Obesity among pregnant women is becoming one of the most important women's health issues. Obesity is associated with increased risk of almost all pregnancy complications: gestational hypertension, preeclampsia, gestational diabetes mellitus, delivery of large-for-GA infants, and higher incidence of congenital defects all occur more frequently than in women with a normal BMI. Evidence shows that a child of an obese mother may suffer from exposure to a suboptimal in utero environment and that early life adversities may extend into adulthood. The evidence available on short- and long-term health impact for mother and child currently favors actions directed at controlling prepregnancy weight and preventing obesity in women of reproductive ages. More randomized controlled trials are needed to evaluate the effects of nutritional and behavioral interventions in pregnancy outcomes. Moreover, suggestions that maternal obesity may transfer obesity risk to child through non-Mendelian (e.g. epigenetic) mechanisms require more long-term investigation.

1. OBESITY IN PREGNANCY
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause
Society, India, Indian medico-legal & ethics association(IMLEA),
ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. Obesity in Pregnancy
• Introduction
• Obesity in pregnancy is defined as a body mass index (BMI)
OF > 30 at antenatal booking appointment.
• a condition characterized by excess of body fat , frequently
resulting in a significant impairment of health and longevity.
• It is an increasing problem in the developed world and one
which is having a significant impact on healthcare.
• Obesity gas now reached epidemic proportions with
numbers more than doubling since 1980.

4. • In India, both the nutritional extremes -
1. Undernutrition is more prevalent in rural areas
2. Obesity is three times higher in urban area.
• Severely undernourished women as well as in those with extreme
degree of obesity - anovulation and amenorrhea highly prevalent.
• Nature’s way of suspending reproduction in nutritional extremes
as nature finds this state metabolically unsuitable for procreation.
• Using the advances in infertility, such women are also getting
pregnant - new challenges.
• Bariatric surgery has added issues in the management of such
pregnant obese women.

6. • The world health organization (WHO) declared obesity ‘a
major public health problem ’in 2000. The estimates by
WHO in 2008 suggested that over 1.5 billion adults were
overweight worldwide , with nearly 300 million being obese
women.
• The rate of obesity amongst those of reproductive age is also
rising rapidly and this has resulted in a big challenge for
maternal care , with effects on both the mother and the
fetus throughout the pregnancy as well as, continuing into
later life.

8. Weight Gain During Pregnancy: Is Pregnancy a
Cause of Obesity??
• Fetus, amniotic fluid, placenta, uterine, and breast
hypertrophy contribute significantly to overall weight gain of
pregnancy.
• Fat deposition is only a minor contribution to weight gain.
• Many women do not attain pre-pregnancy weight after
delivery.
• This is mainly because of high caloric food intake, and not
due to pregnancy itself.
• Rarely women may lose weight during and after pregnancy
due to malnourishment and hyperemesis.

12. Pathophysiology
• The excess adipose tissue functioning as an endocrine tissue.
• This excess adipose tissue mass - increasing inflammation of
adipose tissue - insulin resistance and cardiovascular
disease.
• High levels of interleukin – 6(IL-6) and c- reactive protein
(CRP) in obese women.
• In the non – pregnant population , high CRP is linked to
endothelial dysfunction and impaired insulin sensitivity and
predicts the risk for type 2 diabetes and so inflammation
caused by obesity may be the pathogenesis behind
increased risks of pre – eclampsia , venous
thromboembolism and gestational diabetes (GDM)

17. Metabolic Syndrome of Pregnancy
• There are changes to maternal metabolism during
pregnancy that occurs in order to help the growth of the
fetus.
• In the first two – thirds of gestation , maternal fat stores
increase and the environment encourages lipogenesis and
fat accumulation.
• In the later part of the pregnancy , this changes to a
catabolic state , during which the foetus is undergoing
maximal weight gain and the mother is primarily
metabolizing lipids , causing increased availability of glucose
and amino acids for the fetus.

18. • Obese women have more saturated subcutaneous fat stores
and tend to accumulate fat more centrally than lean women.
• Central adiposity is associated with adverse metabolic
outcomes in pregnancy , including GDM ,gestational
hypertension and pre – eclampsia.
• Normal pregnancy results in significant changes in glucose
metabolism ; initially there is increased insulin secretion ,
with no change in insulin sensitivity. Later on , insulin –
mediated glucose utilization is decreased by around 50 %
and insulin secretion increases several – fold as a result.

20. • Obesity has a large effect on glucose metabolism in
pregnancy - a loss of reduction of fasting glucose in early
pregnancy and
- a significant increase in peripheral and hepatic
insulin resistance.
• Obesity is a state of chronic low – grade inflammation -
increase in insulin resistance , via the modulation of insulin
signalling.
• Obese women are much closer to the threshold over which
metabolic disease in pregnancy occurs, as compared to their
lean counterparts.

23. Maternal Effects
• Pre –eclampsia
– 2 -3 – fold increased risk of pregnancy – induced
hypertension (PIH) or pre – eclampsia. Elevated pre –
pregnancy BMI is an independent risk factor for the
development of pre – eclampsia.
– Hormonal and biochemical pathways have been implicated
including insuling - resistance , endothelial cell activation ,
dyslipidaemia and raised cytokines.

24. Gestational Diabetes Mellitus
• Maternal obesity is associated with an increased risk of
developing GDM with an odds ratio (OR) of 2.1 in
overweight , 3.6 in obese and 8.6 in severely obese women.
• It appears that inter – pregnancy weight change has an
important role in the subsequent development of GDM.
• An increase in BMI of 1-2 units between pregnancies has
been shown to increase the risk of GDM by 20-
- 40 % , during seven years follow – up

26. • Weight reduction can also decrease the chances of
developing GDM in future pregnancies.
• Obese women suffering from GDM are more likely to require
insulin than non – obese counterparts , in order to achieve
adequate glycaemic control , and thus good pregnancy
outcomes.

27. Thromboembolism
• The risk of venous thromboembolism is trippled in the obese
pregnant population compared to the non – obese pregnant
population.
• The post partum period is time of highest risk and the Royal
College of Obstetricians and Gynaecologists (RCOG)
recommends that all women with class 3 obesity (BMI >40)
should be considered for prophylactic LMWH in doses
appropriate for their weight for 10 days after delivery.

29. Preconception & Early Pregnancy
• Increased risks of
• Infertility
• Miscarriage
• congenital abnormalities

30. Antenatal
• Increased risks of
• VTE / PE
• GDM
• PIH
• LFGA
• High GWG
• Difficulty in foetal monitoring

31. Anternatal Ultrasound
• Ultrasound scanning for accurate dating is challenging not
just because of increased fat but also because most obese
women tend to have irregular cycles.
• Mid – trimester foetal abnormality screening poses
additional challenges as good views of the foetal spine and
heart may not be obtained and would possibly require
multiple visits before an accurate diagnosis can be made.
• Maternal awareness of foetal movements may also be
reduced and measurement of symphysio – fundal height are
less accurate. Therefore it is important to organise regular
growth assessment scans in third trimester , especially in the
presence of GDM and PIH.

32. Future Health
• A higher gestational and in – between – pregnancies weight
gain.
• This causes further increased complications in subsequent
pregnancies.
• It will be a good clinical practice to weigh each obese woman
at 36 weeks of gestation , which will help to decide optimal
dose of low molecular weight heparin (LMWH) for DVT
prophylaxis.

36. Foetal Macrosomia
• The most obvious effect of maternal obesity on the neonate
is increased growth.
• The offspring of an obese mother is 2 – 4 times more likely
to be large for gestational age and this is reflected in a
higher percentage of body fat, not just an increase in lean
body mass.
• Macrosomia is itself a risk factor for lower Apgar scores and
arterial PH at birth , as well as the injuries that can be
caused from a difficult delivery , such as fractures and
palsies.

38. Foetal Well – being Assessment
during Pregnancy and Labour
• There are technical difficulties also associated with monitoring
during pregnancy and labour.
• Monitoring the foetus is harder , both via ultrasonography and
external electrical foetal monitoring.
• The severely obese women will also require specialised
equipment , including
 Larger blood pressure cuffs ,
 Larger operating tables ,
 Lifting and tilting equipment ,
 Sit – on weighing scales ,
 Larger wheelchairs ,
 Larger ward and
 Delivery beds. Etc

39. Stillbirth and Neonatal Intensive Care
Unit (NICU)Admission
• There is also an increased stillbirth rate , especially late and
unexplained foetal demise.
• Women with extreme obesity (BMI > 50) have 5.7 times
increased risk of stillbirth compared to normal BMI women
at 39 weeks gestation , and 13.6 times risk at 41 weeks.
• Babies born to obese mothers have an increased risk,
around 3.5 times, of being admitted to the NICU.
• Obesity is also associated with reduced breastfeeding rates,
this is likely to be result of both difficult positioning and
possibly an impaired prolactin response to suckling.

40. FOETAL ABNORMALITIES
• Increases the risks of neural tube defects (NTD) - each excess
1 kg/m in BMI resulted in a 7 % increased risk of NTD to ?
• Decreased folic acid levels reaching the foetus due to
decreased maternal absorption and greater maternal
metabolic demands.
 Anencephaly
 Spina bifida
 Isolated hydrocephaly.
 Congenital heart defects

43. Management of Obese Pregnant Women
Preconceptional Recommendations
• Pre-pregnancy BMI should be brought down
to < 30 kg/m2 even though ideal would be < 25 kg/m2.
• A month prior to planning of pregnancy, 5 mg folic acid
should be started on daily basis.
• Risk assessment of maternity units where patient would
deliver should be carried out.
• Such centers should be equipped with special instruments
and furniture, OT table, BP cuff and other devices, lateral
transfer equipment and strong personnel, and staff
attending the patients.
• Counseling is very important regarding weight gain,
nutrition, fetal risks, malformations, and also information
regarding risks of obesity in pregnancy is also necessary

44. Antenatal Management
• Identify potential risks well in advance in antenatal phase.
• Assessment of the healthcare facility should be done regarding not only infrastructure but
also regarding availability of expert multidisciplinary faculty.
• Expert and experienced anesthetist should be consulted in antenatal period near term, and
one must ensure their availability for the delivery and operative intervention if necessary.
• Screening for deficiencies and diseases, like gestational diabetes and vitamin deficiencies, is
recommended.
• Thromboprophylaxis with low molecular weight heparin is an individualized decision.
• 150 mg aspirin should be started for all women with BMI > 35 kg/m2, multiple pregnancy
and women above 40 years to prevent PIH
• Early hospitalization of patients showing early signs of PIH will help prevention of severe
preeclampsia and other complications.
• Ultrasonography around 18–22 weeks is recommended to rule out anomalies.
• Fetal echo cardiography is relevant as fetal cardiac anomalies are common in obese women
especially those with very high BMI of 40 kg/m2 and above.
• Quadruple markers NT screening and anomaly scan for all women are recommended in
view of high rates of anomalies and advanced age of mother.

45. • Expert nutritionist’s care is required throughout the
pregnancy, and caloric restriction up to 1200 kcal/day is
recommended.
• Routine walking exercise in third trimester is recommended.
• Psychological support and preparation for successful
lactation should be started from antenatal phase. Anti-
obesity drugs are contraindicated during pregnancy.
• Elective induction of labor at 40 weeks is recommended in
obese pregnant women, in view of high rate of post-datism,
GDM, and macrosomia

46. Progress of Labor
• Obese women often have prolonged first and second stages
of labor.
• Early maternal exhaustion and poor bearing down efforts
lead to increased incidence of instrumental deliveries.
• Fundal pressure - can prove difficulty in obese women.
• Mechanical problems in head delivery may occur due to soft
tissue obstruction, malpresentations, and macrosomia.
• Ultrasonography on labor table may be useful as it is very
difficult to assess progress of labor clinically by palpation.

47. Prolonged pregnancy and labour
• Obesity is also a risk factor for
• labour dystocia ,
• need for induction of labour ,
• shoulder dystocia ,
• post – partum haemorrhage and
• an increased caesarean section rate.
• Caesarean rate to be 14.3 % for women with BMI < 19.8 and 42.6
% for those with a BMI > 35.
• Obese women also have a much lower successful rate of vaginal
delivery after caesarean section with success rates being quoted
at under 15 % compared to up 75 % for non – obese women .
• It has been postulated that oxutocin receptors sensitivity is
impaired among obese women.

48. Surgery and Anaesthesia
• Surgery itself is also more complicated in the obese patient.
• Anaesthetic –
• a] Early epidural and venous access is recommended as well
as review by an anesthetist pre– natally , epidural failure
rates are much higher in the obese population.
• b] There are also increased risks associated with induction of
general anaesthesia because of epiglottis , for crash
caesarean sections when compared to lean woman.

49. • An obstetrician and an anaesthetist at specially Trainee year
and above should be informed and available for the care of
women with a BMI >40 during and delivery.
• wound healing is also impaired and wound infection rates
are higher.
• National Institute for Health and Care Excellence
recommends that all women having a caesarean section
with over 2 cm of subcutaneous fat , should have fat
suturing to help reduce wound infection and separation .
• It is important to use appropriate sepsis prophylaxis regimen
, and parenteral antibiotics be prescribed following delivery
of the baby.

50. Difficulties at Cesarean Section
• Technical problems in administration of spinal, general, and epidural analgesia and
anesthesia
• Delivery of the baby is difficult as there is macrosomia, thick abdominal wall,
malpresentations, and poor exposure.
• Poor exposure also makes suturing difficult.
• Nursing care and positioning the patient require strength, and securing intravenous lines
demands a lot of skill.
• Lack of access may necessitate central line.
• Drug dosages need to be adjusted as per body weight, as standard doses can be
inadequate.
• Postoperative thrombotic complications loom large as the three high-risk factors like
obesity, pregnancy and postoperative phase are at work simultaneously. Postpartum
recovery to pre-pregnancy state becomes difficult.
• Obese women have twice than normal LSCS rates. It is said that for every 10 kg rise in body
weight there is 17% increase in LSCS rates.
• Elderly primi, short stature (height under 155 cm), very low-birth-weight baby, post-datism,
failure of induction of labor, failure to progress, cephalopelvic disproportion,
malpresentation like breech or occipitoposterior positions, abruptio placentae, fetal
distress, and severe preeclampsia are common indications for cesarean section.

51. Role of Cholesterol, Leptin, and Other Adipokines in
Pregnancy and Labor
• Adipose tissue produces cytokines, chemokines, and adipokines. Leptin,
kisspeptin, omentin-1, chemerin, ghrelin, visfatin, interleukin-6, resistin, tumor
necrosis factor-alpha, and adiponectin belong to the adipokines Leptin,
adiponectin, and kisspeptin are possibly responsible for diabetes mellitus and
preeclampsia in obese pregnant women
• Myometrial contractility is affected by cytokines and inflammatory processes
which brings about changes in pregnancy and gestational age
• Myometrial function during pregnancy is affected by metabolic complications
associated with obesity.
• High levels of leptin and cholesterol in obese women interfere with progress of
labor.
• Cholesterol is linked with interference in uterine contractility, whereas leptin
interferes with both uterine contractility and cervical ripening and cervical
dilatation.
• Decreased oxytocin receptors and connexin 43 connections between myocytes in
obese women also contributes to dystocia, and postpartum hemorrhage.

52. Management During Labor
• A comfortable position with a left lateral tilt,
• Adequate oxygenation,
• Electronic fetal monitoring,
• Use of ultrasonography on labor table, and
• Use of forceps or vacuum to cut short second stage are few tips to minimize complications.
• Shoulder dystocia is common in macrosomic babies; hence, anticipating the same and
keeping experienced obstetrician available will minimize the associated complications.
• Active management of the third stage should be practiced routinely in view of high
incidence of postpartum hemorrhage.
• There is a high rate of cesarean deliveries in obese patients.
 A combined epidural spinal anesthesia with due risks is recommended due to prolonged
operative time.
 Modification of surgical techniques, like using self-retaining retractors etc.,
 Achieving hemostasis promptly,
 Steps taken for preventing wound infection like use of subcutaneous drainage, and
 Individualized use of thromboprophylaxis are other interventions for cesarean section in
obese pregnant women.

53. Post-bariatric Surgery Pregnancy: A
Recent Challenge in Management
• Pregnancy should be avoided for 12–18 months after
bariatric surgery
• Between 1998 and 2005, the numbers of bariatric surgeries
have increased by 800%
• Weight gain recommendations in pregnancies after bariatric
surgery are given in Table
• Post-bariatric surgery, several complications may occur
during pregnancy.
• Persistent vomiting, gastrointestinal bleeding, anemia,
placental vascular disease, fetal neural tube defects,
intrauterine growth retardation, and miscarriages are some
of the anticipated complications

54. • Adolescents undergoing bariatric surgery need special counseling.
• Pregnancy rates after bariatric surgery are twice than the rate in the general
adolescent population.
• Contraceptive counseling becomes important in adolescents and also in infertile
women as pregnancy should be avoided for 12–18 months. Non-oral
administration of hormonal contraception is recommended, when malabsorption
is a real concern.
• Gastric bands may need some adjustment during pregnancy.
• Alternative testing for gestational diabetes should be considered for those
patients with a malabsorptive-type surgery.
• Intravenous glucose challenge test may be necessary.
• Evaluation for micronutrient deficiencies is recommended in early first trimester
• Delayed or slow release preparations are to be avoided. Post-bariatric surgery,
pregnancy and deliveries should be under combined care by the bariatric
surgeon, physician, and expert obstetrician in a higher center.
• Cesarean delivery rates are higher after bariatric surgery, even though bariatric
surgery is not an indication for cesarean deliveries.

55. Delivery
• Increased rates of
• Failed induction / VBAC
• Caesarean section
• Labour dystocia
• shoulder dystocia
• PPH
• Anaesthetic complications

57. Mortality
• Maternal obesity also appears to be a risk factor for
maternal death.
• The confidential Enquiry into Maternal and Child Health’s
report on maternal death (2003-2005 Triennial) reported
that 28 % of maternal deaths , occurred in obese women ,
whilst the prevalence in the general population of obesity
was only 16 – 19 %.

58. Postnatal
• Increased rates of C/s wound infection
• VTE/PE
• Breastfeeding difficulties
• Long – term health implications.

61. RECOMMENDATIONS
• Clinical and population health practice should focus on
interventions to reduce obesity in all women of reproductive age.
• All pregnant women should be advised to eat a healthy, balanced
diet, and obese women should be informed of the potential risks
associated with obesity and pregnancy outcome.
• To date, there is insufficient evidence to recommend monitoring
GWG in obese (or all) pregnant women to improve perinatal and
later health outcomes. We do not recommend the reintroduction
of antenatal monitoring of GWG in the United Kingdom and
Europe until further evidence informs guidance.
• Should the emphasis remain on GWG, then additional
investigations among women of different ethnic subgroups and
using standardized measurements with a range of outcomes are
required. These could be observational, e.g. from contemporary
cohorts or by using the control arm of ongoing RCTs.

62. • Short- and long-term follow-up of participants in large RCTs
of interventions that are successful in restricting GWG within
IOM guidelines are key to determine the safety and
effectiveness of controlling GWG.
• Primary outcomes in RCTs designed to improve pregnancy
outcome need consideration; clinical endpoints such as
gestational diabetes, preeclampsia, or LGA and small for
gestational age (SGA) may be more relevant than GWG.
• There is a need for improved management or treatment of
adverse outcomes associated with obesity, such as
gestational diabetes and preeclampsia.