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The people in industrialized countries have experienced a dramatic increase in obesity in recent times. Prevalence of obesity has doubled in the last 25 years. In the United States, 17-th on the list of most obese places in the world - average BMI 28.8 Kg/m2, more than 60% of reproductive-age women are overweight and 35% are obese, representing a 70% increase in pre-pregnancy obesity. In Romania, 75th on the list- average BMI is 22.2 Kg/m2, the lowest average BMI in the European Union (9.4% obesity in 2016).  One of three Romanians is overweight, and one of four is obese. There are over 3.5 million obese in Romania. The highest obesity rate is recorded in Moldova, where the percentage is 23.8%. Only 10% of them see a doctor. Only one percent are included in a national obesity education program .
Not all ethnic groups are at equal risk. Of particular concern is the rapid increase in adolescent overweight and obesity. Concordantly, pregnancy obesity rates are also increasing. Obesity is associated with increased morbidity and 6- to 12-fold increase in mortality. Obesity is highly complex in terms of etiology and prevalence. Genetic predisposition, race, socioeconomic status, built environment (e.g., the presence of sidewalks or community design), accessibility of healthy and affordable foods, sleep habits, and geographic region all play a role. Lifestyle changes, which include consuming foods and beverages with a high glycemic index, increased food portion sizes, decreased structured physical activity, and increased screen-based sedentary behavior, have influenced the prevalence of obesity.
An evaluation of dietary intake and exercise habits can provide insight into women at risk. All pregnant women without contraindications should participate in regular exercise. During prenatal visits women should be questioned and advised about their diet and exercise habits. Where available, nutritional
counselling can be a helpful adjunct for women not meeting the weight gain recommendations.
The sonographer’s ability to evaluate fetal structures is largely dependent on maternal size. Approximately 15% of normally visible structures will be sub optimally seen in women with a BMI above the 90th percentile. In women with a BMI above the 97.5th percentile, only 63% of structures are well visualized. Obstetric care providers should take BMI into consideration when arranging for fetal anatomic assessment in the second trimester. Anatomic assessment at 20 to 22 weeks may be a better choice for the obese pregnant patient.
Use all available technical tools improving image quality in obesity: lower transducer emission frequencies; harmonic imaging; compound imaging; speckle reduction filters. Consider approaching the fetus through the four major abdominal areas with least subcutaneous fat: periumbilical area, suprapubic area, right and left iliac fossae. Consider using the transvaginal approach for the assessment of the central nervous system (CNS) in fetuses in vertex presentation.
Gently inform the patient and her partner that obesity will reduce the diagnostic accuracy of the scan. Consider including the BMI value among the demographic data in the report to document the presence or absence of maternal obesity. Report other cofactors of limited acoustic window, such as previous cesarean section (for the scar), twinning and myomata.
The risk of spontaneous abortion is increased in obese women. Lashen et al. identified an odds ratio for spontaneous abortion of 1.2 (95% CI 1.01 to 1.46) for obese women (BMI > 30 kg/m2). The authors also identified an increased risk of recurrent early miscarriages (more than 3 successive miscarriages < 12 weeks’ gestation) in the obese population, odds ratio 3.5 (95% CI 1.03to 12.01). Similar risks have been identified in obese women
undergoing in vitro fertilization treatment .
Pre-gestational diabetes is more prevalent in obese women.
Therefore, testing during early in pregnancy for women with risk
factors is recommended. Obese women are also at increased risk
of developing gestational diabetes (GDM). Not surprisingly, obese
women are also at increased risk of having a macrosomic child.
Physical activity is inexpensive and can significantly reduce the
risk of gestational diabetes. More relevant to the obese population,
they also reported a 34% reduction in the development of
gestational diabetes in women who did not participate in vigorous
exercise but who did participate in brisk walking compared with
those who participated in easy pace walking. Women with GDM
have a 30% chance of developing type 2 diabetes later in life .
The use of antenatal ultrasound to detect fetal macrosomia is
associated with such obstetric interventions as labor induction
and cesarean section. The rate of cesarean section is affected.
Higher cesarean section is more frequent when ultrasound
examination indicates a macrosomic fetus.
The obese abdominal wall may make monitoring more
difficult than in other cases, and of course, the positive predictive
value of antenatal testing (e.g. cardiotocography, nonstress
testing, biophysical profile assessment) is limited. There is no
evidence to support the routine use of internal fetal monitoring
in this population, but it may be more effective in some women.
Monitoring contractions and ensuring adequate labor in obese
women poses a special challenge. Obese women require more
oxytocin in labor. Consider allowing longer first stage of labor
before performing a cesarean for labor arrest. Although most
obstetric care providers rely on manual palpation and/or external
tocometry, the use of an intrauterine pressure catheter may be
advantageous in some cases.
The risk of cesarean section is increased in the obese
parturient. The increase in cesarean section rate may be partly
due to the fact that overweight and obese nulliparous women
have a slower progression of the first stage of labor. When
faced with lack of descent in the second stage of labor, some
practitioners may opt for cesarean section rather than operative
vaginal delivery because of concerns about fetal macrosomia and
shoulder dystocia. This may explain the low rate of operative
vaginal delivery in some series . Obese women undergoing
caesarean section experience more complications, including blood
loss > 1000 mL, increased operative time, increased postoperative
wound infection and endometritis, and need for vertical skin
incision. The obese diabetic women who undergo cesarean
section have an odds ratio for postoperative wound infection of
9.3 (95% CI 4.5 to 19.2), and those who require a vertical skin
incision have a 12% rate of wound complication serious enough
to require opening the incision .
For morbidly obese patients, two standard 50-cm-width
operating tables secured together may be necessary. Specially
constructed wider operating tables would be ideal. Weighing
scales suited for obese patients are necessary not only to measure
weight and evaluate weight gain during pregnancy, but also for
calculating medication dosages. A wider delivery bed that is easy
to move around and that may be used at all stages of delivery,
including cesarean section, without the need to move the patient
into another bed is most useful. Nursing care of obese patients
requires ergonomic adaptation and knowledge about the special
risks involved in caring for these patients. More trained nurses are
necessary to care for morbidly obese patients.
The decision-to-delivery interval may be longer when
an emergent or urgent cesarean section is required in obese
parturient. Causes for this delay may include patient transport
and bed transfer, the time to establish adequate anesthesia, and
the operative time from incision to delivery. The 30-minute rule of
emergency cesarean section is an arbitrary threshold rather than
an evidence-based standard.
In the absence of contraindications, women who have had
their first child by cesarean section are asked to consider vaginal
birth in subsequent pregnancies. The success of vaginal birth after
cesarean section is commonly quoted at 80% . Obese women
are less likely than their lean peers to be successful in delivering
vaginally after previous cesarean section (VBAC). In women with
a BMI > 29 kg/m2 the success rate is 54% to 68% . The success
rate is further reduced in even heavier women. Chauhan et al.
found a 13% VBAC success rate in women >300 lbs (136 kg) .
The risk of thromboembolism is high in obese parturients.
Edwards et al. reported 683 obese women (BMI > 29 kg/m2)
who were matched to 660 normal weight women (BMI 19.8 to
26.0 kg/m2). The incidence of thromboembolism was 2.5% in the
obese women, and only 0.6% in the controls. BMI >30 plus
one additional risk factor qualify for seven days of postpartum
Clexane; BMI >30 plus two additional risk factors require Clexane
antenatally and for 6 weeks postpartum; BMI>40 should be
regarded as already having two risk factors. Clexane dosage
should be calculated by weight:
Early mobilization and T.E.D. anti-embolism stockings are
clinically proven to reduce the incidence of deep vein thrombosis
by up to 50% and to promote increased blood flow velocity in the
legs 138% of baseline by compression of the deep venous system.
Maternal obesity is also an established risk factor for stillbirth.
The reported risk of stillbirth is 2-5 times higher in obese compared
with normal-weight women. The risk of stillbirth associated with
obesity increases with gestational age. Infant mortality rates
increase from 2.4/1000 among normal weight women (BMI
18.5-24.9) to 5.8/1000 among women with grade 3 obesity (BMI
≥ 40.0). Maternal overweight and obesity are associated with
increased risks of infant mortality due to increased mortality risk
in term births and an increased prevalence of preterm births.
Maternal obesity may increase the risk for intellectual disability or
cognitive deficits in offspring from 1.3- to 3.6-fold. Maternal prepregnancy
obesity and high gestational weight gain of > 18 kg was
associated with a 3-fold increase in offspring IQ deficit (mean of
6.5 points lower) . The majority of studies that have examined
a link between high maternal BMI and childhood diagnosis of
autism spectrum disorders have found a significant positive
association. This risk may be further augmented by intrauterine
growth restriction (IUGR), preterm birth, high gestational weight
gain, gestational or pre-gestational diabetes, and preeclampsia
A national information campaign is required to exploit
women’s interest in having as healthy a pregnancy as possible
by giving them the information they need to become fit and
have a normal BMI before they consider pregnancy. Periodic
health check-ups and other appointments for gynecologic care
prior to pregnancy offer ideal opportunities to raise the issue of
weight loss before conception. Women should be encouraged to
enter pregnancy with a BMI < 30 kg/m2, and ideally < 25 kg/m2.
Although obesity is not an indication for the transfer of routine
obstetric care, consultation with or referral to physicians with
expertise in obesity may be appropriate if the obstetrician cannot
safely and effectively care for the patient because of the lack of the
specialized training, experience or institutional resources.
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Chauhan SP, Magann EF, Carroll CS, et al. (2001) Mode of delivery for the morbidly obese with prior cesarean delivery: vaginal versus repeat cesarean section. Am J Obstet Gynecol 185: 349-354.
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