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INTRODUCTION

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It is not uncommon for pregnant women to undergo invasive diagnostic or therapeutic procedures, including surgical operations. In these cases, gravidas present a dual challenge. Namely, the risks and benefits of a proposed procedure for the mother are balanced against the potential fetal risks and benefits associated with the proposed operation.

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PREOPERATIVE ASSESSMENT

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This evaluation begins with a detailed maternal history and clinical examination, indicated laboratory testing, and appraisal of fetal status. Preoperative assessment ideally identifies obstetric and medical risks that may be associated with perioperative maternal or fetal morbidity and mortality. Recognition of risks and benefits allows providers to adequately counsel a gravida and permits shared decision making and informed consent. This often requires a collaborative effort with input from anesthesiologists, obstetricians, pediatricians, neonatologists, and associated surgeons. Even so, despite improved obstetric, surgical, and medical care, all operative procedures carry risk.

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Maternal Assessment

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To begin, an inventory of medical comorbidities is assembled. Some may be of greater importance for the surgical patient. Cardiopulmonary status, which undergoes profound physiologic changes during pregnancy, may be particularly vulnerable during surgery and should be an area of increased focus. A summary of these normal changes in the gravida is found in Chapter 19 (p. 307). Of other clinical points, baseline anemia may increase needs for transfusion. Diabetes mellitus and smoking can elevate wound infection complication risks. Women with prior venous thromboembolism have greater chances for recurrence, especially with long pelvic or orthopedic surgeries. Surgery poses added physical strain, and gravidas taking large doses of corticosteroids may benefit from perioperative stress dosing. Last, a patient's religious beliefs, such as with Jehovah's Witnesses, may limit blood transfusion options.

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During physical examination, basic components are completed. Again, cardiopulmonary status is a primary focus. The airway is assessed as described on page 293, and spine inspection should investigate for scoliosis. Aberrations in these areas may merit special anesthesia consultation. Patient body habitus also alters surgical risks. For example, obese patients have diminished pulmonary reserve, and their pannus can influence incision selection. Underweight patients may be at greater risk for nerve injury if not correctly positioned when anesthetized in dorsal lithotomy position for an extended time. Digital cervical assessment to determine dilatation or effacement may be helpful prior to some surgeries that pose a risk for associated preterm labor. Examples include cervical cerclage or fetal surgery, discussed in Chapters 11 and 16, respectively.

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Laboratory Assessment

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For most healthy pregnant women, laboratory testing prior to surgery can be minimal. A complete blood count; chemistry panel that evaluates electrolytes, renal function, and glucose levels; and type and screen are common for procedures with associated blood loss risks. For cases with greater anticipated bleeding, such as with placenta previa or the accrete syndrome, a type and crossmatch is prudent. In women without prior prenatal care, blood typing to ...

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