Complicated OB pt2

Question 1

What is the most prominent symptom associated with umbilical cord compression from cord prolapse?

Answer 1

• Fetal bradycardia (from FHT)

Question 2

What are the possible causes of umbilical cord prolapse?

Answer 2

• Multiple gestation
• Abnormal presentation (breech, shoulder, etc.)

Question 3

What is the initial primary management of cord prolapse?

Answer 3

Manual elevation of the presenting part to offload the umbilical cord.

Question 4

Other than manual displacement of the fetus, what other option is available to manage cord prolapse?

Answer 4

Retrograde bladder filling w/ 500 - 600 mls.

If this doesnt work or fetal distress, then c-section.

Question 5

What are the two different types of twins?

Answer 5

• Monozygomatic twins (identical)
• Dizygotic twins (fraternal)

monozygomatic: conceived from one egg

Question 6

In what type of situation is it more likely to have twin-twin transfusion to the other in the womb?

Answer 6

Monochorionic (rare in dichorionic)

vascular communications

Question 7

Monochorionic monoamniotic refers to what?

Answer 7

• Same placenta
• Same amniotic fluid

Question 8

What are the two body systems we typically worry about with mom when she is multiple-gestation?

Answer 8

CV & pulmonary issues

Question 9

How much does CO increase for a multiple-gestation mom?

Answer 9

20% greater than a typical parturient

primarily related to increased stroke volume

Question 10

multiple-gestation parturients are at increased risk of hypoxemia. Why?

Answer 10

↓ TLC & FRC near gestation due to increased uterine size

Question 11

What systems do not change in a multiple-gestation parturient vs a woman having only one baby?

Answer 11

• Renal
• Hepatic
• CNS

All the same whether you have one baby or multiple.

Question 12

What are the consequences of the stomach being displaced cephalad in a multiple-gestation patient?

Answer 12

↓ LES competence = ↑ aspiration risk

Question 13

What is the maternal estimated blood volume of a multiple-gestation patient?

Answer 13

105 mL/kg

Question 14

multiple-gestation delivery EBL is typically _____ greater than a single baby delivery.

Answer 14

500 mL

Question 15

How much more plasma volume does a multigestational patient have than a monogestational patient?

Answer 15

additional 750 mL plasma volume

Question 16

Regarding twin-to-twin transfusion syndrome, what would be likely to be seen from the donor twin?

Answer 16

• Smaller size
• ↑ risk of IUGR
• ↑ risk of anemia

giving away all his nutrients

Question 17

Regarding twin-to-twin transfusion syndrome, what would be likely to be seen from the recipient twin?

Answer 17

• Larger size
• ↑ risk of volume overload
• ↑ risk of cardiac failure

Question 18

Multiple-gestation patients tend to be at risk for _____ delivery.

Answer 18

early (preterm)

>50% delivery before 37 weeks.

Question 19

Planned delivery for twins typically occurs at ____ weeks.
Planned delivery for triplets typically occurs at ____ weeks.

Answer 19

38 weeks

35 weeks

to decrease perinatal mortality

Question 20

Increased fetal weight and larger volume of amniotic fluid in a multiple gestation mom can lead to?

Answer 20

• increased risk aortocaval compression and supine HoTN syndrome

Question 21

Increased uterine distention from multiple gestation increases the risk of ______ and ______.

Answer 21

uterine atony & PPH

Have methergine & hemabate ready.

Question 22

Delivery with GETA usually poses what risks?

Answer 22

• increased risk of difficult airway
• increased EBL

Question 23

How are PIH (pregnancy induced hypertension) and preeclampsia differentiated?

Answer 23

Proteinuria = Preeclampsia

Question 24

What is the BP criteria for pregnancy induced HTN?

Answer 24

• BP elevated > 139/89 mmHg x2 (visits)
• after 20 weeks gestation
• without proteinuria

Question 25

___% of parturients with gestational HTN will develop preeclampsia

Answer 25

25%

Question 26

What makes a definitive diagnosis of PIH?

Answer 26

Delivery of baby and return to normotension (resolves by 12 weeks post-partum)

Question 27

A new onset HTN & proteinuria after 20 weeks would be suspect for _______.

Answer 27

Preeclampsia *key feature: proteinuria*

Question 28

What alternate s/s can develop with preeclampsia (besides HTN & proteinuria)?

Answer 28

- Persistent epigastric/RUQ pain - Persistent cerebral s/s (syncope, blurry vision) - IUGR - Thrombocytopenia - ↑ LFT's

Question 29

What are the characteristics of preeclampsia **without severe** features?

Answer 29

- BP ≥ 140/90 after 20 weeks gestation - Renal Insufficiency: [Proteinuria ≥ 300mg/24hrs or Protein:Creatinine ≥ 0.3 or 1+ on urine dipstick]

Question 30

What features are typical of **severe** preeclampsia?

Answer 30

- BP ≥ 160/110 - Thrombocytopenia (PLT < 100k) - Creatinine > 1.1 or 2x baseline - Pulmonary edema - New onset cerebral/vision disturbances - Impaired liver function

Question 31

How can chronic HTN be distinguished from pregnancy induced?

Answer 31

* Prepregnancy HTN >140/90 * HTN does not resolve postpartum

Question 32

Review: Pregnancy HTN Disorders Table

Answer 32

Question 33

Is a fetus necessary to develop preeclampsia?

Answer 33

Technically no, can be in a molar pregnancy

Question 34

Abnormal placental implantation and impaired remodeling of spiral arteries is indicative of what?

Answer 34

Preeclampsia *small and constricted spiral arteries unable to adequately provide O2 and nutrients to fetus*

Question 35

What are the vascular features of preeclampsia?

Answer 35

Question 36

Preeclampsia is early onset if it occurs before ____ weeks. Is this associated with better or worse outcomes?

Answer 36

Before 34 weeks ⇒ worse outcomes

Question 37

What are the features of postpartum-onset of preeclampsia?

Answer 37

- Occurs within one week of delivery. - Proteinuria - Seizures

Question 38

What is prophylaxis on preeclampsia patients?

Answer 38

Aspirin

Question 39

Why is aspirin a prophylactic for preeclampsia?

Answer 39

- Inhibits synthesis of prostaglandins & synthesis of thromboxane α2

Question 40

When should aspirin be initiated for patients at high risk of preeclampsia?

Answer 40

16 weeks or earlier for best benefit

Question 41

________ is increased relative to prostacyclin in preeclamptic patients.

Answer 41

Thromboxane