Assessment of the Pregnant Patient PDF

Assessment of the Pregnant Patient Health Assessment Pregnancy and Anesthesia Increase in surgery during pregnancy Cancer detection Laparoscopic techniques Improvements in medications and management Fetal monitoring technology Maternal changes during pregnancy are critical to understand Number one g...

Assessment of the Pregnant Patient Health Assessment Pregnancy and Anesthesia Increase in surgery during pregnancy Cancer detection Laparoscopic techniques Improvements in medications and management Fetal monitoring technology Maternal changes during pregnancy are critical to understand Number one goal is to take care of the mother Good maternal care = good fetal care! Physiological Changes in Pregnancy Almost every organ system is impacted by pregnancy Changes begin in first trimester PK and PD are both impacted Changes in hormone activity Increased maternal metabolic demands and biochemical alterations Mechanical effects of a gravid uterus CV Changes Increased in intravascular volume (35-45%) 45-55% increase in plasma volume 20-30% increase in erythrocyte volume Increase in cardiac output (40-50%) 25-35% SV 15-25% CO Decrease in SVR (20%) Decrease in PVR (35%) Supine hypotension develops Respiratory Changes MV increases 45-50% TV increases 40-45% RR increases 0-15% TLC decreases 0-5% VC unchanged FRC decreases 20% Oxygen consumption increases 20% Upper airway capillary engorgement Hepatic and Biliary Changes AST, ALT, and bilirubin increase to upper limits of normal Plasma protein concentrations decrease Plasma cholinesterase levels decrease 30% Placenta production of alkaline phosphate levels results in double the normal value resulting in gallbladder issues Renal Changes Renal blood flow increases 60% Clearance of creatinine, urea, and uric acid are increased Upper limits of BUN and Cr in pregnancy are 50% lower Ureteroplacental Physiology Blood flow increases from 100 ml/min to 700 ml/min (10% of CO) 80% of uterine blood flow perfuses the intervillous space (placenta) and the rest perfuses the myometrium (muscle) Uterine blood flow has minimal autoregulation Maternal CO Maternal blood pressure Surgery in Pregnancy Mostly limited to non-elective surgery Cholecystectomy/Appendectomy Maternal trauma Cancer Fetal procedures (EXIT) Maternal hemorrhage is the number one cause of maternal death worldwide (including the US) Up to 2% of pregnant patients will require surgery Anesthesia Toxicity All general anesthetic drugs cross the placenta No studies found increase in birth defects in women undergoing anesthesia while pregnant Small increase in risk for miscarriage or preterm delivery In general, the second trimester is the safest First = ogranogenesis Third = preterm labor Regional anesthesia is always preferred Preoperative Considerations Consultation with OB provider, always Maternal coexisting disease Pregnancy overlaying the coexisting disease New disease of pregnancy Capabilities of the facility Progression of the pregnancy Refer to OB provider Increased progesterone levels à smooth muscle relaxation, delayed gastric emptying Fetal Heart Rate Monitoring FHTs should be monitored after 18 weeks At 25 weeks, FHT variability is a sign of fetal wellbeing Decision to monitor FHTs during surgery needs to be a three-way discussion OB provider Surgeon Anesthesia Individualized but at least pre- and post-op at a minimum