Episode 64 — Problems During Pregnancy With Jacqueline Galvan Part 2
Highlights
- Causes of Thrombocytopenia During Pregnancy
Summary:
G gestational thrombocytopenia has a higher incidence during pregnancy. I would probably leave it in, repeat the playlets at some interval, you know, maybe six, eight, 12 hours later. Or it might be time to consider the steroids or IVIG to improve the playlet number per se and then pull it. In general, it's safer regional anesthesia and not as dangerous theoretically.
Transcript:
Speaker 1
I would probably leave it in, repeat the playlets at some interval, you know, maybe six, eight, 12 hours later, kind of, you know, depending on the clinical scenario and when the plither and the upswing, I would probably then pull it then. Or it might be time to consider the steroids or IVIG to improve the playlet number per se and then pull it. But I think it's a great question that we now need to be concerned about replacing it but also pulling the epidurals at a time when you can cause an epidural hematoma theoretically. Gotcha. Okay. Great.
Speaker 2
So we talked about kind of the management around the epidural. Are there other causes of thrombocytopenia other than ITP? Oh, yes.
Speaker 1
So gestational thrombocytopenia has a higher incidence during pregnancy, so it's usually described as a mild, again, asymptomatic thrombocytopenia with playlet numbers in the 90,000 to 100,000 levels. And it often occurs late in the pregnancy. So it's often a diagnosis of exclusion and sometimes you have to rule this ITP or related preeclampsia first before you can declare it a stationary thrombocytopenia. But in general, it's safer regional anesthesia and not as (Time 0:14:30)
- Preeclampsia Without Severe Features
Summary:
Preeclampsia may have an incidence of a 1 to 8% of pregnant women with developed preeclampsia. It's really the second cause of maternal mortality worldwide. One of the five leading causes of maternal mortality in the developed world. There is a good to moderate chance that these poor outcomes will discuss coming up next year are actually modifiable, says Dr. David Perry.
Transcript:
Speaker 2
So preeclampsia, depending on the country that is surveyed, may have an incidence of a 1 to 8% of pregnant women with developed preeclampsia.
Speaker 1
But even though it has a, if I would call it a relatively low incidence, it's really the second cause of maternal mortality worldwide. One of the five leading causes of maternal mortality in the developed world, and according to the work from the California Maternal Quality Collaborative, patients with preeclampsia and their associated negative outcomes, there is a good to moderate chance that these poor outcomes will discuss coming up next year are actually modifiable, meaning there's something we can do during their antenatal period or labor course that might change their outcome. I think it's important point to highlight. That's great. And so how do we define preeclampsia? Great. So in 2013-14, ACOG changed their definitions. So there's preeclampsia without severe features, which is a blood pressure of greater than 140 over 90, at least four hours apart in a patient with previously normal blood pressures after 20 weeks of gestation. Preeclampsia with severe features is a systolic blood pressure of greater than 160 or a diastolic blood pressure of greater than 110, again, at least four hours apart after that 20-week of gestation mark. You no longer need a certain area to have severe preeclampsia, which was part of the previous diagnosis. (Time 0:22:20)
- Multiple Sclerosis Pregnancy
Summary:
Two-thirds of patients who have MS are women of child-bearing age. Are the immune-modulating therapies okay during pregnancy in terms of trinogenicity? Can you use a spinal anesthetic or an epidural anesthetic in part turns in multiple sclerosis? I would say yes, and probably our contemporary low dose, epidural, is there considered pretty safe.
Transcript:
Speaker 2
I just want to clarify what you said up front. So two-thirds of patients who have MS are women of child-bearing age. Right. Gotcha. All right. So maybe it gets better, but what are we worried about if it doesn't? Yes.
Speaker 1
So I think important concerns, again, is pregnancy going to make their disease worse, which we kind of touched based on that? Are the immune-modulating therapies okay during pregnancy in terms of trinogenicity? And then the important for patients and anesthesiologists are things like spinal and epidurals, right, which are things that we do to their cerebral spinal fluid, to their nerve axis. Is that going to worsen their disease, their MS? So let's talk about that next. Can you use a spinal anesthetic or an epidural anesthetic in part turns in multiple sclerosis? And the answer, I think, generally, is there considered pretty safe? I would say yes, and probably our contemporary low dose, epidural, (Time 0:36:28)
- Having a Spinal Neurofibroma in Pregnancy?
Summary:
There are case reports of epidural hematoma in patients with neurofibromatosis type one, so I think it is a genuine concern. During pregnancy, these patients have increased risk of things like preeclampsia, cerevascular disease, preterm labor, and C-section. It probably is very, really prudent to have some sort of imaging around the peripartum time before anorectal anesthetic is performed. And there are some authors that suggest that even patients that are asymptomatic in terms of spinal neurofibrome might be present.
Transcript:
Speaker 1
So another neurologic disorder, rather, is neurofibromatosis type one, right? There's a type two, which again, I'm not going to get into for brevity. It's a fairly common autosomal dominant disease, and one of the most important aspects of this genetic disorder is that patients with neurofibromatosis type one will likely exhibit one of the phenotypic traits, which as we know can be spinal neurofibromas. So with that, I think there are a couple of things. These patients, neurofibromas, so just type one, in particular, during pregnancy, have increased risk of things like preeclampsia, right, cerevascular disease, preterm labor, and C-section. So we are likely, anesthesiologist going to interact with these patients. So the next question is, should we do a neuroaxial, and these patients that may have spinal neurofibroma, or possibly a risk for a spinal neurofibroma? And there are case reports of epidural hematoma in patients with neurofibromatosis type one, so I think it is a genuine concern. And there are some authors that suggest that even patients that are asymptomatic in terms of spinal neurofibromas, they still might be present. So it probably is very, really prudent to have some sort of imaging around the peripartum time before anorectal anesthetic is performed. I do think the risk of epidural hematoma is pretty high unless you've ruled out that they don't have a neuroaxial spinal fibromon. (Time 0:40:37)
- Neuroaxial Anesthesia - Idiopathic Intracranial Hypertension
Summary:
Idiopathic intracranial hypertension is an increase in intracrania pressure without a demonstrable etiology. In pregnancy, it's associated with obesity and optic nerve atrophy or blindness down the road. Treatments are generally carbonic and hydrating inhibitors and serial lumbar punctures.
Transcript:
Speaker 1
And the third neurologic disorder we'll cover today is idiopathic intracranial hypertension, otherwise known as benign intracranial hypertension or pseudo-tumor serifry, which is an increase in intracranial pressure really without a demonstrable etiology. So there isn't a obstructing hydrocephalus or mass that would otherwise explain and increase in ICP. The patients generally have things like headache, papillatema, and it's really the question is there's overproduction under absorption of CSF. In pregnancy in particular, idiopathic intracranial hypertension is associated with obesity. The course of it is generally benign, but these patients can have optic nerve atrophy or blindness down the road. And again, just to reaffirm that those really normal CSF composition and imaging studies don't show, again, things like, reconstructing hydrocephalus. Treatments is generally carbonic and hydrating inhibitors and serial lumbar punctures. So how it interacts with pregnancy, rather, is a couple of things. So the patient's baseline headache, again, associated with an increased ICP, can actually worsen during the labor and delivery process because you get this intermittent epidural venous engorgement with each contraction, and that transverse pressure on the dura to the cranium, and that can temporarily worsen the headache, and the velsalva maneuver during the explosive phase of delivery can also exacerbate headache. So what can anesthesiologists do? And I think this is actually really interesting case reports. (Time 0:42:50)
- Is Sogaminex in Pregnancy?
Summary:
If for some reason you can't use succinylcholine like hyperkalemia, then you can use a relatively high dose of remifentanyl and propylol. So these can be very challenging patients, and really, if time warrants a system-by-system evaluation plan, it's probably prudent. Right. Then the other thing I'm sure to keep in mind would be these people could have an elevated potassium level,. If you end up having to use succ vinylcholine and induce them for general anesthesia, obviously you need to be aware of that. Exactly. And then you would use a long-acting neuromuscular in the studying of difficult airway.
Transcript:
Speaker 2
And then the other thing I'm sure to keep in mind would be these people could have an elevated potassium level, and if you end up having to use succinylcholine and induce them for general anesthesia, obviously you need to be aware of that.
Speaker 1
Exactly. And then you would use a long-acting neuromuscular in the studying of difficult airway. So these can be very challenging patients, and really, if time warrants a system-by-system evaluation plan, it's probably prudent.
Speaker 2
Right. And I will just say that because I just did it the other day, not for a pregnant patient, but I've talked about this on another podcast, but a great option, if for some reason you can't use succinylcholine like hyperkalemia, and either you can't or don't want to use a longer-acting neuromuscular blocker like rockuronium, then you can use actually a relatively high dose of remifentanyl and propylol. So the dose I use is 4 mics per kilo of remi, and then something between 2 and 3 mg per kilogram of propylol, and that gives you pretty similar intubating conditions compared to succes and propylol. (Time 0:53:34)