I have read with great interest the review article by Gunatilake and Perlow in your February 2011 issue. Although the article is presented as a comprehensive review about the clinical management of the obese gravida, it did not recognize the current literature regarding the antepartum weight management in the obese pregnant woman. The authors state, “Patients should be advised that limited weight gain, rather than weight loss, is a primary goal during pregnancy.” Unfortunately, this statement was interpreted from the revised 2009 recommendations of the Institute of Medicine, which were based on older literature. More recent scholarship, however, based on the first and only (to date) randomized, clinical trial published in 2009, which studied the perinatal outcomes of obese pregnant women, concluded that rather than focusing on a numerical endpoint with respect to weight gain (or loss) in the obese pregnant woman, obese gravidas should adhere to a monitored, well-balanced nutritional program.

As one continues to read through the review, there are several concerns regarding the discussion of the intraoperative management of the obese gravida. The approach for pannus retraction described in the review of “tape (being) attached to the ‘ether screen,’” in my experience, has resulted in an unstable and precarious anchor for the large panniculus in a truly massively obese patient. With that said, the authors are referred to an observational study demonstrating panniculus retraction in the morbidly obese patient. Moreover, successful outcomes using a low transverse incision challenge the assertion of the authors who recommend “avoiding incision placement in the deep intertriginous fold inferior to the pannus because of the greater potential for surgical site infection… .” The 2001 study demonstrated no increase in the incidence of wound infection when a low transverse abdominal incision (Pfannenstiel) was used in obese women.

The authors should be commended for their due diligence in this review; however, the inclusion of current and established studies about the obese gravida would have made the review more complete.

Thank you for allowing me to voice my opinions regarding this article.