OB Flashcards
DDx 3rd trimester bleeding
Placenta previa
Abruption
Less commonly polyps, cancer, rupture, vasa previa
Risk factors for uterine rupture
Scars from previous c-section Use of prostaglandins Uterine trauma Breech version Extraction Placenta perceta
Signs of uterine rupture
Most common is fetal distress Hypotension Bleeding Abdominal pain Change in contour of abdomen
What are options to control peripartum hemorrhage?
After uterotonics like oxytocin, hemabate, methergine, misoprostol, Cell saver
Uterine ballon Uterine artery embolization Iliac or uterine artery ligation B-lunch suture Hysterectomy
Risk factors for PPH
Uterine atony High birthweight Labor induction and augmentation Chorio Mag sulfate Previous PPH
Anesthetic considerations with hx IVDU in pregnant patient
Poor IV access Hepatitis/HIV Dependence/withdrawal symptoms Uncontrolled HTN —> abruption, PPH Tachycardia, arrthymia MI IUGR IVH
Side effects of Mag therapy
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
Considerations with pregnant CF patient
Coags (poor vit K abs)
Glucose - gestational DM
Newborns may have intestinal obstruction
How does pregnancy affect MS
Dec relapse, most in 3rd trimester
Inc in first 3 months postpartum
Fetal effects of maternal epilepsy
Fetal hydantoin syndrome
P - Cleft palate, lip
H - Heart defects, hypoplastic face, small head
Fetal asphyxia
Anticoagulation guidelines for neuraxial
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
Contraindications to epidural
Refusal Sepsis Hypovolemia Elevated ICP Back injury with deficit Infection at the site Coagulopathy
Hemodynamic changes with pregnancy
Inc fluid volume
Anemia
CO inc 50%, HR, SV inc
Types of vWD
1 - most common, deficiency
2 - qualitative
3 - most severe, absence, hemorrhage
Tx - DDAVP, cryo, FFP, factor concentrate
Considerations with Pre-E
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
Epidural/spinal not working, what would you do?
Depending on time and status of baby
- re-bolus
- re-do - coagulopathy with pre-e?
- local w/ sedation - aspiration risk?
- GA - ? Difficult airway
Emergency C/S with difficult airway, how will you intubate?
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
Steps for neonatal resuscitation
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
Mech for oxytocin, methergine, hemabate
Contraction of uterine smooth muscle through inc intracellular calcium
What is DIC
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
Concerns for nonobstetric surgery in pregnant patient
Inc risk of failed intubation Aspiration Hemorrhage Infection Thromboembolism
Pre-term delivery Teratogenesis IUDR Fetal asphyxia Miscarriage
Best time to perform semi-elective surgery in pregnant patient
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?
Which anesthetics are teratogenic
Non conclusively shown to result in inc congenital abnormalities
Possible teratogenic effects with nitrous oxide and benzos
Tocolytic? Monitoring for nonobstetric surgery in pregnant patient?
No evidence to support routine PPx tocolytic
Would use tocodynomatry to identify onset of labor
Monitoring for pregnant patient undergoing surgery
Foley OG Continuous fetal HR - optimize mother’s hemodynamics with FHR distress Left uterine displacement ABG for blood draws if diabetic etc
ECT considerations for pregnant patient
Weigh risks of psychotropic medications and performing treatment
Assoc with vaginal bleeding, abdominal pain, contractions, pre-term labor, neonatal cerebral infarction
EKG abnormalities in pregnancy
Left axis deviation
ST depression
Q-wave in lead III
Timing for baby delivery with maternal cardiac arrest
within 5 minutes if resuscitative efforts not successful
What is normal FHR variability?
fluctuations fo more than 2 cycles per minute
Epidural with HOCM
Ensure euvolemia to maintain adequate pre-load and dose slowly to avoid sympathectomy
Remember vasodilation and tachycardia with Pitocin - consider methergine or hematite first
What factors lead to to exacerbate LVOT obstruction ?
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
Would you risk radiation to baby to obtain a CT scan?
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
Irregular contractions and vaginal bleeding following trauma, no IV access, no CT done yet, would you proceed to urgent C/S?
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
Emergency C/S, AMS pregnant patient with difficult airway, swollen tongue. Would you consider a regional anesthetic, is spinal better than an epidural?
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.
Post Eclamptic seizure on magnesium, now notice widened QRS. What would you do?
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
How would you evaluate the need for blood patch?
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
What are the respiratory changes during pregnancy?
Inc O2 consumption
Inc MV d/t inc Tv
Dec FRC
OB patient receiving terbutaline for premature labor experiencing respiratory distress and B/L crackles. What do you think is the cause?
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
Tetanic uterine contractions and fetal bradycardia in transplanted heart following CSE cause?
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
How could you treat severely elevated uterine tone or tachysystole with fetal brady?
50-100mcg Nitro
125-250mcg IV terbutaline
How would you evaluate a previous heart transplant patient pre-op?
- talk to transplant team about immunosuppression, abc ppx
- review ECHO, angio, endocardial bx
- evaluate for signs of rejection - arrhythmias, fever, malaise, SOB
- identify and eval pacemaker
- review EKG for signs of ischemia (silent common from denervation)
- evaluate for chemo toxicity/complications - nephrotoxicity, anemia, hepatotoxicity, infections, HTN (cyclosporine)
- stress dose steroids
- ensure normovolemia (preload dependent)
Avoid beta blockers (need catecholamines) Avoid vasodilators (preload dependent)
OB patient with recent MI, ICM, Pre-E presents with PROM, would you recommend a C/S for this patient?
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.
OB patient with recent MI, ICM, Pre-E, raising level of epidural and you notice ST depressions. What would ou do?
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
Platelet level is 92,000, would you perform a regional anesthetic? What if it was 74,000?
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.
Pregnant patient admitted vaginal bleeding for urgent C/S. Would you perform a regional or general anesthetic?
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.
What is the role of cell salvage in obstetric patients?
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.
What features make pre-eclampsia severe?
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)
How would you manage mitral stenosis in pregnancy?
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
Should an epidural be used for labor analgesia in a patient with mitral stenosis?
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
How would you induce GA in pregnant patient with mitral stenosis and pulmonary HTN?
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
