CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 63, Number 2, 351–363

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia for
Nonobstetric Surgery
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in Pregnancy
MAURICIO VASCO RAMIREZ, MD,*†
and CATALINA M. VALENCIA G, MD‡§
*Universidad CES; ‡Medicina Fetal SAS, Medellín;
§FUNDARED Materna, Bogotá, Colombia;
and †World Federation of Societies of Anaesthesiologists (WFSA),
London, United Kingdom

Abstract: Nonobstetric surgery during pregnancy occurs
in 1% to 2% of pregnant women. Physiologic changes
during pregnancy may have an impact when anesthesia is
needed. Anesthetic agents commonly used during preg-
nancy are not associated with teratogenic effects in clinical
doses. Surgery-related risks of miscarriage and prematurity
need to be elucidated with well-designed studies. Recom-
mended practices include individualized use of intraoper-
ative fetal monitoring and multidisciplinary planning
to address the timing and type of surgery, anesthetic
technique, pain management, and thromboprophylaxis.
Emergency procedures should be performed immediately
and elective surgery should be deferred during pregnancy.
Key words: nonobstetric surgery, anesthesia, obstet-
rics, pregnancy, high-risk pregnancy
Introduction
The frequency of nonobstetric surgery per-
formed during pregnancy ranges from 0.3%
to 2.2%, accounting for ∼100,000 cases per
year in both the United States and countries
of the European Union. Surgery may be
Correspondence: Mauricio Vasco Ramirez, MD, Clinical
Simulation Center, Facultad de Medicina, Universidad
CES, Cl. 10a #22—04, Medellin, Colombia. E-mail:
mvascor@ces.edu.co
The authors declare that they have nothing to disclose.
necessary during any stage of pregnancy.
Indications for non–pregnancy-related sur-
gery include the presence of acute abdomi-
nal disease, most commonly, appendicitis
and cholecystitis, malignancies, and trau-
ma. Among 5405 Swedish women who had
undergone operations during pregnancy,
42% occurred during the first trimester,
35% during the second trimester, and 23%
during the third trimester; laparoscopy for
gynecologic indications and appendectomy
were the most common procedures among
these patients.1,2
After clinical evaluation and before any
surgical procedure, preoperative pregnancy
testing (POPT) should be offered to all
childbearing age patients who, on the basis
of history, could be possibly pregnant; the
patient should be informed on the possibil-
ity of pregnancy and its implications with
respect to anesthesia and surgery. Indica-
tions or refusal of POPT should be clearly
documented in medical records.3
The diagnosis of surgical conditions dur-
ing pregnancy might be confusing or difficult
and sometimes delayed. The primary

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 63 / NUMBER 2 / JUNE 2020

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352 Vasco and Valencia G

concerns of maternal and fetal safety are
achieved by a focused multidisciplinary
team-based approach with respect to the
surgical condition.
management when surgery is required inci-
dentally during pregnancy. These adapta-
tions, illustrated in Table 1, primarily
occur so that the metabolic demands of
the growing fetus may be met.4

Physiological Changes
of Pregnancy Fetal Considerations
Pregnancy causes anatomical and physiolog-
ical changes that have implications for a RISK FOR TERATOGENICITY
perioperative team not only for anesthesia During the first 2 weeks of development,
administration but also for intrapartum the embryo typically is not susceptible to

TABLE 1. Physiological Changes of Pregnancy and Their Perioperative Implications

Physiological Changes Perioperative Implications
Cardiovascular system
Decreased BP, SVR Increased incidence of hypotension after anesthesia
Lack of autoregulation of uterine vasculature Fetal blood supply depends on maternal BP
Aortocaval compression after 20 wk Supine hypotension syndrome is common.
of gestation Left uterine lateral tilt (15 degrees) to reduce
aortocaval compression
Gallop rhythm, left axis deviation, systolic Misleads the clinician to a cardiac disease
murmur, mild ST-T changes
Increased blood volume and cardiac output Decompensation of structural cardiac diseases
(valvular lesions)
Airway
Increased soft tissue in the neck, weight gain, Difficult mask ventilation, laryngoscopy,
and breast engorgement and intubation
Increase in Mallampatti grading as pregnancy Difficult intubation. Smaller sized endotracheal
progresses tubes should be used
Increased edema of the airway and vocal cord Epistaxis with nasal intubation
Increased vascularity of mucous membranes
Respiratory system
Reduced FRC (20%), increased Tendency for early desaturation. Careful
oxygen demand (20%) preoxygenation is a must
Mild respiratory alkalosis (PaCO2 28-32 mm Hg) Maintain PaCO2 at normal pregnancy levels
Increased minute ventilation Faster inhalational induction
Blood and coagulation
Basal tachycardia and hemodilution Delay in the onset of classical signs of hypovolemia
Hypercoagulability Perioperative DVT prophylaxis
Gastrointestinal system
Reduced lower esophageal sphincter tone Consider all pregnant patients as full stomach.
Mandates rapid sequence induction
Altered gastric and pyloric anatomy Preoperative antiaspiration prophylaxis
and antacids after 16 wk
Increased gastric volume and acidity
Central nervous system
Engorged epidural veins Increased incidence of bloody tap
Reduced epidural space volume More extensive spread of LA
Increased CSF pressure Reduced dosage requirements
Increased sensitivity to opioids and inhalational agents Faster induction with inhalational agents

BP indicates blood pressure; CSF, cerebrospinal fluid; DVT, deep vein thrombosis; FRC, functional residual capacity; LA, local
anesthetic; PaCO2, partial pressure of carbon dioxide; SVR, systemic vascular resistance.

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 Anesthesia for Nonobstetric Surgery in Pregnancy 353

FIGURE 1. Critical periods in human development. The ages shown refer to the actual ages of the
embryo and fetus. Clinical estimates of gestational age represent intervals beginning with the first
day of the last menstrual period. Because fertilization typically occurs 2 weeks after the first day of
the last menstrual period, the reader should add 14 days to the ages shown here for conversion into
the estimated gestational ages that are used clinically. From Chestnut et al.6

teratogens. During these predifferentiation that fetal blood concentrations of muscle

stages, a substance either damages all or
most cells of the embryo, resulting in its
death, or damages only a few cells, allowing
the embryo to recover without development
of defects; this concept has historically been
known as the “All or None phenomenon.”5
The dark bars (Fig. 1) denote highly sensi-
tive periods, whereas the light bars indicate
periods of lesser sensitivity. Derangements
of normal maternal physiology secondary
to surgery and anesthesia may result in
stress, hypoxia, hypercapnia, and abnor-
malities of carbohydrate metabolism and
temperature. These states can increase ox-
idative stress and be teratogenic themselves,
or they may enhance the teratogenicity of
other agents.7
Anesthetic agents commonly used for
surgical procedures during pregnancy such
as barbiturates, propofol, benzodiazepines
(BZD), opioids, and ketamine have not
been associated with any teratogenic effects
when administered in clinical doses. Given
relaxants are only 10% to 20% of maternal
concentrations, these drugs also appear
to have a wide margin of safety when
administered to pregnant women during
organogenesis. No evidence supports tera-
togenicity with the clinical administration
of local anesthetic agents, with the excep-
tion of cocaine. Maternal cocaine abuse is
associated with congenital cardiac defects
and facial, genitourinary, and gastrointesti-
nal tract anomalies.8
Nitrous oxide is considered a weak
teratogen in rats and mice; reproductive
effects occur only after prolonged expo-
sure to high concentrations that are
unlikely to be encountered in humans
during clinical anesthesia. Finally, vola-
tile halogenated agents such as halothane,
isoflurane, enflurane, sevoflurane, and
desflurane used in doses <1 minimum
alveolar concentration (MAC) have not
been associated in humans with a higher
risk of teratogenic effects.8

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354 Vasco and Valencia G
In summary, actual evidence does not
support that anesthesia agents used in
clinical doses during nonobstetric surgery
in pregnancy result in an overall increase in
congenital abnormalities; the patient must
be clearly instructed about this during the
informed consent before surgery and anes-
thesia, and must be well documented in the
medical record.
BEHAVIORAL TERATOLOGY
Some teratogens produce enduring behav-
ioral abnormalities without any observable
morphologic changes. The central nervous
system may be particularly sensitive to such
influences during the period of major mye-
lination, which, in humans, extends from
the fourth intrauterine month to the second
postnatal month.
On December 14, 2016, the US Food and
Drug Administration (FDA) issued a Drug
Safety Communication warning that “…
repeated or lengthy use of general anesthetic
(GA) and sedation drugs during surgeries or
procedures in children younger than 3 years
or in pregnant women during their third
trimester may affect the development of
children’s brains.” Human and animal stud-
ies suggest that in utero short (< 3 h) and
single exposures to anesthetic or sedative
drugs have no deleterious effects on the
developing fetal brain.9 Because most re-
peated or lengthy procedures in pregnant
women are necessary or urgent and alter-
native anesthetic techniques different to GA
are not feasible for many of these surgical
procedures, the implications will primarily be
to discuss and balance the benefits of appro-
priate anesthesia in pregnant women against
the potential risks for procedures that may
last > 3 hours or if multiple procedures are
required.
EXPOSURE TO ANESTHETIC GASES
AMONG OPERATING ROOM AND
RECOVERY ROOM PERSONNEL
Since the introduction of volatile anesthetics,
the possible adverse effects of chronic expo-
sure in health workers, especially surgical
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areas workers, have been a matter of concern.
Studies with methodological biases found
contradictory results about chronic exposure
to anesthetic gases and the risk of sponta-
neous miscarriage and congenital malforma-
tions in health workers exposed to volatile
anesthetics.10–13 However, even if chronic
exposure has not to date been shown to be
associated with adverse health effects, the
existence of some risk cannot be completely
ruled out.
We must update and revise local and
national surveillance guidelines and proce-
dures in this area. It is important to protect
the health and safety of operating and
recovery room personnel working around
the administration of anesthetic gases,
and reduce workers’ exposure to and related
health risks from inadequately controlled
waste anesthetic gases.14
PREGNANCY LOSS AND PRETERM
BIRTH
Surgery during the first trimester of preg-
nancy has been linked to an increased risk
of miscarriage compared with the general
population.15 However, the majority of pub-
lished studies, examining the risks of preg-
nancy loss related to surgery, are generally
not controlled and, therefore, such data
cannot differentiate the effect of the disease
for which surgery was performed from the
effects of the procedure itself.
One of the possible explanations for a
theoretical increased risk of miscarriage in
women undergoing surgery during the first
trimester is the fact that many protocols
include performing a POPT for all women
of childbearing age. This could lead to the
recognition of many pregnancies that would
be unnoticed otherwise. It is important to
note that the miscarriage rate in the first
trimester before clinical recognition of preg-
nancy is known to be around 25% compared
with 8% at the time when the pregnancy is
commonly diagnosed.16 Well-controlled stud-
ies are needed to obtain more reliable data on
risk of early pregnancy loss associated with
nonobstetric surgical procedures.17,18
 Anesthesia for Nonobstetric Surgery in Pregnancy
Preterm birth is also an important
concern to patients and physicians when
surgery is performed during the second
and third trimesters of pregnancy. However,
data on this adverse outcome are confusing
as many of the published series based their
reports on premature contractions rather
than premature labor or premature birth
itself.19 Due to the inflammatory response
related to invasive procedures, it is likely that
surgery and the nature and severity of the
underlying pathology are responsible for
premature contractions.20 Therefore, it is
advised that “at a minimum, if the fetus is
considered to be viable, simultaneous elec-
tronic fetal heart rate (FHR) and contraction
monitoring should be performed before and
after the procedure to assess fetal well-being
and the absence of contractions.”21
Preterm labor should be diagnosed and
treated according to accepted guidelines. The
use of prophylactic antenatal steroids should
be considered for viable fetuses in selected
pregnancies when the risk of preterm birth
related to surgery and/or the underlying
pathology outweighs the possibility of need-
ing repeated doses that might be potentially
harmful.22 Prophylactic tocolytics are not
recommended on a routine basis.
Practical Considerations
Several factors are likely to contribute to
perioperative labor and delivery outcomes,
including the underlying maternal pathology
and the timing, type, and location of surgery
during pregnancy. Multidisciplinary planning
to address the timing and type of surgery
(ie, open approach vs. laparoscopic), the
optimal anesthetic technique (general, region-
al, or balanced), postoperative pain manage-
ment, and thromboprophylaxis options may
provide the most effective means of minimiz-
ing the risk of maternal and fetal adverse
outcomes.23,24
TIMING OF SURGERY
Emergency procedures should be performed
without delay, irrespective of gestational age,
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355
and elective surgery should be deferred during
pregnancy. The early second trimester, when
the risks of teratogenicity and preterm labor
are the lowest and when the uterus is small
enough not to interfere with visualization of
the operative field, is the preferred time to
undertake nonelective, nonurgent surgical
procedures, when indicated.19
INTRAOPERATIVE FETAL
MONITORING
According to the American College of
Obstetricians and Gynecologists (ACOG),21
the decision to use intraoperative monitoring
should be individualized, with consideration
of the type of surgery, the gestational age of
the fetus, and available personnel and facili-
ties (surgery should be performed at
an institution with neonatal and pediatric
services). If the fetus is considered previable,
it is generally sufficient to ascertain the FHR
by Doppler before and after the procedure.
In minimally invasive cases (eg, carpel tunnel
release) and procedures performed under
peripheral nerve blocks and/or monitored
anesthesia, continuous monitoring may be
feasible, but unnecessary. Preprocedure and
postprocedure assessments of uterine tone
and FHR suffice in these cases. A greater
discussion of the subject is addressed in
subsequent chapters.
Considerations of Anesthetic
Management
PREOPERATIVE PREPARATION
AND PREMEDICATION
Adequate preoperative patient evaluation
and preparation may improve maternal
fetal outcomes, reduce delays, cancella-
tions, costs, and mortality.25 Pregnant pa-
tients without comorbidities are routinely
classified as American Society of Anesthesi-
ologists (ASA) Physical Status Classifica-
tion System II.26 After a clinical evaluation
to identify comorbid conditions, allergies,
and previous complications of anesthesia, a
focused physical examination of the airway,
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356 Vasco and Valencia G
lungs, and heart is performed.27 Difficult
intubation has been reported to occur in 1
in 21 obstetric intubations compared with 1
in 50 nonobstetric intubations and factors
that predict problems with tracheal intuba-
tion that must be recognized are as follows:
body mass index > 35, neck circumference
> 50 cm, thyromental distance > 6 cm,
Mallampati grade 3 to 4, and mouth open-
ing <4 cm28,29; if regional analgesia/anes-
thesia is planned, the regional anesthesia
site must be examined to assess for potential
difficulty or infection and any preexisting
weakness or neuropathy should be re-
corded. Informed anesthetic consent, in-
cluding a discussion on the risks and
benefits of maternal and fetal anesthetic
exposure, must be documented in the med-
ical record.27
Premedication may be necessary to
prevent gastric contents’ aspiration and
relieve maternal anxiety.
Standard adult fasting guidelines (ie, 6 to
8 h for solid food and 2 h for clear liquids)
must be followed for elective procedures.
Pregnant women are at an increased risk for
gastric contents aspiration after 18 weeks’
gestation and pharmacologic prophylaxis
against acid aspiration may include the
administration of a histamine 2 receptor
antagonist (ranitidine), metoclopramide,
and/or a nonparticulate antacid such as
sodium citrate. BZD are used to reduce
the level of maternal anxiety and to avoid
increases in circulating catecholamine lev-
els, which impair uteroplacental perfusion.
BZD in clinical doses during pregnancy are
safe and may be appropriate to provide
preoperative anxiolysis.27
Thromboprophylaxis is a common
practice in pregnant women, especially
in those with additional risk factors for
thromboembolic events. Before surgery,
the use of pharmacological thrombopro-
phylaxis must be interrupted for safe use
of neuraxial techniques. Some of the most
relevant recommendations on the timing
of anticoagulant use in patients receiving
neuraxial analgesia/anesthesia according
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to different evidence-based guidelines are
summarized as follows30,31:
Prophylactic dose of low–molecular-
weight heparins (LMWH) (eg, subcuta-
neous enoxaparin 40 mg once daily):
 Before surgery, wait at least 12 hours
after the last dose of LMWH is admin-
istered before a neuraxial technique.
Therapeutic dose LMWH (eg, subcu-
taneous enoxaparin, 1 mg/kg twice daily):
 Before surgery, wait at least 24 hours
after the last dose of LMWH is admin-
istered before a neuraxial technique.
Prophylactic dose of unfractionated
heparins (eg, subcutaneous heparin 5000
to 7500 IU twice daily):
 Before surgery, wait at least 4 to 6 hours
after the last dose of unfractionated
heparins is administered before a neu-
raxial technique.
MONITORING
Maternal monitoring should include non-
invasive blood pressure measurement,
electrocardiography, pulse oximetry, cap-
nography, temperature monitoring, uri-
nary output, and the use of a peripheral
nerve stimulator. The FHR and uterine
activity should be monitored before, during,
and after surgery, when indicated, according
to guidelines as previously described.23,32
Arterial line, central venous catheter (cen-
tral and peripherally inserted), and mini-
mally invasive monitoring for cardiac output
monitoring including cardiac ultrasound can
be used and must be selected in high-risk
obstetrics patients or major surgeries accord-
ing to availability and training.23,32
Point-of-care ultrasound is increasingly
being used as an everyday tool in clinical
anesthesia for diagnostic and therapeutic
procedures such as ultrasound-guided airway
assessments, airway management, cricothyr-
oidotomy, transthoracic echocardiography,
gastric volume assessments, lung ultrasound
diagnoses, intracranial pressure assessments,
vascular access, neuraxial blocks, and thor-
acoabdominal wall blocks.33
 Anesthesia for Nonobstetric Surgery in Pregnancy
ANESTHETIC TECHNIQUE
There is no association between improved
fetal outcome and any specific anesthetic
technique. We suggest using regional anes-
thesia when appropriate rather than GA to
minimize fetal drug exposure, avoid the need
to manage the airway, and provide a degree
of postoperative analgesia; rapid intravenous
infusion of crystalloid or colloid fluids during
the initiation of spinal or epidural anesthesia
with prophylactic vasopressor administration
or early treatment of hypotension is advised.
The anesthesiologist should be vigilant to the
signs of high neuraxial blockade and local
anesthetic systemic toxicity.23,32
Important components of safe obstetric
airway management during GA include
adequate and timely airway assessment,
consideration of fasting status, pharmaco-
logic aspiration prophylaxis, optimal
patient positioning, adequate preoxygena-
tion, and provision of a secure airway.
Optimal patient positioning is essential
before induction of GA; the head-
up position may facilitate insertion of the
laryngoscope, improve the view of the
glottis, increase functional residual ca-
pacity, and reduce the risk of gastric
regurgitation. Aligning the external audi-
tory meatus with the suprasternal notch
(ramped position) is particularly helpful in
the obese pregnant patient. Adequate pre-
oxygenation, defined as end-tidal oxygen
fraction (FetO2) > 0.9, delays desaturation
and should precede the induction of GA.
Fresh gas flows ≥ 10 L/min and a tight-
fitting face mask are required for effective
preoxygenation; 3 to 4 maximal capacity
breaths of 100% oxygen may be as effec-
tive as 3 minutes of normal tidal breathing.
Alternative techniques such as insufflation
of oxygen at 5 L/min via a nasal cannula or
delivery of high-flow humidified nasal
oxygen (named transnasal humidified rap-
id insufflation ventilatory exchange) useful
in selected patients (eg, obese pregnant
patients) and may prolong the apneic time
without hypoxemia.29 As pregnant women
are at increased risk for gastric contents
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357
are aspiration after 18 weeks’ gestation,
most anesthesiologists agree that GA
above this gestational age mandates
tracheal intubation; supraglottic airway
devices may also be an alternative airway
management technique for rescuing diffi-
cult airways in pregnant patients who
cannot be ventilated or intubated. Cricoid
pressure has been questioned because of
the limited evidence of its effectiveness in
decreasing aspiration and the potential
for making airway management more
difficult if incorrectly applied. Simulation-
based training and backup equipment
(bougie, supraglottic airway devices,
video-laryngoscope, cricothyroidotomy
set, guidelines for difficult airway manage-
ment, and use of cognitive aids) are
recommended to acquire and maintain
skills for difficult obstetric airway manage-
ment clinical scenarios.28,29
Drugs with a history of safe use during
pregnancy include thiopental, Propofol,
ketamine, fentanyl, alfentanil, remifenta-
nil, succinylcholine, and the nondepola-
rizing muscle relaxants. A 30% to 40%
decrease in the MAC of volatile anes-
thetic agents has been observed in preg-
nancy, correlating with higher serum
progesterone levels and faster inhalation-
al induction related to an increase in
minute ventilation. Anesthetic gases relax
the uterus, depress myometrial irritability
proportional to the MAC exposure, and
increase uterine blood flow.23,32
Maternal administration of reversal
agents, especially rapid intravenous injec-
tion of an anticholinesterase agent, could
stimulate acetylcholine release and theo-
retically increase uterine tone and precip-
itate preterm labor. Magnesium sulfate
commonly used in obstetrics increases
neuromuscular blockade.23,32 We advise
a slow administration of an anticholines-
terase (neostigmine) after previous injec-
tion of an anticholinergic agent (atropine)
for neuromuscular blockade reversal be-
fore extubating; all forms of neuromus-
cular blockade must be monitored with a
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358 Vasco and Valencia G
nerve stimulator to ensure adequate
muscle relaxation and reversal before
extubating. The Society for Obstetric
Anesthesia and Perinatology (SOAP) re-
leased a Statement on sugammadex dur-
ing pregnancy and lactation in April
2019: “The literature is insufficient to
evaluate the safety of sugammadex with
regards to effects on plasma hormone
levels and teratogenicity. Therefore, the
SOAP task force recommends traditional
neuromuscular blockade reversal during
pregnancy.”34
Extubating criteria must be stricter
with the patient fully awake and following
commands to prevent postextubating as-
piration and hypoxemia.
Irrespective of the anesthetic technique,
steps to avoid hypoxemia, hyperoxia, hypo-
tension, acidosis, intraoperative awareness,
and hyperventilation are the most critical
elements of anesthetic management,23,32 and
have a low threshold to perform intrauterine
resuscitation during nonobstetric surgery
(Table 2).
ANALGESIA
Opioids can be used to control postoperative
pain, but attempts should be made to reduce
the amount and time of opioid medications
prescribed to pregnant women while ensur-
ing adequate pain management. Preference
TABLE 2. Checklist for Intrauterine
Resuscitation During
Nonobstetric Surgery
Increase left uterine displacement
Administer fluids and/or vasopressor to return
blood pressure to baseline
Increase of the inspired oxygen fraction (FiO2)
Release pneumoperitoneum, surgical retraction,
and surgical manipulation
Ensure end-tidal CO2 levels between 28 and 32
mm Hg (arterial blood gas analysis)
Ensure appropriate acid-base status (arterial
blood gas analysis)
Check maternal hemoglobin (Hemocue)
Administering medications to improve uterine
relaxation (eg, nitroglycerin administration
increases volatile agent)
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for analgesic techniques such as regional,23,32
peripheral nerve (ideally ultrasound-guided),
field blocks, and surgical techniques such
as laparoscopy that reduce the need for
postoperative opioids should be used in
pregnant women. Multimodal analgesia,
including maximizing the use of nonopioid
medications that are considered safe in
pregnancy, should be considered. Paraceta-
mol is the analgesic of choice for the treat-
ment of mild to moderate pain during any
stage of pregnancy.32 Nonsteroidal anti-
inflammatory drugs can inhibit uterine con-
traction, but nonsteroidal anti-inflammatory
drugs should be avoided, particularly
after 28 weeks of gestation because they
may cause premature closure of the fetal
ductus arteriosus and oligohydramnios as
they reduce fetal renal function mainly if
administered for > 48 hours.35,36
THROMBOPROPHYLAXIS
Due to the physiologic changes of pregnancy
that lead to a relative hypercoagulable state,
the overall risk of thromboembolic events
may be increased. Deep venous thrombosis
(DVT) during pregnancy is associated with
high mortality, morbidity, and costs. Pulmo-
nary embolism is its most feared complica-
tion and is one of the leading causes of
maternal death in high-income countries.
Maternal safety organizations recom-
mend mechanical compression devices
and/or pharmacological interventions for
thromboembolism prophylaxis in all wom-
en undergoing nonobstetric surgery during
pregnancy or obstetric procedures such as
cervical cerclage and cesarean delivery
especially for women with additional risk
factors, including obesity, thrombophilia,
prolonged immobility, and any condition
that may increase a pregnant woman’s risk
for venous thromboembolism.37
Pharmacological thromboprophylaxis has
been highlighted as a key preventive measure
to reduce DVT/pulmonary embolism and
related maternal deaths. It must be resumed
in selected patients when there is adequate
surgical-site hemostasis and a neuraxial
 Anesthesia for Nonobstetric Surgery in Pregnancy
catheter has been safely removed following
the times recommended by evidence-based
guidelines on anesthetic management of
pregnant and postpartum women receiv-
ing thromboprophylaxis or higher dose
anticoagulants.30,31,38
SPECIFIC SURGICAL
CONSIDERATIONS
Laparoscopic Abdominal Surgery
Laparoscopy has the advantage of re-
duced postoperative pain, faster recovery,
and lower thromboembolic events and
may allow better abdominal exploration
with less uterine manipulation compared
with laparotomy. The use of laparoscopic
surgery during pregnancy is a very com-
mon practice nowadays. Reedy et al39
published data from 458 laparoscopic
procedures performed during pregnancy,
from which 48% were cholecystectomies,
28% were adnexal operations, 16% were
appendectomies, and 8% were diagnostic
procedures. Overall, 32% of the opera-
tions were performed in the first trimester,
54% in the second trimester, and 13% in
the third trimester.
In 2017, the Society of American Gastro-
intestinal Endoscopic Surgeons (SAGES)
published the “Guidelines for the use of
laparoscopy during pregnancy,” which pro-
vide updated evidence-based recommenda-
tions for this type of surgical procedure.40
Some of the most important aspects cited in
this document are as follows:
 Gravid patients beyond the first trimes-
ter should be placed in the left lateral
decubitus position or partial left lateral
decubitus position to minimize com-
pression of the vena cava.
 Initial abdominal access can be safely
accomplished with an open (Hasson),
Veress needle, or optical trocar techni-
que, by surgeons experienced with these
techniques, if the location is adjusted
according to fundal height.
 CO2 insufflation of 10 to 15 mm Hg
can be safely used for laparoscopy and
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359
should be adjusted to the pregnant
patient’s physiology.
 Intraoperative CO2 monitoring by cap-
nography should be used.
 Intraoperative and postoperative pneu-
matic compression devices and early
postoperative ambulation are recom-
mended prophylaxis for DVT in the
gravid patient.
Pregnancy is no longer considered a
contraindication to laparoscopy and this
technique can be safely performed during
any trimester of pregnancy.
Neurosurgery
Neurosurgical conditions most common
encountered during pregnancy include brain
tumors, intracranial hemorrhage (ruptured
aneurysms, arteriovenous malformations,
preeclampsia) traumatic brain injury,
and spinal surgery.41 The critical care and
anesthetic neurosurgical treatment of these
patients occasionally include controlled
hypotension, hyperventilation, diuresis, and
hypothermia, which must be undertaken
carefully in the pregnant patient. The prone
position for neurosurgery may cause difficul-
ties with fetal monitoring and the ability to
perform emergent cesarean delivery.42
The use of neurosurgical hypotensive
anesthetic techniques, which, although
sometimes essential for maternal well-being
(avoid or treat major intraoperative bleed-
ing), would be expected to regularly result in
fetal hypoperfusion with the potential for
fetal neurologic injury. Controlled hypoten-
sion can be induced with ultra-short action
beta blockers (esmolol), adenosine, volatile
anesthetic, or intravenous vasodilators
(nicardipine, sodium nitroprusside, nitrogly-
cerin). Each one of these drugs carries its
own potential hazards in addition to reduc-
tion in uteroplacental blood flow and fetal-
induced hypotension due to the crossing
of the placental barrier. When controlled
hypotension is necessary, a continuous
electronic FHR monitor should be used
during surgery and special attention must
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360 Vasco and Valencia G
be paid to detect and correct suboptimal
fetal conditions related to maternal hemo-
dynamics and oxygenation.
Short periods of hyperventilation and
osmotic diuresis are often used to relieve
elevated intracranial pressure; extreme
hyperventilation (partial pressure of car-
bon dioxide <25 mm Hg) can cause ute-
rine artery vasoconstriction and leftward
shift of the maternal oxyhemoglobin dis-
sociation curve; mannitol, in small doses
of 0.25 to 0.5 mg/kg used intravenously,
has been used without any harmful effect
to the fetus and appears to be safe if
required at those doses.43
There are no studies in the literature of
the use of hypertonic saline during preg-
nancy to recommend its use to relieve
elevated intracranial pressure. Hypocar-
bia and maternal alkalosis can cause fetal
distress and must be addressed by manag-
ing ventilator parameters.
The use of intraoperative maternal hypo-
thermia, utilized for adult neuroprotection
or targeted temperature management, is an
additional concern if needed in pregnant
patients. This technique, previously known
as mild therapeutic hypothermia, has been
used in selected patients surviving out-of-
hospital sudden cardiac arrest and has been
shown to significantly improve rates of long-
term neurologically intact survival.44 Fetal
bradycardia resulting from maternal hypo-
thermia is reversible on maternal rewarming
and does not warrant delivery.45 Therapeu-
tic hypothermia has been shown to improve
neurologic outcomes in the setting of hy-
poxic encephalopathy in newborns by block-
ing damaging inflammatory cascades.46
Cardiothoracic Surgery
As the mortality in pregnant women under-
going cardiac surgery is 3% to 15% and, in
emergency situations, fetal mortality may
even reach 43%, cardiac surgery should be
delayed until the fetus is viable and has been
delivered. Ideally, operation should be
planned after 6 weeks postpartum to mini-
mize risks of thromboembolism. However,
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Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
in rare circumstances where hemodynamics
is compromised, cardiac intervention in a
pregnant woman cannot be avoided. A
multidisciplinary approach to carry out the
planning in a center with experience in
cardiac procedures is essential, to optimize
maternal and fetal outcomes. In these sit-
uations, special care in anesthetic manage-
ment, conduct of cardiopulmonary bypass
(CPB), and intraoperative monitoring of the
fetus may decrease risks of fetal loss.47
The fetal death rate associated with
cardiac surgery with CPB is as high as
30%. Valvular heart disease is the most
common indication for heart surgery
in pregnant patients, and the most com-
mon pathologies affect the left side of
the heart.
Current CPB recommendations in-
clude the following47:
(1) Maintaining the pump flow rate
> 2.5 L/min/m2 of body surface area
and perfusion pressure > 70 mm Hg.
(2) Maintaining the hematocrit > 28%.
(3) Using normothermic perfusion when
feasible.
(4) Using pulsatile flow.
(5) Using alpha-stat pH management.
During CBP, fetal monitoring may help
guide adjustments to pump perfusion param-
eters; such adjustments may result in resolu-
tion of an abnormal FHR pattern and avoid
emergency cesarean delivery.
Percutaneous endovascular interventions
(percutaneous balloon valvuloplasty) seem
to be a better alternative than surgical repair
and are associated with a significant reduc-
tion in fetal and neonatal mortality.48
If cardiac intervention during pregnancy is
absolutely necessary, percutaneous proce-
dures can be performed relatively safely and
are usually preferred over open surgery.
Cardiac surgery should be reserved for pa-
tients in whom operation cannot be delayed,
such as those with progressive heart failure
refractory to medical, placement of assist
devices or percutaneous procedures, and/or
life-threatening conditions including acute
 Anesthesia for Nonobstetric Surgery in Pregnancy
ascending aortic dissection. In compensated
cases, the safest window for surgery seems to
be the second trimester of the pregnancy.47
Maternal Cardiac Arrest, Resuscitation,
and Perimortem Cesarean Delivery
Cardiopulmonary resuscitation in preg-
nant women should be performed accord-
ing to standard Basic and Advanced
Cardiac Life Support (BLS/ACLS) guide-
lines; the maternal (and hence fetal) cir-
culation may optimized through patient
positioning to prevent aortocaval com-
pression and performance of quality chest
compression to improve maternal perfu-
sion. The woman should be placed fully
supine on a firm surface; if the uterine
fundus is above the level of the umbilicus,
manual left uterine displacement should
be optimally performed by pulling with 2
hands leftward and upward, ideally con-
ducted from the left side of the patient.
The depth and rate of chest compres-
sion remain unchanged in pregnancy, at
least 100 to 120 per minute at a depth of at
least 5 cm, allowing full recoil before the
next compression, with minimal interrup-
tions, and at a compression-ventilation
ratio of 30:2; when indicated, defibrilla-
tion should be performed in the pregnant
patient without hesitation or delay, endo-
tracheal intubation should be performed
early by an experienced laryngoscopist
and supraglottic airway placement is the
preferred rescue strategy for failed intu-
bation. Continuous capnography should
be used, if available, to assess correct
placement of the endotracheal tube. In-
travenous or intraosseous access should
be established above the diaphragm and
medication doses (adrenaline, amiodar-
one) do not require alteration to accom-
modate the physiological changes of
pregnancy; fetal assessment should not
be performed during resuscitation and
looking for the possible causes of cardiac
arrest simultaneously to BLS and ACLS
must be assured. The reversible causes
of cardiac arrest during pregnancy are
Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
361
similar to those in nonpregnant patients;
however, additional causes specific to
pregnancy include amniotic fluid embo-
lism, eclampsia, placental abruption, and
hemorrhage.
Perimortem cesarean delivery should
be strongly considered in every mother in
whom return of spontaneous circulation
has not been achieved after 4 minutes of
high-class resuscitative efforts.49,50
Conclusions
Nonobstetric surgery during pregnancy
in not uncommon. POPT should be
offered to all childbearing age patients
who, on the basis of history, could be
possibly pregnant before performing any
surgical procedure to guarantee accurate
information to the patient on the possi-
bility of pregnancy and its implications
with respect to anesthesia and surgery;
indications or refusal for POPT should
be clearly documented in medical
records.
Anesthetic agents commonly used dur-
ing pregnancy are not associated with
teratogenic effects in clinical doses and
have no harmful effects on the developing
fetal brain with single limited exposures of
<3 hours in duration.
Surgery-related risks of miscarriage and
prematurity need to be elucidated with well-
designed studies and diagnosis and treatment
of such conditions during or after nonobstet-
rical surgical procedures should be accom-
plished according to accepted guidelines for
such entities.
Recommended practices include individu-
alized use of intraoperative fetal monitoring
and multidisciplinary planning to address the
timing and type of surgery, anesthetic techni-
que, pain management and thromboprophy-
laxis according to individual patients’ risk,
and underlying pathology.
Emergency procedures should be per-
formed without delay and elective surgery
should be deferred during pregnancy.
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362 Vasco and Valencia G
Special technical and maternal and
fetal considerations must be taken into
account according to the type of surgery,
selected surgical technique, and response
to possible complications providing a
multidisciplinary planning and structured
team work.
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