Obesity and Pregnancy

Obesity and Pregnancy

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Results from the 2013-1014 National Health and Nutrition Examination Survey indicate that an estimated 32.7% of U.S. adults aged 20 and over are overweight (body mass index [BMI] 25.0 – 29.9), 37.9% are obese (BMI greater than or equal to 30.0), and 7.7% are extremely obese (BMI greater than or equal to 40.0). Among women, many of whom are reproductive age, 26.5% are overweight, 40.4% are obese, and 9.9% are extremely obese. The prevalence of obesity has been steadily increasing in the United States. [1] A pregnancy-specific definition of obesity has not been standardized, so pregnant women are often considered obese or non-obese based on their pre-pregnancy BMI, or the BMI at the initial prenatal visit if this is unknown.  Many factors contribute to the development of obesity with lifestyle and diet being the most important. Due to increasing prevalence, obstetric care providers will need to be well-versed in care of the pregnant obese patient.

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Antepartum Care

Initial OB visit

<40 BMI

BMI 40+

H&P screening for maternal co-morbidities

Consider maternal echocardiogram, pulmonary function testing,

sleep study

Laboratory testing

+/- Thyroid function tests 

Thyroid function tests

A1c if not diabetic [20]

A1c if not diabetic with GTT as indicated [20]

U/S

First trimester dating/rule out multiples

First trimester dating/rule out multiples

Counsel on weight gain

11-20 lbs. total

<15 lbs. and none is acceptable in the setting of excellent nutrition

Exercise

Aerobic activity minimizing high impact

Walking and swimming (likely best tolerated)

Genetic Counseling/Screening

           Aneuploidy – no different

Serum analytes OK

Serum analytes OK

         

NT can be difficult [12]

NT very challenging [12]

NIPS – may have test failure more commonly

NIPS may not perform well especially early

           Patient counseling regarding              screening

Test performance similar to non-obese patients

Testing performance is compromised by obesity and this is “dose” based

Prenatal Care through 24 weeks gestation

Ultrasound

Detailed anatomy scan at 20 wks

Detailed anatomy scan at 20 wks

Possible fetal echo at 24 wks [15]

Weight

Closely monitor and counsel patient

Closely monitor and counsel patient

Prenatal Care 24 – 36 weeks gestation

Labs

1 hr 50 gm glucola

challenge / Hct

1 hr 50 gm glucola challenge/Hct

Ultrasounds

Serially for growth q 4-8 wks until delivery

Serially for growth q 3-4 wks until delivery

Frequency of visits for screening – (development of complications will require more frequent visits)

Q 4 wks until 28-32 wks then q 2 wks until 36 wks then q 1-2 wks until delivery

Q 4 wks until 28 wks then q 1-2 wks until 36 wks then weekly

Weight gain

Closely monitor and counsel patient

Closely monitor and counsel patient

Antenatal surveillance (NST / AFI)

Only as done for non-obese patients

Potentially start at 32 wks in super morbid obesity (BMI 50+)

Anesthesiology

Consider anesthesia consult, Evaluate L&D unit to see if they have the equipment to handle patient’s size

TOLAC counseling

Per routine for non-obese patients

Factor in lower success rate with elevated BMI

Prenatal Care 36+ weeks

Antenatal surveillance

FKC and other only as indicated for non-obese patients

Potentially consider NSTs/AFI starting at 34-36 wks  if not started sooner due to complications

Delivery /Intrapartum Care

Timing of delivery

By 41.0 wks but 40 wks reasonable and even 39 wks if excellent Bishop score [30]

Some experts recommend delivery at 39 wks if not already delivered for co-morbidities [30]

Anesthesiology

Consult as indicated for non-obese patients

Alert them for anesthesia assessment when patient admitted even if not anticipating need for anesthesia services

Can assess if regional anesthesia is an option or not

Unscheduled cesarean section for indications

Routine management [35]

Consider in labor management given the inability to do a truly emergent cesarean section [35]

Incision type for cesarean section

Routine management [17]

Consider patient body habitus

Antibiotic coverage for cesarean section

Routine management [40]

Consider increased dose based on weight and consider repeat dose 4 hours post initial dose [40]

Postpartum Care

DVT prevention

Similar to non-obese patients [45]

Consider use of anticoagulation meds especially if other risk factors for DVT such as cesarean section, preeclampsia, infection, etc. [45]

Difficulty with lactation

Lactation consultation in hospital and after discharge [47]

Lactation consultation in hospital and after discharge [47]

Dawn M Palaszewski, MD Assistant Professor, Division of General Obstetrics and Gynecology, Assistant Clerkship Director of Surgical Care Clerkship, Clerkship Co-Director of Maternal Newborn Pediatrics Clerkship, Director of Preclinical Integration for Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine

Dawn M Palaszewski, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology, Society for Academic Specialists in General Obstetrics and Gynecology

Disclosure: Nothing to disclose.

Sharon T Phelan, MD Professor Emerita, Department of Obstetrics/Gynecology, University of New Mexico School of Medicine

Sharon T Phelan, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, New Mexico Medical Society

Disclosure: Received income in an amount equal to or greater than $250 from: Advanstar – Contemporary Ob-Gyn publishers as an editorial board member.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Yonah Korngold 

Disclosure: Nothing to disclose.

Edward H Springel, MD, FACOG Assistant Professor, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine; Attending Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Health System

Edward H Springel, MD, FACOG is a member of the following medical societies: American Congress of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine, Society for Reproductive Investigation

Disclosure: Nothing to disclose.

Obesity and Pregnancy

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