In the name of GOD The Compassionate & The Merciful

In the name of GOD

The Compassionate &

The Merciful

Impact of obesity on pregnancy

Fahimeh Ramezani Tehrani

ProfessorReproductive Endocrinology Research Center

Shahid Beheshti University of Medical Sciences2014

Global prevalence of obesity (BMI 30)

Women of Childbearing AgePercent Overweight or Obese

Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-41.

Sub-fertility & Infertility Ovulatory dysfunction

PCOS

Poorer out come of infertility treatments

Adverse effect on implantation?

Higher doses of ovulation inducing agent Higher risk of OHSS

Spontaneous abortion

OR of miscarriage foe obese women was 1.8(95%CI 1.14-3.13) in meta analysis conducted in 2008.

Chromosomal abnormality? PCOS Poor endometrial receptivity Confounding factors age, S.E status

Maternal Complications

Higher Rates of Cesarean Section and labor dysfunction

Gestational HypertensionPre-eclampsia preterm birthGestational DiabetesLGA and Shoulder dystociaStillbirthDVT/PEAnesthetic complications

Risk of Cesarean Section

Increased risk due to:Dysfunctional laborMonitoring challengesIncreased rates of pre-eclampsia,

hypertension and LGA babies all contribute to likelihood of cesarean section

Cesarean Section – Clinical Challenges

Access to lower uterine segment can be challenging

Higher rate of wound complications after surgery

Higher risk of anesthetic complications

Difficulties with Regional Anesthesia

150 kg Difficult veins Unable to curve

lumbar spine Impalpable iliac

crests Impalpable

vertebral spines

Aortocaval Compression

120 kg 150 kg

Gestational Hypertension

Pre-existing hypertension is more common among obese women

Among those without hypertension at baseline, increased risk of developing gestational hypertension

Gestational Hypertension

Population-based study in the Netherlands

Increased rates of gestational hypertension among obese women (BMI >35), with odds ratio 4.67

Gaillard R et al. Associations of maternal obesity with blood pressure and the risks of gestational hypertensive disorders.

Journal of Hypertension 2011, 29:937-944.

Gestational Hypertension: A UK population-based study

Among extremely obese women (BMI >50):1 in 5 develop hypertensive disorder in

pregnancy1 in ten develop pre-eclampsia

Among women with less severe obesity, risk is increased but to a lesser degree

Knight, M et al. Extreme Obesity in Pregnancy in the UK. Obstet Gynecol, Vol 115, No 5. May 2010.

Pre-eclampsia

Risk of pre-eclampsia is increased in obese pregnant women

Pre-eclampsia can lead to compromised fetal perfusion and to medically-indicated preterm birth.

In population-based study in Netherlands, increased risk of pre-eclampsia was observed for obese women (BMI >35), with odds ratio of 2.5.

Gestational Diabetes

Gestational diabetes is more common in obese pregnant women

In addition, there is a higher rate of pre-existing diabetes in obese pregnant women

Gestational Diabetes: A UK population-based study

Among extremely obese women, 11% developed gestational diabetesOf those, 70% required insulinRisk of developing diabetes was seven

times higher than in non-obese controlsAmong women with less severe

obesity, risk is increased but to a lesser degree

Knight, M et al. Extreme Obesity in Pregnancy in the UK. Obstet Gynecol, Vol 115, No 5. May 2010

Cohort Study of Rates of Stillbirth

There was significant racial disparity, with higher rates of stillbirth among black women than white women

Disparity widened with increasing BMI, with disproportionately highest stillbirth among extremely obese black women (BMI > 40).

Salihu, HM et al. Extreme Obesity and Risk of Stillbirth Among Black and White Gravidas. Obstet Gynecol 2007; 110:552-7.

DVT/PE

Immobilization and pregnancy are both risk factors for DVT/PE

Obese pregnant women often have decreased mobility, particularly with extreme obesity

Cesarean delivery further increases the risk

Multi-fetal pregnancy

Increase incidence of dizygotic not monzygotic

Elevated FSH

Obstructive sleep apnea

May be associated with hypertensive disorder and impaired fetal growth

Post operative respiratory depression after receiving opiates

Urinary tract infection

42% increase in risk of UTI

Not more frequent UTI screening for asymptomatic bacteriuria

Placenta and cord

No increase placenta previa

No increase abruption of placenta

No cord accident

Fetal and Neonatal Complications

Complication BMI 19.8-26 BMI 35.1-40 BMI > 40

Stillbirth 0.3% 0.6% (OR 1.99) 0.8% (OR 2.79)

Fetal distress 2.0% 3.5% (OR 2.13) 3.9% (OR 2.52)

Meconium aspiration

0.1% 0.3% (OR 2.87) 0.3% (OR 2.85)

Neonatal death 0.1% 0.3% (OR 2.09) 0.4% (OR 3.41)

Cedergren, MI. Maternal Morbid Obesity and the Risk of Adverse Pregnancy Outcome. Obstet Gynecol, Vol 103, No 2. Feb 2004.

Fetal and Neonatal Complications

As maternal BMI has risen, there has been a significant increase in the number of babies born with high birth weight.

Larger babies have more adipose tissue.

Surkan PJ, Hsieh CC, Johansson AL, Dickman PW, Cnattingius S. Reasons for increasing trends in large for gestational age births. Obstet Gynecol 2004; 104: 720-6.

What happens later in life for children born

to obese mothers? Children born to obese mothers are twice

as likely to be obese and develop type 2 diabetes in adult life.

Higher maternal gestational weight gain has been associated with high blood pressure in offspring. One study showed an association between maternal BMI and the hepatic lipid content in the infants.

The increased lipid content in the liver may initiate programming of the metabolic syndrome in utero

The Influence of Maternal Body Mass Index on Infant Adiposity and Hepatic Lipid Content. Pediatric Research,2011

Clinic Challenges

Identifying fetal heart tonesAssessing fetal growth

Fundal height difficult to obtainAssessing for hypertension

Blood pressure cuffs may be of inadequate size

Difficulty in reliable sonographic assessment

Difficulty in anesthesia proceduresDifficulty in surgical procedures

Recommended total weight gain ranges for pregnant women by pre-pregnancy BMI

BMI Category Recommended total gain (Kg)

Low(BMI<19.8) 12.5-18

Normal(BMI 19.8-26) 11.5-16

over( BMI>26-29) 7- 11.5

High(BMI >29) At least 6.9

Excess Gestational Weight Gain

Health Impacts on Neonates & Children:

• Low 5-minute Apgar scores• Neonatal seizures• Hypoglycemia• Large for gestational age infants• Meconium aspiration• NICU admission• 4-fold increased lifetime risk of

overweight/obesity• Lifelong elevated risk for diabetes,

hypertension, cardiovascular disease, cancer, early death

Excess Gestational Weight Gain

Health Impacts on Women:• Postpartum weight retention• Long-term weight gain • Excess body fat• Sleep apnea• Pre-diabetes/diabetes• Coronary heart disease

Attitude to weight gain

For women who normally restrain their eating to preserve their figures, the inevitable change of shape during pregnancy serve as justification for “letting themselves go”.

They should “eat for two”.

Depriving themselves, depriving their child

Change of body image

Mothers who more dissatisfied with their bodies postpartum, increase energy intake following pregnancy

Mothers who more dissatisfied with their bodies postpartum, higher long term weight gain

Figure Rating Scale

Risk factors associated with postpartum period

Psychological factorso Depressiono Self-esteemo Stresso Social support

Depression

As a result of obesity

As modifier of biological or behavioral process that affect body weight

Compensatory action of “comfort eating”

Postpartum weight loss (kg) in

groups with different lactation scores.

Recommendation

Weight restriction may diminish the risk of maternal obesity but may have negative effect on fetus development

Preconception weight reduction and limitation of maternal weight gain in obese gravidas is recommended

Recommendations Extreme cautious for recommending

weight restriction during pregnancy Pregnant women eat to appetite by

consuming a varied and balance diet Not “eat for two” Address the problem of pregnancy related

weight gain soon after the birth Encourage the appropriate excersise Give them realistic expectation about

weight loss following delivery

Thank you for your attention