This is called her background risk. There have been at least five studies that have looked at the risk for birth defects in women who had surgery and anesthesia in the first and early second trimester of pregnancy. The studies did not show an increased risk for birth defects. Could exposure to general anesthesia in the second or third trimester cause other pregnancy complications?
Some studies have noticed a chance for premature delivery delivery before 37 weeks of pregnancy after a surgical procedure later in pregnancy. Other studies have not shown an increased chance for pregnancy complications, including premature delivery.
Does exposure to general anesthesia in pregnancy cause long-term problems in behavior or learning for the baby? A single, relatively short procedure with exposure to general anesthesia is unlikely to have negative effects on behavior or learning. Some studies in young children have suggested that long surgical procedures might affect the brain. However, it is not clear if these findings are due to the anesthesia, the condition for which the child needed surgery, or other factors.
Women who are pregnant and need surgery, especially for life-threatening conditions should not be discouraged from the use of general anesthesia. Talk with your healthcare providers about the benefits, risks, and appropriate timing of surgery or procedures requiring general anesthesia.
I work in an office that uses general anesthesia. Would that affect the baby? However, the mid-trimester is a critical time for NSC proliferation. If NSC self-renewal can compensate for cell death, fetal neurodevelopment may not be affected.
Therefore, apoptosis is not the only mechanism, and there may be an imbalance between cell proliferation and death. The findings of our study suggest that fetal NSC proliferation is inhibited by 3. In past studies, relevant researches mainly expounded on the mechanism of apoptosis, such as mitochondrial injury, intracellular calcium imbalance, neuroinflammatory Lei et al.
In addition to apoptosis and proliferation, we found that sevoflurane anesthesia during the mid-trimester upregulated autophagy levels of the NSCs concentration-dependently.
We also demonstrat that autophagy is related to the apoptosis increase and proliferation inhibition induced by sevoflurane. Autophagy inhibition alleviated NSC apoptosis, proliferation inhibition and learning and memory impairment Li et al. Since then, several studies have reported the correlation between anesthetics and autophagy. Ketamine-induced neurotoxicity was caused by ROS-mediated activation of mitochondrial apoptotic pathway and autophagy Li et al.
In particular developmental stages during pregnancy, any significant high-dose, prolonged duration of drugs can theoretically lead to teratogenicity, but not all anesthetics showed detrimental effects.
Similar to the results above, isoflurane exposure in mid-trimester mice led to embryo neuroinflammation, apoptosis, and impaired cognitive function, however, a combination of propofol alleviated these adverse effects Nie et al. Besides, in one of the mid-trimester studies, high doses of dexmedetomidine for 12 h at days of gestation mid-pregnancy did not affect neuronal apoptosis in the frontal cortex of the fetal cynomolgus monkey brain Koo et al.
The combined use of dexmedetomidine and isoflurane during the second trimester of pregnancy 14 days of pregnancy can alleviate the impairment of spatial learning and memory function Su et al. Besides anesthesia, surgical stimulation appears to reduce anesthesia-induced neuroapoptosis in the mid-trimester ovine fetus Olutoye et al.
Further studies are needed to determine the long-term effects and consequences of these findings on fetal and uterine anesthesia and postoperative behavioral and cognitive functions. These studies may provide a wealth of information to prevent or treat the associated adverse effects of anesthesia during the mid-trimester.
While animal studies mimic anesthesia, they ignore the effects of surgical pain on the fetus. Before 22 weeks, the fetus has no neuroanatomical pathway to feel pain; between 22 and 26 weeks, thalamocortical fibers, which are crucial for pain perception, start forming; after 26 weeks, the fetus develops the necessary nervous system to feel pain Littleford, The effects of pain on neurodevelopment are however unclear.
Liu found that pain during emergency operations and procedures can reduce neuroapoptosis caused by ketamine Liu et al.
Appropriate pain management is also important, because improper pain management may lead to a premature delivery. If there are no contraindications, acute pain can be treated with an epidural block and peripheral nerve blocks Okeagu et al. Based on current knowledge of anesthesia and surgery during pregnancy, intervention is risky for both the mother and the fetus. First, elective surgery should be avoided during pregnancy and be delayed as far as possible until delivery Flood, Regional anesthesia has always been preferred for the operations that must be conducted during pregnancy.
Regional anesthesia has the advantages of effectively reducing pain and having little impact on fetal heart tone variability Cheek and Baird, highlight, but not all surgical operations can be carried out under regional anesthesia. Secondly, although spinal anesthesia is still the main anesthesia management for patients during pregnancy, general anesthesia, mainly inhalation anesthesia, is also a common method of emergency non-obstetric or open fetal surgery.
Unfortunately, the FDA warning does not provide recommended concentrations and dose-related guidelines for anesthetics avoid neurodevelopment damage. Since there is a lack of relevant guidelines, we suggest to minimize the exposure duration and avoid high concentration anesthetics, for instance by limiting the interval from anesthesia induction to operation start to reduce patients' anesthetic exposure.
It is important and appropriate that the fetus should be exposed to anesthetics for as short as possible. The health of fetuses and newborns is the main criterion for evaluating obstetric operations and anesthesia management of pregnant women, but not all infants can benefit from early intervention or fetal surgery, and more work is needed to determine this. In the future, we need to explore techniques to predict the outcome of pregnancy surgery by measuring the basic characteristics of the fetus, and to develop fetal intervention methods that cause less trauma.
At the same time, intraoperative fetal monitoring Doppler ultrasound and uterine contraction monitoring is also significantly important Okeagu et al. Further studies are needed to determine the best anesthesia method to ensure maternal and fetal cardiovascular stability, optimal uterine perfusion, adequate uterine relaxation, sufficient anesthesia depth, minimal fetal myocardial inhibition, and appropriate blocking of the fetal stress response Sviggum and Kodali, During the observation period, attention should also be paid to keeping the umbilical connection between the fetus and mother to avoid affecting the neurological, biochemical and behavioral functions of the fetus due to the decrease of oxygen and nutrient supply Ronca et al.
Finally, proper communication and teamwork between anesthesiologists, obstetricians, and pediatricians is necessary to ensure the safety of pregnant women and fetuses. Ideal pregnant anesthetics or techniques should be safe and effective for mothers, without harming the fetus in the uterus or affecting the normal labor process, providing satisfactory delivery conditions, allowing early interaction between mothers and infants, without short-term or long-term effects on newborns Littleford, , For example, studies have shown that dexmedetomidine significantly reduced spatial learning and memory impairment, but its neuroprotective mechanism for fetuses remains to be studied further Koo et al.
However, these agents cannot be recommended as protective or mitigating strategies at present, and more rigorous research is needed. In the future, based on more in-depth animal experiments, we should carry out multicenter randomized controlled tests to obtain authoritative experimental conclusions as soon as possible. In short, the emergence of new anesthetics, the improvement of anesthesia technology, and the deep understanding of the placental transport and mechanisms of drug action are all of great significance to the prognosis of mothers and infants.
The anesthetic neurotoxicity could be a problem in anesthesia practice. However, family, life events and social environment may also be the major determinants of neurodevelopment and long-term cognitive functions Koo et al. In the future, continuous efforts and explorations by anesthesiologists are recommended. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Andropoulos, D. Effect of anesthesia on the developing brain: infant and fetus. Fetal Diagn. Avet-Rochex, A. Unkempt is negatively regulated by mTOR and uncouples neuronal differentiation from growth control. PLoS Genet. Balinskaite, V. The risk of adverse pregnancy outcomes following nonobstetric surgery during pregnancy: estimates from a retrospective cohort study of 6.
Cheek, T. Anesthesia for nonobstetric surgery: maternal and fetal considerations. Clancy, B. Web-based method for translating neurodevelopment from laboratory species to humans. Neuroinformatics 5 1 , 79— Translating developmental time across mammalian species. Neuroscience 1 , 7— De Tina, A.
General anesthesia during the third trimester: any link to neurocognitive outcomes? Devroe, S. Anesthesia for non-obstetric surgery during pregnancy in a tertiary referral center: a year retrospective, matched case-control, cohort study.
Disma, N. Anesthesia and the developing brain: a way forward for laboratory and clinical research. Dobbing, J. Comparative aspects of the brain growth spurt. Early Hum. Fang, F. Multiple sevoflurane anesthesia in pregnant mice inhibits neurogenesis of fetal hippocampus via repressing transcription factor Pax6. Life Sci.
Flood, P. Fetal anesthesia and brain development. Anesthesiology 3 , — Garcia, P. Anesthesiology 6 , — Gregory, G. Fetal anesthetic requirement MAC for halothane. Google Scholar. Huang, H. Gaining insight of fetal brain development with diffusion MRI and histology. Istaphanous, G. Characterization and quantification of isoflurane-induced developmental apoptotic cell death in mouse cerebral cortex.
Jenkins, T. Non-obstetric surgery during gestation: risk factors for lower birthweight. Kampe, S. Muscle relaxants. Airway concerns: Functional residual capacity is decreased during pregnancy, so full preoxygenation and denitrogenation should be used to prolong time to desaturation during laryngoscopy and intubation. Full stomach precautions and rapid sequence induction with cricoid pressure should reduce aspiration risk from a full stomach.
Smaller endotracheal tubes should be available in case the airway is edematous. The risk of failed intubation is much higher in pregnancy, so have tools available for an unanticipated difficulty airway. Drawbacks: Sedatives will reduce fetal heart rate variability if monitoring is being used. Avoid deep sedation because of full stomach concerns and risk of aspiration. Other Issues: Any sedative preferred by the anesthesiologist can be used: midazolam, propofol, ketamine, dexmedetomidine, or opioids.
The safest anesthetic that you would use for a non-pregnant patient having the same or similar procedure should be chosen, with modifications for the physiologic changes of pregnancy such as full stomach precautions and uterine displacement. The goals are maintaining maternal oxygenation and avoiding hypotension or decreases in cardiac output that would compromise uteroplacental perfusion. No outcome data has shown regional or general anesthesia to be preferable. If the procedure could be done using either a regional or general anesthetic, I prefer to discuss those options with the patient and let her choose the technique she is most comfortable with, based on questions about exposure to medications, being awake during the procedure, postoperative pain management, ability to observe the fetal monitor, or other concerns.
She can be reassured that both techniques are routinely used for cesarean delivery and are safe for the fetus. What prophylactic antibiotics should be administered? The antibiotic will be chosen based on the type of surgery being performed, but all antibiotics are acceptable during pregnancy. What do I need to know about the surgical technique to optimize my anesthetic care?
Pelvic and intra-abdominal procedures will preclude the use of intraoperative fetal monitoring. Uterine displacement should be maintained at all times in pregnancies in the second and third trimester.
For laparoscopic techniques, open trocar placement may be preferred to avoid injury to the uterus, and the lowest possible insufflation pressure should be used.
What can I do intraoperatively to assist the surgeon and optimize patient care? This will depend on the specific surgical procedure. Prioritize them by urgency. The surgeon should be notified if there are decelerations on the fetal heart rate monitor, and the obstetric team should be consulted.
Maneuvers other than delivery that may improve uteroplacental perfusion and fetal oxygenation should be initiated. They may include increasing maternal FIO2, increasing maternal blood pressure, increasing left uterine displacement or trying displacement to the right, moving retractors away from the uterus, having the surgeons temporarily stop intra-abdominal manipulations, and administering a tocolytic such as nitroglycerin mcg or terbutaline 0.
Cardiac complications: Pregnant patients are at high risk for thromboembolic complications, and prophylaxis should include compression stockings at a minimum, with consideration of pharmacologic prophylaxis if the patient cannot be mobilized soon after surgery. Pulmonary: The pregnant patient may be more at risk for pulmonary edema because of low oncotic pressure in later gestation. If an infectious process is present e.
Pregnant patients are assumed to have a full stomach and should be extubated only when strong and awake enough to protect their airway. What analgesic modalities can I implement? Continuous peripheral or neuraxial blocks with infusions are optimal if appropriate. All opioids may be used in pregnancy.
Non-steroidal anti-inflammatory medications are usually avoided after 32 weeks gestation because prostaglandin inhibition could cause the fetal ductus arteriosus to close, leading to intrauterine fetal death.
NSAID use in early pregnancy is probably acceptable, but acetaminophen or opioids are usually preferred. What level bed acuity is appropriate? Example: floor, telemetry, step-down, or ICU and justification : Beyond 24 weeks gestation, there should be obstetric nursing either physically present or by telemetry to monitor for uterine contractions and fetal heart rate abnormalities. For low acuity procedures, recovery can occur on labor and delivery. For higher acuity procedures, a labor and delivery nurse may be brought to the intensive care or step-down unit.
What are common postoperative complications, and ways to prevent and treat them? Preterm labor and delivery is most common after pelvic or intra-abdominal procedures and is associated with infectious processes as well. Monitoring for uterine contractions for at least 24 hours is appropriate, and the obstetric service may recommend prophylactic or therapeutic tocolysis with indomethacin, magnesium sulfate infusion, or calcium channel blocking agents.
Thromboembolism prophylaxis should continue at least until the patient is mobilized. Reitman, E, Flood, P. Br J Anaesth. Brown, HL. Obstet Gynecol. Baysinger, CL. Anesth Analg. Chohan, L, Kilpatrick, C. Clin Obstet Gynecol. Hong, JY. Int J Obstet Anesth. Ann Thoracic Surg. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC.
Show More. Login Register. Enjoying our content? Thanks for visiting Clinical Pain Advisor. If you wish to read unlimited content, please log in or register below. Registration is free. Register for free and gain unlimited access to:. What the Anesthesiologist Should Know before the Operative Procedure Providing anesthesia for non-obstetric surgery during pregnancy can be anxiety-provoking for all involved. What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
Preoperative evaluation 3. What are the implications of co-existing disease on perioperative care? Cardiovascular system c. Pulmonary d. Renal-GI: e. Neurologic: f. Endocrine: g. What are the patient's medications and how should they be managed in the perioperative period? Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern? What should be recommended with regard to continuation of medications taken chronically?
How To modify care for patients with known allergies - k. Latex allergy - If the patient has a sensitivity to latex e.
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