|Year : 2014 | Volume
| Issue : 3 | Page : 180-182
Maternal obesity and twin pregnancy: A case report and literature review
Preeti Galvankar, Rajkumar Shah
Department of Obstetrics and Gynecology, Nanavati Super Speciality Hospital, Vile Parle (W), Mumbai, Maharashtra, India
|Date of Submission||02-Sep-2014|
|Date of Decision||05-Sep-2014|
|Date of Acceptance||06-Sep-2014|
|Date of Web Publication||19-Sep-2014|
Nanavati Super Speciality Hospital, Vile Parle (W), Mumbai 400 056, Maharashtra
Source of Support: None, Conflict of Interest: None
Maternal obesity is defined as obesity during pregnancy. Many obese women, in their child-bearing age, are entering into the pregnancy, not aware of the fact that they are a high-risk pregnancy group. It is very well-documented that a strong link exists between maternal overweight/obesity and gestational diabetes mellitus (GDM) and gestational weight gain and resultant large for gestational age babies. A twin pregnancy adds to the associated maternal co-morbid conditions and fetal morbidity/mortality. The present case study of maternal obesity specified the likely complications of maternal obesity and associated co-morbid conditions like pregnancy-induced hypertension and GDM. A single case study cannot account for the generalized application for population of obese pregnant women at large, but can be corroborated with various studies of maternal obesity from the literature review.
Keywords: Gestational diabetes mellitus, gestational weight gain, maternal obesity, pregnancy-induced hypertension
|How to cite this article:|
Galvankar P, Shah R. Maternal obesity and twin pregnancy: A case report and literature review. J Obes Metab Res 2014;1:180-2
| Introduction|| |
Maternal obesity, signifying high body mass index (BMI), encompasses issues of health during pregnancy to the mother as well as to the fetus/neonate. Obese women, per se, have high incidence of infertility, recurrent abortions, congenital fetal malformations, large for gestational age (LGA) babies and associated complications. Many women of child-bearing age are now entering into the pregnancy as obese individuals. The proneness to obesity may be due to polycystic ovary syndrome, stress of life, social factors, improper life-style or iatrogenic factors. The management of obesity, prior to conception and pre-conceptional counseling regarding the associated feto-maternal risks, would go a long way to limit the likely co-morbid conditions during pregnancy. The awareness among the clinicians regarding desired gestational weight gain (GWG) and its effect on maternal and infant health outcome is essential to impart the knowledge to the parturient mother. In the present case report, we detail the effects of maternal obesity compounded with a twin pregnancy.
| Case report|| |
A 43-year-old elderly obese primigravida, married for 21 years, weighing 104 kg with twin pregnancy (in vitro fertilization [IVF] conception) at 22 weeks of gestation, was referred for acute care to the Obstetric Department of the Dr. Balabhai Nanavati Hospital, a tertiary care hospital, with chief complaint of dyspnea. As per her account, she had undergone multiple attempts of assisted reproductive treatment (ART) in the last 4 years. She had five failed attempts at intra-uterine insemination, following controlled ovarian stimulation and postovulatory progesterone support. After each ART attempt, she had gained 4-5 kg of weight.
Prior to her infertility treatment, she said weighed 60 kg and had gained more than 30 kg in 4 years of treatment. Finally, after a successful IVF pregnancy, her peri-conceptional weight was 96 kg and BMI 37 kg/m 2 . There was no other major illness or surgery in the past. There was no family history of diabetes mellitus. Her father had high blood pressure (BP).
She had gained 8 kg in the previous month and was weighing 104 kg at the time of the hospital admission. She had breathing difficulties, and BP was 170/100 mm of Hg. She was put on suitable antihypertensive and symptomatic treatment for respiratory distress.
The obstetric scan confirmed diamniotic, dichorionic twin pregnancy, corresponding to the gestational period. She was discharged from the hospital after 4 days with a fair control of BP and breathing problems and advised to continue hematinics, calcium, vitamins, anti-hypertensive, low-dose aspirin and regular ante-natal follow-ups.
Around 26 weeks of gestation, she was found to have impaired glucose tolerance and confirmed to be a gestational diabetic, after 75 g of glucose challenge test. She was treated with insulin therapy and given diet advice. She steadily gained weight at the rate of almost 1 kg/week. Her blood sugar was maintained at optimum levels. At 32 weeks of gestation, she was re-admitted to the hospital with breathing difficulties, with difficulty in lying supine in the bed, itching and swelling of both the legs, with ulcers and cellulitis. The ulcers on legs were treated with local antibiotics, local anesthetic gel and soothing agents. At the time of discharge 72 h later, her BP was 130/90 mm of Hg and was normoglycemic.
At 33 weeks of gestation, with patient's request, a decision was made to deliver the babies. An elective lower segment caesarean section under regional anesthetics was performed and twin babies are weighing 2.02 kg and 1.93 kg were delivered. In views of premature delivery, both the neonates were kept in Neonatal Intensive Care Unit for observation for 48 h. The postdelivery recovery for both, mother and babies were satisfactory and were discharged from the hospital on the 6 th postnatal day.
At the time of discharge, the patient's weight was 114 kg and BP was 130/90 mm of Hg. Subsequently, postnatal check-ups were continued for 6 weeks. She has been referred to a dietician and a physical therapist for weight management. 6 months, postdelivery, the patient's weight is 104 kg - a loss of 10 kg.
| Discussion|| |
Obesity is a rapidly growing global health problem, and is more likely to cause complications in women of child-bearing age, when they enter into pregnancy. National Family and Health Survey (NFHS-3), India, has reported an increase in the percentage of obese married women to 15% (2005-2006).  Complications such as pregnancy-induced hypertension, preeclampsia, gestational diabetes mellitus, premature deliveries, induction of labor, instrumental delivery, including caesarean section, large newborns for the gestational age (LGA) or newborns with small for gestational age, shoulder dystocia, and perinatal complications are well documented in literature from abroad and the sparse literature from India. ,,,,,,
In May 2009, the Institute of Medicine (IOM) revised its GWG guidelines, by a year-long review of research to investigate the implications of varying amounts of GWG on maternal and infant healthcare outcome.  The last comprehensive review was in the year 1990. In a consensus statement for diagnosis of obesity, abdominal obesity and metabolic syndrome in Asian Indians, Misra stated that the levels of normal BMI are narrower and lower in Asian Indians (based on the percentage of body fat and morbidity data) than in the white Caucasians.  The revised guidelines for diagnosis for obesity and metabolic syndrome estimated that 10-15% of Indian population were overweight/obese. However, there are no reported guidelines for GWG for Indian population. The IOM guidelines also are for a singleton pregnancy, and there are no specific guidelines for GWG for multiple pregnancies.
The obese pregnant women are more likely to have LGA babies, with or without gestational diabetes. The progeny is shown to be associated with childhood obesity largely if accompanied by excessive GWG. , It has also been shown that maternal obesity induces more neonatal fat body mass and not lean body mass.  In a study to evaluate the pattern of GWG and its relation with fetal growth in normoglycemic obese (BMI ≥ 30) women and lean (BMI 19-25) women, Chmitorz et al. in UK, reported a prevalence of macrosomia to be 21% and 3% in obese and lean mothers respectively.  The GWG was biphasic in lean women (max weight gain occurred in second-trimester), whereas in the obese women there was a slow and gradual increase throughout the pregnancy. In another interesting study, the authors have observed trimester-specific maternal weight gain so as to predict excessive GWG by the second-trimester and avert the total GWG by taking appropriate preventive measures.  Since the interventional physical activity alone or with nutritional counseling and weight monitoring during pregnancy have resulted in a desirable reduction of GWG,  it could be useful to draw guidelines for trimester-specific maternal weight gain.
| Conclusion|| |
Maternal obesity has to be anticipated and prevented by pre- and peri-conceptional weight management by appropriate counseling and providing professional and skilled team work between dietician/nutritionist, physical therapist and obstetrician. If, the problem is not attended earlier in pre/peri-conceptional time, opportunity should be seized to monitor GWG in a trimester-stratified manner and to prevent accelerated GWG. Maternal obesity should be viewed and recognized as high-risk pregnancy as much as gestational diabetes and treated accordingly.
It is rightly pointed out by Schumann et al. that maternal obesity is largely a neglected health issue by various national and international bodies, including WHO that has published guidelines for ante-natal care that does not include any guidance for management of maternal obesity.  Through this article we suggest that All India Association for Advancing Research in Obesity (AIAARO) along with Federation of Obstetrics and Gynecological Societies of india (FOGSI) create a consensus for the management of maternal obesity and provide guidelines for GWG keeping Indian context in mind.
| Acknowledgement|| |
We sincerely thank Dr. Rama Vaidya for sharing her insights in the field of maternal obesity and her critical inputs as we prepared this Case Report.
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