OB: Non-Obstetric Sx During Pregnancy Flashcards
Up to 1 in ___ parturients will require surgery during their pregnancy
_____/year in the US
50
80,000
Most are urgent or emergent surgeries
Trauma
Ovarian cysts
Appendicectomy
Cholecystectomy
Breast
Cervical incompetence
Craniotomy
CPB
Liver transplantation
Anesthetic Management
Maternal Physiology (4)
Respiratory
Cardiovascular
Gastrointestinal
CNS
Anesthetic Management
Maintenance of ____ _____
Fetal Oxygenation
Anesthetic Management
Prevention of _____ Labor
Preterm
Teratogenicity - what not to give
The usual suspects (2)
Nitrous Oxide
Benzodiazepines
Teratogenicity - what not to give
New issues
Neurotoxicity?
Apoptic neurodegeneration?
Anesthetic Management less than 24 wks gestation
Postpone if possible
Post op assessment by OB
Counsel preoperatively
Nonparticulate antacid
Maintain normal O2, CO2, BP, & Glucose
Regional when appropriate
Document FHT before & after
Anesthetic Management greater than 24 weeks
Postpone if possible
Counsel preoperatively
OB consult, prophylactic tocolytics?
Aspiration prophylaxis
Uterine displacement
Maintain normal O2, CO2, BP, & Glucose
Document FHT before & after, or continuous if feasible
Regional when possible
Tocolysis - PO/PR _____ few anesthesia implications
Indomethacin
Tocolysis - PO _____ contribute to hypotension
Nifidepine
Tocolysis - IV Mag Sulfate potentiates ______ and attenuates ______ responsiveness
nondepolarizers
vascular
Preoperative Pregnancy Testing
Minimum: date of ____
LMP
Preoperative Pregnancy Testing
_____ testing is controversial
mandatory
Intraoperative Management
No preference as to type of anesthesia maintenance, assuming maintenance of _______
normotension
One small study suggested general better than regional of ovarian mass, but not replicated in larger studies
Intraoperative Management
_____ monitoring
standard
Intraoperative Management
____ pre and post at minimum, intraoperatively either continuous or intermittent if it won’t interfere with surgery
FHT
Intraoperative Management
Loss of beat-to-beat is _____ (General or MAC), but not fetal ______
expected
bradycardia
Intraoperative Management
Decelerations: increase maternal _____, increase maternal ___, increase uterine _____, adjust surgical ______, begin tocolysis
oxygenation
BP
displacement
retraction
Intraoperative Management
Monitoring ____ ____ to improve fetal outcomes
hasn’t shown
General Anesthesia implications (7)
Full preoxygenation/denitrogenation
RSI
Avoid hypoxia
Difficult airway??
First trimester – high dose ketamine (>2mg/kg) can cause uterine hypertonus
MAC is decreased 20-40% in pregnancy
Muscle relaxants should be given slowly to prevent acute increases in acetylcholine
Regional Anesthesia implications (4)
Minimize drug exposure
No change in FHT variability
Adequate volume and ephedrine or phenylephrine to prevent hypotension
Decrease neuraxial dose by 1/3
Postoperative Care
Continue monitoring ____ & _____ activity
FHT & uterine
Postoperative Care
Treat preterm labor ____ & ____
early and aggressively
Postoperative Care
L&D unit or L&D RN in ____ area
recovery
Postoperative Care
Pain meds will _____ beat-to-beat variability
decrease
Postoperative Care
High risk for embolus, should ____ as early as possible
ambulate
Postoperative Care
Maintain oxygenation and ____ ____
uterine displacement
Postoperative Care
_____ consult if greater than 23 weeks
Neonatology
Trauma
Leading cause of ____ ____
maternal death
Trauma
Fetal loss due to (3)
hemodynamic instability, abruption or maternal death
Trauma
Continuous fetal monitoring ____ weeks
> 23
Trauma
Do not avoid diagnostic tests, but ____ ____ if possible
shield fetus
Trauma
___ & ____ do not use ionizing radiation, Head CT is of ___ risk to fetus
U/S & MRI
no
Trauma
Cesarean delivery indication (4)
Stable mom, fetus in distress
Uterine rupture
Gravid uterus interfering with maternal abdominal repairs
Viable fetus, nonviable mom
ECT
_____ disease is a significant cause of maternal morbidity and mortality
Psychiatric
ECT
Withholding treatment for any disease is ____ ____
rarely justified
Cardioversion
Direct current cardioversion is ____ in all stages of pregnancy
safe
Cardioversion
Careful ___ monitoring is required
___ ____ displacement
FHT
Left uterine
Cardioversion
Aspiration risk: sedation vs. GETA precuations (2)
Non-particulate antacid
Consider H2 antagonist
Maternal Cardiac Arrest
____ Uterine displacement, Hands __-____ ____ on sternum for compressions
Left
1-2 cm higher
Maternal Cardiac Arrest
Perimortem cesarean delivery within __ _____
5 minutes
Maternal Cardiac Arrest
Similar causes for arrest as non-pregnant, with addition of (4)
AFE
Eclampsia
Placental abruption
Hemorrhage
Laparoscopic - Fetal outcomes are ____ with laparotomy or laparoscopy
similar
Laparoscopic - CO2 insufflation does cause fetal ___ ____
respiratory acidosis
Laparoscopic - Keep intraabdominal pressures as ___ as possible and as ___ as possible
low
short
Laparoscopic - Fetal shielding during ____ (cholangiograms)
x-ray
Laparoscopic - Maintain ___ ____ displacement
left uterine
Laparoscopic - ____ _____ to prevent DVT
Compression stockings
Cardiopulmonary Bypass - Maternal decompensation can occur 28-30 weeks with increase of blood volume and cardiac output with _____ _____ ______ or ____
stenotic valvular lesions or PHTN
Cardiopulmonary Bypass - Immediate _____ is another time of concern
postpartum
Cardiopulmonary Bypass - If possible, delay to ____ trimester
second
Cardiopulmonary Bypass - In patients close to term combined ____ and ____ replacement has been successful
cesarean and valve
Cardiopulmonary Bypass - Beyond ___ weeks, monitor fetus & maintain uterine displacement
24
Cardiopulmonary Bypass - Higher pump flows may be ______ per animal studies
beneficial
Cardiopulmonary Bypass - Fetal ____ is common when going on pump, but returns to normal without beat-to-beat
bradycardia
Cardiopulmonary Bypass - Hypo____? Normo____?
Hypothermia? Normothermia?
Fetal Interventions
Rapidly _____
Ethical issue: maternal safety vs. risks to the mother & fetus vs. benefits to the fetus
evolving
Fetal Interventions
Performed at few highly ____ centers
specialized
Fetal Interventions
_____, ultrasound guided trocars into amniotic cavity
Fetoscope
Fetal Interventions
Work around placenta _____
implantation
Fetal Interventions
Can be with ____ or ____ with sedation depending on case and surgical technique
local or neuraxial
EXIT Procedures
__-__ MAC for uterine relaxation
2-3
EXIT Procedures
Partial ____, then ___ _____ for fetal analgesia & immobilization
delivery
IM injection
EXIT Procedures
Step one is secure ___ ____
fetal airway
EXIT Procedures
After procedure, ___ decreased to increase uterine tone, then ____ _____ baby delivered. Now uterine tone = good
MAC
cord clamped
Open Mid-Gestation Fetal Surgery
Myelomeningocele
Intrathoracic ____ with _____ (severe fetal edema)
Similar to EXIT, but fetus is returned to uterus prior to ____ ____
Aggressive _____
lesions with hydrops
uterine closure
tocolysis
___ ____ increase risk of uterine rupture
Fetal surgeries
____ ____ is necessary for this (uterine rupture) and all future deliveries prior to onset of labor
Cesarean delivery
