No disclosures Naomi E. Stotland, MD Professor Dept. of - - PowerPoint PPT Presentation

6/9/2018 1

The Obesity Epidemic: Impact on Pregnancy A Patient-centered and Community-centered Approach

Naomi E. Stotland, MD Professor

• Dept. of Obstetrics, Gynecology, and Reproductive Sciences

University of California, San Francisco San Francisco General Hospital

No disclosures

“In my experience, doctors tend to fall into one of two camps: They either ignore my weight, even when it seems relevant and I press the issue, or they make it the center focus of all of my health issues.” “When I first Googled obesity and pregnancy, I was just one month pregnant with my first child and only partly prepared for the bad news. The rhetoric was alarming — words like “dangerous complications” and “life-threatening” filled my search results, along with rundowns on risk factors for everything from gestational diabetes to infant mortality. And, at the end of most articles, there was a statement that went something like this: Doctors recommend that obese women thinking about getting pregnant should attempt to lose weight before conceiving. I remember thinking, Well, too late for that.”

Colleen Able, “What I Wish I Knew About Pregnancy and Obesity”. Refinery29, 4/24/17 https://www.refinery29.com/2017/04/148573/maternal-obesity-and-pregnancy- complications-risks

The Patient Experience

Obesity is associated with metabolic dysfunction

Obesity Chronic inflammation HTN, DM, liver disease

• Some obese have little to no metabolic dysfunction
• Many normal weight people have metabolic

dysfunction

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Obesity and Stigma

• Weight bias = inequities in education, employment,

& healthcare

• Widespread negative stereotypes: “lazy,

unmotivated, lacking discipline, not competent, non- compliant, sloppy”

• Implicit bias tests in providers shows strong

preference for thin

• Obese persons are less likely to undergo

recommended cancer screening

Obesity and Stigma

• 68% of women with BMI > 55 reported delaying

healthcare because of their weight, and 83% reported that their weight was a barrier to getting care

• Women reported disrespectful treatment and

negative attitudes from providers, embarrassment about being weighed, and too small gowns, exam tables, equipment

Obesity and Stigma

• Language is important
• In one study, patients preferred the term “weight”

to “obesity” or “fat”

• Focus on patients’ chosen behavioral and lifestyle

goals (rather than emphasizing weight measurement as only measure of success)

• Avoid blaming and judgmental statements

“It’s interesting because we recently had someone who was

• ver 400 pounds who got transferred to us because her out-of-

the-city hospital was too terrified of delivering her. They thought if she needed a C-section or whatever it would be impossible to do it and they just didn't want to deal with her . So we induced her and it was just like passing the hot potato. No one wanted to be around. We induced her for days, we sent her home, we brought her back, we induced her some

• more. Because there’s a situation – you may not want to pull

the baby out but you do not want to do a C-section either.”

Stigma – Role of Providers

• Academic CNM, from focus group study

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Stigma – Role of Providers

• It’s our duty as providers and hospitals to

make birth as safe as possible for ALL patients

• If we need different equipment, more

providers/staff, we need push to get these resources rather than blame our patients for having particular needs

• Because as a society we still blame individuals

for having a high body weight, we may be less likely to fight for what is needed to keep our patients safe

Intersection of Race and Obesity

“So what is successful in lowering risk and improving pregnancy outcomes? Years of data that show that successful public health interventions such as Black Infant Health, Nurse Family Partnership and Centering Pregnancy improve birth outcomes. … These programs are built on several principles, including culturally relevant care, peer-to-peer learning, and establishing cohorts among the women. “

https://www.centerforhealthjournalism.org/2018/02/18/what-blame-mother-stories-get-wrong-about-birth-outcomes-among- black-moms

Monica Mclemore, PhD, MPH, RN Assistant Professor School of Nursing, UCSF

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Early Pregnancy Concerns

• Spontaneous abortion & recurrent

loss more common

• Fetal anomalies, esp neural tube

defects

• 20% decrease in detection of

anomalies by ultrasound Early Pregnancy Concerns

• Cell-free fetal DNA screening may result in test

failure or inaccurate result as obese women may have a lower fetal fraction of the cell-free DNA

• First and second trimester serum-based screening

tests are adjusted for maternal weight

• Accurate NT measurement may be more difficult to
• btain

Antepartum Complications

• GDM and DM2
• Chronic hypertension
• Postterm pregnancy

Intrapartum Complications

• Prolonged labor (only first stage)
• Lower likelihood of VBAC success
• Preeclampsia
• Higher rates of cesarean delivery
• Anesthetic complications
• Macrosomia and shoulder dystocia
• Stillbirth

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Postpartum Complications

• Longer hospital stays
• Infections

–Wound infection and endometritis

• Lower rates of breastfeeding

At first prenatal visit

• Screen for DM2 (repeat at 24 wks if neg)
• Measure and record BMI in chart
• Review weight gain goals and strategies with patient
• Discuss MODIFIABLE risks especially re: weight gain
• If concern for CHTN: baseline Cr, 24hour urine, LFTs

Weight Gain During Pregnancy for Obese Women

The IOM Report and Guidelines

IOM Recommendations for Weight Gain in Pregnancy 2009

Pre-pregnancy BMI (kg/m2) IOM Recommended Gestational Weight Gain (kg / lbs) <18.5 (Underweight) 12.5-18 / 28-40 18.5 – 24.9 (Normal) 11.5-16 / 25-35 25.0 - 29.9 (Overweight) 7-11.5 / 15-25 ≥30.0 (Obese) 5-9 / 11-20

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Comparison of weight gain by BMI category between PRAMS 2002-2003, and new IOM guidelines

Does Prenatal Advice on Weight Gain Matter?

• Receiving correct advice about weight gain was

associated with actual weight gain within guidelines;

• Receiving no advice about weight gain was

associated with gain outside guidelines;

• About a third of women report receiving no advice

about how much weight to gain.

Cogswell et al. Obstet Gynecol 1999. Stotland et al. Obstet Gynecol 2005.

What interventions have been tested?

• Traditional diet, exercise, and diet + exercise
• Digital Health
• Meal replacement
• Centering Pregnancy (secondary analysis)

Diet and Exercise Interventions

• Overall, diet, exercise, and diet + exercise interventions in

pregnancy show a modest but significant effect on reducing GWG

• However, many studies (esp in U.S.) show that these interventions

are LESS effective among obese women

• The interventions studied are often not well-described and are

heterogeneous from study to study, so difficult to interpret as a whole

• Not surprisingly, more intensive (and expensive) interventions with

more frequent human interaction seem to be more effective

• Type of diet (eg low glycemic, low fat) seems to be less important

than overall caloric restriction, similar to non-pregnant studies, but little is known about long-term impact on offspring

• Digital Tools (apps) show promise and are widely accessible

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MEAL REPLACEMENT STUDY – Phelan et al The clinical impact was small but statistically significant, and especially impressive given that this intervention (Centering) was not specifically designed to prevent excessive weight gain. The effect was seen among all BMI groups including obese women. The effect persisted at 12 months postpartum

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Behavioral Health – the 5 “As”

• Ask/Assess Ask permission before discussing weight with a patient, and be

non-judgmental. Screen for weight status, obesity-associated comorbid conditions and conditions that may interfere with weight loss, and patient interest in weight management.

• Advise – on risks associated with obesity (avoid “gloom and doom”) and

benefits associated with lower weight gain/improved diet (eg GDM risk)

• Agree – In discussion with provider, patient chooses and sets goals for

behavior change – eg cutting out sugar-sweetened drinks

• Assist – suggest resources (apps, online tools), provide support
• Arrange – Follow-up visits. A consistent predictor of weight loss progress is

having regular, ongoing interaction with provider or group. Kahan et al. The Role of Behavioral Medicine in the Treatment of Obesity in Primary Care. Med Clin N Am 102 (2018) 125–133 https://doi.org/10.1016/j.mcna.2017.09.002

Behavioral Health – Evidence- Based Techniques for long-term weight maintenance

• Self-monitoring and self-weighing
• Reduced calorie intake - most dietary patterns intended to reduce caloric intake lead to

near-equivalent weight loss magnitude (low fat vs low glycemic/low carb)

• Smaller and more frequent meals/snacks throughout the day
• Increased physical activity, which has some contribution to initial weight loss but has been

shown to be one of the most consistent predictors of long-term weight loss maintenance

• Eating breakfast
• More frequent at-home meals compared with restaurant and fast-food meals
• Reducing screen time
• Use of portion-controlled meals or meal substitutes
• Reducing sweetened beverage intake

Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr 2005; 82(1 Suppl):222S–5S. Thomas JG, Bond DS, Phelan S, et al. Weight-loss maintenance for 10 years in the national weight control registry. Am J Prev Med 2014;46(1):17–23. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr 2001;21: 323–41.

Fetal growth

• Obese women at increased risk for both SGA and

LGA, so growth US usually recommended for BMI 40

• r higher. Can begin at 28 weeks and individualize

based on baseline exam and risk factors.

• Fundal heights and Leopold can generally be done as

usual

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Antenatal Testing

• Increased stillbirth risk in obese women
• No RCT to support or refute benefit of

antenatal testing, but many recommend it

• At SFGH we start weekly NST/AFI at 36 weeks

for women with BMI of 40 or greater

ECV and BMI ECV and BMI

• Success rates don’t drop significantly until BMI 40 or

above

• Offer ECV to women and discuss risks and benefits
• f all options

Intrapartum Managment

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When to deliver?

• No evidence to support nor refute, but we offer

induction of labor at 39-40 weeks in women with BMI ≥ 40 if cervix is favorable If induction is not progressing after 24+ hours and maternal/fetal status reassuring (and intact membranes), option to stop induction and either try again in a few days or wait for spontaneous labor

• Retrospective cohort study showed
• reduced risk of cesarean delivery and

macrosomia among obese women undergoing elective IOL 37-39 weeks versus expectant management

• RCT needed to address this question especially

neonatal risks

“Trial of Induction”

• Unpublished cohort study, UCSF
• Women sent home after failed IOL, reassuring

maternal and fetal status and no urgent indication for delivery

• ~70% ultimately delivered vaginally
• ~23% came in later in spontaneous labor, the rest

came back for second induction attempt

• This is our approach to BMI >= 40

On admission to L&D

• Consult anesthesia on admission (or prior)
• Place internal monitors if needed
• Assess IV access
• Prepare for shoulder dystocia, especially if

GDM/DM2 or suspected macrosomia

• Staffing considerations

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Cesarean with BMI >= 40 Preparing for cesarean

• 20-degree Left lateral tilt is even more important because of

the added weight of the abdomen, but,

• The tilt puts the midline far from the operating surgeon and

is ergonomically challenging

• Retraction of the abdomen with Traxi and/or extra surgical

assistants

• Retraction of the extremely large apron can cause

hypotension, difficult ventilation, and fetal compromise

• If patient can tolerate or is intubated, some degree of

Trendelenberg can help with retraction

Cesarean – type of incision and closure?

• No randomized trial of incision type; no evidence that

vertical skin is preferable – choose based on surgeon’s preference

• When there is a great amount of overhanging abdominal

tissue, a supra-umbilical incision may be considered – transverse or vertical

• Some evidence that vertical incisions are associated with

more pain and poorer healing, but study results are mixed

• Vertical incisions may increase the risk of classical uterine

incision if access to LUS is limited

Traxi Retractor

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Supraumbilical Incision

Cesarean – type of incision and closure?

• Pre-op antibiotics – at least 2g cefazolin IV
• Subcutaneous sutures decrease risk of seroma, but not good

evidence in BMI ≥ 50

• Drains not shown to provide benefit and may increase

infection

• Staple vs. suture – ongoing clinical trial in obese women, but

current evidence suggests some benefit of suture over staples

• If staples uses, delayed removal may improve outcomes

Prevent difficult extraction of infant

• Make all incisions larger than usual – skin, fascia,

and uterus, especially if repeat CS

• Have vacuum available since fundal pressure may be

difficult to apply

• Station of presenting part may be lower than it feels

DVT Prophylaxis for CS?

• Women with BMI > 35 should receive in-hospital

post CS pharmacologic prophylaxis

• See Dr. Druzin’s talk for more details on BMI and

VTE prophylaxis

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Emergency Cesarean BMI ≥ 40

Need to plan for extra time to

• move patient to OR table
• induce anesthesia, and
• do the surgery

All will take longer, so have to move earlier to C/S especially for fetal indications

BMI<30 9 minutes BMI 30-39 11 minutes BMI 40-49 13 minutes BMI >=50 16 minutes Incision to Delivery Time Increases with Increasing BMI

Length of labor

• First stage of labor takes longer among obese

women

• As long as maternal and fetal status

reassuring, may tolerate a slower labor curve in obese patient

• Second stage length NOT

associated with BMI (nullips)

Why are cesarean rates so high among

• bese women?
• Much of this may be iatrogenic
• Obese women should be given a chance for a safe

vaginal birth

• Allow labor to take longer
• Provide continuous labor support (doulas)
• Obesity alone should not “risk a woman out” for

midwifery or birth center delivery

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Previous C-section: Balancing Risks

TOLAC vs. Planned Repeat? The patient should decide based on her values and an informed discussion Advantages of vaginal birth VS. Risks of unplanned c-section

Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery: Failed TOL 15.2% in normal weight (1,344) vs 39.3% in BMI 40 or above (1,638) Combined risk of rupture/dehiscence increasing from 0.9% to 2.1% in morbidly obese women. HOWEVER, 60% of women with BMI 40 or above had successful VBAC!

What can we do to reduce risks?

• While higher pre-pregnancy BMI is associated with a number of adverse
• utcomes, it is not a modifiable risk factor once a woman is pregnant
• It’s unclear to what degree it is harmful or beneficial to emphasize

dangers of elevated weight once a woman is pregnant – compare how we counsel women with other risk factors

• Stigma and being judgmental may result in delay in care >> poor
• utcomes
• In RCTs to prevent excessive weight gain, not much evidence of

improvement of outcomes other than weight gain itself

• Identifying DM2 and GDM is one area where we can improve outcomes
• Avoid unnecessary cesarean birth
• Being prepared, especially on the inpatient unit, is one of the most

important ways we can reduce risks

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Parting Quote

• “Trust us, especially recognize we’re the experts in
• ur own bodies…No, I’m not a doctor but I have a

body and I’ve done this before.” - Focus group participant

To contact me: Naomi.Stotland@ucsf.edu