surgery in the pregnant patient - tennessee society of … · 2018-02-23 · 2/22/18 2 statistics!...

2/22/18

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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



Systemic medications

! Propofol

! Thiopental

! Ketamine

! Benzodiazepines



! Local Anesthetics

! Muscle Relaxants

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! Volatile anesthetics in animals

! Humans exposed to clinical doses

! N2O exposure in animals vs humans

! Epidemiologic surveys of reproductive

hazards in OR personnel



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 Effects of AnesthesiaMaintenance of Fetal Well-Being

! Avoidance of maternal hypoxia

! Normocapnea

! Avoiding Hypotension


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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! Anticholinesterases

! Atropine vs glycopyyrolate

! Esmolol

! Suggammadex



Prevention of Preterm Labor

! Nonobstetric surgery during pregnancy -higher

incidences of abortion and preterm delivery.1,49-51

! Causative agents?



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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Laparoscopy

! Increasing frequency

! CO2 insufflation impacts

! Maintenance of blood volume, BP and continuous fetal monitoring are indicated.59


ECT

! Performed for medically refractory depression

! Complications can occur

DC Cardioversion

! FHR monitoring is recommended


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


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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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

References

1. Mazze RI, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: A registry study of 5405 cases. Am J Obstet Gynecol 1989; 161: 1178-85.

2. Brodsky Jb, Cohen EN, Brown BW, et al. Surgery during pregnancy and fetal outcome. Am J Obstet Gynecol 1980; 138:1165-7.

3. Shnider SM, Webster GM. Maternal and fetal hazards of surgery during pregnancy. Am J Obstet Gynecol 1965; 92:891-900.

4. Manley S, De Kelaita G, Joseph NJ. Preoperative pregnancy testing in ambulatory surgery. Anesthesiology 1995; 83:690-3.

5. Kasliwal A, Farquharson RG. Pregnancy testing prior to sterilization. Br J Obstet Gynaecol 2000; 107:1407-9.

6. Azzam FJ, Padda GS, DeBoard JW, et al. Preoperative pregnancy testing in adolescents. Anesth Analg 1996; 82:4-7.

7. Gin T, Chan MTV. Decreased minimum alveolar concentration of isoflurane in pregnant humans. Anesthesiology 1994; 81:829-32.

8. Chan MTV, Mainland P, Gin T. Minimum alveolar concentration of halothane and enflurane are decreased in early pregnancy. Anesthesiology 1996; 85:782-6.

9. Spaanderman ME, Meertens M, van Bussel M, et al. Cardiac output increases independently of basal metabolic rate in early human prenancy. Am J Physiol Heart Circ Physiol 2000; 278:H1585-8.

10. Leighton BL, Cheek TG, Gross JB, et al. Succinylcholine pharmacodynamics in peripartum patients. Anesthesiology 1986; 64:202-5.

11. Wilson JG. Environment and Birth Defects. New York, Academic Press, 1973:1-82.

12. Roberts CJ, Lowe CR. Where have all the conceptions gone? Lancet 1975; 1(7907):498-9.

13. Fredriksson A, Ponten E, Gordh T, Eriksson P. Neonatal exposure to a combination of N-methyl-D-aspartate and p-aminobutyric acid type A receptor anesthetic agents potentiates apoptotic neurodegeneration and persistent behavioral

deficits. Anesthesiology 2007; 107:427-36.

References

14. Nikizad H, Yon JH, Carter LB, Jevtovic-Todorovic V. Early exposure to general anesthesia causes significant neuronal deletion in the developing rat brain. Ann N Y Acad Sci 2007; 1122:69-82.

15. Perouansky M. General anesthetics and long-term neurotoxicity. In Schuttler J, Schwilden H, editors. Modern Anesthetics: Handbook of Experimental Pharmacology. New York, Springer, 2008; 143-57.

16. Shepard TH. Catalog of Teratogenic Agents. 7th edition. Baltimore, Johns Hopkins University Press, 1992.

17. Safra MJ, Oakley GP. Association between cleft lip with or without cleft palate and prenatal exposure to diazepam. Lancet 1975; 2(7933):478-80.

18. Saxen I, Saxen L. Association between maternal intake of diazepam and oral clefts (letter). Lancet 1975; 2(7933):498.

19. Shiono PH, Mills JL. Oral clefts and diazepam use during pregnancy. N Engl J Med 1984; 311:919-20.

20. Sturrock JE, Nunn JF. Cytotoxic effects of procaine, lignocaine and bupivacaine. Br J Anaesth 1979; 51:273-81.

21. Fujinaga M, Baden JM, Mazze RI. Developmental toxicity of nondepolarizing muscle relaxants in cultured rat embryos. Anesthesiology 1992; 76:999-1003.

22. Jacobs RM. Failure of muscle relaxants to produce cleft palate in mice. Teratology 1971; 4:25-30.

23. Wharton RS, Wilson AI, Mazze RI, et al. Fetal morphology in mice exposed to halothane. Anesthesiology 1979; 51:532-7.

24. Mazze RI, Wilson AI, Rice SA, et al. Fetal development in mice exposed to isoflurane. Teratology 1985; 32:339-45.

25. Buring JE, Hennekens CH, Mayrent SL, et al. Health experiences of operating room personnel. Anesthesiology 1985; 62:325- 30.

26. Tannenbaum TN, Goldberg RJ. Exposure to anesthetic gases and reproductive outcome. J Occup Med 1985; 27:659-68.

27. Mazze RI, Lecky JH. The health of operating room personnel (editorial). Anesthesiology 1985; 62:226-8.

28. Lane GA, Nahrwold ML, Tait AR, et al. Anesthetics as teratogens: Nitrous oxide is teratogenic, xenon is not. Science 1980; 210:899-901.

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References

29. Chanarin I. Cobalamins and nitrous oxide: A review. J Clin Pathol 1980; 33:909-16.

30. Baden JM, Rice SA, Serra M, et al. Thymidine and methionine syntheses in pregnant rats exposed to nitrous oxide. Anesth Analg 1983; 62:738-41.

31. Cohen EN, Belville JW, Brown BW. Anesthesia, pregnancy, and miscarriage: A study of operating room nurses and anesthetists. Anesthesiology 1971; 35:343-7.

32. Ericson HA, Kallen B. Hospitalization for miscarriage and delivery outcome among Swedish nurses working in operating rooms. 1973-1978. Anesth Analg 1985; 64:981-9.

33. Spence AA. Environmental pollution by inhalation anaesthetics. Br J Anaesth 1987; 59:96-103.

34. Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci 2003; 23:876-82.

35. U.S. Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research, Anesthetic and Life Support Drugs Advisory Committee. Meeting, Rockville, Maryland, March 29,2007. Available at

http://www.fda.gov/ohrms/dockets/ac/07/transcripts/2007-4285t1.pdf

36. Khazin AF, Hon EH, Hehre FW. Effects of maternal hyperoxia on the fetus. I. Oxygen tension. Am J Obstet Gynecol 1971; 109:628-37.

37. Motoyama EK, Rivard G, Acheson F, et al. The effect of changes in maternal pH and PCO2 on the PO2 of fetal lambs. Anesthesiology 1967; 28:891-903.

38. Kamban JR, Handte RE, Brown WU, et al. The effect of normal and preeclamptic pregnancies on the oxyhemoglobin dissociation curve. Anesthesiology 1986; 65:426-7.

39. Levinson G, Shnider SM, de Lorimier AA, et al. Effects of maternal hyperventilation on uterine blood flow and fetal oxygenation and hyperventilation on uterine blood flow and fetal oxygenation and acid-base status. Anesthesiology

1974; 40:340-7.

References

40. Palahniuk RJ, Scnider SM. Maternal and fetal cardiovascular and acid-base changes during halothane and isoflurane anesthesia in the pregnant ewe. Anesthesiology 1974; 41:462-72.

41. Johnson ES, Colley PS. Effects of nitrous oxide and fentanyl anesthesia on fetal heart-rate variability intra- and postoperatively. Anesthesiology 1980; 52:429-30.

42. Liu PL, Warren TM, Ostheimer GW, et al. Toetal monitoring in parturients undergoing surgery unrelated to pregnancy. Can Anaesth Soc J 1985; 32:525-32.

43. Immer-Bansi A, Immer FF, Henle S, et al. Unnecessary emergency caesarean section due to silent CTG during anesthesia? Br J Anaesth 2001; 87:791-3.

44. McNall PG, Jafarnia MR. Management of myasthenia gravis in the obstetrical patient. Am J Obstet Gynecol 1965; 93:518- 25.

45. Clark RB, Brown MA, Lattin DL. Neostigmine, atropine and glycopyrrolate: Does neostigmine cross the placenta? Anesthesiology 1996; 84:450-2.

46. Eisenach JC, Castro MI. Maternally administered esmolol produces beta-adrenergic blockade and hypoxemia in sheep. Anesthesiology 1989; 71:718-22.

47. Larson CP Jr, Shuer LM, Cohen SE. Maternally administered esmolol decreases fetal as well as maternal heart rate. J Clin Anesth 1990; 2:427-9.

48. Losasso TJ, Muzzi DA, Cucchiara RF. Response of fetal heart rate to maternal administration of esmolol. Anesthesiology 1991; 74:782-4.

49. Shnider SM, Webster GM. Maternal and fetal hazards of surgery during pregnancy. Am J Obstet Gynecol 1965; 92:891-900.

50. Crawford JS, Lewis M. Nitrous oxide in early human pregnancy. Anaesthesia 1986; 41:900-5.

51. Mazze RI, Kallen B. Appendectomy during pregnancy: A Swedish registry study of 778 cases. Obstet Gynecol 1991; 77:835-40.

References

52. McKellar DP, Anderson CT, Boynton CJ, et al. Cholecystectomy during pregnancy without fetal loss. Surg Gynecol Obstet 1992; 174:465-8.

53. Cherry SH. The pregnant patient: Need for surgery unrelated to pregnancy. Mt Sinai J Med 1991; 58:81-4.

54. Coleman NT, Trianfo VA, Rund DA. Nonobstetric emergencies in pregnancy: Trauma and surgical conditions. Am J Obstet Gynecol 1997; 177:494-502.

55. Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obestet Gynecol Reprod Biol 2007; 131:4-12.

56. Fatum M, Rojansky N. Laparoscopic surgery during pregnancy. Obstet Gynecol surv 2001; 56:50-9.

57. Reedy MB, Galan HL, Richards WE. Laparoscopy during pregnancy: A survey of laparoendoscopic surgeons. J Reprod Med 1997; 42:33-8.

58. Bhavani-Shankar K, Steinbrook RA, Brooks DC, et al. Arterial to end-tidal carbon dioxide pressure difference during laproscopic surgery in pregnancy. Anesthesiology 2000; 93:370-3.

59. Steinbrook RA, Brooks DC, Datta S. Laparoscopic cholecystectomy during pregnancy. Surg Endosc 1996; 10:511-6.

60. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry 1994; 45:444-50.

61. Adamson DL, Nelson-Piercy C. Managing palpitations and arrythmias during pregnancy. Heart 2007; 93:1630-6.

62. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Nonobstetric Surgery in Pregnancy. ACOG Committee Opinion No. 284, 2003. (Obstet Gynecol 2003; 102:431.)

63. Biehl DR. Foetal monitoring during surgery unrelated to pregnancy. Can Anaesth Soc J 1985; 32:455-9.

64. The American College of Obstetricians and Gynecologists 2017 Committee Opinion

http://www.fda.gov/ohrms/dockets/ac/07/transcripts/2007-4285t1.pdf

surgery in the pregnant patient - tennessee society of … · 2018-02-23 · 2/22/18 2 statistics!...

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