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Effect of maternal obesity on labor induction in postdate pregnancy

Article  in  Archives of Gynecology and Obstetrics · April 2018

DOI: 10.1007/s00404-018-4767-8

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Archives of Gynecology and Obstetrics
https://doi.org/10.1007/s00404-018-4767-8

MATERNAL-FETAL MEDICINE

Effect of maternal obesity on labor induction in postdate pregnancy

Ahmed M. Maged1 · Ali M. El‑Semary1 · Heba M. Marie1 · Doaa S. Belal1 · Ayman Hany1 · Mohammad A. Taymour1 ·
Eman F. Omran1 · Sahar M. Y. Elbaradie2 · Mohamed A. Kamal Mohamed1

Received: 19 October 2017 / Accepted: 4 March 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Objective  To test the hypothesis that there is a higher rate of unsuccessful induction of labor (IOL) in post-term obese
pregnant women compared to non-obese ones.
Methods  In this prospective cohort study, 144 obese (BMI > 30) and 144 non-obese (BMI < 29.9) post-term (> 41 weeks)
pregnant women were recruited. IOL was done by misoprostol or amniotomy and oxytocin infusion according to the Bishop
score. Comparison of percentage of failed IOL in both groups (primary outcome) was performed by the Chi-test. Logistic
regression and multivariable regression were performed to assess the odds ratio (OR) of cesarean section (CS) and coefficient
of delay in labor till vaginal delivery (VD) in obese versus (vs) non-obese groups. Adjustment for gestational age, parity,
Bishop Score, membrane rupture and amniotic fluid index was done in both regression analyses.
Results  CS rate was significantly higher in obese group [26.4 vs 15.9%; difference in proportion (95% CI) 0.1 (0.01, 0.19);
P value 0.02]. 106 (73.6%) obese women and 121 (84.1%) non-obese women delivered vaginally. In addition, the duration
till VD was significantly higher in obese group (22 vs 19 h, P value 0.01). After adjustment for possible confounding factors,
the CS was still higher in the obese group in comparison to non-obese group (OR 2.02; 95% CI 1.1, 3.7; P value 0.02). This
finding suggested that obesity was an independent factor for failure of IOL. In addition, after adjustment for these confound-
ers, obesity had the risk of increasing labor duration by 2.3 h (95% CI 0.1, 4.5) in cases that ended in VD.
Conclusion  Based on our results, we conclude that there is a higher risk of CS in obese postdate pregnant women undergo-
ing IOL in comparison to non-obese counterparts. Therefore, obstetricians should pay more attention to advising pregnant
women about optimal weight gain during pregnancy and counseling about the chances of VD in cases of IOL.
ClincalTrial.gov ID NCT02788305.

Keywords  Bishop score · Induction of labor · Obesity · Failure of induction

* Ahmed M. Maged Eman F. Omran

prof.ahmedmaged@gmail.com omraneman9@gmail.com
Ali M. El‑Semary Sahar M. Y. Elbaradie
alimsemary@yahoo.com sbaradie@gmail.com
Heba M. Marie Mohamed A. Kamal Mohamed
hebamarie2014@gmail.com Dr.kimo.0101@gmail.com
Doaa S. Belal 1
Department of Obstetrics and Gynecology, Kasr Al‑Ainy
doaash@live.com
Hospital, Cairo University, Cairo, Egypt
Ayman Hany 2
Department of Obstetrics and Gynecology, Fayoum
aymanobgyn@gmail.com
University, Fayoum, Egypt
Mohammad A. Taymour
mohammadtaymour@gmail.com

13
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Introduction
The rising incidence of obesity, all over the world, repre-
sents a critical health care challenge being doubled over
the past 30 years [1]. Around 17.3% of pregnant women
are obese [2]. It has been demonstrated that obesity has
various harmful effects on reproduction and pregnancy
outcomes like increased incidence of hypertension and
gestational diabetes and higher rate of induction of labor
(IOL) [3–5]. Moreover, a recent analysis of more than
million pregnant women concluded that 47% of them had
higher gestational weight gain than recommended values
which resulted in higher rates of adverse maternal and fetal
outcomes [6]. This analysis explains why maternal obesity
has become a major threat in modern obstetric practice.
Some studies suggested that prolonged pregnancy
beyond term is more prevalent in obese women [7, 8].
For example, in a large retrospective study of 9336 births,
28.2% of obese women progressed beyond 41 weeks with
an odds ratio (OR) 2.27 relative to normal weight preg-
nant women [7]. Post-term pregnancy has been shown
to be associated with increased pregnancy problems as
increased need for induction of labor, increased cesar-
ean delivery rate, postpartum hemorrhage and increased
perinatal morbidity and mortality [9, 10]. Some authors
suggested that endocrine factors may be responsible for
delayed initiation of labor in those obese women [11].
Therefore, obese women with prolonged pregnancy
became recently a common problem encountered in obstet-
ric practice. However, it represents a challenge to obstetri-
cians, as IOL is associated with complications and expect-
ant management is associated with perinatal risks [7].
Although it was estimated that 34.4% of obese preg-
nant women had IOL compared with 26.6% in non-obese
women [7], few retrospective studies assessed IOL out-
come in obese pregnant women [12–14]. Moreover, little
is known about answering the question of whether failure
of induction is higher in such increasing category of our
pregnant population particularly in cases with prolonged
pregnancy.
Therefore, the primary aim of this study was to test
the hypothesis that there is a higher rate of unsuccess-
ful IOL in post-term obese pregnant women relative to
non-obese ones. The other aim was to assess the possible
risks confronted in those high risk cases, as regards to the
maternal and fetal outcomes, compared to their normal
weight counterparts.
13
Archives of Gynecology and Obstetrics
Materials and methods
We performed a prospective cohort study, at Kasr El-Ainy
Hospital, Cairo University from May 2016 to June 2017
after approval of the local ethical committee. The ethical
standards of declaration of Helsinki were followed and
the study was registered in ClinicalTrial.gov registry. Its
identifier is NCT02788305.
The study was performed on 288 pregnant women
with prolonged gestation (beyond 41  weeks gestation)
who were candidates for IOL with singleton living fetus
and unscarred uterus and who were not in active labor.
Informed consent was taken from each patient to be
enrolled in the study. Women who had diabetes, hyper-
tension, drained liquor, cephalopelvic disproportion, fetal
macrosomia (> 4.5 kg), placenta previa, accidental hemor-
rhage, BMI < 18.5 kg/m2 or spontaneous labor onset were
excluded. The method of sampling was a consecutive one
recruiting eligible women until 144 obese and 144 non-
obese pregnant women were enrolled in the study.
Gestational age assessment was based on the first day of
last menstrual period (LMP) or based upon first trimester
ultrasound (US) scan in case of unreliable dating. Full his-
tory taking and obstetric examination were done. Maternal
weight and height were measured to calculate the body
mass index (BMI). We further subdivided them into two
groups: the non-obese group with a BMI ≤ 29.9 kg/m 2,
and, the obese group with a BMI > 29.9 kg/m2. We per-
formed US scan to document fetal viability, fetal weight,
placental location and amount of liquor.
IOL was done following our University hospital proto-
col. Vaginal examination was done for women set for IOL
to calculate the Bishop score [15]. Accordingly, if Bishop
score was > 6, (favorable cervix), amniotomy was done
and, after confirming reassuring fetal heart rate, intrave-
nous oxytocin (Syntocinon, Novartis, Basel, Switzerland)
was given at an individually calculated rate sufficient
to produce efficient uterine contractions (3 contractions
of 200 Montevideo units over 10 min, each lasting for
40–60 s). If Bishop Score was ≤ 6, cervical ripening was
induced as follows: 25 micrograms of vaginal misoprostol
(Vagiprost, Adwia Co., Cairo, Egypt) were given every 6 h
in the posterior vaginal fornix. Re-assessment was done
6 h after the initial dose. The maximum allowable dose
was 100 μg. When uterine contractions started, continuous
electronic fetal monitoring was done for our cases.
Our primary outcome was to calculate and compare the
percentage of unsuccessful IOL in the two study groups.
Unsuccessful induction was the one that ended in cesar-
ean delivery (CS). Secondary outcomes were: the duration
of labor till vaginal delivery (VD) (in cases that ended
in VD), and the occurrence of postpartum hemorrhage
Archives of Gynecology and Obstetrics

(estimated blood loss of > 500 ml for VD, and > 1000 ml Results

for CS delivery),
Sample size calculation was based on CS rate in obese
versus non-obese groups as the primary outcome. Accord-
ing to a previous study [7], there was 22% CS rate in
non-obese pregnant women undergoing IOL. We set the
power at 90%, alpha error at 0.05 and ratio of the two
study groups at 1:1. Accordingly, 144 cases were needed
in each group to detect 15% difference in CS rate. Sample
size calculation was done using IBM SPSS SamplePower
software, release 3.0.1 (IBM Corp., Armonk, NY, USA).
Normal distribution of data was checked by Kolmogo-
rov–Smirnov test. Description of data was done by mean
(SD), median (range) or count (percent) when appropriate.
Comparison of both study groups was done by Student
t test, Mann–Whitney test, Chi square (χ2) and Fisher’s
exact tests. All hypotheses testing was done 2 tailed and
95% confidence intervals (CI) were provided when appli-
cable. Logistic regression analysis was done to estimate
the odds ratio (with its 95% CI) of unsuccessful IOL in
obese group (in comparison with non-obese group) after
adjustment for parity, gestational age (GA), Bishop Score,
fetal weight, membrane rupture and amniotic fluid index
(AFI). Then, multivariate regression analysis was done to
calculate B coefficient of duration of labor in relation to
obesity after adjustment for the same above confounding
factors. Statistical analysis was done using SPSS software,
version 23 (IBM Corp., Armonk, NY, USA).
308 postdate pregnancies were initially screened for eligi-
bility to our study. 17 cases were excluded due to exclusion
criteria and 3 women refused to participate. 288 pregnant
women (144 obese and 144 non-obese) continued the study
(Fig. 1).
The general and clinical characteristics are represented in
Tables 1 and 2. The obese and non-obese groups were simi-
lar in age (mean ± SD: 27.6 ± 5.8 vs 26.3 ± 5 years, respec-
tively), parity (55.6 vs 54.9%, respectively, were multipa-
rous), Bishop Score [median (range) 3(0, 8) in both groups].
Also, they were similar in AFI, total misoprostol needed for
IOL, and Apgar score of their neonates. 3 (2%) obese and 5
(3.4%) non-obese women had postpartum hemorrhage that
needed only oxytocic medications (Tables 1, 2).
As regards our primary outcome, the CS rate was sig-
nificantly higher in obese group [26.4 vs 15.9%; differ-
ence in proportion (95% CI) 0.1 (0.01, 0.19); P value
0.02]. Indications for CS were similar in both study
groups. Upon stratification according to parity, CS rate
was higher in primiparous (26.6% in obese and 27% in
non-obese counterparts) in comparison to multiparous
women (26.3% in obese and 6.3% in non-obese groups).
Unsuccessful IOL was significantly higher in multiparous
obese compared to non-obese counterparts. However, the
difference was not significant in nulliparous obese and
non-obese subgroups. Nevertheless, the power was not
enough in this subgroup analysis to draw conclusion from

Fig. 1  Flowchart of the study

population Total 308 postdate pregnant women

(>41weeks) were screened for eligibility

17 were excluded due to age>40 (n=10),

unreliable dating (n=5) and 2 fetal deaths

291 pregnant women were eligible

3 women refused to participate

288 women; 144 obese and 144 non-

obese women continued the study

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 Archives of Gynecology and Obstetrics

Table 1  General characteristics of study population

Characteristic Obese group (n = 144) Non-obese group (n = 144) Difference between groups P value
(95% CI)

Age (years) 27.6 ± 5.8 26.3 ± 5 1.3 (− 0.001, 2.59) 0.06

Parity
 Multiparity 80 (55.6%) 79 (54.9%) 0.006 (− 0.1, 0.12) 0.9
 Nulliparity 64 (44.4%) 65 (45.1%)
Gestational age (days) 289.8 ± 2.46 289.4 ± 2.55 0.45 (− 0.13. 1.03) 0.13
BMI (kg/m2) 34 (30, 42.9) 27 (23.4, 29.9) 7 (6.1, 7.5) < 0.001
Neonatal birth weight (kg) 3.27 ± 0.4 3.18 ± 0.38 (− 0.002, 0.18) 0.06
Amniotic fluid index 9 (3, 19) 9 (2, 19) 0 (− 1, 1) 0.7
Bishop score 3 (0, 8) 3 (0, 8) 0 (− 0.99, 0.001) 0.06
Total misoprostol needed for 75 (0, 100) 62.5 (0, 100) 13.5 (− 0.001, 14.1) 0.15
induction (ug)

Values are in the form of mean ± SD, median (range) or count (percent). Bold font indicates significance
BMI body mass index, CI confidence interval

Table 2  Outcome of labor induction and complications after delivery

Obese group (n = 144) Non-obese group Difference (95% CI) P value
(n = 144)

Mode of delivery
 Cesarean section 38 (26.4%) 23 (15.9%) 0.1 (0.01, 0.19) 0.02
  Cesarean section in multiparous women (n = 159) 21/80 (26.3%) 5/79 (6.3%) 0.2 (0.08, 0.3) < 0.001
  Cesarean section in primiparous women (n = 129) 17/64 (26.6%) 18/65 (27%) − 0.01 (− 0.1, 0.1) 0.8
 Vaginal delivery 106 (73.6%) 121 (84.1%) 0.02
Indication of cesarean delivery N = 38 N = 23 0.4
 Failure of induction 16 (42.1%) 10 (43.5%)
 Fetal distress 13 (34.2%) 6 (26.1%)
 Failure of progress 9 (23.7%) 7 (30.4%)
Duration till vaginal delivery 22 (5, 38) 19 (5, 37) 3 (0.1, 5.9) 0.01
Postpartum hemorrhage 3 (2%) 5 (3.4%) − 0.013 (− 0.05, 0.02) 0.47
Apgar score at 5 min 8 (4, 10) 8 (6, 10) 0 (− 0.001, 0.001) 0.97

Values are in the form of mean ± SD, median (range) or count (percent). Bold font indicates significance
CI confidence interval

this result. 106 (73.6%) obese and 121 (84.1%) non-obese
women delivered vaginally and the duration till VD was
significantly higher in obese group (22 vs 19 h, P value
0.01), Table 2.
After adjustment for possible confounding factors,
the CS was still higher in the obese group in comparison
to non-obese group (OR 2.02; 95% CI 1.1, 3.7; P value
0.02). This result suggested that obesity was an independ-
ent factor for failure of IOL. In addition, after adjustment
for these confounders, obesity had the risk of increasing
labor duration by 2.3 h (95% CI 0.1, 4.5) in cases that
ended in VD, Table 3.
Discussion
Maternal obesity has been demonstrated to impose high
risk of prolonged gestation [7]. Little data in the literature
are known about the risk of unsuccessful IOL in obese
postdate pregnant women. In the present study, we dem-
onstrated higher risk of failure of IOL in obese postdate
pregnant women with OR of 2.02 relative to non-obese
counterparts after adjustment for possible confounders.
Some investigators have suggested that excess adipose
tissue may lead to hormonal imbalance which can result

13
Archives of Gynecology and Obstetrics
Table 3  Logistic regression analysis for mode of delivery (cesarean
versus normal delivery), and multivariable regression for duration till
vaginal delivery
Odds ratio or B 95% CI P value
coefficient
Unsuccessful induction; 2.02a 1.1, 3.7 0.02
cesarean section (obese
vs non-obese group)
Duration till vaginal 2.3b 0.1, 4.5 0.04
delivery in hours(obese
vs non-obese group)
Bold indicates significance
vs versus
a
 The odds of having versus not having unsuccessful induction after
adjustment for gestational age, parity, Bishop score, membrane rup-
ture and amniotic fluid index
b
 B coefficient for duration of labor in cases of vaginal delivery after
adjustment for the same confounding factors
in prolonged gestation [11, 16]. Pefzner and colleagues
performed secondary analysis of data collected during the
misoprostol for IOL study and found that the incidence of
cesarean delivery increased from 21.3% in the group with
BMI less than 30 to 29.8% in the group with BMI 30–39.9
[13]. In addition, Wolfe and associates reported, in their
retrospective study, that 29% of women with BMI > 40 and
13% of cases with normal BMI had failure of IOL [12]. In
the above two studies, they related the incidence of failure
of IOL to pre-pregnancy BMI.
We also demonstrated that labor is prolonged by 2.2 h
till vaginal delivery in obese in comparison to non-obese
pregnant women after adjustment for possible confound-
ing factors. Similar results were reported by other stud-
ies. Nuthalapaty and associates observed 0.3 h increase
in time interval from oxytocin initiation to delivery with
each 10 kg increase in body weight in nulliparous women
undergoing IOL [17]. Also, Kominiarek and colleagues, in
their retrospective study, found a delay of 1–1.2 h in labor
duration in the highest category of BMI (> 40) relative to
the lowest category (< 25) [18].
The cause of our findings of prolonged labor and
higher CS rates in obese postdate pregnant women may
be impaired uterine contractility which may be related to
impaired cholesterol level and increased leptin concentra-
tion [4, 19].
Our results are supported by other retrospective studies
which demonstrated that the risk of CS in obese women
is higher relative to non-obese women [7, 13]. However,
the present study, with a prospective design, addressed the
special situation of obese women undergoing IOL for pro-
longed pregnancy. In addition, adjustment for confounders
was performed to proof the independence of obesity as a risk
factor for failure of IOL.
We directly assessed the BMI at the time of IOL. That
was different from retrospective studies that related pre-
pregnancy BMI with pregnancy outcome. It is logical that
real obesity at time of delivery may affect response to labor
induction. It was also demonstrated in a recent systematic
review that gestational weight gain is an important predictor
of maternal and fetal outcomes in general [6].
Our study has also limitations. The BMI at the book-
ing visit was not included in data collection from patients’
antenatal records, as in our tertiary hospital, many pregnant
women started their antenatal care after the first trimester.
These data could have enriched the analysis by assessment
of correlation between gestational weight gain and our study
outcomes.
Based on our results, we conclude that there is a higher
risk of CS in obese postdate pregnant women undergoing
IOL in comparison to non-obese counterparts. Therefore,
obstetricians should pay more attention when advising preg-
nant women about optimal weight gain during pregnancy
and counseling about the chances of VD in cases of IOL.
Author contributions  AM: project development. AE-S: project devel-
opment and revision of data. HM: project development, data collection
and revision of the manuscript. DB: review of literature, data collection
and manuscript writing. AA: data collection. EO: review of literature,
data analysis and manuscript writing. MT: data collection. SE: manu-
script revision. MK: data collection.
Compliance with ethical statements 
Conflict of interest  The author reports no conflicts of interest in this
work.
Ethical approval  The study was performed in accordance with the Dec-
laration of Helsinki ethical standards.
Informed consent  Informed consents were taken from study partici-
pants.
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