Complicated OB Pt. 1 (Exam I) Flashcards
When is optimal timing to attempt ECV (External Cephalic Version)?
36-37 weeks
A fetus is unlikely to revert back to breach presentation after ECV after ____ weeks.
37
What medication should be given prior to ECV?
Tocolytic agents:
Terbutaline
NTG
ECV is commonly unsuccessful if the mom is feeling ____.
pain
What is done to treat the pain of ECV?
Neuraxial analgesia/anesthesia
What dermatome level is attempted with ECV?
T6
What complications can occur with ECV?
- Placental abruption
- Preterm labor
- Worsening FHT’s
_______ _____ is characterized by abnormal placenta implantation on the upper uterine segment.
Placenta Previa
What are the four subcategories of placenta previa?
- Low Lying - doesn’t infringe on cervical os.
- Marginal - touches but doesnt cover top of cervix.
- Partial - partially covers cervix.
- Complete - covers cervix completely.
what are risk factors for placenta previa?
- Older maternal age
- Multiparity
- Hx of smoking
- Previous c-section / uterine surgery
- Hx of placenta previa
What is the classic sign of placenta previa?
Painless vaginal bleeding in 2ⁿᵈ or 3ʳᵈ trimester.
In abruptio placentae, bleeding occurs from exposure of ______ vessels at the _________ interface.
decidual : decidual-placental
How is abruptio placentae defined?
Premature separation of the placenta (can be complete or partial).
What are the consequences of placental abruption on the fetus?
Reduced gas-exchange due to loss of placental-uterine interface:
- bradycardia
- late or variable decels
- decreased / absent variability
What are some of the risk factors for placental abruption?
Which of these are the greatest?
- HTN
- Cocaine
- Advanced maternal age
- Smoking
- Trauma
- Multiple gestation
- Pre-eclampsia
- Chorioamnionitis
The classic sign of placental abruption is characterized by ________ vaginal bleeding.
Painful
What is couvelaire uterus?
When does it occur?
- Blood forced through uterine wall into gastric serosa.
- occurs with serious placental abruption.
What is the primary risk associated with placental abruption?
Hypovolemic / hemorrhagic shock
What causes consumptive coagulopathy on placental abruption patients?
- Activation & usage of circulating plasminogen
- Placental thromboplastin
Uterine rupture is most commonly associated with ______.
TOLAC
Trial of Labor after Cesarean
What is the most consistent clinical feature of uterine rupture?
Fetal bradycardia
What clinical features are seen with uterine rupture?
- Fetal bradycardia
- Vaginal bleeding
- Severe abdominal pain (breakthrough neuraxial analgesia)
- Shoulder pain
- Hypotension
What is uterine blood flow at term gestation?
700 - 900 mL/min
Primary postpartum hemorrhage occurs within _____ hours of delivery.
24
Has a higher maternal morbidity & mortality.
Secondary postpartum hemorrhage occurs from _____ to _____ weeks post partum.
1 day to 6 weeks
Postpartum hemorrhage is defined as blood loss ≥ _____ mls or blood loss with signs of symptoms of hypovolemia within ____ hours of delivery.
1000 mls : 24 hours
What are some common causes of postpartum hemorrhage?
- Uterine atony (most common)
- Retained placenta
- Cervical/vaginal lacerations
Failed release of _____ and ______ is the typical cause of uterine atony.
oxytocin & prostaglandins (uterotonics)
What is the first line uterotonic?
Oxytocin
What is the half life of oxytocin?
3 - 5 minutes
How is pitocin typically diluted?
20 units in 1000mLs
What are possible side effects of oxytocin?
Dose-dependent:
- Tachycardia
- Hypotension
- Coronary vasoconstriction
- Hyponatremia
- Seizures
Typically, oxytocin is given at a rate of ______ to prevent side effects.
< 1 unit/min
What is the 2ⁿᵈ line uterotonic agent?
Methylergonovine (Methergine)
What is the dose of methergine?
0.2mg IM
Can methergine be given IV?
NO
What is the duration of methergine?
2 - 4 hours
Which uterotonic is unstable at room temperature?
Methergine
What is the max dose of Methergine?
0.8mg
What are contraindications to methergine administration?
- Preeclampsia
- HTN
- Vascular disease
- Coronary artery disease
If hypertension results from methergine, what drugs should be used to treat the hypertension?
- NTG
- Nitroprusside
What is the 3ʳᵈ line uterotonic agent?
Carboprost (Hemabate)
What drug should be given in a preeclamptic patient that has already received oxytocin for refractory uterine atony?
Carboprost
What is the dose of carboprost?
250 mcg IM
or
Intrauterine q15-90 min
What is the max dose of carboprost?
2000 mcg
What are the primary adverse effects seen from carboprost?
Pulmonary:
- Bronchospasm
- VQ mismatch
- Shunt
- Hypoxia
- ↑ PVR
Extra caution should be given to patients with what condition before adminstering carboprost?
Reactive Airway Disease
aka
Asthma
What is the dose of Misoprostol (Cytotec)?
600 - 1000mcg
Risk for postpartum hemorrhage will increase if the interval between fetal delivery and placental delivery is greater than _______.
30 minutes
What is the anesthetic treatment for retained placenta?
Induced uterine relaxation for surgical removal.
What drugs are typically used to relax the uterus for retained placenta removal?
- Nitroglycerin 25 - 50mcg IV
- VAA’s
What is placenta accreta?
Placenta invasion of the uterine wall
What is placenta increta?
Placenta invasion of the myometrium
What is placenta percreta?
Placental intrusion through myometrium into serosa & abdominal cavity (and potentially other organs).
What are risk factors for placenta accreta?
- C-section history
- Placenta previa w/ or w/o uterine sx
- Myomectomy hx
- Asherman syndrome
- Advanced maternal age
What are the degrees of uterine inversion?
What are the risk factors for uterine inversion?
- Overzealous fundal pressure
- Umbilical cord traction
- Uterine atony
- Placenta accreta
- Overall anatomical abnormalities
What are two complications commonly associated with uterine inversion?
- Hemorrhage
- Vagal bradycardia
What is the definitive surgical treatment for PPH?
Peripartum hysterectomy
Possible risk for needing a hysterectomy will increase with the patient’s number of previous ________.
c-sections
How much higher is mortality for a peripartum hysterectomy vs a non-pregnant hysterectomy?
25x higher!
Why are peripartum hysterectomy’s more challenging?
- Large uterus
- ↑ blood flow (700 - 900 mL/min)
- Engorged vasculature
What sensory level for neuraxial anesthesia must be maintained for a peripartum hysterectomy?
T4
Often these patients get GETA
Parturients can typically tolerate EBL of ___% total blood volume before symptoms or vital sign changes occur.
15%
_______ is a late sign of hemorrhage in parturient patients.
hypotension
Parturients have a higher blood volume at baseline.
Fibrinogen should be maintained at > ________.
150 - 200 mg/dL
What blood product should be given for a low fibrinogen?
Cryoprecipitate
If blood loss is greater than 5L then ______ transfusion is indicated.
platelet
1 bag of platelets increases the total count by ______ to ______.
5000 to 10000 mm3
What dosing of TXA is indicated for PPH?
1g IV within 3hours of recognition of hemorrhage
Can one attempt TOLAC after their previous c-section had a classic incision?
No
Only low transverse or low vertical incisions may attempt TOLAC
Elevated levels of Fetal fibronectin (fFN) is predictive for what?
Preterm labor
What medication class is used to accelerate fetal lung development?
Corticosteroids
- Betamethasone 12mg IM q24
- Dexamethasone 6mg IM q12
What drug is given for fetal neuroprotection in preterm labor?
Magnesium sulfate
What is a tocolytic?
β-adrenergic agonist that relaxes uterine smooth muscle
What is a common tocolytic given for preterm labor?
Terbutaline
What are the side effects of terbutaline?
- Dysrhythmias
- Pulmonary edema
- Hypotension
- Tachycardia
Caution should be used when giving terbutaline to a parturient that is fluid overloaded, why?
↑ risk of pulmonary edema
What NSAID tocolytic can be given for preterm labor?
Indomethacin
- Inhibits cyclooxygenase, thus prevening synthesis of prostaglandins from arachidonic acid
What are the side effects of indomethacin?
Nausea & heartburn
How does magnesium treat preterm labor?
- Competitive agonism of Ca⁺⁺ → reduces Ca⁺⁺ influx into uterine myocytes.
- Limits acetylcholine
What s/s are associated with long-term magnesium administration?
- Flushing
- Sedation
- Chest pain
- Blurry vision
- Hypotension
- Pulmonary edema
- Abnormal neuromuscular function
What is the primary diagnostic sign of hypermagnesemia?
Decreased deep tendon reflexes
associated with ↓ compensatory responses to hemorrhage.
How will magnesium effect neuromuscular blocking drugs?
Mg⁺⁺ potentiates depolarizing and non-depolarizing neuromuscular blockers.
give sugammadex
How is Mg⁺⁺ dosed?
- 2 - 4 g load
- 1 - 2 g/hr
What are normal serum Mg⁺⁺ levels?
1.7 - 2.4 mg/dL
What are therapeutic Mg⁺⁺ levels?
5 - 9 mg/dL
