Incidental Surgery During Pregnancy

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Incidental Surgery During Pregnancy

  1. 1. Incidental surgery during pregnancy Dr.Shailendra .V.L. Specialist of Anesthesia Al Bukariya general hospital
  2. 2. Case presentation <ul><li>A 23 year old Saudi lady is posted for emergency appendicectomy. She is 14 weeks pregnant with twins. </li></ul>
  3. 3. Introduction <ul><li>1 - 2 % of women require incidental surgery during pregnancy </li></ul><ul><li>Surgery associated with increased fetal loss & premature delivery </li></ul><ul><li>All elective procedures should be done 6 weeks post partum </li></ul>
  4. 5. General considerations <ul><li>Avoid surgery during embryogenesis 15 days to 55 days </li></ul><ul><li>Ideal time to operate is in II trimester </li></ul>
  5. 6. Common surgeries in pregnancy <ul><li>Cervical encirclage </li></ul><ul><li>Appendicectomy ( 1 in 1500 pregnancies) </li></ul><ul><li>Cholecytectomy ( 1 in 2000 to 10000 pregnancies) </li></ul><ul><li>Ovarian cysts </li></ul>
  6. 8. Laparoscopy surgery in pregnancy <ul><li>Inert gases : Helium /Argon or N 2 O is used, as CO 2 insufflation causes fetal acidosis. Best is gasless lap. </li></ul><ul><li>Ideally before 23 weeks of pregnancy </li></ul><ul><ul><li>Minimize preterm labor </li></ul></ul><ul><ul><li>Adequate working place inside </li></ul></ul><ul><li>Minimal pressure used to create pneumo-peritoneum - ???? </li></ul><ul><li>Tocolytics used to arrest preterm labor – prophylactic use -- debatable </li></ul><ul><li>Fetal montitoring using vaginal scan </li></ul><ul><li>EtCO 2 monitored & ventilation adjusted accordingly </li></ul>
  7. 9. Objectives <ul><li>Maternal safety </li></ul><ul><li>Avoidance of fetal hypoxia & acidosis </li></ul><ul><li>Premature labor </li></ul><ul><li>Avoidance of teratogenic drugs </li></ul>
  8. 10. Maternal safety <ul><li>Recognize decreased Oxygen reserves </li></ul><ul><li>Airway management may be difficult </li></ul><ul><li>Supine hypotension syndrome (after 25 weeks) </li></ul><ul><li>Altered anesthetic requirements </li></ul><ul><li>↑ risk of aspiration </li></ul>
  9. 11. Avoidance of fetal hypoxia & acidosis <ul><li>Minimize maternal hypotension/arterial hypoxia/changes in PaCO 2 </li></ul><ul><li>Treat hypotension with left uterine displacement </li></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Leg elevation </li></ul></ul><ul><ul><li>Ephedrine </li></ul></ul><ul><li>Maternal supplemental oxygen </li></ul>
  10. 12. Premature labor <ul><li>No evidence that anesthetic drugs/techniques predispose to premature labor </li></ul><ul><li>Underlying disease or site of surgery determines likelihood of premature labor </li></ul><ul><ul><li>28% to 40% of premature labor following cervical encirclage </li></ul></ul>
  11. 13. Avoidance of teratogenic drugs <ul><li>Critical period of organogenesis between 15 – 56 days </li></ul><ul><li>No evidence that inhaled anesthetics is teratogenic </li></ul><ul><ul><li>Inhaled N 2 O </li></ul></ul><ul><ul><li>Opioids </li></ul></ul><ul><ul><li>Sedatives </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul><ul><ul><li>Local anesthetics </li></ul></ul><ul><li>No evidence that anesthetics adversely affect later mental & neurologic development </li></ul>
  12. 14. Studies supporting safe N 2 0 use <ul><li>Santos et al – Current controversies in obstetric anesthesia – Anesthesia Analgesia 1994; 78: 753 – 60 </li></ul>
  13. 15. Studies supporting safe use of anesthetic drugs <ul><li>Koren et al, Drugs in pregnancy, N Engl. J Med 1998; 1128 - 37 </li></ul>
  14. 16. Management of Anesthesia <ul><li>Regional techniques: </li></ul><ul><ul><li>Will not expose fetus to harmful depressant effects </li></ul></ul><ul><ul><li>Minimal physiological derangements </li></ul></ul><ul><li>Balanced Anesthesia also safe: </li></ul><ul><ul><li>No evidence suggestive of teratogenic effects </li></ul></ul><ul><ul><li>Left lateral lift after 25 weeks to prevent SHS </li></ul></ul><ul><ul><li>H 2 receptor antagonists & non-particulate antacid </li></ul></ul>
  15. 17. Post partum tubal ligation <ul><li>Done in early postpartum period </li></ul><ul><li>Continuous epidural used in labor analgesia extended to this procedure </li></ul><ul><li>If general anesthesia used: </li></ul><ul><ul><li>H 2 antagonists & non-particulate antacid given </li></ul></ul><ul><ul><li>Cuffed endotracheal tube is a must </li></ul></ul>
  16. 18. In-vitro fertilization <ul><li>Anesthetics detected in follicular fluid during aspiration of oocytes ??? Could affect reproductive potential of Ova </li></ul><ul><li>Conflicting reports on outcome of invitro fertilization & gamate intra fallopian transfer procedure </li></ul>
  17. 19. Thank you

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