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

2. ?

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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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);

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

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

15. 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 ??

16. Factors which influence anesthesia

17. Options
Regional
General

18. 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

19. 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

21. 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.)

22. Metabolic
Increase in oxygen consumption by 20%
Hypercoagulable but thrombocytopenic

23. 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

24. 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

25. Narcotics
Fentanyl
Morphine
Pethidine
Sufentanyl

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

27. 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

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

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

30. 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

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

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

33. 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.

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

35. 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

36. 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

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

38. 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

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

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