A CHALLENGE-ANESTHETIC MANAGEMENT OF A MORBIDLY OBESE PREGNANT PATIENT
Abstract Number: 254
Abstract Type: Case Report/Case Series
INTRODUCTION: Obesity has reached epidemic proportions and the incidence has doubled in adults and tripled in children in the United States. The prevalence of obesity in the childbearing age has been increasing and an obese parturient is at increased risk for pregnancy related complications and poor perinatal outcome.
CASE REPORT: A 28 year old female at 38 weeks gestational age, was admitted to L& D for labor induction, because of decreased fetal movements and hypertension. Her medical history was significant for morbid obesity (BMI 73.6 kg/m2.)
On examination: Height 5 feet 10 inches, Weight 507 lbs, BP 158/95 mm of Hg, HR 123 per minute and SpO2 97. Airway: Mallampati Class 2, abundant soft tissue in the neck and good mouth opening. Platelets, PT/PTT, liver profile and Chem 7 Profile were within normal limits.
Patient was explained the risks, benefits of the epidural block. The excess fat pads were taped and an assistant firmly pushed the fat pads away from the midline. A longer Combined Spinal- Epidural (CSE) needle set was used to perform CSE. Catheter was sutured and a special adhesive dressing was used to tape the catheter in place. Patient received 0.5% Bupivacaine 1.5mg and fentanyl 15 mcgs intrathecally followed by an infusion of 0.1% Bupivacaine with Fentanyl 2mcgs/ml.
Approximately 3 hours later, a decision was made to perform C-Section. Patient was positioned on a special OR table with a intubation ramp in place. The Difficult airway, large bore intravenous lines, PRBCs and left uterine displacement were ensured. Fifteen ml of 2%Lidocaine with epinephrine and Fentanyl 100 mcgs was injected intermittently to achieve a level of T6. The course of the C-Section was uneventful. Postoperative analgesia was maintained with a continuous epidural infusion and catheter was removed on the third postoperative day.
DISCUSSION: Morbidly obese pregnant patients have co-existing morbidities such as diabetes, hypertension, left ventricular hypertrophy, gastroesophageal reflux, obesity-hypoventilation syndrome, pulmonary hypertension and right ventricular failure. These are superimposed on the pregnancy induced physiologic changes and severely decrease the functional reserve. A strategy must be developed for the appropriate management of a morbidly obese parturient for optimal peripartum and perioperative outcomes.
Regional anesthesia is certainly safer compared to General anesthesia because of the risk of difficult airway, aspiration and respiratory compromise. But, the technical difficulties due to excess soft tissue, poor landmarks, the need for special needles and extra care in securing the catheters, the decreased requirement for the local anesthestics need to be appreciated. The advantage of neuraxial opioids to achieve superior analgesia with lesser amount of local anesthetics is to be utilized.