Anestesia Raquidea Obesidad

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Brazilian Journal of Anesthesiology xxxx;xxx(xx):xxx---xxx

CLINICAL RESEARCH

Epidural analgesia in the obese obstetric patient: a


retrospective and comparative study with non-obese
patients at a tertiary hospital
a,∗ a
Claudia Cuesta González-Tascón , Elena Gredilla Díaz , Itsaso Losantos García b

a
Servicio de Anestesiología y Reanimación. Hospital universitario La Paz, Madrid, Spain
b
Departamento de Bioestadística. Hospital universitario La Paz, Madrid, Spain

Received 18 February 2020; accepted 27 February 2021

KEYWORDS Abstract
Obesity; Background and objectives: Obesity is becoming a frequent condition among obstetric patients.
Neuraxial anesthesia; A high body mass index (BMI) has been closely related to a higher difficulty to perform the
Labor analgesia; neuraxial technique and to the failure of epidural analgesia. Our study is aimed at analyzing
Cesarean section obese obstetric patients who received neuraxial analgesia for labor at a tertiary hospital and
assessing aspects related to the technique and its success.
Methods: Retrospective observational descriptive study during one year. Women with a BMI
higher than 30 were identified, and variables related to the difficulty and complications of
performing the technique, and to analgesia failure rate were assessed.
Results and conclusions: Out of 3653 patients, 27.4% had their BMI ≥ 30 kg.m-2 . Neuraxial
techniques are difficult to be performed in obese obstetric patients, as showed by the number
of puncture attempts (≥ 3 in 9.1% obese versus 5.3% in non-obese being p < 0.001), but the
incidence of complications, as hematic puncture (6.6%) and accidental dural puncture (0.7%)
seems to be similar in both obese and non-obese patients. The incidence of cesarean section in
obese patients was 23.4% (p < 0.001). Thus, an early performance of epidural analgesia turns
out to be essential to control labor pain and to avoid a general anesthesia in such high-risk
patients.
© 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

Background
∗ Corresponding author. Obesity has become an increasi ng concern worldwide and
E-mail: claucuestagt@gmail.com (C.C. González-Tascón). continues to rise in developed countries, both among gen-
https://doi.org/10.1016/j.bjane.2021.02.054
© 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: C.C. González-Tascón, E.G. Díaz and I.L. García, Epidural analgesia in the obese obstet-
ric patient: a retrospective and comparative study with non-obese patients at a tertiary hospital, Brazilian Journal of
Anesthesiology, https://doi.org/10.1016/j.bjane.2021.02.054
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BJANE-744110; No. of Pages 7 ARTICLE IN PRESS
C.C. González-Tascón, E.G. Díaz and I.L. García

eral and obstetric population. Body mass index (BMI) is able to establish a comparison with the non-obese obstetric
nowadays considered a reliable and well-known indica- population for the same period. For such reason, we pro-
tor used worldwide in overweight and obesity diagnosis. posed the hypotheses that a high BMI was associated with
Overweight and obesity are defined as a BMI ≥ 25 and ≥ greater maternal and neonatal comorbidity, a higher diffi-
30 kg.m-2 , respectively. According to the World Health Orga- culty to perform the neuraxial technique and failure rate,
nization (WHO), obesity is classified in three categories: as well as a higher cesarean section rate.
obesity grade I (BMI range, 30---34.9 kg.m-2 ), grade II (range, Out of the whole sample, women with a BMI ≥ 30 kg.m-2
35---39.9 kg.m-2 ), and grade III (> 40 kg.m-2 ). According to were identified, while variables related to the difficulty
the last data published by the Spanish National Statistics of performing the technique, to analgesia failure rate and
Institute in 2017, 44.3% of men and 30% of women were complications were evaluated. Maternal body mass index
overweight, and obesity rate was 18.2% in men and 16.7% in was calculated based on the recorded height and weight at
women.1 BMI has in fact increased up to 0.4% during the delivery. Thus, patients were classified into two groups: non-
last 30 years worldwide.2 Overweight and obese patients obese pregnant women (BMI < 30 kg.m-2 ) and obese pregnant
are associated with greater comorbidity, such as coronary women (BMI ≥ 30 kg.m-2 ).
diseases, hypertension, obstructive sleep apnea, or gas- Demographic data related to maternal age, to BMI and
trointestinal reflux.2 maternal pathologies, were collected as well as obstetric
Obesity during pregnancy is also implicated in the mater- data (i.e. gestational age, parity, single or twin pregnancy,
nal and perinatal outcome. On one hand, obesity is an type of labor (spontaneous or instrumental delivery, and
important risk factor of hypertensive disorders and gesta- cesarean section), and neonatal data. Information on the
tional diabetes during pregnancy.3,4 Hypertension can evolve technique performed (epidural or combined spinal-epidural)
to preeclampsia, which considerably increases maternal and was collected as well. On the bases of the complications
perinatal morbimortality, and causes intrauterine growth of the technique, we defined the success or failure of our
retardation of the fetus. Moreover, a BMI ≥ 25 kg.m-2 has technique as the number of puncture attempts, as well as
been associated to a greater risk of miscarriage (58% versus the incidence of hematic puncture (HP) and accidental dural
37% in non-obese pregnant women) and congenital mal- puncture (ADP).
formations, mainly spina bifida, neural tube defects, cleft Finally, we identified those cases that required general
palate and congenital heart diseases.5 A delayed diagnose anesthesia due to a failed neuraxial technique.
may be due to the greater difficulty of using ultrasound in Qualitative data description was made in the form of
these patients. On the other hand, the placenta of obese absolute frequencies and percentages. Quantitative data
pregnant women weighs around 60---80 grams more at the were presented through an average ± typical deviation,
time of birth, and it is just placenta weight that has a greater minimum and maximum when they were continuous and
relation to the weight of the newborn.5 Therefore, it seems through the percentile and the interquartile range when
that fetal macrosomia index, defined as a weight at the dealing with ordinary variables. Qualitative variable asso-
time of birth over 4000---4500 grams, is greater among obese ciation was analyzed by the chi-square test or Fisher’s exact
women, which justifies a higher odd of cesarean section test. Mann-Whitney U test was used for comparing qual-
among these patients.5---7 itative and quantitative data, for independent data, as
The greater rates of instrumental or cesarean delivery in non-parametric evidence, and the Student’s t-student test
obese pregnant women turns neuraxial anesthesia into the for independent data as parametric evidence. All statistic
technique of choice. The key is to avoid general anesthe- tests were considered bilateral and those including p-values
sia in patients, whose pregnant condition plus their obesity lower than 0.05 were considered significant. Data were ana-
altogether, increase complications dramatically, such as a lyzed by the statistics software SAS 9.3 (SAS Institute, Cary,
difficult airway or failed resuscitation after hemodynamic NC, USA).
collapse.4
Therefore, we will discuss the impact of obesity in the
obstetric and anesthetic management, as well as focus on
the importance of a suitable neuraxial technique on time so
as so guarantee the safety of this kind of patient.
Results

Material and methods Demographic data

Based on the increasing prevalence of obesity among preg- The study covered a total number of 3653 patients with an
nant women and the close relationship between obesity and average age of 32.82 ± 5.8 years and an average weight of
maternal and perinatal outcomes, we have carried out a 74.51 ± 12.16 kg (average BMI 27.51 ± 5.75 kg.m-2 ). Average
retrospective observational descriptive study at a tertiary gestational age was 38.83 ± 2.49 weeks.
hospital among pregnant women (obese and non-obese), Out of the total number of patients observed (n = 3653),
who received neuraxial analgesia for labor at our center 1001 patients (27,4%) had a BMI ≥ 30 kg.m-2 (Fig. 1). Accord-
between January and December 2017. ing to the BMI, 747 patients (74.62%) had obesity grade I (BMI
The main purpose was to analyze the features of all preg- range, 30---34.99), 189 patients (18.88%) had obesity grade II
nant women over 18 years old, as well as different variables (BMI range, 35---39.99), 63 patients (6.3%) had obesity grade
in relation to the difficulty of performing the neuraxial tech- III or extreme (BMI range, 40---49.99), and 2 patients (0.2%)
nique, and the maternal and neonatal outcomes, so as to be had obesity grade IV or morbid (BMI 50 or greater).

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Figure 1 Distribution of obesity grade among obese pregnant women.

Table 1 Hypertensive disorders in obese and non-obese Table 2 Difficulty of neuraxial technique regarding punc-
pregnant women (p = 0,799). ture attempts (p < 0,001).*

Hypertensive disorders in pregnancy PATIENT COLLECTION PUNCTURE ATTEMPTS % OBESE % NON-OBESES


NON-OBESES 2,3% (n = 60) 1---2 90,8% (n = 883) 94,8% (n = 2373)
OBESES 2,1% (n = 20) 3---4 8,3% (n = 81) * 5,2% (n = 129) *
Obesity grade I 2,1% (n = 15) >4 0,8% (n = 8) * 0,1% (n = 2) *
Obesity grade II 1,6% (n = 3)
* These results are statistically significant (p < 0,001).
Obesity grade III 3,3% (n = 2)
Obesity grade IV 0%
If all possible complications related to the neurax-
ial technique are taken into account, the odds of these
Obstetric pathology complications altogether were 72.7% (n = 2021) in the group
of non-obese and 27.3% (n = 758) in the obese one. When
analyzing each of the complications separately, HP incidence
Gestational Diabetes (GD)
was 6,6% in both groups, being n = 50 among the obese pop-
In our study, gestational diabetes rate was slightly higher
ulation against n = 133 in non-obese, with p = 0,659, as well
in obese women (5.2% versus 5% in non-obese), being
as the odds of ADP, which was 0,7% (n = 5) in obese and 0,7%
p = 0.757. Out of the total number of obese pregnant women
(n = 15) in non-obese with p = 0.659. However, the number
with GD (n = 51), 39 patients presented obesity grade I
of patients who had headache after delivery was higher (8
(76.5%), 9 patients obesity grade II (17.6%) and 3 patients
obese and 37 non-obese women) than the number of ADP
obesity grade III (5.9%). We did not find any patient among
recorded in both groups. This can be explained because of
the population studied with obesity grade IV who had GD.
the fact that post-dural puncture headache (PDPH) is one
of the most common postpartum complications following
Hypertensive disorders in pregnancy neuraxial block, but dural puncture is not the only cause
In spite of the fact that the incidence of gestational hyper- of postpartum headache. Other possible causes can be ten-
tension has turned out to be greater in non-obese (2.3%, sion headache, migraine or cortical vein thrombosis, whose
n = 60) versus obese (2.1%; n = 20), being p = 0.799, it must be incidence is increased during pregnancy and in the puer-
highlighted that there was a greater presence of hyperten- perium. A blood patch was performed in only two patients
sive disorders in those pregnant women with obesity grade (25%) out of the total obese pregnant women with post-
III (3.3%) versus the other obese patients, with p = 0.882 partum headache (n = 8), against 22 out of 37 non-obese
(Table 1). pregnant women with postpartum headache (Table 3). In
this case, p-value could not be calculated because of the
Neuroaxial technique and complications lack of data.
Despite the fact that the number of HP and ADP alto-
It was performed 3237 epidural techniques and 416 com- gether was greater among non-obese population, when
bined spinal-epidural (CSE). The technique was required to analyzing these complications among the obese population,
be repeated in 52 patients out of the total number of obese and depending on the BMI of the patient, we faced in our
pregnant women (5.19%) due to the lack of analgesia 45 min- study a greater incidence in those patients with obesity
utes after the placement of the catheter, and this time, a grade III (16.36%, n = 9), being p = 0.022.
combined spinal-epidural (CSE) technique was performed.
One or two puncture attempts were needed in 94.8% of non- Expulsive phase of labor
obese compared to 90.7% of obese. According to our data,
the need of three or more attempts was clearly more fre- Among our studied population, labor was induced in 63.1%
quent among obese, 9.1% against 5.3% of non-obese, being (n = 632) of obese versus 26.2% (n = 694) of non-obese. On
p < 0.001 (Table 2). one hand, delivery was spontaneous in 79% (n = 2096) of non-

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Table 3 Incidence of postpartum headache and accidental medical comorbidity, which had been widely studied and
dural puncture (ADP) and the need of blood patch in obese identified in previous studies. Our findings suggest that the
and non-obese parturients. odds of gestational diabetes are slightly higher in the group
of obese pregnant women, although statistical significance
OBESE NON-OBESE
could not be reached. However, the incidence of hyperten-
(IMC > 30) (IMC < 30)
sive disorders was 25% (n = 20) in obese against 75% (n = 60)
Accidental dural 5/1001 15/2652 in non-obese. Therefore, although it has not been possible
puncture (ADP) to find a close relation between obese women and hyper-
Postpartum headache 8/1001 37/2652 tensive conditions, it is quite interesting the higher rate
of hypertension in obesity grade III. We should be aware
OBESE NON-OBESE that obesity is only one of the multiple risk factors associ-
(IMC > 30) (IMC < 30) ated with hypertensive disorders during pregnancy, such as
advanced gestational age or medical conditions (e.g. chronic
BLOOD PATCH 2 (25%) 22 (59,45%)
hypertension, diabetes mellitus or chronic renal disease).
NO BLOOD PATCH 6 (75%) 15 (40,54%)
In our center, the epidural technique is the first option in
any case, but when pregnant women show a breakthrough
pain related to strong uterine dynamics or advanced cer-
obese, against 67,6% (n = 677) of obese, where p < 0,001. vical dilatation, then the CSE technique will be preferably
On the other hand, instrumental delivery was recorded in 9% performed.
(n = 90) of obese, contrary to 9.2% (n = 246) of non-obese. Recent studies show that a high BMI is correlated to4,5,7,8 :
Finally, cesarean section rate in obese pregnant women was greater complication to perform the technique, determined
23,4% (n = 234), whereas among non-obese was 11.7% (n as a higher number of puncture attempts and more time
= 310), being p < 0,001. In our study, the main reason for needed to find the epidural space; greater failure of epidural
cesarean section was failure of induction or disproportion analgesia; and greater delay in detecting the failure of the
between the fetus and the uterus (Table 4). technique.
In our population, seven of the patients who underwent Despite the fact that a high BMI means a risk factor for
a cesarean section required sedation besides the epidural the failure of the technique, in our daily practice, we do not
anesthesia due to the lack of pain control. In addition, five observe such a high failure rate in obese pregnant women as
women needed general anesthesia because of an incomplete the one described in the literature. In our hospital, analge-
epidural block. sia for delivery is performed by residents from second up to
On the bases of our database, the average weight of a their last year of training. However, neuraxial techniques in
newborn child was 3187.26 ± 455.53 grams in non-obese complicated patients (e.g. obese patients or scoliosis) are
and 3326.67 ± 485.12 grams in obese, being the incidence usually carried out by residents in their last year or the
of fetal macrosomia higher in this latter group (5.6%, n = 51) attending anesthesiologist.
against 2.6% (n = 64) in non-obese pregnant women, where In most cases, locating the epidural space in obese
p < 0.001. pregnant women becomes complicated due to the loss of
anatomical references and because the epidural skin-space
Discussion distance (ESD) may be bigger than usual.4,8 Previous studies
have already recorded the directly proportional association
Based on our study results, the prevalence of overweight and between BMI and ESD, although this distance is not normally
obesity in obstetric patients is markedly high in our centre, longer than 8 cm in most patients.9,10 Our study did not mea-
as it has recently become a reference center nationwide for sure ESD, but has collected a greater number of puncture
the obstetric follow-up of obese pregnant women. Accord- attempts in obese pregnant women, which confirms a higher
ing to test results, obese pregnant women show greater difficulty in locating epidural spaces in this type of patient.

Table 4 Delivery in obese and non-obese parturients (p < 0,001).*.

OBESE (IMC >30) NON-OBESE (IMC < 30)


SPONTANEOUS DELIVERY 677 (67,6%) * 2096 (79%) *
INSTRUMENTAL DELIVERY 90 (9%) * 246 (9,2%) *
Spatula 29 (2,9%) 91 (3,4%)
Forceps 47 (4,7%) 101 (3,8%)
Ventouse 14 (1,4%) 54 (2%)

OBESE (IMC >30) NON-OBESE (IMC < 30)


CESAREAN SECTION 234 (23,4%) * 310 (11,7%) *
- FI or disproportion (NICE III) 190 (19%) 234 (8,8%)
- NRFS (NICE I) 44 (4,4%) 76 (2,9%)
NON CESAREAN SECTION 767 (76,6%) * 2342 (88,2%) *
* FI (Failed Induction); NRFS (Non-reassuring Fetal Status).

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Air or saline solution can be used to identify the loss of ing to non-obese in our study. As previously mentioned, the
resistance when finding the epidural space. It is important technique in the obese parturient has been performed by
to highlight that ligaments are softer in obese and pregnant experienced anesthesiologists, so the probability of success
patients due to the influence of progesterone. Based on this, was higher in such patients. Around 50-80% of patients with
it seems that the feeling of losing resistance using air is more ADP develop PDPH.19---22 Our study has not found a higher
confusing and so the likelihood of false positives increases. PDPH incidence among obese population, which matches
Therefore, we can state that the greater the BMI of the the results obtained in previous studies. In fact, the Peralta
patient, the more difficult the puncture becomes, and so the et al. study16 demonstrated that a BMI ≥ 35 kg.m-2 was a pro-
loss of resistance technique with saline solution is recom- tective factor against the development of PDPH. The reason
mended for these patients.11 However, we should be aware is related to a higher pressure in the epidural space, which
that epidural space localization using loss of resistance tech- limits the leak of cerebral spinal fluid (CSF) just through
nique with saline can hinder the identification of an ADP the dural rent. Nonetheless, once PDPH has developed, its
(inadvertent dural puncture). When air is used to identify severity and treatment (analgesia and/or blood patch) do
the epidural space, any cerebrospinal leak can be easily not seem to be related to the BMI of the patient.
recognized, unlike when saline is used. Hence, the ideal As there is not still a standard definition of failure of
technique for identification of the epidural space remains the epidural technique, it appears to be difficult to report
unclear. Moreover, accurate identification of the anatomical its real incidence. A widely acceptable definition is the
references in the obese patient can be widely complicated. lack of analgesia during the first 45 minutes after placing
The risk of a general anesthesia in such patients is so high, the catheter in the epidural space.8 Kula et al., in their
not only because of the pregnancy but also the obesity, that study,4 mentioned the assessment of the number of nec-
an adequate epidural analgesia must be achieved. Ultra- essary attempts to place a catheter as the way to estimate
sound (US) techniques are proposed to improve the success how difficult the technique was and the likelihood of failure.
rate during epidural catheter insertion, as well as to reduce Saravanakumar et al. found in their study that 74% of preg-
the complications related to the accidental dural puncture. nant women needed more than one attempt, and up to 14%
US imaging of the spine is thought to reduce the likelihood required three or more attempts, being the total failure rate
of a failed and traumatic catheterization. Several studies for this technique 42% in this kind of patient.23 In our study,
tried to investigate the ease of catheter insertion, the time we have been able to assess the success of the technique
needed for the procedure and the rate of success, compared according to the number of puncture attempts and we did
to the traditional palpation technique. Some of these stud- identify a correlation with data obtained in the literature.
ies compared the US examination of the spine in lean and Finally, we noted a higher rate of cesarean delivery
obese patients12 and others analyzed the US guidance only in obese pregnant women. The literature states a greater
in obese patients scheduled for elective cesarean section13 anesthetic risk among obese women who undergo cesarean
or otherwise only in patients with BMI < 35 kg.m-2 .14 Given section under general anesthesia, as it is expected due to
the results of these studies, US imaging helps locate the the physiological and anatomical changes during pregnancy.
epidural space in the obese parturient, and so reduces the In this sense, Brick et al. do mention a higher cesarean deliv-
number of puncture attempts and the time needed to per- ery rate among obese multiparous pregnant women, while
form the technique. Nonetheless, the use of US appears not such relation between BMI and the likelihood of cesarean
to be that helpful in lean parturients, in which anatomical section is not found in obese nulliparous pregnant women.24
landmarks are clearly palpable. Thus, there is some evi- Eventually, we observed in our population significant
dence that US guidance may improve the success of the statistics when referring to a greater incidence of fetal
neuraxial block in the obese parturient, as well as reduce macrosomia in obese pregnant women, which is in line
the rate of procedure-related adverse events. Furthermore, with the latest breakthroughs in the literature. This
the impact of US on patient satisfaction regarding the tech- can be related to a greater concentration of leptin and
nique and analgesia has been highly positive.15 However, interleukin-6 (IL6) in the umbilical cord of babies delivered
the learning curve can be complicated and so US-guided by obese mothers, which seems to be in relation to a higher
techniques are recommended only when the anesthesiolo- resistance to insulin and long-term metabolic disorders
gist is used to perform and interpret US images. In fact, the among these newborn children, according to Catalano and
studies mentioned above have been carried out by expe- Shankar studies.5
rienced anesthesiologists trained in US scanning. In recent To sum up, neuraxial techniques are preferred for obese
years, the use of ultrasonography has become increasingly parturient, in who the placement of a well-functioning
popular in anesthesiology. Hence, it should be considered epidural catheter is one of the safest methods of provid-
in obstetric anesthesia because of its potential benefits in ing labor analgesia. It must be taken into account that labor
the obese parturient, avoiding a general anesthesia in these epidural analgesia can be converted to surgical anesthesia if
patients. needed for cesarean delivery and, given the increased risk
According to the literature, ADP incidence in the obstet- of fetal macrosomia, a well-functioning epidural catheter
ric population is up to 4% in obese pregnant women versus can be helpful in the management of a shoulder dysto-
1% in non-obese ones.16---18 In our study, complications such cia. Therefore, regular assessment of the labor epidural
as ADP or HP seem to be similar in both groups, although we catheter is paramount to ensure that the block can be reli-
have not been able to demonstrate that such associations ably extended to provide adequate surgical anesthesia if
are statistically significant. When all complications related needed.23,25,26
to the neuraxial technique are considered, the rate of these Our results should be interpreted in the context of study’s
complications in the obese patient is not higher compar- limitations:

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