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My OB > Quiz 3 > Flashcards

Quiz 3 Flashcards

1
Q

C/S: Common indications include

A
  • failure to progress
  • fetal distress
  • fetal malpresentation
  • previous C/S (or failed VBAC)
  • maternal condition making vaginal delivery unsafe
  • fetal condition making vaginal delivery unsafe
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2
Q

C/S: Indications For General anesthesia

A
  • Acute severe fetal distress with no time for block
  • Non-functioning epidural catheter
  • Parturient has contraindication to regional block
  • Regional block inadequate
  • Patient refusal of block
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3
Q

anesthesia effects on the uterus

A
  • Avoid hypotension, hypoxia, acidosis, hyperventilation.
  • Limit time between uterine incision and delivery to less than 3 minutes.
  • Infants exposed to GA have lower Apgar at one minute but no difference at 5 mins.
  • No significant alteration in neurobehavioral scores with regional techniques.
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4
Q

largest and second largest predictor of difficult airway

A

Mallampti 4

Receding mandible

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5
Q

Antacid:

A

Sodium citrate used to raise gastric pH. May last only 15 min. Should be given to all pts prior to C/S (general or regional).

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6
Q

Ranitidine (Zantac):

A

H2 blocker, usually used in addition to antacid as it does nothing for acid that is already there. 50 mg iv dose. Max effect seen 2 hrs after administration

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7
Q

Metoclopramide (Reglan):

A

Decreases gastric volume within minutes after administration. May have antiemetic effects. Effects inhibited by opioids.

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8
Q

Patients for elective procedures should be NPO for __ hrs although still at risk for aspiration.

A

6

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9
Q

Critically important for denitrogenation:

A

At term O2 consumption increased 20-30%; this is accompanied by a decrease in FRC.

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10
Q

Propofol dose:

A

Dose 2.0-2.8 mg/kg
readily crosses the placenta

A single induction dose does not significantly change Apgar scores

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11
Q

Ketamine: dose and effects

A

Dose 1.0-1.5 mg/kg
Useful in the face of maternal hemorrhage as it supports the BP, also decreases risk of bronchospasm.
Side effects hypertension and dysphoria.

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12
Q

midazolam not used bc?

A

Causes more neonatal depression than other agents

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13
Q

Etomidate not used bc?

A

May cause transient adrenal suppression in the neonate

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14
Q

Muscle relaxants

A
  • Rapid sequence induction is mandatory in all but the rarest of cases.
  • No need for defasciculating dose prior to succinycholine (9% incidence of fasciculation at term)
  • Any relaxant is safe as their hydrophilic charged nature significantly limits placental transfer.
  • There have been cases of neonatal paralysis in infants with homozygous atypical pseudocholinesterase.
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15
Q

Maintenance of Anesthesia: Options

A
  • Prior to delivery many practitioners will deliver 50% nitrous oxide and 2/3 MAC of volatile agent.
  • Another option is to not use nitrous until the fetus is delivered and to use up to 1.2 MAC of volatile plus 2-3 mcg/kg of fentanyl. After delivery, reduce the volatile agent to 0.5 MAC or less and use nitrous oxide. Midazolam can also be given after delivery to reduce the likelihood of recall.
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16
Q

The uterine _______ to delivery interval does make a difference, possibly due to ____________.

A

incision

uterine artery spasm.

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17
Q

Greatest 2 Causes of death in parturients undergoing regional anesthesia for C/S

A

1 - Local toxicity

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18
Q

Physiological Effects of Regional: Pulmonary

A
  • No effect on inspiration.
  • Expiratory pressures and flows are reduced in proportion to decreased abdominal muscle strength.
  • A sensory block above T2 often gives patients a sense of dyspnea – reassurance is helpful.
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19
Q

Epidural management for C/S:

A
  • Dose catheter slowly. 15 cc of 2% lido or 3% 2-chloroprocaine should be given over 5 min, continuously question the patient for signs of local toxicity.
  • 100-150 mcg of fentanyl via the epidural should also be given prior to incision
  • NaHCO3 will speed the onset of lidocaine or 2-chloroprocaine
  • The ideal block height is somewhere between T4-T8.
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20
Q

C/S Management with Epidurals: Breakthrough pain

A
  • A bolus of 5cc of local
  • Epidural or iv fentanyl
  • Nitrous oxide
  • Ketamine iv (keep total dose below 1 mg/kg) ~10 mg at a time
  • Ask the surgeon to infiltrate with some local
  • If epidural is clearly inadequate, convert to GA
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21
Q

Laboring women have ____ hypotension with spinals than non-laboring

A

less

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22
Q

_____________ for hypotension is now considered the drug of choice by many practitioners

A

phenylephrine

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23
Q

Far and away the best drug for spinal? Because?

A

Bupivicaine

combines quick onset with intermediate duration.

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24
Q

Bupivicaine dosing for spinal

A

Typically, 12-14 mg of hyperbaric bupivacaine combined with 10-25 mcg of fentanyl and 0.1-0.3 mg of Duramorph (preservative-free morphine) for spinal anesthesia

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25
Q

Side effects of adding duramorph?

A

increases risk of delayed respiratory depression

produces side effects such as:

  • nausea
  • pruritis
26
Q

Once baby is delivered, administer _______, dose of _____ in a 1 liter IV bag

A

pitocin

20 units

27
Q

Maternal Altered response to anesthesia

A
  • Decrease in MAC
  • Increased sensitivity to neuraxial agents
  • Decreased plasma cholinesterase
  • Decreased protein binding (more free drug)
  • Limited drug information in parturients
28
Q

Anesthetic agents deemed safe include:

A
  • thiopental
  • morphine
  • meperidine
  • fentanyl
  • succinylcholine
  • NDMRs
29
Q

Anesthetic management in the parturient should be directed to:

A
  • Avoidance of hypoxemia
  • Avoidance of hypotension
  • Avoidance of acidosis
  • Maintain PaCO2 in the normal range for the parturient
  • Minimize effects of aortocaval compression
30
Q

In addition to standard monitors if possible, fetal heart rate and uterine activity should be monitored in women of ___ weeks GA or greater

A

20

31
Q

When organized uterine activity is detected a Beta agonist like _______ can be used as a tocolytic. ________ may also work

A

ritodrine

Magnesium

32
Q

Drugs to avoid:

A
  • Benzodiazepines have been linked to congenital anomalies. Weeks 3-8 are most critical as that is when organogenesis occurs.
  • It may also be wise to avoid nitrous oxide as it may interfere with B12 metabolism.
33
Q

Elective procedures should be postponed until __ weeks after delivery.

A

6

34
Q

Volatile agent may _______ preterm labor

A

suppress

35
Q

Hematological diseases of the parturient

A
  • Sickle Cell
  • VonWillebrand’s
  • Idiopathic thrombocytopenia
  • factor V Leiden
  • proteins C & S deficiency
  • phospholipid Ab
36
Q

Autoimmune Diseases of the parturient

A
  • Systemic Lupus Erythematosus
  • Systemic Sclerosis (Scleroderma)
  • Myasthenia Gravis
  • Rheumatoid Arthritis
37
Q

Hyperthyroidism

A
  • Patient may be receiving propranolol therapy.
  • Fetal goiter may occur.
  • Myocardium is sensitive to catecholamines.
  • Potential for thyroid storm.
    - High fever
    - tachycardia
    - agitation
    - severe dehydration.
38
Q

_________ may exacerbate hypotension following SAB

A

Propranolol

39
Q

Anticipate ________ responses to pressors d/t hypersensitive myocardium. in what disease?

A

exaggerated

Hyperthyroidism

40
Q

Neuroendocrine tumorof themedullaof theadrenal glands, or extra-adrenal chromaffin tissue that failed to involute,that secretes excessive catecholamines – norepinephrine and epinephrine

A

Pheochromoctyoma

41
Q

_____________ can mimic preeclampsia

A

Pheochromocytoma

42
Q

Pheochromocytoma: Elective C-section

A
  • Pre-op therapy with α-blockers followed by β-blockers.

- Avoid β-blockade without prior α-blockade because of risks with unopposed α stimulation, severe HTN, etc.

43
Q

Bronchial Asthma: C/S. Regional? GA?

A

Regional – epidural preferable to spinal block.

          - Gradual onset – tolerate intercostal muscle weakness.
          - Reports of bronchoconstriction following SAB.

GA – avoid if possible – ETT can trigger bronchospasm.

  • Avoid H2 blockers (cimetidine, ranitidine) – can increase sensitivity to histamine that causes spasm.
  • Consider atropine or glycopyrrolate to decrease secretions.
  • Ketamine for induction – bronchial relaxation.
  • Avoid Desflurane.
44
Q

Paraplegia

A
  • Triggered by stimulation of skin, distension of hollow viscus (bladder, uterus).
  • Pilomotor erection, sweating, flushing, headache, severe HTN, bradycardia.
  • Avoid Succinylcholine d/t risk of hyperkalemia
45
Q

Multiple Sclerosis: Concerns w/ neuraxial anesthesia

A
  • Potential neurotoxic exposure of demyelinated spinal cord.
  • Concerns over relapse of symptoms.
  • Do not exceed concentrations > 0.25% bupivacaine infusions. Use lowest concentration and volume of local anesthetic that can achieve analgesia.
46
Q

Brain Tumor

A

Major concern – brain herniation and death following rapid CSF reduction with dural puncture. Review radiographic studies for evidence of mass effect.

47
Q

Benign Intracranial Hypertension

A

Pseudotumor cerebri

  • NOT mass-related
  • Epidural or spinal block is OK.
48
Q

Look at slide 18 OB6

A

.

49
Q

Myesthenia gravis contraindicated drugs

A

ABX

  • Gentamycin
  • Kanamycin
  • Streptomycin
  • Plymyxin
  • Colistin
  • Tetracycline
  • Lincomycin

Tocolytics
-Magnesium Sulfate

Cardiac Meds

  • Quinidine
  • Propranolol

Beta Adrenergics

  • Ritodrine
  • Terbutaline

Others

  • Quinine
  • Penicillamine
  • Lithium
50
Q

Neostigmine for myesthenia gravis

A
  • Maintain on normal regimen
  • IV dose is given in ratio of 30:1 to oral dose
    - Monitor fetal HR closely
    - Observe for s/s of “cholinergic crisis”
51
Q

Look at slide 21 OB6

A

.

52
Q

Myasthenia Gravis: Cholinergic crisis symptoms, and Tx

A
  • Profound muscle weakness
  • Respiratory failure
  • Loss of bowel and bladder function
  • Disorientation
  • Diplopia

(Treat with IV and IM atropine)

53
Q

Sickle cells that have more severe anemia, higher incidence of preeclampsia

A

HgbSS or HgbSC

54
Q

how to avoid sickle cell crisis:

A

avoid:

  • hypoxia
  • hypotension
  • dehydration
  • hypothermia
  • acidosis
  • tourniquets!
55
Q

Most common type of vWF, tx?

A

Most common – type 1, Rx with DDAVP 0.3 mg/kg

No DDAVP in type 3, can increase bleeding

56
Q

look at slide 31 OB6

A

.

57
Q

look at slide 35 OB6

A

.

58
Q

Amphetamines: CNS stimulants

A
  • catecholamine depletion -> limited response to indirectly acting sympathomimetics, e.g. ephedrine
  • Increased MAC for GA
  • Increased volatile agent = inc. risk uterine atony
59
Q

look at slide 38 OB6

A

.

60
Q

HIV Infection

A

Pharyngeal lymphatic hypertrophy can create potentially difficult airway.

61
Q

Cardiac Disease

A
  • cardiac output is highest (~80% above baseline, immediately following delivery), this will be stressful for a pt with cardiomyopathy…
  • Hypotension d/t dec. afterload will reverse a L>R shunt, with resultant R>L shunting and cyanosis – Beware SAB in these patients…

My OB (4 decks)

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