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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 109-112

Anesthetic management in a super obese parturient undergoing elective caesarean section: A case report


Department of Anaesthesiology, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India

Date of Submission13-Jan-2019
Date of Decision27-Apr-2019
Date of Acceptance05-May-2019
Date of Web Publication06-Sep-2019

Correspondence Address:
Dr. Beena Thada
IW/3/7, Behind Isolation Ward, J.L.N. Hospital Campus, Ajmer - 305 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_3_19

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  Abstract 


Obesity has become a global epidemic nowadays with a considerable rise in prevalence among reproductive age group. In obese parturients, the perinatal and maternal morbidity are more common, so it is more likely to plan for elective caesarean section. Morbidly obese parturients along with physiological and pharmacological variations pose significant challenges such as patient positioning, difficult intravenous cannulation, anticipated difficult airway, risk of aspiration, associated comorbidities, postoperative ventilatory support, and risk of thromboembolism under general anesthesia. Hence, regional anesthesia is the preferred technique; however, it can also be challenging with factors such as identification of midline and epidural space, number of attempts, accidental dural puncture, and correct placement of catheter. Here, we report a case of a 34-year-old super obese parturient with gestational hypertension and hypothyroidism who underwent elective caesarean section under combined spinal epidural anesthesia.

Keywords: Caesarean delivery, combined spinal epidural anesthesia, obesity


How to cite this article:
Jain K, Thada B, Sethi SK. Anesthetic management in a super obese parturient undergoing elective caesarean section: A case report. J Obstet Anaesth Crit Care 2019;9:109-12

How to cite this URL:
Jain K, Thada B, Sethi SK. Anesthetic management in a super obese parturient undergoing elective caesarean section: A case report. J Obstet Anaesth Crit Care [serial online] 2019 [cited 2019 Sep 19];9:109-12. Available from: http://www.joacc.com/text.asp?2019/9/2/109/266145




  Introduction Top


Obesity is a worldwide epidemic.[1] Globally, there are 14.6 million obese pregnant women, out of which India has 4.3 million which accounts for 11.1% in the world population.[2] According to the World Health Organization, and the National Heart, Lung and Blood Institute, obesity is defi ned as body mass index (BMI) >30 kg/m 2[3] which is further classified as obese class 1 (30–34.9 kg/m 2), obese class 2 (35–39.9 kg/m 2), obese class 3 (BMI >40 kg/m 2), morbidly obese (BMI >40 kg/m 2), and super obese with BMI >50 kg/m 2.

Obesity has been recognized as a significant risk factor for anesthesia-related mortality in obstetrics.[4] When compared with normal weight parturients, these are at increased risk of having either concurrent medical problems or superimposed antenatal diseases including pre-eclampsia and gestational diabetes.[5] Complications during labor such as intrapartum fetal distress, failure to progress, abnormal presentation necessitating instrumental delivery, and caesarean section are more common. In addition, there is an increased incidence of deep vein thrombosis, hypoxemia, and wound infections perioperatively. Furthermore, the anesthesiologist has to deal with technical difficulties of regional anesthesia and difficult airway management in these patients. Hence, here we report a case of a super obese parturient who underwent elective caesarean section under combined spinal epidural anesthesia.


  Case Report Top


A 34-year-old super obese parturient (G5P1A3) at 36 weeks of gestation with gestational hypertension and hypothyroidism was scheduled for elective caesarean section. Her body weight and height were 150 kg and 158 cm, respectively, with BMI of 60 kg/m 2. Since she was a super obese term parturient, elective caesarean sectionwas planned. During her preanesthetic evaluation, she gave history of hypothyroidism since the past 18 years (was on tab. thyroxin 100 μg once a day) with gestational hypertension since 1 month and was on tab. labetalol 100 mg twice a day. She had undergone laparoscopic cholecystectomy 8 years back under general anesthesia and caesarean section 13 years back under spinal anesthesia which were uneventful. She had no history of diabetes mellitus, dyspnea, obstructive sleep apnea, and any drug allergy. On examination, her general condition was fair except for pedal edema and fat accumulation over the nape of neck. Her vitals were as follows: pulse rate 80/min and regular, noninvasive blood pressure (NIBP) 150/100 mmHg, respiratory rate 16/min, and oxygen saturation 98% at room air in sitting position. On respiratory system examination, bilateral air entry was equal with no added sounds. On cardiovascular system examination, both heart sounds S1and S2 were normal. Airway examination revealed Mallampati class IV, short thick neck, thyromental distance of <3 cm, hyomental distance of<2 cm, adequate mouth opening with artificial removable upper incisors, and normal temporomandibular joint. Peripheral venous access and palpation of spine were difficult due to obesity. Preoperative investigations showed hemoglobin of 10.1 g%, total leucocyte count 5100/cmm, platelets 2.4 lac/cmm, blood urea 24 m%, and serum creatinine 0.7 m%. Liver function tests, coagulation profile, blood sugar, serum electrolytes, urine analysis, and recent thyroid profile were normal. Electrocardiogram (ECG) and two-dimensional echocardiography findings were normal. Fetal echocardiography was also normal. She was kept nil per oral for 8 h before surgery and elective caesarean section was planned under combined spinal epidural anesthesia. The patient was shifted to the operation theater (OT). Two OT tables were attached to accommodate the patient comfortably since we do not have any bariatric OT table in our setup. Monitoring included pulse oximetry (SpO2), NIBP with extra large cuff, ECG, temperature, and urine output. Intravenous (IV) access was made using two wide bore (18 G) IV cannulae. She was supplemented with oxygen through O2 mask at 4 L/min. Difficult airway cart was kept ready [Figure 1]. The patient was preloaded with 500 mL of Ringer's lactate, and antiaspiration prophylaxis was given as metoclopramide 10 mg IV and ranitidine 50 mg IV slowly. She was placed in the sitting position [Figure 2], and under all aseptic precautions, 18-G Touhyepidural needle was inserted after local anesthesic infiltration in L3–L4 space. The epidural space was located using loss of resistance technique. A 27-G spinal needle of combined spinal epidural set was inserted through Touhy needle (18 G) for dural puncture, and after clear free flow of CSF, 3 mL of 0.5% bupivacaine heavy was given intrathecally. After that, epidural catheter was inserted and fixed at 12 cm. The patient was kept in RAMP position with 15° left lateral and head down tilt [Figure 3].
Figure 1: Difficult airway cart

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Figure 2: Patient in sitting position for combined spinal epidural technique

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Figure 3: Patient in ramp position with wedge under right hip

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After attaining sensory block upto T4 level and Bromage grade III motor block, the surgery was started. During intraoperative period, two episodes of hypotension were observed which were successfully managed with IV fluids and mephentermine IV bolus. After delivery of single live baby, 10 IU of oxytocin was infused in 500 mL of normal saline. Neonatal outcome was good and APGAR score was >7 at 1 and 5 min. The surgery was completed uneventfully. Postoperative pain management was done using 0.125% plain bupivacaine intermittently through epidural catheter eight hourly or before when the patient demanded for rescue analgesia. On the second postoperative day, epidural catheter was removed and IV paracetamol infusion was given six hourly. She did not receive any thromboprophylaxis by the surgeon and was ambulatory on the third postoperative day as per the protocol. Her postoperative course was uneventful.


  Discussion Top


The physiological changes associated with pregnancy can be accentuated by morbid obesity.[5] Because the large panniculus adds to the uterine compression of the vasculature, supine hypotension syndrome associated with pregnancy can be greatly exaggerated. There are case reports of sudden death in morbidly obese pregnant patients on assuming the supine position.[6] These patients are at increased risk of aspiration during anesthesia since the prevalence and severity of gastric reflux are increased.[7] Both morbid obesity and physiological and anatomical changes in pregnancy increase the potential risk of anticipated difficult airway, difficult mask ventilation, and rapid desaturation during the apneic phase during anesthesia. Early and meticulous multidisciplinary planning involving senior anesthesiologists, surgeons, and the procurement of special equipment is mandatory for successful management of these parturients.

Owing to anticipated difficult airway and intubation, we avoided general anesthesia. Caesarean section under regional anesthesia is associated with less maternal morbidity and mortality than general anesthesia as it reduces the chances of pulmonary aspiration, failed intubation, the incidence of venous thrombosis, and pulmonary embolism. Due to gravid uterus and obesity, there was decreased functional residual capacity so supplemental oxygen was given throughout the intraoperative period. Super obese patient parturients are at an increased risk of complications such as hypertension, gestational diabetes, wound infection, deep vein thrombosis, pulmonary embolism, and maternal deaths, and foetal complications included congenital malformations such as neural tube defects, macrosomia, and defects of central nervous system.[8] Prophylaxis for deep vein thrombosis must be started postoperatively. There are case reports of caesarean section done under spinal and epidural anesthesia for the obese parturients.[9] Despite technical difficulties associated with regional anesthesia in the morbidly obese, such as patient positioning, identification of anatomical landmarks, and more frequent dislodgment of epidural catheters, its successful use for caesarean section has been reported. Hence, in this case we opted for needle-through-needle combined spinal epidural anesthesia as it combines the benefit of epidural catheter and single-shot spinal anesthesia technique as it is easy to perform, provides early onset of neuraxial blockade, sequential blockade, and postop analgesia can be given. So it is the technique of choice for elective caesarean delivery in the obese and morbidly obese parturients. Single-shot spinal anesthesia has several disadvantages, such as more technical difficulty in these patients, more chances of high spinal blockade leading to cardiorespiratory compromise, inability to prolong the blockade if surgery demands, and postoperative analgesia cannot be prolonged. In this case, we did not give test dose through epidural catheter so there might be chances of failure of epidural block if spinal block weans off, but studies suggest that cerebrospinal fluid flow through the spinal needle indirectly confirms the correct positioning of the epidural needle.[10],[11] Epidural anesthesia offers several advantages, including an easily titratable local anesthetic dose and level of anesthesia, ability to extend the block for surgical delivery and prolonged surgery, slower and more easily controllable hemodynamic changes, and its utilization for postoperative analgesia. In our case, we avoided epidural block alone with concern regarding chances of inadequate block. The possibility of conversion to general anesthesia should be in the mind of the anesthesiologist attending the obese parturient and there should be a back-up plan for difficult airway management. In the postoperative period, pain management through epidural catheter reduces the systemic opioid requirement and decreases the chances of hypoventilation and atelectasis in morbidly obese parturients. However, if general anesthesia is required, the airway should be secured awake using fiberoptic bronchoscopy.


  Conclusion Top


The successful perioperative management in these parturients requires a multidisciplinary team approach including anesthesiologist, obstetrician, and a neonatologist. A meticulous preoperative assessment and preparation is required. So caesarean section in a morbid obese parturient can be successfully conducted under combined spinal epidural anesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity among adults: United States, 2011-2012. NCHS Data Brief 2013;1-8.  Back to cited text no. 1
    
2.
Chen C, Xu X, Yan Y. Estimated global overweight and obesity burden in pregnant women based on panel data model. PLoS ONE 2018;13:e0202183.  Back to cited text no. 2
    
3.
Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i-xii, 1-253.  Back to cited text no. 3
    
4.
Endler GC, Mariona FG, Sokol RJ, Stevenson LB. Anesthesia-related maternal mortality in Michigan, 1972 to 1984. Am J Obstet Gynecol 1988;159:187-93.  Back to cited text no. 4
    
5.
Ramsey JE, Ferrell WR, Crawford L, Wallace AM, Greer IA, Sattar N. Maternal obesity is associated with dysregulation of metabolic, vascular, and inflammatory pathways. J Clin Endocrinol Metab 2002;87:4231-7.  Back to cited text no. 5
    
6.
Drenick EJ, Fisler JS. Sudden cardiac arrest in morbidly obese surgical patients unexplained after autopsy. Am J Surg 1988;155:720-6.  Back to cited text no. 6
    
7.
Roberts RB, Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesth Analg 1974;53:859-68.  Back to cited text no. 7
    
8.
Rao DP, Rao VA. Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new? Indian J Anaesth 2010;54:508-21.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Hanan ES, Ian K, Thomas S. Anesthetic management of a morbidly obese parturient undergoing cesareansection. Middle East J Anesth 2011;21:289-311.  Back to cited text no. 9
    
10.
Miro M, Guasch E, Gilsanz F. Comparison of epidural analgesia with combined spinal epidural analgesia for labor: A retrospective study of 6497 cases. Int J Obstet Anesth 2008;17:15-9.  Back to cited text no. 10
    
11.
Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: A retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13:227-33.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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