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OB New Stuff > OB Lecture 2 Complications > Flashcards

OB Lecture 2 Complications Flashcards

1
Q

What is the most common cause of postpartum maternal palsy?

A

Cephalopelvic disproportion (big head, little pelvis) which results in lumbosacral trunk compression as it crosses pelvic brim by the fetal head.

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2
Q

How many parturients describe a backache?

A

75%, new onset for 60%

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3
Q

What are some reasons for backache?

A
  • Inc. lumbar lordosis to counterbalance growing uterus.

* Inc. laxity of sacrococcygeal, sacroiliac, pubic joints.

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4
Q

What are some complications of neuraxial block?

A 
Nerve injury
	—Epidural Hematoma
	—Epidural Abscess
	—Chemical nerve injury
	—Needle trauma
	—Positioning injury
PDPH
High or total spinal
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5
Q

This is a rare complication to neuraxial block and usually occurs in pts with hemostatic abnormality or coagulability

A

Epidural Hematoma

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6
Q

T/F: Epidural hematomas can only occur with block placement

A

False, can occur with catheter removal as well

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7
Q

What are some things that need checked if a patient has pregnancy induced HTN and you would like to place a block

A

Plt count >100K

Normal PT and PTT

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8
Q

How long do you avoid a neuraxial block with a therapeutically anticoagulated pt with LMWH

A

24 hours

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9
Q

How long do you avoid a neuraxial block with a prophylactically anticoagulated pt with LMWH

A

12 hours

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10
Q

When can you remove an epidural catheter when patients are on LMWH?

A

At least 12 hours after last dose

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11
Q

T/F: it is safe to administer a dose of LMWH an hour after a block has been placed

A

False must wait 2-4 hours after

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12
Q

Signs and symptoms of an epidural hematoma

A
  • Bilateral leg weakness
  • Incontinence
  • Absent rectal sphincter tone
  • Back pain
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13
Q

What do you do if you suspect an epidural hematoma?

A

CT or MRI, surgical decompression must occur within 6 hours for full neurological recovery to occur

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14
Q

How long does it take for symptoms to occur if you have an epidural abscess?

A

4-10 days, usually pain and loss of function

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15
Q

How do you treat an epidural abscess?

A

ABX and laminectomy, you have a 6-12 hour window before permanent damage occurs

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16
Q

What is the presentation of an epidural abscess?

A

• Severe back pain
—Worse with flexion; sometimes with radiation
• Exquisite local tenderness
• Fever, malaise, meningitis-like headache with neck stiffness

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17
Q

What are the lab value changes with an epidural abscess?

A

—Inc. WBC, inc. ESR, positive blood culture

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18
Q

Why is the epidural space very resistant to toxicity?

A
  • Very vascular

- Intact membrane between it and the subarachnoid space

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19
Q

What is transient neurological symptoms?

A

• Pain and dysesthesia in buttocks, legs or calves that can follow SAB, resolves w/in 72 hrs

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20
Q

What is TNS most commonly caused by?

A

Lidocaine

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21
Q

How long does it take for compression injuries to heal?

A

2-6 days if mild, 2-3 years if severe

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22
Q

What is postpartum foot drop caused by?

A

Either common peroneal nerve from stirrups or brow compression of lumbosacral trunk

23
Q

What is femoral or obturator neuropathy caused by?

A

–25% bilateral lithotomy of fetal head compression

24
Q

What s/s do you have if you have a femoral nerve injury?

A

Difficulty climbing stairs

25
Q

What s/s do you have if you have an obturator nerve injury?

A

Decreased sensation over upper inner thigh, weak hip adduction

26
Q

What is the onset and duration of a PDPH?

A

Onset: 12-48 hours
Duration: Few days to weeks

27
Q

What are the principle determinants of a PDPH?

A

Size of dura hole and type of needle used

28
Q

T/F: Larger gauge and cutting edge needles increase PDPH incidence

A

True

29
Q

What is the normal CSF volume and how much CSF is made per day?

A

Normal volume 150 cc

450 cc made/day

30
Q

How much CSF fluid needs to be lost in order to create a PDPH?

A

As little as 20 cc

31
Q

What is a PDPH caused by?

A

Sagging of intracranial contents and stretching of the pain sensitive tissues when the patient assumes an upright posture.

32
Q

What can you encourage your patient to do to help with a PDPH

A

Caffeine intake, will help vasoconstrict blood vessels in brain

33
Q

What are the PDPH risk factors?

A
  • Younger age
  • Larger needle gauge
  • Cutting-edge Quincke spinal needle
  • Cephalad or caudal orientation of Quincke needle
  • History of PDPH or migraines.
34
Q

What are the risk factors for dural puncture with an epidural needle?

A

Experience
Loss of resistance technique
Fatigue and haste
Accuracy of audit

35
Q

Which needle has the highest risk for a PDPH?

A

16-18 g epidural

36
Q

What is the hallmark sign of a PDPH?

A

Head pain when patient sitting or standing that is completely or almost completely relieved by recumbence

37
Q

What is a pneumocephalus?

A

Seen with LOR to air that injects intrathecal, headache almost instant and of short duration (hours).

38
Q

What is the most common cause of a perioperative HA?

A

Caffeine withdrawal

39
Q

What is a cortical vein thrombosis?

A

Rare, throbbing HA, not relieved by bed rest, may have SZ, diagnosed by CT or MRI, no clear treatment beyond symptomatic mgmt

40
Q

What are some other causes of HA besides a PDPH?

A 
Sinusitis
Caffeine withdrawal
Migraine
Meningitis
Cortical vein thrombosis
SAH
SDH
Tension HA
Pneumocephalus
41
Q

Can a PDPH cause permanent impairment?

A

Yes

42
Q

What is some non-invasive treatment of a PDPH

A 
Bedrest
IV hydration
ABD binder/compression
PO/IV/epidural analgesics
Cerebral vasoconstrictors
ACTH
43
Q

What is an epidural blood patch?

A

—Epidural space is identified and 15-20 cc of the patient’s own blood is injected (in strict aseptic manner) into the epidural space. Start slow and stop either when patient says headache is gone or they have a pressure sensation in the ears.

44
Q

How often does an epidural blood patch work?

A

80%

90% effective on the 2nd try

45
Q

What are the risks for an epidural blood patch?

A

Same as with regular epidural, has a higher incidence of backache. Risk of infection very rare but of theoretical concern.

46
Q

What is a prophylactic blood patch?

A

Given prophylactically through epidural catheter. HA incidence of 10-21%
Controversial
25% do prophylactic blood patch

47
Q

How does an EBP work?

A
  • Clotting factors in blood help seal the hole in the dura
  • The mass effect of the blood compresses the CSF giving nearly instant relief
  • Try to inject at the same level as the initial dural puncture. Blood will spread a few levels however.
48
Q

Total anesthesia involves what?

A

—Hypotension
—Dyspnea
—Aphonia

49
Q

What are some causes of a total spinal?

A

—Migrated epidural catheter
—Unrecognized dural puncture
—SAB after failed epidural

50
Q

What is the management of a total spinal?

A
  • Place patient in LUD and Trendelenberg
  • Early resuscitation, ventilation, and circulatory support.
  • Epinephrine may be needed
  • Naloxone for intraspinal opioid.
  • Intensive maternal monitoring.
  • Intensive fetal monitoring.
  • Maintain maternal sedation.
  • Possibly an urgent c-section
51
Q

What are some s/s of aspiration?

A

—Hypoxia
—Pulmonary edema
—Bronchospasm

52
Q

How do you prevent aspiration?

A 
Cricoid pressure
NPO
Sodium citrate
H2 blockers
Reglan
53
Q

How do you manage aspiration?

A
  • Intubation and positive pressure ventilation w/ PEEP. Use only enough O2 to maintain O2 saturation in the 90s (high FiO2 may exacerbate lung injury)
  • Suction as much as possible from airway.
  • Rigid bronchoscopy only used when large food debris needs to be removed.
  • Prophylactic antibiotics are controversial, may be detrimental.
  • Prophylactic steroids have no role.
  • Lavage is not routinely recommended.
  • Patients may become hypovolemic through fluid shifts

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