Elective Surgery for Pregnant Patients

Specialties CRNA

Published

I have a question for those of you in practice.

Where I am at, in the past few weeks our general surgeon has scheduled what could have been considered elective surgery for two patients in early to mid second trimester. The first was a lap chole for a patient about 22 weeks pregnant. The second, also 22 weeks pregnant, is scheduled for an umbilical hernia repair.

Neither case has been at all urgent. The lap chole was for biliary dyskinesia. I did that case, and did so under general. My thinking was that though the case was not urgent, the patient was in considerable discomfort, and there was always the risk that the gall bladder could go very bad, and leave us no choice but to do the case emergently. I felt that doing the case before it became emergent was the preferable course of action. Of course, before the case, I consented the patient thoroughly, including the risk to the fetus, and the risk of later developmental problems, then documented the consent thoroughly in the chart.

The second case (scheduled for this week) involves an umbilical hernia that is not incarcerated. I don't believe that incarceration is a concern in the case, and in fact, the surgeon stated that he could do the case under local anesthesia. The primary reason that we are doing the case is that the patient swears to the surgeon that she cannot tolerate having the hernia for the remainder of the pregnancy.

The other CRNA I work with feels that elective surgery is not to be undertaken lightly on pregnant patients. Illinois does not have peer review, and malpractice cases are decided by jury. Her concern is that should the child be born with ANY problems, any time in the next 21 years the anesthesia provider could be sued by the patient or the child for any problems the child experiences. ("Your honor, had my client but known that anesthesia might have caused ADHD, they would never have agreed to the surgery. My client was in distress and was willing to agree to anything. These people should never have undertaken to do the case, as it was not an emergency and could have easily waited until after the birth of the child.") The surgeon's position is that he has thoroughly informed the patients of the risks, and if the patient opts to proceed, we should go ahead and do it. After all, if we don't, someone else will.

A greater issue for me here is that it is highly questionable whether or not we, the CRNA's, would have the authority to tell the surgeon that we are not going to do a case. Of course, we can refuse, and have done so, but as hospital employees, neither of us feel as though we would have any backing should we refuse cases based on anesthetic risk. Colonoscopy with sedation has often been scheduled on ASA IV patients. In many of these cases, though we feel that the patient could tolerate MAC, our concern is if the patient is perforated and needs immediate surgery, a general or spinal anesthetic has a much higher risk. The scope guys are beginning to understand our concern, but it has taken me seven months to get them to reach this level of understanding. This one issue may be the cause of my leaving this job.

So, my question is for those of you in practice, are you willing to do anesthesia, particularly general anesthesia, for elective surgery on pregnant patients in the second trimester?

Edited to add: The surgeon's position on legal matters is that any patient can sue any provider at any time. Therefore, we cannot allow this to stop us from doing surgery. While I think there is merit to this argument, I question the wisdom of doing elective procedures on a patient population with a much higher likelihood of filing lawsuits, and for whom juries are historically much more sympathetic.

Kevin McHugh CRNA

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Sorry for how long this is getting. We are planning to proceed with this case, but only if the patient will agree to have it done entirely under local or under a spinal anesthetic. I have not met the patient, but my gut feeling is that this is a small hernia, with little to no chance for incarceration. Therefore, I think the patient has noticed the bulge since becoming pregnant, and does not like it. In short, whatever the patient has told the surgeon, I am wondering whether or not the patient wants it done for cosmetic reasons.

KM

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What about an OB/GYN consult? Who is pt's OB provider... family doc,CNM (must have ob back-up), or OB?GYN doc? Usually ob doc would hesitate to authourize surgery unless absolutely necessary. They are about the most lawsuit fearing people around. This is an interesting situation. I don't have much to offer since I am an OB nurse, not a CRNA. We only usually see the rare appy or chole during pregnancy, other surgeries are rare except maybe circlage which of course is for pregnancy and done, at our hospital, under general.

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I have to agree with your partner on this one. There is no legal justification to do elective surgery on pregnant patients. Besides the basic legal issue, I think it would be impossible to find an expert witness, who is a member of the profession (which is how standard of care is determined) to testify in your favor.

From a practical standpoint, I would go to the head of the surgery department, head of OB/GYN and to the hospital carrier for a consensus opinion. I would also insist on a full c-section set up with an obstetrician, ob nurses and neonatologist handy. There should also be fetal monitoring and concern about venal caval compression. If the surgeon still insists with all of that present, find someone who will do the anesthesia and take the day off. Let the hospital pay for the new anesthetist/anesthesiologist.

Also, I would check the ACOG website and the society of obstetrical anesthesia website.

YogaCRNA

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A c-section set-up and neonatologist will do you no good at 22 weeks...the fetus isn't viable. As someone who is pregnant right now, I do not understand why a mom-to-be would want to put herself and the fetus at any unneccessary risk...which a hernia repair definitely is. Do you think the surgeon has honestly informed the patient of all the risks of surgery/anesthesia during pregnancy? As someone said before, I cannot imagine an OB doc giving the go-ahead for such a procedure. Although I am not yet a CRNA (just a want-to-be who will apply next year), I have to say I am with Yoga....I wouldn't do it!

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Kevin,

First off I applaud your serious thinking in this matter and trying to be a safe practitioner. I think it is wise to not rush into these kind of cases foolheartedly.

In the case of the hernia repair, well give the info you offered, I totally agree, sounds cosmetic. I do know that some women suffer discomfort from an umbilical hernia expecially as the gestation continues, however this is a minor discomfort and something that could be held off until after delivery, not something which exposing a 22 wk fetus to general would be wise.

However, I have put some thought into the other one, the lap chole. IF the patient is in discomfort, and it is not just an incidental finding during a routine US, then I agree to the surgery under the info you provided. Infection and inflammation are known to cause pre-term uterine contractions. If this was something that was not able to be held off with conservative treatment:time in the hospital, TEMPORARY pain medication and a change in diet. Remember this can be very painful and debilitation, I have cared for more than a few patients with this condition some do well without the surgery and are complient, others NEED the surgery. Remember it is all risk vs benes and this patient's prenatal provider, which should be a OB/GYN at this point, should be on the team of those who decide which is the safest route of action. I noticed that someone posted something along the lines of wanting a full team in the room incase of ?fetal distress? Well that might be overkill given the gestation of the pregnancy. 22 wks is non-viable, while you try and preserve the pregnancy the fetus is just not likely to survive outside the uterus at this point a few weeks down the line yes, but even then a crash c/s is usually not the indication, interuterine ressucitation is the best route as the fetus is reacting to a maternal factor usually hypotension. During these cases that require the patient to be supine, it is wise to have a wedge under the right hip, to help prevent vena-cava syndrome. Also preloading the patient with crystalloid solution (usually LR) helps. Continuous fetal monitoring during the case could go either way as it would be beneificial to know if the uterus is contracting, but as far as the fetal heart tones are concerned, at 22 wks it is difficult to monitor continously, and if done there is not really much to do as far as seeing the usual ominous signs of fetal distress as the fetal brain is not developed enough to produce a reactive tracing.

You might also want to read up on what maternal physiological changes are occuring. Try and get your eyes on a copy of William's Obstetrics, there is a section regarding obstetrical anesthesia and on physiological changes, week by week.

Wow, now I am the long-winded one, if you made it though this positing I hope that it has shed some light from a different perspective. Good luck with the case if you decide to do it. Again I think it is great that you are willing to stick out your neck and question a case like this.

Regards.

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elective anesthesia for pregnant women is a very dangerous path to tread on ... the lap chole is more semi-elective than truly elective so it should proceed

the umbilical hernia is a farce!!!! and the surgeon's argument that somebody else will do it if he doesn't is a stupid argument...

Recently i did a thoracotomy for right pneumonectomy (that's right - no more right lung) on a 21 week pregnant patient who also had an EF=15% (severe cardiac myopathy after her 1st pregnancy).... the risks the fetus were exposed to were ridiculous - but this was a semi-urgent case.... a far stretch from a hernia!!! if you feel that you are being asked to provide anesthesia for something that can cause loss of life or limb you have the absolute right to refuse to provide the anesthesia.... and for the surgeon to argue that he could do it under local or spinal is EVEN more ASININE!!! we all know that general anesthesia is the back-up for when things go wrong.... i have had a few asystoles in young patients after spinals (i am sure that would do wonders on uterine perfusion!!!)

1) patient needs an OB/Gyn consult (mandatory at my hospital)

2) patient needs a more honest surgeon

3) just because a surgeon wants to do surgery doesn't mean that you have to provide the anesthesia!!!!

Kevin - remember the surgeon is trained in fixing hernias, he is not trained in life support, not trained in providing the ideal environment for utero-placental perfusion, etc... tell him to go fU&& himself :) or at least that is what i would do :D

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