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APEX-across the lifespan > LIFESPAN-obstetrics 1-8 > Flashcards

LIFESPAN-obstetrics 1-8 Flashcards

1
Q

What 3 airway difficulties are parturients at risk for

A
  1. Difficult mask ventilation
  2. Difficult DL
  3. Difficult intubation
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2
Q

What 3 hormones are responsible for vascular engorgement

A

Increased

  1. progesterone
  2. estrogen
  3. relaxin
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3
Q

What are 2 contributors to airway swelling in the parturient

A
  1. increased progesterone, estrogen, and relaxin causing vascular engorgement
  2. Increased ECF volume
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4
Q

How are the following affected during pregnancy:
Mallampati=
Intubation=
Glottic opening=

A

Mallampati= increases
Intubation= 8x greater incidence of difficult or failed attempts
Glottic opening= narrowed, downsize ETT

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5
Q

What are 3 factors that can make airway edema worse

A
  1. PreE
  2. Tocolytics
  3. Prolonged T-burg position
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6
Q

What type of intubation should be avoided in the parturient and why

A

Nasal intubation

The tissues are very friable and prone to bleeding

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7
Q

How is the chest wall altered by pregnancy

A

Relaxin relaxes ligaments of the rib cage, allowing ribs to assume a more horizontal position
It increases AP diameter of chest, giving more space for lungs

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8
Q

How is lung positioning affect by pregnancy

A
  1. Increased AP diameter allows more space for lungs

2. Diaphragm shifts up d/t gravid uterus

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9
Q

What lung volumes and capacities are affected by pregnancy

A 
FRC = reduced
ERV = reduced
RV = reduced
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10
Q

Why does apneic hypoxemia occur quicker in pregnant pts

A

Increased O2 consumption PLUS decreased FRC hastens hypoxemia

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11
Q

How do FRC and closing capacity relate in the parturient

Why is this significant

A

FRC is below closing capacity

This means airways collapse during tidal breathing

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12
Q

What effect dose progesterone have on respiratory pattern

A

It is a respiratory stimulant

Increases Vm by 50%

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13
Q

How does maternal reduction in physiologic shunt affect fetal oxygenation

A

A small reduction in physiologic shunt explains the mild increase of PaO2

This increased partial pressure of O2 drives more O2 across the placenta for fetal oxygenation

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14
Q

What acid-base state are parturients likely to be in

How does the body compensate

A

Respiratory alkalosis

Compensation = renal elimination of HCO3

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15
Q 
How are the following altered during pregnancy:
Arterial pH
PaO2
PaCO2
HCO3
A

Arterial pH = no change d/t compensation
PaO2 = increased
PaCO2 = decreased
HCO3 = decreased

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16
Q

How is the oxyHgb dissociation curve affected by pregnancy

How does this affect fetal oxygenation

A 
RIGHT shift (release O2)
P50 is increased

promotes O2 transfer to fetus

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17
Q

How are the following respiratory parameters altered during pregnancy:
Vm=
Vt=
RR=

A 
Vm= inc 50%
Vt= inc 40%
RR= inc 10%
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18
Q

2 reasons Vm, Vt, and RR increased in the parturient

A
  1. d/t inc O2 consumption and CO2 production

2. Progesterone is a respiratory stimulant

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19
Q

How are the following lung capacities altered during pregnancy:
TLC=
VC=
CC=

A 
TLC= decreases 5%
VC= no change
CC= no change
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20
Q

How is O2 consumption affect by each of the following stages:
Term pregnancy=
First stage labor=
Second stage labor=

A

Term pregnancy= inc 20%
First stage labor= inc 40% prelabor
Second stage labor= inc 75% prelabor

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21
Q

How are the following affected by pregnancy:
CO=
HR=
SV=

A 
CO= inc 40%
HR= inc 15%
SV= inc 30%
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22
Q

How much CO does the gravid uterus receive

A

10%

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23
Q

How does preload increase during labow

A

uterine contraction cause autotransfusion

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24
Q

How does CO change during the stages of labor:
1st=
2nd=
3rd=

A 
1st= inc 20%
2nd= inc 50%
3rd= inc 80%
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25
Q

How long does it take after delivery for CO to return to pre-labor values

A

24-48 hrs

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26
Q

How long does it take after delivery does it take for CO to return to pre-pregnancy values

A

2 weeks

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27
Q

How does a twin pregnancy affect CO

A

increase CO to 20% above singleton

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28
Q

How are the following BP parameters altered during pregnancy:
MAP=
SBP=
DBP=

A 
MAP= no change
SBP= no change
DBP= dec 15%
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29
Q

How does DBP change during pregnancy and why

A

decreases

decreased SVR d/t increased vasodilation

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30
Q

How are the following vascular resistance parameters altered in the parturient:
SVR=
PVR=

A 
SVR= dec 15%
PVR= dec 30%
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31
Q

How does progesterone affect nitric oxide

A

Increases NO which leads to vasodilation

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32
Q

How does progesterone alter the bodies response to angiotensin and NE in the parturient

A

The body has a decreased response to both

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33
Q

How is cardiac axis affected by pregnancy and why

A

Left axis deviation

Gravid uterus pushes diaphragm cephalad => heart pushed UP and LEFT

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34
Q

How does progesterone contribute to increased blood volume and CO

A

By increasing RAAS activity (reabsorption of Na and H2O)

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35
Q

What is the syndrome of supine HoTN in the parturient

A

aka aortocaval compression

In the supine position, gravid uterus compresses the vena cava and aorta

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36
Q

What are the 4 consequences of aortocaval compression

A
  1. Decreased VR to heart
  2. Decreased arterial flow to uterus and LE
  3. Compromised fetal perfusion
  4. Maternal LOC
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37
Q

How is aortocaval compression treated

A

Displace uterus by elevating right side to 15*

aka left uterine displacement (LUD)

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38
Q

How are the following fluid components affected by pregnancy:
Intravascular fluid vol=
Plasma vol=
Erythrocyte vol=

A

Intravascular fluid vol= inc 35%
Plasma vol= inc 45%
Erythrocyte vol= inc 20%

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39
Q

How does increased intravascular volume affect maternal h/h

A

causes dilutional anemia

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40
Q

How are the following hematologic factors affected in pregnancy:
Clotting factors= (5)
Anticoags= (3)

A

Clotting factors= inc 1, 8, 9, 10, 12

Anticoags= dec AT, dec protein S, no change protein C

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41
Q

How are the following hematologic factors affected in pregnancy:
Fibrinolytics=
Anti-fibrinolytics=

A 
Fibrinolytics= inc fibrin breakdown
Anti-fibrinolytics= dec 11 and 13
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42
Q

How is total coagulation affected by pregnancy

A

Pregnancy creates a hypercoagulable state

DVT is 6 times higher

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43
Q

How are the following labs affected during pregnancy:
PT=
PTT=
Plt count=

A

PT= dec 20%
PTT= dec 20%
Plt count= unchanged or dilutional

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44
Q

How is MAC altered during pregnancy

A

decreased by 30-40%

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45
Q

How are the following parameters altered by pregnancy:
LA sensitivity=
Epidural vein volume=

A

LA sensitivity= inc

Epidural vein volume= inc

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46
Q

How should the dose of LA be adjusted in the parturient and why

A

Decrease dose d/t increased sensitivity to LA

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47
Q

Why do gastric volume and gastric pH change during pregnancy

A

d/t increased gastrin

48
Q 
How are the following GI parameters affected by pregnancy:
Gastric volume=
Gastric pH=
LES sphincter tone=
Gastric emptying=
A

Gastric volume= inc
Gastric pH= dec
LES sphincter tone= dec
Gastric emptying= no change or dec

49
Q

Why are LES sphincter tone and gastric emptying altered in pregnancy

A

D/t inc progesterone, inc estrogen, and cephalad displacement of diaphragm

50
Q

What is gastric emptying delayed in the parturient

A

Once labor begins

51
Q 
How are the following renal parameters altered in pregnancy:
GFR=
Crt clearance=
Glucose in urine=
Crt and BUN=
A

GFR= inc
Crt clearance= inc
Glucose in urine= inc
Crt and BUN= dec

52
Q

Why are maternal GFR and crt clearance increased

A

d/t increased blood volume and CO

53
Q

Why is there increased glucose in maternal urine

A

d/t inc GFR and dec renal absorption

54
Q

Why are maternal crt and BUN decreased

A

d/t inc crt clearance

55
Q

How are the following affected by pregnancy:
uterine blood flow=
Serum albumin=
Pseudocholinesterase=

A

uterine blood flow= up to 700-900 mL/min
Serum albumin= inc free fraction of protein bound drugs
Pseudocholinesterase= dec

56
Q

What are the 3 variables that uterine blood flow is dependent on since it cannot autoregulate

A
  1. MAP
  2. CO
  3. uterine vascular resistance
57
Q

What are the 2 categories that reduce uterine blood flow

A
  1. decreased perfusion

2. increased resistance

58
Q

What are 4 factors that decrease uterine perfusion

A
  1. Maternal HoTN
  2. Sympathectomy
  3. Hemorrhage
  4. Aortocaval compression
59
Q

What are 3 factors that increase uterine resistance

A
  1. uterine contraction

2. HTN conditions that increase UVR

60
Q

What fetal factor can increase concentration gradients across the placenta

What is the result

A

Fetal acidosis

result = ion trapping

61
Q

How does fetal acidosis affect concentration gradients across the placenta

A

it can lead to increase concentration gradient, causing more to pass into the fetus and lead to ion trapping

62
Q

What are 4 drug characteristics that favor placental transfer

A
  1. low molecular weight <500 Daltons
  2. High lipid solubility
  3. Non-ionized fraction
  4. Non-polar fraction
63
Q

What 8 anesthetic drugs can have significant placental transfer

A
  1. LA (x chloroprocaine)
  2. IV anesthetics
  3. Volatile anesthetics
  4. Opioids
  5. BZDs
  6. Atropine
  7. Beta-blockers
  8. Magnesium
64
Q

What anesthetic drugs have no placental transfer

A
  1. NMB
  2. Glycopyrrolate
  3. Heparin
  4. Insulin
65
Q

What are the 3 stages of labor

A
  1. beginning of regular contractions to full cervical dilation (10 cm)
  2. full cervical dilation to delivery of fetus (pain in perineum begins)
  3. Delivery of placenta
66
Q

What drug may be used with dysfunctional labor

A

Oxytocin

67
Q

What are the NPO guidelines for the laboring parturient

A
  1. Drink moderate clears throughout labor

2. Eat solid food until neuraxial block

68
Q

What is the distribution of pain in the first stage of labor

A

Begins in the lower uterine segment and cervix

69
Q

What spinal levels do pain signals travel during the first stage of labor

A

T10-T11 posterior nerve roots

70
Q

What is the distribution of pain in the second stage of labor

A

Same as first stage but there are added pain impulses from vagina, perineum and pelvic floor

71
Q

What spinal levels do pain signals travel during the second stage of labor

A

S2-S4 posterior nerve roots

72
Q

What is the afferent nerve pathway for the uterus and cervix

A

Visceral C fibers hypogastric plexus

73
Q

What is the afferent nerve pathway for the perineum

A

Pudendal nerve

74
Q

What spinal segments cover the uterus and cervix

A

T10-T11

75
Q

What spinal segments cover the perineum

A

S2-S4

76
Q

Which regional technique has high risk for fetal bradycardia

A

paracervical block

77
Q

What type of block covers the perineum

A

Pudendal nerve block

78
Q

What are consequences of uncontrolled maternal pain during labor

A
  1. increased maternal catecholamines

2. maternal hyperventilation

79
Q

How does increased maternal catecholamines from uncontrolled pain affect the laboring parturient

A

Can lead to HTN and reduced UBF

80
Q

How does maternal hyperventilation from uncontrolled pain affect the laboring parturient

A

Shifts oxyhgb curve LEFT

Reduces O2 delivery to the fetus

81
Q

What are 3 benefits of N2O use during labor

A
  1. self-administered pain control
  2. Preserved uterine contractility
  3. No neonatal depression
82
Q

What are the steps of performing a CSE

A
  1. Reach epidural space with epidural needle
  2. Spinal needle through epidural w/ LA injected into intrathecal space
  3. Spinal needle is removed
  4. Epidural catheter threaded into space
83
Q

Describe the epidural volume extension technique and rationale

A

Injection of saline into the epidural space immediately after LA is administered into the SA space to compress the space and enhance rostral spread of LA

84
Q

What are the benefits of using the epidural volume extension technique

A
  1. Allows for less LA for better hemodynamic stability and faster recovery
85
Q

Describe the possibility of placental transfer of bupivacaine

A

Low placental transfer d/t inc protein binding and inc ionization

86
Q

What are 2 reasons for low bupivacaine placental transfer

A
  1. increased protein binding

2. increased ionization

87
Q

Describe the block quality of bupivacaine compared to other LA

A

Greater sensory block

88
Q

What risks are greatest with bupivacaine

A

Cardiac toxicity

Occurs before seizures

89
Q

How does ropivacaine compare to bupivacaine (4)

A
  1. S-enantiomer of bupiv + propyl group
  2. dec CV toxicity
  3. dec potency
  4. dec motor block
90
Q

Why is lidocaine avoided for labor analgesia

A

d/t the strong motor block

91
Q

What risks are associated with lidocaine given in the SA space

A

high risk of neurotoxicity

92
Q

When is 2-chloroprocaine useful for labor neuraxial techniques

A

For emergency C/S when epidural is already in place d/t fast onset

93
Q

How does 2-chloroprocaine affect epidural opioids

A

It antagonizes the opioid receptors (mu and kappa) reducing efficacy of epidural morphine

94
Q

What are the risks of 2-chloroprocaine use w/ spinal anesthetics

A

Risk for arachnoiditis d/t preservatives

95
Q

What are 3 benefits of neuraxial opioid solo injection

A
  1. no loss of sensation or proprioception
  2. No sympathectomy, better hemodynamic stability
  3. No impairment with ability to push
96
Q

How does neuraxial meperidine compare to LA

A

It possesses LA properties

97
Q

What are 4 common side effects of neuraxial opioids

A
  1. Pruritis
  2. N/V
  3. Sedation
  4. Respiratory depression
98
Q 
Spinal bolus for the following:
Bupivacaine=
Ropivacaine= 
Levobupivacaine=
Lidocaine=
A 
Bupivacaine= 1.25-2.5 mg
Ropivacaine= 2-3.5 mg
Levobupivacaine= 2-3.5 mg
Lidocaine= NA
99
Q 
Epidural bolus for the following:
Bupivacaine=
Ropivacaine= 
Levobupivacaine=
Lidocaine=
A 
Bupivacaine= 0.0625 - 0.125%
Ropivacaine= 0.08-0.2%
Levobupivacaine= 0.0625-0.125%
Lidocaine= 0.75-1%
100
Q

What is the lumbar infusion rate for continuous epidural infusions

A

8-15 ml/hr

101
Q 
Spinal bolus for the following:
Fentanyl= 
Sufentanil= 
Morphine= 
Meperidine=
A 
Fentanyl= 15-25 mcg
Sufentanil= 1.5-5 mcg
Morphine= 125-250 mcg
Meperidine= 10-20 mg
102
Q 
Epidural bolus for the following:
Fentanyl= 
Sufentanil= 
Morphine= 
Meperidine=
A 
Fentanyl= 50-100 mcg
Sufentanil= 5-10 mcg
Morphine= NA
Meperidine= NA
103
Q

What is the typical epidural continuous infusion rate for fentanyl

A

1.5-3 mcg/mL at 8-15 mL/hr

104
Q

Spinal bolus for the following:
Epinephrine=
Clonidine=
Neostigmine=

A 
Epinephrine= 2.25-200 mcg
Clonidine= 15-30 mcg
Neostigmine= NA
105
Q

Epidural bolus for the following:
Epinephrine=
Clonidine=
Neostigmine=

A 
Epinephrine= 25-75 mcg
Clonidine= 75-100 mcg
Neostigmine= 500-750 mcg
106
Q

Which LA are metabolized by pseudocholinesterase

A

Esters

2-chloroprocaine

107
Q

What are 3 ways a pt can develop a total spinal

A
  1. epidural dose injected into SA space
  2. epidural dose injected into SD space
  3. Single shot spinal after failed epidural block
108
Q

What happens if an epidural dose is injected into the SA space

A

there will be a high spinal

Expect to intubate and wait for pt to stabilize

109
Q

The result of subdural injection of epidural dose

A

With-in 10-25 minutes of injection pt will experience symptoms of excessive cephalad spread of LA

110
Q

Why does LA spread cephalad so quickly if injected into the subdural space

A

b/c it is a potential space that holds very low volume

111
Q

What are 3 symptoms of total spinal

A
  1. dyspnea
  2. difficulty phonating
  3. HoTN
112
Q

Why does LOC happen with total spinal

A

D/t cerebral hypoperfusion from HoTN

113
Q

What are 3 differential diagnoses for total spinal

A
  1. anaphylactic shock
  2. eclampsia
  3. AFE
114
Q

What is the presentation of total spinal

A
  1. rapid progression of sensory and motor block
  2. dyspnea, difficulty phonating, HoTN
  3. LOC
115
Q

5 interventions for total spinal

A
  1. vasopressors
  2. IVF
  3. LUD
  4. Leg elevation
  5. intubate

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