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OB > Pre-eclampsia, PIH, Obesity and diabetes > Flashcards

Pre-eclampsia, PIH, Obesity and diabetes Flashcards

1
Q

What is Gestational diabetes?

A

-Dm that is first diagnosed in pregnancy
-requires insulin or diet control

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2
Q

What are the risk factors for gestational diabetes?

A

-advanced maternal age
-obesity
-history of DM
-hx of stillbirth, neonatal death, fetal malformation/macrosomia

-occurs when pts can’t mount a sufficient compensatory insulin response during pregnancy

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3
Q

When is gestational diabetes more prevalent?

A

-2nd and 3rd trimesters
- after delivery, most pts return to normal glucose tolerance

  • high recurrence rate with subsequent pregnancies
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4
Q

What are some acute complications of gestational DM?

A

-DKA
-hyperglycemic nonketotic state (primarily type 2s)
-hypoglycemia

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5
Q

What are the chronic complications of gestational DM?

A

Macrovascular:
-coronary
-cerebrovascular
-peripheral vascular

microvascular:
-retinopathy
-nephropathy

Neuropathy:
-autonomic
-somatic

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6
Q

What is gestational DM associated with?

A

-gestational HTN
-polyhydramnios
-c-section

Early glycemic control is the best way to prevent fetal structural abnormalities

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7
Q

At what A1c does the risk of vascular disease increase?

A

6.5%

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8
Q

what’s a normal A1C?

A

4-6%

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9
Q

When does stiff joint syndrome occur?

A

Long-standing type 1

  • associated w nonfamilial short stature, joint contractions and tight skin

DL can be difficult d/t c-spine rigidity in the atlantooccipital joint

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10
Q

Maternal insulin requirements _______ progressively during the 2nd and 3rd trimesters and decrease at the _______ and continue to decrease following delivery

A

Increase
onset of labor

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11
Q

What are the symptoms of Diabetic autonomic neuropathy?

A

-HTN
-Orthostatic Hypotension
-Painless MI
-Decreased HR variability
-Decreased response to medications- (Atropine and propanolol)
-Resting tachycardia
-Neurogenic atonic bladder
-Hemoglobin A1C
-Gastroparesis with delayed emptying

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12
Q

What should you maintain a pts BG at?

A

> 100 mg/dL and < 180 mg/dL

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13
Q

How would you manage blood sugar in the OR?

A

Begin D5W 1-1.5 ml/kg/hr as an IV piggy back into crystalloid solution

One-half of the total daily dose as intermediate form (NPH) plus an intraoperative “sliding scale
Continuous infusion of regular insulin
Start infusion based on serum glucose using formula:
Units/hr = Plasma glucose/150+ (desired range of 150 etc)

i.e. glucose of 220/150 = 1.4 units/hr (usually delivered in 250 units regular insulin/250 ml 09% NaCl solution

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14
Q

When could you see anaphylaxis d/t protamine?

A

in pts taking NPH or protamine zinc insulin

stop protamine, supportive care, epi

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15
Q

What is placental insufficiency?

A

Uteroplacental blood flow index is reduced by 35-45% (more with poor glucose control)

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16
Q

what are the 4 categories of hypertension in pregnancy?

A

-Chronic HTN
-Pregnancy induced hypertension
-Preeclampsia- eclampsia
-preeclampsia superimposed on chronic HTN

(most common medical issue during pregnancy)
Increase in maternal and fetal morbidity and remains a leading source of maternal mortality

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17
Q

Leading causes of maternal mortality:

A

-thromboembolism
-non-obstetric injuries
-HTN

18
Q

What is a maternal DBP > 110 associated with?

A

increased risk of placental abruption and fetal growth restriction

19
Q

what causes most maternal morbidity?

A

Superimposed preeclampsia

20
Q

What is PIH?

A

Sustained BP increase to SBP> 140 or DBP >90
-usually mild and later in pregnancy
-no renal or other systemic involvement
-resolves 12 wks postpartum
-May evolve to preeclampsia

21
Q

What is pre-eclampsia?

A

New onset HTN after 20 wks gestation or early postpartum.
-Usually resolves within 48 hrs postpartum

-Proteinuria >300mg/24 hrs
-Oliguria or serum plasma creatinine ratio > 0.09 mmol/L
- headaches w hyperreflexia, eclampsia, clonus, or visual disturbances
- increased LTFs, glutathione-S-transferase alpha 1-1, alanine aminotransferase, or right abdominal pain
-thrombocytopenia, increased LDH, hemolysis, DIC
-Swelling (edema)
-excessive wt. gain (2-3 lbs)

  • 10% in primigravida
    -20-25% w Hx of chronic HTN
22
Q

Maternal risk factors for pre-eclampsia

A

-first pregnancy
-younger than 18 or older than 35
-prior hx of pre-eclampsia
-Black race
- chronic HTN
-renal disease
-diabetes
-anti-phospholipid syndrome
-twins
-family hx

23
Q

What are the characteristics of DKA?

A

Plasma glucose >300
HCO3 < 15
pH <7.30
Acetone positive: 1:2
Ketones cross the placenta and decrease fetal oxygenation
maintain continuous fetal heart monitoring

24
Q

What are the complications of obesity in the parturient?

A

Risk for medical, obstetrical, and anesthetic complications

difficulty with intubation
problems with the placement of neuraxial anesthesia

-Higher sensory blockade with no difference in pain score
-Greater distribution of epidural local anesthetic within epidural spaces

25
Q

What is the most common medical issue during pregnancy?

A

Hypertension

26
Q

Which signs are consistent with a diagnosis of preeclampsia? (select 3)

-Seizures
-Increased thromboxane
-Increased prostacyclin
-Proteinuria
-Vasoconstriction
-Impaired platelet aggregation

A

-Increased thromboxane
-Vasoconstriction
-Proteinuria

Pts also have enhanced platelet aggregation (not impaired) and decreased prostacyclin

The pt w eclampsia has seizures, and the pt with preeclampsia does not- although she is at risk.

will have: visual disturbances, headache, epigastric pain, rapidly increasing nondependent edema, and rapid weight gain (a result of edema d/t capillary leak as well as renal Na+ and fluid retention)

27
Q

When will preeclampsia develop?

A

After 20 weeks gestations or early postpartum

28
Q

What are the characteristics or mild preeclampsia?

A

SBP: 140-160
DBP: 90-110
urinary protein: <5g/24 hr
Dipstick: + or 2+
Urine output: >500 mL/24 hrs
Headache: NO
visual disturbances: NO
epigastric pain: NO

29
Q

What are the characteristics of severe preeclampsia?

A

SBP: >160
DBP: >110
Urinary protein: > 5g/24 hrs
Dipstick: 3+ or 4+
Urine output: < 500mL/24hrs
Headache: yes
Visual disturbances: yes
Epigastric pain: yes

30
Q

What are the cardiac complications of preeclampsia?

A

Increased CO and SVR
CVP normal/slightly increased
Plasma volume reduced

31
Q

What causes pulmonary edema in someone w preeclampsia?

A

Decreased oncotic/colloid pressure
capillary/endothelial damage = leak
vasoconstriction
Increased PWP, and CVP

32
Q

What are the renal complications of preeclampsia?

A

-Proteinuria
-decreased GFR & Crcl
-Increased BUN
-decreased RBF
-Acute renal failure w oliguria –> PIH, DIC, HELP

Oliguria and renal failure may occur in the absence of hypovolemia
-be careful w hydration (can cause pulm. edema)

33
Q

What are the uterine complications of preeclampsia?

A

-Activity increased
-Hypersensitive to oxytocin
-frequent preterm labor
-uterine/placental blood flow decreased by 50-70%
-Increased incidence of abruption

34
Q

What are the fetal complications of PIH/ preeclampsia?

A

-Abruptio placentae
-Intrauterine growth restriction
-premature delivery
-intrauterine fetal death

35
Q

What does HELLP stand for?

A

H: hemolysis
EL: elevated liver enzymes
LP: low platelet count

Occurs <36 weeks

other symptoms are: malaise, epigastric pain , N/V-
usually self-limiting

36
Q

When is the platelet count back to normal in after delivery in someone who has HELLP?

A

within 72 hrs.

37
Q

Which maternal condition would most likely be be an indication for immediate delivery of the fetus?

A. HELLP syndrome
B. diabetes mellitus
C. preeclampsia
D. supine hypotension syndrome

A

A. HELLP syndrome

HELLP Syndrome is a complication of preeclampsia that often leads to the progressive, often sudden deterioration of both mother and fetus. The acronym HELLP represents a condition consisting of Hemolysis, Elevated Liver enzymes, and Low Platelets. Approximately 5-10% of preeclamptic women develop this syndrome, and it is generally an indication for immediate delivery of the fetus due to increased maternal morbidity and mortality.

38
Q

The incidence of placental abruption is much higher in patients with

A. multiple sclerosis
B. rheumatoid arthritis
C. preeclampsia
D. HELLP syndrome
A

C. preeclampsia

Placental abruption is the separation of an implanted placenta after 20 weeks of pregnancy. It can result in massive blood loss and is one of the most common causes of fetal demise. If the abruption is mild, a vaginal delivery may be attempted, but at any sign of fetal distress an emergency cesarean section must be carried out. It is more common in patients with preeclampsia (up to 1 in 4).

39
Q

Which of the following is a predictor of difficult epidural placement in obese parturients? (select two)

A. The ability of the patient to flex their back
B. Body mass index
C. The practitioner’s experience level
D. The ability to palpate bony landmarks

A

A. The ability of the patient to flex their back
D. The ability to palpate bony landmarks

Studies have shown that the ability to palpate bony landmarks and the ability of the patient to flex their back were predictive of difficulty in placing an epidural in a parturient. The body mass index of the patient and the experience level of the practitioner were not predictive of difficulty.

40
Q

In general, regional anesthesia is not contraindicated in obstetric patients with mild preeclampsia if the platelet count is at least

A. 25,000 per microliter
B. 50,000 per microliter
C. 80,000 per microliter
D. 100,000 per microliter

A

C. 80,000 per microliter

A platelet count less than 75,000-80,000 is considered too low to perform a neuraxial anesthetic.

41
Q

The drug of choice for treating hypertension during anesthesia in a parturient with preeclampsia is

A. labetolol
B. metoprolol
C. nitroglycerin
D. morphine 20 mg IV
A

A. labetolol

The first line drug for treating hypertension during anesthesia for preeclamptic patients is labetolol. Esmolol may also be used during induction. Large doses of opioids are avoided as they could produce maternal and fetal respiratory depression.

OB (8 decks)

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