OB exam 2-S4 Flashcards by Brad Koester

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)

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What drug can patients with SLE not have?

Toradol

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Pericarditis, pleural effusions, valve disorder and pulmonary HTN are associated heavily with which disorder?

SLE

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Which antibodies are tested for due to the ability to cause misscarriage?

Antiphospholipid antibodies

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This is also known as Hughes Syndrome, it is an autoimmune prothrombotic disorder with the presence of aPL, aCL, and aB2GPI?

Antiphospholipid syndrome (APS)

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What 2 things are associated with both arterial and venous thrombotic events?

aPL and aCL
lupus anticoagulant and anticardiolipin antibodies

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How is Antiphospholipid Syndrome (APS) diagnosed?

Unexplained recurrent venous or arterial thrombosis, pregnany loss, and evidence of aCL or aPL.

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Pregnant women with APS are at risk for what?

DVT, PE, MI, cerebral infarction and fetal loss.

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What drug will help treat thrombocytopenia in women with APS?

Prednisone therapy

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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

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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

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T/F
In the absence of underlying coagulation deficit, A prolonged PTT does not suggest a bleeding tendency and neuraxial is safe?

True

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T/F
Aspirin is a contraindication to neuraxial?

False

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A spinal or epidural should wait __ hours after the last dose of Unfractionated heparin?

4 hours

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A spinal or epidural should wait __ hours after last dose of LMWH for prophylaxis?
(Low dose)

12 hours

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A spinal or epidural should wait __ hours after last dose of LMWH for therapeutic?
(High dose)

24 hours

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What can be used to document the clearance of heparin?

TEG

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T/F
General anesthesia can cause a higher risk of venous thrombosis in pregnant moms with APS?

True

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NYHA Classification of Heart failure
-NO limitations of physical activity?

Class 1

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NYHA Classification of Heart failure
-Mild limitations of physical activity, regular activity causes symptoms?

Class 2

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NYHA Classification of Heart failure
-Marked limitations of physical activity, no symptoms at rest, minimal activity causes symptoms?

Class 3

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NYHA Classification of Heart failure
- Symptoms at rest?

Class 4

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Cardiac Risk Prediction
- Class I?

No increase or mild increase in morbidity

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Cardiac Risk Prediction
- Class II?

Small increase in maternal mortality,
- Arrhythmias
- Marfan
- Repaired tetralogy of Fallot

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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?

1. Increased risk of fasting hypoglycemia 2. Insulin Resistance 3. Accelerated starvation resulting in increased lipolysis and ketone production

Insulin sensitivity is decreased by ___% in the 3rd trimester?

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?

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.