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AP: Summer Exam 3 > Obstetric Anesthesia Part 2: Hertz > Flashcards

Obstetric Anesthesia Part 2: Hertz Flashcards

1
Q

What are considered complicated pregnancies? (6)

A

Preterm labor
Premature rupture of membranes (PROM)
Chorioamnionitis
Umbilical cord prolapse
Amniotic fluid embolism
Partum hemorrhages

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2
Q

What defines premature labor?

A

Labor that occurs between 20-37 weeks gestation

Note: 8% of deliveries

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3
Q

What are the contributing factors to premature labor? (7)

A

Extremes of age
Inadequate prenatal care
Unusual body habitus
Increased physical activity
Infections
Prior preterm labor
Multiple gestations

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4
Q

Preterm infants under ______ weeks and weighing < ______grams have more complications.

A

30 weeks

1500 grams

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5
Q

What are breech premis at increased risk of?

A

Hypoxia and asphyxia

Note: picture of breeched baby.

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6
Q

What are complications relating to premature infants? (3)

A
  • Inadequate surfactant before 35 weeks
  • Soft, poorly calcified cranium predisposes to hemorrhage
  • Many premature fetuses are in breech position
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7
Q

What is premature rupture of membranes (PROM)?

A

Leakage of amniotic fluid before onset of labor

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8
Q

What does the combination of PROM and preterm labor increase the risk of?

A

umbilical cord compression–>fetal hypoxemia

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9
Q

What are the predisposing factors causing the premature rupture of membranes? (6)

A
  • Short cervix
  • Hx of PROM or preterm labor
  • Infection
  • Multiple gestations (twins, triplets)
  • Polyhydramnios (too much amniotic fluid)
  • Smoking
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10
Q

What occurs within 24 hrs in 90% of PROM patients?

A

spontaneous labor

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11
Q

When is delivery indicated for PROM patients?

What drugs are indicated?

A

After 34 weeks of gestation

Otherwise, antibiotics and tocolytics given for 5-7 days

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12
Q

What is chorioamnionitis?

A

Infection of the chorionic and amnionic membranes which may involve the placenta, uterus, and umbilical cord.

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13
Q

What are the maternal complications from chorioamnionitis? (4)

A
  • Dysfunctional labor–not contracting well
  • Intraabdominal infection
  • Septicemia
  • Postpartum hemorrhage
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14
Q

What are the fetal complications of chorioamnionitis? (3)

A
  • Acidosis
  • Hypoxia
  • Septicemia
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15
Q

What are the signs of chorioamnionitis? (4)

A
  • Fever > 38ºC
  • Maternal AND fetal tachycardia
  • Foul smelling fluid
  • Uterine tenderness
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16
Q

When is regional safe for a pt with chorioamnionitis? (3)

A

No signs of septicemia, thrombocytopenia, or coagulopathy.

Note: Pt will be on antibiotic therapy.

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17
Q

What is depicted?

A

umbilical cord prolapse

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18
Q

What are predisposing factors for this to occur? (5)

A
  • Excessive cord length
  • Baby in poor position
  • Low birth weight
  • Parity (births) > 5
  • Rupture of membranes
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19
Q

How is this diagnosed? (3)

A
  • Sudden fetal bradycardia
  • Profound decelerations
  • Confirmation by doctor
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20
Q

What is the treatment for this? (2)

A
  • Immediate steep trendelenburg or knees to chest
  • Push fetal part back into pelvis until stat c-section under general anesthesia
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21
Q

What is amniotic fluid embolism?

A

The entry of amniotic fluid into the mom’s circulation which occcurs through any break in uteroplacental membranes.

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22
Q

What is the incidence and mortality rate of amniotic fluid embolism?

A

low incidence

high mortality rate

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23
Q

What does amniotic fluid contain? (3)

A
  • fetal debris
  • leukotrienes
  • prostaglandins
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24
Q

When is amniotic fluid embolism likely to occur? (4)

A
  • Labor
  • Delivery
  • C-section
  • Postpartum

Note: 50% of mortality in the 1st hour.

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25
Q

What is the classic triad of symptoms of amniotic fluid embolism?

A
  • Hypoxemia
  • Hypotension
  • Coagulopathy
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26
Q

What are other symptoms of amniotic fluid embolism? (6)

A

Pulmonary edema
Cyanosis
CV arrest
DIC
Fetal distress
Seizures

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27
Q

What are 3 main characteristics that embody amniotic fluid embolism?

A

Pulmonary embolism
DIC
Atony of uterus

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28
Q

How do you treat amniotic fluid embolism? (2)

A

Aggressive CPR in supine position (do not tilt uterus)

Immediate c-section because quick delivery is better for baby and mom

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29
Q

What is placenta previa?

A

The placenta is abnormally placed and covers the cervix.

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30
Q

Identify the differing placenta previa categories.

A
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31
Q

List the type of previa that occurs from most to least frequently.

A

Low-lying or marginal (46%)

Complete (37%)

Partial (27%)

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32
Q

What are risk factor of placenta previa? (3)

A

Scarring of uterus from surgeries, pregnancies, ect

Multiple gestations

Abnormal uterus

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33
Q

What are the symptoms of placenta previa? (2)

A

PAINLESS vaginal bleeding

Episodic bleeding but severe hemorrhage can occur at any time

34
Q

What is the management for placenta previa?

A

Less than 37 weeks, bedrest

After 37 weeks, c-section

35
Q

Pts with a low-lying placenta must have a c-section. True or false?

A

False

May deliver vaginally if bleeding is mild.

36
Q

All patients wiht vaginal bleeding are assumed to have placenta previa until proven otherwise. True or false?

A

True

U/S can localize placenta.

37
Q

What is anesthesia type for unstable placenta previa pt>

A

Stat c-section with general anesthesia

38
Q

What is needed for anesthesia for placenta previa pt?

A

Regional is considered in fluid loaded

2 large IVs

2 crossmatched blood units

Central line may be good option for rapid transfusion

39
Q

What is depicted?

A

Placental abruption aka detachment

40
Q

When does separation of the placenta normal occur with placenta abruption?

A

after 20 weeks

41
Q

What is the danger of placental abruption?

A

Loss of area for maternal-fetal gas exchange leading to fetal distress

42
Q

What is the most common cause of intrapartum fetal death?

A

placental abruption

43
Q

What are risk factors of placental abruption? (7)

A

HTN
Trauma
Short umbilical cord
Multiple gestations
ROM
Drugs
Abnormal uterus

44
Q

What are the symptoms of placental abruption? (4)

A

Painful bleeding
Uterine tenderness
Uterine activity increased
HTN is common, DIC possible

45
Q

How is placenta abruption diagnosed? (2)

A

Ultrasound
Amniotic fluid is port wine colored

46
Q

How is mild to moderate abruption treated?

A

Hospitalized

If > 37 weeks and no fetal distress, vaginal delivery

If fetal distress, c-section

47
Q

What lab value will change as a result of mild to moderate abruption?

A

decreased fibrinogen, 150-250 mg/dL

48
Q

What occurs to labs with severe abruption? (4)

A

Coagulopathy in 10% of cases

Fibrinogen < 150 due to active plasminogen

Platelets reduced

Factors 5 and 7 reduced

49
Q

What are anesthetic considerations for severe abruption? (4)

A

C-section preferred to prevent further abruption

Aggressive fluid resuscitation to anticipate high blood loss

Vaginal bleeding may not reflect actual bleeding!

General preferred to treat hypovolemia

50
Q

What is the incidence of uterine rupture and the causes? (5)

A

Rare

  • Scar from previous surgery. Vertical scars bleed more.
  • Forceps
  • Prolonged labor
  • Strong contractions
  • Large, thin, weak uterus
51
Q

What are the signs of uterine rupture? (5)

A

Fetal distress is most reliable sign

Frank hemorrhage

Cessation of labor, ineffective contractions

Abdominal pain that breaks through epidural

Constant pain with NO RELIEF BETWEEN CTX

52
Q

How do you treat uterine rupture? (3)

A

Control bleeding by repairing arteries, etc

Volume rescuscitation

Immediate laparotomy under GETA

53
Q

What situation will present with abrupt onset of continuous abdominal pain and hypotension even with an epidural?

A

uterine rupture

54
Q

What occurs with a retained placenta?

A

The uterus cannot contract properly and continues to bleed.

55
Q

Nitroglycerine must not be used when there is a retained placenta. True or false?

A

False, may be useful in relaxing the uterus.

56
Q

What is placenta accreta?

A

abnormally adherent placenta

57
Q

Label

A
58
Q

List occurrence of placenta accreta from most to least.

A

Accreta (78%)

Increta (17%)

Percreta (5%)

59
Q

What is the adherence to myometrium without invasion of or passage through the uterine muscle?

A

placenta accreta

60
Q

What is the placental invasion of the myometrium?

A

increta

61
Q

What is the invasion of the uterine serosa or other pelvic structures?

A

percreta, which can also invade the bladder and bowel

62
Q

What are the risk factors for placenta accreta? (2)

A

Hx of placenta previa

Previous c-section

63
Q

What is the treatment for placenta accreta?

A

uterine curretage, then oversewing the bleeding placenta bed but not usually successful

most cases require postpartum hysterectomy

64
Q

What is the anesthetic treatment for placenta accreta? (3)

A

c/s or lap stat under general

blood rescusitate

coagulopathy correction

65
Q

What is the major cause of postpartum hemorrhage?

A

uterine atony, which is usually accompanied by retained placenta

66
Q

What is the treatment for uterine atony? (3)

A

Oxytocin

Metherigine (methylergonovine maleate)

Carboprost, Hemabate (Prostaglandin F2Alpha )

67
Q

Where does oxytocin have an effect?

A

Uterus contractions

Mammary glands stimulates contraction of myoepithelial cells for milking

Smooth muscle when given in large doses resulting in decreased BP

68
Q

What is the postpartum dose of oxytocin?

A

20 units in 1000ml LR

Infusion: 20-40 mU/min

69
Q

What are the side effects of oxytocin? (2)

A

HYPOTENSION
N/V

70
Q

What is methylergonovine maleate (Methergine)? (3 points)

A

Acts directly on smooth muscle of the uterus via alpha receptors

Increases tone, rate of contractions

Raises BP and CVP

71
Q

What is the dosage of methergonovine maleate (Methergine)?

A

IM: 0.2 mg or

IV: 0.02 mg increments

72
Q

What should you consider when giving methylergonovine maleate (Methergine)? (3)

A

Use cautiously in pts with HTN or cardiac disease

Caution in ASTHMA pts!

May produce severe HTN, CVAs and retinal detachment

73
Q

What is prostaglandine F2alpha (Carboprost, Hemabate)?

A

Synthetic prostaglandin

Stimulates smooth muscle for contracting the uterus

74
Q

What is the dose of Carbaprost, Hemabate?

A

IM: 250 mcg q 15-90 min as needed

Max dose: 2 mg

75
Q

What is a contraindication of prostaglandin F2alpha (Carbaprost, Hemabate)?

A

ASTHMA

76
Q

What drugs do you administer for uterine inversion?

A

NTG

Sevo

Helps relax the uterus to put things back inside.

77
Q

What causes partum hemorrhages? (6)

A
  • Placenta previa
  • Placental abruption
  • Uterine rupture
  • Placenta retained
  • Placenta accreta
  • Uterine atony
78
Q

Do the following cause pain?

placenta previa
placental abruption
uterine rupture
retained placenta
placenta accreta
uterine atony

A

The only ones that cause pain are:

  • Placental abruption
  • Uterine rupture
79
Q

What can result in potentially massive blood loss?

A

Placenta previa

Placenta accreta

80
Q

What may conceal bleeding?

A

Placental abruption

Uterine rupture

81
Q

In what situation may the FHR disappear?

A

Uterine rupture

82
Q

What are causes of hemorrhages:

antepartum
peripartum
postpartum?

A

Antepartum–placenta previa, abruption PA

Peripartum–uterine rupture U

Post partum–placeneta accreta, uterine atony PU

AP: Summer Exam 3 (7 decks)

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