Obese Parturients Research Articles

Utility of ultrasonography in identification of midline and epidural placement in severely obese parturients.

Due to body habitus, lumbar epidural placement can be challenging in severely obese parturients. Several studies have been published assessing the usefulness of ultrasonography in the placement of neuraxial blocks. One patient population that is under-represented in these studies is the severely obese parturient. We sought to determine if performing an abbreviated ultrasound exam of the lumbar spine to determine midline by locating spinous process could facilitate lumbar epidural placement in severely obese parturients. One hundred fifty patients with a Body Mass Index (BMI) of ≥35 kg/m2 were randomized into two groups. The palpation (P) group had midline identified by the traditional palpation technique. The ultrasonography (U) group had midline identified by ultrasound visualization of the spinous process in the transverse plane. Midline identification and epidural placement were done by both junior and senior anesthesiology residents at our teaching institution. Data were analyzed on all 150 patients. BMI was similar in the U and P groups (43.3 vs. 44.4 kg/m2, P=0.359). Time for epidural placement (6.2 vs. 9.0 minutes, P<0.01) and total procedure time (6.9 vs. 9.5 minutes, P<0.01) were significantly less in the U group. The number of needle passes (2.1 vs. 2.8, P=0.02) was also less in the U group. There was no significant difference in the failure rates of the U and P groups (4.0% vs. 9.3%, P=0.19). The use of an abbreviated ultrasound exam to identify midline in severely obese parturients can reduce the time required for lumbar epidural placement.

Unmonitored Labor Episodes in Obese Parturients With Wireless Versus Conventional Fetal Heart Rate Monitoring [16S

INTRODUCTION: To determine the frequency and duration of unmonitored labor (UL) episodes in obese parturients exposed to wireless fetal heart rate (FHR) monitoring compared to exclusively conventional wired FHR monitoring. METHODS: Retrospective cohort of obese gravidas with non-anomalous, term singleton gestations admitted for induction or early labor at a tertiary hospital. Patients were excluded for initial cervical dilation ≥5 cm or prior cesarean delivery. Groups were defined by whether any exposure to wireless FHR monitoring (Monica Novii Wireless Patch System, GE Healthcare) occurred during admission for delivery. Each subject's complete FHR tracing was reviewed. Outcomes were UL episodes/hour and minutes/hour of FHR monitoring. UL is defined as ≥2 minutes of absent or discontinuous FHR tracing, excluding intentional interruptions exceeding 30 minutes. RESULTS: A total of 1,350 hours of FHR monitoring were reviewed for 52 deliveries (24 wireless, 28 wired). BMI was higher in the wireless compared to the wired group (38.1 vs. 34.7 kg/m2); no other demographic differences were observed. In the wireless group, 54.2% of FHR monitoring time was wireless. No differences in UL were observed between the wireless and wired groups. However, within the wired group, which was exposed to both forms of FHR monitoring, there were fewer UL episodes/hour (0.41 vs. 0.85; P&lt;0.005) and UL minutes/hour (2.8 vs. 7.5; P&lt;0.001) during the wireless FHR monitoring period compared with the wired FHR monitoring period. CONCLUSION: Wireless FHR monitoring may reduce periods of UL, particularly in high BMI patients. Future studies should evaluate whether this affects obstetrical outcomes.

Mock delivery drill in a super morbidly obese parturient

Mock delivery drill in a super morbidly obese parturient

Oxytocin and Oxytocinase in the Obese and Nonobese Parturients during Induction and Augmentation of Labor.

Objective To investigate differences in oxytocin (OXT) biodistribution between nonobese and obese parturients during labor. Study Design Patients with body mass index (BMI) of either ≥ 18 ≤ 24.9 kg/m 2 (“nonobese”) or ≥ 30 kg/m 2 (“obese”) undergoing elective induction of labor were included ( N = 25 each). Blood samples were collected at baseline (T 0 ), and 20 minutes after maximal OXT augmentation or adequate uterine contractions (T 1 ) for OXT and oxytocinase assays. A mixed-model repeated-measures analysis of variance was used to test for group versus time interaction and analysis of covariance to detect a difference in OXT level at T 1 . Data presented as mean ± standard deviation or median (interquartile range), with p < 0.05 considered significant. Results The mean BMIs (kg/m 2 ) were 22.1 ± 1.6 and 35.9 ± 5.1 in the nonobese and obese groups, respectively. No differences were observed in either the duration of OXT infusion, total dose of OXT, or plasma OXT (pg/mL) either at T 0 or T 1 . However, plasma oxytocinase (ng/mL) was significantly lower at T 0 (1.41 [0.67, 3.51] vs. 0.40 [0.29, 1.12]; p = 0.03) in the obese group. Conclusion We provide preliminary evidence that the disposition of OXT may not be different between obese and nonobese women during labor.

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

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.

371: Non-invasive Uterine Monitoring: Comparison of Electrical Uterine Myography (EUM) and Tocodynamometry (TOCO) among Obese Parturients

To validate the accuracy of an external device which monitors uterine electrical activity by comparing it to tocodynamometry among obese patients. This was a prospective observational study of laboring women at Montefiore Medical Center from February 2017 to April 2018. Inclusion criteria: maternal age >18 years old, singleton pregnancy, gestational age > 24 weeks and BMI >/= 30 kg/m2. Exclusion criteria: allergy to silver, implanted electronic device of any kind and irritated skin or open wound on the abdominal wall. Patients were monitored simultaneously with the EUM device, EUM300 (OB Tools, Migdal HaEmek, Israel), and by TOCO for at least 30 minutes. Two blinded obstetricians reviewed the tracings. The primary outcome of the study was continuous, interpretable tracing and secondary outcomes were total number of contractions, timing of onset of contractions and duration of contractions. Based on McNemar’s test to compare proportion of discontinuity between the two methods, enrolling 55 patients provided 80% study power to detect an odds ratio of 3.2 with a two-sided type I error rate of 5%. A total of 65 obese patients were monitored via simultaneous EUM and TOCO devices. The average gestational age was 39.0 weeks with 43 (66.15%) patients in latent labor. 35 (53.85%) patients were receiving oxytocin at the time of the recordings and 45 (69.3%) patients had epidural. On average, the EUM was 1.49 minutes (CI= 0.62, 2.37) more interpretable/continuous in a 30 min tracing (p=0.001). Overall, EUM detected 39% (CI= 23%, 57%) more contractions in a 30 min tracing compared to TOCO (p<0.0001). With regards to patient preference, 42 (64.62%) patients undergoing simultaneous monitoring preferred the EUM device over the TOCO. Given the challenges of using a tocodynomameter with obese women, consideration should be given to replacing it with the EUM device, which appears to be more sensitive and accurate and preferred by patients.

Maternal Prepregnancy Obesity and the Risk of Shoulder Dystocia: A Meta-Analysis

(BJOG. 2018;125:407–413) Shoulder dystocia has been reported to affect between 0.1% and 2.4% of pregnancies, and is associated with maternal and fetal complications. While obesity is associated with many adverse pregnancy outcomes, including preeclampsia, postpartum hemorrhage, and cesarean delivery, previous studies examining a link between prepregnancy obesity and shoulder dystocia have yielded conflicting results. This meta-analysis aimed to assess the risk of shoulder dystocia in obese parturients using combined results from all available observational studies.

An Original Suprapannicular Incision Technique for Cesarean Delivery in the Morbidly Obese Parturient.

Obese patients are at an increased risk of cesarean delivery and its associated wound complications. We present an alternative incision technique for obese parturients that avoids making a Pfannenstiel incision under the panniculus while still providing access to the lower uterine segment. For our technique, an assistant uses Allis clamps to exert caudal traction on the patient's panniculus and a transverse skin incision is made under the umbilicus, 3 cm below the line joining the anterosuperior iliac crests. On entry to the abdominal cavity, a wound retractor is placed to optimize access to the lower uterine segment so that a low transverse uterine incision can be made. We have used this incision technique on 17 obese patients with no incidence of intraoperative complications, no requirement to perform a vertical hysterotomy incision, and no postoperative wound infections. Our technique is a feasible alternative incision for obese parturients that avoids making a subpannicular Pfannenstiel incision and still allows for good access to the lower uterine segment.

The Third Stage of Labour in the Extremely Obese Parturient

BackgroundMaternal obesity has been associated with an increased risk for an abnormal progression of labour; however, less is known about the length of the third stage of labour and its relation to maternal obesity. ObjectiveTo determine if the length of the third stage of labour is increased in extremely obese women and its possible correlation with an increased risk for postpartum hemorrhage. Study DesignThis was a retrospective cohort study of deliveries from January 2008 to December 2015 at our university hospital. Women with a BMI ≥40 and a vaginal delivery were compared with the next vaginal delivery of a woman with a BMI <30. There were 147 women with a BMI ≥40 compared with 157 with a BMI <30. Outcomes evaluated the length of the third stage of labour and the risk for postpartum hemorrhage and included antepartum, intrapartum, and perinatal complications. ResultsSubjects in the extreme obese group were more likely to be African American, older, diabetic (pregestational and gestational), hypertensive, pre-eclamptic, had a preterm delivery, and underwent an induction of labour. The overall length of the third stage of labour was significantly longer in the extreme obese group, 5 minutes (3, 8 [25th and 75th percentiles]) compared with 4 minutes (3,7) (P = 0.0374) in the non-obese group. Postpartum hemorrhage occurred more often in the extreme obese group (N = 16/147; 11%) compared with the non-obese group (N = 5/157; 3%) (P = 0.01). There were no differences between groups in respect to the following: gravidity, parity, length of the second stage of labour, birth weight, GA at delivery, Apgar score, cord blood gases, hematocrit change, need for postpartum transfusion, operative delivery, and development of chorioamnionitis. After an adjustment for ethnicity, maternal age, diabetes, preeclampsia, preterm labour, hypertension, and induction/augmentation, the analysis failed to show a significant difference in estimated blood loss and postpartum hemorrhage between the groups. ConclusionsThe length of the third stage of labour is longer in the extreme obese parturient. Postpartum hemorrhage also occurs more often, but after adjustments for confounding variables, it is no longer significant.

Relationship between severe obesity and depth to the cricothyroid membrane in third-trimester non-labouring parturients: a prospective observational study

BackgroundSeverely obese parturients have increased ‘cannot intubate, cannot oxygenate’ risk during Caesarean section under general anaesthesia. Front-of-neck access (FONA) at the cricothyroid membrane (CTM) is definitive management; however, attempted FONA can fail. Point-of-care ultrasonography may provide useful information about CTM depth to aid FONA in obesity. This study determined the difference in CTM depth between severely obese and non-obese parturients, utilising ultrasonography. MethodsIn this prospective observational study, two anaesthetists performed airway ultrasonography on 15 severely obese (BMI >45 kg m−2) and 15 normal-weight (BMI ≤25 kg m−2) parturients in the third trimester, using the transverse and longitudinal planes, sniffing and extended head positions, and nil and firm transducer pressures. The primary outcome was CTM depth (millimetres) measured in the transverse plane with the head extended and nil transducer pressure. Secondary outcomes included CTM depth measurements using other factor configurations. Intra-class correlation coefficients assessed the inter-observer reliability. ResultsCTM depth measured in the transverse plane with head extended and nil transducer pressure was significantly greater in severely obese parturients, mean 18.0 mm (95% confidence interval 16.3–19.8), vs 10.6 mm (8.81–12.4) in non-obese (P<0.001); mean difference 7.4 mm (4.9–9.9; P<0.001). CTM depths were increased in the severely obese group regardless of scanning plane, head and neck position, or transducer pressure (all P<0.001). There was excellent inter-observer reliability. ConclusionsCricothyroid membrane depth is significantly increased in severely obese vs normal-weight parturients independently of scanning plane, head and neck position, or transducer pressure.

Complications of Obesity in Cesarized Parturients in the Teaching Centers of Cotonou

This survey had the objective to determine the frequency of the obesity at the parturient, to value the impact of the obesity on the childbirth by Caesarean and the complications postoperative immediate in the teaching hospitals of Cotonou. Patients and Method: We did a prospective, comparative and analytic survey from January 13 to April 13, 2012. Eight hundred ninety-one consecutive parturients having had a Caesarean were included. We studied the anesthetic techniques, the techniques of control of the aerial ways, the number of necessary tests for the tracheal intubation, the complications and aftercare of the first 48 hours. A comparison has been made according to the BMI. The obesity has been defined by a BMI ≥ 30 kg/m2. The parturient has been classified in two groups: Non-obese: BMI ≤ 30 kg/m2, obese: BMI ≥ 30. Results: There were 703 (78.90%) Caesareans in emergency and 188 (21.09%) programmed Caesareans. The obesity which has been recovered at 286 parturient is 32.10%. The obese parturient also required more frequently several lumbar punctures (p < 0.001) at the time of the spinal anesthesia and more of conversion of the spinal anesthesia into a general anesthesia (p = 0.008). The postoperative complications: laryngeal pain, back pain and suppuration of the wound were more frequent at the obese parturient. Conclusion: Many changes led by pregnancy are added to those of the obesity to drive to functional changes, a reduction of the physiological reserve and finally to an increased anesthetic and obstetric risk. The obesity is frequent at the parturient in Benin. The post-operative complications are more frequent after the Caesarean at the obese parturient.

Point-of-care Ultrasound for Anesthetic Management of a Severely Obese Parturient

Point-of-care Ultrasound for Anesthetic Management of a Severely Obese Parturient

Risk assessment of morbidly obese parturient in cesarean section delivery: A prospective, cohort, single-center study.

Up to 40% of women gain excessive weight during pregnancy. Obesity complications and risks in parturient women undergoing cesarean section (CS) with different anesthetic methods remain unknown. This study aimed to assess the safety and risk of obese women undergoing CS delivery with various perioperative anesthetic methods. Seven hundred ninety parturient women underwent CS under general anesthesia (GA), intraspinal anesthesia including epidural anesthesia (EA) and combined spinal-epidural anesthesia (CSEA). They were divided into morbid (n = 255), severe (n = 274), and non-obesity (n = 261) groups. This study is registered with ClinicalTrials.gov (number NCT03002636). Between 2013 and 2016, 790 pregnant were assessed. Compared with the non-obesity group, there were significantly more fetal distress and higher body mass index (BMI) in the morbid obesity group (P = .0001 and P = .001, respectively). Significantly more patients showed preeclampsia, multifetation, amniotic fluid abnormality, and high bleeding amounts in the morbid obesity group compared with the non-obesity group (P = .0001, P = .048, P = .017, and P = .018, respectively); more patients were administered EA and GA compared with the non-obesity group (P = .0001 and P = .0001, respectively). More post-anesthesia care unit (PACU) patients were found in the severe obesity group no more than the non-obesity group. Significantly increased anesthesia puncture times for 5 > n ≥ 3 and n ≥ 5 were obtained in the morbid obesity group (P = .0001 and P = .0001, respectively), with more patients in the puncture sitting position, compared with the non-obesity group (P = .0001). GA, EA, and CSEA are safe and effective in severely or morbidly obese patients. Morbidly obese parturient show increased likelihood for fetal distress, PACU, sitting position puncture, puncture difficulty, and other pregnancy complications. There were more anesthesia puncture times in morbidly obese patients.

Focus on cardiotocography: Intrapartum monitoring of uterine contractions

When undertaking training on electronic fetal monitoring, much is discussed about the fetal heart rate and less on the uterine contractions. This is also reflected when discussing the history of both fetal heart rate monitoring and uterine contraction monitoring.Adequately monitoring the uterine contractions is an essential part of cardiotocography. It allows for an assessment of the fetal heart rate in relation to the uterine contractions, especially when there is a non-reassuring or an abnormal trace. When oxytocin is used in induced or augmented labours, it is imperative to ensure that there is no evidence of uterine hyperstimulation and that sufficient resting phases occur between contractions. However, assessing contractions adequately can be challenging in practice, especially in cases of obese parturients.This article explores the methods used to assess uterine contractions, using clinical skills in conjunction with external tocodynamometry and electrohysterography, as well as exploring some of the background to monitoring uterine contractions.

The Skin-to-epidural distance of parturients by ultrasonography: sitting position versus left lateral position

Background: Pre-procedural lumbar ultrasound scanning is a reliable tool to estimate the skin to epidural distance (SED). We conducted an observational study to compare the SED between the sitting position and lateral position using pre-procedural ultrasound imaging of the lumbar spine in parturients. Methods: Using a 2-5 MHz curvilinear transducer, we obtained images of the lumbar interspaces from L2-3 to L5-S1 in the paramedian sagittal oblique view. The individual distance from the skin to the ligamentum flavum-dura mater unit was measured at the level of L2-3, L3-4, L4-5, and L5-S1 in the left lateral position (distance in lateral position; D-lat). Subsequently, participants were placed in the sitting position, and the distance was measured in the same manner (distance in sitting position; D-sit). Data were grouped according to body mass index (BMI; kg/m2) measurements of ≥ 25 or < 25 and analyzed. The primary outcome was the change determined by ultrasound between D-lat and D-sit at the same lumbar level according to position. Results: Thirty parturients were studied. The difference between D-lat and D-sit in the same lumbar level was not statistically significant. The mean changes between D-lat and D-sit in the same lumbar level were less than 0.18 cm. In BMI ≥ 25 group, the difference between D-lat and D-sit were greater than that of BMI < 25 group at L3-4 level (P = 0.042). Conclusions: It is important for clinicians to consider that position change is associated with greater differences in SED in obese parturients (BMI ≥ 25) compared with thin parturients (BMI < 25). For obese parturients, the sitting position may be helpful. Keywords: Epidural; Obstetric; Ultrasound

Obesity and Pregnancy

More than one half of pregnant women are presently classified as overweight or obese and 8% of reproductive age women are extremely obese. Since 1980, obesity rates have doubled for adults and tripled for adolescents aged 12-19 years. The sturdy gains in overall health that have been achieved by Americans since the dawn of the 20th century may be perturbed by the obesogenic epidemic The aim of this review is to highlight the risks that the high-risk obese parturients encounter and discuss dietary, medical and surgical options in the care of these patients from pregestational stages until postpartum. We will review the role of diet, exercise, bariatric surgery, mode of delivery and regional or general anesthesia, where special concerns are required in the obese gravida. Keywords: Desirable weight gain, management, obesity, obstetric risks, pregnancy, perinatal risks.

The impact of body mass index on the risk of high spinal block in parturients undergoing cesarean delivery: a retrospective cohort study.

To investigate the hypothesis that the risk of high spinal block is not increased in obese parturients undergoing cesarean delivery compared to non-obese parturients. This is a retrospective study at an academic center. We searched the perioperative database for women who underwent cesarean delivery under spinal or combined spinal epidural anesthesia with hyperbaric bupivacaine ≥10.5mg. A body mass index (BMI) ≥30kg/m2 was defined as obese. We categorized obesity into: obesity class I (BMI=30-34.9kg/m2), obesity class II (BMI=35-39.9kg/m2), obesity class III (BMI=40-49.9kg/m2), and super obese (BMI ≥50kg/m2). The primary outcome was high spinal block defined as need to convert to general anesthesia within 20min of spinal placement as a result of altered mental status, weakness, or respiratory distress resulting from the high block, or a recorded block height ≥T1. The analysis included 5015 women. High spinal blocks occurred in 29 patients (0.6%). The risk of high spinal was significantly different according to BMI (p=0.025). In a multivariate model, BMI (p=0.008) and cesarean delivery priority (p=0.009) were associated with high blocks. BMI ≥50kg/m2 was associated with greater odds of high block compared to BMI <30kg/m2 [odds ratio (95% confidence interval): 6.3 (2.2, 18.5)]. Scheduled cesarean delivery was also associated with greater odds of high block compared with unscheduled delivery. At standard spinal doses of hyperbaric bupivacaine used in our practice (≥10.5mg), there were greater odds of high block in those with BMI ≥50kg/m2.

The performance of neck circumference and other airway assessment tests for the prediction of difficult intubation in obese parturients undergoing cesarean delivery

BackgroundPregnancy and obesity each increase the chance of difficult tracheal intubation. This study assessed the performance of the neck circumference and other bedside tests in predicting difficult intubation, and aimed to identify the optimal cutoff point of the test(s) with the highest performance. MethodsParturients with a body mass index ≥30kg/m2, undergoing a cesarean delivery employing conventional tracheal intubation, were enrolled. Preoperative neck circumference, sternomental distance and modified Mallampati test were examined. Difficult intubation was defined as intubation difficulty scale score ≥5. ResultsFive hundred and seventy parturients of mean body mass index 34.1 (±SD 3.8) kg/m2 were recruited. The incidence of difficult intubation was 3.5%. The performance of the neck circumference test, conducted with the patient sitting or supine, and using the area under the receiver operating characteristic (ROC) curves, was 0.6 (95% CI 0.5 to 0.7) and 0.6 (95% CI 0.4 to 0.7) respectively. The area under the ROC for the modified Mallampati test was 0.6 (95% CI 0.5 to 0.7) and for the sternomental distance test was 0.7 (95% CI 0.6 to 0.8). A sternomental distance less than 14.5cm, and a ratio of neck circumference in the sitting position to sternomental distance of greater than or equal to 2.7, were optimal cutoff points to identify difficult intubation. ConclusionThe neck circumference, the sternomental distance, the modified Mallampati test and the ratio of neck circumference to the sternomental distance show limited performance as screening tests to predict difficult intubation among obese parturients.

Elevated Chemokine C-C motif ligand 2 (CCL2) early in pregnancy is associated with increased risk of preeclampsia in obese parturients

The objective of this study is to measure plasma CCl2 and leptin early in control and obese women and associate pregnancy outcomes with these levels. We hypothesize that early elevations of plasma CCL2 will be predictive of the development of poor pregnancy outcomes.

Increasing body mass index predicts increasing difficulty, failure rate, and time to discovery of failure of epidural anesthesia in laboring patients

Study objectiveObese parturients both greatly benefit from neuraxial techniques, and may represent a technical challenge to obstetric anesthesiologists. Several studies address the topic of obesity and neuraxial analgesia in general, but few offer well described definitions or rates of “difficulty” and “failure” of labor epidural analgesia. Providing those definitions, we hypothesized that increasing body mass index (BMI) is associated with negative outcomes in both categories and increased time needed for epidural placement. DesignSingle center retrospective chart review. SettingLabor and Delivery Unit of an inner city academic teaching hospital. Patients2485 parturients, ASA status 2 to 4, receiving labor epidural analgesia for anticipated vaginal delivery. InterventionsNone. MeasurementsWe reviewed quality assurance and anesthesia records over a 12-month period. “Failure” was defined as either inadequate analgesia or a positive test dose, requiring replacement, and/or when the anesthesia record stated they failed. “Difficulty” was defined as six or more needle redirections or a note indicating difficulty in the anesthesia record. Main resultsOverall epidural failure and difficulty rates were 4.3% and 3.0%, respectively. Patients with a BMI of 30kg/m2 or higher had a higher chance of both failure and difficulty with two and almost three fold increases, respectively. Regression analysis indicated that failure was best predicted by BMI and less provider training while difficulty was best predicted by BMI. Additionally, increased BMI was associated with increased time of discovery of epidural catheter failure. ConclusionsObesity is associated with increasing technical difficulty and failure of neuraxial analgesia for labor. Practitioners should consider allotting extra time for obese parturients in order to manage potential problems.