Advanced Principles II > OB I > Flashcards

OB I Flashcards

(39 cards)

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1
Q

What makes a pregnancy high risk?

A
  • Hypertensive disorders
  • antepartum hemorrhage
  • diabetes, cardiac, renal, thyroid, neurologic disease, asthma, obesity, drug abuse
  • advanced maternal age
  • prematurity
  • multiple gestation
  • fetal malpresentation, placental abruption, compression of umbilical cord, intrauterine infections
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2
Q

What is the maternal mortality rate?

most frequent causes?

What are the anesthesia related complications?

A
  • Maternal mortality in US is 7.5 per 100,000 live births
    • pregnancy-induced HTN
    • hemorrhage
    • PE
  • Anesthesia related complications- accounted for 5.2% of maternal deaths
    • airway problems/aspiration
    • LA toxicity or high block
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3
Q

How is hypertension defined in pregnancy?

What can it cause?

A
  • 7-10% of all pregnancies are complicated by HTN
  • mild HTN >140/90 or a rise in SBP of 30 mmHg above baseline or rise in DBP of 15 over baseline
  • Severe HTN >160/110
  • HTN can cause:
    • abruptio placentae
    • DIC
    • hepatic failure
    • cerebral hemorrhage
    • others on separate card
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4
Q

What are the complications caused by hypertension during pregnancy?

Neurological

pulmonary

CV

A
  • Neurological
    • HA
    • visual disturbances
    • hyperexcitability
    • sz
    • intracranial hemorrhage
    • cerebral edema
  • Pulmonary
    • upper airway edema
    • pulmonary edema
  • CV
    • decreased intravascular volume
    • increased arteriolar resistance
    • heart failure
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5
Q

What are the complications caused by hypertension during pregnancy?

Hepatic

Renal

Hematological

A
  • Hepatic
    • impaired function
    • elevated enzymes
    • hematoma
    • rupture
  • Renal
    • proteinuria
    • Na retention
    • decreased GFR
    • renal failure
  • Hematological
    • coagulopathy
      • thrombocytopenia
      • platelet dysfunction
      • prolonged PPT?
    • DIC
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6
Q

How does maternal HTN during pregnancy affect the fetus?

A

Impaired uteroplacental perfusion

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7
Q

What conditions predispose a woman to pregnancy-induced hytension (PIH)?

A
  • Primaparity
  • maternal age >40
  • african american race
  • chronic HTN
  • chronic renal disease
  • Insulin-dependent diabetes
  • history of preeclampsia (maternal- familial)
  • Obesity
  • multiple gestation
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8
Q

What is preeclampsia?

What can it cause?

When does it return to normal?

A
  • Condition characterized by:
    • vasoconstriction
    • hypovolemia
    • coagulation abnormalities
    • poor organ perfusion
  • Defines as new onset HTN that occurs after the 20th week gestation with proteinuria
  • Can cause:
    • cerebral bleeds
    • pulmonary edema
    • hepatic rupture
    • HELLP syndrome
  • Returns to normal within 3 months after delivery
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9
Q

How is preeclampsia categorized (mild vs severe)?

A
  • Mild
    • HTN:
      • 140/90 or greater or
      • increase of 30 mmHg above systolic or
      • 15 above diastolic
    • Proteinuria: >500 mg/day
  • Severe
    • HTN:
      • 160/110 or greater
    • Proteinuria:
      • >5 g/day and/or
      • oliguria (UOP < 500 ml/day)
      • evidence of severe end-organ damage
        • oliguria
        • cerebral disturbances
        • pulmonary edema
        • epigastric pain or impaired liver fxn
        • intrauterine growth retardation
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10
Q

What is Eclampsia?

When does it usually occur?

What are early manifestations?

Treatment?

A
  • Preeclampsia (HTN, edema, and proteinuria) with seizures
  • Life-threatening emergency
  • most common in 3rd trimester
  • Early CNS manifestations are HA and visual disturbances
  • Treatment:
    • Oxygen (ABC’s)
    • LUD
    • IV access
    • Mag sulfate
    • antihypertensives
    • fluid balance
    • coag studies
    • fetal monitoring and resuscitation
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11
Q

How is preeclampsia treated?

A
  • Mainstay of therapy is to control HTN, prevent seizures, and deliver fetus
  • Treatment of maternal HTN (a-line)
    • goal is DBP <110
    • labetalol and hydralazine commonly used
    • other options Nitroglycerine or nifedipine
    • want to gradually decrease BP- may cause fetal distress to drop too quick
  • Seizure prophylaxis with Magnesium sulfate
  • Correct hypovolemia (hydration, foley)
  • Correct coagulation abnormalities
  • Correct acid/base and electrolyte abnormalities
  • assure fetal viability
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12
Q

How does Magnesium sulfate work?

A
  • drug of choice for hyperreflexia, prevention and control of sz related to preeclampsia and eclampsia
  • Causes relaxation of vascular, bronchial and uterine smooth muscle
  • decreases cerebral irritability and prevents/treats sz
  • mildly sedates
  • vasodilates (caution hypotension)
  • decreases uterine tone
  • potentiates the action of depolarizing and non depolarizing muscle relaxants
  • croses placenta and causes neonatal hypotonia and respiratory depression
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13
Q

What is the Magnesium sulfate dose?

What are the maternal side effects?

How can you reverse Magnesium sulfate?

A
  • Dose:
    • bolus 4 g IV over 10 minutes
    • maintenance: 1 6/hr IV infusion
  • Maternal side effects:
    • flushing
    • HA
    • dizziness
    • skeletal muscle weakness
    • deep tendon reflex depression
    • respiratory depression
    • pulmonary edema
  • **monitor serum levels for toxicity
  • Revers the effects of Mag sulfate by administering Calcium
    • Calcium gluconate 1 gm or calcium chloride 300 mg
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14
Q

How does magnesium therapy affect the anesthetic management?

A
  • It potentiates depolarizing and non-depolarizing neuromuscular blockers
    • Never administer defisiculating dose of NMB
    • Standardize dose of Sch to 1 mg/kg
    • Administer 1/2 to 1/3 maintenance dose of non-depolarizers
    • Dose by PNS
  • Mag sulfate antagonizes vasoconstrictive effects of alpha agonists, so ephedrine and phenylephrine are less effective
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15
Q

What are the key points in managing the anesthetic for a preeclamptic or eclamptic patient?

A
  • Assess sz control and neurologic status
  • assess airway
  • correct hypovolemia with colloid fluid bolus (250-500 ml)
  • control BP (DBP <100)
  • Consider A-line, CVP, SWAN
  • continuous FHR monitoring
  • oxygen to parturient
  • Lab workup:
    • CBC
    • renal profile
    • liver function tests
    • Pt/PTT
    • FDP- fibrin degredation products
    • FSP- fibrin split products
    • TEG
    • platelet count
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16
Q

Why is continuous epidural anesthesia preferrable for the preeclamptic or eclamptic patient?

What do you need to be careful of?

Study These Flashcards
A
  • May improve maternal HTN and improve organ blood flow, uteroplacental perfusion and fetal oxygenation
  • Gradual onset of sympathetic block
    • CV stability
    • avoids neonatal depression
  • Avoids airway instrumentation
  • Careful with:
    • hypotension (esp SAB) and its affect on uteroplacental flow
    • Avoid regional if signs of increased ICP, coagulopathies or severe hypovolemia
17
Q

Why can GA be dangerous in a preeclamptic or eclamptic patient?

Study These Flashcards
A
  • exaggerated response to laryngoscopy and intubation
  • more airway edema
  • avoid ketamine
  • exaggerated response to NDMR if on mag sulfate
18
Q

What is HELLP syndrome?

Study These Flashcards
A
  • A severe form of preeclampsia characterized by:
    • Hemolytic anemia
    • Elevated Liver enzymes
    • Low Platelet count
  • Ranges from mild self-limiting condition to multiorgan failure
19
Q

What is the hallmark sign of HELLP syndrome?

When do they present?

What are the other symptoms?

Study These Flashcards
A
  • Hallmark sign of HELLP is hemolysis (microangiopathic hemolytic anemia)
  • Most present preterm (20% postpartum)
  • Other signs and symptoms:
    • Malaise (90%)
    • epigastric pain (90%) ** most common initial symptom
    • N/V (50%)
    • Evidence of preeclampsia before delivery (80%)
20
Q

What are the problems associated with vaginal delivery after C-section?

Study These Flashcards
A
  • Incidence of uterine ruptuer 1%
  • Increase in uterine infections
  • risk of blood transfusions
  • risk of emergency c-sections
21
Q

What is primary dysfunctional labor?

Treatment?

Study These Flashcards
A
  • Failure of labor to progress normally d/t:
    • ineffective uterine contractions
    • arrest of cervix dilation
  • Treatment
    • oxytocin
    • may require anesthesia
22
Q

What are the different breech presentations?

Study These Flashcards
A

A. Complete

B. Incomplete

C. Frank

23
Q

What is this position?

Study These Flashcards
A

Transverse Lie position

24
Q

How is Occiput posterior position different from normal position?

Occiput anterior (normal presentation) pictured here

Study These Flashcards
A

Occiput posterior

25
What problems are multiple gestation pregnancies associated with?
* Premature labor * abnormal fetal presentations * PIH * Increased risk of postpartum hemorrhage (uterine atony) * may require higher doses of oxytocin for uterus to contract * Do not start until all fetuses delivered * Increase anesthesia morbidity * prone to aortocaval compression * prone to hypoxia (greatly reduced FRC) * Risk high spinal/epidural blockade
26
Anesthesia for multiple gestations Labor and delivery twins triplets (+)
* Labor and delivery * continuous epidural analgesia/CSE * Constantly be prepared for emergency C/S * Twins * double "set up" * Sometimes GA is required to facilitate delivery of 2nd twin * Triplets + * C/S preferred route of delivery * epidural or spinal
27
What is preterm labor? What determines survivability of the infant?
* Preterm labor- regular uterine contractions that occur between 20-37 weeks of gestation that result in dilation or effacement of cervix * Survivability of infant depends on the maturity of major organs as well as gestational age/fetal size * Pre-term labor is leading cause of perinatal morbidity and mortality
28
What are the maternal risk factors for premature labor? (15)
* History of preterm delivery * young age (\<18) or old age (\>35) * low socioeconomic status * acute or chronic illness * trauma * abdominal surgery during pregnancy * infection (genital, UTI) * pyelonephritis * smoking * drug use * obesity * multiple gestation * abnormal fetal presentation * low prepregnancy BMI * abnormal uterine/cervical anatomy
29
How is premature labor treated?
* Bedrest * FHR monitoring * check for PROM * abx to prevent maternal chorioamnionitis * Progesterone therapy * Tocolytic agents (to suppress uterine activity) * CCB- Nifedipine * Prostaglandin inhibitors (NSAIDS- Indomethacin, ketorolac) * Beta-2 agonists * Mag sulfate * Corticosteroids for fetal lung development
30
What CCB is used to treat preterm labor? What are the maternal side effects?
* Nifedipine * Maternal side effects: * hypotension * flushing * HA * dizziness * nausea
31
What are the cyclooxygenase inhibitors used to treat preterm labor? Maternal side effets? Fetal side effects?
* NSAIDS- Indomethacin, ketorolac, sulindac * Maternal side effects: * nausea * heartburn * Fetal side effects: * constriction of DA * Pulmonary HTN * reversible renal dysfunction * intraventricular hemorrhage
32
What beta agonist is used to treat preterm labor? How does it work? Maternal side effects? Fetal side effects? Neonatal side effects?
* Terbutaline * tocolysis- smooth muscle relaxation, including uterus; also increases HR, SV, CO * Maternal SE * cerebral vasospasm * CP ?? * tachycardia * arrhythmias * MI * hypotension * hyperglycemia * hypokalemia * ileius * Nausea * palpitations * pulmonary edema * Fetal SE * fetal tachycardia * hyperinsulinemia * Neonatal SE * hypoglycemia * hypocalcemia * tachycardia * hypotension * \*\*\*Careful with fluids, pulmonary edema!!
33
Magnesium Sulfate for Tocolysis: What does it do? Dosage Neonatal effects?
* Causes relaxation of vascular, bronchial, and uterine smooth muscle * Dose: (same as previous dose learned) * Bolus 4 g IV over 10 min * Maintenance 1 g/hr IV * Therapeutic serum mag level of 4-9 mg/dL for tocolysis * Maternal SE same as previous card * Neonatal SE: * lethargy * hypotension * hypotonia * resp distress
34
What is the goal for vaginal delivery of a preterm infant? How is the anesthesia done? Why is GA not ideal?
* Goal during vaginal delivery is slow and controlled with minimal pushing by the mother * make larger episiotomy * low forceps * Spinal and/or Epidural analgesia * complete pelvic relaxation * may add IV NTG * better apgar scores compared to GA * can have depressant effects on fetus * watch fluid preloading with beta agonists d/t risk of pulm edema * GA- fetus is more vulnerable * decreased protein available for drug binding * elevated bilirubin levels that compete for drug binding sites * immature blood brain barrier in the fetus * decreased ability to metabolize and excrete drugs * higher affinity towards acidosis (ion trapping)
35
What is significant regarding hemorrhage in an OB patient? What is average blood loss for vaginal delivery? Cesarean section?
* Hemorrhage in the OB patient is often unexpected and can lead to death within minutes * Antepartum hemorhage occurs in association with placenta previa and abruptio placentae * Average blood loss for vaginal delivery is 500 ml * Average blood loss for c-section is 800-1000 ml * with hysterectomy expect 1500 ml * Blood loss is usually well tolerated and rarely requires transfusion
36
What inherent compensation mecanisms does the parturient have?
* 35-50% increase in blood volume * 500 ml autotransfusion from uterine involution during placental expulsion * increased renin, ADH and catecholamines * help maintain plasma volume, CO and perfusion pressure * hypercoagulable with extra coagulation factors
37
What are some key points regarding blood loss in the parturient?
* Blood loss is usually underestimated * Need good IV access- at least 2 large bore * IV volume replacement is more important than Hct/Hgb * Rapid fluid infusion is more important than type of fluid * Type-specific uncrossmatched blood is preferable to O-neg for emergency transfusion * If parturient is bleeding severely, do not delay surgery for labs tests * Give mother oxygen * Do not hesitate to call for help
38
What can be used to treat bleeding?
* Drugs: * Oxytocin: 20-40 units in 1 L IV fluid * 10 units IM * small incremental IV injections of 2-3 units * Ergot alkaloids * methylergonovine (methergin) * Ergonovine (Ergotrate) * 0.2 mg IM * Prostaglandins * 15- methyl prostaglandine F2-alpha * 0.25 mg IM/intrauterine * Arterial embolization of uterine/ovarian arteries * surgical ligation * hysterectomy
39
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