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Advanced Principles II > Obstetrics I > Flashcards

Obstetrics I Flashcards

1
Q

What pH changes are associated with pregnancy?

A

Respiratory Alkalosis

Compensated by increased bicarb excretion

So they have a low PaCO2 and a low bicarb

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2
Q

What happens to PaCO2 levels during labor?

A

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

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3
Q

ART hormonal stimulation regimens are associated with what hemostatic changes?

A

Cause increased coagulation and decreased fibrinolysis

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4
Q

What is the most common complication of ART hormone therapy?

A

Ovarian Hyperstimulation Syndrome (OHSS)

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5
Q

What are the manifestations of OHSS?

A

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

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6
Q

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

A

More likely

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7
Q

What are the anesthetic considerations associated with OHSS?

A
  1. Retrieval of the oocyte may occur earlier
  2. Increased free drug concentrations
  3. Greater perioperative pain
  4. May need emergency Lap
  5. May need paracentesis and thoracentesis before induction
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8
Q

What fetal complications are associated with ART pregnancies?

A

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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9
Q

What’s the difference between GIFT and ZIFT?

A

GIFT: Gamete, not fertilized - 1 procedure

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

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10
Q

How do intraoperative LAs effect pregnancy rates?

A

It doesn’t seem like they do

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11
Q

Which opioids do not interfere with fertilization or preimplantation?

A

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

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12
Q

Does midazolam impair fertilization or embryo development?

A

No. It is not teratogenic.

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13
Q

Which anesthetics should not be used in ART surgeries?

A

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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14
Q

Which antiemetics may impact oocyte development?

A

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

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15
Q

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

A

34-36 hours

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16
Q

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

A

MAC

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17
Q

Is paracervical anesthesia sufficient for oocyte retrieval?

A

No. Additional analgesia is required

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18
Q

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

A

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

GIFT and ZIFT are usually laparoscopic procedures and require trendelenburg

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19
Q

How is induction usually performed for GIFT procedures?

A

TIVA: Prop, Fent, Lido, Succ

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20
Q

What respiratory changes occur by 12 WGA?

A

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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21
Q

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

A

None

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22
Q

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

A

They need an increased minute ventilation

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23
Q

In a typical pregnancy, when can aortocaval compression occur?

A

after 18-20 weeks

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24
Q

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

A

Lower

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25
Q

What are possible sequelae of ectopic pregnancy?

A

Death, infertility, and recurrent ectopic pregnancy

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26
Q

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

A

hemorrhage from a ruptured ectopic pregnancy

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27
Q

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

A

30%

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28
Q

What factors increase the risk of an ectopic pregnancy?

A
  1. Previous ectopic
  2. Infertility Treatments
  3. Prior PID or ruptured appendix
  4. Prior BTL
  5. AMA
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29
Q

Where do most ectopic pregnancies occur?

A

98% are tubal

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

30
Q

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

A
  1. Abdominal or pelvic pain
  2. Delayed menses
  3. Vaginal Bleeding
31
Q

Patients with hemorrhagic/ruptured ectopic cysts may experience:

A
  1. Dizziness or syncope from hypovolemia
  2. Urge to defecate
  3. Shoulder pain from diaphragmatic irritation from intra-abdominal blood
32
Q

What physical findings may be seen with an ectopic pregnancy?

A

Abdominal tenderness with OR without rebound

Small uterus for gestational age

Tender adnexal mass

33
Q

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

A

pelvic pain and a positive pregnancy test

34
Q

What determines how “active” an ectopic pregnancy is?

A

Symptoms and hCG levels

35
Q

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

A

No symptoms, hCG < 1500 and plateaued

Expectant management

36
Q

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

A

hCG < 5000 and no fetal cardiac activity, no symptoms, hemodynamically stable

Methotrexate “medical management”

37
Q

What is Methotrexate’s MOA?

A

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

38
Q

What is a heterotopic pregnancy?

A

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

39
Q

Maternal death from abortion is usually the result of:

A

sepsis, hemorrhage, or embolism

40
Q

What gestational age does fetal demise usually occur?

A

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

41
Q

What causes most early pregnancy losses?

A

chromosomal abnormalities

42
Q

What is a threatened EPL?

A

uterine bleeding WITHOUT cervical dilation before 20 WGA

43
Q

What is inevitable pregnancy loss?

A

cervical dilation or ROM without expulsion of the fetus

44
Q

What is an incomplete EPL?

A

when only partial expulsion of uterine contents occurs

45
Q

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

A

At least 5 minutes before leaving the OR table

46
Q

MAC is appropriate for what kind of dilation procedure?

A

when the cervix is dilated and gestational age is first trimester

47
Q

When should volatile gases be avoided?

A

When there is significant bleeding or uterine atony

48
Q

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

A

T10 to S4

49
Q

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

A

T4

50
Q

For a D&E, anesthesia maintenance is usually:

A

IV (propofol and fentanyl)

Avoid above 0.5 MAC gas

51
Q

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

A

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

52
Q

What are symptoms of cervical insufficiency?

A

Altered vaginal discharge

Lower ab or back pain

vaginal fullness

urinary frequency

53
Q

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

A

12-14 weeks

54
Q

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

A

Multiple gestations

55
Q

What are contraindications to cerclage placement?

A

preterm labor

vaginal bleeding

fetal anomalies

fetal death

ROM

Abruption

Infection

56
Q

What is the greatest risk during a cerclage?

A

ROM

57
Q

What anesthetic may be optimal for a cerclage?

A

Anesthetic gases. Uterine relaxation is imperative.

Can also use nitroglycerin and/or trendelenburg positioning

58
Q

When might general anesthesia be recommended for cerclage placement?

A

If the cervix is dilated and uterine relaxation is needed

59
Q

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

A

Usually epidural or spinal

60
Q

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

A

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

61
Q

When are cerclages removed?

A

37-38 WGA

62
Q

What anesthesia is optimal for cerclage removal?

A

Usually anesthesia isn’t required for a McDonald

Paracervical block may be needed for Shirodkar

63
Q

What is gestational trophoblastic disease (GTD)?

A

when trophoblastic tissue proliferates after the pregnancy is concluded

Includes hydatiform moles, choriocarcinomas, and placental site trophoblastic tumor

64
Q

What is the most malignant form of GTD?

A

gestational choriocarcinoma

65
Q

What is the least malignant form of GTD?

A

partial hydatidiform mole

66
Q

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

A

Hyperemesis gravidarium

gHTN

Pre-E

Anemia

Thyrotoxicosis

67
Q

What are the main anesthetic considerations in molar pregnancy removals?

A

potential for rapid blood loss

risk for cardiopulmonary distress during evacuation of the uterus

68
Q

What is the preferred anesthesia type for molar pregnancy removal?

A

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

69
Q

Serious complications of hyperemesis may include:

A

Wernicke encephalopathy

ATN

Esophageal rupture

Splenic avulsion

70
Q

When do corpus luteum cysts usually occur?

A

during early pregnancy

71
Q

What is the treatment for corpus luteum cysts?

A

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

72
Q

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

A

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

Advanced Principles II (5 decks)

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