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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.
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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.
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When a pregnant woman has a surgery or procedure, it is important that the entire health care team
The Pregnant Patient: Assessment and Perioperative Management
Section snippets
Key points
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:
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Viable fetus
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Physically possible to monitor
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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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Cited by (4)
Aspiration: Understanding the Risks and Optimizing Management
2022, Evidence-Based Practice of AnesthesiologyPerioperative management of pregnant women undergoing nonobstetric surgery
2021, Cleveland Clinic Journal of MedicineFacial fracture in pregnancy: Case report and review
2018, Journal of International Oral Health
Disclosures: The authors have nothing to disclose.