DOI: 10.1097/01.aoa.0000362055.97494.49

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Issn Print: 0275-665X

Publication Date: 2009/12/01


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Obesity and Pregnancy

N.E. Stotland

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The epidemic of obesity has lead to an increase in obstetric complications. This article summarizes the effects of obesity on pregnancy and vice versa, suggesting strategies to minimize risks. Obesity is a major predictor of maternal mortality. Pregnancy-related complications that are increased in obese women include preeclampsia, spontaneous abortion, gestational diabetes, macrosomia, prolonged labor, preterm and postterm birth, stillbirth, and congenital malformations. Obese women are more likely to require cesarean delivery (CS), and anesthetic and surgical challenges are increased in these women. Postpartum, obese women experience greater difficulties with breast-feeding. Overweight/obese women have higher rates of excessive weight gain during pregnancy and are more likely to retain this weight postpartum. Most experts advise obese women to achieve a normal body mass index (BMI) before conception, recognizing that obesity can lower the efficacy of contraception.
As soon as pregnancy is established, BMI should be documented and women in the overweight category should be given special guidelines on weight control, including strategies to optimize nutrition and physical activity. It is generally recommended that weight gain be limited to 7 kg during pregnancy in obese women to optimize outcomes, although more research in this area is needed. Nutrition can be improved with the following strategies: replacing high caloric drinks with water and refined flours with whole grains; increasing dietary fruit, vegetables, and fiber; eschewing restaurant/“fast food”; consuming healthy snacks; and keeping a food diary for review with heathcare providers. Suggestions for increasing physical activity include walking whenever possible, taking stairs instead of elevators, playing outdoors with children, and using exercise videos.
Early blood glucose screening for diabetes in women with a BMI of >29 is advocated by experts. Overweight/obese women are more likely to have suboptimal visualization of fetal anatomy. The use of advanced ultrasound equipment and delaying ultrasound screening until >18 weeks gestation may improve accuracy. In the third trimester, serial ultrasonography may be needed to assess fetal growth. Methods to prevent stillbirth in obese women have not been defined, although use of kick counts may be helpful. The higher the maternal BMI, the greater the risk for post-term birth, which is associated with increased neonatal morbidity and mortality. Altered management to include sweeping of amniotic membranes at ≥38 weeks may be helpful in preventing postterm birth. Weekly blood pressure and urine protein monitoring late in pregnancy also is essential.
During labor and delivery, primary concerns include the increased risk for emergency CS, postpartum endometritis, and surgical wound infection. Prophylactic antibiotic administration prior to surgery is recommended, along with closure of the subcutaneous wound layers, graduated compression stockings, hydration, and early ambulation. Whether a vaginal birth after previous CS is safe in obese parturients is controversial, and the decision should be made by the patient and her clinicians once the various risks have been explained. Anesthetic considerations in obese women include higher rates of epidural failure, unintentional dural puncture, pulmonary aspiration, and difficult intubation. The use of regional anesthesia is recommended over general anesthesia.
Bariatric surgery can improve fertility in obese women and decrease the rates of gestational diabetes and hypertensive disorders, but more research is needed to verify the benefits. Following bariatric surgery, The American College of Obstetricians and Gynecologists recommends that conception be delayed for 18 months. During this period, the diet should be supplemented with iron, folate, calcium, and vitamin B12. During pregnancy, the patient should be monitored by a bariatric surgeon to determine whether adjustment of the gastric bands is needed.
In summary, pregnancy may worsen obesity and obesity may complicate pregnancy.

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