• 1.
  

  a) T b) T c) T d) F e) F

Recent evidence suggests that maternal obesity increases the risk of autism spectrum disorder in children. Maternal obesity increases the risk intra-uterine growth restriction as well as the risk of a macrosomic baby. There is no recognized link with Type 1 diabetes or cancer in childhood.

• 2.
  

  a) T b) T c) T d) F e) T

Studies show that maternal obesity increases the risk of Caesarean section and also reduces the success of vaginal delivery after Caesarean section. Maternal obesity increases the risk of vitamin D deficiency. Starvation or weight reduction is not recommended in obese women in pregnancy. The recommended carbohydrate intake is 45% –65 % of total energy in obese women in pregnancy.

• 3.
  

  a) F b) F c) T d) T e) T

There is no robust evidence supporting the use of Metformin in non-diabetic obese pregnant women. Low dose aspirin is not recommended in all obese pregnant women – it is recommended if additional risk factors for pre-eclampsia are present. Folic acid requirements are higher in obese pregnant women, therefore 5 mg of folic acid is recommended. Maternal obesity increases the risk of vitamin D deficiency.

• 4.
  

  a) F b) F c) T d) T e) F

The obesity epidemic is affecting both developed and developing countries alike. The incidence has actually doubled since the 1980s. Obesity is disproportionately higher in women compared to men. BMI > 30 is the level for obesity and >40 for morbid obesity. The 2003–05 report highlighted obesity as a significant risk for maternal death – more than half of all women who died from direct or indirect causes were either overweight or obese. The obese women account for 28% of the direct causes of maternal death.

• 5.
  

  a) F b) F c) T d) F e) T

Gestational diabetes mellitus affects about 5% of all pregnancies and the incidence is increasing worldwide. Langer et al. have shown that in order to achieve good pregnancy outcomes, obese women with GDM will need to be treated with insulin. If gestational diabetes mellitus is diagnosed, tight metabolic control should be achieved through diet and, when indicated, insulin therapy. A population-based cohort study of 4102 non-diabetic women with maternal obesity prior to their first singleton pregnancy found that a weight loss of at least 4.5 kg before the second pregnancy reduced the risk of developing GDM by up to 40%.

• 6.
  

  a) F b) F c) T d) F e) F

A recent Swedish Retrospective Study of 186,087 primiparous women concluded that higher maternal BMI in the first trimester was associated with longer gestation and an increased risk of post-date pregnancy. A retrospective review of 287,213 deliveries reported an adjusted OR of 2.24(95%CI 1.91 – 2.64) for wound infection in obese women compared with healthy weight women. However, the risk of morbidly obese the risk is almost 4 times the normal weight mother. Edwards et al. reported 683 obese women (BMI > 29 kg/m2) who were matched to 660 women of normal weight (BMI 19.8 to 26.0 kg/m2). The incidence of thromboembolism was 2.5% in the obese women, and only 0.6% in the control subjects. Many obese women will have indications for continuous fetal monitoring, such as hypertension, gestational diabetes or induction of labour. The rate of breast feeding is lower in obese mothers due to multiple reasons including: women’s perception of breastfeeding, difficulty with correct positioning of the baby and the possibility of an impaired prolactin response to suckling.

• 7.
  

  a) T b) T c) F d) T e) T

Obesity is caused by a several factors that are physiological, genetic, environmental, political, cultural and socio-economic in nature. The most powerful contributions to why people are overweight and obese are cultural factors which affect how, why, when and how much people eat and how they perceive their body types. Although there are ongoing studies into the genetics of obesity, it is known to be multifactorial and not only caused by genetic factors. A cohort of pregnant mothers and their adult children from the Dutch famine in 1944–1945 have shown that severe malnutrition during the first half of pregnancy can contribute to obesity later in life. Epigenetics is a rapidly growing field hoping to further describe the impact that the in-utero environment has on diseases later in life. In order to gain weight the body’s total energy expenditure must be less than the total caloric intake.

• 8.
  

  a) F b) T c) T d) T e) F

The most recent WHO published data of overweight/obesity estimates that the United Kingdom has a prevalence of 64%, the United states 76.7, Bolivia 73.2%, Egypt 76%, and France 36.9%.

• 9.
  

  a) F b) T c) F d) F e) T

In adults a BMI of >25 kg/m ² is considered overweight and >30 kg/m ² is obese. For children, the definition of obesity is if they are over the 95 ^th percentile for height and weight.

• 10.
  

  a) T b) T c) F d) F e) T

These costs in a and b were estimated and published by Balen et al. in an attempt to quantify the cost of obesity to the health care system and larger economy in the UK. Costs vary from country to country but obesity is having a significant impact on both direct health care costs and indirect costs to society. Direct costs include medical treatment for co-morbidities whereas indirect costs are those that result from loss of work or hiring of replacement employees. The direct and indirect costs of obesity are predicted to continue to increase given the ongoing increasing incidence of overweight and obesity. Obese patients often require different medical equipment ranging from larger retractors and speculums in surgery to different beds, wheelchairs and even operating tables adding up to significant costs.

• 11.
  

  a) T b) F c) T d) T e) F

Women with unknown overt diabetes in pregnancy are at increased risk of congenital anomalies due to their greater degree of hyperglycemia earlier in pregnancy. Since the frequency of obesity and type 2 diabetes in young adults is increasing worldwide, most guidelines recommend now screening for overt diabetes at the first prenatal visit, especially in high risk groups. The Carpenter & Coustan criteria were chosen to identify women at high risk for the development of diabetes after pregnancy and not to identify pregnancies with increased risk of adverse perinatal outcome. The IADPSG criteria were derived from the HAPO study which showed a continuous and graded relationship between maternal hyperglycemia and the risk of an adverse perinatal outcome, independent of other risk factors. The IADPSG criteria are therefore the first diagnostic criteria for GDM based on perinatal outcome. Studies have shown that by using an HbA1c an OGTT could be avoided in approximately 40%–60% of women but the HAPO study showed that associations with adverse outcomes were significantly stronger with glucose measures than with Hba1c. All together, these findings suggest that an Hba1c measurement is not a useful alternative to an OGTT in pregnant women. A systematic review showed that for universal screening the sensitivity of the glucose challenge test was 0.74 for a specificity of 0.85. All together, these findings show that the GCT is acceptable to screen for GDM, but cannot replace the OGTT. Shortly after delivery the glucose values are generally restored to normal, but women with GDM have a seven-fold increased risk of developing type 2 diabetes after pregnancy. A history of GDM is also a marker for raised cardiovascular risk and early atherosclerosis. Women with a history of GDM, irrespective whether they needed insulin during pregnancy, should therefore have lifelong screening for the development of glucose intolerance, at least every 3 years. Currently there is insufficient evidence to recommend one test over the other and therefore HbA1C, FPG, or 75-g 2-h OGTT are appropriate to test for glucose intolerance.

• 12.
  

  a) T b) T c) T d) T e) T

Since the frequency of obesity and type 2 diabetes in young adults is increasing worldwide, most guidelines recommend now screening for overt diabetes at the first prenatal visit, especially in high risk groups. Cut-offs for tests used to detect diabetes in the non-pregnant population are recommended in early pregnancy. The Carpenter & Coustan criteria were indeed chosen to identify women at high risk for the development of diabetes after pregnancy. Studies have shown that by using a HbA1c an OGTT could be avoided in approximately 40%–60% of women but the HAPO study showed that associations with adverse outcomes were significantly stronger with glucose measures than with Hba1c. A systematic review showed that for universal screening the sensitivity of the glucose challenge test was 0.74 for a specificity of 0.85. Women with GDM do have a seven-fold increased risk of developing type 2 diabetes after pregnancy.

• 13.
  

  a) F b) T c) T d) F e) T

The FTO gene together with a series of the genomic genes has been shown to have proven signals related to adiposity. However the association cannot be said to often contribute towards the development of adult obesity. Metabolic programming through under or over nutrition during fetal life or infancy has been shown to be a strong associate for the eventual development of childhood and adult metabolic syndrome including obesity. The woman with features of metabolic syndrome during her pregnancy is much more likely to over-feed the developing fetus. Adulthood nutritional and physical lifestyle attitudes are often established during childhood and hence the parental attitudes towards lifestyle will influence the child’s eventual attitudes. Inappropriate lifestyle predisposes to adiposity. The social class status of a particular family can affect the development of adiposity through inappropriate lifestyles. However it is low social class families who are predisposed to developing obesity in the developed world. Research has suggested that direct control over the food eaten by the child through restricting children’s access to specific foods may make that food more desirable so that, when unsupervised, children will choose the restricted food more readily than acceptable foods. Less direct forms of parental control and more subtle approaches, such as covert control and an authoritarian parenting style, may be more beneficial in the development of healthy eating and self-regulation in children.

• 14.
  

  a) T b) F c) T d) F e) T

Birth weight is an important predisposing factor for the development of childhood and adult adiposity. Macrosomia has long been associated with the subsequent increased risk for developing features of adult-onset metabolic syndrome including obesity. At the other end of the scale, low birth weight resulting from prematurity or growth restriction has been similarly associated. Inappropriate overfeeding during neonatal and infant life has been associated with a greater predisposition for childhood and adult adiposity. Inappropriate overfeeding is unlikely to occur with breastfeeding and is more likely when the child is bottle-fed. A mother who now has features of the metabolic syndrome was more likely to have had a relative hyperglycaemia or gestational diabetes during her pregnancy thus presenting the developing fetus with inappropriate intrauterine overnutrition. Adult obesity is much more likely to develop in children who have elevated age/gender standardized BMI values during their childhood or who demonstrate rapid weight gain during infancy or early childhood. Obesity may develop as a secondary consequence of particular genetic defects including Prader-Willi Syndrome.

• 15.
  

  a) T b) F c) T d) F e) T

Genomic defects associated with obesity include Trisomy 21, Albright hereditary osteodystrophy, Cohen syndrome, Borjeson-Forssman-Lehmann syndrome, Beckwith-Weidemann syndrome, and Bradet-Biedl syndrome.

• 16.
  

  a) T b) T c) F d) T e) T

A large meta-analysis showed increased rates of certain fetal anomalies in obese women when compared to normal weight women. These anomalies with their respective significant odds ratio include: Neural tube defects (1.87), hydrocephaly (1.68), anorectal atresia (1.48), cardiac anomalies (1.39), limb reduction defects (1.34), and facial clefting (1.20). Ultrasound visualization is reduced in women with obesity due to the increased distance from the ultrasound probe to the target through adipose tissue. Two separate studies found that the duration of time required to obtain the nuchal translucency image is longer in obese women. One of these studies further sub-classified obesity and found that the duration was specifically longer in Class II and Class III obese women. Although the duration of time required to complete the nuchal translucency measurement in obese women was found to be longer when compared to normal weight women, there was no difference noted in the actual completion rate. The rate of inadequate nasal bone measurement was increased in obese women when compared to normal weight women. This again lends itself to the difficulty in fetal imaging due to the increased distance of insonation. When the nuchal translucency cannot be adequately visualized, an alternative approach is to perform trans-vaginal sonography in an attempt to obtain the desired image. When compared to normal weight women, obese women had higher rates of trans-vaginal ultrasound to obtain the necessary image.

• 17.
  

  a) T b) F c) T d) T e) T

The FaSTER trial performed a sub-analysis of patients who underwent second trimester ultrasound and found that maternal obesity decreased the sensitivity of certain soft markers for fetal aneuploidy including pyelectasis. The detection of anomalous fetuses was similar between overweight and obese women. Overweight women had a detection rate of 49%, whereas class I and II obese women had detection rates of 48% and 42% respectively. Class III obese women had a significant reduction in the detection of fetal anomalies with a rate of only 25%. Several retrospective studies have assessed the optimal gestational age at which to perform targeted ultrasound in obese women. Overall, the optimal gestational age range appears to be between 18-24 weeks. However, this range should be applied based on local policy on invasive aneuploidy testing and laws concerning pregnancy termination in cases of fetal aneuploidy. When compared to obese women with other high-risk medical co-morbidities, obese women with pre-gestational diabetes had lower rates of detection of fetal anomalies (38% vs. 88%). This finding most likely results from increased adiposity in women with pre-gestational diabetes compared to other high-risk medical comorbidities. Several factors affect ultrasound completion rates and visualization including sonographer experience, repeated exams, timing of the exam, and ultrasound technology used. A retrospective study showed senior faculty (>20 years experience) were more likely to achieve adequate visualization compared to junior faculty (aOR 3.27, CI 1.15–9.25) and the optimal gestational age for a complete anatomic survey was 22 to 24 weeks compared to 14 to 16 weeks (OR 41.3, CI 7.89–215.8). Tissue harmonic imaging may be helpful in improving visualization of the ultrasound target in obese women.

• 18.
  

  a) T b) F c) F d) F e) F

The FaSTER trial performed a sub-analysis of patients who underwent second trimester ultrasound and found that maternal obesity decreased the sensitivity of certain soft markers for fetal aneuploidy including short long bone length and pyelectasis. Other soft markers including nuchal fold, echogenic bowel, and intracardiac echogenic foci were not altered.

• 19.
  

  a) T b) T c) T d) T e) F

Both maternal estimation and third trimester ultrasound were within 10% of actual live birth weight in a recent prospective cohort study. However, third trimester ultrasound was still better at predicting live birth weight in 72% of patients versus in only 63% of those with maternal estimates. A retrospective study determined that obesity, as determined by maternal body mass index, did not have an effect on the ability of third trimester ultrasound to accurately estimate fetal weight. In part, this is due to maximum displacement and thinning of maternal adipose tissue which allows greater penetration of ultrasound and decreases the distance to the ultrasound target. Obesity is an independent risk factor for fetal macrosomia and large for gestational age born infants. This finding holds true even in the absence of maternal diabetes mellitus. Given this, third trimester ultrasound can be a helpful tool to help identify macrosomic infants in an effort to reduce birth trauma to both the mother and fetus. The data regarding estimation of fetal weight in twin gestations of obese women is inconclusive at this time. Two separate retrospective reviews demonstrated conflicting findings. The secondary analysis of the ESPRiT study did not show any effect of obesity on the ability to estimate fetal weight of twin gestations in the third trimester. A separate retrospective review by Ghandi et al. demonstrated decreasing accuracy of ultrasound estimation of fetal weight with increasing maternal body mass index in the third trimester. When compared to normal weight women with twin gestation, obese women had a statistically significant increase in absolute percent error in the estimated weight of both twins. Sims technique where the patient is placed in an almost prone position with upper leg flexed at the knee and lower leg extended. This position shifts the panniculus and allows access to the uterus through the flank and from the side of the uterus.

• 20.
  

  a) T b) T c) F d) T e) F

There is indeed a Type 2 Helper T cell shift. There is increased susceptibility to Listeriosis which can result in CNS infection, endocarditis, miscarriage/stillbirth, PTL or neonatal infection. There is no evidence that pregnant women are at increased risk from all pathogens. There is potentially increased disease severity by viral haemorragic fevers. There are decreased Natural Killer cells with decreased cytotoxicity in the peripheral blood system of pregnant women.

• 21.
  

  a) F b) T c) T d) F e) F

30–60 minutes pre knife-to-skin is optimum to reduce surgical site infections. Hyperglycaemia increases the risk of infection but very tight control in sepsis can put patients at risk of hypoglycaemia. Hypothermia increases the risk of infection. Obese patients are more at risk of this as operative times are increased. There is no clear evidence for optimum skin closure. Vertical incisions are at increased risk of infections.

• 22.
  

  a) T b) T c) F d) F e) F

There is indeed decreased T cell diversity and functionality in obesity. Increased baseline cytokines and monocytes reflect a chronic inflammatory state which is seen in obesity. Adiponectin is one of the adipokines which is actually reduced in obesity. Leptin levels are increased in obesity. People with a leptin deficiency develop obesity and immune deficiency. Theoretically the increased B cell levels should be protective against previously encountered pathogens but obesity has been shown to change the memory T cell response making individuals at risk of repeat infections.

• 23.
  

  a) F b) F c) T d) F e) T

Both pregnancy and the puerperium increase the risk of VTE but the risk is higher in the puerperium than during pregnancy. According to a recent systematic review of 13 studies, the incidence is increased fourfold in pregnancy and twentyfold in the puerperium and is highest just after delivery. Obesity now affects 25% of women in the UK and the prevalence still seems to be rising. In the USA it affects 33% of women but the rise seems to have plateaued in recent years. Despite this difference in prevalence, estimates of the mortality from pregnancy-associated VTE are similar in the two countries: 1 in 150 000 births in the USA and 1 in 127 000 pregnancies in the UK. Differences in the denominators and in ascertainment may affect these estimates, making detailed comparison difficult. The increased risk of VTE reduces during the puerperium and has been thought to return to pre-pregnancy levels by six weeks post-partum. A recent large study in California, however, concluded that although the absolute risk after 6 weeks is low, an elevated risk persists for at least 12 weeks after delivery, and the risks and benefits of continuing thrombo-prophylaxis beyond 6 weeks need more research. Obesity is associated with a fourfold increase in the risk of VTE – relatively low in comparison with thrombophilia or a history of thrombosis, which were associated with a 50-fold and 16-fold increase respectively in a recent study. The same Californian study as in answer c looked at stroke and myocardial infarction as well as VTE and found a similar pattern of increased risk for all three conditions during the puerperium. This is particularly interesting in view of the finding that the leading cause of Indirect maternal death is now acquired cardiac disease.

• 24.
  

  a) F b) T c) F d) T e) F

The most recent RCOG guideline recommends that when obesity (BMI >30 kg/m ² ) is present at the beginning of pregnancy, two other risk factors must also be present before prophylactic LMWH is considered. If the woman is hospitalised during pregnancy, only one other risk factor is necessary. The RCOG guideline recommends a further risk assessment at delivery. If the BMI is > 30 kg/m ² , one other risk factor is necessary for consideration of prophylactic LMWH, but if the BMI is > 40 kg/m ² , this in itself is an indication for consideration of LMWH. If further risk factors are present in either case, more prolonged thrombo-prophylaxis may be considered. Although graduated compression stockings are widely recommended, the evidence for their use comes mainly from studies outside pregnancy and there is little evidence for their effectiveness in the obese patient. Stockings and intermittent compression devices may be ineffective when the thigh circumference is too large. The term “morbid obesity” refers to a BMI of >40 kg/m ² , called “class III obesity” by WHO. An important recommendation of the most recent RCOG guideline is that the dose of prophylactic LMWH should be increased in women with severe or morbid obesity. A table in the RCOG guideline gives doses in relation to body weight, with 90kg being the upper limit for standard doses. A woman with morbid obesity is likely to weigh over 100kg. Studies on the implementation of thrombo-prophylaxis guidelines are few but they are consistent in showing poor implementation of guidelines in morbidly obese women. The CMACE report on obesity found that only half the women with morbid obesity were offered thrombo-prophylaxis. A study in Ireland found that 69% of at-risk women received thrombo-prophylaxis but only 54% received the correct weight-related dose and none of the women with morbid obesity received the appropriate dose.

• 25.
  

  a) F b) F c) F d) T e) F

The left common iliac vein is compressed as it passes under the right common iliac artery and this is thought to explain why in non-pregnant patients DVT is slightly more common in the left leg than the right. In pregnancy, this effect appears to be increased by pressure from the pregnant uterus and in pregnant women 85% of DVTs affect the left leg. No large-scale trials have been performed for the diagnosis of VTE in pregnancy but the consensus is that compression Duplex ultrasound has become the primary diagnostic test for DVT, with a reported sensitivity and specificity of 97% and 94% respectively for symptomatic patients. Contrast venography used to be regarded as the definitive test for DVT but its performance during pregnancy is limited due to its invasive nature and the radiation associated with the technique. LMWH is preferred over unfractionated heparin (UFH) for prophylaxis and for the initial treatment of deep venous thrombosis because of increased effectiveness and a lower risk of bleeding. However, in the acute treatment of massive life-threatening pulmonary embolism, UFH is still preferred because of its rapidity of action. D-dimer is increased in normal pregnancy and the puerperium, and can be further increased in the presence of complications such as pre-eclampsia. A low level of D-dimer does not entirely rule out VTE. All guidelines therefore agree that D-timer testing is not recommended in pregnancy. The radiation dose to the fetus from a chest X-ray performed at any stage of pregnancy is negligible and therefore chest X-ray is safe for a pregnant woman. However, computerised tomographic pulmonary angiography delivers a relatively high radiation dose to the thorax, which increases a woman’s lifetime risk of developing breast cancer. The widely quoted figure of a 13.6% increase may be an overestimate, but the risk must be discussed with the woman as part of informed consent.

• 26.
  

  a) T b) F c) F d) T e) T

In the 2000–2, 2003–5, and 2006–8 triennia, 29%, 27% and 27% respectively of all Direct and Indirect pregnancy related deaths in the UK occurred in obese women with a BMI of 30 kg/m ² or more. Despite the increased risks, there were no maternal deaths among the 665 extremely obese women in the UKOSS study. Obesity was especially predominant among the women who died from thromboembolism, sepsis and cardiac disease, but not in those who died from amniotic fluid embolism.

• 27.
  

  a) F b) T c) T d)F e) F

Calcium supplements are not routinely recommended in pregnancy unless there is nutritional deficiency, for example in some women who have undergone bariatric surgery. Obesity is associated with vitamin D deficiency; supplementation during pregnancy increases maternal serum vitamin D levels at term and the current recommendation is that pregnant women with a booking BMI of 30 kg/m ² or more should take 10 mcg of vitamin D supplement daily. Obese women have an increased risk of fetal neural tube defects, and women with a BMI >27 kg/m ² have lower folate levels compared with women with BMI <27 kg/m ² . Peri-conceptual folic acid supplements decrease the risk of neural tube defects, and women with a BMI of 30 kg/m ² or more wishing to become pregnant should be advised to take the higher dose (5mg) of folic acid supplementation daily, starting at least one month before conception and continuing during the first trimester of pregnancy. Aspirin is not routinely recommended for obese pregnant women. Aspirin 75 mg daily from 12 weeks until the birth of the baby is recommended for women with a BMI of 35 kg/m ² or more who have one or more additional moderate risk factors for pre-eclampsia. Iron supplements are only recommended for women whose haemoglobin falls below the normal range for pregnancy (11g/100ml at first contact and 10.5g/100ml at 28 weeks) and are iron deficient.

• 28.
  

  a) F b) F c) F d) T e) T

Women with a BMI of 30 kg/m ² or more are at increased risk and should be screened for gestational diabetes; however the recommended method is the 2-hour 75g oral glucose tolerance test at 24–28 weeks gestation. Women with a BMI of 40 kg/m ² or more should have an antenatal consultation with an anaesthetist as these extremely obese women are at the greatest risk of anaesthetic complications such as venous and epidural cannula placement and difficulties with intubation and ventilation; some women with a lower BMI may also benefit from anaesthetic review if they have co-morbidity, but this is not routinely recommended. Obesity is a moderate risk factor for thromboembolism; a VTE risk assessment should be done after delivery and LMWH prescribed only if there are any additional risk factors for thromboembolism or if BMI is 40 kg/m ² or more. Prophylactic antibiotics are recommended for all women undergoing Caesarean section; they are most effective if given prior to the skin incision. Obesity is associated with an increased risk of postpartum haemorrhage and active management of the third stage of labour is recommended for all women with a BMI of 30 kg/m ² or more as this reduces the risk of postpartum haemorrhage.

• 29.
  

  a) T b) F c) T d) T e) F

There is ample data from non-pregnant obese women to suggest that tissue penetration is decreased in this population and therefore higher doses of prophylactic antibiotics are required. Experimental data in Caesarean section patients also suggests that at least 2 g of cefazolin are required for adequate prophylaxis in obese women. There is consistent evidence from the general Caesarean section population showing that pre-operative vaginal cleaning with an antiseptic solution reduces postoperative infections, and there is nothing to suggest that this should be different in obese women. There is consistent data from the general Caesarean section population to show that avoiding manual removal of the placenta reduces postoperative infectious complications, and there is nothing to suggest that this should be different in obese women. There is robust evidence to indicate that the subcutaneous tissue layer should be closed when its depth exceeds 2 cm. Randomised controlled trials carried out in the general Caesarean section population have not shown different complication rates, pain or cosmetic results, between sub-cuticular sutures, interrupted sutures and non-absorbable staples. There is little to suggest that the method of skin closure in obese women should be different from that of the general population.

• 30.
  

  a) T b) T c) T d) T e) F

Conservative management of small and asymptomatic seromas is commonly practiced, usually with complete long-term resolution. Non-liquefied haematomas cannot be adequately drained percutaneously and when symptomatic require surgical treatment to reduce pain and control the bleeding site. There is robust data from the general surgical population to show that topical treatment of wound infection associated with dehiscence should preferably avoid the use of gauze, as the latter is associated with more pain, increased nursing time and less patient satisfaction. There is nothing to suggest that this should be different in obese women undergoing Caesarean section. There is consistent data from the general surgical population showing that negative pressure wound therapy reduces total healing time in acute and chronic wounds. There is nothing to suggest that this should be different in obese women undergoing Caesarean section. Many studies carried out in the general surgical population and in obstetrics and gynaecology patients have shown that re-closure of surgical wounds is frequently successful, as soon as there are no signs of ongoing infection. It is not associated with important morbidity and results in shorter healing times than closure by secondary intention. There is nothing to suggest that this should be different in obese women undergoing Caesarean section.