Exam 2: Labor/Vaginal delivery, systemic disease, anesthetic complications Flashcards
(213 cards)
1
Q
what are the risk factors for gestational Diabetes
A
maternal age (30-35)
obesity
family hx DM2
hx gestational DM
Hx PCOS
HX still births
hx macrosomic babies
2
Q
what weight of the baby is considered macrosomic
A
8lbs 13 oz
3
Q
when is the testing for gestational diabetes done
A
24-28 weeks gestation
4
Q
describe the 1 step process for gestational diabetes testing
A
8 hr fast BG<92
75g oral glucose
1 hr- BG <180
2 hr- BG <153
5
Q
describe the 2 step process for gestational diabetes testing
A
non fasting
50 g oral glucose
1 hr BG> 130, go to step 2
step 2: 100 g oral glucose test with BG tested at 1,2,3 hours
6
Q
What causes gestational diabetes?
A
progressive resistance to insulin
-maternal adipokines
7
Q
what are HgA1C levels pre and intra pregnancy
A
pre: 4-5.5%
post: 4.8-6.5%
8
Q
T/F if you have gestational DM, you have DM2 after preggers
A
F, most return to baseline after birth
-but have an increased risk for DM and gestational DM
9
Q
how are insulin requirements affected in pregestational DM
A
increase from 0.7 units/kg to 1.0 units/kg at term
10
Q
how are insulin requirements in pregnancies with multiple gestation
A
higher
11
Q
how are nighttime maternal insulin requirements
A
requirements may drop
12
Q
T/F epidural analgesia and oxytocin affect insulin requirements during first and second stages of labor
A
false
13
Q
how is insulin requirment for DM 1 after birth
A
decreases for several days
14
Q
what risks are increased with maternal DM
A
HTN
polyhydramnios
C section
15
Q
why does DM increase risk of C section
A
big babies
16
Q
what is a large amount of amniotic fluid
A
polyhydramnios
17
Q
DM 1 are _____x more likely to develop gestational HTN
A
3
18
Q
pregestational DM is at a ____-______x greater risk of preterm labor and delivery
A
2-3
19
Q
what are risks of macrosomia
A
birth trauma and shoulder dystocia
20
Q
what is macrosomia
A
A high-birthweight infant
21
Q
what are some fetal risks of maternal DM
A
macrosomia
5x more likely to have anomalies (cardiac)
neonatal hypoglycemia
22
Q
what treatment can reduce anomalies from 10% to 1%
A
strict BG control
23
Q
in maternal DM is hyper or hypoglycemia preferred
A
hypo
24
Q
what level should BG be maintained at in maternal DM
A
nondiabetic levels
25
DM lab values chart
26
what does DM increase risk of anesthesia wise
autonomic cardiovascular dysfunction
gastroparesis (aspiration)
27
what is sign of autonomic cardiovascular dysfunction
increased QT interval on EKG
28
what fluids do we avoid in preggers with DM
D5W, causes fetal acidosis
29
how are insulin requirements in second stage of labor
increased
30
what is BG risk after delivery with DM
hypoglycemia
31
what kind of anesthesia is preferred for C section with DM
neuraxial over GA
32
what is thyroid state in normal pregnancy
euthyroid
33
what is the leading cause of thyroid disorders in prgnancy
graves disease
34
what are signs of graves disease
nervousness
sweating
heat intolerance
tremors
weakness
35
what does graves disease mimic
MH
36
what physical change is associated with thyroid disorders
increase in thyroid nodules number and size
37
how are maternal iodine level in preggers
decreased
38
what is the percent of hyperthyroid in preggers
0.2%
39
what events precipitate thyroid storm
surgery
childbirth
trauma
iodinated contrast agents
treatment with iodine-131
emotional stress
PE
stroke
infection
diabetic ketoacidosis
hypoglycemia
CHF
Bowel infarction
40
how do you treat thyroid storm
cooling blankets
meperidine
hydration
acetaminophen
O2
beta blockers
41
how do you decrease thyroid hormone secretion
iodine
glucocorticoids
42
what do we give to reduce T4 conversion for thyroid storm management
glucocorticoids
propranolol
radiographic contrast agents
propylthiouracil
43
what are the modes of treatment for thyroid storm
treat symptoms
reduce thyroid hormone secretion
reduce T4 conversion
plasma exchange
44
what are the 4 principles ways to minimize thyroid storm
1-antithyroid medication (propylthiouracil)
2- beta blockers
3-glucocorticoids
4-iodine
45
T/F you can elective procedure with thyroid storm
F, not without 1 week premeds?
46
what drugs do we avoid in thyroid issues
glycopyrrolate, ephedrine
47
how is cardiovascular response in hyperthroid
hyperdynamic, dont increase BP more than thyroid already is
48
what is risk of enlarged thyroid/goiter
may pose airway issues
49
how are resp muscles in hyperthyroid
weak, make sure are fully reversed
50
what labs do you check in thyroid issues
electrolytes
51
where do 90% of phemochromocytoma occur
adrenal medulla or adjacent sympathetic tissue
52
what can occur after resection of phemochromocyroma
hypotension
53
what percentage of pheochromocytoma are malignant
10%
54
what do pheochromocytomas release
epi and norepi
55
what are most common symptoms of phemochromocytoma
sweating, tachycardia, HA
56
what is the definitive therapy for pheochromocytoma
surgical intervention
57
how do you treat hypotension after pheochromocytoma resection
short acting vasopressors
58
how do you preop pheochromocytoma patient
alpha adrenergic antagonist and IV bolus
59
what monitors do you use for pheochromocytoma
standard plus A-line
60
what lab do you check for after pheochromocytoma resection
blood glucose for hypoglycemia
61
what medications do we avoid in patient with phemochromocytoma
atracurium
droperidol
glucocorticoids
metoclopramide
morphine
pancuronium
pentazocine
succs
vanc
(increase release of catecholamines by tumor)
62
how much does RBC increase in preggers
how much does plasma volume increase in preggers
what does this lead to?
30%
50%
physiological anemia
63
what is HGB level for anemia in preggers
<10.5 g/dL
64
what is the most common cause of anemia in preggers
iron deficiency anemia
65
what values are low in iron deficiency anemia
low MCV
low total iron
low ferratin
low transferrin
66
what is anemia increase risk for in preggers
preterm delivery
low birthweight
67
what are risk factors for anemia
advanced age
short parity interval
hispanic-american and african american race
68
what are side effects of iron supplements
N/V
constipation
abd cramps
69
what is the leading cause for postpartum blood transfusions
antepartum anemia
70
what are emergencies of sickle cell anemia
vaso-occlusive crisis
organ injury
71
what is the most important factor in sickling
O2 tension
72
what factors affect sickling
Hgb > 50%, dehydration, hypotension, hypothermia, acidosis
73
What happens to a sickled erythrocyte when it becomes oxygenated
returns to normal shape
74
what does repeated sickling of Hgb lead to
irreversable metabolic abnormalities and membrane damage
75
what is the lifecycle of sickled cell
12 days
76
how does pregnancy affect sickle cell disease
exacerbates
77
what causes maternal deaths from sickle cell disease
thromboembolitic events
infections
cardiomyopathy
pulm HTN
infarctions
78
what are risks of maternal sickle cell disease
preterm labor
placental abruption
fetal growth restrictions
preeclampsia
eclampsia
79
what are management methods for sickle cell
crystalloid to maintain volume
transfuse RBCs
supplemental O2
maintain normothermia
reduce peripheral venous stasis
thromboembolism prophylaxis
80
what do you do preop for sickle cell
-recent exacerbations
-level of anemia
-chronic organ injury
-echo to rule out pulm HTN
-increased CO
-wall motion
-transfuse for HGB>10
-cross matched blood on hand
-plan for perioperative pain control
-continuous neuraxial anesthesia is recommended although GA is acceptable
81
what factor is associated with Von Willebrands
factor 8
82
Hemophilia A and B are _______ linked traits
X
83
heterozygous females usually have ____ the concentration of factor ______ and _______ in hemophilia A and B
1/2
8
9
84
what kind of delivery is preferred to protect fetus from trauma in hemophilia A and B
c section
85
what is the formation of large amounts of thrombin, fibrinolytic system activation, coagulation factor depletion and hmmg
DIC
86
DIC scoring system
87
what are parts of the DIC scoring system
decreased platelet counts
decreased fibrinogen levels
variable increases in PT and PTT
increased concentration of D-dimer
increased fibrin monomer and fibrin degredation products
88
how often does acute cholecystitis occur in preggers
0.1%
89
how often does cholelithiasis occur in preggers
3%
90
how is cholelithiasis diagnosed
ultrasound
91
what are s/s of cholecystitis
RUQ pain
fever
leukocytosis
92
what is treatment for cholecystitis
IV hydration
antibiotics
opioids
bowel rest
percutaneous cholecystostomy
93
what trimester is it preferred to have surgical intervention for cholecystostomy
2nd trimester
94
what is incidence of miscarrigae and preterm labor for surgical intervention of cholecystostomy
25%
95
what are some liver disease specific to pregnancy
hyperemesis gravidarum
intrahepatic cholestasis of preggers
preeclampsia/eclampsia
HELLP syndrome
acute fatty liver of preggers
96
how do volatile anesthetics affect hepatic blood flow
decrease by 20%
97
what volatiles are preferred for liver disease
iso and des (no liver metabolism)
98
how does neuraxial anesthesia affect liver blood flow
decreases
99
what are risk factors for neuraxial anesthesia of liver disease
coagulation factors
venous engorgement
100
T/F lever disease has a large affect on standard dose of induction agents
F, standard dose is fine
101
what is the drug of choice for RSI in liver disease
succs
102
what is an inherited disorder in the regulation of intracellular Ca++
MH
103
what receptor gene mutations result in MH
dihydropyrodine and ryanodine
104
what is the test for MH
caffeine-halothane contracture test
105
T/F MH is heterozygous autosomal dominant
true
106
what are S/S MH
increased etCO2, HR, muscle rigidity, temp
107
what are triggers for MH
sucss and volatiles
108
how do we prepare anesthesia machine for MH
change circuit
change CO2 absorber
take off volatiles
flush with O2 for 5 min
109
what is treatment of MH
dantrolene 2.5 mg/kg and repeat 5-10 min
ryanodex is the new drug
110
what measure the severity of the curve of scoliosis
cobb angle
111
what angle of curve of scoliosis should be further evaluated
>30 degrees (or precious corrective sx)
112
what should we evaluate with scoliosis
angle
past sx
etiology
severy/ life altering symptoms
past neuraxil anesthesia
113
what are complications of scoliosis with neuraxial block
spine curves and rotates
previous fusion or instrumentation
variations in block spread
114
what is a helpful tool for neuraxial blocks in scoliosis
ultrasound guidance
115
what is epidural technique to have a more positive confirmation of placement
DPE
116
what should you educate patients on with neuraxial especially with scoliosis
block failure
117
what kind of intubation do we do with RA
use videoscope
118
what are airway complications with RA
stiff jaws
calcified thyroid membrane
small mandible
TMJ
cricoarytenoid arthritis
laryngeal deviation
119
what positioning technique do we use caution in with RA
neck manipulation/sniffing
120
T/F neuraxial anesthesia is contraindicated in RA
false
121
what kind of disease is MS
autoimmune
122
do males or females have MS more
females
123
when does MS present
20s-30s
124
what are S/S MS
motor weakness
impaired vision
ataxia
bladder and bowel dysfunction
emotional lability
125
what is pathology of MS
local inflammation
demyelination
gliotic scarring
axonal loss
gray and white matter plaques seen on MRI
126
T/F there are sever maternal and fetal outcomes with MS
false
127
when does MS relapse occur postpartum?
3 months
128
what level of compromise do we watch for with MS
resp involvement
129
what is a concern with MS and neuraxial anesthesia
demyelinated nerves
130
what types of anesthesia is safe in MS
neuraxial and general
131
what risks do migraines increase
2x more placental abruption
4x greater chance for preeclampsia
132
what block is for migraines
SPG
133
what symptoms of spinal cord injury does pregnancy aggravate
decrease resp reserve
DVT
PE
HTN
autonomic hyppereflexia
134
spinal cord lesions above what level might not feel labor pain
T10-T11
135
what level lesion has increased risk of autonomic hyperreflexisa
above T6
136
what do spinal cord lesions increase risk of pregnancy wise
preterm labor
137
what is recommended for spinal cord injuries to prevent autonomic hyperreflexia
early neuraxial anesthesia
138
what monitor do we want for autonomic hyperreflexia risk
a line
139
what is the anesthetic of choice for SPinal cord injury C section
spinal
140
what is an autonomic skeletal weakness disorder caused by the production of antibodies against nicotinic receptors resulting in receptor destruction and antibody induced blockade of the remaining acetylcholine receptors
myasthenia gravis
141
what medication can trigger myasthesnia crisis
mag therapy
142
T/F uterine contractility is affected by MG
false
143
when do we do neuraxial in MG
early in labor
144
when are we cautions of neuraxial in MG
with resp involvement, it weakness occurs turn off epidural
145
T/F use succs in MG
false
146
what is dose of nondepolarizers in MG
50%
147
what is reversal for MG
sugammadex
148
what kind of anesthesia is preferred for labor and C sections with myotonic dystrophy
neuraxial
149
what effects of opioids are myotonic dystrophy sensitive to
resp effects
150
how can we avoid triggering myotonic dystrophy
keep rooms warm
prevent shivering (demerol)
no duramorph
no succs
151
how do we reverse myotonic dystrophy patient
sugammadex
152
what anesthetic drugs do we avoid in muscular dystrophy
volatiles and succs
153
what is progressive degeneration of skeletal muscles with intact innervation
muscular dystrophy
154
what do limb-girdle dystrophies involve
shoulders and pelvic muscles
155
how does pregnancy effect limb-girdle dystrophies
exacerbated, ends with c section
156
what heart issues can occur with muscular dystrophy
cardiomyopathy
conduction abnormalities
157
what kind of anesthesia is preferred with muscular dystrophy
neuraxial for vaginal and C section
158
what can sever muscular dystrophy lead to that effects anesthesia
spinal and airway malformations
159
what can succs cause in muscular dystrophy
rhabdo
160
T/F dont use roc in muscular dystrophy
F, nondepolarizing are fine
161
what causes carpal tunnel syndrome in preggers
compression of median nerve in the flexor retinaculum in wrist
162
when is carpal tunnel worst
morning
163
when do carpal tunnel syndromes go away postpartum
2 month
164
what is considered Obese in preggers
BMI>30
165
how is morbidity and mortality in obesity
increased
166
how is labor in obsesity
slowed
167
how is C section risk in obesity
increased
168
what are obese OB patients at risk for more than non obese
gestational DM
gestational HTN
Preeclampsia
high birth weight
preterm delivery (morbidly)
operative vaginal delivery (morbidly)
C section
169
how is airway and neuraxial blocks in obesity
difficult
170
how are ligaments and landmarks in obesity for neuraxial
ligaments have less distinct feel and landmarks cannot be palpated
171
how does obesity effect vent weaning
more difficult
172
what position do obese not tolerate
lying flat
173
what methods can we use to help with neuraxial blocks
ultrasound and DPE
174
T/F base induction doses on total body weight of obese patient
F, lean/ideal body weight
175
why do obese patients often have failed epidural
multiple fat pockets can give false loss of resistance test
use DPE to confirm
176
what causes the increase insulin requirements in labor
increased catecholamines increase insulin
177
what are signs of hyperthyroid is prggers
hypermetabolic
fever
hot
sweating
178
T/F give radioative iodine in pregger
false
179
what do you do with ETT size and goiter
decreased tube size
180
what differentiates thyroid storm from MH
increased etCO2 in MH
181
T/F thyroid storm has increased etCO2
T, but not as much as MH
182
what does decadron do fo thyroid
decrease T4 conversion, reduce thyroid hormone secretion
183
if a patient comes in on thyroid storm proceded with surgery? T/F
false
184
what beta blocker do we use for thyroid storm
propanolol (esmolol good for when they are removing the gland due to shorter half life)
185
when should thyroid storm be treated before anesthesia
1 week
186
what do you reverse thyroid patient with
suggamadex, cause thyroid also causes weak resp muscle
187
what are alpha 1 blockers for phenochromocytoma
phentolamine
phenoxybenzamine
188
what is phenoxybenzamine dose
10 mg BID (max dose 50 mg BID)
189
T/F phenoxybenzamine crosses placenta
true
but no side effects
190
what are line considerations for pheochromocytoma
multiple iVs
a line
191
what drip is common in pheochromocytomas
nipride (1 mcg/kg/min or lower)
nitroprusside
192
what beta blocker do you use for pheochromocytoma
esmolol
193
what order do you block pheochromocytoma
alpha then beta
194
when should pheochromocytoma be removed in preggers
16-23 weeks
195
what is risk of nipride
cyanide poisoning
196
pheochromocytoma sx and pregger
197
T/F we want a long venous time in sickle cell
false
causes sickling
198
what causes a long venous time in sickle cell
low CO
199
what chamber is enlarged in sickle cell
LV hypertrophy
200
why do we control pain in sickle cell
catecholamine release can lead to sickling
201
what does factor 8 do
binds collagen in platelet adhesion
202
are men or women more effected by factor 8
women
203
what is most common type of VW
type 1
204
what is the most severe VW
type 3, autosomal recessive
205
what do we do to treat VW in preggers
DDAVP at start of labor and then 12-24 hours after
206
what modified ISTH score is DIC
>/= 26 is high probability
207
what do you treat DIC with
FFP (1-1.5x normal PT/PTT)
cryo
fibrin
platelets (50,000 or greater)
208
what is anesthesia plan for DIC
general
209
what is cholecystitis
inflammation of the gallbladder
210
What is cholelithiasis?
gallstones
211
what does dantrolene do
prevent Ca++ release from SR
212
early vs late symptoms of MH
early:
masseter rigidity
increased etCO2
increased HR
Late:
high temp
213
s/s MH
