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

Airway, Breathing…

Cardiovascular & Circulation…

Cardiovascular & Circulation…

Gastrointestinal…

• Increased gastric volume

• Mechanical outflow obstruction

• Delayed gastric emptying

• Increased gastric pressure

• Decreased motility and esophageal sphincter tone

Other Changes…

Non-Obstetric Surgery0.75-2% 1:500-635 75,000 per year

Appendicitis & Cholecystitis

You can do that?...

(Appendectomy)

Quick breather…

• Protection of Fetus• Pre-Term Labor• Principles & Guidelines

Fetal Vulnerability & Teratogenicity (Protection)

Timing

Physical & Chemical Properties

• Size : < 500 Da (Daltons) • Charge: Non-ionized• Protein Binding: Unbound drugs• Lipophilic

Placental Drug Transfer (Protection)

Teratogenicity (Protection)

• Susceptibility• Dose• Duration • Timing of exposure

Important Factors:

“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

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

Respiratory and Hemodynamic Stability (Principles)

28-32 mmHg

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

American College of Obstetricians and Gynecologists (ACOG)

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.

Supplementary…

Supplementary…

Supplementary…