maternal excess weight - nova scotia health...
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Maternal Excess Weight Current Knowledge and Future Directions
B Anthony Armson MD
Weight Times in Perinatal Health
October 2, 2014
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Global Health Epidemic
• 1 billion overweight or obese worldwide
– 300 million obese
– Major cause of mortality
• Obesity in Canada
– Overweight: 8.6 million (36%)
– Obese: 5.5 million (23%)
– First Nations: 38% obese
– Economic burden: $7 billion per year
Branca F, WHO 2010
Statistics Canada Community Health Survey 2004
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Statistics Canada: CCHS 2011
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Prevalence by Obesity Category
Obesity Category Canada NS
Overweight (BMI 25-29.9) 33.6 37.5
Obese (BMI ≥ 30) 18.3 23.7
Obese Class I (BMI 30-34.9) 13.1 15.6
Obese Class II (BMI 35-39.9) 3.6 5.8
Obese Class III (BMI ≥ 40) 1.6 2.3
Overweight or obese (BMI ≥ 25) 51.9 61.2
Twells, LK, CMAJ 2014
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Twells, LK, CMAJ 2014
Adult Obesity Trends in Canada
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Twells, LK, CMAJ 2014
Future obesity prevalence in Canada
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0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Women with Pre Pregnancy Weight >90kg in NS % of women
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Maternal and Newborn
Consequences
Robinson HE, Obstet Gynecol 2005
Arendas K, J Obstet Gynecol Can 2008
Davies GA, J Obstet Gynecol Can 2010
Marshall NE, Semin Reprod Med 2012
Blomberg M, Obstet Gynecol 2013
Papachatzi E, J Neonat-Perinat Med, 2013
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Effects on Fertility and
Early Pregnancy
• Early reproductive dysfunction
– Precocious menarche
– Irregular menses
– Oligo/amenorrhea
• Infertility
– Ovulatory dysfunction
– IVF/ICSI failure
• Spontaneous abortion
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Antenatal Complications
• Gestational Diabetes (OR=2 - 8)
– Increased insulin resistance
– Inadequate insulin response
• Gestational HTN/Preeclampsia (OR = 2 – 7)
– BMI increase of >3 between pregnancies
increases risk 2-fold
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Antenatal Complications
• Indicated Preterm Birth
• Dizygotic Twin pregnancy
• Thromboembolism (OR = 2 – 4.3)
• Obstructive sleep apnea
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Antenatal Complications
• Infection
– Urinary tract
– Genital tract
– Fever of unknown origin
– Chorioamnionitis
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Fetal Complications
Congenital anomalies
– Neural tube defects
– Cardiac malformations
– Oral/facial clefts
– Limb reduction anomalies
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Fetal Complications
• Stillbirth/IUFD
– OR = 1.5(overweight); 2(obese)
– Unexplained; uteroplacental insufficiency
• Suboptimal fetal imaging
– BMI 30-34 2.5 fold
– BMI 35-39 5 fold
– BMI >40 8 fold
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Intrapartum Complications
• Dysfunctional labour
– Prolonged active phase
– Failure to progress
• Labour induction (OR=1.2 - 2.6)
– Failed induction
• Increased failed VBAC rates
– Normal weight – 15%
– Overweight – 22%
– Obese – 30%
– Morbidly obese – 40%
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Intrapartum Complications
• Shoulder Dystocia (OR = 1.5)
• Operative vaginal delivery
• Cesarean birth (OR=1.5 - 3) – Dysfunctional labour/Fetal distress
• Intraoperative complications – Increased OR time
– Increased blood loss
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Intrapartum Complications
• Perineal trauma
• Anesthesia (OR=1.3 – 2.2)
– Multiple epidural attempts
– Epidural failure
– Hypotension FHR bradycardia
– Postdural puncture headache
– Difficult intubation
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Neonatal Complications
• Neonatal Death
• NICU admission
• Birth trauma
• Sepsis
• Respiratory distress
• Hypoglycemia
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Postpartum Complications
• Maternal Death
– 35% are in obese women
• Postpartum hemorrhage (OR=1.3 – 3)
• Wound infection/ Dehiscence (OR = 1.7/ 2)
• Breastfeeding Difficulties
– Decreased lactogenesis
– Decreased prolactin response to suckling
– Breast morphology
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Long Term Complications
• Type 2 Diabetes
– 50% of obese women with GDM have
Type 2DM within 15 years
• Metabolic syndrome
– Obesity, hypertension
– Insulin resistance, dyslipedemia
• Obesity in offspring
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Management Strategies
SOGC Clinical Practice Guideline 2010
NICE Public Health Guideline 2010
ACOG Committee Opinion 2013
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Pre-pregnancy Care
• Preconception weight reduction
– Dietary and lifestyle interventions
– Bariatric surgery
• Counsel regarding risks of obesity in
pregnancy
• Prenatal vitamins and folic acid
supplementation
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Prenatal Care
• Calculate BMI and counsel on optimal
weight gain during pregnancy
• Referral to dietician
• Early ultrasound to confirm viability and
gestational age
• Dietary and lifestyle interventions
• Promote physical activity
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Prenatal Care
• Maternal serum screening
• GDM screening in first trimester, if negative
repeat at 24-28 weeks
• Detailed fetal anatomy ultrasound at 20
weeks
• Fetal movement surveillance
• Frequent blood pressure measurement
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Optimal Weight Gain in Pregnancy
Pre-pregnancy weight Weight Gain
(BMI) (kg) (lbs)
Underweight (<20) 12.7 – 18.2 25 – 40
Normal (20-25) 11.4 – 15.9 25 – 35
Overweight (26-29) 8.8 – 11.4 15 – 25
Obese ( >30) 6.8 15
US Institute of Medicine, 1990
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Gestational Weight Gain Interventions
Weight loss during pregnancy in obese women
macrosomia, preeclampsia, C-section
maternal weight retention, childhood obesity
- concern regarding risk of SGA
Diet and lifestyle intervention RCTs
- inconsistent influence on pregnancy weight gain
- conflicting evidence of improved outcomes
No evidence-based guidelines on gestational
weight management
Furber CM, Cochrane Library, 2013
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Peripartum Care
• Anesthesia consult for BMI>40
• Anticipate need for induction
• Consider elective C-section for EFW>4500g
for GDM, EFW>5000g for non-GDM
• Anticipate dysfunctional labour
• Anticipate failed VBAC
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Peripartum Care
• Anticipate difficulty with external FHR monitoring
• Anticipate shoulder dystocia
• Active management of the third stage
• Subcutaneous sutures if adipose tissue greater than 2 cm
• Adequate personnel and material resources
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Postpartum Care
• Early mobilization and thrombosis
precautions
• Anticipate post-operative infections
• Lactation consultant
• Screen for Type 2 DM
• Counsel regarding risks of weight retention
• Encourage weight loss prior to next
pregnancy
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Opportunities for the Future
• Advocate for active healthy lifestyle choices by women and youth
• Call to action for NS governing bodies and society
• Education program for adolescents regarding the reproductive implications of obesity
• DHW education and lobbying roll for RCP using data from the NS Atlee Perinatal Database
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Research Opportunities
• Determinants of maternal/child obesity and pregnancy outcomes
• Pre-pregnancy obesity weight reduction interventions
• Pregnancy weight management
• Prenatal programs for optimal interdisciplinary care and research
• Weight reduction after childbirth
• Breastfeeding and postpartum weight
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Maternal Child Obesity Research Team
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