Clinical obstetrics and gynecology
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In the United States, trauma is the leading nonobstetric cause of maternal death. The principal causes of trauma in pregnancy include motor vehicle accidents, falls, assaults, homicides, domestic violence, and penetrating wounds. The managing team evaluating and coordinating the care of the pregnant trauma patient should be multidisciplinary so that it is able to understand the physiologic changes in pregnancy. ⋯ Evaluation of the pregnant trauma patient requires a primary and secondary survey with emphasis on airway, breathing, circulation, and disability. The use of imaging studies, invasive hemodynamics, critical care medications, and surgery, if necessary, should be individualized and guided by a coordinating team effort to improve maternal and fetal conditions. A clear understanding of gestational age and fetal viability should be documented in the record.
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The need for cardiac surgery during pregnancy is rare. Only 1% to 4% of pregnancies are complicated by maternal cardiac disease and most of these can be managed with medical therapy and lifestyle changes. On occasion, whether owing to natural progression of the underlying cardiac disease or precipitated by the cardiovascular changes of pregnancy, cardiac surgical therapy must be considered. ⋯ For others, cardiac surgery, including procedures that mandate the use of cardiopulmonary bypass, must be entertained to save the life of the mother. Given the extreme risks to the fetus, if the patient is in the third trimester, strong consideration should be given to delivery before surgery involving cardiopulmonary bypass. At earlier gestational ages when this is not feasible, modifications to the perfusion protocol including higher flow rates, normothermic perfusion, pulsatile flow, and the use of intraoperative external fetal heart rate monitoring should be considered.
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Clin Obstet Gynecol · Dec 2009
ReviewAnesthesia for nonobstetric surgery: maternal and fetal considerations.
This monograph will review and update our understanding of the administration of anesthesia for nonobstetric surgery and its maternal and fetal effects. It begins with a summary of the subject and a short review of maternal physiologic changes during pregnancy with an emphasis on their anesthetic implications. Attention will be paid to a review of the literature and meta-anlyses that crystallize our understanding of fetal vulnerability to teratogenicity and the evidence for and against anesthetic effects in this regard. ⋯ The question of whether to and when to monitor the fetus during nonobstetric surgery will be discussed with some suggested guidelines. Special surgical situations such as laparoscopy, cardiac surgery, trauma, and fetal therapy will also be discussed. The conclusion contains clinical suggestions for the approach to anesthetizing the pregnant patient.
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This study reviews issues that complicate surgery in obese pregnant patients. Maternal obesity is prevalent in the United States and is associated with numerous adverse health outcomes. ⋯ Specific risks are identified and strategies to avoid them are evaluated. The prognosis and management of pregnant women who have undergone bariatric surgery are also discussed, and practical guidelines for obstetric management of these patients are presented.