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OB Exam 1 > Module 1: Maternal and Fetal Physiology > Flashcards

Module 1: Maternal and Fetal Physiology Flashcards

1
Q

James Young Simpson

A

Used diethyl ether to anesthetize a woman with a “deformed” pelvis for delivery

Famous Obstetrician

First forceps

Thought all pain, including labor pain was without physiologic value

He thought that pain only degraded and destroyed the experience of childbirth

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2
Q

Charles D. Meigs

A

Professor of Midwifery in Philadelphia

Thought labor pain had a purpose and drugs used to alleviate labor pain would alter contractions

Questioned the safety of anesthesia in laboring women

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3
Q

John Snow

A

became the first physician to restrict his practice to anesthesia

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4
Q

Paul Zweifel

A

Established the placental transfer of oxygen

Drugs given to the mother cross the placenta and affect the fetus

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5
Q

APGAR Scoring Sysem

A
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6
Q

how did the first anesthetics (ether) effect labor

A

depressed uterine contractions (ether) and abolished the pushing reflex, uterine atony, post partum hemorrhage

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7
Q

introduced regional anesthesia

A

Carl Koller used cocaine for eye surgery in 1884

“Carl Koller’s Cocaine”

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8
Q

years the first papers on the application of spinal, epidural, caudal, and pudendal blocks for OB appeared

A

1900-1930

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9
Q

latent stage dilation

A

0-3 cm

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10
Q

active stage cm

A

4-7 cm

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11
Q

transitional stage cm

A

8-10 cm

Latent: 0-3
Active: 4-7
Transitional: 8-10

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12
Q

first stage of labor

A
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13
Q

second stage of labor

A

stage of expulsion

begins with complete cervical dilation and ends with the delivery of the fetus

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14
Q

third stage

A

placental stage

begins immediately after fetus is born and ends when the placenta is delivered

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15
Q

fourth stage of labor

A

maternal hemostatic stabilization stage

after delivery of the placenta and continues for 1-4 hours after delivery

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16
Q

why so many changes during pregnancy?

A
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17
Q

a trigger of the primary respiratory center by increasing the sensitivity of the the respiratory center to CO2

A

progesterone

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18
Q

what does progesterone do to smooth muscle

A

alters smooth muscle tone of the airways and can act as a bronchodilator

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19
Q

progesterone systemic effects

A

Causes nasal congestion, edema and bleeding potential

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20
Q

prostaglandins stimulate ____________ in labor

A

smooth muscle

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21
Q

prostaglandin F2 alpha effects

A

increases airway resistance by bronchial smooth muscle constriction

“F U F2 for causing constriction”

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22
Q

prostaglandin E1 and E2 have a ____________ effect

A

bronchodilation

Bronchodilation:
Progesterone
PGE1
PGE2

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23
Q

changes to the back during pregnancy

A

Exaggerated lordosis of the lower back

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24
Q

relaxin

A

causes widening and ↑ mobility of sacroiliac joints and pubis

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25
Q

expected weight gain in pregnancy

A

about 12 kg

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26
Q

weight breakdown in pregnancy

A

Uterus 1 kg
Amniotic fluid 1 kg
Blood volume and interstitial fluid (about 1 kg each)
Fetus and placenta 4 kg
New fat and protein 4 kg

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27
Q

cardiovascular changes

A

Heart increases in size
(d/t increased blood volume, stretch & force of contraction)

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28
Q

heart sound changes in pregnancy

A

accentuation of the first heart sound (S1) and exaggerated splitting of the mitral and tricuspid components

4th heart sound in 16% (usually disappears by term)

grade II systolic ejection murmur

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29
Q

grade II systolic ejection murmur is heard at the ____________ and is attributed to ____________

A

heard at the left sternal border

attributed to cardiac enlargement from increased volume which causes dilation of tricuspid annulus and regurgitation)…benign flow murmur

(Grade II murmur: soft, heard in all positions; no thrill)

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30
Q

does the aortic annulus dilate from normal physiologic changes of pregnancy

A

NO

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31
Q

LV hypertrophy
-increase during pregnancy
-increase @ term

A

23% increase in mass from 1st to 3rd trimester

50% increase in mass at term

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32
Q

Normal cardiac exam and ECG findings in pregnancy (7)

A
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33
Q

when is a mom considered full stomach

A

18 weeks pregnant to 8 weeks postpartum

“18 - 8”

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34
Q

cardiac output to the body during pregnancy

A

Increased perfusion to the uterus, kidneys and extremities

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35
Q

uterine blood flow during pregnancy

A

Increases from a baseline of 50 mL/min (pre-pregnancy) to 700-900 mL/min at term

90% perfuses the intervillous space and 10% to myometrium

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36
Q

renal plasma flow during pregnancy

A

Increases by 80% between 16-26 weeks

Decreases to 50% above baseline at term

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37
Q

things that affect blood pressure in pregnancy

A

Position:
-highest is brachial in supine position
-lowest in lateral position

Age: increases with maternal age, nulliparous>multiparous

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38
Q

blood pressure decreases during ____________ and returns to baseline _____________

A

mid-pregnancy; around term

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39
Q

change in blood pressure is consistent with changes in ____________

A

SVR

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40
Q

why do moms have low SVR

A

Low-resistance uteroplacental vascular bed

maternal vasodilation d/t increased prostacyclin, estrogen, and progesterone

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41
Q

define supine hypotensive syndrome

A

Compression of the aorta and inferior vena cava by the gravid uterus

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42
Q

why do we ask “are they wedged” ?

A

to prevent supine hypotensive syndrome

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43
Q

when does supine hypotensive syndrome begin

A

Starts around 20 weeks but can happen earlier (13-16 weeks)

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44
Q

s/s supine hypotensive syndrome

A

tachycardia/bradycardia and hypotension

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45
Q

how should moms be placed to prevent supine hypotensive syndrome

A

left lateral

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46
Q

what causes supine hypotensive syndrome

A

uterus compresses the IVC and results in profound decrease in venous return

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47
Q

CO by the 3rd trimester is about ____________ higher than baseline

A

~50 %

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48
Q

in early first stage of labor, CO is about ____________ above predelivery

A

10%

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49
Q

in 2nd stage of labor, CO increases from pre-labor values by ____________

A

40%

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50
Q

immediate postpartum period CO is about ____________ above the prepregnancy baseline

A

125-150%

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51
Q

during contractions, ____________ mL of blood is autotransfused into central circulation

A

300-500 mL

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52
Q

postpartum ↑ in CO results from (4)

A

Relief of vena caval compression

Diminished lower extremity venous pressure

Sustained myometrial contraction

Reduction in maternal vascular capacitance

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53
Q

CO returns to pre-labor values within

A

24 hrs

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54
Q

CO returns to prepregnancy levels between

A

12-24 weeks

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55
Q

HR decreased to prepregnancy levels by

A

2 weeks postpartum

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56
Q

respiratory changes in pregnancy

A
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57
Q

Keep in mind which parameters increase/decrease/do not change

A

cross reference with this chart

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58
Q

OB Respiratory Volumes
-TLC
-FRC
-VC
-TV

A

Total lung capacity reduced 5%

FRC decreased 20%

VC unchanged

TV increased 40%

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59
Q

Ventilation & ABG:
Minute ventilation

A

increased by:
30% at 7th week
50% by term

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60
Q

Increase in MV due to

A

hormonal changes & ↑CO2 production at rest

(progesterone which is a respiratory stimulant)

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61
Q

Increased MV & CO2 production @ rest is the sum of…

A

metabolic rate of mom, fetus, placenta and uterus

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62
Q

an OB ABG will reflect…

A

hyperventilation/Primary respiratory alkalosis

w/ compensation: ↑ renal bicarb excretion

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63
Q

(increased/decreased) minute ventilation during pregnancy results in respiratory (alkalosis/acidosis)

A

increased MV = resp. alkalosis

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64
Q

There is a primary respiratory (alkalosis/acidosis). This is due to…. (2)

A

alkalosis

increased MV and lower CO2

(moving more air and exhaling more CO2)

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65
Q

Dyspnea while pregnant causes

A

↑ respiratory drive
↓ PaCO2
Enlarging uterus
Larger pulmonary blood volume
Anemia
Nasal congestion

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66
Q

Hypoxic ventilatory response is (decreased/increased) to ___ the normal level.

A

increased
2x

(……increase in estrogen and progesterone levels)

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67
Q

T/F
Dyspnea during pregnancy is rare and an immediate cause for concern.

A

False
Very common during pregnancy

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68
Q

O2 Hgb Curve
normal vs. fetal

A

Normal is 26.7
Fetal is 17-20

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69
Q

P50 Oxygen tension

A

tension at which hemoglobin is 50% saturated

(O2 Hgb Dissociation Curve)

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70
Q

Oxygen Hemoglobin Dissociation Curve:
Right shift causes ___.
Left shift causes ___.

A

Right: release O2 to tissues

Left: decreases O2 to tissues

Right = Release

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71
Q

A (R/L) shift on the O2 Hgb Curve reflects a higher affinity of Hgb for O2.

A

Left shift
(decreases O2 delivery to tissues so the Hgb is holding the O2)

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72
Q

MV changes in stages of labor

A

First stage: ↑70-140%
Second stage: ↑120-200%

compared to prepregnancy

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73
Q

T/F
You auscultate an extra heart sound in your pregnant patient that she didnt have before. This is an immediate cause for concern.

A

False
increased blood volume causes these murmurs

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74
Q

Pain, anxiety, & coached breathing will increase ___ & decrease ___.

A

increase MV
decrease PaCO2

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75
Q

Oxygen consumption increases during labor stages

A

first stage: 40%
second stage: 75%

d/t:
hyperventilation
contractions pushing/work of labor

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76
Q

blood lactate concentration is an index of ____ ____

A

anaerobic metabolism

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77
Q

In Labor, blood lactate will _____

A

increase

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78
Q

Plasma volume increases starts at ___ weeks & up to 50% by ___ weeks

A

6
34

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79
Q

Red blood cell volume increases ___% above pre-pregnancy by term

A

30

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80
Q

T/F
Pregnancy-related cardiac remodeling can worsen current cardiac conditions and be permanent.

A

True

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81
Q

Physiologic Anemia of Pregnancy:

A

expansion of plasma volume greater than the increase of red blood cell mass

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82
Q

Hemoglobin/Hematocrit concentration
prepreg & each trimester

A

nonpreg: 12-16 & 35-44%

1st: 11-14 & 31-41%

2nd: 10-15 & 30-39%

3rd: 9.5-15 & 28-40%

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83
Q

Increase in Blood Volume is positively correlated to…

A

size of the fetus in single births

(greater in multiple gestation)

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84
Q

Physiologic hypervolemia facilitates: (3)

A

Deliver nutrients to baby
Protect mom from hypotension
↓ risks a/w hemorrhage at delivery

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85
Q

Blood viscosity in OB

A

decreases (lower Hct)

creates low resistance to blood flow = patent uteroplacental vascular bed

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86
Q

Expansion of plasma volume helps to…

A

maintain BP

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87
Q

Maternal concentration of estrogen and progesterone is increased ___x

A

100

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88
Q

Estrogen & plasma volume

A

↑ plasma renin activity
↑ sodium absorption
↑ water retention

estrogen = bloating
story of our lives

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89
Q

Progesterone
Enhances ____ production

A

aldosterone

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90
Q

Plasma proteins during the trimesters

A

mostly decreases

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91
Q

T/F
Plasma Cholinesterase increases during pregnancy.

A

False

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92
Q

Colloid osmotic pressure (mm Hg) (increases/decreases) during pregnancy.

A

decreases

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93
Q

Coagulation in Pregnancy is associated with:

A

Clotting
fibrinolysis
enhanced platelet turnover

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94
Q

Platelet count during pregnancy

A

falls progressively during normal pregnancy but stays WNL
(100-150,000/mm3)

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95
Q

Most common causes of thrombocytopenia in pregnancy (3)

A
  • Gestational thrombocytopenia
  • Hypertensive disorders of pregnancy
  • Idiopathic thrombocytopenia
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96
Q

Coag factor changes

A

INCREASED:
I, VII, VIII, IX, X, XII

DECREASED:
XI & XIII + Antithrombin III

UNCHANGED:
II & V

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97
Q

PT and PTT changes

A

both shortened 20%

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98
Q

TEG will show:

A

HYPERCOAGULABLE

↓R & K values & lysis

↑ alpha angle & maximum amplitude (MA)

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99
Q

OB pts will show (higher/lower) fibrin degradation products

A

higher

(substances left behind when clots dissolve in the blood)

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100
Q

Protein S activity (increases/decreases)

A

decreases

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101
Q

2 questions will be from this slide!

A
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102
Q

not sure how well we need to know this

A
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103
Q

Blood loss
vaginal delivery vs C sxn

A

500-600 mL vs 1000 mL
(usually grossly underestimated)

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104
Q

T/F
Physiologic changes of pregnancy helps prepare mom for blood loss.

A

True!

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105
Q

Postpartum Coagulation changes:
@ delivery & PP day 1

A

Rapid ↓ in platelets, fibrinogen, factor VIII and plasminogen

↑ antifibrinolytic activity

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106
Q

⭐️
Coagulation profile returns to nonpregnant state by….

A

2 weeks postpartum

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107
Q

H&H changes after delivery

A

drops in first 3 PP days

increase gradually over the next 3 days due to reduction on plasma volume

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108
Q

Hormone changes

A

first tri: hCG peak from placenta but becomes least plentiful in 2nd & 3rd

estrogen can come from placenta and ovaries and is highest among the 3 in 2nd and 3rd trimester

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109
Q

Relaxin

A

peptide hormone
prod by corpus luteum & placenta

regulates hemodynamic & water metab during preg

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110
Q

Relaxin stimulates formation of ____, which….

A

endothelin
mediates vasodilation or renal arteries via NO synthesis

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111
Q

First trimester
The kidneys vaso(dilate/constrict) which ___ SVR.

A

dilate
drops

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112
Q

How does renal blood flow affects the uterus & ureters?

A

(kidneys vasodilate)
increased renal blood flow
increased renal size
compression of uterus & ureters

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113
Q

80% of OB pts get hydronephrosis d/t

A

ureters dilate
renal calculi

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114
Q

Why are preggos at risk for pyelonephritis?

A

urinary stasis in a dilated collecting system

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115
Q

Expected changes in Renal Markers

A

decreased:
-renal vascular resistance
-BUN
-CrtCl (at term)

increased:
-GFR
-renal blood/plasma flow
-CrtCl (until end of 1st Tri)
-glucose excretion

(think higher flow to kidneys)

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116
Q

Renal blood flow is 75% greater (vs nonpreg) by __ weeks gestation up to __ weeks, when a slight decrease occurs.

A

16
34

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117
Q

Posterior pituitary produces (2)

A

oxytocin and arginine vasopressin (AVP)

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118
Q

Oxytocin levels increase in pregnancy and peak at ___

A

term

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119
Q

Thyroid changes

A

gland enlarges 50-70%

↑ T3 & T4
(Concentrations of free T3 and T4 don’t change)

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120
Q

Gestational Diabetes Causes

A

late pregnancy:
hormones can block insulin
⬇️
insulin resistance

early pregnancy:
pancreatic B-cells (secrete insulin) hyperplasia:
↑ insulin secretion & sensitivity
⬇️
Gestational Diabetes!

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121
Q

T/F
Glucose metabolism allows shunting of glucose to the fetus

A

True
promotes fetal development

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122
Q

Liver and Gallbladder
Changes

A

Bile stasis + ↑secretion = risk gallbladder Dz

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123
Q

Why are preggers susceptible to gallbladder Dz?

A

Progesterone inhibits contractility of GI smooth muscle leading to gallbladder hypomotility

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124
Q

T/F
Gastric emptying is unaltered during pregnancy

A

True
can be slowed in labor

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125
Q

Nausea usually resolves around

A

week 16
(up to 3% can get hyperemesis gravidarum)

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126
Q

prevalence of GERD in OB

A

30-50%

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127
Q

Mechanical changes of pregnancy effects on stomach

A

stomach displaced upward:
↑ intragastric pressure
↓ esophageal sphincter tone

RESULT: reflux & N/V

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128
Q

Possible mechanism of N/V

A

mechanism isn’t clear

↑ hCG, estrogen & progesterone

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129
Q

Lumbar (lordosis/kyphosis) is seen.

A

lordosis

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130
Q

Mobility increases in ___ & ___ to prepare for delivery

A

sacroiliac and pubic joints

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131
Q

Meralgia Paresthetica

A

exaggerated lumbar lordosis stretches the lateral femoral cutaneous

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132
Q

During pregnancy, Ca requirements may ___.

A

increase

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133
Q

T/F
Pregnancy reflects an increased incidence of carpal tunnel syndrome

A

True

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134
Q

Sleep Issues

A

Hormones
insomnia and excessive sleepiness
Upper airway changes (snoring-esp pre-ecl.)

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135
Q

Pregnancy-induced sleep disorder

A

insomnia and excessive sleepiness

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136
Q

Snoring is more common in women with

A

preeclampsia

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137
Q

T/F
We can expect pregnant pts to have higher incidence of restless leg syndrome.

A

True

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138
Q

OB spinal changes (for LA administration)

A

decreased:
Epidural space volume
Spinal CSF
sensitivity to vasopressors (hypoTN)
SAB dose requirements

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139
Q

Epidural space volume is decreased due to

A

epidural vein engorgement + epidural fat

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140
Q

(OB/non-preg) patients usually require lower doses of neuraxial anesthetic.

A

OB
they are more sensitive to LAs

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141
Q

When giving a preggo neuraxial anesthesia, you inspect her ligaments. What do you find?

A

Ligaments more relaxed in the spine (Relaxin)

lumbar lordosis changes the Tuffier’s line

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142
Q

D/t pregnancy related changes, how should we position mom for her epidural/spinal?

A

Head down tilt in lateral position

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143
Q

Mom may need (higher/lower) doses of vasopressors.

A

higher
(Decreased sensitivity to vasopressors)

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144
Q

OB sensitivity to SAB vs epidural

A

SAB: ↓25% in theory

Epidural: unaltered or slightly decreased

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145
Q

More rapid onset and longer duration of action
A) epidural
B) spinal/SAB

A

B) spinal/SAB

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146
Q

Mom’s CSF pH is (higher/lower)

A

higher

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147
Q

Lower dose of hyperbaric locals (25%) associated with: (5)

A

Reduction in spinal CSF volume (distention of vertebral venous plexus)
Enhanced neural sensitivity to locals
Increased rostral spread in lateral position
Increased abdominal pressure
Thoracic kyphosis

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148
Q

⭐️
Changes in the airway

A

Vascular engorgement of airway (bleeding)
upper airway edema
increased secretions

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149
Q

⭐️
OBs need a (larger/smaller) ETT.

A

smaller (ie: 6.5)

150
Q

⭐️
Expected Mallampati

A

go from Mallampati 1 or 2 to a grade 4 by term

151
Q

⭐️
What can worsen mom’s mallampati?

A

prolonged labor
pregnancy-induced hypertension
fluids

152
Q

⭐️
Which hormone delays gastric emptying and increases risk of aspiration?

A

Progesterone

153
Q

⭐️
Changes in mom that makes intubation and masking more difficult (2)

A

Gravid uterus
big breasts

154
Q

⭐️
Why do OB pts desat so quickly?

A

FRC is decreased less than closing capacity
⬇️
higher O2 consumption

155
Q

⭐️
T/F
OB’s Denitrogenate slower.

A

False
faster due to elevated MV and decreased FRC

(moving more air + less volume sitting in lungs at rest)

156
Q

⭐️
T/F
Over-ventilating is a safe way to compensate for the OB pt’s tendency to desat fast.

A

False
She has a lower PaCO2 so don’t over-ventilate!

157
Q

⭐️
MAC requirements

A

decreases 40% (increased progesterone)

normal ~1 week postpartum

158
Q

⭐️
Rate of rise of alveolar versus inspired anesthetic concentration (FA/FI) “speed of induction”
in OB

A

INCREASED

Greater minute ventilation
Reduced FRC
Despite an increased CO

159
Q

⭐️
Pseudocholinesterase trends

A

↓24% before delivery
↓33% PP day 3

normal: 2-6 weeks PP

160
Q

⭐️
How does preggo’s AchE changes affect our NMB dose?

A

Reduced activity

-does not usually prolong suxx (probably d/t larger Vd)

-Aminosteroids: enhanced sensitivity

161
Q

Uteroplacental blood flow is responsible for

A

delivering oxygen and nutrients to the fetus

162
Q

Acute reduction of uterine blood flow can threaten

A

fetal viability

163
Q

(T/F) Acute reductions of uterine BF are responsible for preeclampsia, fetal growth restriction (IUGR) and possible cardiac disease later in life

A

FALSE

Chronic reductions of uterine blood flow cause these complications

164
Q

non-pregnant uterine blood flow is ______ml/min compared to ______ml/min at term

A

50-100 ml/min
700-900 ml/min

165
Q

Blood supply to the uterus is mainly from the

A

uterine arteries

166
Q

(T/F) uterine arteries arise bilaterally from the internal iliac artery and passes medially to the side of the uterus

A

True

167
Q

May be targeted during angiographic embolization procedures for TX of OB & gyn hemorrhage and TX of uterine fibroids

A

uterine artery

168
Q

Uterine blood flow represents ___% of CO at term (___% in early pregnancy)

A

12%
3.5%

169
Q

During gestation, trophoblastic invasion of the spiral arteries
results in

A

loss of smooth muscle and loss of contractile ability,
leading to vasodilation with decreased resistance and
increased blood flow.

170
Q

Suspected to be the source/cause of pre-eclampsia and high BP during pregnancy

A

Abnormal trophoblastic invasion

171
Q

Oxygenated maternal blood enters via the ____ arteries into the intervillous space

A

spiral

172
Q

Blood traveling toward the chorionic plate bathes the villi permitting the exchange of

A

oxygen, nutrients, and wastes between maternal
and fetal blood.

173
Q

Venous drainage of uterus occurs via

A

uterine veins
internal iliac veins
ovarian veins
inferior vena cava (on the right )
renal vein (on the left)

174
Q

Maternal blood returns to basal plate and drains into

A

collecting veins

175
Q

Alternately vasoconstricting or vasodilating in response to different stimuli.

A

autoregulation

176
Q

(T/F) Nonpregnant uterine circulation exhibits autoregulation

A

True

177
Q

is a dilated, low-resistance system with perfusion that is pressure dependent

A

Uteroplacental circulation

178
Q

Limited autoregulation during pregnancy will cause a decrease or increase in placental blood flow?

A

Decrease
*placental BF will decrease with decreases in maternal BP

179
Q

is directly proportional to uterine perfusion pressure

A

Uterine blood flow
(and therefore placental and fetal)

180
Q

Uterine perfusion pressure is the difference between

A

uterine arterial pressure
uterine venous pressure
and vascular resistance

181
Q

Can cause a decrease in maternal blood pressure:

A

Neuraxial anesthesia
General anesthesia
Laying supine with NO WEDGE

182
Q

Uterine blood flow is inversely proportional to

A

uterine artery vascular tone

183
Q

Lack of autoregulation makes blood flow proportional to

A

perfusion pressure

184
Q

Uterine vasculature is maximally dilated during

A

pregnancy

185
Q

Uterine vasculature is responsive to

A

vasoconstrictors

186
Q

Uterine blood flow equation

A

uterine blood flow is related to perfusion pressure (the difference between uterine arterial pressure and uterine venous pressure) and vascular resistance,

187
Q

Increases in uterine smooth muscle tone constricts uterine vessels (decreasing/increasing) flow

A

decreasing

188
Q

Fetus is dependent on the placenta for

A

respiratory gas exchange, nutrition and waste elimination

189
Q

Causes of Decreased Uterine Blood Flow

A

↓perfusion pressure due to ↓uterine arterial pressure
↓perfusion pressure due to ↑uterine venous pressure
↑uterine vascular resistance

190
Q

Decreases uterine arterial pressure

A

Supine position (aortocaval compression)
Hemorrhage and hypovolemia
Drug-induced hypotension
Hypotension during sympathetic block

191
Q

Increases uterine venous pressure

A

Vena caval compression
Uterine contractions
Drug-induced uterine tachysystole
Skeletal muscle hypertonus (seizures, Valsalva)

192
Q

What Increases Uterine Vascular Resistance?

A

Endogenous and exogenous vasoconstrictors

193
Q

Endogenous Vasoconstrictors

A

Catecholamines (stress can ↑plasma epinephrine and cause abnormal fetal heart rate patterns)
Vasopressin (in response to hypovolemia)

194
Q

Exogenous Vasoconstrictors

A

Epinephrine
Vasopressors (Neo>Ephedrine)
Local Anesthetics (in high concentrations)

Others: Hypertension, cocaine, medications

195
Q

Increase in vessel diameter and length

A

Vascular remodeling

196
Q

Vasodilatory response d/t endothelial and vascular smooth muscle

A

Changes in vascular reactivity

197
Q

Contributing factors that decrease vascular resistance

A

Vascular remodeling
Changes in vascular are activity
Development of dilated placental circulation
Steroid Hormones

198
Q

increases with ↑ in uterine BF (causes uterine vasodilation and therefore ↑UBF) and ↑nitric oxide

A

Estrogen

199
Q

helps regulate UBF by increasing plasma volume

A

plasma cortisol

200
Q

increases to help redistribute CO and increase UBF

A

Angiotensin II

201
Q

Sensitivity to vasoconstrictors is (reduced/increased) during pregnancy

A

Reduced

*may explain why relatively large doses of vasoconstrictors are often required to maintain BP
during spinal anesthesia for cesarean delivery

202
Q

(T/F) In pregnancy, there’s a reduction in response
to endogenous and exogenous vasoconstrictors, including
angiotensin II, epinephrine & norepinephrine

A

True

203
Q

Vasodilators that contribute to decreased vascular resistance

A

Prostacyclin
Nitric oxide: increased activity in uterine arteries during pregnancy

204
Q

fetal hemoglobin is different from adult hemoglobin (HbA) in that it _____

A

binds to oxygen with greater affinity than adult which increases the access to oxygen from mom

205
Q

Uterine vascular resistance in early pregnancy may be increased by

A

relaxin
*may have a role in modulating the effects of estrogen and progesterone

206
Q

The P50 for HbF is _____

A

lower than HbA (partial pressure of oxygen which 50% saturated, lower the value the greater the affinity)

207
Q

in Nueraxial Anesthesia, decreased UBF as a result of

A

Hypotension
Unintentional intravenous injection of local anesthetic and/or epinephrine
Absorbed local anesthetic (little effect)

208
Q

in Nueraxial Anesthesia, Increased UBF as a result of

A

Pain relief
Decreased sympathetic activity
Decreased maternal hyperventilation

209
Q

Fetal hemoglobin vs Maternal

A

Fetal hemoglobin (17 mg/dL) has a higher O2 affinity and lower partial pressure at which 50% saturated (P50: 18-20 mm Hg) than maternal Hb (P50: 26-27 m Hg)

210
Q

May increase plasma norepinephrine levels and decrease uterine blood flow in gravid ewes

A

Pain and stress of labor

211
Q

decreases uteroplacental blood flow

A

Sympathetic stimulation and catecholamine release due to pain or stress during labor

212
Q

Placenta is formed by

A

both maternal and fetal tissues and gets blood supply from each

213
Q

Oxygen dissociation curve is shifted ____ for fetal hemoglobin

A

left

moms curve will shift left

214
Q

Placental Anatomy

A

Placenta has projections of fetal tissue (villi) that are in the maternal vascular spaces (intervillous spaces)
Intervillous space in the placenta which the chorionic villa project and maternal blood circulates

215
Q

_____ is a small molecule that readily crosses the placenta by passive diffusion

A

oxygen

216
Q

What is the placental barrier function?

A

placenta allows different substances to cross from the maternal to fetal circulation and back

217
Q

transfer of oxygen depends on _____

A

the oxygen partial pressure gradient between maternal blood in the intervillous space and fetal blood in the umbilical arteries

218
Q

What is the hormonal function of the placenta?

A

placental production of estrogen, progesterone, human chronic gonadotropin, growth hormones, proteins; allows for the placental influence and control of the fetal environment

219
Q

Oxygen transfer to the fetus in enhanced by the ____

A

BOHR effect

220
Q

regulation of placental blood flow

A

maternal blood flow: spiral arteries and their ability to dilate 10x their normal diameter and lowers resistance to passage of blood through intervillous spaces; fetal blood flow

221
Q

At materno-fetal interface ____

A

maternal blood takes up CO2 and becomes acidotic and fetal alkalotic

222
Q

Is formed by both maternal and fetal tissues and gets blood supply from each

A

Placenta

223
Q

Right shift in oxyhemoglobin dissociation curve favors

A

O2 release to the fetus

224
Q

Fetus is dependent on the placenta for

A

respiratory gas exchange
nutrition
waste elimination

225
Q

DOUBLE BOHR EFFECT

A

At materno-fetal interface, maternal blood takes up CO2 and becomes acidotic and fetal alkalotic
Right shift in oxyhemoglobin dissociation curve (favors O2 release to the fetus)

Concurrently, fetal blood release CO2 and becomes more alkalotic
This leads to a Left shift in oxyhemoglobin curve (favors O2 uptake by the fetus)

226
Q

This picture depicts what?

A

The Double Bohr Effect

227
Q

Area in the placenta where chorionic villa project and maternal blood circulates

A

Intervillous space

228
Q

_____ means that the oxygen dissociation curves for the maternal and fetal hemoglobin move in opposite directions

A

the double bohr effect

229
Q

In the placenta, projections of fetal tissue (villi) are located in the

A

maternal vascular spaces (intervillous spaces)

230
Q

Carbon dioxide crosses the placenta ____

A

readily by passive diffusion

231
Q

placental vasculature has no _____

A

innervation by the SNS

232
Q

Fetus modulates fetoplacental perfusion by:

A

Endocrine effects of adrenomedullin

Via net efflux/influx of water regulated by fetal BP

Via local autoregulatory effects mediated by vasodilators (nitric oxide, acetylcholine)

233
Q

Transfer of CO2 from fetus to mother depends on

A

the partial pressure gradient for CO2 (fetal 40 versus 34 mm Hg maternal) between fetal blood in the umbilical arteries and maternal blood in intervillous space

234
Q

_____ help control fetoplacental circulation

A

Endothelium-derived relaxing factors (prostacyclin and nitric oxide)

235
Q

______ is 20x more diffusible than O2 and readily crosses the placenta

A

CO2

236
Q

_______ and ______ alter fetal blood flow (probably through vascular mediators)

A

Maternal hyperglycemia and hypoxia

237
Q

Rapid movement of CO2 from fetal capillary to maternal blood causes

A

a shift in equilibrium of carbonic anhydrase reaction (La CHATELIER’S PRINCIPLE) to produce more CO2 for diffusion

238
Q

Most drugs cross the placenta by this mechanism

A

Passive Transport (Simple Diffusion)

239
Q

CO2 transfer from fetus to mother is facilitated by

A

HALDANE EFFECT (increased production of deoxyhemoglobin in mom which has a higher affinity for CO2 than oxyhemoglobin)

240
Q

Transfer of drugs which passively diffuse from mother to fetus is governed by

A

Fick’s Law of Diffusion

241
Q

Maternal and fetal concentrations of a drug are influenced by:

A

Drug metabolism in the mother, placenta, and the fetus
Changes that occur during delivery (altered uteroplacental blood flow)

242
Q

Passive Transport (Simple Diffusion) depends on:

A

molecular weight, lipid solubility, degree of ionization, protein binding

243
Q

Some drugs are given deliberately to mom to treat fetal conditions such as:

A

steroids for fetal lung maturation and cardiac drugs for fetal arrhythmias

244
Q

Placenta allows different substances to cross from maternal to fetal circulation and back

A

Barrier Function

245
Q

Facilitated Diffusion includes:

A

cephalosporins and glucocorticoids

246
Q

Other drugs can have detrimental effects, with the greatest risk during ____

A

organogenesis or first trimester (direct effect or alter uteroplacental blood flow)

247
Q

Needs a carrier substance within the placenta to facilitate across it

A

facilitated diffusion

248
Q

Drug concentration gradient is determined by ____

A

concentration of free drug in maternal arterial blood, fetal circulation, and maternal and fetal placental blood flow

249
Q

Active Transport includes:

A

NE, dopamine

250
Q

Utilizes energy, usually ATP, to transport substances against a concentration or electrochemical gradient

A

active transport

251
Q

Maternal and fetal protein binding affects _____

A

the amount of free unbound drug on both sides of the placental barrier (high maternal protein binding deters drug transfer and high fetal drug binding promotes transfer

252
Q

Pinocytosis

A

Cell membrane invaginates around the macromolecule

253
Q

Factors affecting placental permeability:

A

Molecular weight
Lipid solubility
Ionization/electric charge
pH/pKa (fraction of drug that is non-ionized at physiologic pH)
Transporter protein
Protein binding

254
Q

direct mixing of blood-Rh sensitization

A

breaks

255
Q

factors affecting placental transfer of drug (maternal fetal)

A

picture

256
Q

Other Factors That Effect Maternal-Fetal Exchange:

A

Maternal and fetal blood flow
Placental binding
Placental metabolism
Diffusion capacity
Maternal and fetal plasma protein binding
Gestational age (placenta is more permeable in early pregnancy)
Lipid solubility, pH gradients between maternal and fetal environments for certain basic drugs (ION TRAPPING)
Certain disease states (Preeclampsia)

257
Q

Rate of Diffusion =

A

Diffusion coefficient x Surface area x (concentration gradient between mom and fetus)/Membrane Thickness

258
Q

Factors that INCREASE the maternal fetal placental transfer of drugs:

A

<1000 molecular weight
uncharged
higher proportion of un-ionized drug in maternal plasma
lipophilic
binding protein type = albumin (lower binding affinity)
absent placental efflux transporter proteins
high free (unbound) drug fraction

259
Q

Placental production of estrogen, progesterone, HGD, growth hormones and proteins.

A

Hormone Function of placenta

260
Q

Most important variables for transfer of drugs across the placenta are:

A

diffusion coefficient (drug characteristics) and the concentration gradient between maternal and fetal circulation

261
Q

Factors that DECREASE the maternal fetal placental transfer of drugs:

A

> 1000 molecular weight
charged
higher proportion of ionized drug in maternal plasma
hydrophilic
binding protein type = alpha 1 acid glycoprotein (higher binding affinity)
present placental efflux transporter proteins
low free (unbound) drug fraction

262
Q

Fetal acidosis can increase _______ which leads to ______

A

the concentration gradient, which leads to fetal ion trapping

263
Q

How is fetal pH related to maternal?

A

Fetal pH is .1-.15 lower than maternal pH

264
Q

Drugs That Readily Cross The Placenta:

A

Anticholinergics: atropine and scopolamine (tertiary amines)
Antihypertensives: Nitroprusside(cyanide), Nitroglycerine, Beta-adrenergic receptor antagonist
Benzodiazepines: Diazepam and Versed (highly lipid soluble)
Induction Agents: Propofol (lipid soluble), Ketamine, Etomidate, Thiopental
Inhalationals (very lipid soluble and low molecular wt)
Local Anesthetics
Opioids (Meperidine is 50% plasma-protein bound)
Vasopressor: Ephedrine
Neostigmine (quaternary ammonium but small enough to cross) ???

265
Q

____ are more ionized than in maternal blood and “ion trapping” may occur leading to fetal drug accumulation

A

basic drugs

266
Q

Drugs That DO NOT Readily Cross The Placenta

A

Anticholinergics: Glycopyrrolate
Anticoagulants: Heparin
Muscle Relaxants: Depolarizing and Nondepolarizing (large, poorly lipid soluble and highly ionized molecules)
Vasopressor: Phenylephrine
Anticholinesterase Agents: Neostigmine?, pyridostigmine, edrophonium
Sugammadex: low placental transfer rate due to molecule structure and wt

267
Q

LAs are ____ drugs

A

basic

268
Q

slide 104

A
269
Q

Fetal circulation differs from the adult in that it ____

A

bypasses the lungs

270
Q

is on baby’s side

A

Chorionic plate

271
Q

Transfer of Respiratory Gases

A
272
Q

Oxygen and carbon dioxide exchange occurs via

A

simple diffusion

273
Q

Fetus relies completely on the mother and the placenta for

A

basic metabolic needs
Nutrient delivery
Gas exchange
Acid-base balance
Electrolyte homeostasis

274
Q

higher maternal ____ favors diffusion to the fetus

A

PaO2

275
Q

One of the first functional organ systems in developing fetus

A

Fetal Cardiovascular System

276
Q

is fetal or maternal CO2 higher? what does this cause?

A

fetal; favoring diffusion back to the mother.

277
Q

Fetal CV system allows ____

A

blood to bypass the lungs and provide max perfusion to the placenta

278
Q

O2 transfer across the placenta depends on:

A

Membrane surface area
Oxygen partial pressure gradient between maternal and fetal blood
Affinity of maternal and fetal hemoglobin
Maternal and fetal blood flow

279
Q

_____ is the predominant factor controlling fetal oxygen transfer

A

Maternal delivery of blood (oxygen) to the uterus

280
Q

Fetal blood flow has 3 anatomic communications:

A

ductus venosus
foramen ovale
ductus arteriosus

281
Q

Oxygen Transfer to the Fetus

A

Dissolved oxygen diffuses across the villous membranes, then bound O2 is released by maternal hemoglobin in the intervillous space and diffuses across the placenta

282
Q

____ connects the umbilical vein with the inferior vena cava, bypassing the portal circulation and liver

A

ductus venosus

283
Q

Substances are transferred across the placenta by one of
several mechanisms

A

Transport Mechanisms

284
Q

after reaching the right atrium, oxygenated blood passes through this to the left ventricle before entering the aorta and systemic circulation (drives blood to the 2 organs with the highest O2 requirements..brain and heart)

A

foramen ovale

285
Q

Placental physiology involves

A

Barrier Function
Hormonal Function
Regulation of Placental Blood Flow (maternal & fetal)
Transport mechanisms

286
Q

fetal blood passes from the pulmonary artery into the descending aorta, which supplies the lower extremities and hypogastrics =

A

ductus ateriosus

287
Q

Allows for placental influence & control of fetal environment.

A

Hormonal function

288
Q

what does amniotic fluid do?

A

Facilitates fetal growth
Microgravity environment that cushions the fetus
Generation of defense against invading microbes

289
Q

(T/F) Placental vasculature is innervated by SNS

A

False
Has no innervation by SNS

290
Q

Formation and maintenance of amniotic fluid depends on:

A

Fetal maturation
Maternal hydration
Hormonal status
Unteroplacental perfusion

291
Q

Fetus modulates fetoplacental perfusion by

A

Endocrine effects of adrenomedullin
Via net efflux/influx of water regulated by fetal BP
Via local autoregulatory effects mediated by vasodilators (nitric oxide, acetylcholine)

292
Q

Between 10-20 weeks gestation the fluid increases from ___ to ____

A

about 25 mL to 400 mL

293
Q

Endothelium-derived relaxing factors that help control fetoplacental circulation

A

prostacyclin and nitric oxide

294
Q

Volume of amniotic fluid is a function of ___

A

production

295
Q

How do maternal hyperglycemia and hypoxia alter fetal blood flow?

A

Possibly through vascular mediators

296
Q

fetal urine

A

(600 to 1200 mL/day near term)

297
Q

Hypoxia-induced fetal placental vasoconstriction is mediated by decreases in

A

nitric oxide

298
Q

Respiratory tract secretions

A

(60 to 100 mL/kg fetal body wt/day)

299
Q

villi, placental layers and umbilical cord form during

A

embryology

300
Q

200-250 mL/kg fetal body wt/day =

A

Removal through fetal swallowing

301
Q

amniotic fluid consists of:

A

Urea and creatinine from fetal kidney urine production
Carbohydrates, proteins, lipids, electrolytes, hormones
Growth factors
And a bunch of other stuff

302
Q

wastes and carbon dioxide delivered from the baby via

A

umbilical arteries

303
Q
A
304
Q

oxygen, nutrients, and hormones delivered to the baby via

A

umbilical vein

305
Q
A
306
Q

uterine artery

A

PO2 = 96
PCO2 = 28
PH = 7.45
BE = -5

307
Q

development of placenta begins when

A

blastocyte evokes the decidual reaction in the maternal endometrium
and transforms into the basal plate

308
Q

uterine vein

A

PO2 = 33
PCO2 = 37
PH = 7.35
BE = -3

309
Q

Fetal bradycardia after regional maybe d/t rapid decrease in

A

circulating catecholamines (Combined SAB/EPIDURAL)

310
Q

umbilical vein

A

PO2 = 28
PCO2 = 35
PH = 7.37
BE = -4.50

311
Q

Phenylephrine

A

Careful after sympathetic blockade
Uterine arteriolar vasoconstrictor (must be careful!)

312
Q

umbilical arteries

A

PO2 = 15
PCO2 = 44
PH = 7.33
BE = -2.64

313
Q

maternal uterine tissue, protects embryo from being attacked by maternal immune cells and provides nutritional support for the developing embryo prior to placenta formation

A

Decidua

314
Q

Decreased P50

A

left shift
increased affinity
decreased temperature
decreased PCO2
decreased 2,3-DPG
increased pH

315
Q

fingerlike villi transport oxygen and nutrients between fetus and mother

A

Chorionic villi

316
Q

Increased P50

A

right shift
decreased affinity
increased temperature
increased PCO2
increased 2,3-DPG
decreased pH

317
Q

With vasopressors, most important factor is rapid correction of

A

hypotension (<100 systolic)

318
Q

Uteroplacental perfusion is proportionate to

A

blood pressure

319
Q

During GA, uteroplacental perfusion may be affected by

A

BPchanges
Sympathetic stimulation: response to intubation
Opioids: ↓stimulation of intubation but risk of neonate respiratory depression
Inhalational anesthetics and uterine tone (dose-dependent reduction- floppy uterus)

320
Q

endometrial veins and arteries

A

maternal circulation

321
Q

Fertilization, Implantation of a blastocyte and development of an embryonic yolk sac

A

embryology

322
Q

what happens during organogenesis?

A

placental-fetal unit can’t tolerate oxidative stress
so there is a state of relative hypoxia in the early development

323
Q

Basal plate anatomy contains spiral arteries (up to ____ to feed the placenta to be able to handle blood flow up to ___ mL/min to the fetus)

A

200
600 mL/min

324
Q

Inadequate spiral artery development can cause

A

relative ischemia
pre-eclampsia
fetal growth restriction - was called intrauterine growth restriction (IUGR)

325
Q

Maternal blood enters the placenta through the

A

basal plate endometrial arteries (spiral artery)

326
Q

spiral arteries in the placenta perfuse

A

intervillous spaces
and flows around the villi where exchange of oxygen and nutrients occurs with fetal blood

327
Q

Maternal blood traverses through

A

the placenta intervillous space
and drains back through venous orifices into the basal plate
then returns to the maternal systemic circulation via uterine veins

328
Q

Placental blood circulation has how many circulatory systems

A

Two separate circulatory systems for blood:
Maternal-placental(uteroplacental) blood circulation
Fetal-placental (fetoplacental) blood circulation

329
Q

Fetal or maternal blood circulation:
Allows Umbilical arteries to carry deoxygenated blood and nutrient-depleted fetal blood from the fetus to the villous core fetal vessels

A

Fetal

330
Q

Fetal or maternal blood circulation:
Starts with the blood flow into the intervillous space through decidual spiral arteries

A

maternal

331
Q

Fetal or maternal blood circulation:
After the exchange of oxygen and nutrients, the umbilical vein carries fresh oxygenated and nutrient-rich blood circulating back into circulation

A

fetal

332
Q

Fetal or maternal blood circulation:
Exchange of oxygen and nutrients as blood flows around terminal villi in the intervillous space

A

maternal

333
Q

Fetal or maternal blood circulation:
In-flowing arterial blood pushes deoxygenated blood into the endometrial and then uterine veins back into circulation

A

maternal

334
Q

MV (minute ventilation) is equal to…

A

Vt x RR

(tidal vol x resp rate)

335
Q

DPG
what is it?
what increases it?

A

in RBCs and controls how easily it releases O2 to tissues

primary response to lack of oxygen (anemia, cystic fibrosis, congenital heart disease, hyperthyroidism)

336
Q

RAAS activity

A

increases @ 4-6 week gestation

in response to dilated blood vessels (increased plasma volume)

337
Q

T/F
A larger fetus means greater increase in blood volume.

A

False
not always

338
Q

In pregnancy, the ____:____ ratio will decrease

A

albumin: globulin

339
Q

Your parturient’s hypoTN is not responding to IVF and pressors as desired. Due to decreased ____, you know that ___ should be used next.

A

albumin

340
Q

Expect mom to have a (high/low) platelet count d/t (2)

A

low

dilutional
increased platelet consumption

341
Q

thrombocytopenia is platelets < _____

A

150,000

342
Q

severe thrombocytopenia

A

<50,000

343
Q

Labs that suggest DIC (4)

A

prolonged PT, PTT
thrombocytopenia
low fibrinogen
elevated D-Dimer

344
Q

TEG
what it tests & what the results mean

A
345
Q

TEG
R value

A
346
Q

TEG
K value

A
347
Q

TEG
a angle

A
348
Q

TEG
Max amplitude (MA)

A
349
Q

TEG
LY-30

A
350
Q

Cortisol effect on uteroplacental blood flow

A

increases

351
Q

T/F
Dialysis patients have higher incidences of premature delivery.

A

True

352
Q

Best time in pregnancy to do elective surgery

A

2nd trimester

353
Q

Around 12-14 weeks, many moms have which surgery done?

A

cholecystectomy
(increased sludge from gallstone formation)

also seen:
appendicitis
pancreatitis

354
Q

T/F
Intragastric and intraesophageal pressure is higher in OB.

A

False

intragastric = higher
intraesophageal = lower

355
Q

Why do we see hemorrhoids in pregnancy?

A

-constipation
-elevated pressures in veins below enlarged uterus

356
Q

T/F
The liver enlarges during pregnancy.

A

False

357
Q

Meralgia paresthetica
(Bernhardt Roth syndrome; lateral femoral cutaneous nerve syndrome)

A

compression of the lateral femoral cutaneous nerve (LFCN) (exaggerated lumbar lordosis!)

pain, numbness, tingling, or a burning sensation in the outer thigh

358
Q

Joint issues & exercising after delivery

A

starts after delivery
finishes 3-6 months PP
(relaxin returning to normal)

Issues persisting >6 months PP usually permanent

359
Q

impaired memory

A

limited to third trimester
resolves

360
Q

Thought to cause RLG seen in pregnancy

A

iron deficiency anemia

361
Q

sleep time in pregnancy

A

1st trimester: longer sleep

3rd: shorter

362
Q

Place your spinal/epidural, below ___ and above ___.

A

below L1
above L5

363
Q

Neuraxial anesthesia affects mom (faster/slower)

A

faster

364
Q

Why use head down tilt in lateral position for neuraxials?

A

less likely to hit artery/vein

365
Q

3 most important modifiable factors in determining LA distribution

A

-baricity
-position before and after admin
-dose

366
Q

hypobaric LAs (2)

A

tetracaine 0.33%
lidocaine 0.5%

367
Q

hyperbaric LAs (4)

A

tertacaine 0.5
lido 5%
bupiv 0.5% in dextrose
bupiv 0.75% (for SAB)

368
Q

isobaric LA (2)

A

lido 2%
bupivicaine 0.2-0.5% in water

369
Q
A
370
Q

Factors Affecting Placental Transfer of Drug (Maternal to Fetal)

A

OB Exam 1 (13 decks)

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