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.