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JOGC

Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

      Abstract

      Objective

      This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on pre-conception and pregnancy care. Part II will focus on team planning for delivery and Postpartum Care.

      Intended Users

      All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

      Target Population

      Women with obesity who are pregnant or planning pregnancies.

      Evidence

      Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

      Validation Methods

      The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committee peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings, at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

      Benefits, Harms, and Costs

      Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affected pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

      Guideline Update

      SOGC guidelines will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

      Sponsors

      This guideline was developed with resources funded by the SOGC.

      Summary Statements

      • 1
        Maternal obesity carries both maternal and fetal risks (II-2).
      • 2
        There are limited options for weight loss and management during pregnancy (II-2).
      • 3
        Guidelines can assist with individualized recommendations regarding maternal gestational weight gain and calorie and nutrient intake during pregnancy (II-2).
      • 4
        Maternal obesity is a risk factor for fetal macrosomia (II-2).
      • 5
        The accuracy of fetal imaging for pregnancy dating, anatomical assessment, and fetal weight estimates is reduced in the setting of maternal obesity (II-2).
      • 6
        Stillbirth is more common with maternal obesity (II-1).
      • 7
        Multiple gestations carry additional risks in pregnancies complicated by maternal obesity (II-2).
      • 8
        Weight loss surgery before pregnancy, while generally conferring benefits to mother and fetus, also carries rare and serious morbidity during gestation (II-1).

      Recommendations

      • 1
        Weight management strategies prior to pregnancy may include dietary, exercise, medical, and surgical approaches. When pursued before pregnancy, health benefits may carry forward into future pregnancies (III B).
      • 2
        As obesity carries many medical risks, assessment for conditions of the cardiac, pulmonary, renal, endocrine, and skin systems, as well as obstructive sleep apnea, is warranted in the pre-pregnancy period (II-3 B).
      • 3
        Folic acid supplementation in the 3 months prior to conception is warranted given the increased risks of congenital abnormalities of the fetal heart and neural tube related to maternal obesity (II-2 A).
      • 4
        It is recommended that both monitoring of gestational weight gain and approaches for gestational weight gain management be formally integrated into routine prenatal care (III A).
      • 5
        There is good evidence to support the role of exercise in pregnancy (I A).
      • 6
        There is good evidence to support supplementation with folic acid (at least 0.4 mg) and vitamin D (400 IU) during pregnancy (II-2 A).
      • 7
        Fetal macrosomia may be altered by well-controlled maternal gestational weight gain (II-2 A).
      • 8
        Increased fetal surveillance for well-being is suggested in the third trimester if the reduced fetal movements are reported, given the increased rate of stillbirth (II-3).
      • 9
        Aspirin prophylaxis can be recommended for women with obesity when other risk factors are present for the prevention of preeclampsia (I A).
      • 10
        It is recommended that delivery be considered at 39–40 weeks gestation for women with a body mass index of 40 kg/m2 or greater given the increased rate of stillbirth (II-2 A).
      • 11
        Multiple gestations in women with obesity require increased surveillance and may benefit from consultation with a Maternal-Fetal Medicine consultant, especially in the setting of monochorionic gestations (II-2 A).
      • 12
        Pregnancy after weight loss surgery may benefit from Maternal-Fetal Medicine consultation given the potential for significant albeit rare maternal morbidity (III B).

      Key Words

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