Placenta increta: an unexpected case and the benefit of conservative management

Abstract

Objectives: (1) To investigate the proportion of primiparous women in our unit with a BMI ≥30 during pregnancy and compare their outcomes to those with a BMI <30. (2) To audit our compliance with local trust and RCOG guidelines on the management of obesity during pregnancy. Methods: We carried out a retrospective audit over 6 months from January to June 2015. We obtained data for 100 of the 129 primiparous women with a BMI ≥30 who delivered in our unit during this period. We reviewed their maternity notes and completed a standard proforma for each patient. We also used data from our Northern Ireland Maternity System to compare outcomes with primiparous women with a BMI <30 delivering in our unit during this time period. Results: The proportion of primiparous women with a BMI ≥30 delivering during this period was 18.7% (n = 129). The results demonstrated in the graph above, show increased rates of PIH and GDM in women with BMI ≥35, consistent with rates reported in the literature. Furthermore, 22% and 17% of women with a BMI ≥35 were induced due to gestational diabetes and PIH respectively, compared to 6% for each indication in women with a BMI <30. There was also a high rate (20%) of postnatal infection in women with BMI ≥40. Ultrasound is another challenge in women with obesity and we found 22% of women BMI ≥35 had an anomaly scan 20 weeks which was documented as technically difficult due to body habitus. In assessment of our compliance with trust and RCOG guidance, we found high rates of appropriate risk assessment for thromboembolism and diabetes. However, only 8% of women with a BMI ≥35 received low dose aspirin, 18% of women received high dose folic acid, and 51% received vitamin D during pregnancy. Our trust also has a policy of informing women of the risks of obesity by providing patient information leaflets 'being overweight and pregnant'. This was only recorded as given to 1% of women. Conclusion: This audit highlights the burden that maternal obesity places on the healthcare system in our local context. It is clear that we need to ensure both staff and women understand the risks of obesity during pregnancy. To improve patient education we will design a poster that clearly shows the adverse outcomes associated with increased BMI in our unit, and display it in the waiting area of the maternity outpatient department. A public health initiative "weigh to a healthy pregnancy" has already been initiated to provide these women with midwifery and dietetic support to manage their weight and lifestyle. We will educate both community and hospital staff by presenting our audit results and by providing an update on the guidelines. As a result we hope improve the numbers of these women that receive high dose folic acid and low dose aspirin where appropriate. Lastly, we plan to introduce a checklist to remind staff in clinics to complete the full bundle of care for women with BMI ≥35 at their booking appointment.