The American College of Obstetricians and Gynecologists (ACOG) is warning that obesity during pregnancy increases the risk of several complications, including high blood pressure, a serious condition called preeclampsia and gestational diabetes. The ACOG opinion, published in the September issue of Obstetrics & Gynecology, says obese women also are more likely to miscarry, to need a Caesarean section, and to have excessive bleeding and infection after a Caesarean section. Babies of obese women are more likely to be stillborn, be born prematurely and have spinal cord abnormalities called neural tube defects. The risks affect women with a body mass index (BMI) of 25 to 30, and are even higher for women with a BMI of more than 30.
ACOG Issues Guidance to Ob-Gyns on Impact of Obesity During Pregnancy
Washington, DC–The American College of Obstetricians and Gynecologists (ACOG) today released its first committee opinion on obesity during pregnancy, a paramount issue as one-third of adult women in the US are obese. The ACOG document, “Obesity in Pregnancy,” explains the known risks that obesity poses to pregnant women and their babies and is published in the September issue of Obstetrics & Gynecology.
“Obesity has become an epidemic,” says Gary D.V. Hankins, MD, chair of ACOG’s Committee on Obstetric Practice, which developed the document. “At this point, 49% of non-Hispanic black women are obese, 38% of Mexican-American women are obese, and 31% of non-Hispanic white women are. And, everything we do in obstetrics is made more difficult and more complex by obesity*from using external monitors to performing surgery.”
According to ACOG, some studies show that obesity is an independent risk factor for miscarriage among women who undergo fertility treatment. Data also links obesity to miscarriage in women who conceived naturally. Obesity has been linked to an increased risk of gestational hypertension, preeclampsia, and gestational diabetes. And the higher the body mass index (BMI) a woman has, the higher the chance she will need a cesarean.
Other studies show that obese women have more complications during and after cesarean surgery, including excessive blood loss, operating time greater than two hours, and wound infection. Surgery in obese women also poses anesthetic challenges, among them difficult epidural placement and respiratory problems from difficult intubation.
Elevated risks to the babies of obese women include stillbirth, prematurity, macrosomia (large for gestational age), neural tube defects, and higher rates of childhood obesity.
“A lot of ob-gyns don’t bring up weight with patients,” says Laura E. Riley, MD, immediate past chair of ACOG’s Committee on Obstetric Practice. “We’re hoping to open the dialogue between patient and physician, so that patients come to understand that maintaining a healthy weight isn’t just about how you look, but that it also has real medical implications.”
Vivian M. Dickerson, MD, immediate past president of ACOG, emphasizes that the time to begin frank discussions about weight is before a pregnancy is achieved. “In preconception visits, we talk to patients about genetic risks and immunity to rubella, but rarely do we discuss their weight or diet and exercise,” Dr. Dickerson says. “But optimizing your weight before conception is one of the most important things you can do to have a healthy baby.”
ACOG makes the following recommendations for ob-gyns dealing with obese patients:
Explain to patients the Institute of Medicine (IOM) recommendations for prenatal weight gain: 25-35 lbs. for women of normal weight, 15-25 lbs. for overweight women, and 15 lbs. for obese women.
Record height and weight for all women at the initial prenatal visit to allow BMI calculation.
Offer nutrition consultation to all obese women and encourage them to follow an exercise program. This should be continued after the baby is born and prior to attempting another pregnancy.
Consider screening obese pregnant women for gestational diabetes during the first trimester and repeating it later in pregnancy if initial screening is negative.
Discuss potential pregnancy complications such as difficulty estimating fetal weight and obtaining fetal heart rate.
– Suggest that patients consult with an anesthesiologist prior to delivery or at the very latest, early in labor because they are at high risk for emergency cesareans.
To battle obesity, more people are turning to bariatric surgery. But as a result of the surgery, many patients who later become pregnant may see a host of complications such as gastrointestinal bleeding, anemia, intrauterine growth restriction, prematurity, and neural tube defects. The surgery can also lead to deficiencies in iron, vitamin B12, folate, and calcium. On the other hand, pregnancies following bariatric surgery are often less likely to be complicated by gestational diabetes, hypertension, macrosomia (large babies), and cesarean delivery.
“Because we’re just beginning to learn what the risks and upsides might be, it’s a balancing act for doctors and patients,” said Dr. Dickerson. “Patients need to proceed with caution because we really haven’t had enough experience yet with this to make solid conclusions.”
ACOG’s recommendations for obese patients who are pregnant or planning to conceive include having a preconception consultation and weight-loss counseling, seeking information on the risks of obesity and pregnancy, and continuing nutritional counseling and exercise programs after delivery.
What Is The Doctor’s Reaction?
During most pregnancies, everything goes well.
But up to 25% of pregnancies are not routine. Some problems are minor and have no long-lasting effects; others, such as premature labor and maternal hypertension (high blood pressure) can endanger the life of the mother, the baby or both. Current screening and monitoring procedures are useful, but doctors still cannot predict or prevent every complication of pregnancy.
A report released today links a number of pregnancy-related problems to a single, preventable condition: excess weight. The risk of trouble during pregnancy is increased among women who are overweight (body mass index, or BMI, of 25 to 30) compared with women who are not; and the risks are even greater among women who are obese (BMI of 30 or greater).
Overweight and obese women face an increased risk of:
gestational hypertension (high blood pressure during pregnancy)
gestational diabetes (elevated blood sugar during pregnancy)
pre-eclampsia (leg swelling, high blood pressure and kidney disease) or eclampsia (similar symptoms as pre-eclampsia plus seizures or coma)
excessive bleeding or infection following Cesarean section
delivering a baby with abnormalities in the spinal cord (called neural tube defects)
delivering a baby that is premature or stillborn
problems monitoring the health of the baby (such as detecting the fetal heart rate and estimating fetal size)
Studies also suggest that children of mothers who were obese during their pregnancy have a higher than average risk of childhood obesity.
Obstetricians and gynecologists are taking note, especially as the incidence of obesity is increasing. Experts are suggesting this important first step: talk about it. While doctors routinely discuss and recommend testing for a number of conditions around the time of pregnancy (including German Measles, HIV, hepatitis B, syphilis and gonorrhea), it is far less common for pregnant women and their doctors to focus on excess weight. These new guidelines aim to change that.
What Changes Can I Make Now?
Calculate your BMI and work hard to avoid excess weight. While it’s generally best to have a BMI under 25, it’s especially important to keep it less than 30. Talk with your doctors well before pregnancy about what you can do to lose those excess pounds. There is no one way that works for everyone, but most successful weight loss programs combine calorie restriction (including moderation of portion size) and exercise aiming for gradual, steady weight loss. If your weight is higher than ideal, ask your doctor about nutritional counseling and an exercise program that you can follow before, during and after pregnancy.
Regardless of your weight before pregnancy, weight gain during pregnancy is expected and encouraged; however, for your health and for that of your baby, excessive weight gain should be avoided. According to current guidelines, the weight gain during a routine pregnancy should be between 25 and 35 pounds; however, overweight women should aim for a weight gain of 15 to 25 pounds and obese women should aim for a weight gain of 15 pounds.
Despite the risks associated with obesity during pregnancy, I would not recommend bariatric surgery (such as “gastric stapling”) for every obese woman who is considering pregnancy. While certain risks may be decrease with profound weight loss, others may increase (such as vitamin deficiencies or intestinal bleeding) – we need more information about this approach before it can be routinely recommended.
What Can I Expect Looking To The Future?
Because the incidence of obesity is rising dramatically in this country, you can expect a dramatic increase in the number of women who become pregnant while overweight or obese. And that means you can expect a rising incidence of complicated pregnancies and deliveries. Increasing awareness regarding the impact of a woman’s weight on her pregnancy is an important first step, but only time will tell whether this awareness will translate into effective action.
You can expect researchers to study which programs work best to combat excess weight before pregnancy (including the option of bariatric surgery) and how best to handle complications that arise.
In the future, doctors will probably measure BMI more regularly for women who are planning pregnancy and will make their patients aware of the real risks associated with excess weight. It’s also likely that doctors will recommend more extensive screening for overweight and obese women who are pregnant so that problems are detected as early as possible. Finally, you can expect referrals for nutritional counseling and exercise programs to become a more routine part of obstetric practice.