Diagnosic criteria for preE with and without severe features? Eclampsia?
PreE:
- SBP >140, DBP >90
- Proteinuria (>300mg/24hrs, or >.3 urine protein/Cr ratio)
- >20WGA
W/severe features:
- SBP >160, DBP >110
- new renal insuff
- new CNS issues (AMS, H/A)
- new liver dysfxn
- pulm edema
- epigastric/RUQ pain
- thrombocytopenia
Eclampsia:
- must have seizure!
For preggos, what are the first things to check if called to bedside?
- Vitals
- Assess adequate IV access
- Uterine displacement
- Eval baby’s heart tones
- If significant AMS, think about securing airway
Something major to consider when thinking about neuraxial vs GA in AMS patient?
- HOW altered are they? Can argue that would go straight to GA bc concerned about further deterioration, placing her at risk for aspiration/hypoventilation (which also isn’t great if c/f inc ICP either)
- Also can argue that in a pt where you’re concerned about difficult airway, would rather ensure that all necessary equipment and personnel are present and perform induction in a more controlled setting than emergently in the middle of the C-section
- Also risk of sympathectomy induced hypoTN in a spinal which would compromise cerebral perfusion i/s/o elevated ICP
Steps to take if c/f Mg toxicity? What levels coorelate with what sxs/findings?
- Order STAT Mg level
- Check DTRs (will be diminished)
- D/c infusion
- Prepare to tx seizure if occurs (BDZ, propofol, etc)
- Give diuretic to inc renal excretion of Mg
- Give Ca gluconate to antagonize neuro and cardiac effects of Mg
How is your management of this trauma patient affected by the fact that she’s pregnant?
- primary goal: resuscitate mother (primary pt + best way to optimize baby’s condition anyway)
- primary and secondary survey like always
- left uterine displacement if > 20 WGA
- risk of diff airway (dec FRC, inc O2 consumption, airway edema), pulm aspiration, delayed recognition of severe hemorrhage d/t inc blood vol and CO, thromboembolic events
- employ FHR monitoring (wellbeing of baby + mom) and tocodynamometry (preterm labor)
- eval for uterine rupture/placental abruption
- consider med affects on baby
- prepare for delivery if needed, transferring to OB floor for monitoring, RhoGAM admin
What is Rhesus isosensitization?
- Occurs only if mother is Rh-, father is Rh+, and he passes on the Rh+ onto baby
- Then during delivery, miscarriage, abortion, amniocentesis, ectopic preg, abdominal trauma, or external cephalic version –> entrance of blood from Rh+ baby into circ of Rh- mother –> mom produces IgG ABs against baby’s RBCs that can cross placenta in current or future pregnancies –> Rh disease (range of mild anemia, hydrops detalis, stillbirth)
- Prevention: give anti-Rh ABs (called RhoGAM) to mom w/in 72 hrs of potentially sensitizing event like delivery, trauma etc –> destroys fetal Rh+ RBCs before maternal immune response occurs
Radiation exposure to baby in a trauma - worry about it or not?
As long as mom is stable enough for transport and not super remote location etc, CT scan to obtain more definitive diagnoses probably outweighs potential risk for teratogenesis (most risky during 1st trimester)
Pain management for preggo in 3rd tri?
- utilize regional whenever possible (intercostal nerve blocks for rib fractures, etc)
- give slow dosing of narcs and inform OB when giving so that they can correlate w/depression of HR variability
- avoid NSAIDS (can close PDA)
What’s the term to use when talking about why you want to keep mom adequately resuscitated if injured or whatnot?
Want to maintain adequate uteroplacental perfusion. Same thing in TBI pt…want to maintain cerebral perfusion
-instead, get 2 PIVs, give NS (for TBI), consider TXA, 1:1:1 products to keep Hct >25% and plts >50, prevent acidosis/hypothermia/hypoTN, maintain nl Ca
When do you give Mg for preggo patients?
What to do if baby’s heart tones dec before you’ve intubated and pt w/likely difficult airway?
- optimize mom’s condition as much as possible while also preparing for emergent C section. So, I would:
- 100% FiO2, ensure b/l breath sounds (rib fx/central line placement could have caused PTX), L uterine displacement, give fluids/pressors PRN, surgeon for airway
- ensure T&C, prep blood bank for MTP, induce after airway secured, get ABG, PAC/echo to r/o MI or tamponade
Arrest in preggo - what to do?
If PEA (ensure that the “organized rhythm” isn’t wide complexes –> VTach haha):
- L uterine displacement
- CPR
- d/c Mg infusion and give CaCl to counter effects
- epi q3-5m
- 5 H&Ts
- check for shockable rhythm q2m during compression switches
- if ROSC not achieved w/in 4 mins of arrest, remove fetal monitors and if > 20 WGA should deliver baby via Csection (goal is to complete delivery w/in 5 mins of arrest)
*delivery of baby also helps mom! 1) relieves aortocaval compression, improving venous return to heart, 2) dec metabolic demands, 3) allows for more effective chest compressions
PTX in preggo…what to think about?
- needle decompression in same spot as usual: 14G in 2nd IC space midclav line
- surgeon to place chest tube 1-2 interspaces higher than normal due to elevation of diaphragm (normally 4-5th ICS just ant to midaxillary line)
S/s of PDPH?
Loss of CSF –> CN stretching
- frontal-occipital h/a worse when sitting up
- n/v
- photophobia, diplopia (CN VI-abducens n stretch), neck stiffness, tinnitis (vestibulocochlear)
- back pain
- occurs ~24 hrs after dural puncture
Tx of PDPH?
- blood patch most effective
- hydration (though no evidence)
- caffeine
- place abd binder –> possible inc in CSF pressure
- pain control
Normal baseline HR for fetus? Like on FHR monitor?
110-160
What are some reasons why a fetus might have decreased FHR variability?
- fetal hypoxia, tachy
- prematurity
- fetal neuro abnlties
- betamethasone
- CNS depressants: opioids, barbiturates, Mg sulfate, BDZs
Normal FHR variability? What age?
Minimal: <5bpm (up and down)
Mod: 6-25
Marked: >25
- doesn’t develop variability until 25-27WGA
- if lose variability intraop in nonOB case for preggo, could be 2/2 drugs (atropine, opiates) vs fetal hypoxia (should LUD, 100% FiO2, vol resuscitation, BP support)
What to do if pt having late decels?
- inform OB
- suppl O2, fluid bolus, uterine displacement, optimize maternal hemodynamics
- perform H&P: coag status, comorbidities, preE complications
- recommend early epidural to avoid GA if C section needed
Any neurotoxicity for fetus when mom needs anesthesia for emergent case?
- animal studies showing effects on memory, decision making, etc but not enough human data
- urgent case must proceed
- available data shows single exposure very unlikely to inc risk of impairment
NonOB surgery for preggo - considerations?
- uterine displacement after __ wga
- HD changes (inc blood vol)
- inc risk thromboembolism
- dec FRC
- airway changes
- inc aspiration risk
- drug considerations/crossing placenta (teratogenosis - highest around 2w-2m), miscarriage, neurotox
- FHR monitoring/preterm labor/delivery esp w/abdominal surgery
- hypercapnia-induced fetal acidosis for lap surgery (can adjust ventilation or use gasless laparoscopy)
Best and worst times for semi-elective surgery for pregnant pt?
- best: 2nd tri!!
- 1st tri: inc risk of miscarriage and teratogenesis
- 3rd tri: inc risk of preterm labor
- after 23wga, inc risk of preterm labor and less surgical access w/in abdomen
When do glucocorticoids benefit fetal lung maturation?
- when the fetus has reached age of viability (23 WGA)
- so no need to give decadron during surgery if before that age unless just for PONV like normal
Any evidence for giving tocolytic for preggo undergoing nonOB surgery?
- no
- can use tocodynamometry during periop though to ID any uterine contractions and give tocolytic at that time (haven’t been proven to dec incidence anyway though)
