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PMH Care Pathways: Management of Obesity in Pregnancy

PMH Care Pathways: Management of Obesity in Pregnancy

Management of Obesity in Pregnancy

April 2016

A. Background
Obesity is the most common health problem in women of reproductive age. Approximately 34% of women have a BMI > 30 and 7.5% have a BMI > 40.1 In North Carolina, 33% of pregnant women receiving care at a Pregnancy Medical Home had a BMI>30.2 In this care pathway we provide suggestions for the care of the obese pregnant patient. For detail behind these recommendations, please review the references included below.

This pathway focuses on two patient groups:
• Patients with BMI >30 - 40 Class I/II Obesity
• Patients with BMI >40 Class III Obesity

Guidance for the management of pregnancy in a patient of any weight with a history of bariatric surgery can be found in Appendix A of this document.

B. Preconception Care: Care of the obese patient should focus on two priorities prior to conception: identification and management of comorbid conditions and aggressive weight loss management. Pregnancy outcomes improve with control of medical comorbidities but weight loss will also reduce the risk of obesity-related complications during a subsequent pregnancy.

1. Screen for co-existent metabolic syndrome/other co-morbid conditions:
a. Diabetes
b. Hypothyroid
c. Lipid abnormalities
d. Hypertension
e. Nonalcoholic steatohepatitis (NASH) syndrome

2. Weight loss strategies:
a. Nutritional consultation
b. Exercise
c. Referral for bariatric surgery
i. BMI > 40
ii. BMI > 35 with 2 comorbid conditions
d. Folic acid supplementation: 1 mg daily

C. Antepartum Care

1. First trimester
a. Screen for comorbid conditions:
i. HgbA1c/early gestational diabetes screening
ii. Metabolic panel
iii. TSH
iv. Urine protein/creatinine ratio
v. Consider maternal EKG in patients with BMI >40 and in those with BMI > 30 and co-morbidities
b. Nutritional information/consultation:
i. Recommended weight gain per Institute of Medicine is 11-20 pounds3
ii. Folic acid supplementation – 1mg/daily
c. Discuss perinatal risks:
i. Fetal anomalies - Obesity increases risk of fetal anomalies and decreases likelihood of detecting anomalies4
ii. Gestational diabetes
iii. Preeclampsia
iv. Macrosomia
v. Cesarean section/wound complications
vi. Stillbirth
d. Ultrasound for accurate dating
e. Suspected sleep apnea
i. Snoring, excessive daytime sleepiness, witnessed apneas, or unexplained hypoxia
ii. Refer to a sleep specialist if needed
f. Consider high-risk obstetrics (HROB) or maternal-fetal medicine (MFM) consult per institutional protocol or for BMI > 50
g. Low dose aspirin - 81 mg daily for BMI > 40 or for BMI > 30 with additional risk factor, initiated between 12-16 weeks of gestation, up to 28 weeks of gestation if delayed entry to prenatal care

2. Second trimester
a. Monitor weight gain
b. Detailed anatomy ultrasound – limitations should be addressed with patient
c. Consider OB Anesthesia consult per institutional protocol or for BMI > 50

3. Third trimester
a. Repeat gestational diabetes screening
b. Consider serial growth ultrasound if pannus precludes accurate fundal height assessment
c. Consider weekly NST/AFI after 36 weeks
d. Consider referral to HROB/MFM for delivery planning based on Institutional protocol or with BMI > 50

D. Delivery

1. Induction per institutional protocol
a. Timing and method per local preference
b. Consider pneumatic compression devices for those with prolonged bed rest with induction

2. Cesarean delivery:
a. In patients with BMI >60, there are instances where inability to perform emergent cesarean may preclude attempt at vaginal delivery and primary cesarean is recommended
b. Consider 3 grams cefazolin with cesarean delivery
c. Consider Hibiclens® shower/wipe prior to cesarean
d. Operative prep per local protocol
e. Pneumatic compression devices for all cesarean patients
f. Consider a negative pressure wound dressing in high risk patients (BMI > 40, chorioamnionitis in labor, prolonged labor, preeclampsia with significant edema)
g. Occupational/physical therapy consult post-delivery if difficulties with wound care and or daily living are anticipated

3. Consider low molecular weight heparin prophylaxis in highest risk patients (BMI > 50, chorioamnionitis in labor, prolonged labor, preeclampsia)7
a. Initiate at 12-24 hours post delivery
i. 40 mg BID BMI 40-60
ii. 60 mg BID BMI >60

E. Postpartum

See the Pregnancy Medical Home Care Pathway on Postpartum Care and the Transition to Well Woman Care for detailed guidance about timing of postpartum care and the content of the comprehensive postpartum visit.

1. Incisional check at 5-7 days with external wound vacuum removal, if utilized

2. Comprehensive postpartum visit:
a. Depression screen at comprehensive postpartum visit
b. Review contraceptive options: IUD or implant are preferred methods
c. Encourage breastfeeding
d. Nutritional counseling
e. Exercise

3. Ensure transition to primary care provider

4. Consider bariatric surgery referral
a. BMI > 40
b. BMI > 35 with 2 co-morbid conditions

F. References

  1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-497. doi:10.1001/jama.2012.39.
  2. Tucker CM, Berrien K, Menard MK, et al. Predicting Preterm Birth Among Women Screened by North Carolina’s Pregnancy Medical Home Program. Matern Child Health J. 2015;19(11):2438-2452. doi:10.1007/s10995-015-1763-5.
  3. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 548: weight gain during pregnancy. Obstet Gynecol. 2013;121(1):210-212. doi:http://10.1097/01.AOG.0000425668.87506.4c.
  4. Aagaard-Tillery KM, Flint Porter T, Malone FD, et al. Influence of maternal BMI on genetic sonography in the FaSTER trial. Prenat Diagn. 2010;30(1):14-22. doi:10.1002/pd.2399.
  5. Louis J, Auckley D, Miladinovic B, et al. Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women. Obstet Gynecol. 2012;120(5):1085-1092. doi:10.1097/AOG.0b013e31826eb9d8.
  6. Facco FL, Ouyang DW, Zee PC, Grobman WA. Development of a pregnancy-specific screening tool for sleep apnea. J Clin Sleep Med. 2012;8(4):389-394. doi:10.5664/jcsm.2030.
  7. Overcash RT, Somers AT, LaCoursiere DY. Enoxaparin dosing after cesarean delivery in morbidly obese women. Obstet Gynecol. 2015;125(6):1371-1376. doi:10.1097/AOG.0000000000000873.

Note: Pregnancy Medical Home Care Pathways are intended to assist providers of obstetrical care in the clinical management of problems that can occur during pregnancy. They are intended to support the safest maternal and fetal outcomes for patients receiving care at North Carolina Pregnancy Medical Home practices. This pathway was developed after reviewing ACOG resources such as practice bulletins, committee opinions, and Guidelines for Perinatal Care as well as current obstetrical literature. PMH Care Pathways offer a framework for the provision of obstetrical care, rather than an inflexible set of mandates. Clinicians should use their professional knowledge and judgment when applying pathway recommendations to their management of individual patients.