Mod 7 + 8 Flashcards
Can pregnant women take asthma medications?
Yes
_________ does not commonly involve wheezing and coughing while asthma does
Dyspnea
Risks associated with_______:
FGR
SGA
PTB
Asthma
Pregnancy causes ___% of cases to improve, ____% of cases to unchange, ____% of cases will worsen
33%, 33%, 33%
first test to order when PE is suspected
CXR
pregnant women are in stable respiratory:
alkalosis
progesterone causes decreased ___________ and _____________
airway conduction and pulmonary resistance
elevated diaphragm causes ___________ and ___________
functional residual capacity and residual air volume
GERD can make asthma:
worse
Asthma Severity: symptom frequency: 2 days per week or less night waking: 2x/month or less NO intereference with normal activity PFR > 80% of personal best
Intermittent
Asthma Severity:
symptom frequency: >2 days per week but not daily
night waking: >2x/month
Intereference with normal activity: minor
PFR > 80% of personal best
Mild Persistent
Asthma Severity: symptom frequency: daily night waking: >1x/week Intereference with normal activity: some limitation PFR 60-80% of personal best
Moderate Persistent
Asthma Severity: symptom frequency: throughout day night waking: 4x/week or more Intereference with normal activity: extreme limitation PFR <60% of personal best
Severe Persistent
Treatment for _________ Asthma:
No daily meds
Albuterol PRN
Mild Intermittent
Treatment for _________ Asthma:
Preferred: Low-dose inhaled corticosteroids
Alternative: Cromolyn, Leukotriene Receptor Antagonist, Theophylline
Mild Persistent
Treatment for _________ Asthma:
Preferred: Low-dose inhaled corticosteroids AND Salmeterol or Medium-dose inhaled corticosteroids
Alternative: Low-dose or Medium-dose inhaled corticosteroids AND Leukotriene Receptor Antagonist or Theophylline
Moderate Persistent
Treatment for _________ Asthma:
Preferred: High-dose inhaled corticosteroids AND Salmeterol AND oral corticosteroid (if needed)
Alternative: High-dose inhaled corticosteroids AND Theophylline AND oral corticosteroid (if needed)
Severe Persistent
Maternal Implications of \_\_\_\_\_\_\_\_\_: Variable - 23% improve, 30% worsen Need monitoring w/ PEFR and FEV1 testing + tracking symptoms throughout pregnancy LBW Prematurity Susceptibility to hypoxia and hypoxemia Slight increase (studies not consistent): -stillbirth -preeclampsia -PTL -FGR -perinatal mortality -abruption -previa -PROM -GDM Morbidity (severe disease, poor control, or both) **Otherwise usually good outcomes Status asthmaticus can → morbidity, muscle fatigue, resp arrest, pneumothorax, pneumomediastinum, acute cor pulmonale, cardiac arrhythmias
Asthma
**Fetal Implications of \_\_\_\_\_\_\_\_\_: Fairly uncommon--If any risk it is slight and studies are not consistent** SAB PTL/PTB FGR (with increased severity) Abruption/Previa PROM Fetal response to maternal hypoxemia → ↓umbilical blood flow, ↑systemic and pulmonary vascular resistance, ↓cardiac output Possible teratogenic or adverse effects of Meds Slight risk for abnormalities: -Cleft lip and palate -Autism spectrum disorders
Asthma
Differential Dx for \_\_\_\_\_\_\_\_: Dyspnea of pregnancy GERD Chronic cough from postnasal drip Bronchitis
Asthma
Collaborate or refer for ANY level of _______ asthma
persistent
Avoid ______ corticosteroid in ____ trimester
oral in 1st
Give stress dose of corticosteroids to women in labor that have used ___________ in the past 4 weeks
oral steroids
med that is possibly teratogenic or may have adverse fetal effects - several reports show slightly higher risk for abnormalities such as cleft lip/palate and autism spectrum
oral steroids
ICS usually bumped up to q__-__ hours to reduce need for extra SABAs in persistent asthma
3-4
Interventions for Asthma during __________:
Keep rescue inhaler at bedside
Continue ICS
Labor
Avoid nubain during:
acute asthma attack
Labetolol and Hemabate - not first line for:
asthmatics
If patient also allergic to ASA, DO NOT give ____________ during labor, consult physician
corticosteroids
Medication for all severities of asthma
SABAs
Add __________ to SABA for Mild Persistent Asthma
Low-dose ICS
Add __________ to SABA for Moderate Persistent Asthma
Low-dose ICS + LABA
Add __________ to SABA for Severe Persistent Asthma
High-dose ICS + LABA
Add __________ to SABA for VERY Severe Persistent Asthma
High-dose ICS + LABA + PO corticosteroids
Do not _______ asthma medications DURING pregnancy
step-down
What to assess if asthma symptoms ___________:
medication technique, adherence, and environmental control
not controlled
Nonpharmacologic Interventions for \_\_\_\_\_\_\_\_: Control of triggers Herbal remedies (NOT in place of meds!) Licorice, Ginkgo Biloba, Coltsfoot, Hops Fish Oil, Vitamin C Yoga, acupuncture, biofeedback
Asthma
Causes increased risk for __________ in pregnancy:
decreased venous outflow
hypercoagulable state
damage to venous lining
VTE
V I R C H ow's Triad
Vascular Injury
Reduced blood flow (venous stasis)
HyperCoaguability
pauses in respiratory movements greater than 20 sec that is common in preterm infants…involves changes in HR (often <80 bpm)
apnea
apnea with no breathing effort and no airflow
central apnea
apnea with breathing effort but no airflow
obstructive apnea
apnea that begins with no breathing effort then once breathing effort starts, there is no airflow
mixed apnea
venous stasis, hypercoagulable state, vascular trauma
Virchow’s
Venous wall relaxation due progesterone and venous pressure due to gravid uterus
venous stasis
DVT is usually in _______ left leg– ileal femoral veins
proximal
Pathophysiology of ____________:
the placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter
preeclampsia
Preeclampsia: ___creased serum creatinine
increased
Preeclampsia: ___creased creatinin clearance
decreased
Preeclampsia: ___creased liver enzymes
increased
Preeclampsia: ___creased Lactate Dehydrogenase (LDH)
increased
level that indicates proteinuria in 24-hour urine
> 300
Risk Factors for \_\_\_\_\_\_\_\_\_\_: Obesity (BMI>30) Smoking Age>35 Hx thrombosis Inherited thrombophilias Antiphospholipid antibody syndrome Sickle cell disease Heart disease Diabetes Immobility (paraplegia) [Due to Pregnancy:] Hypercoagulable state Venous stasis Multiple pregnancy Preeclampsia [Due to Labor and Birth:] Operative vaginal birth C/S Infection Vascular trauma Immobilization PPH Preterm birth Stillbirth
DVT
LOOK AT ACOG Chronic HTN & Gestational HTN tables that explain difference b/t severe and nonsevere features
!!!!!!!!
LOOK AT CLINICAL RISK FACTORS FOR ASPIRIN USE IN PREGNANCY
!!!!!!!!!
Management of ____________:
**Immediate referral
Thrombophilia testing first if indicated
Anticoagulation w/ unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH)
PP: simultaneously start warfarin (safe during lactation)
Anticoagulation continues for 6 months minimum
Limited activity, leg rest, elevation
Over several days leg pain should subside
After symptoms pass - graded ambulation started, fit elastic stockings, continue anticoagulation
Graduated compression stockings are worn for 2 yrs to prevent post-thrombotic syndrome
DVT
Recovery of DVT is usually __-___ days
7-10
PE incidence: 1 in _______
7,000
Symptoms of \_\_\_\_\_\_\_: Dyspnea Chest pain Cough Syncope Hemoptysis Tachypnea Apprehension Tachycardia Pulmonic closure sound Rales Friction rub Deceptively nonspecific - s/s and lab testing
PE
Diagnostics for _______:
ECG (right axis deviation + T wave inversion)
CXR (results normal 40% of the time, otherwise may have atelectasis, infiltrate, cardiomegaly, or effusion)
Most hypoxemic–Normal arterial blood glass does not exclude
⅓ have PO2 value of >80mmHg
Alveolar-arterial oxygen tension difference more useful indicator - 86% have alveolar-arterial difference >20mmHg
PE
Gestational HTN will deliver @ ___ weeks
37
Risk Factors for __________:
Rapid labor
MSAF
Tears into uterine/other large pelvic veins (permits fluid exchange b/w mother & fetus)
AMA Post-term pregnancy Labor induction or augmentation Eclampsia Cesarean, forceps, or vacuum delivery Abruption or previa Hydramnios
AFE
Risk Factors for __________:
Rapid labor
MSAF
Tears into uterine/other large pelvic veins (permits fluid exchange b/w mother & fetus)
AMA Post-term pregnancy Labor induction or augmentation Eclampsia Cesarean, forceps, or vacuum delivery Abruption or previa Hydramnios
Male gender fetus
Fetal distress
PROM
IUFD
AMA >35
Multiparity
Diabetes
C/S
cervical laceration
Uterine rupture
Uterine Hypertonus - likely effect rather than cause, hypertonus from oxytocin not implicated
AFE
Symptoms of __________:
Classic triad:
hemodynamic compromise, respiratory compromise, DIC
Classic example:
dramatic behavior
late stages of labor immediately postpartum
gasping for air
Seizures or cardiorespiratory arrest rapidly follows w/ massive hemorrhage from consumptive coagulopathy
Manifestations can be variable
AFE
Management for \_\_\_\_\_\_\_\_\_\_\_: Protect airway 2 large-bore IVs Type+Cross Consider vasopressors Contact OR Emergent C/S ICU Volume resuscitation serial ACT/ABG/VBG PRBC/FFP/platelets
AFE
Most efficient way for NB to temporarily increase ventilation and compensate for hypoxia and hypercarbia
tachypnea
developmental deficiency in surfactant synthesis accompanied by lung immaturity and hypoperfusion
Neonatal Respiratory Distress
Do NOT give ___________ to protect against infections from MVP (mitral valve prolapse)
prophylactic abx
Causes of ___________:
Prematurity and exacerbated by asphyxia
Impaired or delayed surfactant synthesis
Neonatal Respiratory Distress
Risk Factors for ____________:
Fetal - Prematurity, asphyxia, anemia
Maternal - poorly controlled GDM
Pregnancy- polyhydramnios, oligohydramnios
Intrapartum - previa, abruption, MSAF
Risk decreases w/ higher gestational age
Neonatal Respiratory Distress
Risk Factors for \_\_\_\_\_\_\_\_\_\_: Male gender Maternal GDM Perinatal asphyxia Hypothermia Multiple gestations
Respiratory Distress Syndrome
NB’s most efficient way to temporarily increase ventilation and compensate for hypoxia and hypercarbia
tachypnea
sound created by exhaling against a partially closed glottis in an attempt to increase functional residual capacity in lungs and stabilize (stint) alveoli
helps keep the lungs expanded and preserves oxygen
grunting
attempt to decrease resistance to airflow by increasing the size of nostrils that results from increased inspiratory pressure
this decrease in resistance will decrease total work of breathing
nasal flaring
Attempt to increase lung compliance and assist the diaphragm as it mechanically expands the lung during inspiration
occurs with airway obstruction
retractions
apparent when 5 g/100 mL of hemoglobin is unsaturated and SpO2 decreases to 80-85%
central cyanosis
developmental deficiency in surfactant synthesis accompanied by lung immaturity and hypoperfusion
caused by prematurity and exacerbated by asphyxia
or impaired/delayed surfactant synthesis
neonatal respiratory distress
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_\_: Fetal - Male gender Prematurity Asphyxia Anemia Hypothermia Multiple gestations
Maternal -
Poorly controlled diabetes
Pregnancy-
Polyhydramnios
Oligohydramnios
Intrapartum- Previa Abruption MSAF **Risk decreases w/ increased gestational age
neonatal respiratory distress
NB Respiratory Problem:
Begins early
and Increases in severity over the first 72 hours
neonatal respiratory distress
results in poor compliance, rapid, shallow breathing
surfactant deficiency
results in slower deep breathing
increased airway resistance
Symptoms of _________________:
Tachypnea
Grunting
Pitting edema
Cyanosis
Diminished breath sounds
Retractions
Isolated tachypnea w/ congenital heart disease
Temp instability (infection?)
Tachycardia (hypovolemia?)
Scaphoid abdomen (congenital diaphragmatic hernia?)
Asymmetric chest movement/ breath sounds
Tension pneumothorax possible
Stridor (possible subglottic stenosis in previously intubated)
neonatal respiratory distress
Diagnostics for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: Follow NRP guidelines until infant is stable then... -Chest x-ray -ABG -CBC w/diff -Blood cultures -Review maternal/fetal history
neonatal respiratory distress
Inadequate or delayed clearance of lung liquid leading to transient pulmonary edema
Transient Tachypnea of the Newborn
Caused by fluid in lungs increasing inspiratory activity, RR, and grunting
- Possibly from alteration in permeability of pulmonary capillary vessels, aspiration of amniotic fluid during in uterine gasping efforts or decreased vaginal thoracic squeeze
- Immaturity leads to slower lung fluid removal
- Delayed respiratory transition w/ increase in diffusion distance
- Increased risk of V/Q mismatching
Transient Tachypnea of the Newborn
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: Cesarean birth before labor onset Perinatal hypoxic stress event Precipitous labor Male gender infant Genetic change in alveoli 𝛃-adrenergic receptor expression
Transient Tachypnea of the Newborn
Uncommon in preterm infants born by C/S possibly due to increased interstitial tissue and smaller gas exchange areas that decrease movement of lung fluid from the interstitial space back into the airway
Transient Tachypnea of the Newborn
No transition after birth with symptoms resolving usually in 48-72 hours
Transient Tachypnea of the Newborn
Symptoms of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_: Tachypnea (up to 120-140 bpm) Mild to moderate retractions Grunting Cyanosis (usually not prominent) Breath sounds may be initially moist but clear quickly
Transient Tachypnea of the Newborn
