The Impact of Increasing Obesity Class on Obstetrical Outcomes

El-Chaâr, Darine; Finkelstein, Sara A.; Tu, Xin; Fell, Deshayne B.; Gaudet, Laura; Sylvain, Jacques; Tawagi, George; Wen, Shi Wu; Walker, Mark

doi:10.1016/s1701-2163(15)30994-4

Cited by 68 publications

(65 citation statements)

References 56 publications

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“…In the United Kingdom, for example, nulliparous, morbidly obese women with a BMI Ͼ 40 determined at 10 wk of gestation were found to have a 30% chance of developing PE (13). This strong positive correlation between obesity and the prevalence of PE has also been observed in Americans (110), New Zealanders (103), and Canadians (43).…”

Section: Epidemiological Evidence Supporting That Obesity Increases Tmentioning

confidence: 87%

Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms

Spradley

Palei

Granger

2015

American Journal of Physiology-Regulatory, Integrative and Comp

113

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) is a pregnancy-specific disorder typically presenting as new-onset hypertension and proteinuria. While numerous epidemiological studies have demonstrated that obesity increases the risk of PE, the mechanisms have yet to be fully elucidated. Growing evidence from animal and human studies implicate placental ischemia in the etiology of this maternal syndrome. It is thought that placental ischemia is brought about by dysfunctional cytotrophoblast migration and invasion into the uterus and subsequent lack of spiral arteriole widening and placental perfusion. Placental ischemia/ hypoxia stimulates the release of soluble placental factors into the maternal circulation where they cause endothelial dysfunction, particularly in the kidney, to elicit the clinical manifestations of PE. The most recognized of these factors are the anti-angiogenic sFlt-1 and pro-inflammatory TNF-␣ and AT1-AA, which promote endothelial dysfunction by reducing levels of the provasodilator nitric oxide and stimulating production of the potent vasoconstrictor endothelin-1 and reactive oxygen species. We hypothesize that obesity-related metabolic factors increase the risk for developing PE by impacting various stages in the pathogenesis of PE, namely, 1) cytotrophoblast migration and placental ischemia; 2) release of soluble placental factors into the maternal circulation; and 3) maternal endothelial and vascular dysfunction. This review will summarize the current experimental evidence supporting the concept that obesity and metabolic factors like lipids, insulin, glucose, and leptin affect placental function and increase the risk for developing hypertension in pregnancy by reducing placental perfusion; enhancing placental release of soluble factors; and by increasing the sensitivity of the maternal vasculature to placental ischemia-induced soluble factors. body mass index; inflammation; placental ischemia; pregnancy; RUPP; sFlt-1 PE IS A PREGNANCY-SPECIFIC DISORDER typically identified by new-onset hypertension in the second half of pregnancy. Although often accompanied by new-onset proteinuria, PE can be associated with many other signs and symptoms including headaches, visual disturbances, epigastric pain, and the development of edema (4,192). Globally, this disease affects over 8 million pregnancies per year and is estimated to account for 40 -60% of maternal deaths in developing countries (125). In the United States, there was a 25% increase in the rate of PE between the years 1987-2004 (189). This significant increase highlights the importance of understanding how risk factors like obesity play a role in the pathogenesis of this maternal syndrome. Obesity is defined as a body mass index (BMI) of greater than or equal to 30 kg/m 2 . Greater than one-half of pregnant women are overweight or obese (48), and more than two-thirds of reproductive-aged women in the United States are overweight or obese (49). Although mounting epidemiological evidence supports obesity as a major risk factor for PE, the mechanisms linking these two morbidities are...

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Section: Epidemiological Evidence Supporting That Obesity Increases Tmentioning

confidence: 87%

Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms

Spradley

Palei

Granger

2015

American Journal of Physiology-Regulatory, Integrative and Comp

113

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“…Obese parturients have a tendency to labour abnormally, which may contribute to increased instrumental and caesarean delivery (2 to 4 fold increase) [9,10,20,21]. Considerable challenges are faced by anesthesiologists when helping …”

Section: Discussionmentioning

confidence: 99%

“…• to deliver these patients by caesarean: these patients are more likely to have technical challenges with airway access, ease of intubation, intravenous access, spinal or epidural placement, and analgesic/anesthetic success with regional techniques, not to mention prolonged operation times and difficulty with adequate left uterine displacement positioning on the operating table [9,19,20,22,23].…”

Section: Citation: Faris As Chaput Aj Goheen S Gallant C (2014) Anmentioning

confidence: 99%

“…It is well known that any bariatric patient is at risk for diseases such as diabetes, hypertension, respiratory diseases (including obstructive sleep apnea), and deep venous thrombosis, in addition to surgical complications such as wound infection [1]. If pregnancy is superimposed on being significantly overweight, patients become more prone to the development of antenatal diseases including pre-eclampsia, gestational diabetes, venous thrombo-embolism, large for gestational age infants, and preterm deliveries [4,9,10].…”

Section: Introductionmentioning

confidence: 99%

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Anesthesia for Cesarean Delivery in the Morbidly Obese Parturient - Comparison of Commonly used Anesthesia Techniques

Faris¹

2014

ACC

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Background: Obesity in pregnancy can add significantly to obstetric and anesthetic complications. The objective of this study is to identify and compare anesthesia-related complications in different types of elective cesarean anesthetics in morbidly obese parturients. Methods:Retrospective review was done on 205 records of elective cesareans for pregnants with Body Mass Index (BMI) ≥ 40. Data extracted include: type of anesthesia, intraoperative and early postoperative complications, duration of surgery, newborn birth weight, cord blood pH and Apgar scores. Results: The incidence of significant intra-operative hypotension: 65.0%, bradycardia 3.04%, nausea and vomiting 14.21%. Intraoperative hypotension: 67% in spinal and CSE group vs. 34.8% in epidural group (p = 0.0022). Super Morbid Obese (SMO) patients (BMI > 50) had a greater number of attempts at placement for regional techniques compared to Morbidly Obese (MO) patients (BMI 40−49.9) (2.02 vs. 2.61, p = 0.0255). SMO patients had longer mean surgical times (86.6 vs. 107.55 min, p = 0.0001), received more intraoperative crystalloids (1887 vs. 1699 ml, p = 0.0376) and colloids (33.9 vs. 12.6%, p = 0.0007) compared to MO patients. No other complications were significantly different between the 2 compared anesthetic techniques or BMI classes. Conclusion:Spinal anesthesia was the most commonly used technique. It resulted in more hypotension. Parturients with BMI ≥ 50 were more challenging to manage with more regional anesthesia placement attempts, larger fluid volumes and longer surgery times. A well-organized RCT could prove beneficial in validating the most profitable and safe anesthetic technique for bariatric parturients.

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“…29 However, this is the first study of risk factors to outline a strength of association. Maternal BMI 25,46 and outcomes from previous deliveries 1 are considered in practice but were not recorded in the database. While comorbid humerus and clavicle fractures are correlated with OBPI, these factors are not identified prior to labor and delivery; they occur concomitantly with OBPI itself.…”

Section: Risk Factorsmentioning

confidence: 99%

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

Coroneos¹,

Voineskos²,

Coroneos

et al. 2016

PED

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OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada’s 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group’s guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, “good” if assessed by the time the patient was 1 month of age, “satisfactory” if by 3 months of age, and “poor” if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%–60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was “good” in 28%, “satisfactory” in 66%, and “poor” in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

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The Impact of Increasing Obesity Class on Obstetrical Outcomes

Cited by 68 publications

References 56 publications

Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms

Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms

Anesthesia for Cesarean Delivery in the Morbidly Obese Parturient - Comparison of Commonly used Anesthesia Techniques

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

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