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Obesity in pregnancy: maternal and perinatal outcome

Obesity is a health problem that is increasing in prevalence globally with a higher incidence in females than males according to the World Health Organization (WHO). Obesity in pregnant women increases the risks of maternal and perinatal complications. The WHO has defined the criteria of overweight as body mass index (BMI) >25 kg/m2 and that for obesity as BMI >30 kg/m. The increasing prevalence of obesity worldwide has prompted the WHO to designate obesity as one of the most important public health threats in the world. Obesity in pregnancy puts the mother and the fetus at increased risk of several complications such as gestational diabetes mellitus, hypertensive disorders of pregnancy, preeclampsia, preterm labor, post term pregnancy, dysfunctional labor, caesarean section, instrumental delivery.

study will highlight the importance of pre-conceptional counseling regarding obesity and related issues. The results of this study will emphasize addressing a problem which can be modified and thus several complications during pregnancy and also a long-term risk factor for cardiovascular diseases and for diabetes mellitus can be prevented.

METHODS
A retrospective observational study was conducted in obstetrics and gynecology department of Sardar Vallabhbhai Patel Institute of Medical Science and Research (SVPIMSR), Ahmedabad from June 2019 to December 2019 amongst 61 antenatal patients with booking BMI >30 kg/m 2 . Details of antenatal patients needed for the study was taken from medical records of patients delivered by cesarean section or vaginal delivery after due permission from authority. Patients were categorized into 3 classes based on their booking visit BMI (calculated by dividing weight in kilogram by square of height in meters). 2 The 3 classes were -class I: 30-34.9 kg/m 2obese; class II: 35-39.9 kg/m 2 -morbidly obese; and class III: ≥40 kg/m 2 -extremely obese.
The raw frequencies of various outcomes of pregnancy in maternal BMI groups were calculated and incidence was drawn out using excel sheets and descriptive statistics. For each outcome variable, BMI (class I, class II and class III) the maternal age, parity, need of induction, mode of termination, history of hypertension, or diabetes mellitus, and perinatal outcome (birth weight, growth retardation and neonatal intensive care unit admission) were included in the model. The maternal and perinatal outcome of the patients evaluated in relation to body mass index. The software used to analyze data was descriptive statistics and excel sheets.

Inclusion criteria
All antenatal patients who were registered and delivered at the obstetrics and gynecology department of SVPIMSR during the period from June 2019 to December 2019 with booking BMI is >30 kg/m 2 .

As shown in
Of the 61 women post-partum hemorrhage (PPH) was encountered in 6 women (9.8), of which 2 women delivered vaginally and 4 by cesarean. 5 women had wound gaping postoperatively and one woman developed peripartum cardiomyopathy ( neonates having low Apgar score (<4) needed NICU admission which included 2 preterm neonates (Table 5).

DISCUSSION
A number of systems have been used to define and classify obesity. The BMI, also known as the Quetelet index, is currently most often used. The BMI is calculated as weight in kilograms divided by the square of the height in meters (kg/m 2 ). 2 This study has demonstrated that many adverse outcomes of pregnancy are associated with maternal obesity and has provided quantification of these risks. We have confirmed an increase in the previously reported complications of pregnancy in obese women such as gestational diabetes, preeclampsia, induction of labor, increased rate of cesarean section and wound infection.

Antenatal complications
The risk of preeclampsia is positively associated with a raised BMI. The overall incidence of pre-eclampsia in obese women is 39.3 which is consistent with the study conducted by Dasgupta et al were the incidence of hypertensive disorders is 38. 3 Hypertensive disorders of pregnancy are significantly higher among obese women, O'Brien et al demonstrated that the risk of preeclampsia is typically doubled every 5-7 kg/m 2 increase in pregnancy BMI. 4 The increase in the risk of GDM increased with the increase in BMI from 5.4 in class I obese women to 7.6 in class II obese women to 50 in class III. In previous study about 17 of obese women show GDM in pregnancy compared to 1-3 women in normal BMI. 5 Therefore, diabetes is associated with increasing BMI and thus obesity.
Post term pregnancy was seen in 21.5 women and the percentage women with post term pregnancy increased as BMI increased. Obese women are more likely to go for posterm pregnancy and induction of labor.
Obese women are more prone for delivery by cesarean section. In our study the rate of cesarean increased with BMI. There was increased planned elective caesarean section for predicted macrosomia. The increase in emergency caesarean sections is the consequence of the increased rate of large for gestational age infants leading to cephalopelvic disproportion during labor or uterine contractility being suboptimal in obese women. The same study also found that there was a progressive reduction in the successful vaginal delivery rate with increasing BMI. 6 The increased risk of PPH in obese women is due to relatively larger area of implantation of the placenta usually associated with a large for gestational age fetus. In our study PPH and wound infections were significantly raised from obese women (PPH=7, 13 and 50) to morbidly obese women (wound gap=5, 13 and 50). Sebire et al reported a 44 increase of PPH with BMI >30 kg/m 2 . 7 Alanis et al had demonstrated higher risks of post caesarean wound gape, discharge and seroma formation among the morbidly obese. 8

Perinatal outcome
Obesity is associated with maternal insulin resistance and foetal hyperinsulinemia even in the absence of maternal diabetes. 9 Insulin resistant individuals have higher fasting plasma triglyceride levels and greater leucine turnover. 10 Amino acids are insulin secretagogues and an increased flux on amino acids could stimulate foetal hyperinsulinemia. Triglycerides are energy rich and placental lipases can cleave triglyceride and transfer free fatty acids to the fetus. The combination of an increased energy flux to the fetus and foetal hyperinsulinemia may explain the increased frequency of large for gestational age infants seen in the obese non-diabetic women in this study.
The original Pedersen hypothesis suggested that increased glucose concentrations in the diabetic mother led to foetal hyperglycemia and hyperinsulinemia causing increased foetal growth. 11 GDM is thus associated with increased incidence of macrosomia (birth weight >4 kg). In our study macrosomia is seen in 11 neonates and its incidence increases with increase in BMI of mother.

CONCLUSION
Obesity causes significant complications for the mother and fetus. Interventions directed towards weight loss and prevention of excessive weight gain must begin in the preconception period. Obstetrician must counsel their obese patients regarding the risks and complications conferred due to obesity and the importance of weight loss. Maternal and fetal surveillance may need to be heightened during pregnancy; a multidisciplinary approach is useful. Women need to be informed about both maternal and fetal complications and about the measures that are necessary to optimize outcome, but the most important measure is to address the issue of weight prior to pregnancy. Obesity in pregnancy is a major predictor of obesity later in life, which is commonly associated with the development of chronic hypertension, dyslipidemia and type 2 DM. The macrosomic babies (weight >3.5 kg) are at high risk of developing obesity in adolescence and diabetes mellitus in their adult life. Therefore, from a public health perspective, obesity represents an important modifiable risk factor for adverse pregnancy outcome which must be addressed during preconceptional and early pregnancy visit.