Management of the pregnant patient undergoing nonobstetric surgery
- Errol R Norwitz, MD, PhD, MBA
Errol R Norwitz, MD, PhD, MBA
- Professor and Chair
- Department of Obstetrics and Gynecology
- Tufts Medical Center and Tufts University School of Medicine
- Joong Shin Park, MD, PhD
Joong Shin Park, MD, PhD
- Professor, Department of Obstetrics and Gynecology
- Seoul National University College of Medicine, Korea
- Denis Snegovskikh, MD
Denis Snegovskikh, MD
- Adjunct Assistant Professor of Anesthesiology
- Yale University School of Medicine
- Section Editors
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deputy Editors
- Marianna Crowley, MD
Marianna Crowley, MD
- Deputy Editor — Anesthesiology
- Assistant Professor of Anesthesiology
- Harvard Medical School
- Kristen Eckler, MD, FACOG
Kristen Eckler, MD, FACOG
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Assistant Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Surgical procedures unrelated to pregnancy are sometimes necessary; for example, in a series of 720,000 pregnant women, there were 5405 nonobstetric operations, for an incidence of 0.75 percent . The most common operations during pregnancy are appendectomy and cholecystectomy, but almost every type of surgical procedure has been performed.
Whenever a pregnant woman undergoes nonobstetric surgery, consultations among her obstetrical team, surgeon(s), anesthesiologist(s), and neonatologist(s) are important to coordinate management . Anatomic and physiologic changes related to pregnancy and concerns about the fetus may require modifications to anesthetic and surgical management.
There are no randomized trials evaluating management of nonobstetric surgery in pregnant patients. The following discussion is based upon data from observational studies, expert opinion, and extrapolation from trials during cesarean delivery.
The most common nonobstetric conditions requiring surgery during pregnancy are appendicitis, biliary disease, ovarian disorders (torsion, neoplasm), trauma, breast or cervical disease, and bowel obstruction (table 1). Surgical management of specific disorders in pregnant women is discussed in detail in individual topic reviews for each disorder.
PHYSIOLOGICAL CHANGES RELATED TO PREGNANCY
Physiological changes related to pregnancy occur in virtually all systems and are caused by both hormonal and mechanical factors. Pertinent changes in major organ systems are summarized below; in-depth reviews of each topic can be found separately:
- Mazze RI, Källén B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 1989; 161:1178.
- ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery during pregnancy. Obstet Gynecol 2011; 117:420.
- Wilcox AJ, Weinberg CR, O'Connor JF, et al. Incidence of early loss of pregnancy. N Engl J Med 1988; 319:189.
- Boklage CE. Survival probability of human conceptions from fertilization to term. Int J Fertil 1990; 35:75, 79.
- Cohen-Kerem R, Railton C, Oren D, et al. Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 2005; 190:467.
- Fatum M, Rojansky N. Laparoscopic surgery during pregnancy. Obstet Gynecol Surv 2001; 56:50.
- Siddiqui N, Goldszmidt E, Haque SU, Carvalho JC. Ultrasound simulation of internal jugular vein cannulation in pregnant and non-pregnant women. Can J Anaesth 2010; 57:966.
- Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016; 124:270.
- American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011; 114:495.
- Paranjothy S, Griffiths JD, Broughton HK, et al. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev 2010; :CD004943.
- Hong JY, Park JW, Oh JI. Comparison of preoperative gastric contents and serum gastrin concentrations in pregnant and nonpregnant women. J Clin Anesth 2005; 17:451.
- Gaiser R. Physiologic changes of pregnancy. In: Chestnut's Obstetric Anesthesia: Principles and Practice, 4th, Chestnut DH, Polley LS, Tsen LC, Wong CA (Eds), Mosby, Philadelphia, PA 2009. p.24.
- Dean G, Jacobs AR, Goldstein RC, et al. The safety of deep sedation without intubation for abortion in the outpatient setting. J Clin Anesth 2011; 23:437.
- Guyatt GH, Akl EA, Crowther M, et al. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:7S.
- Liu PL, Warren TM, Ostheimer GW, et al. Foetal monitoring in parturients undergoing surgery unrelated to pregnancy. Can Anaesth Soc J 1985; 32:525.
- Vincent RD Jr. Anesthesia for the pregnant patient. Clin Obstet Gynecol 1994; 37:256.
- Rapaport S, Joannes-Boyau O, Bazin R, Janvier G. [Comparison of eight deep breaths and tidal volume breathing preoxygenation techniques in morbid obese patients]. Ann Fr Anesth Reanim 2004; 23:1155.
- Norris MC, Dewan DM. Preoxygenation for cesarean section: a comparison of two techniques. Anesthesiology 1985; 62:827.
- Conklin KA. Maternal physiological adaptations during gestation, labor and the puerperium. Semin Anesth 1991; 10:221.
- Kaneko T, Iwama H, Tobishima S, et al. [Placental transfer of vecuronium administered with priming principle regimen in patients undergoing cesarean section]. Masui 1997; 46:750.
- Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med 2007; 50:653.
- Noguchi T, Koga K, Shiga Y, Shigematsu A. The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet. Can J Anaesth 2003; 50:712.
- Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at laryngoscopy. Anaesthesia 2005; 60:41.
- Tournadre JP, Chassard D, Berrada KR, Boulétreau P. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology 1997; 86:7.
- Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anaesth 2007; 54:748.
- Alon E, Ball RH, Gillie MH, et al. Effects of propofol and thiopental on maternal and fetal cardiovascular and acid-base variables in the pregnant ewe. Anesthesiology 1993; 78:562.
- Okutomi T, Whittington RA, Stein DJ, Morishima HO. Comparison of the effects of sevoflurane and isoflurane anesthesia on the maternal-fetal unit in sheep. J Anesth 2009; 23:392.
- Qaiser R, Black P. Neurosurgery in pregnancy. Semin Neurol 2007; 27:476.
- Shankar KB, Moseley H, Kumar Y, Vemula V. Arterial to end tidal carbon dioxide tension difference during caesarean section anaesthesia. Anaesthesia 1986; 41:698.
- Haruta M, Funato T, Naka Y, Saeki N. [Effects of maternal hyperventilation and oxygen inhalation during labor on fetal blood-gas status]. Nihon Sanka Fujinka Gakkai Zasshi 1988; 40:1377.
- Müller G, Huber JC, Salzer H, Reinold E. Maternal hyperventilation as a possible cause of fetal tachycardia sub partu. A clinical and experimental study. Gynecol Obstet Invest 1984; 17:270.
- Hohimer AR, Bissonnette JM, Metcalfe J, McKean TA. Effect of exercise on uterine blood flow in the pregnant Pygmy goat. Am J Physiol 1984; 246:H207.
- Levinson G, Shnider SM, DeLorimier AA, Steffenson JL. Effects of maternal hyperventilation on uterine blood flow and fetal oxygenation and acid-base status. Anesthesiology 1974; 40:340.
- Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology 2007; 106:1096.
- McClure JH, Cooper GM, Clutton-Brock TH, Centre for Maternal and Child Enquiries. Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006-8: a review. Br J Anaesth 2011; 107:127.
- Higuchi H, Adachi Y, Arimura S, et al. Early pregnancy does not reduce the C(50) of propofol for loss of consciousness. Anesth Analg 2001; 93:1565.
- Mongardon N, Servin F, Perrin M, et al. Predicted propofol effect-site concentration for induction and emergence of anesthesia during early pregnancy. Anesth Analg 2009; 109:90.
- Gin T, Mainland P, Chan MT, Short TG. Decreased thiopental requirements in early pregnancy. Anesthesiology 1997; 86:73.
- Gin T, Chan MT. Decreased minimum alveolar concentration of isoflurane in pregnant humans. Anesthesiology 1994; 81:829.
- Chan MT, Gin T. Postpartum changes in the minimum alveolar concentration of isoflurane. Anesthesiology 1995; 82:1360.
- Zhou HH, Norman P, DeLima LG, et al. The minimum alveolar concentration of isoflurane in patients undergoing bilateral tubal ligation in the postpartum period. Anesthesiology 1995; 82:1364.
- Ueyama H, Hagihira S, Takashina M, et al. Pregnancy does not enhance volatile anesthetic sensitivity on the brain: an electroencephalographic analysis study. Anesthesiology 2010; 113:577.
- Baraka A, Jabbour S, Tabboush Z, et al. Onset of vecuronium neuromuscular block is more rapid in patients undergoing caesarean section. Can J Anaesth 1992; 39:135.
- Sakurai Y, Uchida M, Aiba J, et al. [Effects of pregnancy on the onset time of rocuronium]. Masui 2014; 63:324.
- SHNIDER SM. SERUM CHLONESTERASE ACTIVITY DURING PREGNANCY, LABOR AND THE PUERPERIUM. Anesthesiology 1965; 26:335.
- Whittaker M, Crawford JS, Lewis M. Some observations of levels of plasma cholinesterase activity within an obstetric population. Anaesthesia 1988; 43:42.
- Leighton BL, Cheek TG, Gross JB, et al. Succinylcholine pharmacodynamics in peripartum patients. Anesthesiology 1986; 64:202.
- Thind GS, Bryson TH. Single dose suxamethonium and muscle pain in pregnancy. Br J Anaesth 1983; 55:743.
- Creeley CE, Dikranian KT, Dissen GA, et al. Isoflurane-induced apoptosis of neurons and oligodendrocytes in the fetal rhesus macaque brain. Anesthesiology 2014; 120:626.
- Brambrink AM, Evers AS, Avidan MS, et al. Ketamine-induced neuroapoptosis in the fetal and neonatal rhesus macaque brain. Anesthesiology 2012; 116:372.
- Creeley C, Dikranian K, Dissen G, et al. Propofol-induced apoptosis of neurones and oligodendrocytes in fetal and neonatal rhesus macaque brain. Br J Anaesth 2013; 110 Suppl 1:i29.
- Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci 2003; 23:876.
- Paule MG, Li M, Allen RR, et al. Ketamine anesthesia during the first week of life can cause long-lasting cognitive deficits in rhesus monkeys. Neurotoxicol Teratol 2011; 33:220.
- Slikker W Jr, Zou X, Hotchkiss CE, et al. Ketamine-induced neuronal cell death in the perinatal rhesus monkey. Toxicol Sci 2007; 98:145.
- Hansen TG, Pedersen JK, Henneberg SW, et al. Academic performance in adolescence after inguinal hernia repair in infancy: a nationwide cohort study. Anesthesiology 2011; 114:1076.
- Hansen TG, Pedersen JK, Henneberg SW, et al. Educational outcome in adolescence following pyloric stenosis repair before 3 months of age: a nationwide cohort study. Paediatr Anaesth 2013; 23:883.
- Bartels M, Althoff RR, Boomsma DI. Anesthesia and cognitive performance in children: no evidence for a causal relationship. Twin Res Hum Genet 2009; 12:246.
- Ko WR, Liaw YP, Huang JY, et al. Exposure to general anesthesia in early life and the risk of attention deficit/hyperactivity disorder development: a nationwide, retrospective matched-cohort study. Paediatr Anaesth 2014; 24:741.
- O'Leary JD, Janus M, Duku E, et al. A Population-based Study Evaluating the Association between Surgery in Early Life and Child Development at Primary School Entry. Anesthesiology 2016; 125:272.
- Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 2012; 130:e476.
- Flick RP, Katusic SK, Colligan RC, et al. Cognitive and behavioral outcomes after early exposure to anesthesia and surgery. Pediatrics 2011; 128:e1053.
- Wilder RT, Flick RP, Sprung J, et al. Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology 2009; 110:796.
- Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016; 387:239.
- Sun LS, Li G, Miller TL, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016; 315:2312.
- Practice Advisory: FDA warnings regarding use of general anesthetics and sedation drugs in young children and pregnant women. The American College of Obstetricians and Gynecologists. December 21, 2016 http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/FDA-Warnings-Regarding-Use-of-General-Anesthetics-and-Sedation-Drugs (Accessed on December 22, 2016).
- Czeizel AE, Pataki T, Rockenbauer M. Reproductive outcome after exposure to surgery under anesthesia during pregnancy. Arch Gynecol Obstet 1998; 261:193.
- Friedman JM. Teratogen update: anesthetic agents. Teratology 1988; 37:69.
- Duncan PG, Pope WD, Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986; 64:790.
- Kort B, Katz VL, Watson WJ. The effect of nonobstetric operation during pregnancy. Surg Gynecol Obstet 1993; 177:371.
- Visser BC, Glasgow RE, Mulvihill KK, Mulvihill SJ. Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg 2001; 18:409.
- Dolovich LR, Addis A, Vaillancourt JM, et al. Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies. BMJ 1998; 317:839.
- Wikner BN, Stiller CO, Bergman U, et al. Use of benzodiazepines and benzodiazepine receptor agonists during pregnancy: neonatal outcome and congenital malformations. Pharmacoepidemiol Drug Saf 2007; 16:1203.
- Ornoy A, Arnon J, Shechtman S, et al. Is benzodiazepine use during pregnancy really teratogenic? Reprod Toxicol 1998; 12:511.
- Hawkins JL, Johnson TD, Kubicek MA, et al. Vecuronium for rapid-sequence intubation for cesarean section. Anesth Analg 1990; 71:185.
- Yildiz K, Dogru K, Dalgic H, et al. Inhibitory effects of desflurane and sevoflurane on oxytocin-induced contractions of isolated pregnant human myometrium. Acta Anaesthesiol Scand 2005; 49:1355.
- Volmanen P, Akural E, Raudaskoski T, et al. Comparison of remifentanil and nitrous oxide in labour analgesia. Acta Anaesthesiol Scand 2005; 49:453.
- Polvi HJ, Pirhonen JP, Erkkola RU. Nitrous oxide inhalation: effects on maternal and fetal circulations at term. Obstet Gynecol 1996; 87:1045.
- Pritts EA, Atwood AK. Luteal phase support in infertility treatment: a meta-analysis of the randomized trials. Hum Reprod 2002; 17:2287.
- Bourgain C, Devroey P, Van Waesberghe L, et al. Effects of natural progesterone on the morphology of the endometrium in patients with primary ovarian failure. Hum Reprod 1990; 5:537.
- Cicinelli E, de Ziegler D, Bulletti C, et al. Direct transport of progesterone from vagina to uterus. Obstet Gynecol 2000; 95:403.
- Csapo AI, Pulkkinen MO, Ruttner B, et al. The significance of the human corpus luteum in pregnancy maintenance. I. Preliminary studies. Am J Obstet Gynecol 1972; 112:1061.
- Scott R, Navot D, Liu HC, Rosenwaks Z. A human in vivo model for the luteoplacental shift. Fertil Steril 1991; 56:481.
- Mazze RI, Källén B. Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol 1991; 77:835.
- Moore HB, Juarez-Colunga E, Bronsert M, et al. Effect of Pregnancy on Adverse Outcomes After General Surgery. JAMA Surg 2015; 150:637.
- Silvestri MT, Pettker CM, Brousseau EC, et al. Morbidity of appendectomy and cholecystectomy in pregnant and nonpregnant women. Obstet Gynecol 2011; 118:1261.
- Kuy S, Roman SA, Desai R, Sosa JA. Outcomes following cholecystectomy in pregnant and nonpregnant women. Surgery 2009; 146:358.
- Huang SY, Lo PH, Liu WM, et al. Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study. Mayo Clin Proc 2016; 91:1166.
- Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute appendicitis in pregnancy-population-based study of over 7000 cases. BJOG 2014; 121:1509.
- COMMON INDICATIONS
- PHYSIOLOGICAL CHANGES RELATED TO PREGNANCY
- LABORATORY CHANGES
- PREOPERATIVE EVALUATION
- PATIENT PREPARATION
- Fetal heart rate monitoring
- Fasting guidelines
- Aspiration mitigation
- Antibiotic prophylaxis
- Prophylactic glucocorticoids
- Prophylactic tocolytics
- ANESTHESIA MANAGEMENT
- Intraoperative fetal heart rate monitoring
- Type of anesthetic
- - Monitored anesthesia care
- - Regional anesthesia
- - General anesthesia
- Induction of anesthesia
- - Preoxygenation
- - Induction
- - Intubation
- Maintenance of anesthesia
- - Hemodynamic and fluid management
- - Mechanical ventilation
- - Recovery from anesthesia
- Fetal assessment
- Maternal position
- - Postoperative pain control
- Anesthetic drugs during pregnancy
- - Anesthetic dosing
- - Fetal effects of anesthetics
- Fetal brain development
- Neonatal support with emergent delivery
- - Uterine effects
- SURGICAL APPROACH
- POSTOPERATIVE OBSTETRIC MANAGEMENT
- Progesterone supplementation
- Delivery route after surgery during pregnancy
- Outcome of pregnancy
- Outcome of surgery
- SUMMARY AND RECOMMENDATIONS