1. Managing Pregnancy and Delivery for women with obesity A/Prof Leonie Callaway

2. GOAL: A PRACTICAL OUTLINE

3. MATERNAL OBESITY IS IMPORTANT AND COMMON

4. Queensland: Where Australia shines!

5. Maternal Obesity in Queensland 2006: 33% overweight and obese (Callaway et al, MJA, 2006) 2008: 50.5% overweight and obese (QH statbites)

6. Importance UK Confidential Enquiry into Maternal and Child Health Obesity is a significant risk factor for maternal mortality 35% of all mothers who died were obese (10-18.9% of the UK obstetric population are obese)

7. HOW DO WOMEN BECOME OBESE?

8. Reduced Physical Activity Increased consumption processed foods Low breastfeeding ratesSocial changesSleep debtEndocrine disrupters Decreased variability in ambient temperatures Decreased smoking Increased use of steroids and antipsychotics Pregnancy at older age in overweight women Demographic changes with older people, ethnic changes Chronic stressMicronutrient deficiency Keith et al, Int J Obesity, 2006

9. What do obese pregnant women eat?

10. Energy intake (n=50) 3 Day food recall, administered by trained dieticians All participants were within 10% of recommended daily caloric intake

11. Dietary intake of obese pregnant women at 12 weeks gestation (n=50) Serves / dayRecommendedMeanSt DevMinimumMaximum Breads & cereals62.601.120.505.40 Vegetables53.051.760.509.30 Fruit33.062.210.009.80 Dairy21.761.400.005.90 Meat & alternatives 22.171.150.006.80 Extras0-24.622.681.4015.00 Dietary folate (micrograms) 60028410464541 Croaker S et al, Nutrition and Dietetics, 2010.

12. THE COMPLICATIONS?

13. Maternal Complications Thromboembolism Hypertensive disorders of pregnancy Gestational diabetes Abnormal liver function tests

14. Obstetric Complications Increased IOL Higher rate of failed VBAC Dramatically increased rates of C Section Increased rates of complicated normal vaginal delivery – Shoulder dystocia – Third/fourth degree lacerations – Failure to progress

15. Anaesthetic Complications Epidural analgesia during labour is more likely to fail as BMI increases General anaesthesia complicated by: – Postpartum sleep apnoea – Difficult intubation

16. Practical Difficulties Inaccurate assessment of growth, lie, presentation Blood pressure cuffs/automated blood pressure devices Vascular access Theatre beds/trolleys/staff Ultrasonography Monitoring during labour

17. Peripartum Neonatal Monitoring Maternal obesity associated with: – Difficulties obtaining an adequate CTG – Increased rates of fetal distress – Increased rates of meconium aspiration

18. Perioperative complications Increased post partum haemorrhage Endometritis Wound breakdown and infection

19. Perinatal Complications Length of stay>5 days – Overweight OR 1.36 – Class I and II Obese OR 1.49 – Class III Obese 3.18 (Callaway et al, 2006) For obese women: – Chest infection OR 1.34 – Genital infection OR 1.3 – Wound infection OR 1.34 – UTI OR 1.39 – PUO OR 1.29 – Prolonged postnatal stay OR 1.48 (Sebire et al, 2001)

20. Neonatal Complications Macrosomia Lower rates of breastfeeding Increased rates of congenital anomalies Stillbirth, neonatal death

21. WHAT CAN WE DO ABOUT IT?

22. Interesting Issues from Guidelines American College of O&G (2005) – Height and weight measured in all women – Weight gain guidelines (IOM) – Dietary advice – Consider screen for GDM at presentation – Consider cardiac evaluation if BMI>35 – Anaesthetic consultation – Careful thromboembolism prophylaxis – If not pregnant –preconception counselling, provision of information regarding risk, weight loss prior to pregnancy RCOG Consensus View (2007) – BMI should be measured in all pregnant women, and weight measured at every clinic visit; interpregnancy weight change should also be recorded – Diet, exercise and psychopathology should be attended to – Women with a BMI of over 35 should not have infertility investigation or treatment until their BMI is less than 35, and ART should be reserved for women with a BMI under 30. – Aspirin 75 mg/day from 12 weeks if BMI>35 – Consider high dose folic acid (5mg per day) – Consider antenatal thromboprophylaxis if additional risk factors – Detailed anomaly scan – GTT at 28 weeks

23. Interventions during pregnancy: Monitoring/Screening Weighing pregnant women Early OGTT, early ELFTs Early screening for vascular disease Anomaly screening High risk model of care with regular screening for preeclampsia –early urinary protein estimation and baseline blood pressure measurement All based on expert opinion, underpinned by good data about increased risk in obese pregnant women

24. When we see women at the beginning of pregnancy, can we effectively prevent complications in obese women? Preeclampsia: No good evidence yet GDM: Maybe Excessive weight gain: Yes Neonatal morbidity: No evidence yet

25. Therapeutic options Metformin –unstudied Diet Exercise Lifestyle intervention CPAP Probiotics

26. Dietary intervention to prevent weight gain – 10 x 1 hour nutrition consultations – Fat 30%, protein 15- 20%, Carb 50-55% – Caloric restriction (individual calculation) Intervention N=23 Control N=27 P kJ per day 27 weeks 73199867<0.001 Total weight gain 6.6kg13.3kg0.002 Wolff et al, 2008, Int J Obesity.

27. Diet intervention in obese pregnant women RCT 257 women, BMI>30 Study group: – Dietitian review, – 18-24 kcal/kg, – F30,P30,C40, – all >2000 cal Gained less weight (11 vs 31 lbs) Retained less weight No ketonuria Less gestational hypertension No difference in perinatal outcomes Thornton et al, J Nat Med Ass 2009

28. Lifestyle intervention ControlPassiveActivep Calories 2 nd trimester kCal/day 202018911880<0.004 Weight gain kg 6.87.127.140.47 No difference in physical activity No difference in any maternal, obstetric, neonatal outcomes 35 F/10P/55C Guelinckx et al, AJCN 2009

29. Lifestyle intervention RCT 100 women stratified for BMI Intervention group: – Dietitian visit, F30,P30,C40 – Advice re moderate intensity exercise 5 times per week Weight gain reduced in intervention group Absee et al, Obstet Gynecol 2009

30. Exercise in Obese Pregnant Women RCT, n=50 Individually tailored, goal directed intervention At 28 weeks: – 16/22 in intervention met targets – 8/19 in control met targets – No difference in HOMA Callaway et al, Diabetes Care, 2010. P=0.047

31. Is screening for and aggressive management of complications effective? Hypertensive disorders? GDM: Yes Congenital anomalies?

32. GDM treatment prevents preeclampsia Crowther et al, NEJM; 2005.

33. Interventions during pregnancy: Models of Care Guidelines support: – Multidisciplinary care (obstetricians, physicians, ultrasonographers, maternal-fetal medicine specialists, dieticians, physios, anaesthetists) – Physical requirements (beds, theatre beds etc) – High risk pregnancy care Need for health services research and detailed economic analysis of models of care Potential to examine the impact of models of care on pregnancy and neonatal outcomes

34. Interventions in Pregnancy: Postpartum care Guidelines and expert opinions suggest: – Timely uterotonics – Thromboprophylaxis – Surveillance for infections – Expert lactation support

35. Interconception Care Modest amounts of weight loss between pregnancies can reduce the risk of GDM in subsequent pregnancies Guidelines suggest: – Nutrition counselling – Exercise programs – Weight management support – Follow up of complications of pregnancy (eg hypertension, gestational diabetes) Important time in shaping family habits Potential for high quality interconception care trials

36. A PRACTICAL APPROACH

37. First Visit First visit: – Detailed history and physical examination –consider hypothyroidism, PCOS, endocrinopathies, depression. – FBC, ELFT’s, OGTT, urine protein creatinine ratio – Advice regarding diet, exercise, weight gain, smoking cessation – Consider higher dose folic acid and aspirin – Refer to obstetrician and anaesthetist – Midwife support essential – Consider risk factors for thromboprophylaxis – Multidisciplinary care – Consider appropriate facility for delivery

38. Subsequent visits Breastfeeding information 28 week OGTT Monitor weight gain Expert USS of fetus at 18-20 weeks Ward test urine and blood pressure at every visit –low threshold for further tests for preeclampsia Ensure anaesthetic review

39. At delivery Skills of health care professionals and the capacity of the facility Monitoring and IV access issues Uterotonics IV antibiotic prophylaxis Thromboprophylaxis Breastfeeding support

40. Post partum Breastfeeding support which takes much longer than in normal weight women Watch carefully for infections Thromboprophylaxis Advise regarding weight loss and follow up for pregnancy complications