The multidisciplinary approach to the care of the obese parturient




Maternal obesity in pregnancy is associated with increased maternal and fetal risks. Pregnancy management should include counseling, screening, and optimization of maternal health, increased fetal surveillance, and preparation for parturition. A multidisciplinary approach should be implemented including collaboration from obstetricians, nutritionists, anesthesiologists, social workers, and neonatologists to optimize perinatal outcomes. Pregnancy is an ideal window of opportunity to influence both the patient’s long-term health and the health of the offspring.


In the United States, the prevalence of obesity is increasing. In 2012, 36.5% of US adult women reported a body mass index (BMI) of 30 kg/m 2 or greater, which classified them as obese. Furthermore, more than 50% of all pregnant women are overweight or obese.


Maternal obesity connotes an increased risk of the following perinatal complications: gestational hypertension, preeclampsia, gestational diabetes, cesarean delivery, miscarriage, anesthesia difficulties, failed induction of labor, postpartum hemorrhage, infectious morbidity, and venous thromboembolism. Additionally, infants born to obese women are at increased risk of congenital anomalies, prematurity, stillbirth, macrosomia with possible birth injury, and childhood obesity. Maternal obesity has long-term health implications for the mother including the development of metabolic and cardiovascular disease.


The management of obese women can be challenging for clinicians and hospital systems. Obese women require more health care resources and additional equipment to provide the necessary and appropriate prenatal and delivery care. This ultimately leads to increased health care costs. Although the focus of this review is to provide guidelines for a multidisciplinary approach to the care of the obese parturient, studies regarding the efficacy of these interventions are limited.


A pragmatic approach to comprehensive care of obese women includes specialized nursing care, anesthesia, and obstetrical staff as well as nutritional and social work support. By using an interdisciplinary approach to health care, providers can not only optimize care related to the current pregnancy but also discuss the long-term implications of obesity on a woman’s future health, thereby creating a framework for change.


Classification of obesity


The American Congress of Obstetricians and Gynecologists (ACOG) endorses the World Health Organization’s and the National Institutes of Health’s definitions for obesity: underweight as a BMI of 18.5 kg/m 2 , normal weight as a BMI of 18.5–24.9 kg/m 2 , overweight as a BMI of 25.0–29.9 kg/m 2 , and obesity as a BMI of 30 kg/m 2 or greater. Obesity can be further subdivided into class I (30.0–34.9 kg/m 2 ), class II (35.0–39.9 kg/m 2 ), and class III (>40 kg/m 2 ).


The Institute of Medicine reexamined recommendations for gestational weight gain in pregnancy in 2009 based on more women entering pregnancy at heavier BMIs and gaining excess weight during pregnancy. This increases perinatal risks to both the mother and fetus. Current recommendations for weight gain in pregnancy based on prepregnancy BMI are listed in Table 1 .



Table 1

IOM recommendations for weight gain in pregnancy based on prepregnancy BMI





























Prepregnancy BMI BMI, kg/m 2 Total weight gain range, lb Rates of weight gain second and third trimester, lb/wk (mean range)
Underweight <18.5 28–40 1 (1–1.3)
Normal weight 18.5–24.9 25–35 1 (0.8–1.0)
Overweight 25–29.9 15–25 0.6 (0.5–0.7)
Obese ≥30.0 11–20 0.5 (0.4–0.6)

BMI , body mass index; IOM , Institute of Medicine.

Ghaffari. Multidisciplinary approach to care of obese parturient. Am J Obstet Gynecol 2015 .

Adapted from Rasmussen.


A common criticism of the newly adopted guidelines is that weight gain is not stratified by class of obesity. Based on expert opinion and clinical judgment, there is no absolute minimum amount of weight gain necessary as long as fetal growth is assessed and is appropriate for the stated gestational age.




Preconception care


In reproductive-aged obese women, optimization of pregnancy outcomes should begin with preconception counseling ( Table 2 ). The optimal time for women to improve their health and decrease weight-related complications is prior to pregnancy. Weight management is an essential part of counseling at the time of annual health maintenance. Achieving a normal BMI prior to pregnancy decreases the rate of perinatal complications more than any other intervention during pregnancy, such as minimizing weight gain.



Table 2

Key considerations in the care of obese women in pregnancy



















Phase of pregnancy care Considerations
Preconception


  • Document height, weight, BMI



  • Counsel on risks during pregnancy and for long-term maternal health



  • Screen for diabetes with a 2 hour glucose tolerance test or HbA1C



  • Document blood pressure



  • Consider EKG, especially with comorbidities



  • Consider echocardiogram if EKG abnormalities



  • Screen for depression; refer to mental health professional if indicated



  • Screen for obstructive sleep apnea ( Table 3 ); refer to sleep specialist if indicated



  • Consider lipid screening



  • Discuss weight loss and exercise



  • Refer to nutritionist



  • Consider referral to bariatric surgery program



  • Arrange follow-up to track weight loss and review goals

Prenatal care


  • Document height, weight, and BMI at every visit



  • Discuss weight gain goals per IOM guidelines ( Table 1 ) and address throughout prenatal care



  • Refer to nutritionist



  • Recommend at least 30 minutes of daily exercise



  • Counsel on risks of obesity in pregnancy



  • Recommend first-trimester ultrasound for dating and diagnosis of multiple gestation



  • Early 1 hour GCT



  • Consider baseline EKG (if not done preconceptionally), especially with comorbidities



  • Screen for obstructive sleep apnea ( Table 3 ); refer to sleep specialist if indicated



  • Offer aneuploidy screening and discuss limitations in obesity



  • Schedule anatomical survey at 20 weeks and discuss limitations in obesity



  • Discuss delivery planning



  • Discuss neuraxial anesthesia and set expectations for difficult placement



  • Growth ultrasound at 32 weeks



  • If BMI >40 kg/m 2 or per regional guidelines: consider antepartum testing, starting at 32 weeks

Intrapartum care


  • Induction of labor by obstetric indications or for comorbidities



  • Anesthesia consult early in labor



  • Early epidural placement



  • Establish reliable fetal monitoring



  • Active management of labor with preparedness for cesarean delivery



  • If delivery via cesarean delivery:



    • 1.

      Decide on incision type and discuss with patient


    • 2.

      Consider using self-retaining wound retractor


    • 3.

      Consider increased dose of preoperative antibiotic



    • (cefazolin 3 g IV [weight ≥120 kg])


Postpartum


  • Encourage ambulation



  • Consider postpartum chemoprophylaxis in high-risk patients



  • Contraceptive counseling



  • Encourage breast-feeding



  • Establish a plan for postpartum weight loss


BMI , body mass index; EKG , electrocardiogram; GCT , glucose challenge test; HbA1C , hemoglobin A1C; IOM , Institute of Medicine; IV , intravenous.

Ghaffari. Multidisciplinary approach to care of obese parturient. Am J Obstet Gynecol 2015 .


Women can often decrease risks of adverse outcomes in pregnancy with modest weight reductions of as little as 10 pounds. Women’s health providers of all disciplines should consider offering community health resources for weight loss consultation with a nutritionist. Health care coverage should focus on these preventative efforts. Realistic goals for weight loss should be set.


Additionally, bariatric surgery prior to conception has been shown to improve perinatal outcomes in obese women. A subset of obese women would benefit from referral for bariatric surgery. In general, bariatric surgery is considered for patients with a BMI greater than 40 kg/m 2 or a BMI greater than 35 kg/m 2 and at least 1 obesity-related comorbidity, most commonly: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), obesity-hypoventilation syndrome, or asthma. In many centers, including our own, at least 2 months of medical weight management needs to be completed in the bariatric surgery program, and medical comorbidities must be optimized prior to undergoing the operative procedure. If a patient is planning a future pregnancy, she should delay pregnancy following bariatric surgery for 1-2 years to allow for complete weight loss and recovery.




Preconception care


In reproductive-aged obese women, optimization of pregnancy outcomes should begin with preconception counseling ( Table 2 ). The optimal time for women to improve their health and decrease weight-related complications is prior to pregnancy. Weight management is an essential part of counseling at the time of annual health maintenance. Achieving a normal BMI prior to pregnancy decreases the rate of perinatal complications more than any other intervention during pregnancy, such as minimizing weight gain.



Table 2

Key considerations in the care of obese women in pregnancy



















Phase of pregnancy care Considerations
Preconception


  • Document height, weight, BMI



  • Counsel on risks during pregnancy and for long-term maternal health



  • Screen for diabetes with a 2 hour glucose tolerance test or HbA1C



  • Document blood pressure



  • Consider EKG, especially with comorbidities



  • Consider echocardiogram if EKG abnormalities



  • Screen for depression; refer to mental health professional if indicated



  • Screen for obstructive sleep apnea ( Table 3 ); refer to sleep specialist if indicated



  • Consider lipid screening



  • Discuss weight loss and exercise



  • Refer to nutritionist



  • Consider referral to bariatric surgery program



  • Arrange follow-up to track weight loss and review goals

Prenatal care


  • Document height, weight, and BMI at every visit



  • Discuss weight gain goals per IOM guidelines ( Table 1 ) and address throughout prenatal care



  • Refer to nutritionist



  • Recommend at least 30 minutes of daily exercise



  • Counsel on risks of obesity in pregnancy



  • Recommend first-trimester ultrasound for dating and diagnosis of multiple gestation



  • Early 1 hour GCT



  • Consider baseline EKG (if not done preconceptionally), especially with comorbidities



  • Screen for obstructive sleep apnea ( Table 3 ); refer to sleep specialist if indicated



  • Offer aneuploidy screening and discuss limitations in obesity



  • Schedule anatomical survey at 20 weeks and discuss limitations in obesity



  • Discuss delivery planning



  • Discuss neuraxial anesthesia and set expectations for difficult placement



  • Growth ultrasound at 32 weeks



  • If BMI >40 kg/m 2 or per regional guidelines: consider antepartum testing, starting at 32 weeks

Intrapartum care


  • Induction of labor by obstetric indications or for comorbidities



  • Anesthesia consult early in labor



  • Early epidural placement



  • Establish reliable fetal monitoring



  • Active management of labor with preparedness for cesarean delivery



  • If delivery via cesarean delivery:



    • 1.

      Decide on incision type and discuss with patient


    • 2.

      Consider using self-retaining wound retractor


    • 3.

      Consider increased dose of preoperative antibiotic



    • (cefazolin 3 g IV [weight ≥120 kg])


Postpartum


  • Encourage ambulation



  • Consider postpartum chemoprophylaxis in high-risk patients



  • Contraceptive counseling



  • Encourage breast-feeding



  • Establish a plan for postpartum weight loss


BMI , body mass index; EKG , electrocardiogram; GCT , glucose challenge test; HbA1C , hemoglobin A1C; IOM , Institute of Medicine; IV , intravenous.

Ghaffari. Multidisciplinary approach to care of obese parturient. Am J Obstet Gynecol 2015 .


Women can often decrease risks of adverse outcomes in pregnancy with modest weight reductions of as little as 10 pounds. Women’s health providers of all disciplines should consider offering community health resources for weight loss consultation with a nutritionist. Health care coverage should focus on these preventative efforts. Realistic goals for weight loss should be set.


Additionally, bariatric surgery prior to conception has been shown to improve perinatal outcomes in obese women. A subset of obese women would benefit from referral for bariatric surgery. In general, bariatric surgery is considered for patients with a BMI greater than 40 kg/m 2 or a BMI greater than 35 kg/m 2 and at least 1 obesity-related comorbidity, most commonly: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), obesity-hypoventilation syndrome, or asthma. In many centers, including our own, at least 2 months of medical weight management needs to be completed in the bariatric surgery program, and medical comorbidities must be optimized prior to undergoing the operative procedure. If a patient is planning a future pregnancy, she should delay pregnancy following bariatric surgery for 1-2 years to allow for complete weight loss and recovery.




Health screening for comorbid conditions


Obese women should be screened for medical comorbidities before conception or in early pregnancy. This includes screening for type 2 diabetes mellitus, chronic hypertension, cardiac disease, and obstructive sleep apnea. Standard screening methods such as the 2 hour oral glucose tolerance test, hemoglobin A1C, and ambulatory blood pressure assessment should be completed. An electrocardiogram (EKG) may be considered in select cases of medical comorbidities, with echocardiogram if EKG findings are suggestive of an abnormality. The Snoring, Tired, Observed, and blood Pressure (STOP) questionnaire should be used to screen for sleep apnea ( Table 3 ).



Table 3

STOP questionnaire a















S “Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?”
T “Do you often feel tired , fatigued, or sleepy during daytime?”
O “Has anyone observed you stop breathing during your sleep?”
P “Do you have or are you being treated for high blood pressure ?”

Ghaffari. Multidisciplinary approach to care of obese parturient. Am J Obstet Gynecol 2015 .

Adapted from Chung et al.

a If answer is yes to 2 or more questions, refer to a sleep specialist.



All women should be screened for dyslipidemia at age 45 years, and testing at age 20-45 years should be considered in women with obesity, especially if other risk factors of coronary heart disease (diabetes, previous personal history of coronary heart disease or noncoronary atherosclerosis, family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives, tobacco use, or hypertension) are present.


Additionally, obese women have higher rates of depression during pregnancy and in the postpartum period compared with their normal BMI counterparts. They may need additional resources during pregnancy, such as social work or mental health resources. Depression screening should be performed routinely throughout pregnancy and in the postpartum period with referral to mental health resources as needed.




Pregnancy


At the first prenatal visit, calculation of BMI should be performed based on a measured height and weight. Discussion of optimal weight gain is a key component of the first prenatal visit ( Table 1 ). Documentation of weight at each prenatal visit and gestational weight gain in each trimester will aid in ongoing counseling throughout prenatal care. All obese women are encouraged to complete a consultative visit with a nutritionist early in pregnancy so that a diet and exercise plan can be developed for the remainder of the pregnancy.


The Centers for Disease Control and Prevention and the American College of Sports Medicine recommend exercise at least 30 minutes on most days of the week. ACOG endorses this recommendation in pregnancy in the absence of either medical or obstetric complications. When approaching exercise, women should be encouraged that any activity is better than none and that walking may be appropriate for most women. Walking may be as effective as structured aerobic activity and is feasible in pregnancy, especially for women who have been sedentary prior to pregnancy. Water exercise or stretching may be advisable for women who are deconditioned. Buoyancy helps support the weight.




Perinatal complications and counseling


Women should be counseled regarding the increased risks of perinatal complications throughout pregnancy and the rationale for the interventions and preventive strategies offered. During the first prenatal visit, obstetrical care providers are encouraged to engage in a discussion regarding antepartum, intrapartum, and postpartum complications associated with maternal obesity.


Antepartum complications include an increased risk of miscarriage (odds ratio [OR], 4.02; 95% confidence interval [CI], 1.53–10.57), development of gestational diabetes (OR, 2.6; 95% CI, 2.1–3.4 for BMI 30–34.9 kg/m 2 , OR, 4.0; 95% CI, 3.1–5.2 for BMI >35 kg/m 2 ), and preeclampsia (OR, 1.6; 95% CI, 1.1–2.25 for BMI 30–34.9 kg/m 2 ; OR, 3.3; 95% CI, 2.4–4.5 for BMI >35 kg/m 2 ) as well as intrauterine fetal demise (OR, 4.3; 95% CI, 2.0–9.3). In early pregnancy, screening with an early 1-hour glucose challenge test as well as a baseline EKG is recommended.


Intrapartum complications include difficulty or inability to accurately monitor the fetus in labor, increased risk of failed induction of labor, and cesarean delivery. A delivery plan should be made in the office setting and patient expectations for parturition should be set. Neuraxial anesthesia in labor should be encouraged, and appropriate expectations should be established regarding the possible difficulty in its placement and the increased need for replacement to achieve adequate pain relief.


Postpartum complications, including postpartum hemorrhage, wound disruption, or infection in the event of cesarean delivery, and increased risk of venous thromboembolism (VTE) postpartum should be reviewed.

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May 6, 2017 | Posted by in GYNECOLOGY | Comments Off on The multidisciplinary approach to the care of the obese parturient

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