Review articleAnesthesia in pregnant patients for nonobstetric surgery
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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