Bilge ÇATALOĞLU ŞENTÜRK, AYTEN SARAÇOĞLU

Obez gebelerde anestezi yönetimi

Obezite artan prevalansıyla, global bir sağlık problemidir. Günümüzde gelişmiş ülkelerin birçoğunda, doğurganlık çağındaki kadınların yarısından fazlası, fazla kilolu yada obez sınıfındadır (vücut kitle indeksi ≥30 kg/m2). Obez gebelerde anestezi yönetimi obezitenin ve gebeliğin fizyolojik etkilerini bilmek ve bu durumların anestezi ile ilişkisini çözümlemek ile mümkündür. Bu derlemede amacımız obez gebelerde anestezi yönetiminin önemini ortaya koymak ve perioperatif dönemde seçilecek yöntemleri gözden geçirmektir.

Anesthetic management of the obese parturients

Obesity is a global health threat with an increasing prevalance. In many developed countries more than half of the women at the age of giving birth are overweight or obese (BMI ≥ 30 kg/m 2). Obesity and pregnancy even are solidly important topics of anaeshtesiologist, but dealing with both needs a better understanding of physiological mechanisms and relation between the anaesthesiological practices. In this review we have tried to emphasize the importance of this growing threat and to highlight how to deal with obese pregnancy from preoperative considerations until the postoperative care.

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1.Satpathy HK, Fleming A, Frey D, Barsoom M, Satpathy C, Khandalavala J. Maternal obesity and pregnancy. Postgrad Med 2008; 120: E01-E09.
2.Oteng-Ntim E, Kopeika J, Seed P, Wandiembe S, Doyle P. Impact of obesity on pregnancy outcome in different ethnic groups: calculating population attributable fractions. PLoS One 2013; 8: e53749.
3.Laederach K. What is obesity? Ther Umsch 2013; 70: 61-72.
4.Hall KD, Heymsfield SB, Kemnitz JW, et al. Energy balance and its components: implications for body weight regulation. Am J Clin Nutr 2012; 95: 989-994.
5.Speakman JR, O'Rahilly S. Fat: an evolving issue. Dis Model Mech 2012; 5: 569-573
6.Stevens GA, Singh GM, Lu Y, et al. National, regional, and global trends in adult overweight and obesity prevalences. Popul Health Metr 2012; 10: 22.
7.Hatemi H, Yumuk VD, Turan N, Arik N. Prevalence of overweight and obesity in Turkey. Metab Syndr Relat Disord 2003; 1: 285- 290
8.Ozgul N, Tuncer M, Abacioglu M, Gultekin M. Prevalence of obesity among women in Turkey: analysis of KETEM data. Asian Pac J Cancer Prev 2011; 12: 2401-2404.
9.O¤uz A, Temizhan A, Abaci A, ve ark. Obesity and abdominal obesity; an alarming challenge for cardio-metabolic risk in Turkish adults. Anadolu Kardiyol Derg 2008; 8: 401-406.
10.Fishburne JI. Physiology and disease of the respiratory system in pregnancy. A review. J Reprod Med 1979; 22: 177-189.
11. Contreras G, Gutiérrez M, Beroíza T, et al. Ventilatory drive and respiratory muscle function in pregnancy. Am Rev Respir Dis 1991; 144: 837-841.
12. Baldwin GR, Moorthi DS, Whelton JA, MacDonnell KF. New lung functions and pregnancy. Am J Obstet Gynecol 1977; 127: 235-239.
13. Elkus R, Popovich J Jr. . Respiratory physiology in pregnancy. Clin Chest Med 1992; 13: 555-565.
14. Sroczynski T. Evaluation of respiratory tract function in healthy women in the last month of uncomplicated pregnancy. Ann Acad Med Stetin 2002; 48: 331-350.
15. Templeton A, Kelman GR. Maternal blood-gases, PAo2--Pao2), physiological shunt and VD/VT in normal pregnancy. Br J Anaesth 1976; 48: 1001-1004.
16. Ouzounian JG, Elkayam U. Physiologic changes during normal pregnancy and delivery. Cardiol Clin 2012; 30: 317-329.
17. Mabie WC, DiSessa TG, Crocker LG, Sibai BM, Arheart KL. A longitudinal study of cardiac output in normal human pregnancy. Am J Obstet Gynecol 1994; 170: 849-856
18. Lapinsky SE, Kruczynski K, Slutsky AS. Critical care in the pregnant patient. Am J Respir Crit Care Med 1995; 152: 427-455.
19. Longo SA, Moore RC, Canzoneri BJ, Robichaux A. Gastrointestinal Conditions during Pregnancy. Clin Colon Rectal Surg 2010; 23: 80-89.
20. Singer A J, Brandt L J. Pathophysiology of the gastrointestinal tract during pregnancy. Am J Gastroenterol 1991; 86: 16951712.
21. Pelosi P, Luecke T, Rocco PR. Chest wall mechanics and abdominal pressure during general anaesthesia in normal and obese individuals and in acute lung injury. Curr Opin Crit Care 2011; 17: 72-79.
22. Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol 2010; 108: 206-211.
23. Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, Smith PL. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc 2008; 5: 185-192.
24. Hiremath AS, Hillman DR, James AL, Noffsinger WJ, Platt PR, Singer SL. Relationship between difficult tracheal intubation and obstructive sleep apnoea. Br J Anaesth 1998; 80: 606-611.
25. El-Solh AA. Clinical approach to the critically ill, morbidly obese patient. Am J Respir Crit Care Med 2004; 169: 557-561.
26. Oppenheimer BW, Berger KI, Rennert DA, et al. Effect of circulatory congestion on the components of pulmonary diffusing capacity in morbid obesity. Obesity (Silver Spring) 2006; 14: 1172-1180.
27. Pontiroli AE, Pizzocri P, Saibene A, Girola A, Koprivec D, Fragasso G. Left ventricular hypertrophy and QT interval in obesity and in hypertension: effects of weight loss and of normalisation of blood pressure. Int J Obes Relat Metab Disord 2004; 28: 1118-1123.
28. Seyfeli E, Duru M, Kuvandik G, Kaya H, Yalcin F. Effect of obesity on P-wave dispersion and QT dispersion in women. Int J Obes (Lond) 2006; 30: 957-961.
29. Heslehurst N, Simpson H, Ells LJ, et al. The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis. Obes Rev 2008; 9: 635-683.
30. Torloni MR, Betrán AP, Horta BL, et al. Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis. Obes Rev 2009; 10: 194-203.
31. Alanis MC, Goodnight WH, Hill EG, et al. Maternal super-obesity (body mass index > or = 50) and adverse pregnancy outcomes. Acta Obstet Gynecol Scand 2010; 89: 924-930.
32. Castro LC, Avina RL. Maternal obesity and pregnancy outcomes. Curr Opin Obstet Gynecol 2002; 14: 601-606.
33. Knight M; UKOSS. Antenatal pulmonary embolism: risk factors, management and outcomes. BJOG 2008; 115: 453-461.
34. Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. Effect of Body Mass Index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007; 7: 168.
35. Lang JM, Lieberman E, Cohen A. A comparison of risk factors for preterm labor and term small-for-gestational-age birth. Epidemiology 1996; 7: 369-376.
36. Sebire NJ, Jolly M, Harris JP, et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord 2001; 25: 1175-1182.
37. Grossetti E, Beucher G, Régeasse A, et al. Obstetrical complications of morbid obesity. J Gynecol Obstet Biol Reprod (Paris) 2004; 33: 739-744.
38. Nohr EA, Bech BH, Vaeth M, et al. Obesity, gestational weight gain and preterm birth: a study within the Danish National Birth Cohort. Paediatr Perinat Epidemiol 2007; 21: 5-14.
39. Dietl J. Maternal obesity and complications during pregnancy. J Perinat Med 2005; 33: 100-105.
40. Wataba K, Mizutani T, Wasada K, et al. Impact of prepregnant body mass index and maternal weight gain on the risk of pregnancy complications in Japanese women. Acta Obstet Gynecol Scand 2006; 85: 269-276.
41. Hedderson MM, Weiss NS, Sacks DA, et al. Pregnancy weight gain and risk of neonatal complications: macrosomia, hypoglycemia, and hyperbilirubinemia. Obstet Gynecol 2006; 108: 1153-1161.
42. Stotland NE, Cheng YW, Hopkins LM, Caughey AB. Gestational weight gain and adverse neonatal outcome among term infants. Obstet Gynecol 2006; 108: 635-643.
43. Nohr EA, Vaeth M, Baker JL, et al. Combined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. Am J Clin Nutr 2008; 87: 1750-1759.
44. Thornton YS, Smarkola C, Kopacz SM, Ishoof SB. Perinatal outcomes in nutritionally monitored obese pregnant women: a randomized clinical trial. J Natl Med Assoc 2009; 101: 569-577.
45. Phelan S, Phipps MG, Abrams B, et al. Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study. Am J Clin Nutr 2011; 93: 772-779.
46. Walker L, Freeland-Graves JH, Milani T, et al. Weight and behavioral and psychosocial factors among ethnically diverse, low-income women after childbirth: II. Trends and correlates. Women Health 2004; 40: 19-34.
47. Muscati SK, Gray-Donald K, Koski KG. Timing of weight gain during pregnancy: promoting fetal growth and minimizing maternal weight retention. Int J Obes Relat Metab Disord 1996; 20: 526-532.
48. Soltani H, Fraser RB. A longitudinal study of maternal anthropometric changes in normal weight, overweight and obese women during pregnancy and postpartum. Br J Nutr 2000; 84: 95-101.
49. Crane JM, White J, Murphy P, Burrage L, Hutchens D. The effect of gestational weight gain by body mass index on maternal and neonatal outcomes. J Obstet Gynaecol Can 2009; 31: 28-35.
50. Poobalan AS, Aucott LS, Gurung T, Smith WC, Bhattacharya S. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women--systematic review and meta-analysis of cohort studies. Obes Rev 2009; 10: 28-35.
51. Aydin C, Baloglu A, Yavuzcan A, Inci A. The effect of body mass index value during labor on pregnancy outcomes in Turkish population (obesity and pregnancy outcomes). Arch Gynecol Obstet 2010; 281: 49-54.
52. Lu GC, Rouse DJ, DuBard M, et al. The effect of the increasing prevalence of maternal obesity on perinatal morbidity. Am J Obstet Gynecol 2001; 185: 845-849.
53. HAPO Study Cooperative Research Group. Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) Study: associations with maternal body mass index. BJOG 2010; 117: 575-584.
54. Lotia S, Bellamy MC. Anaesthesia and morbid obesity. Continuing Education in Anaesthesia, Critical Care and Pain 2008; 8: 151-156.
55. Gross TL. Operative considerations in the obese pregnant patient. Clin Perinatol 1983; 10: 411-421.
56. James DC, Maher MA. Caring for the extremely obese woman during pregnancy and birth. MCN Am J Matern Child Nurs 2009; 34: 24-30.
57. Brodsky JB, Mariano ER. Regional anaesthesia in the obese patient: lost landmarks and evolving ultrasound guidance. Best Pract Res Clin Anaesthesiol 2011; 25: 61-72.
58. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med 2010; 28: 1-7.
59. Brusasco C, Corradi F, Zattoni PL, et al. Ultrasound-guided central venous cannulation in bariatric patients. Obes Surg 2009; 19: 1365-1370.
60. Morton T, Brady S, Clancy M. Difficult airway equipment in English emergency departments. Anaesthesia 2000; 55: 485-488.
61. Bonanno FG. The critical airway in adults: The facts. J Emerg Trauma Shock 2012; 5: 153-159.
62. Veiga EV, Arcuri EA, Cloutier L, Santos JL. Blood pressure measurement: arm circumference and cuff size availability. Rev Lat Am Enfermagem 2009; 17: 455-461.
63. Hogan JL, Maguire P, Farah N, et al. Body mass index and blood pressure measurement during pregnancy. Hypertens Pregnancy 2011; 30: 396-400.
64. DeMaria EJ, Carmody BJ. Perioperative management of special populations: obesity. Surg Clin North Am 2005; 85: 1283-1289.
65. Munnur U, de Boisblanc B, Suresh MS. Airway problems in pregnancy. Crit Care Med 2005; 33: S259-268. 66. Saravanakumar K, Rao SG, Cooper GM. The challenges of obesity and obstetric anaesthesia. Curr Opin Obstet Gynecol 2006; 18: 631-635.
67. Saravanakumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia 2006; 61: 36-48.
68. Adam C, Standl T. Regional anaesthesia in obese patients: what's different? Anasthesiol Intensivmed Notfallmed Schmerzther 2012; 47: 676-681.
69. Roofthooft E. Anesthesia for the morbidly obese parturient. Curr Opin Anaesthesiol 2009; 22: 341-346.
70. Rao DP, Rao VA. Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new? Indian J Anaesth 2010; 54: 508-521.
71. Wills JS, Bowie R, Bogod DG. A pilot study of patient-led identification of the midline of the lumbar spine. Anaesthesia 2002; 57: 390-394.
72. Grau T, Leipold RW, Horter J, et al. Paramedian access to the epidural space: the optimum window for ultrasound imaging. J Clin Anesth 2001; 13: 213-217.
73. Watts RW. The influence of obesity on the relationship between body mass index and the distance to the epidural space from the skin. Anaesth Intensive Care 1993; 21: 309-310.
74. Bahk JH, Kim JH, Lee JS, Lee SC. Computed tomographic study of lumbar (L3-4) epidural depth and its relationship to physical measurements in young adult men. Reg Anesth Pain Med 1998; 23: 262-265.
75. Saracoglu KT, Saracoglu A,Umuroglu T, Eti Z. Neuraxial block versus general anaesthesia for cesarean section: post-operative pain scores and analgesic requirements. J Pak Med Assoc 2012; 62: 441-444.
76. Tuteja LV, Vanarase MY, Deval DB. Anaesthetic management of a morbidly obese patient. J Postgrad Med 1996; 42: 127-128.
77. Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin Anaesthesiol 2007; 20: 175-180.
78. Pedoto A. Lung physiology and obesity: anesthetic implications for thoracic procedures. Anesthesiol Res Pract 2012; 2012: 154208.
79. Faure E, Moreno R, Thisted R. Incidence of postdural puncture headache in morbidly obese parturients. Reg Anesth 1994; 19: 361-363.
80. Saracoglu KT, Saracoglu A, Celik M. Anesthesia management after inadvertent dural puncture during application of epidural blockage. Dicle Med J 2010; 37: 394-396.
81. Coker LL. Continuous spinal anesthesia for cesarean section for a morbidly obese parturient patient: a case report. AANA J 2002; 70: 189-192.
82. Kuczkowski KM, Reisner LS, Benumof JL. Airway problems and new solutions for the obstetric patient . J Clin Anesth 2003; 15: 552-563.
83. Stuart JC, Kan AF, Rowbottom SJ, Yau G, Gin T. Acid aspiration prophylaxis for emergency Caesarean section. Anaesthesia 1996; 51: 415-421.
84. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg 2004; 14: 1171-1175.
85. Boutonnet M, Faitot V, Keïta H. Airway management in obstetrics. Ann Fr Anesth Reanim 2011; 30: 651-664.
86. Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth 2000; 85: 91-108.
87. Reinius H, Jonsson L, Gustafsson S, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology 2009; 111: 979-987.
88. Futier E, Constantin JM, Pelosi P, et al. Intraoperative recruitment maneuver reverses detrimental pneumoperitoneum-induced respiratory effects in healthy weight and obese patients undergoing laparoscopy. Anesthesiology 2010; 113: 1310-1319.
89. Ashburn DD, DeAntonio A, Reed MJ. Pulmonary system and obesity. Crit Care Clin 2010; 26: 597-602.
90. Parameswaran K, Todd DC, Soth M. Altered respiratory physiology in obesity. Can Respir J 2006; 13: 203-210.
91. Neligan PJ, Malhotra G, Fraser M, et al. Noninvasive ventilation immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg 2010; 110: 1360-1365.
92. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998; 86: 598-612.
93. Levin A, Klein SL, Brolin RE, Pitchford DE. Patient-controlled analgesia for morbidly obese patients: an effective modality if used correctly. Anesthesiology 1992; 76: 857-858.
94. Cotter JT, Nielsen KC, Guller U, et al. Increased body mass index and ASA physical status IV are risk factors for block failure in ambulatory surgery - an analysis of 9.342 blocks. Can J Anaesth 2004; 51: 810-816.
95. Perlow JH, Morgan MA. Massive maternal obesity and perioperative cesarean morbidity Am J Obstet Gynecol 1994; 170: 560-565.
96. von Ungern-Sternberg BS, Regli A, Bucher E, Reber A, Schneider MC. Impact of spinal anaesthesia and obesity on maternal respiratory function during elective Caesarean section. Anaesthesia 2004; 59: 743-749.