Non Obstetrical Surgery for the Pregnant Patient

Case report 33 year old G3P2 at 32 weeks gestation presenting for outpatient lap chole Npo after MN NKDA Meds:PNV No prior surgery SVDx2 uncomplicated deliveries PMH GERD with pregnancy

Physical Exam Ht 163 cm Wt 90kg MP 2 airway Gravid uterus Exam otherwise unremarkable FHT’s 136

Plan GA: RSI Fetal Heart Tones before and after surgery

Induction Pre med: Fentanyl 50 mcg RSI: Propofol 200mg Easy intubation Roc 5 mg Sux 140mg Easy intubation VSS Left uterine displacement

Intra-op 10:47 am incision 11:11 am surgeon asks for OB stat to OR for suspected uterine rupture 11:17 OB in room for report 11:20 OB scrubbed in/emergency C-section performed After delivery OB asks “Why wasn’t I informed that a pregnant pt was coming to the OR?”

Post-OP Healthy mom and baby OB broke scrub, saw pt’s chart stated: “This pt is seen in my office why wasn’t I informed she was having surgery?????”

Most Common Procedures Laparoscopic cholecystectomy Cystoscopy Appendectomy

Real Cases Over the years 24 week pregnant pt for breast bx followed by mastectomy and port 2 weeks later 32 week pregnant burn pt for debridement and skin graft to back (prone positoning) 18 week pregnant pt for total thyroidectomy for thyroid ca 17 week ex lap for ovarian mass (retained sponge from prior C-section at another institution

34 week pregnant pt for ORIF fifth finger fracture from fist fight

Other Procedures Burn surgery Thyroidectomy Mastectomy Ovarian mass Orthopedic injuries

ACOG Guidelines Pregnant patient should not be denied indicated surgery regardless of trimester Elective surgery should be postponed until after delivery If possible non urgent surgery should be performed in the second trimester when pre term contractions and spontaneous abortions are least likely

Obstetric Provider OB should be notified (must be) OB provider with C-section privileges should be immediately available Qualified individual for interpreting fhr patterns immediately available (Neonatology and L&D should be notified for viable fetus)

Guidelines for Fetal Monitoring Pre-viable fetus: FHR by Doppler pre and post op Viable fetus: FHR and contraction monitoring pre and post op to assess fetal well being and absence of contractions FHR should be evaluated by qualified individual ACOG guidelines published 4/17

Intra Operative Monitoring May be appropriate when all of the following apply 1. fetus is viable 2. physically possible 3. informed consent for emergency C-section 4. nature of surgery would allow for access for C-Section

Other issues May monitor pre viable fetus to facilitate positioning or oxygenation

C-section Tray immediately available

Left Uterine Displacement After 18-20 weeks provide left uterine displacement to prevent aortocaval compression Goal is to reduce maternal hypotension and preserve placental perfusion Tilt of at least 15 degrees

NPO Guidelines Same as for nonpregnant patients Clear liquids 2 hours Solids 6-8 hours depending on fat content Adjust for confounding factors: morbid obesity, difficult airway, diabetes RSI often performed

Anesthesia No specific anesthetic agents are contraindicated but historically midazolam and nitrous oxide have been avoided Regional anesthesia is preferable Consider aspiration risk Optimize placental perfusion by optimizing hemodynamic stability and oxygenation Expect decreased fetal heart rate variability with narcotics, sedation, and GA

Hemodynamic Stability Uteroplacental unit does not have autoregulation Placental perfusion directly related to maternal BP Goal: maintain maternal BP within 20% of basline Fluids Ephedrine Phenylephrine

Anesthesia Hyperoxia-not dangerous for fetus. PAO2 will not increase above 60mmhg Hypoxemia-bad Hypercarbia: acidosis Hypocarbia: Uterine artery vasoconstriction Shift of hemoglobin oxygen disassociation curve

Muscle Relaxant Reversal Neostigmine readily crosses placenta Glycopyrrolate does not Possible fetal bradycardia Consider Atropine 10-20 mcg/kg as atropine readily crosses placenta

Antibiotics Ancef Class B Clindamycin Class B Metronidazole Class B Unasyn Class B Vancomycin Class C Ciprofloxacin Class C Gentamycin Class D Class A safe Class B no fetal risk in animal studies Class C not enough research to know Class D human risk involved

VTE Prophylaxis Pregnancy: hypercoagulable state Surgery: venostasis/hypercoagulabilty Prophylaxis should be considered for all pregnant patients undergoing surgery

Maternal Cardiac Arrest Same drugs/same management as nonpregnant Left uterine displacement Chest compressions higher on sternum All drugs administered above diaphragm If no response at 4 minutes-deliver the baby

Summary Preferable notification prior to day of surgery Pre-op Post-Op OB, neonatology,L&D,anesthesia,OR Pre-op FHT/contraction monitoring Confirm all parties notified C-Section tray outside of room Post-Op appropriate monitoring for gestational age clear with OB before discharge