Obesity in Pregnancy: ACOG Committee Opinion

The American College of Obstetricians and Gynecologists (ACOG) has released an opinion statement on issues specific to pregnancy in obese women. The statement, “Obesity in Pregnancy,” was published in the September 2005 issue of Obstetrics & Gynecology.

Women who are obese (i.e., those with a body mass index [BMI] of 30 kg per m2 or greater) are at increased risk of complications of pregnancy such as gestational hypertension and diabetes, preeclampsia, fetal macrosomia, spontaneous abortion, cesarean delivery, neural tube defects in the fetus, and stillbirth. Estimation of fetal weight and interpretation of external fetal heart rate and patterns of uterine contraction also may be problematic in women who are obese. Infants who are large for their gestational age are more common in mothers who are obese, and these infants subsequently are at increased risk of childhood obesity. In addition, operative and postoperative complications such as excessive blood loss, longer operative time, wound infection, endometritis, and anesthetic challenges are more common in obese patients.

ACOG strongly encourages preconception assessment and counseling of women who are obese, with provision of education about the risks and potential complications for mother and fetus. Nutrition advice should be provided, and patients should be encouraged to make changes in diet and exercise before pregnancy is attempted. Weight loss also should be encouraged before initiation of infertility treatment because of the increased risk of spontaneous abortion in obese women who undergo this therapy. Counseling and exercise programs should continue after delivery.

Women who have had bariatric surgery should be counseled to avoid pregnancy during the postsurgery phase of rapid weight loss. Pregnant women who have had bariatric surgery should have levels of vitamin B12, folate, iron, and calcium assessed to determine whether supplementation is necessary.

Prenatal weight gain recommendations should correspond to the Institute of Medicine guidelines: 25 to 35 lb (11.4 to 15.9 kg) for women with a BMI below 25 kg per m2; 15 to 25 lb (6.8 to 11.4 kg) for women with a BMI of 25 to 29 kg per m2; and 15 lb (6.8 kg) for women with a BMI of 30 or greater kg per m2. In pregnant women who are obese, screening for gestational diabetes should be considered at presentation or in the first trimester, with screenings repeated throughout pregnancy if the results are negative.

Because of the increased likelihood of cesarean delivery and complications of surgery, ACOG recommends that pregnant women who are obese have an anesthesiology consultation before delivery. Because of the increased risk of wound breakdowns and infections in obese patients, antibiotic prophylaxis should be given if cesarean delivery is required. The use of graduated compression stockings, hydration, and early mobilization may be helpful during and after cesarean delivery.

ACOG Releases Guidelines on Tay-Sachs Screening

The American College of Obstetricians and Gynecologists (ACOG) has released recommendations for screening for Tay-Sachs disease. The report was published in the October 2005 issue of Obstetrics & Gynecology.

ACOG recommends that persons of Ashkenazi Jewish, French-Canadian, or Cajun descent be offered a screening test before pregnancy, as should couples with a family history of the disease. If a person is determined to be a carrier for Tay-Sachs disease, his or her partner also should be offered screening. If the couple is already pregnant, both partners should be screened at the same time to ensure immediate results, and they should be informed of their options promptly. Genetic counseling and prenatal diagnosis should be offered if both partners are determined to be carriers.

Screening for carriers of Tay-Sachs disease can be done through molecular or biochemical analysis; biochemical analysis should be used when screening patients at less risk of being carriers. Pregnant women and women using oral contraceptives who were screened using biochemical analysis also should be screened using leukocyte testing. Any screening tests that return ambiguous or positive results should be confirmed by biochemical and DNA analyses for the most common mutations. These tests will identify patients who carry genes associated with mild disease or pseudodeficiency states, in which case a referral to a subspecialist in genetics can be beneficial.

CDC Recommendations for Improving Oral Health

The Centers for Disease Control and Prevention (CDC) has released recommendations for preventing dental caries and improving oral health. The recommendations YOU appeared in the August 26, 2005, issue of Morbidity and Mortality Weekly Report and are available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm.

The prevalence and severity of dental caries in permanent teeth declined across all demographic and age groups from 1988 to 1994 and from 1999 to 2002. The use of dental sealants among children and adolescents has increased significantly, and older adults are retaining more of their teeth. Although general oral health is improving, some disparities remain, and minorities, persons with lower income and education levels, and current smokers have larger unmet needs than other groups. To continue oral health improvements, the CDC makes the following recommendations:

• Public health interventions to prevent dental caries should extend to persons in all age groups and sociodemographic categories.

• Factors related to the lack of reduction of dental caries in primary teeth should be studied.

• As the U.S. population ages and more adults keep their natural teeth, preventive interventions are needed at the individual, clinical, and community levels.

• Programs designed to promote oral health (e.g., dental sealants, smoking cessation programs) should include interventions to reduce disparities in racial and ethnic minorities, persons with lower income and education levels, and current smokers.

• Surveillance tools are needed to monitor fluoride exposure from multiple sources.