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Bstetric Anesthesia Handbook Fourth Edition O BSTETRIC ANESTHESIA HANDBOOK Fourth Edition Sanjay Datta, MD, FFARCS (Eng)

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Bstetric Anesthesia Handbook Fourth Edition O BSTETRIC ANESTHESIA HANDBOOK Fourth Edition Sanjay Datta, MD, FFARCS (Eng) O bstetric Anesthesia Handbook Fourth Edition O BSTETRIC ANESTHESIA HANDBOOK Fourth Edition Sanjay Datta, MD, FFARCS (Eng) Professor of Anesthesia Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts With 72 Illustrations Sanjay Datta, MD, FFARCS (Eng) Professor of Anesthesia Brigham and Women’s Hospital Harvard Medical School Boston, MA 02115 USA Library of Congress Control Number: 2005926767 ISBN 0-387-26075-7 ISBN 978-0387-26075-4 Printed on acid-free paper. © 2006 Springer Science+Business Media, Inc. Third edition © 2000 by Hanley & Belfus, Inc All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, Inc., 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author nor the editor nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no war- ranty, express or implied, with respect to the material contained herein. The recommendations in this book should not be viewed as an exclu- sive treatment option or serve as a standard medical practice. Neither the author nor the publisher can accept any legal responsibility for any errors or omissions that may be made. Printed in the United States of America. (BS/MVY) 987654321 springeronline.com Preface ᭢ Three previous editions of Obstetric Anesthesia Handbook have proven valuable in serving those interested in managing pregnant women, each edition has become popular among anesthesiology residents, fellows, staff, and also among obste- tricians. This book has enjoyed strong international appeal and has been widely translated. Obstetric anesthesia has undergone changes in its field, changes in the technique as well as in its specific pharma- ceutical agents. Updating these fields has been the primary focus for the fourth edition. The text has been written to retain the cohesiveness of a single-author work; all efforts have been made to keep the text concise and to keep it in a true hand- book format. I sincerely hope the fourth edition will be as useful and as popular as previous editions. I thank Mrs. Elizabeth Kiernan, whose help has been immeasurable. Sanjay Datta, MD Contents ᭢ Preface . v 1. Maternal Physiological Changes During Pregnancy, Labor, and the Postpartum Period . 1 2. Local Anesthetic Pharmacology . 14 3. Perinatal Pharmacology . 27 4. Drug Interactions and Obstetric Anesthesia . 38 5. Uteroplacental Blood Flow . 59 6. Physiology of Labor and Delivery . 72 7. Relief of Labor Pain by Systemic Medication . 79 8. Spinal Opiates in Obstetrics . 89 9. Effect of Maternally Administered Anesthetics and Analgesics on Neonates and Neurobehavioral Testing . 100 10. Fetal Monitoring . 117 11. Relief of Labor Pain by Regional Analgesia/Anesthesia . 130 12. Anesthesia for Cesarean Delivery . 172 13. High-Risk Pregnancy . 211 14. Neonatal Resuscitation . 302 viii CONTENTS 15. Postpartum Tubal Ligation . 325 16. Anesthesia for Surgery During Pregnancy . 333 17. In Vitro Fertilization . 347 18. Maternal Mortality and Morbidity . 353 Index . 381 1 Maternal Physiological Changes During Pregnancy, Labor, and the Postpartum Period ᭢ Changes in Blood Volume Clinical Implications Changes in the Cardiovascular System Clinical Implications Changes in the Respiratory System Clinical Implications Changes in the Renal System Clinical Implications Changes in the Gastrointestinal System Clinical Implications Changes in the Central and Peripheral Nervous Systems Clinical Implications Changes in the Musculoskeletal System Changes in the Dermatological System Changes in the Mammary Tissue Changes in the Ocular System Clinical Implications Parturients undergo remarkable changes during pregnancy, labor, and the immediate postpartum period that can directly affect anesthetic techniques; hence a broad knowledge of these changes is essential for proper management of these women. 2MATERNAL PHYSIOLOGICAL CHANGES Changes in Blood Volume Maternal blood volume increases during pregnancy, and this involves an increase in plasma volume as well as in red cell and white cell volumes.1 The plasma volume increases by 40% to 50%, whereas the red cell volume goes up by only 15% to 20%, which causes a situation that is described as “physiological anemia of pregnancy” (normal hemoglobin, 12 g/dL; hematocrit, 35).2 Because of this apparent hemodi- lution, blood viscosity decreases by approximately 20%. The exact mechanism of this increase in plasma volume is unknown. However, several hormones such as renin- angiotensin-aldosterone, atrial natriuretic peptide, estrogen, and progesterone may be involved in this interesting phe- nomenon. Two current hypothesis attribute the increase to (1) an underfill state caused by initial vasodilation, which stimu- lates hormones such as renin, angiotensin, and aldosterone or (2) an overfill state characterized by an early increase in sodium retention (due to an increase in mineralcorticoids) that retains fluid, causing an increase in blood volume. Levels of clotting factors I, VII, VIII, IX, X, and XII, and the fibrinogen count are elevated during pregnancy as well. At present the majority of observers report a statistically significant fall in platelet count as pregnancy progresses.3 A recent study that observed an increase in thrombopoietin with the advance- ment of the gestational age also confirmed this finding.3a Sys- temic fibrinolysis also may increase slightly. Clinical Implications The increased blood volume serves several important functions: (1) it takes care of the increased circulatory need of the enlarging uterus as well as the needs of the fetopla- cental unit, (2) it fills the ever-increasing venous reservoir, (3) it protects the parturient from the bleeding at the time of delivery, and (4) parturients become hypercoaguable as the gestation progresses. It takes about 8 weeks after delivery for the blood volume to return to normal. MATERNAL PHYSIOLOGICAL CHANGES 3 Changes in the Cardiovascular System An increase in cardiac output is one of the most important changes of pregnancy. Cardiac output increases by 30% to 40% during pregnancy, and the maximum increase is attained around 24 weeks’ gestation.4 The increase in heart rate lags behind the increase in cardiac output initially and then ulti- mately rises by 10 to 15 beats per minute by 28 to 32 weeks’ gestation. The increase in cardiac output initially depends mainly on the rise in stroke volume, and later the increase in heart rate also becomes an important factor. With Doppler and M-mode echocardiography technique, increases in end dias- tolic chamber size and total left ventricular wall thickness have been observed in recent years. Cardiac output can vary depend- ing on the uterine size as well as on the maternal position at the time of measurement. The enlarged gravid uterus can cause aortocaval compression while the pregnant woman is in the supine position, and this will lead to reduced venous return and ultimately maternal hypotension. This effect will be exaggerated in parturients with polyhydramnios or multiple gestations. Cardiac output increases further during labor and may show values 50% higher than prelabor values. In the imme- diate postpartum period, cardiac output increases maximally and can rise 80% above prelabor values and approximately 100% above nonpregnant measurements. The increase in stroke volume as well as in heart rate maintains the increased cardiac output. Clinical Implications An increased cardiac output might not be well tolerated by pregnant women with valvular heart disease (e.g., aortic or mitral stenosis) or coronary arterial disease. A severe decom- pensation in myocardial function can develop at 24 weeks’ ges- tation, during labor, and especially immediately after delivery. Cardiac output, heart rate, and stroke volume decrease to pre-labor values 24 to 72 hours postpartum and return to non- pregnant levels within 6 to 8 weeks after delivery.5 Even with this increase in cardiac output the systolic blood pressure does not change during pregnancy; however, the dia- 4MATERNAL PHYSIOLOGICAL CHANGES stolic blood pressure drops by I to 15 mm Hg. There is a decrease in mean arterial pressure because of an associated decrease in systemic vascular resistance. Pregnancy hormones like estradiol-17b and progesterone are probably responsible for these vascular changes.6 Prostacyclin as well as nitric oxide also may play an important role. The down regulation of a and b receptors may also be an important factor. The heart is displaced to the left and upward during pregnancy because of the progressive elevation of the diaphragm by the gravid uterus. The electro- cardiogram of normal parturients may include: (1) benign dysrhythmia, (2) reversal of ST, T, and Q waves, and (3) left axis deviation. Aortocaval compression is one of the most important events during pregnancy, especially when the
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