OBSTETRIC CONSEQUENCES FOR THE OBESE GRAVIDA Alan Peaceman, MD. Standardized BMI Classification 11/7/2011. OBSTETRIC CONSEQUENCES Outline

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1 OBSTETRIC CONSEQUENCES FOR THE OBESE GRAVIDA Alan Peaceman, MD OBSTETRIC CONSEQUENCES Outline Epidemiology Pre pregnancy approach Talking about diet Issues in antepartum care Intrapartum management Post partum approach What are we doing about it? Standardized BMI Classification County-level Estimates of Obesity among Adults aged 20 years: United States 2008 Body Mass Index kg/m2 Classification < 18.5 Underweight Normal weight Overweight Obese ClassI Obese Class II 40 Obese Class III (Extreme) NHLBI Obesity Education Initiative, NIH Publication No September 1998 Age-adjusted percent > Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Gender/Racial Differences in Obesity Obesity (BMI 30 kg/m 2 )) Diabetes No Data <14.0% % % % >26.0% No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at Women have higher rates of obesity or overweight/obesity based on data Obesity: 35.5% versus 32.2% Overweight/Obesity: 72.3% vs. 64.1% Non Hispanic African Americans, especially women, have the highest rates of obesity, including morbid obesity, of all races/ethnicities % Obese (BMI > 30) % Extremely Obese (BMI > 40) Obesity in minorities years old Ogden et al. NCHS Data brief No JAMA. 2010;303(3):

2 Prevalence Reproductive age women: overweight or obese 1990: 37% 2008: 59.5% Adverse Consequences Fetal anomalies NTD OR 2.2 ( ) Gestational diabetes OR 2.8 ( ) Venous thromboembolism OR 2.2 ( ) Preeclampsia OR 24(2 2.4 ( ) 2 25) Cesarean OR 1.6 ( ) Shoulder dystocia OR 1.5 ( ) Stillbirth OR All of these are even higher with severe obesity Adverse Consequences Offspring consequences Anomalies Metabolic abnormalities Childhood obesity Childhood diabetes Preconception Counseling Screening for comorbid conditions: Hypertension Pregestational Diabetes: 2 hour GTT Random or fasting FSBG Hgb A1c Thyroid disease Heart disease Respiratory complications Sleep apnea Preconception Counseling Recommend weight loss prior to pregnancy Review perinatal consequences Assess readiness for behavioral changes Diet Exercise Medications Folic acid Surgery Antepartum care Review of risks and complications Discussion of weight gain target Dietary counseling Dietary counseling Encouragement of exercise Screen for preexisting diabetes Screen for sleep apnea 2

3 Regardless of how much women weigh before they become pregnant, gaining between pounds during pregnancy can improve the outcome of pregnancy and reduce their chances of having the pregnancy end in fetal death. ACOG Newsletter 1986;30:9 For normal weight women, mean weight gain >1.0 lb/wk associated with: BMI category Recommended total gain Kg Lb Mean (kg/wk) Rate of Weight gain 2 nd and 3 rd trimesters Mean (lb/wk) Obstet Gyn Sept 2011 Underweight (<18.5) Normal ( ) Overweight ( ) Obese ( 30.0) IOM Guidelines BMI category Recommended total gain Kg Lb Low (<19.8) Normal ( ) High ( ) Extremely obese (>29.0) At least BMI category Recommended total gain Kg Lb Underweight (<18.5) Normal ( ) Overweight ( ) Obese ( 30.0) Shift in emphasis from making sure pregnant women eat enough to reduce risk of FGR To: Emphasis on counseling to avoid excess weight gain 3

4 Specific Recommendations: Offering preconception services to all overweight and obese women to reach healthier weight before conception Offering counseling on diet and activity to all women during pregnancy Offering counseling on diet and activity to all women post partum Insufficient evidence to recommend lower weight gain for obese patients Lower weight ihgain does appear to lower incidence of macrosomia Avoid ketonemia Programs for Weight Gain Limited data regarding the success of programs to control gestational weight gain Limited data that programs improve pregnancy outcomes No data that programs improve long term health for the mother or the baby How do you get from total weight gain recommendations to the dinner table? and Are the recommendations for what you should eat any different for obese women? Patient Motivation Patients may be unaware that concept of eating for two is outdated Instruction as to risks associated with excess weight gain on pregnancy outcomes, long term maternal health Patients may be uniquely motivated by desire to improve long term outcome for their child Calorie Recommendations 35 cal/kg/d (based on ideal body weight) 60kg (132 lb) 2100 cal outdated? Should we even be adding 300 calories for pregnancy and lactation? Allowances for level of activity 4

5 Calorie Recommendations Harris Benedict equation (non pregnant) (9.563 x kg) + (1.850 x cm) (4.676 x age) Multiply by activity factor ( ) Add 300 for pregnancy if normal weight Or choosemyplate.gov Portion control Correct mix of calories Avoidance of bad foods Frequent meals Good eating habits Use 24 hour food recall diary Portion Control Correct Mix of Calories Learn serving sizes for different foods Limits even on good foods fruits fruits and vegetables, dairy Balanced 40% carbs 20 30% fat 30 40% protein Divided up into meals and snacks Protein will not increase weight as much as carbohydrates Servings by calories range Starch Dairy Fruit Vegetables Protein Fat Biggest Issues Fast foods (calorie dense) Cultural issues Behaviors (eating for stress) Lack of activity Fast eating, distractions Dessert/snacking All of these may benefit from behavior modification interventions 5

6 Limitations of Antepartum care Serum screening Ultrasound detection of anomalies Assessment of fetal growth Prevention of stillbirth Sleep Disordered Breathing Sleep disordered breathing (SDB) Poor quality of ventilation during sleep Obstructive sleep apnea is most common Repetitive episodes of upperairway obstruction during sleep Intermittent hypoxemia and poor sleep quality Symptoms Poor Sleep Quality Snoring Witnessed nocturnal breathing pauses, gasping Difficulties maintaining sleep Frequent awakenings Restless sleep Excessive daytime sleepiness Impairment of daytime function Morning headaches Altered mood Fragmented Sleep Shortened Sleep Durations Autonomic dysregulation Inflammation Insulin Resistance Abnormalities in appetite regulating hormones Screening for SDB in Pregnancy Higher risk if: Overweight or Obese, or Chronic Hypertension + Self reported habitual snoring and/or witnessed nocturnal breathing pauses AND Poor daytime functioning because of unrefreshing sleep Fetal Surveillance Increased rate of stillbirth BMI kg/m 2 OR (12 15/1000) BMI > 30 kg/m 2 OR (13 18/1000) Present even after correction for smoking, diabetes, preeclampsia Risk appears to be greatest at later gestational ages. Hazard ratio for stillbirth: 2.0 at 30 weeks to 4.0 at term No evidence based recommendation exists for AP monitoring (? > 35BMI or >40 BMI) Obstet Gynecol 2009; 113: Am J Obstet Gynecol 2005; 193: Obstet Gynecol 2005;106:

7 Post Partum Care Breast feeding Weight loss Exercise Testing for diabetes in those with GDM Bariatric Surgery Principles Restrictive restricts the total intake and thereby limits calories obtained Roux en Y gastric bypass Sleeve gastrectomy Laparoscopic adjustable banding (LapBand) Malabsorptive and restrictive also limits absorption of caloric intake Roux en Y gastric bypass Biliopancreatic diversion +/ duodenal switch Rate of Cesarean after Bariatric Surgery Reduction in Rate of GDM after Bariatric Surgery % LapBand (3) Gastric Bypass (4) Biliary Pancreatic Diversion (2) Reduction in Rate of Macrosomia after Bariatric Surgery Vitamin and Mineral Deficiency after Gastric Bypass vs Banding % Procedure Iron Folate B12 Calcium Vit D Thiamine (B1) Gastric Banding + + ± ± ± ± Gastric Bypass ± 7

8 Preconception Counseling after Bariatric Surgery Avoid pregnancy in the first postoperative year stabilize weight loss Decreases risk for IUGR Achieve maternal weight loss goals Allows for stabilization of nutrition and repletion Reliable contraception increased failure in oral contraceptives in year 1. Pregnancy rates 2x that of adolescent population following bariatric surgery (12.8% vs. 6.4%) Preconception Counseling after Bariatric Surgery Supplemental Folic Acid as possible increased risk for NTD s. Screen for micronutrient i dfii deficiency (Fe, Folate, B12, Ca, Vit D) and anemia. Recommend weight gain of 15 lbs or less in these pregnancies Obes Surg 2007; 17:873-7 Obes Res 2005; 13:274 Obstet Gynecol 2009; 113: OBSTETRIC CONSEQUENCES Summary Recognition of increase risks of adverse outcome Review the adverse consequences associated with pre pregnancy obesity and excess gestational weight gain Talk to all patients about appropriate diet and recommended weight gain Continued attention to weight throughout the pregnancy and weight loss after Appropriate surveillance for adverse events 8