OB exam 2-S4 Flashcards
What disease is a multi-system inflammatory disease. Hyperactivity of antibody producing B cells and defects of the helper and suppressor T cells.
Triggered by viruses and bacteria.
- Flares occur mostly in 2nd and 3rd trimesters and in the puerperium.
-Women with this have 2-4 fold increase in overall pregnancy complications: HTN, renal disease, preeclampsia, anemia.
Treated with DMARDS, Hydroxychloroquine, Corticosteroids and NSAIDS.
Systemic Lupus Erythematosus (SLE)
What drug can patients with SLE not have?
Toradol
Pericarditis, pleural effusions, valve disorder and pulmonary HTN are associated heavily with which disorder?
SLE
Which antibodies are tested for due to the ability to cause misscarriage?
Antiphospholipid antibodies
This is also known as Hughes Syndrome, it is an autoimmune prothrombotic disorder with the presence of aPL, aCL, and aB2GPI?
Antiphospholipid syndrome (APS)
What 2 things are associated with both arterial and venous thrombotic events?
aPL and aCL
lupus anticoagulant and anticardiolipin antibodies
How is Antiphospholipid Syndrome (APS) diagnosed?
Unexplained recurrent venous or arterial thrombosis, pregnany loss, and evidence of aCL or aPL.
Pregnant women with APS are at risk for what?
DVT, PE, MI, cerebral infarction and fetal loss.
What drug will help treat thrombocytopenia in women with APS?
Prednisone therapy
What is characterized by small vessel occlusions of various organs (thrombotic microangiopathy) and can cause intrauterine fetal death?
Catastrophic Antiphospholipid Syndrome (cAPS) or Asherson’s syndrome
Antiphospholipid Syndrome (APS) treatment involves the use of what drugs?
Thromboprophylaxis with low dose aspirin and heparin
or
Full anticoagulation with unfractionated heparin or LMWH for patients with history of APS with thrombosis
T/F
In the absence of underlying coagulation deficit, A prolonged PTT does not suggest a bleeding tendency and neuraxial is safe?
True
T/F
Aspirin is a contraindication to neuraxial?
False
A spinal or epidural should wait __ hours after the last dose of Unfractionated heparin?
4 hours
A spinal or epidural should wait __ hours after last dose of LMWH for prophylaxis?
(Low dose)
12 hours
A spinal or epidural should wait __ hours after last dose of LMWH for therapeutic?
(High dose)
24 hours
What can be used to document the clearance of heparin?
TEG
T/F
General anesthesia can cause a higher risk of venous thrombosis in pregnant moms with APS?
True
NYHA Classification of Heart failure
-NO limitations of physical activity?
Class 1
NYHA Classification of Heart failure
-Mild limitations of physical activity, regular activity causes symptoms?
Class 2
NYHA Classification of Heart failure
-Marked limitations of physical activity, no symptoms at rest, minimal activity causes symptoms?
Class 3
NYHA Classification of Heart failure
- Symptoms at rest?
Class 4
Cardiac Risk Prediction
- Class I?
No increase or mild increase in morbidity
Cardiac Risk Prediction
- Class II?
Small increase in maternal mortality,
- Arrhythmias
- Marfan
- Repaired tetralogy of Fallot
Cardiac Risk Prediction
- Class III?
Significant increase in maternal mortality
-Mechanical valves
- Complex congenital heart disease
-Marfan
Cardiac Risk Prediction
- Class IV?
Pregnancy is not recommended
- Severe aortic or mitral stenosis
- Pulmonary artery HTN
Treatment of SVT during pregnancy?
Stable- Vagal, Adenosine
Unstable- Synchronized Cardioversion
This disease is poorly tolerated in pregnancy.
-36% mortality
-Associated with IUGR, fetal loss and preterm delivery.
-Increased CV demands of pregnancy which can not be met?
Pulmonary HTN
Which drug do we avoid giving to mothers with Pulmonary HTN?
Methergine
WHO Group __? Pulmonary HTN
- Idiopathic PAH
- Heritable PAH
- Drug and Toxin induced
- Associated with HIV, connective tissue disorder, portal HTN.
Group 1 PAH
WHO Group __? Pulmonary HTN
- Associated with left ventricular systolic or diastolic dysfunction, left sided valve disease.
Group 2 due to left heart disease
WHO Group __? Pulmonary HTN
- Associated with COPD, lung diseases
Group 3 due to lung disease/hypoxia
WHO Group __? Pulmonary HTN
-Chronic
Group 4
WHO Group __? Pulmonary HTN
- Includes systemic diseases, hematologic disorders, chronic renal, chronic anemia
Group 5 with unclear or multifactorial
CO increases how much with pregnancy?
30-50%
SVR decreases how much with pregnancy?
-10%
Pulmonary artery pressure greater than___ indicates pulmonary artery hypertension?
> 25mmHg
Which syndrome is a subclass to PAH and occurs in patient with congenital heart disease who suffer from anatomic systemic to pulmonary shunt?
Eisenmenger syndrome
The hypoxemia and cyanosis associated with Eisenmenger syndrome occurs from which shunt?
Right to left shunt
Management of which syndrome includes ?
-diuretics to manage volume control
- Dobutamine to improve RVF
- Inhaled Nitric Oxide to dilate pulmonary vasculature
- Chronic anticoagulation to prevent thromboembolism (LMWH)
Eisenmenger syndrome
Which delivery form is preferred in patients with Eisenmenger syndrome?
Cesarean delivery @ 34-36 weeks
Vaginal delivery is contraindicated in mothers with Eisenmenger syndrome due to what?
Valsava could lead to rapid CV collapse and pain/anxiety can greatly affect SNS
Maintain adequate SVR
Maintain intravascular volume
Avoidance of aortocaval compression
Prevent pain
Avoid myocardial depression
Slow titrate of locals
all are what?
Goals of treatment
This congenital heart disease is associated with ?
-Right ventricular overload leading to pulmonary HTN and Eisenmenger syndrome
- SVT/ Ventricular arrhythmias
- Pre-eclampsia, fetal demise, Small gestational age
Atrial Septal Defect
This congenital heart disease is associated with ?
- Pregnancy is tolerated with repaired defect or small defect in absence of Pulm HTN
- Unrepaired defect has high risk of maternal cardiac complications
- Preeclampsia is seen more frequently in those with unrepaired defect
Ventricular Septal Defect
This congenital heart disease is associated with ?
-Pregnancy well tolerated
- Left to right shunt may cause Pulm HTN
-Pregnancy not recommended if associated with Eisenmenger syndrome
Patient Ductus Arteriosus (PDA)
What heart condition is most commonly caused by congenital bicuspid aortic valve?
-symptoms include dyspnea on exertion, chest pain and syncope.
- General anesthesia is gold standard
Aortic Stenosis
Patients with aortic stenosis need what for induction?
Etomidate
A-line
Chronic Aortic Regurgitation is caused by what?
Degenerated bicuspid aortic valve
Acute Aortic Regurgitation is caused by what?
Endocarditis
What is okay to maintain in mothers with Aortic Regurgitation?
Slightly elevated Heart Rate
This heart condition is caused by Rhematic disease, can become symptomatic during pregnancy.
- May lead to pulmonary edema due to increased blood volume and decreased diastolic filling
- Systemic anticoagulation is recommended during pregnancy and postpartum
Mitral stenosis
A pregnant mother with Mitral stenosis cannot have this medication?
Hemabate due to increase in PVR
This condition is associated with-
- Biventricular failure with orthopnea
- Dyspnea on exertion, palpitations, chest pain
- Unknown cause during the last month of pregnancy or within 5 months of delivery ?
Peripartum Cardiomyopathy
What is required for peripartum cardiomyopathy diagnosis?
-Heart failure wtithin last month of pregnancy or 5 months postpartum
- Absence of prior heart disease
- No determinable cause
- Strict echocardiographic indication of Left ventricular dysfunction EF<45% or Fractional shortening <30%
This condition includes any degree of glucose intolerance with onset during pregnancy
-screening at 24-28 weeks
- Cannot produce enough insulin to compensate for enhanced resistance to insulin during 2&3 trimesters
Gestational Diabetes
T/F
Mothers who have gestational DM have an increased risk for DM later in life and 30-70% chance of Gestational DM in another pregnancy?
True
T/F
Pregnant Mothers with pregestational DM will have an increased insulin requirement due to peripheral insulin resistance in the 2&3 trimesters?
True
2-3x more insulin required
Pregestational DM or Gestational DM?
- Is associated with 2-3 fold incidence of preterm labor and delivery?
Pregestational DM
T/F
Incidence of hyperglycemia in first trimester (5-8 weeks) increases the risk of first trimester fetal loss and congenital malformations?
True
Neonatal macrosomia weight?
> 4000-4500 grams
What is the most clinically significant neonatal morbidly usually resulting from sustained hyperinsulinemia?
Neonatal hypoglycemia
What are the 3 physiologic changes in glucose metabolism occur during pregnancy?
- Increased risk of fasting hypoglycemia
- Insulin Resistance
- Accelerated starvation resulting in increased lipolysis and ketone production
Insulin sensitivity is decreased by ___% in the 3rd trimester?
50
T/F
After the placenta is delivered a rapid decrease in insulin dose occurs?
Decreased by 2/3 of prepregnancy dose
True
Which condition is associated with ?
-Prayer sign
-Difficult intubation
- Limited movement of the atlantooccipital joint
Diabetic Stiff-Joint Syndrome
Target values during pregnancy for mothers with DM-
Fasting?
1 hour post meal?
Hemoglobin A1C?
Fasting= 65-99
1 hour post meal= 100-120
A1C= 6-6.5%
Normal total T3 value?
1.4-3.2 nmol/L
Normal total T4 value?
50-150 nmol/L
T/F
Do concentrations of FREE T3 and T4 change during pregnancy?
False
No change in free
T/F
Do concentrations of TOTAL T3 and T4 change during pregnancy?
50% change
Hypothyroidism is diagnosed by measuring what?
A decreased level of FREE T4
The fetus depends on maternal Thyroxine until the fetal thyroid system is fully functional at ___ weeks?
20 weeks
Then independent of maternal
Maternal Hypothyroidism in 1st trimester can affect fetal___?
Brain development
What disease is the leading cause of hyperthyroidism in pregnancy?
Graves disease
Which drugs should be avoided in mothers with hyperthyroidism?
Ketamine and Atropine
Thyroid storm symptoms include?
Fever, HTN, Tachycardia, Agitation
Infants at risk for congenital cretinism
(Growth failure, Mental retardation or neuro deficits) are associated with which disorder?
Iodine-deficient hypothyroidism
This disorder is the persistent severe form of N/V
- Specific to pregnancy
- Usually resolves 12-20 weeks gestation
- Can be a sign of molar pregnancy
- Not a true liver disease
- Treated with Ginger, Vitamins, Antiemetics, IV hydration
Hyperemesis Gravidarum
This condition is associated with
- Increasing levels of estrogen
- Moderate to severe Itching and elevated bile acid levels
- Older mom, family history, Hep C at higher risk
- Labs will have 10-100x increase in bile acid, Bilirubin levels >6mg/dL
-Treated with antihistamines, antipruritic and Ursodeoxycholic acid (UDCA) in severe cases
-Rapid resolution after delivery
Intrahepatic Cholestasis of Pregnancy
This condition is also called reversible peripartum liver failure
- More common with twins
- Microvesicular fatty infiltration of liver due to defective beta oxidation of fat in 3rd trimester
- Primiparous with multiple gestation and male fetus are high risk factors.
-Genetic defect in the fetus and placenta cause toxic free fatty acid metabolites.
Acute Fatty Liver of Pregnancy (AFLP)
This condition is an Emergency that needs rapid treatment.
- Can progress to DIC, hepatic and renal failure, ARDS
- Fetal compromise and death secondary
- Immediate delivery of the fetus of termination of pregnancy must happen
- Anticipate Hemorrhage
Acute Fatty Liver of Pregnancy (AFLP)
AFLP is distinguished by a marked increase in what lab value?
Serum Bilirubin
Management of what condition is associated with controlling HTN, seizure prophylaxis, immediate delivery of fetus or termination of pregnancy, Liver transplant in severe cases. Postpartum hemorrhage?
Acute Fatty Liver Pregnancy
AFLP
The main difference between HELLP and AFLP is signs of what?
AFLP has signs of coagulopathy, hypoglycemia, encephalopathy and renal impairment.
Postural scoliosis or Idiopathic scoliosis is associated with Nonstructural curves?
Postural Scoliosis
also sciatica
Postural scoliosis or Idiopathic scoliosis is associated with Structural curves?
Idiopathic Scoliosis
leads to rib hump and reduced mobility
MAC is decreased by ___% for pregnant women?
30% decrease
Neuraxial anesthetic doses decreased by ___% at term for pregnant mothers?
40% decrease
Which neurological condition is caused by immune mediated inflammatory demyelination of white matter throughout the CNS?
-often between 20-40 years old
-Unpredictable course of frequent attacks and remissions, can progress to incapacitation.
- Ataxia, paresthesias, diplopia, bladder/bowel dysfunction, motor weakness
- DO NOT Give Succinycholine/Rocuronium
Multiple Sclerosis
MS
Multiple Sclerosis (MS) relapses are caused by what?
Stress
Emotional distress
Infection
Trauma
Increased Body Temperature
Treatment of Multiple Sclerosis (MS) in pregnant patients includes ?
Corticosteroids
Glatiramer
IVIG
Which condition is associated with ?
-Infants with high incidence of meconium aspiration
- Small for gestational age
- Rate of relapse increases in first 3 month postpartum
- Pregnancy does not affect long term course
Multiple Sclerosis (MS)
Which condition is an autoimmune disorder with episodes of muscle weakness and fatigue that are made worse by activity?
- autoimmune destruction of inactivation of post-synapatic acetycholine receptors at the NMJ.
Myasthenia Gravis
T/F
In Myasthenia Gravis smooth muscle and cardiac muscle are not affected?
True
only skeletal
Which condition is caused by Immunoglobin G (IgG) antibodies targeting the nicotinic acetycholine receptors leading to repetitive contractile ability exhaustion?
Myasthenia Gravis
What is the order of muscle involvement in Myasthenia Gravis, which affected first?
-Proximal limb
-Bulbar
-Ocular
-Respiratory muscles
Ocular-First
Bulbar
Proximal limb
Respiratory muscles- Last
What drug is the preferred therapy for Myasthenia Gravis?
Pyridostigmine
Myasthenia Gravis exacerbation in a pregnant mother commonly occurs during ___?
Delivery and postpartum
Uterine smooth muscle is unaffected
Which class of local anesthetic should be used for a patient with Myasthenia Gravis?
Amide locals due to prolongation half life of esters
Which drugs can exacerbate Myasthenia Gravis?
NMBA- Succyncholine/Rocuronium
-Aminoglycosides
- Tocolytics/ Magnesium sulfate
- Lithium, quinidine, propanolol
- Ester locals
Which condition occurs during the first few days of life in 20% of infants born to Myasthenia Gravis mothers?
-Caused by maternal IgG crosses placenta causing generalized weakness, hypotonia, weak cry and resp distress.
-Rapid decrease in alpha-fetoprotein
Treated with Pyridostigmine and ventilator can take weeks to months to resolve
Transitory Neonatal Myasthenia Gravis
This condition is associated with acute onset of paralysis of the facial nerve (CN7) and excessive tear production?
Bells Palsy
Which labor drug is a contraindication for mothers with asthma?
Hemabate
IUGR
Preterm labor
SIDS
Tachycardia/HTN
Abruption placenta
Placenta previa
Ectopic pregnancy
all associated with mother use of what during pregnancy?
Nicotine use
What is the leading cause of preventable birth defects in the US?
Intrauterine alcohol exposure
Maternal use of what drug is associated with High placental abruption rate?
Cocaine
What is the leading cause of maternal death worldwide?
Peripartum Hemorrhage
Which drug is the first line treatment for uterine atony?
Oxytocin-pitocin
What is this drug?
-1st line treatment for atony
-20U/40U in 1L bag
-must be given slow IV gtt
- Rapid infusion can cause CV collapse/hypotension
Oxytocin/pitocin
What is this drug?
- 0.2mg IM
-10 min onset
- repeat q2-4hours
- Can cause vasoconstriction/Hypertension
-IM only
- Do not give to HTN or Preeclampsia
Methergine
What is this drug?
- Synthetic prostaglandin F2
- stimulates uterine contractions
- 250mcg IM
- Repeat 15-90 mins up to 8 doses
- Can cause diarrhea, bronchospasm, pulmonary vasoconstriction
- Caution with asthmatics
Hemabate-Carboprost
What is this drug?
- Synthetic Prostaglandin E1
- Rapid onset
- 200-1000mcg oral/rectal
- can cause increase in temperature
Misoprostol-Cytotec
Which Umbilical cord prolapse is past the presenting part and easily palpable or visible?
Overt or Complete Prolapse
Which Umbilical cord prolapse is alongside the presenting part and not externally visible?
Occult
What is the most common sign of uterine rupture?
FHR abnormalities
Can sometimes have breakthrough pain
What is the treatment for uterine rupture?
Emergency C-section
Manipulation of the uterus and abdominal organs can cause what type of pain?
Visceral
What is the gold standard for providing effective postcesarean analgesia?
Neuraxial opioids
Morphine epidural dose?
2-5mg
Morphine spinal dose?
.025-0.5mg
_____ refers to the portion of the fetus that overlies the pelvic inlet?
-lie
-presentation
-position
Presentation
____ refers to the alignment of the fetal spine to the maternal spine?
-lie
-presentation
-position
Lie
_____ refers to the relationship of specific fetal bony point to the maternal pelvis?
-lie
-presentation
-position
Position
Injury to common perineal nerve is associated with what symptom?
Foot drop
Injury to the Femoral nerve is associated with what?
Medial sensory changes
What 2 nerve injuries are potential complications in Lithotomy position?
Common Perineal Nerve
Femoral Nerve
What dermatome level is needed for a Cervical Cerclage?
T10
Low dose spinal
Persistent elevation in beta-hcg after the pregnancy is concluded is a a key sign/diagnosis of what disease?
Gestational Trophoblastic Disease (GTD)
What is the main anesthetic consideration for a patient with GTD (molar pregnancy) suction D/C?
Risk for rapid, significant blood loss
What dermatome level is needed for a Tubal Sterilization?
T4
Elective surgery should be postponed until when?
6 weeks postpartum
Before 24 weeks is considered what?
Pre-Viable
After 24 weeks is considered what?
Viable
In maternal Cardiac arrest how long after downtime of the arrest must the baby be delivered?
Fetus must be delivered Within 5 minutes after 4 mins downtime.
