1. MANAGEMENT OF THE OBESE PREGNANT PATIENT Max Brinsmead PhD FRANZCOG May 2010

2. Definition & Incidence  BMI > 30  Class 1 obesity = BMI 30 - 35  Class 2 " = BMI 35 – 40  Class 3 “ = BMI >40 Also called morbid obesity  Incidence has doubled in the past decade  Now ≈ 20% of patients in first world societies

3. Risks and Complications  Increased maternal risk of: Miscarriage Thromboembolism (9.7 fold) Gestational diabetes (2.4-3.6 fold) Pre eclampsia (2.1-3.3 fold) Dysfunctional labour (1.3x length of labour) Caesarean section (2.1 fold) Wound infection (2.2 fold) Anaesthetic complications Maternal mortality  NB Most studies demonstrate a linear relationship between risk and BMI

4. Risks and Complications (2)  Increased fetal risk of: Congenital malformation (1.6 fold) Fetal macrosomia (2.1-3.1 fold) Shoulder dystocia Stillbirth (2.1 fold) Neonatal death (2.6 fold) Neonatal morbidity i.e. NICU admission Reduced rates of breast feeding

5. Management Recommendations (RCOG)  Optimise weight before pregnancy Educate & advise all women with BMI>30 to lose weight before conception Weight loss >4.5 Kg before pregnancy reduces the risk of gestational diabetes by 40%  Dietary Supplementation Folic acid 5 mg/day for -1 to +3 months of pregnancy Vitamin D 10 ug/day (? Required for a sun-loving Aussie)  Measure and calculate BMI at first ANV Preferably before 12w Don’t rely on self estimates of height & weight  Dietary Advice

6. Management Recommendations (2)  Recommend daily physical activity & reinforce  Provide detailed, accurate and specific pregnancy risk advise to all women with BMI>30  Women with BMI>35 need obstetrician-led Delivery Unit  Discuss & document intrapartum risks and plans management  Induction of delivery only for obstetric indications  Requests for VBAC require individual assessment  IV access in labour  Active management third stage  Subcutaneous suture if Caesarean is required  Special education and support for breastfeeding should begin antenatally  Encourage postnatal weight loss or refer

7. Thromboprophylaxis  Assess additional risk factors  BMI>30 plus one additional risk factor qualify for seven (7) days of postpartum Clexane  BMI>30 plus two additional risk factors consider antenatal Clexane & six (6)weeks postnatal treatment  BMI>40 should be regarded as already having two risk factors  Dose of Clexane should be titrated by weight: 70 – 90 Kg 40 mg once daily 91 – 130 Kg 30 mg 12 hourly 131 – 170 Kg 40 mg 12 hourly >170 Kg use 0.6 mg/Kg/day in two divided doses  Early mobilisation and TED stockings

8. Gestational Diabetes  75G GTT recommended for all obese patients at 24 - 28 weeks  Manage as per existing guidelines for gestational diabetes  Follow up postpartum with GTT at 3m and annually thereafter screen for cardiovascular risk factors  Offer puerperal weight loss and lifestyle changes

9. Pre eclampsia  Use the appropriate-sized cuff for BP measures  Consider increased surveillance if there is another risk factor present i.e. Primigravida Age >40 years More than 10 years since the last baby Family history of preeclampsia Booking BP >80 diastolic Multiple pregnancy Chronic hypertension, thrombophilia, diabetes, renal disease  These patients may benefit from low dose aspirin from 12w until delivery

10. For Women Whose BMI > 40  Antenatal review by anaesthetist to develop an anaesthetic plan  Plan for manual handling/skin care, TED stockings etc.  Experienced obstetrician & anaesthetist available for labour  Notify both when admitted in labour  Alert theatre for all patients >120 Kg  One to one midwifery care required  Offer postpartum thomboprophylaxis

11. Unproven or Controversial  Specialised antenatal clinics for the obese  Best practice in dietary and exercise advice  Role of gastric banding before and after pregnancy & management of pregnant banded patients  Anti-obesity drugs in pregnancy  Ultrasound for the obese pregnant woman  Who requires elective Caesarean section?  Issues of contraception