2012 Dialogue presentation by Chanel Tyler, MD – Assistant Professor, Department of Obstetrics and Gynecology at the UW School of Medicine and Public Health
Assessing the Economics of Obesity and Obesity Interventions by Michael J. O'...
Obesity and Pregnancy presentation by Chanel Tyler, MD
1. Wisconsin Women’s Health
Foundation’s 2012 Dialogue
Chanel T. Tyler, MD
Assistant Professor
University of Wisconsin School of Medicine
Department of Obstetrics and Gynecology Division of
Maternal Fetal Medicine
3. • 23 Million (1/3 of )adult women in the United
States are obese
• Non-Hispanic black women 49%
• Mexican-American women 38%
• Non-Hispanic white women 31%
• 18% of obstetric causes of maternal death
related to obesity
• 80% of anesthesia-related maternal mortality
related to obesity
4. Women of Childbearing Age
Percent Overweight or Obese
Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008.
JAMA 2010;303:235-41.
5. • Increased risk of gestational diabetes
– Primarily related to an exaggerated
increase in insulin resistance in the obese
state
– Women who are obese during pregnancy
and develop gestational diabetes have a
2-fold increased prevalence of
subsequent type2 diabetes
• Increased risk of gestational
hypertension
6. • Increased risk of preeclampsia
– Among the morbidly obese this is almost 5-fold
• Prevalence of LGA infants is almost 4 times as high
among the morbidly obese than those with normal
BMI.
• Increased risk of having SGA infant, however after
adjusting for preeclampsia the risk is no longer
statistically significant.
• Increased risk of antepartum stillbirths
– Almost 3-fold (Cedergren et al)
8. Waller et al
• Found in a population-based control
study that for every incremental unit
increase (kg/m2) in BMI, the risk of
NTD increased by 7%
9. Wolfe et al
Heart 50.5%
BMI Visualization
Umbilical
25.8%
Less than cord
10th % 90.2%
Diaphragm 17%
97.5th % 63% Kidneys 10%
10. Risk of Induction
• Increased risk of post-term pregnancy
• Subsequently there is an increased
incidence of labor induction estimated
to be between 1.7-2.2 fold.
11. Weiss et al 2004
• Increased risk of operative delivery
– Instrumental delivery increased by 18% in
women with BMI 35.1-40
– Increased 34% in women with BMI >40
• Cesarean delivery more common:
47.4% compared to control patients
20.7%
12. VBAC
• The success rate for VBAC in the
massively obese patient has been
found to be just 15%
• More than 50% of these VBAC
attempts are complicated by infectious
morbidity
– Jordan h. Perlow Obstetric Intensive Care Manual second edition 2004
13. Operative Risks
• Increased operative times
– Found in the morbidly obese compared to
normal and obese women (p<0.05)
As BMI rose there was an exponential
increase in
EBL and OR time. A linear increase in skin
incision to uterus time and a linear decline
in umbilical artery pH
16. Difficulties with Regional
Anesthesia
• 150 kg
• Difficult veins
• Unable to curve
lumbar spine
• Impalpable iliac
crests
• Impalpable vertebral
spines
17. Difficulties with General
Anesthesia
• Rapid desaturation on induction
• Risk of regurgitation
• Potential difficult intubation
• Potential difficult ventilation
• Difficult tracheostomy
18. Excess Gestational Weight Gain
Health Impacts on Women:
• Postpartum weight retention
• Long-term weight gain
• Excess body fat
• Sleep apnea
• Pre-diabetes/diabetes
• Coronary heart disease
19. Excess Gestational Weight Gain
Health Impacts on Neonates & Children:
• Low 5-minute Apgar scores
• Neonatal seizures
• Hypoglycemia
• Large for gestational age infants
• Meconium aspiration
• NICU admission
• 4-fold increased lifetime risk of overweight/obesity
• Lifelong elevated risk for diabetes, hypertension,
cardiovascular disease, cancer, early death
20. • More than a 2-fold increased risk from
fetal distress and low APGARS
• Meconium aspiration occurred more
often in infants of morbidly obese
women
21. Maternal Benefits of
Breastfeeding
• Decreased risk of breast15-17 and ovarian
cancer18,19
• Decreased risk of type 2 diabetes. 20
• Returns of uterine tone,21;22
• Stopping post-birth bleeding,21
• Temporarily suppressing ovulation
which aids the spacing of children.21;23
22. Breastfeeding Decreases
Infant Risks of
• Ear1-3 and respiratory infections.4
• Atopic dermatitis5
• Gastroenteritis6
• Necrotizing enterocolitis7
• Type 2 diabetes8
• Sudden infant death syndrome (SIDS) 9-
14
.
Notas del editor
The amount of preconception counseling is inadequate for most women. Infertility is a huge problem for many women who are overweight/obese and when pregnant, miscarriage rates are higher for obese women. This trend continues
C-section rates reaching 50% for women whose BMI exceeds 40 (ACOG). Excess GWG is the strongest predictor of postpartum weight retention, long-term weight gain, excess body fat, and long term risk of maternal obesity (Weisman, 2010). Excess GWG is further associated with intrauterine fetal macrosomia, neonatates that are large for gestational age, and overweight during infancy. This leads to a variety of long-term health risks including increased risk for diabetes, cancers, and excess cardiovascular disease In addition to the increased risk for obesity, children whose mothers experienced excess GWG also have higher levels of fat mass, systolic blood pressure, C-reactive protein, and interleukin-6, as well as lower HDL cholesterol and apolipoprotein levels during childhood - all of which are cardiovascular and metabolic risk markers (Fraser, et al. 2010 Most disturbing, newer data from human studies finds that intrauterine exposure to excess fat and calories predisposes to obesity in postnatal life, an effect which is magnified when combined with maternal diabetes (Pirkola, 2010). This has lead investigators to posit that intrauterine genomic programming may exist, such that postnatal maladaptive metabolism leads to the presence of overweight and obesity later in life (Tamashiro, 2010).
Excess GWG is further associated with intrauterine fetal macrosomia, neonatates that are large for gestational age, and overweight during infancy. This leads to a variety of long-term health risks including increased risk for diabetes, cancers, and excess cardiovascular disease