ob

Why Shiver?

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Notes from Truelearn and UpToDate on Shivering in OB

Shivering during labor

  • 10-20% of laboring patients without epidural, 30-55% with epidural
  • multifactorial
  • hormonal changes: less progesterone than normal cycle results in less NE -> less augmentation of core temps
  • immunological reaction to fetomaternal transfusion
  • use of Misoprostol
  • possibly non-thermogenic: bursting tremor similar to clonus
  • Epidural shivering from central hypothermia and peripheral vasoconstriction
  • First hour with an epidural: core heat -> periphery 2/2 neuraxial blunt autonomic thermoregulatory below level of blockade, vasodilation causes redistribution of heat

Prevention and Treatment

  • Warming prior to epidural/spinal placement can decrease shivering
  • Warming after shivering
  • Dopaminergic/seretonergic pathway drugs can reduce shivering (25mg IV Meperidine (demerol), clonidine, tramadol, ketamine, dexmedatomidine)

Quick Hit: Myotonic Dystrophy

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Myotonic Dystrophy
Quick hit notes from QBanks and Obstetric Anesthesia and Uncommon Disorders

-autosomal dominant CTG-trinucleotide repeat
-impaired muslce relaxation
-Succinycholine –> excessive fasciulations, difficult intubation
-restrictive lung disease -> P/O resp failure
-poor cough/pharyngeal muscle dysynch. -> aspiration/PNA
-imparied response to hypoxia and hypercarbia (senstive to opioids, benzos, barbs, inh)
-comorbidities include: cardiomypathy/dysrhythmias/av block, DM, adreneal insufficiency, thyroid dysfx
-OB pt with MD: increased heart failure risk and myotonic crisis, also increased is placenta accreta, failed labor
-Monitoring: Myotnoia can appear as sustainaed tetanus (even if there is actually sig blockade) -> too early extubations
-MYOTONIC CRISIS: marked contracture of skeletal muscles, 2-3+minutes, ventilation compromised, NOT relieved by nerve block/nmbd/GA
-Prevent Crisis: Warm patient, handle muscles gently, avoid succ and shivering
-Treat Crisis: Procainamide (100mg/min to 1g caution with conduction defects), dantrolene, phenytoin (if localized only, some suggest direct injection of local anesth into muscle)
Plan: avoid succ, easy on resp depressant meds, no superior regional vs. GA