Clinical obstetrics and gynecology
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The need for cardiac surgery during pregnancy is rare. Only 1% to 4% of pregnancies are complicated by maternal cardiac disease and most of these can be managed with medical therapy and lifestyle changes. On occasion, whether owing to natural progression of the underlying cardiac disease or precipitated by the cardiovascular changes of pregnancy, cardiac surgical therapy must be considered. ⋯ For others, cardiac surgery, including procedures that mandate the use of cardiopulmonary bypass, must be entertained to save the life of the mother. Given the extreme risks to the fetus, if the patient is in the third trimester, strong consideration should be given to delivery before surgery involving cardiopulmonary bypass. At earlier gestational ages when this is not feasible, modifications to the perfusion protocol including higher flow rates, normothermic perfusion, pulsatile flow, and the use of intraoperative external fetal heart rate monitoring should be considered.
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Clin Obstet Gynecol · Dec 2009
ReviewAnesthesia for nonobstetric surgery: maternal and fetal considerations.
This monograph will review and update our understanding of the administration of anesthesia for nonobstetric surgery and its maternal and fetal effects. It begins with a summary of the subject and a short review of maternal physiologic changes during pregnancy with an emphasis on their anesthetic implications. Attention will be paid to a review of the literature and meta-anlyses that crystallize our understanding of fetal vulnerability to teratogenicity and the evidence for and against anesthetic effects in this regard. ⋯ The question of whether to and when to monitor the fetus during nonobstetric surgery will be discussed with some suggested guidelines. Special surgical situations such as laparoscopy, cardiac surgery, trauma, and fetal therapy will also be discussed. The conclusion contains clinical suggestions for the approach to anesthetizing the pregnant patient.
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Minimally invasive techniques to treat children and adolescents requiring surgery have increasingly become standard of care. Similarly, gynecologists frequently use laparoscopy to treat pelvic pathology. ⋯ We will give particular focus to the treatment of adnexal masses, chronic pelvic pain, endometriosis, and ovarian torsion. We will also discuss the role of the incidental appendectomy in children and adolescents.
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Infectious complications are a significant source of morbidity and mortality associated with pregnancy termination worldwide. However, in areas where abortion practices are legal, the risk of infection is very low. Proper technique, prophylaxis, and initial management of septic abortion have led to a significant decrease in risk of serious complications such as sepsis and death. Clinical features, management, and prevention of postabortal infection will be reviewed in the setting of legalized abortion.
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Dilation and evacuation, the most common method performed for second-trimester abortion in the United States, requires sufficient cervical dilation to reduce the risk of complications such as cervical laceration or uterine perforation. The cervix may be prepared with osmotic dilators such as laminaria, Lamicel, or Dilapan-S, or with pharmacologic agents such as misoprostol. ⋯ Misoprostol has limited data supporting its use in this setting. Decisions regarding which method is best are clinician-dependent, and factors such as gestational age and time allowed for preparation should be considered.