REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Perioperative
management
of
a
morbidly
obese
pregnant
patient
undergoing
cesarean
section
under
general
anesthesia
---
case
report
夽
Márcio
Luiz
Benevides
a,b,∗,
Verônica
Cristina
Moraes
Brandão
c,
Jacqueline
Ivonne
Arenas
Lovera
baDepartmentofAnesthesiology,HospitalUniversitárioJúlioMuller,UniversidadeFederaldeMatoGrosso(UFMT),
Cuiabá,MT,Brazil
bCentrodeEnsinoeTreinamentodaSociedadeBrasileiradeAnestesiologia(CET/SBA),Cuiabá,MT,Brazil
cDepartmentofGynecologyandObstetrics,UniversidadeFederaldeMatoGrosso(UFMT),Cuiabá,MT,Brazil
Received5January2014;accepted6May2014 Availableonline30April2016
KEYWORDS
Morbidobesity; Cesareansection; Generalanesthesia: remifentanil
Abstract
Backgroundandobjectives: The increased prevalence of obesity in the general population extendstowomenofreproductiveage.Theaimofthisstudy istoreporttheperioperative managementofamorbidlyobesepregnantwoman,bodymassindex>50kg/m2,whounderwent
cesareansectionundergeneralanesthesia.
Casereport: Pregnantwomaninlabor,35yearsofage,bodymassindex59.8kg/m2.Cesarean
sectionwasindicatedduetothepresumedfetalmacrosomia.Thepatientrefusedspinal anes-thesia.Shewasplacedintheramppositionwithcushionsfrombacktoheadtofacilitatetracheal intubation.Anothercushionwasplacedontopoftherightgluteustocreateanangleof approx-imately15◦ totheoperatingtable.Immediatelybeforeinductionofanesthesia,asepsiswas
carriedoutandsterilesurgicalfieldswereplaced.Anesthesiawasinducedinrapidsequence, withSellickmaneuverandadministrationofremifentanil,propofol,andsuccinilcolina. Intuba-tionwasperformedusingagumelasticbougie,andanesthesiawasmaintainedwithsevoflurane andremifentanil.Theintervalbetweenskinincisionandfetalextractionwas21min,withthe useofaSimpson’sforcepsscooptoassistintheextraction.Thepatientgavebirthtoanewborn weighing4850g,withApgarscoresof2inthe1stminute(receivedpositivepressureventilation bymaskforabout2min)and8inthe5thminute.Thepatientwasextubateduneventfully. Mul-timodalanalgesiaandprophylaxisofnauseaandvomitingwasperformed.Motherandnewborn weredischargedonthe4thpostoperativeday.
© 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
夽
Studysite:HospitalUniversitárioJúlioMuller,Cuiabá,MT,Brazil. ∗Correspondingauthor.
E-mail:mmmmb@terra.com.br(M.L.Benevides).
http://dx.doi.org/10.1016/j.bjane.2014.05.011
0104-0014/©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC
PALAVRAS-CHAVE
Obesidademórbida; Partocesariano; Anestesiageral: remifentanil
Controleperioperatóriodegestanteobesamórbidasubmetidaapartocesarianosob anestesiageral---relatodecaso
Resumo
Justificativaeobjetivos: O aumento na prevalência da obesidade na populac¸ão geral se estendeparamulheresnaidadereprodutiva.Oobjetivodesteestudoérelatarocontrole peri-operatóriodeumagestanteobesamórbidacomíndicedemassacorporal>50Kg/m2,submetida
apartocesarianosobanestesiageral.
Relatodocaso: Gestante de 35 anoscom índice de massa corporal de 59,8 Kg/m2. Estava
em trabalho departo. Foiindicado partocesarianodevidoa macrossomiafetal presumida. A pacienterecusouraquianestesia.Elafoiposicionadaemrampacomcoxinsnodorsoatéa cabec¸aparafacilitaraintubac¸ãotraqueal.Outrocoximfoicolocadonapartesuperiordo glú-teodireito paracriar uma angulac¸ãopróxima de15◦ comamesacirúrgica. Imediatamente
antesdainduc¸ãoanestésica,procedeu-seaassepsiaecolocac¸ãodecamposcirúrgicosestéreis. Foifeitainduc¸ãoemsequênciarápidacommanobradeSellick,comremifentanil,propofole succinilcolina.Aintubac¸ãofoifeitacomauxíliodegumelasticbougie.Aanestesiafoimantida comremifentanilesevoflurano.Ointervaloentreaincisãonapeleeaextrac¸ãofetalfoide21 minutosefoiusadaumadascolheresdofórcepsdeSimpsonparaauxílionaextrac¸ão.Paciente concebeu recém-nascidocompesode4.850g,apresentouíndice deApgarde2noprimeiro minuto(recebeuventilac¸ãocompressãopositivasobmáscaraporaproximadamentedois min-utos)e8noquintominuto.Apacientefoiextubada,semintercorrências.Foifeitaanalgesia multimodaleprofilaxiadenáuseasevômitos.Mãeerécem-nascidoreceberamaltanoquarto diadepós-operatório.
© 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença de CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
The prevalence of obesityis onthe risein countrieswith low and middle income, especially in urban areas.1 This
increase in the prevalence of obesity in the general pop-ulation extendstowomen ofreproductive age. Obesityis associated with several unwanted clinical outcomes dur-ingpregnancy,includingpreeclampsia,gestationaldiabetes mellitus, venous thromboembolism, post-term pregnancy, fetal macrosomia, and stillbirth.2 Cesarean delivery rate
ishigherinobesepregnantwomen,especiallyin morbidly obese ones.2---4 Obese pregnant women are at increased
risk for labor induction, dysfunctional labor, shoulder dystocia, higher rate of surgical site infection, urinary tractinfection,endometritis,andpostpartumhemorrhage.5
Maternal obesity is associated withincreased difficultyin performingneuraxialanesthesia,6higherincidenceof
arte-rial hypotension,7 and intubation failure during general
anesthesia.8 Newbornsof obesepatients are at increased
risk for perinatal complications (low blood pH, lower base excess, hypoglycemia, and lower Apgar index).9,10
Pregnant women withbody mass index (BMI) ≥50kgm−2,
also called super-obese,2,11 have significantly higher risk
for complications during pregnancycompared withothers lessobese.11Theperioperativeanestheticandsurgical
man-agementofobesepatientswithBMI>50kgm−2undergoing
cesareandeliverycanbequiteachallenge.Theobjectiveof thispaperistoreporttheperioperativemanagementof a pregnantwomanwithBMI>50kgm−2,undergoingcesarean
sectionundergeneralanesthesia.
Case
report
Pregnant woman, 35 years old, 169kg and 168cm (BMI=59.8kgm−2)(Fig.1),gravida4,para2,abortion1with
41weeksandsixdaysofgestation.Withhypertensionfor14 years,thepatientwastakingalphamethyldopa1.5gday−1;
withuterinemiomatosis,shehadseveralepisodesof metr-orrhagia before the pregnancy. She underwent curettage formissedabortionfouryearsago,withoutanestheticand surgical complications. The patient was admitted to the obstetricunitin laborwithamniotic sacrupture, andwas fastingforeighthours.Cesareansectionwasindicateddue tosuspectedfetalmacrosomia (estimated fetalweightof 4600g in ultrasound) and the expected difficulty of fetal monitoring.Laboratorytestsshowedhemoglobin9.8gdL−1,
hematocrit31.3%, WBC 7900mm3,platelets 190,000mm3,
urea 26mgdL−1, and creatinine 0.6mgdL−1. The patient
complained of discomfort when placed in the supine position. She was lucid, collaborative, with dry mucous membranesand pallor skin. Airwayexamination revealed Mallampatigrade II, mouthopening largerthan 3cm,and thyromentaldistance greater than 6cm.Neck flexionand extensionwerelimited.Apronabdomen,gravid,with hyper-emia in the lower region, diffusely tender to palpation. The patient refused spinal anesthesia despite arguments to the contrary. In the operating room, the patient was monitoredwith 5-leadECG, pulseoximetry (oxygen satu-ration),noninvasive blood pressure and,after intubation, capnographyandgasanalyzer(O2andCO2andinhalational
Figure1 35-yearoldpregnantwoman,weighing169kgand 168cm.
heartandrespiratoryrateatbaselinewere130/80mmHg, 89%,80beatsperminute(bpm),and15breathsperminute (rpm),respectively.Aftervenouspuncturewithintravenous catheter 16G, infusion of lactated Ringer’s solution (RS) was started (10mLkg−1 ideal body weight). The patient
wasplaced in the rampposition withcushions fromback to head to parallel her with the ground, the imaginary line from the ear canal to the sternum. Another cush-ion was placed on top of the right gluteus to create an angleofabout15◦totheoperatingtableinordertomove theuterustotheleft.Intravenous(IV)ranitidine(100mg) was administered and bladder catheterization performed beforestartingtheoperation.Immediatelybeforeinduction of anesthesia, asepsis was carried out and sterile surgi-cal fields were placed. The patient received 7Lmin−1 of
oxygenviafacemaskforthreeminutesfollowedby remifen-tanil70gIVover 60s, lidocaine80mg,propofol200mg,
and succinylcholine 150mg. During airway management Cormack-Lehane grade III was identified by laryngoscopy, andtrachealintubationwasperformedwitha7.5mm can-nulainquicksequencewithSellickmaneuveranduseofa trachealtubeintroducer(gumelasticbougie,GEB)without complications. Controlled ventilation wasperformed with tidal volume of 680mL, respiratory rate of 12rpm, PEEP of 5cm H2O, and FiO2 of 0.5. Maintenance of anesthesia
performed with sevoflurane 1.5---2.5%, atracurium 25mg, andremifentanilof0.3gkg−1min−1uptofetalextraction
and0.2gkg−1min−1 after fetal extraction tothe end of
theoperation. Ephedrine wasadministered IVbeforeand afterfetalextraction,15mgand5mg, respectively.After clampingthe umbilical cordoxytocin wasadministeredin a bolus injection of 5IU and 10IU in 500mL of RS solu-tion.CephalothinIV2g(maintainedwith1g6/6hforfour days),dexamethasone10mg,andketorolac30mgwerealso infused.Thirtyminutesbeforetheendofsurgerythepatient receiveddipyrone2gIV,methadone10mg,andondansetron 8mg.Ittooktwoassistants,oneoneachsideofthepatient, tolifttheapronabdomencephalicallyinordertofacilitate thePfannenstielincision.Theintervalbetweentheskin inci-sionand fetalextraction was21minutes. Oneof Simpson forcepsspoonswasusedtoaidintheextraction.The new-bornwas male, weighing4850g,withApgar score of2 in
the firstminute (receivedpositive pressureventilation by mask for about 2min) and of 8 in the fifth minute. After 140minutesfromthestart of anesthesia, thepatientwas extubated uneventfully. The patient hadno perioperative awareness.Intravenousdipyrone2g/every4handketorolac 30mgevery8hweremaintainedfor48h.Thepatienthadno painatrestwithinthefirst12hours.Intravenoustramadol (100mg)wasadministereddilutedin100mLsalinesolution approximately13h after theoperation due tocomplaints ofmoderatepainduringambulation.Thepatientwas satis-fiedwiththepost-operativepainmanagementandhadno postoperativenauseaorvomiting.Motherandnewbornwere dischargedonthefourthdayaftersurgery.
Discussion
Pregnant women with BMI≥50kgm−2 have an increased
risk for cesarean delivery, regardless of parity.11 In our
case, we believe that cesarean delivery would be better because there was an estimated fetal macrosomia, com-binedwithexpectationsoftechnicaldifficultyinmonitoring the fetal well-being. Because general anesthesia is asso-ciated with increased morbidity and mortality,12 regional
anesthesiahasbecomethemostwidelyrecommended anes-thetic technique. However, because the patient refused spinal anesthesia despite arguments to the contrary, the useof thistechniquewasdiscarded.Thepatientreceived intravenous ranitidine before surgery in order to reduce thegastric pH,tomitigateapossibleaspirationof gastric contents during tracheal intubation. Oral non-particulate antacid(0.3molarsodiumcitrate)wasnotgiven preoper-atively,asrecommendedbytheguidelines,13 becausethis
drugisnotavailableinourservice. Thepositioningofthe patient onthe operatingtable, usingramp cushionsfrom backtoheadordevicethatdoesthesamefunction,as sug-gestedby Simoni,14 ismandatoryin apatientlikethis,as
it greatly facilitates tracheal intubation. Placing a cush-ion under the right gluteus of the patient was also very importanttomovethepregnantuterustotheleft,inorder to prevent the aortocaval compression syndrome, as the manualdisplacementofthepregnantuteruscouldbevery difficult or evenunproductive inthis patientwithaquite large abdomen. Furthermore, the cushion allowed letting one of the staff members free for other tasks. The uri-narycatheter,asepsisandplacementofsurgicalfieldsprior toinductionofanesthesiamayenableshorteningthedrug transfertimetothefetus.Weusedremifentanil,apotent syntheticopioidoffastonsetofaction,aroundoneminute, thatpresentsauniquepharmacokineticfeatureof,among other opioids, plasma and tissue esterases metabolism into inactive metabolite, with a context-dependent half-life of3min. Consequently,it does notaccumulatein the mother,evenafterprolongedadministration.15Remifentanil
can offer maternal hemodynamic stability and attenuate responsestoairwaymanagementandsurgicalstimulation.16
Similartootheropioids,remifentanilcrossesthe placental-uterus barrier, but itis rapidlycleared fromthe newborn plasma.17 Therefore,it maynothave thedisadvantage of
neonatal respiratory depression associated with fentanyl andalfentanil.18,19Thedecreasedfunctionalresidual
in more rapid onset of oxyhemoglobin desaturation dur-ing apneacompared tonon-pregnantwomen. In morbidly obesepregnant women, theonset ofdesaturation can be even faster.20 The cricoid pressureapplication during the
Sellickmaneuver,inrapidsequenceinduction,worsensthe glottisview.Trachealintubationinthissituationisgreatly facilitatedbytheuseof GEB.21 This deviceiseasytouse,
portable,andrelativelyinexpensive.GEBwasthemost com-monlyuseddevicein3423emergencyintubationsanalyzed byMartinetal.22Duringintubation,theuseofGEBcombined
with the ramp positioning of our patient was very help-fulbecauseitallowedrapidintubationwithoutloweringof oxygensaturation.Thepatientremainedhemodynamically stableduringsurgery,requiredsmalldosesofephedrinefor correctionof shortperiodsof hypotension. Averticalskin incisionisatechniqueoften usedforcesarean deliveryin morbidly obesepregnant women.23,24 However,skin
verti-calincisions, comparedwithlow transverse incisions, are associatedwithincreasedsurgicaltime,greaterbloodloss, increased postoperative pain, higher incidence of atelec-tasis,superficialwound,andfasciadehiscence.24---26 Inthis
case,thepresenceofhyperemiaandwarmthinthe perium-bilicalregion(cellulitis?)definitelyruledoutthepossibility ofacross-surgicalapproach.Andthebiggestproblemwith thePfannenstielsurgicalapproachwasthefetalextraction difficulty,which requiredtheuseof Simpsonforceps.Itis alsonoteworthythatbecauseoftheuniqueanatomical char-acteristics of the patient the time interval between skin incisionandfetalextractionwaslarge(21min),but compa-rable tothatreported byConneretal. (16±11.3min for BMI>50kgm−2).27 Conner et al.27 also reported that the
increase in BMI was associatedwith a statistically signifi-cant increase in pH <7.2 and excess base ≤8mmolL−1 of
umbilicalcordblood.The Apgarscoreofthenewbornwas lowinthefirstminute,butrecoveredpromptlyafter posi-tivepressure ventilationby mask.This mayhave resulted from the longer period of time between the skin inci-sionandfetalextractionitself,prolongedexposuretothe effectofbalancedgeneralanesthesiawithremifentanil,and some degree of aortocaval syndrome. Obese patients are susceptibletoincreasedrisk forsurgical wound infection, urinarytractinfection,endometritis,andsepsis.Evaluating 133morbidlyobesepatientsundergoingcesareandelivery, Brocato etal.26 reported27% incidenceof surgicalwound
complications(infectionor dehiscence)and4% endometri-tis.Alanisetal.,25studying194womenwithBMI≥50kgm−2
undergoingcesareansection,reportedanincidenceofabout 27% of surgical wound dehiscence and 4% of cellulite in thesurgicalwound.Therefore,itisimportanttoestablish preventive measures against infection for these patients. Prophylacticantibioticsforcesareandeliveryhas tradition-allybeenusedaftertheumbilicalcordclampingforfearthat theantibioticwasharmfultothebabyandcouldproduce resistanceofmicroorganismstoantibioticsormaskneonatal infections. However,in 2010, the ACOG Committee Opin-ionrecommendedthattheantibioticisadministeredwithin 60minbeforeskinincision.28 Morerecently,BaaqeelHand
BaaqeelR, ina meta-analysisthat included 2313 women, reported a 41% reduction in the incidence of endometri-osis with the preoperative use of antibiotics.29 However,
ourpatientreceived antibioticafter clamping,which was maintainedforsevendaysonsuspicionofcellulite.Provide
adequate postoperative analgesiato patients shouldbe a commitment of the entire team of caregivers. Because thepatientreceivedremifentanilinhighdoses,therewas concernabout the possibility of hyperalgesia in the early postoperativeperiod.30 To obviatethis problem, an
anal-gesicregimenincludingmethadone,dipyrone,andketorolac (multimodalanalgesia)wasestablished.Particularattention wasgiven to methadone for itsaction as NMDA receptor antagonist.31,32Andthisregimenwassatisfactoryin
control-lingpostoperativepain.
Conclusion
Because the prevalence of obesity is increasing among pregnant women, an increasing number of patients will undergocesareandelivery.Andmanypregnantwomen,for variousreasons, willrequire general anesthesiafor deliv-ery. The multidisciplinary team should take into account the anatomical, physiological, and clinical characteristics ofthesepatientsfor thebestpossibleperioperative man-agement,aimedattheirrapidrecoveryandtopreservethe integrityoftheirnewborns.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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