Extreme Obesity in Pregnancy in the United Kingdom

Knight, Marian; Kurinczuk, Jennifer J; Spark, P; Brocklehurst, Peter

doi:10.1097/aog.0b013e3181da8f09

Cited by 156 publications

(173 citation statements)

References 22 publications

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“…Obese women are more likely to require both caesarean section and instrumental delivery (11) (Table 1), paradoxically obese pregnant women are at an increased risk of the complications associated with operative delivery. These risks are further exaggerated in morbid obesity (12) (Table 2), where operative delivery poses challenges to both the anaesthetist and obstetrician. Given the high likelihood of operative delivery, even where vaginal delivery is attempted, the fact that 'emergency' caesarean section carries greater risks than 'elective' caesarean section, and the need for experienced members of staff if operative delivery is needed, one could argue that women with morbid obesity might be best delivered by elective caesarean section.…”

Section: Delivery Complicationsmentioning

confidence: 99%

“…In extreme obesity (BMI> 50) the risk of adverse outcomes increases further. The United Kingdom Obstetric Surveillance system study of extreme obesity identified that BMI > 50 was associated with increased adjusted OR of a range of adverse outcomes, including gestational diabetes, thrombosis, preeclampsia, postpartum haemorrhage and intensive care unit admission (Table 2) (12) .…”

Section: Antenatal Pregnancy Complications Increased By Obesitymentioning

confidence: 99%

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The consequences of obesity and excess weight gain in pregnancy

2011

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The prevalence of obesity in pregnancy is rising exponentially; about 15–20% of pregnant women now enter pregnancy with a BMI which would define them as obese. This paper provides a review of the strong links between obesity and adverse pregnancy outcome which operate across a range of pregnancy complications. For example, obesity is associated with an increased risk of maternal mortality, gestational diabetes mellitus, thromboembolism, pre-eclampsia and postpartum haemorrhage. Obesity also complicates operative delivery; it makes operative delivery more difficult, increases complications and paradoxically increases the need for operative delivery. The risk of the majority of these complications is amplified by excess weight gain in pregnancy and increases in proportion to the degree of obesity, for example, women with extreme obesity have OR of 7·89 for gestational diabetes and 3·84 for postpartum haemorrhage compared to their lean counterparts. The consequences of maternal obesity do not stop once the baby is born. Maternal obesity programmes a variety of long-term adverse outcomes, including obesity in the offspring at adulthood. Such an effect is mediated at least in part via high birthweight; a recent study has suggested that the odds of adult obesity are two-fold greater in babies weighing more than 4 kg at birth. The mechanism by which obesity causes adverse pregnancy outcome is uncertain. This paper reviews the emerging evidence that hyperglycaemia and insulin resistance may both play a role: the links between hyperglycaemia in pregnancy and both increased birthweight and insulin resistance have been demonstrated in two large studies. Lastly, we discuss the nature and rationale for possible intervention strategies in obese pregnant women.

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Section: Delivery Complicationsmentioning

confidence: 99%

Section: Antenatal Pregnancy Complications Increased By Obesitymentioning

confidence: 99%

The consequences of obesity and excess weight gain in pregnancy

2011

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“…Recording BMI and being aware of associated risks of obesity remains important. 73,123 Recommendations l Health professionals should be aware of the associated risk of dying from severe obstetric morbidity in women with medical comorbidities. l Women with medical comorbidities should be identified and fully assessed for their risks in pregnancy.…”

Section: Box 6 Signs and Symptoms Of Sepsismentioning

confidence: 99%

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight

Acosta

Brocklehurst

et al. 2016

Programme Grants Appl Res

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101

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BackgroundStudies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision.ObjectivesTo (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts.MethodsMixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group.SettingMaternity units in all four countries of the UK.ParticipantsWomen with near-miss maternal morbidities, their partners and comparison women without severe morbidity.Main outcome measuresThe incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches.ResultsWomen and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services.LimitationsThis programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded.ConclusionsImplementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…Inadequate labor analgesia has consistently been identified as a factor associated with extension failure7, 20, 21, 22, 23, 24 and this relationship is also demonstrated in this cohort. Published data on pregnant women with ‘extreme obesity’ (BMI 50 kg/m 2 ) have estimated a prevalence of 1 : 1000 in the United Kingdom28 and 2.1 : 1000 in Australia 29. These cohort studies have identified a significantly higher rate of cesarean section, general anesthesia and problems or failure of neuraxial anesthesia in this group 28, 29.…”

Section: Discussionmentioning

confidence: 99%

“…Published data on pregnant women with ‘extreme obesity’ (BMI 50 kg/m 2 ) have estimated a prevalence of 1 : 1000 in the United Kingdom28 and 2.1 : 1000 in Australia 29. These cohort studies have identified a significantly higher rate of cesarean section, general anesthesia and problems or failure of neuraxial anesthesia in this group 28, 29. International maternity care guidelines make recommendations regarding the care of pregnant women with a BMI > 40 kg/m 2 , but do not differentiate between levels of BMI greater than 40 kg/m 2 25, 26, 30.…”

Section: Discussionmentioning

confidence: 99%

Epidural extension failure in obese women is comparable to that of non‐obese women

Eley

Chin

Tham

et al. 2018

Acta Anaesthesiol Scand

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BackgroundManagement of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non‐obese women and to identify risk factors for extension failure.MethodsOne hundred obese participants (Group O, body mass index ≥ 40 kg/m2) were prospectively identified and allocated two sequential controls (Group C, body mass index ≤ 30 kg/m2). All subjects utilized epidural labor analgesia and subsequently required anesthesia for cesarean section. The primary outcome measure was failure of the labor epidural to be used as the primary anesthetic technique. Risk factors for extension failure were identified using Chi‐squared and logistic regression.ResultsThe odds ratio (OR) of extension failure was 1.69 in Group O (20% vs. 13%; 95% CI: 0.88–3.21, P = 0.11). Risk factors for failure in obese women included ineffective labor analgesia requiring anesthesiologist intervention, (OR 3.94, 95% CI: 1.16–13.45, P = 0.028) and BMI > 50 kg/m2 (OR 3.42, 95% CI: 1.07–10.96, P = 0.038).ConclusionThe failure rate of epidural extension did not differ significantly between the groups. Further research is needed to determine the influence of body mass index > 50 kg/m2 on epidural extension for cesarean section.

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Extreme Obesity in Pregnancy in the United Kingdom

Cited by 156 publications

References 22 publications

The consequences of obesity and excess weight gain in pregnancy

The consequences of obesity and excess weight gain in pregnancy

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Epidural extension failure in obese women is comparable to that of non‐obese women

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