Obs&gyn: Obesity

Question 1

How to calculate BMI?

Answer 1

Body Mass Index (BMI)

Weight (kg)/ Height2 (m2)

Question 2

BMI ranges

Answer 2

• BMI of 25-30: Overweight
• BMI 30-34.9: Class 1 Obesity
• BMI 35-39.9: Class 2 Obesity
• BMI 40+: Class 3 or Morbid Obesity

Question 3

How does obesity may cause a disease?

Answer 3

White fat around viscera sets up inflammation and cell death and causes disease

Question 4

What’s Leptin?

Answer 4

Leptin

• produced by adipose tissue
• mediates long term appetite controls
• encourage us to eat more when fat stores are low, and less when storage is high

Question 5

What’s Ghrelin?

Answer 5

Ghrelin

• produced by the empty stomach
• modulating short term appetite
• encouraging us to eat when the stomach is empty, and stop when the stomach is stretched

Question 6

By use of what pathways leptin and ghrelin produce their effects on appetite?

Answer 6

• Leptin and ghrelin control the appetite through action on the central nervous system
• Act on the paraventricular and arcuate nuclei of the hypothalamus through several pathways

Question 7

What (3) hormones adipose cells produce?

Answer 7

• Adiponectin → regulates fatty acid and glucose metabolism - levels are lower in obesity, which is related to insulin resistance
• Oestrogen
• Leptin - note levels of leptin are higher, but obesity leads to Leptin resistance

Question 8

Complications of obesity

Answer 8

Question 9

What BMI of >30 in pregnancy increases the risk of?

Answer 9

• Thrombosis
• Gestational Diabetes - 3 fold increase
• Pre-eclampsia - with BMI of 35 the risk is double that of a woman with a BMI of 25
• Neural tube defect
• Miscarriage - increases from 20% to 25%
• Increased birth weight - chances of a baby weighing more than 4kg are increased from 7% to 14%
• Stillbirth - risk increased from 1 in 200 to 1 in 100
• Increased risk of baby developing obesity or diabetes in later life

Question 10

Risks of BMI >40 in pregnancy and labour

Answer 10

With a BMI of more than 40:

• Increased risk of prematurity
• Labour dystocia
• Shoulder dystocia
• Emergency caesarean section
• Intraoperative complications, including bleeding
• Postoperative complications, including wound infection
• Anaesthetic complications, particularly with general anaesthesia
• Postpartum haemorrhage

Question 11

What advice to give for a woman of BMI of 30 or more wants to conceive?

Answer 11

• advice on weight and lifestyle should be given to all women of childbearing age
• support to lose weight prior to conception for all women with a BMI of 30 or more
• BMI of 30 or more should be advised to commence 5mg Folic Acid supplementation at least a month before conception and continuing during the first trimester of pregnancy

• BMI of 30 or more should be advised to commence 10 micrograms Vitamin D supplementation daily throughout pregnancy and while breastfeeding

Question 12

Do we need to refer a pregnant obese woman?

Answer 12

Women with a BMI of 30 or more should be referred to a consultant obstetrician

Question 13

When during pregnancy should we measure maternal weight and height?

Answer 13

• Weight and height should be measured and BMI recorded at booking visit
• Re-measurement of maternal weight in the third trimester will aid planning with regard to equipment and personnel

Question 14

Considerations for maternal BMI >35 and pre-eclampsia

Answer 14

Women with a BMI of 35 or more have an increased risk of pre-eclampsia.

Assess additional risk factors and commence low dose aspirin

Question 15

When and for whom do we do OGTT in pregnancy?

Answer 15

Women with a BMI of 30 or more should have a 2 hour 75g oral glucose tolerance test at 24-28 weeks

Question 16

The anaesthetic risk for women with BMI 40 or more

Answer 16

Women with a BMI of 40 and above should have an antenatal consultation with an obstetric anaesthetist to assess and discuss potential risks with IV access and regional and general anaesthesia

• Epidural re-site and failure rates higher
• Higher risk of gastric content aspiration, difficult intubation and postoperative atelectasis with general anaesthesia
• Increased comorbidities including IHD and hypertension

Question 17

Extra nursing and manual handling considerations for women with BMI of 40 or more

Answer 17

Women with a BMI of more than 40 should have:

• a manual handling and tissue viability assessment
• safe workloads of beds and theatre tables
• appropriately sized TEDS or boots
• plan for body position, repositioning, skin care and support services in women at risk of pressure sores

Question 18

Potential intrapartum complications in obese women

Answer 18

• Slow progress
• Shoulder dystocia
• Emergency caesarean section
• Increased risk of PPH
• Vaginal Birth After Caesarean (VBAC) can be considered on an individual basis – obesity is a risk factor for uterine rupture

Question 19

Place of birth for obese women

Answer 19

Women with a BMI of 35 or more should give birth on a consultant led unit with appropriate neonatal services – babies are 1.5 times more likely to require admission to special care

•Duty anaesthetist should be informed when a woman with a BMI of 40 or more is admitted if delivery/theatre is anticipated. Early epidural may be advisable if required

Question 20

What (extra) interventions woman with BMI of 40 or more may require during labour?

Answer 20

Women with BMI of 40 or more should have:

• continuous midwifery care
• continuous fetal monitoring by CTG recommended, and fetal scalp electrode may be required to adequately monitor baby’s heart rate pattern
• IV access in labour
• Active management of 3rd stage due to increased risk of PPH

Question 21

How do we manage wound infection risk in women with BMI 30 or more?

Answer 21

Increased risk of wound infection at caesarean with BMI of 30 or more

• prophylactic Abx and consideration of dressing type and use of fat stitch during abdominal closure

Question 22

Who to test for gestational diabetes?

Answer 22

Screen for GDM at 24-28 weeks with 75g OGTT if any of the following are present:

• BMI above 30 kg/m2
• Previous macrosomic baby weighing 4.5 kg or above
• Previous gestational diabetes (although most units advise BG monitoring from around 14 weeks
• Family history of diabetes (first‑degree relative with diabetes)
• Minority ethnic family origin with a high prevalence of diabetes
• Test opportunistically if Glycosuria of 2+ or above on 1 occasion or 1+ or above on 2 or more occasions during routine antenatal checks

Question 23

Positive result renges of OGTT in pregnancy

Answer 23

Positive 75g OGTT:

•Fasting plasma glucose level of 5.6 mmol/l

•2‑hour plasma glucose level of 7.8 mmol/l

Question 24

Management of gestational diabetes

Answer 24

• Advise capillary glucose testing pre-meal and 1 hour postprandial
• refer to Obstetrician and Diabetes team (usually a joint clinic)
• Intervention includes diet control, medication and/or insulin

Question 25

Chronic hypertension vs gestational hypertension (definitions)

Answer 25

* **Chronic hypertension** is present at booking or before 20 weeks or if already being treated for hypertension prior to pregnancy * **Gestational hypertension** is new hypertension presenting after 20 weeks without significant proteinuria

Question 26

Pre-eclampsia vs severe pre-eclampsia | (definitions)

Answer 26

* **Pre-eclampsia** is new hypertension presenting after 20 weeks with significant proteinuria, or superimposed on chronic hypertension * **Severe pre-eclampsia** is pre-eclampsia with severe hypertension with significant proteinuria and/or with symptoms, and/or biochemical and/or haematological impairment

Question 27

What's HELLP syndrome?

Answer 27

HELLP syndrome: * haemolysis * elevated liver enzymes * low platelet count * It'sconsidered a severe variant of pre-eclampsia

Question 28

What's eclampsia?

Answer 28

Eclampsia is a convulsive condition associated with pre-eclampsia

Question 29

Mild HTN in pregnancy ranges

Answer 29

Question 30

Moderate HTN in pregnancy - ranges

Answer 30

Question 31

Severe HTN in pregnancy - ranges

Answer 31

Question 32

Symptoms of pre-eclampsia

Answer 32

* severe headache * problems with vision, such as blurring or flashing before the eyes * severe pain just below the ribs * vomiting * sudden swelling of the face, hands or feet \*make pregnant women aware of these symptoms and that they should seek immediate medical attention

Question 33

What's defined as significant proteinuria?

Answer 33

* Urinary **protein:creatinine** ratio is greater than **30 mg/mmol** (preferred method) * Validated **24-hour urine collection** result shows greater **than 300 mg protein**

Question 34

Aspirin prophylaxis for women at high risk of pre-eclampsia

Answer 34

women at high risk of pre-eclampsia to take **75 mg of aspirin** daily **from 12 weeks until the birth** of the baby

Question 35

What places a woman in **high risk** of pre-eclampsia category?

Answer 35

* Hypertensive disease during a previous pregnancy * Chronic kidney disease * Autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome * Type 1 or 2 diabetes * Chronic hypertension

Question 36

Aspirin prophylaxis for woman with **moderate** risk of pre-eclampsia category

Answer 36

More than one **moderate risk** factor for pre-eclampsia: take 75 mg of aspirin daily from 12 weeks until the birth of the baby

Question 37

Moderate risk for pre-eclampsia

Answer 37

* First pregnancy * Age 40 years or older * Pregnancy interval of more than 10 years * Body mass index (BMI) of 35 kg/m2 or more at first visit * Family history of pre-eclampsia * Multiple pregnancy

Question 38

Obesity increases the risks of which gynaecological cancers?

Answer 38

* Increased BMI reduces risk of premenopausal breast cancer * Increased risk of ovarian and endometrial cancers * Increased risk of postmenopausal breast cancer * 30% of endometrial cancers in the UK are due to overweight and obese BMIs * Risk of endometrial cancer is increased by x 2-3 (x 6 if morbidly obese) * Physical activity can reduce endometrial cancer risk by up to 20-30% * PCOS women have an increased x 4 risk of endometrial cancer pre-menopause related to obesity

Question 39

What gynaecological conditions early-onset obesity is associated with?

Answer 39

Early onset obesity is associated with: * Oligomenorrhoea * Menstrual irregularity * Anovulation * Subfertility * Miscarriage * Polycystic Ovarian Syndrome

Question 40

Surgical considerations for obese women

Answer 40

* Laparotomy and Laparoscopy technically more difficult * Consider robotic surgery in morbidly obese women * Anaesthetic risks * Wound infection * Thromboembolism

Question 41

Obesity and contraceptive methods

Answer 41

Question 42

Emergency contraception in obese women

Answer 42

Emergency contraceptives can be used: * in women of any weight or body mass index (BMI) * obesity is not a contraindication to any of these methods