6/5/2014 The Obese Patient During Pregnancy & Labor No disclosures Naomi E. Stotland, MD Associate Professor Dept. of Obstetrics, Gynecology, and Reproductive Sciences University of California, San Francisco San Francisco General Hospital Obesity Classification Limitations of BMI • Class I Obesity – BMI 30 – 34.9 • Does not account for body 5’4’’ woman who weighs 175 lbs has BMI = 30 composition • Class II Obesity – BMI 35 – 39.9 • Muscle weighs more than fat 5’4’’ woman who weighs 205 lbs has BMI = 35 • Class III Obesity – BMI ≥ 40 • Isn’t a great proxy for 5’4’’ woman who weighs 235 lbs has BMI = 40 metabolic health Don’t “eyeball it” – calculate BMI and write it on the chart 1
6/5/2014 Etiology of Obesity Animal studies have shown similarities in the way the brain responds to classic Genetics & Fetal drugs of abuse (e.g., Programming morphine, alcohol, nicotine) and to sugar (Avena, Rada, and Hoebel 2008). Behavior/ Environment Psychology Obesity is associated with Early Pregnancy Concerns metabolic dysfunction • Spontaneous abortion Obesity • Fetal anomalies, esp neural tube defects • Difficult U/S HTN, DM, Chronic liver disease inflammation -Some obese have little to no metabolic dysfunction -Many normal weight people have metabolic dysfunction 2
6/5/2014 Antepartum Complications Intrapartum Complications • Prolonged labor • GDM and DM2 • Lower likelihood of VBAC success • Chronic hypertension • Preeclampsia • Postterm pregnancy • Higher rates of cesarean delivery • Anesthetic complications • Failed ECV • Macrosomia and shoulder dystocia • Stillbirth Postpartum Complications Long-term Risks to Offspring • Obesity • Longer hospital stays • Cardiometabolic diseases • Autism/developmental delay • Infections – Wound infection and endometritis • Lower rates of breastfeeding 3
6/5/2014 Fetal Programming • Animal studies support the role of diet during Prenatal Care for Obese Women pregnancy on body composition and metabolism after birth • Improving diet during pregnancy may have long-term benefits for offspring At first prenatal visit Fetal growth • Screen for DM2 (repeat at 24 wks if neg) • Obese women at increased risk for both SGA • Measure and record BMI in chart and LGA • If fundus easily palpated, can follow fundal • Review weight gain goals and strategies with height patient • If fundus not easily palpated, consider serial • Discuss risks especially re: weight gain ultrasound for fetal growth • If concern for CHTN: baseline Cr, 24hour urine, LFTs 4
6/5/2014 Antenatal Testing Intrapartum Managment • Increased stillbirth risk in obese women • No RCT to support or refute benefit of antenatal testing, but many recommend it • At SFGH we start weekly NST/AFI at 32 weeks for women with BMI of 40 or greater When to deliver? On admission to L&D • No evidence to support nor refute, but we • Consult anesthesia on admission • Place internal monitors if needed consider induction of labor at 39-40 weeks in women with BMI ≥ 40, especially if cervix is • Assess IV access favorable • Prepare for shoulder dystocia, especially if • Elevated risk of IUFD GDM/DM2 or suspected macrosomia If induction is not progressing after 24+ hours and • Staffing considerations maternal/fetal status reassuring (and intact membranes), will stop induction and either try again in a few days or wait for spontaneous labor 5
6/5/2014 6 weeks post–op Cesarean in the morbidly obese Transverse skin incision under the panniculus patient http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289484/?report=reader#!po= 19.2308 Cesarean – type of incision and Preparing for cesarean closure? • 20-degree Left lateral tilt is even more important • No randomized trial of incision type; no evidence because of the added weight of the abdominal that vertical skin is preferable – choose based on pannus, but, surgeon’s preference • The tilt puts the midline far from the operating • When pannus is massive, a supra-umbilical incision surgeon and is ergonomically challenging may be considered – transverse or vertical • Retraction of the pannus with Montgomery straps • Some evidence that vertical incisions are associated and/or extra surgical assistants with more pain and poorer healing, but study results • Retraction of the extremely large pannus can cause are mixed • Vertical incisions may increase the risk of classical hypotension, difficult ventilation, and fetal compromise uterine incision if access to LUS is limited 6
6/5/2014 Cesarean – type of incision and Prevent difficult extraction of infant closure? • Pre-op antibiotics – at least 2g cefazolin IV • Make all incisions larger than usual – skin, • Subcutaneous sutures decrease risk of seroma, but fascia, and uterus not good evidence in BMI ≥ 50 • Have vacuum available since fundal pressure • Drains not shown to provide benefit and may may be difficult to apply increase infection • Staple vs. suture – ongoing clinical trial in obese women, but current evidence suggests some benefit of suture over staples • If staples uses, delayed removal may improve outcomes DVT Prophylaxis? Emergency Cesarean BMI ≥ 40 • Mechanical thromboprophylaxis (pneumatic Need to plan for extra time to compression) SCDs pre and post-operatively • move patient to OR table • Early ambulation • induce anesthesia, and • do the surgery • If BMI>40 consider unfractionated heparin All will take longer, so have to move earlier to 5000-10000 u q 8-12 hrs C/S especially for fetal indications No well designed RTCs to assess risk reduction therefore recommendations is expert opinion 7
6/5/2014 Why are cesarean rates so high among Length of labor obese women? • First stage of labor takes longer among obese • Much of this may be iatrogenic women • Obese women should be given a chance for a • As long as maternal and fetal status safe vaginal birth reassuring , may tolerate a slower labor curve • Allow labor to take longer in obese patient • Second stage length NOT • Provide continuous labor support (doulas) • Obesity alone (BMI of 30-39/Classes 1-2) may associated with BMI (nullips) not “risk a woman out” for midwifery or birth center delivery Previous C-section: Balancing Risks Consider patient preferences and values Weight Gain During Pregnancy for Obese Women Advantages of vaginal birth VS. Risks of unplanned c-section HARD ROCK PLACE 8
6/5/2014 Combined effects of obesity & excessive The IOM Report and Guidelines weight gain IOM Recommendations for Weight Gain in Pregnancy 2009 • Preeclampsia, macrosomia, and cesarean birth increase with increasing Pre-pregnancy BMI IOM Recommended weight gain among obese women (kg/m 2 ) Gestational Weight Gain (kg / lbs) • Some evidence that weight gain <11 lbs <18.5 (Underweight) 12.5-18 / 28-40 decreases these risks, but may also 18.5 – 24.9 (Normal) 11.5-16 / 25-35 increase risk of SGA 25.0 - 29.9 (Overweight) 7-11.5 / 15-25 ≥ 30.0 (Obese) 5-9 / 11-20 Does Prenatal Advice on Weight Gain Matter? • Receiving correct advice about weight gain was associated with actual weight gain within guidelines; • Receiving no advice about weight gain was associated with gain outside guidelines; • About a third of women report receiving no advice about how much weight to gain. Cogswell et al. Obstet Gynecol 1999. Stotland et al. Obstet Gynecol 2005. Comparison of weight gain by BMI category between PRAMS 2002-2003, and new IOM guidelines 9
6/5/2014 Barriers to weight gain counseling What do patients want? Insufficient nutrition CME, training dieticians Belief that counseling is Literature ineffective Concern about normalize sensitivity of topic Preliminary Outcome Data (n=93) What do patients want? The Healthy Moms Trial Vesco et al, Kaiser Portland • Women were advised to gain too much weight Presented at The Obesity Society 2012 or given no advice; � DASH diet, caloric restriction, weekly • Providers perceived as being unconcerned meetings about excessive gain; � Goal: maintain weight within 3% • Women desire and value weight gain advice � Mean pre-pregnancy BMI (36.2 kg/m2) from providers 10
6/5/2014 Summary - Weight Gain Intervention Preliminary Outcome Data (n=93) The Healthy Moms Trial Studies Vesco et al, Kaiser Portland • Small sample sizes – unknown if impact on Presented at The Obesity Society 2012 outcomes other than weight (GDM, c-section, macrosomia) • Not powered to exclude possibility of harm � Gain of ≤ 3% in 28% vs. 10% from weight restriction (OR=3.7, 95% CI [1.1,12.6], p=.04). • Diet and exercise can reduce weight gain among obese women � Average gain 4.5 kg vs 8.3 • More intensive (and expensive) interventions difference=3.7 kg , 95% CI [2.0, 12.2], may be necessary to see an impact p<.001. MANY studies ongoing… Bariatric Surgery & Pregnancy • 220,000 procedures in 2008, ½ in reproductive-age women • Fewer obesity-related pregnancy complications post-surgery • Risks of vitamin deficiencies: iron, vitamin B12, calcium, folic acid, vitamin D 11
Recommend
More recommend
