Introduction: Obesity is a global epidemic that crosses all demographic and socioeconomic lines. In addition, the incidence of severely obese (BMI > 35 kg/m2) parturients is growing.1,2 These patients have several unique anesthetic, obstetric, and post-operative pain considerations. We present the case of a 25 year old G4P3 at 39 weeks with a BMI of 96.7 kg/m2 (height 147cm, weight 209kg), the highest documented in the literature, who successfully underwent repeat cesarean section with a combined spinal-epidural (CSE).
Case: The patient presented to our institution at almost 39 weeks having been turned away from multiple hospitals due to her weight. With scant prenatal care, she underwent transthoracic cardiac echo, general surgery consultation for an untreated breast abscess, ultrasound for asymmetric lower extremity swelling, respiratory therapy consultation for CPAP fitting, and a complete obstetrical evaluation. She had a history three prior cesarean sections, and fundal placentation this pregnancy was noted on prenatal ultrasound. An elective operative delivery by supraumbilical vertical midline incision was planned. Due to poor vascular access and an inability to measure blood pressures non-invasively, a central venous catheter and arterial line were placed prior to surgery. A Styrofoam intubation wedge and video laryngoscopy were available, as were two units of typed and crossed red blood cells. Due to absent anatomical landmarks, midline and distance to the epidural space were identified with ultrasound. Consistent with ultrasound estimation, loss of resistance was found at 15cm with a 6” 17 gauge Tuohy needle. A 190mm 25 gauge Gertie Marx spinal needle was passed into the subarachnoid space, and 12mg of 0.75% hyperbaric bupivacaine and 10mcg of fentanyl were injected. No neuraxial morphine was given due to concerns of respiratory complications. An epidural catheter was uneventfully threaded through the epidural needle and taped at 20cm at the skin. Five epidural boluses of local anesthetic were given throughout the 89 minute surgery. Estimated blood loss was 1500mL. A viable female infant was delivered with APGARs of 3, 7, and 8 at 1, 5, and 10 minutes respectively, and was taken briefly to the NICU following delivery for non-invasive respiratory support and hypoglycemia. The patient’s epidural catheter was left in place, and 0.1% bupivacaine with 2mcg/ml fentanyl was infused for 24 hours until the patient successfully transitioned to oral analgesics. The patient recovered on in the Labor and Delivery unit, although an ICU bed had been made available.
Discussion: A team-based, multidisciplinary approach to this patient’s care assured the safest delivery for this severely obese patient. A CSE allowed for profound anesthesia for a complex operative case, while the epidural catheter provided flexibility and safety for an uncertain surgical course as well as post-operative analgesia to minimize systemic opioid use.
1.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief 2012;82:1-8
2.Tonidandel A, Booth J, D’Angelo R, Harris L, Tonidandel S. Anesthetic and obstetric outcomes in morbidly obese parturients: A 20-year follow-up retrospective cohort study. International Journal of Obstetric Anesthesia 2014;23(4):357-364
