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Anesthetic Considerations for Women Having Surgery While Pregnant Alan. C. Santos, MD, MPH St. Luke’s-Roosevelt Hospital Center New York, NY 10025.

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Presentation on theme: "Anesthetic Considerations for Women Having Surgery While Pregnant Alan. C. Santos, MD, MPH St. Luke’s-Roosevelt Hospital Center New York, NY 10025."— Presentation transcript:

1 Anesthetic Considerations for Women Having Surgery While Pregnant Alan. C. Santos, MD, MPH St. Luke’s-Roosevelt Hospital Center New York, NY 10025

2 Contents Scope of the Problem Maternal Considerations (brief) Fetal Considerations Teratogenicity Obstetric Outcome Long-Term Consequences? Nuts and Bolts

3 Scope of the Problem 0.3 to 2.2% of all pregnancies 87,000 in US and 115,000 in Europe Am J OB/GYN 1980; 138:1167 Am J OB/GYN 1989; 161:1178

4 Breakdown by Trimester %

5 Indications Gynecologic/Obstetric circlage torsion Other Abdominal Surgery appendectomy cholecystectomy Trauma

6 Maternal - Hemodynamics Increase in plasma volume hemodilution - lower hematocrit greater free fraction of drug dilution of cholinesterase Increase CO/decrease SVR/±BP Aorta-caval compression Hypercoagulable state

7 Maternal - Respiratory Increase in minute ventilation increase arterial oxygen tension decrease in arterial carbon dioxide Ph remains unchanged Decrease in FRC Increase in oxygen consumption

8 Maternal - Gastrointestinal Relaxation of gastroesophageal sphincter heartburn Mechanical factors (growing uterus) Delayed gastric emptying opioids labor

9 Maternal – Induction Agents CD 50 Anesthesiology 1997;86:73 Anesth Analg 2001;93:1565

10 Maternal – MAC Vol % Anesthesiology 1994; 81:829 Anesthesiology 1996; 85:782

11 Maternal – Inhalational Agents Anesthesiology 1994; 81:829

12 Maternal – Local Anesthetic Effect GroupCSF Progesterone ng.ml-1 Dermatomal Spread Non-pregnant0T3-T11 1 st Trimester0.23T3-T11 2 nd Trimester0.49C8-T11 3 rd Trimester1.46C7-T7 BJA 1995; 75:683

13 Maternal – Local Anesthetic Effect Epidural venous engorgement Reduced CSF volume

14 Fetal Risks Congenital Anomalies Spontaneous abortion/embryonic loss Premature labor Fetal demise Long term consequences???

15 Teratogenicity Structural (exposure day 15 – 55) Congenital anomalies Growth restriction Enzyme deficiency Resorptions/Death Behavioral (exposure late pregnancy) Emotions Learning Adaptive

16 Teratogenicity Species Vulnerability Timing of Exposure Magnitude of Exposure Susceptibility/Genetic Predisposition

17 Teratogens Cocaine! Diazepam? Nitrous Oxide???

18 METHYLTERAHYDROFOLATEHOMOCYSTEINE METHIONINE TERAHYDROFOLATE S-ADENOSYL METHIONINE ACTIVE FORMATE FORMYLTETRAHYDROFOLATE (FOLINIC ACID) Methionine Synthetase METHYLENE TETRAHYDROFOLATE DIHYDROFOLATE THYMIDINE DNA DEOXYURIDINE

19 Nitrous Oxide Teratogenicity N2O 70% - fetal resorption/malformation N2O & Folinic – partial reversal N20 & Isoflurane – reversal N20 7 Pnenoxybenzamine - reversal

20 Preventing Nitrous Oxide Effects Limit exposure No benefit from folinic acid Combine with potent agent

21 CNS Growth and Development 2 nd trimester to 2 nd postnatal month: major period of myelination 2 nd and 3 rd trimester: neuronal proliferation and migration region specific synaptogenesis remodeling 80% of adult brain volume by age 2 years

22 Potential Anesthesia CNS Effects: Exposure + GABA -NMDA Cognitive: IQ psychomotor memory, attention Morbidity: mental retardation affective disorders degenerative dis. Mortality: early death CNS Toxicity Mechanisms: (+) Apoptosis (-) Neurogenesis ∆ Cytoskeleton ∆ Dendritic spines (-)Synapse UNDEFINED? Courtesy: Lena Sun

23 Early Exposure to Anesthetics ANIMALS: Sprague-Dawley rat pups day 7 METHODS: Control: DMSO Study: 6 hour exposure to mock GA N 2 O in oxygen midazolam in DMSO isoflurane J Neurosci 2003; 23:876

24 Neuroapoptosis Courtesy Lena Sun

25 Behavioral Effects

26 CNS Effects Atlanta Birth Defects Case-Control Database Infants born with major CNS defects No anesthesia General Anesthesia Am J Public Health 1994; 84:1757

27 1 st Trimester & CNS Effects *

28 Anesthesia for Cesarean Delivery and Learning Disabilities Deliveries in Olmsted County, Cohort review: Vaginal Delivery Cesarean Delivery – GEA Cesarean Delivery – Regional Assessment of Learning Anesthesiology 2009; 111:302

29 Cumulative Learning Disabilities Copyright © 2011 Anesthesiolo gy. Published by Lippincott Williams & Wilkins.

30 Isoflurane Exposure In Utero Animals: Pregnant rats at day 14 Methods: Exposure to: isoflurane in 100% oxygen 100% oxygen Results: impaired spatial memory reduced anxiety Anesthesiology 2011; 114:521

31 Hyperoxia is also bad! J Neurosci 2008; 28:1236 J Neurosci Res 2006; 84:306 Cell Death Differ 2006; 13:1097 Neurobiol Dis 2004; 17:273

32 What Are the Limitations? Species: Rats vs Lambs vs Humans Study Design: Retrospective Dose and Magnitude of Exposure Specificity: All Drugs Equal All the Time?

33 The Studies We Need Large scale, national studies Agents and exposure Timing

34 An Academic Exercise? Surgery during pregnancy is undertaken only if absolutely necessary Mothers will require an anesthetic is regional better than general? Children requiring surgery need anesthesia

35 Prevention Lithium Hypothermia Are some agents better than others

36 Any inhalational agent better: desflurane-isoflurane-sevflurane? Animals: Neonatal mice Methods: Determine MAC in littermates Study: 0.6 MAC for 6 H Control: 6 h fast in RA Euthanize – caspase-3 neurons Results: No differences among the 3 agents Anesthesiology 2011; 114;578

37 What Are the Important Determinants of Fetal Outcome? Maternal Disease Site of Surgery Obstetric Pelvic Abdominal Peripheral

38 Reproductive Outcome After Anesthesia and Surgery During Pregnancy All women delivering in Sweden Linked Registries: Birth registry Congenital Anomalies Hospital Discharges AJOG 1989; 161:1178

39 Results Deliveries 880,000 Non-Ob Surgery 5,404 Incidence 0.75%

40 Outcomes * *

41 Anesthetic Technique

42 When Is the Best Time? TERATOGENICITY PREMATURE LABOR

43 Appendectomy During Pregnancy All women delivering in Sweden *appendectomy Linked Registries: Birth registry Congenital Anomalies Hospital Discharges Obstet Gynecol 1991; 77:835

44 Appendectomy During Pregnancy Prior to 24 weeks – no effect Of women at 24 to 36 weeks delivered: day of 16% day after 5% within 1 week 22%

45 Laparoscopy During Pregnancy Subjects: Women having abd/pelvic surgery Sweden – Method: Linked registries: Birth registry Congenital Anomalies Hospital Discharges Am J OB/GYN 1997; 177:673

46 Obstetric Outcome Relative Risk

47 Pregnant Patient Elective SurgeryEssential SurgeryEmergency Surgery Delay until postpartum1 st trimester2 nd /3 rd trimester If no minimal increased risk to mother, consider delaying until mid-gestation. If greater than minimal increased risk to mother, proceed with surgery. Proceed with optimal anesthetic for mother, modified by considerations for maternal physiologic changes and fetal well being. Consider consulting a perinatologist or an obstetrician. Intraoperative and postoperative fetal and uterine monitoring may be useful.

48 Nuts and Bolts (1) Timing as discussed Pre-anesthesia assessment: surgical disease co-morbidities gestational age risk of aspiration physiologic alterations fetal assessment

49 Nuts and Bolts (2) Prior to fetal viability: confirmation of FHR by Doppler At fetal viability: hospital that can manage obstetric issues obstetrician to assume care continuous fetal monitoring????

50 Nuts and Bolts (3) Second trimester on: avoid aorta-caval compression oxygenation and ventilation maintain blood pressure Choice of Anesthesia based on maternal condition avoid hyperoxia regional vs general??????

51 Nuts and Bolts (4) Post-operative care: vigilance and monitoring assess fetal status assess/prevent/treat preterm labor treat pain and discomfort aggressively


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