Anesthesia for non-obstetric surgery during pregnancy in a tertiary referral center: a 16-year retrospective, matched case-control, cohort study.

INTRODUCTION: This retrospective, matched case-control cohort study describes the incidence, indications, anesthesia techniques and outcomes of pregnancies complicated by surgery in a single tertiary-referral hospital. METHODS: Retrospective review of the hospital records of 171 patients who had non-obstetric surgery in the current pregnancy, between 2001 and 2016. Pregnancy outcomes of these women were firstly compared with all contemporary non-exposed patients (n=35 411), and secondly with 684 non-exposed control patients, matched for age, time of delivery and parity. RESULTS: The incidence of non-obstetric surgery during pregnancy was 0.48%, mostly performed during the second trimester (44%) and under general anesthesia (81%). Intra-abdominal surgery (44%) was the most commonly performed procedure, predominantly using laparoscopy (79%). Women undergoing surgery delivered earlier and more frequently preterm (25% vs. 17%, P=0.018); and birth weight was significantly lower [median (95% CI) 3.16 (3.06 to 3.26) vs. 3.27 (3.22 to 3.32) kg, P=0.044]. When surgery was performed under general anesthesia, low birth weight was more frequent (22% vs 6%, P=0.046). Overall pregnancy outcomes were neither influenced by trimester nor location (intra- vs extra-abdominal) of surgery. However, preterm birth rate secondary to surgery was higher for interventions during the third trimester, compared with other trimesters (10% vs 0, P <0.001). CONCLUSION: Pregnant women who underwent surgery delivered preterm more frequently and their babies had lower birth weights. Laparoscopic surgery did not increase the incidence of adverse pregnancy outcomes. General anesthesia was associated with low birth weight. Whether these associations suggest causation or reflect the severity of the underlying condition remains speculative.

Fetal stress hormone changes during intrauterine transfusions.

OBJECTIVE: To document fetal stress hormone and Doppler changes after intrauterine transfusions (IUTs) in either the intrahepatic portion of the umbilical vein (IHV) or the placental cord insertion (PCI). METHOD: Pregnant women scheduled for IUT for fetal anemia (N = 25) were included prospectively. Cortisol, ß-endorphin and noradrenalin concentrations in fetal plasma and middle cerebral artery pulsatility index before and after transfusion were compared. Transfusions were performed through the (IHV), thus puncturing the fetus, or at the PCI. RESULTS: There were no measurable differences between the transfusion sites. CONCLUSION: In anemic fetuses undergoing transfusion, Doppler changes and fetal stress hormone changes were unrelated to the site of needle insertion.

Effects of epidural clonidine and neostigmine following intrathecal labour analgesia: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: The limited duration of spinal labour analgesia combined with problems associated with maintenance of epidural analgesia, have prompted the search for combinations that could prolong spinal analgesia. A randomised, double-blind trial was carried out to test the hypotheses (a) that initial spinal labour analgesia is prolonged by administering clonidine and neostigmine epidurally whilst (b) the hourly local anaesthetic consumption is reduced. METHODS: Seventy labouring patients received spinal analgesia with ropivacaine and sufentanil. Fifteen minutes after spinal injection, 10 mL of study solution was administered epidurally. The study solution was plain saline or neostigmine 500 microg combined with clonidine 75 microg. Outcome parameters were duration of spinal analgesia, local anaesthetic consumption and number of patients delivering without additional epidural analgesia. RESULTS: Epidural clonidine and neostigmine significantly prolonged initial analgesia: 144 (105-163) min vs. 95 (70-120) min in the placebo group and reduced hourly ropivacaine consumption: 7.5 (3.0-11.9) mg vs. 12.7 (9.6-16.9) mg. More patients in the experimental group delivered before the first request for additional analgesia (9 vs. 2). CONCLUSION: Epidural administration of neostigmine 500 microg and clonidine 75 microg, following the intrathecal injection of ropivacaine and sufentanil, prolongs analgesia and reduces hourly ropivacaine consumption.

Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department.

BACKGROUND: Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anaesthesia. METHODS: Between January 1997 and October 2006 in our tertiary obstetric referral centre 17 198 neuraxial blocks were recorded; 965 epidural, 16193 combined spinal-epidural and 40 spinal. Records of all parturients who experienced either ADP or PDPH were reviewed. RESULTS: There were 89 ADPs (0.5%), 55 observed and 34 in which PDPH followed unrecognised dural puncture. Following known ADP, 28 women had epidural catheters re-sited at a different lumbar interspace and 27 had intrathecal catheters for at least 24 h. Thirty-one women developed PDPH after observed ADP; the incidence of PDPH was similar after puncture with needle and catheter, after epidural and CSE techniques, after 27- and 29-gauge pencil-point spinal needles and after spinal and epidural catheter insertion (61% vs 52%; P>0.05). All headaches presented within 72 h. A blood patch was needed in 26/55 women after known ADP and 27/34 unrecognised ADP. A repeat blood patch was needed in 8 (15%). DISCUSSION: The incidence of ADP, PDPH, blood patching and repeat blood patching is similar to previous studies. Many ADPs are unrecognised during epidural insertion. CSE does not appear to increase the risk of ADP or PDPH; 29-gauge rather than 27-gauge pencil-point spinal needles conferred no benefit. Inserting the epidural catheter intrathecally did not significantly reduce the incidence of PDPH and blood patching in our series.

Anesthesia for non-obstetric surgery in the pregnant patient.

Surgery during pregnancy is relatively common. The present review of the literature will focus on relevant issues such as maternal safety during non-obstetric surgery in pregnancy, teratogenicity of anesthetic drugs, the avoidance of fetal asphyxia, the prevention of preterm labor, the safety of laparoscopy, the need to monitor the fetal heart rate and will finally give a practical approach to manage these patients.