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1、Obstetric Anesthesia Department of anesthesiologyCui Xiao GuangPHYSIOLOGICCHANGESOFPREGNANCY1CardiovascularSystem:cardiacoutput,heartrateHematologicSystem:bloodvolumeincreasesbyupto45%,redcellvolumeincreasesbyonly30%-physiologicanemiaRespiratory System:increase in the respiratory minute volume and w
2、ork of breathingGastrointestinal System:riskofincidence ofaspirationendotracheal intubation:the risk Renal System:GFR rises 50%;glycosuriaCentral Nervous System:sensitivity to anesthetics.PHYSIOLOGICCHANGESOFPREGNANCY2PLACENTAL TRANSFER OF ANESTHETIC DRUGS Placenta transport:Simple diffusion Facilit
3、ated diffusion Active transport PinocytosisReadily cross:low molecular weights,high lipid solubility,non-ionized Approximately 50%of the umbilical venous blood bypasses the liver.Morphine Placental transfer is rapidMother:uterus reactiveness orthostatic hypotension nausea vomiting delayed gastric em
4、ptyingFetus:respiratory depressionPethidine Most commonly usedduring labor intramuscular dose:50-100 mgTime of IM:before expulsion 1 h or 4 huterine contraction,frequency and intension Fentanyl Alfentanil Sufentanil Placental transfer is rapid Low dose:10-25 g fentanyl or 5-10 g sufentanil in subara
5、chnoid space PCEA:low dose of fentanyl and 0.1%-0.3%ropivacaineTramadol Placental transfer No inhibiting uterine contraction No Respiratory depressionDiazepam Readily cross the placentaHalf-lives:48 hours Problems:sedation,hypotonia,cyanosis,impaired metabolic responses to stress.MidazolamPlasma pro
6、tein binding:94%Respiratory depression:depended on dose 0.075 mg/kg no problem 0.15 mg/kg different degree Chlorderazin Preeclampsia and eclampsia IM：12.5 25 mg Overdose:central inhibitionPromethazine Prevent emesis Appears in fetal blood within 1 to 2 minutes after intravenous injection in the moth
7、er Reaches equilibrium within 15 minutesDroperidol Pregnant woman:慎用ApgarscoreThiopental sodiumNeonatus sleep:little Premature and intrauterine embarrass:carefully usingKetamine High doses(greater than 2 mg/kg)may cause low Apgar scores and abnormalities in neonatal muscle toneLabor pains of uterine
8、 contractionUterine muscular tension and contraction forceContraindication:psychosis,gestational hypertension syndrome or preeclampsia,metrorrhexisPropofol Recommendation:induction:2.5 mg/kg maintenance:2.5-5.0 mg/kg/h Discontinue gravidity onlyN2OPlacental transfer is rapid Mothers respiration,circ
9、ulation and Uterine muscular contraction force 20-30 s before of first stage of labor:50%O2 and 50%N2O,maximumhalothaneSuccinylcholine Cholinesterase:normal doseno placental transfer Dose 300 mg or single dose is larger:still have placental transfer Nondepolarizing Muscle Relaxants Onset is quick,ma
10、intanence is short and placental transfer is leastAtracurium:0.3 mg/kgLocal anestheticsFactors:Proteinbinding:MolecularweightLiposolubilityCatabolismintheplacentLocal anesthetics Procaine Lidocaine Bupivacaine RopivacaineANESTHESIA FOR CESAREAN SECTION Choice depends on:the indications for the surge
11、ry the degree of urgency maternal status desires of the patientSpinal Anesthesia Hyperbaric bupivacaine Advantages:rapid onset,little risk of local anesthetic toxicity,minimal transfer to the fetus,infrequent failure.Disadvantages:finite duration hypotension headacheEpidural Anesthesia L 23 or L 121
12、.5%2%Lidocaineor0.5%Ropivacaine emergency cesarean sectionCombined Spinal-Epidural Technique Increased dramatically in popularity Advantages:rapid onset supplemented at any time anesthetic dosesacral nerves block is sufficientGeneral Anesthesia rapid induction:obviate positive pressure ventilation o
13、ppress the cricoid cartilage mainterance:light ansthesia vomiting,backstreaming and aspiration:atropine,0.5 mg,IM or glycopyrolate,0.2 mg,IMSupine hypotensive syndrome Incidence:2%30%Time:after 28 weeks,specially 3236 weeks Symptoms:hypotension,dizziness,nausea,chest distress,cold sweat,to yawn,puls
14、e rate,pallescenceMechanismPreventHigh risk pregnancy Emergency operation:late trimester of pregnancy:hemorrhage gestational hypertension syndrom and eclampsia Selective operation:hypertension cardiac disease diabetes multifetationPlacenta Previa and Placental Abruption Preanesthtic preparation:bloo
15、d coagulation function DIC sifting test acute renal failure Principle:general anesthesia:active bleeding,hypovolemic shock,definite blood coagulation disfunction or DIC intraspinal anesthesia:condition of mother and fetus is okay Managementdegrees of abruptio placentae.A,Concealed hemorrhage.B,Exter
16、nal hemorrhage.C,Complete placental separation.Types of placenta previa.Management of anesthesiaAnnouncements of the induction:difficult airway cricoid cartilage backstreaming and aspiration Prepare to salvage the blood coagulation disfunction and the hemorrhoea.Prevent the acute renal function fail
17、ure:urine volume urea nitrogen and creatinine Prevention and cure of DICPregnancy-induced hypertension syndromeIncidence:10.3%Cause of death:cerebrovascular accident,pneumonedema,liver necrosis Pathophysiology:systemic arteriola systole,fetusManagement:HELLP syndrome cardiacfailurecerebralhemorrhage
18、placentalabruptionbloodcoagulationdisfunctionhaematolysishepaticenzymethrombocytopeniaacuterenalfailureManagement 1tryingstableanesthesia:stressreaction:fentanylavoidtouseketamineSBP:140150mmHg,DBP:about90mmHgganglioplegicornitroglycerinmaintainheart,kindeyandlungfunction:treatmentofcomplication:Man
19、agement 2basicmonitoring:ECGSpO2NIBPCVPurinevolumebloodgasanalysispreparetosalvagetheneonatalasphyxiaICUpostoperationanalgesiaMultiple Births pathophysiology:abdominal aorta and inferior vena cava compression;fetal lung maturity;incidence of postpartum hemorrhage.anesthesia:epidural anesthesia manag
20、ement:addition of volume:colloid oxygen,prevention and cure of Supine hypotensive syndrome preparation of resuscitation of newbornNeonatal asphyxia and emergency treatment ASSESSMENT OF THE FETUS AT BIRTH Apgar score is a simple,useful guide-The Apgar scoring system Score*Sign 0 1 2 Heart rate Absen
21、t Less than 100/min More than 100/min Respiratory effort Absent Slow,irregular Good,crying Color Blue,pale Body pink,extre mities blue(acrocyanosis)Completely pink Reflex irritability(response to insertion of a nasal catheter)Absent Grimace Cough,sneeze Muscle tone Limp Some flexion of extremities A
22、ctive motion Apgar score 1-minute score -degree of asphyxia 5-minute score-prognosis evaluated at 1 and 5 minutes.should not wait until 1 minute has passed before initiating resuscitation.normal:7-10 mild asphyxia:4-6 severe asphyxia:0-3 Resuscitation of newborn A(Airway)B(Breathing)C(Circulation)D(
23、Drug)E(Evaluation)Initial resuscitation Incubation:2731Position:Suctioning:mouthandnoseStimulate:Completeitwithin20sEvaluation and further treatmentEvaluation:accordingtobreath,heartrateandskincolourNormal:stopresuscitationNospontaneouslybrathing,HR100/min:bagrespiratorHR80/min:closedcardiacmassage;
24、trachealintubation,medicationBag respiratorManiphalanxpressurizeTidalvolume:2040mlI:E=1.5:1RP:3040/minfirsttwice:pressure3040cmH2Osubsequently:pressure1020cmH2ORESUSCITATION EQUIPMENTClosed cardiac massage HR:120/minDepth:12cmRESUSCITATION DRUGS 30s after the closed cardiac massage,still cant recove
25、ry:drug Epinephrine:0.10.2mg/kg,intratracheal drop inHypovolemia causes umbilical cord was clamped and cut earlier intrauterine asphyxia placental abruption hemorrhage too much:antepartum or intrapartumDetection of Hypovolemia arterial blood pressure and CVP pale skin poor capillary refill extremiti
26、es are cold pulses are weak or absentTreatment of Hypovolemia intravascular volume expansion blood,plasma,crystalloid,Albumin 10 mL/kg of normal saline,1 to 2 g/kg of 25%albumin,or 10 mL/kg of plasma.Care must be taken Correction of Acidosis Respiratory acidosis is corrected by controlling ventilati
27、onMetabolic acidosis is corrected by infusing sodium bicarbonate.Requisite amount ofsodium bicarbonate(mmol):=0.6BW(kg)(normal BE-present BE)/4 sodium bicarbonate 1 mmol/kg/minSodium bicarbonate should not be infused unless ventilation is adequate.Monitoring After resuscitationtemperaturebreathheartratebloodpressureurinevolumeGynecologic anesthesiaSpecialposition:headdownandlithotomypositionOldage:comorbiditiesEmergencycase:exfetation,ovariancystintortion,perinealpositiontrauma,uterineperforationMoreother:selectiveoperationHysteroscopeandLaparoscopicSurgery: