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Management of the obese pregnant patient

Management of the obese pregnant patient. Max Brinsmead PhD FRANZCOG May 2010. 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

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Management of the obese pregnant patient

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  1. Management of the obese pregnant patient Max Brinsmead PhD FRANZCOG May 2010

  2. 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

  3. 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

  4. Risks and Complications (2) • Increased fetal risk of: • Congenital malformation (1.6 fold) • Fetalmacrosomia (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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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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