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OB Flashcards

1
Q

Lung Patho: the gravid uterus shifts the diaphragm cephalad. What 3 things does this do?

A

FRC reduced (d/t decreased ERV and RV)

Increased O2 consumption with decreased FRC = hastens hypoxemia

FRC falls below closing capacity = airway closure during TV breathing

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2
Q

Progesterone is a respiratory

A

stimulant

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3
Q

What does progesterone do to minute ventilation?

A

MV increased up to 50% = moms PaCO2 falls and developed respiratory alkalosis. Renal compensation to normalize bicarb.

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4
Q 
ABG:
pH
PaO2
PaCO2
HCO3
A

pH - no change
PaO2 - increase (104-108)
PaCO2 - decrease (28-32)
HCO3 - decrease (20)

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5
Q

How does the oxyHGB dissociation curve change with pregnancy?

A

shifts to the right (increased P50)

facilitates O2 transfer to fetus

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6
Q

Minute ventilation = TV X RR

how to each change?

A

MV - Increased by 50%

TV - Increased by 40%
RR - increased by 10%

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7
Q

Lung Volumes:

TLC

A

decreased (5%)

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8
Q

Lung Volumes:

Vital capacity

A

No change

VC = TV + ERV + IRV

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9
Q

Lung Volumes:

FRC

A

Decreased (20%)

diaphragm compresses lungs

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10
Q

Lung Volumes:

ERV

A

Decreased (20-30%)

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11
Q

Lung Volumes:

Residual volume

A

Decreased (15-20%)

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12
Q

Lung Volumes:

Closing capacity

A

No change

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13
Q

O2 consumption @

  • TERM
  • 1st stage labor
  • 2nd stage labor
A
  • TERM - increased 20%
  • 1st stage - increased 40%
  • 2nd stage - increased 75%
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14
Q

What happens to mallampati score

A

increases d/t vascular engorgement and soft tissue edema

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15
Q

CV O2 consumption

A

increases 20%

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16
Q

CO = HR X SV

CO -

A

CO - increases 40%

Uterus receives 10% CO
Uterine contraction causes autotransfusion/increased preload

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17
Q

CO = HR X SV

HR

A

Increased 15%

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18
Q

CO = HR X SV

SV

A

increased 30%

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19
Q

Compared to prelabor values, CO during labor

1st stage
2nd stage
3rd stage

A

1st stage - increased 20%
2nd stage - increased 50%
3rd stage - increased 80%

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20
Q

CO returns to preLABOR values in ______

CO returns to prePREGNANCY values in ______

A

24-48 hours

~2 weeks

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21
Q

Blood Pressure

MAP
SBP
DBP

A

MAP - no change
SBP - no change
DBP - decreased

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22
Q

SVR

A

decrease 15%

progesterone causes vascular muscle relaxation

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23
Q

PVR

A

Decrease 30%

progesterone causes vascular muscle relaxation

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24
Q

Filling pressures

CVP
PAOP

A

CVP - no change

PAOP - no change

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25
Q

How does the cardiac axis change?

A

left deviation

gravid uterus pushes diaphragm cephalad and heart pushed up/left

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26
Q

intravascular fluid volume

  • plasma volume
  • erythrocyte volume
A

intravascular fluid volume - increased 35%

plasma - increased 45%
erythrocyte - increased 20%

(creates dilution anemia)

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27
Q

Clotting factors that are increased

A

I, VII, VIII, IX, X, XII

pregnancy creates hypercoaguable state

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28
Q

Anticoagulants that are decreased

A

C & S

DVT 6X more likely

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29
Q

Fibrinolytics that are increased

A

increased fibrin breakdown

counteracts hypercoagulability

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30
Q

Anti-fibrinolytics that are decreased

A

XI and XIII

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31
Q

How does MAC change?

A

Decreased 30-40%

begins at 8-12 weeks

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32
Q

How does sensitivity to LAs change?

A

Increased

d/t increased progesterone

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33
Q

How does epidural vein volume change?

A

Decreased

decrease volume of subarachnoid space and epidural space - compressive effect

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34
Q

How does ICP change?

A

No change

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35
Q

How does gastric volume change?

A

Increased

give H2 receptor blocker to decrease volume –> ranitidine

(d/t increased gastrin)

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36
Q

How does gastric pH change

A

Decreased

this means more acidic –> give citrate

(d/t increased gastrin)

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37
Q

How does LES tone change?

A

Decreased

reglan increases LES

(d/t increased progesterone, estrogen and cephalad displacement of diaphragm)

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38
Q

How does gastric emptying change?

A

No change before onset of labor, DECREASED after labor begins

reglan hastens gastric emptying

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39
Q

How does GFR change?

A

Increased

d/t increased blood volume and CO

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40
Q

How does creatine clearance change?

A

Increased

d/t increased blood volume and CO

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41
Q

How does glucose in urine change?

A

Increased

d/t increased GFR and decreased renal absorption

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42
Q

How does Cr and BUN change?

A

Decreased

d/t increased CrCl
–> if Cr and BUN are unchanged, they are actually elevated

43
Q

How does uterine blood flow change?

A

Increased

500-700 ml/min
10% CO

44
Q

How does serum albumin change?

A

Decreased

= increased free fraction of highly protein bound drugs

45
Q

How does pseudocholinesterase change?

A

Decreased

no meaningful effects of Succs on metabolism

46
Q

What are the drug characteristics that favor placental transfer

A

low molecular weight (<500 daltons)

most anesthetic drugs are <500 daltons

47
Q

Drugs with significant placental transfer

A 
LAs (except chloroprocaine)
IV anesthetics
Volatile Anesthetics
Opioids
Benzos
Atropine
Beta-blockers
Mag (no lipophilic but its small)
48
Q

Drugs with no placental transfer

A

NMBs
Heparin
Insulin
Glyco

49
Q

What is stage 1 of labor

A

Beginning of regular contractions to full cervical dilation (10cm)

50
Q

What is stage 2 of labor

A

Full cervical dilation (10cm) to delivery of fetus

Pain in perineum begins during stage 2

51
Q

What is stage 3 of labor

A

Delivery of placenta

52
Q

Active and latent phase are part of which stage?

A

Stage 1

Latent phase - 2-3 cm dilated
Active phase full dilation

53
Q

What are NPO guidelines during labor

A

Drink moderate amount of clear liquids throughout labor

Eat solid foods until neuraxial block is placed

54
Q

1st stage of labor pain begins where? Which nerve roots?

A

Pain begins in lower uterine segment and cervix

T10-L1 posterior nerve roots

55
Q

1st stage of labor pain afferent pathway –> starts in what fibers and goes where?

A

visceral C fibers –> hypogastric plexus

dull, diffuse, cramping pain

56
Q

Regions techniques for 1st stage labor pain

A

Neuraxial (spinal, epidural, CSE)

Paravertebral lumbar sympathetic block

Paracervical block

57
Q

What is the risk with paracervical blocks?

A

high risk of fetal bradycardia!

58
Q

2nd stage pain adds pain impulses from where?

A

Vagina, perineum, pelvic floor

59
Q

2nd stage pain impulses travel from perineum to which nerve roots?

A

S2-S4 posterior nerve roots

sharp, well localized pain

60
Q

Regions techniques for 2nd stage labor pain

A

Neuraxial (spinal, epidural, CSE)

Pudendal nerve block

61
Q

Normal Fetal HR

  • Fetal causes
  • Maternal causes
A

110-160

Fetal: Intact CNS/ANS & normal acid base balance

Maternal: normal uteroplacent blood flow

62
Q

Bradycardic Fetal HR

  • Fetal causes
  • Maternal causes
A

<110

Fetal: Asphyxia & Acidosis

Maternal: Hypoxia & drugs that reduce placental blood flow

63
Q

Tachycardic Fetal HR

  • Fetal causes
  • Maternal causes
A

> 160

Fetal: hypoxia & arrhythmias

Maternal: Fever, Chorioamnionitis, Atropine, Ephedrine, Terbuterline

64
Q

Evaluation of FHR

Category 1

A
  • Baseline HR 110-160
  • Moderate variability
  • Accelerations absent or present
  • Early decels absent or present
  • NO late or variable decels
65
Q

Evaluation of FHR

Category 2

A
  • Bradycardia w/o absence of baseline FHR variability
  • Tachycardia
  • Variable variability
  • Absent/minimal acceleration with fetal stimulation
  • Recurrent variable decels
66
Q

Evaluation of FHR

Category 3

A
  • Bradycardia
  • Absent baseline variability
  • Recurrent late decels
  • Recurrent variable decels
  • Sinusoidal pattern
67
Q

Complications of premature delivery

A 
Resp distress syndrome
Intraventricular hemorrhage
NEC
HYPOglycemia
HYPOcalcemia
Hyperbilirubinemia
68
Q

What drug is given to hasten fetal lung maturity and when does it begin to work

A

betamethasone

begins to take effect within 18 hours and peak benefit at 48 hours

69
Q

What is a tocolytic and what are some examples

A

Used to delay labor by suppressing uterine contractions up to 24-48 hours (provide bridge to allow corticosteroids to work)

Beta 2 agonists
mag
Ca Channel blockers
Nitric oxide donors

70
Q

What are examples of beta 2 agonists

A

ritodrine and terbutaline

71
Q

What are side effects of beta 2 agonists

A

Hyperglycemia (mother)
Hypoglycemia (infant)
Hypokalemia
Can cross placenta and increase FHR

72
Q

What patient population should you use mag cautiously in?

A

kidneys eliminate mag, so caution in renal insufficiency

73
Q

What is the first sign of mag toxicity?

A

If deep tendon reflexes are present - risk of toxicity is low

Deep tendon reflexes are the first sign of mag toxicity

74
Q

What is the normal mag level

A

1.8-2.5 mg/dL

75
Q

Hypomag symptoms

A

<1.2
Tentany, seizure, dysrhythmia

1.2-1.8
neuromuscular irritability, hypokalemia, hypocalcemia

76
Q

What mag level typically has no symptoms

A

2.5-5 mg/dL

77
Q

symptoms of mag level 5-7 mg/dL

A

Diminished deep tendon reflexes
lethargy/drowsiness
flushing
N/V

78
Q

symptoms of mag level 7-12 mg/dL

A

Loss deep tendon reflexes
hypotension
EKG changes
somnolence

79
Q

symptoms of mag level >12 mg/dL

A 
Resp depression --> apnea
complete heart block
cardiac arrest
coma
paralysis
80
Q

Side effects of mag toxicity

A

Pulmonary edema
hypotension
skeletal muscle weakness (potentials NMB)
CNS depression
Reduced response to ephedrine and phenylephrine

81
Q

What is the first line agent for tocolysis

A

PO nifedipine

82
Q

Co-admin of nifedipine with what other agent can contribute to skeletal muscle weakness

A

magnesium

83
Q

what mag level is considered tocolysis

A

4-8 mg/dL

84
Q

What are uterotonic drugs used for? what are examples

A

stimulate uterine contraction

Oxytocin
Methergine (ergot alkaloid)
Prostaglandin F2

85
Q

indicators for use of oxytocin/pitocin

A

to induce or augment labor, stimulate uterine contraction, combat uterine hypotonia or hemorrhage

86
Q

when do you admin oxytocin

A

during c/s, admin after delivery of placenta

87
Q

side effects of oxytocin

A

water retention, hyponatremia, hypotension, reflex tachycardia, coronary vasoconstricton

88
Q

Methergine (ergot alkaloid) is a second line uterotonic, what is the dose & how is it administered

A

0.2mg IM

IV admin can cause significant vasoconstriction, HTN and cerebral vasoconstriction

89
Q

Prostaglandin F2 is a 3rd line uterotonic, what is the dose & how is it administered

A

250mcg IM or injected into uterus

90
Q

Side effects of prostaglandin F2

A

N/V
Diarrhea
Hyper or hypotension

91
Q

ideally, nonobstretical surgery is delayed until _____ weeks after delivers. Otherwise, when is the best time to perform surgery in the pregnant patient

A

2-6 weeks

second trimester

92
Q

Why should you avoid NSAIDs in the pregnant patient?

A

they may close the ductus arteriosis

93
Q

What the difference between gestation HTN, pre-eclampsia, and eclampsia

A

Gestational HTN

  • occurs after 20 weeks
  • HTN

Pre-eclampsia

  • occurs after 20 weeks
  • HTN
  • protenuria
  • edema

Eclampsia

  • occurs after 20 weeks
  • HTN
  • protenuria
  • edema
  • Seizures
94
Q

A healthy placenta produces thromboxane and prostacyclin in equal amounts, however, the pre-eclamptic patient produces 7X more ____

A

more thromboxane than prostacyclin

thromboxane favors increased vasoconstriction, platelet aggregation, uterine activity
&
decreased uteroplacental blood flow

95
Q

What is SBP and DBP for mild and severe disease

A

mild
= 160
= 110

severe
>/= 160
>/=110

no need to medicate with antihypertensives until BP > 160/110

96
Q

What is the preferred anesthetic management for the pre-eclamptic patient

A

neuraxial anesthesia assists with BP control and provided better uteroplacental perfusion. BE SURE TO RULE OUT THROMBOCYTOPENIA (<100,000)

97
Q

maternal cocaine use will cause HTN, what is best choice for treatment

A

labetalol (Blocks alpha and beta - NEED BOTH)

Vasodilators

98
Q

hypotension from maternal cocaine use will not respond to _____, what should be used instead?

A

ephedrine (becuase this is indirect acting - dependent on catecholamine stores, which are depleted)

give phenylephrine

99
Q

What is chronic cocaine use associated with?

A

thrombocytopenia

100
Q

With placenta accreta, increata, and percreta - what is the preferred anesthetic technique

A

although RA is safe, GA is preferred

101
Q

APGAR Score

normal
moderate distress
impending demise

A

APGAR Score

normal: 8-10
moderate distress: 4-7
impending demise: 0-3

102
Q

KNOW HOW TO CALCULATE AN APGAR SCORE

A

look at chart (all pretty easy to figure out..)

HR >100 = 2
HR<100 = 1
HR absent = 0

103
Q

Newborn HR, RR , SPO2

A

HR 120-160 (HR <60 = CPR)
RR 30-60
SPO2 immediately after delivery is 60% and should rise to 90 after 10 min

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