Anaesthetic management of ruptured ectopic pregnancy by Arowojolu Boluwaji
- 1. ANAESTHETICMANAGEMENT OF A PATIENT WITH RUPTURED ECTOPIC PREGNANCY BY AROWOJOLU BOLUWAJI
- 2. INTRODUCTION • Ectopic pregnancy also known as eccyesis or tubal pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus • It is the leading cause of maternal mortality in the first trimester and accounts for 10–15% of all maternal deaths • Implantation sites are; fallopian tube (95.5%), ovary (3.2%) and abdomen (1.3%) sites.
- 3. • The sites of tubal implantation in descending order of frequency are ampulla (73.3%), isthmus (12.5%), fimbrial (11.6%) and interstitial (2.6%) • In ectopic pregnancy, the fimbriae fails to catch the ovum so the ovum becomes fertilized outside the reproductive system or, more commonly, the fertilized ovum becomes caught or delayed while progressing along the Fallopian tube
- 4. • As the pregnancy continues to grow inside the tube, it causes the tube to burst or otherwise severely damage it leading to ruptured ectopic pregnancy. • Ruptured ectopic pregnancy is a form of obstetric hemorrhage • Obstetric hemorrhage is the world leading cause of maternal mortality. • Hence, early recognition and treatment are essential to ensure the best outcome
- 5. • The anaesthetist should include the following management principles in the anaesthetic management of a patient with REP; 1. Early recognition 2. Prompt resuscitation in conjunction with prompt identification 3. Treatment of the underlying cause
- 6. Objectives • Describe the anatomy & physiology of female reproductive system • Discuss the etiology & pathophysiology of REP • Discuss the anaesthetic consideration of patient undergoing surgery due to REP • Discuss the anesthetic management of patient undergoing surgery due to REP • Discuss the anaesthetic complications involved in the anaesthetic management of this condition
- 7. Anatomy & Physiology of Female Reproductive System
- 8. Ovaries • They are the female gonads or glands • They lie in a shallow fossa on the lateral walls of the pelvis. • They are 2.5 to 3.5 cm long, 2 cm wide and 1 cm thick. • Each is attached to the upper part of the uterus by the ovarian ligament and to the back of the broad ligament by a broad band of tissue, the mesovarium.
- 9. • It has 2 layers of tissue namely; medulla & cortex • Arterial supply: ovarian arteries, which branch from the abdominal aorta just below the renal arteries. • Venous drainage: This is into a plexus of veins behind the uterus from which the ovarian veins arise. • Lymph drainage: This is to the lateral aortic and preaortic lymph nodes. • Nerve supply: The ovaries are supplied by parasympathetic nerves from the sacral outflow and sympathetic nerves from the lumbar outflow.
- 10. Uterine tubes/Fallopian tubes/Oviduct • It is about 10 cm long & extend from the sides of the uterus between the body and the fundus. • They lie in the upper free border of the broad ligament & their trumpet-shaped lateral ends penetrate the posterior wall, opening into the peritoneal cavity close to the ovaries. • Layers include; outer covering of peritoneum (broad ligament), middle layer of smooth muscle and inner layer of ciliated epithelium
- 11. Uterus • The uterus is a hollow muscular pear-shaped organ • It lies in the pelvic cavity between the urinary bladder and the rectum • It leans forward (anteversion), and is bent forward (anteflexion) almost at right angles to the vagina • It is about 7.5 cm long, 5 cm wide and its walls are about 2.5 cm thick. It weighs from 30 to 40 grams.
- 12. • The parts of the uterus are the fundus, body and cervix • The walls of the uterus are composed of three layers of tissue: perimetrium, myometrium & endometrium. • The arterial supply is by the uterine arteries • Venous drainage: The veins follow the same route as the arteries & eventually drain into the internal iliac veins • Nerve supply: it consist of parasympathetic fibres from the sacral outflow and sympathetic fibres from the lumbar outflow.
- 13. Risk factors/Etiology • Tubal damage • History of previous ectopic pregnancy • Smoking • History of multiple sexual partners • Maternal age • Pelvic inflammatory disease • History of tubal surgery and conception after tubal ligation • Use of oral contraceptives or an intrauterine device • Use of fertility drugs or assisted reproductive technology • Increasing age
- 14. • Effective transport of embryos in the fallopian tube requires a delicately regulated complex interaction between the tubal epithelium, tubal fluid & tubal contents • This interaction ultimately generates a mechanical force, composed of tubal peristalsis, ciliary motion, and tubal fluid flow, to drive the embryo towards the uterine cavity Pathophysiology
- 15. • An ovum is released from the woman’s ovary • This is drawn into one of the fine finger-like tubes called fimbriae of the fallopian tube • The fimbriae can fail to catch the ovum so the ovum becomes fertilized by the sperm outside the reproductive system or, more commonly, the fertilized ovum becomes caught or delayed while progressing along the Fallopian tube • In this case, the pregnancy continues to grow inside the tube where it can cause the tube to burst or otherwise severely damage it
- 16. Signs and Symptoms • Pain • Bleeding • Hypotension • Tachycardia • Tachypnea • Pallor • Oliguria • Pathological cardiotocographic changes
- 17. ANAESTHETIC CONSIDERATIONS • Risk for Aspiration: It is an emergency surgical case that is regarded as a full stomach case. There is delayed gastric emptying & the last time the patient ate may be difficult to ascertain. The anaesthetist should ensure: • Use of suitable anaesthetic technique like RSI • Passage of NGT to decompress the stomach • Administration of clear oral antacids e.g sodium citrate
- 18. Hypovolemia: It is a condition of low volume of fluid in the intravascular space that is associated with severe bleeding. The anaesthetist should ensure: • Prompt replacement of lost fluid and electrolytes • The anaesthetist takes into consideration the choice of technique as general anaesthesia with intubation is the best • Ketamine is the best induction agent in hypovolemic patient
- 19. Hypothermia Thermoregulation is mediated in the hypothalamus in response to temperature input from both central and peripheral sites. This regulatory mechanism may be lost as a result of hemorrhage which may lead to hemorrhagic shock. The anesthetist should avoid this by; • Using warm intravenous infusion • Maintain a warm operating room environment by turning off air conditioning system • Cover patient appropriately • Prompt replacement of lost fluids
- 20. Hypotension Reduction in blood pressure may be due to blood loss as a result of the rupture. Also, the effect of the anaesthetic agent may further lower the blood pressure The anesthetist should ensure • Replacement of lost fluids & electrolytes • Administration of vasopressors • Discontinuation of volatile anesthetic agent • Utilization of ketamine which tends to increase the blood pressure
- 21. Co-existing diseases • The sudden onset of ruptured ectopic pregnancy may not allow the early detection of diseases that may adversely affect the success of the surgery. • Uncontrolled medical diseases like hypertension, diabetes may be present at the same time of surgery. • • There is limited time to undergo necessary diagnostic investigations
- 22. ANAESTHETIC MANAGEMENT The main aims of management are to: • Improve oxygenation • Resuscitate with intravenous fluids • Correct haemostatic disorders.
- 23. Staging scheme for assessment of obstetric hemorrhage is: %ofbloodloss Findings Severity of shock 1 <15%- 20% None None 2 20%- 25% Tachycardia(<100b/m) Mildhypotension Peripheralvasoconstriction Mild 3 25%- 35% Tachycardia( 100-120bpm) Hypotension(SBP 80-100mmHg) Restlessness Oliguria Moderate 4 >35% Tachycardia( >120bpm) Hypotension(SBP <60mmHg) Alteredconciousness Severe
- 24. 1. Immediate resuscitation of the patient: • (a) high-flow oxygen (8L/min) • (b) IV access (two 14 or 16 gauge cannula) and take blood for complete blood count, clotting and cross-match; • (c) Administer warm IV fluids which include crystalloid, colloid as well as blood. • (d) Patient should be kept warm with active warming devices or warmed blankets.
- 25. 2. Obtain brief history of the patient 3. Monitoring a. Monitor ECG, BP, pulse, respiration & SPO2 continuously. b. Monitor urine output hourly. c. Consider invasive monitoring if the patient is hemodynamically unstable or repeated venepunture is anticipated 4. Pass nasogastric tube to decompress the stomach
- 26. 5. Administration of premedications which include; antacid, H2 receptor antagonist, Anticholinergics and antiemetics. 6. Airway assessment using mouth opening, mallampatti grading and thyromental distance 7. Instrument check
- 27. Intraoperative phase Technique: Rapid Sequence Induction (RSI) Reasons for choice of technique • Hemodynamic stability • Security of the airway from the onset of the surgery. • Surgery may be lengthy with the potential for further patient deterioration • Regional anaesthesia may be contra-indicated due to maternal haemodynamic compromise, coagulopathy and risk of neuraxial haematoma.
- 28. • Induction agent: IV Ketamine at a dose of 1 – 2mg per body Kg • Patient is placed in a supine position • Preoxygenate patient with 100% oxygen for 5 minutes at about 8L/min • Administer induction agent, then depolarizing muscle relaxant (Suxamethonium 100mg) • Cricoid pressure is applied as patient begins to loose consciousness
- 29. • Watch for fasciculation and support the jaw until it is fully relaxed • After fasciculation, the patient is intubated with cuff endotracheal tube of appropriate size and the cuff is inflated. • Confirm correct tube placement by auscultation with stethoscope for bilateral equal air entry, capnograph and other methods available.
- 30. Maintenance during Intraoperative Phase • Administration of warm fluids should be continued throughout the operative period. • The choice of fluids are: crystalloid, colloid, blood and blood products. • In practice, crystalloids can be given 3 – 4 times the estimated volume of blood lost by patient, whereas, colloids and blood products are replaced in 1:1 ratio. • Administer analgesics like Fentanyl 1 -2 mCg/kg , pentazocine 30mg, Tramadol 100mg
- 31. • Maintain anaesthesia with volatile anesthetic agent (isoflurane or halothane in titrated doses) or ketamine 2.5–15 mcg/kg/min • Administer non- depolarizing muscle relaxant like atracurium 0.25 – 0.5 mg/kg or pancuronium 0.07 – 0.12 mg/kg • Estimate intraoperative blood loss and replace accordingly.
- 32. • This can be done by approximately measuring blood volume in suction container or visually estimating the blood in surgical gauge and pads • Fully soaked gauge (4 x 4) hold about 10 – 15 mls of blood • Fully soaked pad hold about 100 – 150 mls of blood. • Administer 1000mg of Tranexamic acid as a slow IV bolus or in infusion.
- 33. Reversal and Emergence • On application of last skin suture, anaesthetic gases are stopped. • If intravenous anesthetics are used, they are also discontinued few minutes to the end of surgery. • Remove secretions from the pharynx by suctioning • If nasogastric tube is in situ, it is aspirated and left unspigotted. • Glycopyrrolate 0.6mg and neostigmine 2.5mg are administered respectively.
- 34. • Patient is observed carefully for evidence of spontaneous ventilation and intact protective airway reflexes. • Deflate the tube at the peak of inspiration • Remove the ETT as the patient exhales. Thus, assisting the removal of any secretions which may have accumulated above the cuff. • Administer 100% oxygen until a regular ventilator rhythm is established • Transfer patient to the recovery room
- 35. Postoperative phase • Discharge patient to the recovery room • Place patient in the recovery position. • Insert oropharyngeal or nasopharyngeal airway to prevent airway obstruction or leave ETT if woman is unable to maintain adequate SPO2 • Suction residual secretions in mouth and nostrils • Monitor airway, breathing and circulation
- 36. • Administer suitable analgesics postoperatively e.g fentanyl or tramadol • Monitor patient & recovery room temperature. Maintenance of fluid balance should be continued • Patient is watched further for hemorrhage • Discharge patient to the ward/ICU when patient has met the discharge criteria.
- 37. ANESTHETIC COMPLICATIONS Postoperative nausea & vomiting (PONV) • The commonest complications in the postoperative period despite the use of modern- day anaesthetic techniques • Risk factors are female gender, inadequate starvation, emergency nature of REP, opioid administration, full stomach, anxiety, reversal with neostigmine
- 38. Management of POVN • Avoidance of emetogenic drugs and the use of anti-emetic agents. • Opiods should be used sparingly and NSAIDs should be used where appropriate • D2 – dopaminergic antagonists e.g. prochloeperazine, Metoclopramide • 5-HT3 – serotonergic antagonists e.g. ondansetron • H1 – histaminergic antagonists e.g. Cyclizine • Dexamethasone administration also prevents POVN
- 39. Fluid imbalance • It may occur as a result of over transfusion or hemodilution, under transfusion. • Avoid dilutional coagulopathy with excessive crystalloid or colloid • Avoid massive transfusion which is defined as transfusion of blood more than patient’s blood volume in less than 24 hours or transfusion of more than 10% blood volume in less than 10 minutes • Estimate intraoperative blood loss and replace accordingly
- 40. • Electrolyte Imbalance • It is common in gynecological conditions associated with hemorrhage • Hyperkalemia may be secondary to high concentrations of potassium in transfused blood • • Hypocalcaemia may be due to chelation of the citrate found in transfused fresh frozen plasma.
- 41. Shivering • It occurs in up to 65% of cases and is related to age, female gender, duration of anaesthesia & hemorrhage • Consequences of shivering include greater oxygen demand and CO2 production • Treatment include; oxygen administration to prevent hypoxia, active warming of fluids and operating environment, use of specific drugs like tramadol, pentazocine
- 42. Pulmonary Aspiration • It is a serious complication that is more likely in inadequately fasted patients. • It is better to prevent aspiration than to treat it. • Management should be supportive, with ventilation and ICU admission if required. • Antibiotics are only indicated in demonstrated pneumonia
- 43. Complications are: • sore throat • post operative drowsiness and dizziness • dental damage • Bronchospasm • anaphylaxis • malignant hyperthermia.
- 44. Conclusion • It is imperative for the anesthetistst o have a thorough knowledge of normal physiological changes in pregnancy and hence their role is crucial in the management of REP. • A multidisciplinary approach with consensual planning catalyzes the management even in crisis situation.