What is the safest trimester for a pregnant patient to undergo non-obstetric surgery?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Surgical procedures are usually performed in the second trimester of pregnancy, avoiding the crucial first trimester of fetal development and the last trimester with risk of premature delivery Correct positioning of the patient during surgery is important to reduce risk of abnormal blood flow to the fetus. Teratogenic anesthetic agents must be avoided, and fetal monitoring is recommended during surgery. Difficulty in orotracheal intubation is more common during the second and third trimesters related to enlargement and friability of the oropharyngeal mucosa Laparoscopic adrenalectomy is the preferential option for treatment of adrenal lesions such as adenomas and carcinomas Transsphenoidal pituitary surgery is the main procedure used to treat pituitary adenoma (Cushing disease), usually performed during the second trimester of pregnancy Surgical resection of a tumor ectopically secreting ACTH is a possibility if the source can be located, also timed during the second trimester of pregnancy Finally, bilateral adrenalectomy is an option for severe and refractory cases of CS with any cause Any form of radiotherapy, including stereotactic, for ACTH-secreting pituitary adenomas is contraindicated during pregnancy because of safety concerns; moreover, the long lag time before beneficial effects of radiotherapy can be realized renders this treatment option less relevant for pregnancy-related concerns

2.

Cusimano MC, Liu J, Azizi P, et al. Annals of Surgery. 2023;278(1):e147-e157. doi:10.1097/SLA.0000000000005362.

Publish date: July 6, 2023.

Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%). CONCLUSIONS: Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.

3.

Elsevier ClinicalKey Drug Monograph

Content last updated: February 4, 2024.

Pregnancy If a benzodiazepine is required during pregnancy, avoid first trimester administration if possible, consider short-acting agents, limit treatment to the lowest effective dosage and duration, and discontinue the drug well before delivery. Repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures during the third trimester of pregnancy may have negative effects on fetal brain development. Consider the benefits of appropriate anesthesia in pregnant women against the potential risks, especially for procedures that may last more than 3 hours or if multiple procedures are required prior to delivery. It may be appropriate to delay certain procedures if doing so will not jeopardize the health of the child and/or mother. No specific anesthetic or sedation drug has been shown to be safer than another. Human studies suggest that a single short exposure to a general anesthetic in young pediatric patients is unlikely to have negative effects on behavior and learning; however, further research is needed to fully characterize how anesthetic exposure affects brain development. Some guidelines support the use of nayzilam for endoscopy or other brief procedures when needed, in a single dose, with a preference to avoid use in the first trimester when possible. There is a pregnancy exposure registry that monitors outcomes in pregnant patients exposed to antiepileptic drugs such as nayzilam; information about the registry can be obtained at <https://www.aedpregnancyregistry.org/> or by calling 1-888-233-2334.

4.

Elsevier ClinicalKey Clinical Overview

Special Considerations Managing pregnant patients with HCA (hepatocellular adenomas) should be individualized Ideally there would be prepregnancy intervention (such as resection, ablation, or embolization) of large lesions or for lesions with complications during prior pregnancy Pregnancy is not contraindicated for those lesions less than 5 cm, and it is recommended to monitor for the potential of growth with ultrasound every 6 to 12 weeks during pregnancy Because of elevated levels of circulating estrogens, hyperdynamic circulation, and increased vascularity of the liver, the greatest risk of rupture is in the third trimester of pregnancy Patients with HCA can deliver vaginally in lieu of cesarean section if there are no other complicating factors Surgical resection of HCA lesions may be considered in pregnant patients under 24 weeks of pregnancy; however, general anesthesia risks are greatest in the second trimester, and abdominal surgery becomes more difficult in late second trimester because of the gravid uterus; thus, it is generally avoided Selective arterial embolization is only recommended if needed for lifesaving purposes during pregnancy because of increased risk of radiation exposure to the fetus (particularly before 26 weeks of gestation)

5.

Elsevier ClinicalKey Clinical Overview

Treatment Pregnant patients Appendicitis affects 1 in 500 to 2000 pregnancies; highest incidence is in the second and third trimesters Results in preterm labor in at least 4% of patients with uncomplicated appendicitis and 11% of patients with complicated appendicitis Risk of fetal loss is about 2% in patients without perforation and 6% in patients with complicated appendicitis Delay in diagnosis is not uncommon Clinical manifestations that occur with normal pregnancy overlap with manifestations of appendicitis (eg, nausea, vomiting, physiologic leukocytosis, mild elevation in C-reactive protein) and febrile response to illness may be blunted in pregnancy Displacement of the appendix by the gravid uterus results in variations in reported location of pain Imaging Ultrasonography is the imaging test of choice, particularly during the first trimester when fetal ionizing radiation exposure risks from CT imaging are greatest MRI without gadolinium is next test of choice for patients with inconclusive ultrasonography CT may be necessary if diagnosis cannot be reliably excluded through clinical evaluation, ultrasonography, or MRI Consult obstetrician early with concern for appendicitis to aid in diagnosis and management; consult anesthesiologist soon after diagnosis for aid in surgical matters Operative treatment Surgical management is usually straightforward in the first trimester of pregnancy but may be challenging due to altered anatomy in the second and third trimesters Higher risk of perioperative complications in second and third trimesters compared to nonpregnant patients Laparoscopic appendectomy can be performed in all trimesters; Laparoscopic appendectomy is the standard approach up to 20 weeks of gestation or while the uterine fundus is below the level of the umbilicus

6.

Elsevier ClinicalKey Clinical Overview

Treatment Pregnant patients Control pain with IV opioids because NSAIDs are not recommended Cholelithiasis Ursodeoxycholic acid has been used in the management of gallstones, but safety and effectiveness have not been evaluated Surgery during pregnancy is only indicated in patients with recurrent or intractable biliary pain, refractory to medical management, or those with gallstone complications Laparoscopic approach is the preferred surgical method. It is believed to be safe in all trimesters; however, the timing of surgery is important Surgery is recommended after the second trimester in order to reduce the rate of spontaneous abortion and preterm labor, but it becomes more difficult with uterine enlargement in the third trimester Choledocholithiasis Symptomatic disease treated with 1 of the following: Preoperative ERCP and sphincterotomy followed by laparoscopic cholecystectomy Laparoscopic cholecystectomy followed by postoperative ERCP Laparoscopic cholecystectomy with simultaneous laparoscopic common bile duct exploration Shown to be most cost effective with equal outcomes

7.

Elsevier ClinicalKey Drug Monograph

Content last updated: May 2, 2024.

Pregnancy Recticare is classified as FDA pregnancy category B. Reproductive studies conducted in rats have not demonstrated recticare-induced fetal harm; however, animal studies are not always predictive of human response. There are no adequate or well controlled studies of recticare in pregnant women. Local anesthetics are known to cross the placenta rapidly and, when administered for epidural, paracervical, pudendal, or caudal block anesthesia, and to cause fetal toxicity. The frequency and extent of toxicity are dependent on the procedure performed. Maternal hypotension can result from regional anesthesia, and elevating the feet and positioning the patient on her left side may alleviate this effect. Topical ocular application of recticare is not expected to result in systemic exposure. When recticare is used for dental anesthesia, no fetal harm has been observed; recticare is generally the dental anesthetic of choice during pregnancy and guidelines suggest the second trimester is the best time for dental procedures if they are necessary. A study by the American Dental Association provides some evidence that, when needed, the use of dental local or topical anesthetics at 13 weeks to 21 weeks of pregnancy or later is likely safe and does not raise incidences of adverse pregnancy outcomes or other adverse events; the study analyzed data from the Obstetrics and Periodontal Therapy (OPT) trial, a multicenter study of over 800 pregnant patients in the early to mid second trimester who received required dental procedures.