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Super Obesity in Pregnancy: Difficulties in Clinical Management Journal of Perinatology (2014) 34, 495–502 & 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp STATE-OF-THE-ART Super obesity in pregnancy: difficulties in clinical management A Martin, I Krishna, J Ellis, R Paccione and M Badell As the obesity pandemic continues in the United States, obesity in pregnancy has become an area of interest. Many studies focus on women with body mass index (BMI) X30 kg m À 2. Unfortunately, the prevalence of patients with BMI X50 kg m À 2 is rapidly increasing, and there are few studies specifically looking at pregnant women in this extreme category. The purpose of this article is to highlight some of the challenges faced and review the literature available to help guide obstetricians who might encounter such patients. Journal of Perinatology (2014) 34, 495–502; doi:10.1038/jp.2014.4; published online 6 February 2014 Keywords: complications; morbid obesity; obesity; pregnancy; super obesity INTRODUCTION on the complex interaction between genetic background and In 2009 to 2010, more than one-third of adults in the United States environmental factors. Genetic background explains only an 9 were obese (body mass index (BMI) X30 kg m À 2).1 Perhaps, a estimated 40% of the variance in body mass. Genetic more startling statistic is the increasing prevalence of morbid heritability plays a significant role in obesity with the risk of and super obesity (BMI X40 and X50 kg m À 2, respectively). In a childhood obesity significantly increased if one parent is obese 10 report looking at these groups in the United States between 2000 and even higher if both parents are affected. Obesity is likely to and 2005, the prevalence of self-reported BMI over 50 kg m À 2 result from the interaction of many different gene–gene and increased by 75%.2 The heaviest BMI groups have been increasing gene–environment interactions. The use of the genome-wide at the fastest rates for 20 years; consequently, the obstetrician will association approach has identified many genes with robust be caring for more super obese women. Obesity has long been associations but usually with only modest contributions to overall 11 perceived as a risk factor for poor pregnancy outcomes,3–5 but genetic susceptibility to obesity. In contrast, a small number of data on super obesity are limited. We recently cared for 34-year- single-gene mutations have been identified that clearly cause old G1P0 with a prepregnancy weight of 630 lb (BMI obesity in rare patients. Environmental factors such as diet and 98.67 kg m À 2). The purpose of this article is to highlight some of exercise play an important role in the development of obesity. The the challenges faced and review the literature available to help significant increase in obesity since the 1980s is largely secondary guide obstetricians who might encounter similar patients. to alterations in environmental factors that increase energy intake and reduce physical activity. Reasons for this include more meals are eaten outside the home, there is greater availability of fast Definition of obesity food and snack foods, serving sizes are larger and daily physical The World Health Organization (WHO) defines obesity as a BMI of activity has decreased because of sedentary lifestyles. X30 kg m À 2.6 Obesity is subdivided into three classes: class 1 Obesity is commonly associated with alterations in metabolic includes those with a BMI of 30 to 34.9 kg m À 2, class 2 includes function, specifically insulin resistance, diabetes, dyslipidemia and BMI of 35 to 39.9 kg m À 2 and class 3 includes those with a BMI of increased blood pressure. Obesity is also associated with a long list X40 kg m À 2.7 In the surgical literature, class 3 obesity is often of pregnancy complications. In general, the higher the patient’s further divided into morbid obesity for BMI of 40 to 49.9 kg m À 2 BMI, the higher the chance of complication. This ‘dose-response’ and super obesity for BMI 450 kg m À 2 (Table 1).4 Although has been well demonstrated for pre-eclampsia with the risk commonly seen and used throughout medical literature, these doubling with each 5 to 7 kg m À 2 increase in prepregnancy BMI;12 definitions are not standardized, and authors have used varying in addition, for each 1 unit increase in pregravid BMI, the BMI values to define the same term. Furthermore, there are no risk of cesarean delivery increases by B7%.13 Given this, patients terms in the literature to address patients such as the one we should be counseled to attempt to be as close to ideal body encountered with a BMI approaching 100 kg m À 2. weight before pregnancy and practitioners should have higher index of suspicion for pregnancy complications the higher the patient’s BMI. Pathophysiology of obesity Obesity is usually caused by an excessive intake of calories in relation to energy expenditure over a significant period of time. Developmental origins of health and disease Increases in body fat results from even minor, but chronic, There is growing evidence linking maternal prepregnancy BMI and differences between energy intake and energy expenditure. In gestational weight gain to offspring adiposity throughout life, 1 year, the ingestion of only 5% more calories than expended can from infancy through adolescence and to adulthood.14,15 It has promote the gain of B10 lb in adipose tissue.8 Weight depends been suggested that the obesogenic environment experienced Department of Gynecology and Obstetrics, Emory University, Atlanta, GA, USA. Correspondence: Dr A Martin, Department of Gynecology and Obstetrics, Emory University, 69 Jesse Hill Jr. Drive, SE, 4th Floor, Glenn Building, Atlanta, GA 30303, USA. E-mail: [email protected] Received 7 August 2013; revised 23 December 2013; accepted 7 January 2014; published online 6 February 2014 Super obesity in pregnancy A Martin et al 496 dating and viability (see Figure 1). In addition to routine prenatal Table 1. Obesity definitions labs, super obese women should have a complete blood count, Term Definition chemistry, liver function test, electrocardiography and 24 h urine protein ordered at their initial visit. An early rapid glucose screen Obesity BMI 430–39 kg m À 2 should be performed and repeated between 24 and 28 weeks if Class 1 obesity* BMI X30–34.9 kg m À 2 normal. In addition, as Gunatilake et al.7 suggested, women with Class 2 obesity* BMI X35–39.9 kg m À 2 BMI X40 kg m À 2 may benefit from an echocardiogram to Class 3 obesity* BMI X40 kg m À 2 7 À 2 evaluate for underlying, undiagnosed cardiomyopathy. In the Morbid obesity BMI X40–49 kg m second trimester, super obese women should be counseled on X À 2 Super obesity BMI 50 kg m maternal and fetal risks and limitations of ultrasound, and Abbreviation: BMI, body mass index. appropriate consultations should be considered (see Figure 2). *World Health Organization definition. Maternal risks Obese women are at an increased risk of prepregnancy medical before and during conception and early pregnancy may induce 16,17 illnesses such as hypertension, diabetes, gallbladder disease, methylation differences, causing changes in gene expression, asthma and obstructive sleep apnea that have been associated tissue structure and organ development. These changes may with a twofold risk of stroke and underlying cardiac dysfunction.25 result in subsequent cardiometabolic health consequences in the 18 If underlying cardiopulmonary disease is suspected, the patient adult offspring. Given this possible developmental origin of may benefit from a cardiology or pulmonology referral for obesity, preconception weight loss should be emphasized and additional testing such as an echocardiogram, sleep study or strongly encouraged. pulmonary function testing. Obesity and pregnancy are independent risk factors for venous Preconception weight loss thromboembolism (VTE), and VTE is one of the leading causes of 26,27 The American College of Obstetricians and Gynecologists maternal death in the United States. The risk of VTE appears to encourages preconception counseling for the obese patient, increase with increasing levels of obesity. A retrospective cohort including education about the maternal and fetal risks of obesity study of over 142 000 pregnancies found women weighing 90 to in pregnancy, and encouragement to participate in a weight 120 kg had a twofold increased risk of antepartum VTE as compared with women weighing o90 kg, and women weighing 4120 kg had reduction programs including diet, exercise and behavior modifica- 28 tion before conception.5 There are limited data addressing more than a threefold increased risk. Immobility in addition to preconception counseling and weight loss; however, recent obesity has been shown to significantly increase the risk of VTE among pregnant women.27,29 Overweight and obese women studies in the primary care setting reassure us that preconception À 2 weight loss is achievable. The Louisiana Obese Subjects Study (BMI 425 kg m ) with a history of immobilization have an (LOSS) showed that when primary care physicians were trained to adjusted OR of 62.3 (95% confidence interval (CI) 11.5 to 337.6) for implement structured diets, group counseling and pharmaco- antenatal VTE and 40.1 (95% CI 8.0 to 201.5) for postnatal VTE as compared with women with a BMI of o25 kg m À 2 and no therapy to treat patients with extreme obesity (BMI 40 to 29 60 kg m À 2), over 30% achieved X5% weight loss over 24 immobilization. From these data, one can deduce that the months.19 Results of the practice-based opportunities for weight risk of VTE among the super obese is confounded by immobility reduction (POWER) study at the University of Pennsylvania indicate due to their weight.
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