Tuesday, May 8, 2012

Fetal Over-testing in the Last Trimester Because of Fat?

This is a comment that was left on my blog recently, in the "Will I Feel My Baby Move If I'm Fat?" post. It's a new twist on the old wives' tale (more like old OB's tale) that fat women supposedly have too much abdominal fat to feel their babies move in pregnancy.
"I am 29 weeks today and a nurse practitioner I saw last week told me I have to have nonstress tests 2X week because of my weight. She claims I won't feel the baby's movements so they need to monitor them. Has anyone else been told this? I'm a very busy woman and incredibly stressed about having to go to the hospital 2X week, plus she says I have to do an ultrasound monthly, plus do my weekly doctors appts. Advice would be great because I don't want to do this but I feel I have to so the baby will be monitored appropriately."
Seriously?  A non-stress test 2x per week from 29 weeks on because a fat woman supposedly won't feel her baby's movements? 

This is pure and unadulterated bullsh*t.  Women of size feel their babies move perfectly well, thank you. There's no fat between the baby and the inside of the uterus; we feel every roll and punch and kick.

Nearly every woman of size I've ever spoken to has said that yes, they feel their babies move just fine; I certainly did. Yet this myth about fat "preventing" women from feeling their babies still persists. That it persists among the public is disappointing but attributable to ignorance; that it persists among some healthcare providers is nothing short of appalling.

But the second question here is whether fat women are so incredibly high-risk from "obesity" alone that we have to be monitored 2x/week from the middle of the second trimester on?  Yet other women only start monitoring around week 41? Oh puleeeze.

Even most diabetics aren't monitored this aggressively. Insulin-dependent diabetics usually start fetal surveillance around 32 weeks. For gestational diabetics not on insulin, the need for fetal surveillance is widely debated; if used at all, it is usually introduced around the end of pregnancy.  Only diabetics with severe comorbid complications like vascular issues or kidney disease usually benefit from this kind of aggressive monitoring starting in the late second trimester. Are the providers in the above scenario seriously comparing the risk of an uncomplicated pregnancy in an obese woman to that of a brittle type 1 insulin-dependent diabetic with pre-existing kidney damage?

The only time I can see this kind of over-the-top monitoring being truly needed in a woman of size would be in someone who has experienced serious major poor outcomes in a previous pregnancy, or who is experiencing major complications in a current pregnancy (HELLP syndrome, hypertensive disorders, prior stillbirth, brittle or uncontrolled diabetes, diabetes with comorbidities, IUGR, or various other serious complications). The commenter didn't mention any such comorbidities.

Now, the argument some docs make for increased fetal surveillance in "obese" women is that some studies have shown an increase in the risk for stillbirth in these women.  However, not all studies have shown an increase in the risk of stillbirth in obese women. Moreover, there is no data to prove that aggressive monitoring in obese women lowers the risk for stillbirth.  

It is questionable whether obesity itself, without concurrent complications like HELLP or uncontrolled diabetes, necessitates this kind of frequent monitoring.  It is telling that most care providers do not require it. The American College of Obstetricians and Gynecologists (ACOG) does not currently recommend increased antepartum surveillance in the last trimester for obese women.  Nor does the Society of Obstetricians and Gynaecologists of Canada (SOGC).  And research suggests that obese women don't have more poor results on non-stress tests.

Although there may be a somewhat higher risk for stillbirth in women of size, and although non-stress tests and biophysical profiles can sometimes help identify babies at high risk for stillbirth, these tests don't always help and come with downsides too. The rate of  false-positives is quite high, and often results in unnecessary interventions like early induction of labor or cesareans, and these also carry risks.

So while I can understand some providers wanting to offer this as an option to women of size (especially those who experience comorbid complications like hypertension disorders or restricted growth), I strongly question the value of its routine use in women of size with uncomplicated pregnancies. Furthermore, the testing schedule this woman has been put on is quite excessive (barring some complication we are not aware of).

Awareness of the possibility of complications in women of size is one thing, but clinicians must remember that over-testing brings its own risks and often becomes a self-fulfilling prophecy.

I've been through four pregnancies as a "morbidly obese" woman and I was never required to do this kind of monitoring. Nor do I know many other fat women who have been required to do this extreme amount of monitoring. And I can assure you that I most definitely felt my baby well enough to do kick counts by the end of pregnancy.  The idea that non-stress tests or biophysical profiles are required because fat women are too fat to adequately keep track of their baby's movements is ludicrous.

Commenter, unless you have some major complication we don't know about, you might want to think about running far and fast from this practice so you can find one that doesn't see you as such a ticking time bomb.  Pick a practice that knows that fetal surveillance testing has both pros and cons, that knows there is a high risk of false positives and over-intervention with these tests, and that is willing to discuss these pros and cons with you and let you make the final decision on their use instead of compelling you to follow an arbitrary schedule of testing virtually designed to find problems and intervene.

*How about you?  If you are a woman of size, have you been required to have such aggressive fetal surveillance from so early on?  What kind of fetal testing was recommended for you as a woman of size by your providers?


Mrs. Gamgee said...

I'm currently pregnant with my second child (fourth pregnancy... two early losses). I am morbidly obese, have pregnancy induced hypertension, and have insulin dependant GD. I also have a low lying placenta (partial previa). I am 38 weeks, and am scheduled for c-section in two days.

All that to say, I think what the commentor is being put through is ridiculous! I have been having weekly NSTs (once every 7 or 8 days) for the last 4 or 5 weeks, and my doc has scheduled them for when she is on call at the hospital so that we don't have to have an office appointment each week as well. I haven't had an ultrasound in two months (the last one was to determine where my placenta was sitting).

I can feel my baby move just fine, and so can anyone who touches my belly when baby is active. My husband finds it amusing to watch my belly move around after dinner each evening.

This doctor obviously has some serious prejudices against women of size, and I would run away screaming. I hope she can find a doc who is better grounded in reality.

Elizabeth said...

As a fat woman (292 pre-pregnancy, and 299.5 when I got to the hospital which included about a 10 lb loss during the first to early second trimester), I did have more u/s and NSTs than an average sized woman probably did. I had an u/s at about 30 weeks, and then one at every appointment from 36 weeks on. I also had an NST from I think 32 or 34 weeks on. My ob's office had an u/s machine and full time tech and a room dedicated full time for NST, so all of these were done in connection with a regular appointment. I only had one u/s that wasn't a regular appointment, and that was at 8 weeks since they had wanted me to come back so they could get a better picture to rule out twins and make sure it was a viable pregnancy. My ob met with me for a few minutes in his office and discussed his concerns about my weight loss (8lbs in two weeks), and went over the u/s and any concerns I had.
With all that said, I had either pre-existing or pregnancy induced hypertension that I was on medication for from about 12 weeks on. We weren't sure which since I had a couple of high readings before I got pregnant but had never been diagnosed, but it went down to normal after my daughter was born when they took me off the medication at the hospital where they could monitor it and I could go back on it if it went up. Even with the high blood pressure, I wasn't monitored as closely as this woman's provider is recommending. The biggest issue was we discussed inducing at 39 weeks, but since my blood pressure was controlled at that point and the BFPs and NSTs were all normal I wasn't induced until the night of 41 weeks 3 days. And I think most ob's would be insisting on an induction at that point regardless of weight.

MomTFH said...

@Bazile, I think any hypertension as early as 12 weeks is considered chronic, not pregnancy induced, but that may be mere semantics if it went away when you were no longer pregnant. Please keep an eye on it, though!

As for the original commenter, that does sounds really excessive. Can she offer to do kick counts instead? If she feels the baby move adequately every day, it seems like the indication for the NSTs is moot.

Janeen said...

Didn't have even one NST when pregnant with my older daughter in 2005 and only had one ultrasound. I was treated no differently than a woman with a lower BMI (I weighed around 300 when I got pregnant and delivered weighing 325).

Only had one NST with the younger one and it was because the OB scared her with a dopplar that was broken. That ended up not only being a trip for the NST but since her heart rate was still up a little (probably as a result of me realizing I had lost my cell phone), they sent me to L&D. That was 15 days before my daughter was born and I didn't return for my 39 week appointment because I felt that he was being over cautious. I was able to feel the little one more just fine, had been able to feel her move earlier in the pregnancy than her older sister, from at least 17 weeks on if not sooner and was able to feel her outside as well.

I would definitely be running far away from this practice. It appalls me how women of size are being treated worse and worse as the years go by. I sincerely hope I do not become pregnant again with another baby because I really fear how worse things will be the next time if I ever had to.

Anonymous said...

I refused the sick-up sugar solution test with my last pregnancy, so the clinic providing shadow care said I had to come pee in a cup every week instead because anybody with a butt and arms like mine had to be right on the edge of gestational diabetes. They were so obsessed with GD that they didn't test for anything else. I reported hot-feeling lower back pain, painful urination, and weird colored pee and was brushed off. Yes, even the weird colored pee was not recognized as a symptom of the severe UTI that I in fact had. The midwife believed me and had me pee in a Dixie cup in my own bathroom. She used a paper strip to check for unusual pH (IIRC), then told me to go in and demand that they test for bacteria. I walked out of the clinic with a two-week scrip for antibiotics. "Wow," said the doctor, "if we hadn't caught this, you might have had a preemie, or a kidney infection."

Yeah, thanks, folks.

Oh, and I never had GD.

Oh, here's a good one. I had to go to the same clinic for all three pregnancies because they were the only one in my network. I was instructed to see whoever was available because if I did end up with a hospital birth, I would get whoever was on rotation, so I should get to know them all. (The clinic was attached to the hospital.) I kept ending up with a lugubrious, muttering fellow I will call Dr. Eeyore. Every single week he would tell me that my fundal height was too much or too little (too much and later on too little!) and allude to complications that would require an OB to come save me. I could not pin him down as to specifics. Finally I demanded my records and took them to the midwife, who promptly produced a fundal height chart and had me check my recorded measurements myself: normal, normal, normal, normal, normal. I threw Dr. Eeyore one appointment for each succeeding pregnancy and asked the receptionist not to schedule him for me ever again.

But that's not the worst. Eight years later, Dr. Eeyore is still at it. Just last week I spoke with a woman who was told by Dr. Eeyore that she either had too much amniotic fluid or a big baby and so she needed another ultrasound. Her measurement sounded fine to me. As I discovered when I looked it up that evening, it was in fact just a fraction above the 50th percentile. I told her that she did not have to see Dr. Eeyore ever again and she could tell the receptionist to schedule her appointments with some other OB. (Hopefully she will not get Dr. Eeyore in the delivery room!)

Jenny Islander

Anonymous said...

For me it was the diabetes-prejudice, which you have already discussed in many previous posts. My doctor simply assumed that I had diabetes (without testing for it) and insisted on a tighter schedule for ultrasounds and CTGs. She also insisted that I loose weight. I changed doctor and things did not improve by much. Now I was just supposed to have plenty of tests and keep my weight constant...

Anonymous said...

... oh, one addition: I got a glucose tolerance test on my own initiative. It was negative. But the doctor insisted that I was at a high diabetes risk and needed close monitoring...

onesillyme said...

I had NO trouble accurately counting movements for BOTH of my twins. I had a clicker in each hand. While you might not have seen the babies' movement as clearly as on a thinner woman, I had no problem knowing when they kicked. Especially when they nailed me in the bladder (both breech). Is you NP perhaps going for some extra co-pay &/or procedure fees? The schedule they have proposed sounds both exhausting and expensive.

Sara A. said...

I'm 25 weeks along and so far my only concern is that I have an anterior placenta that's towards the top of the womb. I really only feel movements in the lower section of my uterus, unless the baby is really really kicking up top. Baby gets really upset with my laptop and will just beat up on it if I rest it on my belly. It's kind of funny to watch it jump around.

Is it normal for baby to have periods of inaction throughout the day? They sometimes last a few hours. Also baby seems to be nocturnal, kicking away after 10:00 PM and sometimes waking me up very early in the morning. I'm concerned with doing one of those tests because baby isn't very active during office hours.

Becky said...

I developed choleostasis of the liver at 32 weeks and had to go for weekly ultrasounds and blood testing until I was induced at 38 weeks. (Thank goodness I live in Canada where all that was covered by the health care system!) But before that my pregnancy was treated as low risk even though my BMI was in the "Class II obese" category and I had the normal amount of monitoring. (And I could feel her move just fine!)

Anonymous said...

@Sara A.: Babies sleep in utero. Keep track of the quiet periods because they will probably be your baby's naptimes for the fourth trimester. Activity at nighttime is also normal; these will probably be your baby's night-nursing sessions. (If you can set up the bedroom so that the baby sleeps in your bed or in a sidecar, you may not even have to wake up for these--just roll over!)

However, babies don't grok daytime and nighttime, so you may be feeling what will be your baby's night cycle during the day and the day cycle at night. Making sleep time darker and quieter than wake time should cue him/her in pretty quickly after birth, however.

Jenny Islander

bowrungsbaby said...

please please please can someone help me. I am 10 weeks pregnant and current have a bmi of 35. Firstly i have suffered with severe sickness since 5 weeks and doctor said it was ok as i 'could do with losing some weight' and refused to give me medications, and now i have had my first midwife appointment today and was told that more than 50 percent of maternal deaths in pregnancy and childbirth are obese mothers and that i will have to have special monitoring and won't be allowed to have a natural birth at the birth centre and will have to be under consultant care and be constantly monitered throughout labour (meaning no water birth, no moving around, no getting into positive positions to birth). I am so scared and disappointed, i feel like i am an unfit mother already and feel that the drs think i do not care about the health of my unborn baby. Now i know that this will not go down well with some people but i am considering a termination so that i can lose more weight before carrying a child (i have currently lost 70 pound). I came across this blog and i am aware that you are based in th US and i am in the UK so some things are different for instance i can't actually choose a provider and am stuck with who i have :( but please any advice would be so appreciated. Both myself and my partner are concerned and do not know what to do. xx

Anonymous said...

Hi bowrungsbaby,

I'm in the UK and I had a pre-pregnancy weight BMI of 41. I was not told any of these things by any of my care providers.

Maternal mortality in the UK is 4.27 deaths per 100,000 and given that overweight/obese women are roughly half of the female population this looks like it correlates directly.

You are able to refuse constant monitoring at the hospital. All of these things that they are telling you to have are only recommended. You don't have to do any of them. The only thing is they probably won't let you in the birth centre but you are still able to have a natural birth on the labour ward. You can actually alter the hospital that you are currently at for another one. You can also change your GP.

If you want this child then have it. I'm not sure what these people are gaining from scaring you so very badly. Do some more reading of this blog and around the internet about the risks associated with being obese and pregnant. I think you'll find that in most cases it's not that different than if you were 'normal' weight. Take these facts in with you to your appointments with your professionals so that you can counteract them and so you feel better.

You are NOT an unfit mother already. These people are being vastly unprofessional and judging you solely on your weight and not on your general health.

You will be fine. Your baby will be fine and stuff the rest of them!

Anonymous said...

I hate that they do this. I have a high-deductible insurance plan and it has cost me roughly $4,000 out of pocket to have my baby due to all of these tests. From 32 weeks on, I had to have a NST and ultrasound every week; even though all of my bloodwork was normal - even up until delivery. I was 30 and 400 pounds, yes, but I could feel my baby and everything was fine. I even had a normal delivery with no complications. I was in active labor for about 11 hours and this was my first child!! If I have another one, I don't know what I'll do because all these doctors see is weight. I suppose I could refuse the additional testing...

Anonymous said...

So glad I saw this post. I just came from my 38 week appointment and the midwife suggested I get fetal monitoring twice a week, have another ultrasound to check the size of the baby and continue to come in every week. When I asked her about the fetal monitoring, she said that new research indicates that women with a BMI>30 are at risk for placenta issues and its standard to do fetal monitoring 2x a week from 36 weeks. I asked her for more information - but basically she said it was to make sure everything is fine with the baby. I just feel there is no indication for all these tests and I am really trying for a VBAC, so I'm avoiding unnecessary interventions - my blood pressure is normal, no gestational diabetes, I've only gained 10lbs and I started at 300lbs. I figured I'd just not make an appointment for the ultrasound and the fetal monitoring, but at this point my insurance only covers this group practice, so I can't change.

Jennifer Petry said...

My current BMI is 48 and I'm 35w5d pregnant and NO OTHER COMPLICATIONS, yet have had to do two NSTs weekly since 32 weeks and monthly ultrasounds from 20 weeks on. When I asked Dr why (previous pregnancy at same weight but with hypertension didn't have this much testing), all he said was "just all the legal mumbo jumbo bullshit." So basically, I'm guessing I have to go through all this craziness to cover his butt? I'm soooo done