High Risk OB Flashcards
Once uterine incision is made if fetal problems are occurring a higher incidence of low APGAR scores and acidosis are related to time it takes to get fetus out, this occurs if it takes longer than?
3 minutes
180 seconds
Where does central catecholamine release occur?
Periventricular and paraventricular tissue and dorsal medial medulla and throughout the brain
Neuraxial anesthesia for asthma patients has minor effects on which effort?
Inspiratory
Expiratory function is more affected by neuraxial because of?
More intense motor block affects:
ABD wall muscles
Cough strength
Some prefer epidural over spinal with severe asthma patients because?
Not as much decrease in epinephrine secretion
-helps bronchodilation
What can be used to help dry up secretions and bronchodilation in asthma patients?
Atropine
Glycopyrrolate
For GA with asthma patients, what is the drug of choice?
Ketamine
What is considered to be the most important factor in producing acute airway obstruction in asthma patients?
Constriction of airway smooth muscle
Definition of asthma
Reversible airway obstruction
Airway inflammation
Airway hyper responsiveness
Other mechanisms of acute airway obstruction in asthma patients
Neural imbalance between constricting and dilation influences
Airway inflammation
Airway epithelial destruction > changes it’s function
Neural components of asthma
PNS
SNS
Alpha adrenergic system
Non-adrenergic non-cholinergic system
What system is the most predominant constrictor of the airway in asthma patients?
Parasympathetic nervous system
What is the dilator in the non-adrenergic, non-catecholamine system (NANC)?
Nitric oxide
What is the leading cause of maternal mortality?
DVT & PTE
Pregnant women vs non-pregnant women have a ____ time greater risk of thrombotic event
5 times greater
When is the highest risk for a pregnant women’s thrombotic event?
Immediately postpartum
How much does a c-section increase the risk of a thrombotic event?
Doubles the risk
What are the 2 most important risk factors for thromboembolic events in pregnancy?
Previous history of thromboembolism
Diagnosis of thrombophilia
Which thrombophilia increases the risk for VTE in pregnancy the most?
Homozygous factor V Leiden mutation
What are the most modifiable risk factors for thromboembolic event
Antenatal
Immobilization
Obesity
Physical s/sx of PE
SOB Anxiety Palpitations CP Cyanosis Diaphoresis Coughing +/- blood Crackles Decreased breath sounds Tachycardia Tachypnea JVD Split 2 heart sounds Right axis shift ST segment abnormalities T wave inversion
Most air emboli are small with no sequelae, but emboli larger than _____ may be lethal
200-300 mL
-or 3-5ml/kg
When is the most common time of air entrainment with c-section?
Immediately after placental separation
What are the manifestations of massive VAE?
Hypotension Hypoxemia Dyspnea Arrhythmia Chest pain Cardiac arrest
During neuraxial anesthesia how can a VAE present?
Hypoxemia
Dyspnea
Chest pain during uterine repair
During GA what suggests VAE?
Hypoxemia
Slight decrease in end-tidal CO2
What is the treatment for VAE?
Flood sx field with saline
Drop ABD lower than heart
Vasopressors
CPR
Deliver infant
100% O2 (turn off nitrous if in use- grows air embolus)
Avoid PEEP and valsalva maneuvers (can cause paradoxical embolism)
During what stage of labor does amniotic fluid embolus usually occur?
Second stage
-during labor or after delivery of placenta
S/Sx of amniotic fluid embolus
Sudden onset chills Shivering Diaphoresis Tachypnea Cyanosis CV collapse DIC
What other conditions appear just like amniotic fluid embolus (AFE)?
Placental abruption
Uterine Rupture
Anaphylaxis
What is the classic triad of AFE?
Acute hypoxia (respiratory distress) Hemodynamic collapse (CV collapse) Coagulopathy without precipitating cause, may not manifest for several hours
Risk factors of AFE
Meconium in fluid Older age Abnormal presentation Placental abruption Eclampsia Multiple gestation Induction of labor Artificial rupture of membranes Operative delivery
Test/diagnosis of AFE?
No specific one, often diagnosed after death
What are the 2 phases of AFE?
Stage 1: CV collapse within 30 minutes of delivery
Stage 2: Hemorrhage and DIC
What is often the first sign of AFE?
Respiratory failure due to RV failure from severe pulmonary vasoconstriction
Treatment for AFE?
Intubate - 100% O2 CPR - must deliver fetus to be effective Inhaled nitric oxide or prostacyclin Cardiopulmonary bypass Aggressive volume and press or support Order blood, FFP, Cryo RV assist device ECMO
What is the AOK protocol? What is it used to treat?
Atropine 1mg
Ondansetron 8mg
Ketorolac 30mg
Amniotic fluid embolus
What does atropine do for AOK protocol?
Blocks vagal responses
Prevents systemic hypotension because it prevents bradycardia
Decreases vasoconstriction in pulmonary vasculature
What does Zofran do in AOK treatment?
Serotonin antagonist
Help with vagotomy
Also prevents CV collapse
What does Ketorolac do in AOK treatment?
Directly inhibits thromboxane > stopping coagulation cascade and prevent DIC
AOK shows profound hemodynamic recovery with complete neurological recovery within how long?
2 minutes
After cardiac arrest what has the largest impact on saving mom and fetus avoiding severe neurological injury
CPR
If mother survives what should be expected?
Hemorrhage and DIC
+/- Emergency hysterectomy
What is cervical insufficiency?
Inability of the cervix to hold a pregnancy in the uterus through the second trimester in the absence of labor
List 4 causes of cervical insufficiency
Congenital disorders
Acquired
Previous D&C
Loop electrical excision procedure (LOOP)
When is transvaginal cervical cerclage done?
12-18 weeks
-more successful if done before problems
What is the anesthetic of choice for cervical cerclage?
SAB
What position is used for cerclage placement and why?
Steep trendelenburg
-to help get membranes out of the way
What needs to be avoided during cerclage placement?
Coughing and vomiting
-give meds to avoid
Symptoms of cervical insufficiency
Altered vaginal discharge Lower abdominal or back pressure or discomfort Vaginal fullness Urinary frequency Can be asymptomatic
When is diagnosis of cervical insufficiency definitive?
If delivery occurs in the second trimester before 24 weeks gestation in the absence of bleeding, infection, or labor as the initial symptom
-she says when herniated fetal membrane is seen or palpated during second trimester
What provides proficient certainty of cervical insufficiency?
Cervical dilation or prolapse of membranes through the cervix in the absence of other findings or symptoms
Why is a spinal preferred with cerclage? (She says)
Faster onset q
GA may need to be performed for cerclage if what?
Uterine relaxation is needed
Is dantrolene safe in pregnancy
Yes
Trial of labor after c-section/vaginal birth after c-section is advised to be
In the hospital
What anesthetic should be avoided in epilepsy?
Ketamine
Multiple Sclerosis relapse rate is 3x higher when?
First 3 months postpartum
With intrauterine fetal death what develops in the mother if the fetus stays in how long?
DIC
More than 1 month
HIV/AIDS may have difficult intubation why?
Pharyngeal lymphatic hypertrophy
Myasthenia Gravis prolongs what stage of labor and why?
Second stage
Muscle weakness
What medications should be avoided and used cautiously in myasthenia gravis patients?
Avoid Magnesium
Overly sensitive to ND-NMB
Why should Mg be avoided in myasthenia gravis patients?
It can precipitate a myasthenic crisis
When is neuraxial anesthesia for c-section not the preferred choice in MG patients?
When myasthenia gravis patient has significant bulbar involvement or respiratory compromise
What procedure decreases myasthenia gravis exacerbations and exerts a favorable outcome in pregnancy?
Thymectomy
Why and how long should a woman delay pregnancy after initial myasthenia gravis diagnosis?
Exacerbations occur more frequently in the first year after diagnosis
Delay for 1-2 years
What stage of labor does myasthenia gravis affect, why?
Second stage
First stage is smooth muscle in the uterus (not affected by MG)
Second stage often requires use of striated muscle
Myasthenia gravis symptoms in neonate
Poor sucking Generalized hypotonia Difficulty feeding Feeble cry Ptosis Respiratory distress
When do myasthenia gravis symptoms develop in the newborn and when do they usually abate?
Develop within the first 12-48 hours
Abate within 2-4 weeks as antibodies are metabolized
Why may succinylcholine be prolonged in myasthenia gravis patients?
Decrease in plasma cholinesterase from their MG treatment with anticholinesterases
What genital herpes outbreak requires a c-section for delivery to prevent transmission to baby?
Primary outbreak
When is vaginal delivery and regional anesthesia acceptable with a genial herpes patient?
Secondary infection and if cervical cultures are negative
What is the major concern with genital herpes and fetus?
Neonatal HSV is a life-threatening infection with the potential for permanent CNS sequelae
-encephalitis
Why med/anesthetic technique increases the recurrence of oral HSV?
Spinal or epidural morphine
-avoid using
Risk of maternal death is greater with what anesthetic?
GA vs neuraxial
