Limitations of BMI in Pregnancy Using BMI, in pregnancy in not accurate. It should be done pre and post pregnancy. BMI does not really convey differences in shape that are relevant to obstetric anaesthetists and for the surgery during normal pregnancy and instrumental delivery or C/S.

The Scale of the Problem WHO: “Obesity is a worldwide epidemic”. 250 Million obese people, 7% of world population. USA: 65% of adults are obese or overweight. NHANES. UK: Fastest growing obese population. 16% of obstetric patients >100kg. 19.6% of women in the reproductive age are above BMI >30.

Transition from Overweight to Obesity Worsens Pregnancy Outcome in a BMI- dependent Manner. –Raatikainen K, Heiskanen N, Heinonen S. Obes Res Jan;14(1): –The risk of perinatal death more than doubles in the transition from an overweight to an obese condition.

Teratology public affairs committee position paper: Maternal obesity and pregnancy. –Scialli AR. Birth Defects Res A Clin Mol Teratol Feb; 76(2): The literature suggests that women with a body mass index (BMI) >/=30 have approximately double the risk of having a child with a neural tube defect (NTD) compared to normal-weight women, and the increased risk associated with higher maternal body weight does not appear to be modified by folic acid supplementation.

The prevalence and impact of overweight and obesity in an Australian obstetric population. –Callaway LK, Prins JB, Chang AM, McIntyre HD. E Floor, Clinical Sciences Building, Royal Brisbane and Women’s Hospital, Herston QLD 4029, Australia. Med J Aust Jan 16; 184(2): of 252 women -  BP, GDM,  hospital admission, C/S, birth defect, preterm delivery, NICU admission. BMI should be routinely recorded on perinatal data collection sheets.

Recommendations for Weight Gain During Pregnancy DescriptionRecommended Total Weight Gain (lbs) Underweight28 – 40 (12-17 kgs.) Normal weight25 – 35 (11-15 kgs.) Overweight15-25 ( kgs.) Obese15 (6.5 kgs.) Note multiple pregnancies.

Recommendations for ALL women (including preconception): Inform and counsel women about the health risks associated with overweight and obesity. Encourage a healthy diet –Diets that restrict particular food groups are discouraged, especially during pregnancy. Screen for hypertension and diabetes mellitus in women who are at risk. Counsel women to consume adequate folic acid, iron and calcium.

cont. Recommendations … Encourage regular exercise (  30 minutes of moderate physical activity daily) Counsel women to quit smoking Counsel women to avoid consuming alcohol during pregnancy. Discuss recommended weight gain during pregnancy.

After Pregnancy (postpartum) Recommendations for “for ALL women” PLUS the following: Encourage breastfeeding. Counsel women to return to a healthy weight For women who are attempting to or have quit smoking, continue support to prevent postpartum relapse.

Odds Ratios of Obesity and Overweight vs. Normal Weight Status on Selected Pregnancy Outcomes: Missouri Singleton Pregnancies Outcome Obesity vs. Normal Odds Ratio 95 percent confidence interval Very low birth weight (<1500 grams) Macrosomia (>4499 grams) Early preterm (<32 weeks) Congenital anomalies Fetal death Neonatal (<28 days) death Post-neonatal (1-11 months) death Perinatal (fetal or neonatal death) Infant (<1 year) death Fetal or infant death Note: Odds ratios calculated using multivariate logistic regression with the following covariates: race, education, age, marital status, & smoking status of mother and birth order.

Infertility – PCO – Early pregnancy loss _________ – Insulin resistant Birth defects particularly neural tube defect

Labor delivery complications – Preterm labour – Prolonge 2 nd stage – Large babies  shoulder dystocia + instrumental delivery –C/S  C.P.D. – Need for Oxytocin

Antenatal complications Maternal  D.M.  PET  Hypertension

Maternal complications Preterm Labour – could be iotrogenic due to  D.M., PET, HTN. Low birth weight - Women with relatively low pre-pregnancy weight more like to have PTL + L.B.W.

cont. Maternal complications Postpartum haemorrhage Wound infection Post C/S endometritis  prolonged hospitalization Postpartum thromboembolic manifestation DVT, P.E.

Fetal complications Neonatal death Birth defect – neural tube defect Low Apgar Score More NICU admission

Cedergren MI (2004): A Swedish, population-based cohort study (n=805,275) Study GroupControl Group – Normal Weight BMI > 40 PETX 5 fold Still Birthx 3 fold LGAx 4 folds Early NNDx 3.5 fold

Baeten JM et al (2001): A population-based cohort study in Washington state based on birth data (n=96,801). –  GDM – PET – Eclampsia – C/S – LGA infants