Cervical Cerclage and Anesthesia Considerations

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Questions and Answers

What is a significant anesthetic consideration for a parturient with preeclampsia undergoing a cesarean section?

Spinal anesthesia is considered ideal. (correct)

Epidural anesthesia is contraindicated in all cases.

General anesthesia is preferred for quicker recovery.

Local anesthesia is sufficient for pain management.

Which of the following is NOT a postoperative treatment consideration for parturients with preeclampsia?

Increased fluid intake regardless of condition (correct)

Seizure prophylaxis

Hemodynamic control

Maintenance of adequate analgesia

What percentage of pregnancies is affected by preeclampsia?

5% to 9% (correct)

10% to 15%

1% to 3%

15% to 20%

Which of the following pathophysiological changes is NOT associated with preeclampsia?

Decreased intracellular free calcium concentration Signup and view all the answers

In which scenario is a cesarean section indicated?

In cases of deteriorating maternal health such as severe preeclampsia Signup and view all the answers

Which of the following factors is NOT considered a risk factor for the development of preeclampsia?

Routine physical activity Signup and view all the answers

What role does endothelial damage play in the pathology of preeclampsia?

It increases platelet aggregation and vascular resistance. Signup and view all the answers

Which factor is NOT a common comorbidity found in parturients?

Chronic fatigue syndrome Signup and view all the answers

What is the minimum diastolic blood pressure criteria for diagnosing mild preeclampsia?

90 mm Hg Signup and view all the answers

Which urine protein threshold indicates severe preeclampsia?

5 g in 24 hours Signup and view all the answers

Which symptom would not be indicative of severe preeclampsia?

Mild edema Signup and view all the answers

What is considered a diagnostic urine output level for oliguria in a parturient with severe preeclampsia?

500 mL in 24 hours Signup and view all the answers

Which laboratory assessment is most indicative of thrombo-cytopenia in a preeclamptic patient?

Platelet counts Signup and view all the answers

Which serum enzyme levels might suggest the progression of preeclampsia?

Increased serum transaminase levels Signup and view all the answers

What is the diagnostic blood pressure for severe preeclampsia?

Systolic pressure greater than 160 mm Hg Signup and view all the answers

Which of the following symptoms is NOT commonly evaluated in a parturient with suspected preeclampsia?

Chest pain Signup and view all the answers

What is a key benefit of explaining the sequence of events during spinal anesthetic placement to the parturient and their significant other?

Builds patient-anesthetist confidence Signup and view all the answers

Which symptom should the parturient inform the anesthetist about regarding low blood pressure?

Feelings of anxiety Signup and view all the answers

What is the purpose of administering metoclopramide before a cesarean section?

To decrease postoperative nausea and vomiting Signup and view all the answers

Why is it important for the parturient to know they will experience pressure and pulling during the cesarean section?

To mitigate anxiety and set realistic expectations Signup and view all the answers

What are the recommended medications to be administered for aspiration prophylaxis prior to a cesarean section?

Nonparticulate antacids and H2 receptor antagonists Signup and view all the answers

What can result from the administration of spinal anesthesia in a preeclamptic patient?

Severe hypotension due to sympathectomy Signup and view all the answers

What invasive procedure can be particularly risky for patients with preeclampsia due to the potential for hypotension?

Subarachnoid block (SAB) Signup and view all the answers

Why is intravenous fluid administration indicated prior to spinal anesthesia in preeclamptic patients?

To reduce the risk of severe hypotension Signup and view all the answers

What is the sensory nerve block level typically achieved within 8 minutes after spinal anesthesia placement?

T4 Signup and view all the answers

What sensation might preeclamptic patients experience due to inactivation of proprioceptive nerves after spinal anesthesia?

Feeling as though they cannot breathe Signup and view all the answers

What is an appropriate action if a significant drop in blood pressure is observed during spinal anesthesia?

Increase the IV fluid infusion rate Signup and view all the answers

What is a recommended strategy to alleviate aortocaval compression during spinal anesthesia in pregnant patients?

Sustained left uterine displacement (SLUD) Signup and view all the answers

What psychological reaction may occur in patients experiencing numbness and heaviness in their lower extremities after spinal anesthesia?

Feelings of claustrophobia and anxiety Signup and view all the answers

What should be done first to reassure a patient experiencing inadequate sensory blockade during a cesarean section when she reports feeling pressure or pulling?

Encourage her significant other to provide distraction. Signup and view all the answers

Which medication is appropriate to administer if surgery is ongoing and the patient experiences pain during a cesarean section?

Small doses of ketamine. Signup and view all the answers

In which scenario should general anesthesia be considered for a patient undergoing a cesarean section?

In cases of high risk of airway complications. Signup and view all the answers

What potential side effect should be monitored when administering ketamine during a cesarean section?

Increase in blood pressure. Signup and view all the answers

What is a common reason for postponing a cesarean section when the sensory block has not been achieved?

To avoid further complications from an incomplete block. Signup and view all the answers

What is the role of midazolam after the delivery of the baby in a cesarean section?

To manage potential emergence delirium. Signup and view all the answers

When should a local anesthetic be injected at the incision site during a cesarean section?

When the surgery has commenced and pain is localized. Signup and view all the answers

Why might a second spinal anesthesia be administered if the initial sensory block has receded?

To achieve a more adequate sensory block. Signup and view all the answers

What is a disadvantage of spinal anesthesia in parturients with preeclampsia?

High SAB resulting in hypotension Signup and view all the answers

Which advantage is unique to epidural anesthesia compared to spinal anesthesia for parturients?

Ability to gradually control sympathetic blockade Signup and view all the answers

What is a significant risk when using phenylephrine to manage hypotension in parturients?

Potential exacerbation of bradycardia Signup and view all the answers

Which disadvantage is associated with epidural anesthesia?

Increased level of technical difficulty Signup and view all the answers

Which condition reflects the potential negative outcome of spinal anesthesia use in parturients with preeclampsia?

Hypotension and bradycardia Signup and view all the answers

Which of the following statements regarding phenylephrine and ephedrine is correct?

Both drugs cause the same fetal acid-base balance after administration. Signup and view all the answers

What may result from the sudden-onset hypotension associated with epidural anesthesia?

Interruption of the baroreceptor response Signup and view all the answers

What physiological factor underlies the risk of bradycardia when administering phenylephrine?

Baroreceptor reflex activation Signup and view all the answers

What is one of the primary mechanisms through which magnesium sulfate exerts its anticonvulsant effect in preeclampsia?

By reducing cerebral vasoconstriction and mediating NMDA receptors Signup and view all the answers

Which of the following effects is NOT attributed to magnesium sulfate in the treatment of preeclampsia?

Respiratory stimulant Signup and view all the answers

What clinical sign is NOT considered a symptom of magnesium toxicity?

Elevated blood pressure Signup and view all the answers

During a cesarean section, which communication aspect should the anesthetist prioritize for the comfort of the patient and their significant other?

Providing constant reassurance and updates about the procedure Signup and view all the answers

Which factor contributes significantly to the situational disorientation of parents during a cesarean section?

Unfamiliar sights, sounds, and smells of the operating room Signup and view all the answers

What is the primary purpose of continuing magnesium sulfate therapy after cesarean delivery?

To reduce the risk of seizures in preeclamptic patients Signup and view all the answers

Which of the following is NOT a disadvantage associated with intrathecal narcotics used in postoperative care?

Increased blood pressure Signup and view all the answers

When should magnesium sulfate therapy be discontinued in a postoperative preeclamptic patient?

Once signs and symptoms of preeclampsia are resolved Signup and view all the answers

Which method is considered most effective in maintaining hemodynamic control in postoperative preeclamptic patients?

Ensuring adequate intravascular volume Signup and view all the answers

What is the recommended dosage range of intrathecal preservative-free morphine for patients receiving spinal anesthesia during cesarean sections?

0.1 to 0.2 mg Signup and view all the answers

Study Notes

Key Considerations for Anesthesia in Cesarean Sections

Spinal anesthesia is preferred for cesarean section due to its effectiveness and safety profile.
A thorough physical examination and medical history are vital for assessing parturients with preeclampsia.
An anesthetist must clearly inform the mother about the procedure and what to expect during surgery.
A treatment strategy for inadequate spinal analgesia should be predetermined before the procedure.
Postoperative care for parturients with preeclampsia includes managing analgesia, hemodynamic stability, fluid and electrolyte balance, and seizure prevention.

Understanding Preeclampsia

Preeclampsia affects 5% to 9% of pregnancies, primarily in first-time mothers (85% of cases).
No definitive pathogenesis has been established for preeclampsia, leaving its etiology largely unknown.
Risk factors include immunologic, genetic predispositions, atypical responses during pregnancy, endothelial dysfunction, and inflammatory responses.
Endothelial damage leads to conditions like thrombocytopenia, elevated liver enzymes, increased systemic vascular resistance, proteinuria, and edema.

Cesarean Section Overview

Approximately one-third of births in the U.S. are delivered via cesarean section, totaling about 1 million annually.
Common indications for cesarean delivery include arrested labor, previous cesarean, abnormal placentation, or severe maternal health issues like preeclampsia.
Fetal reasons for cesarean delivery may include macrosomia, malpresentation, or concerns about fetal well-being.
The surgical procedure typically begins with a Pfannenstiel incision, followed by a lower uterine segment incision.
Post-delivery, the uterus and abdominal cavity are closed, but potential complications can include hemorrhage, infection, and organ laceration.

Preeclampsia Diagnostic Criteria

Mild Preeclampsia:
- Blood pressure: Systolic ≥140 mm Hg, diastolic ≥90 mm Hg after 20 weeks in previously normotensive individuals
- Proteinuria: >300 mg in a 24-hour period
- Edema: Not a reliable sign; present in ~30% of pregnant women
Severe Preeclampsia:
- Blood pressure: Systolic >160-180 mm Hg, diastolic >110 mm Hg
- Proteinuria: >5 g within 24 hours or urine dipstick of +3 or +4
- Oliguria: Urine output <500 mL per day
- Neurologic symptoms: Includes headache, visual disturbances, seizures (grand mal indicates eclampsia)
- Associated symptoms: Epigastric pain, pulmonary edema, liver dysfunction, thrombocytopenia

Assessment Interventions for Preeclampsia

Vital Signs Monitoring: Blood pressure, heart rate, oxygen saturation, temperature, respiratory rate
Physical Examination/History: Assess for headache, epigastric pain, visual disturbances, seizures
Laboratory Assessments:
- Hematocrit and Hemoglobin: Check for hemoconcentration indicating hypertension
- Platelet Counts: Evaluate for thrombocytopenia
- Renal Function: Serum uric acid (normal lower during pregnancy; >5 mg/dL abnormal) and creatinine levels (normal ~0.5 mg/dL; >0.9 mg/dL abnormal)
- Urine Protein: Collect 24-hour sample as an indicator of renal dysfunction
- Liver Function: Increasing serum transaminase levels may indicate disease progression
- Serum Albumin Levels: Decreased levels suggest capillary leakage and severity of disease
- Lactate Dehydrogenase (LDH): Increasing levels may indicate hemolysis
- Coagulation Studies: Required for severe preeclampsia, signs of coagulopathy or right upper quadrant pain; tests include PT/aPTT, fibrinogen, D-dimer

Anesthetic Teaching Points Before Cesarean Section

Explain the sequence of events during spinal anesthetic placement and cesarean section to reduce anxiety.
Provide information to build confidence between the patient and the anesthetist.
Encourage the patient to report any symptoms of low blood pressure, including anxiety, sweating, or nausea.
Instruct the patient that they might experience pressure and pulling during the procedure, particularly before delivery.
Warn the patient about potential nausea and vomiting as the uterus is exteriorized.

Preoperative Medications for Cesarean Section

Nonparticulate antacids, H2 receptor antagonists, and/or metoclopramide should be administered 60 to 90 minutes prior to surgery.
These medications are crucial for aspiration prophylaxis to prevent complications during anesthesia.
Metoclopramide's gastrokinetic effects also help to reduce postoperative nausea and vomiting (PONV) in obstetric patients undergoing cesarean sections.

Clinical Effects of Spinal Anesthesia in Preeclampsia Patients

Spinal anesthesia is generally safe for patients with mild preeclampsia.
Hypotension is a common side effect, exacerbated by intravascular volume depletion found in preeclampsia.
The onset of sympathectomy due to preganglionic beta-fiber blockade can lead to rapid hypotension.
Preemptive IV fluid administration is critical before spinal anesthesia to mitigate severe hypotension risk.
If IV fluids are given more than 15 minutes prior to the spinal block, intravascular volume expansion may not be sufficient.
Typical sensory block levels include T10 at 4 minutes and T4 at 8 minutes post-spinal placement.
Patients may experience warmth, tingling, numbness, and heaviness in lower extremities, progressing upwards.
Inactivation of T6 proprioceptive nerves may lead to feelings of breathlessness, which can be anxiety-inducing.
Pre-operative briefing on potential sensations can help mitigate anxiety related to breathing difficulties.
A significant blood pressure drop (20% below baseline) can incite restlessness and nausea, indicating central medullary hypoxia.
Aortocaval compression from the gravid uterus is heightened in supine positioning; sustained left uterine displacement (SLUD) alleviates this.
Administration of vasopressors is reasonable to prevent severe hypotension; rapid IV fluid infusion is recommended during hypotension events.

Sensory Blockade Levels for Cesarean Section

A sensory blockade targeting T4-5 is optimal for cesarean sections.
A sensory block around TG (tip of the xiphoid process) is generally tolerated for surgical intervention.

Plan of Treatment for Inadequate Sensory Blockade

Assessment is vital if a patient experiences inadequate sensory blockade during a cesarean section.
Normal sensations of pressure or pulling should be reassured as non-painful; support from family can aid in distraction.
If pain is reported, location identification is critical.
For incision site pain, the surgeon may inject local anesthetic directly at the site.
If ineffective or if pain is not incision-related, consider placing an epidural if surgery hasn't commenced for optimal blockade.
Alternatively, defer the procedure until the spinal block recedes before attempting a second spinal.
Timing for a second SAB lacks definitive guidelines, and it risks potential high or complete spinal outcomes.
If surgery is ongoing and pain occurs, ketamine (10 to 40 mg IV) can be administered cautiously due to its sympathomimetic effects.
Midazolam can be given post-delivery to reduce emergence delirium risks.
Rapid-acting narcotics like IV fentanyl should be used after umbilical cord clamping, alongside nitrous oxide in a 50% mixture with oxygen.
General anesthesia poses higher risks for airway difficulties and hemodynamic variability, particularly in patients with preeclampsia, as well as potential neonatal respiratory depression.

Spinal vs. Epidural Anesthesia in Preeclampsia

Spinal Anesthesia Block (SAB) Advantages:
- Rapid onset facilitates quick pain relief during labor and delivery.
- Relative ease of placement increases efficiency in emergency situations.
- High reliability for effective analgesia in parturients.
Spinal Anesthesia Block (SAB) Disadvantages:
- Rapid onset of sympathetic blockade can lead to significant cardiovascular complications.
- Risk of hypotension can affect maternal and fetal well-being.
- Potential for post-dural puncture headache, causing prolonged discomfort.
- High SAB levels may result in severe hypotension, loss of consciousness, or bradycardia.
- Inadequate sensory blockade may complicate labor management.
Epidural Anesthesia Advantages:
- Provides a gradual, controlled onset of sympathetic blockade, allowing for better management of maternal hemodynamics.
- Facilitates titration of local anesthetic volume for desired sensory levels, enhancing pain control.
- Improved intervillous blood flow supports fetal well-being during anesthesia.
Epidural Anesthesia Disadvantages:
- Sudden-onset hypotension poses acute risks, challenging stable patient management.
- Inadequate, patchy, or unilateral blockade may lead to insufficient analgesia.
- Local anesthetic toxicity is a potential risk with improper dosing or administration.
- There is a risk of intravascular injection, which could lead to systemic toxicity.
- Technical difficulty in placement compared to SAB may complicate the procedure.
- Increased risk of epidural hematoma in patients with coagulopathies, requiring careful assessment.

Management of Hypotension Post-SAB

Historical Treatment Choice:
- Ephedrine is traditionally used for treating neuraxial anesthesia-induced hypotension in the context of SAB.
Current Preference:
- Phenylephrine may be preferred during routine pregnancies due to better efficacy in maintaining maternal hemodynamics.
Fetal Outcomes:
- Both phenylephrine and ephedrine yield similar fetal acid-base balance, ensuring minimal impact on the fetus.
Bradycardia Concerns:
- The use of phenylephrine in bradycardic patients after SAB can exacerbate the condition if not managed carefully.
Physiologic Rationale:
- Cardio-accelerator fiber blockade (T1-T5 level) combined with arterial constriction can trigger baroreceptor reflex responses, necessitating cautious drug selection.
Incidence of Hypotension:
- Approximately 70% of obstetric patients experience clinically significant hypotension following SAB administration.

Magnesium Sulfate in Preeclampsia

First-line treatment for preeclampsia, specifically effective in preventing seizures.
Acts as an anticonvulsant by reducing cerebral vasoconstriction and mediating N-methyl-D-aspartate receptors in the brain.
Exerts vasodilatory effects by increasing cyclic guanosine monophosphate (cGMP), decreasing angiotensin-converting enzyme levels, and enhancing production of prostaglandin I2 (PGI2) from endothelial cells.
May serve as a tocolytic agent, aiding in the prevention of premature labor.
Signs of magnesium toxicity include absent deep tendon reflexes, decreased respiratory rate, unexplained hypotension, fetal distress, and loss of consciousness.
Calcium gluconate 10% is recommended for IV administration if magnesium toxicity symptoms occur, typically delivered over 3 to 5 minutes.

Communication During Cesarean Section

During a cesarean section, the patient remains awake and alert, often accompanied by a significant other.
Expectant parents may be unfamiliar with the surgical environment, including the sights, sounds, and smells, leading to situational disorientation.
The anesthetist must consider the unique emotional and psychological states of both the patient and their partner during the surgery.
Continuous communication is essential between the anesthetist and the surgeon, ensuring coordination and safety throughout the procedure.

Magnesium Sulfate Therapy

Continued postpartum for 24 to 48 hours after cesarean delivery to reduce seizure risk.
Postpartum convulsions are rare, but magnesium sulfate therapy provides a safeguard against seizures.

Goals of Postoperative Management in Preeclamptic Patients

Adequate Analgesia:
- Patients may receive 0.1 to 0.2 mg of intrathecal preservative-free morphine.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac can be administered intravenously.
- Intrathecal narcotics may lead to side effects such as delayed respiratory depression, pruritus, nausea, and vomiting.
Maintenance of Hemodynamic Control:
- Essential to monitor and stabilize blood pressure and other vital signs.
Maintenance of Intravascular Volume:
- Magnesium sulfate is continued until recovery from preeclampsia symptoms, including hypertension, coagulopathy, and oliguria.
Assessment of Electrolyte Values:
- Regular monitoring of electrolyte levels is needed to manage potential imbalances.

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Description

This quiz covers essential points regarding cervical cerclage and the anesthetic management during cesarean sections. Key topics include the use of spinal anesthesia for parturients, considerations related to preeclampsia, and the importance of thorough preoperative assessment. Understand the critical elements that influence effective anesthesia during cesarean deliveries.