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Oral case 37

Created: 4/10/2004

A 25-year old, 60 kg woman requires emergency cesarean section at 36 weeks of pregnancy for vaginal bleeding and fetal distress. She is in early labor, and complains of continuous abdominal pain also. Blood pressure is 90/60 mm Hg, pulse is 120 bpm, respirations are 24, temperature is 37.5 degrees centigrade, and hematocrit is 30.

 Preoperative evaluation

I. Evaluation of bleeding

1. What are causes of vaginal bleeding in the third trimester?

2. What is the significance of this, related to anesthesia care?

3. How do you evaluate the patient's blood volume preoperatively?

4. Are sequential hematocrits useful in monitoring hemorrhage? Why or why not?

5. How will you evaluate blood loss?

6. Do you want any coagulation labs? Explain.

7. Will you give the patient a preoperative blood transfusion?

There is no definite minimum preoperative hematocrit, which is acceptable.

II. Diagnosis of fetal distress

1. The fetal monitor first displays early deceleration and then late decelerations. What is the significance of each?

2. Will maternal administration of oxygen be helpful? Explain.

3. Will maternal administration of atropine be helpful? Explain.

III. Premedication:

1. Will you give a preoperative antacid? Why or why not?

2. Will you give cimetidine? Why or why not?

 Intraoperative course:

I. Selection of anesthesia for placenta previa:

1. The patient prefers to be awake. Do you agree?

2. What will you tell the patient regarding risks to her and to the fetus?

3. She consents to general anesthesia. What are the risks?

II. Induction of anesthesia

1. What agents will you use for induction of anesthesia? Explain.

2. You are unable to intubate and she vomits, aspirating abdominal contents. What are the priorities of treatment now?

3. Tracheal aspirate pH is 6.5. What is the significance of this?

4. Gastric aspirate pH is 2.0. What is the significance of this?

5. How would you manage each of the above two situations?

6. Should the obstetrician make the abdominal incision prior to your intubating the patient?

III. Infant resuscitation

1. The baby has a one-minute Apgar score of 2 and the skin is green-black. What is the significance of this?

2. What are the steps in managing this?

3. Should ventilation by mask occur? Explain.

4. In spite of intubation and ventilation with 100% oxygen, the heart rate does not exceed 75 bpm. What do you do now?

IV. Management of uterine atony

1. The uterus continues to bleed heavily after delivery of the placenta. Are anesthetics implicated?

2. Which anesthetics could be implicated?

3. What are other causes?

4. Would you treat this patient with methergine? Why or why not?

5. Is disseminated intravascular coagulopathy a possibility?

6. What is disseminated intravascular coagulopathy?

It occurs in certain clinical conditions, and results in deposition of intravascular fibrin thrombi, consumption of factor V and factor VIII, platelet consumption, and activation of the fibrinolytic system.

7. What conditions are associated with disseminated intravascular coagulation?

It is associated with obstetric conditions like amniotic fluid embolism, abruptio placentae, retained fetus, eclampsia, and saline-induced abortion. Other causes include intravascular hemolysis from hemolytic or massive transfusion, septicemia, viral infection like cytomegalovirus, hepatitis, varicella, or HIV, disseminated malignancy, leukemia, burns, crush injury and tissue necrosis, liver disease like obstructive jaundice or acute liver failure, and prosthetic devices like the LeVeen shunt or the aortic balloon can cause it also.

6. How would you diagnose and treat it?

In acute disseminated intravascular coagulation, the prothrombin time is increased 75% of the time, and partial thromboplastin time is prolonged in 50-60% of the time. The platelet count and fibrinogen are low, and D-dimer is elevated 85-100% of the time.

Treatment is controversial, and the underlying cause must be treated. Heparin can stop the consumption process if bleeding continues, and then coagulation replacement products can be given. If bleeding persists, antifibrinolytic treatment with epsilon aminocaproic acid should be considered after intravascular coagulation has stopped and residual fibrinolysis continues.

 Postoperative care

I. Management of respiratory failure

1. After delivery, the mother now has increasing expiratory wheezing. FIO2 is 50%, and arterial blood gas shows pH = 7.30, paO2 =45 mmHg, and paCO2 =50. What are your criteria for management of ventilation?

2. When is positive end-expiratory pressure indicated?

3. What are the hazards?

4. What is the "best" positive end-expiratory pressure?

5. Is intermittent mandatory ventilation indicated?

6. Would pressure support be better than intermittent mandatory ventilation? Explain.

II. Amnesia

1. On the first postoperative day, she states that she remembers "nearly everything", and felt apprehensive. What do you tell her?

2. Will you write it in the chart?

III. Missing tooth:

1. An avulsed tooth was discovered in the recovery room, and the tooth cannot be found. What do you tell the patient?

2. What studies are indicated?

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