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Flashcards in ACE Review - OB Deck (191)
1

Risk factors for PDPH

Age 20-40,female,spinals, cutting needles.

2

Highest risk factor for PDPH

Age

3

When should non ob surgery be done for obstetrics pt.

Recommended to be done after pregnancy, but if required to be dine, then in the second trimester.

4

Why is the second term the best time for pregnant patients who cannot postpone past pregnancy

Avoids the spontaneous abortions of first trimester and the premature contractions of the third trimester

5

If a fetus is previable, how do you monitor intraop

A pre and post op Doppler of fetal heart rate

6

If a fetus is viable, how do you monitor intraop

A pre and post fetal heart monitor and contraction monitor pre and post.

7

What was the concern of diazepam/ bentos in a past retrospective study on teratogenesis

Cleft palate

8

What is the concern about using nitrous oxide in obstetric patients.

It inhibits methionine synthase activity involved in DNA synth

9

does nitrous oxide decrease uterine tone

no

10

do anesthetic gases decrease uterine tone

yes

11

does epidural medication provide uterine relaxation

no

12

a pt w/ retained placenta. Bp and hr stable…what can help to give uterine relaxation.

intravenous nitrous 50-100mcg

13

what other uterine relaxants can you use

magnesium or terbutaline

14

what sensory level do you need to have for analgesia of retained placenta removal proceedure

at least t10

15

what happens to intestinal motility during pregnancy

drecrease motility

16

what happens to LES during pregnancy

decrease LES

17

what happens to gastric volume during pregnancy

increased

18

when dose gastric emptying during pregnancy get delayed

not until the onset of labor

19

does decrase intestinal motility only occur after the onset of labor like gastric emptying

no it starts right at the first trimester

20

what is the onset and end of first stage of labor

onset is dilation of cervix, end of first stage is full cervix dilation

21

what nerve fibers is the pain of first stage of labor

t10 to l1

22

what causes the pain during first stage of labor

cervix dilation

23

how do you know first stage of labor pain is not cause by uterine fundus contraction and actually cervix dilation

during labor, nerve fibers to uterine fundus is decreased

24

is pain of the first stage of labor somatic or visceral

visceral

25

what is the onset of second stage of labor,

when the fetus engages the vagina

26

what is the cause of second stage pain

vagina and perinium

27

what is the second stage nerve for pain

pudendal

28

what is the nerve source of pudendal

s2-s4

29

what kind of pain is second stage pain

somatic takes over the visceral pain of stage 2

30

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31

why is amniotic fluid embolism a misnomer

because it is not a real clot, it is just amniotic fluid causing pulmonary artery to vasospasm

32

what cardiac manifestation will make you more concerned for amniotic fluid emboism

elevated PA pressures

33

how did they find out that afe is cause by pulm aa vasosopasm

this is what is seen in TEE

34

what is the main co-pathology that occurs with AFE

DIC

35

if a pt is developing coagulopathy with AFE, should you heparinize the pt?

no, you should stop the bleeding…it takes priority…bc the pt is not a true emboism…transfusion of prbc ffp and plt and cryo needed to stop bleeding will end the DIC

36

what lab work will drop precipituously in afe

drop of fibrinogen

37

how to help the drop in fibrinogen?

cryo should be given early in afe pts

38

what is hemabate

prostaglandin F2A

39

what is a side effect of prostaglandin f2a

it causes pulm htn

40

can you use prostaglandin f2a in an AFE pt bleeding

actually it might worsen pulm htn and worsen right heart failure

41

what is the purpose of measureing the fetal cord gas

it tells you how well the fetus did before delivery

42

what vessel is better at determining fetal well being

the umbilical arter is better than the 2 umbilical viens

43

which baby will have a better umbilical artery pH, a post vag or a post c/s

a post c/s

44

what is a normal fetal umbilica aa blood gas

7.26, pco2 50, po2 20, be -3, hco3 22

45

what is considered acidosis it fetal blood gas

pH less than 7.2

46

what is the first step in interpreting fetal umbilica aa blood gas

look for the type of acidemia….respiratory versus metabolic

47

what is worse for the baby, resp acidosis or metabolic acidosis

metabolic acidosis

48

what is seen in fetal metab acidosis

low pH, elevated base excess and drop in hc03

49

what is gluteal pain that occurs after a spinal

possibly TNS

50

what anesthestic is assoc w TNS

lidocaine…has a 7x greater risk of getting tns than other anesthetics

51

when does tns occur

24hrs after spinal

52

when does tns resolved

after 72 hrs

53

is tns a permanent nerve injury

no it is only transient

54

is TNS associated with dosing of the lidocaine or its concentration

no it is not dependant on dose or concentration

55

what predisposes pt to TNS other than getting lidocaine for spinal

type or surgeruy…usually gyn cases in lithotomy position

56

how much more does lithotomy position predisopose pt to tns

lithotomy has 30% risk rate of tns vs 4% risk rate of supine cases

57

what is the treatment for TNS

opiods, NSAIDS, muscle spasm relaxants

58

what is the etiology of TNS

still unknown

59

how many ob patients who have eisenmengers die

30-40% die bc they have fixed cardiac funx

60

what 2 things may happened during surgery that may worsen a pregos eisenmengers right to left shunt

increase in pulm vasc resistance or decrease in svr

61

what increases pulm vasc resistnace

can get pulm vascular resistance 2ndry to hypercarb, hypoxia, acidosis

62

what can cause svr drop in eisenmengers pregos

neuralaxial block using local anesthetic

63

what should be included in eisenmengers preos anesthesia plan

invasive lines for bp and volume status checking

64

can you use epinephrine in neuraxial block for eisenmenger prego pt

no…not recommended…epi has beta 2 effect that can vasodilate and drop svr

65

What are the 3 cardiovascular changes in pregnancy

Decreased SVR, increased cardiac output, increased vascular volume

66

Why does svr decrease in pregnant patients?

Because of the effects of estrogen and progesterone. The increase in vascular beds also decrease the SVR

67

Is cvp increased or decreased in pregnancy

Even though you get increase in plasma volume, there is also an increase in vascular beds that causes No increased in cvp

68

What happens to minute ventilation in pregnancy

There is an increase in minute ventilation

69

How does minute ventilation increase in pregnancy

Tidal volume and respiratory rate...the increase is mainly due to an increase of tidal volume

70

According to ACOG, what is not recommended in patients with a previous history of c sec or major uterine surgery.

Misoprostol

71

According to level b recommendations, should a history of 2 c sec be a contraindication for a trial of labor after csec

No it is not a contraindication

72

According to level b recommendation should a twin pregnancy after 1 csec go for trial of labor

It is not a contraindication

73

If a pt had a low transverse c sec and a breech presentation, can they still have a. Trial of labor after c sec

Yes according to level b recommendations of ACOG

74

Who are candidates that cannot have trial of labor after c section

Placenta Previa, history of uterine rupture, previous classical uterine incision,

75

What are strong predictors of a successful vbac

Spontaneous labor and history of a successful vbac

76

According to level b recommendations of ACOG. Is it a contraindication to induce labor

Induction is not a contraindication

77

Is an epidural a contraindication in vbac patients

No...epidural will not mask uterine rupture...which is a misconception of epidurals

78

What is the most common sign of uterine rupture

Fetal heart rate abnormalities

79

How many predictors are there of decrease success of a vbac

8

80

What is one of the 8 predictors that discuss timing of pregnancy

Decrease probability of successful vbac if interpregnancy time is less than 19 months

81

What 2 of the 8 predictors talk about the baby

If the baby is macrosomia or gestational age is greater than 40wk, then there is less likelihood that the vbac will be successful

82

What are 5/8 predictors of a less likelihood for successful vbac dealing with maternal qualities

1. If her previous csec was because of shoulder dystocia, 2. If she is advance maternal age, 3. Preeclampsia, 4. Maternal obesity, 5. Nonwhite

83

What is the mortality rate in trial of labor after c sec compared to repeat csec

Decrease mortality

84

What is the rate of hysterectomy comparing tolac to repeat csec

Rate of hysterectomy is the same in both groups

85

Comparing between tolac to repeat csec, who is more likely to get blood transfusion

Same in both groups

86

How is the length of hospital stay comparing tolac to repeat csec

Tolac had decrease hospital stay

87

How is the rate of DVT comparing tolac to repeat csec

Tolac has a decrease rate of dvt

88

How is the rate of uterine rupture comparing tolac to repeat csec

Tolac has a clear increase of rate of uterine rupture

89

How is the perinatal mortality comparing tolac to repeat csec

There is an increase rate of perinatal mortality for tolac

90

What is the sensory block needed for csec

About t4 to s4

91

is epidural in ob patient assoc with maternal fever above 38

yes

92

What are the risk factors for pdph?

Age 20-30, history of pdph, low opening pressures after dural puncture, female gender, lower him

93

What is the most significant risk factor for pdph

Age 20-30

94

Does a history of migranes increase risk for pdph

No

95

What is the minute ventilation in pregnancy

Increased

96

What causes the increase in minute ventilation in pregnancy

Progesterone and increased co2 production

97

What mechanism does the increase in minute ventilation

Tidal volume

98

What is the end result of increase in minute ventilation in pregnancy

The increase minute ventilation overpowers the production of CO2 and ends up with respiratory alkalosis.

99

How does pregnant patients deal with respiratory alkalosis

The kidneys preserve H+ and excretes excess bicarb

100

What happens to pregnant frc

Decrease in frc

101

When do pregnant get decrease in frc

After 12 weeks

102

what volumes are decreased in obesity

vital capacity, expiratory reserve volume, frc, total lung capacity

103

what do lungs of obesity mimic

restrictive lung disease

104

what volume is increased in obesity

closing capacity

105

what happens to the pft of obesity

decreased fev1 and fvc

106

what does supine positiion in obese pt cause

increase closing capacity, decrease frc,

107

A pregnant patient has prolong Prothrombin Time, Significant decrease Anti-Thrombin Three, Hypoglycemia. Increase LFTs

acute fatty liver disease in pregnancy

108

Mechanism in acute fatty liver disease

Fetus has deficiency in liver enzyme called LongchainThree hydroxy acyl CoA dehydrogenase

109

why may diagnosis of acute fatty liver disease be Delayed

40% of the time they are associated with preeclampsia

110

What is the treatment of acute buddy liver disease and pregnancy

Correct the hypoglycemia, supportive care,delivery of the baby

111

When does acute fatty liver disease and pregnancy present

Usually third trimester

112

What other problems of acute fatty liver disease is present that is emergency

DIC

113

What is the anesthetic management of choice for pain in obstetric patients with aortic regurgitation

Labor epidural

114

Why is labor epidural anesthetic management choice for AR in ob patience

The goal is to have forward flow through the aortic valve. labor epidural decreases SvR allowing for flow

115

Is phenylephrine a vasopressor of choice for AR ob. patients

No it will increase SVR. ephedrine is the pressure of choice

116

In patients with cardiac lesions, Is it necessary to use Endocarditis prophylaxis in vaginal or C-section

And a carditis prophylaxis is not indicated in vaginal or C-section Even if the patient has cardiac lesions

117

What is The initial goal for inverted uterus

Uterine relaxation

118

What drug can be given for uterine relaxation

Intravenous nitroglycerin

119

What if nitroglycerin fails what other agent can be used

inheld anesthetics

120

After uterine relaxation of an inverted uterus what is the second goal of treatment

Utero tonic

121

Amniotic fluid embolism... What is the common clinical presentation

Hypoxia, hypotension, altered mental, dic

122

Amniotic fluid embolism... Wat percent of labor mortality is related to afe?

12 percent

123

Amniotic fluid embolism...when do these patients die

1/4 die in the first hour, 2/3 die within 5 house

124

Amniotic fluid embolism...what test can you do to check for afe

None. There is no current test

125

inverted uterus...what is the quickest way to get uterine relaxation

intravenous nitroglycerine

126

inverted uterus...what is the nitroglycerine dose

50-200mcg

127

inverted uterus...what is the speed of nitroglycerine

within 1 minute

128

inverted uterus...what should be given once inversion is fixed

uterotonics

129

inverted uterus...what is a second line treatment

halogented gases

130

inverted uterus...why is halogenated gases second line treatment

because it requires ETT...which requires time...ett is required because pregos are full stomachs

131

inverted uterus...can magnesium be used for uterus relax?

no...the dose is 4-6 g in 20 mins...and it has long lasting effectts....this makes it not an ideal agent

132

inverted uterus...can u use propofol

no...it has no uterine tonicity effect

133

aortic regurg. what is the most common cause in pregos

bicusp aortic valve

134

aortic regurg. what is the goal

prevent pain because it increases svr

135

aortic regurg. what is the anesthetic management

labor epidural...it can help do rapid and relax

136

aortic regurg. what is the pressor of choice

ephedrine is better than phenylephrine

137

Cardiac. Of all the cardiovascular parameters, which decreases in pregnancy

Svr decreases

138

Cardiac. Of all the cardiovascular parameters. What increase in pregnancy.

Hr, stroke volume, CO, blood volume, left ventricle mass

139

Cardiac. When is the cardiac output greatest in pregnancy.

Right after the postpartum period. Up to 75% increase.

140

Cardiac. What card lesion is well tolerated in pregnancy.

Mitral regurgitation because both the tachycardia and decrease svr helps forward flow.

141

decelerations. what are late decelerations

begin after peak of contraction and resolve 10-30 sec afterwards

142

decelerations. what is a cause of deceleration commonly

uteroplacental insufficiency

143

deceleration. what condition has uteroplacental insufficiency commonly causing late decelerations

preeclampsia

144

deceleration. what is early

head compression causing reflex vagal response

145

deceleration. what is the cause of varible deceleration

umbilical cord compression

146

fetal heart tracing. what does variability represent

fetal well being

147

Preeclampsia. Hypertension. How does hydralazine work

It is a veno dilator.

148

Preeclampsia. Hypertension. What are the side effects to the mom

Hypotension.

149

Preeclampsia. Hypertension. What are the side effects to the neonate with hydralazine.

Thrombocytopenia and lupus like syndrome.

150

Preeclampsia. Hypertension. What is good about labetalol.

It has both alpha 1 and beta blockade. This allows for decrease Bp without reflex tachycardia.

151

Preeclampsia. Hypertension. How long does labetalol work.

Peak effect is 20 minutes, but duration is up to 6 hours.

152

Preeclampsia. Hypertension. What is the side effect of nitro glycerine.

Headaches

153

Preeclampsia. Hypertension. What is the risk associated with nitroprusside.

It can develop cyanide toxicity in neonate if prolong use

154

Preeclampsia. Hypertension. What is the risk of using ACE inhibitors in pregnancy.

Neonate craniofacial abnormalities, pulmonary hypoplasia. Renal tubular dysplasia

155

Preeclampsia. Hypertension. Is the magnesium enough for treatment of hypertension.

No it will not be sufficient. If you use too much, there is risk for mg toxicity.

156

Cardiac arrest. At what gestation should wedge be placed during acls.

After 20 weeks where aortocaval compression can occur.

157

Cardiac arrest. At what age of gestation should bedside csec be considered

After 24 weeks when neonate is considered viable.

158

Cardiac arrest. If ventricular fibrillation occurs what should be done

Defibrillator.

159

Cardiac arrest. What joules should be used in a preggos

Same as non preggos. The fetal heart needs a lot higher current to cause dysrythmia.

160

respiratory physiology. what is increased in pregnancy

tidal volume

161

respiratory physiology. how is the minute ventilation increased the most by in pregnancy

tidal volume has the biggest contribution

162

respiratory physiology. when is the increased minute ventilation

apparent after the first trimester

163

respiratory physiology. what does the increase minute ventilation do to the pH

normally it makes the ph more alkalotic...aka around 7.4

164

respiratory physiology. what is the increase minute ventilation on the pco2

there is a decrease to about 30 for pco2

165

respiratory physiology. what is the bodies way to compensate for the decrease in pco2

the kidneys kick out bicarb down toward 20

166

respiratory physiology. if you look at an abg and you see a pao2 greater than 100, what can u assume about the pt if she is otherwise normal

she is sitting upright

167

respiratory physiology. if you look at an abg and you see a pao2 less than 100, what can you assume about the pt if she is otherwise normal

she is supine

168

respiratory physiology. what does the pao2 greater than 100 tell you about the cardiac function of a pregnant pt

the increase in cardiac output in a pregnant pt is greater than the increase in oxyen consumption in a pregnant pt...this is an evolutionary defense mechanism to prevent lactic acidosis it pregnancy

169

late decelerations and hypotension. what should first be done.

give maternal oxygen and left uterine displacement

170

late decelerations. and hypotension. if the pt has an appropriate level of epidural control. should u stop the pump first or give vasopressor first

vasopressor first. (depending on heart rate ...ephed vs phenyl) then fluids...no need to turn off epidural bc the pain that mom feels may compromise uteroplacental perfusion bc increase catecholamine release

171

late decelerations and hypotension. what else can be done. besides giving pressors and fluids

tocolysis...stop all drips that are causing contraction like oxytocin bc uterine contraction may also decrease perfusion to placenta

172

late decelerations and hypotension. when is c-section necessary.

when resuscitative measures do not improve late decels

173

intrathecal opiods. when is resp depression most common

when intrathecal opiods are given follow a previou dose of oral/iv opiods...but understand that even this is not common

174

intrathecal opiods. how common is puritis

50% of pts get this

175

placenta. what is accreta

into the myometrium

176

placenta. what is increta

through the entire myometrium

177

placenta. what is percreta

pass serosa and possibly into pelvic structures

178

placenta. what is the blood flow rate

600-750cc/ hr

179

labor pain. what kind of pain is the first stage

visceral. due to uterine contraction and cervical dilation

180

labor pain. what kind of pain is the second stage

somatic pain. due to vaginal and pelvic floor dilation

181

labor pain. what kind of block can u do for first stage of labor

epidural, lumbar sympathetic, paracervical

182

labor pain. what kind of block can u do for the second stage of labor

once first stage blocks, are done, you can add pudendal

183

labor pain. what is associated with paracervical block

fetal brady cardia. thats why this is not used n e more

184

placenta transfer. local anesthetics. does molecular weight affect its transfer through

when comparing local anesthetics. all have low molec wt. so molec weight is not a significant factor when comparing local anes to eachother

185

placenta transfer. local anesthetics. how does protein binding affect local anes transfer

the more you are bound the less you cross to fetus

186

placenta transfer. local anesthetics. what are the highest protien bound local anes

ropivicaine most and then marcaine

187

placenta transfer. local anesthetics. what kind of bases or acids are they

they are weak bases

188

placenta transfer. local anesthetics. how does pka of these weak bases affect their transfer to fetal side

local anesthetics...have pka 7.8-8.1...they are baseline non-ionized...when put into body ph 7.4, environment makes it protinated...ionized w a + charge...and now ionized.

189

placenta transfer. local anesthtics. what has the greatest effect on local anes transfer to fetal side

amount of protein binding

190

placenta transfer. local anesthetics. what are amids

amides have 2 I's in their name

191

placenta transfer. local anesthetics. what are esters

they only have 1 I in their name ...chloroprocain and tetraciane