Download BMI - Healthy Mothers, Healthy Babies Coalition of Broward County

FLUFFY MOMS
Obesity and Pregnancy
Shelia Love, ARNP, MS, CNM,
C-FEM
Private Practice
Dr. Delisa Skeete-Henry
September 25, 2015
Objectives
• Understanding the severity of obesity in United States and
increased health care costs
• Identify labor, birth and post partum management
strategies for the obese patient
• To specify the importance of pre-pregnancy health status
for positive birth outcomes
• Identify the specific implications of maternal and newborn
complication associated with obesity
• Identify long term consequences of obesity on society
Incidence of obesity
United States
• US statistics according to American
Congress of Obstetrics and Gynecology
(ACOG) January 2013
• 1/3 of women
• 1/2 of all pregnant women
• 8% are extremely obese
• 50% non Hispanic black women
• 45% Mexican American
• 33% non Hispanic white
3
(American Congress of Obstetrics and Gynecology (ACOG) January 2013)
• January 2015 March of Dimes (MOD)
quoted obesity rates in US women at 75%
• Obesity has more than doubled in the last
25 year
• 2013 Broward Fetal Infant Review 39% of
cases involved obese Mothers
4
(March of Dimes, 2015)
• January 2015 March of Dimes (MOD)
quoted obesity rates in US women at 75%
• Obesity has more than doubled in the last
25 year
• 2013 Broward Fetal Infant Review 39% of
cases involved obese Mothers
5
(March of Dimes, 2015)
Contributing factors
• Obesity is more
complex than just
“overeating”
• Genetics
• Psychosocial ex:
abuse, poverty,
depression
• When counseling
patients identification
of these issues may
assist with counseling
Genetics
Psychosocial
Complexity
Obesity Factors
6
Financial Impact
Consists of 3 cost factors
Direct medical
care
Transportation
Productivity
• Obesity related medical
treatment costs in 2006
• $147-210 per year. Majority of
dollars obesity related disorders ie.
HTN, diabetes
• Obese patients spend 42% more on
health care than non obese patients
• Decreased worker production and
increased absenteeism an
estimated costs to employers of
$4.3 billion annually
• Typical ambulance weight capacity
400 lbs = $70,000.00
• Bariatric ambulance = $110,000.00
• Standard hospital bed = $1000.00
• Bariatric bed = $4000.00
If current obesity trends continue, the per capita health care
spending will increase to $7,760.00 by 2020 which is 70% jump
from. 2007
ACOG, 2011
Definitions
• Body Mass Index (BMI) calculated weight
in kilograms divided by height in meters
squared
• Normal BMI 18.5 to 24.9
• Overweight 25-29.9
• Obese 30 and greater
• Morbid obesity 40 and greater
• Class 1 BMI 30-34.9
• Class 2 BMI 35-39
• Fluffy
Obesity/ BMI
Class 1
Class 2
Class 3
• 30-34.9
•35-39
• greater than or
equal to 40
9
10
Lets put it into perspective
• 5’5” female
• Weight 155lbs
• BMI =25.8
• OVERWEIGHT
• 5'2” pregnant female
weight 120lbs can only
gain 20lbs to maintain
normal BMI
11
Serena Williams
• Height 5”9”
175 cms
• Weight 155lbs 70.3 kgs
• BMI:
23
12
Kim Kardashian
• Height 5’2”
159 cms
• Weight 143 lbs
68 kgs
• BMI: 26.4
13
Angelina Jolie
• Height
• Weight
5’8”
173 cms
128lbs 58 kgs
• BMI: 18.5
14
Beyonce
• Height 5’6” 169 cms
• Weight 137lbs 62kgs
• BMI: 23.4
15
Pregnancy
Weight Gain Guidelines
BMI
• 18.5- 24.5
25-35 lbs
• 25-29.9
15-25 lbs
• > 30
11-20 lbs
• > 40
morbid obesity ?????
16
Weight Gain Controversy
• ACOG supports
• 11-20 lbs weight gain for obese women
• There is no differentiation between
obesity classes or diabetics
• Studies have shown weight loss with
monitored adequate fetal growth did not
have significant difference in outcomes
compared to those who were encouraged
to gain weight
17
Controversy
Some Maternal Fetal
Medicine providers
are recommending no
weight gain in morbid
obese clients
especially those with
diabetes
Loss of weight in the
obese pregnant:
women are able to
generate additional
calories to sustain
fetal growth from their
own reserves
18
Professional Conflicts
Providers declining OB care for obese
women d/t increased exposure to poor
outcomes and litigation, co-morbidities and
possible physical strain on staff
Are we obligated to care of all patients???
Weight loss
• Some MFM specialist advocate weight loss
based on research data demonstrating
additional maternal fat stores provide
adequate nutrition for fetal development
when weight loss is achieved by appropriate
maternal calorie intake and exercise
Pre Conceptual Considerations
• Maternal health prior to pregnancy is a
major contributor to birth outcome
• Health care issues should be stable prior to
conception ie. wt, HTN, diabetes, asthma
• Consult care providers
• Specialty consults difficult to obtain so
establish relationship with providers on staff
at birth hospital
21
Implications
Maternal
• BMI 30-39.9 increased risks of GDM,
gestational hypertension, pre-eclampsia and
macrosomia, birth injury
• C/S rate ^ with higher BMI Florida stats BMI
35-39 C/S rate 47.4% (??)
• Higher spontaneous abortion (SAB) rate with
assisted reproduction (natural as well)
• Decreased efficacy of ultrasound technology
in detecting anomalies ex Open neural Tube
defect (ONTD)
• Increased induction rate due to co morbidities
• 39% VBAC failure rate
Implications
Fetal/Newborn
•
•
•
•
Prematurity
Stillbirth
Congenital Anomalies
Macrosomia 4500 GMS (9# 11oz) diabetic
5000 GMS 11lbs .02oz lbs non diabetic
• Childhood obesity
• Hypoglycemia in IDM
• Fetal Injury
23
Labor and delivery
•
•
•
•
•
•
•
IV access
Proper BP cuff size
Position change/mobility
EFM and uterine activity
Physical strain on staff/additional help
Pain management
Literature recommends epidural ????
24
Challenges : Epidural/ Spinal
• Difficult positioning for pt comfort
• Obscured landmarks d/t adipose
• Loss of motor control increased risk staff
injury assisting withposition change
• Additional personnel for birth (anticipate
shoulder dystocia, positioning)
• Adequate visualization for birth and repair
• Fluid balance
25
Surgical Considerations
• Additional staff for transport and positioning
• Thromboprophylaxis with SCDs and
anticoagulant prior to surgery
• Prophylactic antibiotics 30 minutes prior to
surgery ( increased dose recommended)
• Weight/width appropriate OR table
• Risks of PPH (blood available)
• Fluid balance
26
Anticipate longer OR time
• Closure of sub cutaneous tissue may
decrease incidence of wound breakdown
• Drains have found to be of no value
• Additional personal at OR table for
retraction
• Transverse skin and uterine incision
• Visualization (pannus/abdominal drape)
27
• Possible shoulder or abdominal dystocia
• Increased DVT risks
• Airway complications (Sleep Apnea) or
difficult intubation (tray)
• Preoperative scrub (scheduled)
28
Panniculeous Adiopse
• surgical picture of exposure
29
Post Partum
•
•
•
•
•
•
•
•
DVT/PE
Infections (respiratory, wound, fungal)
PPH
Pain management
Hygiene
Lactation
Ambulation
Wound breakdown
30
Dehiscence
31
Plan of care
Labor and Birth
•
•
•
•
Team approach
Most experienced for IV start
Versatile EFM strategies
Pain management anesthesia consult
consider alternatives
• Recruit help for position change moving
bed
• Position for birth
32
Pre conception and Antepartal
Care
• Establish reality based diet/exercise
program (psychological support when
indicated) more than handing out diet list
• Maternal Fetal Medicine (MFM) for
ultrasound studies (some machines made
be inadequate to penetrate adipose, limits
diagnostic capabilities)
• MFM consult to follow co morbidities
• Non judgmental care
• Childbirth preparation birth plan
33
Labor
Plan of Care
•
•
•
•
•
•
•
Patient gown
Bed size
IV access
PPH risk (Blood on hold??)
Prepare patient for additional staff at birth
EFM challenges
Induction challenges (palpation) finding the
sweet spot
• Pushing/Birth position Lithotomy???
34
Postpartum
Plan of Care
•
•
•
•
•
•
•
Early ambulation
Lactation support
Pain management
Fluid shift: assess respiratory or cardiac
Hygiene: peri and incision care
Discuss birth control
Long term health
35
Recommendations
• As care providers, parents, relatives,
friends, spouses and members of society,
we must recognize global implications of
obesity (second preventable health risks in
the United States.
• Being proactive with our own health status
and those we care for both professionally
and personally may slow this epidemic
36
SUMMARY
•Prenatal
• All providers PCPs, Internists,
Chiropractors, Dentists , Fertility
Specialists, should address health
implications of obesity with their clients
• OB/GYN open discussion of obesity risks
at GYN visits and importance of improving
health status prior to conception
• Attempt to identify etiology of obesity
• 1st prenatal visit should include health status
and BMI, with a discussion of weight
recommendations, diet and exercise
• Consider Perinatal consults
• Regardless whether you support minimal weight
gain or no weight gain for morbid obesity women
their diet history, adequate nutritional intake and
psychosocial status should be monitored not just
the scale
• Labor and birth plan
• Intrapartum
• Be sensitive
• Team approach recruit help IV start,
position changes transport
• Support physiological birth
• Pain management options
• Anesthesia consults
• Additional personnel
•
•
•
•
•
•
•
Creative fetal and uterine assessment
Birth position options
Anticipate shoulder dystocia
Prepare for PPH
NICU support when indicated
Extra personnel for birth
Spacing of future pregnancies for optimal
health status
40
REFERENCES
ACOG Committee Opinion, January 2013
Obesity in Pregnancy
March of Dimes
ACOG Committee Opinion 548 January 2013
Weight Gain in pregnancy
Contemporary OB/GYN Obesity and Weight Gain in Pregnancy
July/01/2013
Healthy Mothers Healthy Babies Broward Fetal Infant Mortality
Review Statistics (2013)
State of Obesity Report Series 2014: Better Policies for a Healthy
America