Seminars in Fetal & Neonatal Medicine 15 (2010) 83–88

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Seminars in Fetal & Neonatal Medicine

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Obstetric management of obesity in pregnancy

Eleanor Jarvie*, Jane E. Ramsay
Department of Obstetrics and Gynaecology, Ayrshire Maternity Unit, Crosshouse Hospital, Kilmarnock KA2 OBE, UK

s u m m a r y

Keywords: Rates of obesity among the pregnant population have increased substantially and adiposity has
Epidemiology a damaging effect on every aspect of female reproductive life. This review summarises epidemiological
Obesity data concerning obesity-related complications of pregnancy. Obesity is linked to a number of adverse
Obstetric management
obstetric outcomes as well as increased maternal and neonatal morbidity and mortality. These compli-
Risk
cations include miscarriage, congenital abnormalities, pre-eclampsia, gestational diabetes mellitus,
iatrogenic preterm delivery, postdates pregnancy with increased rates of induction of labour, caesarean
section, postpartum haemorrhage, shoulder dystocia, infection, venous thromboembolism, and increased
hospital stay. It is important to consider obese pregnant women as a high risk group with a linear
increase in risk of complications associated with their degree of obesity. Their obstetric management
should be consultant-led and involve a multidisciplinary team approach to improve outcome.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction and in those with normal ovarian morphology. It is believed that up to

The effect of adiposity is manifest in nearly every aspect of
female reproductive life whether as a metabolic or reproductive
complication or as a technical problem affecting clinical issues such
as ultrasound scanning or surgery (Table 1). The 2002–2004
Confidential Enquiries into Maternal and Child Health (CEMACH)
first highlighted obesity as a significant risk for maternal death,
with 35% of the women who died being obese; 50% more than in
the general population.1 The 2003–2005 report recommended
preconception counselling for women with a body mass index
(BMI; kg/m2) >30.2 In addition, offspring of obese mothers have
a higher perinatal morbidity and long-term health problems.
Maternal obesity is an increasing big problem in clinical obstetric
practice, with epidemiological data indicating that the prevalence
of obesity has doubled over the last ten years.3
2. Early pregnancy complications
2.1. Miscarriage
Amenorrhoea and infertility among obese women is more
common than in their lean counterparts. Obesity is associated with
miscarriage in both women with polycystic ovarian syndrome (PCOS)
* Corresponding author. Tel.: þ44 1563 825467; fax: þ44 1563 825413.
E-mail address: elliegate@doctors.org.uk (E. Jarvie).
50% of obese women have PCOS compared with 30% of lean.4
A recent meta-analysis of 13 studies examined patient predic-
tors for outcome of gonadotrophin ovulation induction in women
with normogonadotrophic anovulatory infertility. This work
concluded that the most clinically useful predictors of poor
outcome were obesity and insulin resistance.5 The pooled odds
ratio (OR) for obese vs non-obese women and rate of spontaneous
miscarriage was 3.05 (95% confidence interval: 1.45–6.44)]
(Table 2). This association emphasises the importance of encour-
aging weight loss in order to maximise the chance of a successful
pregnancy outcome, prior to embarking on the management of
anovulatory subfertility.
Most published data have examined the rates of miscarriage
within the PCOS population and in women who have received
fertility treatment. Few studies have looked at identifying the risk
of miscarriage within the obese general population. Lashen et al.6
carried out a matched case–control study (parous women with one
live child) which aimed to address this topic. A total of 1644 obese
women (BMI >30) were paired with 3288 normal weight controls
(BMI 19–24.9). The rates of spontaneous early (6–12 weeks), late
(12–24 weeks) and recurrent (more than three) early miscarriage
were observed. The obese women had a significantly higher inci-
dence of early and recurrent early miscarriage.
The incidence of spontaneous miscarriage has been reported to
increase with decreasing insulin sensitivity7 and it has been sug-
gested that insulin-sensitising agents, such as metformin, also
reduce miscarriage rates.8 One potential mechanism is increased
production of inflammatory and pro-thrombotic agents by adipose

1744-165X/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.siny.2009.10.001
84 E. Jarvie, J.E. Ramsay / Seminars in Fetal & Neonatal Medicine 15 (2010) 83–88

Table 1 further control for the effects of glucose dysregulation and examine
Potential effects of adiposity in pregnancy. effects of maternal obesity in isolation, this group performed
Medical complications Technical complications a subanalysis excluding all cases where mothers were diagnosed
Maternal Menstrual disorders Difficult ultrasound with gestational diabetes. Spina bifida (2.1), heart defects (1.3) and
examination diaphragmatic hernia (1.4) were persistently associated with
Prepregnancy Infertility maternal obesity.
Early Miscarriage
In another recent study, central nervous system abnormalities
pregnancy Fetal anomalies
Antenatal Pregnancy-induced were examined in relation to increasing quintiles of maternal
hypertension BMI.16 A linear relationship was demonstrated. Maternal BMI >40
Pre-eclampsia was associated with a five-fold (odds ratio: 4.8) increased risk of
Gestational diabetes spina bifida.
Venous thromboembolism
Intrapartum Induction of labour Operative issues
The mechanisms involved in the association between obesity
Caesarean section Anaesthetic issues and congenital anomalies are not fully understood. The prevalence
Postpartum Haemorrhage of significant insulin resistance without frank glucose dysregula-
Infection tion may have some influence. Hyperinsulinaemia has been noted
Venous thromboembolism
to be an independent risk factor for NTDs.20 It has been concluded
Fetal Macrosomia Birth injury
Fetal distress in some studies that prepregnancy diagnosis of diabetes may
Perinatal morbidity/mortality permit appropriate intervention prior to conception and those
obese women planning a pregnancy should be screened. One could
tissue or endothelium secondary to stimulation by adipocyte- postulate that weight reduction and tight glycaemic control may
derived factors. Plasminogen activator inhibitor type 1 (PAI-1) has help reduce rates of congenital abnormalities in this high risk
been suggested to be associated with increased rates of miscarriage group.
in association with maternal obesity. Treatment with metformin Another hypothesis suggests that obese women may have
appeared to reduce PAI-1 and miscarriage rates.9,10 This may increased nutritional requirements, or nutritional deficiencies
suggest central or visceral obesity to be more important in the consequent to poor quality diet. Werler et al.12 concluded that
aetiology of miscarriage than ‘overweight’ alone. 400 mg of folic acid was protective against NTDs in women whose
absolute body weight was <70 kg. This was not the case in those
>70 kg. They also concluded that the risk of NTD increases with
2.2. Congenital abnormalities
maternal weight independent of folic acid intake.

Studies have reported maternal obesity as an independent risk

factor for fetal abnormalities. In 1994, a case–control study by 2.3. Technical difficulties in obstetric ultrasound
Waller et al.11 first demonstrated that women with a BMI >31 were
at risk of delivering a baby with neural tube defects (NTDs). In Ultrasound imaging in the obese patient can be challenging.
addition, obese women had a significant risk of having a child with Adipose tissue can significantly attenuate the ultrasound signal by
defects of the great vessels of the heart, ventral wall and intestinal absorption of the associated energy. Therefore a high frequency,
tract. Many more epidemiological studies have since been pub- higher resolution signal would be more significantly absorbed at
lished (Table 3).12–19 a lesser depth, necessitating sacrifice of image quality for depth of
In 2007, Waller et al.19 reviewed data from 10 249 cases, and in field. In an American retrospective cross-sectional study Hendler
an attempt to control data, abnormalities from pregnancies where et al.21 examined the rate of suboptimal ultrasonography visual-
a chromosomal defect was identified or where mothers had pre- isation in 11 019 pregnancies, of which 38.6% were obese (BMI >30).
pregnancy diabetes were excluded from the analysis. This group This indicated that there was a 49.8% increase in the rate of
also corrected for documented use of folic acid. Results confirmed suboptimal visualisation (SUV) of fetal cardiac anomalies and a 31%
that in children born to women with a BMI >30, there was an increase in SUV of craniospinal structures in obese women.
increased risk of spina bifida (OR: 2.1), heart defects (1.4), anorectal
atresia (1.5), hypospadias (1.33), limb reduction defects (1.4), dia- 3. Maternal obstetric complications
phragmatic hernias (1.4) and omphalocele (1.63). In an attempt to
It is recognised that obesity is a risk factor for many maternal
Table 2
Risk of miscarriage in association with obesity.5,6 obstetric complications including pre-eclampsia and gestational
diabetes mellitus (GDM). The mechanisms involved are complex
Pregnancy Study design Risk of complication
but one possible unifying hypothesis may be encompassed by the
complication
‘metabolic’ syndrome as discussed in previous chapters.
Miscarriage Meta-analysis of 13 studies Rate of spontaneous
in women with miscarriage: OR: 3.05; 95% CI:
normogonadotrophic 1.4–6.4 3.1. Pregnancy-induced hypertension, pre-eclampsia and
anovulatory infertility
gestational diabetes
examined patient predictors
for outcome of ovulation
induction with gonadotrophins: A plethora of data exists confirming the relationship between
obese versus non-obese obesity and the development of pregnancy-induced hypertension
women and pre-eclampsia. In 1995, Sibai et al.22 published a prospective
Nested case–control study. Rate of early miscarriage (6–
multicentre study examining possible risk factors for pre-
Obese women (BMI >30) 12 weeks): OR: 1.2; 95% CI:
compared with age-matched 1.0–1.46. eclampsia. One variable included prepregnancy weight and they
control group with normal Rate of recurrent miscarriage concluded that there was an increase of 20% in the occurrence of
BMI (19–24.9) (>3 successive): OR: 3.5; 95% pre-eclampsia in women who were above their ideal weight. Sibai
CI: 1.0–12.0
et al.23 published further evidence based on the assessment of BMI
BMI, body mass index (kg/m2); OR, odds ratio; CI, confidence interval. in the early second trimester. This strongly predicted (P < 0.0001)
 E. Jarvie, J.E. Ramsay / Seminars in Fetal & Neonatal Medicine 15 (2010) 83–88 85

Table 3
Risks of fetal anomalies in association with obesity.

Study Study design Risk of complication

Waller et al. (1994)11
Werler et al. (1996)12
Feldman et al. (1999)13
Moore et al. (2000)14
Watkins et al. (2003)15
Anderson et al. (2005)16
Cedegren et al. (2005)17
Martinez-Frias et al.
(2005)18
Waller et al. (2007)19
Case–control study of NTDs and major birth defects in 1370 births between 1985 and 1987 Neural tube defect OR: 1.8
Spina bifida OR: 2.6
Case–control surveillance programme of NTDs in 2355 births. Relative risk for different Risk of NTDs:
maternal weights during 1988–1994 80–89 kg, OR: 1.9
90–99 kg, OR: 1.3
100–109, kg OR: 3.1
>110 kg, OR: 4.0
Large cohort study of 72–915 consecutive cases of biochemical screening. Five maternal Differences between maternal
weight ranges. Data were analysed based on two groups, obese and non-obese weight ranges not significant
(cut-off point 220 lbs)
Prospective study of birth defects associated with maternal obesity and diabetes mellitus Craniofacial defect PR: 2.2
in 22 951 births between 1984 and 1987 Musculoskeletal defect PR: 1.5
Case–control study of major birth defects among ~40 000 births per year during 1993–1997 Spina bifida OR: 3.5
Omphalocele OR: 3.3
Heart defects OR: 2.0
Case–control study of major birth defects, maternal obesity and GDM in 974 births during Anencephaly OR: 2.3
1997–2001 Spina bifida OR: 2.8
Isolated hydrocephaly OR: 2.7
Case–control study of orofacial clefts among 988 171 births between 1992 and 2001 Orofacial clefts OR: 1.30; 95%
CI: 1.11–1.53
Case–control study and surveillance system of 61 000 births of mothers with GDM, Obese and GDM
between 1976 and 2001 Birth defect OR: 2.78
Cardiovascular defects OR: 2.82
Population-based study enrolled in NBDPS 1997–2002; n ¼ 10 249 cases Spina bifida OR: 2.19
Diaphragmatic hernia OR: 1.20
Heart defects OR: 1.33

NTDs, neural tube defects; OR, odds ratio; PR, prevalence ratio; GDM, gestational diabetes mellitus.

the highest risk of pre-eclampsia being among women with
BMI >34.
Recent published data have aimed to quantify the independent
relationship between prepregnancy BMI and the risk of pre-
eclampsia. In 2005, Bodnar et al.24 examined a population of 1179
nulliparous women who were enrolled at 16 weeks of gestation.
Adjusted results showed that the risk of pre-eclampsia doubled as
the BMI rose from 21 to 26 and nearly tripled at 30. The authors of
this study suggest that women who are overweight could mean-
ingfully lower their risk of pre-eclampsia with achievable reduc-
tions in body weight prior to pregnancy.
In Sweden the rates for obesity among fertile women doubled
between 1980 and 1997. More specifically, Cedergren et al.25
observed that the numbers of morbidly obese women had mark-
edly increased. The study included 972 806 pregnancies delivered
between 1992 and 2001 and showed a five-fold increased risk of
pre-eclampsia among morbidly obese women.
A large population-based study from Australia confirmed the
linear relationship between increasing BMI and pre-eclampsia as
well as gestational diabetes.26 They described the prevalence of
these complications in their morbidly obese cohort (BMI >40) as
14.5% and 9% respectively (OR: 4.9 and 7.44).
Sukalich et al.27 published American data, examining adverse
obstetric outcomes in obese women aged <19 years. Of the
93 605 deliveries observed between 1998 and 2003, 5851 were in
women aged <19 years (5361 women had documented height
and prepregnancy weight). This study confirmed, in a teenage
population, a stepwise increase in the risk of pre-eclampsia over
all groups. Odds ratios for overweight, obese and morbidly obese
were 1.6, 1.9 and 3.0 respectively (95% CI: 1.2–1.4). Perhaps the
greatest concern is that this population group still has a long
potential reproductive lifespan and yet at this stage already
demonstrate serious obstetric complications which may recur in
future pregnancies.
When considering the risks associated with obesity and preg-
nancy, the importance of interpregnancy weight change must not
be underestimated. Vilamor et al.28 published striking data which
(n ¼ 151 025) in Sweden (Table 4). The relationship between
adverse outcomes and weight gain was linear, even after adjust-
ment for confounders. It was also noted that the risk of pre-
eclampsia fell significantly in women who had lost more than one
BMI unit between pregnancies.
3.2. Risk of preterm labour
In the past there has been inconclusive evidence that obesity has
been linked to preterm deliveries. Haeri et al.29 looked at the effect of
obesity in pregnant teenagers and found that they had a lower risk of
delivering at <37 weeks (adjusted OR: 0.28; 95% CI: 0.10–0.77) and
<34 weeks (0.11; 0.01–0.80) of gestation. Women considered to be
at high risk of spontaneous preterm delivery have also been studied
in a multicentre observational study.30 Inclusion criteria were
a history of one or more spontaneous preterm deliveries between 20
and 36 weeks of gestation or a history of second trimester vaginal
bleeding. The authors observed that obese and overweight women
(n ¼ 156) were significantly less likely to deliver before 35 weeks of
gestation (P < 0.01).
A large retrospective cohort study by Smith et al.31 assessed
187 290 women who delivered in Scotland between 1991 and 2001.
They found that obese nulliparous women were at an increased risk
of requiring an elective preterm delivery although the risk of
spontaneous preterm delivery decreased. Morbidly obese women
were at a greater risk of both elective and spontaneous preterm
deliveries, neonatal death, and delivering a baby weighing <1000 g.
Table 4
Adjusted odds ratios for pre-eclampsia in second pregnancy associated with changes
in BMI since first pregnancy, by categories of BMI at first pregnancy.28
Change in BMI (kg/m2) Risks of pre-eclampsia in 2nd pregnancy
(n ¼ 1523) OR (95% CI)
<1 0.82 (0.67–0.99)
1 to <1 1.00
1 to <2 1.23 (1.07–1.41)
2 to <3 1.63 (1.39–1.91)
>3 1.78 (1.52–2.08)

investigated this association, from a large prospective study BMI, body mass index (kg/m2); OR, odds ratio; CI, confidence interval.
86 E. Jarvie, J.E. Ramsay / Seminars in Fetal & Neonatal Medicine 15 (2010) 83–88
As highlighted, these patients are at an increased risk of many
obstetric complications such as pre-eclampsia and these conditions
may necessitate an iatrogenic early delivery.
The risk of preterm delivery among obese women carrying twin
pregnancies has been recently assessed by Salihu et al.32 In the
retrospective analysis they collated data on maternity files from
1989–1997 in Missouri, USA. Their findings indicated that the
prevalence of obesity had risen by a staggering 77% during this time
frame. They concurred with other data which indicated a reduced
risk of spontaneous preterm delivery. In addition, the risk was more
pronounced among twin pregnancies (OR: 0.68; 95% CI: 0.62–0.75)
than singleton pregnancies (0.84; 0.82–0.87). Findings suggested
that the obese women with a singleton pregnancy were 50% more
likely to require elective preterm (1.46; 1.39–1.54) and very
preterm delivery (1.49; 1.34–1.65) and that this risk increased with
increasing BMI. This trend was mirrored in their data for twin
pregnancies among the obese population.
3.3. Induction of labour
Obese women appear to be significantly less likely to establish
in spontaneous labour by 42 weeks of gestation. In a recent study,
Denison et al.33 demonstrated that this effect again follows a linear
relationship with increasing maternal BMI, and once this reaches
levels of 35 kg/m2 the chance of spontaneous labour by 42 weeks
of gestation is <50% (OR: 0.43). Data from Aberdeen have indicated
that rising BMI is a risk factor for induction of labour (IOL) in the
nulliparous population.34 Adjusted OR for overweight, obese and
morbidly obese women are 1.3, 1.8 and 1.8 respectively.
In a population-based study assessing the outcomes of women
with an increased BMI, Kiran et al.35 found that women with
a BMI >30 were more likely to require postdates IOL. This group
noted that obese women were less likely to achieve delivery
consequent to a cervical sweep or artificial rupture of membranes
(ARM) (OR: 0.3; 95% CI: 0.2–0.6). Obese women were also more
likely to require augmentation with syntocinon (1.2; 1–1.6), and
require all three methods of induction (1.8; 1.1–1.9).
Concerns have been expressed that obese women may suffer
from a ‘soft tissue’ dystocia because of more adipose tissue within
the pelvis coupled with poor myometrial contractions, Zhang
et al.36 studied myometrial tissue in vitro in order to ascertain
whether there was a difference in the spontaneous contractility of
the myometrial smooth muscle based on maternal weight. They
found that the myometrial biopsies from obese women contracted
with less force and frequency than lean controls. They also carried
out a retrospective study of their own pregnant population which
indicated an increase in the caesarean section rate with delay in the
first stage of labour being the number one cause.
Taking all concerns into consideration, postdates IOL for signif-
icantly obese women requires an informative discussion between
obstetrician and patient with involvement of all members of the
multidisciplinary team.
3.4. Intrapartum and postpartum considerations
Many studies that have looked at the antenatal risks of obesity
have also observed their cohorts with respect to intrapartum and
postnatal complications. One of the most striking factors is the
increase in the rate of caesarean sections within the obese and
morbidly obese population.
From Australian data, Callaway et al.26 found that the risk of
caesarean section in the obese and morbidly obese population was
doubled (OR: 2.02 and 2.54). In addition, obese and morbidly obese
women were more likely to have a longer hospital admission (more
than five days) (OR: 1.1 and 3.18).
A recent meta-analysis by Chu et al.37 reviewed the risk of
caesarean section and maternal obesity. Data were collected from
cohort-designed studies from 1980 until 2005. They concluded that
for the overweight, obese, and morbidly obese populations the
unadjusted ORs were 1.46 (95% CI: 1.34–1.60), 2.05 (1.86–2.27) and
2.89 (2.28–3.79) respectively when compared with normal weight
women. Based on their findings and the current rate of caesarean
section in the USA in 2007, the authors estimated that if the number of
obese women who were giving birth in the USA was reduced by 1%
this would translate to 16 000 fewer caesarean sections being per-
formed on an annual basis. Haeri et al.29 illustrated that the risk of
caesarean section was mirrored in the obese teenage population.
With reference to the previous data on teenage mothers, significant
obstetric morbidity and operative risk is demonstrated in a pop-
ulation that should, based on age, be healthy.
A retrospective cohort study examining pregnancy outcomes in
a Scottish population (from 1976 until 2005) found that emergency
caesarean section rates were highest among the morbidly obese
population (OR: 2.8; 95% CI: 2.0–3.9) and that these women were
also more likely to suffer from a postpartum haemorrhage (1.5; 1.3–
1.7).34
The increased risk of excessive blood loss at section has already
been documented by Perlow et al.,38 who also found that the
massively obese population have a significantly increased risk for
total operation time, multiple epidural placement failures, post-
operative endometritis and prolonged hospital stay. It is known that
the presence of an apron of adipose tissue delays the healing of
a caesarean section wound by promoting a warm, moist environ-
ment in which bacteria can flourish. More than 10 years ago Beattie
et al. found that there was a linear relationship between the likeli-
hood of a caesarean section wound infection and increased maternal
weight – and that this was statistically significant (P ¼ 0.0001).39
If it is recognised that these women have a much higher chance
of requiring a caesarean delivery then this has planning and
workforce issues. Senior involvement in these cases may be
required, and in women with morbid obesity it may therefore be
useful to plan delivery to enable a multidisciplinary team of
experienced clinicians to be available for the procedure.
3.5. Neonatal issues
Data from Bhattacharya et al.34 found that morbidly obese
women had an increased risk of delivering a baby >4000 g (OR:
2.1; 95% CI: 1.3–3.2). Kiran et al.35 found that there was an
associated increased risk of shoulder dystocia as well as fetal
macrosomia in women with a BMI >30 (OR: 2.9 and 2.1). Rob-
inson et al.40 tried to explore the relationship between maternal
obesity and the risk of shoulder dystocia while controlling for
confounding factors. This case–control study reviewed records
from 45 877 live singleton cephalic vaginal deliveries from 1995
to 1997. Their results indicated that maternal obesity was not
a significant independent risk factor (adjusted OR: 0.9; 95% CI:
0.5–1.6), but that the most significant risk factor for shoulder
dystocia was fetal macrosomia (39.5; 19.1–81.4 when the birth
weight was >4500 g). Estimating fetal weight by palpation is not
sensitive in an obese population and as described above there are
several limitations to the sensitivity of sonography of these
patients. How to predict and prevent this potentially catastrophic
obstetric emergency remains a problem.
3.6. Venous thromboembolic disease
Thromboembolic disease remains the leading direct cause of
maternal mortality in the UK. In the 2003–2005 CEMACH report this
equated to 1.94 deaths per 100 000 maternities.2 Outwith pregnancy,
 E. Jarvie, J.E. Ramsay / Seminars in Fetal & Neonatal Medicine 15 (2010) 83–88
it is well documented that obesity is a risk factor for venous throm-
boembolism (VTE), pulmonary embolism and death. In a long-term
prospective cohort study by Goldhaber et al.,41 women were at
a significant risk of developing a pulmonary embolism if they were
overweight (P < 0.001). In addition, being overweight and obese
increases the risk of recurrent venous thrombosis. Eichinger et al.42
calculated the risk of recurrence as 9.3% (95% CI: 6.0–12.7) for normal
weight patients, 16.7% (11.0–22.3) and 17.5% (13.0–22.0) for over-
weight and obese patients respectively.
A Danish cohort43 stratified risk of VTE and obesity at each stage
of pregnancy. This showed that during early pregnancy (adjusted
OR: 2.7; 95% CI: 1.5–4.9), overall pregnancy (9.7; 3.1–30.8) and
during the pueperium (2.8; 0.8–9.8) obese women were at an
increased risk. The data of Jacobsen et al.44 emphasise the magni-
tude of risk of thromboembolism particularly when risk factors are
combined. They reported adjusted ORs for antenatal VTE as follows:
BMI 25 with no immobilization 1.8 (1.3–2.4), BMI 25 with
immobilization 62.3 (11.5–337.6).
On the basis that the risk of thromboembolic disease in the
obese pregnancy exists at all stages it is imperative that continued
risk assessment is carried out at each stage of the pregnancy and if
any obstetric complications develop as per Royal College of
Obstetricians and Gynaecologists’ guideline 37.45
Practice points
 Prepregnancy. As previously mentioned the CEMACH
report has highlighted obesity as a serious medical
condition which should involve preconceptual counsel-
ling. The report especially recommends this for women
prior to embarking on assisted reproductive techniques
or other fertility treatments.
– High dose folic acid (5 mg) should be recommended.
– Involvement of a dietician should be offered and in
extremes of obesity the recommendations of the
NICE guideline on management of obesity46 should
be considered.
– Women require to be informed of the potential for
increased complications for both themselves and
their offspring in the event of a pregnancy.
 Pregnancy. For women with extremes of obesity, an
early booking visit to plan pregnancy management with
their consultant obstetrician is advisable.
– Low dose aspirin in presence of additional clinical risk
factors for pre-eclampsia should be considered.
– Antenatal thromboprophylaxis should be considered
if additional clinical risk factors for venous thrombo-
embolic disease coexist.
– To screen for gestational diabetes, the current NICE
guideline on antenatal care47 advises a 75 g, 2 h
glucose tolerance test at 16 weeks of gestation for
women at high risk (clinical risk factors including
gestational diabetes in previous pregnancy and
BMI >30) and, if normal, consideration of retesting at
28 weeks of gestation.
– Detailed anomaly scan and serum screening should
be offered to all women during their pregnancy,
although information regarding the reduced sensi-
tivity of scans in obese women should also be
available.
– Anaesthetic assessment may be required for these
women in the third trimester, although the ‘cut-off’
for assessment remains unclear and can be decided
at a local level.
87
4. Conclusion
It is clear that there is an increased requirement for careful
surveillance of obese pregnant women at each stage of pregnancy.
However, randomised controlled trials of interventions for obese
pregnancy are not available and are therefore urgently required.
Conflict of interest statement
None declared.
Funding sources
None.
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