Prenatal anesthetic exposure and offspring neurodevelopmental outcomes-A narrative review.

While it is common for pregnant women to take anesthesia during surgery, the effects of prenatal anesthesia exposure (PAE) on the long-term neurodevelopment of the offspring remain to be clarified. Preclinical animal research has shown that in utero anesthetic exposure causes neurotoxicity in newborns, which is mainly characterized by histomorphological changes and altered learning and memory abilities. Regional birth cohort studies that are based on databases are currently the most convenient and popular types of clinical studies. Specialized questionnaires and scales are usually employed in these studies for the screening and diagnosis of neurodevelopmental disorders in the offspring. The time intervals between the intrauterine exposure and the onset of developmental outcomes often vary over several years and accommodate a large number of confounding factors, which have an even greater impact on the neurodevelopment of the offspring than prenatal anesthesia itself. This narrative review summarized the progress in prenatal anesthetic exposure and neurodevelopmental outcomes in the offspring from animal experimental research and clinical studies and provided a brief introduction to assess the neurodevelopment in children and potential confounding factors.

Fetal outcomes with and without the use of sugammadex in pregnant patients undergoing non-obstetric surgery: a multicenter retrospective study.

BACKGROUND: The influence of sugammadex exposure during pregnancy on progesterone withdrawal and miscarriage is unknown. We aimed to compare the fetal outcomes in pregnant patients who had undergone non-obstetric surgery with and without sugammadex. METHODS: We retrospectively reviewed the medical charts of pregnant women who underwent non-obstetric surgery at three tertiary perinatal care centers in Japan from January 2013 to December 2020. The women were divided into those who received general anesthesia with sugammadex (GA with SGX) and those who received general anesthesia without sugammadex (GA without SGX). We compared miscarriages and preterm births within four weeks after surgery. RESULTS: Among the 124 women, 73 and 51 were included in the GA with SGX and GA without SGX groups, respectively. The two groups showed no differences in the rate of miscarriages or preterm births (3.0 % vs 4.3 %; odds ratio 1.42, 95 % confidence interval 0.19 to 10.47; P = 1.00). The SGX and no SGX groups were missing outcomes for 8.2 % and 7.8 % of cases, respectively. CONCLUSIONS: Having GA with SGX or GA without SGX did not result in different rates of miscarriage or preterm birth within four weeks after the procedure. These findings do not exclude a potential association between sugammadex exposure during pregnancy and adverse pregnancy outcomes. Missing data may have obscured possible adverse outcomes from sugammadex exposure.

Acute intestinal obstruction in pregnancy after previous gastric bypass: A case report.

Background: Intestinal obstruction is an extremely rare condition among pregnant women, but it can be life-threatening for both mother and fetus. Case presentation: A woman in her late twenties with no history of previous pregnancies was admitted to hospital due to regular preterm contractions and cervical shortening. Seven days after her admission, while the contractions had stopped and cervical length was stable, she complained of acute abdominal pain. Bowel obstruction was suspected due to the patient's history of gastric bypass 5 years earlier for weight loss. Computed tomography was not performed due to risk of fetal irradiation. Conservative management was attempted, but the patient stopped passing flatus and started vomiting. The fetus was delivered by emergency exploratory laparotomy, during which small bowel obstruction due to adhesions was identified and resolved. Conclusion: Although uncommon during pregnancy, small bowel obstruction is far more common in women who have had previous abdominal operations, especially involving the stomach. Obstetricians must maintain a high level of suspicion since this condition can be life-threatening for both the mother and the fetus.

Can Ultrasound-Guided Femoral Vein Measurements Predict Spinal Anesthesia-Induced Hypotension in Non-Obstetric Surgery? A Prospective Observational Study.

Background and objectives: To investigate whether ultrasound (US)-guided femoral vein (FV) and inferior vena cava (IVC) measurements obtained before spinal anesthesia (SA) can be utilized to predict SA-induced hypotension (SAIH) and to identify risk factors associated with SAIH in patients undergoing non-obstetric surgery under SA. Methods: This was a prospective observational study conducted between November 2021 and April 2022. The study included 95 patients over the age of 18 with an American Society of Anesthesiologists (ASA) physical status score of 1 or 2. The maximum and minimum diameters of FV and IVC were measured under US guidance before SA initiation, and the collapsibility index values of FV and IVC were calculated. Patients with and without SAIH were compared. Results: SAIH was observed in 12 patients (12.6%). Patients with and without SAIH were similar in terms of age [58 (IQR: 19-70) vs. 48 (IQR: 21-71; p = 0.081) and sex (males comprised 63.9% of the SAIH and 75.0% of the non-SAIH groups) (p = 0.533). According to univariate analysis, no significant relationship was found between SAIH and any of the FV or IVC measurements. Multiple logistic regression analysis revealed that having an ASA class of 2 was the only independent risk factor for SAIH development (p = 0.014), after adjusting for age, sex, and all other relevant parameters. Conclusions: There is not enough evidence to accept the feasibility of utilizing US-guided FV or IVC measurements to screen for SAIH development in patients undergoing non-obstetric surgery under SA. For this, multicenter studies with more participants are needed.

Sugammadex administration in pregnant patients undergoing non-obstetric surgery: a case series.

The use of sugammadex for reversal of rocuronium-induced neuromuscular blockade after caesarean section is nowadays common practice, but concerns exist about its use in pregnant women undergoing non-obstetric surgery. We report six cases of pregnant women submitted to general anesthesia for non-obstetric surgery in which neuromuscular blockade was reversed with sugammadex. We followed the outcome of both mother and baby during and after delivery. Sugammadex seemed to be a safe option for both mother and baby but more reports are necessary to fill the evidence gap and increase the global knowledge about its safety in this special group of patients.

Fetal heart rate mirrors maternal temperature during posterior fossa craniotomy: a case report.

While it is well known that maternal temperature affects fetal heart rate, the exact relationship is not well described. The circumstances accompanying most cases of maternal hypothermia and rewarming (e.g. a drowning event) have precluded a precise quantitative description of this relationship. We describe hypothermia and controlled rewarming during resection of a maternal brain stem tumor in the early third trimester. Continuous electronic fetal heart rate and core temperature monitoring demonstrated a near linear relationship during the development of hypothermia and rewarming. Recognition of the close relationship between maternal temperature and fetal heart rate can help safeguard maternal and fetal health, and prevent unnecessary delivery during non-obstetric surgery in pregnancy.

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.

Intraoperative fetal heart monitoring for non-obstetric surgery: A systematic review.

Limited data are available on fetal monitoring during non-obstetric surgery in pregnancy. We performed a systematic review to evaluate the incidence of emergent cesarean delivery performed for non-reassuring fetal heart rate patterns during non-obstetric surgery. Electronic databases were searched from their inception until October 2018 without limit for language. We included studies evaluating at least five cases of intraoperative fetal heart rate monitoring -either with ultrasound or cardiotocography- during non-obstetric surgery in pregnant women at ≥22 weeks of gestation. The primary outcome was the incidence of intraoperative cesarean delivery performed for non-reassuring fetal heart rate monitoring. Non-reassuring fetal heart rate monitoring was defined by attendant personnel, meeting NICHD criteria for category II or III patterns. Data extracted regarded type of study, demographic characteristics, maternal and perinatal outcomes. Statistical analysis was performed for continuous outcomes by calculating mean and standard deviations for appropriate variables. Of 120 studies identified, 4 with 41 cases of intraoperative monitoring met criteria for inclusion and were analyzed. Most (66%) surgeries were indicated for neurological or abdominal maternal issues and were performed under general anesthesia (88%) at a mean gestational age of 28 weeks. Minimal or absent fetal heart variability was noted in most cases and a 10-25 beats per minutes decrease in fetal heart rate baseline was observed in cases with general anesthesia. No intraoperative cesarean deliveries were needed. The incidence of non-reassuring fetal heart rate monitoring was 4.9% (2/41) and were limited to fetal tachycardia during maternal fever. Two (4.9%) cases of non-reassuring fetal heart rate monitoring were noted within the immediate 48 h after surgery, necessitating cesarean delivery. A single case of intrauterine fetal demise occurred four days postoperatively in a woman who had neurosurgery and remained comatose. In conclusion, limited data exist regarding the clinical application of fetal heart rate monitoring at viable gestational ages during non-obstetric surgical procedures. Fetal heart rate monitoring during non-obstetric surgery at ≥22 weeks was not associated with need for intraoperative cesarean delivery, but two (4.9%) cesarean deliveries were performed for non-reassuring fetal heart rate monitoring within 48 h after surgery.

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.

Research Progress of Developmental Neurotoxicity Induced by General Anesthetics / 中山大学学报(医学科学版)

@#With the rapid development of surgery and the expansion of indications for surgical treatment ，the number of non-obstetric operations during pregnancy and infant operations has been increasing. Most of these operations need to be performed under general anesthesia，and the developing brain of fetus and infants are inevitably exposed to general anesthetics. Therefore，in recent years，the neurotoxicity effects of general anesthetics on the developing brain have become the focus and controversy in the medical sciences. Especially in 2016，US Food and Drug Administration（FDA）added black box for warning of general anesthetics commonly used in clinic，which caused confusion among doctors，patients and staffs in the related fields. Therefore，we will elaborate the preclinical and clinical studies of neurotoxicity of general anesthetics in combination with the characteristics of developing brain.

Operative Management of Perinatal Lumbar Disc Herniation and Cauda Equina Syndrome: A Case Series

Introduction Perinatal lumbar discectomy for lumbar disc herniation or cauda equina syndrome is a rare clinical scenario. This case series outlines the surgical management of this clinical scenario at a national tertiary referral centre over a 10-year period Methods A retrospective review of all females who underwent discectomy / decompression for lumbar disc herniation or cauda equina syndrome in the perinatal period at a national tertiary referral centre for spine surgery over a 10-year period between January 2008 to December 2017. Results 6 cases required surgical intervention. All patients were successfully managed with surgical decompressive procedures and recovered well in the postoperative period without complication. Conclusions The principles of management remain the same in the pregnant and non-pregnant populations, although treatment options are complicated by the desire to avoid risk to the developing foetus. Surgical intervention is safe to both mother and baby and if performed promptly is associated with an excellent functional outcome.

Anaesthesia for non-obstetric surgery in obstetric patients.

Anaesthesia for pregnant patients presenting for non-obstetric surgery needs a thorough understanding of the physiological changes and altered pharmacokinetics of pregnancy. Considering the effects of surgery and anaesthesia on the foetus, only essential and emergency surgeries are performed during pregnancy. Surgical procedures in second trimester have the advantage of better foetal outcome. The primary concerns of maternal and foetal safety are achieved by a focused multidisciplinary team-based approach with respect to the surgical condition. Meticulous attention to preoperative patient counselling, airway management, haemodynamic stability, and thromboprophylaxis are the key factors in anaesthetic management. Choice of anaesthesia or anaesthetic drugs has minimal impact on the foetus provided utero-placental perfusion and uterine relaxation are maintained. Foetal monitoring when feasible and when done by a trained person enables to diagnose and treat the factors responsible for foetal heart rate variability. Anaesthetic technique needs to be modified according to the type of surgery.

Propofol's Effects on the Fetal Brain for Non-Obstetric Surgery.

While the use of Propofol has been increasing in usage for general surgical procedures since its release to market, there has been little work done on its potential link to neurotoxicity in humans. Only recently, following the release of a warning label from the United States Food and Drug Administration (USFDA) regarding a potential link to "neurotoxicity" in the neonate, did the surgical and anesthesiology communities become more aware of its potential for harm. Given the widespread use of this drug in clinical practice, the warning label naturally raised controversy regarding intrapartum Propofol usage. While intended to generate further studies, the lack of a viable anesthetic alternative raises issues regarding its current usage for surgical procedures in pregnant women. To answer the question whether current evidence is supportive of Propofol usage at its current levels in pregnant women, this review summarizes available evidence of fetal Propofol exposure in animal studies.

Damage caused by exposure to propofol during gestation of mice / Danos causados pela exposição ao propofol durante a gestação em camundongos

Literature shows that surgical procedure could be necessary at any stage of pregnancy and can cause adverse effects on the mother and fetus. One of the most used anesthetics in surgical centers is propofol however; the safety during pregnancy has not been completely established. The objective of this study was to investigate the possible toxic and teratogenic effects on the intrauterine and post-natal development of mice exposed to the dose of 15 mg kg- 1 propofol on the caudal vein fifth, tenth and fifteenth day of gestation. A significant reduction in weight gain was observed in female mice who received a 15 mg kg-1 dose of propofol on the fifth gestational day. A higher rate of embryonic loss post implantation and resorption was also observed in this group. In regards to physical development, the anesthetic increased significantly the offspring weight gain, the time in which pinna detachment occurred, and the anogenital distance of pups whose females received propofol on the fifteenth day of gestation. Based on these results, we concluded that administration of propofol in the beginning stages of gestation increases the number of abortions and promotes alterations in the physical development of pups whose mothers were anesthetized in the final stages of gestation.

A literatura mostra que o procedimento cirúrgico pode ser necessário em qualquer fase da gravidez podendo causar efeitos adversos sobre a mãe e o feto. Um dos anestésicos mais utilizados nos centros cirúrgicos é o propofol, no entanto, a sua segurança durante a gravidez não foi completamente estabelecida. O objetivo deste estudo foi investigar os possíveis efeitos tóxicos e teratogênicos no desenvolvimento intrauterino e pós-natal de camundongos expostos à dose de 15 mg kg-1 de propofol no quinto, décimo e décimo quinto dia de gestação. Observou-se uma redução significativa no ganho de peso em camundongos fêmeas que receberam uma dose de 15 mg kg-1 de propofol no quinto dia de gestação. Uma taxa maior de perda embrionária pós-implantação e reabsorção também foi observada neste grupo. Em relação ao desenvolvimento físico, o anestésico alterou significativamente o ganho de peso da prole, o tempo em que ocorreu o desprendimento da orelha e a distância anogenital dos filhotes cujas fêmeas receberam propofol no décimo quinto dia de gestação. Com base nesses resultados, concluiu-se que a administração de propofol nos estágios iniciais da gestação aumenta o número de abortos e promove alterações no desenvolvimento físico de filhotes cujas mães foram anestesiadas nos estádios finais da gestação.

Anaesthesia for non-obstetric surgery during pregnancy.

Non-obstetric surgery during pregnancy posts additional concerns to anaesthesiologists. The chief goals are to preserve maternal safety, maintain the pregnant state and achieve the best possible foetal outcome. The choice of anaesthetic technique and the selection of appropriate anaesthetic drugs should be guided by indication for surgery, nature, and site of the surgical procedure. Anaesthesiologist must consider the effects of the disease process itself and inhibit uterine contractions and avoid preterm labour and delivery. Foetal safety requires avoidance of potentially dangerous drugs and assurance of continuation of adequate uteroplacental perfusion. Until date, no anaesthetic drug has been shown to be clearly dangerous to the human foetus. The decision on proceeding with surgery should be made by multidisciplinary team involving anaesthesiologists, obstetricians, surgeons and perinatologists. This review describes the general anaesthetic principles, concerns regarding anaesthetic drugs and outlines some specific conditions of non-obstetric surgeries.

Popliteal Sciatic Nerve Block in a Pregnant Patient in the Last Trimester.

Although regional anaesthesia is a commonly preferred anaesthesia technique for pregnant patients undergoing non-obstetric surgery, peripheral nerve blocks are relatively less administered. The use of popliteal sciatic nerve block for foot-ankle surgery has been presented for a nulliparous parturient at 32 weeks of gestation scheduled to undergo surgical exploration of an arterial pseudoaneurysm on her right plantar surface due to a penetrating stab injury. Since surgery did not require pneumatic tourniquet, the sciatic nerve was blocked via the popliteal approach with a single shot injection of 30 mL of 0.375% levobupivacaine. The operation and the anaesthesia course were uneventful. In conclusion, popliteal sciatic nerve block was successful and uneventful for a short foot surgery not requiring tourniquet application in a parturient in the last trimester.

Anesthetic management of a pregnant patient with pseudo-pancreatic cyst for cysto-gastrostomy.

Non-obstetric diseases during pregnancy are not uncommon. The presence of systemic disease may further insult the pregnancy leading to alteration in the normal function of other system. Hence, it is important to treat the disease depending upon the severity and type of urgency. Several systemic diseases in pregnancy and management have been reported earlier but it is necessary to report a rare pathology, treatment option and its anesthetic management. We report anesthetic management of a rare case of pseudo pancreatic cyst in a pregnant lady operated for cysto-gastrostomy and also highlighting the recent guidelines for non-obstetric surgery in pregnancy.