A for GYN procedures (linda's PPT) Flashcards
General GYN principles
- have the patient void preoperatively to keep bladder empty (if they don’t void, will straight cath)
- HCG on ALL women of childbearing age
- common position = lithotomy; know the implications of this position
- neuraxial block level is T10 is needed for GYN surgery
- vasovagal can occur in response to traction on uterus or with cervical dilation (have glycol & atropine ready)
- separate sterilization permit is needed
- PONV = big problem
Dilation & Curretage
surgeon opens up cervix and scrapes cervical or endometrial tissue
D&C implications
- abnormal uterine bleeding
- relieve dysmenorrhea
- evaluate infertility
- biopsy to diagnose cervical malignancy
make sure deep enough during dilation so they do not spasm. dilate up to 8 to 9cm
D&C anesthetic choice
- local- paracervical block (inject at 5 and 8 o clock in the cervix)
- SAB - need T10 level
- general: LMA or ETT (can come in for a lot of bleeding as an emergency and have to treat it as a full stomach –> ETT)
D&C: preop
- missed abortion - check hemodynamics
- sepsis
- HCG
- HGB & Hct –> may be impaired depending on how much blood they lose
- can be done for retained placenta: right after birth in the OB area, also can retain placenta for a few weeks and need to be thinking sepsis/unstable
D&C: intraop
- local anesthetic may be infiltrated at the cervix - watch HR
- straight Cath at beginning so the bladder doesn’t push down on the cervix
D&C: complications
- bradycardia
- nerve injury: common peroneal(pad legs around stirrup), obturator, & saphenous (foot drop)
- finger trauma (lift foot of the bed back up)
- PONV
- uterine atony (uterus not clamping down), from having several babies or chorioamnionitis → first thing you do is massage the uterus and then give meds next if that doesn’t work
- uterine perforation→ severe abdominal pain. tx is emergency surgery
uterine atony: pitocin
- hypothalamus → posterior pituitary
- stimulation of uterine contractions
- 10 - 40 u/L, usually 20 u/L
- watch for hypotension
not a good idea to do IVP, as little as 3 units can cause massive vasodilation
uterine atony: methylergonovine maleate (Methergine)
- works on the smooth muscle of the uterus
- 0.2 mg IM (works 2-5 mins after you give it) NOT GIVEN IV → causes massive vasoconstriction & myocardial ischemia
- HTN
uterine atony: Hemabate (Carboprost)
- 250 mcg deep IM/myometrium
- if given IV can cause severe bronchospasm and HTN
- don’t give if hx of asthma
- can repeat Q 15 to 90 mins
- can cause vomiting, diarrhea, or uterine rupture if given too much
D&E ?
dilation and evacuation, the fetus is greater than 16 weeks old
can be done past 20 weeks because they have an appt at 20 weeks and can find out if fetus is having complications
the farther along the fetus the bigger the risk of complications during the procedure like bleeding
hysteroscopy procedure
rigid lighted fiberoptic endoscope is used to examine the uterine cavity
- lithotomy a little bit and help keep the speculum in
- grab cervix with a clamp and is very stimulating, make sure patient is deep enough
hysteroscopy: indications
- intrauterine bleeding
- biopsy
- remove IUD
hysteroscopy: A choice
- usually local with sedation
- GA: LMA v ETT
hysteroscope: Preop
- check Na & K levels → like a TURP patient may absorb a lot of fluid because they use this to distend the uterus
hysteroscope: Intraop
- cervical dilation
- instilled glycine or saline → OR staff monitors how much of the irrigation goes in and comes out. (IF ABSORPTION AMOUNT IS > 500CC PROCEDURE SHOULD BE STOPPED !!) look for signs of hyponatremia and CNS signs
- limit crystalloids
- NSAIDs
Hysteroscope: complications
- uterine perforation
- infection
- bleeding
- gas embolism
Radical hysterectomy
removal of the uterus, cervix, fallopian tubes, ovaries, upper vagina, and supporting vaginal and uterine ligaments, and all pelvic lymph nodes
indication: cancer
TAH-BSO
removal of the uterus, cervix, and fallopian tubes
indication: cancer, severe endometriosis, uterine perforation or uterine prolapse
anesthetic implications for hysterectomies
- with malignancies, staging will be done: take lymph nodes - send them to pathology
- vaginal hysterectomy or lap hysterectomy MOST OFTEN done: shorter hospital stay, decreased postop pain
- Preop: if malignancies - check what kind of chemotherapeutic agents. There may be some type of endocrine dx with some type of tumors (diabetes and/or hypothyroidism)
- Intraop: regional (T5) or GA
- Postop: multimodal analgesia
pelvic exenteration: unique considerations
- full and thorough mechanical and abx intestinal prep → plan on them being dehydrated
- NGT (pre-op)
- 8-12 hrs
- invasive monitoring? a-line
- consider epidural for postop pain
pelvic exenteration: procedure
total excision and removal of internal genitalia, cervix, uterus, upper vagina, bladder and distal ureters, rectum, distal sigmoid colon, pelvic lymph nodes and para-aortic lymph nodes
have to do a fecal and urinary diversion, any reason to do this procedure is cancer
ectopic pregnancy: medical management
- methotrexate
- works well on pregnancies on cervix or ovaries and certain part of fallopian tubes
- will not work if tube is ruptured
ectopic pregnancy: surgical management
- laparoscopy or laparotomy
- hemorrhage
- PAIN !!
- hypovolemia
cervical cerclage
- reinforcement of the cervix to prevent premature cervical dilation with an incompetent cervix
- elective cerclage will be placed between 14 and 18 weeks
- purse-string stitch placed around cervix to keep it closed
- The patient will be placed in dorsal lithotomy; LLD tilt to keep the uterus off IVC and avoid hypotension
- considered full stomach if > 16 weeks
- spinal with therapeutic communication, no sedation
avoid benzos if given in early pregnancy child developing a cleft lip
