Effects of obesity in

gynaecological and obstetric

practice

Presented by Dr Omoregie O.B

• Introduction
• Definition
• Methods of assessing obesity
• incidence
 Introduction
• Obesity is the commonest nutritional disorder in
gynaecological and obstetric practice in the
developed world (USA, Europe) due to
increasing affluence and sedentary life, as well
as higher caloric food.
• There is a well recognized relationship between
obesity and mortality/morbidity – 4 times higher
mortality in obese DM than in those with normal
weight.
• Even higher rates of accident amongst obese –
perhaps because fat people are awkward or
their view of the floor is obstructed.
 Introduction (contd)
• The incidence of medical conditions such as
hypertension, heart dz, noninsulin dependent
DM, gout, gallbladder dz, colorectal cancer,
endometrial cancer, postmenopausal breast
cancer, and osteoarthritis are increased in
overweight people.
• Modern studies of obesity indicates that it is a
multifactorial problem, rather than laziness or
lack of will power.
 Definition
• Obesity is an excess of body fat (20% or
more over ideal weight).
• Overweight is a body weight in excess of
some standard or ideal weight.
• Obesity is a critical weight of 90Kg and
above in pregnancy.
• BMI > 30kg/m2 (roughly equivalent to 30%
excess body weight).
 Methods of assessing obesity
• The most accurate method of determining body
fat is to measure body density by
hydrodensitometry (underwater measurement).
• Skinfold thickness using calipers
• BMI (the Quetelet index) the ratio of the weight
in kilograms divided by height in metres squared
Kg/m2 (corresponds closely to densitometry
measurement)
• Ponderal Index: dividing the square of the
height by the cube root of weight.
• Height and weight tables – obese if weight is
more than 9 Kg in excess of ideal weight.
 Incidence
• About 25% of American women are obese
• The incidence of obesity in pregnancy from a
study in UCH was 7.4% (2002).
• Women are more affected than men – due to the
fact that, they have a lower metabolic rate;
women also gain weight more with age – due to
postmenopausal loss of the increase in
metabolic rate that is associated with the luteal
phase of the menstrual cycle.
 Physiology of Adipose Tissue
Functions of Adipose tissue:
• It is the storehouse of energy
• Fat serves as a cushion from trauma
• It plays a role in the regulation of body heat.
Each adipose cell is regarded as a package of triglyceride,
which is the most concentrated form of stored energy.
Each gram of triglyceride provides 8 calories, compared with 1
calorie from 1 gram of glycogen.
The total store of carbohydrate (both tissue and fluid) in an
adults (about 300 calories) is inadequate to meet between-
meal demands.
Therefore, the storage of energy in fat tissue allows us to do
other things besides eating. Our energy balance, therefore, is
essentially equivalent to our fat balance. Thus, obesity is a
consequence of the fat imbalance inherent in high caloric
diets.
Following the ingestion of fat and its breakdown by gastric
and pancreatic lipases, absorption of long-chain
triglycerides and FFA takes place in the small bowel.
Chylomicrons (microscopic particles of fat) transferred
through lymph channels into the systemic venous
circulation are normally removed by hepatic
parenchymal cells where a new lipoprotein is released
into the circulation. When this lipoprotein is exposed to
adipose tissue, lipolysis occurs through the action of
lipoprotein lipase, an enzyme derived from the fat cells
themselves. The fatty acids that are released then enter
the fat cells where they are re-esterified with
glycerophosphate into triglycerides.
Because alcohol diverts fat from oxidation to storage, body
weight is directly correlated with the level of alcohol
consumption.
 Glucose serves 3 important functions:
• Glucose supplies carbon atoms in the form of
acetyl coenzyme A (acetyl CoA).
• Glucose provides hydrogen for reductive steps.
• Glucose is the main source of glycerophosphate.
The production and availability of
glycerophosphate is regarded as the rate limiting
step in lipogenesis.
After esterification, subsequent lipolysis results in
the release of fatty acids and glycerol.
In the cycle of lipolysis and re-esterification,
energy is freed as heat. A low variable level of
lipolysis takes place continuously; its basic
function is to provide body heat.
The chief metabolic products produced from fat are the
circulating free fatty acids. When CHO is in short supply,
a flood of FFA can be released. The FFA in the
peripheral circulation are almost wholly derived from
endogenous triglycerides that undergo rapid hydrolysis,
glycerol is also produced in the process.
The glycerol is returned to the liver for resynthesis of
glycogen.
The release of FFA from adipose tissue is stimulated by
physical exercise, fasting, exposure to cold, nervous
tension, and anxiety.
The release of FFA by lipolysis varies from one anatomic
site to another. Omental, mesenteric, and subcutaneous
fat is more labile and easily mobilized than fat from other
sources. Areas from which energy is not easily mobilized
are retrobulbar and perirenal fat where the tissue serves
a structural function.
Adipose tissue lipase is sensitive to epinephrine
and norepinephrine. Other hormones that
activate lipase are ACTH, TSH, growth
hormone, thyroxine, triiodothyronine, cortisol,
glucagon, vasopressin and human placental
lactogen.
Lipase activity is inhibited by insulin (a lone as the
physiologic antagonist to the array of stimulating
agents).
When glucose and insulin are abundant, transport
of glucose into fat cells is high, and
glycerophosphate production increases to
esterify fatty acids
The CHO and fat composition of the fuel supply is
constantly changing, depending on stresses and
demands.
The CNS and some other tissue utilizes only glucose for
energy, therefore, an homeostatic mechanism for
conserving CHO is essential.
When glucose is abundant and easily available, it is utilized
in adipose tissue for producing glycerophosphate used to
esterify fatty acids as triglycerides. The circulating levels
of FFA in muscle will, therefore, be low, and glucose will
be used by all of the tissue.
When CHO is scarce, the amount of glucose reaching the
fat cells declines, and glycerophosphate production is
reduced. The fat cell releases fatty acids, and their
circulating level rise to a point where glycolysis is
inhibited. Thus, carbohydrate is spared in those tissue
capable of using lipid substrates. If the rise of fatty acids
is great enough, the liver is flooded with acetyl coA. This
is converted into ketone bodies, and clinical ketosis
results.
In simple terms, when a person eats,
glucose is available, insulin is secreted,
and fat is stored. In starvation, the glucose
level falls, insulin secretion decreases,
and fat is mobilized.
If only single large meals are consumed, the
body learns to convert CHO to fat very
quickly. Epidemiologic studies with school
children demonstrate a positive correlation
between fewer meals and a greater
tendency towards obesity.
 Effects of obesity in obstetric
practice
Antepartum
• Feel more uncomfortable, with easy fatigability, and
exertional dyspnoea in pregnancy
• Medical disorder in pregnancy
Hypertension – obese women are twice as likely to develop
HT in preg
Diabetes – maternal obesity is one of the indicators of
potential DM, obesity increases the risk of GDM by 4-fold
• UTI – the risk is increased in obesity
• Pre-term labour is less likely in obesity, compared to
post-term pregnancy which is more common in obesity.
• difficulty in abdominal palpation – hence twin pregnancy
may be missed, inaccurated estimation of gestational
age
• Difficulty in assessing lie, presentation and
hearing fetal heart sounds – higher incidence of
abnormal lie and malpresentation.
• Increase use of ultrasound imaging
• Increased need for induction of labour due to
postterm, medical indications.
• Higher incidence of protracted labour – due to
fetal macrosomia, shoulder dystocia
• Increased use of augumentation in labour
• Increased use of operative delivery
• Increased risk of PPH
• Increased C/S rate
• Difficult/failed intubation during anaesthesia
• Failure of lactation
Puerperal complications
• Thromboembolism
• Increased incidence of wound sepsis
Increased perinatal mortality and morbidity
• Traumatic delivery/shoulder dystocia
• Placental insufficiency from postterm preg
• Meconium aspiration syndrome
• Failure to diagnose malpresentation
• Birth asphyxia
Effects of obesity in gynaecological
practice
• Menstrual abnormalities – anovulatory cycles,
menorrhagia, abnormal uterine bleeding
• Uterine fibroid – obesity is an associated risk factor for
fibroid (peripheral conversion of androgens to oestrogen)
• Endometrial cancer – same as above is implicated
• Contraceptive use – avoiding the use of oral and
injectable hormonal contraceptive methods
• Laparoscopic procedure – difficulty in accessing the
peritoneal cavity.
• Infertility – menstrual abnormalities, DM, PCOS
• Difficult gynaecological surgery
• Difficult in anaesthesia
• Wound sepsis/ thromboembolism