Anaesthetic considerations for non-obstetric surgery during pregnancy

Treatment of Pregnant Patients With Orthopaedic Trauma

Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.

Postoperative management with dexmedetomidine in a pregnant patient who underwent AVM nidus removal: a case report

Background

Following cerebral arteriovenous malformation (AVM) surgery, severe brain edema and hemorrhage may be caused by postoperative normal perfusion pressure breakthrough (NPPB). Sedation is necessary for this population. It is a challenge for the anesthesiologist to maintain hemodynamic stability without interfering with the neurological assessment. In Japan, propofol is contraindicated for pregnant patients. Dexmedetomidine is a versatile drug in anesthesia practice and may be useful for this situation. There is no report using dexmedetomidine for the purpose of NPPB control in pregnant patients. We describe the postoperative management with dexmedetomidine for a pregnant patient who underwent cerebral AVM nidus removal.

Case presentation

A 32-year-old patient presented with headache at the 16th week of gestation. Neuroimaging revealed an intraventricular hemorrhage and an AVM at the right anterior horn of the lateral ventricle which caused bleeding. A multidisciplinary team discussion was done, and then a craniotomy for AVM nidus removal was performed under general anesthesia. Preanesthetic aspiration prophylaxis and rapid sequence induction were added to our conventional anesthetic management. Hypotension occurred after anesthetic induction but the patient recovered by volume resuscitation and vasopressors. Anesthesia was maintained with 50% O₂ in air and sevoflurane. The AVM was completely removed, and no perioperative complications occurred. Postoperative sedation with dexmedetomidine was used to prevent breakthrough hyperperfusion and cerebral edema.

Conclusions

Dexmedetomidine infusion was used for postoperative sedation without causing any side effects, and it can be an alternative for sedation, especially when propofol is contraindicated.

Anaesthetic management for combined emergency caesarean section and craniotomy tumour removal

Presentation of primary intracranial tumour during pregnancy is extremely rare. Symptoms of brain tumour include nausea, vomiting, headache and seizures which mimic symptoms of pregnancy-related hyperemesis or eclampsia. In very few cases, craniotomy tumour removal is performed earlier or even simultaneously with foetal delivery. A 40-year-old woman at 32 weeks of gestation in foetal distress presented to the emergency room with decreased level of consciousness Glasgow Coma Scale 6 (E2M2V2). Computed tomographic scan revealed a mass lesion over the left temporoparietal region with midline shift and intratumoural bleeding. In view of high risk of herniation and foetal distress, she underwent emergency caesarean section followed by craniotomy tumour removal. In parturient with brain tumour, combined surgery of tumour removal and caesarean section is decided based on clinical symptoms, type of tumour and foetal viability. Successful anaesthetic management requires a comprehensive knowledge of physiology and pharmacology, individually tailored to control intracranial pressure while ensuring the safety of mother and foetus.

Sevoflurane inhibits embryonic stem cell self-renewal and subsequent neural differentiation by modulating the let-7a-Lin28 signaling pathway

The commonly used inhalational anesthetic, sevoflurane, can cause toxicity to the central nervous system of the developing fetus. Lin28 has been reported to regulate let-7a, thereby modulating embryo development, neurodegeneration, and even neuron-related tumorigenesis. We demonstrate that pregnant mice receiving sevoflurane treatment during the early stage of pregnancy give birth to fewer offspring presenting a lower birth weight. We have also treated mouse embryonic stem cells (mESCs) with sevoflurane for 6 h and determined that mESCs self-renewal is repressed, and that differentiation is initiated earlier than in controls. We have induced neural differentiation in the treated mESCs and determined that their neurogenesis is weakened. Furthermore, sevoflurane upregulates the level of let-7a, which might repress mESC self-renewal by directly targeting the Lin28 3'-untranslated region. Lin28 overexpression attenuates the influence of sevoflurane or of let-7a on the self-renewal of mESCs and their subsequent neural differentiation. The let-7a inhibitor also abolishes the influence of sevoflurane. Thus, the let-7a-Lin28 pathway is involved in the sevoflurane-induced inhibition of ESC self-renewal and subsequent neurogenesis. Our study demonstrates the molecular mechanism underlying the side effects of sevoflurane during early development, laying the foundation for studies on the safe and reasonable usage of other inhalational anesthetics.

The Pregnant Patient: Assessment and Perioperative Management

Pathologic changes can occur during pregnancy requiring diagnostic tests and procedures. A preoperative assessment and perioperative planning are essential. Normal physiologic changes include increased cardiac output and decreased functional residual capacity. Perioperative care should follow American Congress of Obstetricians and Gynecologists guidelines. Anesthetic concerns include desaturation during periods of apnea, aspiration, difficult intubation, friable nasal tissue, decreased MAC, and hypotension and/or decreased uterine perfusion from the uterus. Anesthesia and medications must be individualized and given only as needed. Limit exposure to multiple drugs and monitor for fetal wellbeing and premature labor per consultation and guidelines.

Gestational Gigantomastia Complicating Pregnancy: A Case Report and Review of the Literature

Background. Gestational gigantomastia is a rare disorder without clear etiology or well-established risk factors. Several pathogenic mechanisms contributing to the disease process have been proposed, all of which can lead to a similar phenotype of breast hypertrophy. Case. A 28-year-old Guinean woman presented at 37 weeks of gestation with bilateral gigantomastia, mastalgia, peau d'orange, and back pain. Prolactin levels were 103.3 μg/L (with a normal reference value for prolactin in pregnancy being 36–372 μg/L). The patient was treated with bromocriptine (2.5 mg twice daily), scheduled for a repeat cesarean, and referred to surgery for bilateral mammoplasty. Conclusion. Gestational gigantomastia is a rare disorder, characterized by enlargement and hypertrophy of breast tissue. Our patient presented with no endocrine or hematological abnormalities, adding to a review of the literature for differential diagnoses, workup, and management of cases of gestational gigantomastia with normal hormone levels.

Urolithiasis in pregnancy: a cost-effectiveness analysis of ureteroscopic management vs ureteral stenting

OBJECTIVE

The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis.

STUDY DESIGN

We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model.

RESULTS

Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from -$74,469 to -$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables.

CONCLUSION

Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.

Pregnancy and Thoracic Aortic Disease: Managing the Risks

The most common aortopathies in women of childbearing age are bicuspid aortic valve, coarctation of the aorta, Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, SMAD3 aortopathy, Turner syndrome, and familial thoracic aneurysm and dissection. The hemodynamic and hormonal changes of pregnancy increase the risk of progressive dilatation or dissection of the aorta in these women. The presence of hypertension increases the risk further. Therefore, appropriate preconception counselling is advised. For women who become pregnant, serial follow-up by a specialized multidisciplinary team throughout pregnancy and postpartum period is required. In this review we discuss risk assessment and management strategies for women with aortopathies.

Case Report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery

Trauma is estimated to complicate approximately one in twelve pregnancies, and is currently a leading non-obstetric cause of maternal death. Pregnant trauma patients requiring non-obstetric surgery pose a number of challenges for anesthesiologists. Here we present the successful perioperative management of a pregnant trauma patient with multiple injuries including occult pneumothorax who underwent T9 to L1 fusion in prone position, and address the pertinent perioperative anesthetic considerations and management.

[Anaesthetic management of excision of a cervical intraspinal tumor with intraoperative neurophysiologic monitoring in a pregnant woman at 29 weeks]

The intraoperative neurophysiological monitoring is a technique used to test and monitor nervous function. This technique has become essential in some neurosurgery interventions, since it avoids neurological injuries during surgery and reduces morbidity. The experience of intraoperative neurophysiological monitoring is limited in some clinical cases due to the low incidence of pregnant women undergoing a surgical procedure. A case is presented of a 29-weeks pregnant woman suffering from a cervical intraspinal tumour with intense pain, which required surgery. The collaboration of a multidisciplinary team composed of anaesthesiologists, neurosurgeons, neurophysiologists and obstetricians, the continuous monitoring of the foetus, the intraoperative neurophysiological monitoring, and maintaining the neurophysiological and utero-placental variables were crucial for the proper development of the surgery. According to our experience and the limited publications in the literature, no damaging effects of this technique were detected at maternal-foetal level. On the contrary, it brings important benefits during the surgery and for the final result.

Isoflurane inhibits embryonic stem cell self-renewal through retinoic acid receptor

The commonly used inhalation anesthetic isoflurane could permeate rapidly through the placental barrier and induce toxicity to the central nervous system of the developing fetus. However, the effects of isoflurane in utero during early gestation are unknown. We therefore treated pregnant mice with 1.4% isoflurane for 2h per day for three days at day3.5 (E3.5) to day6.5 (E6.5) to investigated the toxicity of isoflurane. Pregnant mice were executed and the fetal mice were weighed and observed. Mouse ESCs (E14) was exposed to 2% isoflurane for 6h. Twenty-four hours later, self-renewal was examined with AP staining. Effects of isoflurane on the expression of RAR-γ were examined using Western blot. As a result, anesthesia with 1.4% isoflurane for 2 hour per day for 3 days reduced fetal growth and development. Isoflurane decreased self-renewal and the expression stemness genes (Nanog, Oct4, Sox2, and Lin28) in mESCs. Vitamin A attenuated the effects of isoflurane inducing self-renewal inhibition. In summary, Anesthesia with 1.4% isoflurane for 2h per day for 3 days reduced fetal growth and development. Moreover, isoflurane inhibits mESCs self-renewal through retinoic acid receptor.

Maternal and fetal arterial blood gas data during general anaesthesia for caesarean delivery of preterm twin lambs

Much remains to be understood with regards the effects of prolonged anaesthesia on maternal and fetal haemodynamics and oxygenation. With the aim of improving anaesthetic management of pregnant sheep undergoing recovery surgery under anaesthesia, paired maternal and fetal arterial blood samples were collected during caesarean delivery of twin preterm lambs to document the blood gas status of the ewe and fetus. Twenty-one Merino twin pregnant ewes at 126 (±1) days of gestation were anaesthetized for caesarean delivery of their fetuses. Arterial blood samples were collected from the radial artery of the ewe and umbilical artery of the fetus at the point of delivery. There was a significant difference between maternal PaCO2 and end-tidal CO2 and alveolar and arterial PaO2, indicating ventilation perfusion mismatch. Interestingly, the ewes were anaemic but the fetuses were not. These data underscore the need to undertake further work to determine the optimal anaesthetic regimen for twin pregnant ewes at different gestational ages in a biomedical research setting.

Challenges in magnetic resonance imaging for suspected acute appendicitis in pregnant patients

The assessment of a gravid patient with abdominal pain is a clinical challenge, as one must consider not only the common etiologies for abdominal pain but also etiologies resulting from the pregnancy. Further complicating the assessment is the altered anatomy and physiology that result from the enlarged uterus displacing and compressing normal anatomical structures. This alteration of anatomy makes the symptoms of appendicitis more variable and thus the diagnosis more difficult. Appropriate and timely imaging can result in better patient outcomes, and when appendicitis is suspected, imaging investigation should not be delayed. This article reviews some of the challenges of magnetic resonance imaging in gravid patients with suspected appendicitis and presents strategies for imaging this population.

Isoflurane Inhibits Embryonic Stem Cell Self-Renewal and Neural Differentiation Through miR-9/E-cadherin Signaling

The commonly used inhalation anesthetic, isoflurane, can permeate rapidly through the placental barrier and thus cause toxicity to the central nervous system of the developing fetus. In this study, we treated pregnant mice with clinically relevant concentration of isoflurane early on in development (days 3.5-6.5), and then found that the fetus growth was inhibited by isoflurane. We further used the mouse embryonic stem cell (mES cell) to be the early development model to investigate the mechanism of the embryotoxicity of isoflurane and found that isoflurane inhibited self-renewal of mES cells. In addition, neuronal differentiation from the mES cells treated with isoflurane was also inhibited. Overexpression of E-cadherin attenuated the effects of isoflurane on self-renewal and the subsequent neuronal differentiation. We also found that miR-9 can be upregulated by isoflurane. Overexpression of miR-9 inhibited the self-renewal and subsequent neuronal differentiation. E-cadherin was directly targeted by miR-9. Overexpression of E-cadherin can abolish the function of miR-9 or isoflurane on self-renewal and subsequent neuronal differentiation. These data suggested that isoflurane inhibits self-renewal and neuronal differentiation of mES cells, possibly by regulating the miR-9-E-cadherin signaling. The result of the current study may provide a novel idea for preventing the toxicity of inhalation anesthetics in the developing fetal brain in clinical practice when pregnant women accept nonobstetric surgery under inhalation general anesthesia.

Anesthetic management of a pregnant patient undergoing open splenectomy for hypersplenism

An estimated 0.75-2% of pregnant women undergo nonobstetric surgery during pregnancy. Surgery is indicated during pregnancy only if it is absolutely essential for wellbeing of mother and fetus. A 25-year-old primigravida with 22 weeks gestation diagnosed with extra hepatic portal venous obstruction, hypersplenism, and refractory pancytopenia was posted for open splenectomy. General anesthesia was administered by rapid sequence induction and endotracheal intubation. The perioperative management involved ensuring hemodynamic stability with administration of blood and blood products for around 2.5 L blood loss. The procedure was completed in 4 h. Patient was extubated with an uneventful postoperative course. A fetal ultrasound showed no variation from preprocedure baseline. Optimal anesthetic management requires an understanding into normal alterations in maternal physiology during pregnancy and potential fetal effects from anesthesia and surgery.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Anesthetic management of labor and delivery in patients with elevated intracranial pressure

The anesthetic management of labor and delivery in patients with elevated intracranial pressure is complex. This review discusses the etiologies of diffuse and focal pathologies which lead to elevated intracranial pressure in pregnancy. The role of neuraxial and general anesthesia in the management of labor and delivery is also examined. Finally, a comprehensive review of strategies to minimize increases in intracranial pressure during general anesthesia for cesarean delivery is presented.

Management of pregnant patients undergoing general surgical procedures

Pregnant patients have a 0.2% to 0.75% chance of developing a medical condition that requires a general surgical intervention during pregnancy. To safely and appropriately care for patients, surgeons must be cognizant of the maternal physiologic changes in pregnancy as well as of the unique risk to both mothers and fetuses of diagnostic modalities, anesthetic care, operative intervention, and postoperative management. Surgeons can be assured that, if these risks are understood and considered, operating during pregnancy, even in the abdomen, can be safely undertaken.

Obstetric anesthesia: not just for cesareans and labor

The scope of obstetric anesthesia practice ranges far beyond the delivery of care to women for vaginal and cesarean deliveries. Increasingly, obstetric anesthesiologists are involved in the management of anesthetics for new procedures and for new indications. Anesthesia is frequently needed for maternal procedures, as well as fetal procedures, and at varying times in the intrapartum period. Maternal-specific procedures include cerclage, external cephalic version (ECV), postpartum bilateral tubal ligation (BTL), and dilation and evacuation (D and E). Fetus-specific procedures include fetoscopic laser photocoagulation and ex-utero intrapartum treatment (EXIT). This review will not include discussion of the anesthetic management of non-obstetric surgery during pregnancy, such as appendectomy or cholecystectomy.

Anesthetic management of a parturient with glioma brain for cesarean section immediately followed by craniotomy

The anesthetic management of a parturient with an intracranial tumor can be quite challenging for the anesthetist as it requires a fine balance of both maternal and fetal safety. The literature pertaining to anesthetic management of such cases is limited. We describe the anesthetic management and peri-operative concerns of this unusual case of a parturient aged 25 years with 8 months amenorrhea and a high grade glioma in the left temporo-parietal region who underwent cesarean section under general anesthesia immediately followed by craniotomy. Anesthetic management was tailored keeping in mind maternal safety and fetal considerations.

Pressure and volume controlled mechanical ventilation in anaesthetized pregnant sheep

Optimal mechanical ventilation of the pregnant ewe during anaesthesia is of vital importance for maintaining fetal viability. This study aimed to compare peak inspiratory pressure (PIP), oxygenation and cardiovascular parameters with pressure-control (PCV) or volume-control (VCV) mechanical ventilation of anaesthetized pregnant sheep. Twenty ewes at 110 days gestation underwent general anaesthesia in dorsal recumbency for fetal surgery in a research setting. All the sheep were mechanically ventilated; one group with PCV ( n = 10) and another with VCV ( n = 10) to maintain normocapnia. PIP, direct arterial blood pressure, heart rate, arterial pH and arterial oxygen tension were recorded. PIP was lower in the PCV group ( P < 0.001). Arterial oxygen tension was higher in the PCV group ( P = 0.013). Mean and diastolic pressures were lower in the PCV group ( P = 0.029 and P = 0.047, respectively). Both VCV and PCV provide adequate oxygenation of pregnant sheep anaesthetized in dorsal recumbency, though PCV may provide superior oxygenation at a lower PIP.

Type A Aortic Dissection in Pregnancy: Two Operations Yielding Five Healthy Patients

Type A aortic dissection in pregnancy is a rare, life-threatening condition with a higher incidence in patients with connective tissue diseases. Mortality is high, reflecting the challenges of protecting both maternal and fetal well-being. We discuss two pregnancies complicated by aortic dissection, including one twin pregnancy, and describe the successful aortic repair immediately following Caesarean section. A total of three healthy neonates were delivered. The challenging management and implications of this precarious condition are explored in the context of these cases.

Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States

BACKGROUND

There are few data regarding the utilization of opioids during pregnancy. The objective of this study was to define the prevalence and patterns of opioid use in a large cohort of pregnant women who were commercial insurance beneficiaries.

METHODS

Data for the study were derived from a deidentified research database of women from across the United States who had both medical and prescription benefits. By using diagnostic codes, the authors defined a cohort of 534,500 women with completed pregnancies who were enrolled in a commercial insurance plan from 6 months before pregnancy through delivery.

RESULTS

Overall, 76,742 women (14.4%) were dispensed an opioid at some point during pregnancy. There were 30,566 women (5.7%) dispensed an opioid during the first trimester, 30,434 women (5.7%) during the second trimester, and 34,906 women (6.5%) during the third trimester. Of these, 11,747 women (2.2%) were dispensed opioids three or more times during pregnancy. The most commonly dispensed opioids during pregnancy were hydrocodone (6.8%), codeine (6.1%), and oxycodone (2.0%). The prevalence of exposure at anytime during pregnancy decreased slightly during the study period from 14.9% for pregnancies that delivered in 2005 to 12.9% in 2011. The prevalence of exposure varied significantly by region and was lowest in the Northeast and highest in the South.

CONCLUSIONS

This study demonstrates that opioids are very common exposures during pregnancy. Given the small and inconsistent body of literature on their safety in pregnancy, these findings suggest a need for research in this area.

Utility of intraoperative fetal heart rate monitoring for cerebral arteriovenous malformation surgery during pregnancy

We report two methods of intraoperative fetal heart rate (FHR) monitoring in cases of cerebral arteriovenous malformation surgery during pregnancy. In one case in her third trimester, cardiotocography was used. In another case in her second trimester, ultrasound sonography was used, with a transesophageal echo probe attached to her lower abdomen. Especially, the transesophageal echo probe was useful because of the advantages of being flexible and easy to attach to the mother's lower abdomen comparing with the usual doppler ultrasound probe. In both cases, the surgery was successfully performed and FHR was monitored safely and stably. The use of intraoperative FHR monitoring provides information about the influence of induced maternal hypotension and unexpected bleeding on fetus during surgery. These monitoring techniques would be especially emphasized in cerebrovascular surgery for the safe management of both mother and fetus.

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.

Heterotopic pregnancy following IVF-ET: successful treatment with salpingostomy under spinal anesthesia and continuation of intrauterine twin pregnancy

The extended use of assisted reproductive technologies is increasing the heterotopic pregnancies, leading to a potentially dangerous condition for the intrauterine pregnancy and the mother. We report a case of unruptured heterotopic pregnancy following IVF-ET at 6 weeks of gestation and the patient was treated with salpingostomy under spinal anesthesia. The intrauterine twin pregnancy course was uneventful with the delivery of healthy babies at 34th week by Cesarean section.

[Perioperative treatment for the urgent orbital decompression surgery in a 30-weeks pregnant woman with Graves' orbitopathy]

Thyroid ophthalmopathy is a rare extra-thyroid complication usually associated with Graves' disease. This disease can occur in the euthyroid pregnant patient. Graves' orbitopathy is characterized by eyelid retraction, proptosis, extraocular muscle dysfunction, and periorbital edema. In some cases an emergency surgical repair may be required to avoid irreversible vision loss. We present the case of a 35-year-old woman in her 30th gestational week, who suffered from Graves' ophthalmopathy, severe exophthalmia, and visual acuity decrease. Following consultations among anesthesiologists, ophthalmologists, maxillofacial surgeons, endocrinologists, obstetricians and the patient, it was decided to perform a surgical orbital wall decompression. The anesthetic and perioperative implications associated with gestational age and the considerations for this surgical procedure, and how to avoid increasing intraocular pressure are discussed.

Sevoflurane anesthesia in pregnant mice induces neurotoxicity in fetal and offspring mice

BACKGROUND

Each year, over 75,000 pregnant women in the United States undergo anesthesia care. The authors set out to assess the effects of the anesthetic sevoflurane on neurotoxicity in pregnant mice and on learning and memory in fetal and offspring mice.

METHODS

Pregnant mice (gestational day 14) and mouse primary neurons were treated with 2.5% sevoflurane for 2 h and 4.1% sevoflurane for 6 h, respectively. Brain tissues of both fetal and offspring mice (P31) and the primary neurons were harvested and subjected to Western blot and immunohistochemistry to assess interleukin-6, the synaptic markers postsynaptic density-95 and synaptophysin, and caspase-3 levels. Separately, learning and memory function in the offspring mice was determined in the Morris water maze.

RESULTS

Sevoflurane anesthesia in pregnant mice induced caspase-3 activation, increased interleukin-6 levels (256 ± 50.98% [mean ± SD] vs. 100 ± 54.12%, P = 0.026), and reduced postsynaptic density-95 (61 ± 13.53% vs. 100 ± 10.08%, P = 0.036) and synaptophysin levels in fetal and offspring mice. The sevoflurane anesthesia impaired learning and memory in offspring mice at P31. Moreover, interleukin-6 antibody mitigated the sevoflurane-induced reduction in postsynaptic density-95 levels in the neurons. Finally, environmental enrichment attenuated the sevoflurane-induced increases in interleukin-6 levels, reductions of synapse markers, and learning and memory impairment.

CONCLUSIONS

These results suggest that sevoflurane may induce detrimental effects in fetal and offspring mice, which can be mitigated by environmental enrichment. These findings should promote more studies to determine the neurotoxicity of anesthesia in the developing brain.