Anesthesia for Non-Obstetric Surgery during Pregnancy Adnan Almazrooa

Incidenc Incidenc U.S.A U.S.A –75000/year –1.5-2% of pregnancies K.S.A K.S.A –K.A.U.H –40/years

Indications Indications Cervical cerclage. Cervical cerclage. Ca Breast. Ca Breast. Thyroidectomy. Thyroidectomy. Cholecystectomy. Cholecystectomy. L.N.Biopsy. L.N.Biopsy. Vaginal Warts. Vaginal Warts.

Indications Indications Appendicectomy. Appendicectomy. Ovarian cystectomy. Ovarian cystectomy. Cervical cerclage. Cervical cerclage. Breast biopsy. Breast biopsy. Trauma. Trauma. Intrauterine surgery,transfusion. Intrauterine surgery,transfusion.

Objectives Objectives Maternal safety. Maternal safety. Avoidance of teratogenic drugs. Avoidance of teratogenic drugs. Maintain uteroplacental physiology. Maintain uteroplacental physiology. Avoidance of premature labour. Avoidance of premature labour.

A-Maternal Safety A-Maternal Safety Physiological changes during pregnancy Physiological changes during pregnancy –Cardiovascular. –Respiratory. –Gastrointestinal.

Cardiovascular Cardiovascular Aortocaval compression Aortocaval compression –20/ /52 –90% pregnancies. –Left lateral tilt. Increased C.O. Increased C.O.

Cardiovascular Cardiovascular Engorgment of intervertibral plexus Engorgment of intervertibral plexus –Reduced L.A. requirments Tendency to thromboembolism Tendency to thromboembolism –Platelets –Fibrinogen –Clotting factors Dilutional anemia Dilutional anemia

Respiratory Respiratory Rapid desaturation Rapid desaturation –F.R.C. Reduced –B.M.R. Raised –Oxygen consumption Raised –Minute ventilation Raised Difficult intubation Difficult intubation

Gastrointestinal Gastrointestinal Gastric volume, Ph, Emptying?? Gastric volume, Ph, Emptying?? Reduced Gastro-esophageal sphincter tone Reduced Gastro-esophageal sphincter tone

Objectives Objectives Maternal safety. Maternal safety. Avoidance of teratogenic drugs. Avoidance of teratogenic drugs. Maintain uteroplacental physiology. Maintain uteroplacental physiology. Avoidance of premature labour. Avoidance of premature labour.

B- Teratogenecity B- Teratogenecity Dose and duration of exposure. Dose and duration of exposure. Embryonic /fetal stage at adminstration. Embryonic /fetal stage at adminstration. Genetic susceptibility. Genetic susceptibility.

Potential teratogenecity Potential teratogenecity Cytotoxicity depends on biodegradation. Cytotoxicity depends on biodegradation. Complications of G.A Complications of G.A –Hpoxia, hypo and hypercapnea, hypotension Enviromental and chemical factors Enviromental and chemical factors –Aminoglyco.,warfrin,antiepileptics,vasopresors

Teratogenecity Teratogenecity Nitrous Oxide Nitrous Oxide –Methionine synthethetase inactivation. –Decrease endogenous Folinic acid. –Impaired DNA synthesis. Benzodiazepine Benzodiazepine –Cleft lip? –Substance Abuse?

No anesthetic drug has been demonstrated to be teratogenic in human No anesthetic drug has been demonstrated to be teratogenic in human

Objectives Objectives Maternal safety. Maternal safety. Avoidance of teratogenic drugs. Avoidance of teratogenic drugs. Maintain uteroplacental physiology. Maintain uteroplacental physiology. Avoidance of premature labour. Avoidance of premature labour.

C-Uteroplacental physiology C-Uteroplacental physiology Avoid hypotension. Avoid hypotension. Avoid hypoxemia. Avoid hypoxemia. Avoid Paco2 changes. Avoid Paco2 changes. Avoid chatecholamine release. Avoid chatecholamine release.

Uterine blood flow Uterine blood flow Depends on B.P Depends on B.P 1.5 MAC deep inhalation 1.5 MAC deep inhalation –Reduction B.P. –Reduction C.O. –Reduction U.B.F. –Raise PaCO2 Treatment Treatment –Left lat,I.V.F.,Ephedrine.

Oxygen Oxygen Hyper oxia will not lead to R.L.F. Hyper oxia will not lead to R.L.F. Premature closure of ductus. Premature closure of ductus.

Paco2 Paco2 Reduced Paco2 due to hyperventilation Reduced Paco2 due to hyperventilation –Decreased UBF –Increased Ph Mechanical effect of IPPV Mechanical effect of IPPV –Decreased UBF Catecholamine release Catecholamine release –Decreased UBF

Objectives Objectives Maternal safety. Maternal safety. Avoidance of teratogenic drugs. Avoidance of teratogenic drugs. Maintain uteroplacental physiology. Maintain uteroplacental physiology. Avoidance of premature labour. Avoidance of premature labour.

D-Prevention of preterm labour D-Prevention of preterm labour Depends on procedure rather than G.A. Depends on procedure rather than G.A. –35% cervical cerclage P.T.L. –Orthopedic,plastic No P.T.L. Monitor uterine activities Monitor uterine activities Tocolysis ?? Tocolysis ?? –B2 agonist –MgSO4 –Indomethacine

B2 Agonist B2 Agonist Ritordine,Terbutaline Ritordine,Terbutaline –Hypokalaemia –Hyperglysemia –Pulmonary edema –Arrhythmias

Magnesium Sulphate Magnesium Sulphate Less side effects. Less side effects. Potentiate relaxants. Potentiate relaxants. Monitor level. Monitor level.

Practical recommendation Practical recommendation Elective surgery /52 post partum Elective surgery /52 post partum Urgent surgery nd trimester Urgent surgery nd trimester

Emergency surgery Emergency surgery Pre med.,pain,anxiouty,folinic acid Pre med.,pain,anxiouty,folinic acid Antacid prophylaxis in 2 nd,3 rd trimester Antacid prophylaxis in 2 nd,3 rd trimester Transport,induction in left lat Transport,induction in left lat Technique, G.A. or Regional? Technique, G.A. or Regional?

Preoxygenation Preoxygenation Rapid sequence induction Rapid sequence induction Ventilate to normocapnea Ventilate to normocapnea Face mask in 1 st trimester Face mask in 1 st trimester Perioperative C.T.G Perioperative C.T.G

Intra uterine fetal surgery Intra uterine fetal surgery Exchange transfusion Exchange transfusion Placement of diversion catheter Placement of diversion catheter Aspiration of cystic masses Aspiration of cystic masses I.V. or I.M. non dep. To the fetus I.V. or I.M. non dep. To the fetus

Fetal sentience Fetal sentience The capacity of the fetus to experience painful or unpleasant sensation The capacity of the fetus to experience painful or unpleasant sensation