Supermorbid obesity in pregnancy

Abstract

Objective: We aimed to carry out an audit and service evaluation for women with supermorbid obesity to ensure that adequate planning is in place for intrapartum and post-delivery care, and to review delivery outcomes and complications.
Methods: Records of pregnant women with supermorbid obesity (body mass index ≥50) who delivered in Rotherham General Hospital, United Kingdom, between January 2018 and December 2019 were retrospectively reviewed. Body mass index was recorded at booking and repeated at 36 weeks. Glucose tolerance test was performed between 26 and 28 weeks of gestation. Antenatal anaesthetic review was carried out at around 36 weeks in the dedicated clinic, along with risk assessment for manual handling. Appropriate antenatal and postnatal thromboprophylaxis was given. Postnatal skin care assessment was performed. Intravenous antibiotics were given before caesarean section, and oral antibiotics were given for 5 days after caesarean section. The time of artificial rupture of membranes (ARM) in relation to the time of delivery was recorded, as were perinatal and neonatal outcome of delivery and complications.
Results: Of 4962 deliveries, 30 (0.6%) were by supermorbid obese women aged 20 to 34 years (n=24) or ≥35 years (n=6) who were primigravidas (n=15) or parity ≥1 (n=15). One woman had gestational diabetes mellitus; none had major antenatal complications or medical disorders. Of the 30 women, nine laboured spontaneously (8 vaginal delivery, 1 emergency caesarean section), 13 underwent induction of labour (6 vaginal delivery, 4 instrumental delivery, 3 emergency caesarean section), and eight had an elective caesarean section. The proportion of women delivering out of hours (20:30-08:30) was 33% if ARM was during 06:00-12:00 and 80% if ARM was during 12:00-18:00. Consultant was present in all caesarean sections, except for one performed by a senior trainee. All women received preoperative antibiotics before caesarean section. Oral antibiotics were given for 5 days postoperatively in all but one patient with caesarean section, with four receiving intravenous antibiotics for 24 hours. Nine (30%) women had minor PPH and one (3.3%) had major PPH related to uterine atony following an elective caesarean section. One (3%) baby was large for gestation (>90th centile) and three (10%) were small for gestation (<5th
centile). There was no immediate admission to neonatal unit. Initial breastfeeding rate was 56%. All women with vaginal or instrumental delivery were discharged home by day 2, those with elective caesarean section by day 3, and those with emergency caesarean section by day 5.
Conclusion: We adhered to most auditable criteria. There is room for improvement in terms of review by anaesthetists in the clinic or on first admission in labour. We have developed a pathway to start the induction process towards the beginning of the week and earlier during the day. Healthcare professional should discuss potential risks and management options with women with obesity presenting for the first time during pregnancy. A brief intervention on
weight management should be delivered in an effective and sensitive manner to help reduce the long-term burden of morbidity associated with supermorbid obesity.