Maternal obesity increases risk of preeclampsia and diabetes mellitus

Article Info ABSTRACT Article history: Received Oct 1, 2020 Revised Nov 9, 2020 Accepted Jan 16, 2021 Published Jul 1, 2021 Background: Obesity in pregnant women has been linked to negative outcomes for both the mother and the fetus. Gestational diabetes, preeclampsia, and postpartum haemorrhage are all threats for mothers during pregnancy. These may also affect labor outcomes because fat accumulation in the pelvis makes obese pregnant women more likely to have a caesarean section. Objective: To analyze the outcome of maternal obesity in pregnancy in 2017. Materials and Methods: This was an analytic cross-sectional, observational study in pregnant women with obesity in Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, within the period of January 1st – December 31st 2017 using medical records. Sample size was determined using cross-sectional sample size calculation with the result of n=162. After receiving approval of ethical clearance, medical records were collected and analyzed. The statistical analysis was done using chi-square test. Results: From a total of 162 subjects, most of the patients were 21-34 y/o (56.8%), under graduate (90.7%) and 58% of the subjects worked. Proportion of grade I, II and III were 60.5%, 22.2%, and 17.3%, and 67% suffered from complications such as PE, DM, PE with DM with percentages as follows: 56.2%, 4.9%, and 6.2%. Neonatal complications were preterm 42.6%, macrosomia 4.3%, stillbirth 4.9%, and low Apgar score 48.1%. No association was identified between maternal age and complications in grade I (p=0.764) and grade III (p=0.716). Obesity grades I and III had correlation with complications (p=0.035). Conclusion: No significant association was found between age and complications in grade III obesity, while there was significant correlation between obesity levels (grade I and grade III) and complications.

. According to Indonesia's five-yearly Health Survey in 2013, the prevalence of obesity among adult women was 32.9 percent, increasing 18.1 percent from 2007 (13.9%) and 17.5 percent from 2010 (15.5%). Risk factors that can occur in obese women are hypertension, high cholesterol and blood glucose level, stroke, kidney problems and cardiovascular disorders (Martin, 2015). Likewise, the incidence of obesity in pregnant women also poses negative outcome risks for the mother and her fetus. Maternal risks during pregnancy include gestational diabetes, preeclampsia, post-partum haemorrhage, and sleep apnea. The fetus is also at higher risks of miscarriage, macrosomia, preterm birth, congenital anomalies and can even lead to infant mortality (The American College of Obstetricians and Gynaecologists, 2016). This can also affect labor outcomes because the accumulation of fat in the pelvis will increase the likelihood of obese pregnant women to undergo caesarean section (Alba, 2018).

OBJECTIVE
The objective of this study was to analyze the outcome of maternal obesity in pregnancy in 2017.

MATERIALS AND METHODS
This research was a descriptive-analytic observational cross-sectional study of pregnant patients with obesity in Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, in the period of January 1st -December 31st 2017 and had received approval of ethical clearance from ethics commission of Faculty of Medicine Universitas Airlangga and Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. The data used was secondary data from medical record. The sample size was determined by a crosssectional sample design technique (n=162). The exclusion criteria were incomplete medical record data (no weight and Apgar score for infants) and obese pregnant women who did not deliver baby at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. As seen in Table 2, most of the patients had complications of preeclampsia, reaching 77.8% in grade II and 78.6% in patients with grade III obesity. Meanwhile only 41.8% patients with grade I obesity had preeclampsia.

DISCUSSION
Based on 162 obese pregnant women patients who were treated at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, most of patients were in the age group of 21-34 years in all grades 56.8%. A similar study was carried out in Manado; based on age, it was found that obese pregnant women were mostly in the age group of 20 to 30 years, which is the reproductive age group (Ekwendi, et al., 2016). Obese women aged >P35 years have higher risk of developing preeclampsia and gestational diabetes mellitus, doubled preterm births, low Apgar score, stillborn fetus, and increased risk of caesarean section (Lamminpää et al., 2015).
Most of the obese pregnant women had education level under graduate in all grades, consisting 90.7%. A similar study was carried out in Sweden, in pregnant women with low education (under graduate), the risk of obesity was 2.7 times greater than pregnant women with college education (Edvardsson et al., 2013).
Most of the obese pregnant women were working in all grades 58%. On the contrary to the study in Sweden, pregnant women who did not work were more likely to be obese than those who worked (14.5% vs. 8.3%) (Edvardsson et al., 2013). The possible cause in the results of this study was that people who work tend to experience stress and ultimately affect dietary pattern such as excessive food with high fat consumption, often eating snacks while at work and increased coffee and tea intake (Khushboo & Shuchi, 2012).
The highest number of complications among these obese pregnant women was preeclampsia 56.2%. A similar study was conducted at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, in 2013-2015 which found that the most frequent complications in obese pregnant women in the Outpatient Pregnancy Ward were preeclampsia, reaching 38 patients (25.8%), followed by dyslipidemia in 36 patients (24.5%), gestational DM in 27 patients (18.4%) (Haslinda & Hermanto, 2017). Preeclampsia is a pregnancy disorder that affects 2-8% of all pregnancies and remains a major cause of maternal and perinatal morbidity and mortality worldwide (Jeyabalan, 2013). The risk of preeclampsia increases 2-fold each increase in body weight by 5-7 kg/m 2 , while in grade III obesity, the increase reaches almost 5-fold. It may be caused by the increased risk of hypertension (Wafiyatunisa & Rodiani, 2016;Dodd, J.M & Briley, A.L., 2017).
If reviewed further in table 3, there was no significant relationship between age and complications in grade I obesity (p=0.764) and grade III (p=0.716) (table 4). However, there were significant differences between obesity rates (grade I and grade III) with complications p=0.035 (table 5).
There were 7 infants with macrosomia 4.3%. A previous study conducted at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, reported 5 (3.3%) cases of macrosomia, 3 (2%) cases of IUGR and congenital abnormalities and 1 (0.7%) fetus with IUFD amongst infants (Haslinda & Hermanto, 2017). The number of infants with low Apgar score was 48.1%. Among the population in Belgium, neonatal intensive needs were increased by 38% in obese pregnant women because the Apgar score of <7 increases by 31% (Minsart et al., 2013). A case study in Sweden reported that there was a two-fold increase of infants with low Apgar score in grade III obesity (Masturzo, B., et all, 2019). Whereas premature infants reaches 42.6%. The link between obesity and prematurity is not significant after several factors affecting the prematurity were excluded (multigravida, diabetes mellitus, hypertension and anemia) (Ju, A.C., et all, 2018).

CONCLUSION
The highest distribution of these obese pregnant women was in the age group of 21-34 years (56.8%), education level below college was 90.7%, and with work status was 58%. The highest proportion of complications in this maternal obesity was preeclampsia 56.2%. No significant association was found between age and complications in grade III obesity. It was found that there was a significant correlation between obesity levels (grade I and grade III) and complications. The outcome of macrosomia infants in pregnant women was 4.3%. The outcome of infants with low Apgar score was 48.1%. The outcome preterm infant was 42.6%. The number of stillbirth from cases of maternal obesity was 4.9%.