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ACE Review - OB Flashcards

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1
Q

Risk factors for PDPH

A

Age 20-40,female,spinals, cutting needles.

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2
Q

Highest risk factor for PDPH

A

Age

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3
Q

When should non ob surgery be done for obstetrics pt.

A

Recommended to be done after pregnancy, but if required to be dine, then in the second trimester.

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4
Q

Why is the second term the best time for pregnant patients who cannot postpone past pregnancy

A

Avoids the spontaneous abortions of first trimester and the premature contractions of the third trimester

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5
Q

If a fetus is previable, how do you monitor intraop

A

A pre and post op Doppler of fetal heart rate

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6
Q

If a fetus is viable, how do you monitor intraop

A

A pre and post fetal heart monitor and contraction monitor pre and post.

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7
Q

What was the concern of diazepam/ bentos in a past retrospective study on teratogenesis

A

Cleft palate

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8
Q

What is the concern about using nitrous oxide in obstetric patients.

A

It inhibits methionine synthase activity involved in DNA synth

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9
Q

does nitrous oxide decrease uterine tone

A

no

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10
Q

do anesthetic gases decrease uterine tone

A

yes

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11
Q

does epidural medication provide uterine relaxation

A

no

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12
Q

a pt w/ retained placenta. Bp and hr stable…what can help to give uterine relaxation.

A

intravenous nitrous 50-100mcg

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13
Q

what other uterine relaxants can you use

A

magnesium or terbutaline

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14
Q

what sensory level do you need to have for analgesia of retained placenta removal proceedure

A

at least t10

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15
Q

what happens to intestinal motility during pregnancy

A

drecrease motility

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16
Q

what happens to LES during pregnancy

A

decrease LES

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17
Q

what happens to gastric volume during pregnancy

A

increased

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18
Q

when dose gastric emptying during pregnancy get delayed

A

not until the onset of labor

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19
Q

does decrase intestinal motility only occur after the onset of labor like gastric emptying

A

no it starts right at the first trimester

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20
Q

what is the onset and end of first stage of labor

A

onset is dilation of cervix, end of first stage is full cervix dilation

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21
Q

what nerve fibers is the pain of first stage of labor

A

t10 to l1

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22
Q

what causes the pain during first stage of labor

A

cervix dilation

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23
Q

how do you know first stage of labor pain is not cause by uterine fundus contraction and actually cervix dilation

A

during labor, nerve fibers to uterine fundus is decreased

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24
Q

is pain of the first stage of labor somatic or visceral

A

visceral

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25
Q

what is the onset of second stage of labor,

A

when the fetus engages the vagina

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26
Q

what is the cause of second stage pain

A

vagina and perinium

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27
Q

what is the second stage nerve for pain

A

pudendal

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28
Q

what is the nerve source of pudendal

A

s2-s4

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29
Q

what kind of pain is second stage pain

A

somatic takes over the visceral pain of stage 2

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30
Q

xxxxxxxxxxxxxxxxxxxxxxxxxx

A

xxxxxxxxxxxxxxxxxxxxxxxxxx

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31
Q

why is amniotic fluid embolism a misnomer

A

because it is not a real clot, it is just amniotic fluid causing pulmonary artery to vasospasm

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32
Q

what cardiac manifestation will make you more concerned for amniotic fluid emboism

A

elevated PA pressures

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33
Q

how did they find out that afe is cause by pulm aa vasosopasm

A

this is what is seen in TEE

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34
Q

what is the main co-pathology that occurs with AFE

A

DIC

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35
Q

if a pt is developing coagulopathy with AFE, should you heparinize the pt?

A

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

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36
Q

what lab work will drop precipituously in afe

A

drop of fibrinogen

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37
Q

how to help the drop in fibrinogen?

A

cryo should be given early in afe pts

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38
Q

what is hemabate

A

prostaglandin F2A

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39
Q

what is a side effect of prostaglandin f2a

A

it causes pulm htn

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40
Q

can you use prostaglandin f2a in an AFE pt bleeding

A

actually it might worsen pulm htn and worsen right heart failure

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41
Q

what is the purpose of measureing the fetal cord gas

A

it tells you how well the fetus did before delivery

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42
Q

what vessel is better at determining fetal well being

A

the umbilical arter is better than the 2 umbilical viens

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43
Q

which baby will have a better umbilical artery pH, a post vag or a post c/s

A

a post c/s

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44
Q

what is a normal fetal umbilica aa blood gas

A

7.26, pco2 50, po2 20, be -3, hco3 22

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45
Q

what is considered acidosis it fetal blood gas

A

pH less than 7.2

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46
Q

what is the first step in interpreting fetal umbilica aa blood gas

A

look for the type of acidemia….respiratory versus metabolic

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47
Q

what is worse for the baby, resp acidosis or metabolic acidosis

A

metabolic acidosis

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48
Q

what is seen in fetal metab acidosis

A

low pH, elevated base excess and drop in hc03

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49
Q

what is gluteal pain that occurs after a spinal

A

possibly TNS

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50
Q

what anesthestic is assoc w TNS

A

lidocaine…has a 7x greater risk of getting tns than other anesthetics

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51
Q

when does tns occur

A

24hrs after spinal

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52
Q

when does tns resolved

A

after 72 hrs

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53
Q

is tns a permanent nerve injury

A

no it is only transient

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54
Q

is TNS associated with dosing of the lidocaine or its concentration

A

no it is not dependant on dose or concentration

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55
Q

what predisposes pt to TNS other than getting lidocaine for spinal

A

type or surgeruy…usually gyn cases in lithotomy position

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56
Q

how much more does lithotomy position predisopose pt to tns

A

lithotomy has 30% risk rate of tns vs 4% risk rate of supine cases

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57
Q

what is the treatment for TNS

A

opiods, NSAIDS, muscle spasm relaxants

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58
Q

what is the etiology of TNS

A

still unknown

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59
Q

how many ob patients who have eisenmengers die

A

30-40% die bc they have fixed cardiac funx

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60
Q

what 2 things may happened during surgery that may worsen a pregos eisenmengers right to left shunt

A

increase in pulm vasc resistance or decrease in svr

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61
Q

what increases pulm vasc resistnace

A

can get pulm vascular resistance 2ndry to hypercarb, hypoxia, acidosis

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62
Q

what can cause svr drop in eisenmengers pregos

A

neuralaxial block using local anesthetic

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63
Q

what should be included in eisenmengers preos anesthesia plan

A

invasive lines for bp and volume status checking

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64
Q

can you use epinephrine in neuraxial block for eisenmenger prego pt

A

no…not recommended…epi has beta 2 effect that can vasodilate and drop svr

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65
Q

What are the 3 cardiovascular changes in pregnancy

A

Decreased SVR, increased cardiac output, increased vascular volume

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66
Q

Why does svr decrease in pregnant patients?

A

Because of the effects of estrogen and progesterone. The increase in vascular beds also decrease the SVR

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67
Q

Is cvp increased or decreased in pregnancy

A

Even though you get increase in plasma volume, there is also an increase in vascular beds that causes No increased in cvp

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68
Q

What happens to minute ventilation in pregnancy

A

There is an increase in minute ventilation

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69
Q

How does minute ventilation increase in pregnancy

A

Tidal volume and respiratory rate…the increase is mainly due to an increase of tidal volume

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70
Q

According to ACOG, what is not recommended in patients with a previous history of c sec or major uterine surgery.

A

Misoprostol

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71
Q

According to level b recommendations, should a history of 2 c sec be a contraindication for a trial of labor after csec

A

No it is not a contraindication

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72
Q

According to level b recommendation should a twin pregnancy after 1 csec go for trial of labor

A

It is not a contraindication

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73
Q

If a pt had a low transverse c sec and a breech presentation, can they still have a. Trial of labor after c sec

A

Yes according to level b recommendations of ACOG

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74
Q

Who are candidates that cannot have trial of labor after c section

A

Placenta Previa, history of uterine rupture, previous classical uterine incision,

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75
Q

What are strong predictors of a successful vbac

A

Spontaneous labor and history of a successful vbac

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76
Q

According to level b recommendations of ACOG. Is it a contraindication to induce labor

A

Induction is not a contraindication

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77
Q

Is an epidural a contraindication in vbac patients

A

No…epidural will not mask uterine rupture…which is a misconception of epidurals

78
Q

What is the most common sign of uterine rupture

A

Fetal heart rate abnormalities

79
Q

How many predictors are there of decrease success of a vbac

A

8

80
Q

What is one of the 8 predictors that discuss timing of pregnancy

A

Decrease probability of successful vbac if interpregnancy time is less than 19 months

81
Q

What 2 of the 8 predictors talk about the baby

A

If the baby is macrosomia or gestational age is greater than 40wk, then there is less likelihood that the vbac will be successful

82
Q

What are 5/8 predictors of a less likelihood for successful vbac dealing with maternal qualities

A
  1. If her previous csec was because of shoulder dystocia, 2. If she is advance maternal age, 3. Preeclampsia, 4. Maternal obesity, 5. Nonwhite
83
Q

What is the mortality rate in trial of labor after c sec compared to repeat csec

A

Decrease mortality

84
Q

What is the rate of hysterectomy comparing tolac to repeat csec

A

Rate of hysterectomy is the same in both groups

85
Q

Comparing between tolac to repeat csec, who is more likely to get blood transfusion

A

Same in both groups

86
Q

How is the length of hospital stay comparing tolac to repeat csec

A

Tolac had decrease hospital stay

87
Q

How is the rate of DVT comparing tolac to repeat csec

A

Tolac has a decrease rate of dvt

88
Q

How is the rate of uterine rupture comparing tolac to repeat csec

A

Tolac has a clear increase of rate of uterine rupture

89
Q

How is the perinatal mortality comparing tolac to repeat csec

A

There is an increase rate of perinatal mortality for tolac

90
Q

What is the sensory block needed for csec

A

About t4 to s4

91
Q

is epidural in ob patient assoc with maternal fever above 38

A

yes

92
Q

What are the risk factors for pdph?

A

Age 20-30, history of pdph, low opening pressures after dural puncture, female gender, lower him

93
Q

What is the most significant risk factor for pdph

A

Age 20-30

94
Q

Does a history of migranes increase risk for pdph

A

No

95
Q

What is the minute ventilation in pregnancy

A

Increased

96
Q

What causes the increase in minute ventilation in pregnancy

A

Progesterone and increased co2 production

97
Q

What mechanism does the increase in minute ventilation

A

Tidal volume

98
Q

What is the end result of increase in minute ventilation in pregnancy

A

The increase minute ventilation overpowers the production of CO2 and ends up with respiratory alkalosis.

99
Q

How does pregnant patients deal with respiratory alkalosis

A

The kidneys preserve H+ and excretes excess bicarb

100
Q

What happens to pregnant frc

A

Decrease in frc

101
Q

When do pregnant get decrease in frc

A

After 12 weeks

102
Q

what volumes are decreased in obesity

A

vital capacity, expiratory reserve volume, frc, total lung capacity

103
Q

what do lungs of obesity mimic

A

restrictive lung disease

104
Q

what volume is increased in obesity

A

closing capacity

105
Q

what happens to the pft of obesity

A

decreased fev1 and fvc

106
Q

what does supine positiion in obese pt cause

A

increase closing capacity, decrease frc,

107
Q

A pregnant patient has prolong Prothrombin Time, Significant decrease Anti-Thrombin Three, Hypoglycemia. Increase LFTs

A

acute fatty liver disease in pregnancy

108
Q

Mechanism in acute fatty liver disease

A

Fetus has deficiency in liver enzyme called LongchainThree hydroxy acyl CoA dehydrogenase

109
Q

why may diagnosis of acute fatty liver disease be Delayed

A

40% of the time they are associated with preeclampsia

110
Q

What is the treatment of acute buddy liver disease and pregnancy

A

Correct the hypoglycemia, supportive care,delivery of the baby

111
Q

When does acute fatty liver disease and pregnancy present

A

Usually third trimester

112
Q

What other problems of acute fatty liver disease is present that is emergency

A

DIC

113
Q

What is the anesthetic management of choice for pain in obstetric patients with aortic regurgitation

A

Labor epidural

114
Q

Why is labor epidural anesthetic management choice for AR in ob patience

A

The goal is to have forward flow through the aortic valve. labor epidural decreases SvR allowing for flow

115
Q

Is phenylephrine a vasopressor of choice for AR ob. patients

A

No it will increase SVR. ephedrine is the pressure of choice

116
Q

In patients with cardiac lesions, Is it necessary to use Endocarditis prophylaxis in vaginal or C-section

A

And a carditis prophylaxis is not indicated in vaginal or C-section Even if the patient has cardiac lesions

117
Q

What is The initial goal for inverted uterus

A

Uterine relaxation

118
Q

What drug can be given for uterine relaxation

A

Intravenous nitroglycerin

119
Q

What if nitroglycerin fails what other agent can be used

A

inheld anesthetics

120
Q

After uterine relaxation of an inverted uterus what is the second goal of treatment

A

Utero tonic

121
Q

Amniotic fluid embolism… What is the common clinical presentation

A

Hypoxia, hypotension, altered mental, dic

122
Q

Amniotic fluid embolism… Wat percent of labor mortality is related to afe?

A

12 percent

123
Q

Amniotic fluid embolism…when do these patients die

A

1/4 die in the first hour, 2/3 die within 5 house

124
Q

Amniotic fluid embolism…what test can you do to check for afe

A

None. There is no current test

125
Q

inverted uterus…what is the quickest way to get uterine relaxation

A

intravenous nitroglycerine

126
Q

inverted uterus…what is the nitroglycerine dose

A

50-200mcg

127
Q

inverted uterus…what is the speed of nitroglycerine

A

within 1 minute

128
Q

inverted uterus…what should be given once inversion is fixed

A

uterotonics

129
Q

inverted uterus…what is a second line treatment

A

halogented gases

130
Q

inverted uterus…why is halogenated gases second line treatment

A

because it requires ETT…which requires time…ett is required because pregos are full stomachs

131
Q

inverted uterus…can magnesium be used for uterus relax?

A

no…the dose is 4-6 g in 20 mins…and it has long lasting effectts….this makes it not an ideal agent

132
Q

inverted uterus…can u use propofol

A

no…it has no uterine tonicity effect

133
Q

aortic regurg. what is the most common cause in pregos

A

bicusp aortic valve

134
Q

aortic regurg. what is the goal

A

prevent pain because it increases svr

135
Q

aortic regurg. what is the anesthetic management

A

labor epidural…it can help do rapid and relax

136
Q

aortic regurg. what is the pressor of choice

A

ephedrine is better than phenylephrine

137
Q

Cardiac. Of all the cardiovascular parameters, which decreases in pregnancy

A

Svr decreases

138
Q

Cardiac. Of all the cardiovascular parameters. What increase in pregnancy.

A

Hr, stroke volume, CO, blood volume, left ventricle mass

139
Q

Cardiac. When is the cardiac output greatest in pregnancy.

A

Right after the postpartum period. Up to 75% increase.

140
Q

Cardiac. What card lesion is well tolerated in pregnancy.

A

Mitral regurgitation because both the tachycardia and decrease svr helps forward flow.

141
Q

decelerations. what are late decelerations

A

begin after peak of contraction and resolve 10-30 sec afterwards

142
Q

decelerations. what is a cause of deceleration commonly

A

uteroplacental insufficiency

143
Q

deceleration. what condition has uteroplacental insufficiency commonly causing late decelerations

A

preeclampsia

144
Q

deceleration. what is early

A

head compression causing reflex vagal response

145
Q

deceleration. what is the cause of varible deceleration

A

umbilical cord compression

146
Q

fetal heart tracing. what does variability represent

A

fetal well being

147
Q

Preeclampsia. Hypertension. How does hydralazine work

A

It is a veno dilator.

148
Q

Preeclampsia. Hypertension. What are the side effects to the mom

A

Hypotension.

149
Q

Preeclampsia. Hypertension. What are the side effects to the neonate with hydralazine.

A

Thrombocytopenia and lupus like syndrome.

150
Q

Preeclampsia. Hypertension. What is good about labetalol.

A

It has both alpha 1 and beta blockade. This allows for decrease Bp without reflex tachycardia.

151
Q

Preeclampsia. Hypertension. How long does labetalol work.

A

Peak effect is 20 minutes, but duration is up to 6 hours.

152
Q

Preeclampsia. Hypertension. What is the side effect of nitro glycerine.

A

Headaches

153
Q

Preeclampsia. Hypertension. What is the risk associated with nitroprusside.

A

It can develop cyanide toxicity in neonate if prolong use

154
Q

Preeclampsia. Hypertension. What is the risk of using ACE inhibitors in pregnancy.

A

Neonate craniofacial abnormalities, pulmonary hypoplasia. Renal tubular dysplasia

155
Q

Preeclampsia. Hypertension. Is the magnesium enough for treatment of hypertension.

A

No it will not be sufficient. If you use too much, there is risk for mg toxicity.

156
Q

Cardiac arrest. At what gestation should wedge be placed during acls.

A

After 20 weeks where aortocaval compression can occur.

157
Q

Cardiac arrest. At what age of gestation should bedside csec be considered

A

After 24 weeks when neonate is considered viable.

158
Q

Cardiac arrest. If ventricular fibrillation occurs what should be done

A

Defibrillator.

159
Q

Cardiac arrest. What joules should be used in a preggos

A

Same as non preggos. The fetal heart needs a lot higher current to cause dysrythmia.

160
Q

respiratory physiology. what is increased in pregnancy

A

tidal volume

161
Q

respiratory physiology. how is the minute ventilation increased the most by in pregnancy

A

tidal volume has the biggest contribution

162
Q

respiratory physiology. when is the increased minute ventilation

A

apparent after the first trimester

163
Q

respiratory physiology. what does the increase minute ventilation do to the pH

A

normally it makes the ph more alkalotic…aka around 7.4

164
Q

respiratory physiology. what is the increase minute ventilation on the pco2

A

there is a decrease to about 30 for pco2

165
Q

respiratory physiology. what is the bodies way to compensate for the decrease in pco2

A

the kidneys kick out bicarb down toward 20

166
Q

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

A

she is sitting upright

167
Q

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

A

she is supine

168
Q

respiratory physiology. what does the pao2 greater than 100 tell you about the cardiac function of a pregnant pt

A

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

169
Q

late decelerations and hypotension. what should first be done.

A

give maternal oxygen and left uterine displacement

170
Q

late decelerations. and hypotension. if the pt has an appropriate level of epidural control. should u stop the pump first or give vasopressor first

A

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

171
Q

late decelerations and hypotension. what else can be done. besides giving pressors and fluids

A

tocolysis…stop all drips that are causing contraction like oxytocin bc uterine contraction may also decrease perfusion to placenta

172
Q

late decelerations and hypotension. when is c-section necessary.

A

when resuscitative measures do not improve late decels

173
Q

intrathecal opiods. when is resp depression most common

A

when intrathecal opiods are given follow a previou dose of oral/iv opiods…but understand that even this is not common

174
Q

intrathecal opiods. how common is puritis

A

50% of pts get this

175
Q

placenta. what is accreta

A

into the myometrium

176
Q

placenta. what is increta

A

through the entire myometrium

177
Q

placenta. what is percreta

A

pass serosa and possibly into pelvic structures

178
Q

placenta. what is the blood flow rate

A

600-750cc/ hr

179
Q

labor pain. what kind of pain is the first stage

A

visceral. due to uterine contraction and cervical dilation

180
Q

labor pain. what kind of pain is the second stage

A

somatic pain. due to vaginal and pelvic floor dilation

181
Q

labor pain. what kind of block can u do for first stage of labor

A

epidural, lumbar sympathetic, paracervical

182
Q

labor pain. what kind of block can u do for the second stage of labor

A

once first stage blocks, are done, you can add pudendal

183
Q

labor pain. what is associated with paracervical block

A

fetal brady cardia. thats why this is not used n e more

184
Q

placenta transfer. local anesthetics. does molecular weight affect its transfer through

A

when comparing local anesthetics. all have low molec wt. so molec weight is not a significant factor when comparing local anes to eachother

185
Q

placenta transfer. local anesthetics. how does protein binding affect local anes transfer

A

the more you are bound the less you cross to fetus

186
Q

placenta transfer. local anesthetics. what are the highest protien bound local anes

A

ropivicaine most and then marcaine

187
Q

placenta transfer. local anesthetics. what kind of bases or acids are they

A

they are weak bases

188
Q

placenta transfer. local anesthetics. how does pka of these weak bases affect their transfer to fetal side

A

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.

189
Q

placenta transfer. local anesthtics. what has the greatest effect on local anes transfer to fetal side

A

amount of protein binding

190
Q

placenta transfer. local anesthetics. what are amids

A

amides have 2 I’s in their name

191
Q

placenta transfer. local anesthetics. what are esters

A

they only have 1 I in their name …chloroprocain and tetraciane

ACE (18 decks)

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