Non-Obstetric Surgery During Pregnancy by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783319907529
Publisher: Springer International Publishing

When a pregnant patient presents with depressed mental status from a neurological condition, immediate interventions should focus on maintaining a patient’s airway and appropriate oxygenation. Rapid sequence intubation should be considered in patients with an initial post-resuscitation GCS of eight or less. Short-acting agents are preferred to enable an examining neurosurgeon to obtain an accurate exam. Even if concern exists about increased intracranial pressure, there is rarely an indication for prolonged hyperventilation as excessive vasoconstriction can precipitate further neurologic injury [23]. A possible exception would be a unilaterally dilated pupil in a patient with a known mass lesion or increased intracranial pressure as a short-term emergent treatment. Intubated patients should be maintained at the lowest positive end-expiratory pressure deemed safe by the primary treatment team.

Blood pressure should be controlled with short-acting agents with the goal of modest reduction while avoiding hypotension. Initial blood pressure goals should be systolic blood pressure <160 mmHg and mean arterial pressure (MAP < 90). The classic “Cushing’s triad ” of hypertension, bradycardia, and disordered breathing is often a late finding and portends a poor prognosis .

When intracranial hypertension is suspected, initial interventions include head of bed elevation, correction of hypercarbia, and administration of hypertonic saline or mannitol. In most scenarios, hypertonic saline (e.g., 3%, 7%, or 23.4%) is the preferred first-line agent. Mannitol is another commonly used osmotic agent but has been tested in pregnant rabbits and found to cross the placenta, increasing fetal osmotic pressure and precipitating both intravascular and extravascular fluid losses [24]. In the setting of hypovolemia, this may exacerbate hemodynamic instability and/or worsen renal function. Uterine hypoperfusion and accumulation of osmotic agents in the fetus should be considered prior to their administration to pregnant patients [25]. Neurosurgical consultation is warranted prior to administration of hypertonic agents as intracranial pressure monitoring may be recommended to help guide therapy. Similarly, in the third trimester, the use of corticosteroids to manage cerebral edema may cause fetal adrenal suppression, and their use should be weighed carefully against the risks of urgent/emergent delivery [25].

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