Comparison of maternal and perinatal outcomes in women with super obesity based on planned mode of delivery

Peripartum interventions for people with class III obesity: a systematic review and meta-analysis

OBJECTIVE

This study aimed to identify evidence-based peripartum interventions for people with a body mass index ≥40 kg/m2.

DATA SOURCES

PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions.

STUDY ELIGIBILITY CRITERIA

Cohort and randomized controlled trials that implemented an intervention and evaluated peripartum outcomes of people with a body mass index ≥40 kg/m2 were included. The primary outcome depended on the intervention but was commonly related to wound morbidity after cesarean delivery (ie, infection, separation, hematoma).

METHODS

Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios with 95% confidence intervals and heterogeneity (I2 statistics) were reported.

RESULTS

Of 20,301 studies screened, 30 studies (17 cohort and 13 randomized controlled trials) encompassing 10 types of interventions were included. The interventions included delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, 6 types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared with planned vaginal delivery did not improve outcomes according to 3 cohort studies. One cohort study compared 3 g with 2 g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 randomized controlled trials, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort and 6 randomized controlled trials) met the inclusion criteria for the meta-analysis. Two randomized controlled trials compared subcuticular closure with suture vs staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; risk ratio, 1.09; 95% confidence interval, 0.75-1.59; I2=9%). Prophylactic negative-pressure wound therapy was compared with standard dressing in 4 cohort and 4 randomized controlled trials, which found no differences in wound morbidity (cohort n=2200; risk ratio, 1.19; 95% confidence interval, 0.88-1.63; I2=66.1%) or surgical site infections (randomized controlled trial n=1262; risk ratio, 0.90; 95% confidence interval, 0.63-1.29; I2=0).

CONCLUSION

Few studies address interventions in people with a body mass index ≥40 kg/m2, and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic negative-pressure wound therapy after cesarean delivery for people with a body mass index ≥40 kg/m2.

Increased maternal body mass index is associated with prolonged anaesthetic and surgical times for caesarean delivery but is partially offset by clinician seniority and established epidural analgesia

BACKGROUND

Obesity is associated with higher surgical and anaesthetic morbidity and difficulties.

AIMS

We aimed to investigate associations between maternal body mass index (BMI) and the in-theatre time taken to produce an anaesthetised state or to perform surgery for caesarean delivery.

MATERIALS AND METHODS

Using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, we identified all women who underwent caesarean section at a single institution (2009-2015). The prospectively collected data arising from antenatal and peripartum care were analysed. Generalised linear regression was used to examine associations between maternal BMI and the time taken to anaesthetise the mother and the duration of surgery.

RESULTS

Of a total of 24 761 caesarean deliveries, 5607 (22.7%) women were obese at antenatal registration. In-theatre anaesthetic preparation (18 vs 32 min, P < 0.001) and surgical duration (38 vs 52 min, P < 0.001) were longer in women with BMI ≥50 kg/m² (BMI-50) than those with normal BMI (BMI-N). This difference remained significant after controlling for antenatal, intra-operative and immediate postoperative variables. Modifiable variables were identified that may mitigate the effects of severe obesity. Senior obstetric and anaesthetic care were both independently associated with a significant reduction in mean in-theatre anaesthetic preparation time and surgical duration, by 11 and three minutes respectively (P < 0.001), while epidural top-up significantly lessened mean anaesthetic in-theatre preparation duration by seven minutes (P < 0.001).

CONCLUSIONS

Obese women had greater anaesthesia and surgery time, but the effect may potentially be mitigated by provision of care by experienced staff and prior establishment of epidural analgesia.

Birth outcomes in women with body mass index of 40 kg/m2 or greater stratified by planned and actual mode of birth: a systematic review and meta-analysis

INTRODUCTION

Pregnant women with a body mass index (BMI) ≥40 kg/m² are at an increased risk of requiring planned- and unplanned cesarean deliveries (CD). The aim of this systematic review is to compare outcomes in women with BMI ≥ 40 kg/m² based on planned and actual mode of birth.

MATERIAL AND METHODS

Five databases were searched for English and French-language publications until February 2019, and all studies reporting on delivery outcomes in women with BMI ≥ 40 kg/m² , stratified by planned and actual mode of birth, were included. Risk-of-bias was assessed using the Newcastle-Ottawa Scale. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis.

RESULTS

Ten observational studies were included. Anticipated vaginal birth vs planned CD (5 studies, n = 2216) was associated with higher risk for postpartum hemorrhage (13.0% vs 4.1%, P < .001, numbers needed to harm (NNH = 11), I²  = 0%) but lower risk for wound complications (7.6% vs 14.5%, P < .001, numbers needed to treat (NNT = 15), I²  = 58.3%). Planned trial of labor vs repeat CD (3 studies, n = 4144) was associated with higher risk for uterine dehiscence (0.94% vs 0.42%, P = .04, NNH = 200, I²  = 0%), endometritis (5.1% vs 2.2%, P < .001, NNH = 35, I²  = 0%), prolonged hospitalization (one study, 30.3% vs 26.0%, P = .003, NNH = 23), low five-minute Apgar scores (4.9% vs 1.7%, RR 2.95 (2.03, 4.28), NNH = 30, I²  = 0%) and birth trauma (1.1% vs 0.2%, P < .001, NNH = 111, I²  = 0%). Successful vaginal birth vs intrapartum CD (n = 3625) was associated with lower risk of postpartum hemorrhage (15.1% vs 70%, P < .001, NNT = 2, I²  = 0%), wound complications (one study, 0% vs 4.4%, P = .007, NNT = 23), prolonged hospitalization (one study, 1.9% vs 6.7%, 0.04, NNT = 21) and low five-minute Apgar scores (one study, 1.0% vs 5.6%, P = .03, NNT = 22), but more birth trauma (5.9% vs 0.6%, P = .005, NNH = 19, I²  = 0%). Compared groups had dissimilar demographic characteristics. Although studies scored 6-7/9 on risk-of-bias assessment, they were at high-risk for confounding by indication.

CONCLUSIONS

Evidence from observational studies suggests clinical equipoise regarding the optimal mode of delivery in women with BMI ≥ 40 kg/m² and no prior CD. This question is best answered by a randomized trial. Based on an unplanned subgroup analysis, for women with BMI ≥ 40 kg/m² and prior CD, repeat CD may be associated with better clinical outcomes.

[Caesarean risk factors during labor for a class III obese nulliparous]

OBJECTIVES

Obesity is a well-known caesarean and obstetrical risk factor. However, the number of obese nulliparous women is increasing worldwide, creating an urgent need for research into the impact of obesity on the mode of delivery. Our objective was to identify caesarean risk factors in obese nulliparous women with a BMI (body mass index) greater than 40kg/m².

METHODS

A literature review was conducted on PubMed; including articles published between 2009 and 2019 in French and English, on caesarean risk during labor among class III obese nulliparous women.

RESULTS

One prospective study, and 6 retrospective analyses were included. Their results suggest that the rate of caesarean delivery increases with the BMI. Maternal age, particularly after 35 years, as well as induced labor and the use of oxytocin during labor, were positively associated with cesarean delivery. Moreover, maternal BMI was linked to an increased risk of non-elective caesarean section due to non-reassuring fetal heart tracing.

CONCLUSION

Extreme BMI, age, induced labor and oxytocin use are associated with caesarean delivery in nulliparous women with BMI≥40kg/m². Further research are needed to estimate the best candidates for elective cesarean delivery.

Neonatal outcome by planned mode of delivery in women with a body mass index of 35 or more: a retrospective cohort study

OBJECTIVE

To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m² who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS).

DESIGN

A retrospective cohort study of births between April 2012 and March 2014.

SETTING

A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada.

POPULATION

A cohort of 8752 women with a BMI of ≥35 kg/m² who had a singleton birth at 38-42 weeks of gestation.

METHODS

Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS.

MAIN OUTCOME MEASURE

A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5-minute Apgar score of <7 or umbilical artery pH of <7.1.

RESULTS

During the study period, 8433 (96.4%) women had a trial of labour and 319 (3.6%) had a planned CS. Intrapartum CS was performed in 1644 (19.5%) cases. There was no association between planned mode of delivery and the primary outcome (aOR 0.80, 95% CI 0.59-1.07). The primary outcome was lower among women who had a successful trial of labour (aOR 0.67, 95% CI 0.50-0.91) and was higher among women who had a failed trial of labour (aOR 1.74, 95% CI 1.21-2.48), compared with women who underwent a planned CS.

CONCLUSIONS

In women with a BMI of ≥35 kg/m² at a gestational age of 38-42 weeks, neonatal outcomes are comparable between planned vaginal delivery and planned CS, although a failed trial of labour is at risk of adverse neonatal outcome.

TWEETABLE ABSTRACT

Neonatal outcomes are not affected by planned mode of delivery in women who are obese, with a BMI of ≥35 kg/m² .