Obesity in pregnancy is an increase in body weight mainly due to excess fat deposits in subcutaneous tissue, organs and tissues that occurred before or during gestation and affects its course. It is manifested by obesity, the formation of visible fat folds, low resistance to physical exertion, awkwardness, decreased mobility, rapid onset of shortness of breath. It is diagnosed based on a comparison of body weight with the recommended one, BMI calculation data, weight gain control. Treatment involves correction of diet, motor activity, therapy of gestation complications.
O26.0 Excessive weight gain during pregnancy
Obesity in pregnancy is the most common violation of lipid genesis, which affects 21-28% of women of childbearing age, while the prevalence of the disease continues to increase constantly. Borderline disorder in the form of obesity (overweight) is determined in 34-39% of patients. According to the observations of specialists in the field of obstetrics, obesity occurs with a frequency of 15.5-26.9% during pregnancy. The urgency of timely detection of excess weight, its correction in pregnant women is associated with the risk of complications during gestation and an increase in perinatal mortality, the level of which, according to various data, reaches 2.07-9.5%.
The key etiological factor leading to the occurrence of obesity in pregnancy is an energy imbalance, in which the intake of energy from food exceeds its consumption. In 95% of cases, the cause of a positive energy balance is incorrect alimentary habits with the consumption of a large number of high-calorie foods with a high glycemic index and physical inactivity. Hereditary predisposition plays a certain, but not the leading role in maintaining excess weight. In 5% of patients, the disease is formed against the background of endocrine and metabolic disorders: genetic failure of enzymes regulating fat metabolism, cerebral disorders, adrenal diseases, ovarian insufficiency, hypothyroid states. During pregnancy, there are a number of additional factors that contribute to the accumulation of excess adipose tissue:
- Hormonal restructuring. To preserve gestation and maintain the necessary activity of anabolic processes in the pregnant woman’s body, the secretion of estrogens, progesterone, prolactin increases, which stimulate lipogenesis. The formation of excess fat is also enhanced by reducing the sensitivity of tissues to insulin, increasing its concentration in the blood, hyperproduction of the peptide hormone ghrelin, which stimulates appetite.
- Decreased motor activity. The additional loads experienced by a woman during pregnancy lead to increased fatigue, cause a feeling of malaise. The situation is aggravated by the development of gestosis, anemia of pregnant women, exacerbation of chronic infections, extragenital pathology. Patients who perceive gestation as a pathological condition become less mobile and as a result spend less energy.
Obesity in pregnancy may be due to an increase in the volume of circulating blood, the formation of the placenta and fetal membranes, fetal growth, polyhydramnios, fluid retention in the body. However, such changes are usually not accompanied by increased lipogenesis. The development of true obesity with the formation of excess adipose tissue directly in the gestational period or after it is provoked by a slowdown in basal metabolism in hypothyroidism of pregnant women and postpartum thyroiditis.
The leading link in the process of accumulation of excess fat is the strengthening of lipogenesis with the accumulation of excess energy in adipocytes. The energy imbalance, against which the disease develops, is usually caused by overeating, often combined with physical inactivity. Excessive calorie intake is facilitated by a violation of the hypothalamic centers of appetite regulation, which occurs in predisposed women and is supported by personal habits or family traditions. Less often, inflammatory processes (meningitis, encephalitis) become the cause of a failure of neurohumoral regulation or a brain injury. Increased appetite during pregnancy is also caused by physiological hypersecretion of ghrelin, the maximum level of which is reached by the middle of the 2nd trimester.
During gestation, conditions are formed that favor the development of subcutaneous fat, the biological role of which is to maintain sufficient energy reserves for carrying and feeding a child. Hormonal changes occurring during pregnancy stimulate the accumulation of fat and inhibit its mobilization from fat depots. Estrogens, whose content increases hundreds of times during gestation, have an activating effect on lipoprotein lipase, an enzyme that promotes fat deposition on the buttocks and thighs. Simultaneously with increased lipogenesis, lipolysis is inhibited by increasing the concentration of progesterone, which competently interacts with adipocyte receptors of glucocorticosteroids.
The systematization of clinical forms of obesity in pregnancy takes into account the causes and nature of eating disorders, the presence or absence of metabolic disorders, the predominant localization of excess fat deposits, the degree of deviation of body weight from normal. Excess weight during pregnancy usually has a primary alimentary-constitutional origin, less often the disorder is secondary (symptomatic). Fat deposits are usually distributed according to the gynoid (lower) type, in some patients — according to the android (upper) or mixed. When predicting the outcome of gestation, it is important to take into account the degree of obesity, determined taking into account the deviation of a woman’s weight before conception from normal, calculated by the formula Height (in cm) -100:
- Pre-obesity. Weight increased by less than 10% compared to normal. The risk of gestational complications is slightly increased.
- I degree. Body weight is 10-29% more than normal. Complicated pregnancy is observed in 25-40% of women.
- II degree. Excess body weight is 30-49%. Obstetric and extragenital disorders are detected in 70-80% of patients.
- III degree. The actual weight in comparison with the optimal increased by 50-99%. Pregnancy is complicated in 97-99% of cases.
- IV degree. The excess mass reaches 100% or more. Gestation occurs extremely rarely and always proceeds with complications.
The severity of clinical symptoms directly depends on the degree of obesity. With pre-obesity and in the initial stages of the disease, a woman complains of fatigue, gets tired faster with physical exertion, notes sweating, shortness of breath. Usually, such patients have earlier and more pronounced constipation, characteristic of the pregnancy period. Externally, there are deposits of excess fat in the hips, buttocks, abdomen, chest, shoulder girdle, back, neck, chin. The mammary glands increase not only due to proliferative processes, but also due to adipose tissue. With III-IV degrees of the disease, excess fat hangs in the form of folds, shortness of breath increases, which can be determined even at rest, mobility is significantly limited, peripheral edema may appear. Complaints of pain in the spine, hip, knee and ankle joints are often noted.
There is a direct correlation between the presence of excess weight in a pregnant woman and the risk of serious obstetric and somatic pathology. The gestational process is complicated in 45-85% of women with pre-obesity and obesity. Half of overweight pregnant women develop gestosis, the frequency of their most severe forms increases 3 times (hypertension of pregnant women, eclampsia, preeclampsia). In the future, such patients have a 7-fold increased risk of cardiovascular disorders. Pregnant women with a body mass index greater than 30.0 are 60% more likely to give birth to children with anencephaly and 40% more likely to have spina bifida. The probability of such fetal abnormalities is 1.8-2.5 times higher in women suffering from android-type obesity.
The frequency of spontaneous miscarriages and miscarriage reaches 25-37%. Fetoplacental insufficiency is determined in 38% of cases, chronic fetal hypoxia — in 25-34%, newborn weight deficiency — in 18%, fetal macrosomia — in 20-44%. With an increase in BMI by 3 or more units, the risk of antenatal death of a child increases by 63%. Premature birth is observed in 5-12.5% of cases, late — in 10-15%. In 40-65% of women in labor, weakness of labor forces is noted, in 10-32% — discoordinated contractions of the myometrium. The probability of coagulopathic bleeding, DIC syndrome is increased. The birth injury rate is 45.7%. Surgical delivery to obese women is carried out 2-4 times more often than pregnant women with normal weight. In 5.5% of cases, postpartum endometritis is detected in patients.
More than half of the surveyed overweight women are diagnosed with other pathological processes that decompensate during pregnancy. In 51.6-59.7% of patients, infectious diseases caused by a decrease in immunity are detected, in 17.1-43.5% — concomitant cardiovascular diseases, in 7.1% – respiratory damage, in 4.8—9.9% – urological pathology, in 3.8-7.9% — digestive disorders. In 17% of pregnancies, gestational diabetes develops, which is 2.8-8.5 times higher than in the general population. Every third woman with a large weight has type 2 diabetes mellitus for 15 years after giving birth.
The main tasks of the diagnostic search in the presence of signs of excess weight are to assess the degree of the disorder, clarify the causes of its occurrence, timely identification of possible complications of pregnancy. Comprehensive examination of the patient includes physical examination, laboratory and instrumental examination. In order to confirm the presence of obesity and determine its severity, in addition to comparing the real weight with the optimal one, methods such as:
- Calculation of BMI. With overweight, the ratio of body weight (in kg) to height (in m) squared is 25.0-29.9 (increased index), with 1 degree of obesity — 30.0-34.9 (high index), with 2 degrees (very high index) — 35.0-39.9, with 3-4 degrees — from 40 and above (excessively high index).
- Weight gain control. The possible formation of obesity or an increase in its degree is indicated by an increased weight gain. By the end of pregnancy, the total gain in women with normal weight should be 11.5-16.0 kg, with pre—obesity — 7-11.5 kg, with obesity – 5-9 kg (taking into account the severity of the disease).
When assessing obesity markers, the pregnant woman’s belonging to special categories is taken into account — women with small stature, adolescents and young women, patients with multiple pregnancies. Measurement of waist circumference, evaluation of the ratio of waist and hip circumference during gestation are less informative, since these indicators are distorted due to an increase in the volume of the abdomen due to the growth of the uterus. To identify the most common organ disorders, blood pressure monitoring, biochemical blood testing (determination of glucose tolerance, lipid metabolism, protein metabolism and their substrates, liver samples), general urine analysis, ECG, EchoCG, ultrasound of the liver, pancreas are additionally prescribed. According to the indications, the pregnant woman is consulted by an endocrinologist, gastroenterologist, hepatologist, cardiologist, neurologist, urologist.
Correction of obesity in pregnancy
The objectives of managing a patient with obesity are to restore energy balance and minimize possible complications. Medical and surgical methods of weight correction are not used, fasting is strictly prohibited due to the formation of ketones that have a toxic effect on the fetus. To reduce body weight , the following are shown:
- Balanced nutrition. The optimal solution is to develop a diet by an experienced nutritionist. To limit the excess intake of calories under the control of weight gain, reduce the amount of fat consumed, simple carbohydrates, salt, spices, supplement the diet with protein products, vegetables, fruits, vitamin and mineral complexes. To prevent inhibition of the basal metabolism, the daily volume of food is divided into 4-5 servings.
- Increased motor activity. To increase the level of energy consumption, the patient is recommended to exercise in the morning, daily walks lasting at least 30 minutes. It is possible to participate in physical therapy groups with the implementation of special complexes for pregnant women with excess weight. Taking into account the gestational age and the severity of the pathology, the physical therapy doctor can advise yoga classes, aqua aerobics, breathing exercises that accelerate the basic metabolism (bodyflex, oxysise).
If complications due to excess weight appear, appropriate drug therapy is prescribed. Natural childbirth is recommended for pregnant women with pre-obesity, stage I obesity without obstetric indications for cesarean section. Patients with stages II-III of the disease are hospitalized 2 weeks before the expected date of delivery. The decision on the preferred method of delivery is made individually, taking into account the results of the examination.
Prognosis and prevention
The outcome of pregnancy and childbirth depends on the severity of the disorder. The most serious prognosis is at the 3rd degree of the disease. Patients suffering from obesity of the 4th degree become pregnant and give birth in extremely rare cases. Women who are overweight are recommended to plan pregnancy with an early correction of body weight. Prevention is aimed at preventing obstetric, extragenital complications and involves early registration in a women’s clinic, regular examinations by an obstetrician-gynecologist, laboratory and instrumental screening of possible disorders, weight gain control.