Laparoscopic management of tubal ectopic pregnancy in obese women

OBJECTIVE: To study the surgical morbidity associated with the laparoscopic management of tubal ectopic pregnancy in an overweight population compared with a lean population. DESIGN: Retrospective study. SETTING: An academic tertiary referral obstetrics and gynecology center. PATIENT(S): One hundred seventeen patients in two groups, lean (n = 90; body mass index 30) who had pathology-confirmed tubal ectopic pregnancies that were managed laparoscopically. Each group was subdivided into a laparoscopically managed group and a group in which laparoscopy was converted to laparotomy. INTERVENTION(S): None.Operative time, blood loss, and complications of laparoscopic surgery as well as causes of conversion from laparoscopy to laparotomy, in obese compared with lean women, with ectopic pregnancy. RESULT(S): There was no significant difference in gestational age; beta-hCG level; or history of previous surgeries, ectopic pregnancy, pelvic inflammatory disease, or endometriosis or in any of the studied outcomes (conversion rate, blood loss, and operative time) between the lean and obese groups or their respective subgroups except for operative time between obese women who underwent laparotomy, which was significantly longer when compared with the case of lean women who underwent laparotomy. Intraoperative and postoperative complications were comparable between the lean and obese groups, and all complications occurred in the completed-laparoscopy group. CONCLUSION(S): Laparoscopic management of tubal ectopic pregnancy does not appear to significantly increase surgical morbidity in obese patients.     

Preparing for and managing a pregnancy after bariatric surgery

The number of bariatric surgeries performed in the United States has increased exponentially. Given that most patients are female and of reproductive age, it is important for clinicians who manage women's health issues to be aware of the surgery, its long-term goals, and the potential effect on future pregnancies. Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with control patients. Following nutritional guidelines and supplementation in the event of deficiencies are critical in the provision of prenatal care to this unique population. Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring.     

Team Planning in Obstetrical Care for Women With Obesity

This paper provides a practical perspective on some parts of care planning for pregnant women with obesity class III and beyond. Obesity affects childbirth, as there are medical risks to mother and fetus. Moreover, the psychological concerns of the mother and family require careful consideration, notably with an interprofessional team of obstetricians, midwives, anaesthesiologists, pediatricians, and lactation specialists, as well as learners. Pregnant women with obesity likely experience stigmatization and weight bias, as such the health care team should be cognizant of evidence-based medical expertise and of the individual sensitivities of mother. Every opportunity must be taken to provide women with a normal birth experience.     

Body mass index and the risk of hypertensive disorders of pregnancy: the great obstetrical syndromes (GOS) study

Objective: To estimate the association between first-trimester body mass index (BMI) and the different types of hypertensive disorders of pregnancy (HDP).

Methods: A prospective cohort of nulliparous women recruited at 11–13 weeks. Height and weight were measured and BMI was reported as binary (more or less than 30?kg/m²), categorical (World Health Organization classification), and continuous variables. Participants were followed for development of any HDP, including preeclampsia and preterm preeclampsia. Receiver operating characteristic curves and their area under the curve (AUC) were used along with multivariate logistic regressions to develop predictive models combining BMI with other maternal characteristics.

Results: We recruited 4683 eligible participants including 645 (14%) affected by obesity. Obesity was associated with greater risks of HDP (22.5 versus 8.5%, p?p?p?=?.006). BMI categories (AUC: 0.65; 95%CI: 0.56–0.74) and BMI combined with maternal characteristics (AUC: 0.76; 95%CI: 0.69–0.83) were better predictors of preterm preeclampsia than BMI as binary variable (AUC: 0.58; 95%CI: 0.50–0.66).

Conclusions: Obesity and BMI are associated with the risk of all types of HDP. Optimal prediction of preterm preeclampsia is achieved by using BMI as a continuous variable combined with other maternal characteristics.     

Obesity in pregnancy

Overweight and obesity are common findings in women of reproductive age in the UK; as 32% of 35- to 64-year-old women are overweight and 21% obese. Obesity causes major changes in many features of maternal intermediary metabolism. Insulin resistance appears to be central to these changes and may also be involved in increased energy accumulation by the fetus. Maternal obesity is associated with many risks to the pregnancy, with increased risk of miscarriage (three-fold) and operative delivery (20.7 versus 33.8% in the obese and 47.4% in the morbidly obese group). Other risks to the mother include an increased risk of pre-eclampsia (3.9 versus 13.5% in the obese group) and thromboembolism (0.05 versus 0.12% in the obese group). There are risks to the fetus with increased perinatal mortality (1.4 per 1000 versus 5.7 per 1000 in the obese group) and macrosomia (>90th centile; 9 versus 17.5% in the obese group). Maternal obesity is associated with an increased risk of obesity in the long term. Obese woman should try to lose weight before pregnancy but probably not during pregnancy. There is no real evidence base for the management of maternal obesity but some practical suggestions are made.     

Triplet gestation outcomes in relation to maternal prepregnancy body mass index and weight gain

Objective.?To study prepregnancy maternal body mass index (BMI) and overall maternal weight gain in triplet gestations in relation to maternal and newborn outcomes.

Study design.?This was a retrospective study of birth certificate data of all live-born triplet gestations occurring between 1999 and 2003 in an eight-county region in New York. An analysis of computerized birth certificate data for variables related to pregnancy and newborn outcomes was conducted, looking at neonatal birth weight, neonatal gestational age, and the occurrence of the maternal pregnancy complications of gestational diabetes, gestational hypertension, and preeclampsia.

Results.?In 56 triplet gestations studied, the prepregnancy BMI was not associated with mean newborn birth weights and gestational age at delivery. The total maternal weight gain was associated with increasing mean birth weight and higher gestational age at delivery. Pregnancy complications in triplet pregnancies of gestational diabetes and gestational hypertension were associated with prepregnancy BMI, but not maternal weight gain.

Conclusion.?For triplet gestations, a normal prepregnancy BMI and a total gestational weight gain of at least 15.9 – 20.5 kg (35 – 45 lb) are associated with fewer pregnancy complications.     

The incidence and impact of increased body mass index on maternal and fetal morbidity in the low-risk primigravid population

Objective. To determine the incidence and impact of increased body mass index (BMI) on maternal and fetal morbidity in the low-risk primigravid population.

Methods. This was a prospective study with retrospective analysis of delivery outcome data. All low-risk primigravida who met the inclusion criteria during the recruitment period were approached. BMI was calculated using the formula weight/height squared. The participants were divided into five categories: ‘underweight’ (BMI <20 kg/m²), ‘normal’ (BMI 20.01–25 kg/m²), ‘overweight’ (BMI 25.01–30 kg/m²), ‘obese’ (BMI 30.01–40 kg/m²), and ‘morbidly obese’ (BMI >40 kg/m²). Maternal outcomes evaluated included gestation at delivery, onset of labor (spontaneous/induced/elective cesarean section), length of labor, use of oxytocin and epidural, mode of delivery, and estimated blood loss. Perinatal outcome measures included infant birth weight (kg) and centile, gestational age, ponderal index, Apgar score <7 at 5 minutes, cord pH <7.1, presence of meconium grade 3 at delivery, degree of resuscitation required, admission to neonatal intensive care unit (NICU), and duration of stay.

Results. One thousand and eleven women participated in the study. Complete outcome data were available for 833 women (82%). A significant difference was identified in gestation at delivery between the subgroups (p < 0.004). A significant positive correlation was identified between cesarean section rates with increasing BMI, even when gestation was controlled for (p = 0.004). Similarly, women in the normal BMI group remained significantly less likely to have an infant requiring NICU admission than obese women (2.2% vs. 8.6%; p = 0.011).

Conclusion. High BMI is associated with longer gestations, higher operative delivery rates, and an increased rate of neonatal intensive care admission.     

Cross-sectional study of weight gain and increase in BMI throughout pregnancy

OBJECTIVE: To generate reliable new reference ranges for weight gain and increase in body mass index (BMI) during pregnancy from a large population. STUDY DESIGN: In a prospective cross-sectional study at the Obstetric outpatient clinic, Zurich University Hospital, weight gain and BMI, before gestation and at the booking visit, were determined in 4034 pregnant women with accurately dateable singleton pregnancies (Caucasian: N = 3242, Asian (predominantly from Sri Lanka, Thailand and the Philippines): N = 578 and Black: N = 214). Women with known insulin-dependent diabetes mellitus before pregnancy were excluded. Fifth, 50th and 95th centiles were presented for Caucasians and corresponding centile curves for Asians and Blacks. Simple and multiple regression analyses were performed for various risk factors. A significance level of P < 0.05 was used in all tests. RESULTS: Mean weight gain was 15.5+/-5.9 kg (34.2+/-13.0 lb) at term with values >25.4 kg (56.0 lb) and <5.7 kg (12.6 lb) for the 95th and the 5th centile, respectively. Mean BMI increased slightly and steadily to 28 kgm(-2) at term. Parity and pre-pregnancy BMI were significant determinants in Caucasians. Weight gain and BMI was slightly lower in Asians and Blacks. CONCLUSIONS: BMI centile curves have the advantage in that they consider height during the whole course of pregnancy. It may be an additional helpful tool in controlling weight gain in pregnancy. Further studies are required to determine the prognostic implications of values > or = 95th centile and < or = 5th centile.     

Maternal leptin and body composition in the first trimester of pregnancy

Background.?Leptin is produced mainly by adipocytes. Levels are increased in women with obesity and during pregnancy. Increased levels are also associated with pregnancy complications such as, pre-eclampsia and gestational diabetes mellitus.

Objective.?We studied what component of body composition correlated best with maternal leptin in the first trimester of pregnancy and, whether maternal leptin correlated better with visceral fat rather than fat distributed elsewhere.

Subjects and methods.?Women were recruited in the first trimester. Maternal adiposity was measured using body mass index and advanced bioelectrical impedance analysis. Maternal leptin was measured using an enzyme-linked immunosorbent assay technique.

Results.?Of the 100 subjects studied, the mean leptin concentration was 37.7?ng/ml (range: 2.1–132.8). Leptin levels did not correlate with gestational age in the first trimester, maternal age, parity or birth weight. Serum leptin correlated positively with maternal weight and body mass index, and with the different parameters of body composition. On multiple regression analysis, serum leptin correlated with visceral fat but not fat distributed elsewhere.

Conclusions.?Visceral fat is the main determinant of circulating maternal leptin in the first trimester of pregnancy. This raises the possibility that maternal leptin in early pregnancy may be a marker for the development of metabolic syndrome, including diabetes mellitus.     

The impact of maternal age,body mass index and maternal weight gain on the glucose challenge test in pregnancy

Objective. The aim of this study was to determine whether maternal age, prepregnancy and mid-trimester body mass index (BMI), or excessive mid-pregnancy weight gain predict abnormal glucose challenge test (GCT) results.

Methods. A retrospective chart review of 75 consecutive singleton pregnancies was performed. Patients were screened at 24–28 weeks of gestation with a 50-g oral GCT. Prepregnancy BMI and pregnancy weight gain up to the time of GCT testing, as well as other demographic data, were recorded. Statistical analysis included regression analysis and Student's t-test, receiver–operator characteristic curve and multivariate logistic regression.

Results. Maternal age and prepregnancy and mid-trimester BMI were significantly higher in women with an abnormal GCT (p < 0.05). A direct correlation was found between these parameters and GCT results (R² = 0.08, R² = 0.102 and R² = 0.116, respectively; p < 0.05). Mid-trimester maternal BMI of ≥30 kg/m² and maternal age ≥32 years are the optimal predictors of abnormal GCT results.

Conclusions. Mid-trimester maternal BMI of ≥30 kg/m² and maternal age ≥32 years are useful predictors of abnormal GCT results. We suggest that these factors should also be considered when selective screening for gestational diabetes mellitus is practiced.     

Attitudes and awareness towards weight gain among normal weight and overweight pregnant women

Objectives: (1) To evaluate the proportion who correctly classify- or misclassify maternal weight gain; (2) to investigate weight gain attitudes, and (3) to compare weight gain attitudes with weight gain recommendations by the Institute of Medicine (IOM), as well as background and lifestyle factors.

Methods: This is secondary analysis of cohort data collected as part of a prospective study of determinants of macrosomic infants in Norway (the STORKproject). The participants (n?=?467) answered a self-administered questionnaire, including report on maternal weight gain and attitudes towards weight gain, in mean gestation week 36.4 (SD?=?1.7). The women were also weighted (kg) at the hospital using a digital beam scale.

Results: A significant discrepancy was found between self-reported and measured maternal weight gain. About 76% reported to be satisfied with maternal weight gain while 24% were dissatisfied. Women reporting to be dissatisfied were significantly more likely to be sedentary, sick-listed, reporting poor eating habits and to be multiparous.

Conclusions: Most women reported to be satisfied with their maternal weight gain, but had gained excessively according to recommended weight gain ranges issued by IOM. Pregnant women may need targeted advice on their specific weight gain and impact of increased weight gain on health variables for mother and child.     

The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes

Objective.?To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM).

Methods.?Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI?≥?30?kg/m²) and non-obese (pre-pregnancy BMI?<?30?kg/m²) women and for women across five increasing pre-pregnancy BMI categories.

Results.?A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes.

Conclusion.?In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.     

The Impact of Obesity on Gynecologic Cancer Screening: An Integrative Literature Review

Introduction : Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening. Methods : A literature search of standard computerized databases was conducted for peer‐reviewed articles published between 1950 and January 2009. Results : Twenty‐three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient–provider communication. Discussion : Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women. J Midwifery Womens Health 2010;55:344–356 © 2010 by the American College of Nurse‐Midwives.