ACOG發表懷孕肥胖管理的指引


  June 9, 2009 — 美國婦產科學院(ACOG)發表一項實務公告,總結懷孕肥胖風險、減重手術之後懷孕的結果、以及提供懷孕時體重管理的建議、減重手術後生產的建議。這篇新指引登載於6月份的婦產科期刊(Obstetrics & Gynecology)。
  
  ACOG的Michelle A. Kominiarek醫師等人寫道,肥胖與降低生育力有關,主要是因為排卵減少或者停止排卵。增加妊娠糖尿病、子癲前症、剖腹產、感染症發病率等風險,這些與肥胖的關聯都已經被確認。肥胖病患比較可能早產、需要引產、需要更多氧氣,以及產程更長。
  
  為了檢視於1975年1月至2008年11月間以英文發表的相關文獻,作者們搜尋了MEDLINE資料庫、Cochrane Library以及ACOG的內部資源與文獻。回顧者將原始研究報告列為優先,也進行文獻回顧與評讀,但是他們並未納入研討會與科學討論會中的研究摘要。回顧者藉由使用美國預防服務小組的方法,評估這些研究的研究方法品質。
  
  同時也回顧ACOG與國家健康研究中心等專家機構的建議,藉由相關文獻的參考文獻找尋更多研究。如果沒有可信賴的研究發現,回顧者採用婦產科專家的意見作為他們的建議。
  
  根據有限的或科學證據等級B提出的特定結論以及臨床建議如下:
  * 減重手術後青少年懷孕率是一般青少年的2倍,這些病患特別需要避孕諮商。
  * 減重手術之後明顯吸收不良的病患,應考慮給予非口服的荷爾蒙避孕,因為這些病患口服避孕失敗風險增加。
  * 必要時需檢測治療藥物的濃度,以確保治療效果。
  
  根據共識與專家意見(證據等級C)的特定結論與臨床建議如下:
  * 當減重手術婦女懷孕且發生明顯腹部症狀時,應高度懷疑是胃腸道的手術併發症。
  * 即使術後體重迅速降低可改善生育力,仍不應以治療不孕症為目的來進行減重手術。
  * 減重手術本身不會造成剖腹產,但這些病患的剖腹產比率達62%。
  * 儘管對於接受可調式胃束帶手術病患的懷孕處置沒有共識,一般認為這些病患應及早與減重醫師諮商。
  * 對於接受過減重手術且有吸收不良和/或傾食症候群的病患,應考量採用其他的妊娠期糖尿病檢測方法。
  * 受孕之後,營養師諮商有助於遵守飲食處方,並且讓病患可以因應懷孕的生理變化。
  * 對於接受過減重手術的婦女,初懷孕時應考量進行廣泛之微量營養素不足的評估。
  
  至於提議進行的測量,指引的作者們建議有關懷孕時體重增加與營養的諮詢文件。
  
  作者們在實務公告中提出的其他觀點如下:
  * 懷孕時的肥胖特定併發症包括死產風險增加2到4倍。
  * 減重手術之後等12到24個月才受孕,有助於避免讓胎兒處在母親體重迅速降低的情況,而且能讓病患達到完整的減重目標。
  * 如果在減重手術之後12到24個月內即懷孕,密切觀察母親的體重與營養狀態,包括以超音波進行一系列的胎兒生長監測,或許會有助益,宜加以考量。
  * 減重手術之後,高血壓、妊娠前糖尿病、妊娠糖尿病、子癲前症的風險降低,胎兒生長過度與巨嬰症的風險也降低。
  * 減重手術之後,早期破水的風險增加,但是早產、先天異常、週產期死亡等風險並未增加。
  
  指引的作者們寫道,因為肥胖比率攀升,婦女健康照護提供者越來越可能面對正打算或已經進行減重手術的病患。減重手術者的懷孕諮商與處置相當複雜。雖然減重手術之後懷孕的結果一般還可接受,但仍可能發生營養與手術的併發症,其中有些併發症會有不好的結果。
  

ACOG Issues Guidelines on Managing Obesity in Pregnancy

By Laurie Barclay, MD
Medscape Medical News

June 9, 2009 — The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin to summarize the risks for obesity in pregnancy and outcomes of pregnancy after bariatric surgery as well as to provide recommendations for management during pregnancy and delivery after bariatric surgery. The new guidelines are published in the June issue of Obstetrics & Gynecology.

"Obesity is associated with reduced fertility primarily as a result of oligo-ovulation and anovulation," write Michelle A. Kominiarek, MD, and colleagues from the ACOG. "The increased risks for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity associated with obesity are well established....Obese patients are more likely to be admitted earlier in labor, need labor induction, require more oxytocin, and have longer labor."

To identify pertinent articles published in the English language between January 1975 and November 2008, the guidelines authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents. The reviewers gave priority to articles reporting findings from original research and also consulted review articles and commentaries, but they did not consider abstracts of research presented at symposia and scientific conferences. Using the method outlined by the US Preventive Services Task Force, the reviewers evaluated the identified studies for methodologic quality.

Recommendations from professional societies including ACOG and the National Institutes of Health were also reviewed. Reference lists from identified articles were used to help identify additional studies. When reliable research findings were not available, the reviewers used expert opinions from obstetrician-gynecologists as a basis for their recommendations.

Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:

• Because pregnancy rates after bariatric surgery in adolescents are twice that in the general adolescent population, contraceptive counseling is especially important in these patients.

• Administration of hormonal contraception by nonoral routes should be considered in patients with a significant malabsorption component after bariatric surgery because these patients have an increased risk for oral contraception failure.

• Testing drug levels may be necessary for medications in which a therapeutic drug level is critical to ensure a therapeutic effect.

Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:

• There should be a high index of suspicion for gastrointestinal tract surgical complications when pregnant women who have had bariatric procedures present with significant abdominal symptoms.

• Bariatric surgery should not be performed with the intention of treating infertility, although fertility may improve in association with rapid postoperative weight loss.

• Bariatric surgery in and of itself does not mandate cesarean delivery, although the rate of cesarean delivery in these patients may approach 62%.

• Despite the lack of consensus regarding the treatment of pregnant patients who have had an adjustable gastric banding procedure, it is suggested that these patients have early consultation with a bariatric surgeon.

• For patients who have had bariatric surgery that may be associated with malabsorption and/or dumping syndrome, alternative testing for gestational diabetes should be considered.

• After conception, consultation with a nutritionist may facilitate adherence to dietary regimens and allow the patient to cope with the physiologic changes of pregnancy.

• For women who have had bariatric surgery, a wide-spectrum assessment for micronutrient deficiencies should be considered at the beginning of pregnancy.

As a proposed performance measure, the guidelines authors suggest documentation of counseling regarding weight gain and nutrition in pregnancy.

Additional points made by the authors of the practice bulletin include the following:

• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.

• Waiting 12 to 24 months after bariatric surgery before conceiving may be helpful to avoid exposing the fetus to an environment of rapid maternal weight loss and to allow the patient to achieve full weight loss goals.

• If pregnancy occurs earlier than 12 to 24 months after bariatric surgery, closer surveillance of maternal weight and nutritional status, including ultrasound for serial monitoring of fetal growth, may be beneficial and should be considered.

• After bariatric surgery, there is a reduced risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia, as well as of large-for-gestational-age infants and macrosomia.

• After bariatric surgery, the risk for premature rupture of membranes is increased, but the risk for preterm delivery, congenital anomalies, and perinatal death is not increased.

"As the rate of obesity increases, it is becoming more common for providers of women's health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery," the guidelines authors write. "The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes."

Obstet Gynecol. 2009;113:1405-1413.

    
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