13 09 13

Prof. A. K.
SethisEORCAPS-2013
1
Prof.A. K. SethisEORCAPS- 2013
Anticoagulants:
Anaesthetic Implications
Dr.Rashmi Salhotra
CoagulationCascade
Prothrombin Time(PT)
Evaluates classicalextrinsicpathway
Normal PT 10 to 12 seconds NormalPT 10to12seconds.
Prolongedindeficiencies,abnormalitiesorinhibitors
offactorsVII,X,V,II,orI
InternationalNormalizedRatio(INR)
WidevariationinnormalvaluesofPTdueto
thromboplastin reagentsused
ComparisonofPTbetweenlaboratoriesdifficult
Eachthromboplastin comparedwithaninternationally
acceptedstandardthromboplastin
InternationalNormalizedRatio(INR)
AnInternationalSensitivityIndex(ISI)assigned
If the test equivalent to the international standard ISI Ifthetestequivalenttotheinternationalstandard ISI
index=1
PTtesttimesobtainedwiththatreagentnormalizedand
reportedasINR
PartialThromboplastin Time(PTT)
Assessesintrinsicandfinalcommonpathways
Normalvaluesvarywidely(upto 120sec)
Narrowedbyadditionofcontactactivator
Hence,activatedpartialthromboplastin time(aPTT)
NormalaPTT value:2535sec
Prof. A. K. SethisEORCAPS-2013
2
Drugs affecting Coagulation: Classification
Anticoagulants:
oHeparins:UFH,LMWH
oWarfarin
oThrombinInhibitors oThrombinInhibitors
oDirectThrombinandFactorXa inhibitors
Fibrinolytics andThrombolytics
Antiplatelet drugs
HerbalMedications
ProphylaxisandtreatmentofVTE(Warfarin)
DecreaseincidenceofsystemicembolizationinAFand
ProstheticHeartValves(Warfarin)
Indications
ReducemortalityinacuteMIandacuteischemicstroke
(Fibrinolytics)
Preventthrombosisaftercoronaryangioplastyand
secondarypreventofMIandstroke(Antiplatelets)
ComplicationsofAnticoagulantTherapy
Bleedingandhaemorrhages
Thrombocytopenia
Hypersensitivity
Spontaneousspinal/epiduralhaematomas
Ecchymoses,purpura
Prof.A. K. SethisEORCAPS- 2013 Prof.A. K. SethisEORCAPS- 2013
Potentialcomplicationinpatientson
Coagulationalteringdrugs:Spinal/Epidural
Haematoma
I id 1 1 50 000 ( id l)
Spinal/EpiduralHaematoma
Incidence:<1:1,50,000(epidural)
<1:2,20,000(spinal)
Recentsurveys:Frequencyisincreasing
Ashighas1:3,000incertainpopulations
3
Spinal/EpiduralHaematoma:Whyare
weconcerned?
NeuraxialSpace:Closedspace
Incompressiblevessels p
Concealedbleeding:compression
Neurologicaldamage:maybepermanentin
nature
ThromboprophylaxiswithLMWH increasein
reportedcasesofepiduralhaematoma
ElderlypopulationsufferingfromMI,stroke,atrial
fibrillation
WhatistheneedofGuidelines?
fibrillation
Youngpatientswithprostheticvalves
Onanticoagulants/antiplatelets forpreventionofVTE
Regionaltechniques:choiceforanaesthesia and
analgesia
4
WhatistheneedforRevisionofGuidelines
ManagementofSpinal/EpiduralHaematoma
Closeneurologicalmonitoring
Highindexofsuspicion Highindexofsuspicion
EmergentCTScan
Urgentlaminectomy anddecompression
Activates plasma antithrombin III (AT III)
Heparin AT III complex binds to factors of
intrinsic and common pathway IIa Xa IXa
UnfractionatedHeparin(UFH)
intrinsic and common pathway IIa, Xa, IXa,
XIa, XIIa, XIIIa
Does not cross Bloodbrain barrier
Prophylaxis: 5000 U sc X 812 hrs
Monitoring: aPTT at therapeutic doses
ACT at higher doses during CPB
M i t i PTT b t ti l Maintain aPTT between 1.52.5 times normal
Smaller doses (5000U sc): no need to monitor
Reversal: protamine (1 mg neutralizes 100 U)
HeparinInducedThrombocytopenia
Pl.countfalls514daysafterfirstdose
Enlargement/extensionofoldclot,or g / ,
developmentofanewclot mostcommon
symptom
Heparin Induced Thrombocytopenia
Systemic Reaction with IV infusion
Fever, chills, high BP, tachycardia, dyspnoea,
chest pain
T/T: Heparin discontinuation
Argatroban, Lepirudin, Fondaparinux
5
60yroldmale
PlannedforTHR
ClinicalDilemma CaseI
OnVTEprophylaxiswithUFH
Willyouplanforregionalanalgesia?
Anaesthetic ManagementonUFH
1. Dailyreviewofmedicalrecordstoidentify
useofotherdrugsaffectingcoagulation.
2 Prophylactic dose: 5000 U 2x/d no 2. Prophylacticdose:5000U,2x/d no
contraindicationtoCNB.Delayheparin
doseuntilaftertheblocktoreducethe
riskofbleeding.(Grade1C)
3. 3x/d increasedriskofsurgicalbleed.Risk
vs benefitshouldbeweighedand
neurologicalassessmentshouldbedone
(G d 2C) (Grade2C)
4. IfUFHusedfor>4d,assessplatelet
counttor/oHITbeforeblockor
catheterremoval(Grade1C)
5. IntraopanticoagulationandCNB:
Avoidinpatientswithcoagulopathies
Delayheparinfor1hafterneedleplacement
Removecatheter24hafterlastdose
N td i ft h f th t l Nextdosegivenafter1hofcatheterremoval
Monitorpostopforearlydetectionofhematoma
Communicatewithsurgeoninc/obloodytap
Therapeuticdoses:neurologicalmonitoringand
carefulselectionofdrugs(Grade2C)
SelectiveinhibitionoffactorXa
DoesnotbindtoATIII
L i id f HIT d h h
LowMolecularWeightHeparin(LMWH)
LowincidenceofHITandhaemorrhage
LackofmonitoringasaPTT notprolonged
Prolongedhalflife:oncedailydosing
Irreversibilitywithprotamine
Dose:
Enoxaparin: 2040 mg OD sc
Dalteparin: 2500 IU OD for prophylaxis, 100 p p p y ,
U/kg 12 hrly or 200 U/kg 24 hrly for treatment of
DVT
6
60yroldmale
PlannedforTHR
ClinicalDilemma CaseII
OnVTEprophylaxiswithLMWH
Willyouplanforregionalanalgesia?
Anaesthetic ManagementonLMWH
1. RoutinemonitoringoffactorXa levels:not
recommended(Grade1A)
2. Concomitantadministrationofother
d ff i l i drugsaffectingcoagulation:not
3. Bloodduringepiduralcatheterorneedle
placement:delaynextdoseofLMWHfor
24h(Grade2C)
4. PreopLMWH:
Timingofneedleplacement
Prophylacticdose:after12h(Grade1C)
Therapeuticdose:after24h(Grade1C) p 4 ( )
CNBnotrecommendedifLMWHgiven2h
preop(Grade1A)
5. PostopLMWH:
Singledailydosing:1
st
doseafter68hrpostop.
Indwellingcatheter:safe
Removecatheter1012hrafterlastdose
Nextdose2hafterremoval
Twicedailydosing:1
st
dosenotbefore24h
postop.
Removeindwellingcatheteratleast2hbefore1
st
dose
Competitiveantagonismandinterferance
withthesynthesisofVitaminKdependent
Warfarin
clottingfactors(II,VII,IX,X)
Effectdevelopsover13days
Narrowtherapeuticindex
ReversalwithVit K 12mgorally(2448hr)
Urgentreversal 2.5 5mgorallyorIV
Warfarin
Immediatereversal FFPtransfusion
Monitoring:PT/INR
C/I:Earlypregnancy:FetalWarfarinSyndrome
7
RecommendedINRfororalanticoagulants
Prophylaxis ofDVT 2 2.5
T f DVT PE TIA hi 2 3 TreatmentofDVT,PE,TIA,hipsurgery 2 3
Recurrent thromboembolism,MI,
prostheticheartvalves
3 3.5
25yroldfemalefornephrolithotomy
K/c/oProstheticMitralValve
OnWarfarin(INR=3 2)
ClinicalDilemma CaseIII
OnWarfarin(INR=3.2)
Howwillyoumanagetheanticoagulanttherapy
perioperatively?
Anaesthetic Management
1. Discontinueatleast45dbeforeplanned
procedureandensurenormalINR(Grade1B)
2. Concurrentuseofotherdrugsnot
3. Reducedosageinptswhocanhave
exaggeratedresponse
4. If1
st
dosegiven24hpreopor2
nd
dose
alreadyadministered,INRshouldbedone
beforeCNB(Grade2C)
L d h i h id li i 5. Lowdosetherapywithepiduralinsitu:
INRmonitoreddaily(Grade2C)
6. Routineneurologicalmonitoring(Grade
1C)
7. Removalofepiduralcatheter:
INR<1.5:Neurologicalmonitoringfor24h
(Grade2C)
INR>1.53:Removewithcaution.Neurological 5 3 g
assessmenttillINRnormalizes(Grade1C)
INR>3:Withholdwarfarinordecreaseinpatients
withindwellingcatheters(Grade1A)
BridgingTherapy
8
Preoperative:
PatientsathighriskforVTE
TherapeuticscLMWHorIVUFH
BridgingTherapy
LastdoseLMWH(half )24hbeforesurgery
LastdoseUFH4hbeforesurgery
Lowrisk:nobridgingtherapy
Postop:
Highrisk:
Minorprocedure:TherapeuticLMWH24h
aftersurgery
BridgingTherapy
aftersurgery
Majorprocedure:therapeuticLMWH4872h
aftersurgeryorlowdose
Lowrisk:
ResumeWarfarinonpostopday
AspirinandotherNSAIDs InhibitplateletCOX
andpreventsTxA2synthesis
Aspirinaffectsplateletfunctionforthelifeof
Antiplatelet Medications
theplatelet
NSAIDs:shorttermdefect(correctsin3days)
Thienopyridine derivatives:Ticlopidine,
Clopidogrel
Interfere with platelet fibrinogen binding
Interferewithplateletfibrinogenbinding
S/E:Agranulocytosis,TTP,aplastic anaemia
Timeanddosedependenteffect
7daysforclopidogrel
1421daysforticlopidine
GlycoproteinIIb/IIIa inhibitors:Abciximab,
Eptifibatide,Tirofiban
InterferewithplateletfibrinogenandvWb
Interfere with platelet fibrinogen and vWb
factorbinding
Normalplateletbindingafter8hrof
discontinuationofeptifibatide andtirofiban and
after2448hrwithabciximab
9
54yroldmale,k/c/oIHD,HTN
Forlaparoscopichernioplasty
PastH/oMI stenting 6monthsback
ClinicalDilemma CaseIV
PastH/oMI stenting 6monthsback
OnAspirinandClopidogrel
Howwillyoumanageantiplatelettherapy
perioperatively?
54yroldmale
Foropeninguinalherniarepair
PastH/oMIforwhichstenting done2yrback
ClinicalDilemma CaseV
PastH/oMIforwhichstenting done2yrback
OnAspirinandClopidogrel
Howwillyoumanageantiplatelettherapyperi
operatively?
1. NSAIDsandAspirin:Nospecificconcerns(Grade1A)
2. Concurrentadministrationofmultipledrugs:CNB
contraindicated
3 Ticlopidine: Discontinue 14 d before block 3. Ticlopidine:Discontinue14dbeforeblock
4. Clopidogrel:Discontinue7dbeforeblock
5. Abciximab:Avoidblockfor2448h
6. Tirofiban andEptifibatide:Avoidblockfor48h
Streptokinase,Urokinase,Alteplase
Activateplasmin whichdissolves
intravascularclots
Fibrinolytic&ThrombolyticDrugs
intravascularclots
Maximalactivityat5hrafterthedose
Casereportsofspontaneousspinal/epidural
haematomas
Anaesthetic Management:
1. Patientsscheduledtoreceivetherapy:AvoidCNBand
avoidthrombolysis for10daysafterpuncture(Grade
1A)
2. Patientswhohavealreadyreceivedthrombolysis:Do
notperformCNB(Grade1A).Duration:notspecified
10
Anaesthetic Management:
3. PatientswhohavereceivedCNBatornearthetime
oftherapy: Neurologicalmonitoring2hrly.Drugs:
allowneurologicalmonitoring(Grade1C)
P ti t ith id l th t h t dl 4. Patientswithepiduralcatheterwhounexpectedly
receivethrombolytics:Nodefinitive
recommendationastowhentoremovecatheter.
Monitorfibrinogenlevels(lastclottingfactorto
recover)todecidethetimeofremoval(Grade2C)
DirectThrombinandFactorXa Inhibitors
Dabigatran
Prodrug
Reversibleinhibitionoffreeandclotboundthrombin
C/Iinrenalfailure
Reversal:administrationofrecombinantFactorVIIa
Rivaroxaban
SelectiveandreversibleoralfactorXa inhibitor
Monitoring:PT,aPTT,Heptest
Doseadjustmentinrenaldiseases
ThrombinInhibitors
Desirudin,Lepirudin,Bivalirudin,Argatroban
Inhibitbothfreeandclotboundthrombin
Uses:InpatientswithHITforanticoagulation
As an adjunct to angioplasty procedures Asanadjuncttoangioplastyprocedures
Monitoring:aPTT
Noantidote
Recommendation:AgainstperformanceofCNB
Fondaparinux
FactorXa inhibitor
Halflife21hr(ODdosing)
1
st
dose:Administered6hrpostoperatively
SyntheticPentasaccharide
Recommendation:Performonlyunderstrictly
controlledconditions:singleattempt,atraumatic
needlepass,noindwellingepiduralcatheter
Garlic Inhibitsplateletaggregation
Increasesfibrinolysis
Ginkgo Inhibitsplateletactivatingfactor
d
HerbalMedications
Ginseng IncreasesPTandaPTT,
Potentialtodecreaseeffectofwarfarin
Recommendation:
Notmandatorytodiscontinueoravoidregional
anesthesia(Grade1C)
Indications
Venousthromboembolism
AnticoagulantsandPregnancy
Thrombophilia
Antiphospholipid antibodies
Multiplepregnancycomplications
11
32yroldfemale
H/orecurrentpregnancyloss
ClinicalDilemma CaseVI
K/c/oAPLAsyndrome
Onanticoagulanttherapy
ComingforCesareanSection
ASRAguidelinesapply
1. SwitchtoLMWHorUFHat36weeks
2. DiscontinueLMWH36hbeforeinductionof
labororcesareansection
3. DiscontinueIVUFH46hbeforeanticipated
delivery
ResumptionofprophylaxisPostdelivery
1. 12hafternormaldeliveryorepidural
removal.
2 24 h after cesarean delivery 2. 24haftercesareandelivery
ResumptionoftherapeuticanticoagulationPost
delivery
1. 24hregardlessofthemodeofdelivery
ResumptionofOralAnticoagulantsPost
delivery
Warfarinfor46wkwithatargetINRof2.0
3.0,withinitialUFHorLMWHoverlapuntilINR
is2.0orhigher
Riskofhematomaformationundefined
Reportsofseverebleeding
PlexusandPeripheralnerveblockade
Noneurologicaldeficit
Recommendations
Recommendationsofneuraxialblocksshouldbe
appliedsimilarly(Grade1C)
1
Prof.A. K. SethisEORCAPS-2013
Presentationofanantenatalcase
Radhika
23 years , female
Primigravida
POG : 39 wk+ 2 days
22/08/2013 f ti 22/08/2013- for routine
ANC check up
History
History of current pregnancy:
H/o amennorhoeafor 9 months
Progressive enlargement of abdomen
Perceiving regular fetal movements 14 -16/ day
H/o of intake of iron & folic acid tablets since 4
th
month
H/o inj. tetanus toxoidtaken at 5
th
and 6
th
month
Increased frequency of micturition- since 2 months
H/o swelling of feet on prolonged standing which subsides on lying down
History
First trimester :
Diagnosed pregnant after 8 weeks amenorrhoea: Urine Pregnancy
Test done, USG done for confirmation
H/o morning sickness +, subsided in 4
th
month.
No h/o excessive vomitingg
No h/o bleeding per vaginum
No h/o increased frequency of micturition
All routine investigations performed
(Haemogram, blood group, RBS, urine R/M, HIV, VDRL, HBsAg)
History
Second trimester :
Quickening - 20 weeks
USG at 24 weeks normal
Came for regular ANC check ups
History
Second trimester (contd.) :
No h/o abnormal uterine enlargement, excessive weight gain
No h/o headache, blurring of vision, swelling of feet, diminished
urine output convulsions urine output, convulsions
No h/o fatigue, breathlessness, awareness of heart beat, loss of
appetite
No h/o heart burn, regurgitation of food, dry cough
No h/o bleeding per vaginum
2
History
Thirdtrimester
H/o swelling of feet for one month on prolonged standing-
subsides on lying down
No h/o headache, blurring of vision, diminished urine output,
convulsions
No h/o fatigue, breathlessness, awareness of heart beat, loss of
appetite
No h/o heart burn, regurgitation of food, dry cough
No h/o bleeding per vaginum, leaking per vaginum, labour pain
History
Obstetric history : Primigravida
Menstrual history : menarche at age of 13 years, regular 30
day cycles. LMP-20/9/2012 day cycles. LMP20/9/2012
Past history : No h/o DM, HTN, TB, asthma, thyroid disease
or any other chronic ailment
History
Past surgical history : Not significant
Family history : No h/o DM, HTN, TB, asthma, blood
dyscrasias dyscrasias
Personal history : Vegetarian by diet , no h/o smoking,
alcohol consumption, no h/o blood transfusion, drug allergy.
Examination
Height : 160 cm
Weight : 65 kg
Nutrition : Average built
Vitals : Vitals :
PR : 96/min, regular, normal volume, rhythm and
character
BP : 104/65 mmHg in right arm in sitting position
GPE : No pallor, icterus, clubbing, cyanosis,
lymphadenopathy. Pedal edema present
Airwayexamination
Facies: no abnormality seen
Tongue : normal
Upper incisor length <15 cm Upper incisor length <1.5 cm,
no loose teeth or absent teeth
Inter - incisor gap > 3 cm
Thyromental distance - 6 .5cm
MPG III
Neck movements normal
Examination
Cardiovascular System:
Apex beat - 4th ICS, 2cms outside midclavicular line
S
1
, S
2
WNL, no murmurs
Respiratory system:
Breath sounds normal vesicular, No crepts/rhonchi/wheeze
CNS examination :
Higher mental functions normal, motor/sensory examination - NAD
Breast examination :
Normal changes for pregnancy
3
Examinationofspine
Lumbar Lordosis +
No Kyphosis/Scoliosis
Intervertebral spaces reduced
No tenderness, sacral edema
Normal movement of spine
present
Examination
Abdominal examination :
Inspection :
Skin normal
Linea nigraseen
Purple striaepresent
Shape ovoid
Examination
Palpation :
Symphysio-fundal Height
after centralising~ 38 weeks
Presentation cephalic
Auscultation :
FHS heard in left
infraumblical region, 140/min
1
Normal pregnancy
with Anaemia with Anaemia
Dr. C K Dua
What is your diagnosis
Pregnancy
Anaemia
Why
Obstetric patient is different p
from a non obstetric patient
Altered physiology and its implications on
mother as well as fetus
Uterine placental circulation and placental
d t f drug tranfer.
Involvement of two lives, although young
and healthy but at high risk
High morbidity and mortality
Physiological changes of
pregnancy & their anesthetic
I li ti Implications
C.V.S
CO : 40%
S.V: 30%,H.R:20%
Plasma vol.:45%
Relative RBC vol.
Maintain volume status
UBFif C.O not maintained
Dilutional anemia of
pregnancy & viscosity
S.B.P,D.B.P(N/)
S.V.R
C.V.P
FemoralvenousP.
Uterinevasodilatation
(Progest.Prostacyclin)
15mm
15%
Nochange
15%
Lackofautoregulation
2
CVS
Heart :upward,
leftward shift
Cardiac chambers
Apical impulse :
E.C.G
RAD ,RBBB
Q in lead III.
Flat T wave in lead III
Apical impulse :
cephalad shift
Spilt & loud 1
st
sound
3
rd
H.sound +
Systolic ejection flow
murmer
Benign dysrhythmias
Echo :LVH ,Mild TR
& MR
C.V.S
Aortocaval Compression
IVC compression :V.R & C.output (15%)
Aortic compression
Int.iliac artery & femoral artery compress.
Supine Hypotension Syndrome
U.B.F & fetal Compromise
Nausea ,vomit.,light headedness , syncope
Uterine Displacement
B.P Upper & Lower limbs.
CVS changes in labor
C.Output 10% I stage
25% II stage
40% III stage
Sympathetic activity
Autotransfusion
Anesthetic implication: Fixed C.O
Severe anemia
Respiratory system
Diaphragm up by 4 cm (vertical diameter)
Thoracic cage circumference 5-7 cm
AP and Transverse diameters both
Flaring of ribs
subcostal angle from 68 to103 degrees
RESP. SYS.
FRC , ERV, RV
20%
O2 cons : 20-50%
T V(40%)
Rapid Hypoxemia
Preoxygenation
T.V(40%)
MV( 50%);R.R:
(15%); Pao2 (10% )
Paco2, Hco3
Ph: normal
P50: (30)
Denitrogenation
Rapid intubation
Respiratory changes during labor
Minute ventilation 75% 300%
Oxygen consumption 40% 75%
Serum lactate
3
Oxygen delivery to the fetus
Hyperventilation--Dissolved O2 in blood
Physiological anemia Right shift in ODC
Maternal p50: 26 to 30 mm
Fetal p50 : 18mm
FetalHb : higher affinity than maternal Hb
Airway
Na & H
2
O retention
colloidal osmotic Pr.
leaky capillaries.
Laryngeal & Facial Oedema
Tongue size, Wt. gain(12kg)
Enlarged Breasts
Distortion of glottis
Emergency situations
Friable mucosa Trauma
Anesthetic Implications
Gentle upper airway instrumentation

Avoid naso- pharyngeal instrumentation
Avoid repeated attempts at intubation
Use of smaller size of tubes
Mechanical distortion of
LES by gravid uterus
Changed Angulation of
Stomach & L E S
Gastro-esophagea
reflux
GIT : Risk of aspiration
Stomach & L.E.S
Gastric acid
secretions
Low PH (gastrin)
Delayed gastric
emptying (progestrone)
Esophagitis
Aspiration prophy.
Airway protection
Hematological Changes
H.B (20%) : Dilutional anemia
Dilutional hypoproteinemia
Leukocytosis
Hypercoagul.: clotting factors (30 to 250%)
Fibrinogen,VII,VIII,IX,X,XII
VI
Risk of thrmbo-embolism
Platelet count : N/: R.A. concerns
Renal System
RBF GFR
GFR & Renal threshold
urea , uric acid,
creatin. clearance
Plasmalevels
Glycosuria&
glucose & proteins
Renin angiotensin
Dilatatation of renal
calyces & ureters
ureteic compression
Drug Responses
y
Proteinuria
Naabsorpon
U.T.I
Unaltered
4
Hepatic changes
Less significant change in the H.B.F
Increased splachnic,portal and
esophageal venous pressure
Serum albumin
drug binding unaffected
Pseudocholinesterase (24%)
Alk. Phosphatase (placenta)
Metabolism
BMR
Protein ,Fat,Carbohydrate metabolism
Nutritional demands of fetus first met
Secretion of insulin in response to glucose Secretion of insulin in response to glucose
augmented
Insulin resistance
Accelerated starvation
Hypoglycemia <60mg (normal <40 mg/dl )
Subclinical Hyperthyroidism : (Hcg & oestrogen )
C.N.S & P.N.S
MAC (25-40%)
sensitivity to inhalationals
Sensitivity to general and
local anesthetics
Drug effects :GA
Induction agents : judicious use
Thiopentone : Reqd. (17-18%) p q ( %)
elimination half life.
Propofol : controversial
Ketamine : myometrial tone
UBF at high doses
Muscle relaxants
Reduced choline-esterase levels
Sch: slight prolongation adm. by weight
Vecuronium & rocuronium
rapid onset & plolonged duration
Atracuriun : No change
All may be used safely
Inhalational agents
Hypotension can lead to fetal
compromise
MAC decreased by 25-40%
With MAC >1,uterine muscle relaxation
can predispose to atonic PPH
5
Reduced dose reqd. of LA for
central neuraxis block in the
obstetric patient
Decreased dose req. For LA
Engorged epidural venous plexus
Epidural pressure, Epidural space ,
CSF volume Higher spread.
Lumbar lordosis Higher spread.
CSF H LA diff i CSF pH LA diffusion
Progesterone & Endorphin
sensitivity of nerves to L.A
Ligament relaxation & softening of
collagenous tissues ,Soft L.flavum
Unintentional Vascular inj. PDPH
Uteroplacental circulation
&&
Placental transfer of drugs
Uteroplacental Circulation
U.B.F =(UAP-UVP) /UVR
critical in the development of a healthy fetus
Insufficiency Fetal hypoxia &,Acidosis,
drug toxicity ; IUGR drug toxicity ; IUGR
progressively during pregnancy (10% of c.o)
maximal v.dilatation autoregulation absent
sensitive adrenegicagents
extremehypocapnia(lessthan20mm.)U.B.F
S B.P , Ut. vasocons., Ut.cont U.B.F
Factors affecting Uteroplacental
circulation under anesthesia
Direct factors
RA : IV injection of high dose LA /adr
GA : Barbiturates, inhalational agents
Oxytocin Oxytocin
Vasoconstrictors : adr, phenyleph., methoxamine
Indirect
RA; hypotension
GA ; catecholamines from Lx & intubation
Drug induced hypotension
Placental transfer of drugs
Placental drug transfer
molecular weight, protein binding, lipid
solubility maternal blood concentration solubility, maternal blood concentration
Drug disposition
Fetal PH and protein binding
Uniqueness of fetal circulation
hepatic uptake, dilution of umblical venus
blood across F.Ovale & Ductus Arteriosus.
6
Prenesthetic check up
Pre anesthetic check-up
History
cause of anemia, coexisting problems
General examination
Pallor ,Oedema , Pulse
S/o CCF : CVS, Resp.Sysmptom
ANAEMIA
Definition : Severity
Classification : causes
Definition
WHO
Hb <11 gm/dl ,Hematocrit <33%1
st
& 3rd
trimester
Hb 10 5 /dl H t it 32% d i Hb<10.5 gm/dl,Hematocrit <32%secondtrimester
Developing countries10gm/dl
USAHb <10.5 gm/dl
India : incidence 87.5%.(1993)
Severity of Anemia: ICMR
Mild; 9-11 gm% ODC-mild shift
Mod; 6.5-8gm% ODC-modest shift
Severe;<6.5gm% ODC- marked shift
V. severe; <4gm% ODC- marked shift
Classification of anemia
Morphological
microcytic hypochromic
normocytic normochromic ; macrocytic
Causative
Physiological : Nutritional: Haemorrhagic
Haemoglobinopathy (sickle ,Thallasemia )
Aplastic: Chronic systemic disease
7
Physiological anemia
plasmavol.50%
combatshemorrhageofdelivery
protects mother from hypotension protectsmotherfromhypotension
RBC2040%
needforextraoxygen
plasmavol.&RBCviscosity&
resistancetobloodow
Investigations
Hb, Hct , P smear, blood indices,
S ferritin, Red cell folate,S folic acid,
Serum.B12 ,S.proteins,
Stool- occult blood,hook worm
Urine, B.U.N &Creatinine
T.F.T
E.C.G
Investigations
BLOOD
INDICES
NORMAL Fe DEF. FOLATE &
B
12
DEF.
M C V (f L )
75 - 100 < 75
140/ 110
M C H (pg) 24 - 33 < 25
33 - 40
M C H C (%) 30 -36
< 30 32 - 38
Problems
Problems
Related to pregnancy
Related to anemia
Tissue Oxygen availability
Compensatory mechanisms
Drug Considerations
Anemia & oxygen Delivery
Oxygen dissociation curve
Oxygen flux
C O xCao2(Hbconc x1 39+100x0 3)=1000 C.O.xCao2(Hbconc.x1.39+100x0.3)=1000
Oxygen availability :1000ml.
Oxygenconsumption(VO2):250ml.
O2ExtractionRatio
CriticallevelofVO2
8
Anemia &Compensatory
responses
Increase in CO & venous return
blood viscosity PVR
S f f O C Shift of ODC to right
2-3 DPG & erythropoitin
Redistribution of tissue blood flow
Increase in extraction ratio ( Hct <25%)
Treatment Of Anemia
Severity of anemia & pregnancy duration
Associating complicating factors
Pregnancy <30wks Oral iron
Intolerance / non-compliance Parenteral
Pregnancy 30-36 wks parenteral iron
Pregnancy >36wks Blood
Oral iron Rx
Problems
Intolerance, non compliance
Unpredictable absorption
Long time to improvement; 0.7gms%/ wk
Can be used only below 30 weeks
Parenteral Rx
Indications
C/I to oral Rx
Patient not compliant with oral Rx
Time availability
Advantages
Certainty of administration
Hb rapid @ 1-1.4gm/100ml/week
Calculation of iron deficit
Elemental iron needed (mg)={normal Hb-
Patients Hb} x 2.21 x 1000 }
250 mg of elemental iron for each gm of
Hb below normal
Add 50% of total for replenishment of iron
stores
Parentral Iron Preparations
Intramuscular
Iron sorbitol citrate/ iron dextran
S/E - Headache , Nausea ,Vomiting
- Anaphylactoid reaction, pain, abscess
- iron dextran is less toxic iron dextran is less toxic
100 mg elemental iron given daily/ alt days, Z technique
Intravenous: Iron sucrose
- Low allergenic effect (slow release)
dose >2500mg: two doses over 2 consecutive days
9
Blood transfusion: Indications
Severity of anemia/ refractory anemia
Duration of pregnancy
Assoc. complicating factors/ Acute blood loss
Elective/ emergency surgery
Disagreement trigger/packedcells
Blood transfusion
Advantages
O2 carrying capacity of blood
Stimulates erythropoiesis
Supplies natural constituents of blood
Improvement within 3 days Improvement within 3 days
Problems
Trigger premature labor
Transfusion reaction, CHF
Infections; HIV, Hepatitis B
23DPGlevels&P50instoredbloodO2
delivery.
Blood transfusion: Guidelines
Prefer correctly typed & matched fresh
blood.
Packed cells: 80-100 ml at a time &
diuretic before transfusion to prevent CCF diuretic before transfusion to prevent CCF
Watch for signs of transfusion reaction
Preferably 48 hrs before expected
delivery.
Do not repeat transfusion within 24 hrs
Role of anesthesiologist in
obstetric practice
Antenatal Involvement
Analgesia services
Standby monitoring & management Standby monitoring & management
Anaesthesia for operative delivery
Post operative analgesia
A.N.C: Role of anesthesiologist
Identify coexist. medical & obst. problems.
Identify Influence of physiological changes
Assess potential anesthetic problems
Plan anesthetic options
10
Labor analgesia: Advantages
Decreased blood loss
symp. stimulation & hyperventilation symp. stimulation & hyperventilation
no leftward shift of ODC
maternal stressless chance of CHF
Improved uterine blood flow
More controlled delivery possible
Anesthetic considerations
for operative delivery
Supine hypotension syndrome
Aspiration risk
Faster hypoxemia during apnea
Difficult airway / Intubation difficulty
Altered drug pharmacology Altered drug pharmacology
Fetal considerations
Regional anesthesia
Technical problems/ Controversies
Anemia related considerations
Post operative pain relief
Supine hypotension syndrome
S.H.S : Implications
Maternal hypotension Uterine hypo-
perfusion
Direct uteroplacental hypoperfusion (aortic
compression) compression)
fetal compromise
Aspiration Prophylaxis
Emergency LSCS
Elective LSCS
11
Aspiration prophylaxis
Emergency L.S.C.S
Oral antacids :30ml of 0.3mol/l Na citrate
PO one hr before Sx.
Metoclopramide Metoclopramide
0.15-0.25mg/Kg, IV, 5-10min before Sx
0.15-0.25mg/Kg, IM, 30-45min before Sx
Ranitidine: 50mg, IV, 15min before Sx.
IM , 30-45min before Sx.
Anticholinergics: Atropine 7mcg/Kg /Glyco; 4mcg
Elective LSCS
Omprazole :40mg PO night before & morn Sx/
Ranitidine :150mg PO night before & morn Sx
Metoclopramide:10mg PO two hrs before Sx
Na citrate :0.3mol/l ,30ml PO, one hr before Sx
Anticholinergics: Atopine / Glyco.
Obstetrician plans LSCS for this
patient at 38 wks of pregnancy.
Pre-anesthetic orders
Pre-anesthetic orders
NPO
Part preparation
Shift in left lateral position
Pre-medication
Arrange adequate blood
Written informed consent
GA Vs RA
RA for all elective & and semi-
urgent procedures
GA / RA for stat procedures
12
Advantatages : Regional
No risk of aspiration
Less blood loss
Analgesia can be extended post op Analgesia can be extended post op.
No risk of failed intubation
Decreased fetal drug exposure
Better neurobehavioural score at birth
Mother is aware of child birth
Anemia: Regional Anesthesia
Safe Hb =8 gm% , No cardiac
compromise.
Avoid Hb < 8 gm % , Megaloblastic A
H i b Haemostatic abnorm.
Precautions Fi O
2
, Preload: 500 ml.
vasoconstrictors
Low Dose L.A + Opioid
Problems Preloading
Riskofheartfailure
Symp. block ppt. B.P
Anemia: General Anaesthesia
Preferred Hb = 8 gm % with cardiac decomp.
Hb < 8 gm %
Adv. rapid induction
less hypotension less hypotension
better c.v.s. stability
better control of airway & vent.
post op. ventilat. support possible
no anxiety
Disadv. failed intubation
gastric aspiration
Anaesthetic Considerations
Anaemia Anaemia
Oxygen delivery to tissues
Adequate FiO2
Avoid factors: cause leftward
hif f ODC shift of ODC
Maintain : normothermia,
normoventilation, normotension
Fluid management / Preloading
Careful titration
Avoid overload & decompensation
Minimize blood loss
Surgical haemostasis
Blood replacement and conservation
I/o blood loss : packed cells/ fresh blood.
Meticulous monitoring: CCF/ shock
13
Regional Technique Used
Spinal
Epidural
C.S.E
SAB
Simple tech
Speed of onset
Reliable
Epidural
Difficult tech
Slower onset of action
Failure rate
Epidural V/S S.A.B.
More dense sacral block
Less shivering
Lower req. of LA
Greater hypotension
Greater shivering
Risk of dural puncture
Risk of intravascular
injection
Less hypotension
Post operative analgesia
C. S. E.
* S.A.B.
SPEED OF ONSET & RELIABILITY
LOW TOXICITY
* EPIDURAL CATHETER -
CONTROL HEIGHT OF BLOCK
SUPPLEMENT INADEQ. BLOCK
POST OP. ANALGESIA
Reduced dose requirement
Technique related problems
Epidural test dose ??
Outline a plan for RA for
LSCS
R.A :Protocol
Preloading : balanced salt solution
Maintain uterine displacement
Sitting/ lateral position Sitting/ lateral position
Achieve a block up to T4
Dose req of LA decreased by 33-30%
LA of choice; Bupivacaine
Addition of opioids
Maintain normotension with fluids/ vasopressors
Why is Epidural R.A technically
more difficult in the parturient?
Soft tissue edema
Softening of the ligaments g g
Increased lumbar lordosis
Engorged epidural veins
Loss of negative epidural pressure
pressureinepiduralspace
highriskofduralpuncture&I/Vinj.
14
Vasopressors
Vasopressor of choice; Ephedrine
mixed & agonist with preferential sparing of
uterine vasculature. BP secondary to
rise in CO and PVR.
Mephentermine, methoxamine, phenylephrine
agonist with transient vasoconstrictor action on
uterine vasculature.
Phenylephrine: recent evidence supports its use
Maintenance of UBF more imp. than type of
vasopressor used
P ti t i tl & C/O Patient is restless & C/O nausea
and vomiting under RA.
R.A : Nausea & Vomitting
Hypotension hypoxia
Unopposed parasympathetic activity with
uterine or peritoneal traction
Loss of thoracic proprioception
Measures to prevent N/V
Adequate preloading to avoid hypotension
Supplemental O2
Adequate block
Use of intrathecal opioids with LA
Prophylactic antiemetics
Outline a protocol for GA Outline a protocol for GA
G.A : Protocol
D.A cart esp. Lx : short handle, polio,mccoy blades
Adequate expert help at hand
Maintain uterine displacement
Preoxygenation : High Fio2
Thio + Sch / Rocuronium. (Ketamine : B.P)
RSI with cricoid pressure : small sized tubes
Halo / Iso (0.5 MAC):O2:N2O (50%)- till delivery
Avoid Hyperventilation, hypoxia, hypotension
Maintain uteroplacental circulation
After delivery of fetus; Opioids, change of flows
Reversal; awake extubation, confirm reversal with NM
monitor
15
Anemia: Induction& maintenance
Sedatives : Cautious use
Preoxygenation, FiO2
I.V induction agents : judicious use
Inhalational agents: not much change Inhalational agents: not much change
Avoid factors shifting ODC to left
avoiddruginducedC.O:Cardiostable
AvoidN2Oinmacrocyticanemia
Minimizebloodloss/replacement
Ergometrine/oxytocin:cautioususe
Expected blood loss
NVD; 500ml
LSCS : 1000ml
ID and UD time and its significance
ID time 8- 10min
UD time 3-5min
Foetal Distress & Anesthetic
management
Foetal Distress & Anesthetic M.
Presence of epidural catheter for labor A.
Genuine fetal distress/obstetrician distress
F.distress: 20-30 min.for emergency CS.
Stable/urgent cases
1st choice : RA spinal/ epidural 1st choice : RA spinal/ epidural
Ext.of prexisting epidural / ph adjusted L.A
(NaHco3) / 2Chloroprocaine (3%)
2nd. Choice: GA
Stat procedures : GA (1st choice)
Ext. of epidural(2nd)
SA in expert hands(3rd )
16
Post operative
Avoid shivering
Supplemental FiO2
Adequate analgesia
Follow up Hb/Hct
Observation for potential complications
Haemoglobinopathies
Thallasemia
microcytic hemolytic anaemia
bloodtransfusionreqd.duringpregnancy
hemosiderosis:funconalabnormalies
liver,endocrine,heart
RiskofC.C.F,S.V.T,Pericardis
Anaestheticconsiderations:RA/GA
plateletcount/spont.Haem.
Sickle Cell Anaemia
P.I.H:P.Previa:P.Abrupo:Pretermlabour
Dehyraon:B.P,Temp:,ph,Hbs.
Predisposestosickling
h d C O Vent.HypertrophyduetoC.Output
Vent.Diastolicdysfuncon
Goalsoftransfusion:Hb.>8gm.,HbA>40%
Anestheticconsid.:Avoidhypoxemia,hypovol.
Hyphothermia,acidosis
RA/GAwithgoodanalgesia
1
Parturient For Painless Labour
Dr. PradeepJain
Labour Analgesia
J Y Simpson
Professor of Midwifery Professor of Midwifery,
Univ. of Edinburgh
1847 ( Diethyl ether)
John Snow 1853
Chloroform
Queen Victoria Prince Leopold
Pain In Labour Stages ?
First stage of labour
Beginning of uterine contraction to dilatation of the
cervix
Uterine contraction
Cervical dilatation
Second stage of labour
From dilatation of the cervix to the delivery of fetus
Descent of presenting part
Pain of Labour Dual Pathways ?
First Stage of Labour
Visceral pain mechanism
receptors in cervix & lower uterine segment
Dull aching pain - abdomen, groin & back g p , g
A & C visceral afferent nerve fibers accompanying sympathetic
nerves go from uterus to the spinal cord (T
10
-L
1
)
Second Stage of Labour
Somatic pain - distention of the pelvic floor, vagina and perineum
Pudendal nerves, enter the spinal column at S
2,3,4
segment
2
Site of
origin
Mechanism Pathway Site of Pain
Uterus and
cervix
Distortion,
stretching,
tearing of fibres
Afferents which accompany
sympathetic pathway to T10,
T11, T12 and L1
Upper
abdomen
and groin
Dorsal rami T10-L1 referred to
cutaneous branches of
posterior divisions
mid-back
Bladder, Pressure by S2, 3, 4 Referred to
urethra,
rectum
presenting part perineum
and sacral
area
Vagina Distension,
tearing
Somatic S2, 3, 4 Not
referred
Perineum Distension,
tearing
Pudenal (S2, 3, 4)
Genito femoral (L1,2)
lleoinguinal L1,
Posterior cutaneous
Nerve of thigh, S2, 3
Not
referred
What Is the Intensity of Pain
in Labour ?
Labour pain is themost painful experiencein a womens life
Effects of Labour Pain
on the Mother and Fetus
h
e
t
i
c

S
t
i
m
u
l
a
t
i
o
n
PAIN
Suffering
Loss of Morale
Anxiety
O
2
Consumption
Hyperventilation
Hypocarbia
Cardiac Output
Peripheral Resistance
Blood Pressure
Delayed gastric emptying
S
y
m
p
a
t
h
Catecholamine release
Impaired uterine
contractions
Uteroplacental
blood flow
Adrenocortical Output
Lactic Acid
Free fatty acid
Maternal metabolic
acidosis Fetal pH
Fetal O
2
WHATARETHE
HARMFUL EFFECTS HARMFULEFFECTS
OFLABOURPAIN?
Plasma hydroxy corticosteroids/ catecholamine
utero placental blood flow
Hyperventilation alkalosis- ODC left shift
Oxygen transfer to the fetus and fetal metabolic
id i acidosis
CO and BP
Anxiety, fatigue and catecholamine leads to
dysfunctional labour
Foetal metabolic acidosis
3
WHATARETHE
BENEFICIAL EFFECTS BENEFICIALEFFECTS
OFRELIEVINGLABOURPAIN?
Requirements of Labour Analgesia
Adequate Analgesia
Safety to mother & fetus
Minimal effect on the progress of labour Minimal effect on the progress of labour
Allows the mother to participate in birth experience
No weakening of muscles power
Capability of extension for emergency LSCS
WHATARETHE
METHODSOFPAINRELIEF
INLABOUR?
Non-pharmacological
Pharmacological
- Systemic drugs
Contd
y g
- Inhalational agents
- Regional analgesia
Non-pharmacological
Methods of Pain Relief
Hypnosis
Biofeed back
Acupuncture
TENS TENS
Breathing & relaxation
Hydrotherapy
Aromatherapy
Touch & massage
Music
NonPharmacologicalPainRelief
PreparedChildBirth
Grantly Dick Reads Correct description of method
Child birth without fear
Relaxation technique
Pavlovs Technique Education of mother
Cooperation during bearing down
Fernand Lamaze Psychoprophylaxis
Constant human support companion
Leboyers Theory Semi dark tranquil environment
Warmbath
4
NonPharmacologicalPainRelief
Modern Approach (Psychoprophylaxis)
T h l t & h i l f l b d Teach normal anatomy & physiology of labour and pregnancy
Training in relaxation techniques
Breathing techniques by Dick - Read
Pharmacological Techniques
HowPharmacologicalMethodsofPain
ReliefRelatedtoCervicalDilatation
Systemic Analgesia Systemic Analgesia
SYSTEMIC MEDICATIONS
Opioids
Non-opioids
Ketamine Ketamine
Benzodiazepines
Phenothiazines
Barbiturates
Opioids
Pethidine
Morphine
Fentanyl
Sufentanil
Remifentanil
Butorphanol
Pentazocine
5
Labour Analgesia
Uterine contractions
fetal heart rate
Neonatal respiratory depression
Effects of Narcotics
Neonatal respiratory depression
Neurobehavioral changes
Maternal side effects
Methods of administration
IM, SC, IV, PCA, PCEA, Transnasal, Aerosol
Pethidine
Half life Mother 2-3 hrs, Fetus 18-23 hrs, Metabolite 60 hrs
IM dose: 50 - 100 mg. Peak analgesic effect - 45 min.
IV dose: 25 to 50 mg. Peak analgesic effect- 5 to 10 minutes.
Durationof action - 3 to 4 hrs Duration of action 3 to 4 hrs.
Risk of resp depression born 2-3 hrs after injection
Disadvantages
Maternal nausea, vomiting, resp depression and sedation
Depressed apgar scores
Fentanyl
Potent short acting opioid
Onset 3-5 min Peak effect 5-15 min
Maternal T <1 hour
No active metabolites
Suitable for PCA
Bolus dose 25-50 g every hr
Continuous infusion 0.25 g/kg/hr
Less nausea, sedation, vomiting than morphine
Can cause hypotension, bradycardia, respiratory depression
Remifentanil
Ultra short acting synthetic opioid
Rapid onset
Readily metabolised by plasma & tissue esterases
The effective analgesic half life 6 min
Dose 0.25-0.5 g/kg
Bolus dose 20 g
LOI 3 min,
Continuous infusion, initially 0.025 g/kg/min, maximum 0.15 g/kg/min
Promising solution when neuraxial techniques are contraindicated
Tramadol
Used IV, IM as well as intrathecal
Satisfactory analgesia for 1st stage of labour
Minimal maternal respiratory depression
Limitation Limitation
Nausea & vomiting
Not very effective for 2
nd
stage.
Dose: IM 50-100mg
IV 1mg/Kg
Butorphanol
Strong kappa agonist, weak antagonist
Ceiling effect on respiratory depression & analgesia
Dose butorphenol 1- 2 mgm Dose butorphenol 1 2 mgm
High neurobehavioral scores
Immense sedation
Psychomimetic effects in larger doses
6
Ketamine
Low dose- 0.2-0.4mg/kg IV not to exceed 1mg/kg
Infusion 0.25g/kg/hr
Potent analgesic in low dose without neonatal
depression
Maintain verbal contact & monitoring
Indications
Imminent vaginal delivery
Patchy epidural anesthesia
Never established for labour analgesia
Enables mother to tailor her analgesic needs
Poor efficacy of intravenous opioids
Patient Controlled Analgesia
Neonatal effects
Expensive
Indications
Where regional contraindicated or technically difficult
Inhalational Analgesia Inhalational Analgesia
Inhalational Analgesics used ?
Entonox
Sevoflurane
Isoflurane
Desflurane
Trilene
Methoxyflurane
Chloroform
Inhalational Analgesia
Used in subanaesthetic dose
Oldest and widely used
Pain not relieved completely, but uterine contractions
more tolerable
Rapid onset
Peak analgesia concentration during peak of contraction
Entonox
PCIIA :safe, self administered
Onset of action 30 secs
Maximum analgesic effect 45-60 secs
Low B/G solubility of N
2
O (0. 46)
Rapid diffusion, induction & recovery
Start using as soon as contraction starts and discontinue at peak of the contraction
Demand valve connected to a face mask
Valve opens when the user applies negative pressure
When system not in use there is no flow
Lack of scavenging systems
Side effects
Dizziness
Nausea
Dysphoria
Lack of cooperation
7
Inhalational analgesia
Desflurane, enflurane & isoflurane effectiveness is comparable to
that of N
2
O
Recent studies suggest sevoflurane in inspired concentration of
0.8% to be acceptable & effective
Provide superior pain relief but with more intense sedation without
adverse effects with compared with entonox
Isoflurane 0.2 - 0.25% with N
2
O (ISONOX)
Desflurane 1 - 4.5% with N
2
O
Use limited by drowsiness, unpleasant smell & high cost
Cyprane Inhaler Cardiff Inhaler
Emotril Inhaler Entonox Inhaler
Whatneuraxialtechniquescan
beusedforprovidinglabour
analgesia?
Neuraxial Techniques
Neuraxial Techniques
Lumbar epidural- Intermittent doses continuous infusion, PCEA or
PCEA plus continuous infusion
Segmental epidural analgesia
Double catheter technique
CSE (walking epidural)
Caudal epidural
Spinal and continuous spinal
Neuraxial Anatomy in Pregnancy
Lumbar lordosis
Widening & rotation of the pelvis
Head down tilt
Tuffiers line crosses spine at a
Reduction in intervertebral gap
Enhanced rostral spread
higher level ie L3-4 space
Engorgement of epidural veins
Difficult identification of
ligamentum flavum
Increased sensitivity to local
anesthetics
Narrow epidural space
8
Lumbar Epidural Analgesia
Indications?
Patient demand
Reduces stress response during labour
Preeclempsia
Diabetes
Obstetric indications
- Incoordinate uterine contraction
- Dystocia
- Full stomach
Fetal indications
- Prematurity
- Multiple pregnancies
- IUGR
Prophylactic Epidural - Indications ?
Maternal request
Morbid obesity
Difficult airway
Non reassuring fetal heart
Maternal cardiovascular disease
Contraindications
Patient refusal
Uncooperative patient
Coagulopathy
Hypovolemia
Epidural site infections
Deformity of back
Lack of resuscitation equipment & drugs
Unskilled or inexperienced anesthesiologist
Preanaesthetic check up
Consent of patient
Intravenous access
Monitoring
Lumbar Epidural Analgesia
Prerequisite ?
Monitoring
Asepsis
Test dose - intravascular, subarachnoid
Trained staff
Resuscitation equipment and drugs
Bed/ OT table maneuverable to
trendelenberg position
Low dose epidural regime ?
Traditionally bupivacaine
L.A. conc. 0.2-0.25%
Now MLAD & MLAV 0.0625% - 0.125%
Ropivacaine 0.1% -0.2%
Total dose of L.A.
Side effects such as motor blockade
Addition of Opioid
Low dose mixture of L.A. & opioid
(0.0625% - 0.125%) +2g/ml
Infusion 6-8 ml/hr
Adjuvants
Advantages
Feeling of control
Immediate access to additional dose of epidural
Patient Controlled Epidural Analgesia (PCEA)
p
Less motor block - ambulation
Lower drug use
Minimal sympathetic block
Lower staff workload
9
Subarachnoid component
Epidural component
Most important new technique in obstetric
analgesia dubbed as Walking epidural
Ad t
Combined Spinal-Epidural Analgesia
Advantages
Rapid onset of pain relief
Better perineal analgesia
Higher ambulatory potential
Lower drug use
Dose Regimen for CSE
Initial
Fentanyl : 25 50 g and Bupivacaine : 1.25-- 2.5 mg
Followed by
Continuous infusion 0.0625% bupivacaine with 2 g/ml fentanyl @
8-10 ml/hr or PCEA 68ml with LOI of 20 min
Epidural versus CSE
Epidural
Slow onset of action
Graded block
Less hypotension
Disadvantage
CSE
Sure technique
Rapid onset of action
Epidural catheter placement
confirmatory
Can be patchy
Ineffective
Catheter dislodgement
Indications
CVS disease
Non reassuring fetal heart
Reduced motor block
Preservation of proprioception -
ambulation possible
Indications
Late labour
Morbid obesity
CRITERIA FOR
WALKING EPIDURALS
No obstetrical contraindications
No change in lying-to-sitting BP
Ability to perform SLR
Some one available to walk with the patient
Alternative technique who can not receive neuraxial block
Pain relief during 1
st
stage of labour
No somatic or motor block
Halts transmission of visceral afferent impulses from uterus & cervix
through paracevical ganglia
Paracervical Nerve Block
5-10 ml of LA are deposited in left & right vaginal fornix
Side effects
LA toxicity, postpartum neuropathy,
sacral plexus trauma, hematoma
Fetal bradycardia
Pudendal Nerve
Sensory innervation of lower vagina, valva perineum, motor to
perineal muscle & external anal sphinter
2
nd
stage of labour
Trans vaginal or transperineal route Trans vaginal or transperineal route
7-10 ml of LA on each side medial & posterior to ischial spine
Forceps delivery, Episiotomy
S/E LA toxicity, infection hematoma
10
What is New ?
Maternal request alone is indication
Ultrasound guided blocks
MLAD & MLAV
Fentanyl & Remifentanil
Ropivacaine
CSE technique
More awareness
1
PreeclampsiaandEclampsia
Dr.Medha Mohta
Case
Radhika,23yearsfemale,primigravida,37weeks
gestation
H/oheadacheandpaininupperabdomen 34
days days
HR 84/min
BP 168/118mmHg
Chest clear
Urineprotein+
DifferentialDiagnosis
GestationalHT
Preeclampsia
Eclampsia
ChronicHT
ChronicHTwithsuperimposedpreeclampsia
GestationalHypertension
SystolicBP> 140mmHgordiastolicBP> 90mmHg
forfirsttimeafter20weeksgestation
Noproteinuria
HTresolvesby12weekspostpartum
Finaldiagnosismadeonlypostpartum
Preeclampsia
Pregnancyspecificmultisystemdisease
NewonsetofHTandproteinuria after20weeks
gestation;resolvesby12weekspostpartum
Mild/Severe
BP> 140/90mmHgontwoormoreoccasionsatleast4
hrsapart(measuredatrest,usingKorotkoff Vas
diastolicvalue,withappropriatelysizedBPcuff)
Proteinuria > 300mg/24hrsor> 1+dipstick(30mg/dl)
Urineprotein:creatinine ratio(UPCR)
(Significantproteinuria >30mg/mmol)
SeverePreeclampsia
SustainedBP> 160mmHgsystolicor> 110mmHgdiastolic
(measuredtwice,atleast6hrsapart)
Proteinuria >5g/24hror>3+dipstick(300mg/dl)
Headache
Visualdisturbances
Epigastric orrightupperquadrantpain p g g pp q p
Pulmonaryoedema
Oliguria
Elevatedserumcreatinine
Thrombocytopenia
HELLPsyndrome
Evidenceoffetal compromise(IUGR,oligohydramnios,
nonreassuring fetal testing)
2
Eclampsia
Occurrenceofgeneralizedconvulsionsduring
pregnancy,labourorwithin7daysofdeliveryin
absenceofepilepsyoranothercondition
predisposing to convulsions predisposingtoconvulsions
Onsetofconvulsionsinawomanwith
preeclampsiathatcannotbeattributedtoother
causes
ChronicHypertension
SystolicBP> 140mmHgordiastolicBP> 90mmHg
beforepregnancyordiagnosedbefore20weeks
gestationnotattributabletogestational
trophoblastic disease trophoblastic disease
HTpersistentafter12weekspostpartum
ChronicHTwithsuperimposed
preeclampsia
Newonsetproteinuria > 300mg/24hoursafter
20weeksgestationinhypertensivewomen,or
Suddenincreaseinproteinuria and/orHTorother
manifestationsofpreeclampsiaafter20weeks
gestationinwomenhavingchronicHTand
proteinuria before20weeks
OurPatient
23years,primigravida,37
weeksgestation
h/oheadache andpainin
upperabdomen x34days
HR 84/min
Bookedcase
LastANCvisit2weeks
back
BP 124/82 H
HR 84/min
BP 168/118mmHg
Chest clear
Urineprotein+
BP124/82mmHg
Noantihypertensives
Urineprotein nil
Noothercomplaints
Severe
Preeclampsia
Preeclampsia
Pathogenesis
Riskfactors
Clinicalmanifestations
Pathogenesis
Exactmechanismnotknown
Placenta pathogenetic focusofdisease
Abnormalplacentation
Geneticfactors
Immunologicfactors
Antiangiogenic proteins
3
Prof.A. K. SethisEORCAPS-2013 Prof.A. K. SethisEORCAPS-2013
Stage1
Poorplacentation
(early)
Stage2
Placentaloxidative
stress(late)
Fetal growth
restriction
Systemicreleaseof
placentalfactors
Systemicinflammatory
response,endothelial
activation
Preeclampsiasyndrome
Geneticfactors
Incidencehigheramongfamilymembers women
withafirstdegreerelativewhohadpreeclampsia
morelikelytodevelopdisease
Menbornfrompreeclamptic pregnancymorelikely
tobefathersinpreeclamptic pregnancy
Geneticpredispositionimportantinlateonset
preeclampsia
Immunologicfactors
Uterinenaturalkillercellsinteractwithfetal
trophoblast cellmarkersviamaternalkiller
immunoglobulinreceptors influence
trophoblastic invasion
Trophoblastic humanleucocyte antigenC(HLAC)
Activatedautoantibodies toangiotensin receptor1
(AT1)
Antiangiogenic proteins
Endogenousantiangiogenic proteinsofplacentalorigin
Solublefmsliketyrosinekinase1(sflt1)
t i f i i th f t l antagonismofangiogenic growthfactors,vascular
endothelialgrowthfactor(VEGF)andplacental
growthfactor(PIGF)
Solubleendoglin (sEng) elevatedinHELLPsyndrome
Whataretheriskfactorsfor
d l f l ? developmentofpreeclampsia?
4
Riskfactors
Maternalobstetricfactors:nulliparity,H/o
preeclampsia,multiplegestation,gestationalHT,
molarpregnancy
Maternalcomorbid conditions:chronicHT,DM,
thromboticvasculardisease
Maternalgeneticfactors:antiphospholipid antibody,
FactorVLeidenmutation(proteinCresistance),first
degreerelativewithapreeclamptic pregnancy
Riskfactors...
Maternallifestylefactors:obesity,smoking(risk)
Othermaternalfactors:race,age>35years
Paternalobstetricfactors:paternitybymalewho
fatheredapreviouspreeclamptic pregnancy,
limitedpreconceptional exposuretopaternalsperm
ClinicalManifestations
ClinicalManifestations
CNS
Headache,visualchanges,hyperexcitability,
hyperreflexia,coma,convulsions(eclampsia)
Visual disturbances photophobia diplopia blurred Visualdisturbances photophobia,diplopia,blurred
vision
Duetoischaemia causedbyvasospasmofposterior
cerebralarteriesorcerebraloedemainoccipitalregions
Headache,hyperreflexia,clonus warningsignsof
increasedcerebralirritation
ClinicalManifestations...
CVS
Increasedvasculartoneandsensitivityto
vasoconstrictors HT,vasospasm,endorgan
ischaemia BPandSVR
Intravascularvolumedepletion
Majority hyperdynamic LVfunction
Smaller,highriskgroup LVfunction,markedly
SVR, intravascularvolume
SignificantdisparitybetweenCVPandPCWP
Respiratorysystem
Pharyngolaryngeal edema
Increasedriskofpulmonaryedema duetolower
colloidoncotic pressureandincreasedvascular p
permeability
Haematologic system
Thrombocytopeniainseveredisease(1520%)
Hypercoagulability inmilddisease,hypocoagulability
inseveredisease
DIC
5
Renalsystem
GFR,proteinuria, uricacid
urineprotein:creatinine ratio
Oliguria
Hepaticsystem
Periportal hmg,fibrindepositioninhepaticsinusoids
serumtransaminases
Hepaticedema/rightupperquadrantabdominal
pain;ruptureofGlissons capsulewithhepatichmg
Endocrinesystem
Imbalanceofprostacyclin relativetothromboxane
Upregulation ofsystemicrenin angiotensin aldosterone
system
Uteroplacental system
Persistenceofahighresistancecircuitwith bloodflow
IUGR;oligohydramnios
Eye
Retinalarteriolarconstriction,retinaldetachment,
blindness
Prof.A. K. SethisEORCAPS-2013 Earlyonset Lateonset
Onsetofclinicalsymptoms <34weeksgestation >34weeksgestation
Relativefrequency
(% ofcases)
20 80
Riskforadverseoutcome High Negligible
Associationwith
intrauterine fetal growth
retardation
Yes No
Clearfamilialcomponent Yes No
l l h l Ab l N l Placentalmorphology Abnormal Normal
Etiology Placental Maternal
Riskfactors(relativerisk) Familyhistory Diabetes,multiplepregnancy,
increasedBPatregistration,
IncreasedBMI,Maternalage
>35yrs,Cardiovascular
disorders
Haemodynamics at24
weeks
Highertotalvascular
resistance,lowercardiac
output
Lowertotalvascular
resistance,highercardiac
output
Prophylaxis
Dietarymanipulation lowsaltdiet,calcium
supplementation,fishoilsupplementation
Cardiovasculardrugs diuretics,antihypertensive
drugs
Antioxidants Ascorbicacid(VitaminC),
tocopherol (VitaminE)
Antithromboticdrugs Lowdoseaspirin,
aspirin+heparin aspirin/dipyridamole
Nonehasbeenfoundtobeefficaciousexceptlow
doseaspirin
Prophylaxis...
Lowdoseaspirin
Inhibitsplateletthromboxane A2synthesiswithout
affectingsynthesisofvascularprostacyclin avoids
imbalanceinthromboxane toprostacyclin ratio
May be of benefit only in women at higher risk for Maybeofbenefitonlyinwomenathigherriskfor
severepreeclampsia
Hypertensivediseaseduringapreviouspregnancy
Chronickidneydisease
AutoimmunediseasesuchasSLEorantiphospholipid
syndrome
Type1ortype2diabetes
Chronichypertension.
ManagementofPreeclampsia
6
Management
Mildpreeclampsia
Sameasanyotherhealthypregnantwoman
Carefulmonitoringneededtodetectprogression
toseverepreeclampsia
Severepreeclampsia
Deliveryoffetus andplacentaistheonlycure
Vaginaldeliverypreferable
CS maternal/fetal conditionmandates
immediatedeliveryORotherindicationsforCS
ManagementofSevere
Preeclampsia
Supportive
Hospitaladmission
Treatmentofhypertension
Seizureprophylaxis
Optimizationofintravascularstatus
Administrationofcorticosteroids
Monitoring
Treatmentofhypertension
NonsevereHT(mildmoderate)
SBP140159mmHg&DBP90109mmHg
Nocleardifferencesbetweenantihypertensivet/tor
placebo placebo
Riskofhaemorrhagicstrokeinpresenceofsystolic
HTloweringofSBPto140150mmHgandDBPof
80100mmHgrecommended
Orallabetalol DOC
(NICEclinicalguidelines107,August2010)
Treatmentofhypertension...
Antihypertensives
Methyldopa,labetalol,nifedipine,isradipine,some
bl k ( t l l i d l l l l) f blockers(metoprolol,pindolol,propranolol) safe
Atenolol notrecommended(fetal growth
restriction)
ACEinhibitors&ARB contraindicated(congenital
anomalies)
Treatmentofhypertension...
SevereHT
SBP>160mmHgorDBP>110mmHgmustbetreated
preventsmaternalcomplicationse.g.myocardialischaemia,
hypertensiveencephalopathy,cerebrovascular hmg,CHF
A id i it f ll i BP t i t i t l t l AvoidprecipitousfallinBPtomaintainuteroplacental
perfusionandO
2
deliverytofetus
BPloweredtosystolic140150mmHg/diastolic80100
mmHg@1020mmHgevery1020min
Commonlyuseddrugs Hydralazine,labetalol,nifedipine,
SNP
Drug Mechanismof
action
Dose& route Onset
of
action
Sideeffects/caution
Hydralazine Direct
vasodilator
5mgIVevery
1520min,max
30mg
1020
min
Hypotension,tachycardia,
palpitations,headache,neonatal
thrombocytopenia
Labetalol 1& blocker
(1:7)
20mgIVevery
10min,max220
mg
510
min
Lessthanhydralazine,avoidin
severeasthma,CHF
Nifedipine Calcium 10 mg oral 30 45 Interactions with MgSO severe Nifedipine Calcium
channel
blocker
10mgoral,
repeatedafter
30min,if
needed
3045
min
InteractionswithMgSO
4
severe
hypotension,neuromuscular
blockade.
S/Lnotrecommended
Sodium
nitro
prusside
Smoothmuscle
vasodilator
releasesNO
0.255
g/kg/minIV
infusion
0.51
min
Hypotension,bradycardia.Riskof
fetal cyanidetoxicity.Usedfor
limitedperiodonly, continuous
intraartmonitoringmandatory
Methyldopa Centralaction,
reducessymp
outflow
13gdailyin34
dividedoral
doses
24
hours
Drowsiness,depression,postural
hypotension
7
Cautiousadministrationofupto 500mlcrystalloidis
recommendedbeforeoratsametimeasinitialdose
ofIVhydralazine toreducethechanceofa
precipitousfallinBP.
(NICEclinicalguidelines107,August2010)
Pharmacological agent of choice in women with Pharmacologicalagentofchoiceinwomenwith
preeclampsiaandacutepulmonaryoedemais
glyceryl trinitrate.
Administeredasaninfusionof5g/min,increasing
every35mintoamaximumdoseof100g/min.
(EuropeanSocietyofCardiologistsguidelines2011)
Seizureprophylaxis
Magnesiumsulphate DOCforpreventionof
recurrentseizuresineclampsia
Effective(Magpietrial)andsuperiortodiazepamand
phenytoin (Collaborativeeclampsia trial)
Useextendedtoseizureprophylaxisinsevere
preeclampsia
Publishedevidencesupportsadministrationof
magnesiumsulphateforpreventionofseizures,but
thereisnoevidenceofbettermaternalorneonatal
outcomeswithitsuse.
Magnesiumsulphate
Cerebralvasodilator(blockscalciuminflux
throughNMDAsubtypeofglutamatechannel)
Mechanismofanticonvulsantaction notwell
understood
E li E l ti i th ht t lt f Earlier Eclamptic seizuresthoughttoresultfrom
cerebralvasospasm
Recentevidence AbruptsustainedBPelevation
overwhelmsmyogenic vasoconstriction forced
dilationofcerebralvessels,hyperperfusion,
cerebraloedema
MagnesiumSulphatedosage
schedule
ContinuousIVinfusion
Loadingdose 46gIVin100mlfluidover1520
min
Maintenance infusion 1 2 g/hr Maintenanceinfusion12g/hr
MonitoringforMgtoxicity
AssessDTR,urineoutput,RRandO
2
saturation
S.Mglevelsat46hrsorifS.creatinine >1.0mg/dl
Discontinued24hrsafterdelivery
MagnesiumSulphatedosage
schedule...
IntermittentIMinjections
4gIV@nottoexceed1g/min
5gdeepIMineachbuttock
5 d IM 4 h i lt t b tt k ft 5gdeepIMevery4hrsinalternatebuttockafter
ensuringthat
Patellarreflexispresent
Respirationisnotdepressed
Urineoutputinprevious4hrs>100ml
Discontinued24hrsafterdelivery
Magnesiumtoxicity
S.Mgconc.
Normalrange 1.72.4mg/dl(1.42.2meq/lor0.71.1
mmol/l)
Therapeuticrange 4.88.4mg/dl(47meq/lor2.03.5
mmol/l)
Loss of DTR 12 mg/dl LossofDTR 12mg/dl
Respiratoryarrest 1520mg/dl
Cardiacarrest>25mg/dl
(mg/dlX0.411=mmol/l)
Treatment
Discontinuationofinfusion
IVCagluconate 1gover10min
O
2
,mechanicalventilation,ifrequired
8
Optimizationofintravascularstatus
Carefuladministrationoffluids(highincidenceof
pulmonaryoedema)
UseofIVfluidstoincreaseplasmavolumeortreat
oliguria inawomanwithnormalrenalfunctionand g
stableserumcreatinine levelsisnotrecommended
(CochraneDatabaseofSystematicReviews1999;4:
CD001805)
Limitmaintenancefluidsto80ml/hrunlessthereare
otherongoingfluidlossese.g.haemorrhage
(NICEclinicalguideline107,August2010)
Monitoring
Regularhaemodynamicmonitoringrequired
RapidchangesinBPduetodiseaseprogression,
antihypertensivedrugsandIVfluids
Intravascularvolumedepletion
Indications for intra arterial BP IndicationsforintraarterialBP
PoorlycontrolledBP,needforcontinuousBP
monitoring
UseofSNP/NTG
NeedforfrequentABGsamples
Needtomonitorcardiacoutputusingminimally
invasivetechnique
Monitoring...
Invasivecentralmonitoring
Indicationssimilartothoseinothermultisystem
disorderse.g.Severesepsis,MODS,pulmonary
oedema,cardiomyopathy
Presenceofseverepreeclampsiapersenotan
indicationforCVPorPApressuremonitoring
Complicationsofsevere
preeclampsia
Maternal
Antepartumhmg due
toplacentalabruption
Cerebrovascular
Fetal
Growthrestriction
Pretermbirth
Intrauterine death
Cerebrovascular
accidents
Eclampsia
Pulmonaryedema
HELLP,DIC
Hepaticfailure/rupture
Renalfailure
Intrauterinedeath
HELLPSyndrome
Variantofseverepreeclampsia
Haemolysis(H),elevatedliverenzymes(EL),
lowplatelets(LP)
Right upper quadrant/ epigastric pain Rightupperquadrant/epigastric pain
Nausea,vomiting
Headache
Hypertension
Proteinuria
HELLP DiagnosticCriteria
Haemolysis
AbnormalP/S fragmentedRBC,schistocytes
Lacticdehydrogenase > 600IU/L
Bilirubin > 1.2mg/dlwithdecreasingHct
Elevatedliverenzymes
SGOT> 70IU/L
Lacticdehydrogenase > 600IU/L
Thrombocytopenia Plateletcount<100,000/mm
3
9
HELLP Management
Similartoseverepreeclampsia(including
antihypertensives,seizureprophylaxis)
Stabilizematernalcondition
Correctcoagulationabnormalities platelet
transfusionincasesofsignificantbleeding,platelet
count<20,000/mm
3
or<50,000/mm
3
undergoing
surgery
Assessfetal condition
GA anaesthetictechniqueofchoiceforcaesarean
delivery
RoleofcorticosteroidsinHELLP
Corticosteroidscanbegiventoacceleratefetal lung
maturitybefore34weeks,iftimepermits
Observationalstudies corticosteroidsshownto
l l f l d increaseplateletcountifgiveninantenatalperiod
Insufficientevidencetosupportortorefute
adjuvantcorticosteroidusewitheither
dexamethasone (1012mg),betamethasone (12
mg)orprednisolone.
(Cochranedatabaseofsystematicreviews2010)
Pulmonaryoedema
Incidence3%
Canoccurpostpartum(within23daysofdelivery)
Only30%casesoccurbeforedelivery
Higherriskinolder,multigravid womenandin
preeclampsia superimposed on chronic HT or renal preeclampsiasuperimposedonchronicHTorrenal
disease
Causes lowcolloidosmoticpressure,
intravascularhydrostaticpressureand
pulmonarycapillarypermeability
Treatment similarprinciplesasinnonobstetric
population
Pulmonaryoedema...
O
2
saturationmonitoring
O
2
supplementationvianoninvasivemethodsor
intubationandventilation
IVfurosemide bolus2040mgover2min repeated
doses of 4060 mg after 30 min if inadequate dosesof4060mgafter30min,ifinadequate
diureticresponse(maxdose120mg/hr)
IVmorphine25mg
Fluidrestriction,strictfluidbalance
Positioning elevatedhead,antenataluterine
displacement
(Anaesthesia2012;67:64659)
Whatistheroleof
anaesthesiologistinmanagement
ofpreeclamptic patient?
RoleofAnaesthesiologist
Toprovidelabouranalgesia
Toprovideanaesthesiaforcaesareansection
Resuscitation
Intensivecaremanagement
10
Labouranalgesiainseverepreeclampsia
Labouranalgesia
InabsenceofC/I,lumbarneuraxial analgesiais
appropriateforwomenwithpreeclampsiaduring
labour
ContinuouslumbarepiduralanalgesiaorCSE
Early administration of epidural analgesia Earlyadministrationofepiduralanalgesia
AvoidsGAineventofemergencyCS
Optimizestimingofcatheterplacementinsetting
ofdecliningplateletcount
Beneficialeffectonuteroplacental perfusion
Goodanalgesiaattenuateshypertensiveresponse
topain
Placeearlyepiduralcatheterinparturients with
preeclampsia,whichmayevenprecedeonsetof
labourorthepatientsrequestforanalgesia.
(ASATaskForceonObstetricAnesthesia.Practice
guidelinesforobstetricanesthesia.
Anesthesiology 2007;106:843863)
Considerationsduringneuraxial
analgesiainpreeclampsia
Assessmentofcoagulationstatus
IVhydrationpriortoLAadministration
Treatmentofhypotension
Coagulationstatus
Plateletcount>100,000/mm
3
furthercoagulation
testingnotrequired
Plateletcount<100,000/mm
3
PT,PTT,fibrinogen
levels
Platelet count < 50,000/mm
3
neuraxial procedure C/I Plateletcount<50,000/mm neuraxial procedureC/I
Plateletcount>75,000/mm
3
inabsenceofother
coagulationabnormalitiesisnotexpectedtoincrease
likelihoodofneuraxial anaestheticcomplicationsin
settingofpreeclampsia adequateforcatheter
insertionaswellasremoval
(Anaesthesia2012;67:10091020)
Plateletcount50,00075,000/mm
3
weighrisk/benefit
Skilledanaesthesiologist
Spinaltechniquepreferred(smallerneedle)
Carefulneurologicmonitoring
Immediateneurosurgicalconsultation,ifrequired
Trendsinplateletcountimportant
Stable measureevery6hrs;fallingtrend within13
hrsbeforeneuraxialprocedure
11
Intravenoushydration
riskofpulmonaryoedema carefulattentionto
fluidinfusionrate
IVfluidloadingnotusedinpatientswithsevere
preeclampsiabeforeestablishinglowdoseanalgesia
Treatmentofhypotension
Mildpreeclampsia routinedosesofvasopressors
Severepreeclampsia smalldosesofvasopressors
initially(e.g.Ephedrine2.5mgorphenylephrine25
50g)toassessmaternalBPresponsebeforegiving
largerdoses
AnaesthesiaforCSinpreeclampsia
Anaestheticconsiderationsin
severepreeclampsia
Hypertension,antihypertensivedrugs
Riskofseizures
Difficultairway
Reducedplasmavolume
Riskofpulmonaryoedema
Coagulopathy
Renaldysfunction
Hypoproteinemia
Alteredliverfunction
IncreasedsensitivitytoNMBA(MgSO
4
)
Anaestheticmanagement
Preanaestheticevaluation
Choiceofanaesthetictechnique
Postoperativemanagement
Preanaestheticevaluation
History
Gravida
Headache
Visualblurring,diplopia,
photophobia
Epigastric /rt upperquadrant
pain
T/tHistory
Medications
(antihypertensives?)
FamilyHistory
1
st
degrelativewith
preeclamptic pregnancy
GPE pain
Urineoutput
Abnormalbleeding
Seizures
PreexistingHT/DM
ObstetricHistory
Preeclampsiainprevious
pregnancy
GPE
Levelofconsciousness
BMI
Icterus
Oedema
BP
Airwayexam
Systemicexamination
DTRimportant
Investigations
Hb,Hct (haemoconcentration,haemolysis)withplatelet
count(thrombocytopenia),P/S(ifsuspectingHELLP)
BG
Urine albumin(proteinuria),sugar(DM)
KFT Urea,creatinine,uricacid(severepreeclampsia) , , ( p p )
LFT bilirubin,transaminases,LDH(severepreeclampsia,
HELLP),proteins(hypoproteinemia)
PT,PTT,fibrinogen(ifcoagulopathy suspected)
S.Magnesiumconc.(ifonMgSO
4
andevidenceoftoxicity)
Fundus examination(severecases)
12
Choiceofanaesthetictechnique
Neuraxial anaesthesiaisthepreferredmethod
AvoidsdisadvantagesofGA
Hypertensive response to intubation intracranial Hypertensiveresponsetointubationintracranial
hmg
Airwayoedema possibilityofdifficultintubation
Singleshotspinal/epidural/CSE
Traditionalview
Epiduralanaesthesiaconsideredtheoptimal
techniqueinseverepreeclampsia
SpinalanaesthesiarelativelyC/I(rapidonsetof
sympatheticblock possibilityofmarked
hypotension)
Advantagesofepidural
AbilitytotitrateLAandfluids
StablematernalBPwithoutprecipitousfall
Lessriskoffluidoverload&pulmonaryoedema
Optimizationofuteroplacental perfusion
RecentEvidence
Patientswithseverepreeclampsiaexperienceless
frequent,lessseverehypotensionthanhealthy
parturients
Spinalmaycausegreaterdegreeofhypotensionthan
epidural;howeverhypotensioniseasilytreatedand
shortlived;nodifferenceinoutcome
Spinalanaesthesiaisreasonableanaestheticoptionin
severepreeclampsiaforCSwhenthereisno
indwellingepiduralcatheterorC/Itospinal
anaesthesia
Hypotension titratedvasopressordoses(greater
vascularsensitivitytovasoconstrictors)
(AnaesthesiaandAnalgesia2013;117:686693)
IndicationsofGA
Coagulopathy/severethrombocytopenia
Severeongoingmaternalhaemorrhage
Pulmonaryoedema
Sustainedfetal bradycardia
Eclampsia
AdministrationofGAtopatient
withseverepreeclampsia
Preparationtodealwithdifficultairway(smaller
trachealtubes)
Avoidrepeatedintubationattempts LMAreasonably
safealternative(?Riskofaspiration)
Attenuationofhypertensiveresponsetolaryngoscopy
andintubation/extubation(riskofcb hmg,pulm
oedema)
Labetalol,esmolol,lidocaine,NTG,SNP,remifentanil
(cliniciansshouldusethedrugswithwhichtheyare
mostfamiliar)
Interactionsofmagnesiumsulphatewithnon
depolarizingmusclerelaxants increasedpotency
&duration givesmalldoses,monitorwith
peripheralnervestimulator
(Achrelease,endplatesensitivitytoAch,
) musclemembraneexcitability)
Onsetanddurationofsuccinylcholine not
prolonged
Interactionofmagnesiumsulphatewith
nifedipine greaterhypotensive effect
13
Useofoxytocic agentsinsevere
preeclampsia
Oxytocin drugofchoice,carefullytitratedto
haemodynamicresponses
Ergometrine notused(hypertensivecrisis)
Prostaglandins(15methylPGF2/misoprostol)
secondlinedrugs
AssociatedwithelevationsinBP,buttoalesser
degreethanergometrine
Monitoring
HR
ECG
NIBP
SpO
2
EtCO
2
Neuromuscular
monitoring
2
Urineoutput
Mglevels
Coagulationprofile
Fetal monitoring
Postoperativecare
Oxygen
VitalsmonitoringincludingNIBP,RR
Analgesics
Antihypertensives tobecontinued yp
MgSO
4
for24hours
CarefuladministrationofIVfluids
Urineoutput
ProphylaxisforVTE(intermittentpneumatic
compressiondevices)
IndicationsforICUadmission
Invasivehaemodynamic
monitoring
SevereHT
Guidedfluidbalance
Mechanical ventilation
HELLPsyndrome
Disseminatedintravascular
coagulation
Acute renal failure Mechanicalventilation
Aspiration,ARDS
Pulmonaryoedema
Airwayprotection
Seizures
Upperairwayoedema
Acuterenalfailure
Neurological
Severeconvulsions
stroke
(CurrentAnaesthesiaandCriticalCare
2000;11:8691)
Eclampsia
Eclampsia
Antepartum
Intrapartum
Postpartum p
Mostcommon intrapartum orwithinfirst
48hoursafterdelivery
14
Complicationsofeclampsia
Maternal
Pulmonaryoedema
Cerebrovascular
accident
Fetal
Placentalabruption
SevereIUGR
Extreme prematurity
accident
Acuterenalfailure
Pulmonaryaspiration
Cardiopulmonaryarrest
Death
Extremeprematurity
Death
Clinicalpresentation
Anypathophysiologic changesofpreeclampsia
Seizures abruptonset,tonicclonic
Diagnosis
Suddenseizureinapregnantwomanhaving
signs/symptomsofpreeclampsia
Awomanlapsingintocomawithoutwitnessed
convulsionscanbeclassifiedaseclamptic
Untilprovenotherwise,occurrenceofseizures
duringpregnancyshouldbeconsideredeclampsia
Mechanismofeclamptic seizures
Previouslysuggestedmechanisms
Vasospasm,ischaemia,haemorrhage,hypertensive
encephalopathy cerebral oedema encephalopathy,cerebraloedema
Latesthypothesis
Lossofnormalcerebralautoregulatory mechanism
hyperperfusion cerebraloedema,decreased
cerebralbloodflow
Management
Stopconvulsions
Establishpatentairway
Preventcomplicationse.g.Aspiration,
hypoxemia
Antihypertensives
Expeditiousdelivery(preferablyvaginal)
Managementofseizures
Airway
Leftlateral,jawthrust
Nasopharyngealairway,
ifnecessary
Breathing
Drugs
IVMagnesiumsulfate
46gIV 12g/hrinfusion
2gIVover10minforrecurrent
seizures
g
Bagandmaskventilationwith
100%O
2
MonitorO
2
saturation
Circulation
IVaccess
MonitorBP
MonitorECG
Antihypertensiveagents
Labetalol 1020mgIVor
hydralazine 510mgIV
Considerations
Considerationsrelatedtoseverepreeclampsia
Assessmentofseizurecontrolandneurologicfunction
Fluidbalance 75to100ml/hr /
AntihypertensivetherapyifBP> 160/110mmHg
Continuouspule oximetry monitoringofmaternal
oxygenation
FHRmonitoring
Investigations coagulationstudiesrequired
irrespectiveofplateletcount
15
Consciouspatient,seizureswellcontrolled,no
evidenceofincreasedintracranialpressure
Regionalanaesthesiaacceptable
Signs/symptomsofcerebraloedema
GA intubate &ventilateforatleast24hours
afterCStocontrolhaemodynamics andcerebral
perfusion
Avoidhyper/hypoventilation
AvoidprecipitousfallinBP
Avoidhypoxia,hyperthermia,hyperglycemia
1
Anaesthetic Considerations
For
l
Dr. Archna Koul
Foetal Surgery
Introduction
Foetus:apatient
Integrationofobstetric&paediatricanaesthesia
Twopatientsanaesthetised
Littlemarginoferror
Basedmainlyonclinicalexperience
Whatsuniqueinfoetalsurgery
Umbilicalcirculation
Healing without scarring Healingwithoutscarring
Absenceoffoetalimmunesurveillance
HistoryofFoetalSurgery
1963:1
st
successfultherapy SirWilliamLiley
t
1983:1
st
successfulsurgery
(VesicostomytotreatB/LHDN)
Dr.MichaelHarrison
TypesofFoetalSurgery
Openfoetalprocedures
Hysterotomy
Ex Utero Intrapartum Therapy (EXIT)
Airway Management on placental support (AMPS) Airway Management on placental support (AMPS)
Operation on placental support (OOPS)
Minimallyinvasiveprocedures
FoetoscopicorFETENDOprocedures
Foetalimageguidedsurgery(FIGS)
OpenFoetalSurgery
1)Hysterotomy
Congenitalcysticadenomatoid
malformation
Sacrococcygealteratoma
Meningomyelocoele
2)Exuterointrapartumtherapy(EXIT)
Congenitalhighairwayobstruction
Foetalneckmasses
2
MinimallyInvasiveProcedures
1) FoetoscopicorFETENDOprocedures
Twin twintransfusionsyndrome
Twinreversedarterialperfusion
B/LHDN
CDH
2)Foetalimageguidedsurgery(FIGS)
Shuntplacement
Radiofrequencyablation
ANAESTHETICCONSIDERATIONS
Maternalsafety
Maximaluterinerelaxation
MaintenanceofUPbloodflow
Maintenance of uterine volume to prevent placental Maintenanceofuterinevolumetopreventplacental
separation
Adequatefoetalanaesthesia
Intraoperativefoetalmonitoring
Postoperativetocolysis
ReitmanEetal.BrJAnaesth2011
MaternalAnaestheticConsiderations
Aspiration
Hypoxia
Difficultairway
Pulmonaryoedema
Supinehypotension
Sensitivitytoanaesthetics
Hypercoaguablestate
FoetalAnaestheticConsiderations
Lowcirculatingbloodvolume
Immaturecoagulationsystem
Evaporativefluidloss
Temperature homeostasis Temperaturehomeostasis
Myocardialcontractility
CardiacoutputdependentonHR
vagaltone baroreceptoractivity
Sensitivitytovolatileanaesthetics,analgesicsand
musclerelaxants
UteroplacentalConsiderations
FoetalO
2
delivery:
Uterinearterybloodflow
Umbilicalarterybloodflow
Placentalbarrier
Avoid:
Maternalhypotensionandhypoxia
Hyperventilation
Increaseduterinetone
Aortocavalcompression
Kinkingofumbilicalcord
OpenFoetalSurgeries
PreoperativeMaternalEvaluation
Historyandphysicalexamination
Routineinvestigations
Foetus Foetus
Ultrasound(Foetalwt)
Echo
MRI
Karyotype
Psychosocialevaluation
Informedconsent
Hysterotomy for sacrococcygeal teratoma
3
PreoperativePreparation
NPO aspirationprophylaxis
Vascularaccess
TemperatureofOR
Bloodproducts
Resuscitationdrugs
Atropine0.02mg/kg
Epinephrine1g/kg
Vecuronium0.2mg/kg
Fentanyl20g/kg
Tocolyticdrugs indomethacin
IntraoperativeManagement
Standardmonitoringdevices,IBP
Lumbar epidural catheter Lumbarepiduralcatheter
Leftuterinedisplacement
Rapidsequenceinduction
IntraoperativeManagement
Uterinerelaxation desflurane/isoflurane/
sevoflurane(23MAC)/IVNTG
Ephedrine/phenylephrine
Contd
Ephedrine/phenylephrine
Amnioticfluidreplacement(Ringerlactate)
I/Vfluids
Placentallocalization
FoetalAnaesthesia
Placental transfer of inhalational agents
Foetal medication IM/cord
Fentanyl 20 g/kg
Vecuronium 0.2 mg/kg or
Pancuronium 0.3 mg/kg
Atropine 0.02 mg/kg
IV catheter in foetus
FoetalMonitoring
Pulse oximetry
Intra-operative sonography
Direct foetal ECG Direct foetal ECG
Foetal echo
Foetal ABG / VBG
Foetal glucose, electrolytes
SubsequentTocolysis
MgSO446gmover20min,23gm/hrover24hrs
Postoperatively
Tocolysis
MgSO4withorwithoutindomethacin
S/Cterbutaline
Oralnifedipine
PostoperativeanalgesiaPCA
4
Ex Utero Intrapartum Therapy (EXIT)
Foetusdelivered
Tocolycisnotrequired
Needfor2operatingrooms
Foetalanaesthesia:airwaymanipulation&
foetalpatterncirculation
Sterilityofairwayequipment
Reversalofuterinerelaxation
Alternative Anaesthesia
Balancedanaesthesia withNTGinlargedose(20
g/kg/min)supplementedbyvasopressor
DeBuckF,etal.Curr Opin Anesthesiol,2008
Propofol andremifentanil (SIVA)
AnneBoatetal.pediatric Anesthesia2010,20:74856
Neuraxial anaesthesia accompanyingInj ofNTG
(epiduralorCSE)GeorgeRB,etal.CanJAnesth,2007
Minimally Invasive Procedures
Oneperipheralline
NoneedofNGtube/arterialcannulation
Smallincisions
Minimal postoperative pain & uterine activity Minimalpostoperativepain&uterineactivity
Lengthofhospitalstayless
Postoperativetocolyticsrare
Subsequentnormalvaginaldelivery
PretermPROM
prophylacticantibiotics&tocolytics
FactorsInfluencingAnaesthetic
Management
Locationofplacenta,cord&membrane
Foetalcardiovascularstatus
H/Outerineactivity
Volumeofamnioticfluid
LA + Sedation
Combinationofopioids+BZP/propofol
Combinationofdiazepam+remifentanil
(0.1mcg/kg)/min
SupplementalO
2
tomothers
Remifentanil Remifentanil
Excellentmaternalsedation
Easilyreversiblefoetalimmobilization
transplacentalpassage
Onlyminimalmaternalrespiratorydepression
Shortdurationofaction
MissantCetal.ActaAnaesthBelg2004
Anaesthesia Foetal
depression
UP blood
flow
Uterine
relaxation
Regional - - -
Balanced
(GA+
epidural)
+ +/- +/-
Deep GA ++ ++ ++
5
Complications
Open EXIT FETENDO FIGS
Pulmonary edema ++ ++ +
Bleeding ++ +++ + -
Preterm labour ++ NA + -
Preterm PROM ++ NA ++ -
Chorio-amnionitis ++ NA + -
Amniotic leak ++ NA + -
Foetal Pain
Painrelieffrommidgestationonwards
Foetalstressresponse
cortisol
endorphins p
Vigorousmovements
Behaviouralresponse
Movements(8weeks)
Reactiontosound20weeks
Responsetopainfulstimuli22weeks
LeeSJetal.Jama2005
FoetalAnalgesia
Neuraldevelopment
Peripheralnervereceptors 7 20weeks
Spinothalamictract 16 20weeks
h l i l fib 2 k Thalamocorticalfibres 17 24weeks
Waysofprovidinganalgesia
Transplacental
DirectIV/IM
Intraamniotic
AnaestheticEffectsontheFoetus
Teratogencity
Volatileanaesthetics
DepressionofFoetalCVS
Intravenous agents ( HRV) Intravenousagents( HRV)
Neurodevelopmentalconsequences
Neuroapoptosis
spatialrecognition
Impairedmemory
Learningproblems
Conclusion
Remembermaternalsafety
Communicationisvital
Medicalsocialethicallegalquestion
Greateruseoffoetoscopic procedures
PROCEEDWITHCAUTION &ENTHUSIASM
1
Pregnant Woman for
Non-obstetric Surgery
Dr. Jayashr ee Sood
CASE I
26yrs, female
24 weeks gestation
Comes to Casualty 2 pm Comes to Casualty 2 pm
H/o accident
H/o crush injury right foot
Requisition : Debridement of foot
CASE II
Casualty
23yrs, female
Primi
37 weeks gestation 37 weeks gestation
H/o painful swelling in upper part of stomach
(previous operation scar)
Diagnosis: Obstructed epigastric incisional hernia
Requisition: Reduction of epigastric hernia
Incidence 0.75 to 2%
(Developed Countries)
1
st
trimester 42% - gynae indications
most common most common
2
nd
trimester 35%
3
rd
trimester 23%
WHAT ARE THE COMMON SURGICAL
PROCEDURES PERFORMED DURING PROCEDURES PERFORMED DURING
PREGNANCY ?
Procedures Performed
Pregnancy related
- Cervical incompetence - Ovarian cyst
- Adenexal disease - Malignancy
- Foetal surgery
Non-pregnancy related
Laparotomy / Laparoscopic procedures Laparotomy / Laparoscopic procedures
- Appendicitis (1 in 1,500-2000 pregnancies)
- Cholecystitis (1 to 8 per 10,000 pregnancies)
- Trauma
Uncommon
- Intracranial tumours - Cardiac surgery
(High circulating oestrogen levels)
2
General Principles
Dealing with two lives
Thorough understanding of maternal and
foetal physiology p y gy
Altered drug pharmacodynamics and
pharmacokinetics in pregnancy
Implications on foetus
Goals
Safe anaesthesia for both mother and foetus
Maternal safety
Altered physiology
Altered pharmacokinetics / dynamics
Foetal safety
Unwanted drug effects on the foetus (teratogenic)
Intrauterine foetal asphyxia
Stimulation the myometrium (preterm labour)
Avoid awareness during general anaesthesia
MATERNAL SAFETY
WHAT ARE THE MAJOR
PHYSIOLOGICAL CHANGES IN PHYSIOLOGICAL CHANGES IN
PREGNANCY ?
Changes in Pregnancy
Primary changes
Gestational hormones (1
st
trimester)
Secondary changes
Mechanical effects (2
nd
half of pregnancy)
Respiratory System
1
st
trimester changes (progesterone)
Tidal volume (40%) and Resp rate (15%)
Minute ventilation (25%)

Full term
Minute ventilation (45-70%)
Respiratory alkalosis
ODC to right
O
2
delivery to foetus
3
Mechanical Changes
Restrictive effect on respiratory mechanics
FRC (20% at term)
May result in airway closure
Anatomical Changes
capillary permeability
Oedema of upper airway and vocal cords
Cardiovascular System
Heart rate by 25%
Stroke volume by 30%
Cardiac output up to 50%
Plasma volume > red cell mass
Physiological anemia of pregnancy
Range of normal lab values change
Blood viscosity
Uteroplacental circulation
Range of normal lab. values change
Compression of IVC and aorta by
gravid uterus
(Aortocaval Compression)
Coagulation
Fibrinogen
Factors VII, VIII, X and XII
Type 1 plasminogen activator inhibitor
Protein S levels
Hypercoaguable state
Thromboembolism
(Pneumatic compression devices)
(Thromboprophylaxis postoperatively)
Gastrointestinal System
Progesterone
LOS tone
+
Gastric acidity (gastrin)
Angle of gastro-esophageal junction
Incompetence of sphincter
(Aspiration prophylaxis, 2
nd
trimester onwards)
4
Gastric emptying in non-labouring parturient
Not delayed
Gastrointestinal System
Onset of labour
Gastric emptying delayed

Delayed Diagnosis of
Intra-abdominal Pathology
Nausea
Vomiting
Constipation
Abdominal distension
Pain
Common symptoms of pregnancy
Position of appendix changes
Ri h ili f
Delayed Diagnosis
Right iliac fossa
Over right kidney (at term)

Appendix
Rotation relative to caecum
Delayed Diagnosis
No longer in contact with
parietal peritoneum (at term)
Absent clinical signs

Dyspnoea
Delayed Diagnosis of
Cardiac Disease
Peripheral oedema
Heart murmurs
Common symptoms of pregnancy
MATERNAL SAFETY
5
Altered Pharmacokinetics / Dynamics
30% in MAC of volatile anaesthetic agents
Central Nervous System
+
Alveolar ventilation
Rapid induction with inhalation technique
Pseudocholinesterase levels
Action of Suxamethonium
but
Volume of distribution
Prolonged duration uncommon

Pregnancy induced in blood volume
Volume of distribution
Physiological hypoalbuminemia
1 glycoprotein
Altered plasma protein binding
Free fraction of drugs

Dose of LA
Sensitivity to LA drugs

Therapeutic doses
Toxic plasma levels
by 30%
IVC compression
Engorgement of epidural venous plexus

Total volume of epidural and subarachnoid space

Extensive spread of LA in CNB
WHAT ARE THE FOETAL
FOETAL SAFETY
WHAT ARE THE FOETAL
CONSIDERATIONS ?
6
Teratogenicity
Intrauterine asphyxia
Risks to Foetus
foetal oxygenation / uteroplacental perfusion
Risk of abortion or preterm delivery
DEFINE TERATOGENICITY
Observation of any significant change in the function
or form of a child secondary to prenatal treatment
Teratogenicity
The trophoblast lipid membrane allows passive
diffusion
Teratogenicity
Lipid soluble drugs
Low molecular weight
WHAT ARE THE PREDISPOSING
FACTORS FOR TERATOGENICITY ?
Perioperative events
- Maternal hypotension - Maternal hypoxemia
- Derangement in carbohydrate metabolism - Hyperthermia
Teratogenicity
Predisposing Factors
Iatrogenic structural abnormalities
Drug exposure during period of organogenesis
Neural tube defects (6-8 weeks)
Functional abnormalities
Drug exposure during late pregnancy
7
Dose and gestational age of administration
Small dose given may be catastrophic in early embryo
Teratogenicity
Predisposing Factors
Large dose of same drug may have no effect at
advanced stage of development
Single short exposure does not pose a significant risk
in clinical practice
1
st
two weeks of human gestation
All or none phenomenon
Either the foetus is lost or preserved fully intat
3
rd
to 8
th
week of gestation (organogenesis)
Teratogenicity
3
rd
to 8
th
week of gestation (organogenesis)
Most serious teratogenic effects
After 12
th
week of gestation
No organ abnormality
Foetal growth retardation
General anaesthetic agents
Neurodevelopmental delay (animals)
Most are safe in humans
Ketamine
Teratogenicity
Effects of Anaesthesia
Ketamine
uterine tone
Foetal asphyxia
Contraindicated in 1
st
two trimesters
Benzodiazepine
- Cleft lip & palate (animals)
Nitrous oxide (rats and mice)
Mild teratogen
Prolonged exposure
&
Teratogenicity
50% N
2
O for than 24 hrs
High doses
N
2
O inhibits methionine synthetase
DNA synthesis in developing foetus
Humans undetermined role
Does not include anaesthetic agents or any
drug used routinely during anaesthesia
Muscle relaxants foetal concentration 10-20% of
Shepards Catalog of Teratogenic Agents
(Proven Human Teratogens)
Muscle relaxants foetal concentration 10 20% of
maternal concentration
No evidence of withholding N
2
O in clinical practice
No evidence of association between diazepam
and craniofacial defects
WHAT ARE THE CAUSES & EFFECTS
INTRAUTERINE ASPHYXIA
OF INTRAUTERINE ASPHYXIA ?
8
Intrauterine Asphyxia
Causes
Maternal arterial oxygen tension
Oxygen carrying capacity
Oxygen affinity
Uteroplacental perfusion
WHAT ARE THE FACTORS AFFECTING
U-P PERFUSION
U-P PERFUSION ?
No autoregulation in uteroplacental
circulation
Perfusion directly dependent on Perfusion directly dependent on
maternal BP
Maternal hypotension (any cause) Maternal hypotension (any cause)
Deep levels of GA Deep levels of GA
High levels of spinal / epidural sympathectomy High levels of spinal / epidural sympathectomy
Aortocaval compression Aortocaval compression
Haemorrhage Haemorrhage
Uteroplacental Perfusion
Hypovolemia Hypovolemia
Uterine vasoconstriction Uterine vasoconstriction
Preoperative anxiety Preoperative anxiety
Light anaesthesia Light anaesthesia
Drugs in high doses Drugs in high doses
-- Ketamine > 2mg/kg Ketamine > 2mg/kg
-- Local anaesthetics Local anaesthetics
Circulatory catecholamines Circulatory catecholamines
Inhalational agents
Up to 1 and 1.5 MAC Halo/ Iso/ Sevo well tolerated Up to 1 and 1.5 MAC Halo/ Iso/ Sevo well tolerated
Uterine vasodilatation Uterine vasodilatation

Compensates for small Compensates for small in maternal BP in maternal BP
Uteroplacental Perfusion
Inhalation agents > 2 MAC Inhalation agents > 2 MAC
Direct Direct
Foetal CVS Depression Foetal CVS Depression
Indirect Indirect
Maternal hypotension Maternal hypotension
Maternal hypoxia Maternal hypoxia
Foetal hypoxia Foetal hypoxia

Transient maternal PaO
2
Well tolerated by foetus

(foetal Hb has high affinity for oxygen)
Severe maternal hypoxemia
Uterplacental vasoconstriction
Maternal & Foetal Oxygenation
Uterplacental vasoconstriction
Perfusion
Foetal hypoxia, acidosis & death

Hyperoxia (maternal)
Foetal PaO
2
never > 60mmHg
(large maternalfoetal oxygen gradient)
9
Maternal hypercapnia
Mild well tolerated
S di l d i
Maternal Carbon Dioxide and
Acid Base Status
Severe myocardial depression
Maternal hyperventilation (hypocapnia)
Umbilical artery vasoconstriction
Shift of ODC to left

Maintain normocarbia
Linear relationship between maternal PaCO
2
& foetal PaCO
2
Maternal hypercarbia
Maternal Hypercarbia
Prevents diffusion of CO
2
from foetus to mother
Fetal acidosis
Foetal loss
Causative factors
Inconclusive
PRETERM LABOUR
Medical disease
Uterine manipulation
Early and late trimester
No particular anaesthetic technique advocated
Routine prophylactic tocolysis not recommended
Monitor uterine contractions intraop and postop
If i d t t t l ti th
Preterm Labour
Prevention
If required, start tocolytic therapy
17 hydroxy progesterone acetate (proluton depot) 250mg IM
Duvadilan 10 mg IM, IV 40 mg in drip
Oral Depin 1 mg tds
Indomethacin
MgSO MgSO
44
Possible adverse effects of surgery and
anaesthesia on the developing foetus
Timing of Surgery
vs
maternal and foetal risk of delaying surgery
Elective surgery should not be performed during pregnancy
When possible, surgery should be avoided during the 1
st
trimester,
especially period of organogenesis
Optimal time for surgery 2
nd
trimester
Emergency surgery must proceed regardless of gestational age
Timing of Surgery
Emergency surgery must proceed regardless of gestational age
If an emergency then maternal life is more important
Occasionally a caesarian delivery is deemed simultaneously along with
the surgical emergency
- The LSCS may be done just before the emergency surgery to avoid foetal risks
- Positioning - Blood loss
- Prolonged anaesthesia - Deliberate hypotension
10
General anaesthesia vs Regional anaesthesia
No superiority of one over the other
Whenever possible, regional anaesthesia is
preferred
CASE I
26yrs, female
24 weeks gestation
Comes to Casualty 2 pm
H/o accident H/o accident
C/o crush injury right foot
O/E
Foot crushed
Tendons exposed
Requisition : Debridement of foot
As for any other parturient
History
General examination
BP supine, left lateral
Airway
Preoperative Assessment
Airway
Examination of foot
CVS
Respiratory system
GI tract
Abdomen
Back
Pre-anaesthetic Examination
Feeding history : breakfast
tea and bread 7 am nothing
after that
Regional Anaesthesia Plan :
Airway management simple (minimal or none)
Regional Anaesthesia
Advantages
Minimizes foetal drug exposure
Overall risk to both is decreased
Anxiety
catecholamines UP perfusion
Short acting benzodiazepine
Single dose not harmful to foetus
Analgesia
Premedication
Ranitidine
Sodium citrate
Metoclopramide
Positioning (after 16 weeks gestation)
15 left lateral tilt
Gradual positioning
11
Preloading or Coloading?
Subarachnoid block (unilateral)
0.5% heavy bupivacaine
Caution
Hypotension
Aortocaval compression
High spinal
Monitor uterine contractions
Tocolytics ?
Monitoring
Epidural Anaesthesia
Disadvantages
Higher LA blood levels Higher LA blood levels
More placental transfer
(although no teratogenic effects in humans)
WHAT IS THE CHOICE OF
VASOPRESSOR ?
EPHEDRINE VS PHENYLEPHRINE?
CASE II
Casualty
23yrs, female
Primi
37 weeks gestation
H/o painful swelling on the
previous operation scar
CASE II
Casualty
Past H/O
Surgery for some reason in stomach
1
st
operation under GA uneventful
Perioperative period uneventful
12
As for any other parturient
History
General examination
- BP supine, left lateral
Airway
Abdomen
Preoperative Assessment
- Swelling in epigastric region, size + , palpation does not get compressed
CVS
Respiratory system
GI tract
Back
Diagnosis: Obstructed epigastric incisional hernia
Requisition: Reduction of epigastric hernia
PLAN
Maternal safety
37 weeks gestation
May be delivered by LSCS before doing repair of
hernia
Two options
LSCS by subarachnoid block
Followed by GA for hernia repair
General anaesthesia
WHY NOT REGIONAL ANAESTHESIA ? WHY NOT REGIONAL ANAESTHESIA ?
Analgesia requirement T
4
Positioning
Respiratory embarrassment
Carboperitoneum
General anaesthesia recommended
Anxiety
catecholamines UP perfusion
Short acting benzodiazepine
Single dose not harmful to foetus
Analgesia
Premedication
Ranitidine
Sodium citrate
Metoclopramide
Positioning (after 16 weeks gestation)
15 left lateral tilt
Gradual positioning
General anaesthesia
Preoxygenation
Rapid sequence induction
Cricoid pressure
Tracheal intubation
13
Positive pressure ventilation
Maintain normocarbia
Volatile anaesthetics not harmful
Air / oxygen mixture
Muscle relaxants have no adverse effect on foetus
Maintain
Maternal oxygenation
Haemodynamic stability
A id
Prevention of Foetal Asphyxia
Avoid
Hypoxia
Extreme hyper and hypocarbia
Hypotension
Uterine hypertonus
Vitals
Pulse oximeter ECG
Maternal Monitoring
NIBP Temp
Capnometer (if GA)
Urine output
Cardiotocography
Document FHR monitoring preop, after
completion and postop
Foetal Monitoring
completion and postop
Detects foetal compromise
Allows optimization of maternal
haemodynamics and oxygenation
Fluid therapy
Vasopressors
Foetal Heart Rate Variability
Management
Blood or blood products
Hyperventilation
Adjustment of position
If carboperitoneum deflation
Lateral position
Fully awake
Extubation
Postoperative Period
Hydration
Tocometry FHS & uterine activity
Prophylactic tocolytics controversial
used only if there has been uterine manipulation
intraoperatively
14
Analgesia
Pain chance of premature labour
Postoperative Period
Alleviation of pain and stress during perinatal
period is essential
Thromboprophylaxis
Advantages
Magnified operative field
Minimal uterine manipulation
Laparoscopy During Pregnancy
Small incisions
Less pain
Early ambulation
DVT
Concerns
Technical difficulty
Uterine or foetal trauma
Uterine or foetal trauma
Foetal acidosis (absorbed CO
2
)
IAP maternal cardiac output U-P perfusion
Potential irritation of myometrium by cautery
Standard
End tidal CO
2
to PaCO
2
gradient is maintained
Laparoscopy
Monitoring
during laparoscopic surgery in pregnant patients
This gradient can be used to guide ventilation in
this patient population
SAGES Guidelines
Left lateral decubitus
Open Hassons technique
Intra-abdominal pressure as low as possible (10-12 mmHg)
Monitor maternal EtCO
2
and maintain it between 30-35 mmHg
Antiembolic devices
Continuous intraoperative fetal monitoring
Minimize operating time
Tocolytic agents should not be administered prophylactically
Principles
Delay elective surgery until after delivery, wherever possible
Try to avoid surgery in 1
st
trimester
Antacid prophylaxis
DVT prophylaxis
Antibiotic prophylaxis p p y
Use regional anaesthesia, whenever feasible
If GA is employed, use adequate dose of inhalation agent
Light anaesthesia is associated with catecholamine release
and U-P perfusion
Airway management vital
Maintain U-P perfusion
15
Conclusion
Multidisciplinary approach to management
Expert management of both, surgical disease
process and anaesthesia

13 09 13

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Prof. A. K.

Gentle upper airway instrumentation

Minute ventilation (25%)

Gastric emptying delayed

Over right kidney (at term)

Rotation relative to caecum

Absent clinical signs

Prolonged duration uncommon

Altered Pharmacokinetics / Dynamics

Altered plasma protein binding

Free fraction of drugs

Altered Pharmacokinetics / Dynamics

Engorgement of epidural venous plexus

Total volume of epidural and subarachnoid space

Uterine vasodilatation Uterine vasodilatation

Maternal hypoxia Maternal hypoxia

Foetal hypoxia Foetal hypoxia

Well tolerated by foetus

Foetal hypoxia, acidosis & death

Mild well tolerated

Shift of ODC to left

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