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Apex > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

How does the airway change in the parturient?

A

Increased mallampati score
Diff intubation is 8x higher
Glottic opening is narrowed (smaller tube)
Datta handle (shorter) is useful
Tissue in nasapharynx is friable
Increased airway edema

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2
Q

What hormone relaxes the ligaments in the rib cage?

A

Relaxin

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3
Q

How is the lung affected in the parturient?

A

Decreased FRC
Increased O2 consumption ~ onset of hypoxemia is quick
Airway closure during tidal breathing.

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4
Q

Which hormone is a resp stimulant?

A

Progesterone

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5
Q

What is the ABG for a parturient?

A

pH ~ normal
PaCO2 ~ decreased (30ish)
PaO2 ~ ^ 105ish
HCO3 ~ decreased (20ish)

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6
Q

How does the OxyHgb dissociation curve shift?

A

Increase in P50 > shift to the right

***facilitates transfer of O2 to fetus

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7
Q

How does minute vent change in the parturient?

A

Increase in tidal volume
Increase in resp rate

**overall increase in minute ventilation

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8
Q

How do lung capacities change in the parturient?

A

TLC ~ decreased
VC ~ no change
FRC ~deceased
Expiratory reserve ~ decreased
Residual volume ~ decreased
Closing capacity ~ no change

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9
Q

How does the oxygen consumption change for the parturient?

A

Term: 20%
First stage of labor: 40%
Second stage of labor: 75%

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10
Q

How does O2 consumption change for the parturient?

A

Increases 20%

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11
Q

How does cardiac output change for the parturient?

A

Increased by 40%
HR ~ ^
SV ~ ^

***CO during labor is different
1st stage: 20%
2nd stage: 50%
3 stage: 80% (auto transfusion from placenta)

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12
Q

How does BP change for the parturient?

A

MAP ~ no change
SBP ~ no change
DBP ~ decreased

Increased in volume + decrease in SVR = net effect

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13
Q

How does vascular resistance change in the parturient?

A

Decreased SVR and PVR

***progesterone increases nitric oxide

(They have a decreased response to angiotensin and NE!!)

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14
Q

How do filling pressure change for the parturient?

A

No change due to compensatory vascular changes

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15
Q

How does the cardiac axis change in the parturient?

A

Left deviation

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16
Q

At what point should we displace the parturient mother’s right torso to relieve aortocaval compression?

A

2nd or 3rd trimester

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17
Q

How does the intravascular fluid change for the parturient?

A

Increased by 35%

  • increased plasma
  • increase RBCs

**this prepares mom for hemorrhage with labor

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18
Q

How does the hematological system change for the parturient?

A

Pregnancy causes HYPER-COAGULABLE state

Clotting factors: increased (1, 7, 8, 9, 10, 12)
Decreased antithrombin
Decreased protein S

Increased fibrin breakdown
Decreased 11 and 13

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19
Q

What is the bottom line for the parturient and her hematological state?

A

Mom makes more clot, BUT she also breaks it down faster

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20
Q

what are the neurological changes with pregnancy?

A

Decreased MAC
Increased sensitivity to local anesthetics ~ decreased epidural space and increased epidural vein volume

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21
Q

What are the GI changes in the parturient?

A

Increased gastric volume
Decreased gastric pH
Decreased sphincter tone
Decreased gastric emptying (after labor begins)

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22
Q

How is the renal system affected in the parturient?

A

Increased GFR (blood volume)
Increased creatinine clearance (blood volume)
Increased glucose in urine (d/t increased GFR)

**decreased creatinine and BUN (d/t increased creatinine clearance) obvs!!

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23
Q

What is uterine blood flow?

A

700-900 mL/min

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24
Q

How does preganancy affect serum albumin?

A

Decreases

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25
Q

How does pregnancy affect pseudocholinesterase?

A

Decreases (but not meaningful for sux)

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26
Q

Is uterine blood flow autoregulates?

A

NO!! Dependent on maternal MAP, CO, and uterine vascular resistance

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27
Q

What % of cardiac output is uterine blood flow in the parturient?

A

10%

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28
Q

What does new research say about neo for pregnant moms?

A

It’s just as good as ephedrine with LESS fetal acidosis

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29
Q

What type of meds can easily transfer via the placenta?

A

Local ansthetics
IV anesthetics
Volatile anesthetics
Opioids
Benzos
Atropine
Beta-blockers
Mag

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30
Q

What types of meds can’t transfer the placenta?

A

NMB
Heparin
Insulin
Glyco

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31
Q

When does the first stage of labor begin/end?

A

Begins: cervical dilation
Ends: full cervical dilation (10 cm)

**divided into latent and active phase

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32
Q

When does the second stage of labor begin?

A

Begin: with full cervical dilation
Ends: the delivery of the newborn

**pain in the perineum begins here!

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33
Q

When does the third stage of labor begin/end?

A

Begin: delivery of the newborn
End: delivery of the placenta

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34
Q

What do the cervical dilation in the latent phase?

A

Latent phase ends when cervix is 2-3 cm dilated

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35
Q

What is the cervical dilation in the active phase?

A

Active phase occurs when cervix is 3-10 cm dilated

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36
Q

When is a laboring mom considered a full stomach?

A

Always!!!

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37
Q

When can a laboring mother who is healthy drink?

A

Moderate amount of clear liquids throughout labor

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38
Q

When can a laboring mother who is healthy eat food?

A

Up until a neuraxial block is placed

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39
Q

Does an epidural prolong first stage of labor?

A

NO!

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40
Q

Does an epidural increase the need for a c-section?

A

NO!

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41
Q

Where is the pain located in the first stage of labor?

A

T10-L1

Lower uterine segment and the cervix

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42
Q

Where is the pain located during the second stage of labor?

A

S2-S4

In addition of pain from vagina, perineum, and pelvic floor

Neuraxial techniques must be extended to cover S2-S4 range

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43
Q

What are appropriate regional techniques for the first stage of labor? I.e. T10-L1

A

Epidural
Paravertebral lumbar block
Paracervical block (high risk of fetal bradycardia)

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44
Q

What are appropriate anesthetic techniques for the second stage of labor? S2-S4

A

Neuraxial or Pudendal nerve block

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45
Q

What are some consequences of uncontrolled pain?

A

Increased maternal catecholamines > hypertension and reduced uterine blood flow

Maternal hyperventilation > alkalosis > leftward shift > decreased delivery of O2 to the fetus

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46
Q

What is the most common CSE approach?

A

“Needle through the needle”

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47
Q

What is the epidural volume extension technique?

A

Injection of saline into the epidural space immediately after the local anesthetic is administered into the subarachnoid space

*compresses subarachnoid space ~ enhances rostral spread

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48
Q

Does Nitrous 50/50 (50% O2) affect uterine contractility?

A

It doesn’t!

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49
Q

Which local anesthetic reduces the efficacies of epidural morphine?

A

2-Chloroprocaine ~ antagonizes Mu and kappa receptors

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50
Q

What is a pure S-enantiomer of Bupivacaine?

A

Levobupivacaine

Less CV toxicity (not available in US though) :(

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51
Q

Which local anesthetic is useful in emergency c/s when epidural is ALREADY in place?

A

2-Chloroprocaine

Min. Placental transfer

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52
Q

Why is lidocaine not popular for labor analgesia?

A

Very strong motor block, BUT it’s great for C/S

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53
Q

Which enantiomer of Bupivacaine is associated with cardio toxicity?

A

R-enantiomer.

0.75% contraindicated via epidural due to risk of toxicity!

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54
Q

What 3 things do neuraxial opioids have!

A

No loss of proprioception
No Sympathectomy
Do not impair mom’s ability to push

55
Q

Which opioid has local anesthetic properties?

A

Meperidine

56
Q

What are the three main ways a patient can develop a total spinal?

A

An epidural dose is injected into the subarachnoid space

An epidural dose is injected into the subdural space

A single shot spinal after a failed epidural block

57
Q

Which accidental epidural catheter placement will neither a test dose or catheter aspiration rule out?

A

SubDURAL injection!

Rare but possible

58
Q

With a subdural injection, how long will it take for the patient to experience symptoms?

A

10-25 mins

59
Q

What is the tx for a high spinal?

A

Vasopressors
IVF
Left uterine displacement
Leg elevation
Intubation if patient is unable to protect airway!

60
Q

What is a normal fetal HR?

A

110-160

61
Q

What is a bradycardia fetal heart rate?

A

< 110

Maternal: Hypoxemia
Drugs that decrease uteri placental perfusion

Fetal: asphyxia, acidosis

62
Q

What is a tachycardic fetal rate?

A

> 160

Maternal: fever, chorioamnionitis, atropine, ephedrine, and terbutaline
Fetal: hypoxemia, arrhythmias

63
Q

What are early decelerations related to?

A

Head compression (no risk for fetal hypoxemia)

64
Q

What are late decelerations associated with?

A

Uteroplacental insufficiency

(Maternal hypotension, hypovolemia, acidosis, preeclampsia)

*risk for fetal hypoxemia

65
Q

What are variable decelerations associated with?

A

Umbilical cord compression

*Risk for fetal hypoxemia

66
Q

What is the mnemonic VEAL CHOP

A

Variable decels ~ Cord compression
Early decels ~ Head compression
Accelerations ~ Ok/ give O2
Late decels ~ Placental insufficiency

67
Q

In a category 3 patient (assessing for fetal heart rate), what are some findings?

A

***significant threat to fetal oxygenation!

Bradycardia
Absent baseline variability
Recurrent late decelerations
Recurrent variable decelerations
SINUSOIDAL pattern.

68
Q

Does someone who is trained in fetal monitoring must monitor and document fetal status before and after any anesthetic procedure?

A

Yes

69
Q

What is the leading cause of perinatal morbidity and mortality?

A

Premature delivery

70
Q

What are the main complications (to the fetus) with a premature delivery?

A

Resp distress
Intraventricular hemorrhage
NEC
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia

71
Q

What are tocolytics used for?

A

To ultimately delay labor by suppressing uterine contractions (up to 24-48 hours).

**they provide a bridge that allows the corticosteroids time to work

72
Q

How do beta-2 agonists affect premature labor?

A

Beta 2 stimulation increases intracellular cAMP ~ this turns off myosin light chain kinase > results in uterine RELAXATION

73
Q

What are the side effects of Beta-2 Agonists used during premature labor?

A

Beta-2 agonists:
Hyperglycemia ~ baby at risk for hypo!
Fetal tachycardia
Hypokalemia

74
Q

How does Magnesium affect premature labor? MOA

A

Calcium antagonist ~ relaxes smooth muscle by turning off myosin light-chain kinase in the vascular, airway, and uterus. Also hyperpolarizes membranes I’m excitable tissue

75
Q

What is a normal mg level?

A

2 mg/dL

76
Q

At what mg level would you have drowsiness and lethargy?

A

5ish

77
Q

At what mg level would you have loss of deep tendon reflexes, hypotension and somnolence?

A

10ish mg/dL

78
Q

at what mg level do you have resp depression , apnea, and cardiac arrest/block?

A

> 12 mg/dL

79
Q

How does mg affect NMB?

A

Potentiates skeletal muscle weakness

80
Q

What are the treatments to HYPERmagnesemia?

A

Support
Diuretics (excretion of mg)
IV calcium gluconate

81
Q

How do calcium channel blocks affect premature delivery?

A

Block influx of Ca into uterine muscle > reduces Ca release from SR > relaxes muscle

82
Q

What is the first-line CCB used for premature labor?

A

Nifedipine

83
Q

What is premature delivery?

A

Delivery < 37 weeks or less than 259 days

84
Q

What is the dose of methergine?

A

0.2 mg

IT SHOULD ALWAYS BE GIVEN IM
**IV admin is associated with severe HTN

85
Q

What is oxytocin?

A

Uterotonic that is synthesized in the paraventricular nuclei of the hypothalamus.

***stored and released from posterior pituitary

86
Q

What are the clinical uses of oxytocin?

A

Induction
Uterine hypotonia
Hemorrhage

87
Q

When is oxytocin administered during a C/S?

A

After delivery of placenta

88
Q

What are the side effects of oxytocin?

A

Water retention (similar to ADH), Hyponatremia, hypotension, reflex tachycardia, and coronary vasoconstriction

***rapid IV can cause cardiovascular collapse

89
Q

What is methergine?

A

Ergot Alkaloid
Second line uterotonic!

IV administration can cause significant vasoconstriction, HTN and cerebral hemorrhage

90
Q

What is Prostaglandin F2 (Hemabate or Carboprost)?

A

Third line uterotonic
Dose: 250 mcg IM or injected into uterus

91
Q

What are the side effects of prostaglandin F2?

A

Hemabate!

Bronchospasm, N&V, hypotension, hypertension

92
Q

In what conditions is a general anesthetic more appropriate that a regional technique for C/S?

A

Maternal hemorrhage
Fetal distress
Coagulopathy
Pt refusal of regional
Contraindications to regional

93
Q

What are the benefits of general anesthesia?

A

Fast onset
Secured airway
Greater Hemodynamic stability

94
Q

What are the downsides of general anesthetia for a C/S?

A

Difficult mask
Difficult intubation
Risk of aspiration
Potential MH
Neonatal resp and CNS depression

95
Q

What is the most common cause of maternal death in a parturient undergoing C/S?

A

Failure to manage the airway

96
Q

What is the triple prophylaxis given for parturients undergoing a C/S?

A

Sodium citrate
H2 receptor antagonist (ranitidine)
Gastrokinectic agent (Reglan)

97
Q

What is the recommended time frame between uterine incision and delivery?

A

3 minutes.

Anything beyond that increases the risk of fetal acidosis

98
Q

What is the best trimester for surgery in the pregnant patient?

A

2nd trimester

99
Q

When is teratogenicity the highest?

A

During organogenesis (day 13-60)

100
Q

At what gestation are pregnant women considered a “full stomach”?

A

18-20

101
Q

When should the antiemetics prior to a C/S be given?

A

Sodium citrate ~ 30 mins
H2 antagonist ~ 1 hours
Gastric prokinetic ~ 1 hour before induction

102
Q

Why should you avoid NSAIDs after the first trimester?

A

The potentially close the ductus arteriosus

103
Q

When considering obstetric HTN disorders, what is chronic HTN?

A

Occurs before 20 weeks gestation and do NOT return to normal after delivery.

104
Q

When considering obstetric HTN disorders, what is gestational HTN?

A

Occurs after 20 wks
Proteinuria does NOT occur

**Patient returns to normotensive state

105
Q

When considering obstetric HTN disorders, what is preeclampsia?

A

HTN ( mild > 140/90 or severe > 160/110) that develops AFTER 29 weeks

+ proteinuria

(Or if the patient has any of the following:)
RUQ pain
CNS symptoms (headache)
Fetal growth restriction
Thrombocytopenia
Elevated serum liver enzymes

106
Q

When does severe preeclampsia occur?

A

BP > 160/110

107
Q

When does eclampsia occur?

A

When the mother with preeclampsia develops seizures

108
Q

What does a healthy placenta produce in equal amounts? What does a patient with preeclampsia produce instead?

A

Healthy: thromboxane = prostacyclin

Preeclampsia: thromboxane > prostacyclin

109
Q

What are some key complications associated with preeclampsia?

A

Heart failure
Pulmonary edema
Intracranial hemorrhage
Cerebral edema
DIC
Proteinuria

110
Q

What is the definite treatment for preeclampsia and eclampsia?

A

Delivery of the fetus and placenta

111
Q

with preeclampsia, when are the risks for pulmonary HTN and stroke the highest?

A

Postpartum period

112
Q

What is HELLP syndrome?

A

Hemolysis
Elevated-Liver enzymes
Low- Platelet

113
Q

What is the definitely treatment for HELLP syndrome?

A

Delivery of the fetus

114
Q

What is cocaine abuse associated with?

A

Low platelet count

115
Q

What is placenta previa?

A

Placenta covers the cervical os

116
Q

What is placenta accrete?

A

Placenta attaches to the surface of the myometrium

117
Q

What is placenta increta?

A

Placenta that invades the myometrium

118
Q

What is placenta percreta?

A

Placenta extends beyond the uterus

119
Q

What is the mnemonic for the categories of placenta previa?

A

“PAIN in the Pussy” in increasing severity

Previa: first ~ just covers is
Accreta ~ myometrium surface
Increta ~ invades “inside” myometrium
Percreta ~ goes beyond the “pussy”

120
Q

What is associated with PAINLESS bleeding?

A

Placenta previa

Will probs require a c-section

121
Q

What is placental abruption?

A

PAINFUL bleeding
Placenta has separated from the uterine wall.

***can result in maternal hemorrhage!!!

Risk factors: HTN, preeclampsia, PIH, cocaine, smoking, ETOH

Will need C/S

122
Q

What is the most common cause of postpartum hemorrhage?

A

Uterine atony

123
Q

What are the risk factors to uterine atony?

A

Multiparity
Multiple gestation
Polyhydramnios
Prolonged oxytocin infusion

124
Q

What medications is used for the retrieval of retained placenta/placenta fragments?

A

IV nitroglycerin

125
Q

What 3 things is DIC associated with in the parturient?

A

Amniotic fluid embolism
Placenta abruption
Intrauterine demise

126
Q

What are the apgar score for fetal heart rate?

A

0 ~ none
1 ~ < 100
2 ~ > 100

127
Q

What are the apgar score for resp rate?

A

0 ~ absent
1 ~ slow, irregular
2~ normal, crying

128
Q

What are the apgar score for muscle tone?

A

0 ~ limp
1 ~ some flexion
2~ active motion

129
Q

What are the apgar score for reflex irritability?

A

0 ~ absent
1 ~ grimace
2 ~ cough, sneeze, cry

130
Q

What are the apgar score for color?

A

0 ~ pale, blue
1~ pink body, blue extremities
2~ completely pink!

131
Q

What is a normal fetal resp rate?

A

30-60

132
Q

What is a normal fetal HR?

A

120-160

133
Q

What is a NORMAL SpO2 after delivery?

A

60%

***it should rise to 90% after 10 mins

134
Q

What is the BEST indicator of adequate ventilation?

A

Resolution of bradycardia

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