Anesthesia for Gynecological Surgery Flashcards
1
Q
What is a dilation and curettage?
A
dilate cervix and curettage (scrape walls of) uterus typically to remove, often vacuum aspirate, products of conception (1st trimester), cysts or tumors
2
Q
What are anesthetic considerations for D&Cs?
A
emotional state venous access baseline CBC volume status intraoperative H&H monitoring availability of type and screen analgesia/antiemetics/ uterine relaxation positioning/lithotomy
3
Q
What is a dilation and evacuation?
A
performed in 2nd trimester (between 12-24 weeks of pregnancy)
miscarriage or elective pregnancy termination
4
Q
What is required with dilation and evacuation?
A
vacuum aspirate and forceps
5
Q
Purpose of uterotonic medications?
A
acts directly on uterine smooth muscle
increase tone, rate and strength of rhythmic contractiosn
6
Q
Oxytocin (Pitocin)
A
naturally secreted hormone
secreted by the pituitary
uterotonic (stimulates uterine contractions, labor onset-> postpartum)
7
Q
What are benefits/uses for oxytocin/ uterotonic medications?
A
prevent/treat postpartum hemorhage (PPH)
ripen the cervix and induce labor
manage incomplete or elective abortion
8
Q
Hemabate
A
carboprost tromethamine
prostaglandin F2a
9
Q
What is the dose and route of hemabate?
A
250mcg IM
intramuscular injection only
10
Q
What is hemabate used for?
A
elective abortions
11
Q
When should hemabate be avoided?
A
asthmatics
12
Q
Cervidil (dinoprostone)
prepidil
prostin E2
A
vaginal insert naturally occurring biomolecule (PGE2) stimulates PGF-2a= sensitized myometrium to oxytocin cervical ripening 10mg/insert
13
Q
What is the route of oxytocin?
A
IM
14
Q
What is the route of misoprostol?
A
PO
15
Q
What is the route of ergometrine?
A
IM
16
Q
What is the route of syntometrine?
A
IM
17
Q
What is the onset of action of oxytocin?
A
2-3 minutes
18
Q
What is the onset of action of misoprostol?
A
3-5 minutes
19
Q
What is the onset of action of ergometrine?
A
6-7 minutes
20
Q
What is the onset of action of syntometrine?
A
2-3 minutes
21
Q
What is the DOA of oxytocin?
A
15-30 minutes
22
Q
What is the DOA of misoprostol?
A
75 minutes (peak 8-34)
23
Q
What is the DOA of of ergometrine?
A
120-240
24
Q
What is the DOA of syntometrine?
A
120-240
25
What are the side effects of oxytocin?
minimal
| NV, cardiac arrhythmias, anaphylaxis
26
What are the side effects of misoprostol?
shivering, diarrhea, transient temperature >38
27
What are the side effects of ergometrine?
```
increased BP (vasoconstriction)
headache
dizziness
n/v
tinnitus
rash
```
28
What are the side effects of syntometrine?
```
N/V
headache
dizziness
hypertension
arrhythmia
rash
```
29
What is conization of the cervix?
excision of a cylindrical (cone-shaped) wedge from the cervix
30
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)
31
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)
32
What is hysteroscopy?
visualization inside uterus to diagnosis or treat uterine problems
33
What are indications for hysteroscopy?
abnormal uterine bleeding, fibroids, polyps, cancer, biopsies, remove adhesions, sterilizations, locate intrauterine device
34
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
35
What are the risks of a hysterectomy?
uterine or cervical puncture/perforation, bleeding, infection, hypervolumia, hyponatremic encephalopathy/cardiac asystole, arrhythmia, hypercarbia/acidosis, gas embolism
36
What is endometrial ablation?
destroys the endometrium (thinning of uterus)
37
what is the purpose of endometrial ablation?
treats heavy bleeding when medications are unsuccessful
| stops or reduces menstrual flow
38
who is endometrial ablation not perform on?
post menopasual women
39
When is endometrial ablation not advised?
```
thin endometrium
endometrial hyperplasia
uterine cancer
recent pregnancy
current or recent uterine infection
```
40
what is the surgical time of endometrial ablation?
30-60 minutes
41
What are the risks of endometrial ablation?
bleeding
infection
uterine or bowel perforation
internal burns
42
What is a colposcopy?
views the cervix using colposcope magnified 2-60x
43
what is a colposcope used to assess?
```
cervitis
uterine polyps
pain
bleeding
cervical warts
```
44
What is tubal ligation?
fallopian tubes pulled through navel, cut and closed (sutures, bands or clips)
45
What is the surgical time for tubual ligation?
30 minutes
46
What anesthesia can be performed for tubal ligation?
```
epidural
spinal
combined spinal/epidural
GA
or IV sedation with local sedation
```
47
When can a tubal ligation be performed?
post cesarean section w/o extending hospital stay
48
Risk of tubal ligation
bleeding, infection
49
What is endometriosis?
endometrial growth outside uterus (ovaries, bowel, bladder, rectum, pelvic wall)
responds to hormonal changes
retrograde menstruation with suspected immune system explanation
50
What does endometriosis cause?
pain
irregular bleeding
adhesion
possibly infertility
51
Treatment options for endometriosis
hormone therapy
| surgical therapy
52
what are surgical therapies for endometriosis?
diagnostic laparoscopy
excision of endometrial tissue
hysterectomy
lapartomy
53
What is an ectopic pregnacy?
fertilized egg attached outside of uterus (most commonly in fallopian tubes)
54
What is the second leading cause of mortality ?
causing 15% of maternal deaths
55
symptoms of ectopic pregnancy?
```
vaginal bleeding
pelvic pain
dizziness
fainting
weakness
shoulder pain (rupture)
```
56
What does a ruptured ectopic pregnancy require?
life threatening
internal bleeding
salpingectomy
57
What medication is used for surgical excision of ectopic pregnancy?
methotrexate
58
What is a hysterectomy?
surgical removal of the uterus
59
What is the second most common major surgery among women of childbearing age?
hysterectomy
60
A hysterectomy is a treatment for
```
uterine fibroids
uterine prolapse
endometriosis
abnormal uterine bleeding
chronic pelvic pain
cancer
```
61
What are the three types of hysterectomy?
total laparoscopic hysterectomy
laparoscopically assisted vaginal hysterectomy
robotic assisted laparoscopic hysterectomy
62
What is total laparoscopic hysterectomy
uterus detached, removed in pieces through incisions or passed through the vagina
63
What is laparoscopically assisted vaginal hysterectomy?
vaginal hysterectomy with laparoscopic assistance laparoscopic visualization & removal organs removed through vagina
64
What is laparoscopic hysterectomy?
abdominal insufflation and use of laparoscope to visualize pelvic organs
65
What are the advantages of laparoscopic hysterectomy?
```
smaller incisions
less pain
shorter hospital stays
shorter recovery
less risk of infection and other postoperative complications
```
66
What are the disadvantages of laparoscopic hysterectomy?
increase surgical time
increase risk for bladder injury
risk associated with pneumoperitonieum
67
What is a radical hysterectomy?
removes uterus, cervix, ovaries, fallopian tubes, upper vagina, parametrium, pelvic lymph nodes
68
Indications for a radical hysterectomy
uterine, cervical or ovarian cancer
endometriosis
fibroids
pelvic relaxation syndrome
69
Surgical time for a radical hysterectomy
3-4 hours
70
Where is the incision for a radical hysterectomy?
midline or lower transverse
71
What is the EBL for a radical hysterectomy?
1500ml
72
What are the post-operative considerations for hysterectomy?
earlier risk for osteoporosis than menopausal women
positioning considerations
treated with estrogen therapy
73
What does an oophorectomy affect?
caused by lack of estrogen
hot flashes
vaginal dryness
sleep problems
74
What are preoperative treatments for myomectomy?
multivitamins, iron supplements, gonadotropin releasing hormone agonist, oral contraeceptives
75
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
76
What is a second look laparotomy?
diagnostic
| most accurate method of assessing disease status in ovarian cancer
77
What does second look laparotomy evaluate?
effectiveness of treatment
size of tumor after treatmetnt
recurrence of tumor
78
What are anesthetic considerations for radical vulvectomy?
```
chemotherapeutics
bowel preparation
general, spinal, epidural anesthesia
pca or epidural for postop pain management
foley catheter
```
79
What is modified dorsal lithotomy?
```
legs extended
hips abducted 30
extended 5-10
knees flexed 90
potential for nerve injury
```
80
What is the indication for pelvic exenteration or evisceration
advanced or recurrent pelvic cancer
81
What is the morbidity or mortality of pelvic exenteration?
3-5% death intraoperatively, 5 year survival
82
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
83
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
84
late complications of pelvic exenteration
fistula, bowel obstruction, ureteral stricture, renal failure, pyelonephritis, and chronic bowel obstructions
85
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
86
Combined lithotomy and trendelenburg considerations
CVP PAP increased CO decreased
| caution with CAD patients
