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Anesthesia for NonAnesthesia for NonObstetric Surgery inObstetric Surgery in
Pregnant PatientsPregnant Patients
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IncidenceIncidence
0.3% to 2.2% of pregnant women undergosurgeries
Annua incidence ! "#$000 &0$000 '(SA)
*entrai+ed data una,aiabe in India
*ommonest surgery ! Appendicectomy
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IncidenceIncidence
Am - Obstetyneco /&
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Surgeries in pregnancySurgeries in pregnancy
Pregnancy related
Cervical encirclage
Fetal surgery
Ovarian Cystectomy
Not related to pregnancy
Appendicectomy, Cholecystectomy
Trauma
Malignancies
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How these patient are diferent romother surgical patients?
1wo patients ! mother
- fetus
Physioogica changes in mother
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hy this topic ishy this topic is
importantimportantMust ensure safe anaesthesia for both motherand child
Standard anaesthetic procedure may have to
be modied to accomodate both maternal physiological changes and presence of fetus
is! to the fetus is more!
the e4ect of disease process$ teratogenicity of anaesthetic agents$
intraoperati,e impairment of uteropacentacircuation$ and
ris5 of abortion or preterm dei,ery
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678 A97AS678 A97AS
Norma aterations in maternal physiologyduring pregnancy
1he potentia etal efects from anaesthesia andsurgery
:aintenance of uteroplacental perusion andetal oxygenation
Practical considerations
Importance of materna counselling andreassurance
Special situations
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Altered maternalAltered maternal
physiologyphysiology9espiratory system;9espiratory system;< O2 consumption = > ?9*rapid desaturation orhypo"emia
< A,eoar ,entiation chronic respiratory al!alosis #$ bicarbonate and base bu%er
< mucosa ,ascuarity = weight gain di&cult mas!ventilation or intubation
*ardio,ascuar system;
Supine hypotension syndrome $ uteroplacental perfusion
@istention of epidura ,enous peus ' li!elihood ofintravascular in(ection and enhanced spread of )A
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Altered maternalAltered maternal
physiologyphysiologyBematoogica changesBematoogica changes< Cood ,oume with esser increase in 9C*s
,oume dilutional anemia
< ?actor I$ DII$ DIII$ E$ EII = ?@P *ncreased ris!of thromboembolic complications
Cenign eu5ocytosis di&cult to di%erentiatefrom infection
astrointestina system changes
> F7S tone$ distortion of gastropyoric anatomy =< gastric pressure from gra,id uterus ris! ofregurgitation and aspiration
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Altered maternalAltered maternal
physiology…physiology…Atered response to anaesthesiaA,eoar hyper,entiation$ reduction of ?9*
and reduction of :A* rapid induction ofgeneral anaesthesia
> thiopenta reGuirements
> protein binding due to ow abumin <
free fraction of drugs
< sensiti,ity to periphera neura boc5ade > )+A+ dose reuirement
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FETAL EFFECTSFETAL EFFECTS
1eratogenicity 1eratogenicity
Any signiHcant postnata change in function orform in an o4spring after prenata treatment
?actors that inuence teratogenicity of a drug
Species susceptibiity 1hreshod or amount of eposure
@uration and timing of administration
enetic predisposition
:anifestation of teratogenicity '@eath$ Structuraabnormaity$ rowth restriction$ functionadeHciency)
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FETAL EFFECTS…FETAL EFFECTS…@ocumented teratogens;@ocumented teratogens;9adiation increased ris5 of maignant disease$ genetic
disease$ cong. maformation =Jor feta death
:aterna metaboic imbaance
Acohoism$ cretinism$ diabetes$ foic aciddeHciency$ hyperthermia$ proonged hypoia$hypercarbia and se,ere hypogycemia
Infection
*:D$ Berpes ,irus$ Par,o ,irus C!/$ rubea,irus$ toopasmosis
@rugs
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FETAL EFFECTS…FETAL EFFECTS…
9adioogy; a threat9adioogy; a threat
74ects are dose reated
Fess than #0 my is safe
Absorbed feta dose for a con,entionaradiographic imaging is ess than #0 my
“No single diagnostic procedure results in aradiation dose that threatens the well-being othe developing embryo and etus'American *oege of 9adioogy)
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Diagnostic ultrasonography:*onsidered to be de,oid of embryotoic e4ects
Potentia side e4ects ?eta hyperthermia with proonged scans
Post!nata neurobeha,iora e4ects with
repeated eposures
Bande et a. 1eratogenic e4ects of repeated eposures to E!raysand or utrasound in mice. Neurotoic 1erato /#
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@ocumented teratogenic@ocumented teratogenic
drugsdrugs'Adapted; A*O 7ducationa Cuetin )'Adapted; A*O 7ducationa Cuetin )A*7 inhibitors Fithium
Acoho :ercury
Androgens Phenytoin
Antithyroid drugs Ditamin A deri,ati,es
*arbama+epine StreptomycinJ5anamycin
*hemotherapy agents 1etracycine
*ocaine 1haidomide
*oumadin 1rimethadione
@iethystibestro Daproic acid
Fead
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FETAL EFFECTS…FETAL EFFECTS…
!naesthetic agents andteratogenicity
1eratogenic e4ects of anaesthetic agents areprobaby minima to non!eistent and ha,ene,er been concusi,ey documented
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FETAL EFFECTS…FETAL EFFECTS…
Safe drugs: IJD induction agents
Narcotics
Neuromuscuar boc5ers
Inhaationa agents Foca anaesthetics
Drugs of concern:Nitrous oide$
CK@
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FETAL EFFECTS…FETAL EFFECTS…
Nitrous oideNitrous oide Animal studies ea5 teratogen in rodents
Interferes with function of methionine synthetase byoidation of ,itamin C/2
decreased 1B?
decreased @NA synthesis
@ecreased uterine bood ow ; pre,ented by addition ofhaogenated inhaationa agents
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FETAL EFFECTS…FETAL EFFECTS…
Nitrous oideLNitrous oideLuman studies No pro,ed teratogenicity
SigniHcant eposure for proonged duration resuts in
atered en+yme acti,ity
No teratogenic e4ects in cinicay administered dose.
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FETAL EFFECTS…FETAL EFFECTS…C7NKO@IAK7PIN7S 'CK@)C7NKO@IAK7PIN7S 'CK@)
7arier retrospecti,e studies;Association between materna dia+epam ingestionduring /st trimester and infant with ceft ip andpaate
Fater prospecti,e studies;
! No higher ris5 when used in /st trimester
Fong term materna administration feta CK@
dependence = withdrawa
Peripartum administration
?eta hypotonia$ hypothermia$ respiratory
depression$ feeding diMcuties
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FETAL EFFECTS…FETAL EFFECTS…
A single shot of short acting ./0 or 1itrous
o"ide in clinically administered anaestheticconcentration is unli!ely to have anyteratogenic e%ects
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FETAL EFFECTS…FETAL EFFECTS…C7BADIO9AF 179A1OFO8C7BADIO9AF 179A1OFO8
Ceha,iora abnormaity in absence of anyobser,abe morphoogica changes
*NS is speciHcay sensiti,e during period of
maor myeination which etends from th
I(month to 2nd postnata month
Animals prenata administration of systemicdrugs e.g.$ Carbiturates$ meperidine$
prometha+ine = haothane beha,iorachanges
uman impication remains un5nown
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FETAL EFFECTS…FETAL EFFECTS…
1here are not adeGuate data to
etrapoate the anima Hnding tohumansQ
2Anesthetic # )ife Support /rug advisoryCommittee of 3S F/A4
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?eta e4ectsL?eta e4ectsL
1o summari+e$ anaesthesia and surgery areassociated with higher incidence of abortion$ I(9and perinata mortaity.
1hese ad,erse outcomes can often be attributed to
the procedure$ the site of the surgery 'e.g.$ proimityto the uterus)$ andJ or the underying maternacondition
No e,idence that anaesthesia resuts in o,eraincrease in congenita abnormaity
No e,idence of cear reation between outcome andtype of anaesthesia
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teroplacental perfusionteroplacental perfusion
and fetal o!ygentationand fetal o!ygentation
?eta oygenation depends on materna oygendei,ery and uteropacenta perfusion
:ost serious ris5 during nonobstetric surgery is"ntrauterine asphy!ia
:aintenance of feta we being ;
Maternal o"ygenation
Maternal carbon dio"ide tension
3terine blood 5o6
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teroplacental perfusionteroplacental perfusion
and fetal o!ygentation…and fetal o!ygentation…#aternal o!ygenation:
Se,ere materna hypoia can occur with;
di&cult 7 oesophageal intubation pulmonary aspiration
total spinal anaesthesia
systemic )A to"icity
:oderate hyperoia impro,es feta oygenation and isnot associated with intrauterine retroenta Hbropasiaand premature @A cosure
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teroplacental perfusionteroplacental perfusion
and fetal o!ygentation…and fetal o!ygentation…
#aternal C$%: ?eta *O2 correates to materna e,es
:aterna hyper,entiation can resuts in
(mbiica artery constriction
A5aosis;
shift materna oyhemogobin dissociation cur,e toeft.
Bypocapnia; < ,entiation > ,enous return > cardiac output > uterine bood ow.
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Factors a&ecting theFactors a&ecting the
teroplacental perfusionteroplacental perfusion
#aternal hypotension deep levels of anaesthesia high levels of spinal or epidural bloc!ade
aortocaval compression, hemorrhage7 hypovolumia
Anaesthetic agents causing uterine'asoconstriction or hypertonus
'eg. 5etamineR2mgJ5g$ toic doses of FA)
Catecholamines Pain$ aniety$ ight anaesthesia increased pasmacatechoamines decreased (C?
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P(ACT"CAL C$NS"DE(AT"$NSP(ACT"CAL C$NS"DE(AT"$NS
1iming of surgery
?eta monitoring
?u stomach precautionsFeft uterine dispacement
Anaesthetic considerations
1ocoytic agents
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
hen to do the surgeryhen to do the surgery @epends on the baance between materna and feta
ris5 and urgency of the surgery
/st trimester Organogenesis
◦ Increased feta ris5 for teratogenesis and abortion
3rd trimester Pea5 of physioogica changes ofpregnancy
◦ Increased materna ris5
◦ Increased ris5 of preterm abour
1hus "nd trimester is considered to be a idea timefor non emergency$ essentia surgeries
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
hen to do the surgeryhen to do the surgery
*ar,aho C$ Anesth Anag Supp
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
?eta monitoring?eta monitoring Intermittent or continuous ?B9 monitoring
shoud be considered for maor surgicaprocedures whene,er technicay feasibe;
7ase of monitoring
1ype = site of surgery 'diMcut during abdomina surgery)
estationa age 'after /&!20 w5s)
1oo to monitor intrauterine feta we being
@one by transabdomina dopper or ,agina dopperprobe
9eGuires the presence of a trained practitioner tomonitor and interpret the tracing
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F variability ood indicator of feta we being after 2#!2" w5s
Foss of beat to beat ,ariabiity and decreasedbaseine ?B9 are common Anaesthetic agentadministration
@ecerations suggests feta hypoemia
*auses of ?B9 decerations Inad,ertent maternahypoemia$ or inadeGuate uterine perfusion e,auation of materna position$ C.P$ oygenation$acid base status and inspection of surgica sites asretractors may impair uterine perfusion.
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
Anaesthetic considerations in/st 1rimester
#aternal < oygen reGuirement:odiHed drug pharmaco5inetics*arefu airway manipuation
$etal 9is5 of teratogenicity Impaired (C?
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
Anaesthetic considerations in 2nd and3rd trimester
#aternal
Prone to hypoiaAspiration prophyais
Preparation for diMcut airway Increased ris5 of thromboemboic
compicationsA,oid hyper,entiation
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P9A*1I*AF *ON*79NS...P9A*1I*AF *ON*79NS...
$etal Premature abour J I(9 Intrauterine asphyia
Surgery related
@isease reated probem@iagnostic diMcuties Proonged eposure to anaesthetics Surgica manipuations < feta ris5 Anatomic and surface andmar5s unreiabe
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P9A*1I*AF *ON*79NSL.P9A*1I*AF *ON*79NSL.
D"A)N$ST"C D"FF"CLT*
As nausea$ ,omiting$ constipation$ and distentionare common symptoms of both norma pregnancy
and abdomina pathoogy
Increase C* count
9euctance to perform necessary studies in,o,ingradiation
Anatomic and surface andmar5s can be unreiabe
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
T$C$L*T"CS A)ENTS
Prophyactic use in nonobstetric surgery is contro,ersia
:ay be considered
abdomina surgeries in,o,ing uterine manipuations or Surgeries with high ris5 of premature abour i.e.$
cer,ica encircage
(terine contractions shoud be monitored during the
surgery and tocoytic therapy to be instituted if reGuired
Not recommended at or after 3 w5s
@o not a4ect the outcome
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P9A*1I*AF *ON*79NSLP9A*1I*AF *ON*79NSL
1ocoytic agents 1ocoytic agents Drugs Side e&ects 2 agonist 1erbutaine
9itodrine Isosuprine
feta tachycardia$hypogycemia$hypotension$Pumonary edema$myocardia ischemia
*acium channeboc5ers
Nifedipine'one of the mostcommony used)
transient hypotension
:agnesium suphate east commonyused
interaction with N:Cs$*NS depression
Indomethacin peptic ucer$
thrombocytopenia$premature cosure of@.A.
Atosiban'newer agent)
oytocin antagonist
Cunts *a2T inu inmyometrium and
inhibit contractiity
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*ounseing and*ounseing and
reassurancereassurance Patient shoud be reassured about the safety of
anaesthesia and the ac5 of documented associatedteratogenicity
arned about the increased ris5 of /st trimester
miscarriage and premature dei,ery in ater trimesters
7ducate the patient about the symptoms ofpremature abour and reinforce the need of eftuterine dispacement
@ocumentation of detais of the ris5 discussed shoudbe maintained in patients records
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ANAEST+ET"C #ANA)E#ENT
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Pre,anaestheticPre,anaesthetic
preparation--preparation-- *ounseing and reassurance *onsut obstetrician = discuss about the use of tocoytics
O,ernight fast
Aspiration prophyais
Anioytic premedication! to aay aniety andapprehension
1ransport in eft atera position
O.1. preparation drugs$ machine$ diMcut airway cart$suction and monitors
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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…*hoice of Anaesthesia*hoice of Anaesthesia
*hoice of Anaesthetic techniGue depends on! PatientUs present surgica status 'site and nature
of surgery)
Present gestationa age of the fetus
Pregnancy induced physioogica changes
Other coeisting comorbidities
No techniGue has been pro,en to ha,e superiorityo,er the other in feta outcomes
9egiona techniGues may be preferabe
Safe anaesthetic management is more important thanparticuar agent or techniGue
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AI: ;
1o maintain oygenation$ normotension$ eucapnand eugycemia
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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…
:onitoring:onitoring:aterna monitoring; Nonin,asi,e J in,asi,e bood pressure
7ectrocardiography
Puse oimetry
*apnography 1emperature monitoring (se of periphera ner,e stimuator
Cood gucose e,es
?eta monitoring; 7terna dopper de,ice '?B9 ) 1ocodynamometer '(terine contractiity)
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ANAEST+ET"CANAEST+ET"C
#ANA)E#ENT…#ANA)E#ENT… ....)eneral anaesthesia
:aintain eft uterine dispacment
Preoygenation
9apid seGuence induction '1hiopent. sod. = succiny choine$cricoid pressure trachea intubation using cu4ed 7.1. tube)
:aintenance ; A moderate conc. of inhaationa agent ' V 2:A*) with high conc. of oygen '?iO2 W 0.#) is
recommended.
1he use of nitrous oide shoud be imited during etremeyong operations in Hrst trimester by gi,ing high conc ofoygen
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Opioids and induction agents decreases ?B9,ariabiity to greater etent than ,oatie agents
Positi,e pressure ,entiation may reduce (C?
A,oid hyper,entiation
Patients on magnesium for tocoysis reduce doseof N:Cs
9e,ersa agent to be gi,en sowy 'increased reeaseof Ach increased uterine tone and preterm abour)
7tubation when fuy awa5e after return ofprotecti,e airway reees
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ANAEST+ET"C #ANA)E#ENT--…ANAEST+ET"C #ANA)E#ENT--…
(egional anaesthesia
Ad,antages;
:inima feta drug eposure
A,oidance of compications of genera anaesthesia
If no sedati,e or narcotics are suppemented nochange in ?B9 ,ariations to confuse interpretation
Post operati,e anagesia
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:anagement of regiona anaesthesia
Pre!op preparation and monitoring same as of eneraanaesthesia
9educed FA reGuirement J < FA 1oicity
*arefu aspiration and test dose
A,oid hypotension i.e.$ adeGuate preoading$ maintain
eft uterine tit$ choice of ,asopressor
Patients on magnesium are more prone to hypotension$often resistant to treatment with ,asopressors
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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…
Postoperati,e managementPostoperati,e management
Oygenation in eft uterine tit
Ditas monitoring
Obstetrician consutation for ?B9 = uterine acti,ity
monitoring
Pediatric consutation in case of premature abour
AdeGuate pain reief reduce the ris5 of premature abour
1ocodynamometry is usefu in high ris5 patients aspostoperati,e anagesia may mas5 awareness of earycontractions and deay tocoysis
7ary mobii+ation or @D1 prophyais if reGuired
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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…
Postoperati,e PainPostoperati,e Pain
managementmanagement
Painincreased endogenous catechoamines uterine,asoconstrictiondecreased (C?intrauterine hypoia
1echniGues; Ner,e boc5s
Foca inHtration
Opioids
NSAI@
NSAI@S
/st and 2nd trimester ! safe
3rd trimester ! ris5 of premature cosure of @A$
Pum B1N$ deayed abour
NS!%& can be used beore '" w(s and
!cetaminophen is sae
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ANAEST+ET"C #ANA)E#ENT…ANAEST+ET"C #ANA)E#ENT…
(ecommendations appro'ed .yAmerican Society of Anaesthesiologists/ASA0 and American College of$.stetricians and )ynecologists /AC$)0%122
1o currently used anaesthetic agents have beensho6n to have any teratogenic e%ects in humans 6henusing standard concentrations at any gestational age
Fetal heart rate monitoring may assist in maternal positioning and cardiorespiratory management, and
may in5uence a decision to deliver the fetus
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9ecommendationsL9ecommendationsL
*t is mandatory to obtain an obstetric consultation before performing any non obstetric surgery or anyinvasive procedures
A pregnant 6oman should never be denied indicated
surgery, regardless of trimester +
8lective surgery should be postponed
*f possible, non-urgent surgery should be performedin the second trimester 6hen preterm contractionsand spontaneous abortion are least li!ely+
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No onger a contraindication in pregnant patients
*oncerns;
! (terine and feta trauma
! ?eta acidosis from absorbed carbon dioide.
! @ecreased materna cardiac output and
uteropacenta perfusion due to increasedabdomina pressure.
Specia situation Specia situation
FaparoscopyFaparoscopy
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uideines by Society of Americanastrointestina 7ndoscopic Surgeons'SA7S) 200&
Safe during any trimester of pregnancy
Obtain preoperati,e obstetrician consutation
Intermittent ower etremity pneumaticcompression de,ices to pre,ent ,enous stasis
1he feta heart rate and uterine tone shoud bemonitored in both preoperati,e and postoperati,eperiods
7nd tida *O2 shoud be maintained
Specia situation Specia situation
FaparoscopyFaparoscopy
i i i
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Specia situation Specia situation
FaparoscopyFaparoscopy Feft uterine dispacement shoud be maintained
An open 'Bassan) techniGue$ a ,eres neede or anoptica trocar techniGue to enter abdomen
Fow pneumoperitoneum pressures '/0!/#mm Bg)shoud be used
1ocoytic agents shoud not be used
prophyacticay but shoud be considered whene,idence of preterm abour is present
S i i i
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Specia situation ?etaSpecia situation ?eta
surgerysurgery Anaesthetic considerations remains simiar to those of
non obstetric surgeries
1wo surgica patients
:aterna safety is important
*hoice of anaesthetic techniGue
:inimay in,asi,e endoscopic procedure Neuraiaanaesthesia
Open intrauterine procedures enera anaesthesia
S i i i ? S i it ti ? t
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Specia situation ?etaSpecia situation ?eta
surgeryL.surgeryL.Important considerations
*onsider anaesthetic reGuirement of fetusincuding amnesia$ anagesia and immobity
*ontro of uterine tone is essentia
:ore intensi,e intraop ?B9 monitoring
S i i iS i it ti
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Specia situation Specia situation
7ectrocon,usi,e Shoc57ectrocon,usi,e Shoc5
1herapy 1herapy(sed to treat maor depression and CP@ duringpregnancy when rapid contro of symptoms isneeded
Ad,antage A,oids potentia teratogenicity from psychotropicmedications
Not a ris5 factor for premature abour$ miscarriageor stibirth
Anaesthetic management *onHrm the absence of uterine contractions using
tocodynamometry before and after 7*1 :onitor ?B9 before and after 7*1
S i it tiS i it ti
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Specia situation Specia situation
Neurosurgery 'e.g.$Neurosurgery 'e.g.$
Aneurysm$ AD maformation)Aneurysm$ AD maformation) Bypotensi,e anaesthetic techniGues ' 2# 30%reduction in SCP or mean CP ess than "0 mmBg) cancause decrease in (C?
@ose 'ess than 0.# mgJ5gJhr) and duration of Sodium
Nitroprusside shoud be imited
?B9 monitoring shoud be performed continuousyspeciay if induced hypotension or hyper,entiation ispanned so that necessary adustments can be made iffeta distress occurs
Bypo,oemia and ,ery arge doses of mannito shoudbe a,oided as they cause feta dehydration
7ndo,ascuar treatments uterine shieding duringperiods of radiation
S i it ti 1S i it ti 1
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Specia situation 1raumaSpecia situation 1rauma
during pregnancyduring pregnancy
1rauma is the eading cause nonobstetric cause ofmorbidity and mortaity
Primary management goas are simiar to the care ofnonpregnant trauma cases
A,oidance of hypoia$ hypotension$ acidosis andhypothermia are important for the maintenance of(C? and feta we being
:ore prone to de,eop pumonary edema
In stabe patients without ongoing bood oss *onser,ati,e uid management
*DP monitoring shoud be considered if renainsuMciency or uid o,eroad occurs
S i it ti 1S i it ti 1
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Specia situation 1raumaSpecia situation 1rauma
during pregnancyLduring pregnancyL
Primary aim shoud be optimi+ation of the mother andthe obstetric management is panned ater
No radioogica tests shoud be withhed because offeta concerns$ uterus shoud be shieded during
radiation procedures
Indications for an 7mergency *esarean dei,ery in apregnant trauma patients
1raumatic uterine rupture
Stabe mother with ,iabe fetus that is in distress
An unsa,agabe mother who sti has a ,iabe fetus
A gra,id uterus that is interfering with intraoperati,esurgica repair
9 f9 f
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9eferences9eferences
Obstetric Anaesthesia$ Principes and Practice. @a,id B
*hestnut$ th 7d
:ierUs anesthesia. 9onad @ :ier. "th ed.
yie and *hurchi @a,idsonUs XA Practice of AnaesthesiaU
"th ed.
*inica AnesthesiaY Carash$ *uen$ Stoeting$ Zth edition
8ao = ArtusioUs Anesthesioogy. "th edition
Nonobstetric surgery during pregnancy$ A*O committee
opinion$ No. "$ ?eb 20//
9oisin Ni :$ @a,id A. Anesthesia on pregnant patients fornonobstetric surgery. -ourna of cinica anesthesia '200Z) /&$Z0!ZZ
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1han5 8ou