NON OBSTETRICAL SURGERY FOR THE PREGNANT PATIENT Case report 33 year old G3P2 at 32 weeks
gestation presenting for outpatient lap chole Npo after MN NKDA Meds:PNV
No prior surgery SVDx2 uncomplicated deliveries PMH GERD with pregnancy Physical Exam Ht 163 cm Wt 90kg MP 2 airway Gravid uterus Exam otherwise unremarkable
FHTs 136 Plan GA: RSI Fetal Heart Tones before and after surgery Induction
Pre med: Fentanyl 50 mcg RSI: Propofol 200mg Roc 5 mg Sux 140mg Easy intubation VSS Left uterine displacement
Intra-op 10:47 am incision 11:11 am surgeon asks for OB stat to OR for suspected uterine rupture 11:17 OB in room for report 11:20 OB scrubbed in/emergency Csection performed After delivery OB asks Why wasnt I informed that a pregnant pt was
coming to the OR? Post-OP Healthy mom and baby OB broke scrub, saw pts chart stated: This pt is seen in my office why wasnt I informed she was having
surgery????? Most Common Procedures Laparoscopic cholecystectomy Cystoscopy Appendectomy Real Cases Over the years 24 week pregnant pt for breast bx
followed by mastectomy and port 2 weeks later 32 week pregnant burn pt for debridement and skin graft to back (prone positoning) 18 week pregnant pt for total thyroidectomy for thyroid ca 17 week ex lap for ovarian mass
(retained sponge from prior C-section 34 week pregnant pt for ORIF fifth finger fracture from fist fight Other Procedures Burn surgery Thyroidectomy
Mastectomy Ovarian mass Orthopedic injuries ACOG Guidelines Pregnant patient should not be denied indicated surgery regardless of trimester
Elective surgery should be postponed until after delivery If possible non urgent surgery should be performed in the second trimester when pre term contractions and spontaneous abortions are least likely Obstetric Provider
OB should be notified (must be) OB provider with C-section privileges should be immediately available Qualified individual for interpreting fhr patterns immediately available (Neonatology and L&D should be notified for viable fetus)
Guidelines for Fetal Monitoring Pre-viable fetus: FHR by Doppler pre and post op Viable fetus: FHR and contraction monitoring pre and post op to assess fetal well being and absence of contractions
FHR should be evaluated by qualified individual ACOG guidelines published 4/17 Intra Operative Monitoring May be appropriate when all of the
following apply 1. fetus is viable 2. physically possible 3. informed consent for emergency
C-section 4. nature of surgery would allow for access for C-Section Other issues May monitor pre viable fetus to facilitate positioning or oxygenation
C-section Tray immediately available Left Uterine Displacement After 18-20 weeks provide left uterine displacement to prevent aortocaval compression Goal is to reduce maternal hypotension and preserve placental
perfusion Tilt of at least 15 degrees NPO Guidelines Same as for nonpregnant patients Clear liquids 2 hours Solids 6-8 hours depending on fat content
Adjust for confounding factors: morbid obesity, difficult airway, diabetes RSI often performed Anesthesia No specific anesthetic agents are
contraindicated but historically midazolam and nitrous oxide have been avoided Regional anesthesia is preferable
Consider aspiration risk Optimize placental perfusion by optimizing hemodynamic stability and oxygenation Expect decreased fetal heart rate Hemodynamic Stability Uteroplacental unit does not have
autoregulation Placental perfusion directly related to maternal BP Goal: maintain maternal BP within 20% of basline Fluids Ephedrine Phenylephrine
Anesthesia Hyperoxia-not dangerous for fetus. PAO2 will not increase above 60mmhg Hypoxemia-bad Hypercarbia: acidosis Hypocarbia: Uterine artery vasoconstriction
Shift of hemoglobin oxygen disassociation curve Muscle Relaxant Reversal Neostigmine readily crosses placenta Glycopyrrolate does not Possible fetal bradycardia Consider Atropine 10-20 mcg/kg as
atropine readily crosses placenta Antibiotics Ancef Class B Clindamycin Class B Metronidazole Class B Unasyn Class B Vancomycin Class C
Ciprofloxacin Class C Gentamycin Class D Class A safe Class B no fetal risk in animal studies Class C not enough research to know Class D human risk involved VTE Prophylaxis Pregnancy: hypercoagulable state
Surgery: venostasis/hypercoagulabilty Prophylaxis should be considered for all pregnant patients undergoing surgery Maternal Cardiac Arrest Same drugs/same management as
nonpregnant Left uterine displacement Chest compressions higher on sternum All drugs administered above diaphragm If no response at 4 minutes-deliver the baby
Summary Preferable notification prior to day of surgery OB, neonatology,L&D,anesthesia,OR Pre-op FHT/contraction monitoring
Confirm all parties notified C-Section tray outside of room Post-Op appropriate monitoring for gestational age clear with OB before discharge
the rhetorical situation. Different kinds of writing may emphasize different elements of the rhetorical situation, but five elements are always present: writer, occasion, audience, topic, and purpose." Barr Ebest, Sally, Alred, Gerald J., Brusaw, Charles T., and Oliu, Walter E....
Piet Mondriaan, Compositie met geel rood, zwart, blauw en grijs, 1920 c/oPictoright Amsterdam/Stedelijk Museum Amsterdam. Cornelis Jouke Blaauw, voorzittersstoel en vergaderstoel voor School voor Kunstnijverheid in Haarlem waar hij docent Bouwkunde was, 1918-1919. Coll.
Questions (from Sparck Jones) Should we take the reader into account and how? "Similarly, the notion of a basic summary, i.e., one reflective of the source, makes hidden fact assumptions, for example that the subject knowledge of the output's readers...
Chapter 10 Business Research and Report Writing 10 Why are executive summaries included in formal reports? Executive summaries are included because they provide brief overviews of report contents. Compare and contrast the terms executive summary and conclusion. Both are summaries...
recognise that some mechanisms, including levers, pulleys and gears, allow a smaller force to have a greater effect. Year 5/6 Electricity: Pupils should be taught to: associate the brightness of a lamp or the volume of a buzzer with the...
By the end of 2016, there will be an estimated 13.3 million mobile workers in Canada, representing 73% of the total workforce. In 2006 (exactly 10 years ago), TELUS introduced Work Styles, a flexible work program that empowers team members...
Coronary Artery Disease. almost 70% of patients. myocardial ischemia: ischemic. cardiomyopathy. fibrosis and scarring. Aneurysmal dilation. When approximately 40% of the LV muscle mass is acutely infarcted, cardiogenic shock ensues.
Times New Roman Garamond Arial Wingdings Bradley Hand ITC Arial Arial Unicode MS Edge Student Success - Time Management Chapter 2 College: New Expectations 10 Tips for Success Student Success TIME MANAGEMENT Time Management Time Management Learning Objectives TIME MANAGEMENT...
Ready to download the document? Go ahead and hit continue!