Flashcards in Exam 2A: Problems of Early Pregnancy Deck (82):
1. At what week of pregnancy does minute ventilation increase by 15%.
2. What is the effect of #1?
1. 12 weeks.
2. Decreased PaCO2. (Respiratory alkalosis)
This stimulates respiratory efforts by increasing sensitivity of the respiratory center to CO2.
Increased progesterone concentrations
Women who undergo mechanical ventilation in early pregnancy require _____.
increased minute ventilation
How much increase in Cardiac output by 8th week?
20 - 25%
SVR decreases ____% by 8th week.
MAP decreases ___ mmHg at 16 - 24 weeks and returns to normal near term.
Aortocaval compression typically occurs after ____ weeks. This is when the uterine funds reaches the umbilicus and is large enough to compress the aorta and vena cava when supine).
18 - 20 weeks
LUD rarely needed in early pregnancy (<15 weeks) except in the presence of (3)
1. multiple gestation
3. Gestational trophoblastic disease.
Pregnant women typically tolerate a blood loss of _____ during the 1st half of pregnancy.
500 - 1500 ml
FYI: In pregnancy, BP normally goes down!
Increased progesterone levels may cause relaxation of LES tone as early as the first trimester.
1. What is the fasting gastric volume in both non pregnant women and women in early pregnancy (15 weeks).
2. Reglan 10 mg IV 30 minutes prior to anesthesia can decrease #1 by how many 50%?
1. 30 ml
2. 50% (15ml)
Movement of the uterus at 18 - 20 weeks out of the pelvis leads to _____.
anatomic and intragastric pressure changes that contribute to GERD.
Some anesthesia providers prefer to intubate the trachea as early as ____ weeks, given that hormone changes leading to sphincter relaxation are present.
12 - 14 weeks.
This is the leading cause of pregnancy-related maternal death during the 1st trimester.
Rupture of an ectopic pregnancy
Causes of death in rupture of ectopic pregnancy (4)
1. Hemorrhage *
4. Anesthetic complications
Where is the most common site for ectopic pregnancy?
This is the most common sign of rupture to impending rupture of ectopic pregnancy.
Abdominal or pelvic pain.
Signs of ruptured or impending rupture of ectopic pregnancy:
1. This is related to presence of blood in the cul-de-sac
2. This is related to diaphragmatic irritation by intra-abdominal blood.
3. Treatment for #3.
1. Urge to defecate
2. Shoulder pain
Diagnostics to rule out ectopic pregnancy.
Pelvic pain with (+) pregnancy test
Ultrasound can detect an intrauterine gestational sac as soon as ____ days after conception.
Drug of choice for ectopic pregnancy. It inhibits growth of the trophoblastic cells of the placenta.
This is performed to confirm the diagnosis and locate the ectopic pregnancy.
Diagnostic laparoscopy or laparotomy
Surgical interventions for tubal pregnancy (3)
salpingostomy, salpingotomy, salpingectomy
In surgical intervention for tubal ectopic pregnancy, the OB doc will inject ____ into the surface of the fallopian tube causing marked blanching of the tube and decreased blood loss.
1. This often go unrecognized and may present with uterine wall rupture, marrisive hemorrhage and shock. (This is an emergency!!!)
2. Often result in massive hemorrhage also because of the inability of the cervix to contract.
3 Associated with high incidence of maternal morbidity and mortality rate of 0.5% to 4.5%.
Surgical management of abdominal pregnancy?
Laparotomy and delivery of fetus
2 anesthetic considerations in patients with ruptured ectopic pregnancies?
1. Large bore IV
2. Type and cross for several units
Neuroaxial anesthesia for hemodynamically stable patients with low likelihood of significant hemorrhage, how much fluid should you give as a rehydration?
1L crystalloid (with supplemental O2, and mild sedation)
Abortion is a pregnancy loss or termination either before ____ weeks or when the fetus weighs < _____.
< 20 weeks or < 500 g
Types of Abortion:
1. Uterine bleeding without cervical dilatation before 20 weeks.
2. Bleeding may be accompanied by ___
1. Threatened abortion
2. Backache and cramping
Types of Abortion:
1. Cervical dilatation or ROM without expulsion of the fetus
2. What is the complication of number 1?
1. Inevitable abortion
Types of Abortion:
Spontaneous expulsion of fetus and placenta.
Types of Abortion:
1. Partial expulsion of uterine contents.
2. What are the signs of #1?
3. Surgical management
4. Drugs readily available.
1. Incomplete abortion
2. Persistent bleeding and cramping after expulsion of tissues
4. Methergine and pitocin
Types of Abortion:
1. Fetal death goes unrecognized for several weeks.
2. If this occurs at advanced gestational age, ____ may occur.
1. Missed abortion
Types of Abortion:
Occurrence of 3 or more consecutive spontaneous abortions.
Recurrent/ habitual (e.g. blighted ovum)
This is the removal of any remaining fetal or placental tissue from uterus.
Dilatation and Curettage (aka Dilatation and Evacuation)
2 drugs which should be readily available; they are administered to increase uterine tone and may be given intra and post op to decrease uterine bleeding.
Oxytocin and (ergot alkaloid) Methergine
Described as intrauterine blood clots with uterine atony associated with lower abdominal pain, tachycardia, and diaphoresis.
This is given to Rh negative mother to prevent Rh sensitization. Some fetal blood may have mixed with maternal blood during D&C.
In patients with significant blood loss: observation of the patient on the operating table for evidence of hypotension for at least ____ minutes after the legs have been lowered from lithotomy to the supine position.
Type of block used in MAC for D&C.
MAC dose which may added to anesthetics if there is little bleeding and no evidence of uterine atony.
MAC < 0.5
At what week of pregnancy and onwards is considered full stomach?
>12 weeks. (you can't use LMA) < 12 weeks ok to mask
This is the most painful part of D&C is ____.
Cervical dilation is time when _____ may occur
1. If cervix is already dilated.
2. Cervix not yet dilated.
1. Sedation with or without paracervical block
2. Paracervical block with sedation or spinal, epidural or GA.
This is the cervical inability to sustain a pregnancy to full term. Recurrent second-trimester pregnancy losses.
Surgical management for incompetent cervix.
Cervical cerclage (spinal mostly used)
Management in cervical cerclage.
Avoid increase intrabdominal and intrauterine pressures (e.g. Coughing on ETT, Vomiting, dorsiflexion for insertion of neuroaxial anesthesia)
At what weeks should FHR be monitored?
> 20 weeks
In normal pregnancy, this tissue forms the placenta.
Abnormal trophoblastic proliferation results in ___.
gestational trophoblastic disease (Hmole)
Difference between partial and complete Hmole.
1. Complete Hmole: derived solely from paternal chromosomes
2. Partial: Usually have complete trisomy (one set maternal)
Characteristics of Hmole (4)
1. Vaginal bleeding after delayed menses
2. Absence of FHR
3. Uterus too large for gestational age
4. B- hCG > 100k (cause hyperemesis gravidarum)
Dx tool to confirm Hmole?
This is the most common complication of complete molar pregnancies.
Excessive uterine size
Management of GTD/ Hmole.
1. Recommended for childbearing age
2. Recommended for those who have completed childbearing.
3. Prevention of pregnancy for _____ months.
4. Evidence of invasive mole or choriocarcinoma.
3. 6 - 12 months
Monitoring recommended when PaO2 is decreased.
Aline and CVP
S/S of acute cardiopulmonary distress develop after_____ in as many as 27% of patients with a molar pregnancy.
1. Preferred type of anesthesia for GTD
2. Preferred induction agent.
3. Drugs to avoid
3. Ketamine and inhalation agents
This is a persistent form of nausea and vomiting in pregnancy.
1. This type of induction is done for convenience for the patient and the physician.
2. #1 is begun by permforming ____ with or without concomitant oxytocin.
1. Elective induction
1. Type of induction performed when delivery is indicated for maternal or fetal reasons and both can tolerate labor and delivery.
2. If bishop score is favorable, ___ alone will suffice as a means of inducing labor.
3. These are also advocated for induction of labor.
1. Indicated induction
3. Cervical prostaglandins
1. Preterm delivery
2. Preterm infant
1. Preterm delivery is defined as delivery before 37 weeks
2. Preterm infant is defined as one delivered between 20 - 37 weeks after the LMP (at least 3 weeks before the expected date of term delivery)
Criteria for diagnoses of preterm labor (3)
1. 20 - 37 weeks
2. Uterine contractions: 4 in 20 mins or 8 in 1 hr
3. Cervical dilation >/= 2cm, effacement >/= 80%
An apparent prolongation of ____ phase may represent false labor. Piton nor amniotomy may cause risk for failure and potential need for unnecessary C/S. ______ are alternatives for these patient.s
latent................ ambulation and opioid sedation
This is the rupture of fetal membranes (chorioamnion) before the onset of labor. This is the precipitating factor in 1/3 of preterm deliveries.
Name 2 risks of PROM
chorioamnionitis and umbilical cord prolapse
If PROM occurs during 2nd trimester and there is a long exposure of the fetus to OLIGOHYDRAMNIOS, there is a risk of ___(2)
1. pulmonary hypoplasia
2. orthopedic deformities
1. Current management of preterm PROM
2. Confirmatory tests for preterm PROM (2)
3. Used to identify variable decelerations that signal umbilical cord compression.
4. The mom is also evaluated for fever and uterine tenderness, which may indicate ____.
5. Adjunct therapy (2)
6. This is ineffective in preterm PROM
2. Inspection and Nitrazine & Fern testing
5. corticosteroids ( enhance lung maturity) and antibiotics (to prevent chorioamnionitis and delay onset of labor)
6. Tocolytic therapy
If chorioamnionitis develops, the uterus must be emptied. Oxytocin and close observation are indicated. What are the 2 antibiotics given intrapartum stats?
ampicillin and gentamicin
Tocolytic therapy does not prolong pregnancy beyond ___ days.
2 - 7 days
A short course of tocolytic therapy may delay delivery 24 - 48 hours, allowing maternal administration of corticosteroid to accelerate fetal lung maturity and administration of antibiotics to prevent ____ infection
neonatal group B streptococcal infection.
Criteria for use of tocolytic therapy (3)
1. Gestational age 20 - 34 weeks
2. No clinical signs of infection
3. Reassuring fetal status
1. This B-adrenergic agonist is no longer available in the US
2. This drug is associated with a high incidence of maternal and fetal effects.
This is the most frequent serious complication of B-agonists (esp in prolonged exposure)
1. This is nature's "physiologic calcium blocker" by competing with calcium for surface-binding sites on smooth muscle membranes.
2. It also acts at the NMJ by _____ and ____
3. Serum Mag level which are sufficient to inhibit contractions of patients in preterm labor.
2. Decreasing ACh release and Decreasing sensitivity of the endplate to ACh.
3. 5 - 7 meq/L
1. What is the precursor of prostaglandin?
2. Most common complaints of Indomethacin? (2)
1. Arachidonic acid
2. Nausea and heartburn
1. ____ has a low fetal: maternal plasma concentration ratio due to its relatively high maternal protein binding, therefore the potential for fetal toxicity seems minimal.
2. It is a good choice of drug due to its rapid hydrolization in both maternal and fetal plasma. Placental transfer not increased by fetal acidosis.
2. Nesacaine 3%
This is the technique of choice during labor and vaginal delivery of preterm infant.
Continuous lumbar epidural analgesia