Anesthetic Management of a Super Morbidly Obese Obstetric Patient With a Body Mass Index of 109 kg/m2 Presenting for Her Fourth Caesarean Delivery

Abstract

Morbidly obese obstetric patients undergoing anesthesia present many unique challenges. Previous caesarean sections (CSs) further complicate their management. We present the successful anesthetic management of a super morbidly obese obstetric patient with body mass index (BMI) of 109 kg/m 2 who underwent her fourth CS. As per our review, this patient has the highest recorded BMI in the obstetric anesthesia literature. A 27-year-old female, G4P3003, presented for fourth repeat CS at 38 weeks' gestation. She had obstructive sleep apnea, hypertension, atrial fibrillation, and type 2 diabetes. Her first CS was emergent under general anesthesia (GA), and the other two were performed under neuraxial anesthesia, with the most recent one complicated by intraoperative cardiac arrest requiring cardiopulmonary resuscitation. Preoperative preparation involved multidisciplinary preparation, planning, and risk stratification. Although neuraxial anesthesia is preferred over GA for CS, she refused neuraxial anesthesia due to her prior traumatic experience and the potential that it caused her prior cardiac arrest. In addition, her inability to position for a block or lay flat, poor anatomical landmarks, unknown length of surgery, plan for periumbilical incision, uncertain placental status, and risk of massive hemorrhage convinced us to consider GA. Surprisingly, her airway examination was reassuring. Two 18G peripheral intravenous lines and an arterial line were obtained prior to induction. With optimum patient positioning and preoxygenation, modified rapid sequence induction with mask ventilation and endotracheal intubation with direct laryngoscopy were performed. A healthy baby was delivered without significant intraoperative complications. Intraoperative lung-protective strategy with recruitment maneuvers, multimodal analgesia, and elective postoperative continuous positive airway pressure aided in successful extubation. Postoperatively, pulmonary toilet, early mobilization, physical therapy, and venous thromboembolism prophylaxis were employed. Her postoperative course was complicated by severe preeclampsia and pulmonary embolism, which were managed successfully in the intensive care unit. She was discharged initially to outpatient rehabilitation followed by home. This case highlights the complexities and significance of an individualized approach in managing super morbidly obese obstetric patients.

Case report: Maternal cardiac arrest at 12 hours postpartum

“…Thromboembolism also can be a cause of cardiac arrest in the peripartum period and is a significant concern for obese parturients [ 10 ]. Reports have demonstrated cases of cardiac arrest resulting from pulmonary embolism in morbidly obese parturients during the perioperative period [ 11 , 12 ]. Given the absence of thromboprophylaxis in our patient, thromboembolism should be considered as a potential differential diagnosis.…”

Comparison of perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section

“…Our patient suffered a massive pulmonary embolism, leading to intraoperative cardiac arrest. In a recent case report, a patient with a BMI of 109 kg/m 2 who underwent a cesarean delivery also had a history of cardiac arrest from a pulmonary embolism in a previous delivery [ 36 ]. These two cases highlight that parturients with obesity have higher risks from anesthesia and cardiac arrest in the peripartum period than pregnant women of normal weight.…”

Cesarean Delivery in a Patient With Body Mass Index Over 100: Continuous Spinal Anesthesia in Two Consecutive Deliveries

“…Although PDPH is a potential risk, studies suggest that PDPH may be reduced among those with BMI >30 [ 18 , 19 ]. Incidence of PDPH in patients with BMI very much higher than 50 remains unstudied, although no PDPH has occurred in any of the cases of cesarean patients with BMI >70 as reported in the literature [ 8 - 11 ]. The mechanism of lowered risk is uncertain, but theories proposed include increased abdominal pressure or epidural lipomatosis possibly compressing the intrathecal space and reducing leakage [ 19 , 20 ].…”

“…There is no consensus as to whether risks rise continuously, plateau, or show an inflection point as BMI rises above 40. Our literature review has revealed only a single case report discussing general anesthesia during a repeat cesarean delivery in a woman with BMI >100, and three case series discussing five cesarean patients with BMI ranging from 70 to 90 [8][9][10][11]. In this report, we describe the anesthetic management of a patient with a BMI >100 during consecutive cesarean deliveries, focusing on considerations unique to cases with this level of obesity.…”