management of the obese pregnant patient
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MANAGEMENT OF THE OBESE PREGNANT
PATIENTMax Brinsmead MB BS PhD
May 2015
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
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
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
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
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
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
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
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
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
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
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