Maternal co-exisiting disease Flashcards
Anesthesthetic considerations for pregnant women with hyperthyroidism:
May be receiving propranolol
-Fetal goiter may occur
-myocardium more sensitive to catecholamines
-Propranolol may exacerbate HoTN following spinal anesthetic block - consider epidural for elective c-section
What is pheochromocytoma?
Neuroendocrine tumorof themedullaof theadrenal glands, or extra-adrenal chromaffin tissue that failed to involutethat secretes excessive catecholamines – norepinephrine and epinephrine.
What can pheochromocytoma mimic?
preeclampsia
what type of analgesia plan is preferred in someone with pheochromocytoma?
continuous epidural
What kind of treatment should someone with pheochromocytoma receive for an elective c-section?
-pre-op therapy with alpha-blockers, followed by beta blockers.
Avoid beta-blockade without prior alpha blockade d/t the risks of unopposed alpha stimulation (severe HTN)
What would the treatments for bronchial asthma during pregnancy be?
Methylxanthines
corticosteroids
Beta-adrenergics
May improve during pregnancy d/t bronchodilation
Pregnancy has no consistent effects of the course of asthma
What are the anesthetic considerations for someone who has asthma while pregnancy?
C-section:
-EPIDURAL preferred over spinal block (reports of bronchoconstriction)
Avoid general anesthesia if possible (ETT can trigger bronchospasm)
-Avoid H2 blockers (cimetidine, ranitidine) can increase sensitivity to histamine that causes spasm
-consider atropine of glycopyrrolate to decrease secretions
-use ketamine for induction= bronchial relaxation
-Avoid the use of desflurane
How can paraplegia affect labor?
Higher incidence of preterm labor
if the lesion is at what level should you consider autonomic hyperreflexia?
above T7
What are some signs and symptoms of autonomic hyperreflexia?
pilomotor erection, sweating, flushing, headache, severe HTN, BRADYCARDIA
Triggered by:
Stimulation of the skin, distension of the bladder/uterus
Is an epidural or a spinal preferred for someone with paraplegia?
Epidural
What drug should be avoided for induction in paraplegia?
Succinylcholine d/t risk of hyperkalemia
What is Multiple sclerosis?
Manifests as neurological defects that present as pyramidal cerebellar or brainstem symptoms
(Loss of myelin in CNS after possible viral exposure or autoimmune response)
What are some symptoms of MS?
-Motor weakness
-impaired vision
-ataxia
-bladder and bowel dysfunction
-labile emotions
How does pregnancy affect MS?
No effects on the progression of MS
-slight increased risk of relapse during pregnancy (most often in the postpartum period though)
-watch for pulm complications
-maintain normal body temp
What are some concerns about neuraxial anesthesia in the MS pt?
-potential neurotoxic exposure of demyelinated spinal cord.
-Do not exceed concentrations >0.25% bupivacaine infusions
(use lowest concentrations and volumes to achieve analgesia)
- Epidural tolerated better than spinal
What med should be avoided during induction for MS?
Succinylcholine should be avoided w severe musculoskeletal involvement
What is the main concern with someone who has a brain tumor?
Herniation and death following rapid CSF reduction w dural puncture.
What is myasthenia gravis?
Rare autoimmune disorder
-progressive muscle weakness
- destruction of ACTH receptors
-treat w anticholinergics (neostigmine or edrophonium)
-pregnancy can exacerbate symptoms = cholinergic crisis
What antibiotics are contraindicated in Myasthenia Gravis?
-Gentamycin
-Kanamycin
-Streptomycin
-Polymyxin
-Tetracycline
-Lincomycin
What tocolytics are contraindicated in myasthenia gravis?
Magnesium sulfate
What cardiac meds are contraindicated in myasthenia gravis?
-Quinidine
-Propranolol
What Beta Adrenergics are contraindicated in myasthenia gravis?
-Ritodrine
-Terbutaline
What other drugs are contraindicated in myasthenia gravis
quinine
penicillamine
lithium
IV to oral dose of neostigmine ratio
30:1
What meds are pts w myasthenia gravis highly sensitive to?
depolarizing and non-depolarizing NMB
-Intubation doses or usually 1/2-1/3 normal
What are signs and symptoms of cholinergic crisis?
-Profound muscle weakness
-resp failure
-loss of bowel and bladder function
-disorientation
-diplopia
What is the treatment for cholinergic crises?
IV/IM atropine
What is sickle cell disease?
Autosomal recessive genetic blood disorder (mutation of hemoglobin gene)
-Affects African Americans more
-RBCs assume an abnormal rigid sickle shape decreasing the cells flexibility and increasing viscosity leading to pain, thrombosis and auto amputation
- Life expectancy shortened (Males: 42, females: 48)
How does sickle cell affect pregnancy?
HgbAS pts (heterozygous) usually have no problems w pregnancy
HgBSS (homozygous) and HgbSC have more severe anemia and higher incidence of preeclampsia
Avoid sickle cell crisis: avoid hypoxia, HoTN, dehydration, hypothermia, and acidosis.
Don’t use a tourniquet.
Anesthetic considerations for sickle cell disease
Epidural (give WARMED fluids prior to block)
avoid hypothermia and hypoxia
Why is an epidural preferred for a C-section?
decreased risk of hypotension- can be used post-op if pt has sickle cell crisis
What is von Willebrand disease?
The most common hereditary coagulation abnormality.
Qualitative or quantitative deficiency of von Willebrand factor (vWF), a multimeric protein that is required for platelet adhesion
What is the treatment for type 1 von Willebrand’s disease?
DDAVP 0.3 mg/kg
-Monitor vWF levels (possible tachyphylaxis > 48 hrs)
In what type of vWF deficiency should DDAVP NOT be used?
type 3- can worsen bleeding
(neuraxial block is a relative contraindication too)
What is Factor V Leiden?
Variant of human coagulation factor V that cannot be inactivated by protein C and thereby causes a HYPERCOAGUALBILITY disorder
What is a patient typically on if they have Factor V disorder in pregnancy?
LMWH (lovenox) very early in pregnancy–> converted to heparin at 38 weeks to facilitate neuraxial blocks
How long should LMWH be held before a block?
Prophylactic : hold >12 hrs before block
Therapeutic: hold > 24hrs before block and consider anti-Xa heparin assay
What is Protein C and Protein S?
Hepatic enzymes that interact with coagulation factors Va (5a), VIIIa (8a) to inhibit fibrin formation= clot
Deficiency of C & S = HYPERcoagulability, recurrent DVT, PE
Hypercoagulability also seen with phospholipid and cardiolipin antibodies
Pts may be on heparin= careful assessment before block
What is Rheumatoid Arthritis?
-Chronic, systemic inflammatory disorder that principally affects synovial joints
-Hyperplasia of synovial cells = excess synovial fluids
- the destruction of articular cartilage= inflammation in lungs, pericardium, pleura, sclera, and subcutaneous nodular lesions
Anesthetic considerations for those who have rheumatoid arthritis:
- Alanto-axial instability= potentially difficult airway
- difficult block placement
-possible pleura effusions
–motor and sensory deficits
-cardiac issues ( pericarditis, valvulitis, fibrosis, atherosclerosis, increased risk of CAD, MI, stroke, angina)
What is Systemic Lupus erythematosus?
Multisystem inflammatory disease of unknown etiology that is characterized by the production of autoantibodies against cell membrane antigens
- most common in women in childbearing years
What are the cardiac considerations of Lupus?
-Pericarditis (check EKG for prolonged PR interval or non-specific T-wave changes
-Valvular disorders (thickening, vegetation, regurg, stenosis)
- prophylactic antibiotics are only required if pt has high risk for endocarditis
Why do you want to make sure you do a complete airway evaluation before GA in a pt with Lupus?
Vocal cord palsy
What are the anesthetic considerations for maternal addiction?
-difficult IV access
-withdrawal symptoms
-fetal withdrawal, hyperactivity, hypoxia
-increase O2 consumption
-increased low birth weight/ very low birth weight
-increased maternal hypovolemia
- adrenal insufficiency
Increased risk of an alcoholic:
Inc. risk of hemorrhage d/t esophageal varices, clotting abnormalities d/t hepatic disease, cardiomyopathy, neuropathy, inc. gastric volume, acidity.
Amphetamines:
Limited response to ephedrine
- INCREASED MAC
- increased risk for uterine atony
Cocaine:
vasoconstrictor= decreased uteroplacental blood flow
- HTN, tachycardia
- chronic= decreased MAC
-Acute= Increased MAC
What drugs can cocaine increase the duration of?
2-chloroprocaine
Succinylcholine
