Pregnany & Surgery Flashcards
What explains physiologic anemia of pregnancy?
Increased intravascular volume > increased RBC mass
What are two common laboratory changes in pregnancy?
- Physiologic anemia
- Leukocytosis
What are the two different ranges of leukocytosis ?
10 000 to 14 000 Late pregnancy
20 000 to 30 000 in Labour
What diagnosis must you rule out with RLQ in a pregnant lady?
Rule out ECTOPIC pregnancy
In which trimester is appendicitis most frequent?
Second trimester
What is the most common non-obstetrical surgery performed in pregnancy?
Appendectomy (25% of non-obs operations)
Rate of rupture (appendicitis) higher or lower in pregnancy?
Higher
4-57% vs 4-19% in non-pregnant patients
Prevalence of appendicitis in pregnant vs non-pregnant?
Prevalence is about the same
What proportion of appendicitis patients demonstrate the classic signs?
Less than 1/3rd
obturator, psoas, rovsing
Most common signs in appencitis of pregnancy?
RLQ 85%, Rebound tenderness 80%
What physiologic change explains 1)GERD and 2) constipation in pregnancy?
1) Progesterone relaxes smooth muscle at LES (decreased tone)
2) Decreased bowel peristalsis increases bowel transit time
What percent of pregnant women are afftected by GERD? Which trimester most often?
30-70%
Third trimester
Where is the appendix displaced in pregnancy?
- Displaced superiorly and away from RLQ, due to enlarging uterus
- Pain localizes to back or flank instead
List 3 Maternal Complications of Appendicitis in pregnancy
1) Infectious
2) Ileus
3) Increased risk of VTE post-op
In the infectious category of maternal complications of appendicitis, what 3 can occur?
- Sepsis
- Wound infection
- Pneumonia
What fetal complications can occur due to appendicitis in pregnancy?
-Fetal loss (3-15% 1T , high as 20-30%)
-PTL and delivery (11-22%)
(Loss rate 7.3 % laparoscopy, 3.3 % laparotomy)
Rate of VTE in pregnancy?
0.7/1000 pregnant women
3-4x more post partum
By what percent are PT and pTT times decreased in pregnancy?
20% Reduction
What explains the reduction in PT and pTT times? (4 things)
- Increased resistance to activated protein C
- Protein S increases
- Factors 1, 2, 5, 7, 8, 10, and 12 increase
- Activity of fibrinolytic inhibitors (PAI-1 and PAI-2) increase
Side effects of CT in pregnancy?
Teratogenesis
Carcinogenesis
Side effects of MRI in pregnancy?
- Heat
- Avoid gadolinium
Amount of radiation exposure from CT pelvis, vs AXR?
Allowed Threshold?
CT 5 rads vs AXR 0.1 to 0.3 rads
Allowed threshold 5-15 rads
What is the change in the fatal childhood cancer rate, due to CT?
increases from 1/2000 to 2/2000
Upper limit gestational age for lapaarscopic Appy in pregnancy?
26 to 28 weeks GA
Effect of pneumoperitoneum (insufflation) in pregnancy?
-No adverse outcome with 10-12 mmHg with 60 min OR (Gilo)
-
Optimal maternal positioning during OR?
Wedge under R side
30 deg left lateral tilt
Reduces IVC compression (which dec CO by 25-30%)
What 4 factors increase the likelihood of technically difficult airway management in a pregnant patient?
- Laryngeal edema
- Wt gain affecting neck soft tissue
- Increased AP chest wall diameter
- Breast enlargement
Rate of FATAL intubation in obstetrical population?
13x HIGHER than non-obstetrical population
What is the #1 cause of death in obstetrical anaesthesia?
Aspiration
3 factors that increase risk for gastric aspiration?
- Mechanical changes in position due to uterus
- Decease G-E sphincter tone
- Decreased gastric motility (labor, opioids, pain etc)
What Fetal anaesthetic consideration must one consider?
Avoid maternal hyperventilation
-Decreases Venous Return, CO and uterine BF
Are anaesthetics teratogenic?
No definitive data
2 things to watch for post-op Appe in pregnant lady?
PTL
DVT
What prophylactic antibiotics should be given in OR for pregnant lady
-Second gen cephalosporin
+ Flagyl or clinda
Should routine use of steroids and tocolytics be used in pregnant patients with appendicitis?
Studies do not recommend it
List 3 physiologic changes associated with pregnancy
- Increased cardiac output (30-50%, inc blood vol and preload)
- Decreased Systemic vascular resistance (dec after-load)
- Increased HR (by 15-20 bpm)
