ITE CA-2 OB anesthesia Flashcards
4 classes of tocolytic drugs
β-adrenergic agonists,
calcium channel blockers,
cyclooxygenase inhibitors (e.g., NSAIDs), and
magnesium sulfate
B-agonists used to treat preterm labor
ritodrine and terbutaline
maternal effects of b-agonists to treat pre-term labor
cardiopulm: pulmonary edema, MI, tachycardia, vasocilation, hypotension, dysrhythmias
Endocrine: hyperglycemia, hyperinsulinemia, hypokalemia (from increased insulin), altered thyroid fxn, antidiuresis
Misc: tremor, palpitations, hallucinations, ileus (N/V), fever, nervousness
Fetal effects of b-agonists to treat pre-term labor
tachycardia, MI, myocardial hypertrophy, hyperglycemia, hyperinsulinemia
Neonatal effects of b-agonists to treat pre-term labor
tachycardia, hypotension, intraventricular hemorrhage, hyperbilirubinemia, hypocalcemia, hyperglycemia -> hypoglycemia
Pregnant women with cord injury above ___ may have an increased risk of preterm labor
Pregnant women with cord injury above T11 may have an increased risk of preterm labor
Pregnant women with cord injury above T11 may have an increased risk of ________
Pregnant women with cord injury above T11 may have an increased risk of preterm labor
For chronic lesions above ___, autonomic hyperreflexia occurs in > 85% of pregnancies
For chronic lesions above T6, autonomic hyperreflexia occurs in > 85% of pregnancies
How treat labor pain in patient with chronic lesion above T6
For chronic lesions above T6, autonomic hyperreflexia occurs in > 85% of pregnancies. Neuraxial anesthesia is often effective and placement of an intrathecal catheter may allow for continuous titration of the block. Most obstetric anesthesiologists choose epidural anesthesia in this situation. Lateral position is preferred for the procedure as the sitting position results in pooling of blood in the lower extremities.
Medical complications of spinal cord injury aggravated by pregnancy
Medical complications of spinal cord injury aggravated by pregnancy include decreased respiratory reserve, atelectasis, impaired cough, anemia, deep vein thrombosis, thromboembolic phenomena, chronic urinary tract infections, urinary tract calculi, proteinuria, renal insufficiency, decubitus ulcers, hypertension, and autonomic hyperreflexia.
Aspiration of meconium stained amniotic fluid treatment
Aspiration of meconium stained amniotic fluid can lead to meconium aspiration syndrome in newborns. Suctioning the oropharynx or intubating and suctioning the trachea of apparently vigorous infants has NOT been shown to be beneficial. If the infant born through meconium-stained amniotic fluid has poor muscle tone and inadequate breathing efforts, resuscitate under a radiant warmer. Positive pressure ventilation should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed.
Can diagnose preeclampsia in absence of proteinuria with any of what
thrombocytopenia, renal insufficiency, pulmonary edema, cerebral disturbances, or hepatic dysfunction.
Chronic hypertension in pregnancy
Chronic hypertension involves pre-pregnancy blood pressures greater than 140/90 mmHg or elevated blood pressure that fails to resolve after the post-partum period.
Gestational hypertension
Gestational hypertension manifests as elevated blood pressure after 20 weeks gestation, without any systemic manifestations, and resolves 12 weeks postpartum.
Preeclampsia is
Preeclampsia is new onset hypertension and proteinuria after 20 weeks gestation. If hypertension exists without proteinuria, preeclampsia is also defined as thrombocytopenia, impaired liver function, new development of renal insufficiency, pulmonary edema, or new-onset cerebral or visual disturbances.
The most common cause of early postpartum hemorrhage and risk factors
The most common cause of early postpartum hemorrhage is uterine atony which results in continued bleeding from intrauterine vessels that are torn with placenta delivery. Risk factors for uterine atony include multiparity, multiple gestations, polyhydramnios, chorioamnionitis, prolonged labor, oxytocin-induced labor, and mechanical factors.
Primary pulmonary hypertension in pregnancy
Primary pulmonary hypertension (PPH) in pregnant patients has a high mortality rate usually from right heart failure. The anesthetic technique is aimed at minimizing increases in peripheral vascular resistance. PPH is most commonly seen in younger women and is poorly tolerated in pregnancy; pregnancy is discouraged in these patients and termination is advised should pregnancy occur.
The normal physiological changes of pregnancy are poorly tolerated by women with pulmonary hypertension. Pregnancy is associated with increased plasma volume and decreased systemic vascular resistance, both resulting in an increase in cardiac output. In healthy women, a decrease in pulmonary vascular resistance accommodates the requirements for increased cardiac output. In women with pulmonary hypertension, pulmonary vascular disease prevents the fall in pulmonary vascular resistance, leading to a rise in pulmonary artery pressure with increased cardiac output. Ultimately, the necessary increase in cardiac output cannot be achieved resulting in right heart failure.
Anesthetic considerations for pregnant patient with primary pulmonary hypertension.
The biggest difficulty in planning for an anesthetic in the pregnant patient with PPH is minimizing increases in PVR (pulmonary vascular resistance). Pain during labor and vaginal delivery is especially detrimental because it may further increase pulmonary vascular resistance and decrease venous return. Neuraxial analgesia is useful for preventing pain-induced increases in pulmonary vascular resistance. Dilute local anesthetic solutions with the addition of opioids will minimize the decrease in systemic vascular resistance (SVR). General and epidural anesthesia have been used for cesarean delivery. Spinal anesthesia may result in a sudden decrease in SVR and is thus not recommended for cesarean delivery. Risks of general anesthesia include increased pulmonary artery pressures during laryngoscopy and tracheal intubation, the adverse effects of PPV on venous return, and the negative inotropic effects of volatile anesthetics. In addition to oxygen, the administration of isoproterenol, inhaled nitric oxide, calcium channel blockers, or sildenafil may be useful for decreasing pulmonary vascular resistance. Hemodynamic monitoring, including systemic and pulmonary arterial pressures, remains controversial in these patients with no evidence to support the use of pulmonary artery catheters. Pulmonary artery rupture and thrombosis are risks of pulmonary artery catheters in the presence of pulmonary hypertension, but some argue that the benefits in these critically ill patients appear to offset these potential hazards.
First line for uterine atony
IV oxytocin
Treatment for uterine atony that is contraindicated in the setting of pregnancy-induced hypertension or preeclampsia and why
Methylergonovine maleate is contraindicated in the setting of pregnancy-induced hypertension or preeclampsia since it is an ergot derivative that may lead to hypertensive emergency.
Treatment for uterine atony contraindicated in asthma
Carboprost tromethamine is contraindicated in patients with significant reactive airway disease since it has prostaglandin-like effects and can cause bronchospasm.
Most effective way to reduce risk of aspiration in OB patients
avoid a general
Why OB patient greater risk of aspiration?
If general anesthesia cannot be avoided, know that the patient will be at increased risk of aspiration compared to a non-pregnant patient, primarily because the increased incidence of difficult airway and the decreased competency of the lower esophageal sphincter.
Main factor for development of pneumonitis in aspiration?
Prophylaxis?
If aspiration occurs, the main factor for the development of pneumonitis appears to be the pH of the aspirate. For prophylaxis, the ASA guidelines recommend avoiding solid food in laboring patients and considering non-particulate antacids, H2-receptor antagonists, and/or metoclopramide before cesarean section.