Obesity and Hypertension in Pregnancy: Does it matter afterwards?

Prof Leonie Callaway

Overview

• The landscape of obstetric medicine research at RBWH

• Metabolic issues in pregnancy

• Why weight matters in pregnancy and afterwards

• Why hypertension matters in pregnancy and afterwards

Why Obstetric Medicine?Major Changes in Pregnancy Care

• Increasing age of first time mothers

• Increasing BMI of pregnant women

• Increasing numbers of women who survive childhood illness and decide to have children

• Increasing numbers of women who proceed with pregnancy despite significant medical problems

Research focus

Preconception

Pregnancy

Lifelong health

Research Themes

Pre Pregnanc

y

• Preconception Care• Interconception Care

Pregnanc

y

• Prevention of Pregnancy Complications• Pregnancy as a Metabolic Stress Test

Long term healt

h

• Neonatal body composition, metabolism and future health• Long term maternal health

SPRING RCT

CRICOS Provider No 00025B

A metabolic miracle

Metabolic Issues in Pregnancy

1. Pregnancy is a “Metabolic Stress Test”

2. Increasing BMI and age underpin the rising incidence of gestational diabetes

3. BMI is an important predictor of pre-eclampsia, macrosomia, neonatal body composition

Pregnancy as a “Metabolic Stress Test”

Gestational Diabetes Type 2 Diabetes Cardiovascular disease

Gestational Hypertension Hypertension Cardiovascular disease

PreeclampsiaHypertension

Renal ImpairmentType 2 Diabetes

Cardiovascular disease

Remote prognosis of HDP?

• Over time, women with HDP gain consistently more weight than women who do not experience HDP (Callaway et al, AJE; 2007)

BMI Pre Pregnancy BMI 21 years post pregnancy20

21

22

23

24

25

26

27

28

29

30

No HDP (n=3254)

HDP (n=318)

Predicted for HDP

Fully adjus-ted difference is 1.35 kg/m2 (0.8, 1.89)

Women who experience HDP have a higher incidence of remote diabetes:MUSP Cohort n=3639HDP n=333 (9.15%)

OR for Diabetes after HDP 95% CI

Unadjusted Model 1.91 1.32, 2.78

Adjusted for age, parity, smoking, family income, physical activity, pre pregnancy BMI

1.60 1.08, 2.40

Adjusted for all of the above, as well as current BMI

1.6 1.11, 2.42

Callaway et al, AJOG 2008

Women with HDP do not have adequate follow up

HDP

(n=191)

No HDP (n=1921) OR (95% CI)*

Hypertension n(%) 62 (32.4) 280 (14.6) 4.09 (2.76, 6.07)

Inadequately identified or

managed hypertension n(%)

33 (17.8) 167 (8.7) 3.56 (2.06, 3.59)

Pre-hypertension 68 (35.6) 513 (26.7) 2.45 (1.68, 3.58)

Callaway et al, ANZJOG 2012

The tricky problem of obesity in pregnancy

Queensland: Where Australia shines!

Maternal Obesity in Queensland

• 2006: 33% overweight and obese (Callaway et al, MJA, 2006)

• 2008: 50.5% overweight and obese (QH statbites)

Pregnancy weight gain

• Institute of Medicine Guidelines

What to do?

• Preconception Care

• Pregnancy Care

• Long term health

Is obesity surgery prior to pregnancy effective?

• Does massive weight loss make a difference?

Copyright restrictions may apply.

Maggard, M. A. et al. JAMA 2008;300:2286-2296.

Observational Studies on Maternal Pregnancy Outcomes Following Bariatric Surgery

Does weight loss prior to pregnancy reduce the risk?

• The case of bariatric surgery:– Case control study– 79 cases mean BMI 45.9 pre LAGB, mean weight

loss 28.3 kg pre pregnancy– 79 matched controls, mean BMI 43.7

GDM HDP0

10203040

Post LAGBControls

Dixon et al, Obstet Gynecol; 2005

Is preconception care effective?

Table I: Baseline Characteristics of surveyed women (n=412)

Age 31.4 (5.4)

Gestation 19.5 (6.2)

Pre Pregnancy BMI 23.8 (5.37)

BMI 1 Year Pre Pregnancy (n=380) (%) 24.0 (5.75)

Gravidity 1.7 (1.7)

Parity 0.8 (1.0)

Nulliparous (%) 179 (43.4)

Planned pregnancy n (%) 266 (64.6)

Periconceptual folic acid supplementation (%) 232 (56.3)

Pre conception health check (%) 220 (53.4)

Completed secondary school (%) 300 (72.9)

Tertiary degree (%) 144 (34.9)

Public (%) 255 (61.9)

Born in (%) 310 (75.2)

Smoked during pregnancy (%) 91 (22.1)

BMI Pre Pregnancy

BMI 1 Year Pre Pregnancy (n=380) (%)

<18.5 7.1

18.5-25 62.6

25.01-30 18.4

>30 11.9

BMI Pre Pregnancy (n=380) (%)

<18.5 32 (8.4)

18.5-25 233 (61.3)

25.01-30 65 (17.1)

>30 50 (13.2)

Values are Mean (SD) unless otherwise indicated.

Callaway et al, MJA, 2009

Table II: Self recorded category of weight according to BMI category (n=380)

BMI Category Prior to Pregnancy % of each BMI category

<18.5 (n=32)

Categorized self as underweight 12 (37.5)

Categorized self as normal weight 20 (62.5)

18.5-24.99 (n=233)

Categorized self as underweight 9 (3.4)

Categorized self as normal weight 208 (89.3)

Categorized self as overweight 16 (6.9)

25 -29.99 (n=65)

Categorized self as normal weight 23 (35.9)

Categorized self as overweight 41 (62.5)

Categorized self as obese 1 (1.6)

≥30 (n=50)

Categorized self as normal weight 4 (8)

Categorized self as overweight 38 (76)

Categorized self as obese 8 (16)

Callaway et al, MJA, 2009

Table III: Number (%)of normal, overweight and obese women reporting weight loss attempts, actual weight loss, advice regarding weight loss and a preconception health care check (n=348).

Normal weight (n=233)

Overweight

(n=65)

Obese

(n=50) p value

Tried to lose weight 57 (24.5) 32 (49.2) 32 (64.0) <0.001

Actually lost weight 70(30.0) 29(44.6) 23(46.0). 0.04

Advised to lose weight (any source) 7 (3.0) 9 (13.8) 21 (42.0) <0.001

Pre conception health check

with doctor 121 (51.9) 26 (40.0) 39 (78.0) 0.7

Doctor advised to lose weight pre pregnancy 8(3.4) 6 (9.2) 14 (28.0) <0.001

Callaway et al, MJA, 2009

Barriers to Preconception Care

• Inadequate pregnancy planning

• Inadequate compliance with simple pre pregnancy interventions (eg folic acid)

• Inadequate recognition of overweight and obesity

• Unsuccessful attempts at pre pregnancy weight loss

Callaway et al, MJA, 2009

Can pregnancy interventions effectively prevent obesity in the future?

Gillman et al, Diabetes Care, 2010: ACHOIS follow up.