Dr. Mala Nanayakkara M.B.B.S, M.D.,F.R.C.

A Consultant Anaesthetist

SPECIAL PROBLEMS related to physiological changes due to Endocrine related Gravid uterus Live fetus

Mainly due to progesterone and estrogen

Smooth muscle relaxation-- LOS, gastric, Ligaments, blood vessels. Increased gastric acidity Salt and water retention Expantion of plasma volume and Dilution of componants, eg: aibumin, Hb Increased B.M.R. and O2 consumption

Cephalic displacement of diaphram--alteration of the lung volumes, compression of the stomach Aorto-Caval compression--- reduction of the cardiac out put and BP, distention of the collateral veins

No auto-regulation in placenta--Blood flow reduces with hypotension and hypovolaemia, uterine artery vasoconstriction due to sympathetic stimulation/catecholamines and hypocarbia. Placental transfer of drugs I-D AND U-D interval is important Maternal awareness

pH less than 2.5 , volume more than 25 mls can cause Gastric prokinetics and H2 receptor, or proton pump inhibitor is mandatory. 2 DOSES 6 HOURS INTERVAL IN ELECTIVES OR IN Emergency IV doses, with the decision making

Adequet fasting Gastric prokinetics and H2 RECEPTOR/ PPI inhibitors Antacid prophylactic on the table 0.3 MOLAR SODIUM CITRATE 15 mls for electives 30 mls for emergencies

More prone to develop hypoxia during intubation. low FRC, Increase B.M.R and O2 consumption, Higher incidence of difficult intubation, Pre oxygenate the patient for 3 minute. This will increase the O2 stores in the body and increase the safe period for intubation. Maternal hypoxia can cause fetal hypoxia.

Prepare for rapid sequence induction Thiopentone 5 mg/kg IV and Suxamethonium 1-2 mg/kg, with cricoid pressure. No place for Propofol. In the presence of severe hypotension Ketamine is recommended

Left lateral position 15 degrees lateral tilted table Wedge under the right loin

Uterine atony and blood loss. Extubate in semi-prone/lateral position after return of cough reflex. Post operative analgesia. Early alimentation. Early mobilization. DVT prophylaxis

Positioning and transporting Iv cannulation Monitoring- correct size BP cuff, IBP Dificult intubation, closing capacity is high , may be hypoxic from the beginingprepare to handle it I.P.P.V. will be a problem, high fio2 and PEEP Surgical technique is difficult, this can cause increse blood loss

Higher incidence of wound infectionANTIBIOTICS Higher incidence of DVT- LMWH Chest infection- deep breathing exercise and chest physiotherapy

Safe if possible Identifying the land marks and positioning is difficult. Length of the needle. 10cm. Will not be adequate. Arrange an extra long needle. Reduces the incidence of DVT

Need to take all precautions like in emergency LSCS Select drugs with caredepending on the POA. Should not have any adverse effect on the fetus Placental transfer and fetal depression ?

Plan to do in 2nd trimester if possible Take precautions not to cause severe hypotension and hypoxia Take all the precautions like in LSSC