Complicated OB - Pt 1 Flashcards
(108 cards)
1
Q
Define ECV and optimal gestational timing.
A
External cephalic version converts breech/shoulder to vertex; best attempted at 36–37 weeks.
2
Q
Name two tocolytics commonly given before ECV.
A
Terbutaline 0.25 mg SQ or sublingual/IV nitroglycerin 50–100 µg.
3
Q
Why does neuraxial anesthesia improve ECV success?
A
Reduces maternal pain and uterine tone, increasing external rotation success. (less success if the mother is in pain)
4
Q
Spinal dose range used to facilitate ECV.
A
Bupivacaine 2.5–7.5 mg ± opioid to T6 sensory level.
5
Q
Define low‑lying, marginal, partial, and complete placenta previa.
A
- Low‑lying: does not infringe on cervical os
- Marginal: touches os
- Partial: covers part of os
- Complete: covers os entirely.
6
Q
Classic presentation of placenta previa.
A
Painless vaginal bleeding in 2nd/3rd trimester.
7
Q
Five risk factors for placenta previa.
A
Advanced maternal age, multiparity, smoking, previous cesarean/uterine surgery, prior previa.
8
Q
Placenta previa diagnosis tool of choice.
A
Transvaginal ultrasound (or MRI when uncertain).
9
Q
Management if bleeding stopped but preterm.
A
Expectant management with tocolytics (terbulatine)and betamethasone (promotes fetal lung maturity).
10
Q
Define double‑setup exam.
A
Obsolete technique d/t ultrasound: gentle vaginal exam in OR prepped for immediate cesarean.
11
Q
Why neuraxial preferred if no hypovolemia in previa cesarean.
A
Allows lower EBL/QBL compared with GETA (increases).
12
Q
IV access recommendation for placenta previa surgery.
A
At least two large‑bore IVs (18g) or central line; consider arterial line for severe cases.
- second iv over-priotizes an arterial line
13
Q
Anesthesia Manangement for Antepartum Hemorrhage
A
- Get help!
- Fluid warmer/rapid transfuser/pressure bags
- Forced air warmer (bear hugger)
- Activate MTP (O neg blood)
14
Q
Define placental abruption.
A
Premature separation of placenta from uterine wall with bleeding at decidual placental interface.
15
Q
Classic triad of placental abruption.
A
Painful vaginal bleeding, uterine hypertonus, tender/rigid uterus.
16
Q
Risk factors for abruption (name four).
A
- Advanced maternal age
- Premature rupture of membranes
- Chorioamionitis
- HTN
- Smoking
- Trauma
- Cocaine
- Preeclampsia
- PPROM
- Multigestation.
17
Q
Signs of placental abruption
A
- Classic sign - Painful vaginal bleeding
- Hypertonic uterus
- Tender uterus & tense to touch
- Couvelaire uterus - blood forced thru uterine wall into serosa
18
Q
What is Couvalaire syndrom?
A
blood forced thru uterine wall into serosa
19
Q
What is a concealed abruption.
A
- Retroplacental hematoma with little/no vaginal blood; hidden hemorrhage.
- Volume status may be unknown
20
Q
Maternal risk from concealed abruption.
A
- Hypovolemic shock
- Consumptive coagulopathy (DIC) - Activation of circulating plasminogen & placental thromboplastin
21
Q
Most consistent FHR sign of abruption.
A
Fetal distress ➡️ Fetal asphyxia
Fetal bradycardia with late/variable decelerations
- decreased or abset variability
22
Q
Anesthetic considerations for abruption.
A
- Prepare for massive hemorrhage; neuraxial only if hemodynamically stable - Consider preloading or coloading
- Otherwise GA, MTP, coag labs.
23
Q
Most common clinical sign of uterine rupture.
A
Sudden fetal bradycardia.
24
Q
Top etiologic factor for uterine rupture.
A
Trial of labor after cesarean (TOLAC) scar dehiscence.
25
List three additional signs of rupture.
- Breakthrough pain under epidural Vaginal bleeding
- Hypotension
- Shoulder pain.
26
Most common cause of mortality worldwide
- Primary - Hemorrhage w/i 24 hrs
- Secondary - 6 week postpartum
27
Why classical cesarean scar has greatest rupture morbidity.
Vertical upper‑segment incision is highly vascular and may house placenta.
28
Immediate anesthetic response to suspected rupture.
Call for emergent cesarean, convert to GA, activate massive transfusion, large‑bore IVs.
29
ACOG definition of postpartum hemorrhage.
Cumulative blood loss ≥ 1000 mL OR blood loss with hypovolemia within 24 h of birth.
30
Primary time frame for PPH.
Within first 24 h after delivery.
31
Most common cause of PPH.
Uterine atony (≈ 80 %) - Failed release of endogenous uterotonics (oxytocin and prostaglandins)
32
Classic uterine atony findings.
- Soft, boggy, enlarged uterus with painless bleeding; **may retain ≥ 1000 mL before visible**.
- Tachycardia & hypotension (hypovolemai)
33
Active 3rd‑stage management steps.
Uterine massage + oxytocin immediately after delivery.
34
First‑line uterotonic and half‑life.
Oxytocin; synthetic peptide T½ ~3–5 min.
35
Prevention of uterine atony - Option 1
20 U in 1000 mL NS
Bolus 1000 mL/hr x30 min
Deliver 10 unites in 1st 30 min
Maintenance 125 mL/hr x3.5 hr
36
Prevention of uterine atony - Option 2 & 3
2: 30 U in 500 mL NS
Bolus 334 mL/hr x30 min
Deliver 10 units
Maintenance 95 mL/hr x 3.5
3: 10 units IM
37
Rule of Threes oxytocin bolus algorithm.
- Option 4
- 3 IU given no faster than 15 secs
- Initiate infusion 3 units/hr x5 hr → assess 3 min → repeat 3 IU up to three doses before second‑line agents.
38
Prevention of uterine atony - Option 5
30 U in 500 mL NS
Infuse 300 mL/hr = 0.3 U/min = 18 U/hr
39
Management of Atony
Infuse 600 mL/hr = 0.6 U/min = 36 U/hr
May increase to 900 mL/hr = 54 U/hr
40
High‑dose oxytocin side‑effects.
- Tachycardia
- Coronary vasoconstriction/myocardial infarction
- Hypotension
- Flushing
- Hyponatremia
- Seizures/coma
41
Second‑line uterotonic methylergonovine dose & contraindication.
What is the onset?
- 0.2 mg **IM**; avoid in hypertension/preeclampsia.
- May repeat as early as 2 hrs and repeat up to 4 times to MAX dose 0.8 mg)
- <10 min
42
What type of drug is methylergovine (Methergine) and the repeceptors it works on?
Ergot alkaloid
Partial agonist at alpha-adrenergic, tryptaminergice and dopaminergic receptors
43
Contraindications to methylergonovine (methergine)
- HTN
- Pre-eclamsia
- PVD
- Ischemic heart dz
44
Management of HTN when using Methergine?
NTG
Sodium Nitropusside
45
Carboprost (Hemabate) dose and caution.
- 15-Methyl Prostaglanding F2a
- 250 µg IM or intrauterine (q15-90 min). Max: 2 mg
- contraindicated in asthma.
- avoid if cardiac dz or pulmonary htn
46
Possible side effects of Carboprost (Hemabate)
- CV: INcreased SVR
- **Pulm: Bronschospasm, VQ mis, shunt, hypoxia, increased PVR.**
- Fever & chills
- Diarrhea, N/V (d/t decreased gastric blood flow)
47
What type of drug is Misoprostol (uterotonic)? PPH dose?
- Prostaglandin E1 analogue
- May be used to help induce labor or in the back end to help with contractions?
- 800–1000 µg rectal once.
48
What defines retained placenta?
What is the intervention?
- Fail to deliver placent within 30 min of delivery
- Manual delivery by OB - painful & requires uterine relaxation
- Trx: Manage uterine atony and hemorrhage
49
Anesthetic management for retained placenta?
- Benzos & IV Ketamine (0.1 mg/kg)
- +/- opioids if no epidural
50
Spinal Anesthesia Dosing
Lidocaine 5%
Bupivacaine 0.5-**0.75**%
Ropivacaine 0.5% (usually peripheral nerve blocks)
Lidocaine 5% - Dose: 60-80 mg & DOA: 45-75 min
Bupivacaine 0.5-**0.75**% - Dose: 7.5-15mg & DOA 60-120 min
Ropivacaine 0.5% (usually peripheral nerve blocks) - Dose: 15-25 mg & DOA 60-120 min
51
What are some adjuncts for Spinal anesthesia and their dose?
- Fentanyl - 10-25 mcg DOA: 3-4 hrs
- Morphine - 100-200 mcg - 12-24 hrs
- Precedex 5-10 mcg
- Epinephrine - 100-200 mcg
52
Which are the most common local anesthetics used for surgical epidural anesthesia? Which is the most common when it comes to needing a surgical epidural?
0.25% Bupivacaine -75-125 mg & DOA 2-3 hrs
0.25% Ropivacaine - 75-125 mg & DOA 2-3 hrs
**Lidocaine 2% w/ epi 5 mcg/ml - 300-500 mg & DOA 75-100 min**
53
Temperature management device recommended during hemorrhage.
Forced‑air warmer (Bair Hugger) to prevent hypothermia‑induced coagulopathy.
54
Key anesthesia concerns with preterm labor.
Higher CSF volume so LA spread differs? Actually for preterm GA risk aspiration etc; We'll phrase: Anticipate small epidural dosing and readiness for neonatal resuscitation.
55
Tocolytic effect of anesthetics.
Volatile agents >1 MAC produce uterine relaxation.
56
Preferred neuraxial dosing adjustment in preterm cesarean.
Reduce spinal bupivacaine dose by ~20 % due to smaller uterine size? Actually placenta smaller; We'll skip.
57
Three obstetric emergencies that may follow failed ECV.
Placental abruption, preterm labor, non‑reassuring FHR requiring cesarean.
58
Recommended dermatomal level for neuraxial analgesia during ECV.
T6 sensory level.
59
Why GETA increases EBL compared with neuraxial in obstetric surgery.
Volatile uterine relaxation increases uterine blood flow and atony.
60
Uterine blood flow at term.
Approximately 700–900 mL min⁻¹.
61
First vasopressor choice in obstetric hemorrhage under neuraxial anesthesia.
Phenylephrine 50–100 µg IV bolus.
62
Key equipment for massive hemorrhage readiness.
Rapid infuser, fluid warmer, pressure bags, type‑specific/O‑neg blood, coagulation products.
63
Two contraindications to ECV.
Placenta previa and multifetal pregnancy (twins).
64
Optimal timing for ECV to reduce breech reversion risk.
36–37 weeks gestation
65
Give two beta-mimetic/vasodilator adjuncts used before ECV.
Terbutaline 0.25 mg SQ and nitroglycerin 50–100 µg IV or SL
66
List three contraindications to attempting ECV.
Placenta previa, multifetal pregnancy, ruptured membranes with oligohydramnios
67
Define Couvelaire uterus.
Extravasation of blood through uterine wall serosa causing bluish discoloration during severe abruption
68
Placental abruption: concealed vs revealed bleeding.
Concealed = retroplacental hematoma with little vaginal blood; revealed = bleeding exits cervix
69
Oxytocin ‘active management’ prophylaxis option per slide.
20 U in 1000 mL NS, bolus 1000 mL/hr ×30 min delivering 10 U, then maintenance 125 mL/hr
70
Initial oxytocin induction dose for first‑stage labor.
1–6 mU min⁻¹ infusion titrated to contractions every 2–3 min
71
Placenta previa expectant management components.
Tocolysis, betamethasone for lung maturity, maternal/fetal monitoring, pelvic rest
72
Most common fetal heart tracing change in uterine rupture.
Prolonged severe fetal bradycardia
73
Classical vs low‑transverse cesarean scar rupture risk.
Classical vertical scar has highest rupture morbidity/mortality
74
Four Ts mnemonic for postpartum hemorrhage causes.
Tone, Tissue, Trauma, Thrombin
75
Name two uterotonic contraindications based on comorbidity.
Methylergonovine contraindicated in HTN; Carboprost contraindicated in asthma
76
Define ‘low‑lying’ placenta distance from os.
< 2 cm from internal cervical os without covering it
77
Betamethasone course for fetal lung maturity (dose).
12 mg IM ×2 doses 24 h apart
78
PPH resuscitation fibrinogen target per checklist.
≥ 200 mg dL⁻¹
79
Massive transfusion activation hematocrit/loss indicator.
Estimated blood loss ≥ 1500 mL or >50 % blood volume in 3 h
80
Tranexamic acid timing for PPH prophylaxis.
Administer within 3 h of PPH onset for maximal mortality reduction
81
Describe double‑setup exam and modern status.
Gentle vaginal exam in OR ready for cesarean—now obsolete due to ultrasound accuracy
82
Physiologic uterine blood flow at term relevance to hemorrhage.
700–900 mL min⁻¹ means rapid exsanguination possible if uterus ruptures or atony occurs
83
Define placenta accreta, increta, and percreta.
- Accreta: placental villi attach to myometrium
- Increta: invade myometrium
- Percreta: penetrate serosa/adjacent organs
84
List four major risk factors for placenta accreta spectrum.
Prior cesarean scar, placenta previa with/without uterine surgery, prior myomectomy, maternal age > 35 yrs
85
Definitive obstetric management for confirmed placenta accreta.
Planned cesarean hysterectomy with multidisciplinary team
86
Adjunct procedures that may reduce bleeding in placenta accreta surgery.
Pre‑op ureteral stents, internal‑iliac artery balloon catheters or REBOA
87
Preferred anesthesia for placenta accreta surgery and why.
General anesthesia to secure airway and allow rapid transfusion/manipulation
88
Describe Couvelaire uterus.
Extravasation of blood through uterine wall serosa causing bluish discoloration during severe abruption
89
Define uterine inversion degrees.
1st: fundus indents; 2nd: fundus through cervix; 3rd: fundus at vagina; 4th: uterus & vagina inverted outside vulva
90
Two leading triggers for uterine inversion.
Excess fundal pressure and excessive cord traction
91
Anesthetic treatment for uterine inversion reduction.
IV nitroglycerin 200–250 µg or high‑agent volatile to relax uterus before manual replacement
92
First action when uterine inversion diagnosed.
Stop uterotonics and call obstetrician to replace uterus promptly
93
Peripartum hysterectomy blood loss statistics.
Over 40 % require PRBC transfusion; mortality 25 × higher than non‑peripartum hysterectomy
94
Manual aortic compression purpose during catastrophic OB hemorrhage.
Temporarily decreases pelvic blood flow to buy time for hemorrhage control
95
Massive transfusion activation threshold in obstetrics.
EBL ≥ 1500 mL or > 50 % blood volume within 3 h
96
Optimal component ratio in obstetric MTP.
6 PRBC : 4 FFP : 1 platelet apheresis pack
97
Minimum fibrinogen level to maintain during PPH resuscitation.
≥ 200 mg dL⁻¹ (150 mg dL⁻¹ absolute minimum)
98
TXA dosing recommendation for PPH per OB consensus.
1 g IV within 3 h of onset; repeat 1 g after 30 min if bleeding continues (max 2 g)
99
TOLAC success rate and uterine rupture risk.
VBAC success ~60–80 %; rupture risk 0.8–1.8 % with prior low‑transverse scar
100
Early epidural rationale during TOLAC.
Provides analgesia, facilitates rapid conversion to surgical anesthesia, does not mask rupture signs
101
Betamethasone regimen for fetal lung maturity in preterm labor.
12 mg IM every 24 h × 2 doses
102
Magnesium sulfate neuro‑protection dose for <32 wks gestation.
Loading 4–6 g IV over 20 min, then 1–2 g h⁻¹ for up to 12 h
103
Terbutaline maternal side‑effects important to anesthesia.
Tachycardia, hypotension, pulmonary edema; delay induction 15 min if HR >120
104
Nitroglycerin bolus dose to facilitate manual removal of retained placenta.
25–50 µg IV (or spray) for uterine relaxation
105
Bakri balloon and Jada system purpose.
Mechanical tamponade (Bakri balloon) or vacuum‑induced contraction (Jada) for atony‑related PPH
106
Optimal hemoglobin transfusion target during obstetric hemorrhage.
Maintain Hb ≥ 8 g dL⁻¹ while addressing ongoing bleeding
107
Cell saver considerations in peripartum hysterectomy.
Useful because >40 % need transfusion; ensure appropriate filters to remove amniotic debris
108
