Schwangerschaft und Geburt bei Adipositas

Zusammenfassung

Eine Adipositas in der Schwangerschaft findet sich bei 10 bis 18 % aller Frauen in Deutschland. Sie trägt maßgeblich zu einer erhöhten Morbidität bei und wirkt sich sowohl auf das mütterliche als auch fetale Schwangerschaftsoutcome ungünstig aus. Besonders bei hochgradiger Adipositas ist eine intensive Überwachung der Schwangerschaft notwendig. Die Schwangerschaft begleitende Ernährungs- und Trainingsinterventionen können zwar dazu beitragen, die intragravide Gewichtszunahme zu reduzieren, wirken sich aber nur unwesentlich auf geburtshilflich relevante Risiken wie Gestationsdiabetes, hypertensive Schwangerschaftserkrankungen oder eine fetale Makrosomie aus. Umso bedeutsamer ist die Gewichtsoptimierung im Vorfeld einer geplanten Schwangerschaft. Bei Frauen mit Zustand nach bariatrischer Operation sind besondere Risikoaspekte zu berücksichtigen.

Abstract

The prevalence of obesity during pregnancy is between 10 to 18 % in Germany. It essentially contributes to an increased morbidity by an impairment of maternal as well as fetal outcome. Especially women with high grade obesity need an intensified observation during pregnancy. Interventions during pregnancy by diet or physical exercises can help to reduce the weight gain during pregnancy, but have only little effects on important obstetric risks like gestational diabetes, hypertensive pregnancy disorders or fetal macrosomia. An optimizing of the body weight before onset of pregnancy is much more important. In women after bariatric surgery special aspects of risks have to be considered.

Schlüsselwörter

Adipositas - Schwangerschaft - bariatrische Operation - Gestationsdiabetes - fetale Makrosomie - Präeklampsie - Sectio caesarea

Key words

Obesity - pregnancy - bariatric surgery - gestational diabetes - fetal macrosomia - preeclampsia - caesarean section

• Literatur

• 1 Mensink GB, Schienkiewitz A, Haftenberger M. et al. [Overweight and obesity in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56: 786-794 doi:10.1007/s00103–012–1656–3
• 2 Bolumar F, Olsen J, Rebagliato M. et al. Body mass index and delayed conception: a European Multicenter Study on Infertility and Subfecundity. Am J Epidemiol 2000; 151: 1072-1079
• 3 Jensen TK, Scheike T, Keiding N. et al. Fecundability in relation to body mass and menstrual cycle patterns. Epidemiology 1999; 10: 422-428
• 4 Metwally M, Li TC, Ledger WL. The impact of obesity on female reproductive function. Obes Rev 2007; 8: 515-523 doi:10.1111/j.1467–789X.2007.00406.x
• 5 van der Steeg JW, Steures P, Eijkemans MJ. et al. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Hum Reprod 2008; 23: 324-328 doi:10.1093/humrep/dem371
• 6 Provost MP, Acharya KS, Acharya CR. et al. Pregnancy outcomes decline with increasing body mass index: analysis of 239,127 fresh autologous in vitro fertilization cycles from the 2008–2010 Society for Assisted Reproductive Technology registry. Fertil Steril 2016; 105: 663-669 doi:10.1016/j.fertnstert.2015.11.008
• 7 Mutsaerts MA, van Oers AM, Groen H. et al. Randomized Trial of a Lifestyle Program in Obese Infertile Women. N Engl J Med 2016; 374: 1942-1953 doi:10.1056/NEJMoa1505297
• 8 Legro RS, Dodson WC, Kris-Etherton PM. et al. Randomized Controlled Trial of Preconception Interventions in Infertile Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2015; 100: 4048-4058 doi:10.1210/jc.2015–2778
• 9 Legro RS. Mr. Fertility Authority, Tear Down That Weight Wall!. Hum Reprod 2016; 31: 2662-2664 doi:10.1093/humrep/dew253
• 10 Johansson K, Cnattingius S, Naslund I. et al. Outcomes of pregnancy after bariatric surgery. N Engl J Med 2015; 372: 814-824 doi:10.1056/NEJMoa1405789
• 11 Stephansson O, Johansson K, Naslund I. et al. Bariatric Surgery and Preterm Birth. N Engl J Med 2016; 375: 805-806 doi:10.1056/NEJMc1516566
• 12 Boots C, Stephenson MD. Does obesity increase the risk of miscarriage in spontaneous conception: a systematic review. Semin Reprod Med 2011; 29: 507-513 doi:10.1055/s-0031–1293204
• 13 Boots CE, Bernardi LA, Stephenson MD. Frequency of euploid miscarriage is increased in obese women with recurrent early pregnancy loss. Fertil Steril 2014; 102: 455-459 doi:10.1016/j.fertnstert.2014.05.005
• 14 Aune D, Saugstad OD, Henriksen T. et al. Maternal body mass index and the risk of fetal death, stillbirth, and infant death: a systematic review and meta-analysis. JAMA 2014; 311: 1536-1546 doi:10.1001/jama.2014.2269
• 15 Bodnar LM, Parks WT, Perkins K. et al. Maternal prepregnancy obesity and cause-specific stillbirth. Am J Clin Nutr 2015; 102: 858-864 doi:10.3945/ajcn.115.112250
• 16 Kim SS, Zhu Y, Grantz KL. et al. Obstetric and Neonatal Risks Among Obese Women Without Chronic Disease. Obstet Gynecol 2016; 128: 104-112 doi:10.1097/AOG.0000000000001465
• 17 Ovesen P, Rasmussen S, Kesmodel U. Effect of prepregnancy maternal overweight and obesity on pregnancy outcome. Obstet Gynecol 2011; 118: 305-312 doi:10.1097/AOG.0b013e3182245d49
• 18 Lisonkova S, Muraca GM, Potts J. et al. Association between prepregnancy body mass index and severe maternal morbidity. JAMA 2017; 318: 1777-1786 doi:10.1001/jama.2017.16191
• 19 Persson M, Cnattingius S, Villamor E. et al. Risk of major congenital malformations in relation to maternal overweight and obesity severity: cohort study of 1.2 million singletons. BMJ 2017; 357: j2563 doi:10.1136/bmj.j2563
• 20 Stothard KJ, Tennant PW, Bell R. et al. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009; 301: 636-650 doi:10.1001/jama.2009.113
• 21 Shapiro AL, Schmiege SJ, Brinton JT. et al. Testing the fuel-mediated hypothesis: maternal insulin resistance and glucose mediate the association between maternal and neonatal adiposity, the Healthy Start study. Diabetologia 2015; 58: 937-941 doi:10.1007/s00125–015–3505-z
• 22 Yu Z, Han S, Zhu J. et al. Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis. PLoS One 2013; 8: e61627 doi:10.1371/journal.pone.0061627
• 23 Sewell MF, Huston-Presley L, Super DM. et al. Increased neonatal fat mass, not lean body mass, is associated with maternal obesity. Am J Obstet Gynecol 2006; 195: 1100-1103 doi:10.1016/j.ajog.2006.06.014
• 24 Lee BH, Park TC, Lee HJ. Association between fetal abdominal circumference and birthweight in maternal hyperglycemia. Acta Obstet Gynecol Scand 2014; 93: 786-793 doi:10.1111/aogs.12420
• 25 Catalano PM, McIntyre HD, Cruickshank JK. et al. The hyperglycemia and adverse pregnancy outcome study: associations of GDM and obesity with pregnancy outcomes. Diabetes Care 2012; 35: 780-786 doi:10.2337/dc11–1790
• 26 Gaillard R, Steegers EA, Franco OH. et al. Maternal weight gain in different periods of pregnancy and childhood cardio-metabolic outcomes. The Generation R Study. Int J Obes (Lond) 2015; 39: 677-685 doi:10.1038/ijo.2014.175
• 27 Gaillard R, Welten M, Oddy WH. et al. Associations of maternal prepregnancy body mass index and gestational weight gain with cardio-metabolic risk factors in adolescent offspring: a prospective cohort study. BJOG 2016; 123: 207-216 doi:10.1111/1471–0528.13700
• 28 Castillo H, Santos IS, Matijasevich A. Relationship between maternal pre-pregnancy body mass index, gestational weight gain and childhood fatness at 6–7 years by air displacement plethysmography. Matern Child Nutr 2015; 11: 606-617 doi:10.1111/mcn.12186
• 29 Starling AP, Brinton JT, Glueck DH. et al. Associations of maternal BMI and gestational weight gain with neonatal adiposity in the Healthy Start study. Am J Clin Nutr 2015; 101: 302-309 doi:10.3945/ajcn.114.094946
• 30 Paladini D. Sonography in obese and overweight pregnant women: clinical, medicolegal and technical issues. Ultrasound Obstet Gynecol 2009; 33: 720-729 doi:10.1002/uog.6393
• 31 Livergood MC, LeChien KA, Trudell AS. Obesity and cell-free DNA “no calls”: is there an optimal gestational age at time of sampling?. Am J Obstet Gynecol 2017; 216: 413 e411-413 e419 doi:10.1016/j.ajog.2017.01.011
• 32 Rolnik DL, Wright D, Poon LC. et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia. N Engl J Med 2017; 377: 613-622 doi:10.1056/NEJMoa1704559
• 33 Faucher MA, Hastings-Tolsma M, Song JJ. et al. Gestational weight gain and preterm birth in obese women: a systematic review and meta-analysis. BJOG 2016; 123: 199-206 doi:10.1111/1471–0528.13797
• 34 American College of O, Gynecologists. ACOG Committee opinion no. 548: weight gain during pregnancy. Obstet Gynecol 2013; 121: 210-212 doi:http://10.1097/01.AOG.0000425668.87506.4c
• 35 Kapadia MZ, Park CK, Beyene J. et al. Weight Loss Instead of Weight Gain within the Guidelines in Obese Women during Pregnancy: A Systematic Review and Meta-Analyses of Maternal and Infant Outcomes. PLoS One 2015; 10: e0132650 doi:10.1371/journal.pone.0132650
• 36 Tieu J, Shepherd E, Middleton P. et al. Dietary advice interventions in pregnancy for preventing gestational diabetes mellitus. Cochrane Database Syst Rev 2017; 1: CD006674 doi:10.1002/14651858.CD006674.pub3
• 37 Shepherd E, Gomersall JC, Tieu J. et al. Combined diet and exercise interventions for preventing gestational diabetes mellitus. Cochrane Database Syst Rev 2017; 11: CD010443 doi:10.1002/14651858.CD010443.pub3
• 38 Muktabhant B, Lawrie TA, Lumbiganon P. et al. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev. 2015
• 39 Magro-Malosso ER, Saccone G, Di Mascio D. et al. Exercise during pregnancy and risk of preterm birth in overweight and obese women: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2017; 96: 263-273 doi:10.1111/aogs.13087
• 40 International Weight Management in Pregnancy Collaborative G. Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials. BMJ 2017; 358: j3119 doi:10.1136/bmj.j3119
• 41 Garnaes KK, Morkved S, Salvesen O. et al. Exercise Training and Weight Gain in Obese Pregnant Women: A Randomized Controlled Trial (ETIP Trial). PLoS Med 2016; 13: e1002079 doi:10.1371/journal.pmed.1002079
• 42 Chiswick C, Reynolds RM, Denison F. et al. Effect of metformin on maternal and fetal outcomes in obese pregnant women (EMPOWaR): a randomised, double-blind, placebo-controlled trial. Lancet Diabetes Endocrinol 2015; 3: 778-786 doi:10.1016/S2213–8587(15)00219–3
• 43 Syngelaki A, Nicolaides KH, Balani J. et al. Metformin versus Placebo in Obese Pregnant Women without Diabetes Mellitus. N Engl J Med 2016; 374: 434-443 doi:10.1056/NEJMoa1509819
• 44 American College of O, Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009; 113: 1405-1413 doi:10.1097/AOG.0b013e3181ac0544
• 45 Harreiter J, Schindler K, Bancher-Todesca D. et al. Management of Pregnant Women after Bariatric Surgery. J Obes 2018; 3: 4587064 doi: 10.1155/2018/4587064. eCollection 2018
• 46 Maggard MA, Yermilov I, Li Z. et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008; 300: 2286-2296 doi:10.1001/jama.2008.641
• 47 Narayanan RP, Syed AA. Pregnancy Following Bariatric Surgery-Medical Complications and Management. Obes Surg 2016; 26: 2523-2529 doi:10.1007/s11695–016–2294-x
• 48 Parent B, Martopullo I, Weiss NS. et al. Bariatric Surgery in Women of Childbearing Age, Timing Between an Operation and Birth, and Associated Perinatal Complications. JAMA Surg 2017; 152: 1-8 doi:10.1001/jamasurg.2016.3621
• 49 Adam S, Ammori B, Soran H. et al. Pregnancy after bariatric surgery: screening for gestational diabetes. BMJ 2017; 356: j533 doi:10.1136/bmj.j533
• 50 van Oers AM, Mutsaerts MAQ, Burggraaff JM. et al. Association between periconceptional weight loss and maternal and neonatal outcomes in obese infertile women. PLoS One 2018; 13: e0192670 doi:10.1371/journal.pone.0192670
• 51 McBain RD, Dekker GA, Clifton VL. et al. Impact of inter-pregnancy BMI change on perinatal outcomes: a retrospective cohort study. European journal of obstetrics, gynecology, and reproductive biology 2016; 205: 98-104 doi:10.1016/j.ejogrb.2016.07.487
• 52 Cnattingius S, Villamor E. Weight change between successive pregnancies and risks of stillbirth and infant mortality: a nationwide cohort study. Lancet 2016; 387: 558-565 doi:10.1016/S0140–6736(15)00990–3
• 53 Nuthalapaty FS, Rouse DJ, Owen J. The association of maternal weight with cesarean risk, labor duration, and cervical dilation rate during labor induction. Obstet Gynecol 2004; 103: 452-456 doi:10.1097/01.AOG.0000102706.84063.C7
• 54 Arrowsmith S, Wray S, Quenby S. Maternal obesity and labour complications following induction of labour in prolonged pregnancy. BJOG 2011; 118: 578-588 doi:10.1111/j.1471–0528.2010.02889.x
• 55 Johansson S, Villamor E, Altman M. et al. Maternal overweight and obesity in early pregnancy and risk of infant mortality: a population based cohort study in Sweden. BMJ 2014; 349: g6572 doi:10.1136/bmj.g6572
• 56 Cnattingius S, Villamor E, Johansson S. et al. Maternal obesity and risk of preterm delivery. JAMA 2013; 309: 2362-2370 doi:10.1001/jama.2013.6295
• 57 Kim SS, Mendola P, Zhu Y. et al. Spontaneous and indicated preterm delivery risk is increased among overweight and obese women without prepregnancy chronic disease. BJOG. 2017
• 58 Shaw GM, Wise PH, Mayo J. et al. Maternal prepregnancy body mass index and risk of spontaneous preterm birth. Paediatr Perinat Epidemiol 2014; 28: 302-311 doi:10.1111/ppe.12125
• 59 Athukorala C, Rumbold AR, Willson KJ. et al. The risk of adverse pregnancy outcomes in women who are overweight or obese. BMC Pregnancy Childbirth 2010; 10: 56 doi:10.1186/1471–2393–10–56
• 60 Kawakita T, Reddy UM, Landy HJ. et al. Indications for primary cesarean delivery relative to body mass index. Am J Obstet Gynecol 2016; 215: 515 e511-519 doi:10.1016/j.ajog.2016.05.023
• 61 Ju H, Chadha Y, Donovan T. et al. Fetal macrosomia and pregnancy outcomes. The Australian & New Zealand journal of obstetrics & gynaecology 2009; 49: 504-509 doi:10.1111/j.1479–828X.2009.01052.x
• 62 Sokol RJ, Blackwell SC. American College of O. et al. ACOG practice bulletin: Shoulder dystocia. Number 40, November 2002. (Replaces practice pattern number 7, October 1997). International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2003; 80: 87-92
• 63 Shoulder Dystocia. RCOG-Guideline No. 42. 2012.. Im Internet: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf Stand: 08.03.2019.
• 64 Persson M, Johansson S, Villamor E. et al. Maternal overweight and obesity and risks of severe birth-asphyxia-related complications in term infants: a population-based cohort study in Sweden. PLoS Med 2014; 11: e1001648 doi:10.1371/journal.pmed.1001648
• 65 Clark-Ganheart CA, Reddy UM, Kominiarek MA. et al. Pregnancy Outcomes Among Obese Women and Their Offspring by Attempted Mode of Delivery. Obstet Gynecol 2015; 126: 987-993 doi:10.1097/AOG.0000000000001084
• 66 Scott-Pillai R, Spence D, Cardwell CR. et al. The impact of body mass index on maternal and neonatal outcomes: a retrospective study in a UK obstetric population, 2004–2011. BJOG 2013; 120: 932-939 doi:10.1111/1471–0528.12193
• 67 Dresner M, Brocklesby J, Bamber J. Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery. BJOG 2006; 113: 1178-1181 doi:10.1111/j.1471–0528.2006.01048.x
• 68 Larsen TB, Sorensen HT, Gislum M. et al. Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: a population-based nested case-control study. Thrombosis research 2007; 120: 505-509 doi:10.1016/j.thromres.2006.12.003
• 69 Li C, Kaur H, Choi WS. et al. Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight. Obes Res 2005; 13: 362-371 doi:10.1038/oby.2005.48
• 70 Abou-Dakn M. [Health effects of breastfeeding on the mother]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61: 986-989 doi:10.1007/s00103–018–2776–1
• 71 Moll U, Olsson H, Landin-Olsson M. Impact of Pregestational Weight and Weight Gain during Pregnancy on Long-Term Risk for Diseases. PLoS One 2017; 12: e0168543 doi:10.1371/journal.pone.0168543