ACOG Practice Bulletin - #156 Dec 2015

OBESITY IN PREGNANCY

Classified based on BMI (kg/m^2): underweight: <18.5, normal: 18.5-24.9, overweight

25-29.9, obesity class I: 30-34.9, obesity class II: 35-39.9, obesity class III: 40 or >
Obesity= most common problem in women of reproductive age (20-39 yrs)
o Prevalence in U.S. women of repro age = 31.8%, 58.8% if add those overweight
Effects on pregnancy
o Increased risk of spontaneous abortion, recurrent miscarriage, and certain
congenital anomalies (neural tube defects, spina bifida, hydrocephaly, cleft
lip/palate, anorectal atresia, and cardiovascular, septal, orofacial, and limb
reduction anomalies)
o Reduced risk of gastroschisis in the neonates among obese gravidas
Antepartum Complications
o Obese women are at increased risk of cardiac dysfunction, proteinuria, sleep
apnea, nonalcoholic fatty liver disease, gestational DM, and preeclampsia
o Obese gravidas are 40% more likely to experience stillbirth
Black obese gravidas > risk vs white
Increasing risk w/ increasing gestational age per obesity class trend
observed
Intrapartum Complications
o Increased risk of cesarean delivery, failed trial of labor, endometritis, wound
rupture or dehiscence, and venous thrombosis
o Associations with indicated preterm birth clear, less so for spontaneous preterm
birth
o Trial of labor after previous c-section in obese gravidas presents 2x increase in
composite maternal morbidity (prolonged hospital stay, endometritis, rupture or
dehiscence) and 5x increase risk in neonatal injury ((fractures, brachial plexus
injuries, and lacerations))
o Pregnant women w/ class III obesity have a significantly increased risk of
postpartum atonic hemorrhage (bleeding > 1,000 mL) after a vaginal delivery
(5.2%) but not after cesarean delivery
Postpartum Complications and Long-Term Outcomes
o Associations with future maternal metabolic dysfunction; risks compounded by
excess gestational weight gain which is also a factor for postpartum weight
retention
o Pregravid obesity is associated with early termination of breastfeeding,
postpartum anemia, and depression
Fetal Complications and Childhood Morbidities
o Fetus: increased risk of macrosomia and impaired growth
o Infants: increased body weight
o Longer term risks: increased risk of metabolic syndrome, childhood obesity,
childhood asthma
o Maternal obesity also linked to autism spectrum disorders, childhood
developmental delay, and attention-deficit/hyperactivity disorder
o Note confounding variables in metabolic outcome analysis: family socioeconomic
issue, behavior, activity, and diet
Managing obesity before and during pregnancy
o Optimal control begins before conception: surgical or nonsurgical, though
medications not recommended during the time of conception or pregnancy i.e.
anorectics
Primary weight management strategies during pregnancy are dietary
control, exercise, and behavior modification alone or in combination
Even small weight reductions before pregnancy may have improved
pregnancy outcomes

Motivational interviewing: a significant decrease in weight; a nonsignificant

decrease in BMI; however a weight loss of 57% over time can significantly
improve metabolic health
o IOM Weight gain recommendations in pregnancy for overweight and obese
women
total weight gain of 6.811.3 kg (1525 lb) for overweight pregnant
women
& 5.09.1 kg (1120 lb) for all obese women (limited data by obesity
class)
Current data also seems indicates that inadequate weight gain and
gestational weight loss should not be encouraged for obese pregnant
women due to an association with SGA (contrasts w/ perceived benefits
such as decreases in the rate of cesarean delivery, decreased risk of
LGA, and postpartum weight retention)
o Maternal obesity alone is not an indication for induction; however w/ increased
risk of a prolonged pregnancy-> increased rate of labor induction
o Allowing a longer first stage of labor before performing cesarean delivery for
labor arrest should be considered
Antenatal care: Detection of congenital anomalies by ultrasonography is significantly
reduced with increasing maternal BMI; counsel patients on limitations
Metabolic Disorders
o Increased risk of metabolic syndrome
o Increased insulin resistance may trigger cardiometabolic dysfunction to emerge
as preeclampsia, gestational diabetes, and OSA
o First antenatal visit: screen for glucose intolerance & OSA
OSA associated w/ preeclampsia, eclampsia, cardiomyopathy, PE, and
in-hospital mortality
Also: increased risk of hypoxemia, hypercapnia, and sudden
death
Stillbirth & Antenatal Fetal Surveillance: no recommendation for or against routine
antenatal fetal surveillance in obese pregnant women (no clear evidence w/ improved
outcomes)
Epidural Issues
o Risk of epidural analgesic failure is greater; consider early labor epidural catheter
placement
o Combo of spinal anesthesia & obesity significantly impairs respiratory function for
up to 2 hours after the procedure
Cesareans
o SubQ drains increase the risk of postpartum cesarean wound complications -do
not use routinely
o Risk of venous thromboembolism
Pneumatic compression devices: placed before a cesarean delivery and
continue postpartum
In very-high-risk groups: add LMWH (enoxaparin 40 mg daily is
commonly used)
Weight-based dosage may be more effective than BMI-stratified
dosage strategies in class III obesity post cesarean
Post pregnancy
o Behavioral interventions employing diet and exercise seen to improve
postpartum weight reduction in contrast to exercise alone
o Weight loss between pregnancies in obese women has been shown to decrease
the risk of a LGA and vice versa
o