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Obstetric Surgery in
Pregnant Patients
Incidence
0.3%
Annual
Centralized
Commonest
surgery - Appendicectomy
Incidence
Am J Obstet
Gynecol 1989
Surgeries in pregnancy
Pregnancy related
Cervical encirclage
Fetal surgery
Ovarian Cystectomy
Not
related to pregnancy
Appendicectomy, Cholecystectomy
Trauma
Malignancies
patients - mother
- fetus
Physiological
changes in mother
Risk
KEY AREAS
Normal
The
Maintenance
Practical
considerations
Importance
Special
situations
Altered maternal
physiology
Cardiovascular system:
Supine
Distention
Altered maternal
physiology
Hematological changes
Benign
Altered maternal
physiology
thiopental requirements
FETAL EFFECTS
Teratogenicity
Any
Factors
Manifestation
FETAL EFFECTS
Documented teratogens:
Radiation
metabolic imbalance
Alcoholism, cretinism, diabetes, folic acid
deficiency, hyperthermia, prolonged hypoxia,
hypercarbia and severe hypoglycemia
Infection
FETAL EFFECTS
Radiology: a threat??
Effects
Less
Absorbed
Diagnostic ultrasonography:
Considered
Potential
side effects
Post-natal neurobehavioral
repeated exposures
effects
with
Documented teratogenic
drugs
(Adapted: ACOG Educational
Bulletin )
Lithium
(Adapted:
ACE
inhibitors
Alcohol
Mercury
Androgens
Phenytoin
Antithyroid drugs
Vitamin A derivatives
Carbamazepine
Streptomycin/kanamycin
Chemotherapy agents
Tetracycline
Cocaine
Thalidomide
Coumadin
Trimethadione
Diethylstilbestrol
Valproic acid
Lead
FETAL EFFECTS
Anaesthetic agents and
teratogenicity
Teratogenic effects of anaesthetic agents are
probably minimal to non-existent and have
never been conclusively documented
FETAL EFFECTS
Safe drugs:
Narcotics
Neuromuscular blockers
Inhalational agents
Local anaesthetics
Drugs of concern:
Nitrous oxide,
BZD
FETAL EFFECTS
Nitrous oxide
Animal studies
FETAL EFFECTS
Nitrous oxide
Human studies
No proved teratogenicity
FETAL EFFECTS
BENZODIAZEPINES (BZD)
Peripartum administration
Fetal hypotonia, hypothermia, respiratory
depression, feeding difficulties
FETAL EFFECTS
FETAL EFFECTS
BEHAVIORAL TERATOLOGY
Behavioral abnormality in absence of any
observable morphological changes
CNS
Animals
Human
FETAL EFFECTS
Fetal effects
Uteroplacental perfusion
and fetal oxygentation
Maternal oxygenation
Uteroplacental perfusion
and fetal oxygentation
Maternal oxygenation:
pulmonary aspiration
systemic LA toxicity
Uteroplacental perfusion
and fetal oxygentation
Maternal CO2:
Alkalosis:
shift maternal oxyhemoglobin dissociation curve to
left.
Hypocapnia:
ventilation venous return cardiac output
uterine blood flow.
hypotension
deep levels of anaesthesia
high levels of spinal or epidural blockade
aortocaval compression,
hemorrhage/ hypovolumia
Anaesthetic
Catecholamines
PRACTICAL CONSIDERATIONS
Timing
of surgery
Fetal monitoring
Full stomach precautions
Left uterine displacement
Anaesthetic considerations
Tocolytic agents
PRACTICAL CONCERNS
PRACTICAL CONCERNS
PRACTICAL CONCERNS
Fetal monitoring
Intermittent
Ease of monitoring
Type & site of surgery (difficult during abdominal surgery)
Gestational age (after 18-20 wks)
FHR variability
PRACTICAL CONCERNS
Anaesthetic considerations in1st
Trimester
Maternal
oxygen requirement
Modified drug pharmacokinetics
Careful airway manipulation
Fetal
Risk
of teratogenicity
Impaired UBF
PRACTICAL CONCERNS
Anaesthetic considerations in 2nd and
3rd trimester
Maternal
Prone
to hypoxia
Aspiration prophylaxis
Preparation for difficult airway
Increased risk of thromboembolic
complications
Avoid hyperventilation
PRACTICAL CONCERNS...
Fetal
Premature
labour / IUGR
Intrauterine asphyxia
Surgery related
Disease
related problem
Diagnostic difficulties
Prolonged exposure to anaesthetics
Surgical manipulations fetal risk
Anatomic and surface landmarks unreliable
PRACTICAL CONCERNS.
DIAGNOSTIC DIFFICULTY
As
Increase
WBC count
Reluctance
radiation
Anatomic
PRACTICAL CONCERNS
TOCOLYTICS AGENTS
May be considered
abdominal surgeries involving uterine manipulations or
Surgeries with high risk of premature labour i.e.,
cervical encirclage
PRACTICAL CONCERNS
Tocolytic agents
Drugs
Side effects
2 agonist
Calcium channel
blockers
Magnesium sulphate
Terbutaline
Ritodrine
Isoxsuprine
Nifedipine
(one of the most
commonly used)
least commonly
used
Indomethacin
Atosiban
(newer agent)
oxytocin antagonist
fetal tachycardia,
hypoglycemia,
hypotension,
Pulmonary edema,
myocardial ischemia
transient hypotension
Counselling and
reassurance
Patient should be reassured about the safety of
ANAESTHETIC MANAGEMENT
Pre-anaesthetic
Counselling and reassurance
preparation..
Overnight fast
Aspiration prophylaxis
ANAESTHETIC MANAGEMENT
Choice of Anaesthesia
Choice of Anaesthetic technique depends on Patients present surgical status (site and nature
of surgery)
Present gestational age of the fetus
Pregnancy induced physiological changes
Other coexisting comorbidities
AIM :
ANAESTHETIC MANAGEMENT
Monitoring
Maternal
monitoring:
Electrocardiography
Pulse oximetry
Capnography
Temperature monitoring
Use of peripheral nerve stimulator
Blood glucose levels
Fetal
monitoring:
ANAESTHETIC
MANAGEMENT
..
General anaesthesia
Preoxygenation
Avoid hyperventilation
ANAESTHETIC MANAGEMENT..
Regional anaesthesia
Advantages:
Minimal
Avoidance
If
Post
operative analgesia
ANAESTHETIC MANAGEMENT
Postoperative management
Vitals monitoring
ANAESTHETIC MANAGEMENT
Postoperative Pain
Painincreased endogenous catecholamines uterine
management
vasoconstrictiondecreased UBFintrauterine hypoxia
Techniques:
Nerve blocks
Local infiltration
Opioids
NSAID
NSAIDS
1st and 2nd trimester - safe
3rd trimester - risk of premature closure of DA,
Pulm HTN, delayed labour
ANAESTHETIC MANAGEMENT
Recommendations approved by
American Society of Anaesthesiologists
(ASA) and American College of
Obstetricians and Gynecologists (ACOG)
2011
Recommendations
Special situation
Laparoscopy
Concerns:
- Uterine and fetal trauma
- Fetal acidosis from absorbed carbon dioxide.
- Decreased maternal cardiac output and
uteroplacental perfusion due to increased
abdominal pressure.
Special situation
Laparoscopy
Guidelines by Society of American
Special situation
Laparoscopy
Control
More
Special situation
Electroconvulsive
Shock
Therapy
Used to treat major depression and BPD during
pregnancy when rapid control of symptoms is
needed
Advantage
Anaesthetic
management
Confirm the absence of uterine contractions using
tocodynamometry before and after ECT
Monitor FHR before and after ECT
Special situation
Neurosurgery (e.g.,
Aneurysm,
AVtechniques
malformation)
Hypotensive anaesthetic
( 25 30%
References
Thank You