MS HSV Cardioversion and ECT during Pregnancy Dr. Daniels by sammyc2007

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									OBSTETRICAL ANESTHESIA: Unusual encounters
DON DANIELS, M.D. LTC(P), MEDICAL CORPS CHIEF, ANESTHESIA & OPERATIVE SERVICE BROOKE ARMY MEDICAL CENTER

DON DANIELS COL MC

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OB ANESTHESIA: OBJECTIVES
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Discuss rare scenarios that you may encounter in the middle of the night
Multiple sclerosis  HSV
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Discuss two scenarios that make you go hmmm
ECT  Cardioversion
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DON DANIELS COL MC 2

Multiple Sclerosis, Pregnancy & Anesthesia
Demyelinating disease  Remissions & exacerbations  Progressive deterioration of the CNS  Etiology unclear but may be viral
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DON DANIELS COL MC

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Multiple Sclerosis, Pregnancy & Anesthesia
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Common symptoms
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Lab findings
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motor weakness impaired vision ataxia bladder dysfunction bowel dysfunction emotional instability

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ed CSF immunoglobulin ed CSF lymphocyte MRI: white matter plagues Prolonged evoked potentials in involved areas
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DON DANIELS COL MC

Multiple Sclerosis, Pregnancy & Anesthesia
No curative treatment  Therapy directed to hasten recovery
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Prednisone  ACTH  Azathioprine  Plasmapheresis
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DON DANIELS COL MC

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Multiple Sclerosis, Pregnancy & Anesthesia
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Relapse rate is 0.3 - 0.4 attacks per year Deficits become more progressive & debilitating Environmental factors ie stress, infection, and increased body temperature may provoke relapse Pregnancy does not cause relapse & MS does not influence pregnancy Most relapses (40%) occur during first 6 mo. postpartum
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Multiple Sclerosis, Pregnancy & General Anesthesia
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General Anesthetic: considered safe
Succinylcholine should be avoided in patients with severe neurological deficit that has caused skeletal muscle wasting  However for the pt in remission Succinylcholine may be used  Use of thiopental, succinylcholine, N2O:O2, halothane or isoflurane, narcotics and diazepam have been used successfully
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Multiple Sclerosis, Pregnancy & Neuraxial Anesthesia
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Bamford et al discourages use of neuraxial anesthesia Abouleish and others believe that pts with MS should not be denied neuroaxial blockade Middle ground: “regional anesthesia should be instituted only when the degree of neurologic defect is stable and well recorded in the pt’s chart and she understands and agrees to the risks involved”
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Multiple Sclerosis, Pregnancy & Neuraxial Anesthesia
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What is the concern?
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Bader: 1 in 5 who had epidural for c/s had relapse Warren: minor exacerbation's noted after labor epidural for 2 separate vaginal deliveries in 1 pt Crawford: 1 post op relapse out of 50 none OB & 7 OB pts receiving surgical epidurals Bamford: 1 relapse after 9 pts who receiving SAB Stenuit & Marchand: 1 relapse after 19 pts who received SAB
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Multiple Sclerosis, Pregnancy & Neuraxial Anesthesia
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What is going on?
Diagnostic lumbar puncture is not associated with increased rate of relapse  Small doses of local anesthetics do not cause neuro damage  Large doses cause reversible inflammatory & degenerative changes
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DON DANIELS COL MC

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Multiple Sclerosis, Pregnancy & Neuraxial Anesthesia
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What is going on II?
All pts in relapse group received higher concentrations of local anesthetic  LA concentration increases in the CSF during prolonged administration of epidural anesthesia which may overwhelm protective effect of CSF dilution  LA concentrations in CSF are 3-4 fold higher following SAB than with epidural
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Multiple Sclerosis, Pregnancy & Neuraxial Anesthesia
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Okay Don, now that you have confused us, what is the bottom line?  Use of the most dilute LA with narcotic epidural solution is recommended for labor epidurals.  Epidural for C/S is preferred over SAB.  Informed consent is critical. Providing the pt as much information, support and choice.
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HERPES SIMPLEX INFECTION, PREGNANCY & ANESTHESIA

DON DANIELS COL MC

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HERPES SIMPLEX INFECTION, PREGNANCY & ANESTHESIA

HSV - 1 & HSV - 2 reside in the neural ganglia cell during latency  Systemic sx seen in 67% of primary genital HSV  Aseptic meningitis and sacral neuropathy seen in 8 - 2% of respectively pts with primary infection  Systemic sx uncommon in recurrent disease
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HERPES SIMPLEX INFECTION, PREGNANCY & ANESTHESIA
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Concern to the anesthesiologist
Risk of intro virus into CNS via SAB or epidural  Disseminated infection following regional anesthetic may be temporally related to anesthesia despite lack of casual relationship
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DON DANIELS COL MC

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HERPES SIMPLEX INFECTION, PREGNANCY & ANESTHESIA
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No case reports documenting CNS placement of HSV during active recurrent disease Both SAB & epidural LA appear safe in recurrent disease Safety in primary disease not known Reactivation of HSV-1 may occur with epidural narcotics

DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy

DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy
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Treatment of psychiatric illness during pregnancy is a challenge Drugs tend to be teratogenic Need for effective & safe treatment First ECT, pregnancy was misdiagnosed By 1940’s, ECT was not contraindicated during pregnancy Over 300 case reports since 1942 There are no controlled studies

DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy

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Physiologic effects of pregnancy
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Lower seizure threshold

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Electroconsulsive Therapy During Pregnancy
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Effects of ECT on pregnancy related hormones
Transient post-ictal hyperprolactinemia  Elevation in plasma cortisol and betaendorphins
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DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy
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Timing of ECT in 300 reported case
1st trimester - 14 (4.7%)  2nd trimester - 36 (12%)  3 rd trimester - 31 (10.3%)  Unknown 219 (73%)
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DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy
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Complications
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Fetal cardiac arrhythmia Vaginal bleeding Uterine contraction Abdominal pain Premature labor Miscarriage Stillbirth & neonatal death Respiratory distress Teratogenicity
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Electroconsulsive Therapy During Pregnancy
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Potential risk
Pulmonary aspiration  Aortocaval compression  Fetal hypoxia
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DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy: Succinycholine Most commonly used muscle relaxant  In ordinary doses, does not cross placenta  Reduces incidence of vertebral compression fractures  Use in 1st trimester reported safe
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DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy: Anticholinergic Agents Given before ECT  Prevent excessive vagal bradycardia  Decrease secretions  Can reduce lower esophageal sphincter tone
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DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy
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Atropine
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Glycopyrrolate
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Quickly crosses the placenta Decreased fetal heart rate beat to beat variability May protect fetus from ECT related bradycardia May mask signs of fetal distress

Limited rate of transfer across placenta Does not affect fetal heart rate Anticholinergic of choice

DON DANIELS COL MC

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Electroconsulsive Therapy During Pregnancy: Barbiturates Methohexital - no teratogenic effects in experimental animals  Thiamylal - increased frequency of limb and digital anomalies in mice  Thiopental - no teratogenic effects in experimental animal  No conclusive evidence of teratogenicity in humans
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ECT during Pregnancy: Modifications in Technique
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Pre-ECT should include a pelvic exam Discontinue nonessential anticholinergic meds Uterine tocodynamometry one hr prior to ECT Intravenous access Gastric prophylaxis peri-ECT external fetal monitoring Consider intubation if >1st trimester Avoid hyperventilation Uterine tocodynamometry post ECT Ensure left uterine displacement

DON DANIELS COL MC

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ECT during Pregnancy: Anesthetic Technique
Pre-oxygenate  Pre-treat with gylcopyrrolate 0.2-0.4 mg IV  Methohexital 0.5-0.75 mg/kg IV  Succinycholine 0.5-1.0 mg/kg IV  If > 1st trimester,“Rapid sequence induction with cricoid pressure”, and intubate
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DON DANIELS COL MC

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Cardioversion during Pregnancy
Described as safe: case reports as early as 6 weeks to as late as 36 weeks gestation  Indicated for tachyarrhythmias that do not respond to medical therapy or those with hemodynamic instability  Watt-seconds range 50-400
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DON DANIELS COL MC

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Cardioversion during Pregnancy: Anesthetic management
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Give clear oral antacid & H2 - receptor antagonist before cardioversion Avoid metoclopramide: excerbates tachyarrhythmias Must weigh risk & benefit of sedation vs GETA Judicious sedation w benzodiazepine or propofol

DON DANIELS COL MC

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