Mod VII: Anesthesia for Nonlaboring Surgery During Pregnancy

Question 1

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What’s the incidence of Nonlaboring Surgery During Pregnancy?

Answer 1

0.75% to 2% of parturients

Question 2

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What are the most common Nonlaboring Surgeries During Pregnancy?

Answer 2

Acute appendicitis

Cholecystitis

Maternal trauma

Cancer

Question 3

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What are Maternal safety anesthetic management goals for Nonlaboring Surgery During Pregnancy?

Answer 3

Consider physiologic changes that begin in 1st trimester

Question 4

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What are Fetal safety anesthetic management goals for Nonlaboring Surgery During Pregnancy?

Answer 4

Avoid teratogenic drugs

Maintain uteroplacental blood flow

Prevent preterm labor

Question 5

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

With regards to Anesthetic Toxicity, all general anesthetics cross the placenta (T/F)?

Answer 5

True

Question 6

_{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?

Answer 6

2nd trimester is preferred

(it’s recommended to postponed procedure to this point)

Question 7

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

With regards to Anesthetic Toxicity - Which anesthetic technique is favored for Nonlaboring Surgery During Pregnancy?

Answer 7

Regional anesthesia favored, when capable

Question 8

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

When is Perioperative Fetal Heart Rate Monitoring practical?

Answer 8

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)

Question 9

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

T/F: FHR monitoring after 25 weeks is a reliable sign of fetal well-being

Answer 9

True

Question 10

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Anesthetic Management}

T/F: Advanced airway equipments must be readily available

Answer 10

True

Question 11

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Anesthetic Management}

T/F: Avoid decreased uterine perfusion and decreased delivery of oxygen to the fetus

Answer 11

True

Question 12

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control}

What could be done for Postoperative Pain Control if using a Regional technique?

Answer 12

Epidural can be continued

Question 13

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control}

NSAIDs are avoided as they are associated with:

Answer 13

Fetal malformation

Miscarriage

Question 14

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Postoperative Pain Control}

T/F: Acetaminophen is generally safe

Answer 14

True

Question 15

_{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??

Answer 15

Be prepared to support the neonate for respiratory depression

Question 16

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What are Important Factors in Maternal Laparoscopic surgery?

Answer 16

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

Question 17

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

Nonlaboring procedures directly related to pregnancy that require Anesthesia include:

Answer 17

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}

Question 18

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What’s the leading cause of 1st trimester maternal death?

Answer 18

Ruptured ectopic

→ (massive hemorrhage)

Question 19

_{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

Answer 19

Incompetent Cervix Cerclage

Question 20

_{Anesthesia for Nonlaboring Surgery During Pregnancy}

What’s the preferred anesthetic technique for Imcompetent cervix?

Answer 20

Spinal

Regional: ideal (Spinal>epidural)

Question 21

_{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

Answer 21

Abortion/miscarriage

Question 22

_{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:

Answer 22

Inevitable abortion

Question 23

_{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:

Answer 23

Complete abortion

Question 24

_{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:

Answer 24

Incomplete abortion

Question 25

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage} The type of abortion that is characterized by unrecognized fetal demise is known as:

Answer 25

**Missed abortion**

Question 26

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage} The procedure required for _missed_ & _incomplete_ Abortion or miscarriage is known as:

Answer 26

**Dilation & Evacuation** or _Dilation & Curettage_

Question 27

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Abortion/miscarriage} Which anesthesia techniques could be used for Dilation & Evacuation procedure?

Answer 27

**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

Question 28

_{Anesthesia for Nonlaboring Surgery During Pregnancy} When are most Postpartum Tubal Ligation (PPTL) scheduled?

Answer 28

Immediate postpartum period

Question 29

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Postpartum Tubal Ligation (PPTL)} What are advantages of performing Postpartum Tubal Ligation (PPTL) during the immediate postpartum period?

Answer 29

Enlarged uterus → fallopian tubes up out of pelvis =\> mini-laparotomy incision 2nd hospital visit avoided Reduced chance of undesired pregnancy while awaiting sterilization

Question 30

_{Anesthesia for Nonlaboring Surgery During Pregnancy - Postpartum Tubal Ligation (PPTL)} What are disadvantages of performing Postpartum Tubal Ligation (PPTL) during the immediate postpartum period?

Answer 30

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)}

Question 31

_{Anesthesia for Nonlaboring Surgery During Pregnancy} How much time is needed for physiologic changes of pregnancy to return to pre pregnant status?

Answer 31

**6 weeks**

Question 32

_{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?

Answer 32

Laparoscopic Bilateral Tubal Ligation (BTL) 6 weeks postpartum under General anesthesia

Question 33

_{Anesthesia for Nonlaboring Surgery During Pregnancy} Recommendations for a Postpartum Tubal Ligation (PPTL) patient w/ Functioning labor epidural & mom/baby stable

Answer 33

Keep NPO after delivery Perform Postpartum Tubal Ligation (PPTL) as soon as personnel available

Question 34

_{Anesthesia for Nonlaboring Surgery During Pregnancy} Recommendations for a Postpartum Tubal Ligation (PPTL) patient w/ Nonfunctional epidural

Answer 34

Place another epidural catheter or administer SAB

Question 35

_{Anesthesia for Nonlaboring Surgery During Pregnancy} Recommendations for a Postpartum Tubal Ligation (PPTL) patient w/ No epidural

Answer 35

Keep NPO for 8hrs Then perform a SAB

Question 36

_{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?

Answer 36

Require higher doses of local anesthetic to attain same level of anesthesia compared to pregnant

Question 37

_{Anesthesia for Nonlaboring Surgery During Pregnancy} What's the desired _dermatomal block leve_l for **Postpartum Tubal Ligation** (PPTL)?

Answer 37

**T4-T6** _{[for Postpartum Tubal Ligation (PPTL)]}

Question 38

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:

Answer 38

**Premature Labor**

Question 39

_{Premature Labor} What are Contributive factors to Premature Labor?

Answer 39

Extremes of age Inadequate prenatal care Infections Prior preterm labor Multiple gestation Other medical illnesses

Question 40

_{Premature Labor} Which drugs are often prescribe to pts experiencing premature labor? why?

Answer 40

**Tocolytics** Delay or stop labor until lungs mature and sufficient pulmonary surfactant is produced, as judged by amniocentesis

Question 41

_{Premature Labor} What are contraindications to Tocolytics?

Answer 41

Chorioamnionitis Fetal distress Intrauterine fetal demise Severe chronic HTN or pre-eclampsia Severe hemorrhage

Question 42

_{Premature Labor} Common Tocolytics used to stop Premature Labor include:

Answer 42

**β2-adrenergic agonist** ^{(Ritodrine, Terbutaline)} **MgSO4** **Prostaglandin inhibitor** ^{(Indomethacin)} **Calcium channel blocker** ^(Nifedipine) NOTE: All Tocolytics may increase postpartum hemorrhage

Question 43

_{Premature Labor - Tocolytics} _Terbutaline_ is sometimes used off-label (an unapproved use) for acute obstetric uses, including:

Answer 43

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**

Question 44

_{Premature Labor - Tocolytics} What's the MOA of β2-adrenergic agonist (Ritodrine, _Terbutaline_) when used as Tocolytics?

Answer 44

_Terbutaline_ **Directly** _relaxes uterine smooth muscle_

Question 45

_{Premature Labor - Tocolytics} What are the maternal side effects of β2-adrenergic agonist (Ritodrine, Terbutaline) when used as Tocolytics?

Answer 45

Hypotension Tachycardia Hyperglycemia Hypokalemia Hyperinsulinemia Metabolic acidosis

Question 46

_{Premature Labor - Tocolytics} What are the fetal side effects of β2-adrenergic agonist (Ritodrine, Terbutaline) when used as Tocolytics?

Answer 46

Tachycardia & Hypoglycemia

Question 47

_{Premature Labor - Tocolytics} What are serious complications of β2-adrenergic agonist (Ritodrine, Terbutaline) that may develop after 24 hrs of therapy?

Answer 47

PE - MI

Question 48

_{Premature Labor - Tocolytics} What are pros and cons of using Prostaglandin inhibitor (Indomethacin) as a Tocolytic?

Answer 48

Pros: Minimal side effects Cons: Questionable interference with PLT aggregation

Question 49

_{Premature Labor - Tocolytics} Calcium channel blocker (_Nifedipine_) is probably the most benign tocolytic - however, what are serious concerns a/w its use?

Answer 49

Maternal **hypotension** _Myocardial depression_

Question 50

_{Premature Labor - Tocolytics} T/F: All Tocolytics may increase postpartum hemorrhage

Answer 50

**True**