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Archive for September, 2018

Georgia’s First-Ever Procedure to Place 3D-Printed Tracheal Splints in a Pediatric Patient

Thursday, September 27th, 2018

3D-Printed Tracheal SplintChildren’s Healthcare of Atlanta has performed Georgia’s first-ever procedure to place 3D-printed tracheal splints in a pediatric patient on August 17. A cross-functional team of Children’s surgeons used three custom-made splints, which biomedical engineers at the Georgia Institute of Technology helped create using an innovative and experimental 3D-printing technology, to assist the breathing of a 7-month-old patient battling life-threatening airway obstruction.

“We are so fortunate to work with a leading engineering school like Georgia Tech to find innovative, potentially life-saving treatment options for our patients,” said Donna Hyland, president and CEO, Children’s Healthcare of Atlanta. “This is a great example of how aligning Children’s clinical expertise with the missions of our research collaborators can improve patient outcomes. Research that can be translated into more effective care at the bedside is why our collaboration with Georgia Tech is so important for the future of pediatric care in Georgia.”

The patient who received the groundbreaking surgery is a 7-month-old boy battling both congenital heart disease and tracheo-bronchomalacia, a condition that causes severe life-threatening airway obstruction. During his six-month inpatient stay in the Pediatric Intensive Care Unit at Children’s, he experienced frequent episodes of airway collapse that could not be corrected by typical surgery protocols. The clinical team proposed surgically inserting an experimental 3D-printed tracheal splint, which is a novel device still in development, to open his airways and expand the trachea and bronchus.

Scott Hollister, Ph.D., who holds the Patsy and Alan Dorris Endowed Chair in Pediatric Technology, a joint initiative supported by Georgia Tech and Children’s Healthcare of Atlanta, developed the process for creating the tracheal splint using 3D printing technology prior to joining Georgia Tech at University of Michigan C.S. Mott Children’s Hospital. The Children’s procedure was the 15th time a 3D-printed tracheal splint was placed in a pediatric patient.

3D-Printed Tracheal SplintThe splints were created using reconstructions of the patient’s airways from CT scans. Dr. Hollister and his team of biomedical engineers collaborated with the Global Center for Medical Innovation (GCMI) so that GCMI could create multiple versions of the splint, of varying sizes, to ensure the perfect fit was available for the surgical team to select and place around the patient’s airways during surgery. GCMI will also support the ongoing development and commercialization of the technology.

In a complex 10-hour surgery, Children’s cross-functional team of surgeons successfully placed three 3D-printed splints around the patient’s trachea. The splints will eventually be absorbed into the body, allowing for expansion of the trachea and bronchus.

The Children’s tracheal splint team included Steve Goudy, MD, and April Landry, MD, (ENT), pediatric otolaryngologists; Subhadra Shashidharan, MD, pediatric cardiothoracic surgeon; and Kevin Maher, MD, pediatric cardiologist.

As the tracheal procedure concluded, the child was placed on a heart lung machine for surgical repair of his cardiac defect. Postoperative care took place in the Cardiac ICU and the Pediatric ICU at Children’s.

“It’s the close relationships we have with our research collaborators that make this kind of groundbreaking procedure possible,” says Dr. Goudy. “A large number of additional physicians, support staff and outside collaborators worked together on this innovative procedure.”

The 3D-printed tracheal splint is a new device still under development, as safety and effectiveness have not yet been determined and is therefore not available for clinical use. The Children’s team sought emergency clearance from the FDA to move forward with the procedure under expanded access guidelines.

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New Pediatric Institute Focuses on Pediatric Research and Training Pediatric Physicians

Thursday, September 27th, 2018

Pediatric InstituteChildren’s Healthcare of Atlanta and Emory University have announced the launch of the Emory + Children’s Pediatric Institute, an affiliation focused on leveraging the capabilities of both organizations. Through the Pediatric Institute, Emory and Children’s will facilitate leading-edge pediatric research and train pediatricians and pediatric subspecialists, both of which are in short supply in the United States.

Emory and Children’s have worked together over the past decade recruiting prominent pediatric researchers to Atlanta, resulting in a nationally-ranked pediatric research program with notable accolades:
• The Department of Pediatrics is ranked No. 5 in National Institutes of Health (NIH) rankings for funding to pediatrics
• Marcus Autism Center is one of only five centers nationwide to be designated an Autism Center of Excellence by the NIH
• The Aflac Cancer and Blood Disorders Center is one of the largest brain tumor and leukemia/lymphoma programs in the country
• Children’s has the largest Sickle Cell program in the country and has cured more than 73 children of sickle cell disease through blood and marrow transplants
• Three researchers appointed as Georgia Research Alliance Eminent Scholars specialize in pediatric research. The Scholars attract significant federal and private research grants every year, which creates jobs and advances discovery and invention

The Pediatric Institute will continue to build and enhance relationships with other partners including Georgia Tech, creating a unique collaborative opportunity to develop treatments and devices that can change the future of pediatric healthcare.

“We are combining the unique strengths and resources of each institution in a way that elevates our shared ability to integrate the outstanding clinical service of Children’s with innovative clinical research of Emory, and to coordinate exceptional education of the future healthcare workforce,” said Liz Blake, Board of Trustees Chair, Emory + Children’s Pediatric Institute.

To address a serious shortage of pediatricians and pediatric specialists across the country, Emory and Children’s continue to be proactive through the physician training program. Last year, the training program supported 97 residents and 117 fellows. In recent years, more than half of the doctors who completed the program stayed in Georgia and now occupy many of the top pediatric leadership positions, providing care to a large number of children across the state of Georgia.

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New roles for Emory Healthcare’s Peterson and Gartland

Thursday, September 27th, 2018

Dane Peterson

As Emory Healthcare continues to grow in size and geography, a new leadership structure is being created to better support Emory’s operations, staff, providers and ultimately, patients.

Dane Peterson, current Emory Healthcare Hospital Group President, has been named to the new role of Emory Healthcare Chief Operating Officer, which took effect September 1. Peterson has been with Emory for nearly 11 years, first as CEO of Emory University Hospital Midtown, then as Hospital Group President beginning in 2014.

Peterson will be accountable for operations across the system, particularly in creating effective and efficient processes among care settings, system resources and teams. He will be fundamentally focused on translating strategy into action and operational excellence.

Bryce Gartland, MD, previous CEO of Emory University Hospital, Emory University Orthopaedics & Spine Hospital and Emory Wesley Woods Hospital, has been promoted into the role of Emory Healthcare Hospital Group President as of September 1. Gartland joined Emory 13 years ago as a hospitalist physician and has served in many leadership roles across the system, including three years in his most recent role as CEO.

Bryce Gartland, MD

Gartland will be responsible for overseeing all of Emory Healthcare’s hospitals and other large system departments. He will also serve as the co-chief of clinical operations alongside the Emory Healthcare Physician Group President.

“Dane has been closely integrated in all aspects of Emory Healthcare operations for many years and will prove to be an exceptional leader in this new role,” says Jonathan S. Lewin, MD, president and CEO of Emory Healthcare. “Bryce is a respected, dynamic leader, and we are excited to welcome him into his new position overseeing our hospitals and system clinical essential services.”

A search to find a new CEO for Emory University Hospital, Emory University Orthopaedics & Spine Hospital and Emory Wesley Woods Hospital is commencing immediately.

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Emory receives $29 million from Wounded Warrior Project

Thursday, September 27th, 2018

The Emory Healthcare Veterans Program has received a five-year, $29.2 million-dollar grant from Wounded Warrior Project to further its work providing care for Veterans suffering from post-traumatic stress disorder (PTSD), traumatic brain injury (TBI),dd depression and anxiety.

The Emory Healthcare Veterans Program is one of four U.S. programs that are part of Wounded Warrior Project’s Warrior Care Network, a first-of-its-kind treatment partnership that provides world class mental health care to Veterans or servicemembers who served/deployed after 9/11.

The Emory Healthcare Veterans Program operates an intensive two-week outpatient treatment program. The program is a comprehensive regimen helping Veterans re-engage in daily life, while promoting physical and mental health and wellness.

Veterans and servicemembers from across the country who qualify for the program are treated at no cost, giving them access to a wide range of services including daily individual therapy, group therapy, family therapy, wellness services, finance and career classes, and various recreational activities.

The $29.2 million grant includes funding to continue treatment for warriors and a capital grant to expand the Emory Healthcare Veterans Program’s physical space and increase treatment capacity. It follows a 2015 grant from Wounded Warrior Project for $15 million to help establish the current program.

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Gift from Hemophilia of Georgia Establishes Newly Renovated Bleeding and Clotting Disorders Center at Emory

Thursday, September 27th, 2018

A $10 million gift from Hemophilia of Georgia has established the Hemophilia of Georgia Center for Bleeding and Clotting Disorders of Emory. The center includes a newly renovated, state-of-the-art clinic, located at Emory University Hospital Midtown. The gift will also support the expansion of clinical services, assist in training physicians and advancing research in both pediatric and adult patients affected by hemophilia and other bleeding disorders.

An opening celebration, ribbon cutting and tours were held at the new clinic on September 6. The renovated space in Emory University Hospital Midtown’s Medical Office Tower includes a 7,500 square foot multi-disciplinary clinic for adult patients with bleeding and clotting disorders, where they can receive integrated care and treatment from Emory’s team of specialists. It also provides adjacent administrative space for physicians and staff.

The new clinic includes eight exam rooms, a point of care lab, a blood-draw station allowing patients to have labs drawn in the clinic rather than the central lab, two consultation rooms equipped with video conferencing, a fully equipped/stocked physical therapy gym including joint ultrasound equipment and a specimen processing room for better integration of clinical research into the clinical operations.

A new electronic monitoring system in the center will track the progress of each patient’s visit, allowing the team to provide the most comprehensive care possible. The clinic will also now be able to offer patients with urgent bleeding disorder-related needs same day clinic appointments.

“The many features found in the new clinic space will help improve the quality of our processes and workflow, while improving the patient experience,” says Christine Kempton, MD, MSc, director of the Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory and associate professor in the Department of Hematology and Medical Oncology at Emory. “We are so grateful for this generous gift from Hemophilia of Georgia, which has pledged over $40 million to Emory University over the past 40 years.”

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Northside Hospital announces new Sports Medicine Network

Thursday, September 27th, 2018

Northside Hospital announced the creation of a new network of experts and facilities to provide comprehensive medical, surgical and concussion care.

From injury prevention, athletic training, physical therapy and sports performance services, to orthopedic surgery, orthobiologic treatments and diagnositic imaging, the new Northside Hospital Sports Medicine Network offers circumferential care and personalized services based entirely around the needs of athletes and active people of all ages and skill levels, from little league to weekend warriors to professional athletes.

The Network represents the consolidation and expansion of three physician practices – Northside Cherokee Orthopedics & Sports Medicine, Northside East Cobb Orthopaedics & Sports Medicine and The Orthopedic Sports Medicine Center of Atlanta.

Vonda J Wright, MD, MS, FAOA, has been named chief of Northside Hospital Sports Medicine and was selected to build and lead the new Network.

Dr. Wright is board certified in orthopedic surgery and sports medicine and is an internationally recognized authority on active aging and mobility. She joins Northside from the University of Pittsburgh Medical Center (UPMC) Sports Medicine Program, where she served as the inaugural medical director of the UPMC Lemieux SportsComplex and maintained a practice focusing on minimally invasive arthroscopic and reconstructive surgical techniques of the shoulder, hip and knee.

Dr. Wright also was the founding director of the Performance and Research Initiative for Masters Athletes (PRIMA). She has written five books, is the author and contributor to multiple peer reviewed journal articles and is frequently consulted by the media as a sports medicine authority.

As a team physician, Dr. Wright served as the head team physician for the University of Pittsburgh Football team and Olympic Sport teams, the Pittsburgh Ballet Theatre and the Pittsburgh Penguins Elite Youth Hockey system. She is a team doctors for the World Rugby 7’s and medical director of the Pittsburgh Triathlon and PGA Players Doc.

The Northside Hospital Sports Medicine Network includes a team of clinical experts – orthopedic sports surgeons, non-operative sports medicine doctors and physician assistants – who provide high-tech, high-touch evidence-based musculoskeletal care and offer a full complement of surgical and medical consultants, a comprehensive sports concussion program, sports nutrition, physical therapy and a sports performance and innovative research initiative.

Locations include Atlanta, Alpharetta, Buckhead, Buford, Cumming, East Cobb, Holly Springs, Midtown, Roswell and Woodstock.

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Piedmont Cancer Genetics Launches Telegenetics for High-Risk Patients

Thursday, September 27th, 2018

Combining the latest in telemedicine with rapidly expanding knowledge about cancer risk, Piedmont Cancer Genetics has launched a telegenetics program for patients at high risk for breast, colon and ovarian cancer.

The program was made possible by a donation from Holland Ware and Faye Hendrix-Ware of Hogansville and employs four genetic counselors who will offer virtual visits via Piedmont’s telemedicine services while those counselors continue in-person visits. Piedmont is the only certified member of MD Anderson Cancer Network® in Georgia.

“Oncology has moved rapidly into an era where we can lower the risk of cancer and precisely target individualized treatments for those who do develop it,” said John W. Henson, M.D., Chief of Oncology Services. “The explosion of genetic research is the basis for making that happen.”

“Though only 5 to 10 percent of cancer is hereditary, genetic testing can identify individuals who have a high risk for cancer,” said Amanda Eppolito, MS, leader of Piedmont Cancer Genetics. “If someone has an inherited susceptibility, he or she can take proactive steps for risk-reduction and early-detection. This new telegenetics service will allow more patients to benefit from genetic counseling and testing.”

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Genomics

Monday, September 24th, 2018

By Helen K. Kelley

Genomic medicine, a discipline that involves using an individual’s genomic information as part of their clinical care, is true personalized medicine. Physicians and researchers in this field are working diligently to find new treatments that customize a patient’s medical care based on their unique genetic makeup.

William R. Wilcox

William R. Wilcox, M.D., Ph.D.

Rapid Advances in Genetic Disease Research
“This is an exciting time in the field of genetic disease research,” says William R. Wilcox, M.D., Ph.D., professor of human genetics and pediatrics at Emory University School of Medicine. “There’s no question, we’re advancing quickly.”

Wilcox says there are three specific areas in genomic medicine that are making rapid progress and are poised to make a significant impact on certain populations:

1 Newborn screening. “In Georgia, we are conducting pilot screening for different disorders with National Institutes of Health (NIH) funding. These screens are for rare disorders that often are missed by healthcare providers or are only diagnosed after permanent damage has occurred,” Wilcox explains.

One example is spinal muscular atrophy (Werdnig-Hoffman disease). “There is a treatment available now that can prevent this disorder from developing if you identify it at the newborn stage,” he says.“These pilot screening programs are a joint effort between Emory University and the Georgia Public Health Laboratory. I’m proud that Georgia is one of the national leaders in this effort.”

2 Diagnostics. “We’re increasingly able to provide the answer as to why a child or an adult with an often bizarre group of symptoms has them – we can come to a specific diagnosis. For example, we are becoming more successful in identifying what causes significant learning disabilities or autism,” Wilcox says.

“We can figure out why it happened from a genetic perspective because of advances in molecular testing that have occurred over the last few years,” he adds. “In the not too distant future, I think we will be moving from the research we’re currently doing to full genome sequencing at a more reasonable cost.”

3 Treatment. Dr. Wilcox says that his colleagues at Emory, Children’s Healthcare of Atlanta (CHOA) and across the country are participating in a significant amount of research to provide new treatments for various genetic diseases.

“We’re learning how to treat disorders like sickle cell disease and hemophilia through clinical trials that involve processes like removing hematopoietic stem cells from the patient, making modifications and then putting them back in. Or we can give an intravenous infusion that can be targeted to help a specific organ, such as delivering a missing enzyme that isn’t being produced,” he says. “There is now even a drug to treat spinal muscular atrophy that can be delivered through a peripheral IV infusion that is able to cross the blood-brain barrier and provide a functional gene to the motor nerve cells. We are advancing rapidly in our knowledge of treatments for genetic diseases.”

When asked what he predicts for the future of genomics, Wilcox says he thinks research will continue to evolve, providing increased efficiency of treatments at lower costs.

“For genetic screening, the sequencing technologies are getting cheaper and more organized,” he says. “It may be that one day, we all have our genome sequencing done and then carry it around with us on a flash drive. You’ll know what genes you carry and what treatments you need.”

In the News: Researchers Discover Roles and Teamwork of CRISPR-Cas Proteins
Recently published research from the University of Georgia and UConn Health provides new insight about the basic biological mechanisms of the RNA-based viral immune system known as CRISPR-Cas.

CRISPR-Cas, short for Clustered Regularly Interspaced Short Palindromic Repeats/CRISPR-associated, is a defense mechanism that has evolved in bacteria and archaea that these single-celled organisms use to ward off attacks from viruses and other invaders. When a bacterium is attacked by a virus, it makes a record of the virus’s DNA by chopping it up into pieces and incorporating a small segment of the invader’s DNA into its own genome. It then uses this DNA to make RNAs that bind with a bacterial protein that then kills the viral DNA.

The system has been studied world- wide in hopes that it can be used to edit genes that predispose humans to countless diseases, such as diabetes and cancer. However, to reach this end goal, scientists must gain further understanding of the basic biological process that leads to successful immunity against the invading virus.

Michael Terns

Michael Terns, distinguished research professor of biochemistry and molecular biology in UGA’s Franklin College of Arts and Sciences, is principal investigator for the project.

“This research is more fundamental and basic than studies that are trying to determine how to use CRISPR for therapeutic or biomedical application,” says Michael Terns, principal investigator for the project. “Our study is about the unique first step in the process, known as adaptation, where fragments of DNA are recognized and integrated into the host genome and provide immunity for future generations.”

Previously, it was not understood how the cell recognized the virus as an invader, nor which bacterial proteins were necessary for successful integration and immunity. Through this study, researchers were able to determine how the bacterial immune system creates a molecular memory to remove harmful viral DNA sequences and how this is passed down to the bacterial progeny.

By looking at patterns in the data, the researchers discovered several new findings about how two previously poorly characterized Cas4 proteins function in tandem with Cas1 and Cas2 proteins found in all CRISPR-Cas systems.

In this initial adaptation phase, one of two different Cas4 proteins recognizes a signaling placeholder in the sequence that occurs adjacent to the snippet of DNA that is excised.

When the Cas1 and Cas2 proteins are present in the cell with either of two Cas4 protein nucleases, Cas4-1 and Cas4-2, they act like the generals of this army-based immune system, communicating uniform-sized clipped DNA fragments, directions on where to go next and ultimately instructions that destroy the lethal DNA fragment.

For a cell to successfully recognize and excise strands of DNA, incorporate them into its own genome and achieve immunity, the Cas4 proteins must be present in conjunction with the Cas1 and Cas2 proteins.

To achieve these findings, the research team from the University of Georgia created strains of archaeal organisms with key genetic deletions. Hundreds of millions of DNA fragments captured in the CRISPR loci were sent to the Graveley lab in Farmington, Conn., where they were sequenced with the Illumina MiSeq system. The researchers then used supercomputing for bioinformatics analysis and data interpretation.

While there is still much to learn about the biological mechanisms involved in CRISPR-Cas systems, this research tells scientists more about the way these proteins work together to save the cell and achieve immunity.

cancer cells

Growing cancer cells (in purple) are surrounded by healthy cells (in pink), illustrating a primary tumor spreading to other parts of the body through the circulatory system.

In the News: NIH Completes In-depth Genomic Analysis of 33 Cancer Types
Researchers funded by the National Institutes of Health have completed a detailed genomic analysis, known as the PanCancer Atlas, on a data set of molecular and clinical information from more than 10,000 tumors representing 33 types of cancer.

“This project is the culmination of more than a decade of groundbreaking work,” says NIH Director Francis S. Collins, M.D., Ph.D. “This analysis provides cancer researchers with unprecedented understanding of how, where and why tumors arise in humans, enabling better informed clinical trials and future treatments.”

The PanCancer Atlas, published as a collection of 27 papers across a suite of Cell journals, sums up the work accomplished by The Cancer Genome Atlas (TCGA), a multi-institution collaboration initiated and supported by the National Human Genome Research Institute (NHGRI) and the National Cancer Institute (NCI), both part of NIH. The program, with more than $300 million in total funding, involved upwards of 150 researchers at more than two dozen institutions across North America.

The project focused not only on cancer genome sequencing, but also on different types of data analyses, such as investigating gene and protein expression profiles, and associating them with clinical and imaging data.

The PanCancer Atlas is divided into three main categories, each anchored by a summary paper that recaps the core findings for the topic. The main topics include cell of origin, oncogenic processes and oncogenic pathways. Multiple companion papers report in-depth explorations of individual topics within these categories.

The entire collection of papers comprising the PanCancer Atlas is available through a portal on cell.com. Additionally, as the decade-long TCGA effort wraps up, there will be a three-day symposium, TCGA Legacy: Multi-Omic Studies in Cancer, in Washington, D.C., September 27-29, 2018, that will discuss the future of large-scale cancer studies, with a session focusing on the PanCancer Atlas. The meeting will feature the latest advances on the genomic architecture of cancer and showcase recent progress toward therapeutic targeting.

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Anesthesia for Surgery in Pregnant Patients

Monday, September 24th, 2018

By Laura E Gilbertson, M.D., Milad Sharifpour, M.D., and Grant C Lynde, M.D.

More than 75,000 pregnant patients undergo non-obstetric surgery in the United States each year. Fortunately, good preparation and planning can lead to good outcomes for both mother and child.

Finding physicians and hospitals with experience in caring for parturients with comorbid conditions is one of the most important considerations. Secondarily, attempting to schedule the surgery for the second trimester –when most organogenesis has been completed, but before the risk of preterm delivery increases –is the second-most important consideration.

It’s important for all physicians referring pregnant patients for surgery to be able to accurately educate their patients on the anesthetic considerations. There is a lot of inaccurate information that patients are presented in the mass media, and even more so, on the internet. With a better understanding of the maternal-fetal dyad, all practitioners should be able to help expecting parents find medically sound answers to their questions regarding the effects of anesthetic agents on their unborn child, what their surgical options are and how to best prepare.

Of utmost concern to any expecting mother is the possibility that surgery will cause harm to their baby. One of the most common questions involves teratogenicity caused by prenatal treatments. While it remains that maternal issues such as severe maternal hypoxia and hypotension pose the greatest risk to the fetus, there has now been considerable attention placed on the role of anesthetic agents on development.

There are several key factors that may influence teratogenicity, such as susceptibility, dose of the teratogenic substance, duration and timing of the exposure as well as genetic predisposition. Due to the substantial concern about the teratogenicity seen in animal models exposed to anesthetics, the U.S. Food and Drug Administration (FDA) issued an extensive statement to the public in December 2016 warning about the potential dangers of general anesthetics to the fetus. As this statement is now in the public realm, it is even more important for physicians to stay knowledgeable on the most recent literature.

Anesthetics primarily work by interfering with normal GABAa and NMDA receptor mediated activity to produce effective amnesia and unconsciousness. These same receptors are also believed to be involved in fetal central nervous system development. The most widely studied deleterious consequence of exposure to sedatives or anesthetics in immature animals is apoptosis (programmed cell death). Frequently used medications in anesthesia such as benzodiazepines and propofol as well as inhalational anesthetics have demonstrated varying degrees of apoptosis after exposure in animal models, however these apoptotic events have yet to show any correlation with future developmental abnormalities.

While concern about the effects of general anesthetics on the developing brain originates from animal observations, human studies have shown that a short duration of general anesthesia in the neonatal period has no profound developmental effects. Although no single anesthetic agent or medication has been shown to be neurotoxic to humans, a risk benefit ratio should always be implemented prior to administration of any anesthetic.

Another common question expecting mothers have is, “Can I have laparoscopic surgery?” Benefits of laparoscopic surgery include reduced surgical pain, decreased postoperative opioid consumption, decreased incidence of post-operative ileus and shorter length of hospital stay. Benefits unique to pregnant patients include decreased risk of fetal respiratory depression, as well as decreased postoperative maternal hypoventilation secondary to decreased opioid consumption, lower risk of wound complications and decreased risk of thromboembolic events. During pregnancy, insufflation pressures of 10-15 mmHg can be safely used for laparoscopy, however the pressure should be adjusted to the patient’s physiology.

A multidisciplinary team including surgeons, anesthesiologists, obstetricians and perinatologists should be involved in the decision to proceed with surgery. Urgent and emergent surgery should proceed without delay to minimize risk to the patient and the fetus. However, semi-elective procedures should be scheduled during the second trimester, when organogenesis is completed, and the risk of preterm labor is not as high as that during the third trimester.

Pregnant patients should undergo the same pre-operative evaluation as non-pregnant patients, and laboratories and other testing should be performed as indicated by the patient’s overall health and condition. In addition, the following risks should be taken into consideration:

1. Aspiration Prophylaxis: While gastric emptying is shown to be normal until active labor, pregnant women may be at a higher risk of aspiration. Aspiration prophylaxis should include a non-particulate antacid (bicitra) and H2-receptor blockers.

2. Difficult Intubation: Due to airway changes during pregnancy, pregnant patients are at increased risk of difficult intubation. Regional and neuraxial anesthesia should be considered when appropriate.

3. Thromboembolism: All pregnant patients undergoing surgery require mechanical and pharmacologic thromboembolic prophylaxis as pregnancy is a hypercoagulable state.

4. Patient Positioning: Depending on gestational age, the gravid uterus may apply pressure over major intra-abdominal vessels specifically in a supine position.

The final consideration for surgical procedures on the pregnant patient involves preparations for emergent delivery of the fetus. There is conflicting guidance for intraoperative fetal heart rate monitoring. Practices vary on whether to perform continuous versus intermittent monitoring, and whether to monitor any time during the pregnancy or only after fetal viability. What is not in question, however, is the need to have obstetrical support for women undergoing surgery once the fetus reaches 24 weeks’ gestation.

In conclusion, with good preparation, surgery may be performed successfully and with minimal risk to the pregnant patient. While some women may have misconceptions about the risks and future effects on their baby, they should be reassured that surgery during pregnancy occurs rather frequently, without significant complication.

Referring physicians should recommend specialists and hospitals that are experienced and are able to manage any possible complications, such as preterm delivery. While occurring infrequently, the fact that thousands of women do successfully undergo surgical procedures every year while pregnant should provide reassurance to our patients.


Suggested Reading:
Ceana Nezhat (ed), Kavic MS, Lanzafame RJ, Lindsay MK, Polk TM (assoc eds). Non-Obstetric Surgery during Pregnancy: A Comprehensive Guide. New York: Springer. In Press.

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Georgia Orthopaedic Society Annual Meeting

Saturday, September 22nd, 2018

Sept. 27-30, 2018. At the Cloister on Sea Island, GA. For more information, visit Georgia Orthopaedic Society.

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