Foetal monitoring in parturients undergoing surgery unrelated to pregnancy

Algorithm of Traumatic Brain Injury in Pregnancy (Perspective on Neurosurgery)

BACKGROUND

The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources.

CASE SERIES

A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E1V1M4, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E1V1M3, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition.

DISCUSSION

We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment.

CONCLUSION

The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.

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.

Acute Respiratory Failure in Pregnancy

Acute respiratory failure in pregnancy has multiple etiologies, including thromboembolism, amniotic fluid embolism, venous air embolism, aspiration of gastric contents, respiratory infections, asthma, beta-adrenergic tocolytic therapy, and pneumomediastinum and pneu mothorax. Proper management of acute respiratory fail ure in pregnancy requires an understanding of the specific diseases and the normal gestational changes that occur in maternal respiration (decreased functional re sidual capacity, increased minute ventilation, mild respi ratory alkalosis) and hemodynamics (increased cardiac output, increased blood and plasma volume, unchanged central pressures). Knowledge of the determinants of oxygen delivery to fetal tissue (uterine blood flow, pla cental transfer, fetal circulation) and how they are af fected by changes in maternal hemodynamics, position, acid-base status, and medications can help sustain nor mal fetal development, whenever possible, without compromising maternal care. Diagnostic testing such as radiography, hemodynamic monitoring, and fetal moni toring are considered in terms of attendant risk to the mother or the fetus, alterations in normal values related to gestation, and indications for usage. Similarly, the risks and benefits of supportive and specific therapies for the various etiologies of acute respiratory therapy are reviewed.

[Silent cardiotocogram during general anesthesia. Indication for emergency Cesarean section?]

This case report of a silent cardiotocogram (CTG) registration during general anesthesia in a 33-week-pregnant patient undergoing non-obstetric surgery demonstrates the possibility of misinterpretation whereby typical CTG patterns of fetal reactions to anesthetics can be misinterpreted as fetal hypoxia or even asphyxia.

Thyroid and parathyroid surgery in pregnancy

The consideration of surgery during pregnancy requires weighing the benefit of urgent surgery against the risk to mother and fetus. Surgery during pregnancy involves an increase in both maternal and fetal risks. Thyroid and parathyroid surgery involves physiological risks to both mother and fetus specific to the disease and function of these endocrine glands. Evaluation of a thyroid mass is similar in pregnant patients with ultrasound and fine-needle aspiration biopsy providing the most important information, while the use of radiographic imaging is severely constrained except when specifically required. In general, thyroid surgery can be delayed until after delivery except in cases of airway compromise or aggressive cancer. In contrast, parathyroid surgery is recommended during pregnancy to avoid adverse effects to the neonate.

A case of acromegaly in pregnancy: Concomitant transsphenoidal adenomectomy and cesarean section

The case of a 32-year-old woman at 29 weeks gestational age with acromegaly initially diagnosed in pregnancy is presented. During follow-up at 34 weeks of gestation, concomitant emergency cesarean section and transsphenoidal surgery were performed because of advancing vision loss. In tertiary centers, success in pregnancy can be made possible for a patient with acromegaly under the constant supervision of an obstetrician and neurosurgeon.

Intraoperative fetal heart rate monitoring during emergency neurosurgery in a parturient

Malignant brain tumors during pregnancy are rare, and these patients seldom require immediate surgical intervention. A 27-year-old pregnant woman underwent emergency craniotomy. Anesthesia was induced with intravenous thiopental-fentanyl; it was maintained with isoflurane in oxygen and continuous intravenous remifentanil infusion. We used full stomach precautions but omitted succinylcholine for fear of increasing the intracranial pressure during induction of anesthesia. To detect fetal hypoxia and the effects of anesthesia on fetal hemodynamics, the fetal heart rate (FHR) was monitored using a fetal Doppler ultrasonography unit fixed to the mother's abdominal wall. Intraoperative and recovery periods were uneventful. Use of an isoflurane and remifentanil combination provided stable hemodynamics with adequate arterial blood pressure to avoid uterine hypoperfusion and fetal hypoxia. In this case, using FHR monitoring we found that craniotomy can be performed safely under isoflurane/remifentanil based-general anesthesia during the second trimester of pregnancy.

[Do we have to monitor foetal heart rate during general anesthesia?]

We present a case of an emergency Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia for treatment of dental abscess. Following failure of the dental abscess treatment under local anaesthesia, a 29-year-old female in the 36th week of a twin pregnancy was to undergo general anaesthesia. Foetal well-being was monitored with ultrasonographic evaluations of foetal heart rate. During surgery, senior obstetrician recorded a lack of beat-to-beat variability of the cardiotocography trace. The CTG pattern was interpreted as foetal distress and an emergency Caesarean section was performed under general anaesthesia. That was probably due to general anaesthesia. Then, two infants were extracted without neonatal distress necessitating intubation. This case report underlines the risk to misread an intraoperative CTG monitoring and if the CTG monitoring is normal before anaesthesia, reduced foetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.

The role of ultrasound in pregnancy-related emergencies

Most complications of pregnancy allow time for transfer to specialized obstetric ultrasound units, but many women present to the emergency room or the labor and delivery unit with signs and symptoms suggesting genuine acute medical emergencies, where successful outcome depends on prompt diagnosis of the disorder and rapid appropriate medical management. The use of ultrasound technology in obstetric emergencies is well established. Ultrasonography plays a major role in such cases as the most important tool clinicians are using to identify the correct etiology and diagnosis, whereas in other cases it helps limit the differential diagnosis. One of the goals of any advanced training program in obstetrics and gynecology and radiology is to allow the skilled physician to perform the proper ultrasound study in case of an obstetric emergency to facilitate the proper diagnosis, enabling the medical team to provide the best possible care.

Anesthesia for nonobstetric surgery in the pregnant patient

Each year over 75,000 pregnant women in the United States undergo nonobstetric surgery. The operations include those directly related to pregnancy, such as cerclage, those indirectly related to pregnancy, such as ovarian cystectomy, and those unrelated to gestation, such as appendectomy. When a pregnant woman presents for surgery, it is a stressful event for everyone involved. Issues about the surgical problem itself often seem secondary to maternal (and physician) concerns about the effect of surgery and anesthesia on the developing fetus, or the potential to trigger preterm labor. This article reviews the physiologic and anatomic changes that affect anesthetic care during pregnancy. The author also reviews the effects of anesthetic drugs and perioperative events on the fetus and on the pregnancy outcome. The relatively small number of published series are reviewed as well as the controversial recommendations regarding fetal and maternal monitoring during surgery.

Unnecessary emergency caesarean section due to silent CTG during anaesthesia?

We present a case of a probably unnecessary Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia. A 27-yr-old patient in her 30th week of an uneventful, normal first pregnancy presented with a deep venous thrombosis in the pelvic region. She was to undergo an emergency thrombectomy under general anaesthesia. During the operation, the CTG showed a lack of beat-to-beat heart rate variation (silent pattern CTG) with normal fetal heart rate. This silent CTG pattern was probably a result of the effect of general anaesthesia on the fetus. The CTG pattern was interpreted as indicating fetal distress, and an emergency Caesarean section was performed after the thrombectomy. The infant was apnoeic and had to be resuscitated and admitted to the neonatal intensive care unit. The pH at delivery was 7.23 and the baby was extubated 2 days later. Mother and child recovered without short-term sequelae. In the absence of alternative explanations, reduced fetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.

Trauma in pregnancy

CONCLUSION

An exhaustive review of the care of the pregnant trauma patient would fill a book. Nevertheless, an understanding of the normal physiologic changes of pregnancy is virtually all there is to go on except in a few special situations such as listed above. Close communication with critical care, surgical and obstetrical colleagues are essential. This is certainly a clinical situation where a truly multi-disciplinary approach brings positive results. With this is mind it should be possible to confidently care for these special patients.

Perioperative assessment of fetal heart rate and uterine activity

Improvements in surgical techniques and anesthesia allow women the option to schedule needed surgery during pregnancy. However, perioperative monitoring of the fetus and uterine activity remains a matter of controversy. Monitoring may allow rapid improvement of the fetal status or uterine activity when early compromise or contractions are detected. The reassurance and decreased medicolegal risks provided by perioperative monitoring may offset the cost of a perinatal nurse and use of monitoring equipment even though the drug and anesthetic effect on the fetal heart limit the benefits of monitoring. Simply providing adequate maternal respiratory support during surgery may improve the fetal pattern but will not eliminate external surgical effects. The need for additional research is described, and the role of the perinatal nurse is detailed in a suggested protocol.

Surveyed use of fetal and uterine monitoring during maternal surgery

The goal of this study was to determine the frequency and methods of intraoperative fetal and uterine monitoring during maternal surgery in the United States. Maternal surgery was defined as nonobstetric surgery during pregnancy that required general or regional anesthesia. We mailed a 21-item questionnaire to the perioperative nurse managers of US hospitals at which more than 2,000 babies are delivered annually (n = 579). Nearly 60% of responding hospitals routinely used some form of fetal monitoring during maternal surgery; more than 40% of responding hospitals did not use intraoperative fetal and uterine monitoring routinely during maternal surgery.

Pregnancy and cirrhosis: management of hematemesis by Warren shunt during third trimester gestation

Considerable pathophysiologic changes accompany cirrhosis. Elevation of portal venous pressure predisposes to esophageal varices and hematemesis. The physiologic changes associated with pregnancy may exacerbate these conditions. Medical management of cirrhosis-associated problems may fail, necessitating surgical intervention. The anesthetic management of a pregnant cirrhotic patient for a Warren shunt is complicated by concerns for pre-existing hepatic dysfunction and pregnancy-induced physiologic changes as well as fetal well-being. The management of such a case is reviewed and relevant pathophysiology discussed.

Anesthesia, cardiopulmonary bypass, and the pregnant patient

For the perioperative management of pregnant patients with severe cardiac or aortic disease who require a cardiac surgical procedure and cardiopulmonary bypass, a close, cohesive, working relationship must exist among several medical and surgical specialties. For appropriate management, the well-being of both the mother and the fetus must be considered. The best interests of the mother and the fetus may not coincide, and optimal therapy for one may be inappropriate for the other. We present 10 cases of severe cardiac or aortic disease in pregnant women who required surgical intervention. Eight patients underwent cardiopulmonary bypass during pregnancy, and two patients had cesarean section performed immediately before cardiopulmonary bypass. We also discuss the pertinent pharmacologic aspects related to the perioperative period and the management of cardiopulmonary bypass for the pregnant patient.

[Hypotension induced by isoflurane for the treatment of intracranial aneurysm in late pregnancy]

A 31-year old primigravida was admitted at 31 week gestation for subarachnoid haemorrhage. Cerebral angiography revealed an aneurysm on the left middle cerebral artery. Eleven days later, the aneurysm was clipped off. General anaesthesia was induced with thiopentone, pancuronium and fentanyl, and maintained with fentanyl (40 micrograms.kg-1) and isoflurane in air/O2 with a non-rebreathing circuit. The patient was mechanically ventilated to maintain mild hypocapnia. Arterial hypotension was induced by increasing the inspired isoflurane concentration from 1 to 3 vol%. The response was immediate and a mean arterial pressure of 60 mmHg was maintained for 80 min with an inspired isoflurane concentration of 2.5 vol%. Foetal heart rate was monitored before, during and after general anaesthesia. Loss of beat to beat variation was observed after induction, and foetal heart rate slowly decreased from 150 to 115 b.min-1 at the end of the operation. Postoperative state was good, except for transitory aphasia. At 35 week gestation, the patient went into premature labour, with hypothermia of 39.5 degrees C; an emergency caesarean section was performed. The 2,340 g female infant had a 10 min Apgar score of 8. One month later, clinical examination of the mother and daughter was quite normal. The precautions and anaesthetic management of patients suffering from ruptured cerebral aneurysm during the end of pregnancy are reviewed. Hypotensive agents are discussed.