Tuesday, June 29, 2010

Big People in Pregnancy

Let me first say that I believe healthy women come in all shapes and sizes. I don’t believe that one body type fits all. I also strongly believe that too many women feel shame, rather than pride for having a body that is less than the super model standard. In other words, our body image as a nation has a long way to go.

On the opposite end of the spectrum, however, is the epidemic that is eating our nation up alive – the obesity epidemic.

What people don’t understand about their obesity is how difficult it makes it for us to provide them with good medical care. On pelvic exam, I can’t accurately assess uterine size or feel for adnexal masses. Fetal monitoring can be near impossible in morbidly obese patients simply due to the amount of tissue between mom’s abdomen and the baby inside. These patients are at much higher risk for both pregnancy complications, like pre-eclampsia and gestational diabetes, and birth complications like shoulder dystocia (when baby gets stuck in the birth canal). Perhaps the most dreaded place to treat a morbidly obese patient is the operating room.

It was my first day as a second year resident on my nights rotation. Instead of the quick and easy primary (or first time) cesarean sections, I was being graduated to repeat and crash cesarean sections. I was excited. It was about 2:00am when I got my first page from the OR in this new position. The patient was a morbidly obese woman with a history of 3 prior c-sections who presented in labor.

From the moment we started prepping and positioning the patient, we knew it would be a challenge. Her belly was too large to see her lower abdomen so it had to be pulled up and held in place with tape. After I made my first incision, I had more than 7 cm of subcutaneous fat to get through before I got to the fascia and muscles underneath. Her fascia, the usually thin layer of tissue covering her muscles, was thickened with scar tissue from her multiple prior c-sections. Instead of cutting easily through a Ziploc bag-like material, it was like cutting through leather. The muscle underneath was no better. In a primary section, you can separate the abdominal muscles in the middle easily and make your way into the abdominal cavity. In this patient, however, her muscle was attached to her uterus was attached to her bladder. She had so much scarring in her belly from her prior c-sections, even my attending and chief resident were having trouble identifying what was what. As if this scarring weren’t a challenge enough, we struggled to keep that thick layer of skin and fat from obstructing our visual field. We tried retractor after retractor and finally settled on using not one but three large retractors. Our poor medical student got a serious arm workout that day. Finally, after almost half an hour of careful dissection, we made our way inside her abdomen.

At this point, we had finally exposed the uterine surface. I made my incision and reached for the baby’s head inside. I grabbed it easily enough but trying to deliver the baby out of the uterus presented a new challenge. Normally, one surgeon applies pressure at the top of the uterus to create the force needed to push the baby out while the hand of the second surgeon is lifting the infant’s head to the uterine incision to guide its way out. In this case, her body mass so much that it was difficult for my chief to apply enough pressure in the right place to push the baby out. She was leaning most of her body weight on the patient’s abdomen to deliver this baby. Knowing this wasn’t going to be easy, we called for a vacuum. This suction cup was applied to the baby’s head and slowly, we were able to pull her out. Delivering this child took probably about 3-4 times as long as normal.

Finally it was time to close up the uterus. Normally, we pull the uterus out of the abdomen, stitch it up under good visualization, then return it to the abdomen. In this patient, with her thick abdominal wall in combination with the scar tissue that made everything stick together, we were forced to stitch her uterus up while it was still inside her belly. Again, the thick layer of fat continued to get in our way and obstruct our field of view. And again, it took us twice the amount of time as usual to close up the uterus. Take note, that a patient continues to bleed until that uterus is closed. By the end of the case, her estimated blood loss was 300-400cc higher than we usually expect. Almost an hour and a half had elapsed since we started to c-section (compare this to the usual 30-40 minutes).

The danger for this patient isn’t over now that the surgery is completed and her baby is delivered. She has got a high risk of poor wound healing and infection. Her belly hangs right over the incision, and as you can imagine, sweat and moisture are not conducive to healing wounds well.

My intention with this post is not to poke fun at morbidly obese patients in any way. I acknowledge that obesity is a struggle and getting/staying thin is not easy. I write this more to point out when one is morbidly obese, pregnancy should not be taken lightly. It benefits both mom and baby to get healthy before pregnancy happens. This particular patient was having her fourth c-section in the setting of morbid obesity. Let me just say I am thankful she wanted her tubes tied that day.

For more on the issue, check out this great New York Times article on the subject: http://www.nytimes.com/2010/06/06/health/06obese.html

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