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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
Q

Whatis Oxytocin Route of administration?

A
  • IV or directly into the uterus.
  • Rapid IV administration can cause cardiovascular collapse.
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26
Q

What is the metabolism and half-life of oxytocin?

A
  • Metabolism: Hepatic.
  • Half-life: 4-17 minutes.
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27
Q

How are obstetric hypertensive disorders classified?

A
  • Chronic hypertension.
  • Gestational hypertension.
  • Preeclampsia.
  • Eclampsia.
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28
Q

What is chronic hypertension in obstetrics, and when does it occur?

A
  • Occurs before 20 weeks of gestation.
  • Does not return to normal after delivery.
  • Risk factors for developing preeclampsia.
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29
Q

What characterizes gestational hypertension?

A
  • Develops after 20 weeks of gestation.
  • No proteinuria.
  • Diagnosed after delivery if a return to normotensive state occurs.
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30
Q

What are the criteria for Preeclampsia?

A
  • Hypertension after 20 weeks gestation.
  • Mild: BP > 140/90.
  • Severe: BP > 160/110.
  • Typically includes proteinuria.
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31
Q

When is preeclampsia considered severe?

A

When BP exceeds 160/110.

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32
Q

What is eclampsia?

A

It occurs when a mother with preeclampsia develops seizures.

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33
Q

Obstetric Hypertensive Disorders table.

A
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34
Q

Preeclampsia Facts

A
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35
Q

What are the blood pressure criteria for mild preeclampsia?

A

SBP: < 160 mmHg.
DBP: < 110 mmHg.

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36
Q

What are the criteria for proteinuria in severe preeclampsia?

A
  • ≥ 5 g/24 hr.
  • ≥ 3+ dipstick.
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37
Q

What is the threshold for a 24-hour Urine Total indicating severe preeclampsia?

A

≤ 500 mL.

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38
Q

Is pulmonary edema a symptom of mild or severe preeclampsia?

A

Severe preeclampsia.

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39
Q

What visual symptom is associated with severe preeclampsia?

A

Visual impairment.

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40
Q

What abdominal symptom indicates severe preeclampsia?

A

Epigastric pain.

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41
Q

Is HELLP Syndrome associated with mild or severe preeclampsia?

A

Severe preeclampsia.

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42
Q

How does severe preeclampsia affect fetal growth?

A

It impaired fetal growth.

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43
Q

What is the relationship between thromboxane and preeclampsia according to the key facts?

A
  • Thromboxane causes vasoconstriction, affecting blood pressure.
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44
Q

What is the significance of the platelet count in preeclampsia?

A
  • A count of < 100,000/mm³ indicates severe preeclampsia.
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45
Q

How does preeclampsia affect oncotically-related pressure and vascular permeability?

A
  • Decreased oncotically related pressure.
  • Increased vascular permeability.
46
Q

What is the definitive treatment for preeclampsia and eclampsia?

A

Delivery of the fetus and placenta.

47
Q

How may mild preeclampsia be managed if the fetus is not full-term?

A

Conservatively with observation and bed rest.

48
Q

What action is taken when preeclampsia symptoms are severe or fetal distress occurs?

A

Immediate delivery to ensure the mother’s safety.

49
Q

What are the treatment options for acute hypertension in preeclampsia?

A
  • 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
Q

What differentiates eclampsia from preeclampsia?

A

The presence of seizures.

51
Q

What is the seizure prophylaxis protocol for eclampsia with magnesium sulfate?

A

Load: 4 g loading dose over 10 minutes.
Infusion: 1 - 2 g/hr.

52
Q

How is magnesium toxicity treated?

A

With 10 mL of 10% calcium gluconate IV.

53
Q

What role does magnesium sulfate play in the management of preeclampsia?

A
  • Decreases the rate of fibrin deposition in vital organs.
  • Improves organ perfusion.
54
Q

What does HELLP syndrome stand for?

A
  • Hemolysis.
  • Elevated Liver enzymes.
  • Low Platelet count.
55
Q

What percentage of those with preeclampsia develop HELLP syndrome?

56
Q

What are the clinical signs of HELLP syndrome?

A
  • Epigastric pain.
  • Upper abdominal tenderness.
  • Proteinuria.
  • Hypertension.
  • Jaundice.
  • Nausea and vomiting.
57
Q

What is the definitive treatment for HELLP syndrome?

A

Delivery of the fetus.

58
Q

When can HELLP syndrome present, and what are its associated risks?

A
  • Can present postpartum.
  • Higher risk for DIC and intra-abdominal bleeding from the liver.
59
Q

What is important to assess before placing a neuraxial block in patients with HELLP syndrome?

A
  • Platelet counts to reduce the risk of epidural hematoma.
60
Q

What is placenta previa, and what symptom does it most commonly cause?

A
  • 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.
62
Q

What is placenta accreta?

A
  • Is abnormal growth onto the myometrium.
  • Normally, it implants into the endometrium.
63
Q

What is placenta increta?

A

Abnormal placental growth into the myometrium.

64
Q

What does placenta Percreta describe?

A
  • Placental growth goes completely through the myometrium.
  • Into surrounding structures like bowel, bladder, or ovaries.
65
Q

What complication is associated with the delivery of patients with Placenta Accreta?

A

Massive intraoperative hemorrhage.

66
Q

What is placental abruption?

A

Premature separation of the placenta from the uterus before delivery.

67
Q

What are the consequences of placental abruption?

A
  • Bleeding behind the placenta.
  • Jeopardized fetal blood supply.
  • Hemorrhage.
  • Uterine irritability.
  • Abdominal pain.
  • Fetal hypoperfusion.
68
Q

Can vaginal delivery be possible in cases of placental abruption?

A

Yes, if there is no fetal distress.

69
Q

What should an anesthetist be prepared for in cases of placental abruption?

A

Administering anesthesia for an emergency cesarean delivery due to potential sudden fetal distress.

70
Q

Amniotic Fluid Embolism

71
Q

What is amniotic fluid embolism, and when may it occur?

A
  • A rare event during labor, vaginal or operative delivery.
  • It may be associated with placental abruption.
72
Q

What is the classic triad of AFE symptoms?

Anmiotic Fluid Embolism (AFE)

A
  • Acute respiratory distress.
  • Cardiovascular collapse.
  • Coagulopathy.
73
Q

What are the additional symptoms of AFE?

Anmiotic Fluid Embolism (AFE)

A
  • Hypotension.
  • Fetal distress.
  • Frothing from the mouth.
  • Uterine atony.
  • Loss of consciousness.
  • Convulsions.
74
Q

What does clinical management of AFE involve?

A
  • Supportive care.
  • Airway management.
  • Hemodynamic resuscitation.
  • Treatment of coagulopathy.
75
Q

How is premature delivery defined?

A

Delivery before 37 weeks of gestation.

76
Q

What is the leading cause of perinatal morbidity and mortality?

A

Premature delivery, especially in newborns weighing less than 1,500 g.

77
Q

What factors increase the incidence of prematurity?

A
  • Multiple gestations.
  • Premature rupture of membranes.
78
Q

What are some fetal complications associated with prematurity?

A
  • Respiratory distress syndrome.
  • Intraventricular hemorrhage.
  • Necrotizing enterocolitis (NEC).
79
Q

What is the purpose of tocolytic agents in the management of prematurity?

A
  • To delay labor by suppressing uterine contractions.
  • Allows time for corticosteroids to enhance fetal lung maturity.
80
Q

Can you name some examples of tocolytic agents?

A
  • Beta-agonists.
  • Magnesium sulfate.
  • Calcium channel blockers.
  • Nitric oxide donors.
81
Q

What is the normal range for magnesium levels in mg/dL?

A

1.8 - 2.5 mg/dL

82
Q

What is the normal range for magnesium levels in mmol/dL?

A

0.75-1.05 mmol/L

83
Q

What is the normal range for magnesium levels in mEq/L?

A

1.5-2.1 mEq/L

84
Q

What symptoms are associated with hypomagnesemia when levels are below 1.2 mg/dL?

A
  • Tetany.
  • Seizures.
  • Dysrhythmias.
85
Q

What are the clinical features of hypermagnesemia with levels between 7 and 12 mg/dL?

A
  • Loss of deep tendon reflexes.
  • Hypotension.
  • EKG changes.
  • Somnolence.
86
Q

What is the treatment for hypermagnesemia?

A

IV calcium gluconate 1 g over 10 minutes (to antagonize Mg+2).

87
Q

What severe symptoms might occur if magnesium levels exceed 12 mg/dL?

A
  • Respiratory depression leading to apnea.
  • Complete heart block.
  • Cardiac arrest.
  • Coma.
  • Paralysis.
90
Q

What are maternal risks associated with anesthesia during pregnancy?

A
  • Anatomic and physiologic changes of pregnancy (e.g., difficult intubation, aspiration).
  • Underlying maternal disease.
91
Q

What are the greatest acute risks to the fetus during maternal anesthesia?

A
  • Severe hypoxia.
  • Hypotension.
  • Acidosis.
92
Q

What are some fetal risks associated with surgery during pregnancy?

A
  • Increased fetal loss.
  • Preterm labor.
  • Growth restriction.
  • Low birth-weight.
93
Q

What should anesthesia management focus on in pregnant surgical patients?

A

Avoidance of hypoxemia, hypotension, acidosis, and hyperventilation.

94
Q

What technique is recommended for maternal laparoscopy to minimize fetal risk?

A

Use of an open technique or a Veress needle for abdominal entry.

95
Q

What intraoperative measures should be taken to prevent fetal hypercarbia and acidosis?

A

Monitor maternal end-tidal carbon dioxide.

96
Q

Monitor maternal end-tidal carbon dioxide range:

A

Between 10 and 15 mm Hg.

97
Q

How should position changes be managed during surgery in pregnant patients?

A
  • Limit the extent of Trendelenburg or reverse Trendelenburg positions
  • Initiate any position slowly.
98
Q

What should be monitored preoperatively and postoperatively in a pregnant surgical patient?

A
  • Fetal heart rate.
  • Uterine tone.
99
Q

When should tocolytic agents be considered in the surgical management of a pregnant patient?

A

When evidence of preterm labor is present, not prophylactically.

100
Q

Anesthesia for NonObstetric Surgery

101
Q

What is the recommended approach for elective surgery in pregnant patients?

A

Delay until post-delivery.

102
Q

How should non-elective surgery in the first trimester be managed?

A

Consider delaying until the second trimester if there’s minimal or no risk to the mother.

103
Q

What is the approach for non-elective surgery in the second or third trimester when there’s greater than minimal risk to the mother?

A
  • Proceed with surgery.
  • Monitor the fetus.
  • Consult a specialist.
104
Q

What is the protocol for emergency surgery in pregnant patients?

A

Proceed with surgery while monitoring the fetus and consulting with a specialist.

105
Q

What is the Apgar score used for?

A
  • To assess the newborn.
  • To guide resuscitative efforts.
106
Q

How many parameters are evaluated in the Apgar score?

A

Five parameters.

107
Q

At which time intervals is the Apgar score evaluated after delivery?

A

At 1 minute and 5 minutes.

108
Q

What does the Apgar score at 1 minute correlate with?

A

Fetal acid-base status.

109
Q

What might the 5-minute Apgar score be predictive of?

A

Neurologic outcome

110
Q

What are the Apgar score ranges for normal, moderate distress, and impending demise?

A

Normal: 8 - 10
Moderate distress: 4 - 7
Impending demise: 0 - 3

Special Population-RCM (8 decks)

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