OB Complications- Test 2 Flashcards
preterm infant
prior to 37 weeks gestation
between 20 0/7 and 36 6/7
low birth weight
<2500 gm
very low birth weight
<1500 gm at birth
extremely low birth weight
<1000 gm at birth
threshold of viability
22-24 weeks
demographic characteristics of preterm
non caucasian race extremes in ages (<17 or >35 yrs) low socioeconomic status lowe prepregnancy BMI history or preterm delivery interpregnancy interval <6 months abnormal uterine anatomy truma abd surgery during pregnancy
behavioral factors
tobacco use
substance abuse
obstetric factors
vaginal bleeding infection short cervical length multiple gestations assisted reproductive technologies preterm premature rupture of membranes polyhydramnios
process of parturition
0-quiescence
1-activation
2-stimulation
3- involution
causes of preterm labor
systemic and uterine infections (most common)
uteroplacental thrombosis
intrauterine vascular lesions (fetal stress or decidual hemorrhage)
uterine overdistension
cervical insufficiency
preterm delivery due to
preterm premature rupture of membranes
spontaneous preterm labor
maternal fetal indications
preterm anestheic management
neuroaxial
csection
tocolytic therapy (CCB, Indomethacin (cycooxygenase inhibitor), terbutaline (beta adrenergic receptor agonist), magnesium sulfate
side effects of terbutaline
hypotension, tachycardia, pulmonary edema, hyperglycemia, hypokalemia
presentation
portion of fetus over pelvic inlet
lie
alignment of fetal spine with maternal spine
position
relationship of specific fetal bony point to maternal pelvis
occiput
position for vertex presentation
sacrum
postion for a breech presentation
mentum
position for face presentation
acromion
position for shoulder presenation
uterine distension or relaxation factors associated with breech presentation
multiparity
multiple gestation
hydramnios
macrosomia
abnormalities of the uterus or pelvis factors associated with breech presentaiton
pelvic tumors
uterine anomalies
pelvic contracture
abnormalities of the fetus factors associated with breech presentation
hydrocephalus
anencephaly
obstetric conditions factors associated with breech presentation
previous breech delivery preterm gestation oligohydramnios cornual-fundal placenta placenta previa
anesthesia for breech delivery
should be in OR and prepped for emergency GA
may need more dense anesthesia
increase GA halogenated agents for uterine relaxation
what is the worst fear for breech delivery
fetal head entrapment
what agent could be used to produce uterine relaxation for breech presentation if using NA
NTG
what is the LA of choice for a dense block while delivering breech baby
3% chloroprocaine or 2% lidocaine with epi and bicarb
monoxygotic twins
single fertilized ovum divides
disygotic twins
2 ova fertilized
placentation
dichorionic diamniotic
monochorionic diamniotic
monochorionic amniotic
multiple gestation
cardiovascular and respiratory changes intensified
20% greater CO
15% great SV
3.5% increase in HR
what are the two causes of hypoxemia occuring more rapidly?
decrease in FRC and increase in maternal metabolic rate
maternal weight is greater rate at what time for multiple gestation parturients?
30 weeks
plasma volume is increased with multple gestation parturients by what value
750mL
fetal complications associated with multiple gestation
preterm delivery congenital anomalies polyhydramnios cord entanglement cord prolapse fetal growth restriction twin to twin transfusion malpresentation
maternal complications associated with multiple gestation
preterm rupture of membranes preterm labor prolonged labor preeclapsia or eclampsia placental abruption DIC operative delivery uterine atony obstetric trauma antepartum or postpartum hemorrhage
what is the optimal management of multiple gestation labor?
epidural
true or false multiple gestation pregnancies require full lateral position
yes increased risk for aortocaval compression
true or false multpile gestations require large bore IVs
true, increased risk of hemorrhage
when should epidurals be augmented for delivery of multiple gestations?
for delivery of twin A; augment with more concentrated local
what should sensory level for delivery of twin A be?
T6-T8
where should the sensory level be extended to for delivery of baby B?
T4-T8
If cesarean required for twin B, what med should be added?
nonparticulate antacid
gestational hypertension
HTN after 20 wks WITHOUT proteinuria
when does gestational HTN resolve?
12 wks postpartum
preeclampsia
new onset HTN and proteinuria after 20 wks gestation
if no proteinuria preeclampsia should be considered with new onset HTN after 20 weeks and the addition of?
persistent epigastric or RUQ pain persistent cerebral symptoms fetal growth restriction thrombocytopenia elevated liver enzymes
eclampsia is signaled with the onset of what?
seizures
HELLP syndrome stands for what?
homolysis, elevated liver enzymes, low platelet count in woman with preeclampsia
chronic hypertension
prepregnancy systolic BP >140 and or diastolic >90 or elevated unresolved BP after delivery
chronic HTN with superimposed preeclampsia
presence of HTN prior to pregnancy
new onset proteinuria or sudden increaes in proteinuria or hypertension or both
diagnostic criteria for preeclampsia without severe features
BP >140/90 after 20 wks
proteinuria (>300mg/24hrs)
protein-creatnine ration >0.3 or 1 on dipstick
preeclapsia with severe symptoms
BP >160/110
thrombocytopenia (platelets <100,000/mm3)
serum cr concentration >1.1mg/dl or >2 from baseline
pulmonary edema
new onset cerebral or visual disturbances
impaired liver function
maternal syndrome
HTN and proteinuria with or without other systemic abnormalities
fetal syndrome
fetal growth restriction
oligohydramnios
abnormal oxygen exchange
preeclampsia presents more frequently in this pooulation
nulliparous usually 3rd trimester
when does preeclampsia usually resolve?
within 48 hrs of delivery
what CNS symptoms accompany preeclampsia
severe HA hyperexcitability hyperreflexia coma visual disturbances (scotoma, amaurosis, blurred vision)
true or false; eclampsia is outward manifestation of disease progression in the brain
true
airway changes in preeclampsia
pharyngolaryngeal edema
subglottic edema
pulmonary changes in preeclampsia
DECREASED colloid osmotic pressure
INCREASED vascular permeability
loss of intravascular fluid and protein into interstitium
–> pulmonary edema
cardiovascular effects of preeclampsia
hypertension vasospams end organ ischemia hyperdynamic state increase CO hyperdynamic LV function increased SVR exaggerated response to catecholamines
hematologic changes in preeclampsia
thrombocytopenia (most common) platelets <100,000
DIC (in liver involvement, intrauterine fetal demise, placental abruption, postpartum hemorrhage)
liver presentation in preeclampsia
periportal hemorrhage and fibrin deposits
renal presentation in preeclampsia
proteinuria,
decreased GFR
hyperuricemia
oliguria (late but severe symptom)
labetolol dose
20mg IV then 40-80mg q 10mins
max 220mg
hydralazine dose
5mg q 20mins
max 20mg
nifedipine dose
10mg PO q 20mins up to 50mg
nicardipine dose
initial infusion of 5mg/h, increase by 2.5mg/h every 5min to max of 15
sodium nitroprusside dose
0.25-5 mcg/kg/min IV infusion
nifedipine dose
10mg PO q 20mins up to 50mg
nicardipine dose
initial infusion of 5mg/h, increase by 2.5mg/h every 5min to max of 15
sodium nitroprusside dose
0.25-5 mcg/kg/min IV infusion
seizure prophylaxis in severe preeclampsia
mag sulfate
loading dose of mag
4-6gm over 20-30 minutes
maintenance dose of mag
1-3 g/hr
duration of maintenance mag
2hrs preop
during surgery
12-24 hrs postop
therapeutic range of mag
5-9mg/dL chestnut
4-6 mEq/L M&M
symptoms of hypermagnesemia
patellar reflexes lost at 12 mg/dL
respiratory arrest at 15-20 mg/dL
asystole at 25 mg/dL
treatment of hypermagnesemia
stop infusion and start calcium gluconate
how long is delivery deferred for HELLP?
24-48 hrs for corticosteroids to enhance fetal lungs
thrombocytopenia of HELLP
platelets <100,000mm3
hemolysis of HELLP
abnormal peripheral blood smear
increased bilirubin >1.2 mg/dL
increased LDH >600 IU/L
elevated liver enzyme levels for HELLP
increased AST >70 IU/L
increased LDH >600 IU/L
thrombocytopenia of HELLP
platelets <100,000mm3
anesthesia plan for hypertensive disorders
expect difficult airway
may need a line or cvp
preferred continuous lumbar epidural or CSE
when should neuroaxial be initiated with hypertensive disorders
early; avoids GA, optimizes placement before platelets decrease, beneficial effects on uteroplacental perfusion
advantages of cont. epidural or CSE
analgesia
reduced catecholamines
improved intervillous blood flow
means for csection
disadvantage of cont. epidural or CSE
cant evaluate function of epidural until spinal gone
what signifies preeclampsia has progressed to eclampsia?
new onset seizures or unexplained coma
when does fetal bradycardia occur with seizure associated with eclampsia?
during or immeditely after; persistant requires immediate delivery
which drugs are appropriate to adminster during or after sz associated with eclampsia?
magnesium 4-6g over 20min
1-2 g for maint
2g for recurrence
antihypertensives
labetalol or hydralazine
fluid balance required for managment of eclampsia
75-100mL/hr to prevent cerebral edema
is continuous FHR monitoring required for eclampsia?
yes
do you need coag studies regardless of platelet count?
yes
total placenta previa
covers entire cervical os
partial placenta previa
covers only part of the cervical os
marginal placenta previa
lies within 2cm of the cervical os
what is the classic sign of placenta previa?
painless vaginal bleeding in the 2nd and 3rd trimester
when will placenta previa require csection?
for total previa or placental edge to os distance <1cm = significant bleeding
what does the anesthetic plan for placenta previa depend on?
indication and urgency for delivery
severity of maternal hypovolemia
obstetric history
what is the anesthetic plan of choice for placenta previa?
neuroaxial
what is required for delivery of placenta previa?
2 large bore IVs
RSI if GA
what drugs should be considered for GA of placenta previa?
low dose propofol
ketamine 0.5-1mg/kg
etomidate 0.3mg/kg
placental abruption
complete or partial separation of placenta from decidua basalis before delivery of the fetus
what are some of the complications associated with placental abruption?
hemorrhagic shock
coagulopathy
fetal compromise or death
what ist the preferred technique for labor and vaginal delivery of placental abruption?
NA
what is the preferred technique for CS of placental abruption?
NA if volume and coags ok
what are the best agents for GA in urgent delivery of placental abruption?
ketamine and etomidate
what is a potential risk associated with placental abruption?
trapped blood under placenta
what are obstetric condiotions associated with placental abruption?
advanced maternal age multiparity preeclampsia premature rupture of membranes chorioamnionitis
maternal comorbitites associated with placental abruption?
hypertension acute or chronic resp illness substance abuse cocaine use tobacco use (maternal or paternal)
trauma associatd with placental abruption
direct (blunt abdominal)
indirect (acceleration/deceleration)
obstetric conditions associated with uterine rupture?
prior uterine surgery induction of labor high dose oxytocin induction prostaglandin induction morbidly adherent placenta grand multiparity (>5) congenital uterine anomaly (bicorniculate uterus)
maternal comobidities associated with uterine rupture
connective tissue disorder (ehlers-danlos)
obstetric characteristics of uterine rupture
corceps delivery
internal podalic version
excessive fundal pressure
nonobstetric conditions associated with uterine rupture
blunt
penetrating
trauma
presenting signs of uterine rupture
abdominal pain and abnormal FHR pattern
what anesthesia method is necessary for uterine rupture
GA unless epidural is already established
what should be part of the anesthetic plan for uterine rupture
agressive volume replacement
monitor UOP
invasive monitoring?
vasa previa
fetal vessels cross fental membranes before presenting part
what usually occurs to fetal membranes in vasa previa
rupture of fetal membranes usually tears vessels leads to fetal exsanguination
what is generally the plan for vasa previa?
immediate delivery- GA
primary postpartum hemorrhage occurs when?
first 24 hrs
secondary postpartum hemorrhage occurs when?
between 24hrs and 6wks
uterine atony accounts for what?
80% of hemorrhage
treatment of uterine atony includes
IV crystalloids colloids, vasopressors
H&H, coags
blood products
obstetric management associated with uterine atony
CS
induction of labor
augmented labor
obstetric conditions associated with uterine atony
multiple gestations macrosomia polyhydramnios high parity prolonged labor precipitous labor chorioamnionitis
maternal comorbidities associated with uterine atony
advanced maternal age
hypertensive disease
diabetes
other conditions associated with uterine atony
tocolytic drugs
high concentrations of halogenated volatiles
oxytocin dose for postpartum hemorrhage
0.3-0.6 IU/min IV
short duration of effect
side effects of oxytocin
tachycardia
hypotension
MI
free water retention
ergonovine or methylergonovine dose for postpartum hemorrhage
0.2 mg IM
long DOA- may be repeated once after 1 hr
side effects of ergonovine or methylergonovine
N/V
arteriolar constriction
HTN
relative contraindications to ergonovine or methylergonovine
HTN
preeclampsia
CAD
dose fo 15-methylprostaglandin
0.25 mg IM
may be repeated q15mins up to 2mg
relative contraindications for 15-methylprostaglandin
reactive airway disease
pulm. HTN
hypoxemia
side effects of 15-methylprostaglandin
fever chills N/V diarrhea bronchoconstriction
dose for misoprostol
600-1000ug per rectum, sublingual, or buccal
this is an off label use for this drug
contraindications for misoprostol
none
side effects of misoprostol
fever
chills
N/V
diarrhea
placenta accreta
part or all of the placenta invades the uterine wall and is inseperable
placenta accreta vera
adherance of basal plate of placenta to uterine myometrium without decidual later
placenta increta
chorionic villi invade the myometrium
placenta percreta
invasion through myometrium into serosa adn adjacent organs
anesthesia management of placenta accreta
similar to other cases of postpartum hemorrhage
peripartum hysterectomy
requires GA
exact trigger of amniotic fluid embolism
unknown
amniotic fluid embolism
systemic inflammatory response associated with inappropriate release of endogenous inflammatory mediators.
clinical presentation of amniotic fluid embolism
acute resp distress
cardiovascular collapse
coagulopathy near delivery
OCCURS MOST OFTEN IN LABOR
2 most important risk factros in developing DVT or PE in pregnancy
history of thromboembolism
diagnosis of thrombophilia
3 factors that increase risk of DVT or PE
venous stais
vascular damage
hypercoagulability
how many major risk factors must be present for increased risk of venous thromboembolism postpartum?
minor?
one for major, two for minor
major risk factors for venous thromboembolism in the postpartum period
immobility (>1week) prevous VTE preeclampsia with fetal grown restriction thrombophilia (antithrombin III def, factor V leiden, prothrombin G20210A) SLE heart disease sickle cell postpartum hemorrhage + surgery blood transfusion postpartum infection
minor risk factors for VTE in postpartum
BMI >30 emergency c section mult. pregnancy postpartum hemorrhage smoking >10/day fetal growth restriction thrombophilia (protein C or S deficiency) preeclampsia
DVT symptoms
nonspecific lower leg pain and edema
erythema
tenderness
palpable cord
PTE symptoms
palpitations anxiety chest pain cyanosis diaphoresis cough with or without hemoptysis SOB
signs of RV failure with PTE
split S2
JVD
parasternal heave
hepatic enlargement
ECG changes in PTE
RV strain= RAD p pulmonale ST abnomalities T wave inversion supraventricular arrhythmias
hemodynamic monitoring for embolic disorders
PAOP
normal to low (<15)
hemodynamic monitoring for embolic disorders
MEAN PAP
increased (usually <35)
hemodynamic monitoring for embolic disorders
CVP
increased (>8)
management for embolic disoders
anticoagulation
potential anesthetic complications for embolic disorder treatments
spinal/epidural hematoma-NA
airway bleeding- GA
warfarin should be held for
4-5 days for INR to normalize
avoid neuroaxial catheter with which drug
fondaparinux
neuroaxial not recommended with which class of drugs
direct thrombin inhibitors
which class is an ABSOLUTE contraindication for NA
thrombolytics
when should you switch oral anticoagulants to LMWH or UFH?
36wk gestation
when should LMWH be discontinued?
36hrs prior to delivery
when should IV UFH be discontinued?
4-6 hours prior to delivery
when is VAE likely to occur?
after placental separation, potential for air entrapment
what are the clinical symptoms of VAE?
mostly without symptoms
massive: hypoTN, hypoexemia, potential cardiac arrest
pathophysiology course of VAE
small amount of air -> pulmonary vasospasm -> VQ mismatch-> hypoxemia-> right sided heart failure-> arrhythmias-> hypoTN
what volume of air can lead to an RV outflow tract obstruction leading to cardiovascular collapse?
> 3mL/kg
suspect VAE if
complaints of intraop chest pain, dyspnea
sudden hypoxemia, hypoTN, arrhythmias
how do you prevent further air entrapment during VAE
flood surgical field with saline solution
lower the surgical field lower than the heart if tolerated
what should be evaluated in the postrescuscitation period after VAE
intracerebral air and potentially hyperbaric O2 therapy
