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The BIG Test > OB > Flashcards

OB Flashcards

1
Q

What is the minimum fasting for elective c-section?

A

6 hours

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2
Q

The diaphragm is displaced cephalad about 4 cm by the expanding uterus. Why is this significant?

A

FRC decreases by 20%

May lead to small airway closure

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3
Q

What lung volumes are not changed during pregnancy? Increased? Decreased?

A

NO change: VC, CV, CC, lung compliance, FEV1, FEV1/FVC, diffusion capacity

Increased: IRV, TV, IC, dead space, MV, diaphragm excursion, O2 consumption

Decreased: ERV, RV, FRC, TLC, chest wall excursion, chest wall compliance, total system compliance, airway resistance, pulmonary resistance

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4
Q

Ventilatory changes produce respiratory ________ (PaCO2 = 30 mmHg) yet the compensation by metabolic ______ (excretion of bicarbonate) will keep the pH normal.

A

Alkalosis (pH 7.44)

Acidosis (HCO3 20-21)

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5
Q

Would you anticipate the PaO2 to be higher in the pregnant or non-pregnant?

A

Pregnant

Non-pregnant: 100, 1st: 107, 2nd: 105, 3rd: 103

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6
Q

Would you anticipate the PaCO2 to be higher in the pregnant or non-pregnant?

A

Non-pregnant

Non-pregnant: 40, pregnant: 30

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7
Q

Describe the changes in alveolar ventilation.

A

70% increase in alveolar ventilation
TV increases by 40%
RR increases by 15%

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8
Q

What enhances the maternal uptake of inhaled anesthetics?

A

Increase in alveolar ventilation
Decrease in FRC
*Faster induction

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9
Q

Airway edema d/t engorgement is most evident during what trimester?

A

3rd

*Use smaller ETT

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10
Q

Why will any episodes of apnea lead to maternal hypoxia quickly?

A

Increase in oxygen consumption
Decrease in FRC
Rapid airway obstruction

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11
Q

Is it ok to allow the mother to hyperventilate?

A

NO
Uterine vasoconstriction - decreased placental perfusion
Left shift - increased affinity of maternal Hgb for O2

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12
Q

Is MAC increased or decreased in pregnancy?

A

Decreased 15-40%

Begins 8-12 weeks

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13
Q

Changes in CV System

No change? Increased? Decreased?

A

NO change: CVP, PADP, PCWP, LVSWI, LVESV

Increased: BV, plasma volume, RBC volume, CO, SV, HR, EF, femoral venous pressure, LVEDV

Decreased: total peripheral resistance, SVR, MAP, SBP, DBP

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14
Q

When does CO increase the most?

A

Postpartum - increases 80%
Increase in SV - uterus no longer obstructs

30-40% during 1st trimester
15% latent
30% active
45% second stage

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15
Q

Why is there an anemia? H/H 11.6/35.5%

A

Blood volume increases by 33-40%
Plasma volume increases by 45%
RBC volume increases by 20%

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16
Q

CO to the uterine vasculature is approx…

A

700 mL/min

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17
Q

Explain maternal supine hypotensive syndrome.

A

Compression of IVC decreases VR - decreased SV and BP
Further compression will decrease uterine perfusion - fetal distress
Maternal response - tachycardia, vasoconstriction of LE
LUD - 15 deg, 15 cm wedge

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18
Q

Why is there an increased incidence of accidental epidural vein puncture?

A

Venodilation

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19
Q

Healthy parturient will tolerate up to _____mL of blood loss.

A

1500

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20
Q

What should you think if you see a high Hgb level (> 14)?

A

Low-volume state
Preeclampsia
HTN
Inappropriate diuretics

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21
Q

Changes in Coagulation Factors

No change? Increased? Decreased?

A

NO change: Factor 2 and 5

Increased: all other factors

Decreased: Factor 11 and 13

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22
Q

Changes in Coagulation

No change? Increased? Decreased?

A

NO change: plt count, bleeding time

Increased: fibrin degradation products, plasminogen

Decreased: PT, PTT, AT

*Hypercoagulable

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23
Q

Changes in GI System

A

Increased gastric emptying time
Decreased gastric motility
Decreased LES tone
*All d/t elevated levels of progesterone

Increased intragastric pressure
Increased secretion of gastric acid
*D/t elevated gastrin

Caution: narcotics, valium, and atropine all decrease LES tone further

*Prone to gastric reflux - FULL stomach at week 12

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24
Q

Changes in Renal System

No change? Increased? Decreased?

A

Increased: RBF, GFR, creatinine clearance

Decreased: BUN, creatinine

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25
Q

What 2 factors cause decreased uterine blood flow?

A
  1. Decreased perfusion pressure — decreased uterine arterial pressure + increased uterine venous pressure
  2. Increase uterine vascular resistance
    endogenous vasoconstrictors + exogenous vasoconstrictors
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26
Q

Uterine artery pressure is determined by…

A

Maternal systemic arterial pressure

*Maternal BP is the ONLY factor that influences blood flow through the placenta

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27
Q

How does maternal blood circulate through the placenta?

A

Uterine artery
Intervillous space
Fetal villi
Veins

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28
Q

How many microscopic tissue layers are found in the placental membrane?

A

3

  1. Fetal trophoplasts
  2. Fetal connective tissue
  3. Endothelium of the fetal capillaries
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29
Q

Pharmacology Considerations

A 
MAC reduced 15-40% 
ED50 of thiopental reduced 
Elimination 1/2 life of thiopental prolonged
Propofol unaltered
Sux unaltered, sensitivity reduced 
Increased sensitivity to Vec and Roc 
Response diminished to chronotropic agents 
Subarachnoid dose of LA reduced by 25%
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30
Q

Regional Effects on Uterine BF

A

Increased BF: pain relief, decreased SNS activity, decreased hyperventilation

Decreased BF: hypotension, IV injection of LA

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31
Q

First Stage of Labor

A

Cervical effacement and dilation

Latent phase: onset of labor to the point at which the cervix begins to rapidly change

Active phase: begins at 2-3 cm dilation, cervix undergoes its max rate of dilation

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32
Q

Second State of Labor

A

Begins at full cervical dilation (10 cm)

Ends with delivery of the fetus

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33
Q

Third Stage of Labor

A

Delivery of the placenta

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34
Q

First Stage Labor Pain

A

Pain source: cervical distention, stretching of the lower uterine segment, and possibly, myometrial ischemia
Pain type: visceral
Fibers: unmyelinated C fibers
Enter the cord at: T10, T11, T12, and L1

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35
Q

Second Stage Labor Pain

A

Pain source: compression and stretching of the pelvic musculature and perineum
Pain type: somatic
Fibers: myelinated A-delta fibers
Enter the cord at: S2, S3, and S4 via pudendal nerves

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36
Q

When should Meperidine be given?

A

Give early in labor (4 hours before delivery)
Max maternal and fetal depression are seen 10-20 min after IV and 1-3 hrs after IM
10-25 mg IV
25-50 mg IM
Total 100 mg

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37
Q

Name 2 partial agonists that can be used.

A
  1. Butorphanol 1-2 mg IV or IM

2. Nalbuphine 10-20 mg IV or IM

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38
Q

What dose of Ketamine is associated with fetal depression?

A

> 1 mg/kg

And can cause hypertonic uterine contractions

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39
Q

Doses of Intrathecal and Epidural Opioids

A 
Intrathecal/Epidural 
Morphine: 0.5-1 mg/7.5-10 mg
Meperidine: 10-20 mg/100 mg
Fentanyl: 10-25 mcg/50-100 mcg
Sufentanil: 3-10 mcg/10-30 mcg
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40
Q

What is the most common SE of regional anesthesia?

A

Hypotension

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41
Q

Bupivacaine-induced cardiovascular collapse may be treated with…

A

Bretylium

Amiodarone may be useful in reversing the decreased threshold for LV tachycardia

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42
Q

Umbilical Cord Prolapse

A

Causes: excessive cord length, malpresentation, low birth weight, graviparity, multiple gestations, artificial rupture of membranes

Diagnosis: sudden fetal bradycardia or profound decelerations

Treatment: immediate steep T-burg or knee-to-chest position, manual pressure against the presenting part, uterine relaxation, emergency cesarean section

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43
Q

List 3 causes of antepartum hemorrhage.

A
  1. Placenta Previa
  2. Placenta Abruption
  3. Abnormal Placental Implantation
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44
Q

Placenta Previa
What is it?
What is the concern?

A

Placenta implanted on the lower uterine segment – either partially or completely covers the opening of the cervix
Results in PAINLESS vaginal bleeding (preterm, no contractions)
Potential for sudden loss of large amounts of blood
Significant bleeding may follow manual examination of the cervix
Increases postpartum bleeding

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45
Q

Placenta Previa
Risk Factors?
Tx?
Associated with what other risks?

A

Risk factors: multiparity, age, previous C-section, previous previa

Tx: Bedrest and observation

Increased risk for - accrete if history of previous C-section, VAE, asymmetric intrauterine growth restriction

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46
Q

What type of placenta previa increases the risk of excessive bleeding for c-section?

A

Anterior lying placenta previa

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47
Q

Placental Abruption
What is it?
Results in…
Incidence is higher in women with what?

A

Separation of the placenta from the deciduas basalis

Results in hemorrhage, uterine irritability, abdominal pain, fetal hypoperfusion

Incidence higher in women with HTN

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48
Q

What is the most common cause of DIC?

A

Placental Abruption

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49
Q 
Placental Abruption 
Significance of bleeding? 
Candidates for regional anesthesia? 
Risk factors? 
How do these patients present? 
Associated with what other risks?
A

Bleeding may be concealed – large volumes, uterus may contain 2500 mL of blood

Contraindication to regional anesthesia

Risk factors: HTN, increased age, tobacco use, cocaine use, trauma, PROM, history of previous abruption

Presentation: painful vaginal bleeding, uterine tenderness, increase uterine activity, fetal distress

AFE, DIC

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50
Q

Abnormal Placental Implantation

A

Placenta normally implants into the endometrium
Placenta accreta – on the myometrium, 78%
Placenta increta – into the myometrium, 17%
Placenta percreta – completely through the myometrium, 5%

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51
Q

What is the most common indication for obstetric hysterectomy?

A

Abnormal Placental Implantation

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52
Q

Abnormal Placental Implantation
Associated with what?
May be unforeseen…why?

A

Associated with placenta previa, previous c-sections

MRI and ultrasonography have poor predictive capability for the diagnosis

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53
Q

Amniotic Fluid Embolism
Mortality rate?
S/S?
Tx?

A 
86%, 50% during first hour 
S/S - hypotension, dyspnea 
Tx - supportive care, A-OK 
Associated with placental abruption 
Prone to develop DIC
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54
Q

What is the 3rd leading cause of maternal death?

A

AFE

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55
Q

What is the most common fetal HR changes seen during labor?

A

Variable decels

56
Q

What is the most common serious side effect of mag sulfate?

A

Pulmonary edema

57
Q

What is the most common cause of postpartum hemorrhage?

A

Uterine atony

58
Q

What is the most common severe morbidity complicating OB anesthesia?

A

Maternal hemorrhage

59
Q

What is the most common cause of maternal death in pregnancy-induced HTN?

A

Cerebral hemorrhage

2nd: pulmonary edema

60
Q

What % of the CO perfuses the gravid uterus at term?

A

10%

800 mL/min

61
Q

When does CO return to baseline?

A

14 days postpartum

62
Q

Rank the amides local anesthetics from greatest to least according to their ability to cross the placenta.

A

Mepivcaine > etidocaine > lidocaine > ropivacaine > bupivacaine

“Maternal Elevated Locals are Risky to Baby!”

63
Q

Methergine

A 
Ergot alkaloid
Dose: 0.2 mg IM 
Potent vascular effects - 
Increase in BP, CVP, and PCWP
NOT administered IV - 
Arterial and venous constriction, coronary artery constriction, severe HTN, cerebral bleeding
Metabolized and eliminated by liver
Onset: 3-5 min  
Half-life: 2 hrs
64
Q

Hemabate

A

Prostaglandin F2a
Dose: 250 mcg IM, Q15 min, max 2 mg
Potent stimulator of uterine contraction
Strong and painful!
Caution with asthmatics
Frequent side effects: N/V/D, bronchospasm, flushing, bradycardia, hypotension
Onset: 5 min

65
Q

Magnesium Sulfate

A

Relaxation of vascular, bronchial, and uterine smooth muscle
Anticonvulsant
Increased uterine BF, renal BF
Increased prostacyclin release by endothelial cells
Decreased plasma renin activity
Decreased plt aggregation

66
Q

What is the therapeutic serum level of Mag?

A

4-8 mg/dL

67
Q

Review serum levels of Mag and associated symptoms.

A 
Normal level = 1.8-3 mg/dL
PQ interval prolonged, wide QRS = 5-10
Loss of deep tendon reflexes = 10 
Heart block = 15 
Respiratory depression with levels > 15 
Cardiac arrest with levels > 25
68
Q

Where does Mag work?

A

NMDA receptor

69
Q

The neuromuscular blocking effects of Mag can be a least partially antagonized by what?

A

Calcium

70
Q

Preeclampsia

A

New onset HTN (>160/110), proteinuria (>5 G/day), and after 20 weeks gestation
Affects 5-7% of pregnancies
Plasma volume is normal in mild disease but may be reduced by up to 40% in severe disease.

71
Q

How long do mothers remain at risk for eclampsia?

A

Usually resolves w/in 48 hrs

Up to 2 weeks postpartum

72
Q

DIC

Associated with what 3 obstetric problems?

A
  1. Intrauterine fetal demise
  2. Placental abruption
  3. Amniotic fluid embolism
    Lab studies:
    Decreased: fibrinogen, platelets
    Increased: PT, PTT, fibrin degradation products
    Definitive treatment = elimination of the cause
    Evacuate the uterus
73
Q

Early Decels Type I

A 
Occur with each contraction
Start and end with the contraction
Uniform in appearance
Beat-to-beat variability not present
Vagal stimulation from compression of the fetal head
74
Q

Late Decels Type II

A

Occur with each contraction
Begin late in the contraction
Lowest point occurs after the peak of the contraction
Uniform in appearance
Beat-to-beat variability may or may not be present
Uteroplacental insufficiency

75
Q

Variable Decels Type III

A

Abrupt onset and recovery
Irrespective of contractions
Vary in appearance, duration, depth, and shape
Beat-to-beat variability present
Baroreflex-mediated response from umbilical cord compression

76
Q

List 2 non-cutting point needles.

A
  1. Sprotte

2. Whitacre

77
Q

Subarachnoid Block for C-section

Dose Requirements and Duration (w/Epi)

A

Tetracaine 7-10 mg - 2.5-3 hrs
Lidocaine 60-75 mg - 1.5-2 hrs
Bupivacaine 11.25-15 mg - 3-3.8 hrs

78
Q

How much of the total uterine blood flow goes to the intervillous space?

A

550 mL/min

79
Q

What is the PaCO2 and PaO2 in the normal fetus?

A

PaCO2 48 mmHg

PaO2 30 mmHg

80
Q

Give the formula for uterine blood flow.

A

Mean uterine artery pressure -uterine vein pressure / uterine vascular resistance

*Uterine artery pressure depends on maternal BP

81
Q

Placental blood flow is directly dependent on the pressure in the uterine artery…therefore, placental blood flow depends solely on…

A

Maternal blood pressure

82
Q

Is uterine blood flow autoregulated?

A

NO

83
Q

What is the predominant adrenergic receptor in the uterine vasculature?

A

Alpha-adrenergic receptors

84
Q

Which maternal hemodynamic parameter shows the greatest decrease during normal gestation?

A

SVR (-20%)

85
Q

Which maternal hemodynamic parameter shows the greatest increase during normal gestation?

A

CO (+50%)

86
Q

What is the normal FHR?

What is normal beat-to-beat variability?

A

120-160 bpm

3-6 beats/min

87
Q

What is the most serious fetal risk associated with maternal surgery during pregnancy?

A

Uterine asphyxia

88
Q

The effect of progesterone on the respiratory system.

A

Acts as a direct respiratory stimulant
Increase in chemoreceptor sensitivity
Steep and left shift of CO2 ventilatory response curve

89
Q

Does pregnancy mimic restrictive or obstructive disease?

A

Restrictive

90
Q

What does HELLP stand for?

A

Hemolysis
Elevated liver enzymes
Low platelets
*Usually occurs b4 36 weeks gestation

91
Q

What does the diagnosis of HELLP call for?

A

Immediate delivery regardless of gestation d/t high maternal and fetal mortality

92
Q

In the pre-eclamptic patient, what are the best tests to evaluate bleeding?

A

PT and PTT

93
Q

What is the mainstay therapy for HTN in the pre-eclamptic patient? Why?

A

Hydralazine

Lowers BP and increases uteroplacental BF

94
Q

What drug should be avoided in the treatment of HTN in the pre-eclamptic patient?

A

Esmolol

Also avoid: Clonidine, Nifedipine, ACE-I

95
Q

What is the most common cause of morbidity and mortality in pregnancy?

A

Pre-eclampsia and eclampsia

96
Q

How do you convert mEq/L to mg/dL?

A

Divide mEq/L by 0.8 to convert to mg/dL

97
Q

How does Mag work as an anticonvulsant?

A

Decreases the presynaptic release of Ach

Reduces the sensitivity of postsynaptic membranes to Ach

98
Q

What is the earliest sign of Mag toxicity?

A

Marked depression of DTR

99
Q

Mag toxicity is treated with IV…

A

Calcium gluconate

100
Q

How is Mag administered in the pre-eclamptic patient?

A

Loading dose: 4-6 G over 20-30 min

Gtt: 1-2 G/hr for up to 24 hours postpartum

101
Q

What is Ritodrine used for?

A

Stop premature labor
Beta 2 agonist
SE: hyperglycemia, hypokalemia, tachycardia - crosses the placenta so could cause these SE in fetus

102
Q

What are the benefits of chloroprocaine?

A

Rapid onset
Crosses the placental barrier in the smallest amount
Rapidly hydrolyzed by pseudocholinesterase
Safest and least toxic

103
Q

What vasopressor has a minimal effect on uterine blood flow?

A

Ephedrine

104
Q

Is prilocaine appropriate for OB use?

A

NO - ortho-toluidine causes methemoglobinemia

105
Q

Why does bupivacaine pass less readily across the placental barrier than the other amides?

A

Greatest protein binding (95%)

106
Q

What is the major concern for a patient who is scheduled for tubal ligation in the early post-partum period?

A

Risk of aspiration

When regional anesthesia has not been used, wait 8-12 hours postpartum to allow the patient to reach CV stability and increase the likelihood of gastric emptying

107
Q

What should you try to avoid in a pregnant patient presenting for nonobstetric surgery?

A

Avoid N2O and benzos

Most organogenesis occurs in the 1st trimester

108
Q

What is the most common surgical emergency procedure during pregnancy?

A

Appendicitis

109
Q

What is the most common cause of maternal death during OB general anesthesia?

A

Hemorrhage

NOT airway

110
Q

Ideally, the uterine-to-delivery interval is less than…

A

3 min

111
Q

At what state of labor is a pudendal block given?

A

Just before delivery (end of second stage)

112
Q

Paracervical block

A

First stage of labor
NOT effective during the second stage
8-40% incidence of fetal bradycardia that develops 2-10 min after injection

113
Q

Disadvantages of Chloroprocaine

A

NOT a suitable agent for use with opioids
Can use opioid agonist-antagonist
Can develop tachyphylaxis

114
Q

What do you want to maintain in the healthy pregnant patient: SBP, DBP, or MAP?

A

SBP

Prevent a decrease of 20-30% OR falling below 100 mmHg

115
Q

APGAR

A
  1. HR
  2. Respiratory effort
  3. Reflex irritability
  4. Muscle tone
  5. Color
116
Q

What is the neonatal dose of epinephrine for treatment of asystole?

A

0.01-0.03 mg/kg

Given for HR < 60

117
Q

What is the appropriate drug for the neonate with an APGAR score of 3 after 5 min?

A

Sodium bicarbonate

118
Q

What general anesthetic factors most depress the APGAR score at 1 min?

A

Low FiO2

High N2O

119
Q

A pregnant patient receives a caudal block…

  1. and suddenly becomes agitated, dyspneic, and her legs thrash.
  2. and suddenly becomes agitated, dyspneic, and unable to move her legs.
A
  1. Intravascular injection

2. High spinal

120
Q

What 2 drugs are used in the situation of uterine inversion/inverted uterus?

A
  1. Inhaled agents

2. Nitroglycerine (50-100 mcg)

121
Q

Should severe maternal hypotension exist, what IV anesthetic would you use for induction and intubation?

A

Ketamine

122
Q

Damage to which of the 3 layers of the uterus is of greatest concern to the anesthetist?

A

Middle, muscular layer, myometrium

123
Q

Treatment of LA toxicity.

A

Thiopental or benzo
Avoid propofol d/t CV instability
Maintain oxygenation - possibly intubate
Support BP
Give Ca to raise the cardiac threshold
Avoid: vasopressin, CCB, BB
20% Intralipid: 1.5 mL/kg over 1 min, repeat, then infusrion of 0.25 mL/kg/min (max 10 mL/kg over the first 30 min)

124
Q

In multiple situations, even in the scenario of a high spinal, what position should the pregnant patient be placed in with hypotension?

A

T-burg and L uterine displacement to increase VR to the heart

125
Q

What fetal pH indicates fetal acidosis?

A

Fetal pH < 7.20

126
Q
  1. Type II decels w/ normal beat-to-beat variability
  2. Type II decels w/ diminished beat-to-beat variability
  3. Type II decels w/ absent beat-to-beat variability
A
  1. Acute insult like hypotension
  2. Prolonged fetal asphyxia
  3. Severe decompensation
127
Q

What is the most common cause of anesthesia-related maternal mortality on the OBESE parturient?

A

Airway complications

128
Q

What are 3 pathophysiological problems that are responsible for the presenting s/s seen in the patient with AFE?

A
  1. Acute PE
  2. DIC
  3. Uterine atony
129
Q

What is the appropriate position for the parturient with AFE?

A

L uterine displacement

Slight head-up position

130
Q

What is the appropriate position for the parturient with VAE?

A

L uterine displacement

Slight head-up position

131
Q

What should you think of with polyhydramnios?

A 
Tracheoesophageal fistula (TEF) 
Or possibly congenital diaphragmatic hernia

Risk for umbilical cord prolapse, possible breech or malpresentation, uterine atony

132
Q

What nerve is most commonly injured in the patient undergoing an abdominal hysterectomy?

A

Femoral nerve

133
Q

Damage to what nerve…inability to dorsiflex the foot?

A

Common peroneal nerve

134
Q

What nerve injury is most commonly associated with vaginal delivery?

A

Lumbosacral nerve

135
Q

A pregnant patient presents with thrombocytopenia…name the most likely cause?

A

Incidental, or gestational thrombocytopenia

Then pre-eclampsia/eclampsia

136
Q

Which opioids produce a greater degree of segmental analgesia - lipophilic or hydrophilic?

A

Lipophilic such as Fentanyl

137
Q

Which intrathecal opioid has the fastest onset?

A

Sufenta

D/t lipid solubility

The BIG Test (21 decks)

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