Maternal super-obesity

Comparison of perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section

OBJECTIVE

To compare the perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section.

METHODS

A retrospective analysis of 6 years of data was performed. Exclusions were cases with gestational ages <24 weeks, placenta accreta spectrum, polyhydramnios, or multiple gestations.

RESULTS

The study included 494 patients whose body mass index (BMI) exceeded 40 kg/m² at delivery. Of these, 469 were morbidly obese (BMI 40-49.9; mean, 42.9 ± 2.4), and 25 were super obese (BMI >50; mean, 54.5 ± 4.2). Twenty-four (5.1%) morbidly obese women received general anesthesia. The other 445 patients (94.9%) in the morbid obesity group underwent cesarean delivery under regional anesthesia; however, some (2.2%; 10/445) received general anesthesia after regional anesthesia failed. In the super-obesity group, 23 patients (92.0%) received regional anesthesia, while two patients (8.0%) received general anesthesia. There were no cases of pulmonary aspiration, maternal deaths, or difficult or failed intubation. There was one episode of cardiac arrest in a patient with a BMI of 47.9. Among the morbidly obese and super-obese women given regional anesthesia, the super-obese patients had significantly greater volumes of ephedrine and norepinephrine consumption (p = 0.027 and 0.030), intravenous fluids (p = 0.006), and bleeding during surgery (p = 0.017). They also had more hypotensive episodes (p = 0.038). The two groups' incidences of neonatal birth asphyxia, postpartum hemorrhage, blood transfusion, and uterine atony did not differ significantly. The lengths of stay in the hospital were also comparable.

CONCLUSIONS

Among the women receiving regional anesthesia, the super-obese parturients had greater intraoperative bleeding, a higher proportion of hypotensive episodes, and a greater vasopressor requirement than the morbidly obese parturients. Anesthesiologists must prepare for the adverse perioperative events that such women risk experiencing during a delivery by cesarean section.

www.clinicaltrials.gov ID: NCT04657692.

Does Daily Self-Weighing Contribute to Postpartum Weight Loss? A Secondary Analysis of Daily Postpartum Weights among Women with Hypertensive Disorders of Pregnancy

OBJECTIVE

This study was aimed to examine the impact of daily self-weighing via remote monitoring on postpartum weight loss.

STUDY DESIGN

This was a secondary analysis of a nonrandomized controlled trial comprised of postpartum women with diagnosed hypertensive-related disorders in pregnancy who received a tablet device linked to Bluetooth-enabled equipment including a scale and blood pressure cuff. In addition to blood pressure monitoring, participants were instructed to perform daily self-weighing. The primary outcome of this study was to determine whether postpartum women who performed daily self-weighing lost more weight than those who did not, with a 42-day endpoint based on a 6-week postpartum visit weight.

RESULTS

Overall, 214 women participated in this program and 214 received usual care. Median weight loss for women participating in the remote blood pressure monitoring system was 23.0 (interquartile range [IQR]: 17-30) pounds versus 23.0 (IQR: 17-29) pounds among controls. Weight loss did not vary by prepregnancy obesity (median: 20 pounds [IQR: 17-28 pounds] for nonobese and 23 [IQR: 17-30] pounds for women with obesity, p = 0.16). Women who weighed themselves more than half of follow-up days lost a median of 24 pounds (IQR: 17-30 pounds) compared with 20.5 pounds (IQR: 14-29 pounds), p = 0.06. Women who weighed themselves more than half of follow-up days lost a mean of 11.4% (standard deviation [SD] = 0.41%) of body weight compared with 9.1% (SD = 0.74%; p = 0.01). The amount of weight loss in the telehealth group was correlated with the number of daily weights performed (Pearson's correlation coefficient 0.164, p = 0.025). Postpartum weight loss for daily self-weighing participants was most notable in the first 2 weeks with ongoing weight loss up to the 42-day (6-week) endpoint of this secondary analysis.

CONCLUSION

Daily self-weighing alone may be insufficient to promote postpartum weight loss. However, there was a slight trend toward more weight loss with more frequent weighing.

KEY POINTS

· Daily self-weighing is insufficient for postpartum weight loss.. · Women who weighed themselves more lost slightly more weight.. · Weight loss was the most notable in the first 2 weeks.. · Its use as one part of a program may be worth studying..

General versus Regional Anesthesia and Neonatal Data: A Propensity-Score-Matched Study

OBJECTIVE

This study aimed to evaluate whether there is a difference in neonatal outcomes with general anesthesia (GA) versus regional anesthesia (RA) when induction of anesthesia to delivery time (IADT) is prolonged (≥10 minutes).

STUDY DESIGN

This is a retrospective case-control study that included cases from July 2014 until August 2020. We reviewed all singleton pregnancies delivered between 24 and 42 weeks of gestation with IADT ≥ 10 minutes. Urgent deliveries, those who received RA for labor pain management or started cesarean delivery under RA and converted to GA, as well as cases with fetal anomalies, were excluded. The propensity score (PS) matching method was performed using age, ethnicity/race, body mass index, gestational age at delivery, preexisting maternal comorbidities, and pregnancy complications. Analyses were performed with SAS software version 9.4.

RESULTS

During the study period, we identified 258 cases meeting inclusion criteria. After the PS matching was applied, the study sample was reduced to 60 cases in each group. The median IADT and uterine incision to delivery time were similar between groups (41.5 [30.5, 52] vs. 46 minutes [38, 53.5], p = 0.2 and 1.5 [1, 3] vs. 2 minutes [1, 3], respectively). There was no significant difference between groups with respect to arterial or venous cord pH (7.24 [7.21, 7.26] vs. 7.23 [7.2, 7.27], p = 0.7 and 7.29 [7.26, 7.33] vs. 7.3 [7.26, 7.33], p = 0.4, respectively). Nor were there any associations between maternal characteristics and Apgar's score at 5 minutes, except for Apgar's score at 1 minute (p < 0.001). No significant difference was identified in the rate of admission to the neonatal intensive care unit (NICU; 11 [52.4%] vs. 10 [47.6%], p = 0.8) or NICU length of stay between GA and RA (4 [3, 14] vs. 4.5 [3, 11], p = 0.9).

CONCLUSION

Our data indicate that even with prolonged IADT, favorable neonatal outcomes are seen with both GA and RA, in contrast with previous studies performed decades ago.

KEY POINTS

· Improving cesarean delivery safety, including the safety of anesthesia, is of paramount importance.. · Reappraisal of historical outcomes is warranted as advances in the medical field unfold.. · Favorable neonatal outcomes are seen with both general and regional anesthesia..

Impact of maternal body mass index on the accuracy of third trimester sonographic estimation of fetal weight

OBJECTIVES

To Determine whether maternal body mass index (BMI) can affect the accuracy of sonographic estimation of fetal weight (EFW) in the third trimester when compared to neonatal birthweight (BW).

METHODS

Secondary analysis from our original prospective cohort of pregnant women beyond 34 weeks, distributed in 4 groups according to their BMI: normal, overweight, obese and morbid obese. Fetal biometry and fluid measurements were obtained by two experienced sonographers, blinded for patient's clinical information and to each other's measurements. Average EFW and neonatal BW were converted into gestational-specific Z-scores. Interobserver correlation coefficient (ICC) and Cronbach's reliability coefficient (CRC) were calculated. Bland-Altman (BA) plots were constructed to assess the level of accuracy.

RESULTS

100 women were enrolled (800 measurements obtained by 17 sonographers): 17 had normal BMI (17%), 27 were overweight (27%), 29 were obese (29%) and 27 were morbidly obese (27%). There was no statistical difference for GA at delivery (p = 0.74), EFW (p = 0.05) or BW (p = 0.09) between groups (Table 1). Mean Z-score for EFW was - 0.17 (SD 0.81) and for neonatal BW was - 0.25 (SD 0.74). ICC was 0.69 (95% CI 0.57, 0.78) and CRC was 0.82. Mean Z-score difference was small (Table 2). When stratifying according to BMI categories, the ICC ranged from 0.49 to 0.76. Reliability indices ranged from 0.66 to 0.86. The Z-scores' differences were overall small with no statistical difference (Table 3). BA showed evenly distributed interobserver differences (Fig. 1).

CONCLUSIONS

When performed by trained sonographers, fetal weight estimation in the third trimester is accurate when compared to neonatal birthweight at increasing BMI categories.

Incidence of obese parturients and the outcomes of their pregnancies: A nationwide register study in Finland

OBJECTIVES

We analyzed the incidence of obese and severely obese parturients and the impact of maternal obesity on mode of delivery, perinatal and neonatal mortality, and neonatal health.

STUDY DESIGN

We included all singleton births from the medical birth register of Finland from 2004 to 2018 (n = 792 437). Maternal body mass index (BMI) was categorized into three classes: non-obese (BMI < 30 kg/m²), obese (BMI 30 - 39.9 kg/m²), and morbidly obese (BMI 40 kg/m² or more). The yearly incidence of obese and severely obese parturients per 10000 births was calculated. Logistic regression was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Between 2004 and 2018, the incidence of obese and morbidly obese parturients increased by 44% and 103%, respectively. Cesarean section rates were 23.6% and 30%, respectively (aOR 1.63 CI 1.61 - 1.66 and 2.33 CI: 2.23 - 2.44). Neonates born to morbidly obese parturients had an increased need for intensive care unit treatment (aOR 2.21 CI: 2.10 - 2.32), higher perinatal mortality (aOR 1.65 CI: 1.28 - 2.14), and higher neonatal mortality (aOR 1.68 CI: 1.04 - 2.72). The need for neonatal intensive care (aOR 1.50 CI: 1.47 - 1.53), perinatal mortality (aOR 1.25 CI: 1.13 - 1.39), and neonatal mortality (aOR 1.33 CI: 1.09 - 1.62) increased also among obese parturients.

CONCLUSIONS

We report a worrying increase in obese and morbidly obese parturients. Neonates born to these parturients were more likely delivered by cesarean sections and had higher rates of perinatal and neonatal mortality, and intensive care unit treatment. This highlights the importance of preventing obesity among fertile-aged females.

Postoperative Respiratory Compromise following Cesarean Birth: The Impact of Obesity and Systemic Opioids

Objective  The aim of this study was to measure the effect of obesity and systemic opioids on respiratory events within the first 24 hours following cesarean. Methods  Opioid-naive women undergoing cesarean between January 2016 and December 2017 were included in this retrospective cohort study. The primary outcome was the proportion of women experiencing at least one composite respiratory outcome (oxygen saturation less than 95% lasting 30+ seconds or need for respiratory support) within 24 hours of cesarean. The impact of obesity and total systemic opioid dose in 24 hours (measured in morphine milligram equivalents [MMEs]) on the composite respiratory compromise outcome were evaluated. Results  Of 2,230 cesarean births, 790 women had at least one composite respiratory event. Predictors of the composite respiratory outcome included body mass index (BMI) as a continuous variable (odds ratio = 1.063 for every one unit increase in BMI [95% confidence interval (CI): 1.021-1.108], p  = 0.003), and MME (odds ratio = 1.005 [95% CI: 1.002-1.008], p  = 0.003), adjusting for magnesium sulfate use. The interaction between obesity and opioid dose demonstrated an odds ratio of 1.000 (95% CI: 0.999-1.000, p  = 0.030). Conclusion  The proportion of women experiencing respiratory events following cesarean birth increases with the degree of obesity and opioid dose. Key Points Respiratory events increase with obesity.Respiratory events increase with systemic opioid use.Odds ratio of respiratory events is 1.063/unit BMI increase.

Accuracy and Completion Rate of the Fetal Anatomic Survey in the Super Obese Parturient

OBJECTIVE

To determine the completion rate of ultrasound in with a body mass index (BMI) ≥ 50 to women with BMI 18.5 to 29.9.

STUDY DESIGN

This study was a retrospective cohort study. Women with a singleton pregnancy, age 18 to 45 with a BMI ≥50 that delivered between 2013-2016 were compared to women with a BMI 18.5 to 29.9 during that same time period to assess the accuracy and, as a second aim, the completion rate of the fetal anatomic survey. Data were analyzed using two-sample t test, chi-square test, or logistic regression as appropriate.

RESULTS

Eighty-one cases with a BMI ≥50 were compared with 81 patients with a BMI 18.5 to 29.9. Maternal demographics and timing (gestational age) at the time of the ultrasound were similar between groups. In women with a BMI 18.5 to 29.9, completion of anatomy was 58% of the time with the first ultrasound, 81% with second ultrasound, and 84% with the third ultrasound. In women with BMI ≥50, completion of anatomy was 10% of the time with the first ultrasound, 33% with the second ultrasound, and 42% with the third ultrasound. Each time frame was statistically significant. Agreement level on the accuracy to detect fetal anomalies between groups were not statistically significant between the groups.

CONCLUSION

In women with a BMI ≥50 compared to women with BMI of 18.8 to 29.9, more ultrasounds are needed to complete the anatomic survey although overall accuracy in fetal anomaly detection is similar.

Prolonged Prepregnant Maternal High-Fat Feeding Reduces Fetal and Neonatal Blood Glucose Concentrations by Enhancing Fetal β-Cell Development in C57BL/6 Mice

The main objective of this study was to investigate the effect of maternal obesity on offspring's glucose metabolism during the perinatal period. Maternal obesity was established by feeding C57BL/6 mice with a high-fat (HF) diet before or during pregnancy. Our results showed that prolonged prepregnant HF feeding but not HF feeding during pregnancy significantly reduced fetal and neonatal blood glucose concentrations. Remarkably, elevated blood insulin concentrations and increased activation of insulin signaling were observed in fetuses and neonates from prepregnant HF-fed dams. In addition, significantly larger β-cell areas were observed in pancreases of fetuses and neonates from prepregnant HF-fed dams. Although there was no significant change in placental cross-sectional area or GLUT 1 expression, prepregnant HF feeding significantly enhanced the expression of genes that control placental fatty acid supply. Interestingly, reducing fatty acid supply to the placenta and fetus by placental-specific knockout of adipose triglyceride lipase not only reduced fetal β-cell area and blood insulin concentration but also attenuated prepregnant HF feeding-induced reduction in offspring blood glucose concentrations during the perinatal period. Together, these results indicate that placental and fetal fatty acid supply plays an important role in fetal β-cell development, insulin secretion, and glucose metabolism. Prolonged prepregnant maternal HF feeding resembles pregravid maternal obesity in mice, which reduces fetal and neonatal blood glucose concentrations by enhancing fetal β-cell development and insulin secretion.

Second trimester ultrasound detection of fetal anomalies in the obese obstetrical population: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify, appraise and synthesize the best available evidence on the impact of maternal obesity on mid second trimester ultrasound detection of fetal anomalies in pregnancy.

Obstetrical correlates and perinatal consequences of neonatal hypoglycemia in term infants

OBJECTIVE

To determine independent perinatal and intrapartum factors associated with neonatal hypoglycemia.

METHOD

Of singleton pregnancies delivered at term in 2013; 318 (3.8%) neonates diagnosed with hypoglycemia were compared to 7955 (96.2%) neonate controls with regression analysis.

RESULTS

Regression analysis showed that independent prenatal factors were multiparity (odds-ratio [OR] = 1.61), gestational age (OR = 0.68), gestational diabetes (OR = 0.22), macrosomia (OR = 4.87), small for gestational age neonate [SGA] (OR = 6.83) and admission cervical dilation (OR = 0.79). For intrapartum factors, only cesarean section (OR = 1.57) and last cervical dilation (OR = 0.92) were independently significantly associated with neonatal hypoglycemia. For biologically plausible risk factors, independent factors were cesarean section (OR = 4.18), gentamycin/clindamycin in labor (OR = 5.35), gestational age (OR = 0.59) and macrosomia (OR = 5.62). Mothers of babies with neonatal hypoglycemia had more blood loss and longer hospital stays, while neonates with hypoglycemia had worse umbilical cord gases, more neonatal hypoxic conditions, neonatal morbidities and NICU admissions.

CONCLUSION

Diabetes was protective of neonatal hypoglycemia, which may be explained by optimum maternal glucose management; nevertheless macrosomia was independently predictive of neonatal hypoglycemia. Cesarean section and decreasing gestational age were the most consistent independent risk factors followed by treatment for chorioamnionitis and SGA. Further studies to evaluate these observations and develop preventive strategies are warranted.