SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez nos Conditions d’utilisation et notre Politique de confidentialité.
SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez notre Politique de confidentialité et nos Conditions d’utilisation pour en savoir plus.
Obesity has many deleterious effects for women of reproductive age.
In the first place, obese women are more likely to encounter problems becoming pregnant and they are more likely to miscarry
They are at greater risk of developing pregnancy complications and problems associated with labour and delivery.
Finally, obese women are more at risk of postpartum complications .
Taken all together, maternal mortality and morbidity is significantly elevated for obese women .
Maternal obesity is also dangerous for the fetus and the newborn.The management of obesity requires a multidisciplinary approach.
Stepwise programmes with realistic time-related goals are required, starting with modification of lifestyle, progressing to pharmacotherapy and ultimately obesity surgery.
Weight loss interventions do not appear to be common practice among fertility centres& pre-pregnancy clinics in spite of clear evidence as to the benefits.
Women should be referred to a nutritionist in cases where clinicians lack the knowledge and/or time to provide adequate counselling.
Wafaa B. Basta
Specialist Gynaecology & Obstetrics at Mataria Teaching Hospital
MBBch., MSc ., Egyptian Fellowship, MRCOG
13th Annual conference Ras El=Bar 12 May 2011
Obesity is a medical condition in which excess body
fat has accumulated to the extent that it may have
an adverse effect on health, leading to reduced life
expectancy and/or increased health problems.
Obesity increases the likelihood of various diseases,
particularly heart disease, type 2 diabetes, breathing
difficulties during sleep, certain types of cancer, and
Obesity has many deleterious effects on fertility,
pregnancy & birth
Obesity is a leading preventable cause of death
The authorities view obesity as one of the most
serious public health problems of the 21st century.
Obesity is most commonly caused by a
* Excessive food energy intake,
* Lack of physical activity,
* And genetic susceptibility.
Although a few cases are caused primarily
by genes, endocrine disorders, medications
or psychiatric illness.
Body mass index ( BMI) is a simple measure of obesity
& is calculated by dividing a person’s weight in
kilograms by the square of their height in metres
The BMI (kg/m2) classification published by both the
World Health Organization (WHO) and the National
Institute for Health and Clinical Excellence (NICE):
* <18.5 : Underweight
* 18.5-24.9 : Normal/Healthy
* 25.0-29.9 : Overweight (pre-obese)
* 30.0-34.9 : Obese (Class I)
* 35.0-39.9 : Obese (Class II)
* ≥40 Obese ( Class III = morbid obesity)
o Waist –hip ratio is another important measure which
correlates more with the metabolic disorder
For thousands of years obesity was rarely seen. In
fact, for most of all the human history, people lived
as hunter-gather societies, where there was no place
The relatively quick shift from hunter-gather
societies to sedentary agriculture has lead to the
rapid development of obesity.
It was not until the 20th century that it became
common, so much so that in 1997 the WHO formally
recognized obesity as a global epidemic.
At 2008, The WHO claimed that 1.5 billion
individuals over the age of 20 are considered obese.
Although considered a problem only of high-income
countries, obesity rates are rising worldwide.
Egypt, and the countries of the Middle East in general, are
typical of many middle income developing countries that
have experienced a rapid rise in the prevalence of obesity.
Obesity in the Eastern Mediterranean Region has reached
‘alarming levels’ according to a WHO study (Musaiger 2004)
Data from the Demographic and Health Surveys show that:
In 1992, mothers with young children had a mean body
mass index (BMI) of 26.9.
By 2005, this had risen to a mean BMI of 30.1, with
nearly half of Egyptian women of reproductive age
classified as obese.
Clearly, Egypt is facing extraordinary changes in the
prevalence of overweight and obesity in a comparatively
short period of time.
Fetal & neonatal
The prevalence of PCOS appears to be rising among
adolescent and young women because of the current
epidemic of obesity, worldwide.
About 50% of women with PCOS are overweight.
Compared with normal weight women with PCOS,
those obese women with PCO are characterised by:
* Worsened hyper-androgenic state,
* Worsened metabolic state,
* Poorer menses,
* Poorer ovulatory performance ,
* Poorer pregnancy rates.
A gain in weight is associated with a worsening of
symptoms of PCO whilst weight loss will improve the
disease profile and its symptoms.
In metabolic terms, the distribution of body fat is more
important than actual body weight. Visceral fat (within the
abdomen) is more metabolically active, and an increased
waist circumference (or waist: hip ratio) correlates better
with both metabolic risk and long term disease.
Insulin resistance is also an important correlate of BMI and is
perceived as a more accurate marker of the metabolic effect
In women with PCOS and a body mass index (BMI) >35kg/m2,
20% of pregnancies end with stillbirth and another 20% has
congenital anomalies. The supposed mechanism that
increases stillbirth and congenital anomaly rate includes
insulin resistance and impending or undiagnosed diabetes.
Weight loss & exercise in women with PCOS improves:
* The endocrine profile,
* Menstrual cyclicity,
* Rate of ovulation
* The likelihood of a healthy pregnancy.
Even a loss of 5% - 10% of total body weight can achieve:
* 30% reduction of central fat,
* An improvement in insulin sensitivity
* Restore ovulation.
Pharmacotherapy, including metformin, is not a substitute
for weight loss or lifestyle improvement in women with
PCOS . Metformin has little benefit in the most overweight
and its role in the management of infertility requires
However obese women with PCOS often report extreme
difficulty in loosing weight and maintaining weight loss.
Fetal & neonatal
Obesity is known to be associated with sub-optimal
reproductive performance but its direct effect on the
outcome of assisted reproduction techniques (ART) is
A study aimed to perform a systematic review of the
available evidence to assess the effects of obesity on
the outcome of ART showed:
Compared with women with a BMI of 25 kg/m2 or less,
women with a BMI ≥ 25 kg/m2 have:
* A lower chance of pregnancy following IVF.
* Require higher dose of gonado-trophins .
* Have an increased miscarriage rate.
There is insufficient evidence on the effect
of BMI on:
* Live birth,
* Cycle cancellation,
* Oocyte recovery ,
* Ovarian hyper-stimulation syndrome.
Further studies with clear entry criteria and
uniform reporting of outcomes are needed to
investigate the true impact of weight on the
outcome of ART.
In accordance with the guidelines of the
British Fertility Society (BFS), it is
inadvisable that women with a BMI greater
than 35kg/m² should receive fertility
investigations or treatment until they reduce
weight to BMI <35kg/m² .
Women with a BMI greater than 30kg/m²
should be advised to reduce weight to a BMI
less than 30 kg/m² before receiving assisted
reproductive technology (ART)
Fetal & neonatal
All women should be encouraged to maintain BMI in the range
20–25 kg/m² .
Weight, body mass index and waist circumference should be
regularly monitored & documented.
Women of childbearing age with a BMI> 30 should :
Receive information and advice about the risks of obesity
during pregnancy and childbirth,
Be supported to lose weight before conception
Advised to take high-dose folic acid (5 mg/day) one month
before conception at least & in the first trimester.
Advised to take 10micrograms Vitamin D supplementation daily
during pregnancy and while breastfeeding
Referred to a dietician.
Screened for diabetes .
All pregnant women should have their BMI
calculated & recorded at the antenatal booking
Waist circumference should be recorded as a
supplementary measure of adiposity in those
with a BMI <35 kg/m².
Early booking visit to plan pregnancy
management for all women who are obese.
All pregnant women with a booking BMI >30
should be provided with accurate and accessible
information about the risks associated with
obesity in pregnancy and how they may be
An appropriate size of arm cuff should be used.
Women with a booking BMI> 35 who also have at least one additional risk
factor for pre-eclampsia should be prescribed aspirin 75 mg daily from
12 weeks’ gestation until birth of the baby .
Additional risk factors include:
* First pregnancy,
* Previous pre-eclampsia,
* >10 years since last baby,
* >40 years old,
* Family history of pre-eclampsia,
* Booking diastolic BP> 80mmHg,
* Booking proteinuria> 1+ on more than one occasion or>
* Multiple pregnancy,
* Certain underlying medical conditions such as anti-
phospholipid antibodies or pre-existing hypertension, renal disease or
Women with a booking BMI 30 should be:
1. Assessed at their first antenatal visit for the
risk of TE.
2. If she has two or more additional risk factors
for TE, prophylactic LMWH is prescribed
3. All women receiving LMWH antenatally should
usually continue prophylactic doses of LMWH
until six weeks postpartum.
4. The prescribed doses of LMWH should be
adjusted for maternal weight, :e.g. For body
weight (91 - 130 kg) , the dose of Enoxaparin is
60 mg daily, while if the weight is from (131-
170kg) the dose will be 80 mg/day.
All pregnant women with a booking BMI 30
should be screened for gestational diabetes,
using 2 hour 75g oral glucose tolerance test at
24-28 weeks, with the potential for repeating in
Fetal & neonatal
Pre- operative/antenatal anaesthetic
assessment is essential, so that potential
difficulties with venous access, regional or
general anaesthesia can be identified.
The duty senior anaesthetist should be
informed, when a women with BMI >40 is
Manual handling requirements include
consideration of safe working loads of beds
and theatre tables, appropriate transfer
equipment, and appropriately sized
thromboembolic deterrent stockings (TEDS).
Continuous electronic fetal monitoring for
Fetal & neonatal
o All women with a BMI 40 should be offered
postnatal thromboprophylaxis regardless of
their mode of delivery
o All women with a BMI 30 should be
encouraged to mobilise as early as
practicable following childbirth to reduce
the risk of thromboembolism.
o The Risk of TE in obese women should be
reassessed post delivery.
Women with a BMI >30 having a caesarean
section have an increased risk of wound
infection, and should receive prophylactic
antibiotic at the time of surgery.
Carful tissue handling, carful haemostasis&
interrupted skin sutures maybe of help.
Women who have more than 2 cm
subcutaneous fat, should have suturing of SC
A detailed anomaly scan and serum screening
for congenital abnormality should be
recommended in all women who are obese.
Women with a BMI 35 should give birth in
an obstetric unit with appropriate
Later in Life
Babies born to obese mothers are at greater
risk of later developing diabetes,
cardiovascular disease and obesity
Confidential Enquiry into Maternal and Child Health’s report UK 2003–2005
Taken all together
Bariatric surgery are more successful than traditional
methods of weight loss.
The acknowledgement of the effectiveness of these
procedures by National Institute for Clinical
Excellence (in the UK) and the Food and Drug
Administration (in the USA), women with severe
obesity increasingly seek such treatment.
The aims of Bariatric surgery in morbidly obese are
Normalise metabolic & psych-social development,
Enhance fertility ,
Improve the outcome of pregnancy
Improve the weight & metabolic development of
Within current guidelines, bariatric surgery is
considered 1st, line treatment in adults with a
BMI above 50kg/m2.
It is considered for patients with a BMI above
40kg/m2 or BMI above 35kg/m2 in the presence
of obesity co-morbidity
Increasingly ,women of reproductive age are
considering bariatric surgery as a precursor to
However it is well established that bariatric
surgery improves the markers of PCO with
improvement in anovulation ,hirsutism, insuline
Obese women who have weight loss surgery
before becoming pregnant have a lower risk
of pregnancy-related health problems and
their children are less likely to be born with
Life-long vitamin supplementation is advised.
It is advised against falling pregnant during
the initial weight loss phase (1 year)
Complication include malapsorbtion,band
slipping , erosion & internal hernia.
Obesity has many deleterious effects for women of
In the first place, obese women are more likely to
encounter problems becoming pregnant and they are
more likely to miscarry
They are at greater risk of developing pregnancy
complications and problems associated with labour
Finally, obese women are more at risk of postpartum
Taken all together, maternal mortality and morbidity
is significantly elevated for obese women .
Maternal obesity is also dangerous for the fetus and
The management of obesity requires a
Stepwise programmes with realistic time-
related goals are required, starting with
modification of lifestyle, progressing to
pharmacotherapy and ultimately obesity surgery.
Weight loss interventions do not appear to be
common practice among fertility centres& pre-
pregnancy clinics in spite of clear evidence as to
Women should be referred to a nutritionist in
cases where clinicians lack the knowledge
and/or time to provide adequate counselling.
Prevention of childhood obesity is a priority.
In particular, barriers to physical activity in
girls and young women should be addressed.
CMACE/RCOG Joint Guideline. Management of Women with Obesity in Pregnancy March 2010
CMACE release: National enquiry into maternal obesity – Implications for women, babies and
Obesity and Reproductive Health - study group statement .Consensus views arising from the
53rd Study Group: Obesity and Reproductive Health
Effect of overweight and obesity on assisted reproductive technology—a systematic review
2007. Published by Oxford University Press on behalf of the European Society of Human
Reproduction and Embryology.
Fertility: assessment and treatment for people with fertility problems Clinical Guideline 11
February 2004 Developed by the National Collaborating Centre for Women’s and Children’s Health
The Impact of Obesity on PCOS and Reproductive Health. Review article: Obesity in pregnancy
,Review article: The short- and long-term implications of maternal obesity on the mother and
her offspring ,Review article: The impact of obesity on reproduction in women with
polycystic ovary syndrome .The BJOG October edition (Volume 113, number 10)
THE ROLE OF BARIATRIC SURGERY IN THE MANAGEMENT OF FEMALE FERTILITY Scientific
Advisory Committee Opinion Paper 17 March 2010
National Institute for Health and Clinical Excellence. Obesity. Guidance on the prevention,
identification, assessment and management of overweight and obesity in adults and children.
London: National Institute for Health and Clinical Excellence (NICE), 2006.
World Health Organization. Obesity: Preventing and managing the global epidemic. Geneva: World
Health Organization, 2000.
Green-Top Guideline No. 37. Reducing the risk of thrombosis and embolism during pregnancy and
puerperium. London: Royal College of Obstetricians and Gynaecologists, 2009.
The Pre-eclampsia Community Guideline Development Group. Pre-eclampsia Community Guideline
(PRECOG). Middlesex: Action on Pre-Eclampsia (APEC), 2004