Maternal surgery and anesthesia during pregnancy and risk of birth defects in the National Birth Defects Prevention Study, 1997-2011

Surgical Management of a Torn ACL and Bucket-Handle Meniscal Tear in the Pregnant Patient: A Case Report

CASE

A 36-year-old, 7-month pregnant woman presented to the office with a locked knee and a displaced bucket-handle medial meniscus tear, in the setting of chronic anterior cruciate ligament (ACL) insufficiency. After thorough discussion with the patient and her husband, the obstetrician, and the anesthesiologist, the patient was treated with left knee ACL reconstruction and medial meniscus repair.

CONCLUSION

With sufficient preoperative planning and coordinated multidisciplinary care among orthopaedic, anesthesiologist, and obstetric specialists, elective knee surgery can be performed safely in time-sensitive situations during pregnancy.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Physiology of pregnancy and oral local anesthesia considerations

Background

Safe and effective local anesthesia is a prerequisite for emergency oral surgeries and most dental treatments. Pregnancy is characterized by complex physiological changes, and increased sensitivity to pain. Pregnant women are particularly vulnerable to oral diseases, such as caries, gingivitis, pyogenic granuloma and third molar pericoronitis. Maternally administered drugs can affect the fetus through the placenta. Therefore, many physicians and patients are reluctant to provide or accept necessary local anesthesia, which leads to delays in the condition and adverse consequences. This review is intended to comprehensively discuss the instructions for local anesthesia in the oral treatment of pregnant patients.

Methodology

An in-depth search on Medline, Embase, and the Cochrane Library was performed to review articles concerned with maternal and fetal physiology, local anesthetic pharmacology, and their applications for oral treatment.

Results

Standard oral local anesthesia is safe throughout the pregnancy. At present, 2% lidocaine with 1:200,000 epinephrine is considered to be the anesthetic agent that best balances safety and efficacy for pregnant women. Maternal and fetal considerations must be taken into account to accommodate the physiological and pharmacological changes in the gestation period. Semi-supine position, blood pressure monitoring, and reassurance are suggested for high-risk mothers to reduce the risk of transient changes in blood pressure, hypoxemia, and hypoglycemia. For patients with underlying diseases, such as eclampsia, hypertension, hypotension, and gestational diabetes, the physicians should use epinephrine cautiously and control the dose of anesthetic. New local anesthesia formulations and equipment, which contribute to minimizing injection pain and relieving the anxiety, have and are being developed but remain understudied.

Conclusions

Understanding the physiological and pharmacological changes during pregnancy is essential to ensure the safety and efficiency of local anesthesia. Optimal outcomes for the mother and fetus hinge on a robust understanding of the physiologic alterations and the appropriate selection of anesthetic drugs and approaches.

Pregnancy and Gastric Cancer: A Narrative Review

Cases of digestive cancers diagnosed during pregnancy are rare. The increasing prevalence of pregnancy in women aged 30-39 years (and not exceptionally 40-49 years) could explain the frequent co-occurrence of cancers and pregnancy. The diagnosis of digestive cancers in pregnancy is difficult due to the overlap between neoplasm symptomatology and the clinical picture of pregnancy. A paraclinical evaluation may also be difficult depending on the trimester of the pregnancy. Diagnosis is also delayed by practitioners' hesitation to use invasive investigations (imaging, endoscopy, etc.) due to fetal safety concerns. Therefore, digestive cancers are often diagnosed during pregnancy in advanced stages, where complications such as occlusions, perforations, and cachexia have already arisen. In this review, we highlight the epidemiology, clinical aspects, paraclinical evaluation, and particularities of the diagnosis and treatment of gastric cancer during pregnancy.

Risk of adverse fetal outcomes following nonobstetric surgery during gestation: a nationwide population-based analysis

BACKGROUND

Literature suggests that nonobstetric surgery during gestation is associated with a higher risk of spontaneous abortion, prematurity, and a higher cesarean section rate, but the direct impact on fetal outcomes is still unclear. In this study, we aimed to investigate whether nonobstetric surgery during pregnancy is associated with negative fetal outcomes by analysing a nation-wide database in Taiwan.

METHODS

This population-based retrospective observational case-control study was based on the linkage of Taiwan's National Health Insurance Research Database, Birth Reporting Database, and Maternal and Child Health Database between 2004 and 2014. For every pregnancy with nonobstetric surgery during gestation, four controls were randomly matched according to maternal age and delivery year. We estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs) of adverse fetal outcomes with the non-surgery group as the reference. The primary outcomes involved stillbirth, prematurity, low birth weight, low Apgar scores, and neonatal and infant death.

RESULTS

Among 23,721 identified pregnancies, 4,747 underwent nonobstetric surgery. Pregnancies with nonobstetric surgery had significantly higher risks of prematurity (aOR: 1.46; 95% CI: 1.31-1.62), lower birth weight (aOR: 1.49; 95% CI: 1.33-1.67), Apgar scores < 7 (1 min, aOR: 1.58; 95% CI: 1.33-1.86; 5 min, aOR: 1.34; 95% CI: 1.03-1.74), neonatal death (aOR: 2.01; 95% CI: 1.18-3.42), and infant death (aOR: 1.69; 95% CI: 1.12-2.54) than those without nonobstetric surgery after adjustment for socioeconomic deprivation, hospital level, and other comorbidities. Surgery performed in the third trimester was associated with a significantly increased rate of prematurity (aOR: 1.38; 95% CI: 1.03-1.85), but lower rates of stillbirth (aOR: 0.1; 95% CI: 0.01-0.75) and Apgar score < 7 at the 5^th minute (aOR: 0.2; 95% CI: 0.05-0.82), than surgery performed in the first trimester.

CONCLUSIONS

Pregnancies with nonobstetric surgery during gestation were associated with increased risks of prematurity, low birth weight, low Apgar scores, neonatal and infant death, longer admission, and higher medical expenses than those without surgery. Furthermore, surgery in the third trimester was associated with a higher rate of prematurity than surgery performed in the first trimester.

TRIAL REGISTRATION

Not applicable.

Inter-Specialty Controversies on the Treatment of Cardiovascular Diseases during Pregnancy: A Questionnaire Study

Background and Objectives: Management of cardiovascular disease (CVD) during pregnancy is challenging and usually requires eminence-based decisions due to limited strong-evidence data in this field. The purpose of our study was to compare the attitudes of anaesthesiologists, cardiologists, and gynaecologists towards the diagnosis and treatment of potentially life-threatening CVDs during pregnancy. Materials and Methods: A cross-sectional, questionnaire-based study was performed among 111 doctors (55 anaesthesiologists, 36 cardiologists, 20 gynaecologists). Personal opinions on the recommendations (n = 19) regarding rare, potentially life-threatening CVDs during pregnancy were recorded using a five-item Likert scale. Results: Opinions regarding eight statements (42%) varied substantially between specialties (p < 0.05). The most distinctive differences between physicians concerned the following recommendations: “thrombolysis should only be used in pulmonary embolism with cardiogenic shock” (agree: 52.7% of anaesthesiologists, 80.4% of cardiologists, 25.0% of gynaecologists; p < 0.001); “women with the antiphospholipid syndrome should restart treatment with vitamin K antagonists from the second trimester of pregnancy” (agree: 12.7% of anaesthesiologists, 69.4% of cardiologists, 20.0% of gynaecologists; p < 0.001); “women with symptomatic pulmonary hypertension should have a Swan–Ganz catheter inserted for labour” (agree: 20.0% of anaesthesiologists, 11.1% of cardiologists, 55.0% of gynaecologists; p = 0.001). Conclusions: Physicians’ opinions regarding diagnostics and treatment of CVDs in pregnancy remain controversial. A multidisciplinary approach is recommended to ensure the safety and effectiveness of management in these unique medical conditions.

Clinical management of the pregnant patient undergoing non-obstetric surgery: Review of guidelines

The management principles of non-obstetric surgery during pregnancy are important concepts for all health care providers to be cognizant of. The goals of non-obstetric surgery are to ensure maternal safety, maintain the pregnancy, and ensure fetal well-being. In this regard, organogenesis occurs roughly between days 7-57 and thus, certain medications have a higher incidence of fetal teratogenicity in this first trimester. Some examples of common surgeries performed urgently or emergently include appendectomies, ovarian detorsions, bowel obstruction, trauma, and cholecystectomies. The choice of anesthetic technique and the selection of appropriate anesthetic drugs should be guided by indication for surgery, the nature of the surgery, and the site of the surgical procedure. Many of the concerns for any patients undergoing urgent or emergent surgery must be considered by anesthesia providers along with steps to ensure the fetus has the best outcome.