A pressing need for culturally relevant preconception programs for obese patients in the USA

J. O’Brien, J. L. Santolaya, R. Townsend, P. Matta,, J. Canterino, J. Santolaya-Forgas* | JNPM 2015;

Abstract. Obstetricians cannot make an impact on the disruptive effects of uncontrolled diabetes mellitus (DM) on early development due to the high-rate of unplanned pregnancies and frequently uncontrolled/undiagnosed Type 2 DM in young obese women [1–3]. We recently saw a 28-year-old-patient at 28 weeks gestation. Her 1st-pregnancy was complicated by DM, late onset preeclampsia and a term cesarean delivery. Class B DM was diagnosed during the 6-week-postnatal-visit and started metformin 500mg orally twice daily. Five months later, the patient became pregnant. During the 1st-trimester her BMI was 38, the HBA1C 8%, a singleton pregnancy with measurements appropriate for gestational age based on last menstrual period was confirmed sonographically. The noninvasive prenatal free fetal DNA screening test predicted a male fetus and low risk for Trisomy’s 21, 18, and 13. Throughout the second trimester she was transitioned to insulin – to a maximal dose of 30 NPH and 16 regular units every morning, and 36 NPH and 32 regular units at night to achieve glucose control. Several second trimester ultrasound and MRI evaluations identified alobar holoprosencephaly, cleft lip and palate. After genetic counseling, the patient expressed that termination of pregnancy was not an option. We explained that HBA1C of 8% correlated with a mean 1st-trimester blood glucose level of 180mg/dL (with each 1% higher or lower than 8% equal to a change of 30 mg/dL). We drew a graph depicting HBA1C of 5–6% associated with 2-3% risk for congenital anomalies and HBA1C of 10% with up to a 25% risk for congenital anomalies [2]. We used real-time ultrasound to point out the fetal abnormalities. The patient voiced understanding of the anticipated decreased life expectancy or profound mental retardation. Consultation with neonatology was organized where delivery room airway management and feeding challenges were addressed. At 33-weeks the patient’s blood pressure increased to 178/93 mmHg, proteinuria was detected and the patient complained of epigastric pain. We also noted fetal growth restriction with mild polyhydramnios. The patient opted for repeat Cesarean delivery knowing that obesity is an independent risk factor for surgical morbidity [4]. She insisted on full resuscitative measures by Neonatology. The newborn had a cleft lip and palate, a weight of 1440 grams and Apgar scores of 8 and 9 at 1 and 5 minutes. Holoprosencephaly was confirmed. The mother was discharged home in stable condition on post-operative day 3. The newborn lived in the Neonatal Intensive Care Unit for 10-weeks when the parents decided to stop supportive care. This scenario is not unique. We singled it out to illuminate the urgent need for culturally relevant programs that combine pregnancy planning and diabetes control in young obese patients in the USA. This will prevent the increased risk for congenital abnormalities/perinatal complications associated with uncontrolled pregestational DM and reduce healthcare costs. Indeed, with the rising numbers of obesity and diabetic mothers, it is paramount that we adopt new practice models to correct a relevant system failure in our health care systems [5].

*Corresponding Author: 

Corresponding author: Joaquin Santolaya, MD, PhD, Professor of Obstetrics, Gynecology and Genetics, Chair of the Center for OBGYN Research and Mentorship, Rutgers-Robert Wood Johnson Medical School, 125 Paterson St. Room 2151, New Brunswick, NJ 08901, USA. Tel.: +1 732 776 4755; Fax: +1 732 776 4754; E-mail: jsantolaya@meridianhealth.com.