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OB - Paul Smith > Final OB > Flashcards

Final OB Flashcards

1
Q

Respiratory Changes in OB patient (3)

What hormone is responsible?

A

1) Engorgement of Tracheobronchial tree
2) Increased MV and O2 consumption
3) Decreased FRC and change in Closing capacity

Progesterone

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2
Q

What anesthesia changes do we need to be careful with due to respiratory changes? (5)

A 
Suctioning caution
Oral Airway caution
Nasal airway 
Shorter DL handle
Smaller ETT 6.0-7.0 (some parts say 6.5 instead of 7.0)
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3
Q

Cardiac output changes in an OB patient

A

Increased CO (+40-50% from baseline; largest increase in 1st trimester)

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4
Q

Changes in blood volume in OB patient?

A

Dilutional anemia (+40% plasma volume and +20% RBC)

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5
Q

Aortocaval Compression begins at what time period?

A

20 weeks

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6
Q

Signs and symptoms of Aortocaval compression?

What causes signs and symptoms?

A

1) Anxiety
2) Light-headed
3) N/V
4) Tachy/Bradycardia
5) Diaphoresis
6) Hypoxia

Causes Decreased Cardiac Output and decreased venous return.

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7
Q

What happens to the fetus during aortocaval compression?

A

Fetal bradycardia and hypoxia

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8
Q

Treatment for Aortal Caval compression?

A

Left Uterine Displacement

Wedge under the hips, doesn’t matter if it’s left or right

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9
Q

Changes in WBC count?

A

Normal up to 13k can reach 30k during labor.
Scheduled C/S should have 6-16k.
>16k consider infection.

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10
Q

What platelet count should we avoid regional in OB patients?

A

<80k

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11
Q

Do Thromboembolic event risks increase/decrease? What causes this?

A

5x increase due to Factor I, VII, X, XII increasing to prevent blood loss.

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12
Q

GI changes in OB patients

What causes this earlier? Later?

A

esophageal SPHINCTER relaxes which increases reflux.
GI motility slowed and absorption
Gastric volume increases

Progesterone initially then due to fetus increasing IABP

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13
Q

How do we intubate OB patients?

Starting at what gestational age to when?

A

RSI starting 18+ weeks to 6 weeks post delivery. Can start 12 weeks if conservative.

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14
Q

Diabetogenic state due to?

What does this due to fasting BG? What about after eating?

A

Secretion of human placental
lactogen reduces tissues sensitivity to insulin leading to a rise in insulin levels (in order to provide fetus with more sugar)

Fasting BG lower than normal
Eating BG higher than normal

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15
Q

What does relaxin cause?

A

Softening of cervix
Inhibits uterine contraction
Relaxes pelvic joints and causes laxity of spine that increases back pain

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16
Q

Placental macroscopic layers

A 
Chorioinic plate (fetal)
Intervillous space
Basal plate (maternal)
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17
Q

Placental microscopic layers

A 
Fetal trophoblasts (cytotrophoblast, syncytiotrophoblast)
Fetal connective tissue
Endothelium of fetal capillaries
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18
Q

Preferential blood flow of oxygenated and deoxygenated blood

A

Oxygenated to. Fetal brain/heart,

Deoxygenated to lower half of body

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19
Q

Uterine blood flow is largely dependent on what?

A

Maternal Mean Arterial Pressure MMAP

UBF= (MMAP-UVP)/UVR

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20
Q

Drug transfer rate determined by what 5 things?

A

1) Size of molecule (<1000 daltons)
2) Concentration gradient (high to low)
3) Protein binding (bound wont pass)
4) Ionization (non-ionized required to pass)
5) Lipid solubility enhances transfer

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21
Q

Drug Transfer Uptake greatest to least

A 
IV
Paracervical
Caudal
Lumbar epidural
Spinal

Paracervical and Caudal flipped from normal

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22
Q

Fetal circulation

A

Umbilical vein oxygenated -> IVC (50% liver, 50% IVC) -> LA (flow stream through PFO) -> Aorta -»innominate artery to brain -> SVC -> RA -> RV -> Lungs (very little blood) -> through Ductus Arteriosus to Lower extremities and gut -> hypogastric artery -< Umbilical artery

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23
Q

What causes fetal bradycardia? (5)

A 
Hypoxia
Fetal head compression
Cord compression
Bradyarrythmias
Maternal drug ingestion
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24
Q

Early Decels occur when?

A 
WITH contractions (mirror)
NBD: fetal head compression
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25
Q

Late Decels occurs when?

A

Starts 10-30 secs after contraction starts and ends 10 - 30 secs after contraction ends

Due to decreased placental pressure BAD

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26
Q

Variable Decels

A

Variably, from cord compression

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27
Q

VEAL

CHOP

A

Variable - Cord Compression

Early - Head Compression

Acceleration - Okay

Late - Placental Pressure

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28
Q

Treatment for brady/late decels

A

Fluids

Ephedrine/phenylephrine

LUD

Decrease epidural

Oxygen

C/S

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29
Q

HTN difference between chronic and gestational?

A

Chronic -> before 20 weeks

Gestational -> after 20 weeks

> 140/90

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30
Q

Mild Preeclmpsia

A

HTN and new onset proteinuria

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31
Q

Severe preeclampsia

A

NEW ONSET PROTENURIC HTN + ONE OF THE FOLLOWING:

Severe HTN (>160/110)
 proteinuria (>5g/day) 
oliguria (<500 mL/day)
Increased Creatinine
Pulmonary Edema
Intrauterine growth restriction
CNS Changes
Liver dysfunction (Increased LFT)
Signs of HELLP (PLTS <100k)
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32
Q

How to manage eclampsia?

A

Prevent seizures (Mg)
Blood pressure meds/epidural
Optimize Volume

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33
Q

Diabetes Mellitus considerations

A

Stiff Joint syndrome
More prone to full stomach
Hypoglycemia after delivery with insulin pumps
More likely to require C/S

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34
Q

Cardiovascular considerations

A 
Prevent Pain
Treat dysrhythmia
LUD to avoid ACCS
Avoid:
Myocardial depression
Hypoxemia
Hypercarbia
Acidosis
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35
Q

During what heart issues do you want Fast Full and Forward?

A

Regurgitation
Prolapse
Insufficiency

36
Q

During what heart issues do you want normal HR, normal Preload, normal SVR?

A

Stenosis

37
Q

Which heart lesion is the most dangerous? What is useful for this issue?

A

Aortic stenosis - Arterial line and epidural (just dose slowly)

38
Q

What causes painless vaginal bleeding? Does it require C/S?

A

Previas (total, partial, marginal) significant partial and total previa requires C/S

39
Q

Signs and Symptoms of placental abruption?

A 
Abdominal pain and tenderness
Fetal distress
Hemorrhage (absent or copius)
Abdominal rigidity
Impending doom
40
Q

Placental abruption anesthesia considerations

A

Abruption “walled off”: continue to monitor mother and baby

Severe: immediate delivery, GETA RSI and large bore IVs (no spinal)

41
Q

Placental Accretias and considerations

A

Accretia - Attaches
Incretia - Invades
Percreta - Perforates
Myometrium

Considerations -> Have blood ready, ready for GETA, hysterectomy may be required depending on severity.

42
Q

Uterine Rupture signs and symptoms

A

1) Vaginal bleeding (rigid abdomen): could be retroperitoneal
2) Hypotension
3) Arrested labor: disengagement of fetal presenting part
4) Fetal distress: extreme bradycardia
5) Uterine tenderness: extreme pain even with anesthesia

43
Q

What is the most common cause off postpartum hemorrhage?

A

Uterine Atony

44
Q

What can cause Uterine atony? (8)

A

1) Polyhydramnios
2) Multiple Gestation
3) Macrosomia (BIG ASS BABY)
4) Multiple Parity
5) Tocolytic agents
6) Drugs
7) chorioamnionitis (bacterial toxins)
8) Oxytocin augmented labor /prolonged labor/ rapid labor

45
Q

Treatment for uterine atony? (7)

A

1) Uterine massage
2) Oxytocin IV or intrauterine
3) Methergine 200 mcg IM (avoid in PIH)
4) Hemabate 250 mcg IM (avoid in asthma)
5) Cytotec 1mg PR/PO
6) Bakri balloon
7) Hysterectomy

46
Q

How to treat hemorrhage?

A

Give fluids (Blood>colloids>crystalloid)
100% O2
GETA w/RSI

47
Q

What is AFE and when does it present?

A

Usually presents in stage 2 of labor when large amounts of amniotic fluid enter the maternal circulation

48
Q

Signs and symptoms of AFE (10)

A

1) Sudden chills/shivering
2) Sweating
3) Tachypnea
4) Hypoxia
5) Cyanosis
6) Hypotension
7) Convulsions
8) CV collapse
9) Coagulopathy
10) DIC

49
Q

Treatment of AFE

5

A

1) CPR
2) Quick delivery of fetus (improves venous return and perfusion to vital organs)
3) ICU with invasive monitoring and vasoactive drugs
4) Expect DIC
5) A-OK protocol

50
Q

What is the A-OK protocol?

A

Atropine - vagal reflex (bradycardia)
Ondansetron - vagal reflex (bradycardia) serotonin (pulmonary vasoconstriction)
Ketorolac - thromboxane (pulmonary vasoconstriction)

51
Q

Signs and symptoms of PE? (7)

A

1) Dyspnea
2) Cyanosis
3) Tachycardia
4) Hypotension
5) Chest pain
6) Palpitations
7) Confirmed with V/Q scan or angiography

52
Q

Treatment of VAE?

6

A

1) Alert surgeon
2) Flood surgical field
3) 100%. O2 and intubate if needed
4) Vasopressors
5) Left lateral decubitus slight head up to keep air from leaving the RA
6) Keep surgical site (uterus) BELOW level of heart.

53
Q

Prolapsed cord definition and considerations

A

Cord exits VAGINA and is compressed by fetus decreasing BF/O2 to baby

TRUE emergency
Hold patient head up and GETA if no epidural already in place

54
Q

First stage pain pathways during labor

A

Visceral pain “referred pain”
Cervical dilation and effacement
T10-L1

55
Q

Second Stage pain pathways during labor

A

Somatic pain
Pelvic floor, vagina, and perineum
Distention, ischemia, frank injury
S2-S4 pudendal nerve

56
Q

Test dose composition

A 
Lidocaine 1.5% 
Epinephrine 1:200,000
3 mL 
45 mg of Lidocaine
15 mcg of Epinephrine
57
Q

Signs of IV injection of test dose

A

Tinnitus
Circumoral numbness
Increased HR

58
Q

Signs of SAB injection of test dose

A

Inability to lift legs 5 minutes post injection

59
Q

Advantages of epidural opiates for labor (7)

A

1) Decrease onset time
2) prolong duration
3) decreased concentration of LA
4) motor function not affected
5) decreases side effects of LA
6) Synergy
7) Can be used for long term pain control

60
Q

Disadvantages of epidural opiates for labor? (3)

A

1) Disguises poor epidural
2) side effects of narcotics (N/V, pruritis, urine retention, decreased resp)
3) Cannot be used in 2nd stage of labor without LA

61
Q

Spinal level needed for C/S in SAB

A

T4

62
Q

Technique for SAB

A 
Large bore IV
Crystalloid 1-1.5L bolus 20-30 min prior
Aspiration prophylaxis
Routine monitors and O2
Lateral decubitus position or sitting position
L2-3, L3-4 intervertebral space
LUD
63
Q

Contraindications to Regional?
Absolute (6)
Relative (2)

A 
Relative - Systemic infection and hemorrhage
Absolute->
1) Patient refuse
2) Infection at site
3) Increased ICP
4) Anatomical abnormalities (spina bifida, myelomeningocele)
5) Coags
6) Personnel
64
Q

Methods of treating pain intraoperatively (6)

A

1) Narcs (IV, Epidural)
2) Ketamine
3) Re-dose epidural
4) propofol
5) N2O
6) GETA

65
Q

5 indications for GETA

A

1) Dire fetal distress and no existing epidural
2) Maternal complications
3) Contraindications to regional
4) Failed regional block
5) BOGGY uterus, decrease gas and give IV meds to ensure amnesia

66
Q

3 Aspiration prophylactic medications

A

1) Nonparticulate antacid (bicitra)
2) H2 agonist (Pepcid)
3) Motility agent (Reglan)

67
Q

Induction agents, doses and considerations (3)

A

Propofol 1-1.5 mg/kg
Hypotension / Lower APGAR scores / Fetus may have hypotonus or somnelence

Ketamine 1 mg/kg
Good for asthma and hypotension / avoid in PIH / will need benzos

Etomidate 0.2 - 0.3 mg/kg
Good choice for heart patients
Avoid in patients with seizures

68
Q

How does hydralazine work and what are the side effects

A

Direct acting vasodilator that decreases afterload

S/E: Tachycardia, H/A, vomiting, and tremors

69
Q

What kind of beta blocker is labetalol? Advantages? Disadvantages?

A

Combined Alpha and Beta adrenergic antagonist

Advantage: More rapid onset than hydralazine with few neonatal complications

Disadvantages: >1mg/kg can cause neonatal bradycardia and there are widely varying dose requirements between individuals.

70
Q

Signs of Magnesium toxicity

A

Loss of DTR at 10 mEq/L
Resp depression at 12-15
Resp arrest at 15
Cardiac arrest at 20-25

71
Q

Magnesium Toxicity treatment

A

1 gm IV of Calcium gluconate

72
Q

What drugs do not cross the placenta?

A 
Heparin
Insulin
Glycopyrrolate
NDNMB
Succinylcholine
He 
Is
Going
Nowhere
Soon
73
Q

What MAC maintains UBF? What MAC significantly decreases UBF? What MAC should you keep volatiles at until baby is delivered?

A

Maintains at 1-1.5 MAC
Decreases at >2 MAC
0.5 MAC until fetus is delivered

74
Q

Magnesium treatment goal level

A

4-7 mEq/L

75
Q

HIV positive mother. How to prevent transmission to baby?

A

Prophylactic antiretrovirals and do C/S to prevent transmission.

76
Q

What is the most important predictor of fetal outcomes in C/S?

A

Time to cut to baby being out. >3 minutes = poor APGAR scores.

77
Q

When can you give IV narcotics during a C/S?

A

After baby is out.

78
Q

Patient has AIDS. What will you change?

A

Decrease dose of paralytics due to muscle wasting.

79
Q

Anesthesia considerations if boggy uterus?

A

Decrease volatiles and give IV meds to ensure amnesia

80
Q

MAC is increased during labor. T/F

A

False -> MAC is decreased in obstetric patients.

81
Q

Steps for induction

A

Only start if surgeon at bedside with scalpel in hand.
RSI with Sux 1-1.5 mg/kg
DL with MAC blade/short handle
Small ETT 6.0-7.0 (slides say both 6.0-6.5 and 6.0-7.0)
After tube placement verified say CUT

82
Q

List 3 Considerations for Fatties

A

Ramping
Longer needles
Decreasing epidural/spinal dose

83
Q

Uterine Inversion patient: How do you relax the uterus?

A

Volatile anesthetic 1.5 MAC

NTG 1mcg/kg IBW IV

Replace uterus

Place on Pitocin 12 hrs after inversion

84
Q

How to relax uterus with retained placenta?

A

GETA

NTG 50-200 mcg IV

85
Q

Indications for C/S

8

A 
Maternal disease:
Hemorrhage
Previa
Preeclampsia
Genital HERPES
Fetal distress
Breech
Elective
Infection
86
Q

What drugs do you avoid in OB patient that is not having OB surgery?

A

Versed
N2O
Esmolol

87
Q

Differential diagnosis of AFE

A 
Aspiration
Anaphylaxis
Seizure
Eclampsia
Cardiogenic shock
Sepsis

OB - Paul Smith (1 decks)

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