Complicated OB part 1 (KM) Flashcards by Kimberly Diane Hill

Terminology

What is the goal of an External Cephalic Version (ECV)?
A. Deliver the fetus via cesarean section
B. Convert the fetus from breech to cephalic presentation
C. Stimulate labor during post-dates pregnancy
D. Conver the fetus from cephalic to breech position

B. Convert the fetus from breech to cephalic presentation

“Spinning babies”

Most commonly done for breech position

Slide 2

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Which period is defined as the time from conception to the onset of labor?
A. Intrapartum
B. Postpartum
C. Antepartum
D. Prepartum

C. Antepartum

Slide 2

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The intrapartum period refers to which of the following time frames?
A. Delivery of the fetus to discharge
B. Conception to delivery
C. Postpartum hemorrhage management
D. Onset of labor to delivery of placenta

D. Onset of labor to delivery of placenta

Slide 2

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PPROM is defined as:
A. Persistent postpartum respiratory obstruction
B. Partial placental rupture on maternal side
C. Preterm premature rupture of membranes
D. Postpartum premature rupture of membranes

C. Preterm premature rupture of membranes

slide 2

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Which of the following best defines postpartum hemorrhage (PPH)?
A. Significant bleeding after delivery of the placenta
B. Vaginal bleeding 8 weeks after birth
C. Blood loss >100 mL during antepartum period
D. Normal blood loss during cesarean delivery

A. Significant bleeding after delivery of the placenta

Slide 2

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External Cephalic Version

What is the primary purpose of an External Cephalic Version (ECV)?
A. Stimulate fetal lung maturity with fundal massage
B. Convert fetal position from shoulder to vertex
C. Movement of the baby to induce labor in a preterm patient
D. Convert fetal position from occiput anterior position to occiput posterior

B. Convert fetal position from shoulder to vertex (cephalic or head down)

Slide 4

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What is the optimal gestational age to perform an ECV?
A. 32–34 weeks
B. 35–36 weeks
C. 36–37 weeks
D. 38–39 weeks

C. 36–37 weeks (unlikely to revert >37wks)

“If you do it too soon, you also run into problems because they may be able to revert back to the breach or shoulder presentation if there’s extra room in there”

slide 4

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Which of the following medications is commonly used as a tocolytic prior to ECV? (Select 2)

A. Oxytocin
B. Terbutaline
C. Magnesium sulfate
D. Misoprostol
E. Nitroglycerine
F.

B. Terbutaline
E. Nitroglycerine (small boluses)

slows down contractions, supresses labor

slide 4

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Which of the following increases the success rate of an external cephalic version?
A. Maternal pain
B. General anesthesia
C. Intramuscular ketamine
D. Neuraxial analgesia

D. Neuraxial analgesia

“Increased pain causes a decreased success of ECV”

slide 5

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What is the typical spinal dose range of bupivacaine used for ECV?
A. 0.5–1 mg
B. 1.25–3.5 mg
C. 2.5–7.5 mg
D. 10.5–15 mg

C. 2.5–7.5 mg

+/- opioids, precedex

Slide 5

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What level of dermatomal anesthesia is targeted during ECV?
A. T6
B. T8
C. T10
D. L1

A. T6

Slide 5

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Which of the following is an alternate to spinal anesthesia during ECV?
Select 2

A. Ketamine bolus
B. Inhalational anesthesia
C. Combined spinal-epidural
D. Peripheral nerve block
E. Epidural

C. Combined spinal-epidural (CSE)
E. Epidural

“…for complicated cases or for teaching facilities that an epidural may be used for this because it takes a little bit longer than teaching faculty and residents can accomplish it.”

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Which of the following are potential complications during or after an external cephalic version?
Select 3

A. Placental abruption
B. Tachycardia from cord compression
C. Preterm labor
D. HELLP syndrome
E. Nonreassuring fetal heart tones

A. Placental abruption
C. Preterm labor
E. Nonreassuring fetal heart tones

“…the cord could become wrapped around the neck, resulting in true bradycardia. You could also tear the placenta off the wall.”

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True or False

Fetal heart monitoring is necessary when doing a external cephalic version

True

“…you are gonna be doing fetal monitoring during this time because you need to know if you’re having those non-reassuring fetal heart tones, bradycardia…”

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Antepartum Hemorrhage

Where does the placenta typically implant in a normal pregnancy?
A. Lower uterine segment
B. Cervical canal
C. Upper uterine segment
D. External myometrium

C. Upper uterine segment

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In placenta previa, the placenta is abnormally implanted in the _____ uterine segment.
A. Upper
B. Lower
C. Posterior
D. Anterior

B. Lower

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The internal cervical os is _____ in cases of placenta previa.
Select 2

A. Completely covered
B. Open prematurely
C. Underdeveloped
D. Fused abnormally
E. Covered partially

A. Completely covered
E. Covered partially

Cervical os - cervical opening

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True or false

The exact cause of placenta previa is well understood and typically linked to maternal hypertension.

FALSE

Unknown exact cause, possible d/t prior uterine surgery

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Matching!

Match the placenta previa and the orientation to the cervical os

1 → B. Partial
2 → D. Low-lying
3 → A. Complete
4 → C. Marginal

8/9

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Which of the following is considered “advanced maternal age” in obstetrics and is a risk factor for placenta previa?
A. Age ≥ 30
B. Age ≥ 35
C. Age ≥ 40
D. Age ≥ 45

B. Age ≥ 35

“…They’re not old at all, but in terms of maternal age, they are.”

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Which of the following are recognized risk factors for placenta previa?
Select 4

A. Previous placenta previa
B. Multiparity
C. Prior cesarean section
D. Breech fetal presentation
E. Smoking history
F. Folic acid deficiency

A. Previous placenta previa
B. Multiparity
C. Prior cesarean section
E. Smoking history

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True or False

Adequate prenatal care allows for early detection of placenta previa, which helps reduce the risk of complications during delivery.

True

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What is the pathognomonic (classic presenting symptom) of placenta previa?
A. Sudden onset abdominal pain
B. Hypertension and proteinuria
C. Painless vaginal bleeding
D. Foul-smelling vaginal discharge

C. Painless vaginal bleeding in the 2nd or 3rd trimester

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Placenta previa is most accurately diagnosed by _____, which measures the distance from the placental edge to the internal cervical os.

A. Abdominal X-ray
B. Transvaginal ultrasound
C. Digital vaginal exam
D. CT scan

B. Transvaginal ultrasound

“…it’s done is transvaginal ultrasound or MRI. One thing to keep in mind is we try and limit radiation exposure to pregnant moms and fetuses so we don’t do a whole lot of CTs.”

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# True or False In placenta previa you may see that the bleeding may be sudden and severe and doesn't really stop.

False "You may see that the bleeding stops suddenly. It may be sudden and severe and part of that really depends on where the placenta is sitting in there." ## Footnote 11

What is the purpose of administering betamethasone in the setting of placenta previa? A. To enhance fetal lung maturity B. To reduce maternal blood pressure C. To stop uterine contractions D. To prevent fetal bradycardia

A. To enhance fetal lung maturity ## Footnote 12

Which of the following is the appropriate management for a stable patient with placenta previa and stopped bleeding during a preterm pregnancy? A. Immediate cesarean section B. Induction of labor C. Expectant management D. Emergent hysterectomy

C. Expectant management "...we're going to try and promote retaining fetal viability and staying inside mom as long as possible. Using tocolytics like Terbutaline" ## Footnote 12

What is the purpose of a “double setup exam” in suspected placenta previa? A. To simultaneously perform ultrasound and fetal monitoring B. To prepare for both vaginal exam and cesarean delivery C. To rule out placental abruption D. To prepare for ECV and vaginal exam evaluate

B. To prepare for both vaginal exam and cesarean delivery ## Footnote 13

Why has the double setup exam become nearly obsolete in modern obstetric practice? A. It poses a high risk of uterine rupture B. It has been replaced by Doppler ultrasound C. Improved ultrasound technology D. MRI is now the only acceptable imaging tool

C. Improved ultrasound technology "Improved ultrasound technology provides safer, earlier diagnosis" ## Footnote 13

What is a critical safety requirement before performing a double setup vaginal exam in suspected placenta previa? A. All team members must be present B. The patient should be fasting for 12 hours C. The patient should receive magnesium sulfate D. Fetal scalp electrodes must be in place

A. All team members must be present and **patient prepared for cesarean delivery** "Have all your friends there" ## Footnote 13

What is the primary concern if placental separation occurs in placenta previa? A. Umbilical cord prolapse B. Maternal hypertension C. Fetal macrosomia D. Uteroplacental insufficiency

D. Uteroplacental insufficiency "...there's not enough oxygenated blood flowing from mom to baby and back" ## Footnote 14

Which of the following are appropriate anesthesia considerations for placenta previa with hemorrhagic risk? Select 3 A. Early anesthesia evaluation B. Type and crossmatch C. One large-bore IVs D. Two central venous catheters E. Arterial line

A. Early anesthesia evaluation B. Type and crossmatch E. Arterial line * TWO large-bore IVs * One central venous catheter ## Footnote 14

For patients at risk of hemorrhage, a type and crossmatch is typically valid for _____ hours before it expires. A. 72 B. 48 C. 36 D. 96

A. 72hrs ## Footnote 14

When choosing between starting an arterial line or a second IV in an actively bleeding patient, priority should be given to _____. A. Arterial line B. Foley catheter C. Second IV D. Epidural placement

C. Second IV "...Arterial lines are really nice, but it's a measuring tool, not a resuscitation device" ## Footnote 14

What is the most immediate action an anesthesia provider should take in a severe obstetric hemorrhage scenario? A. Order platelets B. Get help and call for assistance C. Place an epidural D. Get a Bair hugger

B. Get help and call for assistance ## Footnote 15

Which blood type is used in emergencies when crossmatched blood is unavailable? A. AB positive B. A negative C. O negative D. B positive

C. O negative ## Footnote 15

In a massive hemorrhage during placenta previa, the anesthesia team should activate the _____ to initiate rapid blood and product replacement. A. Massive transfusion protocol B. PACU alert protocol C. Advanced cardiac life support protocol D. Blood bank delay form

A. Massive transfusion protocol ## Footnote 15

Which of the following are key elements in managing massive obstetric hemorrhage? Select 3 A. Fluid warmer B. Pressure bags C. Start a Foley catheter D. External defibrillator E. Rapid transfuser

A. Fluid warmer B. Pressure bags E. Rapid transfuser ## Footnote 15

What is a key reason cryoprecipitate is emphasized early in obstetric massive transfusion protocols? A. It provides platelets for clot formation B. It supplies fibrinogen C. It increases red cell mass for oxygen delivery D. It reverses heparin-induced thrombocytopenia

B. It supplies fibrinogen to correct coagulopathy *keep fibrinogen 150-200mg/dL* ## Footnote 15

When is general anesthesia most appropriate in a patient with placenta previa? A. The patient is stable with no active bleeding B. The C-section is scheduled in 48 hours C. Emergent delivery is required D. There is

C. Emergent delivery is required ## Footnote 16

Which of the following is a major concern when choosing neuraxial anesthesia in a bleeding patient? A. Increased cardiac output B. Vasoconstriction C. Decreased fetal heart tones D. Vasodilation

D. Vasodilation "...we know that we're gonna wind up with a relative hypovolemia as they vasodilate." ## Footnote 16

# True or False Vasodilation from neuraxial techniques can increase EBL/QBL in hypovolemic patient.

False "...You may also see because of that laxity that you tend to *decrease the blood loss*, but it's more by virtue of the fact that the blood loss is lower because they're perfusing less..." ## Footnote 16

Which technique is most likely to result in increased estimated blood loss (EBL) during cesarean delivery? A. Spinal anesthesia B. Combined spinal-epidural C. General endotracheal anesthesia D. Epidural anesthesia

C. General endotracheal anesthesia ## Footnote 16

The maximum time frame allowed for an emergent cesarean delivery is typically considered to be _____. A. 30 minutes B. 10 minutes C. 15 minutes D. 5 minutes

A. 30 minutes "...stated limit for emergent section is 30 minutes. If it's 30 minutes, I can probably do a neuroaxial. If it's five minutes, they're probably gonna get probe sucks in a tube and they're cutting as I'm taping the tube into place..." ## Footnote 16

# Abruptio placentae What is the primary pathophysiologic event in placental abruption (abruptio placentae)? A. Placental invasion of the myometrium of the uterus B. Premature separation of the placenta from the uterine wall C. Umbilical cord prolapse out of the uterus D. Retained products of conception

B. Premature separation of the placenta from the uterine wall **Can be complete or partial** ## Footnote 17

In placental abruption, bleeding occurs from the exposure of _____ at the decidual-placental interface. A. Umbilical arteries B. Spiral arteries C. Decidual vessels D. Chorionic villi

C. Decidual vessels "...Sometimes this happens due to trauma. It could be due to drug use..." ## Footnote 17

Why does bleeding persist in placental abruption? A. The placenta migrates upward during contraction B. Abruption prevents normal dilation of the exposed vessels C. The uterus contracts too tightly around the fetus D. Abruption prevents normal constriction of the exposed vessels

D. Abruption prevents normal constriction of the exposed vessels ## Footnote 17

The formation of a _____ behind the placenta can lead to progressive separation in placental abruption. A. Hematoma B. Polyp C. Fibroid D. Decidual capillary

A. Hematoma ## Footnote 17

Which of the following fetal heart rate findings is most suggestive of progressing fetal hypoxia due to placental abruption? A. Tachycardia with accelerations B. Early decelerations with moderate variability C. Bradycardia with decreased variability D. Sinusoidal pattern with high variability

C. Bradycardia with decreased variability ## Footnote 19

A fetal heart tracing with late decelerations, bradycardia, and absent variability most likely indicates _____. A. Fetal deformities B. Fetal asphyxia C. Umbilical cord prolapse D. Placenta previa

B. Fetal asphyxia ## Footnote 19

Which conditions are associated with increased risk of placental abruption due to vascular or inflammatory compromise? Select 3 A. Primip B. Preeclampsia C. Chorioamnionitis D. Type 1 diabetes E. Smoking

B. Preeclampsia (seizures) C. Chorioamnionitis E. Smoking ## Footnote 20

Which of the following patient histories would raise concern for potential placental abruption during pregnancy? Select 3 A. Marijuana use B. Chronic hypotension C. Multiparity D. History of asthma E. PROM F. Advanced maternal age

C. Multiparity E. PROM (Premature Rupture of Membranes) F. Advanced maternal age

In patients with placental abruption, the presence of _____ and _____ is highly suggestive of a pathognomonic origin. A. Fever; hypertension B. Multiparity; oligohydramnios C. Hypertension; cocaine abuse D. Obesity; gestational diabetes

C. Hypertension; cocaine abuse ## Footnote 20

Which of the following clinical signs are commonly associated with placental abruption? Select 3 A. Hypertonic uterus B. Painless vaginal bleeding C. Uterine tenderness D. Decreased uterine tone E. Concealed vaginal bleeding in abruption

A. Hypertonic uterus (frequent contractions) C. Uterine tenderness **and tense to touch** E. Concealed vaginal bleeding in abruption ## Footnote 21

In a Couvelaire uterus, blood from the abruption dissects through the uterine wall and into the _____. A. Serosa B. Cervical canal C. Endometrium D. Amniotic sac

A. Serosa "...Sometimes you will see that it also carries over into the peritoneum. So at that point, you may have quite a bit of complication, not only in terms of the uterus, but inside the abdomen as well." ## Footnote 21

What is the **primary maternal risk** associated with concealed retroplacental hematoma in placental abruption? A. Uterine atony B. Hypovolemic hemorrhagic shock C. Respiratory failure D. Hyperemesis gravidarum

B. Hypovolemic hemorrhagic shock *Volume status may be unknown* "...You may need to use additional monitors... arterial line, maybe non-invasive cardiac output, that sort of thing...flotrack, swann, ## Footnote 23

Consumptive coagulopathy in placental abruption is driven by activation of **circulating plasminogen** and release of _____ from placental tissue. A. Oxytocin B. Fibrinogen C. Histamine D. Thromboplastin

D. Thromboplastin "...part of the big reason that we put the emphasis on getting cryo in early, because mom is burning through those clotting factors very quickly." ## Footnote 23

Which of the following best describes how placental abruption is diagnosed? Select 2 A. Definitively via CT scan B. Based solely on MRI imaging C. Clinically based D. By measuring uterine tone under sedation E. Ultrasound guidance

C. Clinically based E. Ultrasound guidance ## Footnote 24

Obstetric treatment for placental abruption is based primarily on the amount of blood loss and _____ status. A. maternal cardiac B. uterine contractile C. fetal D. neurologic

C. fetal **Delays --> poor maternal & fetal outcomes** ## Footnote 24

When considering neuraxial anesthesia for placental abruption, _______________ should be considered for preload/co-loading A. Lactated Ringer’s B. Colloids C. Albumin D. PRBCs

D. PRBCs "...So consider having extra doses of Pitocin available, consider additional clotting factors, TXA, we don't really use Nova 7 quite as often and it seems more, but like PCC" **PCC**- Prothrombin Complex Concentrate are concentrates of blood clotting factors, specifically the vitamin K-dependent factors II, VII, IX, and X. Some PCCs also include protein C and S, which are natural anticoagulants. ## Footnote 25

# Uterine rupture Which of the following is the most common **cause** of uterine rupture? A. Previous uterine scar B. Trauma to the abdomen C. Placenta previa D. Fetal macrosomia

A. Previous uterine scar seperation (dehiscence) ## Footnote 28

Uterine rupture may occur: Select 2 A. Only during cesarean delivery B. Only before labor begins C. Intrapartum D. Prepartum E. Postpartum

C. Intrapartum E. Postpartum ## Footnote 28

Which of the following scenarios increases the risk of uterine rupture during labor? A. Scheduled cesarean delivery at 37 weeks B. Epidural analgesia C. Rapid progression of labor D. Use of a cervical ripening balloon

C. Rapid progression of labor ## Footnote 29

Which of the following are risk factors for uterine rupture? Select 3 A. Uterine scar from prior C-section B. Low gravid status C. Forceps-assisted delivery D. Placental abruption E. Pitocin use

A. Uterine scar from prior C-section C. Forceps-assisted delivery E. Pitocin use *with prolonged labor* * High gravid status (weakened uterine musculature) * Trauma ## Footnote 29

Uterine rupture is **most commonly associated** with which of the following? A. Breech presentation B. Trial of labor after cesarean C. Placenta previa D. Preeclampsia

B. Trial of labor after cesarean (TOLAC) ## Footnote 30

**Classical uterine incision** scar rupture has the **greatest** increased maternal and fetal morbidity primarily because: Select 2 A. It occurs silently and slowly B. It is a site of placental implantation C. It is associated with multiple gestations D. It is located in a highly vascular area E. It is a site of uterine strength

B. It is a site of placental implantation D. It is located in a highly vascular area ## Footnote 30

Which of the following is the **most consistent** clinical feature of uterine rupture? A. Maternal hypertension B. Fetal bradycardia C. Vaginal bleeding D. Maternal tachypnea

B. Fetal bradycardia ## Footnote 31

Which of the following are clinical signs or symptoms of uterine rupture? Select 3 A. Hypotension B. Hypertension C. Tachycardia with hypertension D. Vaginal bleeding E. Severe abdominal pain

A. Hypotension D. Vaginal bleeding E. Severe abdominal pain (tearing pain) ## Footnote 31

# True or False Uterine rupture can cause shoulder pain

True Shoulder pain due to irritation of the phrenic nerve (C3-C5) by blood or fluid in the peritoneal cavity. ## Footnote 31

Which of the following may indicate concealed uterine rupture despite a functioning epidural? A. Sudden maternal hypertension B. Increased fetal variability C. Breakthrough pain D. Neck pain

C. Breakthrough pain "They're very comfortable with their labor epidural, and then all of a sudden, they're having this breakthrough pain...their heart rate's a little high, their blood pressure is a little bit low..." ## Footnote 31

The uterine blood flow at term gestation is approximately ________ mL/min. A. 200-500 B. 100–300 C. 400–600 D. 700–900

D. 700–900 ## Footnote 32

Maternal mortality is highest in patients with uterine rupture when it occurs ________. Select 2 A. In a scheduled cesarean section B. In patients with a transverse incision C. Due to trauma D. With neuraxial anesthesia E. In patients without a uterine scar

C. Due to trauma E. In patients without a uterine scar ## Footnote 32

Which intervention has contributed to a decrease in the frequency of peripartum hysterectomy for severe obstetric hemorrhage? A. Increased use of cesarean sections B. Early initiation of magnesium sulfate C. IR for uterine artery embolization D. Use of general anesthesia for delivery

C. IR for uterine artery embolization ## Footnote 32

Which maternal condition would most likely prompt the use of general anesthesia instead of neuraxial techniques in uterine rupture? Selecgt 2 A. Mild anxiety B. Hypovolemia C. Mild breakthrough pain D. Well-functioning epidural in place E. Altered mental status

B. Hypovolemia E. Altered mental status (Change in LOC) ## Footnote 33

Which anesthetic technique is **most commonly** used for emergent operative delivery in cases of uterine rupture? A. General anesthesia B. Combined spinal-epidural C. Spinal anesthesia D. Local infiltration

A. General anesthesia ## Footnote 34

Why is spinal anesthesia typically avoided in cases of uterine rupture? Select 2 A. It increases fetal heart rate variability B. It causes uterine relaxation C. It delays delivery D. Fetal heart tracing abnormalities E. Hemorrhage

D. Fetal heart tracing abnormalities E. Hemorrhage ## Footnote 34

Which of the following **IS NOT** a critical component of managing uterine rupture in the OR? A. Forced air warmer B. Activation of massive transfusion protocol C. General anesthesia D. Delay delivery until fetal bradycardia resolves E. Rapid transfuser with pressure bags

D. Delay delivery until fetal bradycardia resolves ## Footnote 35

________ postpartum hemorrhage occurs within 24 hours of delivery. A. Primary B. Secondary C. Late D. Tertiary

A. Primary ## Footnote 36

**Secondary** postpartum hemorrhage is defined as occurring between ________. A. Delivery and 12 hours postpartum B. 12 hours and 3 days postpartum C. 24 hours and 6 weeks postpartum D. 1 week and 12 weeks postpartum

C. 24 hours and 6 weeks postpartum *More of a slow bleed d/t retained products and going septic* ## Footnote 36

Secondary has higher maternal morbidity & mortality

FALSE Primary has higher maternal morbidity and mortality ## Footnote 36

The ACOG definition of postpartum hemorrhage includes (select 2) A. blood loss >/= 1000mL B. blood loss >/= 500mL C. s/s hypovolemia w/in 24 hours of delivery D. s/s hypertension w/in 48 hours of delivery

A. blood loss >/= 1000mL C. blood loss with s/s hypovolemia w/in 24 hours of delivery ## Footnote slide 37

Cause of postpartum hemorrhage include (select 3) A. cocaine use B. uterine atony C. pre eclampsia D. retained placenta E. cervical/vaginal lacerations

B. uterine atony D. retained placenta E. cervical/vaginal lacerations ## Footnote slide 37

Which cause of postpartum hemorrhage is the most common A.placenta acreta B. retained placenta C. cervial/ vaginal lacerations D. Uterine atony

D. Uterine atony 80% ## Footnote slide 38

What is the cause of uterine atony? A. failed release of endogenous uterotonic agents B. excess release of exogenous uterotnic agents C. Uterine muscles contraction due to excess relase of calcium D. Uterine hypertension causeing constiriction of the uterine wall

A. failed release of endogenous uterotonic agents ## Footnote slide 38

What are the endogenous uterotinic agents responsible for uterine atony (select 2) A. prolactin B. estrogen C. oxytocin D.prostaglandins

C. oxytocin D.prostaglandins ## Footnote slide 38

A patient presents for a soft oversized poorly contracting uterus, painless vaginal bleeding along with tachycardia and hypotension. What is a possible diagnosis A. uterine inversion B. placenta accreta C. uterine atony causing PPH D. placental abruption

C. uterine atony causing PPH ## Footnote slide 39

true or false During PPH due to uterine atony, bleeding is always obvious

false ## Footnote slide 39

How much blood can a atonic uterus hold A. 800mL B. <500mL C. 700mL D. >/= 1000mL

D. >/= 1000mL ## Footnote slide 39

When does active management of postpartum hemorrhage due to uterine atony occur A. 1st stage of labor B. 2nd stage of labor C. 3rd stage of labor D. 4th stage of labor

C. 3rd stage of labor ## Footnote slide 40

What does active management of PPH due to uterine atony consist of? (select 2) A. uterine massage B. NTG administration C. increase anesthetic gas D. oxytocin administration

A. uterine massage D. oxytocin administration | slide 40

What is first line treatment for PPH A. hemabate B. oxytocin C. methergine D. NTG

B. oxytocin ## Footnote slide 41

what is the half life of oxytocin A. 1-2 hours B. 30-45 min C. 10-15 min D. 3-5 min

D. 3-5 min ## Footnote slide 41

What is an approriate total concentration of oxytocin used for uterine atony prevention ? (select 2) A. 30 units in 500 mL NS B. 20 units in 1000 mL NS C. 30 units in 1000 mL NS D. 10 units in 1000 mL NS

A. 30 units in 500 mL NS B. 20 units in 1000 mL NS depending on which dosing option you use ## Footnote slide 42/43/45

One way to manage PPH with oxytocin using a 20u in 1000mL concentration is by bolusing _______ml/hr x ____ min and then deliver _____ units in the 1st _____ min with a maintenance of ________ml/hr x 3.5 hours A. 500ml/hr x30 min; 5units in 1st 30 min; 100 B.334ml/hr x30 min; 10units in 1st 15 min; 95 C.500ml/hr x30 min; 10units in 1st 30 min; 200 D. 1000ml/hr x30 min; 10units in 1st 30 min; 125

D. 1000ml/hr x30 min; 10units in 1st 30 min; 125 ## Footnote slide 42

One way to manage PPH with oxytocin using a 30u in 500mL concentration is by bolusing _______ml/hr x ____ min and then deliver _____ units with a maintenance of ________ml/hr x 3.5 hours A. 500ml/hr x30 min; 5units ; 100 B.334ml/hr x30 min; 10units ; 95 C.500ml/hr x30 min; 10units ; 200 D. 1000ml/hr x30 min; 10units; 125

B.334ml/hr x30 min; 10units ; 95 ## Footnote slide 43

Another option for oxytocin administration for PPH is ______ units IM A. 15 B. 5 C. 10 D.20

C. 10 ## Footnote slide 43

Another option for oxytocin delivery IVP is by giving a loading dose of ______ units no faster than _______ seconds A. 5;20 B. 4;10 C. 1;5 D. 3; 15

D. 3; 15 ## Footnote slide 44

After loading dose IVP of oxytocin you can initiate infusion of ___u/hr for ______hours A. 5;4 B. 3;5 C. 4;3 D. 3;15

B. 3;5 ## Footnote slide 44

During oxytocin infusion after the IV loading dose it is important to assess uterine tone every 3 min in the beginning. What should you do if there is inadequate uterine tone? A. call for help B. give 3 units oxytocin IV rescue C. give PRBCs D. Prepare the OR

B. give 3 units oxytocin IV rescue may repeat dosex1 ## Footnote slide 44

When giving oxytocin with a concentration of 30U in 500mL it is appropriate to give an infusion of _____ml/hr A. 1000 B. 300 C. 200 D. 500

B. 300 ## Footnote slide 45

When giving 300mL/ hour of oxytocin in a 30 U/500mL how many units will you be giving per hour A. 18 B. 20 C. 13 D. 15

A. 18 300ml/hour-0.3u/min=18u/hour ## Footnote slide 45

Management of atony with a 30u in 500ml concentration would include infusion of ___ml/hour which is also ____ units /hr A. 300;18 B. 700;36 C. 600; 36 D. 500;18

C. 600; 36 may increase to 900 ml/hour which is 54U/hr ## Footnote slide 45

Which of the following are used for the management of PPH A. infusion of 600mL/hr with a concentration of 50u/500mL B. bolus 334 ml/hr with a concentration of 30u/500mL C. 10units IM D.infusion 30U in 500ml at 300ml.hr

A. infusion of 600mL/hr with a concentration of 50u/500mL all others are prevention!!! ## Footnote slide 45

Side effects of oxytocin include all the following except A. tachycardia B. hypotension C. coronary vasocontriction/ myocardia ischemia D. hypokalemia E. hyponatremia F. seizures

D. hypokalemia ## Footnote slide 46

What infusion rate should you maintain to decrease the side effects for oxytocin A. >1u/min B. <2U/min C. >5u/min D. <1u/min

D. <1u/min ## Footnote slide 46

Methergine is considered the _________ for treatment of uterine atony A. 1st line agent B. 2nd line agent C. 3rd line agent D. 4th line agent

B. 2nd line agent ## Footnote slide 47

Meghylergonivine (methergine) is classified as __________ A. Ergot Alkaloid B. 15-methyl prostaglandin C. Prostaglandin E1 analogue D. Antagonist at beta

A. Ergot Alkaloid ## Footnote slide 47

True or false Methergine can treat other causes of PPH besides uterine atony

False Tx of uterine atony ONLY ## Footnote slide 47

Methergine is a partial agonist at what 3 receptors? (select 3) A. beta adrenergic B. GABA C. alpha adrenergic D. tryptaminergic E. dopaminergic

C. alpha adrenergic D. tryptaminergic E. dopaminergic ## Footnote slide 47

The dose of Methergine is A. 0.2mg IV B. 0.4 mg IM C. 0.2mg IM D. 0.5mg IV

C. 0.2mg IM CAN NOT GIVE IV - thats a good way to kill your patient ## Footnote slide 47

Methergine has an onset of __________ and duration of ________ A. 15min; 2-4 hours B. <10min; 1-2 hours C. 25min ; 3-4 hours D. <10min; 2-4 hours

D. <10min; 2-4 hours ## Footnote slide 48

Methergine is unstable at room temperature and you can repeat doses as early as _____ hours and may repeat up to _____ times to a max dose of ______ A. 4;2;0.6 B.1; 5;1.0 C. 2;4;0.8 D. 3;6;1.2

C. 2;4;0.8 ## Footnote slide 48

Contraindications of methergine include all the following except A. HTN B. Pre-eclampsia C. PVD D. ischemic heart disease E. Asthma

E. Asthma ## Footnote slide 49

Methergine CV effects include (select 4) A. vasocontriction B. hypotension C. hypertension D. ischemia E. coronary vasospasm F. vasodilation

A. vasocontriction C. hypertension D. ischemia E. coronary vasospasm infarction d/t coronary vasospasm ## Footnote slide 50

Neurological effects of Methergine include (select 2) A. Memory loss B. hemorrhage C. CVA D. Seizures

C. CVA D. Seizures ## Footnote slide 50

GI symptoms of methergine include A. diarrhea B. N/V C. ulcers D. constipation

B. N/V ## Footnote slide 50

Your patient was given Methergine and during a vital sign check the blood pressure is 180/90. What would you consider next? (select 2) A. Cardene B. NTG C. sodium nitroprusside E. Esmolol

B. NTG C. sodium nitroprusside ## Footnote slide 51

Hemabate is typically considered A. 1st line treatment B. 2nd line treatment C. 3rd line treatment D. 4th line treatment

C. 3rd line treatment ## Footnote slide 52

A patient is experiancing PPH and pitocin is given with no success. The patient has a history of HTN and pre-eclampsia. What is the next step to control the PPH? A. Methergine B. Bakri Balloon C. Hemabate D. Cytotec

C. Hemabate 2nd line agent if patient has HTN or preeclampsia ## Footnote slide 52

Carboprost (hemabate) is classified as __________ A. Ergot Alkaloid B. 15-methyl prostaglandin F2a C. Prostaglandin E1 analogue D. Antagonist at beta

B. 15-methyl prostaglandin ## Footnote slide 52

The dose for Hemabate is ________ IM or intrauterine every _______ min A. 250mcg ;15-90min B. 300mcg; 20-30min C. 490mcg ;45-90min D. 150mcg ; 15-90min

A. 250mcg;15-90min ## Footnote slide 52

What is the max dose of Hemabate A. 4mg B. 3mg C. 6mg D. 2mg

D. 2mg ## Footnote slide 52

True or false Hemabate must be refrigerated so it may cause a delay in getting the drug to the patient

true ## Footnote slide 52

Hemabate CV effects include A. Increased CO B. increased SVR C. hypotension D. coronary vasospasm

B. increased SVR ## Footnote slide 53

Pulmonary side effects of hemabate include all the following except A. bronchospams B. V/Q mismatch C. shunt D. hypoxia E. decreased PVR

E. decreased PVR INCREASED PVR ## Footnote slide 53

Systemic side effects of hemabate include (select 2) A. fever B. chills C. coagulopathy D. coma

A. fever B. chills ## Footnote slide 53

GI side effects of hemabate include (select 2) A. constipation B. ulcers C. N/V D. diarrhea

C. N/V D. diarrhea ## Footnote slide 53

Hemabate should be avoided in (select 3) A. HTN B. pre ecclapsia C. reactive airway D. cardiac disease E. pulmonary HTN

C. reactive airway D. cardiac disease E. pulmonary HTN ## Footnote slide 54

Misoprostol (cytotec) is classified as __________ A. Ergot Alkaloid B. 15-methyl prostaglandin F2a C. Prostaglandin E1 analogue D. Antagonist at beta

C. Prostaglandin E1 analogue ## Footnote slide 55

Dose of cytotec is A.600 – 1000 mcg B. 400-600mcg C. 500-750mcg D. 800-900mcg

A.600 – 1000 mcg ## Footnote slide 55

What routes can you give cytotec (select 4) A. oral B. SL C. vaginal D. rectal E. IM F. IV

A. oral B. SL C. vaginal D. rectal ## Footnote slide 55

Side effects of Cytotec include (select 4) A. Fever B. tachycardia C. chills D. diarrhea E. pulmonary HTN F. N/V

A. Fever C. chills D. diarrhea F. N/V ## Footnote slide 55

Bakri Balloon is used for A. Vacuum B. Induces physiologic uterine contraction C. keep integrity of uterus D. intrauterine balloon tamponade

D. intrauterine balloon tamponade ## Footnote slide 56

Jada system is used for (select 2) A. Vacuum B. Induces physiologic uterine contraction C. keep integrity of uterus D. intrauterine balloon tamponade

A. Vacuum B. Induces physiologic uterine contraction ## Footnote slide 56

Retained placenta is the failure to deliver placenta completely within _____ of delivery A. 90min B. 1 hour C. 3 hour D. 30 min

D. 30 min ## Footnote slide 57

If the time between delivery of fetus and delivery of placenta is >30 min the risk for ____ increases A. placenta accreta B. retained placenta C. PPH D. hypertension

C. PPH ## Footnote slide 57

What are 2 treatment options for retained placenta (select 2) A. manual removal by OB B. hysterectomy C. tubal ligation D. tx of uterine atony/ hemorrhage

A. manual removal by OB "wont have much to do with this one except pain control" D. tx of uterine atony/ hemorrhage ## Footnote slide 57

Manual removal by the OB provider for retained placcenta requires _________ and is ________ A. uterine relaxation ; painful B. uterine constriction; painless C. uterine constriction; painful D. uterine relaxation; painless

A. uterine relaxation ; painful ## Footnote slide 57

How does anesthesia play a roll in retained placenta? (select 3) A. Benzos and ketamine B. epidural/ neuraxial C. General anesthetic D. MAC E. emotional support

A. Benzos and ketamine (+/- opioids if not epidural) B. epidural/ neuraxial C. General anesthetic ## Footnote slide 58

What is the dose of IV ketamine that we would give for support in retained placenta management A. 0.2mg/kg B. 15mg C. 1.5mg/kg D. 0.1mg/kg

D. 0.1mg/kg ## Footnote slide 58

Lidocaine 5% dose and duration spinal anesthesia (select 2) A. 7.5-15mg B. 60-80mg C. 45-75min D.60-120min

B. 60-80mg C. 45-75min ## Footnote slide 59

Bupivacaine 0.5-0.75% dose and duration spinal anesthesia (select 2) A. 7.5-15mg B. 12-16mg C. 70-90min D. 60-120min

A. 7.5-15mg D. 60-120min ## Footnote slide 59

Ropivacaine 0.5% dose and duration spinal anesthesia (select 2) A. 70-90min B. 60-120min C. 10-25mcg D. 15-25mg

B. 60-120min D. 15-25mg ## Footnote slide 59

Tetracaine 0.5-1% dose and duration spinal anesthesia (select 2) A. 12-16mg B. 70-90min C. 60-120 min D. 60-70mg

A. 12-16mg B. 70-90min ## Footnote slide 59

fentanyl dose and duration spinal anesthesia (select 2) A. 100-200mcg B. 720-1440 min C. 10-25mcg D. 180-240min

C. 10-25mcg D. 180-240min ## Footnote slide 59

sufentanil dose and duration spinal anesthesia (select 2) A. 5-10mcg B. 2.5-5mcg C. 180-240 min D. 70-90min

B. 2.5-5mcg C. 180-240 min ## Footnote slide 59

Morphine dose and duration spinal anesthesia (select 2) A. 100-200mcg B. 60-70mcg C. 720-1440 min D. 180-240 min

A. 100-200mcg C. 720-1440 min ## Footnote slide 59

Meperidine dose and duration spinal anesthesia (select 2) A. 100-200mcg B. 60-120 min C. 60-70mcg D. 60 min

C. 60-70mcg D. 60 min ## Footnote slide 59

Epinephrine dose for spinal anesthesia A. 500-600mcg B. 100-200mcg C. 5-10mcg D. 1-2mg

B. 100-200mcg ## Footnote slide 59

dexmedetomidine dose for spinal anesthesia A. 500-600mcg B. 100-200mcg C. 5-10mcg D. 1-2mg

C. 5-10mcg ## Footnote slide 59

Lidocaine 2% with epi 5mcg/ml epidural dose and duration (select 2) A. 60-80mg B. 45-75min C.300-500mg D. 75-100min

C.300-500mg D. 75-100min ## Footnote slide 60

2-Chloroprocaine 2-3% epidural anesthesia dose and duration (select 2) A. 350-450mg B. 450-750mg C. 40-50min D. 60-90min

B. 450-750mg C. 40-50min ## Footnote slide 60

Bupivacaine 0.5% dose and druation epidural anesthesia (select 2) A. 120-180min B. 75-125mg C. 50-100mcg D. 120-240 min

A. 120-180min B. 75-125mg ## Footnote slide 60

Ropivacaine 0.5% dose and druation epidural anesthesia (select 2) A. 120-180min B. 75-125mg C. 50-100mcg D. 120-240 min

A. 120-180min B. 75-125mg ## Footnote slide 60

Fentanyl dose and druation epidural anesthesia (select 2) A. 120-180min B. 75-125mg C. 50-100mcg D. 120-240 min

C. 50-100mcg D. 120-240 min ## Footnote slide 60

sufentanil dose and druation epidural anesthesia (select 2) A. 120-180min B. 10-20mcg C. 50-100mcg D. 120-240 min

B. 10-20mcg D. 120-240 min ## Footnote slide 60

Morphine dose and duration epidural anesthesia (select 2) A. 1.25-3.75mg B. 2.25-4.75mg C. 720-1440 min D. 500-1500min

A. 1.25-3.75mg C. 720-1440 min ## Footnote slide 60

A patient has delivered a beautiful baby boy 45 minutes ago and has not completely delivered her placenta. In order to induce uterine relaxation we should expect to give (select 2) A. nitroglycerine B. volatile agents C. esmolol D. precedex

A. nitroglycerine (spray or IV) B. volatile agents - dose dependent ## Footnote slide 61

To induce uterine relaxation for a retained placenta what dose of IV nitroglycerine should we expect to give A. 50-100mcg B. 35-45mcg C. 25-50 mcg D. 15-25mcg

C. 25-50 mcg ## Footnote slide 61

Placenta accreta is A. placenta invades the myometrium B. placenta thru myometrium into serosa C. Placenta invades uterine wall D. placenta invades ovaries

C. Placenta invades uterine wall ## Footnote slide 62

Placenta increta is A. placenta invades the myometrium B. placenta thru myometrium into serosa C. Placenta invades uterine wall D. placenta invades ovaries

A. placenta invades the myometrium ## Footnote slide 62

Placenta precreta is A. placenta invades the myometrium B. placenta thru myometrium into serosa C. Placenta invades uterine wall D. placenta invades ovaries

B. placenta thru myometrium into serosa may invade adjacent organs ## Footnote slide 62

Placenta accreta risk include all the following except A. Hx of C-section B. placenta previa C. low birth weight D. hx myomectomy E. ashermans syndrome F. advanced maternal age

C. low birth weight If patient has placenta previa they are likely to have accreta ## Footnote slide 64

What is the age that determines advanced maternal age A. 50 B. 40 C. 45 D. 35

D. 35 ## Footnote slide 64

Placenta accreta can be diagnosed by (select 2) A. ultrasound B. MRI C. X-ray D. CT scan

A. ultrasound B. MRI ## Footnote slide 65

Obstetric treatment for placenta accreta include (select 2) A. Cesarean hysterectomy B. ureteral stents C. tubal ligation D. Balloon

A. Cesarean hysterectomy B. ureteral stents ## Footnote slide 65

What determines treatment of placenta accreta A. surface area B. size of fetus C. pain level D. area and depth

D. area and depth ## Footnote slide 65

Treatment for lacenta accreta hemorrhage include (select 4) A. internal iliac artery balloon catheters B. Reboa C. GETA D. get help E. nitroglycerine

A. internal iliac artery balloon catheters B. Reboa C. GETA D. get help expected or unexpected ## Footnote slide 66

Anesthetic management of a patient with placenta accreta include all the following except A. spinal anesthesia B. fluid warmer C. rapid transfuser and pressure bags D. massive blood loss preparation E. forced air warmer

A. spinal anesthesia ## Footnote slide 67

How many degrees are there of uterine inversion A. 1 B. 2 C. 3 D. 4

D. 4

Complete degree of uterine inversion is if the fundus____ A. stops before the cervix B. passes thru the cervix C. invades the ovaries D. protrudes into the peritinium

B. passes thru the cervix ## Footnote slide 68

What degree of Uterine inversion is this A. 1st B. 2nd C. 3rd D. 4th

D. 4th ## Footnote slide 69

What degree of Uterine inversion is this A. 1st B. 2nd C. 3rd D. 4th

A. 1st ## Footnote slide 69

What degree of Uterine inversion is this A. 1st B. 2nd C. 3rd D. 4th

B. 2nd ## Footnote slide 69

What degree of Uterine inversion is this A. 1st B. 2nd C. 3rd D. 4th

C. 3rd ## Footnote slide 69

Which of the following is NOT a risk factor for uterine inversion? A. Overzealous fundal pressure B. Umbilical cord traction C. Placenta accreta D. Uterine atony E. Uterine anomalies F. Cervical insufficiency

F. Cervical insufficiency ## Footnote Slide 70

What is the initial step in managing uterine inversion? A. Start Pitocin infusion B. Transfuse packed red blood cells C. Discontinue uterotonic agents D. Administer magnesium sulfate

C. Discontinue uterotonic agents * Postpartum Pitocin infusion ## Footnote Slide 71

Which of the following may be clinical features or complications of uterine inversion? (Select 2) A. Severe hemorrhage B. Vagal-mediated bradycardia C. Uterine perforation D. Hypovolemia

A. Severe hemorrhage B. Vagal-mediated bradycardia ## Footnote Slide 71

Uterine inversion may be missed if it is not a ____ or ____ degree inversion. A. 1st or 2nd B. 2nd or 3rd C. 3rd or 4th D. 4th or complete

C. 3rd or 4th ## Footnote Slide 71

How can anesthesia assist in relaxing the uterus when the OB promptly replaces the uterus due to uterine inversion? A. Administer oxytocin bolus B. Provide uterine massage C. Use nitroglycerin 200–250 mcg IV or sublingual D. Administer misoprostol E. Use volatile anesthetics

C. Use **nitroglycerin** 200–250 mcg IV or sublingual D. Administer misoprostol E. Use **volatile anesthetics** ## Footnote Slide 72

What intervention may be necessary in the treatment of uterine inversion when significant hemorrhage occurs? A. Administer methylergonovine B. Start magnesium sulfate infusion C. Perform fundal massage D. Transfusion

D. Transfusion ## Footnote Slide 72

Which of the following is the definitive treatment for postpartum hemorrhage (PPH) unresponsive to medical and conservative surgical interventions? A. Uterine massage B. Uterine artery embolization C. Peripartum hysterectomy D. Intrauterine balloon tamponade

C. Peripartum hysterectomy ## Footnote Slide 73

Peripartum hysterectomy is most often performed as a last resort in which of the following cases? (Select 2) A. Preeclampsia B. Placenta previa C. Unresponsive uterine atony D. Placenta accreta E. Umbilical cord prolapse

C. Unresponsive uterine atony D. Placenta accreta ## Footnote Slide 73

# True or False The risk of requiring a peripartum hysterectomy increases with the number of prior cesarean deliveries.

True ## Footnote Slide 73

Which of the following contribute to the procedural challenges of peripartum hysterectomy? (Select 3) A. Large uterus B. Decreased uterine vascularity C. Engorged blood vessels D. Increased uterine blood flow (700–900 mL/min) E. Early gestational age

A. Large uterus C. Engorged blood vessels D. Increased uterine blood flow (700–900 mL/min) ## Footnote Slide 74

More than ____ of patients undergoing peripartum hysterectomy require transfusion of packed red blood cells (PRBCs). A. 20% B. 30% C. 40% D. 50%

C. 40% ## Footnote Slide 74

# True or False Mortality is 10 times higher for peripartum hysterectomy compared to non-peripartum hysterectomy

FALSE Mortality is **25 times** higher for peripartum hysterectomy compared to non-peripartum hysterectomy ## Footnote Slide 74

What is the purpose of manual aortic compression during severe obstetric hemorrhage? A. Increase cardiac output B. Stimulate uterine contraction C. Decrease blood flow to the pelvis D. Improve renal perfusion

C. Decrease blood flow to the pelvis *Potentially life saving in catastrophic OB hemorrhage* ## Footnote Slide 75

Which of the following are potential risks associated with manual aortic compression in obstetric hemorrhage? A. Hypernatremia and tachycardia B. Lactic acidosis and hemodynamic instability upon release C. Bradycardia and uterine rupture D. Hypoglycemia and respiratory depression

B. Lactic acidosis and hemodynamic instability upon release ## Footnote Slide 75

Intraperitoneal manipulation during peripartum hysterectomy can lead to ____ and ___. A. Bradycardia and dry mouth B. Hypertension and confusion C. Pain and nausea/vomiting D. Fever and hypotension

C. Pain and nausea/vomiting ## Footnote Slide 76

What is the minimum sensory level that must be maintained for neuraxial anesthesia during peripartum hysterectomy? A. T10 B. T6 C. T4 D. L1

C. T4 ## Footnote Slide 76

# True or False IV sedation may be required as a supplement to neuraxial anesthesia during peripartum hysterectomy.

True ## Footnote Slide 76

Which of the following are valid considerations for using general endotracheal anesthesia (GETA) during peripartum hysterectomy? (Select 3) A. Best option for increased estimated blood loss (EBL) or quantified blood loss (QBL) B. Hypotension may require intubation C. Large fluid shifts or massive transfusion may impair oxygenation D. GETA is avoided in all cases of obstetric hemorrhage E. Regional anesthesia is always preferred regardless of blood loss

A. Best option for increased estimated blood loss (EBL) or quantified blood loss (QBL) B. Hypotension may require intubation C. Large fluid shifts or massive transfusion may impair oxygenation ## Footnote Slide 77

In patients undergoing peripartum hysterectomy, airway edema may develop as a result of ____. A. Hyperventilation B. Hypoglycemia C. Fluid shifts D. Narcotic use

C. Fluid shifts ## Footnote Slide 77

In cases of significant hemodynamic instability during a Peripartum hysterectomy, a ____ may be required for access and monitoring. A. Foley catheter B. PICC line C. Peripheral IV D. Central venous line (CVL)

D. Central venous line (CVL) ## Footnote Slide 77

Which of the following are recommended anesthesia preparations for peripartum hysterectomy due to anticipated hemorrhage? (Select 3) A. Single 20-gauge IV B. Two large-bore IVs C. Arterial line placement D. Intraoperative blood salvage (cell saver) E. Use of epidural-only anesthesia without backup access

B. Two large-bore IVs C. Arterial line placement D. Intraoperative blood salvage (cell saver) ## Footnote Slide 78

Which of the following is NOT typically considered a clinical indicator for transfusion in hemorrhage? A. Tachycardia B. Decreased pulse pressure C. Increased urine output D. Altered mental status E. Tachypnea

C. Increased urine output *Decreased Urine Output is a clinical indicator for transfusion* ## Footnote Slide 79

Most providers consider transfusion when hemoglobin levels fall to: A. 6.0–6.5 g/dL B. 7.0–8.0 g/dL C. 8.5–9.5 g/dL D. 10.0–11.0 g/dL

B. 7.0–8.0 g/dL ## Footnote Slide 79

Parturients can typically tolerate an estimated blood loss (EBL) of approximately ____ without symptoms or vital sign changes. A. 5% B. 10% C. 15% D. 20%

C. 15% ## Footnote Slide 80

# True or False Hypotension is an *early sign* of hemorrhage during pregnancy.

FALSE Hypotension is **late sign** d/t *increased blood volume with pregnancy* ## Footnote Slide 80

Which of the following are recognized complications of blood transfusion? A. TACO (Transfusion-Associated Circulatory Overload) B. TRALI (Transfusion-Related Acute Lung Injury) C. TRIM (Transfusion-Related Immunomodulation) D. TBI (Traumatic Brain Injury) E. TENS (Toxic Epidermal Necrolysis Syndrome)

A. TACO (Transfusion-Associated Circulatory Overload) B. TRALI (Transfusion-Related Acute Lung Injury) C. TRIM (Transfusion-Related Immunomodulation) ## Footnote Slide 81

One of the most serious infectious risks of transfusion is ____. A. Anaphylaxis B. Febrile reaction C. Bacterial contamination D. Hypothermia

C. Bacterial contamination ## Footnote Slide 81

Which of the following are potential complications of massive transfusion? (Select 3) A. Hypocalcemia B. Hyperkalemia C. Hypothermia D. Metabolic alkalosis E. Hypernatremia

A. Hypocalcemia B. Hyperkalemia C. Hypothermia ## Footnote Slide 81

During obstetrics hemorrhage, *cell saver* is an approach of intraoperative blood salvage but the primary concern is? A. Coagulopathy due to dilutional effects B. Introduction of bacteria from the vaginal flora C. Contamination with amniotic fluid D. Hemolysis of red blood cells

**C. Contamination with amniotic fluid ** *Corn: There's some debate back and forth from time to time about when it's appropriate to use cell saver in these patients. And the concern is that if you use cell saver, you may have problems because of potential amniotic fluid exposure. Most of these patients postpartum don't have enough amniotic fluid there to cause a problem* ## Footnote Slide 82

Approximately how much does 1 unit of packed red blood cells (PRBC) increase hemoglobin in a non-bleeding patient? A. 0.5 mg/dL B. 1.0 mg/dL C. 2.5 mg/dL D. 3.0 mg/dL

B. 1.0 mg/dL ## Footnote Slide 82

What is the initial recommended dose of fresh frozen plasma (FFP)? A. 1 unit per 10 kg B. 2 units per 15 kg C. 1 unit per 20 kg D. 1 unit per 50 kg

C. 1 unit per 20 kg ## Footnote Slide 82

Which blood product is specifically used to restore fibrinogen levels in hemorrhagic patients? A. Platelets B. PRBC C. Cryoprecipitate D. Albumin

C. Cryoprecipitate *Fibrinogen rapidly consumed in hemorrhage* ## Footnote Slide 82

The goal is to maintain fibrinogen levels above ___ mg/dL during hemorrhage management. A. 100 B. 125 C. 150–200 D. 250–300

C. > 150-200 mg/dL ## Footnote Slide 82

At what platelet count may transfusion be indicated due to dilutional thrombocytopenia? A. 150,000/mm³ B. 100,000/mm³ C. 50,000/mm³ D. 25,000/mm³

C. 50,000/mm³ ## Footnote Slide 83

In which of the following clinical scenarios should platelets be considered for transfusion? A. EBL 3000 mL with stable vital signs B. EBL > 5000 mL or evidence of consumptive coagulopathy C. Normal coagulation panel with thrombocytosis D. Mild anemia without platelet deficit

B. EBL > 5000 mL or evidence of consumptive coagulopathy ## Footnote Slide 83

One unit of platelet concentrate typically increases the platelet count by _____ per mm³. A. 500–1000 B. 2000–4000 C. 5000–10,000 D. 15,000–20,000

C. 5000–10,000 ## Footnote Slide 83

Which of the following laboratory findings suggest active fibrinolysis during hemorrhage? (Select 2) A. Elevated D-dimer B. Elevated plasmin-antiplasmin complexes C. High hemoglobin and hematocrit D. Decreased INR and PTT E. Low platelet count

A. Elevated D-dimer B. Elevated plasmin-antiplasmin complexes ## Footnote Slide 84

Tranexamic acid (TXA) is an antifibrinoytic that primarily used in the treatment of which of the following conditions during obstetric hemorrhage? A. Hypertension-induced seizures B. Fetal bradycardia C. Coagulopathy associated with postpartum hemorrhage D. Uterine rupture

C. Coagulopathy associated with postpartum hemorrhage ## Footnote Slide 84

Which of the following statements are true regarding tranexamic acid (TXA) dosages? A. 1 gm IV should be given within 3 hours of PPH recognition B. A second dose of 1 gm IV may be repeated in 30 minutes if bleeding continues C. A 2 gm IV dose may be considered initially in some cases D. TXA is ineffective if given more than 1 hour after PPH onset E. TXA replaces the need for blood product transfusion in severe hemorrhage

A. 1 gm IV should be given within 3 hours of PPH recognition B. A second dose of 1 gm IV may be repeated in 30 minutes if bleeding continues C. A 2 gm IV dose may be considered initially in some cases ## Footnote Slide 84

Recombinant activated Factor VIIa works by directly activating ___ to ___. A. Factor II to IIa B. Factor VII to VIIa C. Factor X to Xa D. Fibrinogen to fibrin

C. Direct activation of **Factor X to Xa** ## Footnote Slide 85

The use of recombinant Factor VIIa enhances platelet __ and __. A. Activation and inhibition B. Aggregation and adhesion C. Migration and clearance D. Destruction and formation

B. Enhances platelet **aggregation and adhesion** ## Footnote Slide 85

Why is recombinant activated Factor VIIa not recommended for routine use in obstetrics? A. It has no effect on coagulation B. It increases risk for thromboembolic events C. It causes uterine atony D. It reverses TXA’s mechanism

B. It increases risk for thromboembolic events ## Footnote Slide 85

What is the approximate success rate of TOLAC? A. 20–30% B. 40–50% C. 60–80% D. >90%

C. 60–80% *Decreased popularity d/t **medico-legal concerns*** ## Footnote Slide 86

Risk of ___ is associated with TOLAC. A. Hematoma B. Placenta accreta C. Uterine rupture D. Cervical insufficiency

C. Uterine rupture *0.8-1.8%* ## Footnote Slide 86

Which of the following are eligibility criteria for TOLAC? (Select 3) A. History of 1–2 previous cesarean sections B. Prior classical uterine incision C. Low transverse uterine incision D. Known uterine rupture history E. Low vertical uterine incision

A. History of 1–2 previous cesarean sections C. Low transverse uterine incision E. Low vertical uterine incision ## Footnote Slide 86

Which of the following are true regarding neuraxial analgesia during a Trial of Labor After Cesarean (TOLAC)? (Select 3) A. It should be placed early in labor B. It is contraindicated due to uterine rupture risk C. It may facilitate successful vaginal birth after cesarean (VBAC) D. It masks the signs of uterine rupture E. It does not delay diagnosis of uterine rupture

A. It should be placed early in labor C. It may facilitate successful vaginal birth after cesarean (VBAC) E. It does not delay diagnosis of uterine rupture ## Footnote Slide 87

Preterm labor is defined as labor occurring between which gestational ages? A. 18–36 weeks B. 20–36 6/7 weeks C. 24–38 weeks D. 22–34 weeks

B. 20–36 6/7 weeks *Mortality greater with younger gestational age* ## Footnote Slide 88

Infant survivability exceeds 90% after ___ weeks of gestation. A. 26 B. 28 C. 30 D. 32

C. 30 ## Footnote Slide 88

Elevated levels of fetal fibronectin are associated with an increased risk of ___. A. Fetal macrosomia B. Placental abruption C. Preterm labor D. Post-term delivery

C. Preterm labor *Elevated levels – increased risk* ## Footnote Slide 89

Fetal fibronectin (fFN) is a basement membrane ___ produced by fetal membranes and functions as an ___ protein of placental membranes to the decidua. A. Glycoprotein; adhesive B. Cytokine; transport C. Hormone; receptor D. Enzyme; binding

A. Glycoprotein; adhesive Basement membrane **glycoprotein** produced by fetal membranes. **Adhesive** protein of placental membranes to the decidua ## Footnote Slide 89

Which of the following are benefits of corticosteroid administration in preterm labor? (Select 3) A. Decreased respiratory distress syndrome B. Increased risk of fetal macrosomia C. Decreased intraventricular hemorrhage D. Decreased neonatal mortality E. Increased uterine rupture risk

A. Decreased respiratory distress syndrome C. Decreased intraventricular hemorrhage D. Decreased neonatal mortality *it contributes to really fetal pulmonary maturity* ## Footnote Slide 90

What is the recommended dosing regimen for betamethasone in the setting of preterm labor? A. 12 mg IV every 12 hours × 4 B. 6 mg IM every 12 hours × 2 C. 12 mg IM every 24 hours × 2 D. 6 mg IV every 24 hours × 4

C. 12 mg IM every 24 hours × 2 ## Footnote Slide 91

Dexamethasone is typically administered for fetal lung maturity at a dose of? A. 12 mg IV every 12 hours × 4 B. 6 mg IM every 12 hours × 2 C. 12 mg IM every 24 hours × 2 D. 6 mg IM every 24 hours × 4

D. 6 mg IM every 24 hours × 4 ## Footnote Slide 91

_____ is used for neuroprotection in preterm labor to reduce the risk of cerebral palsy and death. A. Dexamethasone B. Magnesium sulfate C. Terbutaline D. Betamethasone

B. Magnesium sulfate ## Footnote Slide 91

Which of the following are considered tocolytics used in the management of preterm labor? (Select 3) A. Terbutaline B. Indomethacin C. Magnesium sulfate D. Oxytocin E. Methylergonovine

A. Terbutaline (Beta-adrenergic agonists) B. Indomethacin (NSAIDs) C. Magnesium sulfate ## Footnote Slide 92

Which of the following is NOT a known maternal side effect of terbutaline? A. Tachycardia B. Pulmonary edema C. Bradycardia D. Dysrhythmias E. Hypotension

C. Bradycardia ## Footnote Slide 93

After administration of a beta-adrenergic tocolytic, delay approximately ___ to allow maternal heart rate to decrease? A. 5 minutes B. 10 minutes C. 15 minutes D. 30 minutes

C. 15 minutes ## Footnote Slide 94

Why should hydration be used cautiously in patients receiving beta-adrenergic tocolytics such as terbutaline? A. Increased risk of renal failure B. Risk of electrolyte imbalance C. Risk of pulmonary edema D. Delayed onset of uterine relaxation

C. Risk of pulmonary edema ## Footnote Slide 94

What is the mechanism of action of indomethacin as a tocolytic? A. Blocks calcium influx into uterine smooth muscle B. Inhibits beta-adrenergic receptors C. Inhibits cyclooxygenase to reduce prostaglandin synthesis D. Enhances nitric oxide release

C. Inhibits cyclooxygenase to reduce prostaglandin synthesis *from arachidonic acid ## Footnote Slide 95

Which of the following are known side effects of indomethacin when used as a tocolytic? A. Pulmonary edema and hypotension B. Dysrhythmias and tachycardia C. Nausea and heartburn D. Headache and dizziness

C. Nausea and heartburn ## Footnote Slide 95

What are the mechanisms of action of magnesium sulfate as a tocolytic? A. Increases calcium influx into uterine myocytes and enhances uterine contractions B. Inhibits prostaglandin synthesis and stimulates acetylcholine release C. Reduces calcium influx into uterine myocytes and limits acetylcholine release at the neuromuscular endplate D. Enhances neuromuscular transmission by increasing sensitivity to acetylcholine

C. Reduces calcium influx into uterine myocytes and limits acetylcholine release at the neuromuscular endplate * Competitive antagonist of Ca++ * Reduces sensitivity of the neuromuscular endplate to acetylcholine ## Footnote Slide 96

Which of the following is NOT a known side effect of magnesium sulfate when used as a tocolytic? A. Flushing B. Sedation C. Hypertension D. Blurred vision E. Chest pain F. Hypotension G. Pulmonary edema

C. Hypertension ## Footnote Slide 97

Which of the following is a neuromuscular effect of hypermagnesemia associated with magnesium sulfate administration? A. Hyperreflexia B. Muscle spasms C. Decreased deep tendon reflexes D. Seizure activity

C. Decreased deep tendon reflexes *Abnormal neuromuscular function* ## Footnote Slide 98

What is a critical cardiovascular concern in patients with hypermagnesemia due to magnesium sulfate toxicity? A. Enhanced tachycardic response B. Increased preload C. Abolished compensatory sympathetic responses to hemorrhage D. Vasoconstriction and hypertension

C. Abolished compensatory sympathetic responses to hemorrhage ## Footnote Slide 98

What is the most important monitoring strategy when managing a patient receiving magnesium sulfate for tocolysis? A. Monitor heart rate and ECG daily B. Monitor calcium levels and oxygen saturation C. Monitor liver enzymes and bilirubin D. Monitor renal function & magnesium levels

D. Monitor renal function & magnesium levels ## Footnote Slide 99

Magnesium sulfate potentiates the action of ___, which increases the risk of __. A. Beta agonists; tachycardia B. Neuraxial local anesthetics; hypotension C. Vasopressors; hypertension D. Oxytocin; hyperthermia

B. Neuraxial local anesthetics; hypotension Magnesium sulfate potentiates the action of **Neuraxial local anesthetics** which increases the risk of **hypotension**. ## Footnote Slide 99

In a patient receiving magnesium sulfate, what is the most appropriate adjustment to neuraxial anesthesia? A. Increase spinal dose and epidural volume B. Use standard spinal and epidural dosing C. Decrease dose for spinal & volume for epidural D. Switch to general anesthesia only

C. Decrease dose for spinal & volume for epidural ## Footnote Slide 99

Magnesium sulfate potentiates the action of both ___ and ___, increasing the risk of prolonged neuromuscular blockade. A. Propofol; midazolam B. Succinylcholine; non-depolarizing muscle relaxants C. Neostigmine; glycopyrrolate D. Ketamine; etomidate

B. Succinylcholine; non-depolarizing muscle relaxants ## Footnote Slide 100

In patients receiving magnesium sulfate, it is important to ___ due to the potentiation of neuromuscular blockade. A. Increase succinylcholine dose B. Give defasciculating dose of NDMR C. Avoid defasciculating dose of NDMR D. Administer calcium chloride before intubation

**C. Avoid defasciculating dose of NDMR** *Corn: here's also an increased incidence of residual weakness....probably somebody you want to consider giving Suggamadex as opposed to a Neostigmine and Glyco* ## Footnote Slide 100

What is the standard loading dose and maintenance infusion rate for magnesium sulfate when used as a tocolytic? A. 4–6 gm load; 2–4 gm/hour infusion B. 2–4 gm load; 1–2 gm/hour infusion C. 1–2 gm load; 0.5–1 gm/hour infusion D. 5–10 gm load; 3–5 gm/hour infusion

**B. 2–4 gm load; 1–2 gm/hour infusion** *Corn: usually continues until mom becomes borderline toxic or the baby becomes viable or the symptoms resolve. So most of the time, we're putting people on magnesium specifically because they start having blood pressure issues or becoming pre-eclamatic* ## Footnote Slide 101

Magnesium sulfate readily ___, which has important fetal implications. A. binds to albumin B. crosses the placenta C. accumulates in adipose tissue D. crosses the blood-brain barrier

**B. crosses the placenta** *Corn: So whatever you're giving to mom, you're giving to baby. So baby may be delivered and they've got some muscular weakness. Have an increased incidence of pulmonary problems after receiving magnesium. So just be cautious with it.* ## Footnote Slide 101

The normal serum magnesium level in a healthy adult is approximately ____. A. 3.5–5.0 mg/dL B. 1.7–2.4 mg/dL C. 5.0–9.0 mg/dL D. 2.5–3.5 mg/dL

**B. 1.7–2.4 mg/dL** *Corn: There is some variability from one facility to the next to make sure you know what the levels are at your hospital.* ## Footnote Slide 101

What is the therapeutic serum magnesium level when magnesium sulfate is used for seizure prophylaxis or tocolysis? A. 1.7–2.4 mg/dL B. 2–4 mg/dL C. 5–9 mg/dL D. 10–12 mg/dL

**C. 5–9 mg/dL** *Corn: So you see how going from kind of that normal level to those high levels, you're very close to the toxic dosing. So be cautious with that. Make sure they're actually checking magnesium levels as well as doing. physical examinations on those patients because you don't want your patient to become profoundly weak as a result of the magnesium being too high.* *There's also some degree of variability from one hospital to another as far as what they will tolerate for how much magnesium is too much. So just make sure you're aware of everywhere you go and kind of how they manage things.* ## Footnote Slide 101

Complicated OB part 1 (KM) Flashcards

(248 cards)