Week 4 OB Complications & VBAC - Exam 2 Flashcards
A multivariate analysis identified five independent risk factors for difficult face mask ventilation:
(1) age older than 55 years
(2) body mass index (BMI) greater than 26 kg/m2
(3) presence of a beard
(4) lack of teeth
(5) a history of snoring
Difficult tracheal intubation has been variously defined by
(1) the time taken to intubate
(2) the number of attempts
(3) the view at laryngoscopy
(4) the requirement for special equipment
when are the the majority of obstetric general anesthetics administered for emergency deliveries?
often during off-hours;
these anesthetic procedures may be conducted by inexperienced anesthesia providers with less proficiency in difficult airway management.
larynx visualization - various strategies can minimize this problem, the most important is
optimizing the pts position
Comprehensive airway evaluation, prophylactic administration of nonparticulate antacids, and use of regional anesthesia decrease
the risk of aspiration.
General anesthesia may be unavoidable occasionally; therefore, awake intubation may be indicated in women in whom
airway difficulties are anticipated.
At term gestation the pregnant woman who requires anesthesia should be regarded as having anincompetent
lower esophageal sphincter.
When does LES return to normal? post partum
48hrs
1-4 weeks for pyloric sphincter tone to return
chestnut p 35
what two “things” likely account for the slight decrease in PaO2and increase in shunting that are observed in asp pneumonitis?
Bronchospasm and disruption of surfactant
Mild to moderate headache, lasting 30 minutes to 7 days. Often bilateral, non pulsating, and not aggravated by physical activity
tension h/a
*often circumferential and constricting, can be associated with scalp tenderness, and are usually of mild to mod severity.
Recurrent moderate to severe headache, lasting 4 to 72 hours. Often unilateral, pulsating, and aggravated by physical activity. Associated with nausea, photophobia, and phonophobia
Migraine
*rare to manifest for the first time during pp period
examples of :
H2 antagonists
dopamine receptor antagonist
PPI:
matching category of drug
famotidine
ranitidine
metoclopramide
omeprazole
Hypertension and/or HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome Headache
often bilateral, pulsating, and aggravated by physical activity
Preeclampsia/eclampsia
Severe and diffuse headache with an acute or gradual onsetPossible focal neurologic deficits and seizures
Posterior reversible (leuko)encephalopathy syndrome (PRES)
Ischemic or hemorrhagic.Cerebral infarction/ischemia:new headache that is overshadowed by focal signs and/or disorders of consciousness.Subarachnoid hemorrhage: abrupt onset of an intense and incapacitating headache.Often unilateral accompanied by nausea, nuchal rigidity, and altered consciousness.
stroke
Headache usually without typical features Often overshadowed by focal neurologic signs and/or altered consciousness
Subdural hematoma
Late developing headache that is constant in nature Bilateral or unilateral location
Carotid artery dissection
Nonspecific headache that may have a postural component.Often accompanied by focal neurologic signs and seizures
Cerebral venous and sinus thrombosis
Progressive and often localized headacheOften worse in the morningAggravated by coughing/straining
brain tumor
Progressive non pulsating headacheAggravated by coughing/strainingAssociated with increased CSF pressure and normal CSF chemistry
Idiopathic intracranial hypertension (pseudotumor cerebri/benign intracranial hypertension)
No history of dural trauma Diffuse, dull headache worsening within 15 minutes of sitting or standing Associated with neck stiffness, nausea, tinnitus, and photophobiaCSF opening pressure < 60 mm H2O in the sitting position
Spontaneous intracranial hypotension
Frontal headacheOften an abrupt onset immediately after dural punctureSymptoms can worsen with upright posture
Pneumocephalus
Headache is most frequent symptomOften diffuseIntensity increases with timeAssociated with nausea, photophobia, phonophobia, general malaise, and fever
menigitis
Frontal headache with accompanying facial painDevelopment of headache coincides with nasal obstructionPurulent nasal discharge, anosmia, and fever
Sinusitis
Onset of headache within 24 hours of cessation of regular caffeine consumptionOften bilateral and pulsatingRelieved within 1 hour of ingestion of caffeine 100 mg
Caffeine withdrawal
Mild to moderate headache associated temporally with onset of breast-feeding or with breast engorgement
Lactation headache
the classic presentation of subarachnoid hemorrahage:
“worst headache of my life”
sudden onset of a severe h/a that is unlike any previous h/a
Mild to moderate headache associated with ondansetron intake
Ondansetron headache
Headache within 5 days of dural punctureWorsens within 15 minutes of sitting or standingAssociated with neck stiffness, tinnitus, photophobia, and nausea
Post–dural puncture headache
50% of strokes occur w/in the first
6 weeks postpartum
primary headaches are how many times more common than secondary headaches in first week pp?
20 times
Primary headaches:
Migraine Tension-type headache Trigeminal autonomic cephalagias Cluster headache Other primary headaches
Secondary headaches:
Headache attributed to: Head and/or neck trauma Cranial or cervical vascular disorder Nonvascular intracranial disorder A substance or its withdrawal Infection Disorder of homeostasis Disorder of the cranial structures (e.g., eyes, ears, nose, sinuses, teeth, mouth) Psychiatric disorder Lesions of cranial neuralgias and other facial pain Other headache disorders
Secondary headaches:
Headache attributed to: Head and/or neck trauma Cranial or cervical vascular disorder Nonvascular intracranial disorder A substance or its withdrawal Infection Disorder of homeostasis Disorder of the cranial structures (e.g., eyes, ears, nose, sinuses, teeth, mouth) Psychiatric disorder Lesions of cranial neuralgias and other facial pain Other headache disorders
The hallmark of a PDPH is
this postural component.
Contraindications to the administration of an epidural blood patch are related to complications of placing a needle in the central neuraxis or the injection of blood into the epidural space; they include
(1) known coagulopathy (e.g., concurrent pharmacologic anticoagulation)
(2) local cutaneous infection or untreated systemic infection
(3) increased ICP caused by a space-occupying lesion
(4) patient refusal.
Transient bradycardia has been observed after administration of an epidural blood patch, and some anesthesia providers may choose to establish intravenous access
and monitor the electrocardiogram in selected patients.
- also may give fluid bolus as well
Transient bradycardia has been observed after administration of an epidural blood patch, and some anesthesia providers may choose to establish intravenous access
and monitor the electrocardiogram in selected patients.
- also may give fluid bolus as well
Frank breech—
lower extremities flexed at the hips and extended at the knees
Complete breech—
lower extremities flexed at both the hips and the knees
Incomplete breech—
one or both of the lower extremities extended at the hips
Incomplete breech—
one or both of the lower extremities extended at the hips
With chorioamnionitis, a combination _______ should cover most relevant pathogens and is the recommended primary antibiotic regimen.
ofampicillinandgentamicin
The most common source of postpartum infection is the
genital tract.
in parturients with active lesions HSV infection what is recommended?
cesarean delivery
traditionally _________ has been thought to be a risk factor for preterm birth
A history of cervical surgery,
Criteria for the diagnosis of preterm labor include
gestational age between 20 0/7 and 36 6/7 weeks’ gestation and
regular uterine contractions accompanied by a
change in cervical dilation, effacement, or both (or initial presentation with regular contractions and cervical dilation of 2 cm or more).
The ACOG has stated that evidence supports the use of tocolytic treatment WHAT MEDICATIONS are okay to use for short-term prolongation of pregnancy (up to 48 hours) to allow for antenatal maternal corticosteroid administration.
- beta-adrenergic receptor agonist therapy,
- calcium entry–blocking agents, or
- NSAIDs
Betamethasone
nice to know
12 mg IM
Every 24 h × 2
Dexamethasone
nice to know
6 mg IM
Every 12 h × 4
Conventional wisdom holds that the preterm fetus is more vulnerable than the term fetus to the depressant effects of analgesic and anesthetic drugs, for the following reasons:
(1) less protein available for drug binding, leading to a reduction in protein-drug affinity
(2) higher levels of bilirubin, which may compete with the drug for protein binding
(3) greater drug access to the central nervous system (CNS) because of the presence of an incomplete blood-brain barrier
(4) decreased ability to metabolize and excrete drugs
(5) a higher incidence of acidosis during labor and delivery
The most significant update is introduction of clinical signs and symptoms that may be used in the absence of proteinuria as diagnostic criteria for preeclampsia
i.e., thrombocytopenia [platelet count < 100,000/μL – lead to DIC
renal insufficiency [serum creatinine > 1.1 mg/dL],
pulmonary edema, or
cerebral or visual symptoms
thrombocytopenia
[platelet count < 100,000/μL]
can lead to DIC
The hallmark of preeclampsia is an
abnormal placentation-implantation.
Magnesium sulfate is administered for
seizure prophylaxis.
Magnesium 4–6 g IV followed by 1–2 g/h IV as a continuous infusion (goal is to maintain serum concentrations of 2.0–3.5 mEq/L)
Magnesium sulfate is the anticonvulsant of choice because
it is more effective and has a better safety profile than benzodiazepines, phenytoin, or lytic cocktails.
The standard IV regimen is a loading of magnesium sulfate is
2 g every 15 minutes to a maximum of 6 g.
*If a patient develops seizures while receiving a magnesium infusion for seizure prophylaxis, administration of a 1- to 2-g bolus is recommended, after which a plasma magnesium level should be measured
Factors associated with a lower rate of successful VBAC include
- socioeconomic,
- ethnic, and
- medical factors.
contraindications for VBAC: (5)
- previous classic or T-shaped incision or extensive trasnsfundal uterine surgery
- preveious uterine rupture
- medical or obstetric complication that precludes vaginal delivery
- Inability to perform emergency c/s delivery b/c of unavailable surgeon, anesthesia provider, sufficient staff, or facility
- two prior uterine scars and no vaginal deliveries
ECV is most likely to be successful if
- *(1) the presenting part has not entered the pelvis
(2) amniotic fluid volume is normal - **(3) the fetal back is not positioned posteriorly
(4) the patient is not obese
(5) the patient is parous - *(6) the presentation is either frank breech or transverse
leading cause of maternal mortality worldwide.
Peripartum hemorrhage remains a
During cesarean delivery with neuraxial anesthesia, ECG changes have a reported frequency of 25% to 60%; in this setting, administration of droperidol, ondansetron are associated with…
oxytocin may be associated with….
prolongation of the QT interval,
oxytocin administration may be associated with ST-segment depression.
The addition of sodium bicarbonate 1 mEq/10 mL to lidocaine 2% with epinephrine 1 : 200,000 will hasten the onset of anesthesia when a rapid conversion to surgical anesthesia is necessary.
This combination results in:
results in approximately 90 to 120 minutes of surgical anesthesia.
Sodium bicarbonate cannot be added to what LA?
Why?
bupivacaine as it results in precipitation when the pH is raised.
the most common indication for a cesarean hysterectomy.
Placenta accreta is
occurs when the placenta covers the cervix.
Placenta previa
Placenta previa occurs
when the placenta covers the cervix.
The classic clinical sign of placenta previa is
painless vaginal bleeding during the second or third trimester.
the lack of abdominal pain and/or absence of abnormal uterine tone helps distinguish placenta previa from placental abruption
Scenario -
mom comes in bleeding with hypotension. what’s your anesthetic plan?
- ETT
- Etomidate (not propofol) ketamine
Placenta accreta refers to
a placenta that is abnormally adherent to the myometrium but hasnotinvaded the myometrium.
In placenta increta,
the placentahasinvaded the myometrium.
Placenta percreta is
invasion through the serosa.
placenta accreta, Elective cesarean delivery recommendation;
at 34–35 weeks’ gestation to avoid emergent delivery is recommended.
Placental abruption is defined as
complete or partial separation of the placenta from the decidua basalis before delivery of the fetus.
if patients with severe hypovolemic shock what rare thing CAN happen with intubation
intubation can be accomplished without an induction agent.
what IV vasopressors are recommended for amniotic fluid embolism hypotension
dopamine
dobutamine
norepinephrine
how do we guide fluid therapy during amniotic fluid embolus
what are we cautiously aware of
CVP
aware that Pulmonary edema may occu
multimodal analgesia statement regarding magnesium administration
magnesium sulfate administration resulted in small reduction in postoperative pain scores and a substantial reduction in opioid use.
what medication has been used in the treatment of acute and chronic pain in nonobestretic patients
alpha 2 adrenergic receptor agonists.
are IV opioids better than PO opioids
no, evidence suggest IV is not superior to oral
what are the advantages of po opioids
cost savings. facilitate early mobility and greater patient satisfaction .
what is the goal of PCA
maximum analgesia with minimal side effects.
what is the advantage of multimodal pharmacological and non pharmacological treatment for pain
optimal approach and should be offered whenever feasible and medically indicated.
low dose IV nitro- when is this recommended
40mcg bolus- recommended to relax the uterus for placental removal when indicated.
placental accreta- what must be immediately available.
PRBC’s should be immediately available
patient with placental previa - hospitalized for some time before delivery should have
have at least one IV catheter maintained if bleeding is recurrent or imminent delivery is anticipated
the supine hypotension syndrome is caused by
compression of the aorta and inferior vena cava
how does supine hypotension syndrome manifest
pallor tachycardia sweating nausea hypotension dizziness
current guidelines recommend that prophylactic antibiotics be administered within
60 minutes
Per my notes…what is recommended for patient who aspirates
cpap or peep- NOT abx or steroids
how do we distinguish placental previa vs. placental abruption
lack of abdominal pain and or absence of abnormal uterine tone is previa
if patient has an abnormal placental attachment- what may occur if the placenta is removed forcefully
massive hemorrhage
** scenario discussed in class**
You have a pregnant patient you’ve given sux to for c/s but on laryngoscopy you are not able to intubate. pt and baby are stable and you are able to bag/mask adequately.
what would you do?
- wake patient to discuss awake/ fiberoptic (best option since they aren’t in distress)
The most common postpartum headaches are (2)
Tension-type and migraine headaches
________ is the most common indication for a cesarean hysterectomy.
Placenta accreta
Treatment of magnesium toxicity
o D/C magnesium
o Intubation and ventilation
o IV calcium gluconate (calcium antagonizes effects of magnesium)
leading causes of maternal death (associated with PIH)
- Pulmonary edema/cerebral hemorrhages (
________ ______ is associated with more rapid oxygen desaturation during apnea during the induction of general anesthesia.
Increasing BMI
The administration of CPAP in patients breathing spontaneously or the administration of PEEP in patients undergoing mechanical ventilation restores
functional residual capacity,
reduces pulmonary shunting, and
reverses hypoxemia.
The administration of corticosteroids for aspiration pneumonitis recommended?
no
The most effective way to decrease the risk for aspiration is to?
- Comprehensive airway evaluation,
- prophylactic administration of nonparticulate antacids, and
- use of regional anesthesia decrease the risk of aspiration.
The mother undergoing elective cesarean delivery should fast from solid food. Preoperative antacid prophylaxis may include?
“Before surgical procedures (e.g., cesarean delivery and postpartum tubal ligation), consider timely administration of nonparticulate antacids, H2-receptor antagonist, and/or metoclopramide for aspiration prophylaxis.”
Preoperative prophylaxis before emergency cesarean delivery under general anesthesia should include?
General anesthesia may be unavoidable occasionally, therefore, awake intubation may be indicated in women in whom airway difficulties are anticipated.
The hallmark of aspiration pneumonitis is?
Bronchospasm and disruption of surfactant
likely account for the slight decrease in PaO2 and increase shunting that are observed. The anesthesia provider witnesses regurgitation of gastric contents into the hypopharynx. Patients who aspirate while breathing spontaneously have a brief period of breath-holding followed by tachypnea, tachycardia, and a slight respiratory acidosis.
Is the oral intake of clear fluids allowed during labor?
No, a healthy patient undergoing elective C/S may drink modest amounts of clear liquids 2 hrs before induction of anesthesia. Patients with addition risk factors for aspiration may have further restrictions – determined case by case.
Does eating during labor results in larger residual gastric volumes?
Yes. A reduction in gastric content acidity and volume is believed to decrease risk for damage to the respiratory epithelium if aspiration should occur. Fasting periods for solids 6-8 hrs is recommended.
- A patients BP is 80/40, HR is 120, RR 26, and are getting prepped for an emergency C/S. What should you do?
a. Spinal
b. Epidural
c. LMA
d. ETT
ETT
- BP is 80/40 so will you use etomidate or propofol?
Etomidate
why do we avoid oral hypoglycemic agents during pregnancy?
can cause fetal hypoglycemia
The three most common symptoms preceding an eclamptic attack:
- Headache, visual changes
- RUQ/epigastric pain
- Seizures; severe if not controlled with anticonvulsant therapy
HIV test to rule out?
ELISA
presumptive dx
hiv rule out test?
Western blot assay
positive results are then confirmed with
AIDS DX CD4 count:
CD4 < = 200
N = 500-1500
can include a flu-like illness within a month or two of exposure
Stage of HIV?
Stage 1
Seroconversion means the immune system is activated against the virus and antibodies can be detected in the blood
the individual usually remains free of major disease, even without treatment
stage of hiv?
Stage 2
It can last 6-8 years, during which HIV levels in the blood slowly rise
occurs when the immune system loses the fight against HIV
stage of HIV?
stage 3
Symptoms worsen and opportunistic infectious develop
HIV - Four stages of infection:
- Flu-like (acute)
- Feeling fine (latent) – during latent phase virus replicates in lymph node
- Falling count
- Final crisis
Physical examination findings for HIV:
- Low grade fever, night sweat, weight loss
- Facial seborrhea
- Diffuse lymphadenopathy (like Mono)
- Splenomegaly
- Oral candidiasis “thrush”
- Herpes zoster infection (reactiviation of shingles too)
Clinical features of HIV
- Asymptomatic
- Persistent fevers and chill
- Drenching night sweats
- Fatigue, arthralgias (joint pain), myalgias (muscle pain)
- Unintentional weight loss “HIV wasting syndrome”
- Depression, apathy, as early signs of HIV-related encephalopathy
most common complaint with HIV:
fever
- BC should be drawn for bacteria, fungus, atypical mycobacterium (MAI) and CMV
unique feature of Tuberculosis in HIV+
o Tuberculosis (-ve tuberculin test) – because there is no immune system to activate against antigen
most common cause of hiv related blindness
- Blindness
o CMV retinitis – “Cheese and ketchup lesion” MCC
Therapy for HIV
Azidotheymidine (AZT) with CD4 < 500
o Reverse transcriptase inhibitor
With CD4 < 200 add pneumocystis prophylaxis
o Trimethoprim-sulphamethoxazole
why should hiv pts (and close family) not received LIVE vaccines?
lacking immune system usually disease will overcome
decreased FRC in pregnancy - more prone to
hypoxia
Placental transfer
- lipid soluble substances diffuses rapidly
prevent DVT with
pneumatic compression stockings during C/S
what do you give to stop premature contraction?
Beta 2 agonist
ritodrine is given to stop premature contraction
Avoid what with ritodrine?
Atropine
can cause tachy and lead to pulmonary edema
mag sulfate increases sensitivity to both depolarizing and non-depolarizing muscle relaxants therefore….
decrease the dose
lidocaine (in high doses) causes uterine:
vasoconstriction
increased tone
most commonly injured during abdominal hysterectomy
Femoral nerve is
Common peroneal nerve injury during vaginal hysterectomy may lead to
foot drop
most commonly injured during vaginal delivery
Lumbosacral nerve is
most common cause of anesthesia-related maternal mortality
Airways complications are
