Advertisement

Current Anesthesiology Reports

, Volume 9, Issue 1, pp 31–38 | Cite as

Anesthetic Management of Nonobstetric Surgery during Pregnancy

  • R. d’Arby ToledanoEmail author
  • Hannah E. Madden
  • Lisa Leffert
Obstetric Anesthesia (LR Leffert, Section Editor)
  • 20 Downloads
Part of the following topical collections:
  1. Obstetric Anesthesia

Abstract

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.

Recent Findings

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.

Summary

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.

Keywords

Pregnancy 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 

Notes

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.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Gilo NB, Amini D, Landy HJ. Appendicitis and cholecystitis in pregnancy. Clin Obstet Gynecol. 2009;52:586–96.CrossRefPubMedGoogle Scholar
  2. 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
  3. 3.
    •• Tolcher MC, Fisher WE, Clark SL. Nonobstetric surgery during pregnancy. Obstet Gynecol. 2018;132:395–403. A recent, comprehensive review of common issues and concerns that arise during nonobstetric surgery during pregnancy. CrossRefPubMedGoogle Scholar
  4. 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
  5. 5.
    Gin T, Chan MT. Decreased minimum alveolar concentration of isoflurane in pregnant humans. Anesthesiology. 1994;81:829–32.CrossRefPubMedGoogle Scholar
  6. 6.
    Chan MT, Gin T. Postpartum changes in the minimum alveolar concentration of isoflurane. Anesthesiology. 1995;82:1360–3.CrossRefPubMedGoogle Scholar
  7. 7.
    Robins K, Lyons G. Intraoperative awareness during general anesthesia for cesarean delivery. Anesth Analg. 2009;109:886–90.CrossRefPubMedGoogle Scholar
  8. 8.
    Higuchi H, Adachi Y, Arimura S, Kanno M, Satoh T. Early pregnancy does not reduce the C(50) of propofol for loss of consciousness. Anesth Analg. 2001;93:1565–9.CrossRefPubMedGoogle Scholar
  9. 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. 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
  11. 11.
    •• Ngan Kee WD. The use of vasopressors during spinal anaesthesia for caesarean section. Curr Opin Anaesthesiol. 2017;30:319–25. A comprehensive review of current clinical practices to reduce the incidence of spinal-induced hypotension. CrossRefPubMedGoogle Scholar
  12. 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
  13. 13.
    Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology. 2007;106:1096–104.CrossRefPubMedGoogle Scholar
  14. 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
  15. 15.
    Levinson G, Shnider SM, DeLorimier AA, Steffenson JL. Effects of maternal hyperventilation on uterine blood flow and fetal oxygenation and acid-base status. Anesthesiology. 1974;40:340–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Kinsella SM, Lohmann G. Supine hypotensive syndrome. Obstet Gynecol. 1994;83:774–88.PubMedGoogle Scholar
  17. 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. 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. 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
  20. 20.
    Chiloiro M, Darconza G, Piccioli E, de Carne M, Clemente C, Riezzo G. Gastric emptying and orocecal transit time in pregnancy. J Gastroenterol. 2001;36:538–43.CrossRefPubMedGoogle Scholar
  21. 21.
    de Souza DG, Doar LH, Mehta SH, Tiouririne M. Aspiration prophylaxis and rapid sequence induction for elective cesarean delivery: time to reassess old dogma? Anesth Analg. 2010;110:1503–5.CrossRefPubMedGoogle Scholar
  22. 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
  23. 23.
    Dean G, Jacobs AR, Goldstein RC, Gevirtz CM, Paul ME. The safety of deep sedation without intubation for abortion in the outpatient setting. J Clin Anesth. 2011;23:437–42.CrossRefPubMedGoogle Scholar
  24. 24.
    American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 166: thrombocytopenia in pregnancy. Obstet Gynecol. 2016;128:e43–53.CrossRefGoogle Scholar
  25. 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. 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
  27. 27.
    Broussard CS, Rasmussen SA, Reefhuis J, Friedman JM, Jann MW, Riehle-Colarusso, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204:314.e1–314.e11.CrossRefGoogle Scholar
  28. 28.
    Yazdy MM, Mitchell AA, Tinker SC, Parker SE, Werler MM. Periconceptional use of opioids and the risk of neural tube defects. Obstet Gynecol. 2013;122:838–44.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 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. 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. 31.
    Ní Mhuireachtaigh R, O’Gorman DA. Anesthesia in pregnant patients for nonobstetric surgery. J Clin Anesh. 2006;18:60–6.Google Scholar
  32. 32.
    Stoelting RK, Hillier SC. Pharmacology and physiology in anesthetic practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 74.Google Scholar
  33. 33.
    McGregor DG. Occupational exposure to trace concentrations of waste anesthetic gases. Mayo Clin Proc. 2000;75:273–7.CrossRefPubMedGoogle Scholar
  34. 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. 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. 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. 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
  38. 38.
    Kwon H, Lee M, Park HS, Yoon SH, Lee CH, Roh JW. Laparoscopic management is feasible for nonobstetric surgical disease in all trimesters of pregnancy. Surg Endosc. 2018;32:2643–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol. 2018;219:52–61.CrossRefPubMedGoogle Scholar
  40. 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

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • R. d’Arby Toledano
    • 1
    Email author
  • Hannah E. Madden
    • 2
  • Lisa Leffert
    • 2
  1. 1.Department of Anesthesiology, Perioperative Care and Pain MedicineNYU Langone Hospital–BrooklynBrooklynUSA
  2. 2.Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical SchoolMassachusetts General HospitalBostonUSA

Personalised recommendations