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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