1. Obesity, O&G and Risk Diana Hamilton-Fairley Consultant Obstetrician and Gynaecologist Guys and St. Thomas’ NHS Foundation Trust

2. Aims  Obesity is a public health issue  Impact of obesity on women’s health  Weight loss does make a difference  Clinicians have a powerful role to play

3. Health Risks Which of these is the greatest risk to health?

4. Risk  The possibility of suffering harm or loss; danger.  A factor, thing, element, or course involving uncertain danger;  The danger or probability of loss to an insurer.  One considered with respect to the possibility of loss: a poor risk.

5. The Epidemic  “Child obesity has doubled in a decade”  21% increased risk of cancer in girls  Double the risk of dying before 50

6. Reproductive Years – Obesity, Hirsutism and Menstruation P<0.01 % PCOS

7. Implications  Anovulation  Menorrhagia  Endometrial Hyperplasia  Anaemia  Hirsutism / Acne  Psychological impact

8. Obesity and Ovulation induction P<0.02 NSP<0.01

9. Obesity and Miscarriage  Risk of miscarriage before a live birth in 13,123 consecutive pregnancies BMI 19-25 25-29 >29 1 1.42 2.06

10. Reproductive Years Pregnancy - Gestational Diabetes  96 801 Nulliparous women Prepregnancy weight Baeton et al.2001 Am J Pub Health 91;436 - 439 BMI 19-25 (71.7%) 25-29.9 (18.2%) >30 (10.1%) 1 2.4 5.2

11. Pre-eclampsia and Eclampsia BMI 19-25 25-29.9 >30 1 2.0 3.3 Baeton et al.2001 Am J Pub Health 91;436 - 439

12. Delivery at <32 weeks BMI 19-25 25-29.9 >30 1 1.3 1.5 Baeton et al.2001 Am J Pub Health 91;436 - 439

13. Caesarean Delivery BMI 19-25 25-29.9 >30 1 1.8 2.7 Baeton et al.2001 Am J Pub Health 91;436 - 439

14. Other increased risks in pregnancy  Congenital abnormality3 fold  Thromboembolism12 fold  Failed Trial of Labour87% vs 20-40%

15. Shoulder Dystocia and neonatal injury   BMI > 30kg/m 2   Second stage >20 mins   Birthweight > 4.5kg Mehta et al. 2006 J Perinatology 26;85-8

16. Infant Death BMI 19-25 25-29.9 >30 1 1.5 2.0 Baeton et al.2001 Am J Pub Health 91;436 - 439

17. Mean maternal glucose concentrations and infant mortality

18. Obese Parents  Increase the risk of obese children –Increased risk of early onset Type 2 DM –Increased risk of metabolic syndrome  Glucose intolerance, raised VLDL, Decreased HDL, Hypertension, Increased risk for cardiovascular disease –Increased risk of cancer  Increased risk of dying before children reach adulthood

19. Disease for which Obesity is a risk factor DiseaseRisk Risk in PCOS Diabetes3.8 5 fold Cardiovascular disease 2.1 Stroke > IHD 0.7 (NS) Hypertension5.6 Endometrial Cancer 3 – 10 fold Depends

20. Risk factors in endometrial cancer Risk factors in endometrial cancerRisk Fold risk Obesity 3 - 10 Nulliparity 2*2*2*2* Late Menopause 2.4* “bloody menopause” 4*4*4*4* Diabetes 2.8* Hypertension 1.5* Unopposed E2 9.5 Complex Hyperplasia 29*

21. Risk of Surgery  Obesity increases your risk of needing a Hysterectomy –Infection 15.3% vs 11.3% (p<0.01) –Bleeding no difference –Increased duration of surgery –Increased LOS  Manual Handling  Surgical difficulty

22. Weight loss

23. Obesity and PCOS  Does weight loss treat symptoms?

24. Does weight loss improve outcome  In pregnancy reduces  Congenital abnormality  Miscarriage  GDM, macrosomia  Pre-eclampsia  Prematurity  Caesarean section  Postpartum  Type 2 DM  Hypertension  Cancer (Endometrial)

25. Treatment algorithm for obesity Treatment algorithm for obesity

26. What is our role?  Young fit women - INFORMATION  Actively treat obesity in gynaecology and subfertility clinics  Pre-conception obesity clinics  Pregnancy advice on weight gain  Postpartum follow-up and support

27. Obesity is a Public Health Issue We all have a role to play in reducing the risks