Module 9: Part 3 (46-67)

Question 1

air embolism signs and symptoms

Answer 1

Sudden and dramatic
Hypotension, hypoxemia, dyspnea
Chest pain during uterine repair (what else does this
sound like?)
Millwheel murmur
Right sided heart failure, rhythm changes

Question 2

During normal pregnancy, plasma volume increases by approximately

Answer 2

50%

Question 3

red blood cell (RBC) mass increases by only 30%; this differential increase
results in the

Answer 3

physiologic anemia of pregnancy

Question 4

Iron deficiency is the most common cause of anemia in pregnancy

Answer 4

iron deficiency

Question 5

During the first trimester it increases the risk for preterm delivery and low
birth weight

Answer 5

iron deficiency

Question 6

iron deficiency lab findings

Answer 6

Reduced hematocrit, low mean corpuscular volume (MCV), low total serum
iron, ferritin, and transferrin saturation

Question 7

A group of microcytic, hemolytic anemias that
results from the reduced synthesis of one or more of
the polypeptide globin chains

Answer 7

Thalassemias

Question 8

The reduced synthesis of polypeptide globin chains in thalassemia leads to:

Answer 8

An imbalance in globin chain ratios
Defective hemoglobin
Erythrocyte damage resulting from excess globin
subunits

Question 9

Thalassemia transfusion dependent

Answer 9

require ongoing transfusions
for survival

Question 10

Thalassemia non-transfusion dependent

Answer 10

may require transfusions
during stressors such as infection or pregnancy

Question 11

Four types of thalassemia (four genes
2 on each chromosome 16) that
produce α chains

Answer 11

Silent carrier(3 functioning genes)
α-thalassemia trait(2 functioning genes)
Hemoglobin H disease(1 functioning gene)
α0- thalassemia or Bart’s hydrops(no functioning
genes)

Question 12

not at increased risk for adverse outcomes during
pregnancy or surgery, MCV of 78 85 fL

Answer 12

Silent carrier(3 functioning genes)

Question 13

usually have mild anemia, MCV of 70 75 fL , typically
asymptomatic and no additional risk for adverse
outcomes in pregnancy or surgery

Answer 13

α-thalassemia trait(2 functioning genes)

Question 14

moderately severe microcytic anemia,
splenomegaly, fatigue, and generalized
discomfort, these patients may be transfusion
dependent

Answer 14

Hemoglobin H disease(1 functioning gene):

Question 15

incompatible with life, fetus usually dies in
utero or shortly afterward of hydrops fetalis

Answer 15

α0- thalassemia or Bart’s hydrops(no functioning
genes)

Question 16

Hydrops Fetalis

Answer 16

Severe edema in an unborn
baby or newborn

50% don’t survive

Immune (Rh neg mom/Rh
positive baby)and nonimmune
type

Question 17

β-Thalassemias

Answer 17

The production of β chains is reduced
Have only one gene on each chromosome 11
Usually have an excess of alpha chains that accumulate in RBC precursors

Question 18

Types of β-Thalassemias (3)

Answer 18

β0 thalassemia also known as β thalassemia major or Cooley’s anemia there is no beta
chain formation

Thalassemia intermedia

β thalassemia also known as β thalassemia minor

Question 19

β-thalassemia major pts and their chances of getting pregnant

Answer 19

It is unusual for these patients to get pregnant

But…..transfusion and chelation therapy can improve fertility and reproductive
therapies can help

Question 20

These patients can have increased incidence of spontaneous abortion, intrauterine fetal
death and growth restriction

Answer 20

β-thalassemia major pts

Question 21

β-thalassemia major, patient goals

Answer 21

Metabolic demands of pregnancy increase transfusion requirements

Goal: maintain a hemoglobin above 10 g/dL

Question 22

Chelation agents are stopped in the first trimester for pts with

Answer 22

β-thalassemia major

Question 23

Incidence of fetal growth restriction and oligohydramnios are more common

Answer 23

β-thalassemia minor

Answer 24

Usually benign
Anemia is typically mild (Hgb 9
11 g/dL)
Most tolerate pregnancy well
High dose folate during first trimester
Incidence of fetal growth restriction and oligohydramnios are more common
Does not affect anesthetic management during labor cesarean delivery
Moderate anemia during periods of stress (infection, pregnancy)

Question 25

Hemoglobinopathy characterized by a homozygous mutation (hemoglobin S)
where valine is substituted for glutamic acid in the B chain

Answer 25

Sickle Cell Disorder

Question 26

refers to a state in which erythrocytes undergo sickling when
they are deoxygenated

Answer 26

Sickle cell disease

Question 27

refers to disorders in which sickling results in clinical signs and
symptoms; genotypes include hemoglobin SS (Hb SS) disease, hemoglobin SC (Hb
SC) disease and sickle cell β thalassemia (there are other genotypes)

Answer 27

Sickle cell disease

Question 28

Factors that can increase the sickling risk (Sickle cell anemia): (5)

Answer 28

Hemoglobin S concentration greater than 50% of
total hemoglobin
Dehydration leading to increased blood viscosity
Hypotension causing vascular stasis
Hypothermia
Acidosis

Question 29

Hemoglobin S is the main hemoglobin in the disease

Answer 29

Sickle cell anemia

Question 30

___ tension is the most important determinate
in sickling

Answer 30

Oxygen

Question 31

Diagnosis and Treatment of Sickle cell anemia

Answer 31

Couples with high risk for sickle cell disease should
have prenatal screening for abnormal hemoglobin

Blood transfusions (only when necessary for acute
anemia, aplastic crisis, acute chest syndrome,
pneumonia with hypoxemia before or during
surgery)

Goal is a hemoglobin above 8 g/dL

Question 32

In the adult, sickle cell anemia is characterized by:

Answer 32

Hemoglobin of 6
8 g/dL
Elevated reticulocyte count
Presence of sickle cells on the peripheral blood smear
(elongated and crescent shaped vs biconcave)

Question 33

Couples with high risk for sickle cell disease should
have ….

Answer 33

prenatal screening for abnormal hgb

Question 34

Pregnancy typically exacerbates the complications
of

Answer 34

sickle cell anemia

Question 35

serious complications of sickle cell anemia

Answer 35

Thromboembolic complications, infection,
cardiomyopathy, and pulmonary hypertension are
the most serious maternal medical complications

Question 36

Increased incidence of preterm labor, placental
abruption, fetal growth restriction, preeclampsia,
and eclampsia

Answer 36

sickle cell anemia

Question 37

sickle cell anemia management

Answer 37

OB: Antenatal ASA to reduce preeclampsia risk,
thromboprophylaxis:maternal and fetal surveillance

Early preparation of crossmatched blood products
should be considered

Blood transfusions are given only if indicated (acute
anemia, crisis) with the goal of hemoglobin >8 g/dL

Question 38

Anesthetic management of sickle cell anemia (8)

Answer 38

Focus on recent sickle cell disease exacerbations and
the causes or precipitating factors
CBC to check the level of anemia
Check for chronic end organ injury
Crystalloid to maintain intravascular volume
Transfusions as needed to maintain RBCs to maintain oxygen carrying capacity
Supplemental O2
Normothermia, prevent venous stasis, venous thromboembolism therapy
Pain control during labor/cesarean

Question 39

Normal hemostasis involves 3 processes
almost simultaneously

Answer 39

1. Primary hemostasis (formation of a
   friable platelet plug)
2. Coagulation or secondary hemostasis
   (reinforcement of the friable platelet
   plug by the formation of a firm fibrin
   clot)
3. Fibrinolysis (clot lysis and restoration of
   blood flow through the recanalized
   vessel)

Question 40

The increase in the concentration of most
coagulation factors is a/w a
shortening of the ___ & ___ during normal
pregnancy

Answer 40

PT and aPTT

Question 41

Fibrinogen and fibrin degradation products are
(increased/decreased)in normal pregnancy

Answer 41

increased

Question 42

Thrombocytopenia is a sensitive, but not
specific, indicator of

Answer 42

DIC

Question 43

Gestational thrombocytopenia (GT)

Answer 43

is the most common cause of thrombocytopenia
in pregnancy

Question 44

Usually considered a platelet count below 150

Answer 44

Gestational thrombocytopenia (GT)

Question 45

A small subset of women with ______ may develop more significant declines in platelet
count and reduction in antithrombin III associated with preeclampsia, HELLP
syndrome or acute fatty liver of pregnancy, ITP

Answer 45

Gestational thrombocytopenia (GT)

Question 46

(ATP) IgG antibodies are
responsible for the increased platelet destruction

Answer 46

Autoimmune Thrombocytopenic Purpura
(ATP)

Question 47

Antibodies directed against platelet antigens are produced primarily in
the ____, where phagocytosis by macrophages occur

Answer 47

spleen

Question 48

______ are administered if the platelet count is < 20- 30k before the onset of labor or <50k at the time of delivery

Answer 48

Corticosteroids

Question 49

High dose IV ____ if no response to steroids in Thrombocytopenic Coagulopathies

Answer 49

immune globin