Blue rubber bleb nevus syndrome, a syndrome of multifocal venous malformations, has been reported rarely during pregnancy. This syndrome has been associated with airway lesions in some patients and neuraxial abnormalities in other patients. We report the anesthetic and obstetric management of a patient with an extensive distribution of both airway and neuraxial lesions.
We report a gravida in fulminant acute respiratory distress syndrome, mechanically ventilated at 27 weeks estimated gestational age, who further deteriorated into severe combined hypercarbic, hypoxemic respiratory failure. At 30 weeks estimated gestational age, she was placed on venovenous extracorporeal membrane oxygenation (ECMO) because of refractory respiratory failure. Her physical status improved without fetal deterioration. She was managed expectantly in an effort to allow continued fetal maturation. Six days later, complications of ECMO (pulmonary hemorrhage) led to emergent abdominal delivery of a living male child. She was successfully weaned from ECMO 8 days later. The implications of ECMO during pregnancy are discussed.
For obstetric patients undergoing nonobstetric surgeries, the anesthesiologist has to take into consideration both maternal and fetal safety during the pre-, intra-, and postoperative periods. The goal of the anesthetic management should be to apply maternal physiologic changes, avoid teratogenic agents, avoid decreased uteroplacental perfusion and/or fetal oxygenation, and prevent preterm labor. Decisions on the timing of the procedure and intraoperative fetal and uterine monitoring must be multidisciplinary. The chapter uses a case study of a 24-year-old woman who is admitted at 33 weeks gestation with nausea, vomiting, and right upper quadrant pain. Topics covered include teratogenicity, uteroplacental perfusion, and reversal agents.
Caring for the pregnant patient presenting for non-obstetric surgery presents the anesthesiologist with a unique challenge, as the needs of both the pregnant woman and her fetus must be considered within the context of the surgical procedure being performed. A pregnant woman should never be denied medically necessary surgery or have that surgery delayed regardless of trimester because this can adversely affect the pregnant woman and her fetus. The main goals in the anesthetic management of these patients are to apply maternal physiologic changes, avoid uteroplacental hypoperfusion and/or fetal hypoxemia, avoid teratogenic agents, and prevent preterm labor. A multidisciplinary approach involving surgical, anesthesiology, and obstetric teams is essential for decisions on the timing of the procedure and intraoperative fetal and uterine monitoring. Fetal heart rate monitoring may assist in maternal positioning and cardiorespiratory management and may influence a decision to deliver the fetus. No currently used anesthetic agents have been shown to have any teratogenic effects in humans at any gestational age when using standard concentrations.
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