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AP Summer > Obstetrics: Anesthesia for Complicated Pregnancy > Flashcards

Obstetrics: Anesthesia for Complicated Pregnancy Flashcards

1
Q

What is labor that occurs between 20 & 37 weeks?

A

Premature labor

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2
Q

What percentage of deliveries are premature?

A

8%

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3
Q

What are contributing factors to premature labor?

A
    • Extremes of age
    • Inadequate prenatal care
    • Infections
    • Prior preterm labor
    • Multiple gestations
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4
Q

T OR F:

Preterm infants under 30 weeks and weighing less than 1500 G have more complications than term infants

A

TRUE

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5
Q

What is the most common complication in premature babies?

A

Inadequate surfactant levels and low lung maturity

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6
Q

At what age does surfactant become adequate?

A

35 weeks

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7
Q

What is PROM?

A

Premature rupture of membranes

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8
Q

What happens during PROM?

A

Leakage of amniotic fluid that occurs before the onset of labor

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9
Q

What is incidence of PROM?

A
    • 10% of all pregnancies

- - 35% of all premature deliveries

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10
Q

What are contributing factors to PROM?

A
    • History of PROM or premature labor
    • Multiple gestations
    • Smoking
    • Infections
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11
Q

T or F:

Spontaneous labor starts within 24 hours of PROM in 90% of patients

A

TRUE

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12
Q

If PROM occurs before 34 weeks gestation, what is course of action?

A

Stop the pregnancy if you can
Start antibiotics
Start tocolytics for 5-7 days

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13
Q

If PROM occurs after 34 weeks gestation, what is course of action?

A

Deliver the baby

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14
Q

Chorioamnionitis is what?

A

Infection of the chorionic and amnionic membranes that may or may not involve the placenta, uterus, and umbilical cord

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15
Q

What is chorioamnionitis usually associated with?

A

PROM

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16
Q

What are some maternal complications of chorioamnionitis?

A
    • Dysfunctional labor
    • Septicemia (infection)
    • Postpartum hemorrhage
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17
Q

What are some fetal complications of chorioamnionitis?

A
    • Premature labor
    • Acidosis
    • Septicemia (infection)
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18
Q

What are clinical signs of chorioamnionitis?

A
    • Fever >38* C
    • Maternal and fetal tachycardia
    • Foul smelling or purulent amniotic fluid
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19
Q

Is regional anesthesia safe for patients that have chorioamnionitis?

A

Is safe as long as no signs of septicemia at placement site

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20
Q

What has happened when an onset of sudden fetal bradycardia and profound decelerations is noted?

A

Umbilical cord prolapse

when umbilical cord is wedged between baby and canal possibly kinking off cord

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21
Q

What are predisposing factors of umbilical cord prolapse?

A
    • Excessive cord length
    • Malpresentation ( baby not head down)
    • Grand parity >5 ( history of more than 5 pregnancies)
    • Multiple gestations
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22
Q

What is treatment for umbilical cord prolapse?

A
    • Immediate steep trendelendburg

- - Pushing of fetus back into pelvis until stat C-section can be performed

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23
Q

What is an entry of amniotic fluid into the maternal circulation that occurs through any break in uteroplacental membranes?

A

Amniotic fluid embolism

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24
Q

What is the mortality rate of an amniotic fluid embolism?

A

86%

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25
Q

What does amniotic fluid contain?

A
    • Fetal debris
    • Prostaglandin
    • Leukotrienes
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26
Q

What is incidence of Amniotic fluid embolism?

A

Very rare, but accounts for 10% of all maternal deaths with 50% mortality rate in 1st hour

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27
Q

What is the classic triad of symptoms to present during an amniotic fluid embolism?

A
    • Acute hypoxemia
    • Hemodynamic collapse w/ severe hypotension
    • Coagulopathy without obvious cause
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28
Q

What are the 3 main pathophysiological manifestations with amniotic fluid embolism?

A

1) Acute pulmonary embolism
2) DIC
3) Uterine atony

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29
Q

What is the treatment for an amniotic fluid embolism?

A
    • Resuscitation and supportive care
    • CPR
    • Immediate delivery of baby improves maternal and fetal outcome
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30
Q

What are 3 types of partum hemorrhages?

A
    • Antepartum
    • Peripartum (intrapartum)
    • Postpartum
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31
Q

What is antepartum?

A

Placenta previa

Placental abruption

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32
Q

What is peripartum?

A

Uterine rupture

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33
Q

What is postpartum?

A 
Placenta accreta (placenta grows through endometrium)
Uterine atony
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34
Q

What is placenta previa?

A

Complication in which placenta is wedged into uterine segment

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35
Q

What are 3 types of placenta previa?

A
    • Central or complete previa (37% of time)
    • Incomplete or partial previa ( 27% of time)
    • Low lying or marginal previa (46 % of time)
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36
Q

What is complete placenta previa?

A

Placenta completely covers internal cervical OS

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37
Q

What is partial placenta previa?

A

Placenta partially covers internal cervical OS

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38
Q

What is marginal placenta previa?

A

– Placenta is close to the internal cervica OS without extending beyond its edge
(The anterior lying placenta previa increases risk of excessive bleeding during C/S)

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39
Q

What is incidence of placenta previa?

A

0.5%

Goes up to 5% for subsequent pregnancies

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40
Q

What risk factors are associated with placenta previa?

A
    • Scarring of uterine wall
    • Many previous pregnancies
    • Abnormally developed uterus
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41
Q

What is most common symptom of placenta previa?

A

Painless vaginal bleeding

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42
Q

What is the management of placenta previa for a women less than 37 weeks gestation?

A

Bedrest and observation

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43
Q

What is the management of placenta previa for a women after 37 weeks gestation?

A

C/S

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44
Q

When can you deliver vaginally with placenta previa?

A

When marginal placenta previa exist and bleeding is only mild

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45
Q

T or F:

All patients with vaginal bleeding are assumed to have placenta previa until proven otherwise

A

TRUE

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46
Q

What type of anesthetics can you use for placenta previa?

A

– Regional if patient is hemodynamically stable and no active bleeding

– General with stat C/S if active bleeding or patient is unstable

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47
Q

For most OB procedures, how much blood needs to be crossmatched and available for transfusion?

A

2 units

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48
Q

What is a premature separation of normal placenta after 20 weeks of gestation?

A

Placenta abruption

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49
Q

How does placenta abruption cause fetal distress?

A

The separation of placenta equates for a loss of area for maternal-fetal gas exchange causing fetal distress

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50
Q

What is the most common cause of intrapartum fetal death?

A

Placental abruption

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51
Q

What are some risk factors for placental abruption?

A
    • HTN
    • Trauma
    • Prolonged PROM
    • Tobacco, alcohol, cocaine usage
    • Short umbilical cord
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52
Q

What are some symptoms of placental abruption?

A
    • Painful vaginal bleeding
    • HTN
    • Uterine tenderness
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53
Q

What is the unique diagnosis for placental abruption?

A

Amniotic fluid is port wine colored

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54
Q

Minimal placental abruption is characterized by what?

A
    • Preterm with no fetal distress

- - Patient is hospitalized and pregnancy allowed to continue until fetal lung maturation

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55
Q

Mild to moderate placental abruption is characterized by what?

A

– If >37 weeks and no fetal distress, then vaginal delivery is allowed

– If fetal distress is apparent, then immediate C/S

– Fibrinogen levels are mildly reduced and patient starting to get to DIC

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56
Q

Severe placental abruption is characterized by what?

A

– Fibrinogen, Factor 5 and 7, and platelet counts all low

– Is life threatening emergency and requires STAT C-section

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57
Q

What is IFD?

A

Intrauterine fetal demise

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58
Q

What type of anesthetic is preferred for placental abruptions?

A

General b/c of high blood loss and required treatment of hyprovolemia

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59
Q

What is a uterine rupture?

A

When the integrity of the myometrial wall is breached that typically occurs during active labor

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60
Q

What are the signs and symptoms of uterine rupture?

A
    • Frank hemorrhage that causes hypotension
    • Fetal distress (most reliable sign)
    • Abdominal pain that breaks through epidural
    • Constant pain that has no relief between contractions
61
Q

What is the treatment for a uterine rupture?

A

Volume resuscitation & immediate laparotomy

62
Q

What is a retained placenta?

A

Placenta fragments that are still attached to uterus after delivery

63
Q

What is the detrimental effect of a retained placenta?

A

When fragments are still attached, causes the uterus to not be able to contract properly and cause open blood vessels and sinuses to continue to bleed profusely

64
Q

What is treatment for retained placenta?

A

Manual exploration of uterus

— Nitroglycerin may be useful in relaxing the uterus

65
Q

What is an abnormally adherent placenta?

A

Placenta accreta

66
Q

What are 3 types of plenta accreta?

A
    • Placenta accreta vera
    • Placenta increta
    • Placenta percreta
67
Q

Which placenta accreta is an invasion of the myometrium and occurs around 17% of time?

A

Placenta increta

68
Q

Which placenta accreta is only an adherence to the myometrium without invasion or passage through uterine muscle?

A

Placenta accreta vera

occurs majority of time ~78%

69
Q

Which placenta accreta is an invasion of the uterine serosa or other pelvic structures (like a through and through of myometrium) and only occurs around 5% of time?

A

Placenta percreta

70
Q

When is diagnosis made for placenta accreta?

A

Usually during separation of placenta at delivery and is confirmed by laparotomy

71
Q

What is the treatment for placenta accreta?

A

– Uterine curretage and oversewing can be tried but rarely works

– Most require C/S and a postpartum hysterectomy/laparotomy to repair

72
Q

What is uterine atony?

A

Condition in which uterus is not contracting down

73
Q

What is uterine atony usually accompanied with?

A

Retained placenta

74
Q

What is treatment for uterine atony?

A

Oxytocin

if really severe then mertherigine and then if more contraction needed then hemabate

75
Q

What is the 1st line drug treatment that all patients receive to help with uterine contraction?

A

Oxytocin

76
Q

What is the major side effect of oxytocin and what must be done to ensure this doesn’t occur?

A

Hypotension

Give drug slowly as hypotension usually only comes on when drug given too quickly

77
Q

T or F:

Oxytocin stimulates both the frequency and force of contractile activity

A

TRUE

78
Q

What is normal postpartum dose given of oxytocin?

A

20 units diluted in 1000 mL

Titrate infusion to around 30 mU/min

79
Q

What is onset and half life of oxytocin?

A

Onset : 1 min

Half life: 1-5 min

80
Q

What is 2nd line drug therapy used to aid uterine contraction?

A

Methylergonovine maleate or METHERGINE

81
Q

How does methergine work?

A

Works directly on smooth muscle of uterus via alpha receptors

82
Q

What side effect do you usually see with methergine?

A

Increased CVP and BP

83
Q

What is the dose of methergine?

A

IM : 0.2 mg
IV : 0.02 mg

Onsets: IM = 2-5 min
IV= immediate

84
Q

What patient population must you use caution with if giving methergine?

A
    • Preeclampsia (because already HTN)
    • HTN
    • Asthmatics
    • Cardiac disease (because increase in CVP)
85
Q

What is the last line drug therapy used for uterine contractions?

A

Prostaglandin f2alpha or HEMABATE or carboprost

86
Q

What is dose of hemabate and what is maximum dose?

A

IM : 250 mcg
Repeated every 15 min intervals
Max dose : 2 mg

87
Q

T OR F:

You can give hemabate to asthmatics freely

A

FALSE

be very cautious with asthmatics

88
Q

For a uterine inversion, what can your blood loss be and what is effect of this?

A

EBL can be 700 mL/min

Cause patient to become hypotensive

89
Q

What can you give to help OB treat uterine inversion?

A

NTG and Sevo to relax uterus

90
Q

Which condition presents with NO pain, NO fetal distress, and lots of bleeding

A

Placenta previa

91
Q

Which condition presents with pain, fetal distress, and lots of bleeding (some of which can be concealed/hidden from us)

A

Placenta abruption

92
Q

Which condition presents with pain, LOSS of fetal heart rate, and lots of bleeding

A

Uterine rupture

93
Q

Which condition presents postpartum with NO pain with some bleeding

A

Retained placenta

94
Q

Which condition presents postpartum with NO pain with lots of bleeding

A

Placenta accreta

95
Q

Which condition presents postpartum with NO pain with some bleeding

A

Uterine atony

96
Q

Uterine atony and retained placenta both present the same

A

But remember uterine atony is usually accompanied by a retained placenta so to diagnose rule out atony, not retained placenta

97
Q

What are most common causes of HTN in pregnancy?

A
    • Pt chronic HTN
    • PIH (pregnancy induced HTN)
    • Preeclampsia / Eclampsia
    • HELLP syndrome
98
Q

What is defined as a chronic HTN?

A

Systolic BP > 140 mmHg or Diastolic > 90 mmHg before 20 weeks gestation

99
Q

What is the safe beta blocker that can be given to chronic HTN patients that are pregnant?

A

Labetolol

100
Q

How is PIH defined?

A

Same as chronic ( S >140 and D > 90) but brought on by pregnancy

– Can also be defined as consistent increase in S or D pressures by 30 mmHg & 15 mmHg above patients normal baseline BP

101
Q

What is triad of symptoms of preeclampsia?

A

1) HTN
2) Proteinuria
3) Edema after 20 weeks that resolves 48 hours after delivery

102
Q

What are some of the risk factors for preeclampsia?

A
    • Primigravidas (1st baby)
    • Obesity
    • Chronic HTN
    • Previous history
103
Q

What is the pathophysiology of preeclampsia?

A

COMPLICATED AND NOT UNDERSTOOD so no one knows

104
Q

Severe preeclampsia is defined as what?

A 
S > 160 mmHg or D > 110 mmHg 
OR
Proteinuria > 5 G / 24 hours 
OR
*Cerebral edema causing headache
* Pulmonary edema
* Oliguria (< 400 mL / 24 hours)
* Platelets < 100000
105
Q

T or F:

Severe preeclampsia contributes to 20-40% of maternal deaths and 20% of perinatal deaths

A

TRUE

106
Q

What is HELLP syndrome?

A

PIH associated with:
hemolysis
elevated liver enzymes
low platelet counts

107
Q

Which type of anesthetic is needed for HELLP syndrome?

A

GA

regional is contraindicated because actively falling platelet count

108
Q

When does preeclampsia turn into eclampsia?

A

When seizures occurs

109
Q

What is treatment for preeclampsia?

A
  • -Bedrest
    • Antihypertensives
    • Magnesium sulfate
110
Q

What antihypertensives are safe for pregnancy?

A
    • Labetolol 5-10 mg
    • Hydralazine 5 mg
    • Methyldopa 250-500 mg PO
    • Mag sulfate
    • Nitroprusside
111
Q

What is mag sulfate used for ?

A

Treat hyperreflexia and prevention of seizures because it reduces CNS irritability

112
Q

What is the goal therapeutic level of mag sulfate?

A

4-6 mEq / L

113
Q

What are normal levels of mag sulfate?

A

1.5-2 mEq / L

114
Q

What are detrimental effects of increased levels of mag sulfate?

A

Start to have detrimental effects on heart

115
Q

What are ranges for excess mag sulfate and what does each cause?

A

: 5-10 eEq / L causes ECG changes
: 10 mEq causes respiratory depression and weakness
: 15 mEq causes SA and AV blocks
: 25 mEq causes cardiac arrest

116
Q

Which drug poses a risk of cyanide toxicity to the fetus in large doses?

A

Nitroprusside

117
Q

What is only definitive treatment to preeclampsia?

A

Delivery of fetus and placenta

118
Q

Does mild preeclampsia require a C/S?

A

NO

patients just pose higher risk so just be careful and cautious

119
Q

For severe preeclampsia patients, what is anesthetic plan.

A
    • A line always
    • On antihypertensives
    • Monitor urine output closely
    • Hypovolemia corrected slowly ( no more than 500 mL crystalloid)
    • Check platelet counts frequently (no regional if counts < 80000)
    • EPIDURAL OR SPINAL 1st CHOICE
120
Q

Why are epidurals preferred in preeclamptic patients?

A
    • Avoids risk of failed intubation
    • Avoids hypotension
    • Improves uteroplacental perfusion by 75% in PIH patients
121
Q

When treating patients with hypotension, what must you do to doses of drugs given?

A

REDUCE them
ephedrine 5mg at at time
phenylephrine 50 mcg at a time

122
Q

What does mag sulfate do to non-depolarizing muscle relaxants?

A

Potentiates them so require much less of drug

123
Q

What is true of regurgitant valves during pregnancy?

A
    • Pregnancy tolerated well
    • Regional anesthesia well tolerated
    • Avoid pain, increased CO2, decreased O2, avoid myocardial depression
124
Q

What is 2nd most common valve defect in pregnant patients?

A

Mitral regurg

125
Q

How should you handle patients with regurg?

A
    • Avoid bradycardia
    • Avoid HTN
    • Consider afterload reduction
126
Q

Which valve defect may develop after an attack of rheumatic fever?

A

Aortic regurg

127
Q

What is true of stenotic valves during pregnancy?

A
    • Pregnancy poorly tolerated
    • Consider invasive monitoring
    • Maintain normal HR
128
Q

With mitral stenosis, what do you have to watch out for?

A
    • Avoid sinus tachycardia
    • Avoid A fib
    • Avoid increases in blood volume
129
Q

How should you handle patients with aortic stenosis?

A
    • Avoid decreased SVR
    • Avoid bradycardia
    • Avoid hypovolemia
130
Q

Just for review, what are left to right shunts?

A
  • VSD
  • ASD
  • PDA
131
Q

Just for review, what is the right to left shunt?

A
  • ToF (tetrology of fallot)
    1) RV hypertrophy / RV outflow obstruction
    2) Overriding aorta
    3) VSD
132
Q

How can cardiomyopathies present in pregnancy?

A

Fatigue or URI/ congestion

133
Q

What are the risk factors for cardiomyopathy in pregnancy?

A
    • Multiple gestations
    • Preeclampsia
    • Obesity
    • Advanced maternal age
134
Q

What is incidence and risk factors of gestational diabetes?

A

4% of pregnancies

    • Advanced maternal age (AMA)
    • Obesity
    • DM or family history of DM
    • H/O of stillbirth or neonate death
135
Q

What are effects on mother of gestational diabetes?

A
    • PIH increased likelihood
    • C-section likelihood
    • Preterm labor likelihood
    • Polyhydramnios (increased amount of amniotic fluid)
136
Q

What are effects on fetus of gestational diabetes?

A
    • Larger birth weight
    • Structural malformations
    • Neonatal hypoglycemia
    • Neonatal respiratory distress syndrome
137
Q

What is macrosomia?

A

Large birth weight or baby large for gestational age

Increases likelihood of injury/trauma to mother and fetus during delivery

138
Q

T or F:
Hyperglycemia during period of critical organogenesis before 7th week postconception in single strongest factor in DM pregnant women

A

TRUE

139
Q

From question above, known this

A

Basically blood sugar during 1st trimester must be tightly controlled to lower risk of any harm done by DM to mother and fetus

140
Q

T or F:

CNS structural malformations are the most common malformation caused by DM to fetus?

A

FALSE
is 2nd most common

CARDIAC is most common

141
Q

What is target glucose concentration for pregnancy?

A

=< 100 mg/dL

142
Q

T or F:

Asthma has a variable course of action in pregnancy (may improve may worsen may remain the same)

A

TRUE

143
Q

What is normal pregnancy ABG?

A

Respiratory alkalosis
pH 7.44
pCO2 30
pO2 105

144
Q

What is normal non pregnant ABG?

A

pH 7.35
pCO2 30-40
pO2 85

145
Q

What are the goals for asthmatics during labor?

A
    • Regional anesthetic is preferred
    • Avoid pain
    • Avoid hypo and hyper carbia
    • Provide minimal sedation
146
Q

For a stable asthmatic, what is management goal?

A
    • Regional preferred

- - Avoid endotracheal intubation

147
Q

For an unstable asthmatic, what is management goal?

A
    • Regional REALLY PREFERRED
    • If GA, pretreat with albuterol
    • RSI
    • High MAC (1.5)
    • Albuterol before extubation
148
Q

For C/S in obese patients, what 2 detrimental risks are increased?

A
    • Incidence of fetal distress

- - Abnormal labor (arrest of descent)

149
Q

For morbidly obese patients, what detrimental outcomes are increased?

A
    • Incidence of shoulder distocia

- - RIsk of maternal death

AP Summer (24 decks)

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