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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
Q

distance from skin to epidural space in a thin pt

A

3cm if thin

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26
Q

distance from skin to epidural space in an adult

A

4-6cm in adult

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27
Q

distance from skin to epidural space in an obese pt

A

up to 8 cm

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28
Q

duration of a spinal

A

<2hours why they are rarely used for labor

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29
Q

levels that epidurals are inserted

A

L2-3 or L3-4

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30
Q

epidural analgesia dosing

A

8-12mL/hour up to 15mL/hour

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31
Q

volume for epidural boluses

A

6-10mL

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32
Q

spinal dose (volume)

A

1.6mL+/- opioid

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33
Q

neuraxial opioids act where

A

on the substantia geltinosa in the dorsal horn of the spinal cord (Mu receptors)

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34
Q

uncomplicated C-section blood loss

A

500-1000mL EBL amniotic fluid is usually 700 counted in the EBL

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35
Q

Why can’t chronic HTN be managed w ACE inhibitors?

A

they cause renal damage in pregnancy and congenital abnormalities in the fetus.

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36
Q

what is a molar pregnancy

A

absence of a fetus w placental formation (can still cause preeclampsia)

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37
Q

HELLP syndrome

A

Hemolysis, Elevated LFTs, Low Platelets, other S/S:epigastric pain, jaundice, N/V. Hepatic rupture is rare and indicates immediate delivery needed

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38
Q

eclampsia

A

when seizures are present

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39
Q

platelet cut off for neuraxial for preeclamptic pts

A

80,000

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40
Q

what is the defn. of antepartum hemorrhage?

A

vaginal bleeding after 24 weeks gestation and into immediate postpartum period

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41
Q

how much bleeding occurs in postpartum hemorrhage?

A

>500mL vaginal delivery or >1000mL cesarian

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42
Q

what is 80% of post-partum hemorrhage from?

A

uterine atony

43
Q

what are atony risks?

A

multiparity, prolonged oxytocin infusions, polyhydramnios

44
Q

placenta previa s/s

A

PAINLESS vaginal bleeding significant blood loss

45
Q

What is Vasa Previa?

A

fetal vessels implanted on cervical OS fetal mortality 70% rupture of vessels is emergency rare

46
Q

placenta accreta

A

abnormal growth of the placenta ONTO the myometrium most common

47
Q

placenta increta

A

abnormal growth of the placenta INTO the myometrium

48
Q

placenta percreta

A

abnormal growth of the placenta into other non-uterine structures

49
Q

LBW

A

<2500g (5lb, 8 oz)

50
Q

VLBW

A

<1500g (3lb, 4oz)

51
Q

ELBW extremely LBW

A

<1000g (2lb, 3 oz)

52
Q

What is a normal fetal heart rate?

A

110-160 BPM

53
Q

FHR variability

A

best indicator of fetal wellbeing nervous system responses to adjust the HR up or down represents a functional nervous system

54
Q

moderate variabiliity on fetal HR monitoring

A

5-25bpm

55
Q

increase/decrease HR CO SV SVR MAP (SBP, DBP)

A

HR = increase

CO = increase

SV = increase

SVR = decrease

MAP = decrease

SBP = decrease a little

DBP = decrease more

56
Q

Postpartum CO

A

-increases because great vessels in abdomen are no longer compressed allowing for increased venous return

57
Q

Why does CO change?

A

-increase in HR + SV (larger effect)

58
Q

increase of decrease of RASS activation?

A

increase

59
Q

EKG changes

A

-left axis deviation (3rd trimester), right axis deviation (1st trimester) -shortened PR and QTc

60
Q

aortocaval compression

A

-supine position starting at 20 weeks -treatment is left uterine displacement

61
Q

increase/decrease Minute Ventilation FRC ERV RV CC dead space

A

Minute Ventilation = increase due to tidal volume FRC = decrease ERV = decrease RV = decrease CC = same dead space = increase

62
Q

respiratory blood gas

A

compensated metabolic alkalosis

63
Q

nervous system changes

A

-increased SNS -increased sensitivity to LA and GA

64
Q

liver

A

-enzymes increase -albumin level decrease -cholinesterase activity decreases

65
Q

spiral arteries

A

-terminal arteries that spill into the intervillous space

66
Q

do maternal and fetal blood interact (touch)?

A

-no

67
Q

differences in fetal circulation

A

-foramen ovale -ductus arteriosus -ductus venosus (shunt in liver) -umbilical artery(2)/vein

68
Q

factors affecting placental drug transfer to fetus

A

-concentration gradient -molecular weight (<1000 Daltons) -lipid solubility -ionization

69
Q

fetal circulation factors affecting placental drug transfer to fetus

A

-diluted in intervillous blood -redistributed -fetal first-pass effect -fetal shunt

70
Q

drugs that don’t cross the placenta

A

-glycopyrrolate -anticoagulants -muscle relaxants -sugammadex -insulin

71
Q

progesterone

A

promotes smooth muscle relaxation

72
Q

oxytocin

A

-promotes smooth muscle contraction -prostaglandin production

73
Q

labor stage 1 - pain

A

-due to cervical distention, stretching lower uterine segment, myometrial ischemia -T10-L1 -unmyelinated C-fibers -poorly localized visceral pain

74
Q

labor stage 2 - pain

A

-due to stretching/distension of pelvic floor, vagina, perineum -pudendal nerves, S2-S4 -myelinated

75
Q

pregnancy pharmacology risk categories

A

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
Q

MAC for pregnant women

A

-reduced up to 40%

77
Q

first line treatment for hypotension

A

phenylephrine

78
Q

most common sign of hypotension in spinal anesthesia

A

maternal nausea/vomiting

79
Q

Uterotonics

A

-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
Q

Tocolytics

A

-calcium channel blockers -magnesium sulfate - competitive antagonist of calcium, increases sensitivity to NMB -nitroglycerin

81
Q

local anesthetics: amines vs ester

A

amines: two i’s in name, metabolized by liver ester: one i in name, metabolized by cholinesterase

82
Q

local anesthetics: bupivacaine

A

-long, sensory>motor -0.0625%-0.125% -black box = 0.75% -preferentially bind to cardiac receptors leading to refractory cardiac arrest

83
Q

local anesthetics: ropivacaine

A

-long, sensory>motor -less cardiotoxic than bupivacaine -0.1%-0.2%

84
Q

local anesthetics: lidocaine

A

-transient neurological symptoms -subarachnoid space administration potentially neurotoxic -metabolites that can cause seizures

85
Q

local anesthetics: 2-chloroprocaine

A

-rapid onset, short duration (epidural use) -reduces effectiveness of opioids

86
Q

neural axial opioids: respiratory monitoring

A

-lipophilic = 2 hours -hydrophilic = 12 hours

87
Q

neural axial opioids: side effects

A

-less complete analgesia -perineal tone maintained -pruritus -nausea/vomiting -sedation -respiratory depression

88
Q

neural axial opioids: morphine

A

-less lipophilic -may cause HSV reactivation

89
Q

neural axial opioids: dosing

A

-epidural bolus = similar to IV dose -intrathecal = 1/10 of epidural dose

90
Q

local anesthetic test doses

A

-use to confirm non-vascular, non-sub arachnoid placement -aspiration -3 mL test dose between contractions (1.5% lidocaine, 1:200,000 epinephrine)

91
Q

neuroaxial complications: most common drugs

A

bupivacaine > ropivacaine > levobupivacaine > lidocaine > 2-chloroprocaine

92
Q

neuroaxial complications: treatment

A

-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
Q

post dural puncture headache: risks

A

-large bore needle -younger age -bevel orientation -beveled cutting needles -inexperienced operator -air for loss of resistance syringe

94
Q

post dural puncture headache: treatment

A

-bed rest -caffeine -oral analgesia -epidural saline -epidural blood patch -sphenopalatine ganglion block

95
Q

optimal timeframe between induction and delivery of fetus

A

-3 minutes -patient draped and surgeon ready before induction

96
Q

MAC level necessary to avoid anesthesia awareness

A

0.8

97
Q

c-section: necessary epidural level

A

T4

98
Q

c-section: epidural volume

A

1-2 mL per dermatome level

99
Q

c-section: blood loss

A

-500-1000 mL -amniotic fluid is counted in blood loss (300-1500 mL)

100
Q

pre-eclampsia criteria

A

-HTN -proteinuria -non-dependent edema (+/-) *must be greater than 20 weeks pregnant

101
Q

pre-eclampsia treatment

A

-definitive=delivery -corticosteroids (infant lungs) -magnesium sulfate -labetalol, esmolol

102
Q

pre-eclampsia anesthesia considerations

A

-prefer neuraxial -laryngoscopy risk -avoid opioids before delivery -usually remain hypertensive throughout

103
Q

what is polyhydramnios?

A

too much amniotic fluid

104
Q

fetal hgb

maternal hbg

A

fetal 15

maternal 12

6903 - Special Populations (16 decks)

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