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Anesthetic Management of a 19 week Parturient with a Large Mass in the Tail of Pancreas
Abstract Type: Case Report/Case Series
Major abdominal surgery during pregnancy is rare, but when necessary, a number of specific challenges exist. While there are few specific recommendations on the anesthetic management for parturients, we herein provide a report of our experience with such a case, and a discussion of anesthetic considerations.
A 28 year-old G1P0 at 19 weeks gestation with an enlarging mass in the tail of the pancreas was scheduled to undergo an exploratory laparotomy, distal pancreatectomy and splenectomy. The 13 x 12cm mass was first visualized on ultrasound at 16 weeks gestation and its rapid growth resulted in increasing abdominal pain. Her medical history was notable only for thalassemia minor and pre-operative hematocrit of 21%.
A thoracic epidural at T8, an arterial line and two large bore peripheral venous lines were placed prior to induction of general anesthesia to minimize the duration of maternal and fetal anesthetic exposure. The fetal heart rate was monitored intermittently by doppler throughout the perioperative period. The patient was positioned with uterine displacement and a rapid sequence induction was accomplished with propofol and succinylcholine. General anesthesia was maintained with sevoflurane and rocuronium. Twenty four mL of 2% epidural lidocaine was administered throughout the four-hour operation. Fluid replacement was liberally administered to permit hemodilution and minimize the risk of fetal loss. Arterial blood gas analyses were performed hourly and values were consistently found to be within the baseline range. The patient remained normotensive throughout the procedure including the interval when the mass was excised in bulk.
Upon conclusion of the procedure, the patient was extubated in the operating room and the fetal heart rate was present. The epidural catheter was left in place and an infusion of dilute bupivacane was used for post-operative analgesia. Her post-operative course was uneventful and she was discharged six days later. At 41 weeks gestation she returned in labor, received a lumbar epidural and had an uneventful vaginal delivery.
The need for abdominal surgery occurs during 0.19% of pregnancies and is most frequently associated with disorders of the adnexa, appendix or gall bladder. These are usually procedures of short duration, involve minimal fluid shifts and have significantly less post-operative pain than laparotomy. A thoracic epidural facilitated surgical resection, eliminated the need for parenteral opioids, and may have reduced the intra-operative and post-operative stress response which could have been deleterious to uterine perfusion and fetal well-being.
1. ACOG Committee Opinion. Nonobstetric surgery in pregnancy. Number 284, ACOG Committee on Obstetric Practice. Int J Gynaecol Obstet. 2003 Oct;83(1):135
2. Visser BC, et al. Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg. 2001;18(5):409-17