Maternal Obesity & Feto-Maternal Outcomes

epidemic and its prevalence is increasing in pregnant women. Objective: This study aims to highlight the impact of maternal obesity on the fetal and maternal outcome. Methods : The study was conducted on 320 pregnant women in their rst trimester with viable singleton pregnancy at Department of Gynecology & Obstetrics, Liaquat University of Medical & Health Sciences, Jamshoro. The obese group (BMI > 25) of 160 women, were compared for feto-maternal outcome, with parity matched 160 women in non-obese group (BMI < 25). Results : There was increased incidence of antepartum, intrapartum and fetal complications in obese group as compared to non-obese group. Preeclampsia was seen in 42.1% vs 14.1%, GDM in 14.5% vs 10.3%, induction of labor in 31.9% vs 13.3%, in obese as compared to non-obese respectively. Lower segment caesarean second (37.5% vs 13.8%), macrosomia (22.4% vs 1.3%), shoulder dystocia (18.4% vs 3.8%), birth asphyxia (11.8% vs 5.1%) and neonatal intensive care unit (NICU) admission (12.7% vs 6.6%) were more common in obese as compared to non-obese. Conclusion : Maternal obesity is a risk factor for many antepartum, intrapartum, postpartum and fetal complications. All attempts should be made to prevent obesity in women of childbearing age” and to encourage weight loss before pregnancy.

with under nutrition leading to double burden [2]. Body mass index (BMI) is the most commonly used parameter for measuring obesity at population level. WHO de nes obesity as BMI > 30 for the world population [1]. However, this value could be misleading when comparing the Western countries to Asian Pakistani population. This is because of the difference in the phenotype and general body structure of the two diverse set of people in East and West. Pakistani people are obese at a lower BMI than speci ed for Western people. Recent studies have also shown that Asian Pakistani have more pre-disposition for truncal obesity and the risk of complications for Asians is

M E T H O D S
group (26.7 years) as compared to non-obese group (24.55 years), p-value 0.001. Obesity may cause reduced fertility that may be a probable cause of obese women being older than non-obese ones. Parity was similar in both the groups (p-value 0.223).
well below the cut-off values of BMI recommended by WHO, and thus for the Pakistani population, BMI>25 is de ned as obesity [3]. Many studies have observed that maternal obesity can result in adverse outcomes for both women and fetuses like increase in the risk of miscarriage, gestational diabetes mellitus (GDM), gestational hypertension and preeclampsia [4]. It has also been associated with prolonged pregnancies, prolonged labor, two-fold increased risk for a caesarean delivery, increased incidence of post-natal infections with prolonged hospital stay [5,6]. Obesity is often associated with a high risk of adverse neonatal outcomes including stillbirth, birth defects like neural tube defects, abdominal wall defects etc., neonatal intensive care admissions and perinatal mortality rates [7,8]. Furthermore, long term studies demonstrate that having an obese mother increases the risk of child growing up to be obese themselves, thereby possibly inducing a transgenerational effect [9]. With alarmingly increasing prevalence of obesity in India, the need to determine its effect on maternal and fetal outcome is increasing. This study aimeds to highlight the impact of maternal obesity on the outcome of singleton pregnancy in otherwise uncomplicated singleton women" in Pakistani population.
The study was conducted on 320 pregnant women who visited the hospital from October 2020 to September 2021. The participants enrolled were in their rst trimester with viable singleton pregnancy. Women with pre-existing hypertension, diabetes, heart disease, thyroid disorders or any other chronic illness; bad obstetrics history or prior caesarean second were excluded from the study. They were categorized into two groups: obese group comprising of 160 women with BMI > 25 and non-obese group comprising of 160 women with BMI <25. They were followed up for feto-maternal outcome. Routine antenatal care was given as per hospital protocol. Maternal outcome variables included were antepartum complications (miscarriages, GDM, pre-eclampsia, eclampsia), onset of labor (spontaneous, induced), mode of delivery (vaginal, caesarean, instrumental) and postpartum complications (postpartum hemorrhage, wound sepsis, prolonged hospital stay). Perinatal outcome variables included were birth weight, intrauterine deaths (IUDs), stillbirth, macrosomia and NICU admissions. All results were analyzed statistically with the help of parametric and nonparametric tests, wherever applicable. A p-value of <0.05 was considered as statistically signi cant.     Table 3 show the difference in the onset of labor as well as mode of delivery, between the two groups was signi cant. Proportion of pregnant women having induced labor was more in the obese group as compared to non-obese group. The p-value was 0.007 making this correlation signi cant. Also, the rate of caesarean second was signi cantly higher in the obese group (37.5%) when compared to the nonobese group (13.8%), p-value < 0.001. The complication of shoulder dystocia was observed signi cantly more in obese group (18.4%) than in non-obese group (3.8%), pvalue 0.004. Postpartum complications, like postpartum hemorrhage was more in obese group (16%) than in nonobese group (9%). But it was statistically not signi cant; pvalue = 0.188. The wound sepsis was signi cantly higher in obese group (28%) than in non-obese group (9.5%), p-value 0.009. Thus, prolonging hospital stay in the obese group. It was found that the obese group had signi cantly longer duration of stay in the hospital (mean stay 3.34 + 2.04) than the non-obese group (2.44 +1.65), p-value was 0.002.

R E S U L T S
hyper tension and pre-eclampsia/eclampsia was signi cantly higher in obese (36.9%) compared to normal subjects (16.1%) [12]. Walsh et al., concluded both obesity and preeclampsia are associated with increased markers of infammation such as C-reactive protein and in ammatory cytokines, tumor necrosis factor-α, interleukin-6, and interleukin-8 [13]. These ndings suggest that obesity is a risk factor for pre-eclampsia because of pre-existing in ammation. This study does not show signi cant correlation between obesity and GDM, but still GDM cases were found more in obese category (14.5%) than non-obese (10.3%), p-value was 0.426. This may be because of smaller sample size and increased number of GDM complicated pregnancies in non-obese group than previous studies. Chu SY et al., in a meta-analyses estimated the risk of GDM in maternal obesity and their ndings indicate that high maternal weight is associated with a substantially higher risk of GDM [14]. Obesity is considered to be an insulin resistant state, and thus accentuates the insulin resistance of normal pregnancy. Obese women with GDM are more likely to need insulin to achieve optimum glycemic control, as compared to women with normal BMIs, and the use of insulin in these pregnant women is also associated with better pregnancy outcome. In present study, although the proportion of pregnant women having genital infection remained high in the obese group but the p-value was 0.062 making this correlation insigni cant. Sebire et al., also concluded from their study that genital tract infections are more common in obese compared to non-obese pregnant women [15]. Obesity is associated with higher incidence of induction of labor, as seen with many studies conducted earlier. Proportion of pregnant women having induced labor were more in the obese group (31.9%) as compared to non-obese group (13.3%), p-value was 0.007. The indication was mainly hyper tension, post-datism and diabetes related complications. Robinson et al., also found increased rates of labor induction in obese group when compared to nonobese groups (32.1 % in obese and 19.3% in non-obese) [16]. Similarly, Athukorala et al., in their study found that the overweight and obese women were more likely to be induced than women with a normal BMI (RR: 1.33 [95%CI 1.13, 1.57], p = 0.001 and RR 1.78 [95%CI 1.51, 2.09], p < 0.0001 respectively).17 S Arrowsmith and colleagues in their study found that with increase in maternal BMI there was a dose dependent increase in number of women having induction of labor [18]. Results of study showed much higher rates of caesarean second in obese women as compared to nonobese (37.5% vs 13.8%). Although, the rates of operative vaginal delivery were lower in the obese groups. This is likely due to the higher caesarean delivery rates in the obese groups and the reluctance to perform operative Table 4 shows that in perinatal outcomes, the mean birth weight in the obese group (3.29 + 0.4603 Kg) was signi cantly more than in the non-obese group, (2.75 + 0.5960) (p<0.001). The proportion of macrosomia babies were observed signi cantly more in the obese group (pvalue <0.001). Thirteen percent neonates, obese group required NICU admission compared to 6.6% neonates in non-obese group, the difference was not statistically signi cant (p-value 0.19). In obese group, there were three (4%) IUDs while in non-obese group, there were two (2.6%) IUDs. The proportion of IUDs was more in obese group than non-obese group; but p-value was 0.62 making this difference insigni cant.

D I S C U S S I O N
This study demonstrates that maternal obesity can result in adverse outcomes for both mother and fetuses like increase in the risk of miscarriage, gestational diabetes, gestational hypertension, preeclampsia, sudden IUD, macrosomia, shoulder dystocia, and higher caesarean rates. The rate of miscarriage was seemingly more in obese group (6.2% vs 2.5%) though not statistically signi cantly. Recent evidence indicate that obese women undergoing infertility treatment are at increased risk of spontaneous miscarriage [10]. However, this point is controversial. Roth et al conducted a study in 494 patients to ascertain whether BMI affects rst-trimester pregnancy outcome in patients with in rmity [11]. It is concluded that the likelihood of a spontaneous abortion in singleton gestations in the rst trimester, after treatment for infertility, was not affected by BMI. In this study, the number of pregnant women developing gestational hypertension and preeclampsia remained signi cantly high in obese group (42.1%) as compared to non-obese group (14.1%), pvalue <0.001. Similarly, Dasgupta et al., in his prospective cohort study found that the incidence of gestational   Mamun et al 2011, [24] found that women who were obese prior to pregnancy and women who gained excess weight during pregnancy were at greater risk for higher birth weight difference. In this study, the proportion of macrosomic babies was observed more in the obese group (p-value <0.001). Dasgupta et al., also found that there was a signi cant association between macrosomia and morbid obesity [12]. Sheiner et al., concluded that after having adjusted for diabetes mellitus, no signi cant association was found between macrosomia and obesity alone [19]. In this study, there was a signi cant association between macrosomia and obesity. Also many women who delivered macrosomic babies; had developed GDM. Incidences of perinatal mortality were relatively high in the obese group as compared to non-obese group, though statistically insigni cant. Sebire et al.,[15] found that maternal obesity was associated with a higher foetal death rate. In this study the cause of IUD in the non-obese group was PIH with foetal growth restriction in one case and the other was probably because of post-datism with meconium aspiration. In the obese group, the probable causes of IUDs were preeclampsia, GDM, deranged Doppler, etc. The cause of stillbirth was birth asphyxia in two cases and one case had unexplained aetiology". From this study, we can't conclude that obesity is an independent risk factor for IUD and stillbirth; but we can say that due to more emphasis of adequate antenatal checkups and routine investigations, the rates of IUD and stillbirth have declined compared to the previous studies.

C O N C L U S I O N S
Present study supports that "obesity is associated with deleterious effect on feto-maternal outcome. In spite of the limitations of this study in terms of small sample size and short span of me it can be concluded that obesity is a risk factor for many antepartum, intrapartum, postpartum and fetal complications. In order to minimize the adverse effects of obesity on both mother and fetus, appropriate multidisciplinary management should be done.