Green top Guideline

Question 1

What is the percentage of obesity in antenatal population?

Answer 1

21,3 % obese
43 % BMI in the normal range

Question 2

In the review into maternal death, what is the percentage of obese women?

Answer 2

30 % of women who died were obese
22 % of women who died were overweight

Question 3

When a woman with obesity should seek prepregnancy counseling?

Answer 3

If BMI > 30

Question 4

What is the classification of adults according to BMI?

Answer 4

Underweight < 18,5
Normal range 18,5 - 24,99
Overweight > = 25
Preobese 25 - 29,99
Obesity class 1 30 - 34,99
Obesity class 2 35 - 39,99
Obesity class 3 >= 40

Question 5

What are the informations that should be provided preconceptually to women with high BMI?

Answer 5

🚩Weight loss reduces the risk of stillbirth, hypertension , fetal macrosomia
🚩Weight loss increases the chance of successful vaginal birth after CS ( VBAC)

Question 6

What are the maternal risks that can be associated with obesity?

Answer 6

1- ⬆️ risk of miscarriage
2- GDM
3- PET
4- VTE
5- induced labour/ prolonged labour
6 - CS / anaesthetic complications
7- PPH
8 - less likely to maintain breastfeeding
9- wound infection/ mortality

Question 7

What are the fetal risks that can be associated with obesity?

Answer 7

1- congenital anomalies
2- stillbirth
3- prematurity
4- macrosomia/ neonatal death
5- increased risk of developing obesity and metabolic disorders in childhood.

Question 8

What nutritional supplements should be recommended to women with obesity who wish to become pregnant?

Answer 8

❤ BMI > 30 👉 5mg / d folic acid 1 month before conception
* routine vit D:( uncertain evidence)
[ at high risk of vitD deficiency]

Question 9

What is the risk increased by calcium & vitD combinations?

Answer 9

Preterm birth

Question 10

In women with obesity:
- when the need of multidisciplinary team antenatally
- when to deliver in a consultant led unit

Answer 10

• BMI> 30 👉 MDT antenatally
• BMI > 35 👉 CLU at delivery

Question 11

When to assess the moving & handling risk( around delivery) in the 3rd trimester in a woman with obesity?

Answer 11

If BMI > 40

Question 12

When to calculate BMI in pregnancy?

Answer 12

At booking
🚩 in obese women: at booking + at the 3rd trimester

Question 13

What is acceptable gestational weight gain in obese women?

Answer 13

Lack of consensus on optimal gestational weight gain

Question 14

What is the role of anti obesity drugs in pregnancy?

Answer 14

NOT recommended in pregnancy

Question 15

Orlistat as anti obesity drug , is it allowed in pregnancy?

Answer 15

No,
orlistat is a lipase inhibitor
( no increase in major malformation risk was seen)

Question 16

What is the risk of using phentermine/ topiramate ( anti obesity drug ) in pregnancy?

Answer 16

( promotes appetite)
Increase the risk of oral cleft in exposure in 1st trimester.
6 times more

Question 17

What is the risk of taking lorcaserin in pregnancy ?

Answer 17

( serotonin receptor antagonist)
Exposure in late pregnancy result lower birth weight of offspring which persist to adulthood.
👉 contraindicated in pregnancy.

Question 18

What specific risk assessment are required for anaesthetics?

Answer 18

1- BMI> 40 👉 referral to obstetric anesthetist for antenatal assessment
2- assess: venous access +regional & general anaesthesia difficulties
3- MDT: if any potential difficulties

Question 19

What specific risk assessments are required for prevention of pressure sores?

Answer 19

BMI > 40 + IMMOBILITY are:
risk factors of pressure sores
👉 document risk assessment in 3rd trimester 👉 plans for for skin care & repositioning frequency.

Question 20

Above what BMI a woman should be screened for gestational diabetes?why?

Answer 20

BMI > 30
obese women with diabetes have 3 fold increased risk of congenital anomalies.

Question 21

Above what BMI obese women have increased risk of preeclampsia?

Answer 21

Class 2 and more ( BMI > 35)

Question 22

What are the moderate risk factors for preeclampsia that MAY benefit from aspirin in pregnancy?

Answer 22

MORE THAN 1 OF:
1- BMI > 35
2- First pregnancy
3- maternal age > 40
4- family history of PET
5- multiple pregnancy
👉 150 mg aspirin from 12w of pregnancy

Question 23

What are the maternal diseases that should be screened in pregnancy in women with obesity?

Answer 23

1- GDM BMI> 30
2- hypertension BMI > 35
3- VTE BMI > 30
4- mental health problems BMI >30
( depression- anxiety)

Question 24

What are the structural anomalies that the fetuses of obese women at high risk of?

Answer 24

1- spina bifida
2- NTD
3- hydrocephaly
4- Cardiovascular anomalies

Question 25

Above what BMI the higher fetal loss rate after amniocentesis?

Answer 25

BMI > 40
If BMI < 40 👉 don’t have increased risk of fetal loss.

Question 26

What special considerations about NIPT in screening obese pregnant women ?

Answer 26

Free DNA fractions shown to be decreased in maternal serum with increasing maternal weight
👉 NIPT less effective in obese women

Question 27

How & when should the fetus of obese women be monitored antenatally?

Answer 27

🚩 BMI< 35 👉 Symphysis fundal height SFH at each visit from 24w
🚩BMI > 35 👉 serial US to detect SGA

Question 28

How should the fetus of obese women be monitored during labour?

Answer 28

In accordance with NICE

Question 29

Obese women are at increased risk of prolonged pregnancy, what is the risk of the fetus in that case?

Answer 29

Stillbirth
BMI >35👉4 times more normal BMI
[ despite that No routine monitoring of post dates pregnancy]

Question 30

What should be discussed with women with maternal obesity regarding labour &birth?

Answer 30

1- low risk + multiparty 👉 MLUs
2- high risk 👉 CLUs + MDT
3- ACTIVE MANAGEMENT OF 3rd STAGE: to reduce the risk of PPH

Question 31

What are the potential intrapartum complications in women with maternal obesity?

Answer 31

1- labour induction
2- argumentation of labour
3- intrapartum CS
4- shoulder dystocia
5- additional analgesia during labour

Question 32

Is maternal obesity an indication for induction of labour?

Answer 32

Discussion should be made
On individual basis:
📌 elective induction at term in obese women reduce the chance of CS without increasing the risk of adverse outcomes.

Question 33

Maternal obesity is associated with fetal overgrowth, what is the overall OR?

Answer 33

2.4 for LGA more than 90th centile

Question 34

How much the incidence of CS is increased in women with overweight & obese women?

Answer 34

🚩The risk of CS is increased by 50 % in overweight women
🚩More than doubled in obese women

Question 35

What are the benefits of induction labour at term for fetal macrosomia irrespective of maternal BMI?

Answer 35

Reduction in the risk of shoulder dystocia & fetal fractures

Question 36

Fetuses from induction of labour group were at increased risk of what?

Answer 36

1-Raised bilirubin
2- High rates of Phototherapy

Question 37

What is the success rate of VBAC in general population ?
In obese women?

Answer 37

In general population 73%
In obese women 54 %
👉 obesity is a risk factor for unsuccessful VBAC

Question 38

What is the risk associated with trial of labour after CS in obesity class 3 ?

Answer 38

Uterine rupture

Question 39

What specific surgical techniques are recommended for CS on obese women?

Answer 39

🚩BMI>30 👉 Prophylactic antibiotics at the time of surgery
🚩> 2 cm subcutaneous fat 👉 should have suturing of subcutaneous space.
🚩No routine use of negative pressure dressing therapy or subcutaneous drains ( lack of evidence)

Question 40

📒 What is the period of time a woman undergone a bariatric surgery is recommended before attempting pregnancy?

Answer 40

12 - 18 months
And should have CL antenatal care
+ referral to dietitian for advice

Question 41

In comparison between class 3 obesity & bariatric surgery in the pregnancy outcomes?

Answer 41

Better overall obstetric outcomes after bariatric surgery