1. In the name of GOD The Compassionate & The Merciful

2. Impact of obesity on pregnancy Fahimeh Ramezani Tehrani Professor Reproductive Endocrinology Research Center Shahid Beheshti University of Medical Sciences 2014

3. Global prevalence of obesity (BMI 30)

5. Women of Childbearing Age Percent Overweight or Obese Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-41.

8. Sub-fertility & Infertility Ovulatory dysfunction Ovulatory dysfunction PCOS PCOS Poorer out come of infertility treatments Poorer out come of infertility treatments Adverse effect on implantation? Adverse effect on implantation? Higher doses of ovulation inducing agent Higher doses of ovulation inducing agent Higher risk of OHSS Higher risk of OHSS

10. Spontaneous abortion OR of miscarriage foe obese women was 1.8(95%CI 1.14-3.13) in meta analysis conducted in 2008. OR of miscarriage foe obese women was 1.8(95%CI 1.14-3.13) in meta analysis conducted in 2008. Chromosomal abnormality? Chromosomal abnormality? PCOS PCOS Poor endometrial receptivity Poor endometrial receptivity Confounding factors age, S.E status Confounding factors age, S.E status

17. Maternal Complications Maternal Complications Higher Rates of Cesarean Section and labor dysfunction Higher Rates of Cesarean Section and labor dysfunction Gestational Hypertension Gestational Hypertension Pre-eclampsia Pre-eclampsia preterm birth preterm birth Gestational Diabetes Gestational Diabetes LGA and Shoulder dystocia LGA and Shoulder dystocia Stillbirth Stillbirth DVT/PE DVT/PE Anesthetic complications Anesthetic complications

18. Risk of Cesarean Section Increased risk due to: Increased risk due to: Dysfunctional labor Dysfunctional labor Monitoring challenges Monitoring challenges Increased rates of pre-eclampsia, hypertension and LGA babies all contribute to likelihood of cesarean section Increased rates of pre-eclampsia, hypertension and LGA babies all contribute to likelihood of cesarean section

19. Cesarean Section – Clinical Challenges Access to lower uterine segment can be challenging Access to lower uterine segment can be challenging Higher rate of wound complications after surgery Higher rate of wound complications after surgery Higher risk of anesthetic complications Higher risk of anesthetic complications

20. Difficulties with Regional Anesthesia 150 kg 150 kg Difficult veins Difficult veins Unable to curve lumbar spine Unable to curve lumbar spine Impalpable iliac crests Impalpable iliac crests Impalpable vertebral spines Impalpable vertebral spines

21. Aortocaval Compression 120 kg150 kg

22. Gestational Hypertension Pre-existing hypertension is more common among obese women Pre-existing hypertension is more common among obese women Among those without hypertension at baseline, increased risk of developing gestational hypertension Among those without hypertension at baseline, increased risk of developing gestational hypertension

23. Gestational Hypertension Population-based study in the Netherlands Population-based study in the Netherlands Increased rates of gestational hypertension among obese women (BMI >35), with odds ratio 4.67 Increased rates of gestational hypertension among obese women (BMI >35), with odds ratio 4.67 Gaillard R et al. Associations of maternal obesity with blood pressure and the risks of gestational hypertensive disorders. Journal of Hypertension 2011, 29:937-944.

24. Gestational Hypertension: A UK population-based study Among extremely obese women (BMI >50): Among extremely obese women (BMI >50): 1 in 5 develop hypertensive disorder in pregnancy 1 in 5 develop hypertensive disorder in pregnancy 1 in ten develop pre-eclampsia 1 in ten develop pre-eclampsia Among women with less severe obesity, risk is increased but to a lesser degree Among women with less severe obesity, risk is increased but to a lesser degree Knight, M et al. Extreme Obesity in Pregnancy in the UK. Obstet Gynecol, Vol 115, No 5. May 2010.

25. Pre-eclampsia Risk of pre-eclampsia is increased in obese pregnant women Risk of pre-eclampsia is increased in obese pregnant women Pre-eclampsia can lead to compromised fetal perfusion and to medically-indicated preterm birth. Pre-eclampsia can lead to compromised fetal perfusion and to medically-indicated preterm birth. In population-based study in Netherlands, increased risk of pre-eclampsia was observed for obese women (BMI >35), with odds ratio of 2.5. In population-based study in Netherlands, increased risk of pre-eclampsia was observed for obese women (BMI >35), with odds ratio of 2.5.

26. Gestational Diabetes Gestational diabetes is more common in obese pregnant women Gestational diabetes is more common in obese pregnant women In addition, there is a higher rate of pre- existing diabetes in obese pregnant women In addition, there is a higher rate of pre- existing diabetes in obese pregnant women

27. Gestational Diabetes: A UK population-based study Among extremely obese women, 11% developed gestational diabetes Among extremely obese women, 11% developed gestational diabetes Of those, 70% required insulin Of those, 70% required insulin Risk of developing diabetes was seven times higher than in non-obese controls Risk of developing diabetes was seven times higher than in non-obese controls Among women with less severe obesity, risk is increased but to a lesser degree Among women with less severe obesity, risk is increased but to a lesser degree Knight, M et al. Extreme Obesity in Pregnancy in the UK. Obstet Gynecol, Vol 115, No 5. May 2010

28. Cohort Study of Rates of Stillbirth There was significant racial disparity, with higher rates of stillbirth among black women than white women There was significant racial disparity, with higher rates of stillbirth among black women than white women Disparity widened with increasing BMI, with disproportionately highest stillbirth among extremely obese black women (BMI > 40). Disparity widened with increasing BMI, with disproportionately highest stillbirth among extremely obese black women (BMI > 40). Salihu, HM et al. Extreme Obesity and Risk of Stillbirth Among Black and White Gravidas. Obstet Gynecol 2007; 110:552-7.

29. DVT/PE Immobilization and pregnancy are both risk factors for DVT/PE Immobilization and pregnancy are both risk factors for DVT/PE Obese pregnant women often have decreased mobility, particularly with extreme obesity Obese pregnant women often have decreased mobility, particularly with extreme obesity Cesarean delivery further increases the risk Cesarean delivery further increases the risk

31. Multi-fetal pregnancy Increase incidence of dizygotic not monzygotic Increase incidence of dizygotic not monzygotic Elevated FSH Elevated FSH

32. Obstructive sleep apnea May be associated with hypertensive disorder and impaired fetal growth May be associated with hypertensive disorder and impaired fetal growth Post operative respiratory depression after receiving opiates Post operative respiratory depression after receiving opiates

33. Urinary tract infection 42% increase in risk of UTI 42% increase in risk of UTI Not more frequent UTI screening for asymptomatic bacteriuria Not more frequent UTI screening for asymptomatic bacteriuria

34. Placenta and cord No increase placenta previa No increase placenta previa No increase abruption of placenta No increase abruption of placenta No cord accident No cord accident

35. Fetal and Neonatal Complications ComplicationBMI 19.8-26BMI 35.1-40BMI > 40 Stillbirth0.3%0.6% (OR 1.99)0.8% (OR 2.79) Fetal distress2.0%3.5% (OR 2.13)3.9% (OR 2.52) Meconium aspiration 0.1%0.3% (OR 2.87)0.3% (OR 2.85) Neonatal death0.1%0.3% (OR 2.09)0.4% (OR 3.41) Cedergren, MI. Maternal Morbid Obesity and the Risk of Adverse Pregnancy Outcome. Obstet Gynecol, Vol 103, No 2. Feb 2004.

36. Fetal and Neonatal Complications As maternal BMI has risen, there has been a significant increase in the number of babies born with high birth weight. As maternal BMI has risen, there has been a significant increase in the number of babies born with high birth weight. Larger babies have more adipose tissue. Larger babies have more adipose tissue. Surkan PJ, Hsieh CC, Johansson AL, Dickman PW, Cnattingius S. Reasons for increasing trends in large for gestational age births. Obstet Gynecol 2004; 104: 720-6.

39. What happens later in life for children born to obese mothers? Children born to obese mothers are twice as likely to be obese and develop type 2 diabetes in adult life. Children born to obese mothers are twice as likely to be obese and develop type 2 diabetes in adult life. Higher maternal gestational weight gain has been associated with high blood pressure in offspring. One study showed an association between maternal BMI and the hepatic lipid content in the infants. Higher maternal gestational weight gain has been associated with high blood pressure in offspring. One study showed an association between maternal BMI and the hepatic lipid content in the infants. The increased lipid content in the liver may initiate programming of the metabolic syndrome in utero The increased lipid content in the liver may initiate programming of the metabolic syndrome in utero The Influence of Maternal Body Mass Index on Infant Adiposity and Hepatic Lipid Content. Pediatric Research,2011

40. Clinic Challenges Identifying fetal heart tones Identifying fetal heart tones Assessing fetal growth Assessing fetal growth Fundal height difficult to obtain Fundal height difficult to obtain Assessing for hypertension Assessing for hypertension Blood pressure cuffs may be of inadequate size Blood pressure cuffs may be of inadequate size Difficulty in reliable sonographic assessment Difficulty in reliable sonographic assessment Difficulty in anesthesia procedures Difficulty in anesthesia procedures Difficulty in surgical procedures Difficulty in surgical procedures

41. Recommended total weight gain ranges for pregnant women by pre-pregnancy BMI BMI CategoryRecommended total gain (Kg) Low(BMI<19.8)12.5-18 Normal(BMI 19.8-26)11.5-16 over( BMI>26-29)7- 11.5 High(BMI >29)At least 6.9

42. Excess Gestational Weight Gain Health Impacts on Neonates & Children: Low 5-minute Apgar scores Low 5-minute Apgar scores Neonatal seizures Neonatal seizures Hypoglycemia Hypoglycemia Large for gestational age infants Large for gestational age infants Meconium aspiration Meconium aspiration NICU admission NICU admission 4-fold increased lifetime risk of overweight/obesity 4-fold increased lifetime risk of overweight/obesity Lifelong elevated risk for diabetes, hypertension, cardiovascular disease, cancer, early death Lifelong elevated risk for diabetes, hypertension, cardiovascular disease, cancer, early death

43. Excess Gestational Weight Gain Health Impacts on Women: Postpartum weight retention Postpartum weight retention Long-term weight gain Long-term weight gain Excess body fat Excess body fat Sleep apnea Sleep apnea Pre-diabetes/diabetes Pre-diabetes/diabetes Coronary heart disease Coronary heart disease

44. Attitude to weight gain For women who normally restrain their eating to preserve their figures, the inevitable change of shape during pregnancy serve as justification for “letting themselves go”. For women who normally restrain their eating to preserve their figures, the inevitable change of shape during pregnancy serve as justification for “letting themselves go”. They should “eat for two”. They should “eat for two”. Depriving themselves, depriving their child Depriving themselves, depriving their child

45. Change of body image Mothers who more dissatisfied with their bodies postpartum, increase energy intake following pregnancy Mothers who more dissatisfied with their bodies postpartum, increase energy intake following pregnancy Mothers who more dissatisfied with their bodies postpartum, higher long term weight gain Mothers who more dissatisfied with their bodies postpartum, higher long term weight gain

46. Figure Rating Scale

47. Risk factors associated with postpartum period Psychological factors Psychological factors o Depression o Self-esteem o Stress o Social support

48. Depression As a result of obesity As a result of obesity As modifier of biological or behavioral process that affect body weight As modifier of biological or behavioral process that affect body weight Compensatory action of “comfort eating” Compensatory action of “comfort eating”

49. Postpartum weight loss (kg) in groups with different lactation scores.

50. Recommendation Weight restriction may diminish the risk of maternal obesity but may have negative effect on fetus development Weight restriction may diminish the risk of maternal obesity but may have negative effect on fetus development Preconception weight reduction and limitation of maternal weight gain in obese gravidas is recommended Preconception weight reduction and limitation of maternal weight gain in obese gravidas is recommended

51. Recommendations Extreme cautious for recommending weight restriction during pregnancy Extreme cautious for recommending weight restriction during pregnancy Pregnant women eat to appetite by consuming a varied and balance diet Pregnant women eat to appetite by consuming a varied and balance diet Not “eat for two” Not “eat for two” Address the problem of pregnancy related weight gain soon after the birth Address the problem of pregnancy related weight gain soon after the birth Encourage the appropriate excersise Encourage the appropriate excersise Give them realistic expectation about weight loss following delivery Give them realistic expectation about weight loss following delivery

52. Thank you for your attention