Cesarean section in a patient with body mass index > 80 kg/m2: a case report highlighting the clinical challenges
Pedro Guilherme Coelho Hannun, Lorena Delgado Rodrigues, Lauro Ferreira Gonçalves, Carolina Alcoforado de Abreu, Paulo do Nascimento Junior
Abstract
Obesity is a public health concern due to several coexisting conditions like hypertension, diabetes, and pulmonary and cardiovascular limitations. Anesthetic challenges are increased in obese patients, mainly during pregnancy. We report a case of a super obese patient scheduled for elective cesarean section. Spinal anesthesia was performed and went uneventful. Several issues were under concern: difficult venous access and spinal puncture; severe hypotension; difficult airway access; and the need for extra personnel for management. This is a rare and challenging situation for anesthesiologists that requires extra care for successful maternal and fetal outcomes.
Keywords
References
1. Polin CM, Hale B, Mauritz AA, Habib AS, Jones CA, Strouch ZY, et al. Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series. Int J Obstet Anesth. 2015;24(3):276-80. https://doi.org/10.1016/j.ijoa.2015.04.001. PMid:25936783.
2. Kumaraswami S, Futterman I, Pothula S, Rajendran GP, Kaul A. Pushing the envelope in obstetric care: a case report of cesarean delivery in a parturient with a BMI > 100 kg m-2. Case Rep Anesthesiol. 2020;2020:5498584. https://doi.org/10.1155/2020/5498584. PMid:32685215.
3. El Shobary H, Kaufman I, Schricker T. Anesthetic management of a morbidly obese parturient undergoing cesarean section. Middle East J Anaesthesiol. 2011;21(2):289-94. PMid:22435282.
4. McDonnell NJ, Paech MJ. The management of a super morbidly obese parturient delivering twins by caesarean section. Anaesth Intensive Care. 2007;35(6):979-83. https://doi.org/10.1177/0310057X0703500622. PMid:18084995.
5. Ho DK, Karagyozyan DS, Awad TW, Vandse R. Anesthetic management of a super morbidly obese obstetric patient with a body mass index of 109 kg/m2 presenting for her fourth caesarean delivery. Cureus. 2020;12(11):e11803. https://doi.org/10.7759/cureus.11803. PMid:33409048.
6. Amaral CK, Benevides ML, Benevides MM, Sampaio DL, Fontes CJF. Ultrasound assessment of gastric antrum in term pregnant women before elective cesarean section. Braz J Anesthesiol. 2019;69(3):266-71. https://doi.org/10.1016/j.bjan.2019.03.001. PMid:31006483.
7. ACOG: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin, number 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009;114(1):192-202. https://doi.org/10.1097/AOG.0b013e3181aef106. PMid:19546798.
8. ACOG: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin, number 229: antepartum fetal surveillance. Obstet Gynecol. 2021;137(6):e116-27. https://doi.org/10.1097/AOG.0000000000004410. PMid:34011889.
9. Euliano TY, Nguyen MT, Marossero D, Edwards RK. Monitoring contractions in obese parturients: electrohysterography compared with traditional monitoring. Obstet Gynecol. 2007;109(5):1136-40. https://doi.org/10.1097/01.AOG.0000258799.24496.93. PMid:17470595.
10. Eley VA, Christensen R, Kumar S, Callaway LK. A review of blood pressure measurement in obese pregnant women. Int J Obstet Anesth. 2018;35:64-74. https://doi.org/10.1016/j.ijoa.2018.04.004. PMid:29954650.
11. Babadağ K, Zaybak A. Comparing intra-arterial, auscultatory, and oscillometric measurement methods for arterial blood pressure. Florence Nightingale J Nurs. 2021;29(2):194-202. https://doi.org/10.5152/FNJN.2021.19103. PMid:34263238.
12. Maxwell MH, Waks AU, Schroth PC, Karam M, Dornfeld LP. Error in blood-pressure measurement due to incorrect cuff size in obese patients. Lancet. 1982;2(8288):33-6. https://doi.org/10.1016/S0140-6736(82)91163-1. PMid:6123760.
13. Lamon AM, Habib AS. Managing anesthesia for cesarean section in obese patients: current perspectives. Local Reg Anesth. 2016;9:45-57. https://doi.org/10.2147/LRA.S64279. PMid:27574464.
14. Vasudevan A, Snowman CE, Sundar S, Sarge TW, Hess PE. Intrathecal morphine reduces breakthrough pain during labour epidural analgesia. Br J Anaesth. 2007;98(2):241-5. https://doi.org/10.1093/bja/ael346. PMid:17210732.
15. Casati A, Putzu M. Anesthesia in the obese patient: pharmacokinetic considerations. J Clin Anesth. 2005;17(2):134-45. https://doi.org/10.1016/j.jclinane.2004.01.009. PMid:15809132.
16. Kim HJ, Kim WH, Lim HW, Kim JA, Kim DK, Shin BS, et al. Obesity is independently associated with spinal anesthesia outcomes: a prospective observational study. PLoS One. 2015;10(4):e0124264. https://doi.org/10.1371/journal.pone.0124264. PMid:25898360.
17. Sultan P, Halpern SH, Pushpanathan E, Patel S, Carvalho B. The effect of intrathecal morphine dose on outcomes after elective cesarean delivery: a meta-analysis. Anesth Analg. 2016;123(1):154-64. https://doi.org/10.1213/ANE.0000000000001255. PMid:27089000.
18. Sibilla C, Albertazz P, Zatelli R, Martinello R. Perioperative analgesia for caesarean section: comparison of intrathecal morphine and fentanyl alone or in combination. Int J Obstet Anesth. 1997;6(1):43-8. https://doi.org/10.1016/S0959-289X(97)80051-9. PMid:15321310.
19. Ende HB, Dwan RL, Freundlich RE, Shotwell MS, Wanderer JP, Bauchat JR, et al. Quantifying the incidence of clinically significant respiratory depression in women with and without obesity class III receiving neuraxial morphine for post-cesarean analgesia: a retrospective cohort study. Int J Obstet Anesth. 2021;47:103187. https://doi.org/10.1016/j.ijoa.2021.103187. PMid:34053816.
20. van den Bosch OFC, Fiset ME, Downey K, Maxwell C, Carvalho JCA. Anesthetic management of patients with class 3 obesity undergoing elective cesarean delivery: a single-centre historical cohort study. Can J Anaesth. 2023;70(2):202-10. https://doi.org/10.1007/s12630-022-02365-3. PMid:36447090.
21. Kolås T, Øian P, Skjeldestad FE. Risks for peroperative excessive blood loss in cesarean delivery. Acta Obstet Gynecol Scand. 2010;89(5):658-63. https://doi.org/10.3109/00016341003605727. PMid:20218934.
22. Heesen M, Carvalho B, Carvalho JCA, Duvekot JJ, Dyer RA, Lucas RA, et al. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia. 2019;74(10):1305-19. https://doi.org/10.1111/anae.14757. PMid:31347151.
23. Pierpont YN, Dinh TP, Salas RE, Johnson EL, Wright TG, Robson MC, et al. Obesity and surgical wound healing: a current review. ISRN Obes. 2014;2014:638936. https://doi.org/10.1155/2014/638936. PMid:24701367.
24. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-6. https://doi.org/10.1056/NEJM199201303260501. PMid:1728731.
Submitted date:
05/13/2025
Accepted date:
12/12/2025
Facebook
LinkedIn
Mendeley
Reddit
Email