Obstentrics_Williams

Obstentrics_Williams. In addition to these metabolic complications, quality-of-life measures are also negatively afected by obesity during pregnancy (Amador, 2008; Ruhstaller, 2017). One systematic review found significantly higher risks ofdepression in overweight and obese women during and after pregnancy (Molyneaux, 2014). Obese women were also significantly more likely to experience anxiety during pregnancy. Stillbirths are more prevalent as the degree of obesity accrues (Ovesen, 2011; Schummers, 2015). In a review of almost 100 -15-:))..)S 10)):)0'3E 5 0 30 20 FIGURE 48-6 Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: frequency of preeclampsia according to BMI. (Data from the HAPO Study Cooperative Research Group, 2008.) D Controls (BMI <30) (n 3752) D Obese (BMI 30-35) (n = 1473) • Morbidly obese (BMI >35) (n = 877) 4.8 8.3


Obstentrics_Williams

Obstentrics_Williams. D Controls (BMI <30) (n 3752) D Obese (BMI 30-35) (n = 1473) • Morbidly obese (BMI >35) (n = 877) 4.8 8.3 FIGURE 48-5 Incidence of selected pregnancy outcomes in 16,102 women enrolled in the FASTER (First-and Second-Trimester Evaluation of Risk) trial according to BMI. (Data from Weiss, 2004.) studies, obesity was the highest ranking modifiable risk factor for stillbirth (Flenady, 201l). In super-morbidly obese compared with normal-weight gravidas, Yao and associates (2014) found 5.7 and l3.6-fold higher stillbirth rates at 39 and 41 weeks' gestation, respectively. Remarkably, 25 percent of term stillbirths in this study involved obese women. Chronic hypertension with superimposed preeclampsia associated with obesity is one cause of excessive stillbirths.


Obstentrics_Williams

Obstentrics_Williams. Evaluating perinatal death rates, Lindam and coworkers (2016) reported that high maternal BMI in early pregnancy was a risk factor. The risk ofneonatal death is also greater for obese women 0ohansson, 2014; Meehan, 2014). Finally, Cnattingius and Villamor (2016) noted that accruingweight between pregnancies is a risk factor for perinatal mortality, whereas weight loss between pregnancies for overweightwomen lowers this risk. Both fetal and neonatal complications are increased in obese women. Two important and interrelated cofactors that 0.85 • Obese J 0.80 0.75 .J,0.70 .J,0.65 0.60


Obstentrics_Williams

Obstentrics_Williams. Both fetal and neonatal complications are increased in obese women. Two important and interrelated cofactors that 0.85 • Obese J 0.80 0.75 .J,0.70 .J,0.65 0.60 FIGURE 48-7 Geometric changes of ventricular remodeling across pregnancy in obese and normal-weight women. LVM = left ventricular mass, LVEDV = left ventricular end-diastolic volume. (Data from Stewart, 2016.) contribute to excessive rates of perinatal morbidity are chronic hypertension and diabetes, both of which are associated with maternal obesity. hese comorbidities each may playra role in the higher rates of fetal-growth restriction and indicated pre term birth that are seen in obese women (Schummers, 2015). Pregestational diabetes also raises the birth defect rate, and ges tational diabetes is complicated by excessive numbers of large for-gestational-age and macrosomic fetuses (Chap. 44, p. 857). Even when diabetes is not considered, the prevalence of macrosomic newborns is greater in obese women (Kim, 2016;


Obstentrics_Williams

Obstentrics_Williams. Even when diabetes is not considered, the prevalence of macrosomic newborns is greater in obese women (Kim, 2016; Ovesen, 2011; Schummers, 2015). he group from Metro prepregnancy obesity, gestational weight gain, and diabetes and their relationship to adverse pregnancy outcomes and to greater newborn weight and fat mass (Catalano, 2009, 2015; Lassance, 2015; Ma, 2016; Yang, 2016). Although each of these variables is associated with larger and more corpulent newborns, pre gene expression has the strongest influence on the prevalence of macrosomic neonates.


Obstentrics_Williams

Obstentrics_Williams. Rates of birth defects are also higher with comorbid obesity (Stothard, 2009). For neural-tube defects, elevated risks of 1.2-, 1.7-, and 3. I-fold are found in overweight, obese, and severely obese women, respectively (Rasmussen, 2008). he National Birth Defect Prevention Study reported a correlation between BMI and congenital heart defects (Gilboa, 2010). However, this may be related to diabetes as a cofactor (Biggio, 2010). Importantly, obesity is detrimental to the accuracy of obstetrical sonographic examination and to antepartum identiication of birth defects (Adekola, 2015; Dashe, 2009; Weichart, 2011).


Obstentrics_Williams

Obstentrics_Williams. Obese women beget obese children, who themselves become obese adults. Catalano and coworkers (2009) studied ofspring at a mean age of 9 years and found a direct association with maternal prepregnancy obesity and childhood obesity. hey also reported associations with central obesity, elevated systolic blood pressure, increased insulin resistance, and lipid abnormalities-all elements of the metabolic syndrome. Reynolds and associates (2013) reported higher rates of cardiovascular disease and all-cause mortality in 37,709 adult ofspring of overweight and obese mothers. Similar cardiometabolic health efects in ofspring were echoed by Gaillard and colleagues (2016). Other data support that excessive maternal weight gain in pregnancy may predict obesity in adult ofspring (Lawrence, 2014; Reynolds, 2010). Last, rates of glucose intolerance and metabolic syndrome are higher among ofspring of obese women (Gaillard, 2016; Tan, 2015).


Obstentrics_Williams

Obstentrics_Williams. he potential biological mechanisms of these associations are unclear. But such studies raise the possibility ofetal programming, that is, the fetal environment may lead to adverse adult health outcomes. Elucidation is limited by insuicient data on potential maternal and genetic predisposing factors and on the environment of the infant and child in relation to diet and activity. he science of epigenetics has provided some support for the possibility that perturbations of the maternal-fetal environment can adversely alter postdelivery events (Kitsiou-T zeli, 2017). Also possible are contributions of the maternal-child environment subsequent to birth (Gluck, 2009). These and other factors regarding fetal programming are discussed in Chapter 44 (p. 849).


Obstentrics_Williams

Obstentrics_Williams. The Institute of Medicine (2009) has updated its previous maternal weight gain determinants (Table 9-4, p. 166). For overweight women, weight gain of 15 to 25 pounds is sug gested. For obese women, the Institute advocates a gain of 11 to 20 pounds. Intuitively, maternal weight must increase suf iciently to provide for fetal and placental tissue accrual and for amnionic fluid and maternal blood volume expansion. Thus, maternal weight loss is during pregnancy is discouraged. The American College of Obstetricians and Gynecologists (2015) endorses these Institute guidelines.


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists (2015) endorses these Institute guidelines. However, these recommendations were issued without irm scientific evidence to support them, and their value remains unproven (Rasmussen, 2010). For example, recent studies differ with respect to the efect of insuicient weight gain for obese women. Bodnar and colleagues (2016) reported no greater risk for low-birthweight or small-for-gestational-age newborns among 47,494 obese women who had inadequate weight gain during pregnancy. Bogaerts and associates (2015) found that even weight loss among obese women did not yield poor fetal growth. In contrast, however, Hannaford and coworkers (2017) reported that obese women who gained less than the Institute recommendations were almost three times more likely to deliver a small-for-gestational-age neonate. Another study similarly found an almost twofold greater risk among obese women who lost weight during pregnancy (Cox Bauer, 2016).


Obstentrics_Williams

Obstentrics_Williams. Apart from inadequate weight gain, excessive gestational weight gain may portend greater risks for the obese mother. Berggren and coworkers (2016) noted that overweight and obese women accrued maternal fat rather than lean mass with excessive gestational weight gain. From another analysis, overall higher rates of hypertensive disorders, cesarean delivery, and fetal overgrowth as well as lower rates of spontaneous preterm birth and fetal undergrowth were found among women gaining more than recommended Oohnson, 2013). However, when analyzed according to BMI category, significantly higher rates of preeclampsia, cesarean delivery, and fetal overgrowth were identified among the 1937 overweight women, but not for the 1445 obese women, who gained excess weight.


Obstentrics_Williams

Obstentrics_Williams. During pregnancy, overweight and obese women gain more weight than recommended compared with normal-weight gravidas (Endres, 2015). Moreover, overweight and obese women have excessive postpartum weight retention at 1 year, and one third retain at least 20 pounds more than their prep regnancy weight.


Obstentrics_Williams

Obstentrics_Williams. Several dietary interventions can help limit and achieve the weight-gain targets listed in the previous section. Options include lifestyle interventions and physical activity. In one randomized trial of exercise in 300 overweight women, risks for gestational diabetes were lowered (Wang, 2017). That said, in another trial, 75 overweight women were randomly assigned to routine care or to a 16-week moderate-intensity stationary cycling program starting after midpregnancy. NIaternal and neonatal outcomes did not difer between groups (Seneviratne, 2016). Also, a Cochrane database analysis of 11,444 women suggests that lifestyle interventions confer only a modest reduction in maternal weight gain, and their benefits for fetal overgrowth, cesarean delivery rate, and adverse neonatal outcome are not significant (Muktabhant, 2015). Regarding neonatal outcomes, the poor success of lifestyle interventions during pregnancy has been attributed to their late introduction, that is, after early gene


Obstentrics_Williams

Obstentrics_Williams. not significant (Muktabhant, 2015). Regarding neonatal outcomes, the poor success of lifestyle interventions during pregnancy has been attributed to their late introduction, that is, after early gene expression within the placenta has already been programmed (Catalano, 2015).


Obstentrics_Williams

Obstentrics_Williams. Close prenatal monitoring detects most early signs of diabetes or hypertension. Standard screening tests for fetal anomalies are suicient, while remembering the sonographic limitations for fetal anomaly detection in this group. Accurate fetal growth surveillance in obese women usually requires serial sonographic assessment. Antepartum external fetal heart rate monitoring is likewise more diicult. Obese women are at increased risk for multiple labor or intrapartum complications. These include postterm pregnancy or labor abnormalities (Carpenter, 2016). In one study of 143,519 women, the odds of spontaneous labor at term in obese women was approximately half that of normal-weight women (Denison, 2008). In an analysis of more than 5000 parturients, women with a Bh11 >30 kg/mrhad a longer duration of and slower early progression in first-stage labor (Norman, 2012).


Obstentrics_Williams

Obstentrics_Williams. Compared with normal-weight women, obese women are twice as likely to undergo labor induction (Denison, 2008). Unfortunately, obese women are also twice as likely to experience a failed induction, and this risk rises with greater degrees of obesity (Wolfe, 2011). In a retrospective analysis of 470 nul liparous women with a BMI >30 kg/mrand an unfavorable cervix, those who underwent labor induction at 39 weeks' gestation were compared with those expectantly managed beyond 39 weeks (Wolfe, 2014). Two thirds of pregnancies expectantly managed either labored or had spontaneously ruptured membranes. Compared with this cohort, those who underwent planned labor induction had an elevated cesarean delivery rate-26 versus 40 percent. Moreover, their newborns were more frequently admitted to the neonatal intensive care unit-6 versus 18 percent. Conversely, Lee and associates (2016) reviewed statistics from 74,725 deliveries in obese women and reported that elective induction at 37 to 39 weeks in


Obstentrics_Williams

Obstentrics_Williams. intensive care unit-6 versus 18 percent. Conversely, Lee and associates (2016) reviewed statistics from 74,725 deliveries in obese women and reported that elective induction at 37 to 39 weeks in nulliparas and especially multiparas was actually associated with a lower cesarean delivery rate. hese conflicting results highlight the diiculties faced by obstetrical providers as they contemplate the seemingly competing interests of the fetus and the obese mother. To address this, the Maternal-Fetal Medicine Units Network is conducting a randomized trial of planned labor induction at 39 weeks' gestation in nulliparous women.


Obstentrics_Williams

Obstentrics_Williams. Obese women present anesthesia challenges that include diicult epidural and spinal analgesia placement and complications from failed or diicult intubations. Evaluation of super-morbidly obese gravidas by the anesthesiologist is recommended during prenatal care or upon arrival to the labor unit (American College of Obstetricians and Gynecologists, 2017). Although the rationale for antepartum anesthesia consultation and early epidural analgesia access seems logical, little published data truly demonstrates benefits from these practices (Eley, 2016) .


Obstentrics_Williams

Obstentrics_Williams. Regional analgesia for morbidly obese women is associated with longer neuraxial procedure times and more failed placement attempts (Tonidandel, 2014). Importantly, however, spinal analgesia in obese women for cesarean delivery does not appear to have benefits over combined spinal-epidural. For example, Ross and colleagues (2014) compared single-shot spinal analgesia with combined spinal-epidural analgesia and found that both methods could be placed with equal expediency and function similarly in morbidly obese patients.


Obstentrics_Williams

Obstentrics_Williams. Obese women who undergo regional analgesia that is complicated by relative hypotension more frequently have neonates with umbilical artery cord blood acidemia, probably due to delayed delivery. Edwards and colleagues (2013) studied 5742 obese women and found that pH significantly dropped, and base deficit rose, with increasing BMI. The rate of pH <7.1 doubled from 3.5 percent for a BMI <25 kg/mrto 7.1 percent for a BMI ::40 kg/mr. Anesthetic risks and complications are discussed in more detail in Chapter 25.


Obstentrics_Williams

Obstentrics_Williams. These rates are significantly greater in obese women. In one study, the primary rate was 33.8 percent for obese and 47.4 percent for morbidly obese women. These values compare strikingly with the rate of only 20.7 percent for normal-weight gravidas (Weiss, 2004). In an analysis of 226,958 women, cesarean delivery rates rose signiicantly for overweight (34 percent), class I (38 percent), class II (43 percent), and class III (50 percent) obesity (Schummers, 2015). In the same study, rates of gestational diabetes, itself a risk factor for cesarean delivery, increased from 6 percent for women with a BMI <25 kg/mrto 21 percent for those with a BMI of ::40 kg/mr. More worrisome is that obese women also have higher rates of emergency cesarean delivery, and obesity lengthens times for decision-to-incision and for delivery (O'Dwyer, 2013; Pulman, 2015). Girsen and associates (2014) found significantly increased incision-to-delivery times for both emergent and nonemergent cases.


Obstentrics_Williams

Obstentrics_Williams. Discussed in Chapter 31 (p. 596), the incidence of failed trial oflabor after cesarean is higher in obese women (Grasch, 2017; Hibbard, 2006). Women who gain weight between pregnancies also have signiicantly lower rates of vaginal birth after cesarean. IIIII \I.' I FIGURE 48-8 Abdominal incision for the obese woman. A. Frontal view. The dotted line indicates an appropriate skin incision for abdominal entry relative to the panniculus. As shown by the uterus in the background, selection of this periumbilical site permits access to the lower uterine segment. B. Sagittal view.


Obstentrics_Williams

Obstentrics_Williams. For cesarean delivery, forethought is given to optimal placement and type of abdominal incision to allow access to the fetus and to efect the best wound closure. We prefer a vertical incision in obese women to provide the most direct access (Fig. 48-8). Others prefer a low transverse abdominal incision, with or without rostral taping of the pendulous abdomen. Individual diferences in maternal body habitus preclude naming anyrone approach as superior (tfcLean, 2012; Turan, 2016). Some observational studies have compared wound outcomes associated with vertical and transverse skin incisions, but results are conflicting as to a superiority of either (Brocato, 2013; Marrs, 2014; McClean, 2012; Sutton, 2016; Thornburg, 2012).


Obstentrics_Williams

Obstentrics_Williams. he frequency of abdominal wound infections is directly related to BM!. Conner and associates (2014) found the risk of wound infection is threefold higher for super-morbidly obese women compared with nonobese women-23 versus 7 percent. Among women with a BMI >45 kg/mr, wound complication rates range from 14 to 19 percent (Smid, 2015; Stamilio, 2014). Comorbid diabetes apparently raises this risk (Leth, 201l). Other studies describe wound complication rates ranging from 2 to >40 percent in obese women (Conner, 2014; vIarrs, 2014; Smid, 2015; Thornburg, 2012).


Obstentrics_Williams

Obstentrics_Williams. Several interventions maybe preventive. Closure ofsubcuta tion rates (Tipton, 2011). Studies have also examined the use of higher doses of perioperative prophylactic antibiotics. Phar macokinetic studies indicate that tissue concentrations of pro phylactic antibiotics are lower with increasing BMI (Pevzner, 2011; Young, 2015). One prospective study showed that a 3-g dose of cefazolin resulted in higher tissue concentrations com pared with a 2-g dose (Swank, 2015). hat said, a retrospective analysis of 335 women with a median weight of 310 pounds found that the higher dose of cefazolin did not result in few surgical site infections (Ahmadzia, 2015). In one recent study, phylaxis had a surgical infection rate of 13.4 percent compared with a rate of 6.4 percent for those given a 2-day course of oral cephalexin and metronidazole in addition to perioperative prophylaxis (Valent, 2017).


Obstentrics_Williams

Obstentrics_Williams. used prophylactically (Mark, 2014). To address this, Hussamy and colleagues (2018) designed a randomized trial of NPWT going cesarean delivery. Such therapy did not signiicantly lower the postoperative wound complication rate compared with routine care-19 versus 17 percent, respectively. To lower thromboembolic complications, graduated compression stockings, hydration, and early mobilization after cesarean delivery in obese women are recommended by the American College of Obstetricians and Gynecologists (2015). Some also recommend "mini-dose" heparin prophylaxis, but we do not routinely use this (Chap. 52, p. 1019).


Obstentrics_Williams

Obstentrics_Williams. Several surgical procedures are designed to treat morbid obesity either by diminishing gastric volume-restrictive, or by bypassing gastrointestinal absorption-restrictive nalabsorptive. In nonpregnant patients, these procedures improve or resolve diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea and reduce risks of myocardial infarction and death (Beamish, 2016). Of options, the two approved laparoscopic adjustable silicone gastric banding (LASGB) procedures-LAPBAND and REALIZE-place a band 2 cm below the gastroesophageal junction to create a small stomach pouch above the ring. he ring diameter is controlled by a saline reservoir in the band. hese procedures can have positive efects on pregnancy outcomes. For example, Dixon and colleagues (2005) compared TABLE 8-3. Pregnancy Outcomes Following Bariatric Surgery Outcomea (n = 651) (n = 361.) aData not reported identically-frequencies are approxi mations. bData from Adams, 201n5; Bar-Zohar, 2006; Carelli, 201n1;


Obstentrics_Williams

Obstentrics_Williams. Outcomea (n = 651) (n = 361.) aData not reported identically-frequencies are approxi mations. bData from Adams, 201n5; Bar-Zohar, 2006; Carelli, 201n1; Dixon, 2005; Ducarme, 2013; Facchiano, 2012; Lapolla, 2010; Pilone, 2014; Sheiner, 2009; Skull, 2004. (Data from Adams, 2015; Ducarme, 2013; Facchiano, 2012; Gonzalez, 2015; Sheiner, 2009. pregnancy outcomes in bariatric surgery patients against their preprocedural outcomes and those of a matched cohort of obese women. Following banding, the incidences of gestational hypertension-1 0 versus 45 percent-and gestational diabetes-6 versus 15 percent-were significantly lower in the bariatric surgery patients compared with their preprocedural pregnancies. The results from these and other studies are shown in Table 48-3.


Obstentrics_Williams

Obstentrics_Williams. Deflation of the band during pregnancy afects maternal and fetal weight gain. Pilone and coworkers (2014) studied 22 pregnancies after band placement and reported that all women underwent full delation of the band in the first trimester and gained an average of 14.7 kg during pregnancy. In another study, 42 women underwent deflation of the band, whereas 54 women maintained band inlation. A deflated band was associated with higher mean weight gain-15.4 kg versus 7.6 kg, increased birthweight-3712 versus 3380 g, and a twofold greater risk of macrosomia compared with an inflated one (Cornthwaite, 2015). Rarely, the band may slip from nausea and vomiting, especially with advancing gestation or postpartum (Pilone, 2014; Schmitt, 2016; Sufee, 2012). One fatal fetal cerebral hemorrhage developed from maternal vitamin K deiciency secondary to prolonged vomiting due to band slippage that created a gastric outlet obstruction (Van lieghem, 2008).


Obstentrics_Williams

Obstentrics_Williams. The laparoscopically performed Roux-en-Y gastric bypass is the most commonly used procedure for gastric restriction and selective malabsorption. Its surgical steps are described in Figure 48-9. As with other bariatric procedures, pregnancy outcomes are changed remarkably following Roux-en-Y bypass (Adams, 2015). As shown in Table 48-3, rates of hypertension, gestational diabetes, and fetal macrosomia are reduced. Serious complications are uncommon, however, upper abdominal pain is frequent in pregnancy and often associated with internal FIGURE 48-9 Roux-en-Y bypass. With this, the proximal stomach is completely transected to leave a 30-mL pouch. The proximal end of the distal jejunum is then connected to the small pouch. This bypasses a large part of the stomach and duodenum. At a site 60 cm distal to this gastrojejunostomy, a Roux-en-Y enteroenterostomy is also completed to allow drainage of secretions from the unused stomach and duodenum.


Obstentrics_Williams

Obstentrics_Williams. herniation, which is protrusion of the bowel through a mesentery defect. Petersen and associates (2017) described outcomes in a birth cohort including 139 pregnancies. Upper abdominal pain complicated 46 percent, and a third of these had internal herniation. The preterm birth rate was 14 of 64 among those with upper abdominal pain versus 1 of75 in those without pain. Intussusception and small bowel obstruction can develop from internal herniation, and maternal deaths from herniation and obstruction have been reported (Moore, 2004; Renault, 2012). Bowel obstruction is notoriously diicult to diagnose (Vannevel, 2016; Wx, 2013).


Obstentrics_Williams

Obstentrics_Williams. Because of its associated health successes, bariatric surgery is popular, and many women subsequently become pregnant (Narayanan, 2016). From observational studies, fertility rates improve and obstetrical complication rates decline in women after bariatric surgery compared with morbidly obese controls (Kominiarek, 2017; Yi, 2015). In one these studies, despite surgical treatment, almost half of 670 women were still obese at the time of their first pregnancy after bypass Qohansson, 2015). Nevertheless, the frequency of large-for-gestational-age newborns dropped from 22 to 8.6 percent and of small-forgestational-age neonates rose from 7.6 to 15.6 percent. In a systematic review, Yi and colleagues (2015) conirmed these fetal weight trends after bariatric surgery. Also, risks for diabetes and preeclampsia were reduced.


Obstentrics_Williams

Obstentrics_Williams. Currently, the American College of Obstetricians and Gynecologists (2015) recommends that women who have undergone bariatric surgery be assessed for vitamin and nutritional suiciency. When indicated, vitamins Bl2 and D, folic acid, and calcium supplementation are given. Vitamin A deficiency is also possible (Chagas, 2013). Women with a gastric band should be monitored by their bariatric team during pregnancy because adjustments of the band may be necessary. Finally, special vigilance is appropriate for signs of internal herniation with intestinal obstruction (Stuart, 2017; Wx, 2013). Adams TD, Hammoud AO, Davidson LE, et al: Maternal and neonatal outcomes for pregnancies before and after gastric bypass surgery. Int JtObes (Lond) 39:686, 2015 Adekola H, Soto E, Dai J, et al: Optimal visualization of the fetal four-chamber and outlow tract views with transabdominal ultrasound in the morbidly obese: are we there yet? J Clin Ultrasound 43:548, 2015


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Obstentrics_Williams. Ahmadzia HK, Patel EM, Joshi D, et al: Obstetric surgical site infections: 2 grams compared with 3 grams of cefazolin in morbidly obese women. Obstet GynecoIt126:708, 2015 Al-Badri MR, Zantout MS, Azar ST: he role of adipokines in gestational diabetes mellitus. her Adv Endocrinol Metab 6:103, 2015 Alberti KG, Eckel RH, Gtundy SM et al: Harmonizing the metabolic syndrome. A joint interim statement of the International Diabetes Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 120(16):1640,t2009 Amador N, Juarez JM, Guizar JM, et al: Quality of life in obese pregnant women: a longitudinal study. Am J Obstet Gynecol 198:203.e1, 2008 American College of Obstetricians and Gynecologists: Obesity in pregnancy. Practice Bulletin 156, December 20t15


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Obstentrics_Williams. Practice Bulletin 156, December 20t15 American College of Obstetricians and Gynecologists: Obstetric analgesia and anesthesia. Practice Bulletin No. 177, April 2017 American Society for Reproductive Medicine: Obesity and reproduction: a committee opinion. Fertil Steril lO4: 116, 2015 Bar-Zohar D, Azem F, Klausner J, et al: Pregnancy after laparoscopic adjustable gastric banding: perinatal outcome is favorable also for women with relatively high gestational weight gain. Surg Endosc 20: 1580, 2006 Beamish AJ, Olbers T, Kelly AS, et al: Cardiovascular efects of bariatric surgery. Nat Rev Cardiol 13:730,t2016 Berggren EK, Groh-Wargo S, Presley L, et al: Maternal fat, but not lean, mass is increased among overweight/obese women with excess gestational weight gain. Am J Obstet Gynecol 214:745.e1, 2016 Biggio JR J r, Chapman V, Neely C, et al: Fetal anomalies in obese women: the contribution of diabetes. Obstet Gynecol 115:290,t2010


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Obstentrics_Williams. Biggio JR J r, Chapman V, Neely C, et al: Fetal anomalies in obese women: the contribution of diabetes. Obstet Gynecol 115:290,t2010 Bilger M, Kruger EJ, Finkelstein A: Measuring socioeconomic inequality in obesity: looking beyond the obesity threshold. Health Econ 26(8): 1052, 2017 Bodnar LM, Pugh SJ, Lash TL, et al: Low gestational weight gain and risk of adverse perinatal outcomes in obese and severely obese women. Epidemiology 27:894,t2016 Bogaerts A, Ameye L, Martens E, et al: Weight loss in obese pregnant women and risk for adverse perinatal outcomes. Obstet Gynecol 125:566, 2015 Brocato BE, horpe EM Jr, Gomez LM, et al: The efect of cesarean delivery skin incision approach in morbidly obese women on the rate of classical hysterotomy. J Pregnancy 2013:890296,t2013 Carelli AMI, Ren C], Youn A,et al: Impact oflaparoscopic adjustable gastric banding on pregnancy, maternal weight, and neonatal health. Obes Surg 21:1552,t2011


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Obstentrics_Williams. Carelli AMI, Ren C], Youn A,et al: Impact oflaparoscopic adjustable gastric banding on pregnancy, maternal weight, and neonatal health. Obes Surg 21:1552,t2011 Carpenter JR: Intrapartum management of the obese gravida. Clin Obstet Gynecol 59:172, 2016 Catalano P, deMouzon SH: Maternal obesity and metabolic risk to the ofspring: why lifestyle interventions have not achieved the desired outcomes. Int JtObes (Lond) 39:642, 20t15 Catalano PM, Farrell K, Thomas A, et al: Perinatal risk factors for childhood obesity and metabolic dysregulation. Am J Clin Nutr 90:1303, 2009 Chagas CB, Saunders C, Pereira S, et al: Vitamin A deiciency in pregnancy: perspectives after bariatric surgery. Obes Surg 23:249, 2013 Cheung YM, Joham A, Marks S, et al: he obesity paradox: an endocrine perspective. Intern MedJ 47(7):72 ,2017 Cnattingius S, Villamor E: Weight change between successive pregnancies and risks of stillbirth and infant mortality: a nationwide cohort study. Lancet 387:558,t2016


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Obstentrics_Williams. Cnattingius S, Villamor E: Weight change between successive pregnancies and risks of stillbirth and infant mortality: a nationwide cohort study. Lancet 387:558,t2016 Conner SN, Verticchio JC, Tuuli MG, et al: Maternal obesity and risk of postcesarean wound complications. Am J Perinatol 31 :299, 2014 Cornier A, Despres JP, Davis N, et al: Assessing adiposity: a scientiic statement from the American Heart Association. Circulation 124:1996,t2011 Cornthwaite K, Jeferys A, Lenguerrand E, et al: One size does not fit all. Management of the laparoscopic adjustable gastric band in pregnancy: a national prospective cohort study. Lancet 385 Suppl 1 :S32, 2015 Cox Bauer CM, Bernhard A, Greer DM, et al: Maternal and neonatal outcomes in obese women who lose weight during pregnancy. J Perinatol 36:278,t2016


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Obstentrics_Williams. Cox Bauer CM, Bernhard A, Greer DM, et al: Maternal and neonatal outcomes in obese women who lose weight during pregnancy. J Perinatol 36:278,t2016 Crane JM, Murphy P, Burrage L, et al: Maternal and perinatal outcomes of extreme obesity in pregnancy. J Obstet Gynaecol Can 35: 606, 20t13 Cunningham FG: Peripartum cardiomyopathy: we've come a long way, but. ... Obstet Gynecol 120(5):992, 2012 Cunningham FG, Pritchard JA, Hankins GV, et al: Idiopathic cardiomyopathy or compounding cardiovascular events? Obstet GynecoI67:157, 1986 Dashe JS, McIntire DD, Twickler DM: Efect of maternal obesity on the ultrasound detection of anomalous fetuses. Obstet Gynecol 113: 1001, 2009 De Gonzalez AB, Hartge P, Cherhan JR, et al: Body mass index and mortality among 1.46 million white adults. N Engl J Med 363:23, 2010


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Obstentrics_Williams. De Gonzalez AB, Hartge P, Cherhan JR, et al: Body mass index and mortality among 1.46 million white adults. N Engl J Med 363:23, 2010 De Souza LR, Berger H, Rernakaran R, et al: Hepatic fat and abdominal adiposity in early pregnancy together predict impaired glucose homeostasis in mid-pregnancy. Nutr Diabetes 6:e229, 2016a De Souza LR, Berger H, Retnakaran R, et al: Non-alcoholic fatty liver disease in early pregnancy predicts dysglycemia in mid-pregnancy: prospective study. Am J Gastroenterol 111:665, 2016b Denison FC, Price J, Graham C, et al: faternal obesity, length of gestation, risk of postdates pregnancy and spontaneous onset of labour at term. B JOG 115:720,t2008 Dixon JB: Obesity in 2015: advances in managing obesity. Nat Rev Endocrinol 12:65,t2016 Dixon JB, Dixon ME, O'Brien PE: Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol lO6:965, 2005


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Obstentrics_Williams. Dixon JB, Dixon ME, O'Brien PE: Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol lO6:965, 2005 Ducarme G, Parisio L, Santulli P, et al: Neonatal outcomes in pregnancies after bariatric surgery: a retrospective multi-centric cohort study in three French referral centers. J Matern Fetal Neonatal Med 26:275, Edwards RK, Cantu J, Cliver S, et al: The association of maternal obesity with fetal pH and base deicit at cesarean delivery. Obstet Gynecol 122(2 Pt 1): 262, 2013 Eley VA, van Zundert A, Lipman J, et al: Anaesthetic management of obese parturients: what is the evidence supporting practice guidelines? Anaesth Intensive Care 44:552,t2016 Endres LK, Straub H, McKinney C, et al: Postpartum weight retention risk factors and relationship to obesity at one year. Obstet Gynecol 125: 144, 2015


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Obstentrics_Williams. U.S. adults. Findings from the hird National Health and Nutrition Examination Survey. JAMA 287:356, 2002 Fu J, Hofker M, Wijmenga C: Apple or pear: size and shape matter. Cell Metab 7:507,t2015 Gaillard R, Welten M, Oddy H, et al: Associations of maternal prepregnancy body mass index and gestational weight gain with cardio-metabolic risk factors in adolescent ofspring: a prospective cohort study. BJOG 123:207, 2016 Garvey T, Mechanick JI, Brett EM, et al: American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocr Pract 22:842, 2016 GBD 2015 Obesity Collaborators: Health efects of overweight and obesity in 195 countries over 25 years. N Engl J Med 377: 13, 2017 Gilboa SM, Correa A, Botto LD, et al: Association between prepregnancy body mass index and congenital heart defects. Am J Obstet Gynecol 202:51.e1, 2010


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Obstentrics_Williams. Gilboa SM, Correa A, Botto LD, et al: Association between prepregnancy body mass index and congenital heart defects. Am J Obstet Gynecol 202:51.e1, 2010 Gilmore A, Klempel-Donchenko M, Redman LM: Pregnancy as a window to future health: excessive gestational weight gain and obesity. Semin Perinarol 39:296, 2015 Girsen AI, Osmundson SS, Naqvi M, et al: Body mass index and operative times at cesarean delivery. Obstet Gynecol 124:684,t2014 Gluck ME, Venti CA, Lindsay RS, et al: Maternal influence, not diabetic intrauterine environment, predicts children's energy intake. Obesity 17:772, 2009


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Obstentrics_Williams. Gluck ME, Venti CA, Lindsay RS, et al: Maternal influence, not diabetic intrauterine environment, predicts children's energy intake. Obesity 17:772, 2009 Godfrey M, Reynolds M, Prescott SL, et al: Influence of maternal obesity on the long-term health of ofspring. Lancet Diabetes EndocrinoIt5:53,201 Gonzalez I, Rubio MA, Cordido F, et al: Maternal and perinatal outcomes after bar iatric surgery: a Spanish multicenter study. Obes Surg 25:436, 2015 Grasch JL, Thompson JL, Newton JM, et al: Trial of labor compared with cesarean delivery in superobese women. Obstet Gynecol 130:994, 2017 Hagstrom H, Hoijer J, Ludvigsson JF, et al: Adverse outcomes of pregnancy in women with non-alcoholic fatty liver disease. Liver Int 36:268, 2016 Hainer V, Aldhoon-Hainerova I: Obesity paradox does exist. Diabetes Care 36 SuppIt2:S276,t2013 Hannaford E, Tuuli MG, Odibo L, et al: Gestational weight gain: association with adverse pregnancy outcomes. Am J Perinatol 34: 147,t2017


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Obstentrics_Williams. Hannaford E, Tuuli MG, Odibo L, et al: Gestational weight gain: association with adverse pregnancy outcomes. Am J Perinatol 34: 147,t2017 HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al: Hyperglycemia and adverse pregnancy outcomes. N EnglJ Med 358(19):1991,2008 Hibbard JU, Gilbert S, Landon MB, et al: Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery. Obstet Gynecol 108(1): 125, 2006 Hofman BL, Horsager R, RobertS SW et al: Obesity. In Williams Obstetrics, 23rd edition Study Guide, New York, McGraw-Hill, 2011 Hussamy OJ, Wortman AC, McIntire DO, et al: A randomized trial of closed incision negative pressure therapy in morbidly obese women undergoing cesarean delivery. Presented at the 38th Annual Meeting of the Society for Maternal-Fetal Medicine, January 29-Februaty 3, 2018


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Obstentrics_Williams. Institute of Medicine, National Research Council, Rasmussen M, et al (eds): Weight Gain during Pregnancy: Reexamining the Guidelines. Washington, National Academy of Sciences, 2009 Johansson K, Cnattingius S, Naslund I, et al: Outcomes of pregnancy ater bariatric surgery. N Engl J Med 372:814, 2015 Johansson S, Villamor E, Altman M, et al: Maternal overweight and obesity in early pregnancy and risk of infant mortality: a population based cohort study in Sweden. BMJ 349:g6572, 2014


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Obstentrics_Williams. Johnson J, Clifton RG, RobertS JM, et al: Pregnancy outcomes with weight gain above or below the 2009 Institute of Medicine guidelines. Obstet Gynecol 121:969,t2013 Kim SS, Zhu Y, Grantz KL, et al: Obstetric and neonatal risks among obese women without chronic disease. Obstet Gynecol 128: 104, 2016 Kitsiou-Tzeli S, Tzetis M. Maternal epigenetics and fetal and neonatal growth. Curr Opin Endocrinol Diabetes Obes 24:43, 2017 Kominiarek A, Jungheim ES, Hoeger M, et al: American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy. Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society. Surg Obes Relat Dis 13(5):750,t2017 Lapolla A, Marangon M, Dalfra MG, et al: Pregnancy outcome in morbidly obese women before and after laparoscopic gastric banding. Obes Surg 20:1251,t2010 Lassance L, Haghiac M, Leahy P, et al: Identiication of early transcriptome signatures in


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Obstentrics_Williams. outcome in morbidly obese women before and after laparoscopic gastric banding. Obes Surg 20:1251,t2010 Lassance L, Haghiac M, Leahy P, et al: Identiication of early transcriptome signatures in placenta exposed to insulin and obesity. Am J Obstet Gynecol 212:647.e1,t2015 Lawrence GM, Shulman S, Friedlander Y, et al: Associations of maternal prepregnancy and gestational body size with ofspring longitudinal change in BM!. Obesity (Silver Spring) 22: 1165, 2014 Lee VR, Darney BG, Snowden JM, et al: Term elective induction of labour and perinatal outcomes in obese women: retrospective cohort study. BJOG 123:271,2016 Leth A, Uldbjerg N, Norgaard M, et al: Obesity, diabetes, and the risk ofinfections diagnosed in hospital and post-discharge infections ter cesarean section: a prospective cohort study. Acta Obstet Gynecol Scand 90(5) :501, 2011 Lindam A, Johansson S, Stephansson 0, et al: High maternal body mass index in early pregnancy and risks of stillbirth and infant mortality-a


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Obstentrics_Williams. cohort study. Acta Obstet Gynecol Scand 90(5) :501, 2011 Lindam A, Johansson S, Stephansson 0, et al: High maternal body mass index in early pregnancy and risks of stillbirth and infant mortality-a populationbased sibling study in Sweden. Am] EpidemioIt184:98, 2016 Lisonkova S, Muraca GM, Potts J, et al: Association berween prepregnancy body mass index and severe maternal morbidity. JAMA 318:1777,t2017 Locke AE, Kahali B, Berndt SI, et al: Genetic studies of body mass index yield new insights for obesity biology. Nature 518:197, 2015 Long MT, Fox CS: The Framingham Heart Study-67 years of discovery in metabolic disease. Nat Rev Endocrinol 12:177,t2016 Ma RC, Schmidt MI, Tam WH, et al: Clinical management of pregnancy in the obese mother: before conception, during pregnancy, and postpartum. Lancet Diabetes EndocrinoIt4:1037, 2016 Mariona FG: Does maternal obesity impact pregnancy-related deaths? Michigan experience. J Matern Fetal Neonatal Med 30(9):1060, 2017


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Obstentrics_Williams. Mark KS, Alger L, Terplan :M: Incisional negative pressure therapy to prevent wound complications following cesarean section in morbidly obese women: a pilot study. Surg Innov 21:345,t2014 Marrs CC, Moussa HN, Sibai BM, et al: The relationship between primary cesarean delivery skin incision type and wound complications in women with morbid obesity. Am J Obstet Gynecolt210:319.e1, 2014 Marshall NE, Guild C, Cheng W, et al: he efect of maternal body mass index on perinatal outcomes in women with diabetes. Am ] Perinatol 31:249,t2014 Martin CA, Gowda U, Smith B] et al: Systematic review of the efect oflifestyle interventions on the components of the metabolic syndrome in South Asian migrants. J Immigr Minor Health October 21, 2016 [Epub ahead of print]


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Obstentrics_Williams. McLean M, Hines R, Polinkovsky M, et al: Type of skin incision and wound complications in the obese parturient. Am J Perinatol 29:301, 2012 Meehan S, Beck CR, Mair-]enkins J, et al: Maternal obesity and infant mortality: a meta-analysis. Pediatrics 133:863,t2014 Meyer B], Stewart FM, Brown EA, et al: Maternal obesity is associated with the formation of small dense LDL and hypoadiponectinemia in the third trimester. J Clin Endocrinol Metab 98:643, 2013 Mingrone G, Panunzi S, De Gaetano A, et al: Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet 386:964, 2015 Molyneaux E, Poston L, Ashurst-Williams S, et al: Obesity and mental disorders during pregnancy and postpartum: a systematic review and metaanalysis. Obstet GynecoIt123:857, 2014


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Obstentrics_Williams. Molyneaux E, Poston L, Ashurst-Williams S, et al: Obesity and mental disorders during pregnancy and postpartum: a systematic review and metaanalysis. Obstet GynecoIt123:857, 2014 Moore lX, Chaudhary N, Akinyemiju T, et al: Metabolic syndrome prevalence by race/ethnicity and sex in the United States, National Health and Nutrition Examination Survey, 1988-2012. Prev Chronic Dis 14: 160287, 2017 Moore A, Ouyang OW, Whang EE: Maternal and fetal deaths after gastric bypass surgery for morbid obesity. N Engl] Med 351:721, 2004 Muktabhant B, Lawrie TA, Lumbiganon P, et al: Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev 6:CD007145,t2015 Narayanan RP, Syed A: Pregnancy following bariatric surgery-medical complications and management. Obes Surg 26:2523, 2016


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Obstentrics_Williams. Narayanan RP, Syed A: Pregnancy following bariatric surgery-medical complications and management. Obes Surg 26:2523, 2016 National Institutes of Health: The practical guide: identiication, evaluation, and treatment of overweight and obesity in adults. NIH Publication 00-4084. Bethesda, National Institutes of Health, 2000 Norman SM, Tuuli MG, Obido AO, et al: he efects of obesity on the irst stage of labor. Obstet Gynecol 120: 130, 2012 O'Dwyer V, O'Kelly S, Monaghan B, et al: Maternal obesity and induction of labor. Acta Obstet Gynecol Scand 92: 1414, 2013 Ogden CL, Carroll MD, Fryar CD, et al: Prevalence of obesity in the United States, 2011-2014. NCHS data brief No. 219, Hyattsville, National Center for Health Statistics, 2015 Ovesen P, Rasmussen S, Kesmodel U: Efect of prepregnancy maternal overweight and obesity on pregnancy outcome. Obstet Gynecol 118(2 Pt 1): 305,t2011


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Obstentrics_Williams. Ovesen P, Rasmussen S, Kesmodel U: Efect of prepregnancy maternal overweight and obesity on pregnancy outcome. Obstet Gynecol 118(2 Pt 1): 305,t2011 Peeters A, Barendregt J), Willekens F, et al: Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann Inten Med 138:24, 2003 Petersen L, Lauenborg J, Svare J, et al: he impact of upper abdominal pain during pregnancy following a gastric bypass. Obes Surg 27(3):688,t2017


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Obstentrics_Williams. Petersen L, Lauenborg J, Svare J, et al: he impact of upper abdominal pain during pregnancy following a gastric bypass. Obes Surg 27(3):688,t2017 Pevzner L, Swank M, Krepel C, et al: Efects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet GynecoIt117:877,t2011 Pilone V, Hasani A, Di Micco R, et al: Pregnancy after laparoscopic gastric banding: maternal and neonatal outcomes. Int J Surg 12 Suppl l:S 136, 2014 Pulman ), Tohidi M, Pudwellt], et al: Emergency caesarean section in obese parturients: Is a 30-minute decision-to-incision interval feasible? J Obstet Gynaecol Can 37:988, 2015 Rasmussen KM, Abrams B, Bodnar LM, et al: Recommendations for weight gain during pregnancy in the context of the obesity epidemic. Obstet Gynecol 116:1191,t2010 Rasmussen SA, Chu SY, Kim SY, et al: Maternal obesity and risk of neural tube defects: a metaanalysis. Am J Obstet Gynecol 198(6):611,t2008


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Obstentrics_Williams. Renault K, Gyrtrup H], Damgaard K, et al: Pregnant women with fatal complication after laparoscopic Roux-en-Y gastric bypass. Acta Obstet Gynecol Scand 91:873, 2012 Reynolds RM, Allan KM, Raja EA, et al: Maternal obesity during pregnancy and premature mortality from cardiovascular event in adult ofspring: follow-up of 1 323275 person years. BM] 347:f4539, 2013 Reynolds RM, Osmond C, Phillips 01, et al: Maternal BMI, parity, and pregnancy weight gain: influences on ofspring adiposity in young adulthood. ] Clin Endocrinol Metab 95:5365,t2010 Ross VH, Dean LS, Thomas ]A, et al: A randomized controlled comparison between combined spinal-epidural and single-shot spinal techniques in morbidly obese parturients undergoing cesarean delivery: time for initiation of anesthesia. Anesth Analg 118: 168, 2014


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Obstentrics_Williams. Ruhstaller E, Elovitz A, Stringer M, et al: Obesiry and the association with maternal mental health sym ptoms. ] Matern Fetal Neonatal Med 10: 1, 2017 Rusinek H, Convit A: Obesity: cerebral damage in obesity-associated metabolic syndrome. Nat Rev Endocrinol 10:642,t2014 Sartori C, Lazzeroni P, Merli S: From placenta to polycystic ovarian syndrome: the role of adipokines. Mediators Inlamm 2016:4981916, 2016 Schauer PR, Bhatt DL, Kitwan ]P, et al: Bariatric surgery versus intensive medical therapy for diabetes-3 year outcomes. N Engl ] Med 370:2002, 20t14 Schmitt F, Topart P, Salle A, et a1: Early postpartum gastric band slippage after bariatric surgety in an adolescent obese girl.] Surg Case Rep 2016(9), 2016 Schummers L, Hutcheon ]A, Bodnar LM, et al: Risk of adverse pregnancy outcomes by prep regnancy body mass index: a population-based study to inform prep regnancy weight loss counseling. Obstet Gynecol 125: 133,2015


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Obstentrics_Williams. Sebire N], ]olly M, Harris JP, et al: Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int] Obes Relat Metab Disord 25:1175,t2001 Seneviratne SN, Jiang Y, Derraik], et al: Efects of antenatal exercise in overweight and obese pregnant women on maternal and perinatal outcomes: a randomised controlled trial. B]OG 123:588,t2016 Sheiner E, Balaban E, Dreiher], et al: Pregnancy outcome in patients following diferent types of bar iatric surgeries. Obes Surg 19:1286, 2009 Shungin 0, Winkler TW, Croteau-Chonka De, et al: New genetic loci link adipose and insulin biology to body fat distribution. Nature 518:187, 2015 Skull A], Slater GH, Duncombe ]E, et al: Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and efect on obesity-related pregnancy outcomes. Obes Surg 14:230, 2004


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Obstentrics_Williams. Skull A], Slater GH, Duncombe ]E, et al: Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and efect on obesity-related pregnancy outcomes. Obes Surg 14:230, 2004 Smid MC, Kearney MS, Stamilio OM: Extreme obesity and postcesarean wound complications in the Maternal-Fetal Medicine Unit cesarean registry. Am] PerinatoI32:1336, 2015 Smid Me, Vladutiu q, Dotters-Katz SK, et al: Maternal super obesity and neonatal morbidity ater term cesarean delivery. Am] Perinatol 33:1198, 2016 Stamilio OM, Scifres CM: Extreme obesity and postcesarean maternal complications. Obstet Gynecol 124(2 Pt 1):227,t2014 Stewart RD, Nelson DB, Matulevicius SA, et al: Cardiac magnetic resonance imaging to assess the impact of maternal habitus on cardiac remodeling during pregnancy. An1] Obstet Gynecol 214:640.e1, 2016 Stothard K], Tennant PW, Bell R, et al: Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. ]AMA 30t1t:636, 2009


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Obstentrics_Williams. Stothard K], Tennant PW, Bell R, et al: Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. ]AMA 30t1t:636, 2009 Stuart A, Kallen K: Risk of abdominal surgery in pregnancy among women who have undergone bariatric surgery. Obstet Gynecol 129:887,t2017 Sufee MT, Poncelet e, Barrat C: Gastric band slippage at 30 weeks' gestation: diagnosis and laparoscopic management. Surg Obes Relar Dis 8(3):366, 2012 Sutton AL, Sanders LB, Subramaniam A, et al: Abdominal incision selection for cesarean delivery of women with class III obesity. Am] PerinatoI33:547, 2016 Swank ML, Wing DA, Nicolau DP, et al: Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am ] Obstet Gynecol 213:415.e1,t2015 Tan HC, Roberts ], Catovt]: Mother's pre-pregnancy BMI is an important determinant of adverse cardiometabolic risk in childhood. Pediatr Diabetes 16:419,t2015


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Obstentrics_Williams. Tan HC, Roberts ], Catovt]: Mother's pre-pregnancy BMI is an important determinant of adverse cardiometabolic risk in childhood. Pediatr Diabetes 16:419,t2015 Targher G, Byrne CD, Lonardo A, et a1: Non-alcoholic fatty liver disease and risk of incident cardiovascular disease: a meta-anlysis.t] Hepatol 65:589, 2016 Thornburg LL, Linder A, Durie DE, et al: Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery. ] Matern Fetal Neonatal Med 25:1544, 2012 Tipton M, Cohen SA, Chelmow 0: Wound infection in the obese pregnant woman. Semin Perinatol 35:345, 2011 Tonidandel A, Bootht], D'Angelo R, et al: Anesthetic and obstetric outcomes in morbidly obese parturients: a 20-year follow-up retrospective cohort study. Int] Obstet Anesth 23:357, 2014 Turan OM, Rosenbloom ], Galeyt]L, et al: he relationship between rostral retraction of the pannus and outcomes at cesarean section. Amt] Perinatol 33:951,t2016


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Obstentrics_Williams. Turan OM, Rosenbloom ], Galeyt]L, et al: he relationship between rostral retraction of the pannus and outcomes at cesarean section. Amt] Perinatol 33:951,t2016 Valent M, DeArmond e, Houston ]M, et al: Efect of post-cesarean delivery cephalexin and metronidazole on surgical site infection among obese women. A randomized trial. ]AMA 318: 1026, 2017 Van Mieghem T, Van Schoubroeck 0, Depiere M, et al: Fetal cerebral hemorrhage caused by vitamin K deiciency after complicated bariatric surgety. Obstet Gynecol 11t2:434, 2008 Vannevel V, Jans G, Bialecka M, et al: Internal herniation in pregnancy after gastric bypass. A systematic review. Obstet Gynecol 127: 10 13, 2016 Wang e, Wei Y, Zhang X, et al: A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in ovetweight and obese women. Am ] Obstet Gynecol 21t6:340, 2017


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Obstentrics_Williams. Wax ]F, Pinette MG, Cartin A: Roux-en-Y gastric bypass-associated bowel obstruction complicating pregnancy-an obstetrician's map to the clinical mineield. Am] Obstet GynecoIt208:265, 2013 Weichartt] and Hartge DR: Obstetrical sonography in obese women: a review. ] Clin Ultrasound 39:209, 2011 Weisst]L, Malon FD, Emig 0, et al: Obesity, obstetric complications and cesarean delivery rate-a population based screening study. FASTER Research Consortium. Am J Obstet Gynecol 190: 1 091, 2004 Wolfe H, Timofeev ], Tefera E, et al: Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Am] Obstet Gynecol 211:53.e1, 2014 Wolfe KB, Rossi A, Warshak CR: he efect of maternal obesity on the rate of failed induction oflabor. Am] Obstet Gynecol 205:128.el, 2011 Yang X, Li M, Haghiac M, et a1: Causal relationship between obesity-related traits and TLR-4-driven responses at the maternal-fetal interface. Diabetologia 59:2459,t2016


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Obstentrics_Williams. Yang X, Li M, Haghiac M, et a1: Causal relationship between obesity-related traits and TLR-4-driven responses at the maternal-fetal interface. Diabetologia 59:2459,t2016 Yao R, Ananth CV, Park BY, et al: Obesity and the risk of still birth: a population-based cohort study. Am] Obstet Gynecol 210:457.e1, 2014 YiY, Li QF, Zhang], et al: A meta-analysis of maternal and fetal outcomes of pregnancy after bariatric surgery. Int] Gynaecol Obstet 130:3, 2015 Young OM, Shaik IH, Twedt R, et al: Pharmacokinetics of cefazolin prophylaxis in obese gravidae at time of cesarean delivery. Am ] Obstet Gynecol 213:541.el,t2015 Younossi ZM, Koenig AB, Abdelarif 0, et al: Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology 64:73,t2016 PHYSIOLOGICAL CONSIDERATIONS IN PREGNANCY.. . 948 DISEASE ................... 949


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Obstentrics_Williams. PHYSIOLOGICAL CONSIDERATIONS IN PREGNANCY.. . 948 DISEASE ................... 949 PERIPARTUM MANAGEMENT CONSIDERATIONS ..... 951 SURGICALLY DISEASE.. . . . . . . . . . 954 VALVULAR HEART DISEASE ...................... 955 CONGENITAL HEART DISEASE . . . . . . . . . . . . . . . . . . . . 958 PULMONARY HYPERTENSION . . . . . . . . . . . . . . . . . . . . 960 CARDIOMYOPATHIES ........................... 962 HEART FAILURE ................................ 964 INFECTIVE ENDOCARDITIS ....................... 965 ARRHYTHMIAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965 DISEASES OF THE AORTA ........................ 967 ISCHEMIC HEART DISEASE . . . . . . . . . . . . . . . . . . . . . . . 968 Some authorities recommend that women suering rom heart lesions be dissuaded rom marriage. This, however, appears to be an extreme view, though, of course, when the lesion is serious and the compensation auly, the dangers of childbearing should be caruly explaine.


Obstentrics_Williams

Obstentrics_Williams. -J. Whitridge Williams (1903) As Williams recognized more than a century ago, pregnancy in those with signiicant heart disease can be extremely hazardous and may lead to decompensation and death. In an analysis of maternal mortality in the United States between 2011 and 2013, the causes previously responsible for most maternal deaths-hemorrhage, hypertensive disorders, and embolism-continued to show declining rates. In contrast, deaths attributable to cardiovascular diseases were responsible for approximately 26 percent of all pregnancy-related deaths (Creanga, 2017). Cardiovascular diseases also account for significant maternal morbidity and are a prominent reason for obstetrical intensive care unit admissions (Small, 2012).


Obstentrics_Williams

Obstentrics_Williams. The rising prevalence of cardiovascular diseases complicating pregnancy is likely multifactorial and includes the higher rates of obesity, hypertension, and diabetes (Klingberg, 2017). Indeed, according to the National Center for Health Statistics, almost half of adults aged 20 and older have at least one risk factor for cardiovascular disease (Fryar, 2012). Another related reason is delayed childbearing. Last, as discussed subsequently (p. 958), an increasing number of women with congenital heart disease are now becoming pregnant.


Obstentrics_Williams

Obstentrics_Williams. he marked pregnancy-induced anatomical and functional changes in cardiac physiology can have a profound efect on underlying heart disease (Chap. 4, p. 60). Some of these changes are listed in Table 49-1. Importantly, cardiac output increases approximately 40 percent during pregnancy. Almost half of this total takes place by 8 weeks' gestation and is maximal by midpregnancy (Capeless, 1989). his early rise stems from augmented stroke volume, which results from lowered vascular resistance. Later in pregnancy, resting pulse and stroke volume are even higher because of greater end-diastolic ventricular volume that results from pregnancy hypervolemia. hese changes translate to a cardiac output that enlarges across pregnancy to TABLE 49-'. Hemodynamic Changes in 10 Normal Pregnant Women at Term Compared with Repeat Values Obtained 12 Weeks pregnant women because they do not take into account the spherical remodeling characteristic of normal pregnancy (Savu, 2012; Stewart, 2016).


Obstentrics_Williams

Obstentrics_Williams. Adjusting for these geometrical changes, Melchiorre and coworkers (2016) studied normal cardiac echocardiographic indings in 559 nulliparas at four points during pregnancy and again at 1 year postpartum. At term, signiicant chamber diastolic dysfunction and impaired myocardial relaxation were evident in approximately 18 and 28 percent of the women Data from Clark, 1989. average 40 percent higher at term. hese adaptations are even more profound in multifetal pregnancies (Kametas, 2003; Kuleva, 2011). Importantly, intrinsic left ventricular contractility does not change. hus, normal left ventricular function is maintained during pregnancy. Namely, pregnancy is not characterized by hyperdynamic function or a high cardiac-output state.


Obstentrics_Williams

Obstentrics_Williams. Women with underlying cardiac disease may not always accommodate these changes, and ventricular dysfunction leads to cardiogenic heart failure. A few women with severe cardiac dysfunction can experience evidence of heart failure before midpregnancy. In others, heart failure may develop after 28 weeks' gestation, when pregnancy-induced hypervolemia and cardiac output reach their maximum. In most, however, heart failure develops peripartum, when labor, delivery, and several common obstetrical conditions add undue cardiac burdens. Some of these include preeclampsia, hemorrhage and anemia, and sepsis.


Obstentrics_Williams

Obstentrics_Williams. Ventricular volumes and mass accrue to accommodate pregnancy-induced hypervolemia. his is reflected by greater end-systolic and end-diastolic dimensions. At the same time, however, septal thickness and ejection fraction are unchanged. his is because these alterations are accompanied by substantive ventricular remodeling-plasticiy-which is characterized by eccentric expansion of left-ventricular mass that averages 30 to 35 percent near term. All of these adaptations return to prepregnancy values within a few months postpartum.


Obstentrics_Williams

Obstentrics_Williams. Certainly for clinical purposes, ventricular function during pregnancy is normal as estimated by the Braunwald ventricular function graph depicted in Figure 4-9 (p. 61). For given illing pressures, there is appropriate cardiac output so that cardiac function during pregnancy is eudynamic. In nonpregnant subjects with a normal heart who sustain a high-output state, the left ventricle undergoes longitudinal remodeling, and echocardiographic functional indices of its deformation provide normal values. In pregnancy, there instead appears to be spherical remodeling, and these calculated indices that measure longitudinal deformation are depressed. Thus, normal nonpregnant indices are likely inaccurate when used to assess function in studied, respectively. Moreover, a significant proportion of women studied demonstrated a drop in stroke volume index and a tendency toward eccentric remodeling. hese indings suggest cardiovascular maladaptation to the increased volume demands in a substantial


Obstentrics_Williams

Obstentrics_Williams. women studied demonstrated a drop in stroke volume index and a tendency toward eccentric remodeling. hese indings suggest cardiovascular maladaptation to the increased volume demands in a substantial proportion of apparently normal pregnancies. Of note, signiicant dyspnea at rest was reported by 7.4 percent of the women at term, most of whom had chamber diastolic dysfunction. Cardiac function and all signs of dyspnea fully recovered at 1 year postpartum.


Obstentrics_Williams

Obstentrics_Williams. Cardiac magnetic resonance (MR) imaging increasingly is used to evaluate cardiac structure and function. Stewart and associates (2016) performed cardiac MR imaging studies in 23 women longitudinally across pregnancy and at 12 weeks postpartum. Compared with studies performed at 12 to 16 weeks' gestation, left ventricular mass grew significantly for both normal-weight and overweight women. he calculated geometrical ratio of left ventricular mass to left ventricular end-diastolic volume demonstrated concentric remodeling throughout gestation, which resolved by 12 weeks' postpartum. he right ventricle also remodels (Martin, 2017) . Taken together, these observations likely mean that pregnancy causes a mixture of eccentric and concentric ventricular remodeling.


Obstentrics_Williams

Obstentrics_Williams. he physiological adaptations of normal pregnancy can induce symptoms and alter clinical indings that may confound the diagnosis of heart disease. For example, in normal pregnancy, functional systolic heart murmurs are common, respiratory efort is accentuated, edema frequently accrues in lower extremities after midpregnancy, and fatigue and exercise intolerance often develop. Some systolic flow murmurs can be loud, and normal changes in the various heart sounds depicted in Figure 49-1 may erroneously suggest cardiac disease. In con trast, clinical findings that are more likely to suggest heart disease are listed in Table 49-2. Noninvasive cardiovascular studies such as electrocardiography, chest radiography, and echocardiography will provide the data necessary for evaluation in most women.


Obstentrics_Williams

Obstentrics_Williams. Noninvasive cardiovascular studies such as electrocardiography, chest radiography, and echocardiography will provide the data necessary for evaluation in most women. In the electrocardiogram (ECG) , an average 15-degree leftaxis deviation is found as the diaphragm is elevated in advancing pregnancy. Other indings, depicted in Figure 49-2, include a reduced PR interval, inverted or flattened T waves, and a Q wave in lead DIll (Angeli, 2014). Pregnancy does not alter voltage indings. Atrial and ventricular premature contractions are relatively frequent (Carruth, 1981). FIGURE 49-1 Normal cardiac examination findings in the pregnant woman. Sl = first sound; M1 = mitral first sound; S2 = second sound; P2 = pulmonary second sound. (Data from Gei, 2001; Hytten, 1991o.) TABLE 49-2. Clinical Indicators of Heart Disease During Pregnancy �� + Syncope Leftward deviation of the mean QRS axis .' I,,l, Clubbing of fingers


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Obstentrics_Williams. TABLE 49-2. Clinical Indicators of Heart Disease During Pregnancy �� + Syncope Leftward deviation of the mean QRS axis .' I,,l, Clubbing of fingers Q wave in lead 0'1" (Reproduced with permission from Angeli F, Angeli E, Verdecchia P: Electrocardiographic changes in hypertensive disorders of pregnancy, Hypertens Res. 2014 Nov;37(11 ):973-975.) 0001 ...0001 ",' FIGURE 49-2 Normal electrocardiograph (ECG) adaptations durPersistent tachycardia and/or arrhythmia ing pregnancy, including a reduced mean PR interval, increased Persistent split second sound heart rate, left axis deviation, inverted or flattened T waves and a With radiography, anteroposterior (AP) and lateral chest radiographs are useful, and when a lead apron shield is used, fetal radiation exposure is minimal. Gross cardiomegaly can usually be excluded, but slight heart enlargement cannot be detected accurately because the heart silhouette normally is larger in pregnancy. his is accentuated further with a portable


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Obstentrics_Williams. AP chest radiograph. Echocardiography is now widely used and permits accurate diagnosis of most heart diseases during pregnancy. Some nor the dimensions of all cardiac chambers, a slight but signii cant growth in left ventricular mass, and greater tricuspid and mitral valve regurgitation (Grewal, 2014). Of note, systolic function normally does not change. Savu (2012) and Vitarelli diographic parameters for pregnancy, which are listed in the Appendix (p. 1261). In some situations, such as complex con genital heart disease, transesophageal echo cardiography may be useful. Cardiovascular MR imaging, compared with echocardiography, is associated with higher reproducibility and is less hindered by ventricular geometry and body habitus. The right ventricle can also be assessed (Nelson, 2017). Ducas and associates (2014) have published normal reference values for pregnancy.


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Obstentrics_Williams. Of other studies, albumin or red cells tagged with technetium-99m are rarely needed during pregnancy to evaluate ventricular function. That said, the estimated fetal radiation exposure from nuclear medicine studies of myocardial perfusion is negligible. It is safe to perform cardiac catheterization with limited fluoroscopy time. During coronary angiography, the mean radiation exposure to the unshielded abdomen is 1.5 mGy, and less than 20 percent of this reaches the fetus (European Society of Cardiology, 2011). Shortening the fluoroscopic time may help to minimize radiation exposure (Raman, 2015; Tuzcu, 2015). In women with clear indications, any minimal theoretical fetal risk is outweighed by maternal beneits (Chap. 46, p. 906). • Classification of Functional Heart Disease


Obstentrics_Williams

Obstentrics_Williams. • Classification of Functional Heart Disease No clinically applicable test accurately measures functional cardiac capacity. The clinical classification of the New York Heart Association (NYHA) is based on past and present disability and is uninfluenced by physical signs: • Class I. Uncompromised-no limitation of physical activiy: These women do not have symptoms of cardiac insuiciency or experience anginal pain. Class II. Slight limitation of physical activiy: These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort in the form of excessive fatigue, palpitation, dyspnea, or anginal pain results. Class III. Marked limitation of physical activiy: These women are comfortable at rest, but less than ordinary activity causes excessive fatigue, palpitation, dyspnea, or anginal pain.


Obstentrics_Williams

Obstentrics_Williams. Class III. Marked limitation of physical activiy: These women are comfortable at rest, but less than ordinary activity causes excessive fatigue, palpitation, dyspnea, or anginal pain. Class IV. Severey compromised-inabiliy to peorm any physical activity without discomort: Symptoms of cardiac insufficiency or angina may develop even at rest. If any physical activity is undertaken, discomfort is increased. Cardiovascular Disorders 95.1


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Obstentrics_Williams. Cardiovascular Disorders 95.1 Siu and associates (2001 b) expanded the NYHA classification and developed a scoring system for predicting cardiac complications during pregnancy. The system derives from a Canadian prospective analysis of 562 pregnant women with heart disease during 617 pregnancies. Predictors of cardiac complications included: (1) prior heart failure, transient ischemic attack, arrhythmia, or stroke; (2) baseline NYHA class III or IV or cyanosis; (3) left-sided obstruction defined as mitral valve area <2 cmr, aortic valve area < 1.5 cmr, or peak left tion fraction <40 percent. The risk of pulmonary edema, sus tained arrhythmia, stroke, cardiac arrest, or cardiac death was substantially elevated with one of these factors and even more so with two or more. Khairy and colleagues (2006) reported similar indings.


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Obstentrics_Williams. An even more comprehensive risk stratification system is the tion of Cardiovascular Disease and Pregnancy (Table 49-3). It ceptional counseling. Lu (2015) and Pijuan-Domenech (2015) and their associates in their analyses concluded that the modi ied WHO classification provides the greatest predictive accu racy for cardiac complications during pregnancy.


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Obstentrics_Williams. Women with severe heart disease will beneit immensely from counseling before pregnancy, and they usually are referred for maternal-fetal medicine or cardiology consultation (Clark, 2012; Seshadri, 2012). Maternal mortality rates generally correlate directly with functional classification, and this relationship may change as pregnancy progresses. From the previously described Canadian study, Siu and colleagues (2001 b) observed signiicant worsening of NHA class in 4.4 percent of 579 pregnancies in which the baseline class was I or II. As described later, some women have life-threatening cardiac abnormalities that can be reversed by corrective surgery, and subsequent pregnancy becomes less dangerous. In other cases, such as women with mechanical valves taking warfarin, fetal teratogenic concerns predominate. Last, many congenital heart lesions are inherited as polygenic characteristics (Chap. 13, p. 268). Because of this, some women with congenital heart lesions give birth to similarly


Obstentrics_Williams

Obstentrics_Williams. predominate. Last, many congenital heart lesions are inherited as polygenic characteristics (Chap. 13, p. 268). Because of this, some women with congenital heart lesions give birth to similarly afected neonates, and the risk varies widely (Table 49-4).


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Obstentrics_Williams. In most instances, management involves a team approach with an obstetrician, cardiologist, anesthesiologist, and other specialists as needed. With complex lesions or other high-risk cases, evaluation by a multidisciplinary team is recommended early in pregnancy. Within this framework, both prognosis and management are influenced by the type and severity of the speciic lesion and by the maternal functional classiication. In some, pregnancy termination may be advisable. With rare exceptions, women in NYHA class I and most in class II negotiate pregnancy without morbidity. Special TABLE 49-3. World Health Organization (WHO) Risk Classification of Cardiovascular Disease and Pregnancy with Management Recommendations WHO l-Risk no higher than general population Uncomplicated, small, or mild: Mitral valve prolapse with no more than trivial mitral regurgitation Successfully repaired simple lesions:


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Obstentrics_Williams. WHO l-Risk no higher than general population Uncomplicated, small, or mild: Mitral valve prolapse with no more than trivial mitral regurgitation Successfully repaired simple lesions: WHO 2-Small increase in risk of maternal mortality If otherwise uncomplicated: • Individualized care similar to WHO categories 2 or 3 depending on lesion and disease severity WHO 3-Significantly increased risk of maternal Mechanical valve mortality or expert cardiac and obstetrical care Systemic right ventricle-congenitally corrected transposition, required simple transposition post Mustard or Senning repair WHO 4-Very high risk of maternal mortality or Pulmonary arterial hypertension termination discussed Previous peripartum cardiomyopathy with any residual impairment Marfan syndrome with aorta dilated >40 mm Pregnancy contraindicated. If pregnancy occurs, monthly or bimonthly cardiac and obstetrical monitoring


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Obstentrics_Williams. Marfan syndrome with aorta dilated >40 mm Pregnancy contraindicated. If pregnancy occurs, monthly or bimonthly cardiac and obstetrical monitoring Summarized from European Society of Gynecology, 201a1; Nanna, 2014; Thorne, 2006; World Health Organization, 201a0.


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Obstentrics_Williams. attention is directed toward both prevention and early recogCigarette smoking is prohibited. Illicit drug use may be parnition of heart failure. Of speciic risks, infection with sepsis ticularly harmful, an example being the cardiovascular efects syndrome can precipitate this. Moreover, bacterial endocardiof cocaine or amphetamines. In addition, intravenous drug use tis is a deadly complication of valvular heart disease (p. 965). raises the risk of infective endocarditis. Each woman is instructed to avoid contact with persons who Fortunately, women in NA class III and IV are uncomhave respiratory infections, including the common cold, and to mon today. In the prior Canadian study, only 3 percent of the report at once any evidence for infection. Pneumococcal and approximately 600 pregnancies were complicated by NA inluenza vaccines are recommended (Chap. 9, p. 172). class III heart disease, and no women had class IV when irst


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Obstentrics_Williams. TABLE 49-4. Risks for Fetal Heart Lesions Related to Afected Family Members Atrial septal defect 2.5 1.5 5-11 Patent ductus arteriosus 3 2.5 4 Coarctation of the aorta NS NS 14 Fallot tetralogy 2.5 1.5 2-3 NS = not stated. Data from Lupton, 2002. seen (Siu, 2001b). If a woman chooses pregnancy, she must understand the risks and is encouraged to be compliant with planned care. In some women, prolonged hospitalization or bed rest is often necessary. In general, vaginal delivery is preferred, and labor induction is usually safe (Thurman, 2017). From the large Registry on Pregnancy and Cardiac Disease, Ruys and coworkers (2015) planned cesarean delivery. Planned cesarean delivery conferred no advantage for maternal or neonatal outcome.


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Obstentrics_Williams. Pregnancy and Cardiac Disease, Ruys and coworkers (2015) planned cesarean delivery. Planned cesarean delivery conferred no advantage for maternal or neonatal outcome. Cesarean delivery is usually limited to obstetrical indications, and considerations are given for the speciic cardiac lesion, overall maternal condition, and availability of experienced anesthesia personnel and hospital capabilities. Some of these women tolerate major surgical procedures poorly and are best delivered in a unit experienced with management of complicated cardiac disease. Occasionally, pulmonary artery catheterization may be needed for hemodynamic monitoring (Chap. 47, p. 916). In our experiences, however, invasive monitoring is rarely indicated.


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Obstentrics_Williams. Based on her review, Simpson (2012) recommends cesarean delivery for women with the following: (1) dilated aortic root >4 cm or aortic aneurysm; (2) acute severe congestive heart failure; (3) recent myocardial infarction; (4) severe symptomatic aortic stenosis; (5) warfarin administration within 2 weeks of delivery; and (6) need for emergency valve replacement immediately after delivery. Although we agree with most of these, we have some caveats. For example, we prefer aggressive medical stabilization of pulmonary edema followed by vaginal delivery if possible. Also, warfarin anticoagulation can be reversed with vitamin K, plasma, or prothrombin concentrates.


Obstentrics_Williams

Obstentrics_Williams. During labor, the mother with signiicant heart disease should be kept in a semirecumbent position with a lateral tilt. Vital signs are taken frequently between contractions. Increases in pulse rate much above 100 beats per minute (bpm) or respiratory rate above 24 per minute, particularly when associated with dyspnea, may suggest impending ventricular failure. For evidence of cardiac decompensation, intensive medical management must be instituted immediately. Delivery itself does not necessarily improve the maternal condition and, in fact, may worsen it. Moreover, emergency cesarean delivery may be particularly hazardous. Clearly, both maternal and fetal status must be considered in the decision to hasten delivery under these circumstances.


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Obstentrics_Williams. Relief from pain and from apprehension is important. Although women, continuous epidural analgesia is recommended for most. The major problem with conduction analgesia is mater nal hypotension (Chap. 25, p. 491). This is especially danger ous in women with intracardiac shunts in whom low may be reversed. Hypotension can also be life-threatening if there is pulmonaY arterial hypertension or aortic stenosis because ven tricular output is dependent on adequate preload. In women with these conditions, narcotic regional analgesia or general anesthesia may be preferable.


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Obstentrics_Williams. For vaginal delivery in women with only mild cardiovas cular compromise, epidural analgesia given with intravenous sedation oten suices. his has been shown to minimize intra uum-assisted delivery. Subarachnoid blockade is not generally recommended in women with significant heart disease due to associated hypotension. For cesarean delivery, epidural analge sia is preferred by most clinicians with caveats for its use with pulmonary arterial hypertension (p. 962).


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Obstentrics_Williams. Cardiovascular decompensation during labor may manifest as pulmonary edema with hypoxia or as hypotension, or both. The proper therapeutic approach depends on the speciic hemodynamic status and the underlying cardiac lesion. For example, decompensated mitral stenosis with pulmonary edema due to luid overload is often best treated with aggressive diuresis. If precipitated by tachycardia, heart rate control with �-blocking agents is preferred. Conversely, the same treatment in a woman sufering decompensation and hypotension due to aortic stenosis could prove fatal. Unless the underlying pathophysiology is understood and the cause of the decompensation is clear, empirical therapy may be hazardous.


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Obstentrics_Williams. Women who have shown little or no evidence of cardiac compromise during pregnancy, labor, or delivery may still decompensate postpartum. Fluid mobilized into the intravascular compartment and reduced peripheral vascular resistance place higher demands on myocardial performance. Therefore, meticulous care is continued into the puerperium (Keizer, 2006; Zeeman, 2006). Postpartum hemorrhage, anemia, infection, and thromboembolism are much more serious complications with heart disease. Indeed, these factors often act in concert to precipitate postpartum heart failure. In addition, sepsis and severe preeclampsia cause or worsen pulmonary edema because of endothelial activation and capillary-alveolar leakage (Chap. 47, p. 917).


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Obstentrics_Williams. For puerperal tubal sterilization after vaginal delivery, the procedure can be delayed up to several days to ensure that the mother has normalized hemodynamically and that she is afebrile, not anemic, and ambulating normally. Alternatively, for those desiring future fertility, detailed contraceptive advice is available in the u. Medical Eligibiliy Criteria or Contraceptive Use guidelines (Curtis, 2016). Most clinically signiicant congenital heart lesions are repaired during childhood. Examples of those frequently not diagnosed until adulthood include atrial septal defects, pulmonic stenosis, bicuspid aortic valve, and aortic coarctation (Brickner, 2014). In some cases, the defect is mild and surgery is not required. In others, a significant anomaly is amenable to corrective surgery, performed ideally before pregnancy. In rare instances, surgical corrections are necessary during pregnancy.


Obstentrics_Williams

Obstentrics_Williams. Numerous reports describe subsequent pregnancy outcomes in women who have a prosthetic mitral or aortic valve. The type of valve, either mechanical or biological, is paramount. From one review, the overall estimated maternal mortality rate was 1.2 percent. he rate was 1.8 percent in the mechanical valve subgroup and 0.7 percent in the bioprosthetic subgroup (Lawley, 2015). Using the Registry of Pregnancy and Cardiac Disease, the maternal mortality rate was 1.4 percent in women with a mechanical heart valve and 1.5 percent in women with a tissue heart valve (van Hagen, 2015). Mechanical heart valve thrombosis complicated 4.7 percent. In total, only 58 percent with a mechanical heart valve had a pregnancy free of serious adverse events compared with 79 percent of patients with a tissue heart valve (Table 49-5). Because of thrombosis risks, anticoagulation may be requisite, but its complications are described in the next section. Thus, pregnancy is undertaken only ater serious


Obstentrics_Williams

Obstentrics_Williams. heart valve (Table 49-5). Because of thrombosis risks, anticoagulation may be requisite, but its complications are described in the next section. Thus, pregnancy is undertaken only ater serious consideration for women with a prosthetic mechanical valve.


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Obstentrics_Williams. Bouhout and coworkers (2014) reported the outcomes of 27 pregnancies in 14 women who underwent an aortic valve replacement prior to pregnancy. Seven of the 27 pregnancies occurred in five women with a mechanical prosthesis. Complications in this group included two embolic myocardial infarctions and one each of miscarriage, postpartum hemorrhage, placental abruption, and preterm birth. In the bioprosthetic group, nine miscarriages, two hospitalizations for syncope, and one preterm birth were noted.


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Obstentrics_Williams. Porcine tissue valves are safer during pregnancy, primarily because thrombosis is rare and anticoagulation is not required (see Table 49-5). Despite this, valvular dysfunction with cardiac deterioration poses a serious risk. Another drawback is that bioprostheses are less durable than mechanical ones, and valve replacement longevity averages 10 to 15 years. Cleuziou and colleagues (2010) concluded that pregnancy does not accelerate the risk for replacement. But, Nappi and associates (2014) found an association between pregnancy and valve deterioration in women with cryopreserved mitral homograft valves. his is critical for women with mechanical prosthetic valves . Unfortunately, warfarin is the most efective anticoagulant for preventing maternal thromboembolism but causes harmful fetal efects (Chap. 12, p. 247). Anticoagulation with heparin is less hazardous for the fetus, however, the risk of maternal thromboembolic complications is much higher (McLintock, 2011).


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Obstentrics_Williams. Warfarin is teratogenic and causes miscarriage, stillbirths, and fetal malformations. In one study of 71 women given warfarin throughout pregnancy, the rates of miscarriage were 32 percent; stillbirth, 7 percent; and embryopathy, 6 percent (Cotrufo, 2002). The risk was highest when the mean daily dose of warfarin exceeded 5 mg. Similarly, the American College of Cardiology and the American Heart Association estimate that the risk of embryopathy is dose dependent, with a lower risk-less than 3 percent-if the dose of warfarin is :;5 mg/d (Nishimura, 2014). If the dosage is >5 mg/d, the risk of embryopathy exceeds 8 percent.


Obstentrics_Williams

Obstentrics_Williams. Anticoagulation for mechanical valves using low-dose unfractionated heparin is definitely inadequate and carries a high associated maternal mortality rate (Chan, 2000; Iturbe-Alessio, 1986). Even ful anticoagulation with either unfractionated heparin (UFH) or one of the low-molecular-weight heparins (LMWH) is associated with valvular thrombosis (Leyh, 2002, 2003; Rowan, 2001). But, compliance with twice-daily dosing and therapeutic monitoring may have contributed (McLintock, 2014). hus, if full anticoagulation with dose-adjusted UFH or LMWH is used, meticulous monitoring is recommended. The activated partial thromboplastin time (aPTT) should be at least 2 times control or anti-Xa levels should be 0.8 to 1.2 U/mL at aData from the Registry of Pregnancy and Cardiac Disease. Data from van Hagen, 2015. 4 to 6 hours postdose (Nishimura, 2014).


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Obstentrics_Williams. Several diferent treatment options-none of which are completely ideal-are principally based on consensus opinion. Two are from the American College of Chest Physicians and the other jointly from the merican College of Cardiology and the American Heart Association (Bates, 2012; Nishimura, 2014). Any of four regimens is recommended. First, adjusted-dose LMWH is given twice daily, with a peak anti-Xa level drawn 4 hours ater dosing. In another, adjusted UFH is dosed every 12 hours to keep the midinterval aPTT twice control or anti Xa level between 0.35 0.70 U/mL. As a third option, LMWH or UFH is given as just described until 13 weeks, and then warfarin is substituted until near delivery, at which time it is replaced by LMWH or UFH. Last, in women judged to carry a high risk of thrombosis and for whom the eicacy and safety of heparins are concerns, warfarin is suggested throughout pregnancy. Heparin is then substituted close to delivery. In addition, aspirin, 75 to 100 mg, is given


Obstentrics_Williams

Obstentrics_Williams. and for whom the eicacy and safety of heparins are concerns, warfarin is suggested throughout pregnancy. Heparin is then substituted close to delivery. In addition, aspirin, 75 to 100 mg, is given daily.


Obstentrics_Williams

Obstentrics_Williams. Heparin is discontinued just before delivery. If delivery supervenes while the anticoagulant is still efective, and extensive bleeding is encountered, then protamine sulfate is given intravenously. nticoagulant therapy with warfarin or heparin may be restarted 6 hours following vaginal delivery, usually with no problems. Following cesarean delivery, full anticoagulation is withheld, but the optimal duration is not exactly nown. The American College of Obstetricians and Gynecologists (2017) advises resuming unfractionated or low-molecular-weight heparin 6 to 12 hours ater cesarean delivery. It is our practice, however, to wait at least 24 hours following a major surgical procedure. Because warfarin, LMWH, and UFH do not accumulate in breast milk, they do not induce an anticoagulant efect in the newborn. hese anticoagulants are compatible with breastfeeding (American College of Obstetricians and Gynecologists, 2017).


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Obstentrics_Williams. Although usually postponed until after delivery, valve replacement or other cardiac surgery during pregnancy may be lifesaving. Several reviews conirm that such surgery is associated with major maternal and fetal morbidity and mortality. At the Mayo Clinic between 1976 and 2009,r21 pregnant women underwent cardiothoracic surgery requiring cardiopulmonary bypass Oohn, 2011). The procedures included valve replacements, myxoma excisions, aneurysm repairs, patent foramen ovale closure, prosthetic aortic valve thrombectomy, and septal myectomy. Median cardiopulmonary bypass time was 53 minutes, with a range of 16 to 185 minutes. One woman died 2 days ater surgery, three fetuses died, and 52 percent were delivered before 36 weeks' gestation. Elassy and associates (2014) described 23 women who underwent urgent open cardiac surgery for severe valve malfunction. Two women and 10 fetuses-all at a gestational age below 28 weeks-died before hospital discharge. Only six fetuses were delivered at


Obstentrics_Williams

Obstentrics_Williams. underwent urgent open cardiac surgery for severe valve malfunction. Two women and 10 fetuses-all at a gestational age below 28 weeks-died before hospital discharge. Only six fetuses were delivered at term. To optimize outcomes, Chandrasekhar and coworkers (2009) recommend that surgery be elective when possible, pump low rate should remain >2.5 Llmin/m2, normothermic perfusion pressure should exceed 70 mm Hg, and hematocrit should be keptr> 28 volumes percent.


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Obstentrics_Williams. Many successful pregnancies have followed cardiac transplantation (Abdalla, 2014; Vos, 2014). The current recommendations from The International Society of Heart and Lung Transplantation do not discourage pregnancy in stable heart transplant recipients who are more than 1 year posttransplant (Costanzo, 2010). Obviously, a highly specialized level of care with a mul tidisciplinary team is necessary.


Obstentrics_Williams

Obstentrics_Williams. he transplanted heart appears to responds normally to preg nancy-induced alterations (Key, 1989; Kim, 1996). Despite this, complications are common during pregnancy (Dashe, 1998). Of 53 pregnancies in 37 heart recipients, almost half developed hypertension, and 22 percent sufered at least one rejection episode during pregnancy (Armenti, 2002; Miniero, 2004). They were delivered-usually by cesarean-at a mean of 37 to 38 weeks' gestation. hree fourths of neonates were liveborn. At follow-up, at least ive women had died more than 2 years postpartum. Another analysis of 25 such women with 42 pregnancies found no maternal deaths. Major complica tions included two rejections during the early puerperium, two cases of renal failure, and 11 spontaneous abortions (Estensen, 2011). Five women died 2 to 12 years after delivery. And from the United Kingdom, Mohamed-Ahmed and colleagues (2014) identiied 14 women with transplants between 2007 and 2011r.


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Obstentrics_Williams. Graft rejections occurred in two women, one of whom died. Rheumatic fever is uncommon in the United States because of less crowded living conditions, penicillin availability, and evolution of nonrheumatogenic streptococcal strains. Still, it remains the chief cause of serious mitral valvular disease in women of childbearing age in the nonindustrialized world (Nanna, 2014; Roeder, 2011) . Rheumatic endocarditis causes most mitral stenosis lesions. The normal mitral valve surface area is 4.0 cmr, and when stenosis 2 narrows this to <2.5 cmr, symptoms usually develop (Desai, 2000). The contracted valve impedes blood low from the left atrium to the ventricle.


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Obstentrics_Williams. With more severe stenosis, the left atrium dilates, let atrial pressure is chronically elevated, and signiicant passive pulmonary hypertension develops (Table 49-6). These women have a relatively ixed cardiac output, and thus the increased preload of normal pregnancy and other factors that raise cardiac output may cause ventricular failure and pulmonary edema. Indeed, a fourth of women with mitral stenosis have cardiac failure for the irst time during pregnancy (Caulin-Glaser, 1999). he resulting pulmonary venous hypertension and pulmonary edema create symptoms of dyspnea, fatigue, palpitations, cough, and hemoptysis. The classic murmur may not be heard in some women, and this clinical picture at term may be confused with idiopathic peripartum cardiomyopathy (Cunningham, 1986,r2012).


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Obstentrics_Williams. Also with signiicant stenosis, tachycardia shortens ventricular diastolic illing time and elevates the mitral gradient. his too may lead to pulmonary edema. Thus, sinus tachycardia is often treated prophylactically with 3-blocking agents. Atrial tachyarrhythmias, including ibrillation, are common in mitral stenosis and are treated aggressively. Atrial ibrillation also predisposes to mural thrombus formation and cerebrovascular embolization that can cause stroke (Chap. 60, p. 1161). Atrial thrombosis can develop despite a sinus rhythm (Hameed, 2005). Pregnancy Outcomes 66 newborns who were delivered at term had normal growth and development.


Obstentrics_Williams

Obstentrics_Williams. Pregnancy Outcomes 66 newborns who were delivered at term had normal growth and development. In general, complications are directly associated with the degree2 Labor and delivery are particularly stressful for women withofvalvular stenosis. Women with a mitral-valve area <2 cmrare symptomatic mitral stenosis (Fig. 49-3). Uterine contractionsat greatest risk (Siu, 2001b). In one study of 46 gravidas with increase cardiac output by increasing circulating blood volume. mitral stenosis, 43 percent developed heart failure, and 20 percent Pain, exertion, and anxiety cause tachycardia with possible ratedeveloped arrhythmias (Hameed, 2001). Fetal-growth restriction 2rrelated heart failure. Epidural analgesia for labor is ideal, but was more common in women with a mitral valve area < 1.0 cmr• fluid overload is avoided. Abrupt expansion in preload mayPrognosis is also related to maternal functional capacity.


Obstentrics_Williams

Obstentrics_Williams. raise pulmonary capillary wedge pressure and cause pulmonaryAmong 486 pregnancies complicated by rheumatic heart disedema. Wedge pressures rise immediately postpartum. Oneease-predominantly mitral stenosis-8 of 10 maternal deaths hypothesis for this suggests that the loss of the low-resistance were in women in NYHA classes III or IV (Sawhney, 2003). placental circulation couples with venous "autotransfusion"


Obstentrics_Williams

Obstentrics_Williams. placental circulation couples with venous "autotransfusion" Limited physical activity is generally recommended in women with mitral stenosis. If symptoms of pulmonary congesJ tion develop, activity is further reduced, dietary sodium is restricted, and diuretics are given (Siva, 2005). Also, �-blocker drug therapy slows the ventricular response to activity. If new onset atrial ibrillation develops, intravenous verapamil, 5 to 10 mg, is given, or electrocardioversion is performed. For chronic :) 15 ibrillation, digoxin, a �-blocker, or a calcium-channel blocker ; E can slow ventricular response. Therapeutic anticoagulation is = E 10 indicated with persistent ibrillation, left atrial thrombus, and/ ) A B C or a history of embolism (Nanna, 2014). ..m 5 0 Surgical intervention is considered for women with sympc tomatic severe mitral stenosis and in those with lesser degrees E0 of mitral stenosis-mitral-valve area 1.5 to 2.0 cm2-compli.


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Obstentrics_Williams. hypertension. Balloon valvuloplasty is preferred if the valve is pliable (Bui, 2014). In one review of 71 pregnant women with surements (red graph line) in eight women with mitral valve stenosis. Shaded yellow and blue boxes are mean (± 1 SO) pres neous valvuloplasty, 98 percent were either NYHA class I or sures in nonlaboring normal women at term. A. First-stage labor. II at delivery (Esteves, 2006). At a mean of 44 months, the B. Second-stage labor 15 to 30 minutes before delivery. C. Postpartotal event-free maternalsurvival rate was 54 percent. However, tum 5 to 15 minutes. D. Postpartum 4 to 6 hours. E. Postpartum 18 eight women required another surgical intervention. All of the to 24 hours. (Data from Clark, 1985, 1989.) from a now-empty, contracted uterus and from the lower extremities and pelvis (Clark, 1985). Most prefer vaginal delivery in women with mitral stenosis.


Obstentrics_Williams

Obstentrics_Williams. Most prefer vaginal delivery in women with mitral stenosis. Elective induction is reasonable so that labor and delivery are attended by a scheduled, experienced team. With severe steno sis and chronic heart failure, insertion of a pulmonary artery catheter may help guide management.


Obstentrics_Williams

Obstentrics_Williams. A trivial degree of mitral insuiciency is found in most normal patients. But if mitral valve lealets align improperly during systole, abnormal degrees of mitral regurgitation can develop. his is eventually followed by left ventricular dilation and eccentric hypertrophy (see Table 49-6). Acute mitral insuiciency is caused by chordae tendineae rupture, papillary muscle infarction, or leaflet perforation from infective endocarditis. Chronic mitral regurgitation, in contrast, may derive from rheumatic fever, connective tissue diseases, mitral valve prolapse, or left ventricular dilation of any etiology-for example, dilated cardiomyopathy. Less common causes include a calcified mitral annulus, possibly some appetite suppressants, and in older women, ischemic heart disease. Mitral valve vegetations-Libman-Sacks endocarditis-are relatively common in women with antiphospholipid antibodies (Shrof, 2012). These sometimes coexist with systemic lupus erythematosus.


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Obstentrics_Williams. In nonpregnant patients, symptoms from mitral valve insufficiency are rare, and valve replacement is seldom indicated unless infective endocarditis develops. During pregnancy, mitral regurgitation is similarly well tolerated, probably because the lowered systemic vascular resistance yields less regurgitation. Heart failure rarely develops during pregnancy, and occasionally tachyarrhythmias or severely depressed systolic function require treatment. This diagnosis implies the presence of a pathological connective tissue disorder-often termed myxomatous degenerationwhich may involve the valve lealets themselves, the annulus, or the chordae tendineae. Mitral insuiciency may develop. Most women with mitral valve prolapse are asymptomatic and are diagnosed during routine examination or echocardiography. he few women with symptoms have anxiety, palpitations, atypical chest pain, dyspnea with exertion, and syncope (Guy, 2012).


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Obstentrics_Williams. Pregnant women with mitral valve prolapse rarely have cardiac complications. Hypervolemia may even imptove alignment of the mitral valve, and women without pathological myxomatous degeneration generally have excellent pregnancy outcomes (LdniakSobelga, 2004). For women who are symptomatic, �-blocking drugs diminish sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias.