Elsevier

Anesthesiology Clinics

Volume 34, Issue 1, March 2016, Pages 213-222
Anesthesiology Clinics

The Pregnant Patient: Assessment and Perioperative Management

https://doi.org/10.1016/j.anclin.2015.10.016Get rights and content

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Key points

  • Pregnant women should not be denied indicated surgeries or procedures; however, the benefits and risks (both what is known and not known) need to be communicated so that informed decisions are made.

  • Per American Congress of Obstetricians and Gynecologists guidelines, elective surgery should be postponed until after delivery. If it cannot, nonurgent surgery should be done in the second trimester.

  • When a pregnant woman has a surgery or procedure, it is important that the entire health care team

Physiologic changes of pregnancy

The state of pregnancy has multiple systemic effects. These can vary from what can be considered the body’s normal physiologic response to pregnancy to the abnormal diseased state. When evaluating a pregnant patient, it is important to keep in mind the expected normal physiologic changes of the major systems. This will help the clinician recognize when the level of care should be escalated and other medical services consulted. The expected physiologic responses to pregnancy are reviewed

Maternal effects of anesthesia and surgery or procedures

Due to physiologic changes, additional anesthetic concerns are present for a pregnant patient compared with a nonpregnant patient. There is an increased risk of desaturation during periods of apnea (such as induction), increased risk of aspiration (second and third trimesters), increased risk of difficult intubation, decreased MAC, yet increased risk of awareness.2, 3, 4 In addition, the gravid uterus (second and third trimesters) can cause maternal hypotension in the supine position from

Fetal effects of anesthesia and surgery or procedures and pregnancy outcomes

One of the most concerning fetal effects is teratogenicity. The US Food and Drug Administration has required labeling of a drug to include a use-in-pregnancy category (A, B, C, D, or X) based on the medical evidence (Box 2).10 In December 2014, the Pregnancy and Lactation Labeling Rule stated the pregnancy letter categories would be removed effective June 2015. This change was based on the argument that the categories were oversimplified.11 Instead, under the pregnancy subsection, there will be

Nonobstetric surgeries or procedures requiring anesthesia that occur during pregnancy

Published reviews have shown that most nonobstetric surgeries performed on pregnant women were either appendectomy or cholecystectomy (44% and 22%, respectively).6, 26 Less frequently are surgeries for cancer, neurosurgery, cardiac, or trauma. Nonsurgical procedures can include endoscopy (including ERCP) and ECT.

Before any procedure is performed, adequate counseling should occur and the patient should be aware of the risks of proceeding and the risks of waiting until after delivery. ACOG, in

Coordination of Care and Assurance of Fetal Wellbeing

During the preoperative evaluation of a pregnant patient, her primary obstetric care provider should be identified. The ACOG Committee recommends that the primary obstetric care provider should be notified before any surgery. When the surgery or procedure is planned at another institution where the provider does not have privileges, another obstetric provider should be involved.27

The gestational age of the fetus should be determined to help guide clinical management. In general, 24 weeks and

Intraoperative recommendations

As stated previously, immediately before the procedure, the Doppler fetal heart rate should be documented. If the fetus is viable, ACOG recommends simultaneous electronic fetal heart rate and contraction monitoring be performed immediately before and after.27 They also state that intraoperative fetal monitoring may be appropriate when all the following conditions apply:

  • Viable fetus

  • Physically possible to monitor

  • Health care provider with obstetric surgery privileges available and willing to

Postoperative recommendations

Per the ACOG Committee Opinion, after a procedure, Doppler should be performed to assess fetal heart rate. If the fetus is viable, simultaneous electronic fetal heart rate and contraction monitoring should ensue. Again, plans need to already be in place for the appropriate personnel to interpret the fetal monitoring and intervene with appropriate obstetric management and neonatal services, if indicated.27

Preoperative pregnancy testing

There are many changes that occur during pregnancy and changes in clinical care when a patient is known to be pregnant. When is pregnancy testing appropriate and indicated? There still remains some question about the correct answer. In the most recent update of the practice advisory for the American Society of Anesthesiology Task Force on Preanesthesia Evaluation, it stated that there are insufficient data to adequately inform patients of the risk of anesthesia or surgery in early pregnancy and

Summary

Pregnant patients need special consideration when undergoing any surgery or procedure. An understanding of normal physiologic changes of pregnancy, knowledge of the current evidence (or lack of evidence) of the effects of anesthesia and the surgery or procedure on both the pregnant patient and her fetus, and organizational guidelines that help in coordination of perioperative care are vital to helping patients not only make informed decisions but also improve their overall outcome.

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References (39)

  • R. Gaiser

    Physiologic changes of pregnancy

  • M. Van de Velde

    Nonobstetric surgery during pregnancy

  • E.L. Anderson et al.

    ECT in pregnancy: a review of the literature from 1941 to 2007

    Psychosom Med

    (2009)
  • E.A. Erekson et al.

    Maternal postoperative complications after nonobstetric antennal surgery

    J Matern Fetal Neonatal Med

    (2012)
  • S. Kuy et al.

    Outcomes following thyroid and parathyroid surgery in pregnancy

    Arch Surg

    (2009)
  • H.B. Moore et al.

    Effect of pregnancy on adverse outcomes after general surgery

    JAMA Surg

    (2015)
  • S. Fine et al.

    Continued evidence for safety of endoscopic retrograde cholangiopancreatography

    World J Gastrointest Endosc

    (2014)
  • T. Gin et al.

    Pharmacology and nonanesthetic drugs during pregnancy and lactation

  • FDA News Release

    FDA issues final rule on changes to pregnancy and lactation labeling information for prescription drug and biological products

    (2014)
  • Cited by (4)

    • Aspiration: Understanding the Risks and Optimizing Management

      2022, Evidence-Based Practice of Anesthesiology
    • Facial fracture in pregnancy: Case report and review

      2018, Journal of International Oral Health

    Disclosures: The authors have nothing to disclose.

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