Anesthesia & Co-existing Diseases in the Parturient Joseph E Pellegrini, CRNA, PhD
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Transcript Anesthesia & Co-existing Diseases in the Parturient Joseph E Pellegrini, CRNA, PhD
Anesthesia & Co-existing
Diseases in the Parturient
Joseph E Pellegrini, CRNA, PhD
Co-existing Disease
Estimated that approximately 10-15% of all
parturients have some co-existing disease
Most benign
Autoimmune Diseases
Discussion for all diseases beyond scope of this discussion
Effects 1-2 % of all pregnancies
Systemic Lupus Erythematosus
Systemic Sclerosis (Scleroderma)
Myasthenia Gravis
Diabetes Mellitus
Obesity
Neurological and Neuromuscular Disease
Multiple Sclerosis
Systemic Lupus Erythematosus
Multisystem inflammatory disease of
unknown etiology that is characterized by the
production of autoantibodies against cell
membrane antigens
Most common in women in childbearing
years
Overall see more prevalence in African
Americans, Asians & Native Americans than
Caucasians
Occurs in 1:1200 deliveries
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
Anesthetic Management
Coordinated effort between OB, Rheumatology & Anesthesia
Evaluate for organ involvement
Periocarditis
Valvular Disorders
More prone to Valvular thickening (51%), Vegetations (43%), Regurgitation (25%) and
Stenosis (4%)
Prophylactic antibiotics only required if patient at high risk for endocarditis
(previous infective carditis, unrepaired cyanotic heart disease, implanted
prosthetic devices, cardiac transplantation with cardiac valvulopathy). Not
recommended for women with common valvular lesions undergoing GU
procedures (which includes vaginal delivery)
Neuropathies
Typically asymptomatic
Evaluate EKG for prolongation of PR interval or non-specific T wave changes
Evaluate exercise tolerance
Central & Peripheral neuropathaties noted in approximately 25% of all SLE patients
Vocal Cord palsy – evaluate all SLE prior to implementation of GA/CLE etc
Note any area of sensory deficit prior to implementation of any neuraxial
anesthesia/analgesia
Early implementation of Regional Anesthesia recommended
Systemic Sclerosis (Scleroderma)
Scleroderma is a chronic progressive disease characterized by deposition of
fibrous connective tissue in the skin and other tissues
240 million Americans have Scleroderma
No proven treatment exists for the arrest of scleroderma
Therapy geared towards improving existing symptoms and preventing end organ damage
Five times more prevalent in women than men
Occurs between the ages of 30-50
Death is usually 15-20 years after diagnosis from renal failure & malignant hypertension
Becoming more of a problem with recent trend towards first time pregnancies at 30+ years of age
Effect on Pregnancy
Typically symptoms unchanged with pregnancy
Approximately 20% will have worsening of symptoms with significant esophageal reflux,
cardiac arrhythmias, arthritis, renal crisis
ACE inhibitors are treatment of choice for scleroderma associated renal crisis
Evaluate parturient for evidence of renal, pulmonary & cardiac dysfunction
Work in collaboration with specialists
Some obstetricians recommend termination of pregnancy in advanced disease
However ACE inhibitors are typically not administered during pregnancy secondary to high
incidence of teratogenicity however they should be given at the first indication of maternal
hypertension
Prone to pulmonary HTN, cardiac dysfunction, obstructive uropathy (from enlarged uterus)
No increased frequency of miscarriage
Preterm labor occurs in 25% of pregnancies (as compared to a 5% national average)
Systemic Sclerosis (Scleroderma)
Anesthetic Management
Requires a multi-disciplinary approach
Evaluation of patient should be done prior to labor and delivery
History & Physical directed toward detection of underlying systemic
dysfunction
Lab tests
EKG & PFT’s
CBC, Coagulation profile, Full Chemistry Panel with creatinine clearance, ABG,
Urinalysis with protein
Evaluate for presence of Reynaud’s phenomenon prior to ABG
Should be performed in all patients
Echocardiography useful to evaluate ventricular dysfunction, pericardial and
pleural effusions and pulmonary HTN
Very thorough examination of upper airway
Can have severe limitation of oral opening
Evaluate maximal oral opening, ability to sublux the mandible, visualization of
oropharyngeal structures, degree of atlanto-occipital joint extension and presence
of nasal or oral telangiectasias
Prepare for possibility of awake intubation (equipment for fiberoptic and
emergency cricothyrotomy should be available in labor and delivery suite)
Systemic Sclerosis (Scleroderma)
Anesthetic Implications
Epidural anesthesia can be used
Can see severe prolongation of motor and sensory blockade
Decision to use epidural or GETA dependent on urgency for cesarean section
Spinal anesthesia has been used but difficulty treatment of hypotension
Initiate analgesia/anesthesia using small incremental doses
Incremental doses preferable over continuous infusion for laboring analgesia
Epidural anesthesia preferable over Spinal anesthesia
General Anesthesia most frequently used in severe cases
Awake versus RSI??
CVP cannulation may be required in patients with diffuse cutaneous
involvement
Extensive skin involvement may lead to inaccurate non-invasive blood
pressure readings
Arterial blood pressure measurements preferable in severe cases
Radial artery catheterization contraindicated in patients with Reynaud’s
phenomenon
Brachial artery catherization can be used
Myasthenia Gravis
Rare Autoimmune Disorder
Progressive muscle weakness
Destruction of ACTH receptors
Typically treated with anticholinergic agents such as
neostigmine or edrophonium
Women 3 times more likely to develop
Typically manifests before age 40
Pregnancy can exacerbate symptoms
(cholinergic crisis)
Usually requires adjustment of neostigmine doses
Myasthenia Gravis
(Contraindicated Drugs)
Antibiotics
Gentamycin
Kanamycin
Steptomycin
Plymyxin
Colistin
Tetracycline
Lincomycin
Tocolytics
Magnesium Sulfate
Cardiac Meds
Quinidine
Propanolol
Beta Mimetics
Ritrodrine
Terbutaline
Others
Quinine
Penicillamine
Lithium Salts
Myasthenia Gravis
Anesthetic Management
Careful History and Physical Exam
Best if done before she presents for L&D
Document all medications dose & frequency
Look for possible interactions between drugs
Most commonly on neostigmine
Maintain on normal regimen
IV dose is given in ratio of 30:1 to oral dose
Monitor fetal HR closely
Observe for s/s of “cholinergic crisis”
Myasthenia Gravis
Cholinergic Crisis
Profound muscle weakness
Respiratory failure
Loss of bowel and bladder function
Disorientation
Diplopia
Myasthenia Gravis
Anesthetic Management
Regional Anesthesia preferable to General
Anesthesia
If GETA is required keep to absolute minimum
1/2 MAC usually adequate
Highly sensitive to both depolarizing and nondepolarizing neuromuscular blocking agents
Intubation doses are typically 1/2 to 1/3 normal
More receptive to effects of opioids and local anesthetic
agents
The Diabetic Parturient
Diabetes Mellitus prevalence 6.8-8.2% in the general population
Most common medical problem of pregnancy
Incidence 1:700 to 1:1000 gestations
Hyperplasia of -cells of maternal islets of Langerhans
Pregnancy produces higher levels of insulin
Two types
Type 1 – Decrease in insulin secretion
Primarily an autoimmune disorder
Type 2- Resistance to insulin in target tissues
Altered insulin requirements throughout pregnancy
Accounts for 90-95% of the cases of DM in U.S.
Gestational Diabetes
Refers to DM that is first diagnosed in pregnancy
Present in 4% of all pregnancies in U.S.
Insulin requirements
Diet Control
Gestational Diabetes
Associated with:
Advanced maternal age
Obesity
Family history of DM
History of stillbirth, neonatal death, or fetal malformation or
macrosomia
Presents when patients cannot mount a sufficient compensatory
insulin response during pregnancy
More prevalent in 2nd and 3rd trimesters
After delivery most parturients return to normal glucose tolerance
Recurrence rate with subsequent pregnancies 52-68%
Prevalence Rates
Whites Classification
Modified White Classification of Diabetes Mellitus During Pregnancy
Class
Gestational Diabetes
A1
A2
Pregestational Diabetes
B
C
D*
F
R
T
H
Age of onset (yrs)
Duration of
diabetes (yrs)
Vascular
Disease
Insulin
Required
Any
Any
Any
Any
-
+
>20
10-19
<10
Any
Any
Any
Any
(or)
(or)
<10
10-19
>20
Any
Any
Any
Any
+
+
+
+
+
+
+
+
+
+
+
+
*Vascular Disease in D is hypertension or benign retinopathy
F, Nephropathy; R, proliferative retinopathy; T, status-post renal transplant; H, ischemic heart
disease
Major Complications
Acute Complications
Diabetic Ketoacidosis
Hyperglycemic nonketotic state
Primarily occurs in Type II diabetes
Hypoglycemia
Chronic Complications
Macrovascular
Microvascular
Coronary
Cerebrovascular
Peripheral Vascular
Retinopathy
Nephropathy
Neuropathy
Autonomic
Somatic
The Diabetic Parturient
Pregnancy associated with a progressive peripheral
resistance to insulin in 2nd & 3rd trimester
Diabetes associated with higher incidence of
gestational HTN, polyhydramnios and cesarean
delivery
Initiation of early glycemic control is the best way to
prevent fetal structural abnormalities
Determination of hemoglobin A1C concentrations help
determine adequacy of glycemic control
Normal range is 4-6%
Increased risk of microvascular and macrovascular disease begins
at 6.5%
Stiff Joint Syndrome
30-40% in Type 1 Diabetics
Occurs in patients with long-standing type 1 diabetes and is associated
with nonfamilial short stature, joint contractures and tight skin
Direct laryngoscopy can be difficult in 30% of all parturients with DM
C-spine rigidity (atlanto-occipital joint)
Ensure plan for emergency airway in place
Planned general anesthesia
Awake intubation?
Fiberoptic intubation
Preanesthestic management
Controversial
Some recommend pre-anesthetic flexion-extension cervical spine x-rays
No evidence to indicate that having pre-anesthetic cervical spine series makes
a difference
Anesthetic Management
Maternal insulin requirements increase progressively during the 2 nd and 3rd trimester
& decrease at the onset of labor and continue to decrease following delivery
Preanesthestic Evaluation
Absorption of SQ insulin is unpredictable
IV insulin therapy more flexible
Obtain Preoperative or pre-anesthesia intervention serum glucose levels
Controversy regarding use of insulin infusion during labor and delivery
Tighter controls recommended if patient is going to cesarean section
Evaluate End Organ Damage
Diabetic Autonomic Neuropathy
HTN
Orthostatic Hypotension
Painless MI
Decreased HR variability
Decreased response to medications
Atropine and propanolol
Resting tachycardia
Neurogenic atonic bladder
Hemoglobin A1C
Measure of overall serum glucose
Gastroporesis with delayed emptying
Sodium Citrate
Consider metoclopramide and H2 antagonist premed
Management in Operating Room
Intraoperative
Ensure good intravenous line in place
Evaluate preoperative serum glucose levels with IV start
Begin D5W 1-1.5 ml/kg/hr as an IV piggy back into crystalloid solution
Administer insulin
Either
One-half of total daily dose as intermediate form (NPH) plus an intraoperative “sliding scale
Continuous infusion of regular insulin
Start infusion based on serum glucose using formula:
Units/hr = Plasma glucose/150+ (desired range of 150 etc)
i.e. plasma glucose of 220/150 = 1.4 units/hr (usually delivered in 250 units regular insulin/250 ml 09% NaCl
solution
Monitor Blood Glucose
Maintain serum glucose > 100 mg/dl
Infection
Avoid hypoglycemia and hyperglycemia
Important cause of morbidity in pregnant women
No data regarding incidence of CNS infection after administration of neuraxial anesthesia
Obviously ensure strict aseptic technique during administration
Poor wound healing noted in diabetic parturients
**Can see protamine sulfate anaphylaxis in patients taking NPH or protamine zinc
insulin
Clearance of Local Anesthetic
One study showed delayed
clearance and higher serum
levels following epidural
lidocaine administration in
diabetic groups
Study used 20 ml
Possible toxicity if large
volumes used
Caudal anesthesia etc
Moises EC et al. Eur J Clin Pharmacol. Pharmacokinetics of lidocaine and its metabolite in peridural anesthesia
administered to pregnant women with gestational diabetes mellitus. 2008 Dec;64(12):1189-96
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Diabetic Maternal Insulin
Req (%)
Diabetes Mellitus
Fetal Glucose Utilization
200
150
100
50
0
Obesity
Obesity is a public health issue in
most developed countries
Obese parturients at risk for medical
& obstetrical (and anesthesia)
complications during pregnancy
Difficulty with intubation
All know difficulties with intubation
and GETA
Problems with placement of neuraxial
anesthesia
Significant differences in anesthetic
requirements during labor & delivery
and at cesarean section
Obesity
Study to determine the
minimum local anesthetic
concentration (MLAC) of
bupivacaine in women at term
gestation
MLAC for obese women (>
30kg/m2) was 41% lower than
non-obese women
Despite lower anesthetic
concentrations administered to
obese women they achieved
higher sensory blockade with
no differences in pain scores
Greater distribution of
epidural local anesthestic
within epidural space in
obese women
Don’t standardize epidural dose
Panni MK, Columb MO. Obese parturients have lower epidural local anesthetic requirements for
analgesia in labour. Br J Anaesth 2006; 96: 106-10.
Multiple Sclerosis
Major cause of neurological disability in
young adults
incidence of 0.3-0.8% of population
Presents over a period of several years as
two general patterns:
Exacerbating remitting- attacks appear abruptly & resolve
over several months
Chronic progressive
Manifest as neurological defects that present as pyramidal,
cerebellar or brainstem symptoms
Multiple Sclerosis
Etiology is unclear
? Link to previous exposure to viral agent that
may trigger autoimmune response
Most common Symptoms
Loss of myelin in CNS
Motor weakness, impaired vision, ataxia, bladder & bowel
dysfunction and emotional lability
No curative treatment
Treat symptomatically & by immunosuppression
Often tx is marked by relapses & regression of Sx
Multiple Sclerosis
Interaction with pregnancy
No effect on progression of MS
Slight increased risk for relapse during pregnancy
Stress, exhaustion, infection and hyperpyrexia may
contribute to relapse (most often in the postpartum period)
Pregnancy does not have an overall negative
effect on the long-term outcome of MS
Multiple Sclerosis
Anesthetic Management
Careful assessment of neurological and
respiratory compromise (if any)
Note any areas of motor weakness, visual
disturbances or bowel and bladder disorders
Auscultate all lung fields
Assess any anomalous finding with AP & Lateral Chest Xray and pulmonary function test before analgesic
intervention initiated
Multiple Sclerosis
Concerns w/ neuraxial anesthesia
exposures of de-mylinated areas of spinal cord to
potential neurotoxic effects
concerns over relapse of symptoms
Recommended
Do not exceed concentrations > 0.25% bupivacaine in
CLE infusions
Epidural anesthesia better tolerated than SAB
SAB has been successfully employed
CSF concentrations 4 fold higher with SAB than CLE
CSE technique well tolerated with IT opioids
Multiple Sclerosis
General Anesthesia
Not contraindicated
Succinylcholine should be avoided with severe
musculoskeletal involvement
Remain cognizant of pulmonary complications and
maintenance of normal body temperature
Multiple Sclerosis
1.
2.
3.
4.
5.
6.
7.
Overview of Anesthetic Management for the pregnant MS patient
Most methods of analgesia will be beneficial because they will reduce stress
Obtain careful history & note any neuromuscular anomalies and areas of weakness.
Epidural analgesia (with local anesthetics) is particularly appealing because it is helpful in
relieving abdominal & pelvic spasticity that can interfere with spontaneous delivery.
Research indicates that bupivacaine concentrations for continuous epidural infusions that exceed a
0.25% concentration can lead to exacerbation of neurological symptoms (when used for laboring
analgesia).
1. It is suggested that the lowest concentration of local anesthetic and volume that can
achieve effective analgesia should be used.
a. Typically use concentrations of 0.0625% - 0.125% bupivacaine or 0.08% 0.125% ropivacaine with 1-2 ug/ml of fentanyl
b. Intrathecal opioids have not been investigated fully but anecdotal analysis
shows that fentanyl, morphine and sufentanil have been successfully used
without causing exacerbation of symptoms
The use of intrathecal local anesthetics is controversial because of the potential high
concentrations of subarachnoid local anesthetic levels (research has shown that drug
concentrations of local anesthetics are 3-4 times higher in the CSF following subarachnoid
administration of a local anesthetic when compared to epidurally administered local anesthetics).
Epidural anesthesia is the preferred method for cesarean section.
General anesthesia does not exacerbate the course of MS but succinylcholine should be avoided in
patients having severe musculoskeletal involvement. Particular attention must be directed towards
the prevention of pulmonary complications and the maintenance of normal body temperature.
Questions??
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