Northwestern Medicine launches program for patients with obesity concerns who are planning a pregnancy
Women with higher levels of body fat sometimes struggle to conceive and can face greater health risks during pregnancy. The PEARL program, which stands for Preconception and Early Assessment Care Rooted in Lifestyle Management, aims to help these patients have safe and healthy pregnancies.
Dr. Christina Boots, a reproductive endocrinology and infertility specialist and one of the clinicians in the program, estimates that about one-third of her infertility patients struggle with obesity. 'There's many more beyond that, who maybe don't meet the criteria for obesity, but are struggling with overweight or insulin resistance and prediabetes or any other metabolic health dysfunction that could be optimized before we go forward,' she said.
The PEARL program is designed to help patients with weight-driven concerns about any stage of pregnancy, from infertility to potential complications during delivery. It's open to patients with a BMI, or body mass index, above 27.
BMI is calculated from a person's height-to-weight ratio that can give a quick estimate of total body fat. The Centers for Disease Control and Prevention reports the average American woman's height to be 5 feet, 3.5 inches; at this height, a patient would have to weigh 157 pounds or more to qualify for the PEARL clinic.
'There's so much weight bias and stigma that goes into weight, and there's a lot of stigma and bias and blame that goes into infertility as well,' Boots said. 'We just thought we could do a better job than what we were in terms of counseling women.'
Boots said she and other physicians in the program have been unofficially working with patients on obesity concerns related to pregnancy for a few years. By making it an official program within Northwestern Medicine, clinicians are able to dedicate time to see these patients alongside their usual caseloads. 'We're just making sure that we're blocking out time so that there's always an opportunity for women to get in.'
The program currently has four clinicians. Boots addresses how a higher BMI may affect fertility. Dr. Veronica Johnson, an internal medicine practitioner with a specialty in obesity medicine, primarily focuses on preconception weight loss. Drs. Jacqueline Hairston and Michelle Kominiarek, as the two maternal-fetal medicine specialists, address patients who are close to becoming or are already pregnant.
Some patients are aiming to lower their BMIs in order to increase their fertility; others are aiming to manage BMI-related issues such as cholesterol, blood pressure and blood glucose to decrease risk before, during, or after pregnancy.
'The whole purpose of this is to address their concerns, and not to say, 'Hey, you need to lose a bunch of weight,'' Boots said. 'All the women in the program believe that there can be health at every size, and none of us believe that you must lose weight in order to get pregnant or to have a healthy pregnancy at all.'
One of Johnson's patients, who declined to share her name because of the personal nature of her treatment, came to the clinic through an internal referral from her Northwestern OB-GYN.
'I knew that, even more than having a child, I wanted to be healthy, and I knew that I was at a weight that was completely unhealthy,' she said. 'I was at my largest weight that I had ever been in my life, and I knew I needed to do something about it.'
Johnson's patient knew that she would likely have to go through in vitro fertilization because of her family history. IVF programs often have a maximum BMI limit around 40 or 50 — that's between 230 and 290 pounds at 5 feet 3.5 inches. When the patient first met with Johnson, her BMI was 58; with PEARL's help, she's reduced her BMI to 48 in less than a year. She began IVF in October, and is about to start her fourth cycle.
'It's mainly from an anesthesia perspective that that BMI threshold is there. It's not anything other than that, which is unfortunate, because we're trying to stay away from BMI, but then we're telling patients that you can't proceed with this procedure because your BMI is too high,' Johnson said.
Egg retrieval for IVF is often done under 'twilight' anesthesia, where patients are not completely under. Alongside requiring higher dosages of anesthesia, Hairston explained that patients with higher BMIs may already have breathing issues, and in the event of an emergency, the clinic team may not be able to secure their airway.
'I have a couple patients who had a BMI at 55-60, and I've gotten them, over the last year and some change, to lose 70-80 pounds, where their BMI is now less than 50. And they're really excited, and now they're in the place where they're going to proceed with IVF,' Johnson said.
While the PEARL program tries to emphasize lifestyle management before pharmaceutical intervention, sometimes using weight loss medication is the right choice. 'A lot of times, when patients come to see me, they're like, 'Well, I know how to eat, I know I should be exercising, and I've tried all those things, and it's really hard for me.' And that's when we need to think about other tools to kind of help them get to a healthier weight,' Johnson said.
At the same time, the effects of weight loss medications on pregnancies are still unknown. These medications are expected to be used continuously, Hairston said, but since there is not enough knowledge of how these medications affect a fetus, patients are advised to stop using them at least two months before attempting to get pregnant, and to stop using them immediately if they test positive while on the medication.
'Typically for patients with obesity, the recommended weight gain in pregnancy is 11 to 20 pounds. But you can imagine, some of our patients may have lost more than that as a result of these medications,' Hairston said. When patients stop using many of these medications, there is often rebound weight gain; Hairston said that doctors are still discovering how this factors into pregnancy weight gain.
Another concern the program hopes to address is the conflict between weight loss goals and the expected weight gain of pregnancy. Regardless of BMI, some weight gain is important for a safe pregnancy. That number is lower for patients with higher BMIs, but weight loss during pregnancy, especially in the third trimester, can adversely affect the baby.
Even for a patient who became pregnant with a BMI between 18.5 and 25, which is considered healthy, expected pregnancy weight gain is likely to push them into the overweight category.
'I really think the goal of this program is to be more inclusive in the care of patients with a higher BMI, so that they don't feel like they are being excluded from the pregnancy conversation. And we're excited to meet anyone who wants to meet with us,' Hairston said.
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