Obesity in Pregnancy

Optimizing care through evidence,

education and support

Interprofessional work group created guidelineAnn Forster Page, DNP, APRN, CNM, FACNM

Lisa Gill, MD, MFM

Allison Welle, RN, BSN, Nurse-Midwife DNP student

Credit to other members of the work group:

Katherine Jacobs, MD, MFM

Samantha Hoffman, MD, FACOG

Sabrina Burn, MD, OB/GYN Resident

Tanya Melnik, MD, IM

No Disclosures

Objectives1. Define appropriate preconception and early pregnancy screening for women with

obesity.

2. Identify techniques to optimize communication when discussing evidence-based

recommendations for a healthy pregnancy with women with obesity.

3. List antenatal fetal screening recommendations for pregnant women with obesity.

4. Discuss evidence-based recommendations for preparation for labor and birth and

timing of delivery for pregnant women with obesity.

5. Describe risks and preventative measures during the postpartum period for pregnant

women with obesity.

Prevalence

❏ Of women aged 20-39, 40% have a BMI of > 30 in the US

❏ Prevalence is higher in non-Hispanic black and Hispanic women

❏ Number of women with obesity has continued to rise in the US over the past 45

years

Maternal risksPregnancy loss

Gestational diabetes

Gestational hypertension

Preeclampsia

Anxiety

Depression

Obstructive sleep apnea

Increased gestational weight gain

Labor induction

Cesarean birth

Surgical site infections

Neonatal risksCongenital anomalies

Stillbirth

Preterm birth

LGA

Shoulder dystocia

NICU admission

Lower breastfeeding initiation

Early breastfeeding cessation

Neonatal hypoglycemia

Increased risk of obesity in adulthood

What does maternity care look like for providers and patients with obesity?

Experiences of Pregnant Women with Obesity ❏ Most receive no counseling on gestational weight gain

❏ Desire advice on gestational weight gain

❏ Lack of information leads them to look to other sources for information

❏ Many falsely believe that there were no increased risks to pregnancy or that there

was nothing they could do to minimize risks

❏ Contributes to disappointment in their prenatal care

❏ Can sense provider’s discomfort discussing topic

❏ Vulnerable to judgemental care from practitioners

❏ 19% would avoid future appointments, 21% would seek a new provider (Puhl,

2012)

Experiences of Providers❏ Typically avoid conversation about weight

❏ Wait for patient to bring it up or look for cues from patient

❏ Brought up too late after patient has already gained weight

❏ When it is discussed, tend to give guidelines not consistent with Institute of

Medicine

❏ Key barriers identified by providers:

❏ Lack of knowledge

❏ Negative consequence of intervening

❏ Lack of resources

Techniques to Optimize Communication

Person Centered Language

Open the conversation- Ask for permission to discuss

- Let them tell their story

Word choice- ‘Weight’

- ‘Unhealthy weight’

- ‘BMI’

Use motivational interviewing

- Find out goals, motivations

- Teachable moment

Culturally appropriate suggestions

- Consider finances,

transportation, favorite foods,

etc.

Be aware of your bias❏ Harvard’s Project Implicit

❏ https://implicit.harvard.edu/implicit/selecta

test.html

❏ Obesity Action Coalition

❏ https://4617c1smqldcqsat27z78x17-wpengi

ne.netdna-ssl.com/wp-content/uploads/We

ight_Bias_in_Healthcare_9_12_17-without-

bleed.pdf

Replace judgement with intellectual curiosity

Gestational Weight Gain

Recommended weight gain during pregnancy should be based on

weight at first visit if care is initiated during 1st trimester

Gestational Weight Gain❏ Many women exceed gestational weight gain recommendations

❏ New research shows lower risks for mothers and babies with these guidelines:

❏ No association between low gestational weight gain or weight loss with low birth weight

or small for gestational age neonates and NICU admissions (Bogaerts, Ameye, Martens, & Devliege, 2015)

❏ DIFFERENT than other previous studies showing a positive correlation between

weight loss and SGA

BMI 30-34.9 11-20 lbs

BMI 35-39.9 2-11 lbs

BMI 40+ No weight gain is optimal

(Faucher & Barger, 2015)

Exercise and Diet❏ Exercise is SAFE

❏ No increased risk of preterm birth with vigorous exercise (Wang et al., 2017)

❏ Regular, vigorous exercise provides health benefits

❏ Does seem to be associated with decreases in GWG and lower risk of GDM, C/S,

and macrosomia

❏ Poorly used interventions and high drop-out rates

❏ No specific diet shown to decrease GWG in patients with obesity

❏ Dietary interventions appear to benefit women with a normal or overweight BMI

but might not be sufficient to prevent adverse perinatal outcomes in women with

obesity

The Guideline

1st Trimester❏ 1st trimester dating ultrasound recommended

❏ Discuss neonatal risks and genetic screening options

❏ Early GCT by 12 weeks

❏ Add Hgb A1C with new OB labs

❏ Refer to nutritionist or counsel on food choice

❏ Consider Vit D levels and supplements

❏ Consider 5mg dosing for folic acid

❏ Screen for obstructive sleep disorder, consult or referral

❏ CNM practice inclusion considerations

Educational Handout for

Patients

Sleep Apnea Evaluation

Referral for sleep study: home study vs in clinic overnight

BMI ≥ 30 plus one:

- Snoring

- Observed apnea

- Hypertension

Condition Odds Ratio (95%

CI) with obesity

GDM 4.13 (3.54-4.82)

Preeclampsia 5.32 (4.43-6.37)

Pulmonary

Embolism

14.06 (6.10-32.4)

Cardiomyopathy 19.12 (15.12-24.18)

Hospital stay > 5

days

3.07 (2.59-3.63)

In hospital

mortality

7.84 (3.28-18.74)

Modified STOP

2nd Trimester

❏ Anatomy survey

❏ GCT and other routine labs

❏ Track weight gain, review weight tracking graph in epic with

patient

❏ Discuss and encourage exercise, yoga, walking

❏ Positive reinforcement!

3rd Trimester❏ Return OB visits q 2wks starting at 28 wks

❏ Consider growth and presentation check us at 32- 36 wks

❏ Recommend weekly antenatal testing at 36 wks for BMI ≥ 40

❏ Consider Anesthesia consult BMI ≥ 35

❏ Discuss considerations for labor:

❏ Impact for success of TOLAC

❏ IV access in labor, AMTSL, increased risk for PPH

❏ Intermittent Auscultation: criteria excludes IA with a BMI ≥ 35

❏ Many waterbirth guideline criteria excludes BMI ≥ 35

❏ Induction of labor should be offered at 39 weeks gestational age for women with a BMI

≥ 40.

❏ VTE prevention plans

Labor and Birth❏ Encourage upright and mobility

❏ Recognized possible slower progress

❏ EFM; Monica telemetry prefered, consider IUPC if unable to pick up

contractions.

❏ Anesthesia early consult on admission in labor: airway evaluation and discussion

for BMI ≥35

❏ shoulder dystocia and PPH increased risk

Operating Room:

❏ Have “Traxi” (pannus retractor) available

❏ Ancef 3gm

❏ 0-PDS for fascial closure

Postpartum, 0-7 days❏ Increased breastfeeding support

❏ VTE prevention

❏ Pharmacologic anticoagulation should be considered in women with BMI ≥30

admitted antepartum for an expected stay of 72 hours or more.

❏ All women with a BMI ≥ 35 undergoing cesarean delivery for any indication

should receive pharmacologic anticoagulation within 24 hours of delivery for

the course of their hospitalization.

❏ All women with BMI ≥ 40 undergoing vaginal delivery with an anticipated

hospital stay of 72 hours should receive pharmacologic thromboprophylaxis for

the duration of their postpartum hospitalization.

Postpartum, 1-8 weeks❏ 2 hr GTT as needed

❏ Encourage appropriate return to exercise

❏ Refer to weight management clinic as appropriate

❏ Refer to Internal Med if other comorbidities exist, i.e. hypertensive disorders

❏ Birth control: consider decreased efficacy of OCP

Ultrasound in Obesity

Ultrasound in obesity• Miss rate for anomalies increases up to 20% in obesity

• Detection rate improves with gestational age (up to a point)

• Consider anatomic survey at 20 weeks to optimize detection

rate

Stillbirth rates• At all gestational ages, pregnancy loss is higher in obese

women

• “Dose-dependent”

• Mechanism is not well understood

What risk is too much?

To test or not to test?❏ No consensus

❏ Does not appear to cause increased risk of iatrogenic

early delivery (<39 weeks) or cesarean delivery

❏ No clear evidence that antenatal testing improves

outcomes

Recommendation• ⩾

•••

Delivery timing❏ Again…..no consensus

❏ Decision analyses and cost effectiveness studies

recommend delivery at 39 weeks

❏ No randomized controlled trials for obese women to

date

But….❏ Increased risks exist for

❏ Failed induction

❏ Cesarean delivery (vs spontaneous labor)

❏ Wound infection

❏ Prolonged wound healing

❏ VTE with prolonged hospitalization

Recommendation● Women with class 3 obesity (BMI ⩾ 40) should be offered induction of labor in

the 39th week of gestation

○ Why?

■ Stillbirth risk begins to rapidly increase

■ Neonatal death rate falls below the stillbirth rate

● Compared with expectant management, IOL has a lower cesarean rate at 39 weeks

○ Decision analysis data

■ Improved cesarean rate, decreased health care costs with IOL at 39 weeks for obese patients

Gill et al. J Mat Fet Neonat Med. 2017

VTE Prophylaxis❏ VTE risk increased 2-3 fold in obese women

❏ New guidelines from California recently published

❏ Cesarean or

❏ Vaginal delivery

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CMQCCCalifornia

Maternal

Quality

Care Collaborative

2017

Questions

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