1. Dr. Dawn Boender PGY2

2. Obesity Review Obesity and Pregnancy Treatment of Obesity Managing Pregnancy Following Bariatric Surgery

3. BMI Category BMI (kg/m 2 ) 57 Female (lbs) Underweigh t <18.5<118 Normal Weight 18.5-24.9119-159 Overweight25.0-29.9160-191 Obese>30.0>192 -Class I Obesity 30-34.9192-223 -Class II Obesity 35-39.9224-255 -Class III Obesity >40>256

4. >1/3 of adults (35.7%) are obese Non-Hispanic Blacks (49.5%) Mexican Americans (40.4%) All Hispanics (39.1%) Non-Hispanic Whites (34.3%) In 2008, obese individuals spent $1,429 more per year on health care NOT an epidemic 2 Endemic – condition that is habitually present

5. Comorbidities 2,3 Type II Diabetes Hyperlipidemia Hypertension Obstructive Sleep Apnea Heart Disease Stroke Asthma Musculoskeletal Problems Cancer Depression Metabolic Syndrome Gallbladder Disease Liver Disease DVT

6. Pregnancy Complications: 2,4 Gestational DM Hypertension Preeclampsia C/S Delivery Postpartum Weight Retention Prematurity SAB & Stillbirth Congenital Anomalies Macrosomnia with Possible Birth Injury Infections (pelvic, urinary, wound) Postpartum Depression Decreased Breastfeeding Childhood Obesity

7. Weight reduction programs 4 Diet Exercise Behavior Modification Pharmacotherapy Referral for bariatric surgery 3 BMI >40 BMI >35 with Significant Comorbidities

8. Preconception Assessment and Counseling Discuss risks Encourage weight reduction During pregnancy Height, weight, BMI Discuss goal weight gain Offer nutrition counseling Encourage exercise

9. Prepregnan cy BMI BMI (kg/m 2 )Total Weight Gain (lbs) Underweight<18.528-40 Normal Weight 18.5-24.925-35 Overweight25.0-29.915-25 Obese (all classes) >3011-20 Institute of Medicine Recommendations: 5 Additional guidelines for twin pregnancies IOM

10. Cesarean Section Additional Resources: Tables, Staff, Blood Products Antibiotics Subcutaneous Closure Thromboprophylaxis SCD Unfractionated or LMW Heparin Postpartum Weight-Reduction Specialist

11. Weight Reduction Programs Diet Exercise Behavior Modification Pharmacotherapy Referral for Bariatric Surgery BMI >40 BMI >35 with Significant Comorbidities

12. Incidence increased 800% from 1998-2005 Average age 38.97 years Females 72.6% 50,000 Women Annually from 2003-2005 Mean Excess Weight Loss = 61.2%

13. Adjustable Gastric Banding 2 Restrictive Adjustable band 2 cm Below Gastroesophageal Junction 7

14. Roux-en-Y bypass 2,8 Restrictive and Malabsorptive 20-30 mL Pouch Formed Gastroenterotomy Stomach to Distal Jejunum Enteroenterostomy Anastomosis of 2 Parts of Intestine 7

15. Obesity Decreases Fertility Hyperinsulinemia 2 Oligo-ovulation and Anovulation 9 After Surgery: 9 Improves PCOS, Anovulation, and Menses May Improve Fertility 6 Adolescents: Pregnancy rates after surgery doubles general adolescent population* Consider non-oral modes of birth control* **Level B

16. Contraception failure 9 Nutritional deficiencies 8 Most frequent: iron, Thiamin (Vit B1), folates (Vit B9),Vit D, Calcium, Protein, Vit B12 Improve or resolve: 2,3 Diabetes Hyperlipidemia Hypertension OSA Wait to conceive: 12-24 months 9 Therapeutic medication monitoring Up to 80% remain obese

17. Decreased rates of: 6,9 Hypertension Gestational Diabetes Preeclampsia Maternal Weight Gain Premature Delivery (?) Low Birth Weight (?) Increases rate of: Neural Tube Defects (noncompliance) PPROM

18. Three priorities: preventing iron, folic acid, and vit D/calcium deficiencies 8 Presenting Labs 9 * Protein (prealbumin) Iron Vit B12 Folate Vit D Calcium Trimester labs 9 CBC, iron, ferratin, calcium, Vit D * Level C

19. Prenatal Vitamin Additional Multivitamin Vit A <5,000 IU Postpartum survellience Consult nutritionist* Consult GI* Band loosening Alternative GDM screening* Dumping syndrome No NSAIDS postpartum Therapeutic Drug levels** **Level B*Level C

20. Nausea, Vomiting & Abdominal pain… harder to monitor! Band loosening 20 reports: 6 14 bowel obstructions (internal hernias), 1 ulcer, 3 band events, 1 staple line stricture 13-37wga (average 26 wga) 5 neonates died 3 maternal deaths High index for suspicion 9 * *Level C

21. Deficiencies Supplement 1200 mg Ca and 800 IU Vit D Levels >20 ng/mL (vs) >32 ng/mL Intake of 600 IU/day PNV 400 IU/day Vit D safe up to 1,000 -2,000 IU/day Excess: neonatal tetany, IUGR, IUFD

22. 1. Center for Disease Control Website. Available at: http://www.cdc.gov/obesity/data/adult.ht ml. Accessed February 5, 2013. 2. Cunningham, F.G. Et al. Williams obstetrics. 23rd ed. New York, NY: The McGraw-Hill Companies, Inc. 2010 3. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta- analysis. JAMA 2004; 292: 1724-37. 4. Obesity in pregnancy. Committee Opinion No 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:131;213-7. 5. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academic Press; 2009.

23. 6. Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M. Pregnancy and fertility following bariatric surgery. JAMA 2008;300:2286-96. 7. Up To Date. Immages Roux-en-Y gastric bypass and Adjustable gastric band. Available at www.uptodate.com. Accessed February 5, 2013. 8. Poitou Bernert C, Ciangura C, Coupaye M, Czernichow S, Bouillot JL, Basdevant A. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. 9. Bariatric surgery and pregnancy. ACOG Practice Bulletin No. 105. American College of Obstetricians and Gynecologists. Obstet Gyencol 2009;113:1405-13. 10. Vitamin D: screening and supplementation during pregnancy. Committee Opinion No 459. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:197- 98.