Pathophysiological and Perioperative Features of Morbidly Obese Parturients

Abstract and Introduction

Abstract

The prevalence of obesity is increasing among pregnant women. The association between obesity and pregnancy can result in further limitation of parturient physiological reserve. Indeed, maternal obesity is associated with an increased risk of delivery and postpartum complications, and poses a number of additional challenges for both general and neuroaxial anesthesia. The higher complication rate and the presence of obesity-related co-morbidities concur in placing this population at high risk for anesthesia-related maternal morbidity and mortality. Bariatric surgery scheduled before gestation to allow effective weight reduction, reduces the overall perinatal outcome to levels comparable to the general population. This review provides an insight into the magnitude and pathophysiological features of obese parturients, maternal and neonatal associated risks, along with peculiar anesthesiological management strategies.

Introduction

The prevalence of significant obesity continues to rise in both developed and developing countries, with the proportions of a worldwide epidemic and with marked differences in distribution according to socioeconomic status.^[1,2] The incidence of obesity has been reported to be approximately 15-20% in Europe and 30% of adults in the USA, where it is estimated to exceed 40% by 2025.^[3]

Obesity affects every system in the human body and is the cause of many chronic medical problems. Obese patients have more annual admissions to hospitals, more outpatient visits and higher prescription drug costs than nonobese adults. The implications for anesthetic and perioperative care of severely obese patients are also considerable, and escalate in the presence of comorbidities.^[4,5] Obese patients also have quality-of-life issues that can include depression and a feeling of social incompetence.^[1,2]

The obesity epidemic makes no exception for the female population of reproductive age.^[6] Maternal obesity is associated with increased morbidity, especially gestational diabetes and hypertensive disorders, as well as fetal complications, such as macrosomia, stillbirth and early neonatal death.^[7,8] Maternal obesity is also a long-term risk factor for the child: obesity and Type 2 diabetes are twice as likely to develop later in life.^[9,10] Delivery in this population is characterized by a high cesarean-section rate and an increased risk of anesthetic and postoperative complications.^[11] Both obesity and excessive maternal weight gain during gestation contribute to an increase in the technical difficulties and risks of general and regional anesthesia.^[12]

Disclaimer

No writing assistance was utilized in the production of this manuscript.

Cite this: Pathophysiological and Perioperative Features of Morbidly Obese Parturients - Medscape - May 01, 2009.

Box 1. Obesity and Associated Obstetric Complications
Maternal Hypertensive disease (chronic hypertension and preeclampsia) Diabetes mellitus (pre and gestational) Urinary tract infection Thromboembolic disorder Increased rate of premature delivery Increased rate of instrumental delivery Increased rate of cesarean delivery Wound infection Increased rate of postpartum depression Infant Fetal distress Meconium aspiration Abnormal presentation Low Apgar score Macrosomia Cardiac malformations Neural tube defects (spina bifida) Late fetal death Childhood obesity

Box 2. Obesity-related General and Regional Anesthesia Challenges
General anesthesia Aspiration of gastric content Failed intubation Inadequate ventilation Respiratory failure Different drug dose Regional anesthesia and analgesia Technically difficult to perform Positioning for the block Identifying appropriate landmarks Needle length Definition of local anesthetic dose

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.