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Weight And Pregnancy

By HILARY WALDMAN, Courant Staff Writer

December 10, 2007

When Dr. Carolyn M. Zelop started caring for pregnant women 16 years ago, she rarely saw a patient who weighed more than 300 pounds.

Now she sees them all the time.

But Zelop, the director of maternal and fetal medicine at St. Francis Hospital and Medical Center in Hartford, has not gotten used to it. Instead, she and her colleagues across the country have become increasingly alarmed.

"Mothers are going to die and babies are going to die if we continue to do this," Zelop warned.

Advances in medicine over the past century have transformed death during pregnancy and childbirth from an accepted risk to a rare and tragic event.

But numerous studies confirm that obese women are at higher risk of pregnancy-related complications that can threaten the life of both the mother and the fetus. The complications include high blood pressure, blood clots and complications from Cesarean delivery.

In 2004, the most recent year for which statistics are available, 540 women in the United States died from causes related to pregnancy or childbirth, according to the National Center for Health Statistics. Of them, 343 — more than 60 percent of the total — died from complications including diabetes, high blood pressure, heart or breathing conditions or problems related to the delivery of a baby who does not fit through the birth canal.

So far, scientists have not directly linked those deaths to obesity, and at least some of the deaths may be associated with a simultaneous trend of women having babies in their 40s, when pregnancy complications tend to increase.

But many of the complications responsible for maternal deaths are frequently associated with extreme obesity. And Zelop and others are convinced the obesity epidemic that has swept across the nation — and much of the developed world — is coming to roost in the delivery room.

"Everything is made harder," said Dr. Laura Riley, medical director of labor and delivery at Massachusetts General Hospital in Boston. "There's more diabetes, more prematurity, more pre-eclampsia, more neural tube defects, a greater risk of stillbirth."

Longer Scalpels

The problems associated with caring for more obese pregnant patients have reverberated through hospitals across the country, from the ultrasound suite to the operating room.

To accommodate larger patients, St. Francis and other hospitals have invested in new equipment including longer scalpels, wider operating tables and super-sized compression stockings to fit overweight patients having C-sections.

Anesthesia has become trickier during C-sections as well, because it is not uncommon for overweight patients to suffer from sleep apnea, a condition in which a person briefly stops breathing while asleep.

The obesity epidemic has taken its toll on health care providers, too, said Dr. Joshua Copel, professor of obstetrics, gynecology and reproductive services at the Yale School of Medicine. Performing ultrasound examinations on obese women has caused shoulder, wrist and elbow injuries among physicians and technicians in his department and at other hospitals.

Often, a physician must lift layers of fat and apply pressure on the ultrasound transducer in an attempt to see an image of the fetus. Even when they do, the image is not always clear enough to recognize trouble signs.

When that happens in the doctor's office, overweight patients often are sent to see Dr. Charles Ingardia, director of maternal and fetal medicine at Hartford Hospital and a specialist in imaging for high-risk pregnant women.

But there are times that no amount of expertise or high-tech equipment can compensate for the extra weight. Ingardia said he has been forced to send patients home with the caution that while he hopes everything is OK , he cannot be certain because the image of the fetus is so obscured by excess tissue.

"Sometimes we have to give up and say we couldn't see all of the anatomy because of maternal obesity," Ingardia said.

Complications

Julie McKenna was aware that her weight could make her pregnancy more difficult. But things went so smoothly for the first half that the 35-year-old Newington woman was shocked last July when a routine glucose tolerance test in her 28th week showed that her blood sugar was dangerously high.

Gestational diabetes is one of the most common complications for pregnant women who are overweight. The condition, which can cause a fetus to grow so large that it is difficult to deliver, frequently has no symptoms. And half of women whose diabetes is discovered during pregnancy develop chronic diabetes after they deliver.

McKenna is 5-feet, 3-inches tall and started her pregnancy at a weight of 230 pounds, placing her squarely in the category of morbidly obese. But after years on Weight Watchers, she thought she had adopted a fairly healthy diet.

After controlling the diabetes with insulin injections four times a day, McKenna's first son, William, was born healthy at St. Francis on Oct. 2.

But the birth was not without complications.

McKenna's labor was induced because Billy had already reached 9 pounds by his due date, ensuring a rough delivery at best. When McKenna's labor did not progress — another common occurrence in heavy mothers — she had a Cesarean section.

But she said her only real disappointment was that an insufficient milk supply prevented her from breast-feeding. While research has found that there may be a link between obesity and breast-feeding problems, the jury is still out on whether excess weight is the culprit of lower nursing rates among overweight mothers.

Still, McKenna feels lucky. "I'm exceedingly grateful," she said. She also says she is determined to slim down, whether or not she decides to have another child.

"I've always wanted to do it to look better and feel better, but this just adds [incentive]," McKenna said, cradling 6-week-old Billy. "For him to watch me being more healthy and eating well, that's important even if I don't want to get pregnant again."

Still Taboo

Slimming down before becoming pregnant is the best way to lower the risks for expectant mothers and their offspring, experts say.

But it's not too late for a woman to watch her weight even after she becomes pregnant, several new studies recently published in the journal Obstetrics and Gynecology suggest.

The Institute of Medicine of the National Academies recommends that women gain 25 to 35 pounds for an optimal pregnancy. But a study in Sweden found that women who started their pregnancies obese had better outcomes if they gained less than the recommended amount.

The study found that women with a body mass index of 25 to 29.9, which is considered overweight, did best when they gained less than 20 pounds during pregnancy. Women with a body mass index of 30 or more, which is considered obese, had fewer complications if they gained less than 13 pounds.

But some doctors complain that there appears to be only minimal commitment on the part of women, health care professionals and researchers to address weight loss for pregnant women. Of 58 studies now being funded by the National Institutes of Health related to pregnancy and obesity, only a handful address healthy lifestyles and weight reduction.

And despite the well-known risks, Zelop and Riley complain that many doctors are reluctant to be honest with their patients.

"It's sort of like a taboo," said Zelop, who said she has seen patients leave her office in tears when she warns them that they are dangerously overweight. "Most physicians are afraid to talk about it, they're afraid they're going to offend the patient."

Ingardia said some of his patients seem to resent even his euphemistic allusions to their "size" and appear to be making no effort to control their weight during pregnancy.

But, he and others agree, it is probably time to break the silence.

Even if the consequences are not life-threatening, overweight moms can set up themselves and their children for lifetimes of health problems from diabetes to weight struggles that appear to be passed down from one generation to the next.

"It's sad, they bring children with them and you can see their kids already are on their way to obesity," said Ingardia, noting that he's seen 80-pound 3-year-olds accompanying their mothers to ultrasound exams.

"It's a frustrating problem and I don't know where the trend is going."