Obstetric Problems Birth Outcomes

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Obstetric Problems/ Birth Outcomes

• Warwick Giles
• Mothers and Babies Research Centre
• University of Newcastle
• Northern Clinical School
• University of Sydney

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Introduction.

• In mid 2000 when managing a patient who weighed
  160kg 3 members of staff (2 midwives and 1
  trainee obstetrician) sustained significant back
  injuries.
• Hunter Health (HAHS) had since 1999 a major focus
  on reduction of staff injuries with accompanying
  OHS issues.
• Since then substantial economies/savings for HAHS
  have ensued with savings returned to Hunter
  Health (10m).

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Issues Raised

• The risk of staff and possible patient injuries
  in the situation of very large patients.
• The possibility of prelabour assessment of the
  analgesic needs for these women.
• The appropriateness of the use and choice of
  analgesia for these women (e.g. the walking
  epidural).
• Improvement of OHS issues for the Division.

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Obesity in Australia

• Lay Press
• Student Obesity Fears Growing (Newcastle Herald
  6/3/2004)
• Incorrect Weight for Age (The Age 21/1/2004)
• Boy You Dont Have to Carry That Weight
  (Newcastle Herald 17/1/2004)
• The Better it Gets, the Worse Our Health
  (Newcastle Herald 4/11/2003)
• Fighting Fit (Sydney Morning Herald 14/10/2003)

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Obesity in Australia

• Medical Press
• Cameron et al, MJA 178427-432. 2003
• The AusDiab study.
• 20,347 people gt24 years age completing an
  interview and 11,247 attending a physical
  examination.
• Overweight and obesity (BMI gt 25 kg/m2 and
  waistline 80 cms)
• Sociodemographic factors (incl. Smoking, physical
  activity and TV viewing time)

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Obesity in Australia

• Results
• Women gt men (by waist circumference)
• BMI peaked at age 55-64.
• Waist circ. peaked at 65-74 yrs.
• As defined by BMI incidence of obesity has risen
  from 7.1 (1980) to 18.4 (2000)

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Obesity in Australia

• Risk Factors
• Lower educational attainment (M F)
• Clear relationship to TV viewing time

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Obesity in Australia

• Social Determinants of Health (2000)
• Extracts from the Chief Health Officer Report
  NSW Health. The Health of the People of New
  South Wales May 2000
• There is an association of obesity with other
  determinants of poor sociodemographic status.

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Background.

• Definition of very large patient varied
• Weight gt 200lbs (90kgs)
• Body mass index gt 29 kg/m2
• Weight gt 120-150 above ideal weight
• Weight gt 114 kg
• Morin, 1998

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Obesity on the world stage

• NE Thames Region, London
• 28 of women overweight (BMI 25-30)
• 11 obese (BMI gt30)
• Montpellier, Paris
• 17 BMIgt25
• United States of America
• 57 overweight (BMI 25-30)
• 30 obese (BMI gt30)

• Yu et al, BJOG 2006
• Galtier-Dureure et al, Am J Clin Nutr 2000
• Catalano, OG 2007

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Risks - Antenatal

• Fetal abnormalities
• Difficulties in ultrasound imaging (35
  suboptimal views).
• Neural tube defects (7 ? each 1kg/m2)
• Omphalocoele, cardiac abn (2-3 fold)
• Cardiovascular
• Hypertension Increased 2-24x, (PET 1.2-10x,
  doubles with each 7 kg/m2).
• Thromboembolism doubled.
• Gestational diabetes increased to 10
• Stillbirth 2-3 fold increase in large population
  studies.
• Metabolic disorders (chronic renal and cardiac
  dysfunction, non-EtOH fatty liver, sleep apnoea)

Yu et al, BJOG 2006 Galtier-Dureure et al, Am J
Clin Nutr 2000 Catalano, OG 2007
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Summary of the maternal obesity and PET
studies. Yu et al, BJOG 2006
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TABLE 3. Adjusted odd ratios (ORs) for neural
tube defects in offspring of overweight mothers

Galtier-Dureure et al, Am J Clin Nutr 2000
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Risks - Intrapartum

• Difficulties in monitoring in labour
• Macrosomia (central)
• Increased Induction and failed induction
• Regional/general anaesthesia difficulties
• C section
• Shoulder dystocia
• Operative vaginal delivery, perineal trauma
• Unsuccessful VBAC (50)
• Wound healing problems
• Rates increase/worsen with ? BMI

Yu et al, BJOG 2006 Galtier-Dureure et al, Am J
Clin Nutr 2000 Catalano, OG 2007
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Term singleton birthweights in gms (37-41 wks)
from 1975-2003, MetroHealth Medical Centre,
Cleveland Ohio. Catalano OG 2007.
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Mean term singleton birthweights (37-41 wks) in
gms, centiles, 1975-2003. Catalano et al, OG 2007
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Fetal Adominal Fat high vs. low Maternal BMI
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Fetal Thigh Fat high vs. low Maternal BMI
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Risks Postpartum and Costs

• PPH, endometritis
• Urinary stress and urgency
• Admission to NICU 3x higher
• Infant and childhood obesity, hypertension
• Cost for care 5x higher, length of stay 4-6x
  higher

Yu et al, BJOG 2006 Galtier-Dureure et al, Am J
Clin Nutr 2000 Catalano, OG 2007
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Maternal pregnancy complications according to BMI
grouping. Yu et al BJOG 2006
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Hospital cost of pregnancy follow-up and delivery
in overweight mothers.
2. Significantly diff from overweight women
P0.001 3. P0.0001, 4. P0.0237, 6. P0.0002,
8. P0.0019 5. Sum of night and day
hospitalisation 7. Sum of prenatal cost and
corrected postpartum hospitalisation.

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Data Collection.

• The data were obtained from the OBSTET database a
  VAX database. A Powerhouse program which
  interfaces with patient demographic information
  systems.
• Supervised by a Clinical Nurse Consultant in the
  Division.

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Data Analysis.

• Statistical analysis was undertaken by MINITAB v
  12.22. Chi2 testing was used for categorical
  differences and 2 sample T test for differences
  in means.
• P lt 0.05 was taken as the level of significance.

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Results of OBSTET data analysis

• Total number of women delivered 3,294
• First visit weight lt 100 kgs 3,082
• First visit weight gt 100 kgs 212 (6.4)
• First visit weight gt 120 kgs 62 (1.9)

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Total Distribution of Patient Weights in 5 kg
Increments
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Chi2 46.948, P 0.000
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Chi2 4.678, P 0.031
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Chi2 6.086, P 0.014
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Chi2 7.680, P 0.006
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Reasons for the 120 Kg Cut Off

• The availability to accommodate in the
  preop/predelivery anaesthetic clinic.
• The 130 Kg limit for a standard operating suite
  table.

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Future Management Plan

• The numbers of women gt 100 kgs was expected to be
  3 per week and gt 120 kgs to be at least 1 per
  week.
• To initiate the program those women identified as
  gt 120 kgs were to be directed to the predelivery
  anaesthetic clinic for pain relief consultation.

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Future Management Plan

• Delivery Suite notified from the anaesthetic
  clinic of impending labour.
• Anaesthetist on duty and operating suite NUM
  notified when woman is admitted in labour
• Delivery suite source availability of lifting
  equipment and suitable operating table.

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THANK YOU