Obesity and Pregnancy

Definition and Epidemiology

• Obesity - classified by BMI 

  • Prevalence of obesity has increased to 34.0% in women 20-39 years in 2010  

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ACOG PB 230

Effect of Obesity on Pregnancy 

• Pregnancy Loss 

  • Increased risk of SAB (1.2 OR) and recurrent miscarriage (OR 3.5) 

  • Also have increased risk of pregnancies affected by neural tube defects, hydrocephaly, and other anomalies 

• Pregnancy Complications 

  • Antepartum

    • Medical issues: increased risk of cardiac dysfunction, proteinuria, sleep apnea, nonalcoholic fatty liver disease 

    • Pregnancy issues: increased risk of gestational diabetes, preeclampsia, stillbirth 

      • Risk of stillbirth increases with increasing obesity

        • OR 1.71 for BMI 30-34.9

        • OR 2.0 for BMI 35.0-39.9

        • OR 2.48 for BMI >40

        • OR 3.16 for BMI > 50

      • Of note, the practice bulletin does point out that black pregnant people with obesity have a higher risk of stillbirth than white pregnant people - discusses that while this is not a biological reason, is a proxy for likely negative influence of racism on health 

  • Intrapartum

    • Increased risk of cesarean delivery, failed trial of labor, endometritis, wound rupture/dehiscence, and venous thrombosis  

    • Decreased likelihood of VBAC after TOLAC 

  • Postpartum Complications - increased risk of future metabolic dysfunction 

  • Fetal complications - increased risk of growth abnormalities 

• How Can We Manage Obesity Before And During Pregnancy 

• Pre-pregnancy Counseling 

  • Discussion of control of obesity with weight loss (either surgical or non-surgical) 

  • Even small weight loss can be associated with improved outcomes (even 5-10%) 

  • Can try motivational interviewing 

    • Encourage diet, exercise, and behavior modification 

  • Medications 

    • Not recommended pre-pregnancy or during pregnancy 

• During Pregnancy 

  • Recommended weight gain 

    • Overweight: recommend 15-25 lb weight gain 

    • Obese: recommend 11-20 lb weight gain 

    • There is a lack of data regarding short-term and long-term maternal and newborn outcomes, no recommendation for lower targets for pregnant women with more severe degrees of obesity 

  • Congenital Anomalies

    • As previously discussed, increased risk of congenital anomalies, but detection of these anomalies is significantly decreased with increasing maternal BMI 

    • Cell-free DNA test failures are also more frequent in patients that are obese. This is because a minimum fetal fraction of 2-4% usually is needed. The median fetal fraction between 10-14 weeks is around 10%, but with increasing BMI, it’s associated with decreased fetal fraction. 

    • Can consider repeating screening if it’s because of early gestation, but not recommended if there are ultrasound findings of anomalies 

  • Metabolic Disorders - screen for glucose intolerance and OSA at first antenatal visit with history, exam, and labs 

    • Sleep medicine evaluation 

    • Can consider early glucose screening; if negative, repeat at usual time of 24-28 weeks 

  • Stillbirth and Antepartum fetal testing 

    • This is going to be different based on your institution 

    • Can consider weekly testing after 37 weeks for BMI 35-39.9 

    • Can consider weekly testing after 34 weeks for BMI >40 

• Intrapartum 

  • Many studies that show an increased risk of C-section among overweight and obese women 

    • There are studies that show an increased length of time in labor; another study showed that maternal BMI was not associated with longer second stage 

    • Maybe consider allowing more time in first stage of labor before C-section in obese individuals? 

    • Remember that pregnant women with higher BMI have a higher rate of complications with elective repeat cesarean section - so not a reason to not TOLAC them! 

  • Some considerations during labor 

    • Consider anesthesia consult - especially if OSA. An epidural may be technically more difficult to place 

    • Antibiotics - may need to increase the amount of Ancef before C-section (remember usual is 2g). Increase to 3g if >120 kg 

• Postpartum 

  • There is an increased risk of VTE in obese women, so definitely use your SCDs and encourage early mobilization  

  • In very high risk groups, discuss pharmacologic thromboprophylaxis 

    • Dose can be BMI stratified

      • BMI < 40: 40 mg Lovenox daily 

      • If BMI 40-59.9: 40 mg BID 

      • If BMI 60 or greater: 60 mg BID 

Espresso: Acute Uterine Bleeding

What causes bleeding?

Remember - PALM-COEIN! We talked about this way back in episode 47. As a quick refresher:

PALM - the structural causes:

• P - polyp

• A - adenomyosis

• L - leiomyoma (fibroids)

• M - malignancy

COEIN - the non-structural causes

• C - coagulopathy

• O - ovulation (i.e., anovulatory)

• E - endometrial (local endometrial factors)

• I - iatrogenic 

• N - not otherwise specified

Your EM colleagues call you STAT! It’s really bad! What should you do?

• Start ABCs! 

  • Get your vital signs - assess for signs of hemorrhagic shock

  • IV access - 2 large-bore if possible

  • Resuscitate - balanced crystalloid is a good place to start if relatively stable; blood if appearing unstable 

• Laboratories:

  • Pregnancy test

    • Remember, pregnancy heavy bleeding opens up a whole new can of differential diagnosis and management -- from miscarriages to retained placental fragments.

      • We’ll set that aside for today.

  • CBC - know where you’re starting from. 

    • Note that with an acute bleeding episode, H/H may not accurately reflect actual RBC status as there hasn’t been time to equilibrate.

    • CBC may also clue you into rarer disorders -- i.e., thrombocytopenia due to TTP-HUS or leukemia -- that may result in vaginal bleeding.

  • Coag panel - do you suspect coagulopathy?

    • In the adolescent patient, this may be sign of underlying bleeding disorder like von Willebrand’s disease or hemophilia. 

    • In an older patient without history of bleeding, abnormal coags may point to evolving DIC from very significant bleeding, or acquired coagulopathy (i.e., overdose with warfarin).

  • Type and screen/crossmatch - get blood ready! 

    • A type and screen is always a good place to start, and will be the test that takes the longest.

      • Assuming no antibodies to screen against, a crossmatch can then be had relatively quickly in most large medical centers.

• History & Exam:

  • History should be directed towards understanding how much, how long, and how frequently.

    • How much - get a sense for the amount of acute blood loss, and whether this is life threatening.

    • How long - understand timing of the bleeding as another marker of amount of blood loss, and how long the episodes have lasted if they have happened in the past.

    • How frequently - understand if this is a one-off acute event versus a recurrent issue.

      • Frequent heavy bleeding events may be suggestive of underlying bleeding disorder in younger patients, versus structural causes of heavy bleeding (i.e., fibroids) in older patients. 

    • Examination may help point towards cause immediately - trauma, prolapsing fibroid/polyp. 

      • Also, exam should help increase or ease your suspicion for life-threatening hemorrhage based on what you find!

    • Imaging and other testing may be warranted:

      • Imaging if patient is stable, and suspect but need to diagnose underlying cause (i.e., pelvic ultrasound)

      • Consider endometrial biopsy in those under age 45 with risk factors (unopposed estrogen).

How do I stop the bleeding?!?!

Medical therapy is most ideal in the moment, though surgical therapy is occasionally required! 

Meds to remember:

• Conjugated equine estrogen (IV estrogen). 

  • Source: equine (horses)

  • Dose: 25mg IV, every 4-6 hours for 24 hours

  • Avoid in patients with breast cancers, history or risk of thromboembolic disease,

  • Efficacy: excellent

    • Small RCT demonstrated stoppage of bleeding in 72% of women with exposure to IV estrogen over 8 hours (vs 38% with placebo).

  • Requires observation/inpatient administration as IV only, and will ultimately need to transition to a PO medication (can’t use unopposed estrogen forever!)

• Combined oral contraceptives

  • Suggested dose: 35mcg monophasic combined pill, TID x 7 days.

    • Many alternative regimens that are discussed, likely one exists that is a favorite at your hospital.

  • Avoid in patients who are smokers age 35+, history of or current VTE, migraine with aura, or other major risk factors for VTE (diabetes with vascular complications, recent surgery with immobility, etc).

  • Easy to administer, and patients are generally familiar with OCPs.

  • Side effects generally include nausea from high amount of estrogen - consider coprescription with antiemetic.

  • High efficacy -- 88% stop bleeding within 3 days.

• Medroxyprogesterone acetate (Provera)

  • Suggested dose: 20mg PO, TID x 7 days

    • Like COCs, many alternative regimens exist, and likely one is a favorite at your hospital.

  • Similar contraindications: avoid in those with past/current history of DVT/PE, breast cancer, or liver disease.

  • High efficacy -- 76% stop bleeding within 3 days.

  • May have improved side effect profile over COCs (less nausea)

• Tranexemic acid

  • Dose: 1300mg PO TID x 5 days; alternatively, can use IV formulation at max 600mg q8h.

  • Uncertain thromboembolic risk, but follows again that may increase this risk so use with caution in those with significant risk factors.

  • Reduces bleeding in those with chronic AUB 30-55%.

Bleeding disorder suspected?

Get hematology involved! Resuscitation / treatment may be influenced by particular factor deficiencies.

Surgical management

• D&C, hysteroscopy, etc.

  • May be helpful for known causes (i.e., polyp, submucosal fibroid) but are often just temporizing measures otherwise.

  • Unless cause is truly identified, will not necessarily impact bleeding beyond the current cycle.

• Balloon tamponade

  • On the small, nonpregnant uterus, use a 26F Foley catheter with 30cc saline in the balloon.

• Interventional radiology for uterine artery embolization; hysterectomy

  • These can be considered as options, though ideally not in the mega-acute situation. More ideal to have some planning involved first!

What Your Charge Nurse Wants You to Know: Feat. Julie Park, RN

It’s July, and with everyone moving up into new roles, we thought we’d think a bit about our nursing colleagues!

Today, we welcome Julie Park, an assistant nurse manager and labor and delivery charge nurse at the University of Washington Medical Center. She tells us a bit about her career in nursing, what a charge nurse is and what they do, and offers some tips for success for L&D clinicians and nurses of all experience levels.

Fetal Growth Restriction: An Update

Two years ago we did a podcast on fetal growth restriction with Dr. Chris Nau based on ACOG PB 204. Little did we know that soon there would be even more changes to fetal growth restriction management! We offer up today’s podcast as an overview of those changes.

More reading on these changes in the form of SMFM Consult Series #52 and the new ACOG PB #227.

Terminology to Know

• Estimated fetal weight - is… an estimated fetal weight! In utero 

• Fetal growth restriction - means “fetal” growth restriction. Again… in utero! 

• SGA = small for gestational age - refers to the baby when it is born. So:

  • A fetus cannot be SGA, but can be FGR;

  • A baby can be SGA, but not FGR.

Etiologies of FGR 

• Unchanged… review our prior episode! 

• Realize that it can result from multiple maternal, fetal, and placental disorders 

Why do we care? 

• Fetal growth restriction occurs in up to 10% of pregnancies and is a cause of infant morbidity and mortality around the world 

• Fetuses <10th%ile at any gestational age have a risk of stillbirth of 1.5%, which is 2x the rate of fetuses with normal growth 

• Infants with birthweights <10th%ile have increase risk of acidosis at birth, low 5 min Apgar scores, and need for NICU admission, as well as 2-5x rates of perinatal death 

Who is considered fetally growth restricted, and how do we figure that out? 

• The SMFM Consult Series #52 recommended the definition to be:

  • ultrasonographic EFW < 10%, OR

  • AC <10% for gestational age 

• You need to do an ultrasound - but prior to that, you probably need to have suspicion. 

  • This can be done with fundal heights at appointments.

  • Make sure you have appropriate dating!

• US uses population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles:

  • Hadlock was generated from a study of 392 pregnancies in predominantly white, middle-class women at a single institution in TX

  • An NICHD study previously developed racial/ethnic standards for fetal growth 

    • It was found that Hadlock still was better at predicting SGA and composite neonatal morbidity at birth, and had a lower ultrasound-to-birthweight percentile discrepancy than the NICHD growth standard.

  • Hadlock is usually calculated by using BPD, HC, AC, and Femur length 

Classification of fetal growth restriction 

• Early vs. late fetal growth restriction

  • Again, per SMFM consult series defined as onset <32 weeks (early) or late (at or after 32 weeks) 

  • Early FGR tends to be more severe, tends to follow an established Doppler pattern of fetal deterioration, and can show more severe placental dysfunction than late-onset FGR.

    • Also, early FGR can be associated with genetic abnormalities 

    • Therefore, in early FGR, should get detailed ultrasound.

      • The SMFM consult series also recommends chromosomal microarray analysis if there is also fetal malformation or polyhydramnios is noted. 

• Severity 

  • EFW <3% has been associated with an increased risk of adverse perinatal outcome irrespective of UA or MCA Dopplers.

Management of Fetal Growth Restrictions 

Remember: The reason we care about fetal growth restriction is its association with stillbirth and perinatal mortality/morbidity. To prevent that, we try and look for signs that the baby/placenta is not doing well. We can do this with umbilical artery dopplers and antenatal testing (ie. BPPs, modified BPPs … see our recent episode!) 

• What are umbilical artery dopplers?

  • Assessment of blood flow toward the placenta in the umbilical arteries of the fetus 

  • In systole, the blood is being pumped forward, and in diastole, the blood should still move forward, but may be slower than in systole.

    • We look at the S:D ratios, or the speed of the blood flow toward the placenta in systole compared to diastole 

  • With increasing placental dysfunction comes placental resistance. Therefore, this can start to affect forward flow from the umbilical arteries.

    • In systole, the blood should always flow forward.

    • However, in diastole, without the heart as a pump, that blood flow can slow down. This is where we can begin to see elevated S:D ratios! Generally, elevated is >95%ile.

      • If there is even more resistance, blood flow during diastole stops. This is when you have “absent end diastolic flow” 

      • In very severe cases, the resistance in the placenta is so high that the blood flows backward toward the fetus. This is called “reverse end diastolic flow” 

• Why do we use them?

  • As a way to assess placental dysfunction 

  • Absent and reverse end diastolic flow are associated with high rates of perinatal mortality. ‘

    • One study shows an odds ratio for fetal death of 3.59 and 7.27 for AEDV and REDV, respectively!

• What do we do with UAs? 

  • Once fetal growth restriction is diagnosed, UAs should be serially assessed, usually 1-2 weeks depending on your institution 

  • If elevated, they should be assessed more frequently

  • The SMFM series also recommends assessment of dopplers 2-3x/week when UAs become AEDF to assess for REDF 

Management and Delivery Planning

We should mention that this can vary to some degree based on your institution! Generally speaking:

• If FGR but >/=3rd%ile with normal UA dopplers: 

  • Serial growth scans (every 3-4 weeks) 

  • Weekly or every 2 week UA dopplers 

  • Weekly or 2x/week antenatal testing 

  • Delivery by 39th week 

• If FGR but <3rd%ile with normal UA dopplers 

  • Same as above, but delivery at 37 weeks 

• If Elevated S:D ratios (meaning decrease end diastolic flow)

  • Continue weekly dopplers (some institutions will do 2x/week) 

  • Growth scans q2-4 weeks 

  • 2x/week antenatal testing 

  • Delivery at 37 weeks  

• If absent end diastolic flow 

  • Increase to 2-3x/week dopplers 

  • Discuss corticosteroids for fetal lung maturity 

  • Antenatal testing 2x/week 

  • Consider q2 week growth scans 

  • Deliver at 33-34 weeks (per SMFM). Can consider cesarean delivery. 

• If reversed end diastolic flow (highest risk for stillbirth) 

  • Inpatient admission 

  • Corticosteroids for FLM 

  • 1-2x/day antenatal testing 

  • Consider q2 week growth scans 

  • Deliver at 30-32 weeks. Can consider cesarean delivery. 

Headaches & Pregnancy

What are the different types of headaches? 

• Migraine 

  • Episodic disorder that is usually manifested as unilateral headaches, sometimes associated with nausea or light/sound sensitivity 

  • Common disorder that affects 12-15% of general population 

  • Can occur over several hours to several days 

  • Different phases of migraine:

    • Prodrome - can occur in up to 77% of people, usually can be symptoms like yawning, depression, irritability, food cravings, neck stiffness, etc 

    • Aura - 25% of people will experience an aura that is gradual, sometimes visual (bright lines), auditory (tinnitus, etc), somatosensory, motor, or even can be smell 

    • Headache - usually unilateral, tends to be throbbing 

    • Postdrome - sometimes can happen. Head movement may cause pain in location of the previous headache 

  • Triggers - can be different for different people. Common triggers are things like menstrual cycle, stress, etc 

• Tension headache 

  • Usually moderate headaches with bilateral, non-throbbing quality 

  • Often described as “pressure,” sometimes may feel like a band around the head (headband area) 

  • Precipitated usually by stress

• Cluster headache 

  • Severe headache that can be accompanied by autonomic symptom, come in “clusters”  

  • It is a type of trigeminal autonomic cephalagia (TACs) 

  • Usually characterized by severe orbital, supraorbital, or temporal pain, and also with autonomic features. Always unilateral. 

  • Different from migraines because these patients usually prefer to move around or pace, can be restless (people with migraines want to lie down in a dark room) 

  • Autonomic symptoms: ptosis, miosis, tearing, rhinorrhea, nasal congestion on the same side as the pain 

• Secondary headaches

  • Have an underlying cause (i..e., headache is a symptom of the problem) - this is something we may need to be worried about.

    • More benign: sinusitis, URI, idiopathic intracranial hypertension (IIH) 

    • More serious: tumor, bleeding, meningitis.

Evaluating a Headache 

• History 

  • Your usual history, but be sure to ask about age of onset of headaches (has this been going on for 20 years, or just today?), presence of aura/prodrome, frequency and intensity

  • # of headaches/month, site of headache/other symptoms associated

  • Current meds 

  • Changes in vision, association with trauma, changes in work/lifestyle, timing around menstrual cycle 

• Physical 

  • Blood pressure and pulse - always in pregnancy — worry about preeclampsia!

  • Palpation of neck, head, and shoulder 

  • Full neuro exam 

• Labs and Imaging 

  • CT or MRI are common modalities 

  • Consider imaging if danger signs are present (i.e., abnormal neuro exam)

  • Also consider lumbar puncture if there is concern for infection 

When should I be worried about a headache? 

• Low Risk Features

  • Age <50

  • Features that are typical of primary headaches (see above) 

  • History of similar headaches, no change in usual headache or new symptoms 

  • No abnormal neurologic symptoms  

• Higher Risk Characteristics

  • Fever, abrupt onset, older age, neurologic deficit (including altered mental status), history of tumors, papilledema

  • Change in previous pattern, headache with positional change, post-trauma, painful eyes (or change in vision!) 

  • And of course, pregnancy!

  • Reason for emergency eval: thunderclap headache, Horner syndrome or other neurologic deficit, concern for meningitis or encephalitis, papilledema, possible carbon monoxide exposure. 

What are typical headache treatments? 

• Non-Pregnant 

  • Migraine Headache

    • Analgesics like NSAIDs, Tylenol; treating earlier in the course is more effective 

    • If unresponsive, can consider triptans or ergots 

    • If still severe, consider ketorolac and a dopamine receptor blocker (ie. prochorperazine and metoclopramide)  

    • Some patients may need to be on medications like triptans or beta blockers to prevent headaches 

      • Preventive first line agents are propranolol, amitriptyline, topiramate 

  • Tension Headache

    • Usually rest, hydration

    • NSAIDs, acetaminophen 

    • Then consider caffeine, metoclopramide, diphenydramine, etc. 

  • Cluster Headaches

    • Oxygen! Try it first if available - 100% oxygen inhalation 

    • If not available, then subcutaneous sumatriptan (3mg-6mg); can also use intranasal if subq not available 

      • Administer the intranasal sumatriptan to the contralateral side because patients with cluster headaches and other trigeminal autonomic cephalalgias have rhinorrhea or nasal congestion that is on same side as pain.

    • Prevention: verapamil… agent of choice for initial preventative therapy. Can also start with a short course of prednisone

      • This is because we know that cluster headaches come in… you guessed it! Clusters!  

• In Pregnancy 

  • May need to avoid NSAIDs in certain trimesters 

  • Start with Tylenol (650-1000mg), then can ad metoclopramide 10 mg 

  • Can also try combination like butalbital-acetaminophen-caffeine 

    • Other options are things like diphenhydramine (benadryl), or prochlorperazine, as some types of headaches may be associated with n/v and can help with this 

  • Consider fluids if someone is dehydrated (again, n/v in pregnancy) 

  • Magnesium sulfate or magnesium oxide sometimes can help. If someone has frequent headaches, there is some data that magnesium can prevent headaches 

  • If still bad, consider NSAID, but usually should not be used after 32 weeks to prevent closure of the PDA; usually a one time dose is ok 

  • Third line = opioids because they can be addicting and can worsen other issues of pregnancy like nausea/vomiting/constipation 

  • Triptans - if not responding to anything else, can consider triptans. Most studies showing exposure in pregnancy have been reassuring (most studies are with sumatriptan) 

    • Long term triptan use in pregnancy - discuss individually with patient 

    • Limited data, but from registries, no increased risk of major malformation

    • If patients can use other meds, try those first, but if refractory and need sumatriptan, ok to use 

  • Other things to consider if refractory: 

    • Glucocorticoids, peripheral nerve blocks 

    • Call your neurology colleagues!

  • Meds to avoid 

    • Ergotamine - do not use because can cause tetanic uterine contractions