Obesity in Pregnancy: A Qualitative Approach to Inform an Intervention for Patients and Providers

Background: Interventions have not been effective in assisting obese women to meet gestational weight gain (GWG) recommendations. Culturally-tailored prenatal programs may be needed. Objective: To investigate the perceptions of minority pregnant women and their providers about obesity and GWG along with their motivations for and barriers to improving health behaviors during pregnancy and strategies to improve the management of obesity in pregnancy with an emphasis on group programs. Methods: Sixteen primarily non-Hispanic black pregnant women with a prepregnancy body mass index ≥30kg/m2 and 19 prenatal care providers participated in focus groups. Discussion topics included GWG goals, body image, health behaviors, stress management, and group prenatal care for the patients and providers with additional emphasis on education and training needs for the provider. Results: Women frequently stated a target GWG of >20lbs. Women described a body image not in line with clinical recommendations (“200 pounds is not that big.”). They avoided the term “obese” and more commonly used “thick.” They were interested in learning more about nutrition and culturally-specific healthy cooking resources. Women stated they would enjoy massage and exercise in a group setting, though definitions of “exercise” varied. Family members could be helpful, but generational differences posed challenges (Grandmothers would “curse them out” for exercising during pregnancy). As a result, most felt the need to “encourage myself” and “do this for me and the baby.” Providers expressed discomfort discussing GWG and difficulty finding the right words for obesity and this was partially attributed to their own body weight. They gave several examples of the challenges they faced in providing prenatal care to obese women including time constraints, cultural myths, and system issues. They believed that a group setting that provides social support would be an ideal environment to address health behaviors in obese women. Conclusions: Culturally-tailored programs that use acceptable terms for obesity, provide education regarding healthy eating and safe exercise, and encourage appropriate support from social networks may be effective in addressing GWG in obese minority women. Further provider training in communication skills is necessary to appropriately address obesity in pregnancy

Preparing for and Managing a Pregnancy After Bariatric Surgery

The number of bariatric surgeries performed in the United States has risen exponentially. Given that the majority of patients are female and of reproductive age, it is important for clinicians who manage women’s health issues to be aware of the surgery, its long term goals, and the potential effect on future pregnancies. Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with controls. Adherence to nutritional guidelines and supplementation in the event of deficiencies are critical in the provision of prenatal care to this unique population. Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring

Maternal Obesity: Do Patients Understand the Risks?

Objective: To evaluate patient knowledge of the risks of maternal obesity and compare knowledge between non-obese and obese women. Study Design: A face-to-face survey was administered to 105 women at their first prenatal visit. The survey assessed their knowledge of obesity-related risks during pregnancy, weight history and goals, and health behaviors. Descriptive statistics described the entire sample. Student’s t and Chi-square tests compared knowledge between non-obese (BMI<30kg/m2) and obese (BMI≥30kg/m2) gravidas. Results: There were 56(54%) non-obese and 47(46%) obese participants. There were no significant differences between the weight groups with respect to age, race, insurance, education, tobacco use, and primigravity. Overall, 49% participants knew that obesity increases risk in pregnancy. The knowledge of specific risks was similar in the non-obese (60% correct) and obese (64% correct) groups, p=0.76. Obese patients were more aware of the risk for diabetes, 68% vs. 96%, p<0.001. Obese gravidas expressed more interest in weight loss prior to another pregnancy (61% vs. 81%, p=0.03); though the desired BMI's (22.1±2.3 vs. 26.2±3.0 kg/m2, p<0.001) were different for nonobese and obese women, respectively. Of all participants, 9% discussed the risks of maternal obesity with a provider prior to study participation and 75% wanted to participate in a study on weight loss prior to pregnancy to determine whether it leads to healthier pregnancies. 3 Kominiarek Obesity Survey Conclusions: Regardless of BMI category, patients require more knowledge about the risks of obesity in pregnancy, requested additional information, and were motivated to lose weight before future pregnancies. Because obese women underestimated their optimal weight loss goals, it is necessary to target this group for further education

Perinatal Outcome in the Live-Born Infant with Prenatally Diagnosed Omphalocele

Objective: To compare perinatal outcomes between liveborn non-isolated and isolated omphaloceles diagnosed during a prenatal ultrasound. Study Design: Fetuses (n=86) with omphalocele were identified between 1995-2007 at a single institution. Inclusion criteria were an omphalocele >14 weeks gestation, available fetal and/or neonatal karyotype, and a liveborn infant (n=46). Perinatal outcomes were compared in non-isolated (n=23) and isolated omphaloceles (n=23). Results: For all omphaloceles, the majority delivered after 34 weeks by cesarean. Mean birth weight (2782 vs. 2704g), median length of stay (27 vs. 25 days), and mortality (2 in each group) was not different between the non-isolated and isolated groups, P>0.05. In the non-isolated group, 7 major anomalies were not confirmed postnatally. Of the prenatally diagnosed isolated omphaloceles, 8(35%) were diagnosed with a syndrome or other anomalies after birth. Conclusion The outcomes were similar in non-isolated and isolated prenatally diagnosed omphaloceles, but ultrasound did not always accurately determine the presence or absence of associated anomalies

Dosing and monitoring of low-molecular-weight heparin in high-risk pregnancy: Single-center experience

Study Objective. To evaluate dosing requirements and monitoring patterns of low-molecular-weight heparin (LMWH) when used in high-risk pregnancy. Design. Retrospective, observational, cohort study. Setting. University-affiliated medical center. Patients. Forty-nine women treated with LMWH between 2001 and 2005 for either prophylaxis or treatment of venous thromboembolism during pregnancy and monitored with antifactor Xa activity. Measurements and Main Results. Data were obtained on 53 pregnancies in the 49 women. The primary outcome was change in dosing requirements of LMWH throughout pregnancy as determined by the corresponding antifactor Xa activity peak levels. Mean starting doses of twice-daily enoxaparin and doses most proximate to delivery were 39.2 mg (range 30– 60 mg) and 55.0 mg (range 30–100 mg, p=0.06), respectively, for the prophylaxis group and 83.0 mg (range 30–180 mg) and 85.7 mg (range 30–160 mg, p=0.41), respectively, for the therapeutic group. Weight-based mean starting doses and doses most proximate to delivery were 0.46 and 0.62 mg/kg (p=0.03), respectively, for the prophylaxis group and 0.90 and 0.87 mg/kg (p=0.29), respectively, for the therapeutic group. Dose changes were required in 9 (69%) of 13 pregnancies and 21 (55%) of 38 pregnancies (data from two of the 40 pregnancies were excluded—one in a patient receiving dalteparin, and one in a patient with mitral valve replacement who had higher antifactor Xa goals) in the prophylaxis and therapeutic groups, respectively, to achieve target antifactor Xa activity. The weight-based prophylactic dose was consistently 0.6 mg/kg in all three trimesters, achieving a mean ± SD target antifactor Xa activity of 0.39 ± 0.18 units/ml, whereas the therapeutic dose was 0.9 mg/kg to maintain antifactor Xa activity of 0.71 ± 0.22 units/ml. Conclusion. Dose changes for LMWH throughout pregnancy as guided by antifactor Xa activity were common. A significant increase in the LMWH dose requirements in the prophylactic group suggests that more frequent monitoring of antifactor Xa activity may be appropriate in pregnant patients to maintain target anticoagulant levels

Contemporary labor patterns: the impact of maternal body mass index

Objective: To compare labor patterns by body mass index (BMI). Study Design: 118,978 gravidas with a singleton term cephalic gestation were studied. Repeated-measures analysis constructed mean labor curves by parity and BMI categories for those that reached 10cm. Interval censored regression analysis determined median traverse times adjusting for covariates in vaginal deliveries and intrapartum cesareans. Results: In the labor curves, the time difference to reach 10 cm was 1.2 hours from the lowest to highest BMI category for nulliparas. Multiparas entered active phase by 6 cm, but reaching this point took longer for BMI≥40.0 (3.4hours) compared to BMI0.05), but decreased as BMI increased for multiparas (P<0.001). Conclusion: Labor proceeds more slowly as BMI increases suggesting that labor management be altered to allow longer time for these differences

Gestational Weight Gain and Obesity: Is 20 Pounds Too Much?

OBJECTIVE: To compare maternal and neonatal outcomes in obese women according to weight change and obesity class. STUDY DESIGN: Cohort study from the Consortium on Safe Labor of 20,950 obese women with a singleton, term live birth from 2002-2008. Risk for adverse outcomes was calculated by multiple logistic regression analysis for weight change categories (weight loss [9.0 kg]) in each obesity class (I 30.0-34.9 kg/m(2), II 35.0-39.9 kg/m(2), and III ≥40 kg/m(2)) and by predicted probabilities with weight change as a continuous variable. RESULTS: Weight loss was associated with decreased cesareans for class I women (nulliparas odds ratio [OR], 0.21; 95% confidence interval [CI], 0.11-0.42; multiparas OR, 0.61; 95% CI, 0.45-0.83) and increased small for gestational age infants (class I OR, 1.8; 95% CI, 1.3-2.5; class II OR, 2.2; 95% CI, 1.5-3.2; class III OR, 1.7; 95% CI, 1.1-2.6). High weight gain was associated with increased large for gestational age infants (class I OR, 2.4; 95% CI, 1.9-2.9; class II OR, 1.7; 95% CI, 1.3-2.1; class III OR, 1.6; 95% CI, 1.3-2.1). As weight change increased, the predicted probability for cesareans and large for gestational age infants increased. The predicted probability of low birthweight never exceeded 4% for all obesity classes, but small for gestational age infants increased with decreased weight change. The lowest average predicted probability of adverse outcomes (cesarean, postpartum hemorrhage, small for gestational age, large for gestational age, neonatal care unit admission) occurred when women (class I, II, III) lost weight. CONCLUSION: Optimal maternal and neonatal outcomes appear to occur when weight gain is less than current Institute of Medicine recommendations for obese women. Further study of long-term outcomes is needed with respect to gestational weight changes