anesthesia for GYN surgery Flashcards
D&C
dilate cervix and curettage (scrape walls of) uterus to remove and/or vacuum aspirate products of conception (1st trimester), cysts, or tumors
anesthetic considerations for D&C
pt’s emotional state, baseline CBC, intraop H/H, analgesia/antiemetics/uterine relaxation, venous access, volume status, availability of T&S, positioning/lithotomy
what is common in patients needing D&C that is fixed by having the procedure?
anemia
if any products of conception are retained what are patients at risk for?
bleeding
D&E
dilation and evacuation performed in 2nd trimester (between 12-24 weeks), can be for miscarriage or elective pregnancy termination, typically need to use vacuum and/or forceps
what kind of agents would you want on hand for a D&C or D&E?
uterotonic agents
uterotonic medications MOA
act directly on uterine smooth muscle
increase tone, rate, and strength of rhythmic contractions
Oxytocin (Pitocin)
naturally produced hormone
secreted by the posterior pituitary
uterotonic - stimulates uterine contractions
benefits/uses for uterotonics
prevent/treat postpartum hemorrhage
ripen cervix and induce labor
manage incomplete or elective abortion
how do you prepare oxytocin
dilute, either 10units or 20units/mL vials, give 2 units IV and put the rest in 1 L bag of LR
Synthetic oxytocin (pitocin or syntocinon) can be given
given IV or IM but usually IV diluted
Mifeprex is a
synthetic steroid made from norethindrone (active ingredient of norplant)
only FDA approved non surgical option for abortion during first 49 days of pregnancy
Methergine (methylergonovine)
semi-synthetic ergot alkaloid
prevents and controls PPH
0.2 mg IM (can repeat)
when is Methergine contraindicated?
HTN, gestational HTN, eclampsia, pre-eclampsia
Hemabate (Carboprost tromethamine)
prostaglandin F2a
250 mcg IM (can only be given IM)
What kind of patients do you avoid Hemabate in?
asthmatics!
Cervidil (Dinoprostone), Prepidil, Prostin E2
inserted vaginally (10mg)
naturally occurring biomolecule (PGE2)
stimulates PGF-2a = sensitizes myometrium to oxytocin
causes cervical ripening for labor
Oxytocin IM
onset, duration, and side effects
Onset- 2-3 mins
DOA - 15-30 mins
SE - NV, cardiac arrhythmia, anaphylaxis
Misoprostol PO
onset, duration, side effects
onset- 3-5 minutes
DOA - 75, peak 18-34
SE - shivering, diarrhea, transient temp >38 degrees C
Ergometrine IM
onset, duration, side effects
Onset - 6-7 mins
DOA - 120-240 minutes
SE - increased BP, HA, dizziness, NV, tinnitus, rash
Syntometrine IM
onset, duration, side effects
Onset- 2-3 mins
DOA - 120-240 mins
SE - NV, HA, dizziness, HTN, arrhythmia, rash
Conization of the cervix
excision of a cylindrical wedge from the cervix
indications for a conization of the cervix
definitive diagnosis of squamous or glandular intra-epithelial lesions
excluding microinvasive carcinomas
conservative treatment of cervical intra-epithelial neoplasia (CIN)
different methods for conization of the cervix
scalpel, laser, electrosurgical excision loop (LEEP), large loop excision of the transformation zone (LLETZ), combo of laser and scalpel
hysteroscopy
visualization inside the uterus to diagnose or treat uterine problems
indications for hysteroscopy
abnormal uterine bleeding, fibroids, polyps, cancer, biopsies, remove adhesions, sterilization, locate IUD
surgical procedure of hysteroscopy
empty bladder (straight cath), speculum into vagina then hysteroscope is advanced through vagina, cervix, and into uterus, images projected on screen and gas or fluid is injected to expand the uterus to help visualize
risks associated with hysteroscopy
uterine or cervical puncture/perforation, bleeding, infection, hypervolemia, hyponatremic encephalopathy/cardiac asystole, arrhythmia, hypercarbia/acidosis/gas embolism
why is it important to monitor fluids during a hysteroscopy?
instilled a lot of fluid into uterus that can get absorbed and cause hypervolemia, hyponatremia, brain swelling, metabolic acidosis
endometrial ablation treats
heavy bleeding (>2 pads/day) when medications are unsuccessful destroys the endometrium and stops or reduces menstrual flow
endometrial ablation is not advised for:
post menopausal women thin endometriums endometrial hyperplasia uterine cancer recent pregnancy current or recent uterine infection
surgical time for endometrial ablation
30-60 minutes, no incision is made
risks associated with endometrial ablation
bleeding, infection, uterine or bowel perforation, internal burns
colposcopy
typically done in the office
views the cervix using a colposcope magnified 2-60x
colposcopy is used to assess
cervicitis, uterine polyps, pain, bleeding, cervical warts (HPV), carcinoma
tubal ligation
the fallopian tubes are pulled through the naval and cut and closed with sutures, bands, or clips
surgical time for tubal ligation and what other procedure is it often paired with?
30 minutes , post-caesarian section
risks associated with tubal ligation
bleeding and infection
if the fallopian tubes are “banded” what can happen?
can still have an ectopic pregnancy
can be reversed
endometriosis is
endometrial growth outside of the uterus (ovaries, bowel, bladder, rectum, pelvic wall) that responds to hormonal changes
retrograde menstruation with suspected immune system explanation
endometriosis causes
pain, irregular bleeding, adhesions, and possibly infertility
treatment options for endometriosis
hormone therapy diagnostic laparoscopy excision of endometrial tissue hysterectomy laparotomy
ectopic pregnancy is when
a fertilized egg is attached outside of the uterus (usually in fallopian tubes)
ectopic pregnancy is the ___ leading cause of maternal mortality
2nd, 15% of maternal deaths
symptoms of ectopic pregnancy
vaginal bleeding, pelvic pain, dizziness, fainting, weakness, shoulder pain (rupture)
ruptured ectopic pregnancy
LIFE THREATENING
have internal bleeding and may need to have salpingectomy
medical management of ectopic pregnancy
Methotrexate
hysterectomy
surgical removal of uterus
hysterectomy is the ___ most common major surgery among women of childbearing age
2nd
hysterectomy is used for treatment of
uterine fibroids, endometriosis, uterine prolapse, abnormal uterine bleeding, chronic pelvic pain, cancer
subtotal hysterectomy
body of the uterus
total hysterectomy
body of uterus + cervix
radical hysterectomy
body of uterus + cervix + parametrium + part of the vagina
if the ovaries are not removed with hysterectomy then the patient won’t
go into early menopause
3 types of laparoscopic hysterectomy
- total
- laparoscopically assisted vaginal
- robot assisted
total laparoscopic hysterectomy
uterus is detached, removed in pieces through the incisions or passed through the vagina
laparoscopically assisted vaginal hysterectomy (LAVH)
vaginal hysterectomy with laparoscopic assistance with visualization and removal of organs through the vagina
advantages of laparoscopic hysterectomy
smaller incisions, less pain, shorter hospital stay, shorter recovery, less risk of infection
disadvantages of laparoscopic hysterectomy
increased surgical time, increased risk for bladder injury, risks associated with pneumoperitoneum
radical hysterectomy removes
removes uterus, cervix, ovaries, fallopian tubes, upper vagina, parametrium, pelvic lymph nodes
indications for a radical hysterectomy
uterine, cervical or ovarian cancer
endometriosis
fibroids
pelvic relaxation syndrome
surgical time of radical hysterectomy
3-4 hours
incision and EBL for radical hysterectomy
midline or low transverse
EBL 1500 mL
postop considerations for hysterectomy
earlier risk for osteoporosis than menopausal women
treated with estrogen therapy
oophorectomy effects with hysterectomy caused by
lack of estrogen (hot flashes, vaginal dryness, sleep problems)
myomectomy preop treatments
multivitamins, iron supplements, gonadotropin releasing hormone agonist, oral contraceptives
anesthetic considerations for myomectomy
T&C, intraop H/H, IV fluid and blanket warmer, third space fluid loss with open approach, can use general or regional, prophylactic antithrombotic therapy
second look laparotomy (SLL)
diagnostic
most accurate method of assessing disease status in ovarian cancer
should be clinically free of the disease because they already completed treatments
second look laparotomy evaluates
effectiveness of treatment, size of a tumor after treatment, and recurrence of tumor
radical vulvecotmy anesthetic considerations
given bowel prep, may be getting chemo, in modified dorsal lithotomy
modified dorsal lithotomy
legs extended hips abducted 30 degrees extended 5-10 degrees knees flexed 90 degrees potential for nerve injury.. shocker
pelvic exenteration or evisceration (remove all organs from pelvis) indication
advanced or recurrent pelvic cancer
5 year survival for pelvic exenteration
60%
pelvic exenteration or evisceration procedure
radical hysterectomy, total vaginectomy, bladder excision, urinary diversion, bowel resection and colostomy
surgical risks with pelvic exenteration or evisceration
hemorrage (internal and common iliac arteries), sepsis, wound dehiscence, anastomotic breakdown of bowel, urinary pouch, or ureteral sites, DVT, PE, stoma necrosis or reconstructive flap necrosis
increased incidence of renal disease postop d/t UTI and obstruction
late complications of pelvic exenteration or evisceration
fistula, bowel obstruction, ureteral stricture, renal failure, pyelonephritis, chronic bowel obstructions
antiemetics to consider for PONV
ondansetron, reglan, dexamethasone, propofol, diphenhydramine, phenergan, granisetron, scopolamine, euvolemia, amend
cyclizine class, dose, side effects
class : histamine 1 receptor antagonist
dose: 50 mg
SE: sedation, dry mouth, blurred vision, HoTN, tachycardia
Ondansetron class, dose, side effects
class: 5HT3 receptor antagonists
dose: 4 mg, 0.1mg/kg
SE: dizziness, HA
Dexamethasone class, dose, side effects
class: corticosteroid
dose: 4-8 mg IV, 0.2 mg/kg
SE: flushing, perineal itch, hyperglycemia, infection, peptic ulcer, psychosis
hyoscine class, dose, side effects
class: muscarinic receptor antagonist
dose: 1.5 mg patch
SE: dry mouth, blurred vision, sedation
Metoclopramide class, dose, side effects
class: dopamine D2
dose: 10 mg IV, 0.25 mg/kg
SE: abdominal cramping, restlessness, exrtapyramidal effects, sedation, hypotension
promethazine class, dose, side effects
class: phenothiazines
dose: 12.5-25 mg
SE: sedation
dronabinol class, dose, side effects
class: cannabinoid receptor antagonist
dose: variable
SE: euphoria, tachycardia, conjunctival congestion
lithotomy position concerns
prolonged = concern for compartment syndrome
femoral or peroneal nerve injury
autotransfusion
caution with PVD patients
combined lithotomy and trendelenberg
CVP, PAP = increased
CO = decreased
caution with CAD patients
