Obesity and Pregnancy: Implications and Strategies for Positive Birth Outcomes

1. FLUFFY MOMS Obesity and Pregnancy Shelia Love, ARNP, MS, CNM, C-FEM Private Practice Dr. DelisaSkeete-Henry September 25, 2015

2. Objectives • Understanding the severity of obesity in United States and increased health care costs • Identify labor, birth and post partum management strategies for the obese patient • To specify the importance of pre-pregnancy health status for positive birth outcomes • Identify the specific implications of maternal and newborn complication associated with obesity • Identify long term consequences of obesity on society

3. Incidence of obesity United States • US statistics according to American Congress of Obstetrics and Gynecology (ACOG) January 2013 • 1/3 of women • 1/2 of all pregnant women • 8% are extremely obese • 50% non Hispanic black women • 45% Mexican American • 33% non Hispanic white 3 (American Congress of Obstetrics and Gynecology (ACOG) January 2013)

4. January 2015 March of Dimes (MOD) quoted obesity rates in US women at 75% • Obesity has more than doubled in the last 25 year • 2013 Broward Fetal Infant Review 39% of cases involved obese Mothers 4 (March of Dimes, 2015)

5. January 2015 March of Dimes (MOD) quoted obesity rates in US women at 75% • Obesity has more than doubled in the last 25 year • 2013 Broward Fetal Infant Review 39% of cases involved obese Mothers 5 (March of Dimes, 2015)

6. Contributing factors • Obesity is more complex than just “overeating” • Genetics • Psychosocial ex: abuse, poverty, depression • When counseling patients identification of these issues may assist with counseling 6

7. Financial Impact Consists of 3 cost factors • Obesity related medical treatment costs in 2006 • $147-210 per year. Majority of dollars obesity related disorders ie. HTN, diabetes • Obese patients spend 42% more on health care than non obese patients • Decreased worker production and increased absenteeism an estimated costs to employers of $4.3 billion annually • Typical ambulance weight capacity 400 lbs = $70,000.00 • Bariatric ambulance = $110,000.00 • Standard hospital bed = $1000.00 • Bariatric bed = $4000.00 If current obesity trends continue, the per capita health care spending will increase to $7,760.00 by 2020 which is 70% jump from. 2007 ACOG, 2011

8. Definitions • Body Mass Index (BMI) calculated weight in kilograms divided by height in meters squared • Normal BMI 18.5 to 24.9 • Overweight 25-29.9 • Obese 30 and greater • Morbid obesity 40 and greater • Class 1 BMI 30-34.9 • Class 2 BMI 35-39 • Fluffy

9. Obesity/ BMI 9

10. 10

11. Lets put it into perspective • 5’5” female • Weight 155lbs • BMI =25.8 • OVERWEIGHT • 5'2” pregnant female weight 120lbs can only gain 20lbs to maintain normal BMI 11

12. Serena Williams • Height 5”9” 175 cms • Weight 155lbs 70.3 kgs • BMI: 23 12

13. Kim Kardashian • Height 5’2” 159 cms • Weight 143 lbs 68 kgs • BMI: 26.4 13

14. Angelina Jolie • Height 5’8” 173 cms • Weight 128lbs 58 kgs • BMI: 18.5 14

15. Beyonce • Height 5’6” 169 cms • Weight 137lbs 62kgs • BMI: 23.4 15

16. PregnancyWeight Gain Guidelines BMI • 18.5- 24.5 25-35 lbs • 25-29.9 15-25 lbs • > 30 11-20 lbs • > 40 morbid obesity ????? 16

17. Weight Gain Controversy • ACOG supports • 11-20 lbs weight gain for obese women • There is no differentiation between obesity classes or diabetics • Studies have shown weight loss with monitored adequate fetal growth did not have significant difference in outcomes compared to those who were encouraged to gain weight 17

18. Controversy 18

19. Professional Conflicts • Providers declining OB care for obese women d/t increased exposure to poor outcomes and litigation, co-morbidities and possible physical strain on staff • Are we obligated to care of all patients???

20. Weight loss • Some MFM specialist advocate weight loss based on research data demonstrating additional maternal fat stores provide adequate nutrition for fetal development when weight loss is achieved by appropriate maternal calorie intake and exercise

21. Pre Conceptual Considerations • Maternal health prior to pregnancy is a major contributor to birth outcome • Health care issues should be stable prior to conception ie. wt, HTN, diabetes, asthma • Consult care providers • Specialty consults difficult to obtain so establish relationship with providers on staff at birth hospital 21

22. ImplicationsMaternal • BMI 30-39.9 increased risks of GDM, gestational hypertension, pre-eclampsia and macrosomia, birth injury • C/S rate ^ with higher BMI Florida stats BMI 35-39 C/S rate 47.4% (??) • Higher spontaneous abortion (SAB) rate with assisted reproduction (natural as well) • Decreased efficacy of ultrasound technology in detecting anomalies ex Open neural Tube defect (ONTD) • Increased induction rate due to co morbidities • 39% VBAC failure rate

23. ImplicationsFetal/Newborn • Prematurity • Stillbirth • Congenital Anomalies • Macrosomia 4500 GMS (9# 11oz) diabetic 5000 GMS 11lbs .02oz lbs non diabetic • Childhood obesity • Hypoglycemia in IDM • Fetal Injury 23

24. Labor and delivery • IV access • Proper BP cuff size • Position change/mobility • EFM and uterine activity • Physical strain on staff/additional help • Pain management • Literature recommends epidural ???? 24

25. Challenges : Epidural/ Spinal • Difficult positioning for pt comfort • Obscured landmarks d/t adipose • Loss of motor control increased risk staff injury assisting withposition change • Additional personnel for birth (anticipate shoulder dystocia, positioning) • Adequate visualization for birth and repair • Fluid balance 25

26. Surgical Considerations • Additional staff for transport and positioning • Thromboprophylaxis with SCDs and anticoagulant prior to surgery • Prophylactic antibiotics 30 minutes prior to surgery ( increased dose recommended) • Weight/width appropriate OR table • Risks of PPH (blood available) • Fluid balance 26

27. Anticipate longer OR time • Closure of sub cutaneous tissue may decrease incidence of wound breakdown • Drains have found to be of no value • Additional personal at OR table for retraction • Transverse skin and uterine incision • Visualization (pannus/abdominal drape) • Prepare for possible difficult intubation 27

28. Possible shoulder or abdominal dystocia • Increased DVT risks • Airway complications (Sleep Apnea) or difficult intubation (tray) • Preoperative scrub (scheduled) 28

29. Panniculeous Adiopse • surgical picture of exposure 29

30. Post Partum • DVT/PE • Infections (respiratory, wound, fungal) • PPH • Pain management • Hygiene • Lactation • Ambulation • Wound breakdown 30

31. Dehiscence 31

32. Plan of careLabor and Birth • Team approach • Most experienced for IV start • Versatile EFM strategies • Pain management anesthesia consult consider alternatives • Recruit help for position change moving bed • Position for birth 32

33. Pre conception and Antepartal Care • Establish reality based diet/exercise program (psychological support when indicated) more than handing out diet list • Maternal Fetal Medicine (MFM) for ultrasound studies (some machines made be inadequate to penetrate adipose, limits diagnostic capabilities) • MFM consult to follow co morbidities • Non judgmental care • Childbirth preparation birth plan 33

34. Labor Plan of Care • Patient gown • Bed size • IV access • PPH risk (Blood on hold??) • Prepare patient for additional staff at birth • EFM challenges • Induction challenges (palpation) finding the sweet spot • Pushing/Birth position Lithotomy??? 34

35. PostpartumPlan of Care • Early ambulation • Lactation support • Pain management • Fluid shift: assess respiratory or cardiac • Hygiene: peri and incision care • Discuss birth control • Long term health 35

36. Recommendations • As care providers, parents, relatives, friends, spouses and members of society, we must recognize global implications of obesity (second preventable health risks in the United States. • Being proactive with our own health status and those we care for both professionally and personally may slow this epidemic 36

37. SUMMARY • Prenatal • All providers PCPs, Internists, Chiropractors, Dentists , Fertility Specialists, should address health implications of obesity with their clients • OB/GYN open discussion of obesity risks at GYN visits and importance of improving health status prior to conception • Attempt to identify etiology of obesity

38. 1st prenatal visit should include health status and BMI, with a discussion of weight recommendations, diet and exercise • Consider Perinatal consults • Regardless whether you support minimal weight gain or no weight gain for morbid obesity women their diet history, adequate nutritional intake and psychosocial status should be monitored not just the scale • Labor and birth plan

39. Intrapartum • Be sensitive • Team approach recruit help IV start, position changes transport • Support physiological birth • Pain management options • Anesthesia consults • Additional personnel

40. Creative fetal and uterine assessment • Birth position options • Anticipate shoulder dystocia • Prepare for PPH • NICU support when indicated • Extra personnel for birth • Spacing of future pregnancies for optimal health status 40

41. REFERENCES ACOG Committee Opinion, January 2013 Obesity in Pregnancy March of Dimes ACOG Committee Opinion 548 January 2013 Weight Gain in pregnancy Contemporary OB/GYN Obesity and Weight Gain in Pregnancy July/01/2013 Healthy Mothers Healthy Babies Broward Fetal Infant Mortality Review Statistics (2013) State of Obesity Report Series 2014: Better Policies for a Healthy America