Flashcards in Exam 1C: Nonanesthetic Drugs during Pregnancy & Lactation; Effects of anesthesia on Uterine Activity & Labor Deck (121):
Virtually all drugs cross the placenta with the exception of large organic ions such as ___ (2)
heparin and insulin
Drugs should be used only when necessary and minimum effective dose should be employed.
Propofol given with sux has been shown to cause maternal bradycardia on induction. For this reason, ___ remains drug of choice.
Sensitive serum pregnancy tests can diagnose pregnancy as early as ______ after conception. It should be used if there is any question with regard to drug safety during potential pregnancy.
The critical period of organ development extends from approximately day ___ to ___ of gestation.
day 31 - 71 (3-8 weeks)
Fetuses whose mothers receive ______ are at the highest risk for malformations, including NEURAL TUBE DEFECTS and FACIAL DYSMORPHIC features.
combination anticonvulsant therapy
if the drug is needed for a life-threatening condition or a serious disease for which safer drugs can't be used or are ineffective.
All new drugs are fall under what drug category?
What are the common fetal abnormalities associated with anticonvulsants? (4)
1. cleft lip with or without cleft palate
2. Congenital heart disease (Midline heart defects)
3. Higher incidence of epilepsy
4. Urogenital defects
This syndrome includes a constellation of minor anomalies associated with hydantoin. Risk is 10%
fetal hydantoin syndrome
Name 3 other anti convulsive drugs which all have similar risks as Dilantin.
tegretol, depakote, phenobarbital
Pregnant epileptic patients may be given _____ during the last month of pregnancy.
Oral Vit K, due to phenytoin acting as a competitive inhibitor of the placental transport of Vit. K.
Antiepileptic drugs can decrease which fetal coagulation factors? (4)
CF 2,7,9,10 (from liver?)
This drug should be avoided during pregnancy because they can cause fetal renal dysplasia and oligohydramnios.
Before becoming pregnant, women considering taking accutane must have ___ negative pregnancy test and commit to use of ___ forms of contraceptives.
2..... 2 (note: topical tretinoin/ retin-a is not teratogenic)
Studies suggest that versed and other tranquilizers have increased risk for
cleft lip or palate
No significant association with fetal exposure to TCA and SSRIs except for ___
Coumadin taken in pregnancy can result in ____.
embryopathy similar to X-linked chrondrodysplasia punctuate (CDPX)
Coumadin dose which has less teratogenic potential.
< 5mg qday
Patient on coumadin may be switched to this drug
lovenox 0.5 ml BID x 9months
This is the drug of choice for most pregnant patients that require anticoagulation
Heparin dose which may lead to maternal bone deminiralization
An isolated hx of DVT DOES NOT warrant heparin therapy. Full anticoagulation is deemed necessary in pregnant women with ____.
cardiac valve prosthesis
This drug has some advantages over standard heparin. It also does not cross placenta and has longer half-life
If antihistamine is necessary, do not use a combo of 2 drugs if one will suffice. If decongestant is needed, ______ is recommended because of less fetal exposure.
topical nasal spray
This is the preferred corticosteroid for most maternal diseases.
These 2 corticosteroids readily crosses the placenta and are preferred when the OB wants to accelerate fetal lung maturity.
betamethasone and dexamethasone
1. Antibiotics with no risks (3)
2. Avoid in 3rd trimester due to increased risk of hyperbilirubinemia
3. This can cause grey teeth
4. Should be avoided in first trimester.
5. Generally should be avoided.
1. PCN, cephalosporins, erythromycin
4. Quinolones (cipro)
5. Trimethoprim (bactrim)
1. ASA can cause
2. These 2 drugs can cause neonatal-opioid withdrawal symptoms
3. This drug can cause closure of ductus arteriosus and oligohydramnios.
1. peripartum hemorrhage and closure of ductus arteriosus
2. Darvon and Codeine
This is preferred over aspirin because there is no known risk.
What are the effects of caffeine if taken > 300mg/day?
low birth weight, decreased Fe absorption leading to anemia
Drugs with nonionized and small molecular weight transfer into milk, such as
The amount of drug detected in breast milk is a fraction of maternal dose. How many percent?
1 - 2%
if increased dose of drug or decreased maternal renal function causes high maternal blood concentration, a higher concentration may be detected in breast milk.
Infants have immature enzyme systems and metabolic pathways leading to slow elimination time.
Anesthetic management for patients using cocaine, marijuana, amphetamines, heroin?
epidural. Patient's baby should not be given Narcan due to acute narcotic withdrawal.
Moms for radionucleide tests should store breast milk before the test. After they need to pump and dump until the MD checked radioactivity of milk is safe.
Name 2 anticonvulsants which transfer into milk. They are eliminated by infants slowly and accumulation may occur
phenobarbital and versed (monitor for sedation and withdrawal)
Adverse effects of prolonged use of antibiotics when nursing infants?
infant diarrhea or candidiasis
teeth staining and or delayed bone growth HAS NOT been reported with tetracycline use when breastfeeding.
!!! (but it does cross placenta)
Antihypertensives are not contraindicated with the exception of ____ due to neonatal cyanosis and bradycardia.
Why coumadin may be given in a breastfeeding mom?
It is 98% protein bound, it is not detected in breastmilk
Caffeine may be ingested in breastfeeding moms but in moderation. How many cups per day is moderate?
2 - 3 cups (baby may show signs of caffeine stimulation such as irritability and poor sleeping patterns)
These drugs are best avoided during lactation.
Lithium and ergotamine
1. The frequency of uterine contractions and the pressure they generate.
2. This is the production of relaxation by phamacologic agent
1. uterine activity
2. Tocolysis (such as oxytocin)
Monitoring of Uterine Activity
1. Responds to changing shape of lower abdomen caused by contractions and measures frequency. Not pressure generated
2. Measures pressure, resting tone and frequency of contractions
2. IUPC (intrauterine pressure catheter)
1. How many cm is considered fully dilated?
2. This is the thinning of the cervix.
1. 10 cm cervix
This refers to increasing cervical dilatation and effacement combined with descent of the fetus into the pelvis.
Progress of labor
1. Refers to when the baby is above the pelvis (ischial spine)
2. Refers to when the baby is below the pelvis
1. Negative station
2. Positive station
Stages of Labor:
1. Onset of Labor until complete dilation
2. From complete cervical dilation until delivery of infant
3. From birth of infant to delivery of placenta
4. 60 minutes after delivery of placenta
1. First stage (latent and active phases)
2. Second stage
3. Third stage
4. Fourth stage - watch for bleeding
1. labor pain results from
2. Where does labor pain initially starts? Progresses to ___ during active labor.
1. contractions and dilation (travels via visceral afferents accompanying sympathetic nerves)
2. T11 - 12... then T10-L1
When does cervical dilation begin?
Phase of labor where there is normal and regular contraction
first stage: active phase
Hypotension in epidural is usually caused by ____, not the med.
This is the signal of fetal decent and the beginning of the 2nd stage of labor.
1. Innervation of the perineum is provided by
2. 2nd stage of labor involves which dermatomes?
1. Pudendal S2-4
2. T10 - S4 dermatomes
Epidural can block the contraction pain (sharp pain) but not ___.
1. It is thought that when epidural is inserted during 2nd stage of labor can lengthen the laboring process because it interferes with piton and impairs expulsive efforts.
2. Some OB don't want you to put epidural on 1st stage especially latent phase because it slows down labor.
! risk for C/S
You want the mom to be comfortable but you don't want to have such a DENSE block that they can't lift their legs up or can't help push. This can lead to
3 Components of Labor and delivery. The interaction of these determines the success or failure of the process.
1. Power: contraction
2. Passageway: pelvis and soft tissues
3. Passenger: fetus
This accompanies contraction as the myometrial cells shorten. The walls of the upper, contractile portion of the uterus thickens. Cervical dilation and effacement reflect the traction placed on the cervix by the contracting uterus.
At the end of the first stage of labor, NO cervix is palpable on exam! Then the mom perceives an urge to defecate.
1. first time having a baby
2. Has been pregnant before
1. More than 90% of postpartum hemorrhage result from ____.
2. Drug of choice for number 1
1. Uterine atony
2. Methergine and uterine massage
1. Analgesia must be profound in all _____.
2. Segmental anesthesia must be higher than ____ to interrupt all afferent impulses from the lower abdomen.
3. Block needs to extend to ___ or even the ____.
1. lumbosacral segments including L5 - S1
2. T6 dermatome
3. T4 or event he apex of axilla.
These carry nociceptive input during manipulation of the uterus.
L5 and S1
What happens when cardiac accelerator nerves are blocked? (above t4?)
hypotension, respi depression, bradycardia,
Management of hypotension associated with spinal
vasopressor, fluids, LUD
In patients getting epidural/ spinal, educate them the s/sx of high levels of anesthesia such as (2)
1. fingers are tingling
2. Having shortness of breath
1. Local anesthetics are metabolized by ___
2. This is the end product of ester cleavage, passes the placenta but does not appear to cause fetal depression. It is a known antigen and likely contributes to higher incidence of reactions to ESTER-based anesthetics
2. PABA (para-amino benzoic acid)
This LA impairs the anesthetic action of other drugs when used epidurally. Not given via spinal. Covered in colored vials to prevent oxidative decomposition
Chlorprocaine (you can use other drugs before you switch to chlorprocaine but not the other way). This is helpful in CS because you can redose because it is short acting.
This is the most effective local anesthetic available. It is metabolized in the liver with LONG half lives, low MW and nonionized.
Amide linked agents
1. Which among the amide anesthetics crosses easily and more lipid soluble?
2. Which one is more ionized and is difficult to cross the placenta?
1. This LA is an excellent sensory block and good motor block. Quick onset.
2. It can cause ____ when given spinally.
1. Lidocaine (xylocaine)
2. Cauda equina syndrome (compressed S1-S5)
Complications of caudal equine syndrome (compression of S1-5)
1. urinary bladder incontinence
3. Sexual dysfunction
What do you need to monitor when giving Lido-Epi test dose?
Dose limit for spinal Lidocaine
75 mg, not to exceed 2% (the test dose for epidural is the spinal dose!!!)
At what dose Lidocaine can cause caudal equine + transit neurologic symptoms?
This LA can cause methemoglobinemia. Can be used in spinal but not epidural
This LA has a long held-life and is mainly used for extremity blocks.
This LA has high quality analgesia with minimal motor blockade. Mostly used LA for epidural (L&D) and spinal (for C/S).
Bupivacaine (marocaine, sensorcaine)
Bupivacaine dose which is faster and better surgical conditions but this dosage is cardiotoxic.
0.75% (fast in, slow out) May see tachyphylaxis
Why is Bupivacaine not a good epidural choice for C/S?
slow onset, less intense, prolonged motor block
1. This drug mirrors Bupi and Mepivacaine
2. This drug mirrors Bupivacaine
1. Ropivacaine (Naropin): less cardiotoxic
2. Levobupivacaine (chirocaine): slow onset
Questionable use of Epi with Lidocaine.
Epi causes vasoconstriction in the cord and may delay absorption of Lidocaine leading to toxicity.
This nonpharmacologic pain relief methods combines positive conditioning of tithe mother with education about the process of childbirth, the goal being to lessen fear and provide techniques to cope with labor pain.
How does Lamaze differ from hypnosis?
lamaze freely engages mom's conscious and cooperative efforts.
1. the portion of the fetus felt through the cervix on vaginal exam
2. relation of a specific part of the fetus to the mother's pelvis
3. Refers to alignment of the fetal spine with maternal spine.
1. presentation: cephalic, breech, shoulder
2. position: Occiput (90%), sacrum (breech), Acromium (shoulder)
1. These 2 presentations occur with increased frequency in patients with multiple gestation.
2. These 2 positions are referred to as having longitudinal lie.
1. breech and shoulder.
2. Breech and vertex
Types of cephalic presentation (3)
vertex (back of head), brow, face
What is the normal position and presentation?
left occiput anterior
1. Baby's occiput is anterior to mom's pelvic bone. Good thing
2. Baby's face comes out first. Mom has BACK labor pains.
1. Occiput anterior
2. Occiput posterior
This fetal position usually undergoes normal internal rotation, lying beneath symphysis pubis. Slowed dilation, arrested descent and increased pressure on posterior sacral nerves.
occiput transverse or occiput posterior
Vertex remains in the occiput transverse position, known as ____
deep transverse arrest
During normal labor, fetal occiput rotates from a transverse or oblique position to a ___-
direct occiput anterior position
When is forceps delivery indicated in the treatment of occiput transverse?
When baby is 3+ station
Why is mid forceps not used? (3)
trauma, intracranial hemorrhage, asphyxia
Most with face or brow delivered by C/S due to
Management for transverse lie with shoulder presentation
1. This is the most common of abnormal presentations.
2. Most of these Number 1 convert to ____ by 34 weeks.
Before ____ weeks, as many as 40% are breech and will convert to vertex by ____ weeks.
28 weeks...... 34 weeks
Both _____ are associated with an increased incidence of perinatal morbidity and mortality, regardless of the method of delivery.
breech and multipara
Management for breech presentation is decided after ____.
manual exam and ultrasound. usually done by C/S
Complete breech may change presentation throughout labor to ____
This is the entrapment of the baby's anterior shoulder behind the maternal symphysis pubis.
Retraction of the head back toward the vagina at delivery. May push head back in and do CS.
2 risk factors closely associated with shoulder dystocia
1. Maternal DM
1. If delivery is not accomplished soon, umbilical cord compression may result in ____.
2. Excessive traction on the fetal head may result in ___ which may be temporary or permanent.
3. A fracture of ____ may also result
2. Erb's palsy (brachial plexus damage)
3. Fracture of clavicle and humerus
Always be prepared for a C/S. Large uterus predisposes the parturient to more ____.
severe supine hypotension (increased ACC)
What lab is important in multipara?
Intrauterine death of one fetus in a multi gestation can cause ___
treatment for bleeding (3)
1. Pitocin 5-10 mg
2. Methergine IM (takes 5-10 mins onset)
This is the anastomosis between the 2 vascular systems resulting in transfusion of blood from one fetus to the other.
Twin-Twin transfusion syndrome
Twin-Twin transfusion syndrome:
1. Donor will have
2. Recipient will be
1. Smaller (IUGR), anemic
2. polycythemic leading to cardiomegaly and heart failure
Despite a 95% survival rate, triplets have a significantly greater risk for (2)
intraventricular hemorrhage and retinopathy of prematurity
1. This drug is usually administered IV in a Bag to induce or augment uterine contractions or to maintain uterine tone postpartum.
1. Pitocin 10 - 40 units
2. 3- 5 mins
1. This drug causes intense and prolonged uterine contractions. Given only after delivery to treat uterine atony.
1. Methergine (Methylergonovine) (found in fridge)
3. 0.2 mg IM
1. This is a synthetic analogue of prostaglandin F2 that stimulates uterine contractions.
2. Refractory postpartum hemorrhage
3. 0.25 mg IM q15 - 90 mins to a max of 2mg
After giving methergine, how many minutes you should wait before you can give hemabate?
5-10 mins to prevent hypertension and tachycardia
This drug is used for uterine relaxation.