The multidisciplinary approach to the care of the obese parturient

First and second pregnancy outcomes in women with class III obesity: An observational cohort study

INTRODUCTION

Class III obesity (BMI ≥ 40 kg/m²) during pregnancy predisposes mother and offspring to a range of adverse pregnancy complications and outcomes. Risk profiles vary between pregnancies and are affected by interpregnancy weight gain. We evaluated the risk of adverse outcomes in women with BMI ≥ 40 kg/m² in first and second pregnancies, and the impact of interpregnancy weight change on this risk.

MATERIALS AND METHODS

Data were extracted for all women with BMI ≥ 40 kg/m² at first antenatal visit, who completed antenatal and delivery care for first and second pregnancies in NHS Lothian between 1/1/2009-31/12/2018. Multiple pregnancies and recipients of bariatric surgery were excluded.

RESULTS

442 pregnancies among 221 women were included. In first pregnancy, median (interquartile range) weight was 117 kg (108.5-126.7), age 28 years (24-31) and BMI 42 kg/m² (41.0-44.5), 14.4% had gestational diabetes (GDM), 11.3% had pregnancy-induced hypertension and 44.6% had a post-partum haemorrhage (PPH). 20.8% of babies were large for gestational age (LGA, ≥97% centile at birth). In second pregnancy, women were heavier with a median weight of 119.9 kg (109.0-130.0, p = 0.00) with 19.9% gaining over 10 kg. Women were more likely to develop GDM (21.6%, p = 0.02). Babies were heavier with 40% of babies LGA (p < 0.0001). Interpregnancy weight change had no significant impact on GDM, pregnancy induced hypertension, PPH, perinatal mortality or LGA.

CONCLUSIONS

In a population of women with BMI ≥ 40 kg/m², pregnancy complications are common and risk is higher in second pregnancy. The interpregnancy period is a critical time to engage women in health improvement and weight loss strategies to maximise outcomes for mother and offspring.

Influence of Biliopancreatic Diversion on Pregnancy Outcomes in Comparison to Other Bariatric Surgery Procedures

BACKGROUND

Pregnancy after bariatric surgery (BS) has an increased risk for small-for-gestational-age infants (SGA), shorter length of gestation, and probably perinatal mortality. The aim of this study was to investigate if biliopancreatic diversion could impair pregnancy outcomes in comparison to other bariatric surgery procedures.

METHODS

We conducted a cohort retrospective single-center study in 65 women before and after BS. Thirty-one pregnancies occurred before BS, while 109 after BS, amongst which n = 51 after biliopancreatic diversion (BPD) and n = 58 after non-malabsorptive procedures.

RESULTS

The pregnancy outcomes after BS in comparison with those before BS resulted less affected by diabetes, hypertensive disorders, macrosomia, and large-for-gestational-age (LGA), but more complicated by preterm births (14.5 versus 4.0%) and low birth weight (LBW) infants (28.9 versus 0%). Moreover, mean birth weight resulted lower after BS than before BS (p < 0.001). In pregnancies after BPD in comparison to those before BS, the LBW rate (42.5%) resulted a drastic increase (p < 0.001), and mean birth weight (p < 0.001) and mean birth weight centile (p < 0.001) were lower after BPD. When pregnancy outcomes after BPD were compared with those after non-malabsorptive procedures, the rate of congenital anomalies, preterm births, LBW, and SGA resulted an increase (p = 0.002, 0.008, 0.032, and < 0.001, respectively).

CONCLUSIONS

BPD drastically reduced diabetes, hypertensive disorders, macrosomia, and LGA; however, it was associated with the poorest pregnancy outcomes in comparison to those observed after other BS procedures. On the basis of the present study, we recommend a cautious multidisciplinary selection of severely obese patients for BPD during the fertile age.

Infant Mortality Lessons Learned from a Fetal and Infant Mortality Review Program

Objective To review fetal and infant deaths from women enrolled in Indianapolis Healthy Start using the National Fetal and Infant Mortality Review (FIMR) methods to provide strategies for prevention.

METHODS

Marion County Public Health Department (MCPHD) FIMR staff identified and reviewed 22 fetal and infant deaths to Indianapolis Healthy Start program participants between 2005 and 2012. Trained FIMR nurses completed 13 of 20 maternal interviews and compiled case summaries of all deaths from the MCPHD FIMR database.. Results Case review teams identified a total of 349 family strengths, 219 contributing factors, and made 220 recommendations for future pregnancies. FIMR deliberation values for Healthy Start program participant deaths were similar to other infant deaths in Marion County during the same time period. Common themes that emerged from the reviews included lack of social support, absence of paternal involvement, substance abuse, non-compliance, and poor health behaviors leading to chronic health conditions that complicated many pregnancies. Conclusions A number of the infant deaths in this review could have been prevented with preconception and inter-conception education and by improving the quality and content of prenatal care.

Does attendance at a specialist antenatal clinic improve clinical outcomes in women with class III obesity compared with standard care? A retrospective case-note analysis

OBJECTIVES

To determine whether attendance at a specialised multidisciplinary antenatal clinic for women with class III obesity (BMI >40 kg/m²) is associated with improved clinical outcomes compared with standard antenatal care.

DESIGN

Retrospective cohort study using routinely collected data from electronic patient record.

SETTING

Community and hospital based antenatal care.

PARTICIPANTS

Women with a singleton pregnancy with class III obesity booked for antenatal care and delivered in one of two hospitals in NHS Lothian, Scotland, UK between 2008 and 2014. Maternal and offspring outcomes were compared in women who attended a specialised obesity clinic (n=511) compared with standard antenatal care (n=502).

MAIN OUTCOME MEASURES

Included stillbirth, low birth weight, gestational diabetes, induction of labour and caesarean section.

RESULTS

Compared with standard care, women receiving specialist care were less likely to have a stillbirth (OR 0.12, 95% CI 0.06 to 0.97) and a low birthweight baby (OR 0.57, 95% CI 0.33 to 0.99) and more likely to be screened for (100% vs 73.6%; p<0.001) and diagnosed with (26.0% vs 12.5%; p<0.001) gestational diabetes, to require induction of labour (38.4% vs 29.9%; p=0.009), an elective (20.3% vs 17.7%; p<0.001) and emergency (23.9% vs 20.3%; p<0.001) caesarean section and attend antenatal triage one or more times during pregnancy (77.7% vs 53.1%; p<0.001). Women attending the specialist clinic had a higher BMI (44.5 kg/m² (4.3) vs 43.2 kg/m² (3.1); p<0.001) and were more likely to be nulliparous (46.0% vs 24.9%; p<0.001). There were no other differences in maternal demographic or maternal and offspring outcomes between groups.

CONCLUSIONS

Attendance at a specialised antenatal clinic for obesity is associated with reduced rates of stillbirth and low birth weight and improved detection of gestational diabetes. The improvement in clinical outcomes is associated with an increase in healthcare attendance to obstetric triage and clinical interventions including induction of labour and caesarean section.

Early diabetes screening in obese women

OBJECTIVE

To describe maternal characteristics related to early screening for diabetes in obese women and evaluate the benefits of early diabetes screening and diagnosis.

STUDY DESIGN

Retrospective cohort of obese women (BMI ≥30 kg/m²) without pregestational diabetes who delivered a singleton gestation between 2011 and 2012. Maternal characteristics/demographics and maternal and neonatal outcomes were compared between women with early diabetes screening (<20 weeks) versus traditional screening. We additionally compared maternal and neonatal outcomes for women with an early versus traditional diabetes diagnosis.

RESULTS

Of the 504 eligible women, 135 (26.8%) had early diabetes screening. Obese women with early screening were older, had a higher BMI, were more likely to have hypertension and neonates admitted to the NICU. Of women with early screening, 31 (23%) were diagnosed early. Women with an early diagnosis of diabetes were more likely to require treatment with insulin (36% vs. 23%, p = 0.003). Women with an early diagnosis of diabetes were more likely to have neonates in the NICU (48% vs. 26%, p = 0.03).

CONCLUSIONS

Early screening for diabetes was more common in older women with additional comorbidities. Obese women diagnosed via early screening were more likely to require medical treatment for diabetes, suggesting a value to early screening.