Non-Obstetric Surgery During Pregnancy Flashcards
fetal heart tones expected during regional anesthesia for a nonobstetric procedure
should have no change in variability
is electroconvulsive therapy (ECT) needed in preg ladies?
“withholding treatment for any disease is rarely justified”
what medications are suspicious of teratogenic effects?
- nitrous
- benzos
- also zofran apparently
most common reason for a nonobsetric surgery during pregnancy
— careful this one is kinda tricky!
lololol trauma or emergency
examples:
- trauma
- orarian cyst
- appendectomy
- cholecystectomy
- breast (??)
- cervical incompetence
- craniotomy
- CPB
- liver transplant
current concerns with use of nitrous, ketamine, benzos, and other GABAa agonists use during pregnancy revolve around what issues?
current stance on said issues?
***book
- apoptotic neurodegeneration and neurotoxicity/learning impairment
- currently not enough information to change our clinical practice for these agents
what can be seen in FHR when giving maternal pain meds?
decrease of beat-to-beat variability
what is the leading cause of maternal death
trauma
anesthetic management for a nonobstetric procedure focuses on what 3 things?
- maternal physiology
- maintenance of fetal oxygenation
- prevention of preterm labor
if parturient needs cardiac surgery requiring CPB, when is the most optimal time?
after the 1st trimester
“if possible, delay until 2nd trimester”
what is the most common time of concern for cardiac decompensation after the baby is delivered?
why?
- immediate postpartum
- the release of aortocaval compression and autotransfusion of uteroplacental blood increases cardiac output to its maximum (***book)
what are the main causes of fetal death from maternal trauma?
- hemodynamic instability
- abruption (assuming this means placental abruption?)
- maternal death
what are the differences when performing CPR on pregnant lady?
- left uterine displacement
- hands 1-2 cm higher on sternum during compressions
- perimortem c-section delivery if ROSC not established in 5 minutes
if normotensive, what type of anesthesia maintenance should be done?
no preference between regional and GA
— ***book - no difference as long as maternal oxygenation and uteroplacental perfusion are maintained
what are some common tocolytics?
- indomethacin
- nifedipine
- mag sulfate
airway/intubation considerations in pregnant ladies
- need full preoxygenation/denitrogenation
- considered full stomach - RSI
- avoid hypoxia
- “difficult airway ??” - assuming bc airway gets edematous? - also narrowed glottic opening
what are two common indications for an open mid-gestation fetal surgery?
- myelomeningocele
- intrathoracic lesion presenting with hydrops (severe fetal edema)
what is the most minimal method that should be done to check for pre-op pregnancy?
what is usually done, but is controversial?
- minimum: date of last menstrual period
- UPT is most often done but for some ungodly reason mandatory UPTs are “controversial”
anesthetic implications of nifedipine
contributes to hypotension
T/F: no anesthetic medications have been shown to have any teratogenic effects in humans at any gestational age
***book
true
imaging considerations for preg ladies
- do not avoid diagnostic tests
- shield fetus if possible
- ultrasound and MRI don’t use ionizing radiation - safe for babe
- head CT is no risk to babe
what type of monitoring is needed intra-op
- standard maternal monitoring
- intermittent or continuous FHR monitoring if possible
what additional causes for cardiac arrest are seen with pregnancy?
- amniotic fluid embolism
- eclampsia
- placental abruption
- hemorrhage
anesthetic considerations during and after EXIT procedure?
*EXIT procedure is when baby partially delivered, paralyzed, surgery done while still connected to mom, after surgery done baby completely delivered
- 2-3 MAC needed during procedure for uterine relaxation
- securing airway is the first step - done via direct laryngoscopy (***book)
- MAC decreased after procedure complete to increase uterine tone
- cord clamped and baby delivered
T/F: intra-op FHR monitoring is shown to improve fetal outcomes
false
during nonobstetric procedures, MAC should be kept less than what to prevent decreased maternal cardiac output?
***book
keep MAC < 2
delivery considerations for a woman who has had a fetal procedure?
why?
*applies to both EXIT and open mid-gestation
- c-section delivery is necessary for current pregnancy and all future pregnancies
- c-section must be performed prior to onset of labor
- indicated due to the increased risk of uterine rupture
which type of fetal interventional procedure requires aggressive tocolysis - EXIT or open mid-gestation?
open mid-gestation
what are key peri-op goals for nonobstetric procedures? (4)
***book
- maternal oxygenation
- maternal perfusion
- optimal pain control
- early mobilization
what are the two ABSOLUTE avoid at all cost intra-op concerns?
***book
- maternal hypoxia
- maternal hypotension
what is the “central principle” of the EXIT procedure?
***book
achieve controlled uterine hypotonia to preserve the uteroplacental circulation
at what point is continuous fetal monitoring indicated with a maternal trauma?
> 23 weeks
if mom is on CPB, what gestation is it important to monitor fetus and maintain uterine displacement to optimize fetal perfusion?
what is another method that has been seen to optimize fetal perfusion?
- > 24 weeks
- high pump flows can be beneficial (per animal studies)
what is the main advantage of using regional anesthetic technique vs GA in nonobstetric procedure?
other advantages? (***book)
minimizes drug exposure
- **book
- excellent post-op pain control
- reduces maternal sedation - can report symptoms of preterm labor
- FHR variability maintained
- allows early mobility - helps prevent VTEs
if parturient undergoes GA, what should be their goal ETCO2?
***book
- ~ 30 mmHg
- PO2 decreased ~ 10 mmHg during pregnancy due to increased minute ventilation - we need to keep them here
what are the differences between anesthetic management for <24 weeks and >24 weeks
> 24 weeks
- consider prophylactic tocolytics
- uterine displacement needed
- monitor continuous fetal heart tones if possible (in addition to pre and post procedure)
what are the indications for an emergent c-section in the setting of an acute trauma? (4)
- stable mom, fetus in distress
- uterine rupture
- gravid uterus interfering with maternal abdominal repairs
- viable fetus, nonviable mom
dosing considerations for regional anesthesia for a nonobstetric procedure
decrease neuraxial dose by 1/3
how is MAC affected during pregnancy?
MAC is decreased 20-40%
what interventions need to be done in the presence of intra-op decelerations?
- increase maternal oxygenation
- increase maternal BP
- increase uterine displacement
- adjust surgical retraction
- begin tocolytics
what precautionary things should be done during laparoscopic procedures? - aside from abd pressure things
- maintain left uterine displacement
- compression stockings to prevent DVT
- ***book - open trocar placement
how should muscle relaxant REVERSAL AGENTS be administered to preg ladies?
why?
** her ppt says just muscle relaxants but in the book, its reversal agents not the NMB **
- administer slowly
- to prevent acute increases in acetylcholine - which can cause uterine “hypertonus” - means that it can induce contractions
anesthetic implications of mag sulfate
- potentiates NDNMBs
- attenuates vascular responsiveness – decreases vascular responsiveness to catecholamines and vasopressors
evolving ethical concerns over fetal intervention procedures
maternal safety vs. risk to mother/fetus vs. benefits to fetus
ok what
fetal outcomes in laparotomy vs laparoscopy
similar
k cool - blue. bye!
what can be seen with the FHR when mom on CBP?
- fetal bradycardia common when going bypass
- fetal HR slowly returns to a low/normal rate with little to no beat-to-beat variability
what is the most difficult problem to overcome perioperatively in a nonobstetric procedure?
***book
preterm labor
– it is also the most common cause of fetal loss, but duh.
anesthetic implications of indomethacin
few anesthetic implications
—- what are the few? truly who knows.
what can occur in the first trimester with high doses of ketamine?
- > 2 mg/kg
can cause uterine hypertonus
with regard to FHR and GA or MAC, what is expected and what is abnormal?
- expected - loss of beat to beat variability
- abnormal - fetal bradycardia
up to 1 out of ___ parturients will require surgery during their pregnancy (nonobstetric procedure)
1 out of 50
so 2% of parturients will have surgery during pregnancy
effects of CO2 pneumoperitoneum on fetus
- no hypoxia
- no significant hemodynamic changes
- DOES cause fetal respiratory acidosis
what is most important for CRNAs to educate preg patients on during peri-op counseling?
***book
- symptoms of preterm labor
- need for uterine displacement at all times after 24 weeks
~ smells like an OB job to me
what has been successful in patients close to term who need a valve replacement?
combined c-section and valve replacement surgery
when is cardiac decompensation most likely in patients with stenotic vascular lesions or PHTN?
why?
- 28-30 weeks
- physiologic increase in blood volume and cardiac output is max at this time - can cause the decompensation
what is the difference in an EXIT procedure and an open mid-gestation procedure?
baby is returned to uterus after mid-gestation procedure and is delivered after EXIT procedure
if planning anesthetic management for nonobstetric surgery, is a pre-op anxiolytic or pain med appropriate?
why or why not?
***book
- yes
- elevated catecholamines due to anxiety or pain can decrease uterine blood flow
does CO2 insufflation during laparoscopic procedure cause fetal respiratory acidosis?
yep
what 4 maternal physiologic systems are we the most concerned with for anesthetic management?
- respiratory
- CV
- GI
- CNS
when is cardioversion considered safe/unsafe in pregnancy?
considered safe in all stages of pregnancy
considerations for a neurosurgical procedure in a pregnant patient?
- fetal monitoring
- caution with aggressive diuresis - reduces uterine perfusion if maternal cardiac output impaired
which physiologic changes of pregnancy are most relevant to the anesthesia provider?
***book
- decreased FRC
- aortocaval compression if supine
- decresed LES tone
- reduced anesthetic requirement
also says difficult intubation is more common but doesn’t list as most relevant concerns
post-op care for nonobstetric procedure (7)
- continue monitoring fetal heart tones and uterine activity
- treat preterm labor early and aggressively
- send to L&D unit or have L&D nurse in recovery
- high risk for embolus - should ambulate as early as possible
- maintain oxygenation and uterine displacement
- pain meds decrease variability
- neonatology consult if > 23 weeks
goal for intra-abd pressures if pregnant
keep pressures as low as possible and as short as possible
best management for a nonobstetric procedure for <24 weeks gestation
- postpone if possible
- pre-op assessment by OB
- counsel pre-operatively on potential risks (or lack of)
- give non particulate antacid - bicitra
- maintain normal O2, CO2, BP, glucose
- use regional technique when appropriate
- document fetal heart tones before and after procedure
consideration during laparoscopic gallbladder procedure when pregnant
shield fetus during cholangiograms (x-ray of bile duct)
considerations for maternal cardioversion
- careful FHR monitoring is required
- left uterine displacement
- consider sedation vs GETA due to aspiration risk
- administer non-particulate antacid - bicitra
- consider administering H2 antagonist
what type of disease is a significant cause of maternal morbidity and mortality?
**brand new info
psychiatric disease
is preterm labor usually influenced by anesthetic management?
***book
- usually NOT
- preterm labor usually a result of the underlying disease and the surgery itself
advances in fetal intervention procedures have allowed for what type of anesthesia management?
more of these procedures now done with LA or with neuraxial & sedation
*depends on case and surgical technique
what adverse outcome is sometimes seen after fetal surgeries?
uterine rupture
if patient must have surgery while pregnant, what is the most optimal time for the procedure?
why?
***book
- 2nd trimester
- less risk of teratogenicity and spontaneous miscarriage (1st trimester)
- less risk of preterm labor (3rd trimester)
what methods are best to use during regional anesthesia for nonobstetric procedures to prevent hypotension?
- adequate volume
- ephedrine or phenylephrine
delivery considerations for a woman who has had a fetal procedure?
why?
*applies to both EXIT and open mid-gestation
- c-section delivery is necessary for current pregnancy and all future pregnancies
- c-section must be performed prior to onset of labor
- indicated due to the increased risk of uterine rupture
