Final Review Flashcards
Pregnancy is a normal physiologic state, and physiological parameters in pregnancy are altered—T/F
True
MAC is ___ (increased/decreased) in pregnancy
Decreased
Pregnancy causes ___ (increased/decreased) sensitivity to local anesthetics
Increased
Ventilation in pregnancy is ___ (increased/decreased)
Increased
Tidal volume is increased ___% at term
40%
Respiratory rate ___ (increases/decreases) during pregnancy
Increases—15%
Minute ventilation is ___ (increased/decreased) during pregnancy
Increased—50%
PaCO2 ___ (increases/decreases) during pregnancy to ___-___ mm Hg
Decreases to 28-32 mm Hg
PaCO2 decreases during pregnancy d/t ___ventilation, respiratory ___osis,
Hyperventilation, respiratory alkalosis
Body compensates to respiratory alkalosis during pregnancy by excreting ___ ions to maintain a normal pH…this leads to ___ (what acid-base balance?)
Bicarbonate ions; leads to metabolic acidosis
Expanding uterus pushes the diaphragm ___
Cephalad (up towards head)
FRC decreases by ___% in pregnancy
20%
There are no changes in vital capacity or total lung capacity during pregnancy—T/F?
True
FRC ___ (increases/decreases) during pregnancy
Decreases
Maternal oxygen consumption ___ (increases/decreases) during pregnancy
Increases
Decrease in FRC and increase in maternal O2 consumption makes it more likely for mom to develop maternal ___ during induction of general anesthesia
Maternal hypoxia
Need to ___ prior to induction because there is such a high risk of maternal hypoxia
Pre-oxygenate/denitrogenate
P50 of hemoglobin ___ (increases/decreases) from ___ to ___ mm Hg
Increases from 27 to 30 mm Hg
Increase in P50 of hemoglobin during pregnancy allows for ___
Oxygen delivery to the fetus
Dead space in pregnancy is ___ (increased/decreased)
Decreased
Airway resistance in pregnancy is ___ (increased/decreased)
Decreased
Congestion of respiratory mucosa occurs during pregnancy secondary to vasodilation—T/F?
True
Lots of soft tissue in the neck, chest, and breasts may cause obstruction and difficulty placing laryngoscope properly; a shorter laryngoscope handle should be available for use—T/F?
True
Mucosal venous engorgement/edema creates risk for bleeding in airway with intubation—T/F?
True
Nasal instrumentation should be avoided in pregnant patients—T/F?
True
Larger ETTs should be used for pregnant women—T/F?
False…want to use SMALLER ETT—6.5, 7.0, or 7.5 ETT
What induction technique should be used to prevent maternal hypoxia?
Rapid sequence induction with cricoid pressure
Goal is to maintain ___carbia during general anesthesia
Normocarbia
Avoid ___ventilation because decreased PaCO2 will cause uterine vaso___; ___ (increased/decreased) placental blood flow; and metabolic ___ in the mother
Avoid hyperventilation; cause uterine vasoconstriction; decreased placental blood flow; metabolic alkalosis in the mother
Metabolic alkalosis in the mother will shift the oxyhemoglobin curve to the ___, so maternal hemoglobin will ___
To the left, so maternal hemoglobin will hold onto oxygen and not release it to the fetus
Plasma volume ___ (increases/decreases) during pregnancy by ___%
Increases by 45%
RBC volume ___ (increases/decreases) by ___%
Increases by 20%
Sodium/water retention occurs in pregnant patients—T/F?
True
Pregnant patients are hypervolemic—T/F?
True
Cardiac output ___ (increases/decreases) in pregnancy by ___%
Increases by 40%
HR ___ (increases/decreases) by ___%
Increases by 15-30%
Stroke volume ___ (increases/decreases) by ___%
Increases by 30%
In pregnancy, the oxyhemoglobin dissociation curve shifts to the ___
Right—so maternal hemoglobin releases O2 to be delivered to the fetus
Peripheral vascular resistance ___ (increases/decreases) in pregnancy by ___%
Decreases by 15%
Why does PVR drop in pregnancy?
Increased progesterone relaxes venous smooth muscle
Cardiac output change in latent (inactive) phase of labor = ___% increase
15% increase
Cardiac output change in active phase of labor = ___% increase
30% increase
Cardiac output change in second stage of labor = ___% increase
45% increase
Cardiac output change postpartum = ___% increase
80% increase
Pregnant women’s response to adrenergic drugs is increased—T/F?
False—response to adrenergic drugs is blunted in pregnancy
CXR will show cardiac hypertrophy during pregnancy—T/F?
True
Heart murmurs auscultated during pregnancy are a cause of concern—T/F?
False—heart murmurs are common on auscultation in pregnant women
Systolic murmurs are ___
Normal
Diastolic murmurs are ___ if heard
Pathologic
S3 heart sound may be heard during pregnancy—T/F?
True
There is a ___ (increase/decrease) in plasma colloid osmotic pressure d/t relative hypervolemia that occurs during pregnancy
Decrease
Supine hypotension syndrome is aka ___
Aortocaval compression
Aortocaval compression syndrome occurs in ___% of term parturients when they lie flat
20%
Symptoms of aortocaval compression = ___tension, ___, ___, ___, ___
Hypotension, pallor, nausea, vomiting, diaphoresis
Can see symptoms of aortocaval compression as early as ___ weeks gestation
20 weeks
Treatment for aortocaval compression = place patient in ___ position
Left lateral uterine tilt position
Cell mediated immunity is ___ (increased/decreased) during pregnancy
Decreased
Pregnancy creates a hypercoaguable state, putting parturients at higher risk for PE—T/F?
True
Fibrinogen is ___ (increased/decreased) during pregnancy
Increased
PT and PTT ___ (increased/decrease) by ___%
Decrease by 20%
Renal blood flow/glomerular filtration are both ___ (increased/decreased) by 50% by the 16th week of pregnancy; remains ___ until delivery
Increased; remains elevated
Serum BUN and creatinine are mildly ___
Reduced—may see BUN 8, creatinine 0.5
Mild glycosuria/proteinuria is common in pregnancy—T/F?
True
Increased progesterone ___ (increases/decreases) gastroesophageal sphincter tone; displacement of the stomach by the uterus also ___ competence of the gastroesophageal sphincter
Decreases; reduces
___ (increased/decreased) risk of symptomatic aspiration during pregnancy
Increased
There is a 20% decrease in pseudocholinesterase levels in pregnancy, so the amt of succs administered should be reduced—T/F?
True
Gallbladder becomes sluggish during pregnancy, can result in gallstones—T/F?
True
Albumin levels are increased in pregnancy—T/F?
False—decreased albumin levels, affects protein-bound drugs
Insulin resistance occurs during pregnancy d/t higher plasma glucose levels in the parturient—T/F?
True
Oxygen transfer between mom and baby depends on mom’s ___ blood flow and fetal ___ blood flow
Mom’s uterine blood flow and fetal umbilical blood flow
O2 has the smallest storage to utilization ratio in the fetus—fetus can store ___ ml of O2 and O2 consumption is ___ ml/min
Store 42 ml of O2 and O2 consumption is 21 ml/min
Placental blood PaO2 = ___ mm Hg
40 mm Hg
Mom has a ___ (left/right) shift in oxyhemoglobin curve
Right shift—releases O2 to fetus
Fetus has a ___ (left/right) shift in oxyhemoglobin curve
Left shift—accepts O2 from mom
Fetal hemoglobin is ___ (lower/higher) than maternal hemoglobin
Higher
Fetal hemoglobin has a ___ (lower/higher) affinity for CO2 than does maternal hemoglobin
Lower
Uterine blood flow is ___% of cardiac output— ___ ccs per min
10%—700 ccs per min
Under normal conditions, uterine blood flow is only ___ ccs per min
50 ccs per min
___% of uterine blood flow goes to the placenta; the rest goes to the myometrium (uterine muscle)
80%
What are (3) factors that influence uterine blood flow?—systemic ___, uterine ___, uterine ___
- Systemic BP
- Uterine vasoconstriction
- Uterine contractions
Propofol and thiopental mildly reduce UBF via maternal hypotension—T/F?
True
Induction agent dosages can be cut by 1/3-1/2 of the usual doses to minimize maternal hypotension—T/F?
True
Volatile agents ___ (increase/decrease) UBF secondary to hypotension
Decrease UBF
At < 1 MAC, hypotensive effects of volatile agents are minor—T/F?
True
Can keep volatile agents ___ MAC because pregnancy ___ (increases/decreases) MAC
< 1 MAC because pregnancy decreases MAC
Ketamine, nitrous oxide, and opioids have ___ effect on UBF
Little to no effect
High serum local anesthetic levels can result in uterine vaso___
Vasoconstriction
Goal is to maintain ___tension in pregnant mom so baby continues to get adequate blood flow via placenta
Normotension
Neuraxial analgesia ___ (increases/decreases) maternal catecholamine levels and reduces vasoconstriction, thus improving uterine blood flow
Decreases
Once baby is born, pulmonary vascular resistance [in the baby] ___ (increases/decreases) as oxygen enters the lungs
Decreases
If baby isn’t crying when born and still isn’t crying after stimulation, you need to initiate ___
Positive pressure ventilation
Hypoxia or acidosis will increase ___ shunting through the ductus in the newborn, creating a ___
Increase R to L shunting; creates a “downward spiral”
Downward spiral = ___ of the newborn
Persistent pulmonary hypertension of the newborn (occurs when baby is hypoxic/acidotic, blood backs up into R side of heart, causing pulmonary hypertension)
Stages of labor:
Stages 1, 2, and 3
Stage 1 of labor is divided into two phases—___ phase and ___ phase
Latent phase and active phase
Latent phase of labor = minor dilation of cervix ___-___ cm, ___ (frequent/infrequent) contractions
Minor dilation of cervix 2-4 cm, infrequent contractions
Active phase of labor = progressive dilation to ___ cm and ___ (regular/irregular) contractions every ___ to ___ minutes
Progressive dilation to 10 cm and regular contractions every 3 to 5 minutes
Stage 2 of labor = time from ___ until ___
Complete dilation until infant delivered
Stage 3 of labor = time from ___ until ___
Delivery of infant until placenta delivered
Ptocin (oxytocin) can ___ (increase/decrease) rate of contractions to every ___ to ___ minutes
Increase rate of contractions to every 1-1.5 mins
Uterine atony = uterus does ___ contract; risk for ___
Does not contract; risk for massive bleeding
Uterine atony can be caused by too much ___
Oxytocin (ptocin)
What is the most common complication of neuraxial blocks?
Nerve injury
Insertion and removal of epidural catheter should only occur when ___ is normal
Coagulation function
Always make sure that the tip of the catheter is ___ upon removal
Intact
In pregnant women with no history of bleeding problems, no signs/symptoms of PIH, not on anticoagulation, it is safe to proceed with neuraxial block—T/F?
True
Patients with PIH and neuraxial blocks—platelet count > ___ is required before proceeding with block; normal ___, ___ are also required
> 100k; normal PT, PTT are also required
If patient is on low molecular weight heparin, consider ___ instead of neuraxial block
IV analgesia
Avoid block for ___ hours if therapeutic on anticoagulation
24 hours
Avoid block for ___ hours if prophylactic anticoagulation
12 hours
Remove catheter at least ___ hours after last dose
At least 12 hours
Do not administer LMWH until ___-___ hours after block is placed or catheter is removed
2-4 hours
Avoid concurrent ___ or ___ with neuraxial blocks
NSAIDs or anticoagulants with neuraxial blocks
What are two main signs of epidural hematoma?—bilateral ___ weakness and ___ pain
- Bilateral leg weakness
- Back pain
What are two other signs of epidural hematoma? (think bowel/bladder)
- Incontinence
- Absent rectal sphincter tone
If epidural hematoma is suspected, patient must get a stat ___
CT/MRI
Surgical decompression of epidural hematoma must occur within ___ hours for full neurological recovery to occur
6 hours
If an epidural abscess is present, can take ___-___ days for signs to occur
4-10 days
Treatment of epidural abscess = ___ and ___
Antibiotics and laminectomy
Treatment of epidural abscess—have ___-___ hour window before permanent damage ensues
6-12 hour
Epidural abscess s&s—severe ___ pain that is worse with ___
Severe back pain that is worse with flexion
Epidural abscess s&s—exquisite ___ tenderness
Local
Epidural abscess s&s—___, ___, meningitis-like ___ with ___ stiffness
Fever, malaise, meningitis-like headache with neck stiffness
Lab changes with epidural abscess—___ WBC, ___ ESR, ___ blood culture
Increased WBC, increased ESR, positive blood culture
Transient neurological symptoms (TNS) = pain and dysthesia in ___, ___, or ___ that can follow a subarachnoid block, resolves within ___ hours
Pain and dysthesia in buttocks, legs, or calves that can follow a SAB, resolves within 72 hours
Dysthesia = abnormal ___
Sensation—can be aching, burning, prickling feeling
TNS is most commonly caused by ___ spinals
Lidocaine—more common with high doses of concentrated lidocaine 5%
Compression injuries are very common d/t ___ position
Lithotomy
Post-dural puncture headache = ___ headache
Spinal headache
Spinal headache is throbbing, postural***, with variable distribution—T/F?
True
Onset of spinal headache is typically ___-___ hours after dura puncture
12-48 hours
Duration of spinal headache
Few days to weeks
___ gauge and ___ needles increase PDPH incidence
Larger gauge and cutting edge needles
___ point needles are significantly better than ___ tip needles because dura fibers are not cut but just pushed apart
Pencil point needles are better than cutting tip needles
Hallmark sign of PDPH =
Continuous headache when in upright position (i.e.: sitting or standing)
Relief from PDPH only comes when ___
Laying completely flat
Non-invasive treatment of PDPH =
Bed rest
Most PDPH resolve within ___ week
1
Other non-invasive treatment modalities for PDPH include PO, IV, epidural analgesics—i.e.: NSAIDs, acetaminophen, opioids; cerebral vasoconstrictors—i.e.: PO/IV caffeine, theophylline, sumatriptan—T/F
True
Definitive treatment of PDPH = ___
Epidural blood patch
What is this describing?—epidural space is identified and 15-20 ccs of patient’s own blood is injected into the epidural space; clotting factors in the blood help seal the hole in the dura; try to inject at the same level as the initial dural puncture
Epidural blood patch
Epidural blood patch—start slow and stop either when patient says headache is gone or they have a pressure sensation in the ears—T/F?
True
What is the most common cause of perioperative headache?
Caffeine withdrawal
Total spinal anesthesia = ___tension, ___nea, ___nia
Hypotension, dyspnea, aphonia
Management of total spinal—place patient in ___ position
Left uterine displacement/trendelenburg position
Treatment of total spinal—early resuscitation, ventilation, and circulatory support are essential; epi may be needed; intensive maternal/fetal monitoring are crucial—T/F?
True
Management of total spinal—can give naloxone for intraspinal opioid—T/F?
True
Urgent C-section is mandatory for treatment of total spinal—T/F?
False—NOT mandatory—decision is based on fetal assessment after maternal stabilization
OB population is at increased risk for ___
Aspiration
Aspiration is high risk in parturients because they have more ___ which causes smooth muscle ___; gastric sphincter is ___
Progrestrone; smooth muscle relaxation; gastric sphincter is relaxed
Moms have ___ (slower/faster) gastric emptying
Slower
Moms have ___ (higher/lower) gastric pH
Lower
Suspect ___ with hypoxia, pulmonary edema, bronchospasm
Aspiration
Aspiration prevention in parturients = ___ pressure
Cricoid pressure (Sellick’s maneuver)
Aspiration prevention—elective C-section patients should fast for at least ___ hours, even if regional is planned
6 hours
Always assume a ___ stomach in parturients
Full
Sodium citrate can be given to ___ gastric pH; works within ___; lasts ~___ mins
Raise gastric pH; works within minutes; lasts ~30 mins
H2 blockers take at least ___ minutes to work
30 minutes
Reglan facilitates ___, requires ___-___ minutes
Gastric emptying, requires 40-60 mins
Pain pathways—1st stage of labor—pain source is primarily ___
Lower uterine segment from contractions (T10-L1)
Pain pathways—2nd stage of labor—pain source is ___ structures via ___ nerve
Perineal structures via pudendal nerve (S2-S4)
All opioids cross the placenta and depress the fetus—T/F?
True
___ provides great satisfaction scores, less neonatal depression, less nausea, less risk of maternal respiratory depression
PCA
This medication causes increased risk of respiratory depression for neonate d/t immature BBB and is not often used
Morphine
This medication onset is 5 minutes; has a very long half-life of 18-23 hours; respiratory depression can be avoided if this medication is given less than 1 hour before delivery; has active metabolites; causes frequent nausea, vomiting; do NOT give to patients with seizure history or renal failure
Meperidine (Demerol)
This medication is 100x more potent than morphine; onset is 3-5 minutes; rapid transfer across the placenta; respiratory depression may outlast analgesia; you can give a loading dose of this medication through PCA
Fentanyl
This medication is a mu opioid antagonist, kappa agonist; there is a ceiling effect on respiratory depression from this medication but there is no difference in side effects; great for helping mom get through the worst of her contractions; only lasts 45 mins-1 hour
Nalbuphine (Nubain)
Nalbuphine (Nubain)—___ is common with this medication
Dysphoria
Nalbuphine (Nubain) can be used to treat ___
Opioid pruritis
Some reports suggest that this medication offers better analgesia than fentanyl; sedation is common; there is a ceiling effect on respiratory depression
Butorphanol (Stadol)
Meperidine (demerol) has a very long half life of ___-___ hours
18-23 hours
Meperidine (demerol)—respiratory depression can be avoided if this medication is given ___ hour before delivery
1
Meperidine (demerol) has ___
Active metabolites
Meperidine (demerol) should NOT be given to patients with ___ history or ___ failure
Seizure history or renal failure
___ block can be used during the 1st stage of labor; risks include accidental injection into uterine artery, fetal local anesthetic toxicity, nerve injury, or hematoma
Paracervical block
___ block can be used during the 2nd stage of labor; good for patients with contraindications to neuraxial block; needle is placed transvaginally under ischial spines; risks include injury, infection, hematoma
Pudendal block
Local anesthetics—amino ___ are derivatives of PABA (known allergen); metabolized by plasma cholinesterase; examples include cocaine, procaine, chlorpromazine, tetracaine
Esters
Local anesthetics—amino ___ are metabolized by the liver; no PABA; true allergies are rare; examples include lidocaine, bupivacaine, prilocaine, ropivacaine, etidocaine
Amides
Local anesthetics—lipid solubility = ___
Potency
Local anesthetics—the more lipid soluble, the more ___ diffusion
Placental
Local anesthetics—protein binding influences ___…increased protein binding = ___ (shorter/longer) duration
Duration of action…increased protein binding = longer duration
Local anesthetics—high protein binding ___ (increases/decreases) placental transfer
Decreases
Local anesthetics are weak ___
Bases
Local anesthetics work on the ___ channel
Sodium
PKA =
50% ionized, 50% nonionized
PKA determines the ___
Speed of onset
The closer the pKa to the physiologic pH, the ___ the onset
Faster
Can add ___ to artificially raise the pH and speed the onset of action
Sodium bicarbonate
Increasing dose of local anesthetic given = ___ onset, ___ duration
Faster onset, longer duration
Vasoconstrictors given with local anesthetics prevents ___ absorption
Vascular absorption
Increasing temperature of LA ___ onset time
Reduces
In pregnancy, should use ___ (more/less) local anesthetic; there will be a ___ onset of blockade, possibly due to progesterone
Less local anesthetic; there will be a faster onset of blockade
Bupivacaine, ropivacaine, and lidocaine should be used for ___ epidural anesthesia
Labor
Lidocaine and 2-chloroprocaine should be used for ___ epidural anesthesia
Operative
Tetracaine and bupivacaine should be used for ___ anesthesia
Spinal
This LA is used for labor epidural anesthesia; not used as a continuous infusion; can be useful as a top off and to test the function of an epidural catheter; used to activate epidural catheter for c-section; results in a lot of motor block; 45 min DOA
Lidocaine
This LA is used for epidural c/s; this is the only ester local used in epidural space; rapid onset, very short duration; results in lots of motor block; low risk of toxicity; very rapidly metabolized in the blood by pseudocholinesterase; do not use for spinals
2-chloroprocaine
2-chloroprocaine is contraindicated in patients with ___
Atypical pseudocholinesterase
This LA is used for epidural labor; long duration; less motor block than most other agents; produces refractory Vtach/VF if large IV dose is given accidentally
Bupivacaine
This LA is the L isomer of bupivacaine; less cardiotoxic; new drug; NOT approved for spinal
Levobupivacaine
This LA is less cardiotoxic than levobupivacaine; 25% less potent than bupivacaine; NOT approved for spinal
Ropivacaine
Epidurals should be dosed ___
Incrementally—every dose is a test dose!
___ is sometimes used as test dose for epidural
Epi
For OB epidural analgesia, it is best to cover ___-___ dermatomes
T10-S4
Spinal cord ends at ___ in most people
L1 (some people it ends lower at L2/L3)
Spinals should be placed below ___
L3
If at any time during epidural/spinal placement patient complains of paresthesia, you should ___
Remove the needle
___ line is the transverse line passing across the lumbar spine between the posterior iliac crests
Tuffier’s line
___ for epidural placement is becoming more common d/t obese population
Ultrasound
What is the #1 contraindication to neuraxial blockade?
Patient refusal
Other contraindications to neuraxial blockade—___ at the site of injection; ___pathy; intracranial ___; aortic ___; existing ___; hemodynamic ___
Infection; coagulopathy; intracranial mass lesion; aortic stenosis; existing spinal/neurological pathology; hemodynamic instability
Subarachnoid blocks for labor are more often used for ___
C-section
Combination of ___ is also used for labor
Spinal/epidural—spinal for the c/s and epidural for continued pain management
Combined spinal/epidural provides ___ relief; inject ___ dose first, then leave ___ catheter in place
Near instant relief; inject spinal dose, then leave epidural catheter in place
Problem with combined spinal/epidural is that it can make testing an epidural catheter difficult since pain impulses are already blocked from the spinal—T/F?
True
Sub dural block is done in the space between ___ and ___ mater
Dura and arachnoid mater
A sub dural block presents variably, from minimal effects to loss of consciousness/apnea—T/F?
True
Sub dural block may cause Horner’s syndrome—T/F
True
___ syndrome = dry mouth, miosis, ptosis, anhidrosis
Horner’s
A sub dural block should be replaced with an ___
Epidural
What is this describing?—uneventful placement of epidural; sensory change over 10-20 minutes; excessive spread of volume injected—high cephalad spread with poor caudal spread and sacral sparing; asymmetric distribution; minimal to moderate motor block; minimal or easily controlled hypotension
Sub dural block
Preterm labor = regular uterine contractions occurring at least every ___ minutes, resulting in cervical change prior to ___ weeks
10 minutes, prior to 37 weeks
Low birth weight (LBW) = any infant < ___ g at birth
< 2500 g (2.5 kg) at birth
Very low birth weight (VLBW) = any infant < ___ g at birth
< 1500 g (1.5 kg) at birth
Mortality approaches 90% for infants born < ___ weeks; survival exceeds 90% for infants > ___ weeks; survival is greater than 98% by ___ weeks
< 24 weeks; > 30 weeks; 34 weeks
Almost all infants at < 27 weeks gestation experience ___; by 36 weeks, they do not experience this
Respiratory distress syndrome
___ is proven safer in pre-term labor with breech presentation
C-section
Tocolytic therapy = attempt to ___ or ___ contractions and avoid ___
Slow down or stop contractions and avoid pre-term labor
Tocolytic therapy is used for ___-term, < ___ hours to permit corticosteroid treatment to aid fetal lung maturation or allow transfer to a better NICU facility
Short-term, < 48 hours
___ increases surfactant production in neonate’s lungs; takes about ___-___ hours for surfactant to build up; try to get 2 doses in before birth
Betamethasone; takes ~24-48 hours
Tocolytic therapy is used for gestational age ___-___ weeks, EFW < ___ g, absence of fetal ___
20-34 weeks, EFW < 2500 g, absence of fetal distress
Long-term tocolytic therapy is not proven to prolong gestation or reduce neonatal morbidity—T/F?
True
(5) types of tocolytic therapy:
- methylxanthines
- calcium channel blockers
- prostaglandins synthetase inhibitors
- magnesium
- beta adrenergic agonists
Tocolytic therapy—___ can become toxic very easily; frequent monitoring of peaks/troughs required; increases cAMP to produce uterine muscle relaxation
Methylxanthines (i.e.: aminophylline)
Tocolytic therapy—what therapy is this?—myometrium contractility is related to free Ca concentration; decreased Ca = decreased contractility
Calcium channel blockers (i.e.: nifedipine)
Maternal side effects of this drug class include hypotension, tachycardia, dizziness, palpitations, myocardial depression, conduction defects, hepatic dysfunction, hemorrhage, flushing, vasodilation, peripheral edema, decreased UBF leading to fetal hypoxemia and fetal acidosis
Calcium channel blockers
___ is a risk of calcium channel blocker therapy because the uterus can’t contract; uterine atony occurs that is refractory to ___ and ___
Postpartum hemorrhage; uterine atony occurs that is refractory to oxytocin and prostaglandin F-A2
What tocolytic drug class is this?—decreased cyclooxygenase causes decreased prostaglandin, causing uterine relaxation
Prostaglandin synthetase inhibitors
Indomethacin and sulindac are both ___
Prostaglandin synthetase inhibitors
Side effects of this medication class include nausea, heartburn, bleeding d/t low platelets, primary pulmonary HTN; moms feel horrible on this drug
Prostaglandin synthetase inhibitors
Fetal side effects of this drug class include premature closure of ductus, persistent fetal circulation, renal impairment, transient oliguria
Prostaglandin synthetase inhibitors
This drug competes with Ca for uterine smooth muscle surface binding, resulting in decreased contractility/smooth muscle relaxation; prevents increases in intracellular calcium; activates adenylyl cyclase, increases cAMP, causing uterine relaxation
Magnesium
___ is the drug of choice for tocolytic therapy/PTL
Magnesium
Magnesium makes patient more sensitive to ___
NMBs—decrease dosage used
Normal magnesium treatment range is ___-___mg/100mL
4-7 mg/100 mL
Magnesium 8-10 = loss of ___
Deep tendon reflexes
Magnesium 10-15 = ___ depression, wide ___, prolonged ___
Respiratory depression, wide QRS, prolonged PR interval
Treatment of magnesium toxicity = ___
Calcium gluconate or calcium chloride
This tocolytic class causes direct stimulation of B-adrenergic receptors in uterine smooth muscle, increases cAMP, and causes uterine relaxation
Beta-adrenergic agonists
Two types of beta-adrenergic agonists
Terbutaline, ritodrine
Side effects of this drug class = nausea, vomiting, restlessness, hyperglycemia, hypokalemia, acidosis, tachycardia, arrhythmias, pulmonary edema, delusional anemia
Beta-adrenergic agonists
Beta adrenergic agonists can also cause ___; incidence in 1-5% of patients receiving this tocolytic therapy
Beta agonist pulmonary edema
Risk factors for beta agonist pulmonary edema = ___ (increased/decreased) IVF administration; ___ gestation; tocolysis > ___ hours; concomitant ___ therapy; ___ion; ___kalemia; undiagnosed ___ disease
Increased IVF administration; multiple gestation; tocolysis > 24 hours; concomitant Mg therapy; infection; hypokalemia; undiagnosed heart disease
Multiple gestation—mortality of the ___ (first/second) twin is greater
Second twin
Pre-term labor complicates ___-___% of multiple gestation
40-50%
Vaginal birth is possible for most twin pregnancies—T/F?
True
If twin A is in breech position, C/S is a must and vaginal delivery is not possible—T/F?
True
Twin B requires monitoring until delivery is complete—T/F?
True
If twin A is not breech and twin B is breech, vaginal delivery is possible; if twin A is breech, C/S is required—T/F?
True
What local is preferred to be used d/t its rapid onset?
2-chloroprocaine 3%
Uterine ___ may be required for internal manipulation of fetus
Uterine relaxation
What is this describing?—sudden abdominal pain despite functional epidural; vaginal bleeding; hypotension; cessation of labor; fetal distress
Uterine rupture
Fetal distress is the most reliable sign of uterine rupture—T/F?
True…this is when fetal monitor will flat line
With uterine rupture, you should expect massive ___
Hemorrhage
Increased risk of ___ with uterine rupture
Postpartum hemorrhage
Fetal presentation is the most dependent or “presenting” part of the infant—T/F?
True
Most common fetal lie =
Longitudinal over transverse
Greatest chance of uncomplicated vaginal delivery = ___ presentation, ___ C-spine (chin to chest), ___ anterior (face down)
Vertex, flexed C-spine, occiput
(3) types of breech presentation:
- Complete breech
- Incomplete breech
- Frank breech
Complete breech =
Feet first
Incomplete breech =
One foot down, one foot up
Frank breech =
Butt first
Over 90% of breech infants are delivered vaginally—T/F?
False—delivered by c-section
___ lie is an absolute indication for a c-section
Transverse
Post maturity = gestation beyond ___ weeks; risks often evident at ___-___ weeks
Beyond 42 weeks; risks evident at 40-41 weeks
Post maturity causes ___ (increased/decreased) UBF and fetal ___
Decreased UBF and fetal distress
Post maturity—umbilical cord ___ may occur d/t oligohydramnios (low amniotic fluid)
Compression
Post maturity—___ staining of amniotic fluid may occur
Meconium
Post maturity = increased incidence of ___ and shoulder ___
Macrosomia and shoulder dystocia
Anesthetic considerations for post maturity—___ analgesia and preparations for ___ d/t cephalopelvic disproportion
Epidural analgesia and prep for C/S
Umbilical cord accidents—___ = cord prolapse through cervix, compressed; 10 minute window before fetal compromise
Prolapsed cord
Monoamniotic twins share one ___ and ___; risk of cord ___
Share one placenta and amniotic sac; risk of cord entanglement
Short cord < 30 cm risks ___
Compression, constriction, rupture
Long cord > 72 cm risks cord ___
Entanglement
Anesthesia for C/S—___ anesthesia is most common
Regional
Indications for ___ for C/S = acute severe fetal distress with no time for block; non-functioning epidural catheter; parturient has contraindication to regional block (i.e.: coagulopathy); regional block inadequate; patient refusal of block
General anesthesia
Limit time between uterine incision and delivery to less than ___ minutes
3 minutes
Consider ___ if patient is not a stat C/S and regional is not an option
Awake fiberoptic intubation
Aspiration prophylaxis for parturients: (3) drugs
- Sodium citrate (antacid)
- Ranitidine (Zantac)
- Reglan
This medication raises gastric pH; should be given to all patients prior to C/S, whether they are receiving general or regional anesthesia
Sodium citrate
Ranitidine (Zantac) is a ___
H2 blocker
This medication decreases gastric volume within minutes after administration
Reglan
Parturients for elective procedures should be NPO for ___ hours
6
A parturient is always considered to have a ___
Full stomach! Even after being NPO for 6+ hours
What position is mandatory for all cases?
Uterine displacement
At term, O2 consumption is increased ___-___%; this is accompanied by a decrease in ___
20-30%; decrease in FRC
Increased O2 consumption + decreased FRC in pregnancy results in a faster rate of ___ during apnea
Desaturation
The key is to increase oxygen content of the lungs by having the patient breathe 100% O2 with a tight mask fit for at least ___ minutes
3
Propofol dose in parturient
1.5-2 mg/kg
Ketamine dose in parturient
1.1-5 mg/kg
This drug is useful in the face of maternal hemorrhage as it supports BP and decreases the risk of bronchospasm
Ketamine
Side effects of ketamine = ___tension and ___
Hypertension and dysphoria
2 induction agents that are NOT commonly used for GA in parturients = ___ and ___
Midazolam and etomidate
Versed causes more ___ than other agents
Neonatal depression than other agents; can be given to mom after the baby is born
Etomidate may cause transient ___ suppression in the neonate
Adrenal
___ induction is mandatory
Rapid sequence
Any relaxant is safe in pregnancy, as their ___ charged nature significantly limits placental transfer
Hydrophilic
If mom can’t receive succs (i.e.: history of malignant hyperthermia), then use high dose ___ for rapid sequence induction
Roc
There is no correlation between neonatal depression and the interval between ___ and delivery
Anesthetic induction
The uterine incision to delivery interval does make a difference, possibly d/t uterine artery spasm—T/F?
True—time between uterine incision/delivery should be less than 3 minutes
If an epidural is dosed for C/S and does not produce an adequate surgical block, then a general anesthetic may be required as the risk of a total spinal is ten-fold higher in this condition—T/F?
True
Greatest cause of death in parturients undergoing regional anesthesia for C/S = ___
Local anesthetic toxicity
If block extends to T1, a reduction in ___ and ___ may be seen
Heart rate and contractility (because cardiac accelerators = T1-T4)
Epidural has no effect on inspiration—T/F?
True
Expiratory pressures and flows are ___ (increased/decreased) in proportion to decreased abdominal muscle strength from epidural
Decreased
A sensory block above T2 often gives patients a sense of ___
Dyspnea
Epidural—dose catheter ___ and in ___; ___ before each dose
Slowly and in increments; draw back syringe before each dose
Sodium bicarbonate will slow the onset of lidocaine or 2-chloroprocaine—T/F?
False—will speed onset
The ideal block height is somewhere between ___-___
T4-T8
10-50% of patients with epidurals have ___ pain
Breakthrough pain
Treatment options for breakthrough pain—a bolus of ___ cc of local; epidural or IV ___; ___ (think inhalation agent); ___ IV—keep total dose below 1 mg/kg, ~10 mg at a time to minimize dysphoria
bolus of 5 cc of local; epidural or IV fentanyl; nitrous oxide; ketamine IV
If epidural is clearly inadequate, convert to ___
General anesthetic
Intravascular injection is not a concern with spinals—T/F?
True
Maternal hypotension is more common with spinals than epidurals—T/F?
True
Laboring women have less hypotension with spinals than non-laboring women—T/F?
True
Treatment of maternal hypotension—___ was the drug of choice, but was found to increase the likelihood of fetal ___
Ephedrine was the drug of choice, but was found to increase the likelihood of fetal acidosis
Treatment of maternal hypotension—___ is now considered the drug of choice by many practitioners
Phenylephrine
If a mom is already bradycardic, ___ may not be the best choice for treatment of maternal hypotension
Phenylephrine
Can use ___ to maintain mom’s HR/placental perfusion to the baby
Combination of ephedrine + phenylephrine
This drug takes a long time to work, has long duration, and is unreliable
Tetracaine
This drug is short acting and has had reports of transient neurological symptoms; not the best choice for spinal/epidural
Lidocaine
This is the best choice of drug for spinal/epidural in parturients; combines quick onset with intermediate duration
Bupivacaine
Can give ___ via epidural after baby is delivered
Duramorph (morphine)
Addition of duramorph provides long-acting analgesia (12+ hours), but increases risk of delayed ___ and produces side effects such as ___ and ___
Risk of delayed respiratory depression; nausea and pruritis
Important to consider risk of respiratory depression in moms with sleep apnea
Fentanyl and duramorph can cause severe ___
Facial itching
Once baby is delivered, administer pitocin ___ units in ___ cc IV bag
30 units in 500 cc IV bag
Run pitocin as a bolus dose—run it at ___ ccs/hr for first 30 mins, then decrease to ___ ccs/hr for remainder
334 ccs/hr for first 30 mins, then decrease to 95 ccs/hr for remainder
If pitocin is given too fast, can cause a ___ response
Hypertensive
(3) common non-obstetric surgical procedures in the parturient:
- Appendectomy
- Cholecystectomy
- Kidney stones
No anesthetic agent is a proven teratogen in humans—T/F?
True
Limit ___ use in pregnant patients because it has been shown to have a teratogenic effect in rats during the first trimester
Nitrous oxide
Anesthetic management in the parturient should be directed to: avoidance of ___emia, ___tension, ___osis; maintain ___ in the normal range; minimize effects of ___
Avoidance of hypoxemia, hypotension, acidosis; maintain PaCO2 in the normal range; minimize effects of aortocaval compression
Fetal HR and uterine activity should be monitored in women at ___ weeks GA or greater
20
___ have been linked to congenital anomalies and should not be used in pregnant patients
Benzos
Avoid ___ as it may interfere with B12 metabolism
Nitrous oxide
Elective procedures should be postponed until at least ___ weeks after delivery
6 weeks
The physiological effects of pregnancy are usually well established by 20 weeks gestational age—T/F?
True
Volatile agents may suppress preterm labor—T/F?
True
Hyperthyroidism in pregnancy—potential for thyroid storm—high ___, ___cardia, agitation, severe ___
High fever, tachycardia, agitation, severe dehydration
Anesthetic considerations for hyperthyroidism—propranolol may exacerbate ___ following spinal; consider ___ for elective c-section
Hypotension; consider epidural for elective c-section
Hyperthyroidism in pregnancy—anticipate exaggerated responses to ___ d/t hypersensitive myocardium, titrate carefully
Pressors
Pheochromocytoma secretes excessive ___
Catecholamines—epi and norepi
Pheochromocytoma can mimic ___
Preeclampsia
Pheochromocytoma and elective c/s—pre-op therapy with ___ blockers, followed by ___ blockers
Alpha blockers, followed by beta blockers
Pheochromocytoma—avoid beta blockade without prior alpha blockade because of risks with ___
Unopposed alpha stimulation (severe HTN)
Bronchial asthma may improve during pregnancy d/t bronchodilation—T/F?
True
General anesthesia should be avoided if possible in pregnant asthmatics because ETT can trigger ___
bronchospasm
Avoid ___ in pregnant asthmatics because they can cause increased sensitivity to histamine that can cause spasm
H2 blockers (i.e.: cimetidine, ranitidine)
Use ___ for induction in pregnant asthmatics because it causes bronchial relaxation
Ketamine
Avoid ___ in pregnant asthmatics because it can cause airway irritation
Desflurane
For pregnant paraplegics, early epidural analgesia should be initiated to prevent hyperreflexia—T/F?
True
Avoid what NMB in paraplegics d/t risk of hyperkalemia?
Succinylcholine
Pregnancy has no effect on progression of MS—T/F?
True
Slight increased risk for MS relapse during pregnancy—T/F?
True
MS and neuraxial anesthesia—use lowest concentration and volume of local anesthetic that can achieve analgesia—T/F?
True
MS and anesthesia—succinylcholine should be avoided with severe musculoskeletal involvement—T/F?
True
Brain tumor and pregnancy—avoid ___ and ___
Spinal (dural puncture) and epidural (risk for accidental dural puncture)
Brain tumor and pregnancy—bilateral ___ sympathetic blocks for 1st stage of labor, ___ block for 2nd stage labor
Bilateral lumbar sympathetic blocks for 1st stage of labor; pudendal block for 2nd stage labor
Brain tumor and pregnancy—if having C/S, can consider epidural but will usually use GETA with generous narcotic doses to blunt reflexes during laryngoscopy and prevent sudden increases in ___ and ___
BP and ICP
Pseudotumor cerebri = ___
Benign intracranial hypertension
Pseudotumor cerebri is not ___, so epidural or spinal block is OK
Not mass-related
Epilepsy and pregnancy—there is evidence of increased risk of convulsions with use of local anesthetics—T/F?
False—no evidence to support this
Myasthenia gravis and pregnancy—___ are contraindicated
Tocolytics—i.e.: magnesium sulfate, beta adrenergics—ritodrine, terbutaline
IV dosages of myasthenia gravis medications are given in ratio of ___:___ oral dose
30:1
What is the preferred anesthetic technique for myasthenia gravis parturients?
Regional is preferable to general anesthesia
If GETA is required for parturient with myasthenia gravis, keep doses ___
To absolute minimum
___ MAC is usually adequate for patients with myasthenia gravis
1/2
Parturients with myasthenia gravis are highly sensitive to ___
NMBs
Intubation doses of NMBs for parturients with myasthenia gravis are typically ___ to ___ normal
1/2 to 1/3 normal
Parturients with myasthenia gravis are more receptive to effects of ___ and ___
Opioids and local anesthetic agents
What is this describing?—profound muscle weakness, respiratory failure, loss of bowel/bladder function, disorientation, diplopia
Cholinergic crisis
Treat cholinergic crisis with ___
IV or IM atropine
HgbAS patients = ___zygous, sickle ___, usually ___ with pregnancy
Heterozygous, sickle trait, usually no problems with pregnancy
HgbSS or HgbSC patients = ___zygous, more severe ___, higher incidence of ___
Homozygous, more severe anemia, higher incidence of preeclampsia
General considerations for sickle cell disease and pregnancy = avoid ___
Sickle cell crisis
How to avoid sickle cell crisis?—avoid ___ia, ___tension, de___, ___thermia, and ___osis
Avoid hypoxia, hypotension, dehydration, hypothermia, and acidosis
What kind of anesthesia is preferred for parturients with sickle cell disease?
Epidural preferred
Sickle cell/epidural—give ___ prior to block
Adequate bolus of warmed IVF
Sickle cell and C/S—___ preferred d/t decreased risk of hypotension and can be used post-op for pain control if patient has sickle cell crisis
Epidural
If GA is necessary for parturient with sickle cell disease, follow usual precautions with special attention to avoiding ___ and ___
Hypothermia and hypoxia
VWD—neuraxial blockade is a relative contraindication, although can be considered if coagulation times are monitored and appropriately treated—T/F?
True
Factor V Leiden—if taking prophylactic LMWH dose, hold > ___ hours before block
> 12 hours
Factor V Leiden—if on therapeutic LMWH dose, hold > ___ hours before block and consider anti-Xa heparin assay
> 24 hours
Deficiency of proteins C and S lead to ___coagulability, recurrent ___ and ___
Hypercoagulability, recurrent DVT and PE
Patients with protein C and S deficiency may be on heparin therapy, so neuraxial blockade should be timed appropriately—T/F?
True
Main consideration for parturients with RA =
Difficult airway
___ anesthesia is preferred for patients with RA but is sometimes not possible d/t joint deformities
Regional
If regional is not possible for patient with RA, do ___ to secure airway prior to induction
Awake fiberoptic intubation
Lupus in pregnancy—check EKG for ___ or ___ changes
Prolonged PR or T wave changes
Lupus in pregnancy—___ disorders are common
Valve
Addiction and pregnancy—risk for ___, ___ labor, and ___ weight
Withdrawal, pre-term labor, and low birth weight
Alcoholic mothers have increased risk of ___
Hemorrhage
Ampethamines cause catecholamine ___, so mom will have limited response to indirectly acting sympathomimetics, i.e.: ___
Catecholamine depletion; limited response to ephedrine
Ampethamines cause ___ (increased/decreased) MAC for general anesthesia
Increased
Increased volatile agents used for patients who take amphetamines [d/t increased MAC] can increase the risk for uterine atony—T/F?
True
Cocaine is a vaso___ that causes ___ (increased/decreased) uteroplacental blood flow
Vasoconstrictor that causes decreased uteroplacental blood flow
Cocaine and pregnancy—patient can experience severe ___tension, ___cardia
Severe HTN, tachycardia
Chronic cocaine use can cause ___penia
Thrombocytopenia—increased risk for bleeding
Cocaine can decrease plasma ___ and prolong the duration of ___ and ___
Decrease plasma cholinesterase and prolong the duration of ester locals (i.e.: 2 chloroprocaine) and NMBs—succs
There is little evidence to suggest that HIV or antiretroviral drugs increase the incidence of pregnancy complications, or that pregnancy alters the course of infection—T/F?
True
What are the two most common medical problems of pregnancy?
Diabetes and hypertension
Gestational diabetes refers to DM that is first diagnosed in ___
Pregnancy
Gestational diabetes is more prevalent in the ___ and ___ trimesters
Second and third
After delivery, most parturients return to normal glucose tolerance—T/F?
True
Recurrence rate of gestational diabetes with subsequent pregnancies is 52-68%—T/F?
True
What is the best way to prevent fetal structural abnormalities from gestational diabetes?—initiation of early ___
Initiation of early glycemic control
Pregnant women with gestational diabetes may develop ___ which results in delayed emptying
Gastroparesis
Gastroparesis = risk for ___
Aspiration
Gestational diabetics have even more fluid in their stomachs than the average parturient—T/F?
True
Stomach should be decompressed in parturients with gestational diabetes before induction of anesthesia—T/F?
True
Patients who are diabetic take less time to clear local anesthetic from their bodies—T/F?
False—diabetics take longer to clear local anesthetic from their bodies
Uteroplacental blood flow index is reduced by ___-___% in gestational diabetics, even more so with poorer glucose control
35-45%
Diabetic keto acidosis—plasma glucose > ___, HCO3 < ___, pH < ___, acetone ___
Plasma glucose > 300, HCO3 < 15, pH < 7.30, acetone positive
In diabetic keto acidosis, ketones cross the placenta and ___ (increase/decrease) fetal oxygenation
Decrease
Biggest issue with obese parturients = difficulty with ___ and problems with placement of ___
Difficulty with intubation and problems with placement of neuraxial anesthesia
Studies have shown that minimum local anesthetic concentration for obese women was 41% LOWER than non-obese women—T/F?
True—there is greater distribution of epidural local anesthetic within the epidural space in obese women
Hypertension remains a leading source of maternal mortality—it is the ___ leading cause of maternal mortality, after ___ and ___ injuries
It is the third leading cause of maternal mortality, after thromboembolism and non-obstetric injuries
Maternal DBP > ___ is associated with increased risk of placental abruption and fetal growth restriction
Maternal DBP > 90
4 categories of HTN in pregnancy:
- Chronic HTN
- Pregnancy induced HTN
- Preeclampsia-eclampsia
- Preeclampsia superimposed on chronic HTN
Pregnancy induced hypertension—sustained BP increase to SBP > ___ or DBP > ___
SBP > 140 or DBP > 90
Pregnancy induced HTN has no renal or systemic involvement—T/F?
True
PIH resolves ___ weeks postpartum
12
PIH may evolve to ___
Preeclampsia
Preeclampsia is new onset HTN after ___ weeks gestation
20
Preeclampsia resolves within ___ hours postpartum
48
Maternal risk factors for preeclampsia—age younger than ___ or older than ___
Younger than 18 or older than 35
Headache, visual disturbances, and epigastric pain are seen in severe preeclampsia—T/F?
True
Mild preeclampsia—systolic BP ___ to ___; diastolic BP ___ to ___
Systolic 140-160; diastolic 90-110
Severe preeclampsia—systolic BP > ___; diastolic BP > ___
Systolic > 160; diastolic > 110
Preeclampsia is thought to be due to increased levels of thromboxane-A2 relative to prostaglandin in parturients—T/F?
True—thromboxane-A2 is a vasoconstrictor (causes vasospasm that leads to symptoms of preeclampsia)
Airway edema in preeclamptic patients can make intubation difficult—T/F?
True
Use ___ ETT in pregnant patients
6.5
GFR and CrCl ___ (increase/decrease) in preeclampsia; BUN ___ (increases/decreases) in preeclampsia
GFR and CrCl decrease; BUN increases
Overhydrating in preeclampsia can lead to ___
Pulmonary edema—be careful with hydration!!!
Severe PIH or preeclampsia can be complicated by ___
HELLP
HELLP = ___
Hemolysis, Elevated Liver enzymes, Low Platelets
Uterine activity is ___ (increased/decreased) in preeclampsia; the uterus is hyperactive/sensitive to ___; preterm labor is ___
Uterine activity is increased in preeclampsia; uterus is hyperactive/sensitive to oxytocin; preterm labor is common
Uterine/placental blood flow is decreased by 50-70% in preeclampsia—T/F?
True
Leading cause of maternal death in PIH is ___
Intracranial hemorrhage
DIC is uncommon as a primary manifestation of preeclampsia—T/F?
True
Placental abruption presents as ___
Rock hard abdomen…abdomen is full of blood and baby is not being perfused
Treatment of preeclampsia = ___
Mag sulfate
Plasma level of mag for treatment of preeclampsia should be between ___
4-6 mmol/L
Signs of mag toxicity—prolonged PR, widened QRS = ___-___ mEq/L
5-10 meq/L
Signs of mag toxicity—depressed tendon reflexes = ___-___ meq/L
11-14 meq/L
Signs of mag toxicity—SA, AV node block, respiratory paralysis = ___-___ meq/L
15-24 meq/L
Signs of mag toxicity—cardiac arrest > ___ meq/L
> 25 meq/L
Treat mag sulfate toxicity with ___ or ___
Calcium gluconate or calcium chloride
Best anesthetic technique for preeclamptic patients = ___
Epidural
Epidurals in preeclampsia may reduce ___ and ___; may improve ___ blood flow
May reduce vasospasm and HTN; may improve uteroplacental blood flow
Epidural for preeclampsia reduces the risk of ___ complications
Airway
Preeclampsia—in patient receiving mag sulfate, ___ activity is potentiated; patient has enhanced sensitivity to ____
Succs activity; enhanced sensitivity to NMBs
Mag sulfate blunts response to ___ and inhibits ___ release after sympathetic stimulation
Blunts response to vasoconstrictors and inhibits catecholamine release after sympathetic stimulation
HELLP syndrome symptoms—___, ___ pain, ___/___
Malaise, epigastric pain, nausea/vomiting
HELLP syndrome is usually ___
Self-limiting
HELLP syndrome—hemostasis is NOT problematic unless platelets are < ___
< 40,000
HELLP syndrome—rate of fall in platelet count is important; regional anesthesia is contraindicated if fall in platelet count is ___
Sudden
HELLP syndrome—platelet count returns to normal within ___ hours of delivery
72
Definitive cure of HELLP syndrome = ___
Delivery of fetus
What is this?—painless vaginal bleeding is the most common presentation
Placenta previa
Placenta previa is termed a “complete previa” when the cervical os is ___ by placenta
Entirely covered
All patients with vaginal bleeding are considered to have a placenta previa until proven negative by ultrasound—T/F?
True
Patients with a history of previous C/S and a current placenta previa are at very high risk of placenta ___
Accreta
What is this?—placenta does not penetrate entire thickness of myometrium
Placenta accreta
What is this?—placenta invades further into the myometrium
Placenta increta
What is this?—placenta attaches completely through the myometrium, into serosa, and potentially outside of uterus, with invasion into surrounding structures (i.e.: bladder, colon)
Placenta percreta
Which placental abnormality is the worst?
Placenta percreta
Treatment of placenta accreta = planned ___ and ___; prepare for ___ anesthesia
C/S and abdominal hysterectomy; prepare for general anesthesia
What is this?—premature separation of a normal placenta; painful vaginal bleeding
Abruptio placentae
What is the most common cause of intrapartum fetal death?
Abruptio placentae
Most common presentation of this complication is sudden profound fetal distress with continuous severe abdominal pain; often, an epidural will NOT mask this pain
Uterine rupture
Postpartum hemorrhage is considered present when postpartum blood loss exceeds ___ ccs
500
(3) causes of postpartum hemorrhage: uterine ___, ___ placenta, uterine ___
Uterine atony, retained placenta, uterine inversion
Treatment of uterine atony = ___, ___, or ___
Oxytocin, methylergonovine, prostaglandin F2-alpha
Do not give methylergonovine ___ because it can cause hypertension and vasoconstriction
IV…give 0.2 mg IM
Do not give ___ to asthmatic patients because it will cause bronchospasm
Prostaglandin F2-alpha
Retained placenta and uterine inversion require ___ anesthesia
General
If patient is hypovolemic, ___ is not a good idea
Neuraxial block
Amniotic fluid embolism is AKA ___
Anaphylactoid syndrome of pregnancy
Amniotic fluid embolism can occur during labor, delivery, C/S, or even postpartum—T/F?
True
Mechanism of amniotic fluid embolism is thought to involve entry of amniotic fluid into ___ through breaks in uteroplacental membrane
Maternal circulation
Mortality of amniotic fluid embolism is ~85%—T/F?
True
Chest compressions are nearly worthless if the baby is still inside mom because aortocaval compression makes supine resuscitation impossible and compressions don’t work well in the lateral position—T/F?
True
The diagnosis of AFE rests on demonstrating ___ in maternal circulation (often at autopsy)
Demonstrating fetal elements
Baseline FHR = ___-___ bpm
120-160
Decrease in FHR may indicate ___
Asphyxia
Absence of short- and long-term variability may indicate ___
Fetal distress
PH < 7.20 in fetus may be associated with ___
Depressed neonate, needs oxygen
The Apgar score rates what (5) things:
- Respiration
- Reflexes
- Pulse
- Skin color of body and extremities
- Muscle tone
Get Apgar scores at ___ and ___ minutes
1 and 5 minutes
If 5 minute score is less than 7, repeat Apgar assessment every ___ minutes until ___ minutes have passed or two successive scores are greater than or equal to ___
Repeat every 5 minutes until 10 minutes have passed or two successive scores are > or equal to 7
Survival of newborn is unlikely if Apgar score is 0 at 10 minutes—T/F?
True
Anesthesia’s primary responsibility is the ___
Mother
Resuscitation of the neonate is primarily the responsibility of the ___
Neonatal care team
Fetal respiratory rate = ___-___ breaths per min
30-60
Pulse should be > ___ bpm
> 100
If HR < 60 or 60-80 and not rising, start ___ at ___ bpm and ___
Start chest compressions at 120 bpm and intubate
If baby’s BP is low, can give fluid—___ml/kg of LR or NS
10 ml/kg
Rule out ___glycemia, ___magnesemia, or ___calcemia as causes of hypotension
Hyperglycemia, hypermagnesemia, or hypocalcemia as causes of hypotension
Medications are indicated if heart rate remains < ___ bpm with adequate ___ and ___ for 30 seconds
HR remains < 60 bpm with adequate ventilation with 100% O2 and chest compressions for 30 seconds
Can give meds via ___ vein, ___ vein, or ___ tube
Peripheral vein, umbilical vein, or ETT
