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Obstetrics > Pathophysiology of Obstetric Disorders > Flashcards

Pathophysiology of Obstetric Disorders Flashcards

1
Q

How is chronic hypertension defined in the obstetric patient?

A

Occurs before 20 weeks gestation

Does not return to normal after delivery

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2
Q

What is gestational hypertension?

A

Develops after 20 weeks gestation

Proteinuria does not occur

Return to normotensive state after delivery

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3
Q

What is preeclampsia?

A

Hypertension that develops after 20 weeks gestation

Proteinuria typically present

If proteinuria is not present, any of the following conditions are indicative of preeclampsia:

Persistent RUQ or epigastric pain

Persistent CNS or visual symptoms

Fetal growth restriction

Thrombocytopenia

Elevated serum liver enzymes

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4
Q

What is eclampsia?

A

The mother with preeclampsia develops seizures

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5
Q

How does healthy placental implantation compare to that of a preeclamptic patient?

A

Healthy placenta produces equal amounts of thromboxane and prostacyclin

Preeclamptic patient’s placenta produces up to seven times more thromboxane than prostacyclin. It also produces a variety of cytokines.

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6
Q

How do increased levels of thromboxane affect the placenta?

A

Thromboxane increases:
Platelet aggregation
Vasoconstriction
Uterine activity

and decreases:
Uteroplacental bloodflow

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7
Q

What are major potential consequences of preeclampsia?

A

Proteinuria

DIC

Intracranial hemorrhage/ cerebral edema

Heart failure/ pulmonary edema

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8
Q

What are the blood pressure parameters for mild preeclampsia?

A

<160/ <110 mmHg

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9
Q

What are the blood pressure parameters for severe preeclampsia?

A

> = 160/ >= 110 mmHg

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10
Q

What causes the hypertension seen in preeclampsia?

A

Vasoconstriction due to thromboxane

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11
Q

What systemic symptoms may be present in severe preeclampsia that are not present in mild preeclampsia?

A

Decreased urine output
Pulmonary edema
Cyanosis
Headache
Visual impairment
Epigastric pain
HELLP syndrome

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12
Q

What role does thromboxane play in preeclampsia?

A

Increases vasoconstriction = increases blood pressure

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13
Q

How may preeclampsia affect renal function?

A

Glomerular capillary endothelial destruction and renal edema may result in proteinuria and decreased urine output

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14
Q

What is the pathophysiology of the generalized edema that may be present in preeclampsia and the pulmonary edema that may occur in severe preeclampsia?

A

Decreased oncotic pressure

Increased vascular permeability

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15
Q

What is the definitive treatment of preeclampsia and eclampsia?

A

Delivery of the fetus and placent

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16
Q

At what blood pressure should the preeclamptic parturient receive pharmacologic treatment?

A

160/110 mmHg

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17
Q

What is the primary reason for treating blood pressure in preeclampsia?

A

Prevent cerebrovascular accident, myocardial ischemia, and placental abruption

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18
Q

What is the pharmacologic treatment for acute hypertension in pregnancy?

A

Labetalol 20 mg IV then 40-80 mg q 10 min up to a max dose of 220 mg

Hydralazine 5mg IV q 20 min up to a max dose of 20 mg

Nifedipine 10 mg PO q 20 min up to a max dose of 50 mg

Nicardipine infusion started at 5 mg/hr and titrated by 2.5 mg/hr q 5 min up to a max of 15 mg/hr

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19
Q

How long is the patient at risk for complication related to severe preeclampsia?

A

Up to 4 weeks into the postpartum period

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20
Q

When is the patient at highest risk for pulmonary hypertension and stroke?

A

In the postpartum period

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21
Q

How does neuraxial anesthesia impact the preeclamptic patient?

A

Assists with blood pressure control > better uteroplacental perfusion

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22
Q

What are some anesthetic considerations for the preeclamptic patient?

A

Rule out thrombocytopenia prior to a neuraxial block

More likely to be a difficult intubation d/t airway swelling

Beta blockers, remifentanil, and Mg++ blunt the hemodynamic response to laryngoscopy

Exaggerated response to sympathomimetics and methergine

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23
Q

What are anesthetic considerations in the preeclamptic patient receiving Mg++?

A

Increased sensitivity to neuromuscular blockers

Increased risk for postpartum hemorrhage

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24
Q

What is the seizure prophylaxis regimen for eclamptic patients?

A

Mg++:
Loading dose of 4 g over 10 minutes

Infusion 1-2 g/hr

25
Q

What is the treatment for Mg++ toxicity?

A

10 mL of 10% calcium gluconate IV

26
Q

What does HELLP stand for?

A

Hemolysis, Elevated Liver enzymes, and Low Platelet count

27
Q

What are the symptoms of HELLP syndrome?

A

Epigastric pain
Upper abdominal tenderness

28
Q

What is the definitive treatment for HELLP syndrome?

A

Delivery of the fetus

29
Q

What are risks associated with HELLP syndrome?

A

DIC

Intra-abdominal bleeding from the liver

30
Q

When is the patient at risk for developing HELLP syndrome?

A

Throughout pregnancy, but may present for the first time in the postpartum period

31
Q

How does cocaine abuse impact the cardiovascular system?

A

Tachycardia
Dysrhythmias
Coronary vasoconstriciton
Myocardial ischemia

32
Q

How does cocaine abuse impact the CNS?

A

Cerebral vasoconstriction
Ischemia
Seizures
Stroke

33
Q

How does cocaine use affect MAC?

A

Acute intoxication increase MAC

Chronic use decreases MAC

34
Q

What are obstetric risks associated with cocaine abuse?

A

Spontaneous abortion
Premature labor
Placental abruption
Low APGAR scores

35
Q

How can beta blockade affect the patient acutely under the influence of cocaine?

A

If SVR is significantly elevated:

Beta-1 blockade (myocardia depressions + Beta-2 blockade (impaired vasodilation in muscular beds) = heart failure

36
Q

What is the best treatment for hypotension in the patient who is a chronic cocaine abuser?

A

Phenylephrine- ephedrine may be ineffective d/t catecholamine depletion

37
Q

What are the best treatment options for a cocaine abuser who is hypertensive?

A

Labetalol- also blocks alpha-mediated vasoconstriction

Vasodilators- but may cause tachycardia

38
Q

How might chronic cocaine abuse affect coagulation?

A

Association with thrombocytopenia = check plt count prior to neuraxial anesthesia

39
Q

Placenta accreta

A

Placenta attaches to the surface of the myometrium

40
Q

Placenta increta

A

Placenta invades the myometrium

41
Q

Placenta percreta

A

Placenta implantation extends beyond the uterus

42
Q

What is the preferred approach to anesthesia in the setting of abnormal placental implantation?

A

General anesthesia preferred (although neuraxial anesthesia is considered safe)

43
Q

What patient history is associated with abnormal placental implantation?

A

Placenta previa
Prior c-section(s)

44
Q

Placenta previa

A

Placenta attaches to the lower uterine segment. It partially or completely covers the cervical os.

45
Q

What is a sign of placental previa?

A

Painless vaginal bleeding

46
Q

What is a complication of placenta previa?

A

Hemorrhage

47
Q

What are risk factors of placenta previa?

A

Previous c-section
History of multiple births

48
Q

Placental abruption

A

Partial or complete separation of the placenta from the uterine wall before delivery

49
Q

Risk factors for placental abruption

A

Factors that increase the driving pressure to the placenta:

Pregnancy induced hypertension

Preeclampsia

Chronic hypertension

Cocaine use

Smoking

Excessive alcohol use

50
Q

What are signs of placental abruption?

A

Painful vaginal bleeding

51
Q

What are potential complications of placental abruption?

A

Fetal hypoxia
Amniotic fluid embolism
DIC

52
Q

What are anesthesia considerations for placental abruption?

A

Vaginal delivery is possible if the fetus is stable

Obtain large-bore IV access and have blood products available

Prepare for c-section

53
Q

What is the most common cause of postpartum hemorrhage?

A

Uterine atony

54
Q

What are risk factors for postpartum uterine atony?

A

Multiparity

Multiple gestations

Polyhdraminos

Prolonged oxytocin infusion before surgery

55
Q

What are causes of obstetric bleeding?

A

Uterine atony

Retained placenta/ placental fragments

Uterine inversion

Coagulopathy

Placenta previa

Placental abruption

Abnormal placental implantation

56
Q

What medication should the anesthesia provider anticipate administering for the patient with retained placental fragments?

A

IV nitroglycerine- provides uterine relaxation for placental extraction

57
Q

What is the medical management for postpartum hemorrhage?

A

Uterine massage

Ergot alkaloids

Manual massage

Intrauterine balloon (when other approaches are ineffective)

58
Q

What conditions are associated with obstetric DIC?

A

Amniotic fluid embolism
Placenta abruption
Intrauterine fetal demise

Obstetrics (6 decks)

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