Upload
vaibhav-jain
View
216
Download
0
Embed Size (px)
Citation preview
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
1/71
Anaesthesia for Non Obstetric
Surgery in Pregnancy
Presenter: Dr. Vaibhav Jain
Moderator: Dr. Aruna Chandak
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
2/71
Incidence
0.3% to 2.2% of pregnant women undergosurgeries
Annual incidence - 75,00080,000 (USA)
Centralized data unavailable in India
Commonest surgery - Appendicectomy
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
3/71
Incidence
Am J Obstet Gynecol 1989
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
4/71
Surgeries in pregnancy
Pregnancy related
Cervical encirclage
Fetal surgery
Ovarian Cystectomy
Not related to pregnancy
Appendicectomy, Cholecystectomy
Trauma
Malignancies
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
5/71
How these patient are dif ferent from other
surg ical pat ients?
Two patients - mother
- fetus
Physiological changes in mother
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
6/71
Why this topic is important?
Must ensure safe anaesthesia for both mother andchild
Standard anaesthetic procedure may have to be
modified to accomodate both maternalphysiological changes and presence of fetus
Risk to the fetus is more-
the effect of disease process,
teratogenicity of anaesthetic agents,
intraoperative impairment of uteroplacental
circulation, and
risk of abortion or preterm delivery
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
7/71
KEY AREAS
Normal alterations in maternal phys io logy du r ingpregnancy
The potential fetal effectsfrom anaesthesia andsurgery
Maintenance of uteroplacental perfusion and fetaloxygenat ion
Pract ical consid erat ions
Importance of maternal counselling and reassurance
Special situat ions
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
8/71
Altered maternal physiologyRespiratory system: O2 consumption & FRC rapid desaturation or
hypoxemia
Alveolar ventilation chronic respiratory alkalosis & bicarbonate and base buffer
mucosal vascularity & weight gain difficult maskventilation or intubation
Cardiovascular system:
Supine hypotension syndromeuteroplacentalperfusion
Distention of epidural venous plexus likelihood ofintravascular injection and enhanced spread of LA
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
9/71
Altered maternal physiologyHematological changes Blood volume with lesser increase in RBCs volume
dilutional anemia
Factor I, VII, VIII, X, XII & FDP Increased risk ofthromboembolic complications
Benign leukocytosisdifficult to differentiate frominfection
Gastrointestinal system changes
LES tone, distortion of gastropyloric anatomy & gastric pressure from gravid uterusrisk ofregurgitation and aspiration
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
10/71
Altered maternal
physiologyAltered response to anaesthesia Alveolar hyperventilation, reduction of FRC and
reduction of MACrapid induction of generalanaesthesia
thiopental requirements
protein binding due to low albumin free
fraction of drugs
sensitivity to peripheral neural blockadeL.A.dose requirement
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
11/71
KEY AREAS
Normal alterations in maternal phys io logy du r ingpregnancy
The potential fetal effectsfrom anaesthesia andsurgery
Maintenance of uteroplacental perfusion and fetaloxygenat ion
Pract ical consid erat ions
Importance of maternal counselling and reassurance
Special situat ions
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
12/71
FETAL EFFECTS
Teratogenicity
Any significant postnatal change in function or formin an offspring after prenatal treatment
Factors that influence teratogenicity of a drug
Species susceptibility
Threshold or amount of exposure
Duration and timing of administration
Genetic predisposition
Manifestation of teratogenicity (Death, Structural
abnormality, Growth restriction, functional
deficiency)
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
13/71
FETAL EFFECTS
Teratogenicity
Maximum sensitivity of organs for development ofstructural abnormalities
Brain 18-36 days
Heart 18-40 days
Eyes 24-40 days
Limbs 24-36 days
Gonads 37-50 days
Organogenesis: complete at 13 weeks
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
14/71
Critical Periods
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
15/71
FETAL EFFECTSDocumented teratogens: Radiation
increased risk of malignant disease, genetic disease,cong. malformation &/or fetal death
Maternal metabolic imbalance
Alcoholism, cretinism, diabetes, folic acid deficiency,hyperthermia, prolonged hypoxia, hypercarbia andsevere hypoglycemia
Infection
CMV, Herpes virus, Parvo virus B-19, rubella virus,toxoplasmosis
Drugs
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
16/71
FETAL EFFECTSRadiology: a threat??
Effects are dose related
Less than 50 mGy is safe
Absorbed fetal dose for all conventional radiographicimaging is less than 50 mGy
No single diagnostic procedure results in a radiation dosethat threatens the wel l-being of the developing embry o andfetus(American College of Radiology)
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
17/71
Diagnostic ultrasonography:
Considered to be devoid of embryotoxic effects
Potential side effects Fetal hyperthermiawith prolonged scans
Post-natal neurobehavioral effects with repeated
exposures
Hande et al. Teratogenic effects of repeated exposures to X-rays and or
ultrasound in mice. Neurotoxic Teratol 1995
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
18/71
Documented teratogenic drugs(Adapted: ACOG Educational Bulletin )
ACE inhibitors Lithium
Alcohol Mercury
Androgens Phenytoin
Antithyroid drugs Vitamin A derivatives
Carbamazepine Streptomycin/kanamycin
Chemotherapy agents Tetracycline
Cocaine Thalidomide
Coumadin Trimethadione
Diethylstilbestrol Valproic acid
Lead
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
19/71
FETAL EFFECTS
Anaesthet ic agents and
teratogenici ty
Teratogenic effects of anaesthetic agents are
probably minimal to non-existent and have never
been conclusively documented
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
20/71
FETAL EFFECTS
Safe drugs: I/V induction agents
Narcotics
Neuromuscular blockers
Inhalational agents Local anaesthetics
Drugs of concern:
Nitrous oxide,
BZD
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
21/71
FETAL EFFECTS
Nitrous oxideAnimal studies
Weak teratogen in rodents
Interferes with function of methionine synthetase by oxidation ofvitamin B12
decreased THF
decreased DNA synthesis
Decreased uterine blood flow : prevented by addition ofhalogenated inhalational agents
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
22/71
FETAL EFFECTS
Nitrous oxideHuman studies No proved teratogenicity
Significant exposure for prolonged duration results in altered
enzyme activity
No teratogenic effects in clinically administered dose.
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
23/71
FETAL EFFECTSBENZODIAZEPINES (BZD)
Earlier retrospective studies:Association between maternal diazepam ingestion during
1sttrimester and infant with cleft lip and palate
Later prospective studies:
- No higher risk when used in 1st trimester
Long term maternal administrationfetal BZD dependence &
withdrawal
Peripartum administration
Fetal hypotonia, hypothermia, respiratory depression,
feeding difficulties
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
24/71
FETAL EFFECTS
A single shot of short acting BDZ or Nitrous oxide in
clinically administered anaesthetic concentration isunlikely to have any teratogenic effects
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
25/71
FETAL EFFECTSBEHAVIORAL TERATOLOGY
Behavioral abnormality in absence of anyobservable morphological changes
CNS is specifically sensitive during period of major
myelination which extends from 4th
IU month to 2nd
postnatal month
Animalsprenatal administration of systemic
drugs e.g., Barbiturates, meperidine,promethazine & halothanebehavioral changes
Humanimplication remains unknown
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
26/71
FETAL EFFECTS
There are not adequate data to
extrapolate the animal finding tohumans
(Anesthetic & Life Support Drug advisory Committeeof US FDA)
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
27/71
Fetal effects
To summarize, anaesthesia and surgery are associated withhigher incidence of abortion, IUGR and perinatal mortality.
These adverse outcomes can often be attributed to the
procedure, the site of the surgery (e.g., proximity to the
uterus), and/ or the underlying maternal condition
No evidence that anaesthesia results in overall increase in
congenital abnormality
No evidence of clear relation between outcome and type of
anaesthesia
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
28/71
KEY AREAS
Normal alterations in maternal phys io logy du r ingpregnancy
The potential fetal effectsfrom anaesthesia andsurgery
Maintenance of uteroplacental perfusion and fetaloxygenat ion
Pract ical consid erat ions
Importance of maternal counselling and reassurance
Special situat ions
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
29/71
Uteroplacental perfusion and
fetal oxygentation
Fetal oxygenation depends on maternal oxygen delivery and
uteroplacental perfusion
Most serious risk during nonobstetric surgery is Intrauterineasphyxia
Maintenance of fetal well being :
Maternal oxygenation
Maternal carbon dioxide tension
Uterine blood flow
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
30/71
Uteroplacental perfusion and
fetal oxygentation
Maternal oxygenation:
Severe maternal hypoxia can occur with:
difficult / oesophageal intubation pulmonary aspiration
total spinal anaesthesia
systemic LA toxicity
Moderate hyperoxia improves fetal oxygenation and is not
associated with intrauterine retrolental fibroplasia and
premature DA closure
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
31/71
Uteroplacental perfusion and
fetal oxygentation
Maternal CO2: Fetal CO2correlates to maternal levels
Maternal hyperventilation can results in
Umbilical artery constriction
Alkalosis:
shift maternal oxyhemoglobin dissociation curve to left.
Hypocapnia:
ventilation venous return
cardiac output uterine blood flow.
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
32/71
Factors affecting the
Uteroplacental perfusion
Maternal hypotension
deep levels of anaesthesia
high levels of spinal or epidural blockade
aortocaval compression,
hemorrhage/ hypovolumia
Anaesthetic agents causing uterinevasoconstriction or hypertonus
(eg. ketamine>2mg/kg, toxic doses of LA)
CatecholaminesPain, anxiety, light anaesthesia increased plasmacatecholaminesdecreased UBF
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
33/71
KEY AREAS
Normal alterations in maternal phys io logy du r ingpregnancy
The potential fetal effectsfrom anaesthesia andsurgery
Maintenance of uteroplacental perfusion and fetaloxygenat ion
Pract ical consid erat ions
Importance of maternal counselling and reassurance
Special situat ions
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
34/71
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
35/71
PRACTICAL CONCERNS
When to do the surgery?? Depends on the balance between maternal and fetal risk and
urgency of the surgery
1sttrimesterOrganogenesis
Increased fetal risk for teratogenesis and abortion
3rdtrimesterPeak of physiological changes of pregnancy
Increased maternal risk
Increased risk of preterm labour
Thus 2ndtr imesteris considered to be a ideal time for non
emergency, essential surgeries
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
36/71
PRACTICAL CONCERNS
When to do the surgery??
Carvalho B, Anesth Analg Suppl IARS
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
37/71
PRACTICAL CONCERNS
Fetal monitoring Intermittent or continuous FHR monitoring should
be considered for major surgical procedureswhenever technically feasible:
Ease of monitoring
Type & site of surgery (difficult during abdominal surgery)
Gestational age (after 18-20 wks)
Tool to monitor intrauterine fetal well being
Done by transabdominal doppler or vaginal doppler probe
Requires the presence of a trained practitioner to monitor andinterpret the tracing
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
38/71
FHR variability
Good indicator of fetal well being after 25-27 wks
Loss of beat to beat variability and decreased baselineFHR are commonAnaesthetic agent administration
Declerations suggests fetal hypoxemia
Causes of FHR declerations
Inadvertent maternalhypoxemia, or inadequate uterine perfusion evaluation of maternal position, B.P, oxygenation, acidbase status and inspection of surgical sites asretractors may impair uterine perfusion.
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
39/71
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
40/71
PRACTICAL CONCERNS
Anaesthetic considerations in 2nd and 3rdtrimester
Maternal
Prone to hypoxia
Aspiration prophylaxis
Preparation for difficult airway Increased risk of thromboembolic complications
Avoid hyperventilation
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
41/71
PRACTICAL CONCERNS...
Fetal Premature labour / IUGR
Intrauterine asphyxia
Surgery related
Disease related problem
Diagnostic difficulties
Prolonged exposure to anaesthetics
Surgical manipulationsfetal risk
Anatomic and surface landmarks unreliable
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
42/71
PRACTICAL CONCERNS.
DIAGNOSTIC DIFFICULTY
As nausea, vomiting, constipation, and distention are
common symptoms of both normal pregnancy and
abdominal pathology
Increase WBC count
Reluctance to perform necessary studies involvingradiation
Anatomic and surface landmarks can be unreliable
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
43/71
PRACTICAL CONCERNS
TOCOLYTICS AGENTS
Prophylactic use in nonobstetric surgery is controversial
May be considered
abdominal surgeries involving uterine manipulations or Surgeries with high risk of premature labour i.e., cervical
encirclage
Uterine contractions should be monitored during the surgeryand tocolytic therapy to be instituted if required
Not recommended at or after 34 wks
Do not affect the outcome
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
44/71
PRACTICAL CONCERNS
Tocolytic agentsDrugs Side effects
2 agonist Terbutaline
Ritodrine
Isoxsuprine
fetal tachycardia,
hypoglycemia,
hypotension,
Pulmonary edema,
myocardial ischemia
Calcium channel blockers Nifedipine(one of the most commonly
used)
transient hypotension
Magnesium sulphate least commonly used interaction with NMBs,
CNS depression
Indomethacin peptic ulcer,
thrombocytopenia,
premature closure of D.A.
Atosiban
(newer agent)
oxytocin antagonist
Blunts Ca2+ influx in
myometrium and inhibit
contractility
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
45/71
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
46/71
Counselling and reassurance
Patient should bereassured about the safety of anaesthesiaand the lack of documented associated teratogenicity
Warnedabout the increased risk of 1sttrimester miscarriage
and premature delivery in later trimesters
Educatethe patient about the symptoms of premature labour
and reinforce the need of left uterine displacement
Documentation of details of the risk discussed should bemaintained in patients records
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
47/71
ANAESTHETIC MANAGEMENT
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
48/71
Pre-anaesthetic preparation..
Counselling and reassurance
Consult obstetrician & discuss about the use of tocolytics
Overnight fast
Aspiration prophylaxis
Anxiolytic premedication- to allay anxiety and apprehension
Transport in left lateral position
O.T. preparationdrugs, machine, difficult airway cart, suctionand monitors
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
49/71
ANAESTHETIC MANAGEMENTChoice 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
No technique has been proven to have superiority over theother in fetal outcomes
Regional techniques may be preferable
Safe anaesthetic management is more important thanparticular agent or technique
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
50/71
AIM :
To maintain oxygenation, normotension, eucapnia and
euglycemia
ANAESTHETIC MANAGEMENT
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
51/71
ANAESTHETIC MANAGEMENT
Monitoring
Maternal monitoring: Noninvasive / invasive blood pressure
Electrocardiography
Pulse oximetry
Capnography Temperature monitoring
Use of peripheral nerve stimulator
Blood glucose levels
Fetal monitoring: External doppler device (FHR )
Tocodynamometer (Uterine contractility)
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
52/71
ANAESTHETIC MANAGEMENT ..
General anaesthesia
Maintain left uterine displacment
Preoxygenation
Rapid sequence induction (Thiopent. sod. & succinyl choline,cricoid pressure tracheal intubation using cuffed E.T. tube)
Maintenance : A moderate conc. of inhalational agent ( 2MAC) with high conc. of oxygen (FiO2 = 0.5) isrecommended.
The use of nitrous oxide should be limited during extremelylong operations in first trimester by giving high conc of oxygen
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
53/71
Opioids and induction agents decreases FHR variabilityto greater extent than volatile agents
Positive pressure ventilation may reduce UBF
Avoid hyperventilation
Patients on magnesium for tocolysisreduce dose ofNMBs
Reversal agent to be given slowly (increased release ofAchincreased uterine tone and preterm labour)
Extubation when fully awake after return of protectiveairway reflexes
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
54/71
ANAESTHETIC MANAGEMENT..
Regional anaesthesia
Advantages:
Minimal fetal drug exposure
Avoidance of complications of general anaesthesia
If no sedative or narcotics are supplementednochange in FHR variations to confuse interpretation
Post operative analgesia
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
55/71
Management of regional anaesthesia
Pre-op preparation and monitoring same as of Generalanaesthesia
Reduced LA requirement / LA Toxicity
Careful aspiration and test dose
Avoid hypotension i.e., adequate preloading, maintain leftuterine tilt, choice of vasopressor
Patients on magnesium are more prone to hypotension, oftenresistant to treatment with vasopressors
ANAESTHETIC MANAGEMENT
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
56/71
ANAESTHETIC MANAGEMENT
Postoperative management
Oxygenation in left uterine tilt
Vitals monitoring
Obstetrician consultation for FHR & uterine activity monitoring
Pediatric consultation in case of premature labour
Adequate pain relief reduce the risk of premature labour
Tocodynamometry is useful in high risk patients as postoperativeanalgesia may mask awareness of early contractions and delaytocolysis
Early mobilization or DVT prophylaxis if required
ANAESTHETIC MANAGEMENT
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
57/71
ANAESTHETIC MANAGEMENT
Postoperative Pain management
Pain
increased endogenous catecholamines
uterinevasoconstrictiondecreased UBFintrauterine hypoxia
Techniques: Nerve blocks
Local infiltration
Opioids
NSAID
NSAIDS
1stand 2ndtrimester - safe
3rd trimester - risk of premature closure of DA,
Pulm HTN, delayed labour
NSAID can be us ed before 32 wks and
Acetam inophen is safe
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
58/71
ANAESTHETIC MANAGEMENT
Recommendations approved by AmericanSociety of Anaesthesiologists (ASA) and
American College of Obstetricians and
Gynecologists (ACOG) 2011
No currently used anaesthetic agentshave been shown to
have any teratogenic effectsin humans when using
standard concentrations at any gestational age
Fetal heart rate monitoringmay assist in maternalpositioning and cardiorespiratory management, and may
influence a decision to deliver the fetus
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
59/71
Recommendations
It is mandatory to obtain an obstetr ic con sul ta tionbeforeperforming any non obstetric surgery or any invasive
procedures
Apregnant womanshould neverbe denied indicated surgery,
regardless of trimester.
Elective surgeryshould bepostponed
If possible, non-urgent surgery should be performed in thesecond trimesterwhen preterm contractions and
spontaneous abortion are least likely.
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
60/71
KEY AREAS
Normal alterations in maternal phys io logy du r ingpregnancy
The potential fetal effectsfrom anaesthesia andsurgery
Maintenance of uteroplacental perfusion and fetaloxygenat ion
Pract ical consid erat ions
Importance of maternal counselling and reassurance
Special situat ions
Special situation
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
61/71
No longer a contraindication in pregnant patients
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
Special situation
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
62/71
Guidelines by Society of American Gastrointestinal
Endoscopic Surgeons (SAGES) 2008
Safe during any trimester of pregnancy
Obtain preoperative obstetrician consultation
Intermittent lower extremity pneumatic compressiondevices to prevent venous stasis
The fetal heart rate and uterine tone should be
monitored in both preoperative and postoperativeperiods
End tidal CO2 should be maintained
Special situation
Laparoscopy
Special situation
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
63/71
Special situation
Laparoscopy Left uterine displacement should be maintained
An open (Hassan) technique, a veres needle or an
optical trocar technique to enter abdomen
Low pneumoperitoneum pressures (10-15mm Hg)
should be used
Tocolytic agents should not be used prophylactically but
should be considered when evidence of preterm labouris present
Special situation Fetal
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
64/71
Special situationFetal
surgery
Anaesthetic considerations remains similar to those of non
obstetric surgeries
Two surgical patients
Maternal safety is important
Choice of anaesthetic technique
Minimally invasive endoscopic procedureNeuraxial
anaesthesia
Open intrauterine proceduresGeneral anaesthesia
Special situation Fetal
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
65/71
Special situationFetal
surgery.
Important considerations
Consider anaesthetic requirement of fetus
including amnesia, analgesia and immobilty
Control of uterine tone is essential
More intensive intraop FHR monitoring
Special situation
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
66/71
pElectroconvulsive Shock
Therapy Used to treat major depression and BPD during
pregnancy when rapid control of symptoms is needed
Advantage
Avoids potential teratogenicity from psychotropicmedications
Not a risk factor for premature labour, miscarriage orstillbirth
Anaesthetic management
Confirm the absence of uterine contractions usingtocodynamometry before and after ECT
Monitor FHR before and after ECT
Special situationNeurosurgery
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
67/71
p g y(e.g., Aneurysm, AV
malformation) Hypotensive anaesthetic techniques ( 2530% reduction in
SBP or mean BP less than 70 mmHg) can cause decrease inUBF
Dose (less than 0.5 mg/kg/hr) and duration of Sodium
Nitroprusside should be limited
FHR monitoring should be performed continuously specially ifinduced hypotension or hyperventilation is planned so thatnecessary adjustments can be made if fetal distress occurs
Hypovolemia and very large doses of mannitol should beavoided as they cause fetal dehydration
Endovascular treatmentsuterine shielding during periods ofradiation
Special situation Trauma
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
68/71
Special situationTrauma
during pregnancy
Trauma is the leading cause nonobstetric cause of morbidityand mortality
Primary management goals are similar to the care ofnonpregnant trauma cases
Avoidance of hypoxia, hypotension, acidosis and hypothermiaare important for the maintenance of UBF and fetal well being
More prone to develop pulmonary edema
In stable patients without ongoing blood lossConservativefluid management
CVP monitoring should be considered if renal insufficiency orfluid overload occurs
Special situation Trauma
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
69/71
Special situationTrauma
during pregnancy
Primary aim should be optimization of the mother and theobstetric management is planned later
No radiological tests should be withheld because of fetal
concerns, uterus should be shielded during radiation
procedures
Indications for an Emergency Cesarean delivery in a
pregnant trauma patients
Traumatic uterine rupture
Stable mother with viable fetus that is in distress
An unsalvagable mother who still has a viable fetus
A gravid uterus that is interfering with intraoperative surgical
repair
References
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
70/71
References
Obstetric Anaesthesia, Principles and Practice. David H
Chestnut, 5th
Ed
Millers anesthesia. Ronald D Miller. 7thed.
Wylie and Churchill Davidsons A Practice ofAnaesthesia 7thed.
Clinical Anesthesia; Barash, Cullen, Stoelting, 7thedition
Yao &ArtusiosAnesthesiology. 7thedition
Nonobstetric surgery during pregnancy, ACOG committeeopinion, No. 474, Feb 2011
Roisin Ni M, David A. Anesthesia on pregnant patients fornonobstetric surgery. Journal of clinical anesthesia (2006) 18,60-66
8/10/2019 Anaesthesia for Non Obstetric Surgery in Pregnancy
71/71
Thank You