Maternal super obesity and risk for intensive care unit admission in the MFMU Cesarean Registry

The Impact of Body Mass Index on Postpartum Infectious Morbidities and Wound Complications: A Study of Extremes

OBJECTIVE

 As body mass index increases, the risk of postpartum infections has been shown to increase. However, most studies lump women with a body mass index (BMI) of above 40 kg/m2 together, making risk assessment for women in higher BMI categories challenging. The objective of this study was to evaluate the impact of extreme obesity on postpartum infectious morbidity and wound complications during the postpartum period.

STUDY DESIGN

 The present study is a secondary analysis of women who underwent cesarean delivery and had BMI ≥ 40 kg/m2 in the Maternal-Fetal Medicine Units Cesarean Registry. The primary outcome was a composite of postpartum infectious morbidity including endometritis, wound infection, inpatient wound complication prior to discharge, and readmission due to wound complications. Appropriate statistics used to compare baseline demographics, pregnancy complications, and primary outcomes among women by increasing BMI groups (40-49.9, 50-59.9, 60-69.9, and >70 kg/m2).

RESULTS

 Rates of postpartum infectious morbidity increased with BMI category (11.7% BMI: 50-59.9 kg/m2; 13.7% BMI: 60-69.9 kg/m2; and 21.9% BMI >70+ kg/m2; p = 0.001). Readmission for wound complications also increased with BMI (3.1% for BMI: 50-59.9 kg/m2; 6.2% for BMI: 60-69.9 kg/m2; and 9.4% for BMI >70+ kg/m2; p = 0.001). After adjusting for confounders, increased BMI of 70+ kg/m2 category remained the most significant predictor of postpartum infectious complications compared with women with BMI of 40 to 49.9 kg/m2 (adjusted odds ratio [aOR] = 6.38; 95% confidence interval [CI]: 1.37-29.7). The adjusted odds of readmission also increased with BMI (aOR = 2.33, 95% CI: 1.35-4.02 for BMI 50-59.9 kg/m2; aOR = 4.91, 95% CI: 2.07-11.7 for BMI of 60-69.9 kg/m2; and aOR = 36.2, 95% CI: 7.45-176 for BMI >70 kg/m2).

CONCLUSION

 Women with BMI 50 to 70+ kg/m2 are at an increased risk of postpartum wound infections and complications compared with women with BMI 40 to 49.9 kg/m2. These data provide increased guidance for counseling women with an extremely elevated BMI and highlight the importance of postpartum wound prevention bundles.

KEY POINTS

· Women with super obesity have higher rates of wound complications.. · Women at extremes of obesity experience worse postpartum infectious morbidity.. · More research is needed on effective strategies to minimize morbidity in this population..

Increasing Pre-pregnancy Body Mass Index and Pregnancy Outcomes in the United States

INTRODUCTION

 As many Americans are becoming overweight or obese, increased body mass index (BMI) is fast becoming normalized. There is a need for more research that highlights the association between pre-pregnancy obesity and adverse pregnancy outcomes.

AIM

To determine the association between increasing pre-pregnancy BMI and adverse pregnancy outcomes.

METHODS

We utilized the United States Vital Statistics records to collate data on all childbirths in the United States between 2015 and 2019. We determined the association between increasing pre-pregnancy BMI and adverse pregnancy outcomes using multivariate analysis. Neonatal outcomes measures include the five-minute Apgar score, neonatal unit admission, neonates receiving assisted ventilation > six hours, neonatal antibiotics use, and neonatal seizures. Maternal outcomes include cesarean section rate, mothers requiring blood transfusion, unplanned hysterectomy, and intensive care unit admission. In addition, we controlled for maternal parameters such as race/ethnicity, age, insurance type, and pre-existing conditions such as chronic hypertension and prediabetes. Other covariates include paternal race, age and education level, gestational diabetes mellitus, induction of labor, weight gain during pregnancy, gestational age at delivery, and delivery weight.

RESULTS

We studied 15,627,572 deliveries in the US Vital Statistics records between 2015 and 2019. Among these women, 3.36% were underweight, 43.19% were with a normal BMI, 26.34% were overweight, 14.73% were in the obese class I, 7.23% were in the obese class II, and 5.14% were in the obese class III. Increasing pre-pregnancy BMI was associated with significant adverse outcomes across all measures of maternal and neonatal outcomes.

CONCLUSION

 A strong association exists between increasing pre-pregnancy BMI and adverse maternal and neonatal outcomes. The higher risk of adverse pregnancy outcomes among overweight and obese women remained even after controlling for other traditional risk factors of adverse maternal and neonatal outcomes.

Postpartum Respiratory Depression

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.

Severe maternal morbidity and mortality during delivery hospitalization of class I, II, III, and super obese women

BACKGROUND

Previous studies show that obesity predisposes patients to higher risks of adverse pregnancy outcomes. Data on the relationship between increasing degrees of obesity and risks of severe maternal morbidity, including mortality, are limited.

OBJECTIVE

We examined the association of increasing classes of obesity, especially super obesity, with the risk of severe maternal morbidity and mortality at the time of delivery hospitalization.

STUDY DESIGN

Using New York City linked birth certificates and hospital discharge data, we conducted a retrospective cohort study. This study identified delivery hospitalizations for singleton, live births in 2008-2012. Women were classified as having obesity (class I, II, III, or super obesity), as opposed to normal weight or overweight, based on prepregnancy body mass index. Cases of severe maternal morbidity were identified based on International Classification of Diseases, Ninth Revision diagnosis and procedure codes according to Centers for Disease Control and Prevention criteria. Multivariable logistic regression was used to evaluate the association between obesity classes and severe maternal morbidity, adjusting for maternal sociodemographic characteristics.

RESULTS

During 2008-2012, there were 570,997 live singleton births with available information on prepregnancy body mass index that met all inclusion criteria. After adjusting for maternal characteristics, women with class II (adjusted odds ratio, 1.14; 95% confidence interval, 1.05-1.23), class III (adjusted odds ratio, 1.34; 95% confidence interval, 1.21-1.49), and super obesity (adjusted odds ratio, 1.99; 95% confidence interval, 1.57-2.54) were all significantly more likely to have severe maternal morbidity than normal and overweight women. Super obesity was associated with specific severe maternal morbidity indicators, including renal failure, air and thrombotic embolism, blood transfusion, heart failure, and the need for mechanical ventilation.

CONCLUSION

There is a significant dose-response relationship between increasing obesity class and the risk of severe maternal morbidity at delivery hospitalization. The risks of severe maternal morbidity are highest for women with super obesity. Given that this is a modifiable risk factor, women with prepregnancy obesity should be counseled on the specific risks associated with pregnancy before conception to optimize their pregnancy outcomes.

Influence of weight gain on risk for cesarean delivery in obese pregnant women by class of obesity: pregnancy risk assessment monitoring system (PRAMS)

BACKGROUND

Currently, all obese women in the United States (US) are recommend to gain the same amount of weight during pregnancy, regardless of class of obesity. Limited literature has looked at the risk of cesarean, and possible mitigation of this risk, by specific class of obesity.

OBJECTIVE

To determine the influence of weight gain on the odds of cesarean delivery for obese women (as determined by pre-pregnancy body mass index [BMI]), by class of obesity.

STUDY DESIGN

Retrospective cohort, from the Pregnancy Risk Assessment Monitoring System (PRAMS) in the US. Specifically, the unadjusted odds of cesarean delivery were determined for each class of BMI (underweight, normal weight, overweight, class I obesity, class II obesity, and class III obesity). These odds were then adjusted by demographic and prenatal care factors influencing either weight gain during pregnancy or risk of cesarean delivery. Finally, the association of weight gain (insufficient <11 lbs, adequate 11-20 lbs, and excessive >20 lbs) on the odds of cesarean delivery in obese women was noted via multivariate logistic regression analysis.

RESULTS

60,431 women (including 21,208 with a cesarean delivery) were included in this study, with an adjusted odds ratios (OR) of cesarean delivery by BMI: underweight 0.92 (95% CI 0.83, 1.01), normal weight (referent group), overweight 1.38 (95% CI 1.32, 1.45), class I obesity 1.77 (95% CI 1.68, 1.88), class II obesity 2.17 (95% CI 2.02, 2.34), and class III obesity 3.07 (95% CI 2.82, 3.34). Class I and II obese women are more likely to have a cesarean with excessive weight gain, with class I OR 1.20 (95% CI 1.06, 1.36) and class II OR 1.24 (1.04, 1.48) when compared to women in their same class of obesity with adequate weight gain. There was no difference in risk for cesarean for class III obese women by weight gain.

CONCLUSION

Although obesity is a known risk factor for cesarean delivery, this risk is thought to be mitigatable by appropriate weight gain during the pregnancy. Weight gain of 11-20 pounds was associated with the least risk of cesarean delivery among obese (specifically class I and II) individuals.

Epidemiology of obstetric critical illness

Obstetric intensive care unit (ICU) admissions comprise only a small part of severe maternal morbidity. The incidence rate of both remains relatively unclear due to inconsistent definitions across publications, although this has begun to be addressed. There is a relative paucity of information regarding disease-specific survival following obstetric ICU admission, but outcomes are clearly related to the cause of admission and the quality of care. The ratio between maternal near-miss cases (many of whom are admitted to ICUs) and maternal death may provide insight into the preventability of death. Hemorrhage and pre-eclampsia constitute the leading causes of ICU admission and have relatively low mortality rates, perhaps demonstrating the impact of informed care in managing obstetric critical illness. Obstetric sepsis, heart disease and anesthesia complications should be the focus of future research. The incidence of obstetric sepsis has been increasing in the last decade, with mortality rates remaining relatively high. The incidence of obstetric heart disease is increasing and maternal complications have been attributed to fractionated care of mothers within this category. Anesthesia complications remain a predominant cause of maternal death and likely intensive care admission. Data are lacking regarding the relative proportion of cases per disease that remain treated outside the ICU; and the outcomes of various management strategies. The only study of the health status of survivors of obstetric ICU admission revealed that six months after hospital discharge, one in five women still had a poorer health-related quality of life than those of a reference age- and sex-matched cohort.