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Maternal Obesity: A Continuum of
Risk November 22, 2013
Anne M. Jorgensen NNP Assistant
Professor of Pediatrics
New York Medical College
“Globesity” Global Epidemic of
Overweight and Obesity
Obesity Prevalence Worldwide § An
es:mated 500 million adults worldwide
are obese and
1.5 billion are overweight or
obese.
§ If recent trends con:nue unabated,
nearly 60 percent of the
world’s popula:on—3.3 billion people—could
be overweight (2.2 billion) or
obese (1.1 billion) by 2030.
Defining Overweight & Obesity ~
Body Mass Index ~
Obesity: Condi:on characterized by
excess body fat and frequently
resul:ng in significant impairment of
health and longevity
BMI : Reliable indicator of body
fatness
BMI Calcula:on BMI = Weight (lbs.)
/ [height (in.)] 2 x 703
Example: Weight = 150 lbs,
Height = 5’5” (65”)
[150 ÷ (65)2] x 703 = X
(150 ÷
4225) x 703 = X
.0355029585
x 703 = X
24.96 = X
25
= BMI
Obesity: Defined by BMI Weight
classification by Body Mass Index
(BMI)
Standard Weight Categories for Adults
WEIGHT STATUS "
BMI (Kg/M2)"
Underweight "" < 18.5"
Normal" 18.5 - 24.9"Overweight "" 25.0 - 29.9 "
Obese "" > 30.00"Class 1"Class 2 "Class 3 "
30.00 – 34.99"34.99 – 39.99 "> 40"" WHO, CDC, 2012
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Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
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Obesity Trends Among U.S. Adults
BRFSS, 1991
No Data
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Obesity Trends Among U.S. Adults
BRFSS, 1997
No Data
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Obesity Trends Among U.S. Adults
BRFSS, 2004
No Data
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Obesity Trends Among U.S. Adults
BRFSS, 2010
No Data 30 • Waist Circumference
What is Morbid Obesity?
§ Obesity becomes "morbid" when it reaches the point of
significantly increasing the risk of one or
more obesity related health condi:ons
or serious diseases (comorbidi:es).
§ Morbid obesity is considered a
chronic condi:on
§ Obesity related comorbidi:es may
result in significant physical
disability or even death.
§ Morbid obesity is typically defined
as being 100 lbs. or more
over ideal body weight or
having a BMI of 40 or
higher.
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What Causes Obesity? ~
Multifactorial & Complex Etiologies
~
Energy Imbalance: Energy expenditure
is less than food intake,
energy, in the form of
triglycerides are stored in adipose
:ssue. Cultural Influences:
Food volume; food availability;
fast foods & soda
consump:on; media & marke:ng
influences on food choices; exercise
habits; lifestyle habits
Environmental Influences: work
schedule, weather, safety Socioeconomic
Factors: Food scarcity
Biologic Factors: Brain &
diges:ve organs; chemical &
hormonal influences on appe:te
regula:on; lep:n levels
What Causes Obesity? ~
Multifactorial & Complex Etiologies
~
Gene:c Factors: § Gene:cally Low
Lep:n levels § Human obesity gene
map (2005) links more than 600
genes, markers and chromosomal regions
to obesity § Rare Gene:c Syndromes:
Prader-‐Willi, Cohen Alstrom;
Bardet-‐Biedl Medica:ons
§ Steroids, Some An:depressants § Insulin
& Insulin S:mula:ng Drugs
Medical Causes § Underac:ve Thyroid
§ Cushing’s Disease; Polycys:c Ovary
Syndrome
Obesity: An Energy Imbalance
Energy (Kcal) IN > Energy
(Kcal) OUT What Causes
Obesity?
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What Does Obesity Cause?
“Sitting is the Smoking of Our
Generation”
Nilofer Merchant, Healthcare Blog
Maternal Obesity Pre-‐Pregnancy Obesity
Improved Awareness -‐ Correct PercepAon
Maternal Obesity Prevalence ★Pre-‐
Pregnancy Obesity
§ 57% women ages 18-‐42 – overweight
or pre-‐obese § Nearly 60% women
begin pregnancy overweight or obese
§ 8% reproduc:ve-‐aged women are
extremely obese
§ Obesity is most common in Non-‐
Hispanic Black women (50%
prevalence); Mexican American (45%);
and White (33%)
§ Lack of educa:on increases risk
for obesity § Less than high
school educa:on doubles risk,
compared to women with high
school educa:on
§ Inversely related to socioeconomic
status
Pregnancy Risk Assessment Monitoring
System Pre-‐pregnancy Obesity
Prevalence in the US: 2004 -‐
2005
n = 75,403 women, participating in
the PRAMS, from 26
states and New York City "§ One in five women who delivered
were obese"§ State-specific prevalence varied widely and ranged
from
13.9 to 25.1%. "§ Black women had an obesity prevalence about
70%
higher than white and Hispanic women (black: 29.1%; white:
17.4%; Hispanic: 17.4%); however, these race-specific rates varied
notably by location "
§ Obesity prevalence was 50% higher among women whose delivery
was paid for by Medicaid than by other means (e.g., private
insurance, cash, HMO)"
[Chu, Kim & Bish, 2009
Journal of Maternal and Child
Health, 13(5)] "
Obesity is a Well Recognized Risk
Factor Adverse Pregnancy Outcome
§ More than 50 years ago,
obesity associated with pregnancy
complica:ons
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Maternal Obesity: A Continuum of
Risk Infertility &
Miscarriage
Infer:lity § Related to mul:ple
endocrine pathophysiologic mechanisms:
§ Abdominal obesity associated with
increased circula:ng insulin levels,
results in increased androgen levels
– hyperandrogenism clinically manifested
in part by anovula:on &
amenorrhea
§ Morbid obesity increases risk for
polycys:c ovary syndrome
Increased Need for ART
Early Miscarriage [Krishnamoorthy
et al. 2006; Sarwer et al.,
2006]
Maternal Obesity: A Continuum of
Risk Chronic Health Disorders
Diabetes § Overweight or obesity is
the single most important predictor
of DM
Chronic Hypertension Cardiovascular
Disease
§ Waist circumference of 88cm +
Increases risk of CVD related
death
Musculoskeletal Pain
Knee Osteoarthri:s
Mental Health Disease & Depression
Maternal Obesity: A Continuum of
Risk Gestational Health Disorders
Gesta:onal Diabetes § 17% obese vs.
1-‐3% in non-‐obese mothers
[Linne et al. 2002]
§ 24.5 % in morbid obese vs.
2.2% in non-‐obese
[Kumari, 2001]
Hypertensive Disorders of Pregnancy
§ Preeclampsia : 2.9% in non
obese vs. 29.8% in morbidly
obese mothers [Kumari, 2001]
Sleep Apnea [Sohota et al.
2003] § Increased rates reported
in pregnant obese women § Results
in inadequate O2 delivery to
fetus
Maternal Obesity: A Continuum of
Risk Preterm Birth
§ Preterm delivery is a significant
concern for obese women, especially
those mothers with BMI>35
§ Obese women are less likely to
have spontaneous preterm labor
[Salihu, Lynch, Alio, &
Liu, 2008; Smith, Shah, Pell,
& Crossley, & Dobbie, 2007]
§ The higher preterm birth rates
in obese women are related to
a higher incidence of obstetrical
complica:ons
[Smith, Shah, Pell, Crossley,
& Dobbie, 2007]
§ Obese pa:ents are more likely
to be admited earlier in labor,
need labor induc:on, require more
oxytocin, and have longer labor
[VahraYan, Zhang, Troendle, Savitz,
& Siega-‐Riz, 2004]
§ History of preterm birth is the
most significant risk factor for
preterm birth!
Obesity Trends Among U.S. Adults
BRFSS, 2010
No Data
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WHAT STATE DO YOU LIVE IN?
STATE-‐BY-‐STATE ADULT OBESITY RATES
1. Louisiana (34.7%) 2.
Mississippi (34.6%) 3. West
Virginia (32.4%) 4. Alabama (32.0%)
5. Michigan (31.3%); 6. Oklahoma
(31.1%); 7. Arkansas (30.9%); 8.
(:e) Indiana (30.8%); and South
Carolina (30.8%); 10. (Ae) Kentucky
(30.4%); and Texas (30.4%); 12.
Missouri (30.3%); 13. (:e) Kansas
(29.6%); and Ohio (29.6%); 15.
(Ae) Tennessee (29.2%); and Virginia
(29.2%); 17. North Carolina (29.1%);
18. Iowa (29.0%); 19. Delaware
(28.8%); 20. Pennsylvania (28.6%);
21. Nebraska (28.4%); 22.
Maryland (28.3%); 23. South Dakota
(28.1%); 24. Georgia (28.0%); 25.
(:e) Maine (27.8%); and North
Dakota (27.8%); 27. Wisconsin
(27.7%); 28. Alaska (27.4%): 29.
Illinois (27.1%); 30. Idaho
(27.0%); 31. Oregon (26.7%); 32.
Florida (26.6%); 33. Washington
(26.5%); 34. New Mexico (26.3%);
35. New Hampshire (26.2%); 36.
Minnesota (25.7%); 37. (:e) Rhode
Island (25.4%); and Vermont (25.4%);
39. Wyoming (25.0%); 40.
Arizona (24.7%); 41. Montana (24.6%);
42. (:e) Connec:cut (24.5%); Nevada
(24.5%); and New York (24.5%);
45. Utah (24.4%);
46. California
(23.8%); 47. (:e) District of
Columbia (23.7%) and New Jersey
(23.7%); 49. Massachusets (22.7%);
50. Hawaii (21.8%); 51. Colorado
(20.5%).
March of Dimes 2013 Premature Birth Report Card
© 2013 March of Dimes Foundation
Grade for Preterm Birth Rate*
A
B
C
D
F
Grade for National Preterm Birth Rate
C
* Percent of babies born preterm is shown in parentheses (
).
(11.5)
Preterm birth is less than 37 completed weeks of gestation.
Source: National Center for Health Statistics, 2012 preliminary
natality data. Report card grades calculated by March of Dimes
Perinatal Data Center, September 2013.See Technical Notes for more
information.
(11.6)
(9.6) (10.4)
(10.3)
(11.0)
(11.2)
(11.1)(13.0)
(11.5)
(9.9)(9.1)
(10.7)
(10.2)
(9.9)
(10.8)
(13.3)
(11.5)
(15.3)
(10.2)
(11.7)
(13.0)
(12.4)
(10.5)
(12.0)(10.9)
(11.8)
(9.2)
(12.2)
(16.9)
(14.6)
(13.7)
(12.7)
(12.7)
(17.1)
(12.0)
(12.1)
(13.7)
(12.5)
(12.4)
(10.8)
(11.3)
(9.2)
(10.7)
(12.8)
(9.7)
(12.3)
(12.2)
(10.0)
(9.3)
(11.2)
(11.0)
(8.7)
Visit marchofdimes.com/reportcard for an interactive version of
this map.
Maternal Obesity: A Continuum of
Risk Intrapartum Risk
Increased Use of Induc:on
[Sohota et al. 2003] §
InducYon Rates: 28% in nl wt
woman; 34% in woman with
BMI>40
Increased Risk of Failed Induc:on
[Wolfe, Rossi, & Warshak, 2005]
§ 13% in nl wt woman;
29% in woman with BMI>40
§ Previous C-‐S + Macrosomic fetus
– highest risk for failure (80%
failure rates)
Prolonged Labor
§ Prolonged 1st stage § Prolonged
2nd stage § Maternal
Age – important cofounder
Maternal Obesity: A Continuum of
Risk Cesarean Delivery
Cesarean Delivery Risk
§ Increased by 50% in overweight
women and is more than double
for obese women, compared to
women with normal BMI
[Poobolan et al. 2009]
§ Late Preterm infants born via
elecYve C/SecYon to obese
mothers incur serious risk for
acute respiratory morbidity &
neonatal mortality
[Gnanaratnem & Finer, 2000; Kasap
et al. 2008]
Maternal Obesity: A Continuum of
Risk Anesthesia & Intubation
Epidural placement [Dresner et
al. 2006] § More difficult &
more likely to fail
Spinal Anesthesia [von
Ungern-‐Sternberg, 2004] § Obesity can
significantly impair respiratory func:on
in women receiving spinal anesthesia
as height of block is posi:vely
correlated to BMI
Intuba:on § 10X higher rate in OB
popula:on § Much more difficult
[ D’Angelo & Dewan, 2004]
General Anesthesia § More likely
to require general anesthesia
Maternal Obesity: A Continuum of
Risk Stillbirth
S:llbirth: [Salihu et al., 2007]
§ 5.5/1000 for non obese; 8/1000
BMI 30-‐39; 11/1000 BMI ≥ 40
§ Obesity shown to be an
independent risk factor § 40%
more likely, compared to normal
weight women § Greatest risk –
Black women with BMI > 40
(2X more likely)
§ Some evidence shows obesity related
s:llbirth risk increases with
gesta:onal age [Chu et al.,
2007]
§ 28 – 36 weeks -‐ Hazard
ra:o 2.1 § 40 weeks –
Hazard ra:o 4.0
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Maternal Obesity: A Continuum of
Risk Hemorrhage
Post Partum Hemorrhage [Sebire et
al. 2001] § 44% risk with BMI
> 30 [5X more likely
compared to non-‐obese
§ 70% more frequent in obese women
with BMI > 40, compared to
normal weight mother
Maternal Obesity: A Continuum of
Risk Thromboembolism
Thromboembolism § Leading cause of
maternal mortality in US &
UK
[CDC, 2010; Lancet,
2010]
§ Greatest risk at term with
C/Sec:on
§ Pregnancy is a hypercoagulable state,
obesity furthers the risk of
thrombosis by promo:ng venous stasis,
increasing blood viscosity and
promo:ng ac:va:on of the coagula:on
cascade.
40% of Maternal Deaths Worldwide
Occur in Obese Women
Maternal Obesity: A Continuum of
Risk Post Partum Complications
§ Higher rates of PP complica:ons
result in significantly higher
incidence of LOS > 4 days
§ Immediate Complica:ons: § Wound Infec:on
[Wall, Deucy, Glantz, & Pressman,
2003]
§ All obese women delivering via
C-‐S should be given prophylaxis
an:bio:cs [ACOG, 2005]
§ Urinary Tract Infec:on [Bamgbade,
Ruher, Nafiu, & Dorje, 2006]
§ Longer term complica:ons
§ Stress Incon:nence § Post
Partum Depression
Maternal Obesity: A Continuum of
Risk Breast, Endometrial, Ovarian,
& Cervical Cancers
§ Breast Cancer § Several meta-‐analyses,
systema:c reviews, and large cohort
studies have shown obesity worsens
breast cancer mortality. May be
related to: § Less likely to
report mammogram, Late detec:on &
Obesity promotes rapid growth
of metasta:c disease
§ Endometrial Cancer § Obesity associated
with 2-‐3 fold risk
§ Ovarian Cancer
§ Cervical Cancer § Related to
increased estrogenic hormones § May
be related to decreased screening
compliance § Recommenda:on – PAP
Smears at same intervals as
normal weight women
"
Maternal Glucose Load
Glucose Crosses Placenta
Fetus Responds High Glucose Load
Results In Fetal
Hyperinsulinemia
Drives Catabolism of the Oversupply
of Fuel Uses Energy &
Depletes O2 Stores
Fetal Hypertension Cardiac
Remodeling & Hypertrophy
Episodic Fetal Hypoxia ↑ Release
of Fetal Catecholamines
S:mulates Erythropoie:n
Fetal RBC Hyperplasia & ↑
Hemoglobin & Hct Poor Circula:on
& Postnatal Hyperbilirubinemia
©Neostar USA Inc. 2012
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Maternal Obesity: A Continuum of
Risk Fetal Risk
§ Infants conceived with ART have
increased risk for congenital
anomalies: [Reefhuis, 2008] § 2x
the risk of Atrial Septal
Cardiac Defects § > 2X the
risk of clez lip with or
without clez palate
§ > 4 X the risk
esophageal and anal atresia compared
with babies conceived without
fer:lity treatments "
Fetal Risk Increased Risk of
Congenital Anomalies
§ Neural tube defects, Cardiac
Anomalies, Oral -‐ facial clezs,
even azer controlling for diabetes
[King, 2006; Rasmussen, Chu,
Kim, Schmid, & Lau, 2008]
§ The risk of neural tube defects
among obese women is double
that among women of normal
weight [Shaw, Velie, &
Schaffer, 1996; Waller et al.,
1994
Werler, Louick,
Shapiro, & Mitchell, 1996]
§ Hydrocephaly, anorectal atresia, and
limb reduc:ons
[Stothard,
Tennant, Bell, & Rankin, 2009]
§ Diaphragma:c hernia, anorectal atresia,
hypospadias, and omphalocele among
obese women with BMI >30,
compared with women with normal
BMI [Waller et al. 2007]
Fetal Risk Abnormal Fetal Growth
Bigger is Not Always Better
Fetal Risk Abnormal Fetal Growth
– LGA
§ A large body of evidence shows
that pre-‐pregnancy obesity as well
as excessive weight gain during
pregnancy are associated with
macrosomia and large for gesta:onal
age (LGA) infants
[Cedergren, 2004; Rode,
Nilas, Wojdemann, & Tabor, 2005;
Watkins, Rasmussen, Honein, Boho,
& Moore, 2003]
§ Both fetal macrosomia
and
LGA associated with
a higher risk for
delivery
complica:ons and birth trauma
"
"
Fetal Risk
Potential for Inaccurate
Fetal Surveillance
§ Anthropomorphic measurements less accurate
§ Unreliable da:ng, especially in
3rd trimester § Difficulty in
detec:ng fetal anomalies When BMI
>90th
§ Subop:mal in diagnosing heart, spine,
and abdominal wall anomalies
"Hendler et al., 2005
Neonatal Risk Need for Neonatal
Resuscitation & NICU Admission
§ Increased risk for delivery room
resuscita:on requiring posi:ve pressure
ven:la:on with bag and mask or
intuba:on Johnson, Longmate, & Frentzen,1992
§ Infants of obese mothers were
3.5 :mes more likely to be
admited the NICU Pathi, Esen, and
Hildreth, 2006
§ Infants born to morbidly obese
mothers are nearly five :mes
more likely to be transferred
to the NICU Kumari, 2001
§ Aside from the health risks and
the poten:al for poor neonatal
outcome, admission to the NICU
is associated with disrupted
maternal-‐infant atachment and increased
hospital costs
Ramachendran, Bradford, &
Mclean, 2008
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Neonatal Risk Delayed Fetal Lung
Maturity – Respiratory Distress
Syndrome
§ Male Preponderance"
§ Maternal Diabetes"
§ Maternal Obesity "
§ Antepartum Hemorrhage" "
Neonatal Risk Infants of Obese
Mothers Born
Before 39 Weeks Gestation via C/S
with No Labor Incur
Serious Risk for Retained Fetal
Lung Fluid &
Respiratory Distress
Neonatal Risk Infant of Obese
Mother
Severe Respiratory Morbidity
Neonatal Risk Instrument Assisted
Delivery
§ Caput Seccundem
§ Cephalhematoma
§ Subgaleal Hemorrhage
§ Neonatal Anemia
§ Hyperbilirubinemia
Neonatal Risk Brachial Plexus Injuries
Neonatal Risk Hypoglycemia
§ Increasing maternal glucose concentra:on
less severe than diabetes is
associated with fetal overgrowth,
specifically adiposity & LGA
§ Con:nuous rela:onships of maternal
glucose levels below those diagnos:c
of diabetes were strongly associated
birth weight > 90th percen:le,
fetal hyperinsulinemia, cesarean delivery
and clinical neonatal hypoglycemia
Metzger et al., 2008
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Neonatal Risk Polycythemia &
Hyperbilirubinemia
Neonatal Risk Breast Feeding
Failure Risk
§ Related to multiple factors - chronic and gestational health
disorders, prolonged labor, the need for general anesthesia,
cesarean section delivery, wound infections, postpartum
complications, delayed lactogenesis, and difficulties related to
large breasts and proper infant positioning
§ Maternal obesity associated with increased risk of failure to
initiate lactation and decreased duration of breast-feeding Donath
& Amir 2000; Li, Ogden, Ballew, Gillespie, &
Grummer-Strawn, 2002; Sebire et al., 2001
§ BF failure may resulting in dehydration, hypoglycemia, and
extreme levels of unconjugated hyperbilirubinemia and kernicterus
Bhutani, 2006
Neonatal Risk Neonatal &
Infant Mortality
§ At all gesta:onal ages, the
risk of neonatal mortality has
been shown to increase for both
overweight (BMI 25 -‐ 30) and
obese women (BMI > 30)
Cedergren, 2004
§ Infants of obese women nearly
twice as likely to die in
the first year of life,
compared to those born to
normal weight women
Baeten, Bukusi, & Lambe, 2001; Sebire, Jolly,
& Harris, 200
§ Obese women were more likely to
experience fetal death and s:llbirth,
and this risk increased with
advancing gesta:on from an RR
of 1.9 at 20–27 weeks gesta:on,
to 3.5 at 28–36 weeks, and
4.6 at term Nohr et al., 2005
Child Health Morbidity Risk
Childhood Obesity
Child Health Morbidity Risk
Infant of Obese Mother
Risk for Autism Normal
Weight Mothers & Au:sm
§ Prevalence: 1 in 88 § 3:
1 Male to female Preponderance
Maternal Obesity & Au:sm
CHARGE Study – Children aged
2-‐5, popula:on based study, CA
§ Obesity is associated with
increased risk for having an
au:s:c
child to (1 in 53). §
Doubles the risk for having a
child with a developmental delay
Krakowiak, Walker, Bremmer, et al
(2012). Maternal Metabolic Condi:ons
and Risk for Au:sm and Other
Neurodevelopmental Disorders, Pediatrics,
129(5)
Life Course Risk Fetal Origins
of Disease
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Thank you
-
Presentation Handouts: *
Maternal Obesity: A Continuum of
Risk
* Infant of Obese Mother
Anne M. Jorgensen NNP Email:
[email protected]
T 845-‐553-‐5657
©Neostar USA Inc. 2013
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Maternal Glucose Load
Glucose Crosses Placenta
Fetus Responds High Glucose Load
Results In Fetal
Hyperinsulinemia
Drives Catabolism of the Oversupply
of Fuel Uses Energy &
Depletes O2 Stores
Fetal Hypertension Cardiac
Remodeling & Hypertrophy
Episodic Fetal Hypoxia ↑ Release
of Fetal Catecholamines
SOmulates ErythropoieOn
Fetal RBC Hyperplasia & ↑
Hemoglobin & Hct Poor CirculaOon
& Postnatal Hyperbilirubinemia
©Neostar USA Inc. 2012
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Transla'ng Evidence Into Best Prac'ce
Hyperglycemia Adverse Pregnancy
Outcome
The “HAPO Study” Metzger et al.
(2008). NEJM, 358, 19
Research Findings Implica'ons for
Prac'ce Best Prac'ce (Ac'on
Step)
Obese women without history of
elevated glucose tolerance test or
gestaOonal diabetes are at increased
risk for delivering a macrosomic
and LGA infant
Macrosomia and LGA are associated
with cesarean secOon, shoulder
dystocia, and birth trauma, and
increased need for NICU
The NICU should be noOfied when
obese mothers are admi]ed to
labor and delivery and when
birth is expected
Infants of obese women are at
increased risk for fetal
hyperinsulinemia
Fetal hyperinsulinemia has a well-‐known
associaOon with delayed surfactant
synthesis and excreOon, which may
result in respiratory distress
syndrome
Infants of obese mothers, especially
late preterm infants (born 34-‐36
6/7 weeks gestaOon), should be
carefully monitored for signs and
symptoms of respiratory distress
syndrome
Infants of obese women are at
increased risk for neonatal
hypoglycemia
Fetal hyperinsulinemia is well-‐known to
result in neonatal hypoglycemia
Infants of obese mothers should be
closely monitored for hypoglycemia,
beginning at 1-‐2 hours acer
birth
Maternal hyperglycemia is associated
with hyperbilirubinemia
Fetal hyperinsulinemia drives catabolism
of the oversupply of fuel, uses
energy & depletes O2 stores,
resulOng in fetal RBC hyperplasia
and increased hematocrit
Infants of obese mothers should
have bilirubin screening and conOnued
monitoring if warranted
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Maternal Obesity and Congenital
Anomalies Neonatal Assessment –
Best Prac'ce
Research Study Research Findings
Best Prac'ce
Stothard, Tenant, Bell, & Rankin,
2009 Maternal obesity is
associated oral-‐facial clecs
In infants born to
obese women, physicians and nurses
should have higher index of
suspicion for congenital anomalies,
even if prenatal ultrasound reports
normal fetal anatomy
Stothard, Tenant, Bell, & Rankin,
2009 Sarwer et al., 2006
Maternal obesity is associated with
congenital heart defects
Waller et al., 2007 Maternal
obesity associated with diaphragmaOc
hernia and omphalocele
Waller et al., 2007 Maternal
obesity is associated with
hypospadius
Stothard, Tenant, Bell, & Rankin,
2009 Rasmussen, Chu, Kim,
Schmid, & Lau, 2008; Shaw,
Vellie, & Schafer, 1996
Maternal obesity is associated with
neural tube defects
Stothard, Tenant, Bell, & Rankin,
2009 Waller et al., 2007
Maternal obesity is associated with
anorectal atresia
Stothard, Tenant, Bell, & Rankin,
2009 Maternal obesity is
associated with limb reducOons
Hendler et al., 2004 VisualizaOon
of fetal anomalies, especially
cardiac structures, is more difficult
in obese women, compared to
non-‐obese women. Prenatal diagnosis
of cardiac anomalies may be
missed
©Neostar USA Inc. 2012
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Transla'ng Evidence Into Best Prac'ce
Maternal Obesity and
BreasKeeding
Research Study Research Findings
Best PracOce
Donath & Amir, 2000 Li, Jewel,
& Grummer-‐Strawn, 2003
Fewer obese women iniOated breast
feeding, compared to normal weight
women
Obese women need educaOonal efforts
aimed at promoOng breast feeding
Oddy et al., 2006 Li, Jewel,
& Grummer-‐Strawn, 2003
Obese women breasjed their infants
for less Ome (weeks and
months), compared to normal weight
women
Early and on-‐going lactaOon support
should be provided for all
obese mothers
Hilson, Rasmussen, & Kjolhede, 2004
Obese women are more likley to
expreience delayed onset of
lactogenesis (defined as milk coming
in > 72 hours acer
birth) compared to non-‐obese women
Because delayed Iactogenesis may pose
a significant risk for dehydraOon,
thermal instability, hypoglycemia, and
extreme hyperbilirubinemia, exclusively
breast fed infants of obese
mothers, especially those infants
born late preterm, should have:
• Glucose screening at 1-‐2
hours of life and conOnued
monitoring if warranted • Bilirubin
screening at 48 hours of
life and conOnued monitoring if
warranted Infants of obese
mothers may require
supplemental formula feeding unOl
the Mother’s breast milk is
enough to meet the infant’s
nutriOonal requirements
©Neostar USA Inc. 2012
Maternal Obesity - A Continuum of Risk.pdfIntrapartum
ImplicationsAssisting the Obese Breastfeeding MotherTranslating
Evidence into Practice