OB lecture 4: Maternal Coexisting Disease

Question 1

Pheocromaoctyoma can mimic what condition in the parturient?

Answer 1

-Preeclampsia (HTN, HA)

Pheochromocytoma is a neuroendocrine tumor of the delude of the adrenal glands or extra-adrenal chromatin tissue that failed to involute that secretes excessive catecholamines- Norepinephrine and epinephrine.

Question 2

Continuous epidural analgesia and c section are preferred for patients with pheochromocytoma. Prep therapy should include ___ blockers followed by ___ blockers.

Answer 2

Alpha blockers followed by beta blockers in this order to avoid unopposed alpha stimulation and severe HTN.

Question 3

For parturients with bronchial asthma regional anesthesia is preferred and ETT is avoided d/t risk of bronchospasm. What other treatments should be avoided or included in the patient with asthma’s care?

Answer 3

• Avoid H2 blockers (cimetidine, ranitidine) can increase sensitivity to histamine and cause spasm.
• consider atropine or glycopyrrolate (anticholinergics) to decrease secretions
• ketamine for induction- bronchial relaxation
• avoid desflurane, resp irritant.

Question 4

Parturients with Paraplegia:

Have an ______ incidence of preterm labor.

_____ may be mistaken for labor, especially if lesion is above T7.

Early epidural analgesia can prevent _______ from occurring.

Avoid ______ due to risk of hyperkalemia

Answer 4

INCREASED incidence of preterm labor

Autonomic hyperreflexia may mimic labor, especially if lesion is above T7.

Early epidural can prevent Autonomic hyperreflexia from occurring.

Avoid SUCCINYLCHOLINE due to risk of hyperkalemia.

Question 5

Parturients with Multiple Sclerosis have a slightly increased risk from relapse during pregnancy. More commonly, the relapse happens during _____ period.

Answer 5

post partum

Question 6

Parturients with MS have a potential for neurotoxicity due to demyelinated portions of spinal cord taking up more LA. Therefore, bupivicaine concentration should not exceed ___%.

Answer 6

0.25% Bupivicaine and the smallest effective dose should be used.

Question 7

In patients with severe musculoskeletal involvement of there Multiple Sclerosis, _____ should be avoided.

Answer 7

Succinylcholine

Question 8

Brain herniation and death following rapid CSF reduction with dural puncture is associated with what condition?

Answer 8

Brain Tumor.

Review radiographic studies for evidence of mass effect.

***Avoid intentional dural puncture (SAB)

For C-section, consider epidural, but General Endotrachial Anesthesia with generous narcotic doses to blunt reflexes during laryngoscopy and avoid sudden increase in BP and ICP.

Question 9

Pesudotumor Cerebri: can neuroaxial anesthesia be performed?

Answer 9

YES- benign intracranial HTN

No mass present. Spinal/epidural block is ok.

Question 10

Myasthenia Gravis:

Answer 10

• Highly sensitive to both depolarizing and non-depolarizing NMB agents. (1/2-1/3 the normal dose)
• Destruction of ACTH receptors, typically treated with anticholinergics like neostigmine or edrophonium.
• 1/2 MAC is usually adequate
• more receptive to effects of opioids and local anesthetics

Question 11

Myasthenia Gravis: patients are vulnerable to Cholinergic Crisis. Symptoms include:

Treatment for Cholinergic Crisis is:

Answer 11

Symptoms of cholinergic crisis:

• profound muscle weakness
• respiratory failure
• Loss of bowel/bladder function
• disorientation
• diplopia

Treatment: IV or IM Atropine

Question 12

Patients with Sickle trait (HgbAS heterozygous) usually have no problems with pregnancy. Patients with Sickle Cell Disease (HgbSS Homozygous) have more severe anemia and a higher incidence of _______.

Answer 12

Preeclampsia

Question 13

What are triggers for sickle cell crisis?

Answer 13

• Hypoxia (keep patient on O2)
• Dehydration (warmed fluids)
• Hypotension
• Hypothermia (warmed fluids)
• Acidosis

Avoid using tourniquets longer than necessary for lab/IV.

Question 14

_________ is the most common hereditary coagulation abnormality.

Answer 14

VonWillebrand Disease: Qualitative or quantitative deficiency of vonWillebrand Factor (vWF), a multimeric protein that is required for platelet adhesion.

• Type 1 (most common) treated with DDAVP 0.3mg/kg
• No DDAVP in type 3…can worsen bleeding

-Neuraxial blockage is a relative contraindication depending on coagulation times.

Question 15

Factor V Leiden:

Answer 15

Variant of human coagulation factor V that cannot be inactivated by protein C and thereby causes a hyper coagulation disorder.

-Typically on LMWH (lovenox) very early in pregnancy, often converted to heparin at week 38 to facilitate neuraxial blockage.

Question 16

If prophylactic LMWH dose given, must wait ____ hours before proceeding with block.

Answer 16

12 or more.

Question 17

If therapeutic LMWH dose given, must wait ____ hours before proceeding with block.

Answer 17

24 hours and consider anti Xa heparin assay.

Question 18

Protein C & Protein S:

Answer 18

Hepatic enzymes that interact with coagulation factors Va and VIIIa to inhibit fibrin formation, i.e. clot.

• deficiency of C & S lead to hyper coagulability and recurrent DVT/PE.
• Patient may be on LMWH therapy, time blockage carefully.

Question 19

Systemic Lupus Erythematosus considerations:

Answer 19

• Pericarditis
• Prolonged PR interval, non-specific T wave changes
• Valvular disorders (regurg, stenosis, vegatations)
• If previous endocarditis, may need prophylactic abs
• Neuropathies

Early placement of epidural recommended.