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Advanced Principles II > OB Anesthesia > Flashcards

OB Anesthesia Flashcards

1
Q

What are the causes of early changes in the pregnant woman?

A

Effects of progesterone, estrogen and prostaglandins

Increased metabolism demands of the fetus, placenta and uterus

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2
Q

What is the major cause of changes later in pregnancy?

A

Caused my mechanical displacement by the uterus

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3
Q

What cardiovascular changes are seen during pregnancy/

A

CO increases by 40%
HR increases
Blood flow increases to major organs

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4
Q

What organs does blood flow increase during pregnancy?

A

Uterus
Kidneys
Breast
Skin

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5
Q

What do ninety percent of pregnant develop?

A

Systolic ejection murmur, not pathologic unless greater than class III

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6
Q

What causes CO to increase during pregnancy?

A

Increase in chamber volume and increase in size of the ventricular wall

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7
Q

Why is there an increased risk of intravascular injection with regional anesthesia in pregnant women?

A

The extradural veins are distended

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8
Q

How do local anesthetic requirements change during pregnancy?

A

Decrease LA by 30%

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9
Q

Why does the both the SBP and DBP decrease slightly in the second trimester?

A

Due to decrease SVR, will return to baseline in third trimester

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10
Q

Why might EKG changes be seen during pregnancy?

A

The size of the heart increase by 12% and the heart is displaced up to the left and rotates laterally

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11
Q

What type of EKG changes may been seen with pregnancy?

A

Left axis deviation and ST & T wave changes in lead III

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12
Q

How is blood volume affected with pregnancy?

A

40-50% increase in plasma volume with an increased volume of distribution

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13
Q

Why might a pregnant patients labs show a low HH?

A

Hemodilution from a smaller change in blood components than plasma volume

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14
Q

How is clotting affected during pregnancy?

A

Fibrinogen and Factors VII, IX and X increase markedly

Increased in platelet count

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15
Q

After the second trimester, what can cause a decrease in CO?

A

Aortocaval compression, when the uterus compresses the aorta and IVC

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16
Q

What position is known to cause aortocaval compression?

A

The supine position

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17
Q

What can prolonged aortocaval compression cause?

A

Supine hypotension syndrome

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18
Q

How does supine hypotension syndrome affect the fetus?

A

Decreased uterine blood flow can result in fetal acidosis during labor

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19
Q

What are symptoms of supine hypotension syndrome?

A

N/V
Diaphoresis
Possible changes in cerebration
Fetal bradycardia

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20
Q

If a pregnant patient reports nausea while in the supine position what should be assumed?

A

HoTN and the provider should treat immediately

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21
Q

How should supine hypotension syndrome be treated?

A

Left uterine displacement:
Wedge under right hip
Tilting OR tabel 15-30 degrees to the left
Using a mechanical uterine displacing device

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22
Q

What is the thought to cause a decrease in airway resistance in the pregnant patient?

A

Progesterone mediated relaxation of bronchial musculature

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23
Q

Why do pregnant women often complain about having a stuffy nose?

A

Vascular engorgement of the nasopharynx, larynx, trachea and bronchi
Vocal cord changes and difficulty breathing through the nose

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24
Q

What is the compensatory mechanism for the diaphragm being displaced?

A

Increased in transverse and AP chest diameters and rib flaring due to hormonal ligament loosening effects

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25
Q

How much does the placenta displace the diaphragm?

A

4-6cm upward

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26
Q

What lung volumes are affected by the displacement of the diaphragm?

A

20% decrease in ERV, RV and FRC

However TV increased 35-50%

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27
Q

What position is affects the most by the decrease in chest wall compliance?

A

Lithotomy position

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28
Q

Why is a pregnant women’s PaCO2 lower than normal?

A

50% increase in minute ventilation

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29
Q

How much does O2 consumption increase in a pregnant woman?

A

O2 consumption increases by 20% however labor increases O2 consumption by 60%

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30
Q

What is the rule of thumb for choosing an ETT for a pregnant woman?

A

Smaller size needed 6.0-6.5

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31
Q

Why might the anesthetic provider choose to do a mask induction on a pregnant woman?

A

Inhalation induction faster due to increased MV and decreased RV

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32
Q

Why do pregnant women experience heart burn more frequently?

A 
Stomach and intestines are displaced cephalic which increases intragastric pressure
Stomach is more vertically positioned
Angle of GE junction is changed
Relaxation of the LES
Delayed gastric emptying
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33
Q

At what point during pregnancy is a woman considered a full stomach?

A

All women after 14 weeks

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34
Q

What precautions should be taken if GA is required for the pregnant patient?

A

Avoid positive presse ventilation with mask anesthesia

Use RSI with cricoid pressure

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35
Q

What medications can be given pre-op to prevent aspiration on induction?

A

Bicitra
Reglan
H2 blocker

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36
Q

How does pregnancy affect the kidneys?

A

Increases the kidney size and causes the renal pelvis and ureters to dilate

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37
Q

How much does GFR and renal plasma blood flow increase during pregnancy?

A

50-60%

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38
Q

Why is it normal for the pregnant woman to have mild glycosuria and proteinuria?

A

Renal tubule reabsorption is decreased

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39
Q

Why do pregnant women often experience a relative fasting hypoglycemia?

A

Insulin secretion is enhanced and the needs of the fetus are met first

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40
Q

What is a normal pregnant FBG?

A

70mg/dL

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41
Q

When do signs of hypoglycemia begin to occur?

A

At 40mg/dL

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42
Q

Why might the provider give less succinylcholine if GA is required for delivery?

A

Serum cholinesterase levels decrease by 25-30%, lowest being 7 days post-partum

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43
Q

How is MAC affected by pregnancy?

A

MAC decreases by 25-40%, don’t have to give as much agent to achieve the desired effect

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44
Q

Why do pregnant women have a longer elimination half life?

A

Due to increased volume of distribution

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45
Q

How long does a pregnant woman experience altered drug responses?

A

Until 3 months post-partum

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46
Q

What are the two functions of the placenta?

A

Transport and Endocrine function

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47
Q

How does the placenta facilitate in transport?

A

Delivers nutrients and oxygenated blood and removes waste products

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48
Q

What are the endocrine functions of the placenta?

A

Synthesis and secretes progesterone and estrogens and takes function over from the ovaries

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49
Q

At term, how much CO is required for appropriate uterine blood flow?

A

Accounts for 10% of CO

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50
Q

How much uterine blood flow participates in placental exchange?

A

80%

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51
Q

What determines uterine blood flow?

A

Directly dependent on uterine perfusion pressure (MAP) and number and size of spiral arteries
Not autoregulated

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52
Q

What structure delivers 50% of uterine blood flow to the placenta bed?

A

Umbilical artery

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53
Q

What are causes of decreases in uterine blood flow?

A

Uterine contractions, hypertonus, HoTN/HTN, aortocaval compression and drugs that affect BP

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54
Q

How does the fetus receive oxygenated blood if their lungs are not functional?

A

Maternal blood bypasses the lungs and utilized two cardia shunts to deliver oxygenated blood?

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55
Q

What are the two cardiac shunts in fetal circulation?

A

Foramen Ovale

Ductus Arteriosis

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56
Q

How does fetal Hgb affect the oxyHgb dissociation curve?

A

Shifts the curve to the left, enhances placental oxygen uptake

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57
Q

What structure delivers oxygenated blood from the placenta to the fetus?

A

Umbilical vein

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58
Q

What is the average O2 sat of blood delivered via the umbilical vein?

A

80%

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59
Q

What is the average O2 sat of blood once it enters the ductus venosus?

A

O2 sat is 67%

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60
Q

What is the function of the umbilical arteries?

A

Two vessels that take deoxygenated blood from the descending aorta to the placenta

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61
Q

What can cause persistent fetal circulation after birth?

A

Hypoxemia and acidosis

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62
Q

What is the treatment for persistent fetal circulation?

A

Prostaglandins (for vasodilation of the pulmonary vasculature) and Mechanical ventilation

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63
Q

What are the five mechanisms for placental transfer?

A 
Passive diffusion
Active transport
Facilitated diffusion
Filtration
Pinocytosis
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64
Q

What is the function of passive diffusion in placental transfer?

A

Dependent on concentration gradient and is the principle mode of drug transfer
O2, CO2, drugs and eletrolytes

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65
Q

What is the function of active transport in placental transfer?

A

Requires carrier system and energy

Amino acids and water soluble vitamins

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66
Q

What is the function of facilitated diffusion in placental transfer?

A

Also dependent on concentration gradient

Glucose

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67
Q

What is the function of filtration in placental transfer?

A

Dependent on hydrostatic or pressure gradient

Water and some solids

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68
Q

What is the function of pinocytosis in placental transfer?

A

Immunoglobulins, proteins and macromolecules

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69
Q

What factors determine drug concentration in the uterine artery?

A

Drug dose, rout of administration, maternal metabolism and excretion, maternal protein binding and maternal pH and drug pKa

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70
Q

What factors determine drug concentration if the umbilical artery?

A

Umbilical venous concentration, fetal pH, fetal protein and tissue binding, fetal hepatic metabolism and renal excretion

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71
Q

What drug properties affect the rate of placental transfer?

A

Lipid solubility
Molecular weight
Ionization

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72
Q

How does lipid solubility affect placental transfer?

A

Highly lipid soluble substances readily cross the placenta

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73
Q

How does molecular weight affect placental transfer?

A

Smaller molecules cross the placenta more easily

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74
Q

How does ionization affect placental transfer?

A

Highly ionized drugs are not going to cross as easily

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75
Q

What is ion trapping?

A

Occurs when unionized drugs cross the placenta, there they dissociate and the ionized portions will be trapped on the fetal side

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76
Q

What drugs frequently cause ion trapping?

A

Think local anesthetics

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77
Q

How can a provider administer a drug to mom but decrease the amount transferred to the fetus?

A

Administer the dug just before uterine contractions

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78
Q

What ethnicity and sex have the highest rate of RDS after delivery?

A

Young white males

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79
Q

What teratogenesis is associated with benzodiazepine use?

A

Cleft lip and palate

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80
Q

What teratogenesis is associated with nitrous oxide use?

A

Neurologic changes and hematologic changes similar to pernicious anemia

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81
Q

What teratogenesis is associated with cocaine?

A

GI and GU anomalies

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82
Q

When is optimal time for elective surgery during pregnancy?

A

The second trimester

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83
Q

What does the letter G represent when looking at a pregnant patient’s chart?

A

Gravida, meaning the number of pregnancies

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84
Q

What does the letter P indicate when looking at a pregnant patient’s chart?

A

Parity

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85
Q

What does the first number indicate after the letter P in a pregnant patient’s chart?

A

The number of term pregnancies

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86
Q

What does the second number indicate after the letter P in a pregnant patient’s chart?

A

Pre-term pregnancies (20-37 weeks)

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87
Q

What does the third number indicate after the letter P in a pregnant patient’s chart?

A

Spontaneous and elective abortions (

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88
Q

What does the fourth number indicate after the letter P in a pregnant patient’s chart?

A

Living children

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89
Q

What is considered the first trimeter of pregnancy?

A

Week 0-14 weeks

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90
Q

When does maternal drug intake begin to affect the fetus?

A

Does not affect fetus until implantation has occurred

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91
Q

What are the most common complaints in the first trimester of pregnancy?

A

Fatigue and Nausea

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92
Q

What is thought to cause fatigue in the first trimester?

A

Low BP, Low BG and physiologic anemia

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93
Q

What is considered the second trimester of pregnancy?

A

12-28 weeks

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94
Q

When is fetal movement usually felt?

A

15-18 weeks

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95
Q

Secretion of which hormone is thought to cause pelvic widening and gait changes?

A

Relaxin secretion induces biochemical changes in the cervix and ligaments loosen

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96
Q

When does a fetus become viable?

A

Greater than 24 weeks

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97
Q

How is the spine affected in the second trimester of pregnancy?

A

Lumbar lordosis increases progressively

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98
Q

What is considered the third trimester of pregnancy?

A

29-42 weeks

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99
Q

How might a practitioner determine gestational age once in the third trimester?

A

Fundal height

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100
Q

How much weight does the baby gain in the last month of pregnancy?

A

1/2 a pound per week in the last month

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101
Q

What is considered fetal tachycardia?

A

HR greater than 160bpm in term infants

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102
Q

What is considered fetal bradycardia?

A

HR less than 120bpm

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103
Q

What is the single best indicator of fetal well being?

A

Variability in fetal HR

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104
Q

What is considered short term variability?

A

Difference between 2-3 adjacent beats

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105
Q

What is considered long term variability?

A

Denotes the rough sign waves that occur 3-6 times per minute with variation of at least 6bpm

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106
Q

What is variability thought to indicate in a fetus?

A

An intact CNS regulatory mechanism

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107
Q

What are early decelerations associated with?

A

Head compression

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108
Q

What is considered a deceleration?

A

Decrease in HR low the fetal HF baseline

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109
Q

When looking at fetal surveillance what does an early deceleration look like on the strip?

A

Mirror image, the peak of the deceleration occurs with the peak of the contraction

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110
Q

What is the thought to cause the deceleration with uterine contractions?

A

Vagal discharge when the head is compressed by the contraction

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111
Q

What do variable decelerations indicate?

A

Cord compression

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112
Q

What is thought to cause variable decelerations when the cord is compressed?

A

Lack of O2, the decomposition of cerebral blood flow and O2 delivery result in a loss of fetal HR variability

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113
Q

What type of fetus will variability be absent?

A

Ancephalic fetus, why HR variability suggest the integrity of the CNS

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114
Q

What do late decelerations indicate?

A

Placental insufficiency

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115
Q

How might a late deceleration look on fetal surveillance?

A

Deceleration shifted to the right of the contraction, the lowest point of the deceleration occurs after the peak of the contraction

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116
Q

What is thought to cause the bradycardia in late decelerations?

A

O2 level in the fetal blood triggers the chemoreceptors to cause a reflex constriction of blood vessels in non vital peripheral areas so blood can be diverted to vital organs, causes HTN and stimulates baroreceptor mediated vagal response

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117
Q

Why are late deceleration after the contraction?

A

The compensatory process takes time before a result is seen

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118
Q

What occurs in stage 1 of labor?

A

Latent 0-4cm
Active 4-10cm
Transition time periods

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119
Q

What occurs in stage 2 of labor?

A

Delivery

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120
Q

What occurs in stage 3 of labor?

A

Delivery of placenta

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121
Q

Why might the epidural dosing change when a pregnant patient reaches the transitional stage of labor?

A

The pain changes from visceral to somatic

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122
Q

What tool can be used to determine normal labor progression?

A

Freidman’s Labor curves

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123
Q

According to Freidman’s labor curves, what is the normal amount of time it take a pregnant patient to dilate 4cm?

A

0-4cm takes about 8hrs

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124
Q

According to Freidman’s labor curves, what is the normal amount of time it take a pregnant patient to dilate from 4-10cm?

A

4cm hits active labor, dilate 3cm/hr until 10cm is reached

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125
Q

What drug is often used to augment labor?

A

Pitocin

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126
Q

What are the most common risks of using Pitocin?

A

Uterine rupture
Antidiuretic affect –> water toxicity
Hyper stimulation leading to fetal distress

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127
Q

What is a normal labor presentation of the fetus?

A

OA, occiput anterior

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128
Q

What presentation is the fetus in if it comes out face up?

A

OP, occiput posterior

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129
Q

What structures of the fetus allow for head compression as it descends in the labor canal?

A

Fontanels

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130
Q

What is a VBAC delivery?

A

Vaginal birth after c-section

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131
Q

What is a major risk factor of VBAC deliveries?

A

Uterine rupture

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132
Q

What type of uterine incisions are not allowed to have VBACs?

A

If it was a vertical incision

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133
Q

Why might a provider choose not to give a VBAC an epidural?

A

The patient would not know if she ruptured her uterus

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134
Q

How often is some form of resuscitation required at birth for the newborn?

A

25%

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135
Q

Why might newborn resuscitation be required?

A

Maternal reasons
Fetal reasons
Delivery difficulties

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136
Q

What determines resuscitation needs of a newborn?

A

Apgar scores

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137
Q

What are the five parameters of Apgar scores?

A 
HR
RR
Muscle tone
Response to stimulation
Skin color
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138
Q

What is the range of Apgar scores?

A

0-10

Each of the five components receive a score from 0-2

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139
Q

When are Apgar scores assigned?

A

1, 5 and 10 minutes of life

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140
Q

What determines CO in the infant?

A

HR dependent, stroke volume is fixed by a noncompliant poorly developed left ventricle

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141
Q

What is the primary cause of cardiac arrest in neonates and infants?

A

Hypoxemia

142
Q

What airway pressures should be used when giving breaths to a neonate that had a normal delivery?

A

15-20cmH2O

143
Q

What airway pressure should be used on the initial breath after delivery on a neonate?

A

30-40cmH2O

144
Q

What airway pressure should be used when giving breaths to a neonate that has diseased lungs?

A

20-40cmH2O

145
Q

When should a provider initiate rescue breaths on a neonate?

A

Apnea or HR

146
Q

What rate should the provider gives rescue breaths to a neonate?

A

40-60bpm

147
Q

When should a newborn be intubated?

A

Prolonged bag and mask ventilation
Ineffective bag and mask ventilation
Tracheal suctioning
Severe prematurity

148
Q

What is an appropriate ETT size for a newborn that is greater than 3000g

A

4.0 ETT

149
Q

What is an appropriate ETT size for a newborn that is 2000-3000g

A

3.5 ETT

150
Q

What is an appropriate ETT size for a newborn that is 1000-2000g

A

3.0 ETT

151
Q

What is an appropriate ETT size for a newborn that is less than 1000g

A

2.5 ETT

152
Q

What features of the newborn make intubation challenging?

A

Karge occiput can make intubation difficult, consider shoulder roll

153
Q

When are chest compressions indicated in the newborn?

A

If after 15-30 seconds of positive pressure ventilation with 100% FiO2
HR

154
Q

What is the ratio of compressions to breaths in neonatal resuscitation?

A

5:1

Compression rate is 10/min

155
Q

What should the provider do if meconium is present at delivery?

A

Oral and nasopharyngeal suctioning when the infants head is delivered

156
Q

How can the provider prevent meconium aspiration?

A

Limit stimulation and prevent crying

157
Q

After the neonate is delivered, what interventions are done if meconium aspiration is suspected?

A

The infant is immediately intubated and suctioned

158
Q

What is an ectopic pregnancy?

A

Implantation of a fertilized egg outside the uterine cavity

159
Q

Where can an ectopic pregnancy occur?

A 
Fallopian tubes
Cervix
Ovary
Cornual region of the uterus
Abdominal cavity
160
Q

Where is the most common place for an ectopic pregnancy to occur?

A

The fallopian tube

161
Q

What are risk factors for an ectopic pregnancy?

A 
History of PID
Previous ectopic pregnancy
Hx tubal surgery
Fertility drugs
IUD
162
Q

What are potential complications of an ectopic pregnancy?

A

Rupture of pelvic organ or structure
Massive hemorrhage
Infertility
Maternal death

163
Q

When can methotrexate be given to treat and ectopic pregnancy?

A

Fetus must be less than 3.5cm

164
Q

What intervention can be done for an incompetent cervix?

A

Cervical cerclage

165
Q

What is intrauterine growth restriction?

A

Growth of the fetus is inhibited by a hostile intrauterine environment

166
Q

What can cause a hostile uterine environment?

A

Maternal causes-HTN, DM, drug use

Placental causes

167
Q

What are characteristics of IUGR?

A

Birth weight less than 10th percentile
Asymmetrical growth
Oligohydramnios
Fundal height greater than or equal to 3cm from expected

168
Q

What is thought to cause intrauterine growth restriction?

A

Nutrition and gas exchange to the fetus is diminished, causing nutritional stores to be depleted
The blood flow is redistributed to vital organs

169
Q

What are fetal complications of IUGR?

A 
Intolerance of labor
Still birth/fetal demise
Temperature instability
Thrombocytopenia
NEC
Renal failure
170
Q

Why does the fetus with IUGR develop NEC and renal failure?

A

Preferential blood flow away from GI tract and kidneys

171
Q

What can decrease the risk of breech presentation?

A

Incidence decreases with increasing gestational age

172
Q

What are the three types of breech position?

A

Frank
Complete
Incomplete

173
Q

Describe the Frank breech presentation.

A

Hips flexed with legs straight up

174
Q

Describe the complete breech presentation.

A

Sitting indian style

175
Q

Describe the incomplete breech presentation.

A

Feet or knees presenting

176
Q

If a fetus is in the breech position how might this child be delivered?

A

Vaginal trial of labor
Elective C-section
External cephalic version

177
Q

What conditions must be present to do a vaginal trial of labor for a breech fetus?

A

Fetal weight less than 3600gms
Adequate maternal pelvis
Fetal head flexed
Frank or complete breech

178
Q

What are potential labor complications with a breech fetus?

A

Failure to progress
Umbilical cord prolapse
Fetal head entrapment
Increased maternal and fetal morbidity and mortality

179
Q

What are the four types of malpresentation?

A

Face
Brow
Breech
Shoulder/transverse

180
Q

What drugs should be available after a multiple gestation birth?

A

Pitocin
Methergine
Hemabate

181
Q

What is considered premature rupture of membranes?

A

Rupture of membranes prior to 37 weeks gestation

182
Q

What are complications associated with PROM?

A

Chorioamnionitis
Pre term labor
Fetal pulmonary hypoplasia
Umbilical cord prolapse

183
Q

What is considered preterm labor?

A

Contractions with cervical dilation/effacement at 20-37 weeks gestation

184
Q

What can contribute to preterm labor?

A

Infection, uterine distention, uterine anomalies, cervical compromise, placental abruption and uteroplacental insufficiency

185
Q

What are possible treatment options for preterm labor?

A

Delivery

Tocolysis

186
Q

What tocolytic agents can be used to stop preterm labor?

A

MgSO4
Indomethacin
Ritodrine and Terbutaline
Nifedipine

187
Q

What is the mechanism of action of MgSO4 in preventing preterm labor?

A

Calcium channel blocker

188
Q

What is the mechanism of action of Indomethacin in preventing preterm labor?

A

PGE inhibitor

189
Q

What is the mechanism of action of Ritodrine and Terbutaline in preventing preterm labor?

A

Beta Sympathemomimetics

190
Q

What is the mechanism of action of Nifedipine in preventing preterm labor?

A

Calcium channel blocker

191
Q

What are complications associated with treatment of preterm labor with MgSO4?

A

Respiratory/CNS depression

Cardiac conduction block

192
Q

What are complications associated with treatment of preterm labor with Indomethacin?

A

Bronchospasm (do not give to mother with asthma)

Bleeding, fetal NEC and IVH

193
Q

What are complications associated with treatment of preterm labor with Ritodrine and Terbutaline?

A

Cardiac arrythmias or ischemia

CHF

194
Q

What tocolytic agent is not typically the standard of care?

A

Nifedipine

195
Q

What drugs can be given to accelerate fetal lung maturity?

A

Glucocorticoids, however must give 12hrs to be effective

196
Q

What occurs in a pregnant woman who experiences abruptio placenta?

A

Premature separation of the placenta from the uterus

197
Q

What condition is often confused with placental abruption?

A

Placenta previa

198
Q

What is typically the clinical presentation of abruptio placenta?

A

Moderate to severe abdominal pain
Vaginal bleeding
Uterine contractions or hypertonus/tenderness
Fetal distress

199
Q

When placental abruption occurs who is more at risk?

A

Fetal then maternal death

200
Q

What is placenta previa?

A

Placental implantation over the cervical os

201
Q

Why type of delivery is not possible if placenta previa is present?

A

Vaginal delivery

202
Q

What are the four types of placenta previa?

A

Complete
Partial
Marfinal
Low-lying

203
Q

Describe complete placenta previa.

A

Placenta completely covers the cervical os

204
Q

Describe partial placenta previa.

A

Placental edge partially covers os

205
Q

Describe marginal placenta previa.

A

Placental edge approaches cervical os

206
Q

Describe low-lying placenta previa.

A

Located at lower half or third of uterus

207
Q

What is the hallmark symptom of placenta previa?

A

Painless vaginal bleeding in the second or third trimester

208
Q

What is the treatment for placenta previa?

A

Strict bedrest
Pelvic rest
Fluid resuscitation and Transfusion PRN
Tocolysis

209
Q

What types of placenta previa can vaginal delivery be considered?

A

Marginal or partial previa with minimal bleeding

210
Q

What are the tree types of abnormal placental attachment?

A

Placenta accrete
Placenta increta
Placenta percreta

211
Q

What is placenta accrete?

A

Attaches directly to the myometrium

212
Q

What is placenta increta?

A

Placenta invades the myometrium

213
Q

What is placenta percreta?

A

Penetrates the myometrium, the worst to have

214
Q

What are typically the causes of uterine rupture?

A

Can occur along a uterine scar
More common in multiparas
Possibly from forceps delivery or inappropriate use of pitocin

215
Q

What is considered a postpartum hemorrhage?

A

Any bleeding that can or does result in hemodynamic instability
EBL greater than 1000mL with vaginal delivery and a 10% decrease in Hct from prenatal value

216
Q

What is the most common cause of postpartum hemorrhage?

A

Uterine atony

217
Q

What does a normal uterus do after delivery in order to avoid hemorrhage?

A

Contractions of the uterus compress the severed spiral arteries and venous sinuses at the placental detachment site

218
Q

What are treatments for uterine atony?

A

Uterine massage
Have the patient empty the bladder
Pitocin infusion, Methergine, Hemabate

219
Q

Why should pitocin never be given directly in an IV?

A

Can cause peripheral vasodilation, tachycardia and HoTN

220
Q

Why should Methergine only be given IM?

A

Can cause HTN, vasoconstriction and increased PA pressures

221
Q

What medication should not be given for uterine atony if the patient has a history of asthma?

A

Hemebate, it can cause bronchospasm, V/Q mismatch and hypoxemia

222
Q

What is uterine version?

A

Occurs when the uterus flips, most common in multiparious patients

223
Q

What symptoms are associated with uterine inversion?

A

Bradycardia due to a vagal response

Excessive hemorrhage

224
Q

How should a uterine inversion be treated?

A

Treat blood loss
Give uterine relaxants Inhaled anesthetics, NGT and terbutaline)
Immediate uterine replacement

225
Q

What is an amniotic fluid embolism?

A

Rare obstetric emergency in which amniotic fluid, fetal cells, hair or other debris enter the maternal circulation causing cardiopulmonary collapse

226
Q

What is the pathology of an amniotic fluid embolus?

A

Amniotic fluid and fetal cells enter the maternal circulation
Pulmonary vessels are obstructed resulting in vasospasm, pulmonary HTN and hypoxia

227
Q

What are the end organ effects of amniotic fluid embolus?

A

Left heart failure, decreased CO

ARDS develops

228
Q

What are the classic symptoms of an amniotic embolus?

A

Acute shortness of breath and cough

Severe HoTN

229
Q

What is the treatment of an amniotic fluid embolus?

A

Treatment is supportive: O2, hemodynamic, coagulopathy, steroids and CPR

230
Q

What is the mortality rate of amniotic fluid embolus?

A

80%

231
Q

When might DIC occur during pregnancy?

A

DIC usually occurs secondary to another disease process

shock, infection, abruptio placenta, amniotic fluid embolus, IUFD and pre-eclampsia

232
Q

What causes DIC?

A

An imbalance between clot forming and clot lysing systems in the blood

233
Q

What two labs should specifically be checked if a patient is thought to be in DIC?

A

Decreased fibrinogen and Elevated D-dimer and FDP/FSP

234
Q

What is a hydatidiform mole?

A

Placental hyper proliferation without fetal tissue

235
Q

What are symptoms of a hydatidiform mole?

A

Vaginal bleeding, hyperemesis, hyperthyroidism, absence of FHT, pre-eclampsia and ovarian cysts

236
Q

What lab findings may indicate hydatidiform mole?

A 
Hcg levels greater than 10,000
Anemia
Snow storm on US
Possible coagulopathy
Possible lung mets on CXR
237
Q

What is the treatment for a hydatidiform mole?

A

D&E

Start oxytocin at beginning of procedure

238
Q

What are potential complications of a hyddatidiform mole?

A

Uterine perforation, Hemorrhage, Iatrogenic pulmonary edema, DIC and trophoblastic embolism

239
Q

What end organ effects can result if iatrogenic pulmonary edema develops due to s hydatidiform mole?

A

HF, hyperthyroidism, dilutional anemia and pulmonary artery blockage

240
Q

Where can an epidural be dosed for visceral pain in the first stages of labor?

A

T10-L1

241
Q

Where should an epidural be dosed when the laboring patient transitions to second stage of labor and the pain changes from visceral to somatic?

A

Dose down to S2-S4

242
Q

What are the goals for pain relief in the laboring patient?

A

Decreased sense of uterine contraction and fetal descent
Preservation of pressure sensation to facilitate expulsive efforts
Minimal motor block to improve effectiveness of expulsive efforts

243
Q

What makes NO2 effective in brief analgesia during labor?

A

Increased sensitivity

244
Q

What block can be done for pain relief in stage one of labor?

A

Paracervical block

245
Q

What block can be done for pain relief in stage two of labor?

A

Peudundal block

246
Q

What is a complication of a paracervical block that will need to be monitored for when administering?

A

Profound bradycardia

247
Q

What IV analgesic are preferred in the laboring patient?

A

Stadol and Nubain

248
Q

What is the mechanism of action of most epidural adjuvants?

A

Alpha 2 agonists with activate inhibitory pathways

249
Q

What CV effects do epidural/intrathecal analgesics have on the pregnant patient?

A

Veno and arteriodilation, decreased venous return and decreased after load
HoTN with reflex tachycardia
Bradycardia (T4) with high block

250
Q

If prolonged HoTN occurs with epidural placement what can happen to the fetus?

A

Acidemia

251
Q

What is the primary concern of the fetus when opioids are given to mom?

A

Primary concern is sedation and respiratory depression from opioids

252
Q

What opioid is unsatisfactory for the second stage of labor when administered intrathecally?

A

Morphine

253
Q

What are side effects associated with intrathecal opioids?

A

Respiratory depression
Urticaria
Nausea and vomiting
Urinary retention

254
Q

What are intrathecal opioids are most commonly used for the pregnant patient?

A

Fentanyl
Sufenta
Duramorph
Meperidine

255
Q

Which opioids have the fastest onset when given intrathecally?

A

Fentanyl and Sufenta

256
Q

Which intrathecal opioid has the highest incidence of nausea and motor blockade?

A

Meperidine

257
Q

What are the benefits of using LA with opioids for laboring analgesia?

A

No weakening of maternal power, no alteration of maternal assumes and no depression of the passenger

258
Q

What is the most frequent combination of LA with opioids in the laboring patient?

A

Isobaric bupivicaine 2.5mg with 20-25mcg Fentanyl or 10-15 of sufenta

259
Q

How much LA is required for a saddle block?

A

Lidocaine 30-35mg
Tetracaine 3mg
Bupivacaine 7.5mg

260
Q

Which LA isn’t used in the labor patient due to its high likelihood of ion trapping?

A

Mepivacaine

261
Q

What is the benefits of using a vasoconstrictor in intrathecal anesthesia?

A

Potentiates lidocaine and tetracaine, use with caution in maternal HTN

262
Q

What determines epidural level and duration?

A

Dose, volume and concentration of LA

Presence or absence of epinephrine

263
Q

What opioids can be used for a laboring epidural?

A

Fentanyl
Sufenta
Duramorph

264
Q

What is typically the rule of thumb of onset and duration of LA for epidural anesthesia?

A

The faster the onset, the shorter the duration

265
Q

What is a segmental block?

A

Intermittent injections to isolate specific segments

266
Q

What are the benefits of utilizing a complete epidural block compared to a segmental block?

A

More stable depth of analgesia
Lower risk of complete spinal wth continuous
Lower incidence of HoTN
Low risk of blood concentrations if migration of catheter occurs

267
Q

What level block should be achieved before initiating continuous epidural infusion?

A

T10-L1

268
Q

How often should the provider check on the patient an epidural has been placed?

A

Always check level carefully for the first 30min then hourly rounds on the patient to ascertain VS and level of block

269
Q

What intervention should be completed immediately if a patient complains of nausea after an epidural has been placed?

A

Treat for HoTN immediately

270
Q

How can an epidural affect labor?

A

Can slow or stop progression
Disrupt uteroplacental perfusion secondary to HoTN
Fetal hypoxia/asphyxia

271
Q

When should the provider advance the epidural catheter in order to avoid intravascular placement?

A

Thread catheter in between contractions

272
Q

What are characteristics of a PDPHA?

A

It is positional (worse when sitting up), frontal to occiput, visual disturbances, nausea and time

273
Q

What are treatments for a PDPHA?

A

Bedrest
Fluids
Caffeine
Epidural blood patch

274
Q

What neurological complication can be caused from exertional effort of labor causing spinal root compression?

A

Prolapsed intervertebral disk

275
Q

What neurological complication can be seen during labor if the patient develops foot drop, hypothesis of foot and calf, and quadriceps weakness?

A

L4-L5 compression from descending head or use of forceps

276
Q

What neurological complication can be sen during/after labor if the patient develops knee problems and quadriceps paralysis?

A

Femoral nerve L2-4 injured from lithotomy position

277
Q

What neurological injury can be seen during labor that may cause transient numbness of thigh?

A

LFC L2-L3 injured during lithotomy and c-section

278
Q

What neurological injury can be seen during labor that causes pain that radiates from gluteal to foot and inability to flex the leg?

A

Sciatic nerve L4-S3 can be injured during lithotomy

279
Q

What neurological injury can be seen during labor that can cause weakness or paralysis of thigh adductors?

A

Obturator L2-L4 injured with lithotomy position

280
Q

What neurological injury can be seen during labor that contributes to the loss of ability to assume the erect position with foot drop?

A

Common Peroneal Nerve L4-S2 injured during lithotomy position due to prolonged compression of lateral aspect of knee

281
Q

What neurological injury can be seen during labor that causes a loss of sensation over the medial aspect of the foot and anterimedial aspect of the lower portion of the leg?

A

Saphenous Nerve L2-L4 injured during lithotomy position

282
Q

What is the goal level of blockade for a patient undergoing a c-section?

A

T4 Level

283
Q

What anesthetic techniques can be preformed for a patient undergoing a c-section?

A

Regional: subarachnoid or epidural

GA

284
Q

What complication can occur when laying a patient flat for a c-section?

A

Aortocaval compression, left uterine displacement

285
Q

What is the most common LA used in spinal anesthesia for a c-section?

A

0.75% bupivacaine in 8.5% dextrose
less than 65 minutes 1.4mL (10.5mg)
Greater than 65min 1.6mL (12mg)

286
Q

What are complications associated with spinal anesthesia for a c-section?

A 
Post dural puncture headache
Total Spinal Anesthesia
LAST
Neurological injury
Respiratory depression
287
Q

What is typically the LA of choice for epidural anesthesia?

A

Bupivacaine 0.5%, dose 5mL at a time, 20mL usually gives a T4 level

288
Q

What medication can aid in speed of onset?

A

NaBicarb to increase speed of onset, give 5mL aliquots

289
Q

What percentage of Lidocaine is used for epidural anesthesia?

A

2% compared to 5% used in spinal anesthesia

290
Q

What LA can be given if onset of epidural is needed quickly?

A

Chloroprocaine 3%

291
Q

Why is it essential that the provider uses 0.5% Bupivacaine as opposed to 0.75% for epidural anesthesia?

A

Cardiac toxicity especially in pregnant individuals

292
Q

Why might a lot of providers avoid using 2-chloroprocaine for laboring epidurals?

A

There used to be a preservative that caused arachnoiditis

293
Q

Why its a caudal block used very often for a laboring patient?

A

Accidental placement of needle in the baby’s head

294
Q

Why is maternal awareness so common in GA?

A

Midazolam is not given due to effects on fetus

295
Q

What are complications associated with GA in the pregnant patient?

A

Maternal aspiration
Maternal awareness
Airway management

296
Q

Why do pregnant women desaturate more quickly?

A

Increased O2 consumption and decreased FRC

297
Q

What is gestational diabetes?

A

During pregnancy, maternal glucose levels are low at 70-120mg/dL as the fetus continuously draws from maternal supplies

298
Q

What is the goal in treatment of gestational diabetes?

A

To replicate theses low maternal glucose levels

299
Q

What is significant about glucose and insulins regulation from mom to baby?

A

Glucose crosses the placenta, but insulin does not

300
Q

How does GDM affect the fetus?

A

Mothers blood brings more glucose to the fetus
Fetus makes more insulin to handle the extra glucose
Extra glucose is stored as fat and fetus become larger than normal

301
Q

What is GDM often associated with?

A

Birth defects and structural malformations, CV being most common

302
Q

What birth trauma may occur from GDM?

A

Shoulder dystocia and Brachial plexus injury

303
Q

What are fetal complications from GDM?

A 
RDS since lung maturity is delayed
Fetal demise
Hyperbilirubinema
Hypoglycemia for excessive insulin production when receiving maternal glucose (potential for seizures, coma and brain damage)
Childhood/adolescent obesity
304
Q

What complication can affect mom in GDM?

A

Miscarriage
HTN
Pre-eclampsia
C-section

305
Q

How is GDM diagnosed?

A

Screen all patients less than 28 weeks gestation:
1hr glucose challenge
3hr glucose tolerance is 1hr is abnormal

306
Q

How is GDM treated?

A

Supplemental folic acid (decreases neural tube defect)
Tight glucose control, especially 3rd trimester
Intensive fetal surveillance

307
Q

What are the two types of GDM?

A

Diet controlled diabetics

Insulin dependent diabetics

308
Q

How are GDMA1 patients managed in labor?

A

No glucose containing IVF

309
Q

How are GDMA2 patients managed during labor?

A

Ascu checks Q1-2hrs, sliding scale coverage

May require insulin infusion, .5-1u/hr with D5LR at 100mL/hr

310
Q

What are the four categories of HTN associated with pregnancy?

A

Gestational HTN
Pre-eclampsia
Chronic HTN
Chronic HTN with superimposed pre-eclampsia

311
Q

What is pre-eclampsia?

A 
Occurs after the 20th weeks of pregnancy
Triad of symptoms:
     Labile HTN
     Proteinuria
     Non-dependent edema
312
Q

What differentiate pre-eclampsia from eclampsia?

A

Once seizure activity results the patient is now said to have eclampsia

313
Q

What is considered HTN for pre-eclampsia?

A

SBP > 140mmHg
DBP >90mmHg
This must occur on two separate readings greater than 6hrs apart

314
Q

What is considered proteinuria for pre-eclampsia?

A

Greater than 300mg protein in 24hrs

Greater than 2+ protein on dip stick

315
Q

What is thought to cause pre-eclampsia?

A

Unknown, however theory that it is related to decreased placental perfusion and uteroplacental ischemia

316
Q

How would uteroplacental ischemia contribute to causing pre-eclampsia?

A

Uteroplacental ischemia leads to production and release of biochemical mediators into the maternal circulation
Biochemical mediators cause: arteriolar constriction and vasospasm, vascular endothelial dysfunction

317
Q

What are CV effects of pre-eclampsia?

A 
Labile HTN
Vascular leakage of fluid and protein
     Decreased colloid osmotic pressure
     Decreased intravascular volume
     Edema
318
Q

What is considered severe pre-eclampsia?

A

SBP >160mmHg

DBP > 110mmHg

319
Q

How does pre-eclampsia affect the pulmonary system?

A

Upper airway edema and if severe enough can lead to pulmonary edema

320
Q

What effects does pre-eclampsia have on the blood?

A

Hypercoagulable
Hemoconcentrated
DIC

321
Q

What is the most common complication of pre-eclampsia on the hematologic system?

A

Thrombocytopenia

322
Q

How does pre-eclampsia affect the kidneys?

A

Proteinuria
Low urine output
Decrease uric acid clearance

323
Q

What effects does severe pre-eclampsia have on the kidneys?

A

Oliguria and Renal failure

324
Q

How does pre-eclampsia affect the liver?

A

Impairs function resulting in elevated LFTs

325
Q

What are complications to the liver from severe pre-eclampsia?

A

Swelling of the liver capsule
Liver necrosis
Sub capsular hematoma

326
Q

What symptom is usually associated with swelling of the liver capsule?

A

Epigastric pain often felt in the left upper quadrant

327
Q

Why should epinephrine be avoided in epidurals for patients with pre-eclampsia?

A

Can cause vasoconstriction or increase the patients BP even more making their condition worse

328
Q

What are CNS effects of pre-eclampsia?

A

HA and Hyperreflexia

329
Q

What CNS effects are often associated with severe pre-eclampsia?

A

Visual disturbances
Cerebral edema
Cerebral hemorrhage
Maternal death

330
Q

How can severe pre-eclampsia affect placental perfusion?

A

Cause infarction or abruption

331
Q

What is the definitive treatment for pre-eclampsia?

A

Delivery of the fetus and placenta

332
Q

How should we expect pre-eclamptic patients to be medically managed?

A

Control of HTN
Anticonvulsant prophylaxis
Maintenance of renal function
Determining fetal lung maturation

333
Q

What drugs can be used to treat pre-eclamptic HTN?

A

Magnesium sulfate
Hydrazine
Labetalol

334
Q

What drugs can be given to pre-eclamptic patients for seizure prophylaxis?

A

Phenytoin
Midazolam/Diazepam
Nifedipine
Nitropresside

335
Q

What is the anticonvulsant of choice in women with pre-eclampsia?

A

Magnesium sulfate

336
Q

What are the effects of MgSO4 on eclamptic seizures?

A

Antagonizes the calcium channels in smooth muscle cells
Vasodilates ans increases uterine blood flow
Decreases Ach release at the neuromuscular junction

337
Q

What are therapeutic serum levels of MgSO4 on therapy for seizure prophylaxis?

A

4-8mEq/L

338
Q

What are adverse affects of MgSO4 use?

A

Respiratory depression
CNS depression
Cardiac conduction block

339
Q

What are signs of MgSO4 toxicity?

A

Respirations less than 12
Absent deep tendon reflexes
Skeletal muscle weakness

340
Q

What is the treatment of MgSO4 toxicity?

A

10-20mL of 10% calcium gluconate

341
Q

How should the provider consider dosing paralytics if a patient requires GA for an emergent delivery on MgSO4?

A

Decrease NMBAs, MgSO4 decreases endplate sensitivity to Ach motor end plate release

342
Q

Why might a patient be placed on a uterotonic drug while on MgSO4 for seizure prophylaxis?

A

MgSO4 decreases uterine tone

343
Q

What is the goal of HTN treatment in the pre-eclamptic patient?

A

DBP 90-100mmHg

344
Q

What is the antihypertensive of choice in patients with pre-eclampsia?

A

Hydrazine, it vasodilates arterioles and increases HR, increasing CO and improving placental blood flow

345
Q

When do majority of eclamptic seizures occur?

A

Occur prior to delivery
25% prior to the onset of labor
50% occur during labor

346
Q

What are typically the characteristics of seizures by eclamptic patients?

A

Tonic-clonic, lasting 60-70sec, followed by a post-ictal phase

347
Q

Why is GETA usually elected for emergent delivery after an eclamptic seizure?

A

Thrombocytopenia/coagulopathy contraindicated regional anesthesia
Airway is secured

348
Q

When might vertical transmission of HIV occur from mother to child?

A

Prenatally
Intrapartum (most common)
Breastfeeding

349
Q

What are the two routes of fetal HIV infection prenatally?

A

Hematological across the placenta

Across the amniotic membranes

350
Q

When does most vertical HIV transmission occur?

A

During delivery, contact with maternal blood and cervicovaginal secretions
Transmission rate increases with time and amount of neonatal exposure

351
Q

What is the delivery method of choice to prevent HIV transmission?

A

Elective c-section prior to ROM

Advanced Principles II (8 decks)

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