Exam 2: Labor/Vaginal delivery, systemic disease, anesthetic complications Flashcards
what are the risk factors for gestational Diabetes
maternal age (30-35)
obesity
family hx DM2
hx gestational DM
Hx PCOS
HX still births
hx macrosomic babies
what weight of the baby is considered macrosomic
8lbs 13 oz
when is the testing for gestational diabetes done
24-28 weeks gestation
describe the 1 step process for gestational diabetes testing
8 hr fast BG<92
75g oral glucose
1 hr- BG <180
2 hr- BG <153
describe the 2 step process for gestational diabetes testing
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
What causes gestational diabetes?
progressive resistance to insulin
-maternal adipokines
what are HgA1C levels pre and intra pregnancy
pre: 4-5.5%
post: 4.8-6.5%
T/F if you have gestational DM, you have DM2 after preggers
F, most return to baseline after birth
-but have an increased risk for DM and gestational DM
how are insulin requirements affected in pregestational DM
increase from 0.7 units/kg to 1.0 units/kg at term
how are insulin requirements in pregnancies with multiple gestation
higher
how are nighttime maternal insulin requirements
requirements may drop
T/F epidural analgesia and oxytocin affect insulin requirements during first and second stages of labor
false
how is insulin requirment for DM 1 after birth
decreases for several days
what risks are increased with maternal DM
HTN
polyhydramnios
C section
why does DM increase risk of C section
big babies
what is a large amount of amniotic fluid
polyhydramnios
DM 1 are _____x more likely to develop gestational HTN
3
pregestational DM is at a ____-______x greater risk of preterm labor and delivery
2-3
what are risks of macrosomia
birth trauma and shoulder dystocia
what is macrosomia
A high-birthweight infant
what are some fetal risks of maternal DM
macrosomia
5x more likely to have anomalies (cardiac)
neonatal hypoglycemia
what treatment can reduce anomalies from 10% to 1%
strict BG control
in maternal DM is hyper or hypoglycemia preferred
hypo
what level should BG be maintained at in maternal DM
nondiabetic levels
DM lab values chart
what does DM increase risk of anesthesia wise
autonomic cardiovascular dysfunction
gastroparesis (aspiration)
what is sign of autonomic cardiovascular dysfunction
increased QT interval on EKG
what fluids do we avoid in preggers with DM
D5W, causes fetal acidosis
how are insulin requirements in second stage of labor
increased
what is BG risk after delivery with DM
hypoglycemia
what kind of anesthesia is preferred for C section with DM
neuraxial over GA
what is thyroid state in normal pregnancy
euthyroid
what is the leading cause of thyroid disorders in prgnancy
graves disease
what are signs of graves disease
nervousness
sweating
heat intolerance
tremors
weakness
what does graves disease mimic
MH
what physical change is associated with thyroid disorders
increase in thyroid nodules number and size
how are maternal iodine level in preggers
decreased
what is the percent of hyperthyroid in preggers
0.2%
what events precipitate thyroid storm
surgery
childbirth
trauma
iodinated contrast agents
treatment with iodine-131
emotional stress
PE
stroke
infection
diabetic ketoacidosis
hypoglycemia
CHF
Bowel infarction
how do you treat thyroid storm
cooling blankets
meperidine
hydration
acetaminophen
O2
beta blockers
how do you decrease thyroid hormone secretion
iodine
glucocorticoids
what do we give to reduce T4 conversion for thyroid storm management
glucocorticoids
propranolol
radiographic contrast agents
propylthiouracil
what are the modes of treatment for thyroid storm
treat symptoms
reduce thyroid hormone secretion
reduce T4 conversion
plasma exchange
what are the 4 principles ways to minimize thyroid storm
1-antithyroid medication (propylthiouracil)
2- beta blockers
3-glucocorticoids
4-iodine
T/F you can elective procedure with thyroid storm
F, not without 1 week premeds?
what drugs do we avoid in thyroid issues
glycopyrrolate, ephedrine
how is cardiovascular response in hyperthroid
hyperdynamic, dont increase BP more than thyroid already is
what is risk of enlarged thyroid/goiter
may pose airway issues
how are resp muscles in hyperthyroid
weak, make sure are fully reversed
what labs do you check in thyroid issues
electrolytes
where do 90% of phemochromocytoma occur
adrenal medulla or adjacent sympathetic tissue
what can occur after resection of phemochromocyroma
hypotension
what percentage of pheochromocytoma are malignant
10%
what do pheochromocytomas release
epi and norepi
what are most common symptoms of phemochromocytoma
sweating, tachycardia, HA
what is the definitive therapy for pheochromocytoma
surgical intervention
how do you treat hypotension after pheochromocytoma resection
short acting vasopressors
how do you preop pheochromocytoma patient
alpha adrenergic antagonist and IV bolus
what monitors do you use for pheochromocytoma
standard plus A-line
what lab do you check for after pheochromocytoma resection
blood glucose for hypoglycemia
what medications do we avoid in patient with phemochromocytoma
atracurium
droperidol
glucocorticoids
metoclopramide
morphine
pancuronium
pentazocine
succs
vanc
(increase release of catecholamines by tumor)
how much does RBC increase in preggers
how much does plasma volume increase in preggers
what does this lead to?
30%
50%
physiological anemia
what is HGB level for anemia in preggers
<10.5 g/dL
what is the most common cause of anemia in preggers
iron deficiency anemia
what values are low in iron deficiency anemia
low MCV
low total iron
low ferratin
low transferrin
what is anemia increase risk for in preggers
preterm delivery
low birthweight
what are risk factors for anemia
advanced age
short parity interval
hispanic-american and african american race
what are side effects of iron supplements
N/V
constipation
abd cramps
what is the leading cause for postpartum blood transfusions
antepartum anemia
what are emergencies of sickle cell anemia
vaso-occlusive crisis
organ injury
what is the most important factor in sickling
O2 tension
what factors affect sickling
Hgb > 50%, dehydration, hypotension, hypothermia, acidosis
What happens to a sickled erythrocyte when it becomes oxygenated
returns to normal shape
what does repeated sickling of Hgb lead to
irreversable metabolic abnormalities and membrane damage
what is the lifecycle of sickled cell
12 days
how does pregnancy affect sickle cell disease
exacerbates
what causes maternal deaths from sickle cell disease
thromboembolitic events
infections
cardiomyopathy
pulm HTN
infarctions
what are risks of maternal sickle cell disease
preterm labor
placental abruption
fetal growth restrictions
preeclampsia
eclampsia
what are management methods for sickle cell
crystalloid to maintain volume
transfuse RBCs
supplemental O2
maintain normothermia
reduce peripheral venous stasis
thromboembolism prophylaxis
what do you do preop for sickle cell
-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
what factor is associated with Von Willebrands
factor 8
Hemophilia A and B are _______ linked traits
X
heterozygous females usually have ____ the concentration of factor ______ and _______ in hemophilia A and B
1/2
8
9
what kind of delivery is preferred to protect fetus from trauma in hemophilia A and B
c section
what is the formation of large amounts of thrombin, fibrinolytic system activation, coagulation factor depletion and hmmg
DIC
DIC scoring system
what are parts of the DIC scoring system
decreased platelet counts
decreased fibrinogen levels
variable increases in PT and PTT
increased concentration of D-dimer
increased fibrin monomer and fibrin degredation products
how often does acute cholecystitis occur in preggers
0.1%
how often does cholelithiasis occur in preggers
3%
how is cholelithiasis diagnosed
ultrasound
what are s/s of cholecystitis
RUQ pain
fever
leukocytosis
what is treatment for cholecystitis
IV hydration
antibiotics
opioids
bowel rest
percutaneous cholecystostomy
what trimester is it preferred to have surgical intervention for cholecystostomy
2nd trimester
what is incidence of miscarrigae and preterm labor for surgical intervention of cholecystostomy
25%
what are some liver disease specific to pregnancy
hyperemesis gravidarum
intrahepatic cholestasis of preggers
preeclampsia/eclampsia
HELLP syndrome
acute fatty liver of preggers
how do volatile anesthetics affect hepatic blood flow
decrease by 20%
what volatiles are preferred for liver disease
iso and des (no liver metabolism)
how does neuraxial anesthesia affect liver blood flow
decreases
what are risk factors for neuraxial anesthesia of liver disease
coagulation factors
venous engorgement
T/F lever disease has a large affect on standard dose of induction agents
F, standard dose is fine
what is the drug of choice for RSI in liver disease
succs
what is an inherited disorder in the regulation of intracellular Ca++
MH
what receptor gene mutations result in MH
dihydropyrodine and ryanodine
what is the test for MH
caffeine-halothane contracture test
T/F MH is heterozygous autosomal dominant
true
what are S/S MH
increased etCO2, HR, muscle rigidity, temp
what are triggers for MH
sucss and volatiles
how do we prepare anesthesia machine for MH
change circuit
change CO2 absorber
take off volatiles
flush with O2 for 5 min
what is treatment of MH
dantrolene 2.5 mg/kg and repeat 5-10 min
ryanodex is the new drug
what measure the severity of the curve of scoliosis
cobb angle
what angle of curve of scoliosis should be further evaluated
> 30 degrees (or precious corrective sx)
what should we evaluate with scoliosis
angle
past sx
etiology
severy/ life altering symptoms
past neuraxil anesthesia
what are complications of scoliosis with neuraxial block
spine curves and rotates
previous fusion or instrumentation
variations in block spread
what is a helpful tool for neuraxial blocks in scoliosis
ultrasound guidance
what is epidural technique to have a more positive confirmation of placement
DPE
what should you educate patients on with neuraxial especially with scoliosis
block failure
what kind of intubation do we do with RA
use videoscope
what are airway complications with RA
stiff jaws
calcified thyroid membrane
small mandible
TMJ
cricoarytenoid arthritis
laryngeal deviation
what positioning technique do we use caution in with RA
neck manipulation/sniffing
T/F neuraxial anesthesia is contraindicated in RA
false
what kind of disease is MS
autoimmune
do males or females have MS more
females
when does MS present
20s-30s
what are S/S MS
motor weakness
impaired vision
ataxia
bladder and bowel dysfunction
emotional lability
what is pathology of MS
local inflammation
demyelination
gliotic scarring
axonal loss
gray and white matter plaques seen on MRI
T/F there are sever maternal and fetal outcomes with MS
false
when does MS relapse occur postpartum?
3 months
what level of compromise do we watch for with MS
resp involvement
what is a concern with MS and neuraxial anesthesia
demyelinated nerves
what types of anesthesia is safe in MS
neuraxial and general
what risks do migraines increase
2x more placental abruption
4x greater chance for preeclampsia
what block is for migraines
SPG
what symptoms of spinal cord injury does pregnancy aggravate
decrease resp reserve
DVT
PE
HTN
autonomic hyppereflexia
spinal cord lesions above what level might not feel labor pain
T10-T11
what level lesion has increased risk of autonomic hyperreflexisa
above T6
what do spinal cord lesions increase risk of pregnancy wise
preterm labor
what is recommended for spinal cord injuries to prevent autonomic hyperreflexia
early neuraxial anesthesia
what monitor do we want for autonomic hyperreflexia risk
a line
what is the anesthetic of choice for SPinal cord injury C section
spinal
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
myasthenia gravis
what medication can trigger myasthesnia crisis
mag therapy
T/F uterine contractility is affected by MG
false
when do we do neuraxial in MG
early in labor
when are we cautions of neuraxial in MG
with resp involvement, it weakness occurs turn off epidural
T/F use succs in MG
false
what is dose of nondepolarizers in MG
50%
what is reversal for MG
sugammadex
what kind of anesthesia is preferred for labor and C sections with myotonic dystrophy
neuraxial
what effects of opioids are myotonic dystrophy sensitive to
resp effects
how can we avoid triggering myotonic dystrophy
keep rooms warm
prevent shivering (demerol)
no duramorph
no succs
how do we reverse myotonic dystrophy patient
sugammadex
what anesthetic drugs do we avoid in muscular dystrophy
volatiles and succs
what is progressive degeneration of skeletal muscles with intact innervation
muscular dystrophy
what do limb-girdle dystrophies involve
shoulders and pelvic muscles
how does pregnancy effect limb-girdle dystrophies
exacerbated, ends with c section
what heart issues can occur with muscular dystrophy
cardiomyopathy
conduction abnormalities
what kind of anesthesia is preferred with muscular dystrophy
neuraxial for vaginal and C section
what can sever muscular dystrophy lead to that effects anesthesia
spinal and airway malformations
what can succs cause in muscular dystrophy
rhabdo
T/F dont use roc in muscular dystrophy
F, nondepolarizing are fine
what causes carpal tunnel syndrome in preggers
compression of median nerve in the flexor retinaculum in wrist
when is carpal tunnel worst
morning
when do carpal tunnel syndromes go away postpartum
2 month
what is considered Obese in preggers
BMI>30
how is morbidity and mortality in obesity
increased
how is labor in obsesity
slowed
how is C section risk in obesity
increased
what are obese OB patients at risk for more than non obese
gestational DM
gestational HTN
Preeclampsia
high birth weight
preterm delivery (morbidly)
operative vaginal delivery (morbidly)
C section
how is airway and neuraxial blocks in obesity
difficult
how are ligaments and landmarks in obesity for neuraxial
ligaments have less distinct feel and landmarks cannot be palpated
how does obesity effect vent weaning
more difficult
what position do obese not tolerate
lying flat
what methods can we use to help with neuraxial blocks
ultrasound and DPE
T/F base induction doses on total body weight of obese patient
F, lean/ideal body weight
why do obese patients often have failed epidural
multiple fat pockets can give false loss of resistance test
use DPE to confirm
what causes the increase insulin requirements in labor
increased catecholamines increase insulin
what are signs of hyperthyroid is prggers
hypermetabolic
fever
hot
sweating
T/F give radioative iodine in pregger
false
what do you do with ETT size and goiter
decreased tube size
what differentiates thyroid storm from MH
increased etCO2 in MH
T/F thyroid storm has increased etCO2
T, but not as much as MH
what does decadron do fo thyroid
decrease T4 conversion, reduce thyroid hormone secretion
if a patient comes in on thyroid storm proceded with surgery? T/F
false
what beta blocker do we use for thyroid storm
propanolol (esmolol good for when they are removing the gland due to shorter half life)
when should thyroid storm be treated before anesthesia
1 week
what do you reverse thyroid patient with
suggamadex, cause thyroid also causes weak resp muscle
what are alpha 1 blockers for phenochromocytoma
phentolamine
phenoxybenzamine
what is phenoxybenzamine dose
10 mg BID (max dose 50 mg BID)
T/F phenoxybenzamine crosses placenta
true
but no side effects
what are line considerations for pheochromocytoma
multiple iVs
a line
what drip is common in pheochromocytomas
nipride (1 mcg/kg/min or lower)
nitroprusside
what beta blocker do you use for pheochromocytoma
esmolol
what order do you block pheochromocytoma
alpha then beta
when should pheochromocytoma be removed in preggers
16-23 weeks
what is risk of nipride
cyanide poisoning
pheochromocytoma sx and pregger
T/F we want a long venous time in sickle cell
false
causes sickling
what causes a long venous time in sickle cell
low CO
what chamber is enlarged in sickle cell
LV hypertrophy
why do we control pain in sickle cell
catecholamine release can lead to sickling
what does factor 8 do
binds collagen in platelet adhesion
are men or women more effected by factor 8
women
what is most common type of VW
type 1
what is the most severe VW
type 3, autosomal recessive
what do we do to treat VW in preggers
DDAVP at start of labor and then 12-24 hours after
what modified ISTH score is DIC
> /= 26 is high probability
what do you treat DIC with
FFP (1-1.5x normal PT/PTT)
cryo
fibrin
platelets (50,000 or greater)
what is anesthesia plan for DIC
general
what is cholecystitis
inflammation of the gallbladder
What is cholelithiasis?
gallstones
what does dantrolene do
prevent Ca++ release from SR
early vs late symptoms of MH
early:
masseter rigidity
increased etCO2
increased HR
Late:
high temp
s/s MH
