By Katherine Rivlin, MD, MSc
Assistant Professor, Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
Dr. Rivlin reports no financial relationships relevant to this field of study.
SYNOPSIS: In a single-institution, retrospective review of 3,670 postpartum tubal ligations performed after vaginal delivery, there was no association between increasing body mass index and surgical morbidity.
SOURCE: Byrne JJ, Smith EM, Saucedo AM, et al. Examining the association of obesity with postpartum tubal ligation. Obstet Gynecol 2020;136:342-348.
Tubal sterilization remains one of the most commonly used methods of contraception in the United States.1 Offering this service immediately postpartum during hospitalization may improve access for patients who face barriers to postpartum follow-up. Postpartum tubal ligation is permanent and more than 99% effective at preventing pregnancy. However, as many as half of patients who request postpartum tubal ligation ultimately do not undergo the procedure.2
A primary risk factor for not accessing this procedure is a higher body mass index (BMI).3 Concerns about increased surgical morbidity may be at the root of these disparities. However, no data support or refute such concerns, since no study has evaluated the procedural risks of postpartum tubal ligation among patients with obesity.
In this retrospective review including all patients receiving obstetrical care at Parkland Hospital in Dallas between August 2015 and March 2019, data from the electronic medical record was extracted for patients who underwent a postpartum tubal ligation after vaginal delivery. The only patients excluded from analysis were those who underwent a planned additional surgery, such as an ovarian cystectomy, at the time of the tubal ligation. At Parkland Hospital, the postpartum tubal ligation method most commonly used is the Parkland technique, or a bilateral midsegment partial salpingectomy through a 2 cm to 3 cm infra-umbilical incision.
The study team calculated a composite morbidity for each patient, which summed all surgical complications and morbidities. Possible composite morbidities included blood transfusion; aborted procedure; intraoperative, anesthesia, and postoperative complications; return to the operating room; incomplete tube transection; or subsequent pregnancy.
Demographic characteristics, complications, and reproductive outcomes were compared across BMI categories. BMI was calculated from the patient’s height at the first prenatal visit or hospital encounter and the patient’s weight on admission to labor and delivery to reflect the patient’s habitus at the time of the tubal ligation. Since no definitions for obesity exist in pregnancy, the authors used BMI categories from the National Institutes of Health — underweight or normal weight (BMI < 24.9), overweight (BMI 25-29.9), class I obesity (BMI 30-34.9), class II obesity (BMI 35-39.9), and class III obesity (BMI > 40).
The mean BMI of the 3,670 subjects who met inclusion criteria was 32.2. Most subjects identified as Hispanic, and the majority had given birth at least three times. All but one subject received a tubal ligation using the Parkland technique. Composite morbidity occurred in 49 subjects (1.3%) and did not vary by BMI (P = 0.07). No deaths occurred, and no morbidity events occurred in patients who were super-morbid obese (BMI ≥ 50). Six subsequent pregnancies occurred in the study population — three full term, two ectopic, and one pregnancy of unknown location. Twelve subjects had incompletely transected tubes on pathology specimen. These outcomes did not vary by BMI category. Estimated blood loss and length of hospitalization were similar across BMI categories. Operative times increased from a median of 23 minutes in normal weight patients to 31 minutes in patients with class III obesity (P < 0.001).
COMMENTARY
As rates of obesity increase in the United States, with two out of every five women meeting criteria for obesity (BMI ≥ 30), so too does the potential for bias and stigma surrounding this common medical condition. Patients with obesity are vulnerable and often do not receive optimal care.4 This phenomenon has been documented in the setting of postpartum tubal ligation. In one study, patients with a BMI of 40 or higher were 3.7 times less likely to have a postpartum tubal ligation than patients with a normal BMI. Patients who seek but are denied postpartum sterilization have higher rates of pregnancy in the subsequent year than those who do not seek sterilization. Therefore, The American College of Obstetricians and Gynecologists (ACOG) considers postpartum tubal ligation to be an urgent surgical procedure.5 Although not all patients with obesity will experience negative medical outcomes, obesity in pregnancy is associated with increased pregnancy risks, including early pregnancy loss, prematurity, low birth weight, gestational diabetes, hypertension, and cesarean delivery.6 By disproportionally denying postpartum tubal ligation to patients with obesity, providers are disproportionally putting these patients at risk of subsequent pregnancy, as well as the possible sequelae of such pregnancies.
Although retrospective and limited to a single institution, this study has a large sample size. The authors noted that their sample size is more than twice that of the postpartum partial salpingectomy cohort in the U.S. Collaborative Review of Sterilization data set, a commonly cited source for the cumulative 10-year pregnancy risk after postpartum tubal ligation.7 Study subjects were predominantly Hispanic, which may limit generalizability. In addition, most tubal ligations were performed using the Parkland technique — which may not reflect practices at other institutions, such as the commonly used modified Pomeroy technique and bilateral salpingectomy. Finally, the authors could only analyze those patients who successfully accessed postpartum tubal ligation, and not those at Parkland Hospital who were denied care, which may bias results.
The authors concluded that even for patients in the highest BMI category, postpartum tubal ligation is a safe procedure, which is vitally important to clinical practice. On a busy labor and delivery unit, when decisions are made about prioritizing procedures, concerns about surgical risk and complications may motivate decisions. This study argues that BMI should not play a role in this decision. In their Committee Opinion on Ethical Considerations for the Care of Patients with Obesity, ACOG recommends that providers be aware of implicit bias toward patients with obesity, that they engage in self-reflection, and that they take steps to ensure that such bias does not interfere with high-quality care.8
Providers who find themselves denying postpartum tubal ligation to patients with obesity also should consider the risks to their patients that result from withholding such care.
REFERENCES
- Daniels K, Abma JC. Current contraceptive status among women aged 15-49: United States, 2015-2017. NCHS Data Brief No. 327. Centers for Disease Control and Prevention National Center for Health Statistics. December 2018. https://www.cdc.gov/nchs/data/databriefs/db327-h.pdf
- Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril 2010;94:1-6.
- Flink-Bochaki R, Flaum S, Betstadt SJ. Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery. Contraception 2019;99:98-103.
- Spahlholz J, Baer N, Konig HH, et al. Obesity and discrimination—a systematic review and meta-analysis of observational studies. Obes Rev 2016;17:43-55.
- Committee on Health Care for Underserved Women. Committee opinion no. 530: Access to postpartum sterilization. Obstet Gynecol 2012;120:212-215.
- [No authors listed]. ACOG Practice Bulletin No. 156: Obesity in pregnancy. Obstet Gynecol 2015;126:e112-126.
- Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161-1168.
- [No authors listed]. ACOG Committee Opinion No. 763: Ethical considerations for the care of patients with obesity. Obstet Gynecol 2019;133:e90-e96.
In a single-institution, retrospective review of 3,670 postpartum tubal ligations performed after vaginal delivery, there was no association between increasing body mass index and surgical morbidity.
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