If an obese women consults a gynecologist in pre pregnancy era following should be considered-
She should be counseled to optimize weight before pregnancy.
The consequences of obesity on mother’s health as well as on fetus should be discussed in detail.
Lifestyle modifications should be suggested.
It should be explained to her that if she tries to bring her weight down the chances of complications will also reduce
What are the factors which lead to obesity during pregnancy
One there is an association with childhood obesity.
Next, the woman might have retained the weight gained after last delivery
There might be endocrine problems like hypothyroidism.
Then obesity is also related to sedentary lifestyle urban dwelling and higher strata of social economic state.
There is a relation with the history of PCOD.
And there is genetic predisposition too.
Care during pregnancy of an obese pregnant women poses many challenges and practical issues for the gynecologist.
Measuring her blood pressure is difficult and can be fallacious.
Weighing scale may not withstand her weight.
Checking for swelling on her feet, which is the very common phenomena during pregnancy, may not be possible
Palpation of spine for any deformity may not be accurate.
Clinical evaluation of lungs and heart sounds is difficult and may not very informative.
Obstetrics examination to know the size of the uterus, presenting part and quantity of liquor is not accurate.
Now what to do about it.
A few things have solutions but others may not.
BP apparatus with large cuff size can be used.
A special weighing scale can be ordered.
2D ECHO and chest X-ray with abdominal shield can be done if needed.
Frequent ultrasound monitoring for fetal growth along with color doppler can be done.
Obesity in pregnancy, complications arising in pregnancy delivery and postpartum
Obesity in pregnancy poses many management challenges for the gynecologist and puts the pregnant women under high risk category.
These women may experience repeated abortions or even stillbirth.
They may go in preterm labor and can have excessive bleeding after delivery known as postpartum hemorrhage
There is more need for induction of labor and then again higher chances of failure of induction, failure of trial and more chances of elective and emergency Cesarean deliveries.
Pregnant women has more chances of developing hypertension, diabetes, ischemic heart disease and venous thromboembolism.
There are many complications with fetuses too.These babies have higher chances of having congenital anomalies.
They grow too big in size known as fetal macrosomia.
When labor is happening, because of big size of the baby, there may be shoulder distocia, what is that, it means that the head is delivered but the shoulders are too broad to go through the birth canal and the baby gets stuck.
Believe me when I tell you that it is a very difficult situation to manage for any gynecologist.
Because of big baby, more tears happen in the perineum at the time of delivery.As the mother is obese suturing those tears is very difficult as the access is very limited.
There are more chances of instrumental deliveries like use of forceps and vacuum.
All these things are associated with more perinatal morbidity and even mortality.
When these women need to undergo labor analgesia or spinal or epidural anesthesia for Cesarean there are challenges for the anesthetist too.
Finding the correct space in the spine for injecting anesthesia drugs is very difficult. it is even difficult to shift these patients in and out of operation table and operation theater.
In these women wound healing can be prolonged.
Large fatty and dense breasts may not produce adequate milk.
In post operative period prophylaxis for deep vein thrombosis needs to be given.
On average there are more chances of prolonged hospital stay for obese pregnant women after delivery.
Bariatric surgery and pregnancy
Obese women who have had bariatric surgery generally tolerate pregnancy well.
But it is not advisable to perform bariatric surgery during pregnancy.
If bariatric surgery is performed she is advised not to become pregnant for the next 12 to 18 months.
These pregnancies are to be considered as high risk pregnancy.
Nutritional deficiencies are to be specifically looked for and treated.
Hence role of a dietitian is of utmost importance.
Contraceptive advice for obese women
In obese woman following methods of contraception can be used
Levonorgestrel hormone releasing intrauterine device like Mirena.
If a cesarean delivery is being performed ,it is a very good idea to perform family planning operation too at that time.
What is contraindicated is any method which has hormone estrogen in it as it.As it carries the risk of venus thrombo embolism.