Obesity and Pregnancy presentation by Chanel Tyler, MD

Wisconsin Women’s Health Foundation’s 2012 Dialogue

Chanel T. Tyler, MDAssistant Professor

University of Wisconsin School of Medicine Department of Obstetrics and Gynecology Division of

Maternal Fetal Medicine

• 23 Million (1/3 of )adult women in the United States are obese

• Non-Hispanic black women 49%• Mexican-American women 38%• Non-Hispanic white women 31%

• 18% of obstetric causes of maternal death related to obesity

• 80% of anesthesia-related maternal mortality related to obesity

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.

• Increased risk of gestational diabetes– Primarily related to an exaggerated increase

in insulin resistance in the obese state– Women who are obese during pregnancy

and develop gestational diabetes have a 2-fold increased prevalence of subsequent type2 diabetes

• Increased risk of gestational hypertension

• Increased risk of preeclampsia– Among the morbidly obese this is almost 5-fold

• Prevalence of LGA infants is almost 4 times as high among the morbidly obese than those with normal BMI.

• Increased risk of having SGA infant, however after adjusting for preeclampsia the risk is no longer statistically significant.

• Increased risk of antepartum stillbirths – Almost 3-fold (Cedergren et al)

• Shoulder dystocia occurred 3 times more frequently among the morbidly obese.

Additional Risks

• Puerperium deep venous thrombosis

• Endomyometritis

• Postpartum hemorrhage

• Prolonged hospitalizations

• Wound infections

• Dehiscence

Waller et al

• Found in a population-based control study that for every incremental unit increase (kg/m2) in BMI, the risk of NTD increased by 7%

BMI Visualization

Less than 10th % 90.2%

97.5th % 63%

Heart 50.5%

Umbilical cord

25.8%

Diaphragm 17%

Kidneys 10%

Wolfe et al

Risk of Induction

• Increased risk of post-term pregnancy

• Subsequently there is an increased incidence of labor induction estimated to be between 1.7-2.2 fold.

Weiss et al 2004

• Increased risk of operative delivery– Instrumental delivery increased by 18% in

women with BMI 35.1-40 – Increased 34% in women with BMI >40

• Cesarean delivery more common: 47.4% compared to control patients 20.7%

VBAC

• The success rate for VBAC in the massively obese patient has been found to be just 15%

• More than 50% of these VBAC attempts are complicated by infectious morbidity

– Jordan h. Perlow Obstetric Intensive Care Manual second edition 2004

• Inaccurate or difficult blood pressure monitoring

• Reduced functional residual capacity Reduced functional residual capacity

• Sleep apnea syndrome Sleep apnea syndrome

• Increased reflux Increased reflux

• Aortocaval compression. Aortocaval compression.

Aortocaval Compression

120 kg 150 kg

Difficulties with Regional Anesthesia

• 150 kg 150 kg

• Difficult veins Difficult veins

• Unable to curve Unable to curve lumbar spine lumbar spine

• Impalpable iliacImpalpable iliaccrests crests

• Impalpable vertebral Impalpable vertebral spinesspines

Difficulties with General Anesthesia

• Rapid desaturation on induction Rapid desaturation on induction

• Risk of regurgitation Risk of regurgitation

• Potential difficult intubation Potential difficult intubation

• Potential difficult ventilation Potential difficult ventilation

• Difficult tracheostomy Difficult tracheostomy

Excess Gestational Weight GainExcess 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

Excess Gestational Weight GainExcess 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

• More than a 2-fold increased risk from fetal distress and low APGARS

• Meconium aspiration occurred more often in infants of morbidly obese women

Maternal Benefits of Breastfeeding

• Decreased risk of breast15-17 and ovarian cancer18,19

• Decreased risk of type 2 diabetes. 20

• Returns of uterine tone,21;22

• Stopping post-birth bleeding,21

• Temporarily suppressing ovulation which aids the spacing of children.21;23

Breastfeeding Decreases Infant Risks of

• Ear1-3 and respiratory infections.4

• Atopic dermatitis5

• Gastroenteritis6

• Necrotizing enterocolitis7

• Type 2 diabetes8

• Sudden infant death syndrome (SIDS)9-

14.