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Summer 2020 - APA Foundations 2 - OB > Parturient Surgery & Coexisting Disease - Quiz 3 > Flashcards

Parturient Surgery & Coexisting Disease - Quiz 3 Flashcards

1
Q

What are indications for a C-Section?

A

Failure to Progress

Fetal Distress

Malpresentation

Previous C/S

Mom’s or Baby’s Condition making Vaginal Delivery Unsafe

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2
Q

What is Local Infiltration?

A

Surgeon places Local

Rare and in Extreme Cases

Midline Incision w/ No Uteral Exteriorization

Supplements Regional

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3
Q

What is the most common type of Anesthesia for C-Sections?

A

Regional

Safer than General

Epidural Cath already in

Less Baby Depression

Mom can witness birth

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4
Q

What are indications for General Anesthesia for a C-Section?

A

Severe Fetal Distress

No time for block

Epidural Catheter Nonfunction

Inadequate Regional

Patient Refusal of Block

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5
Q

While under General, what should be avoided in the Parturient?

A

Hypotension

Hypoxia

Acidosis

Hyperventilation

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6
Q

How does General Anesthesia affect the baby’s Apgar?

A

Lower @ 1 Minute

Same @ 5 Minutes

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7
Q

What should be done for a Parturient who has a difficult airway?

A

Early Induction of Epidural Analgesia

&

Consider Awake Fiberoptic Intubation

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8
Q

What are some Aspiration Prophylaxis meds?

A
  • Antacid - Sodium Citrate - Lasts 15 min & give to all
  • Ranitidine (Zantac) - H2 blocker
  • Reglan - decrease gastric volume, antiemetic, & inhibited by opioids
  • NPO x 6 hrs
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9
Q

Since parturients have Increased O2 consumption & Decreased FRC, what is critically important before Induction?

A

Preoxygenate & Denitrogenate w/ 100% O2 x 3 minutes

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10
Q

What is the Induction dose for Propofol?

A

2 - 2.8 mg/kg

Crosses placenta

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11
Q

Which Induction agent is useful for a Hemorrhaging Parturient?

A

Ketamine 1 - 1.5 mg/kg

Causes HTN & Dysphoria

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12
Q

Which inductions meds are NOT normally used for induction in the Parturient?

A

Versed - more neonatal depression than other meds

Etomidate - Adrenal supression of baby

N2O - Interferes w/ B12 Metabolism

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13
Q

Why are all NMBs safe for the Parturient?

A

Hydrophillic charged = little placental transfer

Atypical Pseudocholinesterse = paralyzed baby

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14
Q

How is Anesthesia maintained During & After delivery under General?

A
  • Before Delivery:
  • 50% N20 + 2/3 MAC before delivery
  • 1.2 MAC + 2-3 mcg/kg Fentanyl
  • After Delivery
  • N2O + 0.5 MAC + Versed
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15
Q

How does General vs. Regional affect Neonatal Depression?

A

No difference

Only the time from Uterine Incision to Delivery matters d/t Uterine Artery Spasm

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16
Q

What are the Advantages of Epidurals for C-Sections?

A

Tailored Dose

Prolong block for longer procedures

Post-Op Pain Control

Hemodynamic Stability

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17
Q

What are Disadvantages to Epidurals for C-Sections?

A

Contraindications

Block not as good as Spinal

Still may need General for Surgery

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18
Q

What is the highest cause of death associated w/ Regionals for C-Sections?

A

LA Toxicity, then High Spinals

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19
Q

What are the CV effects of a High Block?

A

Sympathectomy of Lower Extremity & Splanchnic Beds

↓Venous Return

↓BP

↓HR

↓Contractility

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20
Q

What are the Pulmonary Effects of Epidurals?

A

Inspiration: None

Expiration: Low Pressures & Flows = Feeling of Dyspnea

Reassure Patient

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21
Q

What is the Ideal Height of an Epidural Block for a C-Section?

A

T4 - T8

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22
Q

How should pain be managed w/ an Epidural before a C-Section Incision?

A

Fentanyl 100 - 150 mcg

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23
Q

How should breakthrough pain be managed during a C-Section?

A

5cc Local Bolus

Fentanyl

N2O

Ketamine 10mg

Local Infiltrate by Surgeon

Convert to GA

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24
Q

Why are Spinals sometimes used over Epidurals for C-Sections?

A

Dense block w/ single shot

Defined Endpoint: CSF Flow = Good

No Risk for Intravascular Injection

Easy & No Catheter

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25
Q

What are Disadvantages of Spinals vs. Epidurals for C-Sections?

A

Finite - cant give more

PDPH risk

Total Spine Risk

Maternal Hypotension

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26
Q

Laboring women have less hypotension w/ Spinals than Non-Laboring women: True or False?

A

True

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27
Q

How effective is Prehydration in the Parturient w/ preventing Hypotension?

A

Not effective - does not stay intravascular long + ANP increase causes diuresis

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28
Q

What is the drug of choice in treating Hypotension in the Parturient?

A

Phenylephrine

&

Also Ephedrine, but increases risk of fetal acidosis

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29
Q

What are some considerations w/ using Tetracaine?

A

Slow Onset

Long Duration

Unreliable

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30
Q

What are some considerations w/ using Lidocaine?

A

Short Acting

&

Neuro Symptoms

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31
Q

What are some considerations w/ using Bupivacaine?

A

Best Choice

Fast Onset

Intermediate Duration

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32
Q

How much Pitocin should be given after C-Section Delivery?

A

20 units of Pitocin in 1L Bag

or

30 units of Pitocin in 500cc Bag

33
Q

What are the risks to the fetus during Non-OB surgeries in the Parturient?

A

Effect of Disease

Fetal Development d/t Anesthetic Agents

Uterine Blood Flow

Preterm Labor

Abortion

34
Q

How does Pregnancy affect Anesthesia?

A

↑Sensitivities to Neuraxial Agents

↓MAC

↓Plasma Cholinesterase

↓Protein Binding

35
Q

Which drug was shown to have teratogenic effects in rats?

A

N2O

Other gases not teratogenic in humans

36
Q

When is it safe for patients to have elective surgery after giving birth?

A

6 weeks after delivery

37
Q

Hyperthyroidism causes the Myocardium to be sensitive to __________

A

Hyperthyroidism causes the Myocardium to be sensitive to catecholamines

38
Q

What are the Anesthetic considerations for caring for a Parturient w/ Hyperthyroidism?

A

May be on Propranolol which exacerbates Hypotension from Subarachnoid Block

&

Titrate pressors carefully - more sensitive

39
Q

What can Pheochromocytoma look like particularly in the Parturient?

A

Preeclampsia

Epidural Preferred

DONT Beta-Block before Alpha Blocking first

40
Q

How does pregnancy affect Bronchial Asthma?

A

May improve d/t Bronchodilation

Give Methylxanthines, Steroids, B-Adrenergics

Prefer Epidural > Spinal > GA

41
Q

What drugs should be avoided in Parturients w/ Bronchial Asthma?

A

General Anesthesia

H2 Blockers - Rinitidine, Cimetidine

Desflurane

42
Q

What Induction meds should be used for parturients w/ Bronchial Asthma?

A

Ketamine

&

Atropine or Robinul

43
Q

Paraplegic Parturients have Autonomic Hyperreflexia & Preterm Labor Risk, what are the symptoms?

A

Triggered by Skin Stimulation & Bladder/Uterus Distension

Pilomotor Erection

Sweating

Flushing

Severe HTN

Bradycardia

44
Q

How is Autonomic Hyperreflexia prevented in the Paraplegic Parturient?

A

Early Epidural Analgesia preferred over SAB

Avoid Sux d/t Hyperkalemia Risk

45
Q

What are the two presenting patterns of Multiple Sclerosis?

A

Exacerbating Remitting - abrupt attacks resolving over months

&

Chronic Progressive

46
Q

What are symptoms of Multiple Sclerosis?

A

Loss of CNS Myelin

Weakness

Impaired Vision

Ataxia

Bladder/Bowel Dysfunction

Labile Emotions

47
Q

How is Multiple Sclerosis treated?

A

No Cure

Immunosupression

48
Q

How does pregnancy affect Multiple Sclerosis?

A

Slight Relapse Risk d/t stress, exhaustion, infection, and fever

No negative effects overall

49
Q

What are concerns regarding Neuraxial blocks w/ Multiple Sclerosis?

A

Toxicity d/t Demyelinated Spinal Cord

Dont use > 0.25% Bupivacaine

50
Q

What should be avoided in parturients w/ Multiple Sclerosis?

A

Avoid Sux - muscles already weak

&

Maintain normal temps

51
Q

What is the main concern w/ Parturients who have Brain Tumors?

A

Brain Herniation & Death

Avoid Dural Puncture

Consider IV pain control, Lumbar & Pudendal Blocks, or GETA

52
Q

What is Pseudotumor cerebri?

A

Benign Intracranial Hypertension unrelated to a mass

OK for Epidural/Spinal

53
Q

What special considerations should you take for Parturients w/ Epilepsy?

A

None - Proceed as normal

54
Q

What is the pathophysiology of Myasthenia Gravis?

A

Progressive muscle weakness

ACTH receptor destruction

Effects Women 3x > Men

Treat w/ Neostigmine or Edrophonium

55
Q

How does pregnancy affect Myasthenia Gravis?

A

Exacerbation

Cholinergic Crisis - may need more Neostigmine

56
Q

What meds are Contraindicated for Parturients w/ Myasthenia Gravis?

A

Some ABX’s

Mag Sulfate

Propranolol

Quinidine

Beta-Adrenergerics - Ritodrine, Terbutaline

Lithium

Penicillamine

Quinine

57
Q

How does Myathenia Gravis affect Anesthetic Management?

A

1/2 MAC

1/2 Intubation Doses

More sensitive to NMBs, Opioids, & Locals

58
Q

What are symptoms of a Cholinergic crisis related to Myathenia Gravis?

A

Profound Muscle Weakness

Resp. Failure

Loss of Bowel/Bladder Function

Disorientation

Diplopia

59
Q

What is used to treat a Cholinergic Crisis?

A

IV & IM Atropine

60
Q

What is Sickle Cell Disease?

A

Recessive Gene Blood Disorder

RBCs are abnormal, rigid, sickle shaped - pain, viscosity, auto-amputation

Shortened Life Span

61
Q

Which form of Sickle Cell Disease causes the most problems for Parturients?

A

Homozygous/Rare Sickle Cell (HgbSS/HgbSC) - severe anemia & preeclampsia

Heterozygous (HgbAS) - no problems

62
Q

What factors may cause a Sickle Cell Crisis?

A

Hypoxia

Hypotension

Dehydration

Hypothermia

Acidosis

Tourniquet

63
Q

What is the most common type of VonWillebrand Disease (vWF)?

A

Type 1 - Treat w/ DDAVP

DONT use DDAVP w/ Type 3 - worsens bleed

Relative contraidication to Neuraxial blocks

64
Q

What is Factor V Leiden?

A

Factor V CANNOT be inactivated by Protein C = Hypercoagulability

65
Q

How are parturients w/ Factor V Leiden managed?

A
  • Early pregnancy Lovenox, then Heparin
  • Prophylactic Heparin - Hold 12 hrs before block
  • Therapuetic Heparin - Hold 24 hrs before block
  • Evaluate Anti-Xa
66
Q

What do Protein C & Protein S do?

A

Work w/ Factors Va & VIIIa to inhibit clot formation

67
Q

What might Phospholipid & Cardiolipid Antibodies suggest?

A

Hypercoagulability

68
Q

What causes Diffuse Inflammation in Lungs, Pericardium, Pleura, Sclera, and Subcutaneous nodular lesions?

A

Rheumatoid Arthritis

69
Q

What are Anesthetic problems related to Rheumatoid Arthritis?

A

Difficult airway d/t ↓Neck Mobility & Hardened Arytenoids

Difficult Epidural/Spinal needle placement

Restrictive Lung Disease

70
Q

What are the CV issues regarding Rheumatoid Arthritis?

A

Pericarditis

Valvulitis

CAD

MI

Stroke

Atypical Angina

71
Q

What is Lupus?

A

Multisystem Inflammatory Disease d/t Auto-Antibodies against cell membrane

Effects Black, Asian, and Native American Women in childbearing years

72
Q

What are problems with Maternal Opioid Addiction?

A

Difficult IV Access

Mom & Baby Withdrawal Symptoms

↑O2 Consumption

↑Preterm Labor & Low Birth Weight

↑Maternal Hypovolemia & Adrenal Insufficiency

73
Q

What are the risks invovled w/ Maternal Alcohol Addiction?

A

Hemorrhage

Clotting Abnormalities

Cardiomyopathy

Neuropathy

↑Gastric Volume & Acidity

74
Q

What are problems w/ Maternal Amphetamine Addiction?

A

↑MAC & Gas = Uterine Atony

&

Catecholamine Depletion

75
Q

What does cocaine do to the parturient & baby?

A

Vasoconstricts - ↓UBF

Thrombocytopenia

HTN & Tachycardia

↑PTL

↑Congenital Abnormalities

Growth Retardation

Low Birth Weight

76
Q

How does Cocaine affect Local Anesthetics?

A

↓Plasma Cholinesterase - prolongs NMB & LA

77
Q

How does HIV affect Pregnancy?

A

No Effect, but can cause paralysis, ataxia, encephalitis, and coma

78
Q

How can HIV cause a difficult airway?

A

Pharyngeal Lymphatic Hypertrophy

79
Q

In parturients w/ Cardiac Disease, what can reverse a L -> R shunt & Cyanosis?

A

Hypotension - be careful w/ SAB’s w/ these patients

Summer 2020 - APA Foundations 2 - OB (4 decks)

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