surgery in the pregnant patient - tennessee society of … · 2018-02-23 · 2/22/18 2 statistics!...
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Surgery in the
Pregnant PatientPatrick McConville, M.D. FASA
Department of Anesthesiology
The University of Tennessee-Knoxville
Objectives
! Review the common surgical procedures performed in parturients
! Review the physiological changes of pregnancy and their effects in the perioperative period
Objectives
! Discuss teratogenicity and fetal effects of anesthetics
and surgery in parturients
! Discuss the obstetrical and anesthetic management
of the parturient undergoing non-obstetrical surgery
in pregnancy
Statistics
! Laparoscopy for gynecologic procedures is the most
common procedure in the 1st trimester.1
! Appendectomy is the most common procedure in the 2nd
trimester.1
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Statistics
! 0.3%-2.2% of pregnant patients undergo nonobstetric
surgery.1-3
! 0.3% of women in ambulatory surgery centers, 2.6% of
women undergoing laparoscopic sterilization, and 1.2%
of adolescents scheduled for surgery are pregnant.4-6
Routine Pregnancy Testing?
ASA 2016 Committee Recommendations
! Screening should be based upon risk for fetal harm
! Testing may be offered to patients for whom the result
would alter management
! Medicolegal Concerns
! Ethical Considerations
Maternal Safety and Physiology
! 1st Trimester-Hormonal Influence
! 2nd/3rd Trimester- Mechanical Influence
Maternal Safety and
Physiology
! An increased MV (minute ventilation): FRC
ratio in pregnancy
! More difficult to ventilate and intubate during
pregnancy.
! Induction of inhalation anesthesia occurs more
rapidly
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Maternal Safety and
Physiology
! Cardiovascular changes begin to occur by 6 weeks’ gestation.9
!Increases in CO secondary to increases in heart rate and stroke volume.
!SVR decreases
Maternal Safety and
Physiology
! Aorto-caval Compression
! Dilutional Anemia
! A mild benign leukocytosis
! Clotting factors increase
Maternal Safety and
Physiology
! Impaired LES tone
! Consider them to be a “full stomach” by
20 weeks’ gestation.
! Gastric emptying times
Maternal Safety and
Physiology
Response to Anesthetics
! 30-40% decrease in MAC
! Spinal and epidural anesthetic requirements are decreased
! Response to peripheral neural blockade is increased
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Maternal Safety and
Physiology
Response to Anesthetics
! Decreased albumin level
! Decreases in plasma cholinesterase
Fetal Considerations
Risks of Teratogenicity
! Medication can cause teratogenic effects
! Prospective clinical trials?
! Animal studies combined with outcome studies
! Manifestations of teratogenicity
Fetal Considerations
Risks of Teratogenicity
Systemic medications
! Propofol
! Thiopental
! Ketamine
! Benzodiazepines
Fetal Considerations
Risks of Teratogenicity
! Local Anesthetics
! Muscle Relaxants
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Fetal Considerations
Risks of Teratogenicity
! Volatile anesthetics in animals
! Humans exposed to clinical doses
! N2O exposure in animals vs humans
! Epidemiologic surveys of reproductive
hazards in OR personnel
Fetal Considerations
Risks of Teratogenicity
Behavioral Teratology
! Jevtovic-Todorvic et al. studied a general anesthetic
cocktail in rats in 2003 34
! The FDA - There is inadequate data to extrapolate
animal findings to humans at this time.35
Fetal Considerations
Fetal Effects of AnesthesiaMaintenance of Fetal Well-Being
! Avoidance of maternal hypoxia
! Normocapnea
! Avoiding Hypotension
Fetal Considerations
Fetal Effects of Anesthesia
! Volatile anesthetics allow placental perfusion provided that hypotension is not present.40 Volatile agents are tocolytic.
! Narcotic and induction agent induced decreased FHR variability and respiratory depression- relevant?
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Fetal Considerations
Fetal Effects of Anesthesia
! Anticholinesterases
! Atropine vs glycopyyrolate
! Esmolol
! Suggammadex
Fetal Considerations
Fetal Effects of Anesthesia
Prevention of Preterm Labor
! Nonobstetric surgery during pregnancy -higher
incidences of abortion and preterm delivery.1,49-51
! Causative agents?
Fetal Considerations
Fetal Effects of Anesthesia
Prevention of Preterm Labor
! Anesthetic technique of choice?
! Monitoring FHR and maintenance of physiologic homeostasis
Practical Considerations
Timing of Surgery
! Elective surgery
! Emergent surgery
! Semi-elective surgery?
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Practical Considerations
Laparoscopy
! Increasing frequency
! CO2 insufflation impacts
! Maintenance of blood volume, BP and continuous fetal monitoring are indicated.59
Practical Considerations
ECT
! Performed for medically refractory depression
! Complications can occur
DC Cardioversion
! FHR monitoring is recommended
Practical Considerations
Fetal Monitoring During Surgery
! 2003 ACOG “the decision to use intraoperative fetal monitoring should be individualized, and each case warrants a team approach for optimal safety of the woman and her baby”62
! FHR monitoring after 20 weeks is feasible
Practical Considerations
Fetal Monitoring During Surgery-2017 ACOG
Pre-viable Fetus- before and after
Viable Fetus – minimally before and after
Continuous Monitoring
1. viable fetus
2. monitoring is physically possible during case
3. OB willing to intervene
4. Surgery allows for interruption
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Practical Considerations
Anesthetic management
! Aspiration prophylaxis ! Left uterine displacement after 18-20
weeks ! Anesthetic of choice?! Standard monitors
plus FHR monitoring per ACOG guidelines
Institutional Guidelines
! All patients with a documented pregnancy prior to surgery should undergo obstetric consultation
! In cases of a viable pregnancy the possibility of emergency cesarean section during or after surgery should be discussed among the patient, surgeon, anesthesiologist and obstetrician prior to the procedure
! The Designated Obstetrician should be immediately available
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References
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