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Assisting Women with Obesity to Have Their Best Perinatal Outcomes
CECILIA JEVITT, RM, CNM, PHD
February 2020
Conflict of Interest-none
– Member Perinatal Services BC Advisory Board
– No financial interest in organizations or corporations related to issues discussed in this presentation
Photos of individuals with obesity are provided by the Rudd Center for Food Policy and Obesity, University of Connecticut
Request slides: [email protected]
Objectives– Understand obesity as adipose tissue disease with multiple origins including broken food
systems, endocrine disrupting chemicals and chronic stress
– Describe the physiological origins for common obesity related complications of the perinatal period
– List maternal and fetal morbidity associated with prepregnancy obesity
– Use the Edmonton Obesity Staging System to triage which women with obesity are at the highest risk for perinatal morbidity
– Apply the physiology of adipose tissue disease to develop measures that ameliorate risk for obesity related morbidities
– Support improved nutrition through advocacy that promotes equitable food distribution, production of nutritious foods, and reduction of environmental pollutants.
White adipose tissue is the largest & most productive
endocrine organ.
OBESITY IS AN ENDOCRINE ORGAN DISEASE
BROKEN FOOD SYSTEMS
– Industrial monoculture dependent on external fertilizers, pesticides, hormones and water sources
– Foods manufactured for long shelf lives: high sodium, high sugars, preservatives
– Foods manufactured and distributed to maximize profits: long shelf lives, hyper-palatable
– Foods maldistributed with 50% of world’s population starving but the other 50% exposed to high quantities of non-nutritious foods
ENDOCRINE DISRUPTING CHEMICALS
highly persistent, bioacculumative synthetic compounds
EDCs– Organochlorines (DDT, DDE
– Bisphenol A (BPA)
– Phthalates
– Polychlorinated biphenyls (PCBs)
– Polybrominated diphenylethers
– Parabens
– phytoestrogens
Environmental sources:– Pesticides
– Household plastics (food storage containers, baby bottles)
– Flame retardants
– Electric insulation
– Plasticizers, adhesives, lubricants, hydraulic fluids
– Coolants
– Soaps, lotions, cosmetics
Obesity has less to do with personal choice than with socioeconomic limits on choices.
From Fleming, et al., Lancet
MATERNAL SMOKING DURING PREGNANCY• Nicotine exposure
downregulates genes responsible for nutrition and lipid metabolism
• Growth restricted fetus gains weight easily when exposed to excess calories, increasing risk for future obesity
• Eggs in female fetus also exposed to nicotine
“You can’t do anything; the women are already obese when they come
for prenatal care!”
Oh, yes, we can!
EPIGENETIC CHANGES:*fetal*ova in female fetus
ECONOMIC & EDUCATIONAL DISPARITIES:˅ access to quality education ˅ access to living wage˅ access to health care˅ access to health information
NUTRITIONAL DISPARITIES:˅ incidence & duration of breastfeeding˅ income for quality nutrition˅ availability of nutritious foods˄ exposure to calorie dense,
high glycemic index foods
ENVIRONMENTAL DISPARITIES:˄ exposure to endocrine disrupting
chemicals˄ increased tobacco product exposure˅ safety of physical activity
OBESITY:˄ white adipose tissue cytokines & hormones˅ satiety signaling from gut microbiome
PERINATAL MORBIDITY &
MORTALITY
FACTORS CONTRIBUTINGTO OBESITY
– Grandmother obese during mother’s gestation
– Mother obese during pregnancy
– Grandmother or mother smoked during pregnancy
– Formula fed instead of breastmilk
– High glycemic index, calorie dense, highly processed foods
– Lack of control over foods
– Public food programs, food pantry use
– Family groups sharing foods
– Chronic stress, racism
– Night shift work, inadequate sleep
– Exposure to endocrine disrupting chemicals
– Canned foods, plastic food containers
– Pesticides
– Environmental pollutants
– Neighborhood unsafe for physical activity
– Starvation
– In utero growth restriction
– Food deprivation
– Poverty
– War, relocation
– Long term dieting to maintain low weight: ballet, athletics, clothing models
PERINATAL-RELATED PHYSIOLOGIC EFFECTS OF OBESITY
– INSULIN RESISTANCE (growth hormone)
– Gestational diabetes
– Fetal macrosomia
– Newborn hypoglycemia
– LEPTIN RESISTANCE (leptin is a tocolytic)
– Prolonged pregnancy (fetal macrosomia, shoulder dystocia)
– Prolonged stages of labor
– Postpartum uterine atony/hemorrhage
– Impaired milk ejection reflex
– INFLAMMATION
– Postpartum DVT
Evidence about Risk & Obesity– Increase with increasing BMI:
– Hypertensive disorders of pregnancy
– Gestational diabetes
– Macrosomia
– Stillbirth
– Risk constant with increasing BMI or clinically insignificant increases:
– Shoulder dystocia
– Postpartum hemorrhage
– The largest increases in risk start at a BMI of 36.
BUT MANY WOMEN HAVE NO PREGNANCY RELATED COMPLICATIONS
Not all obese women are at risk-
The 2 most common pregnancy complications:
228,958 singleton pregnancies in British Columbia 2004-2012:SchmummersA 10% reduction in prepregnancy BMI was associated with at least a 10% lower risk of preeclampsia, gestational diabetes, macrosomia and stillbirth. To reduce risks of cesarean birth and shoulder dystocia, a 20-30% reduction in BMI was needed.
BMI 18.5-24.9Referent group
BMI 25-29.9 BMI 30-34.9 BMI 35.39.9 BMI > 40 P value
Preeclampsia 3.4 6.6 10.0 12.8 16.3 <0.001
Gestational diabetes
6.1 9.7 13.7 16.6 20.8 <0.001
Cesarean birth 26.5 33.1 38.2 43.1 49.7 <0.001
Macrosomic newborn
1.4 2.8 3.8 4.5 6.1 <0.001
Shoulder dystocia
3.5 4.1 4.1 4.4 4.1 <0.001
Postpartum hemorrhage
0.7 0.7 0.8 0.7 0.3 0.010
Stillbirth 0.3 0.3 0.4 0.4 0.6 <0.001
Respectful Care in Pregnancy
– Recognize that women’s choices for purchasing nutritious food, preparing fresh foods and being physically active can be limited
– Respectful counseling relies on information sharing and patient-centered decision making
– Information dumping with expectations for compliance is hierarchical, privileged and demeaning
– Have appropriate equipment: large gowns, large BP cuffs, armless chairs, bariatric beds in hospital
– Use patient-centered language:– Women with obesity not obese women, large women or fat women
– Stop the use of morbid obesity. Use Class III obesity.
Optimizing labor and birth begins with
PRENATAL SELF-MANAGEMENTHEALTH GUIDANCE PHYSIOLOGIC ACTION
NUTRITION:
Low glycemic index, low fat, DASH Fosters healthier gut microbiome, improved satiety signaling
Vitamin supplementation Improves micronutrient intake if nutritious are unavailable
Weight gain within US IOM guidelines Reduces accumulation of excess white adipose
PHYSICAL ACTIVITY:
30 minutes of walking 5 days a week (2 x 15, 3 x 10)
Increases peripheral insulin activity, improves cardio-respiratory fitness for labor
SMOKING CESSATION Decreases DNA methylation-decreasing obesity in offspring
SLEEP:
7-8 hours of nighttime sleepDay time work shifts
Decreases insulin resistance, decreases ghrelin, increases leptin
1990 Institute of Medicine Recommended Prenatal Weight Gains
Re-affirmed in 2009 by IOM
Height for Weight BMI Range Recommended Weight GainCategory kg lb
Underweight women (BMI <19.8) 12.5-18.0 28-40
Normal weight women (BMI 19.8-26.0) 11.5-16.0 25-35
Overweight women (BMI 26.1-29.9) 7.0-11.5 15-25
Obese women (BMI >29.9) at least 6.0 15
Informed choice in place of birthfor women with obese BMIs
COMMUNITY: HOME or BIRTH CENTER
– Women with BMIs of 35-40 without co-morbid disease have risks similar to women with lower BMIs (Hollowell)
– Rates of uncomplicated vaginal birth for nulliparas 68% (Rowe, Jevitt)
– Rates of cesarean birth 7-50%
HOSPITAL– RCOG & NICE guidelines recommend
hospital for BMI > 35
– RCOG
– Notify anesthesia if BMI Class 4
– Continuous IV access if BMI Class 4
– ACOG
– Assumes hospital birth & IV
– Anticoagulation prophylaxis-weight based
Induction of Labor
– Blunted myometrial response to oxytocin (Carlson 2017)
– No superior method of induction: dinoprostone, misoprostol or transcervical catheter + balloon (Sarumi)
– In women with obese BMIs, vaginal compared to oral misoprostol reduced time to 3 cm dilatation and reduced length of labor (Soni)
– Consider “allowing” a longer first stage (ACOG)
Longer labor inductions
Larger, more frequent
applications of cervical ripening
agents
Larger doses of synthetic oxytocin
Increased cesarean birth
(Ellis)
Longer Labor Curves
– 118,978 gravidas, singleton at term, analyzed labor curves by parity & BMI:– 48% nulliparas, 22% cesarean birth
– Inductions of labor and cesarean births increased with increasing BMI
– Stage 1 was 1.2 hours longer for nulliparas at high BMIs
– Stage 1 was 1.0 hour longer for multiparas at high BMIs
– Stage 2 was not prolonged with or without epidural analgesia
Statistically significant but is it clinically significant?
Kominiarek, et al.
US obstetrical units with midwifery care had significantly lower rates of:
– Induction of labor
– Oxytocin augmentation of labor
– Cesarean birth
(Neal JL)
LABOR SUPPORT
– ADMISSION IN ACTIVE LABOR
– UNDISTURBED LABOR
– MOBILITY
– NUTRITION AND HYDRATION
– WATER IMMERSION
– LONGER LABOR CURVES
tried and true
midwifery techniques
IMMEDIATE POSTPARTUMSUPPORT
MOTHER– Active management of 3rd stage
– Reduce embolism risks (consider BMI & co-morbidities)
– Mobility
– Alternating compression stockings
– Anticoagulation?
NEWBORN– Skin to skin
– Undisturbed observation to enable breast crawl and initiation of breastfeeding
– Any & all techniques to increase latch & milk production
– Early breastfeeding
– Uterotonic effect
– Reduces neonatal hypoglycemia
MICROINDIVIDUAL ADVICE
& TREATMENTS
MIDEVIDENCE-BASED
SYSTEMS SUPPORT
MACROGOVERNMENT
POLICY & SUPPORT
FOOD SUPPLYNUTRITIOUS
LIMIT ADVERTISING OF NON-NUTRITIOUS FOODSREDUCE PESTICIDE & FERTILIZER USE
FOOD DISTRIBUTIONAFFORDABILITY
CHOICEHEALTHY PORTIONS
REDUCE FOOD WASTER
ENVIRONMENTREDUCE ENDOCRINE DISRUPTING CHEMICALS
HEALTH CARE REFORMADEQUATE ACCESS TO PREVENTATIVE CARE
ADEQUATE REIMBURSEMENT FOR TIME-CONSUMING COUNSELING
POLICY SUPPORT
QUESTIONS?
SLIDE REFERENCES
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