///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10+00:00

LABOR ANALGESIA FOR THE MORBIDLY OBESE WOMAN INVOLVED IN A MINOR MOTOR VEHICLE ACCIDENT AND UNAWARE OF PREGNANCY UNTIL FULL TERM AND LABOR

Abstract Number: 210
Abstract Type: Case Report/Case Series

Krzysztof M. Kuczkowski M.D.1 ; Claudia L. Fernndez M.D.2

Introduction: The prevalence of morbid obesity (MO) is increasing worldwide (1). The obstetric and anesthetic management of the MO parturient is associated with many special hazards. Trauma in pregnancy is currently a leading cause of non-pregnancy-related maternal death, and maternal death remains the most common cause of fetal demise (2). We herein report a case of the MO woman involved in a minor car accident and unaware of pregnancy until full term (and labor). "Early" uneventful labor analgesia was provided for vaginal delivery of a healthy neonate.

Report of case: A 36-year-old MO [body mass index (BMI) of 69] female was admitted to the Emergency Medicine Department with "abdominal pain" following involvement in a minor car accident. Transabdominal ultrasound scan revealed a live term fetus [in good condition (fetal heart rate of 143 beats/min)] in cephalic presentation. The patient was not aware of her pregnancy. Vaginal examination revealed ruptured membranes and cervical dilatation of 4 cm. Uterine contractions were detected on the electrocardiotocographic monitoring. A single interspace, needle-through-needle combined spinal epidural analgesia (CSEA) was performed (in sitting position at what was believed to be the L3-L4 interspace) with the 17G x 125 mm epidural needle and the 26G x 160 mm spinal needle. Excellent labor analgesia was accomplished with 10 μg of fentanyl combined with 2.5 mg of bupivacane (subarachnoid induction dose) followed by an epidural maintenance infusion of 0.1% bupivacaine with fentanyl 2 μg/ml at the rate of 10 ml/hour. Uneventful vaginal delivery of a healthy neonate was accomplished in 7 hours since the admission.

Discussion: Morbid obesity is perhaps the most common nutritional disorder seen in pregnancy, and MO parturients have more pregnancy complication than normal BMI pregnant women. Common trauma-predisposing factors include environmental conditions such as heavy traffic and bad weather, and/or physical conditions such as intoxication, fatigue, or pregnancy. The pregnant trauma victim presents a unique spectrum of challenges to the healthcare team. The fact that pregnancy may not always be known to be present to the health care team (at the scene of transportation accidents, in the emergency room, or in the operating room) additionally complicates the situation. The risk for difficult or failed intubation in MO parturients is exceedingly high. The early placement of an epidural (or subarachnoid) catheter may overcome the need for general anesthesia; however, the high initial failure rate necessitates careful block assessment and catheter replacement (if indicated). Ultrasound-guided epidural catheter placement should be considered if technical difficulties persist.

Conclusion: With the introduction of a longer needle design the CSEA technique may become an attractive choice of labor analgesia for the MO parturients.

References: 1. Obes Facts 2009; 2:352-4.

2. Acta Anaesthesiol Belg 2005; 5

SOAP 2010