Obesity, O&G and RiskObesity, O&G and Risk

Diana Hamilton-FairleyDiana Hamilton-FairleyConsultant Obstetrician and GynaecologistConsultant Obstetrician and Gynaecologist

Guys and St. Thomas’ NHS Foundation TrustGuys and St. Thomas’ NHS Foundation Trust

AimsAims

Obesity is a public health issueObesity is a public health issue Impact of obesity on women’s healthImpact of obesity on women’s health Weight loss does make a differenceWeight loss does make a difference Clinicians have a powerful role to playClinicians have a powerful role to play

Health RisksHealth Risks

Which of these is the greatest risk to health?

RiskRisk

The possibility of The possibility of suffering harm or loss; suffering harm or loss; danger. danger.

A factor, thing, element, A factor, thing, element, or course involving or course involving uncertain danger; uncertain danger;

The danger or probability The danger or probability of loss to an insurer. of loss to an insurer.

One considered with One considered with respect to the possibility respect to the possibility of loss: of loss: a poor risk.a poor risk.

The EpidemicThe Epidemic

““Child obesity has Child obesity has doubled in a decade”doubled in a decade”

21% increased risk of 21% increased risk of cancer in girlscancer in girls

Double the risk of Double the risk of dying before 50dying before 50

0

5

10

15

20

25

30

1995 2004

GirlsBoysAdults

Reproductive Years – Obesity, Reproductive Years – Obesity, Hirsutism and MenstruationHirsutism and Menstruation

0

10

20

30

40

50

60

70

80

Hirsutism Regular Oligo Amen

Lean

Obese

P<0.01 P<0.01

%

PCOS

ImplicationsImplications

AnovulationAnovulation MenorrhagiaMenorrhagia Endometrial HyperplasiaEndometrial Hyperplasia AnaemiaAnaemia

Hirsutism / AcneHirsutism / Acne Psychological impactPsychological impact

Obesity and Ovulation inductionObesity and Ovulation induction

0

10

20

30

40

50

60

70

80

90

Ovulation Pregnant Miscarriage

Lean

Obese

P<0.02 NS P<0.01

Obesity and MiscarriageObesity and Miscarriage

Risk of miscarriage before a live birth in Risk of miscarriage before a live birth in 13,123 consecutive pregnancies13,123 consecutive pregnancies

BMI

19-25

25-29

>29

1

1.42

2.06

Reproductive Years Reproductive Years Pregnancy - Pregnancy - Gestational DiabetesGestational Diabetes

96 801 Nulliparous women96 801 Nulliparous womenPrepregnancy weightPrepregnancy weight

Baeton et al.2001 Am J Pub Health 91;436 - 439

BMI

19-25 (71.7%)

25-29.9 (18.2%)

>30 (10.1%)

1

2.4

5.2

Pre-eclampsia and EclampsiaPre-eclampsia and Eclampsia

BMI

19-25

25-29.9

>30

1

2.0

3.3

Baeton et al.2001 Am J Pub Health 91;436 - 439

Delivery at <32 weeksDelivery at <32 weeks

BMI

19-25

25-29.9

>30

1

1.3

1.5

Baeton et al.2001 Am J Pub Health 91;436 - 439

Caesarean DeliveryCaesarean Delivery

BMI

19-25

25-29.9

>30

1

1.8

2.7

Baeton et al.2001 Am J Pub Health 91;436 - 439

Other increased risks in Other increased risks in pregnancypregnancy

Congenital abnormalityCongenital abnormality 3 fold3 fold ThromboembolismThromboembolism 12 fold12 fold Failed Trial of LabourFailed Trial of Labour 87% vs 20-87% vs 20-

40%40%

Shoulder Dystocia and neonatal Shoulder Dystocia and neonatal injuryinjury

BMI > 30kg/m2

Second stage >20 mins Birthweight > 4.5kg

Mehta et al. 2006 J Perinatology 26;85-8

Infant DeathInfant Death

BMI

19-25

25-29.9

>30

1

1.5

2.0

Baeton et al.2001 Am J Pub Health 91;436 - 439

Mean maternal glucose concentrations and infant Mean maternal glucose concentrations and infant mortalitymortality

Obese ParentsObese Parents

Increase the risk of obese childrenIncrease the risk of obese children– Increased risk of early onset Type 2 DMIncreased risk of early onset Type 2 DM– Increased risk of metabolic syndromeIncreased risk of metabolic syndrome

Glucose intolerance, raised VLDL, Decreased HDL, Glucose intolerance, raised VLDL, Decreased HDL, Hypertension, Increased risk for cardiovascular Hypertension, Increased risk for cardiovascular diseasedisease

– Increased risk of cancerIncreased risk of cancer

Increased risk of dying before children reach Increased risk of dying before children reach adulthoodadulthood

Disease for which Obesity is a Disease for which Obesity is a risk factorrisk factor

DiseaseDisease RiskRisk Risk in PCOSRisk in PCOS

DiabetesDiabetes 3.83.8 5 fold5 fold

Cardiovascular Cardiovascular diseasedisease

2.12.1

Stroke > IHDStroke > IHD

0.7 (NS)0.7 (NS)

HypertensionHypertension 5.65.6

Endometrial Endometrial CancerCancer

3 – 10 fold3 – 10 fold DependsDepends

Risk factors in endometrial cancerRisk factors in endometrial cancer

RiskRisk Fold riskFold risk

ObesityObesity 3 - 103 - 10

NulliparityNulliparity 22**

Late MenopauseLate Menopause 2.42.4**

““bloody bloody menopause”menopause”

44**

DiabetesDiabetes 2.82.8**

HypertensionHypertension 1.51.5**

Unopposed E2Unopposed E2 9.5 9.5

Complex Complex HyperplasiaHyperplasia

2929**

Risk of SurgeryRisk of Surgery

Obesity increases your risk of needing a Obesity increases your risk of needing a HysterectomyHysterectomy– Infection 15.3% vs 11.3% (p<0.01)Infection 15.3% vs 11.3% (p<0.01)– Bleeding no differenceBleeding no difference– Increased duration of surgeryIncreased duration of surgery– Increased LOSIncreased LOS

Manual Handling Manual Handling Surgical difficultySurgical difficulty

Weight lossWeight loss

Obesity and PCOSObesity and PCOS

0

10

20

30

40

50

60

70

80

90

Menses Fertility Hirsutism

>5%

<5%

Does weight loss treat symptoms?Does weight loss treat symptoms?

Does weight loss improve Does weight loss improve outcomeoutcome

In pregnancy reduces In pregnancy reduces Congenital abnormalityCongenital abnormality MiscarriageMiscarriage GDM, macrosomiaGDM, macrosomia Pre-eclampsiaPre-eclampsia PrematurityPrematurity Caesarean sectionCaesarean section

PostpartumPostpartum Type 2 DMType 2 DM HypertensionHypertension Cancer (Endometrial)Cancer (Endometrial)

Treatment algorithm for obesityTreatment algorithm for obesity

What is our role?What is our role? Young fit women - INFORMATIONYoung fit women - INFORMATION Actively treat obesity in gynaecology and Actively treat obesity in gynaecology and

subfertility clinicssubfertility clinics Pre-conception obesity clinicsPre-conception obesity clinics Pregnancy advice on weight gainPregnancy advice on weight gain Postpartum follow-up and supportPostpartum follow-up and support

Obesity is a Public Health Obesity is a Public Health IssueIssue

We all have a role to play in We all have a role to play in reducing the risksreducing the risks