Saturday, October 15, 2016

Placenta Accreta Rates Reflect High Cesarean Rates and VBAC Bans

October is Accreta Awareness Month. The International Cesarean Awareness Network (ICAN) is featuring Accreta Awareness as part of its focus this month, and is promoting the importance of donating blood in order to help women who experience accretas.

Placenta Accreta is a condition in which the placenta attaches too deeply to the uterine wall, or actually grows into the uterine wall. Occasionally it even grows through the uterine wall and into adjoining tissues. This means the placenta can't separate during birth. It causes massive bleeding, and frequently requires a hysterectomy in order to control the bleeding. Placenta Accreta has about a 7% maternal mortality rate and is one of the most serious obstetric situations a woman can face.

You can read more about Placenta Accreta in my series about it here:

  • Part One: What Is Accreta?
  • Part Two: Life-Threatening Complication of Prior Cesarean
  • Part Three: Risks to Mother and Baby
  • Part Four: Diagnosis, Treatment, and a Cautionary Story

Accretas have several different risk factors, including maternal age, parity, smoking, infection, pregnancy after fertility treatment, and prior uterine procedures such as D&C or fibroid removal.

However, the strongest risk factor for accretas is a history of prior cesarean sections. The discovery of placenta previa (a low-lying placenta) in a woman with a history of prior cesareans is particularly predictive of an accreta.

In addition, the risk for accreta rises strongly as the number of prior cesareans increases. Silver 2006 found the following risk for accreta by number of prior cesareans:

  • First cesarean:                  0.24%
  • Second cesarean:             0.31%
  • Third cesarean:                0.57%
  • Fourth cesarean:              2.13%
  • Fifth cesarean:                 2.33%
  • Sixth or more cesarean:   6.74%

A recent large Nordic study found:
The risk of AIP [abnormally invasive placenta] increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS.
Accretas are associated with poor outcomes, but very high-order repeat cesareans are particularly associated with poor outcomes.

Many accretas occur in women who have a cesarean in their first pregnancy and are automatically scheduled for repeat cesareans thereafter. Women who have larger families are particularly impacted. Yet many of these women say that they were never counseled about the risk of accreta with repeat cesareans. This is wrong. Informed consent should include discussions of all the risks of both VBAC and repeat cesareans.

Alarmingly, the incidence of placenta accreta cases seems to be on the rise. As noted by ACOG in the graphic above, this is likely in response to the rising cesarean rates. This reflects an increase in both primary cesareans and routine repeat cesareans as a result of de facto VBAC bans.

The increase in accretas is not just a U.S. phenomenon. A recent study from Hong Kong, where there is a high underlying cesarean rate, demonstrates that the rate of accreta increased over time as the cesarean rate increased. The authors note:
The overall rate of morbidly adherent placenta...increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013.
For such a rare condition, that's a significant increase. A similar result was found in an Italian region with a strong increase in cesarean rates over the years. Researchers found that:
The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.
One recent analysis concluded:
The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate.
Alarmingly, the increase in accreta rates also seems to parallel the rise in maternal mortality rates over time. There are many other factors that play into the maternal mortality rate, mind, but the high cesarean rate and resulting accretas is one major piece of the puzzle.

If we hope to reduce the number of women impacted by accretas, we must reduce the cesarean rate. The authors of the recent Nordic study pointed this out, saying:
Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP [Abnormally Invasive Placenta]. 
This means not only reducing the number of women who have first cesareans but also the number of women who have automatic repeat cesareans. In order to do that, we must increase access to VBACs. Far too many women have difficulty finding providers who will support them in labor after cesarean. Many hospitals have outright VBAC bans.

Of course, it's only fair to note that most women who have higher-order cesareans will not experience an accreta. However, accreta is such a serious and life-threatening condition that even relatively small incidences carry a huge burden of complications, cost, and potential loss of life. That's why it is vital that women have balanced risk counseling after a prior cesarean and real access to VBAC if they want it.

There are many birth stories online of women who have experienced accretas. It's important to emphasize that many of them have good outcomes, but also important to point out that many of them have challenging outcomes, and some of them have even had tragic outcomes.

This is the bottom line. Real women have died because of accretas, leaving their children motherless. Others have lost their uterus to hysterectomy or their babies to prematurity. Although I have not personally known anyone who died from accreta, I have known several women who have had very close near-misses due to accreta. Nearly all lost their uteri as a result of their accreta, and some lost their babies as well.

This is the real consequence of a too-high cesarean rate. This is why it's so important to avoid non-indicated cesareans and improve VBAC access. 

*If you can, give blood to help support women who have been affected by accreta. 


Support Groups

Accreta Studies

Semin Perinatol. 2012 Oct;36(5):315-23. doi: 10.1053/j.semperi.2012.04.013. Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Silver RM. PMID: 23009962
Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality.
Hong Kong Med J. 2015 Dec;21(6):511-7. doi: 10.12809/hkmj154599. Epub 2015 Nov 6. Rising incidence of morbidly adherent placenta and its association with previous caesarean section: a 15-year analysis in a tertiary hospital in Hong Kong. Cheng KK1, Lee MM1. PMID: 26554269
OBJECTIVES: To identify the incidence of morbidly adherent placenta in the context of a rising caesarean delivery rate within a single institution in the past 15 years, and to determine the contribution of morbidly adherent placenta to the incidence of massive postpartum haemorrhage requiring hysterectomy. SETTING: A regional obstetric unit in Hong Kong. PATIENTS: Patients with a morbidly adherent placenta with or without previous caesarean section scar from 1999 to 2013. RESULTS: A total of 39 patients with morbidly adherent placenta were identified during 1999 to 2013. The overall rate of morbidly adherent placenta was 0.48/1000 births, which increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section (odds ratio=24) and co-existing placenta praevia (odds ratio=585) remained the major risk factors for morbidly adherent placenta. With an increasing rate of morbidly adherent placenta, more patients had haemorrhage with a consequent increased need for peripartum hysterectomy. No significant difference in the hysterectomy rate of morbidly adherent placenta in caesarean scarred uterus (19/25) compared with unscarred uterus (8/14) was noted. This may have been due to increased detection of placenta praevia by ultrasound and awareness of possible adherent placenta in the scarred uterus, as well as more invasive interventions applied to conserve the uterus. CONCLUSION: Presence of a caesarean section scar remained the main risk factor for morbidly adherent placenta. Application of caesarean section should be minimised, especially in those who wish to pursue another future pregnancy, to prevent the subsequent morbidity consequent to a morbidly adherent placenta, in particular, massive postpartum haemorrhage and hysterectomy.
Acta Obstet Gynecol Scand. 2013 Apr;92(4):457-60. doi: 10.1111/aogs.12080. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Morlando M, Sarno L, Napolitano R, Capone A, Tessitore G, Maruotti GM, Martinelli P. PMID: 23347183
...The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.
Obstet Gynecol. 2015 Sep;126(3):654-68. doi: 10.1097/AOG.0000000000001005. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Silver RM1. PMID: 26244528
Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and assisted reproductive technology....
BJOG. 2016 Jul;123(8):1348-55. doi: 10.1111/1471-0528.13547. Epub 2015 Jul 29. Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadóttir RI, Tapper AM, Børdahl PE, Gottvall K, Petersen KB,Krebs L, Gissler M, Langhoff-Roos J, Källen K. PMID: 26227006
OBJECTIVE: The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries. DESIGN: Population-based cohort study. SETTING AND POPULATION: A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS). METHODS: In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries. MAIN OUTCOME MEASURES: Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data. RESULTS: A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia. CONCLUSION: Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.
Am J Obstet Gynecol. 2015 Sep;213(3):384.e1-11. doi: 10.1016/j.ajog.2015.05.002. Epub 2015 May 5. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM. PMID: 25957019
OBJECTIVE: The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States. STUDY DESIGN: We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors. RESULTS: From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals. CONCLUSION: Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.
BJOG. 2013 Jan;120(1):85-91. doi: 10.1111/1471-0528.12010. Epub 2012 Oct 24. Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. Cook JR1, Jarvis S, Knight M, Dhanjal MK. PMID: 23095012
OBJECTIVE: To estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections. DESIGN: A national population-based prospective cohort study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with consultant-led maternity units. POPULATION: Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section. METHODS: Prospective cohort and comparison identification through the UKOSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, maternal and neonatal complications. Relative risk, unadjusted (OR) and adjusted (aOR) odds ratio estimates. RESULTS: The estimated UK incidence of MRCS was 1.20 per 10 000 maternities [95% confidence interval (CI), 0.97-1.47]. Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. CONCLUSIONS: MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.
Obstet Gynecol. 2011 Sep;118(3):687-90. doi: 10.1097/AOG.0b013e318227b8d9. The rising cesarean delivery rate in America: what are the consequences? Blanchette H1. PMID: 21860302
Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children.

Sunday, October 2, 2016

Staples vs. Sutures During Cesareans in High BMI Women

Women of size have higher rates of cesareans in many studies. Many of them are probably preventable but the fact remains that high-BMI women have a high rate of cesareans.

One of the problems with this is that "obese" women are at increased risk for infection and wound complications after a cesarean, and this leads to a great deal of morbidity and healthcare costs.

What can be done to improve outcomes? Past research has strongly suggested that closing the subcutaneous fat layer and avoiding a surgical drain reduces the rates of infection in high-BMI women. Higher doses of antibiotics also seem to be helpful, though the best dosage is still being debated. Using low transverse incisions instead of vertical incisions whenever possible probably also lowers the risk for complications.

Now, new studies seem to suggest that taking the time to suture the wound closed may result in less infection than using staples to close the wound. 

Doctors don't always like to do this because suturing takes longer. And suturing a woman with a lot of abdominal fat is more challenging as well. So most often, staples are used to close a cesarean, especially in women of size. But is this a good idea?

Mackeen 2015 performed a meta-analysis of studies and found that using sutures cut the risk for wound complications in half compared to staples. This risk reduction persisted even when data was stratified by obesity levels.

Zaki 2016 studied sutures vs. staples specifically in obese women. They found:
Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. 
Further studies done specifically on high-BMI women should be done to confirm these findings, but the findings so far seem pretty clear. Using a subcuticular suture to close the incision seems to lessen the risk for wound complications compared to staples.

This is important news because research shows that as BMI increases, doctors are less inclined to use sutures. 

In other words, without intending to, doctors may actually be unnecessarily increasing the risk for wound complications after cesarean in women of size.


I'm glad to see that more research is FINALLY being done on how to lessen the rate of complications in women of size who undergo a cesarean.

For years, doctors simply made assumptions about what they thought would improve cesarean outcomes in obese women ─ but they didn't test their assumptions. Once they started testing the assumptions, they found a few surprises.

Doctors have traditionally been more inclined to use vertical incisions in high-BMI women. They did this because they thought that vertical incisions would lessen the risk for infection by avoiding the area underneath the belly (pannus). They were wrong; most research shows that vertical incisions actually increase the risk for wound complications in obese women.

They thought surgical drains would allow fluids to exit and thereby decrease the chances for wound separations and infections. Yet some research seems to suggest that surgical drains actually increase the risk for problems.

They assumed that the standard antibiotic dosage for all women was sufficient for high-BMI women too. Yet research shows that standard dosages probably do not provide adequate coverage to prevent infections.

When a cesarean is truly needed, it's a wonderful and life-saving thing to have available. Although cesareans carry more risks for obese women, there are important things that doctors can do to improve outcomes in high-BMI women when a cesarean is truly necessary. This list may now include suturing instead of using staples to close the wound, even if it takes slightly longer to accomplish.

However, let's not lose sight of the fact that the most important step that doctors can take to improve outcomes in obese women is to only do cesareans when they are truly needed. 


J Perinatol. 2016 Oct;36(10):819-22. doi: 10.1038/jp.2016.89. Epub 2016 Jun 2. Wound complications in obese women after cesarean: a comparison of staples versus subcuticular suture. Zaki MN, Truong M, Pyra M, Kominiarek MA, Irwin T. PMID: 27253895
OBJECTIVE: To compare wound complications between staples versus subcuticular suture for skin closure in obese women (body mass index (BMI)⩾30 kg m(-2)) after cesarean delivery (CD). STUDY DESIGN: We conducted a retrospective cohort study to compare wound complications between staples and subcuticular suture closure in women, with a prepregnancy BMI⩾30 kg m(-2) after CD between 2006 and 2011 at an inner-city teaching hospital. Wound complication was defined as a composite of wound disruption (hematoma or seroma) or infection diagnosed up to 6 weeks postpartum. Variables collected include age, parity, prior CDs, prior abdominal surgeries, incision type, chorioamnionitis, maternal comorbidities (hypertension, diabetes) and gestational age. RESULTS: Of the 1147 women included in the study, women with staple closure were older and had higher BMIs (40.6±9.3 versus 36.1±5.4) and were more likely to be multiparous, have a prior CD, diabetes and hypertension compared with women with subcuticular suture. The overall occurrence of wound complications was 15.5% (178/1147). Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. CONCLUSIONS: In obese women, skin closure with staples at the time of CD is associated with a higher rate of wound complications compared with subcuticular suture. Skin closure with subcuticular suture over staples should be considered in obese women undergoing a CD regardless of skin incision type.
Am J Obstet Gynecol. 2015 May;212(5):621.e1-10. doi: 10.1016/j.ajog.2014.12.020. Epub 2014 Dec 19. Suture versus staples for skin closure after cesarean: a metaanalysis. Mackeen AD, Schuster M, Berghella V. PMID: 25530592
OBJECTIVE: We sought to perform a metaanalysis to synthesize randomized clinical trials of cesarean skin closure by subcuticular absorbable suture vs metal staples for the outcomes of wound complications, pain perception, patient satisfaction, cosmesis, and operating time...RESULTS: Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43), as there were no significant differences in infection, hematoma, seroma, or readmission. There were also no significant differences in pain perception, patient satisfaction, and cosmetic assessments between the groups. Operating time was approximately 7 minutes longer in those closed with suture (95% CI, 3.10-11.31). CONCLUSION: For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples.
Am J Perinatol. 2014 Apr;31(4):299-304. doi: 10.1055/s-0033-1348402. Epub 2013 Jun 13. Maternal obesity and risk of postcesarean wound complications. Conner SN, Verticchio JC, Tuuli MG, Odibo AO, Macones GA, Cahill AG. PMID: 23765707
OBJECTIVE: To estimate the effect of increasing severity of obesity on postcesarean wound complications and surgical characteristics. STUDY DESIGN: We performed a retrospective cohort study of consecutive cesarean deliveries at a tertiary care facility from 2004 to 2008. Four comparison groups were defined by body mass index (BMI; kg/cm2): < 30 (n = 728), 30 to 39.9 (n = 1,087), 40 to 49.9 (n = 428), or ≥ 50 (n = 201). The primary outcome was wound complication, defined as wound disruption or infection within 6 weeks postoperatively. Surgical characteristics were compared between groups including administration of preoperative antibiotics, type of skin incision, estimated blood loss (EBL), operative time, and type of skin closure. RESULTS: Of the 2,444 women with complete follow-up data, 266 (10.9%) developed a wound complication. Compared with nonobese women (6.6%), increasing BMI was associated with an increased risk of wound complications: BMI 30.0 to 39.9, 9.2%, adjusted odds ratio (aOR) 1.4 (95% confidence interval [CI] 0.99 to 2.0); BMI 40.0 to 49.9, 16.8%, aOR 2.6 (95% CI 1.7 to 3.8); BMI ≥ 50, 22.9%, aOR 3.0 (95% CI 1.9 to 4.9). Increasing BMI was also associated with increased rates of midline vertical incision, longer operative time, higher EBL, and lower rates of subcuticular skin closure. CONCLUSION: A dose-response relationship exists between increasing BMI and risk of postcesarean wound complications. Increasing obesity also significantly influences operative outcomes.
Decreasing Cesarean Wound Complications in Obese Women

Best Pract Res Clin Obstet Gynaecol. 2015 Apr;29(3):406-14. doi: 10.1016/j.bpobgyn.2014.08.009. Epub 2014 Oct 16. Obesity and the challenges of caesarean delivery: prevention and management of wound complications. Ayres-de-Campos D1. PMID: 25457856
Caesarean section in obese patients is associated with an increased risk of surgical wound complications, including haematoma, seroma, abscess and dehiscence. This review focusses on the available strategies to decrease wound complications in this population, and on the clinical management of these situations. Appropriate dose of prophylactic antibiotics, closure of the subcutaneous tissue, and avoidance of subcutaneous drains reduce the incidence of wound complications associated with caesarean section in obese patients. For treatment of superficial wound infection associated with dehiscence, there are data from general surgery patients to suggest that the use of vacuum-assisted devices leads to faster healing and that surgical reclosure is preferable to healing by secondary intention, when there are no signs of ongoing infection. There is a need for stronger evidence regarding the prevention and management of wound complications for caesarean section in obese women.

Sunday, September 25, 2016

Routine Planned Cesareans in Older Mothers Do More Harm Than Good

Many care providers push strongly for elective (planned) cesareans in older moms. However, a recent study challenges the wisdom of this common practice.

This extremely large study confirms that planned cesareans as a routine intervention for older moms is a bad idea. It increased their risk for infection, hysterectomy, kidney failure, cardiac arrest, and death.

This is an issue close to my heart as I was an "AMA" (Advanced Maternal Age, or 35 or older) mom for three of my four pregnancies.

In many practices, a woman like me ─ an older "morbidly obese" mother with a prior cesarean ─ would have faced intense pressure for a planned cesarean. I was fortunate to have care providers that didn't pressure me to have a cesarean just because of my age or weight. (Then again, I purposely chose providers who utilized a more low-intervention model.)

But the pressure for a planned cesarean can be quite strong on older mothers in many practices, especially if the mother is a first-time mom or received fertility treatment. One study found four times the rate of elective cesareans in older first-time moms. But why?

Some doctors see vaginal birth in an older mom as so risky that they prefer to just bypass labor altogether and plan a cesarean. Although the risk for stillbirth does seem to go up somewhat as women age, recent research confirms that this risk is quite modest (and not all research finds an increase in risk). Most healthy older women will do just fine.

Furthermore, a recent study confirms that the difference in outcomes between planned cesareans and planned vaginal births in older moms is quite small. Each choice has its own pros and cons to consider.

Risks probably increase as a woman ages; a woman of 54 probably has a much different risk than a woman of 41. However, many women with very advanced maternal ages have safe vaginal births too. Age alone should not be used as an absolute guide for a planned cesarean.

Although the risk for needing a cesarean during labor does increase as a woman gets older, the research shows that the majority of older women who are given a chance at having a vaginal birth actually do give birth normally. Giving birth under the care of midwives or in a non-obstetric unit setting may improve chances for a vaginal birth in older women who labor.

That is not to say that a planned cesarean is never appropriate in an older mom, only that the decision should be a nuanced one. Risks are higher in those with multiples, with those who have their first pregnancies after 40, and in those who required fertility treatments. Older women who have serious pre-existing health conditions, who have multiple major risk factors, or whose babies do not seem to be growing well have a much different risk profile than an older woman who is healthy, has no pregnancy complications, and has a healthy baby who is growing well.

It would be nice to see further research that provided concrete quantification of absolute risks at various ages in combination with various risk factors. That would be more helpful in guiding decision-making.

Still, all the factors must be considered and birth decisions should be made by the woman and her providers together. The decision should never be imposed on a woman by her provider; age does not negate a woman's right to personal autonomy in her medical decisions.

The bottom line is that routine use of a planned cesarean in older women simply because of age puts that mother's health at risk. Better to have the mother go into labor and see how labor goes. A cesarean can be done in labor if needed, but this very large study shows that routine cesareans for age leads to greater harm overall.

As the authors of the study conclude:
Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.
For an excellent review of the overall research around pregnancy in ages 35 and older, please see this article.


Matern Child Health J. 2016 Jul 29. [Epub ahead of print] Effect of Planned Mode of Delivery in Women with Advanced Maternal Age. Lavecchia M1, Sabbah M1, Abenhaim HA2,3. PMID: 27473092
OBJECTIVES: The purpose of this study was to determine the prognostic value of planned primary elective cesarean section versus planned vaginal delivery in women with advanced maternal age. METHODS: We conducted a population-based, retrospective cohort study using the United States' Health Care Cost and Utilization Project's Nationwide Inpatient Sample to evaluate maternal outcomes in women with advanced maternal age delivering from 2003 to 2012. Healthy women who underwent primary elective cesarean section constituted a surrogate for low-risk planned cesarean delivery. Logistic regression was used to compare outcomes between women with planned cesarean and planned vaginal delivery. RESULTS: Among seven million births, we identified 442,067 deliveries in healthy women with advanced maternal age. The planned cesarean group comprised 7.96 % of women in the cohort. When compared to healthy women in the planned vaginal group, women in the planned cesarean group had a significantly higher mortality ratio (2.56/10,000 vs. 0.44/10,000, p < 0.01). The planned cesarean group was also at higher odds of numerous complications, including peripartum hysterectomy OR 1.81 (1.36-2.40), p < 0.01, cardiac arrest OR 5.39 (4.54-6.38), p < 0.01, acute renal failure OR 3.39 (1.78-6.46), p < 0.01 and sepsis OR 2.27 (1.25-4.14), p < 0.01. CONCLUSIONS FOR PRACTICE: Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.

Monday, September 19, 2016

Estimating Fetal Weight Increases Cesarean Risk

Image from Wikimedia
One intervention often seen in pregnancies these days is estimation of fetal weight. But does this improve outcomes?

Bigger babies are more at risk for getting stuck, which is called "shoulder dystocia." Although the actual numerical risk for shoulder dystocia with big babies is not very great (and small babies get stuck too), the risk for shoulder dystocia is higher with a bigger baby. Most of the time it is resolved without damage, but in some cases babies or moms are hurt, sometimes seriously. In rare cases, babies even die. Damage from shoulder dystocia is one of the main reasons care providers get sued.

As a result, a big baby make many care providers nervous. So they routinely employ estimation of fetal weight near the end of pregnancy, either by hands-on estimation or by ultrasound estimation. But the critical question is whether estimating fetal weight actually improves outcomes.

Here is yet another study that shows that estimating fetal weight does NOT improve outcomes and that it increases the risk for cesareans. 

In this very large multi-center MFMU study, a baby estimated to be above 4000g (8 lbs., 13 oz.) was more than twice as likely to be born by cesarean. A diabetic mother with a baby estimated to be above 3500g (about 7 lbs. 12 oz.) was more than nine times as likely to have a cesarean.

This relationship persisted even when adjusted for actual birth weight and other variables, showing it was not just about the baby's size. The mere prediction of a large baby (whether baby was actually large or not) increased the risk for cesarean, suggesting that it is the way big babies are managed that makes the difference.

This is a particularly pertinent issue for women of size. Because "obese" women tend to have larger babies on average, care providers can get very anxious about fetal size in their pregnancies. Fear of big baby (and the resulting interventions) is one of the top drivers around the outrageously high cesarean rate in high-BMI women.

Sadly, this study does not directly address the effect of fetal weight estimation in the sub-population of obese women. It would be great to have data actually examining a practice that is so common in the management of obese women.

However, this is a very large and very powerful study showing that the practice of estimating fetal weight is harmful in pregnant women in general.

And it is just the latest in a long series of studies that show that the common practice of estimating fetal weight increases the cesarean rate.

Given that it is such a common practice in obstetrics these days, the practice of estimating fetal size before birth needs to be re-evaluated. 

There are times when estimating fetal size can be appropriate, but most of the time it is more harmful than helpful. Care providers need to stop using it routinely.

And its use especially needs to be evaluated in the management of women of size.


Obstet Gynecol. 2016 Sep;128(3):487-94. doi: 10.1097/AOG.0000000000001571. Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term. Froehlich RJ1, Sandoval G, Bailit JL, Grobman WA, Reddy UM, Wapner RJ, Varner MW, Thorp JM Jr, Prasad M, Tita AT, Saade G, Sorokin Y,Blackwell SC, Tolosa JE; MSCE, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. PMID: 27500344
OBJECTIVE: To evaluate the association between documentation of estimated fetal weight, and its value, with cesarean delivery. METHODS: This was a secondary analysis of a multicenter observational cohort of 115,502 deliveries from 2008 to 2011. Data were abstracted by trained and certified study personnel. We included women at 37 weeks of gestation or greater attempting vaginal delivery with live, nonanomalous, singleton, vertex fetuses and no history of cesarean delivery. Rates and odds ratios (ORs) were calculated for women with ultrasonography or clinical estimated fetal weight compared with women without documentation of estimated fetal weight. Further subgroup analyses were performed for estimated fetal weight categories (less than 3,500, 3,500-3,999, and 4,000 g or greater) stratified by diabetic status. Multivariable analyses were performed to adjust for important potential confounding variables. RESULTS: We included 64,030 women. Cesarean delivery rates were 18.5% in the ultrasound estimated fetal weight group, 13.4% in the clinical estimated fetal weight group, and 11.7% in the no documented estimated fetal weight group (P<.001). After adjustment (including for birth weight), the adjusted OR of cesarean delivery was 1.44 (95% confidence interval [CI] 1.31-1.58, P<.001) for women with ultrasound estimated fetal weight and 1.08 for clinical estimated fetal weight (95% CI 1.01-1.15, P=.017) compared with women with no documented estimated fetal weight (referent). The highest estimates of fetal weight conveyed the greatest odds of cesarean delivery. When ultrasound estimated fetal weight was 4,000 g or greater, the adjusted OR was 2.15 (95% CI 1.55-2.98, P<.001) in women without diabetes and 9.00 (95% CI 3.65-22.17, P<.001) in women with diabetes compared to those with estimated fetal weight less than 3,500 g. CONCLUSION: In this contemporary cohort of women attempting vaginal delivery at term, documentation of estimated fetal weight (obtained clinically or, particularly, by ultrasonography) was associated with increased odds of cesarean delivery. This relationship was strongest at higher fetal weight estimates, even after controlling for the effects of birth weight and other factors associated with increased cesarean delivery risk.

Sunday, September 11, 2016

Midwifey-Led Model of Care Increases VBACs

Some hospitals do not allow Certified Nurse-Midwives (CNMs) to attend VBACs (Vaginal Births After Cesarean). Even in my area, which is generally pretty birth-friendly, there are major hospitals that do not allow CNMs to attend VBACs.

This lack of choice is greatly frustrating to the many VBAC women who want to be attended by a midwife. They feel they have a better chance at vaginal birth with a care provider that specializes in more hands-off model of care. Furthermore, they feel that a prior cesarean should not deprive a woman of her autonomy in choosing how and with whom she gives birth.

Here is recent research from a hospital that implemented a midwifery-led model of care. It compared stats from before and from after the switch to see how the change affected things.

The most striking result was that changing to a midwifery-led model of care increased both the number of women who planned VBACs and the number who actually ended up having a VBAC.

Most importantly, safety outcomes were just as good.

This shows that midwives can safely attend VBACs. Midwifery care is likely a key step in lowering the cesarean rate by preventing automatic repeat cesareans and by improving VBAC rates in those who do labor.

It is time for hospitals to stop restricting women who have had previous cesareans from accessing midwifery care.  


Birth. 2016 Sep;43(3):200-8. doi: 10.1111/birt.12229. Epub 2016 Mar 18. Evaluating a Midwife-Led Model of Antenatal Care for Women with a Previous Cesarean Section: A Retrospective, Comparative Cohort Study. White HK1, le May A2, Cluett ER2. PMID: 26991669
BACKGROUND: Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England. METHODS: This was a retrospective, comparative cohort study. Data were collected from the medical records of women with one previous lower segment cesarean delivery and no other obstetric, medical, or psychological complications who gave birth at the hospital before (2008) and after (2011) the implementation of midwife-led antenatal care. Chi-squared analysis was used to calculate the odds ratio, and logistic regression to account for confounders. RESULTS: Intended and actual VBAC rates were higher in 2011 compared with 2008: 90 percent vs. 77 percent, adjusted odds ratio (aOR) 2.69 (1.48-4.87); and 61 percent vs. 47 percent, aOR 1.79 (1.17-2.75), respectively. Mean rates of unscheduled antenatal care sought via the delivery suite and inpatient admissions were lower in 2011 than 2008. Postnatal maternal and neonatal safety outcomes were similar between the two groups, except mean postnatal length of stay, which was shorter in 2011 compared with 2008 (2.67 vs. 3.15 days). CONCLUSIONS: Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.

Tuesday, August 30, 2016

Mammograms: Getting Called Back for Additional Testing

At some point in a woman's life, she should start having regular mammograms. When she should do this is a matter of some controversy, but sooner or later, most women will have regular mammograms every year or two.

But what happens when you get a call back after your mammogram telling you that you need further imaging? What can you expect, and how likely is it that you will be diagnosed with breast cancer? How can you handle the anxiety while waiting for further results? Where can you get further support and information?

Earlier this year, this happened to me. I had my regular mammogram and got a call back telling me they had found two suspicious areas and I needed further testing. It was very unsettling. Even though intellectually you understand it's not an actual diagnosis of cancer, it feels like a sentence of doom. Your anxiety levels go through the roof.

Statistically, only a few women who get called back for additional testing after an "abnormal" mammogram result actually have cancer. Most are just fine, but many of those called back have fears about what additional testing entails.

Let's talk about what diagnostic mammograms are, what additional testing may be used, what to expect during the appointment, how to handle the waiting, and the latest screening guidelines. Then I'll share with you my diagnostic testing experience.

First Step: Don't Panic

Although it's deeply unnerving to get "the call" telling you to get more testing, the first step is to stay calm. Don't panic and start mentally going to worst-case scenarios. As one resource notes (my emphasis):
If doctors find something suspicious, they’ll call you back – usually within just 5 days – to take new pictures or get other tests. Getting that call can be scary, but a suspicious finding does not mean you have cancer. In fact, less than 10% of women called back for more tests are found to have breast cancer.
Although your mind will tend to automatically assume the worst, take a deep breath. Remind yourself that even when extra testing is required, you have a 90%+ chance of not having cancer. 

It's normal to cycle in and out of various "what-if" scenarios in the time before your diagnostic test, but the important thing is to focus as much as possible on the other business of your life. There's no need to panic when you don't know if there's something to actually panic over.

It's understandable to do some worrying, but don't let it consume you. Hard as it is, try not to focus on the uncertainty; let the future take care of itself. Focus instead on the everyday tasks of your life.

Screening vs. Diagnostic Mammograms

An important aid in avoiding panic is to remember that there is a major difference between a screening test and a diagnostic test.

A diagnostic test tells you for sure whether or not you have a certain condition. To get that kind of certainty, diagnostic tests are very involved, expensive, and time-consuming. Because of the time and expense, it simply does not make sense to order them for everyone.

Therefore, a simpler and less-expensive test is used on everyone ─ a screening test. Screening tests are designed to test a wide variety of asymptomatic individuals to look for problems that might need a closer look. These tests are slanted towards what's called "sensitivity" ─ a high chance of finding any existing problems ─ so as not to miss any potential disease. The trade-off is that many people (including many who don't have the disease) will require additional diagnostic testing, and that testing process can be unnerving.

Diagnostic testing looks specifically for disease or a high suspicion of disease. It is geared towards "specificity" ─ accuracy in ruling out disease. If something pops up on the screening test that is unusual or statistically outside of the norm, that person is called back in for further testing. [Of course, anyone with a distinct symptom of a disease goes straight to diagnostic testing.]

This arrangement of starting with a screening test and only going to a diagnostic test for a few people is a smart way to save time and money in an era of limited medical resources. But because most of the public doesn't understand the difference between a screening and diagnostic tests, many people automatically assume that a call-back means they likely have cancer. It doesn't.

Handling the Anxiety of Waiting

Even for people who understand screening vs. diagnostic testing, call-backs can still feel quite alarming. Human nature makes us emotionally jump to worst-case scenarios. That's why you have to keep reminding yourself not to panic. The best thing to do is simply to focus as much of your attention as possible on the tasks of everyday living and not dwell on the fear. Find ways to redirect your anxiety.

Of course, just telling yourself not to worry may be counterproductive; it may be easier instead to let yourself worry but to limit the amount of time spent on it. If you find yourself being taken over with worry, try writing down your worries, putting them into an envelope (physical or mental), and taking them out to indulge the worry only at specified times. When you do indulge the worries, let yourself do it in depth. Think of every worst-case scenario you can, weep and wail, write your good-bye letters, plan your funeral, etc. But then at the end of the specified time, stop and put those fears away until next time. By indulging your fears periodically, you lessen their emotional dominance the rest of the time. It's the rigidly suppressed fear that tends to multiply. Let yourself express your worries but it may help to put some limits on that expression.

Another thing that can help is to journal about why you are so worried. Do some stream-of-consciousness writing to explore your fears. Often the answers seem simple when you start, but the writing process helps uncover more subtle reasons that can give you insight. Journaling won't make the worry go away but understanding the true source of the anxiety may help diffuse its power so it is less emotionally overwhelming.

It's only natural to worry, but try to keep the worry in perspective, try to understand it, and find ways to deal with it that keep it from taking over your life. Soon you will have the answers that you need and can either relax or start developing a positive plan of action. If you need additional support, don't forget that many cancer organizations have 24 hour free phone lines for information and support.

Follow-Up Testing: What to Expect

When you return for follow-up testing, what can you expect?

Basically, plan to devote about half a day to the appointment, give or take. Remember not to wear any powder or lotions to the appointment. Bring a book to help occupy yourself while waiting. The appointment will take several hours and quite a bit of this will be waiting.

You will start by having a longer and more in-depth mammogram. More images will be taken, using more angles, so they can really focus in on the area in question. Although longer than a normal mammogram, this process is usually less than an hour. Don't be afraid to ask questions about the process; technicians are limited in what they can say (and obviously can't give a diagnosis), but often can offer insight into what is being looked at and why.

Next comes the ultrasound. Although not mandatory, most mammography centers also do an ultrasound of the breast during follow-up testing. This process is also around an hour and will examine closely any areas of concern on the breast as well as lymph nodes underneath the arm.

Sometimes an MRI is also done. This is not considered standard-of-care and may not be covered by insurance so it is not part of most routine follow-up testing at this time.

You will be asked to wait on site while a radiologist reviews the results. This can take an hour or two more, so be prepared to wait, but you should get the results that day. The results are usually one of the following:
  • The suspicious area turned out to be nothing to worry about and you can return to your regular mammogram schedule
  • The area is probably nothing to worry about, but you should have your next mammogram sooner than normal – usually in 4 to 6 months – to make sure it doesn’t change over time
  • Cancer was not ruled out and a biopsy is needed to tell for sure
Remember, even if a biopsy is recommended, chances are you still don't have cancer. Often biopsy results are benign. This is hard to remember when you are told you need a biopsy but it's important to keep reminding yourself of this fact.

There are different types of biopsies. Most are done with a needle but some need a small incision. Biopsy results have to be sent away for analysis, which can take anywhere from a few days to a week or two. The wait is difficult. Find some emotional support but don't forget to keep your focus on normalcy during daily life.

If your biopsy results are benign, ask the doctor whether any follow-up is needed and when your next mammogram should be. Get the results and recommendations in writing for future reference.

If your biopsy results show cancer, then it is time to consult a breast specialist. People often report difficulty in recalling the information given at these consultations, so take a knowledgeable and supportive friend or relative with you to the appointment. Ask to record the appointment so you can refer back to it later. Take notes (or have your support person take notes) and ask for correct spellings of any words you don't know so you can research it further. You can find a list of questions to ask here.

Don't be afraid to ask for a second opinion about your options. You can you get completely different advice from another care provider so it really is worthwhile to get a second (or even third) opinion. You can also call the American Cancer Society for information and support at 1-800-227-2345. Many additional online resources for support also exist; don't be afraid to reach out to them. Many women find it helpful to be paired with someone who has been through breast cancer themselves and is trained in offering support to newly-diagnosed patients.

Reminder of Screening Guidelines

With all the anxiety that a positive screening test can generate, it's no surprise that many women opt out of yearly mammograms. They simply don't want to deal with the anxiety it produces. Others are concerned about over-treatment for non-aggressive cancers, false-positives, and the cumulative effect of the radiation from many mammograms.

Yet we know that statistically, mammograms save lives, especially as women age. So when should women start getting mammograms?

Unfortunately, even the experts can't agree on how often women should have mammograms. Some organizations suggest regular screening start at 40, some suggest 45, some suggest waiting till 50.

Once you do start regular screening, some suggest that every 2 years is enough, while others strongly push yearly screening. It's hard to know what to do.

From, Dr. Connie Lehmen gives a summary of the controversy over screening guidelines:
At an absolute minimum, women should begin screening mammography no later than age 50 and get a mammogram every 1 to 2 years until at least age 74. All medical organizations agree with these minimum recommendations for screening...The areas of disagreement, and reasons for differences in the recommendations from different groups, center around the age to begin screening (40, 45, or 50) and the interval of screening (every year or every 2 years). These variations are due to different groups of people who interpret clinical trial data differently.
Bottom line, when you start and how often you screen really depends on your risk factors. Recommendations will vary from woman to woman.

How does "obesity" figure into recommendations? That's harder because it's not always clear. We do know that high-BMI women are less likely to get regular mammograms or follow-ups after abnormal mammograms, which may partially explain why we tend to be diagnosed at more advanced stages of cancer. Yet there is only limited research and recommendations specifically on the trade-off of benefits and risks of screening in obese women at different ages.

As women of size, it is clear that we are at increased risk for post-menopausal cancer ─ but authorities often neglect to mention that we are generally at decreased risk for pre-menopausal breast cancer (except triple negative breast cancer). But when does that initially decreased risk cross over to increased risk? Is it a hard and fast conversion right at menopause, or a gradual increase of risk as you approach menopause? I don't think anyone really knows for sure.

That means it's particularly hard to know what mammogram schedule a woman of size should follow during that in-between time in the 40s when women are peri-menopausal.

The short version is that mammogram decisions then really seem to boil down to your other risk factors (especially family history, breast density, and blood sugar status) and becomes a personal choice you decide in consultation with your healthcare provider.

Personally, not having access to much family medical history and having had a lot of fibrocystic lumps, I had a number of mammograms in my 20s and 30s. In retrospect, I think we did too much. After a lot of research, I opted out of yearly mammograms in my 40s, but did have a couple to establish a baseline. Now that I am past 50 I think it sensible to get regular mammograms (about every year or two) because high-BMI women really are at increased risk for post-menopausal breast cancer.

I still don't love mammograms but have found a center where the care is more sensitive and gentle than I've experienced in the past. It's still anxiety-producing but regular mammograms seem a sensible precaution at my age.

But that's just my choice, based on my own circumstances. Yours may be completely different.

My Experience with Call-Back Testing

Needing a follow-up diagnostic mammogram really threw me. It just goes to show that having intellectual knowledge about a subject doesn't always have a lot to do with how you react to unsettling news.

Even though intellectually I knew that I probably didn't have cancer, I'm very good at "catastrophizing." It took quite a bit of effort to reel back my tendency to immediately go to the worst-case scenarios. Reading up about screening vs. diagnostic testing helped me scale back some of my fears. Education can be a powerful counter to fear.

When the anxiety elevated despite my reading, I made an effort to explore it. Obviously I was deeply concerned about leaving my children motherless, especially because I still have a young one at home. But upon further reflection, I realized that my fear was made worse by the fact that my husband had just been laid off. My big concern was that if I did have breast cancer, we'd run out of health insurance and I'd bankrupt the family and cause us to lose our house. We also have two kids in college, another in high school heading off to college soon, and the young one in private school; I was worried that my medical bills would derail their educations.

For me, handling the anxiety proactively while waiting needed multiple approaches. Research helped reassure my rational mind that I had a 90% chance of not having cancer. Emotionally, taking the time to explore why the fear was persistent helped me understand and diffuse a lot of its power. I was then better able to just focus on the everyday tasks instead of spending my days in constant fear.

In the end, I didn't have cancer, just some "asymmetrical lymph nodes" that the radiologist initially flagged but ultimately considered normal. I don't even have to go back for more frequent testing, just the normal screening.

Whew, what a relief! But oh, how difficult that waiting period is. Especially coming during a job layoff and time of great stress at my own work.

Sadly, there are no magical answers to getting through it; for me doing research and exploring my fears was vital in staying sane. In the end, though, it really boiled down to gritting my teeth and focusing on everyday tasks so I didn't go crazy.

It's totally normal to be anxious while waiting. But if that anxiety gets overwhelming, consider what is effective for you to deal with the worry. Consider developing some additional tools to help.

Has anyone else gone through a similar experience? What helped you get through the waiting period?


Thursday, August 18, 2016

"Safe" Gestational Weight Loss?

Graphic from this misleading article. The article addresses
improving diet and exercise in pregnancy but doesn't mention any
of the studies that show risks associated with weight loss in pregnancy
While researching another post, I was angered to see that some providers ─ and media outlets ─ are still worshiping at the altar of weight loss in pregnancy for "obese" pregnant women.

Augh! I can't believe this is still being promoted, even after a number of studies suggesting there are risks to gestational weight loss.

I know, I know. Many care providers hope weight loss in pregnancy is the magical pill to automatically improve pregnancy outcomes in women of size and leave them forever skinnier afterwards. They see it as a theoretical win-win. But it just doesn't happen this way ─ and it is associated with significant risks. That is not a win-win situation.

Too many authors extol the possible benefits of gestational weight loss (GWL) while significantly downplaying or completely ignoring the possible risks.

I find this incredibly frustrating and irresponsible.

Ignoring the Evidence for Harm

In the article accompanying the graphic above, for example, the author never addresses the potential risks of losing weight during pregnancy. A fair and balanced article ought to look at both benefits and risks, but it doesn't.

The article suggests improving diet and exercise in pregnancy and notes some potential benefits from that. I don't have a problem with promoting good habits and agree that sometimes this may prevent certain complications, but the article makes the typical biased assumption that all fat women have terrible habits. This promotes the stereotype of the gluttonous obese person, which just doesn't match the life experience of the many fat people who have normal habits. So the article is problematic already for its automatic assumptions.

More importantly, the author never mentions any of the studies which have found risks associated with gestational weight loss. This is intellectually dishonest and shows an obvious agenda. The author implies that it's perfectly safe to lose weight in pregnancy, even though the issue of safety was not actually addressed in the article.

So what does the research say?

Over and over again, researchers have found that weight loss in pregnancy is associated with too-small babies and possibly prematurity.

In one study highlighted below, for example, "overweight" and "obese" women who had been diagnosed with gestational diabetes were enrolled in the California Diabetes and Pregnancy Program. Those who lost weight were compared with those who did not. 

The authors found that gestational weight loss was associated with some problematic outcomes, including more Small-for-Gestational-Age (SGA) babies and more premature babies. But this study is not the only one to find risks with Gestational Weight Loss (GWL). Here are a few more that have also found problems:
  • Bodnar 2010 - GWL increased risk for SGA and preterm births among obese women
  • Bayerlein 2011 - GWL increased risk for SGA and preterm births in all but class III obese women
  • Blomberg 2011 - GWL increased risk for SGA even among class III obese women
  • Catalano 2014 - GWL more than doubled the risk for SGA among obese women
  • Cox Bauer 2016 - GWL doubled the risk for low birth weight babies
As a result, one recent meta-analysis concluded:
GWL should not be advocated in general for obese women.
Yet there are still far too many doctors, midwives, and media articles promoting just that.

An Acceptable Trade-Off of Risks?

Critics will point out that gestational weight loss has benefits that off-set the increased risk of SGA and prematurity. For example, in the California Diabetes and Pregnancy Program study above, women who lost weight during the study experienced decreased risks for a big baby (macrosomia or LGA), cesarean sections, and NICU (Neonatal Intensive Care Unit) admission. The authors felt that this trade-off was good enough reason to promote continued inquiry into gestational weight loss, despite the increased risks for SGA and premature babies.

But these arguments have a huge fault in them ─ ignoring iatrogenic (physician-caused) variables. For example, when doctors see a large woman with a larger weight gain, they fear macrosomia and shoulder dystocia. As a result, they may disproportionately induce those who gained more weight and have a low surgical threshold for cesareans in this group. Thus, a higher cesarean rate in this group be more a reflection of their doctors' fears and intervention levels rather than an actual causal effect a larger gain.

Furthermore, a higher induction rate could also explain increased NICU admissions in this group, since induction places increased stress on the baby. Also, bigger babies receive more surveillance for possible low blood sugar, which often entails a trip to the NICU. So while the increased NICU admissions in the weight gain group cannot be dismissed, it may also simply be a surrogate marker for increased interventions in this group.

Only fetal size is directly linked to weight gain in pregnancy. Very high gains lead to bigger babies on average, and avoiding very high gains is probably a good idea. However, that doesn't mean that pressuring women to lose weight in pregnancy is better.

SGA has serious potential consequences, yet this is shrugged off as being fairly unimportant by many researchers. They feel it is worth the trade-off for fewer big babies. Culturally, big babies are the ultimate "boogeyman" in the obstetric world these days because OBs are often sued for birth injuries caused by shoulder dystocia. Yet drugging women, forcing them to birth on their backs in immobile positions, and rushing the baby out too quickly have a lot to do with shoulder dystocia and birth injuries. How sad that doctors would rather risk more SGA babies than learn how to deal more effectively with big babies.

I am alarmed at the number of care providers and researchers who consider SGA and prematurity a "minor" matter and a worthwhile trade-off.

SGA and prematurity are significant concerns for babies because they are at increased risk for fetal death, sudden infant deathcognitive delay, and poor neurodevelopmental outcomes.

SGA babies also tend to have more significant downstream health effects like metabolic disease, including insulin resistance, diabetesmetabolic syndrome, and cardiovascular disease. SGA and growth-restricted babies face life-long health risks.

It doesn't end there. SGA babies are clearly at increased risk for stillbirth. And there is now research shows that SGA babies of obese women are at particular risk for stillbirth. Stillbirth!

Additionally, recent research shows that obese women with gestational weight loss had higher risks of infant death after birth.

Yes, macrosomia has risks too, like higher rates of shoulder dystocia and birth injuries, and possibly higher cesarean rates.

However, some research suggests that SGA babies are worse off than LGA babies. And having a bigger baby on average may be nature's way of protecting the babies of high-BMI women, since stillbirth risks are lower among LGA babies than among SGA or average-sized babies in obese women.

Personally, if I had to choose, I'd rather gain a little more weight and risk a bigger baby than to lose weight and risk an unhealthily-small baby, putting it at risk for possible stillbirth or life-long health problems.

Yet researchers continue to shrug off SGA as a minor thing. The author of one study on limiting weight gain in obese women said, "What conclusions you draw depends on how you value the adverse effects." In other words, is a decrease in cesareans and big babies worth an increase in unhealthily-small babies?

I say NO. SGA babies need to be taken far more seriously as a downside to very low weight gains and weight loss in pregnancy, even if the price is a few more big babies or possibly even a few cesareans.

Or better yet, care providers could learn how to attend the birth of a big baby more safely.

The best route to improve outcome may be to address fears and intervention levels around big babies rather than to make all fat women lose weight in pregnancy and risk too-small babies.

Take-Away Messages

Messages like this are irresponsible and need to stop
Websites that promote weight loss during pregnancy still abound in the media, and articles are still being published that say that weight loss in pregnancy is "safe" (I refuse to link to them).

And some doctors are still advising overweight and obese women to lose weight during pregnancy. Dr. Thomas Myles, a professor of obstetrics and gynecology at Saint Louis University School of Medicine, said in one article, "I usually tell my [obese] patients that gaining less than 10 pounds and even losing up to 10 pounds is appropriate."

Doctors and the media need to stop promoting weight loss in pregnancy for obese women. 

We've talked about this extensively before but despite the studies showing risks, the media and many providers keep promoting it. This is potentially dangerous.
Yes, some women of size naturally lose weight in pregnancy or gain very little. As long as they are not restricting calories to lose weight, have good overall nutrition, and their babies show normal growth curves, their outcomes are usually fine. I'm not worried about women who lose a little weight incidentally. Sometimes that happens in larger women and it's not a big deal.

Nor am I worried about care providers encouraging good basic nutrition principles and regular exercise in women (although I think they should do that for all women and not just fat women). Good nutrition is a basic and ALL pregnant women should be encouraged to work on it, though I would challenge providers to find a way to talk to their clients about nutrition and weight gain without condescension, moralizing, and automatic assumptions.

What I am deeply worried about is encouragement for women of size to intentionally lose weight in pregnancy, and the dangerous nutritional advice that is being given to some obese women in order to promote this dubious goal. 

For example, one doctor told his patient to "lose 1-2 lbs/week for the remaining 7 weeks of pregnancy...He suggests 1000 calories/day and 1 hour of heavy cardio exercise." Others have been told that they should lose 40 lbs. while pregnant, or that the baby will get all it needs from fat reserves so it's okay to lose weight. A few care providers are telling obese women to cut out entire food groups ("never eat carbs" or "cut out all fruit"), to go on SlimFast shakes, or to "eat nothing but vegetables" in order to limit weight gain.

Although most doctors are not this extreme, some women are being pressured into some dangerous nutritional stuff, all in the name of gestational weight loss. And women are being pressured into more interventions (like unnecessary inductions and planned cesareans) if they gain above what their care providers think they "should" be gaining.

Researchers MUST start recognizing the fact that their well-intentioned studies on restricted weight gain in obese women are, in practice, resulting in very harmful dietary advice and punitive practices for women who gain "too much."

Promoting gestational weight loss may be doing FAR more harm than good in obese women, especially those in borderline BMI categories for whom GWL is particularly risky. But even in "morbidly obese" women, there is enough evidence of possible harm that care providers should not be pushing for intentional weight loss in pregnancy.  

Instead, I urge care providers to focus on:
  • Reasonable nutrition
  • Regular exercise
  • Proactive care protocols 
In addition, caregivers MUST start looking at their own practice patterns in response to obese mothers' weight gain (especially induction for big baby) and how this impacts cesarean rates, NICU admissions, and morbidity in high-BMI women and their infants.

Here's what I want researchers and media to change:
  1. Stop promoting weight loss in pregnancy for obese women 
  2. Stop trying to sell gestational weight loss as "perfectly safe" and acknowledge the research that shows significant risks with it 
  3. Start recognizing that providers' responses to obese women's weight gain impacts outcomes, perhaps more than the gain itself
  4. Learn how to attend the births of big babies more safely 
Stop focusing so exclusively on the scale and start focusing on reasonable habits and reducing interventions as ways to improve outcomes in high-BMI women.


Obesity (Silver Spring). 2013 Apr 24. doi: 10.1002/oby.20490. [Epub ahead of print] Gestational weight loss and perinatal outcomes in overweight and obese women subsequent to diagnosis of gestational diabetes mellitus. Yee LM, Cheng YW, Inturrisi M, Caughey AB.  PMID: 23613187
OBJECTIVE: To investigate whether gestational weight loss after the diagnosis of gestational diabetes mellitus (GDM) in overweight and obese women is associated with improved perinatal outcomes...METHODS: Retrospective cohort study of 26,205 overweight and obese gestational diabetic women enrolled in the California Diabetes and Pregnancy Program. Women with gestational weight loss (GWL) during program enrollment were compared to those with weight gain...RESULTS: 5.2% of women experienced GWL. GWL was associated with decreased odds of macrosomia (aOR 0.63, 95% CI 0.52-0.77), NICU admission (aOR 0.51, 95% CI 0.27-0.95), and cesarean delivery (aOR 0.81, 95% CI 0.68-0.97). Odds of SGA status (aOR 1.69, 95% CI 1.32-2.17) and preterm delivery <34 weeks (aOR 1.71, 95% CI 1.23-2.37) were increased.  CONCLUSIONS: In overweight and obese women with GDM, third trimester weight loss is associated with some improved maternal and neonatal outcomes, although this effect is lessened by increased odds of SGA status and preterm delivery. We recommend further research on weight loss and interventions to improve adherence to weight guidelines in this population.
BJOG. 2011 Jan;118(1):55-61. doi: 10.1111/j.1471-0528.2010.02761.x. Epub 2010 Nov 4. Associations of gestational weight loss with birth-related outcome: a retrospective cohort study. Beyerlein A1, Schiessl B, Lack N, von Kries R. PMID: 21054761
...DESIGN: Retrospective cohort study. SETTING AND POPULATION: Data on 709 575 singleton deliveries in Bavarian obstetric units from 2000-2007 were extracted from a standard dataset for which data are regularly collected for the national benchmarking of obstetric units...RESULTS: GWL was associated with a decreased risk of pregnancy complications, such as pre-eclampsia and nonelective caesarean section, in overweight and obese women [e.g. OR = 0.65 (95% confidence interval: 0.51, 0.83) for nonelective caesarean section in obese class I women]. The risks of preterm delivery and SGA births, by contrast, were significantly higher in overweight and obese class I/II mothers [e.g. OR = 1.68 (95% confidence interval: 1.37, 2.06) for SGA in obese class I women]. In obese class III women, no significantly increased risks of poor outcomes for infants were observed. CONCLUSIONS: The association of GWL with a decreased risk of pregnancy complications appears to be outweighed by increased risks of prematurity and SGA in all but obese class III mothers.
Obstet Gynecol. 2011 May;117(5):1065-70. doi: 10.1097/AOG.0b013e318214f1d1. Maternal and neonatal outcomes among obese women with weight gain below the new Institute of Medicine recommendations. Blomberg M1. PMID: 21508744
...METHODS: This was a population-based cohort study, which included 32,991 obesity class I, 10,068 obesity class II, and 3,536 obesity class III women who were divided into four gestational weight gain categories. Women with low (0-4.9 kg) or no gestational weight gain were compared with women gaining the recommended 5-9 kg concerning obstetric and neonatal outcome after suitable adjustments. RESULTS: Women in obesity class III who lost weight during pregnancy had a decreased risk of cesarean delivery (24.4%; odds ratio [OR] 0.77, 95% confidence interval [CI] 0.60-0.99), large-for-gestational-age births (11.2%, OR 0.64, 95% CI 0.46-0.90), and no significantly increased risk for pre-eclampsia, excessive bleeding during delivery, instrumental delivery, low Apgar score, or fetal distress compared with obese (class III) women gaining within the Institute of Medicine recommendations. There was an increased risk for small for gestational age, 3.7% (OR 2.34, 95% CI 1.15-4.76) among women in obesity class III losing weight, but there was no significantly increased risk of small for gestational age in the same group with low weight gain. CONCLUSION: Obese women (class II and III) who lose weight during pregnancy seem to have a decreased or unaffected risk for cesarean delivery, large for gestational age, pre-eclampsia, excessive postpartum bleeding, instrumental delivery, low Apgar score, and fetal distress....
Obes Rev. 2015 Mar;16(3):189-206. doi: 10.1111/obr.12238. Epub 2015 Jan 18. Can we safely recommend gestational weight gain below the 2009 guidelines in obese women? A systematic review and meta-analysis. Kapadia MZ1, Park CK, Beyene J, Giglia L, Maxwell C, McDonald SD. PMID: 25598037
A systematic review was conducted to determine the risk of adverse pregnancy outcomes with gestational weight gain (GWG) below the 2009 Institute of Medicine guidelines compared with within the guidelines in obese women. MEDLINE, Embase, Cochrane Register, CINHAL and Web of Science were searched from 1 January 2009 to 31 July 2014. Quality was assessed using a modified Newcastle-Ottawa scale. Three primary outcomes were included: preterm birth, small for gestational age (SGA) and large for gestational age (LGA). Eighteen cohort studies were included. GWG below the guidelines had higher odds of preterm birth (adjusted odds ratio [AOR] 1.46; 95% confidence interval [CI] 1.07-2.00) and SGA (AOR 1.24; 95% CI 1.13-1.36) and lower odds of LGA (AOR 0.77; 95% CI 0.73-0.81) than GWG within the guidelines. Across the three obesity classes, the odds of SGA and LGA did not show any notable gradient and remained unexplored for preterm birth. Decreased odds were noted for macrosomia (AOR 0.64; 95% CI 0.54-0.77), gestational hypertension (AOR, 0.70; 95% CI 0.53-0.93), pre-eclampsia (AOR 0.90; 95% CI 0.82-0.99) and caesarean (AOR 0.87; 95% CI 0.82-0.92). GWG below the guidelines cannot be routinely recommended but might occasionally be individualized for certain women, with caution, taking into account other known risk factors.
Increased Risks for SGA Infants of Obese Women

J Matern Fetal Neonatal Med. 2016 Jul 22:1-17. [Epub ahead of print] The effects of maternal obesity on perinatal outcomes among those born small for gestational age. Yao R1, Park BY2, Caughey AB3. PMID: 27450769
BACKGROUND:...Small for gestational age (SGA) neonates born to obese women may be associated with pathological growth with increased neonatal complications. METHODS: This was a retrospective cohort study of all non-anomalous singleton neonates born in Texas from 2006-2011. Analyses were limited to births between 34 and 42 weeks gestation with birth weight ≤10th percentile. Results were stratified by maternal pre-pregnancy BMI class. The risk for stillbirth, neonatal death, neonatal intensive care unit (NICU) admission and 5 minute Apgar scores <7 were estimated for each obesity class and compared to the normal weight group. Multivariable logistic regression analyses were performed to control for potential confounding variables. RESULTS: The rate of stillbirth was 1.4/1,000 births for normal weight women, and 2.9/1,000 among obese women (p < 0.001, aOR: 1.83 [1.43, 2.34]). The rate of neonatal deaths among normal weight women was 4.3/1,000 births, whereas among obese women it was 4.7/1,000 (p = 0.94, aOR: 1.10 [0.92, 1.30]). A dose-dependent relationship between maternal obesity and stillbirths was seen, but not for other neonatal outcomes. CONCLUSION: Among SGA neonates, maternal pre-pregnancy obesity was associated with increased risks for stillbirth, NICU admission and low Apgar scores but not neonatal death.
Obstet Gynecol. 2009 Aug;114(2 Pt 1):333-9. doi: 10.1097/AOG.0b013e3181ae9a47. Success of programming fetal growth phenotypes among obese women. Salihu HM1, Mbah AK, Alio AP, Kornosky JL, Bruder K, Belogolovkin V. PMID: 19622995
...METHODS: This was a retrospective cohort study using the Missouri maternally linked cohort files (years 1978-1997)...Fetal growth phenotypes were defined as large for gestational age (LGA), appropriate for gestational age (AGA), and small for gestational age (SGA)...RESULTS:..Neonatal mortality among LGA infants was similar for obese (6.2 in 1,000) and normal (4.9 in 1,000) weight mothers (OR 1.05, 95% confidence interval [CI] 0.75-1.48) and regardless of obesity subtype. By contrast, SGA and AGA infants programmed by obese mothers experienced greater neonatal mortality as compared with those born to normal weight mothers (AGA OR 1.45, 95% CI 1.32-1.59;SGA OR 1.72, 95% CI 1.49-1.98). CONCLUSION: Compared with normal weight mothers, obese women are least successful at programming SGA, less successful at programming AGA, and equally as successful at programming LGA infants.
BJOG. 2016 Feb 8. doi: 10.1111/1471-0528.13896. [Epub ahead of print] Comparison of methods for identifying small-for-gestational-age infants at risk of perinatal mortality among obese mothers: a hospital-based cohort study. Hinkle SN1, Sjaarda LA1, Albert PS2, Mendola P1, Grantz KL1. PMID: 26853429
OBJECTIVE: To assess differences in small-for-gestational age (SGA) classifications for the detection of neonates with increased perinatal mortality risk among obese women and subsequently assess the association between prepregnancy body mass index (BMI) status and SGA. DESIGN: Hospital-based cohort. SETTING: Twelve US clinical centres (2002-08). POPULATION: A total of 114 626 singleton, nonanomalous pregnancies. ...RESULTS: The overall perinatal mortality prevalence was 0.55% and this increased significantly with increasing BMI (P < 0.01)...SGA is less common among obese women but these SGA babies are at a high risk of death and remain an important group for surveillance.