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OB - Paul Smith > Final OB > Flashcards

Final OB Flashcards

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1
Q

Respiratory Changes in OB patient (3)

What hormone is responsible?

A

1) Engorgement of Tracheobronchial tree
2) Increased MV and O2 consumption
3) Decreased FRC and change in Closing capacity

Progesterone

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2
Q

What anesthesia changes do we need to be careful with due to respiratory changes? (5)

A 
Suctioning caution
Oral Airway caution
Nasal airway 
Shorter DL handle
Smaller ETT 6.0-7.0 (some parts say 6.5 instead of 7.0)
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3
Q

Cardiac output changes in an OB patient

A

Increased CO (+40-50% from baseline; largest increase in 1st trimester)

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4
Q

Changes in blood volume in OB patient?

A

Dilutional anemia (+40% plasma volume and +20% RBC)

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5
Q

Aortocaval Compression begins at what time period?

A

20 weeks

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6
Q

Signs and symptoms of Aortocaval compression?

What causes signs and symptoms?

A

1) Anxiety
2) Light-headed
3) N/V
4) Tachy/Bradycardia
5) Diaphoresis
6) Hypoxia

Causes Decreased Cardiac Output and decreased venous return.

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7
Q

What happens to the fetus during aortocaval compression?

A

Fetal bradycardia and hypoxia

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8
Q

Treatment for Aortal Caval compression?

A

Left Uterine Displacement

Wedge under the hips, doesn’t matter if it’s left or right

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9
Q

Changes in WBC count?

A

Normal up to 13k can reach 30k during labor.
Scheduled C/S should have 6-16k.
>16k consider infection.

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10
Q

What platelet count should we avoid regional in OB patients?

A

<80k

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11
Q

Do Thromboembolic event risks increase/decrease? What causes this?

A

5x increase due to Factor I, VII, X, XII increasing to prevent blood loss.

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12
Q

GI changes in OB patients

What causes this earlier? Later?

A

esophageal SPHINCTER relaxes which increases reflux.
GI motility slowed and absorption
Gastric volume increases

Progesterone initially then due to fetus increasing IABP

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13
Q

How do we intubate OB patients?

Starting at what gestational age to when?

A

RSI starting 18+ weeks to 6 weeks post delivery. Can start 12 weeks if conservative.

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14
Q

Diabetogenic state due to?

What does this due to fasting BG? What about after eating?

A

Secretion of human placental
lactogen reduces tissues sensitivity to insulin leading to a rise in insulin levels (in order to provide fetus with more sugar)

Fasting BG lower than normal
Eating BG higher than normal

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15
Q

What does relaxin cause?

A

Softening of cervix
Inhibits uterine contraction
Relaxes pelvic joints and causes laxity of spine that increases back pain

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16
Q

Placental macroscopic layers

A 
Chorioinic plate (fetal)
Intervillous space
Basal plate (maternal)
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17
Q

Placental microscopic layers

A 
Fetal trophoblasts (cytotrophoblast, syncytiotrophoblast)
Fetal connective tissue
Endothelium of fetal capillaries
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18
Q

Preferential blood flow of oxygenated and deoxygenated blood

A

Oxygenated to. Fetal brain/heart,

Deoxygenated to lower half of body

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19
Q

Uterine blood flow is largely dependent on what?

A

Maternal Mean Arterial Pressure MMAP

UBF= (MMAP-UVP)/UVR

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20
Q

Drug transfer rate determined by what 5 things?

A

1) Size of molecule (<1000 daltons)
2) Concentration gradient (high to low)
3) Protein binding (bound wont pass)
4) Ionization (non-ionized required to pass)
5) Lipid solubility enhances transfer

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21
Q

Drug Transfer Uptake greatest to least

A 
IV
Paracervical
Caudal
Lumbar epidural
Spinal

Paracervical and Caudal flipped from normal

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22
Q

Fetal circulation

A

Umbilical vein oxygenated -> IVC (50% liver, 50% IVC) -> LA (flow stream through PFO) -> Aorta -»innominate artery to brain -> SVC -> RA -> RV -> Lungs (very little blood) -> through Ductus Arteriosus to Lower extremities and gut -> hypogastric artery -< Umbilical artery

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23
Q

What causes fetal bradycardia? (5)

A 
Hypoxia
Fetal head compression
Cord compression
Bradyarrythmias
Maternal drug ingestion
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24
Q

Early Decels occur when?

A 
WITH contractions (mirror)
NBD: fetal head compression
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25
Late Decels occurs when?
Starts 10-30 secs after contraction starts and ends 10 - 30 secs after contraction ends Due to decreased placental pressure BAD
26
Variable Decels
Variably, from cord compression
27
VEAL CHOP
Variable - Cord Compression Early - Head Compression Acceleration - Okay Late - Placental Pressure
28
Treatment for brady/late decels
Fluids Ephedrine/phenylephrine LUD Decrease epidural Oxygen C/S
29
HTN difference between chronic and gestational?
Chronic -> before 20 weeks Gestational -> after 20 weeks >140/90
30
Mild Preeclmpsia
HTN and new onset proteinuria
31
Severe preeclampsia
NEW ONSET PROTENURIC HTN + ONE OF THE FOLLOWING: ``` Severe HTN (>160/110) proteinuria (>5g/day) oliguria (<500 mL/day) Increased Creatinine Pulmonary Edema Intrauterine growth restriction CNS Changes Liver dysfunction (Increased LFT) Signs of HELLP (PLTS <100k) ```
32
How to manage eclampsia?
Prevent seizures (Mg) Blood pressure meds/epidural Optimize Volume
33
Diabetes Mellitus considerations
Stiff Joint syndrome More prone to full stomach Hypoglycemia after delivery with insulin pumps More likely to require C/S
34
Cardiovascular considerations
``` Prevent Pain Treat dysrhythmia LUD to avoid ACCS Avoid: Myocardial depression Hypoxemia Hypercarbia Acidosis ```
35
During what heart issues do you want Fast Full and Forward?
Regurgitation Prolapse Insufficiency
36
During what heart issues do you want normal HR, normal Preload, normal SVR?
Stenosis
37
Which heart lesion is the most dangerous? What is useful for this issue?
Aortic stenosis - Arterial line and epidural (just dose slowly)
38
What causes painless vaginal bleeding? Does it require C/S?
Previas (total, partial, marginal) significant partial and total previa requires C/S
39
Signs and Symptoms of placental abruption?
``` Abdominal pain and tenderness Fetal distress Hemorrhage (absent or copius) Abdominal rigidity Impending doom ```
40
Placental abruption anesthesia considerations
Abruption “walled off”: continue to monitor mother and baby Severe: immediate delivery, GETA RSI and large bore IVs (no spinal)
41
Placental Accretias and considerations
Accretia - Attaches Incretia - Invades Percreta - Perforates Myometrium Considerations -> Have blood ready, ready for GETA, hysterectomy may be required depending on severity.
42
Uterine Rupture signs and symptoms
1) Vaginal bleeding (rigid abdomen): could be retroperitoneal 2) Hypotension 3) Arrested labor: disengagement of fetal presenting part 4) Fetal distress: extreme bradycardia 5) Uterine tenderness: extreme pain even with anesthesia
43
What is the most common cause off postpartum hemorrhage?
Uterine Atony
44
What can cause Uterine atony? (8)
1) Polyhydramnios 2) Multiple Gestation 3) Macrosomia (BIG ASS BABY) 4) Multiple Parity 5) Tocolytic agents 6) Drugs 7) chorioamnionitis (bacterial toxins) 8) Oxytocin augmented labor /prolonged labor/ rapid labor
45
Treatment for uterine atony? (7)
1) Uterine massage 2) Oxytocin IV or intrauterine 3) Methergine 200 mcg IM (avoid in PIH) 4) Hemabate 250 mcg IM (avoid in asthma) 5) Cytotec 1mg PR/PO 6) Bakri balloon 7) Hysterectomy
46
How to treat hemorrhage?
Give fluids (Blood>colloids>crystalloid) 100% O2 GETA w/RSI
47
What is AFE and when does it present?
Usually presents in stage 2 of labor when large amounts of amniotic fluid enter the maternal circulation
48
Signs and symptoms of AFE (10)
1) Sudden chills/shivering 2) Sweating 3) Tachypnea 4) Hypoxia 5) Cyanosis 6) Hypotension 7) Convulsions 8) CV collapse 9) Coagulopathy 10) DIC
49
Treatment of AFE | 5
1) CPR 2) Quick delivery of fetus (improves venous return and perfusion to vital organs) 3) ICU with invasive monitoring and vasoactive drugs 4) Expect DIC 5) A-OK protocol
50
What is the A-OK protocol?
Atropine - vagal reflex (bradycardia) Ondansetron - vagal reflex (bradycardia) serotonin (pulmonary vasoconstriction) Ketorolac - thromboxane (pulmonary vasoconstriction)
51
Signs and symptoms of PE? (7)
1) Dyspnea 2) Cyanosis 3) Tachycardia 4) Hypotension 5) Chest pain 6) Palpitations 7) Confirmed with V/Q scan or angiography
52
Treatment of VAE? | 6
1) Alert surgeon 2) Flood surgical field 3) 100%. O2 and intubate if needed 4) Vasopressors 5) Left lateral decubitus slight head up to keep air from leaving the RA 6) Keep surgical site (uterus) BELOW level of heart.
53
Prolapsed cord definition and considerations
Cord exits VAGINA and is compressed by fetus decreasing BF/O2 to baby TRUE emergency Hold patient head up and GETA if no epidural already in place
54
First stage pain pathways during labor
Visceral pain “referred pain” Cervical dilation and effacement T10-L1
55
Second Stage pain pathways during labor
Somatic pain Pelvic floor, vagina, and perineum Distention, ischemia, frank injury S2-S4 pudendal nerve
56
Test dose composition
``` Lidocaine 1.5% Epinephrine 1:200,000 3 mL 45 mg of Lidocaine 15 mcg of Epinephrine ```
57
Signs of IV injection of test dose
Tinnitus Circumoral numbness Increased HR
58
Signs of SAB injection of test dose
Inability to lift legs 5 minutes post injection
59
Advantages of epidural opiates for labor (7)
1) Decrease onset time 2) prolong duration 3) decreased concentration of LA 4) motor function not affected 5) decreases side effects of LA 6) Synergy 7) Can be used for long term pain control
60
Disadvantages of epidural opiates for labor? (3)
1) Disguises poor epidural 2) side effects of narcotics (N/V, pruritis, urine retention, decreased resp) 3) Cannot be used in 2nd stage of labor without LA
61
Spinal level needed for C/S in SAB
T4
62
Technique for SAB
``` Large bore IV Crystalloid 1-1.5L bolus 20-30 min prior Aspiration prophylaxis Routine monitors and O2 Lateral decubitus position or sitting position L2-3, L3-4 intervertebral space LUD ```
63
Contraindications to Regional? Absolute (6) Relative (2)
``` Relative - Systemic infection and hemorrhage Absolute-> 1) Patient refuse 2) Infection at site 3) Increased ICP 4) Anatomical abnormalities (spina bifida, myelomeningocele) 5) Coags 6) Personnel ```
64
Methods of treating pain intraoperatively (6)
1) Narcs (IV, Epidural) 2) Ketamine 3) Re-dose epidural 4) propofol 5) N2O 6) GETA
65
5 indications for GETA
1) Dire fetal distress and no existing epidural 2) Maternal complications 3) Contraindications to regional 4) Failed regional block 5) BOGGY uterus, decrease gas and give IV meds to ensure amnesia
66
3 Aspiration prophylactic medications
1) Nonparticulate antacid (bicitra) 2) H2 agonist (Pepcid) 3) Motility agent (Reglan)
67
Induction agents, doses and considerations (3)
Propofol 1-1.5 mg/kg Hypotension / Lower APGAR scores / Fetus may have hypotonus or somnelence Ketamine 1 mg/kg Good for asthma and hypotension / avoid in PIH / will need benzos Etomidate 0.2 - 0.3 mg/kg Good choice for heart patients Avoid in patients with seizures
68
How does hydralazine work and what are the side effects
Direct acting vasodilator that decreases afterload S/E: Tachycardia, H/A, vomiting, and tremors
69
What kind of beta blocker is labetalol? Advantages? Disadvantages?
Combined Alpha and Beta adrenergic antagonist Advantage: More rapid onset than hydralazine with few neonatal complications Disadvantages: >1mg/kg can cause neonatal bradycardia and there are widely varying dose requirements between individuals.
70
Signs of Magnesium toxicity
Loss of DTR at 10 mEq/L Resp depression at 12-15 Resp arrest at 15 Cardiac arrest at 20-25
71
Magnesium Toxicity treatment
1 gm IV of Calcium gluconate
72
What drugs do not cross the placenta?
``` Heparin Insulin Glycopyrrolate NDNMB Succinylcholine ``` ``` He Is Going Nowhere Soon ```
73
What MAC maintains UBF? What MAC significantly decreases UBF? What MAC should you keep volatiles at until baby is delivered?
Maintains at 1-1.5 MAC Decreases at >2 MAC 0.5 MAC until fetus is delivered
74
Magnesium treatment goal level
4-7 mEq/L
75
HIV positive mother. How to prevent transmission to baby?
Prophylactic antiretrovirals and do C/S to prevent transmission.
76
What is the most important predictor of fetal outcomes in C/S?
Time to cut to baby being out. >3 minutes = poor APGAR scores.
77
When can you give IV narcotics during a C/S?
After baby is out.
78
Patient has AIDS. What will you change?
Decrease dose of paralytics due to muscle wasting.
79
Anesthesia considerations if boggy uterus?
Decrease volatiles and give IV meds to ensure amnesia
80
MAC is increased during labor. T/F
False -> MAC is decreased in obstetric patients.
81
Steps for induction
Only start if surgeon at bedside with scalpel in hand. RSI with Sux 1-1.5 mg/kg DL with MAC blade/short handle Small ETT 6.0-7.0 (slides say both 6.0-6.5 and 6.0-7.0) After tube placement verified say CUT
82
List 3 Considerations for Fatties
Ramping Longer needles Decreasing epidural/spinal dose
83
Uterine Inversion patient: How do you relax the uterus?
Volatile anesthetic 1.5 MAC NTG 1mcg/kg IBW IV Replace uterus Place on Pitocin 12 hrs after inversion
84
How to relax uterus with retained placenta?
GETA | NTG 50-200 mcg IV
85
Indications for C/S | 8
``` Maternal disease: Hemorrhage Previa Preeclampsia Genital HERPES Fetal distress Breech Elective Infection ```
86
What drugs do you avoid in OB patient that is not having OB surgery?
Versed N2O Esmolol
87
Differential diagnosis of AFE
``` Aspiration Anaphylaxis Seizure Eclampsia Cardiogenic shock Sepsis ```

OB - Paul Smith (1 decks)

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