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OB Final Exam > Module 7: Part 2 > Flashcards

Module 7: Part 2 Flashcards

37-70

1
Q

Ultimate treatment for pre-eclampsia

A

deliver that baby!

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2
Q

T/F
BP can be normal in a pt with HELLP syndrome.

A

True

BP can be normal in 15% of the cases and may not have proteinuria

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3
Q

Vasa Previa

A
  • Velamentous insertion of the fetal vessels over the cervical os
  • fetal vessels transverse the fetal membranes ahead of presenting part
  • Fetal vessels are not protected
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4
Q

T/F
The source/cause of pre-eclampsia is the fetus.

A

False
placenta

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5
Q

What happens with ROM in Vasa Previa?

A

fetal vessels often tear
risk fetal distress & exsanguination of the fetus

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6
Q

T/F
Vasa Previa poses no threat to the mother.

A

True
thats you problem, baby

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7
Q

Blood volume of the fetus at term

A

80-100 mL/Kg

doesn’t take much blood loss to cause fetal death

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8
Q

Vasa Previa
occurrence

A

Rare
1 in 2500 to 5000 deliveries

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9
Q

Vasa previa
fetal mortality rates

A

50% to 60%
one of the highest fetal mortality rates of any complications of pregnancy

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10
Q

Vasa Previa
is a/w these pregnancy characteristics

A
  • multiple gestation (triplets)
  • placenta previa or low lying placenta in the second trimester
  • IVF
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11
Q

How is Vasa Previa confirmed/diagnosed?

A

U/S

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12
Q

Vasa Previa
risk of… (2)

A

preterm delivery
vessel rupture

Ruptured Vasa Previa is a major emergency

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13
Q

Vasa Previa
suggested delivery plan

A

Elective C/D 34-35 weeks

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14
Q

Postpartum Hemorrhage
definition

A

> 500 mL blood loss (vaginal)
1000 mL (cesarean)

ACOG: blood loss greater than 1000 ml or blood loss with S/S of hypovolemia within 24 hours of birth

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15
Q

The most common cause of maternal mortality worldwide

A

Postpartum Hemorrhage

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16
Q

Factors increasing the incidence of PPH

A

Increased rates of:
* uterine atony & abnormal placental implantation
* augmented labor
* obesity
* multiple gestation
* HTN disorders of pregnancy
* advanced maternal age

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17
Q

Which is not a cause of PPH?
1. Uterine atony
2. Placenta previa
3. Retained products of conception
4. Lacerations, tears, uterine rupture
5. Placenta Accreta
6. Coagulopathy
7. All are causes of PPH

A
  1. Placenta previa
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18
Q

Postpartum Hemorrhage (PPH)
is a clinical sign of….

A

an underlying condition

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19
Q

Primary PPH
vs.
Secondary PPH
(when do they occur?)

A

Primary: first 24 hours

Secondary: 24 hours - 6 weeks after delivery

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20
Q

T/F
Secondary PPH has a higher maternal mortality and morbidity than Primary PPH.

A

False
primary PPH
(highest maternal mortality and morbidity)

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21
Q

The 4Ts of PPH

A
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22
Q

What is the least common cause of PPH?
A) Boggy uterus
B) retained placenta
C) thrombin abnormality
D) uterine trauma

A

Thrombin (1%)

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23
Q

Uterine Atony causes ___% of PPH cases

A

80%
Most common cause of PPH

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24
Q

Uterine Atony
what is happening?

A

Uncontracted uterus with severe bleeding

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25
Q

Uterine Atony
Risk factors:

A
  • Rapid or protracted delivery
  • Tocolysis, Prolonged oxytocin
  • Overdistended uterus (multigestation, poly, macrosomia)
  • High parity
  • Chorioamnionitis
  • retained placenta
  • operative vaginal delivery
  • volatile agents used in GA
  • previous or current Molar pregnancy
  • HTN of pregnancy
  • diabetes
  • advanced maternal age
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26
Q

Which are risk factors for Uterine Atony?
SATA

Advanced maternal age
Maternal drug use
Macrosomia
Chorioamnionitis
Short term Oxytocin use
Maternal age <25

A

Advanced maternal age
Macrosomia
Chorioamnionitis

  • Rapid or protracted delivery
  • Tocolysis, Prolonged oxytocin
  • Overdistended uterus (multigestation, poly, macrosomia)
  • High parity
  • Chorioamnionitis
  • retained placenta
  • operative vaginal delivery
  • volatile agents used in GA
  • previous or current Molar pregnancy
  • HTN of pregnancy
  • diabetes
  • advanced maternal age
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27
Q

Most common diagnosis of PPH

A

Atonic uterus and Vaginal bleeding (most common)

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28
Q

T/F
Absence of bleeding rules out uterine atony.

A

False!
Absence of bleeding does not exclude uterine atony

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29
Q

An atonic uterus can contain how much blood?

A

can be more than 1 Liter

Absence of bleeding does not exclude uterine atony!

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30
Q

PPH expected changes in V/S
A) tachycardia & hypertension
B) bradycardia & hypertension
C) bradycardia & hypotension
D) tachycardia & hypotension
E) NOTA

A

D) tachycardia & hypotension

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31
Q

Advanced Trauma Life Support (ATLS) Classification of Shock

A

“Review ATLS Classification of Shock (Table 37.2)”

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32
Q

What is NOT expected of a pt in Class 3 ATLS shock?
A) 15-30% blood loss
B) decreased SBP
C) Decreased pulse pressure
D) RR > 35
E) More than one correct answer
F) NOTA

A

A) 15-30% blood loss

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33
Q

What is expected of a pt in Class 2 ATLS shock?
A) 10% blood loss
B) Normal SBP
C) Normal pulse pressure
D) RR > 35
E) More than one correct answer
F) NOTA

A

B) Normal SBP

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34
Q

Mom is having PPH. Her V/S are HR 145, SBP 90/72, RR 37. She is lethargic.
What ATLS class is she?

A

4

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35
Q

Mom is having PPH. Her V/S are HR 122, SBP 100/76, RR 32. She is anxious and confused.
What ATLS class is she?

A

3

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36
Q

When it comes to PPH, what’s normal?

A
  • Normal hemostatic mechanisms
  • Release of endogenous uterotonics (oxytocin and prostaglandins) to contract the uterus and constrict uterine vessels
  • Failure to do the above…….Uterine Atony
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37
Q
A
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38
Q

TXA is included in the algorithms for all of these EXCEPT?
A) uterine atony
B) retained products of conception
C) lacerations, tears
D) uterine rupture
E) placenta accreta
F) coagulopathy

A

E) placenta accreta
go straight to hysterectomy

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39
Q

Uterine atony & PPH
All of the following are appropriate interventions EXCEPT:
A) intrauterine balloon tamponade
B) uterine compression sutures
C) cell savage
D) hysterectomy
E) one dose of TXA
F) all are possible interventions

A

F) all are possible interventions

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40
Q

PPH d/t coagulalopathy
All of the following are appropriate interventions EXCEPT:
A) Fibrinogen concentrate
B) DDAVP
C) cell savage
D) hysterectomy
E) Uterine massage
F) all are possible interventions

A

E) Uterine massage
this is more for PPH d/t uterine atony

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41
Q

Pitocin SEs

A
  • vasodilation/hypotension
  • tachycardia
  • myocardial ischemia
  • coronary vasoconstriction
42
Q

endogenous vs exogenous oxytocin

A

exogenous form (Pitocin, Syntocinon):
* synthetic
* rapid onset
* short half-life

can be a/w serious SEs:
* vasodilation hypotension
* tachycardia
* coronary vasoconstriction
* myocardial ischemia
* even death
esp if hypovolemic/HD unstable

43
Q

Uterine massage
is an appropriate intervention for…

A

PPH d/t uterine atony

44
Q

PPH d/t uterine atony
Invasive measures
(unresponsive to medical therapy)

A
  • Tamponade techniques (balloon)
  • Arterial embolization
  • hysterectomy

Other Techniques
Sengstaken-Blakemore tube or Bakri Balloon
Uterine curettage
Uterine artery ligation
B-Lynch suture
Peripartum Hysterectomy

45
Q

Agents for Uterine atony

A
  • Oxytocin: 0.3-0.6 IU/min drip
  • Ergonovine: 0.2 mg IM
  • Methylprostaglandin: 0.25 mg IM
  • Misoprostol: 600-1000 mcg rectal, PO, SL

Top drawer refresh

46
Q

Arterial Embolization
Procedure

A
  • Interventional radiology
  • Cath femoral artery & advanced above the bifurcation of the aorta where the bleeding spot
  • identified by IV contrast
  • Feeder artery is catheterized and embolized with absorbable gelatin sponge
47
Q

Arterial Embolization usually reabsorbs in
A) 48 hours
B) 3 days
C) 4 hours
D) 10-12 days
E) 1-6 weeks

A

D) 10-12 days

48
Q

Vasa Previa is (maternal/fetal) emergency.

A

fetal

49
Q

Ruptured vasa previa
wyd?

A
  • true obstetric emergency
  • immediate Csxn
  • Neonatal resuscitation: address volume status
50
Q

Contraindications for Methylprostaglandin F2
(hemabate)

A
  • Reactive airway Dz (asthma)
  • Pulmonary HTN
  • Hypoxemia
51
Q

All of these are side effects of Oxytocin EXCEPT
A) Tachycardia
B) Hypotension
C) Nausea & vomiting
D) MI
E) Free water retention
F) All of these are side effects

A

C) Nausea & vomiting

52
Q

Ergonovine/Methylergonovine
Relative c/a

A

HTN
Pre-eclampsia

alpha stimulation → vasoconstriction

53
Q

Genital Trauma

A

Injuries of childbirth

lacerations/hematomas: perineum, vagina, cervix

54
Q

T/F
Hemorrhage from Genital Trauma may be immediate or delayed.

A

True

55
Q

Vaginal hematomas are a/w ___ & ___ type of delivery methods. Bleeding usually occurs from the….

A

forceps/vacuum extractions

uterine artery

56
Q

Vulvar hematoma
-where is the bleeding from?
-S/S

A

pudendal artery
extreme pain & blood loss

Pundendal Pain

57
Q

⭐️
SATA
Which is true about Retroperitoneal hematoma?
A) most dangerous hematoma
B) involves branches of the uterine artery
C) involves branches of the pudendal artery
D) involves branches of the hypogastric artery
E) more common in vaginal delivery
F) least common hematoma

A

A) most dangerous hematoma
D) involves branches of the hypogastric artery
F) least common hematoma

**more common with Csxn

58
Q

⭐️
Retroperitoneal hematoma

A
  • most dangerous
  • can be concealed
  • least common
  • involves branches of the hypogastric artery
  • usually during cesarean
59
Q

Anesthesia Management of Genital Trauma depends on
A) amount of blood loss
B) affected area
C) pain tolerance
D) difficulty of airway
E) NOTA

A

B) affected area

according to PPT

60
Q

Retained Placenta
is defined as

A

failure to deliver the placenta completely within 30 minutes after delivery of the infant

61
Q

T/F
Retained Placenta is a leading cause of BOTH primary and secondary PPH.

A

True

62
Q

Retained Placenta
Risk factors

A
  • history of retained placenta
  • preterm delivery
  • oxytocin use during labor
  • preeclampsia
  • nulliparity
63
Q

Retained Placenta
-Treatment
-Anesthesia options

A

Treatment: manual removal or curettage

Anesthesia = Uterine relaxation
-historically high dose volatiles
but….
-Nitroglycerin 50-100 mcg IV/SL spray (manual removal)

64
Q

T/F
Retained Placenta occurs in 3% of all deliveries.

A

False
Retained Placenta = 3% of vaginal deliveries

65
Q

T/F
Pitocin will cause vasoconstriction and raise BP.

A

False
Pitocin can cause vasodilation, hypotension, tachycardia

66
Q

Uterine Inversion

A

Turning inside-out of the uterus

67
Q

Uterine Inversion
What happens hemodynamically?

A
  • Severe hemorrhage
  • Hemodynamic instability
  • Worsened by vagal-mediated bradycardia
68
Q

Uterine Inversion
Risk factors

A
  • uterine atony
  • short umbilical cord
  • uterine anomalies
  • abnormally implanted placenta
  • overaggressive mgmt of third stage labor
69
Q

SATA
Uterine Inversion Risk factors include
A) nulliparity
B) uterine atony
C) short umbilical cord
D) HTN
E) uterine tachysystole
F) abnormally implanted placenta

A

B) uterine atony
C) short umbilical cord
F) abnormally implanted placenta

  • uterine atony
  • short umbilical cord
  • uterine anomalies
  • abnormally implanted placenta
  • overaggressive mgmt of third stage labor
70
Q

Mom finished delivery, but now uterine inversion has occurred. What do you do next?
A) Start Pitocin drip
B) Nitroglycerin IV (50-250 mcg)
C) Adminster Methergine 0.2 mg IM
D) Turn off any voltaile agents
E) Stop fluids

A

B) Nitroglycerin IV (50-250 mcg)

  • Stop uterotonic drugs
  • Tocolytics
  • Uterine relaxation, get monitors back on, fluids
  • Nitroglycerin IV (50-250 mcg) or Spray
  • Vasopressors
  • Inhalational anesthetics
  • Blood
71
Q

Management of Uterine Inversion

A

OBGYN:
-Immediately replace uterus
(even if placenta not delivered yet)
-Stop uterotonics
-Tocolytics

You:
* Uterine relaxation
* monitors
* fluids
* Nitroglycerin 50-250 mcg IV/SL Spray
* Pressors
* Inhalationals
* Blood

72
Q

Placenta Accreta
definition

A

a placenta wholely/partly invades the uterine wall
inseparable from it

73
Q

Placenta Accreta Spectrum

A

Accreta Vera: placenta’s basal plate adheres directly to myometrium without intervening decidual layer

Increta: chorionic villi invades myometrium

Percreta: invades serosa; sometimes adjacent organs (mostly bladder)

Placenta accreta is a general term for all of the above

74
Q

Placental Accreta Increased incidence due to…

A

increased Cesarean delivery rate

75
Q

This condition of pregnancy accounts for up to 50% of all cesarean hysterectomies

A

Placental Accreta

76
Q

Placental Accreta
risk factors

A
  • Previous C-sxn
  • previous uterine surgery
  • Previous placenta previa
77
Q

Placental Accreta
Diagnosis

A
  • Ultrasound
  • Difficult separation of placenta during delivery!
  • Laparotomy (definitive)
78
Q

T/F
The definitive way to diagnose Placenta Accreta is by ultrasound.

A

False
laparotomy

U/S can be used to diagnose but its not definitive

79
Q

Placenta Accreta risk increases as the number of ____ increases.

A

Cesarean deliveries

80
Q

Placenta Accreta
Mgmt per ACOG

A
  • On hand: Blood products, coag factors, cell saver
  • Tell patient possible hysterectomy may be safer
  • Planned delivery
  • Planned preterm Csxn & hysterectomy with placenta left in situ (↓hemorrhage potential d/t attempted removal)
  • Prophylactic ureteral stents
  • Prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA) to reduce blood loss during the surgery
  • Prophylactic internal iliac artery balloon (questionable)
81
Q

Placenta Accreta
ACOG suggests planned preterm cesarean delivery & hysterectomy with placenta left in situ to decrease….

A

hemorrhage potential due to attempted removal

82
Q

Placenta Accreta
Anesthetic Management

A
  • Regional or General
  • (sometimes preplanned)
  • If epidural → GA: epidural may ↓ VA needs
  • Multiple IVs; A-line (?)
  • Blood, coag factors, rapid insfuser, blood warmer

Its gon’ be bloody

83
Q

Responding to Hemorrhage
delays are likely d/t…

A
  • Accurate assessment of blood loss
  • Diagnosing maternal hypovolemia & shock
  • Aggressive monitoring/treatment of coagulopathy
  • Poor team coordination
84
Q

T/F
Delays in diagnosis and treatment doesn’t affect the severity of hemorrhage.

A

False
increases severity

85
Q

T/F
The speed with which coagulopathy develops is very fast.

A

True

86
Q

Maternal Early Warning Criteria

A

not specific to hemorrhage, but it used to help detect

87
Q

Modified Early Obstetric Warning System (MEOWS)

A

Contact MD for early intervention if 2 yellow or 1 red occurs

the book doesnt include this table, was on ppt only

88
Q

ATLS Classification of Shock
How much blood is lost in each class?

A

1: 900 ml (~15%)
2: 1200-1500 ml (up to 30%)
3: 1800-2100 ml (up to 40%)
4: >2400 ml (>40%)

slightly different than 37.2 in textbook
percentages approximated between the 2 tables

89
Q

Normal Blood Profile for OB

A

40% higher plasma vol
15-25% higher red cell mass
dilutional anemia

increased:
* Factor VII (proconvertin)
* Factor VIII (antihemophilic factor)
* Factor X (Stuart-Prower factor)
* Fibrinogen

90
Q

The Rh System

A

classification system for blood that depends on the presence or absence of the Rh antigen/factor on RBCs

91
Q

How many Rh surface antigens are there?

A
  • 46 Rhesus group red cell surface antigens
  • 6 common antigens
92
Q

You are Rh-negative if you….

A

do not have the “D” antigen

have the “D” antigen = Rh-Positive

93
Q

Prevelance of Rh+ amongst white & black population

A

85% white population
92% black population

94
Q

T/F
Rh negative patients have antibodies against the D antigen.

A

False
they do NOT

95
Q

What happens if we give an Rh(-) mom Rh(+) blood?

A

First exposure: nothing happens but immune system will respond to foreign Rh antigen by producing anti-Rh antibodies

Do it again: attack the RBC →hemolysis

96
Q

T/F
It takes more than one exposure to Rh(+) blood for an Rh(-) person to develop antibodies.

A

False

First exposure: nothing happens but immune system will respond to foreign Rh antigen by producing anti-Rh antibodies

97
Q

RhoGAM

A

Rh(-) mom/Rh(+) baby

  • Sterile solution w/ antibodies to Rh factor (derived from plasma)
  • give IM to mom
  • antibodies circulate and protect mom against Rh-positive RBC from fetus
98
Q

RhoGAM should be given to…
A) Rh negative moms with Rh negative baby
B) Rh positive moms with Rh negative baby
C) Rh negative moms with Rh positive baby
D) Rh positive moms with Rh positive baby

A

C) Rh negative moms with Rh positive baby

mom does not have the antigen, so her immune system will freak tf out when they detect baby’s foreign D antigen = hemolysis

99
Q

What electrolyte abnormalities do we see with tranfusion therapy?

A
  • acidosis
  • hyperkalemia
  • hypothermia
  • hypocalcemia
100
Q

What causes the hypocalcemia r/t blood tranfusion?

A

anticoagulant used contains citrate, which binds ionized calcium

Citrate rapidly metabolized in the liver but
* hypothermic
* liver disease
* rapid infusion
may accumulate = ↓ ionized calcium

101
Q

Blood Conservation Techniques

A

autologous blood transfusion: avoids some transfusion adverse events

intraoperative blood salvage: blood lost in surgery is scavenged; centrifugation, washed, & filtered; back to patient

OB Final Exam (15 decks)

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