[CG] Surgery during pregnancy - incidental

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Key Messages

  •  All females of child bearing age should have their pregnancy status clarified on admission to hospital.
  •  Gestation should be established from a valid EDD:
    • Request maternity notes via Maternity Hospital Coordinator
    • If gestation cannot be established from booking scan in notes, discuss with Obstetrics StR regarding further US scan
  • The patient should have a named consultant obstetrician
  • Where gestation is > 20+0 weeks, Surgery should be performed in a centre with obstetric and neonatal services on site wherever feasible.
  • Multi-disciplinary planning is essential
  • In the rare situation that surgery cannot be performed in a centre with on-site obstetric and neonatal services, the consultant Obstetrician from the patient’s maternity unit should be contacted at the earliest opportunity. Where possible, an appropriate team will be deployed dependent on the gestational age of the fetus.  

Applicable Unit Policies

Background

  • It is estimated that 0.2% of parturients will require a surgical procedure whilst pregnant1
  • Indications for surgery may be pregnancy or non-pregnancy related
  • To maintain maternal safety the physiological and anatomical changes of pregnancy must be considered and surgical and anaesthetic techniques modified accordingly
  • Fetal wellbeing is related to the avoidance of fetal asphyxia, teratogenic drugs and preterm labour. Maternal hypoxia, extreme hypo or hypercarbia, hypotension and uterine hypertonus must be avoided.
  • A review examining 54 studies (12,452 patients) concluded;

The risk of maternal death appears to be very low; surgery and anaesthesia do not appear to be major risk factors for spontaneous abortion.  Non-obstetric surgery does not increase the risk of major birth defects. Acute appendicitis (especially when accompanied by peritonitis) appears to be a genuine risk for surgery induced labour or fetal loss”2

  • Surgery should be performed in the second trimester where possible. Elective surgery is generally postponed until at least 6 weeks after delivery.  However, a pregnant woman should never be denied indicated surgery, regardless of trimester3
  • Pregnancy is not a contraindication for laparoscopic surgery. Discussion with an obstetrician is advised and consideration should be given to fetal monitoring.  Intra-abdominal pressures should be kept below 12mmHg.
  • Anti-D should be considered in patients who are rhesus negative as surgery is a potentially sensitizing event (PSE). This should be discussed with the obstetrician:
    • < 12 weeks gestation – anti D not required
    • o 12 – 20 weeks – 25OU IM anti-D into deltoid within 72 hours of PSE.
    • >20 weeks – Kleihauer test, 500U IM anti-D within 72 hours of PSE. Further doses as directed by Kleihauer result (discuss with obstetrician/haematologist).
  • An abdominal shield should be employed wherever possible if radiation exposure is expected during surgery.

Hospital with on-site obstetric and neonatal services: management of pregnant patient requiring emergency surgery

Hospital with NO on-site obstetric and neonatal services: management of pregnant patient requiring emergency surgery

Guidance for anaesthetists

Pre-operative

  • Ensure FBC and G+S sent (other bloods dependent on clinical situation). Note Rhesus status
    and if rhesus –ve, consider anti-D as directed above
  • Discuss case with ‘Senior on’ anaesthetic consultant. Obstetric anaesthetic consultant should be informed in all cases over 20 weeks gestation and in any other case where advice is required
  • Give Ranitidine 150mg po or 50mg IV pre-operatively
  • Give Sodium Citrate 0.3M oral solution prior to induction in patients > 16 weeks gestation (can be obtained from labour ward)
  • Ensure availability of Syntocinon, Ergometrine, Syntometrine and Hemabate®
  • Site 14 / 16G cannula(e)

Intra-operative

  • 15° left lateral tilt mandatory after 16 weeks and consider at earlier gestation if hypotensive, symptomatic, or large bump (e.g. multiples)
  • Regional technique preferable where feasible. N.B. Uteroplacental circulation is not auto-regulated and perfusion is entirely dependent on maintenance of adequate maternal blood pressure and cardiac output. Placental perfusion must be maintained by rapid treatment of any hypotension
  • Smaller volumes of local anaesthetic required for spinal / epidural blockade. Spinal dose of 2.5ml 0.5% heavy bupivacaine + 0.3mg diamorphine used to achieve block to T4 for caesarean section at term. Greater than 2.5ml used in preterm, IUGR etc. Advice can be obtained from consultant obstetric anaesthetist
  • If GA, careful pre-oxygenation - consider head up position, ramping, Oxford pillow, nasal prongs
  • RSI after 16 weeks or if symptomatic of reflux
  • Use stubby handle and have video-laryngoscope available
  • Use small ETT (size 7). Have bougie / stylet available
  • Thiopentone and Suxamethonium are standard for RSI in obstetric patients (though other induction agents and neuromuscular blockers may be used depending on individual preference)
  • Consider short acting opioid to obtund response to intubation in presence of hypertension / preeclampsia. If these conditions are present, consultant obstetric anaesthetist should attend wherever possible
  • Use of drugs with established safety profile - Thiopentone, Suxamethonium, opioids, neuromuscular blockers, Ondansetron, volatile agents, local anaesthetics
  • MHRA suggests Nitrous Oxide best avoided in first trimester (though not absolutely contraindicated if benefits thought to outweigh risk)”
  • Avoid NSAIDs and Ketamine before delivery
  • ETCO2 should be kept in the normal pregnant range (3.7-4.2kPa)
  • Consider arterial line and PaCO2 monitoring in laparoscopic patients as PaCO2 may be significantly greater than ETCO2
  • Maintain SBP within 20% of pre-operative levels (placental flow dependent on maternal BP / CO)
  • Phenylephrine is commonly used to treat hypotension. Make up as Phenylephrine 10mg in 500ml (20 micrograms/ml).  Give either as Phenylephrine infusion (50ml syringe in PK pump at 60100ml/hr) or as Phenylephrine 40-60 microgram boluses
  • Reversal with Neostigmine and Atropine (Neostigmine crosses the placenta and can cause fetal bradycardia. Glycopyrrolate does not cross the placenta)
  • Consider intra-operative use of intermittent compression stockings in view of increased risk of thromboembolism
  • Analgesia - Paracetamol (weight appropriate dose), opioids and regional techniques can be used. NSAIDs can be used following delivery of the fetus if no other contraindications 

IF DELIVERY OF FETUS REQUIRED

  • Start Syntocinon infusion after umbilical cord cut (5 units Syntocinon slow bolus then 15 units Syntocinon in 500ml Hartmann’s at 999ml/hr via Alaris pump. Further uterotonics at discretion of obstetrician
  • If Syntocinon 5 units bolus requested, this should be given slowly. Rapid administration can cause hypotension
  • Ergometrine (if required) should be given as a slow IV injection (dilute Ergometrine 500 micrograms to 10ml with Sodium Chloride 0.9%).  Ergometrine is associated with nausea and vomiting so co-administration of an anti-emetic is advised.  Avoid in hypertension, sepsis, heart disease
  • Hemabate® (if required) should be given by deep IM injection (Hemabate® 250 micrograms). Caution in hypertension, pre-eclampsia, asthma, heart disease, liver disease, glaucoma.  Can be repeated every 15 minutes up to 8 doses. Hemabate® MUST NEVER BE GIVEN INTRAVENOUSLY

 

Post-operative

  • Post-op fetal monitoring as directed by obstetrician
  • Discharge destination dependent on gestation and clinical situation – liaise with surgeon / obstetrician
  • Thromboprophylaxis - Early mobilisation, hydration, TEDs, LMWH (unless contraindicated). Follow GGC antenatal / postnatal guidance as appropriate. This can be obtained via the Maternity Hospital Coordinator or via Staffnet
  • If breast-feeding, medications should be administered immediately after a breastfeed where possible. Consult Clinical Pharmacist, Medicines Information Service or British National Formulary for further guidance

Telephone Numbers

Contact numbers (GRI / PRM)

  • Labour Ward – tel 25216
  • PRM Hospital coordinator - 13707
  • Obstetric StR - Page 10055
  • Obstetric consultant – Page 10056, 8:30-22:00 (via switchboard outwith these hours)
  • Anaesthetics StR (duty 2) – Page 13298 / 13299
  • Anaesthetic consultant – Page 13259 (via switchboard after 18:00)
  • Consultant obstetric anaesthetist / twilight anaesthetist – Page 12205 (08:00-
    00:00), via switchboard after 00:00
  • Neonatal StR - page 12200
  • Neonatal consultant – page 12210

Contact numbers (RAH)

  • Labour ward – Tel. 06743
  • Maternity Hospital Coordinator – Available via labour ward on page 56297
  • Obstetric StR - Page 56014
  • Obstetric consultant – Page 56193, 9:00-17:00 (via switchboard outwith these hours)
  • Anaesthetic StR  – Page 56233
  • Anaesthetic consultant – Via Labour ward or switchboard
  • Neonatal StR - Page 56017
  • Neonatal consultant – Via switchboard

Contact Numbers (QEUH)

  • Maternity Hospital Coordinator – Page 17292
  • Obstetric StR – Page 17111
  • Obstetric Consultant – Page 17222
  • Anaesthetic StR – (duty 2) – Page 17307
  • Anaesthetist consultant – Consultant obstetric anaesthetist –Page 17272
  • Neonatal consultant – Tel: 62261
References
  1. Jenkins TM, Mackey SF, Benzoni EM, et al. Non-obstetric surgery during gestation: risk factors for lower birthweight. Aust N Z J Obstet Gynaecol 2003; 43: 27-31
  2. Cohen-Keren R, Railton C, Oren D, Lishner M, Koren G. Pregnancy outcome following nonobstetric surgical intervention. Am J Surg 2005; 190: 467-73
  3. Non-obstetric surgery during pregnancy. Committee Opinion No. 474. American College of Obstetricians and Gynaecologists. Obstet Gynecol 2011; 117: 420-1

Last reviewed: 12 October 2017

Next review: 01 October 2022

Author(s): Dr Rachel Kearns; Dr Alan Jackson; Dr Marcus McMillan; Vicki Mazzoni

Approved By: Obstetric Guideline Group; Obstetric Governance Group