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Epidural Placement in the Super Morbidly Obese Parturient
Abstract Number: FCD-532
Abstract Type: Case Report Case Series
Introduction:. More than half of parturients are overweight or obese (BMI >30), and 8% have morbid obesity (BMI>40). MO imparts higher risk for maternal, fetal, and neonatal complications. Anesthesia concerns include increased risk for difficult intubation, aspiration, failed neuraxial techniques, cesarean delivery, hemorrhage, and difficult IV access. Furthermore, MO comorbidities are frequently exacerbated in pregnancy, including diabetes mellitus (DM), obstructive sleep apnea (OSA), hypertension, heart disease, and venous thrombosis. The 2013 ACOG Committee Opinion on MO in pregnancy recommends anesthesia consultation in the third trimester for women with a BMI > 40 kg/m2. We present a novel maneuver for epidural placement in a patient with MO.
Case: A 27 yo G2P0 with a BMI of 83 was admitted with intrauterine fetal demise for anticipated vaginal delivery at 33w6d. The pregnancy was complicated by illicit drug use, OSA, and gestational DM. The patient requested epidural analgesia. She was placed in the sitting position with lumbar flexion and silk tape used to retract excess tissue toward the shoulders. Despite this, complete obscuration of the low lumbar skin entry point by redundant adipose tissue was noted. To improve access to the spine, two sterile silk tape rolls were placed paramedian to the spine (Figure). The epidural space was reached at 13 cm with a 17g, 17cm Gertie Marx needle, a 25g Gertie Marx spinal needle confirmed CSF, and an epidural catheter was threaded. The patient was positioned lateral before taping to avoid anchoring at the skin and catheter dislodgement. The procedure took 40 minutes. Delivery was complicated by dystocia requiring vacuum and forceps delivery then transfer to the OR for D&E of retained tissue. All required procedures were performed under effective epidural anesthesia.
Discussion: Neuraxial use can provide safety for conditions including shoulder dystocia, macrosomia, and cesarean delivery, all of which are more common with MO. However, epidural placement can be time consuming and technically challenging. Parturients with MO benefit from early counseling on the benefits of an early epidural in labor to enable adequate time and planning for personnel with the highest technical expertise.
Figure: sterile tape rolls used as support pillars for adipose tissue in lumbar area