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REVIEW
URRENT
C
OPINION

Nonobstetric anesthesia during pregnancy

Michael Heesen a and Markus Klimek b

Purpose of review
Nonobstetric anesthesia during pregnancy is challenging not only for the anesthetist. Owing to the
difficulties of ethical consent for randomized studies in this special patient group, the available evidence is
quite low. Nevertheless, recently several guidelines for the management of pregnant patients undergoing
nonobstetric anesthesia have been published. We review the current guidelines developed under the
auspices of the Society of American Gastrointestinal Endoscopic Surgeons, guidelines for the management
of difficult and failed tracheal intubation in obstetrics, as well as guidelines for the management of a
pregnant trauma patient.
Recent findings
The algorithms for management of the difficult airway during pregnancy should be made available in
every institution that cares for pregnant women. During laparoscopic surgery strict limitation of the
pneumoperitoneal pressure to avoid maternal hypercapnia and fetal acidosis is strongly
recommended. An injured pregnant woman should be transferred to a maternity facility when the
injury is not life or limb threatening. In case of major trauma, stabilization and care of the woman
is priority.
Summary
Several guidelines with high relevance for the care of pregnant women undergoing nonobstetric surgery
have been published. Although the level of evidence may be low they can probably contribute to an
improvement in the care and outcome of this patient group.
Keywords
airway management, anesthesia, laparoscopy, pregnancy, trauma

INTRODUCTION/GENERAL ASPECTS
Up to 2% of the pregnant women in the USA require
nonobstetric surgery during any trimester of their
pregnancy [1]. The most common diagnoses include
appendicitis, cholecystitis, and disc hernia. Trauma
and cancer resulting in the need of surgery may
also occur.
The American College of Obstetricians and
Gynecologists issued a committee opinion, originally in 2003 which was updated in 2011 [2]. The
most relevant recommendations are summarized in
Table 1. Fetal monitoring should be done before and
after the procedure, intraoperative electronic fetal
monitoring should be considered when the fetus is
viable, when it is physically possible to perform this
monitoring, when dedicated care provider with
obstetric surgery privileges is available, when the
woman has given informed consent to emergency
cesarean section, when the nature of the planned
surgery will allow the well tolerated interruption or
alteration of the procedure to perform emergency
delivery [2].

A systematic review [3] provided data on adverse

outcome after nonobstetric surgery: maternal death
was seen in 1/12 542 cases (0.006%), miscarriage
(<20 weeks) or fetal loss ( 20 weeks) occurred in
10.5% during the first trimester and in 5.8% of all
trimesters. Fetal loss was registered in 1.8% (registry
studies) to 2.5% (nonregistry studies), prematurity
affected 8.2%; major birth defects were observed in
3.9% during all trimesters and during 2% when all
trimesters were analyzed.
Based on this study [3] and one retrospective
study [4] a rapid response report by the Canadian
Agency for Drugs and Technologies in Health [5 ]
&&

Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland

and bDepartment of Anaesthesiology, Erasmus University Medical
Center, Rotterdam, The Netherlands
Correspondence to Michael Heesen, MD, PhD, Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland.
E-mail: michael.heesen@ksb.ch
Curr Opin Anesthesiol 2016, 29:000000
DOI:10.1097/ACO.0000000000000311

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Obstetric and gynaecological anaesthesia

KEY POINTS
 Up to 2% of the pregnant women in the USA require
nonobstetric surgery during any trimester of
their pregnancy.
 Adverse events after nonobstetric surgery are rare,
especially if surgery is not performed during the
first trimester.
 Recent guidelines are available for pregnant trauma
patients and pregnant patients undergoing
laparoscopic procedures.
 Neurosurgery in pregnant patients requires a very
careful evaluation of the maternal and the fetal risks
and benefits, because therapeutic measures might
be conflicting.
 Based on the current level of evidence, being afraid of
fetal neurotoxicity by the anesthetics should not be a
reason to postpone a necessary surgical procedure of
the mother.

from 2015 concluded that adverse events after

nonobstetric surgery are rare. Moreover, it was
concluded that a higher frequency of miscarriage
or fetal loss and major birth defects was seen after
surgery in the first trimester, thereby confirming the
American College of Obstetricians and Gynecologists recommendation to delay surgery to the
second trimester whenever possible.
In recent years, major concerns on the neurotoxic effects of anesthetics, awareness during
general anesthesia, and the airway management
of pregnant women have arisen.

AWARENESS
The fifth National Audit Project in Great Britain and
Ireland set out to establish the incidence as well as

risk factors of accidental awareness during general

anesthesia [6 ]. Obstetric anesthesia was associated
with the highest rate of awareness, affecting 1 in
670 cases [6 ]. This result is not unexpected since
many risk factors of awareness are present in
obstetric anesthesia, including rapid sequence
induction, omission of opioids at induction of anesthesia, use of neuromuscular blocking drugs, difficult airway management, use of thiopental, and
others. The association with the use of thiopental
does not seem to be a problem of the drug itself, but
is more likely associated with the decreasing use of
thiopental for routine cases. This can cause a lack of
experience in dosing thiopental and timing the
addition of another maintenance-anesthetic after
induction. Therefore, routine use of propofol
for rapid sequence induction in stable patients
undergoing cesarean section recently was recommended [7].
Although no data were given for nonobstetric
surgery, it is likely that nonobstetric surgery during
pregnancy involves many of these risk factors.
&

&

AIRWAY MANAGEMENT
According to Leboulanger et al. [8] higher Mallampati classes (III and IV) were found in 12% of the
women during the first trimester, a figure that rose
to 20% during the second trimester, which is the
preferred time for nonurgent surgery. This change
was paralleled by a reduction in the cross-sectional
area of the pharynx, whereas minimal and mean
tracheal cross-sectional areas remained unaffected
[8]. Difficult intubation was observed with a frequency of 1 : 238 to 1 : 100 in a study by Djabatey
and colleagues. A difficult airway was unanticipated
in nine cases out of 3430 compared with 14 expected
cases [9]. This differs only little from the 0.56% of
unanticipated difficult airway in a report by Tao

Table 1. Extracted from the American College of Obstetricians and Gynecologists Committee on Obstetric Practicea
A pregnant woman should never be denied indicated surgery, regardless of trimester.
If possible, nonurgent surgery should be performed in the second trimester, when preterm contractions and spontaneous abortion are least
likely.
Elective surgery should be postponed until after delivery.
No currently used anesthetic 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.
Surgery should be done at an institution with neonatal and pediatric services.
An obstetric care provider with cesarean delivery privileges should be readily available.
A qualified individual should be readily available to interpret the fetal heart rate patterns.
a

American College of Obstetricians and Gynecologists Committee Opinion No. 474: nonobstetric surgery during pregnancy [2].

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ACO 290305

Nonobstetric anesthesia during pregnancy Heesen and Klimek

et al. [10] In 2015 Kinsella and colleagues reported

that the incidence of failed tracheal intubation
remain constant at 0.26% in the observation period
starting in 1970. Maternal deaths were seen in 2.3/
100 000 anesthesia, with aspiration and hypoxemia
as the leading causes [11 ].
Since other guidelines had only little sections or
even completely excluded the obstetric patient the
Obstetric Anesthetists Association and Difficult
Airway Society published guidelines for the management of difficult and failed tracheal intubation in
obstetrics in 2015 [12 ].
&&

&&

TRAUMA
The Society of Obstetricians and Gynaecologists of
Canada has published Guidelines for the Management of a pregnant Trauma Patient in 2015 [13 ].
Because one of 12 pregnant women is affected by
any kind of physical trauma, the importance of
these guidelines should not be underestimated.
Among the 31 recommendations the following
are of anesthesiological relevance (Evidence level):
&&

(1) Every woman of reproductive age with significant injuries should be considered pregnant
until proven otherwise by a definitive pregnancy test or ultrasound scan (III-C).
(2) A nasogastric tube should be inserted in a
semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic
gastric content (III-C).
(3) Oxygen supplementation should be given to
maintain maternal oxygen saturation more
than 95% to ensure adequate fetal oxygenation (II-1B).
(4) If needed, a thoracostomy tube should be
inserted in an injured pregnant woman one
or two intercostal spaces higher than usual
(III-C).
(5) Two large bore (1416 gauge) intravenous
lines should be placed in a seriously injured
pregnant woman (III-C).
(6) Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women
should be used only for intractable hypotension that is unresponsive to fluid resuscitation
(II-3B).
(7) After mid-pregnancy, the gravid uterus should
be moved off the inferior vena cava to increase
venous return and cardiac output in the
acutely injured pregnant woman. This may
be achieved by manual displacement of the
uterus or left lateral tilt. Care should be taken
to secure the spinal cord, when using left lateral tilt (II-1B).

(8) To avoid rhesus D (Rh) alloimmunization in

Rh-negative mothers, O-negative blood should
be transfused when needed until crossmatched
blood becomes available (I-A).
(9) The abdominal portion of military antishock
trousers should not be inflated on a pregnant
woman because this may reduce placental perfusion (II-3B).
(10) Transfer or transport to a maternity facility
(triage of a labor and delivery unit) is advocated when injuries are neither life nor limb
threatening and the fetus is viable (23 weeks),
and to the emergency room when the fetus is
under 23 weeks gestational age or considered
to be nonviable. When the injury is major, the
patient should be transferred or transported to
the trauma unit or emergency room, regardless
of gestational age (III-B).
(11) When the severity of injury is undetermined or
when the gestational age is uncertain, the
patient should be evaluated in the trauma unit
or emergency room to rule out major injuries
(III-C).
(12) In cases of major trauma, the assessment,
stabilization, and care of the pregnant women
is the first priority; then, if the fetus is viable
(23 weeks), fetal heart rate auscultation and
fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible
(II-3B).
(13) In addition to the routine blood tests, a pregnant trauma patient should have a coagulation
panel, including fibrinogen (III-C).
(14) A Caesarean section should be performed for
viable pregnancies (23 weeks) no later than
4 min (when possible) following maternal cardiac arrest to aid with maternal resuscitation
and fetal salvage (III-B).
The low level of evidence of these guidelines is
obvious, but can be explained by the difficulties of
performing prospective randomized trials in pregnant patients. Nevertheless, the recommendations
are completely in line with, for example, the recommendations of the Management of Obstetric Emergency and Trauma and Advanced Trauma Life
Support courses and previous published guidelines
of other organizations like the Eastern Association
for the Surgery of Trauma [14].

NEUROTOXICITY
There has been growing interest in the effects of
anesthesia (and surgery) on infants, but only few
studies dealt with a prenatal effect. Propofol administered prenatally to pregnant rats was associated

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Obstetric and gynaecological anaesthesia

with histopathological changes in the brain of the

offspring, several days after birth [15]. A deletion of
neurons and lower synaptophysin levels in the
hippocampus were observed compared with control
animals. The learning capability of the propofoltreated group was persistently impaired, as was
assessed in several experimental tests [15]. Li and
colleagues [16] extended these results to a slower
maturation of eyes and other neurological reflexes.
Propofol was also found to induce apoptosis of
neurons and oligodendrocytes in primate brains
exposed in utero [17]. This study demonstrated that
the vulnerability of the central nervous system was
present in the prenatal period but persisted into
postnatal life. The neurotoxic effect was also found
for inhalational agents, sevoflurane exposure during
the intrauterine period resulted in alterations of the
synaptogenesis that led to learning and memory
deficits during tests several days after birth [18]. This
finding comes from mice, thereby illustrating that a
neurotoxic potential of anesthetics seems to be
given in various species. When administered to rats
at a gestational age corresponding to the second
human trimester isoflurane caused behavioral
abnormalities, that is, an impaired acquisition of
spatial working memory [19]. This finding was very
interesting because it contradicted the results by Li
and colleagues [20] who were unable to find an
effect during a later gestational period. This raised
the possibility of a higher vulnerability in the second trimester, which is the preferred period of
surgery, and thus would question our current
recommendations. However, there were several
limitation to this study, including the study of only
male animals. Moreover, Palanisamy et al. [19] respirated their animal with 100% oxygen and high
oxygen fractions are known to have a detrimental
effect on neurodevelopment [21]. The results may
have been different with lower oxygen concentrations although a high oxygen fraction may be
chosen by many practitioners to ensure oxygenation of mother and baby.
However, the relevance of these results from
animal models for the human situation is unclear
and there are several major caveats to the extrapolation of animal studies to humans. Among them are
the time of exposure to anesthesia relative to the
duration of gestation in animals.
Palanisamy pointed out that the exposure in
some animal studies would correspond to 48 h of
anesthesia in a woman [22]. Moreover, it is also the
complexity of the human brain that restricts the
generalizability of animal findings.
Most conclusive would be follow-up studies of
children exposed to anesthetics during their intrauterine life and matching them with not-exposed
4

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coeval children or siblings, adjusting for gender,

socioeconomic background and other mediators
of learning, memory, and behavioral capabilities.

LAPAROSCOPIC AND
GASTROINTESTINAL SURGERY
Symptomatic calculous cholecystitis may occur
during pregnancy and is associated with repeat hospital admissions [23]. Therefore, some authors
suggest cholecystectomy during pregnancy given
the low frequency of complications [23]. Cox
et al. [24] compared the outcome after open vs.
laparoscopic appendectomy or cholecystectomy
and evaluated almost 2000 pregnant patients
between 2005 and 2012. The laparoscopic approach
was associated with shorter operative times, shorter
length of hospital stay, and fewer complications
compared with open surgery. These differences were
not observed with perforated cholecystitis.
In a small Australian cohort of 22 patients
undergoing laparoscopic cholecystectomy, spanning a 10-year period, no uterine injury or fetal
loss occurred, two preterm deliveries were noted
[25]. Erekson and colleagues evaluated the 2005
2009 data of American College of Surgeons National
Surgical Quality Improvement Program of 1969
women undergoing nonobstetric surgery during
pregnancy. Major postoperative complications
within the first 30 postoperative days were seen in
5.8%, which encompassed need for reoperation in
3.6%, infectious morbidity in 2.0%, wound morbidity in 1.4%, respiratory morbidity in 2.0%, venous
thromboembolic event morbidity in 0.5%, and postoperative blood transfusion in 0.2% of the cases.
Maternal mortality reached 0.25% [26].
Cholecystitis and appendicitis are among the
most frequent causes of abdominal emergencies
according to a report by Bouyou and colleagues.
The preferred treatment for both entities is laparoscopy. Intestinal obstruction, another abdominal
emergency, is best assigned to medical treatment [27].
To further define the role of laparoscopy
Wilasrusmee et al. [28] performed a meta-analysis
of 11 studies (eight comparative prospective
cohort studies, three retrospective studies), including 3415 patients. Fetal loss occurred significantly
more frequently in the laparoscopy group, the
relative risk was 1.91, 95% confidence interval
1.312.77. This significant difference was mainly
because of one study from the Californian patient
registry which had a weight of more than 80% in the
analysis and a significant difference could not be
reproduced after exclusion from the analysis. As a
major flaw selection of patients and/or surgeons for
laparoscopy or laparotomy may have played a role
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Nonobstetric anesthesia during pregnancy Heesen and Klimek

in the latter study. Also, the rate of negative appendectomy was very high. In the meta-analysis the
relative risks for preterm labor, birth weight, Apgar
score, and for postoperative wound infection were
not statistically significantly different between the
laparoscopy and the laparotomy group.
ss and colleagues underline there are
As Juhasz-Bo
several aspects that deserve attention by surgeons
and anesthesiologists [29]. The pneumoperitoneal
pressure should be less than 15 mmHg to reduce
the increase in PaCO2 that can lead to stimulation
of the sympathetic nervous system, which in turn can

reduce uteroplacental perfusion. Moreover, direct

fetal acidosis is also possible. Therefore, close end
expiratory CO2 monitoring seems strongly recommended during laparoscopic surgery during pregnancy. The functional residual capacity which is
per se lower in pregnancy can be further reduced
by the capnoperitoneum, thereby further increasing
the risk of hypoxemia during emergence from anesthesia. Guidelines developed under the auspices of
the Society of American Gastrointestinal Endoscopic
Surgeons were published in 2011 [30] and some
important issues are summarized in Table 2.

Table 2. Guidelines for laparoscopic surgery during pregnancy, developed under the auspices of the Society of American
Gastrointestinal Endoscopic Surgeonsa
Ultrasonographic imaging during pregnancy is safe and useful in identifying the cause of acute abdominal pain in the pregnant patient
(moderate; strong).
Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Cumulative radiation dosage should be
limited to 510 rads during pregnancy (moderate; strong).
Contemporary multidetector computed tomography protocols deliver a low radiation dose to the fetus and may be used judiciously during
pregnancy (moderate; weak).
MRI without intravenous gadolinium can be performed at any stage of pregnancy (low; strong).
Administration of radionucleotides for diagnostic studies is generally safe for mother and fetus (low; weak).
Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during
pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation
exposure to the fetus (low; weak).
Diagnostic laparoscopy is well tolerated and effective when used selectively in the workup and treatment of acute abdominal processes in
pregnancy (moderate; strong).
Laparoscopic treatment of acute abdominal disease has the same indications in pregnant and nonpregnant patients (moderate; strong).
Laparoscopy can be safely performed during any trimester of pregnancy (moderate; strong).
Gravid patients should be placed in the left lateral decubitus position to minimize compression of the vena cava (moderate; strong).
Initial abdominal access can be safely performed with an open (Hasson) technique, Veress needle, or optical trocar, if the location is
adjusted according to fundal height and previous incisions (moderate; weak).
CO2 insufflation of 1015 mmHg can be safely used for laparoscopy in the pregnant patient (moderate; strong).
Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (moderate; strong).
Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep
venous thrombosis in the gravid patient (moderate; strong).
Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease, regardless of trimester (moderate;
strong).
Choledocholithiasis during pregnancy may be managed with preoperative endoscopic retrograde cholangiopancreatography with
sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration, or postoperative endoscopic
retrograde cholangiopancreatography (moderate; strong).
Laparoscopic appendectomy may be performed safely in pregnant patients with appendicitis (moderate; strong).
Laparoscopic adrenalectomy, nephrectomy, splenectomy, and mesenteric cyst excision are well tolerated procedures in pregnant patients
(low; weak).
Laparoscopy is a well tolerated and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable
for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is
warranted for most cystic lesions <6 cm in size (low; strong).
Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion unless clinical severity warrants laparotomy (low; strong).
Fetal heart monitoring should occur pre and postoperatively in the setting of urgent abdominal surgery during pregnancy (moderate; strong).
Obstetric consultation can be obtained pre and/or postoperatively based on the severity of the patients disease and availability (moderate;
strong).
Tocolytics should not be used prophylactically in pregnant women undergoing surgery but should be considered perioperatively when signs
of preterm labor are present (high, strong).
a

The degree of recommendation is given in parenthesis [30].

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Table 3. Common neurosurgical conditions, treatment options, and effects on maternal and fetal outcome [33 ]
&&

Neurosurgical condition

Maternal outcome

Fetal outcome

Treatment options

Benign brain tumors

Good

Variable

Surgery/conservative

Malignant brain tumors

Variable

Poor

Surgery/radiotherapy/chemotherapy

Cerebrovascular disease
Stroke

Poor

Poor

Conservative/surgery

Subarachnoid hemorrhage

Variable

Variable

Surgery/embolization
Medical/surgery

Others

Variable

Variable

Head injury

Variable

Poor

Conservative/surgery

Spinal disorders

Good

Variable

Conservative/surgery

A rather rare cause of abdominal surgery during

pregnancy is internal herniation secondary to
gastric bypass before pregnancy. Andreasen and
colleagues [31] analysed the data from a Danish
register-based cohort study and found an incidence
of 1% of women with a history of gastric bypass
surgery who required surgery during pregnancy for
internal herniation.
The incidence of cancer during pregnancy rose
over the last decades and nowadays affects approximately one of 1000 pregnant women and this may
be another indication for surgery that cannot be
delayed until after birth [32].

(mostly Cesarean) should be seriously considered

as the first procedure to perform [33 ]. This prevents
not only the fetus to be exposed to some therapies
involved in the management of the neurosurgical
patient like hyperventilation, use of osmodiuretics,
barbiturates, and induced hypo or hypertension, but
makes handling of the mother easier, too.
Another challenge is the balance between an
adequate cerebral perfusion pressure vs. adequate
uteroplacental perfusion pressure [33 ]. Hypotension and hypovolemia are bad for both, mother and
child, and should be strictly avoided. However,
hyperventilation can be useful to reduce intracranial pressure, but also reduces uteroplacental perfusion pressure [33 ]. In general, hemodynamic
fluctuations should be avoided and normoxemia,
normoglycemia, normothermia should be maintained to avoid fetal asphyxia.
In case of an awake craniotomy a bilateral scalp
nerve block can most probably be performed with a
smaller amount of local anesthetics than a surgical
field block [35]. In case of neuroradiological interventions an abdominal shield must be applied and
low doses of water soluble contrast agents should
be used.
In supine position a wedge under the right hip is
recommended, but spinal surgery requires special
attention. Careful, gradual positioning with a free
abdomen under fetal heart rate monitoring is the
method of choice. If possible, the lateral decubitus
position is a good alternative for a prone position,
however, not all neurosurgeons are experienced
with this approach.
The general measures to treat increased intracranial pressure like mild hyperventilation and use
of osmodiuretics seem to be well tolerated by
mother and fetus [33 ]. Whether triple-H-therapy
should be used to prevent vasospasm after aneurysm
rupture is discussed in nonpregnant patients, too
[36 ]. However, there is no evidence of any extra risk
or benefit for maternal or fetal outcome [33 ].
&&

&&

&&

NEUROSURGERY
Hormonal changes, pregnancy-induced hypertension, and other not yet identified factors increase
the risk that neurosurgical conditions present
during pregnancy. Neurosurgical interventions are
not performed frequently in pregnant patients, but
they are associated with high morbidity and
mortality. The therapeutic goals may be conflicting
and there is little high-level evidence about the best
anesthetic regimen. However, two recently published articles give a good overview of the current
knowledge: [33 ,34]
The majority of the procedures is performed as
emergency surgery requiring acute decompression/
craniotomy. Table 3 summarizes common neurosurgical conditions, treatment options and the
effects on maternal and fetal outcome.
All procedures should be performed with periprocedural fetal heart rate monitoring after 24 weeks
gestational age [2].
One challenge is the timing of the neurosurgical
intervention versus the delivery of the fetus.
Maternal condition, the indication for the neurosurgical intervention and the gestational age are the
most relevant factors to consider. In the third
trimester (after 34 weeks), emergency delivery
&&

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&&

&

&&

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Nonobstetric anesthesia during pregnancy Heesen and Klimek

CONCLUSION
In recent years, several guidelines which apply to the
care of pregnant women undergoing nonobstetric
surgery have been published, including airway
guidelines and guidelines for pregnant trauma
patients. Most nonobstetric operations during pregnancy are such of the abdomen and guidelines have
been issued on the specific features of laparoscopic
procedures. Other issues including the neurotoxic
effects of anesthetics on the unborn await further
study.
Acknowledgements
None.
Financial support and sponsorship
This study received only departmental funding.
Conflicts of interest
There are no conflicts of interest.

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&
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&&
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&
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