Obat Anastesi Pada Kehamilan
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Transcript of Obat Anastesi Pada Kehamilan
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Anaesthesia in pregnancy
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Incidence
0.3% to 2.2% of pregnant women undergosurgeries
Annual incidence - 75,000 80,000 (USA)
Commonest surgery - Appendicectomy
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Surgeries in pregnancy
Pregnancy related
Cervical encirclage Fetal surgery Ovarian Cystectomy
Not related to pregnancy
Appendicectomy, Cholecystectomy Trauma Malignancies
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Altered maternal physiologyRespiratory system:
O2 consumptionrapid desaturation or hypoxemia
Alveolar ventilation chronic respiratory alkalosis &bicarbonate and base buffer
mucosal vascularity & weight gain difficult maskventilation or intubation
Cardiovascular system:
Supine hypotension syndrome uteroplacental perfusion
Distention of epidural venous plexus likelihood ofintravascular injection and enhanced spread of LA
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Altered maternal physiologyHematological changes
Blood volume with lesser increase in RBCs volumedilutionalanemia
Factor VII, VIII, X, XII, enhanced platelet turnover;clotting; and fibrinolysis Increased risk of thromboemboliccomplications
Benign leukocytosisdifficult to differentiate from infection
Gastrointestinal system changes LES tone, distortion of gastropyloric anatomy & gastric
pressure from gravid uterusrisk of regurgitation andaspiration
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Altered maternal physiology
Altered response to anaesthesia thiopental requirements
protein binding due to low albumin freefraction of drugs
sensitivity to peripheral neural blockade
L.A.dose requirement
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FETAL EFFECTSAnaesthetic agents andteratogenicity
Teratogenic effects of anaesthetic agents areprobably minimal to non-existent and have neverbeen conclusively documented
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INHALATION ANAESTHESIANitrous oxide
Animal studies
Weak teratogen in rodents
Interferes with function of methionine synthetase by oxidation of vitamin B12
decreased DNA synthesis
Decreased uterine blood flow : prevented by addition of halogenatedinhalational agents
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Nitrous oxide
Human studies
No proved teratogenicity
Significant exposure for prolonged duration results inaltered enzyme activity
No teratogenic effects in clinically administered dose.
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Sevoflurane and desflurane
are considered safe products.
No teratogenic effects have beenobserved in animal studies.
However, there are no adequate andwell-controlled studies in pregnantwomen
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halothane
The reports have been conflicting. Onestudy demonstrated an increased incidence
of aberrant skeletal development and fetaldeath when pregnant rats, in variousgestational periods, were exposed tohalothane for 12 hours.
Other investigators could not validate thisteratogenic effect when exposing rats,rabbits and mice to halothane
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enflurane or isoflu-rane
Pregnant mice exposed to showed anincreased incidence of cleft palate
None of these teratogenic findingshave been reported in humans despiteworldwide use of these products
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Induction Agentspropofol, etomidate, thiopental,
ketamineNeither is known to be a teratogen inclinically effective doses
lack of adequate and well-controlledstudies in pregnant women.
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Neuromuscular BlockingAgents
do not reach fetal circulation inclinically significant amounts
no teratogenic effect has beenreported after administration ofneuromuscular blocking agents to
pregnant women
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ANAESTHETIC MANAGEMENT
Postoperative Pain management
Painincreased endogenous catecholamines uterinevasoconstrictiondecreased UBFintrauterine hypoxia
Some well-documented case reports demonstrate the safeuse of opioids for acute and chronic pain
NSAIDS
1st and 2nd trimester - safe
3rd
trimester - risk of premature closure of DA,Pulm HTN, delayed labour
Paracetamol is safe
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BENZODIAZEPINES
Earlier retrospective studies:Association between maternal diazepam ingestion
during 1st trimester and infant with cleft lip and palate
Later prospective studies:
- No higher risk when used in 1st trimester
Long term maternal administration fetal BZDdependence & withdrawal
Peripartum administration
Fetal hypotonia, hypothermia, respiratory depression,feeding difficulties
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FETAL EFFECTSBEHAVIORAL TERATOLOGY
Behavioral abnormality in absence of any observablemorphological changes
CNS is specifically sensitive during period of majormyelination which extends from 4th IU month to 2ndpostnatal month
Animalsprenatal administration of systemic drugs
e.g., Barbiturates, meperidine, promethazine &halothane behavioral changes
Humanimplication remains unknown
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FETAL EFFECTS
There are not adequate data toextrapolate the animal finding tohumans
(Anesthetic & Life Support Drug advisory Committeeof US FDA)
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Fetal effects
To summarize, anaesthesia and surgery are associated withhigher incidence of abortion, IUGR and perinatal mortality.
These adverse outcomes can often be attributed to theprocedure, the site of the surgery (e.g., proximity to theuterus), and/ or the underlying maternal condition
No evidence that anaesthesia results in overall increase incongenital abnormality
No evidence of clear relation between outcome and type ofanaesthesia
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ANAESTHETIC MANAGEMENT ..
General anaesthesia
Maintain left uterine displacment
Preoxygenation
Rapid sequence induction (Thiopent. sod. & succinyl choline,cricoid pressure tracheal intubation using cuffed E.T. tube)
Maintenance : A moderate conc. of inhalational agent ( 2 MAC)with high conc. of oxygen (FiO2 = 0.5) is recommended.
The use of nitrous oxide should be limited during extremelylong operations in first trimester by giving high conc of oxygen
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Opioids and induction agents decreases FHR variabilityto greater extent than volatile agents
Positive pressure ventilation may reduce UBF
Avoid hyperventilation
Reversal agent to be given slowly (increased release of
Ach
increased uterine tone and preterm labour)
Extubation when fully awake after return ofprotective airway reflexes
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ANAESTHETIC MANAGEMENT..
Regional anaesthesia
Advantages:
Minimal fetal drug exposure
Avoidance of complications of general anaesthesia
If no sedative or narcotics are supplemented no change inFHR variations to confuse interpretation
Post operative analgesia
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Management of regional anaesthesia
Pre-op preparation and monitoring same as of Generalanaesthesia
Reduced LA requirement / LA Toxicity
Careful aspiration and test dose
Avoid hypotension i.e., adequate preloading, maintain leftuterine tilt, choice of vasopressor
Patients on magnesium are more prone to hypotension, oftenresistant to treatment with vasopressors
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ANAESTHETIC MANAGEMENT
Recommendations approved by AmericanSociety of Anaesthesiologists (ASA) andAmerican College of Obstetricians and
Gynecologists (ACOG) 2011
No currently usedanaesthetic agentshave been shown tohave anyteratogenic effectsin humans when usingstandard concentrations at any gestational age
Fetal heart rate monitoringmay assist in maternalpositioning and cardiorespiratory management, and mayinfluence a decision to deliver the fetus