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Postoperative Respiratory Compromise following Cesarean Birth: The Impact of Obesity and Systemic OpioidsFunding This project was supported by the Clinical and Translational Science Award (CTSA) program, through the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS), grant no. UL1TR002373 and the University of Wisconsin School of Medicine and Public Health Department of Obstetrics and Gynecology. The funding source had no role in the study design, collection, analysis or interpretation of data, writing of the report, or decision to submit the article for publication.
Objective The aim of this study was to measure the effect of obesity and systemic opioids on respiratory events within the first 24 hours following cesarean.
Methods Opioid-naive women undergoing cesarean between January 2016 and December 2017 were included in this retrospective cohort study. The primary outcome was the proportion of women experiencing at least one composite respiratory outcome (oxygen saturation less than 95% lasting 30+ seconds or need for respiratory support) within 24 hours of cesarean. The impact of obesity and total systemic opioid dose in 24 hours (measured in morphine milligram equivalents [MMEs]) on the composite respiratory compromise outcome were evaluated.
Results Of 2,230 cesarean births, 790 women had at least one composite respiratory event. Predictors of the composite respiratory outcome included body mass index (BMI) as a continuous variable (odds ratio = 1.063 for every one unit increase in BMI [95% confidence interval (CI): 1.021–1.108], p = 0.003), and MME (odds ratio = 1.005 [95% CI: 1.002–1.008], p = 0.003), adjusting for magnesium sulfate use. The interaction between obesity and opioid dose demonstrated an odds ratio of 1.000 (95% CI: 0.999–1.000, p = 0.030).
Conclusion The proportion of women experiencing respiratory events following cesarean birth increases with the degree of obesity and opioid dose.
Respiratory events increase with obesity.
Respiratory events increase with systemic opioid use.
Odds ratio of respiratory events is 1.063/unit BMI increase.
Keywordsobesity - analgesia - obstetrics - opioids - postoperative respiratory compromise - cesarean
Paper Presentation Information
Data from this study were presented as a poster presentation at the Wisconsin Association for Perinatal Care, Oshkosh, WI, April 7–9, 2019, abstract number 16.
Received: 19 October 2020
Accepted: 08 October 2021
Article published online:
13 January 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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- 1 Mamun AA, Callaway LK, O'Callaghan MJ. et al. Associations of maternal pre-pregnancy obesity and excess pregnancy weight gains with adverse pregnancy outcomes and length of hospital stay. BMC Pregnancy Childbirth 2011; 11: 62
- 2 Hartge D, Spiegler J, Schroeer A, Deckwart V, Weichert J. Maternal super-obesity. Arch Gynecol Obstet 2016; 293 (05) 987-992
- 3 Stamilio DM, Scifres CM. Extreme obesity and postcesarean maternal complications. Obstet Gynecol 2014; 124 (2 Pt 1): 227-232
- 4 Fyfe EM, Anderson NH, North RA. et al; Screening for Pregnancy Endpoints (SCOPE) Consortium. Risk of first-stage and second-stage cesarean delivery by maternal body mass index among nulliparous women in labor at term. Obstet Gynecol 2011; 117 (06) 1315-1322
- 5 Magriples U, Kershaw TS, Rising SS, Westdahl C, Ickovics JR. The effects of obesity and weight gain in young women on obstetric outcomes. Am J Perinatol 2009; 26 (05) 365-371
- 6 O'Dwyer V, Farah N, Fattah C, O'Connor N, Kennelly MM, Turner MJ. The risk of caesarean section in obese women analysed by parity. Eur J Obstet Gynecol Reprod Biol 2011; 158 (01) 28-32
- 7 Pallasmaa N, Ekblad U, Aitokallio-Tallberg A. et al. Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta Obstet Gynecol Scand 2010; 89 (07) 896-902
- 8 Bonnesen B, Secher NJ, Møller LK, Rasmussen S, Andreasen KR, Renault K. Pregnancy outcomes in a cohort of women with a preconception body mass index >50 kg/m2 . Acta Obstet Gynecol Scand 2013; 92 (09) 1111-1114
- 9 Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology 2007; 106 (06) 1096-1104
- 10 The American College of Obstetricians and Gynecologists. Obesity in pregnancy. Practice Bulletin No. 156. Obstet Gynecol 2015; 126: e112-e126
- 11 Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ 2017; 356: j1
- 12 Alvarez A, Singh PM, Sinha AC. Postoperative analgesia in morbid obesity. Obes Surg 2014; 24 (04) 652-659
- 13 Lloret-Linares C, Lopes A, Declèves X. et al. Challenges in the optimisation of post-operative pain management with opioids in obese patients: a literature review. Obes Surg 2013; 23 (09) 1458-1475
- 14 Nightingale CE, Margarson MP, Shearer E. et al; Members of the Working Party, Association of Anaesthetists of Great Britain, Ireland Society for Obesity and Bariatric Anaesthesia. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia 2015; 70 (07) 859-876
- 15 Oderda G. Challenges in the management of acute postsurgical pain. Pharmacotherapy 2012; 32 (9, Suppl): 6S-11S
- 16 Overdyk F, Dahan A, Roozekrans M, van der Schrier R, Aarts L, Niesters M. Opioid-induced respiratory depression in the acute care setting: a compendium of case reports. Pain Manag 2014; 4 (04) 317-325
- 17 Lee LA, Caplan RA, Stephens LS. et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology 2015; 122 (03) 659-665
- 18 Mason EE, Renquist KE, Jiang D. Perioperative risks and safety of surgery for severe obesity. Am J Clin Nutr 1992; 55 (2, Suppl): 573S-576S
- 19 Hagle ME, Lehr VT, Brubakken K, Shippee A. Respiratory depression in adult patients with intravenous patient-controlled analgesia. Orthop Nurs 2004; 23 (01) 18-27 , quiz 28–29
- 20 Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Pract Res Clin Anaesthesiol 2011; 25 (01) 73-81
- 21 Gross JB, Bachenberg KL, Benumof JL. et al; American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104 (05) 1081-1093 , quiz 1117–1118
- 22 Blake DW, Yew CY, Donnan GB, Williams DL. Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesth Intensive Care 2009; 37 (05) 720-725
- 23 Kessler ER, Shah M, Gruschkus SK, Raju A. Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy 2013; 33 (04) 383-391
- 24 Crowgey TR, Dominguez JE, Peterson-Layne C, Allen TK, Muir HA, Habib AS. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Anesth Analg 2013; 117 (06) 1368-1370
- 25 Sharawi N, Carvalho B, Habib AS, Blake L, Mhyre JM, Sultan P. A systematic review evaluating neuraxial morphine and diamorphine-associated respiratory depression after cesarean delivery. Anesth Analg 2018; 127 (06) 1385-1395
- 26 Loubert C, Fernando R. Cesarean delivery in the obese parturient: anesthetic considerations. Womens Health (Lond) 2011; 7 (02) 163-179
- 27 Mace HS, Paech MJ, McDonnell NJ. Obesity and obstetric anaesthesia. Anaesth Intensive Care 2011; 39 (04) 559-570
- 28 Mhyre JM. Anesthetic management for the morbidly obese pregnant woman. Int Anesthesiol Clin 2007; 45 (01) 51-70
- 29 Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment. Acta Anaesthesiol Scand 2008; 52 (01) 6-19
- 30 Taylor S, Kirton OC, Staff I, Kozol RA. Postoperative day one: a high risk period for respiratory events. Am J Surg 2005; 190 (05) 752-756
- 31 American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy. Hypertension in Pregnancy (Task Force on Hypertension in Pregnancy, ed.). Washington, DC: American College of Obstetricians and Gynecologists; 2013
- 32 The American College of Obstetricians and Gynecologists. Pregestational diabetes mellitus. ACOG Practice Bulletin No. 60. Obstet Gynecol 2005; 105: 675-685
- 33 The American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. ACOG Practice Bulletin No. 190. Obstet Gynecol 2018; 131 (180) 49-64
- 34 World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894 :i–xii, 1-253
- 35 Nielsen S, Degenhardt L, Hoban B, Gisev N. A synthesis of oral morphine equivalents (OME) for opioid utilisation studies. Pharmacoepidemiol Drug Saf 2016; 25 (06) 733-737
- 36 Centers for Disease Control and Prevention. Calculating total daily dose of opioids for safer dosage. Accessed on July 2, 2019, at: https://www.cdc.gov/drugoverdose/prescribing/guideline.html
- 37 American Society of Addiction Medicine. Public Policy Statement on Morphine Equivalent Units/Morphine Milligram Equivalents. 2016 . Accesssed on July 8, 2020, at: https://www.asam.org/docs/default-source/public-policy-statements/2016-statement-on-morphine-equivalent-units-morphine-milligram-equivalents.pdf?sfvrsn=3bc177c2_6#search=%22omemme%22
- 38 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335 (7624): 806-808
- 39 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 (08) 743-749
- 40 Abouleish E. Apnoea associated with the intrathecal administration of morphine in obstetrics. A case report. Br J Anaesth 1988; 60 (05) 592-594
- 41 Bauchat JR, Weiniger CF, Sultan P. et al. Society for Obstetric Anesthesia and Perinatology Consensus Statement: monitoring recommendations for prevention and detection of respiratory depression associated with administration of neuraxial morphine for cesarean delivery analgesia. Anesth Analg 2019; 129 (02) 458-474
- 42 Bonner JC, McClymont W. Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia. Anaesthesia 2012; 67 (05) 538-540
- 43 Marr R, Hyams J, Bythell V. Cardiac arrest in an obstetric patient using remifentanil patient-controlled analgesia. Anaesthesia 2013; 68 (03) 283-287
- 44 Fuller JD, Crombleholme WR. Respiratory arrest and prolonged respiratory depression after one low, subcutaneous dose of alphaprodine for obstetric analgesia. A case report. J Reprod Med 1987; 32 (02) 149-151
- 45 Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases. Reg Anesth 1991; 16 (03) 137-140
- 46 Altenau B, Crisp CC, Devaiah CG, Lambers DS. Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control. Am J Obstet Gynecol 2017; 217 (03) 362.e1-362.e6
- 47 Horlocker TT, Burton AW, Connis RT. et al; American Society of Anesthesiologists Task Force on Neuraxial Opioids. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009; 110 (02) 218-230