Seminars in perinatology
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Obesity is associated with serious morbidity during pregnancy, and obese women also are at a high risk of developing complications during labor, leading to an increased risk for instrumental and Cesarean deliveries. The engagement of the obstetrical anesthetist in the management of this group of high-risk patients should be performed antenatally so that an appropriate management strategy can be planned in advance to prevent an adverse outcome. ⋯ Apart from providing analgesia and alleviating physiological derangements during labor, the presence of a functioning epidural catheter can also be used to induce anesthesia quickly in the event of an emergency cesarean section, thus avoiding a general anesthesia, which has exceedingly high risks in the obese parturient. Successful management of the obese patient necessitates a comprehensive strategy that encompasses a multidisciplinary and holistic approach from all care-providers.
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Obesity has been linked as a risk factor for wound complications and is becoming a more common occurrence. We reviewed the risk factors, preventive strategies, and recommended management of wound complications in obese women undergoing cesarean delivery. The limited available data support the use of prophylactic antibiotic before cesarean delivery, closure of subcutaneous space >2 cm, and maintaining normothermia intraoperatively to help reduce the incidence of postoperative wound complications. ⋯ Antibiotics should be administered in the presence of cellulitis or systemic toxicity. Use of vacuum-assisted wound closure devices may be useful in wound management. There is a need for randomized controlled trials which evaluate the prevention and management of wound complications in obese women undergoing cesarean delivery.
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We sought to quantify the added risk of thromboembolism in the obese parturient, evaluate risk factors for thromboembolism in the obese parturient, and provide suggestions as to when and in what form thromboembolism prophylaxis should be considered. Although recent guidelines from national colleges and advisory groups have attempted to guide the clinician in thromboprophylaxis in the obese parturient, the lack of adequate prospective series and trials has lead to some contrary recommendations. ⋯ Despite a paucity of gold standard evidence, the prevalence of obesity and its associated risk of venous thromboembolism warrants careful consideration for the use of thromboprophylaxis in the obese pregnant population. This is especially important in the presence of additional thromboembolism risk factors.
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The current obesity epidemic appears to contribute significantly to adverse fetal outcomes, and in this work we compile up-to-date evidence for the link between maternal obesity and risk of stillbirth. The review revealed a preponderance of evidence showing that the risk of stillbirth is increased among obese mothers with amplified risk estimates as the severity of obesity increases. ⋯ The literature has predominantly reported a strong association between maternal prepregnancy obesity and stillbirth. The considerable magnitude of association, consistency of positive results for the association between maternal obesity and stillbirth, the establishment of temporality between maternal obesity and stillbirth, the incremental elevation in risk with ascending BMI values, as well as the improvement in fetal survival with decrease in interpregnancy BMI among obese mothers strongly provide sufficient evidence that the relationship between maternal obesity and stillbirth may be causal.
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The epidemic of obesity continues to grow undaunted, promising to affect the lives of more women of childbearing age. The challenges facing those charged with obstetrical care of the obese may require variation in care from forethought and planning, to consultation or referral for care at specialized centers. ⋯ Awareness of prolonged labor curves and the risk of shoulder dystocia must also be part of the management of labor. The data regarding many interventions attempted on behalf of these at risk gravidas are rudimentary but may allow for modifications in care that will positively impact outcomes for mother and child.