Marcela Carolina Smid1, Sarah K Dotters-Katz2, Robert M Silver3, Jeffrey A Kuller4. 1. Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT. 2. Clinical Instructor and Fellow, Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, University of North Carolina-Chapel Hill, Chapel Hill, NC. 3. Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT. 4. Professor, Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Duke University Medical Center, Durham, NC.
Abstract
IMPORTANCE: Superobesity, defined as body mass index 50 kg/m2 or greater, is the fastest-growing obesity group in the United States. Currently, 2% of pregnant women in the United States are superobese, and 50% will deliver via cesarean delivery. OBJECTIVE: To review evidence of perioperative care during cesarean delivery among superobese women. EVIDENCE ACQUISITION: We performed an evidence-based review of maternal and neonatal risks of cesarean delivery and of intraoperative management and immediate postpartum care of superobese pregnant women. We also reviewed bariatric and general literature surgery on perioperative care of superobese patients. RESULTS: There is limited information to direct evidence-based care of superobese women who undergo cesarean delivery. Superobese women have a 30% to 50% risk of wound complications, a 20% risk of neonatal intensive care unit admission, and a 1% to 2% risk of maternal intensive care unit admission. Preoperative discussion with superobese women should include a review of maternal and fetal risks associated with cesarean delivery, as well as operative options including skin incision. Preoperative cefazolin with a 3-g dose, chlorhexidine skin preparation, and availability of adequate personnel for patient transfers are important evidence-directed approaches to reducing maternal and personnel morbidity. Postoperatively, early ambulation and chemical prophylaxis are reasonable, although there is a lack of evidence as to whether these measures prevent thromboembolic complications. CONCLUSIONS: Superobese women are at increased risk of cesarean delivery and resultant complications. Most evidence-directed recommendations for perioperative care are extrapolated from studies of obese women undergoing bariatric surgery. As the prevalence of reproductive-age women with superobesity increases, studies directed at this high-risk population are urgently need.
IMPORTANCE: Superobesity, defined as body mass index 50 kg/m2 or greater, is the fastest-growing obesity group in the United States. Currently, 2% of pregnant women in the United States are superobese, and 50% will deliver via cesarean delivery. OBJECTIVE: To review evidence of perioperative care during cesarean delivery among superobese women. EVIDENCE ACQUISITION: We performed an evidence-based review of maternal and neonatal risks of cesarean delivery and of intraoperative management and immediate postpartum care of superobese pregnant women. We also reviewed bariatric and general literature surgery on perioperative care of superobese patients. RESULTS: There is limited information to direct evidence-based care of superobese women who undergo cesarean delivery. Superobese women have a 30% to 50% risk of wound complications, a 20% risk of neonatal intensive care unit admission, and a 1% to 2% risk of maternal intensive care unit admission. Preoperative discussion with superobese women should include a review of maternal and fetal risks associated with cesarean delivery, as well as operative options including skin incision. Preoperative cefazolin with a 3-g dose, chlorhexidine skin preparation, and availability of adequate personnel for patient transfers are important evidence-directed approaches to reducing maternal and personnel morbidity. Postoperatively, early ambulation and chemical prophylaxis are reasonable, although there is a lack of evidence as to whether these measures prevent thromboembolic complications. CONCLUSIONS: Superobese women are at increased risk of cesarean delivery and resultant complications. Most evidence-directed recommendations for perioperative care are extrapolated from studies of obese women undergoing bariatric surgery. As the prevalence of reproductive-age women with superobesity increases, studies directed at this high-risk population are urgently need.