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Management of a super morbidly obese parturient with heart failure and COPD for Cesarean Delivery secondary to preeclampsia with severe features and uncontrollable hypertension
Abstract Number: S-43
Abstract Type: Case Report/Case Series
Background: Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, hypertension and pre-eclampsia. (1, 2) We describe the peripartum anesthetic management of a super obese parturient for emergent repeat cesearean delivery in the setting of pre eclampsia with severe features.
Clinical Features: A 33-year-old multiparous woman with BMI of 70 presented at 29 weeks for management of systolic blood pressures in the severe range. Her past medical history was significant for an in-situ tracheostomy, placed 4 years prior for respiratory failure secondary to BMI > 100; as well as chronic hypertension, CHF with EF of 30-40% and COPD. An arterial line, and peripheral intravenous access were placed by anesthesia at bedside. Due to severe range blood pressures refractory to medical management, emergent repeat C/D was called. Following ENT consult for exchange to cuffed tracheostomy in the OR, peripheral intravenous access failed. Ultrasound guided central intravenous access was obtained via the right internal jugular, and ultrasound was utilized to obtain midline for placement of an intentional intrathecal catheter. A sensory level to T4 was obtained with 1cc of local anesthetic with narcotic, and delivery proceeded uneventfully. The patient was transferred to PACU on 4L trach collar, and observed overnight. The patient was then transferred to the postpartum floor, and discharged home on POD #4.
Conclusions: The rate of obesity in the general population is increasing dramatically particularly among females of childbearing age (2). Morbid obesity in this population, is associated with multiple problems (1). Asides from the increased prevalence of DM, HTN and poor neonatal outcomes, morbid obese patients present challenges for the anesthesiologist including airway management, intravenous access and neuraxial procedures. Ultrasound facilitates line placement and neuraxial anesthesia (3) ; particularly in the setting of severe preeclampsia, where blood pressure stabilization precludes repeated attempts at invasive procedures. Intrathecal catheter provides a reliable, rapidly titratable and hemostable anesthetic technique for the super obese preeclamptic undergoing repeat cesarean delivery (4).
1. Soens MA1, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment .Acta Anaesthesiol Scand. 2008 Jan;52(1):6-19.
2. Whitty RJ1, Maxwell CV, Carvalho JC. Complications of neuraxial anesthesia in an extreme morbidly obese patient for Cesarean section. Int J Obstet Anesth. 2007 Apr;16(2):139-44.
3. Indirect sonographic guidance for epidural anesthesia in obese pregnant patients. Reg Anesth. 1992 (17) 233–236
4. K.R. Milligan, H. Carp. Continuous spinal anaesthesia for caesarean section in the
morbidly obese. Int J Obstet Anesth, 1992 (1): 111–113