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Incidental surgery Incidental surgery during pregnancyduring pregnancy

Dr.Shailendra .V.L.Dr.Shailendra .V.L.

Specialist of AnesthesiaSpecialist of Anesthesia

Al Bukariya general hospitalAl Bukariya general hospital

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Case presentationCase presentation

• A 23 year old Saudi lady is posted A 23 year old Saudi lady is posted for emergency appendicectomy. She for emergency appendicectomy. She is 14 weeks pregnant with twins.is 14 weeks pregnant with twins.

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Introduction Introduction

• 1 - 2 % of women require incidental 1 - 2 % of women require incidental surgery during pregnancysurgery during pregnancy

• Surgery associated with increased Surgery associated with increased fetal loss & premature deliveryfetal loss & premature delivery

• All elective procedures should be All elective procedures should be done 6 weeks post partumdone 6 weeks post partum

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General considerationsGeneral considerations

• Avoid surgery during embryogenesis Avoid surgery during embryogenesis 15 days to 55 days15 days to 55 days

• Ideal time to operate is in II Ideal time to operate is in II trimestertrimester

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Common surgeries in Common surgeries in pregnancypregnancy

• Cervical encirclage Cervical encirclage • Appendicectomy ( 1 in 1500 Appendicectomy ( 1 in 1500

pregnancies)pregnancies)• Cholecytectomy ( 1 in 2000 to 10000 Cholecytectomy ( 1 in 2000 to 10000

pregnancies)pregnancies)• Ovarian cystsOvarian cysts

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Laparoscopy surgery in Laparoscopy surgery in pregnancypregnancy

• Inert gases : Helium /Argon or NInert gases : Helium /Argon or N22O is used, as COO is used, as CO22 insufflation causes fetal acidosis. Best is gasless insufflation causes fetal acidosis. Best is gasless lap.lap.

• Ideally before 23 weeks of pregnancy Ideally before 23 weeks of pregnancy – Minimize preterm laborMinimize preterm labor– Adequate working place insideAdequate working place inside

• Minimal pressure used to create pneumo-Minimal pressure used to create pneumo-peritoneum - ????peritoneum - ????

• Tocolytics used to arrest preterm labor – Tocolytics used to arrest preterm labor – prophylactic use -- debatableprophylactic use -- debatable

• Fetal montitoring using vaginal scanFetal montitoring using vaginal scan• EtCOEtCO22 monitored & ventilation adjusted accordingly monitored & ventilation adjusted accordingly

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Objectives Objectives

1.1. Maternal safetyMaternal safety

2.2. Avoidance of fetal hypoxia & Avoidance of fetal hypoxia & acidosisacidosis

3.3. Premature laborPremature labor

4.4. Avoidance of teratogenic drugsAvoidance of teratogenic drugs

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Maternal safetyMaternal safety

1.1. Recognize decreased Oxygen Recognize decreased Oxygen reservesreserves

2.2. Airway management may be Airway management may be difficultdifficult

3.3. Supine hypotension syndrome Supine hypotension syndrome (after 25 weeks)(after 25 weeks)

4.4. Altered anesthetic requirementsAltered anesthetic requirements

5.5. ￪￪ risk of aspirationrisk of aspiration

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Avoidance of fetal hypoxia Avoidance of fetal hypoxia & acidosis& acidosis

• Minimize maternal Minimize maternal hypotension/arterial hypoxia/changes hypotension/arterial hypoxia/changes in PaCOin PaCO22

• Treat hypotension with left uterine Treat hypotension with left uterine displacementdisplacement– IV fluidsIV fluids– Leg elevationLeg elevation– EphedrineEphedrine

• Maternal supplemental oxygenMaternal supplemental oxygen

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Premature laborPremature labor

• No evidence that anesthetic No evidence that anesthetic drugs/techniques predispose to drugs/techniques predispose to premature laborpremature labor

• Underlying disease or site of surgery Underlying disease or site of surgery determines likelihood of premature determines likelihood of premature laborlabor– 28% to 40% of premature labor 28% to 40% of premature labor

following cervical encirclagefollowing cervical encirclage

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Avoidance of teratogenic Avoidance of teratogenic drugsdrugs

• Critical period of organogenesis between 15 – Critical period of organogenesis between 15 – 56 days56 days

• No evidence that inhaled anesthetics is No evidence that inhaled anesthetics is teratogenicteratogenic– Inhaled NInhaled N22OO– OpioidsOpioids– SedativesSedatives– BenzodiazepinesBenzodiazepines– Local anestheticsLocal anesthetics

• No evidence that anesthetics adversely affect No evidence that anesthetics adversely affect later mental & neurologic developmentlater mental & neurologic development

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Studies supporting safe Studies supporting safe NN220 use0 use

1.1. Santos et al – Current Santos et al – Current controversies in obstetric controversies in obstetric anesthesia – Anesthesia Analgesia anesthesia – Anesthesia Analgesia 1994; 78: 753 – 601994; 78: 753 – 60

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Studies supporting safe use Studies supporting safe use of anesthetic drugs of anesthetic drugs

1.1. Koren et al, Drugs in pregnancy, N Koren et al, Drugs in pregnancy, N Engl. J Med 1998; 1128 - 37Engl. J Med 1998; 1128 - 37

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Management of Management of AnesthesiaAnesthesia

• Regional techniques:Regional techniques:– Will not expose fetus to harmful depressant Will not expose fetus to harmful depressant

effects effects – Minimal physiological derangements Minimal physiological derangements

• Balanced Anesthesia also safe:Balanced Anesthesia also safe:– No evidence suggestive of teratogenic effects No evidence suggestive of teratogenic effects – Left lateral lift after 25 weeks to prevent SHSLeft lateral lift after 25 weeks to prevent SHS– HH2 2 receptor antagonists & non-particulate receptor antagonists & non-particulate

antacidantacid

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Post partum tubal Post partum tubal ligationligation

• Done in early postpartum periodDone in early postpartum period• Continuous epidural used in labor Continuous epidural used in labor

analgesia extended to this procedureanalgesia extended to this procedure• If general anesthesia used:If general anesthesia used:

– HH22 antagonists & non-particulate antagonists & non-particulate antacid givenantacid given

– Cuffed endotracheal tube is a mustCuffed endotracheal tube is a must

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In-vitro fertilizationIn-vitro fertilization

• Anesthetics detected in follicular Anesthetics detected in follicular fluid during aspiration of fluid during aspiration of oocytes ??? Could affect oocytes ??? Could affect reproductive potential of Ova reproductive potential of Ova

• Conflicting reports on outcome of Conflicting reports on outcome of invitro fertilization & gamate intra invitro fertilization & gamate intra fallopian transfer procedurefallopian transfer procedure

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