evidence based approach to cesarean delivery in the obese gravida
TRANSCRIPT
Objectives
• Name 3 comorbidities associated with obesity in the general population and 2 additional comorbidities associated with obesity in the pregnant population.
• Name 3 measures that can be taken preoperatively to decrease morbidity during a C-Section
• Name 2 measure that can be taken intraoperatively to decrease morbidity during a C-Section
Definition of Obesity
• Definition BMI (kg/m2)Obesity Class
• Underweight BMI<18.5
• Normal BMI 18.5-24.9
• Overweight BMI 25.0-29.9
• Obese BMI 30.0-34.9Class I
BMI 35.0-39.9 Class II
• Extreme Obesity BMI >40 Class III
Epidemiology of pregnant population
• In one 2007 Californian study (Kim et al) it was found that >40% of women are overweight or obese when initiating pregnancy
• A 2006 study (Johnson et al) looking at a US database showed 25% incidence of obesity when initiating pregnancy
• In a 1999 study (lu et al)o 25% of women >200 lbs at first PNVo 10% >250 lbso 5% >300 lbs
Risks of Obesity in General Population
• CAD, HTN, hyperlipidemia
• DM Type II
• Obesity hypoventilation syndrome, OSA, Asthma
• GERD
• Fatty Liver, Cholelithiasis, NASH, Cirrhosis
• Stress urinary incontinence
• Venous stasis, DVTs, PEs
• Hernias
• Infection (cellulitis, post-op wound infections)
• Depression
• PCOS, infertility
Risks of Obesity in Pregnancy
• Increased miscarriages
• GDM
• GHTN, PreE
• Prolonged hospitalization
• UTIs
• Dysfunctional Labor
• Hemorrhage
• Increased rates of C-sections
• Perioperative Risks
Fetal Risks
• Preterm Deliveries
• Post Term Pregnancy
• Lower Apgar Scores
• IUGR
• Macrosomia & shoulder dystocia
• NICU admissions
• neonatal and childhood obesity
• Congenital malformations (spina bifida, omphalocele, heart defects)
Increased incidence of C/S
• European prospective study with more than 200,000 deliveries a BMI >40 was associated with 4 times risk of C/S. Cedergren MI et al
• Another study C/S for nonobese was 20.7%, compared with 33.8% for obese (BMI 30-34.9) and 50% for extremely obese (BMI>35) Wiess JL et al.
• Increase in Emergent C-Sections. Poobalan AS et al.o Overwieght OR 1.53o Obese (30-34.9) OR 2.26o Extremely Obese (>35) OR 3.38
Perioperative morbidities
• Prolonged operative time
• Increased Blood Losso Fe in PNCo T&Co H/H before OR
• Increased risk of thromboembolismo Thrombopyphylaxis
• Aspiration/Failed intubation
• Anesthetic Morbidities
Anesthesia Considerations
• 75% of all anesthesia-related maternal deaths happened in obese ptso Difficult placement of IV accesso Difficult achieving endotracheal airway
Pts more quickly desaturateo Difficulty placing epidural/spinal
Pt can't flex back as well More tissue to go through Importance of prophylactic CSE
o Aspiration Prophylaxis Bicitra Consider NPO in labor
o Anesthesia Consult in Class III obesity in third trimester (Class C)
Prophylactic antibiotics
• Review of 66 trials showed prophylactic abx reduces risk of infection up to 75%. Smaill et. al (Level A)o Study with bariatric pts showed inadequate abx
levels in obese pts receiving 2 g of ancef (Edmiston et al)
Thromboembolic prophylaxis
• One of the leading causes of maternal deatho Occurs more frequently in obese pts
• SCDs Pre and postoperatively (Level C)
• If BMI>40 Unfractionated Heparin 5000-10000 u q 8-12 hrso No well designed RTCs to assess risk reduction
therefore recommendations is expert opinion (Level C)
Importance of team approach
• Appropriately trained OR staff
• Surgical assistant(s)
• Anesthesiology staff trained in fiberoptic intubation
Incision Choice• Lack of randomized control studies.
• Vertical incision o 12 fold greater risk of wound complications compared to
transverseo Rapid, Easy to extend
• Transverse Incisiono Low
warm moist area under pannus • thought to increase risk of infection
Cephalad retraction of pannus• May lead to cardiopulmonary comprimise
o Perumbilical/Supraumbilical Avoid button hole Avoid using the umbilicus as a landmark
• Joel-Cohen recommended
• Pannulectomy if necessary
Intraoperative Considerations
• Self retaining retractoro Alexis retractor
• Fundal pressure often difficult and limitedo Have vacuum available
Closure
• 1 or 2 delayed absorbable monofilament suture on facia. o Fascial stitch should incorporate >1cm of facia and
stitch interval no <1 cm aparto Consider Mass closure (Smead Jones Technique)
• Subcutaneous Sutureo In a 2004 metanalysis (Chelmow et al)34% decrease
in risk of wound complications with subcutatneous sutures when subcutaneous tissue >2cm (Grade A)
• Drainso No additional benefit (Grade A)
• Staples vs subcuticularo Decreased incidence of postop wound exploration
with staples (Grade C)
Post operative morbidities• 10 fold increase in post-operative endometritis
• Higher rates of wound infectiono Close inspection of woundo Consider removing staples after discharge in office esp
with vertical incision
• Increased risk of thromboembolismo Encourage early ambulation
• Postpartum weight retentiono Encourage breast feedingo Nutrition counselingo Consider bariatric consult
• Higher rates of PP depressiono 40% with Class III obesity
• Higher rates of pregnancy with OCPso Consider IUD
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