CARE OF WOMEN WITH

OBESITY IN PREGNANCY.
RCOG GREEN TOP GUIDELINE 72.

Fatima Shah, SHO OB-GYN , UHK.

Classification of Adults by BMI. WHO

Classifiction BMI
Under Weight < 18.50

Normal Range 18.50-24.99

Overweight >= 25.00

Preobese 25.00-29.99

Obese Class l 30.00-34.99

Obese Class ll 35.00-39.99

Obese Class lll > 40.00

Epidemiology.

Region Antenatal Obese Population.

UK (GTG 72, 2018) 21.3 %

Dublin (Fattah et al, 2010) 19%

Galway (Lynch et al, 2008) 25%

MBRRACE 2014-2016. Nov 2018 Report.

BMI Direct n=98 (%) Indirect n=127(%) Total n=225 (%)

<18 0 (0) 3(2) 3(1)

18-24 28(29) 38(30) 66(29)

25-29 26(27) 19(15) 45(20)

>30 34(35) 50(39) 84(37)

 Prepregnancy Care.

 Measurement of BMI to encourage weight optimisation.

 If BMI > 30, information &advice on risks during pregnancy & delivery.
 Weight loss between pregnancies reduces risks of
 hypertensive complications, macrosomia& stillbirth&
 increases chance of successful vbac.
 Nutritional Supplements:
 Folic Acid 5mg one month before and during first trimester.
 Vitamin D.
Antenatal Care Provision.

 Care integrated into all clinics – provision of clear local policies

and guidelines.

 Documented environmental risk assessment addressing issues.

 Moving & handling risk assessment in BMI of 40> in 3rd trimester

to determine requirements for labour & birth.

 Clear communication of same between Theatre & labour ward in

early labour.
Information During Pregnancy.

 Lack of consensus on acceptable gestational weight gain.

 Focus on healthy diet than prescribed weight gain targets.

 Dietry advice by Dietitian in early pregnancy.

 Anti-obesity or weight loss drugs not recommended.

 At booking clinic provide accurate & accessible information on risks

to pregnancy & how to minimise same.
Specific Risk Assessment with BMI>40.

 Referral to Obstetric Anaesthetist for

 assessment & documentation of difficulties with access, anaesthesia, Mx plan
for labor & birth.

 Referral to qualified professional for tissue viability issues to prevent

pressure sores.
Considerations for Hypertensive
Complications.
 Appropriate size cuff & its documentation.

 Risk of Pre-eclampsia higher in Class ll & higher Obesity.

 If more than one moderate risk factor may benefit from 150mg
Aspirin from 12wks gestation.

 Management is essentially same regardless of BMI.

Moderate Risk Factors For Pre-Eclampsia.

 BMI of 35 or more.

 First Pregnancy.

 Previous hx or family of Pre-eclampsia.

 Advanced maternal age.

 Multiple pregnancy.
Considerations for VTE.

 BMI of >30 is a pre-existing risk factor, risk higher for PE than DVT.

 Risk assessment to be individually assessed, discussed &documented

at each visit.

 Acute VTE to be managed according to guidelines.

 LMWH to be titrated against booking weight.
Considerations for Mental Health in Women with
Obesity.

 High risk.

 Screening at booking visit for mental health.

 Insufficient evidence for recommendation of specific

lifestyle intervention to prevent depression & anxiety.
Antental Screening For Fetal Anomalies.

 Obese women risk for fetal structural anomalies.

 Offer Screening for Chromosomal Anomalies to all women.

 Counselling that some forms of screening are less effective with

raised BMI.
 Difficulty in obtaining accurate NT measurements.

 Free Fetal DNA fraction.

 Higher loss rates following amniocentesis in class lll obesity.

Fetal Surveillance in Pregnant Women with Obesity.

 Serial measurement of SFH from 24wks onwards.

 Assessment of fetal size by US recommended in bmi of > 35.

 US as alternative or complementary method for assessment of fetal

presentation.

 No evidence to support continuous fetal Monitoring during labour..

 Lack of data to recommend routine monitoring of postdates gestation.

 Increased risk of Prolong pregnancy & IOL.

Labour & Birth in Pregnant women with Obesity.

 Documented plan for labour by Anaesthetist & Obstetrician.

 Multiprous & otherwise low risk offered choice for birth in MLUs.

 Active management of third stage.

 Elective IOL at term may reduce the chance of c.section without

increasing risk of adverse outcomes.

 Induction of labour may be considered in suspicion of macrosomia.

 Obesity is a risk factor for unsuccessful vbac. (54.5% vs 70%)

 Care During Delivery in Class lll Obese Pregnant
Women.

 Anaesthetist on call to be informed.

 Continuous Midwifery support with additional measures to prevent pressure

sores and monitor fetal condition.

 Venous access to be established early & consider 2nd siting.

 Prophylactic antibiotics at time of surgery.

 Suturing of subcutaneous tissue space if more than 2cm.

 Lack of evidence to recommend negative pressure dressing therapy, barrier

retractors and subcutaneous drains.
Post-natal care

 Maternal obesity associated with reduced lactogenesis, delayed

initiation & earlier cessation of breast feeding; receive specialist
advice antenatally & postnatally.

 Support to lose weight postpartum and referral to weight managment

services.

 Attempts for conception should be after minimum of 12-18months of

bariatric surgery & in CLU + referral to Dietitian.
Questions...