Cesarean section in morbidly obese parturients: practical implications and complications

The Soleymani and Collins Obstetric morbidity score (SaCOMS): A quantitative tool for measuring maternal morbidity from complex obstetric surgery such as placenta accreta spectrum (PAS)

It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS), as there is no widely accepted consensus for the classification of maternal surgical morbidity. Many studies focus on the amount of blood products transfused or admission to intensive care units (ICU). However, these are dependent on local policies and available resources. It also gives an incomplete representation of the entire 'patient journey' after they leave the operating room. Subsequent repeat procedures for lower urinary track damage is arguably worse from the woman's perspective than a short stay on an intensive care unit (ICU) for observation. We suggest a version of the Clavien-Dindo morbidity classification specific to obstetrics. Then employ it to build a quantitative morbidity score which aims to reflect the whole 'patient experience' including the post-operative pathway. We then demonstrate the utility of this system in a cohort of women with Placenta Accreta Spectrum (PAS). The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a survey-based consultation of a panel of experts in PAS and retrospectively applied to a cohort of 54 women who underwent caesarean hysterectomy for PAS. Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the 'patient experience'. Application of the classification system to a single-centre PAS cohort suggested that surgery by gynecologic-oncology surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation. This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centered representation of morbidity.

The association between obesity and the success of trial of labor after cesarean delivery (TOLAC) in women with past vaginal delivery

OBJECTIVES

To evaluate the effect of overweight (body mass index; BMI 25.0-29.9 kg/m2), and obesity (BMI>30 kg/m2), on the success of trial of labor after cesarean delivery (TOLAC), with consideration of successful past vaginal birth.

METHODS

This retrospective cohort study was performed using electronic database of obstetrics department at a university-affiliated tertiary medical center. All women admitted for TOLAC at 37-42 weeks of gestational age, carrying a singleton live fetus at cephalic presentation, with a single previous low segment transverse cesarean delivery between 1/2015 and 5/2021 were included. Primary outcome was the rate of cesarean delivery during labor, and subgroup analysis was performed for the presence of past vaginal birth.

RESULTS

Of the 1200 TOLAC deliveries meeting the inclusion criteria, 61.9 % had BMI in the normal range, 24.6 % were overweight (BMI 25.0-29.9 kg/m2), and 13.4 % were obese (BMI of 30 kg/m2 and over). Using a multivariate analysis, BMI≥30 kg/m2 was associated with increased risk of cesarean delivery compared to normal weight. However, in the subgroup of 292 women with a history of successful vaginal birth BMI did not affect TOLAC success.

CONCLUSIONS

BMI does not affect the success of TOLAC in women with previous vaginal birth. This information should be considered during patients counselling, in order to achieve a better selection of mode of delivery and higher patients' satisfaction.

The association between epidural labor analgesia and the fetal outcome and mode of delivery of the second twin: a nationwide register-based cohort study in Finland

BACKGROUND

The aim of this study was to assess the association between epidural labor analgesia and the mode of delivery for the second twin and to analyze the health outcomes of the second twin.

METHODS

In this nationwide, retrospective, register-based cohort study, data from the National Medical Birth Register (MBR) of Finland (2004-2018) were used to analyze the association between epidural analgesia and delivery mode (emergency and urgent cesarean section, and assisted vaginal delivery) and fetal outcomes (neonatal mortality and need for intensive care unit admission) for the second twin. Multivariable logistic regression was used to assess the delivery mode and fetal outcomes of the second twin.

RESULTS

A total of 3242 twin pregnancies with epidural analgesia were compared with a control group consisting of 2780 twin pregnancies without epidural analgesia. Epidural analgesia was associated with lower odds for all cesarean delivery (aOR 0.64, 95% CI 0.44 to 0.92) for the second twin and for emergency cesarean delivery (aOR 0.52, 95% CI 0.33 to 0.79) when compared with the odds for the second twin in the control group. Epidural analgesia was associated with lower odds of neonatal mortality for the second twin (aOR 0.61, 95% CI 0.73 to 0.90).

CONCLUSION

This study found epidural labor analgesia was associated with a lower rate of emergency cesarean delivery and neonatal mortality for the second twin. These results should be acknowledged by obstetricians and anesthesiologists when planning optimal peripartum management for mothers with twin pregnancies.

Proof of principle study replicating microbial clusters in connection to birth mode and diet in the early life intestine

The human gut ecosystem starts developing at birth and is influenced by many factors during early life. In this study we make use of a Belgian cohort of 64 children, followed until the age of 6 years, to analyze different phases of microbiota development. We analyzed fecal samples taken before weaning (age 1 month), shortly after weaning (age 6 months), when milk feeding has been discontinued completely (age 1 year), and at the age of 6 years. We performed 16S rRNA gene amplicon sequencing on the collected fecal samples and analyzed the compositional data in relation to dietary metadata and birth mode. Human and formula milk feeding promotes a microbiota dominated by either Bacteroides or Bifidobacterium, respectively. Into later life stages, the microbiota composition follows distinct microbiota clusters, related to abundance dynamics of certain bacterial groups. Furthermore, it becomes apparent that a formula diet leads to early maturation of the infant gut microbiota. Despite other clinical variables within the infant cohort, they did not significantly contribute to the microbiota patterns we observed. Our data provide a proof of principle study of the importance of diet to the development of the microbiota in early life that replicates earlier findings in other cohorts.

Crucial nuances in understanding (mis)associations between the neonatal microbiome and Cesarean delivery

As rates of Cesarean delivery and common non-communicable disorders (NCDs), such as obesity, metabolic disease, and atopy/asthma, have concomitantly increased in recent decades, investigators have attempted to discern a causal link. One line of research has led to a hypothesis that Cesarean birth disrupts the presumed normal process of colonization of the neonatal microbiome with vaginal microbes, yielding NCDs later in life. However, a direct link between a disrupted microbiota transfer at time of delivery and acute and/or chronic illness in infants born via Cesarean has not been causally established. Microbiota seeding from maternal vaginal or stool sources has been preliminarily evaluated as an intervention designed to compensate for the lack of (or limited) exposure to such sources among Cesarean-delivered neonates. However, to date, clinical trials have yet to show a clear health benefit with neonatal 'vaginal seeding' practices. Until the long-term effects of these microbiome alterations can be fully determined, it is paramount to conduct parallel meaningful and mechanistic-minded interrogations of the impact of clinically modifiable maternal, nutritional, or environmental exposure on the functional microbiome over the duration of pregnancy and lactation to determine their role in the mitigation of childhood and adult NCDs.

Inequalities in overweight and obesity among reproductive age group women in India: evidence from National Family Health Survey (2015-16)

Background

In developing nations like India, fertility and mortality have decreased, and diseases related to lifestyle have become more common. Females in India are more prone to being overweight and obese than their male counterparts, more specifically in affluent families than the poor ones. Understanding the overweight and obesity trend may help develop feasible public health interventions to reduce the burden of obesity and associated adverse health outcomes.

Methods

The study utilizes the fourth round of the National Family Health Survey (NFHS-4), 2015–16. Descriptive statistics, bivariate and multivariate analysis was used to check the significant relationship between overweight and obesity, and other background characteristics. Income-related inequality in overweight and obesity among women was quantified by the concentration index and the concentration curve. Further, Wagstaff decomposition analysis was done to decompose the concentration index, into the contributions of each factor to the income-related inequalities.

Results

Overweight & obesity among women had a significant positive association with their age and educational level. The odds of overweight and obesity were 57% more likely among women who ever had any caesarean births than those who did not [AOR: 1.57; CI: 1.53–1.62]. The likelihood of overweight and obesity was 4.31 times more likely among women who belonged to richest [AOR: 5.84; CI: 5.61–6.08] wealth quintile, than those who belonged to poor wealth quintile. Women who ever terminated the pregnancy had 20% higher risk of overweight and obesity than those who did not [AOR: 1.20; CI: 1.17–1.22]. The concentration of overweight and obesity among women was mostly in rich households of all the Indian states and union territories. Among the geographical regions of India, the highest inequality was witnessed in Eastern India (0.41), followed by Central India (0.36).

Conclusion

The study results also reveal a huge proportion of women belonging to the BMI categories of non-normal, which is a concern and can increase the risks of developing non-communicable diseases. Hence, the study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status which can reduce the risks of health consequences due to overweight and obesity. Development nutrition-specific as well as sensitive interventions can be done for mobilization of local resources that addresses the multiple issues under which a woman is overweight or obese.

The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia

BACKGROUND

Pulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia.

METHODS

This survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers.

RESULTS

Four hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration.

CONCLUSIONS

More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

Socio-economic inequalities in overweight and obesity among women of reproductive age in Bangladesh: a decomposition approach

BACKGROUND

Overweight and obesity of women is a growing concern all over the world. However, an understanding on the socio-economic inequalities in overweight and obesity of women received little attention, especially in the context of Bangladesh. Therefore, the objective of this study was to measure the inequality in overweight and obesity among women of reproductive age in Bangladesh as well as to explore the effect of various socio-economic factors on this inequality.

METHODS

This study used data from the Bangladesh Demographic and Health Survey 2014 which is a nationally representative data. The concentration index of overweight and obesity was applied to measure the extent of socio-economic inequality. Finally, the concertation index was decomposed in order to understand the contribution of different socio-economic variables in inequality in overweight and obesity of women.

RESULTS

This study included a total of 16,624 women of reproductive age. The study found that the prevalence of overweight was about 29% and the rate of obesity was approximately 11%. The value of concentration index for overweight and obesity was 0.37 (p < 0.001). This study also observed that about 52% inequality was explained by household's wealth status followed by watching television (25%), husband/partner's educational status (around 7%), women's educational status (about 5%), place of residence (approximately 4%).

CONCLUSIONS

This study found notable level of overweight and obesity among the women of Bangladesh. Various socio-economic factors like wealth status, education levels of women and partners, urban settings, women watching television predominantly contributed to the inequality in overweight and obesity among women of reproductive age. Therefore, the study suggests adopting necessary interventions targeting the women of higher socio-economic status to reduce the risk of life-threatening problems caused by overweight and obesity.

Abdominal Cutaneous Thermography and Perfusion Mapping after Caesarean Section: A Scoping Review

Introduction: Caesarean section (CS) is the most prevalent surgical procedure in women. The incidence of surgical site infection (SSI) after CS remains high but recent observations of CS wounds using infrared thermography has shown promise for the technique in SSI prognosis. Although thermography is recognised as a 'surrogate' of skin perfusion, little is known of the relationship between skin temperature and skin perfusion in the context of wound healing. Aim: To assess the extent of literature regarding the application of infrared thermography and mapping of abdominal cutaneous perfusion after CS. Methods: Wide eligibility criteria were used to capture all relevant studies of any design, published in English, and addressing thermal imaging or skin perfusion mapping of the abdominal wall. The CINAHL and MEDLINE databases were searched, with two independent reviewers screening the title and abstracts of all identified citations, followed by full-text screening of relevant studies. Data extraction from included studies was undertaken using a pre-specified data extraction chart. Data were tabulated and synthesised in narrative format. Results: From 83 citations identified, 18 studies were considered relevant. With three additional studies identified from the reference lists, 21 studies were screened via full text. None of the studies reported thermal imaging and cutaneous perfusion patterns of the anterior abdominal wall. However, two observational studies partially met the inclusion criteria. The first explored analysis methodologies to 'interrogate' the abdominal thermal map. A specific thermal signature ('cold spots') was identified as an early 'flag' for SSI risk. A second study, by the same authors, focusing on obesity (a known risk factor for SSI after CS) showed that a 1 °C lower abdominal skin temperature led to a 3-fold odds of SSI. Conclusion: There is a significant gap in knowledge on how to forewarn of wound complications after CS. By utilising the known association between skin temperature and blood flow, thermographic assessment of the wound and adjacent thermal territories has potential as a non-invasive, independent, imaging option with which to identify tissue 'at risk'. By identifying skin 'hot' or 'cold' spots, commensurate with high or low blood flow regions, there is potential to shed light on the underlying mechanisms leading to infective and non-infective wound complications.

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 .

Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care

OBJECTIVE

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

TARGET POPULATION

Women with obesity who are pregnant or planning pregnancies.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

GUIDELINE UPDATE

SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

SPONSORS

This guideline was developed with resources funded by the SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Pushing the Envelope in Obstetric Care: A Case Report of Cesarean Delivery in a Parturient with a BMI >100 kg m-2

An increasing number of women with a body mass index (BMI) ≥ 60 kg m⁻², referred to as super-super obesity, are requiring anesthetic care for labor and delivery. Management of these patients presents obstetric, anesthetic, and logistical challenges. We report our experience in the management of cesarean delivery in a parturient with a BMI of 112 kg m⁻². Use of epidural anesthesia and performance of a supraumbilical transverse surgical incision with caudal placement of the panniculus resulted in optimal hemodynamic and ventilatory parameters. Effective multidisciplinary planning and communication is key. We present this case to highlight decision-making strategies and elucidate our approach in the management of this complex obstetric case.

Fetal myelomeningocele diagnosed in the antenatal period: Maternal-fetal characteristics and their relationship with pregnancy decision-making

BACKGROUND

Spina bifida is the most common fetal anomaly of the central nervous system, which affects approximately 1:1000 live births in the United States. Myelomeningocele (MMC) is the most common presentation of spina bifida, representing half of these cases. Given the deformation to the spinal cord and the nerve roots, this defect may result in significant morbidity to infants and major life-long disabilities. In this study we aimed to identify maternal and fetal characteristics associated with expectant management or termination of pregnancy in the setting of antenatally diagnosed MMC. We hypothesized that the level of the defect would correlate with patient's decision to continue the pregnancy.

METHODS

A retrospective cohort analysis was performed with patients who had presented to the Cleveland Clinic Fetal Care Center between 2005-2017.

RESULTS

Our data showed 36% of patients with antenatal diagnosis of MMC elected for second trimester terminations versus 64% who chose to continue their pregnancy and deliver either by cesarean section or vaginal delivery. Based on ultrasound findings, there were no significant differences between these two groups. Maternal body mass index was significantly higher in those who continued pregnancies (p = 0.036). In addition, the fetal diagnostic methods chosen by patients were significantly different. Those who elected to terminate were more likely to pursue amniocentesis (p = 0.03) and less likely to opt for MRI characterization of the fetus (p = 0.007).

CONCLUSION

We conclude, in the setting of fetal MMC diagnosed during pregnancy, patients often rely less on the associated ultrasonographic findings. Personal decisions likely influence the choice of other fetal diagnostic modalities. Other than BMI, we did not see an association between maternal factors and decisions regarding second trimester pregnancy termination.

Caesarean sections are associated with sonographic determined fetal size from the second trimester onwards

Human birth represents a critical and life-threatening event in the life of mother and child and is therefore of special importance for anthropological as well as public health research.

Study aims: to analyze the association patterns between fetal biometry and delivery modes from the first trimester onwards.

In this electronic medical record-based study, a dataset of 3408 singleton term birth taking place at the Viennese Danube hospital in Austria. was analyzed. Fetal biometry was reconstructed by the results of three ultrasound examinations carried out at the 11th/12th, 20th/21th and 32th/33thweek of gestation. In detail, crown-rump length, biparietal diameter, fronto-occipital diameter, head circumference, abdominal trans-verse diameter, abdominal sagittal diameter, abdominal circumference, and femur length were determined. Birth weight, birth length and head circumference were measured immediately after birth. Four delivery modes were compared: spontaneous vaginal birth, instrumental vaginal birth, planned cesarean section and emergency cesarean section.

The total cesarean section rate was 10.2%. Fetal biometry and newborn size differed significantly between the four delivery modes. From the second trimester onward, head circumferences were significantly larger (p=0.005) among fetuses delivered by instrumental delivery or emergency cesarean section than among fetuses delivered by spontaneous vaginal birth. The fetal abdominal dimensions during the third trimester were significantly largest (p=0.001) among fetuses delivered by emergency cesarean section. In comparison to spontaneous vaginal delivery the risk to require instrumental delivery increased significantly with increasing fetal head dimensions at the second (p=0.019) and third trimester(p=0.032) independent of maternal somatic factors. The risk of emergency CS increased significantly with increasing head dimensions (p=0.030) as well as abdominal dimensions (p=0.001) at the third trimester and newborn size (p=0.002), also independently of maternal somatic factors.

In general, larger fetuses are on an increased risk of experiencing instrumental delivery or emergency caesarean section. This association between fetal size and delivery mode is detectable from the second trimester onwards.

Considering Labor After Cesarean in a Woman with Class 3 Obesity

Because of the high cesarean rate in the United States, perinatal care providers are increasingly called upon to counsel women considering labor after cesarean. This counseling can be more complicated for women with class 3 obesity, defined as a body mass index at or exceeding 40. Although labor after cesarean may be less likely to result in successful vaginal birth after cesarean (VBAC) for this population, the risks of repeat cesarean are also higher for these women. This case report describes the benefits and risks of labor after cesarean, the chance of successful VBAC, and clinical recommendations to aid women in achieving VBAC when class 3 obesity is present.

Subcuticular interrupted versus continuous skin suturing in elective cesarean section in obese women: a randomized controlled trial

Objective: To compare the interrupted subcuticular skin closure with continuous one in obese women undergoing cesarean delivery.Materials and methods: A randomized controlled study conducted on 169 obese women with term uncomplicated singleton pregnancy who underwent elective cesarean delivery. They were randomized to either skin closure through continuous subcuticular sutures using vicryl 3/0 or interrupted subcuticular suturing using vicryl 3/0. The primary outcome parameter was occurrence of wound infection. Secondary outcomes included other skin complications, postoperative pain, operative duration and hospital stayResults: There was a statistically higher number of cases with wound hematoma (20 vs. 10, p = .04), infection (30 vs. 15, p = .008) and those who needed reclosure of wound (8 vs. 0, p = .004) in the continuous when compared to women in the interrupted subcuticular group, respectively. Healing with secondary intension was significantly higher in women in the continuous subcuticular group (52 vs. 26, respectively, p < .001). The number of cases with wound seroma and keloid formation was not statistically different between the two groups (25 vs. 19, p = .272 and 12 vs. 5, p = .069 in the continuous vs. interrupted groups, respectively). The duration of CS was longer in those who underwent interrupted closure when compared to continuous ones. However, that was statistically insignificant (40.95 + 6.376 vs. 37.05 + 6.455, p = 0.14).Conclusions: Most surgical wound complications were reduced if skin closure with continuous subcuticular sutures is replaced with interrupted one.

Directive clinique No 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum

OBJECTIF

La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum. UTILISATEURS CONCERNéS: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité.

POPULATION CIBLE

Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir. DONNéES PROBANTES: Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d'évaluation décrits par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICE ET COûTS: La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l'équipe de soins de santé, la patiente et la famille; et de la planification de l'équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité. MISE à JOUR DE LA DIRECTIVE CLINIQUE: Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.

PROMOTEURS

La présente directive a été élaborée à l'aide de ressources financées par la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Reducing post-caesarean delivery surgical site infections: a narrative review

Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.

Recent Lifestyle Parameters Are Associated with Increasing Caesarean Section Rates among Singleton Term Births in Austria

Caesarean section (CS) rates are increasing in many parts of the world, recently reaching about 20% worldwide. The postmodern lifestyle characteristics, obesity and delayed childbirth, have been put forward as the main reasons for high CS rates. The present study tests the association patterns between lifestyle parameters and delivery mode on a data set of 3786 births in Vienna between 2005 and 2013. The focus is exclusively on singleton term births. As well as maternal age, prepregnancy weight status, maternal body height and gestational weight gain, newborn size (birth weight, birth length, and head circumference), Apgar scores and child presentation were recorded. Planned as well as emergency CS rates increased significantly (p < 0.0001) with increasing maternal age and decreasing maternal body height. Emergency CS rates, however, increased significantly with increasing maternal prepregnancy weight status and gestational weight gain. An especially high risk of emergency CS occurred among four groups of mothers: those older than 40 years (OR = 2.68; 95% CI 1.87⁻3.86), those who were obese (OR = 1.44; 95% 1.15⁻1.81), those experiencing a gestational weight gain above 15 kg (OR = 1.32; 95% CI 1.13⁻1.54), and those shorter than 160 cm (OR = 1.216; 95% CI 1.02⁻1.45). Emergency CS rates were significantly higher among low-weight newborns (<2500 g) and macrosome newborns (>4000 g) than among normal-weight newborns. Furthermore, breech presentation was associated with an increased risk of caesarean delivery (OR 6.97; 95% CI 6.09⁻7.96). Logistic regression analyses reveal that maternal age, maternal body height, prepregnancy weight status, gestational weight gain, birth weight, newborn head circumference and child presentation show an independent, highly significant association with caesarean delivery. We conclude that maternal and newborn characteristics typical of recent lifestyle patterns, such as advanced maternal age, obesity, increased gestational weight gain and increased newborn size, are highly significantly associated with increased emergency CS rates. Moreover, maternal shortness and breech presentation are risk factors for emergency CS.

Skin Microbiota in Obese Women at Risk for Surgical Site Infection After Cesarean Delivery

The obesity pandemic in the obstetrical population plus increased frequency of Cesarean delivery (CD) has increased vulnerability to surgical site infection (SSI). Here we characterized the microbiome at the site of skin incision before and after CD. Skin and relevant surgical sites were sampled before and after surgical antisepsis from obese (n = 31) and non-obese (n = 27) pregnant women. We quantified bacterial biomass by qPCR, microbial community composition by 16sRNA sequencing, assigned operational taxonomic units, and stained skin biopsies from incision for bacteria and biofilms. In obese women, incision site harbors significantly higher bacterial biomass of lower diversity. Phylum Firmicutes predominated over Actinobacteria, with phylotypes Clostridales and Bacteroidales over commensal Staphylococcus and Propionbacterium spp. Skin dysbiosis increased post-surgical prep and at end of surgery. Biofilms were identified post-prep in the majority (73%) of skin biopsies. At end of surgery, incision had significant gains in bacterial DNA and diversity, and obese women shared more genera with vagina and surgeon's glove in CD. Our findings suggest microbiota at incision differs between obese and non-obese pregnant women, and changes throughout CD. An interaction between vaginal and cutaneous dysbiosis at the incision site may explain the a priori increased risk for SSI among obese pregnant women.

Influence of maternal obesity on Bishop Score and failed induction of labour: A retrospective cohort study in a regional tertiary centre

BACKGROUND

Maternal obesity is a growing health concern that has previously been associated with increased need for induction of labour (IOL) and caesarean section (CS) rates. Currently, limited evidence explores the influence of maternal body mass index (BMI) on Bishop Score (BS) and outcome of IOL. This study hypothesises that maternal obesity will lead to a lower BS at presentation, higher rates of failed IOL, and increased CS rates.

AIMS

To explore the influence of maternal obesity on BS and likelihood of failed IOL.

METHODS

A retrospective cohort analysis was conducted of all live, term, singleton, cephalic deliveries initiated with IOL across normal BMI (18.00-24.99), overweight BMI (25.00-29.99), and obese BMI (>30.00) at the Townsville Hospital and Health Service (THHS) between July 2011 to June 2016. Student's t-test, χ² test, and binary logistic regression were used for statistical analysis. BS and failed IOL, defined as CS with cervical dilatation <3 cm, were the primary outcome measures. Delivery mode was the secondary outcome measure.

RESULTS

A total of 1543 women were included, 678 with normal BMI, 370 with overweight BMI, and 495 with obese BMI. Obese women are more likely to have a low BS (<5) at presentation (unadjusted odds ratio (OR) 1.5 (1.1-2.0), P < 0.05), an increased rate of failed IOL (adjusted OR (aOR) 1.6 (1.0-2.5), P < 0.05) and increased CS rate (aOR 1.1 (1.0-1.9), P < 0.05), compared to normal weight women.

CONCLUSIONS

Maternal obesity is associated with a lower BS, more difficult IOL process, and increased risk of failed IOL and CS.

Implications of Early Pregnancy Obesity on Maternal, Fetal and Neonatal Health: Retrospective cohort study from Oman

Objectives

This study aimed to determine the prevalence of early pregnancy obesity among Omani women and to review maternal antenatal complications, intrapartum and postpartum events and neonatal complications among such women in comparison to women of normal weight.

Methods

This retrospective cohort study included 2,652 pregnant Omani women who delivered at the Royal Hospital, Muscat, Oman, between November 2011 and April 2012. The patients' electronic medical records were reviewed for antenatal, intrapartum and postpartum data. Body mass index was measured during the first trimester (≤12 gestational weeks) and classified according to the World Health Organization categories. Maternal and neonatal complications were compared between obese women and those of normal weight. Obstetric outcomes in uncomplicated pregnancies were also compared.

Results

In the study cohort, there were 901 (34%) obese women and 912 (34.4%) women of normal weight; of these, 440 (48.8%) and 672 (73.7%) had uncomplicated pregnancies, respectively. Obese women had a significantly increased incidence of gestational diabetes (relative risk [RR]: 2.23; 95% confidence interval [CI]: 1.70-2.92; P <0.01), gestational hypertension (RR: 3.04; 95% CI: 1.63-5.65; P <0.01), Caesarean delivery (RR: 1.48; 95% CI: 1.08-2.03; P <0.01), postpartum haemorrhage (RR: 2.10; 95% CI: 1.11-4.10; P = 0.01) and fetal macrosomia (RR: 2.71; 95% CI: 1.21-6.09; P <0.01).

Conclusion

Approximately one-third of the studied Omani women were obese. These women had a significantly increased risk of various maternal antenatal complications, intrapartum and postpartum events and neonatal complications.

Risk assessment of morbidly obese parturient in cesarean section delivery: A prospective, cohort, single-center study

BACKGROUND

Up to 40% of women gain excessive weight during pregnancy. Obesity complications and risks in parturient women undergoing cesarean section (CS) with different anesthetic methods remain unknown. This study aimed to assess the safety and risk of obese women undergoing CS delivery with various perioperative anesthetic methods.

METHODS

Seven hundred ninety parturient women underwent CS under general anesthesia (GA), intraspinal anesthesia including epidural anesthesia (EA) and combined spinal-epidural anesthesia (CSEA). They were divided into morbid (n = 255), severe (n = 274), and non-obesity (n = 261) groups. This study is registered with ClinicalTrials.gov (number NCT03002636).

RESULT

Between 2013 and 2016, 790 pregnant were assessed. Compared with the non-obesity group, there were significantly more fetal distress and higher body mass index (BMI) in the morbid obesity group (P = .0001 and P = .001, respectively). Significantly more patients showed preeclampsia, multifetation, amniotic fluid abnormality, and high bleeding amounts in the morbid obesity group compared with the non-obesity group (P = .0001, P = .048, P = .017, and P = .018, respectively); more patients were administered EA and GA compared with the non-obesity group (P = .0001 and P = .0001, respectively). More post-anesthesia care unit (PACU) patients were found in the severe obesity group no more than the non-obesity group. Significantly increased anesthesia puncture times for 5 > n ≥ 3 and n ≥ 5 were obtained in the morbid obesity group (P = .0001 and P = .0001, respectively), with more patients in the puncture sitting position, compared with the non-obesity group (P = .0001).

CONCLUSION

GA, EA, and CSEA are safe and effective in severely or morbidly obese patients. Morbidly obese parturient show increased likelihood for fetal distress, PACU, sitting position puncture, puncture difficulty, and other pregnancy complications. There were more anesthesia puncture times in morbidly obese patients.

Clinical management of pregnancy in the obese mother: before conception, during pregnancy, and post partum

The global epidemic of obesity has led to an increasing number of obese women of reproductive age. Obesity is associated with reduced fertility, and pregnancies complicated by maternal obesity are associated with adverse outcomes, including increased risk of gestational diabetes, pre-eclampsia, preterm birth, instrumental and caesarean births, infections, and post-partum haemorrhage. The medical and obstetric management of obese women is focused on identifying, addressing, and preventing some of these associated complications, and is a daunting challenge given the high percentage of patients with obesity and few therapeutic options proven to improve outcomes in this population. The UK's National Institute for Health and Care Excellence guidelines and the American College of Obstetricians and Gynecologists recommend that all pregnant women follow a healthy diet, and consider at least half an hour of moderate physical activity per day during pregnancy. However, although obese women are often directed to seek the advice of a nutritionist and to limit gestational weight gain, guidelines for the management of pregnancy and delivery in this high-risk group are lacking. The post-partum period represents an important opportunity to optimise maternal health before the next pregnancy. As many of the physiological changes of pregnancy associated with maternal obesity are present from early pregnancy onward, reducing maternal obesity before conception is probably the best strategy to decrease the health burden associated with maternal obesity.

Risk factors of HIV-1 vertical transmission (VT) and the influence of antiretroviral therapy (ART) in pregnancy outcome

In the absence of intervention, the rate of vertical transmission of HIV can range from 15-45%. With the inclusion of antiretroviral drugs during pregnancy and the choice of delivery route this amounts to less than 2%. However ARV use during pregnancy has generated several questions regarding the adverse effects of the gestational and neonatal outcome. This study aims to analyze the risk factors for vertical transmission of HIV-1 seropositive pregnant women living in Rio Grande and the influence of the use of ARVs in pregnancy outcome. Among the 262 pregnant women studied the rate of vertical transmission of HIV was found to be 3.8%. Regarding the VT, there was a lower risk of transmission when antiretroviral drugs were used and prenatal care was conducted at the referral service. However, the use of ART did not influence the outcome of pregnancy. However, initiation of prenatal care after the first trimester had an influence on low birth weight, as well as performance of less than six visits increased the risk of prematurity. Therefore, the risk factors analyzed in this study appear to be related to the realization of inadequate pre-natal and maternal behavior.

Safety and efficacy of low molecular weight heparin therapy during pregnancy: three year experience at a tertiary care center

PURPOSE

To evaluate safety and efficacy of low molecular weight heparin given for various indications during pregnancy.

METHODOLOGY

A detailed retrospective analysis of all the patients who received low molecular weight heparin (LMWH) for various indications over a period of 3 years (2010-2012) at a tertiary care hospital in Northern India was performed.

RESULTS

Fifty-five patients received LMWH over the period of 3 years, for various indications. Enoxaparin (1 mg/kg body weight OD/BD subcutaneously) was used. The indications were valvular heart disease with valve replacement, atrial fibrillation, or thrombus in 60 % patients; chronic deep vein thrombosis (DVT) in 7 % patients; thrombophilia in 9.1 % patients; recurrent pregnancy losses in 18 % patients; and DVT prophylaxis in 5.5 % patients. Abortion was seen in 7.2 % patients; fetal growth restriction in 10.9 % patients; and oligohydramnios, preeclampsia, gestational hypertension, placenta previa, abruptio placentae, and postpartum hemorrhage in 1.8 % patients. Stillbirth occurred in 3.6 % patients. No thromboembolic event was noted in any of the patients. None of the patients had any documented thrombocytopenia or clinical fracture.

CONCLUSION

Low molecular weight heparin can be used in pregnancy for various indications as an alternative to unfractionated heparin or warfarin as it is efficacious and safe.

Reflections on the maternal mortality millennium goal

BACKGROUND

Nearly every 2 minutes, somewhere in the world, a woman dies because of complications of pregnancy and childbirth. Every such death is an overwhelming catastrophe for everyone confronted with it. Most deaths occur in developing countries, especially in Africa and southern Asia, but a significant number also occur in the developed world.

METHODS

We examined the available data on the progress and the challenges to the United Nations' fifth Millennium Development Goal of achieving a 75 percent worldwide reduction in the maternal mortality by 2015 from what it was in 1990.

RESULTS

Some countries, such as Belarus, Egypt, Estonia, Honduras, Iran, Lithuania, Malaysia, Romania, Sri Lanka and Thailand, are likely to meet the target by 2015. Many poor countries with weak health infrastructures and high fertility rates are unlikely to meet the goal. Some, such as Botswana, Cameroon, Chad, Congo, Guyana, Lesotho, Namibia, Somalia, South Africa, Swaziland and Zimbabwe, had worse maternal mortality ratios in 2010 than in 1990, partially because of wars and civil strife. Worldwide, the leading causes of maternal death are still hemorrhage, hypertension, sepsis, obstructed labor, and unsafe abortions, while indirect causes are gaining in importance in developed countries.

CONCLUSIONS

Maternal death is especially distressing if it was potentially preventable. However, as there is no single cause, there is no silver bullet to correct the problem. Many countries also face new challenges as their childbearing population is growing in age and in weight. Much remains to be done to make safe motherhood a reality.