Anaesthesia for the obese pregnant patient

1
Anaesthesia for the obese pregnant patient

• Dr Craig Hargreaves
• VMO Royal Hospital Women

2
summary

• General figures
• Analgesia for labour
• LSCS
• DVT risk

3
Obesity

• BMI (kg/m2)
• 52 Female population, 34 obstetric population
• Co morbidities with stressful physiology
• Increased risk death,CAD and Stroke
• Increased morbidity and mortality with
  anaesthesia
• CEMCH obesity overrepresented
• 50 anaesthesia deaths obese

4
Comorbitities

• Respiratory
• Hypoxia
• OSA
• Cardiovascular
• Hypertension
• CAD
• Increased work for heart
• Heart Failure

5
FRC
Reduced FRC Hypoxia Reduced
Reserve Increased demand
6
Obstetric risks

• Associated disease
• diabetes, hypertension and preeclampsia
• Difficult monitoring
• Large babies
• Longer, more painful labour
• Increased risk birth trauma
• Increased instrumental deliveries
• Increased LSCS

7
Analgesia for Labour

• Non epidural analgesia
• IV access
• Epidural analgesia
• Difficult
• Increased risks
• Remifentanyl PCA
• Early notification, consider early epidural,
  senior help

8
Depth 40 7cm
Midline
1st pass 40 47
Failure 40 7.7 40 11.7 (46)
Complications Dural Puncture 4

9
Labour Epidurals

• Low dose mixtures to try to preserve motor
  function
• Suggestion obese may be more sensitive to local
  anaesthetics

10
Remifentanyl PCA

• Ultra short acting opioid
• CS1/2T 3min
• Concerns
• Wide individual variation
• Sedation / resp depression
• Fetal / neonatal effects
• Careful in OSA
• Labour ward protocol

11
LSCS

• Not to be taken lightly
• Surgically difficult, longer, greater blood loss
• Regional techniques vs GA
• Logistics
• Premedication
• ranitidine/metoclopramide 12/2 hrs
• Antibiotics
• 2g cephazolin and for 24hrs
• Oxygen
• Post operative care

12
Regional Techniques

• Method of choice
• Combined Spinal Epidural
• Longer proceedure
• Unpredicable block height
• Reduce failures
• Long needles
• Greater failure rate, increased complications
• Intrathecal catheter
• Blood Pressure Monitoring

13
(No Transcript)
14
(No Transcript)
15
Logistics

• Time
• Table
• Iv access
• Equipment
• Monitoring
• Moving patient (Regional best done on table)
• Positioning Patient
• Aortocaval Compression
• For intubation
• Extra staff,surgeons

16
Hovermat
17
(No Transcript)
18
Emergency LSCS

• Hopefully avoid
• Epidural topup
• CSE
• High risk converting to GA
• Resusitation and monitoring of mother and baby to
  buy some time.

19
General Anaesthesia

• To be avoided!
• Over represented in CEMCH reports
• Obesity and Pregnancy compound risks
• Difficult Intubation
• Consultant, planning, time
• Aspiration
• Awake Intubation
• Hemodynamic instability and risk

20
Post Op analgesia

• Paracetamol, NSAIDS, others
• Local
• Catheter left in
• 24hrs max
• pethidine
• Intrathecal/Epidural Morphine
• Good
• Itch
• Liposomal morphine
• PCA

21
DVT

• Obesity risk factor for thromboembolic events
• RCOG Guidelines consider heparin prophylaxis
• urgent need for guidelines ... Obese pregnant
  women
• Early mobilisation
• Good hydration
• Compression stockings
• Clexane 40mg daily 3-5 days
• Wound haematoma 2, PPH risk 1.17

22
Epidurals and LMWH

• 4 hours after epidural/LSCS
• 12 hrs between dose and remove/insertion with
  prophylaxis
• 24 hrs between dose and remove/insertion with
  treatment
• Concerns with NSAIDS
• Best remove catheter

23
Conclusion

• Difficult and challenging patients
• High risk for complications
• CEMCH suggests
• All Obstetric units have protocols
• Early Anaesthetic assessment
• Team approach with planning
• Anaesthetic consultant
• All morbidly obese should have LMWH heparin