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OB > DM Obesity, Multile Gestation, Abnormal Presentation > Flashcards

DM Obesity, Multile Gestation, Abnormal Presentation Flashcards

1
Q

Abnormal presentations

A

Transverse lie, face, brow, compound

Breech (frank, incomplete, complete)

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2
Q

Describe normal presentation of fetus

A 
Cephalic presentation
Head enters birth canal first
Face backward towards mother spine
Arms crossed
Chin and neck bent forward down toward chest
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3
Q

Most common complication with breech and its treatment?

A

Umbilical cord prolapse

Stat c section

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4
Q

Fetal entrapment happens more often with that babies

A

Pre term <32 weeks bc of their small heads

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5
Q

Pharmacologic treatment for vaginal breech

A

Goal is complete relaxation
NTG 1-2 sublingual sprays 400-800 mcg
IV 50-500mcg

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6
Q

External cephalic version is done when

A

Ideally at term and at the hospital due to CS capability

prior to labor

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7
Q

What pharmacologic meds can be used for skeletal and cervical/uterine smooth muscle relaxation

A 
Skeletal muscle relaxation 3% 2-Chloro
Smooth muscle relaxation NTG 
160-600 mcg for fetal head entrapment
50-100mcg for retained placenta
GA:2-3 MAC
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8
Q

Maternal complications with multiple gestation

A 
Antepartum/postpartum hemorrhage
DIC
Operative delivery - forceps CS
Obstetric Trauma
Preterm premature ROM
Preterm labor
Prolonged labor
Preeclampsia/eclampsia
Placental abruption
Uterine atony
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9
Q

Fetal complications in multiple gestation

A 
Congenital anomalies
Cord enlargement
IUGR
Malpresentation
Preterm delivery
Polyhydramnios
Twin to twin transfusion
Umbilical cord prolapse
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10
Q

Fetal consequence for twin to twin transfusion

A

Circulatory overload with HF
Occlusive thrombosis Polycythemia
hyperbilirubinemia and kernicterus

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11
Q

Maternal physiologic changes for multiple gestation

A 
Greater decrease in FRC
Increased O2 consumption
Blood volume 500ml greater with twins
Increased CO2
Aortocaval compression
CNS spread of spinal, reduce dose (increased uterine size, more progesterone)
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12
Q

Route of delivery for triplets or higher

A

CS

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13
Q

Fetal presentation types for twins

A

Can be either vertex or non vertex

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14
Q

Steps for anesthetic management of multiple gestation

A 
Large bore IV, T&S
Epidural or CSE
Twin B may need manipulation
LUD
Fluids/vasopressors
GA
Uterine relaxation, NTG
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15
Q

What anesthetic management is preferred with multiple gestation

A

Regional - epidural over spinal

GA causes a greater decrease in FRC and increased O2 consumption

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16
Q

Class of DM during pregnancy where gestational DM is diet controlled

A

A1

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17
Q

Class where gestational diabetes requiring insulin

A

A2

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18
Q

What class has pre-existing DM with onset >20 y/o and duration <10 years without complications

A

B

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19
Q

What class has pre-existing diabetes with onset between ages 10 and 19 or duration of ages 10 to 19 without complications

A

C

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20
Q

What class of diabetes has pre-existing diabetes with onset <10 or duration >20 years, without complications

A

D

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21
Q

What class of diabetes has pre-existing diabetes complicated by neuropathy

A

F

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22
Q

What class of diabetes has pre-existing diabetes complicated by proliferative retinopathy

A

R

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23
Q

What class of diabetes has pre-existing diabetes and status/post kidney transplant

24
Q

What class of diabetes has pre-existing diabetes complicated by ischemic heart disease

25
Q

What hormones cause a progressive insulin resistance in pregnancy

A

Progesterone, cortisol, placental lactogen increases

26
Q

Definition of gestational diabetes

A

Unable to increase insulin production

27
Q

Type 1 DM has an increased risk of what during pregnancy

A

Hypoglycemia

28
Q

DKA can occur when

A

BS 200-250, Type 1

29
Q

What in pregnancy causes DKA

A

Insulin resistance, enhanced lipolysis, ketogenesis

30
Q

DKA causes what for fetus

A

NRFHR

Resolves when maternal metabolism is corrected

31
Q

Complications with DM

A 
CS
FHR abnormal 
Pre-eclampsia
Polyhydramnios
UPP decreases
32
Q

Fetal effects from DM

A 
Macrosomia
Congenital anomalies
Perinatal mortality
Shoulder dystocia
Hypoglycemia - fetal hyperinsulinemia in response to maternal hyperglycemia
33
Q

DM management during labor

A

Optimal glucose control 60-120
Hourly checks
IVF NS
Hold AM insulin

> 140 consider insulin drip
<70 consider D5

34
Q

DM management after delivery

A

Decreased insulin requirement
Stop insulin drip
Avoid hypoglycemia

35
Q

DKA management

A 
ABGs
IVF NS
Insulin/potassium drips
LUD
O2
Avoid premature delivery
36
Q

Glucose tolerance testing is done

A

Between 24-28weeks of pregnancy
1 hour test
3 hour test if first one comes back abnormal

37
Q

Gestational diabetes requires what testing

A

28-32 weeks twice weekly non stress test

38
Q

Regional and DM

A

Increased risk of hypotension during regional and GA

39
Q

What pre-anesthetic considerations should you consider with DM

A 
Cardiac, vascular, renal involvement
Glycemic control
Autonomic neuropathy
Ischemic heart disease
Gastroparesis
Stiff joint syndrome - atlanto occipital joint. Positive prayers sign
40
Q

What is stiff joint syndrome d/t

A

Non enzymatic glycosylation of collage and its deposition to joints

41
Q

Epidural precautions with DM

A

Hydrate
Hypotension = fetal compromise
Ephedrine!
Autonomic neuropathy = hypotension

42
Q

Advantages of epidurals with DM

A

Analgesia
Decreases plasma catecholamines (catecholamines oppose insulin activity)
Improved glucose control
Improved UPP

43
Q

NRFHR in DM means one of the following features

A 
Baseline FHR 100-109 or 161-170
Variability reduced
Decelerations are variable without complicating features
Absence of of accelerations
Sinusoidal rhythm
44
Q

DM anesthetic considerations for CS

A

Increased incidence
Regional vs GA
Epidural vs spinal
Hydration ephedrine

45
Q

DM anesthetic considerations for GA

A

Reglan, Bicitra, ranitadine
More severe hypotension d/t autonomic neuropathy
LUD, hydration
+ prayer sign

46
Q

Pulmonary changes for obese OB

A 
Increased O2 consumption and CO2 production
Increased WOB
Decreased TV
Decreased FRC, ERV, VC
Airway closure during TV
V/Q mismatch
Increased plasma volume
Chronic hypoxemia
Pulmonary hypertension associated with high mortality rate
47
Q

GI changes for Obese OB patients

A

Ph <2.5

Gastric volume >25ml

48
Q

What are the increased risks of Obese OB patients

A 
HTN, preeclampsia
Gestational DM
Thromboembolic disease and infection
Anesthesia related mortality (airway)
Maternal death
49
Q

Obese OB patients and perinatal adverse outcomes

A

NRFHR
Macrosomia: birth trauma, should dystocia
Meconium aspiration
Neural tube defects and congenital anomalies
Higher incidence of antepartum death and early neonatal death

50
Q

Anesthetic management for obese OB patients

A

Obesity hypoventilation syndrome ABG
Long needle for neuraxial techniques

Encourage neuraxial early
Airway: exam and equipment
Pulm cardiac status

51
Q

Things to consider with epidurals for OB obese patients during labor

A 
Ability to extend block
Challenging
Increased depth of epidural space
Positioning sitting is easier
Increased failure rate
Secure after positioning laterally
Minimize motor block
CSE unproven epidural
52
Q

Considerations for Spinal for Obese OB patients in labor

A

Easier
Superior labor analgesia
Motor block nonexistent, dense sensory block
Catheter placement easily confirmed with CSF
Titrate level and density of block
Increased risk of PDPH secondary to needle size

53
Q

Anesthetic considerations for CS obese

A
  1. Increased risk with GA, regional preferred
    Epidural slow titration, exaggerated spread in obese patients
    Slow onset of sympathetic blockade
    High failure rate
  2. Longer surgery duration
  3. LUD
  4. Cephalad retraction of panniculus (respiratory compromise)
  5. Aspiration prophylaxis
54
Q

Spinal vs epidural in obese patients

A

Spinal - surgery duration, lack of titration, high spinal/inadequate spinal, quickest technique great with urgency
Epidural - high failure rate, slow onset of sympathetic blockage, slow titration - exaggerated spread in obese patient

55
Q

Considerations GA for obese

A 
Avoid when possible
Airway/aspiration prophyalxis 
Previous easy airway does not guarantee airway in pregnancy
Careful positioning
Consider awake intubation

OB (10 decks)

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