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AP: Summer Exam 3 > Pregnancy: Physiologic Changes and Pathophysiology > Flashcards

Pregnancy: Physiologic Changes and Pathophysiology Flashcards

1
Q

What is the average healthy weight gain during pregnancy?

A

25 - 35 lbs, or 12 kg

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2
Q

What causes increase in body weight during pregnancy?(3)

A

Increased size of uterus (4kg)

Increased blood volume and interstitial fluid (4kg)

Increased fat and protein deposit (4kg)

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3
Q

How much weight is gained in the 1st, 2nd, and 3rd trimesters?

A

1st: 1-2 kg

2nd, 3rd: 5-6 kg

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4
Q

How much is VO2 increased during pregancy and what is the primary cause?

Note: VO2 is oxygen consumption.

A

~ 60%

Primarily: Needs of fetus, uterus, and placenta
Secondarily: Increased work of mom

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5
Q

What are anatomical physiological changes during pregancy? (4)

A

Thoracic cage circumference increases

Vertical measurement of chest decreases

Capillary engorgement of oropharynx, nasal mucosa, larynx

Dilation of large a/w to allow more ventilation

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6
Q

What can we expect with nasal instrumentation to a pregnant patient?

A

increased epistaxis

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7
Q

What are respiratory mechanics in pregnant women? (2)

A

More diaphragmatic excursion

Less thoracic cage movement

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8
Q

What are cardiovascular changes in a pregnant woman? (5)

A

increased blood volume

increased cardiac output

increased HR

increased stroke volume

right shift of oxyhemoglobin dissociation curve

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9
Q

How much is blood volume increased at full-term?

A

~1 liter

Note: BV increase mostly due to plasma.

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10
Q

Most CO output changes is due to stroke volume. True or false?

A

True

Note how CO increases 125% at birth.

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11
Q

What are the hemodynamic changes at full-term gestation relating to:

CO
SV
HR
Contractility
SVR
PVR

A

Cardiac Output +40%

Stroke Volume +30%

Heart Rate +15 (15-20 bpm)

Contractility negligible

SVR - 20%

PVR - 30%

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12
Q

What is the p50O2 in mmHg?

Fetal
Normal
Parturient (mom)

A

19

27

30

Note: P50 = 50% of Hb is saturated with oxygen.

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13
Q

What are uterine blood flow increases at full-term gestation?

A

Normal 50 ml/min to 600-700 ml/min

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14
Q

What are other hemodynamic changes at term gestation besides increased uterine blood flow?

A

Renal plasma flow increase

Skin blood flow increases 3-4 times

Blood pressure falls

  • Systolic 6-8%
  • Diastolic 20-25% early, normal at full-term
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15
Q

What are factors that impair uterine blood flow? (5)

A
  • Decreased perfusion pressure
  • Decreased uterine arterial pressure
  • Increased uterine venous pressure
  • Increased uterine vascular resistance
  • Exogenous vasoconstrictors
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16
Q

What is important to know regarding uterine blood flow?

A

It is pressure dependent and not auto-regulated!

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17
Q

What factors decrease uterine arterial pressure? (3)

A

Supine position due to aortocaval compression

Hemorrhage, hypovolemia

Hypotension from drugs or sympathetic blockade

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18
Q

What factors cause increased uterine venous pressure, which in turn impairs uterine flow? (4)

A

Vena caval compressions

Uterine contractions

Drug-induced hypertonus (oxytocin, local anesthetics)

Skeletal muscle hypertonus (seizures, Valsava)

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19
Q

What factors cause increased uterine vascular resistance which in turn impair uterine blood flow?

A

Endogenous vasoconstrictors

  • Catecholamines (stress)
  • Vasopressin (in response to hypovolemia)

Exogenous vasoconstrictors

  • Epi
  • Phenyl > ephedrine
  • Local anesthetics in high conc.
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20
Q

What is of greater concern, aortic or caval compression?

A

caval compression

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21
Q

What position results in complete caval compression?

How much does it decrease CO?

A

supine, begins at 13 weeks

25-40%

Note: lateral decubitus partially obstructs the vena cava, but collateral circulation can compensate.

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22
Q

Lateral decubitus causes little aortic compression. True or false?

A

True.

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23
Q

At what spinal levels does significant compression of the aorta occur?

A

L3-L5

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24
Q

What are the greatest changes in lung volumes at full-term?

A

Tidal volume increases 40%

FRC decreases 20%

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25
Q

What changes in respiratory physiology occur at full-term? (3)

A

Respiratory Rate +0-15%

Minute ventilation + 40%

Alveolar ventilation + 40%

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26
Q

What is PaCO2 in a non-pregnant vs. a pregnant woman?

A

Normal: 40mmHg

Pregnant (all trimesters): 30mmHg

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27
Q

How does HCO3 change in a non-pregnant vs. pregnant womam?

A

Normal HCO3: 24 mmHg

Pregnant (full-term): 20 mmHg

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28
Q

What happens to pH in a pregnant woman?

A

Slightly increases

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29
Q

What causes CNS depression in a pregnant woman?

A

progesterone

Note: As a result, less local anesthetics are needed for spinals and epidurals.

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30
Q

Because the CNS is depressed, MAC and amount of local anesthetics needed is decreased as much as ___-____%

A

30 (LA)-40 (MAC)%

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31
Q

What are special considerations for spinals and epidurals in pregnant women? (2)

A

Engorged venous plexus can increase risk of puncturing epidural vein or intravascular injection

Decreased CSF volume causes enhanced cephalad spread of LA

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32
Q

What are renal changes relating to:

Blood flow
GFR
BUN/Cr

A

BF increases

GFR increases

BUN/Cr decrease

33
Q

What are hepatic changes in pregnant women relating to:

Blood flow
Plasma cholinesterase

A

Hepatic function and blood flow remain largely unchanged

Plasma cholinesterase decreases, but not signicantly for our purposes

34
Q

What are hepatic related issues that may present to the pregnant woman?

A

Acute fatty liver

Gallstone formation more likely due to concentration of bile

35
Q

What are changes in colloid (a portion of plasma proteins) osmotic pressures in the pregnant pt?

A

Decreases by 5mmHg at term

36
Q

What are coagulation changes that occur with pregnant women relating to:

platelet turnover
clotting
fibrinolysis

A

all increase

37
Q

By how much does PT and PTT change during pregnancy?

A

both decrease by 20%

Note: Normal PT is 10-14 sec and PTT is 25-38 sec.

38
Q

What are changes to the endocrine system with pregnant women relating to the:

thyroid
parathyroid
insulin

A

Hyper or hypo-thyroidism

Increased PTH

Insulin-resistance in 3rd trimester

39
Q

What are GI changes during pregnancy? (7)

A

Delayed gastric emptying
Decreased GI mobility
Decreased gastric pH
Decreased gastric acid secretion
Silent regurgitation
Increased gastric volume
INCREASED ASPIRATION RISK

40
Q

What are general anesthesia concerns relating to the pregnant pt? (4)

A

Smaller ETT required

Increased shunt when supine

Increased rate of denitrogenation

Increased rate of decline of PaO2 during apnea

41
Q

When should you proceed with surgery in the pregnant pt?

A

If elective, postpone until postpartum.

If greater than minimal increased risk to mother, proceed with surgery.

42
Q

What are the phases in Stage 1 labor?

What are the cervical dilations for each?

A

Latent phase: onset of labor, 2-4 cm

Active phase: increased frequency of contractions, up to 10 cm

43
Q

What is Stage 2 of labor?

A

Full cervical dilation→Fetal descent→delivery of fetus

44
Q

What is Stage 3 of labor?

A

Delivery of the placenta

45
Q

How much blood is dispaced from the uterus to the central circulation with each contraction?

A

300-500ml

46
Q

What drug is given to induce labor?

A

Pitocin (Oxytocin)

47
Q

What drugs are given after delivery to contract the uterus back down to prevent hemorrhage?

A

Methergine

Hemabate

48
Q

What drug is given for pre-eclampsia?

A

Magnesium

49
Q

What are pregnancy induced diseases? (6)

A
  • Pre-eclampsia (pregnancy-induced HTN)
  • Eclampsia (severe preg-induced HTN)
  • Acute fatty liver
  • Amniotic fluid embolism
  • Thromboembolic disease
  • DVT/pulmonary embolus
50
Q

What is preeclampsia?

A

BP > 140/90, or >20% above baseline

Proteinuria and/or Edema

Usually presents 20 weeks after gestation

51
Q

What is HELLP syndrome?

A

Hemolysis

Elevated Liver Enzymes

Low Platelets

Note: Only 2 of 3 conditions are needed.

52
Q

What is eclampsia?

A

Preeclampsia with seizures

53
Q

Preeclampsia and HELLP syndrome is an _______ situation.

A

emergent

54
Q

What is the treatment for preeclampsia?

A

Generally resolves after delivery, but others may require ICU if pulmonary/renal issues.

55
Q

What are the symptoms of eclampsia? (5)

A

profound HTN
headache
double vision
hyperreflexia
convulsions

56
Q

What is the differential diagnosis for eclampsia?

A

Amniotic fluid embolism which leads to hypoxia and seizures

IV injection of LA but no HTN will be present in this instance

57
Q

What are anesthetic considerations for pts with eclampsia?

A

Secure the a/w in event of seizure!

Smaller tube

RSI

58
Q

What are neurological complications of PIH (pregnancy-induced HTN)? (5)

A

Headache
Visual disturbances
Hyperexcitability
Seizures
Intracranial hemorrhage

59
Q

What are cardiovascular complications of PIH? (3)

A

decreased intravascular volume

increased arteriolar resistance

heart failure

60
Q

What are hepatic complications of PIH? (3)

A

elevated liver enzymes

hematoma

hepatic rupture

61
Q

What are renal complications of PIH? (4)

A

Proteinuria

Na retention

Decreased GFR

Renal failure

62
Q

What are hematologic complications of PIH? (2)

A

Coagulopathy

Microangiopathic hemolysis

63
Q

Acute Fatty Liver is common/rare.

A

Rare, 1/12,000 of deliveries but deadly.

64
Q

What are the symptoms of acute fatty liver?

A

N/V

Epigastric pain

Jaundice

Decreased serum glucose

Increased liver enzymes

Note: Presents in 3rd trimester.

65
Q

What is the treatment of acute fatty liver? (3)

A

Supportive

FFP, platelets, albumin

Give vitamin K

Note: Hope that pts do not go into DIC (excessive thrombin).

66
Q

When is the onset of amniotic fluid embolism?

What are the symptoms? (6)

A

During delivery

Sudden CV collapse
Profound hypotension
Cyanosis
Seizures, Coma
DIC
Presents as anaphylaxis

Note: Rare, but deadly.

67
Q

What is the treatment of amniotic fluid embolism?

A

Deliver the baby

Provide supportive care

68
Q

What is DIC (disseminated intravascular coagulation)?

A

Widespread systemic activation of coagulation, resulting in intravascular formation of fibrin and ultimately thrombotic formation occlusion of small and mid-sized vessels.

69
Q

What are the causes of DIC?

A

Sepsis

Trauma

Obstretics

Note: Treatment is supportive and treat underlying cause.

70
Q

What is thromoembolic disease?

A

Pregnancy causes an increase in most clotting factors.

Gravid uterus causes venous stasis.

71
Q

What are risk factors for thromboembolic disease? (4)

A

Smoking

Obesity

Age

Genetics

72
Q

How do we diagnose DVTs?

What can they ultimately cause?

What is the treatment?

A

Doppler

Pulmonary embolus

Massage, heparin therapy

Note: Heparin is OK for the baby.

73
Q

What are anesthetic considerations for respiratory patients with asthma and cystic fibrosis, for example?

A

Do not go above T8 with the epidural due to effects on breathing!

74
Q

Is synthroid OK for the pregnant woman?

A

Yes

75
Q

Is glucophage OK for the pregnant woman?

A

Yes, oral hypoglycemics are fine.

76
Q

What are anesthetic considerations for pregnant women with renal disease?

A

Increased risk for HTN

Decreased fluid clearance

77
Q

What are anesthetic considerations for epileptic pregnant patients?

A

More seizures

Decrease meds due to increased risk of cleft lip/palate

78
Q

What are anesthetic considerations for myasthenia gravis pregnant pts?

A

Some pts get better, worse, or stay about the same

Stress can exacerbate MG

Resistance to anticholinesterases?

79
Q

What are the anesthetic considerations for pregnant women that are morbidly obese?

A

GI issues

A/w issues

Diabetes

AP: Summer Exam 3 (7 decks)

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