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Perioperative management for cesarean delivery of a woman with super-morbid obesity and severe preeclampsia
Abstract Number: S-48
Abstract Type: Case Report/Case Series
We present the anesthetic and perioperative management of a woman with super-morbid obesity and preeclampsia presenting for cesarean delivery (CD).
A 30-year old primiparous patient with super-morbid obesity (weight 228 kg; BMI 86 kg.m−2), chronic hypertension with superimposed severe preeclampsia and type II diabetes mellitus presented for CD at 35+4 weeks due to worsening preeclampsia. An arterial line and 2 peripheral venous catheters were placed preoperatively with ultrasound guidance. A combined-spinal epidural was performed with pre-procedure ultrasound examination to estimate midline and depth of epidural space. Loss-of-resistance was identified at 10 cm, a depth consistent with ultrasound estimation. Intrathecal fentanyl 15 mcg, morphine 75 mcg and hyperbaric bupivacaine 4 mg was administered, and the epidural catheter secured at 15 cm. General anesthesia (GA) was induced with propofol, remifentanil and succinylcholine after 10 min of pre-oxygenation in a head-up, ramped position with 100% O2 and continuous positive airway pressure (CPAP) 5 cmH20. After an uneventful rapid sequence intubation with videolaryngoscopy, anesthesia was maintained with sevoflurane, nitrous oxide and remifentanil. During forceful retraction of the pannus to facilitate surgical access, airway pressures markedly increased; this was associated with a rapid decrease in Sp02. Endobronchial intubation was excluded and the changes resolved immediately with muscle relaxation and pressure controlled ventilation with 100% O2. CD of a 2030 g neonate was accomplished with vacuum extraction with an estimated blood loss of 700 ml. The patient was extubated in the operating room without any respiratory or hemodynamic events. She received overnight monitoring in the recovery room for adequacy of oxygenation (continuous pulse oximetry), ventilation (respiratory rate) and hemodynamics (arterial blood pressure monitoring). Epidural analgesia was maintained with bupivacaine 0.125% for 24 h, at which time the catheter was discontinued to allow thromboprophylaxis to be restarted. CPAP was administered due to the high risk of obstructive sleep apnea. The patient and her baby had an uneventful recovery.
Obese parturients are at increased risk for anesthesia-related maternal mortality. Although avoidance of GA is often advised in obese parturients, general anesthesia and mechanical ventilation proved essential in our case. Spontaneous respiration with pannus retraction and CD under neuraxial anesthesia would not have been tolerated. Neuraxial opioids and local anesthetic minimized systemic opioids, reducing the risk of postoperative respiratory failure. This case suggests that combined regional and general anesthesia may be an optimal approach in super-morbidly obese patients undergoing CD. Ultrasound was invaluable in attaining neuraxial and vascular access.
1. Women’s Health. 2011;7(2):163-79
2. Anaesthesia. 2006;61(1)