Episode 160: Non-OB Surgery in Pregnancy With Dave Berman

In this 160th episode I welcome Dr. Dave Berman back to the show to discuss anesthesia for non-OB surgery during pregnancy.

References:

1. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124(2):270–300.

2. Nonobstetric Surgery During Pregnancy – ACOG [Internet]. [cited 2019 Jul 18];Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Nonobstetric-Surgery-During-Pregnancy?IsMobileSet=false

3. Tolcher MC, Fisher WE, Clark SL. Nonobstetric Surgery During Pregnancy. ObstetGynecol 2018;132(2):395–403.

4. UpToDate [Internet]. [cited 2019 Jul 18];Available from: https://www.uptodate.com/contents/management-of-the-pregnant-patientundergoing-nonobstetric-surgery

5. Upadya M, Saneesh PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian J Anaesth 2016;60(4):234–41.

6. Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery duringpregnancy. Br J Anaesth 2011;107 Suppl 1:i72–8.

7. Nejdlova M, Johnson T. Anaesthesia for non-obstetric procedures during pregnancy. Contin Educ Anaesth Crit Care Pain 2012;12(4):203–6.

8. Mazze RI, Källén B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 1989;161(5):1178–85.

9. Committee on Obstetric Practice and the American Society of Anesthesiologists. Committee Opinion No. 696: Nonobstetric Surgery During Pregnancy. Obstet Gynecol 2017;129(4):777–8.

10. Wilcox AJ, Weinberg CR, O’Connor JF, et al. Incidence of early loss of pregnancy. N Engl J Med 1988;319(4):189–94.

11. Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016;387(10015):239–50.

12. Sun LS, Li G, Miller TLK, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016;315(21):2312–20.

13. Center for Drug Evaluation, Research. FDA Drug Safety Communication [Internet]. U.S. Food and Drug Administration. 2019 [cited 2019 Jul 21];Available from: http://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communicationfda-review-results-new-warnings-about-using-general-anesthetics-and

14. Huang S-Y, Lo P-H, Liu W-M, et al. Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study. Mayo Clin Proc 2016;91(9):1166–72.

3 Replies to “Episode 160: Non-OB Surgery in Pregnancy With Dave Berman”

  1. Great a Podcast by Dr. Berman! Perhaps he’d like to weigh-in on a related topic: how does he counsel patients that require a general anesthetic, who are also breastfeeding?

    1. From Dr. Berman:

      Thanks so much for your kind words! Great to be on ACCRAC.

      I tell our residents to question dogma with regularity: the dogma of “pump and dump for 24 hours” is overkill and does not reflect the evidence and our current understanding of drug transfer and neonatal effects. A recently published article1 discussed varying doses of epidural fentanyl in breastmilk and its effects on breastfeeding, and this spurred the publication of a great infographic2 (attached) that discusses our current understanding of this emerging area. Current thinking is that aside from a few key players (longer-acting opiates, meperidine, and maybe ketamine), if a woman is awake and hemodynamically stable, she is safe to breastfeed her infant. While there may be a theoretical risk of transmission of some agents to fetus, general consensus is that it’s far more traumatic to interrupt the breastfeeding relationship (an actual risk with real harm) than to expose a neonate to low concentrations of minimal clinical significance (a theoretical harm).

      When patients/families or other healthcare providers ask me for more information about a specific agent or drug class, I direct them to LactMed.3 This amazing resource is a NIH-maintained compendium of studies on specific drugs and their safety in lactation. This compendium is extensively resourced and is a treasure trove of literature for those interested.

      As quoted by another excellent reference,4 “A general principle is that a mother can resume breastfeeding once she is awake, stable, and alert after anesthesia has been given.”

      Lee AI, McCarthy RJ, Toledo P, Jones MJ, White N, Wong CA. Epidural Labor Analgesia-Fentanyl Dose and Breastfeeding Success: A Randomized Clinical Trial. Anesthesiology 2017;127(4):614–24.)
      Wanderer JP, Rathmell JP. Anesthesia & Breastfeeding: More Often Than Not, They Are Compatible. Anesthesiology 2017;127(4):A15–A15.
      Drugs and Lactation Database (LactMed), United States National Library of Medicine, National Institutes of Health, Department of Health and Human Services. Available at: https:// toxnet.nlm.nih.gov/newtoxnet/lactmed.htm. Accessed February 25th, 2020.
      Cobb B, Liu R, Valentine E, Onuoha O. Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk. Transl Perioper Pain Med 2015;1(2):1–7.

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