OB final exam- S4 Flashcards
What is the condition?
Patient has diagnosis of essential HTN before pregnancy
- Systolic of 140 or greater
- Diastolic of 90 or greater
- Before pregnancy or before 20 weeks gestation
- Risk of superimposed preeclampsia
Chronic Hypertension
What is the condition?
- Most frequent cause of HTN during pregnancy often after 37 weeks
- Elevated BP after 20 weeks gestation WITHOUT proteinuria
- Usually resolves by 12 week postpartum
- May lead to chronic HTN
Gestational Hypertension
What is the condition?
- Multi-organ disease with NEW onset of HTN and Proteinuria after 20th week gestation.
Preeclampsia
What is the condition?
- Preeclampsia in 20-34 weeks
- Younger than 18 or older than 45 yo
- Fetal growth restriction
- Familial component
- Primarily placental
- 20% of cases
Early Form (Type I) Preeclampsia
What is the condition?
- Preeclampsia after 34 weeks
- From obesity, DM or high cholesterol
- No fetal growth restriction
- No familial component
- 80% of cases
Late Form (Type II) Preeclampsia
What is the condition?
- BP ≥ 140/90 after 20 weeks gestation
- Proteinuria
- Asymptomatic, mild headaches that resolve
Preeclampsia WITHOUT Severe Features
(Mild preeclampsia)
What is the condition?
- BP ≥ 160/110
- Thrombocytopenia (platelets < 100,000)
- Creatinine > 1.1
- Oliguria < 500ml in 24hr
- Pulmonary edema
- Severe RUQ or Epigastric pain
- Visual disturbances
Preeclampsia WITH Severe Features
What is the condition?
- New onset of seizures or unexpected Coma in preeclamptics without disorder
- Headache and visual disturbances
- Central nervous system involvement
- up to 6 weeks postpartum
- Associated with placental abruption
- Must deliver baby
Eclampsia
What is the condition?
- Hemolysis, Elevated Liver enzymes, Low Platelet with preeclampsia
- Elevated bilirubin
- AST > 70
- ALT elevated
- Platelets <100k
- Lactate > 600
- BP can be normal
- Associated with DIC, placental abruption, liver hemorrhage, renal failure, ARDS
- Clear indication is if patient is trending down in labs and >30k drop in platelets q6h
HELLP syndrome
What is the condition?
- Presence of new onset proteinuria or sudden increase in proteinuria
- HTN already
- Very hard to differentiate with preeclampsia
Chronic HTN with superimposed Preeclampsia
What is the condition?
- Preeclampsia with or without severe organ involvement
- Seizures can develop in the postpartum period
- Presents within 7 days of delivery
- Can develop from 2-6 weeks postpartum
Post partum Hypertension
What is a protective factor from developing Preeclampsia?
Smoker
The nicotine inhibition of thromboxane A-2 synthesis and stimulates nitric oxide release
First pregnancy
Advanced maternal Age
Previous history
Family history
Chronic HTN
Chronic Renal disease
DM
Multiple gestation
Obesity
Black
Risk factors of developing Preeclampsia
Fetal Growth Restriction, Oligohydramnios and Abnormal oxygen exchange are associated with what?
Fetal Syndrome associated to Preeclampsa
New onset Hypertension and Proteinuria after 20 weeks gestation are associated with what maternal condition?
Preeclampsia
Defective trophoblastic invasion can lead to what 3 things?
- Reduced uteroplacental blood flow
- Stressed placenta
- Preeclampsia
What is the ultimate resolution of preeclampsia?
Delivery of the placenta.
T/F
Preeclampsia can occur without a fetus?
True
It is the placenta that causes preeclampsia
How are the spiral arteries affected during preeclampsia?
They cannot undergo vessel remodeling and lead to decreased blood flow causing multi organ disease
In preeclampsia there is hyperperfusion of the brain, what are some common symptoms associated with that?
Severe unrelieved headache
Coma
Visual disturbances
Hemorrhagic stroke
Loss of cerebral vascular autoregulation
What biomarker can identify cardiac dysfunction in preeclamptic mothers?
BNP
What is the most common hematologic disorder in women with preeclampsia?
Thrombocytopenia
What is the most common cause of severe thrombocytopenia in the second half of pregnancy?
Preeclampsia
Low fibrinogen
Prolonged PT and PTT
Drop in platelets
Signs of bleeding
Severe liver involvement
Fetal Demise
Are all signs/symptoms of what severe issue?
DIC
Preeclampsia WITHOUT severe features are _____coagulable?
Hyper or Hypo
Hyper
Preeclampsia WITH severe features are _____coagulable?
Hyper or Hypo
Hypo
How is the Renal system affected by preeclampsia?
Proteinuria
GFR decreases
Elevated uric acid levels
Renal insufficiency
Oliguria is late sign
What is the only cure to preeclampsia?
Delivery of the placenta
Must be > 34 weeks
Preeclamptics have intravascular volume depletion.
Volume expansion is not recommended therefore they should receive how much fluids?
80ml/hr
Blood pressure control of a preeclamptic involves the use of antihypertensives to treat a systolic/diastolic of what?
Systolic of 160
Diastolic of 110 or higher treated
What the 2 first line medications for treatment of HTN in a preeclamptic with IV access?
Labetablol= 20mg
Hydralazine= 5-10mg
What is the most common calcium channel blocker used to treating HTN in pregnancy?
Nifidipine
What the first line medication for treatment of HTN in a preeclamptic without IV access?
PO only
Nifidipine
Calcium channel blocker
What is this drug?
-Most common calcium channel blocker for HTN treatment
- Relaxes arterial smooth muscle beds
- Can also cause exaggerated hypotension
- First line agent without IV access
Nifidipine
What is this drug?
- Combined alpha and beta adrenergic (1:7 ratio)
- Rapid onset
- Does not cause reflex tachycardia
- Decreases cerebral vasospasm
- Can cause neonatal hypoglycemia and bradycardia
Labetalol
What is this drug?
- Direct acting arteriolar vasodilator
- Reduces afterload
- Vasodilates uterine and renal vasculature
- Reflex tachycardia (careful with CAD)
- First line treatment for SEVERE hypertension
Hydralazine
What is this drug?
- Arteriolar dilator
- potential for tachyphylaxis and metabolic acidosis with prolonged use
- Cyanide toxicity risk
- Titrated to a max of 5 mcg/kg/min
Nipride (nitroprusside)
What is this drug?
- Venodilator
- Careful with lowering the BP too quick or too much
- 0.5-1mcg/kg/min
- Can also cause uterine relaxation
Nitroglycerin
What is the anticonvulsant of choice to prevent seizures in preeclamptics with severe features?
10% Magnesium sulfate
What is this drug?
- acts centrally at NMDA receptor to raise seizure threshold
- Inhibits release of acetylcholine
- Mild vasodilator in cerebral circulation
- Improves hepatic and renal blood flow
- Do not stop during surgical procedures
- eliminated by renal excretion so levels are routinely checked
- Reflex testing
- 4-6 grams in 100ml over 20 mins followed by infusion 1-2 grams/hr
Magnesium Sulfate
What is the normal magnesium level?
1.8-2.4
What is the therapeutic magnesium level?
4-8
What is the treatment for magnesium toxicity?
Stop infusion
Administer 1gram Calcium Gluconate
Provide oxygen
Does magnesium cross the placenta?
Yes, can cause fetal bradycardia and respiratory depression
can rise quickly in 2-3 hours
Must be treated with Calcium gluconate
What drugs should you reduce dosages with when giving a patient magnesium?
NMBA
can cause further muscle relaxation
At what platelet level is regional anesthesia NOT appropriate?
< 50k
NO regional anesthesia
What is the leading cause of maternal mortality in pregnancy?
Obstetrical hemorrhage
What is the primary mechanism for controlling blood loss at delivery?
Uterine contraction stimulated by endogenous oxytocin
Which Procoagulation factor is decreased during pregnancy?
Protein S
Which Procoagulation factors are increased in pregnancy?
Fibrinogen
Factors I, VII, VIII, IX, X
1, 7, 8, 9, 10
Average EBL for vaginal delivery?
500ml
Average EBL for c- section?
1000ml
What are the 2 late signs of excessive blood loss in mothers?
Hypotension
Tachycardia
Most cases of this are in the first trimester ?
- Greatest threat is to the fetus
- Can be caused by cervicitis or placenta previa/abruption
- Not typically life threatening
Antepartum Hemorrhage
“Before”
What is present when the placenta implants in advance of the fetal presenting part?
- Placenta overlies to the cervical os
- Classic sign is painless vaginal bleeding during 2/3 trimesters
Placenta previa
Attachment of the placenta to the Lower Uterine Segment (LUS) leads to what?
Increased risk of bleeding
These are all risk factors for what abnormality?
- multiparity
- advanced age
- smoking history
- male fetus
- previous c section
- previous placenta previa
Placenta previa
What is the Gold standard for diagnosis of placenta previa?
Transvaginal ultrasound
What is the classic sign of placenta previa?
Painless vaginal bleeding during the 2nd or 3rd trimester
After 20 weeks
Painless vaginal bleeding after 20 weeks is the classic sign for what?
Placenta previa
Lack of abdominal pain or absence of abnormal uterine tone distinguishes placenta previa from what?
Placental abruption
Very painful
Treatment for placenta previa > 36 weeks?
prompt delivery of baby/fetus
Prepare for massive blood loss
Treatment for placenta previa < 36 weeks?
Bed rest, limit physical activity, no sex, no vaginal exams
Steroids if bleeding
What is the complete or partial separation of the placenta from the decidua basalis before delivery of the fetus which can lead to maternal hemorrhage and fetal compromise?
Placental abruption
- Breakthrough epidural pain
- Vaginal bleeding
- Uterine tenderness
- Tense to palpation,
- Increased uterine activity (hypertonus)
These are all classic presentation of what severe maternal issue?
(not all are necessary)
Placental abruption
Shallow trophoblastic invasion of spiral arteries in placental abruption is known as what disease?
Ischemic placental disease
Complications of this condition include
- Hemorrhagic shock
- Coagulopathy
- Fetal compromise or death
- 1/3 of coagulopathies = fetal death
- Decidual vessels are the cause of the bleeding
Placental abruption
This complication of abruption occurs when vascular damage within the placenta causes hemorrhaging that progresses to and infiltrates the wall of the uterus into the peritoneum?
Couvelaire Uterus
What is the treatment of placental abruption?
Delivery of the infant and placenta
Can be vaginal if near term and ok status or cesarean
- Emergent C-section with significant abruption and massive bleeding
What is the single most important risk factor of uterine rupture?
Prior uterine surgery
Classical vertical scar
What is caused by the separation of a uterine scar that results in fetal distress and maternal hemorrhage requiring emergent delivery or laparotomy?
- Most common/reliable clinical sign is fetal bradycardia
Uterine rupture
T/F
Uterine rupture requires emergent cesarean or laparotomy, but uterine scar dehiscence does not?
True
Uterine scar dehiscence does not result in massive hemorrhage or require emergent c-section
Which prior uterine cut is the highest risk for uterine rupture?
Classical vertical scar
The most common and most reliable clinical sign of uterine rupture is what?
Fetal bradycardia
Major signs of intrapartum uterine rupture in a TOLAC are change in uterine tone or contraction pattern and what?
FHR abnormalities
Fetal bradycardia
What condition is the insertion of the fetal vessels over the cervical os and is a major fetal emergency?
- Rupture of the membranes is accompanied by tearing of fetal vessels
- No threat to mother
- Diagnosed by ultrasonography
Vasa Previa
What is the blood volume of the fetus at term?
80-100ml/kg
More than 500 ml blood loss after vaginal delivery and more than 1,000 ml blood loss after cesarean delivery is associated with what?
S/S of hypovolemia within 24 hrs of birth
- Most common cause of maternal mortality
Postpartum hemorrhage
Primary postpartum hemorrhage is defined as what?
Occurs during the first 24 hours post partum
(highest mortality)
Secondary postpartum hemorrhage is defined as what?
Between 24 hours and 6 weeks postpartum
All are potential causes of what condition?
- Uterine atony
- Retained products of conception
- Lacerations
- uterine rupture
- Placenta Accreta
- Coagulopathy
Postpartum hemorrhage
What are the 4 T’s of postpartum hemorrhage management?
4 most common causes
Tone- 70%
Trauma- 20%
Tissue- 10%
Thrombin- 1%
What is the most common cause of postpartum hemorrhage?
Uterine atony
Which ATLS shock class?
- less than 15% blood loss. 900ml total
- less than 100 HR
- Normal Blood pressure
- Normal pulse
- 14-20 Respirations
- Slightly anxious
Class 1
Which ATLS shock class?
- 15-30% blood loss. 1200-1500ml total
- 100-120 HR
- Normal Blood pressure
- Decreased pulse pressure
- 20-30 Respirations
- Mildly anxious
Class 2
Which ATLS shock class?
- 30-40% blood loss. 1800-2100ml total
- >120 HR
- Decreased BP
- Decreased pulse pressure
- 30-40 Respirations
- Anxious, confused
Class 3
Which ATLS shock class?
- >40% blood loss. >2400ml total
- >140 HR
- Decreased BP
- Decreased pulse pressure
- >35 Respirations
- Confused/Lethargic
Class 4
This drug is a uterotonic that can cause vasodilation, tachycardia, hypotension and myocardial ischemia
- Used to treat uterine atony
- 40U in 1L bag given over 1 hour
Pitocin (Oxytocin)
This drug is a uterotonic that is contraindicated in patients with HTN or preeclampsia.
- Cause arteriolar constriction
- 0.2mg IM
- May be repeated q1h
Methergine
Methylergonovine
This drug is a uterotonic that is contraindicated in patients with reactive airway disease and asthma.
- can cause bronchoconstriction
- Prostaglandin F2
- 0.25mg IM
- May be repeated q15 mins up to 2mg total
Hemabate/ Carboprost
Methylprostaglandin F2
This drug is a uterotonic that is given rectally, sublingually or vaginally.
- Prostaglandin E1
- 600-1000 mcg
- Can cause fever, chills, diarrhea
Misoprostol
Cytotec
The bleeding involved with a Vaginal hematoma comes from ____ artery?
Uterine
The bleeding involved with a Vulvar hematoma comes from ____ artery?
Pudendal
Extreme pain and blood loss
What is the most dangerous and least common genital trauma injury that can occur during a cesarean delivery?
Retroperitoneal hematoma
What is defined as failure to deliver the placenta completely within 30 minutes after delivery off the infant?
- Leading cause of primary and secondary Postpartum hemorrhage
Retained placenta
What is the inside-out turning of the uterus that can cause severe hemorrhage and worsened by concurrent vagal reflex mediated bradycardia?
Uterine inversion
What is the anesthetic treatment of a uterine inversion?
Uterine relaxation
Stop uterotonics and give tocolytics so surgeon can replace uterus
Nitroglycerin IV 50-250 mcg
vasopressors
What condition is when a placenta in whole/in part invades the uterine wall and is inseparable from it?
Placenta accreta
What condition is when the basal plate of the placenta is directly adhered to uterine myometrium without an intervening decidual layer?
Placenta accreta Vera
What condition occurs when the chorionic villa of the placenta invades the myometrium?
Placenta Increta
What condition represents invasion of the Placenta through the myometrium into serosa and sometimes adjacent organs most often the bladder?
- Uterus must be removed
Placenta Percreta
What is the definitive diagnosis of placenta accreta?
Laparotomy
Why has there been an increased incidence of placental accreta?
Due to increased Cesarean delivery rate. 50% of all hysterectomies
What is caused by a 50% increase in plasma volume and a 30% increase in red blood cell mass during pregnancy?
Physiologic anemia of pregnancy
The majority of the white and black population of mothers have the “D” antigen which makes them Rh- _____?
Rh-Positive
Without the “D” antigen mothers are considered Rh- _____?
Rh-Negative
What will happen to an Rh negative mom if she receives Rh positive blood for the first time?
NOTHING on first exposure.
But on second exposure anti-Rh antibodies will attack the RBCs and result in hemolysis
What drug derived from antibodies can be given to protect Rh negative mothers who have Rh positive babies?
- via IM injection
RhoGAM
contains antibodies to Rh factor
What condition is a new acute lung injury/acute respiratory distress syndrome that occurs within 6 hours of blood transfusion?
- HLA antibodies against the lung parenchyma
- More common in Multiparous donors
- Neutrophil activation results in inflammatory pulmonary edema
- Higher incidence in mothers with liver surgery/ chronic alcoholics
- Leading cause of transfusion related death
- Hypotension, cyanosis, pulmonary infiltrates, fever
TRALI
Transfusion Related Acute Lung Injury
Treatment of TRALI?
Transfusion related acute lung injury
Stop the transfusion
Respiratory support via ventilator
vasopressors
What condition is the 2nd most common cause of transfusion associated death?
- Hydrostatic pulmonary edema due to transfusion
- 1 RBC is sufficient to trigger reaction
- Circulatory system becomes overwhelmed by high volume transfusion or high transfusion rate
- Elevated Jugular venous pulse
- Sudden dyspnea, orthopnea, tachycardia, Wide pulse pressure
- Can progress to cardiac collapse
TACO
Transfusion associated Circulatory Overload
Treatment of TACO?
Transfusion Associated Circulatory Overload
Diuretics
Oxygen
TRALI patients are more ____volemic state?
TACO patients are more _____volemic state?
TRALI hypovolemic
TACO hypervolemic
This drug is a synthetic derivative of lysine that inhibits fibrinolysis and also anti-inflammatory?
- Blocks interaction of plasminogen with lysine residues
- Used to decrease blood loss
- May attenuate elevation in D-dimer
- Loading dose of 1g in 100mL over 10 mins
- Recombinant activated factor VII
TXA
Tranexamic Acid
Which blood product would be given for an expected response of 1g/dl increase in hemoglobin concentration?
Packed Red Blood Cells (PRBCs)
1 unit
250-300ml volume
Which blood product would be given for an expected response of Correction of PT, aPTT, INR by replacement of coagulation factors?
Plasma
10-15ml/kg
200mL
Which blood product would be given for an expected response of Increase in platelet count of 30-60k ?
Platelets
4-6 units
200-250ml
Which blood product would be given for an expected response of Increase in levels of fibrinogen, von Willebrand factor, factor VIII, factor XIII?
Cryoprecipitate
10 pooled units
100ml
What is the most common anesthesia related injury claim to mothers?
Maternal nerve damage
more with vaginal than cesarean
What is the most common anesthesia related injury claim to neonates?
Neonatal brain damage
more with cesarean than vaginal
What functions as the anti-reflux barrier?
- Passive reflux and regurgitation of gastric contents is prevented by this
Lower Esophageal Sphincter (LES)
Aspiration of 25ml with a pH < 2.5 can cause a granulocytic reaction that can cause injury to alveolar epithelium?
- More common in Right lower lobe
- Can produce ARDS
Mendelson’s Syndrome or
Aspiration Pneumonitis
Treatment of Mendelson’s syndrome?
Trendelenburg position
Suction the airway and intubation
then suction the primary bronchi with soft suction
Which aspiration prophylaxis drug is a Nonparticulate antacid 30ml is given at least 20 mins prior to induction to buffer gastric fluid and raise pH?
Bicitra
Which aspiration prophylaxis drug is an H-2 antagonist 20mg given within 30 mins of induction to prevent histamines potentiation of acid production?
Famotidine (Pepcid)
Which aspiration prophylaxis drug increases LES and reduces gastric volume by increasing peristalsis?
- 10mg given
Metoclopramide (Reglan)
Which nerve lesions are most often bilateral?
- Paralysis from the site distally
- autonomic dysfunction
- Bowel/bladder dysfunction
Central lesions
Which nerve lesions are most often unilateral?
- Paralysis limited to a single muscle or muscle group
Peripheral lesions
Prolonged second stage of pregnancy and positioning are risk factors for what?
Neurologic injuries
What is the most common nerve injury involved with child birth?
- Compressions under inguinal ligament
- Prolonged hip flexion
- Sensory deficit
- Purely Sensory
Lateral Femoral Cutaneous
What is the second most common nerve injury involved with child birth?
- Partial hip flexion
- diminished patellar reflex
- Retractor compression against pelvic wall in cesarean
Femoral
Which cranial nerve is most vulnerable to cranial nerve palsy related to major loss of CSF following spinal anesthesia?
Abducens
CN VI
Which cranial nerve is associated with tinnitus following dural puncture?
Vestibulocochlear
CN VIII
Which condition presents with severe backache and localized tenderness 4-10 days postpartum with associated fever, headache and neck stiffness?
- WBC increased
- requires prompt MRI and antibiotics
- Surgical decompression
Epidural abscess
Which condition involves pressure or swelling of the lumbar nerves?
- Hematoma
- Severe low back pain, motor weakness, sensory loss and bowel/bladder dysfunction
- Needs immediate treatment
Cauda Equina Syndrome
Which neurologic condition causes pain, stinging or burning in the back, perineum, legs, arms, and feet.
- Exposure to chemicals that do damage the arachnoid and meninges
- Treatment with MRI, pain meds and steroids
Arachnoiditis
This syndrome can be seen after epidural insertion or brachial plexus block?
- Benign and short lived
- Unilateral ptosis (drooped eyelid) with miosis (constricted pupil) is most common presentation
- Anhidrosis (no sweat) and enopthalmos (eye goes inward)
Horner’s syndrome
This primary headache type is often circumferential and constricting
- Associated with scalp tenderness and mild to moderate severity?
Tension-type headache
This primary headache type is usually pulsating in unilateral location
- nausea
- photophobia
- aura before
- often have history of this type?
Migraine headache
This secondary headache is worsened by maternal physical exertion during labor and lack of sleep?
- Neck and shoulder pain without history of dural puncture
Musculoskeletal
This secondary headache has variable signs but can have evidence of increased ICP?
- somnolence
- vomiting
-confusion
- focal abnormalities
Subdural Hematoma
This secondary headache has a classic presentation with sudden onset of severe headache and decreased level of consciousness?
Subarachnoid hemorrhage
This secondary headache is caused by the injection of air into the subdural or subarachnoid space?
- sudden onset of severe headache, back pain, neck pain
- can mimic PDPH but resolves in 1 week
Pneumocephalus
This headache occurs within 5 days of lumbar puncture caused by a CSF leak?
- Can occur immediately or within mins of moving to upright position
- Resolves within a minute of moving to the supine position
- Can cause headache, neck stiffness, tinnitus, photophobia or hearing loss
Post dural puncture headache
PDPH
What is the overall cause of PDPH?
Continuous leak of CSF creating tension on the meninges leading to reflex cerebral vasodilation.
Treatment of PDPH?
Bed rest, hydration, caffeine, muscle relaxants, pain meds
Blood patch is still having pain for 24hrs
What is the treatment of choice for a PDPH if patient has cranial symptoms?
Epidural blood patch
Stay supine for 1-2 hours
What is the time frame in cardiac arrest of mother > 20 weeks pregnant?
No circulation within 4 mins of cardiac arrest, perform emergent C-section within 5 mins of arrest then continue resuscitation
Coagulation factor levels I, VIII, IX, X, XI all do what in normal pregnancy?
Increase
Which factors are unchanged in normal pregnancy?
Factor II and Factor V
Which factors are decreased in normal pregnancy?
Factor XI and Factor XIII
UFH LOW prophylactic dose should wait how long until neuraxial?
4-6 hours
UFH HIGH Therapeutic dose should wait how long until neuraxial?
24 hours
LMWH LOW prophylactic dose should wait how long until neuraxial?
-Enoxaparin
12 hours
LMWH HIGH Therapeutic dose should wait how long until neuraxial?
-Enoxaparin
24 hours
Each 1mg IV of protamine can reverse how much of IV Heparin?
100 units
How should IV protamine be given?
Give slowly as it can cause hypotension from histamine release
Fetal material in the maternal circulation has the potential to trigger a massive cascade of inflammatory and hemostatic reactions that cause CV collapse and DIC from what cause?
Amniotic fluid embolism
Amniotic fluid embolism (AFE) is diagnosed clinically by what?
Acute hypotension
Acute hypoxia
Coagulopathy
Onset of above during labor
What is often described as the anaphylactoid syndrome of pregnancy?
Amniotic fluid embolism (AFE)
Amniotic fluid embolism activates the clotting cascade by affecting what first?
Tissue factor binds to factor VII activating the extrinsic pathway and triggering clotting by activating factor X.
What is the classic Triad of symptoms of Amniotic fluid embolism?
Respiratory distress
CV collapse
Coagulopathy
What are the common symptoms of Amniotic fluid embolism before collapsing?
Seizure and dyspnea
What is the anesthetic management of Amniotic Fluid Embolism (AFE)?
Intubate and oxygenate with 100% FiO2
Hemodynamic support with fluids and vasopressors
correction of coagulopathy
What drugs should be given will help with Amniotic Fluid embolism (AFE)?
Atropine 0.2mg and Ondansetron 8mg can block serotonin and vagal stimulation improving CV function.
Ketorolac 30mg can inhibit thromboxane coagulopathy
What is the most important risk factor for Venous thromboembolism (VTE) in pregnancy?
Previous history of thrombosis
Virchow’s triad describes 3 factors that contribute to increased risk of thromboembolism, what are the 3 factors?
Venous stasis
Vascular damage
Hypercoagulability
Shortness of breath, Palpitations, Cyanosis, diaphoresis, split heart sound, and right ventricular strain are all symptoms of what type of emoblism?
Pulmonary Embolism
What is the gold standard diagnosis of DVT?
Ultrasonography
D-dimer is not accurate
Which form of Heparin does not affect the aPTT?
LMWH or UFH
LMWH
This form of Heparin must be measured q6h and adjusted to 1.5-2.5x the normal range?
Unfractionated Heparin (UFH)
This occurs when the surgical field is above the level of the heart and has a potential during c-section?
- hypotension, hypoxemia, dyspnea
- Millwheel murmur
- Right sided heart failure with Peaked P waves
Venous air embolism
What is the most common cause of anemia in pregnancy?
Iron deficiency
This condition is a group of microcytic hemolytic anemias that result from the reduced synthesis of one or more of the polypeptide globin chains which leads to defective hemoglobin, erythrocyte damage and imbalanced globin chain ratios?
Thalassemias
This form of Thalassemia has 3 functioning genes?
- no increased risk during pregnancy
Silent carrier
This form of Thalassemia has 2 functioning genes?
Alpha- thalassemia
Mild anemia
This form of Thalassemia has 1 functioning gene?
Hemoglobin H disease
Moderate anemia
This form of Thalassemia has no functioning genes?
Alpha thalassemia or Bart’s hydrops
incompatible with life
What condition has severe edema in an unborn baby or newborn?
- 50% mortality
- Rh neg mom and Rh pos baby
- Very large uterus size
Hydrops Fetalis
Which Beta- thalassemia can be treated with transfusion and Chelation agents and must maintain a hemoglobin above 10?
Beta Thalassemia Major
Which Beta-thalassemia is usually benign with mild anemia?
Beta Thalassemia Minor
This disorder is characterized by a homozygous mutation where Valine is substituted for glutamic acid on the B-chain?
- Hemoglobin of 6-8
- Elevated reticulocyte count
- Presence of sickle cells on blood smear
- Goal is hemoglobin above 8
Sick Cell Disorder
What is the main hemoglobin in sickle cell disease?
What is the most important determinant of sickling?
Hemoglobin S
Oxygen tension
What are 2 potent platelet activators of hemostasis?
Collagen
Thrombin
Which Coagulation pathway?
- Factor XII activates
- Heparin
- PTT lab value
Intrinsic
Which coagulation pathway?
- Factor III (tissue factor) activates
- Warfarin
- PT/INR lab value
Extrinsic
Gestational thrombocytopenia occurs most often in third trimester and diagnosed by a platelet count below what?
below 150,000
This syndrome classic pentad of
- thrombocytopenia
- Microangiopathic hemolytic anemia
- Fever
- Photophobia/headache
- Renal failure
- DIC is the hallmark of it
- NO neuraxial anesthesia
Thrombotic Thrombocytopenia Purpura (TTP)
The presence of vWF but not fibrinogen in platelet aggregates helps differentiate this condition from DIC?
Thrombotic Thrombocytpenia Purpura (TTP)
The presence of fibrinogen but not vWF in platelet aggregates helps differentiate this condition from TTP?
DIC
What is the most common congenital bleeding disorder?
Type 1 von Willebrand’s disease
For patients with Von Willebrand’s disease type I or 2A what drug should be administered during labor?
Desmopressin (DDAVP) 0.3mcg/kg IV
If acute bleeding them FFP or cryo
Treatment of DIC includes what?
Remove precipitating cause
Transfuse FFP
Cryoprecipitate
Platelets
Keep patient warm
This condition is caused by a point mutation in factor V gene that produces a single amino acid switch (arginine to glutamine) that makes protein resistant to inactivation by activated protein C?
- Thrombophilia
- hypercoagulable state
- 40% of OB thrombo events
Factor V Leiden
This condition is synthesized in liver and endothelial cells?
- Inactivates thrombin and factors
- activity is potentiated by heparin
- Risk of thrombosis in pregnancy
Antithrombin III deficiency
This condition is a vitamin K dependent protein synthesized in the liver and inhibits blood coagulation by activation of factors V and VIII?
- Occurs when the gene on both chromosomes #2 are affected
- Normally the levels are increased in pregnancy
- Risk for thrombosis in pregnancy
- Treated with LMWH up to 6 weeks post
Protein C deficiency
This condition is associated with increased risk of VTE?
- This normally acts as a cofactor for protein C
- Normally the plasma levels of this decrease during pregnancy
- Risk for antepartum and postpartum VTE is low
Protein S deficiency
1st trimester?
0-12 weeks
2nd trimester?
13-28 weeks
Safer for surgery
1st stage of labor is from what to what?
- Cervical stage
Cervical dilation and contractions
3rd trimester?
29-40 weeks
2nd stage of labor is from what to what?
- Pelvic stage
Complete dilation to fetus delivery
3rd stage of labor is from what to what?
- Placental stage
Placenta delivery
4th stage of labor is what?
After delivery of placenta to 1-4 hours postpartum
CO returns to pre labor values within __ postpartum?
24 hours
CO returns to prepregnancy levels between _____ post partum?
12-24 weeks
HR decreases to prepregnancy levels by ____ postpartum?
2 weeks
What are the 7 cardinal movements of labor?
- Engagement
- Descent
- Flexion
- Internal Rotation
- Extension
- External Rotation
- Expulsion
What is the most important determinant of placental function?
Uterine blood flow
V C
E H
A O
L P
Variable decels= Cord compression
Early decels= Head compression
Accels= OK
Late decels= Placental Insufficiency BAD
FHR classification?
Baseline 110-160
Variability: Moderate
Late or variable decels: Absent
Early decels: Present
Accelerations: Present
Category I
NORMAL
FHR classification?
Bradycardia with variability
Variability: Moderate with late or variable decels
Absent variability without recurrent decels
Prolonged Decels
Category II
Undeterminant
FHR classification?
Bradycardia
Absent variability with late decels
Sinusoidal pattern
Category III
Abnormal
BAD
What is the normal rate of uterine contractions?
1 contraction every 2 mins is normal
5 or less in 10 min period
6 or more uterine contractions in 10 minute period is known as what?
Tachysystole
1 single sustained uterine contraction without relaxing for more than 2 mins is known as what?
Tetanic contraction or
Uterine Hypertonus
Which pain pathway during labor?
- Uterus and cervix
- T10-L2
- Visceral afferent type C fibers
- Treat with Paracervical block
Stage 1
Which pain pathway during labor?
- Vagina and Perineum
- S2-S4
- Somatic and Pudendal nerves
- Treat with Pudendal block
Stage 2
