IM PLICATIO N S O F

O BESITY IN PREG N AN CY
BY: BERNARD KWAKU OKAI

FACILITATOR: PROF. ALFRED

TAWIAH ODOI

O U TLIN E
INTRODUCTION
DEFINITION
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

Kabo's Presentation

5/2/16

O U TLIN E
INTRODUCTION
DEFINITION
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

Kabo's Presentation

5/2/16

IN TRO D U CTIO N
Obesity is considered by the WHO to be a
disease and is defined as a condition of excess
body fat to a degree where it causes impairment
to the health of an individual.
Obesity is recognized as a chronic relapsing
disease that has genetic, environmental,
metabolic, and behavioural components.
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IN TRO D U CTIO N
According to the estimates by the WHO, more than
1.5 billion adults are overweight, and of those,
over 200 million men and nearly 300 million
women are obese.
In the United States, more than 1 in 3 women are
obese, more than half of pregnant women are
overweight or obese, and 8% or more (depending
on geographical distribution) are extremely obese.
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IN TRO D U CTIO N
THE BURDEN IN GHANA
In Ghana the prevalence of obesity was found to be 5.5% and
higher among females 7.4% compared to males 2.8%.
It was more common among the married than unmarried.
Obesity was highest among the employed compared to selfemployed or the not working for pay.
Obesity was highest in Greater Accra 16.1% and virtually not
present in Upper East or Upper West regions.
By ethnicity, obesity was highest among Ga Adangbe, Ewes and
Akans 14.6%, 6.6% and 6.0% respectively.
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IN TRO D U CTIO N
A study by Dr. VN Addo in Kumasi to show how BMI and
maternal weight gain influence pregnancy outcome pegged
the prevalence at 34% .
A study conducted in the KATH diabetic clinic on the
prevalence of obesity among newly booked type II DM
patient found a rate of about 36% (overweight and obese).
KATH ANC ????
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O U TLIN E
INTRODUCTION
DEFINITION
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

Kabo's Presentation

5/2/16

D EFIN ITIO N
Obesity is diagnosed and classified based on Body Mass
Index (BMI) .

Body Mass Index (BMI) is a person's weight in kilograms

divided by the square of height in meters (kg/m 2).
The BMI categories for adults are as follows: BMI under 18.5
kg/m2, underweight; BMI 18.524.9 kg/m 2, normal weight;
BMI 25.029.9 kg/m2, overweight; BMI 30.0 kg/m 2 and
above, obese.
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D EFIN ITIO N
Obesity in pregnancy is defined as body mass
index (BMI) 30 kg/m2 based on maternal prepregnancy weight or the first weight measured
at the booking antenatal care.
The definition of obesity in pregnant women
involves issues unique to this population.

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D EFIN ITIO N
The IOM gestational weight gain guidelines should
be used in concert with good clinical judgment as
well as a discussion between the woman and her
provider about diet and exercise.
Recommendations by ACOG emphasize that
individualized care and clinical judgment are
necessary in the management of the overweight
or obese woman.
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O U TLIN E
INTRODUCTION
DEFINITION
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

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CO M PLICATIO N S
The complications of maternal obesity are
associated more with pre-pregnancy obesity
rather than excessive weight gain in pregnancy.
Maternal and fetal complications
Addressed in the following subdivisions namely,
antenatal, intrapartum and postnatal.
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IM PACT O F O BESITY IN AN TEN ATAL

PERIO D 1 ST TRIM ESTER
Intrinsic

Interventional

Miscarriages

Difficulty with dating

Fetal Anomaly (neural tube defect)

Difficulty with chorionic villus sampling

Thromboembolism

Difficulty with calculation of EDD due to

irregular cycle

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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND MISCARRIAGE
Obesity is associated with an increased risk of
first trimester and recurrent miscarriage.
Possible mechanisms include an adverse impact
on endometrial development or a detrimental
effect on ovaries affecting oocyte quality and
hence embryo viability or combination of both.
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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

2 N D TRIM ESTER
Intrinsic

Interventional

Fetal Anomalies (omphalocele, cardiac

defects)

Difficulty with anomaly scan

Gestational diabetes mellitus

Difficulty with amniocentesis

Thromboembolism

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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND CONGENITAL ANOMALY
Maternal obesity confers an elevated risk of
congenital anomalies, in particular neural tube
defects (NTDs), congenital heart defects (CHDs)
and orofacial clefts.

The suggested mechanisms included undiagnosed

diabetes mellitus, reduced folate intake and
technical difficulties in diagnosing these congenital
defects by ultrasound, which in turn resulted in
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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND ULTRASOUND
Ultrasound assessment in obese mothers is
notoriously difficult.
Approximately
15%
of
normally
visible
structures will be sub-optimally seen in women
with a BMI above the 90th percentile. In women
with a BMI above the 97.5th percentile, only
63% of structures are well visualized.
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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND ULTRASOUND
The anatomic structures commonly less well
seen with increasing BMI include the fetal heart,
spine, kidneys, diaphragm and umbilical cord.
A worrying consequence of maternal obesity,
consequently, is the reduced sensitivity of
ultrasound as a screening test for fetal anomaly.
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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND GESTATIONAL DIABETES MELLITUS
Obesity is considered to be an insulin resistant state, and thus
accentuates the insulin resistance of normal pregnancy.
If an increase in maternal BMI of 1-2 units occurs between
pregnancies, the risk of gestational diabetes rises by 20-40%.
If she becomes overweight, her risk of gestational diabetes
rises by 100%. If she becomes obese, her risk of gestational
diabetes rises by 200%.
Inter-pregnancy weight reduction among women with obesity
has been shown to significantly reduce the risk of developing
GDM.
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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

3 R D TRIM ESTER
Intrinsic

Interventional

Pre-eclampsia

Difficulty in assessment of fetal lie

Gestational diabetes mellitus

Difficulty in assessment of fetal growth

Prolonged pregnancy

Difficulty in CTG monitoring

Large for gestational age babies

Thromboembolism

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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND PRE-ECLAMPSIA
The mechanisms explaining the relationship between
obesity and pre-eclampsia are complex and not fully
understood.
A number of hormonal and biochemical pathways
have been implicated including insulin resistance
,endothelial cell activation, dyslipidaemia
and
elevated cytokines like the tumour necrosis factor.
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IM PACT O F O BESITY IN AN TEN ATAL PERIO D

OBESITY AND PROLONGED PREGNANCY
Circulating levels of corticotrophin-releasing hormone
(CRH), mainly synthesized by the placenta and cortisol
may play a role in the onset on labour.

Another potential mechanism which is that the

metabolism of oestrogen by the adipose tissue of obese
women may result in an alteration in the oestrogenprogesterone ratio in maternal plasma which in turn has a
role in the initiation of labour.
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IM PACT O F O BESITY IN IN TRAPARTU M -1 ST

STAG E
Intrinsic

Interventional

High rate of induction of labour

Difficulty in assessment of fetal lie

Immobilisation

Difficulty in fetal monitoring

Prolonged labour

Requirement of fetal scalp electrode for

fetal monitoring

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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND INTRAPARTUM MONITORING
Monitoring contractions and assessing adequate
labour progress can be challenging in obese
women.
Manual
palpation
and/or
external
tocodynamometry are most commonly used, but in
obese women, the distance between the skin
and the uterus would render this technique
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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND INTRAPARTUM MONITORING
Newer techniques, such as electrohysterography, may prove
superior to both toco-dynamometry and intrauterine pressure
assessment for labour monitoring in this population.

While there is no specific requirement for continuous electronic

fetal monitoring in labour in an otherwise uncomplicated
pregnancy, many obese women will have other indications for
continuous fetal monitoring, such as hypertension, gestational
diabetes or induction of labour.

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IM PACT O F O BESITY IN IN TRAPARTU M -2 N D

STAG E
Intrinsic

Interventional

Cephalo-pelvic disproportion

Technical difficulties of C/S in morbidly

obese patients

High rate of shoulder dystocia and fetal

trauma

Increased operating time at caesarean

section

High rate of instrumental deliveries

Technical difficulty in giving spinal or

epidural anaesthesia

High rate of perineal tears

Higher rates of general anaesthesia

High rate of caesarean sections

Difficulty in intubation

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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND CAESAREAN SECTION
The increase in the rate of caesarean section may be due,
in part, to the fact that overweight and obese nulliparous
women progress more slowly through the first stage of
labour.

When faced with lack of descent in the second stage of

labour, some practitioners may opt for caesarean section
because of concerns about fetal macrosomia and shoulder
dystocia.
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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND CAESAREAN SECTION
In the case of an emergency caesarean section,
delays from decision to delivery may occur due
to longer time for patient transport and set-up,
establishment of anaesthesia and longer
operative time, including incision-to-delivery
time.
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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND CAESAREAN SECTION
Technically, it can be challenging to perform a
caesarean section in morbidly obese women
(big panniculus, deeper skin incision, difficult
access to the lower segment, longer operating
time and the need for more experienced
assistants) and an experienced surgeon is
required.
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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND ANAESTHETIC COMPLICATIONS
Minor procedures like IV access are difficult as
increased fat deposition can obscure cutaneous veins.

Regional anaesthesia is not only time consuming but

also challenging due to difficulty in palpating the bony
landmarks. The need for longer needles to reach the
epidural and spinal space may increase technical
challenges.
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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND ANAESTHETIC COMPLICATIONS
The sitting position is recommended for regional anaesthesia,
to better define the bony landmarks, however, this may prove
practically difficult for morbidly obese pregnant women in
labour.
There is a need for an experienced senior anaesthetist to be
involved in view of higher rate of general anaesthesia and
difficult intubation.
The general rules of premedication to prevent reflux of acid
contents of stomach into lungs are particularly applicable to
obese women.
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IM PACT O F O BESITY IN IN TRAPARTU M

PERIO D
OBESITY AND OTHER THEATRE COMPLICATIONS
An appropriate operating table is necessary to avoid
hazards including falling off, breaking the bed and
compression injuries in these women.
It is important not to forget about the health of the staff,
who can be put at risk of occupational injuries when
moving anaesthetised obese women, and therefore
training in lifting of patients should become mandatory.
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O TH ER CO M PLICATIO N S O F O BESITY
3RD STAGE : Difficulty in assessing vaginal and
cervical tears and increased incidence of PPHs.
Postnatal:
Wound
infection,
postpartum
endometritis,
venous
thromboembolism,
lactation failure and increased hospital stay.
Long term: Increased morbidity and mortality
from co-morbidities like
diabetes mellitus,
hypertension and its complications and cancers.
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IM PACT O F O BESITY IN PO STN ATAL PERIO D

OBESITY AND INFECTION
There is higher risk for postpartum infection (wound,
episiotomy, endometritis), regardless of mode of
delivery and despite use of common prophylactic
antibiotic regimens.

Poor vascularity of subcutaneous adipose tissue and

formation of seromas and hematomas account, at least
in part, for the increased risk of wound infection.
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IM PACT O F O BESITY IN PO STN ATAL PERIO D

OBESITY AND VENOUS THROMBOEMBOLISM
The postpartum period is the time of greatest risk for
the development of venous thromboembolism (VTE)
although the risk still pertains in the antenatal period.

Pregnancy alone impacts significantly on Virchow's triad

(hypercoagulability, haemodynamic changes (stasis,
turbulence) and endothelial injury).

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IM PACT O F O BESITY IN PO STN ATAL PERIO D

OBESITY AND VENOUS THROMBOEMBOLISM
Severe adiposity further impedes venous return,
worsening stasis.
Additionally, in morbidly obese women, a general
lack of mobility may contribute to venous stasis.
Maternal obesity is also associated with endothelial
injury and dysfunction .

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IM PACT O F O BESITY IN PO STN ATAL PERIO D

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IM PACT O F O BESITY IN PO STN ATAL PERIO D

OBESITY AND BREASTFEEDING
Maternal
obesity
is
associated
with
reduced
breastfeeding rates, in terms of both breastfeeding
initiation and duration.

This is likely to be multifactorial in origin, women's

perception of breastfeeding, difficulty with correct
positioning of the baby, and the possibility of an
impaired prolactin response to suckling.
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O U TLIN E
INTRODUCTION
DEFINITION
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

Kabo's Presentation

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M A N A G EM EN T
The obesity treatment pyramid for non-pregnant
patients includes lifestyle modification (diet and
physical
activity),
pharmacotherapy,
and
surgery.

Currently,
the
management
options
in
pregnancy are limited to lifestyle modification.
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M AN AG EM EN T- IN ITIAL VISIT
Ideally, overweight or obese patients should
have pre-pregnancy counselling and lifestyle
modifications prescribed at that time.
At the initial antenatal visit, patients should be
counselled regarding the benefits of appropriate
weight gain, nutrition and exercise, to achieve
best pregnancy outcomes.
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M AN AG EM EN T- IN ITIAL VISIT
Establish if the patients obesity is related to a
sedentary lifestyle or to a pre-existing medical
condition.
Thus, at the first visit certain rare genetic and
other medical causes for obesity should be ruled
out
such
as
Cushing
Syndrome
and
Hypothyroidism.
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M AN AG EM EN T- SU BSEQ U EN T VISITS
Vitamin D supplementation (10g/daily). An inverse
relationship between maternal pre-pregnancy BMI and
maternal blood and cord blood concentrations.
Difficulty in abdominal palpation may necessitate serial
abdominal scans. (CAVEAT!!!).
Blood pressure checked
appropriate size cuff.

at

each

visit

with

an

Screening for GDM.

VTE prophylaxis.
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M AN AG EM EN T- LABO U R,D ELIVERY &

PO STN ATAL
IV Access with blood for GXM. Blood should be secured.
Continuous fetal monitoring.
In cases of anaesthesia regional preferred to general.
Choice of abdominal incision (size of panniculus,
experience
of
obstetrician,
other
patients
characteristics).
VTE prophylaxis.
Contraception.
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M AN AG EM EN T- N U TRITIO N
Ideally,
nutrition
counselling
should
individualized and provided by a dietician.

be

The daily caloric requirements are :

25 kcal/kg (BMI 2529.9 kgm2)
20 kcal/kg (BMI 3039.9 kg/m2)
15 kcal/kg (BMI more than 40 kg/m2).

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M AN AG EM EN T PH YSICAL ACTIVITY
Patients are advised to engage in at least 30
minutes of physical activity each day, and since
most of them were previously sedentary should
be encouraged to walk at a moderate to brisk
pace after each meal if possible for a total of
150 minutes or more per week.

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??? N EW IN TERVEN TIO N S

The Metformin in Obese Nondiabetic Pregnant Women
(MOP) trial
A daily dose of 3.0 g of metformin from 12 to 18 weeks of
gestation until delivery was associated with less maternal
gestational weight gain than that observed with placebo
but not with a lower median neonatal birth weight.
http://www.nejm.org/doi/full/10.1056/NEJMoa1509819#t=article
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O U TLIN E
INTRODUCTION
DEFINITION
PATHOPHYSIOLOGY
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

Kabo's Presentation

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CO N CLU SIO N
Obesity in pregnancy is associated with
pathophysiological changes leading to:
Increased pregnancy loss (early and late pregnancy).
Increase in congenital malformations.
Increase in maternal co-morbidities
Increased caesarean delivery rate.
Increase in risk of maternal death, based on above
risk factors.

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CO N CLU SIO N
Judicious lifestyle modifications in pregnancy
improve both maternal and neonatal outcomes
in obese patients.

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O U TLIN E
INTRODUCTION
DEFINITION
COMPLICATIONS
MANAGEMENT
CONCLUSION
REFERENCES

Kabo's Presentation

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REFEREN CES
1) World Health Organization. Factsheet: obesity and overweight.
2012. http://www.who.int/mediacentre/factsheets/fs311/en/2012/.
2)The Epidemiology of Obesity in Ghana by RB Biritwum, J
Gyapong and G Mensah. http
://www.ncbi.nlm.nih.gov/pmc/articles/PMC1790818 /
3) Body Mass Index, Weight Gain during Pregnancy and Obstetric
Outcomes by VN Addo
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994149 /
4) Metwally M, Ong KJ, Ledger WL, et al. Does high body mass
index increase the risk of miscarriage after spontaneous and
assisted conception? A meta-analysis of the evidence. Fertil Steril
2008;90(3):714e26.
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REFEREN CES
5) Wolfe HM, Sokol RJ, Martier SM, et al. Maternal obesity: a potential source
of error in sonographic prenatal diagnosis. Obstet Gynecol 1990;76:339e42.
6) Chu SY, Callaghan WM, Kim SY, et al. Maternal obesity and risk of
gestational diabetes mellitus. Diabetes Care 2007; 30:2070e6.
7) Villamor E, Cnattingius S. Interpregnancy weight change and risk of
adverse pregnancy outcomes: a population-based study. Lancet
2006;368:1164e70.
8)Froen JF, Arnestad M, Frey K, et al. Risk factors for sudden intrauterine
unexplained death: epidemiologic characteristics of singleton cases in Oslo,
Norway, 1986e1995. Am J Obstet Gynecol 2001;184:694e702.
9) Flenady V, Koopmans L, Middleton P, et al. Major risk factors for still birth
in high-income countries: a systematic review and meta-analysis. Lancet
2011;377(9774):1331e40.

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REFEREN CES
ARTICLES
Impact of obesity on female fertility (http://
www.uptodate.com/contents/the-impact-of-obesity-on-female-fertility-and-pre
gnancy
)
The implications of obesity on pregnancy (Obstetrics, Gynaecology &
Reproductive Medicine Volume 25, Issue 4, April 2015, Pages 102105)
The implications of obesity on pregnancy (Obstetrics, Gynaecology &
Reproductive Medicine Volume 19, Issue 12, Dec 2009, Pages 334339)
BOOKS
Williams Obstetrics(2014), 24th Edition by F. Gary Cunningham et al, Chapter
48 .
Comprehensive Obstetrics in the Tropics(2015), 2 nd Edition by E.Y. Kwawukume
et al, Chapter 31.
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TH AN K YO U
CONTRIBUTIONS?
ADDITIONS?
COMMENTS?
QUESTIONS!!!
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TH E EN D

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