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Placental dysfunction in obese women and antenatal surveillance strategies

https://doi.org/10.1016/j.bpobgyn.2014.09.007Get rights and content

Highlights

  • Obesity is associated with significant short-term and long-term feto-maternal complications.

  • Excess gestational weight gain is associated with metabolic disorders.

  • Placental dysfunction is mediated through inflammatory pathways.

  • Antenatal surveillance, counselling on ideal weight gain and screening and management of complications are the key for good outcomes.

  • Metformin is not recommended in non-diabetic obese women.

This review is aimed at discussing placental dysfunction in obesity and its clinical implication in pregnancy as well as an antenatal surveillance strategy for these women. Maternal obesity is associated with adverse perinatal outcome. Obesity is an independent risk factor for fetal hyperinsulinaemia, birthweight and newborn adiposity. Maternal obesity is associated with childhood obesity and obesity in adult life. Obesity induces a low-grade inflammatory response in placenta, which results in short- and long-term programming of obesity in fetal life. Preconception and antenatal counselling on obstetrics risk in pregnancy, on diet and lifestyle in pregnancy and on gestational weight gain is associated with a better outcome. Fetal growth velocity is closely associated with maternal weight and gestational weight gain. Careful monitoring of gestational weight gain and fetal growth, and screening and management of obstetrical complications such as gestational diabetes and pre-eclampsia, improves perinatal outcome. The use of metformin in non-diabetic obese women is under investigation; further evidence is required before recommending it.

Introduction

Obesity has become a global epidemic. It is estimated that 205 million men and 297 million women were obese in 2008 [1]. Obesity in pregnancy is defined as a body mass index (BMI) of ≥30 kg/m2 at booking. One in five women in the UK is obese at antenatal booking; this is a threefold increase since 1980 [2]. Body fat distribution differs with race. Asian populations have more fat and more co-morbidity for any given BMI; therefore, it has been suggested to use lower BMI cut-off points for these populations [3]. Maternal obesity is associated with an increased risk of feto-maternal complications. Maternal obesity causes not only risks during the perinatal period but also long-term complications for the offspring. It creates a significant risk for the next generations with metabolic compromise already apparent at birth. The risks of developing adulthood obesity, hypertension, diabetes and metabolic syndromes are engineered in fetal life. The financial implications of obesity results in the rise in the health-care cost by 23% among overweight women and 37% among obese women after adjusting for maternal age, parity, ethnicity and co-morbidity, when compared with women with normal weight [4]. The present review is aimed at providing a comprehensive view on placental dysfunction in obese women and the need for antenatal surveillance strategies.

Section snippets

Molecular basis of placental dysfunction in obesity

In pregnancy, the feto-placental unit is a major site of protein and steroid hormone production and secretion, which results in metabolic changes. During in utero development, the fetus relies primarily on glucose as an energy substrate. There is a steady supply of glucose even during maternal fasting by increased hepatic gluconeogenesis in normal pregnancy. During early pregnancy, glucose tolerance is normal as insulin sensitivity and hepatic basal glucose production are normal [5], [6]. In

Clinical impact of placental dysfunction in obesity

Overweight and obese women are at a high risk of immediate and late maternal and fetal complications [28]. Studies show that obese women have a higher prevalence of infertility, recurrent miscarriage and congenital malformations [29], [30]. Pre-pregnancy obesity is a risk factor for gestational diabetes, pre-eclampsia, labour induction and caesarean section *[31], [32], *[33]. Post-delivery maternal complications include low breastfeeding rates [34], caesarean wound infection [33],

Maternal weight gain and fetal growth velocity

Fetal growth velocity depends upon genetic factors and the maternal environment. The maternal environment is reflected by signals transmitted by the placenta including nutrient transfer, blood hormone or oxygen levels. The fetus uses this information to make immediate survival choices and to make longer-term adjustments to maximize its advantage after birth [45]. The amount of weight gained during pregnancy affects the immediate and future health of a woman and her infant. The normal pattern of

Preconception care

Counselling and proper dietary advice are vital for obese mothers as evidence suggests that women's actual weight gain in pregnancy is strongly correlated with health-care provider advice [61]. Women should receive advice and information on interventions to achieve normal weight and be encouraged to undertake a weight-reduction programme [62]. Women should have the opportunity to optimize their weight before pregnancy. Other co-morbidities such as hypertension and diabetes should be treated

Role of metformin in non-GDM pregnant obese women and its effects on placenta

Metformin is an effective oral biguanide insulin sensitizer widely used for treating type 2 diabetes mellitus. It improves tissue sensitivity to insulin while inhibiting hepatic glucose production, enhancing peripheral glucose uptake, and decreasing insulin levels. Increasing obesity is associated with greater insulin resistance. As discussed earlier, inflammation is a central feature of the insulin resistance syndrome in obesity. Metformin has anti-inflammatory actions along with an increase

Conclusion

Maternal obesity poses a challenge in modern obstetrics. It is associated with various short-term and long-term feto-maternal complications. Obesity-induced insulin resistance, hyperglycaemia and inflammatory response causing epigenetic modifications are at the centre of the pathogenesis of fetal endocrine and metabolic changes. Maternal obesity, gestational weight gain and gestational diabetes are independently associated with adverse feto-maternal outcome. Antenatal surveillance; counselling

Conflict of interest

None.

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