OB (9/10) Flashcards
a pt with a placenta previa should be instructed to NOT….
- have vaginal exam
- have intercourse
T/F: a parturient with a placenta previa can deliver vaginally
false
_______________ is painless vaginal bleeding
placenta previa
risk factors for placenta previa
- uterine myomectomy
- advanced maternal age
- previous C/S
- multiparity
- previous previa
how is a placenta previa confirmed?
ultrasound
how do you anesthetically manage a parturient with placenta previa
based on…
1. amount of bleeding
2. stability of mother
3. maturity of fetus (delay delivery until 37 weeks if possible)
how does a placental abruption present
- painful vaginal bleeding
or - pain with no bleeding (bc concealed behind placenta)
S/Sx: of placental abruption
- painful vaginal bleeding
- decreased BP
- decreased fetal heart tones
- uterine tenderness
- back pain
- preterm labor
risk factors for placental abruption
- HTN
- preeclampsia
- advanced maternal age
4 tobacco use - cocaine use
- trauma
- PROM
- chorio
- bleeding in early pregnancy
- previous abruption
management of placental abruption
- emergency! due to risk of death in mother and fetus
- 2 lg bore ivs
- assess volume and clotting factors
- cross match
- GETA with etomidate for C/S
- support BP with fluids and pressors
causes of uterine rupture
- trauma
- excessive fundal pressure
- extensive cervical lac
- intrauterine manipulation
- forceps use
- manual placenta extration
- version
- inappropriate use of pit
- Grand maltip
- uterine anomaly
- placenta percreta
- tumors
- fetal problems (macrosomia, malposition)
treatment for uterine rupture
- repair
- arterial ligation
- hysterectomy
common causes of POSTpartum hemorrhage
- uterine atony
- genital trauma (at birth)
- retained placenta
- placenta accreta
- uterine inversion
________________ is when the placenta is adhered to the myometrium without invasion of myometrium
placenta accreta vera
________________ placental adherence with invasion of myometrium
placenta increta
_____________ placental adherence with invasion to the uterine serosa or other pelvic structures
placenta percreta
what is the most common type of accreta
placenta accreta vera
RF for accreta
- previous C/S
- uterine trauma
- D&C following miscarriage
pt has a history of previous C/S and comes in with previa; this should draw high suspicion of what?
accreta
tx of accreta
C/S with possible hysterectomy without delay
risk factors of uterine inversion
- uterine atony
- inappropriate fundal pressure
- excessive umbilical cord traction
- short umbilical cord
- uterine anomalies
Treatment of uterine inversion
- immediate replacement of uterus!
- consider: terbutaline, magnesium, IV/SL nitroglycerine
- general anesthesia
risk of postpartum hemorrhage increases significantly due to retained placenta when delivery of placenta is longer than _______________ min
30
anesthesia tx for retained placenta
- heavy dose existing CLE
- nitroglycerin (SL/IV)
- GETA/IV sedation
preterm labor is defined as labor between ________________ weeks gestation, and is defined as ____________ contractions in ___________ min or ___________ contractions in __________ min
20-37; 4 in 20; 8 in 60
intervention for preterm labor
- tocolytics (mag sulf)
- corticosteroid therapy
- neuraxial would aid with controlled vaginal delivery
what corticosteroids (and doses) would be administered for preterm labor
- betamethasone 12 mg IM q24h x2
or - dexmethasone 6 mg IM q12h x4
what is the leading cause of pregnancy related 1st trimester death
ruptured ectopic hemorrhage
causes of ectopic pregnancy
- altered fallpian tube transport
- prior tubal surgery
- pelvic inflammation
- previous pelvic surgery
- IUD use
- delayed ovulation
- hormonal changes
- smoking
- hx of infertility
- assisted reproductive procedure
early phase amniotic fluid embolism sx
- pulmonary vasospasm
- low CO
- VQ mismatch
- hypoxemia
- hypotension
early phase of amniotic fluid embolism lasts less than _____________ min
30
sx of 2nd phase amniotic fluid embolism
LV failure and pulm edema, then disruption of normal clotting cascade
what tx has increased survival of moms with amniotic fluid emboli?
- 1 mg of atropine
- 8 mg ondansetron
- 30 mg ketorolac
“AOK”
what types of LA are most likely to cause ion trapping in the acidotic fetus
amides (ones with 2 “i” in the name)
if you are having to do CPR on pregnant woman and the uterus is above the umbilicus, what should you do
perform aortocaval decompression via manual left uterine displacement or left lateral tilt
planning for labor analgesia in parturient
- perform pre-anesthetic eval (OB prenatal record, ask about HA, pre-existing numbness in LE)
- thorough airway assesment
- family hx of MH?
- surgical hx
- previous hx of labor analgesia - difficult placement? effective? complications
- pt VS
- NPO status
contraindications to neuraxial
- refusal/inability to cooperate
- increased ICP
- infection at site
- frank coagulopathy
- hemorrhage
- fetal instabiliyt
- inadequate training
ideally informed consent for laboring neuraxial analgesia should be obtained before ____________________
pts pain is severe or pt has received any analgesics
factors that affect the parturients decision to get an epidural
- pitocin (causes intense contraction with pain)
- prolonged labor
- unfavorable fetal positions (transverse, OP)
- small pelvis
- macrosomia
- primigravida
- IV meds are inadequate
- substance abuse hx (need epidural whether they want it or not)
- MD or RN preference
- when mom enters transition phase of labor
how many mg of lidocaine is in an epidural test dose?
15 mg/mL (1.5% solution) in 3-5 mL (45-75 mg)
how many mcg of epi in an epidural test dose
1:200,000 epi = 5 mcg/mL
3-5 mL = 15 - 25 mcg
what is the most common local used for epidural analgesia
bupivicaine
common loading dose of epidural is ________% bupivicaine and infusion = _______% bupiv + ___________
0.25; 0.125 + 2 mcg/mL fentanyl
bupivicaine in epidural will give pain relief in ___________ minutes, will peak at ________ min and lasts approximately _______ min
8-10; 20; 90
__________________ is ONLY used in epidurals and gives you less of a motor block than bupivicaine
ropivicaine - used for “walking epidural”
what does adding fentanyl to for continuous epidural
dilutes the LA and you get less of motor block –> allows mom to move legs
concentration for ropivicaine in continuous epidural
0.08-0.2%
benefits of ropivicaine in epidural over bupivicaine
- less cardiodepressant and less arrhythmogenic
- safer (cleared more rapidly)
- less motor block
what are the different epidural infusion modes
- continuous infusion with basal rate
- PCEA
- timed intermittent bolus injection
s/e of neuraxial analgesia
- hypotension
- pruritus (most common)
- N/V
- fever
- shivering
- urinary retention
- delayed gastric emptying
