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��ࡱ�>��	XZ����W�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������y�	���bbjbj��.h�{�{�J���������RRRRR����ffff$�$fN0��������y{{{{{{$~�0"r�iR������RR���AAA��R�R�yA�yAAA�������N�n�����#�Ae0NA�""�"A�"RA$��A�������A���N�������������������������������������������������������������������������"����������$:Introduction : obesity is a common issue among women of childbearing age. In the United States, 40% of pregnant women are overweight and 28% obese [1]. In France, the respective rates are 15.4 and 7.4% [2]. In Martinique, F.W.I, the prevalence is close to American statistics with 25.5% of woman who are obese and 29.4% who are overweight [3]. Obesity is a risk factor for various obstetrical complications such as gestational hypertension, preeclampsia, diabetes mellitus, fetal macrosomia and malformations, intra-uterine fetal demise and caesarean section delivery [1, 4]. Success rate of a trial of labour after a first caesarean section is much lower in obese parturients compared with their non-obese counterparts (respectively 60.8% and 84.8%) [5]. A previous caesarean section is the main indication for a caesarean delivery among multiparous obese patients [6]. Higher rates of caesarean delivery are largely stated throughout the studies on this topic in obese patients [1, 4, 7], with a linear relationship between BMI and caesarean section rate (+7% per unit of BMI) [4], but the explanation for this observation remains partly elusive. Numerous complications of pregnancy which are encountered with an increased frequency in obese patients are responsible for the higher rate of caesarean section [4]. Nevertheless, an independent link between obesity and caesarean delivery is observed by many authors [8, 9] in large studies on the subject. We sought to determine if such a link exists in our population.
Material and methods : deliveries taking place at the University hospital in Fort de France, F.W.I, were prospectively recorded between January, 1st and September, 30th 2010 Pregnancies with fetal abnormalities, non-cephalic presentation, placenta previa, scarred  uteri as well as multiple pregnancies were excluded. In-Patients were categorized in four groups, according to their body mass index (BMI) : group 1 (BMI inferior to 25kg/m�), group 2 (BMI e" 25 kg/m� and < 30 kg/m�), group 3 (BMI e" 30 kg/m� and < 40 kg/m�) and group 4 (BMI e" 40 kg/m�). Size and weight were measured at the first prenatal visit. Several demographic and medical features were recorded (maternal age, parity, educational level, marital status, history of hypertensive disorder or diabetes, smoking habits and place of birth (French West Indies, metropolitan France, Caribbean islands or others)). Gestational diabetes was diagnosed after oral glucose charge test after administering 100 g of glucose. Hypertensive disorder during pregnancy could be chronic hypertension (blood pressure higher than 140/90 mmHg at least two times before 20 weeks GA), gestational hypertension (same criteria diagnosed after 20 weeks GA) or preeclampsia (hypertension plus proteinuria higher than 300 mg per day). Gestational weight gain was recorded. Term at delivery was determined by the date of last menstrual period but nearly always confirmed by ultrasonography performed before 15 weeks GA. Labour initiation was described as spontaneous or induced. Route of delivery (caesarean section, assisted vaginal or spontaneous vaginal delivery) and its indication were recorded. Shoulder dystocia was present when a specific manoeuver was necessary to assist delivery. The modalities of third stage of labour and the existence of a post-partum haemorrhage were analysed. Neonatal Apgar scores and weights were recorded, as well as neonatal transfer to pediatric unit. The main goal of the study was to determine the influence of maternal BMI category on route of delivery, after controlling for other parameters. In the univariate analysis reported here, quantitative variables were compared using Student's t test or Mann -Whitney's test. Discrete (qualitative) variables were compared using the �� test or Fisher's exact test. We conducted a stepwise multivariate analysis with bidirectional elimination to establish the proper role of obesity in the occurrence of a caesarean section. The same method was used to determine the proper role of obesity in the occurrence of assisted delivery.  Before modelling, we checked for the absence of interactions between the explanatory variables. The results are considered significant in our study if the first species risk is less than 5 %. All calculations were performed with the software Stata V10. College Station, TX: StataCorp LP. Ethical approval was obtained from the institutional review board of the French National College of Obstetricians and Gynecologists (CNGOF) (CEROG, number OBS 2013-08-07).
Results : During the nine months of the study, 1,291 patients gave birth in the maternity of the University Hospital of Martinique . The patients' BMI distribution in four groups were as follows: 791 patients in group 1 (BMI < 25 kg / m�) including 34 with a BMI <17 kg / m� , 61% of the total number, 304 in group 2 (BMI e" 25 kg / m� and < 30 kg / m�), 24 % of the total, 171 in group 3 (BMI e" 30 kg / m�) 15 % of the total and 25 in group 4 (1.93%) with a maximum BMI of 52.5 kg / m�. The socio-demographic variables and history of diabetes or hypertension in the four groups are displayed in Table 1. Parity varies from group to group. There was a higher proportion of nulliparous women in group 1 compared to the overweight and obese groups. Obstetrical care was comparable in the three groups (the proportion of patients who had less than 4 antenatal consultations was respectively 7.1%, 4.9 %, 8.8 % and 4.2% in groups 1, 2, 3 and 4, i.e. without significant differences). The average weight gain during pregnancy was lower in group 3 (mean IC95 5.7 kg [4.7 to 6.7]) and 4 (1 kg [(-1.5) -3.5]) than in group 1 (mean IC95 12.3 kg [12 to 12.7], p <0.001). Weight gain in group 2 was also lower (IC95 10 kg [9.2 to 10.7]) than in group 1 (p < 0.001). Complications that occurred during pregnancy are listed in Table 2. Induced labour was more frequent in groups 2 and 3 than in group 1. The difference was not significant between group 1 and 4, which can be explained by lack of power due to the low number of patients in group 4 (table 2). However, when we exclude induction of labour motivated by diabetes or a hypertensive disease during pregnancy, groups 2, 3 and 4 do not require  induction more often than group 1 (respectively OR = 1.38 [0.8 to 2.4], OR = 1.36 [0.8 to 2.3] and OR = 1.16 [0.26 to 5.18]) . Table 3 shows the course of events during labour and delivery in the three groups. The nulliparous patients are also reported there as well as the rates of shoulder dystocia, perineal lesions and postpartum hemorrhage. Fetal weight at birth was similar in groups 1 and 2 (respectively 3079.6 g [3041.3 to 3117 8] and 3147.9 g [3077.7 to 3218.2]). However, it was significantly higher in groups 3 (3199 g [3099-3298]) and 4 (3301 [3139-3462]) compared to group 1.
The multivariate analysis of the factors associated with C-section (Table 4) yields an adjusted odds ratio (aOR) of 52.3 [18.7 to 146.2] for preeclampsia. The adjusted OR of overweight (0.64 [0.33 to 1.24]) and obese patients (0.64 [0.29 to 1.39]) do not show an independent link between maternal weight parameters and cesarean section. The analysis of the c-section indications (dystocia, abnormal fetal heart rate, fetal or obstetrical pathology, failure of labour induction or obstetric pathology contraindicating vaginal delivery (eg placenta previa)) reveals no differences in distribution between the four groups. The multivariate analysis of the parameters associated with assisted delivery (Table 4) showed a significant correlation between low educational level and assisted delivery (aOR = 3.92 [1.04 to 14.8]). Neither BMI between 25 and 29.9 kg/m� (aOR = 0.9 [0.44 to 1.81]) nor obesity (aOR = 1.36 [0.63 to 1.96]) appear to be independent risk factors for instrumental extraction.

Comment�: overweight and obese patients in our population have several obstetrical complications which have been largely described elsewhere and are, to this point of view, comparable to obese women in other settings [8-13]. Mean maternal age and parity reveal higher among obese and overweight women, as weight is commonly acquired during previous pregnancies [4, 11, 12, 14, 15]. Consequently, age and parity are classical confusing factors when analysing the links between body mass index and obstetrical complications [4, 9, 14]. Diabetes and chronic hypertension are also encountered more frequently in the index as well as in previous pregnancies in our obese and overweight population, as classically observed elsewhere [11, 16, 17]. The lack of significance for previous hypertensive complications in the morbidly obese group is probably attributable to a lack of power. Pregnant patients with BMI superior or equal to 25 kg/m� constitute 39% of our cohort. This rate is higher than those reported in other countries such as United Kingdom [9], Canada [12], North West USA [8] or continental France [2, 4]. Number of medical visits during pregnancy is not inferior in our overweight and obese populations than for women with normal BMIs. Weight gain during pregnancy appears lower in our patients with excessive BMIs than in pregnant women with normal BMIs. The observed mean weight gain in the obese subgroup is in the range of ideal weight gain recommended by the American Institute of Medicine [18]. This moderate weight gain may have contributed to improvement of selected obstetrical outcomes, such as caesarean section rate which has been demonstrated to be negatively correlated with weight gain among obese patients during pregnancy [18]. Gestational hypertension is increased in our obese population, with an Odds ratio of 16 which is very comparable to what has been described in other populations [1, 4, 7-11]. The incidence of gestational hypertension in our population is positively correlated with maternal BMI, as generally observed [1, 12, 16]. Conversely, we did not notice a significant difference for preeclampsia throughout BMI groups, albeit preeclampsia rate in obese patients is almost twice the rate of patients with normal BMI. A lack of power may explain this result. Incidence of preeclampsia at 3% among our obese women is somewhat lower than in other series [7, 14]. Morbidly obese women account for only 12.7% of our obese women and this may partly explain the lower than expected incidence of preeclampsia. Premature delivery rate before 35 of 37 weeks of gestational age is not different between our four BMI groups. The link between obesity and premature delivery is controversial, some authors describe an increased rate of fetal prematurity, persisting after adjustment on hypertensive diseases and diabetes [8, 19], others denying any influence of maternal obesity with premature births [4, 9, 10, 16]. Influence of maternal obesity on premature delivery may vary according to parity [14] or to BMI [1].
In our series, in multivariate analysis, only preeclampsia is an independent risk factor for caesarean delivery whereas obesity is not. The absence of link observed in our series between obesity and caesarean delivery is unusual. Caesarean section rate has generally a linear positive link with maternal BMI [1, 4, 7-12, 16]. In morbidly obese patients, caesarean section rates up to 50% are encountered in certain series [1, 10]. Obstetrical complications met during pregnancy in obese patient may partly account for the higher caesarean section rate (hypertensive disorders, diabetes, fetal macrosomia) but nevertheless, caesarean delivery remains more prevalent in obese women even after controlling these pathologies [7-10]. Success of trial of labour after caesarean section is also reduced among obese women when compared to patients with normal BMI and part of the higher rate of caesarean section in this population is attributed to a more liberal decision in favour of repetitive caesarean sections when dealing with obese patients, as emergent caesarean sections on a scarred uterus may prove more technically difficult and hazardous in this situation [1, 5]. We excluded scarred uteri from our series, excluding previous caesarean sections as an indication for this route of delivery. Arrest of progress during labour seems to drive caregivers to perform a caesarean section more liberally in obese than in non-obese patients [6, 12, 20]. Thus, the choice of the route of delivery in obese patients is partially subjective and obesity appears to have a negative impact on the trust of the attending obstetrician on success of vaginal delivery. Instrumental delivery displays similar rates between our four BMI groups. Data on the relationship between maternal BMI and instrumental delivery are conflicting, some authors find no difference [4, 10], others point to an increased rate of instrumental deliveries exclusively in morbidly obese patients [1], others state a lower rate of instrumental deliveries among obese patients [17]. The higher prevalence of fetal macrosomia among obese patients may render caregivers reluctant to use extractors, fearing an increased risk of dystocia and subsequent trauma [20].
Neonatal wellbeing was not altered in the groups of obese or overweight patients. No difference in 5 minutes Apgar scores was observed. There were more transfers for suspected maternal-fetal infection in the obese patients group, and a trend toward more transfers for prematurity, compared with patients with normal BMI. A difference in transfer rate for suspected infection was observed in the morbidly obese group but did not reach statistical significance, probably for a lack of power due to the low number of patients in this group. Several neonates transferred for suspicion of infection did not have clinical (i.e. fever, prostration�) nor biological signs of sepsis but were monitored because the conditions of delivery were considered at risk for sepsis (i.e. rupture of membranes superior to 12h before delivery, stained amniotic liquor, long duration of labour�). Suspected infection thus remains a largely subjective diagnosis. We could not obtain accurate data on the final diagnosis of sepsis for many neonates. We can notice than although prematurity was not more prevalent in the obese group, neonates born prematurely were more liberally hospitalized in neonatal unit than when mothers had a normal BMI.
Our study has potential biases and some data obtained from medical records may be inaccurate. We nevertheless took into consideration objective outcomes to limit imprecision. As stated earlier, we chose to exclude women with a previous caesarean delivery, which may reduce the impact of our conclusions on the relationship between excessive BMI and route of delivery, but the link between obesity and repetitious caesarean delivery is quite specific, and inclusion of these patients may have proved misleading. Exclusion of patients with previous caesarean section led to a lower final caesarean section rate than expected in the whole population (15.6% in our department in 2013).
Obesity in our series is not an independent risk factor for caesarean section delivery nor instrumental delivery. We have a rather low caesarean section rate in our department compared to French statistics and we have to deal with a population where obesity is highly common. This may have an influence on our practice. Considering the difficulties to manage obese patients with scarred uteri, it seems of outmost importance to avoid undue first caesarean section in this population [5]. Limitation of weight gain in our obese patients may have had a positive impact on the caesarean section rate as well [21].
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18	{

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