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6903 - Special Populations > OB COPY > Flashcards

OB COPY Flashcards

1
Q

explain dilutional anemia w pregnancy 3rd semester normal hgb 11-12g/dL

A

blood volume increases ~40%
plasma volume increases ~50%
RBC volume only increases ~20%
progesterone and estrogen activate RAAS, which causes water retention.

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2
Q

pregnancy increases which clotting factors?

A

VII, VIII, IX, and fibrinogen (I).
fibrinolysis activity decreases.
platelets stay the same.
end result is a hypercoagulable pt.

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3
Q

WBC in 3rd trimester

A

can get up to 30,000mm during labor

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4
Q

airway changes

A

glottic lumen narrows due to swelling
edema makes tissues more prone to bleeding
use smaller tube 6.0 ETT
use shorter handle (Datta handle) to not hit breast tissue

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5
Q

O2 consumption with labor

A

33% higher just before labor.

100% higher w labor

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6
Q

GI: progesterone causes..

A
  • GI smooth muscle relaxation
  • delayed gastric emptying
  • increased risk of gallbladder disease/cholelithiasis (progesterone inhibits SM, so can’t clear from the gallbladder leading to biliary stasis)
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7
Q

renal changes during pregnancy

A
  • increased CO leads to increase in GFR and CC
  • BUN lowers to 8mg/dL
  • creat lowers to 0.5mg/dL
  • glucose in urine bc absorption can’t keep up w flow
  • trace protein in urine for same reason
  • uterus can compress the ureter and cause urinary obstruction (hydronephrosis common)
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8
Q

uterine blood flow at term

A

800mL/min (10% CO)

most ends up in intervillous space

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9
Q

molecular weight to cross

A

> 1000 daltons cross poorly.

most anesthetic drugs are <500Da and cross readily.

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10
Q

stages of laborstage 1

A
  • cervical dilation in response to REGULAR uterine contractions
  • effacement occurs (softening, shortening, and thinning of cervix)
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11
Q

stages of laborstage 2

A

full cervical dilation to delivery of fetus

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12
Q

stages of laborstage 3

A

includes delivery of the the placenta

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13
Q

3 Ps of successful vaginal delivery

A

powers-uterine contractions

passenger-fetal positioning to get into position

passage-bony pelvis shape, relaxation and soft tissue relaxation

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14
Q

parenteral opioid effects

A

spinal and supraspinal effects

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15
Q

neuraxial opioid effects

A

bind in substantia geltinosa (Rexed lamina II) in dorsal horn of spinal cord

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16
Q

normal magnesium level

A

1.7-2.4

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17
Q

Therapeutic Magnesium level

A

5-9

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18
Q

Mag level when patellar reflexes are lost

A

12

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19
Q

mag level when respiratory arrest

A

15-20

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20
Q

mag level when cardiac arrest

A

> 25

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21
Q

Mag MOA

A

*competitive antagonist of calcium.

Also decreases release of Ach at NMJ and sensitivity of motor endplate to Ach

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22
Q

unwanted fetal effects from indomethacin(3)

A

premature closure of ductus arteriosus, pulm htn, low amniotic fluid levels

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23
Q

MAC level when uterine atony becomes a concern

A

MAC >0.5

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24
Q

GTPAL

A 
G-Gravidity
T-term births
P-preterm births
A-abortion (spontaneous/elective)
L-living children
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25
Q

distance from skin to epidural space in athin pt

A

3cm if thin

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26
Q

distance from skin to epidural space in an adult

A

4-6cm in adult

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27
Q

distance from skin to epidural space in an obese pt

A

up to 8 cm

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28
Q

duration of a spinal

A

<2hours (why they are rarely used for labor)

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29
Q

levels that epidurals are inserted

A

L2-3 or L3-4

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30
Q

epidural analgesia dosing

A

8-12mL/hourup to 15mL/hour

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31
Q

volume for epidural boluses

A

6-10mL

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32
Q

spinal dose (volume)

A

1.6mL+/- opioid

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33
Q

neuraxial opioids act where

A

on the substantia geltinosa in the dorsal horn of the spinal cord (Mu receptors)

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34
Q

uncomplicated C-section blood loss

A

500-1000mL EBLamniotic fluid is usually 700 counted in the EBL

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35
Q

Why can’t chronic HTN be managed w ACE inhibitors?

A

they cause renal damage in pregnancy and congenital abnormalities in the fetus.

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36
Q

what is a molar pregnancy

A

absence of a fetus w placental formation (can still cause preeclampsia)

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37
Q

HELLP syndrome

A

Hemolysis, Elevated LFTs, Low Platelets
other S/S:epigastric pain, jaundice, N/V.
Hepatic rupture is rare and indicates immediate delivery needed

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38
Q

eclampsia

A

when seizures are present

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39
Q

platelet cut off for neuraxial for preeclamptic pts

A

80,000

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40
Q

what is the defn. of antepartum hemorrhage?

A

vaginal bleeding after 24 weeks gestation and into immediate postpartum period

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41
Q

how much bleeding occurs in postpartum hemorrhage?

A

> 500mL vaginal delivery or >1000mL cesarian

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42
Q

what is 80% of post-partum hemorrhage from?

A

uterine atony

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43
Q

what are atony risks?

A

multiparity, prolonged oxytocin infusions, polyhydramnios

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44
Q

placenta previa s/s

A

PAINLESS vaginal bleeding significant blood loss

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45
Q

What is Vasa Previa?

A

fetal vessels implanted on cervical OS.
fetal mortality 70%
rupture of vessels is emergency, rare

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46
Q

placenta accreta

A

abnormal growth of the placenta ONTO the myometrium

most common

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47
Q

placenta increta

A

abnormal growth of the placenta INTO the myometrium

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48
Q

placenta percreta

A

abnormal growth of the placenta into other non-uterine structures

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49
Q

LBW

A

<2500g (5lb, 8 oz)

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50
Q

VLBW

A

<1500g (3lb, 4oz)

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51
Q

ELBWextremely LBW

A

<1000g (2lb, 3 oz)

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52
Q

What is a normal fetal heart rate?

A

110-160 BPM

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53
Q

FHR variability

A
  • best indicator of fetal wellbeing
  • nervous system responses to adjust the HR up or down
  • represents a functional of autonomic nervous system
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54
Q

fetal heart rate monitoring: moderate variability

A

6-25bpm=normal

*is the goal

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55
Q

increase/decrease HR CO SV SVR MAP (SBP, DBP)

A 
HR = increase
CO = increase
SV = increase
SVR = decrease
MAP = decrease
SBP = decrease a little
DBP = decrease more
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56
Q

Postpartum CO

A

-increases because great vessels in abdomen are no longer compressed allowing for increased venous return

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57
Q

Why does CO change?

A

-increase in HR + SV (larger effect)

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58
Q

increase of decrease of RASS activation?

A

increase

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59
Q

EKG changes

A
  • left axis deviation (3rd trimester)
  • right axis deviation (1st trimester)
  • shortened PR and QTc
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60
Q

aortocaval compression

A
  • supine position starting at 20 weeks

- treatment is left uterine displacement

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61
Q

increase/decrease: Minute Ventilation, FRC, ERV, RV, CC dead space

A 
Minute Ventilation = increase due to tidal volume
FRC = decrease
ERV = decrease
RV = decrease
CC = same
dead space = increase
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62
Q

respiratory blood gas

A

compensated metabolic alkalosis

63
Q

nervous system changes

A
  • increased SNS

- increased sensitivity to LA and GA

64
Q

liver

A
  • enzymes increase (AST, ALT, LDH)
  • albumin level decrease from dilutional anemia = higher free drug levels that are protein bound
  • cholinesterase activity decreases
65
Q

spiral arteries

A

-terminal arteries that spill into the intervillous space

66
Q

do maternal and fetal blood interact (touch)?

A

-no

67
Q

differences in fetal circulation

A
  • foramen ovale
  • ductus arteriosus
  • ductus venosus (shunt in liver)
  • umbilical artery(2)/vein
68
Q

factors affecting placental drug transfer to fetus

A
  • concentration gradient
  • molecular weight (<1000 Daltons)
  • lipid solubility
  • ionization
69
Q

fetal circulation factors affecting placental drug transfer to fetus

A
  • diluted in intervillous blood
  • redistributed
  • fetal first-pass effect-fetal shunt
70
Q

drugs that don’t cross the placenta

A
  • glycopyrrolate
  • anticoagulants
  • muscle relaxants
  • sugammadex
  • insulin
71
Q

progesterone

A

promotes smooth muscle relaxation

72
Q

oxytocin

A
  • promotes smooth muscle contraction

- prostaglandin production

73
Q

labor stage 1 - pain

A
  • due to cervical distention, stretching lower uterine segment, myometrial ischemia
  • T10-L1
  • UNMYELINATED C-fibers travel through hypogastric plexus
  • poorly localized visceral pain
74
Q

labor stage 2 - pain

A
  • due to stretching/distension of pelvic floor, vagina, perineum
  • somatic pain from pudendal nerves, S2-S4-MYELINATED
75
Q

pregnancy pharmacology risk categories

A

A: controlled studies demonstrate no risk
B: controlled animal studies demonstrate no risk
C: studies have revealed adverse effects on fetus
D: fetal risk but benefit outweighs risk
X: known fetal abnormalities

76
Q

MAC for pregnant women

A
  • reduced up to 40% (d/t progesterone, CNS depressive effect)
  • induction rate increased
77
Q

first line treatment for hypotension

A

phenylephrine

78
Q

most common sign of hypotension in spinal anesthesia

A

maternal nausea/vomiting

79
Q

Uterotonics

A
  • methergine: avoid in HTN, pulm HTN, preeclampsia, PVD, ischemic heart disease
  • prostaglandin E2: avoid in asthma, glaucoma, renal/pulmonary/hepatic disease
  • prostaglandin E1: given for uterine atony, side effects - malaise
  • prostaglandin F2a: (hemabate) side effects bronchospasm, increase PVR, PHTN
  • oxytocin: increases strength + frequency of contractions, side effects - hypotension from preservative, water intoxication
80
Q

Tocolytics (given to halt contractions)

A
  • calcium channel blockers (1st line)-niphedipine
  • magnesium sulfate - competitive antagonist of calcium, increases sensitivity to NMB
  • nitroglycerin

When MAC >0.5, uterine atony becomes a concern, not a concern w N20.

81
Q

local anesthetics: amines vs ester

A

amines: two i’s in name, metabolized by liver
ester: one i in name, metabolized by cholinesterase

82
Q

local anesthetics: bupivacaine

A
  • long duration, sensory>motor
  • 0.0625%-0.125%
  • black box = 0.75% for epidurals
  • preferentially bind to cardiac receptors leading to refractory cardiac arrest
83
Q

local anesthetics: ropivacaine

A
  • long, sensory>motor
  • less cardiotoxic than bupivacaine
  • epidural 0.1%-0.2%
84
Q

local anesthetics: lidocaine

A
  • intermediate duration
  • rapid onset
  • transient neurological symptoms
  • subarachnoid space administration potentially neurotoxic
  • metabolites that can cause seizures
85
Q

local anesthetics: 2-chloroprocaine

A
  • rapid onset, short duration (epidural use)

- reduces effectiveness of opioids bc of competition w the receptors

86
Q

neural axial opioids: respiratory monitoring

A
  • lipophilic = 2 hours

- hydrophilic = 12 hours

87
Q

neural axial opioids: side effects

A
  • less complete analgesia
  • perineal tone maintained
  • pruritus
  • nausea/vomiting
  • sedation
  • respiratory depression
88
Q

neural axial opioids: morphine

A
  • less lipophilic

- may cause HSV reactivation

89
Q

neural axial opioids: dosing

A
  • epidural bolus = similar to IV dose

- intrathecal = 1/10 of epidural dose

90
Q

local anesthetic test doses

A
  • use to confirm non-vascular, non-sub arachnoid placement
  • aspiration
  • 3 mL test dose between contractions (1.5% lidocaine, 1:200,000 epinephrine)
91
Q

neuroaxial complications: most common drugs used

A

bupivacaine > ropivacaine > levobupivacaine > lidocaine > 2-chloroprocaine

92
Q

neuroaxial complications: treatment

A

-stop drug, administer O2, support ventilation-20% lipid therapy 1.5 mL/kg over 1 minute than 0.25-0.5 mL/kg/min infusion-anticonvulsants (not cardiac depressing)-avoid vasopressin, BB, CCB, LA

93
Q

post dural puncture headache: risks

A
  • large bore needle
  • younger age
  • bevel orientation
  • beveled cutting needles
  • inexperienced operator
  • air for loss of resistance syringe
94
Q

post dural puncture headache: treatment

A
  • bed rest
  • caffeine
  • oral analgesia
  • epidural saline
  • epidural blood patch
  • sphenopalatine ganglion block
95
Q

optimal timeframe between induction and delivery of fetus

A
  • 3 minutes

- patient draped and surgeon ready before induction

96
Q

MAC level necessary to avoid anesthesia awareness

A

0.8

97
Q

c-section: necessary epidural level

A

T4

98
Q

c-section: epidural volume

A

1-2 mL per dermatome level

99
Q

c-section: blood loss

A
  • 500-1000 mL

- amniotic fluid is counted in blood loss (300-1500 mL)

100
Q

pre-eclampsia criteria

A
  • HTN
  • proteinuria
  • non-dependent edema (+/-)

*must be greater than 20 weeks pregnant

101
Q

pre-eclampsia treatment

A
  • definitive=delivery
  • corticosteroids (infant lungs)
  • magnesium sulfate
  • labetalol, esmolol
102
Q

pre-eclampsia anesthesia considerations

A
  • prefer neuraxial
  • laryngoscopy risk(HTN & hemorrhagic stroke)
  • avoid opioids before delivery
  • usually remain hypertensive throughout
103
Q

what is polyhydramnios?

A

too much amniotic fluid

104
Q

fetal hgbmaternal hbg

A

fetal 15

maternal 12

105
Q

pretreat if GA/RSI

A

nonparticulate antacids
H2 receptor antagonists
metoclopramide

106
Q

placental arterial supply (uterine side)

A
  • arcuate arteries
  • radial arteries
  • spiral arteries-spill into intervillous space (KNOW THIS) responsive to alpha agonists
107
Q

fetal-placental supply

A

2 umbilical arteries (finger shaped projections) where gas and waste diffuse across

no mixing of maternal and fetal blood

perfusion limited gas exchange

p17, 18 pwpt

108
Q

if you are a RBC, explain your route from mother’s heart, through the uterine circulation and back to the maternal heart…

A

p20 pwpt?

109
Q

uterine arterial supply

A

2 uterine arteries

110
Q

first pass effect

A

the umbilical vein picks up blood from the placenta and goes the fetal liver 1st.

111
Q

fentanyl

onset and how long it lasts

A

onset: 2-3 min
lasts: 30-60 min

112
Q

nalbuphine

onset and how long it lasts

A

onset: 2-3 min
lasts: 3-6 hours

113
Q

butorphanol

onset and how long it lasts

A

onset: 5-10 min
lasts: 4-6 hours

114
Q

tramadol

onset and how long it lasts

A

onset: 10 min IM
lasts: 2-4 hours

115
Q

meperidine

onset and how long it lasts

A

onset: 5-10 min
lasts: 2-3 hours

116
Q

morphine

onset and how long it lasts

A

onset: 10min IV, 20-40min IM
lasts: 3-4 hours

117
Q

what is the most common sign of hypotension in spinal anesthesia

A

maternal nausea and vomiting

118
Q

when passing a needle for an epidural, what structures in order do you pass through?

A

skin, subQ, supraspinous ligament, interspinous ligament, ligamentum flavum.

119
Q

neuraxial complications: LAST

A

bupivacaine>ropivacaine>levobupivacaine>lidocaine>2-chloroprocaine

120
Q

LAST treatment

A 
stop drug
intralipid 1.5mL/kg over 1 min then infusion (0.25-0.5mL/kg/min)
anticonvulsants
reduce epi to <1mcg/kg
avoid vaso, CCB, BB, and other LA
CPB/ECM
121
Q

RSI induction doses

A 
prop 2-2.5mg/kg
ketamine1mg/kg
etomidate 0.3mg/kg
succinylcholine 1-1.5mg/kg
roc 0.5-1mg/kg
MAC >0.8
122
Q

VBAC contraindication

A

if high vertical incision was made, fetal distress, or previa. uterine rupture a life-threatening complication. epidural can mask signs (abd pain mostly)

123
Q

rhogam

A

give if mother rh negative and hemorhage occurring. maternal and fetal blood may mix.

124
Q

placental abruption

risk factors

A

placenta separates from uterus before delivery=decreased fetal blood supply

risk factors: HTN, prior placental abruption, trauma, cocaine, premature ROM, coagulopathy, excessive amniontic fluid.

125
Q

HIGH risk maternal heart disease=high mortality rates

A

coarctation of aorta (with valvular involvement)

marfan syndrome w aortic involvement

126
Q

cardiac arrest in pregnancy

A

compressions 2-3 cm higher in 3rd trimester

push uterus to the side during compressions

127
Q

fetal scalp blood gases. what pH is acidotic

A

pH<7.2 is abnormal and deliver is expectant

128
Q

early FHR decelerations

A

uniform, occur w uterine contractions, gradually decrease rate then return to baseline

thought to be caused by vagal stimulation from head compression of the fetus

129
Q

late FHR decelerations

A

lowest point in FHR occurs after the peak of uterine contraction. reflects fetal chemoreceptor response to hypoxemia.
*worrisome

130
Q

variable FHR decelerations

A

most frequent type of FHR changes, irrespective of uterine contraction. comes from baroreflex to fetal cord compression

131
Q

ACOG

category 1

A

normal

132
Q

ACOG

category 2

A

observation needed

possibly abnormal acid/base

133
Q

ACOG

category 3

A

prompt intervention

abnormal acid/base

134
Q

S/S of ectopic pregnancy

A

abd pain
menses absent
irregular vag bleeding

shoulder pain comes from rupture of ectopic pregnancy causing hemoperitoneum and diaphragm irritation.

135
Q

what is adenomyosis?

A

when endometrial glands are within the myometrium

treatment-hysterectomy

136
Q

what is endometriosis?

A

when there are functional endometrial glands outside the uterine cavity

137
Q

placental abruption signs and symptoms

A
  • massive hemorrhage
  • early contractions
  • fetal distress
  • abdominal pain
  • DIC
  • amniotic fluid embolism
138
Q

uterine rupture S/S

A
  • pain is common
  • hypotension
  • cessation of labor
  • fetal compromise
139
Q

uterine rupture anesthesia plan

A

-general anesthesia unless epidural already in place

140
Q

amniotic fluid embolism response

A

-biphasic: pulmonary vasospasm + LV failure/pulmonary edema

141
Q

amniotic fluid embolism S/S

A
  • anxiety
  • dyspnea
  • hypoxia
  • hypotension
  • coagulopathy
  • CV collapse
142
Q

amniotic fluid embolism treatment

A
  • supportive
  • airway management
  • coagulopathy
  • corticosteroids
143
Q

thyroid levels in pregnancy

A

-increased, contributes to increased sympathetic response

144
Q

umbilical cord prolapse - S/S + treatment

A
  • sudden fetal bradycardia

- manual displacement of compression, emergency C-section

145
Q

Gestational Age: LPT

A

34 weeks - 36 weeks 6 days

146
Q

Gestational Age: VPT

A

<32 weeks

147
Q

Gestational Age: EPT

A

<28 weeks

148
Q

normal fetal pulse oximetry

A

35-65%

149
Q

fetal heart rate monitoring: minimal variability

A

<5 BPM

*worrisome, non-intact autonomic nervous system

150
Q

fetal heart rate monitoring: marked variability

A

> 25 BPM

151
Q

APGAR scale: signs

A
  • heart rate
  • respiratory effort
  • muscle tone
  • reflex irritability
  • color
152
Q

APGAR scale: what total scores mean

A

WNL = 8-10
moderate impairment = 4-7
HELP NOW = 0-3

153
Q

cervical cerclage: procedure and anesthesia

A
  • suture around incompetent cervix

- spinal (T10), epidural, general

6903 - Special Populations (16 decks)

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