Anesthetic Management of Nonobstetric Surgery during Pregnancy
- 9 Downloads
Purpose of Review
This article reviews several controversial aspects of management of nonobstetric surgery during pregnancy, including the optimal timing for nonurgent surgery, when to perform intraoperative fetal monitoring, modifications to anesthetic techniques to account for the physiologic changes of pregnancy, and management of maternal cardiac arrest.
There have been several advances in the management of nonobstetric surgery during pregnancy, including the increased use of laparoscopic techniques, an improved understanding of the importance of adequate pain management, and new initiatives to improve the maternal cardiac resuscitation algorithm. Traditional dogma regarding aspiration prophylaxis during pregnancy and concerns about abortifacient and teratogenic properties of diagnostic imaging and anesthetic agents have also recently been reevaluated.
Urgent and emergent surgeries should proceed without delay during pregnancy in order to ensure optimal outcomes for both the mother and fetus. Anesthetic management may require several modifications to account for physiologic changes of pregnancy. In general, uteroplacental perfusion is best maintained by avoidance of maternal hypoxemia, hypotension, hyper- and hypocapnia, temperature extremes, and stress.
KeywordsPregnancy Physiologic changes of pregnancy Nonobstetric surgery during pregnancy Teratogenicity Preterm labor Intraoperative fetal monitoring Left uterine displacement General anesthetics in pregnancy Deep sedation during pregnancy Regional anesthesia Neuraxial anesthesia Laparoscopic surgery Maternal cardiac arrest Perimortem delivery
Compliance with Ethical Standards
Conflict of Interest
R. d’Arby Toledano, Hannah E. Madden and Lisa Leffert declare they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.Toledano RD: Urologic emergencies and nonobstetric surgery during pregnancy. In: Gainsburg DM, Bryon EO, Frost EAM, editors. Anesthesia for urologic surgery. New York, NY: Springer; 2014.Google Scholar
- 4.• Erekson EA, Brousseau EC, Dick-Biascoechea MA, Ciarleglio MM, Lockwood CJ, Pettker CM. Maternal postoperative complications after nonobstetric antenatal surgery. J Matern Fetal Neonatal Med. 2012;25:2639–44. A comprehensive review of the most frequently encountered postoperative complications in pregnant patients undergoing nonobstetric surgery. Google Scholar
- 9.Mongardon N, Servin F, Perrin M, Bedairia E, Retout S, Yazbeck C, et al. Predicted propofol effect-site concentration for induction and emergence of anesthesia during early pregnancy. Anesth Analg. 2009;109:90–5.Google Scholar
- 10.Ngan Kee WD, Lee A, Khaw KS, Ng FF, Karmakar MK, Gin T. A randomized double-blinded comparison of phenylephrine and ephedrine infusion combinations to maintain blood pressure during spinal anesthesia for cesarean delivery: the effects on fetal acid-base status and hemodynamic control. Anesth Analg. 2008;107:1295–302.CrossRefPubMedGoogle Scholar
- 12.Leboulanger N, Louvet N, Rigouzzo A, de Mesmay M, Louis B, Farrugia M, et al. Pregnancy is associated with a decrease in pharyngeal but not tracheal or laryngeal cross-sectional area: a pilot study using the acoustic reflection method. Int J Obstet Anesth. 2014;23:35–9.Google Scholar
- 14.Toledano RD: Physiological changes associated with pregnancy. In: Clark V, Van de Velde M, Fernando R, editors. Oxford textbook of Obstetric Anaesthesia. Oxford: Oxford University Press; 2016.Google Scholar
- 17.• Lee AJ, Landau R, Mattingly JL, Meenan MM, Corradini B, Wang S, et al. Left lateral table tilt for elective cesarean delivery under spinal anesthesia has no effect on neonatal acid-base status: a randomized controlled trial. Anesthesiology. 2017;127:241–9. A prospective study reassessing the role of left uterine displacement after spinal anesthesia in the setting of a continuous phenylephrine infusion in healthy obstetric patients. CrossRefPubMedGoogle Scholar
- 18.Rossi A, Cornette J, Johnson MR, Karamermer Y, Springeling T, Opic P, et al. Quantitative cardiovascular magnetic resonance in pregnant women: cross-sectional analysis of physiological parameters throughout pregnancy and the impact of the supine position. J Cardiovasc Magn Reson. 2011;13:31.Google Scholar
- 19.Higuchi H, Takagi S, Zhang K, Furui I, Ozaki M. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging. Anesthesiology. 2015;122:286–93.Google Scholar
- 22.Apfelbaum JL, Caplan RA, Connis RT, Epstein BS, Nickinovich DG, Warner MA. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126:376–93.Google Scholar
- 25.• American College of Obstetricians and Gynecologists. Committee opinion no. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol. 2017;130:e210–6. Recently updated guidelines regarding the safety and appropriate use of diagnostic imaging during pregnancy. Google Scholar
- 26.Interrante JD, Ailes EC, Lind JN, Anderka M, Feldkamp ML, Werler MM, et al. Risk comparison for prenatal use of analgesics and selected birth defects, National Birth Defects Prevention Study 1997-2011. Ann Epidemiol. 2017;27:645–53.Google Scholar
- 29.•• Lind JN, Interrante JD, Ailes EC, Gilboa SM, Khan S, Frey MT, et al. Maternal use of opioids during pregnancy and congenital malformations: a systematic review. Pediatrics. 2017;139:e20164131. A recent review of controversial issues regarding opioid use during pregnancy. CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Rosenberg L, Mitchell AA, Parsells JL, Pashayan H, Louik C, Shapiro S. Lack of relation of oral clefts to diazepam use during pregnancy. N Engl J Med. 1983;338:1128–37.Google Scholar
- 31.Ní Mhuireachtaigh R, O’Gorman DA. Anesthesia in pregnant patients for nonobstetric surgery. J Clin Anesh. 2006;18:60–6.Google Scholar
- 32.Stoelting RK, Hillier SC. Pharmacology and physiology in anesthetic practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 74.Google Scholar
- 34.Practice Advisory: FDA warning regarding use of general anesthetics and sedation drugs in young children and pregnant women. The American College of Obstetricians and Gynecologists. 2016. https://acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/FDA-Warnings-Regarding-Use-of-General-Anesthetics-and-Sedation-Drugs. Accessed November 9, 2018.
- 35.Committee on Obstetric Practice and the American Society of Anesthesiologists. Committee opinion no. 696: nonobstetric surgery during pregnancy. Obstet Gynecol. 2017;129:777–8.Google Scholar
- 36.Jevtovic-Todorovic V, Hartman RE, Izumi Y, Benshoff ND, Dikranian K, Zorumski CF, 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.Google Scholar
- 37.Yildiz K, Dogru K, Dalgic H, Serin IS, Sezer Z, Madenoglu H, et al. Inhibitory effects of desflurane and sevoflurane on oxytocin-induced contractions of isolated pregnant human myometrium. Acta Anaesthesiol Scand. 2005;49:1355–9.Google Scholar
- 40.Lipman S, Cohen S, Einav S, Jeejeebhoy F, Mhyre JM, Morrison LJ, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesth Analg. 2014;118:1003–16.Google Scholar