OBSTETRIC ANESTHESIA AND AMBULATORY ANESTHESIA Berrin Gunaydin, MD, PhD Depart ent !" Ane#the#i!$!%y & Di'i#i!

n !" O(#tetri) Ane#the#ia *a)u$ty !" Medi)ine, Ga+i Uni'er#ity, An,ara& Tur,ey Ba),%r!undAmbulatory obstetric surgery enables fast recovery of vital functions, ambulation and a relational life of quality and procedure costs can be significantly reduced when a hospital stay is avoided. Many factors affect ambulatory surgery or procedures. For instance; length of surgery is not a criterion for ambulatory procedures because patients undergoing longer procedures should have their operations earlier in the day. Therefore, improved material and surgical practices broaden potential indications of ambulatory surgery. The choice of the anesthetic techniques or the agents used during the intervention ensures fast recovery of higher functions and limits the risk of postoperative pain which can be controlled with simple analgesic protocols. owever, use of teratogenic drugs before, during and after the procedure particularly for the pregnants and development of nausea and vomiting after returning home and compromise oral drug intake must be prevented. Many parturients might undergo operations !generally nonobstetric" during their pregnancy but most of them can not be performed on ambulatory basis. #rocedures appropriate for obstetric ambulatory surgery are those associated with postoperative care easily managed at home and with low rates of postoperative complications requiring intensive physician or nursing management. $ome of these ambulatory !or outpatient" operations or procedures are evacuation of incomplete miscarriage, surgical treatment of tubal ectopic pregnancy either performed by laparoscopically or open surgery, hysterosalpingography ! $%", hysteroscopy, cervical cerclage and assisted reproductive !A&" surgery. Genera$ )!n#iderati!n#'hatever their age, ambulatory surgery is no longer restricted to patients of A$A physical status ( or ((. #atients whose disease is well)controlled at the anesthesia consultation, even patients of A$A physical status ((( or (* who are medically stable can benefit from ambulatory procedures. #reoperative screening involves complete medical history of the patient and the family, the medications that the patient is taking, and the problems of the patient or the patient+s family may have had with previous anesthetics. This process also provides the staff to remind patient+s arrival time, suitable attire, dietary restrictions !nothing to eat or drink after midnight, no ,ewelry or make up". $taff members can determine whether a responsible person is available to escort the patient to and from the ambulatory unit-hospital and care for the patient at home after surgery. The screening is the ideal time for the anesthesiologist to talk with the patient if possible and to

review the screening record to determine whether additional evaluation by other consultant and if laboratory tests must be obtained. To decrease the risk of aspiration of gastric contents, patients are routinely asked not to eat or drink anything !non per os. /#0 or nothing by mouth" for at least 1 to 2 hours before surgery. According to A$A published practice guidelines for preoperative fasting, patients are allowed to have a light meal up to 1 hours before an elective surgery. The guidelines also support a fasting period for clear fluids of 3 hours for all patients. 4offee is not transparent but is free of particulate matter is accepted as a clear liquid. Therefore, coffee drinkers can be encouraged to drink coffee prior to their procedure because withdrawal symptoms might easily occur. #atients having chronic medications mandatory to continue preoperatively also should be encouraged to take their pills with clear liquids up to 3 hours before surgery. 'hen anesthesia requirement for ambulatory surgery or procedure arises, there are basically two considerations !general or regional". owever, factors related to the alterations in maternal physiologic condition with advancing pregnancy, teratogenic effects of anesthetic drugs, the indirect effects of anesthesia on uteroplacental blood flow, and the potential for abortion or premature delivery should be taken into account. 0f the premedicants; anticholinergics have not been found to be teratogenic, whereas tranquili5ers and sedatives such as phenotia5ines and barbiturates produce anomalies in some species. $everal reports have described a specific relationship between dia5epam and oral clefts. &egarding general anesthesia, intravenous anesthetic agents such as; thiopental, methohe6ital, and ketamine in doses normally used in the operating room have not been associated with birth defects. alogentaed inhalation agents have conflicting results. The teratogenic effect of nitrous o6ide may be related to the inhibitory effect of the agent in both maternal and fetal methionine synthetase activity and vitamine 783. Failure of this en5yme to convert homocystein to the essential amino acid methionine may lead to abnormalities of myelini5ation of nerve fibres. (nhibition of methionine synthesis results in decreased 9/A synthesis and inhibition of cell division. Therefore, it has been recommended not to administer it to pregnant women in the first two trimesters. (t is controversial whether pretreatment with folinic acid, the concentration of which is reduced when methionine synthetase inhibited, affords protection against the effects of nitrous o6ide. :ocal anesthetics have not been shown to be teratogenic in animals or humans. ;vacuation of incomplete miscarriage is a procedure that empties the uterus either by vacuum aspiration or dilatation and curettage. *acuum aspiration is a safer and quicker treatment with less pain than dilatation and curettage which is often done under general anesthesia in an operating room. #ropofol induction and remifentanil infusion have been the popular anesthetic drugs lately for both approaches. ;ctopic pregnancies can occur anywhere along the reproductive tract with the most common side being the fallopian tube. (f an ectopic pregnancy in the fallopian tube is not treated, it can cause tubal rupture and-or intraabdominal bleeding. :aparoscopic surgery under general anesthesia is feasible and less e6pensive than open surgery in the treatment of tubal ectopic pregnancy.

$% is a test frequently undertaken to find out whether fallopian tubes are open in the investigation of infertility. (t involves a dye being in,ected via the cervi6 and uterus into the fallopian tubes which enables them to be visuali5ed using an <)ray which can be painful procedure requiring analgesia. Additionally, minimal invasive operative hysteroscopy can replace laparotomic surgery in many intrauterine lesions which can be satisfactorily done under loco)regional anesthesia with paracervical block !#47" and periorificial infiltration as an alternative to general anesthesia. Transvaginal ultrasound guided oocyte retrieval !T=%0&" and laparoscopic A& procedures require anesthesia as well. 4onscious sedation or monitored anesthesia care !MA4", total intravenous anesthesia, #47, neura6ial blocks and general anesthesia have all been used successfully for T=%0&, whereas general anesthesia has been the most commonly used technique for laparoscopic A& procedure particularly because of the necessity of Trendelenburg position. For T=%0&, ben5odia5epins, ketamin and opioids !fentanyl, alfentanil, remifentanil, or meperidine" does not appear to interfere with either fertili5ation or embryo development in animals and humans. Although propofol accumulates in the follicular fluid, there have been no differences in fertili5ation, embryo cleavage or implantation rates when compared to volatile agents or #47. Thiopental is detected in follicular fluid but no adverse reproductive effects have been found compared to propofol. *olatile agents have been observed to depress 9/A synthesis and mitosis in cell cultures; regarding sevoflurane and desflurane, compound A and fluorine have been noted to have adverse effects on rapidly dividing cells. 9opaminergic antiemetic agents like droperidol and metoclopramide induce hyperprolactinemia leading to potential impairment of ovarian follicle maturation and corpus luteum function. Additional analgesia is often required when #47 is used alone. &emifentanil with its short elimination half)life and increased metabolism by blood and tissue esterases makes it a suitable agent to provide analgesia with #47 as a part of MA4. More ambulatory obstetric procedures can be e6pected in the near future, pointing out the importance of developing more adapted medical structures. RE*ERENCES 8. 7arash #%, 4ullen 7F, $toelting &>. 4linical Anesthesia, ?th ed, :ippincott 'illiams and 'ilikins, #hiladelphia, 3@@1, 88?3)882@ 3. Forna F, %ulme5oglu A. $urgical procedures to evacuate incomplete miscarriage. 4ochrane database of $ystematic &eviews 3@@A;B C. Marinangeli F, 4icco55i A, Antonucci $, (ovinelli %, 4olangeli A, *arrassi %. =se of remifenatnil in ambulatory obstetric surgery. A dose effect study. Minerva Anestesiol 8DDD; 1?!A)2". BD8)A. B. a,enius #E, Mol F, Mol 7'E, 7ossuyt #MM, Ankum 'M, *an der *een F. (nterventions for tubal ectopic pregnancy. 4ochrane database of $ystematic &eviews 3@@A;B

?. Ahmad %, 9uffy E, 'atson AE$. #ain relief in hysterosalpingography. 4ochrane database of $ystematic &eviews 3@@A;B

1. 4anni M, %allia :, Fan5ago ;, 7occi F, 7ertini =, 7arbero M. 9ay)surgery operative hysteroscopy with loco)regional anesthesia. Minerva %inecol 3@@8; ?C !?". C@A)88. A. /eilson E#. (nterventions for suspected placenta praevia. 4ochrane database of $ystematic &eviews 3@@A;B 2. Tsen :4. Anesthesia for assisted reproductive technologies. (nt Anaesthesiol 4lin 3@@A; B?. DD)88C D. %unaydin 7, >FvFlcFm 05ulgen (, 05turk ;, Tekgul G, >aya >. &emifenatnil versus remifentanil with paracervical block on plasma remifentanil concentrations and pulmonary function tests for transvaginal ultrasound guided oocyte retrieval. E 0pioid Management 3@@A; C. 31A)3A3