Professional Documents
Culture Documents
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10.1576/toag.11.1.25.27465 www.rcog.org.uk/togonline
2009;11:2531
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Key content:
Prepregnancy obesity is increasingly common.
More than half of all women who died from direct or indirect causes in the
200305 report, Saving Mothers Lives, were overweight or obese.
Obese mothers have an increased risk of complications.
Learning objectives:
To learn about the increased incidence of miscarriage, congenital malformation
and metabolic complications.
To learn about the increased risks of intrapartum complications.
Ethical issues:
Should medical assistance to conceive be withheld until BMI!35?
More of the healthcare budget should be spent on prevention rather than
treatment of obesity.
Keywords congenital abnormality / deep vein thrombosis / gestational diabetes
mellitus / hypertension / perinatal mortality
Please cite this article as: Stewart FM, Ramsay JE, Greer IA. Obesity: impact on obstetric practice and outcome . The Obstetrician & Gynaecologist 2009;11:2531.
Author details
Frances M Stewart MD MRCOG
Consultant, Obstetrics and Gynaecology
Antrim Area Hospital, Bush Road, Antrim,
County Antrim BT41 2RL, UK
Email: francesstewart1@hotmail.com
(corresponding author)
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Introduction
The 200305 report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom1
highlighted obesity as a significant risk for
maternal death. More than half of all women who
died from direct or indirect causes were either
overweight or obese.
For the mother, obesity increases the risk of
obstetric complications during the antenatal,
intrapartum and postnatal period, as well as
contributing to technical difficulties with fetal
assessment (Box 1). The offspring of obese mothers
also have a higher rate of perinatal morbidity and
an increased risk of long-term health problems.
26
Prepregnancy
Early pregnancy
Antenatal
Pregnancy-induced hypertension,
pre-eclampsia, gestational diabetes,
venous thromboembolism
Intrapartum
Postpartum
Fetal
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Box 2
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BMI # 30
Previous gestational diabetes
Previous macrosomic baby "4.5 kg
Family history of diabetes (first-degree relative with type 1
diabetes)
Belonging to a high-risk ethnic group, including:
South Asian (Indian, Pakistani, Bangladeshi)
Black Caribbean
Chinese
Intrapartum issues
Obesity and diabetes are independently associated
with adverse pregnancy outcomes. Rosenberg
et al.29 undertook a large population-based study.
Data were collected from the 1999, 2000 and 2001
New York City birth files for 329 988 singleton
births, containing information on prepregnancy
weight and antenatal weight gain. During
pregnancy, obese women are at increased risk of
several adverse perinatal outcomes, including
28
Postpartum issues
It is now recognised that adipose tissue produces a
variety of bioactive peptides, collectively termed
adipokines. Alteration of adipose tissue mass in
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obesity affects the production of most adiposesecreted factors: there is an increase in several
adipokines. Increased levels of angiotensinogen
have been implicated in hypertension; PAI-1 in
impaired fibrinolysis; and acylation-stimulating
protein, tumour necrosis factor-alpha, interleukin-6
and resistin in insulin resistance.38 Pregnancy is a
prothrombotic state, secondary to an increase in
activity of coagulation factors XII, X and VIII, as
well as fibrinogen.39 In the puerperium, deep
venous thrombosis, endometritis, postpartum
haemorrhage, prolonged hospitalisation and
wound infection and dehiscence are also seen with
increased frequency in obese women.37
The leading cause of maternal mortality remains
venous thromboembolism and the postpartum
period is the time of greatest risk, secondary to
vascular damage at childbirth. The coagulation
cascade is activated by inflammatory cytokines
causing endothelial activation and this is further
increased with obesity. Several studies have shown
that obese patients have higher plasma
concentrations of all prothrombotic factors
(fibrinogen, von Willebrand factor [VWF] and
factor VII), compared with non-obese controls,
with a positive association with central fat.40 It has
been proposed that the secretion of interleukin-6
by adipose tissue, combined with the actions of
adipose tissue-expressed tumour necrosis factoralpha in obesity, could underlie the association of
insulin resistance with endothelial dysfunction,
coagulopathy and coronary heart disease.40
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Cost implications
In 2000, a prospective study46 examined the cost of
care of 435 women seen consecutively within their
obstetric service. The average cost in terms of
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Conclusion and
recommendations
It is essential that obstetricians have guidelines for
management of the obese woman. Obesity is a risk
factor for both gynaecological and obstetric
complications. A multidisciplinary approach to
management is necessary to decrease the risks of
morbidity and mortality. There are a number of
recommendations for clinical management prior to
and during pregnancy:
Provide prepregnancy counselling for morbidly
obese women (in primary care/subfertility/
recurrent miscarriage/diabetic clinics).
Consider high doses of folic acid (5 mg).
A healthy diet and exercise are important in
pregnancy: refer to a dietician, advise to avoid
excessive weight gain, consider screening for
diabetes.
Provide an early booking visit to plan pregnancy
management.
Prescribe low-dose aspirin in the presence of
additional clinical risk factors for pre-eclampsia.
Consider antenatal thromboprophylaxis if there
are additional clinical risk factors for venous
thromboembolic disease.
Recommend a detailed anomaly scan and serum
screening for congenital abnormality.
Consider glucose tolerance testing at 28 weeks,
with the potential for repeating it in later pregnancy.
This group of women requires both primary and
secondary care intervention if we are to limit or
even reverse the epidemic of obesity within Western
society.
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