Part 1 of ebook Cunningham and Gilstrap’s operative obstetrics provide readers with content about: general considerations; surgical instruments; perioperative imaging; clinical simulation; critical illness in pregnancy; antepartum; ectopic pregnancy; first- and second-trimester pregnancy termination; gestational trophoblastic disease; lower genital tract procedures;... Please refer to the ebook for details!
NOTICE Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs Copyright © 2017 by McGraw-Hill Education All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-184907-4 MHID: 0-07-174122-4 The material in this eBook also appears in the print version of this title: ISBN: 978-007-184906-7, MHID: 0-07-184906-8 eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs To contact a representative, please visit the Contact Us page at www.mhprofessional.com TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise DEDICATION Each day around the world, young doctors in residency training present to work with weighty goals In this edition of Cunningham and Gilstrap’s Operative Obstetrics, we acknowledge and celebrate their daily efforts to provide safe, compassionate, evidencebased care As they strengthen their clinical foundation, their insightful questions sharpen our clinical skills As mentors, we attempt to logically delineate the anatomy, physiology, and pathology of a given problem Indeed, many of the nuances in this text find their origins in these discussions Thus, we applaud all residents’ academic curiosity and drive to improve their craft In this role, they make us stronger physicians and better teachers, and we are grateful Edward R Yeomans, MD Barbara L Hoffman, MD Larry C Gilstrap, III, MD F Gary Cunningham, MD EDITORS Edward R Yeomans, MD Professor and Chairman Robert H Messer, M.D Endowed Chair Department of Obstetrics and Gynecology Texas Tech University Health Sciences Center Barbara L Hoffman, MD Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Parkland Health and Hospital System Larry C Gilstrap, III, MD Executive Director, American Board of Obstetrics and Gynecology F Gary Cunningham, MD Beatrice & Miguel Elias Distinguished Chair in Obstetrics and Gynecology Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Parkland Health and Hospital System Artists Lewis Calver, MS, CMI, FAMI Associate Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Marie Sena Graduate, Biomedical Communications Graduate Program University of Texas Southwestern Medical Center at Dallas CONTRIBUTORS April A Bailey, MD Assistant Professor, Department of Radiology Assistant Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Chapter 5: Perioperative Imaging Sunil Balgobin, MD Assistant Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Chapter 28: Urologic and Gastrointestinal Injuries Michael A Belfort, MBBCH, DA (SA), MD (Cape Town), PhD, FRCSC, FRCOG Ernst W Bertner Chairman and Professor, Department of Obstetrics and Gynecology Professor, Department of Surgery Professor, Department of Anesthesiology Baylor College of Medicine Obstetrician and Gynecologist-in-Chief Texas Children’s Hospital Chapter 16: Fetal Therapy Lubna Chohan, MD Associate Professor, Department of Obstetrics and Gynecology Baylor College of Medicine Chapter 14: Adnexal Masses Marlene M Corton, MD, MSCS Director, Anatomical Education and Research Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Chapter 3: Anatomy Geoffrey W Cundiff, MD, FACOG, FACS, FRCSC Dr Victor Gomel Professor of Obstetrics & Gynaecology Professor & Head, Department of Obstetrics & Gynaecology University of British Columbia Chapter 4: Incisions and Closures F Gary Cunningham, MD Beatrice & Miguel Elias Distinguished Chair in Obstetrics and Gynecology Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Parkland Health and Hospital System Chapter 1: Needles, Sutures, and Knots Chapter 2: Surgical Instruments Chapter 24: Shoulder Dystocia Chapter 26: Peripartum Hysterectomy Chapter 27: Placenta Previa and Morbidly Adherent Placenta Chapter 30: Genital Tract Lacerations and Hematomas Jimmy Espinoza, MD, MSc, FACOG Associate Professor Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine Baylor College of Medicine and Texas Children’s Hospital Chapter 13: Invasive Prenatal Diagnostic Procedures Rajiv B Gala, MD, FACOG Residency Program Director Vice-Chairman, Department of Obstetrics and Gynecology Ochsner Clinic Foundation Associate Professor of Obstetrics and Gynecology, University of Queensland Ochsner Clinical School Chapter 8: Ectopic Pregnancy Larry C Gilstrap III, MD Executive Director, American Board of Obstetrics and Gynecology Chapter 29: Management of Postpartum Hemorrhage J Seth Hawkins, MD Assistant Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Chapter 11: Lower Genital Tract Procedures Joy L Hawkins, MD Professor, Department of Anesthesiology Director of Obstetric Anesthesia University of Colorado School of Medicine Chapter 19: Anesthesia for the Pregnant Woman Barbara L Hoffman, MD Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Parkland Health and Hospital System Chapter 2: Surgical Instruments Clark T Johnson, MD MPH Assistant Professor, Division of Maternal Fetal Medicine Department of Gynecology and Obstetrics Johns Hopkins School of Medicine Chapter 6: Clinical Simulation Donna D Johnson, MD Lawrence L Hester Professor Chair, Department of Obstetrics and Gynecology Medical University of South Carolina Chapter 25: Cesarean Delivery Kimberly Kenton, MD, MS Professor, Obstetrics & Gynecology and Urology Chief, Female Pelvic Medicine & Reconstructive Surgery Northwestern University Feinberg School of Medicine Chapter 20: Episiotomy and Obstetric Anal Sphincter Lacerations Kimberly A Kho, MD, MPH, MSCS Director, Minimally Invasive Gynecologic Surgery Fellowship Associate Professor, Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas Chapter 15: Diagnostic and Operative Laparoscopy Stephanie N Lin, MD Visiting Instructor, Department of Obstetrics and Gynecology University of Utah Chapter 7: Critical Illness in Pregnancy Stephanie R Martin, DO Director, Southern Colorado Maternal Fetal Medicine Director, Maternal Fetal Medicine/Centura Southstate Visiting Associate Clinical Professor percent 2-chloroprocaine To rapidly respond to these changing conditions, the anesthesiologist must be present in the delivery suite The epidural catheter should be tested and functioning well All monitors are in place in case urgent cesarean delivery is needed Aspiration prophylaxis ideally is given en route to the OR or before A uterine relaxant such as nitroglycerin should be immediately available (Caponas, 2001) During delivery, it is imperative that the obstetrician and anesthesiologist have ongoing communication Finally, individuals skilled in neonatal resuscitation should be immediately available ANESTHESIA FOR CESAREAN DELIVERY Four types of anesthesia are used for cesarean delivery: general endotracheal, epidural, spinal, and combined spinal-epidural As stated in the American Society of Anesthesiologists Practice Guidelines (2016): “The decision to use a particular anesthetic technique for cesarean delivery should be individualized, based on several factors These include anesthetic, obstetric, or fetal risk factors, for example, elective versus emergency, the preferences of the patient, and the judgment of the anesthesiologist Neuraxial techniques are preferable to general anesthesia for most cesarean deliveries An indwelling epidural catheter may provide equivalent onset of anesthesia compared with initiation of spinal anesthesia for urgent cesarean delivery General anesthesia may be the most appropriate choice in some circumstances, for example, profound fetal bradycardia, ruptured uterus, substantial hemorrhage, or placental abruption.” In the United States, regional anesthesia is strongly preferred to general anesthesia for cesarean delivery (Traynor, 2016) General anesthesia is used for approximately percent of elective and 15 percent of emergent cesarean births Spinal, epidural, or combined spinal-epidural anesthetics are used for approximately 90 percent of cesarean deliveries Local anesthesia for cesarean delivery is possible but is rarely used or taught in modern practice Evidence suggests that the relative risk for maternal death is probably the same whether neuraxial or general anesthesia is used (Hawkins, 2011) High neuraxial block is the leading cause of major anesthetic complications, although problems with the airway—including aspiration—are still a significant concern (D’Angelo, 2014) Neuraxial anesthesia may have benefits for the mother, but neuraxial or general anesthesia results in similar fetal outcomes as ascertained by Apgar scores and blood gas measurements Premedication using a sedative or opioid agent is usually omitted because of the risk of newborn depression To decrease aspiration risk in cases of unplanned cesarean delivery, oral intake during labor should be limited to modest amounts of clear liquids or ice chips Use of a clear nonparticulate antacid is considered routine for all parturients prior to surgery Additional aspiration prophylaxis using an H2-receptor blocking agent and metoclopramide may be given to parturients with risk factors such as morbid obesity, diabetes mellitus, a difficult airway, or having previously received opioids Chalky-white particulate antacids are avoided because they can produce lung damage if aspirated (Eyler, 1982) As during labor, the uterus may compress the inferior vena cava and the aorta during cesarean delivery Compression leads to reduced venous return to the heart, reduced cardiac output, and reduced uteroplacental perfusion The duration of anesthesia has little effect on neonatal acid-base status when uterine displacement is practiced However, when the woman remains supine, Apgar scores decline over time General Anesthesia for Emergent Cesarean Delivery General anesthesia for cesarean delivery offers several advantages A woman can be anesthetized quickly for an emergent delivery, and agents provide total pain relief Moreover, she can be asleep during a major operation, operating conditions are optimal, and 100-percent oxygen can be supplied if needed Disadvantageously, although the patient will not be awake during the delivery, there is a small risk of undesirable awareness A recent British audit of awareness during general anesthesia found that obstetric anesthesia was the most overrepresented of all surgical specialties (Pandit, 2014) Other disadvantages are the risk of transient neonatal depression immediately after birth because many anesthetics cross the placenta For the mother, intubation may cause hypertension and tachycardia, can sometimes be difficult or impossible, and may lead to aspiration of stomach contents To provide a general anesthetic, the anesthesiologist administers a short-acting induction agent to render the woman unconscious Induction agents include propofol, etomidate, and ketamine, all of which are rapidly redistributed in the mother and fetus Although obstetricians are often concerned about the induction-to-delivery interval during general anesthesia, uterine incision-to-delivery interval is more predictive of neonatal status With a prolonged induction-to-delivery interval, there is fetal uptake of the inhaled anesthetic and depressed Apgar scores However, fetal acid-base status is usually normal, and effective ventilation is sufficient for resuscitation Immediately after an induction agent is administered, a muscle relaxant is given to aid intubation Succinylcholine, a rapid-onset, short-acting muscle relaxant, is the preferred agent in most cases As the patient becomes unconscious, pressure on the cricoid cartilage compresses the esophagus to prevent regurgitation and aspiration To accomplish this, an assistant applies pressure to the cricoid cartilage, just below the thyroid cartilage Pressure is not released until an endotracheal tube is placed, the cuff inflated, and its position verified by end-tidal carbon dioxide measurement and auscultation of bilateral breath sounds In most cases, intubation proceeds smoothly However, in approximately in 500 obstetric patients, it is difficult, delayed, or impossible (D’Angelo, 2014) The critical factor is delivering oxygen to the now unconscious and paralyzed patient The anesthesiologist uses an algorithm for managing the difficult airway, and this algorithm should be practiced as a drill in the labor and delivery unit so that other team members know how to assist (Mhyre, 2011) The patient at risk for a difficult or impossible intubation can often be identified before surgery Examination of the airway is a critical part of such preanesthetic evaluation The anesthesiologist will assess (1) the ability to visualize oropharyngeal structures—Mallampati classification; (2) range of neck motion; (3) presence of a receding mandible; and (4) whether protruding maxillary incisors are present The Mallampati classification is shown in Figure 18-1 (p 294) Importantly, a woman’s airway status can worsen during labor One study found significant increases in the Mallampati score and the incidence of difficult airways when prelabor and postlabor airway examinations were compared (Kodali, 2008) When airway abnormalities are recognized or suspected, patients are ideally referred for an early preoperative evaluation by the anesthesiologist Some examples include obesity; severe edema; anatomic abnormalities of the face, neck, or spine; prior trauma or surgery; abnormal dentition; difficulty opening the mouth; extremely short stature; short neck; neck arthritis; or goiter After intubation, nitrous oxide and a low concentration of a volatile halogenated agent is added to provide maternal amnesia and additional analgesia Volatile agents include isoflurane, sevoflurane, or desflurane Uterine relaxation does not result from low concentrations of these agents, and bleeding should not be increased secondary to their use Notably, proceeding without a potent inhalation agent results in an unacceptably high incidence of maternal awareness and recall Even with the use of one of these agents, maternal awareness and recall occasionally occur Therefore, all OR personnel should use discretion in their conversations In the OR but after delivery, anesthesia is supplemented with an opioid such as fentanyl or morphine Other intravenous agents such as benzodiazepines may be added to ensure maternal amnesia Dilute oxytocin is infused intravenously to improve uterine tone However, bolus injections of oxytocin are avoided because this practice can drop systemic vascular resistance to incite hypotension and tachycardia (Stephens, 2012) To prevent aspiration, the patient must be awake and conscious at the end of the case before extubation The endotracheal tube is not removed until the patient can respond appropriately to commands Neuraxial Anesthesia for Cesarean Delivery As long as fetal status permits and no maternal contraindications are present, regional anesthesia is favored for cesarean delivery (Traynor, 2016) That said, some women prefer not to be awake during this major surgical procedure and will choose general anesthesia For others, neuraxial anesthesia permits a patient to participate in the birth of her child, and the father is more likely to be allowed in the OR Greater alertness and pain control after neuraxial anesthesia also assist initial bonding and breastfeeding Importantly, intubation difficulties are also avoided, and the risks of maternal aspiration or neonatal drug depression are minimal A working epidural catheter used for labor analgesia can provide an excellent anesthetic for cesarean delivery without the need to initiate another technique Postoperative pain control using neuraxial opioids may be superior to intravenous patient-controlled analgesia Some drawbacks of a neuraxial anesthetic include inadequate anesthesia; hypotension, which is recognized in 25 to 85 percent of cases; high neuraxial blockade, which necessitates greater airway management; and local anesthetic toxicity Although rare, permanent neurologic sequelae may result Nerve injury is the most common reason for obstetric anesthesia liability claims (Davies, 2009) Most women prefer some type of neuraxial anesthesia for the reasons mentioned Situations that contraindicate neuraxial anesthesia include patient refusal, hemodynamic instability due to hemorrhage or sepsis, clinical coagulopathy, or infection at the injection site Technical difficulties may arise from spinal instrumentation placed during prior scoliosis repair The choice of neuraxial versus general anesthesia must be made quickly in the setting of an emergent cesarean delivery The obstetrician and anesthesiologist must communicate their concerns to each other For example, the obstetrician may feel that time is insufficient to initiate spinal or extend epidural anesthesia, while the anesthesiologist may feel the potential for airway difficulties is significant In these situations, maternal safety must always come first The choice of single-shot spinal, combined spinal-epidural, or epidural anesthesia is often provider-dependent However, unless a well-functioning epidural catheter is already place, a spinal anesthetic may be faster and easier to initiate (Fig 19-2) Although time-limited, a spinal anesthetic with bupivacaine will provide at least hours of surgical anesthesia If longer surgical duration is anticipated, a combined spinalepidural technique can be used to achieve the benefits of both techniques Since the advent of small-gauge spinal needles with pencil-point tip design, the risk of headache is no different after spinal or epidural anesthesia Most consider spinal block to be easier and quicker to perform, and most believe that the resulting anesthesia will be more solid and complete Perhaps the most significant advantage of spinal anesthesia is that it requires considerably less local anesthetic Therefore, the potential for local anesthetic toxicity is reduced The combined technique provides the benefits of spinal anesthesia to initiate the block plus the ability to prolong the anesthetic if needed by dosing the epidural catheter Any of these techniques is satisfactory, however, and should provide safe, effective anesthesia for mother and newborn FIGURE 19-2 Neuraxial anatomy for placement of combined spinal-epidural anesthesia Postoperative Care Pain management is an important part of anesthesia care In addition to comfort, maternal mobility is improved to lower thromboembolism risks and hasten bowel function return If spinal or epidural anesthesia was used for cesarean delivery, excellent postoperative analgesia can be obtained by addition of preservative-free morphine to the local anesthetic solution Morphine acts up to 24 hours, but its water solubility gives it a long onset time and higher incidence of side effects The most common side effects of spinal and epidural opioids are itching and nausea Respiratory depression is a rare but serious complication (Crowgey, 2013) Several studies have shown that spinal or epidural opioids provide superior pain relief compared with parenteral opioids—either intramuscular or intravenous patient-controlled analgesia Moreover, a trend toward earlier hospital discharge and lower cost is seen with spinal or epidural opioids If general anesthesia was used or neuraxial opioids provide inadequate pain control, a transversus abdominis plane (TAP) block may be placed (Fig 19-3) A TAP block is an effective field block that can be administered intraoperatively by the obstetrician or postoperatively by the anesthesiologist (Sharkey, 2013) Although these blocks provide less effective analgesia than neuraxial morphine, a TAP block results in less itching and nausea (Kanazi, 2010) Unfortunately, because of the large volume of local anesthetic required for bilateral blockade, seizures due to local anesthetic toxicity have been reported This is despite use of sonographic guidance during placement (D’Angelo, 2014) FIGURE 19-3 Transversus abdominis plane (TAP) block A Abdominal wall anatomy B Needle placement for TAP block EO = external oblique m.; ES = erector spinae m.; IO = internal oblique m.; LD = latissimus dorsi m.; m = muscle; PM = psoas major m.; QL = quadratus lumborum m.; TA = transversus abdominis m When used with neuraxial morphine, the addition of nonsteroidal antiinflammatory agents significantly improves pain scores and reduces use of patient-controlled opioids (White, 2012) Intravenous ketorolac, rectal indomethacin, oral ibuprofen, or intravenous or oral acetaminophen can be used as part of a multimodal regimen Contraindications to nonsteroidal antiinflammatory agents include renal insufficiency or low urine output, use of gentamicin or other drugs with renal toxicity, thrombocytopenia or other coagulopathy, and uterine atony Although the package insert for ketorolac states that it is contraindicated for use in breastfeeding mothers, the American Academy of Pediatrics approves its use while women are breastfeeding Women who have undergone cesarean delivery may develop postoperative nausea and vomiting Some risk factors include young age and women who are nonsmokers and who are given opioids Prevention and treatment of postoperative nausea and vomiting may include metoclopramide, ondansetron, dexamethasone, and a scopolamine patch (Allen, 2012; Harnett, 2007; Mishriky, 2012) Multimodal therapy is most effective The postoperative period can be an important time for anesthetic-related maternal morbidity due to hypoventilation or airway obstruction, especially in obese patients (Mhyre, 2007) These cases raise important questions about appropriate postanesthesia care unit (PACU) management after general anesthesia for cesarean delivery and the need for additional monitoring in obese patients at risk for obstructive sleep apnea A survey of obstetric anesthesiology directors reported that 45 percent of institutions had no specific postanesthesia recovery training for nursing staff in their labor and delivery units (Wilkins, 2009) In addition, 43 percent of respondents rated the recovery care provided to cesarean delivery patients as lower quality than care given to general surgical patients The Practice Guidelines for Obstetric Anesthesia emphasize that equipment, facilities, and support personnel in the labor and delivery unit should be comparable to those available in a general surgical unit This care should extend to obstetric patients recovering from major neuraxial or general anesthesia (American Society of Anesthesiologists Task Force on Obstetric Anesthesia, 2016) CESAREAN HYSTERECTOMY Whenever a cesarean hysterectomy is anticipated or becomes necessary, the anesthesiologist should adapt the anesthetic plan Additional large-bore intravenous access is obtained, fluid warmers are used, blood should be available, equipment for placing central monitoring and arterial lines should be in the room, and additional help must be nearby El-Messidi and associates (2012) have summarized a checklist with all aspects of delivery care including site, resources, personnel, and surgical approach For anticipated cesarean hysterectomy, small hospitals with insufficient blood bank supply or inadequate availability of subspecialty and support personnel should consider antepartum patient transfer to a tertiary perinatal care center Although regional anesthesia is not contraindicated, hysterectomy and massive transfusion usually require general endotracheal anesthesia (Parekh, 2000) If a woman is highly motivated to be awake to see her newborn, the case can be started using a neuraxial technique This is followed by general anesthesia that is induced after delivery (Clark, 2013) With severe hemorrhage and implementation of a massive transfusion protocol, additional management may include cell salvage and interventional radiology procedures Massive transfusion protocols are considered in detail in Chapter (p 98) Peripartum resuscitation should always include maintenance of normal acid-base status, avoidance of hypothermia, and resuscitation measures similarly used for hemorrhage in trauma or other surgical cases (Main, 2015) Use of red blood cell (RBC) salvage during cesarean delivery has been limited due to concern for amnionic-fluid embolism and for alloimmunization due to fetal RBC contamination That said, more than 400 case reports of cell salvage in parturients have been reported With these, no cases of embolism were attributed to infusion of salvaged blood If banked blood cannot be adequately crossmatched because of atypical antibodies or if the woman refuses transfusion, cell salvage can be lifesaving and costeffective, and it may have fewer complications than banked blood (Goucher, 2015) Placement of balloon catheters into the iliac vessels by an interventional radiologist either preoperatively or when life-threatening hemorrhage develops may also be considered The technique seems to be less effective in the presence of coagulopathy or during acute massive hemorrhage Catheter insertion should not replace ongoing resuscitation and transfusion and should not delay proceeding with hysterectomy when necessary Although rare, serious complications can result with this technique and include leg ischemia, tissue necrosis, pseudoaneurysms, and even paraplegia (Lee, 2012a) Despite the lack of randomized controlled trials in obstetric patients, many labor and delivery units have adopted massive transfusion protocols similar to those used for military trauma cases and other traumatic injury These protocols focus on early administration of fresh frozen plasma (FFP) and platelets with RBCs to achieve a ratio of 1:1:1 without waiting for laboratory tests of coagulation One observational study of 142 women with postpartum hemorrhage reported that a higher FFP:RBC ratio was associated with a lower requirement for advanced interventional procedures such as embolization, B-Lynch suture, or hysterectomy (Pasquier, 2013) Laboratory studies are an integral part of resuscitation Plasma fibrinogen levels may be particularly helpful in obstetric hemorrhage A low fibrinogen level—less than 200 mg/dL—in the early phase of obstetric hemorrhage is an important predictor of severe postpartum hemorrhage (Butwick, 2013) Because obstetric complications may be associated with increased fibrinolytic activity, some recommend thromboelastometry— also known as thromboelastography (TEG) or rotational thromboelastometry (ROTEM), which are described and illustrated in Chapter (p 98) (deLange, 2014) These tests give a global picture of real-time clotting activity and can be used to guide component therapy However, they have not been well studied with obstetric hemorrhage (Cunningham, 2015) Pharmacologic therapy for obstetric hemorrhage may include recombinant factor VIIa and antifibrinolytic agents such as tranexamic acid (Pavord, 2015) These agents are used with caution in postpartum patients because of the risk of thrombotic events ANESTHESIA FOR POSTPARTUM TUBAL LIGATION The timing of postpartum tubal ligation has been controversial Both the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists consider the procedure to be elective Thus, these surgeries are not performed during times that might compromise other aspects of patient care in a labor and delivery unit As discussed in Chapter 33 (p 524), this policy may decrease access to this valuable method of contraception for many puerperal patients For example, in one study, 47 percent of women who requested puerperal tubal ligation but were not able to receive it became pregnant the following year This compared with only 22 percent of those who had not requested tubal sterilization and who chose another form of birth control (Thurman, 2010) No woman became pregnant in the group who underwent postpartum sterilization For these reasons, the American College of Obstetricians and Gynecologists (2014) encourages improved access to puerperal sterilization and considers it to be an “urgent” procedure Postpartum tubal ligation may be completed proximate to delivery or the following day Advantages to immediate surgery include cost savings from less day in the hospital This timing also allows her to eat shortly after delivery (and surgery), and it enables her to avoid the apprehension of undergoing a surgical procedure the following day However, the two main anesthetic concerns with this approach are aspiration risk and unrecognized or ongoing excessive blood loss during and after delivery (Hawkins, 2014) If an immediate postpartum tubal ligation is planned, it seems reasonable to administer an H2-receptor antagonist and metoclopramide at least hour before the procedure, use regional anesthesia whenever appropriate, and check orthostatic vital signs prior to moving to the OR The choice of anesthesia for postpartum tubal ligation is based primarily on patient preference Epidural catheters placed for labor analgesia may be more likely to fail if used more than hours after delivery (Goodman, 1998) Despite this, if the epidural catheter provided good analgesia for labor and the interval since delivery is less than hours, then a short-acting local anesthetic suitable for surgical anesthesia, for example, 3-percent 2-chloroprocaine, may be administered through the epidural catheter Sedative drugs may be given if needed Spinal anesthesia is simple to perform, rapid in onset, and provides dense sensory and motor block Initiation of spinal anesthesia for the procedure may be faster and less expensive than reactivation of an existing epidural catheter (Viscomi, 1995) Because tubal ligations are short procedures, there is no reason to initiate epidural anesthesia if a catheter is not already in place A sensory level of T4 is needed with spinal or epidural anesthesia to block visceral pain during exposure and manipulation of the fallopian tubes Local anesthetic requirements for spinal and epidural anesthesia are decreased during pregnancy, but studies have demonstrated a return to nonpregnant requirements by 36 hours postpartum The reason for the rapid decrease in sensitivity to local anesthetics is unclear but may be related to the rapid fall in progesterone levels after delivery of the placenta If general anesthesia is chosen for puerperal sterilization, a rapid-sequence induction with cricoid pressure and intubation should be used in all postpartum patients Propofol has some advantages as an induction agent Its association with rapid awakening and decreased incidence of emesis makes it attractive for short sterilization procedures Propofol results in negligible neonatal exposure during subsequent breastfeeding Volatile anesthetic agents cause uterine relaxation in high concentrations and could potentially increase the risk for postpartum hemorrhage Fortunately, the reduced anesthetic requirement for volatile anesthetics observed during pregnancy persists for 12 to 36 hours postpartum This allows lower concentrations to be used FETAL SURGERY Fetal surgical procedures are performed at only a few centers and for limited indications (Lin, 2013) These are discussed in greater detail in Chapter 16 (p 260) Minimally invasive fetoscopic interventions for conditions such as twin-twin transfusion syndrome involve sonographically guided percutaneous placement of trocar(s) or needles through the uterus and into the amnionic cavity These procedures can be performed with local anesthetic infiltration or neuraxial techniques coupled with sedation Open midgestation fetal surgery is performed for selected indications including closure of myelomeningocele and resection of some intrathoracic lesions (Adzick, 2011) Preterm delivery is the most significant perioperative problem, requiring multiple tocolytics During surgery, high doses of inhalation agents are used for maternal and fetal anesthesia and for uterine relaxation (Ferschl, 2013) Ex utero intrapartum treatment (EXIT) is performed at the time of cesarean delivery to secure the airway in fetuses with large oropharyngeal, neck, or thoracic masses The goal of EXIT is to achieve prolonged uterine relaxation and thereby preserve the uteroplacental circulation until delivery These fetal procedures are most commonly performed under maternal general anesthesia using high doses of volatile anesthetics such as desflurane to maintain uterine relaxation (Garcia, 2011) With EXIT, the fetal head is delivered One arm of the fetus is also brought out through the hysterotomy to allow pulse-oximetry monitoring At this point, the indicated procedure such as endoscopy or a tracheostomy is performed to achieve neonatal endotracheal intubation After the airway is secured, the inhalational agent is decreased to allow uterine tone to return to normal Delivery then proceeds as with a normal caesarean delivery Additional uterotonic dugs should be readily available SUMMARY Anesthetic management of gravidas should be adapted to the physiologic changes of pregnancy Another key to successfully performed procedures is active communication between the anesthesiologist and the surgeon Pregnancy and delivery are both exciting and highly emotional times for a woman Accordingly, anesthesia providers must be cognizant of their patients’ concerns and should feel privileged to be a part of their care REFERENCES Adzick NS, Thom EA, Spong CY, et al: A randomized trial of prenatal versus postnatal repair of myelomeningocele N Engl J Med 364:993, 2011 Allen TK, Jones CA, Habib AS: Dexamethasone for the prophylaxis of postoperative nausea and vomiting associated with neuraxial morphine administration: a systematic review and meta-analysis Anesth Analg 114:813, 2012 American College of Obstetricians and Gynecologists: Access to postpartum sterilization Committee Opinion No 530, Obstet Gynecol 120:212, July 2012, Reaffirmed 2014 American College of Obstetricians and Gynecologists: External cephalic version Practice Bulletin No 161, February 2016 American Society of Anesthesiologists Task Force on Obstetric Anesthesia Practice Guidelines for Obstetric Anesthesia: An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology Anesthesiology 124(2):270, 2016 Barbieri RL, Camann W, McGovern C: Nitrous oxide for labor pain (Editorial) OBG Manag 26:10, 2014 Barrett JFR, Hannah ME, Hutton EK: A randomized trial of planned cesarean or vaginal delivery for twin pregnancy N Engl J Med 369:1295, 2013 Benhamou D, Mercier FJ, Ben Ayed M, et al: Continuous epidural analgesia with bupivacaine 0.125% or bupivacaine 0.0625% plus sufentanil 0.25 microg/mL: a study in singleton breech presentation Int J Obstet Anesth 11:13, 2002 Butwick AJ: Postpartum hemorrhage and low fibrinogen levels: the past, present and future Int J Obstet Anesth 22:87, 2013 Caponas G: Glyceryl trinitrate and acute uterine relaxation: a literature review Anaesth Intensive Care 29:163, 2001 Clark A, Farber MK, Sviggum H, et al: Cesarean delivery in the hybrid operating suite: a promising new location for high-risk obstetric procedures Anesth Analg 117:1187, 2013 Creanga AA, Berg CJ, Syverson C, et al: Pregnancy-related mortality in the United States, 2006—2010 Obstet Gynecol 125:5, 2015 Crowgey TR, Dominguez JE, Peterson-Layne C, et al: A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia Anesth Analg 117:1368, 2013 Cunningham FG, Nelson DB: Disseminated intravascular coagulation syndromes in obstetrics Obstet Gynecol 126(5):99, 2015 D’Angelo R, Smiley RM, Riley ET, et al: Serious complications related to obstetric anesthesia Anesthesiology 120:1505, 2014 Davies JM, Posner KL, Lee LA: Liability associated with obstetric anesthesia; a closed claims analysis Anesthesiology 110:131, 2009 deLange NM, van Rheenen-Flach LE, Lance MD, et al: Peri-partum reference ranges for ROTEM thromboelastometry Br J Anaesth 112:852, 2014 Dorian R: Anesthesia of the surgical patient Brunicardi F, Andersen D, Billiar T, et al (eds): Schwartz’s Principles of Surgery, 10th ed New York, McGraw-Hill, 2015 El-Messidi A, Mallozzi A, Oppenheimer L: A multidisciplinary checklist for management of suspected placenta accreta J Obstet Gynaecol Can 34:320, 2012 Eyler SW, Cullen BF, Murphy ME, et al: Antacid aspiration in rabbits: a comparison of Mylanta and bicitra Anesth Analg 61:288, 1982 Ferschl M, Ball R, Lee H, et al: Anesthesia for in utero repair of myelomeningocele Anesthesiology 118:1211, 2013 Gaiser R: Physiologic changes of pregnancy In Chestnut DH, Wong CA, Tsen LC, et al (eds): Chestnut’s Obstetric Anesthesia Principles and Practice, 5th ed Philadelphia, Elsevier, 2014, p 15 Garcia PJ, Olutoye OO, Ivey RT, et al: Case scenario: anesthesia for maternal-fetal surgery The ex-utero intrapartum therapy (EXIT) procedure Anesthesiology 114:1446, 2011 Goodman EJ, Dumas SD: The rate of successful reactivation of labor epidural catheters for postpartum tubal ligation surgery Reg Anesth Pain Med 23:258, 1998 Goucher H, Wong CA, Patel SK, Toledo P: Cell salvage in obstetrics Anesth Analg 121:465, 2015 Harnett MJP, O’Rourke N, Walsh M, et al: Transdermal scopolamine for prevention of intrathecal morphine-induced nausea and vomiting after cesarean delivery Anesth Analg 105:764, 2007 Hawkins JL: Postpartum tubal sterilization In Chestnut DH, Wong CA, Tsen LC, et al (eds): Chestnut’s Obstetric Anesthesia Principles and Practice, 5th ed Philadelphia, Elsevier, 2014, p 530 Hawkins JL, Chang J, Palmer SK, et al: Anesthesia-related maternal mortality in the United States: 1979–2002 Obstet Gynecol 117:69, 2011 Joselyn AS, Cherian VT, Joel S: Ketamine for labour analgesia Int J Obstet Anesth 19:122, 2010 Kanazi GE, Aouad MT, Abdallah FW, et al: The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial Anesth Analg 111:475, 2010 Knight M, Kenyon S, Brocklehurst P, et al (eds): Saving Lives, Improving Mothers’ Care —Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12 Oxford, National Perinatal Epidemiology Unit, University of Oxford, 2014 Kodali BS, Chandrasekhar S, Bulich LN: Airway changes during labor and delivery Anesthesiology 108:357, 2008 Kulier R, Hofmeyr GJ: Tocolytics for suspected intrapartum fetal distress Cochrane Database System Rev 2:000035, 2000 Lavoie A, Guay J: Anesthetic dose neuraxial blockade increases the success rate of external fetal version: a meta-analysis Can J Anaesth 57:408, 2010 Lee HY, Shin JH, Kim J, et al: Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution Radiology 264:903, 2012a Lee J, Lee J, Ko S: The relationship between serum progesterone concentration and anesthetic and analgesic requirements: a prospective observational study of parturients undergoing cesarean delivery Anesth Analg 119:901, 2014 Lee SW, Khaw KS, Ngan Kee WD, et al: Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women Br J Anaesth 109:950, 2012b Likis FE, Andrews JC, Collins MR: Nitrous oxide for the management of labor pain: a systematic review Anesth Analg 118:153, 2014 Lin EE, Tran KM: Anesthesia for fetal surgery Semin Pediatr Surg 22:50, 2013 Main EK, Goffman D, Scavone BM, et al: National partnership for maternal safety: consensus bundle on maternal hemorrhage Anesth Analg 121:142, 2015 Mhyre JM, Healy D: The unanticipated difficult intubation in obstetrics Anesth Analg 112:648, 2011 Mhyre JM, Riesner MN, Polley LS, et al: A series of anesthesia-related maternal deaths in Michigan, 1985–2003 Anesthesiology 106:1096, 2007 Mishriky BM, Habib AS: Metoclopramide for nausea and vomiting prophylaxis during and after cesarean delivery: a systematic review and meta-analysis Br J Anaesth 108:374, 2012 National Institute for Occupational Safety and Health: Controlling exposures to nitrous oxide during anesthetic administration Publication Number 94–100 1994 Available at: http://www.cdc.gov/niosh/docs/94–100 Accessed December 5, 2015 Pandit JJ, Andrade J, Bogod DG, et al: 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors Br J Anaesth 113:549, 2014 Parekh N, Husaini WU, Russell IF: Caesarean section for placenta praevia: a retrospective study of anaesthetic management Br J Anaesth 84:725, 2000 Pasquier P, Gayat E, Rackelboom T, et al: An observational study of the fresh frozen plasma:red blood cell ratio in postpartum hemorrhage Anesth Analg 116:155, 2013 Pavord S, Maybury H: How I treat postpartum hemorrhage Blood 125:2759, 2015 Sharkey A, Finnerty O, McDonnell AG: Role of the transversus abdominis plane block after caesarean delivery Curr Opin Anesthesiol 26:268, 2013 Stephens LC, Bruessel T: Systematic review of oxytocin dosing at delivery Anaesth Intensive Care 40:247, 2012 Thurman AR, Janecek T: One-year follow-up of women with unfulfilled postpartum sterilization requests Obstet Gynecol 116:1071, 2010 Traynor AJ, Aragon M, Ghosh D, et al: Obstetric Anesthesia Workforce Survey: a 30Year update Anesth Analg 122:1939, 2016 Viscomi CM, Rathmell JP: Labor epidural catheter reactivation or spinal anesthesia for delayed postpartum tubal ligation: a cost comparison J Clin Anesth 7:380, 1995 White PF, Raeder J, Kehlet H: Ketorolac: its role as part of a multi-modal analgesic regimen Anesth Analg 114:250, 2012 Wilkins KK, Greenfield ML, Polley LS, et al: A survey of obstetric postanesthesia care unit standards Anesth Analg 108:1869, 2009 ... Infections 13 Invasive Prenatal DiagnosticProcedures 14 Adnexal Masses 15 Diagnostic and OperativeLaparoscopy 16 Fetal Therapy 17 Trauma in Pregnancy 18 Perioperative Considerations 19 Anesthesia... 978-0-07 -18 4907-4 MHID: 0-07 -17 412 2-4 The material in this eBook also appears in the print version of this title: ISBN: 978-007 -18 4906-7, MHID: 0-07 -18 4906-8 eBook conversion by codeMantra Version 1. 0... approximation (Goulbourne, 19 88) Nylon is eventually degraded and absorbed and has little remaining tensile strength after months (Moloney, 19 61) Birdwell and associates (19 81) found that, in human