Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment

Abstract

Background: The incidence of obesity has been dramatically increasing across the globe. Anesthesiologists, are increasingly faced with the care for these patients. Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, diabetes, hypertension and pre-eclampsia. A thorough understanding of the physiology, associated conditions and morbidity, available options for anesthesia and possible complications is therefore important for today's anesthesiologist. Methods: This is a personal review in which different aspects of obesity in the pregnant woman, that are relevant to the anesthesiologist, are discussed. An overview of maternal and fetal morbidity and physiologic changes associated with pregnancy and obesity is provided and different options for labor analgesia, the anesthetic management for cesarean delivery and potential post-partum complications are discussed in detail. Results and Conclusion: The anesthetic management of the morbidly obese parturient is associated with special hazards. The risk for difficult or failed intubation is exceedingly high. The early placement of an epidural or intrathecal catheter may overcome the need for general anesthesia, however, the high initial failure rate necessitates critical block assessment and catheter replacement when indicated

Epidural extension failure in obese women is comparable to that of non‐obese women

“…The significantly longer catheter dwell time and insertion at an earlier cervical dilatation, were not associated with extension failure. This result is important, given suggestions by experts and international guidelines, that epidurals be inserted early in labor, for obese women 9, 25, 26…”

“…Body mass index (BMI) has not been consistently identified as a risk factor for failed epidural extension,7, 8 however, this may be influenced by under‐representation in study populations. The effectiveness of epidural extension in obese women is important to know, as epidurals may be placed with the explicit intention of permitting extension for subsequent cesarean delivery if required 9, 10. Our previous retrospective pilot study found epidural extension was more likely to fail in women with BMI ≥ 40 kg/m 2 11.…”

Anesthesia for Cesarean Delivery in the Morbidly Obese Parturient - Comparison of Commonly used Anesthesia Techniques

“…Both oxygen consumption and carbon dioxide production have linear relationship with body weight. Because of the augmented fat mass in the chest and abdominal walls and the upward retraction of this adipose tissue caused by supine position, respiratory difficulty and even oxygen desaturation can be experienced by the obese pregnant woman as these factors further lower the functional residual capacity, expiratory and inspiratory reserve volumes and chest wall compliance leading to worsening of the V/Q relationship [12][13][14].…”

Determination of Maternal Weight Gain and Fetal Outcome in Relation to Pre-pregnant Body Mass Index

“…In addition to increase in operative delivery obese group also have risk of wound infections and thromboembolic events. They also have anesthetic complications like failed intubation 17 . Our study did not show any risk of wound infections or any other post-operative complications.…”