Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

OB Final Exam > Module 9: Part 2 (23-45) > Flashcards

Module 9: Part 2 (23-45) Flashcards

1
Q

Challenges when diagnosing
AFE

(amniotic fluid embolism)

A
  • difficult
  • no universal definition
  • made retrospectively
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Most severe reaction to protamine sulfate

A
  1. Anaphylaxis
  2. Vasodilation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What do we give if hypotension and vasodilation from protamine sulfate persists?

A

methylene blue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How does AFE affect CV/pulmonary system

A
  • ↑↑↑ pulmonary pressures
  • RV pressures increase until RV fails
  • LV fails = hypoTN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

T/F
A histologic sample of fetal squamous cells, vernix, lanugo, and trophoblasts obtained from the mother can be used to diagnose AFE.

A

False
NOT diagnostic
can be found in mom’s lungs even if she doesn’t have AFE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Atypical case of AFE will show just these 2 S/S

A
  • acute respiratory failure
  • hypoTN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

T/F
DIC can be the presenting feature for AFE.

A

True
but sometimes absent; like with atypical AFE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

DIC causes hemorrhage in over ____% of patients with AFE

A

80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

The most common manifestations of DIC
-if she has not delivered
-if she has delivered

A

not delivered: bleeding from IV sites

delivered: bleeding from uterus or C/S incision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Prolonged HTN will give what ABG result?

A

metabolic acidosis

(also seen if cardiac arrest)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

AFE CXR will show

A

dense B/L infiltrates (pulmonary edema & ARDS)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

AFE
echo will show…

A
  • increased pulmonary pressures
  • reduced LV EF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

AFE will cause release of catecholamines before delivery. What does this cause?

A
  • decreased uteroplacental perfusion
  • fetal hypoxemia
  • fetal acidosis
  • no baseline FHR variability; late decels; terminal bradycardia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Management of
AFE

A

Initial strat: cardiac support maneuvers

  • ETT 100% FiO2
  • Large bore IVs, A-line, PA catheter
  • Pressors: DA, Dobutamine, NE
  • (remember it’s a preload and CO problem)
  • Rapid fluids 500ml+ of crystalloid
  • LUD
  • Prepare for DIC
  • consider massive transfusion protocol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

If AFE was d/t anaphylaxis, you should choose ___ as your vasopressor.
(assuming the fluids did not provide HD stability)

A

Epi

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Drug of choice for post-anesthesia hypotension

A

ephedrine
phenlephrine also OK

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

ECMO for AFE

A

use wisely
ECMO requires anticoagulation
AFE often leads to DIC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

In AFE, expedite delivery if…(2)

A

fetal distress or cardiac arrest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

AFE
A-OK Treatment

A
  • Atropine (.2-1 mg IV) + Zofran (8 mg IV) can block serotonin & vagal stimulation
  • Ketorolac (15-30 mg IV): Blocks cause of coagulopathy by inhibiting thromboxane
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

T/F
A-OK treatment is not evidence-based and should not be the first like treatment for AFE.

A

True!

  • Atropine (.2-1 mg IV) + Zofran (8 mg IV): blocks serotonin & vagal stimulation
  • Ketorolac (15-30 mg IV): inhibits thromboxane
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

⭐️
In AFE, intact neonatal survival is related to…

A

time interval from the onset of maternal compromise to delivery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Responsible for 50% of deaths that occur within 1 hour of AFE onset.

A

profound hypoxia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

85% of AFE pts die d/t..

A

cardiogenic shock
cardiac arrest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

⭐️
4 minutes of unsuccesful CPR has passed. What do you do?

A
  • decide if delivering or not
  • baby must be out by the fifth minute
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

⭐️
In the event of cardiopulmonary arrest, the American Heart Association recommends to deliver within ____ to increase the probability of
good outcomes for both neonate AND mother.

A

5 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Venous thromboembolic events (VTE) in pregnancy refer to..

A

deep vein thrombosis
(DVT)
&
pulmonary thromboembolism (PTE)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

T/F
Pregnancy and the post partum period are well established risk factors for VTE.

A

TRUE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

How many VTE cases are d/t: DVT?
PE?

A

DVT: 75-80%
PE: 20-25%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

When is VTE risk highest?

A

immediately postpartum & first week
declines thereafter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

There is a ____ increase in the odds of thromboembolic event during
pregnancy and ___ greater odds in the postpartum period than in non-pregnant patients.

A

during preg: 5x
post-partum: 60x

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

T/F
VTE risk is elevated in all trimesters of pregnancy, but highest in PP period.

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

⭐️
The most important individual risk factor for VTE in pregnancy

A

1: history of

thrombosis
#2: thrombophilia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

T/F
Most parturients do not need thromboprophylaxis.

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

All known thrombophilias increase VTE risk, but greatest risk is with…

A

homozygous factor V Leiden mutation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Less prominent risk factors for VTE

A

1: history of

  • advanced age
  • race/ethnicity
  • obesity
  • HTN
  • smoking

thrombosis
#2: thrombophilia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Know this chart

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

most important modifiable risk factors for VTE

A

Antenatal immobilization and obesity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

T/F
Unplanned C/S doubles risk for post-partum VTE, but planned C/S holds the similar VTE risk to vaginal delivery.

A

False
elective C/S doubles PP VTE risk; even greater increase if unplanned C/S

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

T/F
Mom has lost over 1 L of blood and now has a temp of 38.4C. You can rule out VTE.

A

False!
Postpartum hemorrhage 1L and over & Postpartum infection are risk factors for PP VTE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

⭐️
Virchow’s triad

A

3 factors that contribute to ↑ risk for thromboembolism
1. Venous stasis
2. Vascular damage
3. Hypercoagulability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Which of the factors of Virchow’s triad are present during pregnancy?

A

all 3!
1. Venous stasis
2. Vascular damage
3. Hypercoagulability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

How does each Virchow Triad factor relate to pregnancy?

A
  • Venous stasis – venocaval compression &
    ↓ mobility later in pregnancy
  • Vascular damage – endometrial trauma when placenta separates from uterine wall = accelerates coag cascade
  • Hypercoagulability – relatively hypercoagulable state d/t ↑clotting factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

PTE Prognosis
depends on…
(3)

pulmonary thromboembolism

A
  • Size, number, location of emboli
  • Concurrent cardiopulmonary function
  • Rate of fragmentation and lysis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Where do PEs come from?

A

DVTs from large leg veins or pelvis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Death from PE is usually d/t

A

RV failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

PE
S/S

A
  • dyspnea
  • pleutiric hest pain
  • cough
  • sweating

(“in this order”)

Also:
Palpitations, anxiety, Cyanosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

PE
Pathophysiology

A
  1. Clot’s platelets release serotonin, adenosine diphosphate & thrombin = vasoconstriction & bronchoconstriction
  2. Large V/Q mismatch
  3. Hypoxic pulmonary vasoconstriction exacerbates pulmonary HTN initiated by mechanical & humoral factors.
  4. Intracardiac shunting if elevated RV pressure forces blood across a probe-patent foramen ovale.
  5. ↑ RV pressure = dilation
  6. Increased wall tension & O2 demand
  7. left shift of the interventricular septum
  8. LV compression + ↓ preload impairs LV function, CO & coronary perfusion
  9. Eventual ischemia & cardiopulmonary failure.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

PE
definition

A

Clot occludes the pulmonary vasculature

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

PE
small vs large clots

A

Smaller: cardiopulmonary failure by triggering pulmonary vasospasm & secondary pulmonary edema

Massive: can precipitate cardiopulmonary failure/arrest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

How does hypoxia affect the pulmonary circuit?

A
  • Causes pulmonary vasoconstriction exacerbates pulmonary HTN initiated by mechanical & humoral factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

T/F
PE can present with a cough without hemoptysis.

A

True
cough with or without hemoptysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

T/F
The SOB seen with PE can mimic pregnancy.

A

True

53
Q

T/F
Normal oxygenation parameters do not rule out PE, but abnormal ones should raise alarm.

A

True

54
Q

PE
physical exam
EKG

A
  • Tachypnea, tachycardia
  • Crackles, decreased breath sounds
  • RV failure: Split S2, JVD
  • EKG: signs of RV strain (right-axis shift, ST abnormalities, T wave inversion, SVT)
55
Q

An EKG suggestive of PE would show:
A) Left axis shift
B) Inverted T wave with normal ST
C) Normal T wave with ST elevation
D) SVT
E) More than one correct answer

A

D) SVT

EKG: signs of RV strain
* right-axis shift
* ST abnormalities
* T wave inversion
* SVT

56
Q

PE Diagnosis alogrithm

A
57
Q

T/F
DVT Signs and symptoms are highly specific.

A

False
nonspecific and mimic normal
symptoms of pregnancy

58
Q

DVT S/S including …. mimic normal pregnancy

A

lower leg pain and edema

59
Q

Most DVTs (__%) occur in the ___

A

left leg (88%)

60
Q

Likely vein/location for DVT in preg vs non-preg

A

preg: proximal iliac or femoral
veins or both

non-preg: distal calf vessels

61
Q

T/F
DVT presenation in pregnant patients is comparable to non-pregnant patients.

A

True

62
Q

3 things that should alert us of DVT

A
  • increased occurence of LLE thrombosis
  • increased occurence of pelvic vein thrombosis
  • overlapping symptoms with pregnancy (swelling, buttock/flank pain, leg swelling)
63
Q

T/F
The ACOG recommends doppler ultrasound of distal veins as the initial diagnostic test for DVT.

A

False
compression U/S of proximal veins

CUS: compression ultrasound

64
Q

Is a D-Dimer useful to detect DVT in pregnant pts? Why?

A

high sensitivity & high negative predictive
value
BUT
not useful because D-dimer levels are elevated in pregnancy

65
Q

T/F
A positive D-Dimer confirms a DVT in a parturient.

A

False

66
Q

T/F
Unfractionated heparin (UFH) is preferred over low-molecular weight heparin
(LMWH)(Lovenox).

A

False
LMWH is drug of choice

67
Q

Warfarin in pregnancy

A

usually avoided along with other direct acting anticoagulants

68
Q

UFH vs LMWH
Which should we use during labor and delivery? Why?

A

UFH
we can clear it within 4 hours

LMWH heparin usually preferred but we switch to UFH during L&D

69
Q

If diagnosed with VTE during pregnancy, how long is anticoagulant therapy?

A
  • at least 3 months
  • remainder of pregnancy and AT LEAST 6 weeks post partum

if diagnosed with VTE in PP period, treat for at least 3 months

70
Q

T/F
All women with new-onset thromboembolic event in pregnancy should be therapeutically anticoagulated.

A

TRUE

71
Q

When to anticoagulate during pregnancy
through postpartum

A

history of thrombosis
certain high-risk populations:
- acquired/inherited thrombophilia
- mechanical heart valve

72
Q

The exact dose and regimen for anticoagulation

A

controversial and differs among providers

73
Q

Two major classes of anticoagulants used

A
  • unfractionated heparin (UFH)
  • low-molecular weight heparin (LMWH)
74
Q

Pregnancy can change volume of distribution, clearance, bioavailability, and metabolism of drugs. How?

A

Increased volume of distribution and clearance a/w pregnancy
⬇️
decreased peak effect & lower plasma concentrations

75
Q

T/F
The decreased doA and aPTT response of UFH is due to normal physiologic changes of pregnancy.

A

True!

76
Q

LMWH response in pregnant patients

A

DECREASED:
* peak antifactorXa level
* duration
* total exposure to drug over time

UFH: decreased duration and aPTT response

77
Q

When using LMWH at therapuetic doses, use ____ levels to guide dosing.

A

antifactorXa
desired peak: 0.6-1
measured 4H after injection

78
Q

T/F
Renal failure does not require dose adjustment for LMWH.

A

False

79
Q

ACOG & American College of Chest Physicians recommend ___ instead of ___ for prophylactic & therapeutic anticoagulation in pregnant patients.

A

LMWH instead of UFH

UFH good for L&D tho

80
Q

LMWH vs UFH

A

LMWH:
* enhanced ratio of antithrombotic (antifactor Xa) to anticoagulant (anti-factor IIa) activity
* does not affect the aPTT

81
Q

T/F
Pharmacokinetics of LMWH are altered during pregnancy.

A

True

82
Q

Unfractionated Heparin (UFH)
moA

A
  • Binds to antithrombin III
  • potentiates inactivation of other coagulation factors including thrombin (factor IIa)
83
Q

When to draw aPTT for UFH? Whats the goal?

A
  • every 6 hours
  • adjusted to 1.5-2.5x the normal range
84
Q

UFH dosing

A
  • SQ 2x daily of 10K units or greater
  • with a PTT monitoring for therapeutic dosing
85
Q

Consider transitioning from LMWH to UFH at…

A

36
weeks

86
Q

Anticoagulation
Timing Neuraxial

A

SQ UFH:
-prophylactic: 4-6H or assess coags
-Therapeutic: 24H & verify coag status
-Restart: 1H after NA or d/c epidural

IV UFH: d/c 4-6H before NA/delivery

LMWH:
-Prophylactic: 12H (Lovenox 40 mg SQ QD)
-Therapeutic: 24H (Lovenox 1 mg/kg Q12H)
Restart:
-Prophylactic: 12H NA; 4H d/c epidural
-Therapeutic: 24H NA; 4 H d/c epidural

87
Q

Aspirin for thromboembolism prophylaxis should be stopped…

A

35-36 weeks

88
Q

For patients treated with LMWH or UFH > 4 days, a _____ should be assessed before initiation of neuraxial procedures

A

platelet count

89
Q

UFH vs LMWH
Which is discontinued before planned delivery?

A

LMWH

90
Q

Your patient is a 27 year old G2P1, weighing 60 kg receving Lovenox 60mg every 12 hours since her 2nd trimester. She needs an epidural.
What do you need before placing it?
When can it be restarted?

A

platelet count

restart: 24 hours after placement, or 4 hours after removing the catheter

LMWH or UFH >4 days, get platelet count before starting NA

91
Q

T/F
UFH given subQ is only effective as prophylaxis, not therapeutic dosing.

A

False
works for both

92
Q

A pt on LMWH is showing decreased renal function on monitoring labs. Wyd?

A

switch to UFH

93
Q

T/F
A multi dose vial of LMWH or UFH are safe to reuse, so long as its used on the same parturient.

A

False
preservative free must be used

multi-dose contains benzyl alcohol or other perservatives
alcohols are C/I in pregnancy; fetal toxicity

94
Q

Protamine sulfate is used to reverse the effects of

A

UFH

useful in situations where bleeding is anticipated: placenta previa, placental abruption

95
Q

Repeat small doses of (LMWH/UFH) may be needed because…

A

UFH
ongoing absroption of heparin from subQ tissues

96
Q

If an anticoagulated mom presents to the hospital at ___ weeks, we do not convert her LMWH to UFH & instead stop anticoagulation and start plans for delivery.

A

37

97
Q

If on UFH, wait ___ before doing neuraxial.
If on prophlyactic LMWH, wait ___.
If on therappeutic LMWH, wait ___.

A
  • UFH: 4 H
  • Prophylactic LMWH: 12 H
  • Therapeutic LMWH: 24H
98
Q

T/F
A common risk of Epidural placement in an anticoagulated patient is subdural hematoma.

A

False
epidural hematoma

99
Q

epidural hematoma
S/S

A

1) severe, unremitting backache
2) neuro deficit (bowel/bladder dysfxn; radiculopathy)
3) spinous or paraspinous area tenderness
4) unexplained fever

100
Q

You suspect epidural hematoma. Wyd?

A

immediate diagnostic imaging of the spinal cord & neurosurg consult for possible spinal cord decompression

101
Q

Who should get Mechanical thromboprophylaxis?

A
  • contraindications to anticoagulants
  • after all cesarean births
  • every patient really
102
Q

Literally said nothing about this slide

A
103
Q

Intermittent pneumatic compression devices are to be used….

A

after cesarean delivery

104
Q

Women with significant thromboembolisms risk factors after delivery should have prophylaxis up to…

A

6-8 weeks postpartum

105
Q

⭐️
When is risk of thrombotic events the highest?

A

first week post partum

106
Q

Venous Air Embolism
can occur anytime there is…

A
  1. direct communication between a source of air and vasculature
  2. a pressure rgadient favoring the passage of air into circulation rather than bleeding from the vessel
107
Q

A pressure gradient as small as ______ between the surgical field and the heart allows a significant amount of air to be entrained into the venous circulation.

A

–5 cm H2O

108
Q

Surgical incisions above the ___ increase risk of venous air embolism.

A

phlebostatic axis

Occurs when the surgical field is above the level of the heart

109
Q

T/F
An air embolism can be venous or arterial.

A

True

110
Q

Venous air embolism is a common occurrence during ____

A

cesarean delivery

111
Q

Most air emboli are small, but volumes greater than __________ may be lethal

A

200-300 ml, or 3-5 ml/kg

112
Q

Venous air embolism rates of occurrence range from…

A

10-65%

113
Q

T/F
The majority of VAEs are subclinical.

A

True

114
Q

T/F
Amniotic fluid embolism is a diagnosis of exclusion. It may occur at any time during labor or delivery, as well as antepartum or postpartum.

A

True

115
Q

Pregnant patients are at a ___fold higher risk than nonpregnant patients for thromboembolic events. Periods of highest risk?

A

5
3rd trimester & first postpartum week

116
Q

Most common causes of venous air embolism

A
  • surgery
  • trauma
  • vascular intervention
  • barotrauma from mechnical ventilation & diving
117
Q

T/F
Almost all episodes of VAE during C/S are noted after the delivery of the fetus.

A

False
after delivery of the placenta

118
Q

T/F
VAE can occur in a noncesarean delivery setting

A

True

119
Q
A
120
Q

Venous air embolism:
The pulmonary vascular bed can actually remove up to ____ gas via gas diffusion acorss the aterial wall and into the alveolar spaces.

A

50 ml

when this is exceeded, pulmonary outflow obstruction with/without arterial embolization can occur

121
Q

(Venous Air Embolism)
Vasoactive mediators/mechanical obstruction of small vessels induce pulmonary vasoconstriction that leads to…

A
  • V/Q mismatch
  • hypoxemia
  • right heart failure
  • arrhythmias
  • hypotension
122
Q

Venous air embolism
>3 ml/kg
(large volume)

A

risk CV collapse by creating an “air lock” that causes RV outflow obstruction

123
Q

Venous air emboli of _____ (size) can cause CV collapse.

A

> 3ml/kg

124
Q

“air lock”

A
  • causes RV outflow obstruction
  • seen with venous air embolism >3 ml/kg
125
Q

T/F
Hemostatic & immune mediators in pulmonary emboli may trigger a cascade of physiologic derangements disproportionate to the cross-sectional area of occluded lung tissue.

A

True

126
Q

Amniotic fluid embolism is a diagnosis of ___

A

exclusion

127
Q

When can Amniotic fluid embolism occur?

A
  • labor
  • delivery
  • antepartum
  • postpartum
128
Q

SATA
Resuscitation in Massive Venous Air Embolism should include:
A) flood the surgical field with saline solution
B) lower the surgical field relative to the heart
C) Start nitrous oxide
D) intravascular volume expansion
E) Valsva maneuver

A

A) flood the surgical field with saline solution
B) lower the surgical field relative to the heart
D) intravascular volume expansion

STOP nitrous oxide

AVOID Valsva maneuver & PEEP (increase RA pressure can cause paradoxical embolism)

129
Q

T/F
Differential Diagnosis of Amniotic Fluid Embolism includes high neuraxial blockade (“total spinal”).

A

True

OB Final Exam (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions