Abdominal surgery in pregnancy--an interdisciplinary challenge

Anesthetic Management of the Pregnant Patient Undergoing Non-Obstetric Surgery

Anesthetic management of the pregnant patient undergoing non-obstetric surgery requires careful consideration of both maternal and fetal well-being. Key factors include appropriate drug selection to minimize fetal exposure, maintenance of uteroplacental perfusion, and management of physiological changes associated with pregnancy, such as altered respiratory function and increased blood volume. Regional anesthesia is often preferred to reduce the risks of general anesthesia, although considerations such as positioning, airway management, and monitoring are crucial. Multidisciplinary collaboration is essential to optimize outcomes, ensuring that both maternal health and fetal safety are prioritized throughout the perioperative period.

Case - Inferior vena caval thrombus associated with a left-sided renal cell carcinoma during pregnancy

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Perioperative management of surgical procedure during pregnancy: a systematic review

Background

Approximately 1-2% of pregnant women undergo non-obstetric surgery under anaesthesia during their pregnancy. This review specifically targets anaesthesia management for pregnant women undergoing non-obstetric surgery in resource-limited settings.

Methods

Following the delineation of primary questions, scope, and inclusion criteria, a comprehensive search strategy utilizing advanced techniques was implemented across electronic sources, databases, and websites to identify relevant articles. A rigorous screening process was applied during the literature evaluation. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement guided the conduct of this review, ensuring adherence to standardized reporting practices.

Results

A total of 240 articles were initially identified from databases and websites. After screening titles and abstracts, 85 papers were excluded, and an additional 43 were removed due to duplication. Subsequently, 68 items were subjected to eligibility screening. Finally, 30 papers that specifically addressed anaesthetic considerations for pregnant women undergoing non-obstetric operations were reviewed.

Conclusion

Thorough preoperative evaluation is essential for all patients, with particular attention to modifications in anaesthetic management to accommodate physiological changes during pregnancy. Urgent and emergent surgeries should proceed promptly during pregnancy to optimize outcomes for both the mother and foetus. Maintaining uteroplacental perfusion generally involves avoiding maternal hypoxaemia, hypotension, hyper- and hypocapnia, temperature extremes, and stress. When deemed safe, regional anaesthesia may offer favourable outcomes for both the mother and foetus.

Airway management and pulmonary aspiration during surgical interventions in pregnant women in the 2nd/3rd trimester and immediate postpartum - a retrospective study in a tertiary care university hospital

BACKGROUND

Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined.

METHODS

We performed a retrospective database review in a tertiary care university hospital to determine the incidence of pulmonary aspiration in pregnant patients undergoing endotracheal intubation, with and without Rapid Sequence Induction (RSI), as well as face-mask ventilation and supraglottic airway devices. We included Patients in the 2nd or 3rd trimester of pregnancy and immediate postpartum undergoing surgical procedures. The primary endpoint was the occurrence of pulmonary aspiration.

RESULTS

Data from 2,390 patients undergoing general anaesthesia for cerclage of cervix uteri, manual removal of retained placenta, repair of obstetric laceration, or postpartum bleeding were retrospectively evaluated. A supraglottic airway device or face-mask ventilation was used in 1,425/2,390 (60%) of patients, while 638/2,390 (27%) were intubated. RSI was used in 522/638 (82%) of patients undergoing tracheal intubation, or 522/2,390 (22%) of the entire cohort. In-depth review of the charts, including 54 patients who had been initially classified as "possible pulmonary aspiration" by anaesthetists, revealed that this adverse event did not occur in the cohort.

CONCLUSIONS

In conclusion, in this obstetric surgery patient population at risk for pulmonary aspiration, supraglottic airway devices were used in approximately 60% of cases. Yet, no aspiration event was detected with either a supraglottic airway or endotracheal intubation.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Laparoscopic appendectomy vs open appendectomy during pregnancy: a systematic re-view

BACKGROUND

Acute appendicitis and cholecystitis during pregnancy are the most common non-obstetrical surgical emergencies and can create severe clinical issues. Surgical treatment tends to be the method physicians recommend due to its tolerability and safety. During pregnancy, surgical intervention should minimize fetal risk without compromising the mother's health, although a favorable outcome for pregnant women is heavily dependent on accurate, early diagnosis and prompt intervention. Furthermore, the physicians should remain informed on the differences in current techniques to optimize the outcome of the operation.

METHODS

This article performs a systematic review of the literature to examine whether laparoscopic treatment of acute appendicitis in pregnancy is a better option when compared to open surgery. We searched all major medical databases, identified the most relevant published studies on the subject, and performed a statistical analysis to answer that question.

RESULTS

We identified 15 studies for inclusion, and their data were extracted. The resulting pool referred to 2,837 pregnant patients. Of those included patients, 1,103 underwent laparoscopic surgery and 1,656 had open surgery. All surgeries occurred in the second trimester. For laparoscopic surgery, the fetal demises rate was 2.44 % (27 deaths), and the preterm deliveries rate was 9.79 % (108 deliveries) as opposed to open surgery with a fetal demise rate of 2.64 % (48 deaths), and preterm deliveries rate at 10.7 % (178 deliveries).

CONCLUSIONS

Our meta-analysis and data suggest that laparoscopic appendectomy is a safer option for treatment. There is a reduced risk of fetal demise and preterm delivery for pregnant women. HIPPOKRATIA 2022, 26 (1):1-6.

Association of treatments for acute appendicitis with pregnancy outcomes in the United States from 2000 to 2016: Results from a multi-level analysis

Background

Open appendectomy, laparoscopic appendectomy, and non-surgical treatment are three options to treat acute appendicitis during pregnancy. Previous studies on the association of different treatment methods for acute appendicitis with pregnancy outcomes have been limited by small sample sizes and residual confounding, especially with respect to hospital-level factors. This study aimed to investigate the association of treatment method for acute appendicitis with pregnancy outcomes using a multi-level analysis.

Methods

A retrospective cohort study was conducted based on a large electronic health records database in the United States during the period 2000 to 2016. All pregnancies diagnosed with acute appendicitis and treated in participating hospitals during the study period were included. We conducted multi-level hierarchical logistic regression to analyze both individual- and hospital-level factors for abortion, preterm labor, and cesarean section.

Results

A total of 10,271 acute appendicitis during pregnancy were identified during the study period. Of them, 5,872 (57.2%) were treated by laparoscopic appendectomy, 1,403 (13.7%) by open appendectomy, and 2,996 (29.2%) by non-surgical treatment. Compared with open appendectomy, both laparoscopic appendectomy (adjusted OR, 0.6, 95% CI, 0.4, 0.9) and non-surgical treatment (adjusted OR, 0.4; 95% CI, 0.3–0.7) showed a decreased risk of preterm labor. Other important individual-level determinants of adverse pregnancy outcomes included maternal age, gestational hypertension, and anemia during pregnancy, the hospital-level determinant included the number of beds.

Conclusions

Compared with open appendectomy, both laparoscopic appendectomy and non-surgical treatment may be associated with a lower risk of preterm labor, without increased risks of abortion and cesarean section.

Effects of sevoflurane general anesthesia during early pregnancy on AIM2 expression in the hippocampus and parietal cortex of Sprague-Dawley offspring rats

The aim of the present study was to investigate the effect of exposure to sevoflurane general anesthesia during early pregnancy on interferon-inducible protein AIM2 (AIM2) expression in the hippocampus and parietal cortex of the offspring Sprague-Dawley (SD) rats. A total of 18 SD rats at a gestational age of 5-7 days were randomly divided into three groups: i) A control group (control); ii) 2-h sevoflurane general anesthesia, group 1 (S1); and iii) 4-h sevoflurane general anesthesia, group 2 (S2). The six offspring rats in each group were maintained for 30 days and assessed by Morris water maze testing. Brain specimens were collected from offspring rats 30 days after birth. Changes in the structural morphology of neurons in the hippocampus and parietal cortex were observed using hematoxylin and eosin staining. Nissl bodies in the hippocampus and parietal cortex were observed by Nissl staining. The expression of glial fibrillary acidic protein (GFAP), AIM2, CD45 and IL-1β was detected by immunohistochemistry and the protein levels of CD45, IL-1β, pro-caspase-1 and caspase-1 p10 were detected by western blotting. Compared with the control group, offspring rats in the S1 and S2 groups exhibited poor long-term learning and memory ability and experienced different degrees of damage to both the hippocampus and parietal cortex. The expression levels of GFAP, AIM2, CD45, IL-1β, caspase-1 and caspase-1 p10 in the offspring of both the S1 and the S2 groups were significantly increased (P<0.05) compared with offspring of the control group. Moreover, compared with the offspring of the S1 group, hippocampal and parietal cortex injury in the offspring of the S2 group was further aggravated, and the expression of GFAP, AIM2, CD45, IL-1β, pro-caspase-1 and cleaved-caspase-1 was significantly increased (P<0.05). In conclusion, sevoflurane general anesthesia in SD rat early pregnancy promoted the expression of AIM2 and the inflammatory response in the hippocampus and parietal cortex of offspring rats.

Do Small Incisions Need Only Minimal Anesthesia?-Anesthetic Management in Laparoscopic and Robotic Surgery

Laparoscopic techniques have established themselves as a major part of modern surgery. Their implementation in every surgical discipline has played a vital part in the reduction of perioperative morbidity and mortality. Precise robotic surgery, as an evolution of this, is shaping the present and future operating theatre that an anesthetist is facing. While incisions get smaller and the impact on the organism seems to dwindle, challenges for anesthetists do not lessen and could even become more demanding than in open procedures. This review focuses on the pathophysiological effects of contemporary laparoscopic and robotic procedures and summarizes anesthetic challenges and strategies for perioperative management.

Metastatic colorectal cancer during pregnancy: A tertiary center experience and review of the literature

Background

Colorectal cancer during pregnancy is rare. Diagnosis may be delayed and clinicians are faced with unique challenges when formulating management plans, having to consider the well-being of both fetus and mother.

Cases

Our series outlines five cases of metastatic colorectal cancer during pregnancy. There was one patient who presented in each of the first, second and third trimesters, whilst the remaining were post-partum. Diagnosis was difficult as the patients were either asymptomatic or their symptoms were misconstrued as features of pregnancy. Two patients received chemotherapy while pregnant but only one had a successful delivery. Survival of patients in this series ranged between 1 and 35 months from diagnosis.

Conclusion

Women with gestational colorectal cancer are often diagnosed at an advanced stage and have a poor prognosis.

Accuracy of ultrasonography in diagnosing acute appendicitis during pregnancy based on surgical findings

Background: Acute appendicitis is the most common nonobstetric surgical problem in pregnancy. Common signs and symptoms of appendicitis are less reliable during pregnancy due to physiological changes; thus, the role of imaging becomes prominent. Thus, in the present study, we aimed at assessing the accuracy of sonography in diagnosing acute appendicitis during pregnancy. Methods: In this prospective analytic study, among 1000 patients diagnosed and treated as acute appendicitis, clinical and sonographic findings of 58 consecutive pregnant patients, who underwent appendectomy, were recorded and analyzed. All surgically resected samples were evaluated and confirmed through histological evaluation. Sonographic criteria were utilized to judge the results for appendicitis. Diagnostic test performance characteristics (sensitivity, specificity, predictive values, and likelihood ratios) were calculated. Results: The mean age of the patients was 27.1±4.9 years, and the most common clinical symptom was right lower quadrant pain. There was no significant difference in the mean leukocyte count between the appendicitis group and normal appendix group (p=0.768). Left shift was also unrelated with the appendix pathology (p= 0.549). The sensitivity, specificity, predictive values (positive and negative), and likelihood ratios (positive and negative) were 80%, 75%, 91.4%, 52.9%, 3.2, and 0.26, respectively during all trimesters of pregnancy. Conclusion: Ultrasonography is the initially preferred imaging modality in pregnant women suspected of having acute appendicitis with an acceptable sensitivity; however, application of other imaging modalities such as CT scan or MRI is recommended after inconclusive ultrasonography results.

Endometriosis-associated Maternal Pregnancy Complications - Case Report and Literature Review

The incidence of endometriosis is increasing. Particularly during pregnancy and labour, clinicians should be alert to possible endometriosis-associated complications or complications of previous endometriosis treatment, despite a low relative risk. In addition to an increased rate of early miscarriage, complications such as spontaneous bowel perforation, rupture of ovarian cysts, uterine rupture and intraabdominal bleeding from decidualised endometriosis lesions or previous surgery are described in the literature. Unfavourable neonatal outcomes have also been discussed. We report on an irreducible ovarian torsion in the 16th week of pregnancy following extensive endometriosis surgery, and an intraabdominal haemorrhage due to endometriosis of the bowel in the 29th week of pregnancy.

Meckel's diverticular perforation presenting as acute abdomen in the second trimester of pregnancy

Meckel's diverticular perforation is a rare cause of acute abdomen during pregnancy. We report the case of a 24-year-old woman at 24 weeks of gestation who presented with abdominal pain for 4 days accompanied with abdominal distension, tenderness and guarding in right lower quadrant. Ultrasonography was inconclusive. The patient underwent exploratory laparotomy with the clinical suspicion of appendicular perforation peritonitis. Intraoperatively, a perforated Meckel's diverticulum was detected. Owing to gross contamination of the peritoneal cavity, a diverticulectomy with ileostomy was performed. She had a normal full-term vaginal delivery, and ileostomy was reversed 1 month after delivery. The physiological and anatomical changes in pregnancy can make a straightforward clinical diagnosis difficult. A high index of suspicion is required to prevent delay in diagnosis and surgical intervention, which could prove detrimental to the mother and fetus.

Laparoscopic Sleeve Gastrectomy in the Postpartum Period: Increased Risk of Bleeding, a Challenging Situation

The female population represents three-fourths of patients undergoing a bariatric procedure and could be scheduled for surgery in their postpartum period. We report a difficult case of a female patient who underwent a laparoscopic sleeve gastrectomy 6 weeks postpartum. The postpartum period is accompanied by pronounced vasodilatation with transient portal hypertension. Most of the hemodynamic alterations occurring during pregnancy return to baseline within 6-8 weeks after delivery. Bariatric surgery in the postpartum period should be avoided in order for the cardiovascular system to regain its normality.