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Principles II > OB Study Guide Questions > Flashcards

OB Study Guide Questions Flashcards

Questions from the comprehensive OB study guide... a ton of shit... There is still a lot on info to fill in some of the things I skipped from the SG, be sure to check it out if you have questions or deficiencies. Thank you for your time, now get to work!

1
Q

Cardiovascular changes in pregnancy?

A
  • 10th week of gestation~ 10% - 3rd trimester ~ 40-50% - Post delivery as high as 60-80% - Increases: -Stroke volume (30%) -Heart rate (15-25%) -Placental and ovarian steroids
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2
Q

Hemapoietic changes in pregnancy?

A
  • Increased IVF volume/constituents o- Begins @1st trimester - - - 1500ml by term o- Plasma volume increases ~ 45% o- Erythrocyte volume increases ~ 20% o- Plasma protein (albumin) concentration-decreases o- Dilutional effect of increased IVF volume
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3
Q

Respiratory changes in pregnancy?

A

Capillary engorgement Edematous vocal cords/arytenoids Min Vent 50% incr 1st trimester (decr resting maternal PaCO2) Decr. FRC 3rd trimester (incr atelectasis) Incr MV + decr. FRC = Incr. Alv. conc. of inhaled anesthetics

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4
Q

Renal changes in pregnancy?

A

o 3rd Month of Pregnancy o 50-60% Increase  RBF  Glomerular filtration rate o 50% decrease (upper normal limits)  Blood urea nitrogen  Creatinine concentrations

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5
Q

GI changes in preg?

A

Commonly experience esophagitis, GERDS Gastric fluid volume and gastric fluid pH “full stomach” Reglan 10 MG IV, Zantac 50 mg IV, Bicitra 30 mL PO

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6
Q

CNS changes in preg?

A

o Decreased anesthetic requirements – Engorgement of epidural veins – Decreased epidural space – Decreased volume of CSF - Exaggerated spread of local anesthetics - Decrease in dose requirement by 30% to 50%

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7
Q

Periph nerv sys changes inpreg?

A
  • Pregnancy induced analgesia (MAC 40% lower in pregnancy) - elevation in pain threshold
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8
Q

Endocrine chagnes in preg?

A

Thyroid gland enlarges 50-70% Estrogen induced increase in thyroid binding globulin results in a 50% increase in T3 and T4 concentrations Mean blood glucose usually remains the same, but can decrease in third trimester (due to greater demands by fetus)

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9
Q

Effect of preg on plasma protein content?

A

Plasma albumin decreases from 4.5 to 3.9 g/dL during 1st trimester. Globulins decline by 10% in the first trimester and rise throughout the remainder of pregnancy to 10% above prepregnancy levels at term. This can affect the amount of available protein binding sites for highly protein bound drugsdue to the fluctuations throughout pregnancy

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10
Q

Affect of preg on inhalational agents?

A

MAC is decreased by 15-40% (volatile halogenated agents) due to (1) elevated progesterone levels (2) ↑’d CNS serotonergic activity (3) activation of the endorphin system

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11
Q

Affect of preg on IV anesthetics?

A

(1) Induction dose of thiopental ↓ by 35% (due to same mechanisms as inhaled agents), elimination T1/2 prolonged to 26 hrs vs. 11 hrs due to larger Vd. (2) Propofol pharmacokinetics are unchanged by pregnancy. (3) Succinylcholine’s elimination T1/2 is not altered due to 1st order kinetics and faster recovery due to larger Vd. (4) ↑’d sensitivity to vecuronium and rocuronium noted ↑ clearance and shortened elimination T1/2 also noted. (5) Atricurium pharmacokinetics are unchanged by pregnancy

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12
Q

Affect of preg on local anesthetics?

A

engorgement of epidural veins w/ ↓ of epidural space ↓ CSF vol. in subarachnoid space ↑ intra-abdominal pressure facilitates spread of LA thereby ↓ing dose by 30-50%

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13
Q

Factors affecting maternal uptake and elimination of anesthetics?

A

Inc. MV and Decr. FRC=more rapid induction and emergence

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14
Q

Which nerves carry pain in 1st stage labor? 2nd stage? 3rd stage?

A

1st: T10-L1 Sympathetic (cervical dilation pain); S1-4 somatic nerves (vaginal perineal pain) 2nd: Pelvic musculature and ligaments send via sacral plexus 3rd: Pudendal nerve ?

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15
Q

Definitions of 1st, 2nd, 3rd stages of labor?

A

1st: Regular contractions - cervical dilation 2nd: Dilation - birth of man-child 3rd: Birth of man-child - delivery of placenta and associated afterbirth

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16
Q

Factors that affect placental transfer of drugs?

A

Mat-fet concentration gradients mat protein binding Molecular weight Lipid solubility degree of ionization of substance

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17
Q

When should IV drugs be administered (in relation to contraction) to decrease fetal exposure and uptake?

A

Administering IV drugs during a contraction decreases fetal exposure and uptake due to a marked decrease of maternal blood flow to the placenta during this time.

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18
Q

How will fetal acidosis affect drug delivery in the fetus?

A

Fetal pH is 0.1 lower than maternal, making weakly basic drugs cross placenta in nonionized form then become ionized in the fetus. Due to the gradient, they thenhave difficulty moving back to the mother (against the gradient). This is called ion trapping.

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19
Q

What are the determinants of uterine blood flow?

A

Uterine Blood Flow (UBF)=Uterin perfusion pressue/Uterine Venous return (UBF=UPP/UVR)

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20
Q

Is uteroplacental blood flow autoregulated?

A

the placental circulation displays limited autoregulation ability. What this means is that placental blood flow will most likely decrease with reductions in maternal blood pressure.

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21
Q

Three factors to decrease uterine blood flow?

A

Systemic BP Uterine Vascular Pressure Uterine Vascular Resistance

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22
Q

How does extreme maternal hyperventilation affect uterine oxygenation?

A

Mechanical hyperventilation may limit gas exchange between the mother and the fetus in two ways: (1) it can significantly decrease the uterine blood flow by decreasing maternal cardiac output and blood pressure, and (2) in theory, it can decrease transplacental oxygen delivery by causing maternal respiratory alkalosis, which shifts the maternal oxyhemoglobin dissociation curve to the left.

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23
Q

Causes of pain in 1st stage of labor? Which dermatomes would that be?

A

Several lines of evidence suggest that pain during the first stage of labor is transduced by afferents with peripheral terminals in the cervix and lower uterine segment rather than the uterine body, as is often depicted. T10-L1 dermatomes

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24
Q

Causes of pain in 2nd stage of labor? Which nerve fibers? Affect on uterine blood flow?

A

Distension, ischemia, and frank injury in or around the perinuem.

Innervation from vaginal surface of cervix, vagina, and perineum:

Pudendal nerve (S2-4)

SNS outflow results in increased CO and SVR, leading to a reduction in uteroplacental perfusion.

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25
Q

Sedative of choice during C-Sect w/ regional anesthetic?

A

.Most women do not require sedatives, BUT if they HAVE to have it, use a small dose of benzo (midazolam 0.5-2 mg) and/or opioid (fentanyl 25-50 mcg)

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26
Q

When is GETA the technique of choice for a C-Sect?

A

.Meternal hemorrhage or fetal distress

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27
Q

What causes supine hypotensive syndrome? What is the treatment?

A

Uteral compression of aorta and vena cava

LUD w RHE

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28
Q

S/S of supine hypotensive syndrome (aortacaval compression syndrome)?

A

Decreased BP/CO

Decreased blood flow to lower extremeties

Unchanged blood flow to upper extremeties

Increased brachial artery pressure

Possible tachycardia followed by bradycardia

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29
Q

Which LAs are used in OB?

A

Spinal: Lidocaine, tetracaine, ropivacaine, levobupivicaine, bupivicaine

Epidural: 2-chloroprocaine, lidocaine, mepivicaine, bupivicaine, ropivicaine, levobupivicaine, etidocaine (M&E infrequently)

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30
Q

Which LA is least cardiotoxic, fastest acting, and safest for use in OB?

A

Ropivicaine

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31
Q

In an epidural, how much should we decrease the dose?

A

Subarachnoid 25%

Large dose epidural unaltered

Small dose epidural reduced

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32
Q

Physiologic mechanisms behind “anemia of preg”?

A

Dilutional:

Plasma volume increases 50%, but RBC increases only 30%

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33
Q

When does the greatest increasein CO occur in preg?

A

During labor and delivery

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34
Q

What happens to CO immediately after delivery?

A

CO may be as muh as 75% above predelivery measurements

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35
Q

Does preg mimic restrictive or obstructive disease?

A

Restrictive

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36
Q

6 resp system variable that do NOT change during preg?

A

Vital capacity

Resp rate

FEV1

FEV1/FVC

Flow-Volume loop

Closing capacity

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37
Q

Most frequent complication of epidural/spinal anesthesia for labor & delivery?

A

Epidural:

Hypotension, limited/patchy block, dizziness, restlessness, tinnitus, seizures, loss of conc., CV collapse, high block

Spinal:

Hypotension, high spinal, patchy block

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38
Q

Contraindications for spinal/epidural anesthesia?

A

Patient refusal

Coagulopathy

Uncontrolled hemorrhage

Infection at needle site

Relative: systemic maternal infection, elevated ICP, prior spinal instrumentation with hardware, neuro dx

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39
Q

What is induction to delivery time?

A

Induction of labor (maybe of anesthesia?) to delivery of fetus

Dysfunctional labor: 20 hrs in nulliparous, 14 hrs in multiparous

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40
Q

What is uterine incision to delivery time?

A

.From when the incision is made until the baby is out (3 minutes seems to be a critical time, babies out after 3 min tend to be depressed)

41
Q

What is Variability?

A

Small, normal changes in fetal heart rate (FHR)

42
Q

Range of fetal heart rate?

A

120-160 in a term fetus (immature is higher)

Brady to 100 is OK if less than 2 min

Brady to 80 is unacceptable.

43
Q

Understand early, late, variable decelerations…

A

Early: occurs with contractions. This is OK.

Late: occurs after contraction starts, lingers until after contraction is over. This is NOT OK.

Variable: occurs with some contractions, but not all… Possibly from umbilical cord compression. Not particularly good…

44
Q

Fetal scalp pH?

A

Older method to confirm/exclude fetal acidosis when monitoring suggests fetal compromise.

45
Q

Components of APGAR score?

A

A- Appearance

P- Pulse

G- Grimmace

A- Activity

R- Respirations

46
Q

In a baby born to a heroin-addicted mother, what drug should be avoided in the newborn?

A

Narcan?

47
Q

What is organogenesis?

A

It is the development of organs.(<8 weeks gest. according to Dr. Whats-his-name we saw last week)

48
Q

What is hemolytic disease of newborn?

A

(AKA Erythroblastosis fetalis)

Transplacental passage of maternal IgG antibodies against fetal erythrocytes

(Mother Rh -, fetus Rh +) Mother is treated with Anti-D immunoglobulin during and after pregnancy

49
Q

What is preeclampsia?

A

New onset of HTN (140/90) & proteinuria after 20 wks gestation

50
Q

What is eclampsia?

A

CNS involvement results in new onset of seizures in preeclamptic women

51
Q

What is severe preeclampsia?

A

BP > 160/110

Proteinuria >5g/24hr

elevated serum creatine

oliguria

pulm HTN

pulm edema

visual disturbances

IUGR

RUQ/epigastric pain

S/S HELLP syndrome

52
Q

What is HELLP syndrome?

A

Hemolysis

Elevated Liver enymes

Low Platelets

53
Q

Essential pharm interventions of preeclampsia and eclampsia?

A

MgSO4 (seizure prophylaxis)

Steroids (accelerate fetal lung maturity, surfactant production)

54
Q

What are the 1st and 2nd causes of death in preeclampsia?

A

1st: CVA
2nd: Placental abruption

55
Q

How does preeclampsia affect uteroplacental circulation?

A

Increased downstream resistance in the uteroplacental bed -> decreases diastolic flow -> increases systolic/diastoli flow ratio -> IUGR

56
Q

What is uterine atony?

A

Soft, boggy uterus (most common cause of PP hemorrhage)

57
Q

List 5 requirements for anesthetic management of uterine atony.

A

Large-bore IV access

Volume resus

Type & Cross

CBC & CoAgs

Prep for hysterectomy!!!

-Oxytocin, ergot alkaloids, prostaglandins

58
Q

What is placenta previa?

A

Implantation of the placenta in advance of the fetal presenting part

(placenta covers the cervical os)

Painless bleeding in 2/3 trimester

DX via US

Double set-up

59
Q

What is placenta accreta?

A

Abnormally adherent placenta

60
Q

What is placenta increta?

A

.Placental invasion of the myometrium

61
Q

What is placenta percenta?

A

Placental invasion of the uterine serosa or other pelvic structures

62
Q

Predisposing factors for placenta accreta?

A

Hx of previous C/Sects with current placenta previa

63
Q

What is abruptio placenta?

A

A complete of partial speraration of the placenta from the decidua basalis before delivery of the fetus.

Fetal compromise occurs d/t the loss of placental surface area for maternal-fetal exchange.

64
Q

What is amniotic fluid embolism?

A

Embolism of amniotic fluid……….

Etiology unclear, but there is a disruption of the barrier between the amniotic fluid and maternal circulation.

(AKA “anaphylactoid syndrome of pregnancy”)

65
Q

Why does DIC occur?

A

Theorized that amniotic fluid contains a procoagulant (Factor X activator) as well as possible circulating trophoblast, whih may disrupt the normal clotting cascade

66
Q

What is amniotic fluid? What is a normal amount? What is an L-S ratio?

A

Clear fluid that surrounds the fetusin the amniotic sac.

Suspends and protects fetus

Nml volume is 50 ml @ 12 wks to 800 ml @ 38 wks

L-S ratio: lecithin/sphingomyelin ratio-lab test to determine fetal lung maturity; immature lung begins to produe more lecithin than sphingomyelin and the reversal of the ratio signifies the lung is beginning to mature (~34 wks)

67
Q

What is choriamnionitis?

A

infection of the placental membranes and amniotic fluid

may lead to systemic infection and possible exclusion of neuraxial anesthesia

68
Q

What is a tocolytic drug? Name 3 of them.

A

“Taco-destroying”

or… med given to stop or slow down uterine contractions in preterm labor

CCBs, B-agonists, prostaglandin inhibitors

Mag sulfate

69
Q

Why is mag sulfate the drug of choice for preeclampsia?

A

Reduces the risk of full-blown eclampsia, reduces HELLP by reducing fibrin deposition, reduces maternal mortality, all while maintaining uterine blood flow

70
Q

The preeclamptic patient should not receive which general anesthetic?

A

Do not give Ketamine to a preeclamptic patient. Ketamine increases sympathetic outflow, further increasing blood pressure.

71
Q

Name 2 pharm treatments for hypertonic uterus.

A

Terbutaline (B-agonist) & nitroglycerin

72
Q

Therapeutic action of oxytocin?

A

Oxytocin (Pitocin) is used to induce or augment labor and is a first line drug for tx of uterine atony. It enhances uterine contraction, decreasing bleeding post-delivery.

73
Q

Which LA accumulates the least in the fetus?

A

Chlorprocaine

It is an ester LA and is metabolized by plasma cholinersterase very rapidly. A chlorine atom in its structure allow it to be metabolized 3x faster than other ester LAs. (Mother and fetus have active plasma cholinesterase)

74
Q

Should the OB patient be pre-curarized priorto the delivery of general anesthesia for E-C/Sect?

A

Nope. It can take way too long, and more sux is needed to be effetive.

75
Q

Which maternal nerve block will cause the most fetal bradycardia?

A

Paracervical block.

Mechanism is uncertain: may be related to local anesthetic-induced vasoconstriction of the umbilical artery, fetal manipulation while performing the block, local anesthetic effects directly in the fetus, or sudden increase in uterine tone with injection.

76
Q

Whic types of blocks can be used for 1st stage of labor pain?

A

paracervical block

lumbar sympathetic block

epidural block

77
Q

What is meconium aspiration?

A

Aspiration of meconium (i love these kinds of questions…)

Fetus inhales his own in-house poops, what a dumb-shit…

Leads to Meconium Aspiration Syndrome: resp distress, cxr shows pulm consolidation and atelectasis

Tx: airway suction, PPV, extracorporeal membrane oxygenation, and inhaled nitric oxide

78
Q

What nerve is most commonly associated with vaginal delivery?

A

Pudendal nerve

79
Q

What is normal blood loss for vaginal delivery? C-Sect?

A

Vag: 500 mL

C/Sect: 1000mL

80
Q

Most common causes of fetal distress?

A

Hypoxia

81
Q

Precipitating factors of pre-eclampsia?

A
  1. Primary Primaparous women (85%)
  2. Chronic HTN
  3. Renal Disease
  4. Insulin Dependant Diabetes
  5. Obesity
  6. Hx of preeclampsia
  7. Hx of close relatives developing the disease
  8. Conditions associated with rapid uterine rupture
  9. Hydatiform moles
  10. Diabetes
  11. Multiple gestation
82
Q

PaO2 and PaCO2 in normal fetus?

A

PaO2: 50-60 mmHg

PaCO2: 40 mmHg

83
Q

How does fetal heart rate fluctuate with maternal blood pressure?

A

fetal oxygenation is limited primarily by uteroplacental blood, not maternal oxygenation

84
Q

2 signs of fetal hypoxia?

A

Late decels

variable decels w brady

85
Q

Definitive treatment for preg-induced HTN?

A

Delivery of fetus and placenta

86
Q

When is ketamine used for C-Sect?

A

Placenta previa with hemorrhage (EMERGENT)

87
Q

Actions to prevent hypotension during C-sect?

A

Ephedrine

Phenylephrine

Supp O2

LUD

IV fluid bolus

88
Q

Greatest maternal/fetal danger of using general anesthesia for deliveries?

A

Death

89
Q

Epidural opioid effectiveness is decreased when used with which LA?

A

Chloroprocaine (that’s a bitch, huh?)

may also interfere with epidural bupivicaine…

90
Q

What does the fetal scalp monitor measure?

A

Fetal heart rate

Fetal pH

91
Q

What nerve injury is most commonly associated with vaginal delivery?

A

Perineal?

92
Q

Most common “nonOB” procedures performed on OB patients? Least?

A

Most:

  • Cervical incompetence
  • Appy
  • Adnexal/Ovarian surgery
  • Chole
  • Bowel obstruction
  • Breast surgery

Least:

  • Neuro procedures
  • Cardiac/ Valve surgery
  • Transplant
  • Urological
93
Q

How do you best avoid contributing to malformation of the fetus during surgery?

A

Have someone relieve you for a break.

OR maintain fetal well-being

(maintain maternal oxygenation, maintainance of nml mat. oxygen tension, oxy-carrying capacity, oxygen affinity, and uteroplacental perfusion)

94
Q

Four major objectives of anesthetic management in the OB patient which corresponds to fetal wellbeing.

A

avoidance of teratogenic drugs

avoidance of intrauterine fetal hypoxia and acidosis

prevention of preterm labor

management of anesthesia including fetal monitoring, careful choices of anesthetic drugs (spinal and epidural anesthesia in the first trimester), and ensuring inhaled concentrations of oxygen remain above 50%

95
Q

What is teratogenicty?

A

any significant postnatal change in function or form in an offspring after prenatal treatment

96
Q

What are some documented teratogens?

A

radiation

CMV

herpes

toxoplasmosis

alcoholism

DM

folic acid deficiency

hyperthermia

ACE inhibitors

anticonvulsants

cocaine

anticoagulants

tetracyclines

androgenic hormones

cyclophosphamide

iodides

lithium

97
Q

FDA classification of commonly used anesthetics.

A

Mostly B’s and C’s in clinical doses

98
Q

At what point is an OB patient no longer considered an OB patient?

A

Several weeks post partum

99
Q

Six H’s to avoid during induction and maintenance of the OB patient.

A

hypoxemia

hypotension

hypertension

hyper/hypocarbia

hypoglycemia

hyper/hypothermia

Principles II (25 decks)

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