Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-76fb5796d-zzh7m Total loading time: 0 Render date: 2024-04-26T01:27:37.389Z Has data issue: false hasContentIssue false

18 - Clinical management of obesity in pregnancy

from Section 5 - Management and policy

Published online by Cambridge University Press:  05 August 2012

By
Carolyn Chiswick  and
Fiona C. Denison
Edited by
Matthew W. Gillman  and
Lucilla Poston
Matthew W. Gillman
Affiliation:
Harvard Medical School
Lucilla Poston
Affiliation:
King's College London
Get access

Summary

Introduction

Obesity is now the commonest antenatal co-morbidity. With one in five of the antenatal population in both the US and the UK being obese, maternal obesity will inevitably be encountered by all obstetricians, from those with a special interest in high-risk obstetrics, to those covering the delivery suite out of hours. Therefore it is essential that all clinicians have the knowledge and expertise to manage obese women during pregnancy and labor.

As reviewed in Chapter 4 pregnant women who are obese are at greater risk of a wide range of pregnancy complications from pre-pregnancy, throughout the antenatal period, intrapartum, and postnatally (Table 18.1). The offspring of obese mothers are also at greater risk of perinatal morbidity and long-term health problems. There are also technical challenges such as the availability of appropriate equipment and moving and handling problems.

This chapter aims to provide a summary of the clinical management of obesity in pregnancy, based on evidence where it exists, and highlighting areas where further research is needed.

Pre-pregnancy care

Primary care services have a responsibility to ensure that all women of childbearing age are aware of the excess risks associated with obesity in pregnancy [ 1 ] . Any visit to a health care provider by a young woman who is overweight should be viewed as an opportunity to advise about the benei ts of weight loss and strategies to achieve this [ 2 ]. Overweight women planning a pregnancy should be given the opportunity and encouragement to optimize their pre-pregnancy weight. Losing 5% to 10% of their body weight prior to conception has signii cant health benei ts [3, 4] . For example, minimal weight loss in women with polycystic ovarian syndrome and anovulation can result in ovulation induction, restoration of fertility, and spontaneous conception. Rapid weight loss immediately prior to pregnancy should not be encouraged as it is associated with poorer outcomes [2].

Type
Chapter
Information
Maternal Obesity , pp. 223 - 236
Publisher: Cambridge University Press
Print publication year: 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Cantwell, R Clutton-Brock, T Cooper, G Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom BJOG 118 1
Nelson, S M Fleming, R F The preconceptual contraception paradigm: obesity and infertility Hum Reprod 2007 22 912 Google Scholar
NICE London National Institute for Health and Clinical Excellence 2006 www.nice.org.uk/nicemedia/pdf/CG43NICEGuideline.pdf
NICE National Institute for Health and Clinical Excellence 2010 http://guidance.nice.org.uk/PH27
Friedman, J M ACE inhibitors and congenital anomalies N Engl J Med 2006 354 2498 Google Scholar
Rubin, P C Ramsey, M Prescribing in Pregnancy Blackwell Publishing 2008
Rasmussen, S A Chu, S Y Kim, S Y Maternal obesity and risk of neural tube defects: a metaanalysis Am J Obstet Gynecol 2008 198 611 Google Scholar
Jovanovic, L. Definition, size of the problem, screening and diagnostic criteria: who should be screened, cost-effectiveness, and feasibility of screening Int J Gynaecol Obstet 2009 104 s17 Google Scholar
Mojtabai, R. Body mass index and serum folate in childbearing age women Eur J Epidemiol 2004 19 1029 Google Scholar
Dashe, J S McIntire, D D Twickler, D M Effect of maternal obesity on the ultrasound detection of anomalous fetuses Obstet Gynecol 2009 113 1001 Google Scholar
Scholl, T O Johnson, W G Folic acid: influence on the outcome of pregnancy Am J Clin Nutr 2000 71 1295S Google Scholar
De-Regil, L M Fernandez-Gaxiola, A C Dowswell, T Cochrane Database Syst Rev 10 www.thecochranelibrary.com/view/0/index.html
Anon, Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group Lancet 1991 338 131 Google Scholar
Ray, J G Wyatt, P R Vermeulen, M J Greater maternal weight and the ongoing risk of neural tube defects after folic acid flour fortification Obstet Gynecol 2005 105 261 Google Scholar
Modder, J Fitzsimons, K J London Centre for Maternal and Child Enquiries and the Royal College of Obstetricians and Gynaecologists 2010 www.rcog.org.uk/womens-health/clinical-guidance/management-women-obesity-pregnancy
American College of Obstetricians and Gynecologists ACOG Committee Opinion number 315, September 2005. Obesity in pregnancy Obstet Gynecol 2005 106 671 Google Scholar
Bodnar, L M Catov, J M Roberts, J M Prepregnancy obesity predicts poor vitamin D status in mothers and their neonates J Nutr 2007 137 2437 Google Scholar
Swan, G. Findings from the latest National Diet and Nutrition Survey Proc Nutr Soc 2004 63 505 Google Scholar
Roth, D E Vitamin D supplementation during pregnancy: safety considerations in the design and interpretation of clinical trials J Perinatol 2011 31 Google Scholar
Gorber, S C Tremblay, M Moher, D A comparison of direct vs. self-report measures for assessing height, weight and body mass index: a systematic review Obes Rev 2007 8 307 Google Scholar
Beyerlein, A Schiessl, B Lack, N Associations of gestational weight loss with birth-related outcome: a retrospective cohort study BJOG 118 55
Dawes, M G Grudzinskas, J G Patterns of maternal weight gain in pregnancy Br J Obstet Gynaecol 1991 98 195 Google Scholar
Dawes, M G Grudzinskas, J G Repeated measurement of maternal weight during pregnancy. Is this a useful practice? Br J Obstet Gynaecol 1991 98 189 Google Scholar
Institute of Medicine 2009 www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx
Cedergren, M I Optimal gestational weight gain for body mass index categories Obstet Gynecol 2007 110 759 Google Scholar
Abrams, B Altman, S L Pickett, K E Pregnancy weight gain: still controversial Am J Clin Nutr 2000 71 1233S Google Scholar
Parker, J D Abrams, B. Prenatal weight gain advice: an examination of the recent prenatal weight gain recommendations of the Institute of Medicine Obstet Gynecol 1992 79 664 Google Scholar
Viswanathan, M Siega-Riz, A M Moos, M K Outcomes of maternal weight gain Evid Rep Technol Assess 2008 168 1 Google Scholar
Hedderson, M M Weiss, N S Sacks, D A Pregnancy weight gain and risk of neonatal complications: macrosomia, hypoglycemia, and hyperbilirubinemia Obstet Gynecol 2006 108 1153 Google Scholar
Oken, E Taveras, E M Kleinman, K P Gestational weight gain and child adiposity at age 3 years Am J Obstet Gynecol 2007 196 322 Google Scholar
Artal, R Lockwood, C J Brown, H L Weight gain recommendations in pregnancy and the obesity epidemic Obstet Gynecol 2010 115 152 Google Scholar
Amorim, A R Rossner, S Neovius, M Does excess pregnancy weight gain constitute a major risk for increasing long-term BMI? Obesity (Silver Spring) 2007 15 1278 Google Scholar
Stotland, N E Cheng, Y W Hopkins, L M Gestational weight gain and adverse neonatal outcome among term infants Obstet Gynecol 2006 108 635 Google Scholar
Schieve, L A Cogswell, M E Scanlon, K S Trends in pregnancy weight gain within and outside ranges recommended by the Institute of Medicine in a WIC population Matern Child Health J 1998 2 111 Google Scholar
Haakstad, L A Voldner, N Henriksen, T Physical activity level and weight gain in a cohort of pregnant Norwegian women Acta Obstet Gynecol Scand 2007 86 559 Google Scholar
Cogswell, M E Scanlon, K S Fein, S B Medically advised, mother’s personal target, and actual weight gain during pregnancy Obstet Gynecol 1999 94 616 Google Scholar
Kramer, M S McDonald, S W Aerobic exercise for women during pregnancy Cochrane Database Syst Rev 2006 3 www.thecochranelibrary.com/view/0/index.html Google Scholar
Davies, G A Wolfe, L A Mottola, M F Exercise in pregnancy and the postpartum period J Obstet Gynaecol Can 2003 25 516 Google Scholar
Tobias, D K Zhang, C van Dam, R M Physical activity before and during pregnancy and risk of gestational diabetes mellitus: a meta-analysis Diabetes Care 34 223
Melzer, K Schutz, Y Boulvain, M Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes Sports Med 40 493
Jolly, M C Sebire, N J Harris, J P Risk factors for macrosomia and its clinical consequences: a study of 350,311 pregnancies Eur J Obstet Gynecol Reprod Biol 2003 111 9 Google Scholar
Wolfe, H M Sokol, R J Martier, S M Maternal obesity: a potential source of error in sonographic prenatal diagnosis Obstet Gynecol 1990 76 339 Google Scholar
Phatak, M Ramsay, J. Impact of maternal obesity on procedure of mid-trimester anomaly scan J Obstet Gynaecol 30 447
Gandhi, M Fox, N S Russo-Stieglitz, K Effect of increased body mass index on first-trimester ultrasound examination for aneuploidy risk assessment Obstet Gynecol 2009 114 856 Google Scholar
Rode, L Ekelund, C Pedersen, N G Maternal smoking, obesity and male fetal sex predispose to a large nuchal translucency thickness in healthy fetuses Fetal Diagn Ther 2011 29 201 Google Scholar
Wald, N Cuckle, H Boreham, J The effect of maternal weight on maternal serum alpha-fetoprotein levels Br J Obstet Gynaecol 1981 88 1094 Google Scholar
Colman, A Maharaj, D Hutton, J Reliability of ultrasound estimation of fetal weight in term singleton pregnancies N Z Med J 2006 119 U2146 Google Scholar
Dudley, N J A systematic review of the ultrasound estimation of fetal weight Ultrasound Obstet Gynecol 2005 25 80 Google Scholar
Crowther, C A Hiller, J E Moss, J R Effect of treatment of gestational diabetes mellitus on pregnancy outcomes N Engl J Med 2005 352 2477 Google Scholar
NICE London NICE 2008 www.nice.org.uk/CG63
American College of Obstetricians and Gynecologists Committee on Practice Bulletins – Obstetrics Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes Obstet Gynecol 2001 98 525 Google Scholar
Metzger, B E Gabbe, S G Persson, B International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy Diabetes Care 33 676
American Diabetes Association Standards of medical care in diabetes – 2011 Diabetes Care 2011 34 s11 Google Scholar
Alberti, K G Zimmet, P Z Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation Diabet Med 1998 15 539 Google Scholar
Scottish Intercollegiate Guidelines Network Edinburgh Scottish Intercollegiate Guidelines Network 2010 www.sign.ac.uk/guidelines/fulltext/116/index.html
Comtois, R Seguin, M C Aris-Jilwan, N Comparison of obese and non-obese patients with gestational diabetes Int J Obes Relat Metab Disord 1993 17 605 Google Scholar
Rowan, J A Hague, W M Gao, W Metformin versus insulin for the treatment of gestational diabetes N Engl J Med 2008 358 2003 Google Scholar
Kannel, W B Brand, N Skinner, J J The relation of adiposity to blood pressure and development of hypertension. The Framingham study Ann Intern Med 1967 67 48 Google Scholar
Bhattacharya, S Campbell, D M Liston, W A Effect of body mass index on pregnancy outcomes in nulliparous women delivering singleton babies BMC Public Health 2007 7 168 Google Scholar
Denison, F C Price, J Graham, C Maternal obesity, length of gestation, risk of postdates pregnancy and spontaneous onset of labour at term BJOG 2008 115 720 Google Scholar
Sebire, N J Jolly, M Harris, J P Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London Int J Obes Relat Metab Disord 2001 25 1175 Google Scholar
Maxwell, M H Waks, A U Schroth, P C Error in blood-pressure measurement due to incorrect cuff size in obese patients Lancet 1982 2 33 Google Scholar
PRECOG Development Group www.apec.org.uk/pdf/guidelinepublishedvers04.pdf
ACOG Committee on Obstetric Practice Diagnosis and management of preeclampsia and eclampsia. Number 33, January 2002. American College of Obstetricians and Gynecologists Int J Gynaecol Obstet 2002 77 67 Google Scholar
Nelson-Piercy, C M Handbook of Obstetric Medicine London Informa Healthcare 2010
Duley, L Henderson-Smart, D J Knight, M Antiplatelet agents for preventing pre-eclampsia and its complications Cochrane Database Syst Rev 2004 www2.cochrane.org/reviews/en/ab004659.html Google Scholar
NICE 2010 www.nice.org.uk/guidance/CG107
Sibai, B Dekker, G Kupferminc, M. Pre-eclampsia Lancet 2005 365 785 Google Scholar
McDonald, S D Han, Z Mulla, S Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses BMJ 2010 341 c3428 Google Scholar
Denison, F C Norrie, G Graham, B Increased maternal BMI is associated with an increased risk of minor complications during pregnancy with consequent cost implications BJOG 2009 116 1467 Google Scholar
Denison, F C Norrie, G Graham, B Increased maternal BMI is associated with an increased risk of minor complications during pregnancy with consequent cost implications BJOG 2009 116 1467 Google Scholar
Yates, L Pierce, M Stephens, S Influenza A/H1N1v in pregnancy: an investigation of the characteristics and management of affected women and the relationship to pregnancy outcomes for mother and infant Health Technol Assess 14 109
Lewis, G 2007
Royal College of Obstetricians and Gynaecologists 2009
Duhl, A J Paidas, M J Ural, S H Antithrombotic therapy and pregnancy: consensus report and recommendations for prevention and treatment of venous thromboembolism and adverse pregnancy outcomes Am J Obstet Gynecol 2007 197 457e1 Google Scholar
Saravanakumar, K Rao, S G Cooper, G M The challenges of obesity and obstetric anaesthesia Curr Opin Obstet Gynecol 2006 18 631 Google Scholar
Barnardo, P D Jenkins, J G Failed tracheal intubation in obstetrics: a 6-year review in a UK region Anaesthesia 2000 55 690 Google Scholar
Balki, M Lee, Y Halpern, S Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients Anesth Analg 2009 108 1876 Google Scholar
Abera, A B Sales, K J Catalano, R D EP2 receptor mediated cAMP release is augmented by PGF 2 alpha activation of the FP receptor via the calcium-calmodulin pathway Cell Signal 22 71
Homer, C S Kurinczuk, J J Spark, P Planned vaginal delivery or planned caesarean delivery in women with extreme obesity BJOG 118 480
Alexander, C I Liston, W A Operating on the obese woman – a review BJOG 2006 113 1167 Google Scholar
Zywiel, M G Daley, J A Delanois, R E Advance pre-operative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty Int Orthop 2011 35 Google Scholar
Rauk, P N Educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections Am J Infect Control 38 319
Cliby, W A Abdominal incision wound breakdown Clin Obstet Gynecol 2002 45 507 Google Scholar
Naumann, R W Hauth, J C Owen, J Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women Obstet Gynecol 1995 85 412 Google Scholar
Gates, S Anderson, E R Wound drainage for caesarean section Cochrane Database Syst Rev 2005 Google Scholar
Hellums, E K Lin, M G Ramsey, P S Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery – a metaanalysis Am J Obstet Gynecol 2007 197 229 Google Scholar
Tran, T S Jamulitrat, S Chongsuvivatwong, V Risk factors for postcesarean surgical site infection Obstet Gynecol 2000 95 367 Google Scholar
Costantine, M M Rahman, M Ghulmiyah, L Timing of perioperative antibiotics for cesarean delivery: a metaanalysis Am J Obstet Gynecol 2008 199 301 Google Scholar
Cheymol, G. Effects of obesity on pharmacokinetics implications for drug therapy Clin Pharmacokinet 2000 39 215 Google Scholar
Hibbard, J U Gilbert, S Landon, M B Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery Obstet Gynecol 2006 108 125 Google Scholar
Durnwald, C P Ehrenberg, H M Mercer, B M The impact of maternal obesity and weight gain on vaginal birth after cesarean section success Am J Obstet Gynecol 2004 191 954 Google Scholar
Chiswick, C Cooper, E S Norman, J E Fat necrois of the abdominal pannus following caesarean section in patients with morbid obesity Eur J Gynecol Reprod Biol 2012 160 118 Google Scholar
Amir, L H Donath, S. A systematic review of maternal obesity and breastfeeding intention, initiation and duration BMC Pregnancy Childbirth 2007 7 9 Google Scholar
Rasmussen, K M Kjolhede, C L Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum Pediatrics 2004 113 e465 Google Scholar
Armitage, J A Poston, L Taylor, P D Developmental origins of obesity and the metabolic syndrome: the role of maternal obesity Front Horm Res 2008 36 73 Google Scholar
Baker, J L Gamborg, M Heitmann, B L Breastfeeding reduces postpartum weight retention Am J Clin Nutr 2008 88 1543 Google Scholar
HAPO Study Cooperative Research Group Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associations with maternal body mass index BJOG 2010 117 575 Google Scholar
Lashen, H Fear, K Sturdee, D W Obesity is associated with increased risk of first trimester and recurrent miscarriage: matched case-control study Hum Reprod 2004 19 1644 Google Scholar
Watkins, M L Rasmussen, S A Honein, M A Maternal obesity and risk for birth defects Pediatrics 2003 111 1152 Google Scholar
McDonald, S D Han, Z Mulla, S Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses BMJ 2010 341 c3428 Google Scholar
O’Brien, T E Ray, J G Chan, W S Maternal body mass index and the risk of preeclampsia: a systematic overview Epidemiology 2003 14 368 Google Scholar
Jacobsen, A F Skjeldestad, F E Sandset, P M Ante- and postnatal risk factors of venous thrombosis: a hospital-based case-control study J Thromb Haemost 2008 6 905 Google Scholar
Chu, S Y Kim, S Y Lau, J Maternal obesity and risk of stillbirth: a metaanalysis Am J Obstet Gynecol 2007 197 223 Google Scholar
Metzger, B E Lowe, L P Dyer, A R Hyperglycemia and adverse pregnancy outcomes N Engl J Med 2008 358 2002 Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×