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Obesity in Pregnancy: A Growing Epidemic

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  1. Obesity in Pregnancy:A Growing Epidemic Jennifer Krupp, MD University of Iowa Hospital & Clinics Department of Obstetrics & Gynecology Division of Maternal Fetal Medicine

  2. Disclosures I have no financial or other conflicts of interest that I need to disclose.

  3. Objectives This presentation will review the following: • The obesity epidemic in the United States and worldwide • Current classifications of obesity • Maternal and fetal complications during pregnancy • Delivery considerations and complications during labor • Postpartum complications • How to counsel patients in the office

  4. Worldwide Obesity

  5. The Obesity Problem In the U.S. • 34% of U.S Adults are obese • No state has met Healthy People 2010 goal to lower obesity rate < 15% • 2008 Obesity related costs: $150 billion • Obesity related conditions: heart disease, stroke, diabetes, cancer, and death http://www.cdc.gov/obesity/data/adult.html

  6. Obesity Trends* Among U.S. AdultsBRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  7. Obesity Trends* Among U.S. AdultsBRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

  8. Obesity Trends* Among U.S. AdultsBRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

  9. Obesity Trends* Among U.S. AdultsBRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

  10. Obesity Trends* Among U.S. AdultsBRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  11. Obesity Trends* Among U.S. AdultsBRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  12. 2009–201036% of U.S. adults were obese Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012.

  13. 2009–2010,17% of U.S. children & adolescents were obese Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012.

  14. May 2013

  15. Obesity in Iowa

  16. 2008 Iowa Obesity by County Lowest – Johnson County 23.5% Highest – Warren County 31.9% BMI 2008 Age-Adjusted Estimates of the Percentage of Adults Who are Obese in Iowa. apps.nccd.cdc.gov/DDT_STRS2/CountyPrevalenceData.aspx?mode=OBS

  17. WHO Obesity Classifications Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

  18. Weight Gain During Pregnancy – Recommendations from IOM 2009 Kathleen M. Rasmussen and Ann L. Yaktine, Editors; Committee to Reexamine IOM Pregnancy Weight Guidelines; IOM; NRC

  19. Antepartum Considerations • First Trimester Screen/Integrated Screen • Increasing BMI and Attainable NT

  20. Failure Rate to Obtain NT Measurement First Attempt Multiple Attempts http://www.fetalmedicine.com/fmf/training-certification/certificates-of-competence/11-13-week-scan/nuchal Thornberg et al Ultrasound ObstetGynecol 2009

  21. What about the Biochemical Tests ? • First Trimester Screen • Quadruple Screen • Obesity causes dilutional effect • Falsely lowered results • Labs have correction factor in software to correct test results up to 400 pounds • Over 400 pounds, the results are inaccurate

  22. Detailed Anatomy Ultrasound Dashe and colleagues in 2009 • Retrospective cohort study • Pregnancies 18-24 weeks over 5-year period • Assessed BMI and detection of fetal anomalies • 10,112 standard exams in low-risk pregnancies • 1098 targeted exams in pregnancies with high-risk indication or abnormality detected on standard exam Dashe, J. et al. Effect of maternal obesity on the ultrasound detection of anomalous fetuses. Obstetrics & Gynecology. 2009;113:1001-7.

  23. Fetal Detailed Ultrasound Completion Rate Thornburg, L et al. Fetal anatomic evaluation in the overweight and obese gravida. Ultrasound Obstetrics and Gynecology. 2009;33:670-5.

  24. Fetal Anomaly Detection on Detailed Ultrasound Dashe, J. et al. Effect of maternal obesity on the ultrasound detection of anomalous fetuses. Obstetrics & Gynecology. 2009;113:1001-7.

  25. Ultrasound Limited by Obesity Evaluate the ability to adequately visualize 10 anatomic components of the ultrasound • Cerebral ventricles • Posterior fossa • Midline face • 4-chamber view of the heart • Spine • Ventral wall • Umbilical cord vessels • Stomach • Kidneys • Bladder Dashe, J. et al. Maternal obesity limits the ultrasound evaluation of fetal anomaly. J Ultrasound Med. 2009;28:1025-1030

  26. Ultrasound Limited by Obesity Dashe, J. et al. Maternal obesity limits the ultrasound evaluation of fetal anomaly. J Ultrasound Med. 2009;28:1025-1030

  27. Cardiac and Craniospinal Structures • 11,019 singleton pregnancies • 14 0/7 – 23 6/7 weeks gestation • 38.6% of patients were obese • Divided into 4 groups • Nonobese (BMI <30) • Class I (BMI 30-34.9) • Class II (BMI 35-39.9) • Class III (BMI >40) • Examined rate of suboptimal ultrasound visualization (SUV) of cardiac and craniospinal structures

  28. Cardiac and Craniospinal Structures Hendler, I et al. The impact of maternal obesity on midtrimestersonographic visualization of fetal cardiac and craniospinal structures. International Journal of Obesity. 2004;28:1607-11.

  29. Summary • Significantly increased rate of NTD and cardiac defects • 8-15% failure rate to obtain NT in Class III obesity • Increased time is needed to obtain NT • Biochemical screen results are inaccurate in patients who weigh > 400 pounds

  30. Effect of Obesity on Pregnancy Maternal & Fetal Complications

  31. Immediate Effect of Maternal Obesity on the Child • Congenital anomalies • Small for Gestational Age • Macrosomia • Increased preterm mortality • Maternal obesity second only to GA at delivery in predicting preterm mortality Martin et al Early Hum Dev2010

  32. Long Term Effect of Maternal Obesity on the Child • Obesity up to 18 years of follow-up • Higher fasting blood sugar • Metabolic syndrome • Hypertension • Gestational weight gain correlated with hypertension • Behavioral Disorders, ADHD, poor emotional control Martin et al Early Hum Dev2010

  33. Maternal Risks Maternal Mortality and Related Concepts, Vital and Health Statistics, Series 3 Number 33 Feb. 2007 CDC

  34. Effect of Obesity on Pregnancy

  35. Adverse Pregnancy Outcomes El-Chaar, D. et al. The Impact of Increasing Obesity Class on Obstetrical Outcomes. JOGC, 2013;224-233.

  36. Intrapartum Complications

  37. Obesity and Failed Induction

  38. Obesity and Failed Induction

  39. Obesity and Failed Induction Possible Causes: • Obesity has adverse effect on uterine muscle contractility • In-vitro studies show decreased strength and rate of contraction of the myometrium • Increased leptin (adipose derived hormone) leads to metabolic dysfunction • Increased adipose tissue in pelvis and birth canal – theory – soft tissue dystocia

  40. What About Trial of Labor After Cesarean Delivery? Hibbard, J et al. NICHD and SMFMU network. Obstetrics & Gynecology, 2006

  41. Composite Neonatal Injury in Morbidly Obese Hibbard, J et al. NICHD and SMFMU network. Obstetrics & Gynecology, 2006

  42. What About The New Term Superobesity?

  43. Superobesity - BMI>50Maternal & Neonatal Outcomes Marshall, N et al AJOG, 2012

  44. What About The Incision? Vertical or Pfannenstiel? • Vertical skin incision increases risk • Classical uterine incision • Uterine rupture in subsequent pregnancies • Post operative morbidity – pulmonary, intestinal and wound infection • Difficult pain control

  45. Anesthesia • Most complications related to general anesthesia • Combined spinal epidural is considered safest option • Provides dense surgical blockade (spinal) • Potential prolongation of anesthesia (epidural) • ANESTHESIA CONSULT in early 3rd trimester or on admission to labor and delivery

  46. Special Circumstances • Obstructive Sleep Apnea • Bariatric Surgery

  47. Obstructive Sleep Apnea • Among 158 obese pregnant women • OSA prevalence 15% • Recurrent cycles upper airway obstruction • Nocturnal hypoxemia and reoxygenation • Sleep fragmentation • Among live births – increased risk for • Cesarean delivery (65% vs 32%) • Preeclampsia (42% vs 17%) • NICU admission (46% vs 18%) Louis, J et al. Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women. Obstetrics & Gynecology, Vol 120, 2012.

  48. Bariatric Surgery • Multiple procedures • Laparoscopic adjustable gastric banding • Laparoscopic gastric bypass • Vertical sleeve • Increasing in incidence in U.S. • 8500 procedures in 1993 • 115,000 procedures in 2004

  49. Types of Bariatric Surgery