OB Flashcards
What is the diagnosis for mild pre-eclampsia?
1) two readings SBP over 140 and/or DBP over 90, need 2 readings at least 4 hrs apart
2) proteinuria
- 24 urine protein more than 300 mg
- or spot urine protein / Cr ratio of 0.3
3) more than 20weeks GA
What is severe preeclampsia
1) SBP over 160 or DBP over 110, ideally 2 measurements taken 4hrs apart
2) Cr over 1.1 or doubled baseline
3) new CNS deficits (headache, vision changes)
4) pulm edema
5) liver, elevated LFTs 2x normal
6) Epigastric or RUQ pain
7) thrombocytopenia <100
Methemoglobinemia
- cause?
- physiology?
- how affects pulse ox
- levels and toxicity
- treatment
- cause: benzocaine and prilocaine
- decreased oxygen carrying capacity and impaired oxygen delivery to tissues.
- oxygen/Hgb curve to the left
- methemoglobin absorbs the same amount of light at both 660nm and 960nm, same as pulse ox, resulting in 85% sat reading
- toxicity
Under 30 no hypoxia
30- 50%: signs of hypoxia
More than 50: coma and death - treatment is methylene blue, unless patient has G6PD, then you give 100% O2 and consider exchange transfusion . Methylene blue requires G6PD to be effective, may cause hemolysis in patients deficient
What is G6PD deficiency?
Inhibits regeneration of glutathione in RBC
- RBC more susceptible to oxidative damage
- gets cleared from circulation faster, in 60days instead of 120 days
- x linked disorder
- can find Heinz bodies in peripheral blood smear
When is therapeutic hypothermia indicated post-cardiac arrest?
comatose pt after ROSC after resuscitated for a:
- out of hospital V fib (class 1)
- in-hospital with initial (class 2b rhythm)
- out of hospital arrest where the initial rhythm was PEA (class 2b)
How do you induce therapeutic hypothermia
Cooling blankets Ice packs Infuse cold fluids Reduce temp to 32 - 34 deg C Monitor core body temp (esophageal, bladder or PAC temp probe) Maintain hypothermia for 12-24hrs
What is Cushing response?
- high BP
- low HR
- irregular respirations
Some sources say instead of irregular respirations you will see widened pulse pressure
What does it indicate neurologically if a pupil is dilated and non reactive to light?
Suggests CN3 (occulomotor) compression secondary to uncal herniation
How does mannitol decrease ICP
- osmotically shifts fluid from intracranial to intravascular compartment
- decreases CSF production
- increases reflex cerebral vasoconstriction (2/2 decreased blood viscosity)
When would mannitol hurt more than help?
Can worsen cerebral edema if blood brain artist is not intact
Can worsen expansion of intracranial hematoma when there is intracranial bleeding (osmotic diuretics can lead to shrinkage of surrounding brain allowing for expansion of hematoma)
List serum magnesium levels and their physiologic effect
1.5 - 2.5mEq/L = normal 4-7 = therapeutic 7-10 = loss of patellar reflexes, hypotension, CNS depression 13 - 15 = respiratory paralysis 16 - 25 = EKG, widened QRS 20 - 25 = cardiac arrest
What intervention do you do if patient has widened QRS
Causes: elevated ICP or elevated Mg
If Mg toxicity
- stop drip
- check Mg level
- check DTR
- prepare to treat seizure
- calcium gluconate
- diuretic for renal excretion
If someone sticks themselves with a needle from HIV pt, what do you tell them
- wash our wound
- risk of transmission 0.3% with percutaneous exposure
- see employee health to draw blood for testing
- post-exposure PPX
What is DIC?
- disseminated intravascular coagulation = pathological activation of the coagulation cascade
- wide spread formation of clots in the blood vessels
- consumption of coagulation factors, thrombocytopenia, hemolytic anemia, diffuse bleeding, thrombotic phenomena
- increased PT and PTT
- decreased fibrinogen < 100mg/dL
- fibrin degradation products, high D-dimer
if in DIC, when is appropriate to given cryo?
fibrinogen levels under 50 mg/dL
What is TACO? Cause? Pathophys? Treatment?
- Transfusion Associated Circulatory Overload
- 2/2 large volumes of fluids given for resuscitation
- cardiogenic pulmonary edema
- Rx: diuretics
What is TRALI? Pathophys? Cause? symptoms? Diagnosis? Treatment?
Transfusion Related Acute Lung Injury (TRALI)
- non-cardiogenic pulmonary edema
- Cause: transmission of donor leukocyte antibodies during transfusion –> activates neutrophils on pulm endothelium
- happens 1-6hrs of transfusion
- more likely if plasma (FFP or PLTs)
- Sx: fever, tachy, dyspnea, cyanosis, chills, hypoT
- Dx: hypoxemia (Pa/FiO2 <300, SpO2 < 90%) and pulm edema, NO CARDIAC FAILURE or fluid overload
- Rx: STOP TRANSFUSION, tell blood bank, supportive: give O2, low TVs, , recover in 96hrs (4days)
TACO vs TRALI?
TACO = cardiogenic pulm edema, from vol overload during transfusion TRALI = non-cardiogenic (increased endothelial permeability likely 2/2 transmission of donor leukocyte antibodies)
What are the signs of post-dural puncture headache?
fronto-occipital headache decreased pain with laying down N/V neck stiffness back pain photophobia diplopia (stretching of abducens nerve) tinnitus hearing loss (due to reduced CSF rarely seizures (2/2 cerebral vasospasm)
What are symptoms of PE?
dyspnea tachypnea cough hemoptysis tachycardia fever accentuated or split heart sound pleuritic pain rales hypoxemia JVD distension
What are diagnostic tests for PE?
pulmonary angiography (gold standard) lower venous ultrasound (for DVT) spiral helical CT V/Q scan CXR D-dimer TEE (RV overload)
treatment for PE?
100% O2 inotropes and fluids monitor with art line, CVC, PAC consider pulm vasodilator (if pulm HTN: PDEi, milrinone) intubate ICU transport
AC with unfractionated heparin or LMWH
if can’t due to recent surgery, place IVC filter
What is Lamaze?
psychological and physical preparation in various techniques (as controlled breathing and alternative birthing positions) by the mother in order to reduce pain and facilitate delivery without unnecessary medical intervention.
What two nerve block can be done beside epidural for labor? Complications? What stages for each?
- Paracervical block for the first stage of labor
○ High risk of fetal bradycardia and decreased uteroplacental perfusion.
Pudendal block with simultaneous infiltration of the perineum for the 2nd stage of labor.
Causes of DIC?
Burn, head trauma, preeclampsia etc.
What is the risk factors for DIC in cesarean section?
Uterine rupture can lead to exposure of the vasculature to amniotic fluid rich in procoagulant thromboplastins, hypovolemia with low pressures can increase the risk of amniotic fluid entering the intravascular system as well as extensive vascular endothelial damage that occurs with preeclampsia.
Etiology of foot drop in postpartum patient who had a cesarean section?
May be L5 dermatomal sensory disturbance from compression of lumbosacral trunk when baby passing the pelvic brim.
Also may be peroneal nerve palsy from excessive knee flexion in prolonged lithotomy position/compression of lateral knee against hard objects.
