DM Obesity, Multile Gestation, Abnormal Presentation

Question 1

Abnormal presentations

Answer 1

Transverse lie, face, brow, compound

Breech (frank, incomplete, complete)

Question 2

Describe normal presentation of fetus

Answer 2

Cephalic presentation
Head enters birth canal first
Face backward towards mother spine
Arms crossed
Chin and neck bent forward down toward chest

Question 3

Most common complication with breech and its treatment?

Answer 3

Umbilical cord prolapse

Stat c section

Question 4

Fetal entrapment happens more often with that babies

Answer 4

Pre term <32 weeks bc of their small heads

Question 5

Pharmacologic treatment for vaginal breech

Answer 5

Goal is complete relaxation
NTG 1-2 sublingual sprays 400-800 mcg
IV 50-500mcg

Question 6

External cephalic version is done when

Answer 6

Ideally at term and at the hospital due to CS capability

prior to labor

Question 7

What pharmacologic meds can be used for skeletal and cervical/uterine smooth muscle relaxation

Answer 7

Skeletal muscle relaxation 3% 2-Chloro
Smooth muscle relaxation NTG 
160-600 mcg for fetal head entrapment
50-100mcg for retained placenta
GA:2-3 MAC

Question 8

Maternal complications with multiple gestation

Answer 8

Antepartum/postpartum hemorrhage
DIC
Operative delivery - forceps CS
Obstetric Trauma
Preterm premature ROM
Preterm labor
Prolonged labor
Preeclampsia/eclampsia
Placental abruption
Uterine atony

Question 9

Fetal complications in multiple gestation

Answer 9

Congenital anomalies
Cord enlargement
IUGR
Malpresentation
Preterm delivery
Polyhydramnios
Twin to twin transfusion
Umbilical cord prolapse

Question 10

Fetal consequence for twin to twin transfusion

Answer 10

Circulatory overload with HF
Occlusive thrombosis Polycythemia
hyperbilirubinemia and kernicterus

Question 11

Maternal physiologic changes for multiple gestation

Answer 11

Greater decrease in FRC
Increased O2 consumption
Blood volume 500ml greater with twins
Increased CO2
Aortocaval compression
CNS spread of spinal, reduce dose (increased uterine size, more progesterone)

Question 12

Route of delivery for triplets or higher

Answer 12

CS

Question 13

Fetal presentation types for twins

Answer 13

Can be either vertex or non vertex

Question 14

Steps for anesthetic management of multiple gestation

Answer 14

Large bore IV, T&S
Epidural or CSE
Twin B may need manipulation
LUD
Fluids/vasopressors
GA
Uterine relaxation, NTG

Question 15

What anesthetic management is preferred with multiple gestation

Answer 15

Regional - epidural over spinal

GA causes a greater decrease in FRC and increased O2 consumption

Question 16

Class of DM during pregnancy where gestational DM is diet controlled

Answer 16

A1

Question 17

Class where gestational diabetes requiring insulin

Answer 17

A2

Question 18

What class has pre-existing DM with onset >20 y/o and duration <10 years without complications

Answer 18

B

Question 19

What class has pre-existing diabetes with onset between ages 10 and 19 or duration of ages 10 to 19 without complications

Answer 19

C

Question 20

What class of diabetes has pre-existing diabetes with onset <10 or duration >20 years, without complications

Answer 20

D

Question 21

What class of diabetes has pre-existing diabetes complicated by neuropathy

Answer 21

F

Question 22

What class of diabetes has pre-existing diabetes complicated by proliferative retinopathy

Answer 22

R

Question 23

What class of diabetes has pre-existing diabetes and status/post kidney transplant

Answer 23

T

Question 24

What class of diabetes has pre-existing diabetes complicated by ischemic heart disease

Answer 24

H

Question 25

What hormones cause a progressive insulin resistance in pregnancy

Answer 25

Progesterone, cortisol, placental lactogen increases

Question 26

Definition of gestational diabetes

Answer 26

Unable to increase insulin production

Question 27

Type 1 DM has an increased risk of what during pregnancy

Answer 27

Hypoglycemia

Question 28

DKA can occur when

Answer 28

BS 200-250, Type 1

Question 29

What in pregnancy causes DKA

Answer 29

Insulin resistance, enhanced lipolysis, ketogenesis

Question 30

DKA causes what for fetus

Answer 30

NRFHR | Resolves when maternal metabolism is corrected

Question 31

Complications with DM

Answer 31

``` CS FHR abnormal Pre-eclampsia Polyhydramnios UPP decreases ```

Question 32

Fetal effects from DM

Answer 32

``` Macrosomia Congenital anomalies Perinatal mortality Shoulder dystocia Hypoglycemia - fetal hyperinsulinemia in response to maternal hyperglycemia ```

Question 33

DM management during labor

Answer 33

Optimal glucose control 60-120 Hourly checks IVF NS Hold AM insulin >140 consider insulin drip <70 consider D5

Question 34

DM management after delivery

Answer 34

Decreased insulin requirement Stop insulin drip Avoid hypoglycemia

Question 35

DKA management

Answer 35

``` ABGs IVF NS Insulin/potassium drips LUD O2 Avoid premature delivery ```

Question 36

Glucose tolerance testing is done

Answer 36

Between 24-28weeks of pregnancy 1 hour test 3 hour test if first one comes back abnormal

Question 37

Gestational diabetes requires what testing

Answer 37

28-32 weeks twice weekly non stress test

Question 38

Regional and DM

Answer 38

Increased risk of hypotension during regional and GA

Question 39

What pre-anesthetic considerations should you consider with DM

Answer 39

``` Cardiac, vascular, renal involvement Glycemic control Autonomic neuropathy Ischemic heart disease Gastroparesis Stiff joint syndrome - atlanto occipital joint. Positive prayers sign ```

Question 40

What is stiff joint syndrome d/t

Answer 40

Non enzymatic glycosylation of collage and its deposition to joints

Question 41

Epidural precautions with DM

Answer 41

Hydrate Hypotension = fetal compromise Ephedrine! Autonomic neuropathy = hypotension

Question 42

Advantages of epidurals with DM

Answer 42

Analgesia Decreases plasma catecholamines (catecholamines oppose insulin activity) Improved glucose control Improved UPP

Question 43

NRFHR in DM means one of the following features

Answer 43

``` Baseline FHR 100-109 or 161-170 Variability reduced Decelerations are variable without complicating features Absence of of accelerations Sinusoidal rhythm ```

Question 44

DM anesthetic considerations for CS

Answer 44

Increased incidence Regional vs GA Epidural vs spinal Hydration ephedrine

Question 45

DM anesthetic considerations for GA

Answer 45

Reglan, Bicitra, ranitadine More severe hypotension d/t autonomic neuropathy LUD, hydration + prayer sign

Question 46

Pulmonary changes for obese OB

Answer 46

``` Increased O2 consumption and CO2 production Increased WOB Decreased TV Decreased FRC, ERV, VC Airway closure during TV V/Q mismatch Increased plasma volume Chronic hypoxemia Pulmonary hypertension associated with high mortality rate ```

Question 47

GI changes for Obese OB patients

Answer 47

Ph <2.5 | Gastric volume >25ml

Question 48

What are the increased risks of Obese OB patients

Answer 48

``` HTN, preeclampsia Gestational DM Thromboembolic disease and infection Anesthesia related mortality (airway) Maternal death ```

Question 49

Obese OB patients and perinatal adverse outcomes

Answer 49

NRFHR Macrosomia: birth trauma, should dystocia Meconium aspiration Neural tube defects and congenital anomalies Higher incidence of antepartum death and early neonatal death

Question 50

Anesthetic management for obese OB patients

Answer 50

Obesity hypoventilation syndrome ABG Long needle for neuraxial techniques Encourage neuraxial early Airway: exam and equipment Pulm cardiac status

Question 51

Things to consider with epidurals for OB obese patients during labor

Answer 51

``` Ability to extend block Challenging Increased depth of epidural space Positioning sitting is easier Increased failure rate Secure after positioning laterally Minimize motor block CSE unproven epidural ```

Question 52

Considerations for Spinal for Obese OB patients in labor

Answer 52

Easier Superior labor analgesia Motor block nonexistent, dense sensory block Catheter placement easily confirmed with CSF Titrate level and density of block Increased risk of PDPH secondary to needle size

Question 53

Anesthetic considerations for CS obese

Answer 53

1. Increased risk with GA, regional preferred Epidural slow titration, exaggerated spread in obese patients Slow onset of sympathetic blockade High failure rate 2. Longer surgery duration 3. LUD 4. Cephalad retraction of panniculus (respiratory compromise) 5. Aspiration prophylaxis

Question 54

Spinal vs epidural in obese patients

Answer 54

Spinal - surgery duration, lack of titration, high spinal/inadequate spinal, quickest technique great with urgency Epidural - high failure rate, slow onset of sympathetic blockage, slow titration - exaggerated spread in obese patient

Question 55

Considerations GA for obese

Answer 55

``` Avoid when possible Airway/aspiration prophyalxis Previous easy airway does not guarantee airway in pregnancy Careful positioning Consider awake intubation ```