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Anesthesia for Non

Obstetric Surgery in
Pregnant Patients

Incidence
0.3%

to 2.2% of pregnant women undergo


surgeries

Annual

incidence - 75,000 80,000 (USA)

Centralized

data unavailable in India

Commonest

surgery - Appendicectomy

Incidence

Am J Obstet
Gynecol 1989

Surgeries in pregnancy
Pregnancy related
Cervical encirclage
Fetal surgery
Ovarian Cystectomy
Not

related to pregnancy

Appendicectomy, Cholecystectomy
Trauma
Malignancies

How these patient are different from


other surgical patients?
Two

patients - mother
- fetus

Physiological

changes in mother

Why this topic is


important?
Must ensure safe anaesthesia for both mother
and child
Standard

anaesthetic procedure may have to


be modified to accomodate both maternal
physiological changes and presence of fetus

Risk

to the fetus is more the effect of disease process,


teratogenicity of anaesthetic agents,
intraoperative impairment of uteroplacental
circulation, and
risk of abortion or preterm delivery

KEY AREAS
Normal

alterations in maternal physiology


during pregnancy

The

potential fetal effects from anaesthesia and


surgery

Maintenance

of uteroplacental perfusion and


fetal oxygenation

Practical

considerations

Importance

of maternal counselling and


reassurance

Special

situations

Altered maternal
physiology

O2 consumption & FRC rapid desaturation or


Respiratory
system:
hypoxemia

Alveolar ventilation chronic respiratory alkalosis &


bicarbonate and base buffer

mucosal vascularity & weight gain difficult mask


ventilation or intubation

Cardiovascular system:
Supine

hypotension syndrome uteroplacental


perfusion

Distention

of epidural venous plexus likelihood of


intravascular injection and enhanced spread of LA

Altered maternal
physiology

Blood volume with lesser increase in RBCs


volume dilutional anemia

Hematological changes

Factor I, VII, VIII, X, XII & FDP Increased risk


of thromboembolic complications

Benign

leukocytosis difficult to differentiate


from infection

Gastrointestinal system changes

LES tone, distortion of gastropyloric anatomy &


gastric pressure from gravid uterus risk of
regurgitation and aspiration

Altered maternal
physiology

Altered response to anaesthesia


Alveolar

hyperventilation, reduction of FRC


and reduction of MAC rapid induction of
general anaesthesia

thiopental requirements

protein binding due to low albumin


free fraction of drugs

sensitivity to peripheral neural blockade


L.A. dose requirement

FETAL EFFECTS
Teratogenicity
Any

significant postnatal change in function or


form in an offspring after prenatal treatment

Factors

that influence teratogenicity of a drug


Species susceptibility
Threshold or amount of exposure
Duration and timing of administration
Genetic predisposition

Manifestation

of teratogenicity (Death, Structural


abnormality, Growth restriction, functional
deficiency)

FETAL EFFECTS

Documented teratogens:
Radiation

increased risk of malignant disease, genetic


disease, cong. malformation &/or fetal death
Maternal

metabolic imbalance
Alcoholism, cretinism, diabetes, folic acid
deficiency, hyperthermia, prolonged hypoxia,
hypercarbia and severe hypoglycemia

Infection

CMV, Herpes virus, Parvo virus B-19, rubella


virus, toxoplasmosis
Drugs

FETAL EFFECTS
Radiology: a threat??
Effects
Less

are dose related

than 50 mGy is safe

Absorbed

fetal dose for all conventional


radiographic imaging is less than 50 mGy

No single diagnostic procedure results in a


radiation dose that threatens the well-being of
the developing embryo and fetus
(American College of Radiology)

Diagnostic ultrasonography:
Considered
Potential

to be devoid of embryotoxic effects

side effects

Fetal hyperthermia with prolonged scans

Post-natal neurobehavioral
repeated exposures

effects

with

Hande et al. Teratogenic effects of repeated exposures to X-rays


and or ultrasound in mice. Neurotoxic Teratol 1995

Documented teratogenic
drugs
(Adapted: ACOG Educational
Bulletin )
Lithium

(Adapted:
ACE
inhibitors
Alcohol

Mercury

Androgens

Phenytoin

Antithyroid drugs

Vitamin A derivatives

Carbamazepine

Streptomycin/kanamycin

Chemotherapy agents

Tetracycline

Cocaine

Thalidomide

Coumadin

Trimethadione

Diethylstilbestrol

Valproic acid

Lead

FETAL EFFECTS
Anaesthetic agents and
teratogenicity
Teratogenic effects of anaesthetic agents are
probably minimal to non-existent and have
never been conclusively documented

FETAL EFFECTS
Safe drugs:

I/V induction agents

Narcotics

Neuromuscular blockers

Inhalational agents

Local anaesthetics

Drugs of concern:
Nitrous oxide,
BZD

FETAL EFFECTS

Nitrous oxide
Animal studies

Weak teratogen in rodents

Interferes with function of methionine synthetase by


oxidation of vitamin B12
decreased THF

decreased DNA synthesis

Decreased uterine blood flow : prevented by addition of


halogenated inhalational agents

FETAL EFFECTS
Nitrous oxide
Human studies

No proved teratogenicity

Significant exposure for prolonged duration results in


altered enzyme activity

No teratogenic effects in clinically administered dose.

FETAL EFFECTS
BENZODIAZEPINES (BZD)

Earlier retrospective studies:


Association between maternal diazepam ingestion
during 1st trimester and infant with cleft lip and
palate

Later prospective studies:


- No higher risk when used in 1st trimester

Long term maternal administration fetal BZD


dependence & withdrawal

Peripartum administration
Fetal hypotonia, hypothermia, respiratory
depression, feeding difficulties

FETAL EFFECTS

A single shot of short acting BDZ or Nitrous


oxide in clinically administered anaesthetic
concentration is unlikely to have any
teratogenic effects

FETAL EFFECTS

BEHAVIORAL TERATOLOGY
Behavioral abnormality in absence of any
observable morphological changes
CNS

is specifically sensitive during period of


major myelination which extends from 4 th IU
month to 2nd postnatal month

Animals

prenatal administration of systemic


drugs e.g., Barbiturates, meperidine,
promethazine & halothane behavioral
changes

Human

implication remains unknown

FETAL EFFECTS

There are not adequate data to


extrapolate the animal finding to
humans
(Anesthetic & Life Support Drug advisory
Committee of US FDA)

Fetal effects

To summarize, anaesthesia and surgery are


associated with higher incidence of abortion, IUGR
and perinatal mortality.

These adverse outcomes can often be attributed to


the procedure, the site of the surgery (e.g., proximity
to the uterus), and/ or the underlying maternal
condition

No evidence that anaesthesia results in overall


increase in congenital abnormality

No evidence of clear relation between outcome and


type of anaesthesia

Uteroplacental perfusion
and fetal oxygentation

Fetal oxygenation depends on maternal oxygen


delivery and uteroplacental perfusion

Most serious risk during nonobstetric surgery is


Intrauterine asphyxia

Maintenance of fetal well being :

Maternal oxygenation

Maternal carbon dioxide tension

Uterine blood flow

Uteroplacental perfusion
and fetal oxygentation
Maternal oxygenation:

Severe maternal hypoxia can occur with:

difficult / oesophageal intubation

pulmonary aspiration

total spinal anaesthesia

systemic LA toxicity

Moderate hyperoxia improves fetal oxygenation and is


not associated with intrauterine retrolental fibroplasia
and premature DA closure

Uteroplacental perfusion
and fetal oxygentation
Maternal CO2:

Fetal CO2 correlates to maternal levels

Maternal hyperventilation can results in

Umbilical artery constriction

Alkalosis:
shift maternal oxyhemoglobin dissociation curve to
left.

Hypocapnia:
ventilation venous return cardiac output
uterine blood flow.

Factors affecting the


Uteroplacental perfusion
Maternal

hypotension
deep levels of anaesthesia
high levels of spinal or epidural blockade
aortocaval compression,
hemorrhage/ hypovolumia
Anaesthetic

agents causing uterine


vasoconstriction or hypertonus
(eg. ketamine>2mg/kg, toxic doses of LA)

Catecholamines

Pain, anxiety, light anaesthesia increased plasma


catecholamines decreased UBF

PRACTICAL CONSIDERATIONS
Timing

of surgery
Fetal monitoring
Full stomach precautions
Left uterine displacement
Anaesthetic considerations
Tocolytic agents

PRACTICAL CONCERNS

When to do the surgery??

Depends on the balance between maternal and fetal


risk and urgency of the surgery
1st trimester Organogenesis
Increased fetal risk for teratogenesis and abortion
3rd trimester Peak of physiological changes of
pregnancy
Increased maternal risk
Increased risk of preterm labour

Thus 2nd trimester is considered to be a ideal time


for non emergency, essential surgeries

PRACTICAL CONCERNS

When to do the surgery??

Carvalho B, Anesth Analg Suppl

PRACTICAL CONCERNS

Fetal monitoring
Intermittent

or continuous FHR monitoring


should be considered for major surgical
procedures whenever technically feasible:

Ease of monitoring
Type & site of surgery (difficult during abdominal surgery)
Gestational age (after 18-20 wks)

Tool to monitor intrauterine fetal well being

Done by transabdominal doppler or vaginal doppler


probe

Requires the presence of a trained practitioner to


monitor and interpret the tracing

FHR variability

Good indicator of fetal well being after 25-27 wks

Loss of beat to beat variability and decreased


baseline FHR are common Anaesthetic agent
administration

Declerations suggests fetal hypoxemia

Causes of FHR declerations Inadvertent maternal


hypoxemia, or inadequate uterine perfusion
evaluation of maternal position, B.P, oxygenation,
acid base status and inspection of surgical sites as
retractors may impair uterine perfusion.

PRACTICAL CONCERNS
Anaesthetic considerations in1st
Trimester
Maternal

oxygen requirement
Modified drug pharmacokinetics
Careful airway manipulation

Fetal
Risk

of teratogenicity
Impaired UBF

PRACTICAL CONCERNS
Anaesthetic considerations in 2nd and
3rd trimester
Maternal
Prone

to hypoxia
Aspiration prophylaxis
Preparation for difficult airway
Increased risk of thromboembolic
complications
Avoid hyperventilation

PRACTICAL CONCERNS...
Fetal
Premature

labour / IUGR
Intrauterine asphyxia

Surgery related
Disease

related problem
Diagnostic difficulties
Prolonged exposure to anaesthetics
Surgical manipulations fetal risk
Anatomic and surface landmarks unreliable

PRACTICAL CONCERNS.
DIAGNOSTIC DIFFICULTY
As

nausea, vomiting, constipation, and distention


are common symptoms of both normal pregnancy
and abdominal pathology

Increase

WBC count

Reluctance

to perform necessary studies involving

radiation
Anatomic

and surface landmarks can be unreliable

PRACTICAL CONCERNS
TOCOLYTICS AGENTS

Prophylactic use in nonobstetric surgery is controversial

May be considered
abdominal surgeries involving uterine manipulations or
Surgeries with high risk of premature labour i.e.,
cervical encirclage

Uterine contractions should be monitored during the


surgery and tocolytic therapy to be instituted if required

Not recommended at or after 34 wks

Do not affect the outcome

PRACTICAL CONCERNS
Tocolytic agents
Drugs
Side effects
2 agonist

Calcium channel
blockers
Magnesium sulphate

Terbutaline
Ritodrine
Isoxsuprine

Nifedipine
(one of the most
commonly used)
least commonly
used

Indomethacin

Atosiban
(newer agent)
oxytocin antagonist

fetal tachycardia,
hypoglycemia,
hypotension,
Pulmonary edema,
myocardial ischemia
transient hypotension

interaction with NMBs,


CNS depression
peptic ulcer,
thrombocytopenia,
premature closure of
D.A.

Blunts Ca2+ influx in


myometrium and
inhibit contractility

Counselling and
reassurance
Patient should be reassured about the safety of

anaesthesia and the lack of documented associated


teratogenicity

Warned about the increased risk of 1st trimester


miscarriage and premature delivery in later trimesters

Educate the patient about the symptoms of


premature labour and reinforce the need of left
uterine displacement

Documentation of details of the risk discussed should


be maintained in patients records

ANAESTHETIC MANAGEMENT

Pre-anaesthetic
Counselling and reassurance
preparation..

Consult obstetrician & discuss about the use of tocolytics

Overnight fast

Aspiration prophylaxis

Anxiolytic premedication- to allay anxiety and


apprehension

Transport in left lateral position

O.T. preparation drugs, machine, difficult airway cart,


suction and monitors

ANAESTHETIC MANAGEMENT
Choice of Anaesthesia

Choice of Anaesthetic technique depends on Patients present surgical status (site and nature
of surgery)
Present gestational age of the fetus
Pregnancy induced physiological changes
Other coexisting comorbidities

No technique has been proven to have superiority


over the other in fetal outcomes

Regional techniques may be preferable

Safe anaesthetic management is more important than


particular agent or technique

AIM :

To maintain oxygenation, normotension, eucapni


and euglycemia

ANAESTHETIC MANAGEMENT

Monitoring
Maternal

monitoring:

Noninvasive / invasive blood pressure

Electrocardiography
Pulse oximetry
Capnography
Temperature monitoring
Use of peripheral nerve stimulator
Blood glucose levels

Fetal

monitoring:

External doppler device (FHR )


Tocodynamometer (Uterine contractility)

ANAESTHETIC
MANAGEMENT

..

General anaesthesia

Maintain left uterine displacment

Preoxygenation

Rapid sequence induction (Thiopent. sod. & succinyl choline,


cricoid pressure tracheal intubation using cuffed E.T. tube)

Maintenance : A moderate conc. of inhalational agent ( 2


MAC) with high conc. of oxygen (FiO2 = 0.5) is
recommended.

The use of nitrous oxide should be limited during extremely


long operations in first trimester by giving high conc of
oxygen

Opioids and induction agents decreases FHR


variability to greater extent than volatile agents

Positive pressure ventilation may reduce UBF

Avoid hyperventilation

Patients on magnesium for tocolysis reduce dose


of NMBs

Reversal agent to be given slowly (increased release


of Ach increased uterine tone and preterm labour)

Extubation when fully awake after return of


protective airway reflexes

ANAESTHETIC MANAGEMENT..
Regional anaesthesia
Advantages:
Minimal

fetal drug exposure

Avoidance

of complications of general anaesthesia

If

no sedative or narcotics are supplemented no


change in FHR variations to confuse interpretation

Post

operative analgesia

Management of regional anaesthesia

Pre-op preparation and monitoring same as of General


anaesthesia

Reduced LA requirement / LA Toxicity

Careful aspiration and test dose

Avoid hypotension i.e., adequate preloading, maintain


left uterine tilt, choice of vasopressor

Patients on magnesium are more prone to hypotension,


often resistant to treatment with vasopressors

ANAESTHETIC MANAGEMENT

Postoperative management

Oxygenation in left uterine tilt

Vitals monitoring

Obstetrician consultation for FHR & uterine activity


monitoring

Pediatric consultation in case of premature labour

Adequate pain relief reduce the risk of premature labour

Tocodynamometry is useful in high risk patients as


postoperative analgesia may mask awareness of early
contractions and delay tocolysis

Early mobilization or DVT prophylaxis if required

ANAESTHETIC MANAGEMENT

Postoperative Pain
Painincreased endogenous catecholamines uterine
management
vasoconstrictiondecreased UBFintrauterine hypoxia

Techniques:

Nerve blocks
Local infiltration
Opioids
NSAID

NSAIDS
1st and 2nd trimester - safe
3rd trimester - risk of premature closure of DA,
Pulm HTN, delayed labour

NSAID can be used before 32 wks and


Acetaminophen is safe

ANAESTHETIC MANAGEMENT
Recommendations approved by
American Society of Anaesthesiologists
(ASA) and American College of
Obstetricians and Gynecologists (ACOG)
2011

No currently used anaesthetic agents have been


shown to have any teratogenic effects in humans when
using standard concentrations at any gestational age

Fetal heart rate monitoring may assist in maternal


positioning and cardiorespiratory management, and
may influence a decision to deliver the fetus

Recommendations

It is mandatory to obtain an obstetric consultation


before performing any non obstetric surgery or any
invasive procedures

A pregnant woman should never be denied indicated


surgery, regardless of trimester.

Elective surgery should be postponed

If possible, non-urgent surgery should be performed


in the second trimester when preterm contractions
and spontaneous abortion are least likely.

Special situation
Laparoscopy

No longer a contraindication in pregnant patients

Concerns:
- Uterine and fetal trauma
- Fetal acidosis from absorbed carbon dioxide.
- Decreased maternal cardiac output and
uteroplacental perfusion due to increased
abdominal pressure.

Special situation
Laparoscopy
Guidelines by Society of American

Gastrointestinal Endoscopic Surgeons


(SAGES) 2008

Safe during any trimester of pregnancy

Obtain preoperative obstetrician consultation

Intermittent lower extremity pneumatic


compression devices to prevent venous stasis

The fetal heart rate and uterine tone should be


monitored in both preoperative and postoperative
periods

End tidal CO2 should be maintained

Special situation
Laparoscopy

Left uterine displacement should be maintained

An open (Hassan) technique, a veres needle or an


optical trocar technique to enter abdomen

Low pneumoperitoneum pressures (10-15mm Hg)


should be used

Tocolytic agents should not be used


prophylactically but should be considered when
evidence of preterm labour is present

Special situation Fetal


surgery

Anaesthetic considerations remains similar to those of


non obstetric surgeries

Two surgical patients

Maternal safety is important

Choice of anaesthetic technique

Minimally invasive endoscopic procedure Neuraxial


anaesthesia

Open intrauterine procedures General anaesthesia

Special situation Fetal


surgery.
Important considerations
Consider

anaesthetic requirement of fetus


including amnesia, analgesia and immobilty

Control
More

of uterine tone is essential

intensive intraop FHR monitoring

Special situation
Electroconvulsive
Shock
Therapy
Used to treat major depression and BPD during
pregnancy when rapid control of symptoms is
needed

Advantage

Avoids potential teratogenicity from psychotropic


medications
Not a risk factor for premature labour, miscarriage
or stillbirth

Anaesthetic

management
Confirm the absence of uterine contractions using
tocodynamometry before and after ECT
Monitor FHR before and after ECT

Special situation
Neurosurgery (e.g.,
Aneurysm,
AVtechniques
malformation)
Hypotensive anaesthetic
( 25 30%

reduction in SBP or mean BP less than 70 mmHg) can


cause decrease in UBF

Dose (less than 0.5 mg/kg/hr) and duration of Sodium


Nitroprusside should be limited

FHR monitoring should be performed continuously


specially if induced hypotension or hyperventilation is
planned so that necessary adjustments can be made if
fetal distress occurs

Hypovolemia and very large doses of mannitol should


be avoided as they cause fetal dehydration

Endovascular treatments uterine shielding during


periods of radiation

Special situation Trauma


during pregnancy

Trauma is the leading cause nonobstetric cause of


morbidity and mortality

Primary management goals are similar to the care of


nonpregnant trauma cases

Avoidance of hypoxia, hypotension, acidosis and


hypothermia are important for the maintenance of
UBF and fetal well being

More prone to develop pulmonary edema

In stable patients without ongoing blood loss


Conservative fluid management
CVP monitoring should be considered if renal
insufficiency or fluid overload occurs

Special situation Trauma


during pregnancy

Primary aim should be optimization of the mother and


the obstetric management is planned later

No radiological tests should be withheld because of


fetal concerns, uterus should be shielded during
radiation procedures

Indications for an Emergency Cesarean delivery in a


pregnant trauma patients

Traumatic uterine rupture

Stable mother with viable fetus that is in distress

An unsalvagable mother who still has a viable fetus

A gravid uterus that is interfering with intraoperative


surgical repair

References

Obstetric Anaesthesia, Principles and Practice. David H


Chestnut, 4th Ed

Millers anesthesia. Ronald D Miller. 7 th ed.

Wylie and Churchill Davidsons A Practice of Anaesthesia


7th ed.

Clinical Anesthesia; Barash, Cullen, Stoelting, 6 th edition

Yao & Artusios Anesthesiology. 7th edition

Nonobstetric surgery during pregnancy, ACOG committee


opinion, No. 474, Feb 2011

Roisin Ni M, David A. Anesthesia on pregnant patients for


nonobstetric surgery. Journal of clinical anesthesia (2006) 18,
60-66

Thank You