Preeclampsia, DM, PIH, Obesity, Hemorrhage, & Baby Resuscitation

What is the most common medical problem of pregnancy?

Diabetes - hyperplasia of pancreatic beta-cells

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What is the difference b/t Gestational Diabetes & Diabetes?

Gestational is when DM is first diagnosed in Pregnancy

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What factors contribute to Gestational Diabetes?

Older Mom

Obesity

Family DM History

Hx of Stillbirth, Baby Death, Fetal Malformation , or Big Baby

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Which trimester is Gestational Diabetes more prevalent?

2nd & 3rd Trimesters

Back to Normal after Delivery w/ High Recurrence rate

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What are the Acute Complications of Gestational Diabetes?

DKA

Hyperglycemic NonKetotic State

Hypoglycemia

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What are the Chronic Complications of Gestational Diabetes?

Macrovascular
(Coronary, Cerebrovascular, Peripheral Vascular)

Microvascular
(Retinopathy, Nephropathy)

Neuropathy
(Autonomic, Somatic)

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What other conditions are associated w/ Gestational Diabetes?

HTN

Superimposed Preeclampsia

Polyhydraminios - excess amniotic fluid

C-Section

Nephropathy

Placental Insufficiency

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What is the best way to Prevent Fetal Structural Abnormalities in regards to Gestational Diabetes?

Early Glycemic Control

Target A1c: 4-6%

> 6.5% = Vascular Disease

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Type 1 Diabetes may cause Stiff Joint Syndrome, what do these patients look like?

Short Stature

Contractures

Tight Skin

Difficult Airway

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How should Insulin be managed for Gestational Diabetes?

Preggos need more insulin in the 2nd & 3rd trimesters & less once labor starts and after delivery

Give Half of NPH + Sliding Scale or Insulin Drip

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What can Diabetic Autonomic Neuropathy cause?

HTN

Ortho Hypotension

Painless MI

Decreased Response to Atropine & Propranolol

Neuro Bladder

Gastroparesis

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What should be done for Protamine Sulfate Anaphylaxis from NPH?

Stop Protamine & Give Epinephrine

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How does DKA affect the fetus?

Ketones cross placenta & decreases fetal oxygenation

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True/False? Obese parturients require less Local Anesthetic and achieve higher blocks w/ no difference in pain?

True

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What is the Third leading cause of Maternal Mortality?

Hypertension

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What are the categories of Hypertension during Pregancy?

Chronic HTN

PIH

Preeclampsia-Eclampsia (Seizure)

Superimposed Preeclampsia

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At what Diastolic BP does the risk of Placental Abruption & Fetal Growth Restriction increase?

DBP > 110

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What BP is considered Pregnancy Induced Hypertension?

> 140/90 mmHg

Resolves 12wks postpartum

No Renal/Systemic Involvement

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What is Preeclampsia?

New Onset HTN > 20 wks gestation or Early Postpartum

Resolves 48hrs Postpartum

Renal/Systemic Involvement

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What can develop w/ Preeclampsia when there is Renal/Systemic Involvement?

Proteinuria

Oliguria

Headaches

Clonus

↑LFTs

Thrombocytopenia

DIC

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What are the Risk Factors of Preeclampsia?

First Pregnancy

Black < 18 yo & > 35 yo

Prior History & Fam. History

DM, Renal Disease, HTN, Anti-Phospholipid

Twins

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What are Preeclampsia Symptoms?

Vision Problems

Headache

Epigastric Pain

Increasing Edema & Weight

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How can Preeclampsia cause a Difficult Airway?

Upper Airway Edema

Laryngeal Edema

Airway Obstruction

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How does Preeclampsia affect the CV system?

↑CO

↑SVR

↑CVP or No Change

↓Plasma Volume

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What are the Pulmonary Effects of Preeclampsia?

↓Oncotic Pressure Capillary Leak Vasoconstriction ↑PAWP

What are the Liver problems associated w/ PIH or Preeclampsia?

Periportal Hemorrhage Ischemic Legion Swelling Epigastric Pain

What are the Renal Effects of Preeclampsia?

Proteinuria ARF w/ Oliguria ↑BUN ↓GFR & Clearance

How does Preeclampsia affect the Uterus?

↑Activity Oxytocin Sensitivity PTL ↑Abruption Risk ↓UBF

What is the leading cause of Maternal Death relating to PIH?

Intracranial Hemorrhage

What are Fetal Complications of Preeclampsia?

Abruptio Placentae IUGR PTL Death

What is HELLP Syndrome?

**H**emolysis **E**levated **L**iver Enzymes **L**ow **P**latelets

What are symptoms of HELLP Syndrome?

Malaise Epigastric Pain N/V Mutli-System Failure Self-Limiting

What type of Anesthesia is Contraindicated in HELLP Syndrome?

Regional

What should be closely monitored in HELPP Syndrome?

Platelet count Hemostasis not a problem til \< 40,000

What is the Definitive Cure for HELLP Syndrome?

Delivery Platelets will normalize 72 hrs after

What is the drug of choice for treating Preeclampsia?

Mag Sulfate - narrow therapeutic index - used to prevent seizure Mag goal of 4 - 6 mmol/L

What is the concern when using Sodium Nitroprusside to control HTN in the parturient?

Fetal Cyanide Toxicity

What should be given for Mag Sulfate Toxicity?

Calcium Gluconate IV

What happens w/ a Mag Level of 5-10?

Wide PR & QRS

What happens w/ a Mag Level of 11 - 14?

Depressed Tendon Reflexes

What happens w/ a Mag Level of 15 - 24?

SA, AV Block & Resp. Paralysis

At what level of Magnesium will the patient go into Cardiac Arrest?

\> 25 mEq/L

What meds can be given to Blunt the Laryngeal Response?

Hydralazine Nitroglycerin Labetalol

How does Magnesium Sulfate affect NMBs & Pressors?

Enhances all NMBs & Inhibits catecholamine release and blunts pressor response

What is Placenta Previa?

Painless Vaginal Bleeding Complete Previa = Full Cervical Os Coverage by Placenta

Are Regionals contraindicated for Placenta Previa?

No. Ok for Regional if patient is stable

What is Placenta Accreta?

When Placenta is attached abnormally deep thru the endometrium to the myometrium

Whats the difference b/t Accreta, Increta, and Percreta?

**Accreta**: no myometrium penetration **Increta:** further into myometrium **Percreta**: all the way thru myometrium into the serosa

After the baby has been delivered, there is still no delivery of the placenta after 30 minutes, what should you suspect?

Placenta Accreta

What factors increase the risk for Placenta Accreta?

Placenta Previa Uterine Scar d/t D&C, C/S, Myomectomy Asherman's Syndrome Thin Placental Decidua

How is Placenta Accreta treated?

C-Section Hysterectomy Myometrium Resection**\*** Pelvic Artery Embolization**\*** Balloon Tamponade**\*** **(\*utereus-sparing)**

What is the most common cause of Intrapartum Fetal Death?

Abruptio Placentae - premature separation of placenta w/ _painful_ vaginal bleed

What are the risk factors associated w/ Abruptio Placentae?

HTN Trauma Cocaine & ETOH Abnormal Uterine Structure Multiparity

What are risk factors for Uterine Rupture?

Prior C/S Hx Myomectomy Prolong Labor w/ Oxytocin Big Uterus

What are signs and symptoms of Uterine Rupture?

Sudden Severe Fetal Distress Severe Abd. Pain even w/ Epidural Bleeding

What should be done once a Uterine Rupture has been identified?

Restore Volume & Emergent Lapartomy under GA

How much blood loss would be considered Postpartum Hemorrhage?

\> 500 cc

What causes Postpartum Hemorrhage?

Uterine Atony Uterine Overdistension d/t Twins or Polyhydramnios Uterine Inversion Perineal Laceration Retained Placenta

How is Uterine Atony treated?

* Oxytocin IV * Methylergonovine (Methergine) IM - can cause HTN IV * Hemabate - prostaglandin IM - can cause Bronchospasm

Which condition is sometimes referred to as an Anaphylactoid Syndrome of Pregnancy?

Amniotic Fluid Embolism that can happen b/t labor & postpartum where amniotic fluid gets into mom's circulation **85% Mortality**

What are signs & symptoms of an Amniotic Fluid Embolism?

Sudden Tachypnea Cyanosis Shock Generalized Bleeding (DIC) Uterine Atony

What is the normal Fetal Heart Rate?

120 - 160 bpm \< 120 = Asphyxia

What is Short Term Variability for Fetal Heart Rates?

3 - 6 bpm Reduced by CNS Depressants

What is Long Term Variability in Fetal Heart Rates?

15 - 40 Accelerations per hour w/ fetal movement Decreases w/ Fetal Sleep

What kind of Fetal Heart Decelerations are NOT associated w/ Fetal Distress?

**Early** Decelerations from Vagal Response d/t head compression

What kind of Fetal Heart Decelerations signify Uteroplacental Insuffiency & Decreased O₂Supply?

**Late** Decelerations - Fetal Distress

\_\_\_\_\_ decelerations are related to cord compression

**Variable** Decelerations \>70 bpm & \> 60 secs = Fetal Asphyxia

What is the Normal ABG for a Neonate?

**pH:** 7.25 - 7.35 **pCO2:** 40 - 50 mmHg **pO2:** 20 - 30 mmHg **Base:** \< 10

How is a baby's Apgar Scored?

Respirations Crying Reflex Irritability Skin Color Muscle Tone @1 Minute & @5 Minutes

What should be done if the Apgar is \< 7 @ 5 Minutes?

Repeat Apgar q5 min for 20 min or until two successive Apgars of 7 or more

When resuscitating the neonate, what should be done?

* Suction Muconium * BMV w/ 40 peep initially, the keep pressure \< 30 cm H₂0 after * RR should be 30 - 60 /min * HR should be \> 100 bpm * Start CPR & Intubate if HR at 60-80 and not rising

What is the Normal Neonate BP?

**For 1-2 kg** 50/25 **\>3 kg** 70/40 If Low BP, give fluids @ 10cc/kg

What can cause Hypotension in the Neonate?

Hypoglycemia Hypermagnesemia Hypocalcemia

True/False: Dosing is the same when giving meds through an ETT for both Pediatric & Neonatal Resuscitation?

**FALSE** Pediatric Resuscitation needs higher dose thru ETT Higher doses thru ETT **_NOT_** recommended for Neonatal Resuscitation

Preeclampsia, DM, PIH, Obesity, Hemorrhage, & Baby Resuscitation - Quiz 4 Flashcards