Gebelikte Obstetrik Olmayan Cerrahi İşlemler
Özet
Gebelikte obstetrik dışı nedenlerle yapılan cerrahi işlemler tüm gebeliklerin yaklaşık %1'ini etkilemekte olup, en sık apendektomi ve kolesistektomi gibi abdominal operasyonlar uygulanmaktadır. Travma cerrahisi ve acil ameliyatlar gebelik haftasına bakılmaksızın ertelenmeden hemen yapılmalı, elektif işlemler ise doğum sonrasına bırakılmalıdır; acil olmayan fakat ertelenemeyen müdahaleler için ise fetal organogenezin tamamlandığı ve erken doğum riskinin daha düşük olduğu ikinci trimester tercih edilmektedir. Ameliyat öncesinde tromboemboli riskine karşı kompresyon çorapları ve bireysel antikoagülan profilaksisi uygulanmalı, enfeksiyon riskine karşı penisilin veya sefalosporin gibi güvenli antibiyotikler seçilmelidir. Olası erken doğum riskinde perinatal morbiditeyi ve yenidoğan nörolojik hasarlarını azaltmak amacıyla 24 ila 34. gebelik haftaları arasında antenatal glukokortikoid ile nöroprotektif magnezyum sülfat tedavileri cerrahi öncesinde uygulanabilir. Şartlar uygun olduğunda tercih edilen laparoskopik cerrahi, açık cerrahiye kıyasla daha az uterus manipülasyonu ve daha küçük insizyon avantajı sunarken; fetal asidoz ve hipoksi riskini en aza indirmek için karın içi basınç 8-12 mmHg arasında tutulmalı ve 16. haftadan sonra vena cava kompresyonunu önlemek için hastaya sol lateral pozisyon verilmelidir. Operasyon esnasında yaşam sınırının üzerindeki fetuslarda sürekli veya aralıklı fetal izlem yapılmalı, anestezi ilaçlarının fetal kalp atımlarında (10-25 atım düşüş gibi) ve variabilitede neden olabileceği fizyolojik değişiklikler dikkate alınmalıdır. Postoperatif dönemde ise tromboemboli profilaksisi, erken mobilizasyon sağlanmalı ve 32. haftadan sonra fetal duktus arteriozusun erken kapanma riski nedeniyle nonsteroid antiinflamatuar ilaçlardan kesinlikle kaçınılmalıdır.
Non-obstetric surgical procedures during pregnancy affect approximately 1% of all pregnancies, with abdominal operations such as appendectomy and cholecystectomy being the most frequently performed. Trauma surgery and emergency operations must be performed immediately without delay regardless of the gestational week, while elective procedures should be postponed until postpartum; for non-emergency but non-postponable interventions, the second trimester is preferred due to completed fetal organogenesis and a lower risk of preterm labor. Preoperatively, compression stockings and individualized anticoagulant prophylaxis should be applied against thromboembolism risk, and safe antibiotics like penicillin or cephalosporin should be selected against infection risk. In cases with a potential risk of preterm labor, antenatal glucocorticoids and neuroprotective magnesium sulfate treatments can be administered prior to surgery between the 24th and 34th gestational weeks to reduce perinatal morbidity and newborn neurological damage. Laparoscopic surgery, preferred when conditions are suitable, offers advantages of less uterine manipulation and smaller incisions compared to open surgery; to minimize fetal acidosis and hypoxia risks, intra-abdominal pressure should be maintained between 8-12 mmHg, and the patient should be placed in a left lateral position after the 16th week to prevent vena cava compression. During the operation, continuous or intermittent fetal monitoring should be performed for fetuses above the limit of viability, taking into account the physiological changes that anesthetic drugs can cause in fetal heart rates (such as a 10-25 beat drop) and variability. In the postoperative period, thromboembolism prophylaxis and early mobilization must be ensured, and nonsteroidal anti-inflammatory drugs must be strictly avoided after the 32nd week due to the risk of premature closure of the fetal ductus arteriosus.
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