Antenatal Management of Obesity

Purpose: To assist OB providers managing women who are obese with respect to antenatal surveillance, management, timing of delivery and postpartum management.

Definition: Class I obesity BMI≥30-34.9 kg/m2, Class II obesity BMI≥35-39.9 kg/m2, Class III obesity BMI≥40 kg/m2. NB: all BMI calculations are pre-pregnancy.

Recommendations:

Recommendation	Class I	Class II	Class III	BMI>60
ASA 162mg	X	X	X	X
Early ultrasound for accurate dating	X	X	X	X
Consider nutrition consult	X	X	X	X
Early screening for GDM, baseline preeclampsia labs and HgbA1c should be done at first prenatal visit	X	X	X	X
Maternal Echocardiogram	X (with risk factors: cHTN/GDM)	X (with risk factors: cHTN/GDM)	X (with risk factors: cHTN/GDM)	X
Consider early anatomy survey at 18 weeks with MFM; otherwise, initial anatomy can be done at 20 weeks in your facility. msAFP can be used as an adjunct to screen for NTDs especially if ultrasound visualization is poor.	X	X	X	X
Pediatric Cardiology/MFM fetal echocardiography should be considered if detailed anatomy scan cannot adequately visualize: 4CH, RVOT/LVOT, 3VV and tracheal view.	X	X	X	X
Consider sleep apnea screening (STOPBANG questionnaire: https://www.mdcalc.com/stop-bang-score-obstructive-sleep-apnea)	X	X	X	X
Fetal growth assessment at 30 and 36 weeks	X	X	X	X
Start once weekly NSTs once a week at 36 weeks.	X	X
Anesthesia consult	X
Perioperative Antibiotics: Azithro + Ancef (3g if >120kg)	X	X	X	X
Delivery timing	40w (39w with risk factors: LGA,GDM,poly)	40w (39w with risk factors: LGA,GDM,poly)	39-40w	39-40w
Consider wound vac placement postop	X (with risk factors such as DM/chorio)	X
Postop prophylactic Lovenox while inpatient	X (with risk factors)	X (with risk factors)	X	X

References:

American College of Obstetricians and Gynecologists. Practice Advisory on low-dose aspirin and prevention of preeclampsia: Updated recommendations. http://www.acog.org.

Wax et al. Consensus report on the detailed fetal anatomic ultrasound examination: indications, components and qualifications. J Ultrasound Med 2014;33:189-95.

Donofrio et al. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014;129:2183.

Schuster M et al. The effect of the MFM obesity protocol on cesarean delivery rates. Am J Obstet Gynecol 2016;215:492e1-6.