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Obesity& reproductive health

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.

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Obesity& reproductive health

  1. 1. Wafaa B. Basta Specialist Gynaecology & Obstetrics at Mataria Teaching Hospital MBBch., MSc ., Egyptian Fellowship, MRCOG ERC MEMBER 13th Annual conference Ras El=Bar 12 May 2011
  2. 2.  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 osteoarthritis.  Obesity has many deleterious effects on fertility, pregnancy & birth  Obesity is a leading preventable cause of death worldwide.  The authorities view obesity as one of the most serious public health problems of the 21st century.
  3. 3.  Obesity is most commonly caused by a combination of: * 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.
  4. 4.  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 (kg/m2).  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
  5. 5.  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 for obesity.  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.
  6. 6.  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.
  7. 7.  PCO  ART  Pregnancy  Labour  Postpartum  Fetal & neonatal
  8. 8.  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.
  9. 9.  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 of obesity.  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.
  10. 10.  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 further evidence.  However obese women with PCOS often report extreme difficulty in loosing weight and maintaining weight loss.
  11. 11.  PCO  ART Pregnancy  Labour  Postpartum  Fetal & neonatal
  12. 12.  Obesity is known to be associated with sub-optimal reproductive performance but its direct effect on the outcome of assisted reproduction techniques (ART) is less clear.  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.
  13. 13.  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.
  14. 14.  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) therapy/ovulation induction.
  15. 15.  PCO  ART  Pregnancy  Labour  Postpartum  Fetal & neonatal
  16. 16. Miscarriage Pre- eclampsia (3-4 times) Gestational Diabetes (3times) Thrombo- embolism PREGNANCY RISKS
  17. 17.  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 .
  18. 18.  All pregnant women should have their BMI calculated & recorded at the antenatal booking visit.  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 minimised.
  19. 19. Pre- eclampsia (3-4 times) PREGNANCY RISKS
  20. 20.  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> 0.3g/24 hours, * Multiple pregnancy, * Certain underlying medical conditions such as anti- phospholipid antibodies or pre-existing hypertension, renal disease or diabetes.
  21. 21. Thrombo- embolism PREGNANCY RISKS
  22. 22.  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 antenatally. 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.
  23. 23. Gestational Diabetes (3times) PREGNANCY RISKS
  24. 24.  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 later pregnancy.
  25. 25.  PCO  ART  Pregnancy  Labour  Postpartum  Fetal & neonatal
  26. 26. Dys-functional labour Shoulder Dystocia Anaesthetic Complications Technical difficulties (IV access,.....) Higher CS Rate (1.5 times) LABOUR RISKS
  27. 27. Anaesthetic Complications LABOUR RISKS
  28. 28.  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 admitted.
  29. 29. Technical difficulties (IV access,.....) LABOUR RISKS
  30. 30.  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 surveillance.
  31. 31.  PCO  ART  Pregnancy  Labour  Postpartum  Fetal & neonatal
  32. 32. Thrombo- embolism Depression Post-partum Haemorrhage (4 times) Lower Breast Feeding Rate Wound Infection POST-PARTUM RISKS
  33. 33. Thrombo- embolism POST-PARTUM RISKS
  34. 34. 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.
  35. 35. Wound Infection POST-PARTUM RISKS
  36. 36.  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 tissue.
  37. 37. Post-partum Haemorrhage (4 times) POST-PARTUM RISKS
  38. 38.  Women with a BMI >40 should have venous access established early in labour.  Active management of 3rd stage of labour.
  39. 39.  PCO  ART  Pregnancy  Labour  Postpartum  Fetal & neonatal
  40. 40. NICU Admission (1.5 times) Stillbirth (2 times) Neonatal Death Complications Later in Life Congenital Anomalies Fetal & Neonatal Risks
  41. 41. Congenital Anomalies Fetal & Neonatal Risks
  42. 42.  A detailed anomaly scan and serum screening for congenital abnormality should be recommended in all women who are obese.
  43. 43. NICU Admission (1.5 times) Fetal & Neonatal Risks
  44. 44.  Women with a BMI 35 should give birth in an obstetric unit with appropriate neonatal services.
  45. 45. Complications Later in Life Fetal & Neonatal Risks
  46. 46.  Babies born to obese mothers are at greater risk of later developing diabetes, cardiovascular disease and obesity themselves.
  47. 47. Maternal Death Confidential Enquiry into Maternal and Child Health’s report UK 2003–2005 Taken all together
  48. 48.  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 to:  Normalise metabolic & psych-social development,  Enhance fertility ,  Improve the outcome of pregnancy  Improve the weight & metabolic development of offspring.
  49. 49.  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 fertility treatment  However it is well established that bariatric surgery improves the markers of PCO with improvement in anovulation ,hirsutism, insuline resistance.
  50. 50. 1. Laparoscopic adjustable gastric banding (LAGB) 2. Vertical banded gastroplasty (VBG) 3. Laparoscopic ROUX-en-Y gastric bypass 4. Biliopancreatic diversion (BPD)& biliopancreatic diversion with duodenal switch (DS)
  51. 51.  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 complications.  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.
  52. 52.  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.
  53. 53.  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. 
  54. 54.  Prevention of childhood obesity is a priority. In particular, barriers to physical activity in girls and young women should be addressed.
  55. 55.  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 the NHS  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 (NICE)  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

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