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Nur 943 OB > Exam 2-OB complications part 1 > Flashcards

Exam 2-OB complications part 1 Flashcards

Master this Obiz

1
Q

Define Preterm Delivery

A

Delivery before 37 weeks gestation

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2
Q

Low Birth Weight is

A

<2500gm

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3
Q

Very Low Birth Weight is

A

<1500gm

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4
Q

Extremely Low Birth Weight is

A

<1000gm

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5
Q

22-24 weeks gestations is termed:

A

Threshold of Viability, and births during this time generally have very poor outcome.

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6
Q

Full term delivery is ones that occur at ___ weeks gestation or later.

A

37

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7
Q

Counting for gestation days begins:

A

1st day of last menstrual period

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8
Q

Name the 3 significant factors associated with preterm labor.

A

Non-Hispanic black race
Multiple Gestation
History of Preterm Labor

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9
Q

Name all the Demographic Factors associated with Preterm Labor.

A 
Non-Hispanic Black Race
Low Socio-Economic Status
Extremes of Age (<17 and >35)
Low prepregnancy BMI
Hx of preterm delivery
Interpregnancy interval <6months
Abnormal uterine anatomy
Trauma
Abd surgery during pregnancy
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10
Q

Name the Behavioral Factors associated with Preterm Labor

A

Tobacco use

Substance Abuse

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11
Q

Name the OB Factors associated with Preterm Labor

A 
Vaginal bleeding
Infection
Short Cervical Length
Multiple gestation
Assisted reproductive technologies
Preterm premature rupture of Membranes (PROM)
Polyhydramnios
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12
Q

Which phase of uterine contractility is associated with uterine stretch and fetal hypothalamic pituitary adrenal activation?

A

Phase 1 Activation

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13
Q

Phase 2 Stimulation of uterine contractility is defined as:

A

Stimulation of the uterus by various substances- corticotropic releasing hormone, oxytocin, and prostaglandins.

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14
Q

Which phase of uterine contractility is associated with a relatively quiet uterus?

A

Quiescence- Most of pregnancy is during this phase.

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15
Q

The 3rd phase of uterine contractility is called _____, and this begins at the 3rd stage of labor and is associated with shrinkage of the uterus, placental separation and uterine contraction.

A

Involution

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16
Q

What is the possible causes of preterm labor?

A 
Systemic and uterine infection (majority of cases)
Stress
Uteroplacental Thrombosis
Intrauterine Vascular Lesions
Uterine Overdistention
Cervical Insufficiency
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17
Q

Preterm delivery is due to: (3 maj. categories and % of cases)

A

Preterm Premature Rupture of Membranes (Preterm PROM- 30% of cases)
Spontaneous Preterm Labor (45%)
Maternal/Fetal Indications for delivery (25%)

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18
Q

What the heck is the DECIDUA?

A

The thick layer of modified mucus membrane that lines the uterus during pregnancy and is shed after delivery with the afterbirth.

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19
Q

What anesthetic technique is preferred for preterm labor and delivery?

A

NA- timing is challenging- place epidural early in case of emergency C-Sec.

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20
Q

Give some examples of Tocolytic Therapy Agents

A

Calcium Channel Blocker
Indomethacin (cyclooxygenase inhibitor)
Terbutaline (Beta Agonist)
Mag Sulfate

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21
Q

What is associated with CCB tocolytic therapy?

A

Potential for hypotension, vasodilation, conduction deficits and myocardial depression.

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22
Q

What is associated with cyclooxygenase inhibitors (Indomethacin)?

A

Transient effects on platelet function.

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23
Q

What is associated with Terbutaline (Beta-adrenergic receptor agonist)?

A

Hypotension, tachycardia, pulmonary edema, hyperglycemia and hypokalemia. Avoid with agents that increase HR.

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24
Q

What is associated with Mag. Sulfate?

A

Hypotension, potentiation of NMB agents (decrease dose of NDNMB, but Sux still 1mg/kg).

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25
Q

Presentation is:

A

the portion of fetus over pelvic inlet

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26
Q

Cephalic presentation is:

A

Head down (head first). Can be Vertex (occiput first), Brow, or Face.

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27
Q

Lie is:

A

Alignment of fetal spine with maternal spine. Longitudinal or transverse.

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28
Q

Breech or Vertex have at ____ lie.

A

Longitudinal

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29
Q

Transverse or oblique lie will probably need____.

A

C-Sec

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30
Q

Occiput- Position for ____ presentation

A

Vertex

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31
Q

Sacrum- Position for ____ presentation

A

Breech

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32
Q

Mentum- Position for ____ presentation

A

Face

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33
Q

Acromion- Position for ____ presentation

A

Shoulder

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34
Q

Position is relationship:

A

Specific fetal bony point to maternal pelvis

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35
Q

Which position is the most common of all abnormal presentations?

A

Breech

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36
Q

Hips flexed at hips and knees is ____

A

Complete Breech

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37
Q

1 or both legs are extended at the hip is _____

A

Incomplete Breech

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38
Q

Lower extremities are flexed at hip and extended at the knee is _____

A

Frank Breech

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39
Q

Factors Associated with Breech Presentation:

A 
Multiparity
Multiple Gestation
Hydramnios
Macrosmia
Pelvic Tumors
Uterine Abnormalities
Pelvic Contracture
Hydrocephalus
Ancephaly
Previous Breech delivery
Preterm Gestation
Oligohydramnios
Cornual-Fundal Placenta
Placenta Previa
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40
Q

Delivery of Breech babies should be performed where?

A

In the OR or dedicated area so that emergency general can be initiated safely.

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41
Q

Breech deliveries may need DENSE ANESTHESIA. Give a couple examples of LA used:

A

3% 2-Chloroprocaine or 2% Lidocaine with Epi and Bicarb

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42
Q

What uterine relaxant is preferred with NA?

A

NTG

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43
Q

What uterine relaxant with GA?

A

Just increase the halogenated agent—Increased MAC will cause uterine to relax.

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44
Q

NTG for uterine relaxant may cause:

A

Headache and hypotension, have neo handy.

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45
Q

What are the FETAL complications associated with Multiple Gestation?

A 
Preterm Labor
Congenital Anomalies
Polyhydramnios
Cord Entanglement
Umbilical Cord Prolapse
Fetal Growth Restriction
Twin-to-Twin Transfusion
Malpresentation
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46
Q

What is the maternal CV changes with multiple gestation?

A

20% greater increase in CO (SV increases 15% more, HR increases 3.5% more).

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47
Q

What is the major pulmonary change concern with multiple gestation?

A

Intensified Decrease in FRC and Increased Maternal Metabolic Rate—So HYPOXEMIA occurs more rapidly.

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48
Q

Plasma volume increases and addition ____ml with multiple gestation compared to singleton.

A

750ml

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49
Q

Full lateral position may be utilized for LUD in multiple gestation because of greater risk for:

A

Aortocaval compression and supine hypotensive syndrome.

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50
Q

List the Maternal Complications associated with Multiple Gestation.

A 
Preterm PROM
Preterm Labor
Prolonged Labor
Preeclampsia/Eclampsia
Placental Abruption
DIC
Operative Delivery (Forceps or C-Sec)
Uterine Atony
OB Trauma
Antepartum and/or postpartum HEMORRHAGE
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51
Q

What anesthesia technique is preferred with Multiple Gestation

A

NA- Epidural for optimal analgesia

52
Q

There is a greater risk for aortocaval compression with multiple gestations, so what position would you place mother?

A

Full Lateral

53
Q

What level do you want your NA for vaginal delivery of multiple gestation?

A

T6-T8

54
Q

What level do you want your NA for C-Sec for multiple gestation delivery.

A

T4

55
Q

What is the most common medical condition associated with pregnancy?

A

HTN (6-10%).

56
Q

Gestational Hypertension is defined as:

A

Increased BP AFTER 20 weeks gestation WITHOUT PROTEINURIA. Resolves by 12 weeks postpartum if no prior Hx of HTN.

57
Q

Preeclampsia is defined as:

A

New onset of HTN and Proteinuria after 20 weeks gestation.

58
Q

What other Symptoms would you consider for possible preeclampsia for Pt with new onset HTN without proteinuria?

A 
Persistent epigastric or RUQ pain
Persistent cerebral symptoms
Fetal Growth Restriction
Thrombocytopenia
Elevated Liver Enzymes
59
Q

Eclampsia is defined as:

A

Same as Preeclampsia but with addition of SEIZURES.

New onset HTN, Proteinuria, and SCZ

60
Q

Chronic HTN is defined as:

A

Prepregnancy Systolic BP > 140mmhg, and/or Diastolic BP > 90 ….. or HTN unresolved by delivery.

61
Q

Chronic HTN with superimposed preeclampsia is defined as:

A

Pt with Chronic HTN (before pregnancy) develops preeclampsia (new onset proteinuria or sudden increase in proteinuria and/or sudden increase HTN).

62
Q

Diagnostic Criteria for Preeclampsia without Severe Features:

A

BP > 140/90 after 20 weeks gestation

Proteinuria >300mg/24hr, protein-creatinine >0.3, or 1+ on urine dipstick.

63
Q

Diagnostic Criteria for Preeclampsia:

A 
BP > 160/110
Thrombocytopenia (plt < 100,000)
Serum Creatinine >1.1 or 2x baseline 
Pulmonary Edema
New-onset cerebral or visual changes
Impaired Liver Function
64
Q

What is HELLP Syndrome

A

Hemolysis, Elevated Liver enzymes, Low Platelet in Women with PREECLAMPSIA.

65
Q

Name all the HTN Disorders classifications in pregnancy.

A

Gestational HTN
Preeclampsia (without severe features and severe)
Eclampsia
Chronic HTN
Chronic HTN with Superimposed preeclampsia

66
Q

What factors are associated with the Maternal Syndrome of HTN disorders?

A

HTN and Proteinuria with/without other systemic abnormalities

67
Q

What factors are associated with the Fetal Syndrome of HTN disorders?

A

Fetal growth restriction, oligohydramnios, abnormal oxygen exchange.

68
Q

CNS presentations associated with preeclampsia

A

Severe headache, hyperexcitability, hyperreflexia, coma, visual disturbances (scotoma, amaurosis, and blurred vision).

69
Q

Airway changes associated with preeclampsia

A

Pharyngolaryngeal edema, subglottic edema- AW Changes worsen with preeclampsia!

70
Q

Pulmonary changes associated with preeclampsia

A

Decreased colloid osmotic pressure and increased vascular permeability and loss of intravascular fluid and protein into the interstitial areas leads to pulmonary edema.

71
Q

CV changes with preeclampsia

A

HTN, Hyperdynamic LV function, Increased SVR with exaggerated response to circulating catecholamines.

72
Q

Preeclampsia is more common with (nulliparous or multiparous) women?

A

Nulliparous

73
Q

Preeclampsia usually resolves when?

A

after delivery, within 48 hours.

74
Q

What is the most definitive treatment for Preeclampsia?

A

Delivery of the fetus

75
Q

Other than delivery, what other treatments are available for preeclampsia Sx?

A

Bedrest, Sedation, Antihypertensives.

76
Q

Onset and Dosage of Labetalol for Preeclampsia Tx:

A

Onset 5-10min

Dosage: 20mg IV, then 40-80mg every 10min to max dos of 220mg.

77
Q

Onset and Dosage of Hydralazine for Preeclampsia Tx:

A

Onset 10-20min

Dosage: 5mg every 20min to max dose of 20mg

78
Q

Onset and Dosage of Nifedipine for Preeclampsia Tx:

A

Onset 10-20min

Dosage 10mg PO every 20 min up to max dos of 50 mg

79
Q

Onset and Dosage of Nicardipine for Preeclampsia Tx:

A

Onset 10-15 min

Dosage: Initial infusion 5mg/hr, titrate by 2.5 mg/h every 5 mins to a max of 15mg/hr

80
Q

Onset and Dosage of Sodium Nitroprusside for Preeclampsia Tx:

A

Onset: 0.5-1min

Dosage 0.25-5ugkg/min IV infusion

81
Q

Hematologic Sx associated with Preeclampsia:

A

Thrombocytopenia is the most common hematologic abnormality (plt <100,000 in severe stages and HELLP)
DIC can occur with severe liver involvement, intrauterine fetal demise, placental abruption, or postpartum hemorrhage.

82
Q

Liver Sx associated with Preeclampsia

A

Periportal hemorrhage and fibrin deposits (presents as RUQ or Epigastric Pain)

83
Q

Renal Sx associated with Preeclampsia

A

Proteinuria, decreased GFR, hyperuricemia. Oliguria is a late Sx of preeclampsia.

84
Q

What Tx is used for Scz prophylaxis in severe preeclampsia?

A

Magnesium Sulfate

85
Q

What dose of Mag Sulfate is used for Scz prophylaxis with preeclampsia?

A

Loading Dose: 4-6gm over 20-30mins
Maintenance: 1-3g/hr
“Start 2hr preop, continue through surgery and 12-24hr postop.

86
Q

What is the Therapeutic range for Mag Sulfate for Scz prophylaxis Tx?

A

5-9mg/dl for serum Mg levels (Chestnut)
4-6mEq/L (M&M)
Of course she says know them both. SMH

87
Q

Give Sx and associated serum levels of hypermagnesemia.

A

5-9mg/dl Therapeutic Range (Scz prophylaxis)
12mg/dl- Patellar reflexes lost
15-20mg/dl- Respiratory arrest
>25 Asystole

88
Q

What is the treatment for hypermagnesemia?

A

Stop infusion

Calcium Gluconate IV

89
Q

Give Detailed Laboratory Figures for HELLP Dx.

A

Hemolysis - Abnormal peripheral blood smear, Increased bilirubin >1.2 mg/dl, Increased LDH >600 IU/L

Elevated Liver enzymes- AST>70 IU/L, LDH>600 IU/L

Thrombocytopenia- Plt <100,000

(LDH=Lactic Dehydrogenase)

90
Q

4 Considerations for NA with Preeclampsia

A
  1. Assess coagulation (<50,000 = No NA, go GA)
  2. IV hydration prior to epidural dosing of LA (lower fluid intake- don’t want pulmonary edema)
  3. Hypotension (keep BP tight, Neo 25-50mcg, Ephedrine 5-10mg)
  4. Use of epi (avoid Epi, will increase HR and BP=BAD)
91
Q

Preferred technique with Pt with hypotensive disorder or HELLP?

A

Continuous Lumbar Epidural or CSE

92
Q

Define Eclampsia

A

New onset of seizures for Pt with Preeclampsia or unexplained coma in Pt with Preeclampsia

93
Q

ABCDs of Eclamptic SCZ control

A

Airway- Turn Pt to left, apply jaw thrust, attempt bag/mask ventilation (Fi02=1), Insert soft nasopharyngeal AW if needed

Breathing- Control bag/mask ventilation, apply pulse ox and monitor Sp02

Circulation- Secure IV access, Check BP at frequent intervals, monitor ECG

Drugs- Mag. Sulfate 4-5mg IV over 20 mins followed by 1-2g/h for maintenance. 2g IV over 10 mins for recurrent SCZ. Antihypotensives- Labetalol or hydralazine PRN.

94
Q

Would Ketamine be a good drug of choice for GA induction with patient with severe preeclampsia?

A

No Way- Increases BP.

95
Q

Two fertilized ova is called:

A

Dizygotic twins

96
Q

Monozygotic twins is where:

A

Single fertilized ovum divides

97
Q

Dizygotic twins are always:

A

Dichorionic Diamniotic

98
Q

Define placenta Previa

A

When the placenta covers the opening of the Mother’s Cervix. Can Cause Bleeding throughout pregnancy and/or delivery.

99
Q

Describe the 3 types of Placenta Previa:

A

Total: Covers Cervical Os
Partial: Covers Part of the Cervical Os
Marginal: Lies within 2cm of Cervical Os

100
Q

What is the most common cause of maternal mortality worldwide???

A

OB Hemorrhage

101
Q

The greatest threat of antepartum hemorrhage is to the:

A

Fetus

102
Q

What is the Classic Sign of Placenta Previa?

A

Painless vaginal bleeding in the 2nd or 3rd trimester

103
Q

Total previa, placental edge to os distance <1cm, &/or significant bleeding will require:

A

C-sec.

104
Q

What is the preferred anesthetic technique for Mother with overt active bleeding?

A

RSI with GA- Use low dose Propofol, Ketamine 0.5-1mg/kg, Etomidate 0.3mg/kg. Maintenance with N2O with low dose Halogenated agent. If bleeding is Severe or with fetal compromise, avoid N2O.

105
Q

Define Placental Abruption:

A

Complete or partial separation of placenta from Mother’s Decidua Basalis before delivery of the fetus.

106
Q

What are the complications associated with Placental Abruption?

A

Hemorrhagic Shock
Coagulopathy
Fetal Compromise or Demise

107
Q

What is the preferred anesthetic technique for Pt’s with Placenta Previa who are NOT actively bleeding or hypovolemic?

A

NA

108
Q

What Conditions are Associated with Placental Abruption?

A 
OB CONDITIONS
prior uterine surgery
induction of labor
high-dose oxytocin induction
prostaglandin induction
grand multiparity (>5)
morbidly adherent placenta
congenital uterine anomaly
MATERNAL COMORBIDITIES
connective tissue disorder (eg ehlers-danlos syndrome)
OB-TRAUMA
forceps application
internal podalic version 
excessive fundal pressure
NONOB-TRAUMA
blunt
penetrating
109
Q

Define Uterine Rupture:

A

Nonsurgical disruption of ALL uterine layers

110
Q

Define Uterine Dehiscence

A

Incomplete disruption of uterine layers

111
Q

What is the presenting signs of Uterine Rupture?

A

abdominal pain and abnormal FHR pattern

112
Q

Anesthetic choice for uterine rupture?

A

GA, unless Pt has preexisting epidural catheter

113
Q

Anesthetic considerations for uterine rupture?

A

Aggressive volume replacement including transfusion
Monitor uterine output
May need invasive monitoring for volume status

114
Q

Define Vasa Previa

A

Fetal vessels cross fetal membranes before presenting part. Rupture of fetal membranes usually tears vellels and leads to FETAL EXSANGUINATION- Thuman.
Vasa Previa is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

115
Q

Anesthetic choice for Vasa Previa?

A

GA for IMMEDIATE DELIVERY. This is an OB EMERGENCY

116
Q

Define Uterine Atony

A

Loss of uterine musculature tone. Accounts for 80% of Hemorrhage.

117
Q

Some Tx for Uterine Atony

A 
Uterine Massage
Uterotonic Agents
Uterine Compression Sutures
Intrauterine Balloon Tamponade
IV Crystalloids, colloids, and vasopressors
Serial H&amp;Hs, Coag studies
Blood products ready for transfusion
118
Q

Conditions associated with uterine atony:

A 
C-sec
Induced labor
augmented labor
multiple gestation
macrosomia
polyhydramnios
high parity
prolonged labor
precipitous labor
chorioamnionitis
advanced maternal age
Hypertensive disease
Diabetes
Tocolytic drugs
High concentrations of volatile halogenated agents
119
Q

Define Placenta Accreta

A

Placenta accrete- a part or all of the placenta invades the uterine wall and is inseparable for it.

120
Q

Describe all three types of Placenta Accreta

A

Placenta Acceta vera- adherence of basal plate of placenta to uterine myometrium

Placenta Increta: Chorionic villi invade the myometrium

Placenta Percreta: Invasion through myometrium into serosa and adjacent organs

121
Q

What’s an easy way to remember Accretas?

A

Accreta- Attaches
Increta- Invades
Percreta- Penetrates or Protrudes

122
Q

What are the 4 common pharmaceutical agents used for bleeding associated with uterine atony/postpartum hemorrhage?

A

Oxytocin 0.3-0.6IU/min IV infusion
Ergonovine or methylergonovine 0.3mg IM
15-Methylprotaglandin (“Hemabate”) 0.25 mg IM
Misoprostol (“cytotek”) 600-1000ug per rectum, sublingual, or buccal.

123
Q

Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” of Oxytocin

A

Oxytocin 0.3-0.6IU/min IV infusion
Contraindication: None
Side Effects: Tachycardia, Hypotension, Myocardial Ischemia, Free Water Retention.
Notes: Short Duration of Effect

124
Q

Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” of Ergonovine/Methylergonovine

A

Ergonovine/Methylergonovin 0.2mg/IM
Contraindication: HTN, Preeclampsia, CAD
S/E: N/V/arteriolar constriction, HTN
Notes: Long duration, may be repeated in 1 hour

125
Q

Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” of 15-Methylprostaglandin (aka Hemabate)

A

0.25mg/IM
C/I: Reactive AW disease, pulm HTN, hypoxemia
S/E: Fever, Chills, N/V/D, Bronchoconstriction
Notes: May be repeated every 15min up to 2mg

126
Q

Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” with Misoprostol (Cytotek)

A

600-1000ug per rectum, sublingual, or buccal
C/I-none
S/E-Fever, Chills, N//V/D
Notes- off label use

Nur 943 OB (11 decks)

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