0
Anesthesia for the  Pregnant Patient Undergoing NonOB-Surgery Reference: Hawkins, JL. Anesthesia for the Pregnant Patient ...
NonOB SURGERY for OB Patients <ul><li>Annually, 1 - 2.5% of pregnant patients require surgical procedures  </li></ul><ul><...
NonOB SURGERY for OB Patients <ul><li>Most patients have a fear of anesthesia. </li></ul><ul><li>Most OB patients have a p...
NonOB SURGERY PROCEDURES <ul><li>MOST COMMON PROCEDURES: </li></ul><ul><ul><li>TRAUMA </li></ul></ul><ul><ul><li>APPENDICI...
SURGICAL PROCEDURES <ul><li>LESS COMMON PROCEDURES </li></ul><ul><ul><li>NEUROSURGICAL PROCEDURES </li></ul></ul><ul><ul><...
Fetal Surgery <ul><li>Performed in a few major centers </li></ul><ul><li>Major problem is postoperative preterm labor </li...
RISK AND OUTCOME <ul><li>RISK OF FETAL MORBIDITY RISES </li></ul><ul><li>CONGENITAL MALFORMATIONS DO NOT CORRELATE WITH  A...
ANESTHESIA MANAGEMENT ISSUES IN PREGNANCY <ul><ul><li>ALTERATIONS IN MATERNAL PHYSIOLOGY </li></ul></ul><ul><ul><li>POSSIB...
Management Objective <ul><li>Maintain:  </li></ul><ul><ul><li>maternal oxygenation, </li></ul></ul><ul><ul><li>cardiac out...
Blood Flow to Uterus
PHYSIOLOGIC CHANGES OF PREGNANCY
 
 
Late Gestation and Anesthesia Risks <ul><li>Intubation difficulties with or without gastric acid aspiration </li></ul><ul>...
 
ANESTHETICS AND FETUS <ul><li>RISK CHANGES WITH GESTATIONAL AGE </li></ul><ul><ul><li>CONCEPTION TO DAY 13, ADVERSE REACTI...
Changes in Risk Throughout Gestation <ul><li>Early gestation - direct fetal effects mainly toxicity </li></ul><ul><li>Thal...
Fetal Safety: Developmental Alterations and Anesthesia <ul><li>Virtually all anesthetic agents given to the mother are rap...
Risk Classification System <ul><li>The Food and Drug Administration (FDA) 1980 </li></ul><ul><li>Drug Use in Pregnancy and...
U.S. Food and Drug Administration Classification of Teratogenic Drug Risk Adapted from Federal Register(1979) Contraindica...
 
TERATOGENICITY <ul><li>TIMING OF ADMINISTRATION </li></ul><ul><li>INDIVIDUAL SENSITIVITY TO THE AGENT </li></ul><ul><li>TH...
DOCUMENTED TERATOGENS <ul><li>ACE INHIBITORS </li></ul><ul><li>ALCOHOL </li></ul><ul><li>ANDROGENS </li></ul><ul><li>ANTIT...
MEDICAL & SOCIAL FACTORS <ul><li>DIABETIC MOTHERS </li></ul><ul><li>DRUG ABUSE - MOTHER & FATHER </li></ul><ul><li>GENETIC...
 
FDA
FDA ratings <ul><li>DRUG CATEGORY </li></ul><ul><li>Induction agents </li></ul><ul><li>Thiopental C </li></ul><ul><li>Meth...
Categories <ul><li>Inhaled Agents </li></ul><ul><li>Halothane C </li></ul><ul><li>Enflurane B </li></ul><ul><li>Isoflurane...
Categories <ul><li>Local Anesthetics </li></ul><ul><li>2-Chloroprocaine C </li></ul><ul><li>Tetracaine C </li></ul><ul><li...
NITROUS OXIDE <ul><li>CONTROVERSIAL  </li></ul><ul><li>SMALL ANIMAL STUDIES AND DNA SYNTHESIS </li></ul><ul><li>N20 - ADRE...
BENZODIAZEPINES <ul><li>CLEFT PALATE AND EXPOSURE TO DIAZEPAM IN FIRST TRIMESTER </li></ul><ul><li>LACK OF DATA </li></ul>...
FETAL OUTCOME AFTER SURGERY <ul><li>NO ANESTHETIC AGENTS EXCEPT COCAINE IS TERATOGENIC </li></ul><ul><li>HOWEVER </li></ul...
PreAnesthesia Assessment  and  Risks vs. Benefits
PRE-ANESTHESIA ASSESSMENT <ul><li>WOMEN OF REPRODUCTIVE AGE CHECK FOR POSSIBLE PREGNANCY </li></ul><ul><li>PATIENT INFORMA...
<ul><li>TYPE OF ANESTHESIA IS DICTATED BY: </li></ul><ul><ul><li>PHYSICAL & MENTAL CONDITION OF PATIENT </li></ul></ul><ul...
PREOPERATIVE TREATMENT <ul><li>HISTORY AND PHYSICAL EXAM </li></ul><ul><li>AIRWAY ASSESSMENT </li></ul><ul><li>PATIENT RAP...
GENERAL GUIDELINES <ul><li>ASPIRATION PRECAUTIONS </li></ul><ul><li>POSITIONING </li></ul><ul><li>MONITORING </li></ul>
Management Objective <ul><li>Maintain:  </li></ul><ul><ul><li>maternal oxygenation, </li></ul></ul><ul><ul><li>cardiac out...
Risk Factors for Aspiration in Pregnancy <ul><li>Compromised LES function </li></ul><ul><li>Higher intragastric pressure <...
Factors Known to Worsen Aspiration Syndrome <ul><ul><li>Solid material aspiration </li></ul></ul><ul><ul><li>Increased aci...
Agents for aspiration prophylaxis <ul><li>Ranitidine (Zantac) 50mg IV </li></ul><ul><li>Cimetidine   300 mg IV </li></ul><...
MATERNAL POSITIONING <ul><li>BEGINNING WITH SECOND TRIMESTER, AVOID SUPINE POSITION </li></ul><ul><li>USE LEFT UTERINE DIS...
FETAL MONITORING <ul><li>BECOMES PRACTICAL AFTER 16-24 WEEKS GESTATION </li></ul><ul><li>EQUIPMENT AND PERSONNEL MUST BE A...
FETAL MONITORNG <ul><li>Loss of beat-to-beat variability is normal after anesthesia </li></ul><ul><li>Decelerations may in...
INDUCTION AND MAINTENANCE <ul><li>AVOID HYPOXIA </li></ul><ul><li>AVOID HYPOTENSION </li></ul><ul><li>AVOID HYPERTENSION <...
REGIONAL <ul><li>Decrease dose by 1/3 </li></ul><ul><li>Prehydrate </li></ul><ul><li>Treat hypotension with fluid & ephedr...
PostOperative   <ul><li>Monitor VS and FHT </li></ul><ul><li>Treat preterm labor </li></ul><ul><li>Appropriate pain manage...
Trauma <ul><li>Leading cause of maternal death </li></ul><ul><li>Fetal death secondary to maternal death or abruptio place...
Appendectomy and Adnexal Masses Most Common Surgery <ul><li>Parturients undergoing appendectomy have an 18% incidence of p...
Laparotomy Versus Laparoscopic Surgery <ul><li>Laparoscopy – most common 1 st  trimester procedure </li></ul><ul><li>Reduc...
CO 2  Pneumoperitoneum <ul><li>Continuous FHR monitoring ? </li></ul><ul><li>Limit abdominal insufflation pressure to 15 t...
Cervical Cerclage <ul><li>Cervical cerclage is the surgical intervention used to prevent second - trimester fetal loss fro...
Contraindications to cervical cerclage <ul><li>Bleeding </li></ul><ul><li>Active labor </li></ul><ul><li>Ruptured membrane...
SUMMARY <16-20 WEEKS GESTATION <ul><li>POSTPONE UNTIL 2nd TRIMESTER, PRN </li></ul><ul><li>PRE-OP EVAL. BY OBSTETRICIAN </...
SUMMARY > 16-20 WEEKS GESTATION <ul><li>COUNSUL PREOPERATIVELY </li></ul><ul><li>TOCOLYTIC AGENTS? </li></ul><ul><li>ASPIR...
QUESTIONS ?
Upcoming SlideShare
Loading in...5
×

Anesthesiology Information

3,821

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,821
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
116
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Transcript of "Anesthesiology Information"

  1. 1. Anesthesia for the Pregnant Patient Undergoing NonOB-Surgery Reference: Hawkins, JL. Anesthesia for the Pregnant Patient Undergoing NonOB -Surgery. ASA Refresher Course. 2001. Jeffrey Groom, MS, CRNA, ARNP FIU - Anesthesiology Nursing Program NGR 6992 Principles of Anesthesiology Nursing II
  2. 2. NonOB SURGERY for OB Patients <ul><li>Annually, 1 - 2.5% of pregnant patients require surgical procedures </li></ul><ul><li>Annually, approximately 75,000 anesthetics are administered </li></ul><ul><li>Whether or not your facility does OB Service, you will likely see OB patients </li></ul>
  3. 3. NonOB SURGERY for OB Patients <ul><li>Most patients have a fear of anesthesia. </li></ul><ul><li>Most OB patients have a profound fear (concern) about anesthesia. </li></ul><ul><li>Many will want to forego analgesia and/or sedation…..which may in the end do more harm than good. </li></ul>
  4. 4. NonOB SURGERY PROCEDURES <ul><li>MOST COMMON PROCEDURES: </li></ul><ul><ul><li>TRAUMA </li></ul></ul><ul><ul><li>APPENDICITIS </li></ul></ul><ul><ul><li>OVARIAN CYST </li></ul></ul><ul><ul><li>CHOLECYSTECTOMY </li></ul></ul><ul><ul><li>BREAST BIOPSY </li></ul></ul><ul><ul><li>ABDOMINAL LAPAROSCOPIC PROCEDURES </li></ul></ul><ul><ul><li>CERVICAL CERCLAGE </li></ul></ul>
  5. 5. SURGICAL PROCEDURES <ul><li>LESS COMMON PROCEDURES </li></ul><ul><ul><li>NEUROSURGICAL PROCEDURES </li></ul></ul><ul><ul><li>CARDIAC SURGERY </li></ul></ul><ul><ul><li>TRANSPLANT </li></ul></ul><ul><ul><li>PHEOCHROMOCYTOMAS </li></ul></ul><ul><ul><li>UROLOGICAL PROCEDURES </li></ul></ul><ul><ul><ul><li>(Extracorporeal shock-wave lithotripsy is absolutely contraindicated) </li></ul></ul></ul>
  6. 6. Fetal Surgery <ul><li>Performed in a few major centers </li></ul><ul><li>Major problem is postoperative preterm labor </li></ul><ul><li>Tocolytics: Preoperative Indomethacin and perioperative magnesium sulfate </li></ul><ul><li>High dose inhalational anesthesia for anesthetizing mother and fetus and provide uterine relaxation </li></ul>
  7. 7. RISK AND OUTCOME <ul><li>RISK OF FETAL MORBIDITY RISES </li></ul><ul><li>CONGENITAL MALFORMATIONS DO NOT CORRELATE WITH ANESTHESIA EXPOSURE </li></ul><ul><li>INCREASE IN LOW BIRTH WEIGHT </li></ul><ul><li>RISK OF EARLY PERINATAL DEATH </li></ul><ul><li>INCREASE IN SPONTANEOUS AB </li></ul>
  8. 8. ANESTHESIA MANAGEMENT ISSUES IN PREGNANCY <ul><ul><li>ALTERATIONS IN MATERNAL PHYSIOLOGY </li></ul></ul><ul><ul><li>POSSIBLE TERATOGENIC EFFECTS </li></ul></ul><ul><ul><li>MAINTENANCE OF UTERINE PERFUSION AND EFFECTS OF ANESTHESIA ON FETUS </li></ul></ul><ul><ul><li>PREVENTION OF PREMATURE LABOR </li></ul></ul>
  9. 9. Management Objective <ul><li>Maintain: </li></ul><ul><ul><li>maternal oxygenation, </li></ul></ul><ul><ul><li>cardiac output, </li></ul></ul><ul><ul><li>oxygen delivery, and </li></ul></ul><ul><ul><li>uterine blood flow </li></ul></ul>
  10. 10. Blood Flow to Uterus
  11. 11. PHYSIOLOGIC CHANGES OF PREGNANCY
  12. 14. Late Gestation and Anesthesia Risks <ul><li>Intubation difficulties with or without gastric acid aspiration </li></ul><ul><li>Unrecognized esophageal intubation </li></ul><ul><li>High or complete spinal block during regional anesthesia </li></ul><ul><li>Unintended deep inhalational anesthesia </li></ul>
  13. 16. ANESTHETICS AND FETUS <ul><li>RISK CHANGES WITH GESTATIONAL AGE </li></ul><ul><ul><li>CONCEPTION TO DAY 13, ADVERSE REACTIONS USUALLY RESULT IN DEATH </li></ul></ul><ul><ul><li>ORGANOGENESIS DAY 13 TO 90, MOST VULNERABLE </li></ul></ul><ul><ul><li>AFTER 13 WEEKS LESS DEVELOPMENTAL RISK </li></ul></ul><ul><ul><li>BY 3 rd TRIMESTER, RISK IS GREATEST FOR PRETERM LABOR </li></ul></ul>
  14. 17. Changes in Risk Throughout Gestation <ul><li>Early gestation - direct fetal effects mainly toxicity </li></ul><ul><li>Thalidomide Babies </li></ul><ul><li>Late gestation - maternal effects that indirectly produce fetal injury </li></ul><ul><li>Cerebral palsy induced by profound maternal hypoxia or hypotension near birth </li></ul>
  15. 18. Fetal Safety: Developmental Alterations and Anesthesia <ul><li>Virtually all anesthetic agents given to the mother are rapidly shared with the unborn child. </li></ul><ul><li>The notable exception to this statement is paralytic agents which cross the placenta with difficulty because they are quaternary ammonium salts. </li></ul>
  16. 19. Risk Classification System <ul><li>The Food and Drug Administration (FDA) 1980 </li></ul><ul><li>Drug Use in Pregnancy and Lactation </li></ul><ul><li>Drug Facts and Comparisons </li></ul><ul><li>Physicians Desk Reference </li></ul>
  17. 20. U.S. Food and Drug Administration Classification of Teratogenic Drug Risk Adapted from Federal Register(1979) Contraindicated in Pregnancy. X Positive human evidence of fetal risk. D Risk cannot be ruled out. C No evidence of risk in humans. Either animal studies show no fetal risk or animal studies show risk but human studies do not show risk B Controlled studies show no risk. Well controlled human studies failed to demonstrate risk to fetus A Description of Risk Category
  18. 22. TERATOGENICITY <ul><li>TIMING OF ADMINISTRATION </li></ul><ul><li>INDIVIDUAL SENSITIVITY TO THE AGENT </li></ul><ul><li>THE THRESHOLD AMOUNT OF EXPOSURE </li></ul><ul><li>NATURALLY OCCURING INCIDENCE OF CONGENITAL ANOMALIES </li></ul>
  19. 23. DOCUMENTED TERATOGENS <ul><li>ACE INHIBITORS </li></ul><ul><li>ALCOHOL </li></ul><ul><li>ANDROGENS </li></ul><ul><li>ANTITHYROID </li></ul><ul><li>CHEMO-DRUGS </li></ul><ul><li>COCAINE </li></ul><ul><li>COUMADIN </li></ul><ul><li>DIETHYLSTIBESTEROL </li></ul><ul><li>LEAD </li></ul><ul><li>LITHIUM </li></ul><ul><li>MERCURY </li></ul><ul><li>PHENYTOIN </li></ul><ul><li>STREPTOMYCIN </li></ul><ul><li>THALIDOMIDE </li></ul><ul><li>TRIMETHADIONE </li></ul><ul><li>VALPROIC ACID </li></ul>
  20. 24. MEDICAL & SOCIAL FACTORS <ul><li>DIABETIC MOTHERS </li></ul><ul><li>DRUG ABUSE - MOTHER & FATHER </li></ul><ul><li>GENETIC PREDISPOSITION </li></ul><ul><li>HYPOXIA </li></ul><ul><li>EXTREMES IN TEMPERATURE </li></ul><ul><li>ENVIRONMENTAL HAZARDS </li></ul>
  21. 26. FDA
  22. 27. FDA ratings <ul><li>DRUG CATEGORY </li></ul><ul><li>Induction agents </li></ul><ul><li>Thiopental C </li></ul><ul><li>Methohexital B </li></ul><ul><li>Ketamine C </li></ul><ul><li>Etomidate C </li></ul><ul><li>Propofol B </li></ul>
  23. 28. Categories <ul><li>Inhaled Agents </li></ul><ul><li>Halothane C </li></ul><ul><li>Enflurane B </li></ul><ul><li>Isoflurane C </li></ul><ul><li>Desflurane B </li></ul><ul><li>Sevoflurane B </li></ul>
  24. 29. Categories <ul><li>Local Anesthetics </li></ul><ul><li>2-Chloroprocaine C </li></ul><ul><li>Tetracaine C </li></ul><ul><li>Bupivacaine C </li></ul><ul><li>Lidocaine B </li></ul><ul><li>Ropivacaine B </li></ul>
  25. 30. NITROUS OXIDE <ul><li>CONTROVERSIAL </li></ul><ul><li>SMALL ANIMAL STUDIES AND DNA SYNTHESIS </li></ul><ul><li>N20 - ADRENERGIC TONE -VASOCONSTRICTION </li></ul><ul><li>TERATOGENICITY HAS NOT BEEN DEMONSTRATED IN HUMANS </li></ul><ul><li>CATEGORY X ? </li></ul>
  26. 31. BENZODIAZEPINES <ul><li>CLEFT PALATE AND EXPOSURE TO DIAZEPAM IN FIRST TRIMESTER </li></ul><ul><li>LACK OF DATA </li></ul><ul><li>STILL CLASSIFIED AS A CATEGORY D AGENT </li></ul><ul><li>USE OR NOT </li></ul><ul><li>PDR </li></ul>
  27. 32. FETAL OUTCOME AFTER SURGERY <ul><li>NO ANESTHETIC AGENTS EXCEPT COCAINE IS TERATOGENIC </li></ul><ul><li>HOWEVER </li></ul><ul><ul><li>AVOID HYPOXIA, HYPERCARBIA, AND HYPOTENSION, </li></ul></ul><ul><ul><li>ALL CAPABLE OF INDUCING MALFORMATIONS AND FETAL DEATH </li></ul></ul>
  28. 33. PreAnesthesia Assessment and Risks vs. Benefits
  29. 34. PRE-ANESTHESIA ASSESSMENT <ul><li>WOMEN OF REPRODUCTIVE AGE CHECK FOR POSSIBLE PREGNANCY </li></ul><ul><li>PATIENT INFORMATION AND RISK COUNSELING </li></ul><ul><li>POSTPONE ELECTIVE SURGERY UNTIL AFTER DELIVERY </li></ul><ul><li>POSTPONE NONELECTIVE SURGERY UNTIL SECOND TRIMESTER </li></ul><ul><li>NO ANESTHETIC TECHNIQUE CORRELATES WITH A BETTER OUTCOME </li></ul><ul><li>EDUCATE ON SIGNS OF PRETERM LABOR </li></ul>
  30. 35. <ul><li>TYPE OF ANESTHESIA IS DICTATED BY: </li></ul><ul><ul><li>PHYSICAL & MENTAL CONDITION OF PATIENT </li></ul></ul><ul><ul><li>EXTENT OF PLANNED PROCEDURE </li></ul></ul><ul><ul><li>PERCEPTION THAT MAC > Regional > GETA IS SAFEST ORDER OF ANESTHESIA METHODS, NOT VALIDATED BY THE DATA </li></ul></ul>Type of Anesthesia
  31. 36. PREOPERATIVE TREATMENT <ul><li>HISTORY AND PHYSICAL EXAM </li></ul><ul><li>AIRWAY ASSESSMENT </li></ul><ul><li>PATIENT RAPPORT </li></ul><ul><li>ALLEVIATE ANXIETY </li></ul><ul><li>ADVISE AS TO RISKS </li></ul><ul><li>OB CONSULTATION </li></ul><ul><li>PRE-OP MEDICATIONS </li></ul>
  32. 37. GENERAL GUIDELINES <ul><li>ASPIRATION PRECAUTIONS </li></ul><ul><li>POSITIONING </li></ul><ul><li>MONITORING </li></ul>
  33. 38. Management Objective <ul><li>Maintain: </li></ul><ul><ul><li>maternal oxygenation, </li></ul></ul><ul><ul><li>cardiac output, </li></ul></ul><ul><ul><li>oxygen delivery, and </li></ul></ul><ul><ul><li>uterine blood flow </li></ul></ul>
  34. 39. Risk Factors for Aspiration in Pregnancy <ul><li>Compromised LES function </li></ul><ul><li>Higher intragastric pressure </li></ul><ul><li>Anatomic displacement of stomach </li></ul><ul><li>Decreased gastric emptying in labor </li></ul><ul><li>Potential for no NPO period </li></ul><ul><li>Potential for difficult intubation </li></ul>
  35. 40. Factors Known to Worsen Aspiration Syndrome <ul><ul><li>Solid material aspiration </li></ul></ul><ul><ul><li>Increased acidity of contents </li></ul></ul><ul><ul><li>Higher aspirated volume </li></ul></ul><ul><ul><li>Regardless of NPO status all pregnant patients are at risk for aspiration from 8 weeks gestation to 6-8 weeks postpartum! </li></ul></ul>
  36. 41. Agents for aspiration prophylaxis <ul><li>Ranitidine (Zantac) 50mg IV </li></ul><ul><li>Cimetidine 300 mg IV </li></ul><ul><li>Metoclopromide (Reglan) 10 mgIV </li></ul><ul><li>Oral sodium citrate( Bicitra)30cc po </li></ul>
  37. 42. MATERNAL POSITIONING <ul><li>BEGINNING WITH SECOND TRIMESTER, AVOID SUPINE POSITION </li></ul><ul><li>USE LEFT UTERINE DISPLACEMENT </li></ul>
  38. 43. FETAL MONITORING <ul><li>BECOMES PRACTICAL AFTER 16-24 WEEKS GESTATION </li></ul><ul><li>EQUIPMENT AND PERSONNEL MUST BE AVAILABLE </li></ul><ul><li>TRANSDUCER MUST NOT ENCROACH ON THE SURGICAL FIELD </li></ul><ul><li>THERAPEUTIC INTERVENTIONS? </li></ul>
  39. 44. FETAL MONITORNG <ul><li>Loss of beat-to-beat variability is normal after anesthesia </li></ul><ul><li>Decelerations may indicate need for: </li></ul><ul><ul><li>Increased oxygenation, increased BP </li></ul></ul><ul><ul><li>Decreased surgical retraction </li></ul></ul><ul><ul><li>Initiation of tocolytics </li></ul></ul><ul><li>HOWEVER, MONITORING NEEDS TO BE ACCURATE AND PROPERLY INTERPRETED </li></ul>
  40. 45. INDUCTION AND MAINTENANCE <ul><li>AVOID HYPOXIA </li></ul><ul><li>AVOID HYPOTENSION </li></ul><ul><li>AVOID HYPERTENSION </li></ul><ul><li>AVOID HYPER/HYPOCARBIA </li></ul><ul><li>AVOID HYPOGLYCEMIA </li></ul><ul><li>AVOID HYPO/HYPERTHERMIA </li></ul>
  41. 46. REGIONAL <ul><li>Decrease dose by 1/3 </li></ul><ul><li>Prehydrate </li></ul><ul><li>Treat hypotension with fluid & ephedrine </li></ul><ul><li>If not used operatively, consider regional for post-op pain management </li></ul>
  42. 47. PostOperative <ul><li>Monitor VS and FHT </li></ul><ul><li>Treat preterm labor </li></ul><ul><li>Appropriate pain management </li></ul><ul><li>Increased risk for thromboembolism </li></ul>
  43. 48. Trauma <ul><li>Leading cause of maternal death </li></ul><ul><li>Fetal death secondary to maternal death or abruptio placenta </li></ul><ul><li>Fetal Assessment – STAT Ultrasound </li></ul><ul><li>Maternal Evaluation – Shield fetus </li></ul><ul><li>STAT Post-mortum C-Section </li></ul><ul><li>Stabilize/Optimize mother – VD or CS at 9mo better than emergent CS at time of injury </li></ul><ul><li>Emergent C-Section: </li></ul><ul><ul><li>Stable MOM – FETAL distress </li></ul></ul><ul><ul><li>Traumatic uterine rupture – Unstable MOM and FETUS </li></ul></ul><ul><ul><li>Gravid uterus interfering with MOM E-lap </li></ul></ul><ul><ul><li>Unsalvageable MOM with viable FETUS </li></ul></ul>
  44. 49. Appendectomy and Adnexal Masses Most Common Surgery <ul><li>Parturients undergoing appendectomy have an 18% incidence of postoperative pulmonary edema or ARDS </li></ul><ul><li>Risk Factors for development of pulmonary edema are: </li></ul><ul><ul><li>Gestational age > 20 weeks </li></ul></ul><ul><ul><li>Preoperative respiratory rate over 24 /min </li></ul></ul><ul><ul><li>Preoperative temperature > 100.4°F </li></ul></ul><ul><ul><li>A fluid load (I>O) > 4 liters in the first 48 hours </li></ul></ul><ul><ul><li>Concomitant tocolytic usage </li></ul></ul><ul><li>Conservative FLUIDS, consider CVP line </li></ul>
  45. 50. Laparotomy Versus Laparoscopic Surgery <ul><li>Laparoscopy – most common 1 st trimester procedure </li></ul><ul><li>Reduced pain and limited fetal exposure to postoperative opioids </li></ul><ul><li>More economical </li></ul><ul><li>Better surgical view with limited manipulation of uterus </li></ul><ul><li>More rapid return to mobility, reducing risk of thrombophlebitis </li></ul>
  46. 51. CO 2 Pneumoperitoneum <ul><li>Continuous FHR monitoring ? </li></ul><ul><li>Limit abdominal insufflation pressure to 15 to 20 mm Hg </li></ul><ul><li>Increase minute ventilation </li></ul><ul><li>If fetal compromise develops-check ABG </li></ul><ul><li>Convert to Open procedure </li></ul>
  47. 52. Cervical Cerclage <ul><li>Cervical cerclage is the surgical intervention used to prevent second - trimester fetal loss from cervical incompetence. </li></ul><ul><li>An incompetent cervix is the result of weakness of cervical os caused by trauma, congenital or multiple pregnancies </li></ul><ul><li>Usually done between 12 and 26 weeks gestation </li></ul>
  48. 53. Contraindications to cervical cerclage <ul><li>Bleeding </li></ul><ul><li>Active labor </li></ul><ul><li>Ruptured membranes </li></ul><ul><li>Cervical dilation > 4 cm </li></ul><ul><li>Intrauterine infection </li></ul><ul><li>Fetal abnormalities </li></ul><ul><li>Abruptio Placenta </li></ul>
  49. 54. SUMMARY <16-20 WEEKS GESTATION <ul><li>POSTPONE UNTIL 2nd TRIMESTER, PRN </li></ul><ul><li>PRE-OP EVAL. BY OBSTETRICIAN </li></ul><ul><li>PRE-OP COUNSULING </li></ul><ul><li>NONPARTICULATE ANTACID </li></ul><ul><li>OXYGENATION,NORMOCARBIA, NORMOTENSION & NORMOGLYCEMIA </li></ul><ul><li>REGIONAL if possible </li></ul><ul><li>FOR GETA – WEIGH BENEFIT v RISK of N2O </li></ul><ul><li>DOCUMENT FHT’s BEFORE, DURING, AFTER </li></ul>
  50. 55. SUMMARY > 16-20 WEEKS GESTATION <ul><li>COUNSUL PREOPERATIVELY </li></ul><ul><li>TOCOLYTIC AGENTS? </li></ul><ul><li>ASPIRATION PROPHYLAXIS </li></ul><ul><li>USE LEFT UTERINE DISPLACEMENT </li></ul><ul><li>OXYGENATION, NORMCARBIA, NORMOTENSION, & NORMOGLYCEMIA </li></ul><ul><li>USE FHR MONITORING & MONITOR FOR UTERINE CONTRACTIONS </li></ul>
  51. 56. QUESTIONS ?
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×