Exam 2-OB complications part 1 Flashcards
Master this Obiz
Define Preterm Delivery
Delivery before 37 weeks gestation
Low Birth Weight is
<2500gm
Very Low Birth Weight is
<1500gm
Extremely Low Birth Weight is
<1000gm
22-24 weeks gestations is termed:
Threshold of Viability, and births during this time generally have very poor outcome.
Full term delivery is ones that occur at ___ weeks gestation or later.
37
Counting for gestation days begins:
1st day of last menstrual period
Name the 3 significant factors associated with preterm labor.
Non-Hispanic black race
Multiple Gestation
History of Preterm Labor
Name all the Demographic Factors associated with Preterm Labor.
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
Name the Behavioral Factors associated with Preterm Labor
Tobacco use
Substance Abuse
Name the OB Factors associated with Preterm Labor
Vaginal bleeding Infection Short Cervical Length Multiple gestation Assisted reproductive technologies Preterm premature rupture of Membranes (PROM) Polyhydramnios
Which phase of uterine contractility is associated with uterine stretch and fetal hypothalamic pituitary adrenal activation?
Phase 1 Activation
Phase 2 Stimulation of uterine contractility is defined as:
Stimulation of the uterus by various substances- corticotropic releasing hormone, oxytocin, and prostaglandins.
Which phase of uterine contractility is associated with a relatively quiet uterus?
Quiescence- Most of pregnancy is during this phase.
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.
Involution
What is the possible causes of preterm labor?
Systemic and uterine infection (majority of cases) Stress Uteroplacental Thrombosis Intrauterine Vascular Lesions Uterine Overdistention Cervical Insufficiency
Preterm delivery is due to: (3 maj. categories and % of cases)
Preterm Premature Rupture of Membranes (Preterm PROM- 30% of cases)
Spontaneous Preterm Labor (45%)
Maternal/Fetal Indications for delivery (25%)
What the heck is the DECIDUA?
The thick layer of modified mucus membrane that lines the uterus during pregnancy and is shed after delivery with the afterbirth.
What anesthetic technique is preferred for preterm labor and delivery?
NA- timing is challenging- place epidural early in case of emergency C-Sec.
Give some examples of Tocolytic Therapy Agents
Calcium Channel Blocker
Indomethacin (cyclooxygenase inhibitor)
Terbutaline (Beta Agonist)
Mag Sulfate
What is associated with CCB tocolytic therapy?
Potential for hypotension, vasodilation, conduction deficits and myocardial depression.
What is associated with cyclooxygenase inhibitors (Indomethacin)?
Transient effects on platelet function.
What is associated with Terbutaline (Beta-adrenergic receptor agonist)?
Hypotension, tachycardia, pulmonary edema, hyperglycemia and hypokalemia. Avoid with agents that increase HR.
What is associated with Mag. Sulfate?
Hypotension, potentiation of NMB agents (decrease dose of NDNMB, but Sux still 1mg/kg).
Presentation is:
the portion of fetus over pelvic inlet
Cephalic presentation is:
Head down (head first). Can be Vertex (occiput first), Brow, or Face.
Lie is:
Alignment of fetal spine with maternal spine. Longitudinal or transverse.
Breech or Vertex have at ____ lie.
Longitudinal
Transverse or oblique lie will probably need____.
C-Sec
Occiput- Position for ____ presentation
Vertex
Sacrum- Position for ____ presentation
Breech
Mentum- Position for ____ presentation
Face
Acromion- Position for ____ presentation
Shoulder
Position is relationship:
Specific fetal bony point to maternal pelvis
Which position is the most common of all abnormal presentations?
Breech
Hips flexed at hips and knees is ____
Complete Breech
1 or both legs are extended at the hip is _____
Incomplete Breech
Lower extremities are flexed at hip and extended at the knee is _____
Frank Breech
Factors Associated with Breech Presentation:
Multiparity Multiple Gestation Hydramnios Macrosmia Pelvic Tumors Uterine Abnormalities Pelvic Contracture Hydrocephalus Ancephaly Previous Breech delivery Preterm Gestation Oligohydramnios Cornual-Fundal Placenta Placenta Previa
Delivery of Breech babies should be performed where?
In the OR or dedicated area so that emergency general can be initiated safely.
Breech deliveries may need DENSE ANESTHESIA. Give a couple examples of LA used:
3% 2-Chloroprocaine or 2% Lidocaine with Epi and Bicarb
What uterine relaxant is preferred with NA?
NTG
What uterine relaxant with GA?
Just increase the halogenated agent—Increased MAC will cause uterine to relax.
NTG for uterine relaxant may cause:
Headache and hypotension, have neo handy.
What are the FETAL complications associated with Multiple Gestation?
Preterm Labor Congenital Anomalies Polyhydramnios Cord Entanglement Umbilical Cord Prolapse Fetal Growth Restriction Twin-to-Twin Transfusion Malpresentation
What is the maternal CV changes with multiple gestation?
20% greater increase in CO (SV increases 15% more, HR increases 3.5% more).
What is the major pulmonary change concern with multiple gestation?
Intensified Decrease in FRC and Increased Maternal Metabolic Rate—So HYPOXEMIA occurs more rapidly.
Plasma volume increases and addition ____ml with multiple gestation compared to singleton.
750ml
Full lateral position may be utilized for LUD in multiple gestation because of greater risk for:
Aortocaval compression and supine hypotensive syndrome.
List the Maternal Complications associated with Multiple Gestation.
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
What anesthesia technique is preferred with Multiple Gestation
NA- Epidural for optimal analgesia
There is a greater risk for aortocaval compression with multiple gestations, so what position would you place mother?
Full Lateral
What level do you want your NA for vaginal delivery of multiple gestation?
T6-T8
What level do you want your NA for C-Sec for multiple gestation delivery.
T4
What is the most common medical condition associated with pregnancy?
HTN (6-10%).
Gestational Hypertension is defined as:
Increased BP AFTER 20 weeks gestation WITHOUT PROTEINURIA. Resolves by 12 weeks postpartum if no prior Hx of HTN.
Preeclampsia is defined as:
New onset of HTN and Proteinuria after 20 weeks gestation.
What other Symptoms would you consider for possible preeclampsia for Pt with new onset HTN without proteinuria?
Persistent epigastric or RUQ pain Persistent cerebral symptoms Fetal Growth Restriction Thrombocytopenia Elevated Liver Enzymes
Eclampsia is defined as:
Same as Preeclampsia but with addition of SEIZURES.
New onset HTN, Proteinuria, and SCZ
Chronic HTN is defined as:
Prepregnancy Systolic BP > 140mmhg, and/or Diastolic BP > 90 ….. or HTN unresolved by delivery.
Chronic HTN with superimposed preeclampsia is defined as:
Pt with Chronic HTN (before pregnancy) develops preeclampsia (new onset proteinuria or sudden increase in proteinuria and/or sudden increase HTN).
Diagnostic Criteria for Preeclampsia without Severe Features:
BP > 140/90 after 20 weeks gestation
Proteinuria >300mg/24hr, protein-creatinine >0.3, or 1+ on urine dipstick.
Diagnostic Criteria for Preeclampsia:
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
What is HELLP Syndrome
Hemolysis, Elevated Liver enzymes, Low Platelet in Women with PREECLAMPSIA.
Name all the HTN Disorders classifications in pregnancy.
Gestational HTN
Preeclampsia (without severe features and severe)
Eclampsia
Chronic HTN
Chronic HTN with Superimposed preeclampsia
What factors are associated with the Maternal Syndrome of HTN disorders?
HTN and Proteinuria with/without other systemic abnormalities
What factors are associated with the Fetal Syndrome of HTN disorders?
Fetal growth restriction, oligohydramnios, abnormal oxygen exchange.
CNS presentations associated with preeclampsia
Severe headache, hyperexcitability, hyperreflexia, coma, visual disturbances (scotoma, amaurosis, and blurred vision).
Airway changes associated with preeclampsia
Pharyngolaryngeal edema, subglottic edema- AW Changes worsen with preeclampsia!
Pulmonary changes associated with preeclampsia
Decreased colloid osmotic pressure and increased vascular permeability and loss of intravascular fluid and protein into the interstitial areas leads to pulmonary edema.
CV changes with preeclampsia
HTN, Hyperdynamic LV function, Increased SVR with exaggerated response to circulating catecholamines.
Preeclampsia is more common with (nulliparous or multiparous) women?
Nulliparous
Preeclampsia usually resolves when?
after delivery, within 48 hours.
What is the most definitive treatment for Preeclampsia?
Delivery of the fetus
Other than delivery, what other treatments are available for preeclampsia Sx?
Bedrest, Sedation, Antihypertensives.
Onset and Dosage of Labetalol for Preeclampsia Tx:
Onset 5-10min
Dosage: 20mg IV, then 40-80mg every 10min to max dos of 220mg.
Onset and Dosage of Hydralazine for Preeclampsia Tx:
Onset 10-20min
Dosage: 5mg every 20min to max dose of 20mg
Onset and Dosage of Nifedipine for Preeclampsia Tx:
Onset 10-20min
Dosage 10mg PO every 20 min up to max dos of 50 mg
Onset and Dosage of Nicardipine for Preeclampsia Tx:
Onset 10-15 min
Dosage: Initial infusion 5mg/hr, titrate by 2.5 mg/h every 5 mins to a max of 15mg/hr
Onset and Dosage of Sodium Nitroprusside for Preeclampsia Tx:
Onset: 0.5-1min
Dosage 0.25-5ugkg/min IV infusion
Hematologic Sx associated with Preeclampsia:
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.
Liver Sx associated with Preeclampsia
Periportal hemorrhage and fibrin deposits (presents as RUQ or Epigastric Pain)
Renal Sx associated with Preeclampsia
Proteinuria, decreased GFR, hyperuricemia. Oliguria is a late Sx of preeclampsia.
What Tx is used for Scz prophylaxis in severe preeclampsia?
Magnesium Sulfate
What dose of Mag Sulfate is used for Scz prophylaxis with preeclampsia?
Loading Dose: 4-6gm over 20-30mins
Maintenance: 1-3g/hr
“Start 2hr preop, continue through surgery and 12-24hr postop.
What is the Therapeutic range for Mag Sulfate for Scz prophylaxis Tx?
5-9mg/dl for serum Mg levels (Chestnut)
4-6mEq/L (M&M)
Of course she says know them both. SMH
Give Sx and associated serum levels of hypermagnesemia.
5-9mg/dl Therapeutic Range (Scz prophylaxis)
12mg/dl- Patellar reflexes lost
15-20mg/dl- Respiratory arrest
>25 Asystole
What is the treatment for hypermagnesemia?
Stop infusion
Calcium Gluconate IV
Give Detailed Laboratory Figures for HELLP Dx.
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)
4 Considerations for NA with Preeclampsia
- Assess coagulation (<50,000 = No NA, go GA)
- IV hydration prior to epidural dosing of LA (lower fluid intake- don’t want pulmonary edema)
- Hypotension (keep BP tight, Neo 25-50mcg, Ephedrine 5-10mg)
- Use of epi (avoid Epi, will increase HR and BP=BAD)
Preferred technique with Pt with hypotensive disorder or HELLP?
Continuous Lumbar Epidural or CSE
Define Eclampsia
New onset of seizures for Pt with Preeclampsia or unexplained coma in Pt with Preeclampsia
ABCDs of Eclamptic SCZ control
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.
Would Ketamine be a good drug of choice for GA induction with patient with severe preeclampsia?
No Way- Increases BP.
Two fertilized ova is called:
Dizygotic twins
Monozygotic twins is where:
Single fertilized ovum divides
Dizygotic twins are always:
Dichorionic Diamniotic
Define placenta Previa
When the placenta covers the opening of the Mother’s Cervix. Can Cause Bleeding throughout pregnancy and/or delivery.
Describe the 3 types of Placenta Previa:
Total: Covers Cervical Os
Partial: Covers Part of the Cervical Os
Marginal: Lies within 2cm of Cervical Os
What is the most common cause of maternal mortality worldwide???
OB Hemorrhage
The greatest threat of antepartum hemorrhage is to the:
Fetus
What is the Classic Sign of Placenta Previa?
Painless vaginal bleeding in the 2nd or 3rd trimester
Total previa, placental edge to os distance <1cm, &/or significant bleeding will require:
C-sec.
What is the preferred anesthetic technique for Mother with overt active bleeding?
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.
Define Placental Abruption:
Complete or partial separation of placenta from Mother’s Decidua Basalis before delivery of the fetus.
What are the complications associated with Placental Abruption?
Hemorrhagic Shock
Coagulopathy
Fetal Compromise or Demise
What is the preferred anesthetic technique for Pt’s with Placenta Previa who are NOT actively bleeding or hypovolemic?
NA
What Conditions are Associated with Placental Abruption?
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
Define Uterine Rupture:
Nonsurgical disruption of ALL uterine layers
Define Uterine Dehiscence
Incomplete disruption of uterine layers
What is the presenting signs of Uterine Rupture?
abdominal pain and abnormal FHR pattern
Anesthetic choice for uterine rupture?
GA, unless Pt has preexisting epidural catheter
Anesthetic considerations for uterine rupture?
Aggressive volume replacement including transfusion
Monitor uterine output
May need invasive monitoring for volume status
Define Vasa Previa
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.
Anesthetic choice for Vasa Previa?
GA for IMMEDIATE DELIVERY. This is an OB EMERGENCY
Define Uterine Atony
Loss of uterine musculature tone. Accounts for 80% of Hemorrhage.
Some Tx for Uterine Atony
Uterine Massage Uterotonic Agents Uterine Compression Sutures Intrauterine Balloon Tamponade IV Crystalloids, colloids, and vasopressors Serial H&Hs, Coag studies Blood products ready for transfusion
Conditions associated with uterine atony:
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
Define Placenta Accreta
Placenta accrete- a part or all of the placenta invades the uterine wall and is inseparable for it.
Describe all three types of Placenta Accreta
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
What’s an easy way to remember Accretas?
Accreta- Attaches
Increta- Invades
Percreta- Penetrates or Protrudes
What are the 4 common pharmaceutical agents used for bleeding associated with uterine atony/postpartum hemorrhage?
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.
Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” of Oxytocin
Oxytocin 0.3-0.6IU/min IV infusion
Contraindication: None
Side Effects: Tachycardia, Hypotension, Myocardial Ischemia, Free Water Retention.
Notes: Short Duration of Effect
Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” of Ergonovine/Methylergonovine
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
Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” of 15-Methylprostaglandin (aka Hemabate)
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
Discuss the Drug, Dose, Relative Contraindication, Side Effects and “Notes” with Misoprostol (Cytotek)
600-1000ug per rectum, sublingual, or buccal
C/I-none
S/E-Fever, Chills, N//V/D
Notes- off label use
