What PCPs should know about obesity during pregnancy

Obesity is a chronic, complex disease that can lead to a spectrum of additional serious health concerns.

For pregnant patients with obesity, those health concerns are amplified. Studies highlight the correlation between high BMI and mortality and the probability of health care expenditures. Higher rates of mortality and the overall increase of pregnancy-related complications can result in longer lengths of hospital stays. Increased cesarean section rates, which are associated with a longer length of stay than vaginal deliveries, and increased breastfeeding difficulties, including being less likely to initiate lactation, can also impact the duration of stay.

Obesity has become such a common condition that the implications in pregnancy are often overlooked or underrecognized. Management requires a long-term approach that should begin before pregnancy and continue through the postpartum period and beyond. The primary goal for patients with obesity is targeting the prevention of obesity-associated pregnancy concerns with preconception counseling, beginning pregnancy with a lower BMI and limiting subsequent weight gain. Early dietician involvement as part of a multi-disciplinary process is also key to success.

As primary care physicians, there are several care services we can provide to patients with obesity who are pregnant or are considering becoming pregnant. Assessing risk factors and associations while delivering nonbiased care is paramount to successful care.

Potential complications from obesity and pregnancy

Obesity during pregnancy can increase several health problems, including those associated with high blood pressure and diabetes. Gestational hypertension or preeclampsia can lead to serious complications that can result in seizures, myocardial infarction and stroke, as well as placental concerns affecting the growth of the fetus.

Obesity can also increase the risk for gestational diabetes, which is universally screened around 26 to 28 weeks of gestation. Gestational diabetes presents serious implications for both mothers and fetuses, including an increased likelihood of shoulder dystocia, macrosomia and cesarean section deliveries. It also increases the lifetime rate of diabetes for mothers and their children.

Specialized care for pregnant patients with obesity

Reducing preeclampsia risk

Before 16 weeks’ gestation, patients with obesity should consider taking low-dose aspirin to reduce the risk for preeclampsia. Throughout pregnancy, patients should monitor their blood pressure regularly for a more accurate blood pressure evaluation than sporadic clinic reads. Consider a baseline for 24-hour urine protein, platelet and transaminase levels.

Screening for sleep apnea

Obstructive sleep apnea (OSA) symptoms can mimic the symptoms of pregnancy. Remember to evaluate OSA in pregnant patients with obesity, consider and distribute a questionnaire and consider an overnight sleep study (polysomnogram). Research shows that continuous positive airway pressure therapy is a safe and effective way to reduce risks before, during and after pregnancy.

Evaluating for diabetes

Early glucose testing on pregnant patients with obesity can evaluate for underlying diabetes and allow for early intervention and improved glycemia. Continuous glucose monitors have transformed many patients’ understanding of their levels and allowed tighter glucose control and increased compliance. An early glucose tolerance test is recommended around 16 weeks’ gestation. If identified, treatment includes a multidisciplinary approach with diabetic education, a dietician and potential medication.

Risk factors of obesity during pregnancy

Obesity poses unique risks that extend toward the fetus, such as neural tube defects, cardiac anomalies and orofacial clefts. Unfortunately, the quality of the prenatal fetal anatomic survey and certain aspects of prenatal diagnostic screening programs are significantly limited. Level 2 detailed morphology scans are suggested for those with a BMI greater than 35 kg/m², and fetal echocardiography is suggested for those with a BMI greater than 40 kg/m².

Birth defects

Obesity during pregnancy both increases the risk for birth defects and decreases the sensitivity of identification. More challenges develop with imaging and heart rate monitoring. Increased imaging requirements, patient dissatisfaction and the increased cost of evaluation can also be substantial. Newer popular noninvasive prenatal testing for the most common fetal aneuploidies, such as trisomy 21, also has a higher incidence of inconclusive results at the first blood draw due to fetal fraction below the specified cutoff compared with the normal weight category.

Preterm birth

The increased risks for associated disorders in pregnant patients with obesity, such as preeclampsia and uncontrolled diabetes, may lead to earlier medically indicated deliveries.

Stillbirth

Obesity remains one of the most frequent modifiable risk factors for stillbirth, as a linear increase in risk is noted with BMI increase.

Placental function

Changes in placental function play a critical role in the development of pregnancy complications but may also be involved in linking maternal obesity to long-term health risks in the infant. Increased development of hyperinsulinemia and hypoglycemia in the neonatal period are common.

Neuropsychiatric disorders

Long-term longitudinal and associative studies reveal that children born to mothers with obesity have an increased risk for neuropsychiatric and mood disorders as well as an increased risk for cognitive impairment.

For PCPs, it’s never too early to collaborate with patients with obesity on risk-reduction strategies to promote a healthy, lower-risk pregnancy. Similar to preparing patients with obesity for a surgical procedure, an integrated approach should be taken for those planning a pregnancy. Simply asking for a patient’s basic reproductive wishes in the upcoming year is a great way to initiate the conversation.

Our knowledge of obesity continues to evolve. Learn the latest from the best in obesity treatment through the Obesity Medicine Association’s (OMA) spectrum of resources and tools. To learn more about OMA or to become a member, visit www.obesitymedicine.org/join.