Evidence Based Approach to Cesarean Delivery in the Obese Gravida.

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 Losso 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

transverseo 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 infectiono 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

Sources• Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida. Am J Obstet

Gynecol 2011;204:106-119.

• Perlow, Jordan H. "Chapter 6: Obesity in the Obstetric Intensive Care Patient." Obstetric Intensive Care Manual. 3rd ed. New York: McGraw Hill, 2011. 61-72. Print.

• Beattie PG, Rings TR, Hunter MF, Lake Y. Risk factors for wound infection following Cesarean Section. Aust N Z J Obstet Gynaecol. 1994;34:398-402

• http://www.cdc.gov/obesity/data/trends.html

• Kim SY, Dietz PM, England L, Morrow B, Calligan WM, Trends in pre-pregnancy obesity in nine states, 1993-2003. Obesity (Silver Spring) 2007; 15:986-93

• Lu GC, Rouse DJ, Dubard M, Cliver S, Kimberlin D, hauth JC. The effect of the increasing prevalence of maternal obesity on perinatal morbidity. AM J obstet Gyneecol 2001;185:845-9

• Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009;301:636-650.

• Weiss JL, Malone FD, Emig D, et al. Obesity, obstetric complications and cesarean delivery rate: a population-based screening study. Am J Obstet Gynecol 2004;190:1091-1097.

• Cedergren MI. Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation to maternal body mass index. Eur J Obstet Gynecol Reprod Biol 2009;145:163-166.

• Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin Anaesthesiol 2007;20:175-180.

• Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev 2002; CD000933.

• Edmiston CE, Krepel C, Kelly H, et al. Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels? Surgery 2004;136:738-747.

• Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143:697-706.

Sources (cont)• Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient.

Obstet Gynecol 2003;102:952-956.

• Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol 2000;182:1502-1505.

• Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 2005;62:220-225.

• Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 2004;103:974-980.

• Magann EF, Chauhan SP, Rodts-Palenik S, Bufkin L, Martin JN Jr, Morrison JC. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002;186:1119-1123.

• Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol 2005;105:967-973.

• Vesco KK, Dietz PM, Rizzo J, et al. Excessive gestational weight gain and postpartum weight retention among obese women. Obstet Gynecol 2009;114:1069-1075.

• LaCoursiere DY, Barrett-Connor E, O'Hara MW, Hutton A, Varner MW. The association between prepregnancy obesity and screening positive for postpartum depression. BJOG 2010;117:1011-1018.