Complications in OB Flashcards by Andrew Skuta

“Term for singleton pregnancy is ____ completed weeks to ____ weeks.

37-42

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pre-term labor: regular uterine contractions occurring at least q___ min resulting in cervical change prior to ___ weeks.

q10
37 weeks

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Very low birth weight (VLBW)

any infant < 1500g.

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Low birth weight (LBW)

any infant < 2500g at birth.

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Respiratory Distress Syndrome: Exacerbated by…..

intrapartum hypoxia, maternal stress

Almost all infants <27 wks GA, almost 0% by 36 wks GA.

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Cause of Intracranial Hemorrhage

Uncontrolled delivery/trauma, neonatal HTN.

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Association of PTL with genital tract colonization with :

Group B Strep, Neisseria gonorrhoeae, and bacterial vaginosis organisms.

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C-section or vaginal delivery?
Concern regarding intracranial hemorrhage:

No difference

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C-section or vaginal delivery?
Obstetrician use of outlet forceps to assist delivery :

no difference

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C-section or vaginal delivery?
Breech:

C-section is proven safer in PTL with breech presentation
Will do scheduled c section with breech

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What is Tocolylitic therapy?

Attempt to stop or slow contractions to avoid PTL.

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Reasons for tocolytic therapy:

Gestational age 20-34 wks, EFW < 2500 g, absence of fetal distress.

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How long can Tocolytic therapy be used?

Used for short-term (<48 hrs),

to permit corticosteroid treatment to aid fetal lung maturation, or allow transfer to a facility with appropriate NICU facilities.

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Methylxanthines: how does Phosphodiesterase work?

increase intracellular cAMP —> uterine muscle relaxation.

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Tocolytic Therapy: Calcium Channel Blockers (Nifedipine) MOA…

Myometrium contractility related to free calcium concentration: decrease in Ca2+ —->decrease contractility.

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Maternal side effects of CCBs

-Hypotension, tachycardia, dizziness, palpitations
-Facial flushing
-Vasodilation, peripheral edema
-Myocardial depression, conduction defects
-Hepatic dysfunction
-Postpartum hemorrhage
-Fetal side effects
-Decreased UBF –>fetal hypoxemia and fetal acidosis

LOTS!

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Calcium Channel Blockers may increase risk of_______ _________ due to uterine atony refractory to ________ and _________ F-α2

postpartum hemorrhage
oxytocin and prostaglandin F-α2

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Tocolytics: Prostaglandin Synthetase Inhibitors MOA

Mechanism of action: decrease cyclooxygenase ———> decrease prostaglandin

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TOCOLYTIC THERAPY: Magnesium MOA

-May compete with calcium for uterine smooth muscle surface binding —–> decrease contractility.

-Prevents increase in intracellular calcium.

-Activates adenylcyclase —–> increase cAMP.

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Magnesium: Patient is more sensitive to both _________ and _________

depolarizing and nondepolarizing muscle relaxants.

1 treatment in tocyltic therapy

Magnesium

Magnesium and MAC:

MAC is decreased for inhalational anesthetics

Normal treatment range of Magnesium for tocolytic therapy:

4-7 mg/100 mL

Magnesium toxicity dose: = loss of deep tendon reflexes

8-10 mg/100 mL

Magnesium toxicity dose: respiratory depression, cardiac conduction defects (wide QRS, inc. P-R interval)

10-15 mg/100 mL

Magnesium toxicity dose: cardiac arrest

20+ mg/100 mL

Magnesium toxicity treatment

calcium gluconate or CaCl

Tocolytic: Beta adrenergic agonists (terbutaline, ritodrine) MOA

Direct stimulation of β-adrenergic receptors in uterine smooth muscle -----> increase cAMP ------> uterine relaxation.

Side effects of Beta adrenergic agonists (terbutaline, ritodrine)

-Nausea, vomiting -Anxiety, restlessness -Hyperglycemia, hyperinsulinemia, hypokalemia, acidosis -Tachycardia, arrhythmias, dec. peripheral vascular resistance, dilutional anemia, dec. colloid oncotic pressure, pulmonary edema

Frequency of Beta agonist pulmonary edema

Incidence 1-5% of parturients receiving beta adrenergic tocolytic therapy

Risk factors for Beta agonist pulmonary edema

-Increased IVF administration -Multiple gestation -Tocolysis greater than 24 hrs -Concomitant magnesium therapy -Infection -Hypokalemia -Undiagnosed heart disease Infection – increased pulmonary capillary permeability Echocardiogram – no evidence of LV dysfunction Decreased colloidal oncotic pressure – further dec. due to sodium and water retention with beta adrenergics

Fetal mortality risk is increased ___-___x in twins vs. singleton pregnancy

5-6 times

Mortality of second twin is greater than first twin because...

-Placental abruption -cord prolapse -malpresentation

Triplet or higher pregnancy – almost always delivery by ________.

c-section

Local anesthetic considerations for Multiple gestation pregnancy.

-May require rapid increase in density of block if internal manipulation of twin B or conversion to C-section. -2-chloroprocaine 3% is preferred for rapid onset

MULTIPLE GESTATION ANESTHESIA CONSIDERATIONS :

-Early epidural placement and time to assess functionality. -Inc. risk of hemorrhage – large bore IV, blood T&C. -Inc. risk of aortocaval compression due to inc. uterus size. -Delivery in OR, treat as C-section with regards to precautions (i.e. aspiration prophylaxis), O2, monitors.

What to give for internal manipulation and uterine relaxation (multiple gestation)

Nitroglycerin 100 mcg initially, repeated to max of 500 mcg.

Signs and Symptoms of Uterine Rupture

-Sudden abdominal pain despite functioning epidural -Vaginal bleeding -Hypotension -Cessation of labor -Fetal distress – most reliable sign

Diagnosis of Uterine Rupture

manual exploration, laparotomy

Risk factors for Uterine Rupture

-Previous uterine surgery -Trauma -Multiparity -Uterine anomaly -Oxytocin -Placenta percreta -Tumors -Macrosomia -Malposition

Most common abnormal presentation

longitudinal – vertex or breech

Risks of abnormal presentation

Inc. risk of fetal death, asphyxia, birth trauma, cord prolapse, maternal infection (d/t internal manipulation)

_______ ______is an absolute indication for c-section

Transverse lie

% success of manipulation of fetus for Breech

50-80% Regional anesthesia – inc. maternal comfort, inc. success rate.

Post Maturity- definition and risks

Gestation beyond 42 wks, risks often evident at 40-41 wks Dec. uteroplacental blood flow --> fetal distress Umbilical cord compression due to oligohydramnios Meconium staining of amniotic fluid Inc. incidence of macrosomia, shoulder dystocia

IUFD Causes

CORD ACCIDENTS! -Chromosomal abnormalities -Congenital malformations -Multiple gestation -Infection -Placental factors -Maternal immunological or thyroid disease -Isoimmunization -Maternal trauma

Cord prolapsed through cervix, compressed, approx. __ minutes window before fetal compromise.

Umbilical cord length

<30 cm risks compression, constriction, rupture. >72 cm risks cord entanglement

Most reliable sign of Uterine Rupture

-Fetal distress – most reliable sign