Anaesthesia for the parturient with obesity

Abstract

Learning objectivesBy reading this article, you should be able to: Discuss the preoperative considerations for the parturient with obesity. Describe the neuraxial and non-neuraxial options for delivering analgesia and anaesthesia in the peripartum period. Discuss the complications associated with obesity in pregnancy.Obesity is a worldwide health problem; its prevalence is increasing in all age groups, including those of childbearing age. Currently in the UK, 23.1% of the antenatal population is obese, with prevalence being highest amongst minority ethnic groups and those from low socio-economic background. 1,2 Similar data have been reported from the USA and Australia. 3 Although once thought to be a disease of highincome countries, the rate of maternal obesity is also increasing in countries, such as India, Bangladesh and Nepal, highlighting the global nature of the disease. 4 These rising rates of obesity are a significant concern for obstetric units, as they are associated with adverse outcomes for both mother and baby. Table 1 summarises the key maternal and fetal complications associated with obesity. Most worrying is the association between maternal obesity and maternal mortality. In the UK, the Confidential Enquiry into Maternal Deaths (CEMD) reports since 2003 have consistently identified that obesity is over-represented in parturients who died from direct causes. In the most recent triennial CEMD report (2015e2017), 34% of women who died were obese and 24% were overweight. 5 Although the overall contribution of anaesthesia to maternal death remains low, obesity is a risk factor for anaesthesia-related maternal morbidity and mortality in CEMD reports since 2010. It is therefore not surprising that current guidance for managing pregnant patients with obesity advocates enhanced antepartum monitoring and detailed delivery planning with multidisciplinary involvement. As such, it is essential that all anaesthetists working on delivery units are able to anticipate and manage the challenges associated with these high-risk patients. Definition and classificationObesity is defined as an excessive or abnormal fat accumulation posing significant health risk. The WHO uses BMI to classify degree of obesity. A BMI between 18.9 and 24.9 kg m À2 is normal, BMI 25e29.99 kg m À2 is overweight and BMI >30 kg m À2 is obese. Obesity is further subclassified as Class 1 (BMI 30e34.9 kg m À2 ), Class 2 (BMI 35e39.9 kg m À2 ) and Class 3 (BMI >40 kg m À2 ). Further definitions for Class 3 obesity include

Lipid-Based Nanotechnology: Liposome

“…Moreover, catheter delivery systems are common techniques for continuously administering local anesthetics to prolong the duration of analgesia [ 174 , 175 ]. However, the value of these systems is limited by the cost of the equipment, the difficulty to maintain the correct position of the catheter, and the additional trainings and skills required for clinicians [ 176 ]. Thus, the development of novel, long-acting local anesthetics, like liposomal bupivacaine, is potentially important in postoperative pain management.…”

Quality of Labor Analgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study

“…3,4 The ostensible advantages of the dural puncture epidural technique would especially benefit obese parturients, in whom difficulty with palpating anatomical landmarks and possible false loss of resistance from increased adipose tissue may make neuraxial placement challenging and increase the epidural catheter failure rate. 6 Moreover, obese parturients are at higher risk of intrapartum cesarean delivery, 7 during which a well-functioning epidural catheter can be used to administer regional anesthesia. This would avoid general anesthesia and its associated risks, such as failed intubation and pulmonary aspiration of gastric contents, which are of particular relevance in obese parturients.…”

Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement Over Conventional Labor Epidural Analgesia?

“…As obesity affects almost a quarter of the antenatal population in high-income countries like the United States, United Kingdom, and Australia6 this is a very important area to research. The increased risks of epidural catheter failure combined with increased risks of instrumental or cesarean birth in the pregnant person with obesity warrant future research endeavors, including further investigation of the DPE, on a larger scale so we could best deliver evidence-based care to this high risk group.…”