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:
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- 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