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OB Anesthesia > Exam 2: Labor/Vaginal delivery, systemic disease, anesthetic complications > Flashcards

Exam 2: Labor/Vaginal delivery, systemic disease, anesthetic complications Flashcards

1
Q

what are the risk factors for gestational Diabetes

A

maternal age (30-35)
obesity
family hx DM2
hx gestational DM
Hx PCOS
HX still births
hx macrosomic babies

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2
Q

what weight of the baby is considered macrosomic

A

8lbs 13 oz

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3
Q

when is the testing for gestational diabetes done

A

24-28 weeks gestation

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4
Q

describe the 1 step process for gestational diabetes testing

A

8 hr fast BG<92
75g oral glucose
1 hr- BG <180
2 hr- BG <153

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5
Q

describe the 2 step process for gestational diabetes testing

A

non fasting
50 g oral glucose
1 hr BG> 130, go to step 2
step 2: 100 g oral glucose test with BG tested at 1,2,3 hours

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6
Q

What causes gestational diabetes?

A

progressive resistance to insulin
-maternal adipokines

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7
Q

what are HgA1C levels pre and intra pregnancy

A

pre: 4-5.5%
post: 4.8-6.5%

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8
Q

T/F if you have gestational DM, you have DM2 after preggers

A

F, most return to baseline after birth
-but have an increased risk for DM and gestational DM

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9
Q

how are insulin requirements affected in pregestational DM

A

increase from 0.7 units/kg to 1.0 units/kg at term

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10
Q

how are insulin requirements in pregnancies with multiple gestation

A

higher

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11
Q

how are nighttime maternal insulin requirements

A

requirements may drop

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12
Q

T/F epidural analgesia and oxytocin affect insulin requirements during first and second stages of labor

A

false

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13
Q

how is insulin requirment for DM 1 after birth

A

decreases for several days

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14
Q

what risks are increased with maternal DM

A

HTN
polyhydramnios
C section

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15
Q

why does DM increase risk of C section

A

big babies

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16
Q

what is a large amount of amniotic fluid

A

polyhydramnios

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17
Q

DM 1 are _____x more likely to develop gestational HTN

A

3

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18
Q

pregestational DM is at a ____-______x greater risk of preterm labor and delivery

A

2-3

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19
Q

what are risks of macrosomia

A

birth trauma and shoulder dystocia

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20
Q

what is macrosomia

A

A high-birthweight infant

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21
Q

what are some fetal risks of maternal DM

A

macrosomia
5x more likely to have anomalies (cardiac)
neonatal hypoglycemia

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22
Q

what treatment can reduce anomalies from 10% to 1%

A

strict BG control

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23
Q

in maternal DM is hyper or hypoglycemia preferred

A

hypo

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24
Q

what level should BG be maintained at in maternal DM

A

nondiabetic levels

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25
Q

DM lab values chart

A
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26
Q

what does DM increase risk of anesthesia wise

A

autonomic cardiovascular dysfunction
gastroparesis (aspiration)

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27
Q

what is sign of autonomic cardiovascular dysfunction

A

increased QT interval on EKG

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28
Q

what fluids do we avoid in preggers with DM

A

D5W, causes fetal acidosis

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29
Q

how are insulin requirements in second stage of labor

A

increased

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30
Q

what is BG risk after delivery with DM

A

hypoglycemia

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31
Q

what kind of anesthesia is preferred for C section with DM

A

neuraxial over GA

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32
Q

what is thyroid state in normal pregnancy

A

euthyroid

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33
Q

what is the leading cause of thyroid disorders in prgnancy

A

graves disease

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34
Q

what are signs of graves disease

A

nervousness
sweating
heat intolerance
tremors
weakness

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35
Q

what does graves disease mimic

A

MH

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36
Q

what physical change is associated with thyroid disorders

A

increase in thyroid nodules number and size

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37
Q

how are maternal iodine level in preggers

A

decreased

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38
Q

what is the percent of hyperthyroid in preggers

A

0.2%

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39
Q

what events precipitate thyroid storm

A

surgery
childbirth
trauma
iodinated contrast agents
treatment with iodine-131
emotional stress
PE
stroke
infection
diabetic ketoacidosis
hypoglycemia
CHF
Bowel infarction

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40
Q

how do you treat thyroid storm

A

cooling blankets
meperidine
hydration
acetaminophen
O2
beta blockers

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41
Q

how do you decrease thyroid hormone secretion

A

iodine
glucocorticoids

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42
Q

what do we give to reduce T4 conversion for thyroid storm management

A

glucocorticoids
propranolol
radiographic contrast agents
propylthiouracil

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43
Q

what are the modes of treatment for thyroid storm

A

treat symptoms
reduce thyroid hormone secretion
reduce T4 conversion
plasma exchange

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44
Q

what are the 4 principles ways to minimize thyroid storm

A

1-antithyroid medication (propylthiouracil)
2- beta blockers
3-glucocorticoids
4-iodine

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45
Q

T/F you can elective procedure with thyroid storm

A

F, not without 1 week premeds?

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46
Q

what drugs do we avoid in thyroid issues

A

glycopyrrolate, ephedrine

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47
Q

how is cardiovascular response in hyperthroid

A

hyperdynamic, dont increase BP more than thyroid already is

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48
Q

what is risk of enlarged thyroid/goiter

A

may pose airway issues

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49
Q

how are resp muscles in hyperthyroid

A

weak, make sure are fully reversed

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50
Q

what labs do you check in thyroid issues

A

electrolytes

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51
Q

where do 90% of phemochromocytoma occur

A

adrenal medulla or adjacent sympathetic tissue

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52
Q

what can occur after resection of phemochromocyroma

A

hypotension

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53
Q

what percentage of pheochromocytoma are malignant

A

10%

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54
Q

what do pheochromocytomas release

A

epi and norepi

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55
Q

what are most common symptoms of phemochromocytoma

A

sweating, tachycardia, HA

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56
Q

what is the definitive therapy for pheochromocytoma

A

surgical intervention

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57
Q

how do you treat hypotension after pheochromocytoma resection

A

short acting vasopressors

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58
Q

how do you preop pheochromocytoma patient

A

alpha adrenergic antagonist and IV bolus

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59
Q

what monitors do you use for pheochromocytoma

A

standard plus A-line

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60
Q

what lab do you check for after pheochromocytoma resection

A

blood glucose for hypoglycemia

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61
Q

what medications do we avoid in patient with phemochromocytoma

A

atracurium
droperidol
glucocorticoids
metoclopramide
morphine
pancuronium
pentazocine
succs
vanc
(increase release of catecholamines by tumor)

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62
Q

how much does RBC increase in preggers
how much does plasma volume increase in preggers
what does this lead to?

A

30%
50%
physiological anemia

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63
Q

what is HGB level for anemia in preggers

A

<10.5 g/dL

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64
Q

what is the most common cause of anemia in preggers

A

iron deficiency anemia

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65
Q

what values are low in iron deficiency anemia

A

low MCV
low total iron
low ferratin
low transferrin

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66
Q

what is anemia increase risk for in preggers

A

preterm delivery
low birthweight

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67
Q

what are risk factors for anemia

A

advanced age
short parity interval
hispanic-american and african american race

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68
Q

what are side effects of iron supplements

A

N/V
constipation
abd cramps

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69
Q

what is the leading cause for postpartum blood transfusions

A

antepartum anemia

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70
Q

what are emergencies of sickle cell anemia

A

vaso-occlusive crisis
organ injury

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71
Q

what is the most important factor in sickling

A

O2 tension

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72
Q

what factors affect sickling

A

Hgb > 50%, dehydration, hypotension, hypothermia, acidosis

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73
Q

What happens to a sickled erythrocyte when it becomes oxygenated

A

returns to normal shape

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74
Q

what does repeated sickling of Hgb lead to

A

irreversable metabolic abnormalities and membrane damage

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75
Q

what is the lifecycle of sickled cell

A

12 days

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76
Q

how does pregnancy affect sickle cell disease

A

exacerbates

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77
Q

what causes maternal deaths from sickle cell disease

A

thromboembolitic events
infections
cardiomyopathy
pulm HTN
infarctions

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78
Q

what are risks of maternal sickle cell disease

A

preterm labor
placental abruption
fetal growth restrictions
preeclampsia
eclampsia

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79
Q

what are management methods for sickle cell

A

crystalloid to maintain volume
transfuse RBCs
supplemental O2
maintain normothermia
reduce peripheral venous stasis
thromboembolism prophylaxis

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80
Q

what do you do preop for sickle cell

A

-recent exacerbations
-level of anemia
-chronic organ injury
-echo to rule out pulm HTN
-increased CO
-wall motion
-transfuse for HGB>10
-cross matched blood on hand
-plan for perioperative pain control
-continuous neuraxial anesthesia is recommended although GA is acceptable

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81
Q

what factor is associated with Von Willebrands

A

factor 8

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82
Q

Hemophilia A and B are _______ linked traits

A

X

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83
Q

heterozygous females usually have ____ the concentration of factor ______ and _______ in hemophilia A and B

A

1/2
8
9

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84
Q

what kind of delivery is preferred to protect fetus from trauma in hemophilia A and B

A

c section

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85
Q

what is the formation of large amounts of thrombin, fibrinolytic system activation, coagulation factor depletion and hmmg

A

DIC

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86
Q

DIC scoring system

A
87
Q

what are parts of the DIC scoring system

A

decreased platelet counts
decreased fibrinogen levels
variable increases in PT and PTT
increased concentration of D-dimer
increased fibrin monomer and fibrin degredation products

88
Q

how often does acute cholecystitis occur in preggers

A

0.1%

89
Q

how often does cholelithiasis occur in preggers

A

3%

90
Q

how is cholelithiasis diagnosed

A

ultrasound

91
Q

what are s/s of cholecystitis

A

RUQ pain
fever
leukocytosis

92
Q

what is treatment for cholecystitis

A

IV hydration
antibiotics
opioids
bowel rest
percutaneous cholecystostomy

93
Q

what trimester is it preferred to have surgical intervention for cholecystostomy

A

2nd trimester

94
Q

what is incidence of miscarrigae and preterm labor for surgical intervention of cholecystostomy

A

25%

95
Q

what are some liver disease specific to pregnancy

A

hyperemesis gravidarum
intrahepatic cholestasis of preggers
preeclampsia/eclampsia
HELLP syndrome
acute fatty liver of preggers

96
Q

how do volatile anesthetics affect hepatic blood flow

A

decrease by 20%

97
Q

what volatiles are preferred for liver disease

A

iso and des (no liver metabolism)

98
Q

how does neuraxial anesthesia affect liver blood flow

A

decreases

99
Q

what are risk factors for neuraxial anesthesia of liver disease

A

coagulation factors
venous engorgement

100
Q

T/F lever disease has a large affect on standard dose of induction agents

A

F, standard dose is fine

101
Q

what is the drug of choice for RSI in liver disease

A

succs

102
Q

what is an inherited disorder in the regulation of intracellular Ca++

A

MH

103
Q

what receptor gene mutations result in MH

A

dihydropyrodine and ryanodine

104
Q

what is the test for MH

A

caffeine-halothane contracture test

105
Q

T/F MH is heterozygous autosomal dominant

A

true

106
Q

what are S/S MH

A

increased etCO2, HR, muscle rigidity, temp

107
Q

what are triggers for MH

A

sucss and volatiles

108
Q

how do we prepare anesthesia machine for MH

A

change circuit
change CO2 absorber
take off volatiles
flush with O2 for 5 min

109
Q

what is treatment of MH

A

dantrolene 2.5 mg/kg and repeat 5-10 min
ryanodex is the new drug

110
Q

what measure the severity of the curve of scoliosis

A

cobb angle

111
Q

what angle of curve of scoliosis should be further evaluated

A

> 30 degrees (or precious corrective sx)

112
Q

what should we evaluate with scoliosis

A

angle
past sx
etiology
severy/ life altering symptoms
past neuraxil anesthesia

113
Q

what are complications of scoliosis with neuraxial block

A

spine curves and rotates
previous fusion or instrumentation
variations in block spread

114
Q

what is a helpful tool for neuraxial blocks in scoliosis

A

ultrasound guidance

115
Q

what is epidural technique to have a more positive confirmation of placement

A

DPE

116
Q

what should you educate patients on with neuraxial especially with scoliosis

A

block failure

117
Q

what kind of intubation do we do with RA

A

use videoscope

118
Q

what are airway complications with RA

A

stiff jaws
calcified thyroid membrane
small mandible
TMJ
cricoarytenoid arthritis
laryngeal deviation

119
Q

what positioning technique do we use caution in with RA

A

neck manipulation/sniffing

120
Q

T/F neuraxial anesthesia is contraindicated in RA

A

false

121
Q

what kind of disease is MS

A

autoimmune

122
Q

do males or females have MS more

A

females

123
Q

when does MS present

A

20s-30s

124
Q

what are S/S MS

A

motor weakness
impaired vision
ataxia
bladder and bowel dysfunction
emotional lability

125
Q

what is pathology of MS

A

local inflammation
demyelination
gliotic scarring
axonal loss
gray and white matter plaques seen on MRI

126
Q

T/F there are sever maternal and fetal outcomes with MS

A

false

127
Q

when does MS relapse occur postpartum?

A

3 months

128
Q

what level of compromise do we watch for with MS

A

resp involvement

129
Q

what is a concern with MS and neuraxial anesthesia

A

demyelinated nerves

130
Q

what types of anesthesia is safe in MS

A

neuraxial and general

131
Q

what risks do migraines increase

A

2x more placental abruption
4x greater chance for preeclampsia

132
Q

what block is for migraines

A

SPG

133
Q

what symptoms of spinal cord injury does pregnancy aggravate

A

decrease resp reserve
DVT
PE
HTN
autonomic hyppereflexia

134
Q

spinal cord lesions above what level might not feel labor pain

A

T10-T11

135
Q

what level lesion has increased risk of autonomic hyperreflexisa

A

above T6

136
Q

what do spinal cord lesions increase risk of pregnancy wise

A

preterm labor

137
Q

what is recommended for spinal cord injuries to prevent autonomic hyperreflexia

A

early neuraxial anesthesia

138
Q

what monitor do we want for autonomic hyperreflexia risk

A

a line

139
Q

what is the anesthetic of choice for SPinal cord injury C section

A

spinal

140
Q

what is an autonomic skeletal weakness disorder caused by the production of antibodies against nicotinic receptors resulting in receptor destruction and antibody induced blockade of the remaining acetylcholine receptors

A

myasthenia gravis

141
Q

what medication can trigger myasthesnia crisis

A

mag therapy

142
Q

T/F uterine contractility is affected by MG

A

false

143
Q

when do we do neuraxial in MG

A

early in labor

144
Q

when are we cautions of neuraxial in MG

A

with resp involvement, it weakness occurs turn off epidural

145
Q

T/F use succs in MG

A

false

146
Q

what is dose of nondepolarizers in MG

A

50%

147
Q

what is reversal for MG

A

sugammadex

148
Q

what kind of anesthesia is preferred for labor and C sections with myotonic dystrophy

A

neuraxial

149
Q

what effects of opioids are myotonic dystrophy sensitive to

A

resp effects

150
Q

how can we avoid triggering myotonic dystrophy

A

keep rooms warm
prevent shivering (demerol)
no duramorph
no succs

151
Q

how do we reverse myotonic dystrophy patient

A

sugammadex

152
Q

what anesthetic drugs do we avoid in muscular dystrophy

A

volatiles and succs

153
Q

what is progressive degeneration of skeletal muscles with intact innervation

A

muscular dystrophy

154
Q

what do limb-girdle dystrophies involve

A

shoulders and pelvic muscles

155
Q

how does pregnancy effect limb-girdle dystrophies

A

exacerbated, ends with c section

156
Q

what heart issues can occur with muscular dystrophy

A

cardiomyopathy
conduction abnormalities

157
Q

what kind of anesthesia is preferred with muscular dystrophy

A

neuraxial for vaginal and C section

158
Q

what can sever muscular dystrophy lead to that effects anesthesia

A

spinal and airway malformations

159
Q

what can succs cause in muscular dystrophy

A

rhabdo

160
Q

T/F dont use roc in muscular dystrophy

A

F, nondepolarizing are fine

161
Q

what causes carpal tunnel syndrome in preggers

A

compression of median nerve in the flexor retinaculum in wrist

162
Q

when is carpal tunnel worst

A

morning

163
Q

when do carpal tunnel syndromes go away postpartum

A

2 month

164
Q

what is considered Obese in preggers

A

BMI>30

165
Q

how is morbidity and mortality in obesity

A

increased

166
Q

how is labor in obsesity

A

slowed

167
Q

how is C section risk in obesity

A

increased

168
Q

what are obese OB patients at risk for more than non obese

A

gestational DM
gestational HTN
Preeclampsia
high birth weight
preterm delivery (morbidly)
operative vaginal delivery (morbidly)
C section

169
Q

how is airway and neuraxial blocks in obesity

A

difficult

170
Q

how are ligaments and landmarks in obesity for neuraxial

A

ligaments have less distinct feel and landmarks cannot be palpated

171
Q

how does obesity effect vent weaning

A

more difficult

172
Q

what position do obese not tolerate

A

lying flat

173
Q

what methods can we use to help with neuraxial blocks

A

ultrasound and DPE

174
Q

T/F base induction doses on total body weight of obese patient

A

F, lean/ideal body weight

175
Q

why do obese patients often have failed epidural

A

multiple fat pockets can give false loss of resistance test
use DPE to confirm

176
Q

what causes the increase insulin requirements in labor

A

increased catecholamines increase insulin

177
Q

what are signs of hyperthyroid is prggers

A

hypermetabolic
fever
hot
sweating

178
Q

T/F give radioative iodine in pregger

A

false

179
Q

what do you do with ETT size and goiter

A

decreased tube size

180
Q

what differentiates thyroid storm from MH

A

increased etCO2 in MH

181
Q

T/F thyroid storm has increased etCO2

A

T, but not as much as MH

182
Q

what does decadron do fo thyroid

A

decrease T4 conversion, reduce thyroid hormone secretion

183
Q

if a patient comes in on thyroid storm proceded with surgery? T/F

A

false

184
Q

what beta blocker do we use for thyroid storm

A

propanolol (esmolol good for when they are removing the gland due to shorter half life)

185
Q

when should thyroid storm be treated before anesthesia

A

1 week

186
Q

what do you reverse thyroid patient with

A

suggamadex, cause thyroid also causes weak resp muscle

187
Q

what are alpha 1 blockers for phenochromocytoma

A

phentolamine
phenoxybenzamine

188
Q

what is phenoxybenzamine dose

A

10 mg BID (max dose 50 mg BID)

189
Q

T/F phenoxybenzamine crosses placenta

A

true
but no side effects

190
Q

what are line considerations for pheochromocytoma

A

multiple iVs
a line

191
Q

what drip is common in pheochromocytomas

A

nipride (1 mcg/kg/min or lower)

nitroprusside

192
Q

what beta blocker do you use for pheochromocytoma

A

esmolol

193
Q

what order do you block pheochromocytoma

A

alpha then beta

194
Q

when should pheochromocytoma be removed in preggers

A

16-23 weeks

195
Q

what is risk of nipride

A

cyanide poisoning

196
Q

pheochromocytoma sx and pregger

A
197
Q

T/F we want a long venous time in sickle cell

A

false
causes sickling

198
Q

what causes a long venous time in sickle cell

A

low CO

199
Q

what chamber is enlarged in sickle cell

A

LV hypertrophy

200
Q

why do we control pain in sickle cell

A

catecholamine release can lead to sickling

201
Q

what does factor 8 do

A

binds collagen in platelet adhesion

202
Q

are men or women more effected by factor 8

A

women

203
Q

what is most common type of VW

A

type 1

204
Q

what is the most severe VW

A

type 3, autosomal recessive

205
Q

what do we do to treat VW in preggers

A

DDAVP at start of labor and then 12-24 hours after

206
Q

what modified ISTH score is DIC

A

> /= 26 is high probability

207
Q

what do you treat DIC with

A

FFP (1-1.5x normal PT/PTT)
cryo
fibrin
platelets (50,000 or greater)

208
Q

what is anesthesia plan for DIC

A

general

209
Q

what is cholecystitis

A

inflammation of the gallbladder

210
Q

What is cholelithiasis?

A

gallstones

211
Q

what does dantrolene do

A

prevent Ca++ release from SR

212
Q

early vs late symptoms of MH

A

early:
masseter rigidity
increased etCO2
increased HR
Late:
high temp

213
Q

s/s MH

A

OB Anesthesia (2 decks)

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