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Monanian G, Greenspan S, Khan Yusufzai N, Daoud B, Jin Z, Factor M. Anesthetic Management of the Pregnant Patient Undergoing Non-Obstetric Surgery. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:698. [PMID: 40282988 PMCID: PMC12028341 DOI: 10.3390/medicina61040698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2025] [Revised: 04/06/2025] [Accepted: 04/08/2025] [Indexed: 04/29/2025]
Abstract
Anesthetic management of the pregnant patient undergoing non-obstetric surgery requires careful consideration of both maternal and fetal well-being. Key factors include appropriate drug selection to minimize fetal exposure, maintenance of uteroplacental perfusion, and management of physiological changes associated with pregnancy, such as altered respiratory function and increased blood volume. Regional anesthesia is often preferred to reduce the risks of general anesthesia, although considerations such as positioning, airway management, and monitoring are crucial. Multidisciplinary collaboration is essential to optimize outcomes, ensuring that both maternal health and fetal safety are prioritized throughout the perioperative period.
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Affiliation(s)
- Genevieve Monanian
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (G.M.); (S.G.); (B.D.); (M.F.)
| | - Seth Greenspan
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (G.M.); (S.G.); (B.D.); (M.F.)
| | - Nadir Khan Yusufzai
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Bahaa Daoud
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (G.M.); (S.G.); (B.D.); (M.F.)
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (G.M.); (S.G.); (B.D.); (M.F.)
| | - Morgane Factor
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (G.M.); (S.G.); (B.D.); (M.F.)
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Pecorella G, Sparic R, Morciano A, Constantin SM, Babovic I, de Rosa F, Tinelli A. Mastering nonobstetric surgery in pregnancy: Insights, guidelines evaluation, and point-by-point discussion. Int J Gynaecol Obstet 2025; 168:472-483. [PMID: 39224999 DOI: 10.1002/ijgo.15877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
For surgeons and clinicians, nonobstetric surgery during pregnancy has certain difficulties and considerations. In order to aid in decision-making in these situations, this manuscript offers a thorough review of the guidelines currently in place from renowned obstetric and surgical societies, such as the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians & Gynecologists, and others. Using AGREE II-S methodology, a comprehensive analysis of guidelines reveals differences in recommendations for anesthetics, surgical procedures, imaging modalities, and thromboembolic prophylaxis. Furthermore, a thorough discussion of strategic surgical planning is provided, covering aspects such as patient positioning, trocar placement, pneumoperitoneum generation, and thromboembolic risk management. The publication highlights that in order to maximize the results for both the mother and the fetus after nonobstetric surgery performed during pregnancy, a multidisciplinary approach and evidence-based decision-making are essential.
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Affiliation(s)
- Giovanni Pecorella
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Radmila Sparic
- Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andrea Morciano
- Department of Obstetrics and Gynaecology, Pia Fondazione Cardinale G. Panico, Tricase, Italy
| | - Silviu Mihai Constantin
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Ivana Babovic
- Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Filippo de Rosa
- Department of Anesthesia and Intensive Care, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Lecce, Italy
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Cathcart AM, Nezhat FR, Emerson J, Pejovic T, Nezhat CH, Nezhat CR. Adnexal masses during pregnancy: diagnosis, treatment, and prognosis. Am J Obstet Gynecol 2022:S0002-9378(22)02179-2. [PMID: 36410423 DOI: 10.1016/j.ajog.2022.11.1291] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.
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Affiliation(s)
- Ann M Cathcart
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Farr R Nezhat
- Weill Cornell Medical College, Cornell University, New York, NY; New York University Long Island School of Medicine, Mineola, NY.
| | - Jenna Emerson
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR; Division of Gynecologic Oncology, Oregon Health & Science University, Portland, OR
| | - Tanja Pejovic
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR; Division of Gynecologic Oncology, Oregon Health & Science University, Portland, OR
| | - Ceana H Nezhat
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA
| | - Camran R Nezhat
- Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA; University of California San Francisco, San Francisco, CA; Stanford University Medical Center, Palo Alto, CA
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Merlin T, Cinti F, Charlesworth TM. Healthy nonobese bitches maintain acceptable spontaneous ventilation during laparoscopic ovariectomies. J Am Vet Med Assoc 2022; 260:1489-1495. [DOI: 10.2460/javma.22.03.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
OBJECTIVE
To determine whether end-tidal CO2 (Petco2), tidal volume (Vt), inspiratory minute volume (i), and respiratory rate (RR) remain within reference limits for spontaneously breathing dogs undergoing laparoscopic ovariectomy; characterize changes in these variables over time; and record the proportion of dogs requiring mechanical ventilation on the basis of predetermined criteria.
ANIMALS
22 client-owned dogs.
PROCEDURES
Between January and June 2019, dogs were anesthetized for abdominal insufflation (CO2; 10 mm Hg) and laparoscopic ovariectomy. Respiratory variables (Petco2, Vt, i, and RR) were recorded at 5 time points: preinsufflation (T2), immediately after insufflation (T3), immediately after first ovary extraction (T4), immediately after second ovary extraction (T5), and after abdominal deflation (T6). Results for variables were assessed to identify differences with reference limits and between time points.
RESULTS
At all time points (T2 to T6), Petco2 was within or above the reference limit, Vt was below or within reference limits, and i was either within or above reference limits. Significant temporal changes were detected in all recorded parameters. One dog had to be ventilated prior to abdominal insufflation due to inappropriately low Vt (< 6 mL/kg) and was excluded from further analysis. One of the 21 remaining dogs required rescue ventilation.
CLINICAL RELEVANCE
Following insufflation, there was a tendency toward inadequate ventilation over time characterized by increased Petco2. Twenty of 21 dogs maintained Petco2 within tolerance via a mild increase in RR and did not require assisted ventilation. Dogs undergoing short surgeries may not require assisted ventilation. Clinicians are advised to monitor for hypercapnia and be prepared to assist ventilation if required.
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Affiliation(s)
| | - Filippo Cinti
- Clinica Veterinaria Apuana, Marina Di Carrara (MS), Italy
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Bleeser T, Vally JC, Van de Velde M, Rex S, Devroe S. General anaesthesia for nonobstetric surgery during pregnancy: A narrative review. EUROPEAN JOURNAL OF ANAESTHESIOLOGY AND INTENSIVE CARE 2022; 1:e003. [PMID: 39916685 PMCID: PMC11783665 DOI: 10.1097/ea9.0000000000000003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2025]
Abstract
Nonobstetric surgery may be required in up to 1% of pregnancies. Most common procedures are urgent abdominal surgeries requiring general anaesthesia. Maintaining normal maternal physiology during anaesthesia is vital. Left lateral tilt position prevents aortocaval compression and preserves normal venous return. Preparation for a difficult airway is required in all obstetric patients due to the known anatomical and physiological changes. Aspiration prophylaxis and a rapid sequence induction are traditionally recommended to avoid the (probably overestimated) risk of aspiration. Although the minimum alveolar concentration (MAC) of volatile anaesthetic agents is reduced by 30 to 40%, awareness occurs more frequently in the obstetric population. Maternal outcomes from surgery are comparable with those of nonpregnant women, but increased incidences of foetal loss, preterm delivery, low birth weight and caesarean section have been reported. Although animal studies have observed impaired foetal brain development after antenatal exposure to anaesthesia, the translational value of these studies remain controversial. Clinical evidence is nearly absent. Withholding urgent/essential procedures is certainly more threatening than proceeding with the surgery. To increase the safety of mother and foetus, nonurgent or nonessential procedures should be postponed until after delivery, and if procedures cannot wait, locoregional anaesthesia should be used if possible. Where general anaesthesia cannot be avoided, the duration of exposure should be kept to a minimum. This narrative review summarises the literature of the past 20 years concerning the anaesthetic management and outcomes of nonobstetric surgery under general anaesthesia during pregnancy.
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Affiliation(s)
- Tom Bleeser
- From the Department of Anaesthesiology, UZ Leuven (TB, JCV, MVDV, SR, SD) and Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium (TB, MCV, SR, SD)
| | - Janine C Vally
- From the Department of Anaesthesiology, UZ Leuven (TB, JCV, MVDV, SR, SD) and Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium (TB, MCV, SR, SD)
| | - Marc Van de Velde
- From the Department of Anaesthesiology, UZ Leuven (TB, JCV, MVDV, SR, SD) and Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium (TB, MCV, SR, SD)
| | - Steffen Rex
- From the Department of Anaesthesiology, UZ Leuven (TB, JCV, MVDV, SR, SD) and Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium (TB, MCV, SR, SD)
| | - Sarah Devroe
- From the Department of Anaesthesiology, UZ Leuven (TB, JCV, MVDV, SR, SD) and Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium (TB, MCV, SR, SD)
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Bradford V, Gaiser R. Preservation of Fetal Viability During Noncardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Surgical trends in the management of acute cholecystitis during pregnancy. Surg Endosc 2020; 35:5752-5759. [PMID: 33025256 DOI: 10.1007/s00464-020-08054-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Since 2007, clinical practice guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend early surgical management with laparoscopic cholecystectomy for pregnant women with symptomatic gallbladder disease regardless of trimester. However, little is known about practice patterns in the management of pregnant patients with acute cholecystitis. This study aims to examine nationwide trends in the surgical management of acute cholecystitis, as well as their impact on clinical outcomes during pregnancy. METHODS The National Inpatient Sample was queried for all pregnant women diagnosed with acute cholecystitis between January 2003 and September 2015. After applying appropriate weights, multivariate regression analysis adjusted for patient- and hospital-level characteristics and quantified the impact of discharge year (2003-2007 versus 2008-2015) on cholecystectomy rates and timing of surgery. Multivariate regression analysis was also used to examine the impact of same admission cholecystectomy and its timing on maternal and fetal outcomes. RESULTS A total of 23,939 pregnant women with acute cholecystitis satisfied our inclusion criteria. The median age was 26 years (interquartile range: 22-30). During the study period, 36.3% were managed non-operatively while 59.6% and 4.1% underwent laparoscopic and open cholecystectomy, respectively. After adjusting for covariates, laparoscopic cholecystectomy was more commonly performed after 2007 (odds ratio [OR] 1.333, p < 0.001). Furthermore, time from admission to surgery was significantly shorter in the latter study period (regression coefficient -0.013, p < 0.001). Compared to non-operative management, laparoscopic cholecystectomy for acute cholecystitis was significantly associated with lower rates of preterm delivery, labor, or abortion (OR 0.410, p < 0.001). Each day that laparoscopic cholecystectomy was delayed significantly associated with an increased risk of fetal complications (OR 1.173, p < 0.001). CONCLUSIONS This nationwide study exhibits significant trends favoring surgical management of acute cholecystitis during pregnancy. Although further studies are still warranted, early laparoscopic cholecystectomy should be considered in pregnant patients with acute cholecystitis.
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2017; 31:3767-3782. [PMID: 28643072 DOI: 10.1007/s00464-017-5637-3] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Jonathan P Pearl
- University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA.
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10
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Huang J. Nonobstetric Surgery During Pregnancy. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shaw CJ, Civale J, Botting KJ, Niu Y, Ter Haar G, Rivens I, Giussani DA, Lees CC. Noninvasive high-intensity focused ultrasound treatment of twin-twin transfusion syndrome: A preliminary in vivo study. Sci Transl Med 2016; 8:347ra95. [PMID: 27412787 DOI: 10.1126/scitranslmed.aaf2135] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/13/2016] [Indexed: 02/11/2024]
Abstract
We investigated the efficacy, maternofetal responses, and safety of using high-intensity focused ultrasound (HIFU) for noninvasive occlusion of placental vasculature compared to sham treatment in anesthetized pregnant sheep. This technique for noninvasive occlusion of placental vasculature may be translatable to the treatment of conditions arising from abnormal placental vasculature, such as twin-twin transfusion syndrome (TTTS). Eleven pregnant sheep were instrumented with maternal and fetal arterial catheters and time-transit flow probes to monitor cardiovascular, acid-base, and metabolic status, and then exposed to HIFU (n = 5) or sham (n = 6) ablation of placental vasculature through the exposed uterine surface. Placental vascular flow was occluded in 28 of 30 targets, and histological examination confirmed occlusion in 24 of 30 targets. In both HIFU and sham exposures, uterine contact reduced maternal uterine artery flow, but delivery of oxygen and glucose to the fetal brain remained normal. HIFU can consistently occlude in vivo placental vessels and ablate blood flow in a pregnant sheep model. Cardiovascular and metabolic fetal responses suggest that the technique is safe in the short term and potentially translatable to human pregnancy.
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Affiliation(s)
- Caroline J Shaw
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK. Institute of Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK
| | - John Civale
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Kimberley J Botting
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Youguo Niu
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Gail Ter Haar
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Ian Rivens
- Joint Department of Physics, Institute of Cancer Research, Sutton, London SM2 5NG, UK
| | - Dino A Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - Christoph C Lees
- Institute of Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK. Department of Obstetrics and Gynaecology, University Hospitals Leuven, 3000 Leuven, Belgium.
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George PE, Shwaartz C, Divino CM. Laparoscopic surgery in pregnancy. World J Obstet Gynecol 2016; 5:175-181. [DOI: 10.5317/wjog.v5.i2.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/18/2016] [Indexed: 02/05/2023] Open
Abstract
Each year, roughly 2% of pregnant women will undergo non-obstetrical abdominal surgery. Appendicitis, symptomatic cholelithiasis and adnexal masses are some of the common diagnoses encountered. Pregnancy poses challenges in the diagnosis and surgical management of these conditions for several reasons. Since the 1990’s, laparoscopic surgery has gained popularity and in the past few years has become the standard of care for pregnant women with surgical pathologies. The advantages of laparoscopic surgery include shorter hospital stay, lower rates of wound infection, and decreased time to bowel function. This brief review discusses key points in laparoscopic surgery during pregnancy and highlights studies comparing laparoscopic and open approaches in common surgical conditions during pregnancy.
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Abstract
Non-obstetric surgery during pregnancy posts additional concerns to anaesthesiologists. The chief goals are to preserve maternal safety, maintain the pregnant state and achieve the best possible foetal outcome. The choice of anaesthetic technique and the selection of appropriate anaesthetic drugs should be guided by indication for surgery, nature, and site of the surgical procedure. Anaesthesiologist must consider the effects of the disease process itself and inhibit uterine contractions and avoid preterm labour and delivery. Foetal safety requires avoidance of potentially dangerous drugs and assurance of continuation of adequate uteroplacental perfusion. Until date, no anaesthetic drug has been shown to be clearly dangerous to the human foetus. The decision on proceeding with surgery should be made by multidisciplinary team involving anaesthesiologists, obstetricians, surgeons and perinatologists. This review describes the general anaesthetic principles, concerns regarding anaesthetic drugs and outlines some specific conditions of non-obstetric surgeries.
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Affiliation(s)
- Madhusudan Upadya
- Department of Anaesthesia, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
| | - P J Saneesh
- Department of Anaesthesia, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
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14
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Laparoscopic cholecystectomy during pregnancy: A systematic review of 590 patients. Int J Surg 2016; 27:165-175. [DOI: 10.1016/j.ijsu.2016.01.070] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023]
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15
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López-Collada Estrada M, Olvera Martínez R. [Anaesthetic management of patients in the third trimester of pregnancy undergoing urgent laparoscopic surgery. Experience in a general hospital]. CIR CIR 2016; 84:429-33. [PMID: 26738654 DOI: 10.1016/j.circir.2015.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Laparoscopic surgery is well accepted as a safe technique when performed on a third trimester pregnant woman. OBJECTIVE The aim is to describe the anaesthetic management of a group of patients undergoing this type of surgery. MATERIAL AND METHODS An analysis was made of records of 6 patients in their third trimester of pregnancy and who underwent urgent laparoscopic surgery from 2011 to 2013. CLINICAL CASES The study included 6 patients, with a diagnosis of acute cholecystitis in 4 of them. The other 2 patients had acute appendicitis, both of who presented threatened preterm labour. CONCLUSION The most frequent indications for laparoscopic surgery during the last trimester of birth were found to be acute cholecystitis and acute appendicitis. Acute appendicitis is related to an elevated risk of presenting threatened preterm labour.
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Affiliation(s)
| | - Rosalba Olvera Martínez
- División de Anestesiología, Hospital General Dr. Manuel Gea González, Ciudad de México, México
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16
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Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc 2015; 30:593-602. [PMID: 26091987 DOI: 10.1007/s00464-015-4244-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/18/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND When pregnant patients require surgery, whether to perform an operation open or laparoscopic is often debated. We evaluated the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends in operative approach over time. METHODS Pregnant patients undergoing appendectomy or cholecystectomy were identified using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed demographics, operative characteristics, and outcomes. Univariate comparison and multivariate regression analysis (MVA) were performed adjusting for confounding factors: age, body mass index (BMI), diabetes, and smoking, and an additional MVA was performed for perforated cases. RESULTS A total of 1999 pregnant patients between 2005 and 2012 were evaluated. Of 1335 appendectomies, 894 were performed laparoscopically (LA) and 441 open (OA). For 664 cholecystectomies, 606 were laparoscopic (LC) and 58 open (OC). There were no deaths. For LA versus OA, patient characteristics were not different {age: 27.7 vs. 28.2 years, p = 0.19; diabetes: 1.8 vs. 0.9%, p = 0.24; smoking: 19 vs. 16.1%, p = 0.2} except for BMI (27.9 vs. 28.4 kg/m(2); p = 0.03). LA had shorter operative times (ORT), length of stay (LOS), and fewer postoperative complications compared to OA. In MVA, difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.01), and wound complications (<0.01). MVA was performed for perforated cases alone: LA had equal ORT (p = 0.19) yet shorter LOS (p = <0.001). The majority of LA were performed in the last 4 years versus the first 4 years (61 vs. 39%, p < 0.001). For LC versus OC, patient characteristics were not different: age (28.3 vs. 28.7 years; p = 0.33), BMI (31.4 vs. 33.2 kg/m(2), p = 0.25), diabetes (2.8 vs. 3.5%, p = 0.68), and smoking (21.1 vs. 25.9%, p = 0.4). LC had a shorter ORT, LOS, and fewer postoperative complications than OC. In MVA, the difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.0001), and minor complications (<0.01). In MVA for cholecystitis with perforation, no difference was seen for LOS, ORT, or postoperative complications (p > 0.05). The percentage of LC cases appeared to increase over time (89 vs. 93%, p = 0.06). CONCLUSION While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter ORT, LOS, and reduced complications and were performed more frequently over time. Even in perforated cases, laparoscopy appears safe in pregnant patients.
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Juhasz-Böss I, Solomayer E, Strik M, Raspé C. Abdominal surgery in pregnancy--an interdisciplinary challenge. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:465-72. [PMID: 25138726 DOI: 10.3238/arztebl.2014.0465] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 09/29/2013] [Accepted: 04/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach. METHOD This review is based on pertinent articles retrieved by a selective search in the PubMed database. RESULTS The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth. CONCLUSION Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.
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Affiliation(s)
- Ingolf Juhasz-Böss
- Department of Gynecology and Obstetrics, Saarland University Medical Center, Homburg/Saar
| | - Erich Solomayer
- Department of Gynecology and Obstetrics, Saarland University Medical Center, Homburg/Saar
| | - Martin Strik
- Department of Surgery and Surgical Oncology, HELIOS-Klinikum Berlin-Buch
| | - Christoph Raspé
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale)
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Ozyuvaci E, Demircioglu O, Toprak N, Topacoglu H, Sitilci T, Akyol O. Comparison of transcutaneous, arterial and end-tidal measurements of carbon dioxide during laparoscopic cholecystectomy in patients with chronic obstructive pulmonary disease. J Int Med Res 2013. [PMID: 23206482 DOI: 10.1177/030006051204000540] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Transcutaneous, arterial and end-tidal measurements of carbon dioxide were compared in patients (American Society of Anesthesiology physical status classes II and III) with chronic obstructive pulmonary disease (COPD) who underwent laparoscopic cholecystectomy with carbon dioxide insufflation. METHODS General anaesthesia was performed in all patients. The Sentec(®) system was used for transcutaneous monitoring of the partial pressure of carbon dioxide (TcPCO(2)). TcPCO(2) and arterial partial pressure of carbon dioxide (PaCO(2)) were recorded preoperatively, after induction of anaesthesia, during insufflation and postoperatively; end-tidal carbon dioxide (ETCO(2)) was recorded after induction and during insufflation. RESULTS PaCO(2) increased during insufflation and reached a maximum at extubation. It declined within 20 min postoperatively but did not return to preoperative levels during this time. TcPCO(2) levels followed a similar pattern. ETCO(2) was significantly lower than PaCO(2) after induction and during insufflation. CONCLUSION TcPCO(2) was a valid and practical measurement compared with ETCO(2). In patients with COPD undergoing laparoscopic cholecystectomy, TcPCO(2) and ETCO(2) could be used instead of arterial blood gas sampling.
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Affiliation(s)
- E Ozyuvaci
- Department of Anaesthesiology and Intensive Care Unit, Istanbul Educational and Research Hospital, Istanbul, Turkey.
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Biscette S, Yoost J, Hertweck P, Reinstine J. Laparoscopy in pregnancy and the pediatric patient. Obstet Gynecol Clin North Am 2012; 38:757-76. [PMID: 22134021 DOI: 10.1016/j.ogc.2011.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Minimally invasive surgery is now standard of care for many procedures in pediatric gynecology. Laparoscopy has been well documented to produce faster recovery,decreased postoperative pain, and because of smaller incisions, a better cosmetic result. These are important when considering an active pediatric patient. Although a laparoscopic approach to endometriosis, adnexal masses, and ovarian torsion are well supported in the literature in the pediatric patient, more data are needed with regard to SILS in younger patients. Laparoscopy seems to be a better approach to oopheropexy in children undergoing radiation, and in resection of certain mullerian anomalies; however, the numbers are low.Similarly in pregnant patients, laparoscopy provides for shorter recovery times,decrease analgesic use and shorter hospital stays. Concerns about poor fetal outcomes in surgery during pregnancy for non gynecologic problems have been brought to light; however, the evidence indicates that these outcomes can be attributed to the nature of the underlying disease and not the surgical approach. With regard to pneumoperitoneum the effect of CO2 insufflation on fetal physiology and long-term outcomes remains unclear, and will continue to be an issue of controversy until larger studies are published.With both the pediatric and pregnant populations, laparoscopic complications can be diminished when performed by skilled surgeons with strict adherence to good technical principles. The advantages of laparoscopy are great, and this approach should be considered in pediatric and pregnant patients.
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Affiliation(s)
- Shan Biscette
- Department of Obstetrics, Gynecology and Women's Health, Kosair Children's Hospital, Louisville, KY 40207, USA
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Donkervoort SC, Boerma D. Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure. JSLS 2011; 15:379-83. [PMID: 21985728 PMCID: PMC3183570 DOI: 10.4293/108680811x13125733356837] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
This review suggests that diagnostic laparoscopy during the third trimester of pregnancy is a logical strategy to minimize maternal and fetal risk when acute appendicitis is suspected. The presentation of acute appendicitis during pregnancy may cause diagnostic and therapeutic difficulty. Delay in diagnosis may lead to increased maternal and fetal risk. Therefore, an aggressive surgical approach is mandatory, even though this may result in an increased number of appendectomies for normal appendices. Diagnostic laparoscopy, followed by laparoscopic appendectomy in case of inflammation, seems a logical strategy. We present the case of a 36-week pregnant woman who presented with suspicion of acute appendicitis. The pro and cons of a laparoscopic approach in the third trimester of pregnancy are discussed as is its safety by reviewing the literature.
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Affiliation(s)
- S C Donkervoort
- Onze Lieve Vrouwe Gasthuis, Department of Surgery, Amsterdam, The Netherlands
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21
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Pearl J, Price R, Richardson W, Fanelli R. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011; 25:3479-3492. [PMID: 21938570 DOI: 10.1007/s00464-011-1927-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 08/24/2011] [Indexed: 12/11/2022]
Affiliation(s)
- Jonathan Pearl
- Department of General Surgery, Uniformed Services University of the Health Sciences, National Naval Medical Center, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Chohan L, Ramirez MM, Wray CJ, Kilpatrick CC. Laparoscopic management of fallopian tube torsion at 35 weeks of gestation: case report. J Minim Invasive Gynecol 2011; 18:390-2. [PMID: 21545965 DOI: 10.1016/j.jmig.2011.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 01/25/2023]
Abstract
Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.
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Affiliation(s)
- Lubna Chohan
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, Texas 77026, USA
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23
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García NIS, Morant JCG, González EH. Cirugía no obstétrica durante el embarazo. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2011. [DOI: 10.5554/rca.v39i3.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Maternal and fetal near-term sheep cytokine responses to carbon dioxide pneumoperitoneum. Surg Laparosc Endosc Percutan Tech 2009; 19:138-41. [PMID: 19390281 DOI: 10.1097/sle.0b013e31819756bf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
It is known that carbon dioxide (CO2) pneumoperitoneum induces fetal acidosis in pregnant ewes. Our aim was to determine changes of the levels of maternal and fetal cytokines interleukin-6, interleukin-8, and tumor necrosis factor alpha after CO2 pneumoperitoneum in pregnant ewes. Eight ewes with singleton pregnancies of 120 to 140 days gestation were anesthetized and intubated. Insufflation produced modest but significant maternal arterial hypercapnia (an increase of 10.7 mm Hg; P<0.001) and acidosis (a decrease in mean pH of 0.1.04; P=0.0005). Fetal pCO2 was increased by 15.3 mm Hg on average and pH was decreased by 0.11 U on average immediately after desufflation (both P<0.001). No significant difference was observed in the concentration of cytokine in the maternal or fetal blood samples. These results suggest that respiratory acidosis does not lead to the elevation of cytokines in pregnant ewes and fetuses, which may contribute to premature labor.
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25
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Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W, Fanelli R. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 2008; 22:1917-1927. [PMID: 18553201 DOI: 10.1007/s00464-008-9989-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 05/05/2008] [Indexed: 12/16/2022]
Abstract
Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.
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Affiliation(s)
- Heidi Jackson
- Department of Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
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26
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Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2008; 22:849-61. [DOI: 10.1007/s00464-008-9758-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Accepted: 01/08/2008] [Indexed: 01/06/2023]
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Arterial and end-tidal carbon dioxide pressure differences during laparoscopic colorectal surgery. Eur J Anaesthesiol 2008; 25:74-5. [DOI: 10.1017/s0265021507001287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Amoli HA, Tavakoli H, Notash AY, Far MS, Khashayar P. [Not Available]. J Minim Access Surg 2008; 4:9-14. [PMID: 19547671 PMCID: PMC2699057 DOI: 10.4103/0972-9941.40991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 01/08/2008] [Indexed: 11/04/2022] Open
Abstract
This study was conducted to evaluate the safety of laparoscopic cholecystectomy (LC) during pregnancy. Patients who underwent LC were selected from several hospital databases, only six were performed during pregnancy. In this series, one of the two patients who had LC in the first trimester underwent elective termination of pregnancy while the other one gave birth to a term child normally. Half of the four who had the second trimester LC had normal deliveries at term whereas for the other two cesarean section was performed. None of our patients underwent LC in the third trimester. The findings of the present study suggest LC to be a safe procedure performed during the first and second trimester of pregnancy.
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Affiliation(s)
- Hadi Ahmadi Amoli
- Department of Surgery, Tehran University of Medical Science, Tehran, Iran
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29
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Kilpatrick CC, Monga M. Approach to the Acute Abdomen in Pregnancy. Obstet Gynecol Clin North Am 2007; 34:389-402, x. [DOI: 10.1016/j.ogc.2007.06.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Felbinger TW, Posner M, Eltzschig HK, Kodali BS. Laparoscopic splenectomy in a pregnant patient with immune thrombocytopenic purpura. Int J Obstet Anesth 2007; 16:281-3. [PMID: 17399979 DOI: 10.1016/j.ijoa.2006.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 10/01/2006] [Indexed: 11/19/2022]
Abstract
We describe the perioperative management of a pregnant woman at 19 weeks' gestation with idiopathic thrombocytopenic purpura requiring laparoscopic splenectomy. The preoperative platelet count ranged between 1 and 5 x 10(9)/L and did not respond to conventional medical therapy. To reduce the risk of intracerebral hemorrhage, platelets were transfused before induction of anesthesia to maintain platelet count closer to 20 x 10(9)/L. The blood pressure was monitored continuously via an arterial line and remifentanil was infused to prevent a hypertensive response to induction/intubation, carbon dioxide insufflation, and surgery. After the splenic artery was clamped, additional platelet units were transfused to assure surgical hemostasis.
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Affiliation(s)
- T W Felbinger
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Ní Mhuireachtaigh R, O'Gorman DA. Anesthesia in pregnant patients for nonobstetric surgery. J Clin Anesth 2006; 18:60-6. [PMID: 16517336 DOI: 10.1016/j.jclinane.2004.11.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2002] [Accepted: 11/10/2004] [Indexed: 11/22/2022]
Abstract
Anesthesiologists in every subspecialty encounter, with varying regularity, patients presenting for surgery during the course of pregnancy. With the increasing sophistication of surgical and anesthetic techniques, increasingly complex surgeries are being undertaken. In this review, we address the fundamental physiologic principles central to the care of pregnant patients and fetuses in this difficult clinical situation.
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Abstract
PURPOSE OF REVIEW In the past decade, laparoscopic procedures have become increasingly popular owing to decreased morbidity and convalescence compared with open procedures. The purpose of this review is to evaluate recent literature on laparoscopic surgery in pregnancy and make recommendations for anesthesia based on understanding of physiology of carbon dioxide pneumoperitoneum. RECENT FINDINGS Increasing numbers of successful cases of laparoscopic surgery are being reported. For reasons unknown, the results obtained in sheep studies do not match the observations in humans. Maternal respiratory acidosis, a common finding in sheep studies during CO2 pneumoperitoneum has not been observed in pregnant women undergoing laparoscopic surgery. A recent finding of persisting fetal sheep hypoxia beyond the duration of CO2 pneumoperitoneum calls for further investigation to determine if this finding is limited to sheep akin to sheep maternal respiratory acidosis. SUMMARY Present evidence suggests laparoscopic surgery in pregnancy is a safe option. Left uterine displacement, maintaining end-tidal carbon dioxide between 32-34 mmHg and maternal blood pressures within 20% of baseline, and limiting abdominal insufflation pressure of carbon dioxide to 12-15 mmHg are essential hallmarks of anesthesia procedure. Although no apparent long time consequences have been reported, further studies are necessary to confirm the validity of sheep fetal hypoxia studies.
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Affiliation(s)
- Nollag O'Rourke
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
Advances in laparoscopic surgery have led to the development of methods to perform traditionally major abdominal surgery and reduce morbidity using minimally invasive surgery techniques. Because a growing number of reports in the literature have suggested its safe use, laparoscopy is being performed in pregnancy with increasing frequency in many centers. Any surgeon treating pregnant patients must have a thorough understanding of the physiology of the pregnant patient and risks and benefits of the surgical procedure. This article discusses the use of laparoscopy in pregnancy focusing on the physiologic changes induced by pregnancy relevant to laparoscopy. Strategies to reduce the risk of complications while performing laparoscopy on a pregnant patient are discussed.
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Affiliation(s)
- Kevin Stepp
- Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, A81, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Chua SMH, Sia ATH. Automated intermittent epidural boluses improve analgesia induced by intrathecal fentanyl during labour. Can J Anaesth 2004; 51:581-5. [PMID: 15197122 DOI: 10.1007/bf03018402] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE We compared the efficacy of epidural continual intermittent boluses (CIB) with a continuous epidural infusion (CEI) in prolonging labour analgesia induced by the combined spinal epidural (CSE) technique. METHODS CSE was instituted in 42 nulliparous parturients at the L3 to 4 level with intrathecal (IT) fentanyl 25 micro g followed by an epidural test dose of 3 mL of 1.5% lidocaine. These parturients were then randomly assigned to receive either epidural CIB (n = 21) or CEI (n = 21) with 0.1% ropivacaine and fentanyl 2 micro g x mL(-1). For the CIB, 5 mL boluses were given hourly, with the first bolus 30 min postinduction. CEI at the rate of 5 mL.hr(-1) was initiated in the minute after CSE. The duration of analgesia, pain score, degree of sensorimotor block were compared. RESULTS From Kaplan Meier survival analysis, the duration of analgesia was significantly longer in CIB (mean survival time 239 +/- SD 24 min vs 181 +/- 17, P < 0.05 using log rank test). During the first three hours postblock, the median sensory block to cold was higher in CIB (P < 0.05, Mann U Whitney test) but no difference in blood pressure was detected [P > 0.05, repeated measure analysis of variance (RMANOVA)]. The serial pain scores were lower in the CIB (P < 0.05, RMANOVA). CONCLUSION CIB prolonged the duration and improved the quality of analgesia. CIB could have resulted in an improved spread of analgesics in the epidural space or encouraged a direct passage of infusate into the IT space. This could have also rendered a higher sensory block to cold in the CIB group. CIB is a good alternative to CEI for the maintenance of epidural analgesia after CSE.
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Lawes EG. Hidden hazards and dangers associated with the use of HME/filters in breathing circuits. Their effect on toxic metabolite production, pulse oximetry and airway resistance. Br J Anaesth 2003; 91:249-64. [PMID: 12878625 DOI: 10.1093/bja/aeg154] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E G Lawes
- Shackleton Department of Anaesthesia, Southampton University Teaching Hospitals, Tremona Road, SO16 6YD, UK.
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Abstract
Minimally invasive surgery is being performed more frequently in pregnant patients. Numerous published reports have documented the safety and advantages of laparoscopic cholecystectomy and laparoscopic appendectomy during pregnancy. Pregnancy is associated with a variety of changes in the respiratory and cardiovascular systems, which make the parturient undergoing laparoscopic surgery particularly susceptible to hypoxia, hypercarbia and hypotension. This chapter provides a review of those physiological changes of pregnancy of particular concern for anaesthesiologists, and of the physiological responses to intra-abdominal carbon dioxide insufflation, not only in healthy patients, but also in the altered physiological state associated with pregnancy. We also describe our approach to anaesthetic management for minimally invasive surgery during pregnancy. With appropriate precautions, including vigilant monitoring and anticipation and treatment of the potential adverse effects of carbon dioxide pneumoperitoneum, anaesthesiologists may provide safe care for these patients, and pregnant women can benefit from the advantages of minimally invasive surgery.
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Affiliation(s)
- Richard A Steinbrook
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
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Abstract
Developments in both instruments and techniques have led to an increasing popularity of endoscopic surgery during the last two decades. Even though there are numerous advantages to using endoscopic surgery, life threatening surgical and anesthetic complications still exist. Precautions must be taken to cope with the potential complications. Anesthetic technique must provide optimal surgical conditions and lead to early recovery of the patient. Monitorization must allow safety of the patient during these potentially hazardous procedures. Both the anesthesiologist and the surgeon must be thoroughly aware of the potential complications of the procedure. This review discusses the physiological alterations occurring during operative endoscopy, the principles of anesthetic management and complications related both to surgery and to anesthesia techniques.
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Affiliation(s)
- F Coşkun
- Department of Anesthesiology and Reanimation, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Literature watch. J Endourol 2001; 15:325-30. [PMID: 11339402 DOI: 10.1089/089277901750161971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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