Influence of weight gain on risk for cesarean delivery in obese pregnant women by class of obesity: pregnancy risk assessment monitoring system (PRAMS)

812: Weight gain in obese pregnant women and risk for cesarean delivery by class of obesity: pregnancy risk assessment monitoring system (PRAMS)

Background: Obesity (BMI ≥30) is a significant independent risk factor for many gestational complications, including cesarean delivery (CD). While CD rates are increasing in women of every BMI, the trend is more pronounced as maternal weight increases. Objective: This review seeks to describe the risk modulators that explain the high prevalence of CD in obese women, as well as to discuss the excess complications of the procedure in this group of parturients. In assessing the rationale for the procedure and weighing this against the excess risks involved, a clearer indication of when to perform CD in obese women might be developed. Results: A thorough review of the literature indicates that a decreased cervical dilation rate, an increased induction rate, the presence of comorbid conditions, concern about shoulder dystocia, and weight gain in excess of recommendations during pregnancy all may contribute to the high rate of CD in obese women. Obese women are at increased risk of CD-related complications including anesthetic complications, wound complications, venous thromboembolism (VTE), and failure of vaginal birth after CD. Conclusions: Given the excess risks associated with CD in obese women, and that some of the rationale for the procedure (e.g. slower labor, concern about shoulder dystocia) may not be justified based on current evidence, a reassessment of the threshold at which obese women are recommended for CD is necessary.

Attempted and Successful Vacuum-Assisted Vaginal Delivery in Relation to Prepregnancy Body Mass Index [138

972: Negative pressure wound therapy does not prevent wound complications after cesarean delivery in obese women

Association between pre-pregnancy obesity and the risk of cesarean delivery

Impact of excessive pre-pregnancy body mass index and abnormal gestational weight gain on pregnancy outcomes in women with chronic hypertension.

To assess the association between pre-gestational obesity and weight gain with cesarean delivery and labor complications. A total of 4,486 women 20-28 weeks pregnant attending general prenatal care clinics of the national health system in Brazil from 1991 to 1995 were enrolled and followed up through birth. Body mass index categories based on prepregnancy weight and total weight gain were calculated. Associations between body mass index categories and labor complications were adjusted through logistic regression analysis. Obesity was present in 308 (6.9%) patients. Cesarean delivery was performed in 164 (53.2%) obese, 407 (43.1%) pre-obese, 1,045 (35.1%) normal weight and 64 (24.5%) underweight women. The relative risk for cesarean delivery in obese women was 1.8 (95% CI: 1.5-2.0) compared to normal weight women. Greater weight gain was particularly associated with cesarean among the obese (RR 4th vs 2nd weight gain quartile 2.2; 95% CI: 1.4-3.2). Increased weight at the beginning of pregnancy was associated with a significantly higher adjusted risk of meconium with vaginal delivery and perinatal death and infection in women submitted to cesarean section. Similarly, greater weight gain during pregnancy increased the risk for meconium and hemorrhage in women submitted to vaginal delivery and for prematurity with cesarean. Pre-gestational obesity and greater weight gain independently increase the risk of cesarean delivery, as well as of several adverse outcomes with vaginal delivery. These findings provide further evidence of the negative effects of prepregnancy obesity and greater gestational weight gain on pregnancy outcomes.

Gestational Weight Gain and Pregnancy Outcomes in Obese Women

Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women

1054 Predictors of surgical-site infection after cesarean delivery in obese women receiving evidence-based preventive measures

To estimate the risk of cesarean delivery due to excess prepregnancy body mass index (BMI) in a multistate, US population-based sample. We analyzed data from the population-based Pregnancy Risk Assessment Monitoring System (PRAMS) on 24,423 nulliparous women with single, term infants delivered between 1998 and 2000 in 19 states. We calculated BMI from self-reported weight and height. We assessed interactions between prepregnancy BMI and other risk factors. We estimated weighted relative risks and 95% confidence intervals for the association between prepregnancy BMI and cesarean section from multiple logistic regression models adjusting for demographic and medical risk factors from the PRAMS questionnaire or birth certificates. The incidence of cesarean delivery increased with increased prepregnancy BMI, from 14.3% (0.8 standard error (SE)) for lean women (BMI < 19.8) to 42.6% (2.0 SE) for very obese women (BMI > or = 35). The risk of cesarean section differed by presence of any medical, labor and/or delivery complication. Among women with any complication, the estimated adjusted RR for cesarean delivery was 1.1 (95% confidence interval (CI) 1.0-1.2) among overweight women, 1.3 (95% CI 1.1-1.4) among obese women, and 1.4 (95% CI 1.2-1.6) among very obese women compared with normal weight women. Among women without any complications, the estimated adjusted RR was 1.4 (95% CI 1.0-1.8) among overweight women, 1.5 (95% CI 1.1-2.1) among obese women, and 3.1 (95% CI 2.3-4.8) among very obese women. Excess prepregnancy weight increases the risk of cesarean delivery among nulliparous women giving birth to single, term infants, especially among very obese women without any complications.

Objective To determine the risk of wound complications by skin incision type in obese women undergoing cesarean delivery. Data sources: Electronic databases (MEDLINE, Scopus, and Ovid) were searched from their inception through August 2018. Methods of study selection: We included all randomized controlled trials and cohort studies reporting the placement of skin incision during cesarean section in obese women, defined as those with BMI ≥30 kg/m2. Studies were included if they compared one placement of skin incision with a different one as comparison group. The primary outcome was incidence of wound complications, while secondary outcomes included wound infection, hematoma, seroma, postpartum hemorrhage, and endometritis. Demographics and outcomes for each individual study identified were reported as part of the review. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Sub-group analyses (vertical versus Pfannenstiel) were also reported. Tabulation, integration and results: Seventeen studies (including 3 RCTs; 8960 participants among the 15 non-overlapping studies) were included in the systematic review. Vertical incisions were associated with a relative risk of 2.07 (95% CI1.61–2.67) for wound complications compared to transverse incisions, however significant possible confounders were present. Studies were mildly-moderately heterogeneous (I 2 44.81%, 95% CI 0.00–71.85%) with varying definitions of obesity and wound complications. High transverse incisions (3 studies, 218 participants) trend toward a lower risk of wound complications compared to low transverse incisions (RR 0.338, 95% CI 0.114–1.004). Conclusions Vertical incisions may be associated with an increased risk for wound complications compared to transverse incisions for cesarean delivery in obese women. Randomized controlled trials are needed to evaluate optimal cesarean skin incisions for these women.

Induction of Labor Compared With Expectant Management and Risk of Cesarean Delivery in Obese Women [7F

Term Elective Induction of Labor and Risk of Cesarean Delivery in Obese Women [326

Attempted and Successful Vacuum-Assisted Vaginal Delivery by Prepregnancy Body Mass Index.