Abdominal mass in a pregnancy
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Abdominal mass in a pregnancy. - C ase presentation By R3 陳世昱. General & Past History. 35 y/o female Denied past history of systemic disease or op No contributable family/drug/allergy history H: 160cm, W: 54kg Pregnancy ( 6wks ; LMP:2003/3/17 ) with progressive abdominal distention.

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Abdominal mass in a pregnancy

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Abdominal mass in a pregnancy

Abdominal mass in a pregnancy

-Case presentation

By R3陳世昱


General past history

General & Past History

  • 35 y/o female

  • Denied past history of systemic disease or op

  • No contributable family/drug/allergy history

  • H: 160cm, W: 54kg

  • Pregnancy (6wks ; LMP:2003/3/17) with progressive abdominal distention


Present illness summary 1

Present Illness (summary 1)

  • RLQ pain 9 yrs ago

  • 1998/10, TAS:7x6cm right pelvic mass, suspect endometriosis (which regressed 3 months later spontaneously)

  • 1999/8, TAS:12x8x8cm heterogeneous mass over uterine fundus and ~30ml ascites; MRI revealed a 1.5cm ROV cyst, and CA-125:WNL

  • No GI or URO S/S nor ↑CA-125, so OPD f/u was suggested and kept.


Present illness summary 2

Present Illness (summary 2)

  • Missed MC period in 2003/4, and urine pregnancy test showed positive result

  • Progressive abdominal distension soon later

  • 4/23 OPD :

    • TAS: >25x20cm pelvic mass c lacunar pattern and solid component and moderate ascites

    • ↑CA-125: 578μ/ml

  • R/O ovarian malignancy → surgical evaluation


Abdominal mass in a pregnancy

麻醉紀錄


Non obstetric surgery during pregnancy

Non-obstetric Surgery during Pregnancy

Discussion :


Incidence

Incidence

  • About 0.3~2% of deliveries

  • Most common: appendectomy

  • Almost every type of surgical procedure


Basic objectives

Basic objectives

  • Maternal safety

  • Avoidance of teratogenic drugs

  • Avoidance of intrauterine fetal asphyxia

  • Prevention of preterm labor


Monitoring

Monitoring

  • Routine monitors

  • Fetal heart rate monitoring: Doppler apparatus such as tocodynamometer(≥umbilicus) after 16wks of pregnancy.

  • An obstetrician is present throughout operation

  • Elevations of maternal BP may treat fetal bradycardia, and inhalation agents may diminish the amplitude of uterine contractions.


Physiologic changes

Physiologic Changes


Teratogenic drugs 1

Teratogenic drugs(1)

  • Teratogen: a substance produces an increase in incidence of a particular defect that can’t be attributed to chance. A sufficient dose at a critical point in development is needed.

  • Critical point in human: during organogenesis, which extends from 15 days’ to approximately 60 days’ gestational age.

    • CNS does not fully develop until after birth, so critical time for this system could be through the entire gestation.


Teratogenic drugs 2

Teratogenic drugs(2)

  • Almost every anesthetic or drug has been found to be a teratogen in an animal model (in greatly exceeded doses than used clinically), but no anesthetic drug has been documented to be a teratogen in humans.

  • BZD, Barbiturates, Ketamine, Propofol and Etomidate are known teratogens in animals, but have never been demonstrated in humans.

  • Narcotics: CNS abnormalities in hamster, but never been reproduced in humans. Low-birth-weight babies has been associated with chronic administration, but no congenital defects.


Teratogenic drugs 3

Teratogenic drugs(3)

  • Muscle relaxants: cause skeletal abnormalities in the chick embryo, but never been reproduced in the human fetus; do NOT cross the placenta

  • Nitrous oxide: ↓Vit.B12→↓methionine synthetase→↓DNA synthesis, but has been used in hundreds of anesthetics s problems.

  • Halogenated agents: beneficial to fetus by  uterine relaxation and  increasing uterine blood flow, and so far found it safe in clinical doses.


Avoidance of intrauterine fetal asphyxia

Avoidance of intrauterine fetal asphyxia

  • Maintain maternal PaO2:

    • Relative difficult airway

    • ↓FRC→↑rate of desaturation

    • Prevent high leveltoxic local anesthetics toxicity andoversedation in regional anesthesia

  • Adequate maternal PaCO2:

    • Hypocapnia:

      • By excessive positive ventilation→↑intrathoracic pressure→↓venous return→↓uterine blood flow

      • Maternal alkalosis→vasoconstriction & left shift of O2-Hb dis. curve

    • Hypercapnia: fetal acidosis

  • Maintain uterine blood flow:

    • Perfusion pressure: prevent hypotension, aortocaval compression, hemorrhage and “heavy” regional anesthesia

    • Vasoconstriction: prevent α-agonist, ↓PaCO2 & ↑catecholamines (pain, insufficient anesthesia or so)


Prevent of preterm labor

Prevent of Preterm Labor

  • The only factors correlated with preterm labor are the type and location of the procedure.

  • No study documents any correlation of anesthetic drug or technique with preterm labor

  • However, in theoretically, some anesthetic agents such as ketamine(>1mg/kg) and phenylephrine that can increase uterine tone should be avoid as possible.

  • The halogenated agents ↓uterine tone &↑uterine blood flow and may be beneficial in this aspect.


Recommendations of anesthetizing a pregnancy for non obstetric surgery

Recommendations of anesthetizing a pregnancy for Non-obstetric Surgery

  • Avoid surgery and anesthesia in the first trimester, if possible, without compromising maternal health.

  • Non-particulate antacid for aspiration pneumonitis prophylaxis after first trimester

  • Transport patient with left uterine displacement

  • Continuing fetal/uterus monitoring if possible

  • Regional anesthesia is recommended whenever possible (fluid preloading; fluid and/or ephedrine)


Recommendations of anesthetizing a pregnancy for non obstetric surgery1

Recommendations of anesthetizing a pregnancy for Non-obstetric Surgery

  • General anesthesia:

    • Avoid hypotension with fluid preloading

    • Airway managements:

      • Pre-oxygenation with 100%O2

      • Induction : rapid-sequence with cricoid-pressure

      • Maintain adequate oxygenation(50% or higher) and normocarbia

    • Anesthetic agents:

      • Drug of Choice: with a long history and relative safety

      • Pentothal, morphine, fentanyl, meperidine,nitro-oxide

      • SCC,Atracurium, vecuronium, curare and pancuronium

      • Halogenated agents may be beneficial

      • Ketamine and α-agonist should be avoid

    • Antagonize muscle relaxant and extubate when fully awake and able to control airway reflexs


Abdominal mass in a pregnancy

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