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Prodigy Quick Review > Obstetric Pharmacology > Flashcards

Obstetric Pharmacology Flashcards

1
Q

How is MAC affected by pregnancy?

A

By 8-12 weeks of pregnancy, the MAC for volatile anesthetics is
decreased and appears to parallel the rising progesterone
levels.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1147.

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2
Q

You have administered large doses of meperidine to
a laboring parturient and now fear respiratory
depression in the neonate. Can you give naloxone
to the mother before delivery to prevent respiratory
depression in the infant?

A

Yes, theoretically you can do this, but it is not recommended.
Administering naloxone to the mother at this point would
reverse her analgesia at a time she needs it most. Doing so
has resulted in pulmonary edema and even cardiac arrest in the
mother. It is recommended to administer naloxone directly to
the neonate at a dose of 0.1 mg/kg IM.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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3
Q

What is the preferred drug for seizure prophylaxis in

obstetric patients with preeclampsia?

A

Magnesium is the drug of choice for seizure prophylaxis in
preeclamptic patients. It works at the NMDA receptor and is
associated with a decrease in systemic vascular resistance and
an increase in the cardiac index.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 564.

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4
Q

Can ketamine be used to provide analgesia during

labor?

A

Yes, but large doses can produce unacceptable levels of
amnesia and neonatal depression. Ketamine 0.2-0.4 mg/kg can
provide supplemental analgesia for an inadequate regional
anesthetic without producing neonatal depression.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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5
Q

How long after intravenous or intramuscular
administration would you expect to see the maximal
maternal and neonatal respiratory depressant effects
of meperidine?

A

Maximal maternal and fetal respiratory depression is seen in 10-
20 minutes following IV administration of meperidine and 1-3
hours following IM injection.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 847.

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6
Q

What is the recommended dose of nalbuphine in a

laboring parturient?

A

The recommended dose of nalbuphine is 10 mg IV or IM.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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7
Q

What is the recommended IV or IM dose of

butorphanol in a laboring patient?

A

The recommended dose of butorphanol is 1-2 mg IV or IM.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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8
Q

What are the advantages of the use of butorphanol

and nalbuphine in laboring patients?

A

Both of these drugs have lower incidences of nausea, vomiting,
and dysphoria. They also have a ceiling effect on the degree of
respiratory depression they produce. Also, their metabolites are
inactive.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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9
Q

What is the elimination half-life of meperidine in the

neonate?

A

62 hours
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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10
Q

How does the maternal administration of meperidine

affect fetal heart rate?

A

It can produce decreased beat-to-beat variability and fetal
tachycardia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1150.

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11
Q

What are the major side effects of meperidine

administration to parturients?

A

It has a high incidence of nausea and vomiting, maternal
sedation, orthostatic hypotension, and can produce neonatal
depression.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1149-1150.

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12
Q

How quickly will intravenous meperidine produce

analgesia in a laboring parturient?

A

Meperidine produces analgesia in about 5-10 minutes.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1149.

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13
Q

What muscle relaxant drugs cross the placenta?

A

None of the neuromuscular relaxants cross the placenta.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63.

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14
Q

Does heparin cross the placenta?

A

No.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63

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15
Q

What antihypertensive agents cross the placenta?

A

Beta-blockers, nitroprusside, and nitroglycerin all cross the
placenta.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63.

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16
Q

Does ephedrine cross the placenta?

A

Yes. Ephedrine causes similar increases in blood pressure,
heart rate, cardiac contractility, and cardiac output, but because
it is a noncatecholamine, ephedrine has a longer duration of
action than epinephrine. It is also less potent. Ephedrine does
not decrease uterine blood flow, however, which makes it the
preferred vasopressor for obstetric cases.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63.

17
Q

Do intravenous and inhaled induction medications

cross the placenta?

A

Yes. This includes propofol, thiopental, local anesthetics,
inhalational anesthetics, nitrous oxide, benzodiazepines, and
opioids.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63.

18
Q

What anticholinergic drugs cross the placenta?

A

Scopolamine and atropine cross the placenta, but
glycopyrrolate does not.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63.

19
Q

How does pregnancy affect the height of neuraxial

anesthetics?

A

Believed to be due to a decrease in the epidural space due to
venous congestion and/or progesterone-induced sensitivity to
local anesthetics, pregnant patients require a lower total dose of
local anesthetic to achieve an equivalent level of blockade.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1147.

20
Q

What anesthetic drugs are most appropriate for
producing uterine relaxation for breech delivery or
removal of a retained placenta?

A

Although general anesthesia with 1.5-2.0 MAC of an inhalation
agent will produce uterine relaxation for maneuvers such as
second twin delivery, breech presentation or postpartum
removal of a retained placenta, the administration of
nitroglycerin 50-500 mcg IV has generally replaced the need for
general anesthesia to relax the uterus.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1152.

21
Q

How does pregnancy affect the protein binding of

lidocaine? What effect could this have?

A

The protein binding of lidocaine decreases during pregnancy.
As protein binding decreases, the free fraction of the drug is
increased and the risk for toxicity increases.
Chestnut DH, Polley LS, Tsen LC, Wong, CA. Chestnut’s
Obstetric Anesthesia: Principles and Practice. 4th ed.
Philadelphia, PA: Mosby Elsevier, 2009: 30.

22
Q

How does pregnancy affect the protein binding of

bupivacaine?

A

Although the two proteins to which bupivacaine binds, albumin
and alpha-1 acid glycoprotein, are both decreased during
pregnancy, the total amount of protein binding is unchanged. It
is believed that alpha-1 acid glycoprotein is not saturated at the
concentrations at which bupivacaine is normally administered,
leaving a ‘reserve’ of alpha-1 acid glycoprotein to which it can
bind.
Chestnut DH, Polley LS, Tsen LC, Wong, CA. Chestnut’s
Obstetric Anesthesia: Principles and Practice. 4th ed.
Philadelphia, PA: Mosby Elsevier, 2009: 30.

23
Q

Does pregnancy affect the rate of absorption of

bupivacaine from the epidural space?

A

No. During pregnancy, the rate of absorption of bupivacaine
from the epidural space is unchanged.
Chestnut DH, Polley LS, Tsen LC, Wong, CA. Chestnut’s
Obstetric Anesthesia: Principles and Practice. 4th ed.
Philadelphia, PA: Mosby Elsevier, 2009: 30.

24
Q

Is ketorolac an acceptable analgesic in a laboring

parturient?

A

NSAIDs such as ketorolac are generally avoided in laboring
parturients because they inhibit uterine contractions and
promote closure of the fetal ductus arteriosus.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 847.

25
Q

A pregnant patient on a magnesium infusion
presents for emergency cesarean section and will be
undergoing a general anesthetic. How might the use
of magnesium affect your anesthetic management?

A

Magnesium potentiates the action of all nondepolarizing
neuromuscular relaxants as well as succinylcholine by
decreasing the amount of acetylcholine released from the motor
end plate. It can also exacerbate the hypotension seen under
regional anesthesia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1158.

26
Q

What is the most commonly administered inhalation

agent for analgesia during labor?

A

Nitrous oxide
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1152.

27
Q

What is the only local anesthetic that is ‘safe’ from

ion trapping in the fetus? Why is this so?

A

Chloroprocaine is metabolized so quickly in the fetus that it has
no opportunity to accumulate in any significant amount.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1148.

28
Q

Which crosses the placenta more easily, drugs that
bind to albumin or drugs that bind to alpha-1 acid
glycoprotein?

A

Drugs that bind to albumin cross the placenta more easily
because they have a lower binding affinity. Drugs that bind to
alpha-1 acid glycoprotein are more ‘tightly’ bound. As a result,
less of the drug is released from the protein and made available
for transport across the placental membrane.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63.

29
Q

Do charged molecules or uncharged molecules

cross the placenta more easily?

A

Uncharged molecules cross the placenta more easily.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
63

30
Q

Can angiotensin converting-enzyme (ACE) inhitors

affect the fetus?

A

Yes, ACE inhibitors cross the placenta. Enalaprilat has been
shown to reduce fetal arterial pressure by 20%.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
67.

31
Q

Do magnesium, nifidipine, or clonidine cause

vasodilation in the fetus?

A

Magnesium and nifidipine both produce fetal vasodilation, but
clonidine does not.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
67.

32
Q

What maternal glucose level should you strive to

maintain in a parturient with diabetes?

A

Glucose levels should be monitored frequently to maintain
glucose levels between 60-120 mg/dL.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1163.

33
Q

How do local anesthetics affect uterine blood flow?

A

Local anesthetics exert a vasoconstrictor property that can
reduce uterine blood flow. The normal concentrations used do
not normally have this effect with two exceptions: 1) inadvertant
intravenous injection of a local anesthetic, and 2) paracervical
block. Bupivacaine exerts a greater vasoconstrictor effect than
either chloroprocaine or lidocaine.
Chestnut DH, Polley LS, Tsen LC, Wong, CA. Chestnut’s
Obstetric Anesthesia: Principles and Practice. 4th ed.
Philadelphia, PA: Mosby Elsevier, 2009: 45-46.

34
Q

How do nitroglycerin and nitroprusside affect uterine

blood flow?

A

Both nitroprusside and nitroglycerin are occasionally used for
the control of severe hypertension in parturients, however, the
vasodilation they produce offsets the reduction in blood
pressure and uterine blood flow is not decreased.
Chestnut DH, Polley LS, Tsen LC, Wong, CA. Chestnut’s
Obstetric Anesthesia: Principles and Practice. 4th ed.
Philadelphia, PA: Mosby Elsevier, 2009: 45-46.

35
Q

How does magenesium affect uterine blood flow?

A

Magnesium increases uterine blood flow in both hypertensive
and normotensive subjects. Even though it may magnify
hypotension in patients undergoing epidural anesthesia,
magnesium still maintains blood flow to the uterus.
Chestnut DH, Polley LS, Tsen LC, Wong, CA. Chestnut’s
Obstetric Anesthesia: Principles and Practice. 4th ed.
Philadelphia, PA: Mosby Elsevier, 2009: 45-46.

36
Q

Does warfarin cross the placenta? Enoxaparin?

A

Warfarin does cross the placenta and is associated with an
increased risk for fetal demise and congenital defects. Low
molecular weight heparins such as enoxaparin do not cross the
placenta in significant amounts, nor do they alter fetal anti-IIa or
anti-Xa activity.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
68.

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