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Terry S. Johnson, APN, NNP-BC, CLEC, MN Neonatal Nurse Practitioner

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Presentation on theme: "Terry S. Johnson, APN, NNP-BC, CLEC, MN Neonatal Nurse Practitioner"— Presentation transcript:

1 “Double Jeopardy” The Impact of Maternal Obesity on Mother and Infant Outcome
Terry S. Johnson, APN, NNP-BC, CLEC, MN Neonatal Nurse Practitioner Founder, Lode Star Enterprises, Inc.

2 Disclosure Statement Terry S. Johnson, APN, NNP-BC, CLEC, MN
In addition to any clinical practice, education and consulting services I provide I am currently on the speaker's bureau and/or consult with these industry partners Prolacta Bioscience and Abbott Nutrition Health Institute I receive financial reimbursement for those services Images & photographs used in this presentation come from publicly accessed sources I will make no recommendations for an off label use of any drug, product or medical device I am honored to be here today

3 Maternal Obesity ACOG “In the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese, putting them at a greater risk of pregnancy complications.”

4 Obesity By Definition Quantified for clinical purposes by a BMI of >30 Institute of Medicine (IOM) published revised pregnancy weight gain guidelines based on WHO pre-pregnancy BMI ranges These ranges are independent of age, parity, smoking history, race, and ethnic background Normal weight as a BMI of 18.5–24.9 Overweight as a BMI of 25–29.9 Obesity as a BMI of 30 or greater

5 Obesity By Geography Percentage of Female Obesity (BMI > 30)
“Pre-pregnancy, 72 percent of German women were at a healthy weight, compared with just 47 percent for the Americans.”

6 Obesity Trends Among U.S. Adults Between 1985 and 2010
Adult Obesity Facts More than one-third of U.S. adults (35.7%) are obese Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death In 2008, medical costs associated with obesity were estimated at $147 billion; the medical costs for people who are obese were $1,429 higher than those of normal weight. The South had the highest prevalence of obesity (29.5%), followed by the Midwest (29.0%), the Northeast (25.3%) and the West (24.3%)

7 Obesity Trends Among U.S. Adults Between 1985 and 2010
Adult Obesity Facts Non-Hispanic blacks have the highest age-adjusted rates of obesity (49.5%) compared with Mexican Americans (40.4%), all Hispanics (39.1%) and non-Hispanic whites (34.3%) Higher income women are less likely to be obese than low-income women There is no significant relationship between obesity and education among men. Among women, however, there is a trend—those with college degrees are less likely to be obese compared with less educated women

8 Prevalence. of Self-Reported Obesity Among U. S
Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011 *Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before 2011. CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK PR GUAM NH MA RI CT NJ DE MD DC 15%–<20% 20%–<25% %–<30% %–<35% ≥35%

9 Prevalence. of Self-Reported Obesity Among U. S
Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2012 *Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before 2011. CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK NH MA RI CT NJ DE MD DC PR GUAM 15%–<20% 20%–<25% %–<30% %–<35% ≥35%

10 Prevalence. of Self-Reported Obesity Among U. S
Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013 *Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before 2011. CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK NH MA RI CT NJ DE MD DC PR GUAM 15%–<20% 20%–<25% %–<30% %–<35% ≥35%

11 Obesity Trends Among U.S. Adults Between 1985 and 2010
Review of Data In 1990, among states participating in the Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no state had prevalence equal to or greater than 15%. By 2000 , no state had a prevalence of obesity less than 10%, 23 states had a prevalence between 20–24%, and no state had prevalence equal to or greater than 25%.

12 Obesity Trends Among U.S. Adults Between 1985 and 2010
Review of Data In 2010, no state had a prevalence rate of obesity less than 20%. Thirty-six states had a prevalence rate equal to or greater than 25%; 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia) had a prevalence rate equal to or greater than 30%.

13 Obesity Associated Mortality
Maternal Morbidity: CV Disease BMI greater than 30 kg/m2 Higher rates of maternal hypertension Risk of preeclampsia 3 times that of normal weight BMI greater than 35 kg/m2 Risk of preeclampsia 5 times greater Etiology – influenced by maternal weigh Insulin resistance Inflammatory changes Oxidative stress Altered vascular bed Increase the lifetime risk for CV disease

14 Obesity Associated Mortality
Maternal Mortality Estimated annual obesity related mortality 112,000 to 365,000 Overweight – 20% to 50% increased mortality Obese – 2-3 fold increased mortality The earlier in life obesity present – worse mortality Framingham Study Obese lived 6-7 years less If smoker, lived years less

15 Impact of Maternal Obesity
Currently, 1 in 5 pregnant women in the United States is obese Maternal obesity results in higher rates of cesarean section, higher rates of infant birth defects and a three-fold higher incidence of neonatal death. Babies born to obese mothers, even if born at a normal weight, have been shown to have multiple metabolic problems with lifelong consequences.

16 Impact of Maternal Obesity
Currently, 1 in 5 pregnant women in the United States is obese Maternal obesity results in higher rates of cesarean section, higher rates of infant birth defects and a three-fold higher incidence of neonatal death. Babies born to obese mothers, even if born at a normal weight, have been shown to have multiple metabolic problems with lifelong consequences.

17 Impact of Maternal Obesity
Currently, 1 in 5 pregnant women in the United States is obese Maternal obesity results in higher rates of cesarean section, higher rates of infant birth defects and a three-fold higher incidence of neonatal death. Babies born to obese mothers, even if born at a normal weight, have been shown to have multiple metabolic problems with lifelong consequences.

18 Body Mass Index and Obesity
Obesity in Pregnancy Definitions of Obesity in Pregnancy Body Mass Index and Obesity Definition BMI kg/m2 Obesity Class Underweight < 18.5 Normal 18.5 – 24.9 Overweight 25.0 – 29.9 Pre-Obese Obese 30.0 – 34.9 I 35.0 – 39.9 II Extremely Obese ≥ 40 III Pi-Sunyer FX, Becker DM, Bouchard C, et al. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: evidence report: NIH publication #4083. Gunatilake. RP & Perlow JH Obesity and pregnancy. Am J Obstet Gynecol 2011.

19 Maternal Obesity and Pregnancy
Pathophysiology of Maternal Obesity in Pregnancy

20 Obstetric Complications by Maternal BMI
Obesity in Pregnancy Obstetric Complications by Maternal BMI Obesity vs. Control Class III Obesity vs. Control Outcome ADJ OR (95% CI) P Value Gestational DM 2.6 ( ) <.0001 1.7 ( ) <.01 Gestational HTN 2.5 ( ) 3.2 ( ) Preeclampsia 1.6 ( ) .007 3.3 ( ) BW > 4500 g 2.0 ( ) .0006 2.4 ( ) BW > 4000 g 1.7 (1.4—2.0) 1.9 ( ) Preterm Delivery 1.1 (0.9—1.5) .4 1.5 ( ) .01

21 Obstetric Complications by Maternal BMI
Obesity in Pregnancy Obstetric Complications by Maternal BMI Obesity vs. Control Class III Obesity vs. Control Outcome ADJ OR (95% CI) P Value Operative Vaginal Del. 1.0 ( ) .9 1.7 ( ) <.01 PPROM 1.3 ( ) .14 1.3 ( ) .2 IUGR 0.9 ( ) .82 0.8 ( ) .6 Placenta Previa 1.3 ( ) .4 0.7 ( ) Placenta Abruption 1.0 ( ) 1.0 ( ) Cesarean Delivery 1.7 ( ) 3.0 ( )

22 Obesity in Pregnancy Antenatal Management Early ultrasound
Confirm viability, assign EGA, Assess for multiples Thorough history Coexistence, severity of comorbidities DM, thyroid disorders, hypertension, liver & gall bladder disease, orthopedic issues Baseline serum chemistries Uric acid, creatinine, hepatic transaminases 24-hour urine for proteinuria

23 Obesity in Pregnancy Antenatal Management Maternal ECHO
Evaluate for cardiomyopathy Sleep disorder evaluation Obesity is one of strongest risk factors for obstructive sleep apnea – associated with a 2-fold risk for HTN, stroke, cardiac dysfunction Hypertension evaluation Strong positive correlation between pre-pregnancy BMI and the risk of preeclampsia even when additional co-exisiting risk factors were excluded Risk of preeclampsia doubles for each 5-7 kg/m2 increase in pre-pregnancy BMI

24 Obesity in Pregnancy Gestational Weight Recommendations
Dietary counseling Ideally, preconceptual normal BMI Limited weight gain, rather than weight loss < 10 pounds of gestational weight gain in class II & III women decreases risk for preeclampsia, C/S, SGA, LGA IOM Recommendations for Gestational Weight Gain Upper limit weight gain for obese women of 20 lbs/9kg Lower limit weight gain from 11 lbs/5kg

25 Obesity in Pregnancy Second Trimester Care
Medical, Nursing, Dietary Optimization Monitoring for congenital anomalies Obese African American woman has a 6-fold greater likelihood for fetal congenital cardiac malformations Detailed fetal anatomy ultrasound mid-trimester Consider fetal ECHO between weeks gestation Complete fetal anatomic survey could only be completed 50% of time due to maternal obese body habitus If anomaly present – amniocentesis, CVS

26 Obesity in Pregnancy Third Trimester Care Critical Period
Monitor for preterm labor 2° obesity related conditions Higher risk for post-date pregnancy Monitor for superimposed preeclampsia Repeat 50 g 1-hour oral glucose challenge 2- to 3-fold increased risk of intrauterine fetal death Higher risk for hypoxic-apneic episodes Monitor for fetal macrosomia or growth-restriction Sonographic fetal growth assessment every 4-6 weeks

27 Obesity in Pregnancy Labor and Delivery Management
Failed Induction of Labor IOL trial where patients stratified by BMI Median dose & duration of pre-delivery oxytocin was greater BMI > 40 kg/m2 = 5.0 units and 8.5 hours Normal BMI = 2.6 units and 6.5 hours European series of > 200,000 deliveries BMI of > 40 kg/m2 associated with a 4 times risk of C/S because of failed labor with/without augmentation

28 Obesity in Pregnancy Labor and Delivery Management
Failed Induction of Labor Prospective study of 509 nulliparous women with IOL As maternal weight ↑ the rate of cervical dilatation ↓ Associated with ↑ induction to delivery interval Slower active phase of labor in overweight/obese women Adjusted for labor augmentation, oxytocin use, epidural analgesia, gestational weight gain, and fetal size Normal weight women – 6.2 hours Overweight women – 7.5 hours Obese women – 7.9 hours ? Role of leptin in inhibiting uterine contractions

29 Obesity in Pregnancy Labor and Delivery Management
Risk of Surgical Delivery Likelihood of operative vaginal delivery (X1.5 in BMI > 30 kg/m2 and X2 in BMI > 40 kg/m2) Associated with higher maternal and fetal morbidity Shoulder dystocia (obesity a 2.7-fold risk) Macrosomia also increases risk Birth trauma Perineal lacerations Postpartum hemorrhage “An attempted operative vaginal delivery in an obese patient must be made judiciously with informed consent.”

30 Obesity in Pregnancy Labor and Delivery Management
Increased Risk of Elective or Emergent C/S Study of >16,000 Pre-pregnancy BMI and Weight Gain C/S rate for control non-obese patients was 20.7% C/S rate for obese (BMI kg/m2) was 33.8% C/S rate for extremely obese women (BMI >35 kg/m2) was 50% Risk is further augmented by Obesity-related pregnancy complications Inherent perioperative risks from surgery C/S complicates management of future pregnancies Uterine rupture, placenta previa, placenta acreta, perioperative morbidity, hemorrhage

31 Obesity in Pregnancy Intrapartum Management Bariatric Obstetrics
Unit equipment needs Bariatric bed and frame with trapeze (eg, pound capacity) Toilet able to accommodate 500+ pounds Inflatable mattress Extra-wide wheelchairs Intraoperative equipment needs Extra-large blood pressure cuffs; fetal monitoring equipment Extra-large inflatable sequential compression devices Larger belts and straps to secure patient Extra-long surgical instruments, self-retaining retractor

32 Obesity in Pregnancy Intrapartum Management Anesthesia Considerations
More likely to have anesthesia failures Initial failed epidural Subsequent epidural placement Higher rates of difficult intubation Inadvertent puncture Intraoperative equipment needs Up to 75% of all anesthesia-related deaths occur among obese pregnant women!

33 Anesthesia Risk Mallampatti Test 2
Correlates tongue size to pharyngeal size Performed with the patient in the sitting position, head in a neutral position, the mouth wide open and the tongue protruding to its maximum Classification is assigned according to the extent the base of tongue is able to mask the visibility of pharyngeal structures into three classes

34 Anesthesia Risk Mallampatti Test 2 Used to predict the ease of
intubation by examining the anatomy of the oral cavity. Modified Mallapatti Test Scoring: Class 1: Full visibility of tonsils, uvula and soft palate Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula Class 3: Soft and hard palate and base of the uvula are visible Class 4: Only Hard Palate visible

35 Obesity in Pregnancy Intrapartum Management Anesthesia Considerations
Early anesthesia consultation During third trimester or on admission to labor and delivery of any Class III obese women Early placement of prophylactic epidural catheter Option for “awake” intubation Fiber-optic laryngoscopes, intubating laryngeal airways Emergency cricothyroidotomy kit Up to 75% of all anesthesia-related deaths occur among obese pregnant women!

36 Obesity-Related Peripartum Complications
↑ Respiratory work and myocardial oxygen requirement Epidural anesthesia, supplemental oxygen, left-lateral laboring Difficult peripheral IV access Central intravenous catheter Inaccurate blood pressure monitoring Appropriate sized cuff, arterial line Increased risk of general anesthesia Anesthesia consultation, early epidural Anticipated difficulty with intubation Capability for awake/fiber-optic intubation Difficulty with patient transfers Bariatric lifts and inflatable mattresses, additional personnel

37 Obesity-Related Peripartum Complications
Prolonged cesarean operative time Combined spinal-epidural anesthesia Poor operative exposure Evaluation of maternal anthropometry, periumbilical skin incision, atraumatic self-retaining retractor Enhanced risk of hemorrhage Blood typed and crossed for transfusion, ligate large subcutaneous vessels, meticulous surgical technique Enhanced aspiration risk Prophylactic epidural, H2 antagonist, sodium citrate with citric acid, metoclopramide, NPO in labor Enhanced thromboembolic risk Early postoperative ambulation, sequential pneumatic compression, heparin until fully ambulatory Enhanced infectious morbidity Thorough skin preparation, adequate antimicrobial prophylaxis, meticulous surgical technique, ? SQ drain Enhanced risk of C/S Informed consent, monitoring labor curve, intervention for labor dystocia

38 Obesity in Pregnancy Postpartum Management
Elevated Risk in Postpartum Period ↑ Rate of wound infection, thromboembolism, fluid retention Postpartum depression (as high as 40% in Class III) Treatment strategies Close inspection of surgical wound (? Skin staple removal) Monitor vital signs closely Early ambulation and incentive spirometry Early follow-up (1-2 weeks) PD screening Contraception counseling Obese mother’s have a 5- to 16-fold increase in hospital costs

39 The H.A.P.O. Study Translating Evidence Into Best Practice:
Hyperglycemia Adverse Pregnancy Outcome (H.AP.O. Study) Research Findings Implications for Practice Best Practice (Action Step) Obese women without history of elevated GTT or GD are at an increased risk for delivering a macrosomic or LGA infant Macrosomia and LGA are associated with C/S, shoulder dystocia, birth trauma, and increased need for NICU The NICU should be notified when obese mothers are admitted to labor and delivery and when birth is expected

40 The H.A.P.O. Study Translating Evidence Into Best Practice:
Hyperglycemia Adverse Pregnancy Outcome (H.AP.O. Study) Research Findings Implications for Practice Best Practice (Action Step) Maternal hyperglycemia, with levels below those diagnostic of GD is associated with fetal hyperinsulinemia Fetal hyperinsulinemia has a well known association with delayed surfactant synthesis and excretion, which may result in respiratory distress syndrome Infants of obese mothers, especially LPI (born /7 weeks gestation) should be carefully monitored for signs and symptoms of respiratory distress syndrome

41 The H.A.P.O. Study Translating Evidence Into Best Practice:
Hyperglycemia Adverse Pregnancy Outcome (H.AP.O. Study) Research Findings Implications for Practice Best Practice (Action Step) Infants of obese women are at an increased risk for neonatal hypoglycemia Fetal hyperinsulinemia is well known to result in neonatal hypoglycemia. Glucose is the primary fuel for the newborn brain. Prolonged neonatal hypoglycemia can result in jitteriness, hypotonia, lethargy, respiratory distress, cyanosis, seizures and neurodevelopmental impairment. Infants of obese mothers should be closely monitored for hypoglycemia, beginning at 1-2 hours after birth and extended through the first day of life if warranted

42 The H.A.P.O. Study Translating Evidence Into Best Practice:
Hyperglycemia Adverse Pregnancy Outcome (H.AP.O. Study) Research Findings Implications for Practice Best Practice (Action Step) Maternal hyperglycemia is associated with fetal hyperinsulinemia and hyperbilirubinemia Fetal hyperinsulinemia drives catabolism of the oversupply of fuel, uses energy and depletes O2 stores resulting in fetal RBC hyperplasia and increased hematocrit Infants of obese mothers should have bilirubin screening and continued monitoring and follow-up after discharge, if warranted

43 The H.A.P.O. Study Translating Evidence Into Best Practice:
Hyperglycemia Adverse Pregnancy Outcome (H.AP.O. Study) Research Findings Implications for Practice Best Practice (Action Step) Obese women without history of elevated GTT or GD are at an increased risk for delivering a macrosomic or LGA infant Macrosomia and LGA are associated with C/S, shoulder dystocia, birth trauma, and increased need for NICU The NICU should be notified when obese mothers are admitted to labor and delivery and when birth is expected Maternal hyperglycemia, with levels below those diagnostic of GD is associated with fetal hyperinsulinemia Fetal hyperinsulinemia has a well known association with delayed surfactant synthesis and excretion, which may result in respiratory distress syndrome Infants of obese mothers, especially LPI (born /7 weeks gestation) should be carefully monitored for signs and symptoms of respiratory distress syndrome

44 Maternal Obesity Impact on Infants
“By the time pregnancy is generally diagnosed, the fetus already has been exposed to the potentially “toxic metabolic environment” that is seen with obesity, and impaired organogenesis may have already occurred. Additionally, the degree of weight loss required to substantially modify important health parameters (blood pressure, blood glucose, and lipid levels) cannot occur safely in pregnancy without concern for the fetus. It cannot be overstated that the ideal time for intervention is before conception”.

45 FFAs + Plasminogen-activator Inhibitor-1 Placental Dysfunction
Fat Cells Release FFAs + Plasminogen-activator Inhibitor-1 ↑ FFAs → Liver Produces More Glucose/Triglycerides + Pancreas ↑ Insulin Secretion Hyperinsulinemia + Insulin Resistance Hyperinsulinemia + ↑ FFA’s Contribute to Hypertension ↑ Proinflammatory Cytokines ↑ Liver Production of Fibrinogen Prothrombotic State Hyperlipidemia + ↑ Circulating Glucose + Insulin Resistance + Pro-inflammatory State Placental Dysfunction

46 Obesity and Congenital Anomalies
Overweight Obesity Congenital Anomaly ADJ OR (95% CI) P Value Neural Tube Defects 1.2 ( ) .01 1.87 ( ) <.001 CV Anomalies 1.17 ( ) .02 1.3 ( ) .03 Cleft Lip and Palate 1.0 ( ) >.99 1.2 ( ) Anorectal Atresia 1.19 ( ) .2 1.48 ( ) .006 Craniosynostosis 1.24 ( ) .07 1.18 ( ) .25 Diaphragmatic Hernia 0.95 ( ) .72 1.28 ( ) .1 Gastroschisis 0.83 ( ) .63 0.17 ( )

47 Obesity and Congenital Anomalies
Overweight Obesity Congenital Anomaly ADJ OR (95% CI) P Value Hydrocephaly 1.28 ( ) .13 1.68 ( ) .003 Hypospadius 1.13 ( ) .21 1.08 ( ) .52 Limb Reduction 1.22 ( ) .09 1.34 ( ) .03 Microcephaly 1.21 ( ) .3 1.10 ( ) .54 Micro/anotia 0.97 ( ) .86 1.11 ( ) .61 Esophageal Atresia 0.89 ( ) .46 1.27 ( )

48 Maternal Obesity and the Newborn
Infants Born to Obese Mothers Increased risk Fetal or neonatal death Late fetal death (> 28 weeks) 4X greater than infants born to normal-weight women Twice as likely to die in first year of life For delivery room resuscitation requiring bag and mask or intubation NICU admission (~3.5 to 5.0 times more likely) LOS Etiology probably multifactorial Endogenous hyperinsulinemia →Rapid fetal growth → Functional placental insufficiency → Relative fetal hypoxia

49 Infants of Diabetic Mothers
Diabetes Mellitus Type I: Insulin Dependent Genetic/environmental influences/auto-immune Destruction of pancreatic β cells Type 2: Non-Insulin Dependent Insulin resistance; impact of advancing age, obesity, previous history of gestational diabetes Type 3: Gestational Diabetes Increase glucose levels/intolerance during pregnancy Disappears after pregnancy; 35-60% go on to Type 2

50 Infants of Diabetic Mothers
Maternal/Neonatal Mortality Rates Type Diabetes Gestational Diabetes No Glucose Issues Delivery <37 weeks 21.0% 8.6% 5.1% Stillbirth 1.5% 0.4% 0.3% RDS 1.0% 0.2% LGA 31.0% 15.1% 3.6% Erb’s Palsy 2.1% 0.7%

51 Infants of Diabetic Mothers
Macrosomia 1 Maternal hyperglycemia Glucose – not insulin –crosses the placenta Fetal hyperglycemia 2 Increased fetal insulin production Pancreatic islet cell hyperplasia Fetal hyperinsulinemia 3 Insulin is a growth hormone Hyperinsulinemia accelerates growth/macrosoma Enlarged liver, spleen, heart, ↑ hepatic fat/glycogen stores

52 Complications in IDMs Complication Associated Problems Macrosomia
↑C/S delivery for failure to descend LGA ↑Birth trauma (fractures, palsy) Cardiomegaly Cardiac septal hypertrophy Metabolic Abnormalities Hypoglycemia Hypocalcemia Hypomagnesemia Relative Hypoxia Polycythemia/hyperviscosity Renal vein thrombosis Hyperbilirubinemai Respiratory Distress Syndrome Surfactant deficiency Flaring, retractions, grunting

53 Complications in IDMs Complication Associated Problems
Congenital Anomalies Glucose as a teratogen Seen in 4-12% of IDMs born to Type I mothers Neural tube defects Caudal or sacral agenesis Cardiac defects (VSD, septal hypertrophy) Small left colon syndrome Genitourinary abnormalities Outcomes Multifactorial, cumulative effects Anomalies resulting in death, morbidity asphyxia, hyperviscosity, hypoxemia, and metabolic acidosis at delivery Persistent hypoglycemia resulting in neurodevelopmental issues

54 Long Term Impact of Maternal Obesity
Center for Disease Control and Prevention About 2 percent of American Schoolchildren were diagnosed with autism disorders in 2011 and 2012, a 72 percent increase from the previous five years. The current data show that 1 in 50 children have been diagnosed with autism or a related disorder. Center for Disease Control and Prevention, March 20, 2013

55 Long Term Impact of Maternal Obesity
UC Davis MIND Institute Over 60 percent of U.S. women of childbearing age are overweight; 34 percent are obese; and 16 percent have metabolic syndrome Nearly 9 percent of U.S. women of childbearing age are diabetic, and more than 1 percent of U.S. pregnancies were complicated by chronic hypertension Found strong links between maternal diabetes and obesity and the likelihood of having a child with autism spectrum disorder (ASD) or another developmental disorder Krakowiak P, et al. Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders. Pediatrics, April 2012 DOI: /peds

56 Long Term Impact of Maternal Obesity
UC Davis MIND Institute Included 1,004 mother/child pairs Enrolled in the Childhood Autism Risks from Genetics and the Environment Study (CHARGE) between January June 2010 Children between 24 and 60 months old, born in California and resided with at least one biological parent who spoke either English or Spanish Krakowiak P, et al. Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders. Pediatrics, April 2012 DOI: /peds

57 Long Term Impact of Maternal Obesity
UC Davis MIND Institute Relationship of maternal metabolic conditions & risk of neurodevelopmental disorders Mothers who were obese 67 percent more likely to have a child with ASD than normal-weight mothers without diabetes or HTN More than twice as likely to have a child with another developmental disorder Krakowiak P, et al. Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders. Pediatrics, April 2012 DOI: /peds

58 Long Term Impact of Maternal Obesity
UC Davis MIND Institute Relationship of maternal metabolic conditions & risk of neurodevelopmental disorders Mothers with diabetes Nearly 67 percent more likely to have a child with developmental delays as healthy mothers Children of diabetic mothers who had ASD were more disabled - greater deficits in language comprehension and adaptive communication Krakowiak P, et al. Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders. Pediatrics, April 2012 DOI: /peds

59 Long Term Impact of Maternal Obesity
UC Davis MIND Institute “Over a third of U.S. women in their childbearing years are obese, and nearly one-tenth have gestational or type 2 diabetes during pregnancy. Our finding that these maternal conditions may be linked with neurodevelopmental problems in children raises concerns and therefore may have serious public-health implications. And while the study does not conclude that diabetes and obesity cause ASD and developmental delays, it suggests that fetal exposure to elevated glucose and maternal inflammation levels adversely affect fetal development." Krakowiak P, et al. Maternal Metabolic Conditions and Risk for Autism and Other Neurodevelopmental Disorders. Pediatrics, April 2012 DOI: /peds

60 Hypoglycemia Screening
Neonatal Glucose Homeostasis In Utero Glucose main energy source for fetus Facilitated transfusion from mother to fetus Insulin does not cross the placenta Fetal glucose levels reflect maternal levels Fetus producing insulin at 13 weeks gestation Unused glucose stores in the liver as glycogen Birth disrupts maternal-fetal glucose transfer Umbilical venous plasma glucose ~ 60-80% of maternal

61 Hypoglycemia Screening
Neonatal Glucose Homeostasis After Birth Glycogenolysis stimulated ↓ Levels of insulin coincide with ↑ levels of catecholamines and glucagon Full term 4-6 mg/kg/min Fetus and preterm 8-9 mg/kg/min Fat mobilization Full term 15% to 16% of body weight Preterm infant 2% of body weight Liver can only store 50 to 75 grams of glycogen per kilogram equivalent of 200 to 300 calories

62 Hypoglycemia Screening
Definition Controversial Variables – SGA, IUGR, “stressed” 40-ish S.T.A.B.L.E. Program 50 mg/dL “Symptomatic” vs. “Assymptomatic” “Whipple’s Triad” Accurate measurement of a low blood glucose level Presence of signs of hypoglycemia Resolution of signs of hypoglycemia after rrestoration of a normal blood sugar

63 Hypoglycemia Screening
Clinical Presentation of Hypoglycemia in the Newborn Jitteriness, irritability, or tremors Lethargy Hypotonia Temperature instability High-pitched/ weak cry Tachypnea Apnea Poor suck, poor coordination of feeding Vomiting Tachycardia/bradycardia Cyanosis Eye-rolling/Doll’s sign Seizures Coma

64 Management of Hypoglycemia
American Academy of Pediatrics (2012)

65 Management of Hypoglycemia
Treatment of Symptomatic Neonatal Hypoglycemia AAP IV glucose initiated immediately for infants with symptomatic hypoglycemia To achieve a plasma glucose level of mg/dL 200 mg/kg (dextrose 10% at 2 mL/kg) or IV infusions of 5-8 mg/kg/min ( mL/kg per day) Blood glucose should be checked every minutes after the start of therapy Glucose therapy decreased gradually as enteral feedings advanced If higher concentration of glucose required – central line

66 Management of Hypoglycemia
Treatment of Resistant Neonatal Hypoglycemia Persistent Glucose Levels Below 40 mg/dL Evaluate for hyperinsulinemic hypoglycemia If higher concentration of glucose required – central line Obtain insulin levels Consult endocrinology Potential medications: Corticosteroids Glucagon Diazoxide Wilker R: Hypoglycemia and hyperglycemia In: Cloherty J, Eichenwald E, Stark A, eds. Manual of Neonatal Care ed.6. Philadelphia: Lippincott Williams & Wilkins,

67 The H.A.P.O Study Increased Maternal Glucose Concentration
25,505 pregnant women at 15 centers in 9 countries 75-g oral glucose-tolerance testing at weeks “Clarify risk of maternal glucose intolerance less severe than that in overt diabetes”

68 The H.A.P.O Study Increased Maternal Glucose Concentration
Found associations between increasing levels of fasting, 1-hour, and 2-hour plasma glucose obtained on oral glucose-tolerance testing and BW > than 90th percentile Cord blood serum C-peptide level > than 90th percentile Weaker associations Primary cesarean section delivery Clinical neonatal hypoglycemia Premature delivery, shoulder dystocia or birth injury, neonatal intensive care, hyperbilirubinemia, and preeclampsia

69 What Happens Here… “Programming”
The term "programming" refers to the concept that an insult or stimulus applied at a critical or sensitive period may have long-term or lifetime effects on the structure or function of an organism Virtually all forms of organ injury start with molecular or structural alteration in cells. Lucas A Journal of Perinatology (2005) 25, S2–S6. doi: /sj.jp

70 Long Term Impact of Maternal Obesity
Long Term Health Outcomes “Recently, mounting epidemiologic evidence suggests that infants of obese mothers are at greater risk for lifelong metabolic complications that include diabetes mellitus, heart disease, and obesity through intriguing mechanisms of “in-utero programming” of adult disease.”

71 Hypotheses Linking Early Events/Risk of Obesity

72 Benefit of Breastfeeding in Reducing Obesity

73 Maternal Obesity and Breastfeeding
Translating Evidence Into Best Practice Research Findings Research Study Best Practice Fewer obese women initiated breast feeding, compared to normal weight women Donath & Amir, 2000 Li, Jewel & Grummer-Strawn, 2003 Obese women need educational efforts aimed at promoting breast feeding Obese women breastfed their infants for less time (weeks and months), compared to normal weight women Oddy et al, 2006 Li, Jewel, & Grummer-Strawn, 2003 Early and on-going lactation support should be provided for all obese mothers Jorgensen AM NICU Currents June 2010, volume1, Issue 1.

74 Maternal Obesity and Breastfeeding
Translating Evidence Into Best Practice Research Findings Research Study Best Practice Obese women are more likely to have delayed onset of lactogenesis (defined as milk coming in > 72 hours after birth), compared to non-obese women Hilson, Rasmussen, & Kjolhede, 2004 Because delayed lactogenesis may pose a significant risk for dehydration, thermal stability, hypoglycemia, and extreme hyperbilirubinemia, exclusively breastfed infants of obese mothers, especially those born LPI should have Jorgensen AM NICU Currents June volume1, Issue 1. ANHI

75 Maternal Obesity and Breastfeeding
Translating Evidence Into Best Practice Best Practice Because delayed lactogenesis may pose a significant risk for dehydration, thermal stability, hypoglycemia, and extreme hyperbilirubinemia, exclusively breastfed infants of obese mothers, especially those born LPI should have: Glucose screening at 1-2 hours of life and continued monitoring if warranted Bilirubin screening at 48 hours of life and continued monitoring if warranted Daily weight assessment and weight loss criteria: LPI – weight loss < 7% of birth weight Term infants – weight loss < 10% of birth weight Infants of obese mothers may require supplementation banked human milk feeding or formula until the mother’s breast milk is enough to meet the infant’s nutritional requirements Jorgensen AM NICU Currents June volume1, Issue 1. ANHI

76 Obesity in Pregnancy “The practitioner of contemporary obstetrics needs no “p value” or “relative risk” statistics to be keenly aware of the prevalence of obesity within the pregnant population and the complications and challenges that are posed by obesity in the care of these patients.”

77 Presenter Terry S. Johnson, APN, NNP-BC, CLEC, MN
Neonatal Nurse Practitioner Founder, Lode Star Enterprises, Inc. 7709 Knottingham Lane Downers Grove, IL 60516 Phone:


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