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Clinical Reviews


PART 1 OF 2: For the obese gravida, try strong counseling and close follow-up

Obese gravidas need to be apprised of the many risks they incur with pregnancy—and be monitored closely to avert disaster

February 2009 · Vol. 21, No. 02

IN THIS ARTICLE

The authors report no financial relationships relevant to this article.

Hear Dr Phillips discuss the key points of this series

CASE: Obesity + coexisting conditions = complicated pregnancy and delivery

A 30-year-old gravida 8 para 5026 is referred from the clinic for evaluation of elevated blood pressure at 36 4/7 weeks’ gestation. She is morbidly obese, with a weight of 440 lb and a body mass index (BMI) of 67. She also has a history of chronic hypertension and was recently given a diagnosis of gestational diabetes, which has been controlled through diet.

Her reproductive history includes four full-term vaginal deliveries followed by cesarean delivery for malpresentation of twins. Her blood pressure is 180/100 mm Hg, and she has new-onset proteinuria (3+) and a headache. The diagnosis? Preeclampsia superimposed on chronic hypertension.

Induction of labor is initiated using a Foley bulb and oxytocin, and magnesium sulfate is given to prevent seizures. Over the next 48 hours there is minimal cervical change, and the patient develops chorioamnionitis, for which she is given intravenous antibiotics. A repeat cesarean delivery is performed via a Pfannenstiel skin incision. The surgery is uneventful, and the infant is healthy.

Are further complications likely?

Yes—additional complications are considerably more likely in this scenario than in one involving a patient of normal weight, especially given the patient’s chronic hypertension and gestational diabetes. Obesity can affect all aspects of pregnancy, from conception through the postpartum period, with the potential for significant adverse maternal and fetal outcomes, including maternal mortality.

As the number of obese women of reproductive age increases, obstetricians face new challenges in the management of complications during pregnancy, labor, delivery, and beyond. In Part 1 of this two-part article, we offer advice on how to counsel the obese patient about the very real risks she faces in pregnancy, and detail trimester-specific recommendations. In Part 2, which follows on page 51, we offer practical management strategies during intrapartum, intraoperative, and postpartum periods.

CASE CONTINUED

The patient becomes febrile and hypoxic on postoperative day 1. When a computed tomography scan fails to rule out pulmonary embolism, she is started on heparin.

On postoperative day 7, omentum is detected at the incision, and the patient is taken to the operating room, where fascial dehiscence is identified and necrotic tissue is debrided. Two days later, a wound vac and inferior vena cava filter are placed.

The patient is discharged to a rehabilitation center on postoperative day 22.

Management starts before conception

The most important strategy to prevent complications associated with obesity and pregnancy is prepregnancy weight loss. Ideally, all obese patients should have a prepregnancy consultation that includes the recommendation to lose weight before conception. At this consultation, the ObGyn should determine the patient’s BMI and risk category and advise her of the relevant maternal and fetal risks (page 51, we take up intrapartum and postpartum concerns.

References

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4. Institute of Medicine, Committee on Nutritional Status During Pregnancy. Nutrition during pregnancy. Washington, DC: National Academy Press; 1990.

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6. Waller DK, Shaw GM, Rasmussen SA, et al. National Birth Defects Prevention Study. Prepregnancy obesity as a risk factor for structural birth defects. Arch Pediatr Adolesc Med. 2007;161:745-750.

7. O’Brien TE, Ray JG, Chan WS. Maternal body mass index and the risk of preeclampsia: a systematic overview. Epidemiology. 2003;14:368-374.

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9. Endler GC, Mariona FG, Sokol RJ, Stevenson LB. Anesthesia-related maternal mortality in Michigan, 1972 to 1984. Am J Obstet Gynecol. 1988;159:187-193.

10. Saravanakumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia. 2006;61:36-48.

11. Salihu HM, Dunlop AL, Hedayatzadeh M, Alio AP, Kirby RS, Alexander GR. Extreme obesity and risk of stillbirth among black and white gravidas. Obstet Gynecol. 2007;110:552-557.

12. World Health Organization. Obesity and overweight. Fact sheet No. 311. Geneva, Switzerland: WHO; 2006. Available at: www.who.int/mediacentre/factsheets/fs311/en/index.html. Accessed December 30, 2008.

13. Centers for Disease Control and Prevention. Overweight and obesity. Atlanta: CDC. Available at: www.cdc.gov/nccdphp/dnpa/obesity/index.htm. Accessed December 30, 2008.

14. Bentley-Lewis R, Koruda K, Seely EW. The metabolic syndrome in women. Nat Clin Pract Endocrinol Metab. 2007;3:696-704.

15. Dixon JB, Dixon ME, O’Brien PE. Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol. 2005;106(5 Pt 1):966-972.

16. American College of Obstetricians and Gynecologists. Committee Opinion No. 315. Obesity in pregnancy. Washington, DC: ACOG; 2005.

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