Managing High-Risk Pregnancy with Extreme Obesity for a Healthy Delivery

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• Welcoming Obese Pregnant Patients
• Medical Risks: BMI and Complications
• Early Induction Delivery Strategy
• Logistical Care Chain Adaptations
• Bariatric Surgery Vitamin Therapy
• Specialized Maternity Hospital Staff

Welcoming Obese Pregnant Patients

Dr. Marc Dommergues, MD, stresses that the first principle in obstetric care for extreme obesity is to welcome patients without prejudice. He notes that a significant problem reported by obese individuals is feeling judged or considered a burden by healthcare providers due to the technical challenges their condition presents, such as a thick abdominal wall or difficulties with epidural anesthesia placement. This welcoming attitude is foundational to establishing trust and effective care from the outset of pregnancy.

Medical Risks: BMI and Complications

The medical risk in pregnancy is directly correlated with Body Mass Index (BMI). Dr. Marc Dommergues, MD, explains that a BMI over 40 significantly increases the risk of numerous obstetrical complications. These include gestational diabetes, hypertension (preeclampsia), respiratory problems, and anesthesia-related risks during delivery. All obstetrical complications are more prevalent in this patient population, necessitating vigilant screening and monitoring throughout the pregnancy to mitigate these risks for both mother and baby.

Early Induction Delivery Strategy

To proactively avoid complications, Dr. Marc Dommergues, MD, discusses a key strategy: inducing delivery early. Accumulating data suggests that for women with a very high BMI, inducing labor at 39 weeks of pregnancy, rather than waiting for spontaneous labor, can be beneficial. This planned approach helps deliver the baby before many of the serious complications associated with extreme obesity and prolonged pregnancy can manifest, thereby increasing the chances of a healthy outcome.

Logistical Care Chain Adaptations

Beyond medical management, Dr. Marc Dommergues, MD, highlights a critical logistical component of care. The entire physical environment of a maternity hospital must be adapted to safely and comfortably accommodate obese pregnant women. This includes having reinforced chairs in waiting rooms, wider and sturdier examination and ultrasound tables, appropriate delivery room equipment, and large blood pressure cuffs. Ensuring this "logistics chain" is in place prevents profoundly distressing situations where a patient is turned away late in pregnancy because the facility cannot safely care for her.

Bariatric Surgery Vitamin Therapy

A crucial point for women with a history of extreme obesity is the management of prior bariatric surgery. Dr. Dommergues advises that patients who have undergone obesity surgery must inform their obstetrician and nutrition doctor. These procedures often lead to malabsorption, creating a major risk for severe vitamin and nutrient deficiencies during pregnancy. Continuous vitamin therapy is essential before and throughout pregnancy to support fetal development and maternal health, and levels must be checked and managed carefully.

Specialized Maternity Hospital Staff

Effective care requires a specialized team. Dr. Marc Dommergues, MD, emphasizes the need for a maternity hospital that treats a sufficient volume of patients with a BMI over 40. This ensures that all staff—including obstetricians, anesthesiologists, nurses, and orderlies—are trained and experienced in the specific protocols for caring for obese pregnant women. This expertise is vital for handling the unique medical and physical challenges, from safely moving a patient to performing a Cesarean section, to ensure the best possible outcome for mother and child.

Full Transcript

Dr. Anton Titov, MD: Dr. Marc Dommergues, we have already discussed several conditions and pregnancy. One of them is obesity, which is common around the world. Obesity is increasing. What are the nuances of managing pregnancy when a woman is obese?

Dr. Marc Dommergues, MD: I am not sure these are truly new answers, at least from a French point of view. We are not that much used to obesity as people in the United States. The most important thing is to welcome people with obesity. Do not consider them as guilty people who just come here to annoy doctors because they have a thick abdominal wall, and the Cesarean section is going to be difficult. Or the epidural anesthesia placement is going to be difficult, and so on.

I don't know how it is in different countries, but this is a problem obese people report. They feel such attitudes, at least in our country. Probably this is something to do with the organization of care for obese pregnant women, at least in countries in which obesity is not so common.

Dr. Anton Titov, MD: There are two levels of pregnancy care in obesity that can be considered very diagrammatically. The first level is the medical risk. This is related to the patient's BMI. Patient risks having complications of obesity, respiratory problems, diabetes, etc. In a BMI over 40, for example, there is an increased risk of anesthesia, risk of complications of delivery, risk of gestational diabetes, hypertension.

Dr. Marc Dommergues, MD: We know that all obstetrical complications are more common in obese pregnant women. One of the possible answers is to screen for the risk of complications. Also, it's possible to induce delivery early, for example, at 39 weeks of pregnancy, before those complications occur.

Dr. Anton Titov, MD: There are some new accumulating data in recent years that shows that with a very high BMI inducing labor a little bit earlier than in women with normal weight can be useful to avoid complications.

Dr. Marc Dommergues, MD: Of course, welcoming pregnant patients with obesity is very important. You probably need to have a maternity hospital with a sufficient number of pregnant women with a BMI over 40 so that all staff is trained to care for pregnant patients with obesity. This includes obstetricians, anesthesiologists, nurses, people who will carry the patient.

Talking about carrying an obese patient, BMI will help us determine the gross level of medical risk. But there is a logistical risk in obesity. It is related to the weight of the patient. This is something that one needs to consider, at least in countries in which we are not very used to very heavy people.

All logistics chain of patient care must be adapted to obese pregnant women. This includes chairs in the waiting room, examination tables, ultrasound table, delivery room table, blood pressure measuring cuffs, and so on. We do not want to become stuck at a particular moment of patient care, because there is a problem with a patient's table or whatever device.

Dr. Anton Titov, MD: So this is the logistics part of caring for pregnant women with obesity. It is very important. It's important to think about it beforehand to avoid situations, which are very painful for patients. At seven months of pregnancy, they are suddenly told, "Dear lady, you are too fat to be delivered here, go elsewhere." This is painful for the patients. It makes them have an extremely distressing feeling.

So if there's a triage to be made, the earlier it's done, the better. If pregnant women with obesity are sent right away to a hospital where they are welcome, then things will be simple. So that's one point to make.

Dr. Marc Dommergues, MD: I have one thing about obesity to ask women to remember. Were you obese in the past? Did you benefit from bariatric surgery? When you become pregnant, you often forget you had bariatric surgery ten years ago. But there's a major risk if you had obesity surgery and you become pregnant.

You require vitamin therapy, and you need to continue this vitamin therapy or restart taking vitamins while you are pregnant. If you had bariatric surgery, and you consider pregnancy, please tell your nutrition doctor.

Dr. Anton Titov, MD: So that she can check your vitamin levels and your vitamin requirements before you start a pregnancy. Of course, obesity is a significant and growing problem around the world. But it is very interesting that we're here in Paris, and in France, it is less of a problem. From a clinician's perspective and experience, what is it that France is doing, right? Why is there is less obesity here?

Dr. Marc Dommergues, MD: I haven't got a clue, because I'm not a specialist in nutrition. And, of course, being French, I will tell you that we probably eat better. But things are getting worse and worse. One of the reasons why things are getting worse and worse is that people are getting poorer and poorer, and they can get only food with very high energy density. This is a major problem, which is probably related to the fact that people are growing more and more poor these days in France.