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National Obstetrics Registry (NOR)

Obesity – the epidemic

World Obesity Federation 2015

WHO Overweight and Obesity January 2015


Malaysian Scenario


Obesity Burden

3.4 million deaths, 3.9% of years lost & DALY

Health burdenBMJ OPEN 2014

Lancet 2014, Global Burden of Disease StudyNational Obstetrics Registry (NOR)

Obesity & Pregnancy

BMI risk stratification tool in Obstetrics

ACOG, Committee Opinion 549, January 2013CMACE/RCOG Joint Guideline 2010NICE, weight management public Health Guidance 27, July 2010RANCOG, College Statement C-Obs 49, March 2013


The Obstetrician


Definition of BMI

Centres for Disease Control and Prevention

•Gender

•Age

•Ethnicity BMI


Population specific BMI

Lancet 2004BMJ 2014IDFIFSO- Asia Pacific 2011

Population

specific

references

ASIAN

Specific

references


OBJECTIVES

•Maternal

•Fetal

BMI1)WHO

2) ASIAN

3) Malaysian


METHODS

Cross sectional retrospective cohort study

Dataset is from the National Obstetric Registry of Malaysia (14 major tertiary hospitals nationwide)

Three year study period from 1st January 2010 till 31st December 2012


DEFINITIONS

Inclusion criteria

Booking BMI < 16 weeks

WHO references

ASIAN references 2004

Malaysian references

GDM based on NICE guidelines 2014

Exclusion criteria

Booking >16 weeks of pregnancy

Missing/incomplete data

Multiple pregnancies

IVF pregnancies


The Malaysian BMI range

• 35.5

Obesity

Receiver operating

characteristics

(ROC) curve• 21.6-24.9


METHODS

Total Sample size 399,274 pregnant mothers

WHO MALAYSIAN

Included in study298,642 pregnant mothers

ASIAN


Primary outcomes

Pre-gestational hypertension

Pre-gestational diabetes

Secondary outcomes

Primary Post partum haemorrhage

Shoulder dystocia

Fetal macrosomia

Caesarean section

Outcome Variables

Adjusted for maternal age, parity & ethnicity


STATISTICAL ANALYSIS

Multivariate analysis using logistic regressions

Crude and adjusted odds ratio with respective 95% confidence interval

Paired sample t-test to compare the mean difference between odds ratio


RESULTSNational Obstetrics Registry (NOR)

Pre-gestational diabetes

(n = 2,722)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Overweight Class 1 obesity Class 2 obesity Class 3 obesity

1.59

2.27

3.12

3.76

1.53

2.29

2.8

4.01

1.64

2.41

2.93

4.18WHO ASIAN MALAYSIAN

BMI

21.6


Pre-gestational Hypertension

(n=3,051)

0

2

4

6

8

10

12

14

Overweight Class 1 Obesity Class 2 obesity Class 3 obesity

2.15

3.96

6.32

11.09

1.83

3.54

6.34

10.78

2.53

5.24

8.01


BMI

21.6


Caesarean section

(n=95,085)

0

0.5

1

1.5

2

2.5

3

3.5

4


1.34

1.84

2.59

3.57

1.26

1.68

2.35

3.4

1.33

1.93

2.58



Primary PPH

(n=2,091)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2


1.19

1.53 1.52

1.84

1.25

1.481.62

1.8

1.21

1.44

1.6



Shoulder dystocia

(n=758)

0

0.5

1

1.5

2

2.5

3

Overweight Class 1 Obesity Class 2 Obesity Class 3 Obesity

1.7

2

2.54

1.781.7

2

2.54

1.71.83 1.88

2.612.44

WHO ASIAN MALAYSIAN

BMI

31.5


Fetal macrosomia

(n=5,331)

0

2

4

6

8

10

12


2.28

4.46

8.16

9.93

1.94

4.12

7.85

11.64

1.83

4.1

6.03

9.68

WHO ASIAN MALAYSIAN


Conclusion &

Recommendations

Population specific range is a more sensitive measure

Range for Malaysians

35.5


Strength and limitations

Strength

Sample size

Limitations

Single registry

Retrospective

Underpowered for

anaesthetic complications

and thromboembolism


Acknowledgements

Director General of Health

NOR site co-ordinators

Dr Japaraj Robert Peter

Declaration of interest - NONE


REFERENCES

World Health Organization: Obesity. Preventing and Managing the Global Endemic. Geneva: WHO,

1998

World Health Organization expert consultation. Appropriate body-mass index for Asian populations and

its implications for policy and intervention strategies. Lancet. 2004;363:157–63.

Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M,Beard RW, et al. Maternal obesity and pregnancy

outcome: A study of 287,213 pregnancies in London. Int J Obesity 2001;25:1175-82.

Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and

obese nulliparous women. Am J Public Health 2001;91:436-40.

Steinfeld JD, Valentine S, Lerer T, Ingardia CJ, Was JR, Curry SL. Obesity-related complications of

pregnancy vary by race. J Matern Fetal Med 2000;9:238-41


THANK

YOUNational Obstetrics Registry (NOR)

Extra SlidesNational Obstetrics Registry (NOR)

Incidence

0.7%

8.1%

0.8%

0.5%

23.8%

3.8%

1.3%

0.2%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Pre-existing Diabetes Mellitus (n=2722)

Gestational Diabetes Mellitus (n= 32328)

Pre-existing Hypertension (n= 3051)

Primary Postpartum Haemorrhage (n=2019)

Caesarean section (n=95085)

Instrumental delivery (n=15320)

Fetal macrosomia (n=5331)

Shoulder Dystocia (n=758) Adjusted for maternal age, parity & ethnicity


ROC curve


BMI as a risk stratification

tool in Obstetrics

strong

• Pre-gestational hypertension

• Fetal macrosomia

Moderate

• Pre-gestational Diabetes

• Shoulder dystocia

• Caesarean section

• Primary PPH

Weak• Stillbirth

• Assisted conception


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