V17.3 Special Report: Maternal Obesity Analysis Sample

V17.3 Special Report: Maternal Obesity Analysis INTRODUCTION

le A review of the V17.3 NPIC Database revealed that 32,265 delivery discharges (10.1% of all deliveries) were coded with Obesity Complicating Pregnancy,

Childbirth and Puerperium (ICD-10 code O99.21x), the majority coded as complicating childbirth. This special report presents an analysis of maternal and

p neonatal outcomes for cases coded with obesity complicating childbirth at your hospital compared to the NPIC Database.

LITERATURE REVIEW

In the United States, between 1999 and 2010, the Body Mass Index (BMI) of women between the ages of 20-39 increased by 5.2% including an increased

m prevalence of women with BMI 35.0-39.9 and BMI 40 or greater (Centers for Disease Control, 2016; The American College of Obstetricians and

Gynecologists, 2015 )1.The World Health Organization (WHO) defines obesity as a BMI at and above 30kg m-2 and divides obesity into three classes : class

a 1 includes BMI 30-34.9 kg m-2, class 2 BMI 35-39.9 and class 3 includes those with a BMI 40 kg m-2 and above (often referred to as morbid obesity) (WHO, S 2000))2.

The American College of Obstetricians and Gynecologist recommends BMI calculation should occur at the outset of prenatal care and based upon this calculation, using the Institute of Medicine's guidelines for gestational weight gain, weight management strategies should be determined (ACOG, 2015). The IOM guidelines recommend the following total weight gain ranges for pregnancy: for underweight pre-pregnancy weight with a BMI< 18.5, a total pregnancy weight gain range of 28-40 pounds is advised; for normal weight, a gain of 25-35 pounds; for overweight, a recommended total weight gain of 15-25 pounds and for all classes of obese only a 11-20 pounds total weight gain in pregnancy (IOM, 2009)3.

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Though weight management is critical for obese women, restriction of weight gain and weight loss is not recommended and has been shown to result in small for gestational age infants (ACOG, 2015). A 2013 ACOG Committee Opinion (reaffirmed in 2016) stated that balancing the risks of fetal growth, obstetric complications and maternal weight retention is both necessary and challenging4. Understanding the relationship of parity , length of inter- pregnancy interval and excessive pregnancy weight gain is important in reducing risk of maternal obesity following delivery (Davis et al, 2014)5 Women who become obese during pregnancy remain significantly overweight or obese within 5 years after childbirth. (Davis et al, 2014).

In a review of the data from the Maine Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire from 2000-2010, a high pre-pregnancy weight and excessive gestational weight gain were predictive of infant prematurity, prolonged hospitalization, and birth weights of greater than 4000 grams (Baugh, Harris, Aboueissa, Sarton, & Lichter, 2016)6.

Obese women are at risk of prepregnancy conditions such as hypertension, diabetes, and cardiovascular disease. In addition, the risk of VTE appears to increase with increasing levels of obesity (Martin et al, 2014)7. Given these pre conditions, pregnancy can become a complicating factor. The risk of hypertensive disorders in pregnancy among obese women is increased. A study of over 16,000 pregnant women in the United States found a BMI of 30-

le 34.9 kg m-2 was associated with 2.5 times increased risk of diabetes and a BMI at or above 35.0 kg m-2 was associated with a 3.2 times increased risk as

compared with normal weight controls (Weiss et al, 2004)8. With increased maternal BMI, the risk of gestational diabetes also rose with obese women having a 2.6 times increase and morbidly obese women having a fourfold increase when compared with normal weight controls. (Weiss et al, 2004).A

p prospective cross-sectional study of 258 pregnant women that evaluated maternal ,delivery and neonatal outcomes showed a greater proportion of obese

mothers (13.4%) had large for gestational age babies (Vemini et al, 2016)9.This in turn increases the risk of cesarean delivery. The cesarean rate is close to 50% for morbidly obese women (Martin et al, 2014).

m Risk factors for the fetus include the known risks and complications of prematurity and maternal diabetes. In addition to the impact of macrosomia and

delivery by cesarean section, the fetus of the morbidly obese woman has a higher risk of fetal anomalies, including neural tube defects, craniofacial

a abnormalities and heart defects. (Martin et al, 2014). S Clearly obesity places pregnant women at great risk for pregnancy complications and adverse fetal outcomes. Strategies for the management of obesity in

women should begin prior to conception and continue through the postpartum period (ACOG, 2015). Providers expressed the benefits of group settings with social support as an ideal approach to address health issues in obese women (Kominiarek et al)10. Providing programs that are sensitive to the issues of body weight and image, culturally-tailored and provide education on healthy eating and exercise are a key component to addressing the complex problem of obesity in pregnancy.

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NPIC DESCRIPTION OF TABLES AND GRAPHS

The tables in this special report provide data for the period 10/1/16 - 9/30/17. Data for your hospital are compared to the averages for your peer subgroup and the NPIC Database.

Table 1: Overview

Section A displays the total number of deliveries.

Section B1 displays the total number of deliveries NOT coded with Obesity Complicating Pregnancy, Childbirth and Puerperium (O99.21x), the percent of total deliveries without this code, their average length of stay (ALOS) and the percent delivered by c-section.

Section B2 displays the total number of deliveries coded with Obesity Complicating Pregnancy, Childbirth and Puerperium, the percent of total deliveries with this code, their ALOS and the percent delivered by c-section. It further subdivides these cases in to those coded with: Complicating Pregnancy, unspecified or in the first, second or third trimester (O99.210 ? O99.213); Complicating Childbirth (O99.214); or Complicating the Puerperium (O99.215).

Most deliveries are coded with Obesity Complicating Childbirth and these cases are the focus of the rest of this Report.

le Section C displays the distribution of these deliveries by coded BMI category: Missing, BMI 19.9, 20.0-24.9, 25.0-29.9 (Overweight), 30.0-39.9 (Obesity

Class I and II) and 40.0 (Obesity Class III).

p Table 2: Outcomes by BMI Category

Section A groups the three lowest BMI categories together as BMI < 30 and displays the total number of deliveries, the percent of total coded with Obesity Complicating Childbirth, the percent delivered by c-section, c-section ALOS, and c-section disruption or infection of obstetrical wound rate. The same metrics are displayed for those delivered vaginally as well as the rate of coded Hypertension, Gestational Diabetes, Diabetes Mellitus, Early Onset

m of Labor, Postpartum Hemorrhage and Excessive Fetal Growth for the overall BMI category. (ICD-10 codes for these metrics are listed in Appendix).

Two linked Mother/Baby metrics are also displayed: percent coded with neonatal hypoglycemia and percent of infants admitted to the special care nursery. If your hospital does not provide a mother/baby linking variable you will not have data for these newborn metrics.

Sa Section B displays the same metrics as above for BMI category 30.0-39.9 and Section C displays the metrics for BMI category 40.0.

Graph 1: Cases Coded with Obesity Complicating Childbirth, Percent of total deliveries 2012 - 2017 (Q1-Q3) displays data for your hospital compared to the NPIC Trend Database. The Trend Database, made up of all NPIC members who have data for the entire 5 year and 3 quarter period shows a significant upward trend (from 5.6% in 2012 to 11.1 % in Q1-Q3, 2017). Graph 2: Cases Coded with Obesity Complicating Childbirth, Percent delivered by c-section 2012 - 2017 (Q1-Q3) displays data for your hospital compared to the NPIC Trend Database. The Trend Database shows a significant downward trend (from 60.4% in 2012 to 52.1 % in Q1-Q3, 2017).

Questions regarding this Special Report should be directed to mservices@. If you would like specific case lists for any of the metrics, please contact your Hospital Liaison/Data Coordinator.

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1 The American College of Obstetricians and Gynecologists. (2015). Practice bulletin: Obesity in pregnancy, 156. Obstetrics and Gynecology, 126, 1321- 1322. doi: 10.1097/AOG.0000000000001206.

2 World Health Organization. (2000). Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO Technical report Series 894> Geneva: World Health Organization.

3 Institute of Medicine. (2009). Weight gain during pregnancy: reexamining the guidelines. Washington, D.C.: National academic Press.

4 The American College of Obstetricians and Gynecologists. (2013, January, Reaffirmed, 2016).Committee Opinion. Weight gain During Pregnancy. Retrieved from -and- Publications /Committee.

5 Davis, E., Babineau, D., Wang., X., Zyzanski, S. , Abrams, B., Bodnar, L. & Horwitz, R. (2014). Short Inter-Pregnancy Intervals, parity, Excessive Pregnancy Weight Gain and Risk of Maternal Obesity. Journal of Maternal Child Health, 18,554-562. doi: 10.1007/s10995-013-1272-3

le 6 Baugh, N., Harris, D. E., Aboueissa, A., Sarton, C., & Lichter, E. (2016). The impact of maternal obesity and excessive gestational weight gain on

maternal and infant outcomes in Maine: Analysis of Pregnancy Risk Assessment Monitoring System results from 2000 to 2010. Journal of Pregnancy,

p 2016, 1-10. doi:10.1155/2016/5871313

7 Martin, A., Krishna, I, . Ellis,J., Paccione & Badell, M. (2014). Super obesity in pregnancy: difficulties in clinical management. Journal of Perinatology, 34, 495-502.

8 Weiss,J., Malone, F., Emig,D., Ball, R, Nyberg, D, Comstock, C et al. (2004). Obesity, obstetric complications and cesarean delivery rate- a population-

m based screening study. American Journal of Obstetrics and Gynecology, 190(4), 1091-1097.

9 Vermini, J., Moreli, J., Magalhaes, C., Costa, R., Rudge, M & Calderon, I. Maternal and fetal outcomes in pregnancies complicated by overweight and

a obesity. Reproductive Health,13:100. Doi: 10.1186/s12978-016-0206-0 S 10 Kominiarek, M., Gay, F., & Peacock, N. (2015). Obesity in pregnancy: A Qualitative Approach to Inform an Intervention for patients and providers.

Journal of Maternal Child Health, 19, 1698-1712. Doi: 10.1007/s10995-015-1684-3

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V17.3 Special Report: Maternal Obesity Analysis

Deliveries coded with Obesity Complicating Childbirth (ICD-10 O99.214)

Table 1: Overview

NPIC ID: SA1

Date Range of Hospital Data: 10/1/2016 - 9/30/2017 Subgroup: AR - Academic Regional

Hospital

Subgroup Average

A. Total Deliveries

2,694

4,141

B1. Deliveries not coded with Obesity Complicating Pregnancy, Childbirth and

2,309

Puerperium (O99.21x)

Percent of Total Deliveries ALOS Percent delivered by c-section

B2. Deliveries coded with Obesity Complicating Pregnancy, Childbirth and Puerperium (O99.21x) Percent of Total Deliveries ALOS

85.7% 2.4

32.4%

le385 14.3%

p 3.6

Percent delivered by c-section Distribution by code:

O99.210 - O99.213 Complicating Pregnancy, Unspecified, first, second or third trimester

m O99.214 Complicating Childbirth

O99.215 Complicating the Puerperium

a C. Deliveries coded with Obesity Complicating Childbirth (O99.214) S Distribution by BMI category:

68.8%

#

%

2

0.5%

382 99.2%

1

0.3%

382

#

%

Missing BMI

50

13.1%

BMI 19.9 (Z68.1)

0

0.0%

BMI 20.0 - 24.9 (Z68.20 - Z68.24)

0

0.0%

BMI 25.0 - 29.9 (Z68.25 - Z68.29) - Overweight

6

1.6%

BMI 30.0 - 39.9 (Z68.30 - Z68.39) - Obesity Class I and II BMI 40 (Z68.40 - Z68.45) - Obesity Class III

172 45.0% 154 40.3%

3,720

89.0% 3.1

29.6%

420

11.0% 3.9

51.6% %

9.0% 91.1% 0.1%

388 % 17.2% 0.0% 0.0% 0.7% 37.4% 44.7%

Database Average

3,605

3,242

89.5% 2.7

30.9%

363

10.5% 3.4

53.9% %

6.9% 93.3% 0.1%

346 % 28.5% 0.0% 0.2% 1.0% 28.7% 41.7%

Date Range of Comparison Data: 10/1/2016 - 9/30/2017 | 5

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