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INTRODUCTION

Obstetric providers should be aware of these risks and modify patient care before pregnancy, during pregnancy, and postpartum to reduce the risk of these adverse outcomes. Although clinical practice guidelines for management of pregnant people and people planning pregnancy with obesity vary, they consistently recommend pregnancy risk counseling, a healthy diet, exercise, and dietician referral for managing weight loss and gestational weight gain [ 6,7 ].

This topic will discuss issues related to obesity and pregnancy. Obesity in the nonpregnant population is reviewed separately. (See "Obesity in adults: Prevalence, screening, and evaluation" and "Overweight and obesity in adults: Health consequences" and "Obesity in adults: Overview of management" .)

PATHOBIOLOGY

Maternal obesity may affect long-term offspring outcomes as a result of epigenetic changes induced by fetal exposure to increased levels of glucose, insulin, lipids, and inflammatory cytokines during development. These in utero effects may cause permanent or transient changes in metabolic programming, leading to adverse health outcomes in adult life (fetal origins of adult disease theory [Barker hypothesis]) [ 14,15 ]. The potential programming effects of maternal overnutrition are difficult to study, however, because of the complex relationships between the maternal metabolic milieu and the developing fetus and the influence of postnatal factors, including lifestyle and environment [ 16 ].

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Pregnancy and obesity: Know the risks

Concerned about pregnancy and obesity? Understand the risks of obesity during pregnancy — plus steps to promote a healthy pregnancy.

Having a high body mass index (BMI) during pregnancy can have a major impact on your health and your baby's health. Find out about the possible complications, recommendations for weight gain and what you can do to promote a healthy pregnancy.

What's considered obese?

Obesity is diagnosed when a person's BMI is 30 or higher. To determine your BMI , divide your weight in pounds by your height in inches squared and multiply by 703. Or divide your weight in kilograms by your height in meters squared.

Could having a high BMI affect my ability to get pregnant?

Having a high BMI can harm fertility by inhibiting regular ovulation. Even in women who regularly ovulate, the higher the BMI , the longer it may take to become pregnant. Some research also suggests that a higher BMI is associated with an increased risk of unsuccessful in vitro fertilization (IVF).

How might a high BMI affect my pregnancy?

Having a high BMI during pregnancy increases the risk of various pregnancy complications, including:

  • Miscarriage, stillbirth and recurrent miscarriage
  • Gestational diabetes
  • A pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys (preeclampsia)
  • Heart problems
  • Sleep apnea
  • The need for a C-section and the risk of C-section complications, such as wound infections

How could obesity affect my baby?

Having a high BMI during pregnancy has been linked to an increased risk of various health problems for a baby, including:

  • Congenital disorders
  • Being significantly larger than average at birth (fetal macrosomia)
  • Growth problems
  • Childhood asthma
  • Childhood obesity
  • Cognitive problems and developmental delay

However, other factors also might play a role in these outcomes.

How much weight should I gain during pregnancy?

It's important to consider your pre-pregnancy weight and BMI when determining how much weight you need to gain during pregnancy. Work with your health care provider to find out what's best for you and to manage your weight throughout pregnancy.

Start by considering these guidelines for pregnancy weight gain and obesity:

  • Single pregnancy. If you have a BMI of 30 or higher and are carrying one baby, the recommended weight gain is 11 to 20 pounds (about 5 to 9 kilograms).
  • Multiple pregnancy. If you have a BMI of 30 or higher and are carrying twins or multiples, the recommended weight gain is 25 to 42 pounds (about 11 to 19 kilograms).

Rather than recommending that you gain a specific amount of weight, your health care provider might encourage you to focus on avoiding excessive weight gain during pregnancy.

Will I need specialized care during pregnancy?

If you have a BMI of 30 or higher, your health care provider will closely monitor your pregnancy. Your provider might recommend:

  • Early testing for gestational diabetes. For women at average risk of gestational diabetes, a screening test called the glucose challenge test is often done between weeks 24 and 28 of pregnancy. If you have a BMI of 30 or higher, your health care provider might recommend the screening test at your first prenatal visit. If your test results show that your glucose levels are within the standard range, you'll likely repeat the screening test between weeks 24 and 28 of pregnancy. If the results show that your blood glucose levels are high, you'll need further testing. Your health care provider can advise you on blood sugar monitoring and control.
  • Changes to your fetal ultrasound. A standard fetal ultrasound is typically done between weeks 18 and 20 of pregnancy to evaluate a baby's anatomy. But ultrasound waves don't easily penetrate abdominal fat tissue. This can interfere with the effectiveness of fetal ultrasound. Talk to your health care provider about the best approach for getting an accurate ultrasound.
  • Screening for obstructive sleep apnea. Sleep apnea is a potentially serious sleep disorder that causes breathing to repeatedly stop and start during sleep. Women who have obstructive sleep apnea during pregnancy are at increased risk of preeclampsia and other complications. You'll likely be screened at your first prenatal visit. If obstructive sleep apnea is suspected, your health care provider may refer you to a sleep medicine specialist for evaluation and possible treatment.

What steps can I take to promote a healthy pregnancy?

You can limit the impact of having a high BMI on your health and your baby's health. For example:

  • Schedule a preconception appointment. If you have a BMI of 30 or higher and you're considering getting pregnant, talk to your health care provider. Your provider might recommend a daily prenatal vitamin and refer you to other health care providers — such as a registered dietitian — who can help you reach a healthy weight before you conceive.
  • Seek regular prenatal care. Prenatal visits can help your health care provider monitor your health and your baby's health. Tell your provider about any medical conditions you have — such as diabetes, high blood pressure or sleep apnea — and discuss what you can do to manage them.
  • Eat a healthy diet. Work with your health care provider or a registered dietitian to maintain a healthy diet and avoid excessive weight gain. Keep in mind that during pregnancy, you'll need more folic acid, protein, calcium, iron and other essential nutrients.
  • Be physically active. Consult your health care provider about safe ways to stay physically active during your pregnancy, such as walking, swimming or doing low-impact aerobics.
  • Avoid risky substances. If you smoke, ask your health care provider to help you quit. Alcohol and illicit drugs are off-limits, too. Get your health care provider's OK before you start or stop taking any medications or supplements.

Having a BMI of 30 or higher during pregnancy can increase the risk of complications for you and your baby. Working with your health care provider can help you manage your risks and promote a healthy pregnancy.

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  • American College of Obstetricians and Gynecologists. Practice Bulletin No. 230: Obesity in Pregnancy. Obstetrics & Gynecology. 2021; doi:10.1097/AOG.0000000000004395.
  • American College of Obstetricians and Gynecologists. Committee Opinion No. 804. Physical activity and exercise during pregnancy and the postpartum period. Obstetrics & Gynecology. 2020; doi:10.1097/AOG.0000000000003772.
  • About adult BMI. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#Interpreted. Accessed March 2, 2022.
  • Hornstein MD, et al. Optimizing natural fertility in couples planning pregnancy. https://www.uptodate.com/contents/search. Accessed March 2, 2022.
  • Poston L. Gestational weight gain. https://www.uptodate.com/contents/search. Accessed March 2, 2022.
  • Landon MB, et al., eds. Preconception and prenatal care. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed March 2, 2022.
  • Staying healthy and safe. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/staying-healthy-and-safe. Accessed March 2, 2022.

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  • v.2(2); 2009 Jun

Obesity in pregnancy: risks and management

Kate j fitzsimons.

* Confidential Enquiry into Maternal and Child Health, Chiltern Court, 188 Baker Street, London NW1 5SD

† UCLH NHS Foundation Trust, 250 Euston Road, London NW1 2PG

Ian A Greer

‡ Hull York Medical School, University of York, Heslington, York YO10 5DD, UK

Maternal obesity is now considered one of the most commonly occurring risk factors seen in obstetric practice. Compared with women with a healthy pre-pregnancy weight, women with obesity are at increased risk of miscarriage, gestational diabetes, preeclampsia, venous thromboembolism, induced labour, caesarean section, anaesthetic complications and wound infections, and they are less likely to initiate or maintain breastfeeding. Babies of obese mothers are at increased risk of stillbirth, congenital anomalies, prematurity, macrosomia and neonatal death. Intrauterine exposure to obesity is also associated with an increased risk of developing obesity and metabolic disorders in childhood. This article reviews the prevalence of obesity in pregnancy and the associated maternal and fetal complications. Recommendations and suggestions for pre-conception, antenatal and postnatal care of women with obesity are presented, and current research in the UK and future research priorities are considered.

CONTEXT OF THIS REVIEW

Maternal obesity is now considered one of the most commonly occurring risk factors seen in obstetric practice, and obstetricians are increasingly faced with caring for women who are obese. Such patients pose particular management problems relating both to increased risks of specific complications, and to medical, surgical and technical challenges in providing safe maternity care. It is therefore not surprising that obesity is associated with increased rates of maternal and perinatal morbidity and mortality. Despite these problems, there remains a lack of awareness of both the range and severity of the problems associated with obesity in pregnancy.

Obesity is a condition in which excess body fat has accumulated to such an extent that health may be adversely affected. 1 The worldwide prevalence of obesity has increased markedly over the past few decades and the World Health Organization (WHO) has described this trend as a ‘global epidemic’ posing a serious threat to public health. 1 Obesity carries considerable human cost; it is associated both with an increased risk of mortality from all causes and with specific increased risks of coronary heart disease, stroke, type 2 diabetes, some types of cancer, respiratory problems and musculoskeletal disorders. 2

In 1993, the prevalence of obesity in the general population in England was 13% in men and 16% in women. 3 In 2006, 13 years later, this had increased to 24% in both men and women. 4 This reflects similar trends seen in other developed countries. The increased prevalence of obesity in women of child-bearing age is of particular concern as obesity in pregnancy carries additional risks for the mother and baby. 5

BODY MASS INDEX AS A MEASURE OF OBESITY

Body mass index (BMI) offers a useful measure of obesity and is a simple index of weight-for-height used to classify underweight, overweight and obese adults. BMI is calculated by dividing a person's weight in kilograms by the square of their height in metres (kg/m 2 ). Table  1 shows a widely accepted classification published by both the WHO 1 and the National Institute for Health and Clinical Excellence (NICE). 6 The classification has been based largely on the association between BMI and mortality, and it therefore allows the identification of individuals or groups at increased risk.

Table 1

Classification of weight status according to BMI 1 , 6

BMI = body mass index

The main advantage of BMI as a measure of obesity is that it can be calculated easily; however, it is important to recognize that it does have certain limitations. The distribution of adipose tissue in an individual, rather than the absolute amount, appears to affect the risk of adverse health outcomes. In particular, abdominal obesity, which is associated with increased insulin resistance, is more strongly associated with morbidity and mortality compared with the accumulation of fat around the hips and thighs, and BMI is not able to account for this. Waist circumference has therefore been used as a better measure of visceral adiposity and its associated risk. 7 BMI is also unable to distinguish between muscle and fat mass, and two individuals with the same BMI could have very different body compositions. Across different populations, a given BMI may not correspond to the same degree of ‘fatness’ and the BMI range considered to be healthy may vary between populations. Despite these significant limitations, BMI is still considered the most useful population-level measure of obesity.

PREVALENCE OF OBESITY IN PREGNANCY

Obesity in pregnancy is usually defined as a maternal BMI ≥30 at the antenatal booking visit. There are currently no national-level data in the UK on the prevalence of obesity in pregnancy. A few observational studies have reported the prevalence rates of obesity in local maternity populations and, at present, these are the best indicators of maternal obesity prevalence in the UK. In the North East of England, BMI recorded at the booking visit in 36,821 pregnancies showed a significant increase in the prevalence of obesity from 9.9% to 16% ( P < 0.01) between 1990 and 2004. 8 In Glasgow, a comparison of booking BMI between two randomly selected groups of women who booked for antenatal care in 1990 and in 2002–2004 also showed an increase in obesity prevalence from 9.4% to 18% ( P = 0.003). 9 Sebire et al. 10 retrospectively analysed data from 287,213 completed singleton pregnancies in the north-west Thames region between 1989 and 1997 and found the overall prevalence of women with a BMI ≥30 to be 10.9%. The change in prevalence over time was not reported in this study.

Demographic predictors of maternal obesity in early pregnancy have been described. After adjustment for potential confounders, the study of 36,821 pregnancies in the north-east of England found that women classed as obese at booking were significantly older, more parous and lived in more deprived areas than women whose weight was classed within the healthy BMI range. 8 The association between maternal obesity and levels of deprivation has also been reported by Kanagalingam et al. 9 This is considered to reflect, at least in part, a suboptimal diet.

PREGNANCY COMPLICATIONS ASSOCIATED WITH MATERNAL OBESITY

There are a number of studies that have investigated the association between BMI and pregnancy outcomes, and the study design and findings of some of these studies are shown in Table  2 . Many studies have used different BMI ranges or values to define obesity in pregnancy. Overall, however, it is clear that higher pre-pregnancy BMI is associated with an increased risk of a number of pregnancy complications and adverse pregnancy outcomes.

Table 2

Studies reporting specific risks associated with maternal obesity

OR = odds ratio; AOR = adjusted odds ratio; NS = non-significant; BMI = body mass index; CI = confidence interval; VTE = venous thromboembolism; GDM = gestational diabetes mellitus; CEMACH = Confidential Enquiry into Maternal and Child Health

Obstetric complications

Gestational diabetes.

A retrospective UK study of 287,213 pregnancies between 1989 and 1997 showed that after adjusting for ethnic group, parity, maternal age and history of hypertension, women with a BMI ≥30 were more likely to develop gestational diabetes than women with a BMI of 20.0–24.9 (odds ratio [OR] 3.6, 99% confidence interval [CI] 3.25–3.98). 10 These findings were similar to a later Australian study of 14,230 pregnancies, which showed that the odds (corrected for maternal age, parity, ethnicity, educational and smoking status) of developing gestational diabetes were 2.95 times higher (95% CI 2.05–4.25) in obese women (BMI 30.01–40.00) compared with normal-weight (BMI 20.01–25.00) women. 11

Gestational diabetes milletus (GDM) increases the long-term risk of developing type 2 diabetes. Data from an observational cohort study of 330 Danish women with diet-treated GDM showed that 41% of these women developed diabetes during a median of 10 years follow-up. 12 This reflected a doubling of the risk compared with an earlier cohort of 241 women with GDM, which was followed by the same research group 10 years previously. The authors attributed the increased incidence of diabetes to a substantial increase in BMI among women with GDM.

Preeclampsia

The majority of observational studies since 1996 have shown a direct correlation between maternal BMI and risk of preeclampsia. 13 A Swedish cohort study of 805,275 pregnancies to women delivering between 1992 and 2001 found that 2.8% of women with a BMI of 29.1–35.0 had preeclampsia compared to 1.4% of women with a BMI of 19.8–26.0 (adjusted OR 2.62, 95% CI 2.49–2.76). 14 This difference was more marked in the Australian study reported by Callaway et al. 11 , where the prevalence of pregnancy-induced hypertension/preeclampsia in normal-weight and obese women (see above) was 2.4% and 9.1%, respectively (adjusted OR 3.00, 95% CI 2.40–3.74). Duckitt and Harrington 15 reported a systematic review of risk factors for preeclampsia. A raised booking BMI, as defined for each included study, compared with a healthy BMI was associated with a 50% increase in the risk of preeclampsia, while a booking BMI >35 doubled the preeclampsia risk. One cohort study included in the review reported that a pre-pregnancy BMI >35 increased the risk of preeclampsia four-fold compared with women with a pre-pregnancy BMI of 19–27. The increased overall risk associated with raised prepregnancy BMI appeared to persist even after adjustment for confounding factors, such as maternal age and chronic hypertension.

Waist circumference is also associated with an increased risk of hypertensive complications. A non-pregnant waist circumference ≥80 cm has been associated with an OR for pregnancy-induced hypertension of 1.8 (95% CI 1.1–2.9) and for preeclampsia of 2.7 (95% CI 1.1–6.8) in a cohort of over 1000 unselected pregnancies. 7

Venous thromboembolism

There is a significant association between BMI and risk of venous thromboembolism (VTE). Perhaps most striking is the fact that 57% of women with a known BMI dying from VTE in pregnancy in the UK are obese. 16 A retrospective case-control study in Denmark of 129 women with deep vein thrombosis or pulmonary embolism during pregnancy or the puerperium and 258 controls (pregnant women with no VTE) showed a significant association between VTE and obesity defined as BMI ≥30 (adjusted OR 5.3, 95% CI 2.1–13.5). 17 The United Kingdom Obstetric Surveillance System (UKOSS), recently reported that a BMI ≥30 was associated with an adjusted OR of 2.65 (95% CI 1.09–6.45) for antenatal pulmonary thromboembolism (PTE). 18 This association is not surprising given the associated problems of reduced mobility, co-morbid conditions that predispose to thrombosis, such as preeclampsia, and an increased frequency of operative delivery, especially when superimposed upon the doubling of risk of VTE seen in non-pregnant women with a BMI ≥30, possibly related to higher levels of coagulation factors VIII and IX. 19 In non-pregnant women, the risk of VTE is exaggerated by concomitant use of oestrogen-containing hormonal contraception. Women with a BMI ≥25 using such contraception have been shown to have a 10-fold risk of thrombosis, 19 and similar interactions are likely to be present in pregnancy when oestrogen levels are known to be increased. The interaction of obesity with other risk factors is also highlighted by the large case-control study of Jacobsen et al. 20 which reported an adjusted OR of 1.8 (95% CI 1.3–2.4) for VTE in pregnant women with a BMI ≥25, increasing to an adjusted OR of 62.3 (95% CI 11.5–337.6) where BMI and immobility were combined.

Labour and delivery

Observational studies have shown that obesity is associated with a higher incidence of intrapartum complications. The pregnancy, delivery and nutrition study found that women with a BMI ≥30 were more likely than women with a BMI ≤26 to have their labour induced and to receive oxytocin. 21 Furthermore, after adjusting for a number of potential confounders including labour induction and oxytocin use, labour progression from four to 10 cm was slower in obese women compared with those with a BMI ≤26 (7.9 versus 6.2 median hours, P < 0.001). These data suggest that obesity is associated with inefficient uterine activity in labour. The authors also found that primary emergency caesarean section rates were higher for obese women compared with women with a healthy BMI (27% versus 19%, P < 0.04), with the majority of the deliveries occurring during the first stage of labour for failure to progress in labour and fetal distress.

Many studies have reported a positive association between maternal BMI or weight and caesarean section. Recently, a meta-analysis of 33 cohort studies calculated the risk of a caesarean delivery for women identified by the authors as normal, overweight and obese. 22 Although there were small variations between studies in the BMI ranges used to define normal and overweight, all but one of the studies defined obesity as a maternal BMI ≥30. The OR of a caesarean section was 1.46 (95% CI 1.34–1.60) and 2.05 (95% CI 1.86–2.27), respectively, among overweight and obese women compared with women with a normal weight. Chu et al. 22 also performed a separate meta-analysis of 12 studies, which included only women without co-morbidities. The odds of a caesarean section remained higher in overweight (OR 1.41, 95% CI 1.17–1.69) and obese women (OR 1.75, 95% CI 1.41–2.23) without complications, compared with women with a healthy BMI.

Anaesthesia

Obese pregnant women have an increased risk of dysfunctional labour and caesarean section delivery as discussed above, which are associated with increased requirements for anaesthesia. However, they are also at higher risk of anaesthesia-related morbidity. Obese women have a higher epidural failure rate in the intrapartum period than women with a BMI <25. 23 There is an increased risk of aspiration under general anaesthesia due to increased gastric volume; difficult endotracheal intubation due to suboptimal laryngoscopic views; difficulty in achieving regional analgesia/anaesthesia due to impalpable bony landmarks; and postoperative hypoxaemia and atelectasis. 24 Obese women are more likely to have co-morbidites such as hypertension, ischaemic heart disease and heart failure, adding to the risks associated with anaesthesia.

Maternal death

There is evidence that obesity is associated with a higher risk of maternal death. In the triennium 2003–2005, 28% of all women who died in the UK were classified as obese. 25 These deaths in obese women are associated with many causes of direct and indirect death, including preeclampsia and pulmonary embolism.

Fetal and neonatal complications

Fertility and miscarriage.

A Danish case-control study of 1644 obese women (BMI ≥30) and 3288 age-matched controls (BMI 19.0–24.9) showed that obese women had a higher incidence of first trimester miscarriage (OR 1.2, 95% CI 1.01–1.46) and recurrent first trimester miscarriage (OR 3.5, 95% CI 1.03–12.01). 26 Compared with women with a healthy BMI, women with obesity also have more fertility problems, largely associated with ovulation disturbance and polycystic ovarian syndrome, and often require assisted reproductive techniques to achieve pregnancy. A systematic review and meta-analysis of 13 studies, examining the predictors of ovulation induction outcome in women with normo-gonadotrophic anovulatory infertility, reported that the most clinically useful predictors of poor treatment outcome were obesity and insulin resistance, with a pooled OR for spontaneous miscarriage of 3.05 (95% CI 1.45–6.44) in obese versus non-obese women. 27

A recent meta-analysis of six cohort studies and three case-control studies found a doubling in the risk of stillbirth among obese women (unadjusted OR 2.07, 95% CI 1.59–2.74) compared with women with a healthy BMI. 28 There was one retrospective UK-based cohort study included in this meta-analysis, which analysed 287,213 pregnancies from 1989 to 1997. 10 Women with a BMI ≥30 had a stillbirth rate of 6.9/1000 total births compared with 4/1000 total births in women with a BMI of 20–25 (adjusted OR 1.40, 99% CI 1.14–1.71, OR adjusted for ethnicity, parity, maternal age, history of hypertension, gestational diabetes, preeclampsia, emergency caesarean section and smoking).

Congenital anomalies

Women who are obese are at increased risk of fetal anomaly (Table  2 ). Several large case-control studies have shown up to a three-fold risk of spina bifida, omphalocele and heart defects in babies of obese mothers. 29 , 30 Prepregnancy and early pregnancy folic acid supplementation is clearly a logical intervention but the increased incidence of neural tube defects in obese women has persisted in populations where flour has been fortified with folic acid. The biological basis for these abnormalities is not clear but may be linked to insulin resistance, diabetes or specific nutritional deficits. Interestingly, a recent large population-based case-control study reported that mothers of babies with gastroschisis were less likely to be obese than those with healthy babies. 31 The same study confirmed an association between maternal obesity and spina bifida, heart defects, anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia and omphalocele.

Maternal obesity is associated with an increased risk of fetal macrosomia. Data from a study of 350,311 pregnancies showed that nearly a fifth of women with a BMI ≥30 had fetal macrosomia defined as birthweight ≥4 kg (OR 1.97, 95% CI 1.88–2.06), or defined as birthweight ≥90th centile for gestational age (OR 2.08, 95% CI 1.97–2.17). 32 The increased incidence of macrosomia was independent of whether the mother also had pre-existing or gestational diabetes. In turn, macrosomia is a risk factor for operative delivery, a low Apgar score at one minute and a low umbilical arterial pH level, as well as shoulder dystocia and significant injuries to the baby, including fractures and nerve palsies. It should be noted that maternal obesity is not an independent risk factor for shoulder dystocia. 33 Thus, it is macrosomia rather than maternal obesity that is the main risk factor for shoulder dystocia. The overall morbidity for macrosomic babies is increased to around 8%. 34

Postpartum complications

Following delivery, obese women have an increased risk of postpartum haemorrhage. Several studies have also shown an increased incidence of genital tract infection, urinary tract infection and wound infection (Table  2 ). 10 , 35 Interestingly, Jacobsen et al. 20 reported that postpartum infection substantially increased the risk of VTE both after caesarean and vaginal delivery. Thus, obese women with postpartum infection may be particularly predisposed to VTE.

Maternal obesity is linked to reduced breastfeeding rates, both in terms of breastfeeding initiation and duration. 36 Possible reasons include physical issues such as difficulty with correct positioning of the baby, psychosocial issues, or endocrine issues such as a lower prolactin response to suckling. 37 Women with obesity may therefore benefit from extra support for breastfeeding. This support should be provided in the antenatal period, the immediate puerperium and after discharge from hospital.

Associated childhood morbidity

Children of obese mothers are at increased risk of longer-term morbidity. Boney et al. 38 followed a cohort of 84 large-for-gestational-age (LGA) and 95 appropriate-for-gestational-age (AGA) babies from birth to ages six, seven, nine and 11 years to examine the development of the metabolic syndrome, defined as two or more of the following four components: obesity, hypertension, glucose intolerance and dyslipidaemia. The prevalence of the metabolic syndrome at any time up to 11 years was 50% for LGA offspring of mothers with gestational diabetes, 29% for LGA offspring of non-diabetic mothers, 21% for AGA offspring of GDM mothers and 18% for AGA offspring of women without GDM. Interestingly, babies of any birth weight with intrauterine exposure to maternal obesity had a similar risk of developing the metabolic syndrome in later life as LGA babies (hazard ratio: 1.8 [95% CI 1.0–3.2] and 2.2 [95% CI 1.3–3.8], respectively).

MANAGEMENT OF WOMEN WITH OBESITY IN PREGNANCY

Current guidelines.

There is currently no specific national evidence-based guideline for the clinical management of obesity in pregnancy, although the American College of Obstetricians and Gynaecologists (ACOG) has published a Committee Opinion paper on Obesity in Pregnancy, which includes suggested interventions. 44 There are a number of existing guidelines on other aspects of maternity care, which include information relevant to obese pregnant women. 45 – 53 The published literature includes suggested management strategies for pregnant obese women and some of these are summarized in Table  3 .

Table 3

Suggested recommendations for the clinical care of obese women before, during and after pregnancy (modified from Yu et al. 59 and Ramsay et al. 34 )

BMI = body mass index; GDM = gestational diabetes milletus

Specific recommendations

Folate supplementation.

During pregnancy, fetal growth is linked to an increase in the total number of rapidly dividing cells, which leads to increased requirements for folate. Maternal folate deficiency in pregnancy is associated with fetal congenital malformations, 54 and supplementing the diet with folic acid 400 µg daily if there is doubt about adequate dietary intake has been recommended for many years. 45 Studies have linked maternal obesity with an increased risk of neural tube defects; although the mechanism for this association remains unknown, obese women have been found to have lower levels of serum folate than non-obese women of child-bearing age. 55 Data from the National Health and Nutrition Examination Survey (NHANES) in the USA showed that women with a BMI ≥27 were less likely to use nutritional supplements and were less likely to receive folate through diet than women with a BMI <27. Interestingly, the inverse association between BMI and serum folate level persisted after controlling for folic acid intake. 55 A large case-control study found that a daily intake of at least 400 µg of folic acid reduced the risk of neural tube defect-affected pregnancy by 40% in women weighing <70 kg, with no risk reduction observed in women weighing ≥70 kg. 56 These findings indicate that higher daily doses of folate in obese women may be required to reduce the risk of neural tube defects.

Weight loss before conception through dietary modification

A weight loss of 4.5 kg between two pregnancies has been shown to reduce the risk of developing gestational diabetes by up to 40%. 57 A 10% weight loss over six months is suggested to be an ideal amount, which is safe and possible to sustain in the long term. Although weight loss regimens in the first trimester of pregnancy may increase the risk of fetal neural tube defects, weight loss prior to pregnancy does not appear to carry this risk. 58

Care following bariatric surgery

Bariatric surgery includes purely restrictive procedures (adjustable gastric banding) and malabsorptive procedures that may also restrict the stomach volume (Roux-en-Y bypass and biliopancreatic diversion). The number of women undergoing bariatric surgery for the treatment of morbid obesity has increased over recent years. Although there were early concerns that pregnancies following bariatric surgery may be associated with increased risk of poor perinatal outcomes and late surgical complications, data from recent studies do not support these concerns.

A recent systematic review of 75 studies, comprising 28 case reports, 26 case series, 18 cohort studies and three matched cohort studies, aimed to assess associations between different types of bariatric surgery and pregnancy outcomes. 60 The reviewed evidence indicated that risks for maternal complications, such as gestational diabetes, preeclampsia and pregnancy-induced hypertension, appeared generally to be lower in women who had undergone bariatric surgery compared with obese women who had not had surgery. Similar findings were reported for all types of bariatric surgery with regard to neonatal complications including premature delivery, low birthweight and macrosomia. Nutritional deficiencies during pregnancy following laparoscopic adjustable gastric banding or gastric bypass procedures appear uncommon when adequate supplementation is maintained. 60 , 61 Severe nutritional deficiencies requiring parenteral nutrition have been reported in approximately 20% of pregnancies following biliopancreatic diversion. 60 Although most studies have attributed deficiencies to non-adherence with supplementation, parenteral nutrition has also been reported for women taking supplements and for those in whom adherence was unclear. 62 – 64 These findings emphasize the importance of careful nutritional monitoring during pregnancy.

To minimize potential risks, the ACOG has recommended that women who have had bariatric surgery should delay conception for 18 months after surgery to avoid conceiving during the period of rapid weight loss, be monitored by their surgeon during pregnancy as adjustment of gastric bands may be necessary and receive nutritional supplementation as necessary to avoid deficiencies of iron, folate, calcium and vitamin B 12 . 44

It is also recognized that women who have undergone bariatric surgery may be prone to dumping syndrome following an oral glucose tolerance test. Dumping syndrome is thought to arise due to malabsorption, osmotic fluid shifts and postprandial hyperinsulinaemic hypoglycaemia, and may result in a number of symptoms, including flushing, palpitations, syncope, abdominal bloating, diarrhoea and sometimes even altered consciousness. 65 To avoid these symptoms, an oral glucose tolerance test is not recommended for women who have had bariatric surgery. Instead, home blood glucose monitoring for a period of at least one week has been suggested for the purpose of screening for gestational diabetes in these women. 66 , 67

Regular moderate-intensity physical activity

Exercise has been found to be helpful in improving glycaemic control in women with GDM and may play a role in its prevention. 68 In 2006, the Royal College of Obstetricians and Gynaecologists (RCOG) produced a statement on exercise in pregnancy which stated that, in most cases, aerobic exercise is safe for both mother and fetus during pregnancy, and women should therefore be encouraged to initiate or continue exercise to derive the health benefits associated with such activities. 49 Recently, a Cochrane Review assessed aerobic exercise during pregnancy. 69 Regular aerobic exercise during pregnancy appeared to improve maternal fitness. There were some data to suggest beneficial effects on fetal growth and the need for more high-quality trials in this area was highlighted.

Measurement of weight and height at first antenatal appointment and during pregnancy

The NICE Antenatal Care guideline published in 2008 recommends that maternal height and weight should be recorded for all women at the initial booking visit to allow the calculation of BMI. 53 Semi-structured interviews of health professionals in the North East Government Office Region of England suggested that self-reported rather than measured height and weight may be used at some community booking visits due to lack of availability of appropriate equipment. 70 However, self-reported height is often overestimated and self-reported weight underestimated, particularly in obese women, 71 which may lead to inaccurate risk assessment during pregnancy. A USA study of 97 overweight and obese (BMI >27.3) non-pregnant women found that the mean weight discrepancy between measured and self-reported weight of those in Obesity Class I (BMI 30–35), Class II (BMI 35–40) and Class III (BMI >40) was −1.56 ± 5.77, −6.52 ± 10.23 and −5.15 ± 9.86 kg, respectively. 72 The extent of inaccurate reporting of weight in obese women highlights the importance of obtaining and documenting measured weight and height in pregnancy.

The NICE Antenatal Care Guideline recommends that repeated weight measurements during pregnancy should occur only in circumstances where clinical management is likely to be influenced. 53 Maternal obesity is an example of one such circumstance as maternal weight throughout pregnancy determines the need for specific additional interventions and specialist equipment. There are also a number of studies that have shown an association between pregnancy weight gain and specific outcomes.

Weight gain during pregnancy

The most widely adopted recommendations relating to pregnancy weight gain are those published by the Institute of Medicine (IOM) in 1990. 45 These recommendations advise a gain of 12.5–18 kg for underweight women (BMI <19.8), 11.5–16 kg for women with a healthy BMI (19.8–26.0), 7–11 kg for overweight women (BMI 26.0–29.0) and at least 7 kg for obese women (BMI ≥29.0), although it has been recognized in the guideline that many obese women with good pregnancy outcomes gain less weight than this recommended minimum. 45 Since the publication of the guidelines, several studies have examined the association between early pregnancy BMI, gestational weight gain and outcomes.

A prospective population-based cohort study of 245,526 singleton term pregnancies examined the effects of pregnancy weight gain within different BMI categories on obstetric and fetal outcomes. 73 Women were grouped into three weight gain categories: <8 kg (low weight gain), 8–16 kg and ≥16 kg (high weight gain). Obese women with low pregnancy weight gain had a decreased risk of preeclampsia (adjusted OR 0.52, 95% CI 0.42–0.62), caesarean section (adjusted OR 0.81, 95% CI 0.73–0.90), instrumental delivery (adjusted OR 0.75, 95% CI 0.63–0.88) and LGA babies (adjusted OR 0.66, 95% CI 0.59–0.75). High pregnancy weight gain was strongly associated with the birth of an LGA infant, with this being more pronounced in the lower BMI categories. However, it is important to note that the risk of SGA infants was increased among women with low gestational weight gain in all BMI categories, although the odds decreased with increasing BMI.

A follow-on publication by the same author suggested optimal gestational weight gain for each maternal BMI category. 74 The optimal gain for underweight, normal weight, overweight and obese women was suggested to be 4–10 kg, 2–10 kg, <9 kg and <6 kg, respectively. These weight gain ranges were associated with the lowest risk of overall adverse maternal and perinatal outcome, and are lower than the IOM recommendations.

In a population-based cohort study of 120,251 pregnant obese women delivering full-term, live singleton infants, Kiel et al. 75 examined the risk of four pregnancy outcomes (preeclampsia, caesarean section, LGA and SGA) by obesity class and total gestational weight gain. The risk of the first three outcomes decreased with decreasing weight gain, although there was an increased risk of SGA babies across all BMI categories. The authors suggested that the overall minimal risk for mother and baby should be taken as the point where there was an equal risk of LGA and SGA babies, which corresponded with a weight gain of 10–25 lb (4.5–9 kg) for Class I obese (BMI 30–34.9) women, and a weight gain of 0–9 lb (0–4 kg) for Class II obese (BMI 35–39.9) and Class III obese (BMI ≥40) women.

It is clear that careful weight management during pregnancy can help minimize the risks of adverse outcomes associated with maternal obesity, although it is important to be aware of the potential risk of increasing the incidence of SGA babies. Achieving appropriate weight management can be challenging for both the woman and the health professional. Several intervention studies have attempted to prevent excessive gestational weight gain using behavioural programmes. 76 – 80 Inconsistent results have been reported, with some studies showing no effect in obese women compared to significantly lower weight gain in normal-weight women. 77 , 79

CURRENT UK RESEARCH

In 2006, the North East Maternal Obesity Research Group completed a scoping study of routine data collection practice in all maternity units in north-east England. 81 More recently, this group carried out a qualitative study of the impact of maternal obesity on National Health Service (NHS) maternity services. 70 Maternity health professionals from different disciplines discussed issues relating to health service provision for obese pregnant women, additional care and cost implications to service providers, policies and guidelines, difficulties encountered in day-to-day care, available multidisciplinary services, and provision of patient information and advice. This group has now completed a survey of all maternity units in England to establish current data collection practice with regard to maternal obesity. Other projects include a retrospective observational study investigating the prevalence of maternal obesity and associated demographic factors in a sample of NHS Trusts in England, 8 and a cost analysis of the additional care and complications associated with obesity in pregnancy.

Evidence for the association of increased maternal BMI with adverse pregnancy outcome has been derived mainly from populations with moderate obesity (BMI 30–40). The risk of pregnancy complications in women with an even higher BMI is likely to be even greater, but to date there have been few published data on women with extreme obesity. UKOSS was established in 2005 to describe the epidemiology of a variety of uncommon disorders in pregnancy. In 2007, UKOSS commenced a surveillance programme to investigate: (1) the prevalence of extreme obesity in pregnancy in the UK; (2) the risk of adverse outcomes attributable to this degree of obesity; and (3) any adverse outcomes relating to inadequate weight capacity equipment. Until November 2008, maternity units in the UK notified UKOSS of all women with a BMI >50 or a weight >140 kg at any point during pregnancy. Preliminary analysis of the data suggests that the prevalence of extreme obesity (BMI >50) is approaching one in every thousand women giving birth. 82 The results from this study are anticipated to provide valuable information about the risks associated with a maternal BMI >50 and will support maternity services to structure more effectively the care they provide for women with extreme obesity.

The Confidential Enquiry into Maternal and Child Health (CEMACH) commenced a national Obesity in Pregnancy project in 2008 that will run until 2010. This project was initiated in response to a number of factors, including: (1) growing evidence that obesity is clearly associated with increased morbidity and mortality for both mother and baby; (2) national and regional prevalence rates are currently unknown; and (3) there is no national clinical guideline available in the UK with regard to clinical care and provision of services for women with obesity in pregnancy. The project comprises three phases, as shown in Box  1 .

Phases of the CEMACH Obesity in Pregnancy Project

Phase 1 – A national survey investigating how well maternity units are equipped to care for women with obesity

Phase 2 – The development of national standards of care based on evidence and consensus expert opinion

Phase 3 – A national audit of care provided women with a BMI ≥35

The CEMACH project will assess current service provision for women with obesity in pregnancy, provide national and regional prevalence rates of severe obesity (BMI ≥35) in pregnancy in the UK, and identify any gaps that may exist in the provision of care for these women. Recommendations based on the project's findings will be made available to health-care providers, commissioners and policy makers, with the aim of improving care and service provision for women with obesity in pregnancy.

Further research on the risks associated with maternal obesity is planned at the Tommy's Centre for Maternal and Fetal Health Research in Edinburgh, which is currently being established. 83 An antenatal clinic has been set up to provide a research base for mothers with obesity. The clinic aims to improve the pregnancy outcomes of these women using an approach of clinical assessment, communication and consultation with other specialists involved in their care throughout pregnancy and prior to delivery.

AREAS FOR FUTURE RESEARCH

The current available evidence supports the development of specific management strategies to decrease maternal and fetal risks in pregnancies complicated by maternal obesity. However, ongoing research in specific areas is required. The RCOG 53rd Study Group on Obesity and Reproductive Health reported that while there is a good body of observational evidence showing a positive association between maternal BMI and risk of pregnancy-related complications, there is now a clear need for prospective randomized studies in obese pregnant women to assess the effects of diet, physical activity and lifestyle changes on maternal, fetal and neonatal outcomes. 84 The group also highlighted a need for further clarification on optimal weight gain in pregnancy for different subsets of the population, with the recognition that weight gain is partly dependent upon maternal BMI at the start of pregnancy. Other potential areas identified for future research included: optimal methods of assessing body fat in women; determination of the optimal gestation of screening obese women for gestational diabetes and whether early detection and management improves outcomes; and investigation of the clinical benefit of low-dose aspirin during pregnancy for women with severe obesity.

CONCLUSIONS

Obesity is a major risk factor for pregnancy complications and carries with it huge social and financial costs. There is a clear need to establish national and regional prevalence rates of maternal obesity so that maternity services can be appropriately organized to ensure suitable care is provided for ‘at-risk’ women. National Clinical Care Guidelines for health professionals are needed to minimize and manage the risks associated with obesity in pregnancy. Although further research is required, there now appears to be sufficient evidence for maternity services to implement strategies to reduce the risks related to pregnancies in women with obesity. National consensus standards of care are now being developed and will soon be available to guide clinical management.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTORSHIP

All authors contributed to the conception and design of this paper, the acquisition and interpretation of the data presented and drafting and revising it critically for important intellectual content and for final approval.

Care of Women with Obesity in Pregnancy (Green-top Guideline No. 72)

Published: 22 November 2018

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Obesity is becoming increasingly prevalent in the UK population and has become one of the most commonly occurring risk factors in obstetric practice with 21.3% of the antenatal population being obese and fewer than one-half of pregnant women (47.3%) having a body mass index (BMI) within the normal range. Pregnant women who are obese are at greater risk of a variety of pregnancy-related complications compared with women of normal BMI, including pre-eclampsia and gestational diabetes. Pregnant women who are obese are also at increased risk of caesarean birth. Maternal size can make the assessment of fetal size, presentation and external monitoring of fetal heart tracing more challenging during pregnancy. Initiation and maintenance of breastfeeding are also more difficult in the women with obesity.

While the majority of the recommendations within this guideline pertain to women with a BMI 30 kg/m 2  or greater, some recommendations are specific to women in the higher classes of obesity only. Obese women with a BMI below a specified threshold may also benefit from recommendations in a higher BMI group, depending on individual circumstances. However, the chosen BMI cut-offs reflect careful consideration given to the balance of medical intervention versus risk, differences in local prevalence of maternal obesity and resource implications for local healthcare organisations.

The recommendations cover interventions prior to conception, and during and after pregnancy.

COVID disclaimer

This guideline developed as part of the regular programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers , and prior to the emergence of COVID-19.

Version history

This is the first edition of this guideline; the second edition is currently in development.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests

Professor FC Denison:  Professor Denison has several grant applications pending and has design protection rights for a device. Professor Denison is also Vice Chair of NICE MTAC Board and a Member of Grant Awarding Bodies (Tenovus, CSO).

Dr NR Aedla:  None declared.

Dr O Keag:  None declared.

Dr K Hor:  None declared.

Professor RM Reynolds:  None declared.

Dr A Milne:  Dr Milne had received an Edinburgh and Lothian’s Health Foundation £33,458 grant for project entitled, ‘Integrated ultrasound needle to facilitate placement of regional anaesthesia in obese pregnant women.”

Mrs A Diamond:  Mrs Diamond has received honoraria for diet input to SPCDs study day. Mrs Diamond has also received payment for diet/lifestyle lecture on diabetes course (Oct 2016).

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obesity and pregnancy associated morbidities

Obesity AND Pregnancy: associated morbidities

Mar 16, 2019

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By Michael Cochran-Boucher University of New Hampshire Manchester 2010 Spring, Undergraduate Research Symposium. Obesity AND Pregnancy: associated morbidities. Source: Fall 2009, Independent Study, Case Study: BMI and Pregnancy. Research Question:

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By Michael Cochran-Boucher University of New Hampshire Manchester 2010 Spring, Undergraduate Research Symposium Obesity AND Pregnancy: associated morbidities Source: Fall 2009, Independent Study, Case Study: BMI and Pregnancy

Research Question: • Why should we as a society be concerned about Obesity? • Introduction: • The pandemic of obesity effects people from every walk of life, young and old, rich and poor (Linne 2008). • The World Health Organization to designate obesity as one of the current most important global health threats facing civilization (Guelinckx 2008). • Unhealthy lifestyle marked by the consumption of a high-energy, high-fat foods mixed with physical inactivity (Guelinckx 2008). Obesity AND Pregnancy: associated morbidities Source: Fall 2009, Independent Study, Case Study: BMI and Pregnancy

Outline: • BMI methods and problems with collection. • BMI data for the United States since 1985. • Gestational diabetes, PCOS, metabolic imprinting as an infant are only a few related complications. • Overall figures derived from the case study research. • Finally, some difficulties in the health care billing and collection of data. Obesity AND Pregnancy: associated morbidities Source: Fall 2009, Independent Study, Case Study: BMI and Pregnancy

Self reporting of height and weight Body Mass Index (BMI): a measure of weight in relation to height = weight (kg) / height (m) Sq. X 703 Classification: Underweight: BMI < 18.5 Overweight: BMI 25.0-29.9 Obese: BMI > 30.0 How is obesity measured in adults? Morbidly Obese: BMI> 39.9 Source: www.Mass.gov

Obesity Trends* Among U.S. AdultsBRFSS, 1985 10%–14% No Data <10% *BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person. Source: U.S. Center for Disease Control (CDC)

Obesity Trends: Among U.S. AdultsBRFSS, 1986 10%–14% No Data <10%

Obesity Trends: Among U.S. AdultsBRFSS, 1987 10%–14% No Data <10%

Obesity Trends: Among U.S. AdultsBRFSS, 1988 10%–14% No Data <10%

Obesity Trends: Among U.S. AdultsBRFSS, 1989 10%–14% No Data <10%

Obesity Trends: Among U.S. Adults BRFSS, 1990 10%–14% No Data <10%

Obesity Trends: Among U.S. AdultsBRFSS, 1991 No Data <10% 10%–14% 15%–19%

Obesity Trends: Among U.S. AdultsBRFSS, 1992 No Data <10% 10%–14% 15%–19%

Obesity Trends: Among U.S. AdultsBRFSS, 1993 No Data <10% 10%–14% 15%–19%

Obesity Trends: Among U.S. AdultsBRFSS, 1994 No Data <10% 10%–14% 15%–19%

Obesity Trends: Among U.S. AdultsBRFSS, 1995 No Data <10% 10%–14% 15%–19%

Obesity Trends: Among U.S. AdultsBRFSS, 1996 No Data <10% 10%–14% 15%–19%

Obesity Trends: Among U.S. AdultsBRFSS, 1997 No Data <10% 10–14% 15–19% ≥20%

Obesity Trends: Among U.S. AdultsBRFSS, 1998 No Data <10% 10–14% 15–19% ≥20%

Obesity Trends: Among U.S. AdultsBRFSS, 1999 No Data <10% 10–14% 15–19% ≥20%

Obesity Trends: Among U.S. AdultsBRFSS, 2000 No Data <10% 10–14% 15–19% ≥20%

Obesity Trends: Among U.S. AdultsBRFSS, 2001 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. AdultsBRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. AdultsBRFSS, 2003 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. AdultsBRFSS, 2004 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. Adults BRFSS, 2005 ≥30% No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. AdultsBRFSS, 2006 ≥30% No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. AdultsBRFSS, 2007 ≥30% No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. AdultsBRFSS, 2008 ≥30% No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends: Among U.S. Adults1990, 1999, 2008 1999 1990 2008 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% ≥30%

BRFSS, Behavioral Risk Factor Surveillance System http: //www.cdc.gov/brfss/ • Mokdad AH, et al. The spread of the obesity epidemic in the United States, 1991—1998 JAMA 1999; 282:16:1519–22. • Mokdad AH, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001; 286:10:1519–22. • Mokdad AH, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003: 289:1: 76–9 • CDC. State-Specific Prevalence of Obesity Among Adults — United States, 2007; MMWR 2008; 57(36);765-8 Citations

Definitions: • Obesity: Body Mass Index (BMI) of 30 or higher. • Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters. Obesity Trends Among U.S. Adults between 1985 and 2008

Source of the data: • The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of telephone interviews with U.S. adults. • Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used. Obesity Trends Among U.S. Adults between 1985 and 2008

In 1990, among states participating in the Behavioral Risk Factor Surveillance System, ten states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%. • By 1999, no state had prevalence less than 10%, eighteen states had a prevalence of obesity between 20-24%, and no state had prevalence equal to or greater than 25%. • In 2008, only one state (Colorado) had a prevalence of obesity less than 20%. Thirty-two states had a prevalence equal to or greater than 25%; six of these states (Alabama, Mississippi, Oklahoma, South Carolina, Tennessee, and West Virginia ) had a prevalence of obesity equal to or greater than 30%.

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50 to 100% increase in premature deaths from all causes. pathophysiology of obesity ... 18% of obstetric causes of maternal death are associated with obesity ... – powerpoint ppt presentation.

  • November 8, 2007
  • General issues of obesity
  • Prevalence of obesity in pregnant women
  • Effect of obesity on maternal outcome
  • Effect of obesity on neonatal outcome
  • Anesthesia considerations
  • Issues of clinical care
  • Normal 18.5 24.9
  • Overweight 25-29.9
  • Class I 30 - 34.9
  • Class II 35 - 39.9
  • Class III 40
  • Prevalence of obesity
  • stable 1960 - 1980
  • steadily increasing
  • NHANES surveys
  • National Health and Nutrition Examination Survey
  • Most recent was 2003-4
  • Being overweight is now more common than normal BMI
  • Healthy People 2010 goal 15 obesity
  • Adults 20-74 years
  • 32.9 obesity
  • Obesity rates in reproductive age women
  • Nonhispanic black 50
  • Hispanic 38
  • Nonhispanic white 31
  • The rise in obesity rates could be explained by as little as an average net increase of 50100 calories per day, which is less than half the calories in a 16-ounce carbonated beverage.
  • Complicated
  • Cheap food, high density calorie
  • Work and lifestyle
  • Restaurants
  • Racial, socioeconomic effects
  • Impact on social mobility
  • The problem is intake more than energy expense
  • ? 10 calorie intake 1985-2000
  • Mostly carbohydrates
  • Mostly beverages 50 increase in fruit juice and soft drinks
  • More snacking
  • Larger portions
  • More US citizens are overweight or obese than are daily smokers, problem drinkers, and living below the federal poverty line combined
  • 117 billion dollars per year in 2000
  • 10 of health care cost attributed to obesity
  • 6-14 of health care costs attributed to smoking
  • Medicare Medicaid
  • disproportionate enrollment
  • 50 of obese patients
  • Stronger association with the occurrence of chronic medical conditions, reduced physical health-related quality of life, and increased health care and medication expenditures than smoking or problem drinking
  • Hypertension
  • Dyslipidemia (for example, high total cholesterol or high levels of triglycerides)
  • Type 2 diabetes
  • Coronary heart disease
  • Gallbladder disease
  • Osteoarthritis
  • Sleep apnea and respiratory problems
  • Some cancers (endometrial, breast, and colon)
  • Nonalcoholic steatohepatitis
  • 50 to 100 increase in premature deaths from all causes
  • Cardiac effects
  • Increased oxygen demand, blood volume, cardiac output, hypertension
  • Longstanding obesity decreased diastolic interval and time for myocardial perfusion, diastolic dysfunction
  • Insulin resistance
  • Sleep apnea
  • Endometrial and breast CA
  • ? 20 - 25 total mortality
  • ? 30 - 40 diabetes deaths
  • ? 40 - 50 cancer deaths
  • ? knee osteoarthitis
  • 5-10 weight loss raise HDL
  • For every two pounds lost, LDL levels are reduced by one percent
  • gestational diabetes
  • preeclampsia/hypertension
  • urinary tract infection
  • thromboembolism
  • perinatal death
  • wound infection
  • cesarean section
  • postdates pregnancy
  • induction of labor
  • postpartum hemorrhage
  • macrosomia and childhood obesity
  • fetal neural tube defects
  • Everything except
  • placenta previa (so far)
  • fetal growth restriction
  • 18 of obstetric causes of maternal death are associated with obesity
  • 80 of anesthesia deaths are associated with obesity
  • UK Maternal mortality 2000-2002
  • 35 or maternal deaths had obesity compared with 23 of general population
  • Different designs
  • Different definitions
  • Widespread agreement that there is increased maternal and fetal morbidity
  • Wide variation on range of RR
  • Very difficult to compare between studies
  • Higher fasting and post absorptive plasma insulin
  • Most women achieve euglycemia
  • Overweight status RR of GDM 1.8 to 6.5
  • Obese RR GDM 1.4 to 20
  • Need early diagnosis of diabetes
  • Higher BP hemoconcentration, altered cardiac function
  • Even moderate obesity increases risk of HTN/PIH
  • RR HTN 2.2 to 21.4
  • RR Preeclampsia 1.22 to 9.7
  • Risk of pre-eclampsia doubles with each 5 to 7 kg/m2 increase in pre-pregnancy BMI
  • Sebine (n 287,213)
  • Normal weight 0.04
  • Overweight 0.07
  • ? induction of labor
  • ? effect on duration of labor
  • ? effect on operative vaginal deliveries
  • ? primary cesarean birth
  • ? OR time, EBL, infectious morbidity
  • Bergholt, et al
  • 2007 Observational cohort
  • 4341 consecutive term, singeton nulliparas
  • OR 3.8 for BMI gt35 compared with BMI lt25 after adjustment for variables
  • No single explanation
  • Increased number of large-for-gestational-age infants
  • Suboptimal uterine contractions
  • Increased fat disposition in the soft tissues of the pelvis
  • Weiss 2004 (compare normal, obese and morbidly obese)
  • Induction of labor OR 1.6
  • Failed induction
  • 7.9, 10.3, 14.6
  • Primary cesarean delivery
  • 20.7, 33.8, 47.4
  • Shoulder dystocia
  • 1, 1.8, 1.9
  • Increased operative vaginal delivery
  • Increased emergency cesarean delivery
  • Durnwald, 2004 n 510
  • 66 success overall
  • 84.7 underweight
  • 65.5 overweight
  • Chauhan, 2001 n69
  • 13 success rate
  • indications labor arrestgt fetal distressgt failed induction
  • ? endometritis, wound breakdown, infectious morbidity
  • Lower success if interpregnancy weight gain but weight loss does not improve outcome
  • Edwards, 2003
  • Historic cohort n120
  • 36 weeks, single prior CS, BMI gt40
  • VBAC success gt 45 in all subgroups
  • 3X increased infection rate (with VBAC attempt no cost saving
  • Hibbard et al, 2006 (SMFMU)
  • 14,142 TOL 14,304 ERCS
  • 4 BMI categories (morbid obesity gt40 BMI)
  • No data about counseling, indication for prior delivery, intrapartum care. Inadequate data to assess death or neurologic damage
  • Success of VBAC
  • Normal weight 85
  • Morbid obesity 60
  • Rupture/dehiscence
  • Normal weight 0.9
  • Morbid obesity 2.1
  • Hibbard, 2006
  • Compare TOL vs ERCS in morbidly obese
  • Compare successful and failed VBAC
  • Risks increase with
  • Subcutaneous thickness
  • Rupture of membranes
  • Multiple vaginal exams
  • Chorioamnionitis
  • Vermillion, 2000
  • SC thickness the only significant variable
  • ? Urinary stress and urge incontinence
  • Weight gains correlate with weight retention and worsening obesity
  • In 15 year follow up after GDM
  • 70 of obese women have type 2 DM
  • 30 of lean women have type 2 DM
  • ? Low Apgar scores
  • LGA RR 1.4 - 18
  • attendant risks of birth trauma, etc
  • Structural abnormalities
  • Perinatal mortality
  • Childhood obesity
  • High prevalence of PCOS
  • Negative impact on infertility treatment
  • Miscarriage after infertility Rx
  • OI with gonadotropins OR 3
  • Egg donor cycle OR 4
  • Miscarriage
  • Recurrent SAb 3.5
  • Watkins et al. 2003 state population-based case-control study
  • RR 3 neural tube defect
  • RR 2 cardiac defects
  • RR 3 omphalocele
  • Multiple abnormalities also increased
  • Challenges of diagnosis
  • Poor sensitivity of ultrasound
  • Heart and spine views
  • MSAFP greater false negatives without weight correction
  • True for other analytes
  • Nuchal translucency more likely be obtained transvaginally
  • Needs to be done later - 13 weeks
  • Possible etiology
  • Undiagnosed diabetes
  • Altered metabolism (increased insulin, triglycerides, uric acid, estrogen)
  • Increased insulin resistance
  • fuel mediated teratogenesis
  • Low folate levels
  • Supplementation not found to decrease risk
  • Weiss, et al.
  • gt4000 grams
  • 8.3 normal weight
  • 14.6 morbidly obese
  • Correlation with weight gain, pregravid weight
  • Fetus of obese women-hyperinsulinemia
  • Obese women- increase glucose, triglycerides and amino acid turnover
  • Hard to assess with increased rate of indicated premature delivery
  • e.g. diabetes, hypertension
  • Preterm birth is more likely associated with low prepregnancy weight and poor weight gain
  • Cedergren 2004 n300,00
  • OR 3 for obese v normal
  • Kristensen 2005 n 25,000
  • OR for fetal death 2.8
  • OR for neonatal death 2.6
  • Meta-analysis Chu, et al. 2007
  • Overweight v normal OR 1.47
  • Obese v normal OR 2.07
  • Partially attributed to co-morbidities. Not completely explained
  • Increase placental histopathologic abnormality
  • Increased risk of infant, childhood and adult obesity
  • Increased risk of metabolic syndrome in adolescence
  • Maternal BMI and diabetes account for most of this relationship
  • Obesity and diabetes likely to be independent risk factors
  • Much greater impact than IUGR
  • Retrospective cohort study 2004
  • 8494 low-income children followed until 24 to 59 months of age.
  • Prevalence of obesity at 4 years of age
  • 24.1 of children with obese mothers
  • 9.0 of children with lean mothers
  • Even with controlling for variables there is over a 2 fold increased risk of childhood obesity with maternal obesity
  • Wide variation in weight loss/gain. Average is 0.5 kg one year postpartum
  • Very difficult to tease out the factors
  • Most important factor for sustained weight gain is gain during pregnancy
  • Not predictive pre pregnancy wt., parity, socioeconomics, occupation, marital status, dietary advise
  • Effect of lactation is small
  • Malabsorptive
  • Jejeunoileal bypass
  • Pancreaticobiliary diversion
  • Restrictive
  • Gastric banding
  • Vertical gastric gastropathy
  • Initial worrisome case reports regarding pregnancy outcome neonatal nutrition deficiency, IUGR, fetal death
  • More recent data are reassuring
  • Recommendations give to delay pregnancy for 18 months. Advise patients of increased fertility.
  • Nutrient deficiencies B12, folate, Fe, Ca, Zinc
  • Monitor nutrients and weight
  • Explain increased calorie, protein and nutrient demands
  • Requires deflation if severe nausea and vomiting
  • May be increased rate of band complications (migration or leaking)
  • Recommendation given to wait 12-18 months. Explain improved fertility with weight loss
  • Nutrient deficiencies still possible B12, folate, Fe, Ca, Zinc
  • Advise risks (all)
  • Dietary counseling
  • Screen for hypertension
  • Screen for diabetes
  • Encourage activity, weight loss
  • Dont ignore overweight issues
  • Clear, unambiguous message about risks
  • Set realistic goals
  • Acknowledge difficulty
  • Praise success
  • IOM minimum increase of 6.8 kg
  • IOM guidelines are under revision
  • Most studies do not show correlation of low weight gain and low birth weight in obese women
  • High weight gains do lead to macrosomia
  • Lower weight gain - less retention
  • Panniculus retraction
  • Study of 48 women
  • incision to delivery time 1.5 to 4 min.
  • no wound complications
  • Supraumbilical incision requires fundal incision
  • case control study no difference in postoperative mobidity c/w low transverse incisions
  • Mobius retractor
  • ?Panniculectomy
  • 2005 Cochrane review no clear benefit for routine use
  • 2007 AJOG no evidence for prevention of wound complications
  • Subcutaneous suture closure of some benefit
  • Difficult IV access
  • Airway obstruction
  • Rapid desaturation with apnea (?FRC)
  • Difficulty with ventilation
  • Very increased cardiac output
  • Challenging regional anesthesia
  • Requires much slower pace of initiating anesthesia for cesarean section
  • Consider prophylactic epidural
  • Difficulty with external monitors
  • Inaccuracy of maternal blood pressure measurement
  • Assess ability to flex, external rotation
  • Assistance for thigh retraction
  • Identification of patients
  • BMI measurements in clinic
  • Early dating sono prn
  • Dietician consultation
  • Review access to timely c/s, risks of c/s and fetal monitoring issues
  • I have had a prior cesarean section. Women with previous cesarean sections often have scar tissue which means that future cesarean section take longer to perform.
  • Because of my body type, a cesarean section will take longer to perform in me.
  • I have what is called a Class II-III airway. This means that it could be difficult to put a breathing tube down me, should I need to go emergently to sleep to delivery my baby.
  • Overall, my doctors state that it could take more than 30 minutes from the decision to perform a cesarean section to the time the baby is out. Thirty minutes may be too long for the baby, and there could be neurologic injury due to this delay.
  • My child is currently coming with its back first. If my child stays in this position, a classical incision will be needed to deliver my child. This means that the upper part of my uterus, which is very thick, will need to be cut open. This type of incision takes a longer time to perform than the typical lower uterine incision.
  • New OB labs including baseline 24 hour urine, creatinine, AST
  • Cardiology eval if ACOG BMI gt35 and comorbity
  • Early glucose challenge!!
  • Anesthesiology Consultation
  • Review birth control plans
  • Type and screen, CBC
  • Consider thromboprophylaxis
  • Consult anesthesia regarding IV access
  • Place a block of wood to support under the toilet of the patients bathroom
  • Obtain a large wheelchair, a large commode, and Big Boy Bed (foot of bed only entry or side or foot of bed entry) also need bypass gowns for the patient.
  • OR table extenders if gt 350 pounds
  • Venodynes on prior to prep and drape and/or heparin
  • Consider obtaining extra operative assistants
  • Antibiotic prophylaxis before skin incision
  • Early ambulation after delivery
  • Venodynes until ambulatory without assistance
  • Or continue heparin until ambulatory without assistance
  • Assure that patient completely changes position in bed q 2 hours
  • Combined OC
  • Venous and arterial thromboembolism risk
  • Increased failure rate especially very low dose
  • No data patch, ring, IUD, implants, plan B
  • Implanon lower serum etonogestrel levels
  • DMPS weight gain, as effective as normal BMI
  • IUD Should be as effective, technically challenging (ultrasound)
  • Essure follicular phase, after DMPA
  • Tubal ligation obesity is risk factor for complications

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  1. Obesity presentation

  2. NUR338 Obesity presentation

  3. Breech delivery in Caesarean Section #withpatientsconsent patient consent taken

  4. pregnancy with obesity #pregnancy #obesity

  5. #pregnancy #pregnancynutrition #duringpregnancy #pregnancycomplications #pregnancysymptoms #प्

  6. Obesity symptoms

COMMENTS

  1. Obesity in pregnancy

    Post-term pregnancy — The body of evidence supports an association between obesity and post-term pregnancy (OR 1.2 to 1.7 in four population-based studies [25,27,46,47]) [25,27,46-50]. The mechanism by which obesity prolongs pregnancy has not been determined.

  2. Obesity in pregnancy

    Pregravid obesity: Early termination of breastfeeding, Postpartum anemia Depression ABOUBAKR ELNASHAR. 12. 4. Fetal and Childhood complications 1. Fetuses of obese gravidas are at increased risk of Macrosomia Impaired growth 2. Infants of obese women tend to have more body fat than infants of normal-weight women.

  3. PDF Obesity and Pregnancy

    Objectives By the end of this presentation, the learner should be able to: Understand current definitions of obesity in non-pregnant and pregnant women. Recognize causes of increased risk of preterm delivery among obese pregnant women. Identify both maternal and neonatal complications related to obesity and pregnancy. Patient Myths

  4. Obesity in Pregnancy

    Association between pre-pregnancy obesity and the risk of cesarean delivery. Obstetrics and Gynecology, 89(2), 213-216. 3Fyfe et al, 2011. Risk of first-stage and second-stage cesarean delivery by maternal body mass index among nulliparous women in labor at term. Obstet Gynecol, 117(6), 1315-1322. 4Kominiarek et al, 2011.

  5. Obesity in Pregnancy

    Objectives: Identify maternal complications associated with obesity in pregnancy. Identify fetal and neonatal complications associated with obesity in pregnancy. Explain the importance of long-term adverse health outcomes associated with fetal overnutrition.

  6. Obesity in pregnancy: Complications and maternal management

    Pregnant people with obesity are at increased risk for an array of maternal and perinatal complications, and the risks are amplified with increasing severity of the condition [ 1-3 ]. It has been estimated that one-quarter of pregnancy complications (eg, gestational hypertension, preeclampsia, gestational diabetes, preterm birth, large for ...

  7. Pregnancy and obesity: Know the risks

    Start by considering these guidelines for pregnancy weight gain and obesity: Single pregnancy. If you have a BMI of 30 or higher and are carrying one baby, the recommended weight gain is 11 to 20 pounds (about 5 to 9 kilograms).; Multiple pregnancy. If you have a BMI of 30 or higher and are carrying twins or multiples, the recommended weight gain is 25 to 42 pounds (about 11 to 19 kilograms).

  8. PPTX PowerPoint Presentation

    Obesity and Pregnancy Outcomes. Women who enter pregnancy obese have more pregnancy complications and are increasedrisk for poor infant outcomes risk of miscarriage. 25% to 37% increased risk risk NTDs compared to normal weight women with same folate intakes and family history. Overweight = 35% of congenital anomaly

  9. Obesity in pregnancy: risks and management

    Obesity in pregnancy is usually defined as a maternal BMI ≥30 at the antenatal booking visit. There are currently no national-level data in the UK on the prevalence of obesity in pregnancy. ... Usha Kiran 35 Population-based observational study including 8350 singleton uncomplicated pregnancies with cephalic presentation of ≥37 weeks. Obese ...

  10. Obesity in Pregnancy

    Obesity in Pregnancy. Andreea A. Creanga, M.D., Patrick M. Catalano, M.D., and Brian T. Bateman, M.D. is the most common health problem in women of repro-. ductive age.1 Not only does obesity pose ...

  11. Obesity and Pregnancy

    Obesity during pregnancy puts you at risk of several serious health problems: Gestational hypertension—High blood pressure that starts during the second half of pregnancy is called gestational hypertension. It can lead to serious complications.. Preeclampsia—Preeclampsia is a serious form of gestational hypertension that usually happens in the second half of pregnancy or soon after childbirth.

  12. Care of Women with Obesity in Pregnancy (Green-top Guideline No. 72)

    Pregnant women who are obese are also at increased risk of caesarean birth. Maternal size can make the assessment of fetal size, presentation and external monitoring of fetal heart tracing more challenging during pregnancy. Initiation and maintenance of breastfeeding are also more difficult in the women with obesity.

  13. Obesity in Pregnancy: A Growing Epidemic

    Objectives This presentation will review the following: • The obesity epidemic in the United States and worldwide • Current classifications of obesity • Maternal and fetal complications during pregnancy • Delivery considerations and complications during labor • Postpartum complications • How to counsel patients in the office Worldwide Obesity

  14. PPT

    PPT - Obesity in Pregnancy PowerPoint Presentation, free download - ID:5179904 Presentation 1 / 25 Download Presentation >> Obesity in Pregnancy Mar 19, 2019 440 likes | 1.22k Views Obesity in Pregnancy. Erin Shaw, CNM, MS Certified Nurse-Midwives at St. Anthony Central Hospital. Objectives.

  15. PDF Obesity: A Complex, Multifactorial Disease

    This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program. Obesity: A Complex, Multifactorial Disease Martin Binks, PhD

  16. PPT

    Presentation 1 / 39 Download Presentation >> Pregnancy and Morbid Obesity Apr 05, 2019 400 likes | 423 Views Pregnancy and Morbid Obesity. Obesity and Pregnancy Health Summit October 18, 2011 Michael D. Trahan, MD, FACS Martha Jefferson Surgical Associates Martha Jefferson Bariatric Care Center. Objectives.

  17. Obesity in pregnancy

    7. Obesity classification Category BMI range - kg/m2 Emaciation less than 14.9 Underweight from 15 to 18.4 Normal from 18.5 to 24.9 Overweight from 25 to 29.9 Obese from 30 to 39.9 Morbidly Obese greater than 40 BMI is a poor prognostic for individual health but a useful tool for population heath of the same ethinicity Metabolic risk for ...

  18. Obesity In Pregnancy PowerPoint PPT Presentations

    4,677 Obesity In Pregnancy PPTs View free & download | PowerShow.com Help Preferences Sign up Log in Advanced View Obesity In Pregnancy PPTs online, safely and virus-free! Many are downloadable. Learn new and interesting things. Get ideas for your own presentations. Share yours for free!

  19. PPT

    By Michael Cochran-Boucher University of New Hampshire Manchester 2010 Spring, Undergraduate Research Symposium. Obesity AND Pregnancy: associated morbidities. Source: Fall 2009, Independent Study, Case Study: BMI and Pregnancy. Research Question: Slideshow 5946420 by uriel-witt

  20. Care of Women With Obesity in Pregnancy

    Care of women with obesity in pregnancy.pptx - Free download as Powerpoint Presentation (.ppt / .pptx), PDF File (.pdf), Text File (.txt) or view presentation slides online. Scribd is the world's largest social reading and publishing site.

  21. obesity and pregnancy

    4. • The prevalence of obesity in pregnancy has been increased from 9-10% in the early 1990s to 16-19% in the 2000s. (UK) • 2/3 of US women of child bearing age are obese or overweight. 5. RISK OF OBESITY DURING PREGNANCY • Depression and Anxiety • Gestational Diabetes • D.M in the future • D.M of their children.

  22. Obesity in Pregnancy

    Obesity in Pregnancy Description: 50 to 100% increase in premature deaths from all causes. Pathophysiology of obesity ... 18% of obstetric causes of maternal death are associated with obesity ... - PowerPoint PPT presentation Number of Views: 1510 Avg rating:3.0/5.0 Slides: 66 Provided by: emilyr9 Category: Tags: obesity | pregnancy less

  23. Obesity During Pregnancy

    Obesity During Pregnancy | PPT Obesity During Pregnancy Dec 6, 2013 • 1 like • 978 views Rosa Estrada Health & Medicine Entertainment & Humor Obesity During Pregnancy 1 of 6 Download Now Save slide Save slide Recommended Obesity and obstetrics chris griffin 1.7K views • 14 slides obesity and pregnancy Osama Yahia 1.6K views • 25 slides