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OB
CMECNE

Obesity in Pregnancy: Classification and Clinical Implications

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Recall the prevalence of obesity in women of reproductive age
2. Discuss with patients the risks associated with obesity

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Jan 25 2022 through Jan 25 2024, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

The prevalence of obesity in women of reproductive age (20 to 39) in the US is 39.7%. Prevalence is found to be lowest among non-Hispanic Asian women (17.2%) and higher in non-Hispanic White (39.8%), Hispanic (43.7%), and non-Hispanic black (56.9%) women (2017 to 2018 data). Obesity is commonly classified based on body mass index (BMI). BMI is defined as weight in kg divided by height in meters squared (kg/m2). Definitions are as follows

  • Underweight: BMI <18.5
  • Normal weight: BMI 18.5 to 24.9
  • Overweight:  BMI 25 to 29.9
  • Obesity class I: BMI 30 to 34.9
  • Obesity class II: BMI 35 to 39.9
  • Obesity class III: BMI ≥40

KEY CLINICAL POINTS:

Potential Fetal and Maternal Complications

Antepartum effects

  • Increased risk of spontaneous abortion and recurrent miscarriage
  • Increased risk of stillbirth
  • Increased risk of fetal anomalies include:
    • Neural tube defects
    • Cardiovascular abnormalities
    • Cleft lip and palate
    • Anorectal atresia
    • Hydrocephalus
    • Limb reduction anomalies
  • Increased risk of maternal cardiac dysfunction, proteinuria, sleep apnea, fatty liver disease, gestational diabetes , preeclampsia

Intrapartum effects

  • Increased risk of
    • Cesarean sections
    • Failed trial of labor
    • Endometritis
    • Wound dehiscence
    • Deep venous thrombosis

Post-partum effects

  • Weight retention
  • Metabolic dysfunction
  • Pregravid obesity in future pregnancies
  • Early termination of breast feeding
  • Post-partum anemia
  • Depression

Fetal and childhood risks

  • Increased risk of neonatal and infant death
  • Macrosomia
  • Impaired growth
  • Metabolic syndrome
  • Childhood obesity

Management Considerations

Preconception Care

  • Behavioral interventions
    • Focus on diet and exercise to improve outcomes vs exercise alone
    • Encourage weight loss prior to pregnancy
  • Refer to behavioral counseling with interventions focused on nutrition, diet and exercise

Note: USPSTF recommends clinicians offer behavioral counseling interventions to promote healthy weight gain and preventing excess gestational weight gain in pregnancy to all pregnant women (see ‘Learn More – Primary Sources’ below) | Table 2 includes a comprehensive summary of behavioral counseling interventions

Prenatal Care

  • Calculate BMI to guide diet and exercise counseling at initial visit
  • Counsel patients about limitations of identifying structural anomalies with ultrasound in obese patients
  • Glucose intolerance
    • Assess for glucose intolerance risk factors including
      • ≥BMI 30 | Previous GDM | Impaired glucose metabolism
    • Recommend early glucose screening for those with risk factors (list for early screening factors can be found in ‘Related ObG Topics’ by tapping on ‘Updated ACOG Guidance on Gestational Diabetes’)
  • Weekly antenatal fetal surveillance
    • BMI of 35 to 39.9: Consider initiating weekly surveillance at 37w0d
    • BMI ≥40 or greater: Consider initiating weekly surveillance at 34w0d

Intrapartum Care

  • Labor pattern
    • First stage of labor may be prolonged in obese patients
    • Consider delaying cesarean delivery for labor arrest
  • Cesarean incision
    • Optimal skin incision is unclear
    • Vertical may be associated with increased complications
    • Supraumbilical incision may be helpful in the presence of a large panniculus
  • Prophylactic antibiotics prior to cesarean
    • Weight-based dosing may be considered
      • BMI ≥30 or weight ≥80 kg: 2 g cefazolin
    • Postoperative oral regimen in obese individuals who may not have received IV azithromycin
      • 500-mg oral cephalexin and 500-mg metronidazole every 8 hours for 48 hours
  • Skin cleansing prior to cesarean
    • Use an alcohol-based solution such as chlorhexidine–alcohol
  • Vaginal cleansing
    • Prior to both vaginal or cesarean delivery with either povidone–iodine or chlorhexidine gluconate

Postpartum Care

  • VTE mechanical prophylaxis
    • Recommended prior to and after cesarean delivery
    • CMQCC recommends mechanical prophylaxis for BMI >40 for vaginal birth
  • VTE chemoprophylaxis
    • LMW heparin: Enoxaparin 40 mg daily commonly used as prophylactic dose following surgery
    • Weight-based VTE chemoprophylaxis dosing may be considered in Class III obesity following cesarean
      • 0.5 mg/kg enoxaparin every 12 hours starting 12 hours after surgery (based on prospective cohort study)
    • Subcutaneous drains
      • Do not use routinely after cesarean due to increased risk for wound complications

Learn More – Primary Sources:

ACOG Practice Bulletin 230: Obesity in Pregnancy

ACOG Committee Opinion No. 548 :Weight Gain During Pregnancy

USPSTF: Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy

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Related ObG Topics:

Practical obstetrics info for your women's healthcare practice
Recommended Weight Gain and Obesity Management in Pregnancy
Updated ACOG Guidance on Gestational Diabetes
Practical obstetrics info for your women's healthcare practice
Gestational Diabetes Mellitus – Definitions, Risk Factors and Complications
The CMQCC Toolkit: Venous Thromboembolism Prevention and Management at Delivery
ACOG Guidance: Antibiotic Prophylaxis during Labor and Delivery
Earn as you Learn: CME FAQs
Increasing BMI and Adverse Pregnancy Outcomes: What Are the Risks?
Maternal Overweight, Obesity and Congenital Malformations – How Strong is the Link?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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