34 year old at 18 weeks recovered from gallstone pancreatitis being considered for cholecystectomy.
She is a reasonable risk for the proposed procedure.
1) Maternal Risks
a. No past medical history, no addictions, no symptoms to suggest cardiac or pulmonary disease.
b. Negligible cardiac risk
c. From the technical standpoint, this is the least complicated time to perform non-obstetric surgery.
2) Fetal Risks
a. Preterm contractions/labor
i. Risk increased if she has a recurrent episode of pancreatitis.
ii. Risk can be decreased by removing additional gallstones.
iii. Avoid the use of tocolytics unless the obstetrician believes that she is having contractions with very high risk of preterm labor.
3) Testing
a. Ultrasound showed a normal common bile duct
i. Controversy exists, but with normal bloodwork and a normal common bile duct by ultrasound, MRCP and intraoperative cholangiogram are not 100% necessary. If indicated they can both be obtained without increased risk to the fetus.
ii. ERCP is best avoided in this case. The risk of pancreatitis is not warranted in a stable patient without evidence of a retained common bile duct stone.
4) Medications
a. Antibiotics should be used as indicated for a non-pregnant patient
i. Penicillins, cephalsporins, metronidazone, and aminoglycosides (dosed every 8 hours) may be used.
ii. Unless other options are not appropriate because of allergies or intolerances, avoid quinolones.
iii. Avoid tetracyclines, erythromycin estolate (EES), once daily aminoglycoside dosing.
b. Pain medications should be used as indicated for a non-pregnant patient
i. No teratogenic risk
ii. No addiction risk for the mother or fetus with appropriate short term use
iii. Consider the effects on the mother if pain is not controlled
1. Splinting/ atelectasis/ pneumonia, hypertension, preterm contractions
iv. Recall that oxycodone/acetominophen and other narcotics are routinely given to breastfeeding women who underwent a caesarean section.
c. Dose Adjustments
i. Use the higher dose ranges because of the increased renal clearance of some medications
5) Intra/Post Operative
a. Fetal Heart Rate Monitoring
i. Not designed for the early antepartum period
ii. Very limited utility for a pre-viable fetus (<24 weeks)
iii. Medical legal concerns exist, so consult with the obstetrician.
b. Avoid supine hypotension/compression of the vena cava by placing a wedge under the right buttock to tilt the pelvis/uterus to the left.
c. When appropriate, consider regional anesthesia to avoid the risk of endotracheal intubation
d. When appropriate, consider a laparoscopic procedure to avoid the longer hospital stay and morbidity associated with an open procedure.
e. Limit use of tocolytics
i. Risk of arrhythmias, pulmonary edema
f. Consider postoperative DVT prophylaxis/early ambulation.
Carson MP, Fisher AJ, Scorza WE. Atrial fibrillation in pregnancy associated with oral terbutaline. Obstet Gynecol. 2002 Nov;100(5 Pt 2):1096-7. PMID: 12423819