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Obesity and Pregnancy

Nov 16 | 1:30 PM

Obesity has become more prevalent among women of reproductive age all around the world. Obesity during pregnancy has both acute and long-term negative effects on both the mother and the fetus. Join us for a discussion with Dr. Munjal Pandya about the negative effects of obesity on pregnancy and how to manage them.

[Music] my name is doctor devanshi majmukha and i'm a clinical ops intern with netflix today we have dr munjal pandya with us who is the honorary secretary of ahmedabad obstetrics and gynecologist society and the assistant professor at amc met medical college ahmedabad and as if that wasn't keeping him busy enough his hobbies include playing tennis badminton cricket guitar he also sings and paints so it's an honor for us to have you here sir thank you so much dr devanshi for your kind words it's an honor actually to be a part of this particular session and um you all are doing wonderful job by by providing uh this uh information in a such a friendly platform uh as in i just got this particular explanation why you are having this only on mobile and that's a very very very much valid uh you know explanation with regards to the people who are busy in their schedule and can use mobile at the same time getting information uh in their hands so thank you so much for giving me this opportunity uh to begin with we would run a simple poll with regards to the prevalence of obesity in india so what is uh the opinion of our viewers with regards to the prevalence can we have the poll please yes thank you uh i think first option is uh 10 to 12 percent uh there is just a typing mistake from my site it's like the first option is 10 to 12 percent the second one is 15 to 17 percent third one is six to eight percent and last one is 20 to 22 percent okay most people have voted for 20 to 22 percent yeah thank you thank you so we can start the presentation actually uh uh the prevalence uh the first option uh it was 10 to 12 and uh that was the correct answer uh can we have the next slide please uh so you can swipe it okay okay i'll do it thank you so uh with with the advancing age uh this picture actually is known to us we have seen a lot of times that that with the passing decades the technology has improved the devices electronic devices and technology are getting smarter and i'm not saying we are getting numbered but yeah still we are not keeping with uh our health and and uh rest of the things so uh with regards to obesity who has called obesity as a global epidemic in the year 2000 from national family health survey 4 that was concluded in 2015 and 16 the prevalence of obesity in india was 12 and postpartum period the obesity was 13 so it is a number which uh we may not expect but it is still there and india even though we call uh india as an uh developing country we know body mass index according to who and nice guidelines this body mass index was devised based on the relation of emi and mortality so when it comes to bmi it is weight in kilogram divided by height in meter square if it is less than 18.5 it is underweight the normal range is 18.5 to 24.9 from 25 to 29.9 it is overweight and the rest of the five segments or points were classified as obesity class one two and three categories and there was direct correlation of pre-pregnancy higher bmi with increased number of crop complications in pregnancy and its outcomes what are the limitations with regards to usage of bmi body mass index does not have any correlation or reflection of distribution of adipose tissue versus absolute amount of fat the abdominal obesity versus the accumulation of fat at hips and thighs are not being reflected in bmi based circumference is much more reflective as comparison to bmi but still it is not well much very much used in comparison to bmi bmi is also unable to declare the muscle mass and the fat mass and it may not reflect the exact degree of fatness with regards to various different population but still it is the most popular and most useful population level uh measure of obesity so we do keep in mind the bmi with regards to obesity whenever we talk about uh in pregnant as well as non-pregnant state internally there are few challenges faced by mothers because the mothers choose uh some of the foods uh which would you know offer or have more liking with regards to taste rather than getting nutritious food uh one of the trials in uk concluded that mothers i mean those mothers in uk were deficient at least forty percent were deficient in iron 24 were deficient in folic acid and four percent when deficient in vitamin b12 with regards to india there are many vegetarian mothers and they are much more deficient in vitamin b12 one of the again major causes for infertility as well folic acid calcium and are one a few of the most essential nutrients required for pregnancy and its optimal outcome so basically this mothers need to be put on healthy and ideal diet that is a mix of fruits vegetables lean proteins and good quality of carbohydrates with regards to optimal weight gain during pregnancy it is gestational weight gain which is actually reflective of or calculated uh accumulation of conception plasma volume expansion extracellular fluid maternal fat and the maternal and fetal adiposity now this has to be kept in mind while regards to the expected weight gain the prior bmi of mother we need to advise up accordingly to the prior or pre-pregnant state bmi with regards to the optimal gestational weight gain if she gains excess weight gain it would lead to higher risk of maternal complications in form of medically indicated preterm birth increased chances of caesarean section more failed labor induction and large for gestational age influence along with infants having more of hypoglycemia obese patient with lesser weight gain would have lesser chances of such complications but again we need to draw a line with regards to optimal weight gain because lesser weight in would lead to more of small for gestational age infants according to institution of medicine from usa there was some uh the recent guidelines suggested that underweight females need to gain weight of approximately 12.5 to 18 kg the healthy ones would require weight gain of 11.5 to 16 kg over weight would require seven to eleven point five kg and obese females would require weight you know five to nine kg one of the studies uh in 2007 concluded that underweight female would require four to 10 kg normal weight would require 2 to 10 kg overweight one would require less than 9 kg and the obese one would require less than 6 kg one more study in 2007 uh actually evaluated four of the outcomes first was eclampsia second one was caesarean section then last fall age of gestational uh large for uh gestational age influence and small for gestational age influence now all these four parameters were studied in relation to bmi and the three first three outcomes were reduced with reduced weight gain but again as previously discussed the small for gestational age in front rates increased with reduced weight gain so the conclusion was drawn that at any point of time with class 1 obesity the weight gain has to be 4.5 to 9 kg and for class 2 and 3 obesity the weight end has to be 0 to 4 kg just to be in the you know middle of the strata with regards to the optimal outcome what are the challenges with regards to obesity in pregnancy excess fat would actually make it difficult you know to have clinical examination of fetal parts and number of fetus being examined at the same time when we talk about first trimester sonography we do evaluate knuckle transdecency now in case of obesity trans abdominal examination or transabdominal sonography would not be uh you know conclusive because there will be fat layer which would increase absorption of ultrasonic sound making it difficult to examine uh the fetal parts so we need to go for transverse and sonography in such cases fetal heart sound may not be audible on auscultation where we would require help of sonography for location as well as for calculation of fetal heart sound when the female has body mass index of more than 35 kilogram per meter square they are likely to have inaccurate symphores of fundal height with regards to examination and again sonography would be the conclusive part with regards to measurement of blood pressure we need to have appropriate cuff size as we know that two-third of circumference will be covered by the cuff and that particular cuff size needs to be mentioned in the papers or opd papers of the patient in 2008 nice guidelines suggested that first examination finding of weight and height needs to be noted particularly in particular you know with the obesity in pregnancy so that the further follow-up becomes easier and correlation with weight gain would be easier for us with regards to anti-neutral feeder surveillance the vigilance needs to be kept starting from 37 completed weeks in case of females with with bmi 35 to 39 9.9 and bmi more than 40 would require antenatal surveillance from 34 completed weeks because there are more chances of complications with regards to patented outcome this is a simple chart reflecting what are the problems complications and the management the risk factors we know that there are certain changes in cardiovascular system with regards to pregnancy there will be increased plasma volume there will be increased cardiac output that will be increased heart rate and hypercoagulable state will be there along with that due to obesity there will be more of insulin resistance more of inflammatory changes in body and more of placental dysfunction leading to comorbidities like hypertension diabetes mellitus and obstructive sleep apnea the complications which may happen would be heart failure arrhythmia preeclampsia more chances of scissoring delivery more chances of shoulder dystocia more chances of induced preterm birth and congenital malformation the management pre-pregnancy that is preconceptional zone would be education about pregnancy risk screening for comorbidities and weight loss advice again weight loss advice has to be in pre-pregnancy state not during pregnancy the pregnancy care would require multi-disciplinary approach it would require as in when the complications may happen or about to happen or have happen uh the role of physician would be actually major along with the observation so cardiovascular surveillance needs to be there blood pressure monitoring gestational diabetes screening pregnancy weight gain and low dose aspirin in certain cases as we will discuss in next slides the postpartum care she would require a psychological support along with cardiovascular surveillance weight and nutritional counselling and cardiovascular risk factor modification so when a female acquires more of adipose tissue she would she would need to she would have obesity leading to more of lifetime cardiovascular disease even after pregnancy future pregnancy complications as well she would have more of insulin resistance leading to gestational diabetes mellitus and majority of them would shift through lifetime maternal diabetes that is diabetes type 2 hyperglycemia would have its own neonatal complications in form of macrosomia leading to more of birth injuries and caesarean section childhood obesity and cardiovascular disease according to barker's hypothesis will be there in that particular child vascular injury leading to preeclampsia and preterm birth would be common in pregnancy now coming on to particular complications with regards to mother in obesity there will be more chances of hypertensive disorders of pregnancy and preeclampsia the risk of developing preeclampsia will be four-fold as compared to non-obese females now this is a wonderful uh study which concluded in 2001 that waste circumference before pregnancy if it is more than 80 centimeter the chances of developing hypertensive disorders of pregnancy the odds ratio will be 1.8 and developing preeclampsia the odds ratio will be 2.7 so even during pre-pregnancy state you would be able to judge the possibility of developing pre-eclampsia in that particular female when she becomes pregnant so we can actually advise upon accordingly gestational diabetes mellitus as we said the insulin resistance increases in obesity that would lead to more chances of gdm in uk and australia uh both the studies conducted that there will be two to three times higher risk in obese female of developing gdm as compared to normal weight females gdm also increases long-term risk of developing type 2 diabetes mellitus in those females uh the risk of developing up to five years postpartum and then it plateaus so up to next five years even after delivery she has to uh you know have proper monitoring of glucose obstructive sleep apnea it is very much common we call it equity and syndrome that is uh the the sleep apnea would increase fatty leading to more chances of hypertension preeclampsia and heart problems venous thromboembolism in uk after uh this uh the metamortality they had post-mortem although of those females now the obese females who had a postmortem done had venus thromboembolism in 57 percent of cases as compared to non-obvious females so the risk of vte increases with obesity and that too increases with more of hypercoagulable state of pregnancy now this is uh actually important because this particular thrombosis increases with the increasing scenario of operative delivery as well as hyper co-global state the odds ratio of uh developing that particular vte increases uh that is uh with obesity 1.8 is odds ratio but if that particular factor is associated with immobility or reduced mobility the odds ratio becomes 62.3 so the risk adds up with regards to reduced mobility due to obesity itself we know that prescribing oral contraceptives with estrogen to obese females is dangerous because the chances of et increases the same risk goes on here because there will be consistently high level of estrogen due to pregnancy and we need to keep in mind and we need to counsel patient accordingly and that is why the mobility is pretty much important with obesity in pregnancy now with regards to pre-term birth there are lesser chances of spontaneous preterm birth in obese females as compared to non-obese females but more chances of medically indicated obese medically indicated pluto birth because we need to induce labor because of certain obstetric indications like interest fetal growth restriction or even changes in doppler or even you know some of the cases the pregnancy will not be at a time induced naturally the respiratory system like asthma and obstructive sleep apnea increases the risk of non-pulmonary complication like scissor insection and preeclampsia there will be 1.5 to 2 times higher risk of exacerbation of asthma in obese females as compared to non-obese females and weight loss in between pregnancies would reduce the risk of stillbirth hypertensive complications and fetal microsomia and weight loss in between pregnancies would increase the chances of vaginal birth after scissoring section even if she had caesarean section in prior pregnancy so that is of utmost importance with regards to fetal complications there are higher chances of first trimester miscarriage so hb a1c is one of the most important indicators if she wants to get pregnant if she comes before pregnancy if the couple is planning pregnancy if it is in higher range we can actually control that particular parameter with regards to proper glucose and then she would be or the couple would be allowed to have pregnancy for optimal outcome the birth defects there are increased chances of heart defects and neural tube defects threefold increased risk of spina bifida omphalocele and heart defects or in obese females there are studies which concluded that even with supplementation of folic acid the risk of neural tube defects persisted if the obesity was not controlled so even if you give folic acid to the to those females the neural tube defects would be individually getting affected or will be seen in this particular females just due to obesity and lack of insulin resistance microsomia is actually uh something which would add up to the higher risk of birth injuries in mother higher chances of caesarean section nearly a fifth of females having bmi more than 30 had fetal macrosomia which was an independent uh you know factor irrespective of she developed gestational diabetes or not so obesity itself was an independent factor leading to macrosomia we need to keep in mind it is a risk factor microsomia is a risk factor for operative delivery a low up car score for one minute at one minute a low umbilical arterial ph as well as shoulder dystocia and significant injuries to baby including fractures and nerve pulses and it is macrosomia rather than maternal obesity that is main risk factor for shoulder dystocia and the morbidity of microscopic babies is increased to around eight percent in some of the studies preterm birth as we discussed was medically indicated and increased in comparison to non-obese females stillbirth was higher the rate till birth in the females with bmi more than 30 was 6.9 per thousand total births as compared to four per thousand total births in females of normal bmi neonatal death the chances increased in these females with regards to cerebral palsy to those live birds uh the overweight females had 22.22 of uh chances of cerebral palsy of those females while in obesity class 1 2 and 3 it was 28 54 and 202 so even though we had live birth the chances of that particular infant developing cerebral palsy was much more higher as the obesity classification with regards to intrapartum complications there were there was difficulty in gaining venous access that is like inserting vigo was pretty much difficult in one of the studies it was concluded that females with bmi more than 30 were more likely to have uh more labor induced and were more likely to receive oxytocin as compared to normal weight females labor progression was slower reflecting inefficient uterine activity uh primary immune system section was pretty much higher in obese females as compared to the healthy ones and major indications were failure to progress that is non-progression of labor and fetal distress anesthesia there were increased complications as well as increased requirement due to increased body weight higher risk of anesthesia related morbidity and increased chances of epidural failure rate increased risk of anesthesia under general anesthesia the more chances of regurgitation more chances of aspiration syndrome because of again reduced capacity of lungs uh difficult endotracheal intubation was that difficulty in achieving regional analgesia and anesthesia post-operative hypoxia and atalactases were much more common in obese females and copernicus such as hypertension systemic heart disease and heart failure were something which add up to the risk associated with anesthesia itself scissor and section pre-operative skin cleansing was anyway uh important uh since uh ages now but then again with regards to obesity it is of utmost importance with regards to vaginal cleaning one study uh concluded and then acog recommended in 2018 that vaginal cleaning with pavilion iodine or chlorhexidine before caesarean section in patients who were in labor and those who had ruptured membranes actually uh add up to reduced chances of post-operative complications so even though we are opting for cesarean section vaginal cleansing in this particular patients who are in labor or having ruptured membrane would add up to reduced chances of postpartum complications or infection rate surgical excess of two uterus now there can be uh two ways like transverse or vertical but in rcog they actually defined in 2018 that transverse approach that is transverse skin incision actually had lesser post-operative complications uh more or better uh wound healing and better uh or earlier ambulation with regards to post-operative zone but then the complications were much more as compared to the transverse one now we went with regards to class three obesity one of the studies conducted that would there will be increased rates of uterine rupture during trial of labor and regards to intra pattern monitoring as well emergency scissors section was associated with increased risk substitutedness fat again uh is uh something controversial uh with regards to literature it suggests that if subcutaneous fat layer is more than four centimeter then only you need to suture it separately but then again it depends on the individual's experience uh one more thing is with regards to skin incision even if you are opting about this transverse skin incision there is a paniculars of obesity there can be suprapanicles or infra panicular sensation you can not go uh at the line of where the paniculars actually joins the inferior part because that will be the line that would be the point where there will be maximum chances of an orbit upwards process of postpartum hemorrhage genital tract infection urinary tract infection and wound infection increased risk of venous thromboembolism after both caesarean section as well as normal delivery and that is why immediate or earlier or the earliest postpartum evolution would be of utmost importance postpartum infection with obesity may increase chances of vta itself breastfeeding the rates of breastfeeding are pretty much lower in obese females because the possible reasons would be difficulty with correct positioning due to obesity psychological issues as well or endocrine changes like prolactin response to cycling the challenges are much more in obese females because it takes longer for milk to you know reach the nipple lower production because breast size does not have anything in relation with the production of or amount of uh the the indicated preterm birth and admission in icu actually increases the gap between mother and other baby and that is where the breast milk production or breastfeeding gets a little uh you know later and that is why there is a role of counselling with regards to breastfeeding in this particular females bmi more than 40 is a risk factor for developing pressure source and that is why again uh you know the the immediate mobility would be uh better with regards to andy as well as scissor in section mental health problems will be anywhere more in this females in form of depression high antenatal anxiety postpartum anxiety eating disorders and antenatal serious mental illness long term implications in childhood we all are aware of this particular publication by barker in form of parker hypothesis in 1990 which concluded that intrauterine exposure to obesity is associated with increased risk of developing obesity and metabolic disorders in childhood metabolic syndrome is defined as two or more of the four components that is obesity hypertension glucose intolerance and dyslipidemia the prevalence of metabolic syndrome at any time up to 11 years was 50 for large for gestational age offspring with diabetes and 29 percent for last for gestational age offspring without diabetes for females who had obesity the chances are similar as having uh as shown in 50 with gdm even though they did not have gdm one of the studies framed as hypo study concluded that amongst obese females there will be increased maternal blood glucose increased triglyceride in fatty acids and fetal insulin concentrations contributing to fat accretion of in offspring maternal and cold blood leptin concentration was elevated with evidence of low grade inflammatory state in mother with high levels of crp and ilcs which are inflammatory markers leading to more of insulin resistance management specific management uh recommendations are like solid folic acid supplementation that is usual 40 i mean 400 micrograms daily weight loss that is indicated between two pregnancies approximately 4.5 kg had uh you know chances of gdm reduced by 40 percent in one of the studies but to be precise it is like 10 weight loss over six months is ideal safe and possible to sustain in long term weight loss during first trimester may increase ntd and that is why it has to be prior pregnancy you cannot advise for weight loss during first trimester or once she has conceived you can only advise for not having you know much of weight gain uh following bariatric surgery now bariatric surgeries are getting common and you know the outcome are pretty much better uh with regards to the previous times so maternal and parental complications after bariatric surgery were very much you know less but they faced dumping syndrome now dumping syndrome is something where the volume of stomach is reduced as well as there will be short circuit circuiting of the food from stomach to jejunum so that particular dumping syndrome will be there so ogtt ogd is like the glucose test even with depsi you cannot allow that particular female to have that particular screening you need to have home based glucose monitoring for at least one week for screening of diabetes in those particular females and rcog and acog both concluded in 2018 that a minimal waiting period of 12 to 18 months would be required after bariatric surgery for that particular female to have that particular pregnancy uh rcog in 2018 again concluded that females with more than one moderate risk factor that is bmi more than 35 first pregnancy maternal age more than 40 years family history of preeclampsia and multiple pregnancy may benefit from taking 150 milligram of aspirin daily from 12 weeks of gestational until birth of baby regular moderate intensity exercise is actually preferred and it would have improved maternal fitness and beneficial effects for fetal growth anti-obesity drugs or weight loss drugs are not recommended no major malformation uh was uh that but still with regards to topicament uh during pregnancy oral clefts were observed and both are excreted in breast milk and carries unknown risk to infer so studies are still not that with regards to safety during even uh black testing phase metformin for overweight or obese females without diabetes addition of metformin to diet and lifestyle changes starting at 10 to 20 weeks did not have improved pregnancy of birth outcome so there is a definite role of metformin with regards to diabetes and obesity but there is no role of metformin if she doesn't have diabetes type 2 diabetes mellitus risk increases within first five years and then plateaus as discussed and contraception can be advised as and when uh you know according to uh accordingly the condition of the mother so these are future prospects we need to have proper prospective randomized controlled trial in obese females for with regards to proper and optimal assessment effects of diet physical activity lifestyle changes on maternal fetal and neonatal outcomes we are not pretty much sure of optimal weight gain and that is why we need to define proper and optimal weight gain uh with regards to particular uh you know region as well as the habits food habits optimal methods of assessing body fat in females which we need to calculate because bmi is still not something which can actually conclude with regards to fat distribution and optimal gestation of a screening obvious females for diabetes and whether early detection and management improves outcomes we need to define all these particular things which regards to future and that is why that is how we can actually get optimal pregnancy and parental outcomes thank you thank you so doctor fatima is asking that she wants to know about patients with umbilical hernia i think umbilical so i yeah basically what happens is uh with regards to obesity there will be anyway weakness of uh wall umbilical hernia may be a coincidental finding even with uh lean and thin patients umbilical hernia can be uh coincidentally finding during pregnancy uh when she gets full-time but again it is uh something uh which uh shouldn't be combined as for recommendations the repair of umbilical hernia along with the infection uh because uh it is like adding up to the infection uh there is one theory where if you uh you know go for repair or putting a mesh for that particular umbilical hernia you're doing cesarean section there are more chances of that particular mesh are getting infected and rejection of mesh might be increased but again uh people do have individualized approach and anyway some of the umbilical hernia the defect size actually is important may not need any treatment so because of pregnancy because of increased intra-abdominal pressure of pregnancy umbilical hernia gets precipitated but after pregnancy it may not have any uh problem and in such a case conservative management would be great but again referring to proper surgeon and having multi-disciplinary approach as discussed would be of great uh you know help to the patient okay so so we have another question what other biochemical tests than lipid and glucose is advised by you for monitoring uh i think uh uh with regards to biochemical tests it is like glucose simple glucose monitoring and uh normal triglycerides hdl and ldl nothing else is required for that particular zone of pregnancy uh we need to monitor glucose because they are more susceptible to diabetes we need to monitor lipids because they are more susceptible to having lifelong hyperlipidemia or dyslipidemia but i don't think anything else is required with that particular pregnancy zone after pregnancy definitely uh she would require a physician reference if we are not um you know as an observation not getting proper results or optimal outcome with regards to those reports dr pooja kalai is asking if estrogen prevents the risk of cad in reproductive html how does obesity and or estrogen increase the risk of vt if a student prevents risk of cad just a second i'm reading in reproductive age females yeah basically if you have read about oral contraceptives it is a continuous exposure of additional exogenous estrogen that increases uh the hyper cognitive state of that particular vessel as in it increases or adds up to the risk of venous thrombobolism and that is why one of the contraindications uh for overall contraceptives or combined oral contraceptive pills are a stroke or even a previous attack of this coronary artery disease the same thing happens here during pregnancy that will be continuous exposure of high level of estrogen uh end process run but that particular high level of estrogen for nine months would add up to you know more uh risk of uh chances of thrombosis and that is why the uh vte risk increases in pregnancy uh this is a simple explanation and as you rightly said in reproductive age group estrogen is beneficial with regards to reducing uh cad but uh exogenous or additional estrogen actually adds up to the risk and that is why thrombotic females are not to be prescribed with combined oral contraceptives and same goes with pregnancy and frankly speaking uh pregnant females usually anyway without obesity as well do have cramps starting from five to six months of feminine so ambulation ambulation and ambulation would actually help to have more of hunger with regards to proper nutrition diet would have more of uh you know comfort on lesser cramps and would actually have more of you know uh maternal as well as a proper parental outcome avoiding such risk even in non-obese females uh there are there are people there are obstetricians who usually practice after every scissoring or after every surgery uh or hysterectomy they they actually have uh you know the bandages on on calf of a female and they actually try to you know flex the thigh and hip even after surgery uh because they do not want the female to go into that particular zone of developing thrombosis or venous thromboembolism okay there's another question uh what advice is to be given to the patient for postpartum weight reduction um as uh discussed in one of the slides it is ten percent of weight loss in first six months of postpartum so we do not have any number as in if the female is 120 kg it is ten percent of that particular weight loss within first six months postpartum and then gradually she can decide upon before having next pregnancy because we cannot have a simple figure like four point five or five or six kg it is ten percent of weight loss in first six months postpartum because uh reducing food intake would be detrimental to the fee to the infant or the baby who is on breastfeeding so basically it is a gradual reduction which is of importance and it is actually a sustainable thing if you if you go for uh you know immediate or a faster weight reduction it is not sustainable anyway so ten percent of weight loss for six months postpartum and then gradually she can decide upon according to her bmi okay uh dr anita has [Music] yeah uh i would like to ask um routinely for an obese primary gravida who is around 100 kg of weight with gestational diabetes and mild bih do you recommend nowadays recently this thrombo prophylaxis immediately after cesarean section or a prefer early impellation i will tell you mine so far i would be uh i would like early ambulation and i would not like to give thrombocracy so what's your take on that obviously definitely early ambulation has uh discussed madam because uh thromboprophylaxis is anyway not harmful but frankly it needs our proper monitoring uh usually they say uh to start with low molecular weight heparin you need to have nt10a activity monitored so so that is something uh which uh many of the people uh you know miss even they start with lmwh so if the parameters are within normal range it is the early ambulation but madam there are uh there are a few studies which uh concluded that with high-risk females that they do prefer starting off lmwh along with low-dose aspirin but lmwh because it is safer in third trimester and and if you are planning for cesarean section they would stop it at least 12 to 24 hours before that particular plant surgery and and they would restart it after 12 hours of that particular caesarean section but then again from my point of view it is early ambulation which is advisable rather than putting them on board prophylaxis i'm not saying it is unnecessary but again it is something that i prefer as as you prefer man thank you very much because i still prefer um though recent studies and other things all these i know but i have seen um these obese very obese patients 90 90 plus 100 kg doing scissor and section early ambulation i have this is my own experience that early ambulation really helps them so i wanted to know your what is your opinion thank you very much honestly speaking honestly speaking madam i am i'm working in a corporation hospital where patients are not such affordable so what i we usually uh cannot go for lmwh because they cannot afford it that is one thing and second thing as you said early evolution does have a good impact theoretical risk of getting embolism and everything is always there but still we have not faced any such problem anyway this is what i do i work in with the high tech patients so i thought i just wanted to know your opinion thank you very much thank you thank you thank you thank you ma'am uh even in developed countries madam they have like antenatal classes with regards to possible intrapartum mode of delivery as well as the preparation in post-partum phase psychological preparation as well as what what to expect and we can actually start the same uh here as well let us hope for the best matter thank you thank you so much doctor i have been doing this because i may be my age group is used to counsel the patients i am not after the patient but my age group patients they are used to counsel the patient right right when they conceive they start with 80 or 90 kgs so the counseling part starts at that stage so you are obese be prepared whether you deliver normally you develop complications whether cesarean section you have to get up from the bed in just four or five hours so we prepare them mentally we have enough time to prepare them thank you very much that's an excellent input thank you so much ma'am thank you [Music] we have a question on hypothyroid pregnant women management hypothyroid actually thyroid disorder adds up to the risk uh with regards to penetrator outcome as well as uh antenatal but yeah still uh it is simply uh the correction of hypothyroidism we need to keep on monitoring tsh if it is out of range then every six weeks with regards to starting off her treatment but then again uh they are they are both separate risk factors adding up to uh the outcome yeah physician reference and proper monitoring of tsh would be that nothing additional with regards to obesity combining with hypothyroidism it is normal routine management of hypothyroidism that is required uh preferred contraceptives in obese and gdm females immediately postpartum government has started for last decade uh that postpartum i introduce and contraceptive device program where they offer now now uh they offer multi-load which is a fantastic thing and free of charge but then again uh with that particular scare of getting infection we do not usually offer it and protest be one thing second thing if there is controlled uh uh you know sugar level glucose level then again iocd won't be an issue and uh we can keep on monitoring the particular glucose in postpartum phase as well and uh obviously we we keep on learning and teaching about cafeteria approach so it is the options that we make them available to the couple and it is up to them to decide upon it so i think uh there is nothing like contraindication with regards to only obesity with regards to diabetes definitely we are going to avoid those contraceptive septum methods which actually increase chances of infection okay just take a couple more dr amrota is asking early physiotherapy uh in intervention how early patients should refer to physiotherapy uh basically after delivery uh she can be ambitious as soon as she wants to as soon as she can be counseled as soon as her relatives you know boasts her up as soon as we post her up uh so uh it is like uh with regards to like breastfeeding we keep on saying that uh at the earliest after delivery she can have a breastfeeding same way emulation is something because uh uh with regards to uh delivery ambulation actually regains or helps in regaining the bladder tone urinary bladder tone it helps in uh you know uh intestinal movement as well and it helps in reducing chances of ete so it likes uh obviously for oner we'll be monitoring her uh in post bottom phase that is like fourth stage of labor we call it and then after uh we can just make her sit a little bit and then uh you know try to make her a military with support and then without support with regards to scissors section what usually we do is a spinal nervous system effect stays there for six hours but again that is not the duration right where we need her to you know keep on lying we would her to you know get up a little bit with some of the pain if she can wear with another six we have and then after a few hours like a couple of hours or three to four hours if she is ready to you know uh get up then with support she can start so again it is obviously about the mental strength and the counseling and the support from uh our side as well as relatives that would decide but after after five to six hours once she has gained the bladder tone we would remove the follis catheter so anywhere she is going to go to washroom on her own so that is how it works there is nothing defined period it is defined by the patient's strength and as well as the support that we give okay i think we have covered we have one we'll take one last question uh yeah and okay it's our question it's just a comment that we generally make patients mobile by 24 hours uh i think it is individualized yeah it is individualized there are people uh frankly speaking uh they are not uh you know uh uh they're doing wrong but there are people who actually make them ability earlier uh because of this many advantages but uh they do give discharge after 24 hours and um actually my wife is gynecologist and then she has taken the stretch for after both the scissor and sections after 24 hours so it's normal it's it's the mental strength it is the knowledge that we have it is the support we provide and uh give to the patient obviously there are chances of litigations and medical issues government has defined is it to be seven days after cesarean section you can discuss patient after seven days under janishi curriculum but obviously no private hospital is going to do that and anyway no patient would uh you know have extra charges if she is able to walk after 24 hours there is no need so obviously it is an individualized approach and experience the the doctor or obstetrician has and the support that is you know uh provided by the patient yourself so it is an individualized thing yeah okay all right uh does early ambulation cause spinal headaches yeah that that's a uh thing you know early evolution may add up to the spinal headache but yeah uh with regards to usage of spinal needle we need to you know be aware of it like previously they used to have 22 and 23 number of spinal legal which actually had a lot of cases of headache after spinal anesthesia but now nowadays they use 24-26 so the spinal headache incidences have anyway gone down but yeah it may it may lead to spinal headache yeah but still uh the the problem of spinal headache if weighed against uh those advantages is like almost nothing and anyway it can be you know uh with proper hydration and even like caffeine and paracetamol it can be controlled and occasional doses can be taken but yeah the advantage we have advantages we have are much more in comparison to the spinal headache all right i think that's it i think i hope i've taken all the questions uh thank you sir so much for this uh insightful session i'm sure everybody had a lot of fun and we had a very healthy conversation with dr anita earlier as well yeah thank you thank you so much for the opportunity

BEING ATTENDED BY

Dr. Darius Justus & 514 others

SPEAKERS

dr. Munjal Pandya

Dr. Munjal Pandya

Hon. Secretary of Ahmedabad Obstetrics and Gynaecological Society | Assistant Professor, AMCMET Medical College, Ahmedabad

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dr. Munjal Pandya

Dr. Munjal Pandya

Hon. Secretary of Ahmedabad Obstetrics and Gy...

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