From the Guidelines
Pregnant women can safely receive anesthesia with propofol, fentanyl, and midazolam 1.
Safe Anesthesia Medications
- Propofol: a typical dose is 1-2 mg/kg administered intravenously
- Fentanyl: can be administered at a dose of 1-2 mcg/kg
- Midazolam: can be used for sedation at a dose of 1-2 mg intravenously The American College of Obstetricians and Gynecologists (ACOG) states that there is no anesthetic agent used currently that has been found to have any teratogenic effect when given in standard concentrations at any gestational age 1.
Key Considerations
- Avoid long-acting opioids and instead opt for shorter-acting agents, such as remifentanil, at a dose of 0.1-0.5 mcg/kg/min, to minimize fetal exposure and potential respiratory depression
- Meperidine is recommended as the preferred agent for moderate sedation, followed by small doses of midazolam as needed, with attempts to limit the use of midazolam during the first trimester 1
- Paracetamol is the analgesic of choice for the treatment of mild to moderate pain during any stage of pregnancy, and short-term narcotic use is also safe 1
- Nonsteroidal anti-inflammatory drugs should be avoided, particularly after 28 weeks of gestation, as they may cause premature closure of the fetal ductus arteriosus and oligohydramnios 1
- Patient positioning is crucial, with the left lateral decubitus or partial left lateral decubitus position recommended after the first trimester of pregnancy 1
- Intraoperative CO2 monitoring by capnography should be used to avoid maternal hypo- and hypercapnia 1
- Energy modalities such as ultrasound, bipolar, and monopolar energy sources are safe to use during laparoscopy in pregnancy 1
From the Research
Safe Anesthesia Medications During Pregnancy
- The following medications have been studied for their safety during pregnancy:
- 2% lidocaine with 1:200,000 epinephrine is considered safe for pregnant women 2
- Fentanyl and midazolam have been shown to have no adverse neonatal effects when used prior to Cesarean section 3
- Alfentanil and propofol can be used for sedation and analgesia during monitored anesthesia care, with a recommended propofol infusion of 25-50 microg x kg(-1) x min(-1) and an alfentanil infusion of 0.2-0.4 microg x kg(-1) x min(-1) 4
- Butorphanol and fentanyl can reduce the induction requirement of propofol, with butorphanol 20 μg/kg and 40 μg/kg conferring hemodynamic stability at induction and intubation 5
- Esketamine has been compared to fentanyl combined with propofol for its effect on hypotension in patients undergoing painless abortion surgery, with a single-dose esketamine (0.25 mg kg- 1) effectively decreasing incidence of hypotension and total adverse events 6
Considerations for Anesthesia Administration
- Maternal and fetal considerations must be taken into account when administering anesthesia to pregnant women, including physiological and pharmacological changes during pregnancy 2
- The semi-supine position, blood pressure monitoring, and reassurance are suggested for high-risk mothers to reduce the risk of transient changes in blood pressure, hypoxemia, and hypoglycemia 2
- Physicians should use epinephrine cautiously and control the dose of anesthetic for patients with underlying diseases, such as eclampsia, hypertension, hypotension, and gestational diabetes 2