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1、Obstetric Anesthesia,Physiologic Changes Of Pregnancy,Cardiovascular System : cardiac output , heart rate Hematologic System : blood volume increases by up to 45% , red cell volume increases by only 30% physiologic anemia,Respiratory System : increase in the respiratory minute volume and work of bre
2、athing Gastrointestinal System : risk of incidence of aspiration endotracheal intubation Renal System : GFR rises 50% ; glycosuria Central Nervous System : sensitivity to anesthetics.,Physiologic Changes Of Pregnancy,Changes Of Respiratory System,O2 (Consumption 消耗 ) +20 to +50% MV(Minute Ventilatio
3、n分钟通气量) +50% TV +40% PaO2 +10% PaCO2 -15% HCO3 -15% FRC -20%,Placental Transfer Of Anesthetic Drugs,Placenta transport : Simple diffusion Facilitated diffusion Active transport Pinocytosis Readily cross : low molecular weights, high lipid solubility , non-ionized Approximately 50% of the umbilical v
4、enous blood bypasses the liver.,Narcotic analgesic morphine pethidine fentanyl alfentanil sufentanil General anesthetics propofol 吗啡、哌替啶、芬太尼,Morphine,Placental transfer is rapid Mother: uterus reactiveness orthostatic hypotension nausea vomiting delayed gastric emptying Fetus: respiratory depression
5、,Pethidine,Most commonly used during labor intramuscular dose : 50 -100 mg Time of IM: before expulsion 1 h or 4 h uterine contraction, frequency and intension ,Fentanyl Alfentanil Sufentanil,Placental transfer is rapid Low dose: 10 -25 g fentanyl or 5-10 g sufentanil in subarachnoid space PCEA: low
6、 dose of fentanyl and 0.1%- 0.3% ropivacaine,Tramadol,Placental transfer No inhibiting uterine contraction No Respiratory depression,Diazepam,Readily cross the placenta Half-lives: 48 hours Problems: sedation, hypotonia, cyanosis, impaired metabolic responses to stress.,Midazolam,Plasma protein bind
7、ing: 94% Respiratory depression: depended on dose 0.075 mg/kg no problem 0.15 mg/kg different degree,Droperidol,Pregnant woman: 慎用 Apgar score ,Thiopental sodium,Neonatus sleep: little Premature and intrauterine embarrass: carefully using,Ketamine,High doses (greater than 2 mg/kg) may cause low Apga
8、r scores and abnormalities in neonatal muscle tone Labor pains of uterine contraction Uterine muscular tension and contraction force Contraindication: psychosis, gestational hypertension syndrome or preeclampsia, metrorrhexis,Propofol,Recommendation: induction: 2.5 mg/kg maintenance: 2.5-5.0 mg/kg/h
9、 Discontinue gravidity only,N2O,Placental transfer is rapid Mothers respiration, circulation and Uterine muscular contraction force 20-30s before of first stage of labor: 50% O2 and 50% N2O, maximum70%,Enflurane and Isoflurane,Light anesthesia: no inhibition Deep anesthesia: mother: inhibition of ut
10、erine contraction, uterine bleeding fetus: disadvantage,Sevoflurane,Placental transfer is more rapid than halothane Inhibition of uterine contraction: halothane,Succinylcholine,Cholinesterase: normal doseno placental transfer Dose 300 mg or single dose is larger: still have placental transfer,Nondep
11、olarizing Muscle Relaxants,Onset is quick, maintanence is short and placental transfer is least Atracurium: 0.3 mg/kg,Local anesthetics,Factors: Protein binding: Molecular weight Liposolubility Catabolism in the placent,Local anesthetics,Procaine Lidocaine Bupivacaine Ropivacaine,Anesthesia For Sesa
12、rean Section,Choice depends on : the indications for the surgery the degree of urgency maternal status desires of the patient,Spinal Anesthesia,Hyperbaric bupivacaine Advantages : rapid onset, little risk of local anesthetic toxicity, minimal transfer to the fetus, infrequent failure. Disadvantages
13、: finite duration hypotension headache,Epidural Anesthesia,L 23 or L 12 1.5%2% Lidocaine or 0.5% Ropivacaine emergency cesarean section,Combined Spinal-Epidural Technique,Increased dramatically in popularity Advantages : rapid onset supplemented at any time anesthetic dose sacral nerves block is suf
14、ficient,General Anesthesia,rapid induction: obviate positive pressure ventilation oppress the cricoid cartilage mainterance: light anesthesia vomiting, backstreaming and aspiration: atropine, 0.5 mg, IM or glycopyrolate, 0.2 mg, IM,Supine hypotensive syndrome,Incidence: 2%30% Time: after 28 weeks, s
15、pecially 3236 weeks Symptoms: hypotension, dizziness, nausea, chest distress, cold sweat, to yawn, pulse rate, pallescence,High risk pregnancy,Emergency operation : late trimester of pregnancy: hemorrhage gestational hypertension syndrom and eclampsia Selective operation : hypertension cardiac disea
16、se diabetes multifetation,Placenta Previa and Placental Abruption,Preanesthtic preparation: blood coagulation function DIC sifting test acute renal failure Principle: general anesthesia: active bleeding, hypovolemic shock, definite blood coagulation disfunction or DIC intraspinal anesthesia: condition of mother and fetus is okay Management,degrees of abruptio placentae. A,
