Evidence Based Approach to Cesarean Delivery in the Obese

Gravida

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 Obesity

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 Loss

o 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

Equipment

• Bariatric set• Alexis retractor• Vacuum• elastoplast tape or Montgomery straps

What to do with the Pannus?

Incision Choice• Lack of randomized control studies.• Vertical incision

o 12 fold greater risk of wound complications compared to transverse

o 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)

Smead Jones Closure

Post operative morbidities• 10 fold increase in post-operative endometritis• Higher rates of wound infection

o 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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