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Surgical Abortion in the Super Morbid Obese: A Case Report
Abstract Number: RF4AD-493
Abstract Type: Case Report Case Series
Surgical abortion is among the most common procedures performed in the United States. Traditionally, there has been concern for increased risk of aspiration in parturients past the first trimester, and therefore the need for endotracheal intubation. Recent data has suggested sedation and/or a regional technique to be a safe alternative in pregnant women who are otherwise healthy undergoing this procedure.1 There is conflicting data as to whether this technique may extend to obese women.2 When faced with a patient with multiple risk factors for aspiration and airway complications such as the morbidly obese, those with difficult airways, and an inappropriate NPO status, there is even less data to guide clinical management. We present our approach to the challenges posed by a woman with risk factors for aspiration and difficult airway for elective surgical abortion.
Our patient is a 26 yo G2P0 @ 16+5 wga with a PMH of OSA, and class III obesity (BMI 56) presenting for dilation and evacuation. Mallampati class 3 airway was noted on exam. The patient endorsed eating a large meal 5 hours prior to presentation, therefore the decision was made to delay surgery until the full 8 hour fasting period could be observed.
To minimize IV sedation, airway instrumentation, and aspiration, a catheter based neuraxial technique with the ability for titration was selected for anesthesia. Once appropriately NPO, the patient was premedicated with 2mg midazolam and then brought to the OR where an opioid-free CSE technique was performed. 7.5mg of hyperbaric bupivacaine was injected intrathecally, achieving a T-8 level bilaterally. The patient was then sedated with 20mcg dexmedetomidine and a total of 50mcg remifentanil given in divided doses as necessary. The patient was comfortable throughout.
The surgical procedure lasted 40 minutes, requiring dosing of the epidural with 100mg of lidocaine to maintain patient comfort. No surgical or anesthetic complications were noted, and the patient was discharged from the hospital that same day.
Surgical abortions for the super-obese parturient present a distinct challenge, particularly from a respiratory standpoint. Over-sedation for this highly emotional procedure can precipitate lost or difficult airway and subsequent aspiration. While sedation with or without a regional technique has been described in low risk populations, there is a paucity of safety data for the super morbidly obese or 2nd trimester elective terminations. We employed an opioid-free lumbar epidural technique to facilitate moderate onset regional anesthesia that provided reliable patient comfort and obviated the need for airway support or instrumentation in this patient with risk factors for difficult airway. This anesthesia technique, along with moderate sedation, can be an excellent alternative to general anesthesia.
1 Dean G, et al. J Clin Anesth. 2011;23:437–42.
2 Gokale P, et al. Anesth Analg. 2016;122:1957–62.