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8361 Exam 3 > Mod VIII: Anesthetic Considerations for Obstetric Emergencies > Flashcards

Mod VIII: Anesthetic Considerations for Obstetric Emergencies Flashcards

1
Q

Anesthetic Considerations for Obstetric Emergencies

What’s the leading cause of maternal and perinatal morbidity and mortality?

A

Obstetrical Hemorrhage

4% of vaginal deliveries & 7% of C-section’s

Because of the normal physiologic changes of pregnancy, including increased blood volume, parturient tolerate mild to moderate hemorrhage with little change in VS

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2
Q

Anesthetic Considerations for Obstetric Emergencies

T/F: UNDERERSTIMATION of blood loss by anesthesia contributes to maternal morbidity and mortality

A

True

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3
Q

Obstetrical Hemorrhage

What clinical signs accompany a Bloss loss of 15% EBV (900 cc)? Which class of Blood loss is it?

A

No clinical signs

CLASS I

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4
Q

Obstetrical Hemorrhage

What clinical signs accompany a Bloss loss of 20-25% EBV or (1200-1500 cc)? Which class of Blood loss is it?

A

↑ Heart rate

Orthostatic hypotension

Narrowed pulse pressure

CLASS II

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5
Q

Obstetrical Hemorrhage

What clinical signs accompany a Bloss loss of 30-35% EBV or (1800-2000 cc)? Which class of Blood loss is it?

A

Hypotension

Marked tachycardia

Cold, clammy skin

CLASS III

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6
Q

Obstetrical Hemorrhage

What clinical signs accompany a Bloss loss of 40% EBV or (> 2000 cc)? Which class of Blood loss is it?

A

Profound shock…requires immediate & aggressive resuscitations

CLASS IV

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7
Q

Obstetrical Hemorrhage

Which Obstetrical Hemorrhage occur in the ANTEPARTUM phase?

A

Abruptio placenta

Placenta previa

Placenta accreta

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8
Q

Obstetrical Hemorrhage

Which Obstetrical Hemorrhage occur in the INTRAPARTUM phase?

A

Uterine Rupture

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9
Q

Obstetrical Hemorrhage

Which Obstetrical Hemorrhage occur in the POSTPARTUM, and are associated with > 500 CC of blood loss for vaginalor delivery or > 1000 cc of blood loss for C-S?

A

Uterine atony

Retained placenta

Cervical/vaginal lacerations

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10
Q

Obstetrical Hemorrhage

The Premature separation of a normally implanted placenta before delivery of fetus causing acute bleeding behind the placenta is also known as:

A

Abruptio Placenta

Aslo means that part of the placenta is not attached to the uterus and therefore is not involved in the normal exchanges that occur btw the uteroplacental unit

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11
Q

Abruptio Placenta

What the incidence of Abruptio Placenta? when does is usually occur?

A

0.2 -2.4% of all pregnancies

Usually occur in the 3rd trimester

(final 10 wks. gestation)

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12
Q

Abruptio Placenta

What are the maternal and perinatal mortality rates of Abruptio Placenta?

A

Maternal → 1.8 – 11%

Perinatal → > 50%

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13
Q

Abruptio Placenta

What % of ALL perinatal deaths occur due to Abruptio Placenta

A

15-25%

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14
Q

Abruptio Placenta

Risk Factors of Abruptio Placenta:

A

Preeclampsia/HTN*

(highest risk!!!)

Advanced maternal age (AMA)

Multiparity

Increased Uterine distention

(DM, multiple gestation, polyhydramnios)

Trauma

Cocaine abuse/Tobacco use

Premature rupture of membranes (PROM)

Previous abruption

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15
Q

Abruptio Placenta

Clinical Presentation of Abruptio Placenta:

A

Uterine tenderness

Uterine hypertonus

Abdominal pain

Vaginal bleeding (dark, clotted)

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16
Q

Abruptio Placenta

Amount of Vaginal bleeding (dark, clotted) may be concealed if:

A

Placental margins remain attached to uterus

→ underestimation of actual degree of hemorrhage

(retro-placental hematoma)

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17
Q

Abruptio Placenta

What’s a hepful diagnosis in severe cases or significant collection concealed blood?

A

Diagnosis by US

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18
Q

Abruptio Placenta

Complications of Abruptio Placenta:

A

Coagulopathies

DIC**

Abruption most common complication in parturient

Uterine atony

Hemorrhagic shock (hypotension/tachycardia)

Acute renal failure

Fetal distress/demise

↓surface area for O2 delivery → hypoxia

Abruption > placenta previa

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19
Q

Abruptio Placenta

What’s the most common complication of abruption in parturient?

A

DIC

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20
Q

Abruptio Placenta

What are causes of Fetal distress/demise in Abruptio Placenta?

A

Decrease surface area for O2 delivery → Fetal hypoxia

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21
Q

Abruptio Placenta

T/F: The risk of Fetal distress/demise is greater with Abruptio Placenta than with Placenta previa

A

True

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22
Q

Obstetrical Management of Abruptio Placenta

The Definitive treatment for Abruptio Placenta is:

A

Delivery of fetus/placenta

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23
Q

Obstetrical Management of Abruptio Placenta

How would a Mild abruption w/o evidence of severe hemorrhage or fetal distress be managed?

A

Attempt induction of labor for vaginal delivery

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24
Q

Obstetrical Management of Abruptio Placenta

How would a Severe abruption, maternal hemorrhage or fetal distress be managed?

A

Emergency C/S

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25
Q

Obstetrical Management of Abruptio Placenta

In the obstetrical management of Abruptio Placenta, when would Epidural anesthesia be indicated?

A

Labor, vaginal delivery, & elective C-S

provided that no contraindications exist

(e.g. s/s that they are not stabel?)

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26
Q

Obstetrical Management of Abruptio Placenta

In the obstetrical management of Abruptio Placenta, what are advantages of epidural anesthesia?

A

Provides a controlled situation

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27
Q

Obstetrical Management of Abruptio Placenta

In the obstetrical management of Abruptio Placenta, what are concerns w/ epidural anesthesia?

A

Sympathectomy from the epidural could prevent the parturient ability to compensate for the hypovalemia

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28
Q

Obstetrical Management of Abruptio Placenta

When would GETA be indicated?

A

Emergency C-S,

if Maternal hemorrhage or Fetal distress

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29
Q

Obstetrical Management of Abruptio Placenta

Why would regional anesthesia no be recommended over GETA if Emergency C-S is required d/t Maternal hemorrhage and/or Fetal distress?

A

Sympathetctomy

Plus, GETA allow to secure airway more quickly

Time is also of an essence if concerns of fetal distress or maternal hemorrhage

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30
Q

Obstetrical Management of Abruptio Placenta

When is it acceptable to use epidural for emergency C-S?

A

Maternal hemmorraghe not severe

Pt remains hemodynamically stable

Patient is already receiving epidural analgesia for labor

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31
Q

Obstetrical Management of Abruptio Placenta

Why are Ketamine & Etomidate the preferred induction agents vs Propofol or STP for the Obstetrical Management of Abruptio Placenta?

A

Less likely to produce hypotension

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32
Q

Obstetrical Management of Abruptio Placenta

In the Obstetrical Management of Abruptio Placent which doses of Ketamine should be avoided? and why?

A

Avoid ketamine (> 2mg/kg) if uterine hypertonus present

Ketamine will further increase uterine tone and can geopardize uterine perfusion pressures

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33
Q

Obstetrical Management of Abruptio Placenta

In the Obstetrical Management of Abruptio Placenta, what should be the minimmum FiO2 delivered to the pt? How long should delivery of this FiO2 concentrations maintained?

A

Must deliver FIO2 at least 50%

until fetus delivered

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34
Q

Obstetrical Management of Abruptio Placenta

The use of Volatiles is acceptable in the Obstetrical Management of Abruptio Placenta only under which condition?

A

Hemodynamically stable

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35
Q

Obstetrical Management of Abruptio Placenta

In the Obstetrical Management of Abruptio Placenta, when is the use of Volatiles agenst actually beneficial?

A

Hypertonus present

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36
Q

Obstetrical Management of Abruptio Placenta

Why should you decrease the MAC of volatile agents to 0.5 MAC

A

To ensure adequate uterine tone after delivery

Parturient with abruption at increased risk for developing uterine atony after delivery

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37
Q

Obstetrical Management of Abruptio Placenta

Tx of Hypovolemia associated with Abruptio Placenta involves:

A

Aggressive fluid resuscitation

2 large-bore IV’s

Availability of blood products must be confirmed

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38
Q

Obstetrical Management of Abruptio Placenta

If cross-matched blood not readily available, what’s the alternative?

A

Type O neg or Type specific

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39
Q

Obstetrical Management of Abruptio Placenta

What’s the Tx for Coagulopathy/DIC?

A

FFP/PLT transfusions may be required

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40
Q

Obstetrical Hemorrhage

Abnormal implantation of placenta on lower uterine segment

A

Placenta Previa

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41
Q

Placenta Previa

What are the different types of Placenta Previa?

A

Complete

complete coverage of cervical os

Partial

covers only part of cervical os

Marginal

lies close but doesn’t cover cervical os

Low lying

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42
Q

Placenta Previa

What’s the incidence of placenta previa?

A

0.1 – 1.0% of all pregnancies

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43
Q

Placenta Previa

What are maternal and perinatal mortality for Placenta Previa?

A

Maternal: Rare (0.9%) unlike abruption

Perinatal: 17-26%

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44
Q

Placenta Previa

What are Risk factors for Placenta Previa?

A

Prior uterine surgery*

(greatest)

Previous C/S

Risk ↑ as number of prior C/S ↑

Advanced maternal age

Multiparity

Previous placenta previa

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45
Q

Placenta Previa

What’s the Clinical presentation of Placenta Previa?

A

Painless, bright red, vaginal bleeding during 2nd & 3rd trimester

First episode of bleeding typically occurs preterm

Severe hemorrhage can occur however at anytime

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46
Q

Placenta Previa

What are possible Complications of Placenta Previa?

A

Maternal hemorrhage

Complications of C-section (esp. anterior lying placenta)

Placenta accreta

Preterm delivery/complications prematurity

Abnormal fetal presentation

Placental separation → fetal anemia/hypoxia

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47
Q

Placenta Previa - Diagnosis

T/F: All parturient with vaginal bleeding are assumed to have placenta previa until proven otherwise

A

True

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48
Q

Placenta Previa

How is the Diagnosis of Placenta Previa made?

A

Determined by ultrasound

(abdominal → transvaginal)

Vaginal exam sometimes required to confirm

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49
Q

Placenta Previa

What the risk associated w/ vaginal exam w/ suspected Placenta Previa?

A

Could separate placenta from uterus and cause maternal hemmorrhage

Often requires “Double set-up” conditions

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50
Q

Placenta Previa - Vaginal Exam Double Set-Up

Why does vaginal Exam for Placenta Previa require “Double Set-Up” and is undertaken only in the OR?

A

OB surgeon & anesthesia present

Prepared to proceed to emergency C/S if acute hemorrhage occurs

(Double Set-Up means that one team ready for emergent cesarean delivery and one team ready for uneventful vaginal delivery)

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51
Q

Placenta Previa - Vaginal Exam Double Set-Up

Preparation for Double Set-Up conditions includes:

A

Large-bore (14- or 16-ga) IV on blood set

2-4 units PRBC must be in the OR

Abdomen prepped/draped

All preparations for GETA available

Assistance available

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52
Q

Obstetrical Management of Placenta Previa

All parturients with a total or partial placenta previa undergo C-S - Why?

A

Great risk for massive hemorrhage that can occur with vaginal delivery

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53
Q

Obstetrical Management of Placenta Previa

All parturient with a total or partial placenta previa undergo C-S because of great risk for massive hemorrhage that can occur with vaginal delivery. For which type of placenta previa would vaginal delivery be attempted?

A

Marginal placenta previa

Vaginal delivery may be attempted with a marginal placenta previa to try for a vaginal birth (RARE!!!)

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54
Q

Obstetrical Management of Placenta Previa

With known placenta previa, at what gestational age would elective C-S be scheduled?

A

@ gestational age that maximizes fetal lung maturity

This is to minimize the risk of hemorrhage that may result from onset of normal labor & uterine contractions

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55
Q

Obstetrical Management of Placenta Previa

In a case of placenta previa whereby minimal or absent bleeding are noted, and fetal/maternal stability are evident, the expectant management is to allow time for fetal lung maturation. What would this involve?

A

Bedrest

High corticosteroids

Tocolytics to prevent normal onset of labor/uterine contractions (severe hemorrhage)

When fetal lung maturation is achieved or 37 weeks gestation reached => proceed with delivery

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56
Q

Obstetrical Management of Placenta Previa

In cases of placenta previa where active bleeding with maternal instability & fetal deterioration are present, which intervention would best serve mothers interest?

A

IMMEDIATE C/S

(regardless of gestational age)

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57
Q

Obstetrical Management of Placenta Previa

If Active bleeding with maternal instability & fetal deterioration, Mothers interest best served by IMMEDIATE C/S regardless of gestational age - H/E must consider interest of the fetus

A

Fluid/blood resuscitation

Tocolytics

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58
Q

Obstetrical Management of Placenta Previa

If initial episode of bleeding resolves with maternal & fetal stability evident, and fetus is premature, reasonable to delay delivery - why?

A

Improve newborn outcome

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59
Q

Anesthetic Management of Placenta Previa

Anesthetic Management of Placenta Previa is dependent on:

A

Maternal/ fetal status

Urgency with which C/S must proceed

60
Q

Anesthetic Management of Placenta Previa

Anesthetic Management of Placenta Previa when Elective C-S is indicated:

A

Regional preferred (no active bleeding evident)

61
Q

Anesthetic Management of Placenta Previa

There is a High risk for intra op bleeding leading to emergent hysterectomy during the Anesthetic Management of Placenta Previa - How do you prepare for this?

A

Large-bore IV access

T&C blood readily available before proceeding

62
Q

Anesthetic Management of Placenta Previa

When is Emergency C-S indicated in the Anesthetic Management of Placenta Previa?

A

Evidence of Maternal hemorrhage, and/or

Evidence of Fetal distress

63
Q

Anesthetic Management of Placenta Previa

What’s the preferred anesthetic technique for the Management of Emergency C-S d/t Placenta Previa?

A

GETA preferred

64
Q

Anesthetic Management of Placenta Previa

Induction of GETA in the Management of Emergency C-S d/t Placenta Previa is similar to abruption - However, unlike abruption, no concerns regarding ketamine use because

A

No association between placenta previa and hypertonus

65
Q

Anesthetic Management of Placenta Previa

Maintenance of GETA in the Management of Emergency C-S d/t Placenta Previa is similar to abruption and is determined by

A

Maternal hemodynamics

66
Q

Anesthetic Management of Placenta Previa

Maintenance of GETA in the Management of Emergency C-S d/t Placenta Previa is similar to abruption - How could you promote uterine contraction or prevent uterine atony?

A

Decrease inspired concentration of N2O/Volatile agent

N2O/Volatile agent before delivery

Opioid added after

67
Q

Anesthetic Considerations for Obstetric Emergencies

The Abnormally firm attachment of placenta to myometrium is also kown as:

A

Placenta Accreta

68
Q

Placenta Accreta

Placenta Accreta comes in three different froms, that include:

A

Placenta Accreta

Most common

Adherent to myometrium w/o invasion

Placenta Increta

Invasion of myometrium

Placenta Percreta

Most serious

Invades entire myometrium, possibly into other pelvic structures (bladder)

69
Q

Placenta Accreta

What’s the most common form of Placenta Accreta ? How does it manifest?

A

Accreta

Adherent to myometrium w/o invasion

70
Q

Placenta Accreta

Which form of placenta accreta invades the myometrium only w/o spreading to other organs?

A

Placenta Increta

(invades the myometrium only w/o spreading to other organs)

71
Q

Placenta Accreta

What’s the most serious form of Placenta Accreta ? How does it manifest?

A

Percreta

Invades entire myometrium, possibly into other pelvic structures (bladder)

72
Q

Placenta Accreta

Placenta Accreta prevents placental separation at time of delivery - What does this lead to?

A

MASSIVE HEMORRHAGE!

73
Q

Placenta Accreta

What’s the reason of the 10-fold increase in the incidence of Placenta Accreta over last 50 yrs? How often do we see it now?

A

Increase in the rate of C/S

1 in 2500 deliveries

74
Q

Placenta Accreta

What are the Risk factors for Placenta Accreta?

A

Prior placenta previa*

(most common)

Prior C-S

(Incidence correlates with number C/S)

Prior uterine surgery

(myomectomy/D&C)

Placenta located over prior uterine scar

Multiparity

75
Q

Placenta Accreta

What is the Clinical presentation of Placenta Accreta?

A

Most asymptomatic

High index of suspicion in parturient with placenta previa and history of prior C/S

Vaginal bleeding likely due to previa

76
Q

Placenta Accreta

Antenatal diagnosis of Placenta Accreta is difficult & non-definitive - When is this diagnosis often made?

A

At time of surgery

(Oh oh! what do we do now?!)

77
Q

Obstetrical Management of Placenta Accreta

When is Elective C-S indicated?

A

If Diagnosis is known

78
Q

Obstetrical Management of Placenta Accreta

Procedure of choice that’s required to definitively treat most cases of placenta previa is:

A

Obstetrical hysterectomy

Parturient counceled & informed of all risks

Conservative management may be attempted if future fertility is desired, however hysterectomy remains procedure of choice

SUBSTANTIAL blood loss => Blood transfusions

79
Q

Obstetrical Management of Placenta Accreta

Which Interventional radiology procedure could be done to ↓blood loss?

A

Arterial embolization

80
Q

Obstetrical Management of Placenta Accreta

Why is Obstetrical Management of Placenta Accreta Schedule in main OR vs. Obstetrical OR?

A

Better resources

81
Q

Obstetrical Management of Placenta Accreta

When is it most preferred to induce general anesthesia in the Obstetrical Management of Placenta Accreta?

A

in a controlled situation

before start of surgery rather than during time of crisis

(esp. concerned about airway)

82
Q

Obstetrical Management of Placenta Accreta

What are Disadvantages of regional in the Obstetrical Management of Placenta Accreta?

A

Sympathectomy

Sympathectomy does not allow for compensation if massive hemorrhage occurs

conversion to GETA during crisis!!

If hysterectomy necessary → ↑ discomfort caused by surgical manipulation → conversion to GETA during crisis!!

Hemodynamic instability => intubation

Hemodynamic instability due to massive hemorrhage also may necessitate intubation

83
Q

Obstetrical Management of Placenta Accreta

Which anesthetic plan can significantly improve parturient outcome during the Obstetrical Management of Placenta Accreta?

A

Thorough preop preparation

Anticipation of potential problems

84
Q

Obstetrical Management of Placenta Accreta

Thorough preop anesthetic preparation & anticipation of potential problems can significantly improve parturient outcome - How can this be facilitated?

A

2 large-bore IV’s (consider a-line/CVP)

_T&C PRBC’_s in OR before surgery starts

Coordinate with blood bank availability of other blood products

Cell-saver set-up

85
Q

Anesthetic Considerations for Obstetric Emergencies

Failure of uterine muscle to contract normally following delivery of fetus/placenta is also known as:

A

Uterine Atony

86
Q

Uterine Atony

What’s the Pathophysiology of Uterine Atony?

A

Shearing of uterine vessels occurs with placental separation

Bleeding normally stopped by contraction of uterus & compression of vessels

Bleeding continues if contraction absent/inadequate

Responsible for 90% of all cases of postpartum hemorrhage

87
Q

Obstetric Emergencies

Which Obstetric Emergency is Responsible for 90% of all cases of postpartum hemorrhage?

A

Uterine Atony

88
Q

Uterine Atony

When and How is the diagnosis of Uterine Atony made?

A

Often occurs immediately after delivery

May occur several hours later

Relaxed, large postpartum uterus

Excessive vaginal bleeding

Absence of vaginal bleeding however should not exclude atony

Atonic engorged uterus may contain > 1000 cc

89
Q

Uterine Atony

What volume of blood may Atonic engorged uterus contain (hidden)?

A

> 1000 cc

90
Q

Uterine Atony

Which physical examination will be performed to identify cause of bleeding? - What would this exam look for specifically?

A

OB examination

Will look for Cervical/vaginal laceration, and

Retained placental fragments (more later)

91
Q

Uterine Atony

What are Predisposing Risk Factors for Uterine Atony?

A

Prolonged labor

Augmented labor (oxytocin or IV induction)

Preeclampsia - Multiparity - Multiple gestation - Volatile agents

Fetal macrosomia - Chorio-amnionitis - Tocolytic agents

Retained placenta

92
Q

Obstetrical Management of Uterine Atony

Which interventions can be conducted in the Obstetrical Management of Uterine Atony?

A

Bimanual compression

Uterine massage

Oxytocics

Emergency exploratory laparotomy

(if Persistent bleeding)

Control bleeding

Ligation of internal iliac (hypogastric) artery

Emergency hysterectomy

93
Q

Obstetrical Management of Uterine Atony

Which procedures are indicated to Control bleeding from Uterine Atony?

A

Ligation of internal iliac (hypogastric) artery

Emergency hysterectomy

94
Q

Obstetrical Management of Uterine Atony

Which drug is used in the treatment of uterine atony and acts on uterine smooth muscle by stimulating the force & frequency of contractions?

A

Oxytocin

95
Q

Obstetrical Management of Uterine Atony

What are the Side effects of Oxytocin?

A

Vasodilation/Hypotension

Tachycardia

Cardiac arrhythmias

Antidiuretic effect at high doses

(which could cause water intoxication, cerebral edema, convulsions)

96
Q

Obstetrical Management of Uterine Atony

How is Oxytocin dosed and administered?

A

Oxytocin

10 - 20 Units in 1000 cc bag LR/NS

97
Q

Obstetrical Management of Uterine Atony

Which drugs are used to increase force & frequency of uterine contraction followed by normal uterine relaxation, and is usually restricted to controlling Post Partum Hemmorrhage?

A

Methergine

Ergot alkaloids (methylergonovine)

98
Q

Obstetrical Management of Uterine Atony

How does Methergine controls Post Partum Hemmorrhage?

A

Contractions more intense/prolonged

Resting tonus increased

Tetanic contractions can occur

99
Q

Obstetrical Management of Uterine Atony

What are Methergine Side effects?

A

Vasoconstriction

HTN

100
Q

Obstetrical Management of Uterine Atony

Methergine must be given IM, NOT IV - What could happen if it was given IV?

A

Severe HTN

Convulsions

Retinal detachment

PE

101
Q

Obstetrical Management of Uterine Atony

In which conditions is Methergine contraindicated?

A

HTN (preeclampsia)

PVD

CAD

102
Q

Obstetrical Management of Uterine Atony

Which drugs are considered 3rd line of therapy in the Obstetrical Management of Uterine Atony?

A

Prostaglandins

(Carboprost, Misoprostol, Dinoprostone)

103
Q

Obstetrical Management of Uterine Atony

What are Prostaglandins Side effects

A

Transient HTN

Increased pulmonary vascular resistance

(This is why Caution is advised for use in <strong>asthmatic</strong>)

104
Q

Obstetrical Management of Uterine Atony

Why is the use of Prostaglandins cautioned in asthmatic?

A

Increased pulmonary vascular resistance

105
Q

Obstetrical Management of Uterine Atony

Table summarizing common drugs used in the Obstetrical Management of Uterine Atony and their side effects

A

Table summarizing common drugs used in the Obstetrical Management of Uterine Atony and their side effects

(Slide 75)

106
Q

Anesthetic Management of Uterine Atony

What’s the overall goal of Anesthetic Management of Uterine Atony?

A

Blood

Fluid resuscitation

107
Q

Anesthetic Management of Uterine Atony

Anesthetic techniques indicated in the management of Uterine Atony a/w Minor peripheral lacerations includes:

A

Local infiltration

Pudendal block

Residual regional analgesia

(Supplement with N20, opioids, or both)

108
Q

Anesthetic Management of Uterine Atony

Which corrective Uterine Atony procedures require GETA?

A

Bimanual massage

Manual extraction of retained placenta

Reversion of inverted uterus

Repair of major lacerations

109
Q

Obstetric Emergencies

The Full thickness separation of uterine wall and visceral peritoneum; associated with substantial bleeding and expulsion/protrusion of fetal &/or placenta into abdominal cavity is also know as:

A

Uterine Rupture

Rare but catastrophic complication

High incidence of maternal & fetal morbidity

Emergency C/S required

110
Q

Obstetric Emergencies

Separation of pre-existing scar tissue that does not disrupt overlying visceral peritoneum is known as:

A

Uterine Dehiscence

Fetus & placenta contained within uterine cavity

Seldom results in complications

C/S not necessarily warranted

111
Q

Obstetric Emergencies

What are Risk factors for Uterine Rupture?

A

Presence of uterine scar*

(most common)

Prior C/S

> vertical uterine incision

< low transverse uterine scar

Myomectomy

Labor induction (Oxytocin)

Abdominal trauma

Fetopelvic disproportion

Abnormal fetal presentation

Grand multiparity

Instrument assisted vaginal delivery

112
Q

Obstetric Emergencies

The most common risk factor for Uterine Rupture is the Presence of uterine scar which could be the result of:

A

Prior C/S

Myomectomy

113
Q

Obstetric Emergencies

Which type of uterine incision during C-S is most likely to potentally lead to Uterine rupture down the road?

A. vertical uterine incision

B. low transverse uterine scar

A

A. vertical uterine incision

B. low transverse uterine scar

114
Q

Obstetric Emergencies

What’s the clinical Presentation of Uterine Rupture?

A

Non-specific

Typically non-specific making diagnosis difficult => delay definitive therapy

Fetal bradycardia Abrupt loss of uterine contraction & pressure

Sudden onset abdominal pain

Recession presenting fetal part

Hemorrhage (vaginal bleeding)

Shock

115
Q

Obstetrical Management of Uterine Rupture

Uterine Rupture is a Life-threatening event for both fetus & mother - What Obstetrical interventions may be require for its management?

A

Emergency C/S

Post-partum laparotomy

Uterine repair

Hysterectomy

116
Q

Obstetrical Management of Uterine Rupture

When is Uterine repair Appropriate in the Obstetrical Management of Uterine Rupture? Does uterine repair eliminate the risk of ruputure in future pregnancy?

A

Uterine repair is appropriate for some cases with old transverse scar

However risk of rupture remains high in future pregnancy

117
Q

Obstetrical Management of Uterine Rupture

What’s the Preferred, definitive corrective/preventive procedure for most cases of Uterine Rupture?

A

Hysterectomy

118
Q

Anesthetic Management of Uterine Rupture

Why is GETA often required in the Anesthetic Management of Uterine Rupture?

A

Maternal hemodynamic instability

Fetal distress

Epidural anesthesia not achieved by time OB ready to make incision

(especially if you are trying to start the epidural right at the time of diagnosis and they didn’t have it already during labor)

High potential for hysterectomy → more painful and requires GETA

119
Q

Anesthetic Management of Uterine Rupture

When is it appropriate to use epidural in the Anesthetic Management of Uterine Rupture?

A

Epidural already in place for labor analgesia

Mother/fetus stable

The LA of choice is 3% 2-chloroprocaine

120
Q

Anesthetic Management of Uterine Rupture

Why is 3% 2-chloroprocaine the LA of choice for epidural in the Anesthetic Management of Uterine Rupture?

A

(Short acting?!)

121
Q

Anesthetic Management of Uterine Rupture

Anesthetic Management of Uterine Rupture requires being aware that Substantial blood loss expected - How is this blood loss replaced?

A

Significant Blood transfusions

Crystalloid infusions

122
Q

Obstetric Emergencies

A common cause of uterine rupture is d/t Women being allowed “trial of labor” after previous C/S - This process is also known as

A

VBAC

(Vaginal Birth After Cesarean)

123
Q

Vaginal Birth After Cesarean (VBAC)

What are ACOG recommendations for potential VBAC candidates?

A

One low-transverse C/S & no other contraindications to vaginal delivery

Two previous C/S may also be offered trial of labor

Counseled on risk of rupture ↑ with number of previous uterine incisions

More than Two previous C/S => NOT recommended

Potential complications of VBAC must be thoroughly discussed with patient and documented

124
Q

Vaginal Birth After Cesarean (VBAC)

Why must you be aware if there’s a VBAC trial of labor on your OB floor?

A

There is Increased risk for emergency C-section w/ VBAC

Prepare for emergency cesarean!!!

“…facilities and personnel, including an obstetrician, anesthetist, and operating room personnel, must be immediately available to perform an emergency cesarean delivery when VBAC is being attempted”

ACOG practice bulletin & ACOG/ASA joint statement

125
Q

Vaginal Birth After Cesarean (VBAC)

In the ACOG practice bulletin & ACOG/ASA joint statement

“facilities and personnel, including an obstetrician, anesthetist, and operating room personnel, must be immediately available to perform an emergency cesarean delivery when VBAC is being attempted”, the term immediately available is not defined - Many physicians and hospitals have interpreted this to mean wthat?

A

in-house presence!!!

The in-house presence of an obstetrician and anesthesia care provider are necessary whenever a patient attempting VBAC is in active labor

126
Q

Vaginal Birth After Cesarean (VBAC)

Why was Epidural Analgesia withheld in past in Vaginal Birth After Cesarean (VBAC)?

A

Concern that it would mask abdominal pain

(from uterine rupture?!)

127
Q

Vaginal Birth After Cesarean (VBAC)

What’s the Current practice regarding epidural analgesia in VBAC?

A

Preferred/ideal technique

Dilute LA + opioid solution commonly used

(Shown to not obscure pain a/w rupture)

Sudden loss of analgesia actually warning of uterine rupture

(notify OB)

Allows for quick conversion to surgical anesthesia

(provided hemodynamically stability evident)

128
Q

Umbilical Cord Prolapse

What % of deliveries are complicated by Umbilical Cord Prolapse?

A

0.2-0.6%

129
Q

Umbilical Cord Prolapse

Compression of the Umbilical Cord could lead to:

A

Fetal asphyxia

130
Q

Umbilical Cord Prolapse

What are predisposing risk factors for Umbilical Cord Prolapse?

A

Excessive cord length

Abnormal fetal presentation

Low birth weight

Grand parity (>5)

Multiple gestation

Artificial rupture of membrane

131
Q

Umbilical Cord Prolapse

Diagnosis/Clinical presentation of Umbilical Cord Prolapse:

A

SUDDEN fetal bradycardia with profound variable decelerations

132
Q

Umbilical Cord Prolapse

Management of Umbilical Cord Prolapse involves:

A

Immediate steep T-burg or knee-chest position

Manual pushing of presenting fetal part back up into pelvis until immediate C/S can be done

Nonviable fetus can be delivered vaginally

133
Q

Obstetric Emergencies

The Entry of amniotic fluid into maternal circulation through break in uteroplacental membrane is called:

A

Amniotic Fluid Embolism

aka

“Anaphylactoid Syndrome of Pregnancy”

134
Q

Amniotic Fluid Embolism

What’s the incidence and mortality of Amniotic Fluid Embolism?

A

Rare (1:20,000 deliveries) but FATAL

10% of all maternal deaths

Mortality exceeds 50% in 1st hour

135
Q

Amniotic Fluid Embolism

What are Risk Factors for Amniotic Fluid Embolism?

A

Severe preeclampsia

Risk is ↑ w/ tumultuous labor/multiparity

Placental abruption

Placenta previa

Uterine rupture

136
Q

Amniotic Fluid Embolism

What are the 3 major pathophysiologic manifestations of Amniotic Fluid Embolism?

A

Respiratory distress/Acute PE

DIC

Uterine Atony

137
Q

Amniotic Fluid Embolism

What’s the Clinical presentation of Amniotic Fluid Embolism?

A

SUDDEN tachypnea

Pulmonary Edema

Shock

CNS changes (seizure, coma)

Cyanosis

Generalized bleeding

138
Q

Amniotic Fluid Embolism

How is firm Diagnosis of Amniotic Fluid Embolism established?

A

Presence of fetal elements in maternal blood only

as evidenced by

Aspirate from CVP

Autopsy

139
Q

Amniotic Fluid Embolism

Which would generate High suspicion of Amniotic Fluid Embolism?

A

SUDDEN onset respiratory distress

Circulatory collapse

140
Q

Amniotic Fluid Embolism

Which are possible differential diagnosis for Amniotic Fluid Embolism?

A

Acute PE/VAE

Aspiration of gastric contents

Local anesthesia toxicity

Hepatic rupture

Cerebral hemorrhage with Preeclampsia

141
Q

Amniotic Fluid Embolism

Treatment for Amniotic Fluid Embolism includes:

A

Aggressive CPR

Stabilization

Supportive care

142
Q

Amniotic Fluid Embolism

Why are closed-chest compressions in a parturient w/ Amniotic Fluid Embolism considered marginal at best?

A

Aortocaval compression in supine impedes venous return

Increased O2 demands make hypoxia more likely even with adequate perfusion

Closed-chest compressions are less effective in LUD

143
Q

Amniotic Fluid Embolism

Which intervention improves maternal/fetal outcome if resuscitative measures for Amniotic Fluid Embolism are unsuccessful after 4mins?

A

Expeditious delivery

Emergent C/S should be carried out IMMEDIATELY

144
Q

Amniotic Fluid Embolism

Stabilization in the context of Amniotic Fluid Embolism involves:

A

Immediately secure airway/mechanical ventilation + PEEP

Fluids

Inotropic support

(full invasive monitoring)

Oxytocin, methylergonovine, or PGF2

Treat coagulopathy

(PLT, coagulation factors) based on labs

145
Q

Amniotic Fluid Embolism

Graphical representation of the Physiologic manifestations of Amniotic Fluid Embolism

A

Physiologic manifestations of Amniotic Fluid Embolism

8361 Exam 3 (14 decks)

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