FINAL MASTER’S THESIS
Faculty
; Faculty of Medicine, Lithuanian University of Health ScienceDepartment
; Obstetric and Gynecology Department, Lithuanian University of Health ScienceAuthor; Zahit DÖNMEZ
Title of Thesis
; Duration of First Cesarean Section for Pregnant Obese andNon-Obese Woman in the Kaunas Hospital of Lithuanian University of Health Sciences
Supervisor (name, surname, degree);
Laura MALAKAUSKIENE, MD, PhDYear of the thesis preparation
; 2017-2018TITLE OF CONTENTS
1.Summary...3-6
1.1 Summary of Final Master’s Thesis (English)...3-4
1.2 Summary of Final Master’s Thesis (Lithuanian)...5-6
2.Acknowledgements...7
3.Clearance issued by the Ethics Committee...9
4.Abbreviations...10
5.Terms...11
6.Introduction...12-13
7.Aim and Objectives...14
8.Literature Review...15-21
9.Resarch Methodology and Methods...22
10.Results...23-38
11.Discussion of the Results...39-41
12. Conclusions...42
13.Literature List...43-45
1.SUMMARY
Author (name and surname); Zahit DONMEZ
Title of Thesis; Duration of First Cesarean Section for Pregnant Obese and Non-Obese Woman in the Kaunas Hospital of Lithuanian University of Health Sciences
Abstract; To determine the duration of first cesarean section for obese pregnant for obese pregnant women in different degrees of obesity and to compare with non-obese pregnant women in 2012-2017
Aim; To assess does the obesity have influence on the duration of first cesarean section and to compare the duration of total surgical operation, extraction of the fetus with non-obese women.
Objectives; To evaluate the duration of first cesarean section for obese and non-obese pregnant women and to compare duration of cesarean section, extraction of the fetus and condition of the newborn in groups of obese and non-obese women, to assess the main indications for the operation.
Methodology; A retrospective chorot study of obese 114 women, who gaven a birth at Hospital of Lithuanian University of Health Sciences (LSMU) Kauno klinikos in period of 2012 to 2017. The study have conducted on selected 41 obese women who had the first cesarean delivery and they were grouped in three subtypes of obesity. The control group of a 41 women with normal body mass index (BMI) was collected. The selection criteria both for obese and non-obese group were: delivery at term (≥37 to 41 week and 6 days), singletone delivery, nulliparous, and had a cesarean section for the first time. The data of selected obese and non-obese women’s newborns were assessed also. The medical data was used in two sources: 1) Extraction and total surgical operation duration data have evaluated at the Lithuanian University of Health Science Archive under the permission from Obstetrics and Gyneacology Department of Lithuanian University of Health Science; 2) Epicrisis of each patient have evaluated from Lithuanian University of Health Science patient data program at university computer. Statistical data have been calculated with IBM Statistics SPSS 25 system.
Study Participants; This study doesn’t require any participants other than author himself. Results; Among 41 selected obese women including all three subtypes of obesity, overall 37 patients had emergency cesarean deliveries (90.2 %) and just 4 patients had planned cesarean delivery. In control group of 41 non-obese women, similarly 33 patients had the first emergency cesarean delivery (80.5 %).
In obese women group an average time of total surgical operation was 46.7 minutes and for non-obese women and 42.2 minutes. Average duration of fetus extraction in obese type I, II, and III were 5.3 , 6.9 , 7.5 minutes respectively. The average duration of fetus extraction for non-obese women was 4.7 minutes. Average total surgical duration in
participants from both obese and non-obese groups, most common indication for cesarean section was non-progressive delivery. Overall 29 women had non-progressive delivery (36.3%). Moreover non-progressive delivery was also one of the most common indication among obese women (51.2%). Among non-obese women second most common indication for cesarean section was malpresentation (28.2%) . Indication values were statistically significant, p value 0.001.
In the obese women’s group 6 newborns were macrosomic (14.6%) and in non-obese women’s group 3 macrosomic newborns (7.3%).
Conclusions; Duration of the first cesarean section is longer in obese pregnant women in comparison with non-obese pregnant women. The average duration of fetus extraction is longer in obese pregnant women in comparison with non-obese pregnant women. Dystocia of non-progressive delivery statistically significant was one of the most common indication among obese women. Macrosomia of newborns have increased little in obese women in comparison with non-obese women.
Santrauka
Autorius (vardas ir pavardė): Zahit DONMEZ
Baigiamojo darbo pavadinimas: Pirmosios cezario pjūvio operacijos, atliktos nutukusioms ir normalaus svorio gimdyvėms trukmės palyginimas LSMU Kauno klinikų ligoninėje.
Santrauka: Nustatyti įvairaus nutukimo laipsnio nėščiųjų pirmojo cezario pjūvio operacijos bei vaisiaus ištraukimo trukmę ir palyginti su normalaus svorio nėščiosiomis gimdžiusiomis 2012-2017 m. laikotarpyje.
Tikslas: Įvertinti, ar nutukimas įtakoja pirmojo cezario pjūvio operacijos trukmę ir palyginti visos chirurginės operacijos ir vaisiaus išėmimo trukmę tarp turinčiųjų nutukimą ir jo neturinčiųjų gimdyvių.
Uždaviniai: Įvertinti pirmosios cezario pjūvio operacijos trukmę tarp nutukusių ir normalaus svorio gimdyvių bei palyginti chirurginės operacijos ir vaisiaus išėmimo trukmę, gimusio naujagimio būklę, nustatyti pagrindines indikacijas operacijai.
Tyrimo metodai: Atliktas retrospektyvinis kohortinis tyrimas 114 nutukusių moterų, gimdžiusiųjų LSMU Ligoninėje Kauno Klinikose 2012-2017 metų laikotarpyje ir atrinkta 41 moteris, kuriai buvo atlikta pirmoji cezario pjūvio operacija. Sudaryta kontrolinė grupė iš 41 moters, kurios turėjo normalų kūno masės indeksą (KMI). Atrankos kritarijai abejose grup4se buvo: išnešiotas nėštumas (≥37 iki 41 savaičių ir 6 dienų), vienvaisis nėštumas, anksčiau buvo negimdžiusios ir joms cezario pjūvis buvo atliekamas pirmąjį kartą. Analizuoti ir turinčiųjų nutukimą ir normalaus svorio gimdyvių naujagimių duomenys. Medicininių duomenų paieška atlika naudojant du šaltinius: 1) Duomenys apie vaisiaus ekstrakciją ir bendrą operacijos trukmę buvo įvertinti remiantis LSMU archyvo chirurginių intervencijų žurnalų duomenimis. 2) Gimdyvių duomenys pagal LSMU Akušerijos skyriaus registro epikrizių duomenis. Statistiniai duomenys buvo apskaičiuoti naudojant IBM Statistics SPSS 25 sistemą.
Tyrimo dalyviai: šiam tyrimui neprireikė jokių dalyvių, išskyrus patį autorių.
Rezultatai: Tiriamosios grupės 41 nutukusios moters tarpe buvo atliktos net 37 skubios cezario pjūvio operacijos (90,2%) ir tik 4 pacientėms pirmoji operacija buvo planuota. Kontrolinėje grupėje 33 pacientėms buvo atliktas skubus cezario pjūvis (80,5%) ir 8 pacientėms buvo atliktas planuotas cezario pjūvis.
Nutukusių gimdyvių grupėje vidutinė cezario pjūvio operacijos trukmė buvo 46.7 minutės, o kontrolinėje nenutukusių gimdyvių grupėje trumpesnė, 42.2 minutės. Vaisiaus ištraukimas užtruko atitinkamai po 5.3 , 6.9 , 7.5 minutes atliekant operaciją I-ojo, II-ojo ir III-iojo nutukimo laipsnio gimdyvėms. Tuo tarpu visutinė vaisiaus ištraukimo trukmė nenutukusių grupėje buvo 4.7 minutės. Vidutinė pirmosios CPO trukmė tarp nutukusių buvo I laipsnio - 41.4, II – 47, III - 50.4 minutės. Tarp visų, tiek nutukusių, tiek normalaus svorio gimdyvių, dažniausia cezario pjūvio operacijos indikacija buvo neprogresuojantis gimdymas, 36.3%. Be
to, neprogresuojantis gimdymas buvo statistiškai reikšmingai dažniausia indikacija nutukusių moterų tarpe, t.y. 51,2% atvejų. Tarp normalaus svorio moterų dažniausia cezario pjūvio operacijos indikacija buvo netaisyklinga vaisiaus padėtis, 28,2%. Šie rodikliai buvo statistiškai reikšmingi, p vertė 0,001.
Nutukusių gimdyvių grupėje 6 naujagimiai buvo dideli pagal gimimo svorį, t.y. nustatyta makrosomina (14,6%). Kontrolinės grupės naujagimių tarpe tik 3 naujagimiai buvo > 90 svorio procentilės. Tačiau šios vertės statistiškai reikšmingai nesiskyrė (p>0.005).
Išvados: Nutukusių gimdyvių pirmosios cezario pjūvio operacijos trukmė yra ilgesnė negu normalaus svorio moterims. Skubaus cezario pjūvio operacijos dažnis yra labai didelis tiek ir turinčių nutukimą (90,2%), tiek ir jo neturinčių (80,5%) moterų tarpe. Statistiškai reikšmingai dažniausia indikacija pirmajam cezario pjūviui tarp nutukusių moterų buvo neprogresuojantis gimdymas. Nutukusių moterų naujagimiai dažniau būna didesnio gimimo svorio nei normalaus svorio gimdyvių.
2.Acknowledgements
I want to thank Lithuanian University of Health Science, Obstetrics and Gynaecology departments, mostly to the head of the obstetrics and gynaecology department Prof. Jolanda Nadišauskienė, also to my supervisor Dr. Laura Malakauskiene, MD, for all the support and oppurtunity. Additionally i want to thank Jurate Tomkeviciute, Statistical Department at Lithuanian University of Health Science.
3.Conflict of Interest
4.Abbreviations List
1. Cesarean Section (CS) 2. Cesarean Delivery (CD) 3. Body Mass Index (BMI) 4. Odds Ratio (OR)
5. Confidence Intervals (CI) 6. Women, Infant, Children (WIC) 7. Pearson Chi-Square Value (P-value)
5.Terms
1.Body Mass Index; The body mass index (BMI), also known as the Quetelet index, is
currently most often used. The BMI is calculated as weight in kilograms divided by the square of the height in meters (kg/m2)
2.Cesarean Section; A surgical procedure involving incision of the walls of the
abdomen and uterus for delivery of offspring
3.Chorioamnionitis; Inflammation of the fetal membranes (amnion and chorion) 4.Dystocia; A difficult labor, which is characterized by abnormally slow labor Progress
5.Gestational diabetes: Carbohydrate intolerance of variable severity with
onset or first recognition during pregnancy
6.Gestational Hypertension; Women whose blood pressures reach 140/90
mm Hg or greater for the first time after mid-pregnancy, but in whom proteinuria is not
identified
7.Macrosomia of New born; Growth beyond a specific threshold, regardless of
gestational age
8.Microsomia of New Born; Small for gestational age
9.Nullioarous Pregnancy; Women who has never given a birth.
10.Obesity; Abnormal or excessive fat accumulation that presents a risk to health
11.Primary Hypertension; Blood pressure exceeds 140 mm Hg systolic or
90 mm Hg diastolic
6.Introduction;
Obesity is defined as a condition of an abnormal or excessive fat accumulation in adipose tissue to the extent that health may be impaired. Obesity is most commonly measured as weight to height ratio and expressed as body mass index (BMI).According to World Health Organization (WHO) [1], classifying of BMI is listed as; Underweight (BMI <18.5 kg/m2), Normal weight (BMI ≥18.5 to 24.9 kg/m2), Overweight (BMI ≥25 to 29.9 kg/m2), Obesity (BMI≥30 kg/m2)
Furthermore, obesity is subdivided into three categories as; Obesity Class I (BMI 30-34.9 kg/m2), Obesity Class II (BMI≥35 to 39.9 kg/m2), Obesity Class III (BMI≥ 40 kg/m2). In some countries obesity class III also referred such as severe, extreme, or massive obesity.
Obesity is recognized as a major public health problem in world wide, especially in maternal obesity this health problem is becoming even more serious and has many outcomes both for the mother as well as the baby. According to studies obesity is one of the risk factor for having a cesarean deliveries (CD). Many researchers have found that, increase in body mass index, results in increase at cesarean section rate. Maternal obesity is not only causing a problems throughout the delivery, but also have influence on a newborns as well. According to systematic review and meta-analysis of A.S. Poobalan [12], has compared women who has normal BMI and women who were obese (BMI≥30 kg/m2) in an order to find out independent risk factor for elective and emergency cesarean delivery in nulliparous women, and the risk of cesarean delivery in nulliparous, singleton pregnancies is increased 1.5 times in overweight, 2.25 times in obese and even more for morbidly obese women, and risk of emergency caesarean delivery was slightly more than elective cesarean deliveries, however both were higher with increasing BMI.
In this final thesis we wanted to emphasize the relationship of obesity in all subtypes (Class I, Class II, Class III) and duration of cesarean section (both planned and emergency), and comparison with non-obese women who have had cesarean section for the first time. Among 82 participants (41 obese and 41 non-obese) in this study have chosen only a at term deliveries (≥37-41 and 6 days), singletone delivery, nulliparous, and had a cesarean section for the first time. Therefore we have only evaluated mothers who were clinically obese according to their BMI (≥30 kg/m2), had a term delivery (≥37-41 and 6 days), singleton, and nulliparous. In an order to be more preciese, we have included the control group (non-obese) who had normal BMI (≥18.5 to 24.9 kg/m2), at term (≥37-41 and 6 days), singletone delivery, and nulliparous. All participants with twins have been excluded both in both obese and non-obese groups.
Among these participants all of them had a first time cesarean section ( either planned or emergency cesarean section), therefore we were able to evaluate if maternal obesity has any influence on duration of cesarean section, when comparison with non-obese women. We also included non-obese and non-non-obese women’s newborns into our
study, to evaluate if maternal obesity has influence on a newborns comparison with newborns from non-obese women. Our study is also including the pathologies of obese and non-obese women, during the pregnancies such as dystocia, gestational hypertension, essential hypertension, gestational diabetes mellitus, chorioamnionitis.
7.Aim and Objectives of the thesis
Aim of the thesis; to assess, the obesity have influence on the duration of first cesarean
section and to compare the duration of total surgical operation, extraction of the fetus with non-obese women.
Objective of the thesis;
1. To evaluate the duration of first cesarean section for obese and non-obese pregnant women.
2. To average the duration of fetus extraction in cesarean section for obese and non-obese women.
3. To compare duration of first cesarean section, pregnancy pathologies, condition of newborn in groups of obese and non-obese women.
8. Literature Review
Obesity is defined as a condition of an abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired. According to World Health Organization [1]. Classifying obesity during childhood or adolescence is further complicated by the fact that height is still increasing and body composition is continually changing. Furthermore, there are substantial international differences in the age of onset of puberty and in the differential inter individual rates of fat accumulation. Obesity is classified for in an order us to allow meaningful comparisons of weight status within and between populations, to identify individuals and groups at increased risk of morbidity and mortality, to identify priorities for intervention at individual and community levels and to firm basis for evaluating interventions.
Classification of Obesity is simply achived by the measurement of Body Mass Index (BMI). BMI is a simple index of weight for height that is commonly used to confirm underweight, overweight and obesity in adults. BMI is calculated as the weight in kilograms divided by the square of the height in meters (kg/m2). For example an adult who weights 80 kg and whose height is 185 m will have a BMI of 23.3.
According to BMI results, here we can achieve and decide whether the person is clinically; underweight (BMI <18.5 kg/m2), Normal Weight (BMI ≥ 18.5 to 24.9 kg/m2), Overweight (BMI ≥ 25 to 29.9 kg/m2), or Obese (BMI ≥30 kg/m2). Moreover, obesity is subdivided according to BMI of an individual. Obesity Class I ( BMI 30 to 34.9 kg/m2), Obesity Class II ( BMI 35 to 39.9 kg/m2), Obesity Class III (BMI ≥ 40 kg/m2). Class III obesity is also referred to as severe, extreme or massive obesity in some countries.
One of the risk factor of having a cesarean delivery is the obesity. In this article review, I am going to explain the link between obesity and cesarean delivery, pre-pregnancy weight gain, maternal obesity and its outcome to newborn
According to Paul S. Kauser [2] , states that researchers have begun to use body mass index (BMI) to differentiate obese from non-obese individuals. Obese women (BMI above 29) have increased risk of cesarean delivery [2]. Paul S. Kauser also includes that [2] even among low-risk women managed by nurse-midwives, the risk of cesarean delivery is three to four times higher if they are obese, which does not make obese women inappropriate for prenatal management by nurse-midwives. Even with the increased risk, this inner city population had an overall cesarean rate of 5.1% and 7.7% for obese women.
Obesity is becoming an epidemic in United States, especially among pregnant women has risen. One study in United States [3], states that the increased perinatal morbidity associated with maternal obesity such as birth defects, preeclampsia, gestational diabetes, stillbirth, abnormal fetal growth, and cesarean deliveries has caught the attention of obstetricians-gynecologists. According to same study [3] , among 124,389 women, 14.0% had cesareans and cesarean delivery is increased with increasing BMI
for nulliparas, multiparas with and without a prior cesarean. Repeat cesareans were performed in >50% of laboring women with a BMI >40kg/m2. The risk for cesarean increased as BMI increased for all subgroups, p<0.001. The risk for cesarean increased by 5%, 2%, and 5% for nulliparas, multiparas with and without a prior cesarean, respectively, for each 1kg/m2 rise in BMI. Increasing BMI is associated with an increased risk of perinatal complications, including cesarean delivery.
We know that risk for having a cesarean delivery progressively increases as the body mass index increases, and most of this cesarean deliveries are required an emergency cesarean delivery. One retrospective cohort study in United States [4], have compared maternal and neonatal outcomes between planned cesarean delivery and induction of labor in women with class III obesity (BMI ≥40 kg/m2). He selected Class III obesity pregnancies who delivered a singleton from January 2007 to February 2013 via planned or induction of labor at 37 to 41 weeks of gestation, and he achieved such result that in term pregnant women ( ≥37 to 41 weeks and 6 days of gestation) with class III obesity, planned cesarean does not appear to reduce maternal and neonatal morbidity compared with induction of labor. However, patients who underwent an induction of labor and require cesarean delivery (failed induction) have significantly worse outcomes in terms of both maternal and neonatal morbidity than either those women who deliver vaginally after a successful induction or those who have planned cesarean. Moreover same study [4], also found out that high rates of chorioamnionitis in induced obese women (12.8 %), also demonstrated high rates of surgical complications in those undergoing planned cesarean delivery. Moreover rate of wound morbidity was lower than expected in both the induction and planned cesarean groups.
Cesarean delivery is not only unfortunate outcomes to newborns at their first years of life. However the risk may still be continued. One interesting question has raised authors from Australia, Abdullah A. Mamun [5], had evaluated the association between the mode of delivery and the risk of offspring obesity by age 21 years. A community-based birth cohort study had 2,625 offspring for whom they had measured physical assessments, including height and weight at 21 years and hospital recorded mode of delivery in the Mater hospital in Brisbane, Australia, between 1981 and 1983. In this cohort study results were; 12.1% were born by cesarean delivery. By 21 years, 21.5% of offspring were overweight and 12.4 % were obese. Offspring’s overweight and obesity status, as well as BMI and waist circumference, were not associated with the mode of delivery. Therefore findings of this study did not support the idea that cesarean delivery has increased the risk of long-term offspring obesity. According to Marcela C. Smid et al. [6], projects that in the United States, nearly one third of reproductive-age women are obese. If current trends continue, more than one half of reproductive age women will be obese by 2030. Maternal obesity increases the risk of prolonged labor, failed induction, cesarean delivery for failure to progress, and cesarean delivery for emergency indications. As maternal body mass index (BMI) increases, the risk of cesarean delivery increases; nearly one half of women with class III obesity (BMI > 40 kg/m2) will delivery via cesarean delivery. Maternal obesity also is associated with prolonged
operative time; however, it is unknown whether the management of intra-operative complications accounts for prolonged operative time during cesarean delivery
Another study about maternal obesity and relationship with cesarean section in Iraq [7], has also suggested similar results, according to Waqar Al-Kubaisy [7], have evaluated the relationship between mode of delivery in the current pregnancy and BMI level, there was an evidence that pregnant women who their pregnancy ended by cesarean section, their BMI was (28.62 ± 4.49) significantly higher (p < 0.001) than (22.85 ± 2.82) those whom delivered normally. Moreover, with increasing BMI (≥25 kg/m2) above normal, CS was significantly increased steadily (p < 0.001). All obese (BMI ≥ 30) multigravidae with a previous history of CS were delivered via CS. CS for the current pregnancy was significantly higher among obese (BMI ≥ 30) primi and multigravida women without previous history of CS (85.7% and 78.3% respectively; p < 0.001) compared to non-obese primigravidae and multigravidae (28.1% and 15.9%, respectively)
Obesity and maternal over weight is not only increases the risk of having a cesarean section. It has some other risk factors as well such as diabetes mellitus type II, hypertension, coronary heart disease, stroke as well as risk of complications during pregnancy and delivery.
Danish study based on population by Per Ovasen [8], evaluated 369,347 women, 20.9% being overweight (body mass index [BMI] 25–29.9), 7.7% obese (BMI 30–35), and 4% severely obese (BMI higher than 35). Overweight, obese, and severely obese women had more complications than did normal weight women. Adjusted odds ratios (ORs) were significantly increased as follows: for gestational diabetes mellitus, 3.5, 7.7, and 11.0 for each BMI category; for preeclampsia 1.9, 3, and 4.4. Planned and especially emergency cesarean delivery was significantly increased with increasing BMI (OR ranging from 1.2 to 2.1).
Maternal obesity have had impact on a new born as well according to the same Danish study [8], which states that; the risk of giving birth to a macrosomic neonate (greater than 4,500 g) increased significantly with increasing BMI (1.6, 2.2, and 2.7), as did the risks of having a neonate with a low Apgar score (1.3, 1.4, and 1.9) and having a stillborn fetus (1.4, 1.6, and 1.9).
Another issue with obesity pregnancies not only a diabetes mellitus type II, hypertension, coronary heart disease, stroke, nor macrosomia of a new born but, also causes a birth injuries or severe illnesses in the newborns. One cohort study in Sweden [9], have included 1,024,471 women, and data were collected from the Swedish Medical Birth Registry, to evaluate adverse neonatal outcomes such as birth injuries or severe illnesses in the newborn with woman who were obese and depending on mode of delivery. Results have showed that neonates born to morbidly obese women have a doubled risk of birth injuries to skeleton and respiratory distress syndrome, a threefold increased risk of bacterial sepsis, convulsions, birth asphyxia and feeding problems, and
a fourfold increased risk of birth injuries to the peripheral nervous system and hypoglycemia, so the risk of any adverse neonatal outcome seemed to increase with increasing maternal body mass index, regardless of mode of delivery. However obesity is increasing risk of cesarean delivery and complications both for mother and newborn as well, but its not only obesity, but being an over weight (BMI ≥25 to 29.9 kg/m2) also have similar outcomes when these pregnancies are compared with women who described as lean body mass (BMI <25 to > 18 kg/m2).
According to Jared M. Baeten [10], the rate of occurrence of most of the outcomes increased with increasing body mass index, when compared with lean women, both overweight and obese women had significantly increased risk for gestational diabetes, preeclampsia, eclampsia, cesarean delivery and delivery of macrosomic infant. A total of 159,072 singleton births to nulliparous women were recorded in Washington State between 1992 and 1996. They were able to calculate prepregnancy BMI for 96801 (60.9%) of these births. By BMI category, 18988 (19.6%) were to women characterized as lean, 50 425 (52.1%) were to women characterized as normal weight, 17571 (18.2%) were to women characterized as overweight, and 9817 (10.1%) were to women characterized as obese. The proportion of women who developed gestational diabetes, preeclampsia, or eclampsia consistently increased with BMI. After potential confounders were controlled for, obese and overweight women were at significantly increased risk for each of these outcomes compared with lean women. Women categorized as having normal prepregnancy BMI had slightly elevated risks of these pregnancy complications.
Comparison with lean women, women with normal BMI were slightly less likely to deliver a low birth weight (<2500 g) infant, and obese, overweight, and normal-weight women were each slightly less likely to deliver a small-for-gestational-age (<10th percentile) infant and were each more likely to deliver a macrosomic infant (≥4000 g). The risk of cesarean delivery increased with each level of increasing BMI. The risk of infant death within one year of birth was significantly higher for obese women, than for lean women. This study confirms that obesity is a strong risk factor for pregnancy complications and adverse outcomes, but more importantly not only obese women, but also overweight women (prepregnancy BMI ≥ 25.0-29.9 kg/m2) had markedly increased risk for gestational diabetes, preeclampsia and eclampsia compared with women with a prepregnancy BMI less than 20.0 kg/m2.
Prevalence of being overweight and obesity is increasing among women especially in childbearing ages and this is becoming a public health problem. According to US National Health and Nutrition Examination Survey 26% of non-pregnant women at the ages between 20-39 years are overweight (BMI 25–29.9 kg/m2), and 29 % are obese (BMI ≥30 kg/m2) and 30% of non-pregnant teenage girls at the ages between 12-19 years, are considered to be overweight or having at high risk. Overweight and obese women are at increased risk for chronic conditions such as cardiovascular disease and diabetes, as i have mentioned earlier, in addition to that these women are also on a
increased risk for infertility problems and menstrual irregularities, and to cesarean deliveries.
One study about maternal pre-pregnancy overweight and obesity and its risk of cesarean delivery in nulliparous women in North Carolina [11], had examined data from 641 nulliparaous women with a term pregnancy that participated in pregnancy, nutrition and infection study from 1995 to 2002. Unadjusted and adjusted risk ratios and 95% confidence intervals (CI) were computed for normal weight (BMI 19.8-26.0 kg/m2), overweight (BMI 26.1-29.0 kg/m2) and obese (BMI ≥30 kg/m2), and compared them with normal weight women whom served as the referent population, and the results was confirming the previous studies. They found that both overweight and obese women were admitted earlier (based on cervical dilation assessment) to labor and delivery and more often reported, no or irregular uterine contractions, compared with normal weight women. Labor induction and oxytocin augmentation was also more common among women who were overweight or obese. Forty-seven percent of obese and 40% of overweight women were induced, compared with 31% of normal weight women. Elective cesarean delivery was slightly higher in obese compared with normal weight women and the most common indication for an elective cesarean delivery was malpresentation.
The rate of caesarean delivery in the western world has been on the increase, mirroring the obesity trends. Higher incidence of pregnancy induced hypertension, macrosomia, deposition of pelvic fat causing obstruction to the birth passage, poor myometrial contractility and consequent dysfunctional labour in overweight and obese women have all been identified as underlying mechanisms and pathogeneses for increased risk of caesarean delivery.
According to systematic review and meta-analysis of A. S. Poobalan [12], has compared women who has normal BMI and women who were obese (BMI≥30 kg/m2) in an order to find out independent risk factor for elective and emergency cesarean delivery in nulliparous women, and the risk of cesarean delivery in nulliparous, singleton pregnancies is increased 1.5 times in overweight, 2.25 times in obese and even more for morbidly obese women, and risk of emergency caesarean delivery was slightly more than elective cesarean deliveries, however both were higher with increasing BMI.
Unfortunately outcomes of maternal obesity to a newborn is not only a macrosomia, birth trauma, nor being preterm but, it can also increase late fetal death as pre-pregnancy BMI and obesity is increase. One Swedish population based cohort study [13], have found the risk of late fetal death which increased consistently increases with pre-pregnancy body mass index among nulliparous women, whereas the risk of early neonatal death is almost doubled among nulliparous women with higher body-mass indexes. Another similar British study [14], have found possibility of increased perinatal mortality for preterm infants was not limited to offspring of obese women, but it also started with offspring of thin women and it started to increased with increasing maternal
body weight. Same study also states that offspring of thin mothers had the lowest mortality rate (37 deaths in 1000 births) and children of obese mothers, unfortunately had the highest rate (121 deaths in 1000 births). Main reason of death was mostly because of preterm birth, and it was responsible nearly half of this mortality increase, other factors which causes, a rise in mortality such as increasing frequencies of older pregnancies (at the ages between 35 to 50 years old), congenital malformations of infants, twins, and maternal diabetes mellitus made smaller contributions to the rising mortality as relative maternal body weight increased.
A study in United States [15], about contribution of excess weight gain during pregnancy and macrosomia to the cesarean delivery rate have proposed. A recommended weight gaining program in an order to limit a gaining of an extra weight and outcomes of pregnancy. In 1990 Institute of Medicine (IOM) has issued weight gain guidelines in an order to lower the risk of fetal death, preterm birth and low birth weight. However in 1990-200, the proportion of women who gained weight outside the IOM recommended range of 7 kg (15 Ib) to 18 kg (40 Ib ) increased by 28%; from 24.1 % in 1990 to 30.5 % in 2000. This increase is largely caused by a 23.9% rise in the number of women who gained more than the maximum recommended weight of 18 kg (40 Ib); from 19.8 % in 1990 to 24.7 % in 2000. Among women who gain more than 18 kg (41 Ib), the median weight gain rose from 22 kg (48 Ib) to 23 kg (50 Ib), and the proportion, who gain weight more than 20kg (45 Ib) rose from 61.8 % in 1990 to 65.9% in 2000. Macrosomia was strongly associated with excess weight gain during pregnancy. Macrosomia rates among women who gained more than 18 kg (40 Ib) were substantially higher than rates among women who gained 7kg (15 Ib) to 18kg (40 Ib). From 1990– 2000, the overall frequency of macrosomic infants fell steadily from 9.9% to 8.8%. This decline was more substantial among women who gained excess weight (19.3%) compared with women who gained within the recommended range of 15 to 40 lb (11.9%). Cesarean delivery rates were lowest for women who gained within the recommended range of 7-18kg (15 to 40 lb) and elevated for both women who gained 7kg (15 lb ) and for women who gained 19kg (41 lb) .
Similar study for about gestational weight gain recommendation and its outcome also conducted from Bianco A.T. [16], and results was weight gains of more than 11 kg (25 Ib) were associated strongly with birth of a large for gestational age of neonate, however, poor weight gain did not appear to increase the risk of delivery of a low birth weight of neonate. Therefore gestational weight gain was not associated with adverse perinatal outcome, but it did affect neonatal outcome. To decrease the risk of delivery of a large for gestational age newborn, the optimal gestational weight gain for morbidly obese women should not be more than 11 kg (25 Ib).
One interesting population based study in United State [17], had also assess the risk of primary cesarean delivery due to excess prepregnancy weight among nulliparous women delivering term infants, and have analyzed 24,423 nulliparous women with single, term infants delivering between 1998 and 2000 in 19 states. They have calculated BMI from self reported weight and height. They have assessed interaction between
pre-pregnancy BMI and other risk factors. The results was an incidence of cesarean delivery was increased with increased pre-pregnancy BMI, from 14.3 % for lean women (BMI<19.8), 42.6% for very obese women (BMI≥35). The risk of cesarean section differed by presence of any medical, labor and or delivery complication.
In the United States, nearly one third of reproductive-age women are obese. If current trends continue, more than one half of reproductive age women will be obese by 2030. However there are twice as many obese children now as there were 20 years ago. In the United States, obesity is recognized as major public health problem that requires population level approaches to prevention that alter the environment to affect food intake and energy expenditure. United States government has developed a special supplemental nutrition for women, infants and children which is shortly, called WIC. It provides an ideal setting for identifying newborns who are at high risk for later obesity and for subsequently developing an approach to preventing the development of obesity in preschoolers. This federal program gives supplemental food and nutrition counseling to low-income pregnant and postpartum mothers and to their children from birth until 60 months of age.
One study ran by the Robert C. Whitaker [18], had a hypothesis, that newborns whose mothers are obese in the first trimester of pregnancy are at increased risk of being obese at 2 to 4 years of age. A retrospective cohort study was applied on 8494 of low-income children who were under the WIC program. This individuals were followed from the first trimester of gestation until 24 to 59 months of age. Their result was prevalence of childhood obesity was 9.5%, 12/5%, and 14.8 % at 2, 3 and 4 years of age respectively, and 30.3 % of children had obese mothers. Among children whose mothers were obese in the first trimester of pregnancy (BMI≥30 kg/m2), the prevalence of obesity at ages 2,3 and 4 years was 15.1%, 20,6%, and 24.1%, respectively, which was 2.4 to 2.7 times the prevalence of obesity among children who were born to normal weight mothers (BMI 18.5 to 25 kg/m2). Among those who were born to obese mothers, the prevalence of BMI 85th percentile at ages 2,3, and 4 years was 28.4%, 36.9%, 41.2%, respectively. Therefore children of obese mothers were twice as likely as those of non-obese mothers to be large for gestational age at birth.
9. Research Methodology and Methods;
A retrospective chorot study of obese 114 women, who gaven a birth at Hospital of Lithuanian University of Health Sciences (LSMU) Kauno klinikos in period of 2012 to 2017. The study have conducted on selected 41 obese women who had the first cesarean delivery and they were grouped in three subtypes of obesity. The control group of a 41 women with normal body mass index (BMI) was collected. The selection criteria both for obese and non-obese group were: delivery at term (≥37 to 41 week and 6 days), singletone delivery, nulliparous, and had a cesarean section for the first time. The data of selected obese and non-obese women’s newborns were assessed also. The medical data was used in two sources: 1) Extraction and total surgical operation duration data have evaluated at the Lithuanian University of Health Science Archive under the permission from Obstetrics and Gyneacology Department of Lithuanian University of Health Science; 2) Epicrisis of each patient have evaluated from Lithuanian University of Health Science patient data program at university computer. Statistical data have been calculated with IBM Statistics SPSS 25 system.
10. Results;
A.Quantitative Results;
The study have evaluated 41 selected obese women, including all subclasses (Obesity type I, Obesity type II, Obesity type III) and 41 women with normal BMI. Our objective was to evaluate if maternal obesity in different subtypes, have affect on duration of cesarean section extraction and total surgical duration, comparison with non-obese group women. We have also included both these women’s pathologies, and it’s affect on newborn.
1.Evaluation of Obese Type I Group
Total number of obese type I women were 21, 13 for obese type II, and 7 for obese type III women.
1.1. Evaluation of Planned Cesarean Section in Obese Type I
Among obese type I women their age varies from 25-40 years old. Total number of obese type I women were 21. Three women had planned cesarean section and their indication were; two women had large fetus, and one woman had malpresentation. We have reached in such results that in obese type I women who had planned cesarean section; longest total surgical duration of cesarean section was 52 minutes, and longest extraction time was 8 minutes. In contrast, shortest total duration of cesarean section was 32 minutes and shortest extraction time was 5 minutes.
1.2. Evaluation of Emergency Cesarean Section in Obese Type I Group
Among 21 obese type I pregnancies two of the patients had missing information about their extraction and total surgical duration in the postoperative journal at archive. However We have suspected they were emergency cesarean section by their indication. Therefore sixteen patients had emergency cesarean section, among obese type I
pregnancies. Indication for emergency cesarean section in obese type I women as follows; eight women had non-progressive delivery, three women had non-stable fetal condition, two women had induction failure, another two women had clinically narrow pelvis and one women had disproportion.
Moreover, we have reached in such results that in obese type I women who had emergency cesarean section; longest total surgical duration of emergency cesarean section was 70 minutes, longest extraction time was 16 minutes. In contrast shortest total surgical duration of emergency cesarean section was 33 minutes, and shortest extraction duration of emergency cesarean section was 2 minutes.
1.3. Evaluation of Pathologies of Obese Type I Group
Among 21 participant of obese type I pregnancies pathologies were as follows; 8 women had dystocia, 5 women had gestational hypertension, 4 had gestational diabetus mellitus (A1), 2 women had gestational diabetus mellitus (A2), one women had primary hypertension, and 1 women had chorioaminonitis.
2.Evaluation of Obese Type II Group
Total number of obese type I women were 21, 13 for obese type II, and 7 for obese type III women.Among obese type II group, women’s ages varies from 26 to 42 years old.
2.1. Evaluation of Planned Cesarean Section in Obese Type II Group
Planned cesarean section has performmed only to a one woman, and this woman was indicated for planned cesarean section due to difficult pregnancy. We have reached in such results in obese type II women who had planned cesarean delivery; extraction time was 8 minutes and total surgical duration time was 55 minutes
2.2.Evaluation of Emergency Cesarean Section in Obese Type II Group
In women who had emergency cesarean delivery in obese type II group, total number was 12 women. They have indicated for emergency cesarean section as follows; six patients had non-progressive delivery, two patients had disproportion, and rest of the each patient had falilure of induction, non-stable fetal condition, severe pre-eclampsia, fetal hypoxia respectively.
Among this 12 obese type II group, emergency cesarean section duration; We have evaluated each of their total duration of emergency cesarean section and the duration of extraction, and results were as follow; longest emergency cesarean section total surgical duration was 64 minutes, and the longest extraction was 10 minutes. In contrast shortest emergency cesarean section total surgical duration was 34 minutes, and the shortest extraction was 8 minutes.
2.3.Evaluation of Pathologies of Obese Type II Group
Among obesity type II pregnancies pathologies of patients were having was as follows; among 13 participants; four women had dystocia, two women had primary hypertension, two women had gestational hypertension, four women had gestational diabetus mellitus (A1), one women had gestational diabetus mellitus (A2), and one women had chorioamnititis.
3.Evaluation of Obese Type III Group
Total number of obese type I women were 21, 13 for obese type II, and 7 for obese type III women. Among obese type III group, women’s ages varies from 25 to 38 years old.
3.1. Evaluation of Emergency Cesarean Section in Obese Type III Group
Among women who were classified as obesity type III; total number of patients was 7 and all the women had indicated for emergency cesarean delivery. Indication for emergency searean deliveries as follows; six women had non-progressive delivery, and only one patient had disproportion. Among type III obesity; longest extraction time was 15 minutes, longest total surgical duration was 64 minutes. In contrast shortest extraction time was 1 minute and shortest total surgical duration was 30 minutes.
3.2. Evaluation of Pathologies of Obese Type III Group
Pathologies of obesity type III women were also evaluated and such results was found; three women had dystocia, three women had gestational hypertenison, one woman had primary hypertension, one woman had gestational diabetus mellitus (A1), one women had gestational diabetus mellitus (A2).
4. Evaluation of Average Extraction and Total Surgical Duration in Obese and Non-obese Women
In obese type I group total cesarean section (planned and emergency) average duration of fetus extraction was 5.3 minutes, and average of total surgical duration was 41.4 minutes. In obese type II group total cesarean section (planned and emergency) average duration of fetus extraction was 6.9 minutes, and average of total surgical duration was 47 minutes. In obese type III group total cesarean section (planned and emergency) average duration of fetus extraction was 7.5 minutes, and average of total surgical duration was 50.4 minutes.
Among 41 obese women average extraction time was 6.6 minutes, however in non-obese women average extraction time was 4.7 minutes, therefore average extraction time is longer in obese women, comparison with non-obese women. Average of total surgical duration in obese women was 46.7 minutes, and average of total surgical duration in non-obese women was 42.2 minutes, therefore average total surgical duration was longer in obese women comparison with non-obese.
5. Duration of Planned Cesarean Section in Obese (all subtypes) and Non-Obese Groups
The longest extraction time in obese women (all subtypes), we have found that was 8 minutes, and longest extraction time for non-obese women we have found that 7 minutes. In contrast shortest extraction time in obese women we have found that 5
minutes, and shortest extraction time in non-obese women we have found that 3 minutes (Table No.1). The longest total surgical duration time in obese women, we have found that was 55 minutes, and longest total surgical duration time for non-obese women we have found that 45 minutes. In contrast shortest total surgical duration in obese women, we have found that 31 minutes and shortest total surgical duration in non-obese women, we have found 30 minutes (Table No.2).
Table No. 1, shows duration of fetus extraction in obese and non-obese women in planned cesarean section
Table No.2, shows duration of total surgical oberation in obese and non-obese women in planned cesarean section.
0 1 2 3 4 5 6 7 8 9 10 1 7 13 19 25 31 37 43 49 55 61 67 73 79
The Duration of Fetus Extraction
in Obese and Non-‐Obese Women in
Planned Cesarean Section
Planned Cesarean Section Extraction Time in Obese Women Planned Cesarean Section Extraction Time in Non-‐Obese Women 0 5 10 15 20 25 30 35 40 45 50 55 60 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81
The Duration of Total Surgical
Operation in Obese and Non-‐
Obese Women in Planned
Cesarean Section
Planned Cesarean Section Total Duration in Obese Women
Planned Cesarean Section Total Duration in Non-‐ Obese Women
6. Duration of Emergency Cesarean Section in Obese (all subtypes) and Non-Obese Women
The longest extraction time in obese women was 16 minutes, and longest extraction time in non-obese women was 8 minutes. In contrast shortest extraction time in obese women was 1 minutes and shortest extraction time in non-obese women was 2 minutes. (Table No.3). The longest total surgical duration time in obese women was 70 minutes and longest total duration time was the same with non-obese women. In contrast shortest total surgical operation in obese women was 30 minutes, and shortest total surgical duration in non-obese women was 20 minutes. (Table No.4)
Table No. 3, shows duration of fetus extraction in obese and non-obese women in emergency cesarean section
Table No.4, shows duration of total surgical operation in obese and non-obese women emergency cesarean section
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81
The Duration of Fetus Extraction in
Obese and Non-‐Obese Women in
EmergencyCesarean Section
Emergency Cesarean Section Extraction Time in Obese women Emergency Cesarean Section Extraction Time in Non-‐Obese Women
B. Qualitative Results
1. Results of Obese and Non-obese Groups
We have selected control group with a same number as obese group. In addition to that non-obese women were also gave a birth at term, singleton, nulliparous, and had cesarean section for the first time.
1.1. Comparison of Emergency and Planned Cesarean Section Duration in Obese and Non-Obese Groups
Among 41 selected obese women including all three subtypes, overall 37 patients had emergency cesarean delivery, and their rate of emergency cesarean delivery was 90.2 %, 4 patients had planned cesarean delivery from obese group, and their rate of planned cesarean delivery was 9.8 % (Table No.5a).
Among 41 participant from non-obese group, 33 patients had emergency cesarean delivery, and their rate of emergency cesarean section was 80.5 %, and 8 patients had planned cesarean delivery from non-obese group and their rate of planned cesarean section was 19.5%(Table No.5a). According to Chi-square test (Table No.6 b), our result was statistically not sigificant, because, our Pearson Chi-square value (p value) was 0.211 (p>0.05)(Table No.5 b).
We can see that rate of planned cesarean section is almost doubeled in non-obese women (19.5%), comparison with obese women (9.8%). How ever rate of emergency
0 10 20 30 40 50 60 70 80 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81
The Duration of Total Surgical
Operation in Obese and Non-‐Obese
Women Emergencey Cesarean Section
Emergency Cesarean Section Total Duration Time in Obese Women Emergency Cesarean Section Total Duration in Non-‐Obese Women
cesarean section in both obese (90.2%) and non-obese (80.5%) were close (Table No.5 a).
Table No.5a Cross Table of Emergency and Planned Cesarean Section Duration Comparison in All Participants
Obese/not Total
Yes No
Emergency / Planned Emergency Cesarean Section Duration (min.) Count 37 33 70 % Within Obese/not 90.2% 80.5% 85.4% Planned Cesarean Section Duration (Min.) Count 4 8 12 % Within Obese/not 9.8% 19.5% 14.6% Total Count 41 41 82 % Within Obese/not 100.0% 100.0% 100.0%
Table No.5 b, Chi-Square Tests
Value df Asymp. Sig.
(2-sided)
Exact Sig. (2-sided)
Exact Sig. (1-sided)
Pearson Chi-Square 1,562a 1 .211
Continuity Correctionb .879 1 .349
Likelihood Ratio 1.588 1 .208
Fisher's Exact Test .349 .175
Linear-by-Linear Association
1.543 1 .214
N of Valid Cases 82
1.2. Comparison of Indication of Cesarean Section in Obese and Non-Obese Groups
Among all women from both obese and non-obese groups, most common indication for cesarean section was non-progressive delivery and overall 29 women had this complication with the rate 36.3% (Table No.6a). Moreover non-progressive delivery was one of the most common indication in obese women (including all subtypes), 21 obese women among 41, had non-progressive delivery with the rate 51.2%(Table No.6a). Therefore we can say that almost, half of the pergant women with all subtypes of obesity, had experienced cesarean section due to non-progressive delivery. Among non-obese women most common indication for cesarean section was malpresentation, 11 participants among 41, had malpresentation with rate 28.2% (Table No.6a).
Indication values were statistically significant, p value 0.001 (p<0.005), (Table No.2 b).
Table No.6a, Rate of Indication for All Participants
Obese/not Total yes no Indication for C/S 0 Count 0 2 2 % within Obese/not 0.0% 5.1% 2.5%
Failure of induction Count 3 1 4
% within
Obese/not
Disproportion Count 5 0 5 % within Obese/not 12.2% 0.0% 6.3% Non-stable Fetal Condition Count 4 6 10 % within Obese/not 9.8% 15.4% 12.5% Non-Progressive Delivery Count 21 8 29 % within Obese/not 51.2% 20.5% 36.3%
Large Fetus Count 2 0 2
% within
Obese/not
4.9% 0.0% 2.5%
Clinically Narrow Pelvis Count 2 3 5
% within Obese/not 4.9% 7.7% 6.3% Malpresentation Count 1 11 12 % within Obese/not 2.4% 28.2% 15.0%
Difficult Pregnancy Count 1 0 1
% within
Obese/not
2.4% 0.0% 1.3%
Severe Preeclampsia Count 1 0 1
% within
Obese/not
2.4% 0.0% 1.3%
Suspected Fetal Hypoxia Count 1 0 1
% within
Obese/not
2.4% 0.0% 1.3%
Leaked Fetal Water Count 0 1 1
% within
Obese/not
Scars in the uterus after a former myomectomy Count 0 1 1 % within Obese/not 0.0% 2.6% 1.3%
Pregnancy and treatment for women’s disease
Count 0 1 1
% within
Obese/not
0.0% 2.6% 1.3%
Pregnancy related
illness, treated infetility
Count 0 2 2
% within
Obese/not
0.0% 5.1% 2.5%
Fetal growth retardation Count 0 1 1
% within Obese/not 0.0% 2.6% 1.3% Extragenital women’s illness Count 0 2 2 % within Obese/not 0.0% 5.1% 2.5% Total Count 41 39 80 % within Obese/not 100.0% 100.0% 100.0%
Table No.6 b, Chi-Square Tests
Value df Asymp. Sig.
(2-sided) Pearson Chi-Square 40,536a 17 .001 Likelihood Ratio 51.848 17 .000 Linear-by-Linear Association 12.951 1 .000 N of Valid Cases 80
1.3. Comparison of Delivery Time in Obese and Non-Obese Groups
However we have restrictly chosen all participants on their delivery time are chosen to be only at term (≥37 to 41 weeks and 6 days). We have also found that, among all 82 participants most common delivery time was at the 40th week with the rate of 42.7%. Delivery time at the 40th week was also most common, seperately each of obese and non-obese groups. However these were statistically not significant, we have found our p value 0.441 (p>0.005),
1.4. Comparison of Aneshtesia in Obese and Non-Obese Groups
Among 82 participants anestheisa has applied, either by epidural anesthesia or spinal anesthesia. Most of the participants among both obese and non-obese group have had spinal anesthesia with rate of 62.2%. Spinal anestheisa was also most commonly in applied type of anesthesia, in seperated groups, 29 non-obese patients had spinal anesthesia with rate of 70.7%, and 22 obese patients had also spinal anesthesia with rate 53.7%. However this results were statistically insignificant, we have found our p value 0.111 (p>0.005)
1.5. Comparison of Pathologies in Obese and Non-Obese Groups
Among 21 women with obese type I pregnancies pathologies of patients were as follows; eight women had dystocia, five women had gestational hypertension, four had gestational diabetus mellitus (A1), two women had gestational diabetus mellitus (A2), one women had primary hypertension, and one women had chorioaminonitis.
Among 13 women with obesity type II pregnancies pathologies of patients were as follows; four women had dystocia, four women had primary hypertension, two women had gestational hypertension, four women had gestational diabetus mellitus (A1), one woman had gestational diabetus mellitus (A2), and one woman had chorioamnititis. Pathologies of obesity type III, among 7 women were also evaluated and such results were found; three women had dystocia, three women had gestational hypertenison, one woman had primary hypertension, one woman had gestational diabetus mellitus (A1), one women had gestational diabetus mellitus (A2).
Among all obese and non-obese groups most common pathology we have detected was dystocia. We have evaluated women with dystocia were 15 with rate of 36.6% (Table No.3 a) in obese group. Moreover from non-obese groups we have evaluated with dystocia were 6 women, with a rate of 14.6% (Table No.7 a).I have found a p-value according to Chi-Square test was 0.023 (Table No.7 b), which is statistically not significant(p<0.005).
Table No.7 a
yes no Dystocia Absenc e Count 26 35 61 % within Obese/n ot 63.4% 85.4 % 74.4% Presen ce Count 15 6 21 % within Obese/n ot 36.6% 14.6 % 25.6% Total Count 41 41 82 % within Obese/n ot 100.0 % 100.0 % 100.0 %
Table No.7 b , Chi-Square Tests
Value df Asymp . Sig. (2-sided) Exact Sig. (2-sided ) Exact Sig. (1-sided) Pearson Chi-Square 5,185a 1 .023 Continuity Correctio nb 4.097 1 .043 Likelihood Ratio 5.318 1 .021 Fisher's Exact Test .041 .021 Linear-by-Linear Associatio n 5.122 1 .024
N of Valid Cases
82
Second most commonly pathologies we have suspected was with both obese and non-obese groups were gestational hypertension. In obese group, we have found 10 women were having a gestational hypertension with rate of 24.4 %(Table No.8a). In non-obese group, we have found 3 patients were having a gestational hypertension with rate of 7.3% (Table No.8a). However our results were statistically not significant, we have found our p value 0.034 (p<0.005), (Table No.8 b).
Table No.8a Obese/not Total yes no Gestational Hypertension Absenc e Count 31 38 69 % within Obese/not 75.6% 92.7% 84.1% Presen ce Count 10 3 13 % within Obese/not 24.4% 7.3% 15.9% Total Count 41 41 82 % within Obese/not 100.0% 100.0% 100.0%
Table No.8b Chi-Square Tests
Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square 4,479a 1 .034 Continuity Correctionb 3.291 1 .070 Likelihood Ratio 4.688 1 .030
Fisher's Exact Test .067 .033 Linear-by-Linear
Association
4.425 1 .035
N of Valid Cases 82
2.Neonatal Outcomes from Obese and Non-Obese Groups
In this section, we are going to evaluate a condition of newborns who were born from selected obese and non-obese groups.We have 82 newborn, from 82 women who had given a birth a singleton baby. We have mentioned that all the women with twin babies were excluded.
Among these 82 babies, we have focused our evaluation on their precentile, to assess outcomes of maternal obesity. We have compared this results from non-obese mother’s babies. We have compared every each one of newborn, according to their gender, weight, and week that they have born. We have used a Mačejus G. 2000 precentile table. According to Mačejus G. 2000, we have evaluated 82 newborn’s gestational percentile. We had 41 newborns which were belongs to obese women, and 41 newborns which were belong to non-obese womens. Among Obese women’s newborn we have evaluated 6 macrosomic newborns, with rate of 14.6% (Table No.9 a ). Among non-obese women’s newborn we have evaluated 3 macrosomic newborns, with rate of 7.3%(Table No.9 a). However we have found p value 0.289 (Table No.9b), and this was statistically not significant (p>0.005).
Table No.9 a
Obese/not Total
yes no
Macrosomia Absence Count 35 38 73
% within
Obese/not
85.4% 92.7% 89.0%
Presence Count 6 3 9
Among obese women’s newborn we have evaluated only 2 microsomic newborns, with rate of 4.9% (Table No.6 a). Among non-obese women’s newborn we have evaluated 10 microsomic newborns, with rate of 24.4%. However we have found a p- value 0.012 (Table No.6 b), and this was statistically not significant (p>0.005)
Table No.6 a
Obese/not Total
yes no
Microsomia Absence Count 39 31 70
% within Obese/not 95.1% 75.6% 85.4% Presence Count 2 10 12 Obese/not Total Count 41 41 82 % within Obese/not 100.0% 100.0% 100.0%
Table No.9 b ,Chi-Square Tests
Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square 1,123a 1 .289 Continuity Correctionb .499 1 .480 Likelihood Ratio 1.143 1 .285 Fisher's Exact Test .482 .241 Linear-by-Linear Association 1.110 1 .292 N of Valid Cases 82
% within Obese/not 4.9% 24.4% 14.6% Total Count 41 41 82 % within Obese/not 100.0% 100.0% 100.0%
Table No.6 b , Chi-Square Tests
Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square 6,248a 1 .012 Continuity Correctionb 4.783 1 .029 Likelihood Ratio 6.738 1 .009 Fisher's Exact Test .026 .013 Linear-by-Linear Association 6.171 1 .013 N of Valid Cases 82
11. Discussion of the Results;
Among 41 selected obese, singleton and nulliparous, women including all three subtypes, overall 37 patients had emergency cesarean delivery, and their rate of emergency cesarean delivery was 90.2 %, 4 patients had planned cesarean delivery from obese group, and their rate of planned cesarean delivery was 9.8 %. Among 41 selected obese women including all three subtypes, overall 37 patients had emergency cesarean delivery, and their rate of emergency cesarean delivery was 90.2 %, 4 patients had planned cesarean delivery from obese group, and their rate of planned cesarean delivery was 9.8 %. We can see that rate of planned cesarean section is almost doubled in non-obese women (19.5%), comparison with non-obese women (9.8%). How ever rate of emergency cesarean section in both obese (90.2%) and non-obese (80.5%) were close. According to Paul S. Kauser [2] even among low-risk women managed by nurse-midwives, the risk of cesarean delivery is three to four times higher if they are obese, which does not make obese women inappropriate for prenatal management by nurse-midwives. According to study in US [3], 124,389 women, 14.0% had cesareans and cesarean delivery is increased with increasing BMI for nulliparous , multiparas with and without a prior cesarean. Repeat cesareans were performed in >50% of laboring women with a BMI >40kg/m2. The risk for cesarean increased as BMI increased for all subgroups, p<0.001. The risk for cesarean increased by 5%, 2%, and 5% for nulliparous, multiparas with and without a prior cesarean, respectively, for each 1kg/m2 rise in BMI. Increasing BMI is associated with an increased risk of perinatal complications, including cesarean delivery.
Among all participants from both obese and non-obese groups, most common indication for cesarean section was non-progressive delivery and overall both obese and non-obese group 29 women had this complication and rate was 36.3%.
Moreover non-progressive delivery was one of the most common indication, among all obese women. Twenty one, women among 41, had non-progressive delivery with rate 51.2%. Therefore we can say that more than half of the pregnant women with all subtypes of obesity , had experienced cesarean section due to non-progressive delivery. One retrospective cohort study in United States [4], have compared maternal and neonatal outcomes between planned cesarean delivery and induction of labor in women with class III obesity (BMI ≥40 kg/m2). He selected Class III obesity pregnancies who delivered a singleton from January 2007 to February 2013 via planned or induction of labor at 37 to 41 weeks of gestation, and he achieved such results that in term pregnant women ( ≥37 to 41 weeks and 6 days of gestation) with class III obesity, planned cesarean does not appear to reduce maternal and neonatal morbidity compared with induction of labor. However, patients who underwent an induction of labor and require cesarean delivery (failed induction) have significantly worse outcomes in terms of both maternal and neonatal morbidity than either those women who deliver vaginally after a successful induction or those who have planned cesarean.
Obesity and maternal overweight is not only increases the risk of having a cesarean section. It has some other risk factors as well such as diabetes mellitus type II, hypertension, coronary heart disease, stroke as well as risk of complications during pregnancy and delivery. According to my results I have reported that among 21 women with obese type I pregnancies, pathologies of patients were as follows; 8 women had dystocia, 5 women had gestational hypertension, 4 had gestational diabetes mellitus (A1), 2 women had gestational diabetes mellitus (A2), 1 women had primary hypertension, and 1 women had chorioaminonitis. Among 13 women with obesity type II pregnancies pathologies of patients were as follows; 4 women had dystocia, 4 women had primary hypertension, 2 women had gestational hypertension, 4 women had gestational diabetus mellitus (A1), 1 woman had gestational diabetes mellitus (A2), and 1 woman had chorioamnititis. Pathologies of obesity type III, among 7 women were also evaluated and such results were found; 3 women had dystocia, 3 women had gestational hypertension, 1 woman had primary hypertension, 1 woman had gestational diabetes mellitus (A1), 1 women had gestational diabetes mellitus (A2).
Among all 82, obese and non-obese groups most common pathology, we have detected was the dystocia (25.6%). The number of women we have evaluated with dystocia were 15 with rate of 36.6% in obese group. Moreover from non-obese groups we have evaluated women with dystocia were 6 women, with a rate of 14.6%.
Second most commonly pathologies we have suspected with both obese and non-obese groups were gestational hypertension(15.9%). In non-obese group, i have found 10 women were having a gestational hypertension with rate of 24.4 %. In non-obese group, we have found 3 patients were having a gestational hypertension with rate of 7.3%. However our results were statistically not significant (p<0.005). One study in United States [3], states, that the increased perinatal morbidity associated with maternal obesity such as birth defects, preeclampsia, gestational diabetes, stillbirth, abnormal fetal growth, and cesarean. Obesity and maternal over weight is not only increases the risk of having a cesarean section. It has some other risk factors as well such as diabetes mellitus type II, hypertension, coronary heart disease, stroke as well as risk of complications during pregnancy and delivery. Danish study based on population by Per Ovasen [8] for gestational diabetes mellitus, 3.5, 7.7, and 11.0 for each BMI category; for preeclampsia 1.9, 3, and 4.4. Planned and especially emergency cesarean delivery was significantly increased with increasing BMI (OR ranging from 1.2 to 2.1).
We had 41 newborns which were belongs to obese women, and 41 newborns which were belong to non-obese women. Among Obese women’s newborn we have evaluated 6 macrosomic newborns, with rate of 14.6%. Among non-obese women’s newborn we have evaluated 3 macrosomic newborns, with rate of 7.3%. However, statistically is not significant. According to One Danish study [8], which states that; the risk of giving birth to a macrosomic neonate (greater than 4,500 g) increased significantly with increasing BMI (1.6, 2.2, and 2.7). According to Jarden M. Baeten [10], women with normal BMI were slightly less likely to deliver a low birth weight (<2500 g) infant, and obese, overweight, and normal-weight women were each slightly
less likely to deliver a small-for-gestational-age (<10th percentile) infant and were each more likely to deliver a macrosomic infant (≥4000 g). The risk of cesarean delivery increased with each level of increasing BMI. The risk
