ACE Review - OB Flashcards
Risk factors for PDPH
Age 20-40,female,spinals, cutting needles.
Highest risk factor for PDPH
Age
When should non ob surgery be done for obstetrics pt.
Recommended to be done after pregnancy, but if required to be dine, then in the second trimester.
Why is the second term the best time for pregnant patients who cannot postpone past pregnancy
Avoids the spontaneous abortions of first trimester and the premature contractions of the third trimester
If a fetus is previable, how do you monitor intraop
A pre and post op Doppler of fetal heart rate
If a fetus is viable, how do you monitor intraop
A pre and post fetal heart monitor and contraction monitor pre and post.
What was the concern of diazepam/ bentos in a past retrospective study on teratogenesis
Cleft palate
What is the concern about using nitrous oxide in obstetric patients.
It inhibits methionine synthase activity involved in DNA synth
does nitrous oxide decrease uterine tone
no
do anesthetic gases decrease uterine tone
yes
does epidural medication provide uterine relaxation
no
a pt w/ retained placenta. Bp and hr stable…what can help to give uterine relaxation.
intravenous nitrous 50-100mcg
what other uterine relaxants can you use
magnesium or terbutaline
what sensory level do you need to have for analgesia of retained placenta removal proceedure
at least t10
what happens to intestinal motility during pregnancy
drecrease motility
what happens to LES during pregnancy
decrease LES
what happens to gastric volume during pregnancy
increased
when dose gastric emptying during pregnancy get delayed
not until the onset of labor
does decrase intestinal motility only occur after the onset of labor like gastric emptying
no it starts right at the first trimester
what is the onset and end of first stage of labor
onset is dilation of cervix, end of first stage is full cervix dilation
what nerve fibers is the pain of first stage of labor
t10 to l1
what causes the pain during first stage of labor
cervix dilation
how do you know first stage of labor pain is not cause by uterine fundus contraction and actually cervix dilation
during labor, nerve fibers to uterine fundus is decreased
is pain of the first stage of labor somatic or visceral
visceral
what is the onset of second stage of labor,
when the fetus engages the vagina
what is the cause of second stage pain
vagina and perinium
what is the second stage nerve for pain
pudendal
what is the nerve source of pudendal
s2-s4
what kind of pain is second stage pain
somatic takes over the visceral pain of stage 2
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why is amniotic fluid embolism a misnomer
because it is not a real clot, it is just amniotic fluid causing pulmonary artery to vasospasm
what cardiac manifestation will make you more concerned for amniotic fluid emboism
elevated PA pressures
how did they find out that afe is cause by pulm aa vasosopasm
this is what is seen in TEE
what is the main co-pathology that occurs with AFE
DIC
if a pt is developing coagulopathy with AFE, should you heparinize the pt?
no, you should stop the bleeding…it takes priority…bc the pt is not a true emboism…transfusion of prbc ffp and plt and cryo needed to stop bleeding will end the DIC
what lab work will drop precipituously in afe
drop of fibrinogen
how to help the drop in fibrinogen?
cryo should be given early in afe pts
what is hemabate
prostaglandin F2A
what is a side effect of prostaglandin f2a
it causes pulm htn
can you use prostaglandin f2a in an AFE pt bleeding
actually it might worsen pulm htn and worsen right heart failure
what is the purpose of measureing the fetal cord gas
it tells you how well the fetus did before delivery
what vessel is better at determining fetal well being
the umbilical arter is better than the 2 umbilical viens
which baby will have a better umbilical artery pH, a post vag or a post c/s
a post c/s
what is a normal fetal umbilica aa blood gas
7.26, pco2 50, po2 20, be -3, hco3 22
what is considered acidosis it fetal blood gas
pH less than 7.2
what is the first step in interpreting fetal umbilica aa blood gas
look for the type of acidemia….respiratory versus metabolic
what is worse for the baby, resp acidosis or metabolic acidosis
metabolic acidosis
what is seen in fetal metab acidosis
low pH, elevated base excess and drop in hc03
what is gluteal pain that occurs after a spinal
possibly TNS
what anesthestic is assoc w TNS
lidocaine…has a 7x greater risk of getting tns than other anesthetics
when does tns occur
24hrs after spinal
when does tns resolved
after 72 hrs
is tns a permanent nerve injury
no it is only transient
is TNS associated with dosing of the lidocaine or its concentration
no it is not dependant on dose or concentration
what predisposes pt to TNS other than getting lidocaine for spinal
type or surgeruy…usually gyn cases in lithotomy position
how much more does lithotomy position predisopose pt to tns
lithotomy has 30% risk rate of tns vs 4% risk rate of supine cases
what is the treatment for TNS
opiods, NSAIDS, muscle spasm relaxants
what is the etiology of TNS
still unknown
how many ob patients who have eisenmengers die
30-40% die bc they have fixed cardiac funx
what 2 things may happened during surgery that may worsen a pregos eisenmengers right to left shunt
increase in pulm vasc resistance or decrease in svr
what increases pulm vasc resistnace
can get pulm vascular resistance 2ndry to hypercarb, hypoxia, acidosis
what can cause svr drop in eisenmengers pregos
neuralaxial block using local anesthetic
what should be included in eisenmengers preos anesthesia plan
invasive lines for bp and volume status checking
can you use epinephrine in neuraxial block for eisenmenger prego pt
no…not recommended…epi has beta 2 effect that can vasodilate and drop svr
What are the 3 cardiovascular changes in pregnancy
Decreased SVR, increased cardiac output, increased vascular volume
Why does svr decrease in pregnant patients?
Because of the effects of estrogen and progesterone. The increase in vascular beds also decrease the SVR
Is cvp increased or decreased in pregnancy
Even though you get increase in plasma volume, there is also an increase in vascular beds that causes No increased in cvp
What happens to minute ventilation in pregnancy
There is an increase in minute ventilation
How does minute ventilation increase in pregnancy
Tidal volume and respiratory rate…the increase is mainly due to an increase of tidal volume
According to ACOG, what is not recommended in patients with a previous history of c sec or major uterine surgery.
Misoprostol
According to level b recommendations, should a history of 2 c sec be a contraindication for a trial of labor after csec
No it is not a contraindication
According to level b recommendation should a twin pregnancy after 1 csec go for trial of labor
It is not a contraindication
If a pt had a low transverse c sec and a breech presentation, can they still have a. Trial of labor after c sec
Yes according to level b recommendations of ACOG
Who are candidates that cannot have trial of labor after c section
Placenta Previa, history of uterine rupture, previous classical uterine incision,
What are strong predictors of a successful vbac
Spontaneous labor and history of a successful vbac
According to level b recommendations of ACOG. Is it a contraindication to induce labor
Induction is not a contraindication
Is an epidural a contraindication in vbac patients
No…epidural will not mask uterine rupture…which is a misconception of epidurals
What is the most common sign of uterine rupture
Fetal heart rate abnormalities
How many predictors are there of decrease success of a vbac
8
What is one of the 8 predictors that discuss timing of pregnancy
Decrease probability of successful vbac if interpregnancy time is less than 19 months
What 2 of the 8 predictors talk about the baby
If the baby is macrosomia or gestational age is greater than 40wk, then there is less likelihood that the vbac will be successful
What are 5/8 predictors of a less likelihood for successful vbac dealing with maternal qualities
- If her previous csec was because of shoulder dystocia, 2. If she is advance maternal age, 3. Preeclampsia, 4. Maternal obesity, 5. Nonwhite
What is the mortality rate in trial of labor after c sec compared to repeat csec
Decrease mortality
What is the rate of hysterectomy comparing tolac to repeat csec
Rate of hysterectomy is the same in both groups
Comparing between tolac to repeat csec, who is more likely to get blood transfusion
Same in both groups
How is the length of hospital stay comparing tolac to repeat csec
Tolac had decrease hospital stay
How is the rate of DVT comparing tolac to repeat csec
Tolac has a decrease rate of dvt
How is the rate of uterine rupture comparing tolac to repeat csec
Tolac has a clear increase of rate of uterine rupture
How is the perinatal mortality comparing tolac to repeat csec
There is an increase rate of perinatal mortality for tolac
What is the sensory block needed for csec
About t4 to s4
is epidural in ob patient assoc with maternal fever above 38
yes
What are the risk factors for pdph?
Age 20-30, history of pdph, low opening pressures after dural puncture, female gender, lower him
What is the most significant risk factor for pdph
Age 20-30
Does a history of migranes increase risk for pdph
No
What is the minute ventilation in pregnancy
Increased
What causes the increase in minute ventilation in pregnancy
Progesterone and increased co2 production
What mechanism does the increase in minute ventilation
Tidal volume
What is the end result of increase in minute ventilation in pregnancy
The increase minute ventilation overpowers the production of CO2 and ends up with respiratory alkalosis.
How does pregnant patients deal with respiratory alkalosis
The kidneys preserve H+ and excretes excess bicarb
What happens to pregnant frc
Decrease in frc
When do pregnant get decrease in frc
After 12 weeks
what volumes are decreased in obesity
vital capacity, expiratory reserve volume, frc, total lung capacity
what do lungs of obesity mimic
restrictive lung disease
what volume is increased in obesity
closing capacity
what happens to the pft of obesity
decreased fev1 and fvc
what does supine positiion in obese pt cause
increase closing capacity, decrease frc,
A pregnant patient has prolong Prothrombin Time, Significant decrease Anti-Thrombin Three, Hypoglycemia. Increase LFTs
acute fatty liver disease in pregnancy
Mechanism in acute fatty liver disease
Fetus has deficiency in liver enzyme called LongchainThree hydroxy acyl CoA dehydrogenase
why may diagnosis of acute fatty liver disease be Delayed
40% of the time they are associated with preeclampsia
What is the treatment of acute buddy liver disease and pregnancy
Correct the hypoglycemia, supportive care,delivery of the baby
When does acute fatty liver disease and pregnancy present
Usually third trimester
What other problems of acute fatty liver disease is present that is emergency
DIC
What is the anesthetic management of choice for pain in obstetric patients with aortic regurgitation
Labor epidural
Why is labor epidural anesthetic management choice for AR in ob patience
The goal is to have forward flow through the aortic valve. labor epidural decreases SvR allowing for flow
Is phenylephrine a vasopressor of choice for AR ob. patients
No it will increase SVR. ephedrine is the pressure of choice
In patients with cardiac lesions, Is it necessary to use Endocarditis prophylaxis in vaginal or C-section
And a carditis prophylaxis is not indicated in vaginal or C-section Even if the patient has cardiac lesions
What is The initial goal for inverted uterus
Uterine relaxation
What drug can be given for uterine relaxation
Intravenous nitroglycerin
What if nitroglycerin fails what other agent can be used
inheld anesthetics
After uterine relaxation of an inverted uterus what is the second goal of treatment
Utero tonic
Amniotic fluid embolism… What is the common clinical presentation
Hypoxia, hypotension, altered mental, dic
Amniotic fluid embolism… Wat percent of labor mortality is related to afe?
12 percent
Amniotic fluid embolism…when do these patients die
1/4 die in the first hour, 2/3 die within 5 house
Amniotic fluid embolism…what test can you do to check for afe
None. There is no current test
inverted uterus…what is the quickest way to get uterine relaxation
intravenous nitroglycerine
inverted uterus…what is the nitroglycerine dose
50-200mcg
inverted uterus…what is the speed of nitroglycerine
within 1 minute
inverted uterus…what should be given once inversion is fixed
uterotonics
inverted uterus…what is a second line treatment
halogented gases
inverted uterus…why is halogenated gases second line treatment
because it requires ETT…which requires time…ett is required because pregos are full stomachs
inverted uterus…can magnesium be used for uterus relax?
no…the dose is 4-6 g in 20 mins…and it has long lasting effectts….this makes it not an ideal agent
inverted uterus…can u use propofol
no…it has no uterine tonicity effect
aortic regurg. what is the most common cause in pregos
bicusp aortic valve
aortic regurg. what is the goal
prevent pain because it increases svr
aortic regurg. what is the anesthetic management
labor epidural…it can help do rapid and relax
aortic regurg. what is the pressor of choice
ephedrine is better than phenylephrine
Cardiac. Of all the cardiovascular parameters, which decreases in pregnancy
Svr decreases
Cardiac. Of all the cardiovascular parameters. What increase in pregnancy.
Hr, stroke volume, CO, blood volume, left ventricle mass
Cardiac. When is the cardiac output greatest in pregnancy.
Right after the postpartum period. Up to 75% increase.
Cardiac. What card lesion is well tolerated in pregnancy.
Mitral regurgitation because both the tachycardia and decrease svr helps forward flow.
decelerations. what are late decelerations
begin after peak of contraction and resolve 10-30 sec afterwards
decelerations. what is a cause of deceleration commonly
uteroplacental insufficiency
deceleration. what condition has uteroplacental insufficiency commonly causing late decelerations
preeclampsia
deceleration. what is early
head compression causing reflex vagal response
deceleration. what is the cause of varible deceleration
umbilical cord compression
fetal heart tracing. what does variability represent
fetal well being
Preeclampsia. Hypertension. How does hydralazine work
It is a veno dilator.
Preeclampsia. Hypertension. What are the side effects to the mom
Hypotension.
Preeclampsia. Hypertension. What are the side effects to the neonate with hydralazine.
Thrombocytopenia and lupus like syndrome.
Preeclampsia. Hypertension. What is good about labetalol.
It has both alpha 1 and beta blockade. This allows for decrease Bp without reflex tachycardia.
Preeclampsia. Hypertension. How long does labetalol work.
Peak effect is 20 minutes, but duration is up to 6 hours.
Preeclampsia. Hypertension. What is the side effect of nitro glycerine.
Headaches
Preeclampsia. Hypertension. What is the risk associated with nitroprusside.
It can develop cyanide toxicity in neonate if prolong use
Preeclampsia. Hypertension. What is the risk of using ACE inhibitors in pregnancy.
Neonate craniofacial abnormalities, pulmonary hypoplasia. Renal tubular dysplasia
Preeclampsia. Hypertension. Is the magnesium enough for treatment of hypertension.
No it will not be sufficient. If you use too much, there is risk for mg toxicity.
Cardiac arrest. At what gestation should wedge be placed during acls.
After 20 weeks where aortocaval compression can occur.
Cardiac arrest. At what age of gestation should bedside csec be considered
After 24 weeks when neonate is considered viable.
Cardiac arrest. If ventricular fibrillation occurs what should be done
Defibrillator.
Cardiac arrest. What joules should be used in a preggos
Same as non preggos. The fetal heart needs a lot higher current to cause dysrythmia.
respiratory physiology. what is increased in pregnancy
tidal volume
respiratory physiology. how is the minute ventilation increased the most by in pregnancy
tidal volume has the biggest contribution
respiratory physiology. when is the increased minute ventilation
apparent after the first trimester
respiratory physiology. what does the increase minute ventilation do to the pH
normally it makes the ph more alkalotic…aka around 7.4
respiratory physiology. what is the increase minute ventilation on the pco2
there is a decrease to about 30 for pco2
respiratory physiology. what is the bodies way to compensate for the decrease in pco2
the kidneys kick out bicarb down toward 20
respiratory physiology. if you look at an abg and you see a pao2 greater than 100, what can u assume about the pt if she is otherwise normal
she is sitting upright
respiratory physiology. if you look at an abg and you see a pao2 less than 100, what can you assume about the pt if she is otherwise normal
she is supine
respiratory physiology. what does the pao2 greater than 100 tell you about the cardiac function of a pregnant pt
the increase in cardiac output in a pregnant pt is greater than the increase in oxyen consumption in a pregnant pt…this is an evolutionary defense mechanism to prevent lactic acidosis it pregnancy
late decelerations and hypotension. what should first be done.
give maternal oxygen and left uterine displacement
late decelerations. and hypotension. if the pt has an appropriate level of epidural control. should u stop the pump first or give vasopressor first
vasopressor first. (depending on heart rate …ephed vs phenyl) then fluids…no need to turn off epidural bc the pain that mom feels may compromise uteroplacental perfusion bc increase catecholamine release
late decelerations and hypotension. what else can be done. besides giving pressors and fluids
tocolysis…stop all drips that are causing contraction like oxytocin bc uterine contraction may also decrease perfusion to placenta
late decelerations and hypotension. when is c-section necessary.
when resuscitative measures do not improve late decels
intrathecal opiods. when is resp depression most common
when intrathecal opiods are given follow a previou dose of oral/iv opiods…but understand that even this is not common
intrathecal opiods. how common is puritis
50% of pts get this
placenta. what is accreta
into the myometrium
placenta. what is increta
through the entire myometrium
placenta. what is percreta
pass serosa and possibly into pelvic structures
placenta. what is the blood flow rate
600-750cc/ hr
labor pain. what kind of pain is the first stage
visceral. due to uterine contraction and cervical dilation
labor pain. what kind of pain is the second stage
somatic pain. due to vaginal and pelvic floor dilation
labor pain. what kind of block can u do for first stage of labor
epidural, lumbar sympathetic, paracervical
labor pain. what kind of block can u do for the second stage of labor
once first stage blocks, are done, you can add pudendal
labor pain. what is associated with paracervical block
fetal brady cardia. thats why this is not used n e more
placenta transfer. local anesthetics. does molecular weight affect its transfer through
when comparing local anesthetics. all have low molec wt. so molec weight is not a significant factor when comparing local anes to eachother
placenta transfer. local anesthetics. how does protein binding affect local anes transfer
the more you are bound the less you cross to fetus
placenta transfer. local anesthetics. what are the highest protien bound local anes
ropivicaine most and then marcaine
placenta transfer. local anesthetics. what kind of bases or acids are they
they are weak bases
placenta transfer. local anesthetics. how does pka of these weak bases affect their transfer to fetal side
local anesthetics…have pka 7.8-8.1…they are baseline non-ionized…when put into body ph 7.4, environment makes it protinated…ionized w a + charge…and now ionized.
placenta transfer. local anesthtics. what has the greatest effect on local anes transfer to fetal side
amount of protein binding
placenta transfer. local anesthetics. what are amids
amides have 2 I’s in their name
placenta transfer. local anesthetics. what are esters
they only have 1 I in their name …chloroprocain and tetraciane
