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Anesthesia for the Obstetric Patient Undergoing Non-Obstetric Surgery. Daniel Rohrer RN, BSN, SRNA-S YCP/ WellSpan Health CRNA Program. Objectives. Briefly review the physiologic changes in the obstetric patient and their implications for anesthetic management
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Anesthesia for the Obstetric PatientUndergoing Non-Obstetric Surgery Daniel Rohrer RN, BSN, SRNA-S YCP/WellSpan Health CRNA Program
Objectives • Briefly review the physiologic changes in the obstetric patient and their implications for anesthetic management • Review common non-obstetric surgical procedures, techniques, and concerns surrounding fetal vulnerability • Outline the anesthetic guidelines in managing the obstetric patient throughout non-obstetric surgery
Gastrointestinal… • Increased gastric volume • Mechanical outflow obstruction • Delayed gastric emptying • Increased gastric pressure • Decreased motility • and esophageal sphincter tone
Non-Obstetric Surgery • 0.75-2% 1:500-635 75,000 per year
Quick breather… • Protection of Fetus • Pre-Term Labor • Principles & Guidelines
Placental Drug Transfer (Protection) Physical & Chemical Properties • Size : < 500 Da (Daltons) • Charge: Non-ionized • Protein Binding: Unbound drugs • Lipophilic
Teratogenicity (Protection) Important Factors: • Susceptibility • Dose • Duration • Timing of exposure • FDA categories: • Category A - known to be safe • Category B - appear to be safe • Category C - may cause problems • Category D - clear risks • Category X - confirmed birth defects “To the best of our knowledge, danger of teratogenic effects from currently available anesthetic or sedative drugs remains only a potential risk” Dr. Rosen-ASA
Uterine Blood Flow & Fetal Asphyxia • Left uterine displacement • Trendelenburg position • Fluid administration as indicated • Leg elevation • Vasopressors • (ephedrine&phenylephrine) • Minimal SBP = 100mmHg • Hypotension = < 2 minutes
Fetal Heart Monitoring(ACOG & ASA) • Individualized • Minimum before and after • Obstetric consultation & interpretation • Institution with neonatal services • Consent for emergent C-section • Physician with C-section privileges
ACOG… • Cesarean section: 30 minutes • “Immediate” availability of personnel • Physician with anesthesia privileges • Resources for local anesthetic toxicity • Newborn resuscitation team
In Conclusion… • Physiological Changes • Protection of the fetus (timing, teratogenicity) • Pre-Term Labor prevention • Principles for maternal and fetal stability …and anesthetists!!!
“Precision and circumspection must be had and utilized when dealing with general anesthesia and pregnancy” Discussion…
References • American College of Obstetricians and Gynecologists . (2009). Optimal Goals for Anesthesia Care in Obstetrics . The American College of Obstetricians and Gynecologists . Washington, DC: Women's Health Care Physicians . • American College of Obstetricians and Gynecologists. (2013). Nonobstetric Surgery During Pregnancy. The American College of Obstetricians and Gynecologists. Washington, DC: Committee on Obstetric Practice. • Birnbach, D., & Browne, I. (2010). Anesthesia for Obstetrics . In R. Miller, L. Eriksson, L. Fleisher, J. Kronish, & W. Young, Miller's Anesthesia (7th Edition ed., pp. 2203-2235). Philadelphia , Pennsylvania: Churchill Livingstone Elsevier . • Cheek, T., & Emily, B. (2009). Anesthesia for Nonobstetric Surgery: Maternal and Fetal Considerations . Clinical Obstetrics and Gynecology , 535-545. • Corneille, M., Gallup, T., Bening, T., Wolf, S., Brougher, C., Myers, J., et al. (2010). The Use of Laparoscopic Surgery in Pregnancy: Evaluation of Safety and Efficacy . The American Journal of Surgery , 363-367. doi:10.1016/j.amjsurg.2009.09.022 • Fardiazar, Z., Derakhshan, I., Torab, R., Vahedi, A., & Goldust, M. (2014). Maternal-Neonatal Outcome in Pregnancies with Non-Obstetric Laparotomy During Pregnancy . Pakistan Journal of Biological Sciences , 260-264. doi: 10.3923/pjbs.2014.260.265 • Hannan, J., Hoque, M., & Begum, L. (2012). Laparoscopic Appendectomy in Pregnant Women: Experience in Chittagong, Bangladesh. World Journal of Surgery , 767-770. doi:10.1007/s00268-012-1445-z • Kuczkowski, K. (2007). Laparoscopic Procedures During Pregnancy and the Risks of Anesthesia: What does an Obstetrician Need to Know? . Archives of Gynecology Obstetricians , 276, 201-209. doi: 10.1007/s00404-007-0338-0 • Mhuircheartaigh, R., & Gorman, D. (2006). Nonobstetric Surgery in the Parturient: Anesthetic Considerations . Journal of Clinical Anesthesia , 18, 5-7. • Mikami, D., Beery, P., & Ellison, C. (2012). Surgery in the Pregnant Patient . In C. Townsend, D. Beauchamp, M. Evers, & K. Mattox, Sabiston Textbook of Surgery (19th Edition ed., pp. 2029-2045). Philadelphia , Pennsylvania. • Nejdlova, M., & Johnson, T. (2012). Anaesthesia for Non-Obstetric Procedures During Pregnancy . Continuing Education in Anaesthesia. Critical Care & Pain , 203-206. doi:10.1093/bjaceaccp/mks022 • Noridelle, G., Dennis, A., & Landy, H. (2009). Appendicitis and Cholecystitis in Pregnancy . Clinical Obstetrics and Gynecology , 52 (4), 586-596. • Reitman, E., & Flood, P. (2011). Anaesthetic considerations for non-obstetric surgery during pregnancy . British Journal of Anaesthesia , 72-78. doi:10.1093/bja/aer343 • Rosen, M. (2011). Anesthesia for the Pregnant Patient Undergoing Nonobstetric Surgery . Refresher Courses in Anesthesiology , 39 (ANESTHESIA), 134-141. • Van de Velde, M. (2009). Nonobstetric Surgery During Pregnancy . In D. Chestnut, L. Tsen, L. Polley, & C. Wong, Obstetric Anesthesia Principles and Practice (pp. 358-378). Philadelphia, Pennsylvania : Mosby Elsevier .
Case Study • 23 year old female, 32 weeks gestation • ASA 3, 67”, 53 kg • Gravida 3, P1-0-1-1 • Allergies: Toradol IV/IM • Presents for Pregnant Cholelithiasis, steadily • increasing abdominal pain (actively writhing in bed) • Past Medical Hx: No prenatal care prior to mid-pregnancy ultrasound, previous month hospital admission for gallbladder sludge and questionable pancreatitis • Social Hx: Current smoker, smoked throughout pregnancy • Assessment: Acute distress, HR 87, BP 140/84, 95% RA • 1 cm dilated, fetal heart rate 135, moderate variability, • + accelerations, N&V w/ bloody emesis x 24 hrs, labs WNL
Plan & Results… • Pre-term labor ruled out, 5 days on L&D floor • US = positive Murphy’s sign & gallbladder sludge, no obstruction of common bile duct and biliary stones • Open cholecystectomy w/ intraoperative fetal monitoring • OB/GYN Physician, L&D nurses with continual fetal monitoring present in OR • Anesthetic: Paravertebral block 30ml 0.5% Ropivacaine at T6-T7 via paramedian, GETA w/ 6.5mm ETT, RSI w/ lidocaine, propofol, • rocuronium, sevoflurane, OG decompression, • 2000 ml crystalloid, Fentanyl 125mcg, • zofran 4mg.
