Krzysztof M. Kuczkowski

Anesthetic implications of drug abuse in pregnancy

Substance abuse has crossed social, economic, and geographic borders and--throughout the world--remains one of the major problems facing society today. The prevalence of substance abuse in young adults (including women) has increased markedly over the past 20 years. Nearly 90% of drug-abusing women are of childbearing age. Consequently, it is not unusual to encounter pregnant women who abuse illicit drugs, as numerous case reports of drug abuse in pregnancy confirm. The diverse clinical manifestations of drug abuse combined with physiologic changes of pregnancy, and pathophysiology of coexisting pregnancy-related disease may lead to life-threatening complications and significantly impact the practice of obstetrical anesthesia. Regardless of the drug(s) ingested and clinical manifestations, it is always difficult to predict the exact anesthetic implications in chemically dependent patients.

The cocaine abusing parturient: a review of anesthetic considerations

PurposeThe prevalence of recreational drug abuse among young women, including in pregnancy, has increased markedly over the past two decades. Cocaine remains the drug commonly used for recreational purposes in pregnancy. However, there appears to be an absence of uniform guidelines for obstetric and anesthetic management of pregnant patients with a history of cocaine abuse.SourceA Medline search for articles highlighting drug abuse in pregnancy, with particular emphasis on cocaine abuse in pregnancy, the drug’s impact on the fetus and implications for administration of obstetrical anesthesia was performed.Main findingsBecause the pharmacological actions of cocaine are complex, the clinical picture can be very unpredictable, the diagnosis often difficult, and management at times controversial. The diverse clinical symptomatology of cocaine intake combined with physiologic changes of pregnancy, and pathophysiology of coexisting pregnancy specific disease may lead to life-threatening complications and significantly impact the management of obstetrical anesthesia.ConclusionsIn the absence of uniform anesthetic guidelines for pregnant patients with a history of cocaine abuse the decision regarding the administration of peripartum analgesia or anesthesia should be individualized and conducted on a case-by-case basis. This article will attempt to heighten the awareness of cocaine use and abuse in pregnancy and review the perioperative anesthetic management of these high-risk parturients.RésuméObjectifLa prévalence d’abus occasionnel de drogues par les jeunes femmes, incluant les femmes enceintes, a beaucoup augmenté pendant les deux dernières décennies. La cocaïne est la drogue récréative le plus souvent utilisée pendant la grossesse. Il semble pourtant exister une absence d’uniformité dans les directives sur la prise en charge obstétricale et anesthésique des parturientes qui présentent une histoire d’abus de cocaïne.SourceNous avons cherché, dans Medline, des articles sur l’abus de drogues pendant la grossesse, surtout sur l’abus de cocaïne, sur les conséquences des drogues sur le fœtus et les implications sur l’administration de l’anesthésie obstétricale.Constatations principalesFace à la complexité des actions pharmacologiques de la cocaïne, le portrait clinique peut être très imprévisible, le diagnostic souvent difficile et le traitement parfois controversé. La symptomatologie clinique changeante de la consommation de cocaïne combinée aux modifications physiologiques de la grossesse et la physiopathologie des maladies concomitantes spécifiques à la grossesse peuvent entraîner de graves complications et influencer significativement la démarche anesthésique obstétricale.ConclusionEn l’absence de directives anesthésiques uniformes pour les patientes enceintes qui ont abusé de drogues, la décision concernant l’analgésie ou l’anesthésie périnatale doit être individualisée et réalisée au cas par cas. Le présent article veut sensibiliser à l’usage et à l’abus de cocaïne pendant la grossesse et revoir la prise en charge anesthésique périopératoire de ces parturientes à haut risque.

Anesthesia for pregnant women with valvular heart disease: the state-of-the-art

Pregnancy results in dramatic changes in the cardiovascular system. Maternal heart disease complicates 0.2%–3% of pregnancies. Valvular heart disease in women of reproductive age is most commonly due to rheumatic heart disease, endocarditis, or congenital abnormalities. In general, regurgitant lesions are well tolerated during pregnancy because the increased plasma volume and lowered systemic vascular resistance result in increased cardiac output. In contrast, stenotic valvular disease is poorly tolerated with advancing pregnancy, owing to the inability to increase cardiac output in relation to the increased plasma volume preload. The choice of anesthesia depends on the lesion and its severity. Usually, regional anesthesia provides the least amount of alteration in hemodynamics, although general anesthesia for cesarean section can be equally safe when the abrupt changes associated with laryngoscopy, intubation, and extubation are blunted by the appropriate choice of pharmacological agents and anesthetic techniques.

The safety of anaesthetics in pregnant women.

Each year, a significant number of pregnant women undergo surgery and anaesthesia for indications unrelated to pregnancy. Estimates of the incidence of non-obstetric surgery in pregnancy, which may be required at any gestational age, and for a number of indications, range from 1.0 to 2%. The diagnosis of any medical condition requiring surgery in pregnancy often raises questions about the safety of anaesthesia in these patients. This controversy is primarily attributed to the lay press speculations that surgery and anaesthesia in pregnancy may pose hazards to the mother and fetus. Despite these concerns, the safety of non-obstetric surgery and anaesthesia in pregnancy is well-documented for nearly every operative procedure. The timing and indications for surgery seem critical to the maternal and fetal outcome. Laparoscopy is the most common surgical procedure performed in the first trimester of pregnancy, whereas appendectomy is the most common procedure performed during the remainder of pregnancy.

Labor analgesia for the parturient with cardiac disease: what does an obstetrician need to know?

Maternal heart disease complicates 0.2–3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the cooperative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for this high‐risk group of patients. This article will review the current guidelines and standards pertinent to management of obstetric analgesia and anesthesia in parturients with cardiac disease.

The management of accidental dural puncture in pregnant women: what does an obstetrician need to know?

Post-dural puncture headache (PDPH) also known as spinal (or post-spinal) headache still remains a disabling complication of needle insertion into the subarachnoid space. Pregnant women are at particular risk of dural puncture, and the subsequent headache, because of sex, young age, and the widespread application of regional anesthesia. Accidental dural puncture complicating epidural anesthesia varies in incidence from 0.19 to 4.4%. The incidence of epidural needle-induced PDPH headache in pregnant women has been reported to range 76–85%. The classic symptoms of PDPH consist of photophobia, nausea, vomiting, neck stiffness, tinnitus, diplopia, and dizziness in addition to the often, severe cephalgia. This article reviews the current literature on the pathophysiology, incidence, prevention, and treatment of PDPH in pregnant women.

Anesthesia for the repeat cesarean section in the parturient with abnormal placentation: What does an obstetrician need to know?

Placenta accreta is an abnormal adherence of the placenta to the uterine wall owing to an absent or faulty decidua basalis. The incidence of this devastating problem is increasing secondary to the increased incidence of Cesarean section. Although rare, the diagnosis of placenta accreta may lead to life-threatening complications (e.g., fatal hemorrhage) and significantly impact the obstetric and anesthetic management of these parturients. I herein present the case of a pregnant patient with abnormal placentation and review the current state-of-the-art obstetric and anesthetic management of this complication.

Advances in obstetric anesthesia: anesthesia for fetal intrapartum operations on placental support

Fetal intrapartum operations on placental support (OOPS), also known as ex-utero intrapartum treatment (EXIT) procedures, are very rare (and often challenging) surgical techniques designed to allow partial delivery (cesarean section) of a fetus with a potentially difficult airway, with subsequent management of the neonatal airway (direct laryngoscopy, fiberoptic bronchoscopy, or tracheostomy) while oxygenation is continuously maintained via the placenta (on placental support). The peripartum management of pregnant women and their fetuses undergoing OOPS is very complex and multidisciplinary, and differs greatly from that of standard cesarean sections. The goal of this article is to review the current recommendations for the peripartum anesthetic management of pregnant women carrying fetuses with fetal congenital malformations undergoing OOPS.

Human immunodeficiency virus in the parturient

Over the last 20 years, the acquired immune deficiency syndrome (AIDS) has grown from a small case series of Pneumocystis carinii infection in four homosexual men to one of the major health problems facing the world today. In the next 5 years, human immunodeficiency virus (HIV) infection is expected to kill more than 2.2 million people. In the United States, women of childbearing age constitute a large percentage of new cases of AIDS. Because of the increased prevalence of HIV in pregnant women, many anesthesiologists encounter these patients in their practice. The safety of regional neuraxial spread has been a concern in the past, nevertheless, recent analysis of the problem has shown that HIV infection in pregnancy does not contraindicate administration of regional anesthesia.

Laparoscopic procedures during pregnancy and the risks of anesthesia: what does an obstetrician need to know?

BackgroundNonobstetric surgery may be necessary during any stage of gestation.MethodsThe purpose of this article is to review the current recommendations (using Medline search for the relevant publications) for the perioperative anesthetic management of pregnant women undergoing laparoscopy for indications unrelated to pregnancy.ResultsThe current estimates of the incidence of nonobstetric surgery in pregnancy range from 1% to 2%. Laparoscopy is the most common surgical procedure performed in the first trimester of pregnancy, whereas appendectomy is the most common procedure performed during the remainder of pregnancy.ConclusionsIn the past pregnancy was considered as an absolute contraindication to laparoscopy. However, recent years have brought an extensive experience with this technique during gestation.