Appendicectomy in pregnancy Dr. S. Parthasarathy MD., DA., DNB, Dip. Diab. DCA, Dip. Software based statistics- PhD ( physiology), IDRA

?

Appendicectomy – common surgical emergency 1 in 350 to 1 in 10000 Third trimester naturally protects against appendicectomy

In a study – incidence ?? Laparoscopy was the most common first-trimester procedure (34% of 2252 operations), whereas appendectomy was the most frequent procedure during the remainder of pregnancy. cervical incompetence, complications of ovarian cysts, trauma, gallbladder disease, bowel obstruction, and removal of breast tumors or other malignancies. Occasionally necessary to cardiac or neurosurgical conditions. Commonest for me

Can we have data Some women get operated for other surgeries without knowing pregnancy Reproductive age – can we do routine preop gravindex ? controversial Many centres practice as a routine

Appendix pushed up – missed loin pain -- perforations more common

RIF pain - ? Uterine Shift to left lateral position – Uterine pain will shift but appendix pain will remain Alders sign No walling off by omentum and increased steroid levels – prone for perforation

Clinical features of appendicitis Abdominal tenderness Rebound pain Abdominal guarding Rectal tenderness Mildly elevated temperature, 37°C to 38°C (98.6°F to 100.4°F) Mildly elevated pulse rate An increase in white blood cell (WBC), although this is not useful because of the already existing relative leukocytosis in pregnancy

Lap or open – how to decide ? I and II trimester – clear – diagnosis – lap – ok III trimester – clear – diagnosis - open – OK Unclear – I and II --- lap and decide III – lap , if appendix , open and do

Think of the disease causing problems to fetus Essence of management Maternal safety No uterine stimulation No preterm labour Fetal safety Uteroplacental perfusion No teratogenic drugs Think of the disease causing problems to fetus

Uterine blood flow Fetal safety Drugs ? Or others maternal hypotension, stress, (which releases maternal catecholamines), pain, anxiety, hypoxia, hypercarbia (fetal acidosis), hyperventilation,(decreased UBF), positive pressure ventilation, and pressor agents. Avoid maternal hypoxemia Fetal safety Drugs ? Or others

Critical points in laparoscopy (1) deferring surgery until the second trimester; (2) obtaining preoperative obstetric consultation; (3) using intermittent pneumatic compression devices to prevent thrombosis resulting from lower extremity stasis; (4) monitoring fetal and uterine status, as well as maternal end-tidal CO2 and arterial blood gas measurements; (5) using an open technique to enter the abdomen; (6) avoiding aortocaval compression; (7) maintaining low pneumoperitoneum pressures (preferably 8 to 12 mm Hg but not to exceed 15 mm Hg);

ALARA principle (as low as reasonably achievable) – radiologist Can take Xray if needed for the mother – mother s life is crucial

Premedication Ranitidine – ok 30 ml of non particulate antacid is also OK Otherwise reassurance

Thrombo ?? The 2012 American College of Chest Physicians clinical practice guideline on prevention and treatment of thrombosis recommends mechanical or pharmacologic thromboprophylaxis for all pregnant patients undergoing surgery. Are they on heparin ??

Factors which influence anesthesia

Options Regional General

Tips !! Delay elective surgery until after delivery. Try to avoid surgery during the first trimester. Use regional anesthesia when feasible. Attach greater importance to anesthetic management than to agents used. Change anesthetic management to conform to changes in maternal physiology

General Difficult airway and Acid aspiration Decreased FRC, increased oxygen consumption, and diminished buffering capacity result in the rapid development of hypoxemia and acidosis during periods of hypoventilation or apnea. induction of inhalation – rapid Difficult airway and Acid aspiration

All these things are there Decreased minimal alveolar concentration (MAC) Increased sensitivity to local anesthesia Decreased volume of epidural anesthetic required, because of engorgement of epidural veins and consequent decrease in size of epidural space Skin and Mucous Membranes More friable mucous membranes and engorged mucosal capillaries (Therefore, avoid insertion of nasal airways, nasotracheal and nasogastric tubes.)

Metabolic Increase in oxygen consumption by 20% Hypercoagulable but thrombocytopenic

All these things are there Cardiac output and blood volume increase with decreased peripheral resistance Decreased gastrointestinal motility and increased gastric emptying time Decreased volume of gastrointestinal secretions Increased gastric acidity Decreased lower esophageal tone

Regional Epidural Single shot LOR – easier ? Position easier ? Ephedrine phenyleph Epidural Single shot LOR – easier ? Position easier ? My view is better L2 L3 as its straight back and easier in pregnant patients 40 % less dose , may be 12 – 13 ml may be enough to get a level of T6 to T5. Lignocaine Ropivacaine Bupivacaine- ok Cocaine – no

Narcotics Fentanyl Morphine Pethidine Sufentanyl

Intravenous drugs Propofol - B Ketamine – low doses – otherwise possible uterine hypertonicity Thiopentone - C Clonidine and dexmed – NO

Calmpose – not so safe !! Benzodiazepine use in pregnancy has been associated with cleft palate and cardiac anomalies. Not very safe But anxiety and decreased uterine blood flow should be kept in mind Recent – single dose midazolam for anesthesia purpose – no harm

Agents ?! Halothane—C Enflurane—B Isoflurane—B Desflurane—B Sevoflurane—B Nitrous oxide (no classification) B is OK C is ? OK

Nitrous oxide nitrous oxide inhibits methionine synthetase potentially affecting DNA synthesis.

Nitrous oxide Nitrous oxide also increases adrenergic tone and decreases uterine blood flow. can be prevented by the addition of a volatile agent. Nitrous oxide can cause teratogenic effects in animals during prolonged exposure at critical times. not been demonstrated in humans

No anesthetics in the list of teratogens But No anesthetics in the list of teratogens

General anesthesia RSI Air oxygen – but think of higher agents and UBF NMBs - ok Extubate awake Neostigmine glyco better - both don’t cross

Fetal monitoring Foetal heart rate (FHR) monitoring is practical from 18 to 22 weeks, and from 25 weeks, heart rate variability (HRV) can be readily observed. Anaesthetic agents reduce both baseline FHR and HRV, so readings must be interpreted in the context of administered drugs.

Laparoscopy capnography is adequate to guide ventilation during laparoscopic surgery. End-tidal CO2 should be maintained approximately at 32 mm Hg

Analgesics may mask preterm labour Post operative period Post op – late trimester – no NSAIDs TAP blocks Provide adequate hydration. Continue left uterine displacement. Administer supplemental oxygen. Analgesics may mask preterm labour

Fetus safe and continuing pregnancy ? Fetal loss – 250 in 1000 when there is peritonitis No peritonitis – may be upto 50/ 1000 women Which causes – anesthesia , surgery or the basic disease

Pregnant patients who underwent other surgeries Taken from the internet for closed academic purpose only

Preterm labour ? 20 % Beta agonists are used by many Some institutes use magsulf to prevent preterm labour Nitrates , alcohol, -- old and historic Calcium channel blockers and atosiban NSAIDs If the patient after appendicectomy goes into labour and posted for LSCS the next day beware of magsulf

When to use tocolytics prior prophylactic tocolytics may be considered third trimester for lower abdominal or pelvic surgery for inflammatory conditions

Summary Appendix – when to operate Why perforate Lap or open maternal and fetal safety Preop RA/ GA Post op Tocolytics