Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1 (Published 08 February 2017) Cite this as: BMJ 2017;356:j1
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Thank you for this concise review. To correct the RCOG recommendations: The RCOG recommends 10 days of prophylactic LMWH postnatally for class 3 Obesity with a BMI greater than or equal to 40 and for 10 days if a women is obese (BMI 30-39) with one additional risk factor.
Antenatal management for women with obesity can be more challenging and includes shared obstetric and midwifery led care, the need for serial growth scans for women with class 3 obesity, anaesthetic input and review, and also consideration of VTE risk. Prophylactic LMWH from 28 weeks gestation for women with a BMI of 40 or above with one additional risk factor is recommended. For labour, the labour ward is the preferred place of delivery where both obstetric and anaesthetic cover is present.
Reference: C Nelson-Piercy, P MacCallum, L Mackillop. RCOG greentop guideline 37a. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. 2015.
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf
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The authors nicely bring out the fact that still-births are caused by obesity. We may like to mention here that in high income countries, overweight, obesity, cigarette smoking and advancing maternal age are three chief causes of stillbirths that are preventable as well.1 Identification of methods to reduce maternal obesity is a foremost priority for high-income countries.1
References:
1. Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, Neilson J, Ezzati M, Koopmans L, Ellwood D, Fretts R, Frøen JF; Lancet's Stillbirths Series steering committee.. Stillbirths: the way forward in high-income countries. Lancet. 2011 May 14;377(9778):1703-17. doi: 10.1016/S0140-6736(11)60064-0.
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Very interesting clinical review on Obesity and pregnancy. Under one Subheading, namely: "Ovaries and reproductive function", we are surprised that the authors have not mentioned the well known "Polycystic Ovarian Syndrome" characterized by menstrual disturbances, anovulation, weight gain, infertility, hirsutism, acne, insulin resistance, etc, as a result of hormonal imbalances due to genetics or life-style.
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Re: Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child
We thank Visha K Tailor for noting the 2015 RCOG guidelines, Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. The RCOG guidelines used in our review were from 2010 and the changes noted were new in 2015. We agree that obesity during pregnancy is a significant risk factor for venous thromboembolism, especially Class III obesity with a BMI > 40 in the postpartum period. As noted in the RCOG guidelines the level of evidence for women with class III obesity receiving prophylactic LMWH in doses appropriate for their weight for 10 days after delivery is only “D” level meaning evidence level 3 or 4; or extrapolated from studies rated 2+. We agree with the RCOG that future research is needed to determine the optimal dose of LMWH in obese pregnant women. The recommendation that women with obesity (BMI 30-39) and 1 additional risk factor as noted in Table 1 in the RCOG guideline receive the similar LMWH in doses appropriate for their weigh for 10 days after delivery is stronger with evidence level “B”. Our review did not address the issue of antenatal thromboprophylaxis but would agree women with multiple risk factors for venous thromboembolism including obesity is more challenging and consideration should be given to prophylaxis in this high risk population.
Competing interests: No competing interests