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.