Obstetrical and neonatal outcomes in obese parturients

Impact of Bariatric Surgery on Female Reproductive Health and Maternal Outcomes

INTRODUCTION

Obesity has a derogatory effect on female reproductive health. Obesity contributes to difficulty in natural conception, increased risk of pregnancy-associated complications, miscarriages, congenital anomalies, and also the long-term negative impact on both mother and the child.

OBJECTIVES

Our study aimed to analyze and assess the reproductive health-associated outcomes of females who underwent bariatric surgery.

METHODS

We performed a retrospective analysis from a prospectively collected database from June 2013 to June2016. Out of 71 females studied, 45 patients (63.5%) had completed 3 years of follow-up. The data were collected from inpatient and outpatient records. Patients were studied under three groups (A, patients with polycystic ovarian disease (PCOD) symptoms; B, patients with primary infertility; and C, patients who conceived after bariatric surgery that were included in groups A and B).

RESULTS

Out of 45 patients studied, 40 patients underwent laparoscopic sleeve gastrectomy (LSG), four patients underwent laparoscopic Roux-en-Y gastric bypass (RYGB), and one patient underwent laparoscopic adjustable gastric banding (LAGB). The mean BMI of the patients was 43.64 ± 6.8 kg/m2. PCOD symptoms improved symptomatically (p = 0.001) after surgery in the group. Seven (43.75%) primary infertility patients conceived after surgery. Three (42.9%) patients conceived naturally while 4 (57.1%) conceived with ART in group B. Out of total population of 45 in group C, percentages of patients who delivered baby with short gestational age (SGA), low birth weight (LBW), normal vaginal deliveries (NVD), and maternal anemia were 63.15%,47.3%,73.4%, and26.3%, respectively.

CONCLUSION

Obesity is closely associated with primary infertility and PCOD. Menstrual abnormalities associated with PCOD significantly improve after bariatric surgery with significant improvement in fertility along with maternal outcomes.

The Edmonton Obesity Staging System Predicts Mode of Delivery After Labour Induction

OBJECTIVE

This study sought to evaluate the use of the Edmonton Obesity Staging System (EOSS) in predicting cesarean delivery among term, nulliparous, singleton pregnancies in women with overweight or obesity who are undergoing an induction of labour.

METHODS

A prospective cohort study was performed in Edmonton, Alberta. Women undergoing an induction of labour at term were recruited to either a sample cohort, including women with a body mass index of ≥25 kg/m² at first antenatal visit, or a control cohort with a body mass index of 18.5 to 24.9 kg/m². Participating women provided a self-reported health history and consented to review of their medical records allowing allocation into EOSS categories. The primary outcome was the rate of cesarean delivery based on EOSS category. Secondary outcomes consisted of a summary score of adverse maternal, delivery, and neonatal events (Canadian Task Force Classification II-2).

RESULTS

Overall, 345 women were recruited, with a participation rate of 93.7%. The sample cohort consisted of 276 women with overweight or obesity, whereas the control cohort included 69 normal-weight women. The overall rate of cesarean delivery was 30.4% for the control cohort and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS category 0, 1, 2, and 3, respectively (P < 0.001). A summary score was not indicative of overall rate of adverse maternal, delivery, and neonatal events (P = 0.22).

CONCLUSION

The EOSS may help predict the chance of cesarean delivery in a high-risk group of nulliparous women with overweight or obesity who are undergoing an induction of labour at term.

First trimester placental vascular indices and volume by three-dimensional ultrasound in pre-gravid overweight women

OBJECTIVES

To investigate changes of placental vascular indices and volume in pre-gravid overweight Chinese women during the first trimester using three-dimensional power Doppler ultrasound.

METHODS

This was a prospective observational study of the morphology of placentas in pre-gravid overweight (body mass index (BMI) ≥ 24 kg/m²) and non-overweight (BMI < 24 kg/m²) Chinese women during the first trimester of pregnancy. Data on placental vascular indices (vascularization index, flow index, and vascularization flow index (VFI)), placental volume, uterine artery pulsatility index (PI), and neonatal outcomes were obtained during the first trimester and analyzed. Linear regression analysis was used to evaluate confounding factors between BMI and ultrasound indices.

RESULTS

Of the 429 pregnant women enrolled, 68 (15.9%) were pre-gravid overweight. Placental VFI was significantly lower in the overweight group (p = 0.037). Conversely, placental volume was significantly larger in the overweight group (p = 0.044), and uterine artery PI was significantly higher in the overweight group (p = 0.021). After adjustments for confounding factors, there were still significant differences in placental VFI (unstandardized coefficient (B) -0.666, 95% confidence interval (CI) -1.306 - (-0.025)), placental volume (B 2.458, 95% CI 0.071-4.844), and uterine artery PI (B 0.152, 95% CI 0.030-0.274) between the two groups.

CONCLUSIONS

Placental vascular indices using three-dimensional power Doppler ultrasound can provide an insight into placental vascularization in pre-gravid overweight women in early pregnancy. Alterations in placental VFI, placental volume, and uterine artery PI occur during the first trimester in pre-gravid overweight women.

Effect of Obesity on Gestational and Perinatal Outcomes

Purpose To assess the impact of pre-pregnancy obesity (body mass index [BMI] ≥ 30 kg/m2) on the gestational and perinatal outcomes. Methods Retrospective cohort study of 731 pregnant women with a BMI ≥ 30 kg/m2 at the first prenatal care visit, comparing them with 3,161 women with a BMI between 18.5 kg/m2 and 24.9 kg/m2. Maternal and neonatal variables were assessed. Statistical analyses reporting the demographic features of the pregnant women (obese and normal) were performed with descriptive statistics followed by two-sided independent Student's t tests for the continuous variables, and the chi-squared (χ2) test, or Fisher's exact test, for the categorical variables. We performed a multiple linear regression analysis of newborn body weight based on the mother's BMI, adjusted by maternal age, hyperglycemic disorders, hypertensive disorders, and cesarean deliveries to analyze the relationships among these variables. All analyses were performed with the R (R Foundation for Statistical Computing, Vienna, Austria) for Windows software, version 3.1.0. A value of p < 0.05 was considered statistically significant. Results Obesity was associated with older age [OR 9.8 (7.8-12.2); p < 0.01], hyperglycemic disorders [OR 6.5 (4.8-8.9); p < 0.01], hypertensive disorders [OR 7.6 (6.1-9.5); p < 0.01], caesarean deliveries [OR 2.5 (2.1-3.0); p < 0.01], fetal macrosomia [OR 2.9 (2.3-3.6); p < 0.01] and umbilical cord pH [OR 2.1 (1.4-2.9); p < 0.01). Conversely, no association was observed with the duration of labor, bleeding during labor, Apgar scores at 1 and 5 minutes after birth, gestational age, stillbirth and early neonatal mortality, congenital malformations, and maternal and fetal injury. Conclusion We observed that pre-pregnancy obesity was associated with maternal age, hyperglycemic disorders, hypertension syndrome, cesarean deliveries, fetal macrosomia, and fetal acidosis.

Increasing maternal body mass index during pregnancy increases neonatal intensive care unit admission in near and full-term infants

BACKGROUND

Obesity is becoming an increasingly commonplace health problem. Obesity during pregnancy is important because the condition adversely affects not only the mother, but also the developing fetus and the newborn.

OBJECTIVE

The primary objective of this study was to evaluate the association between maternal body mass index (mBMI) at the time of delivery and neonatal intensive care unit (NICU) admission of offspring and to analyze the role of possible confounding variables that are often associated with obesity. Comorbidities, such as gestational diabetes mellitus (DM), hypertension (HT) and/or pre-eclampsia (PEC), are more common in more obese mothers, as is a higher association of obesity among non-Caucasian patients.

METHODS

Using a retrospective cohort design, 1736 mothers and their singleton live-born at  ≥35 weeks' gestation were analyzed for mBMI, maternal conditions of DM, HT and/or PEC, and whether NICU care was required and the reason for NICU admission.

RESULTS

NICU admission rate was significantly associated with maternal obesity. In comparing women with mBMI  < 30 versus mBMI ≥ 30, OR was 1.39 (p = 0.045); OR increased to 1.76 (p = 0.006) in comparing patients with mBMI  ≥ 35. mBMI was significantly associated with an increased rate of maternal DM, HT and PEC (p < 0.05 each); however, NICU admission rate was not correlated with DM, HT or PEC. The relationship between NICU admission and mBMI was significant in Caucasian mothers versus a borderline significance in African-American mothers (p = 0.035 versus p = 0.05). After controlling for neonatal hypoglycemia (NH) as the reason for admission to the NICU, no mBMI-NICU association persisted. The rate of infants with NH increased in higher mBMI groups, independent of maternal DM diagnosis.

CONCLUSION

This study demonstrated a significant association between higher mBMI groups and NICU admissions independent of diagnosis of maternal comorbidities. However, accounting for NH eliminating this association suggests a pre-clinical diabetic pathology in obese women that affects newborn outcome. Despite increased percentage of nonwhite mothers in higher mBMI groups, African-American race does not seem to be a significant contributing factor in the increased rate of NICU admission in our population.

Maternal morbid obesity: financial implications of weight management

The objective of this study was to evaluate health outcomes and costs of pregnancies complicated by extreme maternal obesity (class III obesity, body mass index ≥ 40). We conducted a retrospective case-control descriptive study comparing extremely obese women (cases) and their infants with randomly selected controls. Health outcomes were obtained from the medical records and costs from billing data. Total costs for each mother-infant dyad were calculated. Compared with 85 controls, the 82 cases experienced higher morbidity, higher costs and prolonged hospital stay. However, 26% of cases maintained or lost weight during pregnancy, whereas none of the controls maintained or lost weight during pregnancy. When mother/infant dyads were compared on costs, case subjects who maintained or lost weight experienced lower costs than those who gained weight. Neonatal intensive care consumed 78% of total hospital costs for infants of the obese women who gained weight, but only 48% of costs for infants of obese women who maintained or lost weight. For extremely obese women, weight management during pregnancy was achievable, resulted in healthier neonatal outcomes and reduced perinatal healthcare costs.

Blood volume determination in obese and normal-weight gravidas: the hydroxyethyl starch method

OBJECTIVE

The impact of obesity on maternal blood volume in pregnancy has not been reported. We compared the blood volumes of obese and normal-weight gravidas using a validated hydroxyethyl starch (HES) dilution technique for blood volume estimation.

STUDY DESIGN

Blood volumes were estimated in 30 normal-weight (pregravid body mass index [BMI] <25 kg/m(2)) and 30 obese (pregravid BMI >35 kg/m(2)) gravidas >34 weeks' gestation using a modified HES dilution technique. Blood samples obtained before and 10 minutes after HES injection were analyzed for plasma glucose concentrations after acid hydrolysis of HES. Blood volume was calculated from the difference between glucose concentrations measured in hydrolyzed plasma.

RESULTS

Obese gravidas had higher pregravid and visit BMI (mean [SD]): pregravid (41 [4] vs 22 [2] kg/m(2), P = .001); visit (42 [4] vs 27 [2] kg/m(2), P = .001), but lower weight gain (5 [7] vs 12 [4] kg, P = .001) than normal-weight women. Obese gravidas had similar estimated total blood volume to normal-weight women (8103 ± 2452 vs 6944 ± 2830 mL, P = .1), but lower blood volume per kilogram weight (73 ± 22 vs 95 ± 30 mL/kg, P = .007).

CONCLUSION

Obese gravidas have similar circulating blood volume, but lower blood volume per kilogram body weight, than normal-weight gravidas near term.

Neonatal morbidities among full-term infants born to obese mothers

INTRODUCTION

Impact of maternal obesity on full-term neonates is not known.

OBJECTIVE

We hypothesized increased incidence of neonatal morbidities requiring NICU admission in full-term neonates of obese women compared to neonates of normal-weight women.

METHODS

Data from full-term pregnancies collected in the Consortium of Safe Labor study were analyzed. Maternal BMI was classified using the WHO criteria. Incidence of neonatal outcomes including sepsis, PDA, NEC, respiratory distress, or their combination were compared between newborns of obese and normal-weight women.

RESULTS

Of the 109 488 women included in the study, 17.7% were obese. Maternal co-morbidities (diabetes, gestational diabetes, hypertension, and preeclampsia) increased with increasing maternal BMI. Both maternal obesity and its related co-morbidities were associated with higher incidence of neonatal morbidities. After adjusting for maternal comorbidities, there was a higher incidence of sepsis (AOR 1.91(1.45-2.50)), and combination of any of the neonatal outcomes (AOR 1.66(1.32-2.09)) among newborns of obese women than those of normal-weight women, along with an increased trend for incidence of PDA (Cochran-Armitage Test (CA) = 23.1, p < 0.0001) and NEC (CA = 7.2, p = 0.007).

CONCLUSION

Maternal obesity is independently associated with increased incidence of neonatal sepsis and a combination of neonatal morbidities in full-term newborns with an increased trend for PDA and NEC.

Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population

Background

Worldwide there has been a dramatic increase in the prevalence of overweight and obesity in women of childbearing age. Growing evidence suggests that maternal overweight and obesity is associated with poor maternal and perinatal outcomes. This study evaluated the impact of maternal pre-pregnancy overweight and obesity on pregnancy, labour and delivery outcomes in a cohort of women with term, singleton pregnancies cared for by family physicians in community based practices.

Methods

This study is a secondary analysis of the All Our Babies Cohort, a prospective, community-based pregnancy cohort in Calgary, Alberta. Maternal self-reported data on height and pre-pregnancy weight from term, singleton, cephalic pregnancies (n = 1996) were linked to clinical data on pregnancy and birth events retrieved from electronic health records. Descriptive and bivariate regression analysis were used to compare pregnancy and birth outcomes between women categorized as normal weight, overweight and obese based on the pre-pregnancy BMI. Multinomial regression analysis stratified by type of labour onset examined the association between pre-pregnancy BMI and mode of delivery controlling for maternal age, pre-existent health conditions, parity, fertility treatments, history of C-section and pregnancy complications.

Results

The cohort consisted of 65.8% normal weight, 23.6% overweight and 10.6% obese women. Women with increased pre-pregnancy BMI were more likely to develop pregnancy complications such as preeclampsia (OR 3.5, CI 2.0-4.6 for overweight; OR 5.3, CI 3.3-8.5 for obese) and gestational diabetes (OR 3.0, CI 1.8-5.0 for overweight; OR 6.5, CI 3.7-11.2 for obese) than normal weight women. Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1).

Conclusions

Even among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery. These findings highlight the importance of tailored maternal care in pregnancy and at delivery of pregnant women with increased BMI in order to improve the outcomes and wellbeing of these women and their children.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-014-0422-y) contains supplementary material, which is available to authorized users.

Maternal obesity and occurrence of fetal macrosomia: a systematic review and meta-analysis

OBJECTIVE

To determine a precise estimate for the contribution of maternal obesity to macrosomia.

DATA SOURCES

The search strategy included database searches in 2011 of PubMed, Medline (In-Process & Other Non-Indexed Citations and Ovid Medline, 1950-2011), and EMBASE Classic + EMBASE. Appropriate search terms were used for each database. Reference lists of retrieved articles and review articles were cross-referenced.

METHODS OF STUDY SELECTION

All studies that examined the relationship between maternal obesity (BMI ≥30 kg/m(2)) (pregravid or at 1st prenatal visit) and fetal macrosomia (birth weight ≥4000 g, ≥4500 g, or ≥90th percentile) were considered for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Data regarding the outcomes of interest and study quality were independently extracted by two reviewers. Results from the meta-analysis showed that maternal obesity is associated with fetal overgrowth, defined as birth weight ≥ 4000 g (OR 2.17, 95% CI 1.92, 2.45), birth weight ≥4500 g (OR 2.77,95% CI 2.22, 3.45), and birth weight ≥90% ile for gestational age (OR 2.42, 95% CI 2.16, 2.72).

CONCLUSION

Maternal obesity appears to play a significant role in the development of fetal overgrowth. There is a critical need for effective personal and public health initiatives designed to decrease prepregnancy weight and optimize gestational weight gain.

[New aspects of obstetric anesthesia]

BACKGROUND

The risk profile of patients in obstetric anesthesia has substantially changed. Even more so than other disciplines, obstetric anesthesia is therefore in the true sense of the word dependent on the close coordination of all concerned and a good interdisciplinary cooperation.

AIM

This article explains the important anesthesiological risks connected with parturition and presents the corresponding concepts for prevention, diagnosis and management of peripartum complications.

MATERIAL AND METHODS

The increase in the number of high risk pregnancies, which are mostly due to an increase in obesity, require clearly defined guidelines and interdisciplinary concepts which are described and discussed in this article. The neuraxial block is still the most effective procedure for treatment of birth pain and offers a promising new method with the programmed intermittent epidural boluses presented in this article. Finally, the German speaking countries Germany, Austria and Switzerland have developed a treatment algorithm for the management of postpartum hemorrhage which is presented here.

RESULTS

The anesthesiological components of a risk pregnancy must be recognized early and include obesity, preeclampsia and drug-induced coagulopathy. Epidural analgesia is the most effective analgesic procedure in obstetrics. Patient-controlled remifentanil analgesia currently represents the best alternative in cases of contraindications for a neuraxial procedure.

CONCLUSION

In risk situations, such as pre(eclempsia), emergency cesarean section, massive blood loss or other peripartum emergency situations, optimal interdisciplinary cooperation between midwives, obstetricians and anesthetists is required. However, not only emergency situations require a good interdisciplinary cooperation. Just as important is the cooperation to recognize risk pregnancies and a timely joint planning of the approaching birth.

Global obesity and the effect on women's health

The rates of obesity are increasing in all areas of the world. The pattern of diseases in many areas of the world is shifting rapidly to diseases that are chronic and noncommunicable. These changes are occurring so rapidly that existing health care infrastructure in many parts of the world are likely to be stressed. Many aspects of women's health will be worsened as they become more obese. Coordinated efforts to reverse the obesity trend are being made and individuals and teams working within women's health globally should coordinate with existing efforts to provide data and consistent messages.

Healthy Foods North improves diet among Inuit and Inuvialuit women of childbearing age in Arctic Canada

BACKGROUND

Healthy Foods North (HFN) is a community-based intervention designed to promote a healthy diet and lifestyle of Inuit and Inuvialuit populations in Arctic Canada. The objective of the present study was to determine the effects of HFN on the nutrient intake of women of childbearing age.

METHODS

Six communities in Nunavut (n = 3) and the Northwest Territories (n = 3) were selected for programme implementation; four received a 12-month intervention and two served as controls. Quantitative food frequency questionnaires were used to assess dietary intake at baseline and 1 year post-intervention. Among women participants aged 19-44 years (n = 136), 79 were exposed to the intervention and 57 were not. Mean daily energy and nutrient intake and density were determined. Dietary adequacy was assessed by comparing the women's daily nutrient intakes with dietary reference intakes (DRI).

RESULTS

Main outcomes were the pre- to post-intervention changes between intervention and control groups for energy and selected nutrient intakes, nutrient density and dietary adequacy. Among the participants, the intervention had a beneficial effect on vitamin A and D intake. The percentage of individuals with nutrient intakes below the DRI increased from pre- to post-intervention for vitamin A and D in the control group but only for vitamin A in the intervention group. The programme did not have a significant impact on calorie, sugar, or fat consumption.

CONCLUSIONS

The HFN programme is effective in mitigating some of the negative impacts of the nutrition transition on dietary adequacy among Inuit and Inuvialuit women of childbearing age.

Outcome of deliveries in healthy but obese women: obesity and delivery outcome

Background

Obesity among fertile women is a global problem. 25% of pregnant Swedish women are overweight at admission to the antenatal clinic and 12% of them are considered as obese. Previous studies have shown an increased risk of delivery complications with an elevated maternal BMI. The aim of this study was to evaluate delivery outcomes in relation to maternal BMI on admission to the antenatal clinic.

A healthy group of 787 women with full-term pregnancies and spontaneous onset of labor were included in the study. Delivery outcome was assessed in relation to maternal BMI when attending the antenatal clinic.

Results

The results indicated that in deliveries where the maternal BMI was >30 a high frequency of abnormal CTG trace during the last 30 minutes of labor was shown. A blood sample for evaluation of risk of fetal hypoxia was performed in only eight percent of these deliveries. A spontaneous vaginal delivery without intervention was noted in 85.7%, and 12% of neonates were delivered with an adverse fetal outcome compared to 2.8% in the group with a maternal BMI<30 (p<0.001).

Conclusion

These results indicate an increased risk at delivery for healthy, but obese women in labor. Furthermore, the delivery management may not always be optimal in these deliveries.

Racial disparities in preterm birth

In the United States, there is a pronounced and persistent race/ethnic disparity in the rate of preterm birth. Even after decades of basic science research and public health initiatives this disparity remains relatively unchanged. Factors that underpin this disparity are elusive and likely, at least in part, derived from complex mechanisms originating from social inequities. In this article several promising areas of research are explored. Specifically, social context or neighborhood-level exposures, maternal nativity, infection/inflammation, and preconception health differentials are discussed in the context of increasing risk of preterm birth among race/ethnic minorities.

Cesarean delivery in the obese parturient: anesthetic considerations

Obesity is a worldwide health problem and its prevalence is reaching epidemic proportions. As obesity does not spare women of childbearing age, obstetric anesthesiologists will increasingly be exposed to the challenges of anesthesia in this population. The purpose of this article is to give the reader a thorough understanding of the anesthetic implications of obesity relating to cesarean deliveries. Obesity is associated with hypertension, diabetes, obstructive sleep apnea and other comorbidities. It increases the risk of cesarean delivery, postpartum wound infections and deep venous thromboembolism. Obese parturients are prone to anesthetic complications such as aspiration of gastric contents, difficult monitoring, positioning, airway management and challenging neuraxial techniques. A thorough precesarean delivery preparation should include an evaluation by an anesthesiologist for women with a BMI over 40 kg/m² and institution of an antacid prophylaxis protocol, thromboprophylaxis and antibiotic prophylaxis. Regional anesthesia should ideally be used in all obese parturients unless contraindicated. The goals of postpartum care include efficacious analgesia, physiotherapy and early mobilization. Monitoring and vigilance in an intensive care unit or step-down units should be considered for morbidly obese women.