Fetal Assessment for Anesthesiologists

Breast cancer and pregnancy: Why special considerations prior to treatment are needed in multidisciplinary care

Breast cancer diagnosed during pregnancy poses ethical and professional challenges. Clinical management of that condition should ensure the safety of both the mother and fetus. Clinical trials on breast cancer exclude pregnant women, so sufficient evidence with which to formulate guidelines for the management of these patients is lacking. Failing to undergo a breast examination during pregnancy, breast symptoms explained by physiological changes such as pregnancy, and unnecessary abortions after the diagnosis of breast cancer lead to worse outcomes for these patients. Multidisciplinary teams including breast surgeons, obstetricians, radiologists, pathologists, and anesthesiologists need to make an early diagnosis and comprehensively evaluate patients in different gestational weeks and with different stages of breast cancer in order to optimize outcomes.

Complications of Congenital Hernia in Pregnancy: A Case Report

Congenital hernias, frequently misdiagnosed during pregnancy, are potentially fatal and require prompt repair. A pregnant woman with medical history of repaired congenital hernia was admitted with misdiagnosis of preeclampsia. Physical examination and chest x-ray revealed a Bochdalek hernia. Transitory stabilization prompted surgeons to postpone hernia repair, but an urgent thoracotomy was required to relieve a subsequent bowel obstruction that was complicated by an intrathoracic colonic perforation. Emergent cesarean delivery was required with a good maternal and fetal outcome. A multidisciplinary team was present in the operating room. All monitoring catheters were placed in advance in the intensive care unit. During recovery, the patient experienced ventricular fibrillation, presumed to be a manifestation of takotsubo syndrome, which responded favorably to cardiopulmonary resuscitation.

Anesthesia for Urgent Cesarean Section

Cesarean section (CS) is a common surgical procedure worldwide. The anesthesiologist is responsible, together with obstetrician and neonatologist, for safe perioperative management. A continuum of risk exists for urgent CS. The decision-to-delivery interval is an important audit tool, to ensure international standards are upheld and good outcomes for mother and neonate are achieved. Urgent CS may be performed under either GA or RA, with benefits and risks attributable to each. Specific clinical scenarios require an individualized approach to anesthesia, including hemorrhage, hypertensive disorders, cardiac disease, the difficult airway and fetal compromise. Ongoing training is integral to the provision of safe anesthesia.

Surgical Management of the Pregnant Patient With Lumbar Disc Herniation in the Latter Stage of the Second Trimester

STUDY DESIGN

Case report.

OBJECTIVE

To report on a pregnant woman successfully treated with microendoscopic discectomy in the left lateral position under general anesthesia at 24-week gestation.

SUMMARY OF BACKGROUND DATA

Treatment for lumbar disc herniation in pregnant women poses a particular challenge due to the complexity of the clinical situation. Review of the literature emphasizes timely diagnosis with adequate management specific for each gestational period. A surgical approach mandates consideration of the physiologic parameters of pregnancy and the effects of these stressors on the fetus.

METHODS

A 38-year-old primigravid woman presented with persistent and incapacitating low back and left leg pain. Magnetic resonance imaging demonstrated a herniated disc at L4-5 with a severely compressed left L5 nerve root. Symptoms were resistant to conservative treatment (acetaminophen; 1200 mg/day) and nerve root block with corticosteroids (1 mg/0.5 mL of betamethasone plus 0.5 mL of 1% lidocaine) provided only transient pain relief. Operative management with surgical discectomy was discussed. Anesthesiologists, obstetricians, and neonatologists were consulted for preoperative planning, focusing on appropriate anesthesia, ideal positioning for surgical access, and provision for emergent fetal care. Surgery was ultimately performed in the left lateral position, in contrast to the oft-used prone position. Microendoscopic discectomy was performed under general anesthesia at 24-week gestation.

RESULTS

The patient experienced complete relief from pain after surgical intervention and delivered a healthy baby at 39-week gestation after normal labor. Our methods, used in accordance with our preoperative simulation, resulted in a satisfactory outcome for both mother and child.

CONCLUSION

Although previously published cases noted the safety of operating in the prone position under epidural anesthesia, we performed minimally invasive microendoscopic discectomy in the left lateral position in combination with general anesthesia and found that this is a safe and preferable alternative for pregnant patients in the latter stage of the second trimester.

LEVEL OF EVIDENCE

N/A.

Update on the management of non-obstetric acute abdomen in pregnant patients

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.

Fetal outcome in the critically ill pregnant woman

Management of the critically ill pregnant woman is complicated by potential adverse effects of both maternal illness and ICU interventions on the fetus. This paper reviews the potential risks to the fetus of maternal critical illness, including shock, hypoxemia, and fever, as well as the effects of critical care management, such as drug therapy and radiological investigations. The authors’ recommended approach to management is provided. Prior publications and new data presented identify that there is insufficient information to prognosticate accurately on fetal outcome after maternal critical illness, although maternal shock, hypoxemia and early gestational age are likely significant risk factors.