A Randomized Controlled Comparison Between Combined Spinal-Epidural and Single-Shot Spinal Techniques in Morbidly Obese Parturients Undergoing Cesarean Delivery

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Abstract

There is no current consensus on the optimal technique for subarachnoid anesthesia in morbidly obese parturients even though some providers prefer the combined spinal-epidural (CSE) over single-shot spinal (SSS) technique. In this randomized controlled study, we compared the time required for initiation of subarachnoid anesthesia between SSS and CSE techniques in morbidly obese parturients undergoing elective cesarean delivery.

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Trends in pre-pregnancy obesity in nine states, 1993-2003.

G Dietz, Lucinda England, W Callaghan … (2007)

Pre-pregnancy obesity poses risks to both pregnant women and their infants. This study used a large population-based data source to examine trends, from 1993 through 2003, in the prevalence of pre-pregnancy obesity among women who delivered live infants. Data from the Pregnancy Risk Assessment Monitoring System in nine states were analyzed for trends in pre-pregnancy obesity (BMI>29.0 kg/m2) overall and by maternal demographic and behavioral characteristics. Pre-pregnancy BMI was calculated from self-reported weight and height on questionnaires administered after delivery, and demographic characteristics were taken from linked birth certificates. The sample of 66,221 births was weighted to adjust for survey design, non-coverage, and non-response, and it is representative of all women delivering a live birth in each particular state. The sampled births represented 18.5% of all births in the United States. Pre-pregnancy obesity increased 69.3% during the study period, from 13.0% in 1993 to 1994 to 22.0% in 2002 to 2003. The percentage increase ranged from 45% to 105% for individual states. Subgroups of women with the highest prevalence of obesity in 2002 to 2003 were those who were 20 to 29 years of age, black, had three or more children, had a high school education, enrolled in Women, Infants, and Children, or were non-smokers. However, all subgroups of women examined experienced at least a 43% increase in pre-pregnancy obesity over this time period. The prevalence of pre-pregnancy obesity is increasing among women in these nine states, and this trend has important implications for all stages of reproductive health care.

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Anesthetic and obstetric outcome in morbidly obese parturients.

D D Hood, D M Dewan (1993)

Large studies reporting anesthetic outcome for morbidly obese parturients are lacking. This study compares the anesthetic and obstetric outcome in morbidly obese parturients and matched control parturients. Anesthesia records were prospectively collected for all patients delivering between September 1978 and November 1989 whose weight exceeded 136.4 kg (300 pounds) at the time of delivery. A retrospective control patient group was collected by matching the first patient weighing less than 136.4 kg, delivered in the same month by the same obstertrician, to the corresponding morbidly obese parturient. Anesthetic and obstetric outcome variables were extracted from medical records and analyzed. Sixty-two percent of 117 morbidly obese women underwent cesarean section, while only 24% of control patients delivered abdominally (P < 0.05). Forty-eight percent of all laboring morbidly obese parturients required emergency cesarean section, compared with 9% of control laboring parturients (P < 0.05). Epidural anesthesia was used successfully for labor and cesarean delivery in 74 of 79 morbidly obese women and 66 of 67 control patients. When compared with control patients, initial epidural anesthesia failure was significantly more likely in morbidly obese women, requiring epidural catheter replacement. Difficult tracheal intubation occurred in 6 of 17 morbidly obese women, compared with 0 of 8 control women (P = 0.06). Morbidly obese women had increased incidences of antepartum medical disease, prolonged cesarean section operation times, serious postoperative complications, and increased hospital stays. The high incidences of antepartum medical disease and emergency cesarean section complicate anesthetic care in the morbidly obese parturients. Epidural anesthesia is feasible; however, the high initial failure rate necessitates early catheter placement, critical block assessment and catheter replacement when indicated, and provision for alternative airway management.

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Massive maternal obesity and perioperative cesarean morbidity.

J Perlow, M A Morgan (1994)

Our purpose was to determine the impact of massive maternal obesity (weight > 300 pounds) on perioperative morbidity among patients undergoing cesarean section. A case-control study was conducted on 43 massively obese pregnant women, identified by perinatal database search, who were delivered by cesarean section between Jan. 1, 1987, and Dec. 31, 1991, at Long Beach Memorial Women's Hospital. Forty-three randomly selected patients who underwent cesarean delivery served as the control group. Medical records were abstracted for perioperative variables and compared between groups. Student t test, chi 2, and Fisher's exact statistical analysis were used where appropriate. No significant differences were observed between groups for maternal age, parity, use of prophylactic antibiotics, length of recovery room stay, or wound dehiscence. The massively obese group was observed to be at significantly increased risk for emergency cesarean section (32.6% vs 9.3%, p = 0.02), prolonged delivery interval (25.6% vs 4.6%, p = 0.01), and total operative time (48.8% vs 9.3%, p 1000 ml (34.9% vs 9.3%, p = 0.009), multiple epidural placement failures (14.0% vs 0%, p = 0.02), postoperative endometritis (32.6% vs 4.9%, p = 0.002), and prolonged hospitalization (34.9% vs 2.3%, p = 0.0003). Massively obese pregnant women undergoing cesarean section are at significantly increased risk for perioperative morbidity.