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Oral Boards > OB > Flashcards

OB Flashcards

1
Q

DDx 3rd trimester bleeding

A

Placenta previa
Abruption

Less commonly polyps, cancer, rupture, vasa previa

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2
Q

Risk factors for uterine rupture

A 
Scars from previous c-section
Use of prostaglandins 
Uterine trauma
Breech version
Extraction
Placenta perceta
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3
Q

Signs of uterine rupture

A 
Most common is fetal distress
Hypotension
Bleeding
Abdominal pain
Change in contour of abdomen
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4
Q

What are options to control peripartum hemorrhage?

A

After uterotonics like oxytocin, hemabate, methergine, misoprostol, Cell saver

Uterine ballon 
Uterine artery embolization
Iliac or uterine artery ligation
B-lunch suture
Hysterectomy
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5
Q

Risk factors for PPH

A 
Uterine atony 
High birthweight
Labor induction and augmentation
Chorio
Mag sulfate
Previous PPH
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6
Q

Anesthetic considerations with hx IVDU in pregnant patient

A 
Poor IV access
Hepatitis/HIV
Dependence/withdrawal symptoms 
Uncontrolled HTN —> abruption, PPH
Tachycardia, arrthymia 
MI
IUGR
IVH
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7
Q

Side effects of Mag therapy

A 
Dec ACH release
V - vasodilation, hypotension 
A - anticonvulsant 
S - sedative, skeletal muscle relaxant, inc sense to paralytics 
T - tocolytic
Dec DTR - 4-5
Prolonged PR, ST - 4-7
Somnolence - 5-7
Heart block 12
Resp arrest 15
Death 20
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8
Q

Considerations with pregnant CF patient

A

Coags (poor vit K abs)
Glucose - gestational DM

Newborns may have intestinal obstruction

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9
Q

How does pregnancy affect MS

A

Dec relapse, most in 3rd trimester

Inc in first 3 months postpartum

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10
Q

Fetal effects of maternal epilepsy

A

Fetal hydantoin syndrome
P - Cleft palate, lip
H - Heart defects, hypoplastic face, small head

Fetal asphyxia

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11
Q

Anticoagulation guidelines for neuraxial

A

UFH 4-6 hours
LMWH 12-24 hours depending on dose
Ticlopidine 14 days
Plavix 7 days

GA has mortality rate 16 times higher than neuraxial

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12
Q

Contraindications to epidural

A 
Refusal
Sepsis
Hypovolemia
Elevated ICP
Back injury with deficit
Infection at the site
Coagulopathy
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13
Q

Hemodynamic changes with pregnancy

A

Inc fluid volume
Anemia
CO inc 50%, HR, SV inc

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14
Q

Types of vWD

A

1 - most common, deficiency
2 - qualitative
3 - most severe, absence, hemorrhage

Tx - DDAVP, cryo, FFP, factor concentrate

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15
Q

Considerations with Pre-E

A

Hypovolemic
Inc SVR
Dec colloid oncotic pressure and permeability —> cerebral and pulm edema
Dec platelet number and function

Mag tx –> dec SVR and inc placental perfusion

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16
Q

Epidural/spinal not working, what would you do?

A

Depending on time and status of baby

  • re-bolus
  • re-do - coagulopathy with pre-e?
  • local w/ sedation - aspiration risk?
  • GA - ? Difficult airway
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17
Q

Emergency C/S with difficult airway, how will you intubate?

A

Speed and safety are the goals
Optimize mother’s hemodynamics - left uterine, BP normal, has oxygen
Awake fiberoptic
Local infiltration

No time = GA which DI cart, trach kit, induce maintain spontaneous respirations, inc asp risk but losing airway more significant risk

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18
Q

Steps for neonatal resuscitation

A

Stimulate
PPV if apneic or HR<100
HR<60 - intubate and chest compressions after 30s
Another 30s - Epi 0.01-0.03mg/kg
Hypoglycemia?
Mag toxicity?
Ca —> cerebral calcification and dec survival

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19
Q

Mech for oxytocin, methergine, hemabate

A

Contraction of uterine smooth muscle through inc intracellular calcium

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20
Q

What is DIC

A

Activation of coagulation cascade assoc with burns, head trauma, pre-e where there is widespread formation of clots resulting in consumption of clotting factors, thrombocytopenia, hemolytic anemia, diffuse bleeding and thromboembolism.

Inc PT/PTT
Fibrinogen <100
Thrombocytopenia
Dec ATIII
Fibrin degredation products
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21
Q

Concerns for nonobstetric surgery in pregnant patient

A 
Inc risk of failed intubation
Aspiration
Hemorrhage
Infection
Thromboembolism
Pre-term delivery
Teratogenesis 
IUDR
Fetal asphyxia
Miscarriage
22
Q

Best time to perform semi-elective surgery in pregnant patient

A

Given inc risk of miscarriage and teratogenesis in 1st trimester and pre-term labor in 3rd = 2nd is best

Should weigh risks of surgery delay against risks to mother and baby

Can you do regional?

23
Q

Which anesthetics are teratogenic

A

Non conclusively shown to result in inc congenital abnormalities

Possible teratogenic effects with nitrous oxide and benzos

24
Q

Tocolytic? Monitoring for nonobstetric surgery in pregnant patient?

A

No evidence to support routine PPx tocolytic

Would use tocodynomatry to identify onset of labor

25
Q

Monitoring for pregnant patient undergoing surgery

A 
Foley
OG
Continuous fetal HR - optimize mother’s hemodynamics with FHR distress
Left uterine displacement 
ABG for blood draws if diabetic etc
26
Q

ECT considerations for pregnant patient

A

Weigh risks of psychotropic medications and performing treatment

Assoc with vaginal bleeding, abdominal pain, contractions, pre-term labor, neonatal cerebral infarction

27
Q

EKG abnormalities in pregnancy

A

Left axis deviation
ST depression
Q-wave in lead III

28
Q

Timing for baby delivery with maternal cardiac arrest

A

within 5 minutes if resuscitative efforts not successful

29
Q

What is normal FHR variability?

A

fluctuations fo more than 2 cycles per minute

30
Q

Epidural with HOCM

A

Ensure euvolemia to maintain adequate pre-load and dose slowly to avoid sympathectomy

Remember vasodilation and tachycardia with Pitocin - consider methergine or hematite first

31
Q

What factors lead to to exacerbate LVOT obstruction ?

A

Hypovolemia
Sympathectomy/vasodilation (dec SVR/afterload facilitating LV emptying)
Inc myocardial contractility (inc emptying)
Tachycardia (dec diastolic filling)
Dysrhythmias (inc emptying)
Excessive PPV (dec preload)

Tx = euvolemia, beta blockade, phenylephrine

32
Q

Would you risk radiation to baby to obtain a CT scan?

A

If benefits to mother of appropriate imaging outweigh minimal risk to baby, proceed

Also weigh risks of interrupting ongoing resuscitation for the procedure base on stability of mother

33
Q

Irregular contractions and vaginal bleeding following trauma, no IV access, no CT done yet, would you proceed to urgent C/S?

A

considering possibility of uterine rupture or placental abruption i would proceed, HOWEVER, given potential for significant bleeding would be reluctant to proceed without first gaining adequate IV access.

If possible to delay until primary survey is completed (airway, breathing, circulation, disability, exposure) while continuously monitoring FHR and contractions

34
Q

Emergency C/S, AMS pregnant patient with difficult airway, swollen tongue. Would you consider a regional anesthetic, is spinal better than an epidural?

A

Given AMS, inc risk aspiration and further dec in mental status i would prefer GA and secured airway.

Sympathectomy from regional –> compromise cerebral perfusion in with inc ICP.

Inability to cooperate could make regional more difficult.

theoretical risk of unintentional dural puncture leading to brainstem herniation.

35
Q

Post Eclamptic seizure on magnesium, now notice widened QRS. What would you do?

A

Ddx mag toxicity, inc ICP, SAH –> check vitals, draw mag level, check DTRs for hyporeflexia.

Discontinue infusion (long half-life) ready to treat a seizure should one occur and if lab supported hyperMag assuming normal renal function –> diuretic to inc excretion + Ca

36
Q

How would you evaluate the need for blood patch?

A

Review record and assess for S&S of PDPH

  • frontal-occipital HA improved supine
  • N/V
  • Neck stiffness
  • Back pain
  • Visual disturbances (photophobia, diplopia)

Require coagulation profile

37
Q

What are the respiratory changes during pregnancy?

A

Inc O2 consumption
Inc MV d/t inc Tv
Dec FRC

38
Q

OB patient receiving terbutaline for premature labor experiencing respiratory distress and B/L crackles. What do you think is the cause?

A

B/L crackles are suggestive of pulmonary edema which could be assoc w/ use of terbutaline

Pre-E
PE
unrecognized cardiac condition
Fluid overload
Aspiration
NPPE
39
Q

Tetanic uterine contractions and fetal bradycardia in transplanted heart following CSE cause?

A

Rapid dec in pain –> abrupt dec plasma epi –> dec B2 stim of uterus –> inc uterine tone –> dec blood flow and fetal brady

Ddx:
maternal hypotension
caval compression
hypovolemia

40
Q

How could you treat severely elevated uterine tone or tachysystole with fetal brady?

A

50-100mcg Nitro

125-250mcg IV terbutaline

41
Q

How would you evaluate a previous heart transplant patient pre-op?

A
  1. talk to transplant team about immunosuppression, abc ppx
  2. review ECHO, angio, endocardial bx
  3. evaluate for signs of rejection - arrhythmias, fever, malaise, SOB
  4. identify and eval pacemaker
  5. review EKG for signs of ischemia (silent common from denervation)
  6. evaluate for chemo toxicity/complications - nephrotoxicity, anemia, hepatotoxicity, infections, HTN (cyclosporine)
  7. stress dose steroids
  8. ensure normovolemia (preload dependent)
Avoid beta blockers (need catecholamines)
Avoid vasodilators (preload dependent)
42
Q

OB patient with recent MI, ICM, Pre-E presents with PROM, would you recommend a C/S for this patient?

A

I would if there was an obstetric indication or immediate delivery was indicated.

While C/S avoids prolonged stress of labor and profound hyper dynamic circulatory changes with delivery, it is not entirely avoided with C/S.

In addition, C/S is assoc w/ inc blood loss, higher risk of infection, delayed ambulation and inc pain.

I would recommend an early epidural placement (assuming no coagulopathy) and trial of labor.

43
Q

OB patient with recent MI, ICM, Pre-E, raising level of epidural and you notice ST depressions. What would ou do?

A 
Stop epidural injections
Optimize myocardial O2 supply demand
LUD
Apply O2
Look for arrhythmia
Ensure adequate preload
Consider nitroglycerin recognizing this could dec venous return exacerbating inadequate preload
44
Q

Platelet level is 92,000, would you perform a regional anesthetic? What if it was 74,000?

A

Probably.

I recognize that Pre-E can affect platelet number and function, I would weight the risks of epidural hematoma with risks of GA (DI, aspiration, hemodynamic instability) not on a specific number

In weighing the risks I would consider platelet trend and any signs of coagulopathy like bleeding from IV sites, easy bruising

I would take precautions like waiting to remove the catheter until motor function has returned and/or platelet number was up trending.

45
Q

Pregnant patient admitted vaginal bleeding for urgent C/S. Would you perform a regional or general anesthetic?

A

If the patient was hemodynamically stable, bleeding was not brisk and overall blood loss has not been significant I would perform an epidural.

If the patient was hypovolemic or actively hemorrhaging I would want to avoid sympathectomy with regional and perform GA.

46
Q

What is the role of cell salvage in obstetric patients?

A

Somewhat controversial, there is fear of amniotic fluid components being administered to the patient –> embolism

Still beneficial for patients at high risk

  • placenta accrete
  • large fibroids
  • rare blood type or antibodies

Dec risk of infections, and transfusion reactions.

47
Q

What features make pre-eclampsia severe?

A 
SBP >160/110
Evidence of end organ damage - oliguria, inc Cr.
Headache, vision changes
Liver dysfunction - HELLP, RUQ pain
Pulmonary edema
Fetal compromise (IUGR, oligo, NRFHR)
48
Q

How would you manage mitral stenosis in pregnancy?

A

1 = HR control with beta blockers

Immediate tx of AFIB

Maintain adequate LUD/VR and SVR

Avoid tachycardia, pain, hypoxemia, hypercarbia, acidosis that dec filling/emptying and inc PVR

Diuretics
- obstruction –> inc LA volume –> pulm edema worsens with inc plasma volume in pregnancy

49
Q

Should an epidural be used for labor analgesia in a patient with mitral stenosis?

A

Yes

Epidural can dec tachycardia and thus pulmonary edema associated with labor and delivery

Dose slowly to avoid sympathectomy (dec SVR –> tachycardia –> dec CO) and treat with phenylephrine and fluids while avoiding fluid overload

50
Q

How would you induce GA in pregnant patient with mitral stenosis and pulmonary HTN?

A

After aspiration ppx, applying monitors, pre-O2, LUD, ensure adequate intravascular volume

Modified RSI with cricoid, etomidate, remi and sux

Consider esmolol but can –> fetal brady

Avoid ketamine, glyco, atropine (tachycardia), etc

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