Obesity in obstetric

intensive care patient

ERWADI
16360315

PEMBIMBING
Dr. Husnul Mutmainnah, M.Kes, Sp.An

BAGIAN ILMU ANASTESI FAKULTAS KEDOKTERAN

UNVERSITAS MALAHAYATI
RUMAH SAKIT UMUM DAERAH KABANJAHE
PROVINSI SUMATERA UTARA
2017
Obstetric patients are generally young and healthy. However,
potential for catastrophic event is real, and despite the
therapeutic advances of the last few decades, maternal
morbidity and mortality continue to occur. This may be
related to pregnancy itself, aggravation of a pre-existing
illness or complication of delivery
 Obesity and Pregnancy

Obesity has become a major health problem of modern society and is

increasing globally at nearly epidemic proportion especially in
western and European countries . Obesity is often expressed with
reference to body mass index (BMI).

Body mass index = weight (in kg)/height (in m2)

 WHO classification of Obesity

Body mass Associated health

Klasifikasi index (kg/m2) risks

Underweight <18.5 Low

Normal range 18.524.9 Average

Overweight >25

Preobese 2529.9 Increased

Obese class I 3034.9 Moderately

increased

Obese class II 3539.9 Severely increased

Obese class III >40 Very severely

increased
Efek fisiologis dan risiko pada pasien obesitas dengan penyakit kritis
Respirasi Berkurangnya volume paru-paru Atelektasis dan Ketidaksesuaian perfusi ventilasi,
Peningkatan kerja pernapasan dan penggunaan oksigen. Penyakit saluran
pernapasan obstruktif (mekanik dan asma) obstructive sleep apnoea, sindrom
hipoventilisasi obesitas

Kardiovaskular -penyakit arteri koroner

- hipertensi
- disfungsi ventrikel kiri siastolik dan diastolik

Lain-lain -DM risiko peningkatan tromboembolisme vena

- peningkatan risiko aspirasi asam lambung
- perubahan farrmakoninetik obat
- akses vena yang sulit meningkatkan resiko gagal ginjal
- peningkatan risiko tekanan ulkus
Almost all the organ systems are affected by the impact of obesity
either directly or indirectly. The degree of obesity and its prolonged
duration are the main factors which determine the harmful effect
of obesity in the human body. Even moderate over-weight is a risk
factor for gestational diabetes and hypertensive disorders of
pregnancy, and the risk is higher in subjects with overt obesity.
Compared with normal weight, maternal overweight is related to a
higher risk of Caesarean deliveries and a higher incidence of
anaesthetic and postoperative compli-cations in these deliveries.
 Challenges to Anaesthetist
Adding to the spectrum of medical and surgical
pathologies, obesity is also associated with an
increased incidence of antenatal disorders. A thor-
ough understanding of physiology, pathophysiol-
ogy, associated conditions, their complications and
the implications for analgesia and anaesthesia
should place the anaesthetist in a better position
to care for these patients
 Anaesthetic Considerations

Obesity has been identified as a significant risk factor

for anaesthesia-related maternal mortality The
increased incidence of operative pro-cedures, both
elective and emergency, and the concurrent medical
and antenatal problems may contribute to the risk.
Postoperative complica-tions such as wound infection,
deep vein throm-bosis, atelectasis and chest infection
are more prevalent . In addition to the associated
medical problems, the anaesthetist is challenged by
these patients with technical difficulties of air-way
management and insertion of regional blocks
 AIRWAY

The incidence of failed tracheal intubation is

approximately 1 in 280 in the obstetric popula-tion
compared to 1 in 2230 in the general surgical population].
This is in contrast with an incidence of difficult intubation in
an obese pop-ulation as high as 15.5%
So it is evident that difficult or failed tracheal
intubation in obese parturients is very high, and optimal
assessment and management of the air-way cannot be
overemphasised in this population.
Cardiovascular System

Cardiovascular co-morbidities such as hyperten-sion,

ischaemic heart disease and heart failure dominate
the clinical picture in the obese popula-tion, and these
can coexist in obese parturients. Nearly 40% of the
obese population experience angina without
demonstrable coronary artery dis-ease . Hence,
routine electrocardiograph recording may be useful.
Cardiologists should be involved early in the care of
symptomatic mor-bidly obese parturients to
investigate and opti-mise the disease status wherever
appropriate.
 Gastrointestinal and Endocrine Systems

Gastro-oesophageal reflux and diabetes mellitus are

the most commonly seen disorders. Any previous
laboratory investigations such as fasting blood
glucose concentration and liver function tests
should be noted. If there is any abnormality of liver
function, HELLP syndrome should be ruled out.
Though aggressive prophylaxis against acid
aspiration is advocated for all obese mothers
undergoing Caesarean section, there is a lack of
conclusive evidence for starvation poli-cies and
prophylaxis during labour
Postoperative Complications

Obese parturients are at increased risk of postop-erative

complications such as hypoxaemia, atel-ectasis and
pneumonia, deep vein thrombosis and pulmonary
embolism, pulmonary oedema, post-partum
cardiomyopathy, postoperative endome-tritis and wound
complications such as infection and dehiscence. Early
mobilisation, throm-boprophylaxis, aggressive chest
physiotherapy and adequate pain control are the key to the
suc-cess of effective postoperative care.
Conclusion

The critically ill obstetric patient presents a unique clinical

challenge to the intensivist because of maternal physiological
adaptations to pregnancy, pregnancy-specific conditions which
may require critical care management and also the presence of
foetus whose well being is linked to the mother. Successful
maternal and neonatal outcome for patients admitted to a critical
care facility are largely dependent on a multidisciplinary approach
to management requiring input from critical care personnel,
obstetricians, anaesthetists, neona-tologists and midwives.
BUJUR MELALA