Complicated

The vast majority of pregnant patients are young, healthy women; although some may have asthma or hypertension or diabetes of pregnancy, for the most part, they are much less complicated than patients in the general operating room. In fact, this is crucial to the success of pregnancy. If the average Stanford surgical patient (70 year old with hypertension, hyperlipidemia, coronary artery disease, diabetes, chronic obstructive pulmonary disease, arthritis) were subjected to the stress of delivery or C-section, there would be significant morbidity and mortality. It is the young healthy body's resilience that allows the parturient to fly through pregnancy without difficulty.

However, we do have a few patients with complex medical histories or high risk obstetric states. One patient has a congenital anomaly that makes all of anesthesia difficult. With missing limbs, IV and arterial line access become limited. Her height and weight make spinal and epidural dosing difficult. Severe scoliosis makes placement of the neuraxial block challenging. She has a fixed cervical spine and so emergent intubation is out of the question. With only one lung, her breathing is quite risky.

She is scheduled for an elective C-section, and we spend a long time planning the anesthetic. An epidural is placed for post-operative pain control but not intraoperative anesthesia (since the dose is difficult to estimate and there is no margin for error because emergent intubation is impossible). She then undergoes an awake intubation with a fiberoptic bronchoscope prior to induction of general anesthesia. The surgeons deliver a healthy baby, she goes to the ICU intubated due to her lung disease, but is extubated and transferred to post-partum the following day.

A separate case, in which I was not involved, is a mindboggling story. A patient with placenta percreta is scheduled for a C-section. In this disease, uterine tissue (chorionic villi) is found outside the uterus, and in this case, in the bladder. The problem is that this tissue is highly vascular and bleeds profusely. In order to minimize general anesthetic to the fetus, multiple IVs, an arterial line, a central line introducer, and an epidural are placed awake. The epidural is used while the urologists place ureteral stents. Then general anesthesia is induced and the baby is delivered by C-section. The bleeding is uncontrolled, massive, ongoing hemorrhage. Over 12 hours, 75 units of blood is given along with fresh frozen plasma, platelets, cryoprecipitate, and recombinant factors. Interventional radiology, vascular surgery, urology, and trauma surgery are all called to help stop the bleeding. A balloon is placed in the aorta and inflated to decrease blood flow to the lower body. At one point, the patient has a cardiac arrest requiring compressions and epinephrine. Yet in the end, the patient makes it to the ICU, is subsequently closed with bladder repair, and is now doing fairly well, extubated and happy.

These stories remind me to respect the physiologic changes that occur with pregnancy; most of the time, everything goes smoothly, but planning is required for those high risk cases that could potentially be life threatening.