1. Non Obstetrical Surgery for the Pregnant Patient

3. 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

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

5. Plan
GA: RSI
Fetal Heart Tones before and after surgery

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

7. 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?”

8. 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?????”

9. Most Common Procedures
Laparoscopic cholecystectomy
Cystoscopy
Appendectomy

10. 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

11. 34 week pregnant pt for ORIF fifth finger fracture from fist fight

12. Other Procedures Burn surgery Thyroidectomy Mastectomy Ovarian mass
Orthopedic injuries

13. 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

14. 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)

15. 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

16. 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

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

18. C-section Tray immediately available

19. Left Uterine Displacement
After 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

21. 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

22. 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

23. 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

25. 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

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

27. 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

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

30. 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

31. 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