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NUNA 693 Obs/Regional > OB: Obstetric Complications > Flashcards

OB: Obstetric Complications Flashcards

1
Q

Black, American Indian, and Alaska Native women are _______ times more likely to die from pregnancy related causes than white women.
Black PRMR 40.8/100,000
White PRMR 12.7/100,000

A

2-3x

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2
Q

This disparity ____________ with age.

A

increases

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3
Q

Black women with a college degree are _____ times more likely to die from pregnancy related causes than their white counterparts.

A

5.2x

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4
Q

Pregnancy related deaths – death of a woman during pregnancy or within ____ _____ from the end of pregnancy from a pregnancy complication; chain of events initiated by pregnancy; or the aggravation of a chronic condition by the physiologic effects of pregnancy

A

one year

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5
Q

In 2010, 287,000 women died while pregnant or within 42 days of the end of pregnancy
_____ maternal deaths per 100,000 live births

A

210

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6
Q

1 in ____ lifetime risk of maternal death for each girl

A

180

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7
Q

More than 99% of maternal deaths occur in developing countries, 85% in either sub-Saharan Africa or South Asia
In sub-Saharan Africa lifetime risk of maternal death is I in ____

A

39

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8
Q

Most Common Causes of Maternal Mortality

Developed world

A

Hypertensive disorders of pregnancy
Embolic disorders
Hemorrhage

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9
Q

Most Common Causes of Maternal Mortality

Globally

A

Hemorrhage
Hypertensive disorders of pregnancy
Sepsis

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10
Q

Other Causes of Global Maternal Mortality

A
  • Anemia
  • Obstructed labor
  • HIV/AIDS
  • Unsafe abortion
  • Early marriage
  • High parity birth
  • Advanced maternal age
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11
Q

Preterm Delivery

Delivery prior to ____ ____ gestation

A

37 weeks

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12
Q

Preterm Delivery

___-___% of all pregnancies in the US, 5-9% in other developed countries

A

12-13

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13
Q

Preterm Delivery

Responsible for ___-___% of all neonatal deaths and significant neonatal morbidity

A

75-80

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14
Q

Preterm Delivery

Approximately 90% of preterm births occur between _____ and ______ weeks

A

32 and 36 6/7

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15
Q

Preterm Delivery

______ is less common, but _____ is a greater concern in this age range

A

Mortality
morbidity

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16
Q

Risks of Preterm Labor

Demographic Characteristics

A
  • Non-Caucasian race
  • Extremes of age (<17 or >35)
  • Low socioeconomic status
  • Low pre-pregnancy BMI
  • History of preterm delivery
  • Interpregnancy interval <6 months
  • Abnormal uterine anatomy
  • Trauma
  • Abdominal surgery during pregnancy
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17
Q

Risks of Preterm Labor

Obstetric Factors

A
  • Vaginal bleeding
  • Infection
  • Short cervical length
  • Multiple gestation
  • Assisted reproductive technologies
  • Preterm premature rupture of membranes
  • Polyhydramnios
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18
Q

Prevention of Preterm Labor (4)

A

Cervical cerclage
Prophylactic antibiotics??
Prophylactic beta agonists??
Progesterone??

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19
Q

Therapy for Prevention of Preterm Labor

Corticosteroids

A

Betamethasone
Dexamethasone

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20
Q

Therapy for Prevention of Preterm Labor

Tocolysis

A

Magnesium sulfate
Beta agonists (Terbutaline)

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21
Q

Magnesium
May ____ _____ contractions, even at toxic levels
Normal serum Mg is ___-___ mg/dL
Therapeutic ___-___ mg/dL
10-12 mg/dL patellar tendon reflex eliminated
>12 mg/dL respiratory depression
18 mg/dL apnea
25 mg/dL cardiac arrest

A

not stop
1.8-3
4-8

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22
Q

Side effects - Dose dependent
Skeletal muscle weakness, subclinical neuromuscular blockade (depolarizing and nondepolarizing potentiated by Mg). A priming or defasciculating dose _______________________
Vascular dilation – antagonizes the vasoconstrictive effect of alpha agonists so ephedrine and phenylephrine may be _____ ______
Cutaneous vasodilation (flushing)
Headache and dizziness
Depression of deep tendon reflexes
Respiratory depression
Ecg changes

A

may cause profound block
less effective

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23
Q

Beta 2 receptor system stimulates smooth muscle _______ (including ______ of the uterus)
B2 also increases ______ production

A

relaxation
relaxation
progesterone

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24
Q

No pure B2 agonists, B1 increases ____ ____, myocardial contractility, and myocardial ____ _____

Maternal side effects
Cereberal vasospasm
Chest pain or tightness
Glucose intolerance
Hypokalemia
Illeus
Myocardial ischemia
Nausea
Palpitations
Pulmonary edema
Restlessness
Tremor
Ventricular arrhythmias

A

heart rate
O2 demand

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25
Q

______ can antagonize hypoxic pulmonary vasoconstriction through B2 mediated vasodilation can decrease maternal oxygen tension

SEs: fetal tach, neonatal hypoglycemia

A

Turbutaline

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26
Q

Incidence of pregnancy related _______ events is 1-1.7 events per 1,000 pregnancies

A

thromboembolic

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27
Q

Thromboembolism - Five times greater odds during pregnancy and ___ times greater in postpartum period than the nonpregnant patient

A

60

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28
Q

Two most important modifiable risk factors are antenatal:

A

immobility and obesity

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29
Q

Deep Vein Thrombosis
Presentation mimics ______ pregnancy symptoms
_____ _____ edema
Pain

A

normal
Lower leg

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30
Q

DVT -
Diagnosis
__-____ elevated in normal pregnancy
Ultrasound

A

D-dimer

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31
Q

Pulmonary Embolism
One or more DVT symptoms with ____ or _____ findings

A

pulmonary or CV

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32
Q

Treatment of Thromboembolic Events - Anticoagulation

A

Low-molecular weight heparin
Unfractionated heparin

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33
Q

Treatment of Thromboembolic Events - Implications

Neuraxial analgesia –

A

epidural or spinal hematoma

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34
Q

Treatment of Thromboembolic Events - Implications

General -

A

risk of airway trauma/bleeding

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35
Q

Venous Air Embolism

______ during cesarean delivery

A

“Common”

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36
Q

Venous Air Embolism

Most volumes are small, volumes greater than _______ mL may be lethal.

A

200-300

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37
Q

Venous Air Embolism

Reporting incidence varies
Precordial doppler/______ _____ 11/42 (26%)
Increase in the expired _____ 0.1% (=0.25-1.0 mL/kg) 29/30

A

Transthoracic Echo
nitrogen

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38
Q

Venous Air Embolism

Consider for intraoperative chest pain, dyspnea, sudden hypo_____, hypo_____, or ______

A

hypoxemia
hypotension
arrhythmia

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39
Q

Amniotic Fluid Embolism

Diagnosis of ______________

A

exclusion

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40
Q

Amniotic Fluid Embolism

Incidence is ______ to _____
UK 0.8-2:100,000
Australia 3.3:100,000
US 7.7:100,000

A

difficult
determine

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41
Q

Amniotic Fluid Embolism

no _____ _____

A

No confirmatory tests

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42
Q

Amniotic Fluid Embolism

____ exact course or initial symptoms

A

No

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43
Q

AFE Differential Diagnosis

Nonobstetric

A

AMI
PE
Aspiration
Sepsis
Anaphylaxis
VAE

44
Q

AFE Differential Diagnosis

Obstetric

A

Abruption
Eclampsia
Uterine rupture or laceration
Uterine atony

45
Q

AFE Differential Diagnosis

Anesthetic

A

Total spinal
Local anesthetic toxicity
Medication error

46
Q

AFE Management - airway (2)

A

100% O2
Intubate

47
Q

AFE Management - CV support

_____ _____ if indicated
_____ uterine displacement
Fluids and Vasopressors
Large bore IV access
Consider invasive pressure monitoring

A

Chest compressions
Left

48
Q

AFE Management - Fetus (2)

A

monitor fetal wellbeing
expedite delivery

49
Q

AFE Management - Hemostatic supprt

Hemorrhage/____ _____ protocol
Send labs for coags and electrolytes
____thermia

A

massive transfusion
Normo

50
Q

AFE Management - Post-resuscitation care

A

ICU

51
Q

Prolapsed Umbilical Cord

Umbilical cord protrudes ahead of fetus
__________________ is the problem

A

cord compression

52
Q

Hemorrhage

Most common cause of maternal mortality worldwide – ____%

A

25%

53
Q

Hemorrhage

______% of pregnancy related deaths in the US

A

12.5%

54
Q

Hemorrhage

Majority of hemorrhage-related adverse outcomes are considered ______.
Failure to recognize _____ _____
Failure to accurately estimate ____ ____
Failure to initiate treatment in a ____ ____

A

preventable
risk factors
blood loss
timely fashion

55
Q

Mechanisms of Hemostasis

Uterine _____ (due to ______) is the primary mechanism for controlling blood loss

A

contraction
oxytocin

56
Q

Mech of Hemostasis

Uterine contraction constricts ____ ____ & _____ ____

A

spiral arteries and placental veins

57
Q

Mech of Hemostasis

After disruption of vascular integrity coagulation mechanisms:

A
  1. Platelet aggregation and plug formation
  2. Local vasoconstriction
  3. Clot polymerization
  4. Fibrous tissue fortification of the clot
58
Q

Hemorrhage

Tachycardia and hypotension are ____ signs of hemorrhage, especially in healthy young patients

A

LATE

59
Q

Hemorrhage

Estimation of blood loss is ____ accurate with larger volumes of loss

A

less

60
Q

Placenta Previa

When the placenta implants ____/___ the cervix
Incidence 4:1,000
Antepartum _____

A

near/on
hemorrhage

61
Q

Placenta Previa

Be prepared for hemorrhage, even in ______/______ cesarean delivery

A

elective/non-urgent

62
Q

Placenta Previa

Increased risk of placenta _____

A

accreta

63
Q

Placenta Previa

______ anesthesia associated with more stable hemodynamics and lower transfusion rates than ______

A

Epidural
general

64
Q

Placenta Previa

Patients with active bleeding

A
  • Urgent/emergent presentation
  • May keep bleeding until delivery/placenta is removed
  • GETA/RSI
  • Induction agent depend on hemodynamic stability
  • Maintenance – may use 50% Nitrous to limit volatile agents
65
Q

Placental Abruption

When the placenta _____ from the _____ prior to delivery

A

separates from the uterus

66
Q

Placental Abruption

can be _____ or _____

A

complete or partial

67
Q

Placental Abruption

___-___% of all pregnancies

A

0.4-1.0

68
Q

Placental Abruption

Incidence is _____, particularly among African American women in the US cause is not well understood

A

increasing

69
Q

Placental Abruption

Patients hospitalized for acute and chronic respiratory disease at _____ ______, unknown reasons

A

increased risk

70
Q

Placental Abruption Anesthesia Management - Vaginal Delivery

______ analgesia
Treat ______
______ can increase risk to extend abruption
Question further hemorrhage
Consider IV PCA

A

Neuraxial
hypovolemia
Sympathectomy

71
Q

Placental Abruption Anesthesia Management - Cesarean Delivery

General is ____ in most urgent cases, otherwise _____ is may be used in normal coagulation status and volume
Aggressive volume resuscitation is _____
Uterine atony requires uterotonic drugs

A

preferred
neuraxial
critical

72
Q

Uterine Rupture

Previous _____ _____ (c-section, myomectomy)

A

uterine surgery

73
Q

Uterine Rupture

Emergency ______

A

laparotomy

74
Q

Uterine Rupture

_____ compromise is likely

A

fetal

75
Q

Uterine Rupture

Usually general except some stable patients with _____ _______ ______

A

preexisting labor epidural

76
Q

Uterine Rupture

Aggressive _____/______ may be necessary

A

volume/transfusion

77
Q

Uterine Rupture

_____ monitoring?

A

Invasive

78
Q

Postpartum Hemorrhage

Most common definition is >_____cc vaginal delivery, >_____cc c-section

A

500
1000

79
Q

Postpartum Hemorrhage

Only slightly ____ than averages

A

higher

80
Q

Postpartum Hemorrhage

Common causes (5)

A

Uterine atony
Retained placenta
Genital trauma
Uterine Inversion
Placenta Accreta

81
Q

Uterine Atony

____ _____ cause of severe postpartum hemorrhage (80%)

A

Most common

82
Q

Uterine Atony

Prophylaxis
- ACOG recommends prophylactic administration of uterotonic agents to prevent uterine atony
- Uterine _____ & _____ administration decreases blood loss and transfusion requirements
- ______ – first line drug for prophylaxis and treatment
- Side effects – tachycardia, hypotension, ____ ____

A

massage and oxytocin
Oxytocin
myocardial ischemia

83
Q

Uterine Atony

Treatment
____ ____ – fungus - methergine (Unstable unless refrigerated, Rapid onset IM)
_______ - hemobate

A

Ergot alkaloids
Prostaglandins

84
Q

Genital Trauma

_____ & ______ of the perineum, vagina, and cervix

A

Lacerations and hematomas

85
Q

Genital Trauma

May need ____ or ______ for repair

A

anesthesia or sedation

86
Q

Genital Trauma

Vaginal/vulvar ______

A

hematomas

87
Q

Genital Trauma

least common, concealed bleeding

A

retroperitoneal hematomas

88
Q

Retained Placenta

Failure to completely ____ ____

A

deliver placenta

89
Q

Retained Placenta

Anesthetic requirements vary based on _____ _____

A

obstetric needs

90
Q

Retained Placenta

Neuraxial?

A
91
Q

Retained Placenta

May require uterine relaxation

A

High dose volatile anesthetics
Nitroglycerine - (Rapid onset of smooth muscle relaxation, Short half life, Different studies have found success with varying dosages 50-100 mcg, to 500 mcg)

92
Q

Uterine Inversion is ____

A

rare

93
Q

Uterine Inversion

Severe post partum ______

A

hemorrhage

94
Q

Uterine Inversion

May have concurrent _____ _____ _____ bradycardia

A

vagal reflex mediated

95
Q

Uterine Inversion

May need ______ to relax uterus

A

nitroglycerine - Larger (200-250 mcg) may be required

96
Q

Uterine Inversion

Support circulation with ____ ____

A

IV fluids

97
Q

Uterine Inversion

_____ may be necessary

A

GA

98
Q

Uterine Inversion

Once uterus is replaced, a ____ ____ _____ uterus is desired

A

firm well contracted

99
Q

Placenta Accreta

Placenta that invades the uterine wall and is ______ from it.

A

inseparable

100
Q

Placenta Accreta

____ ____ – adherence of the basal plate of the placenta to the myometrium

A

Accreta vera

101
Q

Placenta Accreta

____ – chorionic villi invade myometrium

A

Increta

102
Q

Placenta Accreta

_____ – invasion through the myometrium, into serosa and maybe other organs (usually bladder)

A

Percreta

103
Q

Placenta Accreta Management

  • Transfer to facility with adequate blood banking if necessary
  • _____ c-section
  • Internal iliac artery balloon catheters?
  • Blood loss exceeds _____cc in ____ of cases, 5000cc in 15% and 10,000cc in 6.5%
A

Planned
2000
2/3

104
Q

DIC

Generalized ______ of the clotting system

A

activation

105
Q

DIC

Large portion of vascular system damage or _____ ______ in general circulation

A

thromboplastic materials

106
Q

DIC

usually d/t:

A

Retention of dead fetus
Placental abruption
Amniotic fluid embolism

107
Q

DIC

Accompanied by circulatory shock, renal failure, uncontrolled bleeding due to ______ of ______ ______

A

consumption of clotting factors

NUNA 693 Obs/Regional (13 decks)

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