INTRODUCTION:

Maternal obesity has emerged as a major public health problem in developed, as well as developing countries.¹As a result; many pregnant women are seen with higher body mass index (BMI). Maternal obesity and related co-morbid conditions have serious impact on the health and development of obese women's offspring.

The incidence of maternal obesity at the start of pregnancy is increasing worldwide.² International studies show a prevalence of maternal obesity ranging from 1.8% to 25.3% across countries.³ Approximately 50% of pregnant women have a body mass index (BMI) >25 kg/m.^4,5An increased association ofmorbidity and mortality with obesity is well established in both pregnant and non-pregnant women.^6,7,8,9Pregnancy with obesity is considered as high risk, and it causes substantial feto-maternal morbidity and mortality.¹⁰

1. Definition:

Obesity during pregnancy is defined as a Body Mass Index (BMI) of 30 kg/m² or more calculated using the height and weight measured at the first antenatal consultation.¹Ideally a BMI should be calculated using a pre-pregnancy weight; this is often notavailable/unknown. In which case, the weight at the first antenatal consultation should be used.

BMI is calculated by dividing the woman’s weight in kilograms by the square of their height in meters (kg/m²). The BMI is not a perfect measure - does not take into account age or ethnicity; But, it is widely considered a good measure of obesity for the general population.⁵

Maternal BMI is categorized by the World Health Organization (WHO)⁵ as follows:

· Underweight (BMI <18.5kg/m²)

· Normal (BMI 18.5-24.99 kg/m²)

· Overweight/pre-obese (BMI 25-29.99kg/m²)

· Obese class 1 (BMI 30-34.99 kg/m²)

· Obese class 2 (BMI 35-39.99 kg/m²)

· Obese class 3 (BMI ≥40 kg/m²)

2. Preconception BMI and Gestational Weight Gain:

Preconception BMI is a key indicator for the midwife as pre-pregnancy BMI defines their commended individual gestational weight gain. The Institute of Medicine recently modified their guidelines in regards to healthy weight gain during pregnancy due to the increasing prevalence of obesity among women of childbearing age, increases in gestational weight gain and the associated health implications of both of these factors. These new guidelines recommend a much smaller weight gain range in pregnancy for thosecategorized as overweight (7-11.5 kg) and obese (5-9 kg).¹¹

Gestational weight gain recommendations

BMI Weight (kg) Height (m2)	Recommended Weight Gain
Underweight < 18.5 kg/m²	28-40 lbs (12.5-18 kg)
Normal Weight: 18.5 -24.9 kg/m2	25-35 lbs (11.5-16 kg)
Overweight: 25.0-29.9 kg/m2	15-25 lbs (7-11.5 kg)
Obese ≥ 30.0 kg/m2	11-20 lbs (5-9 kg)

3. Epidemiology

In India, more than 30 million of people are either overweight or obese (NFHS, 2005-06). In India, more than 15% of women are either overweight or obese whereas only one tenth of men report this health condition (NFHS, 2005-06). A study in India to examine the adverse impact of being overweight or obese on pregnancy stated that overweight or obese women experience more stillbirths or terminated pregnancies than normal health women. ¹²

Another study carried out in three South Asian countries (Bangladesh, Nepal, and India), between 1996 and 2006, revealed that prevalence of underweight had remained high in Bangladesh, Nepal, and India, the prevalence of overweight-obesity in women of reproductive age has risen. Overweight-obesity in Indian women (n = 161,755) had increased from 10.6% to 14.8%.¹³

Data regarding the nutritional status of adults, as determined by body mass index (BMI), observed that the BMI values were similar in men and women; however, there were more overweight/obese (BMI≥25 kg/m2) women (6.6%) than men (3.5%).¹⁴

The percentage of women who are overweight or obese is highest in Punjab (30%), followed by Kerala (28%) and Delhi (26%).

4. Risk Factors for Obesity in Women

Overweight or obese during childhood, Increased intake of refined carbohydrates, Decreased intake of fresh fruits and vegetables, Decreased physical activity, Low socioeconomic status, Urbanization and an unhealthy, energy-dense diet (the high presence of oil and fats in cooking), as well as changing lifestyles, are root causes contributing to obesity.

5. Etiology

Obesity caused by multifactorial interactions between genetic and environmental factors. Women are disproportionally affected by obesity due to effects of familial tendency, female sex hormones, themenstrual cycle, Hyperinsulinism, Hyper adrenocorticism, Hypogonadism, Hypothyroidism, use of contraceptive hormones, andAbnormal Eating Behaviour Hormones which control eating are Ghrelin (hunger hormone) from stomach, Insulin from pancreas; leptin from fat, PYY-3-36 (peptide tyrosine tyrosine or pancreatic peptide) from colon; satiety center in hypothalamus control satiety.

6. Pathophysiology

Increased adipose tissue leads to increased insulin resistance, increased tissue insulin levels, increased basal and stimulated insulin, leading to chronic hyperinsulinemia with resultant secondary hypertension and hyperlipidemia leptin, insulin, adiponectin, gherlin a- melanocyte-stimulating hormone, as well as many other neurohormonal factors, interact to influence food intake and energy expenditure.

Increased adipose tissue

Increased insulin resistance, increased tissue insulin levels,

Increased basal and stimulated insulin,

Chronic hyperinsulinemia

With resultant secondary hypertension and hyperlipidemia,

And interact with Leptin, insulin, Adiponectin, Gherlin,

Melanocyte-stimulating hormone, andOther neurohormonal factors,

Influences

Food intake and energy expenditure.

7. Implications of Advanced Maternal Weight

If a woman struggling with obesity is successful at conceiving she is at an increased risk for several pregnancy-related complications.¹⁵The risk of any form of obstetrical complication is about three times more likely in mothers who are obese as compared to mothers who are not obese.¹⁶ As BMI goes up, so does the risk of negative prenatal outcomes for the mother and/or the baby.^{17,
18, 19}

7.1 Maternal outcomes: Pregnancy

As illustrated in figure the most notable complications in pregnancy include increased risk of spontaneous abortion and recurrent miscarriages.^20-23 As a pregnancy progresses women who are obese are at increased risk of gestational diabetes,²⁴ hypertensive disorders, preeclampsia, blood clots, infections, and preterm delivery.^{25, 18, 26, 27} Women who are obese are more likely to experience these complications with a greater severity when compared to women of normal weight.²⁸

Fig 2: Maternal Outcomes: Pregnancy

The x-axis shows the time course and the y-axis illustrates the degree of elevated risk for each outcome based on published literature (IVF = in vitro fertilization, CV = cardiovascular, UTI = urinary tract infection). (Adapted from Adamo, Ferraro, Brett¹⁵)

Fig 3: Complications of Maternal Obesity during Pregnancy

Mental and Emotional Health

Individuals with higher BMIs experience more emotional distress - increased stigmatization or depressive and anxiety disorders.^29,30A study found similar emotional and psychological distress in non-pregnant women with high BMIs such as stereotyping or discrimination.^31-33Obese and overweight women often experience negative interactions with their health care provider - result in psychological distress.³⁴

Lack of guidance from their health care providers causes psychological distress, particularly when discussing their weight.^34-36Psychological and emotional distress - due to feelings of guilt, worry, embarrassment and anxiety during their healthcare visits.^34,36Sensitive and mindful of the psychological approach - while discussing weight management with pregnant women who are overweight or obese.

Insulin Resistance and Gestational Diabetes

Obesity is the most common risk factor for insulin resistance (i.e., when the body has a lowered response to insulin). Insulin sensitivity (i.e., the ability to uptake/use sugar in muscle and fat) supports nutrients to cross the placenta to reach the fetus for optimal growth.³⁷but it is reduced by 50-60% during pregnancy. They face more challenges responding to insulin and clearing sugar from their blood. And also GDM prevalence rates are much higher among them.³⁸

The risk of developing gestational diabetes mellitus rises exponentially with increasing BMI. For example, the odds of developing gestational diabetes mellitus are 1.97 for overweight, 3.01 for obese and 5.55 for women who are morbidly obese.³⁹While increased fat mass is clearly a contributor, the location of the fat mass is also important. Accumulation of intra-abdominal fat (i.e., fat surrounding the organs) is particularly harmful.

In a study, those with increased amounts of intra-abdominal fat compared to those who had increased amounts of subcutaneous adipose fat in the first trimester (12 weeks) of pregnancy had a 17 times greater risk of having insulin sensitivity in later pregnancy (24-28 weeks).⁴⁰Women who develop gestational diabetes mellitus during one pregnancy are at high-risk for developing gestational diabetes mellitus in subsequent pregnancies⁴¹and the majorities (50-60%) develop type 2 diabetes in the years following delivery.⁴²

The prevalence of gestational diabetes (GDM) in India varies from 9.9 % in rural areas to 17.8 % in an urban population.⁴³ The National Family Health Survey (NFHS) - III (2005-06) of India reports an increasing prevalence (14.8%) of overweight or obesity among women aged 15 to 49 years (ranging from 28.9% in urban areas to 8.6% in rural areas) compared to 10.6% in 1998-99.⁴⁴ Gestational diabetes and obesity have adverse consequences on outcomes of pregnancy, including cesarean delivery, perinatal deaths, pre-eclampsia, birth defects, macrosomia, and morbidity associated with subsequent childhood obesity.^17,45-57

A study aimed to determine the prevalence of obesity and gestational diabetes (GDM) reveals that; the prevalence of GDM and obesity in this population was 8.43% (95% CI: 7.47-9.40) and 19.49% (95% CI: 18.12-20.87) respectively. The prevalence of obesity increased to 54.63% (95% CI: 52.91-56.36) - (based on the ICMR guidelines for BMI). Cesarean sections (adjusted OR: 2.04, 95% CI: 1.43-2.89), large for gestational age (LGA) babies (adjusted OR: 3.82, 95% CI: 2.11-6.92) and macrosomia (adjusted OR: 20.90, 95% CI: 3.29-132.77) was associated with obesity in GDM (based on the ICMR guidelines for BMI). It is opined that gestational diabetes and obesity are increasingly important priorities for perinatal care in India.⁵⁹

Hypertensive Disorders and Pre-eclampsia

Obese pregnant women are greater risk for PIH and pre-eclampsia in current and future pregnancy. The risk of gestational hypertension for first time mothers who are obese and severely obese is estimated to be 2.5 to 3.2 times greater respectively than women of normal pregnancy weight.

Similarly, the risk for pre-eclampsia is 1.6 times greater for women who are obese and 3.3 times greater for women who are severely obese. The prevalence of pre-eclampsia doubles with each 5 BMI points above normal weight.⁵⁹Weight loss or gain between pregnancies decrease or increase the risk respectively.

Hypertensive disorders and pre-eclampsia are associated with reduced insulin sensitivity, dysfunctional blood vessels, blood proteins that increase inflammation and the presentation of free radicals/oxidative stress. Women with a history of pre-eclampsia continue to exhibit higher levels of fasting insulin, blood fat and increased levels of blood clotting factors in postpartum.⁵⁹

Dyslipidemia

Elevated blood fats (dyslipidemia) are common in pregnancy. Insulin plays a key role in glucose metabolism, and is also instrumental in fat metabolism. As a pregnancy progresses there is a significant increase in blood fat concentrations and these increases are greater in pregnancies complicated by obesity and/or gestational diabetes mellitus.⁶⁰

This pattern resembles a metabolic syndrome (i.e., a clustering of cardio metabolic risk factors). Normally, insulin is able to control fat breakdown during pregnancy. As a result of increased concentrations of fat in the blood, there are higher levels of free fatty acid to support maternal needs in late pregnancy when energy requirements are greatest. For pregnant women who are obese, elevated free fatty acid levels can occur because insulin is less able to decrease fat breakdown as pregnancy progresses. This leads to obesity-related disturbances in fat cell function resulting in excess circulating free fatty acid in the blood (i.e., dyslipidemia), increased secretion of pro-inflammatory proteins and increased storage of fat. This then leads to the accumulation of fat in skeletal muscle and liver, further promoting insulin resistance.¹⁸

Fetal Monitoring and Clinical Assessment

Because of the potential for pregnancy-related complications, frequent monitoring required. It can be challenging for both the mother and her service provider. Ultrasound - Difficult to visualize the baby, difficulties in fetal surveillance as well as screening for anomalies in heavierwomen.⁶¹Abdominal palpation for fetal growth assessment maybe difficult due to excess fat tissue in the abdominal area.⁶²

Measuring and monitoring fetal growth by ultrasound, arterial Doppler and cardio-tocography are also difficult and these vital tests do not always provide conclusive results. For example, poor or inaccurate findings can lead to unnecessary caesarean sections when fetal overgrowth (i.e. Macrosomia) is mistakenly diagnosed.⁶²In women with the highest BMIs (above the 97.5 percentile), only 63% of fetal structures are well visualized. And difficult to see the fetal heart, spine, kidneys, diaphragm and umbilical cord on an ultrasound in women who are overweight or obese.⁶³Suggestion overweight and obese undergo the use of a non-invasive abdominal fetal electrocardiogram to monitor FHR.⁶⁴

7.2 Maternal outcomes: Labour and Delivery

Obese women (BMI > 30) have more pregnancy-associated disease which results in a greater number of adverse outcomes for both the mother and baby during labour and delivery. Around the time of delivery obese women are at greater risk of labour induction, anaesthetic or surgical complication, caesarean-section or instrumental delivery, haemorrhage, as well as postpartum thromboembolism (i.e., blood clot- which may be related to limited mobility).

Obese women stage II (BMI>35)are at an elevated risk of anesthesia-related complications - delayed recovery from general anesthesia and postoperative hypoxemia. Risk of caesarean delivery more than doubles for women who were obese and triples for women who were severely obese compared with normal weight pregnant women.

Women with obesity may have longer labours. Depending on the frequency of the contraction, the range of time difference noted for duration of the first phase of labour in women who are obese seems to be between 37 minutes to 1.55 hours (length of latent phase). During the latent phase of labour contractions occur between 5–10 minutes apart with each contraction lasting between 45–60 seconds suggesting that the number of contractions experienced by a labouring woman is somewhere between 6–12 contractions per hour. However, once a woman enters the active phase of labour there is no discernible difference in duration of labour between women who are obese, very obese and not obese.

Many studies identified obesity in women - risk factor for PPH, while undergoing induction. It may be due to the effect of obesity on muscle contractibility. Synthetic oxytocin does not work as predictably in women who are obese - increasing the risk of prolonged maternal-fetal exposure. Poor outcomes when induced in part due to the reduced options for positioning and mobility during labour and delivery and risk for injury.

More challenging with obese women are the intermittent auscultation, and monitoring fetal wellbeing during labour and delivery. Electronic fetal monitoring recommended. EFM elastic belts which must be pinned together for dealing with a larger abdominal circumference - frustrating and humiliating for woman and her caregiver. If external monitoring is not effective then internal monitoring will be necessary. Internal monitoring requires access to the fetal scalp - amniotic membranes must first be ruptured.

AROM is strongly associated with the increased use of synthetic oxytocin and the risk for a cascade of interventions which can affect labour and delivery options.⁶²In terms of delivery - the traditional position is not the most effective, more upright and or hands and knees position may be effective. Birthing pools may facilitate the delivery.

7.3 Maternal Outcomes: Postpartum and Long term Maternal Health

Women whose pregnancies are complicated by obesity are heightened and strongly associated with an increased risk of diabetes and cardiovascular diseases in later life.Highly susceptible to postpartum weight retention leads to postpartum maternal obesity and greater increases in body weight before subsequent pregnancies. This contributes to the severity of the intergenerational cycle of obesity.

Increased risk of exceeding gestational weight gain recommendations leads to increased and persistent postpartum weight retention in subsequent pregnancies. They may face greater difficulty in returning to their original pre-pregnancy weight. Gestational weight gain and postpartum weight retention is an issue for all women. Increase in just 3 BMI points between two pregnancies increases the risk of pre-eclampsia, pregnancy hypertension, caesarian-section delivery, still birth and delivering a large for gestational age baby, even for woman with normal BMI for both pregnancies.

Gestational weight gain is a modifiable risk factor; health care providers are encouraged to recommend appropriate gestational weight gain rates and ranges for all women regardless of their pre-pregnancy BMI -To improve the health for the mother and baby. Through Prenatal classes, written materials and prenatal appointments - Information about weight gain.⁶⁵

Breastfeeding

The health benefits of breastfeeding are widely acknowledged. Breastfeeding is recommended for the health of the mother and the baby. A systematic review indicates - women with overweight or obese are less likely to initiate breastfeeding or tend to breastfeed for a shorter period of time. The potential factors are biological, psychological, behavioral and/or cultural.

Exclusive breastfeeding for six months reduces maternal gastrointestinal infection, helps the mother lose weight and delays the return of menstruation. Evidence for the protective effect of breastfeeding against overweight in childhood is mixed. Encouragement to breastfeed can happen through prenatal classes, written materials, prenatal appointments etc.⁶⁵

7.4 Fetal, Neonatal and Childhood Outcomes of Maternal Obesity

Maternal obesity is also associated with a variety of health risks for the fetus and infant. Mothers who are obese are at higher risk for perinatal complications including stillbirth, neonatal death, low Apgar scores, fetal distress, macrosomia (fetal overgrowth), presence of meconium, shoulder dystocia, neural tube defects such as spinabifida and congenital anomalies (cardiovascular anomalies, as well as cranial-facial anomalies including cleft palate and lip).The severity of most pregnancy-related complications increases as the level of obesity increases.Still birth and neural tube defect are increased risk as the maternal weight increases.⁶⁵

7.5 Postnatal and Downstream Child Health

Children born to mothers who are overweight or obese are significantly more likely to be large for gestational age (birth weight ≥90^thpercentile), and to be considered obese as infants, preschoolers, adolescents and adults (Adamo et al.).This may fuel the intergenerational cycle of obesity. (Fig: 4).

Fig 4: Inter-generational cycle of obesity

Birth weight is frequently used as a surrogate marker of the intrauterine environment. There is an association between high birth weight (> 4,000 g) and the risk of downstream obesity. The relationship between high birth weights persists from preschool to school age to adolescence and into adulthood.

The amount of fat and muscle in a newborn (i.e., neonatal body composition) is suggested to be a more reliable marker than birth weight with respect to in utero metabolic disturbance and is strongly linked to impaired maternal glucose tolerance. Poor control of maternal blood sugar leads to dysfunctional fetal growth and babies born with increased body fat.⁶⁵

Obesity and gestational diabetes mellitus - alter the quality of fetal growth and increase susceptibility to excessive weight gain later in life leading to the early onset of childhood obesity. Women with pre-conception obesity - risk for increase in gestational weight gain and increase in fetal body fat.

Babies born to obese mothers may develop insulin resistance in utero and neonates are unable to process the excessive sugar load. In fact, maternal obesity prior to pregnancy is the strongest risk factor for obesity and metabolic dysfunction (early presentation of diabetes) in children. Infants who are exposed to gestational diabetes mellitus in utero are at increased risk for obesity and future development of type 2 diabetes and metabolic syndrome. Obese women delivered baby with large for gestational age have twice the risk of developing insulin resistance along with childhood obesity at age 11 years.

8. Management of maternal obesity in pregnancy

Maternal obesity can be effectively managed by regular physical activity, dietary supplementation, calorie restriction, and at last pharmacological intervention (Fig 5).

Fig 5: Management of maternal obesity in pregnancy

SUMMARY:

Children of mothers with diabetes and/or obesity are at increased risk of metabolic disorders later in life with increased offspring size being a key indicator in this relationship. Maternal obesity is a strong risk factor for impaired downstream physiological health in offspring. Although diabetic control during pregnancy remains vital it is important to maintain a healthy weight in all women of childbearing age.

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Received on 24.01.2016 Modified on 01.02.2016

Int. J. Adv. Nur. Management. 2016; 4(2): 153-160.

DOI: 10.5958/2454-2652.2016.00035.4