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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
How long does it take after delivery for CO to return to pre-labor values
24-48 hrs
26
How long does it take after delivery does it take for CO to return to pre-pregnancy values
2 weeks
27
How does a twin pregnancy affect CO
increase CO to 20% above singleton
28
How are the following BP parameters altered during pregnancy: MAP= SBP= DBP=
``` MAP= no change SBP= no change DBP= dec 15% ```
29
How does DBP change during pregnancy and why
decreases | decreased SVR d/t increased vasodilation
30
How are the following vascular resistance parameters altered in the parturient: SVR= PVR=
``` SVR= dec 15% PVR= dec 30% ```
31
How does progesterone affect nitric oxide
Increases NO which leads to vasodilation
32
How does progesterone alter the bodies response to angiotensin and NE in the parturient
The body has a decreased response to both
33
How is cardiac axis affected by pregnancy and why
Left axis deviation | Gravid uterus pushes diaphragm cephalad => heart pushed UP and LEFT
34
How does progesterone contribute to increased blood volume and CO
By increasing RAAS activity (reabsorption of Na and H2O)
35
What is the syndrome of supine HoTN in the parturient
aka aortocaval compression | In the supine position, gravid uterus compresses the vena cava and aorta
36
What are the 4 consequences of aortocaval compression
1. Decreased VR to heart 2. Decreased arterial flow to uterus and LE 3. Compromised fetal perfusion 4. Maternal LOC
37
How is aortocaval compression treated
Displace uterus by elevating right side to 15* | aka left uterine displacement (LUD)
38
How are the following fluid components affected by pregnancy: Intravascular fluid vol= Plasma vol= Erythrocyte vol=
Intravascular fluid vol= inc 35% Plasma vol= inc 45% Erythrocyte vol= inc 20%
39
How does increased intravascular volume affect maternal h/h
causes dilutional anemia
40
How are the following hematologic factors affected in pregnancy: Clotting factors= (5) Anticoags= (3)
Clotting factors= inc 1, 8, 9, 10, 12 | Anticoags= dec AT, dec protein S, no change protein C
41
How are the following hematologic factors affected in pregnancy: Fibrinolytics= Anti-fibrinolytics=
``` Fibrinolytics= inc fibrin breakdown Anti-fibrinolytics= dec 11 and 13 ```
42
How is total coagulation affected by pregnancy
Pregnancy creates a hypercoagulable state DVT is 6 times higher
43
How are the following labs affected during pregnancy: PT= PTT= Plt count=
PT= dec 20% PTT= dec 20% Plt count= unchanged or dilutional
44
How is MAC altered during pregnancy
decreased by 30-40%
45
How are the following parameters altered by pregnancy: LA sensitivity= Epidural vein volume=
LA sensitivity= inc | Epidural vein volume= inc
46
How should the dose of LA be adjusted in the parturient and why
Decrease dose d/t increased sensitivity to LA
47
Why do gastric volume and gastric pH change during pregnancy
d/t increased gastrin
48
``` How are the following GI parameters affected by pregnancy: Gastric volume= Gastric pH= LES sphincter tone= Gastric emptying= ```
Gastric volume= inc Gastric pH= dec LES sphincter tone= dec Gastric emptying= no change or dec
49
Why are LES sphincter tone and gastric emptying altered in pregnancy
D/t inc progesterone, inc estrogen, and cephalad displacement of diaphragm
50
What is gastric emptying delayed in the parturient
Once labor begins
51
``` How are the following renal parameters altered in pregnancy: GFR= Crt clearance= Glucose in urine= Crt and BUN= ```
GFR= inc Crt clearance= inc Glucose in urine= inc Crt and BUN= dec
52
Why are maternal GFR and crt clearance increased
d/t increased blood volume and CO
53
Why is there increased glucose in maternal urine
d/t inc GFR and dec renal absorption
54
Why are maternal crt and BUN decreased
d/t inc crt clearance
55
How are the following affected by pregnancy: uterine blood flow= Serum albumin= Pseudocholinesterase=
uterine blood flow= up to 700-900 mL/min Serum albumin= inc free fraction of protein bound drugs Pseudocholinesterase= dec
56
What are the 3 variables that uterine blood flow is dependent on since it cannot autoregulate
1. MAP 2. CO 3. uterine vascular resistance
57
What are the 2 categories that reduce uterine blood flow
1. decreased perfusion | 2. increased resistance
58
What are 4 factors that decrease uterine perfusion
1. Maternal HoTN 2. Sympathectomy 3. Hemorrhage 4. Aortocaval compression
59
What are 3 factors that increase uterine resistance
1. uterine contraction | 2. HTN conditions that increase UVR
60
What fetal factor can increase concentration gradients across the placenta What is the result
Fetal acidosis result = ion trapping
61
How does fetal acidosis affect concentration gradients across the placenta
it can lead to increase concentration gradient, causing more to pass into the fetus and lead to ion trapping
62
What are 4 drug characteristics that favor placental transfer
1. low molecular weight <500 Daltons 2. High lipid solubility 3. Non-ionized fraction 4. Non-polar fraction
63
What 8 anesthetic drugs can have significant placental transfer
1. LA (x chloroprocaine) 2. IV anesthetics 3. Volatile anesthetics 4. Opioids 5. BZDs 6. Atropine 7. Beta-blockers 8. Magnesium
64
What anesthetic drugs have no placental transfer
1. NMB 2. Glycopyrrolate 3. Heparin 4. Insulin
65
What are the 3 stages of labor
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
What drug may be used with dysfunctional labor
Oxytocin
67
What are the NPO guidelines for the laboring parturient
1. Drink moderate clears throughout labor | 2. Eat solid food until neuraxial block
68
What is the distribution of pain in the first stage of labor
Begins in the lower uterine segment and cervix
69
What spinal levels do pain signals travel during the first stage of labor
T10-T11 posterior nerve roots
70
What is the distribution of pain in the second stage of labor
Same as first stage but there are added pain impulses from vagina, perineum and pelvic floor
71
What spinal levels do pain signals travel during the second stage of labor
S2-S4 posterior nerve roots
72
What is the afferent nerve pathway for the uterus and cervix
Visceral C fibers hypogastric plexus
73
What is the afferent nerve pathway for the perineum
Pudendal nerve
74
What spinal segments cover the uterus and cervix
T10-T11
75
What spinal segments cover the perineum
S2-S4
76
Which regional technique has high risk for fetal bradycardia
paracervical block
77
What type of block covers the perineum
Pudendal nerve block
78
What are consequences of uncontrolled maternal pain during labor
1. increased maternal catecholamines | 2. maternal hyperventilation
79
How does increased maternal catecholamines from uncontrolled pain affect the laboring parturient
Can lead to HTN and reduced UBF
80
How does maternal hyperventilation from uncontrolled pain affect the laboring parturient
Shifts oxyhgb curve LEFT | Reduces O2 delivery to the fetus
81
What are 3 benefits of N2O use during labor
1. self-administered pain control 2. Preserved uterine contractility 3. No neonatal depression
82
What are the steps of performing a CSE
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
Describe the epidural volume extension technique and rationale
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
What are the benefits of using the epidural volume extension technique
1. Allows for less LA for better hemodynamic stability and faster recovery
85
Describe the possibility of placental transfer of bupivacaine
Low placental transfer d/t inc protein binding and inc ionization
86
What are 2 reasons for low bupivacaine placental transfer
1. increased protein binding | 2. increased ionization
87
Describe the block quality of bupivacaine compared to other LA
Greater sensory block
88
What risks are greatest with bupivacaine
Cardiac toxicity | Occurs before seizures
89
How does ropivacaine compare to bupivacaine (4)
1. S-enantiomer of bupiv + propyl group 2. dec CV toxicity 3. dec potency 4. dec motor block
90
Why is lidocaine avoided for labor analgesia
d/t the strong motor block
91
What risks are associated with lidocaine given in the SA space
high risk of neurotoxicity
92
When is 2-chloroprocaine useful for labor neuraxial techniques
For emergency C/S when epidural is already in place d/t fast onset
93
How does 2-chloroprocaine affect epidural opioids
It antagonizes the opioid receptors (mu and kappa) reducing efficacy of epidural morphine
94
What are the risks of 2-chloroprocaine use w/ spinal anesthetics
Risk for arachnoiditis d/t preservatives
95
What are 3 benefits of neuraxial opioid solo injection
1. no loss of sensation or proprioception 2. No sympathectomy, better hemodynamic stability 3. No impairment with ability to push
96
How does neuraxial meperidine compare to LA
It possesses LA properties
97
What are 4 common side effects of neuraxial opioids
1. Pruritis 2. N/V 3. Sedation 4. Respiratory depression
98
``` Spinal bolus for the following: Bupivacaine= Ropivacaine= Levobupivacaine= Lidocaine= ```
``` Bupivacaine= 1.25-2.5 mg Ropivacaine= 2-3.5 mg Levobupivacaine= 2-3.5 mg Lidocaine= NA ```
99
``` Epidural bolus for the following: Bupivacaine= Ropivacaine= Levobupivacaine= Lidocaine= ```
``` Bupivacaine= 0.0625 - 0.125% Ropivacaine= 0.08-0.2% Levobupivacaine= 0.0625-0.125% Lidocaine= 0.75-1% ```
100
What is the lumbar infusion rate for continuous epidural infusions
8-15 ml/hr
101
``` Spinal bolus for the following: Fentanyl= Sufentanil= Morphine= Meperidine= ```
``` Fentanyl= 15-25 mcg Sufentanil= 1.5-5 mcg Morphine= 125-250 mcg Meperidine= 10-20 mg ```
102
``` Epidural bolus for the following: Fentanyl= Sufentanil= Morphine= Meperidine= ```
``` Fentanyl= 50-100 mcg Sufentanil= 5-10 mcg Morphine= NA Meperidine= NA ```
103
What is the typical epidural continuous infusion rate for fentanyl
1.5-3 mcg/mL at 8-15 mL/hr
104
Spinal bolus for the following: Epinephrine= Clonidine= Neostigmine=
``` Epinephrine= 2.25-200 mcg Clonidine= 15-30 mcg Neostigmine= NA ```
105
Epidural bolus for the following: Epinephrine= Clonidine= Neostigmine=
``` Epinephrine= 25-75 mcg Clonidine= 75-100 mcg Neostigmine= 500-750 mcg ```
106
Which LA are metabolized by pseudocholinesterase
Esters | 2-chloroprocaine
107
What are 3 ways a pt can develop a total spinal
1. epidural dose injected into SA space 2. epidural dose injected into SD space 3. Single shot spinal after failed epidural block
108
What happens if an epidural dose is injected into the SA space
there will be a high spinal | Expect to intubate and wait for pt to stabilize
109
The result of subdural injection of epidural dose
With-in 10-25 minutes of injection pt will experience symptoms of excessive cephalad spread of LA
110
Why does LA spread cephalad so quickly if injected into the subdural space
b/c it is a potential space that holds very low volume
111
What are 3 symptoms of total spinal
1. dyspnea 2. difficulty phonating 3. HoTN
112
Why does LOC happen with total spinal
D/t cerebral hypoperfusion from HoTN
113
What are 3 differential diagnoses for total spinal
1. anaphylactic shock 2. eclampsia 3. AFE
114
What is the presentation of total spinal
1. rapid progression of sensory and motor block 2. dyspnea, difficulty phonating, HoTN 3. LOC
115
5 interventions for total spinal
1. vasopressors 2. IVF 3. LUD 4. Leg elevation 5. intubate

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