The Morbidly Obese Pregnant Patient

1. The Morbidly Obese Pregnant Patient Ursula N. Landman, D.O. Clinical Associate Professor Anesthesiology SUNY Stony Brook University Hospital Stony Brook, NY

3. On call In L&D-the morbidly obese nightmare! • 30 y.o 450++lbs, stated in chart, G1P0 in LDR #4 that is being induced with no epidural and there is no IV still.  • Wt is actually much larger than 450-that was an understatement.  One area of the chart stated 600++. • BP 120/70 P 70 R 15 FHR 140's. • PMH/PSH none. Meds PNV NKDA.  • multiple epidural attempts during the afternoon without success. 

4. What is your plan? The Obstetric anesthesiologist states that “the patient wants general anesthesia if she is to have a csection.”  The obstetrician states that he does not need anesthesia now.  The obstetric anesthesiologist has now left. 

5. Mutually Agreed upon Plan •  The patient needed to gain the trust of the new team •   It was also important to note that the day team had  tried multiple times to get an epidural and an IV.  •  The first concern would be to check the patient's airway-just in case she does have a csection.  • Next-the patient would have to be asked directly about retrying for an epidural and given all the risks that would go along with a general anesthetic. • Although, multiple attempts for an epidural were made-I felt it necessary to try and get an epidural in this morbidly obese patient as well as large bore IV access. The patient actually agreed to another attempt and if an epidural was obtained realized it would be used for csection

6. Morbidly obese Pt • BMI (body mass index)=wt in kg divided by square of her height in meters • BMI calculated to be 103 or 77 depending on which weight was used

7. WHO Classification of Obesity

8. The numbers don’t lie! • In 1990- no state was over 14% obesity • 2007-no state was less than 20% obesity • 72 million Americans are obese (BMI>30) • Robert Wood Johnson Foundation in partnership with University of Wisconsin Population health Institute County Healthy Ratings 2010

9. 1990

10. 2004

11. Treating obesity • Diet • Increased Physical Activity • Behavior Modifications • Medication • Surgery-Bariatric • Education

12. Diet • 10% of body weight can be healthfully lost in 6 months • Gastroenterological Association medical position statement on obesity. Gastroenterology 2002 sept 123 (3) 882-932

13. Physical Activity • Increased activity can improve general health but may have little impact on total body weight in morbid obesity • Gastroenterological Association medical position statement on obesity. Gastroenterology 2002 sept 123 (3) 882-932

14. Beneficial to Exercise

15. ACOG recommends • In the absence of either medical or obstetrical complications, 30 minutes or more of moderate exercise a day on most if not all days of the week is recommended for pregnant women.

16. ACOG committee opinion on contraindications to exercise • Hemodynamically significant heart disease • Restrictive lung disease • Incompetent cervix • Multiple gestations • Persistent 2nd or 3rd trimester bleeding • Placenta previa after 26wks • Premature labor • Premature rupture of membranes • Preecclampsia • PIH

17. Relative Contraindications • Poorly controlled HTN • Orthopedic limitations • Poorly controlled seizures • Poorly controlled hyperthyroidism • Heavy smokers

18. Exercise Termination • Vaginal bleeding • Dyspnea • Dizzyness • HA • CP • Muscle weakness • Calf pain • Preterm labor • Decreased fetal movement

19. Behavior Modification • Can contribute to overall weight loss, but requires ongoing professional contact and the failure rate can be high • Gastroenterological Association medical position statement on obesity. Gastroenterology 2002 sept 123 (3) 882-932

20. Is there a magic pill for weight loss?

21. Drug Treatment • Short term use not recommended since weight is typically regained when the treatment ends and there is a modest difference from placebo long-term • Gastroenterological Association medical position statement on obesity. Gastroenterology 2002 sept 123 (3) 882-932

22. Weight Loss Surgery in the Severely Obese • The most effective approach for long term weight loss • ACOG advises all patients to delay pregnancy for @18 months after bariatric surgery-so that pregnancy is not occurring during the rapid weight loss phase • Adjustment of gastric bands may be necessary • Women should also be monitored by their surgeon

23. ACOG Committee opinion 2005 • Obstetricians should provide preconception counseling/education • Make complications known • Encourage a weight reduction program prior to becoming pregnant • Obesity in Pregnancy ACOG Committee Opinion, number 315, American College of Obstetricians and Gynecologists. Obstet Gynecol 2005; 106: 671-5

24. Some Preconception discussion • Replace juice, juice drinks, and sodas with water • Replace refined flours with whole grains • Increase intake of fruit and vegetables • Increase intake of dietary fiber • Replace restaurant and fast food meals with home prepared meals • Carry healthy snacks in handbag • Keep a food diary and review it with the care provider • Physical activity • Walk instead of drive • Take stairs instead of an elevator • Get off bus or underground train before usual stop and walk • Take the children to play in the park • Get a “walking buddy” to take regular walks with • Borrow exercise videos or DVDs from the local library • Stotland, Naomi. Obesity and Pregnancy. BMJ 338. 2009; 107-110.

25. We are a food centered society

26. Breakfast

27. Lunch

28. Dinner

29. Fertility and Weight Loss • Weight loss before pregnancy improves fertility • Reduces adverse pregnancy outcomes associated with obesity • Medical Clinics of North America vol92. Issue 5 (Sept 2008)

30. Obesity and Anesthesia Considerations • Evidence does not support that preoperative evaluation prior to surgery makes a difference in mortality • There is evidence that preoperative evaluation makes the perioperative period more efficient, reduces pt. anxiety and allows for early identification of problems with pulmonary, cardiovascular, metabolic and nervous system physiology Miller’s Anesthesia vol.1 6th ED., 2005

31. Obesity and Co-Morbidities • > 10% have abnormal glucose tolerance tests • Predisposed to wound infection • Possible glomerulonephropathy

32. Obesity and Co-Morbidities • Type II Diabetes • Hypertension • Infertility • Heart Disease • GB Disease • Osteoarthritis • Breast, Uterine and Colon Cancer • CVA • Metabolic Syndrome: diabetes, dyslipidemia and HTN

33. Obese Pregnant Pt. • Poses a significant risk to mother and fetus • Have specific anesthetic considerations • Improvement of communication among physicians, medical staff and patient as well as early identifying those at risk and formulation of a plan for proper obstetric and anesthetic care can reduce disastrous complications

34. Obese & Pregnant • Cardiovascular changes: -Plasma Volume peaks 32-36 wks gestation -Increased C.O. -Association with HTN

35. Obese & Pregnant • (OSA) is often under diagnosed in women of childbearing age. • Obesity increases the risk of OSA significantly. • OSA has been associated with increased systemic hypertension and pulmonary hypertension. These patients are also at increased risk for arrythmias, coronary artery disease and stroke.

36. Obese & Pregnant • Respiratory changes: -Postural changes -Lung Volumes- Decrease FRC, Increase MV -lower PaO2- 80- 85 mm Hg -Oropharyngeal changes • GI: no evidence that obesity worsen LES tone

37. Obese and Pregnant • Pregnancy associated issues for the obese: -PIH,HTN -DM -Preeclampsia- an increased incidence of 16% -DVT/Thromboembolism -Death • Hood, DD, et al. Anesthesthtic and Obstetric outcomes in morbidly obese. Anesthesiology 1993

39. Risk for C-section • Increased Risk of Cesarean Delivery -Retrospective study -Incidence of Cesarean delivery as it related to patient weight -Rate for obese parturients was 21.5 v.s. 13.5 for nonobese parturients (p<0.001). • Crane JM, O'shea P, et al. Association Between Pre-Pregnancy Obesity and the Risk of Cesarean Section. Obstet Gynecol. Feb 1997;89(2):206-12.

40. BMI & Risk for C-section Crane JM, O'shea P, et al. Association Between Pre-Pregnancy Obesity and the Risk of Cesarean Section. Obstet Gynecol. Feb 1997;89(2):206-12.

41. Risk for C-section -Case-control study on 43 morbidly obese parturients -Reported an increase in emergency Cesarean section (32.6% v.s. 9.3%) and total operative time (48.8% v.s. 9.3%) -Reported increase in multiple epidural attempts (similar in my case presented)and prolonged hospital stay • Perlow, J H; Morgan, M A. Massive Maternal Obesity and Perioperative Cesarean Morbidity. American Journal of Obstetrics & Gynecology. 170(2):560-5, 1994

42. Csection • IV abx • Need adequate table size in OR-something that was not available for my case • Assistants • Incision type/pannus • Consider all in failed VBAC

43. Obstetric Risk • Similar indications for Cesarean delivery among obese and nonobese, however there is increase incidence of umbilical cord accidents, late fetal decels and meconium amniotic fluid. • Less success of a vaginal delivery after an initial section for obese parturients 13% v.s. 60-80% for nonobese parturients Anesthetic and Obstetric Management of High Risk Pregnancy 3rd ED, Datta, 2004

44. Additional Obstetric Issues • Postpartum hemorrhage • Genital, urinary tract and wound infection • Macrosomia leading to birth trauma • Difficult Assessment of FHR • Appropriate location for delivery (labor room versus Operating Room) • Neonatal and Anesthesia Services In house

45. Risks to Fetus • Maternal morbid obesity- an independent factor • Abnormal presentations • Multiple Gestations (IVF) more common • Increased infection transmitted from mother • Birth weight above the 90th percentile (predisposes fetus to risk during the delivery) Anderson JL, Waller DK, Canfield MA, Shaw GM, Watkins ML, Werler MM. Maternal obesity, gestational diabetes, and central nervous system birth defects. Epidemiology 2005;16:87—92.

46. Further Risks to the Fetus • Higher incidence of low APGAR scores • Increase incidence NICU stay • Increase incidence of neural tube defects and congenital malformations • Increased instrumental deliveries, meconium aspiration, stillborn, fetal and neonatal death Waller et al., Risk of Neural Tube Defect-Affected Pregnancies Among Obese Women, Sept. 1996 Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 2004; 103:219-224.

47. Fetal Risk specifics • Cedergreen studied 3480 swedish women with BMI >40 and compared with 535000 normal BMI • LGA-3.82 • Shoulder dytocia 3.4 • Fetal distress 2.52 • Early neonatal death 3.4 • Instrumental deliveries 1.34 • Still birth 2.79

48. Management Summary of key issues in management • Need for a flexible anesthetic plan • Be prepared for everything and anything • Hawkins, J. labor and Delivery management of the morbidly obese patient. IARS march 19 2008 57:06

49. Technical Difficulties • Blood pressure measurement will require an appropriate-sized cuff otherwise both systolic and diastolic readings will be overestimated. • There is a strong argument in favor of invasive blood pressure monitoring peri-operatively. • Venous access may also be difficult and central venous cannulation may be required

50. Management Prior to Delivery • Anesthesia consult • Appropriate OR equipment • Difficult airway equipment, large spinal/epidural needles (my case actually used a longer epidural needle 7”) • Assess IV access and ease of BP measurement • Ancillary Service Early preoperative consultation prn-12 lead EKG, sleep study, PFT with ABGs, CXR, etc.