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Successful Use of Low Dose CSE for a Parturient with Super Morbid Obesity, Preeclampsia with Severe Features and Anasarca for Urgent Repeat Cesarean Delivery
Abstract Number: RF6BI-392
Abstract Type: Case Report Case Series
Parturients with both medical and obstetric comorbidities present a unique challenge when an urgent cesarean delivery (CD) is indicated. Concurrent obstetric disease and non-reassuring fetal status may require timely onset of anesthetic blockade for urgent CD, but maternal comorbidities (such as extreme obesity and kidney disease) may complicate spinal dosing strategies. For example, in parturients with increased intraabdominal pressure (super morbid obesity, multiple gestation, ascites), traditional spinal anesthesia but may result in higher than expected sensory block levels or exaggerated hypotension. However, it is unclear whether reducing the spinal dose in this cohort is beneficial to mother and baby. In acute situations, obstetric anesthesia providers may utilize a hybrid technique: low dose CSE for patients in whom both timely blockade onset and avoidance of high spinal is desirable. We present a case utilizing a low dose CSE in a high risk parturient for urgent repeat CD.
A 35 yo G3P2 at 34 wga with a PMH of CD x2, super morbid obesity (BMI 55), cHTN, nephrotic syndrome and anasarca presented with symptoms concerning for superimposed preeclampsia with severe features (headache and severe range blood pressures). Maternal fetal medicine recommended urgent repeat CD due to difficulty assessing fetal status. Prior to arrival to OR, patient received IV labetalol and magnesium 4 mg bolus. A CSE with IT dose of 1 mL 0.75 % hyperbaric bupivacaine + 15 mcg fentanyl + 150 mcg morphine was given. A T6 sensory and motor block was achieved within 11 minutes of the IT dose. No vasopressor medication or additional IVF was needed for blood pressure support. The patient reported adequate analgesia at start of case and required epidural bolus 100 mg 2% lidocaine with 1:200,000 epinephrine 62 minutes following the intrathecal dose. Maternal and fetal status outcome was stable.
The constellation of super morbid obesity, preeclampsia with severe features, and nephrotic range proteinuria with anasarca in this parturient complicated IT dosing strategies for an urgent, repeat CD in which fetal status was potentially compromised. Full dose spinal or CSE, while providing reliable anesthetic conditions, may result in high spinal in parturients with increased intraabdominal pressure (i.e. extremes of obesity, anasarca) or exaggerated hypotension with resultant placental hypoperfusion. Further, iatrogenic efforts to control the blood pressure (IVF, vassopressors) may be poorly tolerated in mothers with tenuous IV volume and vasomotor tone. In this medically complicated preeclamptic patient, a low dose CSE permitted rapid delivery of the fetus while avoiding high spinal and iatrogenic efforts to control the blood pressure. Low dose CSE (7.5 - 9 mg bupivacaine) technique may accomplish rapid anesthesia without high levels necessitating airway or hemodynamic support for highly complicated parturients for urgent CD.