Review article
Anesthesia in pregnant patients for nonobstetric surgery

https://doi.org/10.1016/j.jclinane.2004.11.009Get rights and content

Abstract

Anesthesiologists in every subspecialty encounter, with varying regularity, patients presenting for surgery during the course of pregnancy. With the increasing sophistication of surgical and anesthetic techniques, increasingly complex surgeries are being undertaken. In this review, we address the fundamental physiologic principles central to the care of pregnant patients and fetuses in this difficult clinical situation.

Introduction

Patients presenting for surgery during the course of pregnancy carry a number of important challenges for anesthesiologists. Optimum management requires a thorough understanding of maternal and fetal physiology, altered drug pharmacodynamics and pharmacokinetics, and a sensitive approach to the parturient, who must be counseled carefully about the risks and benefits of intervention. The ultimate goal is to provide safe anesthesia to the mother while simultaneously minimizing the risk of preterm labor or fetal demise. Multidisciplinary input from surgeons, anesthesiologists, and obstetricians is essential to ensure fetal and maternal well-being throughout the perioperative period. A successful maternal and fetal outcome is dependent on expert management of both the surgical disease process and anesthesia.

Section snippets

Epidemiology

The frequency with which pregnancies are complicated by the need for nonobstetric surgical procedures is of the order of 0.75% to 2.0%. Of these procedures, approximately 42% are performed during the first trimester, 35% during the second, and 23% during the third [1]. The frequency with which nonobstetric surgery is performed in pregnant patients may be considerably higher in the first trimester as pregnancy may be undetected at the time of surgical intervention.

The range and incidence of

Physiologic changes in pregnancy

During pregnancy, maternal physiology undergoes profound changes. Primary changes occur under the influence of gestational hormones, which are essential to ensure adequate supply of oxygen and nutrition to fetuses and to prepare for delivery. Secondary changes occur as a result of the mechanical effects of enlarging gravid uteri.

These changes are extensively reviewed in many textbooks [1], but only those most clinically relevant are briefly discussed in this article.

Pharmacology

Pharmacokinetic and pharmacodynamic profiles are altered in pregnancy; therefore, drug administration must be titrated accordingly. Volume of distribution is increased secondary to pregnancy-induced increase in blood volume. The physiologic hypoalbuminemia of pregnancy is accompanied by increased α1-glycoprotein concentration. Altered plasma protein binding changes the free or unbound fraction of drugs and reduces the doses of drugs such as local anesthetic agents, at which toxicity is observed

Conclusion

Successful outcomes after anesthesia administration for nonobstetric surgery in pregnant patients are dependent on comprehensive preoperative assessment, meticulous attention to detail in relation to maternal and fetal physiology perioperatively, and ongoing supportive care in the postoperative period. Maintenance of maternal stability, optimal timing of surgery, and appropriate selection of anesthetic technique are essential.

Although the chief goal in the management of anesthesia is

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