Prepregnancy History Taking

Pre-conceptual counseling
Preparing, Education and Optimizing Health

Is counseling the same to everyone?

Tailoring the preconception intervention to the patients need.
Genetic disorders Financial and social welfare Domestic violence Maternal psychiatric illnesses

Klerman LV, Jack BW, Coonrod DV, et al. The clinical content of preconception care: care of psychosocial stressors. Am J Obstet Gynecol 2008; 199:S362. Bennett, RL. The practical guide to the genetic family history. New York: John Wiley, 1999.

Recommendations from the CDC

Folic acid supplementation Stop smoking and alcohol Treatment of medical conditions(asthma, diabetes, hypertension, obesity) Review of drugs Avoiding exposure to toxic and infectious agents
Centers for Disease Control and Prevention (CDC). Folic Acid: Frequently Asked Questions. Updated 1/30/08.

Obesity and pregnancy

WHO defines obesity as 30 Kg/m2 and above. Most studies show that BMI>27 is associated with subfertility. A BMI of 18.5 to 25 kg/m2 is associated with little or no increased health risks. The Institute of Medicine recommends a normal BMI prior to conception.
1. van der Steeg JW, Steures P, Eijkemans MJ, et al. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Hum Reprod 2008; 23:324. 2. Gesink Law DC, Maclehose RF, Longnecker MP. Obesity and time to pregnancy. Hum Reprod 2007; 22:414.

Weight reduction
Reducing calorie intake Increasing calorie expenditure

Referral Criteria

 Malaysia- Clinical Practice Guidelines (CPG) has nothing about obesity and pregnancy Australia State Dependent Victoria- More with regards to the facilities and its capabilities
Capability Framework for Victorian Maternity & Newborn Services (2010) provides a guideline that assesses and determines capability of organisations with regards to the ergonomics of the organisations, the facilities, the workforce capabilities as well as transfer of care.

Obstetric/Gynaecology Nutrition Handbook- lists that excessive weight gain during pregnancy as well as prepregnancy obesity are also referral criteria for nutrition consultation.

National Health Service (NHS)

Emphasizes on weight loss through two programs: Fit moms- a free five week lifestyle modification programme in managing weight gain during pregnancy. The referral criteria are pregnant women who have a prepregnancy BMI of 30+. Patients can refer themselves or be referred by their healthcare professionals. Post Natal Size Down- a free 6 weeks weight loss course for women who had a baby in the past three years. The referral criteria are women of childbearing age who have to lose excess weight after childbirth. Patients can refer themselves or be referred by their healthcare professionals.

Pre-pregnancy, antenatal and postnatal care pathway for women with obesity (CMACE & RCOG Joint Guideline)

Risk of obesity in pregnancy

Antepartum issues

Miscarriage in ART
Controversial Meta-analysis of 12 studies: obese women had higher odds of miscarriage, regardless of method of conception (spontaneous/assisted) (OR 1.67, 95% CI 1.25-2.25)
Does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? A meta-analysis of the evidence. Metwally M, Ong KJ, Ledger WL, Li TC. Fertil Steril. 2008;90(3):714.

Higher risk of developing certain conditions?

Gestational diabetes Gestational hypertension and pre-eclampsia
Maternal weight and BMI independent risk factors Review of 13 cohort studies: Risk of PE doubled with each 5-7kg/m2 increase in prepregnancy BMI
Maternal body mass index and the risk of preeclampsia: a systematic overview. O'Brien TE, Ray JG, Chan WS. Epidemiology. 2003;14(3):368.

Obstructive sleep apnoea Venous thromboembolic disease

UKOSS case-control study: antenatal pulmonary thromboembolism OR 2.65 (95% CI 1.09-6.45)

Issues in pregnancy
Multifetal pregnancy
Increased dizygotic twin gestation Attributed to elevated FSH levels

Antepartum stillbirths
Rapid fetal growth (hyperinsulinaemia) + functional limitation of placenta to transfer sufficient oxygen to meet fetal requirements hypoxia and death 3-fold increase in morbidly obese women
Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 2004;103:21924.

Maternal and fetal surveillance

Need for appropriate size of arm cuff for BP measurements
Study of 1240 adults: differences in readings smallest in non-obese progressively greater with increasing arm circumference in obese population Less error if use too large than too small a cuff
Maxwell M, Schroth P, Waks A, Karam M, Dornfeld L. Error in bloodpressure measurement due to incorrect cuff size in obese patients. The Lancet 1982;320(8288):33-36.

Potential for poor ultrasound visualisation of baby difficulty in fetal surveillance and anomaly screening

Intrapartum and postpartum issues

Labor
Longer progress of labor Mainly 1st stage of labor
Vahratian et al. 612 nulliparous women at term pregnancy who were overweight and obese

Robinson et al. concluded that there is no increase in the time of 2nd stage of labor
BMI 18.5-24.9 25.0-29.9 >30
1. 2.

Time taken from 4-10cm 6.2 hours 7.5 hours 7.9 hours

Vahratian, Zhang, Troendle, Savitz Da, Siega-riz Am. Maternal prepregnancy overweight and obesity and the pattern of labor progression in term nulliparous women. Obstet Gynecol 2004; 104(5 Pt 1):943. Robinson, Mapp, Bloom, Rouse Dj, Spong Cy, Varner Mw et al. Increasing Maternal Body Mass Index and Characteristics of the Second Stage of Labor. Obstet Gynecol 2011; 118(6):1309-1313

Induction of labor
More induction in obese women, and also higher rate of failure Wolfe & Gross. The effect of maternal obesity on the rate of failed induction of labor
28% normal weight vs 34% in class III obese women (BMI >40) Failure rate: 13% vs 29%

1.

Wolfe HM, Gross TL. Obesity in pregnancy. Clin Obstet Gynecol 1994; 37:596.

Vaginal birth after cesarean section (VBAC)

Higher rate of failure and adverse outcomes Hibbard et al. on a Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery
Outcomes Failed trial of labor Uterine rupture/dehiscence Normal weight women 15.2% 0.4% BMI >40 39.3% 2.1%

Neonatal injuries
Maternal morbidity

0.2%
3.8%

1.1%
7.2%

1. Hibbard JU, Gilbert S, Landon MB, et al. Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery. Obstet Gynecol 2006; 108:125.

Cesarean section
Increased rates and more adverse outcomes Weiss et al. : For nulliparous patients
20.7% for the control group (BMI <30) 33.8% for obese (BMI 30-34.9) 47.4% for morbidly obese patients (BMI >35)

Failure to progress

1.

Weiss JL, Malone FD, Emig D, et al. Obesity, obstetric complications and cesarean delivery rate--a population-based screening study. Am J Obstet Gynecol 2004; 190:1091.

Complications
Outcome Postoperative endometritis Normal weight women 4.9% >300 lbs 32.6%

Blood loss >1000ml

Wound breakdown Prolonged delivery interval Prolonged hospitalizations

9.3%
8% 4.6% 2.3%

34.9%
20% 25.6% 34.9%

Thromoboembolism: Chisaka et al.: Among the patients who went for a cesarean section, 55% were obese (BMI>29)
1. Perlow JH, Morgan MA. Massive maternal obesity and perioperative cesarean morbidity. Am J Obstet Gynecol 1994; 170:560. 2. Chisaka, Utsunomiya, Okamura, Yaegashi N. Pulmonary thromboembolism following gynecologic surgery and cesarean section. Int J Gynaecol Obstet 2004; 84(1):47-53.

Anaesthesia
Higher epidural failure rate
Case-control study of 43 morbidly obese (>300 pounds), 14% vs 0%

Higher incidence of hypotension and prolonged and late decelerations Difficult intubation

1.

Perlow JH, Morgan MA. Massive maternal obesity and perioperative cesarean morbidity. Am J Obstet Gynecol 1994; 170:560.

Other complications
Macrosomia is common in obese women, and macrosomia is a risk factor for shoulder dystocia
Postpartum hemorrhage Malpresentations Trauma and lacerations

Postpartum complications
1. Longer hospitalization
Infections Postpartum hemorrhage

2. Problems with breastfeeding

Failure to initiate Shorter duration

1.

Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics 2004; 113:e465.

Congenital anomalies
Congenital anomalies Spina bifida Neural tube defects Odds ratio 2.24 1.87

Hydrocephaly
Anorectal atresia Limb reduction anomalies Cardiovascular anomalies Cleft palate Cleft lip and palate Septal anomalies

1.68
1.48 1.34 1.30 1.23 1.20 1.20

Obese women do not experience the same benefit of folic acid in preventing NTDs when compared to normal weight women
1. Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009; 301:636.

Other complications
Perinatal mortality
Still births
Overweight women OR 1.47 (95% CI 1.08-1.94) Obese women OR 2.07 (95% CI 1.59-2.74)

Neonatal death due to preterm delivery

Weight
LGA baby Predisposed to obesity

1. Chu SY, Kim SY, Lau J, et al. Maternal obesity and risk of stillbirth: a metaanalysis. Am J Obstet Gynecol 2007; 197:223.

Summary

MANAGEMENT

Pre-pregnancy care
weight reduction support Obesity risks 5mg folic acid/day

Centre for Maternal and Child Enquiries, Royal College of Obstetricians and Gynaecologist. Management of women with obesity in pregnancy. London: Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologist,2010.

Booking visit
BMI 30
Measure BMI Appropriate size BP cuff Consider 75mg aspirin/day Assess thromboembolic risk Referral to consultant obstetrician Obesity risks minimisation Referral to dietician
Centre for Maternal and Child Enquiries, Royal College of Obstetricians and Gynaecologist. Management of women with obesity in pregnancy. London: Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologist,2010.

 BMI 35
Refer to specialist care

BMI 40
Antenatal anaesthesia review

Centre for Maternal and Child Enquiries, Royal College of Obstetricians and Gynaecologist. Management of women with obesity in pregnancy. London: Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologist,2010.

Throughout pregnancy
BMI 30
Assess thromboembolic risk

BMI 35
Monitor for preeclampsia
3 weekly (24-32 weeks) 2 weekly (>32 weeks)

Centre for Maternal and Child Enquiries, Royal College of Obstetricians and Gynaecologist. Management of women with obesity in pregnancy. London: Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologist,2010.

Third trimester
BMI 30
MGTT (24-28 weeks) Breastfeeding advice & support

BMI 40
Remeasure maternal weight Risk assessment

Centre for Maternal and Child Enquiries, Royal College of Obstetricians and Gynaecologist. Management of women with obesity in pregnancy. London: Centre for Maternal and Child Enquiries & Royal College of Obstetricians and Gynaecologist,2010.

Labour and Delivery

Place of delivery
Risk assessment

Intrapartum
Establish early venous access

Available specialists

Consider early epidural

Adequate neonatal services Early anaesthetic consultation
Develop anaesthetic plan

Consider internal fetal monitoring e.g. CTG

Vaginal Delivery
Avoid Induction Of Labour

Caesarean
One dose of prophylactic antibiotics given at time:
1st Generation cephalosporin or ampicillin

Recommend active management of 3rd Stage of labour Consultants/ Specialists at hand to conduct delivery fetal macrosomia/ shoulder dystocia Neonatal/Paeds Specialist

Extra blood products prepared GSH Early alert of OT staff

Preparation of tools and equipment

Type and placement of incision

e.g. incision above panniculus adiposus vertical

Suture subcutaneous layer if >2cm subcutaneous fat

VBAC

Placement of drain*

Postnatal Care and Follow Up

Thromboembolism
Vaginal Delivery C-Section Thrombopropylaxis

BMI>30 Weight >90kg

Age>35 :

3-5 days post delivery with LMW Heparin

BMI>30

Weight >80kg:

before Csection and 3-5 days post C-Section LMW Heparin

Continue for 7 days if 1 risk factor for thrombo embolism

Provide compress ion stockings if 2 additiona l risk factors

Mobilize as early as possible

Breastfeeding
Low initiation and maintenance rate Proper counselling and education: maternal and fetal benefits Initiation and maintenance

Nutrition
Dietary intervention Weight loss regime

Gestational Diabetes
Annual Screening for cardio-metabolic risk factors Repeat test 6 weeks post delivery Normal results: regular follow up to monitor for development of type 2 Diabetes

Lifestyle Intervention and Advice

Future pregnancies
Weight reduction Physical activity Dietary modifications

Alternatives
Bariatric Surgery Pregnancies after bariatric surgery found to have less complications than without