Anesthetic Management of Ectopic Pregnancy
Pregnancy poses a variety of psychological and physical stressors to the mother and developing fetus.1 Pregnant patients must consider everything from the possibility of premature birth to vaccination during pregnancy to diabetes risk.1 Pregnancy-related complications may also be associated with certain medications, which may cause serious birth defects or maternal health issues.1 This includes use of anesthesia during pregnancy, which is associated with risk of deep vein thrombosis (DVT; blood clot in a large vein), pulmonary embolism (PE; blood clot in the lungs), aspiration, pulmonary edema (excess fluid in the lungs), acute respiratory distress syndrome (ARDS), and spontaneous abortion during the first trimester and preterm labor.2 However, use of anesthesia during pregnancy is often necessary in emergency situations, such as when the pregnancy is ectopic. Ectopic pregnancies, which occur outside of the uterus, are almost never successful and must be terminated as soon as possible to preserve the health of the mother.3 Anesthesia providers should be familiar with the biology, signs, symptoms and appropriate anesthetic management of ectopic pregnancy.
An ectopic pregnancy is one in which the fertilized egg implants somewhere outside the uterus, rather than in the uterine lining.3 In ectopic pregnancy, implantation usually occurs in one of the fallopian tubes, which carry eggs from the ovaries to the uterus.4 However, an ectopic pregnancy can also occur in the ovary, abdominal cavity, cervix or other parts of the body.4 An ectopic pregnancy is almost universally considered inviable,3 as the fertilized egg cannot survive properly outside the uterus.4 Also, as the fetus grows outside the uterus, it can cause tissues and organs to stretch and rupture, leading to life-threatening internal bleeding.3 Because an ectopic pregnancy is dangerous for the mother and unsuccessful for the fetus, clinicians and patients alike should look out for signs and symptoms. Symptoms include severe abdominal or pelvic pain, nausea and vomiting, pain on one side of the body, dizziness, weakness, lightheadedness, fainting, and pain in the shoulder, neck or rectum.4,5 Clinicians can diagnose ectopic pregnancy with transvaginal ultrasound or blood tests, but these steps may be omitted for cases requiring emergency surgery.6 Given the urgency of ectopic pregnancy, health care providers must act quickly to perform surgery and provide pain relief.
Because they are experts in analgesia and surgical anesthesia, anesthesiology professionals are crucial to the care of patients with ectopic pregnancies. Ectopic pregnancy procedures that necessitate anesthesia may occur before or after the rupture of reproductive organs, and can be general or local. For example, an early study on ruptured ectopic pregnancies by Haku et al. found successful anesthetic management with preoperative administration of a plasma expander (used for fluid replacement) and balanced anesthesia with ketamine or fentanyl.7 Meanwhile, Minai et al. report a case of a heterotopic pregnancy (i.e., one pregnancy outside the uterus and one inside), for which they used awake laparoscopic surgery under spinal anesthesia.8 After the operation, the remaining uterine pregnancy and delivery were uneventful.8 Other more complicated cases include patients with ruptured ectopic pregnancies and comorbid cardiac anomalies,9 bleeding disorders10 or skeletal and pulmonary issues,11 all of which warrant unique anesthetic considerations. In all cases of ruptured ectopic pregnancies, a key role of the anesthesiology professional is to monitor internal or external blood loss.12 Such hemorrhage likely leads to cardiac arrest.12 Anesthesia providers must familiarize themselves with the signs of hemorrhagic shock, which ranges from tachycardia (fast heart rate) to a fall in blood pressure to respiratory failure.12 The anesthesiology professional, along with the rest of the surgical team, should be prepared for resuscitation with adequate oxygenation and possible blood transfusion.12 Thus, the anesthesia provider’s duty to a patient with an ectopic pregnancy includes anesthesia, analgesia and vigilant vital signs monitoring. The anesthesia provider must take precautions not only because of the pregnancy itself, but also because of its extrauterine location.
Anesthesia provision during pregnancy is associated with a variety of risks. An ectopic pregnancy is even more risky, as it can lead to life-threatening internal bleeding. Anesthesia providers who work with ectopic pregnancies must consider the patient’s vulnerable condition when choosing the type of anesthesia, administering anesthetic drugs and monitoring for signs of hemorrhage. Future research should investigate the optimal anesthesia for pain relief in patients who present with ectopic pregnancies. Also, data are needed on anesthetic management of ectopic pregnancy both before and after rupture.
1. Centers for Disease Control and Prevention. During Pregnancy. Pregnancy October 16, 2019; https://www.cdc.gov/pregnancy/during.html.
2. Anesthesia During Pregnancy. ScienceDirect. Web: Elsevier B.V.; 2020.
3. Danielsson K. Can an Ectopic Pregnancy Be Saved? Verywell Family. Web: About, Inc.; November 26, 2018.
4. Mayo Clinic. Ectopic pregnancy. Diseases & Conditions May 22, 2018; https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/symptoms-causes/syc-20372088.
5. Pagano T. Ectopic Pregnancy Symptoms and When to Call 911. Ectopic Pregnancy October 29, 2018; https://www.webmd.com/baby/symptoms-ectopic-pregnancy.
6. Selner M. Ectopic Pregnancy. Healthline. Web: Healthline Media; January 8, 2018.
7. Haku E, Yamazaki K, Yamaoka S, et al. Anesthetic management for ruptured ectopic pregnancy. The Journal of Japan Society for Clinical Anesthesia. 1983;3(1):52–56.
8. Minai H, Yamada K, Tashiro K, Yamamoto K. Anesthetic management for awake laparoscopic surgery for ectopic pregnancy in a patient with heterotopic pregnancy. Masui. 2005;54(11):1313–1314.
9. Singh P, Dwivedi S, Dwivedi R, Yadav A. Anaesthetic management of emergency exploratory laparotomy for ruptured ectopic pregnancy in a patient with Ebstein’s anomaly and Wolff-Parkinson-White syndrome: A challenge for the anaesthesiologists. International Journal of Research in Medical Sciences. 2016;4(6).
10. Ambush B, Singh B, Maheshwari S, Karnawat R. Anesthetic management of ruptured ectopic pregnancy in immune thrombocytopenic purpura patient: A case report. The Egyptian Journal of Cardiothoracic Anesthesia. 2015;9(2):29–31.
11. Johnson MZ, Mullins CF, Keane D, Browne I. Emergency salpingectomy for ruptured ectopic pregnancy in patient with Melnick-Needles syndrome: A rare otopalatodigital syndrome. BMJ Case Reports. 2017;2017:bcr-2017-221334.
12. Sudunagunta S. Anaesthetist’s Perspective. Perspectives 2020; https://www.ectopicpregnancy.co.uk/for-professionals/perspectives/anaesthetist/.