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6903 - Special Populations > Obstetric Pt > Flashcards

Obstetric Pt Flashcards

1
Q

explain dilutional anemia w pregnancy 3rd semester normal hgb 11-12g/dL

A

blood volume increases ~40% plasma volume increases ~50% RBC volume only increases ~20% progesterone and estrogen activate RAAS, which causes water retention.

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2
Q

pregnancy increases which factors?

A

VII, VIII, IX, and fibrinogen (I). fibrinolysis activity decreases. platelets stay the same. end result is a hypercoagulable pt.

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3
Q

WBC in 3rd trimester

A

can get up to 30,000mm during labor

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4
Q

airway changes

A

glottic lumen narrows due to swelling edema makes tissues more prone to bleeding use smaller tube 6.0 ETT use shorter handle to not hit breast tissue

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5
Q

O2 consumption

A

33% higher just before labor. 100% higher w labor

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6
Q

GI: progesterone causes..

A

-GI smooth muscle relaxation - delayed gastric emptying -increased risk of gallbladder disease (progesterone inhibits SM, so can’t clear from the gallbladder leading to biliary stasis)

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7
Q

renal

A

-increased CO leads to increase in GFR and CC -BUN lowers to 8mg/dL -creat lowers to 0.5mg/dL -glucose in urine bc absorption can’t keep up w flow -trace protein in urine for same reason -uterus can compress the ureter and cause urinary obstruction

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8
Q

uterine blood flow at term

A

800mL/min (10% CO) most ends up in intervillous space

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9
Q

molecular weight to cross

A

>1000 daltons cross poorly. most anesthetic drugs are <500Da and cross readily.

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10
Q

stages of labor stage 1

A

cervical dilation in response to REGULAR uterine contractions effacement occurs (softening, shortening, and thinning of cervix)

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11
Q

stages of labor stage 2

A

full cervical dilation to delivery of fetus

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12
Q

stages of labor stage 3

A

includes delivery of the the placenta

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13
Q

3 Ps of successful vaginal delivery

A

powers-uterine contractions

passenger-fetal positioning to get into position

passage-bony pelvis shape, relaxation and soft tissue relaxation

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14
Q

parenteral opioid effects

A

spinal and supraspinal effects

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15
Q

neuraxial opioid effects

A

bind in substantia geltinosa (Rexed lamina II) in dorsal horn of spinal cord

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16
Q

normal magnesium level

A

1.7-2.4

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17
Q

Therapeutic Magnesium level

A

5-9

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18
Q

Mag level when patellar reflexes are lost

A

12

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19
Q

mag level when respiratory arrest

A

15-20

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20
Q

mag level when cardiac arrest

A

>25

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21
Q

Mag MOA

A

*competitive antagonist of calcium. Also decreases release of Ach at NMJ and sensitivity of motor endplate to Ach

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22
Q

unwanted fetal effects from indomethacin (3)

A

premature closure of ductus arteriosus, pulm htn, low amniotic fluid levels

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23
Q

MAC level when uterine atony becomes a concern

A

MAC >0.5

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24
Q

G T P A L

A

G-Gravidity T-term births P-preterm births A-abortion (spontaneous/elective) L-living children

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25
distance from skin to epidural space in a thin pt
3cm if thin
26
distance from skin to epidural space in an adult
4-6cm in adult
27
distance from skin to epidural space in an obese pt
up to 8 cm
28
duration of a spinal
\<2hours why they are rarely used for labor
29
levels that epidurals are inserted
L2-3 or L3-4
30
epidural analgesia dosing
8-12mL/hour up to 15mL/hour
31
volume for epidural boluses
6-10mL
32
spinal dose (volume)
1.6mL+/- opioid
33
neuraxial opioids act where
on the substantia geltinosa in the dorsal horn of the spinal cord (Mu receptors)
34
uncomplicated C-section blood loss
500-1000mL EBL amniotic fluid is usually 700 counted in the EBL
35
Why can't chronic HTN be managed w ACE inhibitors?
they cause renal damage in pregnancy and congenital abnormalities in the fetus.
36
what is a molar pregnancy
absence of a fetus w placental formation (can still cause preeclampsia)
37
HELLP syndrome
Hemolysis, Elevated LFTs, Low Platelets, other S/S:epigastric pain, jaundice, N/V. Hepatic rupture is rare and indicates immediate delivery needed
38
eclampsia
when seizures are present
39
platelet cut off for neuraxial for preeclamptic pts
80,000
40
what is the defn. of antepartum hemorrhage?
vaginal bleeding after 24 weeks gestation and into immediate postpartum period
41
how much bleeding occurs in postpartum hemorrhage?
\>500mL vaginal delivery or \>1000mL cesarian
42
what is 80% of post-partum hemorrhage from?
uterine atony
43
what are atony risks?
multiparity, prolonged oxytocin infusions, polyhydramnios
44
placenta previa s/s
PAINLESS vaginal bleeding significant blood loss
45
What is Vasa Previa?
fetal vessels implanted on cervical OS fetal mortality 70% rupture of vessels is emergency rare
46
placenta accreta
abnormal growth of the placenta ONTO the myometrium most common
47
placenta increta
abnormal growth of the placenta INTO the myometrium
48
placenta percreta
abnormal growth of the placenta into other non-uterine structures
49
LBW
\<2500g (5lb, 8 oz)
50
VLBW
\<1500g (3lb, 4oz)
51
ELBW extremely LBW
\<1000g (2lb, 3 oz)
52
What is a normal fetal heart rate?
110-160 BPM
53
FHR variability
best indicator of fetal wellbeing nervous system responses to adjust the HR up or down represents a functional nervous system
54
moderate variabiliity on fetal HR monitoring
5-25bpm
55
increase/decrease HR CO SV SVR MAP (SBP, DBP)
HR = increase CO = increase SV = increase SVR = decrease MAP = decrease SBP = decrease a little DBP = decrease more
56
Postpartum CO
-increases because great vessels in abdomen are no longer compressed allowing for increased venous return
57
Why does CO change?
-increase in HR + SV (larger effect)
58
increase of decrease of RASS activation?
increase
59
EKG changes
-left axis deviation (3rd trimester), right axis deviation (1st trimester) -shortened PR and QTc
60
aortocaval compression
-supine position starting at 20 weeks -treatment is left uterine displacement
61
increase/decrease Minute Ventilation FRC ERV RV CC dead space
Minute Ventilation = increase due to tidal volume FRC = decrease ERV = decrease RV = decrease CC = same dead space = increase
62
respiratory blood gas
compensated metabolic alkalosis
63
nervous system changes
-increased SNS -increased sensitivity to LA and GA
64
liver
-enzymes increase -albumin level decrease -cholinesterase activity decreases
65
spiral arteries
-terminal arteries that spill into the intervillous space
66
do maternal and fetal blood interact (touch)?
-no
67
differences in fetal circulation
-foramen ovale -ductus arteriosus -ductus venosus (shunt in liver) -umbilical artery(2)/vein
68
factors affecting placental drug transfer to fetus
-concentration gradient -molecular weight (\<1000 Daltons) -lipid solubility -ionization
69
fetal circulation factors affecting placental drug transfer to fetus
-diluted in intervillous blood -redistributed -fetal first-pass effect -fetal shunt
70
drugs that don't cross the placenta
-glycopyrrolate -anticoagulants -muscle relaxants -sugammadex -insulin
71
progesterone
promotes smooth muscle relaxation
72
oxytocin
-promotes smooth muscle contraction -prostaglandin production
73
labor stage 1 - pain
-due to cervical distention, stretching lower uterine segment, myometrial ischemia -T10-L1 -unmyelinated C-fibers -poorly localized visceral pain
74
labor stage 2 - pain
-due to stretching/distension of pelvic floor, vagina, perineum -pudendal nerves, S2-S4 -myelinated
75
pregnancy pharmacology risk categories
A: controlled studies demonstrate no risk B: controlled animal studies demonstrate no risk C: studies have revealed adverse effects on fetus D: fetal risk but benefit outweighs risk X: known fetal abnormalities
76
MAC for pregnant women
-reduced up to 40%
77
first line treatment for hypotension
phenylephrine
78
most common sign of hypotension in spinal anesthesia
maternal nausea/vomiting
79
Uterotonics
-methergine: avoid in HTN, preeclampsia, PVD, ischemic heart disease -prostaglandin E3: avoid in asthma, glaucoma, renal/pulmonary/hepatic disease -prostaglandin E1: given for uterine atony, side effects - malaise -prostaglandin F2a: side effects bronchospasm, increase PVR, PHTN -oxytocin: increases strength + frequency of contractions, side effects - hypotension from preservative, water intoxication
80
Tocolytics
-calcium channel blockers -magnesium sulfate - competitive antagonist of calcium, increases sensitivity to NMB -nitroglycerin
81
local anesthetics: amines vs ester
amines: two i's in name, metabolized by liver ester: one i in name, metabolized by cholinesterase
82
local anesthetics: bupivacaine
-long, sensory\>motor -0.0625%-0.125% -black box = 0.75% -preferentially bind to cardiac receptors leading to refractory cardiac arrest
83
local anesthetics: ropivacaine
-long, sensory\>motor -less cardiotoxic than bupivacaine -0.1%-0.2%
84
local anesthetics: lidocaine
-transient neurological symptoms -subarachnoid space administration potentially neurotoxic -metabolites that can cause seizures
85
local anesthetics: 2-chloroprocaine
-rapid onset, short duration (epidural use) -reduces effectiveness of opioids
86
neural axial opioids: respiratory monitoring
-lipophilic = 2 hours -hydrophilic = 12 hours
87
neural axial opioids: side effects
-less complete analgesia -perineal tone maintained -pruritus -nausea/vomiting -sedation -respiratory depression
88
neural axial opioids: morphine
-less lipophilic -may cause HSV reactivation
89
neural axial opioids: dosing
-epidural bolus = similar to IV dose -intrathecal = 1/10 of epidural dose
90
local anesthetic test doses
-use to confirm non-vascular, non-sub arachnoid placement -aspiration -3 mL test dose between contractions (1.5% lidocaine, 1:200,000 epinephrine)
91
neuroaxial complications: most common drugs
bupivacaine \> ropivacaine \> levobupivacaine \> lidocaine \> 2-chloroprocaine
92
neuroaxial complications: treatment
-stop drug, administer O2, support ventilation -20% lipid therapy 1.5 mL/kg over 1 minute than 0.25-0.5 mL/kg/min infusion -anticonvulsants (not cardiac depressing) -avoid vasopressin, BB, CCB, LA
93
post dural puncture headache: risks
-large bore needle -younger age -bevel orientation -beveled cutting needles -inexperienced operator -air for loss of resistance syringe
94
post dural puncture headache: treatment
-bed rest -caffeine -oral analgesia -epidural saline -epidural blood patch -sphenopalatine ganglion block
95
optimal timeframe between induction and delivery of fetus
-3 minutes -patient draped and surgeon ready before induction
96
MAC level necessary to avoid anesthesia awareness
0.8
97
c-section: necessary epidural level
T4
98
c-section: epidural volume
1-2 mL per dermatome level
99
c-section: blood loss
-500-1000 mL -amniotic fluid is counted in blood loss (300-1500 mL)
100
pre-eclampsia criteria
-HTN -proteinuria -non-dependent edema (+/-) \*must be greater than 20 weeks pregnant
101
pre-eclampsia treatment
-definitive=delivery -corticosteroids (infant lungs) -magnesium sulfate -labetalol, esmolol
102
pre-eclampsia anesthesia considerations
-prefer neuraxial -laryngoscopy risk -avoid opioids before delivery -usually remain hypertensive throughout
103
what is polyhydramnios?
too much amniotic fluid
104
fetal hgb maternal hbg
fetal 15 maternal 12

6903 - Special Populations (16 decks)

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