Non Obstetric Surgery During Pregnancy[1]

8/19/2019 Non Obstetric Surgery During Pregnancy[1]

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Anesthesia for NonAnesthesia for NonObstetric Surgery inObstetric Surgery in

Pregnant PatientsPregnant Patients


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IncidenceIncidence

0.3% to 2.2% of pregnant women undergosurgeries

Annua incidence ! "#$000 &0$000 '(SA)

*entrai+ed data una,aiabe in India

*ommonest surgery ! Appendicectomy


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IncidenceIncidence

Am - Obstetyneco /&


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Surgeries in pregnancySurgeries in pregnancy

Pregnancy related

Cervical encirclage

Fetal surgery

Ovarian Cystectomy

Not related to pregnancy

Appendicectomy, Cholecystectomy

Trauma

Malignancies


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How these patient are diferent romother surgical patients?

1wo patients ! mother

- fetus

Physioogica changes in mother


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hy this topic ishy this topic is

importantimportantMust ensure safe anaesthesia for both motherand child

Standard anaesthetic procedure may have to

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

is! to the fetus is more!

the e4ect of disease process$ teratogenicity of anaesthetic agents$

intraoperati,e impairment of uteropacentacircuation$ and

ris5 of abortion or preterm dei,ery


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678 A97AS678 A97AS

Norma aterations in maternal physiologyduring pregnancy

1he potentia etal efects from anaesthesia andsurgery

:aintenance of uteroplacental perusion andetal oxygenation

Practical considerations

Importance of materna counselling andreassurance

Special situations


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Altered maternalAltered maternal

physiologyphysiology9espiratory system;9espiratory system;< O2 consumption = > ?9*rapid desaturation orhypo"emia

< A,eoar ,entiation chronic respiratory al!alosis #$ bicarbonate and base bu%er

< mucosa ,ascuarity = weight gain di&cult mas!ventilation or intubation

*ardio,ascuar system;

Supine hypotension syndrome $ uteroplacental perfusion

@istention of epidura ,enous peus ' li!elihood ofintravascular in(ection and enhanced spread of )A


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physiologyphysiologyBematoogica changesBematoogica changes< Cood ,oume with esser increase in 9C*s

,oume dilutional anemia

< ?actor I$ DII$ DIII$ E$ EII = ?@P *ncreased ris!of thromboembolic complications

Cenign eu5ocytosis di&cult to di%erentiatefrom infection

astrointestina system changes

> F7S tone$ distortion of gastropyoric anatomy =< gastric pressure from gra,id uterus ris! ofregurgitation and aspiration


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physiology…physiology…Atered response to anaesthesiaA,eoar hyper,entiation$ reduction of ?9*

and reduction of :A* rapid induction ofgeneral anaesthesia

> thiopenta reGuirements

> protein binding due to ow abumin <

free fraction of drugs

< sensiti,ity to periphera neura boc5ade > )+A+ dose reuirement


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FETAL EFFECTSFETAL EFFECTS

1eratogenicity 1eratogenicity

Any signiHcant postnata change in function orform in an o4spring after prenata treatment

?actors that inuence teratogenicity of a drug

Species susceptibiity 1hreshod or amount of eposure

@uration and timing of administration

enetic predisposition

:anifestation of teratogenicity '@eath$ Structuraabnormaity$ rowth restriction$ functionadeHciency)


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FETAL EFFECTS…FETAL EFFECTS…@ocumented teratogens;@ocumented teratogens;9adiation increased ris5 of maignant disease$ genetic

disease$ cong. maformation =Jor feta death

:aterna metaboic imbaance

Acohoism$ cretinism$ diabetes$ foic aciddeHciency$ hyperthermia$ proonged hypoia$hypercarbia and se,ere hypogycemia

Infection

*:D$ Berpes ,irus$ Par,o ,irus C!/$ rubea,irus$ toopasmosis

@rugs


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FETAL EFFECTS…FETAL EFFECTS…

9adioogy; a threat9adioogy; a threat

74ects are dose reated

Fess than #0 my is safe

Absorbed feta dose for a con,entionaradiographic imaging is ess than #0 my

“No single diagnostic procedure results in aradiation dose that threatens the well-being othe developing embryo and etus'American *oege of 9adioogy)


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Diagnostic ultrasonography:*onsidered to be de,oid of embryotoic e4ects

Potentia side e4ects ?eta hyperthermia with proonged scans

Post!nata neurobeha,iora e4ects with

repeated eposures

Bande et a. 1eratogenic e4ects of repeated eposures to E!raysand or utrasound in mice. Neurotoic 1erato /#


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@ocumented teratogenic@ocumented teratogenic

drugsdrugs'Adapted; A*O 7ducationa Cuetin )'Adapted; A*O 7ducationa Cuetin )A*7 inhibitors Fithium

Acoho :ercury

Androgens Phenytoin

Antithyroid drugs Ditamin A deri,ati,es

*arbama+epine StreptomycinJ5anamycin

*hemotherapy agents 1etracycine

*ocaine 1haidomide

*oumadin 1rimethadione

@iethystibestro Daproic acid

Fead


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!naesthetic agents andteratogenicity

1eratogenic e4ects of anaesthetic agents areprobaby minima to non!eistent and ha,ene,er been concusi,ey documented


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Safe drugs: IJD induction agents

Narcotics

Neuromuscuar boc5ers

Inhaationa agents Foca anaesthetics

Drugs of concern:Nitrous oide$

CK@


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Nitrous oideNitrous oide Animal studies ea5 teratogen in rodents

Interferes with function of methionine synthetase byoidation of ,itamin C/2

decreased 1B?

decreased @NA synthesis

@ecreased uterine bood ow ; pre,ented by addition ofhaogenated inhaationa agents


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Nitrous oideLNitrous oideLuman studies No pro,ed teratogenicity

SigniHcant eposure for proonged duration resuts in

atered en+yme acti,ity

No teratogenic e4ects in cinicay administered dose.


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FETAL EFFECTS…FETAL EFFECTS…C7NKO@IAK7PIN7S 'CK@)C7NKO@IAK7PIN7S 'CK@)

7arier retrospecti,e studies;Association between materna dia+epam ingestionduring /st trimester and infant with ceft ip andpaate

Fater prospecti,e studies;

! No higher ris5 when used in /st trimester

Fong term materna administration feta CK@

dependence = withdrawa

Peripartum administration

?eta hypotonia$ hypothermia$ respiratory

depression$ feeding diMcuties


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A single shot of short acting ./0 or 1itrous

o"ide in clinically administered anaestheticconcentration is unli!ely to have anyteratogenic e%ects


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FETAL EFFECTS…FETAL EFFECTS…C7BADIO9AF 179A1OFO8C7BADIO9AF 179A1OFO8

Ceha,iora abnormaity in absence of anyobser,abe morphoogica changes

*NS is speciHcay sensiti,e during period of

maor myeination which etends from th

I(month to 2nd postnata month

Animals prenata administration of systemicdrugs e.g.$ Carbiturates$ meperidine$

prometha+ine = haothane beha,iorachanges

uman impication remains un5nown


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1here are not adeGuate data to

etrapoate the anima Hnding tohumansQ

2Anesthetic # )ife Support /rug advisoryCommittee of 3S F/A4


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?eta e4ectsL?eta e4ectsL

1o summari+e$ anaesthesia and surgery areassociated with higher incidence of abortion$ I(9and perinata mortaity.

1hese ad,erse outcomes can often be attributed to

the procedure$ the site of the surgery 'e.g.$ proimityto the uterus)$ andJ or the underying maternacondition

No e,idence that anaesthesia resuts in o,eraincrease in congenita abnormaity

No e,idence of cear reation between outcome andtype of anaesthesia


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teroplacental perfusionteroplacental perfusion

and fetal o!ygentationand fetal o!ygentation

?eta oygenation depends on materna oygendei,ery and uteropacenta perfusion

:ost serious ris5 during nonobstetric surgery is"ntrauterine asphy!ia

:aintenance of feta we being ;

Maternal o"ygenation

Maternal carbon dio"ide tension

3terine blood 5o6


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and fetal o!ygentation…and fetal o!ygentation…#aternal o!ygenation:

Se,ere materna hypoia can occur with;

di&cult 7 oesophageal intubation pulmonary aspiration

total spinal anaesthesia

systemic )A to"icity

:oderate hyperoia impro,es feta oygenation and isnot associated with intrauterine retroenta Hbropasiaand premature @A cosure


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and fetal o!ygentation…and fetal o!ygentation…

#aternal C$%: ?eta *O2 correates to materna e,es

:aterna hyper,entiation can resuts in

(mbiica artery constriction

A5aosis;

shift materna oyhemogobin dissociation cur,e toeft.

Bypocapnia; < ,entiation > ,enous return > cardiac output > uterine bood ow.


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Factors a&ecting theFactors a&ecting the


#aternal hypotension deep levels of anaesthesia high levels of spinal or epidural bloc!ade

aortocaval compression, hemorrhage7 hypovolumia

Anaesthetic agents causing uterine'asoconstriction or hypertonus

'eg. 5etamineR2mgJ5g$ toic doses of FA)

Catecholamines Pain$ aniety$ ight anaesthesia increased pasmacatechoamines decreased (C?


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P(ACT"CAL C$NS"DE(AT"$NSP(ACT"CAL C$NS"DE(AT"$NS

1iming of surgery

?eta monitoring

?u stomach precautionsFeft uterine dispacement

Anaesthetic considerations

1ocoytic agents


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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL

hen to do the surgeryhen to do the surgery @epends on the baance between materna and feta

ris5 and urgency of the surgery

/st trimester Organogenesis

◦ Increased feta ris5 for teratogenesis and abortion

3rd trimester Pea5 of physioogica changes ofpregnancy

◦ Increased materna ris5

◦ Increased ris5 of preterm abour

1hus "nd trimester is considered to be a idea timefor non emergency$ essentia surgeries


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hen to do the surgeryhen to do the surgery

*ar,aho C$ Anesth Anag Supp


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?eta monitoring?eta monitoring Intermittent or continuous ?B9 monitoring

shoud be considered for maor surgicaprocedures whene,er technicay feasibe;

7ase of monitoring

1ype = site of surgery 'diMcut during abdomina surgery)

estationa age 'after /&!20 w5s)

1oo to monitor intrauterine feta we being

@one by transabdomina dopper or ,agina dopperprobe

9eGuires the presence of a trained practitioner tomonitor and interpret the tracing


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F variability ood indicator of feta we being after 2#!2" w5s

Foss of beat to beat ,ariabiity and decreasedbaseine ?B9 are common Anaesthetic agentadministration

@ecerations suggests feta hypoemia

*auses of ?B9 decerations Inad,ertent maternahypoemia$ or inadeGuate uterine perfusion e,auation of materna position$ C.P$ oygenation$acid base status and inspection of surgica sites asretractors may impair uterine perfusion.


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Anaesthetic considerations in/st 1rimester

#aternal < oygen reGuirement:odiHed drug pharmaco5inetics*arefu airway manipuation

$etal 9is5 of teratogenicity Impaired (C?


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Anaesthetic considerations in 2nd and3rd trimester

#aternal

Prone to hypoiaAspiration prophyais

Preparation for diMcut airway Increased ris5 of thromboemboic

compicationsA,oid hyper,entiation


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P9A*1I*AF *ON*79NS...P9A*1I*AF *ON*79NS...

$etal Premature abour J I(9 Intrauterine asphyia

Surgery related

@isease reated probem@iagnostic diMcuties Proonged eposure to anaesthetics Surgica manipuations < feta ris5 Anatomic and surface andmar5s unreiabe


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P9A*1I*AF *ON*79NSL.P9A*1I*AF *ON*79NSL.

D"A)N$ST"C D"FF"CLT*

As nausea$ ,omiting$ constipation$ and distentionare common symptoms of both norma pregnancy

and abdomina pathoogy

Increase C* count

9euctance to perform necessary studies in,o,ingradiation

Anatomic and surface andmar5s can be unreiabe


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T$C$L*T"CS A)ENTS

Prophyactic use in nonobstetric surgery is contro,ersia

:ay be considered

abdomina surgeries in,o,ing uterine manipuations or Surgeries with high ris5 of premature abour i.e.$

cer,ica encircage

(terine contractions shoud be monitored during the

surgery and tocoytic therapy to be instituted if reGuired

Not recommended at or after 3 w5s

@o not a4ect the outcome


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1ocoytic agents 1ocoytic agents Drugs Side e&ects 2 agonist 1erbutaine

9itodrine Isosuprine

feta tachycardia$hypogycemia$hypotension$Pumonary edema$myocardia ischemia

*acium channeboc5ers

Nifedipine'one of the mostcommony used)

transient hypotension

:agnesium suphate east commonyused

interaction with N:Cs$*NS depression

Indomethacin peptic ucer$

thrombocytopenia$premature cosure [email protected].

Atosiban'newer agent)

oytocin antagonist

Cunts *a2T inu inmyometrium and

inhibit contractiity


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*ounseing and*ounseing and

reassurancereassurance Patient shoud be reassured about the safety of

anaesthesia and the ac5 of documented associatedteratogenicity

arned about the increased ris5 of /st trimester

miscarriage and premature dei,ery in ater trimesters

7ducate the patient about the symptoms ofpremature abour and reinforce the need of eftuterine dispacement

@ocumentation of detais of the ris5 discussed shoudbe maintained in patients records


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ANAEST+ET"C #ANA)E#ENT


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Pre,anaestheticPre,anaesthetic

preparation--preparation-- *ounseing and reassurance *onsut obstetrician = discuss about the use of tocoytics

O,ernight fast

Aspiration prophyais

Anioytic premedication! to aay aniety andapprehension

1ransport in eft atera position

O.1. preparation drugs$ machine$ diMcut airway cart$suction and monitors


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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…*hoice of Anaesthesia*hoice of Anaesthesia

*hoice of Anaesthetic techniGue depends on! PatientUs present surgica status 'site and nature

of surgery)

Present gestationa age of the fetus

Pregnancy induced physioogica changes

Other coeisting comorbidities

No techniGue has been pro,en to ha,e superiorityo,er the other in feta outcomes

9egiona techniGues may be preferabe

Safe anaesthetic management is more important thanparticuar agent or techniGue


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AI: ;

1o maintain oygenation$ normotension$ eucapnand eugycemia


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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…

:onitoring:onitoring:aterna monitoring; Nonin,asi,e J in,asi,e bood pressure

7ectrocardiography

Puse oimetry

*apnography 1emperature monitoring (se of periphera ner,e stimuator

Cood gucose e,es

?eta monitoring; 7terna dopper de,ice '?B9 ) 1ocodynamometer '(terine contractiity)


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ANAEST+ET"CANAEST+ET"C

#ANA)E#ENT…#ANA)E#ENT… ....)eneral anaesthesia

:aintain eft uterine dispacment

Preoygenation

9apid seGuence induction '1hiopent. sod. = succiny choine$cricoid pressure trachea intubation using cu4ed 7.1. tube)

:aintenance ; A moderate conc. of inhaationa agent ' V 2:A*) with high conc. of oygen '?iO2 W 0.#) is

recommended.

1he use of nitrous oide shoud be imited during etremeyong operations in Hrst trimester by gi,ing high conc ofoygen


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Opioids and induction agents decreases ?B9,ariabiity to greater etent than ,oatie agents

Positi,e pressure ,entiation may reduce (C?

A,oid hyper,entiation

Patients on magnesium for tocoysis reduce doseof N:Cs

9e,ersa agent to be gi,en sowy 'increased reeaseof Ach increased uterine tone and preterm abour)

7tubation when fuy awa5e after return ofprotecti,e airway reees


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ANAEST+ET"C #ANA)E#ENT--…ANAEST+ET"C #ANA)E#ENT--…

(egional anaesthesia

Ad,antages;

:inima feta drug eposure

A,oidance of compications of genera anaesthesia

If no sedati,e or narcotics are suppemented nochange in ?B9 ,ariations to confuse interpretation

Post operati,e anagesia


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:anagement of regiona anaesthesia

Pre!op preparation and monitoring same as of eneraanaesthesia

9educed FA reGuirement J < FA 1oicity

*arefu aspiration and test dose

A,oid hypotension i.e.$ adeGuate preoading$ maintain

eft uterine tit$ choice of ,asopressor

Patients on magnesium are more prone to hypotension$often resistant to treatment with ,asopressors


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Postoperati,e managementPostoperati,e management

Oygenation in eft uterine tit

Ditas monitoring

Obstetrician consutation for ?B9 = uterine acti,ity

monitoring

Pediatric consutation in case of premature abour

AdeGuate pain reief reduce the ris5 of premature abour

1ocodynamometry is usefu in high ris5 patients aspostoperati,e anagesia may mas5 awareness of earycontractions and deay tocoysis

7ary mobii+ation or @D1 prophyais if reGuired


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Postoperati,e PainPostoperati,e Pain

managementmanagement

Painincreased endogenous catechoamines uterine,asoconstrictiondecreased (C?intrauterine hypoia

1echniGues; Ner,e boc5s

Foca inHtration

Opioids

NSAI@

NSAI@S

/st and 2nd trimester ! safe

3rd trimester ! ris5 of premature cosure of @A$

Pum B1N$ deayed abour

NS!%& can be used beore '" w(s and

!cetaminophen is sae


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(ecommendations appro'ed .yAmerican Society of Anaesthesiologists/ASA0 and American College of$.stetricians and )ynecologists /AC$)0%122

1o currently used anaesthetic agents have beensho6n to have any teratogenic e%ects in humans 6henusing standard concentrations at any gestational age

Fetal heart rate monitoring may assist in maternal positioning and cardiorespiratory management, and

may in5uence a decision to deliver the fetus


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9ecommendationsL9ecommendationsL

*t is mandatory to obtain an obstetric consultation before performing any non obstetric surgery or anyinvasive procedures

A pregnant 6oman should never be denied indicated

surgery, regardless of trimester +

8lective surgery should be postponed

*f possible, non-urgent surgery should be performedin the second trimester 6hen preterm contractionsand spontaneous abortion are least li!ely+


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No onger a contraindication in pregnant patients

*oncerns;

! (terine and feta trauma

! ?eta acidosis from absorbed carbon dioide.

! @ecreased materna cardiac output and

uteropacenta perfusion due to increasedabdomina pressure.

Specia situation Specia situation

FaparoscopyFaparoscopy


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uideines by Society of Americanastrointestina 7ndoscopic Surgeons'SA7S) 200&

Safe during any trimester of pregnancy

Obtain preoperati,e obstetrician consutation

Intermittent ower etremity pneumaticcompression de,ices to pre,ent ,enous stasis

1he feta heart rate and uterine tone shoud bemonitored in both preoperati,e and postoperati,eperiods

7nd tida *O2 shoud be maintained


FaparoscopyFaparoscopy

i i i


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FaparoscopyFaparoscopy Feft uterine dispacement shoud be maintained

An open 'Bassan) techniGue$ a ,eres neede or anoptica trocar techniGue to enter abdomen

Fow pneumoperitoneum pressures '/0!/#mm Bg)shoud be used

1ocoytic agents shoud not be used

prophyacticay but shoud be considered whene,idence of preterm abour is present

S i i i


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Specia situation ?etaSpecia situation ?eta

surgerysurgery Anaesthetic considerations remains simiar to those of

non obstetric surgeries

1wo surgica patients

:aterna safety is important

*hoice of anaesthetic techniGue

:inimay in,asi,e endoscopic procedure Neuraiaanaesthesia

Open intrauterine procedures enera anaesthesia

S i i i ? S i it ti ? t


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Specia situation ?etaSpecia situation ?eta

surgeryL.surgeryL.Important considerations

*onsider anaesthetic reGuirement of fetusincuding amnesia$ anagesia and immobity

*ontro of uterine tone is essentia

:ore intensi,e intraop ?B9 monitoring

S i i iS i it ti


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7ectrocon,usi,e Shoc57ectrocon,usi,e Shoc5

1herapy 1herapy(sed to treat maor depression and CP@ duringpregnancy when rapid contro of symptoms isneeded

Ad,antage A,oids potentia teratogenicity from psychotropicmedications

Not a ris5 factor for premature abour$ miscarriageor stibirth

Anaesthetic management *onHrm the absence of uterine contractions using

tocodynamometry before and after 7*1 :onitor ?B9 before and after 7*1

S i it tiS i it ti


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Neurosurgery 'e.g.$Neurosurgery 'e.g.$

Aneurysm$ AD maformation)Aneurysm$ AD maformation) Bypotensi,e anaesthetic techniGues ' 2# 30%reduction in SCP or mean CP ess than "0 mmBg) cancause decrease in (C?

@ose 'ess than 0.# mgJ5gJhr) and duration of Sodium

Nitroprusside shoud be imited

?B9 monitoring shoud be performed continuousyspeciay if induced hypotension or hyper,entiation ispanned so that necessary adustments can be made iffeta distress occurs

Bypo,oemia and ,ery arge doses of mannito shoudbe a,oided as they cause feta dehydration

7ndo,ascuar treatments uterine shieding duringperiods of radiation

S i it ti 1S i it ti 1


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Specia situation 1raumaSpecia situation 1rauma

during pregnancyduring pregnancy

1rauma is the eading cause nonobstetric cause ofmorbidity and mortaity

Primary management goas are simiar to the care ofnonpregnant trauma cases

A,oidance of hypoia$ hypotension$ acidosis andhypothermia are important for the maintenance of(C? and feta we being

:ore prone to de,eop pumonary edema

In stabe patients without ongoing bood oss *onser,ati,e uid management

*DP monitoring shoud be considered if renainsuMciency or uid o,eroad occurs

S i it ti 1S i it ti 1


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Specia situation 1raumaSpecia situation 1rauma

during pregnancyLduring pregnancyL

Primary aim shoud be optimi+ation of the mother andthe obstetric management is panned ater

No radioogica tests shoud be withhed because offeta concerns$ uterus shoud be shieded during

radiation procedures

Indications for an 7mergency *esarean dei,ery in apregnant trauma patients

1raumatic uterine rupture

Stabe mother with ,iabe fetus that is in distress

An unsa,agabe mother who sti has a ,iabe fetus

A gra,id uterus that is interfering with intraoperati,esurgica repair

9 f9 f


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9eferences9eferences

Obstetric Anaesthesia$ Principes and Practice. @a,id B

*hestnut$ th 7d

:ierUs anesthesia. 9onad @ :ier. "th ed.

yie and *hurchi @a,idsonUs XA Practice of AnaesthesiaU

"th ed.

*inica AnesthesiaY Carash$ *uen$ Stoeting$ Zth edition

8ao = ArtusioUs Anesthesioogy. "th edition

Nonobstetric surgery during pregnancy$ A*O committee

opinion$ No. "$ ?eb 20//

9oisin Ni :$ @a,id A. Anesthesia on pregnant patients fornonobstetric surgery. -ourna of cinica anesthesia '200Z) /&$Z0!ZZ


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Non Obstetric Surgery During Pregnancy[1]

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