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Perils of Delivery in a Multiparous Parturient with BMI of 71
Abstract Number: T-74
Abstract Type: Case Report/Case Series
Introduction: Obesity confers significant risk during pregnancy to both the mother and fetus. We report herein the complicated delivery and postpartum course of a parturient with BMI of 71.
Case report: A 40 year old G6P3 female at 39 4/7 weeks EGA presented to our labor and delivery unit for scheduled induction of labor. Her pregnancy had been complicated by chronic hypertension, advanced maternal age, class III obesity (BMI 71), and obstructive sleep apnea. She had 3 prior vaginal deliveries without complication. On admission, airway exam revealed a Mallampati IV that did not improve with phonation. Epidural was placed early in her labor without complication (LOR 9.5 cm) and worked well during her 24 hour induction. She eventually required cesarean delivery due to arrest of descent, chorioamnionitis, and recurrent late fetal decelerations. Time to prepare the patient in the operating room as well as skin to uterine incision were prolonged due to her extreme obesity. A female neonate with Apgars of 0, 5, and 5 was delivered to the awaiting NICU team and was placed on cooling protocol upon arrival to the NICU. After delivery the patient experienced a postpartum hemorrhage, with inability to exteriorize the uterus due to the patient’s body habitus, eventually requiring hysterectomy. Additional peripheral IV access and radial arterial access were gained with ultrasound guidance. She was intubated for airway protection easily with the Glidescope (grade I view) due to ongoing hemorrhage and transfusion requirements. Estimated blood loss was 4000mL. On POD 1 she was extubated and required emergent reintubation due to acute airway obstruction and negative pressure pulmonary edema. On POD 2 she began to complain of R posterior calf pain. Lower extremity Doppler ultrasound was negative for DVT and the patient was continued on lovenox for prophylaxis. On POD 3 she was extubated without incident. She was discharged to home on POD 8. At 8 month follow up the patient was doing well; her infant was meeting milestones with no pathology noted on MRI and EEG.
Discussion: Although our patient had a history of multiple prior uneventful vaginal births, she remained at high risk for peripartum complications due to her high BMI.(1) A low threshold for expectation and management of labor complications, including arrest of descent, dystocia due to macrosomia and pelvic adiposity, and cesarean delivery should be present. Although evidence is conflicting,(2) postpartum hemorrhage requiring eventual hysterectomy was attributed to patient habitus and inability to exteriorize the uterus for optimal visualization. Postpartum complications, including respiratory complications and venous thromboembolism, are more frequent in the obese population as was seen in our patient. Lastly, perioperative care for the morbidly obese parturient represents a significant cost burden to the healthcare system.(3)