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Mar: Sem 6 - Adv. Principles B > Complicated OB Part 1 > Flashcards

Complicated OB Part 1 Flashcards

1
Q

What does ECV stand for?

A
  • External Cephalic Version
  • A maneuver to rotate the fetus to a better position for delivery.
  • Converts breech/shoulder presentation to vertex
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2
Q

Define Antepartum

A

Conception to the onset of labor

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3
Q

Define Intrapartum

A

Onset of labor to delivery of the placenta

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4
Q

What does PPROM stand for?

A

Preterm Premature Rupture of Membrane

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5
Q

What does PPH stand for?

A

Post Partum Hemorrhage

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6
Q

What is the optimal timing to perform an ECV?

A
  • 36-37 weeks
  • Unlikely to revert back to breach presentation after 37 weeks
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7
Q

What agent is needed before attempting ECV?

A
  • Tocolytic agent (Terbutaline/NTG)
  • Tocolytic agents are drugs that can slow or stop uterine contractions during pregnancy to prevent preterm labor.
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8
Q

What maternal factor will decrease the rate of success of an ECV?

A

Maternal pain

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9
Q

What factors contribute to a successful ECV?

A
  • Neuraxial analgesia/ anesthesia
  • SAB w/ bupivacaine 2.5-7.5 mg w/ or w/o opioids
  • CSE/ epidurals
  • T6 dermatome level analgesia

Be prepare for urgent C-section d/t placental abruption, preterm labor, non-reassuring fetal heart tones

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10
Q

What is placenta previa?

A

When the cervical os is partially or totally covered by the placenta.

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11
Q

What are the four types of placenta previa?

A
  • Low lying: does not infringe on cervical os
  • Marginal: touches but not covering top of cervix
  • Partial: partially covers cervix
  • Complete: covers top of cervix completely
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12
Q

What are risk factors for placenta previa?

A
  • Advanced maternal age
  • Multiparity
  • Hx of smoking
  • Prev. C-section/ uterine sx
  • Previous placenta previa
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13
Q

At what age is a woman considered to be advanced maternal age?

A

35

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14
Q

What is the most common way placenta previa is diagnosed?

A
  • Transvaginal US assessment or MRI
  • Measures distance from the placental edge to the internal os
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15
Q

Can placenta previa be assessed and diagnosed by a vaginal exam?

A
  • No
  • Difficult to assess with complete placenta previa
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16
Q

What is the classical sign of placenta previa?

A
  • PAINLESS vaginal bleeding in 2nd/3rd trimester
  • Bleeding may stop spontaneously
  • May be sudden & severe
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17
Q

Anticipated management of placenta previa in a preterm if bleeding is controlled.

A
  • Anticipate early delivery, but the priority is to maintain fetal viability inside the womb
  • Administration of tocolytics (Tertbuline), decrease contractions
  • Betamethasone to promote fetal lung maturity
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18
Q

Anticipated management of placenta previa in a preterm if bleeding is uncontrolled and ongoing.

A

C-section

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19
Q

Due to the high liability of obstetric anesthesia, explain the setup for a placenta previa exam.

A
  • Double setup exam (examination and emergent C-section)
  • All team members present
  • Patient prepped for C-section delivery
  • Vaginal exam performed in OR
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20
Q

Anesthesia Considerations for Antepartum Hemorrhage

A
  • Early Pre-op
  • Type & Cross
  • 2 large bore IVs
  • Fluid warmer
  • Bair hugger
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21
Q

Define Abruptio Placentae

A
  • Placental Abruption
  • Premature separation of the placenta (complete/partial), causes bleeding from uterus and placenta
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22
Q

Placenta abruption will prevent _________ of vessels → results in continued bleeding and hematoma formation.

A

Constriction

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23
Q

Placental abruption will lead to reduced _______ d/t loss of placental-uterine surface area.

A

Gas Exchange

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24
Q

Reduce gas exchange from placental abruption will result in:

A
  • Fetal distress → Fetal Asphyxia
  • Bradycardia
  • Late or variable decels
  • Decrease/ absent variabilty
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25
Q

Risk Factors for Placental Abruption

A
  • Advanced maternal age
  • Multiparity
  • HTN
  • Cocaine Abuse
  • Smoking
  • Trauma
  • Premature rupture of membranes
  • Pre-eclampsia
  • Chorioamnionitis
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26
Q

What is the classic sign for placental abruption?

A
  • PAINFUL vaginal bleeding
  • Hypertonic uterus (frequent contractions)
  • Uterus tender to touch
  • Vaginal bleeding absent d/t hemotoma in concealed abruption
  • Couvelaire Uterus
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27
Q

What is a Couvelaire Uterus?

A
  • Blood is forced through the uterine wall into the serosa.
  • This bleeding can then force its way into the peritoneal cavity, causing the uterus to become rigid and tense.
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28
Q

What is the primary risk to the mother from placental abruption?

A
  • Hypovolemia
  • Hemorrhagic Shock
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29
Q

Consumptive coagulopathy is caused by:

A
  • Activation of circulating plasminogen
  • Placental thromboplastin
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30
Q

How is Placental Abruption diagnosed?

A
  • Clinical presentation (painful vaginal bleeding)
  • US guidance
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31
Q

OB treatment of Placental Abruption depends on what factors?

A
  • Amount of blood loss
  • Fetal status
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32
Q

Regarding volume status and circulation, placental abruption can result in these three problems.

A
  • Massive blood loss
  • Coagulopathy
  • Uterine Atony
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33
Q

What are the most common causes of uterine rupture?

A
  • Trauma
  • Uterine scar from previous C-section
  • Rapid progression of labor
  • Prolonged labor w/ induction (Pitocin)
  • Weakened uterine musculature (high gravida)
  • Forcep-assisted delivery
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34
Q

Uterine rupture is most commonly associated with ____________.

A

TOLAC (Trial of Labor after Cesarean)

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35
Q

Uterine rupture at this site will result with the most significant morbidity/ mortality.

A
  • Rupture at a uterine incision scar.
  • This site is more vascular and is also the place of placental implantation
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36
Q

What is the most consistent clinical feature of uterine rupture?

Signs and symptoms of uterine rupture.

A
  • Fetal bradycardia (most consistent feature)
  • Vaginal bleed
  • Severe abdominal pain (tearing)
  • Shoulder pain
  • Hypotension
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37
Q

How much is uterine blood flow at term?

A

700-900 mL/min

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38
Q

Uterine rupture requires ___________ operative delivery.

A

Emergent

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39
Q

Anesthesia management of uterine rupture.

A
  • Situational, but GETA most common
  • In situ epidural
  • SAB not likely d/t problematic FHT/ hemorrhage
  • Maternal status (hypovolemia/ change in LOC)
  • Blood/ fluid warmer
  • Get Help
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40
Q

What is the most common cause of maternal mortality worldwide?

A

Postpartum Hemorrhage

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41
Q

Differentiate b/w primary and secondary PPH.

A
  • Primary: PPH within 24 hours of delivery. Higher maternal morbidity and mortality.
  • Secondary: 24 hours - 6 weeks postpartum (slow bleeds → septic)
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42
Q

ACOG Definition of PPH

A
  • Blood loss > 1000 mL
  • Blood loss w/ signs and sx of hypovolemia within 24h of delivery
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43
Q

Causes of PPH

A
  • Uterine atony (80%, most common)
  • Retained placenta
  • Cervical/ vaginal lacerations
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44
Q

What is the cause of uterine atony?

A

Failed release of endogenous uterotonic agents

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45
Q

What are the uterotonic agents?

A
  • Oxytocin
  • Prostaglandin
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46
Q

Uterine atony symptoms

A
  • Soft, boggy, oversized, and poorly contracting uterus
  • Painless vaginal bleeding
  • Atonic uterus may hold >1000 mL of blood
  • Tachycardia/ Hypotension → Hypovolemia
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47
Q

Uterine Atony management

A
  • Prevention first, then treatment
  • Active management in 3rd stage of labor
  • Uterine massage
  • Oxytocin administration
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48
Q

First-line treatment for uterine atony?

A

Oxytocin (Pitocin) - synthetic agent

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49
Q

Half-life of oxytocin

A

3-5 minutes

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50
Q

Dosing of Oxytocin for active management of 3rd stage of labor and prevention of uterine atony. Option 1

A
  • 20 U in 1000 mL NS
  • Bolus 1000 mL over 30 minutes
  • Give a second bag at a maintenance dose at 125 mL/hr
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51
Q

Dosing of Oxytocin for active management of 3rd stage of labor and prevention of uterine atony. Option 2

A
  • 30 U in 500 mL NS
  • Bolus 334 mL over 30 minutes
  • Maintenance dose at 95 mL/hr
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52
Q

Dosing of Oxytocin for active management of 3rd stage of labor and prevention of uterine atony. Option 3

A
  • 10 units IM
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53
Q

Dosing of Oxytocin for active management of 3rd stage of labor and prevention of uterine atony. Option 4 (Rule of 3)

A
  • 3 units IV loading dose over 20-30 seconds
  • Initiate infusion 3 units/hr ( x 5 hrs)
  • Assess uterine q 3 minutes
  • Inadequate uterine tone → give 3 units IV rescue dose
  • May repeat rescue dose x 1
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54
Q

Dosing of Oxytocin for active management of 3rd stage of labor and prevention of uterine atony. Option 5

A
  • 30 units in 500 mL
  • Infuse 300 mL/hr (18U/hr) - prevention of atony
  • Infuse 600 mL/hr (36U/hr) - management of atony
  • May increase to 900 mL/hr (54U/hr)
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55
Q

What are side effects associated with Oxytocin?

A
  • Tachycardia
  • Hypotension
  • Coronary vasoconstriction / myocardial ischemia
  • Hyponatremia
  • Seizures → coma
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56
Q

What is the second line agent for uterine atony?

A

Methylergonovine (Methergine) - Ergot Alkaloid

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57
Q

What receptors does Methergine work on?

A
  • Partial agonist at alpha-adrenergic receptor
  • Tryptaminergic receptor
  • Dopaminergic receptor
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58
Q

Dose of Methergine

A

0.2 mg Intramuscular (medication needs to be refrigerated)

NOT GIVEN IV, you will kill your patient

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59
Q

Onset time for Methergine
Duration of action.

A
  • Onset: 10 minutes
  • Duration: 2-4 hours
60
Q

How often can you repeat Methergine dose?

A
  • May repeat as early as 2 hours
  • May repeat up to 4 times to a max dose of 0.8 mg
61
Q

Contraindication of Methergine

A
  • HTN
  • Pre-eclampsia
  • Peripheral vascular disease
  • Ischemic heart diseae
62
Q

What are the cardiovascular effects of Methergine?

A
  • Vasoconstriction
  • HTN
63
Q

What are the neuro effects of Methergine?

A
  • CVA
  • Seizures
64
Q

What are the GI effects of Methergine?

A
  • N/V
65
Q

Management of HTN secondary to Methergine administration

A
  • NTG
  • Sodium Nitropursside
66
Q

What is the third-line agent for uterine atony?

A

Carboprost (Hemabate)

67
Q

When would you want to use Hemabate over Methergine?

A
  • If the patient has existing hypertension
  • Pre-eclampsia
  • Cardiac Disease
68
Q

What is the dosage for Hemabate?

A

250 mcg IM or intrauterine q 15-90 mins
Max dose of 2 mg
Medication needs to be refrigerated

69
Q

Cardiovascular effects of Hemabate?

A

↑ SVR

70
Q

Pulmonary effects of Hemabate?

A
  • Bronchospasm
  • V/Q Mismatch
  • Shunt
  • Hypoxia
  • ↑ PVR
71
Q

What two drugs used to treat uterine atony must be refrigerated?

A
  • Methergine
  • Hemabate
72
Q

Which drug used to treat atony has primarily cardiovascular complications?

A

Methergine

73
Q

Which drug used to treat atony has primarily pulmonary complications?

A

Hemabate

74
Q

What type of patients would you want to avoid giving Hemabate to?

A
  • Cautious use in patients with reactive airway disease (asthma)
  • Pt w/ cardiac disease
  • Pulmonary HTN
75
Q

What is Misoprostol (Cytotec) used for?

A
  • Induce Labor
  • Uterotonic agent and treatment of PPH
76
Q

MOA of Cytotec

A

Prostaglandin E1 Analogue

77
Q

Dose of Cytotec
Route of Administration (most common)
Side Effects

A
  • Dose: 600-1000 mcg
  • Route: Vaginal
  • SE: N/V/Diarrhea
78
Q

What are medical devices used to manage PPH?

A
  • Bakri Balloon: Intrauterine balloon tamponade
  • Jada System: Vacuum, induces physiologic uterine contraction
79
Q

When is the placenta considered “retained”?

A

Failure to deliver placenta completely within 30 minutes of delivery

80
Q

Risk for _______ increases if the interval b/w delivery and placenta is >30 minutes.

A

PPH

81
Q

Treatment for Retained Placenta

A
  • Manular removal by OB provider (painful, needs relaxation, spinal)
  • Treat uterine atony/hemorrhage
82
Q

Anesthesia Management of Removal of Retained Placenta

A
  • BZD + Ketamine (0.1 mg/kg)
  • In situ epidural (convert to anesthetic epidural)
  • GETA
83
Q

What are ways to induce uterine relaxation?

A
  • Nitroglycerin 25-50 mcg IV
  • Nitroglycerin spray
  • VA - dose-dependent decrease in uterine tone
84
Q

Spinal Anesthesia Dosing Chart

A
85
Q

Epidural Anesthesia Dosing Chart

A
86
Q

Define Placenta Accreta

A

Placenta invades uterine wall

87
Q

Define Placenta Increta

A

Placenta invades the myometrium

88
Q

Define Placenta Percreta

A
  • Placenta through myometrium into serosa
  • May invade adjacent organs
89
Q

Factors that will increase the risk of placenta accreta?

A
  • Hx of C-section
  • Placenta previa with/without uterine sx
  • Hx of myomectomy
  • Asherman syndrome (scar tissues that form inside uterus/cervix)
  • Maternal age > 35
90
Q

How is Placenta Accreta diagnosed?

A
  • US/MRI
  • If the patient has placenta previa, likely to have accreta
91
Q

Obstetric Treatment of Placenta Accreta

A
  • Area and Depth determine tx
  • Definitive approach is a cesarean hysterectomy
  • Preop placement of ureteral stents optional (this will help identify the ureters)
92
Q

Anesthetic Management of Placenta Accreta

A
  • GETA to protect the airway
  • Fluid warmer, Rapid transfuser
  • Forced air warmer
  • MTP
  • Be prepared for coagulopathy
  • Get help
93
Q

Describe the four degrees of uterine inversion

A
  • 1st degree: Uterus is inverted inside the abdomen
  • 2nd degree: Uterus occludes cervical ox
  • 3rd degree: Uterus protrudes through cervical os
  • 4th degree: Complete inversion, fully protruding through cervix
94
Q

What factors will increase the risk of uterine inversion?

A
  • Overzealous fundal pressure
  • Umbilical cord traction
  • Uterine anomalies
  • Uterine atony
  • Placenta accreta
95
Q

Signs and symptoms associated with uterine inversion

A
  • Severe hemorrhage
  • Vagal-mediated bradycardia (consider glycopyrrolate)
96
Q

Uterine inversion treatment

A
  • Discontinue uterotonic administration
  • OB promptly replaces uterus
  • Requires uterine relaxation by anesthesia w/ NTG 200-250 mcg IV or sublingual
  • Volatile anesthetics
  • Transfusion
97
Q

What is the definitive treatment for unresponsive PPH?

A
  • Peripartum Hysterectomy

Biggest cause of hysterectomy: Uterine atony, Placenta Accreta, Increase number of C-sections

98
Q

Peripartum hysterectomy is challenging d/t what factors?

A
  • Large uterus
  • Increased blood flow (700-900 mL/min)
  • Engorged blood vessels
  • > 40% of patients require PRBCs
  • Mortality 25x higher in peripartum vs non-peripartum hysterectomy
99
Q

During a peripartum hysterectomy, why will the surgeon manually compress the aorta?

A
  • Decreases blood flow to pelvis
  • Potentially life-saving in catastrophic OB hemorrhage

This will increase the risk of Lactic acidosis and hemodynamic instability when compression released

100
Q

Anesthesia Management of Peripartum Hysterectomy

A
  • Pain & N/V due to intraperitoneal manipulation
  • Neuraxial (T4 sensory)
  • IV Sedation
  • GETA is the best option for increase EBL
  • Large fluid shifts → airway edema
101
Q

Hemorrhage: When to Transfuse?

A
  • Consider overall picture
  • Tachycardia
  • Decreased pulse pressure
  • Tachypnea
  • Decreased UOP
  • Altered mental status
  • Most providers transfuse for HGB of 7.0– 8.0 g/dL
102
Q

Parturient can tolerate EBL of ~ ____% of blood volume w/o symptoms or change in vital signs

A

15%

103
Q

What is a late sign of hemorrhage?

A

Hypotension

Late sign d/t increased blood volume with pregnancy

104
Q

Risks of transfusion

A
  • TACO, TRALI, TRIM
  • Bacterial contamination & transfusion reaction
  • Hypothermia & hypocalcemia
  • Hyperkalemia

TACO: Transfusion-Associated Circulatory Overload
TRALI: Transfusion-Related Acute Lung Injury
TRIM: Transfusion-Related Immunomodulation

105
Q

How much will 1 PRBC increase a patient’s Hgb?

A

Increases Hgb by 1 mg/dL in a hemodynamically stable patient

106
Q

FFP is 1 pack per ________ kg of body weight as initial dose

A

20 mL/kg

107
Q

Cryoprecipitate is important to transfuse because __________ rapidly gets consumed during a hemorrhage

A

Fibrinogen

108
Q

Fibrinogen level should be maintained at this level

A

> 150-200 mg/dL

109
Q

When to transfuse platelets

A
  • Plt <50,000
  • If EBL > 5000 mL
  • Consumptive coagulopathy
110
Q

How much does 1 pack of platelets increase plt level?

A

5000-10000 mm3

111
Q

How does large volume of crystalloid transfusion affect blood level.

A

Dilutional Thrombocytopenia

112
Q

What can elevated levels of D-dimer & plasmin-antiplasmin complexes indicate?

A

Fibrinolysis

113
Q

Treatment for Fibrinolysis

A
  • Tranexamic Acid (TXA)- Antifibrinolytic
  • Tx of PPH-associated coagulopathy
  • 1 gm IV within 3 hrs of PPH recognition
  • Repeat 1 gm IV in 30 minutes if bleeding continues
  • Consider 2 gm IV initial dosing
114
Q

Recombinant Activated Factor VIIa will have direct activation of __________.

A

Factor X to Xa

115
Q

Recombinant Activated Factor VIIa enhances ______ and ________.

A

platelet aggregation and adhesion

116
Q

Why is Recombinant Activated Factor VIIa not recommended for routine use in OB?

A
  • Concern for increased thromboembolic events
  • Extremely expensive
117
Q

What does TOLAC stand for?

A

Trial of Labor after Cesarean

118
Q

What is the success rate of TOLAC?

A

60-80%

Decrease popularity d/t legal concerns

119
Q

What are the eligibility requirements for TOLAC?

A
  • 1-2 previous C-sections
  • Risk of uterine rupture 0.8-1.8%
  • Low transverse or low vertical incision
120
Q

Anesthesia management of TOLAC

A
  • Neuraxial analgesia- Early placement
  • May facilitate successful VBAC
121
Q

Early epidural placement for TOLAC does not delay diagnosis of __________-

A

uterine rupture

122
Q

Preterm labor and delivery is defined as labor between _____ and _______ weeks of gestation.

A

20 to 36 6/7 weeks gestation

123
Q

Infant survivability > 90% after _______ weeks gestation

A

30 weeks

124
Q

Predictive lab factors of preterm labor

A

Elevated Fetal fibronectin (fFN)

125
Q

What is fetal fibronectin?

A

Basement membrane glycoprotein produced by fetal membranes used to indicate maturity

126
Q

What are the effects of corticosteroids on preterm labor?

A
  • Decreased respiratory distress syndrome
  • Decreased intraventricular hemorrhage
  • Decreased death with preterm delivery
127
Q

Which corticoid steroids are used in preterm labor?

A
  • Betamethasone
  • Dexamethasone
128
Q

Betamethasone dose for preterm labor

A

12 mg IM every 24 hours x 2

129
Q

Dexamethasone dose for preterm labor

A

6 mg IM every 12 hours x 4

130
Q

What is used for neuroprotection of the fetus during preterm labor?

A

Magnesium Sulfate will decrease the incidence of cerebral palsy and death

131
Q

What tocolytics (anti-contractions) are used for pre-term labor?

A

Terbutaline (Beta-adrenergic agonist )

Stimulate β2-adrenergic receptors on uterine smooth muscle, leading to muscle relaxation and inhibition of contractions.

132
Q

What are the effects of Terbutaline on the Uterus?

A

Relaxes smooth muscles and prevents contractions

133
Q

What are the maternal side effects of terbutaline?

A
  • Dysrhythmias
  • Pulmonary edema
  • Hypotension & tachycardia
134
Q

Anesthesia consideration of administering terbutaline

A
  • Preferentially delay ~ 15 mins for maternal HR to decrease
  • Cautious use of hydration d/t risk of pulmonary edema
135
Q

What is the most common NSAID administered for preterm labor?

A

Indomethacin

Indomethacin works by inhibiting COX. COX is crucial for the synthesis of prostaglandins, which play a significant role in initiating and sustaining uterine contractions. By reducing prostaglandin production, indomethacin helps to decrease uterine contractility and delay labor.

136
Q

Why are NSAIDs administered in preterm labor??

A

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, are used during preterm labor primarily because of their ability to inhibit the production of prostaglandins, which play a key role in initiating and sustaining labor contractions.

137
Q

MOA of Indomethacin

A

Inhibit cyclooxygenase → prevent the synthesis of prostaglandins from arachidonic acid → decrease contractions

138
Q

Side Effects of Indomethacin

A
  • Nausea
  • Heartburn
139
Q

MOA of Magnesium Sulfate for preterm labor

A
  • Competitive antagonist of calcium
  • Reduces calcium influx into uterine myocyte
  • Limits release of ACh @ NM endplate
  • Reduces the sensitivity of the NM endplate to ACh
140
Q

Side Effects of Magnesium Sulfate

A
  • Flushing
  • Sedation
  • Chest pain
  • Blurred vision
  • Hypotension
  • Pulmonary edema
141
Q

What are the effects of Hypermagnesemia?

A
  • Abnormal neuromuscular function
  • Decreased or absent deep tendon reflexes
  • Abolishes compensatory response to hemorrhage
142
Q

Anesthetic consideration for magnesium sulfate administration

A
  • Monitor renal function and mag level
  • Assess DTR
  • Mag potentiate neuraxial agents, decrease spinal/epidural dose
  • Potentiate action of depolarizing and NDMR
  • Avoid defasciculating dose of NDMR
143
Q

Magnesium Sulfate dose

A
  • 2-4 gm loading dose
  • 1-2 gram/hour

Most of the time magnesium is initated d/t HTN or pre-eclampsia.

144
Q

Does magnesium readily cross the placenta?

A

Yes

Look for muscular weakness in the baby after delivery and decrease WOB

145
Q

What is a normal magnesium level?
What is the therapeutic range?

A
  • Normal = 1.7 – 2.4 mg/dL
  • Therapeutic range for pre-eclampsia or pre-term labor = 5-9 mg/dL

Mar: Sem 6 - Adv. Principles B (14 decks)

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