Obstetric anesthesia for the obese

and morbidly obese patient

: an ounce of prevention is worth more
than a pound of treatment
R3
Acta Anaesthesiol Scand 2008; 52: 6-19
Introduction
Introduction
Obesity
Global burden of chronic disease and disability
Dramatically increasing rate of obesity
Also extends to women of reproductive age
Pre-pregnancy obesity : 13%(93-94)22%(02-03)
Increase the risk for c/sec
need for anesthesia
Maternal and fetal morbidity
Maternal and fetal morbidity
Risk of pre-pregnancy maternal obesity
Pregnancy-induced HTN
Venous thromboembolism
Labor induction
Cesarean delivery
Wound infection
Gestational diabetes
Fetal macrosomia
Soft tissue dystocia, arrest of labor
Infant of the obese parturient
Risk for head trauma, shoulder dystocia, brachial plexus
lesions, fractured clavicle
Birth defects esp. neural tube defects
Ultrasonographic is often more difficult
Pregnancy, obesity and
physiology
Pregnancy, obesity and physiology
Both obesity and pregnancy
Many of similar physiologic changes
Pregnancy, obesity and physiology
- continued
Dyspnea
Even in early pregnancy
Increased alveolar ventilation
Secondary to progesterone effects on the respiratory center in the
brainstem
Decrease in ERV, RV, FRC (15-20% below)
By the 5
th
month, mechanical effects of uterus
Obesity in non-preg. : also decrease in ERV, RV, FRC
But, obese pregnant women : FRC does not significant additional
reduced
Supine & Trendelenburg position worsen lung volumes
This study performed in sitting position
Relaxing effect of progesterone on smooth muscle
FRC may fall below the closing capacity
Increased venoarterial shunt
Work of breathing is increased
Increases O
2
consumption & CO
2
production
PRE-OXYGENATION is important
Pregnancy, obesity and physiology
- continued
Obstructive sleep apnea
Physiologic protective change in non-obese
pregnant women high progesterone level
Not uncommon in the obese pregnant women
Increased systemic HTN, pulm. HTN
Coronary artery disease, stroke & cardiac arrhythmias
Maternal oxygen desaturation
fetal hypoxia & poor fetal growth
Sx : loud snoring & excessive daytime sleepiness
In pregnancy, daytime fatigue is very common
Continuous positive airway pressure (CPAP)
Safe treatment with minimal adverse effects
Pregnancy, obesity and physiology
- continued
Significantly increased cardiac output in pregnancy
Throughout the 2
nd
trimester, 50% greater
Further increases during labor
40% in the 2
nd
stage
Uterine contractions : additional 10-15% increase
In the immediate post-partum period
Cardiac output peaks at 75% above pre-delivery values
Obesity increases even further
Every 100g of fat increases cardiac output by 30-50ml/min
In non-obese pregnant : reduction in afterload
In obese pregnant : afterload reduction may be impaired
Increased pph resistance, greater conduit artery stiffness
Pregnancy, obesity and physiology
- continued
Obesity is risk factors of CAD, CVA
Higher prevalence of HTN, DM, hyperlipidemia, poor
cardiac function in obesity
Secretion of human placental lactogen, hCG,
steroid hormones during pregnancy
increase resistance of target tissue to insulin
Estrogen : accelerates insulin secretion
Lead to hyperinsulinemia & fat deposition
very similar pathophysiological status of obesity
Risk factor for peripartum cardiomyopathy
Sudden circulatory changes associated with positional
change SUDDEN DEATH
Pregnancy, obesity and physiology
- continued
Aortocaval compression by uterus in supine
position during 2
nd
half of pregnancy
severely reduce cardiac output & placental
perfusion
Greatly exacerbated in obese parturient
More prone to develop fatal arrhythmias
Even minor or borderline Q-T interval
prolongation
can result in sudden cardiac death
Q-T interval prolongation drugs are best avoided
Erythromycin, droperidol, granisetron, nicardipine,
methadone and others
Pregnancy, obesity and physiology
- continued
Increased risk for aspiration and
Mendelsons syndrome
Obese non-pregnant Pts had both a larger
volume & a lower gastric pH
Higher incidence of hiatus hernia & elevated
intra-gastric pressures in obese patients
Obesity is major risk factors for diabetes
Delayed gastric emptying
Obesity pre-disposes to difficult or failed
intubation
Anesthetic management of
the obese parturient
Analgesia for labor
Increased incidence of fetal macrosomia
More painful contractions and complicated labor
Regional analgesia offers many advantages
Can be very challenging in the obese parturient

No anesthetic technique is without difficulty
in the obese parturient
Analgesia for labor
- continued
General anesthesia for c/sec
Much higher risk of maternal mortality
Secondary to the inability to establish or maintain a patent
airway
Obesity : maternal mortality with failed intubation &
aspiration
Failed intubation in the morbidly obese parturient
: as high as 33%
To avoid these complications
For those patients at risk, consideration should be given to
the planned placement in early labor of an epidural catheter,
with confirmation that the catheter is functional.
The American College of Obstetricians and Gynecologists (ACOG)
avoiding the need for general anesthesia

Continuous lumbar epidural
analgesia
Epidural placement is often difficult in morbidly obese patients
because anatomical landmarks are obscured
Identification of midline can be challenging
Authors prefered sitting position
Line joining occiput or prominence of C7 & gluteal dleft
Approximate position of midline
Distance from skin to epidural space was shorter
Weight and BMI were positively correlated with distance
Hamza et al.
In obese, excess body mass can be distributed disproportionately
Only a few patients have an epidural space deeper than 8cm
Use a standard epidural needle for the 1
st
attempt
Parturient assists verbally by indicating
Feelings the needle more on left or right side of the spine
Identification the midline of their own backs
Light touch sense was the most accurate
Probe for posterior process of lumbar vertebra
8.5cm, 26G needle
Continuous lumbar epidural
analgesia - continued
Ultrasound imaging
Paramedian longitudinal
approach
Quality of images are
superior
Transverse approach is
often easier to perform
Authors experience
More logical choice,
because midline
approach for epidural
needle insertion is often
preferred
Often difficult to identify
the shadow of spinal
process in obese
Instead, symmetry of
paraspinous muscles can
be used
Continuous lumbar epidural
analgesia - continued
Risk of epidural catheter dislodgement
Sliding of skin over subcutaneous tissue
3cm skin movement in some patients
So, they routinely place catheters 7cm in epidural space
- Iwama and Katayama
Position change from sitting to lateral recumbent
Epidural catheters not fixed at skin could move 1-2.5cm inward
Before securing the catheter to skin, place the parturient in
lateral position
- Hamilton et al.
Combined spinal epidural (CSE)
anesthesia
CSE
Faster onset of effective pain relief
Effect of intrathecal opioids remains controversial
Uterine hyperactivity and fetal heart rate abNL
Location of epidural catheter is initially uncertain
Initial epidural catheter failure rate is 42% in
morbidly obese
6% in control patients
- Hood et al.
Significantly lower epidural analgesic requirements
in obese parturients
Probably secondary to reduced volume in their epidural
and subarachnoid space
d/t increased abdominal pressures
Continuous spinal analgesia
working catheter in case an emergency
Also considered when accidental dural puncture occurs during
intended epidural placement
Should be clearly labeled
PDPH
30-70% with 17G Tuohy needle, accidental dural
puncture - Faure et al.
Risk of PDPH is significantly decreased in morbidly obese
parturients
Large abdominal panniculus reduce degree of CSF leakage
Although controversial, PDPH seems to be decreased in
CSA
Catheter initially acts as a barrier to CSF leakage & later causes an
inflammatory fibrous reaction - Denny et al.
Puncturing dura with bevel was parallel to longitudinal
axis of back decreases PDPH - Norris et al.
Anesthesia for cesarean
delivery in the obese and
morbidly obese patient
Cesarean delivery
Obesity increased incidence of c/sec
Increased maternal mortality, morbidity, op. Cx
Excessive blood loss
Increased op. time
Increased incidence of postop Wd infection &
endometritis
Antepartum anesthesiology consultation!!!
Suitable bed and operating table
Use of two operating tables (side by side)
Use another set of armboards
Evaluate the patients ability to lie supine
Sleep apnea : CPAP pre-operatively
Nasal CPAP at 10-15 cmH
2
O
Difficulty with NIBP monitoring
Regional anesthesia
Use decreased amounts of neuraxial local
anesthetics in obese patients
Lower average CSF volume
Increased abdominal pressure
Engorgement of epidural venous plexus & increased
epidural space pressure
compression of inferior vena cava
Spinal anesthesia
Widely used for elective c/sec
Increase the risk of a high spinal block
Surgery may be prolonged, requiring additional
anesthesia in obese patients
Regional anesthesia
- continued
Epidural anesthesia could overcome this problem
Inadequate in more than 25%
difficulty in blocking the sacral roots
CSE technique
Quality of a spinal block with Flexibility of an epidural
catheter
Reduce risk of a total spinal block
But, initially unproven
CSA can overcome these disadvantages
Thorough assessment of block before surgical
incision
Conversion to general anesthesia during surgery
catastrophic sequelae

General anesthesia
Prevention of acid aspiration
30ml of non-particulate antacid
0.3M sodium citrate
Optimal time : a half an hour before the procedure
For elective c/sec
H2 antagonist or proton pump inhibitor
Evening before & again 60-90min before induction
Prokinetic agent : metoclopramide
General anesthesia
- continued
Difficult airway
Large neck circumference and/or high Mallampati score
Preoxygenation rapid desaturation in obese Pts
3-5min of 100% O
2
breathing at normal TV
Oxygen flow of 5 l/min
95% complete within 2-3min after breathing
8 deep breaths within 60s at O2 flow 10 l/min
Higher P
a
O
2
& slower Hb desaturation
More suitable for obstetric emergency
More effective in sitting or 25 head-up position
Need for additional pair of experienced hands
Failed intubation, difficult mask ventilation
Need for rapid sequence induction with cricoid pressure
Awake fiberoptic intubation in elective cases
LMA can be life saving in failed intubation
Cannot prevent gastric content aspiration
General anesthesia
- continued
ramped position
Blankets underneath patients upper body and head
Horizontal alignment if achieved
Between external auditory meatus & sternal notch
Improves laryngeal view than sniff position
General anesthesia
- continued
Altered distribution & response to anesthetic
drugs
Thiopental : higher initial induction dose
Increased blood volume, cardiac output, muscle mass
Delayed arousal in failed intubation
Propofol : no difference in initial distribution volume
Induction dose based on lean body weight
Succinulcholine
Increased level of pseudochonlinesterase activity & volume
of ECF in obesity
Dose based on total weight in non-pregnant patients
Prenancy reduces pseudochonlinesterase activity
1.0-1.5 mg/kg (maximum 200mg)
General anesthesia
- continued
For optimal uterine involution
Decrease or discontinue of volatile-halogenated agents
Increase the concentration of N
2
O
In obese, high concentration of N
2
O may not be possible
Desflurane : safe supplement to N
2
O-O
2
mixture
Small doses of opioids, midazolam
To reduce intra-op maternal awareness
In obesity, higher loading doses of midazolam needed
Prolonged sedation should be expected
Extubation
Before extubation, emptying stomach with orogastric tube
may helpful
Extubation should only fully awake, adequate reversal of
neuromuscular blockade & semi-upright position

Post-partum morbidity
Post-partum morbidity
Many post-partum Cx occur more frequently in morbidly
obese women
Hemorrhage
Type & cross match
Endometritis & wound infection
Prophylactic antibiotics after clamping umbilical cord
Atelectasis in general anesthesia
Remained unchanged for at least 24h in morbidly obese
patients
Decrease in respiratory function after spinal anesthesia
Semirecumbent position, early mobilization, adequate pain
control
Neuraxial opioids are more effective
Decrease atelectasis, pulmonary complications
Increased risk for respiratory depression with sleep apnea
vigilant nursing monitoring : hourly during 1
st
24h, every 2h for 2
nd
24h
Post-partum morbidity
- continued
Venous thromboembolism
Mechanical & pharmacological thromboprophylaxis
LMWH dose : based on actual body weight
Anticoagulation status & spinal or epidural
catheter
Catheters can be removed 10-12h after last dose of
LMWH & 4h before next dose
- European guidelines
Should be removed 2h before 1
st
dose & 1
st
dose
should be 24h after surgery
- American Society of Regional Anesthesia and Pain
Medicine guidelines
Small dose (5000U) of SC heparin
Not contraindication for neuraxial techniques