Obstetrics & Gynecology:
Inclusion of Body Mass Index in the History of Present Illness
Vintzileos, Anthony M. MD; Finamore, Peter S. MD; Ananth, Cande V. PhD, MPH
Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, New York and College of Physicians and Surgeons, Columbia University, New York, New York.
Corresponding author: Anthony M. Vintzileos, MD, Department of Obstetrics and Gynecology, Winthrop University Hospital, 259 First Street, Mineola, NY 11501; e-mail: firstname.lastname@example.org.
Financial Disclosure The authors did not report any potential conflicts of interest.
OBJECTIVE: To estimate the degree of association between body mass index (BMI) and some of the most common adverse outcomes and conditions in obstetrics and gynecology, and to compare it with the traditional descriptors such as age, gravidity, parity, history of preterm births, history of abortions or miscarriages, and race and ethnic status.
METHODS: Using a PubMed search, abstracts were identified that dealt with the associations between each of the descriptors (age, gravidity, parity, history of preterm births, history of abortions, racial and ethnic identification, and BMI) and a variety of adverse outcomes and conditions in both obstetrics and in gynecology.
RESULTS: Body mass index had the highest association with the most common adverse outcomes and conditions in obstetrics and in gynecology (53 of 57 [93%]) as compared with the traditional descriptors (age, 39 of 57 [88%]; gravidity, 19 of 57 [33%]; parity, 24 of 57 [42%]; previous preterm births, 22 of 57 [39%]; abortions, 14 of 57 [25%]; and race and ethnic status, 26 of 57 [46%]).
CONCLUSION: This study underscores the prominence BMI plays regarding its frequently cited associations with an array of obstetric and gynecologic conditions. Body mass index should be included in the opening statement of the history of present illness and in all communications of health care providers regarding obstetric and gynecologic patients.
The typical obstetric and gynecologic “history and physical” includes patient age, gravidity, parity, number of previous preterm births, number of abortions or miscarriages, number of living children, and race and ethnic identification in the opening statement of the history of present illness. The chief reason for including these descriptors in the opening statement of the history of present illness and in the situation, background, assessment, and recommendation communications1 is to provide the health care provider with a “snapshot of predictors.” It is hoped that such descriptions will immediately stimulate the thought process regarding differential or confirmed diagnosis, possible complications, and appropriate treatments or interventions. These descriptors are important for safe, effective, and consistent communication among health care professionals who provide care to obstetrics and gynecology patients.
These traditional descriptors have been extremely useful prognosticators and have facilitated communication for many years for obstetricians and gynecologists. However, given the increasing prevalence of obesity in many developed countries2 and its reported associations with adverse health outcomes and conditions, it makes sense to view body mass index (BMI, calculated as weight (kg)/[height (m)]2) as an emerging important descriptor.
The aim of this study was to determine whether BMI is associated frequently enough with obstetric and gynecologic adverse outcomes and conditions to be included with the other, more traditional descriptors used in the history of present illness or in situation, background, assessment, and recommendation communications.
MATERIALS AND METHODS
A PubMed search (performed May 16, 2012) using the key words “obesity and pregnancy” yielded 7,345 articles published between 1947 and 2012; 49% (n=3,600) of these articles were published over the past 7 years (2005–2012). Similarly, a PubMed search (performed May 23, 2012) using the key words “obesity and gynecology” yielded 2,268 articles published between 1954 and 2012; 60% (n=1,350) of these were published over the past 7 years (2005–2012). Through repeated PubMed searches of the abstracts published in years 2005–2012, we sought to identify abstracts in English, including those electronically published ahead of print, using as key words each of the descriptors (age, gravidity, parity, history of preterm births, history of abortions, race and ethnic status, and BMI) and the adverse outcomes or conditions that are depicted in Tables 1 and 2. The most recently published (starting from 2012) and relevant abstracts were reviewed to identify positive associations. Emphasis was given in the identification of articles describing more than one association or review articles that were reviewed in their entirety along with their references (19 such articles, published between 1993 and 2012, were reviewed). In instances in which the review resulted in questionable associations, the articles were discussed between the first two authors (A.M.V. and P.F.), and both had to be in agreement for the final disposition of the reported association being positive or negative. If no well-confirmed positive associations were identified after review of the 10 most recent and relevant abstracts, the associations were considered as being negative. Searches were not performed for associations judged to be well-known negative or common-sense negative. Although approval was sought from the Institutional Review Board of Winthrop University Hospital as an “exempt” status, the study was classified as “non-human subjects” research; so no Institutional Review Board was necessary.
The rate of association of each descriptor with each of the adverse outcomes or conditions was expressed as number and percentage. To compare the proportion of positive associations between each traditional descriptor and the adverse outcomes and conditions compared with the positive associations between BMI and the adverse outcomes and conditions, we constructed a series of two-by-two tables. The significances of associations from these two-by-two tables were based on χ2 test or the Fisher exact probability test. From these tables, we also derived the odds ratio and 95% confidence interval for each association, with BMI as the referent descriptor. Because all associations were planned a priori, none of the associations was corrected for multiple comparisons.
Table 1 describes the most frequent adverse obstetric outcomes or conditions and their association with the various descriptors, including maternal age, gravidity, parity, history of preterm delivery, history of abortions, race and ethnicity, and prepregnancy BMI. Of the 34 listed adverse obstetric outcomes or conditions, maternal age was linked to 20 (59%),3–15 gravidity was linked to 11 (32%),10,12,13,16–21 parity was linked to 14 (41%),10–12,14,18,19,22 history of preterm birth was linked to 18 (53%),9,20,22,23 history of abortions was linked to 8 (24%),17,19–21 and race and ethnicity were linked to 17 (50%).15,23–27 As shown in Table 3, BMI had the strongest association (32 [94%]) with adverse pregnancy outcomes or conditions.27–41 Most importantly, there was a dose--response relationship between increasing maternal BMI categories and outcomes with morbid obesity (BMI higher than 40) associated with increased rates of multiple adverse pregnancy outcomes such as fetuses large for gestational age (odds ratio [OR] 3.82), preeclampsia (OR 4.82), cesarean delivery (OR 2.69), antepartum stillbirth (OR 2.79), shoulder dystocia (OR 3.14), instrumental delivery (OR 1.34), meconium aspiration (OR 2.85), fetal distress (OR 2.52), and early neonatal death (OR 3.41), as compared with mothers with normal weights; the associations were similar for women with BMI between 35.1 and 40, but to a lesser degree.41
Table 2 shows the association of the descriptors with gynecologic outcomes or conditions. In two instances, the first two authors had to convene and discuss the final disposition of these two associations. Of the 23 listed gynecologic conditions, age is linked to 19 (83%),42–55 gravidity is linked to eight (35%),42,45,54,56 parity is linked to 10 (43%),42,45,48,50–52,54,56 history of preterm birth is linked to four (17%),55–58 history of abortion is linked to six (26%),54–56,58 and race and ethnicity are linked to nine (39%).42,47,49,51,52,56,59–61 The descriptor with the highest rate of association was BMI, with 21 of 23 (91%)42,44–48,50–56,58,62–67 of the gynecologic conditions.
Table 3 describes the frequency of association of each descriptor with obstetric, gynecologic, and combined conditions, and also demonstrates a comparison using BMI as the referent. Body mass index had the highest rate of association and reached statistical significance against all other descriptors for the combined obstetric and gynecologic conditions.
The primary finding of this study is that BMI is most frequently associated with combined obstetric and gynecologic adverse outcomes and conditions compared with other descriptors used in the past in the opening statement of the history of present illness. This finding is important, given the fact that most industrialized countries are currently experiencing an epidemic of obesity. Recent statistics indicate that more than one-third of women in the United States are obese,2 and that the prevalence of obesity is continuing to increase. As a result, the prevalence of obesity during pregnancy has dramatically increased and is now associated with an array of adverse obstetric and perinatal outcomes. The literature on obesity and its adverse effects on pregnancy outcome has expanded over the past 12 years. A Google search using the key words “obesity and pregnancy” resulted in 25,400,000 hits (performed May 16, 2012). Similarly, a Google search using the words “gynecology and obesity” resulted in 3,600,000 hits (performed May 23, 2012). There have been thousands of reports of associations of obesity with almost every adverse outcome. Because there is a documented linear dose--response relationship between frequently seen adverse outcomes, such as preeclampsia,68 it makes sense to use the specific BMI number in our communications rather than using the BMI categories. Despite these strong and associations, BMI is not currently included in the brief list of descriptors accompanying the opening statement of the history of present illness or in the “situation” part of the situation, background, assessment, and recommendation communication.
Currently, residents in obstetrics and gynecology at Winthrop University Hospital, Mineola, New York, are taught to include BMI in the opening statement of the history of present illness, as well as in all hand-off communications. The Joint Commission on Accreditation of Hospitals considers “standardized communication” as a prerequisite for patient safety and recommends situation, background, assessment, and recommendation communication as the best practice.69 The situation, background, assessment, and recommendation communication technique includes four components: situation (description of the patient by name, age, sex, gravidity, parity, ethnicity, hopefully BMI, and the reason for report); background (presenting symptom and a brief summary of the medical history); assessment (vital signs and clinical impression); and recommendation (specific action to be taken and urgency). The need for accurate communication among health care providers occurs constantly under a variety of settings such as emergency room, labor and delivery suite, or during changing shifts when specific patient information is passed from one caregiver to another. To ensure safe and effective care, the situation, background, assessment, and recommendation communication should provide the most consistent and precise exchange of patient information by using information-rich descriptors. In our view, BMI is the most informative descriptor, as compared with the other traditional descriptors that we use in everyday practice in obstetrics and gynecology. Given the recent obesity epidemic, it is prudent to include BMI along with our other traditional markers in the situation part of the situation, background, assessment, and recommendation communications. Our management should be drastically altered when a “36-year-old, white female, G3P1Ab1, BMI 42” presents for medical care as compared with a “36-year-old, white female, G3P1Ab1” with the same symptoms.
It is certain that similar convincing arguments can be made for BMI to be included in the history of present illness, as well as in the situation portion of the situation, background, assessment, and recommendation communication, in all communications regarding patients of other medical specialties. However, it is important for the obstetricians and gynecologists to lead this effort. Therefore, it will be prudent for all health care providers in obstetrics and gynecology to be encouraged to include BMI, along with the other typical descriptors, at the start of their communications to enhance awareness of potential complications and their prevention. This can only lead to improvement in women’s health care.
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