Friday, September 19, 2014

PCOS and Birth Control Pills, Part 1: Information about Oral Contraceptives

In previous posts, we have talked about PCOS (Polycystic Ovarian Syndrome). We discussed its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

Then we began discussing common treatment protocols for PCOS, and the pros and cons of each. We are discussing treatment options from a size-friendly point of view (meaning no diet talk, no weight loss promotion).

We've already discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes.

Now we are discussing treatments for PCOS, especially those for regulating the menstrual cycle. We talked about progesterone treatments for bringing on a long-overdue period; now we talk about using birth control pills to regulate the menstrual cycle, reduce androgen levels, and control unpleasant PCOS symptoms like hirsutism, acne, and alopecia.
Disclaimer: I am not a medical health-care professional. While the following information is based on my best understanding of the research, always do your own research. This information is not a complete explanation of all the risks and benefits of a particular medication, nor is it medical advice about a health condition or treatment. Consult your healthcare provider before making any decisions about your care plan.
Trigger Warning: Passing mention of the possible weight effects of several medications and of weight loss as a treatment for menstrual irregularity.
Treating for Menstrual Regularity

Many women with PCOS experience irregular periods, often because of progesterone-deficiency. They don't produce enough progesterone to bring on a period and flush out the uterine lining. They tend to be estrogen-dominant, and as a result, that remaining uterine lining is exposed to an excessive level of estrogen for prolonged periods. This can lead to abnormal overgrowth of the uterine lining and eventually, endometrial cancer in some.

Therefore, one of the most important treatment goals in PCOS is to regulate the menstrual cycle. There are two reasons that this is important:
  • to reduce the overgrowth of the endometrium and thereby reduce the chance for endometrial cancer later in life
  • to improve ovulation for the purposes of fertility (if children are desired)
If you've gone a long time without a period, many doctors will choose to use a progesterone medication to "flush out" the uterine lining before trying other medications and treatments to regulate the cycle.

But once the endometrial lining has been "flushed out," the most common medication used by care providers for PCOS is the birth control pill, or The Pill. Oral Contraceptives regulate the menstrual cycle and makes sure your body has a period every month. Most doctors see this as THE treatment of choice for cycle regulation in PCOS.

Remember, although the focus of these post is oral contraceptives, there are alternative treatments out there for regulating menstrual cycles.

These can include lifestyle approaches that are compatible with Health At Every Size® (like moderating carb intake, enhancing nutrition, increasing exercise, avoiding gluten), acupuncture, herbs like vitex/chasteberry, insulin-sensitizing medications like metformin and inositol, and perhaps vitamin D supplementation.

Women with PCOS should also be checked for hypothyroidism. A number of studies have found that women with PCOS have a higher rate of abnormal thyroid function. Some studies suggest that hypothyroidism is associated with menstrual disturbancesinsulin resistance, and infertility. A number of women with PCOS have found that treating even marginal cases of hypothyroidism helped improve menstrual regularity.

Of course, as anyone who has read traditional PCOS medical advice knows, care providers usually strongly promote weight loss for regulating menstrual cycles. They push the idea that "just a 5-10% weight loss" can improve menstrual regularity and fertility, although it remains unclear what type of diet is most optimal, nor that this type of weight loss results in long-term meaningful health effects or sustained weight loss.

It's true that weight loss can be effective in resuming ovulation for some women but remember that studies on this are often extremely small and very short-term. They typically do not show long-term results, nor do they show what happens if weight loss rebounds to more with time (as so often happens). Nor do they acknowledge that weight loss/weight cycling can have risks as well as benefits (see the Weight References section of this blog).

Nor is weight loss effective for regulating the periods or easing PCOS symptoms in everyone; a number of women with PCOS still experience missed periods and significant symptoms even after considerable weight loss. One research meta-analysis noted a distinct lack of high-quality research that examined clinical reproductive outcomes; in other words, it hasn't really been proven that significant weight loss results in more pregnancies and live births. And some research suggests that rapid weight loss or very low calorie diets could even be harmful in obese women undergoing infertility treatment.

The bottom line is that weight loss is another tool that can be considered if you wish, but weight loss is far from the magic bullet that doctors like to pretend it is. For many, it may actually be counter-productive, resulting in far more weight in the long run from rebound. For others, it can lead to eating disorders and unhealthy behaviors. Weight loss for PCOS should not be mandatory, nor should weight loss be a requirement for accessing fertility services or other treatment. 

Remember, there is no one "right" treatment protocol. Each woman must find the right combination of treatments that work best for her circumstances and needs.

For some, this may include oral contraceptives/birth control pills.

Birth Control Pills

Oral Contraceptives are helpful in regulating the menstrual cycle by providing the progesterone each month to prevent endometrial hyperplasia (overgrowth of the uterine lining) and to help bring on your period:
In PCOS, ovulation does not occur regularly, which prevents the rise and fall of progesterone which brings on a woman's period. Instead, the lining is not shed and is exposed to estrogen for a longer period of time causing the uterine lining to grow much thicker then normal. This can cause heavy and erratic bleeding. However, this is not a true period because ovulation has not occurred. Over time, lack of exposure to progesterone may cause endometrial hyperplasia (a fancy word for overgrowth of the uterine lining) which in rare cases can lead to endometrial cancer. Taking the birth control regulates your menstrual cycle by providing the progesterone that your body needs, causing the uterine lining to be shed frequently and reducing the risk of endometrial hyperplasia.
The advantage of The Pill is that it:
  • provides your body with the hormones it needs to have a normal cycle
  • prevents the build-up of uterine lining
  • lowers your chances for endometrial cancer later on, and probably for ovarian cancer too
  • provides contraception until children are desired
  • has an anti-androgenic effect, lessening acne and hirsutism for some
  • may also lessen the severity of symptoms in those who experience difficult and painful periods
The Pill should be taken every day, and at the same time every day, for it to be most effective.

The last few days of the cycle are typically sugar pills (placebos), to enable your period to start afterwards. Even though these have no hormones in them, using sugar pills keeps the habit of taking a daily pill going so there are no inadvertent gaps in coverage. (Not all types of oral contraceptives have a placebo with them, but most do.)

As a contraceptive, the Pill works in the following way:
Hormonal contraceptives (the pill, the patch, and the vaginal ring) all contain a small amount of synthetic estrogen and progestin hormones. These hormones work to inhibit the body's natural cyclical hormones to prevent pregnancy. Pregnancy is prevented by a combination of factors. The hormonal contraceptive usually stops the body from releasing an egg from the ovary. Hormonal contraceptives also change the cervical mucus to make it difficult for the sperm to find an egg. Hormonal contraceptives can also prevent pregnancy by making the lining of the womb inhospitable for implantation.
Our purpose in this post is not to discuss the pros and cons of the Pill as a contraceptive, but instead its utility for regulating the menstrual cycle in women with PCOS, as well as its anti-androgenic benefits.

Some basic information about the Pill's contraceptive properties is given in this post as a introduction to the subject, but it is by no means a complete discussion of the pros and cons of the Pill as contraception. Nor is this intended to be a discussion of potential ethical issues around oral contraceptives.

A thorough discussion of the Pill as contraceptive is a whole different post and not part of the mission of this blog, except in discussing the implications of its use in women with PCOS/women of size.

Our focus here is primarily on the pros and cons of the Pill for menstrual cycle regulation and treatment of PCOS symptoms. Please keep that in mind as you read and comment on the post.

Types of Birth Control Pills

There are many birth control pills to choose from. Unfortunately, a really complete discussion of types of birth control pills is far beyond the scope of this blog, especially since types of birth control pills change over time, but you can read some summaries about them here.

Basically there are two main types of pills:
  • Combination pills, which use a combination of progestin and estrogen
  • Progestin-only pills 
Combination Pills

Combination pills have both progestin and estrogen, and are about 99.9% effective, if used correctly. This drops to around 91% or so if they are used less than perfectly.

There are a number of different versions of combination pills, as written about here:
Combination pills can be differentiated on whether the dose of estrogen progestin stays the same throughout the pill pack (monophasic), if progestin increases once about halfway through the pill pack while the estrogen stays the same (biphasic) or if the levels of estrogen and progestin are different each week of the pill pack. 
Keep in mind that in each of these types of pills, the last week is only a sugar pill, which contains no active hormone. This allows for normal shedding of the uterine lining. 
Monophasic pills can be classified further based on the dosage of estrogen, known as ethinyl estradiol, in the pill. Low dose oral contraceptives contain 20mcg of estrogen plus the progestin. Regular dose contain(s) 30mcg to 35mcg of estrogen plus progestin and high dose contain 50mcg of estrogen plus the progestin.
The first generation of oral contraceptives contained ~150 micrograms (mcg, or ยต) of estrogen (ethinyl estradiol). Starting in the late 1960s, the estrogen dose was strongly reduced in order to improve efficacy and safety and to decrease side effects. Compare the numbers above; it's amazing how much lower the doses tend to be now (20-50 mcg vs. 150 mcg).

Another difference between combo pills can be the type of progestins that are used in the pill. As of now, these are the different types of progestins used in most combined pills; each with its own pros and cons:
  • Desogestrel
  • Norgestrel
  • Levonorgestrel
  • Norethindrone
  • Norethindrone acetate
  • Ethynodiol diacetate
  • Norgestimate
  • Drospirenone
Some of these progestins have strong androgenic effects (Norgestrol, Levonorgestrol, and to a lesser effect, Norethindrone and Norethindrone acetate) so most women with PCOS may be better off with a combined pill that uses other progestins.

Another couple of progestins (cyproterone acetate and dienogest) that have strong anti-androgen effects are available in combined oral contraceptives for use outside of the United States but are not available in the U.S.

Each combination pill has its own benefits and risks, and it is far beyond the scope of this post to discuss the pros and cons of each. Discuss the choice of combo pills in detail with your care provider, and then do your own research on your own as well. You can find discussions of the pros and cons of the various Pill choices here and here.

So, to summarize, combo pills differ in three main ways:
  1. Dose of estrogen used
  2. Types of progestins used 
  3. How the relative dose of progestin/estrogen changes (or doesn't change) during the month
The wide variety of combo pills available offers women many choices to see which suits their needs best. Women who experience uncomfortable side effects on one type of pill may well find that another type suits them better.

A careful and thorough consultation with a care provider is vital to using oral contraceptives wisely. Don't be afraid to get a second opinion.

Progestin-Only Pills

Progestin-only pills (also called the Mini-Pill) do not contain estrogen, unlike combination pills. They are usually prescribed for breastfeeding women (since estrogen can inhibit milk production, especially in the first few months after birth), and sometimes for those who experience nausea with estrogen. As a contraceptive, Mini-Pills work in the following way:
Mini pills work by thickening the cervical mucus so the sperm cannot reach the egg. The hormone in the pills also changes the lining of the uterus, so that implantation of a fertilized egg is much less likely to occur. In some cases, mini pills stop ovulation (the release of an egg). A pill is taken every day.

If mini pills are used consistently and correctly, they are about 95% effective -- somewhat less effective than standard birth control pills.
It is vitally important to take the Mini-Pill at the same time each day for the best efficacy. Any deviation from this timing can substantially reduce its effectiveness. Missing a dose also significantly increases the chances of inadvertent pregnancy and a back-up method should be used.

Because obese women are at higher risk for blood clots and the estrogen in combined pills can increase the risk for clots, some care providers prefer progestin-only oral contraceptives for this group. ACOG suggests considering progestin-only pills or IUDs with hormonal components for obese women, but does not rule out use of combination pills for this group.

While progestin-only oral contraceptives can help treat irregular periods so common with PCOS, they will not help reduce acne or hair growth issues. Therefore, progestin-only mini-pills may be useful for some women with PCOS, while others will prefer combination pills. Still others will choose to avoid oral contraceptives completely and use alternative methods to promote menstrual regularity and reduce androgenic side effects.

Side Effects and Contraindications

Like any medication, the Pill does come with side effects, contraindications, and interactions with other medications that users should be aware of.

Side Effects

The most common side effects are fairly minor:
  • Nausea
  • Weight gain
  • Sore or swollen breasts
  • Spotting between periods (especially with the Mini-Pill)
  • Lighter periods
  • Mood changes
Some women also report an increase in headaches and blood pressure while on The Pill. 

Some side effects are potentially very serious and need immediate medical attention. They can indicate problems such as liver or gallbladder disease, stroke, blood clots, heart disease, or hypertension. You can remember these by the acronym, ACHES:
  • Abdominal pain (stomach pain)
  • Chest pain
  • Headaches (severe)
  • Eye problems (blurred vision)
  • Swelling and/or aching in the legs and thighs
The risk for blood clots with the Pill seems to be greatest in the first year of use.

While the risk for blood clots, heart attacks and strokes with the Pill is higher than in women who do not use the Pill, it's also important to remember that the actual numerical risk is small, and is less than the risk for blood clots during pregnancy.

Low-dose combo pills seem to have less risk than higher-dose pills, and the risk for blood clots seems to disappear once oral contraceptives are stopped.

Some women who experience negative symptoms with one type of The Pill are able to tolerate a different type better, so it can be useful to try switching if you are bothered by side effects. Sometimes just waiting a few months or taking The Pill with meals (or in the evenings) is enough for side effects to lessen.

Side effects with the Mini-Pill tend to be less severe than with combo pills, but the trade-off is that it is somewhat less effective and can worsen depression in those already experiencing depression.

On the other hand, some women find that the Pill just doesn't feel right to them because of side effects. They may need to consider other options instead for regulating their cycles or birth control.

The question of whether the Pill increases a woman's risk for developing diabetes is more difficult to answer. Some studies have found an increase in insulin resistance/decrease in insulin sensitivity in women on oral contraceptives, while other studies have not. Some have found an increased rate of diabetes, while others have found lower blood glucose levels or no increase in diabetes cases.

Since there are so many formulations, a lot depends on the type of oral contraceptive used; high-dose combination pills (30+ mcg of ethinylestradiol) seem to have a more negative effect on insulin sensitivity. Low-dose pills seem to have less effect.

If there is an effect in most women, it probably is a very modest one, especially with low-dose combination pills. However, if you are borderline already, some types of oral contraceptives may increase your susceptibility to diabetes or glucose intolerance.

Some care providers prescribe a combination of low-dose combination oral contraceptives (for their anti-androgenic effects) and metformin (to help counteract any increase in insulin resistance from the oral contraceptives) for women with PCOS who they feel are particularly at risk for diabetes and metabolic syndrome. 

Contraindications

Women who should not take The Pill include:
  • Women over the age of 35 who smoke
  • Women who smoke
  • Women who have a history of blood clots 
  • Women with serious heart or liver disease
  • Women with serious heart valve problems
  • Women who have had breast cancer, uterine cancer or liver cancer
  • Those with brittle, severe, or long-term diabetes with complications
  • Those on prolonged bed rest
  • Those with a history of migraines with auras
  • Those with uncontrolled high blood pressure
  • Those who had cholestatic jaundice of pregnancy or jaundice with previous oral contraceptive pill use
Whether women with certain other conditions should use oral contraceptives is controversial. These conditions include lupus and poorly controlled hypertension.

Non-smoking women over age 35 is another controversial category. Doctors seem to be leaning towards the view that low-dose combination pills are relatively safe in this group, but that counseling should be individualized based on the woman's personal medical history.

Blood clots may be a significant consideration for women with PCOS on the Pill.

Research shows that women with PCOS tend to have a higher risk for blood clots than the rest of the population; the concern is that use of the Pill in women with PCOS might elevate that risk even further.

And in fact, one study showed that women with PCOS on the Pill had about twice the risk for blood clots as other women on the Pill, and an increased risk compared to women with PCOS not taking the Pill.

However, not all studies agree; some studies have found oral contraceptives to be protective against blood clots in women with PCOS.

All women with PCOS who are considering the Pill should discuss the risk for blood clots with their care providers. If you have further risk for clots, such as a first-degree relative who has experienced blood clots or poorly-controlled hypertension, you will need to consider the use of the Pill especially carefully with a care provider.

Interactions with Other Medications

It's important to remember that some medications may interfere with the efficacy of the Pill, including certain antibiotics, anti-fungals, anti-seizure meds, anti-depressants, and others.

In addition, some "natural" remedies like soy and St. John's Wort can also lessen the effectiveness of the Pill. Vomiting and diarrhea may also cause problems with intestinal absorption, as can weight loss surgery procedures like gastric bypass.

Some evidence also suggests that TZDs (insulin-sensitizing medications like Avandia and possibly Actos) can decrease the effectiveness of oral contraceptives. Since some women with PCOS may be treated with TZDs as well as birth control pills, this is an important possibility to discuss with your doctor.

You can read more about medications that may interfere with the efficacy of oral contraceptives here.

Summary

Most traditional care providers consider oral contraceptives as one of the best first-line treatments for PCOS.

They help regulate menstrual cycles, prevent endometrial hyperplasia, reduce the risk for endometrial cancer, and probably also decrease the risk for ovarian cancer. In addition, some oral contraceptives have an anti-androgenic effect, so problems such as hirsutism and acne may be lessened while on the Pill. These potential benefits are considerable and should not be shrugged off lightly.

However, it's important to point out that some women with PCOS feel that oral contraceptives are merely a band-aid approach to PCOS and may even be harmful. We will discuss that in more detail in the next post, but be aware that while most care providers consider oral contraceptives to be the treatment of choice for PCOS, some in the PCOS field believe they are counter-productive.

If you choose to use them, oral contraceptives come in a dizzying array of choices (monophasic, biphasic, triphasic, low-dose or regular-dose estrogen, type of progestin used, etc.). There are so many choices available that it is vitally important to consult a care provider who is extremely well-versed in the pros and cons of each to decide which might be the right choice for your situation.

Although the estrogen levels have been significantly decreased over time, there is still an increased risk for blood clots with oral contraceptives. These risks seem to be particularly potent in women who smoke and in those with a family history of blood clots. Other groups have some increase in risk as well, so it's important to consult a care provider who can examine all your individual risk factors when considering whether to try an oral contraceptive.

It is not clear at this time whether oral contraceptives present particularly high clotting risks for women with PCOS. Some research suggests that it does, but not all research agrees. This is an area that needs much more research, given how often oral contraceptives are prescribed for menstrual regulation in women with PCOS.

Remember that while oral contraceptives and/or progesterone treatments can be helpful in PCOS, they are not your only choices for treatment. For some, they can be the best choice; for others, they are not.

Some women with PCOS benefit most from a combination approach (oral contraceptives plus other medications like metformin), while others get the best results from alternative protocols (herbs, lifestyle modifications, alternative medicine). For some, weight loss is helpful (at least temporarily), while others do not gain much benefit from it and may even incur harm from it.

The point is that there are no clear answers as to the "best" protocol for treatment of PCOS. Most women find they need to experiment with several different approaches to find the best combination for their individual needs.

And of course, you always have the right to determine the best treatment protocol for your needs. While a knowledgeable care provider can be truly invaluable in this process, there are no protocols that you "have" to follow just because you have PCOS.

YOU are always the ultimate boss of your own body and your own treatment choices.


References

References About PCOS
General Information about The Pill
Information about Different Types of The Pill
Information about Side Effects of The Pill

Monday, September 15, 2014

PCOS Series Resumes

Image Credit: Jessi from www.LifeAbundant-Blog.com 
September is PCOS Awareness Month.

In honor of the many women of size who suffer with Polycystic Ovarian Syndrome (PCOS), we will be resuming our series of posts about PCOS this month.

In previous posts, we have discussed the definition and symptoms of PCOS, how it presents, its testing and diagnosis, and its possible causes.

Then we began discussing common treatment protocols for PCOS, and the pros and cons of each.   We've already discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes. We also discussed the use of progesterone for menstrual irregularity. Now it's time to continue that discussion about other treatment options for various aspects of PCOS.

Next up is a discussion of Oral Contraceptives for menstrual regularity and control of androgenic symptoms. Then we will continue the series with a discussion of anti-androgen medications, and finish up with a discussion of cosmetic treatment options for some of the most distressing side effects of PCOS, like hirsutism, cystic acne, and alopecia.

One of the difficult things about PCOS is how differently it can present in different women. Very few women suffer all the possible symptoms. I'm fortunate that my case is fairly mild, but that makes it more challenging to write about things I haven't personally experienced. Although I can write about it from an intellectual point of view, it's really important to bring out the personal stories of women and how they've dealt with the challenges of this condition.

Therefore, I am particularly looking for more personal stories to share. Stories have already been submitted, but I would like to have many more. Please spread the word on PCOS forums and social media.

Your submission need not be long; just a quick summary of your experiences with an oral contraceptive, an anti-androgen medication, or how you have dealt with hirsutism, acne, or alopecia. Don't forget to give permission for me to share your story and how you want it attributed (anonymous or first name only). Send your submission to me at kmom AT  plus-size-pregnancy DOT  org. (But remember, we want to avoid weight loss talk.*)

As a springboard to the renewal of the PCOS series, I invite you to leave a comment (feel free to be anonymous) about the most challenging or distressing symptom/aspect of PCOS for you. It's a hard condition to have, and the symptoms can provide many social and emotional challenges. Sharing about those is important for healing and dealing with the condition more proactively. Please share about your particular challenges so other women will know that they are not alone.

More PCOS posts will be forthcoming in the future, but for now, this is the current focus. I welcome appropriate feedback on the posts and hope the information is helpful to you.

*Please note that we are discussing PCOS treatment options from a size-friendly point of view (meaning no promotion of/focus on weight loss; no diet talk/no hate talk allowed in comments). There are plenty of other PCOS resources out there that promote weight loss or dieting approaches as treatment. You are certainly welcome to pursue that if you wish, but if you are only interested in that, this is not the site for you. Please find the site that is right for your needs. 
Remember, though, weight loss is not the only way to treat PCOS! Lifestyle management does not have to include trying to lose weight. The Health At Every Size® and HAES® approach to improve health and manage PCOS symptoms can also be useful. What we want here is a safe place to discuss PCOS treatment that does not center on weight loss, radical diets, or body hate talk; sadly, a safe place like that can be hard to find on many PCOS forums. Considering the tremendous failure and regain rate of diets (and the huge profits this brings the weight-loss industry), a weight-neutral approach to PCOS is long overdue. 

Tuesday, September 9, 2014

Preparing Your Family for an Emergency


Among other things, September is National Preparedness Month.

This means it's time to shore up your preparations for unexpected emergencies. This kind of preparation is especially important if you have children or other family members dependent upon you.

You should be asking yourself, do I have enough supplies to get through an emergency where grocery and water supplies might be interrupted? Do I know my school or childcare's emergency plans? How will I reunite my family after an emergency?

Here is a link to an article about emergency planning for families. Among the important points of the article, the author points out that:
  • Despite their disaster risk concerns, the majority of parents (63 percent) are not very familiar with emergency plans at their child’s school or child care
  • Two thirds (67 percent) don’t know if emergency drills are held frequently, or at all
  • Two in five (42 percent) wouldn't know where to reunite with children if evacuated from school or child care
So let's talk about a few important points for family emergency planning:

  • Family Emergency Kits
  • Family Communication Plans
  • Evaluating School Emergency Plans 
Family Emergency Kits

Many parents haven’t set aside key disaster supplies, such as the bare minimum three-day supply of food and water. (Most experts agree that a five-to-seven-day supply is better, and many recommend at least a two-week supply.)

It's most optimal to have multiple kits; one for at home, one in an outbuilding or garage near your home in case you can't get into your home due to damage, and one for your car in case you are away from home when an emergency occurs. Some people choose to have a small emergency kit for their workplaces as well.

These kits don't need to be elaborate. Remember, something is better than nothing.

Yet nothing is what most people have. Even if your kit isn't perfect or doesn't have every recommended thing in it, get SOMETHING going.

Water

The most critical thing to have on hand after a disaster is fresh drinking water ("potable" water). Have a gallon of fresh water in your car, just in case. Because a car is subject to extremes of temperatures, this water should be rotated every 6-12 months, but this is a very easy thing to do.

At home, store a few 5-gallon containers of drinking water in your house or outbuilding in case your regular water supply is disrupted. Each person in the household needs at least 1 gallon of water per day. Don't forget to add in some water for pets too.

Portable water bottles are an important part of any emergency kit. The best are stainless steel so they can be directly heated over a fire.

You should also have a way to filter and purify water in case the emergency extends beyond your stored water supply. You can read more about that process here. Water storage and purification supplies can be bought at most camping stores.

Food

Ready-made snacks are helpful for your emergency kit. Foods such as granola bars, energy bars, and fruit leather pack well and last a long time. Don't forget food for your pets too.

Emergency Information Card

An emergency information card is helpful. This should contain a recent picture of your child, a recent picture of your family, emergency contact information for family members, home address and phone number, the name and number for your child's doctor, a physical description of your child, a list of any special conditions/medications, and an out-of-state emergency contact. 

Most children benefit from a small activity in their emergency bag. A deck of cards, a small game, or a few small toys give an evacuated child something to do and bring a sense of familiarity and safety to an insecure situation. Young children also benefit from a comfort object, like a small stuffed animal, as well as a hand-written letter from a parent to offer them reassurance and love.

Family Communication Plan

Think of all the time you spend separated from your children each day, either due to work or school or their various activities. If an emergency occurs when you are away from your children, how will you find each other? How will you communicate?

A Family Communication Plan can help family members reconnect after an emergency. This doesn't have to be an elaborate plan; it can be quite simple. The key is to have talked about your plan before an emergency occurs.

Create Paper Back-Ups of Important Numbers

Create a paper copy of important contact phone numbers; this can be combined with the emergency information card listed above. Store a copy in each person's backpack, purse, or vehicle.

Most kids today don't bother to memorize their parents' cell phone or work numbers, let alone their relatives' numbers. It's all in their cell phones, so they don't feel the need to memorize anything. But phones fail, get damaged, get lost, or run out of power. Having a paper copy with all contact information on it is important as a back-up.

Even if your child knows all these numbers by heart, a person under stress can forget everyday information like where they live or their own phone number.Memorizing important phone numbers is still a good thing to do, but it's best to have paper back-up too, just in case.

Also designate an out-of-state contact as your emergency notification number. Ironically, it is often easier to reach someone out of state than it is to reach someone locally after a disaster. Have someone far away be the person who helps facilitate communication between family members. Have that number programmed into everyone's phone and written into your emergency information card.

TEXT, DON'T TALK!

If a disaster occurs, your first priority is securing your own safety and that of those around you. As soon as you can manage, however, use your cell phone to send a text message to your family members. Remember, experts recommend that you TEXT, DON'T TALK. 

After an emergency, phone networks will be overwhelmed, and many cell towers will go down pretty quickly or have limited power. Texting takes only a brief amount of power and as a result texts are much more likely to go through during an emergency.

Create a texting tree for your most important contacts. Send a brief message as soon as you safely can after an emergency, as it is more likely to get through sooner than later. Briefly summarize how you are and where you are, remind everyone of your designated meeting place, and tell them to update their status with the out-of-state emergency contact.

You can also briefly post to social media like Facebook or Twitter to let a wider circle of people know that you are all right. Minimize contact, though, to reduce network congestion and help others get through to their families.

The Red Cross also has a program called "Safe and Well" which can help you communicate with loved ones in a disaster. This can help people who have been evacuated to a shelter but who may have very limited online access to connect with loved ones.

Put "ICE" Contacts Onto Your Phone

Identify several ICE ("In Case of Emergency") contacts and program them into your phone. There are smartphone ICE apps now (some free, some at a very low cost) that will show ICE numbers on the cover wallpaper of your cell phone (without someone having to know your phone code to unlock it).

Emergency Responders have been trained to look at your phone to see if there are ICE numbers available. If you are unconscious, they will contact those ICE numbers for you. The emergency information card in your wallet or purse can also serve this function if your phone is damaged or lost, but most Emergency Responders will look at your phone first.

Again, have the information in more than one place. Have it on your phone because that is the first place Emergency Responders will look, and also on a paper back-up in case your phone is broken or not accessible.

Designate a Family Meeting Place

If the family is apart when an emergency happens, where will you meet? The first choice is usually at home, but what if your home is damaged or the neighborhood off-limits because of road washouts from a storm or toxic fumes from a chemical spill?

Be specific about where you'll meet. If you are going to meet at a church, are you going to meet in on the front steps? The back entrance? By the announcements board?

Designate a back-up emergency meeting place in case your first choice doesn't work out. Experts also suggest a regional meeting place in case you have to evacuate out of the immediate area and are not allowed to return for a while.

Establish Retrieval Responsibilities 

Establish ahead of time who is responsible for retrieving which child. If you have multiple children in different schools or activities, having someone assigned ahead of time to each of those children will help minimize duplication of efforts and wasted time. If there is only one parent available, then establish a routine of which child will be fetched in what order (usually youngest to oldest).

Evaluating School Emergency Plans

By a certain age, most kids spend considerable time away from their parents at school or daycare or other activities. How can you help these organizations improve the students' safety profile for when you are not there?

One way to help them is to evaluate their emergency plans and press them to improve drills and planning. Another is to familiarize yourself with their Family Reunification Plan.

Improving Emergency Drills

Your school undoubtedly already holds regular fire drills, since this is required of all public and private schools by law. However, you should ask further questions about the types of drills your school holds. Some not only have fire drills, they also have drills unique to the potential disasters in their area, such as earthquakes, tornadoes, or tsunamis. In addition, many schools these days have Lock-Down Drills and Shelter-In-Place Drills. Ask your school which drills they are holding and press them to hold drills appropriate to the area they are in. 

Also encourage your school administrator to hold emergency drills with a twist. Many kids know exactly what to do if a fire drill occurs in the middle of class (which is when nearly all fire drills are held). But what if a fire occurs during recess? During passing time/bathroom breaks? What if your child's designated exit is blocked during the fire? It's important for schools to practice not just "plain vanilla" drills, but also Deluxe Drills, where unexpected things happen or where drills occur at times of more confusion. 

Reunification Plan

Become familiar with your school's Emergency Reunification Plan. Would you know where you should report to pick up your child in an emergency? Do you know what the protocol is to sign your student out?

Because schools are legally accountable for knowing where students are at all times, there must be an orderly reunification process that documents all actions. Parents will not be allowed to just rush in and grab their children and leave. 

Usually students will be evacuated to a designated area, away from parents and the school building. Parents come to an assigned reunification area and request their student. A runner brings the child to the reunification area, the parent shows ID verifying their identity and signs the child out, and then the parent may leave with the child.

You can save a lot of time and stress by knowing ahead of time where the reunification area is and heading straight there. Also ask how your school plans to communicate with parents in an emergency situation if power is out or phone networks are overwhelmed. It may be that the planned reunification area has to be moved.

As with emergency drills, work with your administrators to improve the planning around the family reunification process. Encourage them to actually do a dry run some time so they can see what the strengths and weaknesses of the procedure are before a true emergency occurs. 




Summary

Emergencies can be scary, but remember, most don't turn into life and death situations. Even so, having a good emergency kit, a family communication plan, and knowing your school's emergency plans can help keep an emergency situation more low-key and less confusing.

And in a true emergency, these things might just save some lives. So take the opportunity of National Preparedness Month and review your family emergency planning today.

Tuesday, September 2, 2014

Obstetric Insanity: An 80% Cesarean Rate in Super Obese Women?

Here is a recent study showing just how severe the problem of high cesarean rates in "obese" women is.

I have not read the full text of the study yet, but was so struck by the outrageous numbers in the abstract that I had to comment.

In this study, the authors unapologetically document a sky-high cesarean rate of 80% in women with a BMI above 50.

Women with a BMI over 50, by the way, is the newest scapegoat of bariatric obstetrics. By focusing on the most obese group, these docs can ratchet up hysteria around obesity and drum up support for extreme interventions (even though intentional weight loss and its rebound afterwards is usually a substantial contributor to this level of obesity).

Listen to the emotionally-loaded way the authors discuss "Globesity." It's no wonder their patients have an 80% cesarean rate; they obviously see this group as a ticking time-bomb waiting to explode.

It's not that we should ignore that this group can have significant complications; they can. Some of them are documented in this study, including a maternal death and an increased rate of stillbirths. We can and should be concerned about these complications and debate ways to lower their rate.

But an 80% c-section rate? A 44% primary cesarean rate? How in the world can they justify that, even when complications exist?

Especially when a British study of women in the same BMI group found that 70% were able to give birth vaginally when given the chance!

We must get away from this obstetric culture of hysteria around obesity. We shouldn't ignore or downplay the risks, but we must not respond to those risks by introducing these women to even more risk by exposing EIGHTY PERCENT of them to the substantial risks of surgery, infection, anesthesia problems, and the downstream effects of cesareans.


Reference

Obstet Gynecol. 2014 May;123 Suppl 1:159S-60S. doi: 10.1097/01.AOG.0000447159.35865.07. Perinatal outcomes in the super obese: a community hospital experience. Papp MM1, Lindsay A, Mariona F, Chatterjee S. PMID: 24770057
INTRODUCTION: Globesity is recognized by the World Health Organization as a pandemic issue. Obesity is considered the second leading cause of preventable death in the United States. Michigan is considered the fifth fattest state in the country. METHODS: Ongoing observational study involving pregnant women with body mass index equal or above 50 kg/m. The study was approved by the Wayne State University institutional review board. The patients were identified in the outpatient clinic and private practice offices and followed during their prenatal care and delivery. RESULTS: One hundred thirteen women are included. Body mass index was between 50 and 106 kg/m. Delivery occurred between 26 and 40 weeks of gestation. A total of 44.24% were delivered by primary cesarean delivery, 36% by repeat cesarean delivery, and 19% by vaginal delivery...Wound infection occurred in 17%. CONCLUSIONS: Pregnant women with extreme obesity incurred a significantly higher number of obstetric-medical complications during the prenatal, intrapartum, and postpartum periods than their counterparts with recommended body mass index. Public health officials and clinicians must join efforts to increase the population awareness of the implications of obesity during pregnancy and the postpartum period. The effect of maternal obesity on the offspring should prompt a community effort to improve preconception health and weight control to improve the maternal and neonatal health.

Monday, August 18, 2014

Even "Complicated" Pregnancies Should Labor Whenever Possible


There's an interesting new study out from Finland. 

I haven't read the full study yet, but from the abstract it looks like the gist is that even in "complicated" pregnancies, women should be given a chance to labor and have a vaginal birth, not just scheduled for a cesarean. 

Many times, in "complicated" pregnancies, there are care providers who believe that there is no point in "trying" for a vaginal birth. They just plan to do a cesarean before labor. They feel they will minimize maternal morbidity that way. 

Not all providers are like this, by any means, but there certainly are quite a few out there that just jump from "complicated" to "planned cesarean."

This very large study shows that the best outcomes were associated with planning a vaginal birth

Of course, each case has to be judged on an individual basis. This study doesn't mean that a planned cesarean is never appropriate; just that outcomes were better on a population-wide basis if the women were usually given the chance to have a vaginal birth.

The only exception was in pre-eclampsia, which in severe cases can sometimes have very poor outcomes. But outcomes in women with pre-eclampsia were equivalent between vaginal birth and planned cesarean...so you could certainly make a case for laboring there too, as long as the condition of the mother and the baby allow it. 

Bottom line, care providers should utilize planned cesareans only when truly necessary. 


Reference

Arch Gynecol Obstet. 2014 Aug 13. [Epub ahead of print] The impact of maternal obesity, age, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity by mode of delivery-a register-based cohort study. Pallasmaa N1, Ekblad U, Gissler M, Alanen A. PMID: 25115277
PURPOSE: To determine the rate of severe maternal morbidity related to delivery by delivery mode and to assess if the impact of studied risk factors varies by delivery mode. 
METHODS: A register-based study including all women having singleton delivery in Finland in 2007-2011, n = 292,253, data derived from the Finnish Medical Birth Registry and Hospital Discharge Registry. Diagnoses and interventions indicating a severe maternal complication were searched and the mode of delivery was assessed by data linkage. The impact of obesity, maternal age 35 years or more, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity (all severe complications, severe infections and severe) was studied in each mode of delivery and calculated as Odds ratios.  
RESULTS: The overall incidence of severe complications was 12.8/1,000 deliveries. The total complication rate was lowest in vaginal deliveries (VD) in all risk groups. Obesity increased the risk for all severe complications and severe infections in the total population, but not significantly in specific delivery modes. Age increased the risk of hemorrhage in VD. Pre-eclampsia increased the risk for hemorrhage in all deliveries except elective CS. In women with pre-eclampsia, overall morbidity was similar in VD, attempted VD and elective CS. The presence of any studied risk factor increased the risk for complications within the risk groups by the high proportion of emergency CS performed.  
CONCLUSIONS: An attempt of VD is the safest way to deliver even for high-risk women with the exception of women with pre-eclampsia, who had a similar risk in an attempt of VD and elective CS.

Sunday, August 3, 2014

Very Low Weight Gain or Gestational Weight Loss in Pregnant Obese Women Risky

[Actual news headline and picture from 2009 media release
because, you know, all obese pregnant women are
constantly stuffing their faces with chocolate]

Here is yet another study that confirms the potential risks of extreme restrictions of prenatal weight gain in women of size.

In this study done by the prestigious MFMU Network, gestational weight loss or a very low weight gain (less than the 11-20 lbs. recommended by the Institute of Medicine) in "obese" women was associated with about twice the rate of Small-for-Gestational-Age (SGA) babies.

This is a concern because SGA babies are at higher risk for metabolic disease as they grow older, including insulin resistance, diabetes, abdominal fatness, the metabolic syndrome, and cardiovascular disease.

In the rush to "cure" obesity, are care providers increasing the next generation's risk for the very conditions they are trying to prevent?

Alarmingly, many clinicians continue to advise high-BMI women to gain little or no weight in pregnancy (even with twins), and some are still telling women of size to lose weight during pregnancy.

This study joins several others that should indicate that extreme prenatal weight gain restriction is not advisable.

Reference

Am J Obstet Gynecol. 2014 Feb 11. pii: S0002-9378(14)00121-5. doi: 10.1016/j.ajog.2014.02.004. [Epub ahead of print] Inadequate weight gain in overweight and obese pregnant women: what is the effect on fetal growth? Catalano PM1, Mele L2, Landon MB3, Ramin SM4, Reddy UM5, Casey B6, Wapner RJ7, Varner MW8, Rouse DJ9, Thorp JM Jr10, Saade G11, Sorokin Y12, Peaceman AM13, Tolosa JE14; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. PMID: 24530820
OBJECTIVE: We sought to evaluate inadequate gestational weight gain and fetal growth among overweight and obese women. STUDY DESIGN: We conducted an analysis of prospective singleton term pregnancies in which 1053 overweight and obese women gained >5 kg (14.4 ± 6.2 kg) or 188 who either lost or gained ≤5 kg (1.1 ± 4.4 kg). Birthweight, fat mass, and lean mass were assessed using anthropometry. Small for gestational age (SGA) was defined as ≤10th percentile of a standard US population. Univariable and multivariable analysis evaluated the association between weight change and neonatal morphometry. RESULTS: There was no significant difference in age, race, smoking, parity, or gestational age between groups. Weight loss or gain ≤5 kg was associated with SGA, 18/188 (9.6%) vs 51/1053 (4.9%); (adjusted odds ratio, 2.6; 95% confidence interval, 1.4-4.7; P = .003). Neonates of women who lost or gained ≤5 kg had lower birthweight (3258 ± 443 vs 3467 ± 492 g, P < .0001), fat mass (403 ± 175 vs 471 ± 193 g, P < .0001), and lean mass (2855 ± 321 vs 2995 ± 347 g, P < .0001), and smaller length, percent fat mass, and head circumference. Adjusting for diabetic status, prepregnancy body mass index, smoking, parity, study site, gestational age, and sex, neonates of women who gained ≤5 kg had significantly lower birthweight, lean body mass, fat mass, percent fat mass, head circumference, and length. There were no significant differences in neonatal outcomes between those who lost weight and those who gained ≤5 kg. CONCLUSION: In overweight and obese women weight loss or gain ≤5 kg is associated with increased risk of SGA and decreased neonatal fat mass, lean mass, and head circumference.

Thursday, July 24, 2014

Induction or Waiting in Obese First-Time Mothers?


This is a follow-up post about a study reported on briefly here earlier this year.

It is about the question of whether "obese" women should have their labors induced proactively at term or be expectantly managed, and whether elective induction increases their risk for cesarean and other poor outcomes (like fetal distress, more Neonatal Intensive Care Unit utilization, etc.).

Induction of Labor: Help or Harm?

Induction of labor is an increasingly common intervention in women of all sizes. The question is whether it does more harm than good.

Much research shows it is associated with an increased risk for cesarean, but other research does not always show this. A definitive answer still eludes us on whether/when induction is appropriate.

Complicating this question is the whether or not the mother's cervix is ripe. Inducing on a very ripe cervix is much less likely to lead to a cesarean than inducing on an unripe cervix (Bishop Score less than 5-7, or cervical dilation more than 3 or 4).  And this is especially true in first-time mothers (nulliparous women).

An increased maternal BMI complicates this debate because of a perceived heightening of risk. One of the biggest dilemmas facing maternity care providers who are caring for "obese" women is how to manage them at term. Should they electively induce labor at 39 or 40 weeks, or should they wait for labor to start on its own if no complications occur?

Many care providers these days seem to be electively inducing obese women at 39 or 40 weeks, sometimes regardless of cervical ripeness (when they are not trying to talk them into a planned cesarean).

Many have the best intentions with this; they think inducing a smaller baby will lessen the risk for cesarean or shoulder dystocia, or they think that baby will have better outcomes if they induce before complications might develop. But do these assumptions hold up under scrutiny?

The problem is that little research has actually examined the question of whether it is beneficial to routinely induce obese mothers without specific medical indications for induction.

Care providers usually go ahead and do so, assuming that inducing obese women at term is beneficial, but there has been little direct evidence one way or the other in a study specifically designed to look at the benefits and risks of routine elective induction in high-BMI women.

Sadly, there is still no large study that rigorously examines this question.

However, we now have a small study that begins to address it. The study looks at the outcomes of elective induction or expectant management of obese first-time mothers with an unripe cervix.

The Study

This retrospective study was conducted by doctors at a hospital in Washington D.C. They studied obese (BMI 30 or more) first-time mothers with no chronic medical co-morbidities (like chronic hypertension, pre-existing diabetes, etc.). Women were admitted to the study between 39 and 41 weeks, and only if they had an unripe cervix (Bishop score less than 5) that was documented during week 38.

The researchers compared the results of electively inducing obese first-time mothers with an unripe cervix (n=60) at 39-41 weeks with expectant management (waiting for spontaneous labor or inducing only if medical indications arose, n=410). Age, BMI at delivery, and prenatal weight gain were similar between groups.

It's important to note that the authors did not compare elective induction to only spontaneous labor. They compared elective induction to expectant management, many of whom eventually were induced if medical indications for induction of labor arose.

The results of this study would probably be even more striking if they compared elective induction only to spontaneous labor, but the authors felt that this was not an appropriate comparison, stating,
"Because spontaneous labor is not something a provider can choose for a patient, it is not realistic to use this as a comparison control group; it is more appropriate to compare the induction of labor to expectant management."

Even so, the bottom line was that the researchers found that electively inducing labor in high-BMI first-time mothers with an unripe cervix raised the risk for cesarean. By quite a bit.

The cesarean rate was 25.9% in the obese women in the expectant management group, and the cesarean rate was 40% in the elective induction group.

That's a significant increase in risk for cesarean.

Only 10.7% of women in the expectant management group were still pregnant by 41 weeks; all the others had either gone into labor spontaneously (36.8%) or had been induced for commonly-accepted medical indications (rupture of membranes, gestational hypertension, non-reassuring fetal heart rate tracings, etc.). So quite a few of the expectant management group were eventually induced, yet the difference in the cesarean rate was still quite marked.

Another important finding was that the elective induction group had three times the rate of admission to the Neonatal Intensive Care Unit (NICU) after the birth (18.3% vs. 6.3%).

This suggests that instead of reducing harm to the baby (as many care providers believe), elective induction in this population may actually increase the risks of poor outcomes.

Now, of course the study had a relatively small sample size, especially in the electively induced group. It was also a retrospective study. So the authors point out that further research on this topic is needed, preferably with a large prospective study.

Still, even with the study's weaknesses, it suggests strong caution towards elective induction in obese women with an unripe cervix. As the authors note:
In a joint summary from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists, physicians are urged to perform labor induction primarily for a medical indication and if done for nonmedical indications...to ensure that the 'cervix should be favorable, especially in the nulliparous patient.' Our findings support this assertion.
Other studies 

This study echoes a number of studies which have found higher c-section rates and complications in obese women who were induced (especially first-time obese mothers).

Of course, these studies did not specifically examine the question of whether routine induction in obese women improved overall outcomes. Still, their findings seem to also suggest caution around the idea of routine induction in obese women.

Although a higher rate of complications like pre-eclampsia means that some obese women will be induced for true medical indications, many others are induced for more dubious indications, based on questionable beliefs. These must be examined carefully.

For example, many providers believe that inducing early when the baby is smaller will lessen the risk for cesarean. Yet a number of studies have shown that it actually increases the risk for cesarean.

The combination of a suspected big baby and a high-BMI mother is a particularly potent combination that leads to many cesareans. A 2006 Massachusetts study found that the combination of induction, a suspected big baby, and first-time mother doubled the cesarean rate in the high-BMI women studied.

Many women of size are induced labor at term ostensibly to prevent a shoulder dystocia. Yet a recent New York study found that induction of labor actually increased the risk for shoulder dystocia (2.85x the risk), and especially so in obese women (5.64x the risk). By inducing women of size, providers may often be creating the very situation they are trying to avoid.

Other care providers induce because they believe it will improve outcomes in high-BMI women. A 2005 Welsh study on obese women with no complications found that the cesarean rate was 19% in the group with spontaneous labor and 41% in the induced group. Like in the present study, the Welsh study noted that the induction of labor was the start of many problems for the obese women in the group, including more blood loss, more UTIs, more babies in the NICU, more feeding difficulties, more neonatal trauma, etc.

So while many care providers think they are doing obese women a favor by inducing them proactively at term, there is strong reason to suspect that they may actually be doing more harm than good.

So much so that a 2013 Irish study (which found higher rates of emergency cesarean in induced obese first-time mothers) concluded:
Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
Conclusion

Research is clear that induction of labor is an extremely common intervention in obese women.

These and other studies suggest that perhaps a little more time and patience is needed at the end of pregnancy in obese women, and that induction should only be undertaken for strict medical indications.

Furthermore, it is time that larger studies directly address the question of whether routine induction at term improves or harms outcomes in obese women and their babies.

These potential studies should particularly look at outcomes among subsets of high-BMI populations, including obese women with complications and those without, those with differing levels of obesity, obese first-time mothers with an unripe cervix, obese multips with a prior vaginal birth, obese women where a big baby is suspected, etc.

Only then will care providers receive clearer guidance on the best management of women of size at term in many of the scenarios they are likely to encounter. It's FAR past time for such targeted research to occur.

We need care based on real evidence, not simply on assumptions about what's best for obese women.


References

Am J Obstet Gynecol. 2014 Jul;211(1):53.e1-5. doi: 10.1016/j.ajog.2014.01.034. Epub 2014 Jan 31. Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m(2) or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks...RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.
Acta Obstet Gynecol Scand. 2013 Dec;92(12):1414-8. doi: 10.1111/aogs.12263. Maternal obesity and induction of labor. O'Dwyer V1, O'Kelly S, Monaghan B, Rowan A, Farah N, Turner MJ. PMID: 24116732
...Of 2000 women enrolled, 50.4% (n = 1008) were primigravidas and 17.3% (n = 346) were obese. The induction rate was 25.6% and the overall cesarean section rate 22.0%. Primigravidas were more likely to have labor induced than multigravidas (38.1% vs. 23.4%, p < 0.001). Compared with women with a normal BMI, obese primigravidas but not obese multigravidas were more likely to have labor induced. In primigravidas who had labor induced, the cesarean section rate was 20.6% (91/442) compared with 8.3% (17/206) in multigravidas who had labor induced (p < 0.001). In obese primigravidas, induction of labor was also more likely to be associated with other interventions such as epidural analgesia, fetal blood sampling and emergency cesarean section. In contrast, induction of labor in obese multigravidas was not only less common but also not associated with an increase in other interventions compared with multigravidas with a normal BMI. CONCLUSIONS: Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
BJOG. 2005 Jun;112(6):768-72. Outcome of pregnancy in a woman with an increased body mass index. Usha Kiran TS1, Hemmadi S, Bethel J, Evans J. PMID: 15924535
...The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999. POPULATION: Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation... METHODS: Comparisons were made between women with a body mass index of 20-30 and those with more than 30...RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events....
J Midwifery Womens Health. 2006 Jul-Aug;51(4):254-9. Maternal body mass index, delivery route, and induction of labor in a midwifery caseload. Graves BW1, DeJoy SA, Heath A, Pekow P. PMID: 16814219
...This retrospective cohort study examined the outcomes of 1500 consecutively delivered women who were cared for by two midwifery practices and delivered between January 1, 1998, and December 31, 2000. Cesarean delivery was significantly associated with the obese BMI (P < .001), nulliparity (P < .02), and newborn birth weight (P =.006). Prenatal weight gain did not have a significant correlation with cesarean birth (P = .24). In multivariable modeling, obese BMI, high newborn birth weight, nulliparity, and induction of labor increased the risk of cesarean birth. There was also a significant association between higher BMI and risk of induction of labor (P < .001). In a secondary analysis, obese BMI was associated with increased risk of induction in cases with ruptured membranes (OR 2.2; 95% CI 1.4-3.4) and postdates pregnancy (OR 2.0; 95% CI 1.1-3.4).
Obstet Gynecol. 2014 May;123 Suppl 1:172S. doi: 10.1097/01.AOG.0000447182.21511.09. Shoulder dystocia and labor induction stratified by maternal weight: to induce or not to induce? Sirota I1, Francis A, Chevalier M, Ashmead G. PMID: 24770084
...Retrospective study of all shoulder dystocia patients who delivered from 1998 to 2010, women in a control group without shoulder dystocia were matched two to one by maternal BMI, age, parity, and diabetic status...RESULTS: Included in the study was 57,259 deliveries; 144 shoulder dystocia cases and 288 women in the control group met study criteria. One hundred seven (74%) shoulder dystocia cases were induced or augmented; 37 (26%) labored spontaneously. One hundred thirty-six (47%) women in the control group were induced or augmented; 152 (53%) labored spontaneously... Across all BMIs, induced patients were 2.85 times more likely to have shoulder dystocia than noninduced patients (95% confidence interval 1.57-6.14; P<.001). After stratifying by BMI, induced normal-weight patients were 2.11 times more likely to have shoulder dystocia than spontaneously laboring normal-weight patients; induced or augmented overweight patients were 4.74 times more likely to have shoulder dystocia than their spontaneously laboring counterparts; and induced or augmented obese patients were 5.64 times more likely to have shoulder dystocia than their noninduced cohorts...CONCLUSION: Induction or augmentation appears to be associated with an increased shoulder dystocia risk with increasing maternal BMI.
Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A114-5. doi: 10.1136/archdischild-2014-306576.330. PLD.30 A 5-year review of maternal obesity and induction of labour on mode of delivery and risk of labour, anaesthetic and neonatal complications. Joannides C, Hon M, McGlone P, Parasuraman R, Al-Rawi S. PMID: 25020968
...Retrospective analysis of women with a booking BMI >45 between January 2009 and October 2013...RESULTS: 158 patients were analysed (mean BMI 49). 68% of all patients were either induced or required labour augmentation (background rate of 39%). 64% of these women achieved a vaginal delivery, increasing to 70% if no induction or augmentation. 71% of multiparous women who spontaneously laboured and had previously achieved a vaginal delivery, delivered vaginally again. Half of primiparous women requiring induction or labour augmentation had an emergency caesarean. 49% had intrapartum regional anaesthetic. 42% required multiple attempts, 19% needed an epidural re-site or spinal for theatre. CONCLUSION: These results mirror the UKOSS study findings. Higher maternal BMI is associated with an increased incidence of induction and augmentation of labour. Despite this the vaginal delivery rate is high. Primiparous women requiring induction or augmentation of labour were most susceptible to obstetric intervention....