Pseudo-epileptic fits were observed a number of times. Only in
two cases the more severe muscle rigidity and respiratory arrest
occurred:
Case 1: A small girl of 16 years comes for
termination of a seven weeks pregnancy. After applying the local
anaesthetic she starts shaking violently as if she has an epileptic
fit. Eventually she lays rigidly on the table, unconscious, with
maximally bent arms and legs Breathing ceases because of muscle
rigidity and she turns blue. Immediately 10 mg of diazepam is
injected intravenously, because of the bent arms into a jugular vein.
Within seconds she relaxes completely and starts breathing deeply and
regularly, still unconscious. Aspiration is done while she is
unconscious The termination is uneventful. Shortly afterwards she
regains consciousness but she remains drowsy. After about two hours
she leaves the clinic in good condition.
Case 2: A forty year old woman with a 16 weeks
pregnancy gets the same symptoms as the girl of case 1. Before
allowing respiratory arrest to develop she is given diazepam in a
jugular vein and she relaxes within seconds. Aspiration is uneventful
and she leaves the clinic after twenty minutes without problems.
Occasionally a patient is allergic for the local anesthetic. This
may lead to serious and even fatal complications. The authors have
never seen one. But it is wise to have an injectable corticosteroid
ready. During anamnesis the existence of allergies, particularly for
local anesthetics, should be asked.
GENERAL ANESTHESIA - Up to 1999 the only absolute indication for general
anesthesia is vaginism. Relative indications are extreme anxiety and
the patients wish not to be confronted with the procedure. For the
abortion procedure intravenous administration of all medicines for
anesthesia is recommended. Experience in the Netherlands over many
thousands of cases without a single fatality or serious side effects
proves that it is safe and almost always sufficient. In the new century new anesthetic drug became available which are safe and shortacting . The use of propofol is prefered in most clinics. Before van den Bergh prefered etomidate which gives more time to work quietly. Propofol must be substituted after a few minutes. Both can be administered without artificial breathing.
It is recommended to have a special trolley for anesthesia.
Filled syringes may be prepared in advance. To avoid mistakes all
syringes must be labeled. Small colored labels are readily available.
Some medicines are packed with suitable labels. All administrations
are recorded in an anesthesia book or on a form which is added to the
patient's file.
Obsolete are the barbiturates. Ketamine gives an excellent
anesthesia. Major surgery is possible with Ketamine and diazepam
alone. But in an abortion clinic it is undesirable for the duration
and the frequent occurrence of hallucinations. Propofol acts very
short and should be administered by another doctor.
Often etomidate is used. Injection of etomidate without proper
premedication leads to a pseudo epileptic insult due to cortical
inhibition. It looks quite alarming but it is not dangerous and
easily prevented by premedication of 2.5 mg's diazepam or midazolam.
If not combined with local anesthesia the premedication should
include a powerful analgesic like one of the new fentanyl family members, (alfentanil or remifentanil). Fentanyl is not given anymore as it may cause a prolonged drowsiness.To prevent vomiting the
patient must be instructed not to eat some six hours before the
procedure. The patient must always be asked to remove anything from
her mouth, like false teeth. In a surprising number of cases we had
to instruct the patient to remove her chewing gum.
Some five minutes after injecting the premedication, which five
minutes can be used for the vaginal toilet and to arrange the
instruments, 7 or 8 ml of etomidate is injected, immediately before
the start of the procedure. If the woman awakes the injection may be
repeated in lower doses. Up till 30 ml may be administered without
danger. If the patient reacts disturbingly on the treatment without
being fully awake the anesthesia is too light for her. In that case
it is advisable to inject an extra dose of a suitable sedative rather
than giving more etomidate. If vomiting occurs (seldom if the patient
is starved), droperidol should be given. Immediately after injecting
etomidate the patient may cease breathing. This is not alarming (and
can be prevented bu slower injecting) within a few minutes normal
breathing is resumed.
In Holland, since a couple of years, we use a safe and effective
combination of 1 mg of alfentanil and 5 mg's of midazolam given
intravenously. ('rapidorm')
Some psychic instability may occur after the use of propofol,
with crying or euphoria. Some drugs cause amnesia and the patient may
forget that she has been treated. Don't forget to tell the patient
that her treatment is finished. In a number of cases when this was
neglected the woman was anxiously waiting for her turn without
realizing that she had already been treated.
Injection of etomidate (or fentanyl) into an artery leads to
ischemia caused by vasoconstriction. In literature a few cases are
described. Generally infusion of saline into the artery is
recommended. It happened twice in Schlebaums clinic. The first case
is reported below, the patient recovered without any specific
therapy.
When using etomidate and a mild premedication the patient may be
awake soon after the procedure and generally she can walk with some
assistance. Often the anaesthesia continues into natural sleep, the
patient readily wakes up if called.