Exam 2 OB complications Flashcards
(88 cards)
1
Q
Low Birth wt is
A
<2500g
2
Q
Very Low BW is
A
<1500g
3
Q
Extremely low BW is
A
<1000g
4
Q
Micropreemie is
A
<750g
5
Q
OB factors associated with preterm labor
A
Vaginal bleeding Infection (systemic, genital tract, periodontal) Short cervical length Multiple gestation Assisted reproductive techniques Preterm premature rupture of membranes Polyhydramnios
6
Q
Preterm delivery due to (3 things)
A
Preterm Premature Rupture of Membranes
Spontaneous preterm labor
Maternal/Fetal indications for delivery
7
Q
Discuss Terbutaline Tx for preterm labor
A
Terbutaline- B-adrenergic agonist
Tocolytic therapy
B1 AND B2 stimulation- smooth muscle relaxation (uterus)(B1) and increased HR (B2)
Side effects- Hypotension, tachycardia, pulmonary edema, hyperglycemia, hypokalemia
*avoid with agents that inc HR
*Will cause SUX to have decreased onset
8
Q
Discuss Mag Sulfate Tx for preterm labor
A
Se- Hypotension, Potentiates all NMBs, decrease dose and don’t use defasciculating dose
9
Q
What is the portion of the fetus over the pelvic inlet
A
presentation
Cephalic, Breech, and Shoulder
10
Q
Vertex, brow or face is what presentation?
A
Cephalic
11
Q
What is the alignment of fetal spine with maternal spine?
A
Lie
longitudinal or traverse
12
Q
Breech or vertex have a ____ lie.
A
Longitudinal
13
Q
The relationship of special fetal bony point to maternal pelvis is
A
Position
14
Q
Sacrum is position
A
Breech
15
Q
Occiput is position
A
Vertex
16
Q
Mentum is position
A
Face
17
Q
Acromion is position
A
Shoulder
18
Q
Complete breech
A
Hips flexed at hip and knees
19
Q
Incomplete breech
A
1 or both legs are extended at the hip
20
Q
Frank breech
A
lower ext are flexed at the hip, extended at the knee
21
Q
Anesthesia for Breech delivery- NA considerations
A
May need more dense anesthesia for vaginal or C-Sec- 3% 2-chloroprocain or 2% lidocaine with epi and bicarb
22
Q
What is the worse fear with breech delivery
A
Fetal head entrapment
23
Q
Monozygotic twins chorion and amnion
1-2days
3-8 days
8-13 days
A
1-2 DD
3-8 MD
8-13 MM
24
Q
Multiple gestation will have _____% increase in CO (SV increases ____% and HR increases _____%
A
CO increases 20% (SV increases 15%, HR increases 3.5%) with multiple gestation
25
Hypoxemia occurs more rapidly with multiple gestation b/c
Decreased FRC and Increased Maternal Metabolic Rate
26
Plasma volume increases and additional _____ml with multiple gestation
750ml
27
Use full lateral position with multiple gestation d/t greater risk for
aortocaval compression and supine hypotensive syndrom
28
Gestational HTN is
Increased BP after 20 weeks gestation without proteinuria
29
Preeclampsia is
New onset HTN and proteinuria after 20 weeks gestation
30
If no proteinuria with HTN after 20 weeks gestation, which other Sx would make you consider preeclampsia?
```
Persistent epigastric or RUQ pain
Persistent cerebral symptoms
Fetal Growth restriction
Thrombocytopenia
Elevated Liver Enzymes
```
31
Eclampsia is
Preeclampsia with onset of seizures
32
What is HELLP Syndrome
Hemolysis (abnormal peripheral blood smear, Increased bilirubin >1.2mg/dl, Increased lactic dehydrogenases (LDH >600)
Elevated Liver- (AST>70, LDH >600)
Thrombocytopenia (plts <100,000)
33
Chronic HTN is
prepregnancy systolic >140 and or dystolic >90 or elevated BP unresolved by delivery
34
Dx criteria for Preeclampsia w/o severe features
BP >140/90 after 20 weeks gestation with proteinuria (>300mg/24h, protein creatine ratio >0.3 or 1+ on urine dipstick)
35
Dx criteria for Severe preeclampsia
BP 160/110, thrombocytopenia <100,000 Serum creatine >1.1 or 2x baseline, pulmonary edema, new onset cerebral or visual disturbance, impaired liver function (HELLP Sx)
36
Tx for HTN disorders
Bedrest, sedation, antihypertensive Tx.
37
Most definitive Tx for hypertensive disorders
delivery of the fetus
38
Labetalol Onset and Dose for HTN disorders
Onset- 5-10 min
| Dose- 20mg IV, then 40-80mg every 10 min to max of 220mg
39
Hydralazine Onset and Dose for HTN disorders
Onset- 10-20min
| 5mg IV every 20 mins for max of 20mg
40
Mag sulfate Dosing and therapeutic levels
4-6g over 20-30 mins followed by 1-3g/hr
| Therapeutic range 5-9ml/dl or 4-6mEq/L
41
Hypermagnesemia plasma levels with toxic effect
>12- loss of patellar reflexes
15-20- respiratory distress
25 asystole
42
Tx for hypermagnesemia
Stop gtt, give calcium gluconate IV
43
Do you want to do GA with HTN disorders?
No- have greater risk for potential AW catastrophe. NA should be initiated early d/t declining platelets and to avoid GA with emergency
44
4 considerations with NA and preeclampsia
Assess Coagulation Status
IV hydration prior to epidural dosing of LA- lower need for fluids- avoid pulm edema
Risk for HTN is increased
Avoid Epi to avoid HTN
45
Fluid maintenance for Pts with HTN disorders
Keep low, 75-100ml/hr to prevent cerebral edema
46
When the placenta covers the opening of the Cervix
Placenta Previa
47
Placenta covers cervical ox
Total Previa
48
Placenta covers part of cervical os
Partial Previa
49
Placenta lies 2cm of cervical os
Marginal previa
50
What is the classic sign of placenta previa
painless vaginal bleeding in 2nd-3rd trimester
51
Total previa with require what?
C-Sec
52
Placental edge to os distance >1cm and or significant bleeding.
Total previa, will required C-Sec
53
What anesthetic technique is preferred for Previa with overt bleeding
GA- RSI
54
What is the best induction drugs for previa with overt bleeding?
Ketamine 0.5-1mg/kg or Etomidate 0.3mg/kg
55
Maintenance with
N2O and Low dose halogenated agent
56
Complete or partial separation of placenta from decidua basalis before delivery of fetus
Placental Abruption
57
Complications for Placental Abruption
Hemorrhagic shock, coagulopathy, fetal compromise or demise
58
Maternal Comorbidities for Placental abruption
HTN, Acute or chronic respiratory illness, Substance abuse, maternal or paternal tobacco use, maternal cocaine use.
59
Conditions associated with uterine rupture
```
Prior uterine surgery
induction of labor
high dose oxytocin
prostaglandin induction
grand multiparity >5
morbidly adherent placenta
congenital uterine anomaly
connective tissue disorder
forceps application/rotation
internal podalic version
excessive fundal pressue
blunt or penetrating trauma
```
60
Nonsurgical disruption of all uterine layers
Uterine rupture
61
Incomplete disruption of uterine layers
Uterine dehiscence
62
Presenting signs of Uterine rupture
Abd pain and abnormal FHR pattern
63
What anesthetic technique for uterine rupture
GA- unless epidural already in place
64
Fetal vessels cross fetal membranes before presenting part
Vasa Previa
65
Loss of uterine tone and accounts for 80% of hemorrhage
Uterine Atony
66
Oxytocin dose, contraindication and side effects
```
Oxytocin
Dose- 0.3-0.6 IU/min IV
Contraindications: none
S/E: tachycardia, hypotension, myocardial ischemia, free water retention
Also: Has SHORT duration of action
```
67
Ergonovine or methylergonovine: Dose, C/I and S/E
Dose:0.2mg IM
C/I: preeclampsia, HTN, CAD
S/E: N/V, arteriolar constriction, HTN
Also:: Has LONG duration of action and may be repeated once after 1 hr
68
Methlyprostaglandin "Hemabate" Dose/CI/SE
Dose- 0.25mg IM
C/I Reactive AW disease, pulm HTN, Hypoxia
SE- Fever,chills,NV,D,BRONCHOCONSTRICTION
Also- may be repeated every 15 min up to 2 mg
69
Adherence of basal plate of placenta to uterine myometrium without decidual layer
Placenta accreta vera
70
Invasion through myometrium into sersoa and adjacent organs
Placenta percreta
71
Chorionic villi invade the myometrium
Placenta increta
72
How to manage Placenta Accreta
Same as other severe postpartum hemorrhage
73
Technique of choice for Peripartum Hysterectomy?
GA
74
Features of Amniotic Fluid Embolism
```
Maternal Hemorrhage
Hypotension
SOB
Coagulopathy
Restlessness / Agitation
Fetal Compromise
Cardiac Arrest
Seizures
```
75
Clinical presentation of amniotic fluid embolism
Acute respiratory distress
Cardiovascular collapse
Coagulopathy near delivery
76
Management of Amniotic Fluid Embolism
```
Admin 100% O2
Intubate and support ventilation
Start CPR if needed
Ensure LUD
Admin fluids and pressors
Est large bore IV
Consider A line
Monitor fetal well being
Expedite delivery
Activate OB massive blood loss protocol
Check electrolytes
Give blood products as needed
Ensure normothermia
Ready the ICU for admission
```
77
3 factors that contribute to increased risk for DVT and PTE
Hyper-Coagulopathy
Venous Stasis
Endothelial injury (Vascular damage)
78
S/Sx of DVT
Nonspecific leg pain and edema
79
S/Sx of PTE (pulm. thrombotic event)
Palpitations, anxiety, CP, cyanosis, diaphoresis, cough with or without hemoptysis, SOB
Signs of RV failure- split S2, JVD, parasternal heave, hepatic enlargement
ECG-RV strain(RAD, P pulmonale, ST changes, T-Wave inversion, SVT
80
LMWH, prophylactic (NA wait time)
10-12 hours
81
LMWH therapeutic (NA wait time)
24 hours
82
Sub Q- UFH prophylactic or therapeutic (NA wait time)
no wait to recommendation
83
Warfarin (NA wait time)
4-5 days for INR to normalize
84
When is Venous Air Embolism most likely to occur during pregnancy?
After placental separation, there is the potential for air trapping. Common during C-Sec- immediately after placenta separates from the endometrial surface and is exposed, air can enter the bloodstream.
85
What is the clinical presentation for Venous Air Embolism?
Small amount- usually no symptoms
Massive amount- Hypotension, Hypoxemia, Potential Cardiac Arrest.
>200-300 ml or 3-5ml/kg is deadly
86
Describe the pathophysiology of VAE.
Small amount of air in bloodstream---> Pulmonary vasospasm-->V/Q mismatch, hypoxemia, R sided HF, arrhythmias, and hypotension.
Air Volume >3ml/kg can cause RV outflow tract obstruction--> CV collapse.
Air into arterial circulation--->CV and neurological events.
87
Worry about VAE if Pt complains of:
Chest pain
Dyspnea
Sudden Hypotension
Arrhythmias
88
Resuscitation protocol of OB Pt with massive VAE
Prevent further air entrainment- flood surgical field with saline, lower the surgical field relative to the heart.
Administer 100% O2, d/c N2O, intubate and ventilate
Support circulation with chest compressions, IV volume expansion, and vasopressors
Expedite delivery
Evaluate for intracerebral air and consider hyperbaric O2 therapy
