Obesity and Pregnancy

According to the National Health and Nutrition Examination Survey, 33.4% of women 20 to 34 years of age are obese, and 58.4% are overweight (ACOG, 2015). Obesity is a commonly overlooked medical problem in pregnant women. Obese women have increased risks for maternal and perinatal complications (Ramsey and Schenken, 2019). Up to 25% of all pregnancy complications such as gestational hypertension, preeclampsia, gestational diabetes, and preterm birth may be related to maternal obesity (Ramsey and Schenken, 2019).

Overall severe maternal morbidity and mortality (SMM) rates increase with increased body mass index (BMI). The higher the BMI, the greater the rate of SMM (Lisonkova et al., 2017). Once pregnant, there are risks associated with obesity. Obese women have a significant increase in early pregnancy loss. Diabetes is another complication that can affect a pregnant woman. An obese woman without recent testing may have undiagnosed type 2 diabetes. Gestational diabetes (diabetes that has an onset during pregnancy) is significantly higher in obese women. Gestational diabetes and type 2 diabetes can lead to additional maternal and fetal complications  (ACOG, 2015). Obesity is a risk factor for gestational hypertension and preeclampsia. Preterm birth is also a risk of obesity. This risk is not usually due to spontaneous preterm labor but medically indicated preterm delivery due to maternal medical reasons (Ramsey and Schenken, 2019). Obstructive sleep apnea worsens with obesity and weight gain in pregnancy, leading to increased complications.

Obesity may lead to longer inductions of labor, longer labor times, and increased rates of c-sections. Obese women are also less likely to have a successful trial of labor after a cesarean section. An obese woman is more likely to have a macrosomic infant (weight >4000 grams). Macrosomia can cause many delivery complications, including shoulder dystocia, an operative vaginal delivery, perineal lacerations, or a c-section. These complications can cause trauma to the mother or the fetus (Ramsey and Schenken, 2019). Obese women may also have complications with anesthesia. The epidural or spinal may be more challenging to place in an obese woman.

As previously discussed, macrosomia is a problem that can affect the mother and fetus during delivery. Infants born to obese women also have an increased risk of hyperinsulinemia and hypoglycemia. As children of obese mothers age, they are more prone to childhood obesity and metabolic disorders. Some studies even show a link between obese mothers and children with neuropsychiatric and mood disorders (Howell and Powell, 2017). Congenital deformities such as neural tube defects, cardiovascular anomalies, and cleft palate have an increased risk in a child delivered to an obese woman.

Obese, postpartum women, especially women who have had a c-section, are at an increased risk for venous thromboembolism (VTE). These women are also at an increased risk for infection and postpartum depression (Ramsey and Schenken, 2019). Women who have had a c-section are more likely to have repeat c-sections, which can increase the risks of placental abnormalities, adhesions, and complications from c-sections. Obese women and women with diabetes may have trouble with infection and wound healing. Women with preeclampsia have an increased risk of cardiovascular disease in the future.

Weight loss is the most important factor in improving outcomes. Diet and exercise before getting pregnant can improve reproductive outcomes and pregnancy outcomes and improve the woman's overall health (ASRM, 2015). A 10% reduction in pre-pregnancy BMI can positively impact outcomes. Weight loss surgery prior to pregnancy may also be beneficial. Weight loss drugs should not be used during pregnancy. Weight gain should be less and varies depending on the severity of obesity (Ramsey and Schenken, 2019). Early screening for diabetes is recommended, and close surveillance of the woman and fetus during pregnancy is important.

When caring for obese, pregnant women, it is important not to judge the woman or make her feel guilty for being overweight but instead teach the woman about ways that she can make small, easy changes to improve her health outcomes (Mccloud, 2018). The nurse can help the woman identify barriers and find motivators to lead the woman to healthier eating and exercise. The nurse should be prepared for longer labor with possible complications, such as shoulder dystocia, vacuum, forceps, or c-section delivery during labor and delivery. Once the woman has delivered, the nurse should watch for signs of infection and VTE. The nurse should encourage breastfeeding, which can lead to more weight loss for the mom and decreased risk of obesity for the infant. These women also need proper long-term medical care, such as diabetes, hypertension, and heart disease screening.

Patient M.S. is a 22-year-old woman who presents to the prenatal clinic at 18 weeks gestation for her first prenatal visit. She is 5'4," and her pre-pregnancy weight was 290, making her BMI 50. She has not had regular preconception medical care. She has not received any screenings at this point. She has gained 15 pounds since getting pregnant. Her vital signs are BP 108/68, HR 78, Resp 16, and temperature 98.5. She complains of excessive thirst, a urinary tract infection, and fatigue.

What risks does M.S have?

M.S. is at risk for all complications associated with obesity. She may be a type 2 or gestational diabetic considering her symptoms. She is at risk for gestational hypertension or preeclampsia, although her BP is currently fine.

What care is needed for M.S.?

M.S. needs a full exam and screening for diabetes. She needs education on diet, exercise, and a healthy weight gain for obesity. She needs to be taught the importance of keeping her appointments and closely monitoring the pregnancy for her and her baby's health. She needs to know how important these things are and find the motivation to follow her care plan.

Obesity is a serious problem in the United States. It is not a problem that can be fixed overnight. Obesity can cause severe complications to the mother and fetus. Women need education on the risks and how to decrease them before getting pregnant. It is important that all nurses and healthcare providers know these risks and educate their patients.

• ACOG Practice Bulletin No 156: Obesity in Pregnancy. Obstet Gynecol 2015; 126:e112. essential.
• American Society for Reproductive Medicine, Practice Committee of the. Obesity and reproduction: a committee opinion. Fertil Steril 2015; 104: 1116.
• Lisonkova S, Muraca GM, Potts J, et al. Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity. JAMA 2017; 318: 1777.
• Howell KR, Powell TL. Effects of maternal obesity on placental function and fetal development. Reproduction. 2017;153(3). doi:10.1530/rep-16-0495. Visit Source.
• Mccloud MB. Health Behavior Change in Pregnant Women With Obesity. Nursing for Womens Health. 2018;22(6):471-480. doi:10.1016/j.nwh.2018.09.002. Visit Source.
• Ramsey PS, Schenken RS. Obesity in Pregnancy: Risks and Management. UpToDate. Updated June 7, 2019. Accessed December 27, 2019. Visit Source.