Managing Pregnancy and Delivery for women with obesity

A/Prof Leonie Callaway

GOAL: A PRACTICAL OUTLINE

MATERNAL OBESITY IS IMPORTANT AND COMMON

Queensland: Where Australia shines!

Maternal Obesity in Queensland

• 2006: 33% overweight and obese (Callaway et al, MJA, 2006)

• 2008: 50.5% overweight and obese (QH statbites)

Importance• UK Confidential Enquiry into

Maternal and Child Health

• Obesity is a significant risk factor for maternal mortality

• 35% of all mothers who died were obese (10-18.9% of the UK obstetric population are obese)

HOW DO WOMEN BECOME OBESE?

Reduced Physical Activity

Increased consumption processed foods

Low breastfeeding rates

Social changes

Sleep debt

Endocrine disrupters

Decreased variability in ambient temperatures

Decreased smoking

Increased use of steroids and antipsychotics

Pregnancy at older age in overweight women

Demographic changes with older people, ethnic changes

Chronic stress

Micronutrient deficiencyKeith et al, Int J Obesity, 2006

What do obese pregnant women eat?

Energy intake (n=50)

• 3 Day food recall, administered by trained dieticians

• All participants were within 10% of recommended daily caloric intake

Dietary intake of obese pregnant women at 12 weeks gestation (n=50)

Serves / day Recommended Mean St Dev Minimum Maximum

Breads & cereals 6 2.60 1.12 0.50 5.40

Vegetables 5 3.05 1.76 0.50 9.30

Fruit 3 3.06 2.21 0.00 9.80

Dairy 2 1.76 1.40 0.00 5.90

Meat & alternatives

2 2.17 1.15 0.00 6.80

Extras 0-2 4.62 2.68 1.40 15.00

Dietary folate(micrograms)

600 284 104 64 541

Croaker S et al, Nutrition and Dietetics, 2010.

THE COMPLICATIONS?

Maternal Complications

• Thromboembolism• Hypertensive disorders of pregnancy• Gestational diabetes• Abnormal liver function tests

Obstetric Complications

• Increased IOL• Higher rate of failed VBAC• Dramatically increased rates of C Section• Increased rates of complicated normal vaginal

delivery– Shoulder dystocia– Third/fourth degree lacerations– Failure to progress

Anaesthetic Complications

• Epidural analgesia during labour is more likely to fail as BMI increases

• General anaesthesia complicated by:– Postpartum sleep apnoea– Difficult intubation

Practical Difficulties

• Inaccurate assessment of growth, lie, presentation• Blood pressure cuffs/automated blood pressure

devices• Vascular access• Theatre beds/trolleys/staff• Ultrasonography• Monitoring during labour

Peripartum Neonatal Monitoring

• Maternal obesity associated with:

– Difficulties obtaining an adequate CTG– Increased rates of fetal distress– Increased rates of meconium aspiration

Perioperative complications

• Increased post partum haemorrhage• Endometritis• Wound breakdown and infection

Perinatal Complications• Length of stay>5 days

– Overweight OR 1.36– Class I and II Obese OR 1.49– Class III Obese 3.18 (Callaway et al, 2006)

• For obese women:– Chest infection OR 1.34– Genital infection OR 1.3– Wound infection OR 1.34– UTI OR 1.39– PUO OR 1.29– Prolonged postnatal stay OR 1.48 (Sebire et al, 2001)

Neonatal Complications

• Macrosomia• Lower rates of breastfeeding• Increased rates of congenital anomalies• Stillbirth, neonatal death

WHAT CAN WE DO ABOUT IT?

Interesting Issues from Guidelines• American College of O&G (2005)

– Height and weight measured in all women

– Weight gain guidelines (IOM)– Dietary advice– Consider screen for GDM at

presentation– Consider cardiac evaluation if

BMI>35– Anaesthetic consultation– Careful thromboembolism

prophylaxis– If not pregnant –preconception

counselling, provision of information regarding risk, weight loss prior to pregnancy

• RCOG Consensus View (2007)– BMI should be measured in all pregnant

women, and weight measured at every clinic visit; interpregnancy weight change should also be recorded

– Diet, exercise and psychopathology should be attended to

– Women with a BMI of over 35 should not have infertility investigation or treatment until their BMI is less than 35, and ART should be reserved for women with a BMI under 30.

– Aspirin 75 mg/day from 12 weeks if BMI>35– Consider high dose folic acid (5mg per day)– Consider antenatal thromboprophylaxis if

additional risk factors– Detailed anomaly scan– GTT at 28 weeks

Interventions during pregnancy: Monitoring/Screening

• Weighing pregnant women• Early OGTT, early ELFTs• Early screening for vascular disease• Anomaly screening• High risk model of care with regular screening for

preeclampsia –early urinary protein estimation and baseline blood pressure measurement

All based on expert opinion, underpinned by good data about increased risk in obese pregnant women

When we see women at the beginning of pregnancy, can we effectively prevent complications in obese women?

• Preeclampsia: No good evidence yet• GDM: Maybe• Excessive weight gain: Yes• Neonatal morbidity: No evidence yet

Therapeutic options

• Metformin –unstudied• Diet• Exercise• Lifestyle intervention• CPAP• Probiotics

Dietary intervention to prevent weight gain

– 10 x 1 hour nutrition consultations

– Fat 30%, protein 15-20%, Carb 50-55%

– Caloric restriction (individual calculation)

InterventionN=23

ControlN=27

P

kJ per day27 weeks

7319 9867 <0.001

Total weight gain

6.6kg 13.3kg 0.002

Wolff et al, 2008, Int J Obesity.

Diet intervention in obese pregnant women

• RCT 257 women, BMI>30• Study group: – Dietitian review, – 18-24 kcal/kg, – F30,P30,C40, – all >2000 cal

• Gained less weight (11 vs 31 lbs)• Retained less weight• No ketonuria• Less gestational hypertension• No difference in perinatal outcomes

Thornton et al, J Nat Med Ass 2009

Lifestyle intervention

Control Passive Active pCalories 2nd trimesterkCal/day

2020 1891 1880 <0.004

Weight gainkg

6.8 7.12 7.14 0.47

• No difference in physical activity

• No difference in any maternal, obstetric, neonatal outcomes

• 35 F/10P/55C

Guelinckx et al, AJCN 2009

Lifestyle intervention

• RCT 100 women stratified for BMI

• Intervention group: – Dietitian visit, F30,P30,C40 – Advice re moderate intensity

exercise 5 times per week

• Weight gain reduced in intervention group

Absee et al, Obstet Gynecol 2009

Exercise in Obese Pregnant Women

• RCT, n=50• Individually tailored,

goal directed intervention

• At 28 weeks:– 16/22 in intervention

met targets– 8/19 in control met

targets– No difference in HOMA Inter-

ventionControl

0

2

4

6

8

10

12

14

16

18

>900 kCal per week<900 kCal per week

Callaway et al, Diabetes Care, 2010.

P=0.047

Is screening for and aggressive management of complications effective?

• Hypertensive disorders?

• GDM: Yes

• Congenital anomalies?

GDM treatment prevents preeclampsia

Crowther et al, NEJM; 2005.

Interventions during pregnancy: Models of Care

• Guidelines support:– Multidisciplinary care (obstetricians, physicians,

ultrasonographers, maternal-fetal medicine specialists, dieticians, physios, anaesthetists)

– Physical requirements (beds, theatre beds etc)– High risk pregnancy care

• Need for health services research and detailed economic analysis of models of care

• Potential to examine the impact of models of care on pregnancy and neonatal outcomes

Interventions in Pregnancy: Postpartum care

• Guidelines and expert opinions suggest:

– Timely uterotonics– Thromboprophylaxis– Surveillance for infections– Expert lactation support

Interconception Care

• Modest amounts of weight loss between pregnancies can reduce the risk of GDM in subsequent pregnancies

• Guidelines suggest:– Nutrition counselling– Exercise programs– Weight management support– Follow up of complications of pregnancy (eg hypertension,

gestational diabetes)• Important time in shaping family habits• Potential for high quality interconception care trials

A PRACTICAL APPROACH

First Visit

• First visit:– Detailed history and physical examination –consider

hypothyroidism, PCOS, endocrinopathies, depression.– FBC, ELFT’s, OGTT, urine protein creatinine ratio– Advice regarding diet, exercise, weight gain, smoking cessation– Consider higher dose folic acid and aspirin– Refer to obstetrician and anaesthetist– Midwife support essential– Consider risk factors for thromboprophylaxis– Multidisciplinary care– Consider appropriate facility for delivery

Subsequent visits

• Breastfeeding information• 28 week OGTT• Monitor weight gain• Expert USS of fetus at 18-20 weeks• Ward test urine and blood pressure at every

visit –low threshold for further tests for preeclampsia

• Ensure anaesthetic review

At delivery

• Skills of health care professionals and the capacity of the facility

• Monitoring and IV access issues• Uterotonics• IV antibiotic prophylaxis• Thromboprophylaxis• Breastfeeding support

Post partum

• Breastfeeding support which takes much longer than in normal weight women

• Watch carefully for infections• Thromboprophylaxis• Advise regarding weight loss and follow up for

pregnancy complications