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Advanced principles > E2 OB > Flashcards

E2 OB Flashcards

1
Q

Define the following terms
Parturient
Gravida/Para
FHT/FHR

A

Parturient=pregnant patient
Gravida=number of times parturient has been pregnant
Para=number of times parturient has delivered
FHT/FHR=fetal heart tones/rate

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2
Q

Define the following terms
1st stage labor
2nd stage labor
3rd stage labor

A

1st stage:
Begins-w/ onset of true labor (regular contractions)
Ends-when 10 cm dilated

2nd stage:
Begins-when 10 cm dilated (complete)
Ends-when fetus delivered

3rd stage:
Begins-when fetus delivered
Ends-with delivery of placenta

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3
Q

Describe changes to heart size

A 
Ventricular hypertrophy (ECCENTRIC)
By term--50% INC in LV mass
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4
Q

How can INC LV mass affect the parturient CV physiology

A

DEC LV compliance affects LV fxn

Can DEC diastolic filling rate

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5
Q

Describe diastolic changes in the parturient

A

Dysfxn causes INC dependence on ATRIAL contraction for VENT filling

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6
Q

What can previous heart problems contribute to during pregnancy

A

Thromboembolism
PIH
HELPP
Amniotic fluid embolism

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7
Q

Describe how the location of the heart is affected by pregnancy?
How can this present on EKG?
How does this affect PMI?

A

SHIFTED:
ANTERIOR & LEFT

EKG:
Left axis deviation
-QRS in V1 positive
-QRS in aVF negative

PMI:
Displaced CEPHALAD & LEFT
To 4th ICS & midclav line
-NORM = 5th ICS & MCL

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8
Q

How is the first heart sound affected by pregnancy

A

Exaggerated splitting of mitral & tricuspid valve (more fluid)

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9
Q

How is the 3rd HS affected by pregnancy and why?

A
  • Can be heard in THIRD trimester
  • Ventricular gallop
  • Result of INC vent size
  • -INC BV
  • -INC contraction force
  • -INC stretch
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10
Q

How is the 4th HS affected by pregnancy?

A

disappears at term

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11
Q

What are normal HS for TERM gestation parturient

A

1st, 2nd, 3rd
-NO 4th HS at term
Systolic ejection murmur

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12
Q

Describe the pregnancy related heart murmur and cause

A

Grade II SEM @ upper sternal border & right side of heart
-benign
Cause = INC BV & flow through valve

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13
Q

What types of valve problems are common in parturient

A 
Tricuspid & pulmonic regurg
Mitral regurg (less common)
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14
Q

How does pregnancy affect a pre-existing murmur from AV/MV regurg

A

-Intensity will DEC d/t DEC SVR

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15
Q

How can phenylephrine affect a pre-existing murmur during pregnancy

A

Can INC intensity of murmur

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16
Q

How does the development of PIH affect pre-existing murmur from AVR/MVR

A

INC intensity

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17
Q

How does pregnancy affect a pre-existing murmur from AS & why

A

INC intensity

-d/t INC FLOW through stenotic valve

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18
Q

What are normal QRS EKG variants during pregnancy
During 1st trimester
During 3rd trimester

A

QRS axis shift
1st trimester = RIGHTWARD (QRS negative in lead I)
3rd trimester = LEFTWARD
(QRS in V1 positive; QRS in aVF negative)

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19
Q

What are ST-T wave EKG variants during pregnancy?
Why?
What is done?

A

DEPRESSION

  • during labor w/ pitocin
  • nothing is done
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20
Q

What is done if a parturient develops ST-T wave elevation

A

REFER to CARDS because this is a pathologic finding and is NOT normal variant

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21
Q

Describe the clinical implications of altered PR intervals & uncorrected QT intervals during pregnancy

A

DEC risk of QT prolongation complications d/t INC HR

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22
Q

When is the parturient at highest risk for complications r/t long QT syndrome

A

40 weeks POST-delivery

high risk for VT

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23
Q

How may parturients with prolong QT syndrome be treated

A

beta-adrenergic antagonist during & post-delivery

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24
Q

What is the most common parturient CV abnormality and causes (4)

A

Tachydysrhythmias

Causes:

  • change in cardiac ion channel conduction
  • INC cardiac size
  • Changes in autonomic tone
  • Hormones
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25
Q

What is the treatment for tachydysrhythmias in the parturient

A

beta-adrenergic antagonist

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26
Q

How does pregnancy affect cardiac output and why

A

INCREASES

  • result of INC HR in 1st trimester
  • d/t INC SV by 2nd trimester
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27
Q

When does CO increase peak in pregnancy and by what %

A

Around 32 weeks (by end of 2nd trimester)

Peak ~50% of baseline

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28
Q

A parturients pre-pregnancy CO is 5 L/min. What would her CO be by the end of the 2nd trimester

A

7.5 L/min

INC by 50%
5 x 1.5 = 7.5

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29
Q

Pre-pregnancy CO is 5, what is the CO by the end of 1st trimester.

A

6.75 - 7 l/m

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30
Q

How does pregnancy affect stroke volume by 1st & 2nd trimester

A

INCREASES
1st=20%
2nd=25 - 30%

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31
Q

The parturients pre-pregnancy SV is 60 - 110 ml. What is the estimated SV by the end of 1st and 2nd trimester?

A

1st:
72 - 132 ml

2nd:
78 - 154 ml

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32
Q

How can CO alter during the 3rd trimester and why

A

Can DECREASE

d/t venous compression impeding VR

33
Q

How does peripheral distribution (blood flow) change during pregnancy and to where

A

Distribution INCREASES

  • UBF is INCREASED
  • INC skin blood flow (3-4x baseline)
34
Q

How does labor alter CO in between contractions

A

There is an additional 40% INCREASE by 2nd stage labor

35
Q

Which increases more, SV or HR, to increase CO during 2nd stage labor

A

INC SV&raquo_space; INC HR

36
Q

How is CO affected by the 1st stage of labor.

What factor may affect the CO

A

Latent phase = INC 10%
Active phase = INC 25%

INC VR & altered SNS activity can INC CO

37
Q

How is distribution of BF affected by contractions and why

A

300 - 500 ml of blood is autotransfused via redistribution from UBF into central circulation d/t INC uterine pressure during contractions

38
Q

When is the greatest INC in CO during pregnancy and why

A

Immediately following delivery (3rd stage)

D/t autotransfusion of BF from uterus during contractions

  • INC VR
  • altered SNS activity
  • Pressure relief on VC
  • DEC LE venous pressure
  • DEC venous capacitance
39
Q

Describe CO 24 hrs postpartum

A

24 hrs = Returns to pre-LABOR values

12 - 24 wks = CO return to pre-pregnancy baseline

40
Q

How does SVR change during pregnancy

A

DEC of 35% at 20 weeks

INC ~20% from baseline when NEAR TERM

41
Q

What factors alter SVR during pregnancy (4)

A
  1. Low resistance placental circulation
  2. Progesterone, prostacyclin, estrogen
  3. DEC blood viscosity
  4. Vasculature loses responsiveness to ANGIOTENSIN
42
Q

How does the low resistance of placental circulation affect SVR and why

A
  • DEC SVR d/t
    1. parallel systemic circulation
    2. DEC afterload
43
Q

How do hormones (progesterone, prostacyclin, estrogen) alter SVR and why

A

DECREASES

-increased levels cause vasodilation and relax vasculature

44
Q

Is is blood viscosity altered and how does it affect SVR

A

DECREASED

  • INC in plasma vol vs RBC
  • Causes decreased viscosity d/t dilutional anemia
45
Q

What 4 factors impact BP during pregnancy

A

Positioning
Gestational age
Maternal age
Parity

46
Q

How do positioning and gestational age affect BP during pregnancy

A

Positioning:
SUPINE leads to aorto-caval HoTN

Gestational age:
SVR INC by end of pregnancy

47
Q

How do maternal age and parity affect BP during pregnancy

A

Maternal age:
Old parturient can have more comorbidities

Parity
Higher parity = higher HTN incidence

48
Q

How is EF altered during pregnancy and why

A

Alteration:
INCREASED

Why:
INC volume
INC HR
DEC SVR

49
Q

How are LVEDV & EF affected by pregnancy

A 
LVEDV = INCREASE
EF = INCREASE
50
Q

How are CVP, PA diastolic pressure, PCWP altered during pregnancy

A

All are unchanged or DECREASED

51
Q

What CV parameters are increased during pregnancy (5)

A

EF, LVEDV, CO, SV, HR

52
Q

What CV parameters are unchanged or decreased during pregnancy (4)

A

CVP, PA diastolic pressure, PCWP, SVR

53
Q

The initial increase in CO is d/t ____

A

an INCREASE in HR

54
Q

**Left axis deviation can be seen on 3rd trimester EKG because **

A

-Heart shifted ANTERIOR & LEFT

55
Q

What is aortocaval compression & why does it happen

A

IVC compression against vertebral column by enlarged uterus when supine

Due to:

  • DEC VR
  • DEC SV & CO b/c DEC RA filling
  • DEC uteroplacental perfusion
56
Q

What does aortocaval compression lead to and when can it be appreciated

A

Supine Hypotensive syndrome

Seen as early as 13 - 16 weeks gestation
Biggest problem @36 - 38 weeks

57
Q

When can aortocaval incidence decrease and why

A

After 38 weeks

D/t fetal head descent into pelvis

58
Q

How is aortocaval compression avoided or treated

A

1Do not lay term gravid pt flat on back

1Place in left uterine displacement position

59
Q

What happens to VR when the pregnant patients lies supine

A 
DEC VR d/t compression
DEC RA filling
DEC CO/SV
DEC uteroplacental perfusion
DEC fetal perfusion/HR
60
Q

Will the BP in the upper extremity INC or DEC when the abdominal aorta is compressed

A

INCREASE (similar to cross-clamping)

61
Q

How is LE BP affected by aortocaval compression

A

Will DECREASE LE BP

62
Q

What are symptoms of aortocaval compression (5)

A
  1. Tachycardia (initially)
  2. Bradycardia (late)
  3. N/V
  4. Pallor
  5. LOC
63
Q

Methods to avoid aortocaval compression

A
  • Do not lie flat
  • Tilt 15* left
  • Do not sit up (leg flexion rotates uterus & compresses IVC)
64
Q

What position would you place the term parturient experiencing tachycardia, n/v, and pallor

A

Left uterine displacement position

65
Q

How is aortocaval compression fixed

A

Left uterine displacement position

66
Q

What respiratory anatomic change occurs d/t INC intraabdominal volume

A
  • Elevated diaphragm displaces lungs cephalad
  • Widened AP/Transverse diameter
  • INC diaphragmatic excursion
  • DEC chest wall excursion
67
Q

What hormone leads to pulmonary anatomic changes & why

A

Relaxin

  • Relaxes ligamentous attachments to lower ribs
  • Progressively widens subcostal angle
68
Q

How does the widened AP & transverse diameter of thoracic cage alter chest wall excursion

69
Q

Is FRC INC or DEC in parturient?

Why is this important to anesthesia provider?

A

DECREASED

Importance = little apneic reserve, desat quickly on induction etc?

70
Q

What factors lead to SOB of the parturient (6)

A
  1. INC respiratory drive
  2. DEC PaCO2
  3. Large uterus
  4. Larger pulmonary BV
  5. Anemia
  6. Nasal congestion
71
Q

How is tidal volume altered during pregnancy?

When is majority of change?

A

Vt + 45%

Majority during 1st trimester

72
Q

How are the following volumes affected by pregnancy
IRV
ERV
RV

A

IRV + 5%
ERV - 25%
RV - 15%

73
Q

Which volumes are increased and decreased

A

Increased:
Vt, IRV

Decreased:
ERV, RV

74
Q

Calculate the pregnancy changes in volume for the following baseline values

Vt 500 ml
IRV 3100 ml
ERV 1200 ml
RV 1000 ml

A

Pregnancy values

Vt = 725 ml
IRV = 3,255 ml
ERV = 900 ml
RV = 850 ml
75
Q

How is FRC altered during pregnancy?

When does the decrease begin?

A

FRC - 20%

Decreases around 5th month

76
Q

How are the following capacities affected by pregnancy
IC
VC
TLC

A

IC + 15%
VC = unchanged
TLC - 5%

77
Q

Which capacities are increased, decreased, or unchanged.

A

Increased:
IC

Decreased:
TLC, FRC

Unchanged:
VC

78
Q

Calculate the pregnancy changes in capacities for the following baseline values

IC 2,050 ml
VC 60 - 70 ml/kg
TLC 6,000 ml
FRC 2,400 ml

A

IC + 15% = 2,385 ml
VC = unchanged
TLC - 5% = 5,700 ml
FRC - 20% = 1,920 ml

Advanced principles (2 decks)

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