Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y...

57
CHARLOTTE CLAUSEN, MD DIVISION OF MATERNAL FETAL MEDICINE 09/16/2011 Obesity and Pregnancy

Transcript of Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y...

Page 1: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

C H A R L O T T E C L A U S E N M D

D I V I S I O N O F M A T E R N A L F E T A L M E D I C I N E

0 9 1 6 2 0 1 1

Obesity and Pregnancy

Objectives

Review maternal complications of obesity and pregnancy

Review the fetal implications of obesity and pregnancy

Review management and prevention of these complications

The Obesity Epidemic

Incidence has risen dramatically since 1960595 in women of reproductive age are overweightobese16 of children 6-19 1 contributor to mortality in US surpassing tobacco alcohol microbial pathogens and motor vehicles

Flegal KM JAMA 2010

The Obesity Epidemic

Obesity increases the risk for premature deathdiabeteshypertensioncoronary artery diseaseobstructive sleep apneaseveral types of malignancy

30 of nonpregnant US women ages 20-39 are obese

Flegal KM JAMA 2010

Obesity

Defined in terms of BMI

BMI is the ratio of weight to height squared kgm2

Overweight is defined as BMI greater than 25 or weight greater than or equal to the 95 for age and sex

Obesity BMI gt 30 kgm2

Prepregnancy Weight StatusObesity classifications by body mass index

Classification Obesity Class BMIUnderweight ---- lt 185

Normal weight ---- 185 ndash 249

Overweight ---- 25 ndash 299Obese Class 1 obesity 30-349

Severely Obese Class 2 obesity 35-399

Morbidly Obese Class 3 obesity gt 40

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 2: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Objectives

Review maternal complications of obesity and pregnancy

Review the fetal implications of obesity and pregnancy

Review management and prevention of these complications

The Obesity Epidemic

Incidence has risen dramatically since 1960595 in women of reproductive age are overweightobese16 of children 6-19 1 contributor to mortality in US surpassing tobacco alcohol microbial pathogens and motor vehicles

Flegal KM JAMA 2010

The Obesity Epidemic

Obesity increases the risk for premature deathdiabeteshypertensioncoronary artery diseaseobstructive sleep apneaseveral types of malignancy

30 of nonpregnant US women ages 20-39 are obese

Flegal KM JAMA 2010

Obesity

Defined in terms of BMI

BMI is the ratio of weight to height squared kgm2

Overweight is defined as BMI greater than 25 or weight greater than or equal to the 95 for age and sex

Obesity BMI gt 30 kgm2

Prepregnancy Weight StatusObesity classifications by body mass index

Classification Obesity Class BMIUnderweight ---- lt 185

Normal weight ---- 185 ndash 249

Overweight ---- 25 ndash 299Obese Class 1 obesity 30-349

Severely Obese Class 2 obesity 35-399

Morbidly Obese Class 3 obesity gt 40

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 3: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

The Obesity Epidemic

Incidence has risen dramatically since 1960595 in women of reproductive age are overweightobese16 of children 6-19 1 contributor to mortality in US surpassing tobacco alcohol microbial pathogens and motor vehicles

Flegal KM JAMA 2010

The Obesity Epidemic

Obesity increases the risk for premature deathdiabeteshypertensioncoronary artery diseaseobstructive sleep apneaseveral types of malignancy

30 of nonpregnant US women ages 20-39 are obese

Flegal KM JAMA 2010

Obesity

Defined in terms of BMI

BMI is the ratio of weight to height squared kgm2

Overweight is defined as BMI greater than 25 or weight greater than or equal to the 95 for age and sex

Obesity BMI gt 30 kgm2

Prepregnancy Weight StatusObesity classifications by body mass index

Classification Obesity Class BMIUnderweight ---- lt 185

Normal weight ---- 185 ndash 249

Overweight ---- 25 ndash 299Obese Class 1 obesity 30-349

Severely Obese Class 2 obesity 35-399

Morbidly Obese Class 3 obesity gt 40

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 4: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

The Obesity Epidemic

Obesity increases the risk for premature deathdiabeteshypertensioncoronary artery diseaseobstructive sleep apneaseveral types of malignancy

30 of nonpregnant US women ages 20-39 are obese

Flegal KM JAMA 2010

Obesity

Defined in terms of BMI

BMI is the ratio of weight to height squared kgm2

Overweight is defined as BMI greater than 25 or weight greater than or equal to the 95 for age and sex

Obesity BMI gt 30 kgm2

Prepregnancy Weight StatusObesity classifications by body mass index

Classification Obesity Class BMIUnderweight ---- lt 185

Normal weight ---- 185 ndash 249

Overweight ---- 25 ndash 299Obese Class 1 obesity 30-349

Severely Obese Class 2 obesity 35-399

Morbidly Obese Class 3 obesity gt 40

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 5: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity

Defined in terms of BMI

BMI is the ratio of weight to height squared kgm2

Overweight is defined as BMI greater than 25 or weight greater than or equal to the 95 for age and sex

Obesity BMI gt 30 kgm2

Prepregnancy Weight StatusObesity classifications by body mass index

Classification Obesity Class BMIUnderweight ---- lt 185

Normal weight ---- 185 ndash 249

Overweight ---- 25 ndash 299Obese Class 1 obesity 30-349

Severely Obese Class 2 obesity 35-399

Morbidly Obese Class 3 obesity gt 40

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 6: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Prepregnancy Weight StatusObesity classifications by body mass index

Classification Obesity Class BMIUnderweight ---- lt 185

Normal weight ---- 185 ndash 249

Overweight ---- 25 ndash 299Obese Class 1 obesity 30-349

Severely Obese Class 2 obesity 35-399

Morbidly Obese Class 3 obesity gt 40

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 7: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Classifications of Obesity

WHO technical report series 894Obes Res1998

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 8: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Minorities and Obesity

Increase has been steep for minorities

Overweight increase has also followed trend but to a lesser degree

Highest increase has been in the non Hispanic blacks

Flegal KM JAMA 2010

Prevalence of obesity among US nonpregnant women ages 20-39 from 2003-4

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 9: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Maternal Fetal

Spontaneous miscarriageMultifetal pregnancyHypertensive disordersGestational DiabetesCesarean sectionAnesthesia complicationsObstructive sleep apneaWound infectionsDeep venous thrombosisPostpartum hemorrhageDecreased breastfeeding

Congenital anomaliesDifficulty in performing US screening and proceduresStillbirthFetal macrosomiaPrematurityAltered metabolic programming development of childhood diabetes HTN and premature CAD

Obesity ndash Pregnancy Effects

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 10: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- population studies

Weiss JL Am J Obstet Gynecol 200416102 pregnancies in US

Sebire NJ Int J Obes Relat Metab Disord 2001287213 pregnancies in London

Cnattingius S NEJM1998167750 pregnancies in Sweden

Robinson HE Obstet Gynecol 2005142 404 pregnancies in Nova Scotia

Athukorala C BMC Pregnancy and Childbirth 20101661 pregnancies in Australia

Owens LA Diabetes care 20102329 pregnancies with normal glucola in Ireland

Ovesen P Obstet Gynecol 2011369347 pregnancies in Denmark

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 11: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Spontaneous miscarriage

Metwally M Fertil Steril 200890714Lashen H Hum Reprod 2004 Jul19(7)1644-6

SAB Early Miscarriage OR 12 (CI 101-146 p=004)Recurrent Miscarriage OR 35 (CI 103-1201 p=004)

Meta-analysisOR 189 (114-313)

Possibly related to PCOS or insulin resistance

Key to careScreen for diabetes

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 12: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Multifetal Pregnancy

Reddy 2005 561 twin cases in 51783 pregnancies from 1959-1966

Increased dizygotic twinningObese gravidas (11) vs control (05)

Possible elevated FSH seen in obese women

Key to careEarly dating ultrasound and evaluation for multiple gestation

Reddy UM Branum AM Obstet Gynecol 2005 105593

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 13: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Hypertensive disorders

Sibai B AJOG 1997177(5)1003-1010Weiss JL AJOG 2004 190 1091-7 Robinson HE Obstet Gynecol 2005 106(6) 1357-64

Obesity BMI 30-349Gestational HTN

Weiss OR 25 (CI 21-30)Preeclampsia

Sibai OR 221 (CI 13-375)Athukorala OR 299 (CI 188-473)Weiss OR 16 (CI 11-225)

Obesity BMIgt35Gestational HTN

Weiss OR 32 (CI 26-40)Preeclampsia

Sibai OR 32 (CI 179-581)Weiss OR 33 (CI 24-45)

Obesity BMI 30-40 (92)Gestational HTN OR 238 (CI 224-252)

Obesity BMIgt40 (8)Gestational HTN OR 300 (CI 249-362)

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 14: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Hypertensive disorders

Key to careBaseline labs

24 hour urine

Prepregnancy weight lossRisk doubles with every 5-7 kgm2 increase in BMI

Correct cuff size

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 15: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Gestational Diabetes

Obesity BMI 30-349Weiss OR 26 (CI 21-34)Athukorala OR 21 (CI 117-379)

Obesity BMIgt35Weiss OR 40 (CI 31-52)

Meta-analysis all studies between 1980 and 2006 and calculated odds ratio for developing GDM

Overweight- OR 214 (CI 182-253)Obese- OR 356 (CI 305-421)Severely obese- OR 856 (CI 507-1604)

Concerning as almost 50 of these women will develop diabetes 5-10 years after delivering

Weiss JL Am J Obstet Gynecol 2004Athukorala C BMC Pregnancy and Childbirth 2010Chu S Diabetes Care 200730(8) 2070-5

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 16: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Gestational Diabetes

Key to careScreen in the 1st trimester

Maternal education

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 17: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Morbid obesity-Trial of Labor vs Repeat cesarean

Hibbard

14142 trial of labor and 14304 elective csMorbidly obese

1638 TOL and 2315 elective cs2 fold increased in composite morbidityFailed TOL 393Risk uterine rupturedehiscence 21NICU admission

Failed TOL 215 vs Successful 88 Overall risk of morbidity with TOL in morbid obesity is 72

Key to careCareful patient selection

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 18: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Cesarean complications

Perlow JH AJOG 1994170(2)560-565Poobalan AS Obes Rev 2009 Jan10(1)28-35 D Heureux-Jones AM Obstet Gynecol 2001 Apr97(4 Suppl 1)S62-S63Vricella LK AJOG 2010276e1-276e5

Increased emergent cs94 vs 26

164 (155-173) in overweight and 223 (207- 242) in obese

Longer operating time488 vs 93

Vricellalt25 BMI 53plusmn20 min

25-35 BMI 62plusmn23 min

gt35 BMI 79plusmn39 min

Longer incision to delivery94 +- 08 minutes vs 99 +- 11minutes respectively (Plt005)

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 19: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Cesarean complications

Key to careBariatric lifts and inflatable mattresses additional personnel

Combined spinal-epidural anesthesia

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 20: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Cesarean Incisions

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 21: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Self-retaining retractor

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 22: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Anesthesia complications

bull Epidural placementgt1 attempt 161 vs 63 vs 11

gt3 attempts 56 vs 28 vs 0

No complications in normal overweight or obese

84 in morbidly obese

Obscured landmarks deeper epidural space

Difficult airway

Sleep apnea postpartum

Vricella LK AJOG 2010 Sept 276e1-e5

Roofthooft E Anesthesia for the morbidly obese parurient Curr Opin Anaesthesiol 2009 Jun 22(3)341-6

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 23: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Anesthesia complications

Key to careAnesthesia consult

Early epidural

Equipment check

Consider central line

Difficult airway kit

Decrease aspiration riskClears or NPO Bicitra H2 blocker

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 24: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Obstructive sleep apnea

Louis JM Am J Obstet Gynecol 2010 Mar202(3)261e1-5

57 women with OSA and 114 controlsPreeclampsia 193 vs 70 P = 02

Decreased fetal growthPossible etiology for stillbirthConcern for postoperative sedation

Very sensitive to opioids

Key to careSleep studyCPAPMaternal echocardiogram

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 25: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Risk of infections

Myles TD Obstet Gynecol 2002 100959Perlow JH AJOG 1994170(2)560-565

Wall 239 pts BMI gt35Wound- risk 121

Increased risk with vertical

RobinsonObesity BMI 30-40 (92)

Wound InfectionOR 167 (CI 138-200)Obesity BMIgt40 (8)

Wound InfectionOR 479(CI 330-695)

PerlowEndometritis 326 vs 49

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 26: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Risk of infections

Key to careThorough skin preparation

Adequate antimicrobial prophylaxis

Avoidance of subpannicular incision

Meticulous surgical technique

Subcutaneous closure

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 27: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Venous thromboembolism

Robinson HE Obstet Gynecol 2005 106(6) 1357-64Larsen TB Thromb Res 2007120(4)505-9

Obesity BMI 30-40 (92)Antepartum VTE OR 217 (CI 130-363)

Obesity BMIgt40 (8)Antepartum VTE OR 413 (CI 126-1354)

Larsen TB Danish cohort 71729 pregnanciesPregnancy and puerperium OR 53 (CI 21- 135)

Key to careEarly ambulation

Intermittent compression stocking

Anticoagulation

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 28: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Postpartum hemorrhage

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82

Conflicting dataPerlow EBL gt1000 ml

349 vs 93

Largest study by SebireOR

Overweight 116(112-121)Obese 139(132-146)

May be due to macrosomia or reduced bioavailabilty of uterotonics

Key to careBlood typed and screenLigate large subcutaneous vesselsMeticulous surgical technique

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 29: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Breast Feeding

Less likely to start breastfeed Liu 2009 (OR 063)

DC breast-feeding within first 6 months(HR 189)

EtiologyPhysiologic darr prolactin response to suckling in the 1st wk postpartumBehavioralPractical Large breasts =gt difficulties with latching

Breastfeeding lower risk of overweight kids1-3 morsquos (OR=081) 4-6 morsquos (OR=076) gt7 morsquos (OR=067)

Key to careEarly support

Liu J Smith MG Dobre MA Maternal Obesity and Breast-Feeding Practices Among White and Black Women Obesity 2009 Jun 11 Rasmussen KM et al Prepregnant overweight diminish prolactin response to suckling in 1st week postpartum Pediatrics 2004 113 Harder T Duration of breastfeeding risk of overweight a meta-analysis Am J Epidemiol 2005 162

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 30: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity ndash Congenital abnormalities

Abnormality Waller Stothard

Neural tube defect 209(163-27) 187(162-215)

Spina bifida 224(186-269)

Congenital heart defect

126(111-143) 13(112-151)

Cleft lippalate 120(103-140)

Increased risks for other anomalies including anorectal atresia limb reduction defectsThese NTDrsquos may to be independent of folate intake

Waller DK Arch Pediatr Adolesc Med 2007161(8)745-50Stothard KJ JAMA 2009301(6)636-50

Werler MM JAMA 1996 Apr 10275(14)1089-92

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 31: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Congenital abnormalities

Gilboa S AJOG 2010S1e1-e10

BMI NTD CHD

25 ndash 299 122(099-149) 116(105-129)

30-349 170(134-215) 115(100-132)

35-399 311(175-546) 131(111-156)

KeysFolic acid supplementation

Serum screening

Detailed ultrasound

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 32: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity and anomaly detection

Dashe JS McIntire DD Twickler DM Obstetrics amp Gynecology May 2009 113(5) Hendler I Int J Obes Relat Metab Disord 2004281607-11

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 33: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity and risk of stillbirth

Meta-analysis reviewed the relationship between maternal overweight and obesity and risk of stillbirthReviewed studies from 1980-2005Pooled estimates of the effect of prepregnancy weight on odds of stillbirth

Overweight vs normal OR 147 (CI108-194)Obese vs normal OR 207 (CI 159-274)

Key to careAntepartum monitoring

Chu S AJOG 2007223-228Chen A Epidemiology 20092074ndash81

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 34: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- fetal size

Macrosomia (gt4000g)Weiss Study

83 of non-obese133 of obese146 of morbid obese

Athukorala454(210-1024) macrosomic

gt90th percentileSeibre

Overweight 157 (150--164)Obese 236 (223--250)

Key to caregrowth ultrasound Careful with assisted delivery

Sebire NJ Int J Obes Relat Metab Disord 2001 Aug25(8)1175-82 Weiss JL AJOG 2004 190 1091-7

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 35: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- fetal size

Catalano PM Obstet Gynecol 2007

IOM 2009

Prevalence of obesity (gt95ile) for school age children

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 36: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- childhood effects

Whitaker RC Pediatrics 2004114e29-36Boney CM Pediatrics 2005115(3)e290-e296

Longterm RisksHigh birth weight correlates with adult obesity in Nurses Health StudyWhitaker Study

8400 children of obese mothers (BMI gt30) at 1st TriChildren were 24 to 27 times more likely to exceed 95ile for weight

Boney CM Pediatrics 2005 LGA =84 AGA = 95Looking for metabolic syndrome- 2 or more

LGAGDM 50AGAGDM 21LGAcontrol 29AGAcontrol 18

Maternal obesity increased risk by 18(CI 103-319)

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 37: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Who to blame

Patients say doctors donrsquot tell themSurvey of 2237 women via questionnaire

27 receive no advice at all

26 receive advice above or below the IOM guidelines

Advised weight and actual weight gain were strongly correlatedbull Cogswell 1999

Survey of 1460 women via questionnaire33 receive no advice at all

24 Overweight women advised to gain more than IOM

4 Normal weight women advised to gain more than IOMbull Stotland 2005

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 38: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

However

Doctors say they dohellip900 responses to ACOG survey

82 report using BMI to screen for obesity

85 counseled pts on pregnancy weight gain

64 used pre-pregnancy BMI to modify weight gainbull Power Obstet Gynecol 2006

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 39: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- What can we do

ACOG Committee Opinion

Prepregnancy counselingGoal Conceive at Normal BMI (185 ndash 249)

Dietary counselingExerciseBehavioral

Provide contraception until at goalEducation

Improves understanding of pregnancy risks and results in behavioral modification (Elsinga 2008)

Gestational weight gain recommendationsBariatric surgery

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 40: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Weight Loss Options

Non-SurgicalLifestyle modification Diet exercise

Lack of long term success

Exercise health benefits even without weight loss

Pharmacotherapy

Pharmacotherapeutic options for weight lossMedication Mechanism for weight loss Mean weight reduction Side effectsPhentermine Sympathomimetic amine

appetite suppressant‐36 kg in 2‐24 weeks Palpitations

tachycardia GI effectsOrlistat Gastric and pancreatic lipase

inhibitor ‐275 kg at 52 weeks Diarrhea flatulence

Sibutramine Norepinephrineserotonin reuptake inhibitor

‐445 kg at 52 weeks Tachycardia insomnia constipation

Bupropion Norepinephrinedopamine uptake inhibitor

‐277 kg at 24‐52 weeks Dry mouth insomnia constipation

Topiramate unknown ‐65 at 24 weeks paresthesias

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 41: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

2009 IOMNRC guidelines

Weight gain recommendations by BMI

Classification BMI Total Weight Gain Rate of Wt Gain 2nd amp 3rd tri (lbswk)

Underweight lt 185 125-180(28-40lbs) 044-058 kg1 ndash 13 lbs

Normal weight 185 ndash 249 115-160(250-350lbs) 035-050 kg08 ndash 1 lbs

Overweight 25 ndash 299 70-115(150-250lbs) 023-033 kg05 ndash 07 lbs

Obese ge30 50-90(110-200lbs) 017-027 kg04-06 lbs

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 42: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Daily intake

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 43: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

The components of gestational weight gain

Pitkin Clin ObGyn 1976

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 44: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Are we sticking with the guidelines

PRAMS 2002-2003

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 45: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Irsquom Pregnant Now What

ldquoLetrsquos set a weight gain goal togetherrdquo

Review the IOM goals individualized to your patient

Chart and review weight gain EACH visit

Give them a Chart for their Pregnancy Binder

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 46: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Congratulations on your pregnancy

Your health is more important than ever as you continue to nourish your growing fetus Eating healthy foods and staying active are important in pregnancy Its also a great time to develop healthy eating habits Eating for two isnrsquot just about thecalories - healthy eating in pregnancy can improve healthy eating habits for the whole family and decrease risk of health problems for both you and your future child The extra caloric need in pregnancy is only at most an additional 300 calories or less per day Thats one healthy snack like a handful of almonds and an apple or a peanut butter sandwich on wheat bread

Today your BMI was BMI Talk to your doctor about a reasonable weight gain goal for you during your pregnancy Staying within the guidelines will help you to lose weight postpartum and stay a healthy weight after delivery and long term

BMI

Recommended Weight Gain (lbs)

Where does the weight go

Baby 8 lbs

Placenta 2-3 lbs

Amniotic Fluid 2-3 lbs

Breast Tissue 2-3 lbs

Blood Supply 4 lbs

Fat stores for delivery amp breast feeding 5-9 lbs

Uterus increase 2-5 lbs

TOTAL 25-35 lbs

The time you will gain the most weight in the second and third trimesters (average 1 pound per week)

If your BMI was greater than 30 today your pregnancy is at higher risk for complications including diabetes and high blood pressure

If you are interested in meeting with a nutritionist please ask your provider for a referral

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 47: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

In pregnancyhellip

Provide information on diet and exercise in pregnancy

30 minutes or more of moderate exercise per dayACOG Committee Opinion-267 2002

Early pertinent referral for Dietary CounselingRecommended by both IOM and ACOG 2005

Refer to individualized dietary guidance onlinehttpwwwmypyramidgovmypyramidmomsindexhtml

Kramer amp Kakuma 2003Counseling decrease energyprotein intake in overweight women led to reduced weekly weight gain

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 48: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Postpartum weight loss

Villamor E200000 women

Compared sequential pregnancies within 10 years

Control BMI change -10 to +09 vs ge30 increaseLinear increase in preeclampsia gestational hypertension GDM cesarean delivery LGA and stillbirth

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 49: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Indications for Bariatric Surgery

Class III obesity (BMI gt 40)

Class II obesity (BMI 35-40) with comorbiditiescardiopulmonary problems or obesity related problems that interfere with lifestyle

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 50: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Categories of Bariatric Surgery

Roux-en-Y most popular in USAdjustable gastric banding popular in Europe

Nguyen NT Ann Surg 2001(234)279-89Belachew M Obesity Surgery 2002 25564-8

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 51: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Complications from Bariatric Surgery

Anastomotic leaksBowel obstructionsInternal herniasVentral herniasBand erosionBand migrationDumping syndrome

ISBR 2005

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 52: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Nutrition Issues during Pregnancy

Nutritional Complications Following Bariatric Surgery

Procedure Type

Iron Folate Vitamin B12

Vitamin D Hemoglobin Calcium Albumin

Restrictive darr darr -- -- darr -- --

Malabsorptive darrdarr darrdarr darrdarr darrdarr darrdarr darrdarr darr

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 53: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Pregnancy and Bariatric Surgery

Overall rate of maternal and fetal complications in pregnancy appears to be reduced among women post bariatric surgery compared to obese controls

Karmon A E Sheiner Arch Gynecol Obstet 2008 277(5)381-8-28

Pregnancy Outcomes Among Women pre and post-Bariatric Surgery

GDM Macrosomia Severe Preeclampsia

Preeclampsia Miscarriage

Post-Bariatric Surgery

6-11 3-7 1 5-11 26

Obese Cohort Pre-surgery

15-17 8-35 4 23-28 22

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 54: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Timing of pregnancy

Sheiner E AJOG 20101e1-1e6

Consensus is that pregnancy should be delayed for 12-24 months

Achieve goal weight loss

Avoid possible nutrient deficiencies

Sheiner E AJOG 2010104 in 1st year vs 385 after 1st year

HTN 154 vs 112 p=0392

DM 105 vs 73 p=0159

IUGR 38 vs 23 p=0396

Bariatric complications 67 vs 70 p=0920

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 55: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Obesity- Setting Maternity care standards

Fitzsimons KJ Seminars in Fetal amp Neonatal Medicine 201015100-107

PrepregnancyOptimize weightBMI gt30 discuss risksFolic acid supplementationConsider echocardiogramScreen sleep apneaConsult as needed

Pregnancy1st Trimester

Baseline labs 24 hour urineScreen for GDMUltrasoundDiscuss wt gainRisk of SAB

2nd TrimesterScreen for congenital abnormalitiesFetal echocardiogram

Pregnancy3rd Trimester

Monitor for complicationsAntepartum testingEFWEvaluate facilitiesEquipmentAnesthesia consult

Labor and deliveryNotify anesthesiaVenous accessActive management of 3rd stageCS prophylactic antibiotics

PostpartumEarly ambulationThromboprophylaxisBF supportWeight reduction education6 week gtt for those with GDM

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59
Page 56: Obesity and Pregnancy - PeaceHealth · Review the fetal implications of obesity and pregnancy. y Review management and prevention of these complications. The Obesity Epidemic y ...

Questions

  • Obesity and Pregnancy
  • Objectives
  • The Obesity Epidemic
  • Slide Number 4
  • The Obesity Epidemic
  • Obesity
  • Prepregnancy Weight Status
  • Classifications of Obesity
  • Minorities and Obesity
  • Obesity ndash Pregnancy Effects
  • Obesity- population studies
  • Obesity- Spontaneous miscarriage
  • Obesity- Multifetal Pregnancy
  • Obesity- Hypertensive disorders
  • Obesity- Hypertensive disorders
  • Obesity- Gestational Diabetes
  • Obesity- Gestational Diabetes
  • Morbid obesity- Trial of Labor vs Repeat cesarean
  • Obesity- Cesarean complications
  • Obesity- Cesarean complications
  • Cesarean Incisions
  • Self-retaining retractor
  • Obesity- Anesthesia complications
  • Obesity- Anesthesia complications
  • Obesity- Obstructive sleep apnea
  • Obesity- Risk of infections
  • Obesity- Risk of infections
  • Obesity- Venous thromboembolism
  • Obesity- Postpartum hemorrhage
  • Obesity- Breast Feeding
  • Obesity ndash Congenital abnormalities
  • Obesity- Congenital abnormalities
  • Obesity and anomaly detection
  • Obesity and risk of stillbirth
  • Slide Number 36
  • Slide Number 37
  • Obesity- childhood effects
  • Obesity- Who to blame
  • However
  • Obesity- What can we do
  • Weight Loss Options
  • Slide Number 43
  • Daily intake
  • Slide Number 46
  • Are we sticking with the guidelines
  • Irsquom Pregnant Now What
  • Slide Number 49
  • In pregnancyhellip
  • Obesity- Postpartum weight loss
  • Indications for Bariatric Surgery
  • Categories of Bariatric Surgery
  • Complications from Bariatric Surgery
  • Nutrition Issues during Pregnancy
  • Pregnancy and Bariatric Surgery
  • Timing of pregnancy
  • Obesity- Setting Maternity care standards
  • Slide Number 59

Obesity and Pregnancy - Iowapublications.iowa.gov/9571/1/progeny_jan2007.pdfObesity and Pregnancy Obesity has become an epidemic not only here in the United States but worldwide. The

Obesity and Pregnancy - Iowapublications.iowa.gov/9571/1/progeny_jan2007.pdfObesity and Pregnancy Obesity has become an epidemic not only here in the United States but worldwide. The

Maternal Pre-Pregnancy Obesity Is Associated with Altered Placental Transcriptome · 2019-09-25 · RESEARCH ARTICLE Maternal Pre-Pregnancy Obesity Is Associated with Altered Placental

Maternal Pre-Pregnancy Obesity Is Associated with Altered Placental Transcriptome · 2019-09-25 · RESEARCH ARTICLE Maternal Pre-Pregnancy Obesity Is Associated with Altered Placental

Obesity in Pregnancy: Obstetrician’ s Obstacle

Obesity in Pregnancy: Obstetrician’ s Obstacle

Obesity in Pregnancy

Obesity in Pregnancy

file · Web viewData on maternal early pregnancy obesity, pre-pregnancy and gestational hypertension, pre-eclampsia, ...

file · Web viewData on maternal early pregnancy obesity, pre-pregnancy and gestational hypertension, pre-eclampsia, ...

Obesity in pregnancy: obstetric complications and outcomes · Obesity in pregnancy • 58% women in England are overweight / obese • Almost 50% of pregnant women are classified

Obesity in pregnancy: obstetric complications and outcomes · Obesity in pregnancy • 58% women in England are overweight / obese • Almost 50% of pregnant women are classified

MATERNAL PRE-PREGNANCY OBESITY : OBSTETRICAL, …...Maternal pre-pregnancy obesity was associated with : a. Fertility: Obese women face fertility problems as a result of high levels

MATERNAL PRE-PREGNANCY OBESITY : OBSTETRICAL, …...Maternal pre-pregnancy obesity was associated with : a. Fertility: Obese women face fertility problems as a result of high levels

OVERWEIGHT AND OBESITY IN PREGNANCY: …...Maternal obesity is a growing health concern throughout the UK with approximately 1 in 20 women obese during pregnancy. Across the nations

OVERWEIGHT AND OBESITY IN PREGNANCY: …...Maternal obesity is a growing health concern throughout the UK with approximately 1 in 20 women obese during pregnancy. Across the nations

Obesity in Pregnancy November 14, 2009. Overview General issues of obesity Prevalence of obesity in pregnant women Effect of obesity on maternal outcome.

Obesity in Pregnancy November 14, 2009. Overview General issues of obesity Prevalence of obesity in pregnant women Effect of obesity on maternal outcome.

Obesity in Pregnancy - Amazon Web Services€¦ · Incidence of Obesity in Pregnancy o Prevalence of Maternal Obesity ranges from 10%-36% depending on region o There has been a 70%

Obesity in Pregnancy - Amazon Web Services€¦ · Incidence of Obesity in Pregnancy o Prevalence of Maternal Obesity ranges from 10%-36% depending on region o There has been a 70%

Obesity and pregnancy Erin Keely Mary-Anne Doyle.

Obesity and pregnancy Erin Keely Mary-Anne Doyle.

Managing Pregnancy and Delivery for women with obesity

Managing Pregnancy and Delivery for women with obesity

Webinar slides: Management of Obesity in Pregnancy … · pregnant patients Funding for this ... Management of Obesity in Pregnancy describes best ... Consider weekly NST/AFI after

Webinar slides: Management of Obesity in Pregnancy … · pregnant patients Funding for this ... Management of Obesity in Pregnancy describes best ... Consider weekly NST/AFI after

Open Access Research Obesity in pregnancy: a retrospective ... · Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS Kelly

Open Access Research Obesity in pregnancy: a retrospective ... · Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS Kelly

Obesity and pregnancy, an epidemiological and intervention study ...

Obesity and pregnancy, an epidemiological and intervention study ...

Obesity During Pregnancy - A Teachable Moment

Obesity During Pregnancy - A Teachable Moment

Obesity in pregnancy Sandbjerg 2017 · 2018-12-21 · 37 Obesity in pregnancy – Sandbjerg 2017 DSOG (Danish Society of Obstetrics and Gynecology) Approved on January st21 , 2017

Obesity in pregnancy Sandbjerg 2017 · 2018-12-21 · 37 Obesity in pregnancy – Sandbjerg 2017 DSOG (Danish Society of Obstetrics and Gynecology) Approved on January st21 , 2017

Management Of Obesity In Pregnancy - ACOG

Management Of Obesity In Pregnancy - ACOG

Obesity, inflammation and pregnancy: a dangerous triad

Obesity, inflammation and pregnancy: a dangerous triad

MATERNAL OBESITY AND ADVERSE PREGNANCY OUTCOMES IN …acrm.org.my/nor/doc/poster/Scholarly_Concentration... · 2020-03-16 · MATERNAL OBESITY AND ADVERSE PREGNANCY OUTCOMES IN MALAYSIA.

MATERNAL OBESITY AND ADVERSE PREGNANCY OUTCOMES IN …acrm.org.my/nor/doc/poster/Scholarly_Concentration... · 2020-03-16 · MATERNAL OBESITY AND ADVERSE PREGNANCY OUTCOMES IN MALAYSIA.