What are the safest surgical timings during pregnancy and lactation?
The safest time for cutaneous surgery during pregnancy is in the second trimester (weeks 13–24) or the postpartum period. These timings are safest because they avoid the risk of spontaneous abortion associated with the first trimester and preterm labor associated with the third trimester. However, the timing of surgery should be decided on a case-by-case basis, as individual patient factors, diagnoses, and indications for surgery all play a role in determining when surgery is appropriate.
When considering the timing of surgery for a pregnant patient, it’s crucial to weigh the risks of delaying treatment against the benefits of performing surgery during the safest time frame.
For breastfeeding patients, the primary perioperative considerations regarding the safety of the infant relate to anesthetic and antibiotic choices. The transmission of most antibiotics and anesthetics through breast milk is minimal.
What are the risks of delaying cutaneous surgery during pregnancy?
Delaying cutaneous surgery during pregnancy can pose different levels of risk depending on the patient’s condition.
If the patient has a subcentimeter superficial basal cell carcinoma on the trunk, the risks associated with delaying treatment until the second trimester or postpartum period are minimal.
However, delaying treatment for a patient with a more serious condition, such as invasive melanoma, carries greater risks. A basal cell carcinoma can also be problematic if the tumor is infiltrative and destructive, as delaying treatment could result in tissue loss, loss of function, and nerve damage.
Ultimately, the decision of whether or not to delay surgery during pregnancy should be made on a case-by-case basis, considering the individual patient’s factors, diagnosis, and indications for surgery.
What are safe anesthetic choices during pregnancy and lactation?
Anesthesia during pregnancy and breastfeeding requires careful consideration to ensure the safety of both the mother and child. Here’s a breakdown of safe anesthetic choices for these situations:
During Pregnancy:
- Lidocaine is considered safe for use during pregnancy. It’s classified as FDA pregnancy category B, meaning animal studies have not shown any risk to the fetus, and there are no well-controlled studies in humans. Lidocaine does cross the placenta, but studies haven’t found any evidence of fetal harm from exposure in the first four months of pregnancy.
- Epinephrine is often added to lidocaine to prolong its effects and reduce bleeding. It’s classified as FDA pregnancy category C, meaning animal studies have shown some adverse effects, but the potential benefits may outweigh the risks in humans. While epinephrine can cross the placenta and reduce blood flow in the uterus, local and dilute administration for dermatologic use is considered safe. The American Academy of Dermatology guidelines support using controlled amounts of lidocaine with epinephrine for local anesthesia in pregnant women.
- Topical lidocaine is also considered safe during pregnancy and breastfeeding due to low serum concentrations after application. However, there is limited data on the use of other topical anesthetics, so they are generally not recommended.
- Bupivacaine and mepivacaine are not recommended during pregnancy because they are FDA category C and associated with potential adverse effects like the inhibition of cardiac conduction, congenital abnormalities, and fetal bradycardia.
During Lactation:
- Lidocaine is considered compatible with breastfeeding by the American Academy of Pediatrics. Studies have shown that lidocaine and its metabolites are present in breast milk at very low concentrations, and there’s no evidence of harm to infants. The plasma lidocaine level needed to treat neonatal seizures is much higher than what is typically reached with local anesthetic use.
- Epinephrine is excreted in breast milk but is poorly absorbed by the infant and has a short lifespan, making it unlikely to have a significant effect. While clear data is lacking, low-dose epinephrine infusion as part of epidural analgesia hasn’t been shown to negatively impact breastfeeding.
Which antibiotics are considered safe during pregnancy and lactation?
Antibiotics Generally Considered Safe During Pregnancy
1. Penicillins
- FDA Category: B
- Safety: Safe throughout pregnancy.
2. Cephalosporins
- FDA Category: B
- Safety: Safe throughout pregnancy but requires caution near term due to a potential risk of kernicterus with ceftriaxone.
3. Erythromycin
- FDA Category: B
- Safety: Generally safe during pregnancy.
- Considerations:
- Prolonged use of the estolate form is associated with hepatotoxicity.
- Some studies suggest a slight increase in the risk of cardiac septal defects and pyloric stenosis during the first trimester.
4. Clindamycin
- FDA Category: B
- Safety: Considered safe during pregnancy.
5. Vancomycin
- FDA Category: B
- Safety: Safe throughout pregnancy.
6. Rifampin
- FDA Category: B
- Safety: Safe during pregnancy.
Antibiotics That May Be Used With Caution and When Indicated
1. Sulfonamides
- Safety: Generally safe but with mixed evidence regarding birth defects.
- Guidance: The American College of Obstetrics and Gynecology supports their use as first-line agents for UTIs and other infections when no alternatives are available, even in the first trimester.
2. Nitrofurantoin
- Safety: Mixed evidence regarding birth defects but can be used when indicated.
3. Aminoglycosides (Excluding Streptomycin)
- Safety: Most aminoglycosides can be used in short courses when necessary, with extra care taken during the first trimester.
Antibiotics To Avoid During Pregnancy
1. Streptomycin
- Reason: Contraindicated due to the risk of irreversible bilateral congenital deafness.
2. Fluoroquinolones
- Reason: Generally avoided due to concerns about bone and cartilage damage, renal toxicity, and cardiac defects.
3. Tetracyclines
- Reason: Contraindicated after the 13th week because they can bind to calcium and affect fetal bone and tooth development.
Antibiotics Generally Considered Safe During Lactation
- Penicillins
- Cephalosporins
- Macrolides (Note: No published data on clarithromycin and telithromycin during lactation.)
- Clindamycin
- Rifampin
- Aminoglycosides
Antibiotics That May Be Used With Caution and Monitoring During Lactation
1. Sulfonamides
- Safety: Considered safe during lactation except for:
- Premature infants
- Infants with jaundice
- Infants with glucose-6-phosphate deficiency
2. Fluoroquinolones
- Safety: Generally avoided, but breast milk concentrations are low, and the risk is minimal.
- Consideration: One reported case of infantile pseudomembranous colitis associated with ciprofloxacin use.
3. Tetracyclines
- Safety: Traditionally avoided due to theoretical risk of tooth staining, though this has not been reported in the literature.
General Considerations for Antibiotic Use During Pregnancy and Lactation
- Individualized Assessment:
- Antibiotic choice should be made on a case-by-case basis, considering the specific infection, medical history, allergies, and potential risks and benefits to both the mother and child.
- Risk vs. Benefit:
- Weigh the potential risks of antibiotic exposure against the risks of leaving an infection untreated, which can lead to more serious complications for both the mother and child.
- Open Communication:
- Discussions between the patient, dermatologist, obstetrician, and pediatrician are crucial to ensure informed decision-making and appropriate monitoring.
What antiseptics are considered safe for use during cutaneous surgery in pregnant patients?
1. Alcohol
- Safety: Generally considered safe during pregnancy.
- Use: Typically limited to skin biopsies rather than larger procedures.
- Precaution: While alcohol is absorbed through the skin, it is rapidly metabolized, resulting in low serum levels.
2. Chlorhexidine
- Safety: Classified as FDA category B and recognized as safe during pregnancy.
- Precaution: Avoid using around the eyes and inner ears to prevent risks such as keratitis, corneal ulcers, and ototoxicity.
3. Povidone-Iodine
- Safety: Iodine from povidone-iodine is minimally absorbed through intact adult skin.
- Concern: A single report linked its use to neonatal hypothyroidism after mucous membrane exposure.
- Exception: One study showed no impact on neonatal urine iodine levels when used during Cesarean delivery.
- Precautions to Minimize Risks
- Use lower concentrations of povidone-iodine.
- Apply it only to small surface areas of the body.
- Shorten contact time and avoid repeated applications.
- Vaginal Use: Avoid douching with povidone-iodine or using iodine-containing tampons during breastfeeding due to significant iodine absorption.
4. Hexachlorophene
- Safety: Contraindicated during pregnancy.
- Concern: Associated with fetal central nervous system toxicity due to absorption through the skin.