Anesthesia for Gynecological Surgery Flashcards
What is a dilation and curettage?
dilate cervix and curettage (scrape walls of) uterus typically to remove, often vacuum aspirate, products of conception (1st trimester), cysts or tumors
What are anesthetic considerations for D&Cs?
emotional state venous access baseline CBC volume status intraoperative H&H monitoring availability of type and screen analgesia/antiemetics/ uterine relaxation positioning/lithotomy
What is a dilation and evacuation?
performed in 2nd trimester (between 12-24 weeks of pregnancy)
miscarriage or elective pregnancy termination
What is required with dilation and evacuation?
vacuum aspirate and forceps
Purpose of uterotonic medications?
acts directly on uterine smooth muscle
increase tone, rate and strength of rhythmic contractiosn
Oxytocin (Pitocin)
naturally secreted hormone
secreted by the pituitary
uterotonic (stimulates uterine contractions, labor onset-> postpartum)
What are benefits/uses for oxytocin/ uterotonic medications?
prevent/treat postpartum hemorhage (PPH)
ripen the cervix and induce labor
manage incomplete or elective abortion
Hemabate
carboprost tromethamine
prostaglandin F2a
What is the dose and route of hemabate?
250mcg IM
intramuscular injection only
What is hemabate used for?
elective abortions
When should hemabate be avoided?
asthmatics
Cervidil (dinoprostone)
prepidil
prostin E2
vaginal insert naturally occurring biomolecule (PGE2) stimulates PGF-2a= sensitized myometrium to oxytocin cervical ripening 10mg/insert
What is the route of oxytocin?
IM
What is the route of misoprostol?
PO
What is the route of ergometrine?
IM
What is the route of syntometrine?
IM
What is the onset of action of oxytocin?
2-3 minutes
What is the onset of action of misoprostol?
3-5 minutes
What is the onset of action of ergometrine?
6-7 minutes
What is the onset of action of syntometrine?
2-3 minutes
What is the DOA of oxytocin?
15-30 minutes
What is the DOA of misoprostol?
75 minutes (peak 8-34)
What is the DOA of of ergometrine?
120-240
What is the DOA of syntometrine?
120-240
What are the side effects of oxytocin?
minimal
NV, cardiac arrhythmias, anaphylaxis
What are the side effects of misoprostol?
shivering, diarrhea, transient temperature >38
What are the side effects of ergometrine?
increased BP (vasoconstriction) headache dizziness n/v tinnitus rash
What are the side effects of syntometrine?
N/V headache dizziness hypertension arrhythmia rash
What is conization of the cervix?
excision of a cylindrical (cone-shaped) wedge from the cervix
What are indications for conization of the cervix?
definitive diagnosis of squamous or glandular intraepithelial lesions
excluding microinvasive carcinomas
conservative treatment of cervical intra-epithelial neoplasia (CIN)
What are methods for conization of the cervix?
scalpel (cold-knife)
laser (excision or vaporization)
electrosurgical excision loop (LEEP)
large loop excision of the transformation zone (LLETZ)
combination (laser and completed with a cold-knife)
What is hysteroscopy?
visualization inside uterus to diagnosis or treat uterine problems
What are indications for hysteroscopy?
abnormal uterine bleeding, fibroids, polyps, cancer, biopsies, remove adhesions, sterilizations, locate intrauterine device
Describe the surgical procedure of a hysteroscopy?
empty bladder (in and out catheter)
speculum into the vagina
hysterscope advanced to vagina, cervix & into the uterus
project image onto a screen
gas (CO2) or fluids (NS or LR) expands uterus
What are the risks of a hysterectomy?
uterine or cervical puncture/perforation, bleeding, infection, hypervolumia, hyponatremic encephalopathy/cardiac asystole, arrhythmia, hypercarbia/acidosis, gas embolism
What is endometrial ablation?
destroys the endometrium (thinning of uterus)
what is the purpose of endometrial ablation?
treats heavy bleeding when medications are unsuccessful
stops or reduces menstrual flow
who is endometrial ablation not perform on?
post menopasual women
When is endometrial ablation not advised?
thin endometrium endometrial hyperplasia uterine cancer recent pregnancy current or recent uterine infection
what is the surgical time of endometrial ablation?
30-60 minutes
What are the risks of endometrial ablation?
bleeding
infection
uterine or bowel perforation
internal burns
What is a colposcopy?
views the cervix using colposcope magnified 2-60x
what is a colposcope used to assess?
cervitis uterine polyps pain bleeding cervical warts
What is tubal ligation?
fallopian tubes pulled through navel, cut and closed (sutures, bands or clips)
What is the surgical time for tubual ligation?
30 minutes
What anesthesia can be performed for tubal ligation?
epidural spinal combined spinal/epidural GA or IV sedation with local sedation
When can a tubal ligation be performed?
post cesarean section w/o extending hospital stay
Risk of tubal ligation
bleeding, infection
What is endometriosis?
endometrial growth outside uterus (ovaries, bowel, bladder, rectum, pelvic wall)
responds to hormonal changes
retrograde menstruation with suspected immune system explanation
What does endometriosis cause?
pain
irregular bleeding
adhesion
possibly infertility
Treatment options for endometriosis
hormone therapy
surgical therapy
what are surgical therapies for endometriosis?
diagnostic laparoscopy
excision of endometrial tissue
hysterectomy
lapartomy
What is an ectopic pregnacy?
fertilized egg attached outside of uterus (most commonly in fallopian tubes)
What is the second leading cause of mortality ?
causing 15% of maternal deaths
symptoms of ectopic pregnancy?
vaginal bleeding pelvic pain dizziness fainting weakness shoulder pain (rupture)
What does a ruptured ectopic pregnancy require?
life threatening
internal bleeding
salpingectomy
What medication is used for surgical excision of ectopic pregnancy?
methotrexate
What is a hysterectomy?
surgical removal of the uterus
What is the second most common major surgery among women of childbearing age?
hysterectomy
A hysterectomy is a treatment for
uterine fibroids uterine prolapse endometriosis abnormal uterine bleeding chronic pelvic pain cancer
What are the three types of hysterectomy?
total laparoscopic hysterectomy
laparoscopically assisted vaginal hysterectomy
robotic assisted laparoscopic hysterectomy
What is total laparoscopic hysterectomy
uterus detached, removed in pieces through incisions or passed through the vagina
What is laparoscopically assisted vaginal hysterectomy?
vaginal hysterectomy with laparoscopic assistance laparoscopic visualization & removal organs removed through vagina
What is laparoscopic hysterectomy?
abdominal insufflation and use of laparoscope to visualize pelvic organs
What are the advantages of laparoscopic hysterectomy?
smaller incisions less pain shorter hospital stays shorter recovery less risk of infection and other postoperative complications
What are the disadvantages of laparoscopic hysterectomy?
increase surgical time
increase risk for bladder injury
risk associated with pneumoperitonieum
What is a radical hysterectomy?
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 for a radical hysterectomy
3-4 hours
Where is the incision for a radical hysterectomy?
midline or lower transverse
What is the EBL for a radical hysterectomy?
1500ml
What are the post-operative considerations for hysterectomy?
earlier risk for osteoporosis than menopausal women
positioning considerations
treated with estrogen therapy
What does an oophorectomy affect?
caused by lack of estrogen
hot flashes
vaginal dryness
sleep problems
What are preoperative treatments for myomectomy?
multivitamins, iron supplements, gonadotropin releasing hormone agonist, oral contraeceptives
What are anesthetic considerations for myomectomy?
type and crossmatch
intraoperative hemoglobin/hematocrit monitoring
IV fluid & blanket warming equipment
third space fluid loss (open approach)
surgical approach determined by type of fibroids
general or regional
prophylactic antithrombotic therapy
What is a second look laparotomy?
diagnostic
most accurate method of assessing disease status in ovarian cancer
What does second look laparotomy evaluate?
effectiveness of treatment
size of tumor after treatmetnt
recurrence of tumor
What are anesthetic considerations for radical vulvectomy?
chemotherapeutics bowel preparation general, spinal, epidural anesthesia pca or epidural for postop pain management foley catheter
What is modified dorsal lithotomy?
legs extended hips abducted 30 extended 5-10 knees flexed 90 potential for nerve injury
What is the indication for pelvic exenteration or evisceration
advanced or recurrent pelvic cancer
What is the morbidity or mortality of pelvic exenteration?
3-5% death intraoperatively, 5 year survival
What is included with pelvic exenteration?
radical hysterectomy, total vaginectomy, bladder excision (urostomy), urinary diversion, bowel resection + colostomy (anterior=bladder removed; posterior= rectum removed)
neovagina construction
Surgical risks of pelvic exenteration
hemorrhage (internal & common iliac arteries), sepsis, wound dehiscence, anastomotic breakdown at bowel, urinary pouch, or ureteral sites, DVT PE stoma necrosis or reconstructive flap necrosis
increased incidence of renal disease postoperatively due to urinary tract infections and obstruction
late complications of pelvic exenteration
fistula, bowel obstruction, ureteral stricture, renal failure, pyelonephritis, and chronic bowel obstructions
Lithotomy positioning considerations
patient supine, legs flexed/abducted, feet at or above hip level
across perineum (table edge)
prolonged lithotomy position associated wiht compartment syndrome
femoral or peroneal nerve injury
autotransfusion- transient hemodynamic changes
caution with PVD patients
simultaneously lift legs adn hip flex to avoid dislocation
Combined lithotomy and trendelenburg considerations
CVP PAP increased CO decreased
caution with CAD patients
