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NA 3 > OB - Nag > Flashcards

OB - Nag Flashcards

1
Q

Preg cardiovascular/HD changes at term
-HR
-SV
-CO
-SVR

A

everything increases except SVR

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2
Q

Preg hematologic changes at term
-total blood volume
-plasma volume
-RBC volume
-coag factors
-platelets

A

everything increases except platelets (no change/ - )

++ coag factors

plasma volume ~40-50% more

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3
Q

Preg respiratory changes at term
-MV
-Vt
-RR
-FRC

A

everything increases except FRC decreases

-MV increases 50%

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4
Q

T/F CO increases in pregnant pts mainly because of HR and to a lesser extent SV

A

False

SV increase > HR increase

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5
Q

T/F Blood volume markedly increases as the body prepares mom for blood loss at delivery

A

True

gross

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6
Q

What is the cause of dilutional anemia during pregnancy?

A

plasma volume increases at a larger extent than RBC volume increases
-40-50% vs 20% increase

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7
Q

What is the main cause of MV increasing so high (45%) during pregnancy?

A

Vt increases

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8
Q

T/F O2 consumption is markedly increased as is CO2 production during pregnancy

A

True

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9
Q

Pregnant pts have a _ (increased / decreased) sensitivity to LA and a _ (increased / decreased) MAC for all general anesthetics.

A

more sensitive to LA
decreased MAC for GA

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10
Q

T/F Pregnant pts are in a hypercoagulable state due to increased platelet count

A

False
they ARE in hypercoagulable state but bc of increased FIBRINOGEN and COAG FACTORS, platelet count is normal or decreased

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11
Q

Aortocaval compression during pregnancy causes profound HOTN and can be relieved by _ _ _

A

Left uterine displacement (LUD)

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12
Q

T/F Pregnant pts should be considered full stomach if they are 20+ wks gestation

A

ehhh…

Nagelhout says 12+ wks
Howie’s PPT says 20 wks, but in reality treat ALL pregnant pts as full stomachs/asp risk

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13
Q

T/F The need for thorough airway eval in pregnant pts is due to their propensity for chipped and damaged teeth

A

False
significant airway changes occur -> difficult airway risk

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14
Q

Pregnant pt’s HR begins increasing in the _ tri and peaks at _ wks. Tachyarrhythmias are more likely to occur in _ (early/late) pregnancy

A

1st tri - 32wks
tachyarrhythmia risk higher in late preg

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15
Q

Increased CO
-begins at: _ wks and increases over time
-ends at: _ days postpartum (returns to baseline)
-highest point during PREG: _ trimester
-highest point during LABOR: _ stage
-reaches MAX VALUE:

A

begins: 5wks
ends: 14 days pp

Highest point during PREG: 2nd tri
Highest point during LABOR: 2nd stage
Reaches MAX VALUE: immediately post partum (80-100% increase)

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16
Q

At term _ % of CO perfuses the gravid uterus

A

10%

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17
Q

Why does labor cause increases in CO for mom?

A

during uterine cx it autotransfuses blood to central circulation

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18
Q

Why does mom’s CO increase so drastically immediately pp? (2 reasons)

A

-uterine cx causes autotransfusion back to central circulation

-increased venous return from aortocaval decompression

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19
Q

Diaphragm is displaced _ during preg, heart shifts up and left causing enlarged cardiac silhouette on CXR. The ventricular walls thicken and _ (EDV / ESV) increases

A

cephalad
up and left
EDV

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20
Q

Normal or not normal: CV exam on preg pt
-grade 1/2 systolic murmur
-grade 3 systolic murmur
-3rd heart sound
-cp or syncope
-diastolic murmur
-cardiac enlargement
-SOB, edema, poor exercise tolerance

A

N:
-grade 1/2 systolic murmur
-3rd heart sound
-SOB, edema, exercise intol

pathologic:
-grade 3+ murmur
-diastolic murmur
-cp or syncope
-cardiac enlargement

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21
Q

What causes increased plasma volume in preg?

A

levels of progesterone and estrogen -> enhance RAAS

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22
Q

What causes increased RBC volume in preg?

A

increased erythropoietin levels in 8th wk

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23
Q

Normal blood loss
-vag delivery
-uncomplicated CS

A

vag: <500mL

uncomp CS: 500-1000mL

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24
Q

During labor each cx moves _ - _ mL blood from uterus to central circulation

A

300-500mL

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25
Q

When do preg pts have stronger baroreceptor reflexes for HR, 6-8wks or at term?

A

term

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26
Q

If mom has neuraxial anesthesia and cx occurs her HR will _ (increase/decrease) as preload transiently _ (increase/decreases)

A

HR drops as preload rises transiently during cx

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27
Q

Biggest hemodynamic decrease in preg is _. Why? (2 reasons)

A

SVR ~20-40%
-bc there is decreased resistance to uteroplacental, pulmonary, renal, and cutaneous capillary beds (more BF going deeper into other tissue)
-venous capacitance system loses tone - > blood pools

think about how mom’s skin/hair/nails are glowing during pregnancy but also her ankles are swollen

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28
Q

By term _ % of the CO perfuses the low resistance intervillous space in the uterus

A

10%

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29
Q

T/F Central sympathetic outflow in preg pt is double that of a nonpreg pt

A

True

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30
Q

T/F The decreased SVR in preg pts causes decreased SBP(15mmHg less), resulting in increased MAP.

A

FALSE
SVR decrease -> decrease in DBP -> decreased MAP

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31
Q

Aortocaval compression
-cause

A

compression of vena cava and aorta by gravid uterus in supine position
-worse if abdomen is tense or when uterus is even bigger (hydramnios, multiparous)

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32
Q

Aortocaval compression
-response

A

decreased CO and venous return -> tachycardia + vasoconstriction of LE BUT uterine BF and fetal O2 is still reduced

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33
Q

T/F If aortocaval compression occurs BP will be low on all parts of body

A

false
upper body will be normal, lower body will be low and poor perfusion to uterus

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34
Q

Aortocaval compression is aka

A

supine hypotensive syndrome

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35
Q

Aortocaval compression
-tx

A

LUD by 15 degree tilt of table or 15cm wedge under R hip

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36
Q

Aortocaval compression
-impact of positioning for neuraxial: lateral vs sitting

A

Maternal cardiac index is better in lateral(both R+L) position than flexed sitting position
-no difference in fetal BF based off positioning

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37
Q

Hypercoag state from preg
-factors that increase

A

I (fibrinogen)
VII
VIII
IX
X
XII
vWF
WBC

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38
Q

Hypercaog state from preg
-factors that decrease

A

XI
XIII
platelets (from hemodilution or accelerated platelet clearance)

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39
Q

Resp changes in preg
-airway

A

capillary engorgement -> narrow glottic opening + airway edema from nasopharynx-trachea = bleed risk
-use smaller ETT(6.5/7fr) + AVOID nasal intubation

higher MP score + breasts in the way
-use short handle blade + ramping

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40
Q

Increased O2 consumption can be up to _% at rest and _% during labor

A

33%
100%

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41
Q

MV in preg pt is increased up to 50%, this is mainly because of increased _ and _ to a lesser extent

A

MV elevated mainly from increased Vt, and a little from increased RR

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42
Q

T/F By 12wk gest arterial PCO2 decreases to 30-32mmHg due to increased FRC. Mom becomes kinda hypoxic from metabolic alkalosis that persists.

A

False
PCO2 is lower from increased MV
not hypoxic, actually has PO2 >100mmHg thru preg
No alkalosis bc compensatory serum bicarb decreases from 26->22

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43
Q

Upward pressure from the pregnant diaphragm results in which lung volumes and what resp pattern?

A

Decreased FRC, ERV, and RV
(FRC=ERV+RV)
restrictive breathing pattern

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44
Q

Decreased FRC and increased O2 consumption in preg pt = _ (increased / decreased) apneic reserve

A

decreased

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45
Q

If FRC is decreased and there is no change to closing capacity in pregnant pts, will small airway closure increase or decrease?

A

increase
-FRC/CC ratio will decrease and cause small airway closure before full exhale of Vt -> desat when sleeping (sometimes <90%)

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46
Q

In preg pt is DO2 increased or decreased?

A

increased
-small airway closure occurs more but the increased CO and RIGHTWARD shift in O2Hgb curve = more O2 delivered to tissue

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47
Q

MV can increase by _ % during maternal cx, potentially causing mom’s PaCO2 to drop to < _ mmHg (alkalemia). This causes her to _ (increase / decreased) RR between cx and eventually become _

A

increase 300%
PaCO2 <15mmHg
decreased RR
hypoxemic

-increased RR causing PaCO2 of ~20 is ok for fetus per scalp blood sample (won’t cause acidosis / hypoxia) unless complicated labor or fetal issues already exist

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48
Q

Increased sensitivity to LA and GA begins in the _ tri

A

1st
-increased nerve sensitivity + engorged epidural veins

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49
Q

Mechanical changes like _ _ veins are responsible for increased block height in pregnancy

A

engorged epidural veins

-from increased intraabdominal pressure, can decrease volume of epidural and SA space

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50
Q

Increased levels of gastrin in preg _ (inc / dec) gastric volume and _ (inc / dec) gastric pH

A

increase
decrease

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51
Q

Meds to tx asp risk in pregnant pt (4)

A

Nonparticulate antacids (Bicitra)
-reduce pH

H2 receptor antagonists (Pepcid)
-reduce pH

Metoclopramide
-increase gastric emptying, decrease N/V, increase LES tone

consider Zofran for HOTN prophylaxis for spinals
-blunts BEZOLD JARISH reflex

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52
Q

What causes mechanical obstruction to outflow thru pylorus, decreased gastric emptying, and increased intragastric pressure in preg pts?

A

upward shift of stomach

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53
Q

Increased levels of the hormone, _, during preg can decrease gastric motility and decrease LES tone -> GERD

A

progesterone

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54
Q

Going into labor _ (inc / dec) gastric emptying due to pain and IV pain meds

A

decreases

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55
Q

GA on preg pt
-technique for induction:

A

RSI + cricoid pressure + preox for 3 min!

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56
Q

Liver enzymes elevated in preg pt:

A

ALT, AST, ALP, LDH

-albumin is DECREASED

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57
Q

Serum cholinesterase activity in preg pt is _ (inc / dec), however they _ (will / will not) have prolonged drug effects

A

decreased
will not

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58
Q

Increased CO in preg pt -> _ (inc/dec) renal plasma flow and _ (inc/dec) GFR

A

increased
increased

-peeing a lot

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59
Q

Increased GFR in preg pt will cause Creatinine clearance to increase to 140 - 160 mL/min - > BUN _ (inc/dec) and Creatinine level will _ (inc/dec) as well

A

BUN decreases
Creatinine decreases

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60
Q

T/F Increased GFR and decreased renal absorption cause preg pt to have glucosuria and proteinuria

A

true

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61
Q

Uterine BF is supplied by 2 _ arteries

A

uterine

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62
Q

Placental BF on the uterine sd is supplied by which 3 type of arteries? Which one supplies the intervillous space?

A

maternal arcuate artery
radial artery
spiral arteries <- supply intervillous space

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63
Q

Maternal _ _ receive blood from intervillous space and send it back to central circulation

A

venous sinuses

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64
Q

Uterine BF at term = _ mL/min or ~ 10% of mom’s CO

A

800mL/min

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65
Q

Deox blood flows from the fetus to the uterus via 2 umbilical _ then into central _ on the placenta, mixing with mom’s blood to exchange nutrients and waste. sorry mom

A

umbilical ARTERIES (like Pulm arteries) - not veins!
central villi

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66
Q

O2 + CO2 are _ limited and do not rely on normal gas diffusion in the placenta

A

PERFUSION
-decreases in mom’s uterine BF or increased placental resistance will drop fetal O2

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67
Q

T/F Uteroplacental perfusion is autoregulation dependent

A

False, depends on mom’s uterine BF/ BP

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68
Q

T/F Phenylephrine is teratogenic to the fetus

A

false
-safe to give in standard doses

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69
Q

T/F Placental BF stays normal with neuraxial anesthesia and becomes impaired from inhaled agents

A

False
impaired from neuraxial, normal with IA

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70
Q

Placental transfer of free drugs (NON-protein-bound) depends on (4 items)

A

-magnitude of concentration gradient
-molecular wt
-lipid solubility
-state of ionization

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71
Q

Drugs with molecular wt < _ Da cross the placenta easily

A

<500 Da

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72
Q

Transfer of drugs from mom’s circulation to fetus is determined PRIMARILY by _

A

diffusion

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73
Q

Factors favoring diffusion of drugs into fetal circulation from maternal blood include: (4 items)

A

-low molecular wt
-high lipid solubility
-low degree of ionization
-low protein binding

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74
Q

T/F Fenanyl has high lipid solubility and easily crosses into placenta

A

True

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75
Q

T/F ionized drugs are polar and hydrophilic/ H2O soluble which prevents diffusion thru the lipid membrane to the placenta

A

True

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76
Q

LA are variably ionized _ (acidic / basic) compounds and more _ (acidic / basic) ambient pH causes a higher degree of _ (ionization/nonionization) which crosses the placenta easier

A

basic
more basic
nonionization

  • basic + basic = less ionization = crosses easier
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77
Q

NDMR are large, ionized drugs that are not affected by ambient pH due to their quaternary amines and _ (do / do not) cross the placenta barrier

A

do not

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78
Q

Factors that decrease effects of maternal drugs on fetus: (3)

A

Dilution
-moms hepatic enzymes drop drug levels before going to uterus, diluted in intervillous spce, then bsorbed and diluted again in placenta before reaching fetus

Shunts
-1/5 of fetal CO goes back to placenta from the shunt from foramen oval and ductus arteriosus without touching fetus

Acid/base status of fetus
-protective for fetus but if more acidic = more ion trapping = more accumulation

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79
Q

1st stage labor pain is from _ distention, stretching of the lower _ segment and possibly myometrial _

A

cervical
uterine
ischemia

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80
Q

1st stage labor pain is from nonspecific nociceptor _ stimulation, carried by _ fibers to the cord from _ - _ segments

A

visceral stimulation
C fibers
T10-L1 segments

C fibers = nonlocalized aching + cramping

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81
Q

2nd stage of labor begins when _ _ is complete and the presenting part of the fetus _

A

cervical dilation
descends

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82
Q

2nd stage labor pain is due to compression and stretching of _ afferent fibers from the pudendal nerve entering the SC at _ - _

A

somatic afferent
S2-S4

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83
Q

Neuraxial anesthesia for labor pain in the 1st and 2nd stages should have a _ - _ sensory block

A

T10-S4

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84
Q

3 essential requirements for successful L+D:

A

Fetus properly positioned and right size to fit thru

Uterus cx regularly and effectively

Pelvic outlet configured for fetus to fit thru

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85
Q

T/F Labor begins officially when cx are regular and cause cervix to change

A

T

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86
Q

1st stage labor
-what is happening?
-when do latent and active phases begin + end?

A

events: effacement + dilation

*Latent Phase: onset of regular cx - point where cervix changes quickly
Active Phase: 2-3cm dilation - 10cm dilation

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87
Q

2nd stage labor
-begins
-ends

A

begins: 10cm or fully dilated

ends: delivery of fetus

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88
Q

3rd stage labor
-begins
-ends

A

begins: fetal delivery

ends: placental delivery

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89
Q

Cervical dilation progresses usually _ - _ cm/hr when in active phase for nulliparous pt

A

1-1.2cm/hr

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90
Q

If labor is dysfunctional, may require _

A

oxytocin

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91
Q

FHR monitoring options:

A

-intermittent w fetoscope

-continuous w doppler

-continuous w internal fetal ECG (requires slight dilation + rupture of membrane)

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92
Q

T/F FHR can be monitored by a tocodynameter

A

false
this monitors uterine cx duration

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93
Q

Uterine cx monitoring options:

A

Tocodynameter
+preserved membrane, less invasive
-lots of artifact, measures duration and not pressure

Internal pressure cath between fetus + uterine wall
+more reliable, measures pressure + duration, allows for amniotic sac infusion if meconium present
-requires partial dilation and rupture of membrane (risks involved)

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94
Q

Indications for internal uterine cx monitoring: (2)

A

-high risk pregnancy

-if oxytocin is being used

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95
Q

ASA recs for FHR monitoring

A

before and after neuraxial interventions

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96
Q

Fetal O2 is limited by _ _ _

A

maternal blood flow

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97
Q

Why can’t the uterus autoregulate blood flow?

A

Uterine arteries are maximally dilated during pregnancy
-drop in moms BP or BF = fetal hypoxia + acidosis = FHR changes

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98
Q

FHR
-normal
-tachy
-brady

A

N = 110-160 (higher if premie)

tachy = >160 (at term)

brady = <110

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99
Q

Causes of fetal tachycardia

A

asphyxia
arrhythmias
mom has fever
chorioamnionitis
mom receives terbutaline or atropine

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100
Q

Causes of fetal bradycardia:

A

drugs given to mom
compression of fetus’ head
umbilical cord compression
mom or fetal hypoxia

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101
Q

Single best indicator of fetal wellness:

A

FHR variability
-intact CNS (ANS+SNS)
-good O2 reserve
-normal cardiac function

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102
Q

Baseline FHR variability is when fluctuations of FHR occur _ or more cycles/min with _ (regular / irregular) amplitude and frequency

A

2+ cycles/min
IRREGULAR amp + freq

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103
Q

FHR variability is described by change in bpm
-absent
-minimal
-moderate
-marked

A

absent = 0

minimal <5

mod 6-25 (ideal)

marked >25

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104
Q

Factors that decrease FHR variability

A

Hypoxia -> CNS depression
Fetus sleeping
Acidosis
Anencephaly
Drugs (CNS depressants and autonomic agents) - opioids can decrease variability for 30 mins, MgSO4 can too
Defects in fetal heart function

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105
Q

T/F FHR variability refers to baseline and accelerations and decelerations

A

false
-just baselien

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106
Q

T/F Only way to accurately monitor FHR variability is with direct FHR monitor with a scalp electrode

A

T

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107
Q

FHR - Accelerations
-define
-causes

A

abrupt increase from baseline

causes:
fetal movement
signifies good O2

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108
Q

FHR accelerations are considered reactive if occurring _ or more times within _ mins

A

2+ times in 20 min

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109
Q

FHR - Early Decel
-define

A

occur w each cx
begin + end w cx
decrease in rate and return to baseline
uniform
mild drop in HR (~20)

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110
Q

FHR - Early Decels
-cause

A

compression of head -> vagal stimulation

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111
Q

FHR - Variable Decels
-define

A

vary in appearance
ABRUPT onset/recovery
maintain variability

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112
Q

FHR - Variable Decels
-causes

A

labor-related
baroreceptor-mediated response to cord compression = nonominous normally
-if delayed recovery phase could mean fetal compromise occuring

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113
Q

FHR - Late Decels
-define

A

occur w each cx
low point of decel occurs AFTER peak point of cx
decrease in rate and return to baseline
uniform
vary in depth and variability

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114
Q

FHR - Late Decels
-causes

A

uteroplacental insufficiency = NONREASSURING, needs investigation

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115
Q

FHR categories
-I
-II
-III

A

I = normal, moderate variability, NO variable or late decels

II = anything not I or III, don’t predict abnormal acid/base status but warrant continued monitoring

III = fetal brady or absent variability with variable or late decels = abnormal acid/base = need intervention

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116
Q

Nonreassuring FHR tracings suggest fetal _. If laboring mom wants anesthesia and FHR tracings are nonreassuring, how do we navigate this?

A

suggest fetal hypoxia

-weigh severity of fetal compromise w risks of worsening it from anesthesia w benefits for mom
-OB team may request anyways to prep for urgent/unplanned operative vag delivery or CS (CYA and put this in note)

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117
Q

Intrauterine resuscitation intervention:

A

change moms position
IV boluses
D/C oxytocin
IV pressors for mom
Tocolytics
O2 for mom

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118
Q

T/F IV analgesia > neuraxial analgesia in labor

A

F
-good option if neuraxial is refused, isn’t available, or CI

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119
Q

IV labor analgesia
-cons

A

poor pain mgmt
resp depression for mom/fetus
N/V
decreases LES tone
increases risk of fetal acidosis compared to neuraxial

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120
Q

T/F Epidurals increase the risk of CS, long term back ache, poor APGAR scores and NICU admissions

A

F

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121
Q

What allows opioids to cross placenta?

A

highly protein bound
lipid soluble
<500Da small

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122
Q

IV/IM Merperidine for labor
-dose
-1/2 life
-pain relief profile

A

Dose: 50-100mg IM Q 4hr PRN

1/2 life: 2-3 hr mom
METABOLITES ARE STRONG - LAST 30 HR IN MOM AND DAYS IN FETUS

pain profile: poor, like 1g tylenol

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123
Q

IV/IM Merperidine for labor
-fetal circulation
-reversal

A

fetal circ within 2 mins

Naloxone reverses it along with its metabolite

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124
Q

IV Fentanyl for labor
-dose
-fetal circulation

A

Doses:
IV bolus: 25-100mcg
IV PCA bolus: 25-50mcg 3-6min lockout time 4hr max of 1-1.5mg

Fetal circ: within 1 min, decreases FHR variability for 30min

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125
Q

T/F IV Morphine is appropriate for labor pain

A

F
-too sedating, duration too long

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126
Q

IV Butorphanol + Nalbuphine
-drug class

A

opioid agonist-antagonists

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127
Q

IV Butorphanol + Nalbuphine
-pros

A

-ceiling effect (higher doses do not increase respiratory depression)
-less N/V than pure opioid agonists
-allows mom to rest and have sedation in 1st stg labor
-BUTORPHANOL has no metabolites that last

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128
Q

IV Butorphanol + Nalbuphine
-cons

A

-Butorphanol increases PAP + myocardial work (bad for preeclampsia)
-Nalbuphine causes more drop in FHR variability than meperidine :/

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129
Q

Butorphanol + Nalbuphine doses

A

Butorphanol (5x morphine strength)
1-2 mg IV or IM ; 1/2 life 3hr

Nalbuphine (10x morphine strength)
5-10mg IV, IM, or SC

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130
Q

T/F IV Remi has highest drop in pain scores but still less than epidural analgesia

A

T

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131
Q

Remifentanil
-class
-metabolism
-fetal impact

A

Class: ultra SA opioid agonist

Metabolism: rapid, plasma/tissue esterase

Fetus: crosses to them but rapid distribution and metabolism bc esterases = SAFE

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132
Q

IV Remifentanil for labor
-dose

A

PCA bolus: 0.25mcg/kg w 2 min lockout

PCA background infusion: 0.025-0.05mcg/kg/min

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133
Q

IV Ketamine for labor
-pros

A

profound analgesia in subhypnotic doses
preserves airway reflexes
somatic analgesia + sedation
sympathomimetic (good if hypovolemic)
no drop in uterine BF
safe for fetus in doses up to 1mg/kg

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134
Q

IV Ketamine for labor
-cons

A

short duration
increased amnesia
sympathomimetic (bad for preeclampsia/HTN)
doses >1mg/kg = increased uterine cx -> acidosis + poor APGAR scores

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135
Q

Agent of choice for induction for pt with acute asthma needing GA for urgent CS =

A

ketamine

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136
Q

IV Ketamine for labor
-dose

A

IV infusion: 0.2mg/kg/hr
IV boluses: 0.2-0.5mg/kg -if neuraxial is inadequate
duration: 5-15mins

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137
Q

Requirements for neuraxial anesthesia in OB:

A

must be in LABOR
-regular cx + dilation + effacement

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138
Q

Early start of neuraxial during labor is a good option for:

A

morbid obese
severe scoliosis
known difficult airway
multiple gest pregnancy
preeclampsia

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139
Q

T/F Epidurals can decrease need for GA if emergent CS needed

A

T
indwelling cath can be dosed for L+D pain but also dosed for different blockade for surgical deliveries

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140
Q

Absolute CI for neuraxial:

A

pt refuse
can’t cooperate
severe uncorrected hypovolemia
uncorrected coag issue/ on ACs
increased ICP from a mass
infection at site
Platelets <80-100k

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141
Q

Relative CI for neuraxial:

A

stable presenting CNS dz
chronic severe HA or backache
severe stenotic valve lesions
untreated bacteremia

-with proper optimization can prolly get neuraxial

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142
Q

Platelets must be _ - _ k + for safe neuraxial anesthesia

A

75-80k

more like 100k tho

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143
Q

Conditions requiring AC in preg pts:

A

DVT
Antiphospholipid antibody syndrome
Factor V leiden mutations
Proteins C + S deficiency

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144
Q

Major concern with ACs and epidurals

A

epidural hematoma
-from uncontrolled bleeding in nondistendable epidural space -> ischemia to SC + neuro issues

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145
Q

T/F Need platelet count right before doing neuraxial

A

f

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146
Q

T/F If mom is HTN or has known coag issue, elective neuraxial should be delayed until labs are ready (coags, etC)

A

T

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147
Q

T/F If mom didn’t get good prenatal care, baseline labs are indicated

A

T

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148
Q

Neuraxial analgesia for labor
-emergency drugs you want nearby

A

Propofol (to stop LAST sX)
Sux
Ephedrine
Epi
Phenyl
Naloxone
Atropine
CaCl (for MgSO4 tox)
Bicarb
Crash + airway cart with ACLS + Intralipid!

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149
Q

Bupivacaine
-pros

A

long duration
differential block (sensory>motor)
less tachyphylaxis than Lido

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150
Q

Bupivacaine
-cons

A

refractory cardiac arrest if given IV accidentally
-harder to resusc than other LAs

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151
Q

Bupivacaine _ % is banned from OB anesthesia bc high risk tox

A

Bupi 0.75%

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152
Q

Bupivacaine safe doses

A

low conc for continuous epidural
spinal <15mg
-give in fractions at a time w freq asp + test dose

153
Q

Lidocaine
-pros

A

rapid onset
intermed duration
great for CS anesthesia
better motor block with Epi

154
Q

Lido
-cons

A

dense motor block too strong for labor analgesia
neurotox if in SA space - risk for cauda equina syndrome from maldistribution

155
Q

2-chloroprocaine
pros

A

rapid onset
brief duration
good for emergent CS with existing epidural
metabolized by ester hydrolysis

156
Q

2-chloroprocaine
cons

A

brief duration
rapid metabolism by ester hydrolysis
neurotox if given in SA space

157
Q

Ropivacaine
pros
cons

A

pro: less tox than bupi

con: less potent than bupi w less motor blk

158
Q

Order of strength of LA: Bupivacaine, Ropivacaine, Levobupivacaine

A

Bupi > Levobupi > Ropi

159
Q

Opioids increase the potency of _ LAs

A

amide
-sufenta extends analgesia

160
Q

Labor duration after epidural is shorter with _ - sufentanil combo

A

bupi + sufenta

161
Q

Antiseptic of choice before neuraxial:

A

CHG in alcohol solution

162
Q

Monitoring for placing neuraxial

A

Baseline BP + pulseox
Q2min for 15 min then Q5min for another 15 mins

163
Q

Neuraxial placement
Sitting pros and cons

A

+:
Easiest for pt
Allows max interspace width for CRNA

-:
Can’t use with fetal head entrapment, prolapse umbilical cord, or breech

164
Q

Neuraxial placement:
Lateral pros and cons

A

+:
Lower rates of IV placement
Limits mom moving too much

-:
Harder to find midline w scapula shifting anterior

165
Q

T/F Higher risk of failure of neuraxial placement if obese mom

A

T
-skin to epidural space is further

166
Q

Why is neuraxial best for laboring obese pt?

A

They have higher rates of CS and potentially diff airway

167
Q

Neuraxial placement tips for obese patient

A

Make sure right size equiptment
Consider early placement
Bring US to help

168
Q

Epidural test dose purpose

A

Identify epidural caths inserted into SA or epidural vein

169
Q

T/F must aspirate for CSF or blood after placing epidural in before each administration of medication

A

T

170
Q

T/F negative aspiration of CSF or blood from epidural cath means it’s definitely not in IV or SA space

A

False but ok for labor epidurals honestly
Do a test dose to be positive

171
Q

T/F an epidural test is the minimum amount of a drug needed to cause moderate detectable effect when given in subarachnoid space or IV

A

T

172
Q

Epidural test dose
Actual dose of Lido +epi

A

3mL of 1.5% Lido + Epi 1:200,000

Or

45mg Lido and 15mcg Epi in 3mL

173
Q

Test dose
Lido effects

A

IV: early s/s tox (numbness, lightheaded, audio changes)

SA: noticeable spinal block in 3-5 min

174
Q

When is Epi useful for test doses in L+D?

A

Before giving larger volumes+conc of LA for CS deliveries

175
Q

Why is Epi not ideal for epidural test doses for labor?

A

HR increasing is unreliable bc moms HR will increase with cx anyways

Also Epi can vasoconstrict uterine artery and decrease BF to fetus

176
Q

Alt techniques for a normal test dose for epidurals for labor:

A

Multi orifice cath incremental admin of small dose of diluted LA

Careful asp for CSF or blood Q injection

177
Q

T/F if laboring mom has epidural and continuous infusion of dilute LA and is comfortable, Cath must be in epidural space

A

T

178
Q

If laboring mom is receiving continuous epidural infusion of dilute LA and develops a dense motor block, where is the cath?

A

SA space

179
Q

T/F pain is a marker for increased risk of CS

A

T

180
Q

Which is false about epidurals:
-increase risk CS
-increase risk forceps delivery
-increase risk prolonged labor

A

Increase risk of CS

181
Q

T/F spinals allow for segmental blks

A

F epidurals

182
Q

Benefits of adding opioids to epidurals for labor

A

reduced conc of LA required
good analgesia
preserved motor function
reduces risk of both drugs since smaller doses of each

183
Q

Epidural for 1st stage labor optimally inserted at the interspaces between _ - _ and the sensory block should extend from _ - _ dermatomes

A

Epidural inserted at L2-L4

1st stg labor dermatome coverage: T10-L1

184
Q

Epidural for 2nd stage labor optimally inserted at _ - _ and the sensory block should extend from _ - _ dermatomes

A

Epidural placed at L2-L4

2nd stg labor dermatome coverage: T10-S4

185
Q

T/F Epi in LA can increase depth of motor blk

A

T

186
Q

Pt should not be left unattended for 1st _ min after initial or following doses of epidural

A

20 mins

187
Q

Benefits of continuous epidurals

A

less change to level of blk
less total drug given
better pain control
less work for staff

188
Q

What happens if continuous epidural migrates
-SA space
-IV

A

SA: gradual increase in motor block easily noticeable

IV: loss of pain relief, no s/s of tox (bc usually diluted)

189
Q

Concentrations of LA for continuous epidurals
-Bupi
-Ropi
-fentanyl + sufentanil

A

Bupi: 0.0635%-0.125%

Ropi: 0.1-0.2%

Fentanyl: 1-3mcg/mL

Sufentanil: 0.3-0.5mcg/mL

@ rates 8-10mL/hr

190
Q

Describe ideal epidural block for L+D:

A

effective pain relief for cx
dense pain relief at perineum at delivery
minor motor blk

191
Q

If pt needs to have an instrumented vag delivery, make blk denser with:

A

2% Lido + Epi 1:200,000 +/- Fentanyl 50-100mcg

192
Q

Concentration of LA for PCEA epidurals

A

Bupi 0.125%
Ropi 0.2%

2-10mL/hr
boluses of 5mL

193
Q

Combined Spinal Epidural (CSE) for labor
-2 methods

A

Needle thru Needle
-larger epidural inserted to epidural space then thinner spinal inserted within it, check for CSF + dose spinal + remove it, leave epidural in; confirms epidural placement

Dural Puncture Epidural
-dura punctured with Touhy needle with spinal, spinal confirmed, dosed, then removed, epidural inserted thru touhy

194
Q

Why are spinals not generally great for labor? When are they particularly useful during labor?

A

finite duration, less flexible

Spinals work for:
multips
imminent delivery in 2nd stg
pts who labor w/o anesthesia and need it for surgical vag delivery or extensive peri repair
pt w spinal surgery hx w obliterated epidural space

195
Q

T/F Spinal anesthesia for labor is not 1st choice bc associated w high risk post dural puncture HA

A

T

196
Q

CSE has the spinal component consisting of:

A

narcotic (fentanyl 15-25mcg or sufenta 10mcg)

or

isobaric bupi

197
Q

Early 1st stg labor spinal option =

A

Narcotics alone
fentanyl 15-25mcg
sufenta 10mcg

198
Q

Late 1st stg labor spinal option =

A

narcotic + LA

fast onset + minimal motor blk

199
Q

There is an increased risk for cauda equina syndrome with _

A

macrocatheters (27-32G)

200
Q

LA work at nerve _ whereas neuraxial opioids bind to R in the substancia _ in the _ horn of the SC

A

axon
substancia gelatinosa
dorsal horn

201
Q

Epidural opioids are absorbed in the _ and eventually the SC where they act on SC opioid R

A

CSF

202
Q

Ceiling effect of opioids in the SA or epidural space:

A

-inc dose doesnt inc analgesia or duration
- will inc s/e tho

203
Q

T/F Naloxone or Nalbuphine can reduce undesirable effects of neuraxial opioids without removing analgesia

A

T
-better to relieve itch than antihistamines

204
Q

Neuraxial Fentanyl add ins for LABOR
-doses
-onset
-DOA

A

Epidural: 50-100mcg Q 90 min
Epidural continuous: 1-2.5mcg/mL

Spinal: 10-25mcg Q 90 min

onset: 10 min
DOA: 60-140 min

205
Q

T/F Epidural fentanyl will enter breast milk in standard doses ~100mcg or less

A

F

206
Q

Neuraxial Sufentanil add ins for LABOR
-doses
-caution

A

Epidural:5-10mcg
Continuous Epidural: 0.3-0.5mcg/mL

caution: sufentanil is prepped often in 50mcg/mL vials - triple check dosing!

207
Q

Why is morphine not good for LABOR?

A

slow onset in spinal or epidural

208
Q

T/F Morphine has no purpose in L+D anesthesia

A

F
-good for CS

209
Q

Neuraxial Morphine for CS
-spinal dose

A

spinal: 0.15mg or 150mcg

210
Q

Common indications for CS:

A

Poor head/pelvic proportions
Nonreassuring fetal state
Labor arrest after dilation
Malpresentation (breech)
Premie (VLBW <1500g)
Prior CS
Prior uterine sx

211
Q

Why is neuraxial better for CS?

A

Decreased risk mortality from failed intubation or asp of gastric content
Better neonate outcomes from less respiratory depression
Mom is awake for birth

212
Q

T/F LUD should be done for GA CS only

A

F
should be done for ALL CS
-less rates of fetal CNS depress and acidosis than supine

213
Q

The _ (upper/lower) extremities should be strapped in for CS

A

lower

214
Q

CS EBL is _ - _mL

A

500-1000mL

215
Q

Factors surrounding CS EBL:

A

surg time
technique
mom’s BP
fetal lie
fetal size
placental implantation
coag status
whether or not uterus cx after placenta is delivered

216
Q

Amniotic fluid volume is _ mL and should be accounted for during EBL measurement

A

700mL

217
Q

CS requires dermatome coverage up to _

A

T4

218
Q

A T4 blk for CS can cause profound _ from sympathectomy

A

HOTN
-risk for fetal compromise

219
Q

Ways to minimize HOTN from T4 blk for CS:

A

LUD!
Fluids and pressors

220
Q

Asp risk proph for CS:

A

Nonparticulate antacid (Bicitra)
H2R antagonist
+/- Metoclopramide
+/- Zofran to prevent N/V + HOTN from neuraxial

increase gastric pH and emptying

221
Q

Hold abx in CS until after:

A

cord clamping

222
Q

Important way to prevent HOTN and preserve CO in CS:

A

LUD!

223
Q

Most commonly used anesthetic in CS:

A

spinal

pros: rapid and dense blk, requires less drug
cons: fixed duration, rapid onset sympathectomy -> HOTN

224
Q

Good spinal dose for CS

A

HYPERBARIC Bupi 0.75% 13 mg
-gives 90-120 min of surgical level anesthesia

225
Q

T/F Hyperbaric LA doesn’t spread high w spinals due to compound curvature of spine

A

T

226
Q

Spinal blk for CS results in _ 80% of time regardless of LUD

A

HOTN

227
Q

Risks of HOTN from spinal for CS for mom:

A

N/V
passing out
reduced uteroplacental BF
CV collapse

228
Q

Ways to prevent HOTN during spinal for CS:

A

fluids (pre or coloading)
proph pressors (ephedrine/phenyl)

229
Q

Drawbacks of Ephedrine for maternal HOTN

A

tachyphylaxis
effects last 5 min

can cross to fetus and risk acidosis

230
Q

MOA for ephedrine

A

Direct beta stim and Indirect alpha stim

231
Q

1st line pressor for maternal HOTN is _. Why?

A

Phenylephrine

safe for baby

232
Q

Choose pressor for mom if HOTN based on _.

A

HR
-ephedrine if HR low
-phenyl if HR high/normal

233
Q

T/F If adding opioids to a Bupi spinal for CS, it will increase analgesia without impacting blk height

A

T

234
Q

Options for opioid add ins for Bupi spinal for CS
-fentanyl
-sufentanil
-morphine

A

Fentanyl: 10-20mcg O: 5-10min DOA: 60-90min
Sufentanil: 2.5-5mcg O: 5-10min DOA: 60-90 min

Morphine: 0.15mg O: 60-90min DOA: 12-18hr

235
Q

When to start oxytocin during a CS?

A

After delivery of placenta and OB tells you to

236
Q

Oxytocin is normally made in the

A

hypothalamus

237
Q

Purpose of oxytocin in OB?

A

increase freq + strength of cx

-induce labor or increase uterine tone/cx after delivery

238
Q

Oxytocin half life + risks with high dose or fast infusion:

A

1/2 life: 4-17 min

risks when given too fast or too much: tachycardia, flushing HOTN from preservative
-start 2nd IV line if bolusing pt with fluids to avoid rapid bolus oxytocin

239
Q

Alt neuraxial options for postop pain mgmt after CS:

A

TAP blk
Quadratus lumborum blk
-blk sensory impulses from anterior abdomen + relieve pain from Pfannenstiel incision

240
Q

Spinal Anesthesia Mgmt for CS BOX 51.2

A

-preop nonpart antacid, H2R antagonist, metoclopramide
-IV preload or coload
-monitors on, FHR / tones
-consider O2
-Lumbar puncture @ L3-L4 in sitting or lateral position
-small 24 or 25G spinal needle (NONCUTTING-Sprotte, Whitacre, Pencan)
-HYPERBARIC Bupi 15mg in 8.25% Dextrose (12-15mg)
-add fentanyl 10-20mcg for intraop pain mgmt
-add morphine 150 mcg for postop pain mgmt
-supine + LUD
-check BP Q 1 min until birth
-confirm blk level (T4)
-tx HOTN (pressors)
-give oxytocin per OB after placenta out

241
Q

Why is placing an epidural in the OR for a CS not ideal?

A

slower onset/takes longer, everyone waiting for you, need larger LA dose

242
Q

Benefits of epidural for CS

A

extended duration for a longer surgery
slower onset = less drastic HOTN changes are easier to manage
if already in from labor, easy to convert to surgical anesthesia

243
Q

T/F Aspirating to check for CSF or blood and giving a test dose is required for an epidural for CS

A

T

244
Q

Good epidural CS dose for a T4 blk

A

Lido 2% + Epi 1:200,000 in 3-5mL increments up to 15-20mL

245
Q

Selection of LA for CS epidural is based on _

A

urgency

246
Q

Add _ to Lido + Epi for epidural to make its onset faster

A

Bicarb
-increases amount of nonionized drug

247
Q

Bicarb dose for add in to epidural

A

1mEq/10mL
DOA: 90-120min

248
Q

Bicarb CANNOT be added to which LA?

A

Bupivacaine
-causes precipitate

249
Q

2-chloroprocaine pros and cons for epidural for CS

A

pros: low tox risk from ester metabolism, good to rapidly convert to CS from labor

cons: duration is 45 min, prolly need to redose, reduced efficacy of morphine when added

250
Q

How to increase block from labor epidural to CS epidural level

A

10-15mL more LA to increase blk from T10 - T4

251
Q

Convert Epidural for labor to CS BOX 51.3

A

-preop nonpart antacid, H2R antagonist, metoclopramide
-DC continuous epidural infusion
-give coload (crystalloid)
-monitors on + FHR or tones
-consider O2
-supine + LUD
-asp for blood and CSF, give 2% Lido + Epi 1:200,000 + Bicarb 1mEq/10mL ~10-15mL total dose
-give in 3-5mL increments watch VS and levels of blk
-tx HOTN (pressors)
-check blk level (T4)
-once cord is clamped give 150mcg (3mL) morphine for postop pain
-give oxytocin per OB once placenta out

252
Q

What should you do if after changing an epidural cath and double checking placement and blk not happening properly?

A

give blk more time to work before trying spinal

253
Q

T/F Presence of dense spinal blk can make test dose less reliable

A

T

254
Q

When is GA useful for CS?

A

-cases of existing or expected severe hypovolemic shock
-maternal heart dz
-failed neuraxial

NECESSARY when:
-neuraxial isn’t in place and surgical delivery is too urgent to wait
-if pt refuses
-pt has coag issues

255
Q

Ways to decrease use of GA for CS

A

optimize high risk moms
early neuraxial
quickly rreplace unreliable epidurals

256
Q

Difficult airway options for GA CS

A

ramping
short handle blade
awake intubation
LMAs, bougie, fiberoptic, follow algorithm, etc
NO NASAL (BLOODY MESS)

257
Q

Induction technique for GA + CS

A

RSI + cricoid pressure + at least 3 min preO2

258
Q

Induction meds for GA CS

A

Propofol 2-2.5mg/kg
-some neonate depression but quickly cleared

Etomidate 0.3mg/kg
-good for HD instability

Ketamine 1mg/kg
-good for HD unstablity or airway dz, supports BP if hypovolemic, decreased pain med requirement for 24hr postop

Sux 1-1.5mg/kg
-DOC for MR, no defasc dose of NDMR needed

Roc 0.6-1.2mg/kr
-if sux is CI, no defasc dose needed w sux

259
Q

Maintenance of GA for CS
-predelivery MAC goal?

A

0.8 MAC w VA +/- N2O
-keep FiO2 50-100%

260
Q

When to raise FiO2 during GA CS?

A

if fetus in distress or mom’s SpO2 < 97%

261
Q

Goal PaCO2 for mom during GA CS

A

30-32mmHg

-<20mmHg = reduced uterine BF + L shift on O2Hgb curve —- AVOID HIGH RR/PAIN

262
Q

T/F VA can increase post delivery blood loss

A

T
-VA is tocolytic so decreased uterine cx

263
Q

Uterus will continue cx from oxytocin if MAC from GA is < _

A

<1.0 MAC will not interfere with oxytocin

264
Q

T/F MR is required for GA + CS

A

False
-easier to adjust anesthetic without it

265
Q

Why delay induction of GA for CS?

A

wait until EVERYONE is ready to go to reduce time of fetal drug exposure

266
Q

Surgeon should delay incision for GA CS until:

A

CONFIRMATION of ETT placement
-+BS, + BL chest rise, + EtCO2

267
Q

T/F Infants delivered via CS w GA are more likely to be depressed and need resusc

A

T

268
Q

Infants delivered later than _ min after incision during GA CS are more likely to be depressed

A

> 3 min = increased risk

269
Q

Deep or awake extubation from GA for CS?

A

AWAKE

270
Q

GA for CS Delivery BOX 51.4

A

-communicate
-preanesthetic assessment + obtain consents
-prep ALL equipment
-supine w LUD
-16 or 18G IV, get baseline labs + T/S or T/C if high risk for PPH
-preop proph asp risk meds: Bicitra, Pepcid, Metoclopramide
-proph abx if needed 60 mins prior to incision
-monitors on + time out
-100% FiO2 preox for 3+ min or 4-8 VS breaths
-make sure EVERYONE is ready
-RSI + cricoid pressure (10->30N)
-Prop 2-2.5mg/kg + Sux 1-1.5mg/kg, wait 30-40s to fasc then intubate + confirm placment
-maintain w VA +/- N2O 50-100FiO2
-tx HOTN (pressors)
-redose NMBD per TOF
-watch for infant delivery
-start oxytocin per OB after placenta out
-monitor blood loss and communicate concern for more meds if needed
-bring MAC to 0.5-0.7, consider IV benzos/opioids or N2O while closing
-reverse pt + extubate AWAKE when safe
-check and treat PONV/pain

271
Q

HOTN for mom manifests often as

A

N/V

272
Q

Maternal HOTN is defined as:

A

20% drop from baseline or SBP <100mmHg

273
Q

BP checked Q _ min from initiation of neuraxial until stable

A

2min

274
Q

How does zofran help prevent HOTN from spinals?

A

reduced occurrence of BEZOLD JARISH reflex (HOTN + brady)

275
Q

T/F Aggressive tx of HOTN can prevvent N/V

A

T

276
Q

Dose of metoclopramide and when to give to mom?

A

10mg IV
give preop or at cord clamp

277
Q

Multimodal options for N/V after neuraxial:

A

tx HOTN
Metoclopramide 10mg IV
Granisetron 1mg IV
Scop patch 2-4hr before

278
Q

PDPH is most commonly from ADP with large bore epidural needle _ - _ G

A

16-18G
-other risks: women, pregnant, old

279
Q

PDPH patho

A

CSF leak from SA space into epidural space -> reduces ICP -> caudal movement of cranial contents + meningeal traction when in head up position

280
Q

PDPH hallmark complaint

A

HA in head up positions, relieved when supine

281
Q

PDPH s/s

A

HA worse sitting/standing, better when supine
frontal + occipital pain rad to neck + shoulders
nausea, vertigo, low back pain, double vision

282
Q

Which spinal needles reduce risk of PDPH?

A

pencil point needles (Whitacre, Pencan, Sprotte)

AVOID CUTTING - QUINCKE

283
Q

Tx for PDPH
-conservative/mild

A

conservative/mild:
rest, caffeine (cerebral vasoconstrictor), po pain meds or topical sphenopalative ganglion blk (SPGB)

284
Q

Tx for PDPH
-severe/persistent

A

epidural blood patch
-20mL of blood from IV obtained w sterile technique injected into epidural space in small increments

285
Q

LAST
-early s/s

A

circumoral numbness
lightheaded
vision or audio changes

286
Q

LAST
-late s/s

A

changed LOC, sx, CV depression

287
Q

LAST
-prevention

A

asp for blood/CSF Q injection
test dose
intermittent/gradual dosing
monitoring

288
Q

LAST
-tx

A

stop LA
benzos/prop for sx
airway mgmt
follow ACLS
Interlipid 20%

289
Q

T/F Total spinal only happens with spinal anesthesia

A

F
-could be from SA migration of epidural cath or from spinal done right after a failed epidural

290
Q

Total Spinal
-s/s

A

rapid onset;
dyspnea
slurring
HOTN
brady

291
Q

If high spinal occurs and pt very bradycardic, block could have gone as high as:

A

T1-T4
-cardiac accelerator fibers = sympathectomy

292
Q

Diff Dx for high spinal s/s

A

anaphylaxis
eclampsia
amniotic fluid embolism

293
Q

Accidental subdural injection
-main issue

A

HOTN from excess sympathetic blk
-fix w pressors

294
Q

Accidental subdural injection
-s/s

A

higher sensory blk of greater magnitude, UL, onset in 10 min
-HOTN, delayed resp compromise is possible

295
Q

Cardiac arrest and pregnancy:
In _ tri, move hand s2-3cm higher during compressions

A

3rd

296
Q

T/F During cardiac arrest in preg pt, LUD is necessary

A

T

297
Q

Perimortem CS delivery should occur within _ min of arrest as compression and ACLs are ongoing

A

5min

298
Q

OB related n injures involve pressure + stretch of _ nerves - > _ _ neuropathy

A

peripheral nerves
single periph neuropathy

299
Q

Neuraxial related n injuries involve a spinal nerve _ and follow a _ distriubtion

A

spinal nerve root
dermatome

300
Q

PPH has few definitions but roughly:

A

500-999mL = high susp PPH
500mL+ for vag, 1000mL+ for CS
1000mL+ loss or symptomatic hypovolemia in 1st 24hr of vag or CS birth

301
Q

Most freq cause of PPH

A

uterine atony

302
Q

Causes of PPH:

A

uterine atony (most common)
retained placenta
uterine abnormalities (previa, accreta, etc)
lacerated cervix or vag wall
uterine inversion
coag issues

303
Q

Uterine atony is associated with(risks):

A

multiparous
prolonged oxytocin infusion
polyhydramnios
mult gestation preg

304
Q

PPH
-prevention/tx

A

oxytocin, methergine, prostaglandins (hemabate), misoprostol

TXA if trad tx fail, massive transfusion, cell salvage after placenta, low dose NTG to pull out retained placenta, surgical tx (ablations), balloon tamponade

305
Q

PPH tx
-doses

A

Methergine IM 0.2mg Q 2-4hr
Carboprost (Hemabate) 0.25mcg IM or IU Q 15-90 min x 8 total doses
Misoprostol 600-1000mg rectal/vaginal/oral x1
TXA 1g Q 30 min

306
Q

CI for methergine

A

HTN, preeclampsia, cv dz, hypersensitivity to ergot alkaloids
-will increase BP, PAWP, and MUST GIVE IM, too potent IV

307
Q

T/F Carboprost/Hemabate is a prostaglandin

A

T

308
Q

Carboprost/Hemabate
CI + s/e

A

CI: asthma
S/E: bspasm, nausea, increased pulm VR

309
Q

Misoprostol
-A/E

A

transient hyperthemic response

310
Q

Intraop options to relax uterus for a surgical uterine exploration

A

GA + VA
Terbutaline
NTG (40mcg IV or SL)

311
Q

Preeclampsia criteria for dx

A

-SBP 140+ or DBP 90+ 2 or more times, more than 4 hr apart after 20wk gest in normotensive pt
PLUS EITHER
-proteinuria (300mg+ in 24hr urine, protein/creat ratio 0.3+, dipstick 2+)
OR
-if no proteinuria, evidence of organ impairment (renal insuff, impaired liver, new onset persistent HA, pulm edema, or thrombocytopenia (plt<100))

312
Q

Primary cause of HTN related maternal mortality:

A

cerebral hemorrhage

313
Q

Organ dysfunction assoc w preeclampsiae

A

pulm edema
renal fail
hepatic rupture
cerebral edema
DIC

314
Q

Eclampsia =

A

preeclampsia + new onset sx

315
Q

Preeclampsia
-patho

A

failure of normal placental angiogenesis -> reduced placental perfusion worsening over time -> release factors that harm maternal organs -> MODS like picture

316
Q

T/F More airway edema with preeclamptic pt

A

T

317
Q

What 2 factors cause pulm edema in preeclampsia?

A

reduced colloid osmotic pressure from protein loss in pee
increased vascular permeability

318
Q

CNS effects of preeclampsia:

A

HA
hyperreflexia
hyperexcitability

319
Q

Proteinuria in preeclampsia is from _ capillary endothelial destruction

A

glomerular capillary endothelial destruction

320
Q

T/F Pt who has been preeclamptic during preg has increased risk for CV dz later in life

A

T

321
Q

Only definitive tx for preeclampsia

A

deliver fetus + placenta

322
Q

OB decision to deliver based on complications:

A

uncontrolled HTN
eclampsia (sx)
pulm edema
placental abruption
nonreassuring fetal status

323
Q

Mode of deliverying for preeclampsia is based on

A

fetal gest age
presentatin
cervical status
maternal and fetal VS

324
Q

If severe features are absent in preeclampsia a _ - _hr trial of corticosteroids are given to speed fetal lung development

A

24-48hr

325
Q

DOC for preeclampsia or eclampsia is

A

MgSO4

326
Q

Therapeutic range for MgSO4 for preeclampsia is

A

5-9mg/dL

327
Q

MgSO4 dosing for preeclampsia

A

loading: 4-6g/30 min
infusion: 1-2g/hr

328
Q

When giving MgSO4 must monitor these in preeclamptic pt (4 items)

A

UO
resp status
DTR
routine labs

329
Q

Mag tox levels

A

Mag >9 loss of patellar reflex
Mag >12 resp paralysis
Mag >30 cardiac arrest

330
Q

Alt effects from MgSO4 in tx of preeclampsia

A

CNS depress
reduced hepatic fibrin deposition = less liver pain
decreased uterine tone

331
Q

Preferred anesthetic for preeclamptic pt having vag or CS delivery

A

regional
-early epidural = best, spinal is ok

332
Q

Uncontrolled HTN in response to _ is a major cause of hemorrhagic stroke in preeclamptic pts

A

laryngoscopy

333
Q

Tx preeclamptic SBP > _ with _ (DOC) to avoid intracranial bleed.

A

SBP>160
labetalol

334
Q

T/F can give opioids to blunt the SNS response from intubation for L+D pts during CS

A

false
bad for babay

335
Q

A _ (inc / dec) dose of MR should be used for pts on MgSO4 tx for preeclampsia during GA

A

decreased
-prolongs effects by 25%, slows onset too

336
Q

What causes thrombocytopenia in preeclamptic pts

A

endothelial dysfunction -> stim platelet activation + consumption

337
Q

Which additional coag labs should you get on preeclamptic pt with thrombocytopenia before neuraxial anesthesia

A

PT and PTT

338
Q

HELPP is a complication of which OB dz?

A

preeclampsia

339
Q

HELLP stands for

A

Hemolysis
Elevated Liver enzymes
Low Platelets

340
Q

HELLP
-s/s

A

epigastric or RUQ pain, upper abdominal tenderness, proteinuria, HTN, jaundice, N/V

341
Q

T/F HELLP is an indication for immediate delivery in preeclampsia

A

T

342
Q

HELLP can cause hepatic _

A

rupture

343
Q

Common labor complication in obese pts

A

difficult placement for neuraxial anesthesia
fetal macrosomia
prolonged labor
failed induction and risk for asp
increased rates CS and high risk of prolonged CS, infection, and thromboembolic events

344
Q

3 variations of placenta PREVIA
-marginal, partial, total

A

marginal: in lower uterus but >3cm from cervical os

partial: in lower uterus within 3 cm of cervical os-partly covered

total: placenta completely covers cervical os

345
Q

Placenta PREVIA
-risk factors

A

uterine scars
prior uterine sx
prior placenta previa
adv maternal age

346
Q

Placenta PREVIA
-dx

A

US

347
Q

T/F Pt w placenta PREVIA can have vag delivery

A

false :(

348
Q

What increases risk of bleeding w placenta PREVIA in laboring mom

A

manual pelvic exams

349
Q

Placenta PREVIA
-risks for mom

A

painless bleeding prior to labor - > HD significant blood loss, increased PP bleeding b/c lower uterine segment doesn’t cx as well as rest of uterus

350
Q

3 variations of placenta ACCRETA
-accreta
-increta
-percreta

A

Accreta: abnormal growth ONTO myometrium - most common

Increta: abnormal growth INTO myometrium

Percreta: abnormal growth THRU myometrium (onto bowels/bladder/ovary) :’(

351
Q

Most common complication w placenta ACCRETA

A

PPH

352
Q

T/F Placenta ACCRETA requires a CS

A

T

353
Q

Placenta ACCRETA
-tx at time of delivery

A

uterine artery embolization/ablation
possible CS + hysterectomy combo

354
Q

What is placental abruption

A

placenta separates from uterine wall before delivery

355
Q

Placental Abruption
-big contributing risk factor (2)

A

HTN + preeclampsia

356
Q

Placental Abruption
-risks for mom

A

bleed/hemorrhage
uterine irritability
poor uterine BF
DIC from amniotic fluid entering open venous sinus

357
Q

T/F Placental Abruption requires a CS

A

F
can have vag delivery only if no fetal distress
-be ready for emergent CS anyways

358
Q

Amniotic fluid embolism
-s/s triad + others

A

triad: acute resp distress, CV collapse, coag issues in labs

-acute HOTN, fetal distress, frothing from mouth, uterine atony, passing out, convulsions/sx

359
Q

Amniotic fluid embolism
-tx

A

supportve
atropine 1mg(vagolytic) + zofran 8mg(antiserotonin) + ketorolac 30mg (antiTXA)

360
Q

Premature L+D occurs before the _ wk

A

37th

361
Q

Biggest risk of complications to premie newborn comes when they are VLBW (< _ g)

A

<1500g

362
Q

Risks for newborn if premature

A

resp distress
intracranial hemorrhage
hyperbilirubinemia

363
Q

Tocolytic drug classes:

A

MgSO4
CCB
-Nicardipine, Nifedipine
Beta sympathomimetic
-Terbutaline, Albuterol, Fenoterol
Prostaglandin Inhibitors
-Indomethicin

364
Q

Can dx preterm labor from measuring _ protein which is normally seen at _ wks

A

fibronectin
35wk

365
Q

Delaying a premature delivery by 24-48 hr to give _ and _ to allow fetal lung development and tx of chorioamnionitis shows good results

A

corticosteroids
abx

-bacteria and inflammation in fetal membranes and amniotic fluid can cause inflammatory response resulting in labor (meconium?)

366
Q

Best analgesia for planned premature vag or CS delivery is

A

neruaxial

367
Q

Can VLBW (<1500g) fetus or fetus in breech be birthed vaginally?

A

no
need a CS

368
Q

Most common nonOB surgeries done on pregnant pts

A

appendectomy, chole, ovary cyst removal, trauma surgery, cervical cerclage

369
Q

Goals for nonOB surgery for anesthesia standpoint

A

keep O2 stable for mom
avoid increased RR (pain!) + HOTN
-pain shift O2hgb curve left = less DO2 to baby
-HOTN decreases BF to baby

370
Q

T/F All top drawer anesthesia drugs cross placenta and affect baby

A

F
-not muscle relaxants

371
Q

NonOB surgery on preg pt
-reversing MR preferred method

A

Neostigmine + Glycopyrrolate
-sugammadex may compete for binding to progesterone, don’t know what this does to lactation and fetal health but fine if an absolute emergency

372
Q

FHR monitoring for nonOB surgery occurs:

A

start doing this at 20wk

previable (<24wks): ok just to doppler before + after

viable (24wks+): electronic FHR + cx monitor before + after

373
Q

Best time for nonOB surgery in preg pt

A

2nd tri
-1st tri risks damage to developing fetal organs
-3rd tri risks inducing premature labor

374
Q

FHR monitor for non OB surgery
-decreased variability vs decreased HR, which is worse?

A

decreased variability = expected, not ominous

decreased HR (<110) = ominous, investigate further

375
Q

Why is regional anesthesia preferred for nonOB surgery in preg pt

A

airway changes pregnany causes = risk diff airways

376
Q

Cervical cerclage prevents fetal loss in the _ tri from incompetent cervix and is normally done in the _ - _ wk with _ anesthesiA

A

Prevents fetal loss in 2nd tri
done 12-26wks
with spinal

377
Q

NonOB surgery and pregnancy BOX 51.5

A

-asp risk and difficult airway risk
-increased risk when delay in dx of abominal dz due to pregnancy
-greatest acute risk to fetus from maternal hypoxia, HOTN, and acidosis
-fetal risks: death, preterm labor, growth restriction, LBW
-hard to tell what exactly causes fetal issues (surgery, meds, anesthesia, etc)
-no anesthetics are teratogenic, but avoid N2O anyways
-AVOID: hypoxemia, HOTN, acidosis, hyperventilation (pain) fetal hypercarbia
-keep pneumo pressures low 10-15
-limit trend or reverse trend, change positions slowly
-monitor FHR before and after
-don’t need tocolytic therapy proph, only need it if preterm labor occurs

378
Q

Tocolytics and anesthesia concerns:
-CCB
-Beta 2 Agonists
-MgSO4

A

CCB: vasodilation + myocardial depression can cause systemic HOTN and conduction issues

Beta 2 Agonists: maternal tachy + sometimes pulm edema

MgSO4: exacerbated HOTN + enhanced NM blockade

NA 3 (6 decks)

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