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Obstetric Anesthesia III Flashcards

1
Q

What can obstetric complications affect during pregnancy?

A
  • The mother’s health.
  • The fetus’s health.
  • Both mother and fetus.
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2
Q

Can healthy women experience complications during pregnancy?

A

Yes, even women who were healthy before pregnancy can experience complications.

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3
Q

How can early and regular prenatal care impact the risk of obstetric complications?

A
  • Decreases risk of complications.
  • Allows to diagnose, treat, or manage conditions before they become serious.
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4
Q

What is the incidence of postpartum hemorrhage (PPH) in vaginal deliveries?

A
  • Approximately 4% of parturients.
  • Incidence is increasing.
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5
Q

How can the development of serious PPH be prevented?

PPH= Post-partum Hemorrhage

A

Aggressive recognition and treatment.

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6
Q

What is the defined blood loss for postpartum hemorrhage in vaginal and cesarean deliveries?

A
  • Greater than 500 mL for vaginal delivery.
  • Greater than 1000 mL for cesarean delivery.
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7
Q

What are the common causes of postpartum hemorrhage?

A
  • Uterine atony (70%–80% of PPH cases).
  • Placental retention.
  • Abnormalities of the uterus.
  • Cervix or vaginal wall lacerations.
  • Uterine inversion.
  • Coagulation abnormalities.
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8
Q

What factors are associated with uterine atony?

A
  • Multiparity.
  • Prolonged infusions of oxytocin before delivery.
  • Polyhydramnios.
  • Multiple gestations.

Polyhydramnios: Is the buildup of increased amniotic fluid

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9
Q

The image below identifies a normal postpartum uterus and a Uterine atony postpartum. Identify them.

A
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10
Q

Postpartum Bleeding Algorithm

A
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11
Q

What are the initial uterotonic agents used to prevent and treat PPH?

A
  • Oxytocin.
  • Followed by methylergonovine, prostaglandins, and misoprostol if oxytocin is ineffective.
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12
Q

What is used when oxytocin does not adequately stimulate uterine contraction?

A

An ergot alkaloid, Methergine.

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13
Q

What is the dosage and frequency of Methergine in stimulating uterine contractions?

A
  • IM dose of 0.2 mg.
  • It can be administered every 2 to 4 hours.
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14
Q

When is Methergine contraindicated?

A
  • In cases of hypertension, preeclampsia, and cardiovascular disease.
  • Hypersensitivity to ergot alkaloids.
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15
Q

What is the next step if uterine massage and uterotonic agents are ineffective in treating PPH?

A
  • Use of an intrauterine balloon to tamponade the bleeding.
  • Follow hemorrhage protocols at your institution.
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16
Q

What is the next step after using oxytocin and ergot alkaloids for PPH?

A
  • Administration of prostaglandin F2 (Carboprost or Hemabate 250 mcg) IM or directly into the uterine muscle.
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17
Q

Side effects of prostaglandins:

A
  • Nausea
  • Bronchospasm
  • Increased pulmonary vascular resistance.
  • Contraindicated in asthmatics due to bronchospasm risk.
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18
Q

Misoprostol dose for continuing Uterine Atony:

A
  • 600 to 1000 mcg rectally, vaginally, or orally as a one-time dose.
  • Adverse reaction: Transient hyperthermic response.
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19
Q

What is the role of antifibrinolytic agents like TXA in PPH?

A
  • Strengthen fibrin clots by inhibiting enzymatic fibrinolysis.
  • Show promise when used with uterotonic agents.
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20
Q

Where is oxytocin synthesized and stored?

A
  • Synthesized in the paraventricular nuclei of the hypothalamus.
  • Stored in and released from the posterior pituitary gland.
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21
Q

What stimulates the release of endogenous oxytocin?

A

Stimulation of the cervix, vagina, and breasts.

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22
Q

What is the synthetic equivalent of oxytocin and its indications?

A
  • Synthetic equivalent: Pitocin.
  • Indications: Induction/augmentation of labor, stimulating uterine contraction, combating uterine hypotonia and hemorrhage.
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23
Q

When is oxytocin administered during a cesarean section (C/S)?

A

After the delivery of the placenta.

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24
Q

What are the side effects of oxytocin?

A
  • Water retention.
  • Hyponatremia.
  • Hypotension.
  • Reflex tachycardia.
  • Coronary vasoconstriction.
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25
Whatis Oxytocin Route of administration?
* IV or directly into the uterus. * Rapid IV administration can cause cardiovascular collapse.
26
What is the metabolism and half-life of oxytocin?
* Metabolism: Hepatic. * Half-life: 4-17 minutes.
27
How are obstetric hypertensive disorders classified?
* Chronic hypertension. * Gestational hypertension. * Preeclampsia. * Eclampsia.
28
What is chronic hypertension in obstetrics, and when does it occur?
* Occurs before 20 weeks of gestation. * Does not return to normal after delivery. * Risk factors for developing preeclampsia.
29
What characterizes gestational hypertension?
* Develops after 20 weeks of gestation. * No proteinuria. * Diagnosed after delivery if a return to normotensive state occurs.
30
What are the criteria for **Preeclampsia**?
* Hypertension after 20 weeks gestation. * Mild: BP > 140/90. * Severe: BP > 160/110. * **Typically includes proteinuria.**
31
When is preeclampsia considered severe?
When BP exceeds 160/110.
32
What is eclampsia?
It occurs when a mother with preeclampsia develops seizures.
33
Obstetric Hypertensive Disorders table.
34
Preeclampsia Facts
35
What are the blood pressure criteria for mild preeclampsia?
SBP: < 160 mmHg. DBP: < 110 mmHg.
36
What are the criteria for proteinuria in severe preeclampsia?
* ≥ 5 g/24 hr. * ≥ 3+ dipstick.
37
What is the threshold for a 24-hour Urine Total indicating severe preeclampsia?
≤ 500 mL.
38
Is pulmonary edema a symptom of mild or severe preeclampsia?
Severe preeclampsia.
39
What visual symptom is associated with severe preeclampsia?
Visual impairment.
40
What abdominal symptom indicates severe preeclampsia?
Epigastric pain.
41
Is HELLP Syndrome associated with mild or severe preeclampsia?
Severe preeclampsia.
42
How does severe preeclampsia affect fetal growth?
It impaired fetal growth.
43
What is the relationship between thromboxane and preeclampsia according to the key facts?
* Thromboxane causes vasoconstriction, affecting blood pressure.
44
What is the significance of the platelet count in preeclampsia?
* A count of < 100,000/mm³ indicates severe preeclampsia.
45
How does preeclampsia affect oncotically-related pressure and vascular permeability?
* Decreased oncotically related pressure. * Increased vascular permeability.
46
What is the definitive treatment for preeclampsia and eclampsia?
Delivery of the fetus and placenta.
47
How may mild preeclampsia be managed if the fetus is not full-term?
Conservatively with observation and bed rest.
48
What action is taken when preeclampsia symptoms are severe or fetal distress occurs?
Immediate delivery to ensure the mother's safety.
49
What are the treatment options for acute hypertension in preeclampsia?
* Labetalol: 20 mg IV, then 40 - 80 mg every 10 minutes, up to 220 mg max. * Hydralazine: 5 mg IV, every 20 minutes, up to 20 mg max. * Nifedipine: 10 mg orally, every 20 minutes, up to 50 mg max. * Nicardipine: Start infusion at 5 mg/hr, increase by 2.5 mg/hr every 5 minutes, up to 15 mg/hr max.
50
What differentiates eclampsia from preeclampsia?
The presence of seizures.
51
What is the seizure prophylaxis protocol for eclampsia with magnesium sulfate?
Load: 4 g loading dose over 10 minutes. Infusion: 1 - 2 g/hr.
52
How is magnesium toxicity treated?
With 10 mL of 10% calcium gluconate IV.
53
What role does magnesium sulfate play in the management of preeclampsia?
* Decreases the rate of fibrin deposition in vital organs. * Improves organ perfusion.
54
What does HELLP syndrome stand for?
* Hemolysis. * Elevated Liver enzymes. * Low Platelet count.
55
What percentage of those with preeclampsia develop HELLP syndrome?
5 - 10%.
56
What are the clinical signs of HELLP syndrome?
* Epigastric pain. * Upper abdominal tenderness. * Proteinuria. * Hypertension. * Jaundice. * Nausea and vomiting.
57
What is the definitive treatment for HELLP syndrome?
Delivery of the fetus.
58
When can HELLP syndrome present, and what are its associated risks?
* Can present postpartum. * Higher risk for DIC and intra-abdominal bleeding from the liver.
59
What is important to assess before placing a neuraxial block in patients with HELLP syndrome?
* **Platelet counts** to reduce the risk of epidural hematoma.
60
What is **placenta previa**, and what symptom does it most commonly cause?
* The placenta is implanted on the lower uterine segment, covering the cervix partially or completely. * Results in **painless vaginal bleeding**, potentially leading to significant blood loss.
61
62
What is placenta accreta?
* Is abnormal growth onto the myometrium. * Normally, it implants into the endometrium.
63
What is placenta increta?
Abnormal placental growth into the myometrium.
64
What does placenta **Percreta** describe?
* Placental growth goes completely through the myometrium. * Into surrounding structures like bowel, bladder, or ovaries.
65
What complication is associated with the delivery of patients with **Placenta Accreta**?
Massive intraoperative hemorrhage.
66
What is placental abruption?
Premature separation of the placenta from the uterus before delivery.
67
What are the consequences of placental abruption?
* Bleeding behind the placenta. * Jeopardized fetal blood supply. * Hemorrhage. * Uterine irritability. * Abdominal pain. * Fetal hypoperfusion.
68
Can vaginal delivery be possible in cases of placental abruption?
Yes, if there is no fetal distress.
69
What should an anesthetist be prepared for in cases of placental abruption?
Administering anesthesia for an emergency cesarean delivery due to potential sudden fetal distress.
70
Amniotic Fluid Embolism
71
What is amniotic fluid embolism, and when may it occur?
* A rare event during labor, vaginal or operative delivery. * It may be associated with placental abruption.
72
What is the classic triad of AFE symptoms? | Anmiotic Fluid Embolism (AFE)
* Acute respiratory distress. * Cardiovascular collapse. * Coagulopathy.
73
What are the additional symptoms of AFE? | Anmiotic Fluid Embolism (AFE)
* Hypotension. * Fetal distress. * Frothing from the mouth. * Uterine atony. * Loss of consciousness. * Convulsions.
74
What does clinical management of AFE involve?
* Supportive care. * Airway management. * Hemodynamic resuscitation. * Treatment of coagulopathy.
75
How is premature delivery defined?
Delivery before 37 weeks of gestation.
76
What is the leading cause of perinatal morbidity and mortality?
Premature delivery, especially in newborns weighing less than 1,500 g.
77
What factors increase the incidence of prematurity?
* Multiple gestations. * Premature rupture of membranes.
78
What are some fetal complications associated with prematurity?
* Respiratory distress syndrome. * Intraventricular hemorrhage. * Necrotizing enterocolitis (NEC).
79
What is the purpose of tocolytic agents in the management of prematurity?
* To delay labor by suppressing uterine contractions. * Allows time for corticosteroids to enhance fetal lung maturity.
80
Can you name some examples of tocolytic agents?
* Beta-agonists. * Magnesium sulfate. * Calcium channel blockers. * Nitric oxide donors.
81
What is the normal range for magnesium levels in mg/dL?
1.8 - 2.5 mg/dL
82
What is the normal range for magnesium levels in mmol/dL?
0.75-1.05 mmol/L
83
What is the normal range for magnesium levels in mEq/L?
1.5-2.1 mEq/L
84
What symptoms are associated with hypomagnesemia when levels are below 1.2 mg/dL?
* Tetany. * Seizures. * Dysrhythmias.
85
What are the clinical features of hypermagnesemia with levels between 7 and 12 mg/dL?
* Loss of deep tendon reflexes. * Hypotension. * EKG changes. * Somnolence.
86
What is the treatment for hypermagnesemia?
IV calcium gluconate 1 g over 10 minutes (to antagonize Mg+2).
87
What severe symptoms might occur if magnesium levels exceed 12 mg/dL?
* Respiratory depression leading to apnea. * Complete heart block. * Cardiac arrest. * Coma. * Paralysis.
88
89
90
What are maternal risks associated with anesthesia during pregnancy?
* Anatomic and physiologic changes of pregnancy (e.g., difficult intubation, aspiration). * Underlying maternal disease.
91
What are the greatest acute risks to the fetus during maternal anesthesia?
* Severe hypoxia. * Hypotension. * Acidosis.
92
What are some fetal risks associated with surgery during pregnancy?
* Increased fetal loss. * Preterm labor. * Growth restriction. * Low birth-weight.
93
What should anesthesia management focus on in pregnant surgical patients?
Avoidance of hypoxemia, hypotension, acidosis, and hyperventilation.
94
What technique is recommended for maternal laparoscopy to minimize fetal risk?
Use of an open technique or a Veress needle for abdominal entry.
95
What intraoperative measures should be taken to prevent fetal hypercarbia and acidosis?
Monitor maternal end-tidal carbon dioxide.
96
Monitor maternal end-tidal carbon dioxide range:
Between 10 and 15 mm Hg.
97
How should position changes be managed during surgery in pregnant patients?
* Limit the extent of Trendelenburg or reverse Trendelenburg positions * Initiate any position slowly.
98
What should be monitored preoperatively and postoperatively in a pregnant surgical patient?
* Fetal heart rate. * Uterine tone.
99
When should tocolytic agents be considered in the surgical management of a pregnant patient?
When evidence of preterm labor is present, not prophylactically.
100
Anesthesia for NonObstetric Surgery
101
What is the recommended approach for elective surgery in pregnant patients?
Delay until post-delivery.
102
How should non-elective surgery in the first trimester be managed?
Consider delaying until the second trimester if there's minimal or no risk to the mother.
103
What is the approach for non-elective surgery in the second or third trimester when there's greater than minimal risk to the mother?
* Proceed with surgery. * Monitor the fetus. * Consult a specialist.
104
What is the protocol for emergency surgery in pregnant patients?
Proceed with surgery while monitoring the fetus and consulting with a specialist.
105
What is the Apgar score used for?
* To assess the newborn. * To guide resuscitative efforts.
106
How many parameters are evaluated in the Apgar score?
Five parameters.
107
At which time intervals is the Apgar score evaluated after delivery?
At 1 minute and 5 minutes.
108
What does the Apgar score at 1 minute correlate with?
Fetal acid-base status.
109
What might the 5-minute Apgar score be predictive of?
Neurologic outcome
110
What are the Apgar score ranges for normal, moderate distress, and impending demise?
Normal: 8 - 10 Moderate distress: 4 - 7 Impending demise: 0 - 3

Special Population-RCM (8 decks)

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