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Should nonobstetric outpatient surgery be performed on a pregnant patient?
It depends, say sources, who offer tips for reducing risk, liability
You work at a freestanding surgery center across from a medical center. A surgeon wants to schedule an incision and drainage (I&D) of a breast abscess on a pregnant patient scheduled for an elective cesarean in a few days. Your anesthesiologist is hesitant and cites concerns about inducing labor and, more importantly, fetal distress.
What do you do?
Nonobstetric outpatient surgery during pregnancy is a controversial topic, as can be seen in this concern about an actual patient, which was posted on the web site for the Society for Ambulatory Anesthesia.1
"Obviously, as a generic platitude, one prefers not to do any surgery while a patient is pregnant," says Mark I. Evans, MD, director of the Institute for Genetics and professor at Mount Sinai School of Medicine, both in New York City. "Just like everyone else, the risks and benefits of whatever condition you’re treating have to be balanced against the small risk of surgery during pregnancy," he adds.
If possible, postpone the surgery, most providers agree. "If the patient has cancer or a ruptured appendix, you’re not going to wait," Evans says.
"If the patient wants breast augmentation, you probably will wait," he notes.
Consult with the patient’s obstetrician to determine if the procedure is warranted during pregnancy or whether it could wait until delivery or after delivery, suggests Lindsay Alger, MD, professor of obstetrics and gynecology and reproductive sciences and director of labor and delivery at the University of Maryland Medical Center in Baltimore. "If it is warranted, determine how best to minimize complications," she adds.
Ashu Wali, MD, FFARCSI, assistant professor of anesthesiology at Baylor College of Medicine and staff anesthesiologist at Ben Taub General Hospital, both in Houston, who responded to the question about performing I&D breast surgery on a third trimester patient, agrees that surgery should be avoided during pregnancy if possible.1
". . . The surgical procedure, site of surgery, and the patient’s underlying condition have been shown to be associated with a higher incidence of abortion in the first trimester, labor in the third trimester, intrauterine growth retardation, and perinatal mortality," Wali says.1
"The risk of inducing labor is fairly high in the third trimester, for pelvic and uterine surgery, due to close proximity to the uterus," Wali says. Instead, postpone surgery until the postpartum period, if possible, he says.1
Consider the type of procedure when deciding whether to perform surgery on a pregnant woman and where it should be performed, say sources interviewed by Same-Day Surgery.
"If the procedure is removed from the abdominal cavity and the pregnancy, say the patient is having foot surgery, there is no major limitation with the exception of making sure the anesthesiologist understands the patient is pregnant and takes that into consideration in terms of [anesthesia] agents," Alger says.
However, any time a surgeon enters the abdominal cavity, that action can initiate preterm labor, she warns. "So you need to monitor someone for that possibility, or if the patient is at high risk of starting preterm labor, you might use a prophylactic medication to decrease uterine contractility," Alger says.
Whether a nonobstetric procedure should be performed on a pregnant patient in a freestanding facility is another controversy. Again, consider the nature of the procedure, note sources interviewed by SDS.
If the patient is being put to sleep, in particular once the fetus is potentially viable at 28 weeks, you might want to be able to do cesarean if an emergency happens, Alger advises.
When you perform an outpatient procedure late in pregnancy, it is safer to monitor the mother and fetus, to diagnose complications early and have the ability to intervene, she says.
There should be a process to ensure the patient doesn’t become hypotensive and is well-oxygenated, she explains. However, she doesn’t go as far as to say that outpatient surgery should never be performed in a freestanding facility late in pregnancy.
"Ask your anesthesiologist about his or her level of comfort," Alger suggests. "If they are uncomfortable, it probably shouldn’t be done."
Facilities and personnel to institute immediate delivery of a baby should be available on site, Wali says. "It may not be wise to rush the patient across the street to the medical center for delivery of a compromised fetus for both safety issues and medico-legal reasons," he says.1
Nonobstetric surgery on pregnant patients should include preoperative evaluation of the patient by an obstetrician; preoperative counseling of the patient by the anesthesiologist and obstetrician, especially regarding possible effects on the fetus from agents and techniques used; and a thorough, preoperative airway examination by the anesthesia care team, Wali says.
Risk of difficult tracheal intubation is almost eight times higher in the pregnant patient, he points out.
In addition, a difficult airway cart must be readily stocked and available on site, Wali says.
Pregnant women are more likely to have bleeding and bleeding complications, Alger warns.
"There’s a greater risk for venous thrombosis or thromboembolism, she adds.
The patient can be given a prophylaxis against venous thrombosis, Wali says.1
Because most outpatient surgery procedures are short and self-limited, fetal monitoring before and after the procedure should be sufficient, says Alger. "If you have a more significant operation you’re doing and the patient does have a viable fetus, if possible, continuous monitoring would be ideal," she says.
Fetal heart tones (FHTs) should be monitored continuously intraoperatively, if technically feasible, Wali says. "Transvaginal probes are available to allow monitoring during abdominal or pelvic surgery," Wali says.
Postoperatively, FHTs and uterine contractions should be monitored for at least 24 hours, Wali says.
Neuraxial analgesia may mask the pain associated with uterine contractions, he warns.
A labor and delivery nurse, midwife, or obstetrician should supervise the monitoring, Wali adds. If necessary, tocolysis can be instituted expeditiously, he says.
"Document FHTs preoperatively, intraoperatively if possible, and postoperatively," he adds.1 (For a discussion on whether pregnancy tests should be performed routinely, see below.)
tests be performed routinely as part of the pre-op work-up for women of
"Not routine pregnancy tests, but part of the surgical work-up prior to surgery is inquiring of patients as to their menstrual history and if they could possibly be pregnant," says Mark I. Evans, MD, director of the Institute for Genetics and professor at Mount Sinai School of Medicine, both in New York City.
Any patient who cannot say her last menstrual period was in the last two to three weeks should probably have a pregnancy test before surgery, unless she has an intrauterine device in place, for example, says Lindsay Alger, MD, professor of obstetrics and gynecology and reproductive sciences and director of labor and delivery at the University of Maryland Medical Center in Baltimore.
"If they have been taking the pill routinely, they probably don’t need a pregnancy test," she adds.
1. SAMBA Talks 2004; 4.1. Web: www.sambahq.org/professional-info/enewsletter.html.
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