Mod VII: Anesthesia for Nonlaboring Surgery During Pregnancy Flashcards
Anesthesia for Nonlaboring Surgery During Pregnancy
What’s the incidence of Nonlaboring Surgery During Pregnancy?
0.75% to 2% of parturients
Anesthesia for Nonlaboring Surgery During Pregnancy
What are the most common Nonlaboring Surgeries During Pregnancy?
Acute appendicitis
Cholecystitis
Maternal trauma
Cancer
Anesthesia for Nonlaboring Surgery During Pregnancy
What are Maternal safety anesthetic management goals for Nonlaboring Surgery During Pregnancy?
Consider physiologic changes that begin in 1st trimester
Anesthesia for Nonlaboring Surgery During Pregnancy
What are Fetal safety anesthetic management goals for Nonlaboring Surgery During Pregnancy?
Avoid teratogenic drugs
Maintain uteroplacental blood flow
Prevent preterm labor
Anesthesia for Nonlaboring Surgery During Pregnancy
With regards to Anesthetic Toxicity, all general anesthetics cross the placenta (T/F)?
True
Anesthesia for Nonlaboring Surgery During Pregnancy
With regrad to Anesthetic Toxicity - when is the preferred time to have Anesthesia (if must) for Nonlaboring Surgery During Pregnancy?
2nd trimester is preferred
(it’s recommended to postponed procedure to this point)
Anesthesia for Nonlaboring Surgery During Pregnancy
With regards to Anesthetic Toxicity - Which anesthetic technique is favored for Nonlaboring Surgery During Pregnancy?
Regional anesthesia favored, when capable
Anesthesia for Nonlaboring Surgery During Pregnancy
When is Perioperative Fetal Heart Rate Monitoring practical?
After 18 weeks
(some hospitals will have a policy whereby they dont’s monitor FHR until the fetus is at an age that is compatible with life - usually 20 -23 weeks depending on institutions)
Anesthesia for Nonlaboring Surgery During Pregnancy
T/F: FHR monitoring after 25 weeks is a reliable sign of fetal well-being
True
Anesthesia for Nonlaboring Surgery During Pregnancy - Anesthetic Management
T/F: Advanced airway equipments must be readily available
True
Anesthesia for Nonlaboring Surgery During Pregnancy - Anesthetic Management
T/F: Avoid decreased uterine perfusion and decreased delivery of oxygen to the fetus
True
Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control
What could be done for Postoperative Pain Control if using a Regional technique?
Epidural can be continued
Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control
NSAIDs are avoided as they are associated with:
Fetal malformation
Miscarriage
Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control
T/F: Acetaminophen is generally safe
True
Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control
Opioids will cross placenta and may decrease FHR - what’s the Biggest concern is delivery of fetus immediately after administration of opioid??
Be prepared to support the neonate for respiratory depression
Anesthesia for Nonlaboring Surgery During Pregnancy
What are Important Factors in Maternal Laparoscopic surgery?
Use an open technique to enter the abdomen
Monitor maternal end-tidal PCO2 (4- to 4.6-kPa range) with or without arterial blood gas to avoid fetal hypercarbia and acidosis
Maintain low pneumoperitoneal pressure (1.1 to 1.6 kPa) or use a gasless technique
Limit the extent of Trendelenburg or reverse Trendelenburg position and initiate any position slowly
Monitor fetal heart rate and uterine tone when feasible
(Box 77-5 in Miller’s Anesthesia)
This is important because half of the Nonlaboring Surgeries During Pregnancy are Laparoscopic
Anesthesia for Nonlaboring Surgery During Pregnancy
Nonlaboring procedures directly related to pregnancy that require Anesthesia include:
Ectopic Pregnancy
Fertilized ovum implants outside endometrial lining of uterus
Ruptured ectopic → leading cause of 1st trimester maternal death (massive hemorrhage)
Surgical emergency (laparoscopy or laparotomy)
Volume resuscitation and availability of blood products before induction prudent
Incompetent cervix
Cerclage is placed transvaginally during 1st or 2nd trimester (prophylactically or emergently) with onset of cervical change
Prevents the cervix from dilating prematurely
Regional: ideal (Spinal>epidural)
Abortion/miscarriage
Loss of pregnancy before 20 weeks gestation or at a fetal weight of < 500 gm
•Inevitable abortion: cervical dilation or ROM w/o expulsion of products of conception (POC)
•Complete abortion: spontaneous expulsion of POC
•Incomplete abortion: partial expulsion of POC
•Missed abortion: unrecognized fetal demise
•Dilation & Evacuation:
•Required for missed & incomplete
•MAC, spinal, epidural, or general can be used after assessment of NPO status, volume status, and presence of DIC, sepsis
Postpartum Tubal Ligation (PPTL)
•Most scheduled during immediate postpartum period
•Advantages
•Enlarged uterus → fallopian tubes up out of pelvis Þ mini-laparotomy incision
•2nd hospital visit avoided
•↓ chance of undesired pregnancy while awaiting sterilization
•Disadvantages
•Physiologic changes of pregnancy not fully returned to pre pregnant status (6 weeks)
•Elective procedure with effective alternatives available
Anesthesia for Nonlaboring Surgery During Pregnancy
What’s the leading cause of 1st trimester maternal death?
Ruptured ectopic
→ (massive hemorrhage)
Anesthesia for Nonlaboring Surgery During Pregnancy
The procedure whereby stiches are placed transvaginally during 1st or 2nd trimester (prophylactically or emergently) with onset of cervical change to prevent the cervix from dilating prematurely is known as
Incompetent Cervix Cerclage
Anesthesia for Nonlaboring Surgery During Pregnancy
What’s the preferred anesthetic technique for Imcompetent cervix?
Spinal
Regional: ideal (Spinal>epidural)
Anesthesia for Nonlaboring Surgery During Pregnancy
The Loss of pregnancy before 20 weeks gestation or at a fetal weight of < 500 gm is also known as
Abortion/miscarriage
Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage
The type of abortion a/w cervical dilation or ROM w/o expulsion of products of conception (POC) is known as:
Inevitable abortion
Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage
The type of abortion that is characterized by spontaneous expulsion of products of conception (POC) is known as:
Complete abortion
Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage
The type of abortion that is characterized by partial expulsion of products of conception (POC) is known as:
Incomplete abortion
Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage
The type of abortion that is characterized by unrecognized fetal demise is known as:
Missed abortion
Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage
The procedure required for missed & incomplete Abortion or miscarriage is known as:
Dilation & Evacuation or
Dilation & Curettage
Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage
Which anesthesia techniques could be used for Dilation & Evacuation procedure?
MAC, Spinal, Epidural, or General
can be used after assessment of NPO status, volume status, and presence of DIC, sepsis
Be aware that, although the pt is no longer pregnant, all the physiologic changes a/w pregnancy are still ongoing
Anesthesia for Nonlaboring Surgery During Pregnancy
When are most Postpartum Tubal Ligation (PPTL) scheduled?
Immediate postpartum period
Anesthesia for Nonlaboring Surgery During Pregnancy - Postpartum Tubal Ligation (PPTL)
What are advantages of performing Postpartum Tubal Ligation (PPTL) during the immediate postpartum period?
Enlarged uterus → fallopian tubes up out of pelvis => mini-laparotomy incision
2nd hospital visit avoided
Reduced chance of undesired pregnancy while awaiting sterilization
Anesthesia for Nonlaboring Surgery During Pregnancy - Postpartum Tubal Ligation (PPTL)
What are disadvantages of performing Postpartum Tubal Ligation (PPTL) during the immediate postpartum period?
Physiologic changes of pregnancy not fully returned to pre pregnant status
(this takes 6 weeks for most changes to return to normal)
Elective procedure with effective alternatives available
(pt could use other methods of birth control while they are allowing their body to return to normal)
Anesthesia for Nonlaboring Surgery During Pregnancy
How much time is needed for physiologic changes of pregnancy to return to pre pregnant status?
6 weeks
Anesthesia for Nonlaboring Surgery During Pregnancy
Which procedure and anesthetic technique is recommended for a Postpartum Tubal Ligation (PPTL) for patients who refuse regional anesthesia?
Laparoscopic Bilateral Tubal Ligation (BTL) 6 weeks postpartum under General anesthesia
Anesthesia for Nonlaboring Surgery During Pregnancy
Recommendations for a Postpartum Tubal Ligation (PPTL) patient w/ Functioning labor epidural & mom/baby stable
Keep NPO after delivery
Perform Postpartum Tubal Ligation (PPTL) as soon as personnel available
Anesthesia for Nonlaboring Surgery During Pregnancy
Recommendations for a Postpartum Tubal Ligation (PPTL) patient w/ Nonfunctional epidural
Place another epidural catheter or administer SAB
Anesthesia for Nonlaboring Surgery During Pregnancy
Recommendations for a Postpartum Tubal Ligation (PPTL) patient w/ No epidural
Keep NPO for 8hrs
Then perform a SAB
Anesthesia for Nonlaboring Surgery During Pregnancy
What are recommended Postpartum Tubal Ligation (PPTL) doses of local anesthetic to attain same level of anesthesia compared to pregnant?
Require higher doses of local anesthetic to attain same level of anesthesia compared to pregnant
Anesthesia for Nonlaboring Surgery During Pregnancy
What’s the desired _dermatomal block leve_l for Postpartum Tubal Ligation (PPTL)?
T4-T6
<strong>[for Postpartum Tubal Ligation</strong> (PPTL)]
At least 8 uterine contractions every hour combined with cervical effacement > 75% in a parturient between 20 & 35 weeks of gestation is the definition of:
Premature Labor
Premature Labor
What are Contributive factors to Premature Labor?
Extremes of age
Inadequate prenatal care
Infections
Prior preterm labor
Multiple gestation
Other medical illnesses
Premature Labor
Which drugs are often prescribe to pts experiencing premature labor? why?
Tocolytics
Delay or stop labor until lungs mature and sufficient pulmonary surfactant is produced, as judged by amniocentesis
Premature Labor
What are contraindications to Tocolytics?
Chorioamnionitis
Fetal distress
Intrauterine fetal demise
Severe chronic HTN or pre-eclampsia
Severe hemorrhage
Premature Labor
Common Tocolytics used to stop Premature Labor include:
β2-adrenergic agonist
(Ritodrine, Terbutaline)
MgSO4
Prostaglandin inhibitor
(Indomethacin)
Calcium channel blocker
(Nifedipine)
NOTE: All Tocolytics may increase postpartum hemorrhage
Premature Labor - Tocolytics
Terbutaline is sometimes used off-label (an unapproved use) for acute obstetric uses, including:
Treating preterm labor and
Treating uterine hyperstimulation
Terbutaline has also been used off-label over longer periods of time in an attempt to prevent recurrent preterm labor
Premature Labor - Tocolytics
What’s the MOA of β2-adrenergic agonist (Ritodrine, Terbutaline) when used as Tocolytics?
Terbutaline
Directly relaxes uterine smooth muscle
Premature Labor - Tocolytics
What are the maternal side effects of β2-adrenergic agonist (Ritodrine, Terbutaline) when used as Tocolytics?
Hypotension
Tachycardia
Hyperglycemia
Hypokalemia
Hyperinsulinemia
Metabolic acidosis
Premature Labor - Tocolytics
What are the fetal side effects of β2-adrenergic agonist (Ritodrine, Terbutaline) when used as Tocolytics?
Tachycardia & Hypoglycemia
Premature Labor - Tocolytics
What are serious complications of β2-adrenergic agonist (Ritodrine, Terbutaline) that may develop after 24 hrs of therapy?
PE - MI
Premature Labor - Tocolytics
What are pros and cons of using Prostaglandin inhibitor (Indomethacin) as a Tocolytic?
Pros: Minimal side effects
Cons: Questionable interference with PLT aggregation
Premature Labor - Tocolytics
Calcium channel blocker (Nifedipine) is probably the most benign tocolytic - however, what are serious concerns a/w its use?
Maternal hypotension
Myocardial depression
Premature Labor - Tocolytics
T/F: All Tocolytics may increase postpartum hemorrhage
True
