Victoria Eley

The effect of antenatal anaesthetic consultation on maternal decision-making, anxiety level and risk perception in obese pregnant women

BACKGROUND Obese parturients are recognised as high risk and an antenatal anaesthetic consultation is recommended. The potential positive and negative effects of this consultation have not been investigated. This prospective observational study aimed to determine if antenatal anaesthetic consultation affects decisional conflict, anxiety scores or risk perception in obese women planning vaginal delivery. METHODS Eligible women had a body mass index of > or = 35 kg/m2, planning a vaginal delivery, aged > or = 18 years and able to complete a questionnaire presented in English. Before their anaesthetic consultation, women completed a written decisional conflict questionnaire, the Six-Point Short Form of the Speilberger State-Trait Anxiety Inventory and two questions regarding risk perception. All questions were repeated by telephone consultation two weeks later. Independent samples t-tests were used to detect differences between pre and post-test scores. RESULTS Of 114 women recruited, 89 completed the protocol and were analysed. Women had a mean ±SD age of 29.4±5.2 years and body mass index of 43.6±5.6 kg/m2. Decisional conflict scores were significantly lower after the consultation (30.04 vs. 16.54, P<0.001). Anxiety scores were lower (9.41 vs. 8.49, P=0.002) but this was not clinically significant. Only 19.1% of women felt their health was at risk in pregnancy; this did not change after the consultation. Thirteen women changed their preference toward epidural analgesia (P=0.01). DISCUSSION Our results support the current practice of referral of obese parturients for anaesthetic consultation, but demonstrate that most women remain unaware of the risks of obesity in pregnancy despite anaesthetic consultation.

A review of blood pressure measurement in obese pregnant women

Blood pressure monitoring is a critical component of antenatal, peripartum and postnatal care. The accurate detection and treatment of abnormal blood pressure during pregnancy is essential for the optimisation of maternal and neonatal outcomes. Increasing maternal obesity in western populations is well documented. The presence of a large arm circumference in obese pregnant women may lead to difficult and inaccurate blood pressure measurements. Difficulties measuring blood pressure in non-pregnant obese patients are well described. In the literature, the problem is uncommonly mentioned in relation to pregnant patients. This topic review will discuss the importance and challenges of blood pressure measurement in pregnancy. The currently available equipment for blood pressure monitoring in pregnancy will be identified and the process of validating devices described. The limitations of the current validation protocols in pregnancy will be highlighted. It is concluded that a pregnancy-specific validation protocol is required: this would facilitate the introduction of new technology for use in high-risk pregnant women. More accurate blood pressure measurement has the potential to improve the diagnosis and management of abnormal blood pressure in pregnancy and influence maternal and neonatal outcomes.

Arm and finger measurements in the third trimester: Implications for blood pressure measurement

OBJECTIVES To obtain arm and finger measurements of women ≥32 weeks gestation to determine: the requirement for different arm cuff sizes; the suitability of available finger cuffs in this population; the best predictor of arm conicity; the frequency of cuff placement on the forearm or leg. STUDY DESIGN Prospective observational pilot study. MAIN OUTCOME MEASURES Right and left mid-arm circumference (MAC) and to compare these to the recommended cuff sizes; right and left finger circumference; right and left arm conicity; the responses of women to a three-point Likert scale regarding cuff placement. RESULTS Measurements were obtained for 450 women at an Australian tertiary hospital with a median (IQR) gestation of 35.7 (34.0-37.0); 299 (66.4%) were Caucasian and 35 (7.8%) had gestational hypertension. The median (IQR) body mass index (BMI) was 29.6 kg/m2 (26.2-33.4), range 18.0-62.2. Median (IQR) right MAC was 29.9 cm (27.4-33), range 19.6-53.2. Based on right MAC, 58 (12.9%) required a large cuff and 6 (1.3%) a thigh cuff. Maximum right finger circumference was 7.0 cm. BMI, weight and right MAC were positively correlated with right arm conicity: r = 0.51, 0.42 and 0.45, p < 0.001 for all. R2 for each were 0.26, 0.17 and 0.20. Fourteen (3.1%) reported cuff placement on the forearm or leg. CONCLUSIONS A small percentage of women are likely to be unsuited to traditional arm cuffs. Available finger-cuffs would suit this population. BMI could potentially be used to select women with cone-shaped arms for future studies of alternative devices.

Increasing body mass index and abdominal subcutaneous fat thickness are associated with increased skin-to-epidural space distance in pregnant women

BACKGROUND Body mass index does not indicate the distribution of adipose tissue. Central adiposity may be measured using ultrasound measurement of subcutaneous fat thickness. This study determined if the abdominal subcutaneous fat thickness measured correlated with skin-to-epidural space distance at delivery, and compared this with the booking body mass index. METHODS We analysed a sub-set of participants from a single-centre, prospective cohort study that assessed the relationship between subcutaneous fat thickness and maternity outcomes. Abdominal subcutaneous fat thickness measurements were obtained during the routine fetal anomaly scan. The skin-to-epidural space distance was obtained in those having epidural or combined spinal-epidural analgesia. Linear regression was used to test for strength of association and adjusted R2 values calculated to determine if subcutaneous fat thickness or body mass index was more strongly associated with skin-to-epidural space distance. RESULTS The 463 women had a median (IQR) booking body mass index of 25.0 kg/m2 (21.8-29.3) and subcutaneous fat thickness of 16.2 mm (13.0-21.0). The median (IQR) skin-to-epidural space distance was 5.0 cm (4.5-6.0). Both parameters significantly correlated with skin-to-epidural space distance (r=0.53 and 0.68 respectively, P <0.001). Adjusted linear regression coefficient (95% CI) for subcutaneous fat thickness was 0.09 (0.08 to 0.11), R2=0.30 and for body mass index 0.12 (0.11 to 0.13), R2=0.47. CONCLUSIONS Booking body mass index had a stronger relationship with skin-to- epidural space distance at delivery than subcutaneous fat thickness, explaining 47% of the variation in the skin-to-epidural distance.

Increased maternal abdominal subcutaneous fat thickness and body mass index are associated with increased cesarean delivery: A prospective cohort study

Early pregnancy body mass index (BMI) is known to predict adverse pregnancy outcomes but does not account for body fat distribution. This study aimed to determine prospectively whether maternal abdominal subcutaneous fat thickness (SCFT) measured by ultrasound at the fetal morphology scan is a better predictor than BMI of mode of delivery and other pregnancy outcomes.

Epidural extension failure in obese women is comparable to that of non-obese women

Management of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non‐obese women and to identify risk factors for extension failure.

Interpretation of Care Guidelines for Obese Women in Labor Intergroup Language and Social Identity

The hospital-based care of pregnant women who are obese is complex. Current guidelines recommend early epidural analgesia, but there is disagreement about the guidelines and their implementation by anesthesiologists. In this study, we conducted semistructured interviews with 42 specialist anesthesiologists about their experiences implementing the “early epidural” recommendation. We examined the impact of intergroup identity and system factors on the language used by anesthesiologists to express their experiences, framing the work by social identity and communication accommodation theory. Leximancer text mining was used to elicit the dominant theme “epidural” in the interviews, and discourse analysis aided in exploring selected extracts. Findings indicated that anesthesiologists expressed their role primarily as technical experts, along with the core value of accommodating patients’ wishes. Furthermore, the extent to which they were prepared to accommodate the perspective of other health professionals was a key indicator of the intergroup climate.

Case Report: Successful resuscitation of maternal cardiac arrest with disseminated intravascular coagulation guided by Rotational thromboelastometry (ROTEM®) and transoesophageal echocardiogram

We present a case of maternal cardiac arrest during an elective cesarean delivery. Transesophageal echocardiography identified a large pulmonary artery mass, and guided resuscitation efforts. After return of spontaneous circulation, the patient developed disseminated intravascular coagulation with massive hemorrhage. Blood product selection and volume replacement were guided by rotational thromboelastometry and transesophageal echocardiography, respectively. Correction of coagulopathy was observed clinically and confirmed by rotational thromboelastometry. The patient fully recovered without neurological deficit.