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Procedures
Operation | Description | Time (min) | Pain | Position | Blood loss/X-match | Notes |
---|---|---|---|---|---|---|
Colposuspension | Abdominal procedure for stress incontinence | 40 | +++ | Supine | G&S | ETT, IPPV |
Cone biopsy/LLETZ | Removal of the terminal part of the cervix through the vagina | 30 | ++ | Supine | G&S | May bleed post-operatively. LMA, SV |
Laparotomy, investigative | Abdominal assessment of pelvic mass | 120 | ++++ | Supine | 2U | Ovarian tumours may be adherent to adjacent structures. Potentially large blood loss |
Myomectomy | Abdominal excision of fibroids from uterus | 60 | +++ | Supine | G&S | Blood loss may be greater than expected. ETT, IPPV |
Oophorectomy | Removal of ovaries | 40 | +++ | Supine | G&S | ETT, IPPV |
Repair, anterior | Repair of anterior vaginal wall | 20 | ++ | Lithotomy | Nil | Often combined with vaginal hysterectomy. LMA ± caudal |
Repair, posterior | Repair of posterior vaginal wall | 20 | ++ | Lithotomy | Nil | Often combined with vaginal hysterectomy. LMA ± caudal |
Sacrocolpopexy | Abdominal repair of vault prolapse | 60 | +++ | Supine | G&S | ETT, IPPV |
Sacrospinous fixation | Vaginal operation for vault prolapse | 40 | +++ | Lithotomy | Nil | |
Shirodkar suture | Insertion of suture around cervix to prevent recurrent miscarriage | 20 | ++ | Lithotomy | Nil | May need antacid prophylaxis |
Thermoablation | Thermal obliteration of endometrium | 20 | ++ | Lithotomy | Nil | May require opioids |
TCRE | Endoscopic resection of endometrium | 30 | ++ | Lithotomy | Nil | Systemic absorption of water may occur from the glycine solution. Treat as for TURP syndrome |
Vulvectomy, simple | Excision of vulva | 90 | +++ | Lithotomy | G&S | |
Vulvectomy, radical | Excision of vulva and lymph nodes | 150 | ++++ | Lithotomy | 2U | Epidural analgesia recommended |
Molar Pregnancy
Overview
- Molar pregnancy (hydatidiform mole) represents placentas with abnormally developed chorionic villi. It is one of the four groups of Gestational Trophoblastic Disease, ranging from molar pregnancy to choriocarcinoma.
- The defect occurs during fertilization, where the ovum is fertilized by more than one sperm.
- Classification:
- Partial mole: Contains placenta and some fetal parts.
- Complete mole: Contains only grape-like placental tissue.
- Incidence: Varies geographically, ranging from 1:2500 in the USA to 1:200 in some Asian countries.
- Risk Factors:
- Age: Less than 20 and more than 35 years.
- History of miscarriage.
- Previous history of molar pregnancy (1-2%).
- Race: More common in South Asians and Africans.
- Diet: Low in vitamin A, folic acid, and protein.
Clinical Presentation
- Vaginal bleeding
- Uterus size greater than gestational age
- Hyperemesis gravidarum
- Symptoms of pre-eclampsia
- Hyperthyroidism
- Respiratory compromise or ARDS
- Theca lutein cysts
Symptom Variability
- Presenting symptoms can range from vaginal bleeding to clinical hyperthyroidism complicated by high output cardiac failure.
- Thorough pre-operative assessment of thyroid function and cardiopulmonary reserve is essential.
- Key concerns for the anesthetist include thyrotoxicosis, acute cardiopulmonary distress, and bleeding.
Management
- Surgical:
- Termination of pregnancy by suction curettage or hysterectomy for those beyond childbearing age.
- Medical:
- Methotrexate.
Hyperthyroidism in Molar Pregnancy
- Clinical hyperthyroidism complicates 7% of molar pregnancies, while biochemical hyperthyroidism can be as high as 50%.
- Presentation varies from no symptoms to thyroid storm.
- Pathophysiology:
- hCG stimulates TSH in molar pregnancy.
- Hyperthyroidism is linked to high circulating hCG levels.
- Management:
- Start anti-thyroid medications before anesthesia for stable patients with clinical hyperthyroidism.
- Emergency cases with bleeding can be managed with beta-blockers and steroids to prevent thyroid storm.
- Thyroid Storm:
- Symptoms include tachycardia, arrhythmias, cardiovascular collapse, coma, and death.
- Managed by supportive measures, administration of beta-blockers, steroids, and anti-thyroid medications.
Drugs for Thyroid Management
Antithyroid Agents
Drug | Typical Adult Dose | Action |
---|---|---|
propylthiouracil (PTU) | 1,200–1,500 mg/day, given in 200–250 mg increments PO or via gastric tube | Prevents production of more T4 and T3 in the thyroid, and blocks the conversion of T4 to T3 outside the thyroid. |
methimazole (Tapazole) | 120 mg given in 20 mg increments PO or via gastric tube | Prevents production of more thyroid hormone. |
Iodides
Drug | Typical Adult Dose | Action |
---|---|---|
Lugol’s solution | 10 drops twice a day PO or via gastric tube | Blocks release of stored thyroid hormone from thyroid gland. |
saturated solution of potassium iodide (Pima, SSKI) | 8 drops every 6 hours PO or via gastric tube | Blocks release of stored thyroid hormone from thyroid gland. |
Glucocorticoids
Drug | Typical Adult Dose | Action |
---|---|---|
dexamethasone (Decadron) | 2 mg every 6 hours, PO or IV | Blocks conversion of T4 to T3. |
hydrocortisone | 100 mg IV every 8 hours | Blocks conversion of T4 to T3. |
Beta-blockers
Drug | Typical Adult Dose | Action |
---|---|---|
propranolol (Inderal) | 1 mg/min IV as required, then 60–80 mg every 4 hours PO or via gastric tube | Reduces symptoms (tachycardia, tremor, restlessness) caused by a heightened response to catecholamines; blocks conversion of T4 to T3. |
esmolol (Brevibloc Injection) | 500 mcg/kg/min for 1 minute, then 50–100 mcg/kg/min for 4 minutes | Reduces symptoms (tachycardia, tremor, restlessness) caused by a heightened response to catecholamines; blocks conversion of T4 to T3. |
Acute Cardiopulmonary Distress
- Typically follows evacuation of the molar pregnancy in patients with very high hCG levels.
- Seen in 27% of patients with uterus size greater than 16 weeks.
- Symptoms appear 4-12 hours post-evacuation.
- Cause: Embolization of trophoblastic tissue causing high pulmonary pressures.
- Management: Support cardiac and respiratory systems, maintain oxygenation, mechanical ventilation if necessary. Condition usually resolves by 72 hours.
Bleeding and Anaemia
- Bleeding can be occult or massive.
- Patients may present fluid depleted or with high output cardiac failure due to anaemia.
- Challenges include fluid management to avoid overloading.
- During Suction Curettage:
- Potential for blood loss, uterine perforation, and massive transfusion.
Anaesthesia for Molar Pregnancy
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Summary of Management of Patients with Molar Pregnancy
- Communication: Essential between the obstetrician and anaesthetist for adequate patient preparation and workup.
- Anaesthetic Workup: Identify complications and avoid intraoperative and postoperative adverse outcomes.
- Baseline investigations: FBC, U&E, TFT, CXR, and baseline ABG.
- Additional investigations as needed based on patient condition.
- Blood Availability: Ensure blood is available for major bleeding.
- Postoperative Care: Patients with thyrotoxicosis or cardiopulmonary compromise need high care or ICU.
- Anaesthetic Technique: General anaesthesia is commonly preferred; regional anaesthesia may be used in stable patients with low risk of bleeding.
Ovarian Hyperstimulation Syndrome (OHSS)
Pathophysiology
- OHSS is a rare and exaggerated response to ovulation induction therapy, usually associated with exogenous gonadotropin stimulation.
- It is a self-limiting disorder that resolves spontaneously within days.
- The spectrum of presentation ranges from mild disease needing observation to severe disease requiring ICU admission.
- The hallmark is an increase in capillary permeability resulting in fluid shift from the intravascular space to the third space.
- Vascular endothelial growth factor (VEGF) is most likely involved in OHSS, but other factors such as interleukin-1, interleukin-6, angiotensin II, and platelet-derived growth factor may also play a role.
Risk Factors
- Young age
- Low body weight
- Polycystic ovarian syndrome
- High doses of exogenous gonadotropins
- Previous episodes of OHSS
Clinical Features
- Symptoms: nausea, vomiting, diarrhoea, abdominal distension, ascites, pleural effusion, pericardial effusion, and hemodynamic instability.
- Hypotension results from fluid extravasation.
- Haemoconcentration with inactivity increases the risk of thromboembolism.
- Classification:
- Mild: abdominal bloating
- Moderate: nausea and moderate abdominal pain
- Severe: oliguria, ARDS, and thromboembolism
- Life-threatening complications: renal failure, adult respiratory distress syndrome, cardiovascular instability, bleeding into ovarian cysts, and thromboembolism.
- Patients with severe OHSS may present needing laparotomy for bleeding ovarian cyst or torsion, presenting an anaesthetic challenge.
Anaesthetic Concerns and Considerations
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Ovarian Torsion
Pathophysiology
- Ovarian torsion involves partial or complete rotation of the ovary around its vascular pedicle or axis.
- Complete torsion causes venous and lymphatic blockage, leading to stasis, venous congestion, hemorrhage, and necrosis.
- The cyst becomes tense and may rupture.
Presentation
- Patients present with severe abdominal pain.
- Higher incidence during pregnancy (22.7%) compared to non-pregnant patients (6.1%).
- Pregnancy increases the risk of ovarian torsion by a factor of 5.
- Ovarian torsion surgery is one of the three most common surgeries during pregnancy.
- Surgery during pregnancy should be avoided unless urgent.
- Understanding physiological and pharmacological changes across trimesters is crucial for safe anaesthesia.
Anaesthetic Goals
- Optimize and maintain normal maternal physiological function.
- Optimize and maintain utero-placental blood flow and oxygen delivery.
- Avoid drugs with teratogenic side effects.
- Prefer regional anaesthesia to avoid drug transfer to the mother and airway manipulation.
- Reduce sympathetic stimulation to prevent preterm labor.
- Prevent awareness during anaesthesia.
Anaesthetic Concerns and Considerations
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Cervical Incompetence
Presentation
- Patients present for modified Shirodkar or McDonald suture, both done transvaginally at 14-18 weeks.
- These procedures increase fetal survival from 20% to 89%.
- Patients with cervical incompetence have painless, recurrent second-trimester miscarriages.
- In cases with bulging membranes, there is a significant concern about rupturing the membranes during the procedure.
Anaesthetic Considerations
- Prophylactic procedures: Regional anaesthesia is preferred. A small RCT found no difference in postoperative oxytocin levels and uterine activity between spinals and general anaesthesia for prophylactic cerclage.
- After 20 weeks, aorto-caval compression decreases utero-placental perfusion.
- Emergency procedures with bulging membranes: General anaesthesia may be preferred to decrease intra-abdominal pressure and reduce the risk of rupturing membranes.
- Tocolysis should be considered if the membranes are bulging.
Links
- Non obstetric surgery
- Obstetric haemorrhage
- Molar pregnancy
- Ovarian hyperstimulation
- Maternal conditions
References:
- Lurain, J. R. (2011). “Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia.” American Journal of Obstetrics and Gynecology 204(1): 11-18
- Swaminathan S, James RA, Chandran R, Joshi R. Anaesthetic Implications of Severe Hyperthyroidism Secondary to Molar Pregnancy: A Case Report and Review of Literature. Anesth Essays Res. 2017 Oct-Dec;11(4):1115-1117. doi: 10.4103/aer.AER_38_17. PMID: 29284889; PMCID: PMC5735464.
- Namavar Jahromi B MD, Parsanezhad ME MD, Shomali Z MD, Bakhshai P MD, Alborzi M MD, Moin Vaziri N MD PhD, Anvar Z PhD. Ovarian Hyperstimulation Syndrome: A Narrative Review of Its Pathophysiology, Risk Factors, Prevention, Classification, and Management. Iran J Med Sci. 2018 May;43(3):248-260. PMID: 29892142; PMCID: PMC5993897.
- Chandra, A., Thakur, V. S., Duggal, R., & Pawar, S. J. (2015). Hydatiform mole and its anesthetic implications. Medical Journal of Dr. D.Y. Patil University, 8(6), 841. https://doi.org/10.4103/0975-2870.169923
- Anaesthesia for gynaecological emergencies Dr Nthatheni Madima. Wits refresher 2013
- Molar pregnancies with a focus on the thyroid. Dr F BhamWits refresher 2017
Summaries:
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