anaesthetic management of a patient with ruptured ectopic pregnancy. helping anaesthetist to know what to do in emergency anaesthesia. this is an emergency case. salpingectomy. 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
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
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
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.
