#NewWorldProblems Obesity in Pregnancy

2016 Midlands Perinatal Conference

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#NewWorldProblems Obesity in Pregnancy

Lauren Castleberry, MD, FACOG

Assistant Professor, Department of Ob/Gyn

USC SOM

Disclosures

• None to Disclose

Objectives

• Discuss the epidemiology of obesity

• Review the effects on pregnancy in the obese patient

• Suggest ways to optimize the care of the obese patient, including:

• Weight gain recommendations

• Intrapartum Care

• Post-operative Considerations

• Postpartum Care


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Definitions

World Health Organization Body Mass Index Categories

Category BMI

Underweight Less than 18.5

Normal Weight 18.5-24.9

Overweight 25.0-29.9

Obesity Class I 30.0-34.9

Obesity Class II 35.0-39.9

Obesity Class III 40 or greater

World Health Organization. Obes ity: preventing and managing the global epidemic. Report of a WHO

consultation. Geneva: WHO; 2000.

Epidemiology

• Based on the 2011-2012 National Health &

Nutrition Examination Survey

• 31.8% of 20-39 year old women are obese

• 58.5% of these women are either obese or overweight

Epidemiology

• Data is concerning

• Prevalence increased between 1999-2010

• 28.4 34%

• Higher prevalence of Class II & III Obesity in 2009-2010

• Class II 17.2%

• Class III 7.5%


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Effects on Pregnancy

• Pregnancy Loss

• Antepartum Complications

• Intrapartum Complications

• Postpartum Complications

• Fetal Complications & Childhood Morbidities

Pregnancy Loss

• Spontaneous abortion

• Odds Ratio 1.2

• Recurrent Miscarriage

• Odds Radio 3.5

• Other increased risks:

• Neural tube defects

• Hydrocephaly

• CV, orofacial, & limb reduction anomalies


4

Antepartum Complications

• Cardiac Dysfunction

• Proteinuria

• Sleep Apnea

• Non-alcoholic fatty liver disease

• Gestational Diabetes Mellitus

• Pre-eclampsia

• Intrauterine fetal demise


5

Risk of Stillbirth by

Gestational Period

Risk of Stillbirth for

Remaining Pregnancies

Intrapartum Complications

• Increased association with:

• Indicated preterm birth

• Increased risk of:

• Cesarean delivery

• Failed trial of labor

• Endometritis

• Wound rupture/dehiscence

• Venous thrombosis


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Postpartum Complications

• 46% of obese pregnant patients gain weight in excess

of IUM recommendations

• Excess weight gain is a significant risk factor for postpartum weight retention

• Pre-pregnancy obesity is associated with:

• Early termination of breastfeeding

• Postpartum anemia

• Depression

Fetal Complications &

Childhood Morbidities

• Macrosomia

• Impaired growth

• Metabolic syndrome & child obesity

• Asthma

• Altered behavior including

• Autism spectrum disorders

• Childhood developmental delay

• Attention-deficit/hyperactivity disorders

How We Can Help

• Prevention is KEY!!!

• Preconceptual counseling is imperative

• Weight loss before pregnancy can improve medical comorbidities

• Either surgical or nonsurgical

• Even a weight loss of 5-7% over time can improve

metabolic health

• Motivational interviewing techniques

• Referral to intensive multicomponent behavioral

interventions if BMI>30.


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How We Can Help

• Weight loss efforts

• Should NOT involve medications if conception is being

attempted or during pregnancy

• Weight management strategies during pregnancy

include:

• Dietary control

• Exercise

• Behavior modification

IOM Weight Gain

Recommendations

Intrapartum Care

• Things to keep in mind:

• Increasing BMI is associated with longer labor

• Patients with Class III Obesity undergoing TOLAC:

• Increased morbidity

• Prolonged hospital stay, endometritis, rupture/dehiscence

• Increased neonatal injury

• Fractures, brachial plexus injuries, lacerations

• Patients with Class III Obesity

• Have a significantly increased risk of postpartum atonic

hemorrhage after vaginal delivery


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Intrapartum Care


• There is an inverse relationship between pre-pregnancy BMI &

Success Rates for VBAC

BMI VBAC Success Rate (%)

<19.8 83.1

19.8 – 26 79.9

26.1 – 29 69.3

>29 68.2

Juhasz G, Gyami C, Gyami P, Tocce K, Stone JL. Effect of body mass index and excess ive weight

gain on success of vaginal birth after cesarean delivery. Obstet Gynecol 2005;106:741-6.

Intrapartum Care


• Risk of Cesarean section increases with

BMI

Odds Ratio for Cesarean Delivery

Overweight 1.46

Obese 2.05

Severely Obese 2.89

Operative & Perioperative

Considerations

• Anesthesia consultation

• Preferably pre-labor or in early labor

• To develop a plan for:

• Proper equipment for BP monitoring

• Venous access

• The influence of other comorbid conditions

• To decide on the mode of anesthesia


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Considerations

• Epidural or Spinal Anesthesia

• Recommended for intrapartum pain relief but may be

technically difficult

• Body habitus

• Loss of landmarks

• Risk of epidural analgesic failure is greater in obese

women compared with normal & overweight women

Dresner M, Brocklesby J, Bamber J. Audit of the influence of body mass index on the performance of epidural

analges ia in labour and the subsequent mode of delivery. BJOG 2006;113:1178-81.


Considerations

• Side effects increased

• Epidurals placed result in significantly greater:

• Hypotension

• Prolonged fetal heart rate decelerations

• Spinal anesthesia & obesity impairs respiratory function for up to 2 hrs after the procedure

• General Anesthesia risks

• Difficulty ET placement due to excessive tissue & edema

Vricella LK, Louis JM, Mercer BM, Bo lden N. Im pact o f morbid obesity on ep idural anesthesia com plications in lab or. Am J Obstet Gy neco l 2 01 1; 20 5:3 70 .e1 -6 . Von Ungern -Sternb erg BS, Regli A, Bucher E, Reb er A, Schneider MC. Imp act o f sp inal anesthesia and ob esity on m aternal resp irato ry function during electiv e Cesarean section.

Anaesthesia 2 0 0 4 ;5 9 :74 3-9 . Mhy re JM. Anesthetic m anagem ent fo r the m orb idly obese p regnant woman. In t Anesthesio l Clin 2 00 7;45 :51 -7 0.


Considerations

• Prophylactic antibiotics for cesarean

• Definitive recommendations are not yet established,

but…

• Higher doses recommended by some

• If >80 kg (175 lb)

• 2g Cefazolin dose

• If >120 kg (265 lb)

• 3g Cefazolin


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Considerations

• Incision

• Vertical vs. Transverse

• Data is conflicting

• Supraumbilical?

• May benefit women with a large panniculus

• Subcutaneous drain or no drain?

• Drains increase the risk of postpartum cesarean wound complications

• Closure of the subcutaneous tissue?

• If >2cm of subcutaneous tissue, closure significantly decreases the incidence of wound disruption

Postpartum Care

• Risks to think about

• VTE

• Surgical site infection

Postpartum Care

• VTE

• Case-control study in Denmark

• >71,000 women

• Obesity in early pregnancy associated with an increased risk of VTE

• OR 5.3

Lauren TB, Sorensen HT, Gis lum M, Jognsen SP. Maternal smoking, obes ity, and risk of venous thromboembol ism

during pregnancy and the p[uerperium: a population-based nes ted case-control s tudy. Thromb Res 2007;120:505-9.


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Postpartum Care

• VTE prophylaxis

• Pneumatic compression devices

• Before AND after cesarean delivery

• Consider use during induction

• Early mobilization

• Consider pharmacologic prophylaxis in very high risk

groups

• Low Molecular Weight Heparin 40 mg daily

• The benefits of weight-based vs. BMI stratified dosage strategies not yet clear

Postpartum Care

• Surgical Site infection

• Baseline risk of infection based on a retrospective study of

2492 cesarean deliveries

• 18%

• Compared to normal-weight women…

BMI Risk of surgical site infection (Odds Ratio)

Overweight 1.6

Obesity Class I 2.4

Obesity Class II & III 3.7

Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical s ite

infection following cesarean section in England: results from a multicentre cohort s tudy. BJOG

2012;119:1324-33.

Postpartum Care

• Surgical Site infection management

• Antibiotics

• May use alone if infection is superficial

• Exploration

• Debridement

• Closure of the resulting open wound

• Secondary closure

• Secondary intention with dressings

• Secondary intention using negative pressure wound therapy


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Nursing Considerations for the Pregnant Obese Patient

Ashley N. Locklear, MSN, RNC-OB, C-EFM

Clinical Practice Specialist

Women’s and Neonatal Services

Palmetto Health Richland

Intrapartum Nursing

Considerations

• Notification from the OB provider of services needed by at least 34 weeks gestation

• Will allow adequate time for staffing and ordering of equipment, if needed

• Notification may also give facility the opportunity to reveal if patient’s needs may be better served at tertiary facility

• Questions for the facility’s leadership team:

• What is the best location for patient’s care?

• Can the facility manage these special needs?

• Is referral to a tertiary or other center necessary?

Intrapartum Nursing

Considerations

• Additional staff needed for:

• Transferring

• Positioning and turning

• Assisting with legs during procedures

• Catheterization

• Internal monitors

• Active pushing phase of 2nd stage labor

• both mother’s safety and staff’s safety


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Equipment

• Bariatric bed

• Labor

• Postpartum

• Lift equipment

• Hover mat to assist with transfer after regional anesthesia

• Bedside commode/toilet

• Extra large gowns

• Blood pressure cuffs

• Extra large SCDs

• Bariatric wheelchair

• Method to weigh patient

• OR table with 1000 lb capacity

• Extension devices to increase width of table

• Extra long surgical instruments and retractors

• Staff will need t ime to rehearse and practice with unfamiliar equipment

• Contact information for equipment suppliers for each item needed should be maintained in a f ile and readily available to leadership team

Intrapartum Nursing

Considerations • IV access

• Consider central line or 2 peripheral lines

• External fetal monitoring

• 1:1 care may be necessary

• May need a nurse dedicated to holding external monitors

• Maternal heart rate vs. fetal heart rate

• Low FHR baseline

• Maternal pushing efforts during 2nd stage

• Maternal repositioning

• Maternal body habitus

• Maternal tachycardia a/w temperature/anxiety/meds

• FHR accelerations consistently coinciding with contractions or with pushing should be evaluated

Intrapartum Nursing

Considerations

• More likely to have IOL or AOL

• 2x the rate of failure of IOL

• Labor proceeds more slowly as BMI increases

• Allow longer time for labor

• Uterine contractility may be diminished

• Anticipate high doses of pitocin

• Does your facility require at bedside evaluation of the

fhr at any specific dose of pitocin?


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Intraoperative Nursing

Considerations

• Decision to incision time intervals may be longer

• Anesthesia, transport to OR, and transfer to table

difficulties

• Incision to birth time intervals may be longer

• Excessive adipose tissue

Intraoperative Nursing

Considerations

• Prophylactic antibiotics especially important d/t

increased risk for SSI and endometritis

• Incision direction based on individual clinical

situations and surgeon preference

• Positioning

• Panniculus retractor

• Silk tape

• Normothermia in the OR

Postpartum Nursing

Considerations

• Consider PACU or ICU for 24hrs s/p cesarean

• End t idal CO2 monitoring during postoperative pain relief with narcotics

• Wound assessment

• Incentive spirometry to prevent respiratory complications

• Accurate and t imely VS and I/O

• Bleeding- quantify blood loss

• Uterine tone dif f icult to assess; risk for PPH

• Consider prophylactic use of uterotonics

• Use of SCDs continued until fully ambulatory and then even during rest periods in the bed


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Infant Feeding Considerations

• Obese patients are less likely to initiate breastfeeding and those that do are more likely to breastfeeding for less time than their thinner counterparts

• Breastfeeding should be encouraged for maternal and neonatal benefits

• Maternal benefit: increased weight loss following delivery

• Neonatal benefits: decreased risk of childhood obesity and type 2 diabetes

• Risk for delayed lactogenesis (more than 72hrs after birth)

• Need for outpatient lactation services • Referral to appropriate facility or private IBCLC

General Nursing

Considerations

• Environment

• Should be sensitive and empathetic

• Avoid reminding the patient that additional clinical issues are r/t obesity

• Focus of care should be safety and clinical needs


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The Case

The Case

• 38 yo G4P2012 at 34 1/7 weeks by a 19 week US

• Presented to the outside hospital with complaints of 4 days of shortness of breath and worsening lower

extremity edema

• Transferred to tertiary care center due to:

• Respiratory Distress

• Pre-eclampsia with severe features

The Case

• Medical History

• Chronic Hypertension

• Diagnosed in 1997

• Type 2 DM (Insulin dependent)

• Diagnosed in 2011

• Advanced Maternal Age

• Morbid Obesity, Class III

• BMI 66

• Surgical History

• Suction D&C for a missed AB


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The Case

• Obstetric History

• 1996 Early SAB with D&C

• 1997 TSVD of 2948g viable male infant

• 1999 TSVD of 2977g viable male infant

The Case

• Family History

• Mom- deceased at age 39 due to heart disease

• Extensive history of DM, Htn, CAD

• Social History

• Neg for tobacco, alcohol, drug use

• Lives with her 2 sons

• Meds

• Levemir 40 units QHS

• Labetalol 600 mg PO BID

• Aspirin 80 mg daily

• Allergies- NKDA

The Details

• Physical Exam

• Vitals

• BP 212/118 HR 90 R 32 T 96.8 95% on 2L NC

• Height 5’7 Weight 432 lbs

• Gen- unable to take deep breaths, pulling at her nasal cannula

• Lungs- coarse crackles throughout & end expiratory wheezes

• CV- RRR; +3 lower extremity edema bilaterally

• Abdomen- morbidly obese, soft, nontender

• Cervical Exam- 1/50/-3

• Bedside US: FHT at 169 bpm, cephalic


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The Details

• Lab Results

• Hgb 9.4, WBC 8.3, Plt 518

• PT 12.4, INR 1.13

• Na 132, K 3.7, Cl 102, CO2 22, Cr 0.6

• AST, ALT normal

• P:C too high to calculate

• Troponin <0.012, D-Dimer 518

The Details

• Imaging

• CXR- Cardiomegaly & diffuse airspace opacities

suggestive of pulmonary edema

• Echo- normal EF, mild to moderate elevation in right

heart pressures, no pericardial effusion

Upon Transfer

• Patient was taken to the Medical ICU

• Pre-eclampsia with Severe Features

• BP controlled with IV Labetalol drip

• Magnesium not given due to pulm status

• Pulmonary Edema

• Aggressive diuresis initiated with Lasix

• O2 support given

• Overall Plan

• Delivery via Cesarean section in the AM


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Change of Plans

• Patient evaluated by MFM service in the AM

• Decision made to proceed with IOL

• Penicillin started for GBS prophylaxis

Time SVE FHT Plan

0945 1/50/-3 Category I AROM, FSE, IUPC placement, Pitocin.

1204 2/70/-3 Category II Discontinue Pitocin. Intrauterine resuscitation due to a prolonged decel.

1602 3/70/-3 Category II Discontinue Pitocin. Intrauterine resuscitation due to recurrent late decels.

1734 3/90/-3 Category II Discontinue Pitocin. Deep variable decels; amnioinfusion started.

1919 4/90/-2 Category II Continue with IOL; FHT overall reassuring.

2231 7/90/-2 Category II Prolonged decel to 60 bpm x 5 minutes, unresponsive to resuscitation. Patient taken to the OR for a stat cesarean section.

The Delivery

• Underwent Primary Low Transverse Cesarean section under general anesthesia

• Pfannenstiel incision performed

• Uncomplicated; wound vac placed at the time of closure

• Neonatal stats:

• Apgars 1, 4, 7

• ApH 7.16, Base Excess -2.9

• VpH 7.21, Base Excess -3.4


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Post-Op

• Unable to be extubated immediately

• Returned to the Medical ICU

• Extubated the following day

• Slowly weaned from oxygen

• BP’s controlled on PO Labetalol

• Discharged from the ICU

• DVT prophylaxis started

• Lovenox 60 BID

References

World Health Organization. Obes ity: preventing and managing the global epidemic. Report of a WHO consultation.

Geneva: WHO; 2000.

Ogden CL, Carroll MD, Kit BK, F legal KM. Prevalence of childhood and adult obes ity in the United States , 2011-2012.

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Catalano PM. Management of obes ity in pregnancy. Obs tet Gynecol 2007;109:419-33.

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http://www.cdc.gov/nchs/data/factsheets/factsheet_obesity.pdf




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Refences

Hibbard JU, Gilbert S, Landon MB, Hauth JC, Leveno KJ, Spong CY, et al. Trial of labor or repeat cesarean delivery in women

with morbid obes ity and previous cesarean delivery. National Ins titute of Child Health and Human Development Maternal -

Fetal Medicine Units Network. Obstet Gynecol 2006;108:125-33.

Juhasz G, Gyami C, Gyami P, Tocce K, Stone JL. Effect of body mass index and excess ive weight gain on success of vaginal

birth after cesarean delivery. Obstet Gynecol 2005;106:741-6.

Chu SY, Kim SY, Schmid CH, Dietz PM, Callaghan WM, Lau J, et al. Maternal obes ity and risk of cesarean deliveryL a meta-

analys is . Obes Rev 2007;8:385-94.

Dresner M, Brocklesby J, Bamber J. Audit of the influence of body mass index on the performance of epidural analges ia in

labour and the subsequent mode of delivery. BJOG 2006;113:1178-81.

Vricella LK, Louis JM, Mercer BM, Bolden N. Impact of morbid obes ity on epidural anes thes ia complications in labor. Am J

Obstet Gynecol 2011; 205:370.e1-6.

Von Ungern-Sternberg BS, Regli A, Bucher E, Reber A, Schneider MC. Impact of spinal anes thes ia and obes ity on maternal

respiratory function during elective Cesarean section. Anaes thes ia 2004;59:743-9.

Mhyre JM. Anes thetic management for the morbidly obese pregnant woman. Int Anes thes iol Clin 2007;45:51-70.


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Lauren TB, Sorensen HT, Gis lum M, Jognsen SP. Maternal smoking, obes ity, and risk of venous thromboembol ism during

pregnancy and the p[uerperium: a population-based nes ted case-control s tudy. Thromb Res 2007;120:505-9.

Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical s ite infection following cesarean

section in England: results from a multicentre cohort s tudy. BJOG 2012;119:1324-33.

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