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