Peripartum Interventions for People with Class III Obesity: A Systematic Review and Meta-Analysis

Objective To identify evidenced-based peripartum interventions for people with a body mass index (BMI) ≥40kg/m2. Data sources PubMed, MEDLINE, EMBASE, Cochrane, CINAHL and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions. Study eligibility criteria Cohort and randomized controlled trials (RCT) that implemented an intervention and evaluated peripartum outcomes of people with a BMI≥40kg/m2 were included. The primary outcome depended on the intervention but commonly related to wound morbidity after cesarean delivery (i.e., infection, separation, hematoma). Study appraisal and synthesis methods Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios (RR) with 95% confidence intervals (CI) and heterogeneity (I2 statistics) were reported. Results Of 20,301 studies screened, 30 studies (17 cohort, 13 RCT) encompassing 10 types of interventions were included. Interventions related to delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, six types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared to planned vaginal delivery did not improve outcomes based on 3 cohort studies. One cohort study compared 3g to 2g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 RCTs, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort, 6 RCT) met inclusion criteria for the meta-analysis. Two RCTs compared subcuticular closure with suture vs. staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; RR 1.09, 95% CI [0.75-1.59], I2=9%). Prophylactic negative pressure wound therapy was compared to standard dressing in 4 cohort and 4 RCTs and found no differences in wound morbidity (cohort n=2200; RR 1.19, 95% CI [0.88-1.63], I2=66.1%) or surgical site infections (RCT n=1262; RR 0.90, 95% CI [0.63-1.29], I2=0). Conclusion Few studies address interventions in people with a BMI≥40kg/m2 and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic NPWT after cesarean delivery for people with a BMI ≥40kg/m2.