Overweight, pregnant and tempting fate
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.
The trend has alarmed Zelop, director of maternal and fetal medicine at Hartford’s St. Francis Hospital and Medical Center, and other physicians nationwide.
“Mothers are going to die and babies are going to die if we continue to do this,” Zelop warned.
Advances in medicine over the last 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. These include high blood pressure, blood clots and complications from Cesarean deliveries.
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% -- died from complications such as diabetes, high blood pressure, heart or breathing conditions or problems related to delivery of a larger baby.
So far, scientists have not linked those deaths to obesity, and at least some may be associated with a simultaneous trend of women having babies in their 40s, which also tends to increase complications.
But many of the most dangerous complications are frequently associated with extreme obesity. During pregnancy, “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.”
The problems associated with caring for increasing numbers of obese patients has reverberated through hospitals nationwide, 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 as well.
The obesity epidemic has taken its toll on healthcare providers, too, said Dr. Joshua Copel, professor of obstetrics, gynecology and reproductive services at the Yale School of Medicine. Performing ultrasound exams on obese women has caused shoulder, wrist and elbow injuries among physicians and technicians.
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, overweight patients often are sent to see specialists in imaging for high-risk pregnancies, such as Dr. Charles Ingardia, director of maternal and fetal medicine at Hartford Hospital.
But there are times that no amount of expertise or high-tech equipment can get around the extra weight. Ingardia said he had been forced to send patients home with the caution that although 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.
Julie McKenna, 35, of Connecticut, was aware that her weight could make her pregnancy more difficult. But things went smoothly until 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 overweight pregnant women. 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.
McKenna, 5-foot-3, started her pregnancy at 230 pounds, categorizing her as morbidly obese.
After controlling the diabetes with insulin injections four times a day, her son, William, was born healthy at St. Francis on Oct. 2.
But the birth was not without complications.
McKenna’s labor was induced because the baby had 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. It is unclear whether excess weight is the culprit behind lower nursing rates among overweight mothers.
Still, McKenna feels lucky. “I’m exceedingly grateful,” she said. She 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 her baby. “For him to watch me being more healthy and eating well, that’s important even if I don’t want to get pregnant again.”
Slimming down before becoming pregnant is the best way to lower the risks, 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 25 to 35 pounds as optimal weight gain during a pregnancy. But a study in Sweden found that women who started their pregnancies obese had better outcomes if they gained less.
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, healthcare 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 had seen patients leave in tears when she warned them that they were 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 seemed to resent even his euphemistic allusions to their “size” and appeared to be making no effort to control their weight during pregnancy.
But, he and others agree, it is probably time to speak up.
Even if the consequences are not life-threatening, overweight moms can set up themselves and their children for lifetimes of health problems that appear to be passed 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,” Ingardia said.
