Week 4 Mo Parturient with Systemic Diseases Flashcards
Maternal Gestational Diabetes Tx?
Diet control
Insulin
Avoid oral hypoglycemic agent (can cause fetal hypoglycemia)
Gestational Diabetes Complications Maternal?
Preterm labor Polyhydramnion C/S for macrosomia Preeclampsia/eclampsia DM type II
Gestational Diabetes Complications Fetal?
Macrosomia Shoulder dystocia Perinatal mortility 2-5% Congenital defects !!!Hypoglycemia!!!
Dilutional Anemia during Pregnancy is due to what?
Due to 50% increase in plasma volume
If Maternal Hb falls below what level, you should look for another cause (not dilutional anemia due to pregnancy)
below 10.5g/dl
Most common hereditary bleeding disorder?
Von Willebrand’s’s disease
What are signs and symptoms of Von Willebrand’s dz?
Prolonged BT despite normal platelet count (cannot stick to injured area)
A functional deficiency of factor VIII (pseudo-hemophilia) occurs as a result of deficit of vWF, its carrier protein. Deficiency is manifested clinically by prolonged PTT
Mucous membrane bleeding
Easy brusiability
Prolonged bleeding from wounds
Menorrhagia– very heavy period
LABS
Prolonged PTT
Prolonged BT
Treatment of Von Willebrand’s dz?
Desmopressin (dDAVP) increases vWF level
Cryoprecipitate is rich in factor VIII:vWF
Estrogen and OCP
Labs performed on a Mom with gestational Diabetes?
Glycosuria, fasting hyperglycemia
Abnormal GTT
Glucose Tolerance Test?
Hemophilia A is a deficiency in what factor?
VIII
Second most common X-linked Coagulation defect? This mean what sex is rarely affected?
Hemophilia A, and females are rarely affected.
Clinical findings with Hemophillia A?
Soft tissue and joint bleeding
Dangerous CNS bleeding with minor trauma
Spontaneous hematuria leading to ureteral colic
Labs with Hemophilia A?
Prolonged PTT (intrinsic pathway)
Low factor VIII
Normal vWF , therefore normal BT
Treatment for Hemophilia A?
FFP and cryo (low in VIII)
Factor VIII replacement
Hepatitis C and HIV infection very common due to tinted blood transfusion
What factor is deficient in Hemophilia B?
IX
Vitamin C deficiency is a coagulation defect (apparently), what will you lack?
Lack of stable collagen (elderly, alcoholics)
Hepatic failure is a coagulation defect, why is this?
Almost all clotting factors are made in the liver.
What clotting factors ARE NOT made in the LIVER?
Factor VIII:vWF Factor III ( tissue factor thromboplastin) Factor IV ( Ca++)
Vitamin K deficiency is considered a coagulation defect. Tell me why?
Yes, Vit K is fat-soluble vitamin and is required for II (prothrombin), VII, IX, and X formation (also protein C and protein S)
What issues would cause a deficiency in Vitamin K?
Fat malabsorption due to lack /obstruction of bile secretion leads to fatty diarrhea causing deficiency of Vit K
What will you give to all surgical patients with liver dz?
Vit. K
What is Thrombocytopenia?
Platelets of less than 150,000
What does Thromboccytopenia cause?
Bleeding from small capillaries and blood vessels Mucosal, skin bleeding.
What is aplastic anemia?
Low number of platelets, you stop producing new blood cells.
Idiopathic thrombocytopenic purpura (ITP), what is it and what does it cause?
Autoimmune, common.
Due to antiplatelet antibodies.
decreased anti-GPIIb/IIIa antibodies causeing peripheral platelet destruction
Thrombotic thrombocytopenic purpura (TTP), what is it associated with?
Associated with chemo, liver disease, splenomegaly, DIC pre- eclampsia
Tell me about DIC?
Abnormal bleeding and clot formation
Critically ill patients
Coagulation and clot lysis in uncontrolled manner
Due to massive tissue damage
Depletion of clotting factors
Anesthesia considerations with coagulation disorders? (what do you want to know, what are they likely to receive?)
Careful history about bleeding disorders
Operation history
Massive blood transfusion causes
Functional deficiency of platelets
Packed RBCs infusion leading to dilution of V & VIII
FFP contains all clotting factors (except platelets)
What is AIDS? (very basically what does it do)
HIV infect and kill T-helper lymphocytes resulting suppression of cell mediated immunity. Host will develop opportunistic infections (Pneumocystis pneumonia) and various tumors
HIV becomes?
AIDS
HIV 1, what exactly is it?
single strand of RNA enclosed in a protein envelope, belongs to Retrovirus family.
What is reverse transcriptase? (has to do with how HIV replicates)
Viral replication is dependent upon a DNA polymerase known as reverse transcriptase, which is responsible for copying the viral RNA to DNA
How does HIV (AIDS) weaken the cellular immunity?
Additional transcription of DNA results in billions of new viral particles that are extruded from cell membrane by killing the T-helper cells (CD4) weakness of cellular immunity
Where does incorporation of DNA take place (talking about HIV)
Incorporation of DNA then takes place into the host cell genome; the T-helper cells (CD4) cell genome
CD4 count?
<200/mm^3
RISK FACTORS for HIV?
Transmitted by body fluids e.g. semen, blood, vaginal fluids and breast milk
Homosexual and bisexual men
IV drug abusers
Hemophiliacs and recipient of other blood products before 1985
Sexual partners of these groups
Vertical transmission through placenta
HIV - Pathogenesis?
what cells does HIV mess with and what does this cause?
T-helper cells coordinates the immune response of T & B lymphocytes, monocytes and macrophages
Therefore, impaired immunity of both cell-mediated and humoral immunity occur
HIV is also neurotropic and neurological dysfunction is common
Is neurological dysfunction common with HIV?
Yes
HIV- Laboratory diagnosis?
Look for antibodies against viral proteins
Presumptive Dx made with ELISA “RULE OUT test”
Positive results are then confirmed with Western blot assay “ RULE IN test”
HIV PCR / viral load tests
AIDS diagnosis less than or equal to 200 CD4 (N=500-1500)
Stage 1 HIV, tell me about it?
Stage I can include a flu-like illness within a month or two of exposure.
What is seroconversion?
Seroconversion means the immune system is activated against the virus, and antibodies can be detected in the blood.
Stage II of HIV?
Sage II, the individual usually remains free of major disease, even without treatment.
It can last 6-8 years, during which HIV levels in the blood slowly rise.
Stage III of HIV?
Stage III occurs when the immune system loses the fight against HIV.
Symptoms worsen and opportunistic infectious develop
Four stages of infection with HIV?
- Flu-like (acute)
- Feeling fine (latent)
- Falling count
- Final crisis
During latent phase, virus replicates in lymph node.
Physical Examination of a person with HIV? (What signs and symptoms may you see (6 things))
Low grade fever, night sweat, weight loss
Facial seborrhea
Diffuse lymphadenopathy (like Mono)
Splenomegaly
Oral candidiasis “thrush”
Herpes zoster infection
Clinical features of a person with HIV?
Asymptomatic
Persistent fevers and chill
Drenching night sweats
Fatigue, arthralgias, myalgias
Unintentional weight loss “HIV wasting syndrome”
Depression, apathy, as early signs of HIV-related encephalopathy
Special features associated with HIV?
Fever Lymphadenopathy is a common finding Skin lesion Dyspnea Dysphagia Diarrhea Headache and seizures Blindness Hematological abnormalities
What is the most common complaint of a person with HIV, and what labs should be done in relation to this?
Fever!
Blood culture should be drawn for bacteria, fungus, atypical mycobacterium (MAI) and CMV
What kind of skin lesions do you see with HIV?
Pruritus and folliculitis common
Kaposi’s sarcoma
What may be causing the Dyspnea in an HIV patient? (also the leading cause of death)
Pneumocystis carinii pneumonia is leading cause of death
Other causes of pulmonary distress in the HIV patient?
Tuberculosis ( -ve tuberculin test)
Atypical mycobacteria
Dysphagia in an HIV patient may be related to?
Candidal esophagitis “oral thrush”.
Diarrhea in the HIV patient may be due to?
Cryptosporidium , microsporidium , giardia, E.histolytica
Colitis – CMV
HA and seizures in the HIV patient may be due to?
Toxoplasma is the most common finding with patients presenting with headache, confusion and seizures.
Blindness in the HIV patient may be due to?
CMV retinitis – “Cheese and ketchup lesion” MCC
Hematological abnormalities in the HIV patient may be due to?
ITP like thrombocytopenia
Anemia of chronic disease
Lymphocytopenia
Therapy for HIV?
Azidotheymidine (AZT) with CD4 < 500
With CD4 < 200 add pneumocystis prophylaxis
Vaccination for pneumococci, influenza and hepatitis
No live vaccine (polio, rubella) should be administered.
High risk of TB
What HIV medication is a reverse transcriptase inhibitor?
AZT
What is Trimethoprim-sulphamethoxazole given for?
With CD4 < 200 add pneumocystis prophylaxi (HIV patient)
What is Preganancy Induced Hypertension?
> 140/90 mmHg after 20th week and resolve within 48 hrs after delivery.
Preeclampsia S/S
HYPERTENSION, PROTENURIA (> 5 g/day) and EDEMA (hand, face, lung)
Oliguria (< 500 ml /day), headache, visual disturbance , hepatic tenderness, hyperreflexia
Eclampsia?
(+)Seizures in preeclampsia
What is HELLP syndrome?
(high maternal and fetal mortality). Call for IMMEDIATE DELIVERY
Hemolysis, Elevated Liver enzymes, Low Platelet count
Risk factors for Pregnancy induced hypertension?
Nulliparity, AA, extreme of age (<15 or >35), multiple gestation. Vascular disease due to SLE and DM, + family history, chronic HTN, HELLP SYNDROME
Pathophysiology for pregnancy induced hypertension?
Increased: Thromboxane A2, endothelin-1, renin.
Decreased: PGI2, NO
COCAINE ABUSE
S/S - pregnancy induced hypertension?
Vasospasm, decreased I/V volume, decreased GFR, edema , CNS dysfunctions decreased uterine BF
CURE of PIH? (Pregnancy induced HTN)
ONLY CURE is delivery of baby. Monitor PT, PTT
Treatment of PIH, that is not delivery?
Hydralazine and methyldopa to control HTN
High dose of nitroprusside (could lead to S/E cyanide toxicity)
Seizures require mag sulf and benzo
Mag Sulf to prevent convulsion (Mag sulf antagonizes calcium)
What do you give for seizures (if your patient has PIH)?
Mag sulfate and benzos
Mag sulfate antagonizes what?
calciujm
What can occur with high dose Nitroprusside?
cyanide toxicity
Magnesium depresses what?
Magnesium depresses CNS by decreasing Ach release
What prevents Calcium entry into the cell?
Mag sulfate
If you prevent calcium from entering the cell, what does that cause?
smooth muscle relaxation.
What does magnesium toxicity look like?
Ventilatory failure ( requires prompt intubation and ventilation)
Absent deep tendon reflexes
Heart block (Prolong PQ, wide QRS), cardiac arrest
Hypotension
Drowsiness, atonia and hypoventilation in fetus
With high dose nitroprusside you may have cyanide toxicity, WHY and what will you give to treat the cyanide toxicity?
Nitroprusside metabolism (hydrolysis) results in cyanide ion production. To treat cyanide toxicity give sodium thiosulfate to produce thiocyanate which is less toxic and is eliminated by the kidneys
Treatment of Magnesium toxcity?
D/C magnesium
Intubation and ventilation
IV calcium gluconate ( calcium antagonizes effects of magnesium)
What anesthesia drug will you avoid if your patient has PIH?
KETAMINE, it causes HTN.
Complications to mother and baby with Pregnancy induced HTN (PIH)?
- Pulmonary edema/ cerebral hemorrhages (leading causes of maternal death)
- Prematurity
- Prematurity/fetal distress
- Intrauterine growth retardation
- Placental abruption
- ARF, cerebral edema
- Fetal/maternal death
Name some things you will see with Mild Preeclampsia?
>140/90 Headache, somnolence, blurred vision. Epigastric pain, rapid weight gain, edema , JV distension. Hyperactive reflexes, clonus. Proteinuria (>300 mg/24 hrs)
Name some things you will see with Severe Preeclampsia?
S/S of mild preeclampsia PLUS: >160/90 Proteinuria (>5 g/24 hrs or 3+ on dipstick Oliguria Pulmonary edema, cyanosis HELLP syndrome Oligohydramnios Intrauterine growth retardation
The three most common symptoms preceding an eclamptic attack?
- Headache, visual changes
- RUQ/epigastric pain
- Seizures; severe if not controlled with anticonvulsant therapy
Management of Preecalmpsia will include?
If term or fetal lung mature; deliver
If severe; expedite delivery by induction or C/S
Bed rest, monitor BP, reflexes, weight and proteinuria
Control BP ; diastolic < 90-100
Seizure prophylaxis by mag sulf
Management of Eclampsia will include?
Supplemental O2
Mag sulf + benzo
Monitor fetal status
Initiate steps to delivery.
What is Rheumatoid Arthritis?
Chronic, destructive ,systemic inflammatory arthritis characterized by symmetric involvement of both large and small joints. RA causes synovial hypertrophy and pannus formation with resultant erosion of adjacent cartilage, bone and tendons.
What age groups/sex/serotype is more likely to have RA?
MC in female 20-40 age
High incidence with HLA-DR4 serotype
What hx/S/S are common with RA?
Insidious onset Morning stiffness improves with use Pain warmth, swelling and decreased mobility Polyarthropathy Fatigue, anorexia, weight loss
What joints are spared in RA?
Distal interphlangeal joints (DIP) are spared in RA
Physical examination of someone with RA, what will you typically see?
Wrist, metacarpophalangeal and proximal interphalangeal (PIP) joints, ankle, knees, shoulder, hip, elbow and cervical spine (C1, C2)
Cricoarytenoid joint involvement is severe cases
Ulnar deviation of the fingers, swan neck deformities of digits
Extra-articular manifestations
Vasculitis, Subcutanous nodules
Pericarditis, pleuritis
Carpal tunnel syndrome
Evaluation of RA, what labs will be significant?
Rheumatoid factor (anti-Fc IgG antibody) increased ESR X-ray: narrowing of joint spaces and erosion, pannus formation
Tx of RA?
NSAIDs
Steroid, methotrexate , choroquine, gold
Osteoarthritis, tell me the basics of this disorder?
Chronic, noninflammatory arthritis of movable joints
Degenerative joint disease- “wear and tear arthritis”
No systemic manifestation
Deterioration of articular cartilage
Osteophyte (bony spur) formation at joint surfaces.
Risk factors for Osteoarthritis?
Family history
Obesity
Previous joint trauma
What will a patient with osteoarthritis report? (hx)
Joint pain worsen by activity and weight bearing and relieved by rest
Crepitus
decreased range of motion
What will you find upon physical examination of a patient with osteoarthritis?
Involvement of weight bearing joints (hip, knee, lumbar)
Also involve DIP, PIP and cervical
Stiffness and marked crepitus of the affected joints
What will labs or imaging of someone with osteoarthritis show?
Normal ESR
X-ray: ulcerated cartilage, narrowing of joints spaces, osteophytes , dense subchondral bone
treatment of osteoarthritis?
Physical therapy Weight reduction NSAID Intra-articular steroids for temporary relief Replacement
Scoliosis, what is it, what does it affect, what changes occur if someone has scoliosis?
Lateral curvature of vertebra and deformity of rib cage
Affect cardiac and respiratory functions
Hypoxia due to V/Q mismatch
Restrictive disease with low lung volume
decreased chest compliance
increased PCO2 in severe disease
Pulmonary hypertension due to increased pul vascular resistance leading to RVH
Anesthetic considerations with Scoliosis?
Significant blood loss and risk of paraplegia during surgery
Monitor sensory and motor EP
Predispose to MH, arrhythmia, and adverse effects of sux i.e. hyperkalemia, myoglobinuria and sustained muscle contraction
Preop what labs do you want on a scoliosis patient?
PFT, ABG, ECG
What causes CF?
Defective chloride channels
What chromosome is responsible for the gene location of Cystic Fibrosis (CF)
chromosome 7
What is CF, what symptoms does it cause?
Hereditary disease of exocrine glands of lungs and GIT
Thick and viscous secretion difficult to clear
Recurrent pneumonia, bronchiectasis
increased RV, increased airway resistance, decreased VC, decreased expriatory flow rate
Fluid and electrolyte imbalance due to malabsorption
Anesthetic considerations in relation to CF?
Anticholinergic drugs are controversial
Prolong inhalation induction
Deep anesthesia for intubation
Avoid hyperventilation; may lead to shallow postop respiration
Respiratory therapy
Bronchodilators, incentive spirometry, postural drainage and proper antibiotics
What is Asthma?
Asthma is’ reversible’ airway obstruction by contraction of smooth muscle of bronchioles
What causes Asthma?
Exposure to antigen–> formation of IgE–> IgE attach to mast cells–> re-exposure to the antigen–> Mast cells release:
- Histamine
- Slow reacting substance of anaphylaxis
- Eiosinophilic chemotactic factor
- Bradykinin
- Heparin, proteolytic enzymes
What S/S will you see with asthma?
Inflammation ,edema and increased secretion
Bronchoconstriction
decreased FEV1 and FEV1/FVC
increased FRC ,increased RV due to air trapping
Hyperventilation- decreased PCO2
On X-Ray what will you see with Asthma?
Hyperinflated lungs, flatening of diaphragm , air trapping
Pathophysiology of Asthma?
“Reversible” increased resistance to airflow due to airway narrowing (normal physiology between the attacks)
Causes of ASTHMA?
Airway bronchospasm
Airway inflammation
Triggering factors of Asthma?
Airway irritants, environmental pollutants (including occupational exposure) Exercise, cold air , dry air Upper and lower resp. tract infection Aspirin, blockers Gastro esophageal reflux
Clinical features of Asthma?
SOB Cough , chest tightness Wheezing Dyspnea Worst at night
Physical findings of Asthma (not during an attack)
Exam (not PFT) is normal between attacks, this a reversible disease
During an Asthma attack, physical findings?
Tachypnea Insp. and exp. wheezing Use of accessory muscles Pulsus paradoxus Paradoxical movement of abdomen
Chest x-ray with asthma?
May be normal Hyperinflation Flattening of diaphragm Mucus plugging Atelactasis
ABG with Asthma?
Hypocapnia
Mild hypoxemia
Hypocarbia is common.Normal CO2 or hypercapnialeading to Respiratory Emergency (40@40) leading to Respiratory failure. Immediate intubation is indicated
Asthma Diagnosis, what labs and measurments will be off?
Peak flow expiratory rate decrease
FVC , FEV1 and FEV1/FVC decrease
Increase RV
Normal diffusion capacity
Improvement of flow rate with bronchodilators
Bronchial hyper-responsiveness to histamine
Eosinophilia
What is the treatment for Asthma?
Anti-inflammatory drugs
Bronchodilators
Anti-inflammatory drugs as a treatment for Asthma would include?
Inhaled steroids
Systemic steroid
Cromolyn-prevents mast cell degranulation; useful for prophylaxis not for an acute attack. Also used to prevent exercise induced asthma.
Bronchodilators for the treatment of Asthma would include?
Beta2 agonist -inhaled and nebulizer
Anticholinergic – atropine and ipratropium
Aminophyllin (PDE inhibitor) preprations
Management of an Acute Asthma Attack?
Beta 2 agonist + steroid + ipratropium
Systemic steroid (I/ V)
Aminophylline not helpful in control of severe acute attack
Management of Chronic Asthma disease?
Inhaled steroid as maintenance + inhaled Beta2 steroid for symptomatic control
Add ipratropium
Consider aminophylline
Short course of oral steroid
most serious risk factor associated with surgery during pregnancy?
UTERINE ASPHYXIA
What position do you want to avoid with pregnant ladies and why?
Supine position due to uterine displacement causing supine hypotesion.
Decrease in what makes pregnant ladies prone to hypoxia?
decreased FRC
What diffuses the plancenta rapidly?
lipid soluble substances
How will you prevent DVT during C/S?
prevent DVT with pneumatic compression stockings during C/S
MOST frequent complication of spinal and epidrual? How do you treat?
Hypotension is the most frequent complication of spinal and epidural; treated by
Left uterine displacement, IV hydration and ephedrine
Beta 2 agonist given to stop premature contraction?
Ritodrine
S/E of ritodrine? (mom and fetus)
Mom: hypokalemia, hyperglycemia, tachycardia
Fetus: : hypokalemia, hyperglycemia, tachycardia (+/-)
Why avoid atropine with ritodrine?
can cause tachycardia leading to pulmonary edema
Mag sulfate and NMB, what’s the issue?
Mag sulf increases sensitivity to both depolarizing and non-depolarizing muscle relaxant , therefore, decrease the dose
What does Lidocaine in high doses do to the uterus?
causes uterine vasoconstriction and increased tone.
base+acid =?
ionized (can not cross, trapped in fetus)
base + base =?
un-ionized (can cross)
LA, base or acid?
weak base
What patients are considered “full stomachs” and are high risk for aspiration?
pregnant ladies (also traumas but that is not for this class)
What two medications can you give to pregnant ladies to help with their “full stomach”
H2 blockers and Reglan
MC morbidities are
mother/child
Hemorrhage
Preeclampsia
What medication can cross the placental barrier, making regionals the preferred?
Opioids
Lumbar epidural, what is it likely to do to MC?
S/E hypotension
Give ephedrine and IV fluid
Problems with GA while pregnant?
Rapid desaturation, laryngeal spasm/edema, aspiration
What anesthesia/analgesia will you use for C/S
spinal/epidural
Level of block for C/S is?
T4
MC adverse effect of regional is hypotension, what will you give?
Give phenylephrine with fluid
Most common cause of polyhydramnios is?
esophageal atresia
What nerve is most commonly injured during the following surgeries/proceedures:
Abd hysterectomy
Vaginal hysterectomy
Vaginal delivery
Abd hy = Femoral nerve
Vag. hy = peroneal nerve
Vag. delivery = Lumbosacral nerve
If you damage the peroneal nerve what will result?
Foot Drop
Most COMMON cause of anethesia-related maternal mortality?
Airway complications
