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AS - N934 Advanced Principles II > Obstetrics/OBGYN > Flashcards

Obstetrics/OBGYN Flashcards

1
Q

Cardiovascular Changes w/ Pregnancy

A 
↑HR 20-30% peaks at 32 weeks
↑CO 40% returns to baseline w/in 14 days
Ventricular walls thicken
↑EDV
Dilutional anemia ↑↑plasma volume ↑RBCs
↓SVR → venous pooling & ↓diastolic BP to compensate BP w/ hypervolemia & ↑blood volume
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2
Q

Aortocaval Compression

A

Supine position → HoTN d/t aorta & vena cava compression from gravid uterus
Treatment = L uterine displacement

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3
Q

Hematological Changes w/ Pregnancy

A

Hypercoagulable ↑clotting factors VII-IX & fibrinogen
↑risk thromboembolic events (leading cause maternal mortality)
↓platelet count minimal
↑WBC count
Dilutional anemia

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4
Q

Airway Changes w/ Pregnancy

A

Airway swelling during labor
Capillary engorgement → narrowed glottic opening (use smaller ETT 6.0 or 6.5 cuffed), oral & nasal pharynx edema (avoid nasal intubation), & laryngeal edema
Consider short laryngoscope handle

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5
Q

Respiratory Changes w/ Pregnancy

A

↑oxygen consumption
↑minute ventilation ↑↑VT ↑RR (tachypnea not normal)
↓PaCO2 minimal w/ compensatory ↓HCO3¯
Diaphragm shifts upward ↓FRC
Rapid desaturation in apneic patient (ensure adequate pre-oxygenation)

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6
Q

Neurological Changes w/ Pregnancy

A

↑sensitivity to anesthetic gases & LAs
↑block height d/t engorged epidural veins that compress the dura & exaggerate the LA spread
↑intra-abdominal pressure ↓epidural & subarachnoid spaces

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7
Q

Gastrointestinal Changes w/ Pregnancy

A

↑risk regurgitation & aspiration
↑gastrin levels
Mechanical obstruction d/t upward displacement
Labor further ↓gastric emptying

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8
Q

What medications to administer prior to C-section to ↓aspiration risk?

A
  1. Bicitra (non-particulate antacid)
  2. Famotidine (Pepcid) H2 receptor antagonist
  3. Metoclopramide (Reglan) prokinetic that neutralizes stomach acid
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9
Q

Hepatic Changes w/ Pregnancy

A

↓serum albumin

↑free fraction highly protein-bound drugs

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10
Q

Renal Changes w/ Pregnancy

A

↑GFR
↓BUN & creatinine
Glucose excreted via urine d/t ↑GFR & ↓renal absorption
↑protein excretion

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11
Q

Uterine Blood Flow

A

Term ↑800mL/min
Receives 10% CO
- 150mL/min supplies nutrients to the myometrium
- 100mL/min flow to the decidua basalis (maternal portion placenta)
Fetus sends O2 poor blood to the placenta AVA
Placenta exchanges nutrients, respiratory gases, & waste
O2 & CO2 exchange are perfusion limited

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12
Q

How do medications transfer across the placenta? What is able to cross?

A

Transfer via diffusion

Other factors:

  • Non-ionized
  • Small (molecular weight)
  • Dependent on concentration gradient & lipid solubility
  • Protein binding
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13
Q

How much fetal CO returns directly back to the placenta? How?

A

1/5 fetal CO

Shunts flows from PFO & PDA

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14
Q

What affects drug accumulation w/in the fetus?

A

Acid-base status

Ion trapping

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15
Q

What decreases the fetal drug effects?

A

Dilution w/ intervillous blood
Redistribution w/in the fetus
1st pass liver effect
↑maternal hepatic enzymes ↓serum drug levels

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16
Q

Labor & Delivery

STAGE I

A

Cervix effacement & dilation
Latent - labor onset to rapid cervix dilation
Active - cervix dilation 2cm to full dilation at 10cm

Non-localized aching or cramping T10-12 & L1

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17
Q

Labor & Delivery

STAGE II

A

Cervix dilation 10cm to fetus delivery

Presenting part descends into the pelvis → perineal stretching S2-4

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18
Q

Labor & Delivery

STAGE III

A

Placenta delivery

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19
Q

Fetal Heart Rate

Variability

A

Indicates fetal well-being & O2 reserve
Hypoxia → CNS depression ↓HR
Accelerations are reactive - indicate fetal movement & adequate oxygenation

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20
Q

Fetal Heart Rate

Early Decelerations

A

Occur w/ uterine contractions
Consistent
↓fetal HR approximately 20bpm

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21
Q

Fetal Heart Rate

Variable Decelerations

A

Abrupt ↓HR irrespective to contractions

Baroreflex-mediated response to umbilical cord compression

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22
Q

Fetal Heart Rate

Late Decelerations

A

NON-REASSURING
Lowest deceleration point occurs after peak contraction
Represent uteroplacental insufficiency

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23
Q

Fetal Heart Rate

Category I

A

Normal baseline HR & moderate variability w/ NO variable or late decels

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24
Q

Fetal Heart Rate

Category II

A

All tracings not included in I or III
Do not indicate acid-base imbalance
Warrant continued observation

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25
Q

Fetal Heart Rate

Category III

A

Fetal bradycardia & absent variability w/ variable or late decels
Warrants prompt intervention

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26
Q

Labor analgesia dermatome level goal:

A

T10-L1

27
Q

Caesarean section dermatome level goal:

A

T4-6 to provide adequate analgesia

Epidural 10-15mL

28
Q

Combined Spinal/Epidural (CSE)

A

Place spinal 1st then place the epidural one level above
OR
Needle through needle technique

29
Q

CSE Advantages

A

Lower spinal dose

Ability to re-dose w/ epidural catheter

30
Q

CSE Disadvantages

A

Potential lower block height

Surgical start delay

31
Q

Neuraxial Opioid Side Effects

A

Respiratory depression
Itching
Urinary retention
N/V

Opioids have ceiling effect beyond conventional doses

32
Q

Caesarean Section Indications

A 
Cephalopelvic disproportion
Non-reassuring fetal status (ex: late decels)
Failure to progress (dilation arrest)
Malpresentation
Prematurity
Previous C/S or uterine surgery
33
Q

Neuraxial Advantages over General

A

↓mortality risk d/t failed intubation
↓aspiration risk
Improved neonatal outcomes
Mother able to participate in birth

34
Q

When to utilize L uterine displacement?

A

Regardless the anesthetic technique to prevent aorta compression → late decels

35
Q

Spinal Advantages

A

Simple to perform
Rapid onset
Reliable block
Less toxic

0.75% hyperbaric Bupivacaine
DOA 90-120min

36
Q

Spinal Disadvantages

A

Fixed DOA (single shot)
HoTN
Inadequate coverage

37
Q

Epidural Advantages

A

Less abrupt blood pressure changes

Able to re-dose catheter

38
Q

Epidural Disadvantages

A

Slower onset

Higher LA dose required

39
Q

General Anesthesia Indications

A

Patient refusal
Coagulopathy
Spinal or epidural does not provide adequate surgical coverage
Urgent delivery

40
Q

OB Complications

Post-Partum Hemorrhage

A

EBL >

  • Vaginal delivery 500mL
  • C-section 1,000mL
41
Q

Post-Partum Hemorrhage

Causes & Risk Factors

A 
Uterine atony 80%
Uterine abnormalities
Placental retention
Lacerations
Uterine inversion
Coagulation abnormalities

Multiparity (previous pregnancy)
Prolonged oxytocin infusion
Polyhydramnios
Multiple gestation

42
Q

Post-Partum Hemorrhage

Treatment

A

Uterotonics stimulate uterine contractions
- Oxytocin, Methergine, PGEs (Carboprost/Hemabate), and/or Misoprostal
Antifibrinolytics TXA
MTP and/or cell salvage
Surgical intervention
- Retained placenta, NTG, hysterectomy
Intrauterine balloon

43
Q

Oxytocin

A

Synthetic Pitocin lowers depolarization threshold
Ca2+ channel activation & ↑prostaglandin production
20-40 units

44
Q

Methylergonovine (Methergine)

A

Ergot alkaloid
0.2mg IM repeat Q15-20min
Max dose 0.8mg
NEVER IV BOLUS → profound HTN & cerebral hemorrhage
Contraindicated in pre-existing HTN, PVD, & ischemic heart disease

45
Q

Prostaglandins

Carboprost (Hemabate)

A

↑myometrial Ca2+ levels & MLCK activity
250mcg IM or direct into myometrium repeat Q15-30min
Max dose 2mg
Reactive airway disease → bronchospasm, VaQ mismatch, & hypoxemia

46
Q

Misoprostol

A

Prostaglandin E1 analog
↑myometrial Ca2+ levels & MLCK activity
800-1,000mcg sublingual or buccal
Okay to admin to patients w/ reactive airway disease or pulmonary HTN

47
Q

Nitroglycerin

A

Nitric oxide donors
↑cyclic guanosine monophosphate
Inactivates MLCK causing smooth muscle relaxation

Administered as muscle relaxant to allow surgeon to remove retained placenta ↑bleeding

48
Q

OB Complications

Preeclampsia

A

Pregnancy-specific multisystem disorder
Etiology not understood - failure normal angiogenesis resulting in ↓placental perfusion
↑vascular tone & sensitivity to catecholamines
Pronounced upper airway edema during labor

49
Q

Preeclampsia S/S

A 
HTN > 140/90
Proteinuria
Thrombocytopenia < 100,000
Impaired liver function & severe RUQ pain
Renal insufficiency
Cerebral or visual disturbances
CNS effects - headache, hyperexcitability, & hyperreflexia
Hepatocellular necrosis
50
Q

Preeclampsia Treatment

A 
Avoid uteroplacental hypoperfusion
Magnesium sulfate (tocolytic) ↓seizure incidence, venous dilation, ↓uterine activity
HTN management
Only way to end disease process = delivery
51
Q

OB Complications

HELLP

A

Preeclampsia complication
Hemolysis, elevated liver enzymes, & low platelet count
Associated w/ progressive & sudden deterioration in maternal & fetal condition

52
Q

HELLP S/S

A

HTN
Proteinuria
N/V

53
Q

OB Complications

Obesity

A

> 20% pregnancies complicated d/t obesity
↑risk HTN, diabetes, & complicated labor → fetal macrosomia (LGA), failed induction/progression, difficult or failed neuraxial, prolonged procedures, & infectious complications

54
Q

OB Complications

Placenta Previa

A 
Abnormal placental implantation
Placenta implants on lower uterine segment & covers the opening to the cervix
1% incidence
Painless vaginal bleeding
- Hemodynamically significant blood loss
- ↑risk postpartum bleeding
C-section indicated
55
Q

OB Complications

Placenta Accreta

A

Placenta normally implants into the endometrium, but placenta accreta implants into the myometrium
Placenta increta describes growth through the myometrium & into surrounding organs
Associated w/ massive hemorrhage - uterine artery embolization & Caesarean hysterectomy

56
Q

OB Complications

Placenta Abruption

A

Placenta separates from the uterus during delivery
More common in women w/ HTN & PEC
Open venous sinuses allows amniotic fluid to enter circulation ↑DIC incidence

57
Q

Placenta Abruption S/S

A 
Hemorrhage
Painful vaginal bleeding
Uterine irritability
Abdominal pain
Fetal hypoperfusion & distress
58
Q

OB Complications

Amniotic Fluid Embolism

A

Rare event
Potential to occur during labor (vaginal delivery or C-section)
Occasionally associated w/ placenta abruption

59
Q

Amniotic Fluid Embolism

S/S

A 
Anxiety
Dyspnea
Hypoxia
HoTN
Cardiovascular collapse
Coagulopathy
60
Q

Amniotic Fluid Embolism

Treatment

A 
Supportive
AOK
- Atropine
- Ondansetron
- Ketorolac
61
Q

OB Complications

Prematurity

A

Labor & delivery before 37 weeks gestation
Birth weight < 1,500g associated w/ long-term complications (respiratory distress syndrome, intracranial hemorrhage, & hyperbilirubinemia)

62
Q

Non-Obstetric Surgeries in Pregnant Women

A 
1-2% pregnant women require non-OB surgeries
Most common = cerclage
2nd lap chole
Avoid HoTN & maintain uterine perfusion
Prevent premature labor
Avoid surgeries in 1st trimester
63
Q

APGAR

A

8-10 normal
4-7 moderate distress or impairment
0-3 immediate resuscitation

AS - N934 Advanced Principles II (18 decks)

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