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OB Final Exam > Module 8: Part 2 > Flashcards

Module 8: Part 2 Flashcards

24-46

1
Q

30-40% pregnant women have a fasting gastric volume of ___ ml and ___ acidity

A

volume > 25 ml
gastric fluid acidity < 2.5

Hi, Mendelson Syndrome, how are ya?

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2
Q

Bicitra
when to give?
how much to give?
why?

A

give 30 ml at least 20 min prior to induction

Non-particulate antacid; buffers gastric fluid and raise pH

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3
Q

H2 antagonist (Pepcid)
when to give?
moA?

A

within 30 minutes of induction
(max effect in 60-90 min)

prevents histamines potentiation of acid production

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4
Q

Pepcid (20 mg) inhibits gastric acid ____

A

secretion

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5
Q

Reglan
dose
moA

A

10 mg
increases LES & reduces gastric volume by increasing peristalsis

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6
Q

Aspiration Prophylaxis
medication options

A
  • Non-particulate antacid (Bicitra 30 ml)
  • H-2 antagonist (Pepcid 20 mg)
  • Reglan (10 mg)
  • Proton-Pump inhibitors
  • Zofran
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7
Q

Decreases in Maternal mortality from pulmonary aspiration are due to:
(5)

A
  • Increased use of NA (most important factor in decline)
  • Reglan, Pepcid and Bicitra, PPI’s
  • RSI and general anesthesia
  • Training, Communication
  • NPO policies
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8
Q

Nerve Lesions can be located…

A

Central
&
Peripheral

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9
Q

Nerve Lesions
Central vs. Peripheral

A

Central:
* Mostly bilateral
* weakness or paralysis from the site of the lesion distally
* autonomic dysfunction
* possible upper motor neuron signs (spasticity, bowel/bladder dysfxn)

Peripheral:
* Usually unilateral
* Weakness or paralysis limited to a single muscle or muscle group that the peripheral nerve innervates

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10
Q

(Central/Peripheral) Nerve Lesions are often a/w as spasticity and bowel/bladder dysfunction.

A

Central

Central:
* Mostly bilateral
* weakness or paralysis from the site of the lesion distally
* autonomic dysfunction
* possible upper motor neuron signs (spasticity, bowel/bladder dysfxn)

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11
Q

Obstetric injuries include compression & palsies of….

A

compression: lumbosacral trunk

palsies: obturator, femoral, lateral femoral cutaneous, sciatic and peroneal nerves

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12
Q

Peripheral Nerve Palsies
ocurrence

A

0.6 to 92 per 10,000 reported incidence

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13
Q

(Central/Peripheral) Nerve Palsies usually have obstetric causes instead of neuraxial

A

peripheral

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14
Q

Peripheral Nerve Palsies often occur from …

A

compression in the pelvis by the fetal head

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15
Q

Distal compression (positioning) is a/w (Central/Peripheral) Nerve Palsies

A

peripheral

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16
Q

Signs of Peripheral Nerve Palsies are often overlooked if…

A

using neuraxial

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17
Q

Peripheral Nerve Palsies
Risk factors

A
  • prolonged second stage of labor
  • difficult instrumental delivery
  • nulliparity
  • prolonged lithotomy position
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18
Q

Neurologic Complications in OB
Anesthesia vs. Childbirth

A

AKA what’s our fault vs what’s part of the process

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19
Q

Neurologic injuries of childbirth
Risk factors

A
  • Prolonged 2nd stage
  • Nulliparity
  • Epidural (stretch and compression injuries masked)
  • Positioning/ time in lithotomy
  • Operative delivery
  • Malpresentation, occiput posterior, fetal macrosomia

vs. risk for periph nerve palsy:
prolonged second stage
difficult instrument delivery
nulliparity
prolonged lithotomy

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20
Q

About 1% of neurlogical injuries is d/t

A

childbirth

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21
Q

Neurologic injuries of childbirth
how long do they last?
does it resolve?

A
  • Median duration 6-8 weeks
  • Symptoms resolve or improve in most
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22
Q

Intrinsic Birth Nerve Injuries
(2)

A

Lateral femoral cutaneous
(MOST common)

Femoral
(second)

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23
Q

T/F
Femoral nerve injuries are the most common nerve injury d/t intrinsic birth.

A

False
Lateral femoral cutaneous

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24
Q

(Intrinsic birth injuries)
Lateral femoral cutaneous
vs
Femoral

A

Lateral femoral cutaneous
* compression under inguinal ligament
* prolonged hip flexion or pressure at waist
* sensory deficit on anterolateral aspect of thigh
* purely sensory

Femoral
* C/S: retractor compression against pelvic wall
* partial hip flexion
* weak knee extension
* diminished patellar reflex
* hyperesthesia: anterior thigh and medial calf

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25
Q

Which nerve injury is purely sensory?

A

Lateral femoral cutaneous

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26
Q

All are true of Lateral femoral cutaneous nerve injury EXCEPT:
A) most common intrinsic birth nerve injury
B) purely sensory
C) can be caused by retractor compression against pelvic wall
D) caused by compression under inguinal ligament
E) prolonged hip flexion or pressure at waist

A

C) can be caused by retractor compression against pelvic wall

this applies to femoral nerve injury

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27
Q

T/F
Bicitra only works if you take all 30 ml.

A

True
suck it up, buttercup

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28
Q

Peripheral nerve injuries other than Lateral femoral cutaneous and Femoral are more r/t…

A
  • fetal head
  • forceps
  • retractors
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29
Q

Lumbosacral plexus injury

A

75% unilateral
25% bilateral

  • large fetus
  • malpresentation
  • small pelvis
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30
Q

Mom has a small pelvis. Wha nerve injury is she at risk for?

A

Lumbosacral plexus injury

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31
Q

Peripheral nerve injuries other than Lateral femoral cutaneous and Femoral

A
  • Lumbosacral plexus
  • Sciatic
  • Peroneal
  • Obturator
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32
Q

Mechanisms by which bladder function may be disturbed

A
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33
Q

SATA
Which can contribute to urinary incontinence and retention?
A) subarachnoid neurotoxicity
B) damage to lateral pelvis
C) uterine hypertrophy
D) cauda quina syndrome
E) trauma to conus

A

A) subarachnoid neurotoxicity
D) cauda quina syndrome
E) trauma to conus

damage to pelvic FLOOR
postpartum ATONY

34
Q

Neurologic Sequelae of Dural Puncture
(2)

A
  • Cranial nerve palsy (major CSF loss d/t dural puncture with a large needle)
  • Cranial subdural hematoma (↓ CSF pressure can rupture bridge meningeal veins)
35
Q

Cranial nerve palsy

A

major CSF loss if dural puncture with a large needle
* Cranial nerve VI, VII and VIII most common
* Abducens (VI) most vulnerable
* prompt epidural patch
* possible delayed recovery
* If cranial nerve VIII, tinnitus may become permanent

36
Q

Cranial subdural hematoma

A

Decreased CSF pressure can rupture bridge meningeal veins
* use blood patch
* if headache persists + altered consciousness, seizures or focal issues…. Immediate MRI and possible surgery

37
Q

T/F
Blood patch is used for Cranial subdural hematoma but not Cranial nerve palsy.

A

False
must use for both!

38
Q

Mechanism by which lesions of the central nervous system may arise in parturients

A
39
Q

Epidural Hematoma must be taken to surgery within..

A

6 hours

40
Q

If paresthesia with insertion of the needle for SAB/Epidural
….

A

Stop advancing and redirect the needle once paresthesia goes away

41
Q

Epidural cath can injure a nerve root if..

A

too rigid or inserted too far

42
Q

Spina bifida occulta

A

Imaging is preferred (practitioner dependent)
insert needle remote from site of malformation seen on imaging

43
Q

Patients with _____ are athigher risk of post dural puncture headache

A

Spina bifida occulta

44
Q

T/F
Neuraxial anesthesia is contraindicated in Spina bifida occulta

A

False
not if its occulta

45
Q

You’re doing a SAB. When injecting the local anesthetic, the patient complaints of pain. What can happen?

A

SAB Insertion Trauma

46
Q

T/F
CSF leak can cause arachnoiditis.

A

False
wrong injection or formulation

47
Q

Epidural Hematoma

A

-Blood collects in epidural space
-Rare in OB

Signs/symptoms:
* Acute back pain and radicular pain
* LE numbness and weakness
* Urinary and bowel dysfunction

48
Q

Epidural Hematoma
Risk factors

A
  • Difficult epidural
  • coagulopathy
  • spinal deformity
  • spinal tumor
49
Q

Epidural Hematoma
what do to if suspected

A
  • Immediate MRI & neuro consult
  • Minimize time to decompression
  • If >6 hours since s/s & diagnosis, often don’t recover
50
Q

Epidural abscess

A
  • 4-10 days postpartum
  • Severe Backache & local tenderness
  • Fever, headache, neck stiffness
  • Staph (most common)
  • WBC and ESR increased
  • Often mistaken for PDPH
51
Q

In contrast to epidural hematoma, symptoms of epidural abscess are more ___

A

insidious

develops slowly without noticing

52
Q

Often mistaken for PDPH

A

Epidural abscess

53
Q

Epidural abscess
intervention

A
  • Prompt MRI
  • Antibiotics, needle drainage
  • Surgical decompression
54
Q

Epidural Abcess vs Meningitis
usual causative organism

A

Epidural Abcess: Staphylococcus aureus

Meningitis: Streptococcus salivarius

55
Q

Procedures to Decrease the Risk for Infection after Neuraxial Anesthesia

A
56
Q

Not wearing a mask during NA can cause

A

meningitis

57
Q

T/F
Cauda Equina Syndrome and transient neurlogical syndrome are examples of a chemical injury.

A

True

58
Q

Cauda Equina Syndrome
what is it?
S/S?

A
  • Pressure or swelling of the lumbar nerves
  • Hematoma
  • Severe low back pain, motor weakness, sensory loss, bowel and bladder dysfunction
  • Needs immediate treatment
59
Q

Cauda Equina Syndrome
caused by…

A

Intrathecal injection of hyperbaric 5% lidocaine and sometimes other locals

60
Q

Transient neurologic syndrome
what is it?
S/S?

A

Pain: buttocks, back, thighs
Lithotomy position
Transient presentation

61
Q

Transient neurologic syndrome

A
  • Follows spinal and usually the use of lidocaine
  • Concentration, additives, and preservatives of LA
  • More with Lidocaine and mepivaine vs prilocaine and bupi
62
Q

Which LA is a/w a higher rate of Transient neurologic syndrome?
A) Prilocaine
B) Bupivicaine
C) Chloroprocaine
D) Tetracaine
E) Lidocaine

A

E) Lidocaine

  • Follows spinal and usually the use of lidocaine
  • More with Lidocaine and mepivaine vs prilocaine and bupi
63
Q

Arachnoiditis

A

Neurologic condition

-pain, stinging or burning in the back, perineum, legs, arms and feet
-worse case: paraplegia

64
Q

Arachnoiditis
-causes
-treatment

A

Injection of dyes, iodine

Exposure to chemicals that do damage to the arachnoid and meninges

Treatment: MRI, Pain meds, Steroids?

65
Q

Adhesive arachnoiditis

A

chemical origin from intrathecal injection of medications with preservatives, iodine

66
Q

We must deliver, If CPR is unsuccessful after this long

A

4 minutes

67
Q

Direct trauma and injury

A
  • Single root neuropathy
  • Radicular injuries often with pain or paresthesia
  • Damage to conus medullaris from SAB/CSE
  • Neurotoxicity from wrong drug or high concentration
  • Lidocaine 5%
68
Q

T/F
0.75% Bupivicaine is the LA most often a/w direct nerve trauma and injury.

A

False
Lidocaine 5%

69
Q

pinching of nerve

A

Radiculopathy

70
Q

Nerve injury prevention

A
  • Stop advancing needle if pain
  • Inject or place catheter if pain resolves
  • Remove & start again if it doesn’t resolve
  • use low lumbar site for SAB
  • Double check drugs & dose (EPI ?)
  • Aseptic technique
71
Q

Assessment of neurologic injury

A
  • Full details of labor & delivery course
  • Assess neurologic deficits & pain
  • Onset, progression
  • Sensory or motor?
  • Consider neuro consult
  • PT consult
  • Differential diagnosis (birth injury or neuraxial)
72
Q

When assessing neurologic injury, what’s the differential diagnosis?

A

birth injury or neuraxial

73
Q

Horner’s Syndrome can be seen after…

A

epidural insertion, brachial plexus block

usually due to the spread of local anesthesia

Stellate blocks; converting labor→c/s epi-d
bc high dose lido

74
Q

T/F
Horner’s Syndrome is benign and short-lived.

A

True
Usually self-limiting

75
Q

Horner’s Syndrome
most common presentation

A

Unilateral ptosis with miosis

76
Q

Horner’s Syndrome
s/s

A
  • Unilateral ptosis w/ miosis (most common)
  • Anhidrosis
  • enophthalmos
  • High sympathetic block but pt is breathing
77
Q

Differential Diagnosis of Postpartum Headache
Review table 30-1

its huge

A
  • Tension headache
  • Migraine
  • Musculoskeletal
  • Preeclampsia/eclampsia
  • Posterior reversible (leuko)encephalopathy syndrome (PRES)
  • Stroke
  • Subdural hematoma
  • Carotid artery dissection
  • Cerebral venous and sinus thrombosis
  • Brain tumor
  • Idiopathic intracranial HTN (pseudotumor cerebri/benign)
  • Spontaneous intracranial hypoTN
  • Pneumocephalus
  • Meningitis
  • Sinusitis
  • Caffeine withdrawal
  • Lactation headache
  • Ondansetron headache
  • Post–dural puncture headache
78
Q

Postpartum headaches occur during the first __ weeks after delivery and manifest as …

A

6
cephalic, neck or shoulder pain

79
Q

Differential Diagnosis
of Postpartum Headache

just what the ppt mentioned

A
  • Migraine
  • tension
  • musculoskeletal
  • pre-E
  • subarachnoid hemorrhage
  • brain tumor
  • subdural hemorrhage
  • meningitis
  • caffeine withdrawal
  • PDPH
80
Q

Postpartum Headache
primary vs. secondary

A

Primary headaches are 20x more common
in the first week postpartum

81
Q

most common postpartum complication of neuraxial anesthesia

A

Post-Dural puncture headaches (PDPH)

OB Final Exam (15 decks)

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