Advanced Principles Exams Flashcards
1
Q
Maternal CO increases by?
A
50% (most correct answer 40%)
2
Q
All of the following increased during pregnancy EXCEPT?
A
SVR
3
Q
Mother becomes hypotension in supine position, what do you do?
A
Turn patient to right side with towel roll
4
Q
What increases risk of hypoxia during pregnancy? Pick 2
A
Decreased FRC INCREASED A-a gradient
5
Q
Which is true during pregnancy? Pick 3
A
Decreased FRC Decreased MAC for GA Decreased PCO2
6
Q
Which structure identifies the cytotrophoblast? Which structure identifies the syncytiotrophoblast?
A
look at image [ctotrophoblast]
7
Q
Which structure identifies the umbilical arteries? Which structure identifies the umbilical veins? What structure identities the ductus arteriosus?
A
insert image [fetal circulation]
8
Q
Which affects drug passage through the placental barrier?
A
Molecular weight, lipid solubility, ionization of drug
9
Q
Normal FHR is 130-80. True or False
A
False (normal is 110/120-160)
10
Q
Oxygenated blood is brought through?
A
Umbilical vein
11
Q
Deoxygenated blood is brought to the placental through?
A
Umbilical arteries
12
Q
What is best used to prevent DVT during pregnancy?
A
Compression stockings
13
Q
Which lab is suggested of NTD (ex: Spina Bifida)?
A
INCREASED alpha fetoprotein
14
Q
Which lab is suggested for Downs Syndrome Trisomy 21?
A
DECREASED alpha fetoprotein
15
Q
Which is true of first stage labor? Pick 2
A
Level of spinal needed is T10-L1 Visceral pain is caused by uterine contraction
16
Q
Which is true of second stage labor? Pick 3
A
Pain is through pudendal nerves
Somatic pain is due to stretching of vagina
Level of spinal needed for anesthesia is S2-S4
17
Q
What describes the birth defect causing the backbone and spinal canal not to properly fuse?
A
myelomeningocele
18
Q
What is true about diaphragmatic hernia (choose 2)
A
-occurs when the diaphragm, the muscle that separates the chest from the abdomen, fails to close during prenatal development -Is a life threatening illness that prevents lung development
19
Q
What is true about anesthetic management for fetal surgery?
A
2 patients and Maternal safety is paramount
20
Q
Absent or minimal variability indicates that there is a compromise to fetal health. True or false?
A
TRUE
21
Q
Which correlates with fetal head compression?
A
Early Decelerations
22
Q
41 weeks describes what term?
A
LATE Term
23
Q
Ultrasonography is recommended for all pregnancies because it? Pick 3
A
Determines gestational age Determines placental position Determines structural abnormalities
24
Q
Lepold’s Manuever used to elevate a 12 week fetus, the fundal height should be measuring at?
A
Pelvic brim
25
what is true of Aspirin use during the 3rd trimester? Pick 3
Oligohydraminios
Renal injury
Intrauterine constriction of the ductus arteriosus
26
Which of the following is true regarding pregnancy and anticoagulants?
-Pregnant women have 5x the normal risk for venous thromboembolism -LMWH is less likely to cause HIT -Unfractionated heparin is easier to reverse
27
Which weight significantly increased newborn and maternal morbidity?
4500 - 4999
28
Major physiologic changes during pregnancy alter drug disposition by:
-Decrease in intestinal motility -Reduced FRC -Increased minute ventilation increases pulmonary uptake of inhalation anesthetics
29
Nonstress test is less useful in the very preterm fetus. True or false?
True
30
The most common indication for 2nd trimester amniocentesis is for?
Cytogenetic analysis of fetal cells
31
Most Common Medications Taken During Pregnancy? Choose 3
Antiemetics Antibiotics Analgesics
32
Drugs taken with long term CNS effects? Choose 3
Antidepressants Anticonvulsants Antipsychotics
33
Parasympathetic outflow by means of the vagus nerve increases the FHR, true or false?
False - (Parasympathetic outflow decreases FHR)
34
An example of physiological changes of pregnancy that may alter drug disposition is?
Placental transfer
35
Caffeine is not shown to produce teratogenic effects. True or false?
true
36
Most anesthetic drugs have been shown to be teratogenic? True or false?
False
37
The Contraction Stress Test assesses fetal heart rate response to uterine activity by? (2)
Maternal exercise monitoring
Nipple stimulation
Oxytocin Administration
Using vibratory stimulation
Nipple stimulation Oxytocin Administration
38
Which is true of the second stage of labor? (choose 3)
Somatic pain caused by stretching of vagina, perineum, & vulva by descent of fetus • Pain is through the Pudendal nerve • Level of spinal anesthesia is needed for S2-S4
39
Obesity is defined as a BMI of ____ •
\>30 kg/m2
40
Which of the following is true regarding anticoagulants in pregnancy? (Choose 3)
• LMWH is preferred • LMWH is less likely to cause HIT • Shorter half-life of UFH means it’s easier to reverse
41
Which of the following is true regarding anticoagulants in pregnancy? (choose 2)
• Warfarin is a vit K antagonist and can cause embryopathy, esp. in 1st trimester • Rivaroxaban and thrombin inhibitor Dabigatran (Pradaxa) cross the placenta and are NOT recommended
42
Which of the following is true regarding transfer of drugs in breast milk? (choose 4)
• Benzos are considered safe • NSAIDs are safe when breastfeeding • Acetaminophen is the standard analgesic • Anesthetic drugs are considered SAFE
43
Fetal growth restriction is associated with which adverse perinatal outcomes? (choose 3)
• Intrauterine demise • Neonatal morbidity and mortality • Cognitive delay in childhood
44
Fetal risk Factors for high risk pregancy:
a. Fetal growth restriction b. Multiparity c. Previous unexplained still birth d. Singledom pregnancy
45
Example of direct pharmacologic effects would be:
Placental transfer
46
Most common medications taken during pregnancy (choose 3)
Antiemetics Analgesics Antibiotics
47
At least 10% of pregnant women are taking these medications that can cause long term CNS effects (choose 3)
Antipsychotics Anticonvulsants Antidepressants
48
Things that affect absorption and uptake of drugs during pregnancy include all of the following EXCEPT:
Oral aborption and bioavailability is majorly affected by pregnancy o Oral absorption and bioavailability is NOT usually affected by pregnancy
* Intestinal motility decreases
* Reduced FRC
* Increased minute ventilation increases pulmonary uptake of inhalational anesthetic agenst
49
True or false? No anesthetic agents have been found to be teratogenic.
True
50
Which of the following is TRUE? (choose 2)
• Acetaminophen is the preferred mild analgesic and antipyretic during pregnancy • NSAIDs have been associated with increased risk for some birth defects
51
True of False? Heparins do NOT cross the placenta
TRUE
52
Is caffeine teratogenic in fetus?
No
53
Myleomeningocele is
A birth defect in which the backbone and spinal canal do not close before birth
54
Parasympathetic outflow by means of the vagus nerve will cause \_\_\_\_
Decreased FHR
55
True or false? You have two patients when dealing with OB and Mom is first priority.
True
56
Giving birth at 41 weeks is considered \_\_\_\_
Late term
57
Ultrasound is recommended for all pregnancies for its ability to: (choose 3)
• Accurately determine gestational age • Determine placental location • Screen for fetal structural abnormalities in the second trimester
58
At approximately 12 weeks where can the uterus be palpated?
Above the pelvic brim
59
Fetal growth restriction is associated with which adverse perinatal outcomes? (choose 3)
• Intrauterine demise • Neonatal morbidity and mortality • Cognitive delay in childhood
60
Newborn and maternal morbidity increases with fetal birth weight between \_\_\_\_\_
4500-4999 g
61
True or false? Non-stress test is useful in the very pre-term fetus
FALSE
62
Contraction stress test is done by: (choose 2)
• Administration of IV Oxytocin • Nipple stimulation
63
The most common indication for 2nd trimester amniocentesis is \_\_\_\_\_
Cytogenetic analysis of fetal cells
64
Fetal conditions that may result in Fetal Growth Restriction? Don’t remember the answer to this one
• CP d/t hypoxia • Congenital heart disease • Teratogenic exposure • Structural malformation
65
1. All of the following are true of multiple gestation(choose 3): It was choose 3 true statements; i didn’t have an idea where this information came from
a. Twin A is more depressed and asphyxiated?
66
2. Which of the following is least indicated for treatment of BP 190/110?
a. Esmolol
hydralazine, labetalol, and nifedipine are all effective antihypertensive in these patients. refractory htn may necessitate continous infusion of ntg, SNP, and fenoldopam for short term therapy.
67
3. Which of the following is not a S&S of magnesium toxicity?
a. Hypertension
68
4. What conditions are associated with placenta PREVIA:
a. Prev C/S; Advanced maternal age; Smoking hx
conditions associated with placenta previa include multiparity, advanced maternal age, smoking hx, male fetus, previous c/s or other uterine surgery, and previous placenta previa.
69
5. Complications of PIH/Preclampsia:
a. Pulm. edema; CVA; Placenta Abruption
70
6. What ECG changes are seen with administration of Ondasetron, Droperidol, and Oxytocin?
a. Prolonged QT Interval (Two answer choices, this answer appeared twice)
71
7. Afr. Am. patient came in with elevated BP (161/110 and 170s), visual disturbances, RUQ pain, headache (Missing some S&S): What is the likely diagnosis?
a. Pre-eclampsia (Question appeared twice; no Seizure )
72
8. Most common nerve injured during abdominal hysterectomy?
a. Femoral
73
9. Two most common postpartum HA?
a. Migraine and Tension
74
10. Headache that radiates to neck and shoulder without a previous dural puncture
a. Musculoskeletal
75
11. Patient 23 weeks pregnant comes in with preterm labor. What medication should be given?
a. Beta stimulant
76
12. S&S of Amniotic Fluid Embolism: (Choose 4)
a. Dyspnea, Anxiety, Hypotension, Coagulopathy
77
13. The most common cause of polyhydramnios is?
Esophageal Atresia
78
14. Health care professionals who prescribe PCA should (choose 3 true statements)
a. be able to respond to side effects and adverse events. b. know drug selection criteria, dosing schedules, lockout periods, and infusion devices c. understand when to alter PCA settings and when to give or withhold additional (rescue) doses of medications d. Have pharmacy set up dose (False)
79
Magnesium works by
a. Preventing calcium entry into cells (smooth muscle relaxation)
80
Aspiration of large solid particles may cause atelectasis by obstructing large airways. TRUE/FALSE?
True
81
Sodium bicarbonate cannot be added to bupivacaine as it results in precipitation when the pH is raised (Think this question asked: What cannot be added to bupivacaine because precipitation may occur?
Sodium bicarbonate
82
Preeclampsia BP goal of therapy :
a. The goal of therapy is to maintain blood pressure below 140/90 mm Hg
83
. In preeclampsia the sensitivity of ______ increases, which contributes to vasoconstriction and placental insufficiency.
a. Angiotensin II (PP slide 142)
84
This headache has accompanying neck and shoulder pain without a history of dural puncture.
a. Musculoskeletal headache
85
All of the following are tx of preeclampsia Except?
a. Treatment plan includes labetalol and calcium gluconate
86
While MgSO4 is running pt goes into respiratory arrest? What is the next step
a. Call for help and secure airway
87
Hallmark for preeclampsia
a. Abnormal placental implantation
88
All of the following are true of abrupto placenta except?
a. Long umbilical cord
89
All of the following are true of placenta accreta except?
a. Painless vaginal bleeding
90
All of the following are complications of PIH except? (I thought this was a choose 3 and macrosomia was the only one not picked - yeah, me too)
a. Macrosomia
91
Parturient that is 41 weeks, spontaneous labor wants VBAC all is true except?
a. \> 40 weeks increases the incidence of uterine rupture (This was a choose three that are correct question. This answer is the one that was not true. Confirmed today at review)
92
All of the following C/I of VBAC Except?
a. Low transverse incision post cesarean (C/I are previous classic/T-shaped incision; uterine rupture, medical or OB complication that precludes vaginal delivery, insufficient staff or c/s delivery, two prior uterine scars and no vaginal deliveries. )
93
Question about patient having low BP and also being in respiratory distress? BP is 80/40, placenta previa actively bleeding, prepping patient for c/s. You have an option for spinal, ETT, LMA… what would you choose?
a. ETT, and give Etomidate
94
The common peroneal nerve may be injured during vaginal hysterectomy and would present as?
a. Foot drop
95
What is the best treatment for prevention of thromboembolism for patients undergoing cesarean section?
a. Compression Stockings
96
Fetal ion trapping is caused by \_\_\_\_\_\_?
a. Fetal acidosis
97
What level of neuraxial blockade is needed for C section?
a. T4
98
With chorioamnionitis, a combination of ______ and \_\_\_\_\_should cover most relevant pathogens and is the recommended primary antibiotic regimen.
a. Ampicillin, Gentamycin
99
External cephalic version is likely to be successful if: (choose 3)
a. The presenting part has not entered the pelvis b. Fetal back is not positioned posteriorly c. Presentation is either frank breech or transverse
100
Which factors are associated with lower success rate for VBAC? (choose 3)
a. Socioeconomic b. Ethnic c. Medical factors
101
The most common source of postpartum infection is the
a. Genital tract
102
Which of the following is NOT a fetal complication of gestational diabetes?
a. Hyperglycemia
103
Hypoplasia is a very rare congenital anomaly: T/F
a. False; it is common
104
When is surfactant administered to preterm infants? (Choose 2)
a. Immediately in delivery room or Later as rescue
105
Benzodiazepines: Preservative free is only for IV administration: T/F
a. False: for Nasal Adm
106
What is disorder of CSF accumulation that results in ventricular dilation resulting from increased intracranial pressure (ICP)?
a. Hydrocephalus
107
NPO time for clear infant formula?
a. 2 and 6 hours were accepted
108
Vaccination: (Choose 2)
a. Inflammatory response & Efficacy of vaccine
109
Extension of the head at the atlantooccipital joint with anterior displacement of the cervical spine (sniffing position) does not improve hypopharyngeal airway patency but does change the position of the tongue.
a. False
110
What is not true of MH:
a. Dexmetotamadine/Precedex is contraindicated
111
Bronchopulmonary Dysplasia: Choose 2
a. Assess resp decompensation and need for intervention b. Subglottic stenosis is a cause for concern (?)
112
11. Acute epiglottitis (choose 2 or 3?)
a. Insp. Stridor is a late sign b. Inhalation induction with sitting position
113
Acute epiglottitis (choose 2 or 3?)
a. Insp. Stridor is a late sign b. Inhalation induction with sitting position
114
A pediatric patient seen squatting during exercise is more likely to have
a. Tetralogy of Fallot
115
Correct dosage for oral Midazolam/Versed is
a. 0.25-0.75mg/kg
116
Correct dosage for IM Ketamine in a pediatric patient
a. 2-10 mg/kg
117
Which of the following are false regarding anticholinergics
a. Atropine is a better sedative than scopolamine b. Scopolamine blocks the vagus nerve
118
The most common cause of airway obstruction in infants is
a. Collapse of the pharyngeal structures
119
Which of the following could be given in the event of laryngospasm (choose 3)
a. Succ IM 3-4 mg/kg 4-5mg/kg - that is conflicting but propofol 0.1 (i think that was the dose) was the other option so it had to be succ IM 3-4 the propofol dose is 1mg/kg b. Succ IV 1-2 mg/kg c. Atropine 0.02 mg/kg IV or IM
120
Which of the following is true regarding Fluid Management in a pediatric patient
a. IV fluid administration should be prepared before the child arrives in the OR b. All sets should have a manual controller c. \> 8 years old may use a set with a macro drip
121
Which of the following is true regarding blood transfusions (choose 2?)
a. Blood loss may be replaced with balanced salt solution of 3 ml per 1 ml of blood loss b. Replacement of third spacing is based on severity of the loss
122
Which of the following is true regarding emergence delirium
a. Peak incidence is the same in both sexes and common in 1-5 years of age b. Use of Desflurane and Sevoflurane have an increased incidence
123
Factors that have a greater likelihood for perianesthetic anxiety (Choose 3)
a. Anxious parents b. Age 1-5 c. Unsatisfactory prior medical experiences
124
Which of the following are true (choose 3):
a. Newborns have a proportionally larger head and tongue b. Cricoid cartilage is the narrowest portion in pediatric patients d. Mac is higher in infants age 1-6 months than the new born c. Larynx has a lower position in the neck (this was the incorrect option - it is HIGHER in the neck)
125
Pregnancy tests are NOT required in pediatric/adolescent preop (T/F)
a. false
126
Which of the following is true
a. MAC steadily increases until 2-3 months of age b. MAC steadily declines with age c. MAC in preterm neonates decreases with decreasing gestational age
127
Protein binding of many drugs is ___ in infants, which results in ____ circulating concentrations of unbound and pharmacologically active drugs
a. Decreased; high
128
Extremely low gestational age newborns represent the most vulnerable of patients (T/F)
a. True
129
Along with administration of surfactant to the newborn with RDS what is combined with treatment?
a. CPAP- surfact is combined with intubation? Once CPAP fails? Both per PPT; With CPAP; and also with Intubation
130
An astute SRNA/CRNA knows that you follow certain guidelines for administration of oxygen during a case for patient with ROP (T/F)
a. False
131
The parents are concerned LESS about the surgical procedure than anesthesia (T/F)
a. True
132
BPD is likely to develop in preterm infants born during
24-26 weeks (the canalicular phase of lung development)
133
A congenital or acquired condition of excessive flaccidity of the laryngeal structures especially the epiglottis and arytenoids
a. Laryngomalacia
134
Primary treatments in the patient with ROP: choose 2
a. Cryotherapy b. Laser photocoagulation
135
Hypoglycemia is the most common metabolic problem occurring in newborn infants (T/F)
a. True
136
Congenital defects of the anterior abdominal wall that permit external herniation of abdominal viscera (choose 2)
a. Omphalocele b. Gastroschisis
137
Which of the following is true regarding Hirschsprung’s disease
a. Anesthesia maintained with air oxygen, volatile agent and muscle relaxant b. Must be considered full stomach c. Extra care should be taken in positioning
138
Bronchomalacia is seen in infants
who have had a prolonged stay in the NICU
139
What is the propofol intubating dose
a. 2.5-3.5mg/kg
140
Anxiety in toddlers is related to what factor
a. Loss of control
141
Which of the following is the most common esophageal abnormality in newborns?
a. Esophageal atresia
142
Which of the following are true regarding cleft lip and palate repair
a. Heterogenous group of tissue approximation defects manifesting as cleft lip, cleft lip and palate, and cleft palate b. Cleft lip results from failure of the fusion between the medial nasal and maxillary processes in early gestation c. Cleft palates are associated with a higher incidence of otitis media
143
Which of the following are decreased in pregnancy? (choose 3)
• PCO2 • FRC • MAC
144
The most serious consequence of fetal macrosomia (this isn’t the exact question, but the concept..)
Shoulder dystocia
145
BPD is likely to develop in preterm infants born during
24-26 weeks (the canalicular phase of lung development)
146
What plane of anesthesia must be established before airway instrumentation (for BPD?)?
Deep plane
147
Fluids should be administered judiciously to avoid
Pulmonary edema
148
ROP is classified into 5 stages of severity. The most severe form?
Stage 5; total detachment of the retina
149
Mainstay drug therapy for AOP (apnea of prematurity):
Methylxanthines (caffeine, aminophylline)
150
Treatment of neonate with hypoglycemia with symptoms (i think this was a question and infant was not having seizures??)
\*\*No seizures: IV bolus of 2ml/kg (200mg/kg) of 10% dextrose Seizures: IV bolus of 4ml/kg of 10% dextrose
151
Or was it maintenance fluid requirements of hypoglycemic neonate intraop?
Glucose containing solution of 5% dextrose in 0.2 NS 4ml/Kg/hr or 10% dextrose in water 2-3ml/kg/hr to prevent intraop hypoglycemia?
152
Hypotension without an obvious cause can lead to bradycardia/asytole and should be treated with
IV calcium over 5-10mins
153
In newborns with congenital diaphragmatic hernia, venous access should be avoided In the
lower extremities (b/c venous return may be impaired as a result of compression of IVC following reduction of hernia)
154
TEF anesthesia management -- ETT placement Should be above carina but
below the TEF
155
Wasn’t there a question about HCT?
TEF/EA blood loss replaced to maintain HCT of 35% or higher
RDS HCT near 40% to optimize systemic O2 delivery
AOP - one of the most significant risk factors is a HCT \< 30%
156
Intraoperative oxygenation levels should be comparable to
Preop levels?
157
Congenital lobar emphysema -- smooth inhalation induction with sevoflurane and oxygen without, if possible any
Positive pressure ventilation
158
Congenital Lobar emphysema and congenital cystic adenomatoid malformation - A surgeon should be present at induction in the event that
sudden cardiopulmonary decompensation necessitates urgent thoracotomy
159
Cerebral Palsy… I don’t remember question, but seems like these were questions or options in a multi-select??
-Spastic CP is the MC -Seizure disorder is common; antieplileptic medications are given even in absence of seizure for off label tx of spasticity and behavioral issues -Administration of NMB should be done in caution, pts generally have prolonged recovery from NMB. Volaties agents do not have to be avoided b/c CP is not associated with MH
160
An important adjunct in managing pain r/t muscle spasm
Diazepam
161
Although controversial in children, medical tx for hydrocephalus mainly consists of
diuretic tx -Furosemide and acetazolamide decrease CSF production -Ketamine is contraindicated b/c it can precipitate sudden increase in ICP -Succinylcholine can increase CBF and ICP but it is more transient and can be attenuated by premedication w/ defasciculating dose of NMB
162
Spina bifida anesthesia management
-Positioning is most critical in the preop care of child with open lesions (meningocele and myelomeningocele); prone or lateral decubitus to avoid sac and nerve injury -Comprehensive preop assessment is needed b/c myelomeningoceles are often associated with other congenital anomalies -Tracheal extubation must take place only after the pt has regained “ spontaneous ventilation
163
Treacher Collins not only difficult to intubate but nearly impossible to
mask ventilate
164
One of the most common causes of hoarseness and airway obstruction in children
Laryngeal papillomatosis Dysphonia or change in voice quality
165
Safety of the patient dictates
Anesthetic technique
166
Dexamethasone may be given to reduce
Postintubation croup
167
Most common type of renal cancer in children
Wilms’s Tumor or nephroblastoma
168
Most common chromosomal abnormality?
Down’s Syndrome/ Trisomy 21
169
CCB are contraindicated in Malignant hyperthermia b/c they can
Worsen hyperkalemia
170
Smallest gauge catheter blood can be rapidly infused through?
22g
171
Deep tracheal extubation requires
an organized plan 1.5 to 2 x MAC?
172
worded as a True or False What is good for one child and family is good for the next
False: What is good for one child and family may not be good for the next
173
Select objectives of pre-anesthetic medication??? Or is not?
Allay anxiety
Block autonomic (vagal) reflexes
Reduces airway secretions
Produce amnesia
Provide prophylaxis against pulm aspiration
Facilitate induction of anesthesia
Provide analgesia if necessary
174
Factors to consider when selecting premedication plan :
Child’s age Parent /child expectations Emotional maturity, anxiety level, History,etc
175
Complete laryngospasm is defined as
closure of the false vocal cords and apposition of the laryngeal surface of teh epiglottis and interarytenoids.
176
For young children 1 or older
- 500ml bag of LR w/graduated buretrol is appropriate (infant \<1 yr) 250ml bag with buretrol
177
What is the only factor that influences blood flow through the placenta?
Maternal BP
178
Hypotension treatment?
Left uterine displacement
IV hydration
Ephedrine
179
Regulation of FHR via autonomic nervous system?
Baroreceptors respond to increase BP
Chemoreceptors respond to decrease PaO2
180
Risk factors for antepartum stillbirths? CHOOSE 3
Congenital malformations
Multiple pregnancies
Prior unexplained IUFD
181
Hallmark PDPH?
Postural component
182
“Worst headache of my life”?
Subarachnoid hemorrhage
183
Difficult airway after giving succ. What do you do?
Awake pt and ask about fiberoptic (since it is non emergent)
184
Hard to see anatomy when intubating, what is the best thing to do?
Optimize pt position
185
Leading cause of maternal death?
PERIPARTUM hemorrhage
186
Droperidol, reglan, and oxytocin all cause what?
QT prolongation
187
Risk factors in placenta accreta
· previous cesarean delivery (short interval from c/s to conception less than 18mos)
· advanced maternal age
· female gender of the fetus
188
What is true about amniotic fluid embolism? CHOOSE 2
1. Rare catastrophic life-threatening event
2. Complication of pregnancy when there is a disruption of barrier b/w amniotic fluid and maternal circulation
(I think this one was asking when it can occur and options were something like during C/S, anytime after birth, anytime during pregnancy, etc.)
This is what I have in my notes: Amniotic fluid embolism is rare and may occur during labor, vaginal, or operative delivery and it is occasionally associated with placental abruption.
189
