refrat obesity pe

7/24/2019 Refrat Obesity Pe

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I. INTRODUCTION

All over the world, since 1980, obesity has doubled and reached epidemic conditions.1

Obesity is a major epidemic in developed countries that is now extending to developing

countries.!xcessive weight is also a major health problem in the "nited #tates and other

a$$luent societies. %or a number o$ years, obesity was said to be epidemicstrictly de$ined,

this implies a temporarywidespread outbrea& o$ greatly increased $re'uency and severity.

"n$ortunately, obesity more correctly is endemic(a condition that is habitually present. )y

1991, approximately a third o$ adults in the "nited #tates were overweight, and thus a stated

goal o$Healthy People 2000 was to reduce the prevalence o$ overweight people to 0 percent

or less by the end o$ the 0th century *+ublic ealth #ervice, 1990-. ot only was this goal

not achieved, but by 000, more than hal$ o$ the population was overweight. /n 010, a third

o$ all adults were obese *Ogden, 01-. /n the "nited #tates, the percentage o$ women who

are overweight or obese has increased by approximately 02 over that last thirty years. 3he

4orld ealth Organi5ation estimates the prevalence o$ obese and overweight women *body

mass index 6 7 &gm- to be 2 in the "nited #tates, 2 in :exico, 2 in %rance, 2

in ;hina, 182 in /ndia, and 92 in #outh A$rica with wide variation within each continent.82 o$

deliveries, a$$ecting one in every 1 women in the "#. Diagnosis o$ preeclampsia is based

on new onset o$ hypertension and proteinuria. :ultiple organ systems can be a$$ected with

severe disease. 3he wide range o$ ris& $actors re$lects the heterogeneity o$ preeclampsia.

Obesity, which is increasing at an alarming rate, is also a ris& $actor $or preeclampsia

as well as $or later li$e cardiovascular disease.eclampsia and a dose>dependent relationship between increasing body mass

index *):/- and the ris& o$ developingpre>eclampsia is well established.,8Obesity increases

the overall ris& o$ preeclampsia by approximately > to >$old. 3he ris& o$ preeclampsia

progressively increases with increasing ):/, even within the normal range. /mportantly, it is

not only the late or mild $orms o$ preeclampsia that are increased, but also early and severe

preeclampsia, which are associated with greater perinatal morbidity and mortality. ,

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II. LITERATURE REVIEW

II.1 OBESITY

Definition

Obesity is the accumulation o$ abnormal or excessive $at that can cause health

problems. %at is stored throughout the body. )ecause o$ that $at can not be measured.1 A

number o$ systems have been used to de$ine and classi$y obesity. 3he body mass index *BMI-,

also &nown as the Quetelet index, is currently most o$ten used. 3he ):/ is calculated as

weight in &ilograms divided by the s'uare o$ the height in meters *&gm-. 3he ational

/nstitutes o$ ealth *000- classi$ies adults according to ):/ as $ollowsF normal *18.7 to


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FIGURE 48-2 +revalence o$ obesity in girls and women in the "nited #tates $or 009010.

*Data $rom %legal, 01G Ogden, 01.-

$ause

;ause o$ obesity is excess inta&e o$ calories compared to usage. 3his causes 1.

/ncreased inta&e o$ high calorie $oods that contain a lot o$ $at, . Ceduced physical activity as

a result o$ changes in wor& patterns, urbani5ation and changes in transport.Eenerally, changes in diet and physical activity is the estuary o$ social and environmental

changes caused by development that is not $ollowed by policies in the areas o$ health,

agriculture, environment, transport, $ood processing, distribution, mar&eting and education .1

Patophysiolo!y

Obesity is de$ined by a ):/ over 0 &g m, while in Asia, obesity is determined by

the si5e o$ ):/ over 7 &g m. Obesity is caused by positive energy balance within a

certain time due to excess energy inta&e compared with the bodyHs needs. :ainly due to

excess $ood inta&e and physical activity de$iciency. Eenetic $actors did play a role in obesity,

but the obese condition will occur when excess energy is possible to be stored in adipose

cells.1

!nergy came out strongly associated with body composition, in this case the amount

o$ $at>$ree period than the period o$ $at. !xcess energy is stored in the $orm o$ triglycerides in

adipose tissue. At the onset o$ obesity, causes enlargement o$ adipose cells, but when energy

inta&e is still excessive, then the excess energy would cause the $ormation o$ new adipose

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cells. 3he average adult has 70 billion adipose cells. !ach adipose cells would save a

maximum o$ 1. mg o$ triglycerides.1

Adipose 3issue as an Organ #ystem

%at tissue is much more complex than its energy storage $unction. :any cell types in

$at tissue communicate with all other tissues via endocrine and paracrine $actors(adipo%ines,

or adipocyto%ines. #ome o$ those with metabolic $unctions include adiponectin, leptin, tumor

necrosis $actor>I *3%>I-, interleu&in */J>-, resistin, vis$atin, apelin, vascular endothelium

growth $actor *K!E%-, lipoprotein lipase, and insulin>li&e growth $actor *)riana, 009G

#cherer, 00-. A principal adipo&ine is adiponectin, which is a 0>&Da protein. /t enhances

insulin sensitivity, bloc&s hepatic release o$ glucose, and has cardioprotective e$$ects on

circulating plasma lipids. An adiponectin de$icit leads to diabetes, hypertension, endothelial

cell activation, and cardiovascular disease.

Adipocyto&ines in +regnancy

;yto&ines that result in insulin resistance(leptin, resistin, 3%>I, and /J>(are increased

during pregnancy. /ndeed, these may be the primary stimulant o$ insulin resistance. #ecretion

o$ the remaining adipo&ines is either unchanged or decreased. #peci$ic patterns have been

variously described with gestational diabetes, preeclampsia, and $etal>growth restriction

*)riana, 009-. /n a longitudinal study o$ 77 pregnant women, :eyer and associates *01-

con$irmed that higher ):/s are associated with lower adiponectin but higher leptin levels.

$omplication

Obese individuals are at increased ris& $or an imposing number o$ complications

*Ta!e 48-2-.Obesity has been lin&ed to numerous adverse health conse'uences including,

among others, 3D:, coronary heart disease, sleep apnea and pulmonary dys$unction,

stro&e, and liver disease. Ceproductive $unction is also a$$ected by obesity.103he direct lin&

between obesity and type diabetes mellitus is well &nown. inety percent o$ type diabetes

cases are attributable to excess weight, and 7 percent o$ these diabetics have the metabolic

syndrome *ossain, 00-. eart disease due to obesity(adipositas cordis(is caused by

hypertension, hypervolemia, and dyslipidemia. igher rates o$ abnormal le$t ventricular

$unction, heart $ailure, myocardial in$arction, and stro&e have been noted *;hinali, 00


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TABLE 48-2. L"#g-Ter$ C"$%!i&a'i"#( ") Oe(i'*

II.2 OBESITY IN +REGNANCY

3he de$inition o$ obesity in pregnancy varies by author and includes women who are

1102 to 102 o$ their ideal body weight or B 91 &g *00 lbs- or who have a ):/ B 0

&gm. 9

4omen should set pregnancy weight gain goals based on their pre>pregnancy ):/ as

shown in 3able . 3o achieve these goals women should be at the healthiest weight possible

when they enter pregnancy. During well>woman chec&s and other health care interactions,

non>pregnant women o$ child>bearing age can be advised o$ their ):/. An evaluation o$

dietary inta&e and exercise habits can provide insight into women at ris&. According to thejoint guidelines on exercise in pregnancy by the #OE; and the ;anadian #ociety $or !xercise

+hysiology, all pregnant women without contraindications should participate in regular

exercise. During prenatal visits women can be 'uestioned and advised about their diet and

exercise habits. 4here available, nutritional counselling can be a help$ul adjunct $or women

not meeting the weight gain guidelines in 3able . +regnancy outcomes are related to

maternal weight gain. %i$ty>two percent o$ a ;anadian cohort o$ women gained more than the

recommended weight in pregnancy. Depending on pre>pregnancy ):/, these pregnancies

were at increased ris& o$ macrosomia B


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hypertension, and neonatal metabolic abnormalities. Cegardless o$ ):/, those women who

gained the recommended amount o$ weight in pregnancy had $ewer adverse outcomes

*;aesarean section, gestational hypertension, birth weight L 700 g or B


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countries, maternal morbidity is high and is a major contributor to intensive care unit

admissions during pregnancy. Approximately 1 to 72 o$ $etal growth restriction and small

$or gestational age in$ants as well as 17 to 02 o$ all preterm births are attributable to

preeclampsiaG the associated complications o$ prematurity are substantial including neonatal

deaths and serious long>term neonatal morbidity. Despite major medical advances, the only

&nown cure $or preeclampsia remains delivery o$ the $etus and placenta. organ damage.,induced

hypertension are now considered outdated. %urthermore, varying diagnostic criteria are used

in di$$erent regions o$ the world with disagreement regarding the degree o$ hypertension,

presenceabsence o$ proteinuria, and classi$ication o$ disease severity. 3hese inconsistencies

have led to challenges in comparing and generali5ing epidemiologic and other research

$indings.,term

neonatal morbidity. One 'uarter o$ stillbirths and neonatal deaths in developing countries are

associated with preeclampsiaeclampsia. /n$ant mortality associated with preeclampsia is

three times higher in low resource settings compared to high income countries, largely due to

the lac& o$ neonatal intensive care $acilities.,1 3his ris& is $urther increased i$ a woman has had two prior preeclamptic

pregnancies and is also in$luenced by gestational age o$ onset.1< !stimates o$ the recurrence

o$ preeclampsia vary widely based on the 'uality o$ the diagnostic criteria used. /n a study

done in /celand using strict diagnostic criteria $or preeclampsia and other hypertensive

disorders, the estimated recurrence o$ preeclampsia or superimposed preeclampsia in a

second pregnancy was 12.

+re&!a$%(ia a#/ !a'er !i)e &ar/i"a(&u!ar /i(ea(e4

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Dr. Jeon ;hesley, a pioneer in the $ield o$ preeclampsia, and his co>wor&ers

demonstrated that women who had eclampsia in any pregnancy a$ter their $irst had a

mortality ris& that was two> to $ive>$old higher over the next 7 years compared to

controls.1 %ollowing this early report, others have demonstrated an association between

preeclampsia and later li$e cardiovascular disease and related mortality. ;ardiovascular

disease ris& was increased eight>$old in a #candinavian population o$ healthy nulliparous

women who developed preeclampsia severe enough to necessitate a preterm delivery. /n a

cohort o$ women delivering in Qerusalem, there was a two>$old higher ris& o$ mortality at

year $ollowup in women with prior preeclampsia compared to women who did not have

this diagnosis. 3he deaths were largely related to cardiovascular causes. 3hese $indings have

also been con$irmed in other populations. ypertension, dyslipidemia, insulin resistance,

endothelial dys$unction and vascular impairment have all been observed months to years a$ter

preeclampsia, $urther supporting the lin& between preeclampsia and subse'uent

cardiovascular disease. /t remains unresolved as to whether these common ris& $actors lead to

the development o$ preeclampsia and later li$e cardiovascular disease or whether

preeclampsia itsel$ may contribute to this $uture ris&. )ased on these data, preeclampsia

should be considered a cardiovascular ris& $actor and women with a history o$ preeclampsia

should have ongoing, close surveillance to prevent andor detect $uture cardiovascular

disease.

Ri( )a&'"r( )"r %ree&!a$%(ia4

3he epidemiology o$ preeclampsia re$lects a wide range o$ ris& $actors as well as the

complexity and heterogeneity o$ the disease. Cis& $actors can be classi$ied into pregnancy

speci$ic characteristics and maternal pre>existing $eatures. 3he incidence o$ preeclampsia is

increasing in the "nited #tates and may be related to the higher prevalence o$ predisposing

disorders such as hypertension, diabetes, obesity, delay in child>bearing, and the use o$

arti$icial reproductive technologies with associated increase in multi>$etal gestation.

+reg#a#&*-(%e&i)i& )ea'ure(

+ari'*3ulliparity is a strong ris& $actor, almost tripling the ris& o$ preeclampsia *odds ratio

o$ .91, 1.8 to .1- based on a systematic review o$ controlled studies. /t is estimated that

two>thirds o$ cases occur in $irst pregnancies that progress beyond the $irst trimester.

ew paternity also increases the ris& o$ preeclampsia in a subse'uent pregnancy. 3he

association between primiparity and preeclampsia suggests an immunological mechanism

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such that later pregnancies are protected against those paternal antigens.< #upporting this

concept, previous pregnancy loss, increased duration o$ sexual activity prior to pregnancy or

prolonged pre>pregnancy cohabitation con$er a lower ris& o$ preeclampsia.7 ;onversely, the

ris& o$ preeclampsia is increased with the use o$ barrier contraceptives, new paternity, and

with donor sperm insemination.

+!a&e#'a! )a&'"r(3!xcess placental volume as with hydatidi$orm moles and multi>$etal

gestations is also associated with the development o$ preeclampsia. 3he disease process may

occur earlier and have more severe mani$estations in these cases. 3he ris& progressively

increases with each additional $etus.

a'er#a! &ara&'eri('i&(

Age3!xtremes o$ childbearing age have been associated with preeclampsia.1 owever,

once adjustments $or parity are made in the younger age group *since most $irst pregnancies

occur at a younger age-, the association between younger age and preeclampsia is lost.

:ultiple studies demonstrate a higher incidence o$ preeclampsia among older women

independent o$ parityG however, many o$ these do not control $or pre>existing medical

conditions. A$ter controlling $or baseline di$$erences, women who were American merican race and preeclampsia has been

con$ounded by the higher prevalence o$ chronic hypertension, o$ten undiagnosed, in this

group. 4hile some studies demonstrate a higher ris& o$ preeclampsia among A$rican>

American women, larger prospective studies which controlled $or other ris& $actors and

rigorously de$ined preeclampsia did not $ind a signi$icant association between preeclampsia

and A$rican>American race. :ore severe $orms o$ preeclampsia may be associated with

maternal non>white race.

+re-e5i('i#g &"#/i'i"#(3:any o$ the maternal ris& $actors $or preeclampsia are similar to

those $or cardiovascular disease. +re>existing hypertension, diabetes, obesity, and vascular

disorders *renal disease, autoimmune conditions- are associated with preeclampsia. Cis& is

correlated with the severity o$ the underlying disorder. 4omen with underlying chronic

hypertension have a 10>72 ris& o$ developing preeclampsia compared to the general

population. 3his ris& is increased to 12 in women with a longer duration o$ hypertension o$

at least $our years or more severe hypertension at baseline. 4ith pre>gestational diabetes, the

overall ris& o$ developing preeclampsia is approximately 12. owever, the ris& is 11>12

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with diabetes o$ less than 10 years duration, which increases to to 7standing diabetes associated with microvascular disease. %or mild renal disease

*serum creatinine o$ less than 1.7mgdJ-, the ris& o$ preeclampsia is estimated at 0 to 72

but greater than 702 $or pregnant women with severe renal disease. +reeclampsia also

occurs more $re'uently among pregnant women with autoimmune conditions such as

systemic lupus erythematosus and antiphospholipid antibody syndrome.

Oe(i'*3!levated body mass index *):/, &gm- is also associated with preeclampsia.

Eiven the obesity epidemic in the "nited #tates and around the world, this is one o$ the

largest attributable and potentially modi$iable ris& $actors $or preeclampsia. 3his will be

discussed in $urther detail below.

Fa$i!* i('"r* ") %ree&!a$%(ia3A $amily history o$ preeclampsia nearly triples the ris& o$

preeclampsia.

S$"i#g3+aradoxically, cigarette smo&ing during pregnancy is associated with a reduced

ris& o$ preeclampsia possibly due to modulation o$ angiogenic $actors.

III.4 OBESITY AND +REECLA+SIA

/n the "nited #tates, the percentage o$ women who are overweight or obese has

increased by approximately 02 over that last thirty years. 3he 4orld ealth Organi5ation

estimates the prevalence o$ obese and overweight women *body mass index 6 7 &gm- to

be 2 in the "nited #tates, 2 in :exico, 2 in %rance, 2 in ;hina, 182 in /ndia,

and 92 in #outh A$rica with wide variation within each continent. 3he high prevalence o$

obesity and projected increase have substantial implications $or pregnancy since obesity is

associated with in$ertility, spontaneous miscarriage, $etal mal$ormations, thromboembolic

complications, gestational diabetes, stillbirth, preterm delivery, cesarean section, $etal

overgrowth and hypertensive complications. to >$old. 3he

ris& o$ preeclampsia progressively increases with increasing ):/, even within the normal

range. /mportantly, it is not only the late or mild $orms o$ preeclampsia that are increased, but

also early and severe preeclampsia, which are associated with greater perinatal morbidity

andmortality. 3he increased ris& is present in both ;aucasian and A$rican>American women.

3he association between preeclampsia ris& and obesity has also been demonstrated in varying

populations across the globe. #upporting the concept that obesity may play a causal role is the

$inding that weight loss reduces the ris& o$ preeclampsia. #ome studies suggest that excessive

maternal weight gain is associated with the ris& o$ preeclampsia, although these may be

con$ounded by the increase in $luid retention with preeclampsia contributing to the higher

weight. Although weight loss is discouraged in pregnancy, obesity is a potential modi$iable

ris& $actor $or preeclampsia. 4eight loss prior to pregnancy is encouraged in overweight and

obese women to decrease the ris& o$ adverse outcomes. /n our population *+ittsburgh,

+ennsylvania-, it is estimated that 02 o$ the preeclampsia ris& is attributable to obesity. eclampsia and a dose>dependent

relationship between increasing body mass index *):/- and the ris& o$ developing

pre>eclampsia is well established.8

Obesity is associated with signi$icant metabolic and physiologic alterations. Adipose

tissue is not simply storage o$ $at, but rather is a hormonally active tissue producing

endocrine mediators such as cyto&ines and adipo&ines.3hese mediators have been associated

with a proin$lammatory and prothrombotic state, insulin resistance and oxidative stress, all o$

which have been associated with pathogenesis o$ preeclampsia, as well as li$etime ris& o$

maternal cardiovascular disease.

Obesity is a ris& $actor $or both preeclampsia and cardiovascular disease. !xploring

common mechanisms may provide insight into the pathophysiology o$ preeclampsia,

potential areas $or $urther investigation, and possible targets $or therapy. ere, we will brie$ly

highlight a $ew $eatures that are shared by these conditions including insulin resistance,

in$lammation, oxidative stress and vascular dys$unction, adipo&ines, and angiogenic $actors.arginine, the precursor o$ nitric oxide synthesis. AD:A $unctions as a nitric

oxide synthase inhibitor resulting in reduced O production and increased superoxide

generation. !levated AD:A concentrations are associated with in$lammation, insulin

resistance, dyslipidemia, obesity, and cardiovascular disease. /nterestingly, circulating AD:A

has been shown to decrease with weight loss. #everal studies have demonstrated higher

concentrations o$ AD:A with preeclampsia and even prior to the onset o$ disease at mid>

gestation J>arginine has been used to reverse some o$ the e$$ects o$ AD:A in clinical

studies. /t has been used sa$ely in pregnancy. One randomi5ed controlled trial demonstrated

that preeclampsia was reduced with administration o$ a combination o$ arginine and anti>

oxidant therapy in a high ris& population compared to placebo or anti>oxidants alone.8

%urther study is needed to elucidate the e$$ects o$ Jarginine administration on the ris& o$

preeclampsia in other populations including obese women. 3hus, a better understanding the

relationship between obesity, preeclampsia and cardiovascular disease may shed light on

common mechanisms and potential targets $or therapy.arginine. "nder these conditions, endothelial

O# generates superoxide anion, increases oxidative stress, attenuates O bioactivity, and

induces additional endothelial dys$unction. 3hus, AD:A is both increased by oxidative stress

and by uncoupling O has the capacity to increase oxidative stress. #everal studies have

reported that plasma AD:A concentrations are higher in women withpreeclampsia. +lasma

AD:A concentrations are also signi$icantly higher in midpregnancy in women who later

develop preeclampsia.171 AD:A concentrations remain high in these same women when

they develop preeclampsia compared to women with an uncomplicated pregnancy and

women who have growth restricted in$ants in the absence o$ developing preeclampsia. 3hese

data are particularly interesting given the central role AD:A plays in the regulation o$

endothelial>dependent vascular $unction, angiogenesis and arteriogenesis, and the &nown

de$iciencies in these activities in preeclampsia.

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;onsistent with a role $or AD:A in the increased ris& o$ cardiovascular disease and

preeclampsia, circulating plasma AD:A concentrations are higher in obese subjects. 4hile

the exact mechanism $or the increase in plasma AD:A in with obesity is un&nown, it is

li&ely mediated in part by a change in DDA activity. /nterestingly, a recent study reported

that plasma AD:A concentrations correlate positively with the acute in$lammatory mar&er

;C+ in obese subjects both be$ore and a$ter weight loss suggesting a role $or in$lammation.

/n addition, AD:A is higher in obese insulin resistant women compared to similarly obese

insulin sensitive women. AD:A concentrations are inversely related to insulin sensitivity,

and AD:A concentrations decrease in response to weight loss. /t is possible that

preeclampsia develops in obese women with the highest AD:A concentrations. As a

competitive antagonist o$ J>arginine many o$ the e$$ects o$ AD:A can be reversed with

modest increases in J>arginine inta&e. Arginine at concentrations that increase O production

has been used sa$ely in pregnancy. AD:A provides targets $or subse'uent randomi5ed

controlled trials in obese women.

TREATENT OF OBESITY

4eight loss is tremendously di$$icult $or obese individuals. /$ achieved, long>term

maintenance poses e'uivalent or even more daunting di$$iculties. !ven the most legitimate

nonsurgical methods are $raught with $re'uent $ailure. /$ they are success$ul, slow and

inexorable return to preintervention weight usually $ollows *Ranovs&i, 007-. #uccess$ul

weight loss approaches include behavioral, pharmacological, and surgical techni'ues or a

combination o$ these methods *!c&el, 008G Simmet, 01-. As such, obstetrician>

gynecologists are encouraged to aid assessment and management o$ obesity in adult women.

4eight loss and li$estyle changes have been shown to reduce the associated metabolic

syndrome *;rist, 01-. 4hen used in conjunction with bariatric surgery, there is improved

glucose control with type diabetes *:ingrone, 01G #chauer, 01-.

Li)e ('*!e )a&'"r( a(("&ia'e/ 6i' "e(i'*

Ji$e style $actors such as diet and physical activity have been associated with obesity

and ris& o$ cardiovascular diseases, however the association o$ these $actors with

preeclampsia remains poorly elucidated. ,


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Die'3+oor nutrition is a major contributor to cardiovascular disease. Diets high in

antioxidants, $ruits and vegetables, ) vitamins, omega> polyunsaturated $atty acids *+"%As-,

$ish and sea$ood, whole grains, and dietary $iber protect against heart disease, and

excessive inta&es o$ saturated $at, trans $atty acids, re$ined grains and sweets increase the ris&

o$ heart disease. A$ter decades o$ research in this area, healthy diet is now a cornerstone o$

cardiovascular disease prevention. Despite the similarities between preeclampsia and

cardiovascular disease, $ew investigators have studied the role o$ diet in the pathophysiology

o$ preeclampsia. Kitamin ;, vitamin !, and the carotenoids are important physiologic

antioxidants. %olate reverses endothelial dys$unction in patients with some chronic diseases,

reduces oxidative stress, and restores the activity o$ nitric oxide.

+*(i&a! a&'ii'*>> is &nown to reduce the ris& o$ obesity and cardiovascular diseases. /n

addition, data $rom observational studies show that exercise may reduce the ris& o$

preeclampsia. #tudies have shown association between physical activity *leisure time and

occupational activities- during and be$ore pregnancy to be associated with reduced ris& o$

preeclampsia.. Data $rom these studies show that physical activity including recreational

activities one year be$ore pregnancy and in early pregnancy is associated with reduced ris& o$

preeclampsia. According to these studies, reduced physical activity may explain the

association between obesity and ris& o$ preeclampsia as well as cardiovascular diseases ris&.

As preeclampsia is associated with signi$icant morbidity and the literature suggests

commonalities in the pathogenesis o$ adverse e$$ects o$ obesity and preeclampsia,

prepregnancy ):/ may be a target $or pubic health $ocus to reduce the ris& o$ preeclampsia.

A#'e%ar'u$ a#age$e#',

Die'ar* I#'ere#'i"# i# +reg#a#&*

4eight reduction is not advisable during pregnancy *;atalano, 01-. As noted,

recommended weight gain in obese women is 11 to 0 pounds, and several dietary

interventions to limit weight gain to these targets have been reported. 3hese include li$estyle

interventions and physical activity *+etrella,01-. Ceviews by Tuinlivan *011- and

3anentsap$ *011- $ound that randomi5ed trials generally reported success$ul results with

intervention. On the other hand, in many other studies, either these have been unsuccess$ul or

the results were insu$$icient to permit a conclusion *;ampbell, 011G Dodd, 010G Euelinc&x,

010G ascimento, 011G Connberg, 010-. #pecial attention to psychological aspects o$

pregnancy has been recommended by some *#&outeris, 010-.

+re#a'a! Care

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;lose prenatal surveillance detects most early signs o$ diabetes or hypertension.

#tandard screening tests $or $etal anomalies are su$$icient, while being mind$ul o$

sonographic limitations $or detection o$ $etal anomalies. Accurate assessment o$ $etal growth

usually re'uires serial sonography. Antepartum and intrapartum external $etal heart rate

monitoring are li&ewise more di$$icult, and sometimes these are even impossible.

Surgi&a! a#/ A#e('e'i& C"#&er#(

!valuation by the anesthesia team is per$ormed at a prenatal visit or on arrival at the

labor unit *American ;ollege o$ Obstetricians and Eynecologists, 01b-. #pecial attention is

given to that might arise during labor and delivery. Kricella and cowor&ers *010- reported

the $ollowing $re'uencies o$ anesthetic complications in 1percent were wound disruptions to the $ascia, but there was only one

evisceration. As indicated above, the transverse abdominal incision had $ewer complications.

4alsh and cowor&ers *009- have reviewed the prevention and management o$ surgical site

in$ections in morbidly obese women. 3o lower thromboembolic complications, graduated

compression stoc&ings, hydration, and early mobili5ation a$ter cesarean delivery in obese

women are recommended by the American ;ollege o$ Obstetricians and Eynecologists

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*01a-. #ome also recommend Nmini>dose heparin prophylaxis, but we do not routinely use

this *;hap. 7,p. 10


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Baria'ri& Surger*

#everal surgical procedures have been designed to treat morbid obesity either by decreasing

gastric volume(restrictive, or by bypassing gastrointestinal absorption(restrictive

malabsorptive *Adams, 00G =ushner, 01-. /n nonpregnant patients, these procedures

have been shown to improve or resolve diabetes, hyperlipidemia, hypertension, and

obstructive sleep apnea *)uchwald, 00G :ingrone, 01G #chauer, 01-.

+reg#a#&*

)ecause o$ these successes, bariatric surgery currently has become popular, and many

women are becoming pregnant $ollowing weight>reduction surgery *Abodeely, 008-. #everal

observational studies have reported improved $ertility rates and reduced ris&s o$ obstetrical

complications in women $ollowing bariatric surgery and compared with morbidly obese

controls *Alatishe, 01G Euelinc&x, 009G =jaer, 01aG Jes&o, 01G 3an, 01-. 3he

largest o$ these studies is $rom the #wedish )irth Cegister, which included 81 women with a

pregnancy $ollowing bariatric surgery *Qose$sson, 011-. Despite surgical treatments, hal$ o$

these women were still obese by the time o$ their $irst pregnancy $ollowing bypass, however,

the proportion with morbid obesity was smaller. 3he $re'uency o$ large>$or>gestational age

in$ants decreased $rom 9.1 to . percent and that o$ small$or> gestational age neonates

increased $rom .1 to 7. percent. /n a recent systematic review, =jaer and ilas *01b-

reported a decreased ris& a$ter bariatric surgery $or diabetes, preeclampsia, and large>$or>

gestational age in$ants. :ost studies con$irmed a higher ris& $or small>$or>gestational age

$etuses.

Re('ri&'ie +r"&e/ure(

3here are three procedures to accomplish gastric restriction and selective

malabsorption. 3he most commonly used is the laparoscopically per$ormed &oux'en'(

!astric bypass and biliopancreatic diversion ith duodenal sitch. 4ith the Coux>en>R

procedure, the proximal stomach is completely to leave a 0>mJ pouch. A gastroenterotomy

is then created by connecting the proximal end o$ the distal jejunum to the pouch. A Coux>en>

R enteroenterostomy is also completed 0 cm distal to this gastrojejunostomy to allow

drainage o$ the unused stomach and proximal small intestine. As with other bariatric

procedures, pregnancy outcomes are changed remar&ably $ollowing Couxen> R bypass

*4ittgrove, 1998-. As shown in 3able


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4ax, 00-. )owel obstruction is notoriously di$$icult to diagnose, and 4ax and associates

*01- caution $or a high index o$ suspicion.

Re&"$$e#/a'i"#(

3he American ;ollege o$ Obstetricians and Eynecologists *01a- recommends that

women who have undergone bariatric surgery be assessed $or vitamin and nutritional

su$$iciency. 4hen indicated, vitamin )1 and D, $olic acid, and calcium supplementation are

given. Kitamin A de$iciency has also been reported *;hagas, 01-. 4omen with a gastric

band should be monitored by their bariatric team during pregnancy because adjustments o$

the band may be necessary. %inally, special vigilance is appropriate $or signs o$ intestinal

obstruction.

III. CONCLUSION

Obesity causes signi$icant complications during pregnancy $or the mother and $etus.

/nterventions promoting pre>pregnancy weight loss and the prevention o$ excessive weight

gain during pregnancy must begin in the preconception period. Obstetrical care providers

need to counsel their obese patients about the ris&s and complications con$erred by obesity

and the importance o$ weight loss be$ore pregnancy. #urveillance may need to be heightened

during pregnancy, and a multidisciplinary approach to the management o$ obese women

during pregnancy is use$ul. 4omen need to be in$ormed about both maternal and $etal

complications and about the measures that are necessary to optimi5e outcome. 10

Jarge population studies have shown that obese women are two to three times more

li&ely to develop preeclampsia than their leaner counterparts. 3here$ore, the recent mar&ed

increase in obesity in women o$ childbearing age has raised speci$ic concerns regarding the

ris& management o$ preeclampsia. #ince maternal obesity appears to shi$t their o$$spring

toward a predisposition to obesity, this cycle may continuously increase not only the

incidence o$ preeclampsia, but also numerous ris& $actors associated with pregnancy duringthe next hal$ century. Ji$estyle interventions be$ore conception as well as postpartum until

attempting another pregnancy is the most e$$ective strategy to reduce the ris&s associated with

pregnancy in obese womenG however, this has not been very success$ul. #ince global

preventive medical care programs have been unsuccess$ul in protecting against the

overwhelming prevalence o$ the NObesity 3sunami in developed as well as developing

countries, new medical care strategies, such as preemptive medicine are needed.4hether

weight reduction prior to pregnancy or restricting weight gain during pregnancy will reduce

the ris& o$ preeclampsia is not established. owever, the general health bene$its o$ weight

25


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loss in obese individuals justi$y weight loss be$ore pregnancy. #imilarly the /nstitute o$

:edicine recommended reduced weight gain $or obese pregnant women. 4hether these

behavioral modi$ications will reduce the ris& o$ preeclampsia will be established over time

but is unli&ely to be tested in randomi5ed controlled trials.

C!%!C!;!#

1. 4allis A), #a$tlas A%, sia Q, Atrash =. #ecular 3rends in the Cates o$ +reeclampsia,

!clampsia,

and Eestational ypertension, "nited #tates, 198>00


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refrat obesity pe

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