Obstetrics I Flashcards by Joanna Brown

What pH changes are associated with pregnancy?

Respiratory Alkalosis

Compensated by increased bicarb excretion

So they have a low PaCO2 and a low bicarb

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What happens to PaCO2 levels during labor?

They may fall to as low as 10-15, because Mv is increased by 200%

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ART hormonal stimulation regimens are associated with what hemostatic changes?

Cause increased coagulation and decreased fibrinolysis

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What is the most common complication of ART hormone therapy?

Ovarian Hyperstimulation Syndrome (OHSS)

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What are the manifestations of OHSS?

Abdominal discomfort, bilateral ovarian enlargement, ascites → hemorrhage, pleural effusion, hemoconcentration, oliguria, thromboembolic events

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Are women who undergo ART more or less likely to have an ectopic pregnancy?

More likely

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What are the anesthetic considerations associated with OHSS?

Retrieval of the oocyte may occur earlier
Increased free drug concentrations
Greater perioperative pain
May need emergency Lap
May need paracentesis and thoracentesis before induction

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What fetal complications are associated with ART pregnancies?

Preterm

LBW

SGA

Appears to be due to infertility rather than the procedure itself BECAUSE women with infertility who conceive without ART have similar risks

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What’s the difference between GIFT and ZIFT?

GIFT: Gamete, not fertilized - 1 procedure

ZIFT: Zygote, fertilized (also called PROST) - 2 procedures

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How do intraoperative LAs effect pregnancy rates?

It doesn’t seem like they do

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Which opioids do not interfere with fertilization or preimplantation?

All of them except morphine, which seems to increase multi-sperm fertilization

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Does midazolam impair fertilization or embryo development?

No. It is not teratogenic.

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Which anesthetics should not be used in ART surgeries?

Volatile halogenated agents and Nitrous

All of them reduce DNA synthesis and mitosis

Volatiles also increase prolactin, which is associated with diminished oocyte development and uterine receptivity

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Which antiemetics may impact oocyte development?

Droperidol and metoclopramide, both of which increase prolactin levels. There is contrasting data on whether this hurts or helps

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What is the window for maximal oocyte retrieval after hCG administration?

34-36 hours

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What is the most commonly used technique for Transvaginal Oocyte Retrievals?

MAC

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Is paracervical anesthesia sufficient for oocyte retrieval?

No. Additional analgesia is required

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Discuss the anesthetic requirements for ET, GIFT, and ZIFT procedures

ET (transcervical) can be done awake or with minimal sedation

GIFT and ZIFT are usually laparoscopic procedures and require trendelenburg

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How is induction usually performed for GIFT procedures?

TIVA: Prop, Fent, Lido, Succ

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What respiratory changes occur by 12 WGA?

Mv increases by 15% from increased Vt, which exceeds the increase in VO2 → Respiratory alkalosis

PaO2 increases to 106-108

Decreased bicarb → compensated pH of 7.44

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What lungs volume changes occur in the first half of pregnancy?

None

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What mechanical ventilation changes should be made for women in early pregnancy?

They need an increased minute ventilation

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In a typical pregnancy, when can aortocaval compression occur?

after 18-20 weeks

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Does neuraxial have a higher or lower risk for aspiration than general anesthesia?

Lower

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What are possible sequelae of ectopic pregnancy?

Death, infertility, and recurrent ectopic pregnancy

What is the leading cause of pregnancy-related maternal death in the first trimester?

hemorrhage from a ruptured ectopic pregnancy

What percentage of women who have an ectopic pregnancy subsequently suffer from ectopic pregnancy?

30%

What factors increase the risk of an ectopic pregnancy?

1. Previous ectopic 2. Infertility Treatments 3. Prior PID or ruptured appendix 4. Prior BTL 5. AMA

Where do most ectopic pregnancies occur?

98% are tubal The remaining 2% are in the cervix, vagina, ovary, or abdomen

What are clinical signs of impending rupture or ruptured tubal pregnancy?

1. Abdominal or pelvic pain 2. Delayed menses 3. Vaginal Bleeding

Patients with hemorrhagic/ruptured ectopic cysts may experience:

1. Dizziness or syncope from hypovolemia 2. Urge to defecate 3. Shoulder pain from diaphragmatic irritation from intra-abdominal blood

What physical findings may be seen with an ectopic pregnancy?

Abdominal tenderness with OR without rebound Small uterus for gestational age Tender adnexal mass

Ectopic pregnancy should be excluded in any patient who has ______ and \_\_\_\_\_\_\_

pelvic pain and a positive pregnancy test

What determines how “active” an ectopic pregnancy is?

Symptoms and hCG levels

What defines a “very less active” ectopic pregnancy and what is the appropriate treatment?

No symptoms, hCG \< 1500 and plateaued Expectant management

What defines a “less active” ectopic pregnancy and what is the appropriate treatment?

hCG \< 5000 and no fetal cardiac activity, no symptoms, hemodynamically stable Methotrexate “medical management”

What is Methotrexate's MOA?

It's a folate antagonist. It interrupts DNA synthesis and inhibits the growth of trophoblastic cells

What is a heterotopic pregnancy?

An ectopic and an intrauterine pregnancy at the same time (usually from ART surgery)

Maternal death from abortion is usually the result of:

sepsis, hemorrhage, or embolism

What gestational age does fetal demise usually occur?

The symptoms of early pregnancy loss are usually around 8-14 weeks, but the actual demise is usually before 8 weeks

What causes most early pregnancy losses?

chromosomal abnormalities

What is a threatened EPL?

uterine bleeding WITHOUT cervical dilation before 20 WGA

What is inevitable pregnancy loss?

cervical dilation or ROM without expulsion of the fetus

What is an incomplete EPL?

when only partial expulsion of uterine contents occurs

In patients with significant blood loss after a D&C or D&E, how long should they be observed after lithotomy is discontinued?

At least 5 minutes before leaving the OR table

MAC is appropriate for what kind of dilation procedure?

when the cervix is dilated and gestational age is first trimester

When should volatile gases be avoided?

When there is significant bleeding or uterine atony

What level of neuraxial anesthesia is required for a D&C or D&E?

T10 to S4

What level of neuraxial anesthesia is required for surgical ectopic pregnancy?

For a D&E, anesthesia maintenance is usually:

IV (propofol and fentanyl) Avoid above 0.5 MAC gas

Why is oxytocin less effective in D&E or D&C patients?

oxytocin receptor expression increases with gestation. At early gestation, they may not have sufficient receptors to cause a big contraction of the uterus

What are symptoms of cervical insufficiency?

Altered vaginal discharge Lower ab or back pain vaginal fullness urinary frequency

For women with two or more second trimester losses due to cervical insufficiency, when may a cerclage be placed?

12-14 weeks

In which women does cerclage tend to worsen outcomes, regardless of cervical length?

Multiple gestations

What are contraindications to cerclage placement?

preterm labor vaginal bleeding fetal anomalies fetal death ROM Abruption Infection

What is the greatest risk during a cerclage?

ROM

What anesthetic may be optimal for a cerclage?

Anesthetic gases. Uterine relaxation is imperative. Can also use nitroglycerin and/or trendelenburg positioning

When might general anesthesia be recommended for cerclage placement?

If the cervix is dilated and uterine relaxation is needed

In a patient whose cervix is not dilated, what is the usual anesthesia choice?

Usually epidural or spinal

Why is a smooth induction and emergence an imperative with cerclage placement?

Any coughing/bucking/vomiting significantly increases intrauterine pressure and may rupture the cerclage

When are cerclages removed?

37-38 WGA

What anesthesia is optimal for cerclage removal?

Usually anesthesia isn't required for a McDonald Paracervical block may be needed for Shirodkar

What is gestational trophoblastic disease (GTD)?

when trophoblastic tissue proliferates after the pregnancy is concluded Includes hydatiform moles, choriocarcinomas, and placental site trophoblastic tumor

What is the most malignant form of GTD?

gestational choriocarcinoma

What is the least malignant form of GTD?

partial hydatidiform mole

What specific complications should be assessed for in patients with molar pregnancy?

Hyperemesis gravidarium gHTN Pre-E Anemia Thyrotoxicosis

What are the main anesthetic considerations in molar pregnancy removals?

potential for rapid blood loss risk for cardiopulmonary distress during evacuation of the uterus

What is the preferred anesthesia type for molar pregnancy removal?

General, because there's such a high risk of complications

Serious complications of hyperemesis may include:

Wernicke encephalopathy ATN Esophageal rupture Splenic avulsion

When do corpus luteum cysts usually occur?

during early pregnancy

What is the treatment for corpus luteum cysts?

usually self resolve over several weeks, but sometimes an oopherectomy is required

What is the fetal prognosis if a corpus luteum cyst arises?

Usually fine as long as supplemental progesterone is administered until 10-12 WGA

Obstetrics I Flashcards

(72 cards)