. Cu
IUD
LNG
IUD
ImplantPO
injec
POPCOC
Patch
Ring
111111
Restrictive:
1.Laparoscopic
adjustable
gastric band
2.Sleeve
gastrectomy
11113
COCs:
3
P/R: 1
Malabsorptive :
1.Roux-en-Y
gastric bypass,
2.Biliopancreatic
diversion
WHO Medical Eligibility Criteria: 2015
History of Bariatric Surgery
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22. II. ANTEPARTUM CARE
1. Recommend weight gain
To optimize outcomes for the pregnant woman and
her infant.
At the initial prenatal visit
Prepregnancy weight
Height
Calculation of BMI: diet and exercise counseling
If the prepregnancy weight is unknown, the initial
prenatal visit weight is recorded.
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23. 2nd and 3rd T
Mean
range(k/W)
Total Wt
gain
BMIPrepregnancy
wt category
0.5(0.5-0.6)12.7-18.1≤18.5Under wt
0.5(0.4-0.5)11.3-15.918.5-24.9Normal wt
0.3(0.2-0.3)6.8-11.325-29.9Over wt
0.2(0.2-0.3)5.0-9.1≥30obese
Wt gain in 1st T: 0.5-2.0 k
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24. a. To avoid excessive gestational weight gain
 Methods:
1. Dietary control
low-glycemic or low caloric diets
2. Exercise
3. Behavior modification.
Dietary strategies
more useful than exercise
Effects:
reduced the risk of
Excessive gestational weight gain by 20%
Macrosomia by 15% in overweight and obese women
No decrease in
CS
Preterm delivery
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25. b. Do not allow
Inadequate weight gain or
weight loss for obese pregnant women
{In obese women with gestational weight loss:
increased risk of SGA below the 10th percentile}
(adjusted OR, 1.76; 95% CI, 1.45–2.14) and 3rd percentile (adjusted OR,
1.62; 95% CI, 1.19–2.20)
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26. 2. Women who have undergone bariatric surgery
Evaluate for nutritional deficiencies
vit supplementation
1. Micronutrient supplementation:
Iron, folate
Fat soluble vitamin (D &K)
 B12
Calcium
2. Fetal growth assessment.
3. Gestational diabetes: Screening
4. Monitoring for complications of bariatric surgery
5. Gestational weight gain
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27. 3. Antenatal Diagnosis of Congenital Anomalies
Obesity:
Reduce detection by US
Affects measures of serum analytes
{ increased plasma volume in obese pregnant women}.
Although weight adjustment for analytes improves
detection of NTD and trisomy 18, this adjustment does
not improve detection of Down syndrome
No effect on markers for aneuploidy
increased nuchal fold
echogenic bowel
echogenic cardiac focus
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29. 4. Screening for Metabolic Disorders
{Obese women are at increased risk of metabolic syndrome.
Increased insulin resistance during pregnancy
may cause preexisting but subclinical cardiometabolic
dysfunction to emerge as
1. PET
2. GDM
3. Obstructive sleep apnea (OSA)
These complications are associated with adverse
pregnancy outcomes
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30. 1. Screening for PET
ACOG Guidelines, 2015
1. laboratory or imaging tests:
Not recommend for screening
(Grade 1B).
2. First-Trimester Risk Assessment
: low positive predictive value
3. Detailed medical history to evaluate for risk
factors:
Best & only recommended screening approach
4. All pregnant women should be
assessed for and educated about
the signs and symptoms of the disease.
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31. 2. Screening for GDM
All pregnant patients
Routine screening: at 24 –28 w.
Early pregnancy screening
based on risk factors
maternal BMI of 30 or greater
known impaired glucose metabolism, or
previous GDM
If the initial early diabetes screening result is
negative:
repeat screening at 24 –28 w.
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32. 3. Screening for OSA
Suspected OSA
Snoring
Excessive daytime sleepiness
Witnessed apneas, or
Unexplained hypoxia
referred to a sleep medicine specialist for
evaluation and possible treatment
OSA are more likely to experience
Preeclampsia/eclampsia
Cardiomyopathy
pulmonary embolism
in-hospital mortality
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33. III. INTRAPARTUM CARE
1. Maternal obesity alone is not an indication for
induction of labor
 obese women are at increased risk of a prolonged
pregnancy and have an increased rate of labor induction.
an increased risk of CS among overweight and obese
women compared with normal-weight women.
unadjusted odds ratios for CS are 1.46 (95% CI, 1.34–1.60), 2.05 (95%
CI, 1.86–2.27), and 2.89 (95% CI, 2.28–3.79) among overweight, obese,
and severely obese women respectively, compared with
normal-weight women
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34. 2. Allowing a longer first stage of labor before performing
CS for labor arrest
Increase maternal BMI
longer labor
longer 1st stage
No effect on 2nd stage of labor
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35. 3. VBAC
An inverse relationship between BMI and success
rates for VBAC
Class III obesity
VBAC Vs elective repeat CS
Greater rates of
Morbidity (prolonged hospital stay, endometritis,
rupture or dehiscence)
Neonatal injury (fractures, brachial plexus
injuries, and lacerations)
Atonic PPH
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37. IV. OPERATIVE AND PERIOPERATIVE CARE
Preoperative and postoperative protocol
1. Anesthesia
An anesthesia consultation
Before labor or in early labor
allow adequate time to develop an anesthetic plan that
addresses the availability of proper equipment for blood
pressure monitoring, venous access, and the influence of
co morbid conditions such as sleep apnea
should be considered for obese pregnant women with
OSA
{at an increased risk of hypoxemia, hypercapnia, and
sudden death}
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38. Epidural or spinal anesthesia
Recommended
± technically difficult
{body habitus and loss of landmarks}.
Epidural in obese : greater
1. Analgesic failure
So, early labor epidural catheter placement
:reduce the decision-to-incision interval for an
emergency CS.
2. Hypotension
3. Prolonged FHR decelerations
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39. Spinal anesthesia in obese
significantly impairs respiratory function for up to 2
h after the procedure
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40. General anesthesia
Not contraindicated
Consideration should be given to
Difficulties with endotracheal intubation
{excessive tissue and edema}
: fiberoptic equipment available for intubation
Preoxygenation
Proper patient positioning
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41. 2. Antibiotics
Broad-spectrum prophylaxis for all CS
unless the patient is already receiving antibiotics for conditions such as
chorioamnionitis.
Higher dose
80 Kg: 2-g cefazolin
120 Kg: 3 g
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42. 3. Skin incision
1. Low transverse skin incisions preferred to vertical
skin incisions .
Vertical
 higher rate of wound complications
(infection, seroma, hematoma, wound evisceration, and
facial dehiscence)
Supraumbilical
on obese women with a large panniculus:
favorable outcomes
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43. 2. Closure of the subcutaneous layer is generally
recommended.
{with a depth greater than 2 cm can significantly
decrease the incidence of wound disruption} .
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44. 3. The role of subcutaneous drains still remains
controversial
Subcutaneous drains
increase risk of postpartum CS wound
complications and should not be
used routinely.
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45. V. POSTPARTUM CARE
1. Prevention of VTE:
1. For all women:
mechanical thromboprophylaxis(Grade 2C).
2. For women at high risk of DVT:
mechanical and
pharmacological thromboprophylaxis (Grade 2C).
 Severe obesity
 Immobility
 PET
 Infection
 Emergency CS
3. Continue prophylaxia until the woman is fully
ambulating
(NICE , 2004 & 2011Berghella , UpTpoDate, 2016)
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46. Pharmacologic thromboprophylaxis
LMWH for the prevention and treatment of VTE
instead of unfractionated heparin
(ACOG, 2016).
 Start 6 to 12 h postoperatively, after concerns for
hge have decreased.
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47. 2. Prevention of SSI
Risk of SSI after CS: 18.4%.
1. Maintain strict glycemic control in DM
2. Antibiotics
1. Higher dose of preoperative
2. IV antibiotic prophylaxis
3. Clippers for preoperative hair removal.
If hair removal is necessary to perform the skin incision
4. Chlorhexidine-alcohol for skin prep immediately
before surgery
5. Alcohol based hand rub for preoperative antisepsis.
{more effective than conventional surgical scrub}
6. Close the skin with subcuticular sutures
{lower risk of wound complications compared with staples}
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48. 3. Breast feeding
which may promote further weight reduction
must be encouraged.
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49. VI. INTERPREGNANCY CARE
1. Weight loss
Permanent change in diet and lifestyle.
Effects:
decrease the risk of LFGA infant in a subsequent pregnancy (adjusted
OR, 0.61; 95% CI, 0.52–0.73)
less than 8 BMI units
no increased risk of SFGA infant
Weight gain:
increased risk of LFGA infant (adjusted OR, 1.37; 95% CI, 1.21–1.54)
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50. 2. Contraceptive counseling
important
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