Maternal Obesity 2

Series
Maternal obesity 2
Clinical management of pregnancy in the obese mother:
before conception, during pregnancy, and post partum
Ronald Ching Wan Ma, Maria Ines Schmidt, Wing Hung Tam, Harold David McIntyre, Patrick M Catalano
The global epidemic of obesity has led to an increasing number of obese women of reproductive age. Obesity is Lancet Diabetes Endocrinol 2016;
associated with reduced fertility, and pregnancies complicated by maternal obesity are associated with adverse 4: 1037–49
outcomes, including increased risk of gestational diabetes, pre-eclampsia, preterm birth, instrumental and caesarean Published Online
October 12, 2016
births, infections, and post-partum haemorrhage. The medical and obstetric management of obese women is focused
http://dx.doi.org/10.1016/
on identifying, addressing, and preventing some of these associated complications, and is a daunting challenge given S2213-8587(16)30278-9
the high percentage of patients with obesity and few therapeutic options proven to improve outcomes in this See Online/Series
population. The UK’s National Institute for Health and Care Excellence guidelines and the American College of http://www.thelancet.com/
Obstetricians and Gynecologists recommend that all pregnant women follow a healthy diet, and consider at least half series/maternal-obesity
an hour of moderate physical activity per day during pregnancy. However, although obese women are often directed See Comment page 966
to seek the advice of a nutritionist and to limit gestational weight gain, guidelines for the management of pregnancy This is the second in a Series of
and delivery in this high-risk group are lacking. The post-partum period represents an important opportunity to four papers about maternal
obesity
optimise maternal health before the next pregnancy. As many of the physiological changes of pregnancy associated
Department of Medicine and
with maternal obesity are present from early pregnancy onward, reducing maternal obesity before conception is Therapeutics
probably the best strategy to decrease the health burden associated with maternal obesity. (Prof R C W Ma FRCP); Hong Kong
Institute of Diabetes and
Introduction metabolic health and fertility and decrease early Obesity (Prof R C W Ma);
Li Ka Shing Institute of Health
Maternal obesity, a nutritional and metabolic life-course pregnancy loss, as well as screening for medical problems Sciences (Prof R C W Ma); and
condition, has become an important public health such as diabetes. In early pregnancy, setting guidelines Department of Obstetrics and
problem, with consequences to the health and wellbeing for gestational weight gain through healthy eating and Gynaecology, The Chinese
of both mother and child (table 1).1–4 physical activity, and screening for fetal structural defects University of Hong Kong,
Hong Kong Special
Traditionally considered a problem of high-income is warranted. In mid-pregnancy, screening for obstetric Administrative Region, China
countries, maternal obesity has received greater attention conditions, such as gestational diabetes and pre- (W H Tam MD); Universidade
in low-income and middle-income countries (LMICs) in eclampsia, needs to be initiated in all pregnancies. As Federal do Rio Grande do Sul,
recent years. A systematic review and meta-analysis of gestation advances, preparation for delivery should Port Alegre, Brazil
(M I Schmidt MD); Mater Clinical
population-based cohort studies done in LMICs include assessment for fetal overgrowth, timing of School and Mater Research,
documents a double burden: maternal underweight is delivery, anaesthesia consultation, and assurance that the The University of Queensland,
associated with higher risk of preterm, low birthweight, delivery suite is appropriately staffed and equipped. Brisbane, QLD, Australia
and small for gestational age (SGA) birth, and by Intra-partum decisions regarding the course of labour, (H D McIntyre MD); and Center
for Reproductive Health, Case
contrast, maternal obesity increases the risk of caesarean delivery, and prophylactic antibiotics should be Western Reserve University and
gestational diabetes, pregnancy-induced hypertension, addressed. Post-partum attention in women who are MetroHealth Medical Center,
pre-eclampsia, caesarean delivery, and post-partum obese should be directed to the increased risk of Cleveland, OH, USA
(Prof P M Catalano MD)
haemorrhage.5,6 In 2008, there were almost three venous thromboembolism, difficulty with lactation,
overweight or obese women of childbearing age for each contraception, and depression. In addition to the need Correspondence to:
Prof Ronald C W Ma, Department
underweight woman in LMICs,7 which raises the for obstetric and medical expertise, very real practical of Medicine and Therapeutics,
question of whether maternal overweight is now more challenges exist in managing pregnancies in this ever- The Chinese University of
important than maternal underweight in influencing the increasing population, including involving occupational Hong Kong, Hong Kong Special
long-term chronic disease burden in these countries.8 health-care professionals in care delivery, and various Administrative Region, China
[email protected]
Table 2 classifies maternal overweight and obesity logistical challenges regarding the availability of
or
according to maternal BMI. appropriate facilities and equipment that could be
Prof Patrick M Catalano, Center
The optimal clinical management of the obese needed in providing care to this patient group.
for Reproductive Health, Case
pregnant woman involves care beyond that afforded to Western Reserve University and
the non-obese pregnant woman. Ideally, care should be Nutrition, lifestyle modification, and Metro Health Medical Center,
provided before, during, and after the pregnancy (figure). management of gestational weight gain Cleveland, OH 44109, USA
[email protected]
Although we believe that detailing routine obstetric Weight gain is an essential aspect of pregnancy, but
management is beyond the scope of this Review, we aim excessive gestational weight gain is associated with
to address issues that are of particular concern for the adverse pregnancy outcomes. Based on population-
obstetric management of obese women. These issues based studies, weight gain in pregnant adults is
include preconception weight management to improve inversely related to maternal pregravid BMI.9 An
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Series
Risk to mother Risk to offspring

Before conception and Reduced fertility; pregnancy loss ··
ante partum
Intra partum Obstructive sleep apnoea; gestational diabetes; pre-eclampsia; Congenital anomalies; small for gestational age; large for
gastro-oesophageal reflux disease; gestational hypertension; gestational age and macrosomia; preterm delivery
preterm delivery
Peri partum Operative delivery; caesarean delivery; failed vaginal birth after Fetal distress; adiposity; neonatal birth injuries
caesarean delivery; endometritis; wound disruption
Post partum Post-partum depression; venous thromboembolism; dyslipidaemia; Less likely to be breastfed; increased adiposity
hypertension; type 2 diabetes; osteoarthritis; obstructive sleep
apnoea; malignancies (eg, breast, endometrial, liver, colon,
haematological)
Long-term impact on .. Obesity; diabetes; hypertension; dyslipidaemia; autism
offspring4 spectrum disorder; cognitive abnormality
Table 1: Hazards of maternal obesity
glycaemia and adverse outcomes appears to differ

BMI in kg/m²
between ethnic groups, with one study proposing
Underweight <18·5
different glycaemic thresholds for diagnosis of
Normal 18·5–24·9 gestational diabetes in south Asian people.15
Overweight 25–29·9 In 2009, the IOM revised the gestational weight
Obese class I 30–34·9 guidelines on the basis of the increased incidence of
Obese class II 35–39·9 obesity in women of reproductive age (table 3).10 Because
Obese class III ≥40 obese women enter pregnancy with excess adipose
Table 2: Classification of maternal BMI and cutoffs for definition of tissue, the recommendation was to primarily meet the
maternal obesity obligatory accrual of water and protein. Approximately
50–60% of obese pregnant women gain in excess of the
IOM recommendations.16 Although some authors have
essential physiological weight gain during pregnancy is suggested that less weight gain than the current IOM
necessary for a healthy pregnancy, and consists of recommendations for obese women could improve
approximately 8 kg of water (increased plasma volume some perinatal outcomes,17 inadequate gestational
and amniotic fluid), 1 kg of protein (maternal, placental, weight gain in obese women might have detrimental
and fetal lean mass) plus variable amounts (1–6 kg) of effects, including an increased risk of SGA infants,18
adipose tissue.10 The increases in fat mass in normal lower birthweight and fat mass, and potentially of
weight pregnant women are required to meet the greater consequence, a decrease in lean body mass,
increased energy needs of late pregnancy and lactation. length, and head circumference.19 In general, inadequate
Estimates of adiposity in pregnancy should be based on weight gain and gestational weight loss should be
pre-pregnancy measures of height and weight. However, avoided for obese women.
with advancing gestation, BMI becomes a poorer Although both maternal obesity and excess gestational
estimate of maternal adiposity11 because of increased weight gain in a mother of normal pre-gestational BMI
water and fetoplacental components of gestational are associated with adverse pregnancy outcomes,
weight gain. On the basis of data published in 2016, obstetric management of obese mothers tends to focus
excess gestational weight gain beyond Institute of on those who enter pregnancy being obese, whereas
Medicine (IOM) guidelines in obese women will result those who enter pregnancy at a healthy BMI but gain
in increased adipose rather than lean body mass weight excess weight during gestation might not be as readily
accrual.12 Furthermore, because of the differences in identified. Greater awareness of the hazards of excess
body composition between various ethnic groups, WHO gestational weight gain and regular review of gestational
has discussed, but not endorsed, using lower criteria weight with advancing gestation could help to address
(increased risk for type 2 diabetes and cardiovascular this issue. In the UK, weight is often not routinely
disease at BMI between 22 kg/m² and ≤25 kg/m², and measured during pregnancy.20 The use of electronic
high risk at BMI between >25 kg/m² and 31 kg/m²) for health records with plotting of gestational weight gain
the classification of obesity in Asian women.13 These relative to IOM guidelines at each antenatal visit is
differences in classification are reflected by the higher being considered at many centres; although, a
prevalence of gestational diabetes at a relatively low randomised controlled trial (RCT)21 suggested that just
BMI for Asian populations than people of European repeatedly measuring weight without adequate
descent, and should be considered in clinical practice.14 guidance or support for appropriate gestational weight
Additionally, the association between maternal hyper- gain might not suffice.
1038 www.thelancet.com/diabetes-endocrinology Vol 4 December 2016

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Various interventions, including diet, lifestyle, and

drugs such as metformin, have been assessed with the Contraception; planned pregnancy
aim to prevent or reduce obesity or excessive weight gain
in pregnancy, and improve maternal and fetal outcomes.
The National Institute for Health and Care Excellence Transdisciplinary
The overweight or
(NICE) in the UK, as well as the American College of Multi-specialty strategy obese woman
Screening and/or control, or both
Obstetricians and Gynecologists (ACOG), recommend a during pregnancy Hypertension
healthy diet and at least half an hour of moderate Diabetes
Dyslipidaemia
physical activity per day during pregnancy. WHO defines
a healthy diet as one in which the proportion of energy Micronutrient or
intake from total fat is less than 30%, preferably from vitamin supplements
Regular exercise
Diet
unsaturated fats rather than saturated fats, with a fruit Optimising weight
and vegetable intake of at least 400 g per day, and at least
25 g of dietary fibre each day.22 In addition to these Figure: Optimising care for the overweight or obese woman: before conception, during, and after pregnancy
general recommendations, guidelines issued by the Optimal care for women who are obese or overweight should involve a transdisciplinary and multi-specialty care
approach, and should not be limited to managing the complications that arise during pregnancy. Recognising this
International Federation of Gynecology and Obstetrics
concept is key to improving long-term outcomes for both mother and offspring. This multidisciplinary approach
(FIGO) have highlighted the need to recognise maternal should include both medical (eg, hypertension, diabetes, dyslipidaemia) and social determinants of health
micronutrient deficiencies (eg, iron, iodine, folate, (eg, diet, exercise, pregnancy planning).
vitamin B12, calcium, and vitamin D) during all
pregnancies, and to address these deficiencies through
BMI (kg/m²; WHO Range of total Rates of weight gain* in second
interventions including dietary diversity, consumption criteria) weight gain and third trimesters (mean [range]
of fortified foods, and supplementation, as appropriate.23 (kg) in kg per week)
Appropriate nutritional advice for obese pregnant Underweight <18·5 12·7–18·1 0·45 (0·45–0·59)
mothers should also take into account cultural issues Normal weight 18·5–24·9 11·3–15·9 0·45 (0·36–0·45)
and diversity, and the fact that no single diet fits all is Overweight 25·0–29·9 6·8–11·3 0·27 (0·23–0·32)
important to note. Because of the effect of obesity on the Obese (includes all classes) ≥30·0 5·0–9·1 0·23 (0·18–0·27)
distribution and metabolism of folate, obese women can
benefit from higher doses of folate supplements (5 mg *These calculations assume a weight gain of 0·5–2·0 kg in the first trimester.
per day, from at least 1 month before conception and Table 3: US Institute of Medicine recommendations for gestational weight gain depending on the before
continuing during the first trimester).23 pregnancy BMI
A systematic review on lifestyle interventions to
manage weight during pregnancy found a significant
reduction in gestational weight gain (mean difference Diagnosis and management of gestational
–1·42 kg; 95% CI –0·95 to –1·89 kg; I²=80%) compared diabetes and diabetes in pregnancy
with the control group, with some suggestion of Diagnosis of gestational diabetes is increased in women
improved pregnancy outcomes for pre-eclampsia, with class I obesity (BMI 30–34·9 kg/m²; odds ratio
shoulder dystocia, gestational hypertension, and preterm [OR] 2·6, 95% CI 2·1–3·4) and class II obesity
birth.24 However, two large-scale RCTs, LIMIT25 and (BMI ≥35 kg/m²; OR 4·0, 3·1–5·2) compared with
UPBEAT,26 reported modest or no improvements in women with a BMI less than 30 kg/m².32 Hyperglycaemia
pregnancy outcomes, such as frequency of gestational in women with gestational diabetes is a result of an
diabetes or large for gestational age (LGA) infants, inadequate insulin response relative to decreased insulin
despite improvements in maternal diet and physical sensitivity. In general, obese women have decreased
activity, highlighting the fact that initiating lifestyle insulin sensitivity before and during pregnancy
changes during the second and third trimester of compared with normal weight women, which partly
pregnancy could be too late to alter the course of explains the increased incidence of gestational diabetes
pregnancy outcomes.1 The results of the Finnish in this population.
Gestational Diabetes Prevention Study (RADIEL),27 of An international consensus regarding the process and
269 obese women with a history of gestational diabetes, criteria for diagnosis of gestational diabetes remains
found that improvements in physical activity and dietary elusive, although the updated WHO criteria33 are the
quality reduced gestational diabetes incidence, but again most widely accepted worldwide. Table 4 shows the major
had no effect on maternal (eg, pre-eclampsia, gestational approaches for screening and diagnosis. One point of
hypertension) or neonatal (eg, birthweight) outcomes. agreement is that all obese women should be tested.
Interventions that are initiated before conception or Screening for gestational diabetes is generally recom-
during the first trimester might be more effective.27–30 mended at 24–28 weeks’ gestation, and screening for
Further discussions of the effect of lifestyle interventions both gestational diabetes and overt diabetes in early
during pregnancy can be found in a comment gestation should be considered among obese women,
accompanying this Series.31 women with impaired glucose tolerance, or those with a

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Early pregnancy testing Standard gestational diabetes Criteria for diagnosing gestational diabetes
test (second to third trimester)
WHO* (global) Yes. Diabetes and gestational 75 g OGTT Any of the following: fasting glucose concentration
diabetes ≥5·1 mmol/L; 1 h OGTT concentration ≥10·0 mmol/L;
2 h OGTT ≥8·5 mmol/L
ACOG* (USA) Yes in presence of risk factors, Two step: non-fasting 50 g glucose Fasting glucose concentration ≥5·3 mmol/L; for OGTT:
including maternal BMI ≥30 kg/m², challenge test, followed by 100 g 1 h glucose ≥10·0 mmol/L; 2 h glucose ≥8·6 mmol/L;
history of gestational diabetes OGTT if glucose challenge test 3 h glucose ≥7·8 mmol/L (two values ≥ threshold for
≥7·8 mmol/L diagnosis)
ADA (USA) Not specified WHO or ACOG approach* WHO or ACOG criteria*
Endocrine Society Yes. Aimed at detection of overt 75 g OGTT Any of the following: fasting glucose concentration
(USA) diabetes ≥5·1 mmol/L; 1 h OGTT ≥10·0 mmol/L; 2 h OGTT ≥8·5 mmol/L
NICE (UK) Only if previous gestational 75 g OGTT Either of these values: fasting glucose concentration
diabetes ≥5·6 mmol/L; 2 h OGTT ≥7·8 mmol/L
EBCOG (Europe) Yes. Aimed at detection of overt Either WHO or ACOG approach* Fasting glucose concentration* ≥5·1 mmol/L; 1 h OGTT
diabetes ≥10·0 mmol/L; 2 h OGTT ≥8·5 mmol/L
OGTT=oral glucose tolerance test. ACOG=American College of Obstetrics and Gynecology. ADA=American Diabetes Association. NICE=National Institute for Health and Care
Excellence. EBCOG=European Board and College of Obstetrics and Gynaecology. *Using the approach or criteria defined by WHO and ACOG.
Table 4: Recommended testing for gestational diabetes in obese pregnant women
history of gestational diabetes. The need to detect pre- maternal and neonatal outcomes,43 and thus the specific
existing diabetes in pregnancy is highlighted in contribution of each is difficult to disentangle.
guidelines from the UK, Europe, USA, and WHO Two large RCTs41,42 and a subsequent systematic
(table 4).34–37 Whether screening or management of review44 demonstrated that in women with gestational
gestational diabetes in early pregnancy is of clinical value diabetes, interventions based primarily on dietary
or is cost-effective is unclear;38 however, studies using the modification (with addition of insulin therapy if
Gestational Diabetes Formulas for Cost-Effectiveness glycaemic goals were not achieved) reduced the
(GeDiForCE) model suggest that standard screening prevalence of LGA infants, pre-eclampsia, and shoulder
(between the second and third trimester) and treatment dystocia. A secondary analysis of one study45 reported
is highly cost-effective in both an Indian and Israeli that reduction in excess fetal growth was related to
setting, especially if long-term effects are taken into maternal BMI, with greater reductions reported in
account.39 Studies to examine the benefit of early women in the overweight and obese class I and II BMI
gestational diabetes diagnosis and treatment are categories and no reduction in women of normal weight
underway (eg, NCT01926457, NCT01864564, and or with class III obesity. However, long-term follow-up
NCT02708758). of these studies has not shown any benefit in terms of
Hyperglycaemia in pregnancy requires immediate action the reduction of childhood obesity.46,47 A multicentre
for its control and for the detection of possible chronic cohort study from Japan48 reported lower rates of LGA
complications.36,40 The primary maternal management infants in obese women than in normal weight or
outcome in all women with gestational diabetes is to overweight women with gestational diabetes treated by
maintain normoglycaemia. However, little evidence exists dietary intervention with or without insulin. However,
to support key accepted practices in the treatment of hypertensive disorders, caesarean section, and induction
gestational diabetes, and even less to support specific of labour were more common in the obese group than
treatment regimens in obese women with the disease. the normal weight group.
Clinical practice varies substantially within and between Optimising maternal nutrition is the cornerstone for
countries partly because of the scarcity of the evidence good maternal and offspring outcomes, although this
base.36,40 For example, glibenclamide remains the approach becomes even more important in the presence
recommended oral drug in the USA,36 whereas metformin of maternal obesity or gestational diabetes, for which
appears to be much more commonly prescribed in the medical nutritional therapy is the first-line treatment.23,40
UK.34 Normalisation of maternal glucose in pregnancies Information regarding the ideal diet for treatment of
complicated by gestational diabetes has been shown to gestational diabetes has been reviewed in detail.49
decrease the incidence of pre-eclampsia and prevent Comparisons of low versus high glycaemic index (GI)
neonatal outcomes such as stillbirth and fetal over- diets50–52 or a low GI versus a conventional high fibre,
growth.41,42 No evidence exists with regard to the recom- moderate GI diet53 showed no differences in LGA infants,
mended weight gain specific to pregnancies complicated macrosomia, or other key outcomes, although Moses and
by diabetes. However, although insulin resistance is a colleagues52 reported that a low GI diet might reduce the
common feature, maternal obesity and gestational need for insulin therapy. Other dietary options, including
diabetes have both independent and additive effects on energy restriction,54,55 low carbohydrate intake,56 and high

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monounsaturated fat intake,57 have also not shown world, and local practice often varies depending on
specific benefits. A general recommendation for available resources and reimbursement policies. In our
medical nutritional therapy in gestational diabetes is a opinion, all obese patients should be considered to have
“carbohydrate-controlled meal plan that promotes a detailed fetal anatomy ultrasound scan to screen for
adequate nutrition with appropriate weight gain, anomalies in the mid-second trimester. Routine
normoglycaemia, and the absence of ketosis”,58 although ultrasound detects 46·2% of structural anomalies with
data to provide evidence-based recommendations for a normal karyotype, but detection rates decreased
most of the nutrition interventions are insufficient.40 significantly with an increasing maternal BMI
Despite not being specifically outlined as a therapy (p=0·007).76 The odds of detection of any anomaly were
intervention in the two RCTs previously mentioned,41,42 lower in obese women than those with a normal BMI
exercise is frequently recommended as a mainstay of (adjusted OR 0·77, 95% CI 0·60–0·99; p=0·046).76
treatment in gestational diabetes for pregnant women, Factors associated with the decreased ability to diagnose
with a general recommendation of 30 min of exercise per congenital anomalies include distance from the skin
day.36,40,59,60 But again, evidence is sparse, with the few surface to the fetus, resolution or penetration of
published clinical trials focusing on glycaemic control sonographic equipment, prolonged time to complete
rather than on pregnancy outcomes.61–63 the examination, and experience of the sonographer.77
Insulin was the only drug used in these two RCTs,41,42 Potential ways to optimise image quality include a
and is clearly the most established drug in women with vaginal approach in the first trimester, use of the
gestational diabetes who do not meet glycaemic goals maternal umbilicus as an acoustic window, tissue
after lifestyle modification. The potential use of the oral harmonic imaging, compound imaging, and speckle
antidiabetic drugs glibenclamide and metformin in reduction filters.77,78 Accuracy of fetal weight estimates
gestational diabetes has been systematically reviewed.64 using ultrasound increases with advancing gestation
Glibenclamide was reported to increase risks of LGA and is greater in women with a BMI less than
infants, macrosomia, and neonatal hypoglycaemia 25 kg/m².79 Referral of obese women to tertiary centres
compared with insulin.65–67 In a retrospective analysis of for expert scans might be helpful, if available.
a population-based cohort of 110 879 women with Different options of screening for aneuploidy are
gestational diabetes from a nationwide insurance now available,80 and first trimester screening in all
database from the USA, newborn babies of mothers pregnancies includes nuchal translucency measurement,
treated with glibenclamide had an increased risk for serum-free β-human chorionic gonadotrophin, or
neonatal intensive care unit admissions, as well as total human chorionic gonadotrophin coupled with
respiratory distress, hypoglycaemia, birth injury, and pregnancy-associated plasma protein A levels, although
LGA infants compared with those treated with insulin.68 cell-free DNA (cfDNA) screening is increasingly being
Metformin was associated with lower maternal weight used.80 Obesity affects the measures of serum analytes
gain, more preterm births, less pregnancy-induced used to screen for aneuploidies because of the increased
hypertension, and less severe neonatal hypoglycaemia plasma volume in obese women. Although weight
compared with insulin.69–73 The retrospective analysis adjustment for analytes related to neural tube defects
concluded that glibenclamide was clearly inferior to and trisomy 18 improves detection, this is not the case
both insulin and metformin in the treatment of for Down’s syndrome.81 In a general population with
gestational diabetes.68 Detailed studies of antidiabetic prenatal testing for trisomies 21 and 18, the false-positive
drugs to inform future clinical practice would be rate with cfNDA was significantly lower than with
extremely valuable. standard screening. The positive predictive value for
cfDNA was also better for trisomy 21 and trisomy 18.80
Surveillance of congenital malformation
Offspring of obese mothers have an increased risk of Coexisting medical problems
congenital anomalies including neural tube defects and Obese women should be screened for pre-existing
cardiovascular anomalies compared with offspring born hypertension and proteinuria at their initial antenatal visit,
to mothers of a normal weight.74 The underlying which is recommended for all women. An appropriate size
metabolic factors that account for this increased risk are of arm cuff should be used and the cuff size used should
not well understood. Although maternal folate status and be documented in the medical records.20 Women with
preconception glucose intolerance have been primary suspected obstructive sleep apnoea (snoring, excessive
theories, no definitive mechanism has been identified.75 daytime sleepiness, witnessed apnoea, or unexplained
A multidisciplinary approach before conception is hypoxia) should be referred for assessment.82 Obstructive
therefore necessary, since many women do not initiate sleep apnoea can be a problem at delivery because of the
antenatal care until after fetal organogenesis is potential complications associated with anaesthesia with
completed.31 caesarean delivery. Non-alcoholic fatty liver disease is the
No general guidelines are available on the use of most common liver disorder in developed countries,
ultrasound during pregnancy for most parts of the usually presenting as elevated liver function tests.83 This

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diagnosis is important because unless recognised early in potential indication for induction of labour. Induction of
gestation, abnormal liver function tests later in gestation labour for suspected LGA infants does not increase the
might be confused with complications of pre-eclampsia— risk of caesarean delivery, but reduces the risk of
ie, HELLP syndrome (haemolysis, elevated liver enzyme shoulder dystocia and associated morbidity compared
scores, and low platelet counts). with expectant management.91 Unfortunately, the ability
The risk of pre-eclampsia is twice as high in pregnant of ultrasound to accurately estimate fetal weight at the
women who are obese compared with those of healthy upper limits of fetal growth is poor, and the reported
weight.84 Although no proven methods to prevent pre- accuracy range is between 47% and 64%.92 Mothers
eclampsia are known, avoiding excessive gestational should be informed about the increased risks involved
weight gain and tight control of diabetes in obese women with induction of labour, including caesarean section,
could be beneficial.24 WHO has recommended that decreased ability to monitor the fetal heart-rate pattern
women at a high risk of pre-eclampsia (including those (which reflects fetal metabolic status), wound infection,
with previous pre-eclampsia, diabetes, or obesity) from and primary post-partum haemorrhage.
areas with low dietary calcium intake should take calcium Infants of obese women are at an increased risk for
supplements during pregnancy, and low-dose aspirin at fetal macrosomia, specifically increased body fat
75 mg per day should be considered for prophylaxis.85 compared with infants of normal weight women.93,94
Obese women are at increased risk of venous thrombo- Although the assessment of macrosomia by clinical
embolism,86 and thus thromboprophylaxis assessment examination or ultrasound-based estimates of fetal
should be done in obese pregnant women at clinical en- weight lacks precision, prophylactic caesarean section
counters throughout the pregnancy and after. Although can be considered for suspected fetal macrosomia with
detailed description of the management of different estimated fetal weight greater than 5 kg in women
obstetric complications is beyond the scope of this without diabetes or greater than 4·5 kg in women with
Review, it is important to note that obstetric complications diabetes to avoid obstructed labour.95
are more common in obese women, and need to be Obese women have an increased risk of stillbirth,
screened for with greater vigilance, and managed shoulder dystocia, peri-partum or post-partum haemor-
according to established guidelines. rhage, and of late complications including pelvic floor
prolapse and fistulae. The length of labour in nulliparous
Preterm delivery women is also correlated to maternal BMI;96 in a study
Indicated preterm deliveries in overweight and obese adjusting for appropriate covariates, the median duration
women are more common (relative risk [RR] 1·30, of labour from 4 cm to 10 cm was significantly longer in
95% CI 1·23–1·37) than in women of normal weight87 obese women compared with women of normal weight
because of ante-partum complications. Many studies do (7·5 h vs 6·2 h).97 However, the second stage of labour
not differentiate between indicated and spontaneous was not different between normal, overweight, and obese
preterm delivery, but this distinction is important women. The underlying cause of increased length of
because of the 2·7 times increased risk of spontaneous labour in obese women is unknown.
preterm birth between 22 weeks and 27 weeks of 30% of obese women are at an increased risk of a
gestation88 in women with a BMI of 40 kg/m² or more. prolonged pregnancy (>290 days) compared with 17% of
The use of progesterone supplementation has been normal weight women, and obese women have an
shown to decrease the risk of preterm delivery in women increased rate of labour induction.98 Induction failure rates
with risk factors (such as previous preterm delivery or are associated with increasing obesity from 13% in normal
short cervical length). A secondary analysis of the weight women to 29% in class III obese women.99 In one
Maternal Fetal Medicine Units’ trial of 17-hydroxy- meta-analysis, the unadjusted OR of caesarean delivery
progesterone caproate showed a non-significant was 2·05 (95% CI 1·86–2·27) for women with class I
increased risk of preterm birth (RR 1·55, 95% CI obesity, and 2·89 (2·28–3·79) for women with class II
0·93–2·89) in women with a BMI over 30 kg/m².89 or III obesity compared with normal weight women.100
However, studies also support elective induction at term
Labour and clinical issues of delivery instead of expectant management in those presenting with
In pregnant women who are obese, the timing, method anticipated LGA neonates.91,101 Nonetheless, the association
of delivery, and the peri-partum management plan between induced labour and higher rates of emergency
should be discussed in light of any other obesity-related caesarean delivery should be discussed with the mother
obstetric complications, such as gestational diabetes and before elective induction of labour at term.
macrosomia.90 Because of the multiple medical and In view of a high risk of either elective or emergency
obstetric problems associated with obesity and caesarean delivery, obese women, especially those with
pregnancy, scheduled induction of labour is common in obstructive sleep apnoea, should have an anaesthetic
obese women. In addition to potential maternal assessment in late gestation. Epidural or spinal
conditions such as pre-eclampsia and gestational anaesthesia is recommended, although this procedure
diabetes, fetal conditions such as LGA are an additional might be technically difficult in an obese woman.

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Delivery during subsequent pregnancies is also enough to rapidly move patients, power lifts to move
complicated by maternal obesity. Success rates of patients from the bed to the operating table, and
vaginal births after previous caesarean delivery are appropriately sized operating instruments to access
inversely related to BMI: less than 19·8 kg/m² (83·1%), proper tissue planes.
19·8–26 kg/m² (79·9%), 26·1–29 kg/m² (69·3%), and
more than 29 kg/m² (68·2%; p<0·001). Similarly, Management of peri-partum complications
gestational weight gain exceeding 18 kg is associated Obese women remain at increased risk of complications
with a decreased success rate of vaginal birth after after delivery. Because of the increased risk of venous
caesarean or trial of labour after caesarean (66·8% vs thromboembolism, pneumatic compression stockings
79·1%, p<0·001).102 BMI class III women undergoing before and after caesarean delivery should be considered
labour after caesarean had greater composite morbidity in obese post-partum women, in addition to early
(prolonged hospital stay, endometritis, rupture or ambulation. Weight-adjusted postnatal thromboprophy-
dehiscence, and neonatal injury including fractures, laxis is now recommended by the Royal College of
brachial plexus injuries, and lacerations) compared Obstetrics and Gynaecology for all women with class III
with class III women having elective caesarean delivery, obesity, and all other obese women with one or more
but absolute morbidities were low in both groups.103 additional risk factors—eg, advanced maternal age,
Class III obese women have a significantly increased history of caesarean section, preterm delivery, and post-
risk of post-partum atonic haemorrhage (>1000 mL) partum haemorrhage. The duration of thromboprophy-
after a vaginal delivery (5·2%) compared with normal laxis with low-molecular-weight heparin should be
weight women (4·4%), and it is more pronounced after extended if there are more than three risk factors, or if
instrumental delivery (13·6%) compared with normal the risk factors are persistent.86
weight women (8·8%).104 Successful breastfeeding in obese women has multiple
Women with a BMI of 45 kg/m² or more have a two to barriers, including the physical issues of large breast size
four times increased risk of postoperative wound and increased risk of caesarean delivery. The need for
infection.105 The choice of skin incision for primary neonates of obese women to be assessed in the intensive
caesarean section in class II and III obese women care nursuries represents an additional barrier to breast-
remains controversial. Although one study reported that feeding compared with normal weight women. Obese
a vertical skin incision was associated with a higher rate post-partum women can also have a decrease in their
of wound complications than a transverse incision,106 a first phase of milk production. Despite these obstacles,
multicentre registry study suggested that vertical skin breastfeeding should be encouraged in obese women,
incision was associated with a lower wound complication not only because of the potential benefits to neonates,
rate in class III obese patients after adjustment for but also potential maternal benefits relating to post-
confounding factors.107 To prevent postoperative wound partum weight reduction.112 This process can be facilitated
complications, closure of the subcutaneous layer is through appropriate specialist advice and support during
recommended when the fat layer is more than 2 cm.108 the antenatal and postnatal period to help overcome
Placement of a subcutaneous drain is not recommended.109 difficulties with breastfeeding, including early
The standard for prophylactic antibiotics after delivery termination.20
is 1 g of cefazolin to patients with a BMI less than During pregnancy, prevalence of depression was 33%
30 kg/m², but 2 g for those with a BMI of 30 kg/m² or among obese women and 23% among normal weight
more. The regimen was supported by a study showing women. Post-partum depression was present in 13% of
adequate antibiotic concentrations (above the minimum obese women compared with 10% in women of normal
inhibitory concentration) in adipose tissue.110 Clinical weight.113 ACOG recommends that all pregnant women
practice guidelines from Canada, for example, should be screened at least once for depression in the
recommend that clinicians consider doubling the post-partum period. When clinically significant
antibiotic dose in the setting of a maternal BMI more depression is diagnosed the care provider should either
than 35 kg/m².111 initiate treatment or refer the patient as needed.114
Finally, given the aforementioned risks, consideration The increased pregnancy complications associated
should be made for proper equipment, facilities, and with obesity are a harbinger of future metabolic
staff for the care and safety of obese pregnant women in dysfunction in these women. Weight gain in excess of
labour. These include, but are not limited to, large chairs, the IOM guidelines, which occurs in 63% of class I obese
blood pressure measuring devices, and birthing beds women,10,115 is a key risk factor for post-partum weight
capable of supporting 200–300 kg or more. Similarly, retention.116 In turn, weight gain increases the risk of
because of the increased need for caesarean delivery future metabolic dysfunction and increases pregravid
among obese pregnant women, operating tables should obesity with future pregnancies. Of note, although
accommodate weights up to 400 kg, yet allow surgeons gestational weight gain and pregravid obesity are
ready access to the operating field. Other considerations interrelated, only increased pregravid obesity is
for the care of obese woman include doors that are wide associated with early termination of breastfeeding.117

Series
energy intake should not be restricted to less than

Panel: Summary of management of overweight and obese 1800 kcal.120 Further studies demonstrated that such
women before and through pregnancy weight loss can be safely achieved in lactating women
Counselling before conception who are overweight by restricting the usual energy intake
• Discuss reduced fertility and risks of pregnancy associated by 500 kcal per day and by doing aerobic exercise 4 days
with obesity per week.121 The safety and feasibility of these recom-
• Advise on lifestyle interventions and goals for weight loss mendations is also supported by systematic reviews.119,122
• Refer for nutritional counselling A lack of appropriately designed, high-quality studies
• Folic acid supplementation on weight management in women before pregnancy or
• Assess for surgical interventions in selected cases between pregnancies was noted in a meta-analysis of
interventions to reduce obesity, although data suggest
Antenatal care that dietary and physical activity counselling before
• Record weight, height, and BMI and advise on appropriate conception or between pregnancies reduces of gestational
targets of gestational weight gain weight gain.123 The ACOG recommends that nutrition
• Counsel on nutrition and physical activity to promote and exercise counselling should continue post partum
healthy behaviours and before attempting another pregnancy.90,124
• Assess social determinants of health As offspring of obese mothers or mothers with
• Monitor blood pressure excessive gestational weight gain are at high risk of
• Screen for gestational diabetes excessive weight gain in childhood,125 post-partum
• Screen for obstructive sleep apnoea counselling of mothers should also highlight the need to
Perinatal care monitor the child’s health and to encourage a healthy
• Require obstetric and anaesthesiology expertise lifestyle for the family. Maternal post-partum weight gain
• Anaesthesia consultation is also an independent predictor of overweight in
• Prescribe prophylactic antibiotics for caesarean delivery preschool children.126
Postnatal care Prevention through treatment of obesity before

• Deep vein thrombosis prophylaxis with caesarean delivery conception
• Encourage breastfeeding One of the best ways to optimise outcomes in pregnancies
• Vigilance for post-partum complications in obese mothers is to reduce obesity before conceiving
• Post-partum oral glucose tolerance test in patients with for the first time, or before conceiving again. This
gestational diabetes approach is due in part to the fact that obese women have
• Education regarding inter-pregnancy weight loss increased lipogenesis and inflammation, along with
• Education regarding long-term risk in mother and altered maternal or placental function starting in the first
offspring and empowering behavioural modification trimester, meaning that lifestyle interventions initiated
• Advise on contraception later in pregnancy are rather too late to be effective.1
Lifestyle modification remains the cornerstone of obesity
Post-partum management management in all people, and NICE guidelines suggest
The prevention of long-term complications associated that women with BMI of 25 kg/m² or more lose weight
with maternal obesity can start in the post-partum before becoming pregnant, at a rate not exceeding
period (panel). This period represents an important 0·5–1 kg per week.118 Additionally, obese women who
window of opportunity to encourage overweight and require fertility interventions are encouraged to reduce
obese women to lose weight at a time when they are bodyweight by at least 5%, a weight reduction associated
usually motivated. The UK NICE guidelines recommend with substantial improvement in cardiometabolic risk
that the 6–8 week postnatal check should be used as an factors, insulin sensitivity, ovulation, and improved
opportunity to discuss the woman’s weight and success of assisted reproductive technology.90,127
treatment strategies.118 In a systematic review and meta- Bariatric or metabolic surgery is currently the most
analysis of strategies to encourage weight loss in post- effective approach for sustained weight reduction,
partum women, subgroup analysis demonstrated that although careful selection of appropriate surgical
the most effective interventions in reducing weight candidates is important to ensure optimal outcome.
were exercise programmes with objectively defined Successful weight loss after bariatric surgery also has
goals, such as the use of a heart rate monitor or benefits during pregnancy. A systematic review of
pedometer, and exercise programmes coupled with 75 studies that examined pregnancy outcome following
intensive dietary intervention.119 bariatric surgery suggested that the rate of many adverse
Weight control interventions can be implemented post maternal and fetal outcomes was lower in pregnant
partum even during lactation. The IOM Subcommittee women who had undergone bariatric surgery compared
on Nutrition During Lactation stated that losing as much with those who had not.128 Recommendations from
as 2 kg per month did not affect milk volume, but daily ACOG suggest that women should avoid conceiving

Series
within 18 months of bariatric surgery to avoid pregnancy

at a time of rapid weight loss.129 Although the optimal gap Search strategy and selection criteria
for conception after bariatric surgery is still not clear,124 We searched MEDLINE (2000–16) for English language papers
pregnancy is probably best deferred until bodyweight has using the search terms “maternal obesity” and “management”
stabilised after surgery. Obese women might be at risk of or “treatment” or “epidemiology” or “bariatric surgery” in
nutritional deficiencies including iron, vitamin B12, combination with the terms “offspring” or “outcome”. The
folate, vitamin D, and calcium, and this risk is of date of the last search was Aug 10, 2016. We mainly selected
particular concern in women after bariatric surgery, who publications in the past 5 years, but did not exclude
should be assessed for the need to take supplements. commonly referenced and highly regarded older publications.
Furthermore, women who have had gastric banding We also searched the reference lists of articles identified by
might need adjustment of the band during pregnancy.124 this search strategy and selected those we judged relevant. We
cited review articles and book chapters to provide readers with
Areas for further research and perspective on more details and more references than possible in this Review.
prevention We modified the reference list further according to
Although obesity is currently defined by an individual’s suggestions from reviewers.
BMI, the important role of body fat distribution is
increasingly recognised, with subcutaneous adiposity
considered a different phenotype compared with visceral the International Diabetes Federation (IDF), all recog-
adiposity.130 The term metabolically healthy obesity has nising the importance of these periods to reduce risk of
been coined to describe individuals whose obesity non-communicable diseases in subsequent gener-
appears to differ from traditional obesity.131 The ations.23,40,134,135 However, treatment of obesity or pre-
relationship between metabolically healthy obesity and vention of obesity in the preconceptional and post-partum
pregnancy outcome and management is not well defined periods (in preparation for future pregnancies) might be
and should be evaluated in future studies. an even better strategy.
In terms of establishing optimal weight gain during Given the global scale of the problem and the need for
pregnancy, RCTs are needed to determine whether effective treatment on a community-wide level, lifestyle
compliance with IOM recommendations for weight modification will remain the mainstay of treatment and
gain improves maternal and fetal outcomes. The global prevention of obesity, with surgery reserved for a highly
International Weight Management in Pregnancy selective subgroup in settings with appropriate expertise
(i-WIP) collaborative network is undertaking an and resources. Public education regarding the hazards of
individual patient data meta-analysis to assess whether maternal obesity is important, but needs to be coupled
various dietary and physical activity interventions have with action to reduce the obesogenic environment as
differential effects based on parity, BMI, and pre- well as research on how best to implement behavioural
existing medical conditions.132 Future trials should also modification on a large scale. The focus needs to shift
incorporate modern technologies to help empower from simply delivering health education to mobilising
behavioural change; a meta-analysis of lifestyle inter- communities to empower young women towards better
ventions to limit post-partum weight retention noted health before conception. Improved integration of
that few trials used modern technology, such as text maternal and child health, along with primary care
messages and apps.133 Large RCTs are also required to services and education, is key to tackling many of the
assess the effects of nutritional supplements such as current problems. For example, although care in the
probiotics in the prevention of gestational diabetes, and post-partum period is often focused on the neonate, this
to compare different pharmacological treatments for period also provides an important opportunity to provide
gestational diabetes. education for the mother on healthy lifestyle choices and
This Review has highlighted the challenges to clinical contraception, and to ensure that post-partum glycaemic
management of the obese pregnant mother. Given the evaluation is performed for women diagnosed with
global epidemic of obesity, the effect of maternal obesity gestational diabetes.136 Given the high-default rate for
on reproductive health and public health is alarming. As postnatal oral glucose tolerance test, glycated
discussed here and in another Review in this Series, haemoglobin has been proposed as an alternative for
maternal obesity is associated with adverse long-term postnatal glycaemic evaluation.34,137 Substantial changes
consequences in the offspring through multiple in health-care organisation and care delivery models will
mechanisms, and early action is needed to break this be required to better integrate the different disciplines
putative intergenerational passage of risk to subsequent such as obstetric, paediatric, medical, and primary care
generations. The pregnancy and inter-pregnancy periods that contribute to postnatal health of both mother and
are increasingly recognised to represent an important child. More details on public health aspects of obesity
window of opportunity for health-care education and prevention before conception and examples of
prevention of non-communicable diseases, with several community programmes can be found in other reviews
international organisations including WHO, FIGO, and in this Series.3,31 The ability to address these issues, and to

Series
implement a transdisciplinary approach involving a 14 Hedderson M, Ehrlich S, Sridhar S, et al. Racial/ethnic disparities
in the prevalence of gestational diabetes mellitus by BMI.
variety of health-care providers, including nutritionists, Diabetes Care 2012; 35: 1492–98.
exercise physiologists, and behavioural scientists, will be 15 Farrar D, Fairley L, Santorelli G, et al. Association between
key to efforts to combat maternal obesity and its long- hyperglycaemia and adverse perinatal outcomes in south Asian and
term effect on non-communicable diseases and other white British women: analysis of data from the Born in Bradford
cohort. Lancet Diabetes Endocrinol 2015; 3: 795–804.
associated complications. 16 Deputy NP, Sharma AJ, Kim SY. Gestational weight gain—
Contributors United States, 2012 and 2013. MMWR Morb Mortal Wkly Rep 2015;
RCWM and PMC conceived the project. All authors contributed to the 64: 1215–20.
literature search, data collection and interpretation, writing, and critical 17 Artal R, Lockwood CJ, Brown HL. Weight gain recommendations in
revision of the manuscript. All authors revised and accepted the final pregnancy and the obesity epidemic. Obstet Gynecol 2010; 115: 152–55.
version. 18 Kapadia MZ, Park CK, Beyene J, et al. Weight loss instead of weight
gain within the guidelines in obese women during pregnancy:
Declaration of interests a systematic review and meta-analyses of maternal and infant
HDM reports personal fees from Novo Nordisk, AstraZeneca Australia, outcomes. PLoS One 2015; 10: e0132650.
and Eli Lilly Australia, outside the submitted work. All other authors 19 Catalano PM, Mele L, Landon MB, et al. Inadequate weight gain in
declare no competing interests. overweight and obese pregnant women: what is the effect on fetal
growth? Am J Obstet Gynecol 2014; 211: 137.
Acknowledgments
20 Modder J, Fitzsimons KJ. CMACE/RCOG joint
RCWM acknowledges support from the Research Grants Council
guideline-management of women with obesity in pregnancy.
General Research Fund (CU471713, CU14110415), the European London: Centre for Maternal and Child Enquiries and the Royal
Foundation for the Study of Diabetes (EFSD)/Chinese Diabetes Society College of Obstetricians and Gynaecologists, 2010.
(CDS)/Lilly Collaborative Research Programme, and the Research 21 Brownfoot FC, Davey MA, Kornman L. Routine weighing to reduce
Grants Council Theme-based Research Scheme (T12–402/13-N). excessive antenatal weight gain: a randomised controlled trial.
PMC acknowledges support from the Eunice Kennedy Shriver National BJOG 2016; 123: 254–61.
Institute of Child Health and Development (HD 11089). 22 WHO and Food and Agriculture Organization of the United States.
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Maternal Obesity 2

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www.thelancet.com/diabetes-endocrinology Vol 4 December 2016 1037

Risk to mother Risk to oﬀspring

Table 1: Hazards of maternal obesity

glycaemia and adverse outcomes appears to diﬀer

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Various interventions, including diet, lifestyle, and

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Table 4: Recommended testing for gestational diabetes in obese pregnant women

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energy intake should not be restricted to less than

Postnatal care Prevention through treatment of obesity before

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within 18 months of bariatric surgery to avoid pregnancy

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