**5.3. Laparoscopic surgery**

**5.2. Pregnancy**

immunosuppression [103].

With the advances in transplantation medicine, female organ transplant recipients are able to conceive and carry pregnancies successfully to term. This state presents a unique challenge to attending physician, obstetrician, and anesthesiologist. These women are at an increased risk of comorbidities and obstetric complications. Therefore, all post-transplant pregnancies should be considered as high risk, and close monitoring is mandatory. Anesthesiologists are involved in the care of these patients for both labor analgesia and operative procedure. Anesthetic considerations include the effects of the physiologic changes of pregnancy on the transplanted organ, graft function in the peripartum period, and the maternal side effects and drug interactions of immunosuppressive agents. Anesthetic management should consider the

Data are lacking regarding the optimal transplant-conception interval. The 2005 American Society of Transplantation Consensus Conference suggested that pregnancy 1 year after transplant is safe as long as the patient has stable graft function. This means: no episodes of rejection in the past year, a low risk for opportunistic infections, stable renal function (including in those receiving organs other than a kidney), and a low stable dose of maintenance

Pregnancy does not appear to cause excessive or irreversible problems with graft dysfunction if the function of the transplanted organ was stable prior to pregnancy [104]. Maternal side effects of immunosuppression therapy include nephrotoxicity, hepatotoxicity, diabetes, and arterial hypertension, which could lead to possible dangerous complications. In kidney, heart, or heart-lung transplant recipients, the rate of complications, such as preeclampsia, premature labor, and risk of acute allograft rejection postpartum, is higher than

Current immunosuppressant drugs are not thought to be teratogenic and their use cannot be discontinued during pregnancy. All immunosuppressants cross the placenta. They are not strongly associated with the increased risk of congenital anomalies in the first trimester. However, they affect the immune system of fetus during the second and third trimesters and

The anesthetic technique for cesarean section depends on indication, functional status of transplanted organ, and cardiovascular and hematological status. Central neuraxial blocks are not contraindicated if coagulation status is normal. However, documentation of paresthesia is important if regional anesthesia is planned. In the case of general anesthesia, all intravenous anesthetics and inhalational agents are safe. Neuromuscular function should be monitored particularly if the patient is receiving magnesium. Postoperative pain relief is provided with narcotics by epidural or spinal route if regional anesthesia is used or by parenteral opioids. Non-steroidal anti-inflammatory drugs should be avoided. Thromboprophylaxis should be administered because of the high risk of thromboembolic complications in these patients, especially after cesarean delivery. The threshold for admission to an intensive care or high-

may result in premature delivery and low birth weight in newborn [106].

important task of protecting graft function [101, 102].

246 Organ Donation and Transplantation - Current Status and Future Challenges

that in the non-transplant population [105].

dependency unit should be low [107].

Laparoscopic surgery is currently a widely accepted approach to several surgical fields because of its advantages in terms of postoperative pain reduction and easy patient recovery. The number of minimally invasive surgical procedures performed in transplant recipients is constantly increasing [108].

Lymphoceles can be successfully treated surgically after kidney transplantation by laparoscopy under general anesthesia [109, 110]. There are also reports of successful laparoscopic bariatric surgery after simultaneous pancreas and kidney transplantation [111]. Laparoscopic cholecystectomy is considered to be safe procedure in the transplant population. It has advantage of short hospital stay, low morbidity, maintenance of oral immunosuppression, and early return to preoperative routines. There is however a slightly higher rate of conversion to an open cholecystectomy among transplant patients compared to general population (27% vs. 11%, respectively) [112, 113]. Generally, laparoscopic approach may be useful even in solid-organ transplantation surgery as a diagnostic or treatment procedure in some surgical complications.
