Gebelikte Obezite
Özet
Gebelikte obezite, maternal ve fetal sağlığı olumsuz etkileyen, gebelik komplikasyonlarının yaklaşık %24'ü ile ilişkili kronik bir hastalıktır. Yağ dokusundan salınan leptin gibi adipokinler kronik inflamasyona yol açarak preeklampsi ve gestasyonel diyabet riskini artırır. Obez gebelerde erken gebelik kaybı, konjenital fetal anomaliler, preterm veya postterm doğum, makrozomi (LGA) ve perinatal mortalite riski yüksektir. Ayrıca, obstrüktif uyku apnesi, anestezi zorlukları, travay süresinin uzaması, sezaryen oranlarında artış, postpartum atoni kanaması, enfeksiyon ve venöz tromboemboli gibi intrapartum ve postpartum riskler de belirgin şekilde artmaktadır. Bu nedenle yönetim, prekonsepsiyonel dönemde kilo kaybı teşviki ve bariyatrik cerrahi değerlendirmesiyle başlamalıdır. Antenatal dönemde ise diyet düzenlemesi, uygun kilo alımı kontrolü, diyabet taramaları, fetal anatomik tarama ve aspirine başlanması kritik önem taşır. Doğumun, donanımlı tersiyer merkezlerde multidisipliner bir yaklaşımla planlanması, aktif üçüncü evre yönetimi ve mekanik/tıbbi tromboprofilaksi uygulanması gerekir. Postpartum süreçte ise emzirme desteği, depresyon takibi ve yaşam tarzı değişiklikleri sürdürülmelidir.
Obesity in pregnancy is a chronic disease that adversely affects maternal and fetal health, being associated with approximately 24% of pregnancy complications. Adipokines like leptin released from adipose tissue lead to chronic inflammation, increasing the risk of preeclampsia and gestational diabetes. Obese pregnant women face high risks of early pregnancy loss, congenital fetal anomalies, preterm or postterm birth, macrosomia (LGA), and perinatal mortality. Furthermore, intrapartum and postpartum risks, such as obstructive sleep apnea, anesthesia difficulties, prolonged labor, increased cesarean rates, postpartum atony hemorrhage, infections, and venous thromboembolism, are significantly elevated. Therefore, management must commence in the preconception period with weight loss encouragement and bariatric surgery evaluation. During the antenatal period, dietary regulation, appropriate weight gain control, diabetes screenings, fetal anatomic surveys, and initiating aspirin are critically important. Delivery should be planned in well-equipped tertiary centers with a multidisciplinary approach, utilizing active third-stage management and mechanical or medical thromboprophylaxis. In the postpartum phase, breastfeeding support, depression monitoring, and lifestyle modifications must be sustained.
Referanslar
Santos S, Voerman E, Amiano P, et al. Impact of maternal body mass index and gestational weight gain on pregnancy complications: an individual participant data meta‐analysis of European, North American, and Australian cohorts. BJOG: An International Journal of Obstetrics & Gynaecology. Published online March 20, 2019:1471-0528.15661. doi:10.1111/1471-0528.15661
GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH, et al. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. New England Journal of Medicine. 2017;377(1):13-27. doi:10.1056/NEJMoa1614362
Hales CM, Carroll MD, Fryar CD, et al. Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief. 2020 Feb;(360):1-8.
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert panel on the ıdentification, evaluation, and treatment of overweight in adults. The American Journal of Clinical Nutrition. 1998;68(4):899-917. doi:10.1093/ajcn/68.4.899
Kratzsch J, Höckel M, Kiess W. Leptin and pregnancy outcome. Current Opinion in Obstetrics and Gynecology. 2000;12(6):501-505. doi:10.1097/00001703-200012000-00008
Vonck S, Lanssens D, Staelens AS, et al. Obesity in pregnancy causes a volume overload in third trimester. European Journal of Clinical Investigation. 2019;49(11):e13173. doi:10.1111/eci.13173
Vinayagam D, Gutierrez J, Binder J, et al. Impaired maternal hemodynamics in morbidly obese women: a case-control study. Ultrasound in Obstetrics & Gynecology. 2017;50(6):761-765. doi:10.1002/uog.17428
Cavalcante MB, Sarno M, Peixoto AB, et al. Obesity and recurrent miscarriage: A systematic review and meta-analysis. Journal of Obstetrics and Gynaecology Research. 2019;45(1):30-38. doi:10.1111/jog.13799
Catalano PM, Kirwan JP, Haugel-de Mouzon S, et al. Gestational diabetes and ınsulin resistance: role in short- and long-term implications for mother and fetus. The Journal of Nutrition. 2003;133(5):1674S-1683S. doi:10.1093/jn/133.5.1674S
American College of Obstetricians and Gynecologists. (2013). ACOG Committee opinion no. 548: weight gain during pregnancy. Obstetrics and gynecology, 121(1), 210-212.
Bedell S, Hutson J, de Vrijer B, et al. Effects of maternal obesity and gestational diabetes mellitus on the placenta: current knowledge and targets for therapeutic ınterventions. Current Vascular Pharmacology.2020;19(2):176-192. doi:10.2174/1570161118666200616144512
O’Brien TE, Ray JG, Chan WS. Maternal body mass index and the risk of preeclampsia: a systematic overview. Epidemiology (Cambridge, Mass). 2003;14(3):368-374. doi:10.1097/00001648-200305000-00020
Reddy UM, Branum AM, Klebanoff MA. Relationship of maternal body mass ındex and height to twinning. Obstetrics & Gynecology. 2005;105(3):593-597. doi:10.1097/01.AOG.0000153491.09525.dd
Waller DK. prepregnancy obesity as a risk factor for structural birth defects. Archives of Pediatrics & Adolescent Medicine. 2007;161(8):745. doi:10.1001/archpedi.161.8.745
Petersen JM, Parker SE, Benedum CM, et al. Periconceptional folic acid and risk for neural tube defects among higher risk pregnancies. Birth Defects Research. 2019;111(19):1501-1512. doi:10.1002/bdr2.1579
McDonald SD, Han Z, Mulla S, et al. Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses. BMJ. 2010;341(jul20 1):c3428-c3428. doi:10.1136/bmj.c3428
Cnattingius S, Villamor E, Johansson S, et al. Maternal obesity and risk of preterm delivery. JAMA. 2013;309(22):2362. doi:10.1001/jama.2013.6295
Ehrenberg HM, Iams JD, Goldenberg RL, et al. Maternal obesity, uterine activity, and the risk of spontaneous preterm birth. Obstetrics & Gynecology.2009;113(1):48-52.doi:10.1097/AOG.0b013e318191c818
Hendler I, Goldenberg RL, Mercer BM, et al. The preterm prediction study: Association between maternal body mass index and spontaneous and indicated preterm birth. American Journal of ObstetricsandGynecology.2005;192(3):882-886. doi:10.1016/j.ajog.2004.09.021
Carlson NS, Hernandez TL, Hurt KJ. Parturition dysfunction in obesity: time to target the pathobiology. Reproductive Biology and Endocrinology. 2015;13(1):135. doi:10.1186/s12958-015-0129-6
Saravanakumar K, Rao SG, Cooper GM. The challenges of obesity and obstetric anaesthesia. Current Opinion in Obstetrics & Gynecology. 2006;18(6):631-635. doi:10.1097/GCO.0b013e3280101019
Yao R, Ananth CV, Park BY, et al. Obesity and the risk of stillbirth: a population-based cohort study. American Journal of Obstetrics and Gynecology.2014;210(5):457.e1-457.e9. doi:10.1016/j.ajog.2014.01.044
Aune D, Saugstad OD, Henriksen T, et al. Maternal body mass ındex and the risk of fetal death, stillbirth, and ınfant death. JAMA. 2014;311(15):1536. doi:10.1001/jama.2014.2269
Vahratian A, Zhang J, Troendle JF, et al. Maternal prepregnancy overweight and obesity and the pattern of labor progression in term nulliparous women. Obstetrics & Gynecology. 2004;104(5, Part 1):943-951. doi:10.1097/01.AOG.0000142713.53197.91
Fyfe EM, Anderson NH, North RA, et al. Risk of first-stage and second-stage cesarean delivery by maternal body mass ındex among nulliparous women in labor at term. Obstetrics & Gynecology. 2011;117(6):1315-1322. doi:10.1097/AOG.0b013e318217922a
Norman SM, Tuuli MG, Odibo AO, et al. The effects of obesity on the first stage of labor. Obstetrics & Gynecology. 2012;120(1):130-135. doi:10.1097/AOG.0b013e318259589c
Wolfe KB, Rossi RA, Warshak CR. The effect of maternal obesity on the rate of failed induction of labor. American Journal of Obstetrics andGynecology.2011;205(2):128.e1-128.e7. doi:10.1016/j.ajog.2011.03.051
Poobalan AS, Aucott LS, Gurung T, et al. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies. Obesity Reviews. 2009;10(1):28-35. doi:10.1111/j.1467-789X.2008.00537.x
Hibbard JU, Gilbert S, Landon MB, et al. Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery. Obstetrics & Gynecology. 2006;108(1):125-133. doi:10.1097/01.AOG.0000223871.69852.31
Blondon M, Harrington LB, Boehlen F, et al. Pre-pregnancy BMI, delivery BMI, gestational weight gain and the risk of postpartum venous thrombosis. Thrombosis Research. 2016;145:151-156. doi:10.1016/j.thromres.2016.06.026
Molyneaux E, Poston L, Ashurst-Williams S, et al. Obesity and mental disorders during pregnancy and postpartum. Obstetrics & Gynecology.2014;123(4):857-867. doi: 10.1097/AOG.0000000000000170
Schummers L, Hutcheon JA, Bodnar LM, et al. Risk of adverse pregnancy outcomes by prepregnancy body mass ındex. Obstetrics &Gynecology.2015;125(1):133-143. doi:10.1097/AOG.0000000000000591
Given JE, Loane M, Garne E, et al. Metformin exposure in first trimester of pregnancy and risk of all or specific congenital anomalies: exploratory case-control study. BMJ. Published online June 25, 2018:k2477. doi:10.1136/bmj.k2477
Getahun D, Fassett MJ, Jacobsen SJ, et al. Perinatal outcomes after bariatric surgery. American Journal of Obstetrics and Gynecology. 2022;226(1):121.e1-121.e16. doi:10.1016/j.ajog.2021.06.087
Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Obesity. 2013;21(S1):S1-S27. doi:10.1002/oby.20461
Scialli AR. Teratology public affairs committee position paper: Maternal obesity and pregnancy. Birth Defects Research Part A: Clinical and Molecular Teratology. 2006;76(2):73-77. doi:10.1002/bdra.20236
Werler MM. Prepregnant weight in relation to risk of neural tube defects. JAMA: The Journal of the American Medical Association. 1996;275(14):1089. doi:10.1001/jama.1996.03530380031027
Denison FC, Aedla NR, Keag O, et al. Royal College of Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy: Green-top Guideline No. 72. BJOG. 2019 Feb;126(3):e62-e106. doi: 10.1111/1471-0528.15386. Epub 2018 Nov 21. PMID: 30465332.
Davidson KW, Barry MJ, Mangione CM, et al. Aspirin use to prevent preeclampsia and related morbidity and mortality. JAMA. 2021;326(12):1186. doi:10.1001/jama.2021.14781
Khaikin Y, Bishop KA, Munawar S, et al. Delay of fetal anatomy ultrasound assessment based on maternal body mass ındex does not reduce the rate of ınadequate visualization. Journal of Ultrasound in Medicine. 2020;39(11):2123-2130. doi:10.1002/jum.15319
American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Indications for outpatient antenatal fetal surveillance: ACOG Committee Opinion, Number 828. Obstet Gynecol. 2021 Jun 1;137(6):e177-e197. doi: 10.1097/AOG.0000000000004407. PMID: 34011892.
Gibbs Pickens CM, Kramer MR, Howards PP, et al. Term elective ınduction of labor and pregnancy outcomes among obese women and their offspring. Obstetrics & Gynecology. 2018;131(1):12-22. doi:10.1097/AOG.0000000000002408
Blomberg M. Maternal obesity and risk of postpartum hemorrhage. Obstetrics&Gynecology.2011;118(3):561-568. doi:10.1097/AOG.0b013e31822a6c59
Tita ATN, Szychowski JM, Boggess K, et al. Adjunctive azithromycin prophylaxis for cesarean delivery. New England Journal of Medicine. 2016;375(13):1231-1241. doi:10.1056/NEJMoa1602044
Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics. 2004;113(5):e465-e471. doi:10.1542/peds.113.5.e465
